THE

MEDICAL AND SURGICAL
REPORTER

EDITED BY
CHARLES W. DULLES, M. D.,

TO APRIL 26th,
AND BY

EDWARD T. REICHERT, M. D.,

AFTER APRIL 26th.

JANUARY TO JUNE, 1891.

VOL. LXIV.
• PHILADELPHIA:

N. E. CORNER THIRTEENTH AND WALNUT STREETS.

1891.

-so*

ANDERS, JAMES M., M. D., Philadelphia.
ANDERSON, M., M. D., Pine Bluffs, Wis.

BARR, A. D., M. D., Calamine, Ark.
BEATES, HENRY, M. D., Philadelphia.
BEHRENS, B. M., M. D., Chicago, 111.
BENEDICT, A. L., M. D., Buffalo, N. Y.
BERGEY, D. H., M. D., North Wales, Pa.
BERTRAND, J. H., M. D., De Forest, Wis.
BLACKWELL, ENOS T., Cedarville, N. J.
BOOTH, DAVID S., M. D., Belleville, 111.
BORER, ERNEST M. D., Graz, Germany.
BYERS, H. F., M. D., Caruthersville, Mo.

CADWALLADER, D. W., M. D., Philadelphia.
CATES, BENJ. B., M. D., Knoxville, Tenn.
CERNA, DAVID, M. D., Philadelphia.
CHAPMAN, J. M. T., M. D., Bessemer, Ala.
CLARKE, AUGUSTUS P., A. M., M. D., Cam-

[bridge, Mass.
COBB, W. H. H., M. D., Goldsboro, N. C.
COLTMAN, ROBT. Jr., M. D., Tung Chow Fu,

[China.

CURRIER, JOHN M., M. D,, Newport, Vermont.
CURTIS, F. C, M. D., Albany, N. Y.

DAWSON, BYRON F., M. D., Kewanne, Ind.
DILLER, JAS. M., M. D., Philadelphia.
DELAFIELD, FRANCIS, M. D., New York City.
DIXON, SAMUEL G., M. D., Philadelphia.
DOCK, GEORGE, M. D., Galveston, Texas.
DODGE, C. L., M. D., Kingston, N. Y.

EAGLETON, S. POTTS, M. D., Philadelphia.
EICHLER, ALFRED, M. D., San Francisco, Cal.
ESHNER, AUGUSTUS, M. D., Philadelphia.

FENGER, CHRISTIAN, M. D., Chicago, 111.
FISHER, JOHN M., M. D., Philadelphia.
FOSTER, HAL, M. D., Kansas City, Mo.
FOX, L. WEBSTER, M. D., Philadelphia.
FREW, JAMES E., M. D., Billings, Montana.

GASTON, J. McFADDEN, M. D., Atlanta, Ga.
GOODELL, WILLIAM, M. D., Philadelphia.
GRIFFITH, J. P. CROZIER, M. D., Philadelphia.
GUYON, DR., Paris, France.

HANSELL, HOWARD F., M. D., Philadelphia.
HARE, H. A., M. D., Philadelphia.
HATCH, J. LEFFINGWELL, M. D., Philadelphia.
H1GHLEY GEO. N., M. D., Conshohocken, Pa.
HILL, T. B., M. D., Ruff's Creek, Pa.
HOFFMAN, JOS. E., M. D., Philadelphia, Pa.
HOLLOPETER, W. C, M. D., Philadelphia.
HOLT, L. EMMET, M. D., New York City.
HUNT, WILLIAM, M. D., Philadelphia.

KAHN, CORNELIA, M. D., Philadelphia.
KIERNAN, J. G., M. D., Chicago, 111.

LA PLACE, ERNEST, M. D., Philadelphia.
LEON, ALEXIS M., M. D., New York City.
LOEFLER, F., M. D., Griefswald, Germany.
LONGSTRETCH, MORRIS, M. D., Philadelphia.

MANSFIELD, ARTHER, M. D., Baltimore. Md.
MASSEY, G. BETTON, M. D., Philadelphia.
MAYS, THOS. J., M. D., Philadelphia.
McALEXANDER, ALEX., M. D., Camden. N. J.
McARTHUR, L, L., M. D., Chicago, 111.
MONTGOMERY, E. E., M. D., Philadelphia.
MOORE, THOS. H., M. D., D. D. S.. Philadelphia.
MORRIS, J. CHESTON, M. D., Philadelphia.
MOYER, HAROLD N., M. D., Chicago, 111.
MUSSER, JOHN H., M. D., Philadelphia.
MUSGROVE, C. W., M. D., Lock Haven, Pa.
MYERS, A. F., M. D., Blooming Glen, Pa.

NEALL, C. H. M., M. D., D. D. S., Philadelphia.
NOBLE, CHAS. P., Philadelphia.

PACKARD, JOHN H., Philadelphia.
PAGE, R. M. C, M. D., New York City.
PATTON, JOSEPH M., M. D., Chicago, 111.
PEPPER, WILLIAM, M. D., Philadelphia.

iii

iv

Contributors.

RANDALL, B. ALEX., M. D., Philadelphia.

REINEKING H., M. D., Sheboygan, Wis.

RIGG, DR., Allegheny, Pa.

RILEY, HENRY A., New York City.

RING, FRANK W., A. M., M. D., New York City.

SARGENT, G. P., M. D., Bryn Mawr, Pa.
SHIMONEK F., M. D., Milwaukee, Wis.
SHIPPS, WILLIAM H., M. D., Bordentown, N. J.
SIMS, H. MARION, M. D., New York City.
SLIFER, H. F., M. D., North Wales, Pa.
SMALL, E. H., M. D., Pittsburg.
SMITH, A. NOEL, M. D., Dover, N. H.
SPOHN, ARTHER., M. D., Corpus Christi, Texas.
STOCKTON, CHAS. G., M. D., Buffalo, N. Y.
SUTTON, R. STANBURRY, M. D., Pittsburg, Pa.

TAYLOR, R. W., M. D., New York City.
THOMAS, CHAS. HERMANN. M. D., Phila.
THOMAS, J. J., M. D., Youngstown, Ohio.
THOMPSON, LUCIA REDDING, M. D., Phila.
TRIPPE, R. J., M. D., Chattanooga, Va.

VEASEY, C. A., M. D., Philadelphia.

WARD, AARON C, M. D., Newark, N. J.
WARD, STANLEY M., M. D., Scranton, Pa.
WASHINGTON, W. S., M. D., Newark, N. J.
WATSON, B. A., A. M., M. D., Jersey City, N. J.
WEBER, M. J., M. D., Lower Providence, Pa. •
WHITE, J. WILLIAM, M. D., Philadelphia.
WILSON, J. C, M. D., Philadelphia.

YOUNG, JAS. K., M. D., Philadelphia.

Abdomen, enlargement of, 433.

Abdominal operations and after-care, 408.

Abdominal section in parturition, conditions requir-
ing, 744; after-treatment, 773; practical points,
796.

Abdominal operations sequalse, 814.

Abortion — for vomiting of pregnancy, 117; habitual,
205 ; medical and social aspects of, 314.

Abscess — mammary in the virgin, 220 ; pelvic, 380 ;
pelvic in man, 128; psoas, 61; tuberculosis, treat-
ment of with hot water flushing, 277.

Acetanilid for chancre and chancroid, 402, 602, 792.

Adenitis, cervical, in children, 194.

Africa, kola-nut of, 390.

African arrow poison, 7.

Alabama, medical law of, 373.

Albumen and other proteids, test for, 565.

Albumin in urine, 471 ; test for, 364.

Albuminuria — caused by antipyrine, 757; in acute
catarrhal enteritis, 488 ; in infantile disease, 728.

Agaricine in night-sweats, 637.

Alcohol and digestion, 566.

Alexander, H. A.— letter, 284.

Alkaloid, opium, new, 18.

American Academy of Medicine, 394.

American childhood from a medical standpoint, 664.

American Electro-therapeutic Association, 87.

Amicrobian fever following arterial obliteration, 680.

Amputation below the knee, 687.

Amyl nitrite — in chloroform poisoning, 549 ; a cure
for hiccough, 396.

Anaesthetics, administration to children, 684; in mid-
wifery, 520; relative value of, 71.

Anatomy, pathological of ecthyma, 116.

Anatomy at Oxford University 804.

Ancephalia, 222.

Anderson, M. — Purpura Hemorrhagica and metror-
rhagia, 350.

Anders, J. M.— Clinical Lecture, 263, 459.

Angeiocholitis, jaundice from, 293.

Angina pectoris, 471 ; nature and treatment, 757.

Animals, diseases of in relationship to those of man,
318.

Ankle, fracture, 61.
Ano, fistula in, 94.
Anti-kidnapping league, 177.

Antipyretics — action of, 750; in childhood, 604;

treatment in children, 559.
Antipyrin — causes albuminuria, 756; injections of,

for hemeralopia, 280; in puerperal fever, 131,

226 ; test for pure, 565.
Antipyrin in tonic spasm of parturient uterus, 837.
Antisepsine, Radlauers, 753.
Antisepsis for chiropodists, 71.

Antiseptics — benzin, 285 ; chloroform as, 168; elixir,
French, 330; medication, 241; poultice, [527;
remedy, tannic acid as, 57.

Antrum of Highmore, suppuration of, 332.

Apomorphia, 115.

Appendicitis, 216, 352; surgical treatment of, 715.
Aristol — in diseases of the eye, 509 ; in venereal dis-
ease, 547.
Arkansas, medical legislation in, 260.
Army medical board, 345; medical department, 227.
Arrow poison, African, 7.
Artesian wells in Iowa, 221.
Arthritis, rheumatoid, 89, 99.
Artificial anus, 687.

Aspiration for the treatment of hernia, 371.

Association of American Anatomists, 259.

Association of American Physicians of Berlin, 373.

Asthma and emphysema, 265.

Ataxia, hyposulphite of sodium and silver in, 509.

Ataxia sign, an early, 513.

Atropine in diseases of the heart, 509.

Auscultatory percussion, value of in diagnosis, 665.

Bacilli of Malaria, 562 ; of syphilis, 564.

Bacteria— pathogenic, 131; 474; Dr. Klein on, 802.

Bacteria of influenza 840.

Bacteriology, 354.

Bagwell, J. F., M. D., letter, 790.

Baldy, J. M., 526.

Barr, A. D., was it relapsing fever, 37.

Bartholinian gland, cancer of, 221.

Beates, Henry — the expectant treatment of syphilitic

infection, 498.
Beef-tea, 133.

Behrens, B. M. — Permanent opening of drumhead
186.

Belladonna and electricity, for tachycardia, 331.
Benedict, A. L.— Metric System, 266.
Benzin as antiseptic, 285.
Bergey, D. H.— Dysentary, 205.
Beri-beri, 306.
Berlin aquarium, 69.

Berlin, Association of American Physicians, 373.
Berlin letter, 69, 329.
Bermuda letter, 787.
Bertrand, J. H., Leprosy, 9.

Bigelow, H. R.— letter, 340.— Electricity in Pelvic

Surgery, 592.
Bile pigment in urine, 168.
Biological laboratory, the Da Costa, 525.
Birds, malaria in, 28.

Blackwell, E. T., Malarial Fever with Liver Involve-
ment, 35.

Blackwell, E. T. — Vomiting of pregnancy, 190.

V

VI

Index.

Bladder — exfoliation in female, 18 ; extirpation of, 26.
Blennorrhagia, albuminuria in, 598.
Blennorrhagic rheumatism, mercury in, 593.
Bigelow, H. R. — Medical Electricity and Batteries,
453.

Blood alkalinity of under normal and pathological
conditions 804.

Book Reviews :

Birnbaum, Max, M. D. — Koch's Method to Cure
Pulmonary Tuberculosis Treated, 706.

Bourneville — Clinical and Therapeutical Investi-
gations of Epilepsy, Hysteria, and Idiocy, 49.

Burt, W. H.— Tuberculosis, 202.

Capp, W. M.— The Daughter, 110.

Charcot, J. M.— Complete Works, 312.

Cordell, Eugene T. — Historical sketch of the
University of Maryland, 752.

Edinger, L. — Nervous System, 477.

Flint and Wilson. — Auscultation and Percussion,
339.

Foster, F. P.— Dictionary, 256.
Gordon, C. A. — Rabies and Hydrophobia, 368.
Goss, I. J. M.— Materia Medica, 225.
Goss, I.J. M. — Practice of Medicine, 201.
Greenleaf, C. R. — Epitome of Tripler's Manual,
49.

Gross and Sturgis. — Impotence, Sterility and Allied
Disorders of the Male Sexual Organs, 340.

Hare, H. A.— Therapeutics, 790.

Hatfield, Marcus P. — A Compend of Diseases of
Children, 705.

International Clinics, 675.

Jastrow, J. — Mental Phenomena, 339.

Kelsey, C. B. — Stricture of Rectum, 173.

Letts & Company. — Medical Diary, 256.

Lutaud. — Studies in Hydrophobia, 395.

Martin, Edward — Essentials of Surgery, 674.

Medicinal — Kalender, 22.

Mitchell, C— Diseases of Kidneys, 202.

Morris, H. — Practice of Medicine, 225.

Nettleship, E. — Diseases of Eye, 395.

Newth, Owen — Post-Mortems, 424.

Paget Sir James— Studies of old case-books 828.

Parvin, T. — Science and Art of Obstetrics, 21.

Penzoldt, F.— Clinical Therapeutics, 311.

Pepper, E.— Malaria, 368.

Potter, S. O. L. — Compend of Human Anatomy,
110.

Powell, W. M.— Diseases of Children, 141.
Purdy, Chas. W.— Diabetes, 791.
Regnier, L., L' Intoxication chronique par la Mor-
phine, 80.

Ribot, Th. — Diseases of Personality, 752.
Roberts, J. B. — Manual of Modern Surgery, 140.
Sayre Lucious E. — Essentials of Pharmacy 829.
Seifert-Miiller, Clinical Diagnosis, 453.
Senn, N. — Surgical Bacteriology, 477, 674.
Smith, J. L. — Diseases of Infancy and Childhood,
173.

Starr, L. — Digestive Organs in Infancy and Child-
hood, 368.

Starr, M. A., nervous disease, 80.

Taylor, F. — Manual of Practice of Medicine, 110.

Thornton, Wm. — Origin, Purpose and Destiny of
Man, 706.

Transactions of American Orthopedic Association,
453.

Transactions New York State Medical Association,
49, 675.

Tyson, J. — Examination of Urine, 424.

Wight, J. S.— Suggestions to Medical Witness, 396.

Whipple, Farrington H. — Clinical Examination of
of the Urine, 751.

Blood, alkalinity affected by large doses of sodic sul-
phate, 646.
Bone grafting, 145.

Booth, D. S. — Pelvis abscess in man, 128.
Boric acid in otorrhcea, 364.
Borner, Earnest — Clinical Lecture, 647.
Bougies, metallic, in gleet and sexual neurasthemia,
554.

Brain, bullet wounds in, 10.

Brain, sarcoma, 216.

Breech presentations, treatment, 836.

Bright's disease, 1 ; aetiology, 759 : treatment of 597 ;

following infantile purpura, 513.
Bromide of ethjl, 71.
Bromoform, poisoning by, 549.
Bromoform in whooping cough 839.
Bronchitis, 651 ; chronic, 613; produced by vapors of

picric acid, 637.
Brown-Sequard fluid in tuberculosis, 175.
Brush, H. L.— Letter, 369.
Burial of so-called stillborn children, 482.
Burns, treatment of, 48.
Burr, Wm. H. — Hydrogen peroxide, 705.
Byers, H. F., hystero-epilepsy, 812.

Cadwallader, D. W., fibro-papilloma of the bladder,
734.

Caffeine for post-partum haemorrhage, 430.

Caffeine, hyperkinetic action of, in large doses, 596.

Calculi, biliary, 291.

California, health legislation in, 464.

California, Southern as health resort, 136.

Calomel and salt, 392.

Calomel in kidney disease, 457.

Canaliculi, occlusion of* 375.

Cancer, of a poisonous nature, 553.

Cancer of breast treated by methyl-violet, 641.

Cancer of Bartholinian gland, 221.

Cancer of stomach, 11.

Cancer of uterus, 4.

Cancrum oris, 284.

Carbuncle, 151. — and diphtheria, caustic treatment
of, 252.

Cardiac — affections, strychnine in, 637 ; hypertrophy

and dilatation, 650.
Gary, C— Report of Clinic, 99.

Carey, Wm. A. — Inadequate hospital facilities, etc.,
704.

Caries of costal cartilage treated with methyl-violet,
733.

Carbolic acid, variations in caustic action, 831.

Carolina, health legislation in, 464.

Carpaine, 548.

Catarrhal dyspepsia, 459.

Cates, B. B., Currette in fistula in ano., 94.

Carcinoma — disappears with development of phthisis,

794 ; of the breast, 688.
Castor oil, 37.

Castration of women, sexual life after, 557.
Cataract, soft, 375.
Cement, insoluble, 453.
Cerebro-spinal meningitis, specimen, 609.
Cerna, David. — The therapeutic uses of Kava-Kava,
492.

Cervix, flexible wire stems for stenosis, 136.

Cetrarin, therapeutic value of, 706.

Cheese, new poison in, 565.

Cervical glands, scrofulous ulceration of, 527.

Chancre and chancroid, acetanilid for, 402, 602, 792.

Index.

vii

Chapman, J. M. T.— Mechanical treatment of umbli-
cal hernia.

Chest — cotton and collodian dressing for, 392 ; trau-
matism of, 577.
Chicago Medical Record 804.

Children — dyspepsia of, 46; medication for, 196;
pleuritic effusion in, 176; tonsils of, 179; vaccina-
tion of, 388 ; burial of so-called stillborn, 482.

China, leprosy in, 73.

Chinese treatment of diptheria, 104.

Chiropodists, 71.

Chloralamide, 755.

Chloroform, 96 ; in typhoid fever, 636 ; as an anti-
septic, 168 ; in tracheotomy. 307.

Chlorosis, its treatment, 513.

Cholera toxine, isolation of, 765.

Cholera, epidemic of in Europe and America from
1830 to 1890, 605.

Chloroform poisoning, amyl nitrite in, 549.

Chorea, 445; association of Sydenhams and rhyth-
mical, 598.

Chylochle — in New Orleans, 318 ; parasitic, 317.

Chronic acid in epistaxis, 308.

Chronic alcoholism, strychnine in, 783.

Chronic phthisis, 739.

Cities, micro-organisms in, 117.

Cirrhosis of liver and nervous symptoms, 833.

Clarke, A. P., M. D., hernia, 776.

Club-foot, 270; operation for, 178.

Cobb, W. H. H., Supra-pubic Cystotomy, 7.

Cocaine, 18; injections, death from, 85; new re-
action of, 646; poisoning, 635; in small-pox, 550,
dangers of, 508.

Cocaine, actions on circulation, 830.

Cocoanut for tape worn, 177.

Cod-liver oil, disguise for, 118.

Cold abscesses, treatment of. 681.

Colds, common, 440.

Colic, hepatic, 42.

Collapse, stimulant in, 174.

Colombia, leprosy in, 198.

Coltman, R.— Clinical Lecture, 233.

Comedones, 430.

Concussion of brain and spinal cord to certain condi-
tions, 614.

Congress of American Physicians and Surgeons, 399.
Constipation, voluntary, 764.

Consumption — and emphysema, 767; antifebriniza-

tion in, 117.
Contagious Diseases Act, 391.

Convulsions — depending upon rickets, 607 ; in chil-
dren, treatment of, 521, 604.

Copaiba as an expectorant, 676 ; as diuretic, 280.

Copper coloring matter in tea, detection of, 646.

Cornea, phlyctenular ulceration, chlrorate of potas-
sium in, 586.

Copyright bill, 144.

Corpuscles, white, in pneumonia, 16 ; white, in dis-
ease, 550.

Corrosive sublimate as a disinfectant, 685.
Coryza, 199.

Cotton and collodion dressing for chest, 392.

Country practice, 314.

Cranium, temporary resection of, 759.

Creasote, 308.

Creasote, emulsion of, 106.

Cremation and its safeguards, 277.

Crematory at Heidelburg 805.

Crico-thyroid joint, luxation of, 70.

Croonian lectures, 766.

Croup— 322; etherization in, 723.

Curative effect of operations, 663.

Curiosity, laryngological, 1/18.

Curetting of uterus in puerpural fever, 633.

Curetting of the uterus 827.

Currier, J. M. — Medical colleges of Vermont, 237'.
Curtis, F. C. — Vesicular eruption in scarlatina, 244.
Cystoma of jaw, 214.
Cyst, parovarian, 487.
Cystotomy, supra-pubic, 38.
Cystoscopy, 7, 215.

Da Costa, J. M., 54.
Davidson, W. T.— Letter, 368.

Dawson, B. F. — Foreign body in ear for nine years,
462.

Day, time of to operate, 514.
Delafield, Francis — clinical lecture, 490, 650.
Diabetes — pathogeny, 600; Jambulin, 754, teeth in,
398.

Diaceturia in infantile disease, 725.

Diarrhoea, arsenite of copper in, 792 ; infusion of
roses for, 400.

Dietetic employment of fat, 397.

Dietetics of chronic nephritis, 343.

Digataline, new method of administering, 549.

Digitalis in pneumonia, 829.

Digestion, influence of exercise on, 457.

Digestive troubles of infants, 362.

Digitalis and strychnine as circulatory stimulants, 509.

Digitalis in pneumonia, 708.

Diller, T. — Care of chronic insane, 549.

Diplomas in Pennsylvania,endorsing, 256.

Diphtherial3, 16, 104; caustic treatment of, 252 ; re-
sorcin in, 233 ; and tetanus, immunity from, 76 ;
statistics and treatment, 560 ; therapy, 769 ; treated
with hydrogen peroxide, 756; treated with mercu-
rial inunctions, 800.

Dirtiest city in the world, 261.

Disease, and starvation, 344.

Diseases, names of, 333.

Disinfection, hints on, 564.

Diuretic, copaiba balsam as, 280.

Diuretine, alterability of 106 ; therapeutic effects,
678.

Dixon, S. G., Koch reagent for tuberculosis, 69 ;

pharmacists, women, 65.
Dyspepsia, diagnosis and treatment of catarrhal,

459.

Dock, G.— Fevers of the South, 92.
Dodge, C. L. — Membranous croup, 322.
Doses, small, 104.

Druggists and venereal patients, 364.
Druggist's error in Germany, 398.
Drugs, impure, 289.
Drumhead, opening of, 186.
Dysentery, 209.

Dysmenorrhoea, dilation for, 54.
Dyspepsia, 235 ; of children, 46.

Eagleton, S. Potts — Hydrogen Peroxide, 542.
Ear, dangers of syringing, 304.

Ear diseases — new remedies for, 279 ; foreign body
in for nine years, 462 ; suppuration of middle in
infancy, 347.

Echinococcus of the lung, 550.

Eclampsia, post-partum, treatment, 723 ; treatment of,

558.
Ecthyma, 116.
Editorials :

Abortive treatment of syphilis, 366.

American Medical Association, 79.

Amylene hydrate and epilepsy, 394.

Anaemia, treatment of, 338.

viii

Index.

Appendicitis, excision of vermiform appendix in,
450.

Asthma in children, treatment of, 339.
Atlanta Medical and Surgical Journal, 201.
Barking cough of puberty, 139.
Boric acid in treatment of chronic constipation,
474.

Cancer germ, 78.
Chancres, excision of, 423.

Chronic constipation with boric acid, treatment of,
474.

Clinical lectures, 173.
Cocaine, dangers of, 508.

Concealed advertisements in medical journals, 309.
Curetting of the uterus in puerperal fever, 633;
Constipation, habitual, 671.
Da Costa, resignation of, 476.
Deaf infants, training school for, 475.
Deaths in cold weather, 283.
Digestion for abscess cavities, 311.
Diseases of women, electricity for, 449.
Dust and tubercle bacilli, 283.
Editor, farewell of, 476. (Dr. Dulles.)
Education and Diseases of School Children. 19.
Electricity for diseases of women, 449.
Electricity in treatment of extra-uterine pregnancy,
366.

Epilepsy and amylene hydrate, 394.

Farewell of the Editor, 476. (Dr. Dulles.)

Female pelvic organs, exploratory puncture of, 200.

Filaria sanguinis hominis, 310.

Genito-urinary apparatus, neuroses of, 223.

Gonococcus in diagnosis of vulvitis, 109.

Gynecological suggestions, 253.

Hematuria in typhoid fever, 281.

Herpes vacciniforme of infants, 452.

Homoeopaths and Medical Examiners' Bill, 255.

Immigration and Public Health, 47.

Impressions, maternal, 282.

Incorporation of Pa. State Medical Society, 48.

Inebriates, legal restraint of, 138.

Infantile Malaria, 749.

Infants, herpes vacciniforme of, 452.

Intra-uterine stem pessary, 703.

Jefferson Medical College, 20.

Koch's fluid in non-tuberculous persons, 337.

Koch's method, 169.

Koch's remedy, 170.

Koch remedy for tuberculosis, 77.

Koch treatment, present states of, 641.

Legal restraint of inebriates, 138.

Lupus, nature of, 254.

Malaria, micro-organism of, 170.

Maternal impressions, 282.

Medical and Surgical College of New Jersey, 395.

Medical and Surgical Reporter, 507.

Medical examiners and medical education, 137.

Medical Examinets' Bill, 48, 255.

Michigan, University of, 452.

Micro-organism of malaria, 170.

Myxoedema relieved by grafting with thyroid, 108.

Nashville Journal of Medicine, 225.

Neuroses of genito-urinary apparatus, 223.

Neuroses, traumatic, 423.

Oesophagus, varices of, 199.

Pathogenesis of tetanus, 421.

Pelvic inflammation and general practitioner, 393.

Pelvic organs, exploratory puncture of, 200.

Pennsylvania, Medical Examiners' Bill for, 48.

Pennsylvania State Medical Society, 48.

Philadelphia Polyclinic, 475.

physicians' accounts, 365.

Pregnancy, electricity in treatment of extra-uterine,,
366.

Presbyterian Hospital in Philadelphia, 421 .

Puberty, barking cough of, ] 39.

Retinol, a new solvent and antiseptic, 591.

Resignation of Dr. Da Costa, 476.

Scarlet fever, tongue in, 394.

Scarlet remedies — Koch's remedy, 170.

Spermine, 473.

Sponges, antiseptic preparation of, 825.
Surgeon-General Sutherland, 20.
Sutherland, Surgeon-General, 20.
Syphilis, abortive treatment of, 366.
Tetanus, 421,

Tongue in scarlet fever, 394.

Tracherlomy vs. intubation, 785.

Training school for deaf infants, 475.

Transfusion of blood and salt solution, 47.

Transperitoneal hysterorrhaphy, 224.

Tubercle bacilli, and dust, 283.

Tubercle bacillus, diagnostic significance of, 107-

Tuberculosis, 77.

Typhoid fever, 281.

University of Michigan, 452.

Varices of oesophagus, 199.

Vermiform appendix, excision of in appendicitis,
450.

Women, electricity for diseases of, 449.

Egypt, hydrophobia in, 135.

Eichler, A. — Resorcin, 124; salol, 454.

Eiffel tower, 195.

Electrical treatment, 217.

Electricity, belladonna for tachycardia, 331.

Electricity and pelvic surgery, 340, 464, 477, 592.

Electric light, analgesic action of, 792.

Electric wires, 71.

Embryotomy of the living foetus, is it justifiable ? 660.
Emmenagogue, salicylate of soda, 797.
Emphysema, 265.
Emulsion of creasote, 106.

Endometritis and its treatment, 519 ; medicated pen-
cils in, 555.

Endocarditis, 101, 154.

Endoscopic examination of bladder, 809.

Enlargement of abdomen, 431.

Enteritis, albuminuria in acute catarrhal, 481.

Entopic gestation, indications for operation, 557.

Epilepsy, 59, 118, 180; teeth in, 136; trephining
for, 193 ; from deformed fracture produced with the
obstretic forceps, 643 ; bromide of ethylene in, 707.

Epistaxis, chromic acid in, 308.

Epididynitus, gonorrhoeal, 641.

Ergot in tyyhoid fever, 61.

Erysipelas, 198; treatment by ichthyol, 509 ; treat-
ment with salicylated glycerine, 680.

Eshner, A. A. — Fibrosis, anterio-capillary, 412.

Ethylene bromide in epilepsy, 707.

Evolution, sexual perversion as phase of, 436.

Exision of vermiform appendix in appendicitis, 450.

Exalgine, therapeutic uses of, 636; untoward effects
of, 547.

Exostosis of humerous 822.

Eye, aristol in diseases of, 509 ; diseases of, with
caries of vertebrae, 99; diseases, massage in, 132.
Eye-lotions, infectious, 794.

Fast, challenge to, 106 ; forty-five days, 25.

Fat, dietetic employment of, 397.

Febrifuge, lantanine as, 46.

Feeding, infant, 26.

Feet, perspiring, remedy for, 206.

Index.

ix

Fenger, Christian — New operation for hare-lip, 621 .

Fetus in utero, death of, 121.

Fever, enteric, oscillations in bodily weight, 134.

Fever, puerperal, antipyrin in, 131.

Fevers of the South, 92.

Fibroid tumors, electrical treatment of, with an an-
alysis of forty-six cases, 697.
Fibroids of the uterus, 432.
Fibrosis, 412.

Fibro-papilloma of bladder, 734.
Fisher, J. M.— Clinical Lecture, 403.
Fish poison, 252.
Fistula in ano, 94.
Fluviograph, 472.
Formula :

Alopecia, 668, 784— Anaesthesia, local, 589— Anti-
septic gauze, 590 — Aphrodisioc pills, 701 —
Aristol in gynaecology, 632 — Asthma, 784 — Anti-
septic betol as an 824.

Balanitis, 702— Bladder, irritable, 747— Blenor-
rhagia, 783— Bronchitis, 632— Bed-rooms 823.

Castor oil mixture, 590 — Chlorosis, 670 — Convul-
sions, infantile, 702 — Cough mixture, 747 —
Coryza, 631, 669 — Croup 823 — Creoline in gas-
tric-enteritis 824: — Corn cnre 824.

Diarrhoea, 748 — Diarrhoea, summer, 701 — Diar-
rhoea, 589— Diarrhoea, infantile, 670— Diphtheria,
748-Diphtheria, 590-Diphtheria, topical applica-
tion, 590 — Dysentery, 701, 747, 784— Dysmenor-
rhoea, 590, 632 — Dyspepsia, 701— Diptheritic
membrane solvent 823 — Diarrhoea 823 — Dysen-
tery 824.

Earache drops, 670 — Ear-wax to soften, 752 —
Eczema, 589, 702, 784— Enema, nutritive, 590—
Epilatory paste, 669 — Epilepsy, 707 — Erysipelas,
792— Erythema, 784— Eczema 824.

Fever mixture for children, 590 — Flatulence, 670 —
Flatus, intestinal, 747 — Foetid breath, 590 —
Freckles, 670.

Gonorrhoea, antipyrine, 590 — carbonate of soda,
747 — ergotine in, 669 — Gout, liniment, 670 —
Gastro-enteritis 824.

Haemorrhoids, chrysarobin for, 632 — Haemorrhoids,
702 — Haemorrhoids, 747 — Hands, chapped or
bruised, 669— Hiccough, 684— Hair tonic 824.

Icteres, 701— Ichthyol, 632— Insomnia, 783—
Intertrigo ointment 823.

Laryngitis 823.

Mercury, salicylate, 632, 701— Metrorrhagia, 632—

Migraine, 590 — Mouth wash, 669.
Night sweats, agaricum in, 637 — Nasal diphtheria

823.

Ox-gall, 702— Oxyurus, 784.

Phthisis, ointment, 670 — Pregnancy, vomiting, 748
— Pruritis, 632— Pruritis, senile, 669— Purga-
tive pills, 747 — Painful teething cocaine in 824.

Quinine, formula for, 669.

Seat worms, 670 — Soothing syrup, 748.

Tetanus, 589 — Tonge fissure, 669 — Toothache,
drops, 589— Tonsilitis, 589— Typhoid fever, 748.

Urethritis, acute, 748 — Uterine wafers, 602 —
Uterus, sub-involution, 702.

Varicose leg ulcers, 707 — Vomiting of pregnancy,
668, 669.

Whooping cough, 670, 701, 702, 747, 748, 783,
823— Warts 824.

Foeted discharges, salol as a deodorizer, 681.

Food, lion flesh, 345.

Foot-ball casualities, 805.

Forceps, how to apply, 134.

Foreign bodies lodged in the body, 640.

Fox, H. Webster — Resection of optic nerve, 152 \
653.

Fracture of ankle, 61.
France, depopulation of, 114.
France, vaccination in, 419.
Fraternity, Nu Sigma Nu, 346.
Free, J. E. — Puerperal pneumonia, 302.
French antiseptic elixir, 380.
Fullerton, Anna M. — Letter, 110.

Gall-bladder, enlarged, 652.
Gall-stones, expurius of, 678.
Galvanism in diseases of uterus, 403.
Galvano-cauterization, intra-uterine, 682.
Ganglion, gasserian, removal of, 282.
Gangrene, 236.

Gas, illuminating, dangers of, 236.

Gaston, J. McFadden — Traumatism of the chest, 577.

Gastric diseases, utilization of food, 755.

Gastric function in chronic nephritis, 448.

Gastric mucous membrane, atrophy of, 570.

Gastric ulcer, 271, 416, 570.

Gastritis, chronic, 570.

Genitals, defective development of, 836.

Germany, druggist's error in, 398.

Gibbes-Shurley method in phthisis, 676.

Gingivitis common to men and dogs in India, 759.

Girls, education of, 216.

Gleet, treatment by metallic bougies, 554.

Glycerin, and meat juice, 363,

Goitre, suffocating, 641.

Goldbeaters skin for cracked nipples, 733.

Gonococcus, some reasons in favor of the non-specific
properties of, 497.

Glycosuria and diabetes, 539.

Goodell, William — Clinical Lecture, 487.

Golden Belt Medical Society, 374.

Gonorrhoea, 75 ; contagiousness of, 454 ; novel treat-
ment of, 711.

Goodell, W. — Abdominal operations and aftercare,
408.

Goodell, Wm.— Clinical Lecture, 319.
Goodell, Wm.— Clinical Lecture, 807.
Grafting, bone, 145.

Griffith, J. P. C. — Climatic treatment of phthisis, 182;

Clinical Lecture, 570.
Guaiac as purgative, 55, 753.
Guiacol for treatment of tuberculosis, 485.
Gumma, tubercular, 214.
Guyon, Dr.— Clinical Lecture, 809.
Gynecology, 217.

Hamilton John B. — Resignation as Surgeon-General-
805.

Hands, peroxide of hydrogen, for cleaning, 237.
Hansell, H. F.— Clinical Lecture, 375.
Harelip, new operation for, 621 .
Hare, H. A., Clinical Lecture 32, 179.
Harvard, Four Years' Course, 843
Hatch, J. L., history of bacteriology, 354.
Health legislation in California and South Carolina..
464.

Headache, syphilitic, 89; treatment of, 468.
Heart, atropine in diseases of, 509.
Helepin, 181.

Hematemesis in gastric ulcer, 416.

Hemeralopia, treatment of, with injections of anti-
pyrin, 280.

Hemiplegia following grippe, 149.

Hemoglobinuria from use of quinine, 318.

Haemorrhage — post-partum, treated with caffeine, 430-
treated with iodoform gauze, 763 ; uterine, 431.

X

Index.

Haemostyptic, 556.
Hemorrhoids, 101, 346.
Haematoporphyrin in the urine, 606.
Hematuria and endoscopic examination of bladder,
809.

Hernia, cerebral, 250 ; surgical treatment for radical
cure of, 988, 688, 776; spontaneous cure, 128;
strangulated, 417; treatment of by aspiration, 371.

Herpes, abortive treatment of, 679.

Herpes Zoster, multiple, 399.

Hiccough cured with nitrate of amyl, 396.

Highley, G. N. — Hygiene of infancy, 122.

Higher medical education, 686.

Hill, T. B.— Ergot in typhoid fever, 61.

Hoffman, Jos. E., abdominal surgery, 814.

Hollopeter, W. C— Clinical Lecture, 29.

Holt, L. Emmet— Clinical Lecture, 607.

Holt's divulsor, 216.

Homcepaths and Medical Examiners' bill, 257.
Homoeopathy by a homoeopath, 248.
Homseopaths converted, 234.
Homoeopaths, how they look at it, 261.
Horse-kicks, treatment of, 554.
Human lymph in therapeutics, 636.
Hunt, W. — Koch's remedy for tuberculosis, 295.
Humphreys, B. Frank, — little liver pills, 509.
Hydrastin, action of on vascular system and uterus,
594.

Hydrastis canadensis in uterine haemorrhage, 683.
Hydrate of amyl in epilepsy, 118.
Hydrocele, varieties of, 443.
Hydrogen peroxide, 463, 582, 645, 705.
Hydrophobia, transmissibility from man to man, 764;

in Egypt, 135.
Hygienic Congress, International, 766.
Hygiene in France, 645.
Hyoscine in mania and insominia, 636.
Hyperemesis, treatment with creasote, 308.
Hyperosmic acid in suborbital neuralgia, 677.
Hyperphoria, treatment of, 831.
Hypnotism as a remedy, safety of, 444.
Hypodermic syringe, 284.
Hysterectomy, 65.
Hysterectomy, 807-
Hystero-epilepsy, 812.

Hysteria, traumatic, surgical intervention, 761.

Ichthyol — in diseases of female genitalia, 798 ; var-
nishes, 483.

Illinois, foreign medical diplomas in, 402.

Immunity from influenza by vaccination with calf
lymph, 685.

Inebriates, legislation for, 75.

Inebriety, narcotic, prevention of, 290.

Infancy, hygiene of, 122.

Infantile malaria, 749.

Infants, digestive troubles of, 362.

Infantile cerebral palsies, 838.

Infection through milk, 562; traumatic, 527 ; through

the soil, 562.
Infectuous disease compulsory notification of 840.
Influenza — 127; epidemic, 795; reputed cause of,

564; statistics of forty-one thousand cases, etc.,

522.

Influenza bacteria 840.

India, women physicians in, 118.

Inhaler, 168.

Insane, fractured ribs in, 402; care of, 461.

Insomnia in infants, 559.

Intestinal obstruction, 410.

Intubation of larynx in diphtheria, 561.

Iodine, 67, 245.

Iodoform-ether-glycerine injections in septic cavities,
359.

Iodoform — in treatment of tuberculosis, 485 ; solu-
bility in oil, 725 ; in chronic eye affections, 595 ; in
tubercular bronchitis, 754.

Iowa, artesion wells in, 220.

Iritis, 376.

Iron in the organs, testing for, 606.
Iron, protochloride, 322.
Italian pharmacopea 843.

Jambul in diabetes, 754.
Jaundice, catarrhal, 150.

Jaundice following passage of biliary calculi, 891.

Jaundice from angeiocholitis, 293.

Jaw, cystoma of, 214.

Jefferson College's new surgeon, 398.

Jefferson Medical College, 766.

Johns Hopkins Hospital, 943.

Johnstown Correspondent's Assoc. 806

Journal Amer. Med. Assoc., 766.

Journal of Gynaecology, 843.

Juvenile smoking suppression of, 840.

Kahn, Cornelia — Incarcerated retroflexed uterus, 535.
Kava-Kava, Therapeutic uses of, 492.
Keloid, 445 ; lupus, 527.

Keen, W. W. — Compression of subclavian artery 821.
Kidneys, salol on, 147 ; calomel in, 457.
Kiernan, J. G. — Sexual perversion as phase of evolu-
tion, 436.

Koch's Lymph, 22, 49, 68, 81, 203, 217, 274, 279,
295, 465, 525, 606, 726 -chemical reactions of, 525.
— treatment, death from, 152; and the German
Government, 165; treatment condemned, 262;
failure with, 276; treatment in Vienna, 218;
treatment in New York, 174; institute in New
York, 178; physiological behavior of, 741.

Kola essence, stimulant, 147.

Kola-nut of Africa, 390.

Labor — protracted, strychnia and hot douche in, 720;

weak in primaparae of advanced age, 647.
Lanolin Milk, 27.
Lantanine as febrifuge, 46.

Laparotomy — for disease of liver, 430; drainage of
abdominal cavity after, 719; in intestinal obstruc-
tion, 410; sequence of, 567; Trendelenburg's post-
ure in, 556.

Laplace, Earnest — Clinical lecture, 527.

Laryngological curiosity, 118.

Larynx, artificial, 194.

Larynx, extirpation of, 194 ; intubation in diptheria,
569.

Larynx, tuberculosis of, 336.

Lassar Dr. — Order of the Legion of Honor conferred
804.

Lavage, internal, 280.

Leeches, effect of in uterine cavity, 835.

Leg Ulcer, 527.

Lehigh Valley Med. Assoc. 805.
Leidy, Joseph, obituary, 544.
Leon, A. M. — Pelvic abscess, 380.
Lepers, progeny of, 724.

Leprosy, 9; in China, 73; in Columbia, 198; in

Norway, 17 ; commission, 447 ; in Russia, 766.
Lewis, W. H., letter, 141.
Life saving methods in still-births, 246.
Ligatures, preparation of, 514.
Linea alba, rupture of, 470.
Lion flesh for food, 345.

Index.

xi

Liver — laparotomy for disease of, 430 ; pills, 509 ;

resection of, 198.
Liver, surgery of, 514.
Loefier, F., M. D., Clinical Lecture, 769.
Logan, Jos. P., death of, 843.
Longstreth, M. — Clinical Lecture, 1.
Lopez, J. H.— Lecture, 226.
Lumbar Nephrotomy, 662.
Lunatic, dangerous, 260.

Lung— death from injection in, 56 ; excision of the
parts of, 796.

Lungs — Terpene iodide in diseases of, 336.

Lupus, 258 ; and Koch fluid, 279 ; excision of, with
immediate skin transplantation, 358 ; treatment,
753; and epithelioma, diagnosis of, 527.

Lycopodium, 92.

Mania and insomnia, hyoscine in, 636.
Malaria in birds, 28.

Malarial cachexia, 90 ; fever, 35 ; hematuria, 597.
Malaria, sunflower plantations as prophylactic

against, 198 , bacilli of, 562.
Mann, Dr. — Reports of Clinics, 357.
Mansfield, A. D. Hydrogen peroxide in otorrhcEa,

463.

Massage, as cause of pysemia, 278; in eye diseases,
132.

Massey, G. Betton — Electrical treatment of fibroid tu-
mors, 697.

Mattison, J. B. — Bermuda letter, 787 ; cocaine poison-
ing, 635.

Mays, Thos. J. — specific and non-specific of pulmo-
nary consumption, 692.

McAlister, A. — Laparotomy in intestinal obstruction,
410.

McArthur, L. L. — cancer of the rectum, 532.

McMurtry, L. S.— Letter, 477.

Measles, 64, 207.

Measles epidemic, 838.

Meat-juice and glycerin, 363.

Meat preservation, 103.

Meat putrefaction of, 462.

Medical and Surgical Reporter, 507.

Medical and Surgical College of New Jersey, 53.

Medical Education, State Board of, 141.

Medical Examiners, 215, 374.

Medical Examiners for Pennsylvania, proposed Act

for, 51, 226, 231, 257; unordained, 144.
Medical legislation in Arkansas, 260; of Alabama,

373; in Missouri, 480.
Medical schools in New York, 448.
Medical Society, Golden Belt, 374.
Medical Society of New York, 86, 215.
Medical Society of the State of Pennsylvania, 290.
Medical diplomas, foreign, in Illinois, 402.
Medical Jurisprudence, 273.
Medical News, 766.
Medication, antiseptic, 241.
Medicine, practiced without registering, 205.
Medicine, study of in Thibet 392.
Medicines to nursing mothers, influence of the milk

upon the infant, 684.
Melano-sarcoma, excision of sternum for, 479.
Menorrhagia, tampon in, 368.
Menstruation, 219.
Mental disorders, 739.
Menthol for vomiting in pregnancy, 364.
Methyl-blue as an ansesthetic, 793.
Methyl-violet, in cases of costal cartilages, 733 ; in

cancer of the breast, 641.
Metric system, 66, 843.
Metrorrhagia, 350.

Microcidin, a new antiseptic, 600, 715.
Microscopic lenses, important improvement in, 646.
Micro-organisms in cities, 117.
Micturition, 113.
Migraine, powder for, 458.

Milk— condensed for emulsions, 28 ; impure in large
cities, 371; lanolin, 27; tuberculous, 105 ; fsetid
from mammery glands, 763.

Minot, Dr. Francis, 843.

Mississippi Valley Medical Association, 346.

Missouri — Medical legislation in, 480; medical
practice in, 252 ; regulation of prostitution in, 362.

Modern discoveries of new cures, 726.

Monesia bark, 251.

Montgomery, E. E. — Clinical Lecture, 4, 431.
Moore, R. L.— Letter, 285.
Moore, T. H. — Cystoma of jaw, 214.
Morphine, antidote for, 217.

Morphine habit treated by gradual withdrawal, 446.

Motor insufficiency of stomach, diagnosis, 757.

Morris, J. E. — Influenza, 127.

Moyer, H. N. — Railway surgery, 327.

Musgrove, C. W. — Diptheria, 96.

Musser, J. H.— Clinical Lecture, 89 ; letter, 174.

Mutual Aid Association, 203.

Myers, A. F. — Measles, 207.

Napthaline in Typhoid fever, 509.
Naplhols, and salol, 346.
Narcotic inebriety, preventton of, 290.
Nasal polypi, crystals in, 580.
National Association of Railway Surgery, 345.
Neall, C. H. M. — Neuralgia from tooth-pressure, 304.
Needle, simple method for removing, 566.
Neilson, W. H. — Tuberculin in Locomotor Ataxia,
673.

Nephritis — following whooping-cough, 29; chronic,
343; mistaken for chlorosis, 30 ; acute parenchy-
matous, 530 ; gastric function in chronic, 448.

Nerve-centres, surgical intervention in, 500.

Nerve disorders, paroxysmal, 222.

Nerve-storms, cardiac, 513.

Nerve-grafting, 835.

Neuralgia — from tooth-pressure, 304; secondary to
la grippe, 610 ; relation of atmospheric conditions
to, 644.

Neurasthemia, sexual, metallic bougies in, 554.
Neurasthemic stigmata, 638.

Neurosis — removal of uterine appendages in, 249 ;

traumatic, 328.
Neuritis, 12 ; optic, of malarial origin, 383.
New Jersey, Medical and Surgical College of, 53;

public health in, 145.
Newspapers and patent medicines, 745.
New Philadelphia, 458.

New York — Academy of Medicine, 10; Letter 10,
192; Med. Soc. 86, 215; vital statistics in 1890,
372; medical schools in, 448.

New Orleans, parasitic chylocele in, 317.

Night sweats, agaricine in, 637.

Night-sweats of phthisis, treatment of, 830.

Nipple, Paget's disease of, 74.

Nipples, fissured, 308 ; cracked gold-beaters skin for,

733 ; fissured, treatment of, 555.
Nitrates and nitrites, estimation 'of in water, 804.
Noble, C. P. — After treatment of cases of abdominal

sections, 773; minor uterine surgery, 156; peroxide

of hydrogen for cleaning hands, 237.
Noble Chas. P.— Letter 827-
Norway, leprosy in, 17.
Nothing new under the sun, 146.
Nurses trained, 315 ; menstruating, 467.

xii

Index.

Nu Sigma Nu Fraternity, 346.
N. Y. Post Graduate School 805.

Obituary — Dr. Joseph Leidy, 544.
Obstruction, intestinal, 410.

Occlusion of the os uteri during four days parituri-
tion, 503 ; Bedema, hysterical blue,599.

Ointment, Mayer's, 27.

Oophorectomy, 807.

Optic Nerve, resection of, 152, 653.

Opthalmia, prevention in the newborn, 684.

Opthalmology, uses of Nitrate of silver and sulphate
of copper in, 546.

Osborne, J. D. — Letter, 113.

Otitis, early treatment of, 359.

Otorrhcea, 463 ; boric acid in, 364.

Ouabaine as a local anaesthetic, 549.

Ovarian cyst, enormous, 761.

Ovarian pregnancy, 642.

Packard, J. H.— Clinical Lecture, 59.
Pagn, R. C. M.— Clinical Lecture, 739.
Paget's disease of nipple, 74.
Palate, adhesion of soft, to pharynx, 385.
Pan-American Congress, 766.
Papillitis, 12.

Paretic dementia, ninety cases of, 711.
Pasteur and his work, 455.

Paralysis — facial, 236 ; in the new-born, obstetrical,
643.

Paralysis spinal in children, 838.

Parasitic, chylocele, 317.

Park, R.— Report of Clinic, 214.

Parturition, uuconscious, in primipara, 133, 799.

Patella, luxation of, 194.

Patients, venereal, and druggists, 364.

Patton, Joseph M.— Clinical Lecture, 610.

Pelvic-abscess, 380 ; surgery, electricity in, 477 ; 592.

Pelvic and abdominal operations, sequalse 814.

Pelvis, malignant disease of, 319.

Palsies, infantile cerebral, 838.

Pennsylvania, endorsing diplomas in, 256.

Pennyroyal, a poison, 70.

Pepper, W.— Clinical Lecture, 291, 767.

Peppermint, oil of, in la grippe, 549.

Pepsins, liquid, 44.

Peptonuria in infantile disease, 725.

Perineum-operation for larcerated, 456; immediate

surgical intervention in larcerations of, 799.
Peritonitis, 67, 211.

Pernicious anaemia of parasitic origin, 513.
Peroxide of hydrogen, 45 ; for cleaning hands, 237.
Pessaries, use of, 567.

Pneumonia, treatment with large doses of digitalis,
829.

Pharmacists, woman, 65.

Pharmaecopsea, Italian, 843.

Pharynx, adhesion of soft palate to, 385.

Phenocol, hydrochloric, 679.

Phenyl, hydrozin test for sugar, 565.

Philadelphia Hospital, use of obstetrical department

for teaching, 146.
Philadelphia Obstetrical Society, 159.
Philadelphia Polyclinic, 144.
Phonograph in medicine, 525.

Phthisis, 83; testicle therapy for, 204; climatic
treatment of, 182; surgical and climatic treat-
ment, 715; chronic, 739; serum infections in, 594;
hypordermic iujections of iodoform in, 597 ; treat-
ment with artificial atrospherus underpressure, 156.

Picrotoxine, antidote for morphine, 217.

Pin ei^ht years in body, 369.

Piperazidine as a solvent for uric acid, 831.

Piperazin, 676 ; apparent growth after labor, 604.

Placenta-prsevia, diagnosis of by palpation, 520; re-
tained in miscarriages, treatment, 721 ; adherent,
487 ; with effusion, 613.

Plaster of Paris bandages, 681.

Pleurisy, 2.

Pleuritic effusion, 613, 768 ; in children, 176.

Pleuritis, sub acute, treatment, 740.

Pneumonia, croupous, infectiousness of, 318 ; puer-
peral, 302 ; white blood corpuscles in, 16 ; treatment
of by large doses of digitalis, 708 ; treatment, 793.

Poison glands of toads and salamanders, 222.

Poison, fish, 252; pennyroyal, 70.

Politics and pension examiners, 229, 285.

Polyclinic, Philada., 560.

Polyuria of frequency, 604.

Porro operation, puerperal hysterectomy, 603

Poultices for spreading ulcers, bad effect of, 484; an-
tiseptic, 527.

Powder blower, 113.

Powder for migraine 458.

Pregnancy, abortion for vomiting of, 117; diagnosis
of previous, 373; duration, 763; extra-uterine,
361 ; menthol for vomiting in, 364 ; bolynia of
604 ; vomiting of, 190.

Premature labor, induction of, in contracted pelvis,
503.

Prescription, who owns it ? 426, 805.
Primipara, parturition in, 133.

Prostitution in Missouri, regulation of, 3?>2, 469, 522,

Prostrate, hypertrophied, 193; new method of treat-
ment of, 424; resection of, 129.

Pruritus, relief of, 145.

Psoas abscess, 61.

Pseudo-chorea, case, 714.

Puerperal — convulsions, 368 ; pneumonia, 301.

Puerperal eclampsia, injections of ether in, 603.

Puerperal fever, curetting of the uretus in, 633.

Puerperal septicaemia, eliminative treatment, 682.

Pulmonary consumption, the specific and non-specific
treatment of, 692.

Pyaemia — massage as a cause of, 278 ; primary, 400.

Pyoktanin, 76 ; stains, 290.

Quackery, suppression of in Italy, 686.
Quill drainage tubes, 234.

Quinines, hemoglobinuria from use of, 318 ; in whoop-
ing cough, 800.

Rabies experiments, 85.
Radlaurs antisepsine, 753.
Randall, B. A.— Clinical Lecture, 347.
Raori resin, 118.

Rectal and pelvic disease in women, association of,
666.

Rectum — cancer of, 530; wound of, 141.
Refraction, 216.

Reflex pain an evidence of internal haemorrhage, 552.

Railway spine, the back in, 699.

Reineking, H. — Appendicitis, 352.

Relapsing fever, 37.

Reports of Clinics, 99, 214, 357.

Resorcin — 124 ; in diphtheria, 233.

Retinol, 591.

Reynaud's disease, 192.

Rheumatic hyperpyrexia, treatment, 709.

Rheumatic neuritis, 769.

Rhematism, chronic, treatment of, 509.

Rheumatoid arthritis, 99.

Ribs, fractured, in the insane, 402.

Index. xiii

Richmond, medical attendance for poor in, 373.

Rigg, Dr. — Typhoid Fever, 655.

Riley, H. A. — Medical jurisprudence, 273.

Ring, F. W.— Optic neuritis of malarial origin, 393.

Roberts John B. — Exostosis of humerus 822.

Robert's fermentation test for sugar 841.

Rupture of linea alba, 470.

Saccharine, action of on heart, 831.

Salicylic acid to prevent scarlet fever, 604.

Salicylate of mercury as an antiseptic, 711.

Saloi, 434; and naphthol, 346; on kidneys, 147;
as a deodorizer of fceted discharges, 681.

Sanitary Convention of Pennsylvania, 205.

Saphena vein, litigation of in varicose veins,387.

Sarcoma in brain, 216; retro-peritoneal, 651; of the
shoulder, 687.

Sargent, G. P.— Coryza, 189.

Scarlatina, vesicular eruption in, 244.

Scarlet fever, prevention of, 764; salcylic acid a pre-
ventative, 604.

Scarlet fever tongue, 801.

Scrofulous ulceration of cervical glands, 527.

Serum injections in tubercular phthisis, 594.

Sexes, numerical relation of, 363.

Sexual perversion as phase of evolution, 436.

Shimonek, F. — When is total hysterectomy indicated?
65.

Shipps, W. H. — Traumatic neurosis, 328.

Shoulder, treatment of injuries of, 514.

Shurley and Gibbes, solution for tuberculosis, 342.

Sims, H. Marion — Clinical Lecture, 567.

Skin, grafting, 527; from dead body, 43.

Skin transplantation following excision of lupus, 358.

Slifer, H. F. — Antiseptic medication, 241.

Small, E. H. — Tetany, 584.

Small-pox, cocaine in, 550.

Small-pox, sublimate spray for, 287.

Smith, A. N. — Common colds. 440.

Smoking, suppression of juvenile, 840.

Soaps, medicinal, 387.

Society Reports.
Allegheny County Medical Society, 657 ; American
Medical Association, 625 ; Mississippi Valley Med.
Asso., 38 ; New York Academy of Medicine. 660;
Penn. State Medical, 736; Phila. City Medical,
779; Phila. Obstetrical Society, 159; Southern
Surg. Gynsecolog. Asso., 38; Philada. County Med.,
819.

Sozoiodol, 706.

Spear, R. C. — Correspondence, 705.
Spectacle-frames, construction of, 377.
Spohn, A. E. — Treatment of carbuncle, 151.
Sponges, preparation of, 825.
Starvation and disease, 344.

State Board of Health, 232 ; Medical Education

Medical Examiners, 374.
Status epilepticus, 713.

Stem pessary, 703. •
Sternum for melano-sarcoma, excision of, 479.
Stenosis of cervical canal, incision vs. dilatation, 717.
Still-births, life-saving methods in, 246.
Stimulant in impending collapse, 174.
Stockton, Chas. G.— Clinical Lecture, 530, 727.
Stomach — cancer of, 11; motor insufficiency, diag-
nosis, 757.

Stomach-tube, appliance to facilitate the insertion of,
401.

Stomatitis, gangrenous, 284.

Stools, green, 32.

Sterility, 441 ; is it a disease ? 399.

Stricture of ileo-caecal valve, treatment of, 397.

Strophanthine, as a local anaesthetic, 549.

Strychnia— and hot douche in prostrated labor, 720 ; as
a circulatory stimulant, 509, 637 ; in chronic alco-
holism, 793 ; hypodermic use of, 57.

Strychnine as a heart stimulant in pneumonia, 811.

Subclavian artery compression of, 821.

Sublimate spray for small-pox vesicles, 287.

Sugar— alpha-naphtol test for, 565 ; phenyl-hydrazin
test for, 565.

Sugar quantitive estimates of with Robert's fermenta-
tion test 841.
Sulphaldehyde, action of, 177.

Sulphonal — in trismus neonatorum, 644 ; dangers of.
594.

Sulphuric acid, 433.

Sunflower plantations as prophylactic against
malaria, 198.

Suppuration of antrum of Highmore, 332.

Surgeons of National Guard, notice to, 346.

Surgery, drainage in, 414; pelvic, 340, 156,159;
railway, 327.

Sutton, R. Stanburry— letter, 751.

Syphilis — from bite, 386; transmission of, 724; ways
in which it may be spread 482 ; treatment of, 601,
689 ; baccili of, 564; infection, the expectant treat-
ment in, 498 ; with lesion of heart and kidneys, 727.

Syphiiized practitioners, practice by, 261.

Syringe, aseptic hypodermic, 284.

Sweating feet, treatment, 550.

Sweating of reflex origin, local, 458.

Sympathetic ophthalmia, pathology and treatment
of, 593.

Tabes, symptom-complex of, 551.

Tachycardia— 513 ; at menapause 798; belladonna

in, 331 ; cured with electricity, 427.
Tait, statement by, corrected 230.
Take dorsalis, vesica, disturbances in, 551.
Talane University 843.
Tape worm, 738.
Tampon in menorrhagia, 369.
Tannic acid as intestinal antiseptic remedy, 57.
Tape worm, cocoanut, for, 177-
Tatoo marks, method of removing, 835.
Taylor, R. W.— Treatment of syphilis, 689.
Taylor D. J. M., 843.
Teeth — in diabetes, 398; in epilepsy, 136.
Tenotomy, open and subcutanious, 429.
Terpene iodide in diseases of lungs, 336.
Tetanus — and diphtheria, 13; immunity from, 76.
Tetany, 584 ; etiology of 562.
Tetrahvdronaphthylamines, 106.
Thallin, 832.
Thialdine, action of, 167-
Thibet, study of medicine in, 392.
Thomas, C. H. — Spectacle frames, 377.
Thomas, J. J.— Letter, 284.
Thomas, J. J., strychnine as a stimulant, 811.
Thompson, L. R.— Club-foot, 270.
Thyroid, resection of, for exophthalmic goitre, 204.
Tilliacin, 86.

Tinnitus aurium, aetiology of, 832.
Titles, extra, 447.
Tobacco-smoking, 116.

Tobacco, influence on digestion and .acidity of urine,
833.

Toe-nail, simple treatment of ingrown, 397.
Tongue in scarlet fever, 801.
Tonsils of children, 169.
Toxine, cholera, isolation of, 765.
Tracheotomy vs. intubation, 785.

XIV

Index.

Trachoma, treatment of, 681.

Transplantation of tissue from lower animals to man,
.514.

Traumatism of chest, 597.
Traumatic neuroses, 757; infection, 527.
Tracheotomy, chloroform in, 307.
Trephining for epilepsy, 58.
Trichinae, vitality of, 606.

Trichloracetic acid as test for albumin in urine, 471.
Trippe, R. J.— Peritionitis, 67.
Trismus neonatorum treated with sulphonal, 644.
Tritopine, 344.

Tubal pregnancy, anatomy of, 837-

Tubercle bacilli, at point of infection, 646; method

of detecting, 315 ; staining, 175.
Tubercular poison, mode of entry into body, 522 ;
. bronchitis, iodoform in, 754; anthritis, excision,

688.

Tuberculine, effects in monkeys, 598.

Tubercule cultures, extracts from, 419.

Tuberculosis, 22,49,68, 81,175, 181, 258;— solu-
tion of Shurley and Gibbes for, 342; of larynx,
336 ; abscesses treatment of, with hot water flush-
ing, 277 ; treated with injections of iodoform and
guiacol, 485 : in children, diagnosis of, 559.

Tuberculous milk and diseased udders, 105.

Tumors, cerebral, 167.

Typhoid fever, 3, 61, 126, 263, 655, 740; rash, 105;

and consumption, antifebrinization " in, 117;

chloroform in, 636 ; new methods of treatment,

547 ; naphtholine in, 509.
Typhus fever, influence of warm enemata, 546.

Udders, diseased, 105.

Ulcer — Gastric, 271 ; haematemesis in gastric, 416 ;
bad effect of poultices for spreading, 484 ; poul-
tices for spreading, 484.

Umbilical Hernia in children, treatment, 735.

University of Texas Med. Dept. 804,

University of Pennsylvania 805.

University of Buda-Pesth 805.

Uremia in persons apparently healthy, 45.

Uremic poisoning, 99.

Ureters, wounds of laparotomies, 642.

Urethra, congenital occlusion of, 312; stricture,
treatment of, 553.

Urethra, remarks on 500 cases of stricture, 834.

Uric acid, piperazidine as a solvent for, 831.

Urine — albumin in, 471 ; bile pigment in, 168; bil-
iary matter in, 197; test for albumin in, 364, 685 ;
ineontinuance of females, massage in 762.

Urology in infantile disease, 725.

Uterine — appendages, removal of, in functional neu-
rosis, 249 ; haemorrhage, hydrestis canadensis in,
683; tumors with electricity, treatment of, 464.

Uterine cavity, effect of leeches in, 835.

Uterus — cancer of, 4 ; fibroids of, 432 ; galvanism in
treatment of diseases of,403 ; incarcerated retroflexed
pregnant, 535 ; retroversion of, 567 ; rupture of,
176.

Uterus curetting of 827. '

Uterus, total extirpation of, 836.

Uterus, parturient antipyrin in tonic spasm of, 837.

Vaccination, in France, 419 ; of children, 388.
Vaginitis, 119.
Vancilla, 608.
Varicose veins, 387.

Varicose leg ulcers, treatment of, 555, 707.
Vaseline, shaving with, 262.
Veasey, C. A. — Ulcerative endocarditis, 154.
Venesection, 305.

Venous hum in neck, diagnostic significance, 758.

Veratrum viride, 297.

Vermont, Medical Colleges of, 237.

Vertebrae, caries of, 97.

Vehicular eruption in scarlatina, 244.

Vesical tumors diagnosis 809.

Viable child at six months and a half, 665.

Virchow testimonial fund, 843.

Virgin, mammary abscess in, 220.

Ward, A. C— Veratrum viride, 297.

Ward, S. M. — Letter, 226 ; hemoptysis following
typhoid fever, 126.

Warren triennial prize, 290.

Washing, in cold weather, 388.

Washington, W. S.— Peritonitis, 211.

Water, supply, 316 ; testing, 55.

Water, estimation of nitrates and nitrites in, 804.

Watson, B. A. — Concussion of brain, etc., 614.

Weber, M. J.— Gastric ulcer, 271.

Welker, A. T.— Letter, 202.

What experience teaches one to unlearn, 519.

White, J. William.— Clinical Lecture, 687.

White swelling, treatment, 760.

Whooping-cough, 29, 32; new remedies for, 275;
quinine in, 810; treatment of, 52; with tube in
trachea, diagnosis of, 486.

Whooping cough, bromoform in, 839.

Wilson, J. C. — Caries of the costal cartilages treated
with methyl-violet, 733; anomalous cases of
measles, 64.

Woman's Hospital of Philadelphia, 110.

Womb, double opening into, 202; complete pro-
lapse of, 487.

Women — law of periodical function in, 398; phar-
macists, 65 ; physicians in India, 118; castration,,
sexual life after, 557.

Wood, crystal coating for, 295.

Wry neck, operation for, 535.

Yale Medical School, valedictory, 766.

Young, J. K. — Diseases of eye, associated with caries

of the vertebrae, 97.
Young, S. E. — Correspondence,, 546.

Zinc paste as a dressing, 602.

Medical and
Reporter

A Weekly Journal.

Established in 1853 by S. W. Butler, M.D

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itered as Second-Class matter at Philadelphia P. O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

'ol. LXIV, No. i.
rhole No. 1766.

JANUARY 3, 1891.

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COnSTTElTTS:

CLINICAL LECTURES.

Longstreth, Morris, M. D., Philadelphia, Pa.—
Acute Bright's Disease— Traumatic Pleurisy.—
Typhoid Fever.— Dangers of Moving Typhoid
Patients 1

Montgomery, E. E., M. D., Philadelphia, Pa.—
Cancer of the Uterus 4

COMMUNICATIONS.

Cobb, W. H. H., M. Dm Goldsboro, N. C— Supra-
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Bertrand. J. H., M. D., De Forest, Wisconsin. —
Report of a Case of Leprosy 9

NEW YORK CORRESPONDENCE.

New York Letter.— New York Academy of Medi-
cine.— Bullet Wound of Brain.— Recovery.— Py-
lorectomy with Gastro-Enterostomy, for Cancer
of the Stomach.— Papillitis.— Orbital Optic Neu-
ritis ..... 10

PERISCOPE.

Immunity to.Tetanusand Diphtheria.— The White
Blood Corpuscles in Croupous Pneumonia.—
Leprosy in Norway.— Risks of Cocaine Injec-

tions.—Exfoliation of the Bladder in the Fe-
male.—Protopine— A New Opium Alkaloid 13-18

EDITORIALS.

Education and the Diseases op School-Chil-
dren 19

Surgeon-General Sutherland 20

Appointment op a Lecturer on Therapeutics
at the Jefferson Medical College 20

BOOK REVIEWS.

Parvin ; The Science and Art of Obstetrics.—
Medicinal-Kalender fur den Preussischen Statt
auf das Jahr, 1891 21-22

LITERARY NOTES 22

SPECIAL ARTICLE.

Koch's Remedy for Tuberculosis 22

NOTES AND COMMENTS.

Forty-five Days' Fast.— Extirpation of the Blad-
der.— Infant Feeding. — Mayer's Ointment.—
Lanolin Milk.— Condensed Milk for Emulsions.
—Malaria in Birds 25-28

NEWS 28

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MEDICAL AND SURGICAL
REPORTER

No. 1766.

PHILADELPHIA, JANUARY 3, 1891. Vol. LXIV.— No. i.

Clinical Lectures,

ACUTE BRIGHT'S DISEASE.— TRAU-
MATIC PLEURISY.— TYPHOID
FEVER.— DANGER OF MOV-
ING TYPHOID PATIENTS.

BY MORRIS LONGSTRETH, M. D.,

PHYSICIAN TO PENNA. HOSPITAL.

Acute Bright' s Disease.

Gentlemen : The small patient before us,
a colored boy, apparently about 10 years
old, was brought in by the patrol a few days
ago. He had been picked up in the streets in
an unconscious condition. It is said that
for several hours previous to this he had lain
unconscious, and had had several convul-
sions. On examination on admittance, he
was still unconscious. His respirations were
irregular and shallow, averaging about eight
to the minute; his pulse was 130. The
heart's impulse was forcible, as felt over the
prsecordia. His pupils were moderately di-
lated, the eyes being turned to the right, but
there was no strabismus. He rapidly be-
came conscious, and after two hours was able
to talk. All that he complained of was pain
in the abdomen ; he had been at work on
the morning of his attack, running errands.
On examination of his urine, it not merely
showed the presence of albumin, but also it
was found on heating it that it became almost
solid ; only a little liquid remaining en-
tangled in thecoagulum. Delirium followed
during the next day and night. The tem-
perature on admission was 970; on that
night it rose to ioo° ; but since it has fallen
gradually to normal except on the third day
following another convulsion. On listening
to his heart beat, a soft systolic murmur was
heard, caused undoubtedly by the rapid action
of the heart. There was no evidence of disease
elsewhere. At first the boy was given tinc-

ture of digitalis, ten drops every four hours,
and with this benzoic acid every third hour.
As soon as he was able to swallow, he was
given a compound jalap povvder, a drachm
in divided doses, which was followed on
the following day by free movement of the
bowels. There was still pain in the abdomen,
the nature of which it was impossible to de-
termine on account of the condition and
age of the patient ; but it was not increased
by the medicine. On the second day after
j admission, only two ounces of urine was
! passed. The next night another convulsion
j appeared. The boy was unconscious also
! again on the next day ; this was followed by
! delirium. In the afternoon and evening
j only four ounces of urine were passed.
That night he was given a hot-air bath and
a sixth of a grain of the muriate of pilocar-
pin hypodermically. This was not followed
by any great amount of perspiration,
I although a slight amount of moisture was
j detected on the skin. Apparently these
j measures produced no relief of the symptoms ;
j but on the following day the boy felt more
I comfortable, and passed more urine —
! 1 2 ounces in the day. His urine is still heavy
with albumin; it contains epithelial and
i granular casts ; but it has greatly improved
I in character. He is now sleeping well, and
taking nourishment ; his tongue is clearing,
he has still some pain in the abdomen, but
j no delirium or convulsions. From noon
yesterday until this morning he has passed
I 21 ounces of urine; it contains some debris
and thick purulent-like material, consisting
nearly entirely of epithelial cells and casts.

There are several ways for testing for al-
bumin in cases where it is due to inflamma-
tory cause. The acid can be put below in
the test tube, with the urine on top ; or the
urine can be placed in the test tube and
the acid rolled below or placed below with a
pipette. By this last means of procedure
a wider band of albumin can be obtained
from the same case than where the urine is

2

Clinical

Lectures.

Vol. lxiv

simply poured on top. Another excellent
method for the same purpose is to fill the
test tube half full of urine and boil the
upper half by tipping the tube over an al-
cohol flame. In this way you will undoubt-
edly break many test tubes, especially if the
flame is in a draught ; but it forms a very
delicate mode of comparison, the urine in
the lower part of the tube remaining un-
changed. This method I believe to be the
best for detecting small amounts of albumin
caused by inflammatory changes. Many
other methods, of course, may detect albu-
min when present in far smaller amounts
than does this boiling test ; but for daily
practical work I wish to enforce the state-
ment I have made.

As to the origin of this boy's illness we
are unable to speak positively. We have an
indefinite history of a wetting some time ago ;
but its date and extent are not known. He
represents excellently well an attack of acute
Bright's in a child. He is restless yet and
requires constant watching. The doses of
benzoic acid and digitalis will be gradually
reduced as the kidneys increase their action;
if thorough relief does not appear later in
his attack we will resort to hot-air baths
.again.

Traumatic Pleurisy.

Our next patient is also a colored boy,
14 years old. He was admitted on Novem-
ber 6, with the following history. Eight
days before, while playing with some other
boys, they placed a rope around his chest,
and, throwing its end over a beam, dragged
him up in the air a number of times. This
produced no pain until four days later,
when he experienced a sharp, severe, stab-
bing pain in the right side, well up under
the axilla. On attempting full inspiration,
this pain was greatly increased ; and since
its commencement it has been growing
rapidly worse. His temperature, on ad-
mission was 1 04!°, and he lay in bed on his
right side, which position gave him some
relief. The expression of his face showed
that he was suffering intense pain. His
respirations, which were short and shallow,
ran 36 to the minute ; his pulse was over
100. His high temperature was due to
moving him into the hospital, and the pain
thereby produced ; it was too high, even
for severe pleurisy in a boy of his age. At
the point exactly where the rope had been
placed around his chest, there was a marked
friction sound. Nothing could be felt.

The lower part of his chest gave a good
respiratory note. On coughing, many rales
could be heard in the lung. At first he had
considerable expectoration ; .the sputa were
rusty in color ; but there was no blood in
clots.

It is a common thing for traumatism to*
produce pneumonia as well as pleurisy, even
when no injury has been done to the rib.
The pneumonia is more common than
pleurisy alone. The rusty sputa is generally
the first sign obtained. In this case the
effusion in the chest disguised, to a degree,
the signs of the pneumonia ; and in the
conjoined diseases the one starting or de-
veloping first always predominates ; the
pleural effusion cannot become excessive
simultaneously with a solidification of the
lung with the pneumonic exudation. This
boy coughs only on exertion now ; the ex-
pectoration of rusty colored sputa has
stopped.

The question now arises as to the course
of treatment. It is evident that we cannot
treat such a case as ordinary pneumonia
or pleurisy, with an underlying constitutional
or diathetic factor. These cases of trauma-
tism must be kept as nearly as possible
in the condition given to a broken bone.
The chest movements must be restrained,
just the same as in a fractured rib. In
this case there has not seemed to be an
urgent necessity for such strict treatment.
We have given the boy anodynes — the
acetate of morphia, of a grain every
three hours — together with eight grains of
the acetate of potash, to help absorb the
fluid and favor its excretion.

I will present another case of pleurisy
of similar origin, which shows a not infre-
quent result, following similar chest injuries.
This man, 58 years old, was admitted on
November 3. He experienced, in the
Spring, a fracture of several ribs. This had
not inconvenienced him since, until Octo-
ber, when he was exposed to excessive wet
weather, remaining for long periods in wet
clothes. There appeared then, a cough,
shortness of breath, and a sharp pain
through the seat of the former fracture.
This is a very common history — the selec-
tion of the seat previously injured for the
recurrence of a pleurisy. An examination
of his chest reveals a few crackling rales at
the base of the right lung ; his heart and
the other lung are normal. There is
diminished resonance on the affected side
below the nipple, and behind the axillary

Jan. 3, 1 89 1.

Clinical

Lectures.

3

line dulness is very marked. This dulness
is not changed in area or position by
change of posture ; this is very likely to
occur in these recurrent pleurisies, because
the pleural sac is, in parts at least, adherent,
% and the new effusion is probably sacculated
and limited in its amount and extent.
There is no rusty sputa as we are likely
to have in a fresh traumatic case. It is a
free frank pleurisy, with some bronchial
trouble. The temperature was higher than
we would expect ; this was due to the agita-
tion experienced by transmission to the
hospital and subsequent physical examina-
tion. In such a case, always wait to see if the
temperature will drop down without the ad-
ministration of any marked remedies ; it fre-
quently or generally does so. The treat-
ment for this man is the same as in the
other case ; the acetate of potash being
given in fifteen-grain doses and the acetate
of morphia in one-third grain doses. In
addition poultices, consisting chiefly of
mustard, were applied to the chest. These
were intended to relieve the pain. The
little effusion which existed is going off.
Adhesion is occurring at the lower part of
the lung. A layer of lymph has been
thrown out and is becoming adherent.

Another point, practical in its bearing, oc-
curs to me here. Generally, when you see
these cases, the bowels have not been acting
for several days, and the question arises,
Should you give a purgative ? It is always
my practice to try to avoid its administra-
tion, if possible. It is a painful strain to
the patient little able to handle himself
properly ; so that, if possible, the purgation
should be put off. The quiet and rest are
more essential. Later not only are enemata
of service, but the remedies which drain
the intestinal mucous membrane are indi-
cated.

Typhoid Fever.

The next man, 22 years old, was admitted
November 1, with the diagnosis of typhoid
fever. He is a printer, and was never ill
before. A week prior to his admission,
dizziness occurred, with headache, loss of
appetite, malaise and aching in the joints
and bones ; and his bowels were very con-
stipated. Two days before his admission he
had an attack of nose-bleed. On examina-
tion some harsh breathing was noted under
the right clavicle ; there were no bronchial
rales; the pulse was acting rapidly; and
there was a slight systolic murmur at the

apex. This murmur has since disappeared.
His liver was normal in its area, but the
spleen was slightly enlarged. His temper-
ature was 990 on admission ; and, on ex-
amination of his skin, four or five suspicious
spots were seen over his abdomen. After
pressure, these spots appeared with re-
kindled redness. The fresher ones came
back promptly, the older ones more slowly.
At present his abdomen is not distended,
and there is a little gurgling in the right
iliac fossa. Don't seek for this latter symp-
tom. It is much better to do without it.
You may easily punch through the thinned
and ulcerated intestinal walls in searching
for it; but if on touching the surface gently
you get the symptom, so much the better.
It shows the presence of air passing through
fluid. Active manipulation of the abdomen
at this point is not only dangerous to the
patient, but, in liquefying solid matter and
producing artificially gurgling, may be de-
ceptive for diagnostic purposes. The tongue
is swollen and coated ; it shows a wedge-
shaped clearing area. The pulse is not high ;
the respiration is even ; and there is a ten-
dency of the temperature to return to nor-
mal ; in fact fourteen days from the day of
first complaint it has become in the morn-
ing sub-normal. The spots which you see
here, which have lasted for many days, are
seen unusually late. •

The treatment of this patient has been of
the simplest character. Enemata, to pre-
vent impaction — for his bowels have sel-
dom moved — have been administered. He
is taking dilute muriatic acid and quinine.
He is being given a liquid diet, and the
surface of his skin is regularly sponged.

In cases of typhoid fever, this has been
the experience of the Pennsylvania Hos-
pital : Brought into the hospital before the
end of the first week, unless the cases are
virulent, they are likely to terminate favor-
ably. In the same grade of cases brought
into the hospital in the second week of their
disease, the mortality is increased threefold.
When brought in in the third week, the mor-
tality is terrific ; it is a miracle if the patient
does not die. The experience of London
hospitals has been the same, especially at
the London Fever Hospital. The practical
lesson of this is to move your patients early.
If mistaken in your diagnosis, no harm has
been done ; your patient can walk out of
the hospital in a few days, if he does not
show the existence of typhoid ; but waiting
until you are certain of your diagnosis, you

4

Clinical

Lectures.

Vol. lxiv

are increasing the risks to your patient tre-
mendously if you intend to send him to a
hospital. In a case which you have seen
late in the course of the disease, no matter
how uncomfortable it may be at home, no
matter how poor the bed or room and
wretched the nursing, remember the fatality
consequent upon moving a patient.

CANCER OF THE UTERUS.

BY E. E. MONTGOMERY, M. D.,

PROFESSOR OF GYNECOLOGY, MEDICO-CHIRURGICAL
COLLEGE ; OBSTETRICIAN, PHILADELPHIA
HOSPITAL.

Gentlemen : The first patient I bring be-
fore you is a German woman, fifty-four
years old ; her father, one sister and two
brothers died of phthisis. She came to this
country at the age of fifteen years; was
married and has had eight children. Eight
years ago she had syphilis. For the last two
years she has been suffering with severe pain
in the back, and occasional prolapse of the
rectum. During the last two months her
suffering has become greatly increased ; the
gravest symptom being periodical uterine
hemorrhages, and recently, the discharge of
feces through the vagina, indicating the de-
velopment of a recto-vaginal fistula. The
symptoms — pain, hemorrhage and fecal dis-
charge from the vagina — are her most seri-
ous disorders. Upon examination, I find a
thickening of the walls of the orifice of the
vagina; and, as I proceed, I meet with ulcer-
ation on the posterior surface, from which
an offensive discharge takes place when the
parts are subjected to pressure. This thick-
ening and ulceration extends from the va-
gina to the uterus ; so that it is difficult to
define one from the other ; and an opening
can be determined between the vagina and
the rectum through which the feces pass.
The disease has evidently developed in the
uterus and extended from it to the vagina,
involving more particularly the left lateral
and posterior walls, although the anterior
wall has not entirely escaped. As the dis-
ease primarily involved the uterus, we may
have in addition a recto-uterine fistula.

I regret that it is so difficult to exhibit
the lesions present in a case of this kind ;
but I shall take occasion to exhibit to you
the post-mortem specimens removed from a
woman who died in the institution two days
ago. The woman was thirty-seven years of

age, a German and a cook. She menstruated
regularly, and had had two children. Dur-
ing the latter part of her life she suffered
with severe pelvic pain, vaginal hemorrhage
and profuse discharge. One year ago she
began to experience severe pain at the men-
strual period ; later the menstrual flow was
excessive; and within the last few months
an inter-menstrual hemorrhage occurred,
followed by a profuse offensive discharge.
Her bowels were constipated, her urine was
mixed with blood and for some months
feces had passed through the vagina. At
the autopsy the heart and lungs were found
healthy ; the pelvic viscera were matted to-
gether, and there was extensive involve-
ment of the lymphatic glands in the pelvis ;
the right ureter was distended to the size of
a finger, and, upon being broken, was found
to be filled with pus. The pelvis of the
right kidney was dilated and contained
considerable pus; the left kidney and left
ureter were normal. Upon examination of
•the vagina, it was found that the posterior
surface was completely destroyed, forming
a large opening into the rectum, through
which the contents of the bowel passed ;
infiltration extended laterally quite exten-
sively upon the right side of the vagina,
and had undoubtedly given rise to obstruc-
tion of the right ureter, causing the accu-
mulation of pus within the kidney and ure-
ter, inducing at first a hydro-nephrosis, and
later a pyo-nephrosis of the kidney. The
uterus was found free from disease ; which
indicated that the vagina was the seat of its
origin.

Cancer of the uterus is a very frequent
disease. This organ is the seat of cancer
in one-third of the cases of malignant dis-
ease in women. Primary cancer of the
vagina is exceedingly rare. In the majority
of cases the disease extends from the cervix
to the vagina. When the disease originates
in the vagina, it is usually of the ephithelial
form and is more rapid in its progress; the
walls of the adjoining viscera being thin,
they are soon perforated, and the bladder or
rectum opened. Where it is seen sufficiently
early, the proper method of procedure would
be the removal of the diseased part, even if
it were necessary to open into the adjoining
viscus to accomplish it, and to bring to-
gether the denuded surfaces with sutures.
They are hopeless cases for treatment, as the
disease, with few exceptions, soon recurs.

Cancer originating in the body of the
uterus is also of rare occurrence, it occurs in

Jan. 3, 1891.

Clinical Lectures.

5

about two per cent, of the cases in which
the uterus is the seat of the disease. It is
quite evident why this should be true ; the
cervix is that portion of the uterus which is
most likely to undergo injury during par-
turition, and the efforts on the part of
nature to restore such lesions result in the
formation of tissue of lower vitality, which,
under favorable occasions, undergoes in-
creased cell proliferation. While it is true
that malignant disease may occur in women
who have not borne children, it is rare, and
it occurs with the greatest frequency in
women who have borne a number of
children, and who have undergone lesions
of the cervix as a result. The disease may
occur at any age, from twenty to seventy
years. It takes place, however, with the
greatest frequency at or near the climacteric.
It may begin upon the mucous surface, in
which the cell proliferation leads to the for-
mation of large cauliflower growths, .which
may fill up the vagina. In these the vessels
are much enlarged ; their walls are thin and
without muscular coat, so that they rupture
easily ; and as they have no contractile
power, hemorrhage is a marked symptom of
the disease. In other cases, the walls of
the cervix become rapidly infiltrated, and
are found to be hard and dense, giving rise
to most excruciating pain. This form is
known as that of scirrhus. Cancer of the
uterus seems to progress with greater
rapidity when it occurs in the young. It
takes place in such cases where there has
been a family predisposition to the develop-
ment of tubercular trouble, so that it is
quite possible that the peculiar condition of
health, of the individual, favors the rapid
progress of the disease.

The prominent symptoms of cancer of
the uterus are pain, hemorrhage and offen-
sive discharge. Of these, hemorrhage is
usually the first, and may make its presence
known by increased flow at the menstrual
periods j later the hemorrhage may take
place at irregular intervals, or give rise to a
continuous bloody discharge. Frequently
the patient suffers from a profuse, thin,
watery discharge, which has somewhat the
odor of decomposing flesh. Pain, while
in many cases a marked symptom, is not a
constant one, some patients, indeed, going
through the whole course of the disease
without suffering any distress. Pain, when
felt, is usually in the region of the uterus,
and radiating from it. As a result of the
profuse bleeding, the constant discharge,

and a severe sleep-destroying pain, the in-
dividual soon becomes emaciated, present-
ing a wearied look, often a straw-yellow
color, producing what is known as cachexia.
This condition is due, in a great degree, to
the chronic poisoning of the system of the
patient by the absorption of septic material,
which takes place from the pockets of the
decomposing tissue. That this has a marked
influence in its development, is evident
from the fact that those patients who under-
go operation, by which this tissue is re-
moved, temporarily regain their color and
healthy appearance to such a degree as to
lead their friends to hope that a mistake has
been made as to the character of the disease.

Patients suffering with this disease appeal
to our sympathy. There is no more distress-
ing position to be placed in, than to be
physician to a lovely woman, who is the
victim of a disease that has progressed to
such an extent as to render it ineradicable.
It is very important, therefore, in every case
presenting symptoms of a suspicious charac-
ter, to proceed, at once, to a careful exami-
nation of the patient, and where she is evi-
dently suffering from incipient development
of malignant trouble, to resort to operative
interference. It is now well recognized that
cancer in the uterus, as in the mammary
gland, is, in the beginning, a local disease ;
and if it is attacked before it has extended
to the surrounding structure, we may hope
to afford our patient immunity against its re-
turn. We have not, however, the same op-
portunity of following the disease when the
uterus is its seat, as where it has involved
the mammary gland.

In the latter organ, it is accepted as an
established rule, that removal of the corre-
sponding axillary glands should accompany
the removal of the mammary gland ; but we
cannot carry out such a rule in operations
upon the uterus. The cases in which we
may hope to proceed to a radical operation
where the uterus is the seat of the disease,
are necessarily limited. It is only in those
cases in which the disease is confined to the
uterus, and in which there is no evidence
of the involvement of the vagina or exten-
sion to the broad ligaments, that we may
hope to be successful in extirpating the dis-
ease. Yet even in such cases, we cannot
say when the disease may have extended
from this organ, through the lymphatics, to
the glands of the pelvis ; and when this is
the case, a return of the disease is certain to
take place.

6

Clinical Lectures.

Vol. lxiv

Now, two plans of procedure are advo-
cated for this — high amputation of the cer-
vix, and entire removal of the uterus. I am
aware that in making this statement, I do
not name amputation by the ecraseur, by the
galvanic ecraseur, by the scissors or by the
knife ; such operations hardly deserve the
name of being palliative, as it is very rarely
that they succeed in arresting the progress
of the disease. The tendency of the dis-
ease is to extend continuously upon the tis-
sue first involved, and from it to the con-
tiguous tissue. Any operation, therefore,
which does not remove the diseased tissue
entire does not deserve the name of a rad-
ical operation. It is a well recognized fact
that in operations upon the mammary gland
for malignant disease, every vestige of the
gland should be removed ; it seems equally
important to us that in operations for the
removal of the malignant disease of the
uterus, every vestige of that organ should be
extirpated, and that when this is done the
opportunities for benefit to the patient are
enhanced.

Extirpation of the uterus is not a new
operation, having been done as early as the
beginning of the present century ; but the
results of the operation were so grave as to
lead to its discontinuance. West quotes
twenty-five cases, twenty-three of which
proved fatal. Freund, in 1878, revived the
operation of removal of the uterus, but per-
formed it by the vagino-abdominal method.
Czerny, in 1879, extirpated the uterus
through the vagina, but was so little im-
pressed with the value of the procedure,
that his subsequent operations were done by
Freund' s method ; and he did not recur to
vaginal operation, until several successful op-
erations had been done by others. Freund's
operation was attended by so great a
mortality — 79 per cent. — that it has been
discontinued. The vaginal procedure has
continued to grow in favor, until now, the
statistics of many hundred operations can
be compiled, and nearly a hundred opera-
tions enumerated by a single individual.
With improved methods of procedure the
operation has been expedited, and its mor-
tality greatly decreased. When the opera-
tion was performed with ligation of the
broad ligaments, with suturing the perito-
neum and the vaginal surface, and with com-
plicated methods of drainage the length of
time required made the operation a severe
test to both patient and physician. Now,
when the uterus is encircled by an incision,

the vagina pushed off anteriorly and pos-
teriorly until the peritoneum is reached, the
uterus depressed into the vagina, and the
broad ligaments clamped upon either side,
the operation can be performed with great
expedition and with less influence upon the
system of the patient.

I have had some six cases in which I ex-
tirpated the uterus, and five of the patients
are now living. The operation has been
performed in periods of time varying from
fifteen minutes to one hour and a half. The
longest time was taken in the first operation,
in which, in my efforts to avoid the bladder,
I became lost in the anterior wall of the
uterus, so that much time was required for
the completion of the operation. In the
last patient, the uterus was readily drawn
down and the operation was completed in
fifteen minutes. The broad ligaments may
be secured with forceps, or with clamps,
such as I show you, in which they are firmly
held, and there is no possibility of the tissue
•slipping or of hemorrhage occurring. These
clamps have been objected to, as being un-
necessarily heavy, but when we consider that
there is a certain amount of sloughing of the
tissue, which is compressed in the clamps,
this does not seem to be a reasonable objec-
tion, as by their weight the broad ligament
is brought down and held, so that the peri-
toneum is glued together before the forceps
are removed, permitting the slough to come
off outside the peritoneal cavity. Drainage
is also favored by the weight of this instru -
ment, and it is still further promoted by the
introduction of a tent of iodoform gauze
between the two instruments. The clamps
are removed at the end of twenty-four
hours and the gauze tent at the end of
forty-eight or seventy-two hours. The cav-
ity of the vagina is subsequently irrigated
by a disinfectant solution.

In the hands of men like Leopold the
mortality of this operation has been reduced
to about four or five per cent. ; and for this
reason some of those who originally ob-
jected, now advocate it as the preferable
plan of procedure. As I have already said,
however, it is of limited application. It
should not be performed where the disease
has extended beyond the uterus, as indicated
by infiltration of the broad ligaments. It
is not wise ; it is not right, to subject a
woman to an operation that is attended with
a certain amount of danger and with a great
amount of anxiety, when it is certain not to
1 result in the eradication of the disease. In

Jan. 3, 1891.

Communications.

7

those cases, where extirpation is unjustifiable,
it becomes difficult to say what should be
our method of procedure. Operations
of curetting the uterus, and the subse-
quent application of strong caustics have
been highly extolled. This method as in-
troduced by Sims, has been extensively
practiced by Van de Warker. I must con-
fess, however, that my own experience in
this plan of procedure has been exceedingly
unsatisfactory. It consists in curetting and
cutting away the diseased tissue until hard
and firm tissue is reached, followed by the
application of a solution of persulphate of
iron upon tampons of cotton, so that the
hemorrhage is arrested. At the end of
forty-eight hours the clotted blood is re-
moved and the cavity thoroughly irrigated,
and this is followed by the application of a
caustic. For this purpose chloride of zinc,
bromide, and acid nitrate of mercury are
used. The chloride of zinc is preferred by
most surgeons. It should be used in strong
solution, from six drachms to one ounce of
the salt to one ounce of water. This is
applied by wetting a number of small tam-
pons of absorbent cotton in the solution,
and, after squeezing them dry, applying
them over the surface to be destroyed. The
caustic agent has a greater affinity for the
diseased tissue than for the healthy, conse-
quently a marked slough results from the
uterus. It is very important that the vaginal
surface and the healthy tissue should be
carefully protected from the superfluous
fluid. For this purpose the walls of the
vagina are covered with an ointment con-
sisting of one or two drachms of bicarbon-
ate of soda to an ounce of cosmoline.
After the tampons have been carefully ap-
plied, they are covered with a dry absorbent
cotton, and then with a tampon of cotton
wet with a saturated solution of bicarbonate
of soda. This solution neutralizes the
chloride of zinc with which it comes in con-
tact, and prevents its destructive effects.
But even with all this care, it is sometimes
difficult to avoid superficial burning and
sloughing of the vagina. The operation at
best is but a palliative one, and wjiere the
disease is not thoroughly eradicated its sub-
sequent progress is rapid.

— Echujin, a glucoside allied to ouabain
and strophantin, is the latest addition to the
interminable list of African arrow poisons.
It is derived from an apocynaceous shrub,
adenium boehmianum.

Communications.

SUPRA-PUBIC CYSTOTOMY IN A
CASE OF ENLARGED PROSTATE.1

BY W. H. H. COBB, M. D.,

GOLDSBORO, N. C.

Without entering into a history of the
varieties of prostrate trouble, or the numer-
ous operations for their relief by surgeons in
Europe and in this country — for this has
been ably and fully described in a paper
before this Association in 1888, by Dr. R.
D. Webb — I will simply report a case of
enlargement of the right lobe of the pros-
tate, with cystitis and symptoms of vesical
calculus, entirely relieved by the operation
of supra-pubic cystotomy performed after
the method of my friend, Dr. Hunter Mc-
Guire.

The patient was a farmer, married,
49 years old, of a rheumatic diathesis,
who dates his troubles back to 1881. While
attending to the duties of Register of Deeds,
he carelessly allowed over-distention of his
bladder, and has suffered more or less since
that time. In 1882 he had an attack of
nephritic colic and passed a small calculus,
similar in size and shape to a grain of wheat,
and has had slight symptoms since. On
three different occasions he passed dark
gritty deposits. In 1883 he suffered much
inconvenience and some pain in urinating.
In 1887 he passed a dark, gristly bloody sub-
stance about the size of a corn-pea, accom-
panied by much pain and bloody urine.
For the past three years he has suffered much
with cystitis in a very aggravated form,
with great pain and difficulty in micturition,
his urine containing much blood, pus and
mucus. He had consulted numerous physi-
cians, besides taking various patent medi-
cines, receiving but little temporary relief.
His efforts to relieve the bladder and bowels
were tormenting, and night after night was
spent in walking over his premises, with
groanings so severe as to disturb his neigh-
bors. There was a constant desire to relieve
the bladder, dull pain at the hypogastrium,
and pain in the glans penis, a feeling of
weight in the rectum with sudden stoppage
of urine, which change of position would
often relieve, his uncomfortable and painful

1 Read before the Southern Surgical and Gynecolog-
ical Association, at Atlanta, Ga., November 12, 1890.

8

Communications.

Vol. Ixiv

sensations being increased in severity by
walking, riding or driving.

This was his condition when he consulted
me, June 15, 1890. From this history of
the case I suspected vesical calculus, but
failed upon examination with the sound to
detect any stone ; however, a digital anami-
nation per rectum disclosed the right lobe
of the prostate greatly enlarged, rough,
indurated, and exceedingly tender and sen-
sitive. Notwithstanding the failure with
the sound to detect a stone, I still thought
from the man's symptoms that he might
have a stone at the base of the bladder in
the posterior prostatic pouch. So distress-
ing were his symptoms that I feared longer
delay would result in uretero-pyelo-neph-
rosis ; and so, after consultation by letter
with Dr. Hunter McGuire, and with Dr.
W. H. H. Cobb, Jr., who saw the case with
me, I decided upon a supra-pubic cystot-
omy as the only hope of securing permanent
relief.

On the night of June 22, I gave the man
a saline purgative, followed by a warm-water
enema early next morning. On the morn-
ing of the operation, June 23, I gave five
grains of quinine at 5, 6 and 7 o'clock.
The patient having been placed upon the
operating table, all hairs were shaved off
from the pubes to the umbilicus, the parts
werexthoroughly washed with soap, hot water
and nail brush, then with 1 to 2,000 solution
bichloride of mercury, our hands, instru-
ments and sponges being rendered thor-
oughly aseptic. Drs. J. F. Miller, Thos.
Hill, M. E. Robinson and W. H. Cobb, Jr.,
were my assistants.

The patient was fully sesthetized with
chloroform, and his bladder was washed out
thoroughly through a soft rubber catheter
with a four per cent, solution of boric
acid, until the returning fluid was perfectly
clear and odorless. Having no rectal bag,
a soft rubber pessary with a stem was
inserted up the rectum, after dilatation,
and about ten ounces of warm water were
injected in same. Now six ounces of
four per cent, solution of boric acid were
thrown into bladder through a soft rubber
catheter, and retained by rubber band
around the penis, while the solution dis-
tended the bladder so that it could be
distinctly felt above the pubes. Instru-
ments, consisting of scalpel, tenaculum,
small forceps, retractors, etc., were placed
in a tin tray with carbolic acid and hot
water 1 to 40. I began three inches above

the symphysis pubis, and made an incision
down to the pubic bone, through the skin,
fat and cellular tissue, down to the linea
alba, which was divided with an incision
half an inch shorter from above, the recti
muscles were next separated with the handle
of the scalpel down to the fascia transver-
salis, carefully keeping in the median line,
using retractors to separate the recti mus-
cles. The fascia transversalis was now in-
cised, shortening the incision another half
inch from above. The fat and cellular tis-
sue between the transversalis fascia and the
bladder having been separated with the
handle of scalpel, the bladder was brought
plainly into view. It was caught up with a
tenaculum and drawn forward, and a free
incision in the lower portion was made ad-
mitting the left index finger, which was in-
troduced into the bladder as the scalpel was
withdrawn.

The bladder having been thoroughly
explored, I must confess that I was dis-
appointed in not finding a stone in the
cul-de-sac posterior to the enlarged pros-
tate, as the previous history of recurring
calculi, with severe cystitis, pains in the
glans penis and sudden arrest of flow of
urine, all combined, seemed strongly to
warrant the belief in the presence of stone
in the bladder, notwithstanding the failure
to detect it with the sound. Careful explora-
tion of the bladder failing to reveal a vesical
calculus, tumors or other abnormalities to
remove, the parts were thoroughly cleansed
with antiseptic solution and a No. 15, Amer-
ican scale, soft rubber catheter was intro-
duced into the bladder through the abdom-
inal incision, the distal end of the catheter
being placed in a cup by the side of the
patient. Three stitches were introduced
through the skin only to approximate to
some extent the gaping edges of the in-
cision, and the wound was now dressed
antiseptically, iodoform, bichloride gauze
and absorbent cotton being used. The
presence of the catheter in the abdominal
incision produced so much vesical tenes-
mus that it could not be retained in place
continuously, and during its absence from
the bladder a large sponge was substituted
for the absorbent cotton to catch the con-
stantly dribbling urine, which was removed,
thoroughly cleansed and rendered antiseptic
as often as it became saturated with the
urine. The temperature rose to gg}40 F. on
the evening of the operation, and ioo^° F.
on the following evening, and at no time

Jan. 3, 1 89 1.

Communications.

9

did the pulse exceed 82. Both temperature
and pulse became normal on the third day
after the operation and remained so from
this time on. Hot water enemata were used
daily to keep the lower bowel open and to
aid in relieving pelvic congestion and in re-
ducing the enlarged prostate. For two weeks
the bladder was washed out daily with a four
per cent, solution of boric acid, and after-
wards on alternate days for about two weeks
longer ; and the patient's urine was kept acid.

About two weeks after the operation the
urine ceased to dribble, and when blad-
der felt uncomfortably distended, the urine
was drawn by the patient, who inserted a
soft rubber catheter through the abdominal
opening, thus affording the urethra perfect
rest. Three weeks after the operation I in-
troduced a hard rubber tube, size 15, Amer-
ican scale, 2}4 inches long, and allowed it
to remain in the abdominal opening the
greater part of the time ; the patient with-
drawing the plug about every three hours to
relieve the bladder. At times, in the pa-
tient's movement of his body, the recti
muscles would suddenly contract and expel
the tube ; and so strong were these contrac-
tions, that great pain would be induced in
attempting the re-introduction of the tube.
At no time was the patient able to relieve
his bladder through this artificial urethra
save with the aid of the catheter or tube.
At intervals of every two weeks the pros-
tate was examined and found to be de-
creasing in size, softening in consistence,
and assuming its normal appearance. At
the expiration of two months (August 23)
I found the prostate perfectly normal, with
no symptoms of cystitis, and withdrew the
plug, allowing the fistula to unite, which it
did in about ten days. My patient now
performs the acts of urination and defeca-
tion without the slightest trouble, expresses
himself entirely relieved, and is following
his usual vocation.

REPORT OF A CASE OF LEPROSY.1
BY J. H. BERTRAND, M. D.,

DE FOREST, WISCONSIN.

To the great majority of persons leprosy
possesses only an historical interest, and it is
classed by them in the same category as pes-
tilences and plagues, which formerly devas-
tated countries, but which now are extinct.

1 Read before the Central Wisconsin Medical Soci-
ety, September, 30, 1890.

But, unfortunately, it cannot be so regarded ;
it is a living and actual reality which the
case I have brought before you to-day is a
sad proof of.

Case 1. M. M., single, a native of Nor-
way, came to this country at the age of seven
years and is now forty years old. The fam-
ily history on the father's side is good. His
father is still living and eighty years old.
His mother died of leprosy in this country,
at the age of fifty-six years, after an illness
of seventeen years. An uncle on the moth-
er's side also died of leprosy. During the
first seven years he was in this country he
enjoyed good health ; at the end of that
time, when he was fourteen years old, the
disease first made its appearance. The on-
set was sudden, without any prodromal
symptoms. Simultaneously with the ap-
pearance of pale, bluish-red spots over the
trunk and extremities, chiefly over the ex-
tensor surfaces, came chills, fever, loss of
appetite, and great prostration, with severe
pains in the upper and lower limbs, which
was diagnosticated as rheumatism by his
physician. The maculae were present for
about two years, when they gradually disap-
peared, leaving the skin apparently as it was
before. During that time they underwent
no alteration except to change to a brown-
ish hue. About eighteen months after the
onset of the disease, hyperesthesia made its
first appearance, first at the site of the mac-
ulae, and gradually spread over the extremi-
ties with increasing intensity. This condi-
tion was present for about a year and a half,
when it was slowly replaced by anaesthesia,
which came on in the same order as the hy-
peraesthesia, beginning in the maculae and
gradually extending. Towards the close of
the third year the man's general condition
commenced to improve, the pains in the
joints and limbs diminished, and he became
able to leave his bed ; but it was with diffi-
culty that he could get about, owing to an-
kylosis of the knee and ankle joints in both
limbs. Both wrists and all the small joints
of the hands were also ankylosed. The
knees and ankles regained their normal
functions in about eight months, and he has
been able to be about with comparative ease
ever since. The wrist joints have only par-
tially recovered ; but none of the smaller
joints have improved. His condition then
remained fair for about seven years, so that
he could do light farm work, when he had
another period of sickness, which he de-
scribes as being like the first attack, and

IO

New York Correspondence.

Vol. lxiv

which confined him to bed for another three
years. Since that time, with the exception
of an occasional short interval of a few days,
he has been sufficiently well to be up and
about up to the present.

During the whole course of the disease
there has been no lesion of the mucous
membranes nor any tubercles. Whether
there has been any thickening of the nerve
trunks I have been unable to learn.

The above is substantially the history
which this patient gives. His present con-
dition is as follows. He is emaciated and
anemic, and his muscles are wasted away.
His skin is atrophied, thin, shining and
slightly drawn over the subjacent parts.
There is no hair on his face. His senses of
smell, taste and hearing' are normal, but his
right eye has been destroyed by an ulcera-
tive process which is still going on, but
which is not now painful. The ulceration
has destroyed the cornea and sclerotic, but
closed up before all of the intra-ocular fluids
escaped. New deposits occurred on the
surface, forming firm cicatricial tissue, but
not sufficiently strong to prevent protrusion
of the fluids, so that now there is a dense,
horn-like staphyloma which protrudes for
about half an inch beyond the eyeball.
There is no hypersesthesia at present, but
there is anaesthesia of the hands and arms
as far as the elbows, and of the feet and legs
up to the knees. There is no regular or
symmetrical arrangement of the anaesthesia,
nor does it seem to follow the course of the
nerves, but affects the entire extremities up to
the first large joints. It is so perfect that the
patient has himself cut off some of his toes
that were falling off, without feeling any
pain, and he has on many occasions been
severely burnt by unconsciously placing his
hands in contact with articles that were hot.
Great changes have taken place in the hands
and feet from atrophy of the bony, muscu-
lar and nervous structures, leading to de-
formity, ulceration and loss of all but four
of the toes. The muscles and tendons of
the hands are atrophied and contracted, and
all the small joints stand out distorted and
rigid, which gives the hands very much the
same appearance as is presented in arthritis
deformans. Under the right foot there is
an ulcer, which has been suppurating for
some time, and through which pieces of ne-
crosed bone are occasionally discharged.
All of the toes, except the fourth one, have
fallen off of this foot. On the left foot the
big and little toes are gone.

New York Correspondence.

NEW YORK LETTER.

New York Academy of Medicine. — Bullet
Wound of Brain. — Recovery. — Pylorec-
tomy with Gastro- Enterostomy , for Cancer
of the Sto?tiach. — Papillitis. — Orbital Op-
tic Neuritis.

Among the more interesting items of the
section work at the New York Academy of
Medicine for the week ending December
20, 1890, may be mentioned a case reported
to the Surgical Section by Dr. J. A. Wyeth.
He said that on October 30 a school boy
was brought to Mt. Sinai Hospital having a
short time before been accidentally shot in
the head with a pistol of No. 22 calibre, in
the hands of his brother. The shot had
been fired at a distance of about three feet
and directly in front. The ball had struck
the forehead. Beyond profuse hemorrhage
and severe pain, there had been no imme-
diate symptoms. On admission the boy
was calm and rational ; pulse good. About
one inch above the middle of right eyebrow
a small round wound existed, the edges be-
ing depressed. Around it there was some
slight swelling. Scattered spots of powder
were present in the skin of the face and the
clothing was covered with blood. Arision
was good in both eyes. The boy had
walked into the hospital without assistance.
He had been taken immediately to the op-
erating-room. He was there etherized and,
the external parts having been thoroughly
cleansed, an incision two inches long was
made at the site of the bullet wound and
parallel to the eyebrow. The periosteum
was raised and loose pieces of bone were
found in the wound, consisting partly of
spiculae of considerable size from the inner
table. Fluhrer's probe was passed into the
wound to a distance of a quarter of an inch.
The patient had then begun to vomit. A
finger was placed over the wound* and on
this being raised there was a sudden gush of
dark clotted blood and particles of white
brain substance. The wound was washed
out with bichloride and packed with iodo-
form gauze secured with a tight bandage.
On November 3 the boy's temperature had
risen to 1040, and there had been some de-
lirium. Ice bags had been applied to the
head. On the following day the wound, on
being dressed, was found to be aseptic.
After this dressing the temperature had

Jan. 3, 1 89 1. New York Correspondence.

fallen to a little above normal and had so
continued. On November 8, upon removal
of the gauze, about half an ounce of blood-
clot and broken-down brain substance had
welled up from the opening. No evidence
of any suppurative process had existed in
the discharged material at any time. Dur-
ing the progress of the case the patient had
experienced more or less pain in the region
of the occipital bone and in the right ear.
He had continued to improve and on No-
vember 25 his temperature was reported as
normal, and the ice coil was stopped. On
December 7 the wound was found to be en-
tirely healed and the patient was suffering
no pain; he was bright, cheerful and did not
seem to suffer any inconvenience from the
loss of brain tissue or from the presence of
the bullet in the cranial cavity. Care would
be taken to keep him quiet for some time
yet in order to give the bullet the best pos-
sible opportunity to become encysted. The
speaker wished to give his late house-surgeon,
Dr. Weber, due credit for his successful man-
agement of this interesting case.

In the discussion which followed, the opin-
ion was freely expressed that the Bell Tele-
phone Co. should be again urged to with-
draw its obstructive decision, which pre-
vented the utilization of certain processes
for the localization of bullets within the
cranial cavity, and Dr. Gardner explained
that he had found out a method by which
the ordinary telephone connections might
be arranged to do the necessary work, and

Dr. W. T. Bull then related the histories
and the details of the operations in three
cases of cancer of the stomach. He thought-
that it was strange that in this country where
so much good work had been done both sci-
entifically and practically in abdominal sur-
gery, so little effort had been made for the
cure of cancer of the pylorus. It was thought
that the operation of pylorectomy had been
simplified by the introduction of Senn's
plates, and that the mortality would be
much diminished. Another departure from
the typical resection was the combination
of pylorectomy with gastro-enterostomy, the
cut edges of the stomach and duodenum
being shut off so as to form a cul-de-sac,
and the anostomosis being made between
the stomach and the jejunum. This has
been the method employed by Dr. Bull in
his three cases. In the preparatory treat-
ment the stomach-pump was employed after
the patients were under the anaesthetic.
This Dr. Bull thought a more effective way

of emptying the stomach, than the old
method of several washings out previous to
the anaesthetic. The median incision had
proved the most satisfactory, and was to be
preferred to any other. He used no clamps
on the stomach or duodenum to prevent
escape of contents. The fingers of an as-
sistant he considered more satisfactory, es-
pecially if with the aid of hooks or loops of
silk the divided ends of the viscera were
kept elevated in a vertical position. A plug
of iodoform gauze was introduced into the
duodenal opening, and a flat sponge in the
stomach. There was but slight bleeding
from the stomach or intestinal wall, and
that which followed the incision for the an-
astomotic opening was effectually controlled
when the catgut rings were approximated.
The loop of jejunum was shut off with strips
of iodoform gauze while the anastomosis was
being made. The continuous catgut suture
through the mucous membrane, reinforced
by interrupted sutures, were used to close
the cut edges of the stomach and duodenum.
In using the rings Dr. Bull always added to
the silk sutures, which held them in appo-
sition, a line of continuous suture, with an
isolated suture where he thought it neces-
sary. He looked upon the rings, not as an
absolutely sure method of uniting serous
surfaces, but as a most convenient adjunct
to a carefully applied peritoneal suture. In
all of his cases the gastro-enterostomy had
been perfect in point of accurate and secure
apposition. One of the patients operated
upon by the speaker was now alive and at
the last hearing was in good health. He
thought that the fatal result in the other two
cases could be traced to faults in the tech-
nique ; in one case, at least, there was no
doubt of this, as the autopsy showed that a
sponge had been unfortunately left in the
stomach.

Statistics showed that out of some thirteen
hundred cases of cancer of this region one-
half had involved the pylorus. Half of
these again were uncomplicated by any in-
volvement of the glands. Therefore half
the cases of pyloric cancer were really amen-
able to treatment by operation. He be-
lieved that death in these cases often took
place from the effects of the mere mechani-
cal obstruction long before the disease had
exhausted the patient. The hydrochloric-
acid test and other means now at disposal
for careful and accurate diagnosis in these
cases should render an early interference
possible and then with perfected technique

12

New York Correspondence.

Vol. lxiv

he thought that the operation of pylorec-
tomy might be raised from its present posi-
tion to that of a life-saving and life-prolong-
ing procedure.

Dr. Robert Weir after critically analyzing
the mortality percentages after the operation
of gastro-enterostomy as against those of
resection of the pylorus, thought that the
latter operation had been performed a suffi-
cient number of times and had been at-
tended as yet by such fearful mortality, and
had proved of such little use in prolonging
lives that it ought now be relegated to a
place among the experimental procedures.

Dr. Robert Abbe thought that if the opT
eration of resection of the pylorus had only
yielded fifty per cent, of satisfactory results,
and took three hours to perform, then no
surgeon of only general experience and
ability should attempt it. Gastro-enteros-
tomy, when its technique was more thor-
oughly written upon and more properly
illustrated, should be possible to any man
who could handle knife, scissors and needles.

Dr. Bull did not wish to be understood as
advocating resection of the pylorus in can-
cer of this region, but thought it was the
duty of surgeons to undertake the operation
when there was a chance of success attend-
ing their effort.

The proceedings at the last stated meeting
comprised the consideration of certain lesions
of the visual tract from the eyeball to the
cerebral cortex. In this relation Dr. C. S.
Bull, in a paper on Papillitis, expressed the
opinion that the most common cause of this
condition was intracranial disease and that
of the intracranial lesions tumor was the
most frequent. The frequency and severity
of the papillitis did not seem to be materially
influenced by either the nature, the size, or
the location of the tumor.

The next most frequent cause was menin-
gitis, then followed abscess of the brain,
hydatid disease and softening from throm-
bosis or embolism. Papillitis was also occa-
sionally met with in acute diseases of the
spinal cord. Dr. Bull then gave a synopsis of
the various views as to causation which have
been from time to time held and promulgated
by distinguished authorities. In summariz-
ing his own consideration of the subject, the
speaker said that optic neuritis, limited to
or most intense in the optic disc, might occur
without any apparent intracranial disease.
Pure papillitis was known to occur in simple
anemia. It seemed therefore fair to con-
clude that the intra-ocular end of the optic

nerve was a structure peculiarly prone to in-
flammation. It was a difficult matter to
connect papillitis with increase of intra-
cranial pressure for it was the rare exception
in chronic hydrocephalus, where the intra-
cranial pressure was raised to the highest
point of which we had any knowledge. On
the other hand in cases of intracranial tumor
with papillitis there might be no sign of
increased intracranial pressure during the
life of the patient. There might also be
signs of increased intracranial pressure in
cases of tumor without papillitis. If we
rejected the theory that pressure on the
cavernous sinuses was the immediate cause
of this condition we could not absolutely
ignore its influence on the retinal circula-
tion. The great distention of the veins and
the narrowing of the arteries took place
mainly when the inflammation had reached
a high degree of intensity and these facts
pointed to the inflammation in the nerve as
the cause of the strangulation by pressure on
the vessels. This view was confirmed by
pathological investigations. The conspicu-
ous constriction of the vessels was always in
the papilla in front of the sclerotic. The
most intense signs of strangulation might be
seen in cases in which there was no reason
to suspect the presence of intracranial dis-
ease. Distention of the optic sheath was
frequently met with in cases of tumor with
papillitis. It might also be absent in cases
of tumor with internal hydrocephalus. It
had been suggested that the fluid might be
found within the sheath itself. If the sheath
was the main lymph channel by which the
fluid was conveyed from the eye, its dis-
tention in optic neuritis by fluid escaping
from the papilla was easily understood. But
there was good ground for believing that
the fluid found in the sheath passed into it
from the subarachnoid space. Dr. Bull
said he really knew very little of the relation
which might exist between dropsy of the
sheath and optic neuritis. The occasional
occurrence of papillitis without it showed
that it was neither the invariable nor the
chief mechanical cause of papillitis. It
therefore seemed proper to draw the infer-
ence that we could not decide in any given
case against the existence of a descending
neuritis from examination of a small portion
of the trunk of the optic nerve, and that a
pathological change in the nerve deviating
but slightly from the normal state might
convey a condition of irritation to the eye
which was sufficient to set up actual papil-

Jan. 3, 1891.

Periscope.

13

litis. It also seemed proper to draw the
following conclusions in regard to the de-
velopment of papillitis in intracranial dis-
ease : (1). In cases of cerebral tumor, evi-
dence of descending inflammation may be
traced in the sheath or nerve much more
commonly than is generally supposed, while
in cases of meningitis the evidence of de-
scending inflammation is almost invariable.

(2) . The resulting papillitis may be slight
or may grow intense, but we are ignorant of
the cases which bring about this difference.

(3) . The mechanical congestion in these
cases of papillitis does not always result from
compression of the vessels behind the scler-
otic ring, but does always follow compression
from inflammatory exudation in the papilla.

(4) . Slow increase of intracranial pressure
has no effect on the retinal vessels, but
sudden increase of such pressure may inten-
sify a papillitis originating in some other
way. (5). Distention of the sheath alone
is probably not sufficient to cause papillitis
by its mechanical effects, but it may inten-
sify the process otherwise set up.

In a paper on optic neuritis, including
alcohol and tobacco amaurosis, Dr. A. Knapp
said that the cases in which people notice a
haze, a blurr, even a perfectly dark patch
in the centre of their field of vision, known
under the name of central amblyopia or cen-
tral scotoma, as well as those cases in which
persons lose their sight in one or a few days
without exhibiting any ocular or general dis-
ease to account for it, were explained more
than twenty years ago by A. Von Grsefe and
Theo. Leber. They supposed the condition
to be an inflammation of the orbital parts
of the optic nerve, retro-bulbar neuritis. This
hypothesis has since been proven to be a
reality by anatomical investigations. Ret-
ro-bulbar neuritis might be idiopathic or the
result of different kinds of intoxication, al-
coholism, nicotinism, lead poisoning, dia-
betes, syphilis, etc. The condition might
take on an acute or chronic form. A num-
ber of very interesting microscopic speci-
mens were exhibited to the society. One
showed the central interstitial neuritis in the
period of nuclear infiltration, another in
the stage of connective tissue hypertrophy.
The process was characteristic by the limi-
tations of its area of inflammation, circum-
scribed and triangular near the disc. In one
specimen the changes passed like a band
from the temporal border of the nerve across
to the nasal side. This explained how the
atrophy of the nerve might become total.

In all of the specimens a certain number of
healthy nerve fibres were seen preserved in
the atrophic parts. This showed how in al-
coholism, that total blindness was rare, and
how, on the other hand, in the field of vision
of persons blind from retro-bulbar neuritis
islets of useful sight were permanently pre-
served. Retro-bulbar optic neuritis presented
an example of peripheric neuritis of great
practical importance.

Periscope,

Immunity to Tetanus and Diph-
theria.

The two researches on immunity, of
which our Berlin Correspondent telegraphed
a brief summary last week, not only have a
special interest at the present time, when the
attention of the whole world is rivetted on
the remarkable discovery of Koch for the
cure of tuberculosis, but possess also great
intrinsic merit. The paper on the Produc-
tion of Immunity against Diphtheria and
Tetanus in Animals, in the Deutsche Medi-
cinische Wochenschrift, December 4, 1890,
by Drs. Behring and Kitasato, is, perhaps,
the more important of the two. These two
observers have been engaged for some time
in a study of the nature of diphtheria and
tetanus, and they have at length succeeded
in not only conferring immunity on animals
against attacks of either disease, but also in
arresting the disease after it has already set
in.

The manner in which this is brought
about is reserved for a later communication.
In the present paper they deal with the sub-
ject only so far as to prove the correctness
of the following proposition : " That the
immunity which can be conferred on rabbits
and mice against tetanus depends on the
power possessed by the serum of the blood
to render innocuous the poisonous products
formed by the tetanus bacilli."

This explanation of the nature of im-
munity has not been distinctly given in any
of the publications which have hitherto dealt
with the subject. The views hitherto held
regarding the nature of acquired immunity
have been three — in the doctrine of phago-
cytosis, which seeks for an explanation in
the activity of living cells; the bacteria-
killing power of the blood ; and lastly, ac-
quired toleration. When any two of these

Periscope.

Vol. lxiv

have failed to explain the phenomena of
immunity, or have been proved by experi-
ment to be false, this has been regarded as
a proof by the process of exclusion that the
remaining one was right. Thus Bouchard,
in his recent address before the International
Medical Congress, declared : "Let us speak
no more of an education of leucocytes, and
a toleration of cells to the action of bacter-
ial poisons ; it is the bacteria-killing power
of the body which constitutes what we term
vaccination, or acquired immunity."

One of the present observers (Behring),
in the course of his investigations on rats
and guinea-pigs rendered immune against
diphthera, failed to find either of the- above
explanations satisfactory. The explanation
was at last, after many failures, found in the
bacteria-killing power possessed by the blood
of animals immune to the diphtheria bacilli.
This explanation was then found to apply
also to tetanus. The results of their obser-
vations they sum up as follows :

1. The blood of rabbits rendered immune
against tetanus possesses bacteria-killing
properties towards the tetanus bacillus.

2. These properties belong also to ex-
travascular blood, and to the serum obtain-
able from such blood.

3. These properties are of such a durable
nature that they remain active even in the
bodies of other animals, so that it is possible
to obtain good therapeutic results by the
operation of serum or blood transfusion.

4. These properties are entirely absent
from the blood of such animals as are not
immune against tetanus; and when the
poison of tetanus is introduced into these
animals, it can be found after death in the
blood fluids of the body.

The following are some of the observa-
tions on which the above conclusions are
based : — Their method of conferring im-
munity against tetanus they reserve for a
coming paper. A rabbit was rendered com-
pletely immune against tetanus, the degree
of immunity being such that 10 cubic centi-
meters of a virulent tetanus culture was en-
tirely without effect, while ^ cubic centi-
meter sufficed to kill an ordinary rabbit. It
was found that the animal had acquired im-
munity, not only against the living tetanus
bacilli, but also against the poison. It
could withstand, without ill effect, twenty
times the dose required to kill a healthy
rabbit. Blood was withdrawn from the
carotid of this animal. Of this fluid blood
0.2 cubic centimeter and 0.5 cubic centi-

meter were injected into the peritoneal cav-
ity of two mice. Twenty-four hours later
both were inoculated with virulent culture of
tetanus, two healthy mice being at the same
time inoculated with the same culture.
While the latter died in twenty-four and
thirty-six hours respectively, the two former
remained perfectly healthy.

The greater quantity of the blood was
allowed to stand till the serum had separated.
Of this serum, 0.2 cubic centimeter was in-
jected into the peritoneal cavity of six mice.
Inoculation of these twenty-four hours later
with virulent tetanus proved without effect,
the mice remaining quite healthy, while the
mice used as control experiments all died in
forty-eight hours.

It is also possible to obtain good thera-
peutic results with such serum, by first inoc-
ulating the animals and then injecting
serum into their peritoneal cavities.

Further experiments were also made show-
ing the intensely destructive action of this
blood serum against the tetanus poison. • A
tetanus culture ten days old was taken and
filtered, so as to be free from all spores. Its
virulence was such that 0.00005 cubic centi-
meter sufficed to kill a mouse in four to six
days, while 0.0001 cubic centimeter killed
it with certainty in less than two days, 0.5
cubic centimeter of the serum of the im-
mune rabbits was mixed with o. 1 cubic cen-
timeter of this culture, and allowed to act
for twenty-four hours on the tetanus poison
contained in it. It was then found that
mice could withstand 0.2 cubic centimeter
to 0.033 cubic centimeter, or 300 times the
dose necessary to kill healthy mice. The
mice remained quite healthy, while the con-
trol mice died in six hours, after a dose of
only 0.0001 cubic centimeter.

All the mice rendered immune in this
way have remained so ; they have been re-
peatedly inoculated with virulent tetanus
cultures without the slightest ill effect. This
fact is the more remarkable since in the
many experiments that have had to be made
not a single mouse or rabbit has ever been
found naturally immune against tetanus, and
furthermore all the attempts made in the
laboratory for a long time back by other
methods to render these same animals im-
mune have completely failed. Thus the
conclusion may be drawn that the explana-
tion of the nature of immunity given above
is one capable of wide application. In all
cases control experiments were made with
the blood and serum of rabbits not immune.

Jan. 3, 1 89 1.

Periscope.

15

Both blood and serum proved to be entirely
inactive. The same was found to apply to
the serum of oxen, calves, horses and sheep.

It was also found that the blood of such
animals while in the vessels was destitute of
such tetanus-destroying properties. Thus
rabbits injected subcutaneously with 0.5
cubic centimeter of a virulent tetanus cul-
ture, free from spores, died in five or six
days with all the symptoms of tetanus well
pronounced. In such cases on post-mortem
examination a serous effusion was found in
every case without exception in the pleural
cavities. On the average 0.3 cubic centi-
meter of this fluid sufficed to give a mouse
tetanus and to kill it, and the blood of such
animals was capable of giving rise in turn to
tetanus when injected into other animals.

The application of these most striking
results to the cure or prevention of these
two diseases in man is reserved for future
consideration. The authors, however,
aptly conclude their communication by
drawing attention to the support given by
their results to the view at all times widely
held, and fitly described by Goethe in the
words of Mephistopheles to Faust :

Das Blut ist ein ganz besonderer Saft.

These words derive a new and altogether
special significance from the result of recent
bacteriological observations.

The second paper is a continuation of one
which appeared early in the present year by
Brieger and Fraenkel, entitled "Researches
on Bacterial Poisons." The main points of
this paper were noted in the British Medical
Journal at the time of its publication. The
present contribution to the same subject is
from Fraenkel alone, and deals with the
methods of producing immunity against
diphtheria. It will be remembered that in
the paper referred to these two observers en-
deavored to show that the pathogenic action
of a number of organisms was to be at-
tributed to certain products of their activity
of an albuminous nature ; to these bodies
they gave the name of " toxalbumins. "
The disease most thoroughly studied in this
•connection at that time was diphtheria.
They considered the most characteristic
features of these toxalbumins to be, first,
their albuminous nature, and, secondly,
their peculiar action on the organism. The
latter, in many respects, resembled that of
ferments, but they were unable to regard
them as ferments, for this reason, that while,
According to them, the action of ferments is

more or less independent of the quantity
present, in the case of toxalbumins the dose
was the most important factor. The larger
it was the more rapid and complete was
their action, and they lost their power alto-
gether when the dose fell below a certain
limit. In this respect, therefore, they re-
sembled in their action ordinary vegetable
and mineral poisons.

Fraenkel's later observations, here com-
municated, deal with the artificial produc-
tion of immunity against diphtheria.

There are two ways in which the body
may be protected against the attacks of
pathogenic micro-organisms. The first of
these we owe to Pasteur. In it use is made
of cultures, the virulence of which has been
lessened in various artificial ways — by heat-
ing, etc. In the other method use is made
of the various products of bacterial activity
— completely free from the organisms them-
selves. Of the comparatively numerous
researches that have already been carried
out by various observers in this latter do-
main ; those of Smith, Chamberland and
Roux, Beumer and Peiper, Gamaleia,
Bouchard, Charrin are here referred to ;
that of Hankin, who succeeded in isolating
the very substance which confers immunity
against anthrax, is, however, not mentioned
— an omission all the more to be noted as
his work is the most conclusive of all, and
was carried on in the same laboratory as
that in which Fraenkel worked.

Both the above methods have been used
by Fraenkel in his present research. Little
difficulty was experienced in weakening the
bacilli of diphtheria either by heating their
cultures to a certain high temperature, or by
adding some antiseptic agent, such as
potassium bichromate or gentian violet.
The results obtained in this way were unsatis-
factory and uncertain, the weakened cultures
varying much in their activity, and very
readily, under certain circumstances regain-
ing their virulence. He found it impossible
to confer immunity, even in a small degree,
by this means.

In his experiments with the products of
their activity, he used at first toxalbumins
which had been kept in a dry condition for
many months without losing in any way
their poisonous properties. These failed
entirely to confer immunity against the dis-
ease. It appeared, indeed, as if the animal
inoculated with this substance in small doses
died more quickly after subsequent inocula-
tion than healthy animals.

i6

Periscope.

Vol. lxiv

Better results were obtained when, instead
of the toxalbumins, he employed the fluids
obtained by filtering the cultures through a
porcelain filter, or heating them for an hour
to a temperature of 550 C, thus freeing
them from all living elements. Some of the
animals injected with these cultures gained
a certain tolerance of the diphtheritic poi-
son, dying, for example, three, four, six and
nine days after an injection of 0.1 cubic
centimeter, instead of in thirty to thirty-six
hours, as in the case of untreated animals.
They all died, however, none of them acquir-
ing a complete immunity. This result, such
as it was, satisfied him that he was on the
right track.

A further advance was made when, in-
stead of small quantities, he used larger quan-
tities of these culture fluids. The filtered
culture, or the culture itself, was heated for
an hour at a temperature of ioo° C, and
10 cubic centimeters injected subcutaneously
into guinea-pigs. A few of the animals so
treated survived subsequent inoculation with
virulent diphtheria; the great majority of
them, however, died, although at later peri-
ods than usual, namely, after two weeks and
a half.

He finally found that a temperature of
65 0 to 700 C, maintained for an hour,
yielded the best results. Injections of 10 to
20 cubic centimeters of a culture of diph-
theria bacilli so treated rendered guinea-pigs
immune against subsequent injections of
even the most virulent poison. Even this
conclusion required modification, for it only
applied when the subsequent inoculations
were made not earlier than fourteen days
after immunity had been conferred. If
made sooner, the result was uncertain, some
animals dying, others not. In the first few
days after the injection the resistance of the
animal seemed, indeed, to be lessened, the
animals dying more rapidly and certainly
than before, when inoculated with virulent-
cultures.

Furthermore, the immunity in this ^way
conferred only applied against subsequent
subcutaneous inoculation, and not to subse-
quent inoculation of mucous membranes —
such as the vaginal — with diphtheria. To
this extent, therefore, it is imperfect, and
considering the ordinary method of propa-
gation of diphtheria in man through the
mucous membrane, this result obviously
leaves a wide blank still to be filled up be-
fore we can apply these results obtained on
animals to man.

The remaining portion of the paper is
taken up with a consideration of the nature
of the body which confers this immunity.
Fraenkel concludes that it is quite distinct
from the one that produces the poisonous
symptoms, that while the latter is destroyed
at a temperature of 5 50 to 6o° C, the for-
mer is not destroyed till a temperature of
ioo° C. is reached, although it is weakened
at any temperature above 900 C.

The best temperature, therefore, at which
to heat the cultures so as to destroy their
toxic properties without destroying those on.
which their power of conferring immunity
depended is 66° to 700 C. This substance
which confers immunity has no therapeutic
properties. So far, indeed, from this being
the case, its injection into animals previously
suffering from diphtheria rather hastens their
death. — British Medical Journal, December
13, 1890.

The White Blood Corpuscles in
Croupous Pneumonia.

Dr. T. S. Kikadze, in the Bolnitchnaya
Gazeta Botkina, May 16, 1890, reports in-
vestigations of the blood in a large number of
cases of croupous pneumonia during the
course of the disease. He describes mi-
nutely the methods and precautions used in
the work.

The results are represented in diagrams
which show distinctly the possibility of pre-
dicting the character that the disease will
assume in its course, the prognosis, and in
case of poor prognosis, the treatment which
is proper to lessen the gravity of conditions.
The conclusions are :

1. During a normal course of croupous
pneumonia the absolute, as well as the rela-
tive, number of white blood-cells is mostly
increased to twice or three times the normal
number.

2. In fatal cases of croupous pneumonia
no increase is observed, and sometimes
there is actual diminution of the same.

3. The increase in the number of leuco-
cytes is on account of the mature and de-
generating elements of the white blood-
cells.

4. The above-cited changes in the blood
take place early in the disease, earlier than
any pulmonary changes show themselves.

5. Once taken place, the above changes
remain with little variation until the occur-
rence of crisis.

Jan. 3, 1 89 1.

Periscope.

17

6. Just before the crisis takes place there
is a sudden increase of the number of leu-
cocytes ] the latter is supposed to be due to
the re-entrance of the leucocytes from the
pulmonary alveoli into the blood-vessels.
This view is supported by the fact that at
the same time there is an increase in the
number of degenerating leucocytes.

7. The increase in the number of the
normal leucocytes and of those in pro-
cess of degeneration is parallel with the
body temperature.

8. During the period of fever in croupous
pneumonia the blood elements show evi-
dences of delayed morphological metamor-
phosis, which is seen from the elements
being in a condition ready to disintegrate.

9. The red blood-cells are progressively
decreased until the end of the disease.

10. The temperature and blood crisis
occur synchronously. The number of the
leucocytes and the body temperature fall
suddenly to the normal or subnormal ;
the amount of the breaking-down elements
is diminished accordingly.

11. During the day of crisis the blood
shows evidences of hastened morphological
metamorphosis in the sense above men-
tioned.

From the large number of pneumonic
patients examined, the author found that
the increase in the leucocytes is independent
of the area of pulmonary involvement, the
intensity of the inflammatory process in the
lungs, or the period in the course of the dis-
ease. It has nothing to do with the patho-
logical pulmonary process. It depends upon
something that is not yet known, but which
the author suggests is a pneumococcus,
or some other pathogenic microbe, or the
products of its vital changes, which fill
the blood, secondary to which the local
pulmonary manifestations show themselves.

With disappearance of the as yet un-
known cause, the blood and temperature
crisis takes place. In many cases the author
predicted the approaching crisis of temper-
ature because of the decrease in number of
the leucocytes, before the temperature took
place.

In view of the fact that an increase in
the number of leucocytes in the beginning
of croupous pneumonia is necessary to a
good issue of the disease, the author sug-
gests to use camphor early, when the in-
crease is absent, because camphor increases
the number of leucocytes twice and some-
times thrice the normal.

Leprosy in Norway.

In an interesting account of a visit to the
Hospital for Lepers at Molde, Norway, pub-
lished in the Edinburgh Medical Journal,
November, 1890, Dr. W. Allan Jamieson
describes its beautiful situation and its ca-
pacity, and discusses certain points in re-
gard to the disease. Himself apparently a
believer in the contagiousness of leprosy, he
says that Dr. Kaurin, the Physician to the
Hospital, is a full believer in the communi-
cability of leprosy. He adds that there are,
however, some curious points with respect
to this. In Norway no nurse nor any medi-
cal man in attendance on lepers has, so far
as is known, ever yet contracted the disease,
nor have any experimental inoculations on
animals been successful. Physicians have
inoculated themselves, their colleagues and
numerous healthy persons, introducing the
leprous material in the form of portions of
the nodules under the skin, but no one so
treated has yet become a leper. To com-
municate the disease two factors would appear
necessary — one, prolonged or very intimate
contact with a leper, as by sleeping in the
same bed, wearing the clothes of an affected
person, etc. ; the other, a peculiar condition
of the system, probably induced by habitu-
ally partaking of a bad or at least unsuita-
ble dietary. Mr. Jonathan Hutchinson, as
is well known, holds strongly that fish is
probably the vehicle by which the poison of
leprosy gains access to the human body.
Medical men have not yet generally adopted
his view, but from several conversations
which Dr. Jamieson held with intelligent
Norwegian peasants as to their opinion of
the cause of leprosy, it seemed evident to
him that they were inclined to think that
fish had at least something to do with its
origin or spread. If such a view is, even to
a limited extent, correct, there can be no
true ground for any leprosy scare as far as
England is concerned. There is no reason
to fear that, under existing conditions, lep-
rosy will again obtain a hold in Great
Britain. Dr. Jamieson weakens his article
a little by introducing an ad captandum ar-
gument founded upon the fact that a
physician who holds strongly the view
that leprosy is non-communicable once
visited a Norwegian leper hospital, and
there expressed his opinions freely and
decidedly. "Will you then occupy a bed
alongside of one of these patients?" asked
the doctor in attendance. "No," replied

i8

Periscope.

Vol. Ixiv

the anti-contagionist, thus put to the proof
after a fashion he did not anticipate, "I
have a wife and children at home depend-
ing on me." Dr. Jamieson says: He had
not, and perhaps one could scarcely expect
him to have, the courage of his opinion.
This may be so, or not; but it has no
bearing whatever upon the correctness or
incorrectness of his opinion.

Risks of Cocaine Injections.

The Medical Press, November 5, 1890,
,says that two warning cases are reported
from France. In one of them, which oc-
curred at Lille, the patient died, and the
dentist who gave the injection was acquitted
of neglect, but condemned for practicing
medicine without qualification. In the
other, which occurred at Paris, the patient
was with great difficulty brought round by
hypodermic injections of ether. The co-
caine injection was also made in this case
by a dentist.

In another place the same journal says
that the Lille dentist who was charged with
causing the death of a girl by injecting co-
caine in order to procure anaesthesia, has
been sentenced to a fine of fifteen francs
for breach of the law regulating the prac-
tice of medicine, the judgment endorsing
the view that cocaine is an anaesthetic which
requires to be used with prudence, and can-
not legally be administered by other than a
qualified medical man.

Exfoliation of the Bladder in the
Female.

The Glasgow Medical Journal, October,
1890, quotes from the Edinburgh Medical
Journal, June, 1890, that Haultain narrates
a case of exfoliation of the bladder in a
woman, due to retention produced by incar-
cerated retroverted gravid uterus. Micro-
scopic examination showed the sac, which
was expelled through the urethra, to consist
of the bladder wall in its entire thickness.
Haultain is of opinion that many cases which
have been reported as exfoliation of the mu-
cous membrane have really been of the en-
tire thickness of the wall, as in his own case.
By others the condition has been confused
with exfoliation of a croupous false mem-
brane. The cases published, occurring in
females, have all been associated with one of
two conditions — retention of urine or la-

bor ; the retention of urine being due in
all cases but one to incarcerated retroposi-
tion of the gravid uterus. Experiments on
dogs by May, of Giessen, have shown that
retention of urine is of itself sufficient to
cause death of the bladder. When the con-
dition is the result of retention, Haultain
considers that this is brought about by pres-
sure of the retained column of urine on the
veins of the neck of the bladder.

In those cases of labor where it occurs
without retention, the pressure on the vesi-
cal neck will affect both arteries and veins,
so as to produce complete arrest of the cir-
culation. Of 33 cases of exfoliation of the
wall in more or less entirety, to which refer-
ence is made, there were only 8 fatal.

The formation gf an adventitious recep-
tacle for the urine would seem to take place
by the agglutination of adjoining pelvic
viscera, and the organization of inflammatory
products. The amount of control over the
urine may be expected to vary with the ex-
tent to which the muscular coat, and more
especially the sphincter fibres, have survived.

Protopine — A New Opium Alkaloid.

Protopine was first isolated from opium
in 1870 by Hesse. It has a formula of
C20H19O5, and is present in but small amount.
Since then its presence has been detected by
Eykmann in the Macleya cordata, and by
Selle in the CheKdonium majus, plants which
also belong to the family of the Paveraceae.

Dr. Engel has recently made some exper-
iments on cold-blooded animals (frogs)
and warm-blooded animals (guinea-pigs,
cats and rabbits) to determine the physiolog-
ical properties of protopine, and his results,
which are summarized in the following state-
ments, are published in the Gazette Medicate
de Paris, October n, 1890:

1. In small doses protopine exercises on
the frog narcotic effects similar to those pro-
duced by other opium alkaloids.

2. In large doses it produces a paralyzing
action on the muscular substance, and on
the terminal ramifications of the peripheral
nerves.

3. With small or moderate doses reflex
action is not abolished, although this occurs
when large doses are given.

4. Protopine produces toxic effects in
mammals comparable to those produced by
camphor, death being produced by a paraly-
sis of the respiratory centre. — Therapeutic
Gazette, November, 1890.

Jan, 3, 1 89 1.

Editorial.

19

THE

MEDICAL AND SURGICAL

REPORTER.

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When it is desired to call our attention to something in a
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newspapers are not looked at.

The Editor will be glad to get medical news, but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

EDUCATION AND THE DISEASES OF
SCHOOL-CHILDREN.

The object of education should be to fit
the pupil for the hightest degree of useful-
ness possible to him. This implies that the
pupil is an individual ; that some knowledge
may be useful to one and not to another ;
that different pupils are capable of assimi-
lating varying amounts of the same form of
knowledge. Childhood is the most critical
time of education. Then thoroughness
rather than extent of knowledge should be
aimed at. Later on in life, when one has
mastered a business or profession, it will be
found that an acquaintance with a variety of
subjects opens up many avenues through
which one may receive pleasurable impres-
sions, while at the same time it makes
general social intercourse enjoyable, and

enlarges the circle of friends. But in early
life the rule should be multum, not multa,
lest the child grow up with a smattering
knowledge of many things and without
knowing one thoroughly. Above all, it
should never be forgotten, in the education
of a child, that the most important consid-
eration is health. A child is not educated
for childhood, but with a view to ultimate
usefulness when fully grown ; and every one
knows that, to the average person, a sound
body is more important for success in life
than a well-stored mind.

These remarks have been suggested by an
article in the Revue Medicale, August, 1890,
which refers to a question raised by Dr.
Axel Key before the last International Medi-
cal Congress, at Berlin. Dr. Key asked if
modern education either at home or at
school is well adapted to its purpose and
calculated to give children a sound mind in
a sound body ? In the course of his inquiry
he made some interesting statements. Boys,
he says, pass through three different periods
of development : An important growth
takes places when they are about seven or
eight years old, another, but less considerable
increase from their ninth to their thirteenth
year ; and at puberty — from fourteen to six-
teen years of age — there is a remarkable
and very rapid increase in height and weight.
Girls pass through the same stages, but the
stages appear some years earlier than in boys.
As regards differences in social position,
those in good circumstances are a year in
advance of the poor of the same age, show-
ing that poverty and faulty conditions of
existence retard the development of chil-
dren.

Key also says that children do not gain
much in height from the end of November
to the end of March ; from March to July,
height increases much, but not weight ; while
from July to the end of November, gain in
height is very slight ; but there is a great
gain in weight — the daily gain in weight be-
ing often three times greater than during the
winter months. When summer vacations

20

Editorial.

Vol. lxiv

are early, they give opportunity for a very
great gain of weight.

The observations of Key have a bearing
upon the subject of the education of children;
for they serve to give point to the trite re-
mark about childhood being the time for
physical growth and development.

The effect of ill-regulated . conditions of
education may be seen in Sweden, where,
Key says, one-third of the secondary scholars
are sick or afflicted with chronic affections.
Myopia increases in frequency uninter-
ruptedly from one class to the following,
while thirteen and five-tenths per cent, of the
boys have habitual headache, and nearly
thirteen per cent, are chlorotic. Of the
girls, nearly thirty-six per cent, are said to
be chlorotic, while an almost equal number
suffer from habitual headache ; ten per cent,
at least, have curvature of the spine.

It is not fair to attribute all the defects
found in school-children to the school and
to study. Many of them would be opera-
tive out of school. The points, however,
which we have sought most to emphasize are
that childhood is the most critical educational
period \ that children should be taught to
" see straight and think clear," to adopt
correct methods of study, to learn thoroughly
rather than to learn many things ; and that
in their studies they should be treated as in-
dividuals as far as possible, their special re-
quirements and probable ultimate destinies
being noted, and their mental and physical
disabilities being taken into account. These
desirable things are well nigh impossible in
our public schools, for the classes are all
large, rarely numbering fewer than fifty.
The chances of a child are better in a small
private school, especially along with careful
home encouragement, and are probably best
of all under a wise man as a private tutor.

SURGEON-GENERAL SUTHERLAND.

The nomination and confirmation of
Colonel Charles Sutherland, to be Surgeon-
General of the Army is such an excellent
choice that we congratulate the President

and the army upon it : the President be-
cause he has acted upon a principle which
is admirable in every department of the
public service, and the army because it will
have a Surgeon-General who is an honorable
man and a most excellent officer. More
than this, the choice is one which will give
support to the idea — so essential to good
feeling in the army — that faithful and con-
tinuous service counts for something when
questions of advancement arise.

Colonel Sutherland was Senior Surgeon
of the Medical Corps, and has — as the
Philadelphia Ledger says — earned his pro-
motion by honorable and meritorious service
on the field of battle, as well as in the hos-
pital— in war as well as in peace. He is as
reserved in matters of personal preferment
as he is forward in all matters in the line of
his professional and military duty ; and his
promotion to the Surgeon-Generalship is
due, we believe, entirely to his creditable
and honorable record.

Dr. John S. Billings, whose name is so
familiar to the medical world, was strongly
urged for appointment, and would, we feel
sure, have admirably filled the position, but
we think the President did well to resist the
pressure to appoint Dr. Billings, who will,
no doubt, wait without repining until his
turn fairly comes. Meanwhile the army
and the medical profession will continue to
have his valuable services, and he will not
have to contend against the difficulties in-
separable from a promotion over his seniors
in service.

APPOINTMENT OF A LECTURER ON
THERAPEUTICS AT THE JEFFER-
SON MEDICAL COLLEGE.

The Committee of the Trustees of the Jef-
ferson Medical College, appointed to select
an instructor to fill for the remainder of the
college term the chair of Materia Medica,
General Therapeutics and Hygiene, lately
occupied by Professor Roberts Bartholow,
on December 12 named Dr. Albert P. Bru-
baker for the position.

When the action of the Trustees in ap-

Jan. 3, 1 891.

Book Reviews.

21

pointing the committee for this purpose be-
came known, the students of the College
who had favored Dr. Brubaker's selection
started a petition to the faculty to that effect,
and in a short time, it is stated, it had over
five hundred names on it. On the petition
coming before the Faculty, that body ap-
pointed a committee to confer with the com-
mittee of the Trustees, with the result noted
above.

Dr. Brubaker is a graduate of the Jeffer-
son College, of the class of 1874. In 1879
he was appointed Demonstrator of Experi-
mental Physiology in Jefferson College.
From 1885 to 1889 he was Demonstrator of
Experimental Therapeutics. Since 1885 he
has also been Professor of Physiology in the
Pennsylvania College of Dental Surgery.

In making this appointment we believe
the Trustees of the Jefferson College have
found a happy solution of the difficulties
into which they were precipitated by Dr.
Bartholow's retirement. Time is afforded
to see if Dr. Bartholow can resume his work,
or to find a successor who will add to the
reputation and success of the College; which
meanwhile will have the services of an ex-
cellent lecturer on one of the most important
branches of its curriculum.

Book Reviews.

[Any book reviewed in these columns may be obtained upon
teceipt of price, from the office of the Reporter.]

THE SCIENCE AND ART OF OBSTETRICS.
By Theophilus Parvin, M. D., LL. D., Pro-
fessor of Obstetrics and Diseases of Women and
Children, in Jefferson Medical College, Philadel-
phia. Second Edition, revised and enlarged. Illus-
trated with 239 wood-cuts, and a colored plate.
8vo, pp. 704. Philadelphia : Lea Bros. & Co., 1890.
Price, Cloth, $4.25 ; Leather, $5.25.

The early appearance of the second edition of this
work is evidence of the favor with which the first
edition was received. Parvin's Obstetrics is universally
conceded to be one of the best manuals extant. The
author has drawn more largely upon French litera-
ture, and leans more strongly towards French practice
than is the case with other English and American
authorities. This feature of the book renders it a more
real addition to American literature. The style
throughout is admirably clear and pleasant, and re-
markably free from dogmatism. The reader is thus
left to form his own judgment when authorities differ.

Appearing at this time, when the subjects of extra-
uterine pregnancy, placenta prsevia, and the Cesarean
section are attracting such merited attention, it will be
interesting to observe the position of so conservative a
man with reference to these subjects.

While tubal pregnancy is considered by far the most
frequent, all the varieties of ectopic pregnancy are
admitted, or at least are not rejected, and ample cita-
tions from the literature of the subject are given. The
work of Mr. Tait is fully appreciated — although his
theories are by no means all accepted — but is not per-
mitted to obscure the work of older and contempo-
raneous men. Ectopic pregnancy is estimated to
occur once for every five hundred cases of pregnancy.
This estimate is far higher than the usual one, but is
amply supported by accumulating evidence. Salpin-
gitis is regarded as the usual cause of ectopic preg-
nancy. The question of diagnosis is admirably pre-
sented. Broadly speaking, abdominal section and re-
moval of the gestation cyst is recommended, whenever
ectopic pregnancy is diagnosticated. After consider-
ing the question of electrical treatment, the author
says : " No impartial reader of the reports of cases by
competent and reputable men, can doubt that some
cases of ectopic gestation have been conducted by this
means to a favorable termination." But he concludes :
" Goodell would restrict the application of electricity
to those cases refusing abdominal section, or'when no
one can be found capable of doing the operation. I
think this is the most that ought now to be said in
favor of the treatment by electricity." This is certainly
the view of impartial men.

During the second half of pregnancy prompt ab-
dominal section is likewise advised. The only excep-
tion is when the fetus is dead, when sufficient delay to
permit obliteration of the placental blood,- vessels is
advised. Whenever it is possible the fetal sac and
placenta should be removed. Otherwise the placenta
must be left. In this case the usual method may be
employed, of leaving the umbilical cord to hang out
of the abdominal wound, trusting to the drainage-tube
to take care of the subsequent suppuration ; or the
cord may be ligated and removed close to the placenta,
the sack thoroughly cleansed, and the wound closed
without drainage, in the hope that the placenta may
be absorbed ; or this failing, a secondary operation
may be done for its removal, should suppuration or
septic changes occur.

A most elaborate review of the subject of placenta
prsevia is presented. The author evidently considers
the tampon a most valuable device, and says but little
concerning its dangers. But the methods of Barnes,
and more especially of Hicks and of Murphy, which
have revolutionized the subject, are fully given. It is
interesting to find that the method of Hicks, employed
in Germany in 190 cases, saved all but nine mothers.
Murphy has had. 38 cases, and only two maternal
deaths. How pleasant a picture compared to the old
mortality of 25 or 30 per cent. !

Our sensibilities are rudely shocked by the state-
ment that the term Cesarean section has no connection
with Caesar, but is derived from the operation — carso
matris utero. No evidence is given in support of this
statement. Parvin accepts the limitations of Winckel
for the performance of Caesarean section, viz., when
the conjugate is 2.6 inches in the generally contracted
pelvis, or 2.1 inches in the flat pelvis. But he adds that
embryotomy in pelves approaching these limits will
prove, in the hands of those not expert, often more
difficult than the Caesarean section. Operation at a
selected time, towards the close of pregnancy, is
advised, rather than to await labor. In discussing the

22

Special Article.

Vol. lxiv

relative indications of embryotomy and Csesarsean
section the author is evidently in sympathy " with the
increasing number who condemn its [embryotomy]
performance where the child is alive." As indications
for embryotomy, other things being equal, are given :
I. When the child's life is endangered, so that the
probabilities of saving it by Csesarean section are
slight; 2. When delivery of the child without mutila-
tion is impossible, and the mother refuses section ; 3. If
pregnancy is at term, and delivery is possible with pre-
mature labor, embryotomy may be selected in the hope
of delivering a living child in a subsequent pregnancy
by inducing premature labor. Cases in which the
delivery of a living child is impossible, and yet in
which embryotomy is safe, are difficult for decision.
The woman must decide herself. Obstruction to labor
due to cancer of the uterus or vagina suggests gastro-
hysterotomy, rather than embryotomy. The mortality
of embryotomy in proper cases given as o ( Winckel) ;
six per cent. (Auvard) ; of Csesarean section, 8.4 per
cent. (Winckel), 25 per cent. (Auvard).

Our space prevents a further examination of this
book ; but these chapters cover those subjects in
obstetrics in which recent advances have been made ;
and most faithfully has the author presented the sub-
jects. With reference to the Csesarean section, we
could wish that emphasis had been laid on the neces-
sity for the examination of women during pregnancy,
so as to be forewarned of existing conditions. Finally
it would be well for women, not only that the book
should find its way into every library, but also that its
precepts should be mastered by every practitioner.

MEDICINAL-KALENDER FUR DEN PREUS-
SISCHEN STATT AUF DAS JAHR, 1891. In
two parts. Berlin : August Hirschwald, 1 891.

This exceedingly useful publication comes promptly
before the beginning of the new year, and contains in
addition to the form of record for physicians' work
which is used in Germany, a large amount of useful
literature. It contains abstracts in regard to thera-
peutics, diagnosis, hygiene, autopsies, and a directory
of physicians in the German Empire. For other than
Germans it is a very valuable means of learning a great
variety of facts in regard to medical matters in the
German Empire.

Literary Notes.

— Mr. George Keil, 1715 Willington Street, Phila-
delphia, has in preparation the Medical and Dental
Register- Directory and Intelligeftcer, for the States of
Pennsylvania, New Jersey and Delaware, to be' ready
early in 1 891, and desires every physician in this
region to send him the following points : Name in full,
school of graduation and year, street and number,
post-office and State, office hours.

The Medical and Dental Intelligencer will contain
in a condensed form information relative to the Asso-
ciations, Colleges, Hospitals, special and general Dis-
pensaries, Homes, etc.

Its list of National and State Medical and Dental
Organizations, giving list of officers, time and place of
meeting, and post-office address of physicians and
dentists, their office hours (in cities) school of gradua-
tion and year, will be complete to date of issue.

The work will be mailed to each physician and
dentist whose name appears in its pages.

Special Article.

KOCH'S REMEDY FOR TUBERCU-
LOSIS.

A RESUME OF ITS HISTORY.

\_Continued from Vol. Ixiii, page /j8.~\

The Glasgow Medical Journal for Decem-
ber contains a letter from Dr. W. Gordon,
written from Berlin, November 18, and giv-
ing the views of Prof. Liebreich in regard
to the Koch remedy. These may be sum-
marized as follows : Prof. Liebreich thinks
the fluid is certainly efficient as a test of the
presence of tuberculosis and in the treatment
of lupus — although he claims only improve-
ment and " dare not" say cure. For phthi-
sis he believes in " general improvement in
some cases," but "no cure yet."

In a lecture before the Society of Physi-
cians of the Charite Hospital in Berlin, Nov.
20, 1890 (Berliner Klinische Wochenschrift,
Dec. 1, 1890), Kohler showed a number of
patients in whom he had used the lymph for
diagnostic and therapeutic purposes. In
regard to the former, he claimed that per-
sons with tuberculosis reveal the fact by a
marked local reaction, while many cases of
other surgical t lesions present no such .reac-
tion. As to the former he showed a case of
superficial lupus which he said was fully
healed. He concluded with the statement
that Koch's discovery is a "triumph of sci-
ence."

In the Berliner Klinische Wochenschrift,
December 8, Leyden gives a most interest-
ing account of his experiences with the
lymph from November 20 to November 27,
covering 46 patients and 136 injections. His
paper is a model of scientific fairness and dis-
cernment. He made an especially and very
important point of the indications of the
tuberculous character of serous pleurisy
which were furnished by the effects of the
lymph under his observation. As to the
diagnostic value of the symptoms of reac-
tion, he says that some patients who pre-
sented the reaction were absolutely free from
suspicion of tuberculosis — as in cases of
scarlatina and erysipelas. He concludes by
saying his impression is that the " lymph "
is an extraordinary medicament, but does
not venture to claim that it is a trustworthy
means of diagnosis. As to its curative prop-
erties he says he cannot express an opinion.

Jan. 3, 1891. Special

Article.

23

As to the changes in the bacilli, he says they
cannot be regarded as a characteristic effect
of the lymph because like changes are ob-
served at times in untreated cases.

The first physician in America to adminis-
ter the Koch lymph was Dr. J. P. C. Foster,
of New Haven, Conn., who on December 3
used it on a patient with consumption.

Oh December 9 Dr. V. P. Gibney, of
New York, used the lymph for Dr. Allan
McLean Hamilton, at the N. Y. Hospital
for Ruptured and Crippled.

On December 10 Dr. William H. Ben-
nett, of Philadelphia, began using the
lymph.

On December 10 Dr. Francis S. Kinnicut
used it at St. Luke's Hospital, New York.

On December 12 Dr. Osier began using
it at the Johns Hopkins Hospital.

On December 13 the University of Penn-
sylvania issued as a special number of the
University Medical Magazine, a bulletin
summarizing the facts so far published in
regard to the Koch remedy and describing
the method determined upon for its system-
atic study by a commission of the Uni-
versity.

On December 17 the lymph was first used
at the University of Pennsylvania by Dr. J.
William White and Dr. J. H. Musser, and
at the Jefferson Medical College by Dr. F.
P. Henry, Dr. William M. Angney and Dr. J.
Solis-Cohen. The reports from the latter
institution indicate nothing of special im-
portance— reaction and hope on the part of
the patient are recorded. At the Univer-
sity the effects of the lymph are being
carefully and thoroughly investigated, and
no reports are to be made public until
enough observations have been made to
warrant them.

[On December 29 Dr. Cohen informs the
Reporter that his patient at the Jefferson
Medical College, a young man set. 26, is an
instance of advanced tuberculosis pulmonum
et laryngis, with softening in the apex of the
right lung and with nodular infiltrations upon
the vocal bands and in the posterior wall of
the larynx. He had been under treatment for
two months, with large doses of creasote in-
ternally, and topical applications of first
lactic acid, then menthol, and subsequently
iodoform, under which he was progressing
favorably ; the night-sweats having ceased,
nutrition having improved and the tempera-
ture having become practically normal. Tu-
bercle bacilli, however, remained very abun-
dant in the sputa. When the Koch treat-

ment was instituted, the former treatment
was suspended. The constitutional reaction
was moderate under the first injection, and
the larynx underwent marked congestion
without any signs of oedema. After the
second injection, the constitutional reaction
was greater ; and the inflammatory manifes-
tations became more marked upon the vocal
bands and in the posterior wall of the larynx.

After the third injection, the reaction was
a little less than after the second, but this
was soon followed by an absolute reduction
of temperature below normal, and by a com-
mencement of ulceration in the posterior
laryngeal wall, so that it was decided to sus-
pend the injections and watch the local man-
ifestations. While the patient considers
himself much better, Dr. Cohen does not
consider his condition as good as it was
when the injections were begun, and, unless
on December 29, a marked improvement
was found upon the condition noted on
Saturday, the treatment with creasote and
iodoform was to be resumed.]

In the Berliner Klinische Wochenschrift,
December 10, 1890, there are instructive
papers by Senator, Henoch, Litten, Turban
and Ewald. Senator calls attention to the
fact that he has now found the reaction did
not correspond in the earliness of its onset,
its amount or its continuance to the severity
or extent of the tuberculous process. He
says this reaction is exactly similar to what
is known as febricula or ephemeral fever.
He found evidences of depression of the
force of the heart during its reaction. On
account of the explanation of the modus
operandi of the "lymph" — necrosis of the
tuberculous tissue — he thinks the |remedy
especially valuable for tuberculosis of open
passages like the pharynx and larynx, the
intestines, and the urinary tract. He has
seen it do good in a number of cases.

Ewald 's paper is of very great interest as
a thorough and systematic study of about
one hundred cases in which the lymph was
administered. The general conclusion may
be stated as that it is useful for diagnostic
purposes and as a remedy in the initial
stages of tuberculosis of the lungs as well as
in pleurisy.

The Deutsche Medicinische Wochenschrift,
December 11, contains an address by Hel-
ferich, delivered before the Greifswald Med-
ical Society on December 6, in which a full
description is given of the effects produced
by Koch's remedy in a number of cases of
lupus and tuberculosis of the bones and

24

Special

Article.

Vol. lxiv

joints. It concludes with the statement
that, in view of his experience, we may have
" not the hope but the certainty that Koch's
remedy in diagnostic and therapeutic rela-
tions marks an epoch-making advance."

In the same journal, Wolff, Director of
Dr. Brehmer's Sanitarium at Gorbersdorf,
gives his experience of the reaction of phthis-
ical patients after receiving injections of
Koch's remedy. He found that advanced
and grave cases furnished more marked re-
action after minimal doses and that incipient
and light cases sometimes reacted only after
a repetition of the first dose. He describes
some cases in which the patients were de-
cidedly worse after receiving the injection ;
but he says the lymph did good service at
Gorbersdorf as an aid to diagnosis.

Arning, of Hamburg, in the same jour-
nal reports the use of Koch's remedy in two
cases of leprosy : one showed no reaction
whatever ; the other, under the care of Dr.
Engel-Reimers had a marked reaction ; but
this was general and not such at the points
of leprous manifestation as is reported in
regard to lupus.

Before the Medical Society of Hamburg,
Schede, on December 2, reported good
early results with the remedy in cases of
lupus, tuberculosis of the joints. Maes, of
Hamburg, reported good early results in lu-
pus cases. Kast expressed a conservative
opinion as to the therapeutic value of
Koch's remedy ; but spoke favorably of it
as a means of diagnosis.

In the same journal in a report of a lec-
ture by Paul Guttmann in which he de-
scribed the manner of administering Koch's
remedy and showed two young women as
cured, who had had pronounced symptoms of
tuberculous catarrh of the apex of the lung.

The British Medical Journal, December
13, contains a lecture delivered by Sir
Joseph Lister at Kings College, December
3, in which he not only expressed great
confidence in the diagnostic and therapeu-
tic value of Koch's lymph, but also intima-
ted that before many weeks the world might
be startled by the disclosure by Koch of an

inorganic chemical substance as easily ob-
tained as any article in the materia medica"
which he saw cut short in animals the other-
wise deadly course of "two of the most
virulent infective diseases to which man is
liable."

In the same journal in an address by Dr.
Yeo describing his observations at Berlin ;
as to the curative value of the lymph he says :

" Here, however, as well as elsewhere, it
was scarcely possible, so short a time had
the patients been under treatment, to ob-
serve that any actual curative changes had
taken place. But it was exceedingly inter- '
esting and important to note the action of
Koch's injections in cases in different stages
of this disease."

As bearing on its diagnostic value he says
he saw a case of chronic phthisis that had
been in Davos for two years, and failed to
react to doses of 3, 5, and 8 milligrams
respectively ; and there were one or two
more case of undoubted chronic phthisis
with bacilli in the sputum that had not re-
acted to the injections that had been made
up to the time of his last visit. Another
case in Professor Ewald's clinic, that yielded
no marked reaction after injection of ordi-
nary doses, was that of a highly neurotic
young man, with tubercle bacilli in the ex-
pectoration, but no well-marked pulmonary
physical signs. This was also the case with
a gentleman who was in a private sanatorium
in Berlin, and whom Dr. Yeo had seen in
London in September, 188.7. ^n this case
there were evidences of a good deal of
pleural thickening, and probably extensive
fibroid changes in the left lung.

Nevertheless, he says : "Of one thing
there can be no doubt ; we have in this fluid
of Koch's an agent which exerts a specific
action on tuberculous processes. A minute
quantity, such as from 1 to 10 milligrammes,
which produces no effect on non-tubercu-
lous persons, gives rise to the remarkable
effects with which we are now familiar in
persons affected with tuberculosis." . . .

Again he asks : " Have we here a cure for
tuberculosis ? and a cure for pulmonary
consumption?" and adds: "I put the
two questions separately because I do not
consider them identical. ... In advanced
pulmonary consumption we have morbid
changes to deal with other than those origi-
nally started by the tubercle bacillus, and
even if we could destroy every bacillus in
the lung as well as the products of their
agency, we should in many instances still
have to deal with a hopelessly damaged
organ. And, even although Koch's treat-
ment may be essential to the arrest of the
disease in less advanced cases, hygienic and
medicinal measures will be as needful as
ever to guide the patient to a permanent
cure. . . . I am disposed, from what I have
already seen, to conclude that Koch has not
been deceived in the observations on the

Jan. 3, 1 89 1. Notes and

Comments.

25

human subject which he has already made,
and that his published conclusions will, in
the main, be found just and accurate."

In the same journal, Dr. R. W. Philip, of
Edinburgh, a special student of consump-
tion, after a careful investigation of the
subject in Berlin and in his own hospital
practice says : " With regard to final results
in these cases, especially in phthisis, it is
premature to say much. In very advanced
cases, of which I had the opportunity of
studying about a dozen, I cannot say that
I was satisfied of any definite improvement.
The post-mortem results of the two or three
fatal cases, so far as they have been com-
municated, point, however, to a local in-
fluence having been exerted on the affected
organs.

"In less advanced cases, but still cases
where, prior to the special treatment, physi-
cal examination revealed considerable areas
of percussion dulness and abundant crepita-
tions and when the patient suffered from loss
of flesh, hemoptysis, night-sweats, and ano-
rexia, the report must be more hopeful.

<£In a considerable proportion of these I
think we may safely admit that very definite
amelioration can be effected. I observed a
number of cases where night-sweats had dis-
appeared, where the cough was practically
gone, where there was a diminution or
cessation of expectoration, and where the
patient's subjective condition was better, and
a few where there was a gain of several
pounds in weight. In very few cases was
I able to trace important improvement in
the physical signs \ but the time was too
short for this, and no case has, so far as I
was able to learn, been released from treat-
ment as cured. Still I think, pending fur-
ther observation, we are bound to fall back
on the authority of Koch, who states cate-
gorically that within four to six weeks
patients under treatment in the first stage of
phthisis were all freed from every symp-
tom of disease, and might be pronounced
cured."

Likewise in the same journal there is a
report of cases observed by Dr. William
Hunter in Berlin, and treated by Mr. Watson
Cheyne and by Dr. Heron in London.
Reports of use of fluid at Manchester,
Dublin, Glasgow are made and it is said that
twenty-three cases were under treatment at
Edinburgh, and that the fluid has been
tested at the Brompton Hospital. It has
also been used for the first time in Italy, by
Prof. Bacelli, on November 29.

Notes and Comments.

Forty-five Days' Fast.

Succi, the Italian faster, who began a fast
of 45 days in New York on November 5,
ended his fast at 8.23 p. m., December 20,
1890. Other fasters have gone forty days
without food, but they were so weak that
they could not sit up. Dr. Tanner could
not sit up after the tenth day, and could not
write his name after the fifteenth day, but
Succi has scorned the idea of weakening all
through the weary weeks. On his fifteenth
day he rode seven miles on horseback, and
has exercised every day since. During his
fast Succi drank freely of water, and took
small quantities of a liquid which he calls
an elixir and which is supposed to contain
morphia.

At 6 p. m., December 20, he was exam-
ined and his weight was found to be 104^
pounds; on November 5 it was 147^
pounds — a loss of 42^ pounds, or less than
a pound a day. His temperature was 98.2 ;
pulse, 62; respiration, 19; general condi-
tion weak ; tongue clear, moist and steady.
The bulletin was signed by the thirteen phy-
sicians who have watched during the fast.
The worst attack of gastric trouble that he
had during his fast occurred on the last day,
during which his pain was so acute that it
was feared he would collapse ; but his will
power carried him through. From 5 p. m.
until he took his first cup of cocoa, at 8.20,
his pain continued to be more or less acute.
It was evident in many ways — by the dis-
tortions of his face, which was horribly
shrunken ; by his frequent change of posi-
tion on the lounge upon which he was re-
clining ; by the nervous twitchings of his
wasted hands ; by the restless glare of his
deep-sunken eyes, and in various other ways.

When the cocoa was prepared, shortly
after 8 o'clock, Succi got off the lounge and
staggered to the table where the nourishing
diet was placed. The spectacle he presented
was pitiable. He looked like a skeleton.

The next day Succi arose from sleep after
a long slumber, which he# fell into shortly
after his feat was ended, and an elaborate
meal was placed before him. He ate with
extraordinary relish.

Following is the menu : Anchovies, with
butter ; chicken soup, with rice ; fried
smelts, fried calves' brains, quail on toast,
cocoa pudding, fruit, confections, ice-cream,
coffee ; one-half pint Rorals Extra ; one-half

26

Notes and

Comments.

Vol. lxiv

pint Grand Sec. He occupied two hours in
consuming the food placed before him. He
never faltered, but ate with zest.

Extirpation of the Bladder.

At the meeting of the Tenth International
Medical Congress, at Berlin, in August last,
Pawlik, of Prague, read a paper on extirpa-
tion of the bladder, which appears, in the
form of an abstract, in the Mercredi Medi-
cal, November 5, 1890. It seems that the
patient upon whom the operation was per-
formed had persistent hematuria, which was
ascertained, by catheterization of the ure-
ters, to come from above the bladder. When
the urethra was dilated, digital exploration
and examination through the endoscope dis-
closed the presence of a polyp having a
slender pedicle. The polyp was removed
with the thermo-cautery through an opening
from the vagina into the bladder, the fistula
being subsequently closed. Complete re-
covery ensued. The woman left the hospi-
tal July 28, 1888.

One year later, in July, 1889, the patient
returned. For eight months after the oper-
ation she had been in very good health, then
hematuria reappeared and persisted. By
endoscopic examination a papillomatous
mass was discovered, attached over a large
part of the surface of the bladder; the
growth proved upon microscopic examina-
tion to be malignant. A radical operation
was decided upon. The one adopted con-
sisted in separating the ureters from the
bladder and fastening them in the anterior
vaginal wall, then excising the bladder and
creating a new bladder by utilizing the re-
maining portions of the urethra and vagina.

The first operation was performed August
3, 1889. After the introduction of a me-
tallic catheter into each ureter, the woman
was placed in the knee-chest position ; the
vagina was then incised, in the direction of
each ureter, for a distance of three-fourths
of an inch, the ureter was dissected up and an
incision of one-third of an inch was made in
its posterior wall. Below this incision, the
ureter was tied, and then separated at its
vesical end from the bladder, the edges of
the orifice of the ureter being then sutured
to the opening into the vagina. Extirpation
of the bidder was performed August 27, at
a second operation. The bc^ ot:
and, without injuring the peritoneum, the
bladder, previously filled with an emulsion
of iodoform so as to make it easily recogniz-

able, was dissected to the internal orifice of
the urethra. The bladder was then emptied
and the sub-vesical space was tamponed
with iodoform gauze, to prevent any hemor-
rhage. A transverse incision was now made
immediately over the prominence made by
the urethra in the anterior vaginal wall ;
this incision was made sufficiently large and
the bladder was brought down through it
into the vagina and excised at the internal
urethral orifice. At this point in the opera-
tion, the patient went into collapse, but re-
covered on receiving a subcutaneous injec-
tion of nine and one-half fluid ounces of
warm physiological salt solution. The an-
terior vaginal wall was sutured to - the an-
terior border of the urethral wound, while
the posterior border of this as well as a
circular freshening of the entrance of the
vagina were utilized to close up the vul-
var outlet. Before trying the sutures, an
elastic catheter was introduced into each
ureter. The abdominal wound was closed
down to its inferior angle, from which
strands of 'iodoform gauze passed. The at-
tempted closure of the vagina (colpocleisis)
failed, and a fistula formed at the junction of
the anterior vaginal wall with the anterior
border of the urethral wound. Another at-
tempt at colpocleisis, made June 20, 1890,
also failed. On July 18, Pawlik performed
sagittal colpocleisis, which succeeded, save
for the persistance of a small fistula imme-
diately behind the urethra. When in bed
the patient retained her urine a long time ;
but when she rose, the urine dribbled
from the fistula. She 'is fully aware when
the new bladder, which has a capacity of
about thirteen fluid ounces, is distended
with urine ; and she is able to evacuate it
voluntarily, by the action of the perineal
muscles. There is no doubt, Pawlik thinks,
that if the fistula closes, the artificial blad-
der will possess sufficient retentive power.
However that may be, it is a satisfactory re-
sult already, that the patient, who for a year
was exposed to imminent death, can endure
a great deal of fatigue.

Infant Feeding.

In an article in the Northwestern Lan-
cet, November 1, 1890, Dr. A. H. Tufts
says :

P ^ularity of time of feeding should be
carefully observed. The infant stomach
needs periods of rest just as much as the
stomach of an adult. The habit of throw-

Jan. 3, 1 89 1. Notes and

Comments.

27

ing a bottle full of milk, accompanied by
the deadly tube, into the crib or into the
carriage for the infant to pull at while being
trundled about in the hot sun, giving him
the opportunity to gorge his stomach at any
and all times, is enough to kill a robust
man, to say nothing of a tender infant.
Under one month of age, once in two hours
is often enough to feed the healthy baby,
the time to be gradually increased until at
six months it is fed once in three or four
hours from six a. m. until ten p. m. From
ten p. m. to six or seven a. m. the child
should sleep through, without feeding. We
need to constantly warn and caution the
over-anxious mother against overfeeding, or
all our painstaking and care may be coun-
terbalanced.

Too often the infant is given food when
it needs and wants water instead. Dr. Tufts
says he has often known of infants several
weeks old who had not been given a spoon-
ful of water, and whose parents seemed sur-
prised when told the little one needed it as
much as any one. Sometimes the mother
says it will not take cold water; when it
may be given warm. If babies were earlier
taught the habit of taking freely of water he
believes constipation would be less frequent
among them.

Symptoms of overfeeding are restlessness,
vomiting and undigested food in the feces.
The latter used to be always called undi-
gested curds or casein. Now comes one
who says this is undigested fat, and proves
his statement by saying this material is solu-
ble in ether and alcohol, while casein is not.
This, if true, must make quite a difference
in our regulating the proportions of milk
and cream.

[In this connection we quote from the
Medical Record, November 15, 1890, thus:
Dr. Macleod says mother's milk is always
considered by the people of India as insuf-
ficient to sustain infant life, and various
kinds of milk or other artificial kinds of
food are suggested by wise friends to replace
it. Cow's milk is generally used as infant
food by all middle-class people of Bengal.
Donkey's milk is largely consumed in rich
families. The Mohammedans, whether rich
or poor, prefer goat's milk to any other of
its kind ; while sheep's milk is considered
to be the best article of food by the people
of the Northwestern Provinces. Instances
have been known where mothers with full
breasts and an abundant supply of milk
have kept their offspring entirely upon arti-

ficial food and thus invoked disease. — Ed.
Reporter.]

Mayer's Ointment.

In a recent issue of the Pharmaceutical
Era Professor J. U. Lloyd goes into the
origin and history of Mayer's ointment, a
favorite with eclectic practitioners. Prob-
ably John Quincy's "Common Plaster"
was a forerunner to it, but it appears certain
that some forty years ago a domestic oint-
ment obtained considerable reputation
among certain citizens of Cincinnati, and
became known under the name " Mayer's
Ointment." This ointment was supplied in
small tin boxes, and was prepared by a Mrs.
Mayer, who exercised great secrecy in the
purchase of the ingredients, buying them
severally from different druggists, a few from
each, in order that no person should learn
the entire composition of the salve. A for-
mula for an ointment similar to this was
given to Professor John King by Mr. Joseph
P. Mayer, of Cincinnati, and it was intro-
duced into his "Eclectic Dispensatory."
The formula is as follows: — To olive oil, 2^
lbs., add white turpentine, y2 lb. ; beeswax,
unsalted butter, of each 4 oz. : melt them
together and heat to nearly the boiling point.
Then add gradually red lead 1 lb. and stir
constantly until the mixture becomes black
or brown ; then remove from the fire, and
when it has become somewhat cool, add to
it a mixture of honey, 12 oz., and powdered
camphor, y2 lb. Lard may be used instead
of butter. — Chemist and IJrttggisl, Novem-
ber 8, 1890.

Lanolin Milk.

Paschkis recommends lanolin milk as a
most excellent cosmetic, especially for skins
poor in fat. It is valuable also as a powder
base, giving the skin an almost invisible
covering of fatty material, which takes and
holds cosmetic powders most admirably. It
is prepared as follows (approximately) :

Rub up 75 grains of lanolin with about
a fluid ounce of water, warming gently. To
this mixture add 4 grams neutral soap dis-
solved in an ounce of water ; rub up again,
and immediately add sufficient warm water
to make about 12 fluid ounces and agi-
tate thoroughly. If desirable, 15 grains of
tincture of benzoin or borax dissolv-d in a
little warm >vater may be added. The mix-
ture must be strained, because, even when
most carefully made, small lumps of uncom-
'bined lanolin wTill remain suspended in it.

28

News.

Vol. lxiv

Condensed Milk for Emulsions.

It is said that nothing equals condensed
milk for making emulsions, and according
to the Formulary, the expense is not rela-
tively great. To make a pint of 50 per
cent, emulsion of cod-liver oil, take of

Cod-liver oil . . 8 fl. ounces.

Condensed milk .......3ft. ounces.

Glycerin or syrup 3 fl. ounces.

Water 2 fl. ounces.

Add of a flavoring oil, such as bitter al-
mond, 10 drops, or wintergreen, 15 drops.

Rub the condensed milk round in a dry
mortar, and gradually add the cod-liver oil,
working it in as is customary in making
emulsions. When thoroughly incorporated
add the glycerin, and lastly the water and
flavoring extract.

Malaria in Birds.

Danilewsky has recently written to Dr.
Dock, of Galveston, Texas, that he has seen
acute malaria in birds, with rosette forms of
the parasites, confirming his earlier view of
the similarity [he says in parenthesis, " iden-
tity?"] of the organisms.

NEWS.

— Dr. Matthew Woods has removed to
1307 South Broad Street, Philadelphia.

— Dr. L. Webster Fox has just been ap-
pointed ophthalmic expert to the Board of
Pension Examiners of the Philadelphia dis-
trict.

— Dr. B. A. Randall has been elected
Clinical Professor of Otology, at the Uni-
versity of Pennsylvania, succeeding Dr.
George Strawbridge, resigned.

— The steamer San Juan, at San Fran-
cisco December 4 from Panama, reported
that the cholera was making terrible ravages
in Guatemala. More than 12,000 cases were
reported in the State and 1,200 deaths had
occurred in the city of Guatemala in seven
weeks.

— The prize offered by the Medical So-
ciety of the County of New York for the
year 1890 has been awarded to Dr. David
Cerna, assistant in physiology, University
of Pennsylvania, for his essay entitled, " A
Physiological and Therapeutical. Study of
Hydrastis Canadensis."

—Dr. Albert P. Brubaker, of Philadel-
phia, was, on December 12, chosen by the
Committee of the Trustees of the Jefferson
Medical College to fill, for the remainder of
the college term, the chair of Materia
Medica, General Therapeutics and Hygiene,
lately occupied by Professor Roberts Bar-
tholow.

— Word is received from Nicaragua that
a new disease has appeared there and has
caused several deaths. The victims are
seized with severe pains in the stomach.
The pain is followed by dysentery and if
prompt measures are not taken the sufferer
dies within four hours. Dr. Espenosa, of
that place, considers the disease a precursor
of cholera.

— It is stated in the newspapers that a
San Francisco physician has cured a num-
ber of cases of cancer, and that three pro-
nounced cases from the New York Cancer
Hospital are now on the way to San Fran-
cisco in charge of a prominent surgeon from
New York, to be operated upon. The result
will perhaps determine whether the treat-
ment shall be introduced into the New York
Hospital.

— The Senate, on December 30, con-
firmed the nomination of Dr. Charles Suth-
erland to be Surgeon-General of the Army.
Dr. Sutherland is the ranking surgeon of
the medical corps, and in making this pro-
motion the President followed the rule of
seniority. Dr. Sutherland is a native of
Pennsylvania, and was appointed to the
army from this State in 1852. He has a
good record for service in the army and
stands high in his profession and with officers
of the line and staff of the army. He has
four years to serve from May next before
reaching the age for compulsory retire-
ment.

— Dr. John Davis, one of the oldest phy-
sicians of Cincinnati, died suddenly on
Christmas night at his home. He had been
at Christmas dinner with his wife and a few
friends, and while sitting in his library, was
attacked with a violent fit of coughing. In
half an hour he was dead. Dr. Davis was
nearly 70 years old. He was an intimate
friend of ex-President Hayes, and often
entertained him and Mrs'. Hayes, on their
visits to Cincinnati. Dr. Davis was, at the
time of his death, President of the Union
Central Life Insurance Company, and also
President of the Law and Order League of
Cincinnati, in whose interest he was earnest
and active.

Medical and Surgical
Reporter

A Weekly Journal.

Established in 1853 by S. W. Butler, M.D

CHARLES W. DULLES, M. D., Editor and Publisher,

Entered as Second-Class matter at Philadelphia P. O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

Vol. LXIV, No. 2.
Whole No. 1767.

JANUARY 10, 1891.

$5.00 per Annum.
10 Cents a Copy.

OOITTEUTS :

CLINICAL LECTURES.

Hollopeter, W. C, M. D., Philadelphia, Pa.—
Acute Parenchymatous Nephritis following
Whooping-cough. — Chronic Parenchymatous
Nephritis mistaken for Chlorosis

Hare, H. A.,M. D., Philadelphia, Pa.— Whooping-
cough.— Green Stools of Childhood

32

COMMUNICATIONS.

Blackwell, Enos T., M. D., Cedarville. N. J.—
Malarial Fever, with Intense Liver Involve-
ment 35

Barr, A. D., M. D , Calamine, Arkansas.— Was it
Relapsing Fever ? 37

SOCIETY REPORTS.

Supra-pubic Cystotomy 38

PERISCOPE.

Hepatic Colic. — Grafting Skin from the Dead
Body.— Liquid Pepsins.— Peroxide of Hydrogen.
— Fatal Uremia in Persons Apparently Healthy.
— The Treatment of Burns.— Dyspepsia of Chil-
dren.—Lantanine as Febrifuge 42-46

EDITORIALS.

Immigration and Public Health 47

Transfusion of Blood and Salt Solution 47

Proposed Medical Examiners' Bill for Penn-
sylvania 48

Incorporation of the Pennsylvania State
Medical Society 48

BOOK REVIEWS.

Bourneville, Sollier and Pilliet ; Recherches
Cliniques et Therapeutiques sur l'Epilepsie,
l'Hysterie et lTdiotie : Clinical and Therapeu-
tical Investigations of Epilepsy, Hysteria and.
Idiocy.— Greenleaf ; An Epitome of Tripler's
Manual, and other publications on the Exami-
nation of Recruits.— Transactions of the New
York State Medical Association for the Year 1889. 49

SPECIAL ARTICLE.

Koch's Remedy for Tuberculosis 49

NOTES AND COMMENTS.

Proposed Act for Medical Examiners for Pennsyl-
vania.—Medical and Surgical College of New
Jersey.— Dilatation for Dysmenorrhcea.— Test-
ing Water.— Guaiac as a Purgative.— Death from
Injection into the Lung.— Hypodermic Use of
Strychnia.— Tannic Acid as an Intestinal Anti-
septic Remedy 51-57

NEWS 57

OBITUARY.

L. M. Huber, M. D 58

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MEDICAL AND SURGICAL
REPORTER

No. 1767. PHILADELPHIA, JANUARY 10, 1891. Vol. LXIV.—No. 2.

Clinical Lectures.

ACUTE PARENCHYMATOUS NEPH-
RITIS FOLLOWING WHOOPING-
COUGH.— CHRONIC PAREN-
CHYMATOUS NEPHRITIS
MISTAKEN FOR
CHLOROSIS.

BY W. C. HOLLOPETER, M. D.,

CLINICAL LECTURER ON DISEASES OF CHILDREN IN
MEDICO-CHIRURGICAL COLLEGE, PHILADELPHIA.

Nephritis after Whooping-Cough.

Gentlemen : You will recall this case as
the one I had before you a few weeks ago,
when I was illustrating the sequelae of whoop-
ing-cough. The child is but three years
old. The mother held the belief, so com-
mon among many of the laity, that the doc-
tor can be of but little use in relieving or
curing whooping-cough. Hence the little
boy has been permitted to encounter a
stormy disease unaided, a storm so violent
that nearly every organ in his body has be-
come involved in consequence.

You will recall the fact that, when I first
presented him to you a few weeks ago, he
was very weak and miserable, besides show-
ing a marked anemic condition, the result
of his recent severe illness. He has a per-
forated membrana tympani, and, as the nat-
ural accompaniment, a purulent otorrhcea ;
also an oblique inguinal hernia of the worst
possible character — the abdominal rings have
been so far dilated that the omentum has fol-
lowed the spermatic cord down into the
scrotum, and by long-continued friction in-
cident to the cough has formed inflamma-
tory adhesions of so firm a character as to
preclude, at least for the present, any hope
of reduction. The chain of cervical lym-
phatics is also enormously enlarged, extend-
ing from the mastoid process down to and
below the clavicle, and entering the medias-

tinum. This enlargement of the bronchial
glands has induced a constant cough by
pressure on the tubes, and the condition
was for a time very suggestive of broncho-
pneumonia. The cough had ceased, how-
ever, and the child was apparently improv-
ing. Two weeks ago the cough reappear-
ing, grew rapidly worse, and, in conjunction
with it, the child commenced to vomit, but
not very frequently at first. He was irrita-
ble, slightly feverish, and had lost his appe-
tite. These symptoms continued for a few
days ; fever of not an unusual type was pres-
ent for one day ; the child was restless and
very irritable, vomiting constantly for one
whole day, and with his sleep much broken.
At the expiration of the first forty-eight hours,
the fever, vomiting and persistent cough
diminished, the urine was now noticed to
be lessened in quantity ; and by the third
day, when the fever and vomiting had en-
tirely ceased, the urine was completely sup-
pressed. The face was now ashy pale ; the
eyes were sunken and dull, and the lids ap-
peared full and swollen. About this time
it was noticed that the most dependent por-
tions of the body commenced to show a
dropsical accumulation. In this sluggish,
stupid — I might say comatose— condition,
the little fellow remained for two days, and
during all that time he did not void one-half
an ounce of urine. A blanket wrung out of
hot water was used to envelop him, while
hot poultices were placed over the back, and
sinapism to the feet and legs. Milk and
water was his only food. Small doses of
calomel, frequently repeated, were exhibited,
until he had a free action of the bowels.
This acted as a derivative to his head, and
as a vicarious means of unloading the renal
pressure. One drachm of Rochelle salts was
also exhibited in hot water for the same pur-
pose. Slowly the kidneys resumed their
function. At first the urine was scanty, very
dark and coffee-colored, smoky from the
blood it contained; but as the quantity in-

29

30

Clinical

Lectures.

Vol. lxiv

creased, the color became lighter ; the dull,
shapeless face assumed a more intelligent
expression ; and the sluggish condition of
the boy became less marked. The outlines
of the eyes and nose grew more natural ;
and with the gradual dawn of intelligent
expression there was a subsidence of all the
nervous symptoms ; and thus our little pa-
tient had at last passed through the acute
stage of parenchymatous nephritis.

Acute nephritis, called parenchymatous or
desquamative nephritis, you will find is an
almost constant sequela of scarlet fever. It
also frequently follows measles, diphtheria,
small-pox, and occasionally typhoid fever ;
but it is extremely rare to find it following
whooping-cough. I have been unable to
find any mention of in the text-books. In
the light of modern investigation relative to
the acute infectious diseases of children, it
has been proven that in most, if not in all
of them, systemic infection occurs through
ptomaines, or the poisonous chemical agents
which are produced by the action of mi-
crobes in the system, which are the original
specific principle.

The symptoms of acute nephritis differ
according to the causes that produce it. If
it follows the specific diseases that I have
mentioned, its onset is much obscured by
the previous indisposition of the patient, as
was illustrated in our present case. If it
follows scarlet fever, the convalescence is of
necessity greatly retarded. We scarcely
know why the child has been so poorly, until
perhaps we make some inquiry concerning its
urine, when we notice that it is suppressed
or scanty, or, perhaps notice the commenc-
ing dropsy. The child may cough — in fact,
this child had scarcely got over the habit of
coughing which so frequently follows pertus-
sis, when the fever, the cough and the sup-
pression of urine announced the kidney
complication. You will recall the physio-
logical relation ■ that the skin and kidneys
bear to each other. You can understand
how we may have acute nephritis ushered in.
When the child'is perspiring at play, sits
down to rest, and is subjected to a draft, or
it takes a cold bath and a sudden suppression
of the urinary secretion is the result, the
whole burden of the excrementitious material
is thrown on the kidneys ; congestion and
inflammatory action is sure to follow.

An analysis of this child's urine as it now
is gives us the following result : Quantity
passed during the twenty-four hours, ten
fluid ounces j color, dark brown ; odor,

strong; albumin, 10 per cent, by volume ;
blood present in small quantity ; a small
quantity of mucus. Microscopical examina-
tion reveals epithelium, mucus, blood-fibrin
and hyaline casts.

»

Nephritis Mistaken for Chlorosis.

Our second case illustrates a train of symp-
toms that we rarely meet with among chil-
dren. This child, that I now bring before
you, has been ill for two years. Her history
is briefly as follows.

Minnie H., 15 years old; father and
mother both living and in fair health. They
have lost no children, and the family history
is good. Minnie has not been sick since
her third year, when she had measles. This
disease, however, was not attended by any of
the usual complications, such as acute ne-
phritis, or ear trouble, or enlarged glands.
She made a good recovery, so far as her pa-
rents could judge. Following measles, the
girl has had a long period of perfect health,
up to her thirteenth year. She was at this
time full of spirits and life, enjoying play,
and seeming as natural as is usual for a girl
of her age. She had a fair color, although she
was never of a rosy complexion. Her appe-
tite was good, although she did not enjoy
her food as a child of her age should.
About two years ago she was noticed to grow
less active; her disposition becoming more
quiet and somewhat sluggish ; her appetite,
at the same time, grew indifferent ; her de-
sire for companionship grew less ; in fact,
she became irritable in temper and morose
in habit. She avoided companionship.
When her girl friends would call on her,
their presence seemed to excite her, rather
than to give her pleasure. She seemed to
be better content to be alone than in their
company. She is a day dreamer. She will
now sit all day long gazing out of the win-
dow into vacancy ; and if you ask her what
she is looking at, she will scarcely be able to
tell you. Her temper has also changed, she
being easily annoyed. She will grow angry
and excited if opposed, or cry, if scolded.
Any unusual sight on the street, such as a
drunken man, or fighting dogs, will greatly
excite her and render her sleep troubled and
broken. She has been in this stupid condi-
tion for nearly two years, it is slowly but
surely becoming more marked.

During this interval she has been treated
for malaria, bronchial catarrh, and finally
for amenorrhea.

I saw this girl for the first time one week

Jan. 10, 1891.

Clinical Lectures.

3i

ago, when I elicited the history that you
have just heard. I was inclined to make a
diagnosis of chlorosis — a very common com-
plication of puberty. There was a heavy,
fetid odor about the girl's breath or person,
that suggested a purulent discharge, either
from the ear or throat. Careful examination
revealed neither ear nor throat trouble. She
was soft, white, anemic, yet not dropsical.
She appeared to be stupid, as she sat in the
chair and answered my questions in mono-
syllables. I could discover no dropsy. The
heart was greatly accelerated on examina-
tion, as would be natural in anemia. I
thought it might have been increased some-
what by my examination. The girl is well
developed for her age ; the mammary glands
are fully enlarged and all the evidences of
maturation have been reached. The mother
tells me she has never seen her monthly ex-
pression. Thinking I had simply a case of
chlorosis, or amenorrhoea, I prescribed a pill
ferri carbonates and arsenic. The mother
informed me at her first visit that she had
repeatedly asked the doctor about the girl's
water, saying it was scanty, and that she
passed it with difficulty and that it was of-
fensive. The day after her first visit, I was
hastily summoned to her bedside, when I
found the following condition. The girl
was unable to lie down, but maintained a
semi-recumbent position. The heart's ac-
tion was intensely accelerated, running at
the rate of 140 beats a minute. Dyspnoea
was painfully great. She was unable to re-
tain a recumbent position at all, and could
find comfort only in leaning forward and
supporting herself on a chair. She com-
plained also of sharp pain in the region of
the heart. On inquiry I found the urine
entirely suppressed. I ordered a counter-
irritation over the heart, and, as she had a
temperature of 1030 and thinking it was a
case of pleurisy, I gave her three grains of
acetanilid and one-fourth *grain of calomel
every hour. At the expiration of six hours
I was again summoned. Her symptoms
were not improved ; indeed she was in a
still more critical condition. The pulse was
so rapid that it was scarcely perceptible ; the
dyspnoea was greatly increased ; the position
that she now assumed was almost a hanging
one, forward; the stabbing, lancinating
pains in the region of the heart were inten-
sified ; her cough was dry, short and con-
stant. At this time I ordered a fly-blister
over the region of the heart, and also made
inquiry in regard to the urinary secretion.

The mother informed me that it was still
suppressed. Eight hours after the second
visit I saw her again, and found the symp-
toms still exaggerated ; her lips were blue ;
her face was blanched, approaching lividity;
the muscles of the chest were laboring fran-
tically ; the radials were imperceptible ; the
pain was still intense ; the cough was short
and dry. She was in a state of collapse. A
short time after this some relief was appar-
ently manifested in the expectoration that
she coughed out, as it was tinged with blood.
This increased until the mucus expectorated
was about one-half blood. The bloody ex-
pectoration, light and frothy, continued for
fully eight or ten hours, when it gradually
subsided, and with it all the distressing
symptoms.

Without going further into details, we
have here, gentlemen, a case of pericarditis,
left pleurisy and acute bronchitis as a result
of chronic parencymatous nephritis. Chronic
parenchymatous nephritis rarely follows the
acute form. It is also a disease of youth
and is seldom found after thirty-five years of
age. It is usually induced by some consti-
tutional defect or depressing surroundings.
These symptoms occurred in the order I
have named, simply by extension, and grad-
ually subsided. We obtained a urinary
analysis at this time, and found that the
girl was passing, on an average, about three
or four ounces of urine per day. This con-
tinued for a few days, when, under active
treatment, it gradually rose until twelve
ounces had been reached. You will remem-
ber that from forty to fifty-five ounces is the
usual average in health. A careful analysis
shows the following results :

Physical Characteristics. — Quantity in
24 hours at this time twelve fluid ounces;
color, pale; condition, sedimentary; reac-
tion, neutral; specific gravity, 1.014; total
solids, 10.87 grams.

Normal Ingredients — Sulphates, normal ;
chlorides, normal ; indican, normal ; earthy
phosphates, diminished ; urea, diminished ;
alkaline phosphate, diminished ; uric acid,
increased.

Abnormal Constituents. — Albumin, in
amount about half the volume ; no sugar.

Sediment. — Crystals of urates, few phos-
phates ; granular and fatty casts.

The diagnosis in a child of this age be-
tween chronic parenchymatous nephritis
and chlorosis or ordinary anemia presents
a very difficult problem. Barthow says that
"girls at the age of puberty are generally

32

Clinical

Lectures.

Vol. lxiv

subject to chlorosis. They may be with or
without disorders of menstruation. The af-
fected person experiences a change of her
feelings, becomes morose or despondent
and capricious, vibrates from the extreme
of high spirits to corresponding depression:
but low spirits is the habitual state of the
largest number."

You will notice how closely this defini-
tion of chlorosis has been followed out in
the patient before you. At the present time,
however, all the chest symptoms have sub-
sided, except a little bronchial catarrh and
pleuritic friction sounds. She is still pale
as you see her, and still somewhat swollen ;
her face is expressionless and shapeless. The
heart is still beating at the rate of 120 or
130, and the urine still remains decidedly
below the normal in quantity, and is loaded
with albumin.

A hint is desirable here in regard to the
treatment. After the counter-irritations and
the poultices, and the sweating, to tide over
the acute spell, infusion of digitalis and
strychnia were exhibited. Digitalis is theo-
retically contra-indicated, as you know, by
reason of undue pressure exerted on the re-
nal structure. I withdrew it, and gave her
Basham's mixture, combined with strychnia;
but at the expiration of twenty-four hours I
found this would not relieve her, as she com-
plained of pain and numbness, and the urine
seemed to be lessened in amount. She has
therefore resumed her infusion of digitalis
and strychnia ; and, by careful attention to
clothing and exercise, and by limiting her
food to milk, we hope to improve her gen-
eral condition.

WHOOPING-COUGH.— GREEN
STOOLS OF CHILDHOOD.1

BY H. A. HARE, M. D.,

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN
THE UNIVERSITY OF PENNSYLVANIA.

Gentlemen : The first case I wish to show
you to-day is one of whooping-cough.
Whooping-cough is the third most important
disease of childhood. According to statis-
tics taken among the children of England,
the greatest mortality is found to be due to
scarlet fever, the second greatest to measles,
and the third to whooping-cough, while in

Delivered at the University Hospital.

London pertussis is second in importance.
But little is known of the etiology of this
disease, further than that it is very probably
due to some micro-organism which has not
yet been isolated. A number of micro-
organisms have been claimed to be the causa-
tive agent, but some who have investigated
the matter pronounce them in no way dif-
ferent from bacteria found elsewhere. We
know, however, that whooping-cough is a
distinctly contagious disease. If whooping-
cough breaks out in a neighborhood, all the
children of that neighborhood will probably
be affected. It runs a course of from six to
eight weeks, and if the child is under two
years of age the prognosis is unfavorable.
We know, also, that the prognosis depends
upon the severity of the attack and the
strength of the child. The pathological ap-
pearances of the air passages macroscorjically
do not differ from those of ordinary bron-
chitis.

Upon listening over the chest, we hear
rales, mive especially at the base posteriorly,
and after a whoop these rales are increased
in intensity and are more diffused, showing
that some mucus has been dislodged in the
bronchial tubes by the effort of coughing.
Some cases of whooping-cough whoop every
five or .ten minutes, or even oftener, and in
some children there seems to be a constant
convulsive condition of the whole respira-
tory tract. In other cases the whoop occurs
but once in twenty-four or forty-eight hours.
In treating these cases of whooping-cough
it is often essential that the child be pam-
pered to some extent, since anything which
tends to cause it to cry will bring on a spell,
and the child will become exhausted.
When once you hear the cough of this dis-
ease you can never mistake it for anything
else. There are two varieties of cough ; in
the first place there is the whoop which gives
the name to the disease, and in the second
place there is a dry, hacking cough which
precedes the whoop. It is by the latter that
we make our diagnosis in fifty per cent, of
the cases we see, which are brought to us
in the early stage of the disease. This pri-
mary cough, which comes on days before the
whoop appears, is as characteristic as is the
whoop. It occurs in from fifteen to twenty
short respiratory movements, and in the ad-
vanced stage of the disease is followed by
the characteristic whoop. We distinguish
this primary cough from the cough of the
first stage of bronchitis, by the fact that the
1 latter is harsher and more rasping than is the

Jan. 10, 1891.

Clinical Lectures.

33

whooping-cough. This first period of the
disease lasts for an indefinite time, but in
time a slight increase in the inspiratory sound
following the cough is heard, which gradu-
ally develops into the characteristic whoop
which can be heard for a remarkably long
distance.

Whooping-cough cannot be cured any
more than can typhoid fever. Neither can
we prevent children from taking it, except
by isolating the cases which are affected. It
is claimed, however, that small doses of qui-
nine seem to exert a slight prophylactic ac-
tion, protecting children who have been ex-
posed to a certain extent. Quinine, it is
known, has a distinct anti-bacterial or germ-
icidal effect, and in the case of any adult
who has never had the disease and who is ex-
posed to this infection, a weak quinine spray
to the fauces may be beneficial in averting an
attack if the patient is willing to stand the
bitter taste of the drug. This treatment has
also been recommended highly for children,
but it is practically impossible to use a spray
upon a child. We must, therefore, either
force the child's mouth open and paint the
fauces, or we must rely upon the drug given
by the mouth, together with some anodyne.
I do not mean to say that whooping-cough
is a disease affecting the fauces, but that
treating the fauces in that way seems to al-
leviate the trouble greatly.

Pneumonia and exhaustion and capillary
bronchitis are the two conditions which
most frequently kill, these children, espe-
cially if they are young children. Whooping-
cough rarely, if ever, produces a fatal result
directly from suffocation. If we do find a
case in which the cough is exceedingly se-
vere, we may use inhalations of the nitrite
of amyl on the hand or upon a handkerchief.
Two to three drops of the drug is sufficient.
Another treatment highly recommended is
the inhalation of chloroform. This is dis-
agreeable to children, and if employed the
proportion should be five parts of the chlo-
roform to ninety-five of air. Ringer rec-
ommends pouring half a drachm of the
chloroform upon the hand of the nurse and
holding it under the child's nostrils. The
child will soon learn to take a couple of
whiffs, enough to postpone the paroxysm.
There is no danger in this unless the child has
a weak and dilated heart. The only disad-
vantage connected with its use is the placing
of a dangerous drug in the hands of the
people. Children often come to learn of the
relief chloroform affords and run to their

parents for it when the paroxysm is coming
on.

In certain cases in the lower walks of life
we cannot use these drugs because of the
cost and the danger. We then resort to
antipyrin, which I regard as the best rem-
edy discovered in the treatment of whoop-
ing-cough as yet. Occasionally we must
push it until we get the physiological effect,
two grains every three hours to a child of 10
or 12 until we get the effect, and then every
four or five hours. We must watch the ef-
fect of the drug carefully, stopping on the
appearance of any bluing of the face or
finger-nails. If I were giving antipyrin to
a child of this age, and were to sit down
near it, I should not notice the cyanosis
probably, while were 1 to sit at a distance
from the patient it would be quite distinct.
This is a curious effect of the drug which I
have frequently noticed. Usually the cya-
nosis first appears under the thumb-nail, as it
does when using antifebrin, but the fingers
are often blue from cold, and it is best to
notice the face. For a child of this age
(4 years) I should give one grain in water
every two or three hours.

Often children with whooping-cough suf-
fer with fever at night, which maybe severe.
In such cases we use antipyrin, stopping the
use of the drug at once if profuse sweating
is produced, as this further exhausts the pa-
tient. We know that any drug which pro-
duces sweating acts as a depressant upon the
system. Antifebrin, phenacetin and the
other coal-tar products probably also exert
some favorable effect upon whooping-cough,
antifebrin positively so. But they are all
more dangerous than antipyrin, and must
be given in smaller doses. Before the in-
troduction of antipyrin, belladonna, small
doses of opium, and other antispasmodics
were used in this disease. Potassium bro-
mide is of great service, especially at night,
to produce sound sleep. It is well to use
the bromide at night together with antipy-
rin during the day. Belladonna does good
by decreasing reflex action. It was for-
merly supposed, and probably it is so, that
the whoop was produced by some reflex irri-.
tation of the bronchial mucous membrane.
It is due to a closure of the glottis followed
by a very sudden inspiratory effort. It is,
in fact, a long drawn-out hiccough, without
a total closure of the glottis as in hiccough,
but only a partial closure through which the
air rushes with the production of the char-
acteristic sound.

34

Clinical

Lectures.

Vol. lxiv

In some cases of whooping-cough ecchy-
moses occur, especially in the conjunctivae,
and at times hemorrhages occur, from the
throat, nose, or hemorrhage occurs from
the ear. On the other hand, some cases are
attended by no bleeding at all. From a
study of the physiological effect of aconite
and veratrum viride I have thought that in
these cases of hemorrhage we may by using
these drugs produce a fall of the arterial
pressure and thus prevent the occurrence of
the bleeding. The asphyxia produced by
the violent coughing gives rise to a rise of
arterial pressure, and a rupture of the small
blood-vessels follows with the production of
ecchymoses. Now, by giving graduated
doses of these drugs we may be able to pre-
vent this terrible strain upon the heart and
arterial system and thus prevent this com-
plication.

The symptoms of an oncoming pneumo-
nia are sometimes those of the catarrhal
form, sometimes of the croupous. This
comes on because the chest and lungs are
weakened and congestions readily occur.
If the pneumonia occurs in a week or two
weeks after the commencement of the dis-
ease, it may be a croupous inflammation,
but coming on late in the course of the dis-
ease it is generally catarrhal in nature, often
bilateral, and affecting usually the lower
lobes posteriorly.

The parents generally inquire as to how
long the child will be sick with pertussis
and you can safely say six weeks at least,
or perhaps it may be eight weeks. German
writers put the limit at sixty-two days, and
during this period the child should be iso-
lated as far as possible from other children.
Occasionally in the course of the disease the
child will swallow a large amount of mucus.
A gastro-intestinal catarrh results and a
lienteric diarrhsea follows, the child dying
rapidly of exhaustion. With every cough
the child will have a passage, and it will
cough every five or ten minutes. Such cases
are very discouraging.

Green Stools.

The next case I have to show you is one
frequently met with in the treatment of
children's diseases, and very readily cured
if seen in the first stage, but if badly treated
it will run on and may develop into cholera
infantum. This baby came in with this his-
tory. .It has always been breast-fed, and
has always been well. A few days ago it
was given some crackers or cake, and a few

days later its stools changed from the nor-
mal infantile passages to small and large
watery discharges containing curds of milk,
and staining the diapers green. The pas-
sages were either passed green, or turned
green within five minutes, a condition in-
dicative of fermentation. This condition
always arises from a torpidity of the liver.
As a rule we get a history of obstinate con-
stipation occurring for a few days before the
attack. Practically, therefore, it is a case of
biliousness. The child is constantly taking
food ; this is not digested, and passes out
as curds, thus giving rise to a lienteric diar-
rhoea. Generally one grain of calomel di-
vided into twelve powders, and one given
every fifteen minutes until one-half a grain
is taken will cure the condition. After giv-
ing this, warn the parents not to be alarmed
if the child has an increase of its diarrhoea,
with passages even worse looking than they
were before. One or two hours after the
calomel has operated give a very small
quantity of bismuth, two or three grains
every hour, till the patient has taken four
or five doses. The calomel sweeps out the
fermenting mass and stirs up the liver ; the
bismuth is slightly astringent and also ant-
acid. If these cases are treated in the early
stage in this way in ninety-nine out of a
hundred we can get a cure in twenty-four
hours. If not so treated they are apt to de-
velop into severe cases of serous diarrhoea.

If any pain exists, as did in this child's
case, we may have to use small doses of sul-
phate of magnesia, or a teaspoonful of sweet
oil, which acts well on the bowels. A spice
plaster is also of service in these cases. This
consists in a heaping tablespoonful of pow-
dered cinnamon, one of powdered allspi'ce
and one of powdered nutmeg ; to these is
added one teaspoonful of black pepper.
These dry powders are stirred together upon
a plate ; a handkerchief is then spread upon
a table, and upon this the spice is laid. I
Then another handkerchief is laid upon
this, and the two are basted together without
removing them from the table. Stitches
are then taken diagonally across the two I
handkerchiefs, that is, they are quilted,
which prevents the spice from falling to one ;
place. Then while still upon the plate
warm vinegar or brandy is trickled upom
the upper cloth. The brandy may go]
through and wet the under handkerchief, ;
but this is not advisable. This is then laid J
over the child's belly from the pubes to the j
ribs. The child may writhe a little at first,!

Jan. 10, 1 89 1. Communications.

35

but generally it will like the plaster, which
is comfortable and warm. This can be left
on from twenty-four to thirty-six hours.
When removed it forms generally a perfect
mold of the stomach, and is quite dry.
The lumps may be broken up, again mois-
tened and again applied. The pepper is a
counter-irritant, the nutmeg and cinnamon
are sedatives and the aromatic oils are ab-
sorbed to some degree and prevent griping.
Should the child pass beyond our control
while using calomel we should then admin-
ister astringents with care.

Communications.

MALARIAL FEVER, WITH INTENSE
LIVER INVOLVEMENT.

BY ENOS T. BLACKWELL, M. D.,

CEDARVILLE, N. J.

It is much to be wished that the terms
applied to diseases or aberrations from
health might more nearly express the patho-
logical changes connected therewith. In
many cases this is impossible, from the lim-
itation of our knowledge respecting the
origin and nature of the infliction. Many
efforts have been made towards amendment
in this particular, with only partial success.
The malady to which I devote this paper
has been named bilious fever, remittent
fever, malarial fever, pernicious fever, etc.
None of these terms appropriately expresses
our notion of the fever, judged by its best
known phases, .much less if judged by its
exceptional forms. We must be content,
therefore, for the present, to accept, to some
extent, the nomenclature in vogue. I do
not purpose to speak of the origin of our
autumnal fevers; for that is not yet posi-
tively established, and I have nothing to
offer beyond the accepted theories. My
design is to describe, as far as I am able, a
very interesting and dangerous case that
came under my consideration at a very
critical period in its career.

Mrs. H., about fifty years old, is the wife
of a dairy farmer, residing in a valley which
formerly was much infected with malaria.
She has an hepatic trouble of many years
standing, and had complained for three
months, especially, of pain in the right hy-
pochondrium, which became so severe at
times, and especially on lying down, that

she was compelled to grasp the side with
the hand, in order to limit the movement of
the ribs, and so to diminish the suffering.
She was unable to lie upon the side, and
her bowels were greatly constipated. She
is a woman of great vigor and activity in
her household affairs, in prosecution of
which, at the end of a most wearisome
day's labor which involved severe lifting,
she suddenly fell sick, and so remained for
three or four weeks before I was called to
assist in her treatment. I submit her own
report of the salient points in her case,
which is fuller than any I received ; and has
the marks of accuracy. It bears date No-
vember 27, 1889, and is the first fruits of
her convalescence.

"I was taken with a chill, which lasted
about two hours and was succeeded by a
high fever; the temperature attaining 1050
F. For three succeeding days I had chill
and fever in alternate paroxysms, of about
the same length, to the number of seven.
During the chill I was extremely sick at the
stomach. When the fever came on, I ached
all over and could not rest. This weariness
began as soon as I was taken sick ; but, as I
grew worse it increased. During the next
four days I had no chill, but I constantly
grew weaker. I had no appetite and slept
but little. The pain and tenderness were
great from the beginning; and increased
as the days wore on. On the tenth day I
had a chill and grew worse very fast. The
headache and pain in both sides increased,
and the sickness also. I was very thirsty,
and swallowed a great deal of cracked ice,
but no food. I was stimulated with alcohol,
taking a teaspoonful of brandy once an hour,
if I was able. Sometimes the intervals were
longer. I never vomited very much at a
time. The vomited matter was frothy and
greenish ; occasionally, there was in it a
little blood. It was very bitter. The sick
feeling that I had was terrible. I felt as if
my stomach was throbbing, or turning*over.
I could lie only on my back ; and no change
could be made in my position, except as I
was lifted. The weariness was very great —
more than I can express. The burning in
the stomach commenced after I had taken
so much brandy. Then wine was tried.
Whatever entered the stomach irritated it.
Diarrhoea commenced tibout the sixteenth
day, the stools being dark and resembling
tar. It lasted a week, and then I became
very costive."

On September 27, 1889, I first saw this

36

Communications.

Vol. lxiv

patient. She was profoundly weak, and
could have her head raised only momen-
tarily to facilitate swallowing. She lay
altogether upon her back, and her voice
was faint and weak. Her pulse was exceed-
ingly small and feeble, and beating 90 times
per minute. Her breath was mawkish and
fetid. Her tongue was very foul, except
just at the tip. She complained of nausea
and extreme burning in the epigastrium.
The alvine discharges were bronze-colored
and very offensive. There was extreme ten-
derness beneath the free edge of the ribs.
The liver boundaries could be traced very
accurately in the right and left hypochon-
drium, and across the epigastrium, by the
tenderness alone. The lower boundary of
the painful area stopped abruptly with the
verge of the liver, and did not at all involve
the stomach. The disturbance of that vis-
cus was purely functional and sympathetic.
Through the attendants I learned that,
when the disease broke out afresh in
the second week, it was with extreme vio-
lence, the pain being exceedingly acute, and
the vomiting severe and long continued.
Collapse occurred during one of the parox-
ysms; and she lay as one dead. Partial
recovery followed, and life continued with
great weakness and extreme nausea and
distress. The attending physician at first
termed the disease " Malaria" — a cause for
an effect. As the symptoms increased in
gravity, it was named " Pernicious Fever."
The consultant, who was called a few days
before me, called it " Gastric Fever," a
term which the attending physician inter-
preted as inflammation of the stomach, or
gastritis.

The treatment in the early days of the
disorder was sulphate of quinine in large
and progressively enlarging doses ; the ex-
treme being eight grains every two hours ; or
ninety-six grains in a day. Mustard had
been perseveringly applied across the suffer-
ing pa'rt, followed by a blister a few inches
square to the right hypochondrium. To
appease the intense stomach disturbance,
chloroform and bismuth subnitrate had
been administered. As an alterative — and, I
suppose as generally useful — calomel was
given ; and as a diffusible stimulant, brandy,
some drug being imposed on the unhappy
stomach, every fifteen minutes. The stom-
ach was the great object of attack, as this
was believed to be the rock of offense. By
the advice of the first consultant, the mer-
curial, which had been used perseveringly,

and in great quantity, was omitted, and
nitro-muriatic acid was substituted. The
other medicaments were continued. The
change was for the worse, rather than the
better ; the ejections becoming intensely
sour, the epigastric heat aggravated and
the nausea intensified.

It was now evident that the treatment was
unsuitedj to the pathological condition,
and must be changed to insure success. My
advice was in line with my diagnosis. Be-
cause of the presence and precedence of the
hepatitis, and the absence of tenderness
over the stomach, I judged that the liver
was mostly in fault ; that the disease was em-
phatically a bilious fever, so called, and that
the treatment should be directed especially
towards this, the point first affected.

In deference to my age and experience,
as well as to my relation to the patient, the
attending physician, under protest, permitted
the following treatment, all else being
omitted.

R Potassii iodidi

Potassii bicarb g ss

Aquae .fjiss

M. Sig. A teaspoonful, in water as hot as can be
drank, every four hours.

R Acetanelid

Cinchonidias sulph aa 3 ss

Pulv. opii gr. ij

Mix, and make fifteen pills, one to be taken every
four hours, alternately with the preceding.

My confrere apprehended grave results
from the action of the liquid mixture, and
waived all responsibility for the consequences.
This was at 9 o'clock a. m. There was
little change in the symptoms during the
forenoon ; the burning in the stomach, the
sourness and bitterness in the mouth, and
the pain continuing much as before.

• During the afternoon and evening there
occurred three or four greenish-black stools.
At bedtime, to relieve the pain and to pro-
cure sleep, one-quarter grain of acetate of
morphia was given ; the other prescrip-
tions to be persevered with.

September 28, at 9 a. m., the patient's
stomach was more comfortable; she had had
two movements of the bowels during the
night, of the same character as before, but
had rested well. The pulse ranged from 90
to 100. The saliva was disagreeable and
bitter ; but she was able to take some pre-
pared gelatine and beef-tea. Dr. saw

Jan. 10, 1891.

Communications.

37

her alone. He was agreeably surprised at the
success of the treatment, and ordered its con-
tinuance. On September 29, the patient
rested well, without anodyne. She had some
relish for food, taking for the first time some
cerealine. Her pulse was 84, and was quite
full and of good force. September 30, she
had rested well. Her pulse was 80, and of
good strength. There had been two more
movements-— not so dark, but apparently
full of globules of bile. j October 1, her
pulse continued satisfactory ; and her voice
had been gaining strength for two or three
days. She could yet have her head only
slightly raised while taking medicine or food,
which were continued without change. The
bowels were moving two or three times
daily, with considerable pain.

At this time I ceased to see the patient ;
but she gradually improved, and was able
near the end of November to write me an
account of her experiences. She did not
become fully convalescent until late in win-
ter, or the beginning of spring.

The mistake in attributing the intense
epigastric distress in this case to inflamma-
tion of the stomach, and the attempt to re-
lieve it by medicines acting directly upon its
mucous membrane, vitiated much of the
early treatment, many of the drugs increas-
ing the irritation and retarding recovery.
This mischase clearly arose from the failure
to recognize and appreciate the tissue or
organ positively at fault. This could be
easily accomplished with care, as the differ-
ential boundaries of the liver and stomach
could be accurately mapped out by using
the proper physical tests. The impropriety
of such " whips " as brandy and chloroform,
and their injurious influence, was amply
shown by the subsidence of the stomach
irritation, and the regulation and strength-
ening of the pulse which followed their with-
drawal. The change for the better suc-
ceeded immediately the change of treatment,
and is attributable to the subsidence of the
hyperemia of the portal vessels, through the
influence of the iodide of potassium, the po-
tations of hot water, and the withdrawal of
irritants and stimulants.

~

Castor oil has been found adulterated with
resin. If shaken with nitric acid the adul-
terated oil becomes deep brown, and the
acid layer assumes a yellow color. With
pure castor oil the acid remains unchanged,
while the oil assumes a light brown color.

WAS IT RELAPSING FEVER ? 1

BY A. D. BARR, M. D.,

CALAMINE, ARKANSAS.

The following is the description of a con-
tinued form of fever that came under my
observation in the latter part of 1888. At
first I thought it to be malaria, and treated
it accordingly ; but I soon found that anti-
periodics had no influence over the disease.
I then abandoned all treatment, except to
modify the symptoms when they were dan-
gerous. When the fever exceeded io3°F.,
an antipyretic was given ; and this was al-
ways acetanilid or quinine. When the
nausea and vomiting were prominent some
form of opium was used. During the first
intervals nux vomica, arsenic and quinine
were administered to prevent a return of the
paroxysms, but without success.. The natural
course of the disease was carefully studied,
uninfluenced by treatment, and the symp-
toms noted at the time furnish the data of
this article. It was a self-limited, continued
form of fever, the distinctive feature of which
was three or more relapses. The recurrence
of fever, as before stated, was the distinc-
tive feature. Abruptness of invasion was
characteristic of the disease. There was no
prodromal or incubative stage. The seiz-
ures were never ushered in by a distinct
chill; though chilly sensations were com-
plained of, followed by a rise of temperature,
usually sufficient to cause the patient to take
to bed at once, though it sometimes required
one, two, or even three days for the temper-
ature to become sufficiently elevated to pro-
duce such a result. Perspiration seldom oc-
curred until the fever began to decline.
The fever attained quickly to considerable
intensity, often reaching 1030 or 1040 F.,
within twenty-four hours. In one case the
fever reached 104^° F. on the evening of
the first day. This was, however, a relapse,
instead of the primary attack. During the
paroxysms the temperature denoted a per-
sistent intensity of fever, ranging from ioo°
to 1050 F. There were no oscillations ; the
temperature either gradually or rapidly
reached its maximum, and then it maintained
about the same elevation for from one to
fours days and sometimes longer, and usually
subsided gradually. The duration of the

1 Read at the sixteenth Annual Meeting of the Mis-
sissippi Valley Medical Association, October, 1890.

38

Society Reports.

Vol. lxiv

primary attack varied from six to twelve
days.

During the intermission, the absence of
fever and all other symptoms was complete.
The period of intermission varied from two
to twelve days, the average being about
seven. The relapse, like the primary attack,
was sudden, and was also generally ushered
in by chilly sensations, though the first
symptom was sometimes an elevation of
temperature. The fever in the relapses
suddenly became more or less elevated,
usually more elevated than in the primary
stage. The relapses also generally subsided
gradually, and with moderate perspiration.
Their duration was from four to ten days,
and the greatest number was five.

Of symptoms referable to the digestive
system, nausea and vomiting occurred often
enough to be somewhat characteristic. They
were generally prominent features, but they
were not always present. They were fre-
quently so severe that the patient was in
danger of sinking from exhaustion or col-
lapse. The vomited matter generally con-
tained bile, and not infrequently blood.
The tongue was generally coated with a
white fur, but sometimes became dry and
cracked. Diarrhoea was very infrequent.
Constipation was the rule. Tenderness over
the epigastric and iliac regions occurred to
a very moderate degree. The appetite was
often impaired, but not to the extent that is
usual in most diseases where the tempera-
ture is elevated to as high a degree as it was
in this case. Sometimes there was a notice-
able craving for food, so much so that it
was highly distinctive. During the parox-
ysms, pain in the muscles of the small of the
back and the calves of the legs were com-
plained of. They were never entirely
wanting, though they varied in intensity.

The perceptions were not blunted in this
as in various other diseases. Delirium was
present sometimes ; but it was of that char-
acter which is likely to occur when there is
a high febrile movement, without regard to
the existing malady. The face was usually
flushed. The amount of urine was usually
decreased. The decrease in one instance
amounted to complete suppression for
twenty-four hours ; and the kidneys acted
badly for several days thereafter ; which in
turn was followed by an excessive diuresis.
A copious flow was apt to occur about the
cessation of each seizure.

Regarding the cause of the disease, I am
unable to give any satisfactory statement.

In one case it seemed probable that it was
contracted by contagion, as the child was
in frequent contact with a young woman suf-
fering with the same disease. The disease
seemed at times to be developed sponta-
neously.

In regard to treatment, all that I could
do was to modify the symptoms. The dis-
ease was essentially a self-limited one, and
was uninfluenced by all treatment instituted
by me. Quinine; given in five or ten grain
doses, from two to six hours apart, seemed
to aggravate the condition by increasing
the nausea and vomiting. Calomel also
seemed to retard convalescence. The nau-
sea and vomiting were best controlled by
morphine and Listerine. In the first stage
the pains were often so severe as to call for
an anodyne ; but as a rule when the tem-
perature was reduced below ioo° F., they
subsided until the fever again became in-
tense enough to call for a repetition of the
antipyretic. Good, plain, wholesome food
was allowed.

Society Reports.

SUPRA-PUBIC CYSTOTOMY.

DISCUSSION AT THE SOUTHERN SURGICAL
AND GYNECOLOGICAL ASSOCIATION,
NOVEMBER 12, 1890.

In discussing the paper of Dr. Cobb (see
P- 7).

Dr. G. Frank Lydston, of Chicago,
said we must necessarily consider the ques-
tion which, as I infer from the title of his
paper, Dr. McGuire would have discussed
if he were here, the best route to the male
bladder in cases of calculus, and more par-
ticularly of prostatic disease.

The revival of the old supra-pubic opera-
tion, which had so long fallen into disuse,
has, under antiseptic methods, resulted, in
my opinion, in a little too much enthusiasm
regarding its merits. I think we must be
guided by the same wise conservatism that
has been suggested here this morning rela-
tive to the question of removal of the dis-
eased appendages in the female. I believe
that a proper selection of cases is necessary.
I do not believe that every case of prostatic
disease, of calculus or of enlarged prostate,
justifies the performance of the supra-pubic
1 operation to the exclusion of everything else.

Jan. 10, 1 89 1. Society Reports.

39

There seems to be a tendency in the direc-
tion of routinism in this respect. When a
calculus is present in connection with an
enlarged prostate, and the prostate is very
large, particularly if it be suspected that
there is hypertrophy, especially some form
of hypertrophy in which a distinct tumor is
present, or in cases in which the bladder is
profoundly involved, it is undoubtedly best
to perform the supra-pubic operation. In
this way we avoid certain dangers which
in severe inflammatory conditions of the
bladder are incurred by the performance
of the perineal section. One of these is the
extreme danger when the bladder is in a
condition of chronic inflammation and the
urine is strongly septic, and of septic ab-
sorption from the perineal wound. There
is no question but that the perineal wound
is dangerous in this respect, and far more so
than a wound inflicted by the supra-pubic
operation. The facilities for absorption are
greater, and the tract over which the urine
is allowed to flow is more important. It is
desirable to avoid this absorption, and in
cases of extreme bladder disease in which
the urine is highly septic the supra-pubic
operation is the best.

Another consideration — and it is one of
the principal dangers we have to contend
with in operations upon the male urinary
apparatus — is shock. It is not only injurious
per se, but indirectly, by reflexly suppressing
the function of the kidneys. The shock in
supra-pubic section is much less than in the
perineal operation. Where this considera-
tion is of importance, it is undoubtedly bet-
ter to perform the supra-pubic section. If
there is a large stone, or if there is any por-
tion of the prostate that is susceptible to
surgical measures, the opening of the bladder
from above of course facilitates matters. It
is a difficult thing to accomplish removal of
a portion of the prostate through a perineal
wound. Some surgeons have reported extra-
ordinary cases which have been operated on
by electrolysis and by the galvano-cautery.
I would rather see the operations than read
of them. I would have to see them per-
formed in order to be convinced of their
utility. Briefly, then, in cases in which the
urine is highly septic, in the cases in which
the kidneys are disturbed, in cases in which
it is desirable to avoid shock, and in cases
where operation on the prostate is contem-
plated— i. e. , where the removal of any por-
tion of- the prostate is deemed advisable,
the supra-pubic operation is undoubtedly

the best. When a calculus is small, pro-
vided that we decide upon a cutting opera-
tion rather than upon litholopaxy with the
bladder in good condition, and when the
prostate is not extremely large, if any opera-
tion be done in the way of exploration of
the bladder, the perineal operation should
be preferred. Danger is avoided by the
procedure of Reginald Harrison, which con-
sists of the introduction of a rubber tube
into the bladder, thus avoiding contact of
the septic urine with the tissues ; this is a
modification of Cock's operation.

When symptoms of serious systemic
poisoning exist, the supra-pubic operation
should be selected. I mean by this, not
symptoms of uraemia so-called, but that
peculiar toxsemic state incidental to the ab-
sorption of ptomaines, which characterizes
many chronic diseases of the urinary organs.
This systematic poisoning is noticed in a
minor degree even- in some cases of rela-
tively slight strictures. I do not think
that the supra-pubic operation is any better
from the standpoint of drainage than the
perineal operation, but where drainage is to
be prolonged it is much more convenient in
this situation. Again, absorption, as I have
already remarked, during the removal of
the septic material by 'washing of the
bladder and during the spontaneous drain-
ing away of the urine, is not nearly so apt
to occur as when the operation is done in
the perineum.

In perineal operations, after the danger
of shock has passed away, there is danger
of septic infection in direct proportion to
the frequency \pth which the urine is al-
lowed to come in contact with the wound.
The same is true of internal cutting opera-
tions in stricture. It will be found in many
cases that the patient will be pretty com-
fortable until the first time he urinates, when
immediately a chill followed by fever is set
up, and very often goes on to a fatal issue,
with all of the symptoms of profound septic
poisoning. The tract of the wound in the
supra-pubic operation is not so long, rela-
tively speaking ; it does not traverse such
important structures, nor are these parts so
well endowed with sensitive nerves and ab-
sorbents as is the case with perineal wounds.

Dr. John D. S. Davis, of Birmingham,
Ala., said : I cannot accept the statement that
the perineal incision is the best for draining
the bladder when we have no enlarged pros-
tate. I have done Reginald Harrison's op-
eration a number of times. I have observed

4o

Society Reports.

Vol. lxiv

the results of the perineal incision many
times, and in no case have I got as good re-
sults as by supra-pubic operation for drain-
ing the bladder per se, from the simple fact
that the tendency of the perineal incision is
to close before the pathological conditions
in the bladder subside, while with the high
operation it does not close so readily. I do
not think the high operation is the ideal
one for the relief of stone. I think the bi-
lateral incision (perineal) is the best, that
is, in cases where you have no enlarged pros-
tate. It is best for the removal of the stone
where you want no after drainage. Where
you want after drainage, my experience as
well as that of Dr. McGuire and other sur-
geons, proves conclusively, and beyond any
possible doubt, that the high operation is
the best.

I have a criticism to offer regarding the
technique .of the operation. I do not agree
with Dr. McGuire in regard to making his
coffee spout fistula. He discarded it over a
year ago, and now follows my technique.
I have three methods for making the fistula :

1. When the distension is great and no
intra-vesical operation is necessary, the open-
ing is made with a trocar, withdrawing the
stylet and replacing it with a rubber catheter,
after the introduction of which the canula
is withdrawn, leaving the catheter in the
bladder. It is necessary sometimes to en-*
large the external or cutaneous opening to
prevent a closure of the catheter by com-
pression, and to render the external opening
sufficiently large.

2. The bladder may be opened, when dis-
tended, by a direct incisiog with the knife,
in the median line, with cutting edge to-
wards the symphysis pubis at an angle of
forty-five degrees. The knife is withdrawn
and a catheter is introduced through the
wound into the bladder.

3. A perpendicular incision, one or two
inches, is made in the median line above
the symphysis pubis. If the pyramidalis
muscles are in the way the fibre should be
cut. The transversalis fascia is divided on
a grooved director from symphysis to upper
margin of superficial wound. Instead of
following Guyon's manoeuvre I catch the
bladder with a tenaculum on a line with the
symphysis, through the pre-vesical fat, and
cut with a bladder knife into the bladder
with one smooth, clean incision, to prevent
undue disturbance of the cellulo-adipose
tissue between the bladder and pubes, and
avoid infiltration. I have never seen a case

where it was necessary to push up the pre-
vesical fat, and with it the peritoneal cul-de-
sac. If the bladder is caught on a line with
the symphysis and cut downward, no fears
need be had for the peritoneum. Cutting
this pre-vesical fat prevents its after dropping
down over the opening into the bladder, and
acting as a valve to prevent easy access to
bladder, escape of urine, and causing infil-
tration.

I agree with Dr. Lydston that the shock
is much greater in the perineal operation,
but this operation is the ideal one in my
judgment for the removal of stone, where
no after drainage is required ; but where we
desire after drainage the high operation is
the better.

The fistula is made competent by a pseudo-
sphincter formed by the fibres of the detrusor
urinae muscle. In all my cases there is the
power to retain and expel the urine at will
regardless of the position of the body.

Dr. Joseph Price, of Philadelphia, said :
Some of the gentlemen differ in method from
the distinguished gentleman that devised this
operation, and surely they deserve credit for
perfecting it. Dr. McGuire, I believe, has
rejected all perineal operations for the re-
moval of stone, and he looks upon this as
the most perfect of all methods of dealing
with vesical troubles, whether disease or
calculus. He has now so completely per-
fected the operation that he tells me he has
a number of men traveling about passing
their urine at intervals of every four or six
hours at ease, having perfect control of both
the bladder and its contents, passing the
urine in a stream and suffering no incon-
venience from the new channel for voiding
their urine. He expresses his regrets that
he has done so many perineal sections for
stone.

What Dr. Davis has said in regard to
drainage I concur in. You can drain any-
thing above the pubes and drain it success-
fully. It is curious to note the results of the
two schools, one advocating vaginal drain-
age, and the other supra-pubic, the first fol-
lowing the methods of Martin and others of
puncturing the vaginal wall and draining
from the vagina, and the second that of
drainage from above. The results are that
Martin lost by vaginal drainage fourteen in
77 cases of pelvic operations, a mortality
that should stay our hands in such work.

Dr. W. E. B. Davis, of Birmingham,
Alabama, said : I would not detract any of the
honor of this operation from Dr. McGuire.

Jan. 10, 1 89 1. Society

Reports.

4i

Dr. McGuire is a great surgeon and has
done good work in this direction. I believe
with him that this is the ideal operation for
stone or for cystitis. The reports of the
histories of Dr. McGuire's cases are not satis-
factory. We can get but little idea of the
after treatment. My brother (Dr. John D.
S. Davis) has operated on more cases than
any other man in the South except Dr.
McGuire, and we have had an opportunity of
following these cases, and have found that it
is a good deal of trouble to keep the fistula
open. Every two or three weeks patients will
come to you complaining of some trouble in
the fistula. I have seen abscesses form in
some cases. Dr. McGuire, you remember,
when he first devised the operation, sug-
gested sewing up the lower part of the wound,
making a coffee-spout fistula, allowing the
urine to come out at the top of the wound.
My brother followed Dr. McGuire in the case
of a man with cystitis. He tried to keep the
fistula open ; but an abscess formed at the
lower angle of the wound. I insisted upon
removing the tube from where it was and
placing it in the bladder through the open-
ing made by the abscess, but he said he was
going to follow Dr. McGuire's technique.
However, the urine did come through the
abscess opening and proved the best opera-
tion to be direct supra-pubic cystotomy. My
brother was the first, I think, to read a paper
on this subject.

Dr. McGuire deserves a great deal of
credit for the operation, but for the tech-
nique of the operation, the credit should be
given where it belongs. We have done the
direct incision a number of times. It is the
ideal operation. We do not want to make
a long canal. It is not a lengthy canal
that controls the urine. There is no question
but what patients will pass their urine
voluntarily through the direct fistula just as
they do through the natural passage.

The trouble is that these cases, where
we resort to supra-pubic cystotomy for
drainage in prostatic troubles, come to
us too late. This is well illustrated in the
case of an ex- vice-president of this Associa-
tion, Dr. R. D. Webb, a man who has
written most valuable papers on this subject,
advising early operation. Dr. Webb, how-
ever, neglected his own case until he was al-
most dead. He had been unable to pass
urine except through a catheter for a great
many years, and for the past six months he
had been compelled to draw it off frequently.
He was having severe paroxysms of pain

constantly. While he has been greatly re-
lieved by the operation, which I performed
more than two months ago, I doubt whether
he will be able to go about his work again.
He waited too long. The prostate was
enormously enlarged, and when we came to
do the operation we had great difficulty in
findin6 the bladder, which would hold only
two or three ounces of urine. We would in-
sist on early operation in prostatic cases.

Dr. Geo. A. Baxter, of Chattanooga,
Tenn., stated that one of his recent cases
was such an apt illustration of some of the
points made in reference to supra-pubic
drainage and the danger from septic infec-
tion by drainage though the perineum that
he felt compelled to make a report of it.

The subject, a former doctor of medicine,
between 70 and 80 years of age, suffered
severely from enlarged prostate, and was in
the habit of relieving himself of occasional
attacks of retention by using the catheter
himself. During a visit to some mountain
springs, thirty miles distant from Chatta-
nooga, he suffered one of these attacks of
retention, but failed to enter the bladder.
A neighboring physician was called in and
failed also, and he was sent post haste to me.
He reached town in the night, and called
temporarily a very competent physician, who
found him over a vessel with a long silver
catheter pushed up to the hilt, but not in
the bladder, and examination disclosed the
fact that this had been done frequently, so
that it was impossible to tell where the real
canal was, so ruptured and torn was the
whole urethra. I saw him early the next
morning, and with the doctor last in attend-
ance determined upon aspiration rather
than further trial to enter the bladder by
the natural passages, or by perineal operation,
after first confirming the condition as re-
ported to me, for the following reasons :

1. The bladder was immediately distended
and had been so for forty-eight hours, hard
as a rock and seemingly likely to burst at
any moment, rendering immediate relief im-
perative.

2. I thought and still hold that a route
through the perineum or the urethra simply
would have necessarily produced infiltration,
sepsis and death.

The man was unconscious by this time
with stertorous breathing, weak, fast pulse.
I aspirated, but had to turn the needle a little
to the left side before the bladder was en-
tered. I followed the immediate supra-pubic
cystotomy for the purpose of complete drain-

42

Periscope.

Vol. lxiv

age in order to protect the parts lacerated
by himself, put in a large double tube and
washed the bladder out with boric acid.
That I was right was evidenced by his con-
dition, and he died either as the result of
uremia, from which he was suffering when
I operated, and from which he was only
partially relieved, or from exhaustion of his
long continued suffering and generally pros-
trated condition, I do not know which, but
it matters little, as the case is here related
for the illustration of points in other direc-
tions made by the gentlemen discussing this
subject.

Dr. F. W. McRae, of Atlanta, Ga., said :
With regard to the termination of some of
these cases, I desire to exemplify the state-
ment which Dr. W. E. B. Davis has made.
The operation is frequently delayed too
long to be of benefit to the patient.

I operated on a man, aged 72 years, last
summer, who had been suffering for five or
six years from supposed prostatic disease.
He had been under my care but a short
time, when an attack of cystitis occurred.
I examined him for stone and was unable to
find it. I finally decided to do the supra-
pubic operation with drainage, and after
cutting down and opening the bladder I
found a stone embedded underneath the
prostate, which I removed. This patient —
I will say by way of parenthesis — had in
the last- five years two strokes of hemiplegia.
He had been paralyzed on one side twice
and was not in the best physical condition
for the operation. I did the operation as
suggested by Dr. Davis. The case pro-
gressed nicely until the fifth day, when the
patient suddenly died. I didn't have a
chance to make an autopsy ; but the pre-
sumption was that he died from some cere-
bral trouble. The wound was opened,
which I found had perfectly healed, except
opening left for drainage-tube, and there
was no apparent suppression of urine.

Dr. W. H. H. Cobb, of Goldsboro, N. C,
said : Some of the interesting points in my
paper have not been touched upon in the dis-
cussion. First, the patient's age. Being only
49 years old, he was rather young for enlarged
prostate. Then the etiology — what was the
cause of prostatic enlargement in this pa-
tient? Could it be attributed in part to his
rheumatic diathesis? And is it not unusual
to find so many symptoms simulating vesical
calculus? the patient having, in addition to
his terrible cystitis, the sudden arrest of
urine, which was relieved by change of pos-

ture, with great pain in the glans penis.
The symptoms were so urgent that the op-
eration was performed simply to save the
patient's life. Had the case been allowed
to progress much longer, the inflammation
would have traveled up the ureters to the
kidneys, and the operation would have
proved useless.

Periscope.

Hepatic Colic.

In a recent number of La Medecine Mod-
erne, Professor Germain See discusses the
always interesting and important subject of
the treatment of hepatic colic. The obvious
primary indication is to promote the expul-
sion of the gall-stone, and this, Professor
See urges, should be accomplished by reme-
dies which increase the flow of bile. The
sufferings of the patient are, however, usu-
ally so intense that we are compelled to con-
sider first the application of measures di-
rected to the relief of pain. Of these by
far the most speedy and effectual is the hy-
podermic injection of morphine. This usu-
ally acts very well, but Professor See warns
us that in some cases the patients, after a fit
of vomiting, fall into a state of alarming
collapse, even when only one centigramme
of morphine has been injected. We must
also bear in mind that morphine is one of
the substances which diminish the biliary
secretion. Of antipyrin Professor See says
that "it will only render mediocre services
in this matter, and that we should not lose
time by prescribing it." Chloral and chlo-
roform have a less certain action than mor-
phine, but possess the advantage of not hin-
dering the secretion of bile. Professor See
advises that chloral, if used at all, should
be given by enema, as it will not be well
tolerated by the stomach. He is disposed
to believe that both chloral and chloroform
may act favorably by relieving spasm and
promoting the relaxation of the walls of the
bile-duct.

The second and most scientific indication
is to increase the biliary secretion. The
mere presence of the gall-stone and the irri-
tation which it excites, have a tendency to
augment the flow of bile, but help may be
obtained from the use of various medicinal
remedies. Of cholagogues Professor See
enumerates bile itself, turpentine and its de-
rivatives, terpine, terpinol, benzoic acid,.

Jan. 10, 1891.

Periscope.

43

salicylate of soda, and olive oil. He points
out that bile is inadmissible, as its employ-
ment tends to make the biliary secretion
thicker rather than to render it more fluid,
as is desirable. Turpentine and its deriva-
tives are comparatively inefficient chola-
gogues, but are nevertheless of some value.
The " Durande remedy" owed its success
to the presence of turpentine. Of two only
of the remedies enumerated does Professor
See hold a high opinion — viz., salicylate of
soda and olive oil. The cholagogue action
of the former of those, although pointed
out by Rutherford, is hardly sufficiently rec-
ognized in this country. It seems to in-
crease the entire biliary secretion, but more
particularly its fluid elements. According
to Professor See, it not only acts as a chola-
gogue, but has also an analgesic effect, which
is obviously desirable in the conditions un-
der consideration. It is advised that sali-
cylate of soda be given with large quantities
of fluid, as this seems to assist its action.

The cholagogue action of olive oil has
been a subject of dispute, and was denied
by Bidder and Schmidt. The later experi-
ments of Rosenberg, however, .seem to show
that if the animal experimented upon be kept
upon a normal diet, and olive oil be admin-
istered, "a considerable augmentation of
the biliary secretion, especially of its fluid
part, begins in from thirty to forty-five min-
utes, the maximum increase is obtained from
the third to the fifth hour, and there is also
a considerable increase of fatty acids which
are capable of dissolving cholestearine. "
Professor See believes that clinical experi-
ence proves that the administration of olive
oil both promotes the removal of the gall-
stone and relieves the attendant pain and
jaundice. Its ??iodus operandi has been the
subject of some fanciful theories. Thus it
was at one time supposed that the oil actu-
ally ascended the duct and acted locally
upon the impacted gall-stone. For this idea
there was never any adequate foundation,
and it must suffice to say that the adminis-
tration of olive oil tends to increase the flow
of bile and to make it more liquid. The
chief objection to this line of treatment is
that the oil is often badly tolerated, and
that even if it be well borne at first, intol-
erance is quickly excited.

Professor See finally discusses the reme-
dies that are contra-indicated in an attack of
biliary colic. Chief among these are those
medicaments which tend to excite strong
peristaltic movements of the intestine, as

these are apt to be propagated to the bile
passages. Hence strong purgatives are in-
jurious. Purgation should only be employed
after the crisis is over, and even then with
caution, as it may excite a fresh attack.
Nevertheless, it cannot be wholly dispensed
with, as it is desirable to clear out the bile
that has found its way into the intestine.
We should also avoid those substances which
diminish the biliary secretion, of which Pro-
fessor See enumerates the salts of potash,
calomel, iron, copper, morphine, atropine
and strychnine.

These recommendations — coming from so
esteemed a source, and founded upon such
ample physiological experiment and clinical
trial — will be received with the respect which
they deserve. Probably the point which
runs most counter to ordinary practice is
the advice given regarding the use of purga-
tives. At the crisis of the malady, when
the duct is contracting violently and the
patient is in extreme agony, no one would
dream of giving a purge ; but a little later
on, when the pain has been subdued, while
the impaction remains and jaundice is deep-
ening, moderate purgation with such an
agent as Glauber's salt has often proved the
most efficient of all methods of treatment.
Turpentine does not seem to have justified
the hopes that, on theoretical grounds, were
raised regarding its value in biliary colic.
Salicylate of soda and olive oil are well
worth a trial, and Professor See's recom-
mendation will ensure their wide employ-
ment. Whatever medicinal remedies we
select, it seems evident that copious draughts
of warm water, to which a little soda has
been added, are invariably advantageous,
and it is well that so simple a measure should
not be overlooked or neglected because of
its simplicity. — Lancet, December 13, 1890.

Grafting Skin from the Dead Body.

The Annals of Surgery, November, 1890,
says that in 1888, Drs. Bertens and Werner
described a remarkable case of a boy, with
intractable extensive ulcers of the legs, in
which they had successfully transplanted 24
skin grafts excised from the body of a woman
75 years old about twenty minutes after her
death. The perusal of this paper induced
Dr. Sophia Ivanova, of St. Petersburg, to try
their method in the case of a poorly-nour-
ished woman, aet. 75 years, who had received
a burn of the third degree involving the

44

Periscope. .

Vol. lxiv

whole leg and dorsal aspect of the foot.
In about a fortnight the injured integuments
sloughed away to leave an enormous freely
suppurating granulating surface. The graft-
ing, resorted to shortly after the separation
of the sloughs, was made at two sittings,
with an interval of three and one-half weeks,
the material being derived from two new
born infants' bodies, one and one-half and
two hours after the children's death. During
the short period elapsing between the excision
and transplantation, the strips and pieces
were kept in a 6: 1,000 solution of chloride of
sodium at 400 C. Every one of them be-
came firmly adherent to the surface in 48
hours, while in two or three days the epider-
mis began to grow around all the grafts.
Speedy and sound healing ensued. Dr. Iva-
nova believes that this method offers un-
doubted advantages over Reverdin's plan," in
securing more rapid healing of lesions and
lessening the injurious effects of prolonged
suppuration and lying in bed; it gives better
functional results, through preventing cica-
tricial contraction; the material is easily ob-
tainable in abundance, and that without in-
flicting suffering or inconvenience to any
human being.

The skin must always be taken from bodies
of patients who have not had syphilis, septi-
cemia or any other infectious disease. The
best material is afforded by bodies of new
born infants of healthy mothers, the infan-
tile tissue possessing most energetic vitality.

It is advisable to employ rather long strips,
measuring not more than an inch or so in
width. Small sized pieces are easily washed
away by pus or blood. Only the skin proper,
freed from all subcutaneous cellular tis-
sue, should be transplanted. If the granu-
lating surface is clean and not very weak, no
scraping is necessary. It is sufficient to pre-
viously thoroughly wash the surface, after
which the grafts should be carefully adjusted
and slightly pressed down with dressing.

The best dressing material is gauze soaked
in a boric acid solution, and then wrung out.
This tissue absorbs secretions very well,
never becomes adherent to grafts, and hence
may be easily removed without disturbing
the latter.

The transplantation must be practiced as
early as possible ; thus in cases of deep
burns, it should be resorted to immediately
after the separation of sloughs. When
large-sized strips or pieces are used, even a
free suppuration cannot prevent their adher-
ing to the surface.

Liquid Pepsins.

The Chemist a?id Druggist, October 18,
1890, says Mr. D. L. Haigh has been abus-
ing liquid pepsins before the Missouri Phar-
maceutical Association. Amongst the things
he said, and which will have occurred to
many pharmacists, was that among the sim-
ple solutions of pepsin which are objection-
able are the wine, elixir, aromatic elixir and
elixir of pepsin and bismuth. In the last
preparation the ammonio-citrate of bismuth
is used. To hold this in solution it must be
either slightly alkaline or neutral. Pepsin,
on the other hand, must be in acid solution
or it will decompose and very likely precip-
itate. The two substances are therefore in-
compatible, and the preparation is almost
worthless. This is a very simple case. How
is it with an alkaloid added, as in elixir pep-
sin, bismuth and strychnia ? It is known
that alkaloids must either be held in solu-
tion by means of a solvent — generally alco-
hol— or be converted into soluble salts by
an acid. This last preparation, then, must
be neutral to be stable. How long can this
be the case with such a loosely-constructed
salt as ammonio-citrate of bismuth, when
the ammonia is being constantly carried off?
The popularity of pepsin has carried its use
to the extreme ; although it is an invaluable
remedy, like many good things it is abused.
The only way to administer pepsin is in the
solid form, preferably in powder. The vast
number of scale pepsins are for the greater
part peptones and do not possess the diges-
tive power of the powdered pepsins. In
fact, the highest digestive power pepsins are
not soluble to any extent, which is another
[ very potent reason why this article should
not be used in liquid form.

There is truth in some of Mr. Haigh' s
statements, but he has not carried his in-
quiries far enough. Liquid pepsins can
easily be made which possess high digestive
power. For years we have pointed out that
the minimum amount of alcohol should be
used for the preservation of these prepara-
tions, as alcohol in certain amount pre-
cipitates the ferment. Mr. Haigh appears
to overlook the fact that the pepsin ferment
is a soluble body. We have no evidence
that it is insoluble in alkaline media; the
question is : Is it desirable to administer it
in such media? We know that in that
condition it is inactive, but how long will it
remain alkaline in the stomach ?

That there is great ignorance regarding

Jan. 10, 1891.

Periscope.

pepsin is evidenced by the fact that some
time ago a medical journal, whose opinion
is highly valued, stated that it had tested
one of the pepsin preparations which Mr.
Haigh objects to, and from the amount of
starch which it converted, it had been
led to form a high opinion, etc. The man-
ufacturers actually advertise this testimonial !

Peroxide of Hydrogen.

The University Medical Magazine, Decem-
ber, 1890, says editorially that peroxide of
hydrogen is a drug which has been gradually
and steadily gaining in favor, and which has
yielded to each who has faithfully tried it
results so constant and so satisfactory that
he has learned to depend upon it. As ordi-
narily found in the shops, peroxide of hy-
drogen is a 3.2 per cent, solution, yielding
fifteen times its bulk of oxygen. This
solution is far more potent than is water
charged with fifteen times its volume of
oxygen, since in the peroxide preparations
the gas is given off in its nascent state and
is peculiarly powerful in its chemical affini-
ties.

There is abundant evidence as to the
value of the peroxide, from both the clin-
ical and the experimental standpoint. The
number of those who have reported excel-
lent results from its use is very large, and to
this must be added the testimony of the
bacteriologists, who find in this drug a po-
tent and almost immediate germicide. It is
devoid of septic properties, its worst effect
being, when used in a too concentrated
form, to cause some local pain and irrita-
tion. It is applicable in all cases where pus
is present, and where the discharge is foul
and profuse its effect is admirable. In sup-
purating otitis media, in purulent conjunc-
tivitis, the aurists and ophthalmologists have
long prized it as one of their most valuable
medicaments. In the sloughing inflamma-
tions following scarlet fever and diphtheria,
the laryngologists place great confidence in
its powers. Surgeons, however, in whose
work it might prove generally valuable, have
been somewhat slow to recognize its virtues.
But its use in a great variety of sloughing
and suppurating cases has given results bet-
ter than those obtained from any other ger-
micide— bichloride of mercury not excepted.
Where the discharging area is represented by
a surface of granulations, the drug can be ap-
plied by means of an atomizer. This enables

a small quantity to reach every portion of the
infected surface. In the case of a suppurating
fistula or cavity, the peroxide may be injected
by means of a syringe. Immediately follow-
ing its application to a purulent surface, an
active effervescence goes on, and every par-
ticle of pus which it reaches is destroyed.
Not only this, but the microbes, the active
agents of pus formation, are also devitalized,
so that a large surface can sometimes be ren-
dered aseptic by one or two thorough appli-
cations. Even if this result is not reached,
the discharge is greatly lessened, and it is
by no means uncommon to see a case, in
which the pus had amounted to drachms, so
favorably affected that the dressings contain
but a few drops of purulent matter.

The strength in which the fifteen volume
solution is used will vary with individual
cases. It can be employed without harm in
full strength. Where this is painful, one,
two or four parts of water may be added.

Fatal Uremia in Persons Appar-
ently Healthy.

The New York Medical Journal, Novem-
ber 15, 1890, says Dr. A. Westphal has de-
scribed an interesting case, in the Berliner
klinische Wochenschrift, of uremic coma
resulting fatally in a person apparently
in a fair state of health. A young man,
twenty-four years old, a joiner, was ad-
mitted into the hospital with sudden symp-
toms of difficulty of breathing, palpita-
tion, swelling of the feet and ankles, and
left-sided headache. His history was that
of a feeble childhood, but without any seri-
ous illness. His feet had never swelled be-
fore, there had been no difficulty with the
urine, and he had always been able to at-
tend to his heavy work. He had not been
a drinker, had not had syphilis, and had
not been a worker in lead, and there was
no ascertainable heredity. His face was
swollen, his ankles were cedematous, and he
was manifestly anemic. The heart was hy-
pertrophied somewhat, the sounds were
weak but pure, with no accentuation of the
pulmonary or aortic second sound. The
pulse was small, regular and without dis-
tinct tension. The urine was clear, acid, of
the specific gravity of 1.005, with some al-
bumin, hyaline casts and leucocytes. There
was nothing abnormal in the internal or-
gans or the blood, but there was albumin-
uric retinitis. During the first few days of

46

Periscope.

Vol. lxiv

his treatment at the hospital the subjective
symptoms lightened up decidedly, and he
expressed himself as feeling quite well and
gave the impression of being not seriously
ill. The albumin remained at a small
amount, and the quantity of urine varied
between forty-five and fifty-eight ounces/^
diem, with a specific gravity of from 1.003
to 1.006. Five days after his admission,
aphasic symptoms made their appearance as
the forerunner of a severe uremic attack,
which set in with full force during the
night; there were both clonic and tonic
convulsions, frothing at the mouth and loss
of consciousness. The temperature rose to
103. 8° F., the respirations to 60 and the
pulse to 160, the cardiac dulness being in-
creased to the right. Death ensued in deep
coma from pulmonary oedema. On autopsy,
both kidneys were found to be contracted,
the right one being somewhat peculiarly dis-
placed, being depressed and lying opposite
the fourth and fifth lumbar vertebrae ; it was
extremely" small, not more than two inches
long by less than an inch broad, and ap-
peared as a grayish-red fibrous mass with
the blood-vessels small and not thickened ;
from these facts, as well as the .microscopic
appearances, the condition was judged to be
congenital. The case was remarkable as oc-
curring in a young person, without previous
uremic symptoms, who was apparently do-
ing well when he fell into a state of pro-
found coma and died in what was, so far as
was known, his first seizure.

He states that, in spite of the large quan-
tities of bismuth which he has employed,
he has never seen any symptoms of poison-
ing follow its use. — Therapeutic Gazette,
November, 1890.

The Treatment of Burns.

In the Friedrichshain Hospital in Berlin
the following is the method of treatment of
burns employed by Dr. Bardeleben.

The burned surface is first carefully
washed with a two or three per cent, solu-
tion of carbolic acid or a three per mille
solution of salicylic acid. The blisters are
then opened, and the entire surface covered
with subnitrate of bismuth finely powdered,
and over this a layer of cotton-wool. This
dressing is to be renewed as soon as it be-
comes at all moistened by discharges from
the wound. If the burn is very extensive,
an ointment of bismuth is substituted for
the dry powder.

Dr. Bardeleben asserts that with this
dressing cicatrization is much more rapid
and suffering much more quickly relieved
than is the case with any other form of
treatment.

Dyspepsia of Children.

The Annals of Gynecology, November,
1890, says that according to Jules Simon,
dyspepsia is sometimes the early manifesta-
tion of a neuropathic state in girls from 6
to 8 years old. The treatment he suggests
is :

1. Tonic. General treatment, hydrothe-
rapy, diet and regimen.

2. Sedative. Administer at each meal,
well diluted, 3-5 drops of:

R

Tr. belladonna.

Tr. opii camphorat aa f^ss. M.

After the meal prescribe a powder com-
posed of:

Codeiae ........ gr. I-30 — gr. I-15

Magnesise ■

Pulv. oculi cancrorum .... aa gr. iss

Pulv. rhei gr. j

Ext. nucis vomicae gr. 1-6 M.

3. As an eupeptic before meals administer
one or two teaspoon fuls of the following,
well diluted.

Tr. cascarillae.

Tr. nucis vomicae

Tr. rhei

Tr. aurantii amar.
Tr. gentian. . . aa f^j

aa f ^ ij
fjss

M.

Lantanine as Febrifuge.

The Journal de Medecine, October 12,
1890, speaks of an alkaloid extracted from
the Lantana Brasiliensis or Verba sagrada.
It is described as a white body, in the form
of a fine powder, bitter, presenting alkaloid
reactions and forming salts with acids. It
exerts a moderating action upon the circu-
lation, like that of quinine, retarding nu-
trition and lowering temperature. It is em-
ployed in intermittent fevers and as an anti-
pyretic. In intermittent fevers it should be
administered immediately after a paroxysm.
It often succeeds where quinine has failed.
The dose is fifteen or thirty grains a day, in
pills.

Jan, io, 1 89 1.

Editorial.

47

THE

MEDICAL AND SURGICAL

REPORTER.

ISSUED EVERY SATURDAY.

CHARLES W. DULLES, M.D.,
Editor and Publisher.

N. E. Cor. 13th and Walnut Streets,
P. O. Box 843. Philadelphia, Pa.

^-Suggestions to Subscribers:

See that your address-label gives the date to which your
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In requesting a change of address, give the old address as
well as the new one.

If your Reporter does not reach you promptly and regu-
larly, notify the publisher at once, so that the cause may be
discovered and corrected.

4ES~ Suggestions to Contributors and Correspondents :
Write in ink.

Write on one side of paper only.

Write on paper of the size usually used for letters.

Make as few paragraphs as possible. Punctuate carefully.
Do not abbreviate or omit words like "the" and "a," or
"an."

Make communications as short as possible.

Never roll a manuscript I Try to get an envelope or
wrapper which will fit it.

When it is desired to call our attention to something in a
newspaper, mark the passage boldly with a colored pencil, and
write on the wrapper "Marked copy." Unless this is done,
newspapers are not looked at.

The Editor will be glad to get medical news, but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

IMMIGRATION AND PUBLIC HEALTH.

The influence of the enormous immigra--
tion which yearly adds hundreds of thou-
sands of human beings to the population of
the United States deserves the most careful
study of all who are interested in its moral
and physical welfare. The economical re-
lations of immigration get a fair share of
attention from Congress ; but moralists and
physicians will have to take the matter up,
if the relations spoken of above are to be
wisely regulated.

Dr. Hamilton, Surgeon-General of the
Marine Hospital Service, has been consider-
ing this subject and recommends more rig-
orous inspection and restriction of immigra-
tion.

He suggests that the law be amended so as
to provide that hereafter any person intend-
ing to immigrate into the United States shall

produce to the United States Consul nearest
him evidence that he has not been convicted
of any crime ; that he has not at any time
been a public charge in the country where
he lives, and that he has not at any time re-
ceived public assistance. And, further, that
he produce to the Consul a certificate from
a legally qualified resident physician to the
effect that he is at the time suffering from no
contagious or chronic disease or disability
such as would make him a public charge.
This paper should also set forth whether the
immigrant intends to become a naturalized
citizen or merely a temporary inhabitant.
These suggestions cover a good deal of
ground, part of it being in the department
of political economy. As physicians we are
especially interested in the proposition to
submit intending immigrants to a strict
scrutiny as to their physical soundness, or at
least their freedom from grave disease. Just
now American experimenters with Koch's
" lymph " find it hard to get a subject with
lupus to operate upon, and it would be a
good thing if the law made it impossible
for our European friends to send any of their
too numerous lupus afflicted countrymen
here. So, it would be well to make leprosy
or syphilis and some other diseases which
need not be named, a bar to immigration.
In this way a certain element of danger to
our country would be eliminated from its
development and a better chance would be
afforded to eradicate certain diseases which
have acquired a real, although as yet a slight
foothold in this country.

We trust that Dr. Hamilton's suggestion
will not be allowed to fall, but that he and
the members of the profession generally will
try to get it into such shape that Congress
can and will act upon it.

TRANSFUSION OF BLOOD AND SALT
SOLUTION.

Dr. John Marshall, of the University of
Pennsylvania, has published in the Zeit-
schrift fur Physiologische Chemie, November
11, 1890, a very interesting article in regard

48 rLdttc

to the transfusion of a mixture of defibri-
nated blood and salt solution. After briefly
indicating the present position of the ques-
tion of the use of salt solution in transfusion,
he gives an account of a number of experi-
ments, in which he used a mixture of one
part of defibrinated blood of the animal on
which he had made the experiment, and
nine parts of a 6 to 1,000 solution of chlo-
ride of sodium. The result of this method
of transfusion was exceedingly satisfactory.
The results were studied not only as to the
general appearance of the animals, but also
by careful investigations of the chemical
and microscopical conditions of the blood
after transfusion. A similar process could
be carried out in the case of human beings,
of course, using a mixture of human blood
with a salt solution. Salt solutions alone
are of a recognized value in preservin g life
after great loss of blood, but the addition
of a certain proportion of blood containing
living corpuscles, furnishes something be-
sides the mere mechanical distension of the
blood-vessels with an innocent circulating
fluid, as is the case in transfusion of salt so-
lution alone.

PROPOSED MEDICAL EXAMINERS'
BILL FOR PENNSYLVANIA.

At a meeting of the State Medical Soci-
ety at Pittsburgh, in June, 1890, a Commit-
tee on Medical Legislation, consisting of
the Presidents of the different County Soci-
eties throughout the State, was appointed.
This Committee met at Harrisburg, Septem-
ber 17, 1890, and, after consultation, ap-
pointed an Executive Committee of seven
to draft a proper bill and present it to the
meeting of the General Assembly in Janu-
ary.

The bill may not suit each individual
member of our profession, but the Commit-
tee, after due deliberation, thinks it is the
best that we can ask for at this time, and it
appeals to the members of our profession in
Pennsylvania to give it their support, and
see to it that their individual influence is

rial. Vol. lxiv

used with their representatives for its pas-
sage.

The text of the proposed law will be
found in another part of this issue of the
Reporter. We give it for the information
of our readers, and hope it will secure their
approval and support. Especially do we
commend to their notice the intimation of
the Committee that it may not exactly suit
everybody, and urge that they avoid the
risk of losing all by proposing unimportant
changes over which disagreement might
arise.

The Reporter thinks this Bill would do
much to protect the community, to raise
the credit of the State and to elevate
the standing of the profession, and will do>
what it can to secure its passage.

INCORPORATION OF THE PENNSYL-
VANIA STATE MEDICAL SOCIETY.

On December 20, 1890, the Medical So-
ciety of the State of Pennsylvania was in-
corporated by a decree of the Court of
Common Pleas of Philadelphia. This is
the outcome of a resolution adopted at the
last meeting of the Society, by which a
Committee was instructed to secure the in-
corporation of the Society. It is well that
the members of the Society shall under-
stand certain effects of this action. At the
next meeting of the Society it will be neces-
sary : 1. To adopt a set of By-Laws (which
may be the old ones or any modification of
them which may be desired) ; 2. To fix the
date of the annual meeting for the election
of Trustees; and, 3. To choose three Trus-
tees to serve for one year, three to serve for
two years and three to serve for three years.
Each year thereafter three Trustees are to
be chosen to take the place of those whose
terms expire. The Trustees to act until the
meeting of the Society are the members of
the present Judicial Council.

The incorporators will be obliged to pro-
vide for the perpetuity of the membership
by electing such other members as they may
see fit— presumably all the present members.

Jan. 10, 1891.

Special Article.

49

— and providing a method by which here-
after new members shall be chosen.

According to law, the Treasurer will here-
after be compelled to give a bond in such
sum, and with such sureties as may be re-
quired by the By-Laws for the faithful per-
formance of his duties.

Book Reviews.

[Any book reviewed in these columns maybe obtained upon
receipt of price, from the office of the Reporter.]

RECHERCHES CLINIQUES ET THERAPEU-
TIQUES SUR L'EPILEPSIE, L'HYSTERIE
ET LTDIOTIE. Compte rendu du service des
enfants idiots, epileptiques et arrieres de Bicetre
pendant l'annee, 1889.

CLINICAL AND THERAPEUTICAL INVESTI-
GATIONS OF EPILEPSY, HYSTERIA AND
IDIOCY. From the service for idiotic, epileptic
and feeble-minded children of the Bicetre Hospital
for the year 1889. By Bourneville, Physician
to the Bicetre; Sollier, Curator of the Museum
of the Bicetre ; and A. Pilliet, Former Interne
of the Service. Vol. x, 22 wood-cuts and
one chromo-lithograph. 8vo, pp. lvi, 188. Paris :
Office of the Progres Medical, 1 890. Price, five
francs.

The first part of the volume before us contains the
report proper of the Bicetre Hospital, with the num-
ber of the patients, the classes to which they belong,
and the general working of the institution. Follow-
ing the report are articles on bromide of gold, bro-
mide of camphor, and picrotoxine. The first is believed
to have a favorable action on nutrition, and some effect
in modifying epileptic seizures. The bromide of
camphor acts well in controlling epileptic vertigo.
Picrotoxin exerted no favorable influence upon the
vertigo. Following these therapeutical papers, Bourne-
ville contributes a very valuable article on " Myxoe-
dematous Idiocy," fully illustrated. Pilliet follows
with a paper on " Chronic Encephalitis of Childhood."
The histological appearances especially have been
studied. The next paper is oh " A Family of Hys-
terical Patients," by Bourneville and Sollier; and, in a
concluding paper Bourneville contributes a " Fresh
Observation of Myxedematous Idiocy."

The entire volume will be welcomed most warmly
by all neurologists. We sincerely hope that it may
be followed by many equally valuable.

AN EPITOME OF TRIPLER'S MANUAL, AND
OTHER PUBLICATIONS ON THE EXAMI-
NATION OF RECRUITS. By Charles R.
Greenleaf, Major and Surgeon, U. S. A. 8vo,
pp. 70. Washington, D. C. : William Ballantyne
& Sons, 1890. Price, 75 cents.

Since the publication of Tripler's Manual, much
has been written on the general subject of physical
examinations, and a number of changes have been
announced in such examinations for the United States
Army. The author states this fact in the preface to
this pamphlet, and says that the recent information on
the subject has been incorporated in this " Epitome."
The application of the vision-test is explained ; in-

structions for chest measurements are revised, and the
subject is in other ways brought up to date.

The Epitome will prove invaluable to recruiting
officers, and we can cordially recommend it to all who
are interested in physical examinations.

TRANSACTIONS OF THE NEW YORK STATE
MEDICAL ASSOCIATION FOR THE YEAR
1889. Volume VI. 8vo, pp. 445. Concord, N.
H. : Republican Press Association, 1890.

This volume contains the papers read at the sixth
annual meeting of the New York State Medical Asso-
ciation, in New York, 'September 25-27, 1889. The
President's address, by Dr. William T. Lusk, was on
Tubal Pregnancy, and is a very able presentation of
the subject. In addition to a number of interesting
papers, there were two principal subjects of discus-
sion : The Treatment of Hernia, and the New Hyp-
notics. Speaking of medical operations for the cure
of hernia, Dr. Bull said that his sixty- nine cases gave
sixty per cent, of cures and forty per cent, of relapses.
H e prefers the operation of ligation, with excision or
drainage of the sac. The discussions upon both sub-
jects were very free and full, and amply justified the
wisdom of the Committee on Arrangements in select-
ing them.

The volume as a whole is a handsome one, and
creditable in the highest degree to the Association, and
to the Editor, Dr. Edward K. Dunham.

Special Article.

KOCH'S REMEDY FOR TUBERCU-
LOSIS.

A RESUME OF ITS HISTORY.

\Continued from page 25.]

The Wiener Med. Presse, Dec. 14, 1890,.
contains the text of the Decree of the Min-
ister of the Interior of Austria regulating
the use of the Koch lymph in the Austro-
Hungarian Empire. This decree, on the
ground that the lymph is a secret remedy
with acknowledged dangerous properties,
restricts its use to heads of hospitals and
scientific medical institutions and physicians
authorized to practice in the Empire. It
indicates the source from which the lymph
must be procured and provides for the mak-
ing of full records of all cases so treated and
the report to the authorities of the circum-
stances under which any death may take
place.

The Progres Medical, Dec. 14, 1890, says
that the Germans are becoming more cir-
cumspect in regard to the cures — or rather
ameliorations — effected with Koch's lymph.
It cites from the Internationale Klinische
Rundschau, Dec. 7, the case of a girl seven-
teen years old, at Innsbruck, who died after

50 Special

an injection for lupus of the face. Reaction
after injection of 2 milligrams was rapid
and marked. The temperature rose to 41.5 0
(106. 70 Fahr.); the respiration became 60;
the pulse became imperceptible, and the
girl became unconscious and died in 36
hours, with signs of paralysis of the heart.
The lymph was obtained from Dr. Libbertz
(Koch's authorized agent). Every precau-
tion had been used in diluting it. The au-
topsy furnished no explanation of the girl's
death, which was the more unexpected be-
cause she was vigorous and well developed.

In the Berliner Klinische Wochenschrift,
December 15, 1890, Dr. R. Heinz, of Bres-
lau, publishes a paper on his experimental
studies of iodide of potassium and proposes
that this salt shall be systematically used in
connection with injections of Koch's rem-
edy, because of its apparent power to pro-
mote the activity of the leucocytes.

The Bulletin Medical, December 17, con-
tains a report of a third lecture by Cornil,
in which he speaks, after having used the
Koch remedy on thirty patients, as to the
temperature change and the variations in the
oxyhemoglobin of the blood after its injec-
tion. As to the former, he calls attention
to the way in which the lymph may seem to
delay its action and then suddenly act with
exceptional force. The oxyhemoglobin, he
finds, diminishes, and for this reason he
thinks that the remedy must be used with
caution in pulmonary tuberculosis, except
in cases in which fever is absent or moder-
ate. He seems to think the remedy may be
useful in lupus, but claims very little for it
in phthisis.

In the same journal Lannelongue reports
using the lymph upon a boy eight years old
with lupus of the face. After the third in-
jection he became quite ill ; he had a con-
fluent papular eruption and inflammation of
the knee, the elbow, the wrist, the shoulder,
the hip, and even of the cervical portion of
the spinal column. Lannelongue says that
if this had occurred after the first injection
this would have been claimed to have re-
vealed foci of latent tuberculosis ; but as it
came on eight days after the first injection
it may be asked if it was not due to the ac-
tion of the lymph setting up new foci of
tuberculosis.

The Scotch correspondent of the Medical
Press and Circular, December 17, 1890,
says: " During last week at the Royal In-
firmary of Glasgow three cases of lupus
were treated with hypodermic injections of

Article. Vol. lxiv

Koch's fluid with the following results. In
two of the cases so far as curative or other
effect was observed they might as well have
been injected with cold water, for neither
beneficial nor prejudicial effect could be no-
ticed. In the third case there was, to use
the cant phrase which is on every person's
tongue just now, a decided 'reaction.'
The seat of the disease became swollen and
congested, and coincident with the subsi-
dence of these effects, and at the present
time, the diseased parts certainly look more
healthy. The inference drawn in such cases
is that lupus is a tubercular disease, that tu-
bercle is due to a microscopic germ termed
the tubercle bacillus, and that whatever kills
or causes the death of the bacillus, no matter
in how roundabout a way, cures the disease ;
and phthisis pulmonalis as well as lupus con-
sequently. Now it must be pointed out that
pathologists are not at all agreed as to lupus
being a tubercular disease, and it does not
necessarily follow that if a remedy is found
for lupus that the dreadful scourge of con-
sumption would be equally amenable to the
same influence. Here in three cases of lupus
under the observation of the writer, but one
of them responded to the Koch fluid, and it
would be premature to say as yet that the
disease is either arrested or cured in this one
case. Again, most men of any experience
in practice have occasionally experienced
gratifying results in the treatment of certain
cases of lupus, from well-known and ancient
remedies of the pharmacopoeia. The writer
has cured cases of lupus more than twenty
years ago, in the sense in which lupus is now
said to be cured, by combinations of bi-
chloride of mercury, iodide of potassium
and arsenic (Donovan's solution), and he
entertains the opinion that the hypodermic
injection of these substances in proper quan-
tity would yield results not inferior to those
of Koch's fluid, so inordinately and so inju-
diciously vaunted. The French have had
most favorable results with hypodermic in-
jections of iodoform dissolved in olive oil.
It is not a little significant in this relation
that Billroth, of Vienna, a gentleman of
acknowledged eminence throughout Europe,
has expressed the opinion that as a curative
agent in lupus iodide of potassium is supe-
rior to 'Koch's lymph.' In the case of
the phthisical cases treated in the Royal
Infirmary of Glasgow, a trifling reaction
took place in one or two of them, that is to
say, the temperature rose considerably, but
so far as amelioration of the urgent symp-

Jan. 10, 1 89 1. Notes and

Comments.

5i

toms was concerned, this existed only in the
luxuriant imagination of 'the sanguine con-
verts to the new doctrine. In other cases
of undoubted phthisis no result whatever
ensued."

The same journal says: "If Koch's
lymph is scarce at Berlin it is abundant at
Davos Platz, where the arrival of some
twenty-five phials was announced a few
days since, being enough to treat a thou-
sand patients for a couple of months ! Con-
sumptive patients at Davos, however, proba-
bly feel pretty comfortable, for only about a
hundred of the fourteen hundred tuberculo-
sis residents elected to undergo the treat-
ment, the others preferring to run the risk
of having to attend the funerals of those to
be experimented upon."

In the New York Medical Record, Dec.
27, 1890, there is an article by Dr. H. P.
Loomis, describing his trip to Berlin to get
lymph for the Bellevue Hospital, and his ob-
servations and opinions. He has apparently
been very much impressed by what he saw.
Under the head of "Conclusions " he says:
" If I were asked to express an opinion as
to the efficacy of the new remedy, I should
say I believe it to be as great a medical dis-
overy as that made by Jenner; that it
pens up a hitherto unknown field in the
reatment of disease, which no one at the
present time can limit ; that it apparently
cures lupus, as admitted by all observers. (!)"
With regard to its curative power in pulmo-
nary tuberculosis, he quotes the answers
made to a series of questions he addressed
to Prof. Leyden a few days before leav-
ing Berlin. The substance of the answers
is that Prof. Leyden has noticed permanent
improvement in some cases of early phthisis
following the use of the remedy, but thinks
time can alone show how frequent such
cases are ; that he has seen improvement in
some advanced cases ; that he would use the
remedy on his own child ; that he favors
its use in private practice ; that he has seen
disastrous effects following its use in unsuit-
able cases and in overdoses ; that as a pre-
caution he would administer small doses,
beginning with from 1 to 5 milligrams;1 that
he continues constitutional treatment while
using the remedy ; and that it has no positive
diagnostic value in all cases.

In New York experimentation with the
lymph continues.

A dose of 2 milligrams killed the girl at Inns-
bruck, spoken of above. — Ed. Reporter.

At St. Francis Hospital, December 24,
Dr. George F. Shrady inoculated seven
cases, two for tubercular disease of knee-
joint; one for tubercular caries of wrist-
joint ; one for carious sinus of thigh ; one
for scrofulous sinus of groin ; one case of
incipient phthisis, and one case of phthi-
sis in second stage. The latter was a pa-
tient of Dr. John H. Ripley. The inocu-
lations were prepared under the supervision
of Drs. Max Einhorn and E. C. Wendt, and
according to the strict Berlin method.

The Medical Record, December 27, says
that, in a general way it may be said that
no new features have been developed. The
reactions in the phthisis cases have been
quite constant, as also in the cases of lupus,
the latter having been reported as improv-
ing. The doses have generally been one
milligram, which has been cautiously in-
creased in accordance with the amount of
reaction produced. As yet no accidents
nor serious complications have occurred in
connection with the inoculations ; neither
has there been any death attributable to
their use.

Notes and Comments,

Proposed Act for Medical Examiners
for Pennsylvania.

An Act to regulate the Practice of Medicine
and Surgery, to establish a State Board of
Medical Examiners and Licensers, to define
the powers and duties of such Board, the
qualifications of applicants for license, the
manner of licensing, and making an appro-
priation for said Board.

Whereas, The safety of the public is en-
dangered by incompetent physicians and
surgeons, and due regard for public health
and the preservation of human life demands
that none but competent and properly quali-
fied physicians and surgeons shall be allowed
to practice their profession :

Section i. Be it enacted by the Senate
and House of Representatives of the Com-
monwealth of Pennsylvania in General As-
sembly met, and it is hereby enacted by
authority of the same, that within one month
after the passage of this Act the Governor
shall appoint a State Board of Medical Ex-
aminers and Licensers consisting of nine
members, three to serve for one year, three
for two years, and three for three years in
the first instance, and thereafter annually

52

Notes and

Comments.

Vol. lxiv

the Governor shall appoint three members to
serve for three years in place of those whose
terms then expire. The said persons so ap-
pointed shall be graduates of some legally-
chartered college or university having the
power to confer medical degrees, citizens of
the United States and of this Common-
wealth who shall have been in the active
practice of medicine or surgery for a period
of not less than ten years, but no two of
whom shall be residents of the same county.1
Each member of the said Board shall receive
a certificate of appointment from the Gov-
enor, and shall file the same within twenty
days with the Prothonotary of the Court of
Common Pleas of the county in which said
member is registered under existing law.

Sect. 2. The said Board shall be known
by the name and style of the State Board of
Medical Examiners and Licensers of the
Commonwealth of Pennsylvania, and shall
have a common seal, and may make and
adopt all necessary rules and regulations and
by-laws not inconsistent with the Constitu-
tion and laws of this Commonwealth, or of
the United States, and shall have power to
locate and maintain an office within this
State for the transaction of business. Five
members of the said Board shall constitute
a quorum for the transaction of business.

Sect. 3. Every appointment to fill a va-
cancy or vacancies in the said Board shall
be for the unexpired term, and the said va-
cancy or vacancies shall be filled by the
Governor within sixty days after notification
of the same by the Board, and he shall have
power to remove any member of said Board
for criminal, scandalous, or dishonorable
conduct.

Sect. 4. The said Board shall organize
at Harrisburg within three months from the
date of their (its) appointment, and shall elect
from its own number a President and Secre-
tary who shall also act as Treasurer, both of
whom shall hold their offices for one year, or
until their successors are chosen.

Sect. 5. The members of the said Board
shall each receive a salary not exceeding
three hundred dollars per annum, to be paid
out of the fees for examination. The Sec-
retary-Treasurer shall receive an additional
salary to be fixed by the Board, and shall
file with the President of the Board a
bond in the sum of one thousand dollars,
conditioned for the faithful performance of

1 And none of whom shall be member of the faculty
or staff of any medical school or university.

his duties. The necessary expenses of the said
Board shall also be paid out of the fees, ex-
cept as provided in Section 1 2 of this Act,
and any balance remaining from the fees,
after the disbursements herein specified, shall
be paid into the treasury of the Common-
wealth.

Sect. 6. The said Board shall examine
all applicants for license to practice medicine
or surgery in this Commonwealth who are
properly qualified according to the provi-
sions of Section 7 of this Act, and no one
shall be excluded or rejected on account of
adherence to any special system or school
of practice. It shall hold two stated meet-
ings in each year, one at Pittsburg on the
first Tuesday of April, and one at Philadel-
phia on the first Tuesday of May respec-
tively, and may hold special meetings at
such times and places as it may deem proper.
All examinations, when practicable, shall
be conducted in writing, and all examina-
tion papers, together with the reports and
action of the examiners thereon, shall be
preserved among the records of the said
Board for a period of five years, during
which time they shall remain open for in-
spection at the office of the said Board.

The applicants shall be examined in anat-
omy, physiology, chemistry, toxicology,
pathology, hygiene, materia medica, and
therapeutics, principles and practice of
medicine, surgery, and obstetrics, and each
applicant upon receiving from the Secre-
tary of the Board an order for examination
shall draw by lot a confidential number,
which he or she shall place upon his or her
examination paper, so that when said papers
are passed upon by the Examiners the latter
shall not know by what applicant said papers
have been prepared, and upon each day of
examination all candidates shall be given
the same set of questions. Provided that
any candidate for examination may elect the
system of materia medica and therapeutics
in which he or she shall be examined.

Sect. 7. Any person on paying twenty
dollars to the Secretary of said Board, and
on presenting satisfactory proof of being
over twenty-one years of age, of good moral
character, and of having received a suffi-
cient preliminary education, as defined by
said Board, and a diploma from some legally-
incorporated medical college or university
having authority to confer degrees in med-
icine, shall be entitled to examination by
the said Board, and in case of failure at any
examination shall have the privilege of sub-

Jan. 10, 1 89 1. Notes and

Comments.

53

sequent examinations without the payment
of an additional fee. Each applicant who
shall have passed a satisfactory examination
shall, receive from the said Board, under
seal, a license to practice medicine and sur-
gery in the Commonwealth of Pennsylvania,
and the said Board may at its discretion
grant licenses without examination to per-
sons holding licenses from similarly-consti-
tuted boards of examiners or boards of health
in other States.

Sect. 8. The Secretary shall record in a
book to be kept for this purpose in the office
of the said Board, the name, age, sex, resi-
dence, date, and place of examination, the
examination number, the examination aver-
age on each branch, the general average,
and date of issue of license, in case such
license is granted. Said book shall be open
to public inspection, and on or before the
last day of December of each year the said
Board shall publish, or cause to be published,
a list of the names and addresses of such
persons as shall have received licenses from
the said Board within twelve months imme-
diately thereto preceding.

Sect. 9. After the first day of July, Anno
Domini one thousand eight hundred and
ninety-one, no person shall enter upon the
practice of medicine or surgery in the State
of Pennsylvania unless he or she has com-
plied with the provisions of this Act, and
shall have exhibited to the Prothonotary of
the Court of Common Pleas of the county
in which he she desires to practice medicine
or surgery, a license duly granted to him or
her by the said State Board of Examiners
and Licensers, whereupon he or she shall
be entitled, upon payment of one dollar, to
be duly registered in the office of the Pro-
thonotary of the Court of Common Pleas
in said county, and any person violating
any of the provisions of this Act shall be
guilty of a misdemeanor, and upon convic-
tion thereof in the Court of Quarter Sessions
of the county where the offence shall have
been committed, shall pay a fine of not less
than one hundred dollars nor more than five
hundred dollars for each offence, one-half
of which fine shall be paid to the prosecu-
tor.

Sect. 10. Nothing in this Act shall apply
to commissioned medical officers of the
United States Army or Navy, or of the
United States Marine Hospital Service, nor
to any member of the house or resident staff
of any legally-chartered medical college or
university or hospital during his term of ser-

vice therein, nor physicians of other States
meeting duly registered physicians in this
State in consultation, nor to those practicing
dentistry exclusively. And. nothing in this
Act shall be construed to prohibit the prac-
tice of medicine and surgery within this
Commonwealth by any practitioner who
shall have been duly registered before the
first day of July, Anno Domini one thou-
sand eight hundred and ninety-one, accord-
ing to the terms of the Act entitled " An
Act to provide for the registration of all
practitioners in medicine and surgery," ap-
proved the eighth day of June, Anno Domini
one thousand eight hundred and eighty-one.

Sect. ii. For the purpose of this Act,
the words "practice," "medicine" or
"surgery" shall mean to treat, operate on
or prescribe for any physicial ailment of
another. But nothing in this Act shall be
construed to prohibit service in cases of
emergency or the domestic administration
of family remedies.

Sect. 12. The sum of one thousand
dollars, or so much thereof as may be ne-
cessary, is hereby appropriated to meet the
necessary and legitimate expenses of the said
Board for the year Anno Domini one thou-
sand eight hundred and ninety-one.

Sect. 13. All Acts or parts of Acts of
Assembly inconsistent herewith shall be and
are hereby repealed.

Medical and Surgical College of New
Jersey. .

The District Medical Society for the
County of Hudson, N. J., recently adopted
the following preambles and resolutions :

Whereas : A certain medical institute,
called the "Medical and Surgical College
of the State of New Jersey," chartered by
special Act of this State, approved March
17, 1870, was organized during the year
1888, and opened in three small rooms on
the top floor of the general office building,
No. 47 Montgomery street, Jersey City; and

Whereas, Said alleged college has grad-
uated several students whose diplomas have
been presented to the Hudson County Board
of Health, and who have been refused reg-
istration ; and

Whereas, It has appeared to this Soci-
ety, by good and sufficient evidence, that
several members of the faculty, nearly all of
whom are non-residents of this State, are
either incompetent to deliver lectures on the
topics assigned them, or are graduates of

54

Notes and

Comments.

Vol. lxiv

disreputable or fraudulent medical colleges ;
that the facilities for instruction in said al-
leged college are totally inadequate, and
that no clinics, dissections or hospital prac-
tice have been or can be given ; that' the
provisions of the charter of said college
have not been observed by the authorities
thereof j that the requirements of said char-
ter, even if the same were strictly followed,
are far below the standard of minimum re-
quirements of medical colleges adopted and
demanded by all medical authorities at the
present time, and that, therefore, the posses-
sion of a diploma from said alleged college
is no proof whatever that the holder thereof
has received a good and sufficient medical
education ; and

Whereas, The State Board of Medical
Examiners of this State will introduce a bill
at the next meeting of the Legislature for
the purpose of repealing said charter :

Be it Resolved, That the District Medical
Society for the County of Hudson does
hereby earnestly protest against the exist-
ence of said alleged college as an unneces-
sary, inadequate and disreputable institution,
tending to degrade and lower the standard
of the medical profession ; that the influ-
ence of this Society and of the individual
members thereof be given to the support and
passage of the bill to repeal said charter,
and that a copy of this resolution be for-
warded to the several medical societies of
this State with requests for their support and
influence for the passage of said bill.

These resolutions are attested by Henry
B. Rue, M. D., Secretary, Jersey City, N. J.,
December 16, 1890.

[As the Reporter exposed the methods of
this "college" in an Editorial, August 24,
1889, it will be understood that we find no
hesitation in supporting the purpose of the
Hudson County Society and of the New
Jersey State Board of Medical Examiners.
It will be a good work if this Board can get
the State freed from the institution which
now bears its name.]

Dilatation for Dysmenorrhoea.

In the Weekly Medical Review, December
6, 1890, Dr. Paul J. Barcus, adopting largely
the views of Dr. W. G. Wylie, of New York,
makes a plea for rapid dilatation of the cer-
vix uteri for dysmenorrhoea. Of the mode
of carrying out rapid dilatation, he says that
care in the selection of cases is not the only
essential to successful treatment. The oper-

ation must be carried out in detail, and at-
tention must be equally directed to the after-
treatment, both constitutional and local.
The proper time for operating is about one
week after a menstrual period, which will
allow sufficient time for the lacerated mu-
cous membrane to recover before the next
period. Before commencing, all peri-uter-
ine tenderness must be subdued, as it gives
no promise of good results if there is pelvic
peritonitis or cellulitis, or any degree of in-
flammatory process in the adnexa. With
these conditions present it becomes an
operation fraught with great danger to the
life of the patient. Endometritis or me-
tritis without implication of the surround-
ing tissues, or flexions or versions do not
contra-indicate.

A bivalve dilator should be used. The
patient should be anaesthetized, the blades
should be introduced closed up to the
shoulder, and should engage the internal os
sufficiently to dilate it without slipping.
The blades should be slowly and carefully
spread to the extent of three-quarters or one
inch and allowed to remain so for several
minutes, care being taken to avoid slipping
of the expanded blades out of the cervix,
and consequent laceration of its tissues.
The dilators being then removed, a hollow,
hard-rubber stem should be introduced, one
of sufficient length to engage the fibers of
the internal os (about two and a quarter
inches), and sufficiently large to maintain
dilatation to some degree, and tapering from
the point, the better to insure its retention.
This should be supported for from twenty- four
to forty-eight hours by a cotton tampon sat-
urated with boroglyceride, by which time
the fibers of the internal os will have con-
tracted down upon the stem sufficiently to
retain it in its place, without the assistance
of the tampon. If the stem causes any de-
gree of irritation it should be removed, to
be reinserted when all irritation has sub-
sided. But it will be found that but few
patients will complain of it, and many will be
ignorant of its presence if not so informed.

The patient should be kept in the recum-
bent position for four or five days, or until
the immediate effects of the operation have
subsided. If there is no obstruction of the
stem, and it causes no inconvenience, it may
be left in position during the next sickness.
Ordinarily it should be removed before, to
be reinserted again. The use of the stem
obviates the necessity for using intra-vaginal
pessaries, and for repeating the dilatation ;

Jan. 10,-1891. Notes and

Comments.

55

serves to correct the position of the uterus ;
and its presence within the canal and body
of the organ seems to exert a therapeutic
effect upon the mucous membrane and nerves
distributed to those parts, and upon the nu-
trition and functions of the organ itself, that
can hardly be accounted for by the better
drainage and corrected position alone.

The condition of the patient is such that
the constitutional treatment must be carried
on at the same time, and with equal care.
Most cases require a course of general ton-
ics, and especial care as to the usual influ-
ence brought to bear upon the mind of the
patient. They do better when removed
from the sympathetic watchfulness of friends
and relatives.

By carrying out this method of treatment
but few cases will be found that cannot be
relieved. Dr. Barcus's experience in the
past convinces him that the large majority
of so-called intractable cases are obstinate
because of the imperfect manner in which
the treatment has been executed.

Testing Water.

Among the scraps of erroneous informa-
tion which appear in scientific journals with
more or less regularity, is one about testing
the purity of water by the addition of a lit-
tle pure sugar. It is said that when water is
so treated, any organic matter present is
after a time discovered in the form of black
specks floating in the liquid.

This scrap is on its rounds again, having
possibly made a transatlantic journey since
its last appearance here, and the method re-
ferred to is now credited to a professor in a
Western university.

The truth about the matter, as has before
been stated in this journal, is that the test
referred to was originally proposed by
Heisch for the detection of a fungus sup-
posed to be peculiar to sewage. Pure sugar
was added to the suspected water in the pro-
portion of about half a gram to 100 cubic
centimeters in a stoppered bottle, and the
bottle being placed in a strong light was
kept at a temperature of 8o° F. for several
hours. It was then examined for the fungus,
which if present was disclosed as a distinct
turbidity to the naked eye, and under a
power of 250 diameters was found to consist
of small spherical cells. Heisch believed
that the cells thus developed were distinct
evidence that the water was contaminated
with sewage, but Frankland showed that the

spores of this particular fungus were present
in all waters that had been exposed even
momentarily to the air, and that their de-
velopment was due simply to the presence
of j^osphates in the water. The addition
of even a minute trace of any phosphate
was sufficient to develop the fungus in any
water under the conditions above stated.

From this it will easily be seen that the
so-called sugar test is not only of no value
for the purpose for which it was recom-
mended, but is positively misleading, and
consequently dangerous.

It ought to be well understood that there
is no " handy " test for the purity of water.
It is sometimes easy enough to show very
promptly that a given water is unfit for
drinking, but to make sure of its safety is
quite another matter.

It is very evident that the dissemination
of misinformation on such a subject is cal-
culated to do much harm, and those who
are concerned with preserving health should
not fail to show, whenever opportunity of-
fers, the danger of forming conclusions as
to the purity of water by "popular" or easy
tests. — Druggists' Circular, December, 1890.

Guaiac as a Purgative.

Dr. William Murrell, Lecturer on Phar-
macology at Westminster Hospital, says in
the Medical Press, Nov. 5, 1890 :

In our thirst for new remedies there seems
to be a danger that some of our good old-
fashioned drugs may be forgotten. Take
guaiacum for example. In most of our text-
books on materia medica we are told that
guaiacum resin acts as " a stimulant, diapho-
retic and diuretic." I cannot find that
there is much evidence in support of this
view. Wood, of Philadelphia, seems to be
of the same opinion, for he says : " Guaia-
cum is believed by some to act as a diapho-
retic, and to do good by increasing the
elimination of the skin, but as I have not
been able to obtain either from medical lit-
erature or from the exhibition of the medi-
cine any distinctive proof of its having any
such action to any marked extent, I have
preferred to consider the drug as an altera-
tive." Schmiedeberg, of Strassburg, curi-
ously enough deals with it under the head
of "Drugs and preparations used for all
sorts of purposes but now mostly antiquated
and obsolete." I am inclined to think that
its main action is as a laxative or purgative,
and this view is evidently shared by Dr. C.

56

Notes and Comments.

Vol. lxiv

D. F. Phillips, who, in his well-known work
on the Vegetable Kingdom, states that in
large doses it produces ''dryness in the
mouth, burning in the throat, a sensation of
heat in the stomach, loss of appetite, heart-
burn, flatulence, nausea, vomiting and purg-
ing. ' ' My attention was drawn to the sub-
ject some two years ago by casually prescrib-
ing for a city man suffering from rheuma-
tism some guaiacum lozenges made up with
black currant paste. He continued taking
them long after the pains had ceased, and
his explanation was that they did him good
by acting on the liver and bowels. He said
that one or two of the lozenges taken in the
morning before breakfast acted promptly
and without inconvenience. I ordered the
lozenges for other of my patients suffering
from constipation, and what is convention-
ally called " biliousness," and the result was
equally satisfactory. The lozenges not be-
ing available for hospital use I had a con-
fection prepared containing ten grains of
guaiac resin to a drachm of honey. This
was curiously popular with the patients, and
for the last two years I have used it exten-
sively not only as a purgative but in the
treatment of chronic rheumatism, sciatica,
tonsillitis, dysmenorrhoea and allied affec-
tions. The confection is nasty, but is ap-
preciated by patients. At first I gave it in
drachm doses once a day, but they were not
satisfied with this and I had to increase the
dose to two drachms three times a day. In
this quantity it seems capable of producing
the maximum of inconvenience and discom-
fort, and gives unlimited satisfaction. The
purgative effect is very pronounced, and in
one case the patient had fifty-six evacuations
in the week. In another case it produced a
well-marked rash, covering the arms and
legs with an eruption which forcibly re-
minded one of copaiba. That this rash is
rare may be gathered from the fact that my
colleague, Dr. C. T. Fox, had seen only one
similar instance. It was accompanied by
intense itching which disappeared on dis-
continuing the drug. The guaiacum not in-
frequently gives rise to a burning sensation
in the throat, and to obviate this I pre-
scribed the ten grains of the resin in half
an ounce of extract of malt, which answered
admirably. This method of treatment is,
perhaps, simply a return to the old-fashioned
" Chelsea Pensioner," which consisted of
guaiacum, rhubarb, ginger, sulphur and cer-
tain other ingredients, but it is interesting
nevertheless. I am sure that a trial of the

guaiacum resin as a laxative or purgative,
according to the dose employed, will be
found satisfactory. It is possible that if the
drug were triturated with cream of tartar,
sugar of milk, or some other equally inert
substance, its efficacy would be increased,
and it would produce the desired effect in
smaller doses.

Death from Injection into the Lung.

Dr. Robert T. French, of Rochester, N.
Y., reports in the Medical News, Nov. 29,
1890, the following mishap, occurring in the
treatment of phthisis by intra-pulmonary in-
jection, is interesting. During part of the
writer's term of service as house physician
of the Buffalo General Hospital in 1888-89,
a large number of cases of phthisis were
treated by intra-pulmonary injections. The
medicament used was a three-per-cent. solu-
tion of beechwood creasote in oil of sweet
almonds. Of this about ten minims were
injected at a time into a cavity or solidified
apex. In most instances the immediate ef-
fects were very encouraging. The expecto-
ration usually decreased, and the tempera-
ture, after the slight rise caused by the op-
eration, fell, and continued for a time nearly
normal. More than fifty such injections had
been made with favorable results, when the
following accident occurred.

The patient was well nourished, and un-
der tonic treatment, and the disease seemed
to be in abeyance. Three injections had
been made, at intervals of four days, into
the left apex, followed in each instance by
decreased expectoration and marked dimi-
nution of evening temperature. The fourth
injection was made by the usual method into
the right apex, and the patient immediately
after the procedure resumed his duties about
the ward. Twenty minutes later he was
seized with violent dyspnoea, which gradu-
ally became worse. He had formerly suf-
fered from asthma, and the present attack
resembled an asthmatic paroxysm. The
irritation caused by the drug on the periph-
eral endings of the vagus seemed to afford
a plausible explanation in support of this
diagnosis. The usual remedies for asthma
were administered, but all failed to give re-
lief. Auscultation was rendered impossible
by the violent tossing and groaning of the
sufferer. About an hour and a half after
the injection the patient died.

At the autopsy the right lung was found
entirely collapsed and the pleural cavity

Jan. 10, 1 891.

News.

57

filled with air. The needle in entering the
lung had passed through tissue as thin as
ordinary writing-paper, into an emphysema-
tous space, communicating with a small cav-
ity, which in turn communicated with a
bronchus. After the puncture the thinness
of the wall prevented it from retracting suf-
ficiently to act as a valve, and the inspired
air must have passed almost directly into the
pleural cavity.

Cases of pneumo-thorax have been re-
ported, following intra-pulmonary injection •
but all were slight, and ended in recovery.
Only one death immediately following this
treatment is recorded, and in that case death
was due to acute suppurative bronchitis.
Had the pneumo-thorax been diagnosed in
Dr. French's case at the outset of the attack
he thinks it is possible that surgical inter-
ference might have saved the patient. The
condition, however, was wholly unexpected,
and was not recognized by any of the phy-
sicians who examined the case.

The slight benefits following this method
of treatment are, in Dr. French's opinion,
secured at too great a risk to make the pro-
cedure advisable.

Hypodermic Use of Strychnia.

Dr. Harold N. Moyer, of Chicago, in a
paper read before the Southern Surgical
and Gynecological Association, at Atlanta,
claimed that the irritating properties of
Fowler's solution, when injected into the
cellular tissue, were largely due to the pres-
ence of free arsenious acid. This objection
to the hypodermic use of the drug had been
obviated by employing a solution of the ar-
seniate of sodium, a stable, neutral salt of
definite composition. This salt could, he
found, be injected beneath the skin without
causing more irritation than would be pro-
duced by so much water. He confirmed
Hammond's conclusions that arsenic was
less poisonous when given by the hypoder-
mic method than when employed by the
mouth. He had had a similar experience,
in administration of the drug by the mouth,
to the utmost limit of toleration, until the
eyes were reddened and the stomach dis-
turbed. Then the use of the drug by the
mouth was suspended, and an increased
dose given hypodermically, with complete
subsidence of the poisonous symptoms. The
toxic properties of arsenic are largely fo-
cused upon the stomach, liver and upper
end of the small intestine. If we adminis-

ter arsenic by the cellular tissue it immedi-
ately enters the general circulation and so
avoids the selective action that the liver un-
doubtedly possesses for metallic salts. An
analogous example was to be found in the
use of mercuric salts, by inunction and in-
jection.— Weekly Medical Review, Decem-
ber 6, 1890.

Tannic Acid as an Intestinal Anti-
septic Remedy.

Professor Cantani has written, in the
Wiener medizinische Blatter, of his thera-
peutical trials of tannic acid in intestinal
diseases. He has found it, in y$, y2, or
even in i-per cent, solutions, acting a useful
part as an antiseptic, as it hinders the vege-
tative activity of the microbes and renders
innocuous many of the poisonous ptomaines.
In diarrhoea and dysentery, therefore, tan-
nic acid becomes an important disinfectant
as well as astringent remedy. Mosler also
reports that this drug is very beneficial in
typhoid fever, particularly for removing the
symptoms of meteorism and diarrhoea. An-
tiseptic solutions are best introduced by en-
teroclysis [injections into the colon], the
fluid thus administered having been proved,
by the subsequent vomiting of some of it,
to reach not only the whole length of the
intestines, but even to the stomach. — New
York Medical Journal, December 6, 1890.

NEWS.

—Dr. W. H. Elliot, of Houston, Texas,
died December 23, 1890.

— Prof. Hyrtl, the Austrian anatomist,
celebrated his eightieth birthday recently.

— Dr. C. H. Hall, of Boston, was arrested
for alleged malpractice December 29, 1890.

— The new St. Christopher's Hospital, in
Philadelphia, was opened December 29,
1890.

— Dr. George P. Wesselhceft, a well-
known physician of Brookline, Mass., died
December 29, 1890.

— H. A. Kelso, of Paxton, 111., was as-
saulted and robbed in Chicago, on Decem-
ber 19, 1890. His skull was fractured.

— Dr. A. F. Holt, Surgeon-General of
Massachusetts, died in Florida, December
28, 1890. He was fifty-two years old.

— Dr. John B. Hayes, a well-known phy-
sician of New York, was attacked by a high-
wayman, while walking through Union
Square, early New Year's morning.

58

Obituary.

Vol. lxiv

— A death under ether anaesthesia occurred
in the St. Barnabas Hospital, Minneapolis,
December 25, 1890. The patient was a
well-built young man, with a tumor of the
foot.

— Dr. Nathaniel R. Boutille, of Coates-
ville, Me., died December 22, 1890, of
paralysis. He was almost seventy years old,
and was a highly-esteemed citizen and prac-
titioner.

— The American Chemical Society, at its
concluding session in Philadelphia, Decem-
ber 30, took steps towards uniting with
other bodies of chemists in the formation of
a national organization.

— Dr. Theron Temple, of Waltham, Mass.,
died December 28, 1890, at the age of 57,
after a long sickness. He had been city
physician of Waltham and for several years
in the Boston Custom House.

— Dr. Nicholas Senn in December re-
signed his Professorship of Surgery at the
Rush Medical College, Chicago. The rea-
son assigned is the refusal of Prof. Parker to
permit Prof. Senn to deliver clinical lec-
tures at the college.

— It is reported that physicians have been
sent by the Russian government to Asia
Minor to test by experiment the treatment
of cholera with the ferubia sumbul, a plant
growing in Turkestan and possessing anti-
spasmodic properties.

— Dr Samuel G. Dixon, the bacteriologist
of the American Academy of Natural Sci-
ences, returned December 29, 1890, from
Berlin, where he had been studying the
merits of the Koch lymph on behalf of the
Jefferson Medical College.

— Mr. John Ogden has associated with
him Mr. W. S. Harvey as a partner in the
drug business, conducted at Walnut and
13th streets and Arch and 19th streets, Phil-
adelphia. Both stores will be conducted
under the firm name of John Ogden & Co.

— A dispensary for the treatment of the
diseases of women amenable to electricity
has been opened at 1632 Cherry St., Phila-
delphia, under the charge of Dr. G. Betton
Massey and Dr. Horatio R. Bigelow. Phy-
sicians are invited to bring or to send suit-
able cases on Mondays, Wednesdays or Fri-
days at 3 p. m.

— Dr. Edgar M. Green, of Easton, Pa.,
who was recently engaged to make certain
chemical and microscopical investigations
for the Court at that place, presented a bill
for $200 for his services. The County
Commissioners refused to pay the bill, but

agreed to abide by an arbitration. The
arbiters decided in favor of Dr. Green and
said the bill was reasonable.

— The advent of the new year in Norris-
town was marked by the formal opening of
the borough's first charity, Charity Hospital,
which was then turned over to the public
for its first inspection. It is claimed by the
directors of the concern that it has more
cubic inches of space per bed than any
other charity hospital in the State.

— The new building of the Polyclinic
Hospital, on Lombard street, above Eigh-
teenth, Philadelphia, was opened for the re-
ception of patients December 29, 1890. All
the clinics were opened in the morning with
their apparatus in full working order. The
wards are not yet ready for the reception of
patients, but are expected to be ready in
about a week.

— According to the Bureau of Vital Sta-
tistics the health of New York, in 1890, was
better than in 1889, as the death-rate was
24.66 per 1,000, against 25 last year. This-
calculation, however, is based on an esti-
mated population of 1,631,232. There were
40,230 deaths in the city during 1890, or
an average of one in every 13 minutes dur-
ing the year. In 1889 the deaths were
39,583. There were 39,250 births and
14,992 marriages. Over one-fourth of all
the deaths were of children under 1 year
old. Phthisis and pneumonia were the chief
causes of death, they being responsible for
10,418 of the deaths. There were only two
fatal cases of small-pox.

OBITUARY.

L. M. HUBER, M. D.

Dr. Lee Huber died in Rocky Ford, Col.,
December 18, 1890. He was born in 1853
in Lancaster Co., Pa., and was graduated in
1877 from the Millersville State Normal
School, of his native State. Some time after
that he received a degree from Lafayette Col-
lege. In the fall of 1882, he entered Jefferson
Medical College, of Philadelphia, and in
1884 was graduated from that College, tak-
ing the first prize in obstetrics. He then
located and entered into a promising prac-
tice in Chicago, but his health failing him,
he moved to the far West, where his life was
terminated by consumption.

He was a contributor to the Medical and*
Surgical Reporter, whose papers were al-
ways interesting and instructive.

MEDICAL AND SURGICAL REPORTER.

XV

"This is an Age of Apollinaris Water!'

—Walter Besant.

Apollinaris

"THE QUEEN OF TABLE WATERS."

€i Familiar in millions of mouths as any ho^csehold
word.

"The popularity of Apollinaris Water is chiefly
due to its irreproachable character.

"More wholesome than any aerated water which

art can supply!' — The Times, London.

"Of late years the Queen, by the advice of Sir William Jenner, has
usually taken Apollinaris Water.— The World, London.

THE BEST NATURAL APERIENT*

THE APOLLINARIS COMPANY, LIMITED, London, beg to announce that, as
numerous Aperient Waters are offered to the public under names of which the word
M Hunyadi " forms part, they have now adopted an additional Label comprising theii
Registered Trade Mark of selection, which consists of

JL RED IDIAlMOlSro.

This Label will henceforth also serve to distinguish the Hungarian Aperient Water
SOLD by THE Company from all other Aperient Waters.

DEMAND THE

DIAMOND MARK.

And insist upon receiving the Hungarian Aperient Water ot the Apollinaris

Company, Limited, Londorju

XVI

MEDICAL AND SLRGICAL REPORTER.

BOUDAULT'SPEPSINE

Tie only Pepsine used in the Hospitals of Paris for the last Thirty Tears,

Unlike the various substitutes which, in most'cases, are but?unscientific or incompatible compounds, forced upon the'Medicai
Profession as aids to digestion by extensive advertising, but which, when submitted to the proper tests, are found to be useless as
digestive agents, Pepsine is constantly gaining in the esteem of the careful practitioner.

Since the introduction of Pepsine by Boudault and Corvisart in 1854, the original BOUDATJLT'S PEPSINE HAS BEEK
AT ALL TIMES CONSIDERED THE BEST, as is attested by the awards it has received at the Expositions of 1867, 1868, 187
1873, in 1876 at the Centennial Exposition of Philadelphia, and in 1878 at the Paris Exposition.

The most reliable tests, carefully applied, will satisfy everyone that BOUDATJLT'S PEPSINE HAS A MUCH HIGHER
DIGESTIVE POWER than the best Pepsines now before the Profession, and is therefore especially worthy of their attention.

BOUDAULT'S PEPSINE is prepared in the form of Pepsine Acid and Pepsine Neutral. It is sold in bottles of one ounce,
with a measure containing exactly five grains; also in bottles of four, eight,Fand sixteen ounces for dispensing.

BOUDAULT'S WINE OF PEPSINE

FORMULA OF DR. CORVISART.

The taste of Pepsine being perfectly disguised in this Wine, it may be recommended to persons who have difficulty in taking
Pepsine in the form of Powder. This Wine is tested so that a tablespoonful of it is equal in digestive power to ten grains of
Boudault's Pepsine in powder. Sold only in bottles of eight ounces.

TAN RETS PELLETI ERI N E

For the Treatment of Tape- Worm (Wa Solium).

This New Tamifuge, the Active Alkaloid of Pomegranate Bark, has of late come into extensive use iu iTrance for the
treatment of Tape- Worm (Taenia Solium). The results of numerous experiments with it at the Marine Hospitals of Toulon,
St. Mandrier, etc., and in the Hospitals of Paris, St. Antoine, La Charite, Necker Beaujon, etc., have all been most satisfactory.
Doctor Dujardin Beaumetz, Member of the Academy of Medicine, and Professor Laboulbene, in their report to the Society of
Therapeutics, have given it their unqualified approval, after the most searching experiments. This preparation is pleasant to
administer, and, if certain preliminaries are observed, success will be insured.

Sold only in bottles containing one dose.

DUCRO'S ALIMENTARY ELIXIR

i Combination uniting the properties of Alcoholic Stimulants and Raw Heat.

This preparation, which has been used with great success in the hospitals of Paris since 1868, is adapted to the treatment •
All diseases requiring administration, in a small volume, of a tonic able to stimulate and support the vital forces, as Pulmonar
Phthisis, Depression and Nervous Debility, Adynamia, Malarious Cachexia, etc.

Prepared by EMTLE DTJRIEZ & CO., Successors to DUORO & OIE, Paris.

KIRKWOOD'S INHALER

This is the only complete, reliable, and effective inhaler in use, arranged for the direct application of Muriate of Ammonia
and other remedial agents in the state of vapor to the diseased parts of the air-passages in the treatment of catarrh and diseased
Of the throat and lungs. No heat oi warm liquids required in its use.

It is entire!)' different from the various frail, cheap instruments that have been introduced.

KIRKWOOD'S INHALER is accompanied by testimonials of the highest professional character, together witil carefully
prepared formulas for use.

MTAIL PRICE, COMPLETE, $2.50.

MS" A liberal discount allowed to the trade and profession. For descriptive pamphlet or other Information addreoi

E. FOUGERA & CO., 30 North William St., New York,

Sole Agents for the' 'above Preparations.

MEDICAL AND SURGICAL REPORTER.

XVII

COTT'S EMULSION

r VERSUS ~

PLAIN COD LIVER OIL.

Plain Cod Liver Oil is indigestible, deranges the stomach, destroys the appetite
not assimilated, and in a majority of cases is detrimental to the patient.

SCOTT'S EMULSION

}an be digested in nearly all cases, is assimilated, does not derange the stomach,,
tor overtax the digestive functions, and can be taken for an indefinite period when th&
lain cod liver oil cannot be tolerated at all, and with most marked results in Anmmiar
Consumption and all wasting conditions. It also contains the Hypophosphites of Lime
md Soda ivith Glycerine, which are most desirable adjuncts.

WHEN PHYSICIANS TRY IT THEY INVARIABLY USE IT
in preference to the plain cod liver oil or other so-called Emulsions that invariably separate,
and hence their integrity and value is destroyed. Scott's Emulsion is palatable and
absolutely permanent hence its integrity is always preserved.

The formula for Scott's Emulsion is 50 per cent, of the finest Norwegian Cod Liver Oil, 6 grains
Hypophosphite of Lime and 3 grains Hypophosphite of Soda to the fluid ounce, Emulsified, or digested
to' the condition of assimilation with chemically pure Glycerine and Mucilage.
We also wish to call your attention to the following preparations :

CHERRY MALT PHOSPHITES.

A combination of the tonic principles of Primus Virginiana, Malted Barley, Hvpophosphites of
Lime and Soda, and Fruit Juices. An elegant and efficient brain aud nerve tonic.

BUCKTHORN CORDIAL (Rhamnus Frangula).

Prepared from carefully selected German Buckthorn Bark, J uglans Bark and Aromatics. The
undoubted remedy for Habitual Constipation.

Be sure and send for samples of the above — delivered free.

SCOTT & BOWNE, 132 South Fifth Avenue, NEW YORK.

CH. MARCHAiND'S

PEROXIDEofHYDROGEN

(MEDICINAL) H2O2

(.ABSOLUTELY HARMLESS.)

Is rapidly growing in favor with the medical profession. It is the most
powerful antiseptic known, almost tasteless, and odorless. Can be taken
internally or applied externally with perfect safety. Its curative proper-
ties are positive, and its strength and purity can always be relied upon.
This remedy is not a Nostrum.

a remedy for DIPHTHERIA ; CROUP ; SORE THROAT,

AND ALL INFLAMMATORY DISEASES OF THE THROAT.
OPINION OF THE PROFESSION.
Dr. Geo. B. Hope, Surgeon Metropolitan Throat Hospital, Professor Diseases of Throat,
University of Vermont, writes in an article headed, "Some Clinical Features of Diphtheria, and
the treatment by Peroxide of Hydrogen " (N. Y. Medical Record, October 13, 1888). Extract :

. . On account of their poisonous or irritant nature the active germicides have a utility limited par-
ticularly to surface or open wound applications, and their free use in reaching diphtheritic formations in the mouth
or throat, particularly in children, is, unfortunately, not within the range of systematic treatment. In Peroxide of
Hydrogen, however, it is confidently believed will be found, if not a specific, at least the most efficient topical agent
in destroying the contagious element and limiting the spread of its formation, and at the same time a remedy which
may be employed in the most thorough manner without dread of producing any vicious constitutional effect. . ^ .

" Inasmuch as the efficacy depends upon the ozonized oxygen in solution, it has seemed desirable to rely on
the full strength of the officinal preparation of fifteen volumes, especially when used in the fauces, where any slight
irritation from its acidity is not apparent. In all the cases treated (at the Metropolitan Throat Hospital), a fresh,
standard Marchand preparation of fifteen volumes was that on which the experience of the writer has been based. . .

"An equally important element is in making the application in such a manner as to produce the most deter-
mined effect on the diseased tissues with as little local disturbance as possible. ... A steady, coarse spray,
with an air pressure of twenty pounds or more, will, in a few moments' time, produce a more positive action than
prolonged efforts to reach the fauces by means of cotton applicators. . . . How frequently the treatment is to
he followed up depends to a considerable extent on the density, as well as the area, of the surface involved. . "

CAUTION.— By specifying in your prescriptions " Ch. Marchand's Peroxide of Hydrogen (Medicinal)," which is sold
only in %-lb., %-\b., and i-lb. bottles, bearing my label aud signature, you will never be imposed upon. Never sold in bulk.

PREPARED ONLY BY

PREPARED ONLY BY a

concerning the thera- (v^^-^ fl ~fl 1

raff 'jaa? a .^m^mmkwM^

ns free of charge on (> "»

A book containing full explanations con
peutical applications of both Ch. Marc
Hydrogen (Medicinal) and Glycozone,
profession, will be mailed to physicians
application. Mention this publication.

sold by leading druggists. Laboratory, lO West Fourth Street, New York.

Chemist and Graduate
of the "Ecole Cent rale-
des Arts et Manufac-
tures de Paris"

( France ) .

XVIII

MEDICAL AND SURGICAL REPORTER.

A CASE WITH A LESSON IN IT.

We have frequently referred to the neces-
sity of keeping the pregnant woman supplied
with those chemical substances which she
must give to the child in the formation of
its little frame, and the dire effects which
may result from a deficiency of those sub-
stances. The headaches, neuralgias, spinal
tenderness, and some of the many disorders
of digestion, and even mental failure, may
be all prevented or relieved by supplying to
the mother the chemical food her system
demands.

We have noticed a few cases where the
most serious results have occurred to the
mother by such a deficiency, one of which
is well worth relating. Mrs. M., aged 30,
pregnant with her third child, suffered from
the second to the fifth month of her preg-
nant term with gradually failing strength
and health, and nervous irritability. She
was very restless nights for three or four
days, the peculiar restlessness of complete
nervous exhaustion, and was irrational for
more than a week.

At this time I advised that she have a
teaspoonful of Murdock's Liquid Food
every hour in milk, and a little wine every
four hours. The third night she had fifteen
drops of hydrobromic acid dil. every three
or four hours, which was continued for a
week. The liquid food after a week every
two hours, and all other medicines were dis-
continued. Her bowels were moved with a
mild laxative at first, and afterward became
regular. Her tongue cleaned quickly and
her skin assumed a more natural appear-
ance.

At this writing, less than three weeks
from our first visit, the patient is able to sit
up an hour at a time, is quite rational and
cheerful, has a good appetite, the bowels
are quite regular, there is no headache, and
but little spinal tenderness. She sleeps
reasonably well if fed frequently. She is
allowed to suit her taste in her diet. The
child is quite active, and the mother is pro-
gressing so nicely that it is hoped that she
will pass safely through her confinement,
which is nearly at handx. She will be kept
on the liquid food and the phosphates
until her confinement after which, the con-
dition will suggest the treatment. This
is the most marked case of a starved
nervous system we have ever seen, and
the benefit derived from the treatment

proves the theory as to the cause of the
trouble.

Apropos with the above, comes the ques-
tion of the selection of nutritious foods for
those many cases which demand strong and
immediate nourishment. The food used in
the above case has produced marvelous re-
sults for us in some of those extreme cases
in which we have used it.

In one case of nervous exhaustion the
insomnia was absolutely painful. When
the exhaustion forced the patient to sleep
there was an immediate- sense of falling or
approaching death, or there were hallucina-
tions which were appalling, rendering the
nights unbearable. One teaspoonful of
Murdock's Liquid Food so nourished the
system the first night it was given that the
patient sank into a quiet, refreshing sleep
which lasted, with a single awakening, until
morning, and the improvement the patient
obtained was most striking.

One case of mitral regurgitation with
leucocythemia and nervous exhaustion im-
proved more rapidly on this food than on
all other measures combined. In cases of
nervous exhaustion and brain tire, its effects
are most marked, as we have experienced
many times in the past five years in the
frequent personal use of the agent. It con-
tains the principles of pure, healthy blood
and nerve tissue ready for immediate as-
similation. Fourteen per cent, of the entire
quantity is uncoagulated albumen, as we
have demonstrated by actual analysis.

We have tided babies over critical periods
often with a few drops in its usual diet.
We have given it to dipsomaniacs with or
without non-alcoholic stimulants with su-
perb results. The sole objection our pa-
tients have to it is its odor. Its taste is not
disagreeable ; it has the. odor and appear-
ance of blood. All objections are soon for-
gotten, however, in the results of its action
upon the nutrition of the system, and the
patient soon learns to like it, and often
craves for it, drinking it from the bottle or
a glass readily, like any beverage. It
ought to be the food par-excellence for
rapid appropriation in all conditions of ex-
haustion.

P. S. — Phosphates act well with the Liquid
Food.

Editorial of the Chicago Medical Times,
June, 1890.

(•29

Medical and surgical
Reporter

CP

A Weekly Journal.

Established in 1853 by S. W. Butler, M.D

CHARLES W. DULLES, M. D., Editor and Publisher,

itered as Second-Class matter at Philadelphia P. O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

>1. LXIV, No. 3.
»ole No. 1767.

JANUARY 17, 1891.

$5.00 per Annum.
10 Cents a Copy.

GOZEnTTZETSTTS :

JNICAL LECTURE.

Packard, John H., M. D., Philadelphia, Pa.—
Trephining for Epilepsy.— Fracture of the Bones
of the Ankle.— Surgical Treatment of Psuas
Abscess 59

>MMUNICATIONS.

Hill, T. Bm M. D., Ruff's Creek, Pa— Ergot in Ty-
phoid Fever 61

Wilson, J. C, M. D. — An Anomalous Case of
Measles 64

Shimonek, F., M. D., Milwaukee, Wis.— When is
Total Hysterectomy Indicated ? A Plea for Con-
servatism 65

Trippe, R. J., M. D., Chattanooga, Tenn.— Case
of Peritonitis 67

Dixon, Samuel G., M. D., Philadelphia Pa.— Value
of the Koch Reagent for Tuberculosis 68

>REIGN CORRESPONDENCE.
Berlin Letter.— The Berlin Aquarium— A Chicago
Doctor s Adventure— Luxation of Crico-thyroid
Joint—" Ether-Fritze"— Pennyroyal as aPoison
—Antisepsis for Chiropodists— Death from
Bromide of Ethyl 69

CRISCOPE.

Relative Value of Various Anaesthetics. —Leprosy
in China.— Diagnosis of Pa get's Disease of the

Nipple.— Legislation for Inebriates.— Treatment
of Gonorrhoea.— Pyoktanin.— Immunity from
Diphtheria and Tetanus 71-76

EDITORIALS.

The Koch Remedy for Tuberculosis 77

Cancer Gf.rm 78

The American Medical Association 79

BOOK REVIEWS.

Starr; Familiar Forms of Nervous Disease. —
R>gnier; L? Intoxication Chronique Par La
Morphine et ses Diverses Formes; Chronic Mor-
phine Poisoning, etc 80

LITERARY NOTES.

SPECIAL ARTICLE.

Koch's Remedy for Tuberculosis 81

NOTES AND COMMENTS.

Treatment of Phthisis.— Experiments in Begard to
Rabies.— Death in a Dentist's Chair from Cocaine
Injections.— Tiliacin.—.-tate Medical Society of
New York.— American Electro-therapeutic Asso-
ciation 83-87

NEWS 87

WITH

COD LIVER OIL

A combination of the 6e$t Norwegian Cod Liver Oil with MAL TINE,
in which, by the vacuum process, rancidity is prevented and
disagreeable odor and taste of the oil removed.

BASE A POWERFUL RECONSTRUCTIVE

CONTAINS NO INERT EMULSIFIER
Does not disturb Digestion nor offend the Palate

A complete list of the Maltine Preparations and their formulae wilt be sent on application.

piease mention thu jo.™!.) THE MALTINE MANUFACTURING CO., Ntw York, N. Y.

GOUDRON DE blount

PREPARED FROM THE GENUINE CAROLINA TAR.

DOSE.— One fluid drachm four or more times a day (as indicated), either full

strength, diluted, or, in combination.
INDICATIONS.— Chronic and acute affections of the Air Passages, Coughs,

Colds, Bronchitis, Asthma and Consumption.

WILLIAM MURRELL, M.D., F.R.C.P.,

Lecturer on Pharmacology and Therapeutics at the Westminster Hospital / Examiner in Mater ic Medico, to
the Royal College of Physicians of London; Fellow of the Medico-Chirurgical College of Philadelphia,

Says:— "I have used with success 'Goudron de Blount.' The results have
been good, and the preparation is popular with patients."

R. E. BLOUNT, 33 RUE ST. ROCH, PARIS.

WHOLESALE AGENTS FOR UNITED STATES AND CANADA,

BATTLE <3c CO.,

CHEMISTS' CORPORATION,

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A PRIVATE HOSPITAL

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and surroundings unusually attractive and cheerful. Heat, light and ventilation perfect.

A PLEASANT, SAFE AND HEALTHFUL HOME,

With constant professional supervision. Music, games, open-air amusements, boating, etc., are provided

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THE OLDEST INSTITUTION OF THE KIND IN THE UNITED STATES.

Both sexes received. A limited number of opium habitues admitted. Pleasant companions for female

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LOCATED A FEW MILES WEST OF PHILADELPHIA,

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Professors H. C. Wood, D. Hayes Agnew, Wm. Pepper, Alfred Stille, William Goodell, Roberts Bartholow,R. A. F. Penrose,
J,M. DaCosta, Charles K. Mills, James Tyson, and Doctor Lawrence Turnbull, of Philadelphia; Prof. William Osier, of
Johns Hopkins University; Prof P. Gervais Robinson, St. Louis, Mo.; W. C. VanBibber, M.D., Baltimore, Md.; Rev. J. B.
Adger, D.D., Pendleton, S. C; A. B. Calhoun, M.D., Newman, Ga.; W. W. Lassiter, M.D., Petersburg, Va.; E. Y. Golds-
borough, Esq., Frederick, Md.

Resident Medical Officers: J. WILLOUGHBY PHILLIPS, M. D., S. A. MERCER GIVEN, M. D.
For further information address BURN BRAE, Clifton Heights, Delaware Co., !*«•

MEDICAL AND SURGICAL
REPORTER

No. 1768. PHILADELPHIA, JANUARY 17, 1891. Vol. LXIV.— No. 3.

Clinical Lecture.

TREPHINING FOR EPILEPSY.—
FRACTURE OF THE BONES OF
THE ANKLE. — SURGICAL
TREATMENT OF PSOAS
ABSCESS.

BY JOHN H. PACKARD, M. D.,

SURGEON TO THE PENNSYLVANIA HOSPITAL.

Gentlemen : The man who presents him-
self to our attention to-day has no especial
family history bearing on his case ; there is
no history of nervous trouble in his family
except that one uncle was an epileptic. Our
patient was a healthy boy until he reached
the age of fifteen, when, on returning
from school one day, he was hit in the head
with a brick. He became unconscious and
was carried home in that condition. He
retained apparent health for a year, until
when sixteen ; then while swimming he was
suddenly seized with a queer feeling and
became again unconscious. He then went
six years without the recurrence of any sim-
ilar symptoms. Then he had a number of
repeated spells of unconsciousness, in one
of which he fell and broke his arm. In
1858 he went to China, where he contracted
gonorrhoea and in addition a chancre. He
"is a moderate drinker ; his only other his-
tory is that of rheumatism. Now his attacks
come on irregularly but with great frequency.
He thinks that the heat of summer makes
them appear at more frequent intervals ; so
that now he is in constant dread lest one
may appear at any time. He is nervous
and debilitated. When the attack comes
on there is loss of memory first, then a con-
vulsion appears in which there is total loss
of consciousness; before coming to, he
walks for squares without consciousness ap-
pearing ; finally coming to his senses he

finds himself far from the spot where the
attack commenced. On going home, he
finds that his muscles are excessively sore
and weak as if they had been subjected to
a severe pounding. On careful examination
there has been found no disease in any of
his organs ; no albumin in his urine.

In a number of features this case differs
from the history of a case of epilepsy as we
ordinarily hear it. In most cases these con-
vulsions and spells of unconsciousness come
on without apparent cause. It is often a
common experience to find children pre-
sented with the history of protracted spells
of violent outbreaks of temper and terrific
screaming spells; in these occasionally it
has been noticed that they have fallen and
examination discloses the fact that in the fall
the tongue has been bitten. Again, ordi-
narily after an epileptic seizure, it is cus-
tomary for the patient to fall into a heavy
sleep, dull and stupid in its character, from
which he awakes unrefreshed. It is not un-
common for an epileptic to run as the attack
is coming on, although in many cases this
may be limited to taking a few steps. I re-
member a patient that always ran for a
stairway when his attacks came on ; it is a
remarkable fact that in these runnings he
never pitched himself down-stairs to destruc-
tion. In some cases a preliminary cry is
heard ; it frequently occurs in a case of
epilepsy that at first the cry is heard, but
that as time goes on, that it gradually
disappears, and finally ceases to occur
altogether.

This man, from the nature of his malady,
is incapacitated for work ; he could not
keep a position as clerk anywhere, for he is
constantly exposed to these attacks and it
would be most awkward indeed for himself
and his employer to have them occurring
in business hours, for they would seriously
interfere with the quantity and quality of his
work.

On careful consideration of the features

59

6o

Clinical

Lecture.

Vol. lxiv

of the case I have determined to trephine
him over the seat of his former injury,
which is in the parietal region above the
zygoma. At the point which he indi-
cates as the place of injury from the brick,
is a slight scar in the scalp and a depression
in the skull. It is probable that his present
malady comes from the blow, although the
spells of unconsciousness did not appear in
very close connection as regards time ; still
the connection between the cause and results
is sufficiently reasonable for our purpose.

I have no idea as to the condition which
we shall find within the skull. The internal
table may be turned in, causing compression
of brain substance. There may be simple
adhesion between the inner surface of the
borie and the dura and pia mater. There
may be thickening of the brain substance at
this point. We will be prepared for any-
thing. Now as to the amount of risk run
by the patient. The objection has been
raised that in the necessary use of ether the
epileptiform condition is liable to be pro-
duced ; this need not influence us in any
way ; this condition in the epileptic under
the circumstances is in no wise different from
that induced in a normal subject. You will
see that this epileptiform condition which
usually appears in patients only after pro-
longed etherization, has appeared in this
man almost immediately on his taking the
first inhalations. It need not alarm us;
we will treat it as in any other case, sim-
ply withdrawing the ether until the disap-
pearance of the unpleasant symptoms. As
he is now recovered from this condition
we will make our first incision. In cutting
the flap of skin covering the affected point,
I do it in such a way as to allow the best
drainage subsequently, as the patient's head
reclines upon the pillow in bed. Hence the
convexity of the curve is downwards. After
I have taken out the plate of bone, I will
use this platinum probe, which is bent at the
end in such a way as to allow its insertion
under the skull around the edges of the hole,
to determine the condition of the inner sur-
face of the cranial vault. If any spicula of
bone is pressing down, this probe will detect
it. Curious as it may seem, it is a fact that,
although the operation of trephining has
been known and practiced for a long time,
it was not until the present century that the
idea of cutting a semicircular incision in
the scalp was published. Before, this time
it was the custom to remove the flap of skin
entirely in performing the operation. Hay,

in 1803, published the first suggestion of
this idea ; it may have been practiced be-
fore ; if so, we have no record of it. Hay
proposed a cruciform or semicircular flap.

The danger which we run from hemor-
rhage is as follows. In this region are found
the terminal branches from the external
carotid artery above the zygoma in the pari-
etal region. These will not cause us much
trouble ; hemostats will control them if they
chance to bleed too freely. On the inner
table we have the branches of the middle
meningeal artery; you have frequently no-
ticed in your examinations of the inner table
of the skull the grooves which branch here
and there across its surface ; in these grooves j
run the branches of this middle meningeal ar-
tery, on the outer surface of the dura mater.
Sometimes these little arteries bleed furiously
when cut. To stop this hemorrhage we will
use if necessary a small pair of forceps,
placing one blade within the skull and one
without, compressing in this way the lumen
of the artery. In applying the trephine we
must not be too liberal in its use ; the skull
is rather thin at this point, hence we could
easily go in too far. On removing this plate
of bone I find that the probe passes freely
around under the skull, showing that appa-
rently there is no projection of bone and
no adhesion as far as I can determine. The
probe makes an uninterrupted passage around
the entire opening. I have bitten away the
edges of the opening to allow more extended
opportunity for examination, all to no pur-
pose. The dura mater bulges, as it should,
into the opening ; but it may require a punc-
ture subsequently to relieve ' the pressure ;
the brain symptoms will reveal this necessity
if it exists. At the temporo-parietal fissure
the dura should be adherent. The tem-
poral fossa is easily reached from this point;
and if care and. thought are not expended,
it may be that fragments of normal bone
will be removed.

I feel satisfied that the simple depression
of the skull is sufficient to explain the oc-
currence of all the symptoms shown in this
case. I am sorry for the sake of a brilliant
demonstration, that I could not have re-
moved a spicule of bone and have been able
to say that it was the disturbing factor, but
I have found enough for the present, and I I
see no. reason for further interference, be- I
yond biting away a little more of the edge
of the hole. For a dressing we shall use I
iodoform gauze, placing it in contact with I
the dura mater, and not filling it in too close :

Jan. 17, 1 89 1. Communications.

61

for twenty-four hours, covering this with an
antiseptic dressing. If no symptoms arise
I may leave this dressing for forty-eight
hours. There is a little troublesome hemor-
rhage from the edge of the wound ; I will
place a hair-lip pin around the vessel and
throw a ligature around it. We also put in
a catgut drain to assist in the free escape of
liquids.

What good have we done ? Often it is hard
to see what the improvement of the symp-
toms is due to ; here a depression has been
removed. This depression may cause con-
gestion of the membranes of the brain, re-
peated at frequent intervals and slowly grow-
ing more severe and prolonged.

Fracture of Ankle.

The next man has trouble at the other end
of the body. He presents a history which
is not uncommon. Eight days ago he was
admitted to the hospital suffering from the
effects of a fall from the second story of a
building. He alighted on his heels ; the
skin over one ankle was broken and there was
free bleeding. Several bones — it is difficult
to say exactly which ones — were fractured.
The same condition existed in the other foot,
except that that was no solution of the con-
tinuity of the skin. The question immediately
arises on seeing a case of this sort, of what
should be done. It is not best, I believe, to
attempt to make accurate apposition of the
fractured bones ; this would require dissec-
tion of the parts and would do more harm
than good. It is better to make moderate
-extension and reduce all apparent deformity
in the ankles. There will be undoubtedly
some subsequent stiffening. In this case we
have simply applied lead-water and laudanum
dressing, to subdue the inflammation ; after
the swelling has subsided sufficiently, read-
justment of the displacement will be made
as carefully as possible. I had a case some
time ago which reverts to my mind. A gen-
tleman leaped from the window during the
excitement of a hotel fire, landing on his
feet. There was such severe contusion that
I etherized the man, but found no fracture.
Eventually he recovered but with inability
to bend the foot in and out. He was an
amateur organist of considerable ability;
unfortunately he found that this was the ex-
act movements required for the pedals. It
was a great disappointment but he will grad-
ually recover the movement in the course of
time.

Psoas Abscess,

The next case is one of psoas abscess ; the
man who lies before you has one such abscess;
but a sudden rise of temperature and the
appearance of symptoms of severe sickness
was followed by the discovery of a swelling
on the other side, which on opening under
ether revealed the existence of pus. I am
going to present the case to my colleagues
and if they assent I will follow the route of
these abscesses back to the carious vertebrae
which they represent and if possible will
remove all the carious material. I have
seen these cases, fifty at least in the past
twenty-eight years, present themselves with
this man's history and all go on to the same
termination. At other points of the body
we remove carious bone ; we take it out of
the fibula or femur ; if it can be taken from
the vertebrae it would be most excellent.
The operation is not so radical and difficult
or serious to life as you would imagine at
first thought. The route has been made for
us ; all that we would have to do would be
to follow it.

Communications.

ERGOT IN TYPHOID FEVER.1

BY T. B. HILL, M. D.,

ruff's creek, pa.

Ergot stimulates the unstriped or invol-
untary muscular fibre to contraction wher-
ever found. Such fibre is found in the ali-
mentary canal from the middle of the oesoph-
agus to the internal sphincter ani, in the
posterior segment of the trachea and the
bronchial tubes to their finest ramifications,
in the heart, in the middle coat of the ar-
teries, veins and lymphatic vessels and in
other situations.

In the treatment of typhoid fever, prior
to the advent of the so-called specific meth-
ods, the proper thing to do, seemed to be
to mitigate the more prominent and unpleas-
ant symptoms, and to guard the avenues of
danger. Moreover, however meritorious in
themselves, the newer ideas have not usurped
and cannot usurp the place of the old. We
are not cognizant of the disease apart from
its symptoms — headache, fever, diarrhoea,

1 Read before the Tri-County Medical Society at
Washington, Pa., October 15, 1890.

62

Comm tmications.

Vol. lxiv

depression, abdominal pains, tympanites and
intestinal hemorrhage. Then we have the
specific lesions— -enlargement of the mesen-
teric glands, with deposit in the glands of
Peyer, which usually advance to ulceration.
One of the earliest and most' persistent
symptoms is feebleness. Not only is the
gait staggering and uncertain, but there is
also relaxation and want of tone in the mus-
cles of the entire economy. A marked ex-
ample is the softness of the pulse and the
feebleness of the first sound of the heart.
Relaxation of the smaller blood-vessels is
common, as shown by the numerous mucous
congestions. Epistaxis is a common, and
diarrhcea an almost universal early symp-
tom.

From a careful study of the pharmacology
of ergot, I was led some years ago to be-
lieve that in it we have a drug capable of
meeting more of the indications presented
in typhoid fever than can be met by any
other single drug or combination of drugs
at our command. At the same time it is
extremely simple and entirely harmless.

The symptom which earliest and most
loudly calls for treatment is headache. I am
aware that there has been some difference of
opinion as to the pathological condition on
which the headache depends, but the pre-
ponderance of evidence is in favor of con-
gestion. The value of ergot in congestion
of the central nervous system is well estab-
lished, hence its indication here..

The condition of the circulation is an-
other circumstance which, though not so
self-asserting as the headache, is of far
greater importance and ought to receive
much earlier attention than is generally ac-
corded to it.

Prof. Pepper in a clinical lecture says :
"Among the indications to be considered
in the prognosis, I have mentioned the
heart and the pulse. This is exceedingly
important. I think that the study of the
sounds of the heart — of the strength of the
muscular or first sound of the heart, the
strength of the impulse, the way in which
the artery fills at the wrist, how it resists
pressure, the quality of the beat, the fre-
quency of it and its regularity — is of the
first importance in the prognosis of typhoid
fever ; and as a guide to treatment, especially
in regard to the important question as to
the administration of stimulants. In a case
in which the pulse-rate is from 120 to 140
per minute, very compressible so that it col-
lapses under the slightest pressure, with an

exceedingly weak first sound, so that it as-
sumes an almost valvular character, stimu-
lants may be given freely." I have given
this quotation to emphasize the importance
of giving earlier attention to the condition
of the circulation. If it is of the first im-
portance, as Prof. Pepper says, why should
we withhold the hand until we are con-
fronted by the critical condition he de-
scribes? Simply, I presume, because no
one is willing at an earlier period to resort
to stimulants (by which is meant some of
the forms of alcohol), because they are not
capable of accomplishing the desired good,
and because they may accomplish undesired
evil. They cannot accomplish the desired
good because their force is directed to the
nervous system, which at this early period
is not at fault. They may accomplish un-
desired evil, because the stage of depression
which follows overstimulation may overtake
the patient at a time when his vital powers
are not able to withstand it. In ergot, on
the other hand, we have an agent which, by
directing its energies to the weakened mus-
cular structures, causes the heart to contract
with more firmness and regularity, while to
the arteries is restored that resiliency which
enables them to carry forward the circula-
ting fluid with healthful vigor ; and a con-
dition of self-confidence is imparted to the
entire circulation.

Diarrhcea is a symptom which is present
in a large part of all cases of typhoid fever,
and usually at one stage or another calls for
some kind of treatment. The use of ergot
in diarrhcea and dysentery is not a new
thing. The indication is as well marked
here as in any other form of diarrhcea.

Intestinal hemorrhage is a symptom which
I believe is always dreaded. Almost every-
body prescribes ergot when hemorrhage has
actually taken place. I hold that it would
be better practice to fortify, not only against
intestinal hemorrhage, but also against all
forms of hemorrhage by an early resort to
the use of ergot.

With the causation of typhoid fever the
present discussion has nothing to do. But
whether it be due to a specific microbe or not,
the special lesion is hyperemia of the intes-
tinal mucous membrane with foci of inflam-
mation in the glands of Peyer. Here the
indication is to remove the hyperemia and
to starve out the inflammation. If there is
a drug in the materia medica available for
this purpose, it is ergot.

Tympanites is often a serious trouble, and

Jan. 17, 1 891.

Communications.

63

sometimes goes so far as to constitute an im-
portant element in the prognosis. By its
upward pressure it causes marked interfer-
ence with respiration, and adds greatly to
any pulmonary complication. In the same
way it hinders the free action of the heart.
It is caused by fermentation of the ingesta,
and is made possible only by the relaxed
state of the muscular layer of the intestinal
wall. Stimulate these muscles to maintain
the caliber of the intestine at its normal di-
mensions, and tympanites can no more occur
in the typhoid patient than it can in an in-
dividual enjoying perfect health. This
looks like a strong statement ; but it is not
inadvertently made.

Perforation may be very appropriately
spoken of as the " king of terrors " in ty-
phoid fever. I do not say that it can be
entirely prevented. I know there are cases,
apparently the mildest, not seeming to call
for any medication whatever, which, without
any premonition of danger, suddenly de-
velop the intense abdominal pain, the chill,
the collapse, that only too unmistakably tell
the sad story of a perforation. But I do
say that when we permit the inflammation in
the intestinal glands to run its course unim-
peded to final ulceration, and when we per-
mit the intestine to be distended to its fullest
extent — the ulcers stretched to many times
their original size, the thickness of the wall
at their bottoms diminished to the most ex-
treme tenuity, while the volume of pent-up
gases, continually reinforced by the putre-
factive processes, momentarily threatens to
burst through the fragile structure and sound
the knell of the unfortunate victim — then,
I say, we have done what we could to render
the untoward event not only possible but
probable. If, however, we have, as already
intimated, made use of means to remove the
hyperemia and to starve out the inflamma-
tion— if wre have limited the size of the ul-
cers, while we have preserved the normal
dimensions of the gut and the tonicity of its
walls, compelling the generated gases to
move on instead of accumulating in such
proportions as to be an ever-present menace
to the life of the patient, we will have re-
duced the danger of perforation to the min-
imum. Again the indication points to ergot.

Now, having shown that ergot is indicated
for headache, for the circulation, for diar-
rhoea, for the intestinal lesions, for tym-
panitis, for hemorrhage, and as a safeguard
against the almost certainly fatal perforation,
it remains to ask : Is ergot capable of ful-

filling these indications ? My experience is
yet so limited — and that is my only source
of information — that I say it with timidity,
but I feel able to answer : It is. The ap-
parent results have been so uniformly and
almost universally gratifying, that I am glad
to believe .-this is not a mere coincidence.
My cases may not have been the worst ; but
I have not lacked bad cases. In one instance
the thermometer marked 1060 for six con-
secutive days. Not only has the ergot had
a salutary effect on the headache, but it has
seemed to ward off delirium and other nerv-
ous manifestations which are apt to appear
later in the attack. In the case already re-
ferred to, in which the temperature was 1060
for six days, there were absolutely no nervous
symptoms, and no other bad symptoms but
the temperature.

In order to anticipate adverse criticism,
I may say that I am not in sympathy with
the antipyretic treatment, as a prominent
factor in the management of typhoid fever.

Under the ergot treatment I have never
seen more than the mildest delirium. I have
seen very little somnolence, and no coma-
vigil. I do not remember having prescribed
anything else for diarrhoea, but have fre-
quently prescribed for the opposite condi-
tion. I have never seen a case of intestinal
hemorrhage. I have not seen tympanites
beyond the slightest degree of fulness. I
have seen only one case in which, as I now
think, it was necessary to resort to alcoholic
stimulation to sustain the flagging energies of
the heart. This was the case of a woman in
whom the menses came on in the second
week of the disease and lasted one week;
during which the ergot was suspended, and
after which it seemed to have lost its useful-
ness. In this case there was decided failure
of the heart which demanded the use of al-
cohol. I have seen no case of perforation.
It goes without saying, I have seen no fatal
case.

It would seem superfluous to enter into
any detail of the manner of using ergot, so
simple is it, yet this brief resume might ap-
pear incomplete without some reference to
that part of the subject. I have used only
the fluid extract, in doses ranging from
twenty to thirty minims every four, six or
eight hours, as the case might require.
Since beginning the use of ergot, all of my
cases — about thirty — have been treated in
this way from the commencement until con-
valescence was established, except the one
case mentioned.

64

Communications.

Vol. lxiv

There is of course nothing specific in this
treatment; nor is it intended to supplant
specific medication, in which I believe, and
which I practice in combination with ergot.
All that is claimed for it, is that it is the
simplest, safest, most rational and most effi-
cient symptomatic treatment conceivable.
As such I respectfully submit it to the con-
sideration of the members of this society,
with the hope that some, at least, may think
well enough of it to give it a trial.

AN ANOMALOUS CASE OF
MEASLES.

BY J. C. WILSON, M. D.

The following case illustrates two points
of importance in regard to the acute infec-
tious diseases :

i. Variation from the ordinary type;
2. The difficulty of diagnosis in atypical
cases.

Case. — Atypical measles ; sudden onset;
absence of coryza ; erythematous sore throat ;
scarlatiniform eruption.

G. L. J., sixteen years old, a schoolboy,
had suffered from rotheln some years ago.
He had never had measles or scarlet fever,
and was peculiarly liable to attacks of sore
throat. He had mild enteric fever in Sep-
tember, 1890; made a good recovery, and
was in his usual health.

November 27, upon rising, he felt chilly.
The chilliness and shivering continued
throughout the day. Towards evening his
throat became sore. There was no sneez-
ing, no coryza, and no cough.

November 28. The boy was feverish and
indisposed, and had what he describes as a
severe attack of indigestion, but without
vomiting. He had no appetite, a good deal
of pain on swallowing, and pains in back
and joints. His evening temperature was
1020 F.

November 29. He had a brilliant ery-
thematous inflammation of the soft palate,
uvula, half arches and tonsils. His tongue
was thickly coated with yellowish white fur,
and his bowels were constipated. His urine
was non-albuminous. He complained of
throbbing headache and backache ; the
pains in the joints had disappeared. His
face was slightly flashed but free from erup-
tion ; his eyes were suffused, but not intol-
erant of light. There was still no sneezing ;
no cough; no rales. Upon examination, the

neck, thorax and sides of the abdomen were
seen to be covered with a diffuse erythema-
tous exanthem, resembling that of scarlet
fever. The back and extremities were free
from rash. The pulse was 112; the tem-
perature ioo° F. The evening temperature
was 1 02. 40 F. The boy was now given
hydrag. chlorid. mitis, gr. v ; pulv. morph.
comp. (Tully's powder) gr. ii, every two
hours.

November 30. The throat was less pain-
ful, but still deeply red ; there was no erup-
tion over the mucous membrane covering
the hard palate. The diffuse scarlatiniform
eruption had extended over the face, trunk,
upper extremities and lower extremities as
far as the knees. Upon the legs and arms
it was most conspicuous upon the extensor
surfaces, but it also covered the flexor sur-
faces. When viewed at a short distance it
preserved its uniform appearance. Upon
closer examination it seemed to be puncti-
form, and the hair follicles were seen to be
especially swollen and congested. The tex-
ture of the patient's skin was rather coarse.
There was also on this day some irritative
cough ; but upon auscultation no rales were
discovered. The morning temperature was
1 02. 40 F. ; the evening temperature was
1 03. 40 F. The use of calomel was followed
by two large movements of the bowels.

The patient was now given

R Chloral, hydrat., gr. iii

Syr. lactucarii (Aubergier's) . . . . rr^ xv
Aquae TT\, xlv

every two hours.

December 1 . The throat was much bet-
ter, and the cough no longer troublesome.
Upon the face, chest and extensor surface
of the extremities, the rash preserved its for-
mer appearance ; on the flexor surface of
the fore-arms, the diffuse rash had disap-
peared, leaving the dull, red, occasionally
discreet, flat, papular eruption of measles,
with characteristic curvilinear and cres-
centic arrangement. The exanthem of
measles showed itself on this day upon the
legs below the knee. The morning and
evening temperature was 101.40 F.

December 2. The morning temperature
was normal ; the throat was well ; the exan-
them was everywhere rapidly fading.

December 6. Convalescence was fully
established ; and there was a fine, scaly des-
quamation of face and neck ; the tempera-
ture was normal, the urine not albuminous.

December 12. A brother of the patient,.

Jan. 17, 1891.

Communications.

65

eleven years old, who had been sent to the
house of a relative, was brought to me on
account of a troublesome irritative cough
and sneezing, which had lasted two days.
The following day he developed the erup-
tion of measles.

This case, trivial as it appears when thus
set forth, is not without practical interest.
During the first three days a correct diagno-
sis was practically impossible. It was only
upon the fourth day, when the fading ery-
thema brought into relief the exanthem of

measles on the flexor surfaces of the fore-
arm, and when the same eruption appeared
upon the legs below the knees, that a doubt
arose. The subsequent history of the case
renders the diagnosis of measles alone ten-
able. The abrupt onset, with shivering and
erythematous sore throat; the site of the
appearances of the rash and the mode of its
distribution ; the absence of coryza ; the
insignificant catarrhal symptoms; and the
temperature range, taken altogether, consti-
tute in this case a wide variation from mea-
sles in its ordinary form.

The practical bearing of such a departure
from type in any of the exanthematous dis-
eases especially occurring in private prac-
tice requires no comment.

Wom£n Pharmacists. — It is said that
there are now four women students of phar-
macy in Philadelphia, and already, before
they are near their graduation, three posi-
tions are waiting for them. Rather differ-
ent this from the mob of poor sewers ever
besieging the gates of that kind of employ-
ment— gates at which only one may be ad-
mitted for ten left outside.

WHEN IS TOTAL HYSTERECTOMY
INDICATED? A PLEA FOR
CONSERVATISM.1

BY F. SHIMONEK, M. D.,

MILWAUKEE, WIS.

In looking over the literature of hysterec-
tomy for carcinoma of the cervix, my mind
became imbued with the idea that the very
wide differences in the views of authors re-
garding the propriety of total or partial ex-
tirpation, depended upon certain positive
pathological elements and required extra
vigilance in order to arrive at a correct
opinion in regard to this important subject.
I therefore desire to read this short paper
regarding some points as means of differen-
tiating the malignant neoplastic prolifera-
tions affecting the cervix uteri, as bearing
on the selection of the proper operation.
The kind of histological elements found in
the new growth, to my mind, should influ-
ence the selection of the proper surgical
procedure.

Since I have arrived at this conclusion, I
saw in the Medical Record, September 6,
1890, an opinion expressed by Dr. John
Williams, that "in cases of cancer of the
cervix and of the portio vaginalis the pro-
priety of operation depends upon the path-
ological variety of the neoplasm, etc."
Therefore, I claim that no man has the
right to perform total hysterectomy without
having satisfied himself beyond all doubt
that he is dealing with a neoplasm whose
great tendency is early to infiltrate the body
of the uterus. Of course, this has reference
to the early stage, for in advanced cancerous
degeneration, whether it be cancroid or car-
cinoma, only one thing is proper, if any,
and that is total extirpation. There are
chiefly the two varieties — squamous-celled
carcinoma or epithelioma, and the spheroi-
dal-celled carcinoma, or the glandular or
true cancer, which frequently affects the
cervix. The epithelioma is the most fre-
quent, and ordinarily it is primarily a su-
perficial lesion, which, as the growth ad-
vances, gradually involves, as a rule, the
surrounding tissue and only towards the
end in some cases, infiltrates the body of
the uterus, though only very exceptionally,

1 Read before the Milwaukee Clinical Society, Oc-
tober, 1890.

66

Communications.

Vol. lxiv

as the great tendency is to destroy more and
more of the infiltrated tissue rather than the
establishment of numerous and remote foci
of infection.

It is an undoubted fact that the epitheli-
oma is not so malignant and is better amen-
able to the knife than the glandular cancer.
Now, I think that the contradictory opin-
ions, regarding the selection of the most
proper procedure, completely ignore this
undoubted and important factor in the di-
agnosis early in the invasion of the neo-
plasm. Such has been the success of some
of the operators who prefer the partial op-
eration, notably Baker and Byrne, that they
report the average length of life, I think, to
be about eight years. Byrne reports the
cases of two women, who, after the opera-
tion, conceived and not only carried the
children to full term, but gave birth to
them without any special difficulty. If the
teachings of some celebrated men had been
followed, those women would have been con-
signed to barrenness. We must not forget,
that, " In all gynecological operations the
ultimate aim must be the preservation of the
sexual activity." Therefore, it is the duty
of every one who does work of this kind to
investigate the exact pathological nature of
the infiltration early, and not simply to
make a diagnosis of cancer, and there let it
rest.

There is no doubt but that the partial
operation is comparatively simple, whereas
complete hysterectomy is liable to be a for-
midable procedure, and the difference in
the fatality of the operations is greatly in
favor of the partial one. The glandular
carcinoma commences deeper in the tissue
and has a greater disposition to infiltrate
the corpus uteri early; the greater malig-
nancy of this variety is too well known to
require an extensive argument in its support,
and its tendency to recur is consequently
also very much greater. Therefore, I con-
tend that, it is of prime importance to make
a most thorough histological research as
early as possible in the invasion of the new
formation, and for that purpose it is not
generally sufficient to secure, merely, some
scrapings or excise small pieces, but one
must remove large wedge-shaped pieces or
the whole intra- vaginal portion, if neces-
sary, in order to make a comprehensive in-
vestigation ; because one cannot judge of
the condition of the whole by examining a
small fragment thereof.

My argument is, then, if careful micro-

scopic examination shows a squamous-celled
growth confined to the cervix uteri, one
should perform supra-vaginal amputation ;
but if there be present a spheroidal-celled
arrangement — be the neoplasm of ever so
small dimensions — the probability is that
there are widely scattered foci throughout
the uterine parenchyma; and then total
extirpation is most certainly the proper
method. My own experience in this mat-
ter is very limited, but from a careful peru-
sal of this subject I determined to make it
the subject of these few remarks.

It may be appropriate in this connection
to present the report of a case of malignant
uterine neoplasm, with microscopic illustra-
tions, which in a measure bears on the ne-
cessity for careful and thorough investiga-
tion for diagnostic and prognostic purposes.
The case very positively proves that it is not
sufficient to examine only a few scrapings.
The specimens which I shall take the pleas-
ure to exhibit to you, were made from a
uterus which was wholly extirpated for an
extensive malignant degeneration of the
cervix uteri, supposed to be confined to that
locality; but the microscope has since shown
cells in their embryonic state, the so-called
indifferent tissue or the pre-cancerous state,
extensively distributed throughout the whole
organ ; and I have no doubt but that there
were cells in the lymphatics and lymphatic
glands in the pelvis. The only symptom of
which the patient complained, at the time
of presenting herself, was hemorrahage dur-
ing coitus, which led me to examine the pa-
tient, and to discover the- real state of af-
fairs.

The first slide, which I show, was taken
from a squamous-celled cancer of the cer-
vix, and it very beautifully shows the typical
cells and cell-nests. The next slide, which
shows a specimen from this case here re-
ported, was made from the cervix uteri in
the immediate vicinity of the internal os,
and it positively demonstrates the patholog-
ical difference between this and the preced-
ing one. This section shows the mature
spheroidal-celled carcinoma. You will no-
tice that the cells are small, as compared
with the squamous cells, and round, con-
taining a nucleus and granular matter, also
quite a development of inter-cellular fibrous
tissue. This alveolar arrangement inclosing
masses of spheroidal cells is characteristic of
true cancer and the consistency depends
upon the amount of the fibrous framework.
The next section, which was made also from

Jan. 17, 1891.

Comm unications.

67

the cervix, but nearer the external os, shows
a different construction, and it would lead
a man astray if he were to prepare only one
slide. It is more like small, round-celled
sarcoma, and in fact it is so much like it,
that from one section it would be impossible
to call it anything else ; but it is the pre-
cancerous or embryonic tissue, or, as Maier's
researches seem to show, the transformation
of a sarcoma into cancer. Klebs denomi-
nates these (somewhat rare) mixtures, car-
cino- sarcomata.

The next slide was prepared from a poly-
pus-like growth, which was situated near the
internal os in the cavum uteri, which, you
will perceive, shows the same sarcomatous
appearance. The last sections were taken
from remote parts of the body of the uterus
and mucous membrane, and, in addition to
the muscular tissue, show on quite close in-
spection similar small-round cells, which I
mistook, at my first examination, for a
transverse section of some muscular fibers,
but since they are scattered irregularly
among bundles of uterine muscular fibers,
and bear a very close resemblance to the
primitive cells, I am forced to conclude that
they are all neoplastic cells.

Judging from the maturity of the glandu-
lar cells and inter-cellular fibrous tissue
found in the deep part of the cervix, from
the great rarity of cervical sarcoma, from
the wide but sparse diffusion of the embry-
onic elements, I conclude that this was a
case of true cancer with extensive infiltra-
tion.

The operation was quite difficult on ac-
count of the great size of the cervix. The
patient succumbed to shock in about twelve
hours. She nearly perished on the table,
but rallied again, then failed and died.

What I have said has been with the de-
sign of suggesting and urging further and
more accurate microscopic work and of
pointing out the distinctive features of these
epithelial new formations and their relations
to the malignancy and infiltrating tenden-
cies, as bearing on the selection of the
proper surgical measures.

— Iodine, free from chlorine, is obtained
{Pharm. Centralh.') by placing commercial
iodine in a beaker glass and covering with
a concentrated solution of potassium iodide.
Place over the vessel a plate of glass, and
apply heat until the iodine is melted. After
cooling, collect the iodine crystals on a fil-
ter, and wash with distilled water.

CASE OF PERITONITIS.1

BY R. J. TRIPPE, M. D.,

CHATTANOOGA, TENN.

On November 4, 1889, Ed. Stokes, 32
years old, a strong heavy-set negro, came to
my office about 8 a. m., suffering excruciat-
ing pain in the abdomen, having received
a blow with a crow-bar across this part of
his body. Perspiration stood in large beads
all over him. His radial pulse was imper-
ceptible. He was not able to tell me any-
thing about how he had been hurt. I ad-
ministered a hypodermic of morphine, half
a grain, and of atropine one-seventy-fifth
of a grain, and gave him stimulants freely.
In about an hour he felt very much better,
and was placed in a hack and sent to his
room, a distance of about eight blocks. I
saw him later in the day, when he informed
me he felt well enough to get up ; but when
an attempt was made, he discovered he was
too weak. His appetite was good, and he was
not thirsty. I told him to remain in bed
until I saw him.

The next day, at 9 a. m., I saw him again.
He now said he was feeling first-rate, and
had taken food regularly and relished it.
His tongue was heavily coated with brown,
and was thick, broad and flabby. His breath
was very offensive ; he had no pain in the
bowels, had passed urine without pain ; and
had no tympanites or tenderness, even on
very deep pressure. I ordered calomel and
soda aa gr. x, to be followed with sulphate
of magnesia in a few hours.

On November 6, the third day, at about
3 p. m., without any warning, stercoraceous
vomiting set in ; but I did not see the man
until 9 o'clock. His temperature was then •
960, his pulse 130, and he was wet all over
with cold perspiration. I filled his stomach
and bowels with hot water, with a view to
overcoming the obstruction if possible. The
water injected into the bowels came away as
clear as it went in, but that in the stomach
was accompanied by fecal matter. At 12
o'clock, as my patient got no better, I de-
termined to wait no longer, and at 2 p. m.
I opened the belly, and to my utter surprise
found the entire cavity full of the most of-
fensive pus I ever saw. (I may mention that
even then there was not the slightest pain
or tenderness of the bowels). The intes-

* 1 Read before the Tri-State Medical Association,
October 16, 1890.

68

Communications.

Vol. lxiv

tines were all adherent, and perforated in
several places.

I realized at once that the case was a
hopeless one, but proceeded with the opera-
tion as though I expected a good result. The
perforations were closed with catgut ; the ad-
hesions were broken up and the guts sepa-
rated ; and the cavity was washed out with
warm sublimate (i to 20,000) until it re-
turned perfectly clear. A drainage-tube
was put in, and the wound was closed and
dressed in the usual way. The patient was
then put to bed, and packed with hot bottles.
Reaction was prompt, and the temperature
in three hours was normal. The man
suffered no pain on the night after the op-
eration, and had no nausea or vomiting.

On November 7, the fourth day, I saw
him at 9 a. m. He then said he had had a
good night, was hungry, and felt so very
well that he declared he was going to get
well. His bowels had begun to move, and
the discharge had the appearance of bloody
water mixed with pus. His diet consisted of
milk and whiskey at regular intervals. His
temperature was normal, his pulse 90.
!f^On November 8, the fifth day, at 9 a. m.,
he was resting well, and said he had had a
good night. He was still hungry. His
temperature was normal, his pulse 78, his
bowels still active. At 6 p. m. he was rest-
ing well, with a temperature of 990, and a
pulse of 90.

On November 9, the sixth day, at 10 a. m.,
his temperature was 98^°, his pulse 80.
He said he thought he would be up in a few
days. His bowels were still acting, and the
movements of better character. I ordered
the same diet to be continued.

About an hour later I was passing, and
on inquiry I learned that my patient had sud-
denly grown worse. His temperature was
950, his pulse 120, and at about 11 o'clock
he died.

VALUE OF THE KOCH REAGENT
FOR TUBERCULOSIS.

BY SAMUEL G. DIXON, M. D.,

BACTERIOLOGIST, ACADEMY OF NATURAL SCIENCES,
PHILADELPHIA.

In considering at present the therapeutic
value of the Koch remedy for human tuber-
culosis, we must weigh its power for good
against its power for evil.

In lupus affections the reagent certainly
produces an active inflammation, which

causes death of the recognizable tuberculo-
sis tissue. During treatment of lupus, a
nodular infiltration takes place. The oedema
in many cases is exaggerated. As the fever
subsides, prostration is often experienced,
the nodules gradually become covered with
a crust, under which can be detected a
healthy looking granulation. When these
crusts fall off, young, red cicatrices are to
be seen. The cases soon present the ap-
pearance of a perfect cure. This condition,
however, does not always remain. In after
weeks the characteristic inflammation of lu-
pus again appears, and the process goes on
as before.

Query. Does the reagent destroy all tu-
berculous tissue or does it only destroy that
which we recognize ? Time must answer.

Owing to the suppuration set up by the
action of the Koch remedy in the vascular
tissues, immediately surrounding the tuber-
cles, the remedy is positively contra-indi-
cated in tubercular meningitis.

With all internal tuberculous affections
there is more or less danger of dissemi-
nating the bacilli. If the remedy attacked
the bacillus as it does recognizable tubercu-
lous tissue there would not be that danger.

In surgical tuberculosis, where there is
not a marked predisposition of the tissues,
we have much reason to look for success.
Such cases more closely resemble the ex-
perimental animal cases than those of other
characters. In these we should have all the
advantages of the remedy and fewer of the
disadvantages than in most others. Here
the reagent may produce a degree of active
tubercular inflammation sufficient to cause
the death of the tubercular tissue, yet not
affect tissues which are not predisposed to
tuberculosis.

Time may show that the Koch remedy
does not injuriously affect any tissue other
than that which we can recognize as tuber-
culous. However, at present, no one can say
that the new manifestations of tubercular
lesions only arise in tissues previously tuber-
culous. The dissemination of the bacilli by
being taken up into the circulation may
produce the tuberculous process in parts
that would under no other circumstances
have taken on the tubercular process.

I must call attention to the fact that the
remedy causes an acute inflammation in all
live tuberculous tissues. All the vascular
tissue surrounding tubercles, when under the
influence of the remedy, is loaded with
' small round cells. The wandering cells are

Jan. 17, 1 89 1. Foreign Correspondence.

69

even found working themselves into the
1 giant cells. Hyperemia is produced. Each
1 tubercle becomes the centre of an inflam-
mation in the lung. Therefore in propor-
tion to the lesion, the alveoli in the periph-
ery of the tubercle are rendered incapable
of performing their duties. In very exten-
sive dissemination of tuberculosis, theenor-
1 mous decrease in the functionable lung pa-
renchyma may prove disastrous to life. This
1 would, therefore, lead us to believe that the
remedy is contra-indicated in widely dis-
seminated invasions on lung tissue.

In laryngeal tuberculosis, we must re-
member, should the area of disease be very
extensive, that this same infiltration of small
round cells and hyperemia with cedemia
may also endanger life.

Experience has taught us that there is
lurking danger that cannot be foreseen. This
arises from the fact that tissues may be tu-
berculous to a degree susceptible to the
action of the Koch remedy, when not other-
wise recognizable, or again it is, as I have al-
ready said, made tuberculous by the process
set up by the remedy. This is to be ex-
plained, possibly, by dissemination of the
live bacilli. Just here I venture to say I do
not approve the method of performing mas-
sage with tuberculous joints after treatment
with the reagent.

If there is any known substance that will
stimulate white blood corpuscles to break up
foreign matter in the blood of the living an-
imal, it should be administered during the
Koch treatment. Iodide of potassium may
assist indirectly in disposing of the bacilli
during and after treatment.

There is one question that time alone will
answer, to wit : Is the tissue immediately
adjacent to the tuberculous tissue necrosed
by the inflammatory process set up by the
Koch remedy sufficiently tuberculous to
slowly develop into recognizable tubercu-
losis, or is it rendered more susceptible to
the action of the bacillus?

In referring to the menstruum sold by
Dr. Libbertz as the Koch remedy or liquid,
it is, I am inclined to believe, a menstruum
made up of glycerine, gelatine and a meta-
bolic product of the tubercle bacillus. This
latter represents about one thousandth part
of the mixture. Probably the menstruum
contains a gold salt.

If the liquid contains that produced by
the tubercle bacillus, 'we cannot be surprised
at its special action on tuberculous tissue
alone, yet it would not be very surprising if

it should react on leprosy. The bacillus of
leprosy has characteristics in many respects
corresponding to the tubercle bacillus.

If the action of the tubercle bacillus on
the animal tissue is wrought by a process of
digestion, we might seek to produce its di-
gestive ferment by growing it on an artificial
medium, inoculating and introducing it into
the animal economy, already the prey of the
tubercle bacillus. In this tissue the bacillus
would be found secreting virus enough to
inflame and break up the tissue to a degree
suited for its absorption and existence. The
artificially added product or digestive fer-
ment would break up the chemical relation-
ship of the constituents of the tissues to a
degree beyond that suited for the consump-
tion by the bacillus. The inflammation
produced would possibly be so acute and
severe as to kill all recognizable tuberculous
tissue.

When in Berlin, Prof. Dr. Koch person-
ally expressed to me his confidence in the
remedy to successfully combat lupus and
laryngeal tuberculosis.

I am inclined to the belief that the rem-
edy should be very cautiously administered
to man and that laboratory work should be
energetically carried on.

Foreign Correspondence.

BERLIN LETTER.

The Berlin Aquarium. — A Chicago Doctor1 s
Adventure. — Luxation of Crico-thyroid
Joint. — ' ' Ether- Fritze. 1 ' — Pennyroyal as
a Poison. — Antisepsis for Chiropodists. —
Death from Bromide of Ethyl.

Visiting the Berlin Aquarium the other
day, I ,was fortunate enough to witness the
representation of an interesting biological
scene before a distinguished invited com-
pany, among whom were the Minister of
Public Worship (Cultus Minister) and sev-
eral University Professors. Dr. Hermes
showed the reviving of African salaman-
der-fish after an eight months' sleep. The
fish were encapsuled in pieces of clay
weighing about twenty pounds. These were
partly placed in water, partly broken, the
encapsuled fish freed from the surrounding
mucus and also placed in water. Almost
directly the fish showed signs of life, and
after the expiration of a few minutes swam

7o

Foreign Correspondence.

Vol. lxiv

freely to and fro. In case of the encapsuled
fish the reviving process occupied a longer
time. The trotopterus, after having lived
as an amphibious animal, showed up invaria-
bly as a lively fish. The Berlin Aquarium —
especially since the government has erected
a station at Rovigno, Italy — contains the
most interesting collection of submarine life
in existence, and is one of the great points
of attraction to visitors.

Speaking of visitors to Berlin, I cannot
refrain from telling you about an exceed-
ingly interesting adventure happening to a
Chicago, physician during the Congress.
The Illinois man passed over the Linden
late at night reflecting over the glory in
store for his native city. Suddenly a suspi-
cious-looking individual hustled by, closely
touching the doctor. The latter, with the
ingenuity of the Western man, felt for his
watch, and missing it unhesitatingly began
the pursuit of the robber. The suspicious
individual fled through the Brandenburg
Gate into the Thiergarten, the American
doctor in close pursuit, loudly crying "put
up that watch ! ' ' Near the Victory Column
the robber was caught by the doctor, and
compelled to deliver the watch, after which
he was released. The Chicago man returned
to his hotel, proud of himself and of his na-
tive city and country. But, lo ! on the table
he beheld his watch, which he had forgotten
when leaving the hotel. Next morning all the
papers published the story of a robbery in
the Thiergarten : a French doctor, they
said, had been pursued by a burly, powerful
robber, attacked and" robbed of his valuable
watch.

Professor Braun, of the Kcenigsberg Uni-
versity, published the first case of habitual
luxation of the crico-thyroid articulation
ever described, and — what adds to the in-
terest of the matter — observed on his own
person. By a singular coincidence the Pro-
fessor had the opportunity to observe two
other cases of the same character. On him-
self, the luxation appears on deep inspira-
tion and during gaping. It is not simul-
taneous on both sides, but occurs either on
the left or the right side. At times the lux-
ation occurs daily, again months may pass
without it. A sensation of oppression and
great anxiety is invariably connected with
the phenomenon. Reduction can be ob-
tained in a very simple manner by mere
manual pressure or the act of swallowing.

A few days ago I renewed a very strange
acquaintance made many years ago. Pass-

ing Stralauer Strasse in the forenoon, I saw
an oddly-dressed man of about thirty-five
standing before the window of an art gal-
lery and making incessant and profound
bows before the pictures of the Imperial
Majesties. Approaching the queer patriot,
I noted at once a penetrating odor of ether.
And seeing the man pouring some of the
contents of a bottle into his handkerchief
with the experience of a skilled anaestheti-
ciser, I understood the situation. The man
in front of me was " Ether-Fritze," the well-
known victim of etheromania. The deplor-
able individual belonged to a rich and
highly-cultured Berlin family, and had stud-
ied chemistry and medicine. In. a chemical
laboratory I had first met him. Later on
he was anaesthetized in a surgical clinic,,
where he acquired the unfortunate habit.
At present he eats almost nothing, the only
desire he has being for ether, the stimulation
of which keeps him up. He consumes about
a pint a day, and it is thought that he would
die if he should dispense with the use of the
drug. I was told that there is another indi-
vidual with the same habit in Berlin, a for-
mer Demonstrator of Dentistry.

Drs. Falk and Langgard, assistants of
Prof. Liebreich, have recently instituted at
the Pharmacological Institute a series of re-
searches to determine whether, pennyroyal
is a veritable emmenagogue, and how its ac-
tion is brought about. The drug, as every-
body knows, being very frequently used by
women without medical advice, the question
whether pennyroyal is a harmless remedy is
not void of interest. Haller, Govan and
Marshall regard the drug as an abortifaci-
ent, while Taylor holds an opposite view,
and in addition believes the drug to be quite
harmless. From two to three grams of
pennyroyal, given to rabbits internally or
subcutaneously, produce no signs of intoxi-
cation save a conspicuous loss of balancing
power. The animals stagger from one side
to another. A dose of three grams suf-
fices to paralyze the animal. Exceptionally
lethal effects have been noted after compar-
atively small doses. Autopsies reveal inva-
riably parenchymatous degenerations in the
principal organs. The liver appears chiefly
affected, showing in case of protracted ex-
hibition of the drug, an enormous swelling ;
the parenchyma is brittle, the peripheral
zone of acini presents yellowish foci, often
as large as a bean. The heart and kidneys
show yellow dots and lines ; the urine con-
tains casts and albumin. It is clear then

Jan. 17, 1891.

Periscope.

7i

that pennyroyal, like phosphorus, produces
fatty degenerations of the organs. Regard-
ing the action of the drug upon the heart,
the experimenters noted a slight increase of
blood-pressure, resulting from a slowing of
the heart's action, due to a stimulation of
the pneumogastric nerve. Hence it must
be said that the emmenagogue action of the
drug is due solely to its deleterious effects
upon the various organs, and that women
ought to be cautioned against taking the
drug without the physician's order. A num-
ber of accidents — collapse, disease of the
liver, etc. — from the use of the drug have
been observed by Dr. Marshall and others.

A recent order of the police demands all
"corn-doctors" to employ perfect antisep-
sis in their surgical manipulations. The fact
that a number of accidents have occurred
here of late in the office of a chiropodist has
given rise to this desirable ukase. Would it
not be indicated to extend the order also to
the tonsorial artists ?

Recently Dr. Edel, a Berlin dentist,
caused the death of his apprentice by the
unwarranted administration of bromide of
ethyl. The enterprising dentist, not contented
with the effects of chloroform given for the
extraction of a molar, resorted in addition to
bromide of ethyl and promptly killed the
boy. Dr. L. Lewin, Docent of Pharmacol-
ogy at the Berlin University, ascribes the
accident exclusively to the combination of
the two anaesthetics, which he regards as an
inexcusable blunder. Others again claim
that the drug was impure, and that the den-
tist is not to be blamed for the accident.
It is certain that with the exclusive use of
bromide of ethyl, prepared by Merck, no
accidents have been reported even by den-
tists who, like Dr. Gilles, of Cologne, have
administered the anaesthetic in nearly a
thousand cases. At the University Dental
Clinics bromide of ethyl is never used, as
Prof. Busch has had some very unpleasant
experience with it. With proper individual-
ization, however — exclusion of nervous and
otherwise organically affected persons —
bromide of ethyl appears a perfectly safe
and very eligible anaesthetic for dental and
minor surgery.

— To diminish the danger to life and
property from electric wires, the Common
Council of Boston, Mass., have passed an
ordinance to appoint an inspector of wires,
who shall have charge of all wires in the
city.

Periscope,

Relative Value of Various Anaes-
thetics.

In a discussion on anaesthetics before the
Medico-Chirurgical Society of Glasgow, Dr.
T. Brown Henderson read an interesting
paper, which is published in the Glasgow
Medical Journal, November, 1890, in which
he said that next to ether and chloroform
nitrous oxide gas appears to be the most useful
anaesthetic agent. For short operations, re-
quiring only a brief narcosis, it is admirably
adapted, as it is rapid in its operation, and
recovery from its effects is equally speedy,
and it can be employed anywhere. It is
gaining the confidence of surgeons, and, he
thinks, it might well be in all operating
theatres. St. Bartholomew's Hospital, Lon-
don, in 1885, used it alone in 378 operations;
in 1887, used it alone in 417 operations ; in
1889, used it alone in 686 operations.

At the present time nitrous oxide is ■
always given by anaesthetists in London be-
fore, and along with, the administration of
ether. By this arrangement the narcosis is
more speedily induced, and the preliminary
taste of ether is avoided. It is a luxury, and
is suitable for timid people particularly ; be-
sides being speedier, it is found to be safer
than narcosis by any other plan.

At St. Bartholomew's Hospital, various
anaesthetics used during the past fifteen
years, were : Chloroform 17,666 times, with
12 deaths, or 1 in 1,472 cases ; ether, 7,493
times, with 1 death; gas and ether, 12,806
cases, with 1 death ; methylene, dichloride
of ethydine, ethyl bromide, ethydine and
gas, and various other anaesthetics, 660
cases.

Ether has been usually given by the open
method — poured on a folded towel, or one
fashioned into the form of a cone.

After referring to various forms of appa-
ratus for giving ether, Dr. Henderson es-
pecially commends Clover's, with which, he
says, the effects are usually of the best kind.
In Leeds, under Mr. Teale, hardly any case
is considered unfit for the giving of ether.
The patients take it kindly with perfect con-
fidence, old and young are easily and effec-
tually brought under its influence. The old
and bronchitic, by judicious management,
have only a small quantity of well-warmed
ether, and a very little suffices.

The danger from giving- chloroform in
small doses nowadays is, Dr. Henderson

72

Periscope,

Vol. lxiv

thinks, the exception. He never hears of
the long time of getting the patient under
that was not uncommon many years ago.
For many years, to push boldly on with the
anaesthetic has been the practice all over
the-United Kingdom, and he says it is wise
to do so in threatened vomiting.

But there are cases where A. C. E. or
ether is preferable ; such as those who
have much fear of the operation, or of the
chloroform ; if the vital powers are weak
from great delicacy, or from exhausting ill-
ness ; if the cardiac, or the pulmonary, or
the nervous system is specially sensitive to
chloroform ; if there is excess of urea in the
blood, or of albumin in the urine, or dam-
aged kidneys. One of the difficulties of
chloroform anaesthesia is due to the uncer-
tainty of the quantity necessary to induce
narcosis. The most recent book on anaes-
thetics (Foy) gives the account of a patient
who was with difficulty recovered from the
narcosis produced by three drops of chloro-
form placed on a piece of cotton wool put
into a hollow tooth ; and of another, who
was narcotized by five drops of chloroform
through a Snow's inhaler. Idiosyncrasies
such as these may be more common than is
supposed, just as some are rapidly and se-
verely affected by small doses of mercury,
opium and other drugs.

Dr. Henderson thinks the safest way is that
introduced by Mr. Bloxam, of St. Bartholo-
mew's, London. A few drops are sprinkled
on a starched towel or flannel cap, and a
drop added every second. It is speedily
successful in producing anaesthesia, though
in some cases it may be a little longer than
when it is poured on more freely. He thinks
the administrator keeps a better grip of his
patient by the drop system.

Four hours before chloroform administra-
tion it is well to allow a light, nourishing,
easily digested meal. Before ether, no food
should be taken for six hours.

Some years ago the nitrite of am yl dropped
on lint and held over the mouth was
supposed to prevent and recover from acci-
dents. It was also used, mixed with chlo-
roform, as chloramyl, but after a short ad-
ministration, it was found to lower the blood-
pressure instead of raising it. Inhalations
of ammonia, in cases of weak or fatty heart,
have been found useful, previous to the use
of chloroform. Oil of turpentine i part, chlo-
roform 4 parts, was believed to prevent pul-
monic paralysis. Hypodermic injection of
morphia half an hour before the adminis-

tration of chloroform was supposed to be
useful in preventing a fatal issue.

Dr. Bietels, at St. Petersburg, has read a
paper on the use of a mixture of chloroform
and oxygen. Less chloroform is required
than by the usual methods of administration,
consequently with less danger, no sickness
follows, and the pulse is unchanged. The
difficulty is to blend the vapor of the chlo-
roform with the oxygen gas.

Dr. Wood, of Philadelphia, in his address
at Berlin, says he found the hypodermic in-
jection of digitalis produced a persistent rise
in the arterial pressure, with an increase in
the size of the individual pulse rate. In
cases of weak heart, where chloroform has
to be administered, a dose or two at least
of digitalis would greatly lessen the risk of
cardiac collapse. The wonder is that this
did -not occur to us before. Dr. Wood also
found the injection of a solution of strych-
nine into the jugular vein to produce sur-
prising results. It caused a gradual rise of
blood-pressure, and always caused an extra-
ordinary and rapid increase in the rate and
extent of the respiration. Every one knows
the antagonism which exists between chlo-
roform and strychnine. Dr. Henderson
would like, however, to have the dose and
mode of giving this powerful restorative
agent from a scientific authority.

Speaking on the subject of ether adminis-
tration on the same occasion, Dr. Hartley,
of Leeds, assistant to Mr. Teale, suggested
the following rules and precautions to be
observed in the use of ether were mentioned.

1. As far as possible anaesthetics of all
kinds are best given in the early morning
when the stomach had been empty for sev-
eral hours and the body refreshed by sleep ;
but in any case let no solid food be taken
for six hours, nor liquid food for four hours
previous to the use of the agent.

2. Avoid giving alcoholic stimulation be-
fore administering ether, the effect of this
being only to increase the narcotization, and
therefore the danger. For a similar reason
avoid the use of opium before or very soon
after ether.

3. Watch the respiration, the dangers in
respect of this function being (1) too deep
carbonization of the blood, and (2) me-
chanical obstruction. The delicate skin of
the lobes of the ear is a good index as to
whether the patient is becoming too deeply
carbonized, and is always open to inspection.
Obstruction to respiration may take place
from the simple falling back of the tongue ;

Jan. 17, 1891.

Periscope.

73

from the presence of blood, food or foreign
bodies in the larynx; from spasm of the
glottis ; from the accumulation of frothy
mucus in the larynx or lungs. If this latter
occurs in marked degree, it is often due to
the use of too large a percentage of ether
vapor in the air breathed.

4. Watch the general character of the
circulation, to note the effects of shock,
hemorrhage, etc., or a tendency to engorge-
ment of the right side of the heart.

5. Be prepared for any vomiting that
might take place.

6. In recharging the inhaler, if this was
necessary, beware of the presence or prox-
imity of a naked light, the vapor being very
inflammable.

7. Do not use more ether than is neces-
sary to keep up complete anaesthesia.

8. Do not allow the patient's body to be
uncovered more than is absolutely necessary
for the conduct of the operation. Where a
large surface has to be exposed, compensate
by extra clothing, hot flannels, hot-water
bags, etc., to the covered portions of the
body.

As to circumstances which might or
might not contra-indicate the use of ether,
Dr. Hartley said that he had given ether to
people of all ages, from a child of 3 to an
old lady of 86, to whom he administered it
on three different occasions. No class of
cases seems specially prohibitive of ether
except patients suffering with acute inflam-
matory affections of the lung. He had used
it in almost all possible operations of sur-
gery, from the extraction of a tooth or the
reduction of a dislocation to prolonged ab-
dominal operations of all kinds, operations
on the cranial cavity, and in numbers of
cases to patients with chest diseases, such as
pleuritic effusions, empyema, abscess of lung,
sub-diaphragmatic abscess, and in one case
to open a suppurating pericardium compli-
cating empyema.

Heart disease does not contra-indicate it.
The general effect of ether in the circula-
tion is as a stimulant. In aortic disease this
is often beneficial ; but if there is a tendency
in the venous system to be overloaded and
turgescent as in mitral disease, or when the
right side of the heart is weak and dilated,
or from simple over-carbonization of the
blood ; then the administration of ether
calls for greater care.

Chronic drinkers are bad subjects for an-
aesthetics of any kind, but specially, per-
haps, for ether.

Leprosy in China.

The Indian Medical Gazette, November,
1890, says editorially that lepers in China
appear to be treated with scant courtesy.
Driven from their homes, from their relations
and friends, and reduced to a state of desti-
tution, there remains to them but one or other
of two things, either to choose to enter the
leper villages of China, or to leave the
country and seek refuge in some of the
adjacent English settlements. Hong-Kong,
with no law against the importation of lep-
ers, nor against their begging in the streets,
becomes a perfect El Dorado to the leprous
Chinamen from the mainland. Dr. Cantlie
in a recent paper, read before the Hong-Kong
Medical Society, brings this subject prom-
inently forward, and in an interesting and
instructive thesis advocates the establishment
of quarantine retreats for lepers, who have
become British subjects, which he thinks
could easily be arranged on one of the nu-
merous islands around Hong-Kong.

In Hong-Kong itself there is an order in
force that whenever there is a leper reported,
the police shall arrest and detain him until
the Colonial Surgeon gives an opinion on
his condition, when the leper may be sent
away to the mainland. The authorities also-
at the Native Hospital have power to send
lepers immediately they are discovered to
some one of the leper villages near Canton.
It is impossible, however, to prevent the im-
port of lepers, for, unless by skilled inspec-
tion, it is impossible to detect a leper in the
earliest stages. Importation of lepers in the
early stages of the disease and deportation
at a later stage when the ulceration has be-
come so unsightly as to cause the authorities
to take action, leave a goodly number of
lepers free in the island, and it is this rem-
nant to which Dr. Cantlie would draw at-
tention. He believes with many others that
leprosy if it had been communicable only
in the later stages, would have long since
disappeared, for the unsightly leper with
ulcers upon his body has always been studi-
ously shunned. In referring to the manner
in which the disease spreads, he attaches
much importance to the possibility of house
infection, a theory commonly held in Dem-
erara, and mentions the case of a General
commanding the troops in that colony, who
with his wife and children were attacked with
leprosy and died.

It is interesting to learn the Chinese opin-
' ion concerning leprosy. They have no

74

Periscope.

Vol. lxiv

doubts on the subject, being strongly con-
vinced of its communicability and incurable
nature. For these reasons they hold that
the only manner of dealing with leprosy is
segregation, and putting these views into
practice, every district in China has its leper
home, the inmates of which receive an al-
lowance from the Government, and have
land to till. Various forms of treatment
have «been tried at Hong-Kong. The most
successful in mitigating the effects of the
disease and in causing improvement in the
leprous patches, has been first of all good
food and tonics, then the internal adminis-
tration of chaulmoogra oil in the form of
pills, 5 to 15 drops twice a day, and the out-
ward application of the ointment recom-
mended by Dr. Unna consisting of chrysar-
obin 5 percent., salicylic acid 2 per cent.,
ichthyol 5 per cent. When the application
was for the face, then pyrogallol was used in
place of chrysabrobin, and 10 minims of
dilute hydrochloric acid was given three
times a day to counteract the deleterious
effects of pyrogallol on the blood. The
amelioration of the symptoms by this method
of treatment is sometimes remarkable, and
though no cure has been or is likely to be
claimed, yet much might be accomplished
in rendering the life of the leper more com-
fortable by a systematic adoption of this
and other similar forms of treatment.

Diagnosis of Paget's Disease of the
Nipple.

Surgeons and dermatologists have not in-
frequently hesitated over a case of chronic
inflammation of the nipple resembling in
its external appearance an eczema, doubting
whether the radical operation of excision of
the breast should be undertaken ; or, in
other words, doubting whether they stood
in the presence of what was really chronic
eczema, or that affection which long ago
Paget taught was likely to be followed by a
carcinomatous involvement of the gland.
Failure in the ordinary applications for ec-
zema, the absence of itching, suspicious in-
duration and long-standing duration have
been the clinical data upon which a diagno-
sis was usually founded.

Darier, in April, 1889, made a communi-
cation to the Biological Society of Paris con-
cerning a new form of psorospermice found
in Paget' s Disease of the Nipple, de-
scribing the parasitic sporozoa as occurring

inside the epithelial cells of the affected
parts. These observations have been con-
firmed and the whole subject greatly elabo-
rated by Louis Wickham, in his admirable
monograph, Maladie de la Peau dite Ma-
ladie de Paget. According to these au-
thors, the parasitic bodies are found usually
in the lower layers of the epidermis of the
diseased tissue, and also in the milk-bearing
ducts, and measure from one-third to one-
half of the stratum muscosum. So impressed
is Wickham with these discoveries, that in
the conclusion of his essay he states that
Paget's disease is due to the parasites of the
class sporozoa, and the order coccidia or pso-
rospermice, and should be relegated to the
group psorospermosis. He believes, more-
over, that the presence of these bodies,,
readily detected by microscopic examina-
tion of the crusts from the diseased nipple,
constitutes an excellent and rapid method
of diagnosis.

Further confirmation of these observations
comes from Dr. A. B. Macallum {Canadian
Practitioner, October 16, 1890), who has.
examined two cases of Paget's disease, and
found the bodies in question. In order to
avoid disputed points in pathology, Macal-
lum suggests the word endocyte as a neutral
and readily applicable term to describe these
bodies, until their true nature shall be ex-
actly determined. Darier advises that the
crust shall be teased out on a slide in Gram's
iodine solution and examined with a mod-
erately high-power objective. ' If fat is pres-
ent, this may be removed by placing the
specimen for several hours in a 10 per cent,
solution of ammonia. Macallum modifies
this method and secures a permanent prepa-
ration by attending to the following direc-
tions : The crust, or a portion scraped from
the nipple, is teased out in a drop of tincture
of iodine on the slide, the cover glass put ony
and after a couple of minutes a drop of 50
per cent, glycerine run in. The alcohol
and the iodine fix the endocytes, and the
iodine gives them a brown-yellow tint,
which fades slowly in glycerine. This in-
vestigator was thus able to demonstrate these
bodies in the free cells, the. unteased por-
tions, and in the epithelial cells covering
the retracted nipple and filling the ducts.
Endocytes present in epitheliomata are dis-
tinguishable from these by the absence of
cystic membrane, their smaller size and
their situation in the central cell of the
"nest." Macallum, while unwilling fully
to endorse the views of Darier and Wick-

Jan. 17, 1 891.

Periscope.

75

ham, is convinced that the sporozoa furnish
a valuable aid in the diagnosis of Paget' s
disease.

This seems to us a most important field
for future work, and not only the diagnostic
value of the endocytes, but also their essen-
tial nature, are worthy of the careful study
which they are at present attracting as etio-
logical factors in various chronic cutaneous
disease, and in epitheliomata. — University
Medical Magazine, December, 1890.

Legislation for Inebriates.

The Southern Medical Record, December,
1890, in an editorial, entitled, " A much
needed legislation," says: " Now that the
representatives of the people are assembled
at the capital in the capacity of legislators,
it is in order for us to make such sugges-
tions as will more fully acquaint them with
our wishes and necessities. Some provision
ought to be made for the care-taking and
reformation of the unfortunate inebriates of
the State. It is a crying shame that noth-
ing has been done in the Empire State of
the South to give this greatly needed relief.
The world is very uncharitable towards the
victims of alcohol. Prohibitory laws have
proven a failure ; public sentiment is morbid
on the subject. Temperance union move-
ments have done much good in educating
public opinion, but cannot reach these poor,
ruined individuals. What shall be done
with them ? If inquiry be made, it will show
that a large per cent, of the crimes commit-
ted— especially the homicides — are due to
the effects of whiskey, or some other alco-
holic liquor. The sale of intoxicants is li-
censed and the revenue turned into the pub-
lic treasury, but there is no provision made
to reform the miserable drunkard. Why is
this? It is because of the false opinion that
is abroad that drunkenness is a sin but not
a disease. Such belief obtains only among
the uninformed. But we will not stop here
to discuss the question. We know whereof
we speak when we say that inebriety is one
of the most intractable diseases known to
the science of medicine. It makes a physi-
cal, mental and moral wreck of the individ-
ual, unless restored by appropriate treatment.
Leaving all other questions aside, we feel
that if the State of Georgia would establish
and endow an asylum for these unfortunate
citizens it will prove a most economic leg-
islation. The cost of keeping and prose-

cuting criminals, and providing for the in-
sane in the asylum, would soon diminish
sufficiently to admit of the establishing of
suitable hospitals for the inebriate without
any increased expense to the State. Hu-
manity cries out, the heart-broken wives cry
out, and the worse than fatherless children
cry out for something to be done in this be-
half. Legislators have promised to make
needed reforms. Here is their golden op-
portunity. We are confident that (Gover-
nor Northen will stand by them ; that the
people will give them their hearty endorse-
ment, and when they return to their homes,
it will be said, ' Well done, thou good and
faithful servants.' "

Treatment of Gonorrhoea.

The following methods of treatment of
gonorrhoea are collected from the Deutsche
Medizinal-Zeitung, October 16 and 23, 1890.

Friedheim made a careful investigation of
the effects of different injections in the der-
matological clinic at Breslau. Of mercurial
agents the best is hydrargyri salicylatume
1-270. The common astringents, zinc and
lead salts, tannin and subnitrate of bismuth,
have no antiseptic properties, and should
not be used during the acute stage of the
disease. Boric acid, antipyrin, resorcin,
salicylate of sodium, often influence the in-
flammation favorably, but are useless as ger-
micides. He uses in the first stages a weak
solution of nitrate of silver, about one to
three thousand, four to six times a day,
later, some milder agent.

Diday uses an injection of nitrate of sil-
ver solution, 1-20, and allows it to remain
in the urethra from fifteen seconds to two
minutes, according to the amount of pain.
Picard believes that nitrate of silver will
abort a gonorrhoea, and is harmless if given
before pus appears ; after that it may do
harm.

O'Brien uses injections of sea-water seven
or eight times a day in the acute stage.

An injection given by Impamlomenti,
consists of a one per cent, solution of crea-
sote in an infusion of camomile, with a lit-
tle boric acid added.

Pyoktanin has been used by several ob-
servers with good results.

The ointment-carrying sound of Unna is
recommended by several authors for chronic
gonorrhoea. Szadek uses an ointment con-
taining nitrate of silver one per cent., and

76

Periscope.

Vol. lxiv

balsam of Peru two per cent. Sperling and
Bender nitrate of silver one per cent, in lan-
olin. The sound remains at first three, later
fifteen minutes in the urethra. For the sec-
ond stage Lewis uses an ointment with lan-
olin as a base, and a non-irritating antisep-
tic, such as resorcin, four per cent.

Allen calls attention to the use of the en-
doscope, through which a cotton-stick may
be used, as a method of application to the
urethral mucous membrane.

Internally, Lane obtained good results in
sixty per cent, of his cases in from two to
seven days, with salol, in doses of from five
to fifteen grains, three times a day. In
chronic cases injections also must be em-
ployed. Dreyfous uses salol at the same
time with the balsamic remedies.

Bird has obtained good results by the in-
ternal administration of calomel.

Stern recommends a thorough washing of
the body in the neighborhood of the geni-
tals, and the patient's clothes, with a one to
two hundred solution of corrosive subli-
mate, to prevent an auto-inoculation, which
he considers a common cause of recurrence
of gonorrhoeal symptoms, and of so-called
chronic gonorrhoea. — Boston Medical and
Surgical Journal, December 4, 1890.

Pyoktanin.

Dr. Riesmeyer has a paper on pyoktanin
in the St. Louis Courier of Medicine, Novem-
ber, 1890, in which he gives his opinion of
pyoktanin after what seems like a fair experi-
ence. He says that pyoktanin has the advan-
tage overall other diffusible germicides in not
coagulating albumin. It keeps the granula-
tions at an even level, the granulations look-
ing solid and healthy. Wherever it was ap-
plied to granulating surfaces, he never saw
spongy or exuberant granulations. He adds
that it will probably put a granulating surface
into an excellent condition for grafting pur-
poses and plastic operations in general. Car-
bolic acid and iodoform often cause the gran-
ulations to be uneven ; while the wounds
treated with bichloride of mercury fre-
quently have white necrotic deposits. In the
granulating wound treated with pyoktanin
he observed a rapid reproduction of epithe-
lium at the edge of the wound. Carbolic
acid and bichloride of mercury have the dis-
advantage of often destroying newly formed
epithelium, unless the solutions are too weak
to combat suppuration effectively.

Dr. Riesmeyer' s observations in the cases
so far treated lead him to surmise that the
chemical composition of pyoktanin is changed
by some substance in the animal tissues,
or it may form new combinations which are
colorless and do not stop the growth of bac-
teria, and that the failures in arresting cer-
tain forms of suppuration, probably all those
where the micro-organisms are located
deeply in the tissues, is due to this property.
Dropped on the skin or mucous membranes,,
the stain produced will soon disappear, show-
ing that here also must be an agent present,,
which produces a change in its composition.
In order to see whether albumin had any-
thing to do with this change, he placed a
silk thread stained with pyoktanin blue,
about m tne wnite of an egg- In 24

hours the thread had lost its blue color, and
no trace of pyoktanin could be seen in the
white of egg. Since, however, the white of
egg contains other substances besides pure
albumin, this experiment may not count for
anything.

It will be of importance to know whether,
when pyoktanin is injected hypodermically
into diseased tissues in as concentrated solu-
tion as possible, it will destroy the micro-
organisms before it undergoes the change re-
ferred to or not. No doubt this point will
soon be cleared up by experimental research.

At the present time we are not able to
formulate its exact indications in surgery
with any degree of accuracy, since the
technique of its application is still in its in-
fancy. In certain selected cases it will be
of excellent service, but on account of the
change it seems to undergo in the tissues,
and also on account of its annoying staining
properties, Dr. Riesmeyer is inclined to think
that the limit of its usefulness in this branch
of medicine will be rather narrow in com-
parison to the hopes that its germicidal prop-
erties in the test-tube have inspired.

Immunity from Diphtheria and
Tetanus.

Dr. Behring has made known the chemi-
cal agent employed by him and Dr. Kita-
sato in their experimental investigations on
diphtheria and tetanus. This is trichloride
of iodine, which, injected subcutaneously in
animals inoculated with either virus, not only
cures them, but renders them immune to
subsequent infection. Peroxide of hydro-
gen in 10 per cent, solution can also confer
such immunity in respect of diphtheria.

Jan. 17, 1891

Editorial.

77

THE

MEDICAL AND SURGICAL

REPORTER.

ISSUED EVERY SATURDAY.

CHARLES W. DULLES, M. D.,
Editor and Publisher.

N. E. Cor. 13th and Walnut Streets,
P. O. Box 843. Philadelphia, Pa.

^^Suggestions to Subscribers :

See that your address-label gives the date to which your
subscription is paid.

In requesting a change of address, give the old address as
well as the new one.

If your Reported does not reach you promptly and regu-
larly, notify the publisher at once, so that the cause may be
discovered and corrected.

J&g=*3UGGESTIONS TO CONTRIBUTORS AND CORRESPONDENTS :

Write in ink.

Write on one side of paper only.

Write on paper of the size usually used for letters.

Make as few para graphs as possible. Punctuate carefully.
Do not abbreviate or omit words like "the" and "a," or
" an."

Make communications as short as possible.

Never roll a manuscript! Try to get an envelope or
wrapper which will fit it.

When it is desired to call our attention to something in a
newspaper, mark the passage boldly with a colored pencil, and
write on the wrapper "Marked copy." Unless this is done,
newspaoers are not looked at.

The Editor will be glad to gret medical news, but it is im-
portant that brevity and actual in terest shall characterize com-
munications intended for publication.

THE KOCH

REMEDY FOR
CULOSIS.

TUBER

It is now about two months since Koch
made the announcement of his " remedy "
for tuberculosis, and it may be said to have
had a fair opportunity to show what it
would accomplish. Of course there has not
been time to show cures without possibility
of recurrence — years might not suffice for
this ; but there has been plenty of time to
show if it could produce improvement of
steadily progressive character and furnish
ground for hope that eventually some form
of tuberculosis would be — in a fair sense of
the term — cured through its influence upon
the human economy.

The readers of the Reporter have been
given, in a series of carefully prepared special
articles, an account of the experiments
made with the " lymph " in all parts of the

world, with their results, and the opinion of
men of recognized ability in regard to the
value of it.

Unfortunately after all it is impossible to say
that the lymph can be relied upon for any
of the purposes indicated by Koch in his
first announcement. It is not a trustworthy
means of diagnosis, or a reliable remedy for
any form of tuberculosis ; while experience
has demonstrated that it is dangerous when
used either for diagnosis or for treatment.

Professor Virchow, who has been making
investigations on the lymph treatment, last
week asserted, after twenty-one post-mortem
examinations of patients who had died after
injection, that the Koch method is not what
had been hoped or claimed for it, and that
there can be no permanent benefit from it
to the patient. The tubercle bacilli he
says are not killed by the lymph, but are
only driven out to take lodgment elsewhere.
Thus, according to his theory, tuberculous
affections, while they may disappear from
one part of the body, break out in other
places in as discouraging a form as ever. To
this we may add that the phenomena of cer-
tain cases, in which it has been asserted that
unsuspected tuberculosis of the lungs had
been revealed by treatment with the lymph,
warrant the belief that the lymph may set
up a tuberculous process in persons entirely
free from disease.

The Reporter has, as stated above, con-
tained a very carefully prepared synopsis of
the developments in connection with the
testing of Koch's " remedy," and the read-
ers of the Reporter will be promptly in-
formed of any developments in connection
with the subject ; but we doubt that it will
require as much space as has been devoted
to it in the last four issues, for it seems
hardly worth while to continue the weekly
publication of accounts which are so largely
mere repetitions of fruitless or injurious ex-
periments on human subjects.

Furthermore, we believe the time has
come when such experiments ought to be
discontinued, or at least restricted to a very

78

Editorial.

Vol. lxiv

small sphere. In this country we think
they ought to be wholly abandoned. Last
week a large number of tuberculous patients
in the Philadelphia (Alms House) Hospital
refused to submit to be experimented on,
and although the physicians with the lymph
from Koch's laboratory were chagrined, we
cannot believe all of them thought the pa-
tients were unwise.

We would suggest that American patients
be allowed the benefit of such medical and
surgical skill as exist in the profession until
the Germans have shown that Koch's
"lymph" is really of use. Let the latter
do as much experimenting as they may con-
sider wise and right ; but let our countrymen
go back — those who left them — to the le-
gitimate methods practiced before it was
heard of.

It is with regret for the disappointed ex-
pectations against which we warned our
readers two months ago, that we suggest to
them to read again and carefully the Edi-
torial in the Reporter of November 15,
1890, and to reflect on the confirmation of
its statements which has been supplied by the
history of Koch's "remedy" since that
Editorial was published.

CANCER GERM.

For several years bacteriologists have
been studying the tissues and secretions of
each of the most important diseases in the
hope of finding some germ which may pos-
sibly be the essential cause of the disease.
The interest at present felt in this kind of
study is widespread and intense. Doubt-
less hundreds are at this moment at work
upon the pathology of cancer, and are en-
deavoring to discover its cause. Many of
those who fail to find any germs in cancer
will think it not worth while to report their
investigations ; but a number have already
announced what they believe to be discov-
eries of germ life in cancerous growths,
although no one has hitherto succeeded in
demonstrating the supposed germs to the

satisfaction of others, still less has any one
succeeded in tracing a causal connection
between any particular micro-organism and
cancer. In the Deutsche Medizinal-Zeitung,
November 20, 1890, Dr. J. E. Alberts gives
a very thorough review of the present con-
dition of the cancer question and of its most
recent and important literature. Dr. Al-
berts's own experiments have not been in-
significant. He injected dogs with a steri-
lized emulsion of cancer-juice, prepared
aseptically from a carcinoma removed from
a living person. The result was entirely
negative ; the animals lived for months
healthy, and at the autopsy nothing was
found by macroscopic or microscopic ex-
amination, except a trace of the injection
wound. Results of transplanting pieces of
recently removed carcinoma were just as
fruitless ; recovery from the operation oc-
curred, and at a subsequent autopsy nearly
all of the transplanted piece had been ab-
sorbed. Other investigators, particularly
Darier, Albarran, Thoma, Wickham and
Sjobring, have* described, with more or less
precision, a parasitic organism which they
have found in cancer. An interesting fact
about their descriptions is that all the wri-
ters named, except Thoma, who expresses
no opinion, speak of the organism as be-
longing to the protozoa.

The most recent article on the subject of
an organism found in cancer is by Dr. Wil-
liam Russell, Lecturer on Pathology in the
Edinburgh School of Medicine, and is pub-
lished in the British Medical Journal, De-
cember 13, 1890. Dr. Russell writes that
he has been occupied for several years in
tracing the mode of growth of cancer in dif-
ferent organs. In the course of these studies
he met with appearances which he could not
fit into modes of cell-growth and nuclear
proliferation. He was finally able to differ-
entiate them by a process of double staining
with fuchsin and iodine green, the latter re-
placing the former in everything except the
bodies in question. Although these bodies
were found in practically every case of

Jan. 17, 1891.

Editorial.

79

cancer examined, Dr. Russell determined to
eliminate all possible sources of error before
coming to any conclusion with regard to
them. To this end, he ascertained, by
check experiments, that they were not pro-
duced by accidental impurities in his mate-
rials, bottles or stains, nor by a trick of
staining ; that they were not nuclei of tis-
sue-cells in exaggerated, formative and re-
productive activity ; and that they were not
globes of some form of degeneration. Dr.
Russell examined with great thoroughness
and apparent fidelity all kinds of tissues
and disease products to see if he could dis-
cover these " fuchsin bodies," as he calls
them provisionally, in anything but cancer.
He found them in one case of supposed sar-
coma; in two old specimens, one of aden-
oma of the mamma and one of gumma of
dura mater; in one case of syphilis in
which, some six or seven weeks after pri-
mary infection, there was only a skin erup-
tion but extensive destructive lesion of the
fauces and larynx, and even of the bones of
the vertebrae behind the fauces; and in a
polypus from the ear, which, consisted in
greater part of fibro-myxomatous structure,
but was in its deeper part adenomatous, and
it recurred in loco after removal; in one
case of gelatinous degeneration of the knee-
joint, with old sinuses; and in a large, very
intractable ulcer of the leg. Tissues were
examined from fifty or sixty different cases
in all.

On the other hand, forty-five cases of
cancer were examined, and in forty-three
the fuchsin bodies were found. As a rule,
they occur in clusters containing from three
to twenty or more. Wherever they occur
they almost always show a clear space
around them. They can, Dr. Russell says,
be found readily with a lens of one hundred
diameters if the light is good; their bril-
liant red or purplish color forms a striking
contrast with the green and delicate purple
of the tissues. The individuals of which the
groups consist are in form perfect spheres,
the largest being half the size of a red blood

corpuscle. They appear perfectly homo-
genous and structureless as examined by
daylight, and the larger clumps are held
together by a delicate cementing substance
which stains faintly. From a careful study
of these fuchsin bodies, Dr. Russell says he
has absolutely no doubt that they are organ-
isms belonging to the sprouting fungi, a class
of fungi which includes the yeast plant.

Dr. Russell's observations are of very
great interest, and seem to have been made
with great care. If they are confirmed by
other pathologists, and these fungi are found
to be the invariable accompaniments of can-
cer, it will remain for "some one to prove
their relation to the cause of the disease.
This can be done only by inoculating ani-
mals with pure cultures, and thus producing
cancer, which must contain the same fungi,
capable of cultivation. At present bearing
in mind Scheuerlen's announcement of a
bacillus of cancer, and its subsequent fate,
we can only suspend judgment and wait for
further light.

THE AMERICAN MEDICAL ASSOCIA-
TION.

In an organization like the American
Medical Association the management is
naturally controlled by those who attend its
meetings regularly and who take the most
active interest in its government. Ordi-
narily this fact enables members who have
no desire for office or emolument to enjoy
the privileges of an association without
bearing the burdens or meeting the cares of
office, while these fall to the lot of those
who think the pleasures or advantages of
office more than compensate for them, and
the organization goes on smoothly and
prosperously under this arrangement.

But at times it is desirable for every mem-
ber of an association to consider carefully
the policy of the organization to which he
belongs and the purposes of those to whom
its management has been delegated, and to
inquire if they be what is best for jthe or-

8o

Book Reviews.

Vol. lxiv

ganization. Such an occasion has just arisen |
in the American Medical Association, and it
has been precipitated by the proposition of
certain of the Trustees of the Journal of the
Association to transfer its place of publica-
tion from Chicago to Washington. This
proposition is so radical and of such conse-
quence to the prosperity of the Journal and
the welfare of the Association that it ought
to be most carefully considered between this
and next May when the Association meets.
A right decision of it is of the utmost im-
portance, and to this we invite the thought-
ful attention of all the members of the As-
sociation.

It might be well to have the subject dis-
cussed in the various County and other
Societies which send delegates to the Asso-
ciation, and that these should instruct their
delegates how to vote on the proposition.

We speak of this because of our convic-
tion that an error committed now would
very seriously impair the usefulness of the
Association, and our hope that no error
may be committed. ^

Book Reviews.

[Any book reviewed in these columns may be obtained upon
receipt of price, from the office of the Reporter.]

FAMILIAR FORMS OF NERVOUS DISEASE.
By M. Allen Starr, M. D., Ph. D., Professor of
' Diseases of the Mind and Nervous System, College
of Physicians and Surgeons, New York. With
illustrations, diagrams and charts. 8vo, pp. xii,
339. New York: William Wood & Company,
1890. Price, $3.00.

Dr. Starr, in his preface, calls attention to the
advances in 'neurology, which he believes have been
of late more rapid than those in any other department
of medicine. The result, he says, has been to render
diagnosis both easier and more precise, and to open to
surgical treatment many diseases formerly considered
fatal The object of the present volume is declared to
be to make available to the general practitioner some
of trie results of later investigations which have a direct
and piactical bearing upon commoner forms of nervous
disease The facts which Dr. Starr seeks to emphasize
are such as enable one to make>n accurate diagnosis
of the nature and of the location of lesions of the
central nervous system. The book is not intended as
a treatise on nervous diseases, but as a series of clinical
studies of their more familiar types. The first eight
chapters are taken up with the localization of cerebral
functions; the functions of the cortex and of the
motor visual and cortical areas, and the tracts within

the brain, and with the diagnosis of sub-cortical
lesions. Chapters ten, eleven and twelve deal with
localization of diseases of the cord, and the following
chapters successively with the paralyses of infancy,
multiple neuritis, paralysis agitans, chorea, epilepsy,
some painful functional affections and their treatment,
the treatment of neurasthenia, the ordinary forms of
insanity, and a final section on electricity as a thera-
peutic agent.

In the treatment of epilepsy Dr. Starr uses a com-
bination of the bromides of potash, soda and ammonia,
with the addition of a small amount of arsenic and an
alkaline potash salt. In cases of nocturnal epilepsy
he recommends giving also five or ten' minims of the
fluid extract of belladona or T^ of a grain of atropine
at bed-time. He says that chloral is sometimes a
helpful adjuvant, and so is tincture of simulo. Every
patient of Dr. Starr who has an aura is furnished with
a small bottle containing cotton saturated with nitrite
of amyl. In about one-fourth of the cases this when
inhaled aborts the attack.

Of electricity as a therapeutic agent, Dr. Starr says :
" My experience coincides with that of Gowers, that
the therapeutic effects of electrical applications have
been much exaggerated and are really quite limited."

The book shows that the author has obtained all
the light possible from experimental physiology and
pathology, and that he has checked those results by
careful clinical observation; as a consequence, he has
produced a thoroughly trustworthy, and a very inter-
esting volume.

LTNTOXICATION CHRONIQUE PAR LA
MORPHINE ET SES DI VERSES FORMES.
Chronic Morphine Poisoning, etc. By Dr. L. R.
Regnier. 8vo, pp. 171. Paris : Office of the
Progres Medical, 1 890. Price, 3 francs 50 cen-
times.

Regnier credits Nussbaum, in 1 864, with the first
observation showing the evil effects of prolonged in-
jections of morphine. Since then important works
have been written by Lewenstein, Erlenmeyer, and
others. Regnier examines particularly the symptoms
evoked by chronic morphine poisoning. He finds that
morphine produces modifications of sensibility, anaes-
thesia in hyperesthesia, while the sense of touch is
often lessened in delicacy or perverted. Paralyses are
rare, but vision is often affected, and the memory,
judgment and will are lessened in some patients to
such a degree that they fall into true dementia. It
would appear that when pain exists and morphine is
used to overcome it, the evil results are less serious,
and that, when the patient dies, it is from the progress
of the disease causing the pain, or from some inter-
current affection. Also, according to Regnier, mor-
phine habitues who are content with moderate doses
may live well for long years with their poison without
being inconvenienced except by more or less consider-
able emaciation, by constipation, and by a certain
degree of apathy.

Those who become addicted to the habit from the
desire for a stimulant appropriate to their fancied needs
Regnier described as morphinomaniacs and " mor-
phinomania" is the title of the second division of the
book. The recent morphinomaniac, Regnier says, is
likely to become a proselyte- maker among his friends,
who may be. led to try the drug out of curiosity, and
then, as Landowski says, there is " one morphino-
maniac more."

The disease appears to be of more frequent occur-
rence in men than in women. Its various and pro-
gressive stages are well described by Regnier, who

Jan. 17, 1 89 1. Special

Article.

81

reports sixty-seven case in illustration of the points
raised. As to treatment, he says that in inveterate mor-
phinomaniacs one cannot count much upon the efficacy
of treatment. When treatment succeeds, the recovery
is not ordinarily maintained. Immediate and complete
suppression of the use of morphine, he says, is not
always possible, and its effect ought to be watched
attentively in inveterate cases. Complete and final
recovery is rare and can be hoped for only in those
whose passion for morphine is of recent date and who
do not have any hereditary defect.

A good bibliography is appended to Regnier's book,
which is a valuable contribution to the literature of an
extremely important subject.

Literary Notes.

— The Illustrirte Monatschsrift der Aertztlichen
Polytechnik, which brings each month a most interest-
ing summary of new inventions in medical and surgical
appliances and advances in the treatment of deformi-
ties, will begin the year 1891 by uniting with the
Fortschritte der Krankenpflege, and will hereafter be
published by Fischer's publishing house in Berlin,
"The union is one which promises increased interest
and usefulness for both journals.

— Rudyard Kipling contributes the complete novel,
I The Light that Failed," to the January number of
Lippincott' 's Magazine. Kipling is attracting more
attention at present than any other living writer. His
force and originality have taken'the world by storm.
" The Light that Failed " is his first novel and fully jus-
tifies the expectations he has raised by his remarkable
short stories. It is the story of an artist's life and love,
and Kipling shows that he fully understands an artist's
outlook upon life, and his hopes, expectations and
fears. It is his comprehension of the inner and outer
life of men, and his ability to portray both, that is the
secret of Kipling's power. In him what is called
realism and idealism are blended.

— The first number of the Balneologisches Central-
blatt, dated October 3, 1 890, is at hand. It is a jour-
nal in appearance like the Centralblatt filr Chirurgie,
and that filr Medecin, with which all medical readers
of German are familiar. It gives promise of being
an interesting and instructive journal on its subjects —
balneotherapy, hydrotherapy, massage, gymnastics,
etc. It is issued every two weeks by B. Konegen, in
Leipsic, and the price is five marks each six months.

Special Article.

KOCH'S REMEDY FOR TUBERCU-
LOSIS.

A RESUME OF ITS HISTORY.

[Continued from page 51. .]

Dr. Saundby and Messrs. Simon and
Barling, in the Birmingham Medical News,
Dec. 1, 1890, give a very moderate account
of their impressions of the value of the
lymph, as seen in use at Berlin, where they

had an opportunity of watching the treatment
of a number of cases of laryngeal and pulmo-
nary phthisis under the care of Professors
Fraentzel and Senator in the Charite Hos-
pital, under Professor Ewald in the Augusta
Hospital, and under Dr. A. Levy at his pri-
vate Clinic. They saw " no case that could
be regarded as cured, and in some improve-
ment was doubtful, but others expressed
themselves as feeling decidedly better, and
there was evidence of this in the cessation
of night-sweats, diminished cough and ex-
pectoration, and increase of weight. ' ' They
point out that it is common in cases of
phthisis for the patients to lose weight in
the early stages of the treatment, but this
loss is more than made good later on. With
regard to lupus, the authors say that what-
ever may be the future fate of the patients
whom they saw, there could be no doubt
that at the time they were remarkably im-
proved, while in some cases no active disease
could be detected. In tuberculosis of lym-
phatic glands they were also able to observe
considerable improvement also. With re-
gard to joint disease, they saw instances in
which there had evidently been distinct
improvement ; but none in which a cure
had been effected.

The British Medical Journal, Decem-
ber 20, quotes a report on the Koch's
Treatment in Leprosy, in the Semaine
Medicate, December 10, of a patient pre-
senting the characteristic signs of leprosy,
shown by Dr. Max Joseph at a meeting of
the Berlin Medical Society on November
26. He had a well-marked leonine coun-
tenance, but there was no ulceration of the
face. He was treated with injections of
Koch's fluid, and in a short time the chin
and the nose became covered with little
crusts very close together. Each of these
scabs covered a tiny ulcer of about the size
of a pin's head. The crusts were exactly
like those which are formed on the surface
of a lupus patch during the period of reac-
tion. There was no fever or other sign of
general reaction. The diagnosis of leprosy
was confirmed by microscopic examination
of a piece of skin excised from the chin a
few days before the injections were begun.

The Berlin correspondent of the Lancet,
December 20, 1890, gives an account of a
patient with tuberculosis of the larynx,
treated by Gerhardt, on whom tracheotomy
had to be performed to prevent imminent
death due to closure of the chink of the
glottis.

82

Special

Article.

Vol. lxiv

The Journal de Medicine, December 14,
1890, says : Seventeen deaths in Germany,
four in Austria and one in Paris — such is
the account of Koch's method during the
week just ended.

In the Revue de Laryngologie, December
15, 1890, Baratoux gives a careful resume
of the operations of the lymph thus far —
especially from the standpoint of the laryn-
gologist. As to its diagnostic value he
calls attention to the uncertainty of the re-
action and the fact that non-tuberculous pa-
tients manifest it — persons with leprosy,
syphilis and scarlatina, while persons with
tuberculosis laryngitis do not always show
it. Its curative properties he regards as
still less worthy of confidence. The ameli-
orations noted are in no sense greater than
are observed under other methods of treat-
ment, while the lymph seems to give rise to
ulceration and the development of acute
miliary tuberculosis — in one case he speaks of
the inoculation as having advanced the
course of the disease six months. The rea-
sons he gives, he says : " compels a reserve
more than justified for this method of treat-
ment which after all has given no results,
but which facilitates the increase of the
malady and even, it is said, the develop-
ment of latent tubercles, and perhaps even
of those which did not exist before."

One of the most important communica-
tions in regard to the Koch remedy is that
of Dr. Williams, of the Brompton Hospital
for Consumptives, in London, in the British
Medical Journal, December 20, 1890.

It is a curious spectacle, he says, and one
by no means flattering to the votaries of
science, to see the medical world of Berlin
given up wholly to the worship of " Koch's
injection" and " reaction process," and all
the usual pathological and clinical phe-
nomena of tuberculosis set aside to make
way for the one newly-found distinction of
reaction or non-reaction after lymph injec-
tion. He visited nearly all the clinics con-
taining cases of phthisis, and examined
about 100 in whom the disease dated from
months to years, and whose lungs showed
great diversity in the extent the lesions
present. There was no lack of opportunity
of studying phthisis in the Berlin hospitals,
for the city was fast becoming the recepta-
cle of the phthisis of Germany, and even
of some neighboring countries, to the ex-
clusion of other diseases. The Moabit
Stadtliches Hospital of 700 beds already
contained a large proportion of consump-

tives, some of whom are under the personal
observation of Professor Koch. The most
striking effects of the injection were in lar-
yngeal phthisis, where, with the reaction,
swelling of the mucous membrane, and sepa-
ration of grayish sloughs are visible under
the laryngoscope, and, according to Profes-
sor Krause, both exfoliation and reabsorp-
tion of the swelling take place. Improve-
ment in laryngeal phthisis is common, but
complete cure rare.

The great mass of the cases of phthisis
were such as may be found in Brompton
and in other chest hospitals — partly cases of
tuberculization, partly cavity cases, though
the conditions of hospital life are in many
respects different. The chief symptoms in
consumptive cases appeared to be rapid rise
of temperature (reaching 1030, 1040, 1050
and even 1060 F.), quickening of pulse
and respiration, the latter being especially
marked, occasionally vomiting, increased
cough and expectoration, with inspiration
of the latter, often aphonia from temporary
laryngeal catarrh. In some cases a scarla-
tinal rash has appeared, and in others
(though generally lupus cases) a papular
eruption, as Dr. Williams witnessed in two
patients. In a few the nervous system ap-
pears much affected, as one patient became
almost melancholic, and another perfectly
unconscious after injection. The whole of
these symptoms pass off in a few hours, and
the patient returns to his ordinary state till
the next injection. This is repeated the
next day or in a day or two with increased
dose, and continued till all reaction ceases,
when the tubercular disease, as far as active
tuberculosis is concerned, is held to be ar-
rested.

Nevertheless cases occur which cease to
react under strong injections but still present
the physical signs of phthisis and whose spu-
tum contains tubercle bacilli. The exist-
ence of a reaction after injection is said to
prove unmistakably the presence of tuber-
culosis, and Professor Koch informed Dr.
Williams that if a patient, after successive
injections, reached the centigram dose
without reaction he could be held free from
tuberculosis. This may be so. But Dr.
Williams examined in one of the clinics a
middle-aged man, with a well-marked cavity
in the upper lobe of the right lung of some
standing, with marked fibrosis of the rest of
the lung and with some necrosis of the ster-
num, the supervention of which had relieved
the cough, expectoration and other lung

Jan. 17, 1 89 1. Notes and

Comments.

83

symptoms. The sputum contained no tu-
bercle bacilli. This patient gave no reaction
after strong injections. As an example of
the extent to which the reaction test is
pressed Dr. Williams gives the following ac-
count.

A young man, with a history of cough
and expectoration, was injected with a mod-
erate dose. He had no physical signs or
tubercle bacilli in the sputum. No reaction
' following, the injection was repeated after a
few days' interval. Still no reaction. A
\ third and somewhat stronger injection was
\ followed, however, by a decided reaction,
the temperature reached 102. 2 0 F., crepita-
tion sounds were audible at one apex and
tubercle bacilli detected in the sputum.
This case was shown to Dr. Williams as a
proof of the value of the injection as a
means of diagnosis, but, he says, if the
lymph is, as is generally believed, some form
of a cultivation of the tubercle bacillus from
which the bacilli are removed, there might
be other ways of explaining these symptoms,
which were, to say the least, very important.

The influence of injections on the tuber-
cle bacilli in the sputum, was, as far as Dr.
Williams could gather from the records, not
very marked.

Two ftost-?nortem examinations on cases
dying of phthisis in tire Charite Hospital,
which had been submitted to the treatment,
and had received several injections, showed
in one case cavities of considerable size,
and in the other a cavity at one apex, pneu-
monia at the base, with a large eruption of
recently-formed tubercle. In neither case
was there any sign of cicatrization or fibro-
sis, nor of more necrosed masses than are
usually to be found in similar cases.

The great portion of consumptives under
the treatment appear to lose weight rather
than gain, presumably on account of the
fever reaction ; the cough and expectoration
seem lessened, but no solid improvement
appears to be gained ; this, however, only
applies to the patients who have been under
the treatment two or three weeks, which is
the case of the majority.

A few old cases from Professor Fraentzel's
clinic, and some which have been in Dr.
Levy's, and are now in the Moabit Stadt-
liches Krankenhaus give better results. He
speaks of eight cases, which, with a few in
Professor Ewald's clinic, were all he could
collect as examples of genuine improvement
under the Koch treatment, out of about one
hundred examined by him. The improve-

ment, though striking, he says, was not
more than is met with in the wards of the
Brompton and other consumption hospitals
under the ordinary conditions of diet and
treatment, and he adds that they would not
for an instant compare with the results ob-
tained at the high altitude sanitoria, such as
Davos, St. Moritz or Colorado, where the
restoration to health is often complete, and
no physical signs or tubercle bacilli remain.

Dr. Williams thinks that the Koch treat-
ment is worthy of a careful and prolonged
trial in proper sanatoria, with the addition of
pure air and good food and careful nursing.
In conclusion he says : ' 1 We owe much to Pro-
fessor Koch, and it is only due to the great
services which he has rendered to medicine
that his treatment of phthisis should have a
fair, full and impartial trial ; and this will
be easier and more willingly undertaken
when he has imparted to all scientific work-
ers the complete details for preparing the
lymph. ' '

Notes and Comments.

Treatment of Phthisis.

Dr. Heneage Gibbes has an interesting
paper on the question of the unity of phthi-
sis in the Boston Medical and Surgical Jour-
nal, December 25, 1890. In this he says:
I presume no' one will doubt that Dr.
Koch has entire belief in the unity of phthi-
sis and its bacillary origin. It is, therefore,
with some surprise that we read the state-
ment that his lymph does not kill the tuber-
cle bacilli but the tuberculous tissue, that
it can influence living tuberculous tissue only,
and has no effect on dead tissue, as, for in-
stance, necrotic cheesy masses. This at
once removes from its action all cases of
pulmonary phthisis, and leaves only tuber-
culosis to be acted upon.

As I have already pointed out, we have in
tubercular tissue a new formation of low vi
tality, which is shown by its proneness to
break down. We have a somewhat similar
tissue in the lesions of syphilis ; and we know
that under the influence of certain drugs, these
lesions will soften and caseate. But the tis-
sue found in syphilis is of a much softer,
less organized, and more unstable character
than that found in tuberculosis. Koch's
remedy is said always to cause a feverish re-
action accompanied with rigors, when inoc-
ulated in a patient, the subject of tubercu-

84

Notes and

Comments.

Vol. lxiv

losis ; and this symptom is absent when the
case is one of syphilis, cancer, or any other
disease. The most marked success so far,
seems to have been obtained in cases of lupus,
and here the parts affected showed a re-
action to the remedy by becoming red and
swollen. Whatever may be the future of
Koch's cure, one thing seems to be certain,
and that is it will not help cases of pul-
monary phthisis. This will necessitate our
making a careful diagnosis in every case, as
fortunately we are able to cure pulmonary
phthisis in the early stages by ordinary rem-
edies, and, as Dr. McCall Anderson has
shown, even cases of galloping consumption,
provided they are not tubercular.

One of Koch's statements is difficult to
understand ; it is, that his lymph destroys
the tubercular tissue in which the tubercle
bacilli are situated. Now, given a lung
studded with tubercles, all of which are sud-
denly killed by the action of the curative
lymph, it does not seem clear what is to be-
come of the necrosed material. We know
that a syphilitic gumma, after it has been
destroyed by the action of a drug, will still
remain as a foreign body in the part, and
set up chronic inflammatory action ; in this
manner forming a fibrous capsule and isolat-
ing itself from the surrounding healthy tissue.
The same thing may be done by a tubercle or
a nematode worm. The centre is a mass of
caseous material having no structure to show
what it originally consisted of ; it becomes,
however, completely isolated by a fibrous
capsule formed by the chronic irritation of
its presence. The central portion may un-
dergo calcification.

If Koch's lymph kills the tubercles in a
diseased lung, what change will take place
in them ? If they are to be softened and
absorbed, the place they occupied will be
left vacant and the lungs full of holes, as
they were formed at the expense of lung tis-
sue. If, on the other hand, they are simply
killed, and dry up like a dead gumma, the
lung will in time be filled with numbers of
small fibro-cystic masses. We need more
light upon this subject; but before all things,
it seems to me, we ought to have a clear idea
of the actual lesion in the lungs to enable
us to appreciate the action of the cure.

It may be of interest to the Society to
hear a short account of the work that Dr.
Shurly and I have been doing during the
last two years on this subject. We came to
the conclusion that the lesions in the lungs
must be formed by some morbid product

circulating in them ; and it seemed to us
that the only way, if our views were correct,
in which this disease could be checked was
by the introduction of some substance which
would enter into chemical combination with
the morbid product and render it inert. We
have never made any attempt to destroy the
tubercle bacilli.

It is now more than two years since our
first experiments were made, and they have
been continued ever since. After trying a
number of different substances we found
that with iodoform we could entirely check
the tubercular process in an inoculated ani-
mal. We inoculated monkeys and guinea-
pigs with tubercular material; and we found
that those treated with iodoform developed
nothing further than an abscess at the seat
of inoculation, with numerous tubercle bac-
illi in the contained pus, while the control
animal, in each series, left untreated, invari-
ably died of the disease. But we found that
the use of iodoform brought on fatty changes
in the liver, of a peculiar character, con-
sisting of an infiltration in patches and
not like that found in ordinary fatty liver.
These patches were not confined to one or
more lobules ; but at the edge of the patch,
in many cases, only a part of a lobule was
changed.

While Dr. Shurly was treating the inocu-
lated animals with various drugs, I made a
series of experiments on pure cultures of the
tubercle bacilli ; and I found a number of
drugs which would render them inert, as far
as their power of producing artificial tuber-
culosis was concerned. Among these, chlo-
ride of gold and sodium exerted a marked
influence when used in very small quantities;
and Dr. Shurly will tell you what a striking
effect it has when used on cases of consump-
tion. As soon as we found that we could
prevent the development of the disease in
inoculated animals, Dr. Shurly directed all
his attention to finding a substance which
could be used on human patients without
deleterious effects; and I investigated the
results of the various inoculations with a
view to proving that tuberculosis and pul-
monary phthisis reproduced themselves in a
different manner in susceptible animals. In
both these lines I think we have been suc-
cessful, although it will require further in-
vestigation before we can consider the mat-
ter definitely proved.

I should like to call attention to the
effect of Dr. Shurly's treatment upon the
sputum of the patients. He has kept me

Jan. 17, 1 89 1. Notes and

Comments.

85

i regularly supplied with sputum from all cases

, under treatment ; and I have found that those

cases treated with substances that produced

[ a marked amelioration of the disease had

I little or no effect when inoculated in ani-

3 mals. I have a number of guinea-pigs inoc-

: ulated with sputum from undoubted cases of

consumption ; and these guinea-pigs are now

i none the worse for the operation, which was

: done some months ago.
1 That a marked change has taken place in

! these consumptive cases is shown by the

; total disappearance of bacilli in most of

• them.

f Experiments in Regard to Rabies,

ProtopoporT states, in an article in the
Zeitschrift fur Heilkunde, of which an ab-

I stract is given in the Centralblatt fur Chi-
rurgie, October 18, 1890, that, apart from
the now disproved theory of phagocytosis,

i there are two opposing explanations of im-
munity, the exhaustion theory, and the
antidote theory. ProtopoporT acknowledges
himself to be an adherent of the latter theory,
for which he brings new proof in his experi-
ments. Before giving the results of his own
experiments, he presents a thorough historical
review of the development of the question,
which is in the main a review of the works
of the French authors, Pasteur and Tous-
saint, but especially of Chauveau — the first
defender of the antidote theory — Roux and
Chamberland, Chantemesse and Widal.

ProtopoporT' s experiments, conducted dur-
ing the last two years, were vfnder taken for
the purpose of investigating whether or not
protection against Pasteur's disease (experi-
mental rabies) depends exclusively upon the
action of Pasteur's so-called vaccine material,
or virus, and therefore upon purely chemi-
cal changes. Pasteur has assumed for im-
munity against rabies that in protective in-
oculation, together with the microbes a
special substance (vaccine) passes into the
body, and that under certain circumstances
this opposes the outbreak of the disease.

ProtopoporT, took the spinal cords of ani-
mals which had died of rabies, and removed
from it the fixed virus by sterilization. He
found that placing such cords in glycerine
bouillon at a temperature of from 650 to 68°
Fahr. , for from fifteen to twenty days, accom-
plished this purpose, and that an emulsion
prepared with spinal cords treated in this way
can be used as a sterilized culture of the virus.
In his confidence in glycerine he is in di-

rect opposition to Gibier, the most con-
spicuous disciple of Pasteur in this country.
But as ProtopoporT is an extremely careful
and trustworthy investigator, it may be as-
sumed that he is correct in what he says.

A series of further experiments and control
experiments by ProtopoporT showed that
immunity against experimental rabies could
be secured by inoculating animals with the
non-poisonous emulsion just described. Out
of nineteen dogs protected by inoculation
with ProtopoporT' s sterilized virus, fourteen
were proof against the usual effects of inoc-
ulation with the virus of Pasteur's disease —
so-called rabies ; while every one of the
fourteen animals used for control experi-
ment— that is, inoculation with virus of
Pasteur's disease, without previous protective
inoculation — died.

ProtopoporT further suggests that the out-
break of experimental rabies can be pre-
vented in cases in which infection has oc-
curred before inoculation.

Death in a Dentist's Chair from
Cocaine Injections.

The Journal fur Zahnheilkunde, Sept. 25,
1890, reports a case of death in a dentist's
chair from injections of cocaine into the
gum, given for the purpose of inducing an-
aesthesia for the extraction of roots of teeth.
The patient was a woman, twenty-nine years
old, apparently perfectly healthy but very
nervous. The extraction was painless, and
nothing abnormal was noted. The operator
withdrew from the patient's chair to get
some water for the patient to rinse her mouth
with, and on his return found her motion-
less. Physicians were summoned and arti-
ficial respiration was practiced, but without
success. The autopsy disclosed the fact
that three injections had been given, which
served for the extraction of three-roots.
The quantity of cocaine in each injection
was two centigrams, or one-third of a
grain. The Journal, after commenting
upon the dangers of cocaine, refers to nine
cases of fatal poisoning reported by Dufour-
nier, in the Archives generates de Medecine.
One of these cases, however, is doubtful, as
the patient took a mixture of chloral and
cocaine. None of them happened to den-
tists, and the Journal thinks the case it re-
ports the only fatal one occurring in the
practice of a dentist. This may be true,

86

Notes and Comments.

Vol. lxiv

but serious and well-nigh fatal cases un-
doubtedly have occurred. The British
Medical Journal, Feb. 9, 1889, p. 311, re-
fers to one in which one grain and a third
of cocaine was used.

To show how uncertain the action of co-
caine may be, a case may be mentioned in
which one-seventh of a grain injected into
the eyelid produced very serious poisoning.
The case is reported by the British Medical
Journal, in the article already referred to.
It would appear not to be safe to inject a
larger quantity than one-half or three-fourths
of a grain, especially into very vascular tis-
sues, from which absorption is likely to be
rapid and the consequent danger of a maxi-
mum effect upon the heart is greatest.

Tiliacin.

The Druggists' Circular, December, 1890,
says that the isolation from the leaves of the
lime tree of a new glucoside, to which the
name tiliacin has been given, is announced
by Professor Latschinow (Cheni. Zeitschrift).
It is described as splitting up into glucose
and tiliaretin, which again decomposes into
anisic acid and other products. The leaves
of Cirsium arveitse appear to contain the
same glucoside, whilst a glucoside from the
leaves of Phlox paniculata appears to differ
from both tiliacin and hesperidin.

State Medical Society of New York.

The eighty-fifth annual meeting of the
Medical Society of the State of New York,
will be held February 3-5, in the City Hall
at Albany. The following scientific business
is announced.

For Tuesday, February 3, the President's
Inaugural Address, and papers on Railroad
Surgery, by Clinton B. Herrick, Troy ; Re-
port oL Cases of Injury to the Knee Joint,
with Remarks, by Henry Flood, Elmira ;
Management of Sinuses in Chronic Bone
and Joint Diseases, by V. P. Gibney, New
York ; Necrosis of the Ribs, Complicating
Pott's Disease, by Louis A. Weigel, Roch-
ester; Brief Notes on Gastrostomy, with
Report of a Successful Case, by Charles A.
Powers, New York ; The Action of Trypsin,
Pancreatin, and Pepsin, upon Sloughs, Coag-
ula and Muco-pus, by Robert T. Morris,
New York ; Operative Procedures in Acute
General Suppurative Peritonitis, by W. E.

B. Davis, Birmingham, Ala. ; The Progress
of Cystoscopy in the last three years, by
Willy Meyer, New York ; A Plea for Rapid
Dilatation, Holt's Operation, in the Treat-
ment of Urethral Stricture, by F. R. Sturgis,
New York ; A Case of Imperforate Anus of
eight weeks standing, Operation and Re-
covery, by Wm. Hailes, Jr., Albany ; Diag-
nostic Significance of the State of the Pu-
pils, by E. C. Spitzka, New York; Three
Diagnostic Symptoms of Melancholia, Sec-
ond Communication, by Landon Carter
Gray, New York ; Hysterical Manifestations
Due to Alcoholism, by H. C. Coe, New
York ; Cases of Traumatic Hysteria, by
Henry Hun, Albany ; Insomnia and its
Treatment, by E. N. Brush, Philadelphia;
Causes of Asthenopia, by D. B. St. John
Roosa, New York; Treatment of Detach-
ment of the Retina, by David Webster,
New York ; Use of Platinum Instruments
in the Extraction of Cataract and in Other
Operations upon the Eye, by E. Gruening,
New York ; Contagion from E.oller Towels,
by Lucien Howe, Buffalo ; One Thousand
Cases of Ocular Headache and the different
States of Refraction connected therewith, by
W. F. Mittendorf, New York; Catarrh and
its Cure, by O. B. Douglas, New York ; On
the Causes of Eczema, by L. Duncan Bulk-
ley, New York ; Points in the Pathogenesis
of Aural Vertigo, by Oren D. Pomeroy,
New York ; Certain Hygienic Measures in
the Treatment of Catarrhal Affections of the
Upper Air Passages, by F. H. Bosworth,
New York; Contribution to the Surgical
Treatment of -Jacksonian Epilepsy, Excis-
ion of the Arm Centre, by Edward B. An-
gell, Rochester.

In the evening there will be a discussion
on Appendicitis, the subject being divided
as follows : Pathology of Appendicitis, by
Herman Mynter, Buffalo, and Arpad G.
Gerster, New York ; Indications for Early
Laparotomy in Appendicitis, by Charles Mc-
Burney, New York, and William W. Keen,
Philadelphia ; Technique of Operative In-
terference in Appendicitis, by Lewis A.
Stimson, New York, and George Ryerson
Fowler, Brooklyn ; Propriety of and Indi-
cations for Resection of the Appendix Ver-
miformis during the Quiescent Stage of
Chronic Relapsing Appendicitis, by Joseph
Price, Philadelphia, and Robert F. Weir,
New York ; Relation of the Physician and
the Surgeon in the Care of Cases of Appen-
dicitis, by Albert Vander Veer, Albany.

On Wednesday morning there will be a

Jan. 17, 1891.

News.

87

discussion on Pelvic Inflammation in
Women ; its Pathology and its Palliative,
Conservative and Radical Treatment, ar-
ranged as follows, Introduction, by Andrew
F. Currier, New York ; Pathology, by A. J.
C. Skene, Brooklyn, and W. Gill Wylie, New
York ; Palliative Treatment, by C. C. Lee,
New York ; Conservative Treatment, by W.
M. Polk, New York; Radical Treatment,
by Joseph Price, Philadelphia, and L. S.
McMurtry, Louisville, Ky.

These papers will be discussed by Dr.
Thomas Addis Emmet, of New York, Dr.
Franklin Townsend, of Albany, and others.

After this papers are announced on Treat-
ment of Posterior Displacements by the
Utero-Vaginal Ligature, by H. J. Boldt, New
York ; Minor Gynecological Surgery, by
Maurice J. Lewi, Albany ; Treatment of In-
juries to the Floor of the Vagina, by Hor-
ace Tracy Hanks, New York ; An Inquiry
into our present knowledge of the Progress
of Myomatous Tumors after (a) the use of
the Electric Current, (b) Removal of Ovaries
and Tubes, (c) The Old Method of Treat-
ment by Rest, Intra-uterine Application and
Ergot, by James F. W. Ross, Toronto ; My
Experience with the Surgical Treatment of
Retroflexion and Prolapsus Uteri, by Paul F.
Munde, New York ; Surgical Treatment of
Ectopic Gestation, by Charles A. L. Reed,
Cincinnati, Ohio ; Some of the Results of
Defective Sanitary Arrangements in the Puer-
peral State, by James P. Boyd, Albany ;
Management of Tedious Labor, by Egbert
H. Grandin, New York ; Report of Four
Cases of Cancer of the Clitoris where Clit-
oridectomy was performed, by Franklin
Townsend, Jr., Albany ; Emotional Element;
the Puerperal Period, by Adam H. Wright,
Toronto. .

On Wednesday afternoon, there will be
a discussion on Pulmonary Tuberculosis, as
follows : History, by H. R. Hopkins, Buf-
falo; Etiology and Pathology, by Heneage
Gibbes, Ann Arbor, Mich. ; Diagnosis and
Prognosis, by A. L. Loomis, New York;
Manifestation in Upper Air Tract and Spe-
cial Treatment thereof, by John O. Roe,
Rochester ; Treatment, including Propylaxis,
as related to Climate, by Samuel B. Ward,
Albany ; Treatment as related to Therapeu-
tics, including Koch's method, by E. L.
Shurley, Detroit.

Papers will be read on Koch's Lymph and
Tuberculosis, by A. Jacobi, New York;
Therapeutical Notes on Acute Respiratory
Diseases, by A. Jacobi, New York ; Lobar

Pneumonia, with the Production of Connec-
tive Tissue in the Air Spaces, by Francis
Delafield, New York ; The Treatment of Gall
Stones, by William Wotkyns Seymour, Troy ;
Treatment of Itching, by Edward B. Bron-
son, New York; Croupous Rhinitis, by Frank
H. Potter, Buffalo ; Correction of Angular
Deformities of the Nose by a Subcutaneous
Operation, by John O. Roe, Rochester;
Case of Pemphigus, by H. R. Hopkins,
Buffalo ; Treatment of Pigmentary and Vas-
cular Nsevi, by George Henry Fox, New
York.

On Wednesday evening the Anniversary
Address will be delivered by the President,
and this will be followed by the Annual
Dinner of the Society, at 9,30 o'clock.

On Thursday morning papers will be read
on The Relation of Physicians to Boards of
Health, by Lewis Balch, Albany ; Necessity
of an Amendment in the Laws Governing
Medical Evidence in Malpractice Suits, by
R. J. Wilding, Malone ; Present Status of the
proposed Law to regulate the Practice of Em-
balming human dead Bodies, by A. Walter
Suiter, Herkimer ; Unrestricted Evil of Pros-
titution, by Andrew F. Currier, New York ;
Case of Scarlet Fever with Vesicular Erup-
tion, by F. C. Curtis, Albany ; Intestinal
Obstruction ; Report of Cases, by J. H.
Glass, Utica ; Subject to be announced, by
William S. Ely, Rochester; Subject to be
announced, by Clarence C. Rice, New
York.

Information in regard to the meeting
may be obtained of the Secretary, Dr.
Frederick C. Curtis, Albany, New York.

American Electro-therapeutic Asso-
ciation.

A convention of American physicians in-
terested in electro-therapeutics has been
called to meet at the Academy of Medicine,
No. 17 West 43d St., New York, on Janu-
ary 22, 1891, at 11 a. m., for the purpose
of organizing an American Electro-thera-
peutic Association. The call is signed by
Drs. G. Betton Massey, Augustin H. Goelet
and Horatio R. Bigelow.

NEWS.

— Dr. Myron Knowlton, of Rochester,
N. Y., died at the age of 84 years, Decem-
ber 30, 1890.

— Dr. B. S. Warren, aged 65, a promi-

88

News.

Vol. lxiv

nent physician of Concord, N. H., dropped
dead of heart disease, January i, 1891.

: — Dr. Wellington V. Walker, formerly on
the staff of the City Hospital of Louisville,
Ky., died suddenly at Mexico, Mo., in De-
cember.

— Dr. F. W. Dancy, a prominent physi-
cian, and President of the State Board of
Health of Mississippi, died at his home in
Holly Springs, Miss., on November 8, 1890.

— Dr. Frederick T. Outley, a rising young
physician of St. Louis, and who spent some
years in the service of the city Health De-
partment in the capacity of quarantine phy-
sician, died December 28, 1890.

— -Dr. Anson L. Hobart, for 32 years a
practicing physician in Worcester, Mass.,
died December 31, 1890, 76 years old. He
was a native of Columbia, N. H., and a
graduate of Williams College, class of 1836.

— Dr. Elisha Sterling, of Cleveland, died
in that city December 29, 1890, after a
short illness. He was born at Palisbury,
Conn., in 1825, and was brought when a
child to Cleveland, when it was a backwoods
settlement. He was an ardent student of
fish culture, as well as an able surgeon.

— The hospital in Brooklyn conducted
by Dr. Mary Dixon-Jones and her son — who
were not long ago held for manslaughter —
has been criticised again because of alleged
false statements to the Brooklyn Board of
Estimate, to which it was making appli-
cation for an appropriation from public
funds.

— Dr. McDaniel Purcell died recently in
this city in his thirty-second year. He was
graduated from the medical department of
the University of Pennsylvania about eight
years ago. He had been in ill health for
several years, but his last illness lasted but
two weeks. He was a native of Richmond,
Va., and his body was taken there for burial.

— The Imperial authorities of Russia have
invited Sir Joseph Lister, Dr. Koch and
Professor Pasteur to a conference, with a
view to founding and establishing a bacteri-
ological institute at St. Petersburg. Sir
Joseph Lister was unable to accept the invi-
tation, and Mr. Watson Cheyne recently left
London to take his place as the English rep-
resentative.

— Passed Assistant Surgeon Kinyoun, of
the Marine Hospital service, who was re-
cently sent by the Marine Hospital Bureau
to Berlin to enter Koch's laboratory, re-
ported by cable, on January 7, his arrival and

asked for authority to purchase the neces-
sary apparatus. The authority was immedi-
ately granted. Dr. Kinyoun will remain in
the laboratory three months.

— Eight patients are being treated in the
New York Post-Graduate Hospital by Koch's
lymph. Three of them are cases of lupus ;
four are cases of phthisis pulmonaris, and
one laryngeal tuberculosis. The inocula-
tions are in charge of Dr. W. C. Bailey,
who was for a long time a student in Koch's
laboratory, assisted by the Director of the
Laboratory, Dr. J. H. Linsley.

— The comparatively rare accident of
fracture of a rib by muscular action took
place in Philadelphia, January 7, 1891. A
woman, fifty-nine years old, had gone into
a shoe store to purchase a pair of shoes.
After trying them on she stooped over to
button them, when she heard something
snap, and at the same time experienced a
stinging sensation in her side. As the pain
continued to grow greater she went to the
Episcopal Hospital, where Dr. Boger, upon
examination, found that one of her ribs was
broken.

— Dr. Gideon B. Perry, one of the oldest
practicing physicians in Brooklyn, died sud-
denly December 30, 1890, at his residence,
627 Bedford avenue. He was born at Hop-
kinton, R. I., in 1826. He first studied
medicine under his father, who was a medical
practitioner in the town in question. Later
he assisted Dr. Alonzo Clark, of Pittsfield,
Mass. He next entered the medical depart-
ment at the University of the City of New
York, graduating therefrom in 185 1. In
the same year he established himself in
practice in Brooklyn, and from that time
up to the moment of his death had pursued
a professional career of singular activity and
success.

— The first of the proposed " Leprosoria'*
in the Baltic provinces will, it is hoped, be
ready for occupation in the spring. A val-
uable piece of land having been presented
for the purpose by the landowners at Nen-
nal, a village seventy versts distant from
Dorpat, it is proposed to locate upon this
forty or fifty lepers who are still able to
work. A small branch establishment, or
hospital, for severe cases — especially such as
require operative measures — is to be estab-
lished in the immediate vicinity of Dorpat.
This hospital will contain ten or fifteen beds.
It will be employed also as an observation
station, where patients may be kept before
being sent on to Nennal.

MEDICAL AND SURGICAL REPORTER.

XIII

"Familiar in millions of mouths as any household word."

— The Times.

Apollinaris

"THE QUEEN OF TABLE WATERS."

"In 1873 the number of bottles filled and ex-
ported was a little under 2,000,000. Last year the
number was nearly 16,000,000.

"Filling went on at the rate of 90,000 a day.

" These figures are gigantic!'

The Times, London, 20th Sept., 1890,

THE BEST NATURAL APERIENT.

THE APOLLINARIS COMPANY, LIMITED, London, beg to announce that, as
numerous Aperient Waters are offered to the public under names of which the word
Hunyadi " forms part, they have now adopted an additional Label comprising their
Registered Trade Mark of selection, which consists of

JL RED DIAMOND.

This Label will henceforth also serve to distinguish the Hungarian Aperient Watse
SOLD BY the Company from all other Aperient Waters.

DEMAND THE

DIAMOND MARK.

And insist upon receiving the Hungarian Aperient Water oi the ApolltnariS

Company, Limited, Londoa.

XIV

MEDICAL AND SURGICAL REPORTER.

BOUDAULT'S PEPSINE

The only Pepsine used in the Hospitals of Paris for the last Thirty Years.

Unlike the yarious substitutes which, in most'cases, are butf'unscientific or incompatible compounds, forced upon the^Medkal
Profession as aids to digestion by extensive advertising, but which, when submitted to the proper tests, are found to be useless at
digestive agents, Pepsine is constantly gaining in the esteem of the careful practitioner.

Since the introduction of Pepsine by Boudault and Corvisart in 1854, the original BOUDAULT'S PEPSINE HAS BEEN
AT ALL TIMES CONSIDERED THE BEST, as is attested by the awards it has received at the Expositions of 1867, 1868, 187
1873, in 1876 at the Centennial Exposition of Philadelphia, and in 1878 at the Paris Exposition.

The most reliable tests, carefully applied, will satisfy everyone that BOUDAULT'S PEPSINE HAS A MUCH HIGHER
DIGESTIVE POWER than the best Pepsines now before the Profession, and is therefore especially worthy of their attention.

BOUDAULT'S PEPSINE is prepared in the form of Pepsine Acid and Pepsine Neutral. It is sold in bottles of one ounce,
with a measure containing exactly five grains; also in bottles of four, eight,?and sixteen ounces for dispensing.

BOUDAULT'S WINE OF PEPSINE

FORMULA OF DR. CORVISART.

The taste of Pepsine being perfectly disguised in this Wine, it may be recommended to persons who have difficulty in taking
Pepsine in the form of Powder. This Wine is tested so that a tablespoonful of it is equal in digestive power to tea grains of
Boudault's Pepsine in powder. Sold only in bottles of eight ounces.

TAN RETS PELLETI ERI N E

For the Treatment of Tape- Worm (Taenia Solium).

This New Taenifuge, the Active Alkaloid of Pomegranate Bark, has of late come into extensive use iu jPrance for t!»
treatment of Tape-Worm (Taenia Solium). The results of numerous experiments with it at the Marine Hospitals of Toulon,
St. Mandrier, etc., and in the Hospitals of Paris, St. Antoine, La Charite, Necker Beaujon, etc., have all been most satisfactory.
Doctor Dujardin Beaumetz, Member of the Academy of Medicine, and Professor Laboulbene, in their report to the Society of
Therapeutics, have given it their unqualified approval, after the most searching experiments. This preparation is pleasant to
administer, and, if certain preliminaries are observed, success will be insured.

Sold only in bottles containing one dose.

DUCRO'S ALIMENTARY ELIXIR

1 Combination uniting the properties o! Alcoholic Stimulants and Raw Meat

This preparation, which has been used with great success in the hospitals of Paris since 1868, is adapted to the treatment •
all diseases requiring administration, in a small volume, of a tonic able to stimulate and support the vital forces, as Pulmonar
Phthisis, Depression and Nervous Debility, Adynamia, Malarious Cachexia, etc.

Prepared by EMILE DURIEZ & CO., Successors to DUORO & OIE, Paris.

KIRKWOOD'S INHALER

This is the only complete, reliable, and effective inhaler in use, arranged for the direct application of Muriate of Ammonia
and other remedial agents in the state of vapor to the diseased parts of the air-passages in the treatment of catarrh and diseasea
«f the throat and lungs. No heat or warm liquids required in its use.

It is entirely different from the various frail, cheap instruments that have been introduced.

KIRKWOOD'S INHALER is accompanied by testimonials of the highest professional character, together with carefully
prepared formulas for use.

RETAIL PRICE, COMPLETE, $3.50.

A liberal discount allowed to the trad© and profession. For descriptive pamphlet or other information addreai

E. FOUGERA & CO., 30 North William St., New York.

Sole Agents for theMabove Preparations.

MEDICAL AND SURGICAL REPORTER.

XV

v- v ;*v-. %#* v ' v.

.s<^>,. • • :<•%,. . >4

Constipation.

Please mention this Journal.

Pavara Pills are pi-epared especially for the
treatment of Constipation. They are tasteless, harm-
less, and produce natural movements of the bowels,
without pain, nausea, or any inconvenience whatever.

Physicians are requested to test these pills in those
cases which they think to be incurable, also, in cases of
constipation during pregnancy. Thousands
of physicians now use and prescribe them.
Physicians will see by the formula (on the outside
PU label) that each medicinal ingredient is absolutely ^
harmless.

Prices : small bottle (25 pills), 25c. ; large, (150 pills),
$1.00. Liberal discount to physicians.

A large bottle will be mailed to any physician,
for trial, on receipt of 25 cents in postage stamps.

Prepared by C. L. Toplipf, New York. Depot, 115
Pulton Street.

—

FRAUD

Unscrupulous parties are selling an inferior Wine, calling
it Royal Tokay, thus profiting by the numberless Medical
Editorials written about our genuine product. The Wine
cannot be used as a substitute for ours, and many physi-
cians have unjustly blamed us for damage done, imagining
they were securing our Wine, which they had already tested
with complete satisfaction. Your patients will not secure
the Wine you prescribe unless you specify CALVICO
TOKAY, by which name it will hereafter be known.

CALIFORNIA VINTAGE CO.

21 Park Place, N. Y.

BOSTON, MASS., Theo. Metcalf & Co., 39 Tremont St.
PHILADELPHIA, PA., Showell & Fryer,

Juniper and Market Sts.
ST. LOUIS, MO., John W. Howard, 307 Garrison Ave.
LOUISVILLE, KY., Geo. A. Newman,

Walnut St. and 5th Ave.
INDIANAPOLIS, IND., Geo. W. Sloan,

22 West Washington St.

EVANSVILLE, IND., H. J. Schlaepfer,

Main and 2d St.
SCHENECTADY, N. Y., Andrew T. Veeder & Son.
NEWHAVEN, CONN., E. A. Gessner, 821 Chapel St.
HARTFORD, CONN., C. A. Rapelye, 321 Main St.
NEW BRITAIN, CONN., E. W. Thompson,

181 Main St,
NEWPORT, R. I., Hazard, Hazard & Co.

PROVIDENCE, R. I., E. F. Mattison, 277 Westminster St.

XVI

MEDICAL AND SURGICAL REPORTER.

A CASE WITH A LESSON IN IT.

We have frequently referred to the neces-
sity of keeping the pregnant woman supplied
with those chemical substances which she
must give to the child in the formation of
its little frame, and the dire effects which
may result from a deficiency of those sub-
stances. The headaches, neuralgias, spinal
tenderness, and some of the many disorders
of digestion, and even mental failure, may
be all prevented or relieved by supplying to
the mother the chemical food her system
demands.

We have noticed a few cases where the
most serious results have occurred to the
mother by such a deficiency, one of which
is well worth relating. Mrs. M., aged 30,
pregnant with her third child, suffered from
the second to the fifth month of her preg-
nant term with gradually failing strength
and health, and nervous irritability. She
was very restless nights for three or four
days, the peculiar restlessness of complete
nervous exhaustion, and was irrational for
more than a week.

At this time I advised that she have a
teaspoonful of Murdock's Liquid Food
every hour in milk, and a little wine every
four hours. The third night she had fifteen
drops of hydrobromic acid dil. every three
or four hours, which was continued for a
week. The liquid food after a week every
two hours, and all other medicines were dis-
continued. Her bowels were moved with a
mild laxative at first, and afterward became
regular. Her tongue cleaned quickly and
her skin assumed a more natural appear-
ance.

At this writing, less than three weeks
from our first visit, the patient is able to sit
up an hour at a time, is quite rational and
cheerful, has a good appetite, the bowels
are quite regular, there is no headache, and
but little spinal tenderness. She sleeps
reasonably well if fed frequently. She is
allowed to suit her taste in her diet. The
child is quite active, and the mother is pro-
gressing so nicely that it is hoped that she
will pass safely through her confinement,
which is nearly at hand. She will be kept
on the liquid food and the phosphates
until her confinement after which, the con-
dition will suggest the treatment. This
is the most marked case of a starved
nervous system we have ever seen, and
the benefit derived from the treatment

proves the theory as to the cause of the
trouble.

Apropos with the above, comes the ques-
tion of the selection of nutritious foods for
those many cases which demand strong and
immediate nourishment. The food used in
the above case has produced marvelous re-
sults for us in some of those extreme cases
in which we have used it.

In one case of nervous exhaustion the
insomnia was absolutely painful. When
the exhaustion forced the patient to sleep
there was an immediate sense of falling or
approaching death, or there were hallucina-
tions which were appalling, rendering the
nights unbearable. One teaspoonful of
Murdock's Liquid Food so nourished the
system the first night it was given that the
patient sank into a quiet, refreshing sleep
which lasted, with a single awakening, until
morning, and the improvement the patient
obtained was most striking.

One case of mitral regurgitation with
leucocythemia and nervous exhaustion im-
proved more rapidly on this food than on
all other measures combined. In cases of
nervous exhaustion and brain tire, its effects
are most marked, as we have experienced
many times in the past five years in the
frequent personal use of the agent. It con-
tains the principles of pure, healthy blood
and nerve tissue ready for immediate as-
similation. Fourteen per cent, of the entire
quantity is uncoagulated albumen, as we
have demonstrated by actual analysis.

We have tided babies over critical periods
often with a few drops in its usual diet.
We have given it to dipsomaniacs with or
without non-alcoholic stimulants with su-
perb results. The sole objection our pa-
tients have to it is its odor. Its taste is not
disagreeable ; it has the odor and appear-
ance of blood. All objections are soon for-
gotten, however, in the results of its action
upon the nutrition of the system, and the
patient soon learns to like it, and often
craves for it, drinking it from the bottle or
a glass readily, like any beverage. It
ought to be the food par-excellence for
rapid appropriation in all conditions of ex-
haustion.

P. S. — Phosphates act well with the Liquid
Food.

Editorial of the Chicago Medical Times,
June, 1890.

Medical and surgical
Reporter

A Weekly Journal.

Established in 1853 by S. W. Butler, M.Dlo

CHARLES W. DULLES, M. D., Editor and Publisher,

Entered as Second-Class matter at Philadelphia P. O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

Vol. LXIV, No. 4.
Whole No. 1769.

JANUARY 24, 1891.

$5.00 per Annum.
10 Cents a Copy.

GOUTETSTTS :

CLINICAL LECTURE.

Mtjsser, John H., M. D., Philadelphia, Pa.— Rheu-
matoid Arthritis.— Syphilitic Headache.— Ma-
larial Cachexia.— Divisions of the Anemias. 89

COMMUNICATIONS.

Dock, George, M. D., Galveston, Texas.— General
Considerations on the Fevers of the South 92

Cates, Ben. Brabson, M. D., Knoxville, Term.—
The Curette in Fistula in Ano 94

Musgrove, C. W., M. D., Lock Haven, Pa —Diph-
theria r. 96

Young, James K , M. D., Philadelphia, Pa.— Dis-
eases of the Eye Associated with Caries of the
Vertebrae 97

Myxcedema Relieved by Grafting with the

Thyroid 108

The Gonococcus in the Diagnosis of Vulvitis.... 109

BOOK REVIEWS

Capp : The Daughter— Her Health, Education and
Wedlock.— Taylor ; A Manual of the Practice
of Medicine.— Potter; A Compend of Human
Anatomy, including the Anatomy of the Viscera. 110

CORRESPONDENCE.

Work in the Woman's Hospital of Philadelphia. —
Powder Blower 110-113

REPORTS OF CLINICS.
Buffalo General Hospital.

99

PERISCOPE.

Treatment of Hemorrhoids.— Meat Preservation.
—Small Doses— Chinese Treatment of Diph-
theria.—Tuberculous Milk and Diseased Udders.
—Irregular Typhoid Fever Rash.— Alterability
of Diuretine.— Palatable Emulsion of Creasote.
—The Tetrahydronaphthylamines. — Challenge
to a Fast 101-106

EDITORIALS.

Diagnostic Significance of the Tubercle Ba-
cillus

QUESTIONS AND ANSWERS.
Difficulty in Micturition

113

NOTES AND COMMENTS.

107

Depopulation of France.— Apomorphia.-^- Patho-
logical Anatomy and Pathogeny of Ecthyma. —
Influence of Tobacco-Smoking on the Stomach.
— Micro-Organisms in Cities.— " Antifebriniza-
tion" in Typhoid Fever and Consumption.—
Abortion for Vomiting of Pregnancy.— Women
and Women Physicians in India.— Hydrate of
Amyl in Epilepsy.— A Laryngological Curiosity.
— Raori Resin.— Disguise for Cod-Liver Oil. ...114-118

FOE THE CTJSE OIF1

NERVOUS HEADACHES

SEDATIVE EFFERVESCENT j EFFERVESCENT ANODYNE
(WARNER & CO.) (WARNER & CO.) ^

Caffein 1 grain, Brom. Soda 30 grains in R
eacli heaping teaspoonfnl.

Caffein 1 grain, Bromide Potash 20 grains
in each heaping teaspoonful.

Useful in Nervous Headache, Sleeplessness, Excessive Study, Useful in Nervous Headache, Sleeplessness, Excessive Study,
Migraine, Nervous Debility, Mania, as a Remedy Migraine, Nervous Debility, Mania, as a Remedy

in Seasickness and Epilepsy. in Seasickness and Epilepsy.

Dose and Composition. — A heaping teaspoonful, con-
taining Bromo-Soda 30 grs., and Caffein 1 gr., in half a glass
of water, to be repeated once after an interval of thirty min-
utes if necessary.

4®=* Physicians desiring the Potash Salt can obtain the
same by ordering or prescribing Bronio-Potash (Warner
& Co.), the composition of which is : Brom. Potash 20 grs.,
Caffein 1 gr.

The composition of the above effervescent salts is such as physicians can use with confidence, and you will please
specify Rromo-Soda or Bromo-Potash, Warner & Co., when ordering or prescribing to avoid the
substitution of other " Bromos." Prepared only by »

WILLIAM R. WARNER &, CO.,

1228 Market Street, Philadelphia. 18 Liberty Street, new York.

FRENCH, CAVE &, CO.

(Successors to French, Richards & Co.),
PHILADELPHIA,

WILL continue the manufacture of the Fine Pharmaceutical Products
made by the late firm at the present laboratory, 16 and 18 North
Tenth Street, Philadelphia.

Physicians who have prescribed these preparations can rest assured that
the high standard of quality which has made for these products a reputation
for consistent strength and purity will be strictly maintained in the future, and
the physician can always prescribe our preparations and depend on uniform
results

To those physicians who have not yet prescribed our products, we request
them to send to us their address and we will forward by EXPRESS, PRE-
PAID, a line of samples free for trial.

Physicians' Price-Liist and Formulary sent oy mail on application.

FRENCH, CAVE & CO.,

Factors op Kink Pharmaceutical Products,
Nos. 16 and 18 NORTH TENTH STREET, PHILADELPHIA.

ANTISEPTICS, DISITSTFECT^LTSJTS ATNI> OXIDANTS.

" Sanitas;" is prepared by Oxidizing Terpene in the presence of Water

with Atmospheric Air.

"SANITAS" DISINFECTING FLUID.

An aqueous extract of Air-Oxidized Terpene. Its active principles include Soluble Camphor
(CioHi602 ), Peroxide of Hydrogen, and Thymol. Invaluable to the physician for internal or
external application.

"SANITAS" DISINFECTING OIL.

Air-Oxidized Terpene. Its active principle is Camphoric Peroxide (C10H16O3 ), a substance which
produces Peroxide of Hydrogen when placed in contact with water or moist surfaces (wounds,
mucous membranes, and other tissues). It is a powerful germicidal and oxidizing agent. For
fumigations and inhalations in the treatment of diseases of the respiratory organs the oil only
requires to be evaporated from boiling water.

"Sanitas" is Fragrant, Non-poisonous, and does not stain or corrode. It is put up in the
FLUIDS, OIL, POWDERS AND SOAPS.

For Reports by Medical and Chemical Experts, Samples, Prices, etc., apply to the Factory,

636, 638, 640, and 642 West 55th Street, New York.

MEDICAL AND SURGICAL REPORTER.

1

To avoid the
evil effects of Tea
and Coffee, use con-
stantly VAN HOU-
TEN'S COCOA,
which is a

STRKNGTHENER OF

tug nerves and a
refreshing and
nourishing bever-
age,

One trial of
VAN HOUTEN'S
COCOA will con-
vince every one of
Its great superior-
ity in strength, fla-
vor, and economy.

WINDSOR HOTEL,

(fronting East on Windsor Park.)

WINTER RESORT,

JACKSONVILLE, FLORIDA.

Open DECEMBER TO MAY. Board $4.00
per day. One hundred pleasant rooms at $21 per
week, each person. F. H . OR VIS.

4Sr* Dogs Not Taken.

FINE OFFICE TO RENT.

In Philadelphia — to a Specialist,
a beautiful room, with light
and heat, from 9 to 10 A. M.,
and in afternoon.

Address

POLLUX,
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m

The Guarantse Trust and Safe Deposit Company,

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RENTS SAFES in its ABSOLUTELY
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COLLECTS INTEREST OR IN-
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RECEIVES FOR SAFE KEEPING,
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Receipts for and safely keeps Wills
"without charge.

For further information, call at the
office, or send for a circular.

MANAGEMENT.
Richard Y. Cook, President.
Geo. H. Earle, jR.,Vice-President.
Harry J. Delany, Treasurer.
John Jay Gilroy, Secretary.
Richard C. Winship, Trust Officer,

DIRECTORS.
Thomas Cochran.
Edward C. Knight.
Thomas MacKellar.
John J. Stadiger.
Clayton French.
W. Rotch Wister.
Alfred Fttler.
J. Dickinson Sergeant,
Aaron Fries.
Charles A. Sparks.
Joseph Moore, Jr.
Richard Y. Cook.
George H. Earle, Jr.

II

MEDICAL AND SURGICAL REPORTER.

SULFONAL-BAYER.

A CORRECT METHOD OF ADMINISTRATION, ESSENTIAL TO OB-
TAINING ITS HYPNOTIC EFFECT.

Inquiries have been made of us from time to time as to the best method of administering Sulfonal-
Bayer. These inquiries indicate that various methods of administration have been employed, and this,
without doubt, accounts for those cases where the results obtained were not wholly satisfactory. We call
special attention to the following :

" Clinically observed, we recognize in Sulfonal a mild calmative, a slowly but progressively active
hypnotic. It has no other action, and its operation is attended by no complications, near or remote. It is,
therefore, a pure hypnotic"

" The essential conditions of success in the exhibition of Sulfonal depend on first, the time when the
remedy should be administered ; second, the method of administration ; third, the dose."

" // is a fact, perhaps wholly unprecedented in what we observe of other neurotic materials, that
Sulfonal demands from two hours to one hour for its physiological incubation ; often quite two hours elapse
between ingestion and the first accession of sensible medicinal energy. With the untried subject it is wise
to stipulate for two hours." — [Extracts from articles by Prof. H. M. Field, New England Medical
Monthly ; Iherapeutic Gazette.~\

According to the experience of Prof. A. Kast, of Freiburg University, Sulfonal- Bayer should be
administered in a plate of soup, a cup of hot tea, milk or broth, at least two hours before retiring, or with
the last meal early in the evening, between 7 and 8 P. M., at which time the stomach contains considerable
amount of muriatic acid, mineral salts and peptones, and the most favorable conditions for the absorption
are satisfied.

Sulfonal has just been incorporated into the Addendum to the British Pharmacopoeia.

Sulfonal-Bayer, prepared by the Farbenfabriken, formerly Friedr. Bayer & Co., Elberfeld, is supplied
by us in ounces and in the form of Tablets of 5, 10 and 15 grains, put up in bottles of 10 and 100 tablets
each.

We also offer Sulfonal-Bayer in the form of our soluble pills, containing 5 grains each.

ARISTOL.

In order to secure the desired effects of Aristol, it is important that the physician be certain that the
article used bears the guarantee furnished by the continuous scientific control and the name of the manu-
facturers, the " Farbenfabriken, vormals Friedr. Bayer <5r» Co., in Elberfeld." This firm are the only
manufacturers of this article, and the word "Aristol" is their registered property.

The preparation of Aristol, theoretically simple, involves the greatest care and experience.

Aristol, a combination of iodine and thymol, manufactured by the Farbenfabriken, formerly Friedr.
Bayer & Co., Elberfeld, Germany, is a valuable, inodorous, and non-toxic antiseptic remedy, superior to
iodoform, iodole, and sozo-iodole.

The general specific action of Aristol is similar to that of iodoform, iodol, and the sozo-iodol com-
pounds, but in addition it has the valuable property of forming an absolutely unirritant covering over the
surfaces on which it is placed, under which the processes of granulation and cicatrization proceed with
extraordinary rapidity.

Aristol is indicated in Mycosis, Lupis, Psoriasis, Syphilitic diseases generally, etc., etc.

Descriptive pamphlet mailed on application.

PHENACETINE-BAYER.

Antineuralgic- Antipyretic.

Much valuable testimony regarding Phenacetine, furnished by the medical profession of other countries,
as well as our own, has, from time to time, been collated by us, and the same has been put before American
practitioners.

The scope of Phenacetine having widened, we have brought together in pamphlet form, classified in
respect to diseases indicated, the results of the latest experience as reported chiefly by American physicians.
This pamphlet mailed to applicants.

W. H. Schieffelin & Co.,

170 & 172 William Street,
NEW YORK.

MEDICAL AND SURGICAL REPORTER.

IV

MEDICAL AND SURGICAL REPORTER.

SPECIAL OFFER

TO SUBSCRIBERS TO THE REPORTER WE MAKE
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MEDICAL AND SURGICAL REPORTER. V

A BRIEF SUMMARY

OF

HYPODERMIC MEDICATION.

will be sent, with our compliments, when application is made and the name of this journal is
mentioned. It. quotes Profs. Dujardin-Beaumetz, Bartholow. Anstie, Erb, Echeverria, Mays
and others. It contains important and the most recent suggestions on the technique of hypo-
dermic medication, and gives the composition, properties, doses, etc., of our

SOLDBLE HYPODERMIC TABLETS, gg

which are quickly and perfectly soluble in cold or warm water, combining accuracy of dose
with perfect preservation of the active ingredient, and the base of which is perfectly harm-
less and unobjectionable. They will cause no abscesses and will not become insoluble by
age. They may also be administered by the mouth, and are

ALWAYS READY FOR INSTANT USE.

We respectfully solicit a trial of these tablets, and will mail samples of them free to
readers of this journal.

That the several objections to
hypodermic medication might be
obviated, we have had manufac-
tured expressly for us a line of

HYPODERMIC SYRINGES, S, & B,'s„ -

which have all the latest improve-
ments, are most accurately made
of the best materials and so con-
structed as to allow the

MAKING OF A SOLUTION IN THE
SYRINGE.

They are sent to any address
at the following prices :

Syringe, in leathered-covered case, two tubes of tablets net, $2.50

" " metal case, latest improved style, two tubes of tablets " 2.50

" " " " four tubes of tablets " 3.50

" flexible leather case, as shown by cut 3.50

SHARP & DOHME,

MANUFACTURERS OF
Standard Medicinal Fluid and Solid Extracts; Soluble Hypodermic Tablets; Soluble
Gelatin and Sugar-Coated Pills and Granules; Granular Effervescent Salts;
. Compressed Lozenges and Tablets; Fine Chemicals, &c, &c.

ESTABLISHED 1860. 3 BALTIMORE, MD.

VI

MEDICAL AND SURGICAL REPORTER.

RABUTEAU'S DRAGEES of IRON

Laureate of the Institute of France— Prize in Therapeutics.

The studies made by the Physicians of the Hospitals have
demonstrated that the Genuine Dragees of Iron of
Rabuteau are superior to all other preparations of Iron
in cases of Chlorosis, Ansemia, Leucorrhcea, Debility, Exhaustion,
Convalescence, Weakness of Children, and the maladies caused
by the Impoverishment and Alteration of the blood after
oeriods of fatigue, watching, and excesses of any kind.

TAKE 4 to 6 DRAGEES DAILY.

Rabuteau' s Elixir of Iron is recommended to those
persons who may be unable to swallow the Dragees. Dose
— A small mneglassful with meals.

Rabuteau's Syrup of Iron is specially designed for
children. Chalybeate medication, by means of Rabuteau's
Iron, is the most economical and the most rational known
to therapeutics.

No constipation, no diarrhoea, complete assimilation.
Take only the GENUINE IRON OF RABUTEAU of

CXjI^T &c CO., DPstris.

SOLUTION OP

THE SALICYLATE of SODA
OF DOCTOR CLIN.

Laureate of the Paris Faculty of Medicine
(MONTYON PRIZE).

Dr. Clin' s Solution, always identical in its composition,

and of an agreeable taste, permits the easy administration
of pure Salicylate of Soda, and the variation of the dose in
accordance with the indications presented.

"The Salicylate of Soda used by Clin is of perfect purity,
"and is prepared with the greatest care; it is a medicament
Min which we may have every confidence."

—Paris Society of Medicine, Meeting of Feb. 8ih, 1879.

Clin's Solution, very exactly mixed, contains: 2
grammes of Salicylate of Soda per tablespoonful, 50 eenti- i
grammes of Salicylate of Soda per teaspoonful.

IFsuris— OXjZ^T <Sc CO.- Varies

AND BY ALL DRUGGISTS.

CAPSULES

MATHEY- CAYLUS

WITH THIN ENVELOPE OF GLUTEN.
CONTAINING COPAIBA AND ESSENCE OF SANTAL;
COPAIBA, CUBEBS, AND THE ESSENCE OF SANTAL;
COPAIBA, IRON, AND THE ESSENCE OF SANTAL.

"The Mathey-Caylus Capsules, of the Essence of
" Santal, associated with the Balsams, possess an incontesta-
ble efficaciousness, and are employed with the greatest
"success for the rapid cure of old or recent Discharges,
** Gonorrhoea, Blenorrhcea, Leucorrhcea, Cystitis of the Neck,

Urethritis, Catarrh, and other diseases of the bladder, together
"with all affections of the Urinary Passages"

M Thanks to their thin envelope of Gluten, which is essen-
" tially assimilable, the Mathey-Caylus Capsules are digested
M by themost delicate persons, and never weary the stomach."

— Gazette des Hopitaux de Paris.

CX-.I3^T <Sc CO., IE>a,ris,

AND OF ALL DRUGGISTS.

NEURALGIAS

PILLS OF DR. MOUSSETTE.

The Moussette Pills of aconitine and quinium, calm or
cure Gastralgia, Hemicrania, Headache, Sciatica, and the
most obstinate Neuralgias.

"The sedative action exerted by the Moussette Pills
"upon the apparatus of the sanguineous circulation by the
"intermediation of the vaso-motor nerves, indicates their
"use in neuralgias of the trigemini nerves, (fifth pair), eon-
"gestive neuralgias, and painful and inflammatory Ehenmalismal
" affections."

"Aconitine produces marvelous effeets in the treatment
"of facial neuralgias when tbey are not symptomatic of
"intracranial tumor." — Society of Biology of Paris, Meeting
"of the 28th February, 1880.

Dose— Take 3 to 6 pills during the twenty-four hours.
ACCEPT ONLY THE GENUINE MOUSSETTE PILLS OF
CX-iXET dc CO.,-Paris.

GRAND NATIONAL PRIZE OF 16,600 FRANCS,

Quina-Laroche

This meritorious Elixir,
QUINA-LAROCHE, is
prepared from the three
Cinchonas ; it is an agreea-
ble and doubtless highly
remedy.

— The Lancet.

VINOUS ELIXIR,

A STIMULATING
RESTORATIVE

AND

ANTI-FEBRILE TONIC.

QUINA - LABOCHE

under the form of a vinous
Elixir contains the totality
of the numer&us principles,
of the three CinchonaS
harks. It is a preparation
which renders great serv-
ices to Therapeutics. — Ex-
tract of the Gazette des
Hopitaux, Paris.

FAR SUPERIOR TO ALL ORDINARY CINCHONA WINES,

LiAROCHE'S QUINA, tried by the Academy of Medicine of Paris, is a specially prepared Compound Extract of
Quinquina, a careful analysis, confirmed by experience, has shown that most of the wines and syrups hitherto used have not
contained all the properties of this precious bark, of these some, although beneficial, are altogether lo6t, while many preparations
contain but half the properties of the bark in varying proportions.

Me. Laroche, by his peculiar method, has succeeded in extracting all the active principles of the quinquina, combining these
With Catalan Wine forming an Elixir free from the disagreeable bitterness of other similar preparations. Practitioners have
found triple advantages in the use of this Elixir, it is a strong tonic, is easily administered, and perfectly harmless, being free
from the unpleasant effects of Quinine.

THE FERRUGINOUS QUINA-IAROCHE is the invigorating tonic par excellenee, having the advantage of being
♦asfly assimilated by the gastric juice ; without, in any way, deranging the action of the digestive organs, proving itself to be amost
efficacious remedy in cases of impoverishment of the blood, Anaemia, Chlorosis, Intestinal Hemorrhage, Castralgia,
Exhaustion, Etc., Etc.

PARIS. — 22 RUB DROTJOT. — PARIS.

E. FOUGERA & CO., New York,

si

Sole Agents for the United States for the above Preparations.

MEDICAL AND SURGICAL REPORTER.

VII

TERTIARY SYPHILIS.

"Your preparation, IODIA, is an excellent altera-
tive, and is the most agreeable of any preparation of
Iod. Potas., as it does not cause the cramps in stomach,
which are often intolerable.

"I have employed IODIA in two cases of Tertiary
Syphilis, in which, after five weeks' treatment, the mani-
festations disappeared.

" In a case of Syphiltic Eczema it was also successful.
— Dr. Sam Petite au, Garches, France, Nov. 10, 1890.

BATTLE & CO., Chemists' Corporation,

St. Louis, Mo., U. S. A.

BRANCHES :

76 New Bond Street, London, W.

5 Rue de la Paix, Paris.

9 and 10 Dalhousie Square, Calcutta.
80 Montague-de-la-Cour, Brussels.
28 Nieuwe Hoogstraat, Amsterdam.

VIII

MEDICAL AND SURGICAL REPORTER.

Books for Subscribers.

BY SPECIAL ARRANGEMENT with the publishers we are able
at this time to offer the following first-class and very valuable
books (last editions) at a very low price, when taken in connection with
paid-up subscriptions. Subscribers will see that we have put in this
list thoroughly good books. See Adv. Page ix.

For

$10.00

REPORTER for one year,

$5.00

HEATH'S DICTIONARY OF PRAC-
TICAL SURGERY. Cloth,. . . $7.50

For

$9.00

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LEIDY'S HUMAN ANATOMY. By

Joseph Leidy, M. D. Cloth, . . $6.00

For

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REPORTER for one year, . $5.00

and any one of the following books —

1. — BYFORD'S DISEASES OF WO-
MEN. Cloth, $5.00

2 FOWLER'S DICTIONARY OF PRACTICAL MEDICINE, $5.00

3. — JACOBSON'S OPERATIONS OF SURGERY, $5.00

4. — CAZEAUX & TARNIER'S MIDWIFERY. With Appendix by Munde' . $5.00

5. — THOMAS'S MEDICAL DICTIONARY, $5,00

These works are all in cloth binding, but can be supplied in leather binding for $1.00 additional.

For

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THE NERVOUS ANDTHE INSANE.

By Chas. K. Mills, M. D., . . . . $1.00

2. — MATERNITY ; INFANCY; CHILDHOOD. By John M. Keating, M. D., . . $1.00

3. — OUTLINES FOR THE MANAGEMENT OF DIET; or, The Regulation of Food

to the Requirements of Health and the Treatment of Disease. By E. T. Bruen, M.D., . . $1,00

4. — FEVER NURSING. Designed for the use of professional and other Nurses. By J. C.
Wilson, A. M., M. D., . . $1.00

5.— DISEASES AND INJURIES OF THE EAR

H. Burnett, A.M., M.D

Their Prevention and Cure. By Chas.

$1.00

Or, For $6.00, any one of the above Nursing Books and THOMSON'S (Sir Henry)
SURGERY OF THE URINARY ORGANS. Some important points connected with
the Surgery of the Urinary Organs. Illustrated. Cloth, $1.25

MEDICAL AND SURGICAL REPORTER.

IX

WHAT IS THOUGHT OF THEM!

(BOOKS FOR SUBSCRIBERS TO REPORTER.)

Ifgg^See adv. page viii.

HEATH'S DICTIONARY OE PRACTICAL SURGERY.

C. B. Porter, M. D., Boston, Mass., says ; "A most excellent book for the library of the surgeon, and especially for the
country practitioner ; as a book of reference it is so concise and at the same time so complete."

A^. Senn, M, D., College of Physicians and Surgeons, Milwaukee , says ; "Asa means of ready reference for the student
and busy practitioner this book stands unexcelled.''

Pro/. E. h. Gregory, St. Louis Medical College, St. Louis, says : " I have examined the book, and find it a most valuable
addition to my library. I am sure it will meet the favor of the surgical profession."

EEIDY'S HUMAN ANATOMY.

The Lancet- Clinic, Cincinnati, O., says: " Professor Leidy again presents to medical practitioners and students a treatise
on human anatomy that at once commands the attention and admiration of all who are at all familiar with the subject. Most
of the plates are original, and in common with the text are very beautiful to behold. The work is a complete illustration of
the method of teaching anatomy adopted by a leading scientist, and one of America's best known professors of anatomy. This
is one of the books that should be in the library of every practitioner of medicine and surgery."

The Medical Advance , Ann Arbor, Mich., says : "The student can master and retain a practical knowledge of anatomy
in a shorter time and with less hard work from this te»t-book than from any other work extant, and it has been our privilege to
teach anatomy for several years."

BYFORD'S DISEASES OE WOMEN.

The Boston' Medical and Surgical Journal says : " It is a satisfaction to observe the discussion of certain topics which
are often neglected by writers, notably of the sympathetic symptoms of organs apparently disconnected with the uterus, for
which he will receive the thanks of the younger members of the profession. Another topic very widely treated is that of Con-
stipation in its relation to uterine diseases. All the other topics which should have a place in a work of this kind have been
fully and properly treated."

The Cincinnati Lancet- Clinic says : " The book is eminently practical and instructive. Its suggestions for treatment are
well up with the times, mostly judicious, conservative, and valuable, and the whole amply repays for thorough perusal."

The St. Louis Courier of Medicine says : " The work of a representative Western practitioner and professor, and is a
thoroughly practical work."

The Virginia Medical Monthly says : " We take pleasure in recommending it to every student and physician desirous of
obtaining a standard work on Gynaecology."

The Chicago Medical Journal and Examiner says: "The chapter on puberty should be carefully studied by every
physician, teacher, and mother in the land. . . . Its style is clear, but concise, and always practical, and shows the author to
be, as we all know, an experienced teacher. The work as a whole is most valuable, both to the student and practitioner."

Gaillard's Medical Journal says : " It is replete with good judgment, broad and practical views. . . . The illustrations
are excellent."

FOWEER'S DICTIONARY OE PRACTICAL MEDICINE.

The Medical Aews says : " For those who do not wish to purchase the much larger book of Quain, or who wish compara-
tively recent information concerning medical subjects in a somewhat narrow space, the book will certainly prove of value, and
we heartily recommend it as one which will give a full return for the money invested in the purchase."

The London Lancet says : " What the writers know they tell simply and plainly, and generally manage to put it in a short
compass, and, what is more, the treatment that is recommended is clearly and sufficiently set forth. . . . We can heartily
congratulate the editor and his colleagues on having admirably fulfilled their purpose, viz., to produce a first-rate dictionary of
medicine, at once scientific and practical, which well deserve the success we have no doubt it will meet with."

JACOBSON'S OPERATIONS OE SURGERY.

The Medical and Surgical Reporter says : " This handsome book is one of the most admirable works on operative surgery
which we have seen for a long time. The author has brought to its preparation a large observation and experience, and a very
thorough acquaintance with the methods of other surgeons. His book is comprehensive and his directions are clear and reli-
able. It is gratifying to an American reader to find that full justice is done to the work of American surgeons by Mr. Jacobson,
and that his book bears no marks of the distance which stretches between his land and ours. This is as it should be, and is no
less an element in the excellence of the technical worth of his book than it is an evidence of the cosmopolitan character of good
scientific work."

CAZEAUX & TARNIER'S MIDWIFERY. Witli Appendix toy MUNDE.

The Memphis Medical Monthly says : " Cazeaux's Obstetrics was authority during our student life, and has been gener-
ally recognized as authority from the publication of the first edition to the present. We cannot do more than to fully endorse
•the following from the pen of T. Gallard Thomas, M. D ; 'I have examined the last edition of Cazeaux & Tarnier's Theory
and Practice of Obstetrics, and pronounce it practical, and just what is needed by every practitioner. I highly recommend the
work. This work should be prominent in every library.' "

Dr. IVm. L. Lusk says : " Cazeaux's Midwifery will always remain an inexhaustible mine of information, and I rejoice to
see it once more accessible to the profession in a new and attractive dress."

Dr. Wm. Goodell says : "I deem Cazeaux & Tarnier's Obstetrics the best yet published."

The Denver Medical Times says ; " It is needless to say anything in praise of this work. Cazeaux's Obstetrics is a clas-
sical work, and Tarnier is one of the best known French writers on Obstetrics. The whole has been brought up to date by the
appendix of Prof. Munde, and altogether it makes a very complete and practical treatise on the subject, unsurpassed if not
unequalled by any work with which we are acquainted. Especially valuable are the signs of delivery in the dead body and of
live and still-births. The chapter on antisepsis and on puerperal septicemia are also worthy of mention."

THOMAS'S MEDICAL, DICTIONARY.

Prof. A. F. Patton, College of Physicians and Surgeons, Boston, Mass., says : " It is just the book for a medical or any
other student, and it should be in the office of every physician. This dictionary supplies a place that has never been filled. I
have looked it through and find all the new words that I have sought."

The St. Joseph Medical Herald says : " No better testimonial to the value of the work can be given than the following
from Dr. J. Gibbon Hunt, the distinguished microscopist : 1 To me the work is invaluable. I am astonished at its fullness of
all recent words which the modern advance of medical science has introduced. Of course, I cannot conceive the learning and
great labor which could edit such a complete, thorough, and admirable volume.' We can add nothing further save that the
book should be in the hands of every physician and every student in the land."

X

MEDICAL AND SURGICAL REPORTER.

DISEASES IN WHICH

Oxygen and Nitrogen Monoxide

HAVE BEEN EMPLOYED.

(See " Therapeutic Uses of Oxygen and Nitrogen Monoxide," which can be obtained upon

application.)

Anaemia, Dyspnoea, Nephritis,

Asphyxia, Emphysema, Pulmonary, Nervous Affections,

Asthenia, Epilepsy, Nervous Prostration,

Asthma, Formication, Neuralgia,

Atonic Conditions, Headache, Paralysis,

Brig-ht's Disease, Hemorrhage, Pulmonary, Phthisis,

Bronchitis, Hypochondriasis, . Pleuritic Adhesions,

Catarrh, Hysteria, Pleurisy,

Croup, Indigestion, Pleuro- Pneumonia,

Cyanosis, Insomnia, Pneumonia,

Diabetes, Laryngitis, Rheumatism.

Diarrhoea, Lithiasis, Scarlet Fever,

Diphtheria, Melancholia, Tuberculosis,

Dyspepsia, Menstrual Irregularities, Uraemia.

ABOUT GAS TBBATMEUT.

We make and sell oxygen and nitrogen monoxide for therapeutic use, and we guarantee them pure.
They are put up in compact form. (A cylinder containing 100 gallons of nitrogen monoxide or 40 gallons
of oxygen measures 12 inches in length, has a diameter of 3^ inches, and weighs 10^ lbs. A cylinder
containing 450 gallons of nitrogen monoxide or 100 gallons of oxygen measures 25 inches in length, has a
diameter of 4^ inches, and weighs 34 lbs.)

Insomnia. Dr. Allan McLane Hamilton states that nitrogen monoxide, N20 (nitrous oxide of the old
nomenclature) has no equal in the treatment of this difficulty.

Melancholia. A short course of nitrogen monoxide is said to change the face of nature for such
patients.

Anemia. Where iron is not tolerated or proves inefficient, the addition of oxygen or a combination
of oxygen and nitrogen monoxide has proven very beneficial.

For those who should, but cannot, go from home for rest or a change of air, or for those who, from any
cause fail to get air enough into their lungs, the inhalation of one or other of these gases, or both in com-
bination, promises great benefit. The testimony is that in cases of

Asthma, more than fifty per cent, of the cases yield to oxygen treatment, others are very greatly
relieved, and a very small per cent, are not improved.

Indigestion and Constipation are said to be greatly relieved and very often conquered by continued
treatment.

A highly esteemed New York physician has used more than twenty thousand gallons of nitrogen
monoxide in his private practice. The letters received from his patients, largely from those who were
afflicted with nervous disorders, are enthusiastic in their testimony as to the benefit received.

Regular practitioners who are using gas treatment testify that when pure oxygen and pure nitrogen
monoxide, or a mixture of these, is used, no therapeutic agents are more uniformly successful when intelli-
gently prescribed.

For descriptive circulars, and term for gas outfits, address

The S. S. White Dental Manufacturing Company,

AT EITHER OF THE BELOW NAMED PLACES:

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1260 and 1262 Broadway (cor. 32d St.), New York, N. Y. 444 Fulton St., Brooklyn, N. Y.

MEDICAL AND SURGICAL REPORTER.

XI

NERVES.

Suppose we find the patient a little giddy upon rising
in the morning. This means that the nerves do not have
perfect control of the muscular system. As a test for this,
direct the patient to stand with his feet close together,
shut his eyes, and if the tendency is to reel, it is another
evidence of lowered nerve tone. Or, stand with the
arms extended, shut the eyes, and then try to bring the
tips of his forefingers together in front of him. If they
pass by or meet imperfectly, it shows the same thing.

Or, the person may not be able to think as quickly as
he should. To test this, ask the patient three simple
questions in rapid succession, as, Where were you just
before you came into this room ? What were you doing ?
How long did you remain ? The rapidity with which the
answers are given indicate the rapidity of brain action.

All these things show that it is of the utmost importance
that the nervous system should be kept in tone. Other-
wise, every part of the body languishes.

This condition indicates the use of Celerina (Rio) in
teaspoonful doses four times a day, to increase the nerve
capital of your patient.

XII

MEDICAL AND SURGICAL REPORTER.

LIQUOR SANTAL FLAY

CUM

BUCHU et CUBEBA.

(ORIGINAL FORMULA.)

This elegant preparation has been very successfully used in the treatment of
long-standing Gonorrhoea and chronic Gleet.

If given in the early stages of Gonorrhoea, it will usually arrest the progress
of the disease.

It is especially effective in all inflammations of genito-urinary mucous
membranes.

It is perfectly miscible in water. Dose, iZ\ to f3ij, three times a day in water
or milk. When prescribing, please specify Liq. Santal Flav. cum Buchu et Cubeba
(Ogden's).

iTOHZliT OGKDIEIsr,
CHEMIST,
WALNUT & THIRTEENTH STREETS,

PHILADELPHIA.

Every Physician in THE WORLD should Read This Advertisement.

THE RIP VAN WINKLE RECLINING ROCKE R

OFFICE AND GYNAECOLOGICAL CHAIR COMBINED.

Special Inducements and Extra Discount Given to Physicians.

It is the most wonderful Chair in the world. You
can sit in the Chair with your feet on the foot-rest and
rock yourself, and it is impossible for a beholder to
tell what makes the Chair rock. It is the finest in-
valid's Chair in the world.

As an Invalid's Chair, a person can recline
the back by quarter-inches until he lies straight or hori-
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of the chair in the least, and CAN ROCK AS WELL
LYING DOWN AS SITTING UP. Upholstered in
Plush, Leather or Wilton Rugs. This Chair has over
200 changes of position, and sells for $25.00.

No. 1.

This Chair can be converted from a splendid
Office Chair (see cuts Nos. 1 and 3) into one
of the most complete Gynaecological Chairs
in'a half minnte, (see cuts 2, 4, and 5).

As a Gynaecological Chair it will take all
the positions of the high-priced chairs costing
two and three times what this one does.

The Rip Van Winkle Chair has over 200
changes of position. Every chair fully war-
ranted.

No. 2.

This Chair is sold with or without the Gyn-
aecological attachment, as desired. It is un~
questionably the most complete and comfort-
able Reclining or Lounging Chair ever made.
I make a special price to physicians, and also
give them a handsome commission on all orders
I receive through them for Chairs for their
patients. No Chair in the world is so well
adapted to ladies suffering from female weak-
ness, and the commission I give on your orders
will soon pay for your own Chair.

No.

The Chair makes 5 pieces of Furniture.

I have attachments by which it can be con-
verted into an Invalid's Rolling Chair in one
minute. Parties can get these attachments from
factory at any time. Send for full particulars,
price-list, and illustrated catalogue showing the
principal positions and changes. The Catalogue
contains the " Legend of Rip Van Winkle."
Without the Gynaecological Attachment these Chairs

Make an Elegant Wedding" or Holiday Present.
Manufactured by p. C. LEWIS, Box ^ Catskill, KT.

MEDICAL AND SURGICAL REPORTER.

XIII

THE BEST ANTISEPTIC

FOR BOTH INTERNAL AND EXTERNAL USE.

ANTISEPTIC,

PROPHYLACTIC.

DEODORANT.

LISTERINE

non-toxio.

Non-Irritant,

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FORMULA — Listerine is the essential antiseptic constituent of Thyme, Eucalyptus, Baptisia, Gaultheria and
Mentha Arvensis, in combination. Each fluid drachm also contains two grains of refined and purified
Benzo-boracic Acid.

DOSE — Internally: One teaspoonful three or more times a day (as indicated) either full strength, or dihited,
as necessary for varied conditions.
LISTERINE is a well -proven antiseptic agent— an antizymotic— especially adapted to
internal use, and to make and maintain surgical cleanliness— asepsis— in the treatment of
all parts of the human body, whether by spray, irrigation, atomization, or simple local
application, and therefore characterized by its particular adaptability to the field oi

PREVENTIVE MEMCISfE-ISTDIVIBIJAI, PROPHYLAXIS.

Diseases of tlie Urio Acid Diatliesis.

LAMBERT'S

LITHIATED HYDRANGEA

KIDNEY ALTERATIVE— ANTI-LITHIC.

FORMULA — Each fluid drachm of "Lithiated Hydrangea" represents thirty grains of fresh Hydrangea and
three grains of chemically pure Benzo-Salicylate of Lithia. Prepared by our improved process of
osmosis, it is invariably of definite and uniform therapeutic strength, and hence can be depended
upon in clinical practice.

DOSE — One or two teaspoonfuls four times a day (preferably between meals).

Urinary Calculus, Gout, Rheumatism, Bright' s Disease, Diabetes, Cystitis, Hema-
turia Albuminuria, and Vesical irritations generally.
We have much valuable \ General Antiseptic Treatment, \ To forward tt Physicians

literature upon < Lithemia, Diabetes, Cystitis, etc. > u^n request:

LAMBERT PHARMACAL CO.. ST, LOUISB MO.

CHARLES LENTZ & SONS,

MAKERS OF

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Lentz's Aseptic Catheter.

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Send for descriptive Circular.

Our No. 10 Operating Case,

of which so much
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having large sale
yet. It is the most

complete set in the market for any ordinary operation. Price, #18.75, and upward. Send
for circular.

SEND FOR SPECIAL LIST OF NEW INSTRUMENTS.

XIV

MEDICAL AND SURGICAL REPORTER.

Physical Exhaustion

HORSFORD'S ACID PHOSPHATE.

It is a well-known physiological fact that the phosphates are involved in all waste
and repair, and are consumed with every effort. The quantity secreted by the kidneys
is. increased by labor of the muscles.

In the healthy organization the phosphate of lime exists in the muscles and bones.
This phosphate is supplied by this preparation in such form as to be readily assimilated.

Dr. J. P. Cowles, Camden, Me., says: "I have used it in cases of physical
debility arising from exhaustive habits or labors, with beneficial results."

Send for descriptive circular. Physicians who wish to test it will be furnished a
bottle on application, without expense, except express charges.

Prepared under the direction of Prof. E. N. Horsford, by the

Rumford Chemical Works, Providence, R. I.

Beware of Substitutes and Imitations.

CAUTION:— Be sure the word " Horsford's " is printed
on the label. All others are spurious. Never sold in bulk.

FRELIGH'S TABLETS,

(Cough and Constituent),

FOR THE PREVENTION AND CURE OF

PULMONARY PHTHISIS

Cough Tablets.

EACH TABLET CONTAINS. •

Morph. Sulph. gr.), Atropise Sulph. (5J„ gr.),
Codeia gr.), Antimony Tart. ,V gr.), Ipecac,
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ite, Rhus-tox, and Lachesis, fractionally so ar-
ranged as to accomplish every indication in any
form of cough.

Constituent Tablets.

EACH TABLET CONTAINS.

Arsenicum (BV gr.), Precipitate Carb. of Iron,
Phos. Lime, Carb. Lime, Silica, and the other
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together with Caraccas. Cocoa and Sugar.

PRICE, THREE DOLLARS PER DOUBLE BOX.

Containing sufficient Tablets of each kind to last from one to three months according to the condition of the patient.

SPECIAL OFFER.

While the above formulae have been in use, in private practice, over 30 years, and we could give testimonials
from well-known clergymen, lawyers and business men, we prefer to leave them to the unbiased judgment of the
profession with the following offer : On receipt of 50 cents, and card, letter-head, bill-head, or other proof that the
aoolicant is a physician in active practice, we will send, delivered, charges prepaid, one of the regular (double)
boxes (retail price, Three Dollars), containing sufficient of each kind of Tablets to test them three months (in the
maiority of cases) in some one case. Card, letter-head, or some proof that the applicant is a physician in active
practice must accompany each application. Pamphlet, with full particulars, price-list, etc., on request.

As we furnish no samples through the trade, wholesale or retail, for samples, directions, price-list, etc., address,

88 Maiden Lane,

I. O. WOODRUFF & CO.,

MANUFACTURERS OF PHYSICIANS' SPECIALTIES,

New York City.

MEDICAL AND SURGICAL
REPORTER

No. 1769.

PHILADELPHIA, JANUARY 24, 1891. Vol. LXIV.— No. 4.

Clinical Lecture.

RHEUMATOID ARTHRITIS.— SYPHI-
LITIC HEADACHE.— MALARIAL
CACHEXIA.— DIVISIONS OF
THE ANEMIAS.

BY JOHN H. MUSSER, M. D.,

ASSISTANT PROFESSOR OF CLINICAL MEDICINE, UNI-
VERSITY OF PENNSYLVANIA; VISITING PHYSI-
CIAN TO THE PHILADELPHIA HOSPITAL.

Rheumatoid Arthritis.

Gentlemen : At our last meeting we
studied the symptoms, course and treatment
of syphilitic, gonorrhceal and simple rheu-
matism ; to-day Ve will take up a disease
which occupies an uncertain position in the
nosology of this broad subject. The exact
relationship existing between rheumatism
and rheumatoid arthritis has not been deter-
mined ; yet there can be no doubt that it is
definite and certain. Rheumatoid arthritis is
a disease associated with grave anatomical
changes, which appears in gouty subjects,
with other affections known to be rheumatic,
frequently mingled with other well recog-
nized gouty or rheumatic symptoms. It is
also occasionally associated with lesions
common in other rheumatic affections,
chronic kidney trouble, endocardial inflam-
mations, etc. In syphilitic rheumatism the
enlarged lymph glands facilitate diagnosis ;
not so much the glands in the groin — which
are apt to enlarge on any adjacent irritation
— as the post-cervical or epitrochlear glands.
If these are swollen, it is an important aid to
diagnosis. In gonorrhceal rheumatism there
is an effusion into the joint of a thick,
cloudy, serous exudation, which is not pus,
nor yet serum. In rhematoid arthritis every
component part of the articulation shows
symptoms of chronic inflammatory change.
There is the curious contraction, the char-
acter of which I am unable to describe ; the

position and shapes of the joints are altered ;
new growths of bone appear around the
heads of the small bones — for the smaller
joints are the ones generally affected ; the
articular cartilage is absorbed ; masses of
hypertrophied cartilage appear in the syno-
vial processes ; the articular cartilages relax,
and displacements and sub-luxations of the
unshapely bones occur. Crepitus can be
detected, until the process is so far advanced
that immobility exists.

In the case before us, which was sent to
us as a true example of this disease, there is
no bony enlargement, no crepitus on move-
ment, no sub-luxations, no disorganization
of the heads of the bones. It is rather a
case of chronic rheumatism with contrac-
tures than a good specimen of rheumatoid
arthritis.

Syphilitic Headache.

The next patient is a man, aged 30, whose
habits are fair ; he is a tobacco user and a
moderate beer drinker ; he has no especial
family history. He is said to have had ma-
laria in Italy thirteen years ago. On the
fifth of August he noticed a chancre;
this was followed by no secondary symp-
toms. On the morning of September 17 he
awakened with pain in the leg. This pain
spread to the lumbar region, and subse-
quently to the occipital region. It was
throbbing in nature, worse on movement
and at night. On admission he had no
fever, but on having his temperature taken
for the past two days, we found that it
ranged from ioo° to ioo-|0. All this time,
despite the use of anodyne and other reme-
dial measures, his condition grew worse.
He was unable to sleep and his general
health was beginning to suffer. The possi-
bility of the existence of headache due to
disease in other organs — the so-called sec-
ondary headaches — led to a careful study of
this man's condition. There was present
no gastric or intestinal disturbance which

9Q

Clinical

Lecture.

Vol. lxiv

would account for the symptom. His heart,
liver and kidneys were in good order. The
possibility of toxic headache being the real
condition then suggested itself. Malaria,
lead-poisoning, rheumatism, syphilis, the
early stages of the fevers — especially ty-
phoid— are all frequent sources of this trou-
blesome symptom. There is an old history
of malaria, thirteen years ago ; there have
certainly been rheumatic pains throughout
the body ; and he has had the primary le-
sion of syphilis. Rest in bed, with warmth
and diet, have brought relief from the pains
in the body of which he complained on his
admission. They were undoubtedly distinct
from his headache. The pain in his head
is localized in the occipital region ; it is
acute, and the spot is tender to the touch.
There is no trace of any malarial poisoning;
the spleen is not enlarged ; there is no cach-
exia or pigmentation ; the blood is in good
condition ; the man has been in the hospital
too long to think of the existence of any
of the specific fevers ; and no trace of lead-
poisoning exists. In obscure cases there
can be found frequently traces of trouble
which point towards rheumatism ; the fam-
ily history, the occupation, the large quan-
tity of uric-acid crystals in the deposits,
high color of the urine, or high specific
gravity, are all suggestive of rheumatic in-
volvement.

From the study of the case, we determined
that anti-syphilitic remedies should be tried.
This early in the course of syphilis, the use
of mercurials with the iodide of potassium
is indicated. This treatment has been tried
for a few days with the result that the man
has had two fair nights, when he experienced
sufficient relief from his pain to obtain con-
siderable sleep.

Malarial Cachexia.

The next patient exhibits such a degree of
pallor that we can at once decide that some
grave change must have taken place in the
economy. It is difficult sometimes to dis-
tinguish jaundice from anemia, which tends
towards sallowness. The patient, a man
aged 52, was born in North Carolina, and
was a resident of that State until within a few
months. He is a laborer, one of that class
which fills this hospital almost exclusively.
He has used alcohol moderately, tobacco
not at all ; which is somewhat remarkable
for a native of a tobacco-growing State. He
confesses to no venereal diseases. His fam-
ily history is exceptionally good; no history

of hereditary disease exists. Of course he
has been for years a constant sufferer from
malaria. He has lived for many years in
the swamps of North Carolina, where this
disease is indigenous. Although living
among the so-called " dirt-eaters " — people
of the region who have that unpleasant
symptom " pica," or a gnawing desire for
unnatural and unsuitable food — he is not
one of them. In July of this year he suf-
fered with chills every day ; at this time he
was taking quinine just as we would take
our daily bread. Under this extreme dos-
ing the chills appeared only every third day.
Suddenly, four weeks ago, these chills began
again every day, each day one-half hour
later. On admission the man was weak,
exhausted and breathless. Early the next
morning after admission he had a chill,
when his temperature went up to 1040;
later descending to normal. The next two
days he had no chill ; although on the sec-
ond day his temperature ran up to 1030, fol-
lowed by a profuse perspiration. His color
is striking ; it is a lemon-yellow, with the
sclerotic and mucous membrane of the con-
junctivae blanched. All the evidences of
anemia exist ; there are murmurs in the ves-
sels and heart, indicative of the poverty of
the blood.

In this case there have been found none of
the characteristics of malarial poisoning ;
the pigment, floating free or confined in the
corpuscles, is wanting. There are, however,
organic changes which show the influence
of long-continued malarial action. The
spleen is greatly enlarged. Normally it ex-
tends from the eighth to the tenth rib ante-
riorly in the mid-axillary line. In this man
it extends from the seventh rib to a point
nearly in a line with the umbilicus. It is firm,
hard, smooth and painless. The location of
the long axis of splenic dulness, running
from the axilla across towards the umbilicus,
making an acute angle to the axillary line
is diagnostic of enlargement of this organ.
The suggestion that this man's trouble is.
due to leucocythemia must not be over-
looked. The examination of the blood dis-
proves this possibility. That this is not
that form of pseudo-leucemia known as
Hodgkin's disease, will be shown presently,
in summarizing the forms of anemia. Arse-
nic and not quinine is indicated in such a
case.

The study of the causes, diagnosis and
coursa of the various forms of anemia is
most interesting and important. In the

Jan. 24, 1 89 1. Clinical

Lecture.

9i

first place, in the consideration of symp-
toms common to all forms of anemia, is the
study of pallor. Pallor, while a useful aid
in diagnosis is not an unvarying sign of
anemia. We can have considerable pallor
in the patient, when the examination of the
blood reveals the fact that it is normal in
quality and quantity. Of the other symp-
toms, shortness of breath and rapidity of
the heart's action are due to the lack of per-
fect oxygenation ; especially is this true
when the corpuscles, which are the oxygen
carriers, are diminished in number or power.
The coolness of the extremities is due to a
similar cause ; the giddiness to lack of
proper nutrition of the brain. In the clas-
sification of the divisions of anemias, great
confusion still exists. First, they are di-
vided into two great classes : primary and
secondary ; the primary are those which ex-
ist at once, and are due to disturbance in the
blood-making organs ; the second follow the
action of organic disease. A far better divi-
sion of these anemias is into idiopathic and
symptomatic ; the idiopathic arising from
the blood-making organs ; the symptomatic
being indicative of disease elsewhere.

Anemia is the want of blood ; its diminu-
tion in quality or quantity. The constituents
of the blood are so altered that it cannot per-
form its proper physiological functions.
Symptomatic anemia appears in the course
of such diseases as phthisis, interstitial
nephritis, wasting due to starvation, etc.
In phthisis it is true that there is some di-
rect loss of material in the discharges ; in
interstitial nephritis there is some loss of
blood in the albumin carried off in the
urine ; still the great source of anemia is in
the disease itself. There is always defective
assimilation and nutrition. In the toxemias
there is symptomatic anemia, due directly to
the destruction of the blood ; such forms are
seen in syphilitic, malarial, mercurial, arseni-
cal and lead poisoning. In the other great
division — the idiopathic anemias, there is
definite change in the blood itself, asso-
ciated with actual destruction of the corpus-
cles or with such change as prevents their
production, hemolysis (?) or hemogenesis.
The three great divisions of idiopathic ane-
mias are chlorosis, pernicious anemia and
the cytogenetic anemias. This latter form is
divided into leucocytic and non-leucocytic,
that is pertaining to the formation of leuco-
cytes.

The distinction between symptomatic and
idiopathic forms is as follows. There is some

reduction in the number of red corpuscles in
symptomatic anemia ; the hemoglobin is not
markedly reduced — the degree depending
on the amount of red cells missing. There
is no change in the character of the blood ;
no elements are gone, and no new ones are
introduced. In idiopathic anemia there is
definite change in the blood; there is dimi-
nution in the number of red corpuscles ; in
some forms there is increase in the number of
white cells. There is diminution in the rich-
ness of the hemoglobin. Then the corpus-
cles change in appearance ; instead of the
red corpuscles being round, they are all sorts
of shapes: larger, smaller, club-shaped, etc.,
forming the so-called Eichorst corpuscle.
There is a change in the power of the red
corpuscle to carry oxygen. The symptoms
are the same as seen in symptomatic forms,
differing only in degree.

In chlorosis, the number of cells remain
about the same, there being a fall in the
amount of hemoglobin, detected by the use
of the hemoglobinometer. The use of such
instruments of precision is essential in. for-
mulating a diagnosis ; it is required for the
definite discovery of the existence of chlo-
rosis. In pernicious anemia, there is marked
diminution in the number of red cells ; these
running down, in one report, as low as
143,000 to the cubic millimeter; 500,000
is a common count. The change in shape,
size and form is more apparent.

The names of "progressive" and "per-
nicious" applied to this form of anemia are
misleading. The disease is not always pro-
gressive, being occasionally intermittent,
and patients sometimes recover. As more
peculiar to this anemia are seen small,
spherical corpuscles, Eichorst' s being almost
pathognomonic of this trouble. Nucleated
red cells are also common. There are more
marked clinical features than in chlorosis ;
the pallor is different in hue, yellowish,
more suggestive of jaundice. There are
some anatomical changes due to the anemia.
Degeneration of the blood-vessel walls oc-
curs ; their tone is lost ; a fatty degeneration
of the intima occurs ; subcutaneous or sub-
mucous hemorrhage follows. This is espe-
cially well seen on examining the eye-ground
in the retina. With the hemoglobinometer
an increase in the richness of the hemoglo-
bin is found, despite the intense diminution
in the number of red cells. This is a most
striking difference between chlorosis and
pernicious anemia.

In the third class, cytogenetic anemia,

92

Communications.

Vol. lxiv

we have the leucocytic and non-leucocytic.
The leucocytic is further divided into the
splenic, medullary and lymphatic. The
principal anemia among the non-leucocytic
is the so-called " Hodgkin's Disease." Here
there is a hyperplastic enlargement of the
lymph glands with the development of ane-
mia.

Based on the combination of pathologi-
cal, clinical and physiological research,
Hunter, in London, has made a number of
remarkable observations. This observer was
anxious to determine the exact position of
pernicious anemia. He found in the urine
marked characteristics : a great destruction
of the red cells producing a high color with-
out alteration in the specific gravity. The
spectroscopic and chemical examination re-
vealed the fact that this pigment came from
the disintegrated blood. There was found
a great increase of iron in the liver, while
there was less iron in the other organs.
Normally there is a definite relation be-
tween the quantities of iron in the various
organs. In malaria, pigment is deposited
in the cells of the intima, along the course
of the blood-vessels. In progressive perni-
cious anemia, it is deposited — not in the
capillaries but in the liver-cells. It was
thought at first that the liver took up the
corpuscles themselves ; but later it was
proved that the liver-cells take up the pig-
ment directly from the portal vessels. This
condition is associated with carcinoma of
the stomach, chronic gastritis, atrophy
of the peptic glands, and other gastric and
intestinal trouble. The reason for this is
the development of specific ptomaines in
the intestinal canal, due to the presence of
parasites in this canal. Their destruction
should take place in the portal circulation,
depositing the iron in the liver. The in-
jection of certain chemical substances into
the blood will produce the same conditions
artificially. In one sense this idiopathic
disease is secondary to this process.

In the condition called paroxysmal hemo-
globinuria, there is destruction of the blood
with its appearance in the urine ; with this
may be associated intense anemia. Hunter
found that these changes occurred in the
general circulation, while in pernicious ane-
mia, as we have seen, they are limited to the
portal circulation.

— Lycopodium sprinkled on oiled silk
prevents the fabric from adhering.

Communications.

GENERAL CONSIDERATIONS ON
THE FEVERS OF THE SOUTH.1

BY GEORGE DOCK, M. D,,

GALVESTON, TEXAS.

The study of the fevers of the South
justly occupies a prominent place in the
medical mind to-day. In every society
meeting * papers are read and discussions
held; in almost every journal articles are
published bearing on this theme. Every-
where there is great zeal, often close obser-
vation and learned reasoning. Yet it must
be confessed, after a careful review of the
subject, that no advance is made in the ac-
curate knowledge of these diseases. But
little is added to what we have long known
of the nosology of the special fevers as they
occur in our latitude, and no progress is
made in clearing up the unsettled points re-
garding the anomalous or unclassified forms.
In every meeting statements concerning
even fundamental matters are met by counter
statements ; in almost every paper old hob-
bies are urged forward by vigorous hands,
often, it seems, " with more desire for vic-
tory than for truth." Yet how seldom do
we see the complete clinical history of a case,
or an analysis of cases ; how seldom a tem-
perature curve ; how seldom — nay, when do
we see the account of an autopsy?

It seems, then, in order to secure better re-
sults, we must follow different lines, and in
order to know more clearly what these shall
be it is necessary to recognize and avoid the
errors and short-comings of the past. The
most important of these I believe to be the
following :

1. Neglect to recognize and follow the
general principles lying at the basis of the
classification of fevers, and often the first
principles of pathological anatomy and eti-
ology.

2. Arbitrary or individual views of spe- j
cial morbid processes and a refusal to accept, !
for the purpose of organized work, the exist-
ence of certain conventional types.

3. A want of objective study, leading to
inaccurate observation of cases and loose orlj
general statements concerning them.

^ead at the meeting of the North Texas Medical
Association, held at Sherman, Texas, December, 1890.

Jan. 24, 1 89 1.

Com m unications.

93

4. An entire absence of anatomical basis
for theories or arguments advanced.

5. A tendency to apply novel and often
unfounded theories of pathology or thera-
peutics to the subject.

Examples of each of these errors could be
quoted from recent literature", but may with
propriety be omitted.

In considering them in detail, we find a
common example of the first kind exhibited
by a perversion or. confusion of certain tech-
nical terms, continued and remittent —
terms of no value in the ultimate classifica-
tion of fevers, but very useful clinically. This
trait is due partly to an attempt, misguided,
I believe, to do away with the distinction of
meaning which the two terms should convey.
That distinction was made long ago, but be-
fore the days of medical thermometry could
not always be observed in practice — an ob-
jection not valid to-day, when the thermom-
eter is consulted as regularly as the tongue.
It is urged with some ingenuity that, as all
remittent fevers are continued, in the sense
of having no stage of apyrexia, one of the
two words is superfluous. But one of the
commonest kinds of remittent fever, the ma-
larial remittent, is etiologically nearly related
to the most common and characteristic in-
termittent, while the existence of fevers prop-
erly called continued cannot be denied.
Now, as the question, whether the malarial
fevers ever follow a continued course (in the
narrow sense) has not yet been answered in
the affirmative, there is great reason why
both terms should not only be used, but be
used with extreme care for accuracy, follow-
ing the usage of correct writers. According
to this a continued fever is one in which,
during a part at least of the disease, the febrile
temperature pursues a course modified only
by such variations as occur in the normal
condition — that is, a difference of not more
than a degree Fahr. between the lowest and
highest daily range. Closely related is the
sub-continued type, where the variation is
greater but not so much as in the remittent,
when maximum and minimum differ by more
than two degrees, without, however, reaching
the normal.

This may. seem a matter of subordinate
importance. A more serious fault, the evil
effects of which are hard to throw off, is a
departure from the only safe guides to clas-
sification— anatomy and etiology. Hence it
is that our fevers have as many names as
they have local habitations, many of them
unintelligible outside of certain localities.

Another misconception of general principles
is shown by the argument so often used,
that a given disease cannot arise in a cer-
tain place on account of the absence of its
supposititious causative germ. In the pre-
sent state of our knowledge of pathogenic
organisms, such arguments are of no value
whatever.

Under the second heading, we find the
neglect or refusal to accept the delineations
of disease given by the masters of our art,
and tested fully in the clear light of patho-
logical anatomy. This is seen especially in
connection with cases of enteric fever, which
are so often the subject of needless contro-
versy, on account of false ideas of its natural
history.

„In the same category belongs a refusal to
accept as possible the occurrence of two
diseases in an individual at the same time,
important here because it leads to an errone-
ous position towards the compound affection
called typho-malarial fever. This curious
mental attitude is usually defended by an
appeal to the authority of John Hunter and
his "principle that no two different fevers
can exist in the same constitution, nor two
local diseases in the same part, at the same
time." From this direct quotation (Palm-
er's ed., vol. iii, p. 3, et seq.) it is a ques-
tion whether the "principle" would apply
to the case in point, for it might be urged
with great reason that one of the two dis-
eases takes place especially in the blood, the
other in certain organs of the abdomen.
But the " principle " itself is so at variance
with common observation, and with our
present ideas of pathology that it is difficult
to see how it can be seriously entertained.
As a matter of fact, the mixed infection of
enteric and malarial fevers, which was recog-
nized by such unbiased observers as Dick-
son, Drake, Flint and many others, and
worked out so impartially by Woodward,
has gone through the final stages in the de-
tection of the morbific germs at the hands
of Kinyoun ; and the question now is, not
whether there is such a combination, but
when, where and with what aspects it ap-
pears.

It is most unfortunate that the term typho-
malarial is applied to a condition entirely
distinct from the one just mentioned, viz.,
when a malarial fever assumes the typhoid
condition, the word being used after the
analogy of typhoid-pneumonia. When such
a use is justified by facts (it has not yet been
satisfactorily demonstrated that it ever is)

94

Communications.

Vol. lxiv

and the person using it makes his meaning
clear, no great harm results, though the prac-
tice is not worthy of perpetuation.

Other errors are seen in the use of such
terms as "catarrhal fever" for conditions
very different from those described under
that name in text-books, and often without
notable catarrhal symptoms; "bilious
fever" when there is no "biliousness,"
etc. Of course, owing to the difficulties of
diagnosis, such terms serve a purpose in in-
tercourse with the laity, but that they should
be used in technical articles is a matter of
distinct disadvantage.

In discussing the evils resulting from in-
accurate observation, I speak with great re-
luctance. Skepticism of the observations
of others, if carried too far, destroys all
possibility of united work ; and yet a great
deal of erroneous observation and still more
erroneous deduction takes place. Combined
with arbitrary views of special diseases it has
been productive of great confusion. As an
example of this, the following experience,
not by any means unique, may be cited :
Some months ago a patient was sent from
the interior of Texas to Galveston, with the
written diagnosis of " continued malarial
fever" from the local physician. This
name, not used by systematic writers, is in
common use in some parts of the country,
and it is maintained by many who use it
that such cases are neither malarial proper
nor enteric. These cases are comparatively
common in the place whence the patient
came, so I think we may assume that the
one under consideration represented the dis-
ease so called. In Galveston, however, the
attending physician looked on the case as
one of enteric fever, and when the patient
died, a few days later, requested me to make
an autopsy. At that I found the complete
anatomical picture of enteric fever, without
a trace of recent or old malarial infection.
The specimens are here for your inspec-
tion.

This brings up the subject of anatomical
investigation, ' the neglect of which is not
altogether owing to prejudice against such
practice on the part of the laity. It is an
interesting fact that those who most strongly
argue for the non-existence of old diseases
and the occurrence of novel forms are those
who pay least attention to the teachings, of
anatomy, though it cannot be said they do
not have fatal cases in which to study it.

The application of novel theories in pa-
thology do no great harm, but they seem to

direct attention from the more tangible parts
of the subject.

As intimated by the title, it was the ob-
ject of this paper to call attention to facts
of wide application, rather than to discuss
the minutiae of special pathology and dif-
ferential diagnosis. Yet there are many
things in these latter branches too often neg-
lected in the study of our fevers, especially
some aids furnished by modern instruments
of research — -the microscope in particular.

To sum up in a few words the best means
of increasing our knowledge of fevers, I
would suggest, in the first place, a familiarity
with the classical description of fevers given
by clinicians whose experience and judg-
ment make them authorities, controlled and
extended by observation at the bedside and
the autopsy table under experienced instruc-
tors. Next, an objective and critical study
of every case of fever, with the assistance of
all the methods of exact diagnosis; and a
thorough study of every fatal case, with the
application of all the modern means of in-
vestigating anatomy and etiology. Working
on these lines ; keeping the anatomical limit
where possible, and, where not, preferring
rather such non-committal terms as " simple
continued ' ' than those expressing supposed
etiological or anatomical characters, a com-
paratively short time would show such pro-
gress in diagnosis, with consequent increased
certainty in treatment as has not been at-
tained by following subjective methods.

THE CURETTE IN FISTULA IN
ANO.1

BY BEN. BRABSON CATES, M. D.,

DEMONSTRATOR OF ANATOMY AND OF OPERATIVE
SURGERY IN THE TENNESSEE MEDICAL COLLEGE.

All patients naturally loathe the idea of a
cutting operation, be it ever so slight, and
will undergo a great many inconveniences
as well as endure an immense amount of suf-
fering, rather than submit to the surgeon's
knife. While I would not be understood as
belonging to that class of physicians who
are slow to use the knife when circumstances
demand it, yet in certain cases of fistula in
ano I should endeavor to effect a cure with
the curette, which in the end is a cutting

1 Read before the Knox County Medical Society, at
Knoxville, Term.

Jan. 24, 1891.

Comm unications.

95

operation, as it effects a cure by scraping
away the tough and thickened pyogenic
membrane, thereby substituting for it a
healthy surface which heals readily. More-
over, the term "curette" is better received
by the patient, who is ignorant of its real
nature. Indeed he will actually regard it
with favor, and gladly welcome it as a sub-
stitute for the knife.

In offering to the profession this mode of
curing fistula in ano, I do not claim for it
any superiority over the knife, or that it will
ever supersede it (believing, as I do, in cases
which will never be cured except by a resort
to the knife or ligature) ; nor do I come with

j a long list of cases cured by this method ;
but I present the subject on its merits, hop-
ing that, like "seed sown in good ground,"
it will find a nidus in a fertile spot, which

1 will give us, at some future time, sufficient
data upon which to base an opinion in sub-

1 sequent cases.

The cases for which I would recommend
the curette in the treatment of fistula should,
for obvious reasons, be select : such as in-
cipient fistula in ano, or those cases after a

, resort to the knife in one or more sittings,
in which healing has taken place in all por-
tions of the wound except at a small tract

, no larger than a knitting needle or a crow's
quill ; or even in cases of fistula with two
or more sinuses it might be tried. Again, I
think it is applicable in cases in which the
fistulous tract shows a tendency to fill up
from the bottom, and buoys the hopes of
the surgeon to that point where he thinks
he can dismiss his patient as cured, but in
which he will notice after careful examina-
tion the least possible drop of pus at some
portion of the cicatrix, and should he at-
tempt to examine it with the probe, will find
to his horror that it passes into a cavity of
considerable size, which is generally barrel-
shaped or fusiform. Here it is that the
curette is of especial value, as in the follow-
ing case, sent me by my esteemed friend,
Dr. J. M. Kennedy. K

The patient was a negro man, about
twenty-two or twenty-four years old, and a
laborer, who had been troubled with fistula
in ano for two years. On examination, I
found a large abscess cavity on the left but-
tock, with four openings, all discharging a
thin offensive fluid, and one sinus extending
into the rectum, just within the verge of the
anus. On November 14, 1889, in the pres-
ence of Dr. Kennedy, I laid open the ab-
scess cavity and all sinuses leading into it,

washed it out thoroughly, and packed it
with lint. The abscess cavity had a worm-
eaten, or honey-comb appearance, and was
covered with a thin, dirty-looking exudate.
The cut edges of the wound were exceedingly
rotten and, on pressure between the fingers,
could be readily crushed like a mushroom.
I saw the patient each succeeding day for
the first week, and then gradually length-
ened the number and frequency of my visits,
washing out and packing the wound each
time I saw him. The wound healed readily
except a single fistulous tract, which ex-
tended up in the ischio-rectal fossa for about
two inches.

On December 20, I again operated, mak-
ing a complete fistula by pushing the grooved
director through the gut into the rectum
above the internal sphincter, bringing it out
at the anus, and dividing all the tissues on
the director ; afterwards I stuffed the cavity
with lint as in the previous case, after hav-
ing thoroughly curetted it. This second
operation was followed by incontinence of
feces and an involuntary escape of flatus,
which disappeared however in a few days.
The wound healed rapidly, except the fistu-
lous tract, which was unclosed as before the
operation.

On March 13, 1890, after having injected
a drachm of a saturated tincture of iodine
into the fistula, I placed the patient on his
feet and let him walk about, he having been
in bed for nearly four months. On March
15, I gave another injection of the iodine
solution, with negative results. On March
27, I injected a four per cent, solution of
cocaine into the fistula, which deadened
sensibility completely; then, taking my
probe-pointed bistoury, I enlarged the open-
ing leading into the fistula sufficiently to in-
troduce a curette, and having thoroughly
scooped it out and irrigated it with simple
pure water, I packed the wound with lint.
I dressed the wound each succeeding day.
On May 3, I repeated this operation, and
again on June 2, all the while allowing my
patient to go about and do as he pleased.
On June 23, after having examined the
wound and found it had healed in every
part, I dismissed the patient as cured ; and
he remains well to this day.

The main reason I have for presenting
this paper before this Society is to show
that, even after one or more cutting opera-
tions have failed, or the application of a
strong irritant is nil, a cure may be obtained
by other means than the use of the knife or

96

Communications.

Vol. Ixiv

an irritant. Again, when, after repeated
failures, the surgeon may be unwilling to
recommend another formal operation to a
doubting patient, and thereby risk estab-
lishing incontinence of feces or incurring
the reproaches of an ungrateful patient, he
may have recourse to the curette; which his
patient will readily submit to, more espe-
cially, if assured that it will be a painless
procedure.

Therefore, after having thoroughly tested
the curette, in a case which had not only
resisted the knife in two formal sittings and
two applications of a strong irritant, but
had also tried the souls of both physician
and patient, I am persuaded that, in certain
select cases, such as incipient and external
blind fistula, etc., the curette will in the
future be the means of curing a good many
fistulas, and will thus deliver our patients
from that horror of men — the knife.

DIPHTHERIA.

BY C. W. MUSGROVE, M. D.,

LOCK HAVEN, PA.

Diphtheria, in its pathological relations,
has been and is still quite complicated in
some respects. However, one important
factor — the cause — seems to have been set-
tled as being a diphtheritic microbe. But
there still remains an important point to be
determined. All our leading pathologists
agree that two distinct conditions exist :
the local and the constitutional, in an indi-
vidual afflicted with this diphtheritic mi-
crobe. But which is primary and which is
secondary, is the question that agitates the
minds of the pathologists to-day. The
opinion of Loeffler on this important ques-
tion is worthy of serious consideration. He
says: "The bacillus is abundant in the
pseudo-membrane, but is not found in the
blood-vessels, lymphatics or internal organs ;
so that its pathogenic action must be local-
ized on the surface. If it be the specific
principle, it must act by producing a poison
where it is localized, which poison causes
neurosis and dilatation of the vessels, from
which lymph exudes, and entering the lym-
phatics and circulatory system causes sys-
temic infection. ' ' W. Watson Cheyne recog-
nizes the importance of LoefHer's researches
and thinks it probable that the micro-organ-
ism which causes diphtheria is a bacillus,
which, lodging upon the throat, is propa-

gated there. Having upon the mucous sur-
face a favorable nidus for its development,
it not only lies upon, but also penetrates the
superficial portion of the mucous layer, and
causes the exudation of fibrinous material.
He furthermore believes it probable that the
bacillus produces very poisonous ptomaines,
which, entering the circulation, give rise to
general systemic infection. That the bacillus
is the causative agent of diphtheria is ren-
dered probable, and that systemic infection
by the diphtheritic poison is not produced di-
rectly by the entrance of the microbe into the
circulation, but by ptomaines which spring
into existence through the agency of the
microbe, is also the opinion of some of the
highest authorities in the study of bacteria.
It seems to be accepted as a fact that this
microbe is capable of setting up a local
diphtheritic action in any portion of the
body where it finds an inflamed, denuded
or cut surface upon which to lodge ; also
that the microbe requires favorable sur-
roundings for its nidus and propagation.
Is it not then probable that this diphther-
itic microbe requires the identical material
found in the throat ; such as saliva, etc. , in
connection with the results of catarrhal af-
fliction in said region, which are so very
prevalent? The principles of medicine teach
that, as a rule, two causes are necessary for
the production of disease : the predisposing
and the exciting cause ; also that a resisting
force exists in the constitution under peculiar
conditions.

Diphtheria is classified as an extremely
contagious disease ; however we frequently
find persons fully exposed to its morbid in-
fluence who escape its evil effects entirely.
On the other hand, we find persons only
slightly exposed, who become victims of the
disease in its most severe form. In such in-
stances we have a complete manifestation of
a resisting force, and the predisposing and
exciting causes displayed ; now if this resist-
ing force did not exist in the individual,
all persons exposed would be sure victims of
the disease. This of course applies not only
to diphtheria, but to all contagious, and
even to other diseases. In diphtheria we
find the constitutional, and local condition
markedly distinct ; so much so, that a per-
son may have the disease locally, beyond
doubt, with the constitution but slightly
affected. We know, futhermore, that diph-
theria never exists as a constitutional disease
unless the local disease is present.

But that the local disease can exist with-

Jan. 24, 1 89 1. Communications.

97

out affecting the constitution, but very
slightly, we also know. In no contagious
disease do we have the same opportunities
for observing and comparing local morbid
conditions with the constitutional condition,
as in diphtheria. Membraneous croup does
not present the same opportunity, for the
reason that the local condition is more out
of sight. It is true that the local predis-
posing cause is present ,in the throat, but
the constitutional effect is that which is pro-
duced by any interruption in the function
of the lungs, while in diphtheria we have
the neurasthenic condition to contend with
in the general system. In other diseases we
have the predisposing cause in the individ-
ual for the exciting cause to act upon. But
when such is the case, if is from the fact
that the constitution is rendered vulnerable
by some abnormal condition existing in the
blood or organs, this producing the pre-
disposing cause. In diphtheria we may have
the predisposed cause in the throat as a local
catarrhal inflammation or even a denuded
surface. It is fully accepted as a fact that
the diphtheria microbe will attach itself to a
denuded surface in any part of the body,
and the throat being subject to slight
catarrhal inflammations at least two-thirds of
the time, the throat is a most suitable nidus
for the diphtheritic microbe, and it is in the
throat that the physician finds the first phy-
sical sign with which to make the diagnosis
of diphtheria. When we consider the prin-
ciples of medicine in connection with the
opinions of authorities such as Loeffler and
Cheyne, who declare, that they believe the
bacillus to be the exciting cause of diph-
theria, and that they have never found the
bacillus beyond the psudo-membrane in
the throat, we have excellent reasons for
concluding that the local or throat conditions
in diphtheria is primary, and the constitu-
tional affection is secondary. From this it
follows that our aim in treatment should be
to suppress the local condition and to
support the constitution in its resistance to
the invasion of the poison.

— In using chloroform as an anaesthetic the
decomposition of the vapor in the presence of
artificial light, especially gas, produces irrita-
ting and noxious fumes. These have been an-
alyzed by Kunkel and found to consist prin-
cipally of hydrochloric acid. Where free
ventilation is not possible, water or lime-
water, or a solution of soda, exposed in a
basin or sprayed will neutralize the acid.

DISEASES OF THE EYE ASSOCIATED
WITH CARIES OF THE
VERTEBRAE.1

BY JAMES K. YOUNG, M. D.,

INSTRUCTOR IN ORTHOPAEDIC SURGERY IN THE UNI-
VERSITY OF PENNSYLVANIA; ATTENDING
SURGEON, ORTHOPAEDIC DEPARTMENT,
UNIVERSITY HOSPITAL, ETC., ETC.

The diseases of the eye, associated with
caries of the spine, are, from necessity, of
the same pathological nature — strumous or
tubercular. The occurrence of ophthalmic
affections, in certain cases of spinal caries,
has frequently been observed, and the di-
rect association has been frequently noted.
It is impossible, in this connection, to
sketch the more important lesions met with ;
suffice it to mention the various affections,
pointing out those which have a particular
significance bearing upon the relationship
existing.

Among the most frequent diseases affect-
ing the lids and lachrymal apparatus are the
various forms of conjunctivitis (acute and
chronic), eczema, lupus or scrofulide tuber-
culeuse, and dacryocystitis. Of these, lupus
is' one of those lesions which may be the
only evidence of a tubercular condition,
and although its tubercular nature has been
doubted by Kaposi, for well-known reasons
(" because of the paucity of the bacilli in
the morbid changes, the non-appearance of
general tuberculosis in the same individual
after a long duration of the lupus, the im-
possibility of multiplying lupus by inocula-
tion, and the almost universal immunity
from lupus of other members of the same
family ")2, anatomically it contains tubercle-
bacilli ; and tuberculosis can be reproduced
by its inoculation. The presence of lupus
is peculiarly significant of struma.

Affecting the anterior portion of the globe
is that peculiarly interesting affection —
phlyctenular disease, and phlyctenular kera-
titis, with their periods of exacerbation and
improvement, almost peculiar to the stru-
mous diathesis. Hypopium keratitis, ulcus
corneas serpens, as the result of dacryocys-
titis, episcleritis, scleritis, sclero-keratitis,
and even staphyloma of the sclera, are met
with as direct evidence of a scrofulous dia-

1 Read before the American Orthopaedic Associa-
tion.

2 Jacobi, Keating 's Cyclopedia of Diseases of Chil-
dren, Vol. ii, p, 173.

98

Communications.

Vol. lxiv

thesis. Particularly significant in this por-
tion of the eye is the so-called iritis serosa —
formerly known as Descemetitis, a strumous
lesion of the iris, involving frequently the
ciliary body and deeper structures ; and
tubercles of the iris, or, as it was formerly
called, granuloma.

The former affection, or scrofulous iritis
as Vernon1 called it (retaining the name
employed by Mackenzie and others), has
not received, in late years, from ophthal-
mologists, the attention it deserves. In
fact, Vernon has spoken particularly of the
unsatisfactory and inexact state of our
knowledge as regards tubercular affections of
the eye in his former paper.2 The nodules
attached to the iris in this disease, upon
microscopical examination, have been found
to consist of " small nucleated cells, with
many free nuclei, and a very scanty inter-
cellular stroma, with debris of cells, but
without blood-vessels or pigment." These
cases cannot be classed in the category
of iritis, as generally observed, on account
of the early age at which they make their
appearance, the futility of therapeutic meas-
ures, and the danger to life.

. The true tubercular affection resembles
somewhat the serous iritis in general course,
symptoms, etc., and may even terminate in
destruction of the globe. The tubercles of
the iris found in this disease, and formerly
described as granuloma, differ, however, es-
sentially from the nodules found in serous
iritis ; but their true nature is perfectly
identified by recognizing the characteristic
bacilli. The posterior portion of the eye,
or deeper structures, are less frequently af-
fected, and when diseases do occur as pri-
mary lesions, they present no distinctive
features. Among these may be mentioned
tubercles of the choroid, as a result of gen-
eral miliary tuberculosis, and especially of
tubercular meningitis; and choroido-retin-
itis, alone, or associated with optic-neuritis.

It will be observed in this enumeration of
the diseases of the eye associated with spinal
caries, that the majority, and certainly the
constant ones, are all of the strumous or tu-
bercular nature ; and this introduces us to
the relationship of these two conditions and
the significance of these diseases to the osse-
ous lesion progressing within. Referring to
the relation between scrofula and tubercle,

1 Vernon, British Medical Journal, 1 874, Vol. ii, p.
276.

2 Si. Bartholomew 's Hospital Reports, Vol. vii. .

Treves has given the following conclu-
sions -}

1. The manifestations of scrofula are
commonly associated with the appearance
of tubercle ; or if no fully formed tubercle
be met with, a condition of tissue obtains
that is recognized as being preliminary to
tubercle. Anatomically, therefore, scrofula
may be regarded as a tuberculous or tuber-
cle-forming process.

2. The form of tubercle met with in
scrofulous diseases is usually of an elemen-
tary and often of an immature character,
whereas in diseases called tuberculous in a
strict clinical sense, a more perfect form of
tubercle is met with in the form of the gray
granulation or adult tubercle. (Grancher.)

3. Scrofula therefore indicates a milder
form or stage of tuberculosis, and the two
processes are simply separated from one an-
other by degree.

Accepting this view there is, in other
words, in scrofulous persons a constitutional
predisposition to caseation, or a tuberculosis
of irritated parts. When the bacillus tuber-
culosis is actually present in the diseased
area, scrofulosis has been succeeded by
tuberculosis. In etiology most of these dis-
eases of the eye are scrofulous rather than
tubercular, possibly from the fact that,
being more superficial and accessible, atten-
tion is earlier directed to them.

In this connection it is interesting to ob-
serve an antagonism, not absolute, but tol-
erably well established, which seems to exist
between the external and internal tubercular
processes. This is why phthisis is not more
frequent in subjects of hip disease, why sub-
jects with external cervical gland disease are
not more often attacked with pulmonary tu-
berculosis, and why subjects with angular
curvature (caries of the vertebrae) are not
more commonly attacked by it. It is be-
cause of this apparent antagonism that exists
between the tubercular diseases, that it is,
moreover, unusual for two grave manifesta-
tions of scrofula to be active at the same
time — one will become manifest, while the
other is observed to improve or subside.
This observation is particularly to be noted
in the associations under consideration. It
is common to observe the ophthalmic dis-
eases improve or subside altogether while an
exacerbation of the osseous affection super-
venes, and vice versa. It may be consid-
ered, then, as established that the majority

Scrofula, etc., London, 1882, p. 21.

Jan. 24, 1 89 1. Reports of Clinics.

99

of cases of spondylitis are tubercular ; that
the etiology of these diseases of the eye and
of the caries is the same (J. e., insufficient
diet and infection) ; and that they are both
liable to exacerbations.

These facts taken altogether have a pecu-
liar significance, and indicate a prophylaxis
and a necessity for treatment which might
otherwise be overlooked.

There is constantly going on, in the
economy, a warfare by the active, healthy,
cellular structures which compose the human
organism, against the invasion of parasites.
Whether the claim of Metschnikoff be ac-
cepted, that the degeneration of the bacilli
(which has long been known to occur
within the giant cells), results directly from
this phagocytic action ; whether the state-
ment of Baumgarten be admitted, to regard
the relation of the giant cells to the bacteria
as one of the strongest evidences against
the theory of phagocytosis ; or whether the
agnostic expression of Osier be taken as the
present state of our knowledge — the indica-
tion to employ both constitutional and local
treatment deserves emphasis.

In conclusion, if this short paper convert
but one practitioner to the importance of
treating all localized tubercular lesions with
constitutional as well as local treatment,
the object for which it was written will have
been accomplished.

To summarize, then,

1. The diseases of the eye associated with
caries of the vertebrae are scrofulous or tu-
berculous.

2. Scrofulosis is a predisposition to casea-
tion ; tuberculosis is the infection with
tubercle bacilli.

3. Both the diseases of the eye and the
caries of the vertebrae require constitutional
as well as local treatment.

Reports of Clinics.

buffalo general hospital.

MEDICAL CLINIC— DR. CHAS. GARY.

The first patient had been before the class
already. He was admitted two months ago,
suffering with uremic poisoning. At one
time the urine fell to 170 c. c, with 4 grams
of urea in the twenty-four hours. Dr. Cary
said that he was brought before the class
now, more to show what humanity can en-
dure than for further elucidation of the case.

He had had oedema and ascites, which grad-
ually diminished as the condition of the
urine improved in quantity and quality.
Albumin was still present in large amount.
The first examination impressed Dr. Cary
with the idea that there was something be-
hind the maladies which were apparent, and
he had therefore examined him daily, and
every two or three days there had been some
new development. He had had pericarditis
with a most marked friction sound, which
disappeared before the day on which the
ward-class was to examine him, but which
had reappeared, and it was now heard in-
distinctly. He also developed endocarditis.
The liver was at one time lower than nor-
mal ; then it returned to its normal posi-
tion ; and now it was down again. The
liver was depressed in position rather than
enlarged, and the change of position was
due to the varying quantity of fluid in the
right chest — for the man had had pleurisy
of both sides with an abundance of effu-
sion. The presence of pain and fever and
the development of inflammation of the en-
docardium and pericardium determined the
diagnosis of pleurisy instead of hydrothorax.
The man also had a pneumonia of the left
lung.

The patient was a mere shadow of his for-
mer self. When first presented to the class
his legs were enlarged from the dropsical
effusion ; now there had been not only an
absorption of the effusion, but also a wast-
ing of the muscles, so that he was reduced
almost to a skeleton. During the course of
the pericarditis he had received small doses
of opium and mild counter-irritation, about
rather than over the pericardium. The ef-
fusions had been carefully watched, so that
aspiration might be performed if necessary ;
but they had been reduced by salines instead,
and when they had become slight nothing
had been done for them. On account of
the chronic renal disease, there was no pros-
pect of the patient's recovery, and the fact
that his life had been prolonged by good
nursing and symptomatic treatment was
really no benefit to one in his deplorable
condition.

Rheumatoid Arthritis,

The next patient was a single man, thirty-
four years old, though appearing much older.
He was born in Buffalo of Irish parents. He
had been a hired man on a farm. His fam-
ily history was wholly negative. He had
enjoyed fair health until two years ago. Five

IOO

Reports of Clinics.

Vol. lxiv

years ago, while killing hogs, one of the pigs
pressed his right knee against a pump-spout,
causing considerable pain but no disable-
ment at the time. Two weeks later the knee
became sore and slightly swollen on the in-
side. He did not consult a physician, but
relieved the pain and swelling by using a
liniment. The knee gave him no further
trouble for two years, when the symptoms
returned spontaneously but without confin-
ing him to the house. The knee improved,
but did not become entirely well ; and a
third attack confined him to bed for three
or four weeks, the right knee being much
inflamed and swollen, and the left partici-
pating to a less degree. A physician aspi-
rated both joints. Even before the knee-
joints were so badly swollen as to need tap-
ping, the wrists, elbows and right ankle
began to swell.

The man had had gonorrhoea eight years
ago, lasting seven days, and without recur-
rence. The beginning of his trouble could
not, therefore, be a gonorrhseal synovitis.
His countenance, sunken eyes, flushed
cheeks and coated tongue indicate that he
is suffering from some constitutional disturb-
ance. His left pupil was shaped like an old-
fashioned kite, curved above and coming to
a V below. This suggested iridectomy, but
the man said the condition was congenital,
and that the vision of this eye was better
than that of the right. Syphilis was denied.

The knees were much enlarged, the pa-
tella was three or four times its normal size
and the swelling, especially at the inner
side, was soft and fluctuating. Under the
finger there were movable masses, undoubt-
edly of cartilage, which could be chased
around by the finger. There was a parch-
ment-like crackling. The legs were mark-
edly atrophied.

A similar enlargement was present to a
less degree in the ankles, wrists, elbows and
metacarpo-phalangeal and many of the in-
terphalangeal articulations. There was also
muscular atrophy of the arm and forearm.

This, said Dr. Cary, is the disease called
rheumatoid arthritis or arthritis deformans,
or, by some, rheumatic gout, which is not
a classical name. It is an essentially chronic
disease prevailing much more among the
poorer classes than among the well-to-do ;
for which reason it has been described as
the arthritis of paupers. A clean-cut differ-
entiation between this disease and rheuma-
tism cannot be made, any more than be-
tween acute and chronic rheumatism. If

this man had been brought before a class
two years ago, he might have been used to
illustrate chronic rheumatism, and his first
serious attack of inflammation might possi-
bly have been erroneously described as acute
articular rheumatism ; but at this stage the
diagnosis is unmistakable.

Rheumatism is a disease that attacks only
fibrous structures, sometimes the synovial
membrane, sometimes the ligaments of a
joint, sometimes the pericardium, heart-
valves, pleura, etc. Chronic articular rheu-
matism damages a joint more by the pro-
duction of fibrous ankylosis than by causing
any definite pathological alteration. In this
disease there is an absolute inflammatory
growth of bone. There is an inflammation
of the cartilages, so that they enlarge and
form nodules projecting into the joint cavity
under the synovial membrane, and fragments
may then break off and lie loose in the fluid
of the joint. The deeper layers of cartilage
become more bony, and the superficial lay-
ers soften, so that the cup which the cartil-
age forms on the end of a bone becomes
deeper. There is an enlargement of the
ligaments about the joint, and even the
synovial fluid is increased, and it is usually
thick, dark and almost mucoid. Later in
the disease the muscles take on spasmodic
contraction. This man has never had
cramps ; but, as he stands, the muscles of
the leg are in a state of tension, and com-
plete extension of the leg is impossible.
The elbow also cannot be flexed and ex-
tended as widely as it normally should.

This disease was described even in the
last century, although under a different
name. The cases are usually not seen so far
advanced as this one.

What is the poison to which the disease is
due ? Many contradictory answers have been
given. Some claim that it is due to sepsis,
citing those cases which begin with gonor-
rhoea! arthritis as proofs. Others say that it is
tubercular, one member of a family having
this form of arthritis while another has typical
tuberculosis. It is not probable, however,
that there is any such close connection, al-
though tuberculosis may arise in a joint
already diseased in this way. Others claim
that it is due to faulty nourishment, bad air and
unfavorable environment. This is certainly
true ; but is not a complete explanation.

Not uncommonly the heart is diseased
along with the rest of the connective tissue
structures. This patient has a mitral regur-
gitant and an aortic obstructive murmur.

Jan. 24, 1 89 1,

Periscope.

101

Treatment is not very promising, mainly
because the persons affected are usually un-
able to follow the directions which would
naturally be given. Massage, sojourns at
Vichy, Carlsbad, Saratoga, etc., are quite
beyond their means. The taking of plenty
of good rich food is beneficial — quite the
Contrary of the indication in rheumatism.
Iron is serviceable. The skin, bowels and
kidneys should be kept active.

Acute Endocarditis.

The history of this patient was as follows :
J. G., twenty-five years old, single, born in
this country of Irish parents, laborer. His
father, fifty years old, had had rheumatism
a great deal. The mother died at the age
of thirty-six years, of some acute disease.
Four brothers and one sister were alive and
in good health. The patient had had vario-
loid and measles in childhood, malarial fever
eight years ago, gonorrhoea six years ago,
chancroid or perhaps chancre five years ago.

He had indulged for six years in periodi-
cal sprees. His general health had been
good. About four weeks ago he got wet
and took cold. He became better, but then
had pain in the back and shoulders, which
were still lame and painful. He had been
rather short of breath for about a year. His
urine was yellow, faintly alkaline, urinous in
odor, with a specific gravity of 1.017, de-
positing considerable white sediment, but
without albumin or sugar. The man's tem-
perature on admission was 98. 20, his pulse
94, his respiration 20. He had an eruption
on his arms which he said came out when
his blood was out of order. He had been
taking " blood medicine. ' ' There was a his-
tory of a sore on the penis, which was de-
scribed as a soft chancre. His hair had not
fallen out, nor had he had sore throat, etc.
Dr. Cary said that he probably had had
syphilis.

When he entered the hospital the man
had a loud mitral regurgitant murmur, and
as there was no cardiac hypertrophy, and as
he never had rheumatism before, acute en-
docarditis was diagnosticated. Rest and sa-
licylates were ordered, and later iodides
were added. He had lost the pain in his
arms and shoulders and the murmur had al-
most disappeared.

— -The Malabar nut of East India is in
vogue amongst the natives as a cure for
scald-head and other microphytic skin dis-
eases.

Periscope

Treatment of Hemorrhoids.

In an article in The Cincinnati Lancet-
Clinic, November 29, 1890, Dr. L, J.
Krouse gives a summary of the treatment of
hemorrhoids, in which he says :

The ligature dates its origin back to the
time of Hippocrates. His method consisted
in applying a woolen thread as ligature to
the base of the tumor, and then cutting off
the strangulated mass. This method, with
some improvements, has been handed down
to our own times, and has been brought
more into favor by Allingham. His method
is to have the bowels first thoroughly moved
by a cathartic, and shortly before the opera-
tion a large enema should be given, both
for its cleansing effect as well as to bring
the piles well into view. While the patient
is straining, each pile should be caught sep-
arately by a tenaculum. Acting on the
anatomical knowledge that a pile is sup-
plied by a blood-vessel which enters from
above, he cuts the pile loose from its attach-
ment below and then dissects up the mass
to about the point where the blood-vessel
enters. A ligature is then thrown around
the pedicle and the mass is cut off. If the
pile is very large, it is divided into two or
more segments by transfixing the mass with
a needle armed with a ligature, and each
segment is separately tied. The stump is
then returned within the sphincter. This
method is the one that is most commonly
used, and requires from ten days to two
weeks' confinement to bed, and frequently
necessitates the use of the catheter.

The clamp and cautery method was first
used in London, in 1848, by Mr. Lee.
His plan of treatment consisted in applying
a clamp to the base of the tumor, cutting
off the greater portion of the protruding
mass, and then applying nitric acid to the
raw surface. Mr. Henry Smith, of the same
city, has used this method for many years,
and has improved it by using the actual
cautery instead of nitric acid to the raw
surface. " The method of using the clamp,"
he says, " is very simple, and consists of the
following manoeuvre. The diseased portions,
being well brought down previously by an
injection, are separately seized with a vul-
sellum and handed to an assistant. The
part is then enclosed within the blades of the
clamp, which are screwed home quickly and
thoroughly. The prominent portion of the

102

Periscope.

Vol. lxiv

pile or prolapsus is then cut away by a sharp
pair of scissors. The cut surface is next
dried by a piece of lint or sponge, and
either nitric acid or the actual cautery, so
shaped as to come into contact with the
whole of the raw tissue, is applied. When
this is effected the blades are gently and
slowly unscrewed, and, if there is no bleed-
ing, the part is well oiled and allowed to re-
turn within the cavity of the gut ; if, how-
ever, any bleeding point is seen, the blades
are quickly screwed together and the cautery
applied until the vessel is thoroughly sealed
up. The finger is then introduced well up
into the rectum. This step serves the triple
purpose of returning all the parts well, of
compressing any point which may possibly
bleed, and of exciting the sphincter to
healthy action."

More formidable than either of the preced-
ing methods is that which goes under the
name of Whitehead's operation. It con-
sists of the removal of the entire pile-bear-
ing region. A circular incision is made
around the anus at the junction of the skin
and mucous membrane, and an inch to an
inch and a half of the mucous membrane of
the lower part of the rectum is removed.
Only the affected and diseased mucous
membrane with some of the submucous
tissue, is excised, the other coats of the gut
not being interfered with. The healthy
portion of the mucous membrane above is
then brought down and is attached to the
skin of the anus. An ideal surgical proced-
ure ! This operation is limited to those
cases of severe type, where the whole cir-
cumference of the gut is studded with piles.

Leaving these more severe surgical opera-
tions, which require the patient to be under
the influence of an anaesthetic, we come to
the simpler methods, which ean be readily
done in the physician's office, and which
most physicians rather prefer, as no blood
is spilt.

The injection method consists of injecting
a certain amount of a coagulating fluid into
the pile by means of a hypodermic syringe.
Different surgeons use different fluids. Kel-
sey employs carbolic acid in 15, 33, 50 and
95 per cent, dissolved in water with enough
glycerine to keep the solution clear. Dr.
Fenn's solution consists of equal parts of
fluid extract of ergot and a 95 per cent, solu-
tion of carbolic acid. Dr. Washburn uses
a solution of carbolic acid in sperm oil in
the proportion of 1 to 2 or 1 to 4, depend-
ing upon whether he wishes to produce slough-

ing of the tumor or only induration. Givard
employs a solution consisting of tannic acid
one part, carbolic acid two parts, alcohol
four parts, and glycerine eight parts. The
injection fluid used by those that follow the
so-called ' ' Brinkerhoff system ' ' is composed
of carbolic acid %i, olive oil £v, and zinc
chloride grs. viii.

Electrolysis has been used to destroy these
tumors. The positive electrode, which is a
needle, is introdnced into the centre of the
tumor, while the negative pole is placed on
an indifferent portion of the body. A cur-
rent strong enough to produce a caustic
effect should be used.

Having mentioned the various modern
methods in use for the destruction of these
tumors, it behooves us to analyze which of
them is the safest for the patient, and which
will cure him in the shortest time.

Henry Smith, in his report of over four
hundred and fifty cases, in which he ap-
plied the clamp and cautery, not only to
hemorrhoids, but also to prolapsus, states
that he has lost but two cases. In only one
of these cases was death due directly to the
operation, the patient suffering from a pro-
lapsus of such extent as to bring down part
of the peritoneal covering of the bowel ;
this caused secondary peritonitis with fatal
issue. He condemns the method of ligation,
saying that it is often followed by ulceration,
tetanus, pyaemia, and occasionally by death.

Bodenhamer, although not agreeing with
Mr. Smith in his general condemnation of
the ligature, still says that " the method by
clamp, scissors and actual cautery, is the
best and safest, and should be preferred if
ever such an operation is resolved upon."

Kelsey now uses almost entirely the clamp
and cautery, and says that after ligating
these tumors, according to the plan of All-
ingham, he often found his patients suffering
great pain, which lasted from eight to ten
days, and that he was frequently compelled
to use the catheter for several days. Since
using this method, his patients are almost
entirely free from pain and seldom has he
need to resort to the catheter. The con-
valescence is shortened, the patient being up
on the second or at most on the third day.
According to Mr. Smith the patient so
treated leaves the hospital on the fourth,
fifth or sixth day.

Van Buren says that " the actual cautery,
with our present facilities of applying it,
stands very nearly on a par with the lig-
ature."

Jan. 24, 1 89 1.

Periscope.

103

As regards the injection plan of treatment,
most authorities who were at first highly
pleased and enthusiastic over it, have, after
their first enthusiasm passed away, given up
this method almost entirely.

It was claimed by those who used this
method that it was safe ; that it was free from
pain, and that it necessitated no confine-
ment from work.

On the contrary, Dr. Matthews declares
" that it is painful, insufficient and liable
to cause death by peritonitis, embolism and
pyaemia."

Allingham says that he has " tried the
injection plan, but the result was much pain,
more inflammation than was desirable, a
lengthy treatment, and the result doubtful ;
certainly not a radical cure."

Kelsey, who at first was an enthusiast, is
not so now, and rarely uses it unless in
selected cases. He claims that sloughs, mar-
ginal abscesses, lymphangitis, ischio-rectal
abscesses and deep fistula frequently follow,
but has never seen a fatal case.

Andrews states ''the method is moder-
ately, put positively dangerous, and we can-
not recommend it as proper in ordinary
cases." In 3,304 cases collected by him,
he finds that there were 13 deaths : embol-
ism of the liver, 8 ; abscess of liver, 1 ; dan-
gerous hemorrhage, 10, permanent impo-
tence, 1 ; stricture of rectum, 2 ; violent
pain, 83 ; severe inflammation, 10 ; sudden
and dangerous prostration, 1; carbolic acid
poisoning, 1 ; failed to cure, 19 ; sloughing
and other accidents, 35.

In conclusion Dr. Krouse says that judg-
ing from the views expressed by well-known
authorities, and from his own experience,
he believed that good results may be ob-
tained by any of the surgical methods men-
tioned above. He says that he has a prefer-
ence for the clamp and cautery operation,
which seems to him to be the safest, produc-
ing a good result in a short time with the least
discomfort to the patient. In cases, however,
in which the patient absolutely refuses the
major operation he would not hesitate to
employ the injection plan, using, however,
the weaker solutions.

Meat Preservation.

Dr. Hans Beu, in the Centralblatt fur
Bakteriologie und Parasitenkunde, points out
that nearly all the newer methods of prepar-
ing preserved meats have- had to give way

before the older methods of boiling, drying,
salting and smoking, which, along with
freezing, preserve the taste and digestibility
of meats better than any of the chemical
methods that have more recently been rec-
ommended. All these old methods, he
maintains, hinder decomposition and keep
meats eatable for a longer or shorter period.
Cold acts by preventing putrefactive changes
in meat, 20 to 40 C, with good ventilation,
preventing the development of most organ-
isms. Boiling with subsequent exclusion of
air is, of course, good, but can only be car-
ried out in large establishments and under
specially favorable conditions. Drying gets
rid of the water, without which micro-organ-
isms cannot develop, but, although there is
no loss, of albuminoid or salts when this
method is used, the taste is somewhat im-
paired. Salt also acts by removing water,
but it also removes the extractives, and in-
terferes with the delicate flavor of both meat
and fish. Smoke acts partly by drying, the
heat at which it is generated rendering this
necessary, but partly, also, by the action of
the small quantities of the antifermentative
constituents, such as creasote, carbolic acid
and even volative oils, which appear to have
a direct action on the vitality of putrefac-
tive organisms. The author agrees with
Forster, that salt has little or no effect upon
most pathogenic organisms, but it undoubt-
edly interferes with the development of the
cholera bacillus and of anthrax bacillus that
contains no spores, and probably, also, of
some of the non-pathogenic but putrefactive
forms. As the result of his experiments on
a very large number of food materials, such
as ham, bacon, pork, various kinds of sau-
sages, and fish, Beu comes to the conclusion
that most meats are salted not only to pre-
serve the taste, but also to withdraw a
large proportion of the water from flesh ;
that smoking also withdraws a considerable
quantity of water, that it hides the salty
taste, and that, being able to penetrate dried
flesh, it is better able to exert its antiputre-
factive action than on fresh meat. Salted
lean flesh,' exposed to the action of smoke
at from 220 to 250 C. for forty-eight hours,
no longer contained liquefying organisms,
which had been present in considerable
numbers before the smoking operation was
commenced, but non-liquefying organisms
disappeared only on the ninth day of smok-
ing. Salt bacon salted for ten days, and
then exposed to the action of smoke for
forty-eight hours, also showed no liquefying

Periscope.

Vol. lxiv

organisms with a fragment from near the
centre taken with the most strict precau-
tions, and broken up in liquid gelatine,
which was afterwards allowed to solidify.
All non-liquefying organisms had disap-
peared on the seventh day of smoking.
Bacon salted for five weeks contained no
organisms after seven days' smoking. Fresh
unsalted meat contained both kinds after six
days of smoking, and sausage also contained
both at the end of twelve days ; this being
exactly in accordance with what would be
-expected from the large amount of water
that is contained, from the nature of the
meat used, and from the many manipulative
processes through which it has to go before
the smoking is commened. Fish may be
preserved for a short time by smoking only,
but it could not be kept permanently.
Hams and larger sausages require a longer
period of smoking than do similar smaller
articles of diet. — British Medical Journal,
Supplement, November 22, 1890.

Small Doses.

In the Edinburgh Medical Journal,
December, 1890, Dr. J. L. Porteous praises
-the use of small and repeated doses of a
variety of drugs, among them gelsemium,
calomel, opium, nux vomica, and nitro-
glycerine. Speaking of the assayed fluid
extract of gelsemium he says : " 1 have
found wonderful benefit derived from the
use of this medicine in minute doses — say
five drops of the extract in four ounces of
water, one teaspoonful of this every ten
minutes for one hour, then every hour.
When I first read of this mode of adminis-
tration of the drug I was sceptical, but at
the same time was determined to try it. I
had an early opportunity, which presented in
the form of threatened pneumonia. The
condition of patient was as follows : — There
were minute crepitations ; pain in lungs ;
temp., 1040; pulse, 130; skin hot and dry.
After two hours' treatment, as above, the
skin became moist, temperature and pulse
were reduced, and what appeared to be the
commencement of an attack of pneumonia
averted. If aconite in same proportion be
added, the results are even more satisfactory.

The drug is powerful. Five drops may
-cause double vision and other toxic symp-
toms, but when given in minute doses these
symptoms are avoided, and the beneficial
•effects of the medicine only are produced.
Of course this medicine is not infallible,

and Dr. Aulde thinks that if it does not re-
lieve within twenty-four hours it ought to be
discontinued. He has found it of service
in the neuralgic pains of dysmenorrhoea. "

Calomel, in small doses (gr. -J^) Dr. Por-
teous says, is a sedative to the stomach,
liver and intestines, and favors the pouring
out of the watery portions of the blood into
the intestines. Small doses increase the se-
cretions, large doses arrest them. Tablet
triturates, each containing gr. prove useful
in derangement of the alimentary tract in
children often due to torpid liver. One
must be given every half-hour till six or
eight have been taken.

Opium given in small (gr. repeated
doses, contrary to general teachings, in-
creases secretions — e. g. , ovarian or other
reflex pain which interferes with secretion
and causes constipation is undoubtedly re-
lieved by them. By them pain is relieved to
such an extent that the secretions are re-es-
tablished and purgation is the result. If
given in like doses in bronchitis, where
there is great dryness and burning pain with
every cough, after several small doses secre-
tion will take place and the raw feeling re-
lieved.

Ten drops of nux vomica in a wine-
glassful of water, of which one teaspoonful
is given every ten minutes for one hour,
then every hour, has proved beneficial in
the only case of vomiting of pregnancy in
which Dr. Porteous tried it. The stimulating
effects are not only felt upon the terminal
filaments of the pneumogastric, but this
action is carried to the liver, and extends to
the entire nervous system, and as long as
there are no astringents given to arrest per-
istalsis, the bile is carried downwards, and
the vomiting ceases. In typhoid fever,
when it is lingering and vitality is at a low
ebb, it proves useful given of same strength
as mentioned above, only every hour during
day, and every two hours during night.

Nitro-glycerine has been in much favor
for some time. Dr. Porteous has found it
useful in one-drop doses of a one per cent,
solution every five minutes during a par-
oxysm of asthma. If given in tablet form
the tablet should be dissolved in the mouth
before swallowing.

Chinese Treatment of Diphtheria.

The Lancet, November 22, 1890, says
that a popular remedy for diphtheria, which
has been employed in China for over 300

Jan. 24, 1891.

Periscope.

years, recently formed the subject of a com-
munication by M. Lecerf to the Societe de
Medecine Pratique of Paris. The treat-
ment consists of blowing a powder into the
throat, using a decoction of plants as a gar-
gle and drink, and the employment of cer-
tain hygienic measures. The powder is
called sin-seh, and it appears to consist
essentially of borax, camphor, powdered
pearls, cinnabar, acetate of copper and
charcoal, the percentage of borax and cam-
phor being respectively 42.5 and 12. From
twenty to thirty centigrams of this powder
are blown through a paper tube every two
hours. The decoction is difficult to imitate,
as it is made from the following : roots of
the coptis teeta (Scutellaria viscidula),
Hanax quinquefolium or ginseng and Platy-
codon grand ; flowers of Caprifolium chin-
ense, fruit of the Uvularia cirrhosa, bark
of Pterocarpus flavus, Capanus flavus root,
and Glycyrrhiza glabra. About fifty grams
of each are boiled in a pint of water until it
is reduced to 200 cubic centigrams. This is
filtered, allowed to cool and given in three
doses in the twenty-four hours. The regi-
men enjoins the avoidance of ice, cold
drinks, sugar and fatty matters and fruits,
but allows at first boiled rice, eggs and salt
fish, and later boiled chicken and bread.
A large number of cases are said to be cured
in three days, but the evidence on which
they are termed diphtheritic is by no means
conclusive.

Tuberculous Milk and Diseased
Udders.

Dr. B. Bang, of Copenhagen, in the
Munchener med. Wochenschrift, October 14,
1890, gives an account of his investigations
undertaken to determine whether or not
milk from tuberculous cows, but cows with
healthy udders, is virulent. Observations
made in the Copenhagen slaughter-house
indicate that only a little over one per cent,
of tuberculous cows have pronounced tuber-
culous udders. It is important, therefore, to
determine whether the milk of tuberculous
cows with healthy udders contains bacilli
and is capable of transmitting the disease.
Bang's first studies, made in 1884, led him
to decide this question in the negative. In
1888, Bang made experiments with the milk
of twenty-eight cows, nearly all tuberculous
in a high degree, but with healthy udders.
Forty-eight rabbits were subjected to intra-

peritoneal inoculation, and of the whole
number only two became affected with the
disease. The results of Hirschberger, work-
ing in Bollinger's Institute, were very dif-
ferent. He inoculated guinea-pigs intra-
peritoneal^ with the milk from twenty dif-
ferent tuberculous cows, and found eleven
of the guinea-pigs infected. As guinea-pigs
are more susceptible of tuberculosis than
rabbits, Bang determined to re-investigate
the question and use guinea-pigs. Forty of
these animals were inoculated with the milk
of twenty-one cows. The cows furnishing
the milk were in a high degree tuberculous.
After furnishing the milk they were, some
time later, slaughtered, and their organs sent
to Bang for investigation. He was thus en-
abled to know with certainty the exact con-
dition of the animals. The milk of seven-
teen of the cows was not virulent, while that
of four proved to be virulent. In three of
these four cows, there was disease of the ud-
der of different degrees. In the fourth cow,
no disease of the udder could be detected,
but the animal had advanced tuberculosis
of the lungs, pleura, mediastinal and mesen-
teric glands, liver and intestinal canal, and
had died of the disease, whereas the other
animals had been slaughtered. Moreover,
the udder had suffered from a chronic in-
flammation with shrinkage. The appear-
ance was not that of tuberculosis, but as the
tissue was not examined under the micro-
scope tuberculosis could not be excluded
absolutely even in this case.

The result of Bang's investigations ap-
pears to prove that the milk of tuberculous
cows is virulent (by inoculation) only when
there is at the same time disease of the ud-
ders.

Irregular Typhoid Fever Rash.

The New York Medical Journal, Decem-
ber 6, 1890, quotes Dr. R. L. MacDonnell
as pointing out in a clinical lecture, in the
Montreal Medical Journal for November,
some atypical conditions of the skin among
his cases at the General Hospital. The
number of patients with the disease — seven
men and five women — was somewhat larger
than usual at this season of the year, but the
type of the disease has, for the most part,
been a mild one. Unilateral sweating was
noticed in the case of the strong young
Englishman who had a fairly severe attack
of the fever. On the day of his admission

io6

Periscope.

Vol. lxiv

the one-sided sweating was well marked,
but it had disappeared three days later. In
one case a pale scarlatiniform rash was noted
within a few hours after admission, confined
to the neck and shoulders ; it was of short
duration. No medicines had been adminis-
tered. In the case of a young girl, urti-
caria in distinct wheals manifested itself in
the third week of an attack that had not
been severe. In the case of a pregnant
woman, who had a protracted attack of
typhoid, there was jaundice lasting three
days. In the case of a man who had a sharp
attack, with extreme meteorism, for the re-
lief of which turpentine stupes were used,
pustules appeared upon the abdomen at the
site of the typhoidal eruptive spots ; in some
of these small abscesses, containing from
half a drachm to a drachm of pus, were
formed.

This accident Dr. MacDonnell had
noticed once before as a result of the use of
turpentine stupes in fever. Four irregular
forms of eruption in typhoid fever have been
specified by Moore, of Dublin, such as ery-
thema fugax, miliary eruptions, erythema
simplex (seu scarlatinale), and urticaria. The
scarlatiniform rash is most likely to show
itself at the end of the first week or in the
course of the third week, and when it ap-
pears early it is apt to give rise to diagnostic
embarrassment, but the prodromes of scarlet
fever are wanting, and the rash has been of
a lighter color, less rough and punctiform
than that of the exanthem ; the rash is a
blush rather than an eruption, and may be
considered as a result of some disturbance
of. the peripheral vaso-motor system.

Alterability of Diuretine.

The American Joicrnal of Pharmacy, De-
cember, 1890, says that diuretine is decom-
posed by all acids, even carbonic acid. Ex-
posed to the air it becomes partially insolu-
ble, making it necessary to treat it with
caustic soda. Even in solutions, carbonic
acid acts upon diuretine, and the mixtures
become cloudy on account of the precipita-
tion of theobromine. Not only weak acids,
but such salts as the biborates, bicarbonates
and dimetallic phosphates, decompose diu-
retine; hence, we cannot use it with fruit
syrups or with soda bicarbonate. There is
no advantage in giving theobromine trans-
formed into diuretine, since, on reaching
the stomach, it is decomposed by the gastric

juice. It would be preferable to give theo-
bromine in cachets or by enema.

Palatable Emulsion of Creasote.

The Western Druggist, November 15,
1890, gives the following for a palatable
preparation of creasote, the taste of which
is notoriously hard to disguise.

R Creasote gtt. 16

Oil of clove " 8

Oil of cinnamon . " 4

Oil of peppermint " 4

Olive oil fl. oz. I

Acacia fl. dr. 4

Water " 6

Make an emulsion and complete the
mixture by adding

B Glycerin fl. dr. 4

Water .... enough to make " " 4

Each tablespoonful contains one drop of
creasote. The aromatics may be increased.

The Tetrahydronaphthylamines.

Dr. R. Stern, in the Archiv fiir patho-
logische Anatomic, ■ gives an account of
some recent experiments made' on animals
with the tetrahydronaphthylamines. The
preparation used was an aqueous solution
administered hypodermically. An increase
in temperature resulted in an hour, with
dilatation of the pupil and general symp-
toms of poisoning. There was an increase
in the quantity of urine voided, and in
its nitrogenous and phosphatic constitu-
ents, the poison reaching its maximum
effect on the second day, when the symp-
toms gradually subsided. The observer
concluded that the changes in the urine
were not those common to high tempera-
ture, but were consequent upon the spe-
cific poisonous action of the drug. — New
York Medical Journal, November 29, 1890.

Challenge to a Fast.

Dr. H. S. Tanner, who fasted forty days,
now lives near Clinton, Missouri. He has
challenged Succi to sit down with him in
Chicago during the World's Fair to test the
matter in a ninety-days' fast on water only,
or, if Succi prefers, let the fast continue
from day to day till one or the other yields
the contest.

Jan. 24, 1 89 1.

Editorial,

107

THE

MEDICAL AND SURGICAL

REPORTER.

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DIAGNOSTIC SIGNIFICANCE OF THE
TUBERCLE BACILLUS.

Whatever views may be held in regard to
the value of Koch's remedy for tuberculosis,
there is certainly a very widespread convic-
tion that the bacillus which he described as
constantly present in tuberculosis is of great
importance as an evidence of the nature of
the morbid process. Careful and conscien-
tious students of tuberculosis have doubted
and have denied the significance attached
to the bacillus by the followers of Koch ;
and the Reporter has more than once indi-
cated a feeling that the latter go further in
some of their assumptions than the facts
warrant. But fairness to our readers de-
mands that we present what we believe are
the views of the profession — even when they
do not accord entirely with those of the
Editor.

For this reason we call attention to a
short communication in the University Medi-
cal Magazine, November, 1890, by Drs.
Fussell and Kelly, of the University of
Pennsylvania, urging the significance of the
tubercle bacillus as diagnostic of tubercular
phthisis.

In 1887 Dr. Fussell read a paper before
the Philadelphia County Medical Society,
based on the examination of the sputa of
100 cases of lung disease. The conclusions
arrived at were : That the presence of tuber-
cle bacilli in the sputa of any given case
was undoubted proof of tuberculous phthi-
sis, and that the continued absence of the
organisms from the sputa of any given case
was good, though not positive, proof of the
absence of phthisis. These conclusions
were confirmed by examination of the sputa
of sixty- five cases in 1890.

In these sixty-five cases, forty-four patients
had undoubted physical signs of phthisis, and
tubercle bacilli were present in the sputa of
all. Four had doubtful physical signs, and
tubercle bacilli were found in the sputa of
all. Eight had no physical signs of phthi-
sis, and tubercle bacilli were absent from all.
Nine had doubtful physical signs, and tuber-
cle bacilli were absent from all.

The nine cases in which the signs were
doubtful, and tubercle bacilli absent, are
full of interest, but space prevents their ex-
tended notice. Two were cases of pneu-
monia, one of the apex in a boy with Pott's
disease, where phthisis was feared, but who
has entirely recovered. Another of the cases
did not take the usual course of pneumonia,
but has completely recovered. There was a
case of pleurisy ; one of anemia, with cough,
etc. In all these cases it was a great relief
to the physicians when repeated examina-
tions failed to demonstrate bacilli.

That the ground, "absence of tubercle
bacilli is good, though not positive, proof
of absence of phthisis" is well taken is
proved — Dr. Fussell thinks — by one of the
cases he cites. This case is quoted in Dr.
Fussell' s article as one with doubtful signs,

io8

Editorial.

Vol. lxiv

absence of bacilli and recovery. In 1887
he had been under observation for one year,
and seemed* entirely well, but in 1889 he
again came under observation, with marked
consolidation of left apex, numerous bacilli
in sputum and death early this year.

As the method of examining sputum
for tubercle bacilli is simple, not requiring
much technical knowledge, and but a mod-
erately powerful microscope, it seems as if
such examinations ought to be made in all
cases in which there is suspicion of tubercu-
losis. By such examinations something
would almost always be gained, and — if
nothing else — a store of observation which
might bring to agreement those who now
do not agree on what is one of the most in-
teresting pathological questions of the pres-
ent day.

MYXCEDEMA RELIEVED BY GRAFT-
ING WITH" THE THYROID.

Myxcedema is a curious affection in which
the features become broad, flattened and
expressionless. The eyes appear too wide
apart, the wings of the nose are thick, the
lips large, the loose tissue below the eyes in-
creased and folded, and heavy folds of con-
nective tissue form under the jaws and in
the neck. The tongue also undergoes en-
largement and interferes with articulation,
while the hands are broad and spade-like.
The person affected gradually becomes less
active mentally and physically, the prevail-
ing mood being one of placid indifference
and apathy.

Several varieties of myxcedema have been
described : Myxcedema of adults (pachy-
dermic cachexia of Charcot) ; operative
myxcedema of Reverdin (cachexia strumi-
priva of Kocher) ; and idiocy with pachy-
dermic cachexia of Bourneville and Bricon
— the sporadic cretinism of English writers.
The link which unites these varieties is ab-
sence of the thyroid body, or its disappear-
ance as the result of disease or surgical op-
eration. Kocher found that removal of the

thyroid for goitre, which is so common in
Switzerland, resulted in producing a condi-
tion very similar to cretinism in the adult ;
and Horsley produced a similar condition
by removing the thyroid in monkeys. Fol-
lowing these experiments, Schiff went a step
further by making the first graft of a thy-
roid. His purpose was to prove that the
thyroid has chemical and hematopoietic
functions independent of its position. He
showed this by transplanting to the perito-
neal cavities of several dogs, some time be-
fore doing thyroidectomy on them, portions
of a thyroid from another dog. The result
was satisfactory : the animals survived thy-
roidectomy without presenting the phenom-
ena usually provoked in animals by ablation
of the thyroid. Eiselsberg confirmed Schiff 's
experiments, employing cats instead of dogs,
and adding the important observation that
the death of the animal from thyroidectomy
is prevented only when the graft of another
portion of thyroid succeeds.

If the grafting of a portion of thyroid
prevents the results of thyroidectomy in
animals, why should it not prevent or over-
come myxcedema in human beings? asked
Horsley, in the British Medical Journal, Feb-
ruary 8, 1890. Lannelongue, as described
in an Editorial in the Reporter, April 12,
1890, undertook to accomplish this, and it
has been tried also by Bircher, Kocher and
others. In Le Mercredi Medical, November
19, 1890, Merklen and Walther give a
review of the cases in which grafting with
the thyroid for myxcedema has been done,
and .report in detail a case of their own.
The patient was a woman, forty-one years
old, who had had myxcedema for ten
years. Metrorrhagia preceded by ten years
the development of myxcedema, and had
never ceased since the occurrence of the
latter. Walther, at the request of Merk-
len, transplanted one of the lobes of a thy-
roid from a sheep into the sub-mammary
region on the right side of the patient. The
operation was done so that only a few sec-
onds elapsed between the removal of the

Jan, 24, 1 89 1.

Editorial.

portion of thyroid from the sheep and its
insertion into the patient.

The metrorrhagia from which the patient
suffered ceased three days after the opera-
tion, and had not been reproduced up to
the time of the report, seventy-two days
subsequent to the operation. At the same
time there was a remarkable improvement
in the patient's myxoedema ; the outward
evidences of the disease became less con-
spicuous, speech was much more distinct,
and the patient could walk easily and quickly
about the ward, whereas several weeks before
it had required fifteen minutes for her to
make the tour of the ward.

The exact future of this operation cannot
be predicted at present. It is perhaps
a step in the right direction ; and while
those who may require it are unquestionably
more numerous in Europe than in this coun-
try, there is no impropriety in calling atten-
tion to it here. One thing deserves mention
before leaving the subject ; in some of the
cases in which grafting has been done,
the transplanted thyroid has, after a time,
atrophied, the symptoms of myxoedema have
reappeared, and a second grafting has been
necessary. In Merklen's case, also, the
transplanted thyroid, when last examined,
appeared to have diminished somewhat in
volume. Perhaps later experience will avoid
the disappearance of the graft by indicating
a better seat for it.

THE GONOCOCCUS IN THE DIAGNOSIS
OF VULVITIS.

Physicians are often in doubt whether a
particular vaginal discharge is gonorrhoeal
or due to some other cause capable of pro-
voking suppurative inflammation. When,
in adults, the discharge has appeared sud-
denly, is purulent in character, and in its
early stages has been associated with scald-
ing pain on micturition, a hot and tender
vagina with bright red points covering the
mucous membrane, and with a red, velvety
or granular os uteri, the probabilities are

altogether in favor of gonorrhoea. And yet
it is doubtful whether many men could be
found willing to take the witness stand and
declare positively, from the symptoms and
appearances we have described, that the dis-
ease is gonorrhoea. The difficulty becomes
still greater when the patient is not an adult
but a child. Fortunately the cases of gon-
orrhoea in little girls are much less frequent
in this country than they appear to be on
the continent of Europe, where physicians
to law courts have been put to it to find an
infallible method of differentiating gonor-
rhoeal vulvitis from that due to other causes.

The discovery of the so-called " gono-
coccus ' ' by Neisser was hailed by many
with enthusiasm. Supposing it to be the
specific cause of gonorrhoea, then to find it
in a suspicious discharge would be proof of
the gonorrhoeal character of the discharge.
But it was scarcely discovered before asser-
tions were made that it could be found in
non-specific discharges, and that it could
not be distinguished under the microscope
from other bacteria, particularly diplococci.
The latter conclusion is the one to which
Vibert and Bordas have come. These wri-
ters have investigated, from a medico-legal
point of view, the discharge present in the
vulvitis of little girls, and declare, in La
Medecine Moderne, November 13, 1890, that
microscopic examination of such discharge
never enables an expert to affirm that a par-
ticular vulvitis is or is not gonorrhoeal.
They find the gonococcus practically indis-
tinguishable from the diplococcus — both
bacteria, they say, have the same form and
dimensions, the same arrangement in masses
and heaps, and not in chains, and they stain
alike and are alike deprived of their stain
by alcohol.

It not infrequently happens that men are
accused of having committed rape upon lit-
tle girls, and sometimes vulvitis is adduced
as one of the evidences of the violation. A
vulvitis, however, has been found in a vio-
lated child although the person guilty of the
rape was free from any evidences of urethral

I IO

Correspondence.

Vol. lxiv

disease. It would seem to be impossible,
therefore, in the present state of our knowl-
edge of the bacteriology of gonorrhoea, to
base upon it a diagnosis sufficiently positive
to warrant a judgment by the court in a
criminal suit. No doubt this difficulty will
be overcome by and by, and perhaps by
cultivation the gonococcus can be distin-
guished from the diplococcus. But just
now the conclusion seems to be that our
methods of detecting the gonococcus are
not precise enough for medico-legal pur-
poses.

Book Reviews.

[Any book reviewed in these columns may be obtained upon
receipt of price, from the office of the Reporter.]

THE DAUGHTER— HER HEALTH, EDUCA-
TION AND WEDLOCK. By William M.
Capp, M. D. 5>£x7 inches, pp. viii, 144. Phila-
delphia and London : F.A.Davis, 1891. Price,
$1.00.

Dr. Capp's little book is written in an attractive
style, and contains a great deal of what he fitly calls
" homely suggestions for mothers and daughters.' ' The
subject of the book is the development and training of
young women for the position and duties peculiar to
their sex. It is decidedly pleasant to see a book of
this sort, which — in the present fever to make women
like men — treats of them as women solely. Dr. Capp
gives such advice as, we think, will be welcomed and
approved by womanly women, and of a sort which,
well pondered and wisely followed, will tend to in-
crease the number of women capable of being good and
loved wives and mothers. We commend his book to
the attention of the readers of the Reporter, and be-
lieve it would be a help to most thoughtful parents
who have daughters to train.

A MANUAL OF THE PRACTICE OF MEDI-
CINE. By Frederick Taylor, M. D., F. R. C.
P., Physician to, and Lecturer on Medicine at Guy's
Hospital, etc. 8vo, pp. 877. With illustrations.
Philadelphia: P. Blakiston, Son & Co., 1890.
Price, $4.00.

Dr. Taylor has undertaken to write a short yet com-
plete account of the present state of medical practice.
It cannot be denied that such an undertaking demands
great courage when one considers the vast extent of
the field to be covered. Only a man of large experi-
ence, and one accustomed, through teaching, to 'concise
and exact methods of thought and expression, could
accomplish the task ; but Dr. Taylor has succeeded
admirably.

After a short but pithy introduction, the author takes
up specific infectious diseases, including in this classi-
fication, influenza, syphilis and tuberculosis. The fol-
lowing two hundred pages are given to diseases of the
nervous system. Then follow in succession accounts of
the diseases of the organs of respiration and of circula-
tion, diseases of digestion, diseases of the ductless
glands, lymphatic system and blood, diseases of the

urinary organs, diseases of the organs of locomotion,
and, finally, diseases of the skin.

The author is aware that in treating of diabetes
under diseases of the kidneys, and of rheumatism and
rickets under diseases of the organs of locomotion, he
lays himself open to criticism. He has placed them
where he has for convenience and provisionally, until
a better understanding of their pathology makes a
proper classification possible.

We have already spoken in warm praise of the book,
and have only to add that it is just the one to put into
the hands of a student who wishes to read up a sub-
ject while he is listening to lectures on practice ; it is
full enough to be clear without being full enough to
confuse.

A COMPEND OF HUMAN ANATOMY, IN-
CLUDING THE ANATOMY OF THE VIS-
CERA. By Samuel O. L. Potter, M. A., M. D.,
Professor of Theory and Practice of Medicine in the
Cooper Medical College of San Francisco, etc.
Small 8vo, pp. 315. Fifth edition, revised and en-
larged. Philadelphia : P. Blakiston, Son & Co.,
1890. Price, $1.00.

The present volume includes in one the author's
compends on " Human Anatomy " and " Visceral Anat-
omy " which were originally published in separate parts.
The text as first published, has been somewhat ampli-
fied, and the number of wood-cuts increased by eigh-
teen, so that now the whole number of cuts is one
hundred and seventeen. In an appendix are given
sixteen plates representing the nerves and arteries.

The book as it stands is a very complete compend
of anatomy ; indeed, if it were not for the arrangement,
one might be justified in speaking of it as a small
treatise on anatomy. We can recommend it to stu-
dents, and to any of our readers who desire such a
book.

CORRESPONDENCE.

Work in the Woman's Hospital of
Philadelphia.

To the Editor.

Sir : Apropos of the excellent Editorial
entitled " The Modern View of Diseases of
the Uterus ' ' in the Medical and Surgical
Reportfr December 13, 1890, it may be of
interest to your readers to learn something
of the past year's work in gynecology at the
Woman's . Hospital of Philadelphia — not
the " Woman's Medical College Hospital "
as is often stated. The " Woman's Medical
College of Pennsylvania" and the "Wo-
man's Hospital of Philadelphia " are dis-
tinct institutions with entirely separate
management, although with a common in-
terest.

A review of the work in the Hospital for
the past year shows that the tendencies of
modern thought and the refinements of sur-
gical science have materially affected its
methods of procedure. Since aseptic sur-

Jan. 24, 1 891.

Correspondence.

1 1 1

gery has robbed the knife of its terrors, and
an exploratory incision may be made, as
every surgeon knows, without costing the
patient the loss of even a drachm of blood, it
has not been thought necessary to subject
patients to a long-continued treatment in the
dark, with palliative measures, before re-
sorting to more radical means for discover-
ing the true nature of their maladies, and
the possibility of relief. Our proportion of
abdominal sections is for this reason larger
than that of previous years, although not
really so large, as yet, as the number and
character of the cases applying to us for re-
lief would Warrant.

Of 668 patients treated in the house,
nearly 500 were gynecological cases, while
1,948 cases were treated during the year at
the gynecological clinic alone. Of 56
laparotomies performed, 48 were for disease
of pelvic origin. Six of these were ovariot-
omies ; four were hysterectomies ; thirty-one
were for the removal of diseased uterine ap-
pendages ; four for the breaking up of ad-
hesions and correction of uterine displace-
ments ; one for the removal of a dermoid
cyst ; two for multiple puncture of cystic
ovaries. Four deaths occurred among the
number ; three of them in cases of suppur-
ating ovarian cystomata — in all of which
general sepsis had existed prior to operation,
from absorption of fetid pus which had long
been incarcerated in the pelvis. The fourth
death occurred a week after the performance
of a successful hysterectomy in a patient
with frequent severe hemorrhages from a
bleeding fibroid. The patient had been thus
bleeding for two years, and her anemia was
extreme. Not an ounce of blood was lost
during the operation. An autopsy showed
a perfect condition of the abdomen, wound
and stump. The heart was very pale with
flabby walls, a small clot was found in one
of the chambers. The stomach was some-
what enlarged and distended with flatus.
The supposition was that death occurred
from embolus, or interference with the action
of a very weak heart caused by the pressure
of the distended stomach. The case had been
afebrile throughout. Death occurred with-
in half an hour of the patient's complaint of
pain in the region of her heart. How
striking a comment do these four cases
offer to the evils of delay in resort to oper-
ative procedure !

Among the cases of simple amputation
of the uterine appendages, no deaths oc-
curred. The results in the cases surviving

operation have been, as a rule, most gratify-
ing. In twenty-five cases of successful
abdominal section this year, reported by
me in the November number of the Annals
of Gynecology and Pediatry, the results
here in every case surpassed my expectations.
All the cases in which pain existed have
been entirely relieved, and the general con-
dition of the patient has been greatly im-
proved. I speak of this here, as reference
was made to some of these cases in an article
in the Reporter, August 16, 1890, when it
was much too early after operation to make
results worth recording. In an experience
with about one hundred and twenty-five
cases of abdominal section which have come
under my immediate charge, I have always
found a logical explanation where the oper-
ation failed to meet expectations. Either
the operation had been undertaken too late
to afford more than a forlorn hope, or the
complications resulting from repeated at-
tacks of inflammation had been found to be
insurmountable, resulting in a partial and
unsatisfactory removal of diseased structures,
the remains of which continued to serve as
a source of local irritation. Surgery must
sometimes undertake desperate cases, and it
loses prestige thereby. Of minor operations,
64 perineorrhaphies were performed and 30
trachelorrhaphies, etc., amounting in sum
total to 155. Operations in general surgery
and those performed in our obstetrical
wards bring the number of house operations
up to 306. The addition of the operations
performed in the various departments of our
Dispensary work makes the total number

Electricity has been but little employed
in the management of our cases during the
past year ; and this because of my honest
conviction that, as yet, the laws governing
the action of this subtle agent are too ill —
defined to render its use safe in conditions
of disease affecting the delicate structures
to be found in the pelvis.

Five years' personal trial of the methods
of electricity as advised by its advanced
teachers, has led me to this decision.
Although, as resident in the Hospital in
1882, I was taught to employ electricity to
some extent for the relief of pain, the con-
trol of hemorrhage, etc., it was not until
1885 that the Apostoli methods were fully
introduced here. It was then that one of
our physicians visiting Apostoli's clinic in
Paris and studying his methods, brought
home with her various forms of electrodes

112

Correspondence.

Vol. lxiv

and appliances as recommended by him.
The Managers of the Hospital generously
supplied us with an excellent and expensive
battery capable of giving a current of
150-200 milliamperes, and imported a gal-
vanometer said to be of the best make.
Since then the literature of the subject has
been carefully followed and every effort
made to bring about the conditions which
would favor success. The Apostoli elec-
trodes have been used, the Apostoli clay-
pads employed and Apostoli rules followed.
Intra-uterine applications have never been
relegated to assistants, excepting under my
direct supervision and instruction.

A pupil of Apostoli, one of Dr. Chas. K.
Mills, and one of Dr. Massey, who have at
different times, had charge of our electrical
clinic, may have occasionally given intra-
uterine applications to dispensary patients ;
but as a rule, such applications have been
confined entirely to house patients. For
many months no intra-uterine applications
have been permitted to be employed in dis-
pensary work. The result has been that in
our hands electricity has proved an uncer-
tain, unsatisfactory and at times a treacher-
ous agent. Among a large number of cases
treated, I cannot recall one we could con-
sider permanently cured by its means. Re-
lief of pain for variable periods of time with
the occasional control of hemorrhage, has
been obtained while the patients continued
under treatment. Repeated attacks of in-
flammation have occurred, notwithstanding
precautions. These, taken in time were
readily suppressed ; but that they left their
impression upon the peritoneum was very
evident in several instances where a final
resort was had to laparotomy. A special
proneness to the occurrence of omental ad-
hesions I have found in many cases. One
case of fibroid will perhaps serve as an illus-
tration. The patient was admitted to the
Hospital in February, 1886, when the rec-
ord states her condition to have been as fol-
lows : "A large fibroid mass, very movable,
apparently interstitial, fills the pelvic brim
and extends to one inch below the umbili-
cus ; cervix effaced. ' '

From February 19 to September 7, 1886,
the patient was treated by galvano-puncture,
alternating with intra-uterine applications,
according to Apostoli' s method. After her
last treatment on September 6, 1886, I find
the following entry: " Tumor about the
same size as when patient came in, the se-
vere paroxysmal pains from which she has

suffered continue to recur." On June 16,
1887, the patient returned to us. The tu-
mor was found to be wider laterally than it
had been before, and the amount of pressure
it exercised bfought the body of the uterus
down in the anterior cul-de-sac to within 1
inches of the vulva. The patient remained
with us under electrical treatment until Au-
gust 26, 1887, when she was discharged, ma-
terially in the same condition as when she
came. She returned for the third time to
the Hospital on December 31, 1887, when
she was seen by Dr. Granville Bantock, of
the Samaritan Hospital, London. Dr. Ban-
tock thought the case unfavorable for oper-
ation, because of the fixation and lateral de-
velopments of the tumor. Treatment with
electricity was again begun, but it was con-
tinued only about one week, domestic diffi-
culties calling the patient home. Her ex-
treme distress, and the fact that the tumor
was greatly increasing in size, so that it now
reached almost to the diaphragm, led her
to return to us for the fourth time on De-
cember 13, 1888. She begged to have an
attempt made for its removal. An explora-
tory incision was performed on December
29, 1888. The tumor and all the contents
of the abdomen were a conglomerate mass
of adhesions, so that removal was an utter
impossibility. A few parietal adhesions
were broken up and the abdomen was closed.

This sad life was terminated by death
from sepsis due to breaking down of the tu-
mor early in the spring of 1890, after the
most intense suffering.

Since the discovery of truth should be the
aim of all earnest workers, and the free dis-
cussion of medical topics can alone stimu-
late the intellectual processes essential to the
development of science, I trust the expres-
sion of my views concerning electricity will
not be regarded as a personal attack upon
any of your readers who may hold different
opinions of its claims.

Experts in electricity will indeed confer
a blessing* on humanity if they can prove
that by the use of this agent disorganized
tissue can be restored to its original condi-
tions and functions. Reconstruction is to be
preferred to ablation. Ordinary conditions
of beginning inflammation are not those
which baffle the skill of the gynecologist.
The vicious conditions of life and thought
which render pelvic disease so prevalent in
this day, result in maladies so various and
complicated that human skill is appalled at
the difficult task of undertaking their cure.

Jan. 24, 1 89 1. Questions and Answers.

113

The wise control of preventive medicine
may in time lead to the extinction of such
maladies ; but as they exist, the important
question is : How shall they be managed ?

It is a difficult thing for any physician to
advise a patient to shut herself out from the
possibility of experiencing the joys of
motherhood, and it can only be done when
one feels the conviction that disease has al-
ready rendered safe motherhood an impossi-
bility to her.

In our Hospital, where we are accustomed
to explain to the patient and her friends the
full nature of any operation with its results,
and obtain from them a written statement as
to their desire to have the procedure carried
out, before it is attempted, I have yet to
find the man who has not been willing to
sacrifice every other consideration to his
wife's good. It has oftener been the woman
who has hesitated or deliberately chosen a
life of suffering with a possibility perhaps of
sudden death, rather than accept the alter-
native of a childless life.

Very truly,
Anna M. Fullerton, M. D.,

Physician in Charge.

Woman's Hospital,
Philadelphia.

Powder Blower.

. To the Editor.

Sir : In January, 1889, I read a paper
on Diphtheria before the Practitioners' Club
of this city, which was published in part by
you in your issue of November 23, 1889. In
this paper I strongly advocated the use of
sulphur in diphtheria and tonsillitis, and
quoted authorities in support of its claim to
usefulness for hundreds of years.

After reading the paper I presented to the
society an instrument I had constructed for
examining the throat and introducing sul-
phur and other medicated powders, to take
the place of quills, cut-off catheters, glass
tubes, putty blowers, rolled-up paper, and the
many troublesome makeshifts, that have al-
ways vexed the souls of doctors and nurses.
It was accepted as a happy solution of the
question, and has since been used with much
satisfaction, especially as it has been found
a great improvement on other tongue spatula
for throat inspection. It consists of a small
tube four or five inches long, with a spoon
attached to it. The spoon is bent on itself
to pass over the tongue and shove it for-
ward, and is highly polished to illuminate

the parts, and is to be washed in boiling
water to prevent contagion. The poVder
is to be blown through the tube by the
mouth, or any powder blower.

A year's experience has demonstrated
its usefulness, and also shown its possible
needs. To make it complete, I have now
added a rubber ball, with a scoop attach-
ment, which makes it a firm continuous in-
strument to be used with one hand. And
to make it still more complete, a tube with
a bulb is to be attached to the ball and
scoop, for nasal insufflation or irrigation.

These attachments also greatly enlarge its
use ; and since aristol has given such an im-
petus to powder medication of the nose and
throat, the instrument seems to promise use-
fulness in the treatment of acute or chronic
catarrh, as well as of diphtheria and tonsil-
litis. But the little illustration sent — which
please have your printer place in your adver-
tisement columns — will tell the story better
than pages of fine print.

Yours truly,
J. D. Osborne, M. D.

1034 Broad Street,
Newark, N. J.

Questions and Answers.

[In this department will be published questions on any medi-
cal subject by readers of the Reporter, and answers by the
Editor or by other readers.]

Difficulty in Micturition.

Dr. Giles Lucas, of Alma, Ark. , writes for
information about the following case. Mrs. J. ,
seventy years old, the mother of two chil-
dren, of nervous temperament, and rather
active for one of her age, consulted him in
May for the relief of the following trouble.
She said that for the last ten years she had
been troubled at intervals of from ten days
to several weeks with spells of painful and
frequent micturition. The spells lasted
from two to ten days. During the spells
she suffered constantly with throbbing pain
about the neck of the bladder. When she
voided urine — which she was compelled to
do every fifteen or twenty minutes — the pain
was almost unbearable.

On examination, Dr. Lucas found that
the urethra was very sensitive about the
sphincter of the bladder, and there was
some resistance to the passage of the cath-
eter. There was no morbid growth or
other abnormality. The introduction of

H4

Notes and Comments.

Vol.lxiv

the catheter gave her so much relief, that
she frequently calls on him to repeat it. The
introduction of the catheter, or sound, and
the local use of morphia, are the only means
that relieve her. Her urine is normal. This
case has given Dr. Lucas great anxiety, and
any information concerning it will be gladly
received.

Notes and Comments.

Depopulation of France.

It is somewhat startling to find that the
depopulation of France is becoming a com-
mon subject of discussion among the savants
of that country. The phrase is perhaps
somewhat stronger than the circumstances
of the case warrant, the fact being that the
population of France is simply stationary.
Still it is a striking and significant circum-
stance that while the population of all the
other great European nations is steadily and
rapidly advancing, that of France remains
at a standstill. On economic grounds this
arrest of increase in number might seem not
altogether an unmixed evil, inasmuch as it
should tend to diminish over-competition,
and to ease the already excessive struggle
for existence among the lower classes ; but
an impression widely prevails that given a
fairly normal and healthy social condition a
growth of population is a natural result, and
that a stationary or declining population is
an index of some grave disorder of the body
politic. We cannot adequately discuss this
large and difficult question, but our French
neighbors evidently think that something is
amiss, and are looking around for the cause
and for its remedy. Probably the causes are
numerous and complex. Social habits may
account for a good deal. The French cus-
tom of subdividing land and of providing
a dowry for girls offers an obvious motive
for keeping down the number of children.
Where, as in the west of Ireland, the peas-
antry have a cheap food supply, and are
constitutionally averse to thrift, large families
are the rule ; but in France thrift is a virtue
carried almost to excess, and the obligation
of the parents to provide for each new ac-
cession to the family is clearly recognized.
Moral causes have been supposed to play a
large part in the arrest of the population of
France, and we are far from under-estimat-
ing their importance, but this is a difficult
and delicate problem, on which it would

be rash to dogmatize without the most ample
evidence.

While some of the causes of the phenom-
enon under' discussion may be obscure and
remote, others lie under our eyes, and can-
not be too carefully scrutinized or too
frankly acknowledged. In a recent address
before the Academie de Medicine, Dr. Brou-
ardel, drew attention to the abnormal mor-
tality from small-pox and typhoid fever
which prevails in France. He points out
that while Germany loses only no persons
per annum from small-pox, France actually
loses 14,000. Dr. Brouardel attributes this
astounding difference to the rigid way in
which vaccination is enforced in Germany,
and to the carelessness of his own country-
men in this matter. Statistics show that in
1865, when vaccination was not obligatory
in Prussia, the mortality was 27 per 100,000
inhabitants. After vaccination was enforced
the mortality fell in 1874 to 3.60 per
100,000, and in 1886 to 0.049. At. the pres-
ent time the mortality from this cause in
France is 43 per 100,000. We make a present
of these figures of Dr. Brouardel to the
Royal Commission on Vaccination.

As regards typhoid fever the deaths due
to this disease in France amount to 23,000
per annum. Dr. Brouardel gives a great
variety of statistics to show that the liability
to typhoid is in direct proportion to the im-
perfections in the water-supply, and that in
proportion as a sufficient supply of pure
water is provided, typhoid abates. Thus, at
Vienne the typhoid mortality was 200 per
100,000 while the inhabitants drank surface,
hence often polluted, water ; but this mor-
tality fell to 10 per 100,000 on a thoroughly
good supply being obtained. At Angouleme
the introduction of a new supply of pure
water reduced the number of cases of ty-
phoid in the proportion of 0.063 t0 J8- At
Amiens, among the military population, the
typhoid mortality fell from in per 10,000
to 7 when a pure supply of water was se-
cured by a/tesian wells. At Rennes the in-
habitants formerly drank from contaminated
wells, with the result that typhoid fever was
always endemic. The introduction of pure
water reduced the deaths from typhoid
among • the military population from 43 per
10,000 to 2. Investigations carried out at
Besancon, Tours, Carcassonne, Paris and
Bordeaux entirely corroborate the above
striking figures. Typhoid fever is responsi-
ble for the deaths of 1 soldier in 335 in
1 France, or 298 per 100,000, and this in time

Jan.- 2.4, 1 89 1. Notes and

Comments.

ii5

of peace. In war its ravages are even far
greater. Thus the expeditionary corps to
Tunis in 1881, consisting of 20,000 men,
had 4,500 cases of typhoid with* 884 deaths.

Dr. Brouardel concludes by affirming that
if vaccination and re-vaccination were ren-
dered obligatory in France, and if the towns
were everywhere supplied with pure water,
the country would save from 25,000 to
30,000 lives annually, and these, for the
most part, of young persons of marriageable
age. He therefore proposes to the Academy
to adopt the following conclusions : " That
the sanitary law in preparation ought to ren-
der vaccination obligatory ; it ought to fur-
nish sufficient authority to the municipali-
ties, or in their default the Prefect or the
Government, to secure the public health
against the dangers which result from using
polluted water."

In the discussion which followed Dr.
Brouardel's communication many important
points were elicited. One speaker drew at-
tention to the evils which arose from cheap
lodging-houses. Another insisted upon the
superiority of supplying pure water to any
methods of filtration. At Angouleme filtra-
tion was tried with some advantage, but the
provision of a pure supply proved much
more successful.

We may learn something from the anxie-
ties of our neighbors. If the outcry against
compulsory vaccination now prevailing in
some quarters in this country should unhap-
pily effect any slackening in our vigilance
in this matter, we shall surely pay the pen-
alty in a heavier mortality from one of the
most loathsome of diseases. The example
of Germany in this matter is admirable and
cannot be too widely known or too care-
fully followed. The provision of an absor
lutely pure supply of water to our large
cities is a much more difficult problem than
the thorough enforcement of vaccination,
but it is at least the ideal towards which our
efforts must be directed. It is an immense
gain to know positively both the source of
danger and the means of averting it, and
we must never rest content so long as an ac-
knowledged source of disease, misery and
national weakness is permitted to exist in
our midst. — Lancet, December 20, 1890.

Apomorphia.

In the Medical Record, December 6,
1890, Dr. J. S. Horsley, of West Point, Ga.,

has an article, in which he advocates the use
of apomorphia to control spasmodic seizures
of various kinds. He describes the results
which followed its administration in four
cases under his care, in all but one of which
it is probable (in our opinion) that the effect
was wholly due to the relief produced by
vomiting.

However, we may quote what Dr. Horsley
says, so that he may speak for himself. He
says he could mention other cases illustra-
tive of the beneficial effects of apomorphia,
but he thinks the cases cited sufficient to
present this new use of the remedy ; that of
preventing and controlling convulsions, and
other motor disturbances. He has seen so
little written on the uses of apomorphia and
that usually in relation to its action as an
emetic, that he concludes that it is not ap-
preciated at its full value by the profession.
He has not been able to find any report of
the use of apomorphia in motor disturbances
for other than the relief to be expected from
emptying the stomach, except a case in which
a German physician succeeded in cutting
short epileptic attacks by the subcutaneous
injection of apomorphia during the aura;
while Dr. Edward Cockrell, of England, is
reported to have successfully treated infan-
tile convulsions by its use. It is not stated
whether the convulsions resulted from gas-
tric disturbance or not ; but as that is the
usual cause of convulsions in children, we
may suppose that its emetic action was
sought in this case. The remedy has hith-
erto been used principally for its emetic ac-
tion, and this was Dr. Horsley' s object in
using it, until he accidentally found that it
controlled the spasms produced by strych-
nine poisoning. Since that time he has
been using apomorphia for all convulsions,
and in no case has he yet been disappointed
as to the result. He calls attention to the
fact that it arrests or prevents spasms and
other motor disturbances. From the results
obtained from its use in his limited experi-
ence, he confidently expects it to control any
spasm not caused by lesion of the brain or
spinal cord.

It is quite probable that this remedy will
be of service in controlling the spasms dur-
ing an attack of tetanus or rabies. He has
had no opportunity of testing its value in
either case, but from the analogy existing
between these affections and poisoning by
strychnine, Dr. Horsley thinks we might
reasonably give it a trial in these affec-
tions.

n6

Notes and

Comments.

Vol. lxiv

Pathological Anatomy and Patho-
geny of Ecthyma.

Leloir and Vidal discuss the pathological
anatomy and pathogeny of ecthyma at con-
siderable length in the Gazette Hebdoi?ia-
daire, November 15, 1890. They define
ecthyma as an auto-inoculable and inocu-
lable disease of the skin, characterized by
large, round, globular pustules with a hard
base, the pustules being succeeded by brown-
ish crusts which leave on falling off more
or less apparent cicatrices. Vidal believes
that he has to a great degree contributed
towards establishing the fact that ecthyma is
a disease by itself, distinct from impetigo
and other diseases. It always leaves an in-
delible trace, a cicatrix more or less depressed
and apparent according as the chorion
has been more or less injured. Leloir and
Vidal have inoculated skin and mucous mem-
branes with the pus from various tissues and
inflammations and have invariably failed to
produce ecthyma. On the other hand, the
pus from true ecthyma, when inoculated or
auto-inoculated, reproduces a characteristic
ecthymatous pustule, which reaches its height
on the fourth day ; and, from this one,
another series of pustules can be obtained,
up to five successive generations. Excep-
tionally a sixth generation can be obtained,
but usually the reproductive power lessens
with each successive crop.

Simple ecthyma usually runs an acute
course. Its duration, which is ordinarily a
few weeks, can be abridged by treatment to
a few days. If uncared for, and in debili-
tated persons or such as are addicted to al-
cohol, it may pass to a chronic state, either
by successive auto-inoculations which per-
petuate the duration, or by giving place to
chronic ulcers.

If it appears probable that in a certain
number of cases at least ecthyma is caused
by the entrance of micro-organisms into the
epidermis, this has not yet been demon-
strated absolutely. Up to the present time
no one, as far as Leloir and Vidal know, has
succeeded in producing ecthyma by inocu-
lating cultures more or less pure of its mi-
cro-organisms. Possibly the alkaloids pro-
duced by the organisms are also necessary.
But the question of causation is more com-
plex than it seems at first sight, for lesions
having all the characteristics of ecthyma
have been seen to follow affections of the
nervous system. It is also certain that in a
number of cases ecthyma is produced by

toxic chemical agents coming from without,
and, in certain cases, perhaps, secreted by the
organism and eliminated by the skin ; but
Leloir and Vidal do not say whether or not
they consider these agents sufficient to pro-
voke suppuration in the absence of micro-
organisms.

Influence of Tobacco-Smoking on the
Stomach.

In the Vratch, No. 48, 1890, p. 1091,
Dr. N. I. Jdan-Pushkin, of St. Petersburg,
writes that in order to study the action of
tobacco-smoking on the gastric functions,
he has undertaken a course of experiments
on seven healthy young men, aged from 17
to 27, all of them being habitually non-
smokers. In each instance, the experiment
lasted nine days, being divided into three
equally long periods, during the second of
which the subject was smoking 25 cigarettes
a day. Briefly told, the following conclu-
sions were reached by the author. 1. To-
bacco-smoking increases the secretion of the
gastric juices, but at the same time lowers
its general acidity. 2. It also decreases
the proportion of free hydrochloric acid in
the juice, and that in a direct ratio to the
fall of the general acidity. 3. The dimi-
nution of the proportion of free hydrochlo-
ric acid, as can be expected, leads to weak-
ening of the digestive powers of the juice.
4. Tobacco-smoking retards the secretion of
the rennet-ferment (Hammarsten's Lab-fer-
?nenf), as shown by a marked retardation of
curdling of milk after the addition of the
juice. 5. All the changes prove to persist for
a couple of days after discontinuing smoking.
6. The motor and absorptive powers of the
stomach, however, are somewhat increased
by the use of tobacco [meanwhile Drs. Tciid-
novsky, Grammatchikoff, and Ossendowski
have found that smoking retards the passage
of food from the stomach into the duo-
denum.— Reporter]. 7. Smoking does
not manifest any influence on the acidity of
the urine. On the whole, the author seems
to entertain rather unfavorable views in re-
gard to tobacco-smoking. Amongst other
things, he points out that the weed de-
presses the assimilation of proteids (as Gram-
matchikoff's and Ossendowski' s experiments
have shown), raises the bodily temperature
and accelerates the pulse (Prof. I. V.
Troitzky), causes sometimes dyspepsia, con-
stipation, meteorism and other gastro-intes-

Jan. 24, 1 89 1. Notes and

Comments.

117

tinal disturbances (Treumann, Dubois),
produces cardiac neuroses, failure of vision,
etc., etc.

Micro-Organisms in Cities.

Professor Tarnier in his course of lectures
on obstetrics, in 1890, referred to M. Mi-
quel's researches on the relative abundance
of micro-organisms in different places. One
to the cubic meter of air is the proportion at
the top of a high mountain. In the Pare de
Montsouris in the south of Paris, M. Miquel
found 480 micro-organisms to the cubic me-
ter of air, whilst in the Rue de Rivoli the
proportion was 3,480. In a new room in
the Rue Censier he found 4,500 to the cubic
meter ; more, that is to say, than in the
centre of Paris in the open air. In a room
in the Rue Monge, he counted 36,000, in
the Hotel Dieu 40,000, and in the Pitie, an
Older hospital, 319,000 micro-organisms to
the cubic meter. At the Observatory Mont-
souris, 650,000 microbes were found in a
gram (15 grains) of dust; in the room in
the Rue Monge the amount was 2,100,000.
In the hospitals the proportion was so high
that counting the number of microbes in a
whole gram of dust was found to be impos-
sible. The dust is the great conveyor of
micro-organisms. At 2 a. m., when a city
is most quiet, the fewest germs are to be
found in the air ; at 8 a. m. the industry of
domestic servants and dustmen has already
made the air to teem with germs. At 2 p. m.
the proportion has again greatly fallen ; at 7
p. M. it is once more high, for many houses
are being " tidied up"; besides sundry
kitchen operations are unhygienic. Thus the
" small hours " unfavorable in many respects
to patients hovering between life and death,
are the least septic of the twenty-four. The
day proportions indicate that household
duties cause more septic diffusion than is ex-
cited by traffic and industry. — British Med-
ical Journal, November 15, 1890.

" Antifebrinization " in Typhoid
Fever and Consumption.

According to the Wiener med. Presse,
October 19, 1890, Dr. Favrat has made
numerous trials in the clinic of Prof. Sahli,
of Berne, of " antifebrinization " with
minute doses of antifebrin. He communi-
cates a paper on the subject to the Archiv
fiir klin. Medicin, Bd. 46, and recommends

the practice in typhoid fever and consump-
tion. He says that antifebrin in doses of
from five to ten centigrammes of a grain
to one and one-half grains), is well borne by
patients with typhoid fever and phthisis. It
produces a gentle antipyresis which is grateful
to the patient, and, administered in the
way just mentioned, to a great degree the
evils of large doses are avoided. In chil-
dren it is proper to begin in all cases with
doses of one-sixth or one-third of a grain.
In typhoid fever the administration of the
minute doses in the way described causes a
lowering of the fever and an improvement
in the subjective sensations of the patient.
The hectic fever of phthisical patients is also
overcome and the patient made more com-
fortable. The remedy acts better the higher
the fever. In phthisical patients a dose of
from five-sixths of a grain to one and one-
half grains sometimes suffices to depress the
temperature more than three and three-fifths
degrees Fahr. In cases in which antipyresis
is long continued the patient becomes grad-
ually accustomed to doses that were at first
effective. It is then best not to increase the
dose but to stop jthe remedy for a time or to
substitute another for it. Later on the doses
used at first will again be found effective.

Abortion for Vomiting of Pregnancy.

Dr. Henry Fruitnight, of New York, in
the American Journal of Obstetrics, Decem-
ber, 1890,. gives a review of the subject of
inducing abortion for the vomiting of preg-
nancy, with description of cases, and says :

" From these histories the following de-
ductions can be drawn : First, that when
nature spontaneously interrupts the course
of pregnancy by the occurrence of prema-
ture delivery, the patient recovers. Sec-
ondly, that when pregnancy is allowed to
proceed uninterruptedly to its natural termi-
nation, an almost certain fatal result will
befall both mother and child. Thirdly,
that when the patient, the victim of grave
vomiting, is permitted to advance too far in
the course of pregnancy before the opera-
tion of induction of premature labor is
done, the probability is that she will not be
able to resist the added shock of the opera-
tion in her already debilitated condition, but
will succumb. Fourthly, that when the opera-
tion is done secundum artem, at the properly
elected period of time, the probability is
that we will save the life of the mother in

n8

Notes and

Comments.

Vol. lxiv

any event, and in many instances, in proper
cases, the lives of both mother and child.
And upon these deductions the following
conclusion is based : When hyperemesis se-
riously and dangerously affects the health of
the woman, and does not respond to a judi-
cious and systematic course of treatment
with all known and approved remedies, then
the operation of the induction of premature
labor in such cases is at once justifiable and
the only thing left for us to do."

Women and Women Physicians in
India.

The Indian Medical Gazette, November,
1890, says that the native women frequent-
ing the Balrampur Hospital, Lucknow, are
so much behind the age that they elect the
services of male in preference to female
doctors. This is what Dr. Rice, the Inspec-
tor-General of Civil Hospitals, says on the
subject : — " With regard to the 934 major
surgical operations done in the female hos-
pitals, it is but right that I should state that
the large majority of them have been done
•by the Civil or Assistant Surgeons, and this
is right generally. The greater part of them
are of a nature unconnected with the sex of
the sufferer. I have myself seen women in-
sist that the operations should be done by
the male doctor : and not only that, but that
they should be done in the male hospital, so
as to make sure of his operating. The prin-
ciple of management is that, as far as we are
concerned, every women shall be left a free
agent in the selection of the particular di-
vision of the hospital in which she shall be
treated."

Hydrate of Amyl in Epilepsy.

In a recent number of the Therapeutische
Monatshefte the experience of the use of this
drug in doses of from five to eight grams
per day, in the cases of seven epileptics, is
related. Two of the patients, previously
subject to from nine to eleven attacks per
month, remained free from them as long as
the drug was taken; in a third improvement
seemed to take place at first ; in the remain-
ing four no appreciable effect was produced
on the number or severity of the fits. In
all seven there was produced by the drug a
great desire for sleep, and after it was left
off the rest was disturbed ; and in cases in
which previously sleep had been sound and

undisturbed, it now became light and
broken. In three patients, also, after the
medicine was left off, there were for several
days series of fits, although those patients
previously had not, as a rule, had more than
one or two convulsions in the day.

A Laryngological Curiosity.

The Medical Press, December 3, 1890,
states that at a recent meeting of laryngol-
ogists in London, Mr. Lennox Browne de-
scribed the case of a middle-aged woman who
was sent to him from the provinces for the
purpose of deciding whether her malady was
laryngeal cancer or phthisis. Though a tall,
large-boned woman, she only weighed a lit-
tle over ninety pounds, and was obviously
very much emaciated. He peeped down
her larynx and to his surprise saw what he
recognized to be a plate with artificial teeth
firmly impacted in the larynx, where it had
been for the last twenty-two months un-
known to the patient. She remembered
having been awoke in the middle of the
night by a violent fit of vomiting, and when
the teeth were inquired after it was assumed
that they had been thrown away with the
dejections. From that day forth, however,
she suffered from difficulty in breathing, pain
on swallowing, etc. , associated with progres-
sive emaciation. With some difficulty the
plate was removed and exhibited to the ad-
miring friends, and the patient rapidly re-
covered health and spirits.

Raori Resin.

The Druggists'1 Circular, December, 1890,
says that a report from Noumea, by M. For-
met, speaks favorably of the use of Raori resin
— otherwise called Sydney gum or Caledo-
nian balsam — as a suitable medium for the ex-
ternal application of antiseptics. It forms
a coating over wounded surfaces. In cuta-
neous affections it is of great service ; and
also in the treatment of sprains and frac-
tures when the limb must be kept rigid.

Disguise for Cod-Liver Oil.

A mixture of equal parts of cod-liver oil
and lime-water is said to be nearly tasteless,
but may be made more palatable by the ad-
dition of an aromatic syrup.

Medical and surgical
Reporter &.

A Weekly Journal. Established in 1853 by S. W. Butlee, M. D

CHARLES W. DULLES, M. D., Editor and Publisher,

Entered as Second-Class matter at Philadelphia P. O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

Vol. LXIV, No. 5.
Whole No. 1770.

JANUARY 31, 1891.

B5.00 per Annum.
10 Cents a Copy,

COZLSTTZEXSTTS :

CLINICAL LECTURE.

Montgomery, E. E., M. D., Philadelphia, Pa.—
Vaginitis ; Its Causes, Diagnosis and Treatment.
—Diagnosis of Death of Fetus in Utero 119

COMMUNICATIONS.

Highley, George N., M. D., Conshohocken, Pa.
—Hygiene of Infancy 122

Eichler, Alfred, M. D., San Francisco, Cal.—
Re<orcin 124

Ward, Stanley M., M. D., Scranton, Pa.— Fatal
Hemoptysis Following Typhoid Fever 126

Morris, J. Cheston, M. D., "Philadelphia, Pa.— Re-
marks on Influenza 127

Booth, David S., Jr., M. D., Belleville, 111.— Pelvic
Abscess in a Man ; Spontaneous Cure of Hernia. 128

PERISCOPE.

Resection of Prostate for Enlargement.— Products
of Pathogenic Bacteria.— Antipyrin in Puerperal
Fever.— Massage in Eye Diseases.— Unconscious
Parturition in a Primipara.— Making Beef-Tea.
—How to Apply Forceps — On Oscillations in
the Bodily Weight in Enteric. Fever. — Hydro-
phobia in Egypt.— Flexible Wire St emsfor Sten-
osis of the Cervix.— The Teeth in Epilepsy.—
Southern California as a Health Resort 129-13fi

EDITORIALS.

Medical Examiners and Medical Education.

Legal Restraint of Inebriates

Barking Cough of Puberty

BOOK REVIEWS.

137
138
139

Roberts; A Manual of Modern Surgery.— Pow-
ell ; Essentials of the Diseases of Children.. 140-141

LITERARY NOTES 141

I CORRESPONDENCE.

Wound of Rectum 141

I NOTES AND COMMENTS.

State Board of Medical Education.— Endorsing
Medical Examiners' Bill.— Philadelphia Poly-
clinic—The Copyright Bill.— Bone Grafting.—
Public Health in New Jersey.— The Relief of
Pruritus— Use of the Obstetrical Department of
the Philadelphia Hospital for Teaching. — Noth-
ing New Under the Sun.— Action of Salol on the
Kidneys.— Kola Essence Stimulant 141-147

NEWS 147

OBITUARY.— Robert A. Taylor 148

CH. MARCHANO'S

Peroxide of Hydrogen

(MEDICINAL) H2 02

(Absolutely Harmless.)

Is rapidly growing in favor with the medical profession, it is the
most powerful antiseptic known, almost tasteless, and odorless.
Can be taken internally or applied externally with perfect safety.
Its curative properties are positive, and its strength and purity
can always be relied upon. This remedy is not a Nostrum.

a remedy for DIPHTHERIA ; CROUP ; SORE THROAT,

AND ALL INFLAMMATORY DISEASES OF THE THROAT.
OPINION OF THE PROFESSION.
Dr. E. R. Squibb, of Brooklyn, writes as follows in an article headed "On the Medical Uses of Hydrogen Peroxide (GaillarcTs
Medical Journal, March, 1889, p. 267), read before the Kings County Medical Association, February 5, 1889 :

"Throughout the discussion upon diphtheria very little has been said of the use of the Peroxide of Hydrogen,
or hydrogen dioxide ; yet it is perhaps the most powerful of all disinfectants and antiseptics, acting both chem-
ically and mechanically upon all excretions and secretions, so as to thoroughly change their character and
reactions instantly. The few physicians who have used it in such diseases as diphtheria, scarlatina, small-pox,
and upon all diseased surfaces, whether of skin or mucous membrane, have uniformly spoken well of it so far as
this writer knows, and perhaps the reason why it is not more used is that it is so little known and its nature and
action so little understood. . . . Now, if diphtheria be at first a local disease, and be auto-infectious ; that
is, if it be propagated to the general organism by a contagious virus located about the tonsils, and if this virus be,
as it really is, an albuminoid substance, it may and will be destroyed by this agent upon a sufficient and a suffi-
ciently repeated contact. ... A child's nostrils, pharynx and mouth may be flooded every two or three
hours, or oftener, from a proper spray apparatus with a two volume solution without force, and with very little
discomfort; and any solution which finds its way into the larynx or stomach is beneficial rather than harmful,
and thus the effect of corrosive sublimate is obtained without its risks or dangers. . .

Further on Dr. Squibb mentions that Charles Marchand is one of the oldest and best makers of Peroxide
of Hydrogen, and one who supplies it to all parts of the country.

CAUTION.— By specifying in your prescriptions "Ch. Marchand's Peroxide of Hydrogen (Medicinal')," which is sold
only in %-lb., %-\b., and idb. bottle>, bearing my label aud signature, you wdl never be imposed upon. Never sold in bulk.

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For further information address BURN BRAE, CliftOll Heights, Delaware CO., Pa,

MEDICAL AND SURGICAL
REPORTER

No. 1770.

PHILADELPHIA, JANUARY 31, 1891. Vol. LXIV.— No. 5

Clinical Lecture

VAGINITIS; ITS CAUSES, DIAGNO-
SIS AND TREATMENT.— DIAG-
NOSIS OF DEATH OF FETUS
IN UTERO.

BY E. E. MONTGOMERY, M. D.,

PROFESSOR OF GYNECOLOGY IN THE MEDLCO-CHIR-
URGICAL COLLEGE ; OBSTETRICIAN TO THE
PHILADELPHIA HOSPITAL.

Gentlemen : Our first patient is a colored
woman, thirty-five years old. She presents
the following history. Her mother died of
phthisis, and she herself was never very
strong. She menstruated for the first time
at sixteen ; the flow was full, free, painless,
and lasted on the average for three days.
She has had four children, all living and
well, has never had a miscarriage, and there
is no history of venereal trouble. She
menstruated the last time, the eighteenth of
this month ; after the cessation of the flow
she felt sick and weak, and had considerable
pain in the lower part of the abdomen, at-
tended with a vaginal ^discharge, purulent
in character. Her appetite is poor ; her
temperature on admission was between 1020
and 1030, and has since ranged a little
lower. Her abdomen is distended and
tender, although there is no increase in ten-
derness upon pressure. Upon separating
her limbs we see that the vulva is red in
color, large, and with the posterior wall of
the vagina protruding through it. The
perineum, usually an inch and a half in
length, is here only about half an inch
long. The walls of the vagina are red and
angry looking, showing at a glance that
there is inflammation of the vaginal mucous
membrane.

Inflammations of the vagina are divided
into acute and chronic, specific and non-
specific, catarrhal, diphtheritic, follicular

and granular. Before entering upon the dis-
1 cussion of the symptoms and causes of the
disease, it is well that we should devote a short
time to the consideration of the anatomy of
1 the vagina. The vagina, as you know, is a
passage which leads from the vulva to the
uterus. It is a musculo-membranous canal,
and serves as the organ of coition and to
I convey the discharges from the uterus, and
also affords passage for the fetus in parturi-
tion. Its wall consists of three layers — an
I outer layer of areolar tissue, a middle or
muscular, and the internal, or mucous raera-
1 brane. The mucous membrane is lined
with pavement epithelium, resembling very
I closely that of the integument ; this resem-
I blance is still more marked where the vagina
is exposed to the air or to friction with the
i clothing or limbs. The mucous membrane
of the uterus has a columnar epithelium,
\ this terminates at the external os. The mu-
cous membrane of the vagina is thrown into
folds called rugae. Under inflammatory
I conditions, the swelling of the mucous
membrane leads to the obliteration of these
folds, and the outer layer of the epithelium
is thrown off, so that it presents a smooth,
glazed appearance, and imparts to the finger
the sensation of passing over velvet or satin.
, In such inflammation we find : First, the
; mucous membrane becoming dry, hot and
glistening ; later there is increased secretion,
the discharge presenting a whitened appear-
ance from the presence of desquamated
l epithelium, or it is yellowish and greenish
from the presence of pus and broken down
! blood. These latter conditions occur where
I the desquamation has gone on to the forma-
j tion of points of ulceration.

Vaginitis may be caused as follows :
i First, from contact with specific poison ;
! second, from the contact of various me-
i chanical agents, such as may be used in the
I vagina for disinfecting or examining ; third,
! from traumatism due to parturition, exces-
sive or violent coition, or by the use of the

1 TO

120

Clinical

Lecture.

Vol. Ixiv

pessary ; fourth, discharge from the uterus
or sinuses, from abscesses opening into the
vagina, such as pyosalpinx, or from the sac
of an extra-uterine pregnancy.

In this patient the cervix is hard and
firm, the body of the uterus is less resisting
and is somewhat enlarged and flabby, it
sags down from its increased weight, so that
it is sometimes felt in a retroverted and at
other times in an anteverted position. The
tympanitis and tenderness show that there
is threatened pelvic trouble, and extension
of the trouble through the uterus into the
Fallopian tubes, suggesting a possible peri-
tonitis. This, is still further demonstrated
by the temperature and constitutional symp-
toms.

It is very difficult to distinguish between
specific and non-specific vaginitis. Fre-
quently the use of the microscope is essential
to demonstrate the presence or absence of
the specific micro-organisms in the dis-
charges. It is not necessary that the dis-
charge be specific in order to be infectious.
Urethritis in the male may be easily devel-
oped by contact with the discharge from an
endometritis. In this patient the condition
is, without doubt, non-specific, from the
rapidity with which the symptoms are sub-
siding under the simple method of cleanli-
ness, which has been used. If it were
specific, so marked an improvement would
not occur so rapidly, or under such simple
treatment. The purulent character of the j
exudation shows that the following process
has occurred : the desquamation of the
epithelium was followed by its decomposi-
tion, which, in its turn, produced inflamma-
tion, resulting in ulceration ; the watery,
milky discharge became yellowish and
greenish in its appearance, and more viscid
in its consistency. Bumm, in his investi-
gation of the subject, has come to the con-
clusion that the vagina is rarely or primarily
the seat of the specific infection ; because
the pavement epithelium, in its normal
condition, proves a resisting wall to the
entrance of the germ, while the columnar
epithelium in the cervix affords a much more
ready opportunity for its entrance, and is
the common seat of its origin, while, from
this point, it spreads to the vagina. Where
the vagina has been the seat of repeated in-
flammation, a new inflammation sets up
more quickly and extends with greater
rapidity. On the other hand, the inflam-
mation is more likely to spread to the
uterus and tubes ; and it is for this reason

that we find tubal disease so frequently as a
result of specific disorder. I would not
wTish to be understood, however, as affirming
that all causes of tubal and ovarian trouble
are due to specific origin ; it is unjust to the
character of many of our patients to assert
this. Exposure to cold or dampness, the
introduction of septic material through ex-
amination, either by the finger or by the
use of instruments, may readily produce
similar disorders in a patient who has been
subjected to an inflammatory condition of
the tubes, and who is very susceptible to re-
curring attacks upon the slightest exposure.
Catarrhal inflammation in the tubes leads to
increased discharge. So long as this can
make its exit through the uterine end, the
patient suffers but slight inconvenience ;
when the latter becomes contracted, as a
result of the swelling of its mucous mem-
brane, the discharge is likely to regurgitate
into the peritoneal cavity, where it leads, at
once, to inflammation which seals up the
abdominal end of the tube. A sac is thus
formed in which fluid is likely to accumu-
late, producing a condition known as hy-
drosalpinx. If septic germs, by any means,
come in contact with it, we may have the
fluid change, producing a pyosalpinx.
Where the distended vessels rupture, and
the tube becomes filled with blood, it is
known as a hematosalpinx. As a sequel to
inflammations which have extended from
the vagina, we may have an irritable condi-
tion of the peritoneum at the tubal orifice,
which is excited at each menstrual period,
producing abdominal pain and tenderness
similar to the irritation of the upper lip and
margin of the nose from a catarrhal condi-
tion of that organ. Another possible sequel
is extra-uterine pregnancy. Under the
inflammatory process, we have the mucous
membrane losing its ciliated epithelium,
producing denuded points, or again the
Fallopian tube is flexed, constricted, or so
bound down as to have lost its peristaltic
action, and the passage of the ovum to the
uterus is delayed or hindered. On the
other hand, the spermatozoa may find their
way through the tube to the delayed ovum,
leading to its fecundation and development
in this situation. This is the theory for the
development of tubal pregnancy. The ad-
vocates of this theory deny the possibility
of abdominal pregnancy, except as second-
ary to rupture of the tube and escape of its
contents into the abdomen. It does not.
however, seem any more difficult to believe

Jan. 31, 1 89 1. Clinical

Lecture.

121

that the ovum, having been fecundated in
the abdominal cavity, may find opportunity,
possibly from the previous irritation of the
peritoneum, for its nutrition and develop-
ment, than that the contents of the tube
should take on new attachments after they
have ruptured that organ. The possibility
of abdominal pregnancy has been demon-
strated in a case in which the uterus was
removed supra-vaginally, an ovary having
been left. Pregnancy occurred in this case
and led to the death of the patient.

In the treatment of vaginitis, many cases
are relieved by no other measure than strict
attention to cleanliness, as in this patient,
for whom the treatment has been simple
washing out of the vagina with hot water,
or hot water containing boric acid, which
has here led to the subsidence of all the
symptoms. Inflammation may be kept up
by the want of removal of the exudations ;
frequent irrigating removes this material.
In more severe inflammation of the mucous
membrane, irrigation with astringent reme-
dies is very beneficial. Avoid syringes
which force the water with violence into the
vagina. Use in preference a fountain syr-
inge, placed about three feet above the pa-
tient, and allow it to be used while she is in
a sitting or semi-sitting position, to permit
a free return of the fluid, whereby ballooning
of the vagina is prevented. Inject several
times, two quarts, of water at one sitting.
Keep the nozzle of the syringe below the
uterus, and move it about, this precludes the
entrance of water into the uterus, which
might give rise to violent attacks of uterine
colic and increase the danger of septic ma-
terial being washed into it. One of the
most effective preparations for injection is a
sublimate solution in the strength of 1, 2, 3 or
4 to 1,000; which may be followed by some
astringent, such as sulphate of zinc — 40 to
60 grains to the quart. Acetate of lead,
gallic acid, tannic acid or extract of hy-
drastis (which is another form of tannic
acid), may be used. If the removal or
sterilizing of the discharge is incomplete, it
is important to supplement this treatment
by placing the patient in the Sims' s position
and go over the mucous membrane with a
mop, containing some such agent as nitrate
of silver, in a two per cent, solution. By
the use of a Sims' s speculum it is possible
to reach the summit of the posterior and
anterior fornices of the vagina, and the pos-
terior surface may be reached as the instru-
ment is withdrawn. In very many cases the

application of the remedy with a spray is a
very effective method, as the evenly-divided
material is driven into the cracks and crev-
ices not touched by the mop.

Where extensive ulceration exists, still
further treatment is essential. The vagina
must be tamponed to keep the surfaces
apart. Gauze is the best agent for this, and
that made with iodoform is the least irri-
tating. This can be packed in lightly, or
the whole vagina may be plugged. The
gauze can be placed in dry, or wet with
some antiseptic solution.

In follicular vaginitis this treatment does
not suffice. In such cases we find the true
layer of epithelium is gone, and in its place
is a growth of papillae. It is necessary to
destroy these papillae. Generally the best
agent for this purpose is the thermo-cautery.

There is a form of granular vaginitis
which is apt to occur in women of intem-
perate habits, especially if they have passed
the climacteric. It is in reality a senile
vaginitis, and is likely to proceed as long as
indiscretions in diet and drinking are kept
up.

Vaginitis is likely to appear in plethoric
subjects with a gouty diathesis. In the lat-
ter case all blood conditions must be im-
proved. In all cases, remember that there
is danger of extension if the case is not
properly treated. In displacement of the
uterus its cavity may be dilated. Its con-
tents are not freely drained, and may be
discharged at intervals, giving rise to the
impression on the patient that she has had
an abscess discharge. This material is ex-
ceedingly irritating, and invariably gives
rise to inflammation of the vagina.

From what I have said of the cause and
treatment of vaginitis, you will readily per-
ceive the importance, in every case, of ex-
amining carefully as to the conditions which
may have originated it, and of directing
your treatment to correction of the condi-
tions by which it has been caused. This
demonstrates that you cannot divorce the
special from the general practitioner with-
out disadvantage to the doctor and patient.

Death of Fetus in Utero.

Our next patient is another colored
woman, twenty-three years old. She has
always had good health, and seven years
ago gave birth to a child at seven months.
Since that time she has been regular. She
saw her menses last in March of this year.
She has suffered with nausea, which was

122

Communications.

Vol. lxiv

brought under control ; and movements of
a fetus were felt in August. But at each
monthly period she has had a slight appear-
ance of the menses. She has reached the
seventh month of pregnancy, but the ques-
tion we have to decide for her, is : Is her
child living ? She has felt no fetal move-
ments for two weeks. The fetal movements
are usually felt first at four and one-half
months, so women are accustomed to reckon
from this period four and a half months to
the time of the expected confinement. This
is, however, unreliable as a date, as move-
ments have been felt, occasionally, as early
as the fourteenth week ; and Underhill has
mentioned a case in which the patient felt
the movements at the eleventh week. The
first sign is a sliding, gliding, quivering
movement, which usually gives rise to nau-
sea, faintness or sickness. It has occurred,
however, that the woman would go through
the entire period without a single movement
of the fetus. This is due to the fact that
the fetus is held tightly in the membranes,
which contain but little fluid, so that its op-
portunity for movement is slight. The ab-
sence of fetal signs is not, then, a positive
indication of disease or death of the fetus.
Ordinarily at the seventh month the fetal
movements become stronger and more fre-
quent. Sudden death of the fetus is often
preceded by violent convulsive movements,
followed by subsequent total cessation. This
may be due to some disease in the fetus or
in the placenta, or to twisting or knotting
of the cord. When the fetus dies the ab-
dominal walls become flaccid, and the fetus
can be pushed from side to side without ex-
citing any resentment. It lies perfectly pas-
sive, when before it would resist movement
with a kick or blow. Another indication
of death would be the absence of the fetal
heart sounds. These sounds are not always
heard. When the fetus is turned with its
back to that of the mother, and does not
approximate the anterior part of the abdo-
men, the fetal sounds may be absent, and
the fetus still in a healthy condition. If
the sounds have been repeatedly heard and
then suddenly disappear, this, with the
other suspicious symptoms, would justify us
in suspecting the death of the fetus. This
is especially true when external examination
demonstrates the fact that the fetus is in such
a position that its heart sounds should be
readily heard. Fetal death is still further
confirmed when the breasts of the mother
become soft and relaxed. This indicates

that Nature recognizes the fact that there
will be no demand made on them for nour-
ishment. As the dead fetus undergoes
changes, auscultation may give sounds like
crackling and bubbling, which arise from
the generation of gas and its passage
through fluids. The patient will also com-
plain of constitutional impairment and las-
situde. All these signs are present in the
patient before us ; so that I have no hesi-
tancy in saying to her that the fetus is posi-
tively dead. The cause of her trouble is
probably a fatty degeneration in the pla-
centa, by which its vessels are interfered
with, and nutrition is arrested. This trou-
ble is due to a specific cause ; the woman is
syphilitic. [This patient was delivered a
few days later of a macerated fetus.]

Communications.

hygiene of infancy.1

BY GEORGE N. HIGHLEY, M. D.,

CONSHOHOCKEN, PA.

There is perhaps no single topic about
which so much has been written and spoken
as the care and management of infancy;
and I should deem my subject too trite to
bring before this Society, were it not for its
great importance, and for the fact that each
of us has to deal daily with the problems
arising therefrom. Further, it is a duty
which we owe to Science and, greater still,
to Humanity, to constantly observe and
study those facts which will aid us to pilot
the little ones safely over that dangerous
period, during which so many fall victims
to disease and death.

With our advancing civilization Society
is constantly making the infant's environ-
ment more unhealthy ; daily making more
difficult its struggle for existence.

Science is ever giving us new facts about
the cause and nature of disease ; but little
progress is made in their prevention or their
treatment. What does it avail that we are
able to detect the cause of disease in living-
germs, so long as we allow to remain around
us fertile fields for their propagation, and j
have no practical means of protecting the
system from their deadly influence ?

In dealing with the problem, how best to
conserve the health and lives of the little

1 Read before the Montgomery County Medical
Society.

Jan. 31, 1891.

Comm unications.

123

ones — we naturally turn our attention to
those elements and conditions which expe-
rience has shown us to be deleterious to
them. These are : excessive heat, impure
air, water and food, improper kind of food
and food improperly administered, errors in
clothing, bathing, etc. I have purposely
placed excessive heat first on the list, be-
cause its influence in the causation of the
diseases of the digestive system of infants is
greater than all the others combined, taking
them as we usually find them. I do not un-
derrate the evil influence of polluted air and
water and food, and of improper and irregu-
lar feeding ; these are bad enough, to be sure ;
but their harmful effects are decidedly miti-
gated by a cool atmosphere, so that in win-
ter death from a diarrhoeal disease is quite
exceptional. On the other hand, the exces-
sive heat of summer carries off many victims
that have been nursed at the breast and have
had their hygienic conditions as favorable
as possible.

Cases like the following are of frequent
occurrence. A child in the sultry summer
weather becomes peevish and restless ; its
head is hot, its mouth and lips dry. The
mother feels its gums and discovers that it is
teething (it is well to remember that children
are always " teething " during the first two
years of life). Should the infant continue ill,
a physician is summoned ; if no diarrhoea or
vomiting has occurred, he is apt to agree with
the mother, prescribe a bromide or an opi-
ate, or perhaps scarify its gums and pass on.
If there has been stomach and intestinal de-
rangement, he will likely inquire carefully
into the character of its food, the methods
of feeding, etc., correcting any errors in
these. He prescribes some medicines, and
expects that he will find it much better on
the following day. Too often he does not;
too often he finds it with a pinched, anxious
expression, sunken eyes, cold extremities
and with frequent vomiting and purging —
in a word, that it has cholera infantum and
that its chances of life are very slim . It is pos-
sible, perhaps probable, that a large number
of the little patients affected in this manner
would make a speedy recovery if early treated
with cold affusion; and if their mothers and
nurses but knew the important part that heat
plays in causing these complaints and as
diligently guarded their babes against the
ravages of summer's heat as they do against
the chilling influence of winter's cold, chol-
era infantum would have a great many less
victims.

I

If the home is a one or two-story dwelling
in a crowded street, unprotected by trees, or
otherwise, from the glare of the sun, it is
often a difficult matter to shelter the infant
from the external heat. But even in the
most unfavorable conditions, much can be
done. The child should be dressed lightly
— a light, thin woolen shirt (made of the
finest lamb's wool if possible), neatly fitting
and long enough to reach the hips, with a
thin dress, is all the clothing required for
the body. If the weather becomes cooler,
more clothing can easily be added.

The child should also have frequent baths
— not with wash-rag and soap and a basin of
water — but immersed in a tub of water at a
temperature of 850, and less as it becomes
accustomed to it. It should remain in the
water only a few minutes, of course.

The infant should also be taken out regu-
larly in the early morning and in the cool
of the evening, to some locality where it
can have a good supply of pure air. In the
midday let it take its nap in the coolest and
airiest room the house affords; if this is
necessarily a hot one, the morning and
evening rides and the cool baths will do
much to enable its system to endure it.

The thought of pure air and water brings
up questions in general hygiene that I need
not enter into here; it will be sufficient to
repeat a well-known truth, namely, if the
streets, alley-ways and back-yards could be
kept free from all decomposing organic mat-
ter, a most important factor in the etiology
of disease would be removed.

The question of infant feeding continues
to be one of supreme importance. High
temperature and bad food are the two prime
factors in causing the diseases that annually
carry off so many little victims, and in a
measure they depend each upon the other
for their pernicious effect.

It is conceded by all that the natural diet
lof the infant — the mother's milk — is the
best that can be given it. Of the large
number of deaths from cholera infantum in
our large cities, only three per cent, occur
among infants fed at the breast, while over
90 per cent, are bottle-fed babies. Natur-
ally it would seem that every effort ought to
be made to help the mother nurse the child.
I venture the assertion that the person who
can invent or discover a remedy that will
promptly cure an eroded nipple, will have
invented or discovered a means of saving
thousands of human lives.

The second best food for the child is un-

124

Commtmications.

Vol. lxiv

doubtedly cow's milk, modified so that it
shall closely correspond in chemical compo-
sition to mother's milk. There have been
numerous attempts at accomplishing this.
Many mixtures have been devised, and the
market has been flooded with patent foods,
all claiming to be perfect substitutes for the
milk of the mother. A careful comparison,
however, will show that, in nearly all of
them, there is a wide departure from the nat-
ural food. The following mixture, recom-
mended by Dr. T. M. Rotch, in the Cyclo-
pedia of the Diseases of Children, approaches
as near to it as any that I have seen, and
thus far it has answered well in the cases in
which I have tried it. It is really a modifi-
cation of what is known as the " Meigs
Mixture," and is made as follows. For an
ordinary 8-oz. nursing bottle: Milk, i oz.;
lime water, oz.; cream, oz.; milk
sugar, y2 oz. (3^ drams) ; water, 4^ oz.
The objections to this are, that at first its
preparation seems a trifle troublesome, and,
second, that it is somewhat expensive — a
matter of some consideration to the poorer
classes. It is, however, quite as easily pre-
pared as many manufactured infants' foods,
and does not cost any more — at any rate, it
is much less expensive than a funeral.

There are other matters, quite as important
as the kind of food, which should have care-
ful attention. These are : the quality of the
food and the quantity, and the method of
its administration.

Pure, unaltered milk, no matter how it
may be mixed, is absolutely indispensable
to the well-being of the infant. If it can
be procured shortly after it is milked from
the cow, and placed on ice, that is all that
is necessary. If it cannot be obtained un-
til it has been carried around in cans for
several hours, then it should be boiled and
bottled — the mouth of the bottle being stop-
pered with a pledget of cotton — after which
it is placed on ice, or in pans of cold water
if ice cannot be obtained.

Having procured and prepared a good
food, the next question is that of its admin-
istration. Errors in this are frequent and
serious. Early the infant should be taught
to want its food at regular intervals — never
less than three hours. If this be carried
out, errors in quantity will be little likely
to occur. The child's desires will be a good
index of how much it ought to have. The
reprehensible practice of giving babies bot-
tles with long tubes, and letting them alter-
nately sleep and suck for hours, is so obvi- '

ously bad that mere mention of it is suffi-
cient.

Of the various methods of peptonizing
milk, little need be said. For a baby whose
digestion has been temporarily overtaxed,
they may be used with much benefit for a
short period. Used regularly, they do harm
by seriously interfering with the normal di-
gestion— diminishing the secretions of the
natural digestive ferments.

The following rules of guidance seem to
me to be as near correct as the present state
of our knowledge will warrant.

Use every reasonable effort to have the
mother nurse her child. If this is impracti-
cable, endeavor to obtain a supply of pure
cow's milk twice daily if possible. Use the
best means possible to protect the milk from
fermentative changes (or from bacteria if
you choose). Modify it in the way that I
have described, if possible; otherwise give
it pure or simply diluted with water and a
little lime water. Give it at regular inter-
vals, and never at shorter intervals than three
hours. A single feeding should not occupy
over half an hour ; nor, on the other hand,
should the milk be taken too rapidly. After
using, the feeding bottle should be thor-
oughly scalded and cleansed. Clothe the
infant lightly in hot weather. Bathe it fre-
quently, using soap sparingly. Keep it in
the outside air as much as possible, especially
in the early morning and in the cool of the
evening. Above all, remember that heat is
a most important factor in the causation of
disease.

RESORCIN.

BY ALFRED EICHLER, M. D.,

SAN FRANCISCO, CAL.

Resorcin is an article deserving of more
attention than it has hitherto received. It
occurs in rhomboid prismatic crystals, white
and shining in its pure state, with a sweetish
taste and a somewhat pungent smell. If ex-
posed to light or kept in a moist place it will
soon acquire a reddish tinge, but it does not
lose its activity. It is soluble in water and
alcohol, also in ether. Solutions assume on
standing a darker, whiskey-like color, with-
out any impairment of their activity. In
very concentrated solutions it acts as a mild
caustic, if applied to mucous membranes ; it
does not irritate sound skin, however. When
sufficiently diluted it seems to have a sooth-

Jan. 31, 1891.

Communications.

125

ing effect on inflamed surfaces and also on
the mucous membranes. Internally it may
be administered in doses ranging from two
to fifteen grains.

Resorcin belongs to the phenol group ;
its medicinal qualities therefore resemble
somewhat those of carbolic acid. It arrests
fermentation and decomposition, and hence
possesses antiseptic properties like its con-
geners. It is to be preferred to carbolic
acid in all instances when the latter proves
too irritating. Consequently it is especially
useful in all affections of the mucous mem-
branes ; it is then used in aqueous solution,
largely diluted. A three to five per cent,
solution is mostly preferred. In catarrh of
the posterior nares and of the pharynx it is
found to be an excellent application ; it is
also useful in all affections of the upper air-
passages. Here it is preferable to almost
any other antiseptic; an aqueous solution
may be used ad libitum, and can do no harm
if swallowed in ordinary quantity. This
alone would be a good reason to prefer it to
bichloride of mercury or carbolic acid ; but
it also improves the local conditions quickly
and gives great relief to the patient. For
this purpose it can be combined with other
substances. A good formula is presented
by the following :

R Resorcin 2 drachms

Salicylate of soda I drachm

Biborate of soda I "

Glycerine 2 fi. ounces

Water to 8 "

Mix and dissolve. S. Use freely three times daily.

This solution will soften and bring away
all hardened secretion, relieve the conges-
tion and lessen the usual discharge. For
thus cleansing the naso-pharynx a posterior
nares syringe should be used instead of a
nasal douche, which in unskilled hands is
very likely to create mischief, that is, in-
flammation of the middle ear. This can be
caused by the patient performing the motion
of swallowing while the liquid passes the
orifice of the Eustachian tubes, connecting
the naso-pharynx with the middle ear.
During this act the tubes open and a small
quantity of liquid may pass up into the ear
and give rise to a severe inflammation. A
posterior nares syringe will do the cleansing
equally well, if not better, and does not en-
danger the patient. .

In many other affections of the air-
passages does resorcin give great relief.
Whooping-cough, asthma, bronchitis and '

laryngeal ulcers are benefited by it. It is
especially valuable in chronic ailments of
this kind ; it is of less use, however, in the
acute affections, like croup and diphtheria.
It should be applied in diseases of the throat
with an atomizer spray or inhaling apparatus.
A five to ten per cent, solution will serve all
purposes.

Resorcin sometimes acts charmingly in
other diseases of the mucous surfaces ; it is
an excellent injection in all stages of gonor-
rhoea, although it here also produces more
benefit during the latter stages ; in inflam-
mation of the neck of the bladder it may also
be employed. From two to five per cent,
solutions will be the proper strength to use.

During the last few years some of the
leading dermatologists have praised resorcin
as an efficient remedy in various diseases of
the skin, especially those of a fungous origin.
It may be conceded that it does exert con-
siderable influence in this way, but it must
also be acknowledged that rosorcin is much
inferior to chrysorobin in this respect. In
very old skin affections, like eczemas of long
standing, where the skin needs stimulation,
it is quite useful and recommends itself by
not producing any stains or other disagree-
able consequences, besides being completely
harmless.

■ Resorcin may be elegantly dispensed in
ointments having lanolin as abase and con-
taining from 10 to 20 per cent, of the
active ingredients. It can also be applied
dissolved in ether and collodion, and will
then form an excellent antiseptic pro-
tective.

The internal use of resorcin is chiefly
limited to producing its antifermentative
action. In gastric and intestinal catarrh,
dilatation and ulcer of the stomach and in
all those diseases where gases are produced
in the alimentary canal, its use is indicated.
Impure resorcin is said to occasion vomiting,
but, according to Andeer, pure resorcin is
one of the very best and most certain rem-
edies against vomiting, and he says that
it will prove efficient in all possible forms
of vomiting, as in those caused by pregnancy,
kidney and liver diseases, also by sea-sick-
ness and after excessive eating and drinking
of alcoholic liquors. The doses as applied
by him range from five to forty grains. It
is most conveniently administered in
capsules.

Resorcin has also been recommended,
like many other antiseptic drugs, in the
1 strictly septic states, like puerperal fever and

126

Comm unications.

Vol. lxiv

erysipelas. It is of little or no use for this
purpose.

An advantage of this drug consists in
the fact that aqueous solutions of resorcin
possess no smell whatever, and also, that
they may be combined with alkalies in any
proportion without losing their antiseptic
value.

FATAL HEMOPTYSIS FOLLOWING
TYPHOID FEVER.

BY STANLEY M. WARD, M. D.,

SCRANTON, PA.

I have purposely abstained from entitling
this communication hemorrhage, a sequel of
typhoid fever (using the term sequel as it is
commonly used in medicine, viz., as follow-
ing or dependent on the antecedent disease)
for two reasons : first, because of my utter
failure to find anything like it in my search
through the standard medical works and
periodical literature of the day, and secondly,
because the history of the case reveals pecu-
liarities which some may think militate
against this view. I have therefore thought
best to term the hemoptysis a sequel only
as regards time, though I am of the opinion
that it was a sequel both as to time and cause.

History, personal and family of E. B.,
male, 21 years old. Habits excellent ; works
as a skilled laborer in a stove foundry, the
air of which is said to contain minute par-
ticles of iron and steel ; is catcher for a
strong amateur base-ball club and is also an
athlete. During the past three years at long
intervals — just how many times is unknown — -
he has, after severe exertion, spat up a little
blood. He never experienced any ill effects
therefrom, and was always well and hearty.
He works every day, and has lost neither
appetite nor flesh. Mother — the only mem-
ber of the family not living — died ten years
ago of acute pneumonia. Has three broth-
ers and two sisters, who, with the father, are
perfectly well. On August 29 he had a
general feeling of malaise, chilliness, head-
ache, etc. Bowels a little inclined to be
loose. Worked but half the day. On the
30th and 31st, these symptoms continued,
though domestic remedies and fair sized
doses of quinine were taken. He did not
feel sick enough to remain in bed, but did
not work. His appetite was nil. On Sep-
tember 1, he took a short trip, and was gone
all day. On returning in the evening he

remarked that he "never felt so tired before
in his life." He arose the next morning,
however, feeling much as he had before. I
saw him at 2 p. m. of this day, having gained
the information herein given. No record
was made of the last blood spitting, but he
thought it occurred some time in the spring.
A careful examination of the chest revealed
no lesions of heart or lungs — wljich some-
what surprised me. His pulse was 100, his
temperature 102^°; he had had two pas-
sages from the bowels that day, he com-
plained somewhat of pain on pressure over
the abdomen. He also had some headache.
The diagnosis was reserved. On September
3 his morning temperature was ioi^°, and
his bowels had not moved again. He had
no cough. There were one or two poorly de-
fined spots on his abdomen, and slight iliac
gurgling. His mind was clear and he in-
sisted that there was nothing the matter, ex-
cept that he was tired.

I now diagnosticated walking typhoid
fever, and put the patient to bed, ordering
a liquid diet and a few drops of acid to be
taken several times daily, also sponging
with lukewarm water twice daily.

So, for ten days more his symptoms re-
mained. Sometimes his temperature would
reach 1030, and sink to 1010 in the morn-
ing. Sometimes the bowels moved naturally,
and sometimes he required a little glycerine
to secure a stool. A few more spots ap-
peared on the abdomen. Indeed, hardly
a symptom was lacking of a typically mild
case of typhoid fever.

On September 13, his temperature was
990, and on the following day reached to
normal, remaining there also at night. He
now became very anxious to eat, and it was
with some difficulty that his appetite was ap-
peased. On September 16 he sat up and
was partially dressed. On the next day he
walked a little way out of doors, sending a
message to me that his people were starving
him. On September 20 he did not leave
his room, complained of headache and
coughed some ; and these symptoms continu-
ing, I was sent for in the afternoon. I
found him in bed, looking anxious and
tired. He felt certain that a relapse was to
occur, and was much discouraged. His
pulse was 120, his respiration 25, his tem- j
perature 103^°. A short, hacking cough
was very presistent, and his lungs now showed
signs of bronchial irritation, rales of every
kind being plentiful. From all the rational )
and physical signs, I looked for an attack of J

Jan. 31, 1891.

Communications.

127

catarrhal pneumonia, and so expressed my-
self. He was ordered a lukewarm bath, and
given eight grains of antifebrin, followed by
a full dose of aromatic spirits of ammonia.
At 9 p. m. his brother informed me that his
temperature was ioi^°and his breathing
more easy, and also that he had raised some
blood. He did not know whether the
blood was mixed or unmixed with the sputa,
and evidently thought the patient a great
deal better.

I saw him at 8 a. m. the following morn-
ing. He was weak, looked ensanguinated,
his pulse was feeble, 130, his temperature
1030, his breathing rapid. He was then ex-
pectorating nearly pure, red blood, and
from the vessel in the room I judged he had
lost nearly a pint. Recognizing the ex-
treme gravity of the case, I requested Dr. L.
as counsel. He joined me a short time
thereafter, and recommended giving gallic
acid in addition to the ergotine I had given
hypodermically, with other approved meas-
ures. We went over the case from its in-
cipiency, and though differing as to the ex-
act cause of the hemoptysis — whether due
to pre-existent lung trouble or a direct sequel
of the fever — neither of us hesitated to di-
agnosticate pulmonary hemorrhage or to
give an unfavorable diagnosis. The lungs
were not hepatized, but the air produced a
slushing sound as it passed through the bron-
chi and entered the ultimate lobules, as
though they were partially filled with liquid.
The patient gradually failed, and died of
exhaustion at noon on September 22.

The question naturally arises : Was the
hemoptysis dependent on the attack of fever
through which he had passed? Unless this
be answered in the affirmative, one is almost
forced to conclude that the patient had
phthisis prior to August, and was suffering
from its ravages even while appearing hearty
and well, exhibiting no symptoms, except a
slight loss of blood after hard exertion, ra-
tional or physical. This opinion, I am
forced to say, was my consultant's ; but it
leaves unexplained the patient's apparent
health and the week of convalescence.

Readers of Da Costa's Medical Diagnosis
will recall the cases there alluded to, of
hemoptysis occurring without perceptible
lung lesion. I do not think, in this case,
the attacks of bleeding prior to the fever
had much, if indeed any, connection with
the fatal one. I believe that had the man
lived, phthisis from hemorrhage would have
existed — cases of phthisis being recorded as

following typhoid fever — but that the first
symptom, hemoptysis, was too severe for his
enfeebled system to overcome, and so death
resulted.

Although I believe hemorrhage from the
lungs in typhoid fever is by no means un-
known, it seems very strange that I failed to
find, after a search quite thorough in its
character, any recorded case of hemoptysis
following typhoid fever. I trust the extreme
rarity of the case will be a sufficient excuse
for reporting it at this length.

REMARKS ON INFLUENZA.

BY J. CHESTON MORRIS, M. D.,

PHILADELPHIA.

I wish to pl„ace a fact on record at this
meeting of the College, and a hypothesis as
to the nature of the epidemic influenza
which we have all been treating during the
past eight months.

The fact is this : In December last I was
called to see Mrs. W., living on Thirteenth
street, below Lombard, and found her suf-
fering from a severe attack of the "grippe."
Her first remark to me was, " Doctor, I am
attacked by the same cold you cured me of
last August. ' ' On turning over my note-
book I found that I had in August recorded
her case as influenza.

Now, then, for my hypothesis as to the
nature of this singular malady. We have
had it recurring more or less irregularly,
with greater or less severity since 1842.
Each epidemic has been marked by symp-
toms of its own — in one year the force of
the disease would seem to expend itself on
the throat; in another, on the mucous mem-
branes of the eyes and nose ; in another, on
the bronchial surface. In all, as in the epi-
demic of this year in a more specially
marked manner, there has been one feature
in common of this Protean disease — that of
debility, prostration of strength and vital
energy. The first uncomplicated fatal case
in this city, I believe (that of Mrs. C, on
Thirty-eighth street, above Market), was
one of simple loss of power in heart and
lungs. From what I have since seen, I be-
lieve that the death of Professor S. (Lom-
bard street, below Fifteenth), whom I saw
in consultation at the close of what his at-
tending physician called a low nervous
fever, preceded by repeated alarming attacks
of heart-failure and pulmonary congestion,

128

Communications.

Vol. lxiv

was due to the same cause. This view, that
there is a loss of power of the heart and
lungs to perform their work is, I believe,
shared by the great majority of observers.
But this epidemic has been characterized by
three other sets of symptoms : First. Violent
neuralgic pains in various parts of the body.
Second. Intense mental and nervous depres-
sion, out of all proportion to any physical
signs to be detected; people "never felt so
ill in their lives;" strong and active men
became nervous and apprehensive in a man-
ner and to a degree to alarm all who knew
them. Third. Many suffered (and of this
form of the disease I have seen a number of
cases lately) from a loaded condition of the
sigmoid flexure and rectum, with constant
straining efforts at stool, ineffectual except
in the discharge of a little glairy mucus,
and with sharp, cutting, colicky pains due
to gaseous distention of the colon.

These symptoms — the failure in heart and
lungs, the abdominal sufferings and the neu-
ralgic pains — all point to a neurotic cause,
such as the paresis or partial paralysis of the
pneumogastric nerve. And this I believe to
be the true nature of our epidemic. I have
fought it accordingly, since I recognized it
as such, with stimulating doses of whiskey,
opium and strychnine, watching for recur-
rences and relapses, and treating them as
they took place.

If we were to look for a cause of this
paresis, affecting so many persons at once,
scattered over so large a portion of the
northern hemisphere, traveling more rapidly
than by human modes of transportation, or
following other than ordinary lines of com-
munication, where should we be so likely to
find it as in a state of the atmosphere which
rendered the process of breathing more diffi-
cult and exhausting than it ordinarily is?
Some slight change of barometric pressure,
or of humidity, would give ample occasion
for fatigue of the pneumogastric and other
nerves controlling respiration and circula-
tion, the effect would be felt in each system
in its weakest spot, and we would have thus
an explanation of the very various symp-
toms and phenomena presented.

The above remarks were made by me at
the meeting of the College of Physicians
last June, and were subsequently embodied
in a paper read before the Academy of
Medicine at its recent session in this city.
Practical experience of the benefits resulting
from the administration of tincture of nux
vomica, in doses of from ten to fifteen drops

every three or four hours, in cases of depres-
sion of pulmonary and circulatory function y
leads me to commend it to the consideration
of the profession.

15 14 Spruce Street.

PELVIC ABSCESS IN A MAN : SPON-
TANEOUS CURE OF HERNIA.1

BY DAVID S. BOOTH, JR., M. D.,

BELLEVILLE, ILL.

The following case of pelvic abscess came
under my observation while surgeon in
charge of the International and Great
Northern Railway Hospital. While author-
ity justifies Gross in saying, " the diagnosis
of deep-seated abdominal abscesses is some-
times extremely obscure," I think this was
unusually so, owing to the urinary symptoms
occasioned by pressure upon the bladder and
urethra; at any rate, not one of the half
dozen physicians who had been connected
with the case, was able to arrive at its true
nature until a free incision had been made,
and the cavity had been explored with a
probe. The urinary symptoms were mis-
leading ; and I find upon referring to the
case-record which is in my possession, that
my diagnosis, made upon the patient's ad-
mission (as required by the hospital rules)
was, " abscess of bladder (?)," which was
revised by substituting "abscess of cavum
Retzii," or the prse vesical space.

About March 25, 1888, A. G. M., a loco-
motive fireman, 28 years old, applied at the
hospital for what was diagnosticated by the
assistant house surgeon who attended him
as cystitis ; but the patient, receiving no re-
lief, fell into other hands ; and it was not
until April 24 — a month later — that I ad-
mitted him to the hospital, and obtained
the following history.

About five or six weeks before, he had
noticed a hard lump in the hypogastric re-
gion and pain about the neck of the blad-
der during micturition. He noticed no al-
teration in the color or character of the
urine, and had no fever. His bowels were
in good condition — in short, he considered
himself in good health, and continued at
work for some ten days after he first noticed
the swelling. He stated that the swelling
had increased in extent of surface involved ;

1 Read before the Southern Illinois Medical Associ-
ation, November 21, 1890.

Jan. 31, 1 89 1. Periscope.

129

that he had had fever lately ; that his urine
was high colored and his micturition more
frequent, causing him to pass urine several
times during the night ; and that his stream
had diminished in size. He had noticed
no sediment in the urine. He had had
gonorrhoea two years before, which gave
him no unusual trouble. His bowels' were
costive but no pain accompanied the act of
defecation. His tongue was coated centrally
with white fur. He did not remember re-
ceiving any injury.

Examination of the hypogastric region
revealed a hard, circular intumescence, some
six inches in diameter, but not very promi-
nent; tender upon light pressure. The man's
pulse was 96 ; his temperature 10 if0 Fahr.

Examination of the urine resulted as fol-
lows : color, somewhat darker than normal ;
flocculent ; faintly alkaline in reaction ; sp.
gr. 1.020; trace of albumin. The micro-
scope revealed pus corpuscles and squamous
' epithelium.

In attempting to pass a catheter, with a
view to ascertaining the condition of the
urethra, as well as to learn whether or not
there was retention of urine, I found the
membranous portion of the urethra dimin-
ished in caliber to such an extent as to per-
mit the passage of a filiform bougie only.
The patient was given the fluid extract of
pichi and quinine, and gradual dilatation
was performed, until I could pass a No. 14
English bougie. As soon as urethra per-
mitted, the bladder was washed out every
day or so with Gerster's solution of* salicylic
and boric acids.

On May 7, twelve days after admission,
the tumor was not so painful and it pitted
on pressure. The urine was more natural
in appearance, and the micturition less fre-
quent. As suppuration was evident, moist
heat was ordered to be applied.

On May 9, palpation gave an indistinct
sense of deep fluctuation, and the tumor was
aspirated, the needle being inserted about
one and one-half inches to the left of linea
alba and about three inches above the pubes.
About seven ounces of a dark fluid, having
the consistency of cream and a stercoraceous
odor, was obtained.

On May 12 the aspirating needle was
again inserted, but the fluid being too thick
to flow through the needle, an incision about
one and one-half inches long was made, to
the left of the linea alba, when about ten
ounces of fluid, having the same offensive
odor as before, was discharged.

The patient improved rapidly, the urinary
symptoms disappearing at once, and he was
able to lie on either side — the dorsal decu-
bitus alone was possible previously. He was.
discharged at his own request June 23, nearly
two months after admission. When I saw
him last, some eight months after his dis-
charge from the hospital, he informed me
that his health had been excellent and that
he had been at work for some months. He
further informed me that he had been cured
of a right oblique inguinal hernia.

As my intention was to report the case
without prolixity, I have failed to call spe-
cial attention to the absence of those symp-
toms of abscesses in general which have the
most diagnostic import : namely, rigors,
perspiration and pain, from the latter of
which he was quite free, except upon move-
ment and during micturition. Furthermore,,
in arriving at the diagnosis, we were mind-
ful of the fact that other abscesses occur in
and about this location which were to be
excluded, and especially were we conscious
of the probability of perityphlitis with the
caecum and appendix vermiformis in the
hypogastric region, an occasional anomalous
position. Without attempting to confirm
the diagnosis by exclusion, I will conclude
with the following hypothesis in regard to
the spontaneous cure of his inguinal hernia.

As the patient wore a truss and his occu-
pation— locomotive fireman — required him
to be a great deal of the time in the stoop-
ing posture, and to make strong exertions in
this posture, inflammation of the fascia trans-
versalis was set up ; and, as this fascia forms
the internal abdominal ring as well as the
inner wall of the inguinal canal, oblitera-
tion of the canal had resulted, and a cure
of his hernia.

Periscope.

Resection of Prostate for Enlarge-
ment.

In the Medical Press, December 3, 1890,
Mr. R. F. Tobin, Surgeon to St. Vincent's
Hospital, says : Clinical and pathological
experience have I think settled the following
points : — (1) That there may be consider-
able enlargement of the prostate without
any stoppage of urine. (2) That when there
is permanent retention it is due in nearly
all cases to a prominence which when pressed
upon by the urine closes the internal orifice of
the urethea. It follows that to do away

130

Periscope.

Vol. lxiv

with the obstruction it is necessary to re-
move as much of the gland as is in the way
and no more. This can, I think, best be
done in the manner adopted by me for the
relief of the patient whose case I here relate.

J. K., aet. 60, was admitted May 31,
1890, into the St. Vincent's Hospital, Dub-
lin, for retention of urine due to an enlarged
prostate. For eleven years he had suffered
more or less from this ailment, and had been
treated for it both by me and my colleagues.
On the last of these occasions, about four
years ago, I made a digital examination of
his bladder through a perineal incision, but
not being able to ascertain thereby anything
more definite than what was already known,
that there was an enlargement of the pros-
tate, I used the incision merely to drain the
bladder and cure thereby a cystitis that was
then adding greatly to his sufferings. The
history of the years that intervened between
that operation and his admission on the
present occasion is the ordinary one of a
poor man who cannot make water without
the use of an instrument. A rough catheter
and a raw urethra sketch it sufficiently.
When admitted he was emaciated and in a
bad state of health, there was a tendency to
the formation of bed sores on every pro-
minence, the urine was fetid, he had hourly
calls to micturate and could do so only
through an instrument, the passage or reten-
tion of which gave intense pain.

The following operation was performed
on May 9. A supra-pubic cystotomy hav-
ing been done in the usual way, a digi-
tal exploration showed the middle and
left lobes of the prostate to be much en-
larged. The enlargement was a ridge,
about an inch in height and an inch at its
base, surrounding and overlapping two-
thirds of the urethral orifice. Although
the whole appeared to be one mass it was
-only so by contact, for the finger could be
passed between the lobes. The instrument
used to shave off this protuberance was an
^craseur extemporized in this way. A wire
doubled and bent to a suitable curve was
passed through the urethra into the bladder.
A silver catheter was then slipped up along
it, but its point in place of being passed
into the bladder was made to impinge against
the urethral obstruction. Next the double
wire lying in the bladder was opened out
into a loop and slipped over the enlarged
middle lobe and was kept embedded round
its base by means of two fingers passed
through the abdominal incision ; while this

wire was being made to cut its way through
the part it encircled, the inserted fingers
helped by the point of the catheter, which
was depressed to the spot it was desired to
reach, regulated its direction. I was sur-
prised how little resistance there was to its
progress. As the lateral lobe was not of a
shape to be encircled by the wire it was
necessary to divide it into two by nicking it
deeply with a scissors. Each half was
then dealt with as had been the middle lobe.
The surface left was found to be smooth and
to slope into the urethra. There was little
or no bleeding. Copious irrigation with
warm boric lotion and a partial bringing
together of the edges of the wound (the low
vitality of the patient gave no prospect of
immediate union) completed the operation.

The chief points noted during the sub-
sequent progress of the case were sloughing
of the cellular tissue in the immediate neigh-
borhood of the abdominal incision ; exten-
sion of the bed sores noted as existing when
admitted ; uremic delirium for ten days
with a large amount of albumin in urine
(about one-sixth) . These complications not-
withstanding, the patient made a good re-
covery. Most of his urine passed away
through an india-ruber tube to a vessel
alongside his bed. What urine overflowed
was absorbed by large peat-moss cushions
placed under the patient. The house dia-
phoretic mixture containing liq. ammon.
acet., pot. nit., and spirit aether nit.,
seemed to favorably influence the uremic
conditio'n.

On the twenty-second day after the opera-
tion the tube — a smaller one than originally
inserted — was withdrawn from the abdom-
inal wound now nearly healed, and a cath-
eter was passed by the urethra and left in.

On June 16, the patient was allowed
up, and a few days later, about seven weeks
after the operation, on being asked how he
was, he answered, "I can make water as
when I was a boy of fifteen. ' ' This sentence
must be taken rather as expressing his won-
der at the change that had been effected in
him than as an accurate statement of his con-
dition. As a matter of fact, he could con-
tain about half a pint of water, and passed it
without pain or difficulty in the usual way.
A week later he was discharged.

The parts removed are three masses, each
about the size of a small walnut. Mr.
Patteson, who has microscopically examined
these, has found in them nothing but hyper-
trophied prostatic tissue.

Jan. 31, 1891.

Periscope.

The method of resecting the prostatic
gland here set forth has I think the follow-
ing advantages : —

1 . As much of the gland as interferes with
the escape of the urine is removed and no
more.

2. The portion that blocks the urethra is
removed in a satisfactory manner, for the
wire cuts up to the point where the instru-
ment has been stopped by the obstruction.

3. A smooth surface sloping into the
urethra is left instead of the more or less
rough one that must result from taking away
the gland piecemeal with a forceps.

4. There is very little hemorrhage.

I do not know that in all cases a wire
would cut its way through an enlargement
as easily as it did in the instance now related,
but this difficulty could be overcome by
preparing a bed for it with the point of a
knife or scissors. Only in the coverings of
the gland need any resistance be expected,
its friable substance is easy of division with
any instrument.

Nov., 1890. — It is now six months since
the performance of the operation. The
outlet from the bladder continues quite free,
and the power of retention improves with
the lapse of time. The general condition
of the patient is also much improved.

Products of Pathogenic Bacteria.

During the past two years great progress
has been made in the study of the action of
pathogenic bacteria. This work has chiefly
been carried on by Koch and Pasteur on
the Continent, and by Drs. Sidney Martin
and Hankin in England. In the Revue
de Medecine, 1890, No. 7, Dr. Charles
Bouchard publishes an article on the prop-
erties of the substances secreted by patho-
genic micro-organisms. It contains the
•chief part of his address before the Tenth
International Congress on the " Mechanism
of Infection and Immunity." After an
exhaustive summary of all that is known
concerning the action of products of meta--
thesis with which we are acquainted,
Bouchard relates a series of thirty-one ex-
periments which he made, partly in order to
investigate the power which blood-serum
possesses of destroying bacteria, and partly
to ascertain how far their products confer
an immunity against similar or other bac-
teria. Many experiments demonstrated the
influence of the same products on phagocy-
tosis.. The space here is too limited to

enter into the details of this interesting
paper, but the general results of Bouchard's
investigations are as follows. Among the
substances secreted by the microbes are some
which have an inhibitory action on them —
that is to say, these products tend to retard
the development, increase and character-
istic action of the micro-organisms ; other
substances are favorable to their growth.
These, however, only act indirectly by mod-
ifying the material upon which they grow
(peptones, etc). Such products may be
favorable or unfavorable for other mi-
crobes. Some organisms produce poisonous
substances upon which depends their viru-
lency. Amongst pathogenic microbes are
some which secrete substances that confer
upon animals inoculated with them an im-
munity against these particular germs ; this
they do not by their presence only, but by
modifying the animal organism, so that it
forms a less favorable pabulum for the de-
velopment and growth of the bacteria, and
causes the leucocytes to perform the process
of diapedesis more rapidly, and to assume
their functions as phagocytes more energeti-
cally. If an animal be inoculated with
these substances, together with a pure cul-
ture of the same bacilli from which they
were obtained, the disease runs a more rapid
course, whilst its development will be de-
layed or. prevented if the animal be inoc-
ulated a few days before the injection is
made. If bacteria which act antagonis-
tically towards one another be cultivated
together in a test-tube, the soluble products
of the " stronger " can be made to retard
the development of the " weaker " organism.
So that if an animal be inoculated with the
products of metathesis of the ' 'stronger"
at the same time as the active principle of
the ' * weaker, " the action of the latter
will be delayed and weakened. Some
microbes appear to assist the action of
others ; these Bouchard terms " auxiliary mi-
crobes." By this means an animal may be
infected with a disease which it would other-
wise resist. — Lancet, December 27, 1890.

Antipyrin in Puerperal Fever.

Dr. Wm. McBeath says in the Lancet, No-
vember 22, 1890 :

After parturition there is no condition
more annoying and troublesome to the phy-
sician or disastrous to the patient than puer-
peral fever. Whether it occurs as the re-
sult of septicemia, from direct absorption

132

Periscope.

Vol. Ixiv

of putrid matter generated in the patient's
own uterus, or from infection, the prognosis
is always bad. The remedial measures gen-
erally used have been so often unsuccessful
and are so unreliable, that any remedy or
mode of treatment by which the great mor-
tality from it can be materially lessened
should be worthy of consideration and trial.
Dr. McBeath has never noticed in any pub-
lication that antipyrin has been used with
success in puerperal fever. In four cases in
which during the past eighteen months he
has prescribed it, it has acted almost as a
specific. He gives details of the last case.
The other three cases were almost the same,
being characterized by the usual symptoms.
They were treated in the same way, and all
got better.

In the case he describes, a primipara,
twenty-two years old, was attended by a
midwife, and delivered of a male child on
July 2, 1890. On July 7 the husband called
in a medical man, who found her suffering
with puerperal fever. He treated her in the
usual way, with large doses of quinine,
opium, hot linseed poultices and irrigation
of the uterus with a solution of Condy's
fluid. On July 10, as she was thought to
be dying, Dr. McBeath was called in to see
her in consultation, and found her pulse
140 ; temperature 103. 50 ; abdomen swollen,
tender, and of the peculiar peaked shape,
which we never see except in puerperal per-
itonitis ; discharge scanty and fetid ; milk
almost gone ; countenance anemic, and
breath sweetish. She was also totally unable
to move in bed. Dr. McBeath advised that
the irrigation of the uterus and the hot poul-
tices should be continued ; and in addition,
that antipyrin should be given in ten-grain
doses every hour for six hours. In five hours
the temperature had fallen below ioo°.
During the next twenty-four hours the anti-
pyrin was given in the same dose every three
hours, and after that the woman took another
half-dozen powders, one every four hours.
Thus in two days and a quarter she had
taken eighteen powders of ten grains each,
the temperature being kept down the whole
time. At the end of this period her other
symptoms had very much improved, the pain
and tenderness had nearly gone, the swollen
condition of the abdomen had disappeared,
the appetite had returned, and she could
move freely in bed. On the fourth day after
Dr. McBeath saw her she had a sharp attack
of diarrhoea, which sent up the temperature
to 1060, but a mixture of soda, bismuth and

opium soon relieved her and stopped it. She
afterwards made a good recovery, no further
bad symptoms supervening.

The symptoms in the other three cases
were almost identical, except that none had
diarrhoea after taking the antipyrin. The
treatment was the same, and so were the re-
sults. In all there was immediate lowering
of the temperature, followed by gradual
amelioration of all the bad symptoms.

It will be noted that irrigation of the
uterus and the hot linseed poultices were
continued during the administration of the
antipyrin, and, indeed, for a day or two
afterwards ; but it must be remembered that
these had been used for several days before
the drug was given, and that the patient was
going from bad to worse. As auxiliaries no
one would be justified in omitting them, but
Dr. McBeath says he has never found irriga-
tion of the uterus with an antiseptic solu-
tion and poulticing alone to cure puerperal
fever. He feels satisfied that in antipyrin we
have a remedy which, if given boldly and
judiciously at the outset, will enable us to
treat these cases with more hope of success.
He has had such good results that he is anx-
ious for others to try it. No doubt in cer-
tain cases a larger dose may be given at the
beginning of the treatment ; but in the case
detailed above ten grains answered every
useful purpose. Dr. McBeath generally or-
ders each powder to be dissolved in two tea-
spoonfuls of brandy, and then a little cold
water to be added, so as to make a draught
of about an ounce and a half. Antipyrin,
he thinks, acts as an antiseptic as well as an
antipyretic, and it may possibly be of use
in other cases of septicaemia or blood poison-
ing besides those arising after childbirth.

Massage in Eye Diseases.

In the Meditzinskdie Obozrenie, Nos. 13
and 14, 1890, p. 59, Dr. W. K. Hirschberg
draws attention to valuable services obtained
by him from local massage in various ocular
affections. In such cases where the eyeball
should be subjected to the manipulations, he
smears the surface of the eye with vaseline
containing some yellow or white mercury
(precipitate) or iodide of potassium, and,
having placed a forefinger on the upper or
lower eyelid, proceeds to quickly rub it
against the eyeball in a radial or circular di-
rection. In cases of massage limited to the
eyelids alone, he makes friction either with
a forefinger, or a tightly rolled cotton-wool

Jan. 31, 1891.

Periscope.

133

globule, commencing at the inner canthus
and passing along a curved line down to the
cheek (that is, correspondingly to the course
of branches of the anterior facial vein, as
suggested by Pfalz). In either case the sit-
tings are repeated daily, lasting each time
from 2 to 4 minutes. The treatment is es-
pecially recommended in, 1, chronic forms of
marginal blepharitis, in milder or relatively
recent cases of which all annoying symptoms
(such as itching, sticking together of the
eyelids, and so on) are said to disappear after
four or five seances. As a rule, a complete cure
ensues in from 10 to 15 days. The manip-
ulations should always be preceded by a
careful removal of dried crusts, which can
be best effected by means of rubbing the
margins with a piece of cotton-wool smeared
with yellow mercurial salve. 2. Phlyctenu-
lar conjunctivitis where massage of the eye-
ball should be performed (after smearing the
latter with a yellow mercurial or boric acid
ointment). 3. Follicular conjunctivitis, in
which Dr. Spaeth's plan should be preferred
to all other methods; that is, the eyelid should
be everted, the fornix conjunctivae anointed
with iodide of potassium salve, and the ex-
posed fold itself subjected to rubbing with
a forefinger's tip. Follicles disappear usu-
ally very quickly. 4. Trachoma of all
stages, where a direct massage of exposed
diseased areas may sometimes prove as suc-
cessful as the treatment by cauterization
(e. g., with sulphate of copper), while being
less disagreeable for the patient. 5. Phlyc-
tenular keratitis. 6. Corneal opacities, re-
maining after keratitis, where the treat-
ment is frequently followed by a marked
improvement of vision, and that not only
in recent cases, but sometimes even in in-
veterate ones. 7. Pannus Trachomatosus
and Scrophulosus, in which massage of the
eyeball (with white mercurial salve and atro-
pia) often proves very beneficial. Of con-
tra-indications, the author mentions the
presence of inflammation or even simple
irritation of the iris. In acute glaucoma
he failed to obtain any amelioration, the
manipulations carrying a vivid pain to the
patient.

Unconscious Parturition in a Pri-
mipara.

A case of high obstetric and medico-legal
interest is to be found in the Archives de To-
cologie for November. Physiologically pain-
less parturition is rare. Tarnier has related

some cases, including one instance where a
Canadian woman occasionally dropped a
baby on the ground, at term, without no-
ticing it. In Howard's case labor took two
hours ; the patient was reading a book till
a quarter of an hour before the child was
delivered, which event occurred after some
straining, not sufficient to make her cry out.
In Dr. Brunon's case, newly reported, a
married woman, aged 22, had a troublesome
cough one day shortly before term. The
coughing was accompanied with lumbar
pains, which increased. At 11 o'clock in
the evening the patient tried to pass a mo-
tion. She sat- over an hour in the closet,
believing that her pains signified painful
defecation. Then she went to bed. At half-
past 1 o'clock she woke up feeling a desire
to pass a motion, with lumbar pains such as
she had felt before when constipated. As
she rose to go to stool a smart lumbar pain
occurred, and she felt something between
her thighs. On handling it she found,
much to her surprise, that it was the head
of her first-born. She declared to Dr.
Brunon that the pains were entirely lumbar,
she had no colicky sensations, and none of
the expulsive pains usually so severe, espe-
cially in primiparae. The desire to defecate
was strong, and she stated that the child
might have been born into the pan of the
closet without her recognizing the truth of
her condition till the moment of its deliv-
ery. The patient was an intelligent, well-
educated woman, free from any neurosis.
This case proves that in the case of an in-
experienced person an infant might be ex-
pelled into the water in the pan of a closet
without any intention of infanticide on the
part of the mother.- — British Medical Jour-
nal, December 20, 1890.

Making Beef-tea.

The Chemist and Druggist, November 29,
1 890, under the title, ' 1 Best Method of Mak-
ing Beef Tea," makes the following state-
ment :

Miss Mary Spahton, of the Hospital for
Women and Children, gets a prize from the
Nursing Record for the following directions :
" Take 1 lb. of the leg of beef, to which,
when minced, add 1 pint of cold water.
Let stand for four hours ; then put it into
an earthenware vessel lightly covered over,
and place it inside another vessel, or pan,
filled with water, which, after coming to
boiling-point, must be allowed to simmer

J 34

Periscope.

Vol. lxiv

from four to six hours gently. This can be
thickened if desired, and the doctor ap-
proves, with arrowroot, sago or rice, when
the patient can take it, or varied by putting
^ lb. of mutton or veal to y2 lb. of beef,
and flavored with celery."

[Anyone who follows these directions will
find that his beef-tea has no beef whatever
in it. The 11 this" which "can be thick-
ened," etc., is the water round the earthen-
ware vessel. It is curious that this slip in
the directions was not noticed by the Nurs-
ing Record, which gave the prize, or the
Chemist and Druggist which recorded the
award. Why any one should get a prize
for re-hashing so ancient a method of mak-
ing beef-tea, and the value of the method
itself, it is not worth while to discuss.]

How to Apply Forceps. t

In a paper in the American Journal of
Obstetrics, December, 1890, Dr. Henry D.
Fry, of Washington, describes what he
thinks the best method of applying the ob-
stetric forceps. He quotes a thesis on this
subject written by Dr. Lepage, of Paris, who
says the ideal method of extraction with
forceps is to apply the instrument in such
manner that during traction the fetal head
is free to execute all the movements that
would occur were the labor normal.

The proper application of the instrument,
to attain this result, is :

1. To grasp the sides of the head with
the blades ;

2. To make traction in the axis of the
pelvic canal ; and

3. To secure mobility of the head during
its passage.

This last indication is most important,
but has been overlooked. The great ad-
vantage of the Tarnier forceps is due to the
traction being independent of the grasp of
the handle, the head is absolutely free to
perform movements of flexion and exten-
sion.

With these facts established, Dr. Lepage
proves that the above advantages are secured
by applying the Tarnier forceps to the sides
of the child's head when at or above the
superior strait. He says it was during the
year 1883 that Pinard first made his high
applications after this method, and since the
beginning of 1884 he has never employed
them otherwise.

Dr. Fry sums up his opinion as to the
application of the forceps as follows.

1. Anesthetize the patient and place her
in proper position — buttocks well over the
edge of the bed, and each limb supported
by an assistant.

2. Ascertain the position of the head,
introducing within the vagina two or three
fingers, or, if necessary, the whole hand.

3. Apply the blades of a Hodge type of
forceps to the sides of the head, with the
concave edge directed towards the occiput.

If, for any reason, this cannot be accom-
plished, withdraw the instrument and sub-
stitute a Simpson, passing the blades to the
sides of the pelvis. While making traction
with this method, watch for anterior rotation
of the occiput, and encourage it in some
cases by reapplying the blades to better ad-
vantage.

4. Make every effort to secure aseptic
conditions during the operation. The fin-
gers, hands and forearms of the operator,
the external genitalia and vagina of the pa-
tient, the instrument and the hands of the
assistants, should be clean and aseptic.

On Oscillations in the Bodily
Weight in Enteric Fever.

In the Bolnitchnaia Gazeta Botkina, Nos.
30 and 31, 1890, p. 747, Dr. Mikhail K.
Zenetz, of Warsaw, publishes an important
clinical contribution to changes in the
bodily weight in typhoid fever, based on
384 carefully-studied typical cases. In
each case the patient was weighed daily,
between 9 and 10 a. m., all other clinical
details possible being also registered from
day to day, from his admission to his
discharge or death. The following are
the principal corollaries deduced by the
author from his elaborate researches. i„
During the whole febrile stage of enteric
fever the patient's weight steadily sinks, the
average daily fall amounting to 0.6 percent,
(of the body's weight). During the first
week of the disease the loss averages 0.8 per
cent, a day; during the second, 0.7; dur-
ing the third, 0.6 ; during the fourth, 0.5.
In other words, as the disease advances, the
relative loss in the weight decreases. 2. In
uncomplicated cases, immediately after the
onset of apyrexia, the weight begins to rise,
the average daily increase amounting to 0.7
per cent. The largest relative gain occurs
during the first week of convalescence, the
rate gradually decreasing with each week.
3. In fatal cases the daily loss in the weight
is usually very considerable, amounting fre-

Jan. 31, 1 891.

Periscope.

135

quently to 3 per cent. 4. In such cases
where a high fever is accompanied by sweats
and diarrhoea, the weight sinks at an in-
creased rate (up to 2 per cent, or even more
a day). 5. Profound typhoid state (delir-
ium, etc.) similarly increases the rate (up
to 1 or 1.5 per cent, in a day). 6. The
same holds true in regard to such complica-
tions as pleurisy, catarrhal or croupous
pneumonia, parotiditis, otitis, etc. 7. An
increase in the weight about the end of fe-
brile stage (during lysis) points to a speedy
advent of convalescence. 8. The retarda-
tion or arrest of increase in the weight after
the onset of defervescence points to a-near-
ing relapse or complication of this or that
kind. 9. The daily losses in the weight
above 1 per cent, justify a grave prognosis.
10. When such high losses coincide with a
continuous and considerable acceleration of
the pulse, the prognosis becomes almost ab-
solutely hopeless. About the same conclu-
sions have been reached by the author in
regard to typhus fever. (See his St. Peters-
burg Inaugural Dissertation, 1887, with 103
cases.)

Hydrophobia in Egypt.

The Egypt correspondent of the Lancet,
November 22, 1890, gives the following
statements in regard to what he calls "hy-
drophobia in Cairo."

"Seven years ago," he says, " the streets
of Cairo used to contain thousands of home-
less dogs, and it was loosely believed that
rabies was unknown among them. But the
town has now been freed of pariahs, because
they are no longer required as scavengers,
and yet hydrophobia occasionally appears.
The only two cases which have been known
at the hospital during the last seven years
have occurred during the past twelve months.
A child arrived with cheek and lip disfigured
by a bite from a dog four weeks before ad-
mission, there being no history of the dog
being rabid. The wounds healed, but be-
fore the child left the hospital a hare-lip
operation was done to prevent disfigurement.
Two days after this operation the child de-
veloped hydrophobia, and died in three
days' time. In the absence of inoculation
experiments on rabbits, I suppose skeptics
would affirm that this might be a case of tet-
anus, in spite of the presence of the clinical
symptoms of hydrophobia. I may mention
here that many cases are reported in Egypt of
rabies and hydrophobia, which prove on

investigation to be bites from healthy dogs,
and some bitten individuals have been sent
at public expense to the Pasteur Institute at
Paris for prophylactic treatment.

"An interesting case, apparently of true
hydrophobia, has just occurred atKasrel-Aini
Hospital. A young man-servant was sent
up by his master with symptoms of exhaus-
tion, great mental excitement, uncontrol-
lable terror of draughts of air, sleeplessness
and thirst. He made pitiable attempts to
drink, and clutched the glass of water a few
inches from his lips. He eventually allowed
about half an ounce to be tilted between his
lips, when he held the fluid several minutes
in his mouth, seemed to swallow it, but then
had a convulsion of throat and whole body,,
and hawked it up again with viscid saliva.
He was treated with morphia injections and
nutrient enemata, but twenty-four hours
after admission he was dangerously maniacal,
and had to be tied down in bed, and he
eventually died six days and a half after
he was first noticed to be ill. His previous
history was that of an irritable, excitable per-
son, but free from alcohol, hasheesh, or relig-
ious excitement. He denied that he had ever
been bitten or scratched by any animal, and
he had no traces of a bite on his body. His
master's account is that eighteen months
previously the boy had rescued a stray cat
from a boar-hound who was playfully hold-
ing it on the ground. The cat was very
frightened, and bit and scratched the boy
through his clothes on the right thigh, but
it is said that no mark was seen on the skin.
If this was the cause of the disease, the long
incubation is deserving of note, and it is the
first time on record of a rabid cat in Egypt.
The boar-hound was certainly not rabid, but
there was no information about the future
life of the cat. At the necropsy, twenty-
one hours after death, the hands were blue
and half clenched, the legs, but not the arms,
were very stiff ; the brain membranes were
much congested, the cervical and dorsal
membranes of the spinal cord were consider-
ably congested, and the blood in the skull
and body was dark and liquid, as in typhus.
There-was, as during life, redness of fauces
and pharynx with great congestion of lungs,
liver and kidneys ; the heart was very firmly
contracted, with no blood on the left side
and a little black clot on the right.

" One of the arguments in favor of hydro-
phobia existing occasionally in Egypt is that
the natives have a remedy for it dating from
the old Arab physicians. It is a beetle of

Periscope. Vol. lxiv

136

the cantharides family, which causes the
patient to urinate and evacuate blood, and
it is believed that in the urine may be seen
tiny effigies of a dog as large as a bar-
ley-corn."

Flexible Wire Stems for Stenosis of
the Cervix.

In the Medical Press, November 26, 1890,
Mr. Alexander Duke says of the value of the
flexible spiral wire stem in the treatment of
stenosis, that it is now some years since he
published a description of this stem, now
well known to gynecologists. Its principal
use is to preserve the potency of the cervical
canal after the operation of division of the
os and cervix, commonly required as a cure
for stenosis, giving rise to destructive dys-
menorrhcea and sterility. He says that if
one of the stems be introduced directly after
this operation, it will not only prevent any
union of the cut surface, but also, the sub-
sequent contraction of the canal so com-
monly observed, and any tendency to ex-
cessive hemorrhage, by exercising a certain
amount of pressure on the incised part.

These stems being self-retaining and re-
quiring no vaginal support whatever, in ad-
dition or tampons of any kind can be worn
by the patient when up and about, being
flexible and short, cause no irritation ; open
at point and hollow, permitting free drain-
age, and easily kept clean while in situ, by
syringing vagina daily during healing pro-
cess, the water finding its way in and out of
stem. His practice is to allow the instru-
ment to remain till one " period" at least
is over, subsequent to its introduction, or in
other words, he allows the patient to men-
struate through the stem, and he finds if this
is done, there is no subsequent contraction
of the canal observable years after the oper-
ation.

In cases thus treated, Mr. Duke has never
had any complaint of a return of the symp-
toms existing before operation, nor has he
had the slightest trouble, such as metritis,
parametritis, cellulitis or septicemia.

The stems are easily introduced, the
"duckbill" being the best speculum to fa-
cilitate this, and when once in situ they
need not be interfered with until removal is
considered desirable.

When Mr. Duke decides on using a stem
that has been employed before, he takes the
precaution to let it lie in boiling solution of
creolin for a few minutes, and then fills the

stem with either boric acid or iodoform,
which does not add any difficulty to its in-
troduction, the "introducer" penetrating
the powder in the stem.

Mr. Duke has also found these stems use-
ful as a drain in cases of chronic endome-
tritis, and as a mechanical agent in plethoric
amenorrhoea, or in those cases where the
usual routine treatment to stimulate uterine
action has failed.

The Teeth in Epilepsy.

Speaking of the importance of examina-
tion of the teeth in epilepsy, the Lancet,
December 27, 1890, says that Dr. Bakowski
mentions in the Przeglad Lekarski an in-
structive case of epilepsy occurring in a
young Jewess. It had been going on for
nine months, and latterly the fits had be-
come more frequent, there being several
every day. Bromide of potassium, quinine,
arsenic and asafoetida had been given with-
out any effect. Finally, although there was
no complaint of toothache, it was decided
to examine the mouth. Two teeth were
found to be carious — the first upper molar
on the right and the first lower molar on the
left side. These were extracted, with the
result that the fits entirely ceased and did
not return, though the patient was under
observation for six months subsequently.
Upon being closely questioned the girl re-
membered that before the fits commenced
she had had some unpleasant sensations in
the affected teeth, but nothing that could be
described as pain.

Southern California as a Health
Resort.

Charles Dudley Warner says, in an article
in Harper's Monthly, January, 1891, that
there are many people in the United States
who could prolong life by moving to South-
ern California. There are many who would
find life easier there by reason of the climate,
and because out-door labor is more agreea-
ble there the year through ; many who have
to fight the weather and a niggardly soil
for existence could there have pretty little
homes with less expense of money and labor.
It is well that people for whom this is true
should know it. It need not influence those
who are already well placed to try the for-
tune of a distant country and new associa-
tions.

Jan. 31, 1891.

Editorial.

137

THE

MEDICAL AND SURGICAL

REPORTER.

ISSUED EVERY SATURDAY.

CHARLES W. DULLES, M. D.,
Editor and Publisher.

N. E. Cor. 13th and Walnut Streets,
P. O. Box 843. Philadelphia,

Pa.

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Write on paper of the size usually used for letters.

Make as few paragraphs as possible. Punctuate carefully.
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Never roll a manuscript ! Try to get an envelope or
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When it is desired to call our attention to something in a
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write on the wrapper " Marked copy." Unless this is done,
newspapers are not looked at.

The Editor will be glad to get medical news, but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

MEDICAL EXAMINERS AND MEDICAL
EDUCATION.

A bill (published at Page 141, of this
number of the Medical and Surgical
Reporter), which is intended to regulate
medical education in Pennsylvania, has been
introduced in the Legislature at Harrisburg
by Mr. Brookes, of Philadelphia. This bill
provides for the appointment of a Board
composed of three eclectics, three homoeo-
paths, and three persons spoken of in the
bill as " allopaths." The bill makes it ille-
gal for any medical school in this State to
give degrees to students who have not gone
through what is spoken of as four years'
study, which shall include three courses of
lectures, or to admit as students persons who
have failed to meet certain requirements of
preliminary examination to be prescribed by
the Board. To this is added that the Board

shall act as a sort of Police Board to report
the failure on the part of any medical school
to obey the provisions of the law, such fail-
ure being punishable by a heavy fine.

There are several unfortunate things about
this bill. In the first place, what it aims at
in regard to medical education might — if
constitutional — be secured quite as well by~
a simple enactment, without the interven-
tion of any Board at all ; in the second
place — considering that in Pennsylvania
about four-fifths of the physicians belong
to the regular portion of the profession, and
that one-fifth are divided between the Eclec-
tics and the Homoeopaths, and that there are
in this State five medical colleges conducted
by the regular profession, while there is only
one Homoeopathic school and not one Eclec-
tic school — it is obviously unequal that a
Board which would be practically a Board
of censors upon the medical schools, should
contain six representatives of the one medi-
cal school as against three representatives of
the five schools. More than that, we be-
lieve that the selection of a Board of this
kind is absolutely impracticable. The mem-
bers of the regular profession are not allo-
paths ; and no one who knows anything
about the use of correct terms thinks they
are ; and it is improbable that three men of
any standing in the profession could be in-
duced to become a part of a Board contain-
ing six members who willingly bear an ex-
clusive title, or to accept the imposition of
an exclusive title upon themselves — facts
and principles would both prevent this.

There seems to be little hope that those
who, in this matter, claim to represent the
body of so-called homoeopathic physicians,
will abate a particle of their seeming dis-
trust of those who desire that Pennsylvania
shall be put on an equal footing with the
best and most intelligent States in the coun-
try, by providing for a Board of Medical
Examiners, who shall represent directly the
State and the community, and shall simply
determine the fitness of persons to whom
are to be entrusted the lives and the health

138

Editorial.

Vol. lxiv

of the citizens of this State. Some of us
who desire this, deprecate most deeply that
what we believe to be a desirable result should
be imperilled by sectarian differences. We
want the State of Pennsylvania to be placed
on the very highest level in this matter. We
naturally believe that that part of the profes-
sion to which we belong is the one which is
most in accord with reason, but we have suf-
ficient confidence in the intelligence of the
Governor and of our fellow-citizens to be
willing to have a bill passed which shall say
nothing whatsoever about the character of
the persons to be appointed on the exam-
ining board, or direct how they shall be
chosen. This we say with full knowledge
that the present Governor is supposed to
have long been under the care of homoeo-
pathic physicians, and to be in some sense
an adherent of that school ; for he is quite
as well known to be a man of integrity and
courage.

The cause for which we strive we believe
to be so just an one, and so sure of ultimate
success, that we are quite willing to entrust
the details of its accomplishment to an hon-
orable man and have no doubt that the issue
would be such as to be approved by all hon-
orable men.

The Reporter is opposed to the bill re-
ferred to above, for the reason that it is, we
believe, in the first place, needless ; in the
second place, impracticable ; in the third
place, unfair in its provisions, and perhaps
unconstitutional. We support heartily the
bill published in the Reporter, January 10,
1 89 1, because we believe it is in the interest
of our fellow-citizens, and that it is thor-
oughly practicable. As we have already
said there are certain details of the bill which
are not precisely what we would have wished ;
but its passage would do much, we believe,
to promote the interest of medical science
and the good of the community.

LEGAL RESTRAINT OF INEBRIATES.

The Reporter has at different times
given considerable space to the claims and

arguments of those who are convinced that
the tendency to excessive indulgence in al-
coholic stimulants is to be regarded and
treated as a disease condition, and this
partly for fairness' sake and partly because
it holds the opinion that in many cases the
tendency is one which can best be com-
batted if regarded from a physical and not
from an exclusively moral standpoint. But
it is sometimes far easier to suggest a general
principle in keeping with which to arrange
a plan of treatment than it is to specify the
details of such a plan. The truth of this
fact appears when we reflect upon a discus-
sion which took place before the Medical
Jurisprudence Society of Philadelphia, Jan-
uary 13. Dr. Dercum, who opened the dis-
cussion, spoke of the change of general and
professional opinion in regard to the treat-
ment of inebriates and claimed that the
inebriate should be treated as a sick man,
and his condition should be considered the
same as in a case of insanity. The State of
Pennsylvania, he said, places no control
over the inebriate until he is practically
beyond recovery, and what is needed is a
system of special asylums maintained by
the State, in a manner similar to insane
hospitals, with special laws and regulations.
Legislation should deal with inebriates in
general, no matter what the narcotic used
may be, whether alcohol, opium or chloral.
He thought, also, that druggists should be
held to a strict account, as he had known
where a prescription once given had been
renewed for years.

John A. Clark, Esq., presented some of
the difficulties from a legal standpoint of
carrying out the plan which seemed to be
approved by physicians. He doubted
whether an inebriate, on the certificate of
two physicians, could be sent* to an insane
asylum. In the State of Wisconsin, he said,
it was tried to control such persons by law,
but the Supreme Court decided against the
constitutionality of such proceedings.

Dr. E. N. Brush, of the Pennsylvania
Hospital for the Insane, who has had all

Jan. 31, 1891.

Editorial.

*39

kinds of inebriates to care for, would clas-
sify them as those who were drunkards by
reason of certain disturbed, unbalanced
nervous conditions ; those who were drunk-
ards through viciousness, and those who
were the victims of disease. The trouble
in dealing with them, he thinks, is the same
as in cases of insanity, where persons are
allowed to go on without treatment because
they are not sufficiently insane to warrant a
certificate being given. In New York, he
said, a man cannot be legally held unless
he is dangerous to himself or those around
him, and, like Dr. Dercum, he thought that
men, unfortunately, were allowed to go on
until beyond the hope of recovery.

Thus the discussion ended without the
proposition of any plan which appeared
feasible to both lawyers and physicians.
This does not signify that the endeavor
after a feasible plan should be abandoned ;
for, if the State should extend a supervising
and controlling care over individuals for
their own good or for the general welfare,
it is desirable that all who are interested in
public questions should continue to inquire
what may properly be done to restrict the
evil consequences of the drink habit. The
question discussed by the Philadelphia Medi-
cal Jurisprudence Society at its last meeting
is — as one of our lay contemporaries calls it
— a " knotty one;" but time and patience
may get through or get round these knots.

BARKING COUGH OF PUBERTY.

It is a well-recognized fact that cough
does not necessarily imply an affection of the
lungs or bronchial tubes. Coughing is a reflex
act, in which the lungs are filled with air by
a deep inspiration ; the glottis is then com-
pletely closed, but it opens suddenly under
the pressure of a forcible expiration, by
which a column of air is driven through the
upper respiratory passages. The apparent
impulse to cough is usually transmitted by
the superior laryngeal nerve, but any one
of the other nine branches of the pneumo-

gastric may carry it. Almost every one, for
example, has seen instances of cough excited
by examining the ear, or by foreign bodies
in the auditory canal. Another variety of
cough, however, which is entitled to be con-
sidered distinct, is described by Sir Andrew
Clark, in the La7icet for December 20,
1890. The paroxysms which characterize
the cough in question are well illustrated
in the first case reported by Dr. Clark. They
consisted of a close succession of loud, dry,
clanging, convulsive coughs, varying in in-
tensity and duration, broken into irregular
bars and phrases, resembling at one time the
barking and at another the howling of a dog.
During the continuance of the paroxysm
the patient appeared to be much distressed ;
his face was swollen and faintly livid ; the
eyeballs became prominent and congested ;
the body, bent forward, was shaken by the
violence of the coughing, and the hands,
which were crossed upon the chest, convul-
sively clutched his clothes. At the close of
the paroxysm the patient appeared to be a
little dazed and was somewhat giddy. He
recovered in a few minutes, passed a quan-
tity of limpid urine, and the storm was at
an end.

The attacks are not always as severe as in
the case just referred to ; they vary greatly
in severity. The age at which patients are
affected is that of puberty, generally from
the thirteenth to the sixteenth year. More
girls are affected than boys. The general
health suffers but little, and there are no
physical signs on the side of the lungs. The
patients are generally, though not always,
of nervous habit and heredity, and most of
those seen by Dr. Clark were over-fed ; in
addition to ordinary meals there were fre-
quent "interludes" of different kinds of
food, preserved for the most part, and alco-
holic beverages of some sort were freely ad-
ministered. The course of the affection,
according to Dr. Clark, though usually te-
dious and sometimes prolonged, has ended
eventually in complete recovery.

As to the pathology of this convulsive

140

Book Reviews.

Vol. lxiv

cough of puberty, Dr. Clark seems to think
that the seat of the disease is in the spinal
ganglia which have recently been shown to
exercise a marked control over respiratory
movements. The condition of unstable
equilibrium and hyper-excitability which
characterize the organism at the period of
sex evolution account for the development
of the cough at this time, especially when
one bears in mind that the larynx is one of
the principal seats of the changes which
take place at puberty. The neurotic ten-
dencies of the patients, and the absence of
any local changes adequate to the explana-
tion of the malady, warrant the belief that
it is of nervous origin.

Regarding the treatment of the affection,
Dr. Clark says that improvement has almost
invariably followed the enforcement of a sim-
ple but liberal dietary, arranged in three, or
at most four, meals a day; abstinence from
alcohol ; cold or tepid sponging ; warm but
not too warm clothing ; active out-door ex-
ercise, early hours and general discipline.
Of local applications, only two have done
good service. The first is glycerine of borax
with oxychlorate of bismuth and morphia,
and the second is the same combination
with the substitution of cocaine (ten per
cent.) for morphia. These applications
should be brushed over the whole interior
of the throat after each meal, and also at
bed-time. In using cocaine, care must be
taken in its application to the larynx, which
is sometimes provoked by it into dangerous
spasm. Only two internal remedies have
been found of service, one is syrup of bro-
mide of quinine and iron, with small doses
of arsenic; and the other is a pill of reduced
iron, valerianate of zinc, belladonna and
nux vomica. These pills must be given in
slowly increased dose until the physiologi-
cal effects of the belladonna become appar-
ent; and then, slightly diminished, the
amount of belladonna administered should
be maintained at that level for some time.
Dr. Clark does not approve of the long sea
voyage in the treatment of this affection.

Dr. Clark has the happy faculty of put-
ting an old truth in a fresh light, and by a
well chosen name giving definiteness and
precision to what many have seen before,
but have not closely studied. The affection
he describes is not new, and he does not
claim that it is ; but he is none the less en-
titled to great credit for his admirably clear
description of it, and for the valuable sug-
gestions as to its treatment.

Book Reviews.

[Any book reviewed in these columns may be obtained upon
receipt of price, from the office of the Reporter.]

A MANUAL OF MODERN SURGERY. An
Exposition of the Accepted Doctrines and Approved
Operative Procedures of the Present Time. For
the Use of Students and Practitioners. By John
B. Roberts, A. M., M. D., Professor of Surgery in
the Woman's Medical College of Pennsylvania, etc.
With five hundred and one illustrations. 8vo, pp. xvi,
800. Philadelphia : Lea Brothers & Co., 1890.

Dr. Roberts has set himself the task of writing a
condensed treatise on modern surgery. He has aimed
to have the work practical, and to this end has avoided
the discussion of theories, historical questions and
traditional views and operations.

The book is divided into two parts. Part I includes
general surgical pathology, or principles of surgery.
Under this heading the author discusses inflammation,
erysipelas and septic processes, scrofula and tubercu-
losis, syphilis, rickets, tumors, wounds and shock,
mode of repair and treatment of wounds, practical sur-
gery and anaesthesia, operative surgery, and plastic or
reparative surgery. Turning to anaesthesia, as a sub-
ject which has excited world-wide interest, especially !
during the past year, we notice that the author appears j
to have been very little influenced by the testimony in-
dicating that chloroform is not as dangerous as it is
generally believed to be in the northern and western part
of the United States. Dr. Roberts declares that chlo-
roform is much more dangerous than ether, and that
" this is a sufficient cause for the abolition of its (chlo-
form's) use." The advantages claimed for chloroform
over ether are attributed to improper methods of giving
the latter. The author's method is to give the patient I
a hypodermic injection of morphine and atropine about
fifteen minutes before inhalation is begun, and then to
give the ether in concentrated form from a napkin
covered by a towel. " When inhalation is once fairly ;
begun the ether cloth should never be removed from
the face unless spasm of respiration or actual vomiting
necessitates its temporary withdrawal." Quite apart
from the choice of ethe/ or chloroform as an anses- j
thetic, what might be termed the " suffocative " method
of administering ether seems to be more saving of the
time and patience of the surgeon than of the comfort
of the patient.

Part II is devoted to Special Surgical Pathology or
Practice of Surgery. The author's descriptions of re- j

section of the intestine and of intestinal anastomasis \

1

Jan. 31, 1 89 1. Notes and

Comments.

141

are especially good, and the illustrations well-chosen
and very helpful to an understanding of the operations.
The definition of amputation is a strange blunder :
f By amputation is meant the removal of a locomotor
extremity of the body ;" the upper extremity, how-
ever, is included, and description of its operative re-
moval given.

The author is to be congratulated upon keeping so
closely to his purpose to make the book modern in its
teaching and practical in its bearing. While the
teaching on some points might be criticised as too dog-
matic, it is in the main sound, and it is presented with
admirable clearness and brevity. The illustrations
seem to have been selected strictly with a view to their
utility, and are certainly well-chosen. The text is re-
markably free from typographical errors for a first edi-
tion. Both author and publisher have every reason
to feel proud of its handsome appearance. We can
cordially recommend it to our readers as one of the
best books for students which has appeared in the
English language.

ESSENTIALS OF THE DISEASES OF CHIL-
DREN. Arranged in the form of questions and
answers, prepared especially for students of medi-
cine. By William M. Powell, M. D., Physician
to the Clinic for Diseases of Children in the Hospi-
tal of the University of Pennsylvania, etc. Small
8vo, pp. 214. Philadelphia : W. B. Saunders,
1890. Price, $1.00.

Dr. Powell has succeeded in compiling, from a
number of the standard works on diseases of children,
a very creditable compend, which forms No. 15, in
Saunder's series. Most attention is given to symptom-
atology and treatment. In both the author follows
Goodhart and Starr very closely. The descriptions
are clear, and for the most part accurate and trust-
worthy as well. In speaking of the treatment of tinea
tonsurans, Dr. Powell gives Dr. Harrison's treatment
incorrectly, the principal ingredient in the formula, bi-
chloride of mercury, being omitted altogether. Dr.
Harrison recommended two solutions, the first consist-
ing of liquor potassse and iodide of potash, and the
second of sweet spirit of nitre and bichloride of mer-
cury. After the first had been well rubbed into the
scalp, the second was to be applied. The object sought
to be obtained was the production of biniodide of mer-
cury, from the reaction between the bichloride of mer-
cury and the iodide of potash, and the bringing of this
biniodide into contact with the fungus. But there is
some doubt whether or not the biniodide results from
the reaction. It may be of interest to mention here
that Dr. Harrison thinks he has found an ointment,
composed of carbolic acid (gr. xxiv), caustic potash
(gr. ix), and lanolin and oil oftheobroma (of each^ss),
much better than the two solutions originally recom-
mended.

The book fulfills a useful purpose, and may well
find a place among others of this excellent series of
compends.

Literary Notes.

— The Medicinische Neuigkeiten commences its
forty-first year in 1891. It will hereafter be published
by Jos. Ant. Finsterlin in Munich. Prof. Martin con-
tinues to be its editor. Under his long connection
with this journal it has acquired a deserved popular-
ity, especially among practical physicians in Germany.

CORRESPONDENCE.

Wound of Rectum.

To the Editor.

Sir : Thinking it might be of interest to
some readers of the Medical and Surgical
Reporter, I write concerning a wound sus-
tained by Mr. A., living some distance in
the country. While feeding his stock after
dark, he accidentally got astraddle of the horn
of an ox, and the animal in raising its head
caught the man on the point of its horn
with such force as to penetrate the left ischio-
rectal region two inches to the left of the
anal orifice, the horn going through the left
wall of the rectum, three inches above,
abrading the opposite internal rectal wall.

I arrived at night and was in doubt as to
the best procedure at the time ; so I used
temporary means and dressings until next
day, injecting per rectum an antiseptic fluid,
which found external exit through the ischio-
rectal wound. I saw also that the bowels
were well emptied, thereafter keeping them
closed by opiates for the period of six days.
Not having in my books anything treating
especially of such wounds, I next day chlo-
roformed the patient and sewed up the rec-
tal wound internally with catgut, using a
rectal speculum and a slightly-bent perineum
needle, with handle. I applied a firm pad
over the external seat of the wound, and in-
structed the patient to keep on the right
side, especially when defecating. As I had
had the sphincter ani to contend with, I was
in doubt as to the success of my treatment.
I noticed but little defecation of a liquid
character from the wound after the first
week. In one month's time the patient
came to my office comparatively well.
Yours truly,

W. H. Lewis, M. D.

Birnamwood, Wis.

Notes and Comments.

State Board of Medical Education.

An Act to Establish a State Board of
Medical Education, to Define the Powers
and Duties of such Board, and to make an
Appropriation therefor.

Section i. Be it enacted by the Senate
and House of Representatives of the Com-
monwealth of Pennsylvania in General As-
sembly met and it is hereby enacted by the
authority of the same : That within three

142

Notes and Comments.

Vol. Ixiv

months after the passage of this Act, the Gov-
ernor shall appoint by and with the advice
and consent of the Senate, a State Board of
Medical Education consisting of nine mem-
bers, physicians in good standing, citizens
of this Commonwealth, three of whom shall
serve for two years, three for four years and
three for six years, and thereafter, bienni-
ally, there shall be appointed in the same
manner three members of the said Board,
one from each school of practice, as pro-
vided in this Section, to serve for six years
in the place of those whose term shall have
expired. They shall be graduates of some
legally chartered medical college, or uni-
versity having the power to confer medical
degrees, who shall have practiced medicine
or surgery for a period of not less than five
years. Provided: That in the appointment
of said Board the members shall be chosen
equally from lists of names each list con-
taining the names of ten registered physi-
cians submitted by the State Medical Soci-
eties of the Commonwealth of Pennsylvania,
to the intent that the three systems of medi-
cine, i. e., homoeopathic, allopathic and ec-
lectic be equally represented thereon, and
provided further : That no two members
shall be residents of the same county. In
default of the submission of such lists, the
appointments shall be made by the Gov-
ernor at his discretion from among the reg-
istered physicians of the Commonwealth
having the qualifications specified in this
section.

Every appointment to fill a vacancy, or
vacancies, in the said Board, shall be for the
unexpired term, and the said vacancy, or
vacancies, shall be filled by the Governor
within sixty days after notification of the
same, in accordance with the provisions
hereinbefore stated ; and he shall have
power to remove any member of said Board
for criminal, scandalous or dishonorable
conduct.

Sect. 2. The said Board shall be known
by the name and style of The State Board
of Medical Education of the Common-
wealth of Pennsylvania, and shall have
a common seal, and may make and adopt
all necessary rules and regulations and by-
laws, not inconsistent with the Constitution
and laws of this Commonwealth, or of the
United States, and shall have power to lo-
cate and maintain an office for the transac-
tion of its business.

Five members of said Board shall consti-
tute a quorum.

Sect. 3. The Board shall meet at least
twice each year, at such times and places as
they may determine upon after the first meet-
ing, which shall be held within sixty days after
their appointment at such time and place as
the Governor may direct, at which time, and
annually thereafter, they shall organize by the
election from their own number, of a Pres-
ident and a Secretary who shall also act as
Treasurer. Provided : That the President
and Secretary are not of the same school of
medicine.

Sect. 4. No member of the Board except
the Secretary shall, as such, receive any sal-
ary; but the actual traveling and other ex-
penses of any member, while engaged in the
actual duties of the Board, shall be allowed
and paid on presentation to, and approval
by, the Auditor-General, of an itemized ac-
count with vouchers annexed.

Sect. 5. It shall be the duty of said Board
of Medical Education, to make all regula-
tions as to the extent and character of the pre-
liminary education, which shall be required
of all students of medicine, and notify the
dean of each medical college of the same.
Any change in the standard required, must
be announced by the Board at least one year
prior to going into effect.

Sect. 6. The Board of Medical Education
shall fix the minimum curriculum, and length
of course of studies requisite to graduation.
Provided : That the course shall not be less
than four years, which shall include three
annual terms of lectures. The Board shall
delegate one or more of their number, who
from time to time shall make an inspection
of the methods of instruction employed,
and the facilities for teaching, in each such
medical college, and annually report the
same to the Board.

Sect. 7. It shall be the duty of the Board
to issue, under seal, to each graduate of such
medical colleges as upon evidence of the dean
and the secretary, or registrar of the same,
shall have conformed to the requirements of
the Board as herein before provided, a certifi-
cate duly setting forth such facts. Such cer-
tificate shall entitle said graduate, to regis-
ter in any county of the State, in accord-
ance with the act entitled, "An Act to pro-
vide for the registration of all practitioners
of medicine and surgery " approved June 8,
Anno Domini 1881.

The fee for such certificate shall not ex-
ceed two dollars.

A similiar certificate may be granted to
graduates of medical colleges of other States,

Jan. 31, 1 89 1. Notes and Comments.

143

who may desire to practice medicine or
surgery in this State, provided that such
colleges stand approved by the Board of
Medical Education of this Commonwealth
as maintaining a standard in every respect,
preliminary and final, equal to that required
of the medical colleges within this Common-
wealth.

The fee for such certificate shall not ex-
ceed five dollars.

Graduates of colleges having a lower stand-
ard than that required by the Board of
Medical Education of this Commonwealth,
may receive the certificate of the Board
upon a satisfactory examination before said
Board. Such examination shall be in writ-
ing, and shall apply to the preliminary ed-
ucation, as well as the medical knowledge of
the applicant. Provided : That all ques-
tions pertaining to materia medica, and
therapeutics, shall be propounded and acted
upon, by members of the Board of the same
school of medicine with the applicant.

The fee for each such examination shall
be twenty dollars.

All examination papers shall be kept
upon file, and open to inspection, for a
period of two years in the office of the
Board.

Sect. 8. If upon investigation the Board
of Medical Education discovers, that after
the passage of this act, any medical college
within this Commonwealth, has granted the
degree of doctor of medicine to any person,
or persons, deficient in respect to either the
aforementioned preliminary or final educa-
tional requirements, or that any medical
college within this Commonwealth, has con-
ferred the degree of doctor of medicine
upon any person, or persons, without having
passed a final examination, it shall be the
duty of the Board to notify the dean of said
college of such fact, and proceed against
such college for such infringement of the
law. The penalty for a first offense, shall
be a fine of not less than two hundred nor
more than one thousand dollars. For a sec-
ond offense, a fine of one thousand dollars
shall be imposed, and the certificate of the
Board of Medical Education shall be with-
held from future graduates of said college,
except upon examination before said Board,
as provided in Section 7 of this act. In
case of conviction for a third offense, the
charter of such college shall be annulled.

Sect. 9. The Board of Medical Educa-
tion is hereby authorized and empowered, to
bring suit for the collection of such fines

and imposition of such penalties, in the
courts of the county wherein such college
may be located.

All fees and fines collected by said Board
shall be paid to the State Treasurer.

Sect, to- After the first day of June, 1892,
no physician shall be permitted to register in
any county of this Commonwealth except
upon presentation of a certificate as provided
for in Section 7 of this Act, whereupon he
or she shall be entitled, upon the payment of
one dollar, to be duly registered in the office
of the Prothonotary of the Court of Com-
mon Pleas in the said county ; and any per-
sons violating the provisions of this Act
shall be guilty of a misdemeanor, and, upon
conviction thereof in the Court of Quarter
Sessions of the county where the offense
shall have been committed, shall pay a fine
of not less than fifty, nor more than five
hundred dollars for each offense.

Sect. ii. Nothing in this Act shall apply
to commissioned medical officers of the
United States army or navy or of the United
States marine hospital service, nor to any
member of the house or resident staff of any
legally chartered medical college or univer-
sity or hospital during his or her term of ser-
vice therein, nor to physicians of other States
meeting duly registered physicians of this
State in consultation, nor to those practic-
ing denistry exclusively, nor in any manner
whatever prevent or interfere with the dis-
pensing and sale of medicines or medical
appliances by apothecaries or pharmacists,
and nothing in this Act shall be construed
to prohibit the practice of medicine and sur-
gery within this Commonwealth by any prac-
titioner who shall have been duly registered
before the first day of February, 1892, ac-
cording to the terms of the Act entitled
" An Act to provide for the Registration of
all Practitioners in Medicine and Surgery"
approved the 8th day of June, Anno Domini
1881. *

Sect. 12. The Board shall make to the
Governor, on or before the first day of De-
cember of each year, a full report of the
work of the Board for the year.

Sect. 13. For the purpose of this Act,
the words " practice of medicine or sur-
gery " shall mean to treat, or attend, any
person for money, gift or reward.

Sect. 14. The sum of two thousand dol-
lars is hereby appropriated, to meet the ne-
cessary and legitimate expenses of the said
Board.

' Sect. 15. Section 4 of an Act entitled

144

Notes aitd

Comments.

Vol. lxiv

" An Act to provide for the Registration of
all practitioners of Medicine and Surgery "
approved the eighth day of June, Anno
Domini 1881, is hereby repealed.

Endorsing Medical Examiners' Bill.

At an informal meeting of a number- of
well-known physicians, held in Philadelphia
this week the bill to establish a State Board
of Medical Examiners and Licensers, pre-
pared by the Committee on Legislation of
the State Medical Society and presented
to the House of Representatives last week
by Representative Riter, was carefully con-
sidered. It was concluded that the bill is
in the interest of public welfare and a reso-
lution was adopted that " the medical pro-
fession should give its heartiest support to
the bill."

Those present at the meeting were : Drs.
S. Weir Mitchell, J. M. DaCosta, William
Pepper, William W. Keen, William H.
Waugh, J. W. Holland, James Tyson, Clara
Marshall, James W. Walk, Charles W. Dulles,
Hobart A. Hare, Edward Jackson, Edward
H. Montgomery, William H. Parish, Hora-
tio C. Wood, Lawrence F. Flick and John
B. Roberts.

Philadelphia Polyclinic.

At the annual meeting of the Philadel-
phia Polyclinic and College for Graduates in
Medicine, held at its building, Lombard,
above Eighteenth street, January 12, 1891,
the Trustees reported that the past year
had been one of great activity in the insti-
tution and continued. The occupancy of
the new building on December 29, 1890,
was made possible by the generous con-
tributions that have been received during
the past two and one-half years. The fur-
niture required for eleven rooms, the en-
tire outfit of the apothecary shop, the
electrical apparatus for the Nervous Depart-
ment, and the outfits for the Orthopedic
and Photographic Departments, are the most
important of these contributions.

During the year just closed four free beds
have been endowed upon the progressive en-
dowment plan, and an agreement has been
entered into with the Nurses' Beneficial As-
sociation whereby any member taken sick
in the pursuit of her calling is cared for,
free of cost, in a room perpetually endowed
by the association.

There were, during the past year, a greater

number of pupils than ever in the college
department, and more patients in the hos-
pital. The new building will provide ac-
commodations in its four wards for about
forty-three patients and private rooms for
eight to twelve patients.

The Board of Public Charities has recom-
mended the Legislature of the State to make
an appropriation of $40,000, which is a re-
cognition by that discerning body of the
importance and needs of the institution.

Three new chairs have been created in
the departments of surgery, diseases of the
eye and diseases of the throat and nose, to
be occupied respectively by Dr. John B.
Deaver, Dr. S. D. Risley and Dr. Arthur W.
Watson, who have been elected Professors.

The Copyright Bill.

Speaking of some of the effects that will
follow the passage of the International
Copyright bill, the Editor of Harper's
Weekly says : The passage of the Interna-
tional Copyright bill by the House of Rep-
resentatives is an event of great importance.
It will pass the Senate probably without
delay, and the President has already ex-
pressed his approval of it. This is the
final success of an intermittent effort of
more than fifty years, during which the
most eminent American statesman have ad-
vocated the measure, and projects of law
and treaties have been carefully discussed.
The opposing forces have been of various
kinds. Chiefly they have been the general
conviction that literary property is different
in kind from other property, and that the
law has acknowledged the difference ; that
the measure would heighten the prices of
books ; and that it was not for the interest
of American printers and publishers.

The reciprocity of action upon the part
of other governments which the act con-
templates will follow its passage, and then
the results of the measure will appear. Its
effect is, in brief, to extend the author's
copyright to all countries in which his work
is sold, without injury to the interest of the
local manufacturer and publisher. It re-
moves from a great industry the imputation
of unfairness, and throws off the burden
which has hitherto oppressed literary effort
in this country. The bill is emphatically a
measure of fair play, which will inevitably
promote a friendly feeling between all the
countries which it affects. In the first week
of the session the House has led the way in

Jan. 31, 1 89 1. Notes and

Comments.

H5

legislation which honest men in every coun-
try will approve. [It is to be feared that
Harper's Weekly has been too sanguine
about the passage of a bill the chief interest
of which is moral.]

Bone Grafting.

Mr. A. G. Miller, in the Lancet for
September 20, reports the history of a
case in which he used decalcified-bone chips
successfully to fill up a large cavity in the
head of the tibia. A piece of the rib of an
ox was used, being first scraped and then
decalcified in a weak solution of hydrochloric
acid. After cleansing by pressure, it was
placed for forty-eight hours in a carbolic-
acid solution, one to twenty, then removed,
and cut into small pieces. During the scrap-
ing out of the cavity in the knee, prepara-
tory to the grafting, a number of small pieces
of bone were removed. These were placed
in a solution of boric acid for use later in
the operation. The cavity was then stuffed
with the decalcified-bone shavings, the
pieces of fresh bone being added last. The
cavity thus filled was about two inches in
diameter. Granulation and healing took
place rapidly ; the only pieces of bone that
became necrosed were from the patient's
own body. Mr. Miller is convinced, from
his observation of this case, that the healing
of large bone cavities, the result of injury or
disease, is greatly facilitated by stuffing
them with decalcified-bone chips, that these
are superior to fresh bone, and that fresh
bone not only is of no use, but actually hin-
ders the process of granulation. New
York Medical Journal, November 29, 1890.

Public Health in New Jersey.

In the annual message to the Legislature
by the Governor of New Jersey, attention is
called to the gradual increase of typhoid
fever in most of the cities of the States.
This is accepted by sanitary authorities as
indicating inadequate sanitary administra-
tion. To protect the people from this and
other pathogenic diseases, the Governor says
there should be systematic house inspection,
and the removal of waste products in cities
should be systematically and rigidly en-
forced. Attention is called to the Ten-
ement-house law, in force in New York, as
being one which would aid in securing more
healthful homes for the people. It is stated
that the use of wells and cesspools in cities

of over five thousand inhabitants is generally
such that there should be prohibitory or
strong legislative regulations.

The message contains a recommendation
that summary control should be given to the
State Board of Health or some proper author-
ity over streams of potable waters so as to pre-
vent their pollution, and further recommends
that the impounding of waters for artificial
lakes should be restrained by law, as such
acts cause partial stagnation, and thereby
render the locality subject to disease ; also
power be given to the State Board to act in
cases of local nuisance where the authorities
of the district fail to act.

The Relief of Pruritus.

The Medical Record, December 20, 1890,
says :

Itching is of various kinds, and depends
upon a great variety of cutaneous lesions.
In some instances there are no eruptive fea-
tures connected with sensation, and we have
an independent disease without eruption,
excepting such as continual scratching will
produce. In the Record of October 18, we
published a scientific study of "The Sensa-
tion of Itching" from the pen of Dr. Bron-
son, which points out the reasons why peo-
ple itch. What will stop the itching is a
question which is of equal interest both to
the sufferer from pruritis and the physician
called upon to relieve it.

Dr. Bronson tells us, among other things,
that scratching relieves itching by directing
the excitation into freer channels of sensation
sometimes, especially when severe, substi-
tuting for the pruritis either painful or vo-
luptuous sensations. It is scarcely ever
necessary for the physician to prescribe this
means of relief. It has been a household
remedy for ages, and the infant has mas-
tered its application before it graduates from
the cradle. More frequently we have to
order our patients not to scratch, because
the relief attending the act is evanescent,
and the damage done to the skin in a mo-
ment may take weeks or months to repair.

It is needless to say that this injunction
can frequently not be enforced by any
means short of the straight jacket.

Fortunately there are a few, out of the
many recommended, drugs for the relief of
pruritus, which have a more or less pro-
nounced and lasting effect.

Menthol is not a new remedy in this
sense, but it has of late received consider-

146

Notes and Comments.

Vol. Ixiv

able attention. Dubreuil and Archambault
have studied its effects in a variety of pruri-
ginous affections, and find that with it they
can succeed in calming itching of whatever
nature it may be, but that it has its greatest
effect in those cases where scratching pro-
vokes or keeps up the lesion of the skin and
the pruritus. This is particularly true of
urticaria, certain eczemas, and the pruritus
following scabies after the itch mites have
been destroyed.

In urticaria a ten per cent, solution in al-
cohol or almond-oil can be employed, and
in the acute and subacute forms is said to
be capable of bringing about a speedy cure.
For itching eczemas a five to ten per cent,
solution in oil may be used, or from two to
five per cent, of menthol may be added to
oxide of zinc ointment. Upon excoriated
surfaces and mucous membranes, care must
be exercised not to use too strong applica-
tions, as a disagreeable sensation of burn-
ing may be determined, and for such parts
an oily rather than an alcoholic solution
should be chosen. Again, applications
should not be made to the whole surface at
once, since the sensation of cold which ac-
companies the anaesthetic action is in some
cases extremely disagreeable.

In pruritus ani, perineal and genito-crural
eczema, the results of treatment by menthol
are said to be very favorable. We must not
confound pruritus, as a symptom of numer-
ous cutaneous diseases, with pruritus, an in-
dependent disease of nervous origin. In
the former the underlying skin affection
must be treated in an appropriate way,
while anti-pruritics are relied upon to se-
cure as much relief as possible.

Use of the Obstetrical Department
of the Philadelphia Hospital
for Teaching.

At a meeting of the Board of Charities
and Correction, January 12, a committee
appointed to consider the application of
Dr. B. C. Hirst, one of the obstetricians to
the Hospital, for permission to use the ob-
stetrical department of the Philadelphia
Hospital for the purpose of instruction to
students, submitted an answer, in which
they said they were fully aware of the im-
portance of furnishing means for the educa-
tion of physicians by the use of the hospi-
tal ; but declined to approve of Dr. Hirst's
proposition.

In face of the assurance that the possibil- i

ity of infection was excluded, they said there
was a possibility that proper precautions
might be disregarded. The answer of the
committee also alluded to the position taken
by the late Miss Fisher, head nurse of the
hospital, who had said that such a use of the
department should not be permitted on any
terms while she was living, and stated that
the same opposition was felt by the present
head nurse.

They also said if they felt bound to pro-
tect a corpse from examination in the cause
of science, could they, with propriety, com*
pel a living woman to submit to such expo-
sure as is inevitable in the proposed scheme
as the price of admission to a public hospi-
tal ? They, therefore, declined the request,
and put their answer on record for the in-
formation of their successors.

Nothing New Under the Sun,

The Edinburgh Medical Journal, Decem-
ber, 1890, says that it is curious to find that
something like the present-day theories of a
struggle between the microbes and leuco-
cytes must have been in vogue more than a
century ago, otherwise this bit 'of satirical
burlesque could scarcely have been written
and played.

Persons — The Devil as Hellebore, President
of the College ; Dr. Last, a new Licenti-
ate ; other Doctors and Pupils.

HeL . . . Proceed we now to the lec-
ture ! Brethren and students, I am going
to open to you some notable discoveries that
I have made respecting the source or primary
cause of all distempers incidental to the hu-
man machine. And these, brethren, I at-
tribute to certain animalculae of piscatory
entities, that insinuate themselves through
the pores into the blood, and in that fluid
sport, toss and tumble about, like mackerel
or cod-fish in the great deep. And to con-
vince you that this is not a mere gratis dic-
tum, an hypothesis only, I will give you
demonstrative proof. Bring hither the mi-
croscope !

Enter a Servant with a microscope.

Dr. Last, regard this receiver. Take a

peep.

Last. — Where ?

Hel. — There. Those two yellow drops
there were drawn from a subject afflicted
with the jaundice. — Well, what d'ye see?

Jan. 31, 1891.

News.

H7

Last. — Some little creatures like yellow
flies, that are hopping and skipping about.

Hel. — Right. Those yellow flies give the
tinge to the skin, and undoubtedly cause the
disease. And now for the cure ! I admin-
ister to every patient the two-and-fiftieth
part of a scruple of the ovaria or eggs of the
spider ; these are thrown by the digestive
powers into the secretory, there separated
from the alimentary, and then precipitated
into the circulatory, where finding a proper
nidus or nest, they quit their torbid state,
and vivify, and upon vivification, discerning
the flies, their natural food, they immedi-
ately fall foul of them, extirpate the race
out of the blood, and restore the patient to
health.

Last. — And what becomes of the spiders?

Hel. — Oh! they die, you know, for want
of nutrition. Then I send the patient down
to Brighthelmston, and a couple of dips in
the salt water washes the cobwebs entirely
out of the blood. — From Foote's Devil on
Two Sticks.

Action of Salol on the Kidneys.

In a report in the Centralblatt fur Chirur-
gie, October 25, 1890, it is stated that
Kobert has pointed out a possible danger in
the use of salol which is of importance.
Salol is so constituted that it undergoes con-
version into carbolic acid in the system of
an animal, so that any dose is equivalent to
about one-third the same quantity of car-
bolic acid. Hesselbach ordered for a strong
girl, twenty-two years old, with acute artic-
ular rheumatism, fifteen grains of salol to
be taken every two hours ; but she was given
by mistake double this dose, so that in eight
hours she took 120 grains. This was fol-
lowed by sopor, suppression of urine and
death in four days.

Kola Essence Stimulant.

The Chemist and Druggist ', November 29,
1890, gives the following formulae for kola
cordials, or what it calls "pick me ups."

R Tincture of kola (1 in 20) . . . 1 ounce

Essence of vanilla 40 minims

Simple syrup ........ ounce

Water to 8

Mix.

Dose : An ounce or more.

Roast kola nuts like coffee, grind and

make into a fluid extract (1 in 2) with 25-
per cent, spirit. Use this in the following :

R Fluid extract of Vola 10 drachms

Tincture of canella (1 in 10) . . .1 drachm
Essence of peppermint .... 8 drops

Mucilage 4 drachms

Syrup of orange 1 ounce

Water to 5 "

Mix.

Dose : From a dessert to a tablespoonful three or
four times a day.

If the latter preparation is to be kept
long it is the better for the addition of a
half drachm of spirit of chloroform to each
ounce.

NEWS.

—Mr. Edward Bellamy, F. R. C. S., se-
nior surgeon of Charing-cross Hospital,
London, died January 4, at the age of forty-
eight years.

— A meeting was held at Elmira, N. Y.r
January 16, at the office of Dr. H. A.
Argue for the purpose of establishing an
academy of medicine.

— It is reported from Upper Sandusky,
Ohio, that Dr. Neal Hardy recently ampu-
tated at the hip joint, after opening the ab-
domen, so that an assistant might compress
the aorta.

— Dr. Jacob H. Gallinger, who was, on
January 20, elected to succeed Mr. Blair as
a United States Senator from New Hamp-
shire, is 53 years old. He began life as a
printer's boy, and has been by turns a
printer, editor and physician.

— The State Board of Medical Examiners
of Colorado met January 6, 1891. Only
four candidates appeared for examination,
though some thirty or forty applications were
on file. Nothing outside of the usual rou-
tine business came up for consideration.

— On January 22, Prof. Sonnenburg ex-
hibited at the Charity Hospital, Berlin, a
consumptive patient who had been subjected
to a surgical operation upon the chest after
inoculation with Koch's lymph. The pa-
tient was said to have improved decidedly.

— It is reported under date of January
26, that a drug trust, with a proposed capi-
tal of $60,000,000, has been proposed to
some wholesale drug manufacturers in De-
troit, Michigan, by a promoter from New
York, who represents capitalists in New
York and London.

148

Obituary.

Vol. lxiv

— A " Central Throat Hospital and Poly-
clinic Dispensary" has been started in
Brooklyn, and is apparently endeavoring to
supplant the Brooklyn Throat Hospital,
which has been in operation for about two
years. Sharp rivalry and sharp practice
seem to characterize the competition.

— At the annual meeting of the Lacka-
wanna County, Pa., Medical Society, Janu-
ary 13, officers for the ensuing year were
elected as follows : President, Dr. Paine ;
First Vice-President, Dr. Barnes; Second
Vice-President, Dr. Pennypacker ; Secretary
and Treasurer, Dr. Ward; Censor, Dr.
Gardner; Librarian, Dr. Gardner.

— The President has received a package
from Minister Phelps, at Berlin, containing
five vials of Koch's lymph, and he has dis-
tributed them as follows : Two vials to Sur-
geon-General Hamilton, of the Marine Hos-
pital Service, Washington, and one vial each
to the Polyclinic Hospital, of Chicago, the
Charity Hospital, of New Orleans, and the
City Hospital, of Indianapolis.

— At the annual meeting of the Camden
(N. J.) Medical Society, January 8, 1891,
the following officers were elected : Presi-
dent, H. F. Palm ; Vice-President, Alexan-
der McAllister; Secretary, Joseph H. Wills;
Treasurer, George T. Robinson ; Reporter,
Daniel Strock ; Librarian, H. F. Palm ;
Standing Committee, H. Genet Taylor, A.
M. Mecray and E. P. Townsend.

— Judge Allison, in the Court of Common
Pleas of Philadelphia, decided on January
24, that members of the medical staff of the
Philadelphia Hospital are neither officers,
subordinate officials nor employes of the
city, and that under the rule which the
Mayor and heads of departments had power
to make, it is the duty of the Board of Char-
ities and Correction to elect the hospital
staff annually.

— At the annual meeting of the Mont-
gomery County, Pa., Medical Society, held
January 21, the following officers were
elected for the ensuing year : President,
George N. Highley, Conshohocken ; Vice-
Presidents, G. F. Hartman, Port Kennedy,
and Mabel W. Moore, Norristown ; Record-
ing Secretary, H. H. Whitcomb ; Corre-
sponding Secretary, J. K. Weaver; Treas-
urer, E. W. Corson.

— -Dr. William J. McClure, aged 53, died
at York, January 24. He represented Adams
county in the Legislature in the session of
1877-78. He was also Coroner of this
county from 1867-70, and held other

offices prior to his removal to York, in 1880,
to practice medicine. He was a graduate
of the Baltimore City College and a member
of the York County Medical Society. He
was a native of Madison county, Indiana.

— William Faulk, living at Laurel Sta-
tion, Pa., killed his wife in a fit of reli-
gious frenzy on January 23. The next day
a warrant was issued for the arrest of George
Knauff as an accessory before the act. Faulk
declares his religious insanity was inspired
by the hypnotic influence of Knauff, who
claimed to be another Messiah, and ordered
him to kill his wife. This Faulk did, and
officers are now hunting Knauff, who has
disappeared.

— The newspapers have been stirred up by
the assertion that on January 18, one hun-
dred and thirty-two Knights Templar con-
tributed pieces of their skin to surgeons, who
transferred them to a fellow-member, who
had had a cancer removed from his thigh.
Enough skin was secured to cover one hun-
dred and forty-four square inches of surface.
The operation took place in the Emergency
Hospital, in Chicago, and it was said that
the result would not be known for ten days.

— The death of Henry M, Martin, Sur-
geon in the United States Navy, was an-
nounced January 19, 1891. He was born
in Philadelphia. He was appointed Assist-
ant Surgeon in the navy May 21, 1870, and
was promoted to Passed Assistant Surgeon
on June 8, 1874. He was with the Alert,
on the Asiatic Station, from 1875 to 1878,
and was promoted Surgeon on April 24,
1884. He was attached to the receiving
ship, St. Louis, at League Island, from
1886 to 1888, and afterwards to the Swa-
tara, on the Asiatic Station. He was re-
tired in November last on account of ill
health.

OBITUARY.

ROBERT A. TAYLOR.

Dr. Robt. A. Taylor, a promising young
physician of Duluth, died December 21,
1890, age 31, of typhoid fever. Dr. Taylor
was a graduate of the Jefferson Medical
College, Class 1886. He served one year at
Blockley Almshouse as resident physician.
Dr. Taylor was gathering about him a very
large practice. Surgery was his special forte.
He leaves a wife and one child to mourn
his loss. His remains were brought on to
this city for interment.

MEDICAL AND SURGICAL REPORTER.

XV

"This is an Age of Apollinaris Water!'

—Walter Besant

Apollinaris

"THE QUEEN OF TABLE WATERS."

"Familiar in millions of mouths as any household
word.

"The popularity of Apollinaris Water is chiefly
dice to its irreproachable character.

"More wholesome than any aerated water which

art can supply" — The Times, London.

"Of late years the Queen, by the advice of Sir William Jenner, has
usually taken Apollinaris Water.— The World, London.

THE BEST NATURAL APERIENT.

THE APOLLINARIS COMPANY, LIMITED, London, beg to announce that, as
numerous Aperient Waters are offered to the public under names of which the word
M Hunyadi " forms part, they have now adopted an additional Label comprising theii
Registered Trade Mark of selection, which consists of

A RED

This Label will henceforth also serve to distinguish the Hungarian Aperient Water
sold by the Company from all other Aperient Waters.

DEMAND THE ^^^^ DIAMOND MARK.

And insist upon receiving the Hungarian Aperient Water ot the APOLLINARIS

Company, Limited, London

XVI

BOUDAULTS PEPSINE

The only Pepsine used in the Hospitals of Paris for the last Thirty Years.

Unlike the various substitutes which, in most'cases, are but^unscientific or incompatible compounds, forced upon tue'Medieai
Profession as aids to digestion by extensive advertising, but which, when submitted to the proper tests, are found to be useless AS
digestive agents, Pepsine is constantly gaining in the esteem of the careful practitioner.

Since the introduction of Pepsine by Boudault and Corvisart in 1854, the original BOUDAULTS PEPSINE HAS BEEN
AT ALL TIMES CONSIDERED THE BEST, as is attested by the awards it has received at the Expositions of 1867, 1868, 187
1873, in 1876 at the Centennial Exposition of Philadelphia, and in 187H at the Paris Exposition.

The most reliable tests, carefully applied, will satisfy everyone that BOUDATJLT'S PEPSINE HAS A MUCH HIGHER
DIGESTIVE POWER than the best Pepsines now before the Profession, and is therefore especially worthy of their attention.

BOUDAULT'S PEPSINE is prepared in the form of Pepsine Acid and Pepsine Neutral. It is sold in bottles of one ounce,
with a measure containing exactly five grains; also in bottles of four, eight/and sixteen ounces for dispensing.

BOUDAULT'S WINE OF PEPSINE

FORMULA OF DR. CORVISART.

The taste of Pepsine being perfectly disguised in this Wine, it may be recommended to persons who have difficulty in taking
Pepsine in the form of Powder. This Wine is tested so that a tablespoonful of it is equal in digestive power to ten grains of
Boudault's Pepsine in powder. Sold only in bottles of eight ounces.

TAN RETS PELLETI ERI N E

For the Treatment of Tape- Worm (Taenia Solium).

This New Tsenifuge, the Active Alkaloid of Pomegranate Bark, has of late come into extensive use h» France for the
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18t. Mandrier, etc., and in the Hospitals of Paris, St. Antoine, La Charity, Necker Beaujon, etc., have all been most satisfactory.
Doctor Dujardin Beaumetz, Member of the Academy of Medicine, and Professor Laboulbene, in their report to the Society of
Therapeutics, have given it their unqualified approval, after the most searching experiments. This preparation is pleasant to
administer, and, if certain preliminaries are observed, success will be insured.

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DUCRO'S ALIMENTARY ELIXIR

I Combination uniting the properties of Alcoholic Stimulants and Raw leal

This preparation, which has been used with great success in the hospitals of Paris since 1868, is adapted to the treatment •
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Prepared by EMTLB DURIEZ & CO., Successors to DUORO & CIE, Paris.

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Sole Agents for thcabove Preparations.

XVII

Constipation.

Pnvam Pills are prepared especially
for the treatment of Constipation. They
are tasteless, harmless, and produce natu-
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Physicians are requested to test these
pills in those cases which they think to
be incurable, also, in cases of ronstipa-
tion durins pregnancy. Thousands of
physicians now use aud prescribe them.

Physicians will see by the formula
(on the outside label) that each medicinal
ingredient is absolutely harmless.

Prices: smnll bottle, (25 pills), 25 cents;
large, (150 pills), $1.00. Liberal discount
to physicians.

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cents in postage stamps.

Prepared by C. L. TOPLTPF, New York.
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my

Suppositories

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Haemorrhoids or Piles.

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physicians and the public have long
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Physicians thoroughly approve of
these Suppositories because they are
so effective, and will not interfere in the
slightest degree with any other medical
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Price 50 cents per box, (24 Supposito-
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Two boxes will be mailed to any physi-
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postage stamps.

Prepared bvC. I,. TOPLIFF, New York.
Depot, 115 Fulton Street.

FRAUD.

Unscrupulous parties are selling an inferior Wine, calling
it Royal Tokay, thus profiting by the numberless Medical
Editorials written about our genuine product. The Wine
cannot be used as a substitute for ours, and many physi-
cians have unjustly blamed us for damage done, imagining
they were securing our Wine, which they had already tested
with complete satisfaction. Your patients will not secure
the Wine you prescribe unless you specify CALVICO
TOKAY, by which name it will hereafter be known.

CALIFORNIA VINTAGE CO.

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BOSTON, MASS., Theo. Metcalf & Co., 39 Tremont St.
PHILADELPHIA, PA., Showell & Fryer,

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ST. LOUIS, MO., John W.Howard, 307 Garrison Ave.
LOUISVILLE, KY., Geo. A. Newman,

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INDIANAPOLIS, IND., Geo. W. Sloan,

22 West Washington St,

EVANSVILLE, IND., H. J. Schlaepfer,

Main and 2d St.
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HARTFORD, CONN., C. A. Rapelye, 321 Main St.
NEW BRITAIN, CONN., E. W. Thompson,

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NEWPORT, R. I., Hazard, Hazard & Co,

PROVIDENCE, R. I., E. F. Mattison, 277 Westminster St.

XV1TI

MEDICAL AND SURGICAL REPORTER.

A CASE WITH A LESSON IN IT.

We have frequently referred to the neces-
sity of keeping the pregnant woman supplied
with those chemical substances which she
must give to the child in the formation of
its little frame, and the dire effects which
may result from a deficiency of those sub-
stances. The headaches, neuralgias, spinal
tenderness, and some of the many disorders
of digestion, and even mental failure, may
be all prevented or relieved by supplying to
the mother the chemical food her system
demands.

We have noticed a few cases where the
most serious results have occurred to the
mother by such a deficiency, one of which
is well worth relating. Mrs. M., aged 30,
pregnant with her third child, suffered from
the second to the fifth month of her preg-
nant term with gradually failing strength
and health, and nervous irritability. She
was very restless nights for three or four
days, the peculiar restlessness of complete
nervous exhaustion, and was irrational for
more than a week.

At this time I advised that she have a
teaspoonful of Murdock's Liquid Food
every hour in milk, and a little wine every
four hours. The third night she had fifteen
drops of hydrobromic acid dil. every three
or four hours, which was continued for a
week. The liquid food after a week every
two hours, and all other medicines were dis-
continued. Her bowels were moved with a
mild laxative at first, and afterward became
regular. Her tongue cleaned quickly and
her skin assumed a more natural appear-
ance.

At this writing, less than three weeks
from our first visit, the patient is able to sit
up an hour at a time, is quite rational and
cheerful, has a good appetite, the bowels
are quite regular, there is no headache, and
but little spinal tenderness. She sleeps
reasonably well if fed frequently. She is
allowed to suit her taste in her diet. The
child is quite active, and the mother is pro-
gressing so nicely that it is hoped that she
will pass safely through her confinement,
which is nearly at hand. She will be kept
on the liquid food and the phosphates
until her confinement after which, the con-
dition will suggest the treatment. This
is the most marked case of a starved
nervous system we have ever seen, and
the benefit derived from the treatment

proves the theory as to the cause of the
trouble.

Apropos with the above, comes the ques-
tion of the selection of nutritious foods for
those many cases which demand strong and
immediate nourishment. The food used in
the above case has produced marvelous re-
sults for us in some of those extreme cases
in which we have used it.

In one case of nervous exhaustion the
insomnia was absolutely painful. When
the exhaustion forced the patient to sleep
there was an immediate sense of falling or
approaching death, or there were hallucina-
tions which were appalling, rendering the
nights unbearable. One teaspoonful of
Murdock's Liquid Food so nourished the
system the first night it was given that the
patient sank into a quiet, refreshing sleep
which lasted, with a single awakening, until
morning, and the improvement the patient
obtained was most striking.

One case of mitral regurgitation with
leucocythemia and nervous exhaustion im-
proved more rapidly on this food than on
all other measures combined. In cases of
nervous exhaustion and brain tire, its effects
are most marked, as we have experienced
many times in the past five years in the
frequent personal use of the agent. It con-
tains the principles of pure, healthy blood
and nerve tissue ready for immediate as-
similation. Fourteen per cent, of the entire
quantity is uncoagulated albumen, as we
have demonstrated by actual analysis.

We have tided babies over critical periods
often with a few drops in its usual diet.
We have given it to dipsomaniacs with or
without non-alcoholic stimulants with su-
perb results. The sole objection our pa-
tients have to it is its odor. Its taste is not
disagreeable ; it has the odor and appear-
ance of blood. All objections are soon for-
gotten, however, in the results of its action
upon the nutrition of the system, and the
patient soon learns to like it, and often
craves for it, drinking it from the bottle or
a glass readily, like any beverage. It
ought to be the food par-excellence for
rapid appropriation in all conditions of ex-
haustion.

P. S. — Phosphates act well with the Liquid
Food.

Editorial of the Chicago Medical Times y
June, 1890.

Medical and surgical
Reporter

A Weekly Journal.

Established in 1853 by S. W. Butler, M.D

CHARLES W. DULLES, M. D., Editor and Publisher,

Entered as Second-Class matter at Philadelphia P. O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

Vol. LXIV, No. 6.
Whole No. 1771.

FEBRUARY 7, 1891.

$5.00 per Annum.
10 Cents a Copy.

COIsTTEl^TS

CLINICAL LECTURE.

Longstreth, Morris, M. D., Philadelphia, Pa. —
Apparent Hemiplegia following the Grippe.—
Acute Catarrhal Jaundice 149

COMMUNICATIONS.

Spohn, Arthur E., M. D., Corpus Christi, Texas.
—Treatment of Carbuncle 151

Fox, L. Webster, M. I)., Philadelphia, Pa.— Re-
section of the Optic Nerve 152

Veasey, C. A., M. D., Philadelphia. Pa.— Case of
Ulcerative Endocarditis..... 154

Noble, Charles P., M. D., Philadelphia, Pa.—
Minor Uterine Surgery 156

SOCIETY REPORTS.

Philadelphia Obstetrical Society

PERISCOPE.

159

Koch and the German Government.— Cerebral Tu-
mors. — Physiological Action of Thialdine. —
Chloroform as an Antiseptic— A Ready Inhaler.
—Detection of Bile Pigment in Urine 165-168

EDITORIALS.

Koch's Method.

169

Secret Remedies.— Koch's Remedy 170

The Micro-organism of Malaria ITjB

Clinical Lectures |78

BOOK REVIEWS.

Kelsey ; Stricture of the Rectum. A Study of
Ninety-six Cases.— Smith ; A Treatise on the Dis-

of Infancy and Childhood 173

CORRESPONDENCE.

Clinical Lecture by Dr. J. H. Musser 174

QUESTIONS AND ANSWERS.

What is the Best Stimulant in Impending Collapse ? 174

NOTES AND COMMENTS.

The Koch Remedy in New York.— Brown-Sequard
Fluid in Tuberculosis. — Practical Method for
Staining Tubercle Bacilli. — Pleuritic Effusion
in Children.— Early Spontaneous Rupture of the
Uterus.— Anti-Kidnapping League.— The Physi-
ological Action of Sulphaldehyde. — Cocoanut
for Tape Worm— Another Koch Institute in
New York.— New Operation for Club-Foot. ...174-178

OBITUARY.— John McCarrell, M. D 178

"Verbum, sat Sapientibus."

EXAMINE

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PAGES IV &, V.

ANTISEPTICS, DISINFECTANTS AND OXIDANTS.

Sanitas;" is prepared by Oxidizing Terpene in the presence of Water
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New York City.

MEDICAL AN D SURGICAL
REPORTER

No. 1771. PHILADELPHIA, FEBRUARY 7, 1891. Vol. LXIV.— No. 6.

Clinical Lecture.

APPARENT HEMIPLEGIA FOLLOW-
ING THE GRIPPE.— ACUTE
CATARRHAL JAUNDICE.

BY MORRIS LONGSTRETH, M. D.,

PHYSICIAN TO THE PENNSYLVANIA HOSPITAL.-
LECTURER ON PATHOLOGY, JEFFERSON MEDICAL

Gentlemen : The case before us, which
was sent as one of hemiplegia due to the '
Grippe, will serve as an illustration for a talk
on the many effects produced by the epi-
demic influenza of last winter. This woman
presents the following history : She is forty-
seven years old, single, and has been nine
years in this country. By trade she is a j
dressmaker. She comes to us with the his- j
tory of a partial loss of power in the right j
arm and leg ; not that she is unable to move j
these members, but she cannot walk nor use
her limbs with any precision or skill ; in
fact, she cannot do any of the useful things
essential in daily life and work. She has
no family history which bears upon her case.
Personally she has always been healthy.
There is an indefinite history of enlarged
glands some time ago ; but she states that
she has not seen a doctor for eighteen years.
In common with many of the rest of us, she
had an attack of influenza last Christmas,
and has not been well since. Her present
trouble dates from four months ago. It be-
gan in a curious way for hemiplegia — at
least of a centric origin. She experienced
a feeling of malaise, of being out of sorts ;
a pain appeared in her right hip, not con-
nected in any way with the abdominal cav-
ity. We can scarcely call it a pain ; it is
rather a twisting sensation, unusual in char-
acter and indefinite in nature. This feeling
spread up and down in her body, and took
away the power of movement. There was
a sensation of loss of power, which lasted

only for a little while. After experiencing
tingling in the fingers, the loss of power be-
came less apparent, lasting on an average
for twenty minutes, and coming and going.
There were no head symptoms, and the eye-
sight was good. Ever since her experience
with the influenza, her digestion has been
impaired, her appetite and bowels were up-
set, and a general indefinite run-down con-
dition of health has settled upon her. There
has been at no time any evidence of the loss
of power in head or face. On protuding
her tongue, we can see that she holds it
straight out. The tongue is covered irregu-
larly with patches and her breath is heavy.
Her heart and lungs are normal, and noth-
ing exists in the abdomen abnormal that we
can detect. Flocculi of mucus are found in
the urine, with a slight trace of albumin,
mucous corpuscles, imperfectly formed epi-
thelial cells, and bodies which approximate
in their appearance hyaline casts. Probably
the mucus had collected in strings, giving
this simulation of hyaline casts. Crystalline
material is abundant in the urinary secre-
tion. This shows that the kidneys are able
to separate the waste products of the blood
fairly well. I believe that, when enough
uric acid, urates, oxalate of lime, etc., are
present, even if there is sufficient change in
some parts of the kidneys to form casts, it
will make but little difference in diagnosis
or prognosis ; for this shows that the kid-
neys are acting in a fairly normal manner.

The specific gravity is above 1.020, show-
ing that there was no deficiency in solid
matter excreted. The grip of each hand is
not good at all, being poor in each instance.
She moves her limbs quickly, however, and
without hesitation. There has been no rise
in temperature. Before deciding exactly
what condition we have before us, let us go
a little, farther into the digestive symptoms.
You will notice that the tongue is smoothed
off, as if it had been skinned. This is di-
agnostic of a coating which for some reason

149

1 50 • Clinical

or another has desquamated, similarly to a
blistered surface of the skin. It should be
velvety and natural in appearance, or else
essentially coated. A patch of coating has
appeared from day to day on the tongue,
creeping around. It sheds off rapidly, either
from contact with the food or teeth, or be-
cause the desquamation is severe. This
shows that the irritation must be severe and
is even more unfavorable than that the
tongue should remain heavily coated. The
coated tongue is dry naturally ; it becomes
no moister after wetting. Apply your finger
to this tongue, you will find that,, after one
or two touches, the surface of the tongue is
dry. It is likely that this intense irritation
of mucous surfaces has spread down the ali-
mentary tract since last January, acting al-
most as severely as if one-half the surface of
the skin were blistered. That this effect has
been produced by the " grippe" is well
known. Many cases have recovered per-
fectly. In many cases of the influenza, the
respiratory mucous membrane was left in a
bad ' condition. This effect can be seen
more sharply and distinctly, and hence is
more liable to be well treated and the con-
dition corrected. But the stomach and in-
testines are more used to non-attention ;
their symptoms are not so sharply marked ;
the patient is able to bear up under them
better. But in this woman we have a story
of depression in nutrition which is a fair
example.

What proof can we seek in this woman to
find if her story of serious illness is true. I
have been in the habit of looking at the
finger nails, for this reason : that, in the
various fevers and the many other conditions
which depress nutrition, the hair comes out
in convalescence or scales drop off the skin.
In febrile processes there is a check of the
natural growth of the tissues of the body. On
the return of health these tissues start again
to grow. If you will examine the roots of the
hair in a convalescent patient, you will' see
that the ends of the hair are splintered and
weak. In the skin this condition is not so
perfectly or readily seen ; but in the finger
nail we find the game nature of epithelial
growth. They stop growing in serious dis-
eases, and bear their records for long periods
of time. In this woman, four months after
her attack, it is too late to look for the re-
cord of serious illness in her hair, but the
nails of the hand bear record for many
months, that of the thumb for nine months,
while the great toe nail is characteristic for 1

Lecture. Vol. lxiv

two years. In hemiplegia there is a stop of
growth on the affected side ; the nutrition
is impaired just as it is in a broken arm.
On looking at this woman's hand, we find
a third way up on the thumb nail, half way
down on the finger nail and on the little
finger nail at the end, a marked depression
or thinning out of the nail. Normally we
have a smooth polished nail, but in these
cases there is a depression and a lack of
appearance of strength which is character-
istic when once noted. If this were a case
of hemiplegia, occurring four months ago,
there would be a depression on the affected
side later than that one produced by the in-
fluenza ; but we find on examination that
this is not so. The question presents itself,
is the " grippe " a sufficient cause for the
production of hemiplegia ? We know what
part- intestinal mischief bears in the produc-
tion of marked nervous trouble ; we know
the effect injudicious food has in children
in causing convulsions, but it is hard to say
what amount of disease the curious epidemic
of last winter is capable of leaving in its
path.

The electrical examination does not favor
at all the hemiplegic view ; the reflexes on
the right side are somewhat exaggerated,
but this I believe is due to want of proper
exercise and use.

In considering the treatment of such a
case as this we must remember that the
tongue points to the existence of a general
condition of digestive depression. The
feeding is one of the most important points.
In catarrh of the intestines, the treatment
varies according to the intensity of the
symptoms. The use of some sedative ap-
plication, such as bismuth, is indicated, to
relieve the irritation which exists. This is
shown by the discoloration of the mucus
seen in the stools, similar to the white
patches found on the tongue. To restore
intestinal action and secretion, minute doses
of calomel can be very advantageously com-
bined with bismuth. We have been giving •
this woman every three hours a one-twenty-
fourth of a grain of calomel with ten grains
of bismuth. The tongue may not get free,
but even if it coats over, it will be a gain,
as we have shown. This simple treatment
is rapidly improving this woman's condition.

Acute Catarrhal Jaundice.

The next patient, a woman sixty years
old, has nothing in her family or personal
history which bears upon her case. She

Feb. 7, 1 89 1.

Communications .

says that she has been subject to " liver
attacks, ' ' .in which the chief symptoms were
nausea, choking, and a band-like pressure-
sensation over the epigastrium. The skin
never became yellow, and she had no severe
colic or pain in the abdomen. Her present
attack began with a chill, a severe pain in
the region of the liver, and nausea, followed
shortly by fever. Almost immediately
jaundice appeared, and the bowels obsti-
nately refused to act. The temperature was
102 1 °, falling on the next day to almost
normal. Night and morning it remained
nearly even, but it was irregular throughout
the day. Occasionally she experienced a
chill. Enemas of soap and water were tried
ineffectually. Subsequently relief was ob-
tained by the addition of glycerine. Since
October 1, she had no serious rise in tem-
perature until the 24th. Since the 26th,
she has been taking one or two compound
colocynth pills. Her movements, which had
been slate-colored before, showing no
evidence whatever of bile, now became
darker, and the tongue cleared up. It had
been thick, yellow, swollen and dry. The
conjunctivae, which have been yellow, still
remain so, due to thickening, not to stain-
ing. The face never was very yellow, the
color being better seen on the abdomen.
Her appetite and sleep have each improved.
Her bowels move regularly, and she is gain-
ing strength. The colocynth acts with more
and more effect. She was taking three pills ;
she is now down to two. This will be re-
duced to one in a short time. The urine,
which was dark in color and contained con-
siderable bile, now shows on testing that
that element has disappeared.

Communications.

treatment of carbuncle.

BY ARTHUR E. SPOHN., M. D.,

CORPUS CHRISTI, TEXAS.

Several years ago I was called to see a pa-
tient, living fifty miles away in the country
— a very frequent occurrence in Southwest-
ern Texas, where pastures contain from ten
to five hundred thousand acres in one en-
closure. I met on the road a man suf-
fering fearfully with carbuncles. He had
three : one on his face, one on his wrist and
one on the back of his neck. I don't think
I ever saw any person suffer as he did. The
only medicine I j had with me which

I thought could give relief was a saturated
solution of chloral hydrate in water and gly-
cerine. Of this I poured one teaspoonful
over bread poultices, and applied them to
the carbuncles, expecting as soon as the man
was relieved of pain to make the ordinary
incisions. To my surprise he was soon re-
lieved of pain, and the next morning the
carbuncles looked so much better that I con-
cluded to continue the treatment, without
making incisions. I did not see this man
again for about two months, when he came
into my office for a prescription of the medi-

| cine I used, saying that he had had no
more trouble after I left; that his carbuncles
had diminished in size without sloughing,
and that they soon got well. The carbun-
cle on his back was fully three inches in di-
ameter. He has had several carbuncles
since, using the same treatment success-
fully. I have not seen him recently ; but I
am told that he is falling off in weight. I
did not examine his urine at the time, but
think he is probably suffering with diabetes.

I have now under treatment four cases of
carbuncle. It is strange that nearly all the
cases of carbuncle I have seen in this cli-
mate occur during February, March and
April. This fact has impressed me with the
idea that they are due to some climatic con-
dition. Two of my patients have carbuncle
on the back of the neck, one on the back,
one on the side of the neck. I am treating
these cases with a ten per cent, solution of
chloral hydrate in glycerine and water, ap-
plied constantly by means of absorbent cot-
ton. The patients are doing well and having
little or no pain. Internally I give sulphide
of calcium. I have a patient who had car-
buncle in April, 1887, and again in Septem-
ber, accompanied by numerous boils. He
has diabetes, his urine containing six grains
of sugar to the ounce. He now has caries of
the ilium on the right side. I removed the
carious part twice, but the bone would not
take on healthy action. I am now irrigating
the diseased surface with a ten per cent, solu-
tion of phosphoric acid. The patient seems
to be improving ; and there is very little dis-
charge from the two sinuses leading down
to the bone, one of which passes in the di-
rection of the sacro-iliac articulation.

I While speaking of this patient, I wish to
mention an -artesian well in this city, the
water of which is very beneficial in cases of
diabetes. The well is about 400 feet deep ;
flows about five feet above the surface of the
ground in a small stream ; and its capacity

152

Communications.

Vol. lxiv

is about 60,000 gallons daily. This water
contains principally chloride of sodium and
sulphate of sodium, strongly impregnated
with sulphuretted hydrogen gas. It sparkles
in a glass like champagne. It is laxative,
in doses of an ordinary glassful ; in larger
quantities it is a brisk cathartic, causing
little or no inconvenience. The water be-
longs to the city and is free to all. It will
not bear transportation under the present
methods of bottling.

I was very much pleased when I read the
lecture on the treatment of carbuncles by
Prof. Verneuil of Paris, in the Reporter of
February 11, 1888. I have used carbolic
•acid, but not as a spray. I think the treat-
ment by chloral is quite as successful and
more easily carried out. The principal merit
in the two methods is the avoidance of the
old crucial incision, which I find still recom-
mended in my latest works on surgery. I
never make incisions into a carbuncle ; they
are useless and painful, and expose a fresh
surface to the virus. It is impossible to open
every cell, as it were ; and I consider the
crucial incision to be a relic of surgical bar-
barism. There may be cases, with an ac-
cumulation of pus, requiring an incision;
but they are very rare. A man came
into my office some months ago, and asked
me to look at the back of his neck. He was
a railroad magnate, and of course, very anx-
ious to get well. He had been told he was
getting a carbuncle, and that a crucial incis-
ion was necessary. I don't know about the
carbuncle, but I do know he had the incis-
ion. The skin on a man's back, is — as near
•as I can estimate it — about a quarter of an
inch thick ; in this case I think it was about
three-quarters of an inch ; the length of
each incision was two inches, and when I
looked at them I thought, if I had my
choice between such an incision and a two-
inch carbuncle, I would take the carbuncle.
Whether the man ever got the edges of that
incision together or not is questionable; but
I fancy he carries a crucial brand, which in
Texas is considered quite an ornament.

— The first patient in this country to re-
ceive the lymph inoculation, died, in New
Haven, Conn., Feb. 2, and another lymph
patient, who has been under treatment for
nearly two months, was then at the point of
death. The first named was a man but little
over thirty years of age and was not in an ad-
vanced stage of consumption when he be-
gan receiving treatment.

RESECTION OF THE OPTIC NERVE.

BY L. WEBSTER FOX, M. D.,

PHILADELPHIA.

The loss of an eye under any circumstances
or conditions is a very serious affliction.
The vacant stare and dull look of an arti-
ficial eye can never compensate, for one
which may be disfigured by a leucoma or
partial atrophy, for even such eyes are pre-
ferable to wearing glass ones, be they ever
so well matched. No matter how smooth
an artificial eye is polished, sooner or later
the secretions corrode its surface and those
irregular projections cause more irritation,
and the result is more offensive secretions,
which become dry and harden upon the sur-
face of the eye, usually appearing as a hori-
zontal band over the cornea. To morbid
individuals, especially women, these results
are, to say the least, disagreeable, and to the
observer equally so.

The question has often arisen : How can
we best overcome the necessity for an enu-
cleation. Eyeballs are removed, as a rule,
for three indications :

1 . If wounded or cut in the ciliary region
(the danger zone), to prevent sympathetic
ophthalmia.

2. If atrophied, to make room for an arti-
ficial eye.

3. For new growths (tumors).

The first indication is the most important.
If we can prevent sympathetic ophthalmia
we also may save an eyeball ; but by sav-
ing the eyeball we do not necessarily pre-
vent sympathetic ophthalmia. In the sec-
ond case an atrophied eyeball is disfiguring
and is removed for cosmetic purposes, and
because it may be a hiding place for new
bone development, which may remotely pro-
duce sympathetic irritation. I have fre-
quently removed a stump and found bone
shells with edges as sharp as a splinter of
glass. With such a foreign body irritating
it, an optic nerve might readily be the focus
of migratory ophthalmia.

Where a tumor exists we have but one re-
course— enucleation .

At the October meeting of the Society
D' Ophtalmologie? of Paris, the question of
resection or laceration of the optic nerve
was discussed, especially by Drs. Be Wecker,
Chauvel, Gillet de Grandmont and others.
Dr. De Wecker, who has had exceptional

Recueil Z>' Ophtalmologie, October, 1890.

Feb. 7, 1 89 1.

Communications.

'53

facilities for putting into practice the text
of his teachings, made the following re-
marks.

"I propose to continue the campaign I
have undertaken against the abuse of enu-
cleation, and I firmly believe that by mak-
ing more popular the simple resection of the
optic nerve in cases where we have danger
of migratory ophthalmia, no more eyes will
be taken out, except when they are the seat
of a neoplasm (tumors).

"If the transmission of migratory oph-
thalmia by the optic nerve is confirmed (and
I am convinced of it), the simple resection
of the nerve will afford a sure means of pre-
venting it. Boucheron and Schoeler's
method, which includes cutting the ciliary
nerves,- does not, however, answer the pur-
pose. The only way to prove conclusively
that resection of the optic nerve can take
the place of enucleation is that a large num-
ber of resections shall be made and the re-
sults noted. The operation must also be
made as simple as the operation for enucle-
ation. If we were to follow the complicated
operations as described by Schvveigger or
Pagenstecher it would certainly never be-
come popular.

"Being aware of the difficulties which be-
set one, and fearing that in the midst of
operation, by an unlucky cut of the scissors,
a hemorrhage should follow, it occurred to
me to forego the section of the nerve, which
is the most difficult part of the operation,
and simply to tear off the nerve near its op-
tic entrance. This idea was suggested to
me by the cases recorded, in which the eyes
were torn out with the optic nerve attached,
and also the savage custom of the Tyrolese
wrestlers, who put eyes out by introducing
their thumbs into the orbits on the temple
side. I suppose that such displacement of
the globe could only be effected after tear-
ing off the nerve at its optic attachment.
On a recent visit to the Tyrol, a wrestler
presented himself with his eyeball hanging
on his cheek and asked whether the eye
could be replaced and be useful to him.
Being answered in the negative, he seized
the eyeball, tore it off and flung it to the
ground. My experiments upon the cadaver
were made with a view to ascertain whether
or not a nerve could be torn. With my
double hook I have never been able to tear
off the nerve at its entrance into the orbit,
even when pulling with all my strength. All
I could do was to sever the nerve by pull-
ing with the hook ; in other words, the hook

cut its way through the nerve. On several
occasions I succeeded in tearing the eyeball
from the nerve, the vitreous humor escaping
through the opening made by the head of
the nerve disappearing. I also tried to tear
the nerve off as it entered the orbital fora-
men ; but I signally failed in this also. We
have a well-known case, in which a drunken
man fell against a door, the key of which
was projecting, and the eye thrust itself
through the ring of the key, the nerve being
completely severed. In another case, a horn
of a cow drove the eye into the maxillary
sinus. Here also the nerve was severed.
In these instances the traction did not act
directly and exclusively on the optic nerve,
as in my experiments on the dead body. In
the case of the intoxicated man who thrust
his eye through the ring of the key, all the
weight of his body exerted a traction on the
whole funnel-shaped bundle of muscles of
the eyeball. The traction pressed on their
insertions around the passage of the optic
nerve into the orbit, and tore them off from
their insertion simultaneously with the
sheath — to which they are attached. This
is also the reason why we do not find the
tearing off of the nerve isolated ; the inter-
nal rectus being always detached in this sort
of traumatism. We must therefore give up
the combined operation of resection and
tearing, in place of the simple resection.
All that is left for us to do is to try to im-
prove the operation of simple resection ; to
make it always feasible and easy so as to
supplant the repulsive enucleation."

M. Chauvel who made some experiments
upon the elongation of the optic nerve stated
that he was never able to tear the nerve of
the human eye, although he was able to do
so in rabbits.

M. Gillet de Grandmont corroborated Dr.
De Wecker's statements, especially those re-
lating to tearing the globe from the nerve,
and related an instance in which a woman in
a fit of melancholy, suddenly thrust her in-
dex finger and thumb into her orbit. Her
strength was so great that with her left hand
she took hold of the eyeball, tore it off with
three centimeters of the optic nerve, and
threw it on an adjacent bed. This was the
work of a few seconds. She made a similar
attempt on the right eye, but the attendant
seized her right hand, only, however, after the
patient had succeeded in thrusting her index
finger under the inferior muscles and had
torn them from the globe. A severe hemor-
rhage followed, no other complications arose,

154

Communications.

Vol. lxiv

and in a few days she recovered the sight in
her right eye.

We miss very much in the foregoing re-
marks a description of the exact way in
which De Wecker, Grandmont and others
perform resection of the nerve.

A few years ago Mr. Brudnell Carter and
Dr. T. Herbert Bickerton performed an op-
eration for opening the sheath of the optic
nerve in optic neuritis. Mr. Carter designed
special instruments for this operation, and
the difficulties were made easy for exposing
the optic nerve. In performing this opera-
tion, I found but little difficulty in follow-
ing Carter's method. The one obstacle
was, that the orbital fat would constantlyget
in the way. Dr. Shakespeare, who assisted
at this operation, suggested a speculum shaped
like Sims's uterine speculum. With this
instrument the difficulties were overcome in
a subsequent operation.

If resection of the optic nerve can be
performed with complete protection against
sympathetic ophthalmia, it will be a boon
to many unfortunates. The wearing of an
artificial eye is as annoying as it is un-
sightly.

The details of the operation for resection
are essentially as follows. The lids are sep-
arated with the ordinary ophthalmostat ; a
vertical incision is made through the con-
junctiva over the insertion of the external
rectus muscle ; the conjunctiva is dissected
off as far back as the external canthus will
permit. This exposes completely the mus-
cle. Two silk threads are then passed
through the muscle near its tendinous inser-
tion. These threads will be required in a
subsequent stage of the operation, to unite
the detached muscle to the eyeball. The
muscle is then cut and drawn to the- temple
side. This exposes the globe. With curved
scissors, all tissue is then separated from the
eyeball. The optic nerve is found by pass-
ing a hook — which is nothing more than a
strabismus hook bent at a right angle. This
hook brings forward the nerve, and then the
retractor is passed downwards until it meets
the nerve, and is then passed down and out,
keeping the adipose tissue out of the way.
A second bent hook is inserted under the
optic nerve, and also pressed backward. A
certain portion of the nerve becomes ex-
posed, and with a delicate flat forceps the
nerve is grasped and held firmly. This is to
prevent hemorrhage from the ophthalmic vein
and artery (central) after the cut with the
scissors. The eyeball is rotated forward, so

that the non-severed nerve becomes exposed
and a small piece of its bulbar end is cut
off. By keeping pressure on the orbital end
of the nerve for a few minutes, all danger
of hemorrhage is aborted. The eyeball is
then rotated into place, and the external
muscle is re-adjusted. Over this the con-
junctiva is replaced, and it is held in posi-
tion with black silk, which may be removed
in three days. Antiphlogistic dressings are
applied day and night for several days. Very
little reaction follows, and in a week or ten
days the eye has assumed its normal appear-
ance, with no disfigurement, and the action
of the muscle is complete.

CASE OF ULCERATIVE ENDOCAR-
DITIS.

BY C. A. VEASEY, M. D.,

RESIDENT PHYSICIAN OF THE JEFFERSON MEDICAL
COLLEGE HOSPITAL, PHILADELPHIA.

The subject of this account was a woman,
twenty-five years old and married, who was
admitted to the Jefferson Medical College
Hospital, under the care of Dr. F. P. Henry,
Visiting Physician, on June 25, 1890. Three
weeks before, she had been very much fright-
ened during a fire in the neighborhood of
her home, and at the time she suffered a
great deal with palpitation of the heart,
which was soon followed by paroxysms of
precordial oppression and pains of great
intensity shooting into the left axilla and
down the left arm, with dyspnoea of the
most painful character. During the parox-
ysms her face became cyanosed, and she ex-
pected every moment to be her last, her
fades indicating great anxiety and terror.
After admission to the Hospital she had
paroxysms similar to those described by her
friends. Sometimes there would be no par-
oxysm for three or four days; then she
would have a most violent one, lasting for
an hour or more before relief could be
given, and being followed by a number of
lighter attacks. On some days there were
as many as eight in the twenty-four hours.

When first admitted to the Hospital the
woman was able to walk around the ward ;
but after July 1, she was confined to her
bed. , During the greater part of the time
she was compelled to use a bed-rest, and to
remain in a half-sitting posture, on account
of the great dyspnoea with which she suf-
fered. She had a severe cough with, at first,

Feb. 7, 1 89 1. Communications.

155

scanty expectoration, soon this was super-
seded by a profuse muco-purulent expecto-
ration, frequently streaked with blood. She
also complained quite often of chilly sensa-
tions, so that external warmth was used
almost constantly. Her finger-nails were
blue, her tongue red and swollen and
marked with indentations by the teeth. A
few days after her admission there was de-
veloped severe and excruciating pain in the
region of the right kidney, and the abdo-
men *was quite tender to the touch. There
was also much pain in the region of the
right nipple ; but it was little compared
with that on the other side. The patient's
appetite was very poor ; in fact, she could
take nothing but some liquid diet, and
towards the end of her life a small quan-
tity of stimulus.

The woman said that she was six months
pregnant ; but her pulse was always so rapid
that the fetal heart sounds could not be dis-
tinguished with absolute certainty.

Physical examination of the heart re-
vealed a loud mitral systolic murmur, trans-
mitted to the axilla and to the angle of the
scapula. The murmur was so marked that
it seemed to take the place of the first sound
of the heart. The second sound was change-
able, being sometimes pronounced and at
other times feeble. The area of cardiac dul-
ness was increased in both directions. The
impulse was diffused, and the pulse was fee-
ble, irregular and rapid, ranging from a
hundred and twenty to a hundred and sixty
beats per minute. Over the lungs percus-
sion dulness was found in spots. Respira-
tion was feeble and rapid — usually thirty to
fifty per minute — and rales were heard in
various parts of the lungs. No pulse could
be detected in the right arm at any point.
The urine was scanty, of a yellowish-red
color, acid, with a specific gravity of 1.030,
on boiling it deposited albumin to about
half its bulk ; it contained no sugar, and a
few pus-cells and some hyaline casts were
found on microscopical examination.

The temperature record was quite pecu-
liar. At the time of the patient's admis-
sion to the Hospital the temperature was
ioo° F. ; the next evening it was 10 1°; the
next morning it was ioo°. That evening it
was 10 20; and there was a slight fall by the
following morning. On the evening of the
next day it was 103.40, it fell the next
morning to 98. i°, and rose again in the
afternoon to 102. 20. The temperature was
of this irregular character for two weeks,

making wide variations, after which, up to
the time of death, which was July 15, it
varied from normal only about one degree.

The diagnosis of the case was : ulcerative
endocarditis and miliary tubercle. It was
also thought that the absence of pulsation
in the right arm was due to the presence of
a thrombus in the subclavian artery, but it
was supposed that this was so covered by
the clavicle that no tumor could be either
felt or seen.

At the autopsy, the pleural sac was found
to be adherent to the chest-wall on both
sides. -The lungs were filled with miliary
tubercles, and infarcts were found at differ-
ent points, some of which had caused rupture
of the vessels, the adjoining lung tissue hav-
ing become cedematous and soft.

The heart was largely hypertrophied, the
left side was firmly contracted, while the
right contained a clot. Upon opening the
heart both ante-mortem and post-mortem
clots were found on the right side, and a
large ante-mortem clot was found at the
aortic valve. One leaflet of the mitral valve
was entirely absent, and there were vegeta-
tions on the side from which the leaflet was
absent which covered at least as much space
as a dime would cover. These vegetations
were about a quarter of an inch deep and
had ulcerated.

In the abdominal cavity all the organs
were congested. There had been peritonitis
with adhesion on the right side ; the liver
and kidneys were full of miliary tubercle
and infarcts — only about one-half of the left
kidney and one-fourth of the right being in
a state to excrete urine. The spleen was en-
larged, softened and full of miliary tubercle.
No tubercles were found in the intestine.
The uterus contained a fetus about seven
months old. [It was desired to make an at-
tempt to save the child by an operation just
before the death of the mother, but the
friends of the patient objected.] Confirm-
ing the diagnosis of obstruction to the
lumen of the right subclavian artery, at its
middle third, an aneurism was found which
had been spontaneously cured by the for-
mation of a clot which was supposed to
have been deposited upon some material
carried into the circulation from the seat of
the vegetations.

The chief points of interest in this case,
which is a typical one of acute ulcerative
endocarditis, are : first, the shock of fright
which brought to light symptoms of heart
' disease, which had before been latent ; sec-

Communications. . Vol. lxiv

156

ond, the marked symptoms referable to the
right kidney, which during life were attri-
buted to emboli — a diagnosis corroborated
post-mortem ; finally, the healed aneurism of
the right subclavian artery. The question
whether the consolidation of the aneurism
was due to coagulation having for its point
of departure emboli derived from the dis-
eased heart, was one which could not be
determined. It is, however, one of consid-
erable interest.

The case, although an isolated one, is of
interest if only as demonstrating the well-
marked features of an affection which, not
many years ago, generally passed unrecog-
nized.

MINOR UTERINE SURGERY.1

BY CHARLES P. NOBLE, M. D.,

SURGEON TO THE KENSINGTON HOSPITAL FOR WOMEN,
PHILADELPHIA.

For several years the attention of gynecol-
ogists has been so largely occupied with ab-
dominal surgery, and particularly with the
diseases of the Fallopian tubes, that but little
has been said concerning the diseases pecu-
liar to the uterus. It may be supposed by
some that the reason so little has been heard
of the uterus and its diseases is that the
labors of the past have placed our knowledge
of these subjects upon an enduring basis. I
am satisfied, however, that the true reason
has been indicated above, and am the more
convinced of it by the recent appearance of
a paper absolutely denying the truth of the
teachings of the past, concerning, more es-
pecially, the treatment of diseases of the
uterus, and attributing evils to the measures
employed greater than the good they have
been designed to accomplish. In view of the
immense strides which have been made in
our appreciation of the diseases of women,
especially those of an inflammatory charac-
ter, in the last ten years, and of the very
different light in which diseases of the uterus
now appear as contrasted with former years,
it has seemed to me that it will be profitable
to review the subject at this time. The
ground to be covered is so considerable that
I shall present my views concisely and of
necessity somewhat dogmatically, so as not

1 Reprinted from report of a meeting of the Philadel-
phia Obstetrical Society, December 4, 1890, in the
Annals of Gynecology, January, 1891.

to consume your time unduly. Presented in
this way, I hope the subject will elicit full
discussion, as I consider it one of the most
important and suggestive in gynecology.

Before treating of the individual diseases
of the uterus requiring surgery, it will be
well to consider the diseases of the uterus as
a whole. It cannot be too strongly insisted
upon that a very sharp distinction should be
made between diseases of the uterus them-
selves and diseases of the uterus complicat-
ing, or complicated by, diseases of the uterine
appendages. This is the key to the situation,
and upon a right appreciation of this fact
depends success, or failure, or even disaster,
in the management of this class of cases.
Uncomplicated diseases of the uterus, barring
neoplasms, seldom or never threaten life, and
belong to the minor ailments of women.
Where the uterine malady is complicated by
inflammation of the uterine appendages, the
conditions are essentially different. The dis-
ease of the appendages overshadows the
disease of the uterus, which must be nearly
or quite disregarded. For were it possible
to cure the uterine malady without modify-
ing the disease of the ovaries or Fallopian
tubes, little would be accomplished, as the
more serious disease would remain. But
this is not all, for experience has amply
shown that to tamper with the uterus, par-
ticularly by operation or by intra-uterine ap-
plications, in the presence of complicating
tubo-ovarian inflammation, is a most danger-
ous thing, liable to set up acute pelvic or
general peritonitis. Hence it- should be laid
down as a rule that operation upon or man-
ipulation of the uterus is contra-indicated in
all cases in which tubo-ovarian inflamma-
tion exists. The contra-indication becomes
the more absolute the greater the gravity of
the complicating disease of the appendages.

The experience of the past has shown the
truth of the foregoing statements, and the
knowledge of the present concerning the
nature of pelvic inflammation has rendered
the whole subject easy of comprehension.
Formerly, various explanations were offered,
some of them quite fantastic, as to the oc-
currence of pelvic inflammation following
manipulation of or operation upon the uterus
when " fixed," or in the presence of " cel-
lulitis," or of " thickening." Now we know
it is due to the rupture of intra-peritoneal ad-
hesions and the escape of septic material
from the diseased appendages.

The Uterine Sound. — I have but little to say
in commendation of the uterine sound. Un-

Feb. 7, 1 89 1.

Comm. unications.

157

questionably, it does far more harm than
good as used to-day. I believe that its field
of usefulness is very limited. For the pur-
poses for which the sound is ordinarily used,
it is an unnecessary instrument. Bimanual
examination teaches the size, shape, position
and mobility of the uterus far more accu-
rately than the sound, and without injury to
the patient. The text-books say that the use
of the sound should be preceded by biman-
ual examination to determine the above ques-
tions and the presence or absence of pelvic
inflammation. If this be so, and the facts be
determined, what is to be gained by the use1
of the sound ? More or less uterine colic,
and perhaps an acute salpingitis, when a
dirty sound has been passed into a healthy
uterus, or a clean sound passed with some
force into a uterus in -the presence of tubal
inflammation. Unquestionably, the use of
the sound has no place in the determination
of the foregoing facts concerning the uterus.
Likewise, I would condemn the use of the
sound as a uterine respositor. Mobile uteri
can be reposited by Schultze's method, and
fixed uteri should be let alone. The sound
is useful in determining the patency of the
uterine canal when this is in doubt ; and may
be useful in the differential diagnosis of ob-
scure morbid conditions in the pelvis, but I
am convinced that the facts apparently de-
termined by its use are often illusory, and
that the practitioner who least relies upon it
will make fewest mistakes in diagnosis. The
sound may be used to determine the pres-
ence of fungosities within the uterus ; but
the history of uterine hemorrhages and leu-
corrhcea, with the absence of disease outside
the uterus, makes the diagnosis so certain as
to obviate the necessity for its use. The
diagnosis and cure can be made with the cu-
rette.

Intra-uterine Medication. — I feel con-
vinced that intra-uterine medication has been
much abused, and that the cases are ex-
tremely rare which require or are benefited
oy the application of a medicament within
the internal os uteri. Intra-uterine applica-
tions have been recommended for chronic
endometritis and chronic metritis. When
uterine leucorrhoea established the diagnosis
of endometritis, and the same, with enlarge-
ment and tenderness of the uterus, not due
to subinvolution or neoplasms, established
the diagnosis of chronic metritis, these dis-
eases were said to be very common — indeed,
.the most frequent diseases of women. Hence
intra-uterine medication became a routine

practice. If I am to judge from my own
experience, uncomplicated chronic endo-
metritis and metritis are not frequently met
with. As an illustration, by going over a
hundred cases in my case book and selecting
uncomplicated cases, I find seven. If the
cases of laceration of the cervix, with
erosion, etc., were added, the list would
be considerably increased. But in by far
the largest number of cases these morbi d
conditions exist in relation with the inflam-
matory affections of the uterine appendages,
preceding and causing the tubo-ovarian dis-
ease, and later being kept up by it.

In the presence of tubo-ovarian inflam-
mation it is now generally accepted that in-
tra-uterine applications should not be made.
They can do no good, and may do great
harm. Fungoid endometritis, and septic
endometritis following incomplete abortion,
require the curette. Excluding the forego-
ing, and cases of endometritis and metritis
complicating laceration of the cervix, few
cases remain for inter-uterine medication.
And I am far from convinced that this small
class cannot be more efficiently treated and
more quickly cured by the dilatation of the
cervix under anaesthesia with thorough cu-
retting of the uterine canal with the sharp
curette. During the past year I have thought
it advisable to make applications to the whole
uterine canal in three cases. One, a case of
chronic endometritis in a virgin, was cured.
The second, also a case of chronic endo-
metritis in a woman the victim of syphilis
years before, was improved by intra-uterine
medication, and was cured when mercury
and iodide of potassium were given by the
mouth, in addition. The third, a case of
small fibroid tumor, with menorrhagia, was
made distinctly worse.

Looking back over my past results, I feel
less and less inclined to make intra-uterine
applications. Formerly I made applications
of Churchill's tincture of iodine, and solu-
tions of nitrate of silver to the endometrium
almost daily. Before I appreciated the dan-
gers of the practice and its* contraindica-
tions salpingitis and peritonitis were "lighted
up " in a number of cases. Fortunately no
deaths resulted. Since I have abandoned
the routine use of intra-uterine medication
in diseases of the pelvic organs accompanied
by uterine leucorrhoea, my patients have
been far happier (as uterine colic is only a
memory), and I am satisfied that the influence
of treatment has been more favorable than
in former years.

158

Comm unications.

Vol. Ixiv

Dilatation of the Cervix. — Dilatation of
the cervix is advised for the cure of obstruc-
tive dysmenorrhcea and sterility due to flex-
ions of the uterus (usually so-called congen-
ital anteflexion), or to stenosis of the cervical
canal, congenital or acquired ; also as a step
in the removal of polypi, small fibroid tu-
mors and the retained products of preg-
nancy; and as a preliminary to the use of
the curette. In selected cases I am heartily
in accord with this advice. It is not possi-
ble to discuss these questions now ; but the
important thing is that cases of uterine dis-
ease are to be selected for dilatation, and
not cases of tubo-ovarian inflammation. In
such cases, when done with full antiseptic
precautions, under anaesthesia, dilatation of
the uterus is practically without danger, im-
mediate or remote, and has given very satis-
factory results in my hands.

The mistake of regarding cases of so-called
acquired anteflexion, due to peritoneal adhe-
sions or shortening of the utero-sacral liga-
ments, as cases of uterine disease is particu-
larly to be guarded against. The folly of
expecting to benefit inflammation of the
peritoneum or of the uterine appendages by
dilating the cervix is apparent ; and I am
convinced that all the disasters following
dilation of the cervix are to be attributed
either to this error in practice or to poor
antisepsis.

Rapid dilatation with the steel dilators
has always been employed, the pattern of
Goodell having been commonly used. I
have never seen a tent introduced into the
cervical canal ; nor have I seen the hard
rubber dilator used.

The Curette. — The uterine curette is a most
valuable instrument, and is indispensable in
the treatment of uterine fungosities and for
the removal of the endometrium in certain
cases of menorrhagia. I believe it capable
of rendering good service in the treatment
of certain cases of congestive and obstruc-
tive dysmenorrhcea — in which the seat of
pain is in the uterus, and the cause, morbid
processes taking place therein — by removing
the endometrium, particularly near the inter-
nal os. After incomplete miscarriages, and
in septic puerperal endometritis, the curette
is useful to remove necrotic tissue ; but in
these cases its use should be preceded by the
finger, used as a curette, by which alone can
the state of the uterine cavity be deter-
mined. In such cases the finger is the best
curette. In all cases I precede the curet-
ting with dilatation of the cervix, and fol-

low it with the intrauterine douche and
intra-uterine iodoform gauze packing, which
acts as a capillary drain.

In cases of chronic endometritis without
complication dilatation and curetting will
either effect a cure or greatly facilitate sub-
sequent intra-uterine medication.

In curetting full antisepsis should be
maintained, and the same care be used to
select uncomplicated uterine cases. Anaes-
thesia is essential to thoroughness. The
curettes of Martin and Schroeder have been
used. The dull curette should be regarded
more as an instrument of diagnosis. It is
useful in cleaning the uterine cavity of
debris before using the douche. It also
finds a place in puerperal septic endomet-
ritis.

Laceration of the Cervix. — Probably no
subject in gynecology has excited more dis-
cussion than that of the pathological im-
portance and the treatment of laceration of
the cervix. I am in accord with those who
regard laceration of the cervix as a lesion of
importance in the causation of pelvic disease,
and the operation devised by Emmet for its
repair as a useful addition to surgery. Cer-
tainly many lacerations of the cervix, occur-
ring during labor, heal spontaneously during
the lying-in, and are of no practical conse-
quence to the puerpera; others heal more or
less perfectly, and involution of the uterus
taking place fully, no ill consequences fol-
low. But the history of laceration of the
cervix in many cases is very different. The
laceration does not heal, the cervix gapes
open, involution of the pelvic organs does
not take place, pelvic congestion is kept up
and uterine catarrh and menorrhagia follow.
The general- health is more or less affected^
depending upon the vigor of the particular
constitution, and the duration of the local
disease. In some cases extensive reflexes
are developed ; but the conservative man
will ever bear in mind the possibility of
overlooking neurasthenia and hysteria in
this class of cases.

Local and general treatment will effect a
cure in many of these cases without opera-
tion. Rest, tonics, regulation of the bowels,,
ergot, hot water, vaginal douches, the appli-
cation of glycerine tampons, painting the
cervix with Churchill's tincture of iodine,
together with scarification of the cervix, will
frequently improve the condition so mark-
edly as to effect, practically, a cure. But
often this treatment proves ineffectual an#d
operation is necessary. Another indication

Feb. 7, 1 89 1.

Society

Reports.

159

for trachelorraphy is the existence of lacera-
tion of the cervix as a complication of retro-
version or retroflexion of the uterus. Not
infrequently the malposition cannot be cor-
rected until the intra-vaginal cervix is re-
stored by operation. It is important that
endometritis, existing as a consequence or as
a complication, should be cured before clos-
ing the laceration. Where this is difficult or
impossible, and in all cases in which uterine
hemorrhage is a feature, the trachelorraphy
should be preceded by dilatation of the cer-
vix and curetting of the uterus. Trachelor-
raphy done under these conditions has given
very satisfactory results in my hands. When
done for supposed reflex effects, due to cica-
tricial tissue, the outlook is not so promising.

It will be observed that the operation has
been recommended only for uterine disease.
When the uterine diseases exist in connec-
tion with inflammatory disease of the ap-
pendages the operation is contra-indicated.
Under these circumstances, there is great
danger of causing acute peritonitis ; or this
failing, drainage from the uterus is inter-
fered with, and subsequent acute attacks of
salpingitis promoted. In a neglect of this
contra-indication lie most of the dangers
and disappointments of trachelorraphy.

The relation of laceration of the cervix to
tubal disease is a subject worthy of careful
study. The laceration of the cervix is a fre-
quent cause of subinvolution of the uterus
and endometritis is generally believed. That
endometritis causes salpingitis by extension
is also true. Hence it appears probable that
laceration of the cervix sustains an import-
ant relation to salpingitis as one of its pre-
disposing causes. The relation between
laceration of the cervix and cancer also is
probably more than accidental. These con-
siderations are further inducements to repair
all lacerations of the cervix which are caus-
ing active symptoms.

I believe that trachelorraphy, done under
the conditions laid down, is a perfectly safe,
and very valuable, operation ; and that the
present tendency to decry its usefulness,
arises from a failure to observe its proper
indications ; or to carry out the principles
laid down by its inventor for the operation
itself. Of lateral and posterior incision of
the cervix I shall say but little. I believe
that the field of usefulness of these opera-
tions is limited, but that, in exceptional
cases, they may be valuable.

t I hope I have made it clear that my own
experience has made me a firm believer in

the value of minor uterine surgery for uter-
ine disease. It seems equally clear to me
that the cause of disappointment in the past,
when it has been met, has been a failure to
properly study the cases ; and thus uterine
surgery has been employed for other than
uterine disease. Also that the disasters of
uterine surgery have been' due to inefficient
antisepsis, or to the fact that operation has
been done in the presence of disease of the
uterine appendages, more especially pyo-
salpinx and abscess of the ovary.

When it was believed that inflammation
of tlje appendages was cellulitis, which was
caused by, and kept up by, disease of the
uterus, and only to be cured by curing the
uterine malady, it was perfectly logical to
attack the uterus with our therapeutic re-
sources. But experience has shown the dan-
gers as well as the futility of this method,
and modern pathology has brushed away
the apparently rational basis upon which it
rested. It is upon this ground that I have
opposed useless and dangerous uterine treat-
ment in complicated cases of pelvic disease.

Society Reports.

PHILADELPHIA OBSTETRICAL
SOCIETY.

Meeting, December 4, 18 go.

After hearing Dr. Noble's paper on
Minor Uterine Surgery

(see p. 156),

Dr. Joseph Price said : I wish in the
first place to thank Dr. Noble for the forti-
fication of my paper which he has given in
the first half of his paper. The last half of
his paper seems in large measure a contra-
diction of the first. A short time ago, be-
fore the County Medical Society, I had the
pleasure of calling the attention of the pro-
fession to the great mischief done by minor
gynecological tinkering. Dr. Noble starts
out by talking about the diseases of the
uterus and the minor ailments of women.
I want to repeat that none of us in our own
homes consider any disease of the uterus as
a minor ailment, or any deviation from
health as a minor trouble. Again, in speak-
ing of methods of treatment, he alludes to
applications in the presence of cellulitis, that
I myth which has long since been brushed

i6o

Society Reports.

Vol. lxiv

away. Again, he alludes to fixed uteri and
recommends that they be let alone. A fixed
uterus rarely means simple uterine disease.
As a rule it means a great deal more, but
not many of us are willing to let fixed uteri
alone and the patient suffering with the com-
plications incident to this fixation with ex-
tensive tubal and ovarian disease. For in-
stance, here is a pus tube six inches long
which contained half a pint of pus removed
from a case with fixed uterus. On the op-
posite side was an abscess of the ovary con-
taining half a pint of pus. These are com-
mon conditions. Dr. Noble states that early
in his experience he had three cases of sal-
pingitis following tinkering, with one death.
Many of these cases have resulted from the
uterine medication and traumatism which a
few years ago was so common. Dr. Engle-
man has recently read a paper of 154 or 158
pages before the American Gynecological
Society on the hystero-neuroses, on which he
dwells at length, and accuses the profession
of forgetting the uterus and of disturbing
the digestion and general health by over-
medication. Such has not been my own
experience. Through the West I have found
they are prone to overtreat the uterus. This
gynecological enthusiasm is largely due to
the money that is in it. There is no' doubt
that in many cases it is the pecuniary con-
sideration.

.1 picked up a piece of paper and noted
from memory purely a large number of phy-
sicians who have asked me in the last six
months to see patients suffering with ad-
vanced forms of tubal disease, due or not
to, but following immediately the treatment
that had been instituted. A physician liv-
ing a couple of doors from me, Dr. Crandall,
has asked me to see six cases which had to
be relieved by abdominal section. They
had had intra-uterine treatment, electricity,
dilatation of the cervix and the like. Dr.
John T. Hampton asked me to see three pa-
tients that had been treated by a number of
men. They had huge pus tubes, and the
specimens I have presented to this society.
Dr. Logan, of Scran ton, brings two cases
following closure of the cervix by a distin-
guished operator ; they presented huge ab-
scess. In one of Dr. Hampton's cases I had
to remove the appendix in addition to a
large abscess and pus tubes. While in Cin-
cinnati three years ago I saw with Dr. Rick-
etts a woman with the pelvis full and huge
pus tubes following intra-uterine treatment.
On my way home, I operated on a few sim-

ilar cases in Youngstown and in Warren,
Ohio, all following intra-uterine treatment.
Dr. Murfree, of Murfree's Borough, Ten-
nessee, sent to Dr. Eagleton a patient who
had been eight years under treatment. She
was seen by two gentlemen and both insisted
upon section. These are simply typical
cases, and I could give many others. I am
sorry that Dr. Duer is not here. Eight years
ago I sent a patient from the Philadelphia
Dispensary to the Presbyterian Hospital to
have the cervix closed. I am satisfied that
she was free from ovarian and tubal disease.
I had myself twice attended her in confine-
ment. Five years later I had to do a sec-
tion on her for double tubal disease. Dr.
DaCosta, in a recent discussion of this sub-
ject, calls attention to some of the difficul-
ties following the cervical operation, and in
one or two of his cases he had a hard fight
to save the patient's life. In the patient of
the lamented Dr. Bruen (and it was in watch-
ing this friend that he got his pneumonia), I
did a section for universal adhesions of every-
thing in the pelvis and everything that could
get into the pelvis. This was done six months
after a cervical operation. This was only
one of four cases following closure of the
cervix by the same operator. I have done
over thirty sections in one town alone in
Ohio for trouble following intra-uterine
medication and treatment. Some of these
patients I examined two years ago.

On Friday, two weeks ago, I removed the
pus tubes which I now show you. Some of
these patients have persisted with treatment
notwithstanding that I told them two years
ago that nothing short of a section and re-
moval of the offending organs would afford
relief. I have no longing for such neglected
and delayed cases. I have had half a dozen
cases from West Chester where the cervix
had been closed or dilated. I operated in
August on a lady, the wife of a prominent
physician in the South. The cervix had been
closed a few months before. I operated to
save life. Dr. McMurtry, of Danville, tells
me that he has had a number of sections of
that character. I remember some years ago
picking a little woman out of the Midnight
Mission and turning her over to one of my
pupils for a cervix operation. Three months
later he asked me to see her with an angry
pelvic inflammation and a huge abscess of
the left ovary. He adopted that imperfect
method of stitching the sac to the abdom-
inal wall, notwithstanding that I opposed it.
The woman died in the Pennsylvania Hos-

Feb. 7, 1 89 1. Society

Reports.

161

pital some months later with the drainage-
tube still in. Dr. Norton has presented the
specimens here. I was asked some months
ago by a physician now present to see a pa-
tient with some pelvic trouble following ap-
plication or dilatation. I insisted upon
prompt section. The physician returned
with instruments for that purpose, but met
with some opposition from the old family
physician, which continued for four or five
days. The operator then resigned all claim
to the patient. I did not see the patient
again. I might say here, that once upon a
time a man saw the same woman with pelvic
trouble and suggested that they wait for a
rigor. They waited some three days and
the rigor came. He then insisted on an ab-
dominal section and the woman died upon
the table. This was nine days after I had
urged the section. Dr. Montgomery will
remember a young woman, an exceedingly
distressing case. She had had every passage,
with the exception of the mouth and nose,
dilated and cut for a period lasting some-
thing over a year, not under Dr. Montgom-
ery's care, however. The urethra had been
dilated five times and the cervix many times.
She had had many attacks of peritonitis,
and some of what were called typhoid fever.
She had been treated for cystitis. I found
large pus tubes which had followed this
treatment. A lady on Darby Road had
been treated by twelve physicians. Finally
one of them closed the cervix and an ab-
scess followed. This was opened from the
bowel. She continued to suffer and de-
manded an operation at my hands. I made
an extensive dissection and resection, and
she had the first and only fecal fistula that I
■ever had follow an abdominal section. This
finally closed and she is now perfectly well.

I took a glance at the transactions of the
Philadelphia Obstetrical Society and I find
four or more deaths reported following the
use of tents. Drs. Hodge, Wilson, Willard
and Richardson each reported one. Last
summer I was called to Trenton to do a sec-
tion on two women dying with peritonitis.
Both had had dilatation or uterine treatment.
Some of you will remember a patient of Dr.
Daland's, on Pine street, some years ago.
Both Dr. Pepper and Dr. Elwood Wilson
saw the case. For eleven days she was
watched with peritonitis and intestinal ob-
struction and I was asked on the eleventh
day to do a section. The bowel was gan-
grenous and presented miliary cracks. The
trouble followed dilatation. There had been

no trouble prior to the dilatation. The op-
eration was done to favor conception. Her
sister has since had a section for double pus
tubes and ovarian abscess also following cer-
vical and intra-uterine treatment.

One of my assistants took a case out of
the Philadelphia Dispensary during my ab-
sence and closed the cervix. On my return
I found her with an angry peritonitis and
huge acute pus tubes. I operated success-
fully to save her life fourteen days after the
cervical operation.

If there were time I could make two or
three quotations from Dr. Goodell. You
have all read them, and it is scarcely worth
while to repeat them. In one of his articles
(Gyn. Transactions, Vol. iii, pp. 28-31), he
says : " Take for instance this too common
picture from life. A girl who enters puberty
in blooming health." . . . " The treatment
goes on and she settles down to a sofa in a
darkened room and lapses into habitual in-
validism." (See Transactions of College of
Physicians, Third Series, Vol. xi, 1889, p.
265.) I could give numerous other refer-
ences from this one author alone, but I have
said enough to demonstrate the great mis-
chief done, demanding the promptest treat-
ment possible to save some lives otherwise
doomed to be lost. Close analysis by the
light of scientific work at the operating
table and study of records should be quite
sufficient to guide honest, scientific workers,
with an honorable motive. I cannot refrain,
in closing, from giving a quotation from Sir
John Tilt. He says: " America with accus-
tomed audacity .... What matters if the
cervix does give way with an audible snap,
the woman is under ether."

Dr. Daniel Longaker said : It seems to
me that if all the cases referred to by the
last speaker had come under his observation
before the serious symptoms had developed,
his position would be distinctly stronger.
As it is, however, but few of the cases were
seen by him before interference was de-
manded, and there is, therefore, a certain
element of doubt. The only force that the
argument has is that the cases were improp-
erly selected — a plea which the author of
the paper had already made. I am fully in
accord with the reader of the paper. In re-
gard to my own experience with the sound,
it has been a matter of great surprise that,
in my earlier years, I did not do more harm
with it than I did. Once I felt the point of
the sound near the umbilicus, but the pa-
tient never had a symptom following the

Society Reports.

Vol. lxiv

accident. My sound was broken some four
or five years ago and I have never bought
another.

Some criticism was made on what* the
reader said in regard to fixed uteri. I think
that the author's idea comes in thereby im-
plication ; i. <?., the uterus per se is to be left
alone and the diseased appendages are to re-
ceive attention.

Dr. E. E. Montgomery said : I was im-
pressed with the paper as being an exceed-
ingly conservative one. In many points I
am fully in accord with the views expressed.
I am not willing to object to intra-uterine
treatment to the same degree as Dr. Noble.
I am not willing to concede that the cases
which have been mentioned by Dr. Price
have been necessarily due to improper use
of intra-uterine treatment. I am inclined
to think that the views of Dr. Price have
been largely influenced by the class of cases
which he has been called upon to see in the
last few years : cases which have been referred
to him, and where he has had more to do
with the abdominal work than with the
other conditions. The extreme views which
he holds in regard to this matter have a good
influence upon the profession, however, in
preventing undue intra-uterine treatment,
and the abuse of measures that in many
cases are of extreme value. There are some
cases which cannot be so quickly relieved by
any measures as by careful and judicious
intra-uterine treatment. In many cases of
uterine catarrh, particularly of the cervix, as
we often find complicating laceration, where
we find the cervix with a plug of viscid mu-
cus sometimes discolored with pus, blood,
etc., in such cases careful cleansing with the
use of the curette, applied to the whole cer-
vical canal, and the subsequent application
of astringents, or tincture of iodine, or
carbolic acid, will relieve the patient very
quickly.

It is true that the operation for laceration
of the cervix has been greatly abused. I
have, like Dr. Price, had to operate on a
patient for the removal of the ovaries one or
two years, and even three years subsequent
to the performance of the operation for
laceration of the cervix.

Many of the cases of fixation of the
uterus are not necessarily cases to be left
alone or treated by abdominal incision.
There are cases where the fixation is the re-
sult of adhesive peritoneal inflammation as
the result of exposure to cold during a men-
strual period. In these cases there is not

necessarily chronic tubal or ovarian trouble
sufficient to require their removal. The
reflex neuroses which arise are more the re-
sult of the disturbance of the circulation.
Such patients subjected to the treatment of
Schultze, by manipulation with two fingers
in the rectum and one hand over the uterus,
have been relieved from distressing symp-
toms, for which it had been necessary to use
morphia. These, however, are special cases.
They are to be carefully selected, and we
necessarily must treat them as carefully and
judiciously before and after the procedure as
if the abdomen had been opened. In cases
where there is the possibility of pus about
the tube or ovary such treatment is objec-
tionable and dangerous.

In regard to the dilatation of the uterus,
I wish to call attention to the method sug-
gested to the profession at the International
Medical Congress held in Washington, in
1887, by Professor Vulliet. The method
suggested was by the introduction of iodo-
form, or other antiseptic gauze. I have
employed this method irt a number of cases
with valuable results. It may be necessary
to reapply the gauze three or four times.
By this method the cavity of the uterus can
even be explored with the eye. Even this
plan of treatment should be used with the
greatest caution. The patient should be
kept quietly in bed during the treatment. I
prefer this method to the mechanical means
of dilatation. I believe that there is less
danger of injuring the mucous membrane
and the tissues of the organ, which must
necessarily be bruised and lacerated by me-
chanical dilatation sufficient to accomplish
the purposes usually desired.

Dr. William Goodell said : I listened
to the paper with pleasure, for it pleases me
to hear so conservative a paper from so
young a member of this society. I agree
with him almost wholly in every respect. I
rarely employ the sound, but I cannot
wholly give it up. I think that it is of ser-
vice in certain cases, for instance, to decide
the question of fixation of the womb when
the adhesions are slight.

In the past few years I have changed my
whole practice in regard to intra-uterine
medication. It is now rare for me to swab
the endometrium, for I have learned that
many of the diseases of the womb cannot
be cured by such application, and there is a
certain amount of danger attending their
use. Leucorrhcea is a symptom which is
often not controlled by the most heroic

Feb. 7, 1 89 1.

Society Reports.

intra-uterine applications. Like a chronic
nasal catarrh it may not do much mischief,
and it is often a symptom of nerve prostra-
tion. I have, therefore, ceased attempting
to cure it by merely local means.

I look upon the curette as a valuable in-
strument, and should hate to give it up. I
'have seen no mischief resulting from its use
since the introduction of the . antiseptic
methods. Indeed, in recent years it is rare
to see any bad results following any kind of
minor surgery.

I am not prepared to go to the extent that
Dr. Price has done. If he had said that too
many manipulations are made, and that too
many surgical operations are done, I should
go hand and glove with him. I am sure
that the womb is an over-treated organ. I
believe that in many cases, perhaps, indeed,
in the majority of cases, the womb is treated
when it is not the cause of the disease. At
the same time I am not prepared to accept
the statement that the profession does this
for gain ; while, of course, a black sheep
turns up here and there, I do not believe
that the majority of the profession . make
these applications simply for the money that
is in it. They do it through ignorance, and
because the womb has been made the scape-
goat for almost all of the diseases of women.
Again, the physicians are in a measure forced
to treat the womb because the women them-
selves attribute nearly all their ailments to
this organ. I think that a good deal of
minor gynecology is done by men who
should not attempt it, and many of the bad
results are due, not to the operations, but to
the operators. I am not willing to accept
the cases brought forward by Dr. Price, for
it is quite probable that in some of them
pus tubes were present which were not re-
cognized at the time of the operation.

I have done so much good with the uter-
ine dilator that I should dislike to give it
up. There is nothing equal to it for the re-
lief of dysmenorrhea, or of sterility. I
have had over 400 cases of dilatation, and
have not seen any serious results, especially
since the introduction of antiseptic surgery.
Dr. Price has quoted from Tilt in regard to
my hearing the cervix snap. I grant that
this was rather an extravagant statement,
made when I was younger and more enthu-
siastic. Yet I have repeatedly heard sounds
like the parting of muscular fibers, but with
only good results, from the operation of
cervical dilatation.

Dr. Price has misunderstood a quotation

which he has made from my Lessons in
Gynecology about a young girl going from
one physician's office to another's, who
is finally doomed to hopeless invalidism.
She is doomed — not because the physicians-
made applications to her womb, but because
they did not understand the cause of her
trouble, which lay in the nervous system,
and not in the uterus. Here lies the great,
mistake of the modern school of medicine.
The womb is brought so prominently into
view as a cause for disease that every other
organ is overlooked.

In regard to cervical tears, I arh sure that
we should operate on them. That they are
over-operated on I am willing to acknowl-
edge. Yet in selected cases great benefit,
accrues from this operation. I am satisfied
that uterine cancers come, in the great ma-
jority of cases, from uterine tears. I do not
think that I have seen half a dozen cases of
cervical cancers in women who have not
borne children. This, in itself, is a strong
argument in favor of the operation. Again,,
out of the hundreds of cases operated on by
myself, not one was ever attacked by cervi-
cal cancer. Further, grave constitutional:
symptoms, even threatened insanity, have
in my hands disappeared after operations on
cervical tears. But one must not promise-
too much from this operation, else one will
disappoint one's patients. I am, however,
quite skeptical about the evil effects of the-
cicatricial tissue sometimes seen in self-
healed tears. In my experience, the symp-
toms attributed to the cicatrix are nerve-
symptoms, and are to be cured by treatment
directed to the nervous system. There is-
another advantage accruing from this oper-
ation, viz., that retroversion is sometimes,
cured by it. I have repeatedly seen this,
good result happen.

There is one statement made by Dr. Noble
which I should like to' take exception to.
That is in regard to the use of the curette-
for the removal of portions of the placenta
and membranes left behind in miscarriages.
In my opinion, this is a mistake. Yesterday
I had at my clinic a woman who had a mis-
carriage three months ago, and since then
has had continuous oozing, occasionally
amounting to free bleeding. I said to the
class that evidently some placental tissue was
retained and had a vital attachment to the
womb ; but that I would show them, practi-
cally, that the curette was not the instru-
ment to use, for it would merely dislodge
the placenta without removing it, and large-

164

Society Reports.

Vol. lxiv

uterine sinuses would then be uncorked, as
it were, by it, causing a serious hemorrhage.
Sure enough ; as soon as I had begun to use
it so large a stream of blood poured out that
I had to thrust my finger into the canal to
plug it up. I then made haste to use the
instrument par excellence for this purpose —
a fenestrated polypus forceps — and in less
than a minute removed a placental fragment
■as large as the first joint of my thumb. The
curette is useful for the removal of fungoid
vegetations of the endometrium and for
villous exaggerations occurring at the placen-
tal site, but not for bulkier bodies.

As I have already said, I was much pleased
with the paper, and I was also with the
remarks of Dr. Price. He is doing good
to the profession and to all of us by calling
attention to remote results of uterine treat-
ment. At the same time, I cannot go 'with
Mm so far as to attribute all the cases he has
brought forward this evening to the use of
the curette, intra-uterine medication and
dilatation.

Dr. John C. DaCosta said : Dr. Good-
ell has expressed so clearly what I feel on
this subject that but few words are necessary.

First, in regard to the sound. I have ex-
amined a great many women and have often
used the sound, oftener in past years than
recently, and am not conscious of having
done mischief with it. There are certain
uterine conditions that you cannot diagnose
accurately without the use of the sound. By
palpation you can explore the exterior of
the uterus and usually determine whether or
not it is adherent. Take, however, a womb
like this sketch, apparently normal in shape.
But the patient is bleeding and you want to
know the cause. The womb maybe a little
enlarged ; but yet we see large wombs that
do not bleed and are not diseased. The
cervical canal may appear to be healthy.
There is something inside that womb, but
bimanual palpation will not tell you what
it is. Introducing the sound, you will find
that instead of passing normally, the instru-
ment meets with obstruction. This cannot
be discovered by bimanual palpation. You.
use your sound and find a fibroid bulging in
the anterior or posterior wall. Here is a
case that needs treatment, and you cannot
treat the patient without getting inside the
uterus. To be sure, you can (as has been
suggested) remove the tubes and ovaries,
but a woman does not want the tubes and
ovaries removed v/hen she can be cured by
other measures, and you do not want to do it.

I have expressed my views in regard to the
curette in the discussion of the paper of Dr.
Price on "Major Pelvic Troubles due to
Minor Gynecology." I should be loth to
do without the curette. In using the cu-
rette a man should know his work. Many of
the troubles referred are due to men under- ,
taking work that they are not fitted for.
There is probably nothing that requires more
careful training than minor gynecological
practice with, perhaps, the exception of ab-
dominal surgery, and that major troubles
may follow minor gynecology is due prob-
ably to the fact that men attempt minor gy-
necology who do not understand it. In
cases coming to the clinics and handled by
unskilled men without due regard to the con-
ditions present, there may be unnecessary
operations performed, and operations may
be performed where there is unrecognized
tubal or ovarian disease. Not so, however,
when men know their business, and are ex-
perienced in the treatment of cases.

I cannot accept all of Dr. Price's cases.
He mentions a remark of mine, that " I had
to fight for the life of a woman after an op-
eration on a lacerated cervix." Well, so I
did, and won the fight, and she has been a
well woman ever since. That was before the
day of aseptic surgery, and I am not satis-
fied that the trouble did not originate from
sepsis. In operations on the torn cervix I
have often found, as Dr. Goodell has stated,
that the flexion that is present has been re-
lieved. This was markedly shown in a case
operated on by me last week. Before the
operation there was a very sharp flexion ;
after it, the uterine canal was normal in
shape.

Some seven or eight years ago, in the dis-
cussion of a paper of mine on laceration of
the cervix, Dr. Goodell stated that it was
rare to find cancer of the cervix except in
cases with a tear of the cervix. Since that
I have borne this point in mind, and have
not since then seen a case of cancer of the
cervix where there had not been a tear.
Many tears do not require operation ; they
will get well by rest and attention to the
general condition. Others will not, and op-
eration is the remedy to cure and prevent
danger in the future.

I have used sponge tents frequently, both
the ordinary sponge tents and those with
watch springs in them. Dr. Ellerslie Wal-
lace told me that he had lost a case from the
use of sponge tents and told me the reasons,
and bearing in mind the reasons, and avoid-

Feb. 7, 1 891.

Periscope.

165

ing means that would cause danger, there
has been no trouble with them. Sponge
tents are like a surgical instrument — you
must know when and how to use them, and
to get results must know how to make them
and must make them yourself. The ordinary
sponge tents as sold in the shops are useless
and even dangerous.

The dilator is too good an instrument to
be lightly given up, and, like any other sur-
gical instrument, while achieving grand re-
sults in able hands, it is a dangerous tool in
careless or unskilled hands. Choose your
cases for it, and you will never regret using
it. But remember also, that every bent womb
does not need a dilator.

As to the money influence that Dr. Price
alluded to, I should be sorry to think that the
members of the profession are influenced by
the pecuniary consideration. I could tell
some touching tales about the money influ-
ence on the other side in patients who have
at times come under my own care.

I do not think that the mortality of minor
gynecology is as great, as Dr. Price has led
us to believe. It is certainly, so far as I
have been able to ascertain, nothing like the
mortality from unwarranted abdominal sur-
gery. Probably a good deal of the difference
in ideas is due to a difference in the class of
patients.

Dr. C. P. Noble, in closing the discus-
sion, said : I am glad that this paper elicited
such a full discussion, and that in general
the criticism has been so kindly ; but some
of the speakers have misunderstood me. It
might be inferred, from what Dr. Price has
said, that I believe chronic cellulitis to be
a frequent pelvic condition. The terms
cellulitis, fixed uteri, and the like, are in
quotation marks in the paper. The whole
tone of the paper shows that I do not regard
cellulitis as a common condition.

What I would say in reply to Dr. Price
has been so well covered in the discussion by
other speakers that it is not necessary for me
to say anything. It is probable that in
many of the cases reported by Dr. Price the
tubal or ovarian disease was present prior to
the minor operation or treatment employed ;
and in order that these cases should have a
bearing upon the argument, an exact diag-
nosis should have been made before treat-
ment was begun. These cases come under
the category which I referred to in the
paper as cases in which minor uterine surgery
is not indicated. Again, women who have
been subjected to minor uterine surgery are

liable to suffer, later, frbm gonorrhoea or
other causes of salpingitis. This fact doubt-
less accounts for some of the cases reported
by Dr. Price.

In regard to what I said about fixed uteri
being left alone, the context clearly shows,
what is meant. The idea is that the sound
should not be used for repositing the fixed
uterus. This class of cases are really not.
uterine. I agree with Dr. Montgomery
that in rare instances, when the adhesions
are light and the Fallopian tubes are com-
paratively healthy, the uterus can be freed
by careful treatment ; but, in general, fixed
uteri are fixed because of tubal and ovarian
disease, with peritonitis. In the cases re-
ferred to by Dr. Price, the uterus was left
alone and he removed the real source of
trouble, the diseased tubes and ovaries.

I agree perfectly with Dr. Goodell with
reference to the use of the curette in mis-
carriage. The curette is not the instrument
for the removal of portions of the placenta.
I prefer to give an anaesthetic and to use my
index finger as dilator and curette. In no
other way can it be known when the uterus
is empty. The results have been so satis-
factory that I have not had occasion to use
any instrument. In most cases of incom-
plete miscarriage the pregnancy has ad-
vanced to or beyond the third month.
When miscarriage takes place earlier, the
ovum is usually thrown off en masse, or in
the earliest weeks as detritus. Under these
circumstances manual interference is seldom
if ever required.

In the paper I said nothing about the use
of the dilator or curette in the office. I
think that this practice should be unqual-
ifiedly condemned, because proper antisepsis
cannot be employed under the circumstan-
ces, and because dilation and curetting cause
too much pain to be done efficiently with-
out an anaesthetic.

Periscope.

Koch and the German Government.

The British Medical Journal of January
10, 1 89 1, says editorially : During the last
fortnight various rumors have been tele-
graphed from Berlin as to the arrangements
made, or about to be made, between the
German Government and Professor Koch
with regard to the future production of his.
remedy for tuberculosis, and it must be ad-

Periscope.

Vol. lxiv

-mitted that these 'rumors have been of a
somewhat disquieting character. It has
been said that Dr. Koch, and each of his
assistants, had accepted a large immediate
payment, and that they were- to receive a
royalty upon all sales in the future. Thus
stated, the arrangement, it must be admitted,
would partake far too much of the commer-
cial transaction to be agreeable to the tradi-
tions of the medical profession, or the cus-
toms of men of science. It is, however,
easy to give an unfavorable complexion to
a transaction really of an honorable nature
by inverting the steps by which the final
results have been obtained and so misrep-
resenting their character. It may be well
to recall the circumstances under which the
lymph has been discovered, and the posi-
tion of Dr. Koch in relation to the German
Government. Dr. Koch has been for many
years the director of the Hygenic Laboratory
in Berlin. This laboratory is a Government
institution, maintained by the Educational
Department of the German Government,
and Dr. Koch, as its director, has been an
officer of that department. All the earlier
experiments for the discovery of the no^
famous lymph were conducted in Dr. Koch's
own laboratory in the Hygenic Institute,
and there the observations upon guinea-
pigs and other animals, which emboldened
Dr. Koch to proceed to inoculate human
beings, were made. The laboratory, how-
ever, presented no facilities for making these
investigations upon human beings, and Dr.
Koch holds no official position with regard
to any of the Berlin hospitals. He there-
fore found himself in a practical dilemma,
inasmuch as if he were to make his experi-
ments in a public hospital it was feared that
the premature and eager discussion of incom-
plete observations and immature results might
easily tend to interfere materially with the
investigations and to produce evil results.
Dr. Koch consequently hired a private house
at his own expense, and obtained the assist-
ance of two gentlemen with whom he had
private acquaintance — Dr. Libber tz, an old
schoolfellow, and Dr. Pfuhl, his own son-in-
law. The lymph was prepared in considera-
ble quantities in this private house by these
two gentlemen under Dr. Koch's supervision,
and the earliest injections in man were made
in the private hospitals of Drs. Cornet and
•Levy. It soon became evident, however,
that the interest, both among the general
public and in the medical profession, was
too keen to permit of the continuance of

the investigation upon these lines ; and Dr.
Koch, acting on the advice, or perhaps it
might be correct to say upon the instruc-
tions, of Herr von Gossler, the Minister of
Education, published the now famous pre-
liminary paper, and distributed the lymph
to certain of the hospitals in Berlin. Mean-
while, the manufacture of the lymph was
carried on in the private house by Dr. Koch
and his two personal private assistants.
Recently this arrangement has ceased ; the
house in which the lymph is manufactured
has been taken over by the Educational
Department of the German Government,
and Drs. Pfuhl and Libbertz have become
officers of that department. The Koch In-
stitute, which the German Government are
now erecting, will consist of two parts— a
laboratory and a clinical department con-
taining 150 beds. The clinical department
will probably be under the direction of
Professor Brieger. The observation and
treatment of the patients received into it, it
is hoped, will afford in the future opportuni-
ties for Qr. Koch to prosecute his studies
with regard not only to tuberculous diseases,
but to tetanus, diphtheria, and typhoid fever.
In this way the inconvenience which has
arisen from his having no clinical wards of
his own will be avoided.

In the laboratory bacteriological investi-
gations will be carried on, and at the ear-
liest possible date the laboratory for the
preparation of the anti-tuberculous liquid
will be transferred to this department of
the Koch Institute. The director of this
bacteriological department has not yet been
appointed, but the whole institute will be
under the general direction of Dr. Koch,
who will remain an officer of the Educa-
tional Department. It is probable that the
German Government will offer to Dr. Koch
some recognition of the great services he
has rendered while acting as a German
official, such as was voted to Jenner for
his services in a cognate research, and more
recently to Pasteur, in France. Large na-
tional awards have repeatedly been made to
successful generals in Germany and in other
countries, and it is felt that there is no rea-
son why a man of science, who has worked
for the relief of human suffering, should
hesitate to accept a reward which the de-
stroyers of men have never felt the least
difficulty in receiving. As to the further
rumor that Dr. Koch and his assistants may
receive a payment as it were by results in
the future, it may be hoped that this rumor

Feb. 7, 1891.

Periscope.

167

is unfounded. Anything like the sale of a
secret or the paying of royalties on a remedy
would be contrary to the Hippocratic
tradition.

Cerebral Tumors.

Dr. P. C. Knapp, in the Boston Medical
and Surgical Journal, January 8, 1891,
•says Oppenheim reports twenty-three cases
of tumor in the cerebrum, with a careful
analysis of the symptoms. Eighteen of
these were gliomata or sarcomata, three
were cancerous, one tubercle, and one
gumma. Only striking cases in adults, how-
ever, are admitted to the hospital. In
three cases a diagnosis of tumor was not
made, and in three others it was at first
doubtful. Oppenheim lays great stress on
the importance of frequent examination of
the eyes, even up to a short time before
death, for choked disc may be a late symp-
tom ; he also distinguishes between choked
disc and neuritis. The changes in the nerve
are of the utmost importance in diagnosis,
and are of very frequent occurrence. In
nephritis, however, the ophthalmoscopic
picture may be that of neuritis, the retina
showing no changes. In such cases, where
there is uraemia or cerebral hemorrhage, with
a negative urine, the diagnosis may be very
difficult. He holds that neuritis or choked
disc is absent only in those cases where the
intra-cranial pressure is only slightly in-
creased. Next to changes in the optic nerve,
stupor and somnolence are of great value in
diagnosis. It is sometimes difficult to keep
patients awake long enough to answer ques-
tions. Oppenheim then analyzes the cases
to learn how far focal symptoms can be
relied on for diagnosis. In twelve cases
there were aphasic symptoms, in nine of
which the left temporal or frontal lobe was
involved. An exact focal diagnosis could
not be made from the symptoms, however,
as the seat of the growth did not correspond
to the particular type of aphasia, and some
of the tumors were in the basal ganglia.
In two cases the tumor was in the right
hemisphere, and in one of these the patient
had become left-handed at the age of seven-
teen, which raises the interesting question
as to the possibility of the transfer of the
speech centre in youth. The same may be
said of the value of motor symptoms in diag-
nosis. In a few cases the new growth
affected the precise centre corresponding to
the disturbance of motion, but in others the

tumor proved more or less remote from the
centre, or deep down near the basal ganglia.
With the uncertainty that still obtains in
regard to the localization of the sensory
centres, it is obvious that sensory disturb-
ances give no more exact information than
motor. Local headache is an entirely un-
trustworthy indication of the position of a
tumor, but localized tenderness on percus-
sion has greater value. In four of these
cases was a more or less accurate focal diag-
nosis possible, and operative interference
could have been undertaken — about seven-
teen per cent. In view, however, of the
uncertainty that still obtains in diagnosis, of
the limited success that recorded operations
thus far show, and of the small percentage
of cases that can be operated on (it must be
remembered that, in this paper, Oppenheim
deals only with tumors of the cerebrum
itself), he considers that operative interfer-
ence has a very limited field.

Physiological Action of Thialdine.

Thialdine, obtained for the first time by
Woehler and Liebig, in the form of large
crystals, of aromatic odor, which volatilize at
the ordinary temperature without decompos-
ing, is but slightly soluble in water, dis-
solves rapidly in alcohol and acids. Ac-
cording to Les Nouveaux Remedes for No-
vember 8, 1890, from experiments made with
this substance the following conclusions
were reached :

1. Thialdine is very poisonous in frogs
in the dose of yi grain for every one hun-
dred and fifty grains body-weight, though
much less poisonous in rabbits.

2. Its administration is followed in the
frog by profound sleep, with loss of
general and reflex sensibility, depressed
sensibility of the motor nerves, while the
muscular irritability remains intact. In the
rabbit the anaesthesia is less intense, and
interrupted by excitation.

3. Thialdine invariably causes slowing of
the pulsations of the heart, which, neverthe-
less remain perfectly regular. It is only
when given in very large doses, and then
only immediately before death, that the
pulsations of the heart become irregular.

4. When given in small doses, the slowing
of the pulse is only transient. Injected in
small doses in the excised heart, thialdine
diminishes the number of pulsations, at first
prolonging the diastole, after rendering the

Periscope.

Vol. lxiv

contractions of the heart irregular and more
rapid, and finally arresting the heart in
diastole.

5. In large doses it slows at the outset
cardiac contractions, and then leads to the
arrest of the heart in diastole.

It would thus seem that carbo-thialdine
and thialdine differ absolutely from each
other as regards their physiological action.
The first is an energetic tetanizer, and never
produces irregularity of the heart, which it
arrests in diastole. On the other hand,
thialdine produces irregularity of the heart,
which, in the majority of cases, it arrests in
systole ; finally, while carbo-thialdine pro-
duces no effect on rabbits, thialdine is poi-
sonous in them, though to a less degree
than in frogs. — Therapeutic Gazette, Jan-
uary, 1 89 1.

Chloroform as an Antiseptic.

The Lancet, December 20, 1890, says,
Salkowski has demonstrated as the results of
his experiments that chloroform prevented
fermentation and decomposition in milk and
other fluids. M. Kirchner (Zeitschr. fur
Hygiene, viii, 1890, Heft 3) has also made
some investigations in regard to this property
of chloroform. He first showed that, when
mixed with blood serum, no decomposition
of the latter occurred, and then further
showed the same action on milk, and also
its purifying properties on waters known to
be rich in bacteria, and, again, on pure cul-
tures of pathogenic and non-pathogenic or-
ganisms. The method employed was as fol-
lows : Chloroform was added in excess to
the fluid to be experimented on ; the vessel
in which it was contained was then hermet-
ically sealed and thoroughly shaken. The
various specimens were kept at different tem-
peratures— namely, that of body or air, or in
an ice chamber. The contents were tested
after variable periods of time, lasting from
hours to years, by means of plate cultiva-
tions. The results obtained were that chlo-
roform has a powerful destructive action
upon a great number of bacteria, but does
not kill their spores. The.bacilli of anthrax,
cholera and enteric fever, as well as the sta-
phylococcus aureus, were quickly destroyed
by chloroform. The spores of the anthrax,
and tetanus bacilli were not affected by the
drug. In spite of its presence the spores de-
veloped into bacilli, which were then rapidly
killed. Kirchner considers from these re-
sults that milk to which chloroform has been

added can be preserved for a long period,
although we cannot be sure that it is free
from spores which will eventually develop.
Kirchner recommends its use for the preser-
vation of fluids containing albumin, and
especially for sterilizing blood serum, the
composition and coagulating power of which
are not appreciably altered by its .presence,
and its use as a cultivating medium is not
influenced. The mixed fluids are best pre-
served at the ordinary temperature of a room
and not in an ice chamber. Kirchner fur-
ther recommends chloroform water for the
disinfection of wounds, and states that it is
especially useful in gynecological and ob-
stetric practice, and also for the disinfection
of bed-pans, linen, etc., in epidemics of chol-
era and typhoid fever. He, supports Sal-
kowski's views as regards its favorable ac-
tion on some intestinal affections, especially
the diarrhoea of children. He also advises
that it should be used in military campaigns
for the purification of drinking water.

A Ready Inhaler.

In the British Medical Journal, November
22, 1890, Mr. Arthur H. Rideal gives the
following description of a ready method of
arranging what he says is a most effective
inhaler. Take an ordinary funnel, and in
it loosely pack some cotton-wool. Oh this
sprinkle the medication (ol. eucalypti., etc.),
and then tie a piece of gauze or muslin over
the funnel to keep the wool in position. In-
vert the funnel over some hot water con-
tained in a breakfast cup, or other vessel,
according to the size of the funnel, and an
inhaler is obtained which is equal, as regards
its utility, to the most elaborate.

Detection of Bile Pigment in Urine.

The American Journal of Pharmacy, De-
cember, 1890, says that bile pigments may
be detected in urine as follows. Slightly
warm about a fluid drachm of the suspected
urine, and add 5 to 10 drops of tincture of
iodine, agitating after the addition of each
drop. In the presence of bile 'pigments, a
pretty olive-green coloration is produced.
Excess of tincture of iodine will produce a
dirty brown-red color. Normal urine at
first decolorizes the iodine solution, then
gives a red coloration, and on addition of
an excess of iodine a dirty brown-red color.

Feb. 7, 1 89 1.

Editorial.

169

THE

MEDICAL AND SURGICAL

REPORTER.

ISSUED EVERY SATURDAY.

CHARLES W. DULLES, M.D.,
Editor and Publisher.

N. E. Cor. 13th and Walnut Streets,
P. O. Box 843. Philadelphia, Pa.

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See that your address-label gives the date to which your
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In requesting a change of address, give the old address as
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If your Reporter does not reach you promptly and regu-
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^^Suggestions to Contributors and Correspondents :
Write in ink.

Write on one side of paper only.

Write on paper of the size usually used for letters.

Make as few paragraphs as possible. Punctuate carefully.
Do not abbreviate or omit words like "the" and -ia," or
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Make communications as short as possible.

Never roll a manuscript ! Try to get an envelope or
wrapper which will fit it.

When it is desired to call our attention to something in a
newspaper, mark the passage boldly with a colored pencil, and
write on the wrapper " Marked copy." Unless this is done,
newspapers are not looked at.

The Editor will be glad to get medical news, but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

KOCH'S METHOD.

The developments in regard to the Koch
method for tuberculosis within the past two
weeks have not been of a very striking char-
acter. The medical journals in different
parts of the world continue to produce pub-
lications about it, some of which are of the
usual non-committal sort, some are hopeful,
while some claim that characteristic reac-
tions and apparently reliable improvements
have been brought about by its use. In
Philadelphia there is nothing novel in the
recent reports in regard to the remedy.
Some of the patients at the Philadelphia
Hospital (Almshouse) consented to be ex-
perimented upon with it, but we have not
heard of the result. At the University Hos-
pital experimentation is continued in a cau-
tious manner. Dr. Musser, who has charge
of the medical experimentation there, made
a public address on Friday, January 23, and

is reported as expressing considerable confi-
dence in the value of the remedy, saying
"It was valuable not only in reaching and
relieving particular diseases, but opening a
new path to medicine, showing how cures
were wrought, and developing new methods
of treatment." The University of Pennsyl-
vania Commission reports its experience in
the number of the University Medical Maga-
zine for February, but there is nothing spe-
cial in it. The Johns Hopkins report in the
Bulletin of the Hospital, January, 1891
(just issued), gives no new ground for con-
fidence in the diagnostic or therapeutic value
of the " lymph."

It is with some regret that we notice that
under various titles, institutes have been
started in New York City, which advertise
that they are what might be called u Koch
Institutes" or Sanitariums. One of these
has connected with it the names of Dr.
George F. Shrady, editor of the New York
Medical Record, Dr. H. P. Loomis and Dr.
W. C. Wendt, who advertise that a limited
number of patients can receive the Koch
treatment at a private sanitarium in New-
York. It is rather hard to reconcile the par-
ticipation of Dr. Shrady in this enterprise
with some of the editorials which he has
published on this subject — although the first
number of the Medical Record in which we
notice this advertisement, contains rather
glowing accounts of the experience by Dr.
Wendt and Dr. Shrady in the use of the
Koch remedy— or to understand the scien-
tific or ethical basis upon which an institu-
tion advertising to treat patients by an
exclusive method can rest. We had hoped
that it would be impossible, even in New
York, to have institutions of this kind or-
ganized, except by persons well known to
the profession, as inclining to this way of
securing notoriety, and we hope the example
set by the men named above will not find
imitators elsewhere.

The news from Berlin, under date of Feb-
ruary 1, was that Professor Koch, who was
about to start for Egypt, had given a fare-

170

Editorial.

Vol. lxiv

well reception to his laboratory assistants
that day. In this he said that he would
probably be absent from Berlin about three
months. He explained that he only par-
tially disclosed the method of the production
of the curative lymph, because he desired to
stop the rush of doctors to Berlin (!). If
he had described the method of manufacture
more fully, he says, he would have been
more worried about the details. The Berlin
report stated that great discontent prevailed
among medical men regarding the published
accounts of the method of manufacture of
the lymph. They had made numberless at-
tempts to produce the lymph, but they find
Koch's description totally inadequate to en-
able them to make it.

SECRET REMEDIES — KOCH'S REM
EDY.

The, Medical Press and Circular, of London,
in its issue for January 14, discusses editori-
ally the curious state of medical ethics into
which the use of Koch's then entirely secret
and now only partially explained remedy has
plunged the world. The tolerance shown to
Koch in his secrecy and to those who used
and exploited his so-called remedy, is con-
trasted with the principles which have been
supposed to govern the medical profession.
"The fact," our contemporary says, "is,
matters are getting critical. The censors of
the Royal Colleges of Physicians are fidget-
ting in their curule chairs, having been made
uncomfortable by the feeling that it is due
to the dignity of the bodies of whose honor
they are pro tern, the custodians, and to con-
sistency, to condemn, and, by condemning,
to prohibit, further "experiments with a rem-
edy which is not only secret but dangerous —
not only dangerous but, so far as our knowl-
edge goes, therapeutically indifferent. Why,
indeed, do the censors stay their hands? Is
it because their correction would fall upon
some of the best known and nosiest of the
tribe of influential self-advertisers ? These
modern Jupiters apparently reserve their
thunderbolts for little people, and at most

mildly expostulate when the sinners are
men occupying a position well in view in
the medical world. These, however, are
democratic times, and if the censors fail to
enforce the rules of professional etiquette
on this occasion they may as well retire into
private life. Humbler men, encouraged by
the latitude accorded to their seniors in the
professional hierarchy will raise their droop-
ing heads and set salutary discipline at defi-
ance. The policy seems to be to postpone
action until the 'boom' is over and the agi-
tation has died a natural death. This may
be politic, but it is not justice or equality.
In face of the evident determination of the
Germans to keep the secret of Koch's dis-
covery, it behooves us to set our faces
against any further meddling with a fluid of
doubtful value and certain danger. The
medical journals ought to speak out in no
uncertain tones before the evil, already
great, becomes a positive scandal."

The Reporter has spoken out, at the
very first announcement, and consistently
ever since. If its example had been fol-
lowed by all the other medical journals, the
most famous bacteriologist of our times
would perhaps have had courage to resist
the strong and unprincipled pressure of the
German Cultus-Minister, von Gossler, to do
for national pride what is opposed to profes-
sional principle.

THE MICRO-ORGANISM OF MALARIA.

When, in 1884, Laveran published his
treatise on Paludal Fevers, and announced
his discovery of certain peculiar Jparasites
(plasmodia) of infusorial order in the blood
of patients in intermittent fever, his an-
nouncement was at first received with in-
difference and scepticism. Microbiologists
were just losing all faith in the etiological
relation to malaria of the bacillus discovered
four years before by Klebs and Tommasi-
Crudeli, although the discovery of these in-
vestigators at first awakened great confidence
and enthusiasm. It is not our present pur-
pose to give a history of the researches of

Feb. 7, 1 89 1.

Editorial.

171

these last named experimenters, or to state
the reasons why the claims which they so
confidently made have been rejected by all
competent authorities, as the whole case
has been well stated by Sternberg in his
treatise on Malaria and Malarial Diseases,
by Councilman, Osier, James and others in
this country.

On the other hand, during the past six
years evidence has been accumulating, from
all parts of the world, confirmatory of the
results obtained by Laveran, and there is
largely the same kind of evidence that the
Plasmodium discovered by him, in 1880, is
the infectious agent of intermittent fever, as
there is that Koch's bacillus is the cause of
tuberculosis. We can only mention here
among those who have made careful re-
searches in this direction and have arrived
at conclusions, in the main, substantiating
Laveran 's claim, the names of Marchiafava
and Celli, Councilman, Osier, Sternberg
and James, Straus, Bouchard, Golgi, Dock-
mann, Richard, Chassin, Mariotti, Ciaroc-
chi, Vandyke Carter and MetschnikorT.

One thing seems to have been settled,
malaria is not a bacterial disease. The most
of the infectious diseases whose living agents
have thus far been discovered are due to
vegetable parasites of the order of fungi ;
the pathological processes engendered by
bacteria are akin to the ravages of the mold,
the rot, the mildew. The micro-organism
of malaria is of the order of protozoa, and
resembles the amoeba. In the words of
James, there takes place in the blood of
persons suffering from malarious disease a
series of phenomena not yet found under
any other conditions — these phenomena
point to the presence of an animal parasite.
The appearances which are obtained are the
following :

1. Colorless protoplasmic bodies inside
the red blood corpuscles. They vary in size
from one-fifth to almost the whole diameter
of the corpuscle. They exhibit active
amoeboid movements. Some contain scat-
tered granules of brownish-black pigment ;

others are unpigmented. The red corpuscle
which contains the amoeboid body gradually
becomes pale by the loss of its haemoglobin,
which is converted by the parasite into the
pigment granules above mentioned.

2. Disk-shaped bodies of colorless pro-
toplasm, which are motionless. These are
believed to be the plasmodia above men-
tioned, which have destroyed (eaten up) the
blood corpuscle, and have entered on the
cyst stage. They contain pigment gran-
ules. •

3. Forms similar to the cysts in which the
pigment granules have become massed at
the centre, while the protoplasm is under-
going segmentation.

4. The small masses of protoplasm that
have resulted from segmentation of the cyst-
form. They are apparently ready to enter
upon active work.

5. Certain hyaline crescentic bodies,
which Laveran regards as a part of blood
corpuscles which have been invaded and
partly destroyed by the parasites. They
have pigment granules in their centre.

6. Certain flagellated bodies. These are
round, pear-shaped bodies about one-half
the diameter of a blood corpuscle contain-
ing pigment granules and provided with
from one to four flagella, which have an
active slashing motion. By means of these
flagella, the organism moves about in the
blood plasma.

7. Free flagella. These have become
detached from their bodies, and seem to be
capable of leading an independent existence.
This flagellum, which has been seen by nu-
merous observers, and which is only a part of
the real parasite, has been identified by some
authorities with the bacillus malaria of
Klebs and Crudeli.

All attempts to cultivate these parasites
(hematozoa) outside of the body have failed,
nor can malarial disease be induced in the
lower animals (though it has been in man)
by injecting into the veins blood charged
with these micro-organisms.

According to Golgi, the relationship be-

172

Editorial.

Vol. lxiv

tween the cyclical evolution of the hema-
tozoa (called by him sporozoa) and the mode
of sucession of the paroxysms (ague fits)
is subject to the same vigorous laws which
we know governs the disease with which
these micro-organisms are associated. In
quartan ague, there are exactly three days
between the invasion of the red globules by
the parasites and the segmentation which the
latter undergo to form the young elements
destined to a new invasion of the red glo-
bules ; in tertian fever, the cycle is two days.
These differences of evolution correspond
to differences in the nature of the parasites ;
for there are two distinct species of spor-
ozoa, distinguished by their morphological
and biological characteristics. The para-
sites of tertian fever have much quicker
amoeboid movements than those of quartan.
They decompose hemoglobin much more
rapidly and more completely ; they disinte-
grate the red corpuscles, while the parasites
of quartan fever only cause them to atrophy.

There has been much interesting discus-
sion respecting the divers forms manifested
by this polymorphic parasite, and their re-
lation to the various phases of malaria. Thus
many authorities believe that the crescents
and the bodies allied to them belong to
chronic cases, usually to those associated
with malarial cachexia. In James's cases,
the amoeboid forms, pigmented and unpig-
mented, as also the flagellated forms, were
peculiar to the acute stages of the disease.

As for the agencies which destroy the he-
matozoa — as might have been expected,
sulphate of quinine is the most effective par-
asiticide. The effect of this remedy in ar-
resting all amoeboid movements when added
to infected blood on the microscopic slide,
and in causing the disappearance from liv-
ing blood of the micro-organisms when the
quinine is given in sufficient doses internally,
is most marked. But apart from remedial
agents, the leucocytes maintain a constant
and often successful struggle with the invad-
ing foe, and Dr. Vandyke Carter, in a re-
cent communication, graphically describes

what he has witnessed in malarial blood —
the war between the micro-organisms of ma-
laria and the leucocytes. He has noticed
that the crescentic bodies are not so attrac-
tive to the leucocyte as the flagellated ; for
the leucocyte will turn from the former,
leaving them untouched, and prey upon the
latter. In the fierce combat between the
leucocytes and the flagellated spheroids the
leucocytes seem often to triumph in the
complete overthrow of their adversaries.

The micro-organisms above described re-
semble much certain flagellated organisms
found by Danilewski in the blood of frogs,
turtles, lizards and birds. As for their con-
stancy in malarial blood, Laveran has found
them in 432 cases out of 480 which he has
studied from this point of view, and he
thinks the negative cases explicable by un-
seasonableness or incomplete methods of
examination ; in a few the blood was exam-
ined when the patient was under the influ-
ence of quinine. Councilman states that
he has noted the presence of hematozoa in
all the cases of paludal fever which he has
examined, and he has never found them in
healthy subjects, or in persons affected with
other diseases.

Laveran has sought for the parasite of
malaria in the water and soil of infected lo-
calities. He reports the discovery of free
flagella presenting almost the same aspect
and dimensions as those found in malarial
blood, and animated by the same move-
ments; also of spherical flagellated bodies
similar to those above described. Of course
(as Hallopeau remarks) they cannot be con-
sidered identical until paroxysms of genu-
ine intermittent shall have been produced
by inoculating the blood of human beings
with these infusoria of the marshes.

As stated in the Reporter, January 3,
page 28, Danilewsky has recently stated that
he has seen venti malaria in birds, with the
characteristic parasite, and believes that this
establishes the identity of the disease in
them and in human beings. This curious
and important subject is still being studied

Feb. 7, 1 89 1.

Book Reviews.

173

by a number of able investigators and the
facts in regard to it are accumulating in a
manner to justify the hope that the doctrines
in regard to it may before long be clearly
understood and precisely formulated.

CLINICAL LECTURES.

In the preparation of Clinical Lectures
for the Reporter, it has been the rule that
nothing should be printed which had not
been revised by the lecturer, in manuscript
or in proof, and approved for publication.
In this way we have been able to present to
our readers a series of very valuable and au-
thoritative communications from some of
the most able teachers in the country. Acci-
dents will happen, however, and in conse-
quence of the mislaying of proof-sheets, a
lecture delivered by Dr. J. H. Musser, and
published in the Reporter for January 24,
did not contain the corrections which he
wished to have made in it, and arty inaccu-
racies which it contains are, of course, not
to be attributed to him. We publish under
the head of Correspondence a note from
him on this subject — in justice to him ; in
justice to the Reporter we may add that
the accident which has happened was not
due to the omission of any of the precau-
tions customary in the editorial office of this
journal.

Book Reviews.

[Any book reviewed in these columns maybe obtained upoB
receipt of price, from the office of the Reporter.]

STRICTURE OF THE RECTUM. A STUDY
OF NINETY-SIX CASES. By Chas. B. Kel-
sey, M. D., Professor of Diseases of the Rectum at
the New York Post-Graduate School and Hospital,
etc. 8vo, pp. 46. (To be had of the Author.)

Dr. Kelsey gives, in this brochure, an instructive
essay on stricture of the rectum and its treatment. In
speaking of the diagnosis, he declares the idea, deeply
rooted in some minds, that stricture of the rectum is
either cancerous or syphilitic, is founded on error.
Besides cancer and venereal diseases as causes, he
describes strictures, according to their etiology, as con-
genital, spasmodic, due to pressure on the gut,
dysenteric, tubercular, inflammatory, and traumatic.
He describes treatment under the following heads :
Dilatation; Incision; Partial Destruction, including
Electrolysis and Raclage ; Excision ; Colotomy ;
General treatment.

By dilatation he means gradual stretching, not for-
cible divulsion. He finds it most applicable, in cases
of limited severity, as a supplement to the treatment by
incision or excision. Incision alone does not radically
cure, but as a means of saving time and of gaining a
wider passage than can be hoped for from dilatation
alone, Dr. Kelsey thinks it of great value. Partial de-
struction, electrolysis and raclage are spoken of as ex-
amples of timid and meddlesome surgery.

With regard to excision he speaks hopefully but
cautiously. One rule, he thinks, may be considered
established — cancer should not be attacked with a
knife unless there is reasonable certainty that it can all
be removed, and that the lymphatics have not become
involved to any extent. The method of procedure in
excision of the rectum is described. Of the operation
of colotomy Dr. Kelsey speaks highly, and he has had
considerable experience. He differs from most of the
older authorities in preferring inguinal to lumbar co-
lotomy. As regards ease and certainty of performance,
the subsequent cleanliness of the patient, and the
ability to care for the opening, all the advantages, he
says, are in favor of the inguinal opening. He has
done the operation eight times, with six recoveries and
two deaths.

The paper is an important contribution to surgery of
the rectum, and Dr. Kelsey has done a service in writ-
ing it.

A TREATISE ON THE DISEASES OF IN-
FANCY AND CHILDHOOD. By J. Lewis
Smith, M. D., Clinical Professor of Diseases of
Children, Bellevue Hospital Medical College, etc.
Seventh Edition, thoroughly revised. With fifty-
one illustrations. 8vo, pp. xiv, 868. Philadelphia :
Lea Brothers & Co., 1890. Price, $5.50.

The appearance of a seventh edition of Dr. Smith's
Treatise on Diseases of Children, indicates the ex-
ceptional activity which prevails in this special field of
medicine. Dr. Smith writes that, since the issue of the
sixth edition of his book, in 1886, so many additional
facts have come to light relating to the etiology,
nature and treatment of the diseases of children
that the necessary revision has produced virtually a
new book. Such a statement is all the more remarka-
ble when we bear in mind that almost the same words
were used by the author in his preface to the sixth
edition, which appeared less than five years ago.

Dr. Smith's Treatise is so well known as a standard
American work on the diseases of children that an'ex-
tended review of it is unnecessary. The present
edition, its author thinks, may be considered to have
doubled in size, so far as the amount of information
presented is concerned. He has endeavored to ex-
clude all obsolete material, and to condense the text
to the limit of clearness. The number of pages is
not much greater, the new material having been ac-
commodated by lengthening and widening the printed
page, and using a somewhat smaller type. The effect
of this change, so far as the eye is concerned, is not
pleasing, but perhaps it is better than running the risk
of making the volume bulky.

The present edition contains articles on the follow-
ing subjects which were not treated in the former
edition : Conjunctivitis, Icterus, Sepsis, Umbilical
Diseases, Haematemesis, Melsena, Sclerema, OZdema
and Pemphigus of the new born ; Epilepsy, Tetany,
Appendicitis, Typhlitis and Perityphlitis. There is
also a paper on Intubation, by Dr. Joseph O'Dwyer.

In its present form the book is more compendious
than formerly, but its practical value, as a trustworthy
guide to the diagnosis and treatment of diseases of

J74

Notes and Comments.

Vol. lxiv

children, has not been diminished. We congratulate
its author upon having kept abreast of times which are
remarkably prolific of discoveries in his special field,
and cordially recommend the book to our readers.

CORRESPONDENCE.

Clinical Lecture by Dr. J. H. Musser.

To the Editor.

Sir : Kindly do me the justice of stating
in your journal, that through an accident
the Clinical Lecture by me, published in the
Reporter, January 24, did not contain the
corrections I had made on the proofs. I
would not like to be held responsible for its
inaccuracies and the erroneous statements
regarding the classification of anemia. I
do not hold to such classification and could
not have made it.

Yours truly,

J. H. Musser, M. D.

Philadelphia.

Questions and Answers.

[In this department will be published questions on any medi-
cal subject by readers of the Reporter, and answers by the
Editor or by other readers.]

What is the Best Stimulant in
Impending Collapse ?

Dr. W. H. Burr, of Wilmington, Del.,
writes: I do not wish to have the reputa-
tion of being a voluminous writer, but read-
ing medical journals stimulates inquiry. I
would like to have from some of your read-
ers a short, scientific and at the same time
practical method of treating persons in im-
pending collapse from whatever cause,
founded on good physiological reasons or
experience, or both.

A good example to work on is the case of
a patient exhausted by previous disease who
is compelled to undergo a serious operative
procedure as an only chance to save life.
We have here three elements to combat.
Exhaustion from previous disease, shock
from operative procedure and anaesthetic
influence. What drugs, if any, either by
stomach, rectum or hypodermically, are
most efficient to help tide the patient over
the emergency? One author says alcohol
finishes those who escape the anaesthetic
effect ; another prominent author uses alco-
hol very freely, and proves his theory by an
experience covering thousands of cases. One
author recommends hypodermic injections

of ammonia, but does not say what form
should be used, how much may be used or
what the chances of abscesses are. Another
recommends digitalis, but is equally reticent
as regards quantity, physiological action,
etc.

Let some one make a list of all diffusible
stimulants which have an action on the vital
centers. Let the list include alcohol, mor-
phia, atropia, digitalis, strychnia, nitroglyc-
erine, ammonia — most of these being, by the
way, powerful poisons in doses of any great
magnitude, and all differing among them-
selves in their ascribed physiological actions.
From this list let there be some plan evolved,
resulting in the use of one or more than one
of these drugs, so that the defenceless subject
may not be liable by well-meant, but ill-
directed efforts to be overwhelmed by a
multitude of powerful drugs indiscriminately
applied.

For humanity's sake let there be a little
more method in medicine.

Notes and Comments,

The Koch Remedy in New York.

The January number of the medical jour-
nal called the Post- Graduate, the journal of
the New York Post-Graduate School, says :

" There have been some grotesque and al-
most ludicrous incidents in the Koch excite-
ment. The race to get and use the lymph
before others ; the suspicions raised, in one
instance at least, that the lymph was not
Koch's at all; the apologies of an ex-presi-
dent of the Academy because his name was
so much in the papers, and .of the president
himself, for his son, who was said' by a Her-
ald reporter to have given an enormous
money value to a vial of lymph ; the red-
colored postals of the County Society an-
nouncing as 1 Notice Extraordinary ' that
one of its members was about to tell what
he saw in Koch's laboratory — ail these things
would make a graphic picture of medical
New York in a ferment in the latter part of
1890. . . ."

And again: ''The dear old code, tor
which the New York State Medical Associa-
tion was born, and in defence of which
every member of the American Medical As-
sociation is supposed to be willing to die,
has suffered dreadfully as a result of Koch's
discovery. The whole medical profession
throughout the civilized world has been en-

Feb. 7, 1 89 1. Notes and

Comments.

175

gaged in using, or in endeavoring to use, a
secret remedy. We might expect this in
lax New York, but in strait-laced Connecti-
cut it is almost unbearable. The old code
has given way in the field of its most enthu-
siastic devotees, about as badly as the Fugi-
tive Slave Law did after the civil war had
broken out. Yet the purest thing in this
ark of the American Medical Association
was the section about secret remedies and
nostrums. We are pained to see unholy
hands laid upon it, even in the name of
Teutonic science."

Browrt-Sequard Fluid in Tubercu-
losis.

The supplement to the Bi-itish Medical
Journal, January 10, 1891, says:

Dr. D. Uspenski, in a lecture recently
delivered before the Russian Society of
Public Hygiene (Deutsche Medizinal-Zei-
tung, December 29, 1890), gives an ac-
count of some clinical experments which he
had made with Brown-Sequard's " emul-
sion " in the treatment of tuberculosis.
He had tried this preparation in eighteen
patients in different stages of the disease.
Two of them had been quite given up. In
one of these the patient was a lad of
eighteen who had long suffered from mitral
insufficiency, and who became the subject
of acute phthisis in the beginning of May,
1890. After all other means of treatment
had been tried in vain Uspenski had re-
course to injections ®f Brown-Sequard's
fluid. After the first three the general 'con-
dition and the appetite were greatly im-
proved, and after six injections the patient
was able to leave his bed and walk about
the room. The treatment was continued
with the result that the strength and weight
increased, while the temperature gradually
fell, and the night-sweats diminished. After
ten injections the latter ceased altogether,
and the patient had so far recovered his
strength as to be able to take a long walk
in the open air. On June 15 the last in-
jection (the fifteenth) was given, and the
patient continued, through the summer, to
improve in health and to gain weight (from
122^ lbs. to 148^ lbs.). The tuberculous
process in the lungs was at a standstill. In
the other case the patient was a man, aged
twenty-eight, who developed phthisis after
influenza. There was considerable fever,
with profuse night-sweats. There was infil-
tration of the right and, to a less extent, of

the left apex, and tubercle bacilli were pres-
ent in the sputum. At the beginning of
May injections of Brown-Sequard's fluid
were commenced ; after the sixth the appe-
tite increased, and after the twelfth the
patient's condition was so much improved
that he was able to leave his bed. After the
eighteenth injection the temperature became
normal. There has been no increase of
weight, nor is there any perceptible amelio-
ration in the condition of the lung. The
patient, however, feels much better. In
chronic cases the injections act more rapidly.
In twelve such patients there was marked
general improvement, with reduction of
temperature and diminution of night-sweats
after from two to four injections. Nine, or,
at most twelve, injections usually suffice.
Even amid the unfavorable surroundings of
a prison infirmary Uspenski obtained good
results by this treatment in seven cases. He
considers that Brown-Sequard's fluid has a
markedly strengthening effect, and is bene-
ficial in all cases of phthisis without excep-
tion, whether the patients have any addi-
tional treatment or not, and whether they
live under favorable conditions or the re-
verse. The tubercle bacilli do not disap-
pear entirely, even in the most successful
cases, but diminish in number in proportion
to the extent to which the diseased process
recedes. Uspenski says the remedy does
not kill the bacilli, but weakens their patho-
genic power.

Practical Method for Staining Tu-
bercle Bacilli.

Assuming for the present that a practical
process for staining and mounting tubercle
bacilli will be acceptable to those of our
readers who are already in possession of,
and familiar with, a microscope, we will
quote here a method of proceeding recently
published by Dr. M. Friendlaender, of Berlin
(in Pharm. Zeit., November 22). This
method permits two mountings to be made
in from five to ten minutes, provided the
operator is skilled and has everything in
readiness.

The materials required are :

1. Ziehl's Solution. — This is a 5 per-
cent, aqueous solution of carbolic acid mixed
with alcoholic solution of fuchsin (almost
saturated).

2. A mixture of 100 gm. of alcohol of
80 per cent, and of 5 gm. of pure nitric
acid.

176

Notes and

Comments.

Vol. lxiv

3. A concentrated solution of methylene
blue in water.

The mounting is done as follows :

A very small quantity of the sputum —
about the size of the head of a pin — is taken
up with the needle and spread by means of
the latter upon an object-glass to a thin
layer about covering the space of a ten-cent
piece. The slide is then allowed to dry in
the air, and meanwhile a second slide is
commenced. The dry mounting is now
drawn three times slowly through the flame
of a Bunsen burner or alcohol lamp. Next
2 to 3 drops of the fuchsin solution are
placed upon the mounting, and the slide
held over the flame (mounting upward) until
light vapors arise. The slide is now drawn
once through water contained in a capsule,
and the mounting then treated with a few
drops of the acidulated alcohol, which is al-
lowed to remain until the spot is completely
decolorized (this will require about one-half
minute). The slide is now again washed
with water and then treated with a few drops
of the methylene-blue solution, which is
allowed to remain until the second slide (to
which the operator now turns) has progressed
to the same point. The first slide is now
washed with water and finally dried with
blotting paper [this is not advisable unless
paper giving off no fibers is at hand] and
over the flame.

Upon the mounting there is now placed
a drop of oil of cedar (no cover glass), and
the object examined with the lens (oil im-
mersion objective).

Usually two specimens or slides suffice for
determining the character of a sputum. —
American Druggist, January 15, 1891.

seen so many cases of spontaneous absorp-
tion under simple diuretic and tonic reme-
dies that he recognizes only two indications
for operation : (1) When there is rapid
and threatening increase in the quantity of
fluid, so as to give rise to excessive dysp-
noea ; and (2) when the effusion has become
purulent. In my two cases there was rapid
absorption of the effusion under simple coun-
ter-irritation with iodine and tonics ; in one,
complete absorption in the unusually short
space of a week, and in the second in about
a month. I have also seen, in a child of three
years, a pericardial effusion which was so
large as to reach the sternal notch above
and the nipple on the right, completely
disappear under tonic treatment in the
course of weeks. The number of cases also
of empyema in children which recover fully
after one or more aspirations, whereas in
adults the radical operation is always neces-
sary, is a further indication that the condi-
tions in children are much more favorable
for absorption than in adults. I believe,
then, that paracentesis should be resorted to
in those cases only where there is danger to
life, or where long observation has shown
no subsidence of the effusion under conser-
vative and tonic treatment. An out-of-door
life is usually indicated, and mountain or
sea air is often very beneficial.

Pleuritic Effusion in Children.

Dr. Herbert B. Whitney gives in the
Denver Medical Times, December, 1890, an
account of two cases of pleurisy with effusion
in children, and then says: The treat-
ment of pleuritic effusion should, I think,
be very conservative. Without stopping to
consider the measures, antiphlogisic and
others, to be taken at the outset of acute
febrile cases, I come at once to the impor-
tant question as to whether paracentesis should
be early resorted to, or should be as long as
possible delayed. Henoch favors emphati-
cally the latter course. He says the activity
of tissue metamorphosis in children causes
in general a more rapid absorption of serous
exudations in them than in adults. He has

Early Spontaneous Rupture of the
Uterus.

The Lancet, January 10, 1891, cites a
case of rupture of the uterus, reported from
Mexico by Dr. Eduardo F. Pla in the Crbn-
ica Medico- Quirurgica, which is in several
respects almost unique. The patient was
a married woman twenty-one years old
who had had only one pregnancy, which
terminated satisfactorily five years before,
since which time she had had no illness.
A medical man was summoned hastily, as
she had been suffering intense pain, and
had suddenly become cold and collapsed.
When he arrived she was dead. The official
post-mortem examination was entrusted to
Dr. Pla, who, after noting the absence of
any marks of violence, opened the abdom-
inal cavity, and found a quantity of blood
and coagula, also the amnion containing a
four months fetus, with umbilical cord
and placenta. This had escaped by an
irregular rent across the fundus of the uterus
three inches in length. There were coagula
in the cavity of the uterus, but no pus or

Feb. 7, 1 891. Notes and Comments.

177

evidence of inflammation in the pelvic or-
gans. The uterine wall was found to be ex-
tremely thin in the neighborhood of the
rupture — under two millimeters — though in
other parts it was as much as eighteen milli-
meters in thickness. A microscopical ex-
amination, which was made by Dr. San
Martin, showed that in the region of the rup-
ture the muscular coat was practically absent,
being represented by a very few attenuated
fibers ; the mucous coat, too, was absent, be-
ing replaced by fibrous tissue without glands
and with scarcely any vessels. Altogether
the appearance was that of a cicatrix, but no
history of any injury or disease could be ob-
tained. The placenta was perfectly normal.

Charpentier mentions eight cases of uter-
ine rupture at or before the end of the
fourth month of pregnancy, and Dr. Pla
mentions two cases cited by Burns in addi-
tion ; these ten being all that he could find
in literature. In most of these cases the
patient was much older and had had diffi-
cult previous labors, and, again, the seat of
the rupture was much less commonly the
fundus than the lower segment. In the
present case, being over the insertion of the
placenta, the hemorrhage was great, and so
led to the immediate fatal termination,
whereas several of the other cases died later
from peritonitis, and in one, that recorded
by Dr. Drake, the fetus ultimately made its
way out through an abscess in the umbilical
region.

women of position and influence are in-
cluded in its membership.

It is said that the investigations of the
League show that in seven years fifty-six sane
persons were imprisoned in the Buffalo Asy-
lum, and that this is admitted by the Asylum
authorities in their reports. It is also as-
serted that the Utica Asylum admits that over
one hundred sane persons have been impris-
oned there in thirty years. The Society ad-
mits in many cases there is no fault on the
part of the Asylum authorities, but says that
the fact that eleven sane persons are an-
nually incarcerated in two institutions shows
that in the numerous public and private asy-
lums there is a field for the Anti-Kidnapping
League.

Anti-Kidnapping League.

The Public Ledger, of Philadelphia, states
that the week before Christmas a new na-
tional association was organized in New
York, under the name of the 'f Anti-Kidnap-
ping League." The purpose of this league
is to hunt down every case of imprisonment
of sane persons in insane asylums which it
can hear of, and give such assistance as the
case demands.

The idea of the League originated with
Miss Clarissa Caldwell Lothrop, of New
York, who was herself the victim of the kid-
napping the society has been organized to
prevent. She was incarcerated for two years
in an asylum, and when she was released she
began the work of exposing the evils of
which she knew, at the same time working
for the organization of a national society to
prevent the kidnapping and incarceration
of sane persons. The society was organized
December 19, 1890, and many men and

The Physiological Action of Sulph-
aldehyde.

Sulphaldehyde, produced by the action of
sulphuretted hydrogen on ethylic aldehyde,
occurs in the form of an oleaginous liquid
of a repulsive odor, solidifying slightly be-
low the freezing-point. Treated with acids,
sulphaldehyde is transformed into a solid,
the point of fusion of the various articles of
commerce varying in accordance with their
greater or less purity. Its analogy in com-
position to paraldehyde led Dr. Lusini to
test the physiological action of the sulphal-
dehyde, administering it by injections intra-
peritoneally,.and into the stomach of rabbits
and frogs (Les Nouveaax Remedes, Novem-
ber 8, 1800).

It appears that sulphaldehyde produces
profound and tranquil sleep without any
phenomena of excitation. On account of
its insolubility, some time is required before
its effects follow its administration ; never-
theless, it is claimed to be much more ener-
getic than paraldehyde. It is eliminated
completely by the urine, to which it gives
its characteristic odor. — Therapeutic Gazette,
January, 1891.

Cocoanut for Tape Worm.

Dr. W. R. Allison, of Good Hope, 111.,
writes, in the Peoria Medical Monthly, No-
vember, 1890, of a man aged 35, who had
always enjoyed good health, and who no-
ticed some time ago that segments of worm
were found in the discharges of the bowels.

He was ordered to fast for twenty-four
hours and to take before breakfast the fol-

1 78

Obituary.

Vol. lxiv

lowing day some pumpkin-seed tea, followed
with a laxative, with the good results of
causing the expulsion of about eighteen feet
of the worm. All seemed well for about six
weeks, when segments again appeared in the
stools and were also discharged in his study
or sleep. The man was accordingly given
felix mass and passed about fifteen feet of
taenia solium, which gave the usual result of
seeming health for a period of from four to
six weeks, he being able to sleep well and
complained only at the time of the reappear-
ance of the segments, of a slight inability
of concentration of thought. He never
seemed to have any other symptom of the
parasite.

He now used chloroform and at another
time turpentine with no good results when
he by chance read of some one who had
eaten a cocoanut and was surprised to see
that he had discharged a tape worm. Ac-
cordingly he determined to try the same
remedy, and was rewarded for his efforts by
the discharge of twelve or fifteen feet of
worm.. As cocoanut is more pleasant to
prescribe than many of the usual remedies,
and does good with no bad results to the
patient, and brings the worm without the
usual following of a cathartic, Dr. Allison
is pleased with its effects.

His patient drank the milk and ate the
meat of the nut until he was satisfied that
more would have made him sick.

Another Koch Institute in New York.

The daily papers of February 3, announce
that a new Koch Institute for the treatment
of consumptives was opened in New York
the day before. It is a four-story brick
structure, fitted up with all hospital conven-
iences. There is room for thirty-five pa-
tients in it. Dr. Alexander I. Aronson,
who spent three months in the Berlin
Clinics under Koch, is in charge and will
be the resident physician.

[Now is the time to conjure consumptives
by the name of Koch ; before long it will
be too late.]

New Operation for Club-Foot.

The Annals of Surgery, December, 1890,
says that Dr. Mensel, of Gotha, has enu-
cleated the bony nucleus in the neck of the
astragalus of a patient suffering from con-

genital bilateral club-foot. The patient
had had the regular orthopedic treatment for
club-foot, but after forcible redressement of
the feet, plaster and splint were applied, and
after eight days the patient contracted gan-
grene from pressure on both feet. During
the process of granulation the feet not only
became as bad (varus) as originally, but
even worse. The cicatricial tissue was not
favorable to the treatment in the regular way,
and the author exposed the astragalus of the
patient (2^ years old). At this age the
astragalus is composed for the most part
(body) of cartilage and the bone nucleus
is situated in the neck of the bone. It was
comparatively easy to expose the neck of
the bone without opening either the scaph-
oid or ankle joint, and by cutting into the
neck the bony centre could be easily enu-
cleated. The deformed bony nucleus may
be very potent in the causation of the varus
position, and after its removal the cartilage
can be easily molded into a normal position.
After removal of the above it was easy to
bring the foot into good position without
any great force, and cure was complete.
The advantage gained is the retention of
the body of the astragalus and the integrity
of the ankle and scaphoid joints.

The operation is only indicated before
the third year, and author would only per-
form it when the orthopedic treatment is
not possible.

OBITUARY.

JOHN McCARRELL, M. D.

Dr. John McCarrell, who has for many
years been a subscriber to the Medical and
Surgical Reporter, died at Wellsville,
Ohio, January 18, 1891, about seventy years
old. Dr McCarrell was born and reared in
Washington county, Pa. He read medi-
cine and practiced fifteen or twenty years,
then about 1866 removed to Wellsville, and
rapidly won a practice which proved very
lucrative. He had not a very robust con-
stitution, yet seldom saw serious illness.
When dangerous disease did get a firm
hold upon him it carried him off in brief
period.

Dr. McCarrell was a man much loved and
trusted in the community in which he lived,
and an exemplary Christian. His life was
one of usefulness and beneficence, and his
death is deeply deplored.

edical and Surgical
Reporter

A Weekly Journal.

Established in 1853 by S. W. Butler, M. D

CHARLES W. DULLES, M. D., Editor and Publisher,

id as Second-Class matter at Philadelphia P. O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

$5.00 per Annum.
10 Cents a Copy.

Vol. LXIV, No. 7.
Whole No. 1772.

FEBRUARY 14, 1891.

CO^TETSTTS:

CLINICAL LECTURE.

Hare, H. A., M. D., Philadelphia, Pa.— Chronic
Enlargement of the Tonsils of Children.— Epi-
lepsy 179

COMMUNICATIONS. *

Griffith, J. P. Crozer, M. D., Philadelphia, Pa .—

Climatic Treatment of Phthisis 182

Behrens, B; M., M. D., Chicago, 111.— Permanent
Opening of the Drumhead and the Artificial

Drumhead 18G

Sargent, G. P., M. D., Bryn Mawr, Pa —Coryza... 189
Blackwell, Enos T., M. D., Cedarville, N. J.—

Vomiting of Pregnancy 190

NEW YORK CORRESPONDENCE.

New York Letter.— Contribution to the Pathol-
ogy of Reynaud's Disease.— Removal of Hyper-
trophied Prostate.— Trephining for Epilepsy-
Total Extirpation of the Larynx.— Artificial
Larynx.— Remarkable Case of Luxation of the
Patella.— Chronic Cervical Adenitis in Chil-
dren 192

PERISCOPE.

Simple Medication for Children.— Detection of Bil-
iary Matter in Urine.— Leprosy in Colombia. —
Sunflower Plantations as a Prophylactic against
Malaria.— Treatment of Erysipelas.— Resection
of the Liver 196-198

EDITORIALS.

Varices of the CEsophagus 199

Exploratory Puncture of the Female Pelvic

Organs 200

Atlanta Medical and Surgical Journal 201

BOOK REVIEWS.

Goss ; The Practice of Medicine ; or, the Specific
Art of Healing.— Mitchell ; A Clinical Study of
Diseases of the Kidneys. — Burt ; Tuberculosis,
or Pulmonary Consumption : its Prophylaxis
and Cure by Suralimentation of Liquid Food 201-202

CORRESPONDENCE.

Double Opening into Womb 202

NOTES AND COMMENTS.

Koch's Lymph.— Mutual Aid Association.— Testi-
cle Therapy for Phthisis.— Resection of Thyroid
for Exophthalmic Goitre.— Practiced Medicine
without Registering.— Sanitary Convention of
Pennsylvania. —Habitual Abortion. — Another
Remedy for Perspiring Feet - 203-206

NEWS 206

OBITUARY.— Troy S. Saunders, M. D 206

"Verbimi sat Sapientibus."

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MEDICAL AND SURGICAL
REPORTER

No. 1772.

PHILADELPHIA, FEBRUARY 14, 1891. Vol. LXIV.— No. 7.

Clinical Lecture.

CHRONIC ENLARGEMENT OF THE
TONSILS OF CHILDREN.—
EPILEPSY.1

BY H. A. HARE, M.. D.,

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN
THE UNIVERSITY OF PENNSYLVANIA.

Gentlemen : The first case I have to show
you this morning is one of a character which
is quite frequently met with, namely, an en-
largement of the tonsils with some follicular
inflammation, but chiefly consisting in an
increase in the connective tissue, an inter-
stitial tonsillitis of a chronic type. This
condition is accompanied by a protrusion
of the tonsils across the pharynx, in this
case touching the uvula on one side, and
almost touching it upon the other. Often
the uvula is touched upon both sides. On
examining this throat, you will notice that
the mucous membrane over the tonsils is
hyperemic, reddened and inflamed, but
not covered with the white spots which are
frequently seen. This tells us that this is
not a case of pure follicular tonsillitis ; for
in it we have large quantities of a cheesy
material poured out, which so closely resem-
bles the false membrane of diphtheria,
that a false diagnosis is often made. The
exudate can be removed, however, on a
small probe, and leaves behind it no bleed-
ing or raw surface. This is not the case in
diphtheria, where the membrane is adherent,
and on removal leaves a bleeding surface.
In acute tonsillitis, true quinsy, or suppura-
tive tonsillitis, death seldom occurs. It
is curious that strangulation does not more
frequently occur from rupture of the abscess
during sleep, or that .pneumonia does not
result from the swallowing or breathing in of

1 Delivered at the University Hospital.

this material, the so-called Schluck-pnenmonie
of the Germans.

Most commonly these cases come to the
physician because the child has a constant
paroxysmal cough, which almost ceases
during the daytime, but is persistent at night,
especially in the early hours of sleep. A
careful examination of the chest in these
cases of tonsillitis shows no sign of pulmon-
ary trouble. The cough is a pharyngeal or
uvular cough, due to irritation. The cause
of the cough is not identical with that of
an ordinary cough, but is due to the two en-
larged tonsils which protrude and tickle the
uvula. During the daytime the muscles
are held tense, and the tonsils are thus pre-
vented from touching the uvula ; but if an
invoj/mtary relaxation occurs, as in sleep,
the uvula is tickled, cough results, and the

j child awakens. At times it is even neces-

j sary for the child to sit up in bed to relieve

j the cough.

It is difficult to treat such cases ; much

I more so than cases of acute follicular ton-
sillitis, which may be treated with diuretics
and cardiac sedatives, and with the local ap-
plication of cold or heat. In the treatment
of the present variety, several interesting
points must be considered. Is chronic in-
terstitial fibrous enlargement of the tonsils
severe enough to interfere so seriously with
respiration as to make the removal of the
tonsils necessary ? A great many physicians,
especially in France, recommend their re-
moval. On the other hand, I have seen
several experienced surgeons operate upon
the tonsils and encounter excessive hemor-
rhage. As you well know, any severe
operation upon the mouth is very apt to be
accompanied by profuse hemorrhage.

The next heroic treatment after tonsil-
lotomy is igni-puncture, or the use of the
actual cautery. It consists in the insertion
into the enlarged mass of a small electric cau-
tery, or the ordinary red-hot iron. The
inflammation which ensues around the burns

179

i8o

Clinical

Lecture.

Vol. lxiv

results in fibrous or cicatricial contraction,
with a consequent decrease in size of the
organ. This results in a ragged-looking
tonsil, with crypts in which food may accu-
mulate and undergo decomposition, with
the production of fetid breath. A mouth
wash or gargle of carbolic acid (i to 100),
sweetens the breath and prevents decompo-
sition from going on. Notwithstanding its
drawbacks, however, igni-puncture is the
operation to be resorted to, instead of ton-
sillotomy. It is safer and just as efficacious.
However, in all these cases, the patient at
first desires you to temporize with medicinal
measures : and probably the best medicine
for an adult is iodide of potassium, five
grains three times a day, at the same time
painting the tonsils with equal parts of io-
dine and glycerine, or one part of iodine to
three parts of glycerine, and also painting
the skin externally with tincture of iodine,
or rubbing in iodine ointment. If you em-
ploy iodine ointment over enlarged glands
in children, it must be mixed with lard ; as
it is too strong to be applied in its officinal
strength. Simple or benzoated lard may be
used with an equal amount of the iodine
ointment. If the child is the age of this
one (8 years), probably you will not be able
to give it iodide of potassium in effective
doses, as the drug would be apt to disorder
the stomach. You should use in its place the
syrup of the iodide of iron internally. Most
of these children are anemic, and iron is
needed. Iodide of iron also exerts a peculiar
influence over inflammation of the upper air
passages. The syrup should be given in
doses of five drops or more three times a
day.

On looking at this child's tongue you will
notice that it is black. This is due to the
iron, which also blackens' the feces. The
discoloration is due to the presence of
sulphide of iron. It is well to warn the
mother that this will occur, to prevent need-
less alarm.

To be more definite, what shall we do for
this case ? We shall give her five drops of
the syrup of the iodide of iron three times
a day, and apply externally over the en-
larged tonsils ichthyol ointment, night and
morning, two drachms to the ounce of lard.
If no irritation of the skin is produced, we
shall apply it at noon as well. It is impos-
sible to make applications to the tonsils in-
ternally every day, and it is dangerous to
give iodine solution to parents of young
children, with which to paint the child's

throat. If I should give anything, it would
be a solution of one drachm of tannic acid
to two ounces of glycerine, to be applied
with a camel' s-hair brush.

I forgot to mention one other course of
treatment which may be resorted to after
igni-puncture, and that is the use of the solid
stick of silver nitrate. This is especially
useful when there is a complication of
chronic interstitial tonsillitis with follicular
tonsillitis. By using the stick in these cases
you mildly cauterize the tonsils, and achieve
good results.

The slight deafness which is frequently
complained of by patients with enlarged
tonsils is due to an extension of the inflam-
mation from the tonsils to the Eustachian
tubes, which either become patulous or
plugged with mucus.

Epilepsy.

The next case is one of epilepsy : an ex-
tremely common disease, and of frequent
occurrence among children. The case is
one of ordinary idiopathic epilepsy, unfor-
tunately not dependent upon trauma or
tubercular growths, and consequently unfa-
vorable as regards prognosis. It depends
upon some organic change which the micro-
scope so far has not been able to reveal.
The boy, however, has one symptom which
gives us a clue, sufficient to start us on
a tour of investigation as to whether it
is a true epilepsy, or an epilepsy hysterical
in origin. His aura consists in the sen-
sation of a globe rising in the throat,
which, as it reaches the level of the
glottis, terminates in an attack of epi-
lepsy. Hysterical epilepsy may occur in
young males as well as in females. There
is also a possibility of this case being one of
the so-called reflex epilepsies. A number of
authorities claim that there is no such thing
as a reflex epilepsy ; but I think that it is
proved conclusively that a certain number
of these cases are reflex, and in such cases
the removal of the cause is apt to be fol-
lowed by a cure of the epilepsy. An adhe-
rent and elongated prepuce is one of the
most common causes of this variety of the
disease. In such cases the prepuce Is never
thoroughly emptied of urine; and the, re-
tained urine sets up an inflammation which
may even result in ulceration. In other
cases a large amount of smegma collects
around the corona, and an inflammation is
thus excited. In these cases circumcision is
always to be tried. It may or may not do

Feb. 14, 1891.

Clinical Lecture.

181

good. In other cases some foreign body may
be found in some portion of the system, which
by its presence creates sufficient irritation to
produce a reflex epilepsy. The nose espe-
cially should be searched for such a cause,
as beans and other bodies are often placed
there by children.

The variety of the auras which come on
in epilepsy is very great. Probably there
are as many as ninety different forms de-
scribed. The globus hystericus, tingling in
the fingers, tingling in the toes, hallucina-
tions and sudden interruption of the heart, are
but a few examples of the great variety of
forms it assumes. There is a point of inter-
est in regard to treatment connected with
the aura. If an attack is always preceded
by an aura, the prognosis is more favorable
than if the aura does not come on. One
nervous act always predisposes to another
nervous act, and the second act is much
more violent as a rule than the first. This
is especially noticeable in epilepsy. Now
you can see at once that those cases which
have an aura may be more favorable in
prognosis than the others ; since, if the
aura is of any duration we can generally,
by using nitrite of amyl, avert the subse-
quent nervous act : and if we do not have
the first nervous act, we will not have the
second. Thus, if the patient can succeed
in putting off his attacks for a year, he will
probably be permanently improved. For
this purpose, pearls of nitrite of amyl,
containing two or three minims each, should
be kept in the pocket, and one should be
broken and used from a handkerchief as
the aura is felt.

Another factor governing the prognosis of
these cases is to be found in the habits of
the parents as regards the use of alcohol. A
number of statistics made in. France show
that a child of alcoholic parents is especially
liable to epilepsy ; and this is greater if both
parents are addicted to the use of alcohol.
The prognosis is more grave when both are
alcoholics. Syphilis also must never be
overlooked in these cases.

In a certain number of cases'of epilepsy
it will be noticed that the child will have a
rotatory convulsion preceding the attack.
What the cause of these rotatory convul-
sions is, is not fully known.

This boy does not suffer with prolonged
unconsciousness or coma, as is usual in most
cases.

There is one other thing I should impress
upon you in studying a case of epilepsy.

Ascertain if any portion of the body is first
affected, as evinced by a movement of one
thumb, or of a hand, or leg, or by a flushing
of one portion of the body. This may give
a clue as to where the lesion is that produces
the attack, or indicate whether or not the
disease is idiopathic in nature. I remember
seeing a man under the care of Dr. Hugh-
lings Jackson some years ago, who was par-
alyzed in the lower extremities from Pott's
disease, and who suddenly developed an
epilepsy in which the movements were con-
fined to the upper extremities. The thumb
of the right hand was the first portion of the
body affected by the paroxysms, and the
diagnosis was made that the thumb centre
upon the opposite side of the brain was in-
volved. Accordingly the man's skull was
trephined, and a tumor the size of a hickory
nut was found and removed, with subsequent
complete or partial cure of the epilepsy.

In the treatment of these cases of epi-
lepsy, bromide of potassium is the standard
remedy. I think that sodium bromide is
better for children, as it is not so apt to
disturb the stomach. The best way to ad-
minister it, is in solution ; since it deliques-
ces if in powder form. Some authorities
claim that it is not so active as the potas-
sium salt ; but I am unable to vouch for the
accuracy of this assertion. In gouty cases,
the bromide of lithium may be of service.
In all cases endeavor to put off the attack
by the use of the nitrite of amyl. If you give
bromide of potassium to a child — and always
when you are giving it to women — give
with it Fowler's solution. This exerts a
useful influence on the disease in some cases,
and it also prevents the formation of acne.
Two to three drops should be given with
ten grains of bromide.

A form of reflex epilepsy which I should
have mentioned, occurs in little girls
from the migration of seat worms from the
rectum into the vagina, with the production
of great reflex irritation and convulsions.
The cure of the disease here is obtained by
removing the worms. In all cases of this
kind, however, the prognosis must be
guarded. If the child has had but one or
two fits, the prognosis is good ; but if it has
had ten or twelve, the habit has been pro-
duced, and this may become more and more
persistent as the child grows older.

— Helenin, the active principle of ele-
campane root, is claimed by Marpmann to
prevent development of tuberculosis.

182

Commtmications.

Vol. lxiv

Communications.

CLIMATIC TREATMENT OF
PHTHISIS.1

BY J. P. CROZER GRIFFITH, M. D.,

PROFESSOR OF CLINICAL MEDICINE IN THE PHILADEL-
PHIA POLYCLINIC ; PHYSICIAN TO ST. AGNES
AND THE HOWARD HOSPITALS,' AND TO
THE RUSH HOSPITAL FOR CON-
SUMPTIVES.

That change of climate is one of the best
— and sometimes the only — means of suc-
cessfully treating phthisis is so universally
admitted that it seems almost unnecessary
to make mention of it. There are, never-
theless, certain details regarding it, which it
may be not without interest to pass in re-
view. For centuries this method has been
in repute. The Romans used to send per-
sons with ulcerated lungs to Libra that they
might there inhale the balsamic odors from
the pines ; and Galen advised that phthisical
patients be sent to localities in which the air
was dry.

Even those who write upon the Home
Treatment of consumption, admit the value
of climatic treatment where it can be car-
ried out. It goes of course without saying
that the vast majority of phthisical patients,
owing to pecuniary or other disability, can-
not be sent away from home. The all-im-
portant subject of the means to be employed
for the recovery of health in these, I cannot
now treat, but must confine myself strictly to
the subject of the influence of climate upon
the disease.

I am myself so thoroughly convinced of
the value of climato-therapy in phthisis,
that were I assured that I had incipient
phthisis, however slight, neither inhalations
of oxygen, nor the use of compressed or
rarified air, nor the breathing of hot air, nor
enemata of foul air, nor trial of Koch's in-
oculations, nor pulmonary gymnastics, nor
the ingestion of cod-liver oil, iron, arsenic,
digitalis, creasote or any other drug should
prevent me — if in any way I could compass
it — from leaving a climate such as this for
some more propitious one. And yet there
are the sceptical — there always are, of every
good thing. Let me, however, give you as
samples, the histories in brief of two cases
which were sent to parts of the world far re-

1 Read before the Philadelphia County Medical
Society, January 28, 1 891.

moved from here and from each other : — the
Austrian Tyrol and Colorado. They Occur
to me because I have heard from each of
them within a short time. The first patient
developed apical phthisis some five or six
years ago. Being a man of means he trav-
eled, chiefly to various parts of the eastern
United States, remaining in each place but
I a short time and returning again home.
While away he improved, but always lost
again on coming back, Finally his cough
grew worse, there was slight hemoptysis, and
examination showed decided depressions at
the left apex with dulness on percussion,
bronchial breathing and rales. I sent him
to Meran in the Austrian Tyrol, where he
remained for over a year. On his return I
was astonished to discover that the dulness
on percussion, the depression and bronchial
breathing had entirely disappeared ; leaving
nothing but a few rales. An improvement
such as this had not been effected by all the
medicinal and hygienic treatment to which
he had been previously subjected. I told
him, however, that he had returned too soon,
and the event proved the truth of this. He
was shortly after returning, debilitated by
a very severe attack of herpes zoster, and
the subjective and objective symptoms of the
phthisical affection returned in full force by
the end of a year. He has again gone to
Meran, where he now is, and is doipg re-
markably well. He has no cough at all, and
only slight expectoration on rising in the
morning. Can he be induced to remain
sufficiently long, I have no doubt of his com-
plete recovery.

The other patient is himself a physician
from a neighboring city. He called upon
me last July on account of obstinate cough,
with loss of weight and strength, which
drugs, rest and a temporary mountain so-
journ had failed to relieve. He suspected
phthisis, and wished to have a diagnosis
made. Neither bronchial breathing nor im-
pairment of percussion resonance could be
detected, but there were a large number of
rales at the left apex, and a few on the other
side. Tubercle bacilli were present in the
sputum. I told him there was no doubt he
had incipient phthisis, and advised him by
all means to go to Colorado and begin the
practice of his profession there as soon as
he felt able. He did so, and wrote me the
other day, saying that he had gained 2 2 lbs.,
but asked my advice about coming on to
take the Koch treatment, as he did not be-
lieve that he was yet quite cured. My

Feb. 14, 1891.

Com m unications.

answer can be readily imagined. But cases
like these are known in numbers to all of
you. Only recently one of the members of
this Society told me that, visiting in Den-
ver recently, he sat down to dinner with, I
think, fifty men, all of them as hale and
hearty as one could wish to see, though all
or nearly all of them had gone West on ac-
count of trouble with the lungs.

Xow as to the way in which climate can
act in curing phthisis. If it is the fact, as
most of us certainly firmly believe, that
phthisis is the direct result of the growth of
the tubercle bacilli in the lungs, the ques-
tion naturally arises how climate can in any
way affect the growth of these organisms
after they have once found a nidus in the
system. This question cannot be answered
with positiveness. One matter bearing upon
it is, however, nearly certain. It would
seem probable that the only reason that
all of us do not take the disease is that,
either from the good condition of the gen-
eral health, or from some peculiar, unsuit-
able state of the respiratory tract, the bacilli
which we all probably inhale at times, do
not find in certain individuals the conditions
suited for their development. Given, then,
a patient with pulmonary phthisis, our ef-
forts must be to render the lungs again of
such a quality that bacilli already present
can no longer thrive and multiply. It seems
beyond question that certain climates have
the power of accomplishing this desideratum
in some way unknown to us, but certainly
more effectively than any other known
agent. What peculiar climatic features they
are which have this power is, as yet, not de-
termined with definiteness. The most gen-
erally accepted view is that high altitudes,
as a rule, are inimical to the development of
phthisis, and conducive to the recovery of
those already affected ; while a low eleva-
tion above tide-water, especially if combined
with dampness, continued high temperature,
or frequent changes of temperature, favors
its development. Particularly are writers
almost at one in reference to the favorable
action of high altitudes. Phthisis-is of rare
occurrence, for example, in the high moun-
tain cities of Mexico, in spite of the unfav-
orable influence exercised by the bad hygiene
and the employment of the inhabitants
largely in mines.

The disease is almost unknown in the
high plateaus of South America, and rare in
the high portion of the western United
States. Switzerland is, on the whole, re-

markably free from it, and it is very rare in
the highlands of upper Egypt. In the
western Highlands of Scotland, too, it is
uncommon as compared with other parts of
the British Isles.

It is not yet definitely understood whether
the immunity of the dwellers in high alti-
tudes is due to the low barometric pressure
or to the purity of the air. The view has
not found favor that it is in any way con-
nected with the greater depth of the respi-
ratory act ; nor does the statement that
microbes live with greater difficulty at a
high elevation satisfactorily explain it. That
the influence of high elevation is not due,
at least entirely, to the low barometric pres-
sure seems probable; since, as is well known,
prolonged sea voyages are often of great
benefit to phthisical patients. Moreover,
some islands, as Iceland and the Hebrides
and Shetland Islands, are singularly free
from the disease ; and the Kirghis enjoy an
absolute immunity, although they inhabit
steppes only 100 feet above sea level,

It has been long assumed that odors of
turpentine and allied substances coming from
pine forests were of value in the treatment
of phthisis, and it has been claimed that to
this factor sojourn in the Adirondacks owes
the undoubted advantages often exercised
by it in many cases of phthisis. There are
clearly, however, other important factors ;
since otherwise all regions filled with these
woods should exert' the same favorable influ-
ence. Yet there are many such districts —
as Maine — where the mortality from phthi-
sis is high. One might argue that the mor-
tality in such places was the result of too
great a degree of dampness ; but in answer
it may be noted that many islands, as already
stated, where the air is, to an extent, damp,
suffer but little, if at all, from phthisis. In
fact, the prevalence of the disease does not
seem to be connected with any geographical
position or condition of temperature.

Our knowledge in this regard may be
summed up by saying that change of climate
is very often of the greatest benefit to phthis-
ical patients, and that, as a rule, this ben-
efit seems to be intimately associated with
elevation above tide-water, though there are
many localities with no considerable alti-
tude where a good effect is often exerted
upon the disease.

It will repeatedly be observed that the
relation of a patient to a certain climate is
very much like that which exists, or should
exist, between a man and his wife. Just as

Communications.

Vol. lxiv

one man finds in his wife's character and
disposition that which entirely satisfies his
moral nature, while his neighbors, perhaps,
can see no good in her at all ; so one phthis-
ical patient may thrive in a certain locality,
while the next patient, with lungs in appa-
rently the same condition, is never comfort-
able there, and suffers a continual deteriora-
tion in health.

It is this fact which renders the matter of
choice of climate so exceedingly difficult.
It is impossible entirely to determine the
nature of what might be called climatic
idiosyncrasies in patients. We are, there-
fore, obliged, in the choice of a climate for
a patient, to follow certain general rules.
First is to be investigated the individual
susceptibility to cold and heat respectively.
We must carefully inquire whether the pa-
tient is always chilly in winter, or whether
he is exhausted and depressed in summer.
It seems to me to be folly as well as cruelty
to compel an anemic, emaciated individual,
who is always chilly and whose circulation
is feeble at the best of times, to spend a
winter in a cold, bleak, windy, northern
elevation. While the Adirondacks in winter
are certainly of benefit to many, it would
seem almost proved that they cannot but
disagree with others ; in fact, experience
proves that they do. On the other hand,
there are many patients to. whom even the
early spring warmth of Florida is invariably
depressing, and who reap no benefit from
sojourning there. It is, .after all, hygiene
throughout which we must keep in mind,
and not merely the effect of a certain cli-
mate upon the lung alone, as though it did
not belong to the body.

Another factor of some importance in se-
lecting a locality is a knowledge of the
diurnal range of temperature. The annual
average temperature, and the average for
each month, can usually be ascertained
without difficulty for the more frequented
health resorts, but the daily variation is not
so easily to be learned ; and yet it is on just
this factor that the comfort of the patient
may depend. A perfectly equable temper-
ature is certainly of great advantage. Un-
fortunately it is not so apt to be found with
dry air and elevation above - the sea as it is
at lower regions. Although elevation is, as
a rule, much the most important, yet in
some cases it will appear best to select the
sea on account of the smaller diurnal tem-
perature range.

Still another matter is the nature of hotel

accomodations and other creature comforts ;
and this has to be considered most carefully
in reference to the individual. Though a
strong man with beginning phthisis, which
has had but little effect upon his general
health, may do well if sent to a region where
he will spend his days in the saddle and his
nights in the open air ; it is clear that, for
women and many male patients, no such re-
gimen can be prescribed.

Patients want to know all these and simi-
lar details before leaving home, and it is
well if the physician can help them in this
respect. In many cases, however, circum-
stances prevent more than the pointing out
of a general plan of action ; especially as
the number of places recommended as health
resorts in phthisis is so large.

Individuals, with beginning phthisis, who
are unwilling to make a radical change; or
in whose case the physician does not deem
it expedient, might seek Florida in winter,
returning northward in the spring by slow
stages, stopping en route in Georgia and
North Carolina. In the summer some moun-
tain resort should be selected, preferably the
Adirondacks. There are, nevertheless,
weighty objections against this course. It
is very difficult to return North without feel-
ing the bad effect of the change of temper-
ature ; while a still greater objection is that
the length of time, during which this con-
tinuation of travel must be persisted in, is
too great for the patience of the .invalid,
thus kept so near home and occupation, and
yet debarred from them. I have, however,
seen cases, presumably of phthisis in its
earliest stages, apparently entirely cured by
a short absence from home in some such
majiner as this. It might be well in some
instances to begin treatment in this way ;
but if the physical signs are well marked,
only the shortest trial should be given to
this plan, as valuable time may be lost there-
by. These more advanced cases, if in fairly
good condition, and offering good hope of
final recovery, should at once be subjected
to a radical change of climate — either for an
indefinite period, or for life.

The question whether a station in the
mountains or at the sea level is to be se-
lected must be decided to some extent in
accordance with the idiosyncrasy of the pa-
tient, as far as this can be determined in
advance. As a rule, a mountain resort is
far preferable and should be chosen when-
ever practicable. Statistics certainly show
that the results in the mountains are better.

Feb. 14, 1 89 1. Communications.

Our own country offers several excellent
localities for phthisical patients. Of all of
them perhaps the high altitudes of Colorado
are to be preferred, since here can be found
comfortable accommodations combined with
pure, dry air and high elevation. In the
" Parks" of this State we find table-lands of
10,000 feet elevation above the sea, pro-
tected by surrounding mountain peaks, and
with an annual range of temperature less
than in the Eastern States of the same lati-
tude. Sudden diurnal changes do occur, it
is true, but to no greater extent than in all
elevated regions. The rainfall is, also, very
slight. It has been stated that the dust
prevalent as a result of this is irritating to
the respiratory tract ; but this is denied by
those who have accurate knowledge in the
matter. In spite of the thousands of phthis-
ical patients who frequent the State the
death-rate from consumption is very low.

New Mexico and Arizona offer somewhat
similar advantages in the way of climate ;
but the facilities for living are not so great.
The summers, too, are apt to be very hot.
There are localities in Texas, too, which are
excellent.

Southern California presents many ad-
vantages, not the least of which is that
patients can easily vary their elevation from
that of the sea level to a considerable moun-
tain height, according to the different sea-
sons of the year, and to what is found to
best suit their health.

Florida is not so favorite a resort as for-
merly, and physicians preferring high alti-
tude will not, of course, recommend it at all.

Phthisical patients in Europe can make
choice from a large number of summer sta-
tions, all equally good, or can go from one
to the other as fancy dictates. A winter
one may be chosen in like manner. The
passage from one to the other may be made
gradually by means of intermediate stations
whose climate is midway between that of the
others.

Nowhere does the climatic idiosyncrasy
come into play more than in the choice of
quarters; in Europe ; what suits one patient
for winter, for example, being entirely too
rigorous for another. For summer time
there is, as a rule, probably no better place
than the high valleys of Switzerland, and
prominent among these is the Engadine val-
ley. This valley, however, is scarcely free
from snow before the middle of June or the
first of July, and becomes cold early in the
fall ; so that, as a pure summer resort, it is

not long tenable. It is also subject in sum- '
mer to cold and disagreeable winds. In
spite of this it is unexcelled by other locali-
ties for the climatic treatment of phthisis.
Davos- Platz also enjoys a similarly good
reputation. The neighborhood of Zermatt
also fills the requirements of elevation and
coolness during the hotter summer months,.
There is no difficulty in choosing among a
number of other places equally well adapted-
Lower valleys may be selected if the summer
is unusually cool, but the higher elevations
are much to be pre'ferred, as far as freedom
from phthisis is concerned. Farther east
there are various resorts in the Dolomite re-
gion which are highly recommended. There
are numerous other places throughout the
mountains of Germany, but for American
patients Switzerland and the Tyrol offer
every advantage to be derived from climate,
while they possess other desiderata not to be
found elsewhere.

For early summer and early fall other lo-
calities than those mentioned are to be pre-
ferred. The choice of such a station is a
rather more difficult matter. Some of the
lower portions of Switzerland may be se-
lected ; as Interlaken, the neighborhood of
Lucerne, and the shores of Lake Geneva,.
Probably the latter situation is the best.
Vevey and Montreux form here excellent
intermediary stations. Ischl and Reichen-
hall, in Austria, are also recommended, and
the Black Forest, in Germany, presents many
attractions. One station which offers in
some respects peculiar advantages as an in-
termediary station is Meran, in the Austrian
Tyrol. It is beautifully situated and shel-
tered from the winds; and patients are able
to spend a great deal of the time in the open
air.

Finally, as to the choice of a winter sta-
tion. For weakly individuals who shun any
degree of cold or variation of temperature
it may not seem best to select an elevated
station. For such the south of France, the
south of Italy, Sicily or the Riviera, have
long and justly been popular. Or the pa-
tients may pass from Europe into Egypt,
Algiers or Morocco. But for uniformity of
temperature and of barometric pressure
there is probably no place known equal to
the Canary Islands. Madeira, once so pop-
ular, has fallen off greatly in general favor.
For a large number of phthisical persons a
dryer, colder and more bracing climate at a
greater elevation is more suitable, even in
winter. For these Meran is eminently

Communications.

Vol. lxiv

adapted, provided only a moderate degree
of cold is desirable. The sunshine here is
always quite warm, and patients are able to
sit out of doors in it the greater part of the
day.

Still more popular have the Engadine
valley and Davos-Platz become, even as win-
ter stations. The cold, it is true, is severe,
but it is dry cold, and the unpleasant, raw
winds of summer are absent at this period
of the year ; while the thermometer in the
sunshine registers high, as is usual in all
climates of high .altitude.

It is to be borne in mind as an inviolable
rule, that such a climate is to be selected
either for summer or winter, as will allow
the greatest amount of exercise in the open
air with the least discomfort to the patient,
and with the greatest advantage to the gen-
eral health.

What has been said is but the briefest and
a necessarily incomplete outline for govern-
ing the choice of climate for the patient. A
few words must be added on what might be
called the choice of the patient for the cli-
mate.

There has existed a wide-spread prejudice
against high altitudes in cases of decided
tendency to hemoptysis. This prejudice is,
in the opinion of the best authorities, un-
warrantable. Patients with this tendency
are perhaps even safer jn the mountains
than at the sea level. The cases most suited
for climatic treatment of any kind — as, in-
deed, for any other method — are those with
but slight infiltration, with but few symp-
toms of the disease, and with strength suffi-
cient to permit of abundant exercise. These
patients should, as a rule,, be sent to high
altitudes for summer, and very probably for
winter also. Other cases wTith a greater ex-
tent of pulmonary lesion, and with a less
degree of strength or of resistance to cold
will probably need the lower, warmer win-
ter resorts, followed by the intermediary
stations, and these again by the highest
elevations for the summer months. In a
still more advanced stage of the disease,
especially where there is much elevation of
temperature with severe subjective symp-
toms, the patient is not in a condition to
stand much traveling nor to take much exer-
cise. In such cases cold situations are out
of the question. A warm, equable climate
is to be chosen, and the nearer home the
better. If improvement take place a more
mountainous locality should be sought as
soon as possible. The existence of fever is

not, however, per se a contra-indication to
high altitudes. It has often been observed
that patients lose all fever soon after reach-
ing the mountain resorts. Nor is the pres-
ence of a cavity a contra-indication in the
selection of high elevations, provided the
lung is not evidently rapidly breaking
down. Cases which are very far advanced
and evidently hopeless should not, of course,
be sent away at all ; for only a hastening of
the final end of the disease can come to the
patient, with disappointment to the family,
and reproach to the physician. *It should
be further clearly explained to patients, in
whatever stage the disease is, that change of
climate is not an infallible cure, and, fur-
ther, that with it must be conjoined all
other necessary hygienic and dietetic meas-
ures, together with the employment of such
medicinal agents as are indicated by the
disease.

[The author would acknowledge his in-
debtedness to the writings of a number of
authors, to whom no direct reference has
been made in the text. Among these are
the following : Wanderings in Search of
Health, H. C. Taylor, 1890 ; Phthisivlogy ,
G. A. Evans, 1888; Climate and Health
Resoi'ts, Burney Yeo, 1890; Treatment of
Disease by Climate, by Hermann Weber, in
Ziemssen' s Hand-book of General Therapeu-
tics ; Etiology, Diagnosis and Treat?7ienl of
Tuberculosis, H. V. Ziemssen ; Articles by
Shattuck, Loomis, Solly, Westbrdok, Piatt,
Gihon, Curtin, Knight, Bowditch, Bruen
and others in the Tra?isactions of the Amer-
ican Climatological Association; Ruehle,
Article on " Consumption " in Ziemssen' s
Hand-buch der spec. Path. u. Therapie.~\

PERMANENT OPENING OF THE
DRUMHEAD AND THE ARTIFI-
CIAL DRUMHEAD.

BY B. M. BEHRENS, M. D.,

CHICAGO, ILL.

It is the common belief that perforation
of the drumhead is a final result of an otitis
media, or tympanitis, and that the closing of
the perforation is well-nigh impossible in
most cases. This sceptic view is held not
only by the medical profession at large, but
also by otologists. Of this we can convince
ourselves best in the otological text-books,
where it certainly is mentioned, that the

Feb. 14, 1891.

Communications.

perforated drumhead shows a vigorous effort
at closing, or trying to close, but not a suf-
ficently vigorous one. The last resource
is therefore the artificial drumhead, from the
little cotton pellet to the rubber drum, that
may in some cases bring a naturul closure
about by the continual irritating effect on
the edges of the remaining part of the drum-
head, but mostly is employed only with the
view of improving the hearing and protect-
ing the middle ear. It does improve the
hearing very often, of course ; but the. pro-
tection of the middle ear is of so dubious a
nature, that where it is possible to do bet-
ter, it ought to be discountenanced. Where
the perforation is of a large extent, the risks
are less than in cases of small perforations,
because we in the first cases can better mas-
ter the ill effects that might be caused by
the irritation of an artificial drumhead, but
here also it is unquestionably the best policy
to try to effect a closing of the perfora-
tion.

To dispel the existing scepticism, I have the
pleasure of presenting some illustrations of
cases that will explain the possibility of clos-
ing even large perforations better than words
can do, Such cases are few and far between,
for the reason that patients will seldom sub-
mit to a treatment lasting for months, not
to speak of the uncertainty of the final re-
sult of the undertaking. In the course
of several years, though, I have had so
many good results, that I dare, lay down the
rule, from which there are very few excep-
tions, that any perforation of any size in
the membrane proper can be made to heal
up, provided the remaining part of the drum-
head is not degenerated. I beg to remark
that I speak of perforation in the membrane
proper, and not of peripheral loss or defect,
nor of perforations in the Schrapnell mem-
brane. The secret of this rests in the fact
that the drum membrane owes its great re-
generative power to the elastic tissue in the
membrane proper, while the Schrapnell
membrane is entirely devoid of this tis-
sue.

As to peripheral loss or defect, the diffi-
culty of healing depends upon the fact that
the bony part of the tympanic ring contrib-
utes a part of the aperture in the passage.
Any effort to bring a natural closure about
here is without avail, and the only resort for
improving the hearing and protecting the
middle ear is the artificial drumhead. The
majority of perforations, though, are the con-
centric or excentric ones, either single or

double, or more numerous — and the more,
and consequently the smaller, the more
tractable they are. As the supreme question
always will be, whether the hearing will be
benefited by a closure, the artificial drum-
head is applied as a test. For this purpose
it is sufficient to apply a small cotton pellet
in the opening, or — what is better still — a
small piece' of sticking plaster over the
opening in the membrane. If by this the
hearing is improved, there is no doubt about
the benefit to be derived from a natural
closing, but if the hearing is not improved
we are not so certain of the reverse. Pol-
itzer, and many other authorities have laid
down this rule. It must be taken with some
allowance, as the result must depend on other
circumstances, as, for instance, the duration
of the existing opening and the possible
changes in the middle ear. So also as to
the question of seeking a closing where the
artificial drumhead produces noises in the
ear. It is very well for a text-book, but
only there.

There is so much difference between
an artificial drumhead and a natural clos-
ure, that results obtained by the first are
not to be compared with those obtained
by a natural closure, because only under this
can the tympanic cavity with its mucous
lining and chain of ossicles return to the
same condition it had before the primary le-
sion took place. The artificial drumhead
is a foreign body, whose irritating and pres-
sing effect is too predominating to give us
any correct idea as to the final effect of a
closing. It is not out of place either to as-
sume that a direct treatment of the tympanic
cavity through the opening will and can do
much good, while the closing goes on, if
proper remedies are employed. If ill effects
are obtained after the closing, as, for in-
stance, impairment of hearing and noises
that were formerly not present, the after-
treatment will have to be directed through
the Eustachian tube, with injection of proper
medicines, or resort can be had to surgical
interference to bring about a permanent
opening again. In cicatricial tissue this is not
a very hard task. But I must say right here
that it is not likely that we will have to. re-
sort to these things if the first testing with
closing the opening is carefully made. For
this purpose I must recommend the sticking
plaster again, as being more reliable than the
cotton pellet, or what is generally under-
stood by the artificial drumhead.

If a considerable improvement of the

Communications.

Vol. lxiv

hearing be produced by covering the entire
opening with sticking plaster, my proceed-
ing is as follows. The whole ear is first
thoroughly cleansed with a Listerine solu-
tion, and dried with borated cotton. After
this I apply a 5 or 10 per cent, solution of
cocaine, and let it remain in the ear for
some minutes, after which I apply the borated
cotton again to dry up the whole meatus.
Next I put a cotton plug, corresponding to
the size of the opening, inside of this, to
protect the inner wall of the tympanic cav-
ity, and apply the galvano-cautery burner
to the inner edge of the opening, only
slightly, so as to cause a superficial eschar.
This done, I remove the cotton plug and
apply another soaked in glycerine and dusted
with iodoform powder, on the opening.
Outside of this I apply a piece of oiled silk,
and cover the whole with borated cotton to
make it all air-tight and, so far as possible,
aseptic. By this packing, the membrane is
continually kept in a warm, moist condition,
which is of paramount importance, if we
want a rapid healing to take place. This
proceeding is repeated once a week until the
opening is closed. Sometimes it is well to
stop for a while and then take the treatment
up again.

In some cases I have tried chloride of
zinc and argentum nitricum, but the best
and quickest results I have obtained with
the galvano-cautery. Of course, it is to be
used with care, so as not to produce a larger
opening, and it must, therefore, not be ap-
plied again until reaction has ceased. If,
by these means, closure cannot be obtained,
then we must look for hindrances elsewhere.
It is quite frequent that the manubrium
mallei is drawn inwards on account of the
weaker resistance of the perforated drum-
head, or there is somewhere adhesion be-
tween the edge of the opening and the inner
wall. In the first case, I divide the tensor
tympani, so as to bring about relaxation of
the drumhead, and in the other case I sepa-
rate the adhesion and apply a piece of
iodoformed cotton, to prevent renewed ad-
hesion. It might be inferred that this
procedure is not without its risks. I can
only say that I have never met with any un-
pleasant effects from it, although I have
practiced it for many years.

My excuse for bringing this view of mine
to the notice of the profession must be
sought for in the fact that what I regard as
an easy affair, is generally considered by the
medical profession as unobtainable. As a

rule, an old perforation of the drumhead is
considered a final condition, and, therefore,
it is left to the patient to find out for him-
self whether an artificial drumhead gives
him any benefit or not. It may be that the
patient falls an easy prey to the vendor of
rubber drums, but the medical profession
cannot regard this as a final victory. If the
artificial drumhead wrould compare, for in-
stance, with the correcting glass for a dis-
turbed vision, it might rightly be suggested
to let well enough alone ; but there is no
comparison, as the artificial drumhead some-
times endangers life, which the glass does
not. Very often an acute otitis media sets
in, produced by applying a soiled drumhead
to such a delicate part as the tympanic
cavity. Patients who are compelled to wear
it for the sake of improving their hearing,
may be ever so scrupulous in cleanliness, it
cannot help but that some harm may be ef-
fected, because it concerns a locality which
is not open to investigation and self-control,
and we know for a certainty that it is never
aseptic. Ignorance is bliss here, and has
its analogy in the utter carelessness that is
manifested by the laity in using the ear as a
receptacle for almost anything with which to
relieve an earache or the like. Resorting to
the artificial drumhead as the ultimum refa-
gium, puts a stop to further investigation as
to altered conditions of the ear, brought
about either contemporary with or after the
primary lesion took place. By trying to
close the perforation, we may probably do
more good than the a&tificial drumhead can
ever accomplish.

Last, but not least, there are a large num-
ber of our patients who, for the reason
above mentioned, cannot and ought not use
the artificial drumhead at all." I mean,
children. To them it is an annoyance more
than a benefit, and is, therefore, not much
appreciated. The above mentioned lack of
control makes the use of it especially dan-
gerous in children, not only from their
carelessness, but also from the weaker resist-
ance to irritation in the tissues of a child's
ear.

To prevent any misunderstandings, allow
me to say that only perforations as sequelae
to an inflammation in the membrane pro-
per, or in the tympanic cavity, are thought
of, and not deeper or more serious lesions
with destruction of the hearing bones, in
which closing the aperture would only pro-
tect the middle ear, and would rather impair
than improve the hearing.

Feb. 14, 1 89 1. Communications.

CORYZA.1

BY G. P. SARGENT, M. D.,

BRYN MAWR, PA.

Coryza is perhaps the most common affec-
tion from which we suffer, and the disorder
itself and its accompanying ills are so dis-
tressing at times as to call for preventive
and remedial treatment. It is an acute in-
flammation of the nasal mucous membrane,
and is held by some to be synonymous with
nasal catarrh ; but I look upon catarrh as a
more deeply seated disorder or at least an
advanced stage of this "cold in the head "
—this nasal blenorrhoea.

It is commonly caused by a check of per-
spiration, or when there is no perspiration
it is often induced by a current of cold air
—not infrequently by inhaling cold air, as
when one faces a sharp cold wind while
driving. Cold feet and hands give rise to
it at times, and a writer, in a well-digested
article in Chambers' Journal, some time
since, attributed many cases to a nervous
disturbance. His paper was entitled : "The
Nervous Origin of Colds," and in it he en-
larged upon the fact that local irritation of
nerves at the seat of the trouble or situated
at a distance and acting by reflex influence,
often produced coryza ; and also upon the
fact that it followed emotional excitement
in some persons. Irritating vapors and dust
frequently provoke an attack. A strumous
constitution is especially susceptible; and
there may be in some a hereditary predispo-
sition. It is often present in measles and
shows itself perhaps in its most formidable
character in influenza. It may be epidemic ;
though it is not considered contagious.

The onset of the disorder is usually char-
acterized by a sense of dryness of the nos-
tril, with tickling and a great propensity to
sneeze. The temperature of the mucous
surface is reduced, to be subsequently ele-
vated above the normal standard. The
dryness and tickling are soon followed by a
full flow of mucus. The engorgement is
rapidly increased, and serum exudes, gradu-
ally becoming thick by the breaking down
of epithelial cells and lymph corpuscles.
There is a fulness of the head and dull and
oppressive pain along the frontal sinus. The
nerves of the region most affected being
numerous and highly sensitive,- the irrita-

1 Read before the Medical Society of Montgomery
County, Pa.

I89

tion, itching, sneezing and general discom-
fort become at times almost unbearable. In
severe cases the eyes become suffused, the
tear ducts are occluded, and smell and hear-
ing are much impaired. In yet severer cases,
as in hay-fever and influenza, the eyes be-
come swollen and the skin of the upper lip
and around the nose and eyes even sore
from the irritation of the mucous discharge.

This is a most uncomfortable state of
things, and one who suffers a severe attack
is in a pitiable condition. Happily the dis-
order passes away 'in most instances in a few
days, even without treatment, and thousands
of patients pass through the several stages
without check and without medical advice.

But, unfortunately, many apparent recov-
eries are only partial, and the inflammation
is revived by a slight provocation, establish-
ing a chronic catarrh, which every one
knows is an obstinate, persistent and deplor-
able evil, interfering seriously with the en-
trance of pure air, and leading to debility,
and either directly or indirectly to disease
of various organs, and greatly vitiating the
general tone of the system.

It is especially in hope of averting so se-
rious a disorder as chronic catarrh that cor-
yza should be treated at an early stage;
since one who has suffered an attack and
allowed it to take its course is more liable
to suffer again, and by frequent visitations
becomes debilitated and a prey to other
forms of disease. For how can the blood be
properly aerated if the breathing be inter-
fered with?

We are not often called upon to give ad-
vice in cases of simple colds, the popular
belief being that there is no way of cutting
short an attack, and that it must have its
course of a week or ten days. There are,
however, remedies which, if employed early,
relieve in a night eight cases out of ten*.
Dr. Ferrier, of London, devised a snuff
composed as follows :

U Bismuth subnitrat % vi

Morphinse hydrochloratis gr. ii

Gum. acacia? . . . . * ^ii

This is mixed and reduced to a fine pow-
der, and one-fourth is used in a day.

I think it would be improved if the aca-
cia were left out. It might be further im-
proved by adding a grain or two of aristol ;
but this is more especially suitable for use in
the chronic trouble. Sidney Ringer thinks
arsenic very useful when sneezing is a prom-
inent symptom in coryza. It is certainly use-

190

ful at a later stage, and as a tonic ; and atropia
or belladonna is a good substitute as a remedy
for this symptom, acting more quickly.
The following formula is excellent.

R Quininae bisulph gr. xxx

Ext.^belladonnae
Ext. nucis vom.

Ext. aconit aa gr. iv

Acid, arsenic si gr. ss

M. Et. ft. pil. No. xxx. Sig. One pill every four
hours.

Another similar prescription is this :

R Quininae sulph gr. xviii

Liq. potass, arsenitis TT^ xii

Liq. atropine rr\, i

Ext. gentianoe i

M. ft. pil.. No. xii. Sig. One pill every three, four
or six hours.

In my own practice, I give at once mor-
phia and atropia, making from one to
twenty-four doses out of what is called a
tablet triturate, now made by many drug-
gists, containing one-sixth grain of morphia
and one-one-hundred-and-eightieth grain of
atropia, dissolving it in water — a dose every
half hour, if required, according to the age
of the patient and the stage of the disorder.
The atropia counteracts any ill effect of the
morphia, and usually prevents headache. It
also tends to diminish the secretion of mucus
very decidedly. Both together diminish the
irritation, and calm the nervous disturbance.

Should headache arise from the morphia
or otherwise, a cathartic may be required.
This should be one that is speedy in its ac-
tion, such as a Seidlitz powder, or the head-
ache may be relieved by caffeine — notably
with bromo-caffeine.

If a case of coryza presents itself at a later
stage, when the mucous secretion has become
thickened or dry, I have found a spray of
equal parts of glycerine and rose-water use-
ful, to thin the secretion, the spray being
thrown into the nostrils at frequent intervals.
Glycerine with spirits of camphor is also use-
ful, introduced by means of a quill brush, as
it does not mix well "enough to be easily ap-
plied with an atomizer.

With the morphia and atropia for the first
medication, and with the pills of quinine,
arsenic and belladonna for later treatment,
nearly all cases of simple coryza will be
found to yield in a day or two ; and these
remedies may be placed within easy reach
of persons subject to frequent attacks, and
much trouble and subsequent disease will be
averted.

Vol. lxiv

VOMITING OF PREGNANCY.
BY ENOS T. BLACKWELL, M. D.,

CEDAR VILLE, N. J.

Puerperal vomiting, when severe and pro-
tracted, tests to the utmost the endurance as
well as the patience of the sufferer. She is
obliged to bear not only the inexpressible
horrors of the deathly nausea, but also the
experiences and prescriptions of all her fe-
male friends. The domestic pharmacopoeia
exhausted, she may learn that the disheart-
ening and weakening things she endures
have been declared on high authority to be
extremely beneficial to her, looking to the
conclusion of her gestation. The suffering
woman, who " beareth all things, hopeth all
things, endureth all things," accepts the
promised boon with such philosophy as she
can muster ; and may prove its truth or
falsity, if she survive the dreadful loss of
strength which attends the continuous and
exhaustive vomiting, and the malnutrition
which results; but the physician who is
called on for relief should look beyond the
phenomena exhibited by the stomach, and
not content himself by attempting to placate
that organ through remedies applied to it
alone.

The reflex symptoms, which radiate from
the pregnant womb, and which are largely
due to conditions affecting its inner struc-
ture, may also originate from causes situated
upon its exterior. Should the practitioner
fail, in a rebellious case, to inspect the neck
of the uterus, he might, while discoursing
learnedly on the impossibility of removing
the cause without destroying the fruit of the
womb, and while devotedly applying reme-
dies to the apparent seat of the difficulty,
namely, the stomach, overlook a patent cause
that admits of cure, both signal and speedy.
If we are able to locate a cause upon the
exterior of the uterus which is easy of ac-
cess, and which may be successfully com-
bated by remedies acting on well-known
principles, we shall pursue a more scientific
and rational method than if, satisfied of the
internal origin of the reflex action, we try in
succession the various drugs recommended,
which are largely empirical.

Dr. Llewellyn Eliot, of Washington, D. C.?
whose therapeutic resources have apparently
been directed to the effects of the uterine
irritation as exhibited in. the stomach (Re-
porter, October 8, 1890), rather than
to the cause, which may sometimes be sit-

Communications.

Feb. 14, 1891.

Communications.

191

uated at the cervix uteri, and in given cases
may be seen by means of a vaginal exami-
nation, brings forward a number of cases in
support of the internal use of tincture iodi, a
remedy recommended by Prof. Lasegue, and
tested and endorsed by M. Darthier (Re-
porter, February 8, 1890, from & Union
Me die ale). This appears to be an excellent
remedy for many cases, but time should not
be lost with temporizing measures, and the
patient allowed to drift into extremity before
an attempt is made to allay the reflex symp-
toms by local applications to the neck of the
uterus. • Medicine by the stomach may be
continued, if thought advisable. Two cases
have come under my observation which
illustrate and emphasize this view.

Case 1. March 4, 1886. Mrs. ,

28 years old, married, and one month ad-
vanced in her fifth pregnancy, had had
almost constant vomiting from the date of
conception. Her experience in all her for-
mer pregnancies had been ceaseless vomiting
for the first three months, and excessive sali-
vation. She had been promised by her last
accoucheur that relief would be afforded her
in any forthcoming trouble of that kind.
As related to me, I judged that the relief
was to be obtained by destroying the fruit
of conception. The husband, who called
me, hinted at this procedure. I found the
patient in an extremely discontented, de-
spondent, and rather savage disposition.
She was most forlorn from the incessant
vomiting, and greatly dispirited because of
lack of sympathy, and of any expectation
of help. Her mental alienation and dis-
like of her husband were complete, and she
abhorred his approach. I presented the
claims of the intra-vaginal treatment as
brought forward by Dr. J. M. Halbert, of
Skipworth, Miss. {Medical Bulletin, Vol. v,
p. 105), consisting of iodide of phenol,
or nitrate of silver, fifty grains to an ounce
of water, applied to the neck of the uterus.
Being in despair, she was ready for any pro-
cedure that gave prospect of relief. Exam-
ining through the speculum, I found an
erosion the size of a nickel five-cent piece
upon one side of the cervix uteri, and ap-
plied the silver solution in the strength
directed by Dr. Halbert. Very great benefit
followed the first application. Two days
later, the erosion was again cauterized, and
cocaine, which had been found successful by
Dr. Wm. Duncan in like cases (Reporter,
Vol. lvii, p. 65, from the Lancet), was also
applied to the abrasion. By March 10, six

days from commencing treatment, the re-
covery was so great that she took a journey
to a city ten miles away. The silver solution
was reapplied on March 18, and on March
25 — four applications in all. From this
time the stomach resumed its healthful con-
dition, the gestation being normal to the
end.

November 22, 1890, I called upon this
woman, whom I had not seen since attending
her for the vomiting, four years and a half
before. She informed me that she again
became pregnant a year ago last March, and
that the vomiting commenced immediately,,
with its accustomed atrocity. Her physi-
cian, it seems, had no knowledge of topical
applications for subduing this horrible and
rebellious infliction. The stomach, there-
fore, had to endure a round of remedies
wondrous in their variety, but alike ineffi-
cient. For two months she was confined to
her bed, and recovered only when the usual
immunity succeeded at the end of three
months.

Case 2. July 27, 1889. Mrs. McP., a
young primipara, applied for treatment for
puerperal vomiting. She was given the fol-
lowing :

R Potassii iodidi gij

Aquae f ^ iv

M. Sig. A teaspoonful in hot water, every few
hours.-

She was commended to pop-corn, and
also, I think, to buttermilk, which figure in
the list of empirical remedies. No relief
having occurred, on August 2, I applied the
vaginal speculum, and discovered an erosion
similar to that in Case 1. An application of
the silver solution, fifty grains to an ounce
of water, having been made, great amend-
ment promptly followed. So complete was
the amelioration, that the patient did not
desire further help. Before the month closed
a diarrhoea came on, which resisted ordi-
nary remedies, and persisted to the end of
the gestation. Whether this was due to
uterine irritation transmitted to the bowels,
I know not. Its intractability would seem-
to indicate this.

She did, indeed, think that she had re-
ceived some advantage from cocaine taken
by the mouth ; but, as its use was persisted
in until the cocaine habit was formed, it is
quite improbable that any benefit was de-
rived from it sufficient to compensate for the
' danger incurred.

192

New York Correspondence.

Vol. lxiv

New York Correspondence.

NEW YORK LETTER.

Contribution to the Pathology of Reynaud' s
Disease. — Removal of Hypertrophied Pros-
tate. — Trephining for Epilepsy. — Total
Extirpation of the Larynx. — Artificial
Larynx. — Remarkable Case of Luxation
of the Patella. — Chronic Cervical Adenitis
in Children.

The holidays and the electing of presid-
ing officers for the year, have somewhat
hampered the scientific work at the New
York Academy of Medicine. As of general
interest in New York, however, since last re-
port, may be mentioned a contribution to
the pathology of Reynaud's disease, by Dr.
G. W. Jacobus, read before the New York
Neurological Society. He said that although
-a great deal had been written upon the sub-
ject of local asphyxia and symmetrical gan-
grene since Reynaud first drew attention to
this disease, and very many new cases of the
affection had been described, the knowledge
at the present time of all of its features, ex-
cept, perhaps, the purely clinical ones, was
hardly any more advanced than it was at the
time of Reynaud's writing. Etiologically we
had in a certain sense made some progress, for
now we "realized that other causes than those
which Reynaud believed to be the only ad-
missible ones, might have a supplementary
productive action. As it was recognized
that the symptoms of local asphyxia and
symmetrical gangrene were often due to un-
recognizable states of disordered blood mix-
ture, the author simply touched upon this
point. He said that upon the question of
anatomical nerve disease as a cause of sym-
metrical gangrene there could not be any
uncertainty. That the nerves did exert a
certain amount of influence upon the pro-
duction of gangrene, either indirectly by
affecting a contraction of the vessels, and
thus suppressing the nutrition of the part
(Reynaud) or by producing it independently
of the vascular system, could not be denied.
According to the assertions of Quesnay,
section of the nerves was said to produce
gangrene of those parts in which they took
their course. This assertion had been made
repeatedly since then, but the proofs were
wanting on account of the impossibility of
completely cutting through all the nerves of
a part and leaving the arteries uninjured.
On the other hand a clinical proof of this

dependence was found in the fact that gan-
grene of an extremity occurred, after liga-
ture of an artery, more easily if the nerve
had been injured than if this was not the
case. As stated, in order to make a diag-
nosis of symmetrical gangrene in Reynaud's
sense, we must be able to exclude gross nerve
disease. This could not be done in many
cases. The class of cases which the speaker
dealt with were those which came under the
caption of gangrene, due to pathological
changes in the blood-vessels. It was a sine
qua non for the diagnosis of Reynaud's dis-
ease that the lumen of the vessels should be
free, and that their walls should be found in
a healthy condition, so that vascular disease
might anatomically be excluded as a causal
agency in the production of this affection.
If, with this in mind, we reviewed the vari-
ous cases reported, we should find that al-
though pathological examinations had not
been frequently made, still in a number of
cases in which this had been done, the con-
dition of the arteries did not fulfill the re-
quired obligations. All cases of spontane-
ous gangrene, symmetrical or unilateral,
would require careful attention and exam-
ination. In many cases we would be able to
discover some local change in the arteries of
the affected parts, while in others some gen-
eral affection of the arterial system would
explain the gangrene. Many cases would,
however, always remain in which, no matter
how careful the examination, no such ex-
planatory conditions could be detected.
There were still other cases, which in view
of the fact that many of the so-called cases
of Reynaud's disease were not symmetrical,
and might be ascribed to nerve influence,
which were better explained by the assump-
tion of an obliterative endarteritis. It was
well known that syphilis produced upon the
arteries a periarteritis which gradually en-
croached upon their entire diameter, finish-
ing as an endarteritis and thus narrowing or
even totally obliterating the caliber of the
vessel. It was also well known that many
cases of spontaneous gangrene, resembling
Reynaud's disease in every particular, were
often due to such affection of the arteries.
What was known about the symptomatology
of syphilitic affections of the superficial ar-
teries, as revealed by a study of the few
published cases, was as follows: Two phases
of the pathological changes found a clinical
expression, and obliged us to differentiate a
stage of induration, with preservation of the
lumen of the artery, and one of obliteration

Feb. 14, 1 89 1. New York Correspondence.

193

of the artery with all its consequences. In
the obliterative stage we had symptoms of
ischaemia progressing in extent according to
the seat of the affected arteries and accord-
ing to the difficulty encountered in the es
tablishment of the collateral circulation ; if
the terminal arteries of the extremities were
affected, the disorders would be very marked,
consisting in oedema, slight syanosis, reduc-
tion of temperature, and finally we might
also have gangrene of the parts. If, how-
ever, small arteries were affected whose col-
lateral ramifications could be replaced, then
the symptoms would be transient or entirely
wanting. From a consideration of the vari-
ous data ; from the nephritic as well as from
the syphilitic cases ; we were unavoidably
forced to the conclusion that those authors
who admitted that an affection of the small
arteries, be this artaritis obliterans or other
change, did produce a similar clinical pic-
ture to that found in Reynaud's disease,
herein were right, but that these same authors
were wrong when they contended that a dif-
ferential diagnosis between the two affections
could always be made. The points which
were adduced by the various writers for the
purpose of making this differential diagno-
sis were the following : Gangrene occurred
in some cases of Reynaud's disease in places
where endarteritis obliterans had thus far
never been described. The lesion in many
cases of Reynaud's disease was confined to
the superficial layers of the cutis, and this
never occurred in endarteritis obliterans;
the absence of those etiological movements
which produced vascular disease, as syphilis,
absence of all palpable anatomical changes
in the vessels ; and finally, the occurrence
of symmetrical gangrene in neuropathic in-
dividuals only. That these points were in-
valid and some of them erroneous became
clear when we considered that it was proba-
ble that arteritis obliterans occurred in the
vessels of the skin,' a condition which had
been pointed out by Klotz and Hutchinson.
From these facts we were justified in con-
cluding that the differential diagnosis be-
tween Reynaud's disease and anatomical
disease of the arteries could, in many cases,
not be made intravitam, or in other words,
many of so-called Reynaud's disease were
really cases of arteritis.

Before the Surgical Section, Dr. R. F.
Weir showed a middle-aged man from whom
he had removed a hypertrophied median lobe
of the prostate gland. The patient had been
for a 'long time in the habit of using a cath-

eter, which had at length broken, leaving a
portion of it in the bladder. Symptoms of
stone had subsequently developed, for which
the speaker had performed supra-pubic sec-
tion, and had extracted from the bladder a
good-sized stone, of which the broken cath-
eter had formed the nucleus. On illuminating
the interior of the bladder he had discov-
ered a projection enlargement of the pros-
tate gland which he had removed. The re-
sulting hemorrhage had been checked by
lessening the pressure of the water bag dis-
tending the rectum. The bladder was then
packed with iodoform gauze. The case had
gone on to a complete and satisfactory re-
covery, with entire restoration of the nor-
mal functions of the part. In the event of
his having to do this operation again he
should make use of the tonsillotome in pref-
erence to any other cutting instrument, in
removing the glandular enlargement.

Dr. A. P. Gerster said that it was not al-
ways the cases of operative interference of
the prostate gland which were as. successful
in their issue as that reported by Dr. Weir.
Half the patients in whom the middle lobe
was removed did not recover to such a de-
gree. This was due to the fact that the con-
tractile powers of the bladder were gone.
The removal of the lobe could not restore
the muscle. The operation was not always
a proper one, and great judgment was called
for in the proper selection of suitable cases.

Dr. Weir also presented a man fifty
years of age, who had suffered for a number
of years with frequently recurring epileptic
attacks, resulting from a depressed fracture
of the skull. A primary operation had been
performed which had been of direct benefit,
but as the patient complained of constant
pain, a second one was undertaken, in which
a very extensive flap was raised, and three
buttons of bone removed. These were re-
placed and the interstices filled with bone
drippings. The result of this part of the
procedure was good, firm union with the
exception of a small point of softening at
which pulsation could be felt. The epilep-
tic seizures had been reduced from several
each day to about one a month, and the pa-
tient was able to attend to his business. This
was the usual outcome of all operations for
epilepsy of this character, improvement
might be looked for, but very seldom cure.

Dr. Robert Abbe thought in the class of
epilepsy to which reference had been made
repeated trephining was likely to be of di-
rect benefit. He had operated upon a case

194

New York Correspondence.

Vol. lxiv

about a year ago and had relieved the pa-
tient from an impending condition of insan-
ity in which there had been half a dozen
maniacal seizures a day. It had been six
months before a recurrence had taken place.
The patient was then put in an asylum. Re-
peated operation might have been of signal
utility in this case.

Dr. Willy Meyer exhibited a patient sixty-
five years old, upon whom he had recently
operated, removing the entire larynx, for
epitheliomatous growth. The man was now
wearing one of Gussenbauer's artificial lar-
ynx tubes. As this had only been in place
fourteen days, the patient, although already
able to articulate and make himself under-
stood, could not do so as well as he un-
doubtedly would, by reason of the non-
closure at present of a small part around the
tube, with some escape of air. The speaker
thought that the larynx he had adjusted
would amply meet the needs of a patient of
this age.

Dr. Towjisend then presented quite a re-
markable case. He placed a young colored
girl in a chair upon the platform and baring
her left knee he stated that she had suffered
from what was said to be congenital disloca-
tion of the patella of that joint. As she
grew up the patella would become spontane-
ously dislocated either on one side or the
other whenever she attempted to run. But
this was not all, she was capable also of
causing dislocation by voluntary muscular
effort. As she had been for some time un-
der treatment this power was lost as to the
inner side. He then directed the girl to
effect the dislocation, when to the astonish-
ment of everybody, and apparently without
the slightest effort, she shot the patella to
the outer side of the joint, bringing it back
into position, repeating the performance at
will.

Before the General Session, Dr. A. Jacobi,
in a paper on chronic cervical adenitis
in children, said that the frequency of the
morbid changes in the lymphytics was ex-
plained by the large amount of cells which
formed the bulk of their structure. They
were still similar to the embryonic cells,
increasing and proliferating as rapidly.
Therefore, tumefactions were brought about
very readily. As an intricate network of
blood-vessels penetrated their follicular sub-
stance, they might undergo morbid changes
through the intervention of the blood.
When the latter was the cause of disease,
the whole system of lymphatics was likely to

be affected simultaneously. This was, how-
ever, rare. In the majority of cases only
groups of lymphatics, or single lymph
bodies, were affected. The cause of the
disease must be looked for in the circulating
lymph which, both in normal and abnor-
mal circumstances, was retained and filtered
in the lymphatics. These were not open
tubes, but a fine network of cavities lined
with endothelium. Foreign bodies of any
description floating in the lymph were there
retained and underwent changes. There
were also chemical changes in the lymph
itself which would irritate the lymph body
and provoke disease. Thus it was that most
of *the morbid changes of the lymphatics
were secondary in character. Such changes
were almost always the result of, or compli-
cated with hyperaemia and inflammation.
The lymphoid cell constituents increased in
different ways. Leucocytes were retained
in large numbers, lymph-cells floated in, a
subdivision took place, and the endothelia
and cells were changed into similar or equal
organic particles.

This condition might undergo restitution,
or a lymphatic induration might take place
through nucleae proliferation in the stroma,
and again suppuration or necrosis might
occur. The fibrous induration was the more
frequently met with in the bronchial, trach-
eal, mesenteric, axillary and inguinahglands
than in the cervical. In the inguinal it was
very common and was frequently met with
in this region without any morbid symp-
toms. This change exhibited often a
chronic character from the beginning. The
glands were not always enlarged, but were
white and hard on section, with thickened
capsule, the cellular substance seemed to be
diminished and the gland appeared to con-
sist more or less of connective tissue only.

The suppurative change might be confined
to the gland, at least temporarily, or the
neighboring tissues participate in the pro-
cess at an early period. Small abcesses
originated mostly in the follicular substance,
might prove confluent so as to form larger
abscesses and finally burst or were incised.
Recovery took place by a shrinking process,
by cicatrization, by the formation, when the
larger lymphatics were injured, of a fistula,
sometimes accompanied with lymphorrhoea,
or by dessication, or caseation, or calorifi-
cation. This was the second form of
chronicity. The third form of chronic
adenitis was the caseous, which generally
occurred under the influence of scrofulous

Feb. 14, 1 89 1. New York Correspondence.

195

or tuberculous predisposition. It was usu-
ally found in the cervical, bronchial and
mesenteric glands.

General infection of the glandular system
might act through the blood as in any putrid
and septic invasion, in anthrax, lepra,
leucocythemia and pseudo-leucocythemia,
under the influence of Koch's lymph, in
syphilis, and in enteric fever. In the two
latter, the local irritation resulted in local
glandular affection, by preference. Still
more local was the action of the diphtheritic
virus. The majority of cases of adenitis
owed their existence to a local influence. In
many instances the study of the origin was
single, in others, particularly in cases of long
duration, the connection of chronic adenitis
with its original source was no longer trace-
able. In a child, therefore, of advanced
years, and the adult, the history of chronic
cervical tumefaction might be quite obscure,
in the infant and young child the elucida-
tion of the etiology was generally simple.
The best protection against adenitis in any
of its forms was the preservation of good
general health and the absence of any breaks
in the integument. Traumatisms, insect
bites, erysipelas, and so on would start an
adenitis directly. Pediculi, eczema, or
impetigo capitis would do the same thing,
heal these, and, contrary to the public pre-
judice, most of the glandular noduli and
nodi would disappear. Among other com-
mon causes given by the speaker were many
of the ear and eye troubles, various forms of
zoster, fever blisters and so on. Any con-
dition interfering with the healthy state of
the mucous membrane might give rise to
adenitis. This was especially true with re-
gard to the nose and naso-pharynx. Boring
at the nose, from reflex intestinal irritation
by worms, was likely to set up a chronic
adenitis. Simple douches of salt and water
were the best treatment for these nasal irri-
tations. There was no better illustration of
the way an adenitis would come and go in
the presence of proper treatment than in
nasal diphtheria. As fast as the glands
swelled, just so rapidly would they diminish
under the influence of cleanliness and disin-
fection, while, if not so reduced, their in-
fection would lead to death or chronic
changes. Cracked lips permitted the inva-
sion of microbes and the development of
adenitis. Epithelioma, stomatitis of every
form, the denuding of the surface by a burn,
or by hot food, were all causative. Abra-
sions of the surface of the tongue through

catarrh or inflammation, or the surface le-
sions of infectious diseases might all provoke
adenitis. Drugs would also produce the
same effect. Chronic bronchitis resulted in
swelling of the mediastinal glands ; their
intimate connection with the lower tier of
the cervical affected these. This observation
could be made in the chronic bronchitides
of the tubercular and rachitic babies in
many instances. Acute pulmonary diseases
exhibited similar results. The vaso-motor
changes of the face, its flush lasting for days,
generally unilateral, on the side of an acute
pneumonia were well known, not so com-
monly known, however, as the tumefaction,
of cervical glands in cases of pleuro-pneu-
monia of the upper lobe. This disease had
an immediate influence upon the intra-thora-
cic lymph-bodies adjacent to the apices, and
through them on the subadjacent cervical
lymph-bodies. '

While touching upon the question of
diagnosis, the speaker said that the sensa-
tion of fluctuation in glandular swellings
was often misleading. Large glands might
be mistaken for sarcomata and vice- versa.
These latter pseudoplasms yielded a peculiar
apparent fluctuation, though there might be
no cystic complication. This semi-fluctua-
tion was almost characteristic for sarcomata
in every region. It was always a difficult
thing to determine the presence of pus dur-
ing the stages of initial softening. Still less
was there absolute certainty in every case of
the presence or absence of a malignant na-
ture in a large glandular swelling. This
difficulty was made very apparent by the
variety in the morphological diagnosis by
the morphologists. The gradual increase in
size, however, of a tumor, without soften-
ing, spoke for the probable malignancy of
the growth. The presence of more swell-
ings of the same character on other parts of
the body, might prove the existence of
Hodgkin's pseudo-leucocythemia, and the
same with enlargement of the spleen or liver
and the characteristic changes in the blood
might indicate leucocythemia.

— At the Eiffel tower a steel ball weigh-
ing 211 pounds is, by a bronze wire 380
feet long, suspended from the second plat-
form, and allowed to swing near a layer of
sand. Under the ball is a style tracing a
mark in sand at each oscillation. The ap-
paratus serves as a popular demonstration of
the earth's rotation.

196

Periscope.

Vol. lxiv

Periscope.

Simple Medication for Children.

Under this title Dr. Charles Warrington
Earle, of Chicago, made some admirable
remarks at the meeting of the American
Pediatric Society last year. From the re-
port of his paper in the Archives of Pedia-
trics, January, 1891, the following extracts
are presented.

I believe in medication always, when
needed, but at the same time belong to that
class of physicians who believe it quite as
much my duty to say to people, " You need
no medicine whatever," if such be the case,
as to prescribe a heroic dose when it is in-
dicated. When, however, good diet, a
better hygiene, more air and sunlight will
not suffice to save, and it is necessary to give
medicine, we owe it to our patients, espe-
cially our little patients, to prescribe a drug
or drugs so that they shall be cured not only
quickly and safely, but, if possible, pleas-
antly.

In the first place, many cases to which we
are called need no medication whatever ;
that is especially true of first visits. There
is a little irritative fever, a slight indigestion,
a trifling nervousness, a few more bowel
movements than usual, or the mother simply
imagines in her solicitude that the baby is
threatened with something. Many condi-
tions similar to these are frequently seen,
and they will recover — correct themselves
without medicine ; indeed, better without
than with medicine. The diagnosis is fre-
quently made by a parent, and the doctor
is summoned to prescribe for a fever or for
malaria, or for worms, and before he sees
the little patient he has devised a combina-
tion of drugs for it. Something to reduce
the pulse ; to correct the secretions ; some-
thing to regulate the excretions. How much
better it would be for this little one to give
it nothing, for in many cases the patient
will be entirely well in a few hours.

I do not advise against the administration
of medicines when they are indicated ; I
know that by the judicious use of a drug, or
drugs, diseases may be modified, a convul-
sion possibly averted. But the indication for
its use should be clear — we should not give
a drug simply to make a show of prescribing.

In the second place, when a single drug is
indicated, we find in many cases too many
prescribed, and a child's appetite destroyed
and its nutrition impaired by the procedure.

This does not apply to diphtheria, or any
other disease which, at times, is local, and
should be combated with vigor and prompt-
ness and frequency in order to keep it from
becoming a general disease ; but it does ap-
ply to that vast category of complaints
where it is absolutely necessary to improve
nutrition.

Again, take the eruptive fevers during the
first stage : why give a little aconite or bella-
donna to reduce the fever ? We want some
fever ; we all prefer a temperature of 1020
to one at 980. Why unload the portal cir-
culation and, in so doing, probably irritate
to a greater degree the already irritated mu-
cous membrane of the alimentary canal ?
Look out for the throat in scarlet fever,
which here will give more trouble than any
other organ (excepting possibly the kidneys),
and for the lungs in measles. This should,
it occurs to me, be the rule in general. Do
not waste time and annoy the patient by
doctoring a symptom ; attack the disease.

And then in convalescence — how much it
is retarded by the reckless administration of
drugs. After a baby has passed through a
fever, or some disease of the lungs, it does
not need something to act on its liver or
kidneys, or to clear up its tongue which is
quite frequently normal when a little coated >
or some alkali to correct a fancied acidity ;
but it does need something to eat, and it
can't eat as long as the stomach is filled with
nauseous medicines. This condition is well
illustrated by a case I saw late in the year
1889. The child, around whom all the love
and devotion and nonsense of a young
father and mother clustered, had the
' ' grippe. ' ' Its temperature had been rather
high and the bronchial catarrh really se-
vere. The attending doctor had diagnosti-
cated pneumonia, and for this I was sum-
moned. After a few days it began to
convalesce, and I left it with the under-
standing that some restorative medicines,
probably the hypophosphites with a little
pepsin and possibly a minute dose of tinc-
ture of nux vomica, was to be administered.
In two days I was recalled and was informed
that the appetite was poor, the pupils di-
lated, the head was being thrown from side
to side, and the doctor and parents were sure
that cerebral congestion, if not meningitis,
was present. By actual count that child
was taking nine different drugs, hardly one
of which was indicated. It was having bi-
carbonate of sodium, iodide of potassium,
muriate of ammonia, tincture of aconite,

Feb. 14, 1891.

Periscope.

197

tincture of belladonna, tincture of camphor,
and a little opium, submuriate of hydrargy-
rum, to which should be added camphorated
oil externally, supplemented and strength-
ened by a plaster of belladonna ointment.
Is it any wonder that that child could not
eat, that its pupils were dilated ? The won-
der to me is that it was alive. I solemnly
declare that I have been more alarmed for
fear that some doctors would kill their little
patients with drugs than that the cases would
terminate fatally from the disease.

We now come to pleasant medication. Of
course, this is' not, by any means, an easy
task; sometimes it is impossible without
sacrificing the usefulness of the drug. With
care, however, we can do much ; we can
avoid prescribing large mixtures, can stop
giving tablespoonful doses, and, in many
instances, give our tinctures in water. Hap-
pily the custom of ordering four, six and
eight ounce bottles of medicine has nearly
ceased. It should be stopped entirely, ex-
cept in those cases where tonics and cough-
mixtures are given, when it is necessary to
see a patient but seldom. In acute sickness
it is usually quite all that is needed to pre-
scribe one-ounce and occasionally two-ounce
mixtures. In the administration of most of
the tinctures, particularly aconite, veratrum,
digitalis, as well as Fowler's solution, etc.,
where the dose is from a fraction of a drop
to one or two drops, it is best for the young
physician to carry the drug and measure out
enough at" each visit for the coming twenty-
four hours. This gives a pleasant medicine,
and it is also economical, and to young
practitioners it is a custom which will make
them friends. It is good practice, too, for
physicians to always be ready to give the
first dose of medicine; it may not be much,
but it convinces the people that you are
ready for emergencies ; this I say more par-
ticularly to those young in the profession.

With a little care we can treat a case
running through several days, if not weeks,
with but little display of drugs. Nothing
makes the people appreciate the expensive-
ness of a doctor so much as, at the end of
two weeks' sickness, having a tableful of
bottles partly emptied. And nothing dis-
gusts the patient to such an extent as to
witness the doctor every morning commence
to write his usual two or three new prescrip-
tions ; a part only, at most, will be taken,
the remainder to go to make up the tableful,
which is to be removed at the conclusion of
the sickness.

Detection of Biliary Matter in Urine.

The American Druggist, December, 1890,
says that according to Dr. Adolph Jolles, of
Vienna, who has made a comparative study
of the various bile reactions so far proposed,
the most reliable tests are those proposed
by'Rosenbach and by Huppert. Rosenbach's
test is- as follows : A piece of filtering paper
is wetted with the filtered urine, and a
drop of nitric acid then applied to it. Col-
ored rings will form about the drop of acid.

Huppert' s test : Precipitate the urine with
milk of lime. Exhaust the precipitate with
alcohol containing sulphuric acid, and apply
heat. A green color is developed. \

Dr. Jolles has found that both tests^ are
capable of improvement. In the case of
Rosenbach's he recommends the following
modification : Filter a large quantity of the
urine to be tested through pure, white filter-
ing paper, then apply to the inside of the
filter a drop of concentrated nitric acid
containing some nitrous acid, and slowly
pass the funnel containing the filter three or
four times over a Bunsen burner. After a
few minutes observe the rings which will
have formed around the drop. If they
are colored green, bile pigments are present.
The application of a gentle heat reveals even
traces of these pigments. The bright-green
ring shows the presence of biliverdin.

The reliability of Huppert' test depends
mainly upon the strength of the milk of lime.
As the author of the test failed to specify
it, Dr. Jolles made experiments, and found
that the most suitable strength was about
1 per cent— that is, a milk of lime contain-
ing about 10 grams of lime in the liter of
water. The test is best performed as
follows :

About 8 to 10 c.c. of the urine are mixed
with an equal volume of the milk of lime,
the mixture is shaken, and the precipitate
separated by filtration.

So far the American Druggist describes
the test correctly. For the rest, we give the
statement to the Reporter of Dr. John
Marshall, of the University of Pennsyl-
vania. Dr. Marshall says :

"The precipitate from icteric urine is
yellow, from normal urine it is white ; and
from urine containing chrysophanic acid, it
is rose-red. The precipitate is now placed
in a beaker and boiled with alcohol contain-
ing a couple of drops of dilute sulphuric
.acid, and then the mixture is filtered. In
case biliary coloring matter is present, a

198

Periscope.

Vol. lxiv

beautiful green coloration is imparted to the
liquid ; while from normal urine the liquid
remains colorless and in the presence of
<;hrvsophanic acid it becomes orange-yel-
low."

Leprosy in Colombia.

An official report on the rapid spread of
this disease is contained in a recent number
of the Revista de Higiene de Bogota. It is
the result of systematic medical inquiries
throughout the Republic regarding the
causes and phenomena of the disease by the
Central Junta of Hygiene of Colombia.
The propositions of this medical commis-
sion are of interest in respect of the primary
steps of relief that will be recommended to
the executive and legislative departments of
the government: 1. To solicit the next
Congress to pass a law providing for the
isolation of individuals affected with leprosy
and elephantiasis. 2. To establish a special
'tax to defray the expense of observing the
method of propagation of the disease and
for the erection and maintenance of lazaret-
tos ; and to include this tax in the central
budget of the government. — New York
Medical Journal, December 6, 1890.

Sunflower Plantations as a Prophy-
lactic against Malaria.

In the Vestnik Obshtchestvennoi Highleny,
Siidebnoi 1 Praktitcheskoi Meditziny, Septem-
ber, 1890, p. 104, Dr. I. D. Imiiidzinovitch,
of Kopal, Sem'iretch'ie, issues an emphatic
appeal in favor of an extensive cultivation
of the sunflower (Jlelianthus annuus) in ma-
larial regions. The author's observations
fully confirm the statements by Maury, Van
Alstein, Martin, Valentin and A. Stiipin,
according to which the beautiful plant pos-
sesses an extraordinary power of draining a
malarial soil, absorbing and destroying the
malarial miasms and thus preventing marsh
fevers. He adduces the following facts
which certainly deserve every attention of
sanitarians. The Kopal district, in which
he practices, belongs to typical abodes of
endemic malarial fevers. In certain villages,
however, inhabited by Ukraine (South-Rus-
sian) emigrants who extensively cultivate
the sunflower for industrial purposes (for
obtaining the sunflower oil, which is largely
used as a food article all over Russia) ma-
laria is almost unknown — and that notwith-
standing the circumstance that the said vil-
lages are situated in exceedingly low and

marshy localities. Meanwhile, in all other
parts of the district — including all settle-
ments in the neighborhood, inhabited by
Cossack*s who do not cultivate the sunflower,
but otherwise live under exactly the same
conditions as the Ukraine planters — marsh
fevers of all varieties are raging to an ap-
palling extent.

Treatment of Erysipelas.

The Lancet, January 10, 1891, says that
an elaborate research, clinical and bacterio-
logical, has recently been published by Pro-
fessor Nussbaurri's assistant, Dr. Julius
Fessler, on the treatment of erysipelas by
ichthyol, a plan which has been for some
years extensively adopted in Munich. From
laboratory experiments it was evident that,
though ichthyol has only a slight effect in
preventing the development of staphylococ-
ci, it has a very potent deterrent influence
on the multiplication of streptococci, and
it is well known that it is the latter kind of
bacteria that are the cause of erysipelas.
The method of treatment consists mainly of
rubbing a strong ichthyol ointment energetic-
ally, and for ten minutes at a time, into the
affected surface and in its neighborhood
ichthyol in the form of pills may also be
given internally. Where there is a wound
it must be very carefully disinfected, and
an antiseptic dressing applied. The results
of this treatment as compared with ordinary
methods are embodied in several instructive
tables. From these it appears that while
the mean duration of the cases treated by
other methods from 1880 to 1888 was about
twelve days, in no single year falling below
nine days, the cases treated by ichthyol from
1886 to 1888 presented a mean duration of
under seven days, while in the first half of
1889 it fell to 5.6 days.

Resection of the Liver.

On December 8, Professor Iginio Tansini,
of Modena, performed total extirpation of
a hydatid cyst of the liver, at the same time
excising a portion of that organ. There
was very free hemorrhage from the large cut
surface of the liver, which was controlled
by catgut ligatures. The wound in the liver
was closed by means of sixteen sutures,
partly silk, partly catgut. The operation
was followed by no rise of temperature, and
the patient (a woman) was quite well in less
than a fortnight. — British Med. Journal.

Feb. 14, 1891.

Editorial.

199

THE • '

MEDICAL AND SURGICAL

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VARICES OF THE OESOPHAGUS.

Vomiting of blood is a common symptom
in cirrhosis of the liver. Most writers on
the subject, ascribe it to capillary oozing,
while some, as Bartholow, have met with
ulcers opening into veins near the pyloric
orifice of the stomach. In a number of
cases, however, no lesion has been discov-
ered post-mortem to account for the hemate-
mesis that occurred during life. It is as-
serted by Mr. T. Stacey Wilson and Mr. J. R.
Ratcliffe, in a paper on GEsophageal Va-
rices as a Cause of Hematemesis in Cirrho-
sis of the Liver, published in the British
Medical Journal, December 27, 1890, that
a varicose condition of the veins of the
lower part of the oesophagus is a very com-
mon cause of hematemesis in cirrhosis of
the liver. When one bears in mind that the
oesophagus is not usually examined at autop-
sies, the fact that comparatively few cases in

which this condition has been found have
been reported is easily accounted for, and
does not militate against the assertion re-
ferred to.

It is well understood that, as the liver
shrinks through the contraction of the inter-
stitial tissue which characterizes cirrhosis, the
radicles of the portal vein become narrowed
and even obliterated, the result of which is
dilatation of the portal vein and its sources.
Now the blood which is thus prevented from
passing through the liver must seek some
other channels by which to reach the vena
cava and the heart — the collateral circula-
tion becomes dilated to accommodate it.
The nature of the circulation around the
lower end of the oesophagus, as Mr. Wilson
and Mr. Ratcliffe say, is such as to admit of
an intercommunication between the blood
and the portal vein, on the one hand, and '
that of the general systemic veins on the
other. For the veins of the cardiac end of
the stomach belong to the portal system,
while those of the oesophagus belong to the
system of the azygos and interior vena cava.
Thus the capillaries in the mucous membrane
at the cardiac orifice of the stomach are
continuous with both systems. This can be
proved by means of injections. Now the
blood from the cardiac end of the stomach
is normally carried to the liver by the coro-
nary vein ; but when the passage of portal
blood through the liver is hindered, the
blood finds an escape through the oesopha-
geal plexus of veins formed by the coronary
and the vasa brevia of the splenic vein — and
there is, therefore, to a greater or less extent,
a reversal of the normal flow in the veins
mentioned, but mainly in the coronary vein.
From the oesophageal plexus the blood finds
its way to the heart through thejeft inferior
phrenic vein, which opens into the left renal,
and so it goes into the inferior cava ; and
through a number of small veins which run
on the surface and in the substance of the
diaphragm, and enter the cava as it passes
through the diaphragm.

The oesophageal plexus already mentioned

200

Editorial.

Vol. lxiv

is external to the muscular coat of the oesoph-
agus, but there is another plexus beneath
the mucous coat, which also becomes enor-
mously dilated under similar conditions, and
is of more clinical significance than the for-
mer. But enough has been said to show how
these veins at the lower end of the oesopha-
gus become dilated and so help to relieve the
congestion of the portal system and prevent
dropsy. It only remains now to mention,
very briefly, that Mr. Wilson and Mr. Rat-
cliffe report five cases which tend to prove
that hematemesis in cirrhosis is produced by
ulceration of one of these varicose veins.
In three of the cases in which hematemesis
occurred, and in one of melsena, there were
three that showed distinct ulcers into the
veins before injecting, and in the fourth
there was an erosion over a thrombosed vein.

In the fifth case there had been no hema-
temesis and no melaena, and the most care-
ful examination failed to show any ulcera-
tion. Ascites was absent is the cases which
showed the most marked varicosity.

To complete this subject, as far as it can
be completed at present, we must refer to an
extremely interesting and beautifully illus-
trated paper by Dr. Maurice Letulle, in La
Medecine Moderne, November 20, 1890.
This author maintains that cirrhosis of the
liver is not the cause of varices of the oesoph-
agus, but that this condition is secondary
to the effects of alcohol on the veins which
first receive it — the mesenteric and their
branches. These become chronically in-
flamed, thrombosis occurs, *and subsequent
dilatation of the collateral circulation, in-
cluding the oesophageal veins. A case which
seems to bear out the view indicated is
reported, and a very complete summary of
the literature given.

Whether varices of the oesophagus are sec-
ondary to a cirrhosis of the liver or to an
alcoholic phlebitis of the veins forming the
portal system, probably cannot be decided
now. But as there is no dispute that the
hematemesis which occurs in these cases is
from dilated "veins, the impropriety, from a

therapeutic point of view, of attempting to
check the bleeding by giving ergot and
other agents which constrict arterioles and
thus force more blood into veins, becomes
manifest. Nitrite of amyl, as suggested by
Dr. Saundby, would meet the requirements
much better, through its action in dilating
arteries and so permitting less blood to pass
into the veins. It is evident, also, that the
oesophagus must be kept at complete rest,
all efforts at swallowing, even of fragments
of ice, being prohibited.

EXPLORATORY PUNCTURE OF THE
FEMALE PELVIC ORGANS.

In years gone by, when the mortality of
abdominal section as then performed was
enough to appal even a stout heart, the ne-
cessity of making an absolutely exact diag-
nosis was far more important than it is at
the present time. Then the advantages of
a proposed operation had to be weighed in
the balance against a prospective mortality
of seventy- five, fifty, or finally twenty-five
per eerit. Hence it was justifiable to oper-
ate only for conditions in themselves ne-
cessarily fatal, and to select the most favora-
ble cases. The use of the aspirator was
considered to be a most desirable way
of differentiating between various pelvic
growths. Experience showed, however, that
the information gained by the use of the
aspirator was often far from satisfactory,
and that even after its use a positive diagno-
sis was often impossible. Moreover its use
was not free from danger. With the intro-
duction of modern aseptic surgery, the dan-
ger attending simple exploratory abdominal
section became so slight that surgeons have
employed this method of diagnosis in ob-
scure cases, affording as it does at the same
time an opportunity to effect a cure. Ex-
ploratory puncture has fallen more and more
into disrepute — being regarded as an un-
certain method of diagnosis at the same
time being more dangerous than exploratory
abdominal section.

Feb. 14, 1 891.

Book Reviews,

201

At a recent meeting of the New York
Academy of Medicine, Dr. G. M. Edebohls
read a paper in which he gives his experi-
ence with exploratory puncture of the fe-
male pelvic organs, and attempts to make
the method again popular with the profes-
sion. He prescribes an elaborate technique :
full antisepsis, outlining and fixing the mass
to be punctured, and puncture with the as-
pirator syringe from the abdominal surface.
Seventy cases are reported in which the
method was employed without untoward re-
sults. The author advises that the method
be used only by the expert, lest harm rather
than good result. In the discussion, in
which Coe, Dudley, Boldt, Murray, Jewett
and others took part, the method met with
decided opposition on the ground that it is
a question whether it is right to expose a
patient to the danger of puncture of the in-
testines, with consequent peritonitis and
probably death, where it is possible to secure
such good results from abdominal section if
a diagnosis cannot be made without an ex-
ploratory operation of some kind. This
opinion is undoubtedly in accord with the
sentiment of to-day. If it be possible to so
outline a mass as to be able to fix it with the
examining fingers for exploratory puncture, it
should be possible to form an intelligent opin-
ion as to its nature. It is the " masses " which
cannot be outlined, definitely, and which
consequently are not adapted for exploratory
puncture, concerning which there will be
the most doubt ; which doubt, in proper
cases, must be cleared up by abdominal sec-
tion. Finally, it is to be hoped that the
method proposed by Dr. Edebohls will
never become popular, as its possibilities
for harm far outweigh its possibilities for
good.

ATLANTA MEDICAL AND SURGICAL
JOURNAL.

In its January issue the Atla?ita Medical
and Surgical Journal expresses the great
pleasure with which it appears .before its
readers free from " inserts," or pages of

advertising interspersed among its pages for
scientific matter ; and the Reporter ex-
presses also a pleasure that so admirable a
contemporary has thus emancipated itself,
The scientific and ethical standing of the
Atlanta Journal is so high, and it has been
such an exponent of honest medical journal-
ism, that we congratulate it and the section
of the country which it represents upon the
improved appearance and more satisfactory-
standard to which it has advanced.

Book Reviews.

I Any book reviewed in these columns may be obtained upon
receipt of price, from the office of the Reporter. J

THE PRACTICE OF MEDICINE; OR, THE
SPECIFIC ART OF HEALING. By I. J. M.
Goss, A. M., M. D., Professor of the Practice of
Medicine in the Georgia Eclectic College of Medi-
cine and Surgery, etc. 8vo, pp. xxix, 569. Chicago s
W. T. Keener, 1888. Price, $5.00.

We find it difficult to review this book and do full
justice to our readers and to Dr. Goss. The latter ap-
pears to think that remedies should be prescribed accord-
ing to the pathological indications in each particular
case. "The old rule of treating disease by name . . . has,'*
he says, " proved a blighting curse to the unfortunate
sick." He is also a believer in the doctrine that there
is a direct or specific affinity of remedies for certain
organs, tissues or parts. Fie seems to believe, to some
extent, in Hahnemann's law of similars, but he refers
to the latter's belief that dilution rendered medicines,
more potent as "the vague chimera of this great man."

The actual value of the book, judged by the scientific
standards of the day, is not great. It is scarcely more
than a compend, in which diseases are not grouped in
an orderly manner, and in which undue prominence
is given to mere symptoms. For example, the title of
Chapter IX is "Fevers : the Exanthemata," and the first
disease considered is " Malarial Hematuria." Whoop-
ing-cough is considered under diseases of respiratory
organs, impotence under diseases of the testes, and
spermatorrhoea and ' onanism" (so Dr. Goss mis-
calls masturbation) under diseases of the prostate,
The author, as was to be expected, devotes most space
to treatment. The value of many of his remedies we
cannot pretend to speak of, but we fear some of his
statements must be accepted with caution. In speak-
ing of the treatment of phthisis, he says that, in 1862;,
he gave to a patient who was bed-ridden and in the
advanced stage of phthisis, " the larger portion of both
lungs " " filled with tubercles," hypo-phosphites,,
ptelia and euonymus. The patient is said to have
mended from the first week or two, finally recovered,
and to be now a " living monument " of the efficacy of
the above remedies. Dr. Goss adds that he has
recently treated several cases with like success. It
may be that his diagnosis was wrong, or that in the.
lapse of years his memory has made the gravity of
the case appear greater than it really was.

The character of the book is perhaps well illustrated
by the section on diabetes mellitus, which occupies

202

Correspondence.

Vol. lxiv

only a little less than two pages, two-thirds of which is
given to treatment. The author says he cured a case of
this disease by giving the patient thirty drops of fluid
extract of rhus aromatica three times a day for several
months. The urine of this patient yielded, upon
evaporation upon a slip of glass over a lamp, " a large
percentage of molasses."

The book as a whole is an odd mixture of good
and bad, and it is difficult to separate one from the
other. We do not think it of any value from a
scientific point of view, but are willing to believe that
many of the remedies it recommends, which are
used almost exclusively by so-called Eclectic and
Homreopathic practitioners, may be very useful.

A CLINICAL STUDY OF DISEASES OF THE
KIDNEYS. By Clifford Mitchell, A. M.,
M. D. 8vo, pp. xii, 431. Chicago: W. T. Kee-
ner, 1890.

The author presents a large amount of useful infor-
mation in this book in such a way that it is easy of
appropriation by beginners. His statements regarding
diagnosis and prognosis are, in the main, correct and
judicious. We think, however, he is wrong in look-
ing upon large tube casts as occuiring. especially* in
chronic nephritis ; large epithelial casts are common
in acute nephritis. The granular casts depicted by the
author are far too black and dense ; they would be
taken by any one, if seen in the urine, for blood casts.
The object figured on page 70 as an epithelial cast is
not a cast at all ; it has no body, and is merely a line
of epithelial cells.

There is much of value in the parts of the book de-
voted to therapeutics. Standard authors on renal dis-
eases are quoted freely, and so are Homoeopathic
writers. The author appears to be truly catholic in his
therapeutics. This fact adds considerably to the
interest of the volume. Practitioners of so-called
eclectic medicine will probadly find Dr. Mitchell's
book very much to their taste.

TUBERCULOSIS, OR PULMONARY CONSUMP-
TION: ITS PROPHYLAXIS AND CURE BY
SUR ALIMENTATION OF LIQUID FOOD. By
W. H. BURT, M. D., Author of Characteristic
Materia Medica, etc. Small 8vo, pp. 223. Chi-
cago : W. T. Keener, 1890.

The author of this book, having noticed that it is
possible to reduce the weight of a fat person by re-
stricting his use of liquids and carbo-hydrates, was
struck with the idea that abundance of water with
carbo-hydrates might cure all wasting diseases, espe-
cially tuberculosis. He states in his introduction,
from the results of his tests, that superabundance of
liquid food, which he calls " .suralimentation," when
used in the first and second stages of phthisis, will
enable the physician to cure more than fifty per cent,
of the patients that would have to die with the best
methods known to medical science up to the present
date. After this astounding statement, we are sur-
prised to find the author admit that, in the third or last
stage, it will give only temporary relief. Under the
etiology of tuberculosis we find the following : " To
me its neural origin is as plain as any fact in path-
ology : its real cause being a debility pareses (sic), or
neurasthenia of the organic nervous system.". The
sort of proof which appears to satisfy the author may
be judged from the following statement : " The
strongest argument that can be used against the ba-
cillus theory is this : cod-liver oil has cured thousands
of cases of phthisis. The attenuated homoeopathic

remedy has cured many thousands of cases, and the
suralimentation of liquids have (has) cured many
cases." As this statement stands, it would appear
that the attenuated homoeopathic remedy has been
more efficient than either cod-liver oil or " suralimen-
tation." Then why not use it, and why not make its
virtues known, 'rather than those of a less-efficient
remedy ? But the truth is, quite apart from the truth
or falsity of the bacillus theory, that no remedy at
present known to science has, of itself, cured a single
case of pulmonary phthisis. The most that cod-liver
oil or any other food can do is to improve the condi-
tion of the patient and help him to overcome the dis-
ease.

To conclude — the book is a mixture of sense and
nonsense which is not worth reading.

CORRESPONDENCE.

Double Opening into Womb.

To the Editor.

Sir : Mrs. D before she was married

fell from overhead in a barn, landing on her
feet on the barn floor. As a result she had
procidentia uteri, for which she was treated
by different physicians.

She wore a pessary — what kind she does
not know — but so long that she says it
had to be removed on account of ulceration
produced.

She first consulted me when pregnant and
threatened with miscarriage in 1888, and
then 1 found on examination that she had
an artificial opening into her womb at the
juncture of the neck with the body poste-
riorly, which would admit the points- of my
index and middle lingers. During her mis-
carriage and in her confinement two weeks
ago I found it no particular obstruction to
labor, though it caused a good deal of anx-
iety.

The miscarriage and confinement cases are
as follows. On December 22, 1888, 1 was

summoned in the night by Mrs. D for

uncommon cramps, as she called it. On ques-
tioning her, I ascertained that she was preg-
nant, and gone four months. On examina-
tion I found that she had all symptoms of
miscarriage, and I also found that she had a
second opening into her womb, from which
membranes were protruding, it being dilated
very much. I administered a full dose of
fluid extract of ergot, and had no difficulty
in delivering her of the product of concep-
tion, the placenta and the membranes. She
made a speedy recovery. I suggested oper-
ation, but she would not consent.

In course of time she became pregnant a .
second time, and after having gone four

Feb. 14, 1 89 1. Notes and

Comments.

203

months she consulted me for symptoms of
another miscarriage. I administered ano-
dyne and she went to term.

On the night of December 4, 1890, I was
again summoned, not for cramps but, as she
then very well knew, with symptoms of labor.
On examination I found the artificial os
dilated as large as a silver dollar, while the
natural os admitted only my index finger.
In vain I tried digital dilatation.

Labor progressed, with a head presenta-
tion, but disproportion between it and the
maternal parts prevented termination by nat-
ural means. I administered chloroform and
applied the forceps and delivered the woman
of a big boy baby through the artificial os
uteri.

The mother made an uncomplicated re-
covery.

The womb and all maternal parts assumed
their natural proportion as before delivery,
no tear occurred in the neck of the womb.

This case I report to ascertain whether
there are any more cases like this.

Yours truly,

A. T. Welker, M. D.

Collomsville, Pa.

Notes and Comments,

Koch's Lymph.

The New York Med. Journal, January 17,
says : It seems that Koch was guided to
his discovery by observing the action of
tubercle bacilli, living or dead, on tubercu-
lous and non-tuberculous guinea-pigs. In
the healthy animal an inoculation of the
pure cultivation gives rise, after a period of
incubation varying from ten to fourteen
days, to a hard nodule, which soon breaks
down into an ulcer and persists until the
animal dies. When, however, a guinea-pig
already tuberculous is thus inoculated, no
nodule forms, but the superficial tissue at
the place of inoculation becomes necrosed
and falls off. Injections of a quite dilute
glycerin infusion of a pure cultivation cause
the animal's condition to improve. Evi-
dently, having got thus far in his observa-
tions, Koch was unable to overlook the ob-
vious suggestion that even dead bacilli, or
at least a solution of some of their constitu-
ents or products, contained something that
might be made available as a drug and pro-
duce the same effect. It was then, therefore,
a comparatively simple matter to arrive at

the production of the curative liquid now
in use. We see no reason why it should not
now be prepared in any well-equipped bac-
teriological laboratory, and thus the restric-
tion heretofore put upon its general employ-
ment be ended. In the absence of a more
detailed account of its preparation than Pro-
fessor Koch gives, it may, we think, be
assumed that any person who would consider
himself conversant enough with bacteriolo-
gical methods to attempt the work of jpro-
ducing such a liquid would not, even with-
out a hint as to the steps in the process
necessary, have been in the least likely to
produce an agent more dangerous than the
Koch liquid itself. But Professor Koch
feared such an occurrence when he first
promulgated his method of treating tubercu-
losis ; and his judgment was deferred to by
the medical profession. He now brings up
in support of his previous secrecy the argu-
ment that the less the clinicians knew
about the nature of the liquid the more un-
biased would they be in their observations
of its action. This strikes us as odd, but
there may be men so constituted. At all
events, we are glad that the nature of the
remedy has now been made known. The
question of its curative action is still far from
being settled.

[The observant reader will observe that
Koch has not yet told just how he prepares
his lymph. The whole affair is much more
marked by forbearance on the part of the
profession than by scientific candor on the
part of Koch. — Editor of Reporter.]

Mutual Aid Association.

The recent meeting of the Philadelphia
County Medical Society, at which the
claims of and objects of the Mutual Aid
Association were especially presented, was
an occasion of unusual interest and awakened
much enthusiasm. Addresses were made by
Drs. Gouverneur M. Smith and Henry Tuck,
of New York, the former and present incum-
bents of the presidential chair of the New
York Society for the Relief of the Widows
and Orphans of Medical Men, and by Pro-
fessors Keen, Pepper, Willard and others of
this city. A brief memoir of Dr. Henry H.
Smith, the founder of the Association, was
read by Dr. Benjamin Lee. Sixteen of
those present followed the example of Pro-
fessor Keen in enrolling themselves as mem-
bers, or increasing the grade of their mem-

204

Notes and

Comments.

Vol. lxiv

bership. The total addition to the Benevo-
lent fund thus made will amount to about
$1,300. On the adjournment of the busi-
ness meeting a reception was extended to
the guests from a distance, at the University
Club.

The following extracts from Dr. Smith's
address will convey an idea of the scope of
the work of the New York Society.

" Our Society has, for a number of years,
proved a blessing to its beneficiaries, and
has been remarkably successful in accumula-
ting a financial capital of $172,180.58,
which insures a continuance of a laudable
work in the future." After emphasizing
the somewhat remarkable fact that the largest
contributors to and most earnest supporters
of their Society had been bachelors, and
mentioning the names of the eminent physi-
cians who in the year 1842 met to inaugu-
rate the movement, he continued: "Do
not for a moment suppose that since then it
has been fostered by lesser dignitaries.
Many of those who have given to it the most
time and care have been men whose families
would, probably, in the ordinary course of
events, never derive any pecuniary benefit
from it. Since 1877, the smallest number
of widows aided in any one year has been
ten, and the largest number fourteen ; the
smallest number of orphans four, and the
largest number eight. During the year the
Society meets once. The Board of Mana-
gers and the Standing Committee hold four
stated meetings, and such special meetings
as may be necessary. One matter should
be especially emphasized, viz., a cha?'itable
element should prevail in the direction of
such fraternities ; while business principles
should be strictly enforced in the investments
of funds, a charitable disposition should be
made of the revenue derived from such
funds. The affluent members of the profes-
sion should deem it a duty to their holy call-
ing to foster any such organization. It is
a work in which men of aH nationalities and
creeds can mutually co-operate, remember-
ing the words of the great poet : —

1 In Faith and Hope the world will disagree,
But all mankind's concern is Charity.' "

Testicle Therapy for Phthisis.

At the meeting of the Paris Societe de
Biologie, December 20, 1890, Dr Brown-Se-
quard declared that charlatans were selling
under the names "elixir" and "tonic
syrup of the nervous system," a liquid

which they pretended contained the princi-
ple which he has announced as possessed of
considerable dynamogenic power, and which
is found in a liquid extracted from the tes-
ticles and spermatic ducts. Brown-Sequard
protests against such deception of the pub-
lic. The preparations to which he objects
are all directed to be taken by the mouth
and thus introduced into the s'tomach ; but
the gastric juice digests the fluid and de-
stroys its dynamogenic powers, so that, even
if the preparations actually contain what
they profess to, they would be inert in the
way they are administered. To be effective,
the fluid must be injected under the skin or
into the rectum.

Brown-Sequard also announced that a year
or more ago several physicians had treated
patients suffering with pulmonary tuberculo-
sis with hypodermic injections of the testic-
ular liquid, and that they had | obtained very
remarkable curative effects. Brown-Se-
quard, however, refuses to admit that phthi-
sis can be cured with the fluid, though he
does admit that, by virtue of its dynamo-
genic power it may produce a great increase
of strength, cessation of fever and sweats,
and a notable improvement in digestion and
nutrition, and in the secretions. At Brown -
Sequard's instance, Goizet has been experi-
menting since June last with the injections
in phthisis. In three patients with phthisis
in the second degree, the symptoms have
disappeared and there has been a gain in
weight and notably in strength. Dr. Us-
pensky has also called attention to this
method of treatment. He reports that in
thirty patients there has been obtained a
disappearance of the symptoms of tubercu-
losis and a notable gain in strength and in
weight. Brown-Sequard adds, that where
the fluid has been filtered with care and used
with proper antiseptic precautions, there is
no fear of any dangerous febrile or other
reaction.

Resection of Thyroid for Exophthal-
mic Goitre.

The Lancet, January 17, 1891, says that
in a recent number of the Deutsche Med.
Wochenschrift, Dr. Lencke, of Hamburg,
discusses the subject of exophthalmic goitre
with special reference to its treatment. He
claims that as the treatment of this condi-
tion by medicine is remarkable for nothing
so much as its inefhcacy, if the surgeon
can offer even a chance of relief his* inter-

Feb. 14, 1 89 1. Notes and

Comments.

205

ference is justifiable, and he relates two cases
in which surgical interference seems to have
had the best results. The first patient was
a lad of seventeen, who had the classical
symptoms of the disease — rapid heart, pal-
pitation, prominence of the eyes, and goitre.
He came under treatment on account of a
sudden access of the swelling, which by the
pressure it exerted produced great distress,
with extreme cyanosis. The heart was rapid
and irregular, no rest or sleep could be ob-
tained, and the patient was in imminent
danger of asphyxia. Tracheotomy was per-
formed, and a week later one-half of the
tumor was extirpated. The operation was
accompanied by much hemorrhage, which,
however, stopped spontaneously, and recov-
ery was uninterrupted. The symptoms rap-
idly vanished, the exophthalmos disappear-
ing and the heart becoming quiet and regu-
lar in action. The improvement was main-
tained until the time at which the paper was
written. Operation was undertaken in the
second case, which had long been under
observation, because of the good result in
the first. The patient in this case was older,
the symptoms were similar, and the opera-
tion was the same. The improvement was
also very marked, and the patient four
months ago was able to resume his occupa-
tion. It is yet too early to estimate the full
value of the procedure adopted, as regards
cure of the disease ; but if relief can be af-
forded in other cases as great as was appar-
ently obtained in those just related, a strong
case will have been made out for the surgi-
cal treatment of this distressing malady.

Practiced Medicine without Regis-
tering.

In Court, at Reading, February 2, Judge
Endlicht decided an interesting case. He
refused a new trial to Mrs. Catharine Ebbert,
of that city, charged and convicted of prac-
ticing medicine without registering, and
ordered her to appear in Court for sentence.
Mrs. Ebbert has since registered. She says
she has been in continuous practice since
1858. In -the particular case in which she
was convicted, she alleged that the compen-
sation she received was for a box of salve
only, and not for medical services. Judge
Endlicht says in his opinion : ' ' Whilst it may
be true that one who undertakes to cure dis-
ease by mere manipulation is not engaged in
practicing either medicine or surgery, it is

at least equally true that the practice of med-
icine includes the application of medicines
for the purpose of curing, mitigating or
alleviating diseases."

Sanitary Convention of Pennsyl-
vania.

The Fifth State Sanitary Convention of
Pennsylvania will be held at Altoona, Friday
and Saturday, May 15 and 16, 1891, under
the auspices of the State Board of, Health,
assisted by the Board of Health of Altoona
and a committee of citizens. This is not,
in any sense, a doctors' convention. All
who take an intelligent interest in the pro-
motion of sanitary reform and the protec-
tion of the public health are invited not
only to be present and take part in the, dis-
cussions, but to forward to the Secretary,
Dr. Benj. Lee, 1532 Pine street, Philadel-
phia, for consideration by the Committee of
the Board, not later than April 15, papers
on sanitary or hygienic subjects, which they
would like to present before the conven-
tion.

Habitual Abortion.

The British Med. Journal, Dec. 20, 1890,
states that at the meeting of the Obstetrical
Society of London, Dec. 3, 1890, Dr. Leith
Napier read a paper on habitual abortion.
Some authorities assert that "habitual"
abortion is often due to indefinite sources
of uterine irritation impossible to recognize.
Others esteem syphilis as the most common
cause of habitual abortion. Both views are
disputed by Dr. Napier. Apart from dis-
ease, malformation, or physiological incom-
petency, there is no " habit ' ' of aborting.
The pathology of "habitual" abortion is
the same as that of ordinary or single abor-
tion. Turning to etiology, Dr. Napier
showed that more than half the cases were
due to uterine congestion or disease, and
only 9 per cent, to syphilis. Reflex causes
were discussed ; at most only 7 per cent,
were truly reflex. Syphilis is much more
commonly the factor of premature birth
than of abortion. Seventy-seven per cent,
of women subject to "habitual" abortion
are either nulliparous gravidae, who begin
their obstetric career by frequent abortions;
or multiparous women, who often terminate
fecundity by repeated abortions. Women

206

Obituary.

Vol. lxiv

who habitually abort are, as a class, very
fertile. "Habitual" abortion is highly
amenable to treatment. Over 67 per cent,
of the patients were delivered at term after
cure of the cause of the ' 1 habit. ' ' Dr. Na-
pier, in reply to a question, said he had
wholly avoided treatment in his paper, but
he regarded viburnum with favor. He
thought congestion of the uterus more im-
portant as a factor in abortion than retro-
flexion. He admitted the importance of
chronic cardiac disease.

Another Remedy for Perspiring Feet.

The Medical Press, January 21, 1891,
says that Dr. Winogradoff recommends a 5
to 8 per cent, solution of chloride of zinc
as an application for the prevention of un-
due prespiration of the feet. He begins by
ordering the feet to be well washed in tepid
water, and then dabs on the solution, wip-
ing off the surplus a few minutes later. The
application is best made at night, and may
require to be repeated a week later. It acts
as a caustic, destroying the sudoriparous
glands, and should never be used except by
the medical man himself.

NEWS.

— It was reported from Odessa, -Feb. 2,
that a hospital at Skopin has been destroyed
by fire, fourteen patients perishing in the
flames.

— A young Englishman named Bosanquet,
was bitten by a rattlesnake, at Daytona, Flor-
ida, on February 1 and died the next day
in great agony.

— On February 3, Dr. John S. Billings
was chosen by the Trustees of the Univer-
sity of Pennsylvania Director pro tern, of the
new Department of Hygiene, and Dr. A. C.
Abbott, of Johns Hopkins University, first
assistant in the department.

— Dr. C. C. Lancaster, a leading physi-
cian of Knoxville, Tennessee, died, Febru-
ary 3, of blood poisoning. He was inocu-
lated with the septic matter a few days ago,
while performing an operation on a body
having a gangrenous wound.

— An amendment to the State Pharma-
ceutical law of Pennsylvania, giving gradu-
ates in pharmacy the privilege of registering
without examination before a Pharmaceuti-
cal Board, was favored at a recent meeting
of druggists in Philadelphia.

— A despatch from New Haven, Connec-
ticut, Feb. 6, says that a girl about 10 years
old, of Shelton, had been hiccoughing in-
cessantly for six weeks, and nothing had af-
forded her any relief. She was wasted to a
skeleton, and death was but a question of a
very few days.

— Dr. J. D. Nicholson, resident physician
of the Cooper Hospital, Camden, N. J., has
resigned to accept a position in the Phila-
delphia Hospital. Dr. I. D. Webster, who
was the junior resident physician, succeeds
him, and the Board of Managers has ap-
pointed Dr. Farrar, of Virginia, to fill the
vacancy.

— Clarence W. Bowen, Secretary of the
Committee on the Cenntennial of Washing-
ton's Inauguration, 251 Broadway, New
York, desires information regarding the
portraits of Thomas Fitzsimons, Thomas
Hartley and Thomas Scott, members of
Congress from Pennsylvania. These por-
traits, for the Memorial Volume, are partic-
ularly desired, to complete the list of por-
traits of the Pennsylvania delegation in
Congress at the time of Washington's In-
auguration.

— Dr. Benjamin Lee, Secretary of the
State Board of Health of Pennsylvania, has
accepted the position of Secretary of the
Section on State Medicine of the American
Medical Association. As the meeting takes
place in Washington, May 5, it is important
that all papers intended for this Section
should be in his hands by the fifth of April.
All members of the Association desiring to
be enrolled in the Section are requested to
forward him their names at 1532 Pine St.,
Philadelphia.

OBITUARY.

TROY S. SAUNDERS, M. D.

Dr. Troy S. Saunders, who has long been
a subscriber to the Medical and Surgical
Reporter, died Jan. 20, 1891, at Indian
Springs, Ga., of acute pneumonia. He was
graduated at the University of Nashville in
1867. He was unmarried, and was nearly
forty-seven years old. He was a noble, good
man, and sacrificed his life to th% profession
he loved. Many people — mostly poor ones
— black and white, have been sick with the
prevailing colds and coughs. He ministered-
to their wants, when he should have been m
bed. This tribute is paid him by a life-long
friend. j. v.

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EDITORIALS.

Myers, A. F., M. D., Blooming Glen, Pa.— Measles,
with Notes of Observations 207

Bergey, D. H., M. D., North Wales, Pa.— Treat-
ment of Dysentery 209

Washington, W. S.,M. D.. Newark, N. J.— Medical
Treatment of Peritonitis 211

Moore, Thomas H., D. D. S., M. 1)., Philadelphia,
Pa.— Cystoma of Jaw 214

REPORTS OF CLINICS.

Buffalo General Hospital 214

SEW YORK CORRESPONDENCE.

Neuroses ok the Genito-Urinary Apparatus....

Transperitoneal H ysterorrhaphy

Nashyille Journal of Medicine

BOOK REVIEWS.

Morris, Wolff; Essentials of Practice of Medi-
cine.—Goss ; A Text-Book of Materia Medica,
Pharmacology and Special Therapeutics

CORRESPONDENCE.

Antipyrin in Puerperal Fever,
ers' Bill in Pennsylvania

-Medical Examin-

Meeting of the Medical Society of the State of New
York

PERISCOPE.

The Koch Treatment in Vienna.— Treatment of
Paiutul Menstruation.— Mammary Abscess in
the Virgin. — Artesian Wells in Iowa.— Cancer of
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Nerve Disorders.— Case of Ancephaiia.— Poison
(.Hands of Toads and Salamanders 218-

NOTES AND COMMENTS.

Information about the Army Medical Depart-
ment. -Politics and Pension Examiners —State-
ment by Tait Corrected —Medical Examiners'
Bill in Pennsylvania —State Board of Health.—
Resorcin in Diphtheria.— Army Medical Boaid.
—Quill Drainage-Tubes. — Homoeopaths Con-
verted 227-

OBITU A RY.— Charles Walter, M. D

WILLIAM R. WARNER & CO.'S

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IN THE TREATMENT OF

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FORMULA

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Chalybeate Comp. (Warner & Co.'s) is almost a specific. The assimilable iron, acting
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ying this salt followed by PILL CHALYBEATE COMP. as above mentioned.

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" SANITAS " DISINFECTING FLUID.

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MEDICAL AN D SURGICAL
REPORTER

No. 1773.

PHILADELPHIA, FEBRUARY 21, 1891. Vol. LXIV.— No. 8.

Communications.

MEASLES, WITH NOTES OF OBSER-
VATIONS.

BY A. F. MYERS, M. D.

BLOOMING GLEN, PA.

Within the past year an epidemic of mea-
sles oocurred in this community, and consid-
ering the number of years since a similar ep-
idemic took place, one will not be surprised
to find a great variety of cases, old and
young, and with various complications and
idiosyncrasies. In February, 1890, they made
their appearance in our public schools, a reg-
ular hot-bed for propagation, and consequent
depopulation. In less than three weeks
forty individuals were affected by this trou-
blesome affliction, and either high or low in
station, they had to succumb, unless they
had paid tribute to a former epidemic.

During the prevalence of this contagious
exanthem, I took note of, and either directed
or prescribed for 153 consecutive cases in
private practice, of either a mild or more
severe nature.

Invasion. — The onset of these cases was
usually slow, with catarrhal symptoms pre-
ceding the fever. The characteristic early
symptoms of the disease were intense nasal,
pharyngeal and laryngeal catarrh, coryza,
troublesome cough, occasionally violent
headache and epistaxis, muscular soreness
and irregular chills. Over one-third of the
patients were distressed with an insatiable
thirst. Redness and irritation of the con-
junctiva and lachrymation was very distinct
in over half of the number for a day, and
in a few for even four and five days before
any other signs or elevation of temperature
became manifest. Many patients had a very
moderate fever ; however, using the clinical
thermometer with everv case noted, not a

j single one occurred where- fever was entirely
i absent, though it has been claimed by some
j observers that such cases frequently exist.
The fever usually came on by the third, and
in a few cases as late as the fifth day after
the prodromic signs were noticed, followed
by remissions, on the appearance of the
eruption of a crimson color in the face
and spreading over the body. The fever
lasted from one to six days — with a few ex-
| ceptions to the seventh and ninth, attaining
j its highest point in nearly every case at the
1 fullest development of the eruption. Marked
i enlargement of the anterior cervical and
I sub-maxillary glands was noticed in twelve
cases during this period.

Temperature.— 'Wit range of temperature
! was a matter of interest. Of the 153 cases ob-
served, in 1 1 5 it did not rise higher than 1030;
I of this number only 14 did not reach ioo°.
! Seven cases ranged at 1030, and in three
! families numbering 7, 6, and 8 patients re-
spectively, together with 5 isolated cases, it
I extended to 1040 and a fraction ; and in
! three exceptional cases it rose to 1050, and in
one to 105. 50. However alarming it seemed,
j all these patients who had such a high fever
j — and where other complications contri-
I buted largely to this dangerous rate — finally
i recovered.

Eruption. — In the eruption nothing un-
| usual was noticed. However, having made
t this epidemic a special object of observation,
j I found 22 cases where I was enabled to rec-
! ognize distinctly the approach of measles
; by a peculiar rose-colored punctation of the
j soft palate, the uvula, and the roof of the
mouth, from eighteen to thirty hours before
the rash made its appearance elsewhere.

Incubation. — The exact period of incuba-
j tion I could not determine ; but in 2 1 cases
that were under personal observation three
times a day, and in which I carefully noted
the time from the exposure until the appear -
I ance of the eruption, it was at the thirteenth
[ day in 17 patients. In one case it was dis-

207

208

Comm unications.

Vol. Ixiv

tinctly noticed on the ninth, in two on the
tenth, and one on the nineteenth day.

Sex. — The sex was noted in every case,
and I found there were more females affected
than males. There were 82 of the former
and 71 of the latter. This proportion of
the sexes is in harmony, however, with the
ratio of the entire population of this com-
munity.

Age. — It will be noticed that the disease
was most frequent between the ages of 6 and
10 years, higher than is generally found ;
but this may be accounted for by the fact
that no similar epidemic had taken place for
a number of years. My observations were
as follows :

No cases under 7 months of age.

6

between

7

and

12

months

19

tt

1

i (

3

years.

33

t(

3

6

< (

47

((

6

((

10

1 i

24

a

10

a

15

i e

18

( (

15

{(

20

a

4

( i

20

n

25

( «

1

at

28

years.

1

at

35

it

Complications. — Of the complications that
usually exist with or succeed this disease,
the following will be briefly noted. Of the
entire number, 128 were simple cases, and 27
complicated. The complications were :
bronchitis, 16; convulsions — all in the early
stage of disease — 4 ; laryngitis, 3 ; pneu-
monia, 4 ; dysentery, 1 ; entero-colitis, 1 ;
acute Bright' s disease, 1 ; stomatitis, 2 ;
otalgia, 1.

In this enumeration several cases are re-
ferred to twice. In no case was measles
conjoined with any other eruptive disease.

Prognosis. — The prognosis was favorable
in all the simple cases, every patient re-
gaining the former excellent health. Of the
153 cases noted, only two terminated fatally.
The unfavorable cases and the attending cir-
cumstances may be briefly stated.

Case 1. The first death occurred in a
boy seventeen months old. The first signs
of ill health were repeated convulsions for a
half day. A brother having just recovered
from this disease, it was surmised what was
coming. I was called at this time and found
the child having another spasm, continuing
for over twenty minutes ; the respirations
were 40 to 43 per minute, the pulse-rate 135
to 140 ; the temperature in the axilla 1050;
the child very restless ; the skin hot and
dry. The patient urinated frequently, but
the urine was scanty. There was no appear-

ance of an eruption. At short intervals
during the intermission of the convulsions,
the child would sit up and ask for water,
and drink small quantities with an apparent
relish. It answered questions and was evi-
dently rational for a few minutes, when it
would suddenly relapse into another fit. It
continued in this manner during the follow-
ing night. In the morning I found all the
symptoms aggravated, continual convulsive
movements, dyspncea, 60 to 65 respirations
a minute, and pulse fluctuating between 165
and 170 per minute. Bronchitis had devel-
oped during the night ; and by mid-day a
paroxysm of cough ended the scene. Per-
mission for an autopsy had been refused.

Case 2. This patient was a girl eleven
years old, with the eruption fully developed
when I first saw her, complicated by an at-
tack of catarrhal bronchitis. This patient
had bad hygienic surroundings; the house
was situated on a low, marshy bottom, with
water in the cellar and the rooms very damp.
As the eruption faded, catarrhal pneumonia
set in, with a temperature fluctuating be-
tween 1030 and 104. 50, rapid and laborious
breathing, prolonged and noisy expirations,
dry, painful cough, which had been loose
during the bronchitis. Expectoration was
now muco-purulent, the urine was scanty,
and slight diarrhoea followed. In spite of
all that I could do, this case proved fatal on
the fifth day from the time that I first saw it.

Sequela. — All the patients have been un-
der observation since their illness, and all
fully recovered promptly, with the exception
of the case complicated with otalgia, which
became protracted, but by persistent atten-
tion for over a month, the inflammation in
the middle ear disappeared, with hearing
fully restored.

Treatment. — I will simply state that no
routine treatment was followed, nor, in all
cases, the advice usually given. I claim
nothing original or novel in my procedure.
The extensive administration of cold water
and the various uses made of it for reducing
the temperature and bringing out the erup-
tion, is my excuse for bringing this subject
to the attention of the profession.

In the management of this disease strict
attention was given to the hygienic surround-
ings of the patient as much as the various
inconveniences would permit. With a few
exceptional cases this condition was very
favorable. The temperature of the rooms
was maintained as near as possible between
650 and 750 continually, to avoid overheat-

Feb. 21, 1891.

Communications.

209

ing as well as chilling the body. The sick
chamber was properly ventilated and shaded
from bright light, to afford comfort to the
eyes. Of the 122 cases having the simple
form, 13 were not confined to the bed, but,
being well clothed, were allowed the freedom
of the room. The rest were comfortably
covered in bed. Amusement was permitted
in the simple cases if desired.

During the febrile period light diet was
ordered, consisting of water and milk,
crackers, or bread soup and tapioca. Later,
as the eruption disappeared, light broths,
toasts, soups and oranges were allowed. The
drinks consisted of cold water, in abundance
but in small quantities and frequently given.
I gave cold water freely to allay the insatia-
ble thirst ; even iced water was exhibited in
several cases, but in frequent small portions.
Cold lemonade, orangeade and other cool-
ing drinks were allowed ad libitum. To give
very large draughts of cold water at once is
injurious; it will frequently cause violent
gastric pain and vomiting, followed by other
unpleasant symptoms.

Where the temperature was very high, the
skin dry and hot, and the patient often suf-
fering from fever-pains, with a tardy appear-
ance of the eruption, a careful sponging
with cold water was very agreeable and
highly beneficial, followed by a gentle rub-
bing with a dry towel. After it was once
tried, the patients frequently solicited its
repetition. In several cases where friends
protested, I used only tepid water, with good
results. The reduction of temperature was
phenomenal in some cases. Using the ther-
mometer, I noted four cases where it de-
clined two degrees in one hour's time. In
three cases where the eruption was tardy and
there was high fever, a warm bath for about
twenty minutes also accomplished our de-
sign. In no case did any unpleasant symp-
toms follow.

Diaphoresis, and the action of the kid-
neys, was carefully looked after. No pa-
tient was permitted to suffer, however, for
the want of the proper medicinal treatment
if indicated. No partiality was shown to
any means or method.

In eighteen cases of high fever, I applied
ice to the head for a few minutes at frequent
intervals, by means of an ice-bag, to relieve
the throbbing pains. Three cases of con-
vulsions, in the early stage of the disease,
were treated similarly together with a warm
bath, until the convulsions ceased, with grati-
fying results.

In the fatal case of the boy cited above,
much to my regret, neither of these plans
was made use of.

The account of the medical treatment will
be abbreviated. Of the simple form, 76
cases received no medicinal treatment ex-
cept syrup mixtures of wild-cherry, scilla or
ipecacuanha, for the relief of the incessant,
dry, scraping cough, in such proportion as
was indicated. For constipation, in the
more severe cases, I prescribed an emulsion
of castor oil or spiced syrup of rhubarb,
according to age. As a diaphoretic, sweet
spirits of nitre was used in twenty-four cases;
and to control the diarrhoea, bismuth sub-
nitrate and Dover's powder, or a few doses
of camphorated tincture of opium as neces-
sary. For six cases of high febrile reaction,
citrate of potash, spirits of nitre and tinc-
ture of aconite was administered. For the
conjunctival inflammation, a warm-water
lotion was frequently used. The local use
of vaseline afforded great relief where prur-
itus existed during the decline of the erup-
tion, or where any desquamation followed.

The remarks on the treatment of the com-
plications will be brief. Absolute rest and
quiet was enforced in this class of cases as
long as was deemed necessary. Bronchitis
was from the onset treated with supporting
measures. The diet was of the most nutri-
tious sort ; febrifuges, expectorants and ex-
ternal applications 'were used as indicated.
The cases of pneumonia were treated accord-
ing to the general principles given in the
text-books. From the other complications,
all recovered under the common treatment
in vogue for such diseases. Only six pa-
tients required tonic treatment for a week,
as a result of the complications.

TREATMENT OF DYSENTERY.1

BY D. H. BERGEY, M. D.,

NORTH WALES, PA.

During fhe month of July I had a num-
ber of cases which so closely resembled
dysentery that, for want of a more appro-
priate term, I called them by that name ; yet
in severity, and possibly in the course of the
disease, they differed somewhat from dys-
entery. I also experienced some difficulty
in giving relief to several of these patients

1 Read before the Montgomery County Medical
Society, September 24, 1890.

2IO

Communications.

Vol. lxiv

by the use of the ordinary remedies. This
difficulty led me to make use of a combina-
tion of agents which gave me good results,
and has given equally good results in un-
doubted cases of dysentery since, and has
led me to change my views with regard to
this disease.

We are taught to regard dysentery as
being primarily an acute inflammation in-
volving the mucous membrane of the large
intestine, which various authorities have
attempted to trace to a bacterial origin.
This theory I consider fallacious, because
the micro-organisms so far found in the de-
jections in this disease have all been fre-
quently found in the mouth of healthy
persons where their presence was not accom-
panied by any pathological conditions.
The bacterial origin has been exploded,
unless we recognize that of Kartulis, which
recently received some confirmation through
Prof. Osier. Yet even these organisms, the
Amcebce. Coli, are denied this distinction by
Baumgarten.

I consider the causative element in dys-
entery to be an arrest of the secretion of
bile, and possibly also of the pancreatic
Juice. I think you will grant that this
theory is not unfounded, when you consider
the absence of the characteristic odor and
color of the dejections in dysentery. This
color and odor we know to be due to the
bile and to certain elements resulting from
intestinal digestion.

The absence of these two characteristics
. in the dejections in dysentery is the most
prominent diagnostic point ; even more so
than the presence of mucus and blood ;
and in the treatment of this disease the re-
turn of the natural coloration and odor of
the feces, and hence the presence in them of
bile constituents and the products of intes-
tinal digestion, is the first indication that
convalescence is being established.

In the cases of which I have spoken I
tried ipecacuanha according to the Brazilian
method of treatment, without obtaining very
gratifying results. The salicylate and the
subnitrate of bismuth, either alone or in
combination with Dover's powder or opium,
had no effect. Salines were tried in several
cases without avail. Repeated doses of cas-
tor oil and laudanum gave partial relief in
some of the cases where tried. Minute
doses of calomel had little effect. These
unsatisfactory results led me to employ an
elixir, the principal agents in which were
ox-gall and pancreatine. The absence of

the natural coloration and odor of the feces
led me to believe that the disease must have
some connection with the functions of the
organs furnishing these secretions ; and I
was led to supply their secretions artificially.
The results were very gratifying. In from
twelve to twenty-four hours the character-
istics, which were absent heretofore, re-
turned and the tenesmus abated, and mucus
and blood were no longer present in the
dejections.

I am led to believe that dysentery is due,
primarily, to an arrest of the secretions of
the liver and pancreas, which allows putre-
factive changes to take place in the intes-
tines, and that these putrefactive elements
are the sole cause of the inflammation. The
lesions, it seems to me, may be looked upon
as the result of the fermentation going on,
because of the absence of bile, the normal
antiseptic ; the lesions prolonging the disease
and offering a habitat for the bacteria.

This condition, therefore, calls for anti-
septic treatment, and we fortunately have, as
proven by Limbourg, an efficient antiseptic
in the biliary elements contained in the ox-
gall, which takes the place of those secre-
tions temporarily absent. Bile is also the
best cholagogue. That it is cathartic in its
action, is shown at once by the diarrhoea
which accompanies excessive secretion of it,
by the constipation which is ordinarily pres-
ent in congestion of the liver ; and by the
purgative properties of ox-gall when given
in sufficient doses. It seems to produce its
purgative action by stimulating the secretion
of the intestinal and pancreatic juices and
by increasing the peristaltic action of the
intestines.

In pancreatine, we have an active agent
bringing about the natural decomposition of
the chyme, thus rendering it rapidly assim-
ilable ; it therefore is a most important
agent in the restoration of the natural func-
tions of the liver and of the organs of as-
similation, and therefore of the entire econ-
omy. The presence of fatty particles in
the dejections of this disease shows the ab-
sence of the pancreatic secretion, since it is
its office to emulsify fats in the presence of
bile. These two agents are assuredly those
whose absence allows the putrefactive
changes to take place in the intestines and
thereby brings about such violent attacks of
inflammation of the mucous membrane of
the large intestine, with its concomitant con-
stitutional conditions — fever and prostra-
tion. It seems to me more than probable,

Feb. 21, 1 89 1. Communications.

211

therefore, that the violent inflammation, at
least in the simple form of this disease, is due
altogether to an irritation set up by these
putrefactive elements and that the disease
is due primarily to an arrest of secretion in
these two organs.

To further substantiate this conclusion, I
may mention the fact that we have a gastro-
intestinal catarrh accompanying cirrhosis of
the liver, and here we have at least a partial
arrest of the secretion of bile; while, when
there are cysts of the pancreas, we have fatty
matters in the dejections, colic-like pains,
and frequently bloody stools. When, as in
dysentery, the secretion of both of these or-
gans is checked simultaneously and sud-
denly, as it is possible for it to be, by con-
tinued high temperature followed by cold
and dampness, or by whatever cause, it is
not necessary to stretch our imagination
very much to picture the resulting conditions.
There is really a constipation existing at
the time, the dejections being composed
largely of mucus and blood from the large
intestine alone. The tormina and tenesmus
may be looked upon as largely due to inef-
fectual efforts on the part of nature to un-
load the bowels.

We have thus far experienced consider-
able disappointment in the treatment of dys-
entery, and it seems proper to conclude that
this disappointment has been due to the fact
that the true causes leading to this affection
have been overlooked. I believe that when
we come to regard this condition in its true
light we shall meet with far more gratifying
results.

In the majority of cases it is preferable to
preface the treatment of dysentery with a
large dose of ox-gall, or other cathartic, as
castor oil, to unload the bowels. When this
is done, my experience leads me to predict
that from twelve to twenty-four hours' treat-
ment with ox-gall and pancreatine will suf-
fice to re-establish the normal secretions, and
to establish convalescence.

Should the tormina and tenesmus con-
tinue after the dejections assume their nor-
mal color and odor, a few injections of bi-
chloride solution with starch-water will be
followed by almost immediate relief.

This has been my experience with acute
dysentery during the present season. Though
it may seem fanciful to some of you, I trust
you will not hesitate to try this mode of
treatment in dysentery.

I have given both of these agents together
in pill form and in the form of an elixir,

from one-half to one grain of the ox-gall
and from seven to fifteen grains of the pan-
creatine, every three to six hours. I have
also given the ox-gall alone, in pill form and
in capsules, and the pancreatine in the form
of a simple elixir.

MEDICAL TREATMENT OF PERI-
TONITIS.1

BY W. S. WASHINGTON, M. D.,

NEWARK, N. J.

Peritonitis was not raised to the dignity
of a disease until about the beginning of the
present century, and during that time its
treatment has undergone many variations.

The earliest authors give copious general
and local depletion, and mercurials, as the
treatment. Some of them, however, used
purgation, though it does not seem to have
been at all popular, and we only occasion-
ally read of it.

We find no mention of opium until about
1820. From that time till 1830, Graves and
Stokes used it in large doses in perforative
peritonitis, but no mention is made of its
use in other forms of the disease. Sir
Thomas Watson, in his classical lectures de-
livered in London, speaks of the profound
impression made upon his mind by these re-
ports. He himself gives rest, venesection
and opium as the three main remedies to be
relied on. Sir Thomas disapproved of pur-
gatives. Dr. Alonzo Clark, about 1840,
was the first to begin the systematic use of
large doses of opium in all forms of peri-
tonitis. He put his patients in a condition
of semi-narcotism and kept them in that
condition until the inflammation subsided.
It is inconceivable, however, that the enor-
mous amounts administered, could all have
been absorbed. No purgatives were allowed,
and the bowels were kept confined as long
as two weeks if necessary.

Dr. Austin Flint advised much the same
plan of treatment, especially disapproving
of purgation. Dr. . George B. Wood, in the
fourth edition of his work on Medicine, pub-
lished in 1855, gives copious bleeding as the
most important remedy ; then came five or
six grains of calomel, followed by castor oil
or Epsom salts. Next in order was from fifty
to one hundred and fifty American leeches,
followed by opium and mercury to ptyalism.

1 Read at the meeting of the Practitioners' Club.

212

Communications.

Vol. lxiv

While Dr. Wood deprecated anything
which tended, as he thought, to produce
continued friction of the inflamed serous
surfaces of the intestinal convolutions, he
deemed it proper to procure one or two soft
evacuations daily by the use of Seidlitz pow-
ders, Epsom salts, Rochelle salts, infusion of
tamarinds with cream of tartar, castor oil,
or castor oil with oil of turpentine. Dr.
Wood did not advise or use large doses of
opium. Bauer, in Ziemssen's Cyclopcedia,
recommends ice in the outset, to withdraw
heat and allay pain. He believes cold les-
sens the hyperemia, reduces nervous irrita-
bility and spasmodic peristaltic action. As
soon as the muscular action of the intestines
and blood-vessels is paralyzed Dy distention
and pressure, the ice is exchanged for heat.
The next remedy, according to him, is
opium. He says the use of cathartics is
completely given up. For the relief of tym-
panites, the rectal tube and puncture of the
colon are employed, though both are ad-
mitted to be of very limited value. War-
dell, in Reynold's System of Medicine, says
our best ally is blood-letting. Then come
leeches, hot fomentations and opium. Pur-
gation means increased irritation. Dr.
Henry Hartshorne, of Philadelphia, entirely
agrees with Wardell. Dr. Ross, in the Ref-
erence Hand-book of the Medical Sciences,
after speaking of local depletion, says opium
is the drug most relied on, and that it should
be given in full doses. The bowels should
not be disturbed by cathartics or enemata
until all active symptoms have subsided.
Bartholow recommends leeches, the ice-bag
until there is exudation, then heat, and
morphia and atropia hypodermically.

Other authors have advocated similar
treatment. Of course other remedial meas-
ures were used as adjuvants, but the forego-
ing represents the principal methods of
treatment used until the last few years. I
believe we are indebted to the gynecologists
for a system now advocated by a large num-
ber of medical gentlemen, and known more
distinctively as the purgative treatment.
Under this method active purgation is em-
ployed and opium is used as little as possi-
ble or not at all. Pain and tympanites are
two distressing symptoms of peritonitis.
Opium will relieve pain but not tympanites.
Purgatives, more especially saline purgatives,
will relieve both. Epsom salts, which I pre-
fer, does not act by increasing the peristal-
tic action of the intestines, but it produces
a watery movement by osmosis from the

blood-vessels of the peritoneum and intes-
tines. That it does increase the amount of
water in the intestinal canal has been proved
by placing a solution of magnesium sulphate
in a knuckle of intestine. On examination
made some time afterwards an augmented
quantity of fluid was found.

Among those who speak of the use of pur-
gatives with approval is Lawson Tait, of
Birmingham. He was among the first, if
not actually the first, to use them, and his
preference is for salines.

Dr. Nancrede, professor of surgery at Ann
Arbor, Michigan, advises the use of salines
in the peritonitis preceding and following
appendicitis. Dr. Gordon, of Portland,
Maine, in a report of a number of cases of
peritonitis of various kinds in women, says:
" I think the first and most important thera-
peutical resource is free catharsis from sa-
lines, preceded sometimes by the calomel
triturates, if the stomach is irritable. If
these fail to act promptly, I supplement by
an enema of a concentrated solution of Ep-
som salts. I find the following formula ef-
fective : Magnesia sulphate, !§ ij ; boiling
water, f^iij; glycerine, fj|i. It acts
promptly and thoroughly, stimulating the
entire intestinal canal, producing profuse
watery discharges, and rapidly reducing
temperature and relieving pain. Opium
should be withheld unless the pain is intol-
erable. The enema alone often completely
aborts the attack."

Dr. A. M. Jacobus, instructor in gyne-
cology in the New York Polyclinic, says:
"Peritonitis, even the so-called idiopathic
form, if there be such a thing, is necessarily
a serious disease ; but when the patient has
not only to fight it, but the non-operating
opium poisoner, it means certain death in a
large percentage of cases. Opium has had
its day as a cure-all, and it seems now only
a question of what kind of a laxative we
shall use. I have seen several instances of
general and pelvic peritonitis in which it ap-
peared certain that without free catharsis the
patient would have died from cardiac or
respiratory paralysis, from the excessive tym-
panites or from septicemia in purulent cases.
In several instances of obstructive periton-
itis, when Seidlitz powders failed and there
was excessive tympanites, an ounce of castor
oil in hot milk saved the patient from cer-
tain death. We use cathartics in the in-
flammatory intestinal diseases of infants, and
in general inflammations elsewhere as revul-
sives, then why not in peritonitis with effu-

Feb. 21, 1 891.

Comm ttnicatiows.

213

sion, whether septic or not ? Whether in
operative cases or not opiates should be used
as little as possible ; but, on the other hand,
saline or vegetable cathartics, followed by
enemata should be used from time to time
to relieve the inflammation, tympanites,
pains and fever, and especially to drain the
peritoneal Cavity of serous or purulent effu-
sions." Dr. W. Gill Wylie, of New York,
advises and uses cathartics in peritonitis,
preceding and following laparotomy for va-
rious causes. Dr. Baldy, of Philadelphia,
expresses himself as follows on this subject :
"The peritoneal cavity is drained of the
products of inflammation ; the inflamed sur-
faces are relieved of all engorgement by a
thorough depletion of the vessels in the in-
testinal walls ; the inflammation is most ef-
fectually stopped ; the pulse and tempera-
ture almost immediately improve ; and the
pain is relieved as quickly as can be by the
use of opium. This may seem strange, but
it is a clinical fact."

Dr. John H. Musser, Assistant Professor
of Clinical Medicine in the University of
Pennsylvania, has reported over twenty cases
of various forms of peritonitis, many of
them very severe, treated after the following
method. Local blood-letting, until pain is
very much relieved. If in progress more
than forty-eight hours, a large blister, fol-
lowed by hot applications ; liquid diet ab-
solutely ; stimulants to prevent collapse, to
lessen its severity and to prevent tympany ;
sips of hot water or hot whiskey and water
for vomiting ; calomel in small doses hourly
until the bowels are moved, and if no relief
is obtained it is pushed to ptyalism. If the
patient is seen early, aconite- is given to
children, veratrum viride to adults, until the
pulse-rate is lessened. Morphia and atropia
are given in small doses as infrequently as
possible to control pain ; twice daily often
suffices. If morphia disagrees, codeia is to
take its place. If the bowels are not opened
in forty-eight hours, one pint of sweet oil is
given by enema, followed by an enema of
tepid water. Dr. Musser considers it of the
utmost importance that the bowels should
be opened. In threatened collapse, active
stimulating medication is employed by sub-
cutaneous injections. It will be observed
that Dr. Musser employs local depletion,
calomel, blisters, etc., which are not new,
but at the same time it will be noted that
he reduces opium to the smallest possible
amount. Although in this summary of his
treatment no mention is made of salines,

yet in the detailed report of cases, one is
recorded as having been relieved by them.
The treatment of these cases by Dr. Musser
was eminently successful.

Dr. Emory Lanphear, editor of the Kansas
City Medical Index, gives his unqualified
support to the saline purgative treatment,
and reports a number of cases, some of
which were treated by opium and others by
salines. The results were startlingly in favor
of the latter. Dr. Maxson, of Hartford,
Kansas, Dr. Lanphear' s preceptor, has
treated peritonitis by salines for the past
twenty years. He believes they unload the
turgid blood-vessels and relieve the impeded
circulation of the abdominal viscera and
peritoneum ; that temperature and pulse
rapidly lessen in frequency ; and that pain
disappears almost as quickly as by the use of
opium. In the second stage, he uses small
doses of salines with tincture of belladonna
and a limited amount of opium to relieve
pain, sustain the heart and prevent shock. .

In the past three years a large number of
gentlemen have reported cases and testified
their faith in the new method. It seems to
have gained a secure footing, and it will
eventually displace the old opium treatment.
I entirely agree with the views of the differ-
ent ones I have quoted in its favor, and can
confidently recommend it to those who have
not as yet had experience with it. In clos-
ing, I will report the following cases.

Case 1. One of general peritonitis. The
immediate cause was sitting on cold door-
steps in front of a boarding-house late at
night ; the remote cause was a previous peri-
tonitis. The patient, a woman, was of a bil-
ious habit, and had much nausea during the
whole of her sickness, which was relieved
by calomel. Saline purgatives, in the form
of magnesia sulphate, promptly relieved
pain and tympanites, being used as often as
required. Sometimes they would be given
daily, at other times an enema took their
place. Turpentine stupes were applied to
the abdomen and liquid diet was given.
One-eighth grain of morphia was adminis-
tered as required ; on some days none was
given, on other days two or three doses
would be given. The woman made a per-
fect recovery, and after the first three or four
days was not considered dangerously sick.

Case 2. One of local peritonitis ac-
companying salpingitis. The patient was
promptly relieved by purges of magnesia
sulphate. The deodorized tincture of opium
was given for pain and flannels wrung out

214

Reports of Clinics.

Vol. lxiv

of hot water were applied to the abdomen.
Very little opium was required or given, and
recovery was satisfactory.

Case 3. One of local peritonitis follow-
ing child-birth. Magnesia sulphate relieved
immediately, and but one dose of one-eighth
grain of morphia was needed. Although
puerperal mania developed within a few days,
the peritonitis disappeared without further
trouble.

CYSTOMA OF JAW.

BY THOMAS H. MOORE, D. D. S., M. D.,

PHILADELPHIA

Mr. I., 46 years old, presented himself at
my office, having a tumor involving the left
half of the inferior maxilla. The growth,
he says, began several months prior to his
coming for treatment, and had attained con-
siderable proportions. The cyst extended
from the angle of the jaw almost to the
median line at the symphysis. The swell-
ing was first noticed upon the lingual por-
tion of the jaw, opposite the second inferior
molar. It gradually increased in size, and
then made its appearance upon the buccal
surface and extended anteriorly and poste-
riorly, involving nearly the whole left half
of the jaw.

No reasonable doubt can be entertained
but that the teeth are, in most cases, the pri-
mary cause of such mischief. But the ques-
tion of the precise manner in which the
morbid conditions are developed is more
difficult of solution. There is no disputing
the fact that foreign bodies, such as the
apices of teeth, broken off during extrac-
tion, or small spiculae of bone, attracting a
serous fluid around them, finally become
encapsulated or encysted and gradually ex-
tend to great proportions.

Cystic tumors of the inferior maxilla are
by no means of common occurrence, and
present especial features, such as slowness of
growth, absence of severe pain, glandular
involvement, or constitutional impairment,
except such as attends any tumor interfering
with mastication or deglutition. The man-
ner of discovering their true nature is by
the aid of the exploring needle. In the
present case I wish to say that the patient,
being possessed wTith a very fine set of nat-
ural teeth, none of them being devitalized,
imagined they could be used for almost any
purpose other than that for which they were

intended. He placed a hard shellbark be-
tween the two second molars of the left side
of the jaw, and cracked it. Immediately
after he experienced a slight pain in the
lower tooth. This was evidently the cause
of the formation of the tumor. The exces-
sive pressure upon the cancellated bone in-
jured the endostium, producing an effusion,
and that is what formed the nucleus for an
extended, but slow, inflammatory action,
with the consequent results

Obviously, there is but one sort of treat-
ment for these tumors, and that is surgical.
When they have not extended or reached to
such proportions as to completely destroy
the contour of the bone, I make a free in-
cision, to evacuate the contents. In the
case being described this consisted of a
dirty, bran-like substance, mingled with a
glairy, blood-stained fluid. I made a
further examination with the exploring nee-
dle, and discovered another but smaller
cyst posterior to the one just opened, and
having its connection by a small sinus open-
ing into the first one. I evacuated its con-
tents also, and proceeded to wash out the
cysts with tepid water. I then injected a
stimulating solution of dilute tincture of
iodine, and packed the cavity with gauze,
which I renewed, repeating the injection of
dilute iodine for a few days, until complete
closure was accomplished. No internal
medication was required in this case.

Reports of Clinics.

BUFFALO GENERAL HOSPITAL.

SURGICAL CLINIC— PROF. ROSWELL PARK.

Tubercular Gumma, breaking down
into Cold Abscess.

Dr. Park said the patient, a young compos-
itor,"asserted that two years ago a swelling
had occurred on his wrist without much pain
or redness of the skin. After applications
of iodine, vigorous handling, etc., it en-
larged. A year ago he noticed a thickening
and softening of the palm of the hand with
a peculiar sensation. When he pressed in
the middle of the hand there was a bulging
of the tumor above the wrist. This phe-
nomenon persisted about six months. The
swelling of the wrist is about 2^ inches in
diameter, considerably elevated, with a red-

Feb. 21, 1 89 1. New York Correspondence.

215

dened surface, and looking very much as if
there was an -acute abscess, but without heat
and with no particular pain ; so that the
idea of acute abscess can be dismissed. The
boy is more or less emaciated and, in time
past, he has been worse than at present. He
has a cough and looks phthisical. He is
not a type of the scrofulous diathesis, and
probably is not phthisical at present ; though
he is on the point of becoming so. The
trouble about the wrist may be cold abscess,
that is, tubercular abscess, or a tuberculous
or syphilitic gumma — new formations of the
type of infectious granuloma — or a cystic
or solid tumor. Leprosy need not be con-
sidered in this part of the country. There
is no history of syphilis. It cannot be a
malignant tumor; for if it were it would
have spread more in the last two years, and
it would have become firmly seated and im-
movable, through the contraction of adhe-
sions to surrounding parts. The patient
can move his fingers freely.

A cyst or lipoma would fluctuate as this
swelling does, but the skin over them would
not be red. A fibroma would be firm and
hard, and it, too, would not be covered by
a reddened skin, unless it were on the point
of ulcerating. The diagnosis is narrowed
down to tubercular trouble — either a gumma
or a gumma broken down into a cold abscess.
It probably began in the cellular tissue be-
tween the skin and the deeper parts, and it
has probably formed adhesions to the
sheathes of the flexor tendons. The expo-
sure of the tendons is a serious thing be-
cause the new formed cicatricial tissue will
lash the tendons down.

A synovial sheath filled with fluid is called
a hygroma, and this is the condition in the
palm. Sometimes a hygroma contains not
only fluid but little solid masses apparently
due to precipitation from the fluid. A hy-
groma may be considered a special form of
" cysts by distention of previously existing
cavities." The solid bodies maybe of the
size of millet seeds or even as large as beans.
The average size is about that of a grain of
rice, and they -are often called rice-grain
bodies. Very little is certainly known of
them. They consist almost entirely of
fibrin and are probably formed by the roll-
ing into masses of fibrinous matter in the
hygroma. This condition is probably quite
independent of the tubercular gumma of the
wrist.

Dr. Park then laid open the tumor on the
wrist and considerable fluid and puruloid

matter and masses of coagulated lymph
were evacuated. The pyogenic — or, as Dr.
Park prefers to call it, the pyophy lactic — -
membrane was peeled off, preserving its sac-
culated appearance. The curette was then
used. Both during the operation and during
the dressing, rigid antisepsis was carried out.
Sometime before the operation the wrist
was shaved and scrubbed and enveloped in an
antiseptic bandage.

ew York Correspondence.

MEETING OF THE MEDICAL SOCI-
ETY OF THE STATE OF
NEW YORK.

President' s .Opening Address : Medical Ex-
aminers.— Cystoscopy. — Holf s Divulsor.
— Sarcoma in Brain. — Discussion on Re-
fraction.-— Appendicitis. — President1 s An-
nual Address : Education of Girls. — Ex-
periments with Koch' s Lymph. — Gynecol-
ogy.— Electrical Treatment. — Election of
a President.

The eighty-fifth annual meeting was held
in Albany, February 3, 4 and 5, 1891, with
Dr. W. W. Potter, of Buffalo, as President.
This meeting was, as usual, well attended by
delegates from all parts of the State and by
invited guests.

The President, in the course of his open-,
ing address, congratulated the Society that
the State was now near the realization of its
long-desired deliverance from the thraldom
of a system which had, more than all other
causes, retarded the progress of medicine.
A State medical examining Board would
come into power this year. The right to
grant medical diplomas was now divorced
from that of the license to practice. The
medical colleges were all bound by the pro-
visions of the new law to give three full
courses of medical instruction in different
years before granting diplomas, since candi-
dates would not be admitted to the exam-
ination for license with less preparation. It
was more than possible that the effort would
be made to weaken the law by amendment,
or to have it repealed. He urged that the
law as it now stood should be accepted loy-
ally. If, on due trial, it should be found
to contain defects they could be remedied
as experience showed their existence.

Dr. Willy Meyer, of New York, in a

2l6

New York Correspondence.

Vol. Ixiv

paper on the progress of cystoscopy in the
last three years, gave the histories of some
very interesting examples of the great ad-
vantages which had been derived from the
use of this instrument in determining many
points, by actual observation, of the pro-
cesses going on within the bladder which
, proved of signal service in the indication
for treatment. The author had demon-
strated to his own satisfaction that cysto-
scopy was an easy and harmless examina-
tion, but that its successful employment re-
quired experience. In all kidney or blad-
der disease it might be practiced repeatedly
if necessary, before operative interference
for diagnostic purposes was undertaken. It
should be performed as a dernier ressort after
all other known means for making a diag-
nosis had been exhausted. If properly ap-,
plied cystoscopy would clear up uncertainty
in an obscure disease of the bladder. In
most cases we could determine with the
help of electric illumination of the bladder
whether we had to deal with disease of the
bladder or of one of the kidneys. We
should soon be able with the instruments
now in process of perfection to catheterize
the ureters and gather the urine from each
kidney separately. These facts would tend
to make superfluous a preliminary section or
a perineal invasion for diagnostic purposes.

Dr. F. R. Sturgis, of New York, made a
plea for the advantages which he contended
the Holt's operation by divulsion of the ure-
thral strictures possessed over internal ure-
throtomy. It was well known that even fatal
hemorrhages occurred as a sequel to the lat-
ter method. Since adopting rapid dilata-
tion he had never had an instance of hemor-
rhage uncontrollable by cold or septic in-
jections- By Holt's method the occurrence
of severe chills was avoided, in fact he now
deemed it unnecessary to take precautions
against this accident. Septic complications
he had never known as the direct result of
rapid divulsion.

Dr. D. Lewis said he had got quite ac-
customed to patients coming to him from
the urethral operator with their boots full of
blood, and then it took as long to gtt them
into shape as it would have done to cure the
stricture by gradual dilatation.

Dr. L. C. Grav narrated an interesting
case of paralysis of the motor and muscular
senses involving the upper and lower ex-
tremity of one side, in which the symptoms
had been rapidly developed and in which a
diagnosis had been made of tumor of the

centrum ovale. At the autopsy a round-cell
sarcoma about the size of a hickory nut was
found about one-fourth of an inch beneath
the cortex at the junction of the leg and arm
centre of the posterior central convolution.
Dr. Gray considered this case unique in view
of the rapid growth of the lesion, as indicat-
ing the exact localization of the muscular
sense.

Dr. St. John Roosa, in a paper on the
causes of asthenopia, denied the existence of
a perfectly normal refraction. The emme-
tropic eye was not known in the human race,
unless as a rarity. It was absurd to attempt
the cure of asthenopia by tenotomies upon
the ocular muscles. All the causes of this
condition, excepting in those cases which
were congenital and resulted from irregular-
ities in the development of various diam-
eters of the eyeball, were to be looked for
in abnormal states of the nervous system.

Dr. Noyes emphatically opposed this view
and believed that muscular insufficiencies
might often be found and treated by prisms
or operation and the existing asthenopia
thereby benefited or cured.

An entire session was devoted to the sub-
ject of appendicitis. Dr. C. McBurney said
that clearly-defined rules as to when a case
of appendicitis might be left to medical
treatment alone could not be laid down. It
might be laid down as a rule with but few
exceptions that the indications for advanc-
ing disease could be clearly made out by the
end of thirty-six hours, if an early diagnosis
had been made and this had been followed
up by subsequent careful examinations. Sig-
nificant symptoms at this period offered the
necessary indications for operation.

Dr. Robert F. Weir said he had been
obliged to modify his opinion of a year ago.
He now believed that intermediate laparot-
omy or operation in the quiescent stage in
recurrent cases might be done where the pa-
tients were debarred from the enjoyment of
life or the ability to earn a living.

Dr. A. Vanderveer, of Albany, con-
sidered that the care of cases of appendicitis,
so far as the physician was concerned, con-
sisted in an early diagnosis, and that then it
became his duty promptly to share the re-
sponsibilities of the case with the operating
surgeon until surgical interference had been
decided upon or negatived.

The President, in his annual address, dis-
cussed the problem of the education of girls.
In the course of his remarks he said that the
sexual system was the pivotal part of wo-

Feb. 21, 1 89 1. New York Correspondence.

217

mau's organism, and when disordered or dis-
eased the pernicious effects of such derange-
ments pervaded her whole being. The re-
productive organs were in ultimate relation
with all the other organs, through the gan-
glionic system and with the brain through
the cerebro -spinal system. At puberty and
. sometimes before, as well as after, the ner-
vous element was dominant in the female
economy, and these two systems, the sexual
and nervous, acted and reacted upon each
other with a complexity difficult to compre-
hend. Now if the nervous supply to the
sexual system was received from an over-
taxed and badly-nourished brain, it was but
reasonable ' to anticipate disturbance of the
functions of the latter. The essence of
many of the diseases which afflicted young
women lay, not in the reproductive organs in
the beginning, but in faults incident to imper-
fect hygienic surroundings, faulty alimenta-
tion, overwork in study, and a variety of
causes which operated banefully at a time
when, by the predomination of the sexual
sphere, the local expression of the fault was
referred to the sexual system. He would
have young girls taught the importance of
eating good, plain, nutritious food, and
above all, the necessity of eating a hearty
breakfast. Too many young women had
grown up to regard it as vulgar to indulge
the appetite at the morning meal, and had
been allowed to cultivate the habit of minc-
ing and sipping at a few dainty dishes or had
been permitted to go without breakfast alto-
gether. It had been said that a woman's
physical beauty was in direct proportion to
the amount of beefsteak and mutton chops
she could consume at this meal.

Elaborate reports were made in a series of
carefully-prepared papers by a number of
physicians, upon whom have devolved the
initial experiments with Koch's lymph in
New York and elsewhere.

It would be superfluous to go over the
ground of evidence and information, the de-
tails of which are already graven upon the
mind of every inquiring physician in the
land. Expressed as a simple equation, it
would appear that with the exception of lu-
pus, and some cases of laryngeal tuberculo-
sis, which are so far reported cured or greatly
benefited, the lymph has failed as yet to re-
alize the overwrought expectations which
characterized its reception as a specific ther-
apeutic agent. It was, however, calmly
stated that the time had not come when a
final opinion could be demanded, and that

to the best of the belief of the various exper-
imenters, the agent would yet prove as pow-
erful, from a remedial point of view, as it
was now shown to be in determining the exist-
ence of tuberculous tissue within the human
organism. It was also conceded that to
Koch would belong the honor of ushering
before the medical profession a therapeutic
principle pregnant with possibilities, the im-
portance of which was beyond prophecy.

In the course of a long session devoted to
the subject of gynecology Dr. McMurtry,
of Louisville, stated that when a patient
presented the history of recurrent attacks of
pelvic inflammations it was at once indica-
tive of leaky tubes. In such event the only
treatment was by abdominal section. It was
amazing to see with what reluctance the
medical profession had come to accept this
great advance in pelvic surgery. Even now,
when masses of suppurating tubes and ova-
ries were dug out of the pelvis in the midst
of virulent peritonitis, and the patients were
saved from an hitherto fatal condition, many
eminent members of the profession stigma-
tized the procedure as the castration of wo-
men. So far as he was aware surgeons oper-
ated upon the female pelvis for local disease
only and never with the idea of affecting
a cure of reflex disturbances and obscure
symptoms.

In a discussion as to the value of electric -
ity as a remedial agent in the treatment of
uterine tumors Dr. Ross, of Toronto, ex-
pressed the opinion that electricity was fast
losing its fashionable favor and that the bat-
tery was walking in the footsteps of the
spray ; still it might remain of use to the
profession in a variety of ways. Dr. Gill
Wylie thought that electricity as a destruc-
tive agent to the tissues of the tumors was
practically of no influence. If used to stop
hemorrhage it must be employed in such
strength as to act as a cautery. It was import-
ant to avoid any form of treatment which
would leave a scar in the uterine tissues,
which would be liable to close up the glands
and follicles, thus interfering with normal
secretion and setting up a train of reflex
symptoms. He considered the use of elec-
tricity as dangerous as that of operative
procedures.

Dr. A. W. Suiter, of Herkimer, was
elected President for the ensuing year.

— Picrotoxine, the active principle of coc-
culus indicus, is considered by Bokai as the
best physiological antidote for morphine.

218

Periscope.

Vol. lxiv

Periscope

The Koch Treatment in Vienna.

The correspondent of The Lancet, Janu-
ary 31, 1891, says: Koch's second pub-
lication .has caused considerable surprise
in medical circles, and especially the first
passages of his paper in which all the pub-
lications made by clinical observers on the
action of the remedy were ignored. Re-
collecting the statement of Minister von
Gossler, that the preparation of the remedy
could not be described (a unique statement
in view of the great advancement of natural
science), the physicians were somewhat as-
tonished by the simplicity of the preparation
of Koch's liquid, the more so as Koch was
found to be following the directions initi-
ated by Pasteur's school, and by the
works of the late Dr. Wooldridge, Hankin
and others, without mentioning even the
names of his scientific predecessors. It
must be assumed that Koch's second publi-
cation has not been less premature than his
first one, and that it has been provoked by
Virchow's reports. The effect of suggestion
on the subjective symptoms in patients could
not be better illustrated than in the recent
era of Koch's treatment. At first it was
rare to find a patient subjected to the cure
who did not feel better at least in some way
after the injections ; ' but after Virchow's
publication, which has been widely circu-
lated by the lay press, the majority of pa-
tients in the General Hospital commenced
to complain of different new subjective
troubles which were ascribed by them to the
action of the liquid, and there were fre-
quently cases where the patients, formerly
highly enthusiastic, declined to be treated
further by Koch's method. Certainly the
General Hospital, with its constant pressure
of space, has not been a suitable place for
such an extensive trial as has been made
here at the clinics, where about 30 per cent,
of the beds were alloted to tuberculosis and
lupus cases — that is, to cases which would not
have applied for admission to hospital wards
under ordinary circumstances.
• It cannot be said that any case has been
cured by the treatment, but it must be
stated that improvement has taken place
in some of the cases of surgical tubercu-
losis. New eruptions of lupus nodules have
made their appearance in Professor Kaposi's
improved cases. There is also a difficulty
in the improved cases as very large doses

(5 centigrams and more) do not produce
any reaction, and one does not know how
far the dose of the injection can be raised.
It is extremely difficult to say anything
about the pulmonary cases. It seems that
there are two different types. In one of
them the temperature curve rises after every
injection corresponding to the reaction, but*
returns to the previous level ; while in the
other the temperature curve does not re-
turn to its former level, and the patients
remain feverish after the reaction has passed .
The latter type is the less favorable for the
treatment, and to it belong most of the fatal
cases. .

Not less difficult is the explanation of
the anatomical facts, as the pathological
changes occurring in the course of tubercu-
lous disease have not been fully recognized
till now, and there is no other disease which
has been more neglected by pathologists on
the Continent on account of its frequency.
But in slight cases of laryngeal tuberculosis,
where the changes could be observed clini-
cally by the laryngoscope day by day, it
could be stated that the injections of
" Kochin " caused the rapid and extensive
appearance of new ulcerations, sometimes
of highly destructive tendency, and at the
last meeting of the Medicinisches Doctor-
encollegium a case was shown where the ul-
cerative process occurring after the injec-
tions was an extensive one, which has never
been observed by any of the Viennese pro-
fessors. These observations seem to cor-
roborate Virchow's statement that a dissemi-
nation of the tuberculous virus takes place
in the body due to the injection. Referring
to the diagnostic value of the fluid, it has
been reported already to The Lancet that it
produced local and general reaction in cases
of leprosy, actinomycosis and fever (with
small doses, one to two milligrams) in
apparently healthy persons. The explana-
tion of the action of his liquid given by
Koch in his recent publication was also not
believed to be satisfactory in medical circles
here. It seems to me that the specific
action of the liquid must correspond to a
specific chemical substance contained in the
mesoblastic tissues under certain pathologi-
cal conditions — e. g., tuberculosis, lupus,
lepra, actinomycosis — and Koch's discovery
will certainly stimulate the hitherto neg-
lected study of pathological chemistry. At
present we know only a single chemical sub-
stance peculiar to tuberculosis — viz., cellu-
lose, or at least a substance exhibiting all the

Feb. 21, 1 891.

Periscope.

219

reactions peculiar to cellulose, which was dis-
covered some years ago in the blood and in
the tissues of tuberculous cases by Dr.
Freund, of Vienna. This discovery, reported
in The Lancet oi 1887, confirmed later by
Dr. Kabrhel, of Prague, and which is also
highly interesting from the naturalist's stand-
point, did not receive much attention.

Treatment of Painful Menstruation.

Dr. E. H. Champneys, at the conclusion
of several lectures on painful menstruation,
writes as follows of the treatment of this
condition in the Lancet, Dec. 27, 1890 : It
will be impossible to do more than indicate
principles of treatment. These comprise
treatment between and during the periods.
In the first place comes the question of
general mode of life. Generally speaking,
this should not be too sedentary. Plenty
of healthy exercise, and especially riding,
will promote the circulation through the
pelvis, and give the generative organs a bet-
ter chance of developing. In the same con-
nection must be mentioned the maintenance
of the regular action of the bowels by laxa-
tives, and particularly salines. This has the
same purpose : to avoid stagnation of blood
in the pelvis. It is probable that of all
drugs in the treatment of chronic pelvic dis-
orders, Epsom salts are the most valuable.
Indeed, with constipation, none of this class
improve, even if treated by the newest alka-
loids. The diet should be simple and whole-
some ; in fact the patient should go into a
sort of gentle training. During the pain
most patients are better at rest, or even in
bed ; but some find their pain relieved by
exercise, even unusually active. Pessaries
(except the Hodge's pessary in a few cases of
descent with retroflection, and except the
stem pessaries) he believes to be absolutely
useless. The stem pessaries are not always
useless, but are dangerous, and should not
be used. Incision of the os externum is
useless ; incision of the os internum is not
always useless, but is highly dangerous.
Among drugs, guaiacum, with or without
sulphur, is sometimes useful, taken regularly
in milk as a powder, or as a confection.
Castoreum sometimes abolishes the spasm
completely.

Dr. Champneys has known cases treated
by nearly, if not quite, all the usual drugs
unsuccessfully, get well suddenly as soon
as castoreum was given. It is. best given

in the form of tincture, from twenty to
thirty drops three or four times daily dur-
ing the pain, with or without a few drops
of tincture of nux vomica. A hot foot bath,
and a good glass of hot gin-and-water at
bedtime, at the beginning of the pain, is an
old and valuable remedy. It probably acts-
by relaxing the vaso-motor and muscular
spasm. The gin should be given once a
month only. Ergot is sometimes useful by
causing tonic contraction, and stopping'
what Reil would call the irregular, fibrillar,,
streaky, non-peristalic uterine contractions.
Dilatation is the last resort. It is generally
contra-indicated in the presence of inflamma-
tory signs in the pelvis, even if old. It
must be carried out with all antiseptic pre-
cautions, and is not, in his opinion, so trivial
a proceeding as to be safely done in the
consulting-room. The pain also is often
agonizing, and is far greater than that
caused by some operations for which anaes-
thetics are habitually given. For these rea-
sons he prefers to perform dilatation at one-
sitting under anaesthesia, and with full anti-
septic precautions, after ascertaining that
the genuine dysmenorrhoeal pain is evoked
by dilatations of the os internum, a point
which greatly improves the prognosis. Noth-
ing can be promised, for dilatation may
give temporary relief, permanent relief, or
no relief at all. Still, considering the slight
risk, he uses it rather freely, for there are
cases which seem most unpromising, and yet
are cured by it. He speaks of one such case ;
"a patient who had suffered for years, had
had many treatments, including division of
the cervix, which was followed by perimetri-
tis, completely matting the posterior part of
the pelvis. The pain was not only men-
strual, but almost continuous. Her medical
-man in the west of England sent her to me
to see what I could do for her. In spite of
the very unfavorable conditions I dilated
her cervix, and she lost from that time both
menstrual and inter-menstrual pain. Her
medical man wrote to me some time later to
suggest that as she was so much better he might
dilate the cervix again. I advised him to
let well alone, and he took my advice."

The best time to dilate the cervix is about
midway between the periods. Hegar's di-
lators do very well, or we can use the me-
tallic bougies. The dilatation should not be
pressed when great resistance is felt, or the
cervix may be lacerated, even with fatal
result. The object is not to enlarge, but to
stretch the canal. But this stretching is gen-

220

Periscope.

Vol. lxiv

erally not satisfactory unless the largest
bogie varies from the size of a cedar pencil
to that of the tip of the little finger. Two
or three-bladed dilators are bad instruments ;
they stretch the canal unequally, and are
liable to tear it. They are out of fashion
in England, though not apparently in Amer-
ica and on the Continent.

Mammary Abscess in the Virgin.

Dr. Jule E. Marcus, of Cincinnati, gives
in the Cincinnati Lancet- Clinic, January
17, 1891, an interesting account of a case
of abscess of the breast in a young girl.

Cases of mastitis in the young, he says,
are not altogether uncommon, as histories
of cases are related, though in limited num-
bers, by various English, German and
French authorities, in connection with the
general subject of breast diseases of an in-
flammatory character. It is, however, a
rare event for the mamma during the period
of its development to go on to suppura-
tion, though frequently subject to temporary
sensations of pain, irritability and tender-
ness from various causes. Dr. Marcus has
had, in a fairly extended practice, but this
one case. The patient was seventeen years
of age, a well matured, hearty appearing
girl, who prided herself on never being sick.
Her menstrual period arrived with her four-
teenth year, and was always correct as to
time and quantity. Her only illness pre-
vious to this abscess was an cedema of the
left knee, in connection with fleeting pains
in the ankle and shoulder of the same side,
occurring during the last spring. She was
placed on the usual anti-rheumatic remedies,
with the result that in ten days she was quite
well, and able to take her place at her desk
as stenographer.

In June she had a painful condition of
the chest on the left side, locating the trouble
over the sternum, and beneath the breast
and under the arm. It had only been within
the past two or three weeks that she has be-
come fully conscious to the fact that there
was an irregular painful condition, con-
stantly becoming more persistent, and claim-
ing her attention.

The only symptom was pain of lancinat-
ing character, snooting from behind the
breast, back to the muscles of the shoulder-
blade, and extending downward in the side.
There was no fever, no malaise ; the girl
had no cough, nor difficulty of breathing,

and Dr. Marcus presumed there was another
exhibition of her rheumatic trouble, and
prescribed accordingly. She took salicylate
of soda, hydriodic acid, etc., etc., but no
marked improvement followed. Dr. Marcus
examined the breast carefully, with no sus-
picion, however, of an inflammatory trouble
being present, but could find nothing to
explain the persistent pain, that was not
varying in character, and was her only com-
plaint. The girl began losing rest at night,
but had no acute or excessive attacks of pain ;
never complained of throbbing or beating
that would have led him to think an abscess
was forming. Dr. Marcus again made a
careful examination, but found no local
visible signs, certainly no lymphatic enlarge-
ment in the region, and was therefore sur-
prised when in the space of twenty-four
hours a rapidly developed inflammatory ac-
tion set in. Diffused redness, swelling,
tenderness over the entire breast and neigh-
boring muscles were present.

Dr. Marcus anticipated 1 deep-seated
trouble, and aspirated, drawing some mat-
ter and settling the diagnosis of a deep-
seated, intra-glandular abscess of the mam-
ma, chronic in character, and of long, slow
development. On opening the lobes with a
curved bistoury, cutting from the areola
downward, with a deep, free incision, two
teacupfuls of pus escaped. At the end of
two weeks there remained a fistulous track.

Some weeks following, the breast again
swelled, became tense and red, and in-
tensely painful. In consultation with Dr.
Ransohoff, the patient was anaesthetized, and
the breast well opened. All the lower lobes
were honeycombed with abscesses, with
deep sacs over the pectoralis-major muscle.
The gland was thoroughly scraped, and the
abscesses broken'up, drainage-tubes inserted,
and iodoform gauze dressing applied, and
the case did nicely, with such local and
constitutional attention as is usually given
to surgical cases.

Nothing remained at the end of the third
week but some disfigurement of the gland.

Chronic abscess of the breast of the young
is probably more influenced by catemenial
disturbance than any other source. The
gland at the period of puberty is in sympa-
thy with the menses in a greater state of
functional activity than at any time ex-
cepting the early period of lactation. Any
unusual interference with the structural
changes of the breast at this period would
be apt to produce inflammatory action — not

Feb. 21, 1 891.

Periscope.

221

frequently going on to suppuration, however.
At the period of full development of the
breast after the menstruation has been fully
established, these gland inflammations are
said to be of most common occurrence, and
the slow developing chronic abscesses of
more frequent occurrence than the acute.
Cases of abscesses in both mammae in a
virgin are cited, establishing a pathological
cause; where a traumatic origin would most
likely suggest itself if only the one breast
were involved.

In a brief review of the literature on the
subject, Dr. Marcus found reference made
by various authorities to cases of mastitis
occurring in young subjects of both sexes.
Velpeau relates histories of three cases not
especially interesting. Bressler ralates a
most interesting case of pyemia and death
from breast abscess in a young female child.
Following the abscesses in both glands, oth-
ers developed in different parts of the body,
and the child died of "pyemic poisoning.
Thomas Bryant relates histories of three cases
of mastitis in virgins ; all interesting, and
in two cases recurrent abscesses developed
after the lapse of considerable interval of
time. In none of the recorded cases com-
ing under my notice was a traumatic origin
assigned, excepting Bressler's. In that case,
squeezing the breast to produce a flow of
milk was the accepted cause for the original
inflammatory action in the breast ; and" he
makes a point of calling attention to the.
fact that such a practice of working the
breasts in young infants is common in the
lying-in room, and may at any time be
productive of harmful effects in the infant.
Such a practice can only be deplored, and
quite forcibly shows how necessarily atten-
tive must be the practitioner to even the
smallest details regarding the welfare of his
patient in the sick-room.

Billroth says, in his treatise on the Dis-
eases of the Female Breasts: "Inflamma-
tion, with formation of abscess after puberty,
and unconnected with pregnancy, are very
rare. The course is more tedious than in
puerperal mastitis. Of the seven cases that
have come under my notice, five suppurated,
and two underwent resolution."

Artesian Wells in Iowa. .

The Engi?ieering Record, January 31,
says that the director of the Iowa Crop and
Weather Service, seems, from a recent article
in the Iowa State Register, to have under-

taken quite an important work in the direc-
tion of developing the subterranean water
supplies of the State. It is probable that
water can be obtained from artesian wells
in nearly all parts of the State. But, as
sinking such wells is an expensive operation,
and, if done hap-hazard, may be barren of
results, it is s proposed to have made, with
the assistance of a geologist, Prof. R.
Ells'worth Call, a systematic geological ex-
amination of the whole State, so as to de-
termine the localities in which desirable
water-bearing strata would be found at mod-
erate depths, making wells *unk therein
reasonably sure of being successful. Direc-
tor Sage hopes, in time, to be able to map
in this way all such areas of artesian prob-
ability, for the benefit of farmers and others
interested in obtaining water supplies.

To assist in this work circulars have also
been sent out for the purpose of obtaining
existing information relative to artesian
wells already sunk, such as character of
strata penetrated and especially of that in
which the water was found, dip of strata,
temperature and quality of water, amount of
flow, etc. , and also a record of unsuccessful
wells.

This project, if pursued intelligently and
thoroughly, must give results of great value
to the citizens of the State.

Cancer of Bartholinian Gland.

At a recent meeting of the St. Petersburg
Obstetrical and Gynecological Society, Dr.
I. A. WofT has related an exceedingly rare
instance of a solid new growth developing
in a Bartholinian gland. A married woman,
aged 42, who had been regularly menstruat-
ing since her fifteenth year, and had a labor
at full term and two abortions, received a
contusion of her left labium majus. Shortly
afterwards she noticed at the spot a lump of
the size of a pea, which began to gradually
increase. On admission to Prof. K. F.
Slaviansky's clinic, the patient had a tumor
of the size of a goose's egg, involving the
posterior part of the labium majus and an
adjacent portion of the labium minus. On
the inner surface of the former there was
present an orifice, from which a dirty-looking
fluid was oozing out. The new growth was
excised together with portions of the labia.
A microscopical examination revealed that
the tumor was an adenoid cancer (adeno-car-
cinomd) of the Bartholinian gland.

During a discussion following Dr. Woff's

222

Periscope.

Vol. lxiv

communication, Dr. Voskresensky said that
he had also seen a case of a solid new growth
of the gland. In 1887 a woman* of 62 years
had consulted him on account of indolent
movable dense tumor. The latter had been
excised fairly easily and proved to be of a
fibroid structure. Two years later the pa-
tient returned with another tumor, which
had developed in the same situation, , but
this time appeared to be of a malignant na-
ture. On this occasion the excision was
very difficult, being accompanied with an
" enormous hemorrhage." Prof. A. I.
Krassowski, the illustrious obstetrician and
gynecologist, emphasized that solid new
growth of the Bartholinian glands were ex-
tremely rare, while cysts and abscesses were
fairly common. Personally, he had not
come across a single case of the former kind.
The speaker added that in his hands excision
of Bartholinian cysts was invariably accom-
panied by a severe hemorrhage. — Vratch,
No. 49, 1890, p. 1127.

Treatment of Paroxysmal Nerve
Disorders.

In the Practitioner, January, 1891, Dr.
Frederick Pearse has a short article on the
treatment of paroxysmal nerve disorders,
including in this class asthma, migraine and
epilepsy. Dr. Pearse has great confidence
in the efficacy of belladonna juice and
chloral. In asthma he gives fifteen to
twenty minims of the juice, with ten grains
of chloral, every four hours, during an at-
tack. To break up the habit, he gives the
chloral and belladonna night and morning,
or every night. He seeks to prevent attacks
of migraine in much the same way, some-
times giving the chloral and belladonna
every night for a few days before an ex-
pected paroxysm. Antipyrin, in large doses,
he says is the most serviceable for the par-
oxysms of pain in migraine. Most persons,
however, find small doses effective.

In the treatment of epilepsy, he has found
chloral and belladonna useful to assist the
bromides, and he mentions borax in thirty-
grain doses with apparent approval.

Case of Ancephalia.

Dr. O. V. Leonova, a medical woman of
Moscow, communicates a remarkable case
of an ancephalous monster, which was born
alive (at full term) and survived for about
seventeen hours (so that the parents had had

enough time to baptize it). On the post-
mortem examination (under Prof. D. N.
Zernoff's guidance), the brain proved to be
entirely absent, while the spinal cord ter-
minated in the shape of a knot, which was
adherent to a layer of cicatricial tissue,
stretched horizontally across the base of the
skull and representing the cranial vault. The
said knot was found to constitute a rudi-
mentary lower end of the medulla oblon-
gata, consisting almost totally of white mat-
ter. The bulbar gray substance was repre-
sented by a single nucleus — namely, by that
of the nervus hypo-glossus. In other words,
the infant had been able to live for nearly a
score of hours in spite of a complete absence
of the respiratory centre. — Transactions of
the Moscow University Physico- Medical
Society, Nos. 3 and 4, 1890, p. 89.

Poison Glands of Toads and Sala-
manders.

Science, January 23, 1891, says that a mi-
croscopical study by Herr Schultz, of the
skin of toads and salamanders, has yielded
some interesting results. As stated in Na-
ture, there are two kinds of glands, — mu-
cous and poison glands. The former are nu-
merous over the whole body ; while the lat-
ter are on the back of body and limbs, and
there are groups in the ear-region behind
the eye, and in the salamander at the angle
of the jaw. The mucous glands are spherical,
have a clear, glassy appearance, and con-
tain mucous cells and mucus : the poison
glands, which are in regular strips on the
salamander, are oval, much larger, and have
a dark, granular look, from strongly refrac-
tive drops of poison, a good re-agent for
which is copper-hematoxylin. The poison-
ous elements are from epithelial cells lining
the glands. The mucous glands are for
moistening the skin ; and the liquid has no
special smell, nor a bitter or acid taste.
The poison glands are, of course, protective ;
and the corrosive juice is discharged differ-
ently in toads and salamanders, on stimulat-
ing electrically. In the latter it is spirted
out in a fine jet, sometimes more than a
foot in length ; whereas in the toad, after
longer action of the current, it exudes spar-
ingly in drops. The physiological action
of the poison has lately been studied by
some Frenchmen. There is no reason, , ac-
cording to Herr Schultz, for supposing that
the mucous glands sometimes become poison-
ous.

Feb. 21, 1891.

Editorial.

223

THE

MEDICAL AND SURGICAL

REPORTER.

ISSUED EVERY SATURDAY.

CHARLES W. DULLES, M.D.,
Editor and Publisher.

N. E. Cor. 13th and Walnut Streets,
P. O. Box 843. Philadelphia, Pa.

4®=* Suggestions to Subscribers :

See that your address-label gives the date to which your
subscription is paid.

In requesting a change of address, give the old address as
well as the new one.

If your Reporter does not reach you promptly and regu-
larly, notify the publisher at once, so that the cause may be
discovered and corrected.

-^^Suggestions to Contributors and Correspondents :
Write in ink.

Write on one side of paper only.

Write on paper of the size usually used for letters.

Make as few paragraphs as possible. Punctuate carefully.
Do not abbreviate or omit words like "the" and "a," or
*' an."

Make communications as short as possible.

Never roll a manuscript ! Try to get an envelope or
wrapper which will fit it.

When it is desired to call our attention to something in a
newspaper, mark the passage boldly with a colored pencil, and
write on the wrapper " Marked copy." Unless this is done,
newspapers are not looked at.

The Editor will be glad to get medical news, but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

NEUROSES OF THE GEN ITO- URINARY
APPARATUS.

At a recent meeting of the Chicago Acad-
emy of Medicine, Dr. G. Frank Lydston
made an address in regard to genito-urinary
neuroses, in which he very properly limited
the term to cases of purely functional de-
rangement of the genito-urinary organs de-
pendent upon pathological conditions of
neighboring organs and conditions — proba-
bly of a spasmodic character — immediately
dependent upon organic lesions of some
portion of the genito-urinary tract itself.
There are few morbid conditions of a func-
tional character, which are so trying to the
patient or so embarrassing to the surgeon,
.and in the experience of physicians it is
found that they are apt to be more often
consulted regarding these functional ner-
vous derangements than for the actual dis-
eases upon which they depend. In view of

the vast amount of labor and talent that has
been devoted to the study of the reflex neu-
roses of women incidental to pathological
conditions of the uterus and its adnexa, it
is, as Dr. Lydston said, surprising that more
attention has not been given to analogous
conditions in the male, due to disturbances
of the generative organs, and especially of
the urethra.

Taking as the point of departure the
prostate, there will be found a close simi-
larity between some of the morbid states
affecting it and certain pathological condi-
tions of the uterus. Anatomically and phy-
siologically the prostate strongly resembles
the uterus. The tendency of its muscular
tissue to undergo degeneration, and to form
fibro -myomatous growths is strikingly like
that observed in the case of the uterus. It
will be found that certain remedies which
have a marked action upon the unstriated
muscular fiber of the uterus have a some-
what similar action upon the prostate, this
being especially true of the ergots of rye
and corn and hamamelis. Certain sedative
remedies have a special controlling effect
upon irritative affections of the uterus, ova-
ries and prostate alike. Carrying the argu-
ment a little further, it will be found that
certain irritations of the prostate produce
effects very like that induced by utero-
ovarian irritation in women. False sper-
matorrhoea — spermatophobia — pseudo-im-
potency, involving disgust for the sexual
act, melancholia, hypochondria, neuralgias
whether of contiguous or remote nervous
filaments and nervous inhibition, amounting
almost to complete paralysis, are all possible
results of urethral or prostatic irritation, and
these conditions are all represented by very
similar disturbances, such as hysteria and its
congeners in the female, due to morbid con-
ditions of the generative organs.

One of the interesting features of stricture
of the urethra is the ensemble of symptoms
of a nervous character that is so often seen,
these neuroses being often entirely dispro-
portionate to the degree of organic trouble

224

Editorial.

Vol. lxiv

present. Cephalagia, neuralgia in various
localities, particularly sciatica, lumbar and
intercostal neuralgia, are quite common, but
are probably regarded by both physician
and patient as coincidences rather than as
bearing any consequential relation to the
stricture. Associated with these symptoms
are others, quite as prominent in some cases,
of a purely mental character, such as melan-
cholia, disturbed sleep, hypochondria, in-
capacity for intellectual effort and deterio-
ration of business capacity, perhaps associ-
ated with great irritability of temper. Dis-
turbed digestion and general impairment of
nutrition are quite constant. That these
various abnormal conditions depend upon
the stricture, Dr. Lydston said, is never ap-
preciated fully until that organic disease is
cured, when the complete restoration to
health demonstrates their true relation to the
primary source of irritation. Some cases of
gleet are associated with considerable men-
tal depression, which is commonly ascribed
to the moral effect and the supposed drain
upon the system. This lack of mental
equilibrium may arise from reflex irritation
through the sympathetic system, which is so
closely allied with the functions and nutri-
tion of the sexual organs. Morbid condi-
tions of the urethra not only cause reflex
neuroses in other portions of the body, but
they are frequently the reflex result of dis-
ease of contiguous strictures. Thus Dr.
Lydston has noted cases of spasmodic stric-
ture depend upon hernia and varicocele,
and Dr. Otis has described some very in-
teresting cases of chronic spasmodic stric-
ture of reflex origin. Operations about the
anus are frequently followed by spasmodic
stricture and consequent urinary retention
and morbid conditions of the interior por-
tion of the urethra often cause reflex dis-
turbances of the deeper portion of the canal
or indeed of the bladder. This is very
familiar in connection with the results of
contraction of the meatus.

These remarks of Dr. Lydston, who has
made a special study of the subject of which

he speaks, may well attract attention. In
one sense it can hardly be said that the re-
mote effects of disturbances of the genito-
urinary apparatus have been neglected, for
many quacks have dwelt upon them too
much to their own advantage. But it is
true that the nervous derangements due to
disturbances or disease of the genito-urinary
apparatus of men have not been studied as
thoroughly and as systematically as their
congeners in women have been, and it may
be well to have this point impressed upon
physicians, so that some of the zeal now per-
haps needlessly spent upon the genitalia of
women may be directed to recognizing and
curing the ailments of the sterner sex.

TRANSPERITONEAL HYSTEROR
RHAPHY.

From time to time the various methods
for permanently anteverting the retro-dis-
placed uterus have been commented upon
in the Reporter. Dr. Florian Krug, of
New York, has proposed a new method of
ventro-fixation of the uterus without open-
ing the peritoneal cavity. His method is
applicable only to cases of obstinate, mova-
ble, backward displacements of the uterus,
which have not proven amenable to other
treatment. The technique is as follows :
The patient is put in Trendelenburg's posi-
tion, the usual preparations for an abdominal
section having been made. An assistant
now seizes the anterior lip of the cervix with
a tenaculum, and inserts a sound into the
uterus, and a catheter into the bladder ; and
brings the uterus forward, by gentle efforts,
against the abdominal wall. A small incis-
ion is now made through the linea alba down
to the peritoneum, at the point which is se-
lected for the attachment of the uterus,,
The finger inserted into the wound can
locate the fundus, and also the bladder,
when the sound and the catheter are alter-
nately pushed upon. A special needle is
now passed through the abdominal wall into
the peritoneal cavity, and is made to de-

Feb. 21, 1 89 1.

Book Reviews.

225

nude about one square inch on the anterior
surface of the uterus, the needle then being
passed through the body of the uterus and
made to emerge at a place opposite to
the point of entrance. It is now threaded
with silkworm gut and withdrawn. The
suture is now tied, and usually suffices to
close the wound. From five to eight min-
utes are required for the operation. Dr.
Krug has operated upon six patients with
good results.

The test of the value of any operative
procedure is the results to be obtained by its
use. At the same time, the writer does not
believe that the procedure proposed by Dr.
Krug has a wide field of usefulness. Many
retro-displacements of the uterus, in which
the uterus is freely movable, give rise to no
symptoms, and require no treatment. Most
cases which cause suffering are curable by
the proper use of tampons and a pessary,
and it is only the small remainder for which
the operation is recommended. In these
cases the operation comes in competition
with Alexander's operation, with hysteror-
rhaphy done without incising the abdominal
wall (Kelly), and with hysterorrhaphy pre-
ceded by abdominal section (Olshausen,
Kelly). It is difficult to see how that this
method gives a better fixation than is ob-
tained by ventro- fixation without incision of
the abdominal wall, and the writer is aware
of no case in which permanent fixation has
been secured by this method. The subse-
quent behavior of these six cases will be
awaited with interest, for if the fixation
prove permanent, Dr. Krug will prove a
benefactor, as providing an easy method of
curing certain obstinate, backward displace-
ments of the uterus.

NASHVILLE JOURNAL OF MEDICINE.

The Nashville Journal of Medicine and
Surgery opens the new year with a new and
very much improved form, and we hope
will enter a new era of success.

Book Reviews.

[Any book reviewed in these columns may be obtained upoa
receipt of price, from the office of the Reporter.]

ESSENTIALS OF PRACTICE OF MEDICINE.
Arranged in the form of questions and answers.
Prepared especially for students of medicine. By
Henry Morris, M. D., Late Demonstrator, Jeffer-
son Medical College, etc. With a very complete
Appendix on the Examination of Urine. By Law-
rence Wolff, M. D., Demonstrator of Chemistry,
Jefferson Medical College. Small 8vo, pp. xv, 426.
Philadelphia: W. B. Saunders, 1890. Price, $1. 00.

This volume includes The Essentials of Practice, hy
Dr. Morris, and The Essentials of the Examination of
Urine, by Dr. Wolff, which have heretofore appeared
as separate parts, forming Nos. 8 and 9 of Saunders'
series of compends. The plan of these books is too
well known to warrant discussion, and the necessarily
brief manner in which diseases are handled almost
disarms criticism. In looking over the book, however,
several improvements have been suggested. For ex-
ample, in speaking of ordinary facial erysipelas, Dr.
Morris would have done well to make it clear that sore
throat and swelling of the cervical and sub-maxillary
glands generally precede an attack, and that a relapse
is liable to occur as long as the throat and nasal pas-
sages remain in an unhealthy condition. Under typh-
litis and peri-typhlitis, also, the author should have
stated that these affections are really, in the great ma-
jority of cases at least, attacks of appendicitis. Again,
he is in error when he says that the urine of chronic
parenchymatous nephritis is " scanty, high-colored and
of high specific gravity." It may be diminished in
quantity, but it is not scanty or high-colored, and the
specific gravity is lower, instead of higher, than nor-
mal. The author makes substantially the same state-
ment regarding the urine of acute parenchymatous
nephritis, of which disease, of course, it is true.

Dr. Wolff's portion of the book has been reviewed
recently in the Reporter, so that no special mention
need be made of it now.

In spite of the defects which we have noted, the
book is a good one, and it will prove very helpful to
students preparing for examination.

A TEXT-BOOK OF MATERIA MEDICA, PHAR-
MACOLOGY AND SPECIAL THERAPEU-
TICS, with many new remedies of late introduc-
tion. By I. J. M. Goss, A. M., M. D., Professor of
the Practice of Medicine in the College of Eclectic
Medicine and Surgery, Atlanta, Ga., etc. Second
edition. Revised by the author. 8vo, pp. xlviii,
586. Chicago : W. T. Keener, 1889. Price, $5.00.

This is a book on materia medica and therapeutics
written by an eclectic for eclectics, as its rather long
title indicates. Theoretically, electicism, that is to say,
the method of one who picks and chooses what he
believes to be best, without following any leader or
theory, is the method adopted by every intelligent prac-
titioner of medicine ; practically, however, those who
adopt the title eclectic have a theory as to the action
of medicines, and, as might be expected, it is as false
as that which forms" the basis of homoeopathy or allo-
pathy. The theory of eclecticism, as stated by Dr.
Goss, is : " That when medicines are introduced into
the system they are digested, and being absorbed and
circulated through the system, they have, per se, an
affinity for certain parts of the organization (sic) upon
which they have a specific action, and are then elim-

226

Correspondence.

Vol. lxiv

■mated." It would appear from this definition that the
real eclectic is the remedy, which selects the part upon
which to act, and not the prescriber, who chooses the
remedy.

The usual assertions are made about medical science
advancing fast, and that " ere long ' pathys ' and 1 isms '
will no longer clog the wheels of advancement." We
could wish that knowledge had traveled so far that
even Dr. Goss would know that no intelligent man
believes in \he theory which the term " allopathy " ex-
presses, and that no school teaches it.

As to the arrangement of the book, nothing need
be said, except that it is unscientific. It is, neverthe-
less, of considerable value as a work on therapeutics,
for most, if not all, of the standard remedies are con-
sidered fairly, with many new ones. Of the value of
the latter one cannot judge from Dr. Goss's statements
alone, because he is too prone to speak dogmatically.
They may, however, be very valuable, and Dr. Goss
has done a real service in calling attention to them.
The chief fault of the book is the fact that the impres-
sion left upon the reader is that diseases are groups of
symptoms instead of processes, having definite causes,
courses and results. One who followed Dr. Goss's
^teachings might become an excellent dispenser of
• drugs, and might give great relief to his patients; but
he never could become a physician. One cannot help
suspecting, also, that Dr. Goss praises many of his
remedies unduly, and that the effects which are as-
serted to follow their use will by no means surely follow
when the remedies are used by others. Of this charge,
however, Ringer and others who ought to know better
. are equally guilty.

Correspondence.

Antipyrin in Puerperal Fever.

To the Editor.

Sir : I was somewhat surprised to read in
the Reporter for June 31, the following,
in an article quoted from the Lancet. "Dr.
McBeath has never noticed in any publica-
tion that antipyrine has been used with suc-
cess in puerperal fever." Not to go any fur-
ther, I may say that as long ago as 1887, I
used antipyrin in a bad case of "puerperal
fever" in twenty-grain doses — smaller quan-
tities having proved ineffectual — with ben-
efit, so far as reducing a high temperature
(105°-]-,) and quieting delirium and rest-
lessness were concerned. That case and
others were reported in the Reporter dur-
ing that year, I think. I have learned to
esteem antipyrin highly in all diseases char-
acterized by restlessness, delirium and high
temperature, and have not observed any bad
effects, perhaps for the reason that I invari-
ably accompany or follow it with either an
alcoholic or aromatic spirits of ammonia.
Nevertheless, I do not believe it exerts any
specific action in puerperal fever. From
what I have seen of this disease, I believe

that the treatment having most to commend
it is that based on what is assumed when it
is spoken of as puerperal septicemia, and
that the good effects obtained by antipyrin
may likewise be obtained by phenacetin or
antifebrin.

Yours truly,
Stanley M. Ward, M. D.

Scranton, Pa.

Medical Examiners' Bill in Penn-
sylvania.

To the Editor.

Sir : Canada and eighteen of own States
have passed laws establishing "examining
boards" as proposed by the " Riter " bill,
now before the Legislature of Pennsylvania,
and in consequence the States not so pro-
tected are receiving more than their quota
of piebald doctors.

The public in this State are protected by
Inspectors of Weights and Measures from
dishonest tradesmen, and druggists are com-
pelled to qualify before a State Board of
Examiners, and why should they not be pro-
tected from incompetent physicians? As
the law now stands, no evidence of medical
knowledge is required before engaging in
the practice of medicine. The most igno-
rant has only to make an affidavit that
he has been in practice for ten years to be-
come a registered physician, even though
he has to make his mark, because he cannot
write his name.

The medical college with hospital attach-
ment has become, of late, one of the money-
making industries of the country, with un-
limited capacity, free raw material, and the
motive power supplied and the running ex-
penses shared by the public by means of tne
"charity act" by appeals for aid for the
hospital.

By the terms of the " Riter " bill, all de-
siring to practice medicine must pass a sat-
isfactory examination before duly-appointed
medical examiners for the State, irrespective
of schools or systems. The eclectic is left
free to make his own selections ; the elec-
tropath can still perform miracles with a fif-
teen-dollar battery ; the hydropath Can
drown every known disease in water; the
faith curer and magnetic healer can pray and
magnetize to his heart's content ; the ho-
moeopath can still administer his prepara-
tions of the matter from small-pox sores, or
the itch pustules of the negro, his solutions
or powders of bed-bugs or cock-roaches, of

Feb. 21, 1 89 1 . Notes and

Comments.

227

the acarus found under the wing of the Phila-
delphia house-fly, of tarantulas, snakes, red
ants, spiders, potato-bugs, plant-lice, snails,
wood-lice, skunks, wasps, lizards, toads,
vipers, or guano, or of the excreta of the
whale, etc. — all of which will be found in
the list of materia medica contained in
the American Ho??iceopathic Pharmacopoeia,
Boericke & Tafel, 1883.

All former legislation on this subject has
been effectually frustrated by the .above
schools, especially the homoeopaths, who
have been most bitter against any law which
would compel them to undergo an open and
public examination of their fitness to prac-
tice medicine. Yet, notwithstanding the
above fact, by posing as martyrs they suc-
ceeded in obtaining State aid to the amount
of fifty thousand dollars last year, and are
aiming to get at double the amount this year.

Many cases might be cited to demonstrate
the necessity for the passage of the proposed
bill, but the following will suffice :

An innocent, hard-working German, suf-
fering from stone in the bladder, applied for
treatment to a member of the Philadelphia
County Medical Society. He had been un-
der treatment for over a year, of a woman
who sold bread from her shop in the morn-
ing and practiced medicine when not other-
wise engaged. According to his statement,
she gave him " yarb " teas to drink, pulled
and manipulated his testicles, causing him
intense pain ; instructed him to urinate in
pigs' bladders and to suspend them on a
tree, and as these bladders rotted he would
be relieved of his trouble, but should he
ever again look at that tree his trouble would
return. This not being successful, she in-
structed him to urinate on a broom, which
would generate a current of electricity which
would pass from the broom, through the
stream, to his bladder, and thereby effect a
cure. This woman was prosecuted by the
Philadelphia County Medical Society, with
a number of others, for practicing without
being registered. She pleaded guilty in or-
der to suppress the foregoing facts, which
would have appeared at the trial, paid the
fine imposed by the Court, then registered
under the ten years' clause of the Registry
Act, and, if still living, is one of Philadel-
phia's registered practicing physicians, with
all the privileges of the most learned and
skilful practitioners of the day.

If the homoeopaths want the community
to have such persons practicing, let them
continue to oppose the Medical Examiners'

Bill — if they do not, let them support it, as
the only measure proposed which would give
the community a satisfactory method of
compelling all who assume such responsibil-
ities to attain a definite standard of educa-
tion, and the only one which could not be
evaded by medical colleges.

Yours truly,

J. H. Lopez, M. D

Philadelphia.

Notes and Comments,

Information about the Army Medi-
cal Department.

The Medical Department of the Army
consists of one Surgeon-General with the
rank of Brigadier-General ; one Assistant
Surgeon- General, one Chief Medical Pur-
veyor and four Surgeons with the rank of
Colonel ; two Assistant Medical Purveyors
and eight Surgeons with the rank of Lieu-
tenant-Colonel ; fifty Surgeons with the
rank of Major ; and one hundred and twenty-
five Assistant Surgeons with the rank of
First Lieutenant of Cavalry for the first five
years of service, and of Captain of Cavalry
subsequently until their promotion by sen-
iority to a majority.

With the rank stated in each case the pay
and emoluments of the rank are associated.
The salary of each grade is a fixed annual sum,
payable monthly ; but at the end of each
period of five years of service the annual sum
representing the pay of the grade is increased
by ten per cent, until forty per cent, is
added. After twenty years of service the
forty per cent, additional continues to be
drawn, but the further increase of the pay
by ten per cent, additions ceases, i. e., an
officer, although he may have served twenty-
five or thirty or more years can, under ex-
isting laws, have no more than forty per
cent, added to his pay proper by way of in-
crease for length of service. The pay of
a first lieutenant of cavalry, or of a medical
officer during the first five years of his ser-
vice is $1,600 per year, or $133.33 per month.
At the expiration of his five years of service
he becomes, by virtue of that fact, a cap-
tain, and his pay is that of a captain of
cavalry, $2,000 per year, increased by ten
per cent, for his years of service, viz., $2,200
annually, or $183.33 monthly. At the end
of his tenth year of service this rate of
pay is increased by the service-addition to

228

Notes and Comments.

Vol. lxiv

$2,400 annually, or $200 per month, and
after five years more the service-addition
makes his pay $2,600 annually, or $216.67
per month. If he continue in the rank of
captain, at the end of twenty years of service
his monthly pay becomes $233.33 ; but
about this time promotion to a majority is
usually obtained, and a major's annual pay
of $2,500 with forty per cent, added, makes
the monthly pay of the major and'surgeon
$291.67. Subsequent promotion, investing
the individual with the rank of lieutenant-
colonel, colonel and brigadier-general, aug-
ments the monthly pay respectively to

$333-33>$375-ooand$458-33- Cumpulsory
retirement at the age of sixty-four years in-
creases the rapidity of promotion to the
younger men ; and when retirement is effected
either by age, or by the accidents of service
prior to reaching the retiring age, the rate of
pay subsequently drawn is seventy-five per
cent, of the total salary and increases of the
rank held by the individual at the time of his
retirement. Thus, a major retired for bro-
ken health after twenty years' service draws
seventy-five per cent, of $291.67 per month ;
a colonel retired for age, seventy-five per
cent, of $375.00. The medical officer has
the right of selecting quarters in accordance
with his rank, and when stationed in a city
where there are no Government quarters,
commutation money, intended to cover the
expense of house rent, is paid to him. The
Government provides forage and stable room
for the horses of the medical officer, and
when traveling under orders the expenses
of transportation are paid by the Quarter-
master's Department.

Among the privileges granted to medical,
as to other officers of the Army, is that of
leave of absence on full pay. The author-
ized leave amounts to thirty days annually.
This leave is not forfeited if not taken dur-
ing the year, but is credited to the officer,
who may thus accumulate a continuous leave
of four months on full pay. If he desires
to be absent for a longer period than four
months, and the permission is accorded
him, he is reduced to half-pay for all time
in excess of the four months or maximum of
cumulated leaves of absence. Absence from
duty on account of sickness does not affect
the relations of the officer with the pay-
master ; he continues to draw full pay.

A commission in the Medical Department
of the Army is an instrument which is good
for life, premising conduct consistent with
its retention on the part of its possessor ;

but it involves no contract which binds the
individual to service for any given number
of years. On the contrary, should the med-
ical officer find on experience that civil life
has greater attractions for him than that of
the Army, there is nothing to prevent him
from at any time tendering the resignation
of his commission.

A young medical officer on appointment
is usually assigned to duty for a few months
at some large post where there are other
officers of his department, to afford him
opportunity of becoming acquainted with
the requirements of the Army Regulations
and the routine duties of military life.
After this he goes to some post west of the
Mississippi river, where he serves a tour of
duty of four years. An assignment in the
east follows the leave of absence which is
usually taken at this time ; and in after years
his stations are selected so as to give him a
fair share of service at what may be called
desirable posts as an offset to the time spent
at less desirable stations.

Candidates for appointment to the Med-
ical Corps -should apply to the Secretary
of War for an invitation to appear before
the Army Medical Board of Examiners.
The application should be in the hand-
writing of the applicant, should give the
date and place of his birth and the place and
State of which he is a permanent resident ;
it should be accompanied by certificates
based on personal acquaintance from at least
two persons of repute as to citizenship, char-
acter and moral habits. Candidates must
be between twenty-one and twenty-eight
years of age (without any exceptions), and
graduates of a regular medical college, evi-
dence of which, the diploma, must be sub-
mitted to the Board. The morals, habits,
physical and mental qualifications and gen-
eral aptitude for the service of each candi-
date will be subjects for careful investigation
by the Board, and a favorable report wull
not be made in any case in which there is
a reasonable doubt.

The following is the general plan of the
examination :

I. The physical examination will be rigid ;
and each candidate will, in addition, be re-
quired to certify " that he labors under no
mental or physical infirmity, nor disability
of any kind, which can in any way inter-
fere with the most efficient discharge of any
duty which may be required."

II. Oral and written examinations on sub-
jects of preliminary education, general liter-

Feb. 21 , 1 89 1. Notes and

Comments.

229

ature, and general science. The Board will
satisfy itself by examination that each candi-
date possesses a thorough knowledge of the
branches taught in the common schools, es-
pecially of English grammar, arithmetic and
the history and geography of the United
States. Any candidate found deficient in
these branches will not be examined further.
The examination on general science will in-
clude chemistry and natural philosophy, and
that on literature will embrace English liter-
ature, Latin, and history, ancient and mod-
ern. Candidates claiming proficiency in
other branches of knowledge, such the
higher mathematics, ancient and modern
languages, etc., will be examined therein,
and receive due credit for their special qual-
ifications.

III. Oral and written examination on
anatomy, physiology, surgery, practice of
medicine, general pathology, obstetrics and
diseases of women and children, medical
jurisprudence and toxicology, materia med-
ica, therapeutics, pharmacy and practical
sanitation.

IV. Clinical examinations, medical and
surgical, at a. hospital, and the performance
of surgical operations on the cadaver.

Due credit will be given for hospital train-
ing, and practical experience in surgery,
practice of medicine and obstetrics.

The Board is authorized to deviate from
this general plan whenever necessary, in such
manner as it may deem best to secure the
interests of the service.

The Board reports the merits of the can-
didates in the several branches of the exami-
nation, and their relative merit in the whole,
according to which the approved candidates
receive appointments to existing vacancies,
or to vacancies which may occur within
two years thereafter. At the present time
there are five vacancies to be filled.

An applicant failing in one examination
may 'be allowed a second after one year, but
not a third.

No allowance is made for the expenses of
persons undergoing examination, but those
who are approved and receive appointments
are entitled to transportation in obeying
their first order assigning them to duty.

Politics and Pension Examiners.

In an editorial, the Indiana Medical Jour-
nal, February, 1891, speaks as follows in
regard to a recent appointment by the Pres-
ident.

The Journal is not a partisan paper, but
occasionally politics trends so closely upon
the interests of the profession and the wel-
fare of the sick, that our readers will excuse
us for entering a solemn and vigorous pro-
test against the appointment by President
Harrison of an incompetent negro, S. A.
Elbert, said to be a* physician, upon the Ex-
amining Board for Pensions in this city,
displacing Dr. R. F. Stone, the ablest phy-
sician on the Board and a veteran Union
soldier. This appointment is, to say the
least, an outrage upon common decency, and
an insult to every soldier residing in Indiana
and every reputable physician of Marion
county and the State.

If Elbert were a physician of eminence or
marked ability in any department of medi-
cine, there might be some word said, by the
administration, in extenuation of the act
reflecting upon the ability of no less than
five ex-Union soldiers, now reputable physi-
cians, who were applicants for position upon
the Board at the beginning of this adminis-
tration. But such is not the case. This
negro does not approach mediocrity in med-
ical attainments, and it is doubtful if he
could give the origin and insertion of one
muscle in the human body.

The appointment is an inexcusable, inde-
fensible and disgraceful blunder. From
among two hundred physicians of this city
and county, many of whom are men of
marked ability in the profession, the little
General is unable to select one who can do
honor to the place, himself, the appointing
power, and the G. A. R., so he is constrained
to select one of the two sable followers of
^Esculapius. The purpose of the appoint-
ment is apparent to the most obtuse ; yet it
remains to be seen whether this appointee
can wield a political influence which will
overbalance that of the two hundred physi-
cians of Indianapolis, the five thousand
physicians of Indiana, and the thousands of
veteran soldiers who are held in contempt
by this administration, and compelled to
submit their claims for pensions to the judg-
ment of an incompetent negro doctor.

The various Boards of Examiners for Pen-
sions were created by the government for
the purpose of fairly adjusting the claims of
wounded and diseased soldiers, and it was
intended that they should be composed of
the very best medical talent available, in
order that justice might be done to both
soldiers and the government. But it has re-
mained for Benj. Harrison to not only vio-

230

Notes and

Comments.

Vol. lxiv

late his pledge made to the soldiers, during
and after the campaign of 1888, viz., that
that section of the revised statutes making
it obligatory — other things being equal — to
appoint soldiers to places of remuneration
under the government in preference to civ-
ilians, should be enforced, but he has delib-
erately, with this promise still fresh upon
his lips, prostituted the office of Pension
Examiner to the basest political purposes,
unmindful of his sacred obligations to the
Union veterans and their interests, the
claims of comradeship, and the sanctity of
his oath of office.

We do not believe there lives a soldier in
Indiana who is so lost to self-respect as to
present himself before the Indianapolis
Board, as now constituted, for examination;
nor can the other members of the Board
preserve their dignity, self-respect, and the
respect of the profession in any other way
than by resigning.

At the stated meeting of the Marion
County Medical Society, January 20, there
being forty members present, the following
resolutions, presented by Dr. Frank Fergu-
son, were unanimously adopted :

Resolved, That the recent action of the
President of the United States, in removing
from the Board of Pension Examiners of
Indianapolis an honored member of this
Society and a veteran Union soldier, in or-
der to give place to one who is not, and who
never has affiliated with the profession, and
who does not possess the necessary qualifica-
tions for the important trust thus committed
to his hands, is a base and inexcusable pros-
titution of the office of Pension Examiner
to partisan purposes and an insult to every
reputable physician in this city and State.

Resolved, That the Secretary is instructed
to forward a copy of these resolutions to the
President of the United States and to the
daily papers of this city.

[It would be pleasant to know that there
was some better reason for the President's
action in this matter than that which our
contemporary's remarks indicate — or that
the President had corrected his error.]

Statement by Tait Corrected.

Sir Spencer Wells writes to the Lancet,
January 31, to correct an assertion made by
Mr. Lawson Tait, and seems to do so pretty
effectually. He says that at the meeting of
the British Gynecological Society, Decem-

ber 12, 1888, Mr. Lawson Tait said "he
had a specimen to show which bore very
much upon what had just been said ; he
showed the appendages from a lady, thirty-
nine years of age, with a very remarkable
history. She had been married at the age
of seventeen or eighteen, and had two chil-
dren within twenty months of her marriage.
Soon after her second confinement she con-
tracted gonorrhoea from her husband, and
she had never known what it was to be well
since. She had led a life of single misery
for several years. Then she married again,
but her health did not improve, and she
never became pregnant by her second hus-
band, so that ever since nineteen or twenty
she had been absolutely sterile. During the
last seven years she had been the patient of
a distinguished gynecological baronet, who
had, however, failed to relieve her. Ulti-
mately she had been referred to him and he
had operated. She had double pyo-salpinx
of old standing, and it was very difficult to
say which was tube and which was ovary.
There were abscesses in both ovaries, and if
he had attempted to tap them from the vag-
ina, he would have been obliged to tap sev-
eral cavities. Instead of doing anything of
the kind, he opened the abdomen a month
since, and the patient was now practically
cured. A case like that was worth a dozen
hypothetical imaginations. There was a
woman who had been an invalid for years,
who could have been relieved at any time,,
who had been under the care of all the well-
known specialists of London, many of whom
had declared that there was nothing the
matter. ' '

In the letter published in the Lancet,
January 24, Tait adds that if anybody is
answerable for this failure "it is Sir
Spencer Wells, who, during seven long
years, treated this poor woman uselessly by
pessaries, etc." And he adds that the case
is "not a failure," . . . the patient is
"absolutely cured, for I have the diseased
parts in a bottle."

Sir Spencer Wells says: "This lady is
now in London. I have submitted the fol-
lowing questions to her, and I add her re-
plies :

" 1. During the seven years 1881—88
were you under my care, and did I fail to
relieve you? Reply: I consulted you in
1879, after Dr. Palfrey had failed to do me
any good. You operated on me in the sum-
mer of 1879; I was in good health after that
until you again operated on me in 1880.

Feb. 21, 1 89 1 . Notes and

Comments.

231

After that I enjoyed good health until
1887.

" 2. Had you, before 1888, been ' an in-
valid for years,' or ' led a life of single mis-
ery for several years ?' Reply : Except be-
tween my second confinement and 1879, I
had been in good health.

"3. After your second confinement had
you ' been absolutely sterile ?' Reply : I
had two children after my second confine-
ment— one born dead, one lived two weeks
and I had one miscarriage at three months.

"4. Have you been 'under the care of
all the well-known specialists in London,
many of whom declared that there was noth-
ing the matter?' Reply : You are the only
medical man I consulted in London be-
tween 1879 and 1888, and no one ever told
me that there was nothing the matter.

"5. Did I treat you 'for seven long
years by pessaries, etc. ?' Reply : No, you
never used a pessary; nor, after your second
operation in 1880, treated me except for
slight ailments, and that seldom. In 1887,
while you were abroad, I was treated by Mr.
Smith, of Brighton, after a carriage accident
and was recovering when you returned.

" 6. Remembering your state before and
after the operation performed at Birming-
ham in November, 1888, has that operation
proved to be, in your opinion, a ' practical
cure ' or a ' deplorable and disastrous fail-
ure?' Reply: A decided failure.

"I need only add to this the fact that the
operation I performed in 1879, assisted by
Mr. Thornton, was amputation of part of
the elongated cervix uteri. Dr. Palfrey had
repeatedly injected solution of perchloride
of mercury into the substance of the cervix,
and it was feared that the disease was papil-
loma or epithelioma. Examination proved
that it was simple hypertrophy of the utric-
ular glands, or adenoma. About a year after
this amputation, the remains of the cervix
showed some tendency to enlarge and pro-
liferate, and I destroyed the left side by the
actual cautery. For two or three days after
this there was a good deal of pain and
some fever, but they soon subsided, and until
1887 — about seven years — the patient was as
well as most people, and for several months
after her second marriage, in February, 1888,
remained in good health, riding, rowing and
walking four or five miles without fatigue.
Since the operation in November, 1888, she
has been a confirmed invalid. The failure
to the husband has been 'disastrous' in ex-
penditure; to two devoted daughters in health

and anxiety from continuous nursing ; to the
patient 'deplorable' in more than two years'
almost continuous suffering and shattered
health. It is a very poor consolation to her
to be assured that she is 'absolutely cured'
because her 'diseased parts are in a bottle.' "

Medical Examiner's Bill in Penn-
sylvania.

Under the head of Correspondence, the
New York Medical Times, February, 1891,
publishes the following, which is especially
interesting as appearing in a journal long
sailing under the homoeopathic flag.

Medical legislation in Pennsylvania is in
an unsettled condition. At the last meet-
ing of the Legislature the Medical Exam-
iners' bill was defeated through the active
efforts of the New School. In anticipation
of renewed efforts for its passage this year,
the New School will offer a substitution
measure entitled "An act to establish a
State Board of Medical Education." This
board is to consist of nine members to be
selected equally from three lists of ten names
submitted by the State medical societies " to
the intent that the three systems of medi-
cine, homoeopathic, allopathic and eclectic,
be equally represented thereon."

The duty of the board is to regulate the
extent and character of the preliminary edu-
cation to be required of all medical students ;
to fix the minimum curriculum of studies in
medical colleges, provided that the course
shall be not less than four years, which shall
include three years of lectures. Each grad-
uate of colleges as upon evidence of the dean,
has conformed to the requirements of the
board, shall receive a certificate entitling
him to register in any county of the State.

Graduates of other colleges whose stand-
ing is approved by the board receive a simi-
lar certificate allowing them to practice, but
if from colleges of a lower standing they
must first pass an examination which shall
apply to their preliminary education as well
as medical knowledge.

Should the board discover after the pas-
sage of the act, that any medical college
has granted the degree to any one deficient
either in preliminary or final examination it
shall proceed against such college for in-
fringement of the law. The penalty for the
first offense is a fine, and for a second of-
fense a fine and the certificate withheld
from future graduates except upon examina-
tion before the board. In conviction for a

232

Notes and

Comments.

Vol. ixiv

third offense the charter of said college shall
be annulled.

It is difficult to see what advantage this
bill has over a fair Medical Examiners' bill.
Both admit the principle of outside inter-
ference with the right of college faculties to
decide who shall enter upon the practice of
medicine. The Medical Education bill does
this by prescribing the curriculum and then
approving the work of colleges living up to
it. The Medical Examiners' bill does it by
requiring a final examination of all gradu-
ates before they shall be allowed to practice
in the State. The latter method is the sim-
pler one, and makes no discrimination in
favor of medical colleges located in the
State, and is similar to the methods adopted
by the profession in other States.

It would be difficult for the Board of
Medical Education to decide that other
medical colleges in the United States were
living up to its standards, because even in
Pennsylvania, to make sure of this fact,
part of section 6 provides that " the board
shall delegate one or more of their number,
who from time to time shall make an in-
spection of the methods of instruction em-
ployed and the facilities for teaching, in
each such medical college and annually
report the same to the board."

The New School bill, by removing the
fear of another examination from all who
graduate at colleges in the State, legislates
for the colleges rather than for the profes-
sion at large, because they would attract
more students by holding out as an induce-
ment the freedom of practice in Pennsyl-
vania to all their graduates, and it is very
probable that a large number of the latter
would enter the already overcrowded ranks
of the profession in that State.

Let Pennsylvania pass a Medical Exam-
iners' bill that is fair to the whole profession
of that State, and when the remaining States
have done likewise, then let us have a Na-
tional Board which shall prescribe a uniform
examination for all graduates in medicine
(this was first suggested by Prof. Osier of
Johns Hopkins), so that having passed the
examination in Pennsylvania, the certificate
of that examining board shall be accepted
by every other State as granting the right to
practice medicine.

State Board of Health.

At the quarterly meeting of the State
Board of Health of Tennessee, January 6,

1 89 1, the Secretary, Dr. J. Berrien Lindsley,
read a report, in which he said that of the
forty-four States forming the American
union, thirty-four have created Boards* of
Health. These differ widely in their powers
and functions and also in the means at their
disposal for efficient work. Some are merely
advisory bodies. Others have great execu-
tive power. Some are so niggardly endowed
as to have only a nominal existence. Others
are so munificently supported as to be seen
and felt through beneficent work in every
section of their field.

The older States of the Northeast first
recognized the value of such agencies for
promoting the public welfare. Among these
Massachusetts and New Jersey are prominent,
I appropriating thousands annually for their
support, and in addition printing for distri-
bution among the people large editions of
reports and circulars.

In no part of America have the objects of
such Boards met with so great favor as in the
new, wide-awake and rapidly advancing
States of the Northwest. The great farm-
ing States, especially Michigan, Illinois and
Minnesota, may be mentioned as illustra-
tions. The volumes issued by .the State
Boards of Michigan and Illinois have given
those States a national — even more, a Euro-
pean reputation. Michigan and Minnesota
are also distinguished for the wonderful co-
operation received from local Boards, which
in each State number fifteen hundred or
more.

In every instance where a State Board has
been furnished with liberal means it has
found favor with the people and has become
a permanent and valued portion of the State
machinery, second alone to its kindred
branch of Public Education.

Tennessee has a Board of Health rather
peculiar in its structure, capable of furnish-
ing to the State great results at a minimum
of cost, as has been tested more than once
in its brief history.

It is in fact a collegiate body, composed
of five medical experts, each proficient in
his own department, and of two men emi-
nent in railroad and mercantile circles.
Each of these members is at the beck and
call of the State whenever his services are
needed, and at very moderate cost. In ad-
dition, the Secretary, who is not a member
of the Board, is always ready on a moment's
notice to visit any locality upon its order.

The ordinary work of the Board and the
readiness for extraordinary occasions is.

Feb. 21, 1 89 1 . Notes and

Comments.

233

greatly facilitated by the publication of a
monthly bulletin [from which the Reporter
makes this abstract] which is systematically
circulated throughout the State, and likewise
sent to public libraries, boards of health, and
similar institutions in all the States as well
as to a very large list of exchanges. The
bound volumes take the place of annual re-
ports, for which there has been no statistical
material. This Bulletin is also the journal of
the State Weather Service, an indispensable
agency of all live States, which was about to
perish five years ago, when this Board, re-
cognizing the intimate connection of clima-
tology with the work, saved its life.

Five and a half years' experience fully
demonstrates the wisdom of this action.
Practically, it has been copied by what is
virtually the National Bureau of Health at
Washington.

A prominent feature in the Bulletin is the
publication of truthful vital statistics, with-
out favor or partiality. Of course, with the
incomplete and perhaps exaggerated returns
from 1885 to 1890, errors were unavoidable.
All statisticians understand this. From now
on these statistics should be accurate and
reliable. One marked result of the steady
circulation of this information has been
greatly increased confidence of life insurance
companies in Tennessee as a field for their
business. A signal instance of this is the
erection in Memphis of a noble structure by
one of the most noted companies in the
world.

Not less noteworthy is the effect of this
Bulletin in directing the attention of desi-
rable emigrants to our State. One of the
greatest treasures Tennessee can boast is its
beneficent climate. Nowhere else has this
life-giving wealth been so well displayed as
in the sixty-six numbers of this monthly,
steadily sent to those throughout the Union
who understand its language and can appre-
ciate its meaning.

Resorcin in Diphtheria,

One of the few of the numerous drugs
introduced in recent years which has stood
the test of time is resorcin, which has been
chiefly used for skin complaints, but has also
been found useful in whooping-cough. The
Lancet, December 20, 1890, says that Dr.
Andeer, of Munich, gives, in the St. Peters-
burger Med. Wochenschrift, 1890, a sum-
mary of its advantages in the treatment of
diphtheria. He refers chiefly to French

authors. Leblond and Baudier have shown,
in an exhaustive treatise, that in resorcin we
have an antiseptic of the first rank ; it ex-
erts a destructive influeuce on micro-organ-
isms, even in extremely dilute solutions, and
in spite of the rapidity with which it is ab-
sorbed and again excreted from the body.
Its easy solubility in all fluids, its rapid
evaporation by heat, in addition to the com-
pleteness with which it mixes with the air,
without any discomfort to the patient, ren-
der it suitable for the destruction of all
pathogenic micro-organisms. Roux and
Yersin have conclusively demonstrated that
diphtheria only attacks open wounds, con-
sequently all further injuries to the parts
attacked ought to be carefully guarded
against, so that all mechanical modes of re-
moving the diphtheritic membranes are to
be avoided, and the same may be said of
the use of drugs for a like purpose. The
latter are particularly dangerous on account
of any excess which may fall on healthy tis-
sues, so preparing fresh ground for the mor-
bid process. Any antiseptics which may
be used ought to have no injurious effects on
the parts not attacked. Such an antiseptic
is a 10 per cent, solution of resorcin in gly-
cerine.

Several severe cases of diphtheria have
been successfully treated -in this way by
Leblond, Baudier, Besnier, Thorens, and
others. They advise that the solution should
be applied by means of a brush every hour
during the day and every two hours during
the night ; also that the air of the room
should be kept saturated by means of a spray
apparatus containing a watery 5 per cent,
solution of resorcin.

The conclusions to which the authors
named above have come are as follows :
1. When the larynx is not affected the
disease usually disappears in from six to
ten days. 2. If the treatment is adopted
at the commencement of the attack, the
formation of membrane is very slight, and
the larynx generally escapes. 3. In ad-
vanced cases, if the glands are swollen, and
plaques of membranes numerous over the
back of the throat, after forty-eight hours'
treatment by resorcin the swelling of the
glands begins to subside, and the formation
of any fresh membrane is prevented. 4. In
all cases the general state of the patient re-
mains satisfactory, the sustained appetite
and clear voice proving that there is no
serious constitutional affection. 5. If the
larynx is attacked, resorcin is not so bene-

234

Obituary.

Vol. lxiv

ficial; nevertheless, the drug may still be
used advantageously by fumigation and
atomization if there is sufficient space in the
larynx to prevent asphyxia, or if tracheotomy
is likely to prove of permanent relief.

Army Medical Board.

An Army Medical Board will be in ses-
sion in New York City during April, 1891,
for the examination of candidates for ap-
pointment in the Medical Corps of the
United States Army, to fill existing vacan-
cies, numbering now five.

Persons desiring to present themselves for
examination by the Board will make appli-
cation to the Secretary of War, before April
1, 1 89 1, for the necessary invitation, stat-
ing the date and place of birth, the place
and State of permanent residence, the fact
of American citizenship, the name of the
medical college from whence they were
graduated, and a record of service in hospi-
tal, if any, from the authorities thereof.
The application should be accompanied by
certificates based on personal knowledge,
from at least two physicians of repute, as to
professional standing, character and moral
habits. The candidate must be between 21
and 28 years of age, and a graduate from a
regular medical college, as evidence of
which, his diploma must be submitted to
the Board.

Further information regarding the exam-
inations may be obtained by addressing the
Surgeon-General U. S. Army, Washington,
D. C. C. Sutherland, Surgeon-General U.
S. Army.

Quill Drainage-Tubes.

Dr. Otis K. Newell, Surgeon to the Out-
patient Department of the Massachusetts
General Hospital, Boston, says, in the Med-
ical Record, February 7, 1891, that Dr.
Beach has used for the past two years, at his
clinic, drainage-tubes made from large-sized
imported goose-quills, such as are used for
making the finer grades of camel's- hair
brushes. The quills are taken without cut-
ting off the dermal end, and perforated at
intervals with an ordinary round leather
punch. As shown in a figure, a delicate
and smooth probe-pointed tube is thus pro-
vided, presenting, the maximum lumen and
minimum thickness of wall. This tube is
made from a natural dermal appendage and
is absolutely un irritating. If can be readily

cut with scissors, and is not fragile like
glass. It does not undergo any of the irritat-
ing chemical changes which are frequently
seen where rubber tubes have remained for
any length of time. These tubes are pre-
served in corrosive sublimate or carbolic
acid solutions, and are easily sterilized.

Homoeopaths Converted.

The New York Medical Times (a sort of
homoeopathic journal), in its issue for Feb-
ruary 7, 1891, says: "Dr. Carroll Dunham,
son of the late Carroll Dunham, M. D., for
a long time Professor of Materia Medica,
etc., in the New York Homoeopathic Medi-
cal College, according to the Afedical Reg-
ister of the United States, is a graduate of
the said homoeopathic college of the year
1880, and of Bellevue Hospital Medical
College of 1887, and is registered as a
' regular ' physician residing at Irvington,
N. Y. We are informed that Dr. E. K.
Dunham, another son of the late Dr. Car-
roll Dunham, is also a ' regular' physician !
We are told that several sons of the late Dr.
Berens, a homoeopathic physician of Phila-
delphia, are in the f regular ' school ! The
list could be extended ! It certainly looks
as if these gentlemen were not satisfied that
homoeopathic colleges in general teach the
whole of medicine."

OBITUARY.

CHARLES WALTER, M. D.

On Thursday, February 12, 1891, Dr.
Charles Walter died of pneumonia, after an
illness of three days, at the premature age of
twenty-five years. Dr. Walter was grad-
uated from the Medical Department of the
University of Pennsylvania, in 1888, and
wras elected one of the resident physicians
to the Philadelphia Hospital, serving from
August, 1888, until early in January, 1890,
when he was elected permanent resident
physician in the Insane Department, which
position he held until the time of his death.

By his associates, to whom his untimely
death will prove a severe blow, Dr. Walter
was held in high esteem for his earnestness,
his conscientiousness and his fidelity to
duty.

But a few days ago, his assiduity was the
means of saving a young life hovering at
the point of death.

Medical and surgical
Reporter

A Weekly Journal.

Established in 1853 by S. W. Butler, M.D

CHARLES W. DULLES, M. D., Editor and Publisher,

as Second-Class matter at Philadelphia P. O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

I. LXIV, No. 9.
rhole No. 1774.

FEBRUARY 28, 1891.

$5.00 per Annum.
10 Cents a Copy.

3NICAL LECTURE.

OOZLsTTZETSTTS :

EDITORIALS.

Coltman, Dr. Robert, Jr., Tung Chow Fu, China.
— Nervous Dyspepsia. — Chronic Dysentery.—
Moist Gangrene.— Facial Paralysis 235

>MMUNICATIONS.

Noble, Charles P., M. D., Philadelphia, Pa.—
Peroxide of Hydrogen for Cleaning the Hands. 237

Currier, John M., M. D., Newport, Vermont.—
Medical Colleges of Vermont.— Bogus and Gen-
uine ... 237

Slifer, H. F., North Wales, Pa.— General Anti-
septic Medication 241

Curtis, F. O, M. D., Albany, New York.— Vesi-
cular Eruption in Scarlatina 241

CRISCOPE.

Life-Saving Methods in Still-Births.— Homoeop-
athy by a Homoeopath — Removal of the Uter-
ine Appendages in Cases of Functional Neuro-
sis.—Operation for Cerebral Hernia.— Practice
by Syphilized Practitioners.— Therapeutic Use
of Monesia Bark.— Medical Practice in Missouri.
—Caustic Treatment of Carbuncle and Diph-
theria.—Fish Poison 216-252

Gynecological Suggestions 263

Nature of Lupus 254

Hoxceopaths and the Medical Examiners' Bill 255

BOOK REVIEWS.

Foster ; Illustrated Encyclopaedic Dictionary.—
Charles Letts & Co.'s ABC Medical Diary and
Visitiug List 256

LITERARY NOTES.

NOTES AND COMMENTS.

Endorsing Diplomas in Pennsylvania — The Ho-
moeopaths and the Medical Examiners' Bill. —
Lupus — or Tuberculosis of the Skin.— Associa-
tion of American Anatomists. — Dangerous
Lunatic. — Medical Legislation in Arkansas. —
Dirtiest City in the World.— How the Homoeo-
paths Look at it. — Koch's Treatment Con-
demned.—Shaving with Vaseline 256-26

CH. MARCHAND'S

Peroxide of Hydrogen

(MEDICINAL) H2 02 (Absolutely Harmless.)

Is rapidly growing in favor with the medical profession. St is the
most powerful antiseptic known, almost tasteless, and odorless.
Can be taken internally or applied externally with perfect safety.
■ Its curative properties are positive, and its strength and purity
can always foe relied upon. This remedy is not a Nostrum.

a remedy for DIPHTHERIA ; CROUP ; SORE THROAT,

AND ALL INFLAMMATORY DISEASES OF THE THROAT.
OPINION OF THE PROFESSION.

Dr. E. R. Squibb, of Brooklyn, writes as follows in an article headed "On the Medical Uses of Hydrogen Peroxide (Ga/Y/ar
Medical Journal, March, 1889, p. 267), read before the Kings County Medical Association, February

" Throughout the discussion upon diphtheria very little has been said of the use of the Peroxide of Hydrogen,
or hydrogen dioxide ; yet it is perhaps the most powerful of all disinfectants and antiseptics, acting both chem-
ically and mechanically upon all excretions and secretions, so as to thoroughly change their character and
reactions instantly. The few physicians who have used it in such diseases as diphtheria, scarlatina, small-pox,
and upon all diseased surfaces, whether of skin or mucous membrane, have uniformly spoken well of it so far as
this writer knows, and perhaps the reason why it is not more used is that it is so little known and its nature and
action so little understood. . . . Now, if diphtheria be at first a local disease, and be auto-infectious; that
is, if it be propagated to the general organism by a contagious virus located about the tonsils, and if this virus be,
as it really is, an albuminoid substance, it may and will be destroyed by this agent upon a sufficient and a suffi-
ciently repeated contact. ... A child's nostrils, pharynx and mouth may be flooded every two or three
hours, or oftener, from a proper spray apparatus with a two volume solution without force, and with very little
discomfort ; and any solution which finds its way into the larynx or stomach is beneficial rather than harmful,
and thus the effect of corrosive sublimate is obtained without its risks or dangers. . .

Further on Dr. Squibb mentions that Charles Marchand is one of the oldest and best makers of Peroxide
of Hydrogen, and one who supplies it to all parts of the country.

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only in %-lb., J^-lb., and i-lb. bottles, bearing my label aud signature, you will never be imposed upon

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Constituent Tablets.

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together with Caraccas. Cocoa and Sugar.

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Containing sufficient Tablets of each kind to last from one to three months according to the condition of the patient.

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HanTniifj „ -f^^j aCosta Charles K. MiHs .James Tyson, and Dr. Lawrence Turnbull; Professor Will
pSerabirg Va HoPkins University; W. C. Van Bibber, M. D., Baltimore, Md.; W. W. Lassiter, M. D.,

Resident Physicians: J. WILLOUGHBY PHILLIPS, M. D., S. A. MERCER GIVEN, M. D.

For further information address

BURN BRAE, Clifton Heights, Delaware Co.. Pa.

SUPPLEMENT TO THE MEDICAL AND SURGICAL
REPORTER, FEBRUARY 28, 1891.

Suggestions for the Treatment of
. Tuberculosis.

After the sheets for the Reporter of Feb-
ruary 28 were printed, the following com-
munication was received from Prof. Samuel
G. Dixon.

To the Editor — Sir : — As I have never
felt sufficient confidence against the toxic
effect produced by subcutaneous injections
of de-vitalized tubercle bacilli upon the
animal economy suffering with tuberculosis,
to risk its use in man, I have been using, for
some time past, as stated in former commu-
nications, a long line of other'agents, and I
believe that it is only right and proper for
me to again call attention of all workers in
bacteriological investigation to what I have
before strongly hinted at, when alluding to
the effects of food, light, temperature, etc.,
upon the growth of the tubercle bacillus on
an artificial culture pabulum.

Glycerine is one of the substances that I
have employed in excess since 1889, as
specially mentioned in previous articles, and
with a marked effect on the growth of the
tubercle bacillus.

After satisfying myself that I had pretty
clearly established the effect of an excess of
glycerine in the nutritive Agar-agar glycer-
ine medium upon the growth of the organ-
isms, I went on to introduce large doses sub-
cutaneously into the animal economy, where
a tuberculous process was going on.

In the few cases thus treated, there has, to
all appearances, been produced a marked
change in the tuberculous process in the
animals. Therefore, to facilitate matters, I
hasten to place before my colleagues the
suggestion indicated above, and I should
be very glad if they would themselves try
its action in the animal economy, and re-
port their observations.

Yours truly,

Samuel G. Dixon, M. D.

Bacteriological Laboratory, Academy of Natural
Science, Philadelphia.

Liebreich's Remedy for Tuberculosis.

The cable brings news, dated February
25, that Prof. Liebreich had, on that day,
described a new method of treating tuber-
culosis at a meeting of the Berlin Medical
Society. The substance used is cantharidate
of potash, which is administered in solution
by systematic injections under the skin.
Clinical experiments made by Drs. Fraenkel
and Hermann seem to prove that the
substance is remedial in tuberculosis and
other diseases. Prof. Liebreich says that he
is still carrying on his investigations, and
that the announcement of his discovery was
made prematurely, under pressure from
Minister von Gossler, who is giving the
matter much attention.

MEDICAL AND SURGICAL
REPORTER

No. 1774.

PHILADELPHIA, FEBRUARY 28, 1891. Vol. LXIV.— No. 9.

Clinical Lecture.

NERVOUS DYSPEPSIA.— C H R O N I C
DYSENTERY.— MOIST GANGRENE.
—FACIAL PARALYSIS.1

BY DR. ROBERT COLTMAN, JR.,

TUNG CHOW FU, CHINA.

Nervous Dyspepsia.

This man, 51 years old, is a physician who
is practicing, without a diploma, a mixed
system, embracing the humbugs of native
origin and to some extent the science of
Western medicine. His history is as fol-
lows. He has always lived a temperate life,
has never been seriously ill, and has never
had syphilis. Last August, during the
cholera epidemic, he had a great run of
cases, including his wife. Many of the pa-
tients died, and his wife, after an illness of
three days, also perished. To loss of sleep,
fright and grief, he attributes his present
trouble. He is tall, slender and looks ane-
mic. He says he sleeps poorly, and that
his appetite is capricious and usually poor.
His bowels are regular, but the stools are dry
and somewhat scanty. He has a cough with-
out expectoration. His tongue is large,
thick and moist, but heavily coated with a
whitish yellow fur. His pulse is irregular
and intermits, losing on an average four
beats per minute — that is to say, it drops out
completely four beats. He tells us he has
doctored himself for three months, and has
got steadily worse, and now feels himself
physically and mentally a wreck. He has
taken quinine, muriatic acid, capsicum, cas-
tor oil, cod-liver oil, pepsin, pyrophosphate
of iron, and any number of native drugs,
and says he never felt any decided effect ex-
cept when taking the cod-liver oil, which

made him decidedly worse. His lungs are
sound, and his heart, although intermittent
in action, is also free from disease.

Now what is the matter ? and what can we
do for him ? I reply he has nervous dys-
pepsia ; and, as it is a recent case, we
can probably effect a cure. First we want
to disabuse the doctor of the idea he has,
that his heart is badly diseased and that he
is going to die. This we can do with such
emphasis that he will readily believe us.
Then as to medicines : we shall direct him
to take a pill made up as follows :

R Ext. nuc. vom gr- 1£

Aloes j

MFrA gr' ss

Ferri sulp. exsiccat .• gr. ss

Pulv. podophylli gr. -1-

Saponis gr ' ss

M.ft. pil. 1. ' * ■* "

To be taken after breakfast and supper.
He will also be given a powder containing
pulv. digitalis and pulv. quininae sulp., aa
gr. 1, three times daily.

Chronic Dysentery.

The second patient is a man 54 years old.
a farmer. This case also dates from August
last. At that time the patient had a sharp
attack of dysentery which was treated by
native physicians ; and although the vio-
lence of the disease abated, he has to this
day some symptoms unrelieved. He says
he gets along very well through the daytime,
but invariably has to have from three to
four stools at night, with more or less strain-
ing. Sometimes he passes a little blood and
mucus with watery feces, and sometimes only
mucus. He lives on hard bread, cabbage
and millet. His diet is a matter of the
greatest importance, for two reasons : First,
he is nearly exhausted and cannot much

longer sustain this tax on his strength on a
vegetable diet ; Second, his present diet is
1 Delivered at the Presbyterian Hospital at Tung I directly irritating to the intestinal tract,
Chow Fu. I besides being difficult of digestion. • We

235

236

Clinical Lecture.

Vol. lxiv

shall direct him to live exclusively on soft
boiled rice, eggs — raw or under done — and
broiled steak. He is to take a tonic con-
taining a fluid drachm each of compound
tincture of cinchona, compound tincture of
gentian and tincture of cardamom, in a
little water before each meal, and at bed-
time a pill containing pulv. opii, gr. iss, and
pulv. plumbiacet., gr. ij. Under this treat-
ment we may hope for his restoration to
health.

Moist Gangrene.

The next patient is a man 60 years old,
a laborer. This poor fellow is in a pitiable
plight, and I fear we can do very little for
him. He is barely able to answer our ques-
tions; his mind seems benumbed, and it takes
him some time to realize what we have asked
him. The whole dorsal surface of his right
foot is about to slough off, and the leg to the
knee is infiltrated and swollen. He says
four days ago the foot began to pain, and in
that time it has reached this condition. I
have seen but one or two cases of this na-
ture, but feel sure that it is of the same na-
ture as noma or rapid gangrene of the
mouth or cheek. This man has been out
of work for some time and starving ; his
blood has become so degenerate that now I
fear the best tonics and alteratives will do
him no good. The condition of his mind
augurs ill, and I fear that in two or three
days at furthest he will have passed away.
His pulse is 60, his tongue pale and but
slightly coated, but tremulous. He has no
dropsy. He has no appetite. His temper-
ature is sub-normal. Although this man
walked in here with difficulty, and will be
able to walk out, I regard him as in a dying
condition, and shall have him placed in the
wards. We will give him what seems to be
indicated, namely, whiskey, quinine, eggs
and beef juice ; but the end is not far off.

It is only among the poorest class that such
a disease is possible. It may be that syph-
ilis has something to do in starting the ul-
ceration, as it resembles phagedenic action
more than anything else I have knowledge
of. Amputation would be impossible in his
condition. Locally we shall apply a poul-
tice of flaxseed meal sprinkled with iodo-
form, partly as an antiseptic but principally
to cover the odor which is penetrating in the
extreme.

Facial Paralysis.

This man, 26 years old, is a school
teacher. He comes to us for the second

time, saying that he is much better than
when he first consulted us some six days ago.
At that time, although he strenuously denied
that he had syphilis, I diagnosticated his
case as facial paralysis due to gumma some-
where along the course of the facial nerve.
He had gone to sleep at night apparently
healthy, though he had been having more
or less headache for a month previously, and
awoke in the morning with his mouth all
drawn to one side, and with dropping of the
eyelid. He consulted us at once, and his
rapid improvement is due to the fact that he
was seen and treated early. If these cases
are left to themselves they seldom manifest
a tendency to improve, but go from bad to
worse until finally imbecility and death en-
sues ; but, if treated early and vigorously,
the prognosis is very favorable, most of the
cases making a complete recovery. It is im-
portant in these cases to mercurialize the
system as rapidly as possible, and to main-
tain the impression for several weeks, after
which the mercury should be exhibited in
minute doses intermittently for a year or so.
If the stomach is weak or irritable, ■ I use
inunction of blue ointment twice daily; but
where — as in this case — the man is strong
and has a good stomach digestion, I prefer
to administer mercury by the mouth. This
man has been taking one-eighth grain of cor-
rosive sublimate and ten grains of iodide of
potash three times daily. We will now de-
crease the corrosive sublimate to one-tenth
grain per dose and renew his medicine for
six days.

I remember a rule of practice taught me
in college, which was : In all cases of facial
paralysis occurring in a subject under thirty
years of age to suspect syphilis. In ten
years' practice I have yet to see an exception
to this rule for diagnosis.

Dangers of Illuminating Gas. — It has
been shown that respiration of the products
of the combustion of an Argand burner pro-
duces upon animals only deoxygenation, be-
cause in this case combustion is complete.
It produces only carbonic acid, and not
carbonic mon-oxide. If, on the contrary,
the combustion of the burner is incomplete,
it gives birth to acetylene and a larger quan-
tity of carbonic mon-oxide. Intoxication
is rapid in this case. It results from these
experiments that it is necessary to remove
the products of combustion from ordinary
gas burners as well as from gas stoves.

Feb. 28, 1 891

Communications.

237

Communications.

PEROXIDE OF HYDROGEN FOR
CLEANING THE HANDS.

BY CHARLES P. NOBLE, M. D.,

SURGEON IN CHARGE OF THE KENSINGTON HOSPITAL
FOR WOMEN, PHILADELPHIA.

The remarkable properties of the peroxide
of hydrogen as a pus destroyer and as a
cleansing agent are becoming better appre-
ciated every day. Every one who uses this
agent in the treatment of suppuration be-
comes enthusiastic in its praises. This be-
ing true, time only is required to overcome
the prejudice against it which heretofore has
existed among the profession as a whole.

I wish at this time to call attention to the
use of the peroxide in cleansing the hands.
It is a demonstrated fact that it is impossible
to render the hands surgically clean, that is,
free from septic germs, by the use of soap
and water, the nail-brush and corrosive sub-
limate solutions. Germs still remain under
and about the finger nails. It seems more
than probable, although I know of no ex-
periments to support the supposition, that
germs will find the most secure hiding-place
about the finger nails, when the skin has
been made rough and thick about the nails,
by excessive use of the hands, or by their
frequent exposure to irritating fluids, as cor-
rosive sublimate solution. For some months,
in preparing for abdominal sections, I have
used the peroxide of hydrogen solution in
full strength, to assist in cleaning my hands,
especially about the finger tips and nails,
whenever, for any reason, I have felt doubt-
ful about their aseptic condition. The per-
oxide has been used whenever the skin about
the nails has not been in good condition ;
and it is remarkable to see how it will soften
horny skin at the side of the nail, and dis-
integrate debris in the subungual space, or
macerate and even remove epidermic scales.
There can be no doubt that foreign material
can be removed from the fingers much more
completely by using the peroxide solution
after using soap and water and the nail
brush, than by the use of these agents alone.
This certainly does promote asepsis. But
whether the hands are made aseptic by the
peroxide solution I have not been able to
determine. Careful bacteriological experi-
ments to determine this question will be of
great practical interest and value.

The method which I employ for render-

ing the hands aseptic is as follows: The
nails are trimmed reasonably short, and the
subungual spaces are cleared with the knife
blade. The hands and forearms are then
thoroughly washed in warm water, a good
lather being made with soap, and a stiff nail
brush being vigorously applied. The water
is renewed three times. The hands are next
soaked in a saturated solution of permanga-
nate of potassium, and this removed by
soaking them in a saturated solution of ox-
alic acid. According to circumstances, the
finger tips are next soaked in peroxide of
hydrogen, for the final bath corrosive sub-
limate solution 1-1,000 is employed. The
hands remain in the sublimate solution three
minutes. At least ten, and often fifteen
minutes are consumed in the cleansing pro*
cess.

To those who are accustomed to wash
the hands quickly, use the nail brush lightly,
and to dip the hands in the sublimate solution,
such elaborate and painstaking care doubt-
less appears like a useless expenditure of en-
ergy. But bacteriological experiments have
shown that germs exist about the nails of
fingers cleaned in this careful manner (omit-
ting the peroxide solution) and have demon-
strated the necessity for some more reliable
method of rendering the hands aseptic, if the
antiseptic conscience is to be satisfied. It
is with the hope that the peroxide of hydro-
gen solution will meet this demand that I
have brought the matter forward.

Aside from using the peroxide solution in
preparing the hands for abdominal opera-
tions, I have found it perfectly reliable in
removing foul odors and stains from the
hands, by contact with decomposing pus,
discharges from cancer, and other septic
fluids. I believe it will be equally useful to
the general surgeon and obstetrician.

MEDICAL COLLEGES OF VERMONT.
—BOGUS AND GENUINE.

BY JOHN M. CURRIER, M. D.,

NEWPORT, VP:RMONT.

Just now we are having quite an epidemic
of bogus medical colleges in some of the
smaller towns of Vermont. Some of these
were unknown to the medical profession of
Vermont until the Censors of the Vermont
Medical Society received letters from the Cen-
sors of some of the medical societies of the
Western States, inquiring about the standing

238

Communications.

Vol. lxiv

of these institutions. The graduates of these
institutions settled in the far West, think-
ing they would never be molested ; but now
and then they are required to present their
credentials to some State Board of Censors,
and are thus shown to be possessors of bogus
diplomas, and frauds upon the public, and
their standing as to medical knowledge and
proficiency is brought to light.

For the fair name of the medical profes-
sion of Vermont I propose to give a short
history of the various medical colleges of
the State, both bogus and regular, those
that have existed and those now in opera-
tion. This history may be of service to
practitioners, living in the far West, who
are striving to elevate the standard of medi-
cal education, and to protect the public
from the impositions of uneducated practi-
tioners and charlatans.

Of the four bogus institutions that have
actually issued diplomas, only one makes
any pretence to delivering lectures or pos-
sess any building or room suitable for im-
parting instruction to a class of medical
students. The citizens of those towns in
which these institutions purport to be lo-
cated were not' aware of the existence of
them until they were exposed by the secular
newspapers. Even the members of the reg-
ular profession, living in the immediate
vicinity, were unaware of their existence.
They seem to be carried on by one leading
spirit in each case, clustering around him
names enough for a Faculty and Board of
Trustees. In the majority of instances these
names were obtained on some pretence, to
act as trustees or officers, without knowing
that they were to be connected with a
bogus medical college, while the Dean of
the faculty was gathering in the profits from
the sale of diplomas. Some of these insti-
tutions have been exposed by the secular
press, when the greater portion of the
faculty and trustees learned for the first
time that they were at the head of a
learned institution ; and credit is due to
many of them, for immediately appearing
in a letter of explanation, disapproving the
institutions with which they were unwillingly
connected.

I will mention first the four bogus col-
leges, then the three regular institutions
that have been chartered by the Legislature.

Union Medical Institute.

In the Argus and Patriot, of Montpelier,
under date of November 19, 1890, ap-

pears an article quoting from the Boston
Herald an exposure of "The Union Medi-
cal College " of Newbury, Vt. It also adds
some comments of its own. The report states
that at the session of the Legislature of
1886 a bill was passed by the House incor-
porating a Homoeopathic medical college
to be located on the east side of the State ;
but it was killed in the Senate. Dr. George
B. Hatch was said to be prime mover in the
scheme. The proposed college failed to ob-
tain legislative sanction, but the scheme was
not abandoned by Dr. Hatch, who seems to
have determined to do business on his own
account, regardless of the State.

Recently, however, a reporter of the
Boston Herald got hold of what purported
to be a catalogue of " The Union Medical
College, of Newbury, Vt. ' ' This pamphlet
was about 4 by 6 inches in size, contained
some 16 pages, and was printed by C. E.
Caswell, a 17-year-old amateur printer at
Warren Summit, N. H., a hamlet of per-
haps a dozen houses. Caswell says he
printed 300 for $7, but has only received
$5 of his pay, although the books were de-
livered in June, 1889. He says that Hatch,
for whom the work was done, suggested that
nothing be said about the job. The cover
bears the name of the alleged college, as-
given above. The second page contains the
list of Trustees, Officers and Faculty.

The President of the Board of Trustees is
Horace W. Bailey, a grocer and Town Clerk
of Newbury, a man of good reputation and
good business ability, but with none of the
requisites usually thought indispensable in
the President of a medical college.

The Daily Journal of Montpelier, under
date of November 7, 1890, makes further
allusion to the matter as follows : The lead-
ing spirit in the college is Dr. George B.
Hatch. There is no doubt that several of
the men whose names are used were de-
ceived as to the nature .of the college, for
they stand high in their respective commu-
nities. The institution has never had a
student, nor has it a location at Newbury,
so far as we know. The Herald says it is
the general opinion that diplomas are being
sold in the West, and one prominent busi-
ness man made this statement: "It is sus-
ceptible of proof that two diplomas have
been sold for $50 apiece."

At a later date appeared the following :
H. W. Bailey, of Newbury, who was adver-
tised as the president of the bogus medical
college up there, writes a letter that exoner-

Feb. 28, 1 89 1.

Communications.

239

ates him from blame. He consented to act
as trustee only for a genuine institution, and
never consented to the use of his name as
president. Dr. G. B. Hatch, the concocter
of the thing, claims that no diplomas were
ever issued, but that he had an idea of start-
ing such an institution at the Montebello
Mineral Spring, got encouragement from a
"Southern gentleman" as to capital, and
had a few catalogues printed as sort of sam-
ples, but allowed only a few copies to go
out.

Dr. Hiram A. Cutting, A. M., M. D.,
Ph. D., of Lunenburgh, is a scholarly man,
mostly self-made. For many years he was
State Geologist of Vermont, and Secretary
of the State Board of Agriculture ; and has
lectured much at agricultural meetings, and
before various colleges. His three degrees
are honorary. About this college he writes
me : " There is no medical college at New-
bury and never has been, to my knowledge.
I received a letter something more than a
year ago from one Dr. Hatch, of Newbury,
saying that a friend of his from the South
was talking of purchasing the school prop-
erty and Medicinal Spring at Newbury and
they might get up an institute class, and if
such was done, he desired me to give two
or three lectures on microscopic work, etc.
I wrote him I would try and do so. The
next I knew was that the project had fallen
through. I have lectured before various col-
leges upon the microscope, mounting ob-
jects and the microscopic advantages in
anatomy, etc., but was never president or
official board member of any."

It seems that Dr. Hatch, who is not a
graduate of a regular school, after the medi-
cinal-spring scheme fell through, turned his
attention to the sale of diplomas. Of his
capacity for study, a friend writes me: "Dr.
Hatch commenced the study of medicine
with Dr. E. V. Watkms [of Newbury] some
years ago, but did not continue with him in
that capacity only about three weeks, when
Dr. W. told him that he could never suc-
ceed unless he would devote all his time and
talents to the study for years, and at that
time Hatch gave up the idea of studying
medicine, and left for other fields."

Shortly after his return to Newbury this
new medical plant came quietly into exist-
ence, sub rosa. It was full-grown when first
discovered. But since its exposure in the
: newspapers the members of the faculty either
keep silent or deny their connection with
it. ' •

The exposure of this and other bogus col-
leges will have the effect to check the imme-
diate sale of diplomas; but as soon as the
excitement in the medical profession dies
down, traffic will revive with renewed en-
ergy. The newspaper exposure will make
them more noted, and those who desire to
possess diplomas, without regard to stand-
ing, have learned where they can be pur-
chased, and avoid hard study. The Legis-
lature of Vermont has done a bad thing, or
rather has neglected to do a good thing, for
the medical profession of the State, at its
recent session. A bill was introduced mak-
ing the sale of bogus degrees a penal offense;
but it failed in its passage. I have been in-
formed that , if the bill had been designed
simply to prevent the sale of diplomas it
would have passed, but it was so framed
with other matters that were objectionable
that the subject of degrees could not be
singled out, so the whole matter was
"heaved over among the rubbish," by the
disinterested representatives. The outcome
of this unwise legislation will be a large
crop of bogus diplomas from Vermont for
the next two years.

Trinity University.

Under this title the State Censors have
received letters from the censors of some of
the Western States inquiring into the stand-
ing of the institution. No such an institu-
tion exists there.

Medical College at Newfane.

I am unable to find the name of the
Medical College at Newfane, but inquiries
have been made as to its standing, recent
graduates having occasion to bring forward
their diplomas, and were thus brought to
light. No College exists there. It is a
small obscure town.

Vermont Medical College.

This concern was located in Rutland
about 1883. Dr. George Dutton is the
originator and the principal man. It should
not be confounded with the Vermont Medi-
cal College that existed in Woodstock be-
tween 1824 and 1856, which will be re-
viewed later on in this article. This Rut-
land plant is located in a room, secured by
the Dean for the purpose, of sufficient size
to accomodate only a few students. Lec-
tures are delivered annually, but they are
superficial, erratic, lacking in method, in

Com m unications.

Vol. lxiv

fact, worthless to a student obtaining knowl-
edge for practice. The students are of an
inferior grade intellectually. This school
claims to be a chartered institution, but it
is not. The State of Vermont several years
ago, passed an act by which an organization
could be formed having privileges similiar
to a corporate body, without making direct
application to the Legislature. These priv-
ileges were, however, somewhat restricted.
Under this law the Rutland school was or-
ganized, and claimed to be a corporate body.
Thert-: seems to be nothing hidden about it
in its movements, on the contrary, the man-
agers seek publicity and notoriety. They
have been defiant and pugnacious, taking
advantage in every spot and place to defend
the institution from attacks. The past sum-
mer they graduated a class ; and they took
great pains to make a display, all the medi-
cal fraternity of the State and the public
were invited to attend the graduating exer-
cises. Each graduate read a paper on some
medical subject, on the occasion. The re-
porters of the press were on hand, and some
of them published quotations from the med-
ical essays read, which reflected upon grad-
uates unfavorably, and afforded much
amusement to the physicians who read the
reports.

One of the graduates of the institution
desired to settle in the State to practice ; but
before she could do so, the law required that
she must have a certificate of qualification
from some Board of Censors of a medical
society, recorded in the County Clerk's of-
fice. She made application to a Board of
Censors for the certificate, and the Board
refused it. Suit was brought to constrain
the Board to issue a certificate ; but the
Courts decided against the application.

It has been charged that the school was
of a "spiritualistic" nature; but the
'* Faculty " every time came forward with a
denial. It has been noticed, however, that
Dr. Button attends the " spiritual " conven-
tions quite frequently, and distributes circu-
lars and announcements of that school very
extensively.

Application was made to the Legislature
of Vermont for a charter of the Rutland
school, but it was refused in the House of
Representatives by almost a unanimous vote.
Thus it will be seen, that not only the
Courts, but the Legislature also, has set this
school down as a bogus institution, and its
diplomas are worthless, and a stigma to the
possessor.

Castleton Medical College.

In 1881 I prepared a history of the Cas-
tleton Medical College for the first volume
of the proceedings of the Rutland County
Historical Society. From that volume I
make such extracts as will be of service
to medical censors throughout the United
States. I was in possession of the written
records of that institution from its origin,
and the most complete file of the catalogues
of it that was in existence in any library.
That institution was chartered on October
29, 1818, as the Castleton Medical Acad-
emy. Drs. Selah Gridley and Theodore
Woodward, of Castleton, were the real
founders. By an Act of the Legislature
passed on November 7, 1822, the name was
changed 'to the Vermont Academy of Medi-
cine. By an Act of the Legislature, Novem-
ber 1, 1 84 1, the name was again changed to
Castleton Medical College. The first course
of medical lectures was delivered ,in the win-
ter of 1 81 8— 19; the last course was deliv-
ered in the spring of 1861. The war of
186 1-5 put an end to its existence. There
were no lectures delivered in 1838 and
1839. Up to and including 1827, degrees
were conferred upon the graduates under
the auspices of Middlebury College. After
that date diplomas were issued by the fac-
ulty of the college independently of Mid-
dlebury College. Many eminent physicians
graduated from this college, and all were in
good standing in the profession. Many of
the graduates are still in active practice.

Vermont Medical College.

This institution was started through the
influence of Dr. Joseph A. Gallup, at Wood-
stock. The first course of lectures was given
in the autumn of 1827. It received the name
of the Clinical School of Medicine. For
three years the graduates received their de-
grees from Waterville College, in the State
of Maine. In 1830, a connection was formed
between that institution and Middlebury
College, from which the graduates received
their degrees until 1836. In October, 1835,
the Legislature of Vermont granted a char-
ter to the Woodstock school under the name
of the Vermont Medical College, with au-
thority to grant diplomas to its graduates.
Lectures were given annually in the spring,
until 1856, when the last course was deliv-
ered ; and its existence ceased then. The
graduates of this, institution stood well in

Feb. 28, 1 89 1.

Communications,

241

the profession, and some became eminent as
medical teachers in other schools.

Medical Department of the University
of Vermont.

This is the only college in Vermont that
now delivers medical lectures and issues di-
plomas to any medical graduates. It is in
a flourishing condition and is careful to
graduate only those found to be competent
to practice. In the autumn of 1822, the
first full course of medical lectures was de-
livered. These lectures were continued an-
nually up to 1833, when they were sus-
pended. In 1854, the department was
again revived, and it has continued to in-
crease up to the present time.

The three last-named colleges are the
only ones that have been authorized to
grant diplomas in the State of Vermont.
AH other before mentioned are bogus.

GENERAL ANTISEPTIC MEDICA-
TION.1

BY H. F. SLIFER,

NORTH WALES, PA.

I desire to bestow some consideration to
the subject of general antiseptic medication.
It is my object to present to the Society the
use of antisgptics in general practice, not
confining my remarks to antiseptic surgery,
which I regard as only a part of the antisep-
tic treatment.

Sepsis is that morbid condition produced
by the absorption of toxic matter into the
tissues or blood. Three primary factors are
engaged in the production of this patholog-
ical condition: 1. Micro-organisms; 2.
Ptomaines ; 3. Leucomaines.

The recognition of micro-organisms as the
essential cause of specific disease, supplies a
scientific basis for diagnosis, and affords a
definite principle by which we are enabled
to test methods of treatment. The existence
of putrid fermentation, taking place in the
tissues of the body, is proved by the follow-
ing evidence: 1. The presence of certain
micro-organisms; 2. Certain cadaveric alka-
loids— ptomaines, the product of putrefac-
tion ; 3. Certain special products — leuco-
maines, which originate in the living tissue
as a result of retrograde metamorphosis.

1 Read before Montgomery County Medical Society.

I These are divided into two groups : the uric
acid group, and the creatinine group.

It has been seen that it is not the organ-
isms themselves that are the irritants that
directly cause disease, but the products that
are formed in the course of their growth and
multiplication, either directly secreted by
them or formed by the decomposition of the
substances on which they feed. From these
facts we can draw this important conclusion :
That man in the physiological state produces
poisons, more or less virulent, the true na-
ture of which we do not as yet understand,
and that the condition of health for him
consists in their regular and rapid elimina-
tion by the different emunctories, and espe-
cially by the skin, the kidneys and the in-
testines; nor must we omit to mention that
colossal eliminator of impurities, the liver,
which has for its function the destroying of
a certain number of these toxic alkaloids.
But let some circumstance come to interrupt
this equilibrium, let the skin close its life-
giving gates ; let the liver cease its function ;
let the glomeruli of the kidneys become ob-
literated ; let too active an absorption take
place from the intestines, whether by abnor-
mal shedding of its epithelium, or by the
presence of ulcerations, or by want of power
on the part of the digestive ferment suffi-
ciently to prevent the production of putrid-
ity and fermentation, and then may ensue a
pathological condition which we will term
sepsis.

The agents with which we antagonize and
destroy the above enumerated toxic products
are termed antiseptics. This system of medi-
cation is destined to have a high place in the
therapeutics of the future, and should be
studied and practiced by every physician
and surgeon. I propose to make some prac-
tical application of this method in diseases
as we meet them in general practice.

In the different forms of stomatitis, it is
of primary importance to maintain perfect
cleanliness, by keeping the teeth well brushed
and by frequent washing of the mouth, espe-
cially after taking food. The most effective
washes for this purpose are : boric acid, car-
bolic acid, chlorinated water, solution of
permanganate of potassium, bicarbonate of
soda, and creoline. When the gums are
tender and disposed to bleed, astringents
are indicated. If ulceration is present, the
mouth should be washed as above indicated,
and the ulcer dusted with iodoform, char-
coal, or boric acid ; or a lotion of carbolic
acid, sulphate of copper (two grains to the

242

Communications.

Vol. lxiv

ounce), or nitrate of silver (five grains to
the ounce), chlorate of potassium or bichlo-
rate of mercury (2 to 1,000) should be ap-
plied.

In diphtheria we have a local as well as a
constitutional pathological condition pre-
sented, in which the antiseptic treatment is
especially applicable, and this, if properly
carried out, will produce excellent results.
In mild cases I use the inhalation of steam
and lime, or steam and carbolic acid, alter-
nating with a gargle of chlorate of potassium
or borate of soda. In cases of graver im-
port, I use medicated steam with a gargle of
bichlorate of mercury (2 to 1,000), bromide
of potassium, or bicarbonate of sodium with
alcohol or whiskey, from which I have had
excellent results. Recently, I have used
sulpho-calcine with great satisfaction. The
direct application of this drug on cotton, or
with a camel' s-hair brush, or as a spray, in
its concentrated form, will often remove or
dissolve the membrane. The use of iodo-
form, mineral acids and vegetable astrin-
. gents has failed in my hands.

In the nasal complications, the injections
should be made every four hours or oftener
if necessary ; at the same time it is advisa-
ble to be careful that the fluid does not en-
ter the Eustachian tubes. This can be pre-
vented, to a certain extent, by compelling
the patient to keep the mouth open during
the operation. In selecting the drug for
this purpose, it is well to avoid those which
stain or produce a firm coagulum. For this
reason I employ carbolic acid, bicarbonate
of sodium, borate of sodium and bichloride
of mercury.

Prof. Alfred L. Loomis speaks highly of
the benzoate of soda, to neutralize the diph-
theritic poison. Dr. Geo. B. Fowler con-
siders calomel the best remedy with which to
combat this terrible malady. Dr. A. Jacobi
advocates turpentine. . Dr. J. Solis Cohen
regards the chlorine compounds as of more
efficacy in diphtheria than all other reme-
dies.

I have had no personal experience with
benzoate of soda, calomel and turpentine
in diphtheria ; but coming from such emi-
nent authority, I am inclined to give them
a test as soon as an opportunity will pre-
sent.

The efficacy of antiseptic treatment, in
diseases of the stomach, depends materially
upon the manner in which it is executed; the
more thoroughly the stomach is washed out,
the greater will be the success. In dyspep-

sia and chronic gastritis the following drugs
are indicated : carbolic acid, salicylate of
bismuth, subnitrate of bismuth, salol, iodo-
form, charcoal, carbon bisulphide water,
and hydrochloric acid. In gastric ulcers,
charcoal, small doses of calomel and ni-
trate of silver are the most efficacious reme-
dies. The food and drink must be boiled
or sterilized, and selected with especial care,
and adapted to the peculiarity of each
case.

Dr. Bouchard has the credit of first at-
tempting intestinal antisepsis. He treated
his typhoid fever patients with a mixture of
charcoal and iodoform, and naphthol in large
doses. Dr. Dujardin-Beaumetz, is perhaps
one of the strongest advocates of this form
of intestinal treatment. He says: "The
physician can, and ought to interfere, to
combat these intestinal septicemias, and he
attains this end in employing two kinds of
drugs : one kind which has for its object to
prevent putrid fermentations from develop-
ing in the digestive tube, and to destroy the
toxic elements which are formed there ;
another which has for its end the favoring
of the rapid elimination of this matter from
the intestines. Let us examine each of
these indications, and the indications de-
signed to fulfil them, commencing with the
last. The indication to eliminate the toxic
matter found in the digestive tube, and to
favor their speedy issue, is milled by pur-
gation. Medical agents which are capable
of modifying the putridity of intestinal
matter, we find may be introduced by two
channels : either directly into the intestines
by means of enemata, or indirectly by the
mouth. The antiseptic substances which can
be used by enemata are not very numerous,
011 account of their irritant and toxic action.
To avoid this, we are obliged to employ sub-
stances which are but slightly irritating and
toxic, such as salicylic acid, boric acid,
cupric sulphate.

' ' These injections have no toxic effect
and they disinfect perfectly the contents of
the large intestine. Their action is, how-
ever, local, and you should endeavor to med-
icate the entire intestinal tract ; and for
this purpose substances should be introduced
by. the mouth. Among the drugs worthy of
being advised for this object, there are three
to which I desire to call attention, namely,
charcoal, iodoform and carbon bi-sulphide
water. ' '

Dujardin-Beaumetz also speaks in high
terms of salicylate of bismuth, associated

Feb. 28, 1 89 1. Communications.

243

with magnesia or bicarbonate of soda, with
naphthal or salol in diarrhoea.

It is evident, that the best results are to
be realized from drugs that are slightly sol-
uble. Only insoluble drugs can be depended
upon to reach the lower part of the in-
testines. In diarrhoea in which the putre-
factive processes are marked, as indicated by
flatulence and offensive stools, I have had
good results from the use of salicylate of
bismuth, charcoal, iodoform and salol ; in
other cases carbon-bisulphide acted more
promptly.

In cholera infantum, the antiseptic treat-
ment consists in : 1. Unloading the bowels.

2. Feeding the child on sterilized food ; and

3. Antiseptic drugs. I use one of the bis-
muth salts, or sulpho-carbonate of zinc, iodo-
form, or small doses of calomel.

In chronic diarrhoea antiseptics are of very
little avail, indeed they have proved unsat-
isfactory.

Dr. Lemoine, of Algiers, has treated
fifty-four cases of dysentery with enemata of
corrosive sublimate, with the happiest results.
The strength of the solution was one to five
thousand, of which two hundred grams
were at first administered three times a day.
In acute cases, a cure resulted from this
treatment in from three to four days ; in no
case was there any sign of systemic poison-
ing. In view of the infectious character of
dysentery, this treatment is eminently ra-
tional, and the demonstration that our most
powerful germicide can be used with im-
punity as an intestinal antiseptic is of de-
cided value.

The antiseptic treatment of phthisis has
thus far been unsatisfactory. The higher
authorities do not recommend it. AH that
we can reasonably expect from antiseptic
inhalations, is that they may decrease the
infective power of the secretions and coun-
teract the offensive odor of the breath and
expiration.

It is in obstetrics that the antiseptic
method of treatment is especially indicated.
The Chicago Medico-Legal Society recently
discussed the question : " Whether the fail-
ure of a physician to accept and practice the
precepts of antiseptic midwifery should
make him legally liable and responsible if
puerperal fever develops in his puerperal
patient during his attendance upon her."
It seems to me that the obstetrician is in a
high degree responsible for unfortunate re-
sults. We find, on examining statistics, that
the mortality of puerperal diseases has

greatly decreased since the institution of the
antiseptic treatment.

Dr. William T. Lusk reports in the Med-
ical News : " The number of deaths from
puerperal sepsis, between the years 1867
and 1875, in New York City, was 1,947, or
an annual average of 215." This is the
result under the old system. In the same
article, Dr. Lusk says: "During the past
five years there have been 837 women con-
fined in the Bellevue Hospital, and there
have been sixteen deaths, two of which were
due to puerperal fever." ' These figures
most emphatically show the value of the an-
tiseptic principle.

In the address on obstetrics before the
last meeting of the American Medical Asso-
ciation, the following statement was made :
" There are a few simple rules pertaining to
the subject of aseptic midwifery, and they
must be scrupulously and delicately adhered
to by every physician who practices the ob-
stetric art. Failure to do this is to shoulder
an awful responsibility, and the conse-
quences of such neglect would be indefen-
sible, either in a court of morals or of law."

It behooves us, therefore, as general prac-
titioners, to exercise every precaution, and
to utilize every means at our command to
prevent sepsis.

This happy end we attain in two ways.
First, asepsis ; second, antisepsis. Asepsis
we secure* by scrupulous cleanliness — not
aesthetic, but chemical cleanliness on the
part of physician, nurse and patient. The
clothing of the physician and nurse should
be perfectly clean and free from contami-
nated air imbibed from the dead-house, or
hospital wards, or the rooms of patients in
which diphtheria, erysipelas, septic wounds^
or the eruptive fevers are being treated. The
hands and fore-arms should be washed with
hot water and soap, then in an antiseptic
solution ; and special attention should be
given to the finger-nails. The patient must
also undergo a cleansing preparation, the
abdomen, the thighs, the labia and the
anus must be thoroughly washed with soap
and water, and finally, with an antiseptic
solution — alcohol or bichlorate of mercury.

Antisepsis is secured by the introduction
of agents that destroy the toxic matter, and
remove the devitalized substances, and those
prone to decomposition. These agents are
indicated after abortion as well as after
labor.

If the labor is perfectly normal, and there
is no danger of sepsis, I use one injection

244

Communications.

Vol. Ixiv

daily of the bichloride solution (i to 5,000),
or carbolic acid (1 percent.), or chlorinated
soda, or permanganate of potash.

In case of any operation, such as version,
the application of forceps, or any manipu-
lation by means of which air is admitted,
the douche of sublimate solution must be
used. The parts are dusted with iodoform
and covered with a piece of gauze wet with
1 to 5,000 bichloride solution, or carbolic
acid solution, or chlorinated soda.

In surgery we more clearly attain the
ideal excellence of antiseptic treatment than
in any other department. There we are en-
abled to apply the antiseptic agents directly
to the seat of infection, and to destroy the
toxic influence and restore the parts to an
aseptic condition. All operations should be
performed with the strictest antiseptic pre-
cautions. The region to be operated on is
cleansed with soap and water, ether or tur-
pentine, and Carbolized water (3 percent.),
or bichloride of mercury (1 to 1,000) and is
then covered with a towel saturated with bi-
chloride solution until ready. The instru-
ments are sterilized by exposure to steam,
or by being placed in boiling water, and
are then laid in a 3 per cent, carbolic acid
solution. Daring the operation the instru-
ments, when not in use, should be placed
in carbolic solution, or on a towel saturated
with sublimate solution. The same precau-
tionary measures must be taken with
needles, sponges, etc. The hands of the
operator should be washed with soap and
water, and alcohol or turpentine, and then
with bichloride solution, care being taken
that the nails are chemically clean. The
operation being completed, the bleeding
vessels are secured with carbolized ligatures,
or those prepared in oil of juniper, which
have been in the bichloride solution for
twenty minutes. The wound is now irri-
gated with bichloride solution. The edges
are adjusted, and secured with sutures. The
cavity of the wound is again irrigated with
an antiseptic solution. The wound is then
freely dusted with iodoform, followed with
a layer of cotton, saturated with a solution
of carbolic acid or the bichloride. This in
turn is covered with two or three layers of
antiseptic gauze. This may be covered with
oiled silk, or oiled muslin, or oiled paper, or
rubber tissue. Over this a layer of antisep-
tic cotton is placed, and then the roller
bandage. If no discharge or bleeding is per-
ceptible, this dressing can remain for a
week without redressing.

It has been asserted that antisepsis could
not be carried out in general practice. This
I regard as an error. Since the method has
been so much simplified, the cumbersome
spray apparatus has been abandoned,, and
the complicated dressings have been dis-
carded, we are enabled to practice it under all
conditions and circumstances, let us there-
fore, bear in mind the principle of the anti-
septic treatment, and do the best we can with
the means at our command.

VESICULAR ERUPTION IN SCARLA-
TINA.1

BY F. C. CURTIS, M. D.,

ALBANY, NEW YORK.

The importance of any unusual deviation
from the ordinary character of the eruption
in one of the exanthemata calls for its report
and record. The following is the report of
a case of scarlatina, in which a vesicular
eruption developed.

The patient was a stout, well-developed
child, four years of age, of German parent-
age, ahd the youngest of a family of several
children. On November 29, after having
been perfectly well all day, he was taken
suddenly towards evening with vomiting,
fever, and, later, diarrhoea. The next morn-
ing a scarlatinal eruption appeared, which
became well marked and presented no unu-
sual characteristics during that or the two
succeeding days. At the request of his at-
tending physician, Dr. William Hailes, I
saw him in the evening of December 3, the
fourth day of sickness. He was having
scarlatina of moderate severity; his pulse
was rapid ; his tongue had the red, straw-
berry appearance ; the throat was congested.
His face was clear of eruption, and on the
chin and neck was beginning to peel. The
body and limbs were covered with a deep
scarlatinal eruption, fading on deep pres-
sure except at punctate points, the color
returning slowly. The abdomen was cov-
ered thickly with petechial, pin-head sized,
acuminated vesicles, closely set so as to
impart a rough feeling to the touch, and
of a whitish color. Similar vesicles covered
the inside of the thighs, but less thickly set.
A few scattered vesicles were on the chest,
none on the back, neck or face. On the

1 Presented at the meeting of the Medical Society
of the State of New York, February 3, 1891.

Feb. 28, 1 89 1. Commm

arms there were a few here and there, but
about the elbows they were more numerous.
On the wrists and back of the hands, how-
ever, there were vesicles differing much from
those on other parts in regard to their size ;
they were large, about the size of a split pea,
many were of irregular outline as if formed
by the confluence of several vesicles ; they
were flat, superficial, and their contents were
turbid and whitish as if semi-purulent. They
involved about one-half of the area of tis-
sue of these parts. At first glance they pre-
sented much the appearance of small-pox on
the fourth day of eruption ; they were lack-
ing in a solid raised edge of a vesicular
papule and were not acuminated. This new
eruption had developed without apparent
accession of fever.

December 4. The vesicles on the ab-
domen and thighs had not developed be-
yond this pin-head size, and extended over
no greater area. The skin covering the
knees had the large flat turbid vesicles found
the day before on the wrists, and they were
thickly set. Those on the wrists were un-
changed, but had extended up the ulnar
side of the arms. They appeared to cause
no inconvenience to the child. The body
was still quite red.

December 5. On the abdomen the ves-
icles had almost entirely disappeared by ab-
sorption, and at their sites were scales yet
adherent. About half of the vesicles on the
hands and arms had disappeared by absorp-
tion. None had been ruptured or torn by
scratching. On the knees the vesiculation
was still active. The vesicles of the knees
and wrists had appeared upon the ankles,
and were quite similar in every way. Be-
tween joints there were only few vesicles.
The redness of the entire body was fading,
and there was but moderate febrile action.

December 9, four days later, the child was
up and dressed. The vesicular eruption had
entirely disappeared, and at the sites of the
large and profuse vesiculation the cuticle
was peeling actively in large, thin flakes,
aside from which there was no mark to in-
dicate their' former existence, they having
entirely disappeared by absorption. A more
furfuraceous exfoliation was going on over
the covered parts of the body. The tongue
was still red and showed elevated papillae,
and the fauces were still congested. The
child subsequently made a perfect recovery
without accident, and there were no other
cases of scarlatina in the family.

Pathologically, the eruption of scarlatina

11 1 cations. 245

is a dermatitis. While the efflorescence is
due to general engorgement of the cuta-
neous vessels, there is always a larger de-
gree of engorgement of the capillary loops
in the papillae of the derma, producing the
pin-head sized reddish points seen at the
commencement of the eruption and the
small, red points which often cover the
blanched spot remaining after pressure upon
the scarlatinous skin at its height. Some-
times these papillae are so congested as to
impart a rough sensation to the touch. The
production of vesicles may be accounted for
in pursuance of this pathological process,
the engorgement of the papillary capillaries
being such that relief may be found, just as
in other conditions of dermatitis, by escape
of serum and the formation of a vesicle. It
would appear that lymphoid corpuscles ^.Iso
escape and produce the whitish appearance
that is noted. This would better satisfy the
conditions, apparently, than that they are pro-
duced as a miliaria, occurring in any febrile
condition from follicular inflammation, the
sudamina of fever or the prickly heat of hot
weather. It is exactly in keeping with
the production of scarlatina hemorrhagica,
where minute points of reddish-brown color,
not obliterated by pressure, develop from es-
cape of blood-globules from the congested
papillary capillaries. The occurrence of the
vesicles at parts where the dermatitis is most
intense, and the whitish appearance of their
contents, add force, in a case such as that
reported, to this pathogeny.

The literature of this anomaly of scarla-
tina is scant. It is not detailed with that
completeness which would be looked for in
consideration of its importance, for while it
is referred to very casually as a possibility
by Robinson, Hebra, Meigs and Pepper
and Bussey, in Keating's Cyclopedia, by
which author a miliaria eruption is referred
to casually, by many writers even of elabo-
rate and compendious articles it obtains no
notice. Its importance as a possible occur-
rence in a common exanthem, usually re-
garded as altogether an efflorescence, should
be recognized and made familiar to the pro-
fession.

17 Washington Avenue.

— It is said that the unpleasant symptoms
sometimes associated with the continued use
of iodine may be prevented by the daily
administration of fifteen grains of bicarbo-
nate of soda.

246

Periscope.

Vol. lxiv

Periscope

Life-Saving Methods in Still-Births.

At a meeting of the Section on Pediatrics
of the New York Academy of Medicine,
December 4, 1890, Dr. William T. Lusk
read a paper in which he said that a few
weeks ago he had been called to the bed-
side of a primipara in labor. The child's
head was low in the pelvis, but for two hours
there had been no progress. Extraction of
the head by the forceps was easily accom-
plished, but the cord was found tight around
the neck. It was divided with scissors,
and the body was extracted. The child,
however, had become asphyxiated, respira-
tion had ceased, the heart-beat was scarcely
perceptible. He placed, the child upon a
table, wrapped in warm cloths, expelled
the mucus from the posterior fauces, passed
a No. 8 English catheter into the trachea,
and removed mucus by suction. The quan-
tity of mucus in the bronchial tubes was
large, and the catheter had to be introduced
many times. Direct inflation was then prac-
ticed, and in ten minutes slight heart move-
ments were observed, but these ceased again,
and life-saving methods had to be continued
for nearly three hours before respiratory
movements were finally established. These
methods consisted in removal of mucus
from the bronchi, inflation through the
catheter, warm-water baths with sprinkling
of the epigastrium with cold water, and
the use of Schultze's and Sylvester's methods
alternately. Before using Sylvester's method
it had been necessary to draw the tongue
forward and depress the base. The next
day the child had spasms, but recovered
after twenty-four hours, and remains to-day
robust and the joy of a family.

He would grant that the story was a famil-
iar one, but its importance led him to bring
the subject before the Academy on this oc-
casion. According to his observation, the
method usually pursued was to spank the
child, wrap it in warm cloths, or dip it
alternately in warm and cold water, and lay
it away to die. But to manage these cases
successfully required perseverance and a
knowledge of the physiological laws in-
volved.

It was known that during the period of
gestation the child remained in a state of
apncea ; that the respiratory function was
performed by the placenta. But as soon as
the child was born, in normal cases, the

thorax expanded, the diaphragm contracted,
pulmonary respiration was established. The
premature establishing of pulmonary respira-
tion while the child was still in the passages
was followed by asphyxia, and was generally
the cause- of still-births. The author here
mentioned the two prevailing theories re-
garding the cause of respiration taking place
at birth, and also cited the experiments of
Engstok made on guinea-pigs and other
animals, which demonstrated that fetal res-
pirations were excited in the absence of ex-
ternal sources of irritation so soon as the
blood in the umbilical veins became dark-
ened or was cut off from the fetus. Pe-
ripheral stimuli, however, were capable of
exciting the respiratory act before the inter-
nal stimuli had increased sufficiently to
induce independent action.

After describing the fetal circulation,
Dr. Lusk said that, owing to the less amount
of blood supplied through the placenta dur-
ing contractions of the uterus before birth,
the respiratory centre in the medulla received
less arterialized blood, became more irrita-
ble, and this, with the friction upon the
body of the child as it passed through the
genital tract and came in contact with the
air, caused the first respiratory act to take
place. This was accompanied by expansion
of the chest, opening up of the pulmonary air-
cells and of the blood-channels distributed
to the lungs, which before had been nearly
closed. The blood, therefore, which had
before passed from the right ventricle di-
rectly to the aorta, was now directed to
the lungs. This caused diminution in blood-
pressure in all the vessels of the body, the
pressure being partially compensated for by
aspiration in the vena cava with the acts of
respiration. Since the blood, after respira-
tion had set in, was most diminished in the
ductus arteriosus, this channel soon became
obliterated. In the regular channels the
diminished pressure was most marked at a
distance from the heart. It was particularly
noticeable in the umbilical arteries, the pul-
sation here often being scarcely perceptible
after the child had breathed a few7 times.

In cases of asphyxia it was somewhat dif-
ferent. In nearly all cases of asphyxia after
birth the child had breathed in utero. Intra-
uterine respiration was due to tetanic con-
tractions of jthe uterus, a condition oftener
seen when it was more common to give ergot
before birth of the child ; to premature
death of the mother ; but oftenest of all, to
pressure upon the cord. Cutting off the

Feb. 28, 1 89 1.

Periscope.

247

blood suddenly from the placenta caused a
backward coupe and increased arterial ten-
sion, together with an increased amount of
work thrown upon the right side of the heart.
Intra-uterine respiration taking place, the
lung expanded, amniotic fluid, meconium,
epithelium, and mucus entered the nose and
throat, and, if the efforts at inspiration had
been active, even reached the trachea and
bronchi. As the respiratory attempt went
on, but no oxygen reached the medulla, it
gradually lost its irritability, respiration
ceased, and the heart and vessels were left
engorged with blood. Ecchymoses, if not
hemorrhages, were seen in different parts of
the autopsy. The time during which the
asphyxia had existed, or its degree, differed
in different cases. In the milder ones the
muscular tone was preserved, the head did
not drop, the skin was dusky red or cyanotic,
the conjunctivae were congested, the umbili-
cal vessels distended, reflex movements
could be excited by irritation. In these
cases respiration often returned. But in
the more advanced state of asphyxia the sur-
face was pale, cold, the heart- beat was fee-
ble and infrequent, the umbilical vessels
were nearly empty, the head dropped, there
was loss of muscular tone ; if there was any
attempt at respiration there were no associ-
ated movements of the muscles of the face.

The first signs of returning animation
were the refilling of the capillaries and of
muscular tonicity.

The indications for treatment were to
clear out the air-passages, restore the irrita-
bility of the medulla, increase the force of
the heart-contractions, relieve the plethora
of the heart and blood-channels, expand
the thorax. Where muscular tonicity was
still present these conditions were easily ful-
filled ; and clearing out the fauces and nose
of mucus, the use of flagellations and the
stimulus of warm and cold water were likely
• to prove sufficient. But in a number of
instances the skin in a few days became
dusky, the heart-action feeble, and the child
died of atelectasis. To avoid this no
method excelled Schultze's.

Schultze's method was illustrated on the
child cadaver. The thumbs were placed
upon the anterior portion of the child's
head, the index-finger in the armpits, the
hands diagonally over the back, the body
hanging down. The mouth being open,
the pulling upward on the thoracic muscles
drew the nipper ribs upward, while the
attachment of the abdominal muscles caused

the lower ribs to be drawn downward, the
diaphragm fell downward, and thus the
cavity of the chest was expanded to the
greatest possible degree. Inspiration was
thus induced. Now, by extending the
hands horizontally and giving the body of
the child a forward turn, the position was
assumed in which the abdominal viscera
pushed up the diaphragm, the ribs were
brought in close contact with each other,
and the most efficient farm of expiration
was carried out.. Perhaps there was no
other way in which the mucosities taken up
into the lungs could be so efficiently ex-
pelled. Before laying the child' aside it
was desirable to swing it gently a few times
forward and upward over the hands so as to
completely ventilate the lungs and expel
the mucus from the air-passages. But the
greatest advantage of the Schultze method
related to the manner in which the congested
heart-cavities, thorax and blood-vessels were
unloaded of engorged blood. There was
no doubt but what the Schultze method
would save many of that class of cases which
heretofore had been resuscitated only to die
the third or fourth day.

But the method was capable of abuse. '
Before it was employed, the child should
be placed in warm cloths, and its nose and
fauces cleared of mucus. Then proceed to
clear the trachea and bronchi by passing a
No. 8 English catheter and using suction.
This often required time and repeated in-
troduction of the elastic tube. Meanwhile,
insufflations should be employed at inter-
vals. Gentle compression of the chest-
wall should now and then be practiced.
By these means, little by little, the blood
received oxygen, and returning irritability
of the medulla was manifested by occasional
movements. Then Sylvester's method was
practiced. It was not of much use, how-
ever, unless one had an assistant to hold
the extremities. The tongue should be
drawn forward and its base depressed, to
permit entrance of air. As soon as the
heart-movements became plainly perceptible
the child should be placed in warm water,
lifted again, and sprinkled with cold water.
But to dip it suddenly in cold water had
often caused instantaneous death. Putting
it into warm water and sprinkling the face
with cold water was harmless. Finally, the
swinging method of Schultze should be em-
ployed, especially for its effects upon the
circulation. It should be remembered that
cases of asphyxia required watchfulness and

248

Periscope.

Vol. Ixiv

a hopeful spirit. Even after having pre-
sumably resuscitated the child by the pro-
cedure just outlined, it might again be
necessary to go back to the catheter and
insufflation.

Homoeopathy by a Homoeopath.

Dr. W. M. Decker, of Kingston, N. Y.,
in the New York Medical Times, February,
1 89 1, has a paper in which he quotes criti-
cisms of a Dr. Tooker on some resolutions,
which Dr. Decker submitted to the Homoeo-
pathic Medical Society of the State of New
York, at its semi-annual meeting held at
Brooklyn last year.

The first resolution proposed by Dr.
Decker reads as follows : "Resolved, That,
in the opinion of this society, the theory of
the psoric origin of chronic diseases, as set
forth by Hahnemann in the Organon and in
his other writings, is erroneous ; and, there-
fore, as a basis for treatment, it is mislead-
ing."

The second resolution is ' ' Resolved, That
all symptoms attributed to provings with
high potencies are of doubtful reliability ;
and, therefore, they are not trustworthy
guides in practice."

Of this resolution Dr. Tooker says : " The
second resolution is only worthy of consid-
eration because Hahnemann in his dotage
and some of his disciples in their early en-
thusiasm believed it and taught it. As the
great majority of the followers of Hahne-
mann, however, at the present day, have
seen its fallacy and have already discarded
it, there seems to be no special harm in giv-
ing it official and respectful burial in the
resolution as formulated."

Dr. Decker says he cannot understand
how he can accept the one and reject the
other. If he is not a believer in high po-
tencies, then, he cannot accept the doctrine
of potentiation or dynamization ; and that
is all the third resolution condemns.

The third resolution is "Resolved, That,
in the opinion of this society, the theory of
potentiation of drugs, as taught by Hahne-
mann in the Organon and in his other writ-
ings, that is, the doctrine that the more
drugs are attenuated by successive tritura-
tions, or the more they are diluted and
succussed, the more their power and effect-
iveness is increased, is hereby declared un-
sound and unreasonable in principle, except
the fact that division of drug matter is
accomplished." "

This is the resolution which Dr. Tooker
cannot accept ; and yet he does indirectly
accept it, as before stated. The above reso-
lution does not reject attenuation or dilution
of drugs. The divisibility of matter is
embodied in the resolution as an exception.
The resolution does not declare that unsound
and unreasonable ; but only the doctrine of
potentiation. Dr. Tooker seems to lose sight
of the distinction between the meaning of
the terms attenuation and dilution as com-
pared with potentiation and dynamization
when applied to drugs. They are not syn-
onymous terms, and cannot be used inter-
changeably.

After explaining his notions, Dr. Decker
says : "To prove that potentiation of drugs
as taught by Hahnemann is false, absurd and
unreasonable, I need only refer you to
Hahnemann's own statements, viewed in the
light of our present knowledge. I refer you
to Hahnemanri s Lesser Writings, by Dr.
Dudgeon, p. 733, from which we quote the
following : ' In the same way liquid medi-
cines do not become, by their greater and
greater attenuation, weaker in power, but
always more potent and penetrating. For
homoeopathic purposes this dilution is per-
formed by well shaking a drop of the medi-
cine with a hundred drops of a non-medi-
cinal fluid ; from the bottle so shaken a drop
is taken and shaken up in the same manner
with another hundred drops of unmedicated
fluid, and so on. This result, so incompre-
hensible to the man of figures, goes so far
that we must set bounds to the succussion
process, in order that the degree of attenua-
tion be not over-balanced by the increased
potency of the medicine, and in that way
the highest attenuation become too active.
If we wish, for example, to attenuate a drop
of the juice of sundew1 to the decillionth,
but shake each of the bottles with twenty or
more succussions from a powerful arm, in
the hand of which the bottle is held, in that
case this medicine, which I have discovered
to be the specific remedy for the frightful
epidemic whooping- cough of children, will
have become so powerful in the fifteenth at-
tenuation (spiritualization) that a drop of it
given in a teaspoonful of water would en-
danger the life of such a child ; whereas* if
each dilution bottle were shaken but twice
(with two strokes of the arm) and prepared
in this manner up to the decillionth attenu-
ation, a sugar globule the size of a poppy

1 Drosera rotiindifolia .

Feb. 28, 1891.

Periscope.

249

seed moistened with the last attenuation
cures this terrible disease with this single
dose without endangering the health of the
child in the slightest degree.' "

According to Hahnemann the process of
succussion and trituration develops in drugs,
or imparts to drugs, more and more power
the further the process is carried on ; or the
more dilute and attenuated they become by
this process the more actual power and force
is engendered ; and this force, or power,
started in the material, becomes greater as
the material becomes less and less ; and
finally, when the material has passed away,
the accumulated power is transmitted or
passed over to the spiritual ; and that goes
on increasing in power ad infinitum, if the
process is continued.

According to the process, Hahnemann
believed that, when the spirit world was
reached with drosera (" the fifteenth attenu-
ation [spiritualization "]), provided each
potency had-received twenty succussions in-
stead of two from a powerful arm, then it
would endanger the life of a child with
whooping-cough.

He directed that each successive dilution
should be succussed twice, if more than that,
the power would be developed too rapidly,
for each and every additional shake meant
more power. Hence, in the case of drosera,
when the point is reached where there is no
drug material left — where the body of the
drug is all gone, then the spirit of the drug,
like the soul of John Brown, goes marching
on mighty in its power and deadly in its
effects. Now, if this be so, it should be re-
garded, by the law of the State, malpractice
to dispense the so-called high potencies
without a label signifying that they are
deadly ; and it should be generally under-
stood and taught that a high dilution should
be brought low by dilution ; but mind you
don't shake it. The only safety in diluting a
high potency is in not succussing it.

Such is the logic of Hahnemann. To-day
it is nonsense ! folly ! delusion ! craziness !
and there is no danger of killing a child
with drosera in any dilution. Hahnemann
takes us out of the tangible into the spirit
world — of which we know nothing ; and the
nearer we approach to nothingness, if on
the given scale, by jerks, the nearer, he tells
us, we approach to something — call it dis-
embodied power, which is a misnomer, a
fallacy.

The more material the more power. We
cannot comprehend or utilize a force inde-

pendent and separate from material. In all
science, in all mechanics, there is no such
thing as power without material. This is a
self-evident truth, which confutes and con-
founds and makes a lie of Hahnemann's
doctrine of potentiation.

A drug's usefulness, or beneficial influ-
ence, may be increased by dilution, but not
its power. The less material the less power,
on general principles, whether it is succussed
or not. Does a tornado become more pow-
erful by dilution ? Does a man's arm be-
come stronger by emaciation ?

Is the thirtieth attenuation of prussicacid
more powerful and deadly, when succussed
according to Hahnemann's directions, than
the pure acid itself?

Power or potency is one thing ; but the
fitness, the adaptability of things is some-
thing else. A drug, by dilution or tritura-
tion, may be better adapted to the cure of
disease, it may, by that process, be the
better fitted for efficient use by the system;
but its power has not thereby been increased ;
and it does not continue to increase as the
material is lessened ad infinitum.

There is no such thing as a high potency,
because power does not increase with suc-
cessive diminution of matter, notwithstand-
ing it may have been triturated or succussed.
You cannot get out of a drug anything more
than is in it; and succussion and attenuation
possess nothing and give nothing. There is
no such thing as a high dilution, for the so-
called high dilutions contain none of the
original drug material. In order to dilute,
there must be something for dilution — some
material ; and, if there is no material, there
can be no dilution.

Force or power cannot be conveyed or
exhibited beyond matter nor without matter :
and to claim that it can, or to advance such
doctrine, is nonsense ;■ for it is unscientific,
untenable, undemonstrable and false. I
close with a little prayer — "With all thy
getting, get understanding." Amen S

[All this is very interesting, and suggests
the query : What is a homoeopath ? — Editor
of Reporter.]

Removal of the Uterine Appendages
in Cases of Functional Neurosis.

At the meeting of the Obstetrical Society
of London, January 7, 1891, Dr. Playfair
read a paper on removal of the appendages
of the uterus for neuroses, an abstract of

250

Periscope.

Vol. lxiv

which appears in the British Medical Jour-
nal, January 17, 1891. He detailed several
cases that had come under his observation :
— 1. A case of neurosis treated by removal
of the appendages, without benefit, subse-
quently cured by systematic treatment. 2.
A similiar case in which the operation was
recommended, and about to be performed,
when the patient refused her consent, like-
wise cured by systematic treatment. 3. A
case of neurosis, in which there was distinct
evidence of structural disease of the appen-
dages. In this instance the neurotic symp-
toms were first dealt with, in the hope that
the patient would be sufficiently bettered to
avoid the necessity of operation.

The subject of hystero-epilepsy and mania
treated by removal of the uterine appen-
dages was considered, and an illustrative
case given. The general conclusions ar-
rived at were : — 1. That the removal of the
appendages is not a legitimate procedure
in cases of purely functional neurosis. 2.
That when marked structural disease of the
appendages co-exist with severe neurotic
conditions, the latter should be treated in
the first instance, in the hope that operation
might be avoided. 3. That in hystero-epi-
lepsy and hystero-mania the results of op-
eration have been so unsatisfactory that it
is a procedure of very doubtful expediency,
and not to be recommended.

Sir Spencer Wells referred to a pamphlet
by Dr. Ross, of Toronto, on " The failure of
the removal of the tubes and ovaries to re-
lieve symptoms." Dr. Ross says: uTo
operate on organs not diseased for the
relief of indefinable pain symptoms, hysteri -
cal symptoms, cataleptic symptoms, epilep-
tic symptoms, is in my mind unjustifiable.
A craze seems to have taken hold of the pro-
fession. The axiom seems to have become,
if a woman has indefinite pains and local
symptoms, take out her ovaries. This axiom
requires a radical change." Dr. Ross went
on to say : " I have seen these unjustifiable
operations done both in Europe and
America. . . . Many cases in which ovaries
and tubes are removed to relieve certain
nervous symptoms remain unrelieved. . . .
Many cases I hear of as cures are not cures.
. . . From our many failures to remove'
nervous diseases, as hysteria and epilepsy,
by castration, we can see that the ovaries
play but a part in their causation ; and I be-
lieve that we might as well hope for relief
of these diseases by enucleation of both eyes
as by removal of both ovaries, or both tubes,

or both tubes and ovaries, or even tubes,
ovaries, and uterus." Dr. Ross related a
case in which he removed the ovaries in
1886. In 1888 he was able to report that
his patient had been in splendid health ever
since operation, but in 1890 had to say :
" her mental condition is not what it was
before. She seems lazy, indolent and fat,
and is not the bright little woman she was
before the operation, even when she had her
aches and pains. Sexual intercourse is only
indulged in as a marital duty; it gives
neither pain nor pleasure." Then Dr. Ross
proceeded : " Many deaths from these op-
erations have been recorded. . . . A girl's
prospect of marriage, maternity, and a
happy life are blasted forever by such a
procedure." Dr. Ross then referred to a
case in which a woman of his acquaintance
was operated on in the provinces, and her
case was brought before the Gynecological
Society in December, 1888, very soon after
the operation as a practical cure. Sir Spen-
cer Wells had seen that lady that day ; she
had never been well since the operation,
but very much worse than before, and her
case instead of being a cure was a deplorable
and disastrous failure. He had seen other
cases almost as unsatisfactory, and he fully
concurred in all that Dr. Playfair and Dr.
Ross had said against unnecessary and un-
justifiable mutilation for transitory disease.

Operation for Cerebral Hernia.

The Western Medical Reporter, January,
1 89 1, contains an interesting report of a
successful operation for cerebral hernia by
Dr. J. Frank, of Chicago.

On August 11, 1890, the mother brought
a little three-year-old girl to the Cook
County Hospital, saying the child was
kicked by a horse which was being shod. On
examination paresis of the left arm and leg
was found. The right pupil was somewhat
larger than the left and both reacted to
light. Stupor was well marked. After
shaving the" head, the scalp was found to be
intact, with the exception of its being dis-
colored. On account of swelling, a depres-
sion of the skull could not be determined.
The stupor and paresis justified an explora-
tory operation. After the operation, there
was an immediate improvement of the pare-
sis and stupor. Several days after the
operation the child was able to sit up in
bed and play.

Feb. 28, 1 89 1.

Periscope.

Where the dura was destroyed and over
the region where the drainage was placed, a
hernia developed, which kept on growing
larger. As the hernia kept on increasing in
size, an operation was decided on. The
method adopted in this case is as follows :
The scalp was dissected from the tumor
where it was reflected and firmly united.
The dissection was carried on until healthy
brain tissue was reached, when, with the
handle of the scalpel, the hernia was cut
away, during which time cerebral fluid
oozed out. As soon as the hernia was
removed the brain filled out the empty
space. A smart hemorrhage now suc-
ceeded, which had to be controlled by
packing. It was seen that the dura could
not be brought together, so the edges of the
scalp were freshened and united with inter-
rupted sutures. A compress was put over
the wound to keep the parts as quiet as pos-
sible and for the purpose of securing pri-
mary union, as upon this rested the success
of the operation. Tlie evening of the fol-
lowing day the child had a slight general
convulsion, commencing in left arm and
leg, followed by stupor which lasted about
six hours, which apparently was produced
by the compress being strapped on too
tightly over the area where the brain pul-
sated against the scalp.

Four days after the operation the child
was running about the yard. In a week the
stitches were removed. Everything looked
favorable until about the second week after
the operation, when a small point in the
middle of the line of the incision com-
menced to slough. Fortunately, the slough-
ing did not extend very far, leaving the
parts in a fair condition.

Practice by Syphilized Practitioners.

The Medical Press January 21, 1890,
says : A foreign contemporary discusses the
question of the duty of a medical man who
has been unfortunate enough to contract
syphilis in the matter of continuing to prac-
tice his profession. Everything must, of
course, depend upon the nature of the man-
ifestations, their site and their age. It is
obvious that no conscientious man with a
specific ulceration on the hand would under-
take any obstetrical or surgical operation in-
volving the risk of infection to the patient.
There is no reason to suppose that infection
is possible in the absence of cutaneous le-

sions, though any serous of sanguineous ex-
udation might conceivably convey the con-
tagion. This, however, is still a moot ques-
tion, and the circumstances under which a
medical man would be constrained to cease
to practice are rare and improbable.

Therapeutic Use of Monesia Bark.

The so-called " monesia bark " {Cortex
monesia, or cortex Buranham or Guaran-
hani) is derived chiefly from a Brazilian
txteChrysophyllum glycyphlmim Casaretti, but
also from other six varieties of the species
Chrysophyllum, belonging to the natural
family Sapotacece. According to Henry and
Payen, the bark contains saponin, an allied
body " monesin," tannic acid, glycyrrhizin,
wax, a crystalline fatty substance, etc. Years
ago the drug (in the shape of a solid aque-
ous extract, termed simply " monesia ") was
much vaunted and used, especially in France,
as a tonic and an astringent. Subsequently,
however, it gradually fell into oblivion.
Quite recently, Dr. Pavel G. Rozanoff, of
•Moscow, has once more drawn the attention
of the profession to the long-forgotten re-
medy {Moscow Inaugural Dissertation,
1890), emphatically pointing out that mo-
nesia actually affords an excellent expectorant
and astringent agent. He describes a number
of cases of respiratory and intestinal affec-
tions (acute and chronic bronchitis, pneu-
monia, subacute enteritis, chronic diarrhoeas,
etc.), in which he most successfully resorted
to the internal administration of a mixture,
made of from ^ to 1 drachm of aqueous ex-
tract of the bark to 6 ounces of water. The
mixture was always given in tablespoonful
doses, repeated every two- hours. The
author's experience seems to justify the fol-
lowing general propositions. 1. The bark af-
fords a good expectorant, which is depend-
ent upon its containing saponin and mo-
nesia. 2. At the same time, owing to a
rich proportion of tannin, the remedy con-
stitutes a good astringent. 3. It is quite
free from any unpleasant accessory effects
and hence, as an expectorant, should be
preferred to ipecacuanha, senega and such
like drugs. It is especially indicated in
cases of respiratory disease in which a more
or less prolonged administration of an ex-
pectorant is deemed necessary, as well as
in cases where the ordinary expectorants
are apt to give rise to gastr'o- intestinal dis-
turbances. 4. As an astringent monesia

252

Periscope.

Vol. lxiv

proves to be useful in chronic diarrhoeas.
5. In virtue of its simultaneously possessing
expectorant and astringent properties, the
bark will be found eminently beneficial and
convenient in cases of co-existing chronic
catarrhal affections of the respiratory and in-
testinal tracts.

Medical Practice in Missouri.

The St. Louis Courier of Medicine, Janu-
ary, 1 891, says :

" Unless steps are taken in the near future
to raise the standard of requirements for the
practice of medicine and surgery in this
State, we will find to our sorrow and dismay,
that when the higher standard adopted by
all our sister States goes into effect, Missouri
will be overrun with 'quacks.' We have
an abundant supply of them now, without
any emigration of the ' scum and rot ' of
other States. The very day they are af-
fected by this change in the present laws,
there will be an exodus, the like of which
was never seen. The wagon-roads from
every point of the compass will be crowded
with the vehicles of the traveling quack
with their banners flying, hurrying to the
Mecca ; the paradise, which the narrow-
minded policy of our State government has
maintained for years." To this, it adds:
li Let us arise in our might ere our strength
and present power has passed away, and
place Missouri on an equality with all the
States around us !"

Caustic Treatment of Carbuncle and
Diphtheria.

Dr. Georgy I. Gisler, of Semipalatinsk,
describes {Proceedings of the Omsk \Si-
be'riari] Medical Society, No. 8, 1890, p. 187)
six successive cases of severe carbuncle of the
neck, rapidly cured by the application of
the following mixture, prepared extempore.

& Potassre s sodee causticse fusee

Magne ke ust?e aa gr. ii

Aquoe destillatae . . . . q. s. ut ft. linimentum

Sig. Carefully paint over the diseased area, by-
means of a brush, until an equal layer, one-fourth
inch thick, has formed. Then cover the part with a
piece of linen, soaked in a 50 per cent, solution of
carbolic acid, or in wintergreen oil.

Simultaneously, antefebrin (5 grains at
bed-time) and quinine (from 10 to 15 grains
similarly at bed-time) were given internally.
In every one of the cases, in 3 or 4 hours

after the application a profuse perspiration
appeared and the temperature returned to
the standard. On the next day the ulcer
was found to be replaced by a black, dry
and firm scurf, which gradually became de-
tached from the subjacent tissues, leaving a
soundly granulating and rapidly healing sur-
face.

Dr. Gisler states, further, that in such
cases of gangrenous faucial diphtheria as are
not accompanied by an intense enlargement
of the submaxillary lymphatic glands, he
invariably obtains most satisfactory results
from cauterizing the diseased region with
chloride of zinc. He commences the treat-
ment with carefully touching the area with
the solid chloride ; two hours later he paints
the region with a 50 percent, solution of the
salt, and subsequently passes to an 8 per
cent, one, repeating the application every
two hours. After each seance the patient is
given internally a solution of bicarbonate of
soda ("to decompose the zinc salt, if swal-
lowed "). If the nasal passages are simul-
taneously involved, he irrigates them with a
solution of perchloride of iron in a saturated
chlorine water and lets the patient gargle
his throat with the same fluid. Of internal
remedies he administers calomel "in drastic
doses," in the beginning of the treatment,
and subsequently gives salicylic acid every
two hours (in 5-grain doses to a child under
2 years of age, and from 15 to 20 grains
to older patients). The patient should be
constantly kept in the room at 8° or io°
Reaumur (5o°-54.5° Fahr.) [This would
be thought a low temperature in this country,
for a sick room. — Ed. Reporter.]

Fish Poison.

The Vierterjahrsschrift fur Gerichtliche
Medicin, January, 1891, calls attention to a
very important matter in connection with
the "use of fish as a food. It appears that an
investigation of the result of eating fish
preserved on ice for use in the London
markets, has led to the discovery that those
were most dangerous which were kept in
immediate contact with the ice. Poison-
ing by fish which had not been in contact
with ice was not observed at all. This is
attributed to the influence of the water de-
rived from the ice, and bearing whatever
impurities it had had before being frozen,
which promotes the formation of the animal
alkaloids known as fish poison.

Feb. 28, 1 89 1.

Editorial.

253

THE

MEDICAL AND SURGICAL

REPORTER.

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When it is desired to call our attention to something in a
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newspaners are not looked at.

The Editor will be glad to get medical news, but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

GYNECOLOGICAL SUGGESTIONS.

With characteristic felicity of expression,
Professor Goodell has chosen for the title of
a recently published paper the expression
" What I have Learned to Unlearn in
Gynecology."

In this paper, while he confines himself
to the discussion of misconceptions which
pertain exclusively to maladies peculiar to
women, he adopts a course, which, if fol-
lowed out by others entitled to speak author-
itatively, would prove of incalculable value
to the profession.

The history of recent medicine records
the uprooting of time-honored dogmas to
an extent heretofore unexampled ; and the
experience of Dr. Goodell, which he so
frankly relates, must have been that of all
progressive men. If they would record, in
short, concise papers, what they have found
to be wholly unreliable, it would deter many

from undertaking what is not only of no
value, but what unfortunately is too often
positively injurious, and, in addition, it
would act as an incentive to more careful
investigation into the causes which underlie
disease, and the adoption of better means
for its relief.

The paper which suggests this article de-
serves thoughtful consideration for the sound
views gathered from a wide and varied ex-
perience. The first subject considered is the
disposition, prevalent both in the profession
and among the laity, to regard the menapause
as responsible for a large percentage of the
maladies of matronhood, and, having ac-
cepted that view, to allow without investi-
gation conditions which can be relieved only
by early interference, to advance so far that,
when recognized, the sufferer is beyond re-
lief, either by reason of the fatal nature of
the disease itself or the ravages which it has
produced in the vital energies. Dr. Goodell
very strongly insists that the climacteric
should not be considered a cause for uterine
disease, and suggests that unusual hemor-
rhages or other discharges occurring at this
period in a woman's life should always be
regarded as symptomatic of the existence of
organic disease, calling for careful investi-
gation and prompt treatment. He points
out that cancer of the cervix, polypi or fun-
gus vegetations of the endometrium are
almost invariably responsible for these con-
ditions, while the part played by the mena-
pause in the disorders attendant on the
climacteric is almost exclusively detected in
the many nervous phenomena present at
that time, or as a factor in the production
of insanity.

The belief that the menstrual period is
unsuited to surgical procedure he clearly
shows to be a fallacy, pointing out that,
where the curette is to be used for the re-
moval of uterine vegetations, this time is
the best, because they are then swollen by
the afflux of blood and can be more readily
removed. He says, " there is no surer way
of checking a menorrhagia or of stopping a

254

Editorial.

Vol. lxiv

metrorrhagia than by curetting the womb
during the very flow." Indeed, where time
is precious, the gravest operations not only
may be, but, with few exceptions, should be
performed. Further he says, " while I do
not select this period for the removal of
ovarian cysts or for other abdominal work,'
such as the extirpation of the ovaries, of a
kidney, of breaking up intestinal adhesions,
etc., yet I have not hesitated to perform
these operations at such a time, and have
never had reason to regret the course. The
only operations that I should dislike to per-
form during menstruation would be those
involving the womb itself — such as the re-
moval of a uterine fibroid or a partial or a
complete hysterectomy, and the various op-
erations for uterine cancer, etc

For obvious mechanical reasons it would
also hardly be wise to sew up the torn cervix
of a menstruating womb."

Dr. Goodell's suggestions in regard to the
management of lying-in women, a subject
of the greatest importance and one which
confronts so many of .us, is so practical that
we cannot refrain from reproducing it in
full. " In the lying-in chamber," he says,
" the fear of septicaemia will ever haunt me,
but I have long since abandoned the idea
cherished by that class of waistless and wit-
less nurses, now happily obsolescent, that
the parturient woman is to be swathed like
a mummy and kept as immovable. What
earthly harm can accrue to a woman after a
natural labor if she turns over from side to
side, sits up in bed, or even gets up to use
the commode, if she feels like it, I cannot
see. Natural labor is a physiological pro-
cess,, not a pathological one, but tradition
has thrown around the lying-in bed a glam-
our of mischievous sentiment.

" In relation to this, let me express my dis-
belief that % mammary abscess comes from
' caked ' breasts, or from breasts over-dis-
tended from a secretion too great for the
infant's needs. Mammary abscess in the
suckling woman comes, in my opinion, from
cracked nipples, and from cracked nipples

alone. In proof of this let me ask my read-
ers if any one of them has ever had a case
of mastitis after a miscarriage, or one of
gathered breast following a still-birth — al-
ways provided the breasts were let pretty
much alone so far as pumping and sucking
are concerned. Under these circumstances
the unsucked and unpumped breast will
swell up and grow painfully hard, but will
not inflame or suppurate. Let me not be
understood as saying that an over-distended
breast snould not be relieved by sucking or
pumping ; but the means employed for this
relief must be so sparingly used, and at such
long intervals, as not to crack the nipples.
This immunity from mammary abscess after
miscarriages and still-births is attributed by
the physician to his local applications of
belladonna, or other milk-drying drugs.
But it comes from the absence of the excit-
ing cause of cracked nipples — a sucking
child."

We call attention to these suggestions of
Dr. Goodell because they are eminently
worthy of careful consideration by all who
have women for their patients, and because
they illustrate a spirit in the art of medicine
which it is. pleasant to applaud and to com-
mend for imitation.

NATURE OF LUPUS.

Within the past few months, since the
announcement by Dr. Koch of the discovery
of a remedy for tuberculosis, English-speak-
ing people have been made familiar with the
name lupus. In reply to their inquiries as
to what lupus is, it is not too much to say
that the almost invariable answer has been,
it is tuberculosis of the skin. The teaching
of German and American dermatologists is
practically unanimous on this point, and the
treatment of lupus with Koch's remedy as-
sumes it as a starting point. It is with
much interest, therefore, that we have read
the first of Mr. Jonathan Hutchinson's
Post- Graduate Lectures on the ' ' Nature of
Lupus," in the Lancet, Jan. 17, 1891.

Feb. 28, 1 89 1.

Editorial.

255

This author says that the sum of the evi-
dence seems to him much in favor of the
belief that lupus is a specialized form of
chronic inflammation rather than the result
of infection.- He does not altogether, in
his theory, exclude the influence of the para-
site, but appears to think that conditions of
local irritation favor the implantation of the
bacillus, as ploughing and manuring of a field
prepare it for the sowing of seed. He de-
clares, what every one knows to be true, that
it is extremely difficult in many cases to di-
agnosticate lupus from scrofulous ulcers
and ulcerating chilblains. But whenever
a chronic inflammation of skin or mucous
membrane, not due to syphilis, shows a per-
sisting tendency to spread at its edges, to
produce satellites near it, and to leave a con-
dition of scar behind it, such a process Mr.
Hutchinson regards as lupus. Another con-
dition, which he believes to be diagnostic of
lupus, is the presence beneath a thinned layer
of epidermis of a deposit or growth of a
semi-translucent ("apple-jelly") granula-
tion material, often in considerable thick-
ness.

As to the classification of lupus, Mr.
Hutchinson questions whether clinical evi-
dence can be held to prove the alliance
of lupus with tuberculosis, rather than
with cancer. As an argument against the
bacillary nature of the disease, he remarks :
"I doubt much if many observers could
collect from their own observations as many
as four cases of lupus in which the patients
has subsequently succumbed to any form of
internal tuberculosis." The Lancet, how-
ever, reminds him editorially that Besnier
has observed phthisis in association with
lupus eight times in thirty- eight cases of lu-
pus, that is, in over twenty per cent, of the
cases.

Lupus is so rare in this country that we
must look to the pathologists of Europe to
settle the question of its nature. Taking
the skin dispensaries in connection with the
hospitals of Philadelphia, we doubt if they
average one case of lupus vulgaris a year.

Mr. Hutchinson's communication is re-
markable as showing that a man of great
experience and close observation is far from
believing that lupus is tuberculosis, in spite
of the fact that scarcely any Other voice is
heard against that view. If Koch's remedy
were to prove of unfailing accuracy in the
detection of lupus, it would be a valuable
agent ; but it has not attained this position
yet, so that we must look to older means of
diagnosis for help.

In order to estimate fairly Mr. Hutchin-
son's paper, it should be borne in mind that
he does not accept all the pathological'
views which now prevail ; and, on the other
hand, that tubercle bacilli, which are gen-
erally accepted as an evidence of the exist-
ence of tubercular tissue, do not seem to be
found in the very early stages of lupus.

HOMCEOPATHS AND THE MEDICAL
EXAMINERS' BILL.

In order that the readers of the Medical
and Surgical Reporter may understand
into what a fever of excitement the homoeo-
paths in Pennsylvania have been thrown by
the proposition to have their graduates ex-
amined by some body besides their own
College Faculty, we reproduce in another
part of this number of the Reporter an
editorial from the Hahnemannian Monthly.

We take it for granted the readers of the
Reporter and the community will appre-
ciate the signifiance of the fear which seems;
to fill the homoeopathic (college?) breast
when there is any chance that the State may
take into its own hands the determination of
fitness for practicing medicine, as contrasted
with the composure with which the Regular
School consents to undergo — without mak-
ing any conditions — any test of merit which
the wisdom and honesty of our law-givers
may appoint.

This singular contrast receives a curious
side-light in view of a letter published in the
Reporter August 24, 1889, to which so far
we have seen no answer. This letter is re-

256

Notes and Comments.

Vol. Ixiv

printed in the present issue, so that it may-
be, considered in connection with the oppo-
sition to -a Medical Examiners' bill which
would make it impossible for a graduate of
the Eastern Penitentiary to get a medical edu-
cation, a diploma, and endorsement by
the Hahnemann Medical College, and the
legal right to practice medicine, in the short
space of eight months !

Book Reviews.

[Aiiy book reviewed in these columns maybe obtained upon
receipt of price, from the office of the Reporter.]

ILLUSTRATED ENCYCLOPEDIC DICTION-
ARY. By Frank P. Foster, M. D. Volume II.
4to, Cac. — Fasay, pp. 753-1544. New York : D.
Appleton & Co., 1890.

This is the second volume of the Dictionary of
Medicine edited by Dr. Frank P. Foster, of which we
noticed the first volume October 6, 1888. The second
volume is fully up to the standard of the first in com-
pleteness and reliability. For a medical dictionary
there is some inequality of space to different subjects.
For example, the word " corolla " occupies more than
one page of space, and is illustrated with great com-
pleteness, while the word " douche " occupies as much
space, and is illustrated with a variety of cuts which
look a> if they had been borrowed from the instrument
makers. The principal advantage of the book, so far
as we can judge, is the fact that 'it contains a very
large number of words, and is that much superior to
most medical dictionaries. It must have demanded
an enormous expenditure of labor for Dr. Foster to
carry on the work of getting out a volume like thh in
addition to his work as Editor of the New York Medi-
cal Journal, and we congratulate him upon the high
degree of excellence to which he has brought it.

CHARLES LETTS & CO.'S ABC MEDICAL
DIARY AND VISITING LIST. London: Bur-
roughs, Welcome & Co., 1891.

We have received a copy of this English book,
which corresponds with our American Visiting Lists.
Nearly one-half of its thickness is made up of reading
matter of interest and value, while the tabular parts
are very well ruled and conveniently arranged. The
whole is well made, as a book, and neatly bound,
though we miss' the cover flap which is put upon all
similar boolis in this country.

Literary Notes.

— The Dietetic Gazette, with the number for Janu-
ary, 1 891, passed into the editorial management of Dr.
Simon Baruch, of New York. Notwithstanding the
principles announced in his salutatory, the Depart-
ment of " Annotations " (presumably editorial) con-
tains no less than thirteen reading notices.

Notes and Comments.

Endorsing Diplomas in Pennsylvania.

In the Medical and Surgical Reporter,
August 24, 1889, was published a letter from
one of our subscribers who said : In your
issue of August 3, there appears a commu-
nication from " Jno. E. James, M. D.,
Registrar of Hahnemann Med. College of
Philadelphia," in which he takes you to
task for not basing an Editorial in the
Reporter, July 13, 1889, upon facts nearer
home than England. Now I wish to relate
some facts, and would like to have made
manifest the consistency between them and
the declarations in the article referred to
above.

On the 2 2d day of April, 1884, Hiram
T. Kinsman registered in the Prothonotary's
office in Bradford Co., Pa., as a practitioner
of medicine, claiming that he had been in
continuous practice in this county since
1 87 1 — " Degrees, ' None ' " — enumerating
five different places in the county where he
had been in practice during that time. Sub-
sequent events, however, showed that there
was one place more of alleged practice (not
in the county) that he did not have recorded
on the Register.

The said Kinsman was charged with illegal
registration. Daring the trial it was in evi-
dence, and admitted by defendant, that for
four years of the time of his alleged prac-
tice in Bradford Co. he was an inmate of
the Eastern Penitentiary. His crime was
criminal abortion. It is said that the woman
died of hemorrhage, which he did not know
how to control. Kinsman claimed that he
practiced while in prison, by sending pre-
scriptions to persons in this county. Suffice
it to say that the jury disagreed ; but before
the second trial, Kinsman agreed to have
his name stricken off the Register, and this
was done by order of the court on Septem-
ber 6, 1886. Kinsman was absent a few
months from home (at least it was so re-
ported), and on May 9, 1887, registered
again — this time as a graduate of " Bennett
Eclectic Medical College," "endorsed by
Hahnemann Medical College of Philadelphia,
and Eclectic Medical College of City of
New York."

Here is an ignorant migrating "doctor,"
convicted of a penal offense, and of false
registration, who, after not more than a few
months of medical study, is registered as
endorsed by the college that " Jno. E. James,

Feb. 28, 1891/ Notes and

Continents.

257

M. D.," says sits on such a high and lofty
elevation and requires a high standard of
medical knowledge ! I would say, with Jno.
E. James, M. D., "Please note .... the
whole of numbers 4 and 5." Yes, sir, we
have noted them, and desire to ask what
kind of professional and moral standing the
person in question has, and what was the
character and quality of his examination by
the faculty of the Hahnemann Med. Col-
lege ?

Reading these rules in the light of these
facts they appear very much like first-of-
January resolutions. I think these rules
need bracing up in the year 1889, without
waiting until 1890 and 1891, judging by
the case cited.

The Homoeopaths and the Medical
Examiners' Bill.

Under the amusing title, " The Proposed
Allopathic Bill to Establish in Pennsylvania
a State Board of Medical Examiners," the
Hahnemannian Monthly, in its February
issue^ publishes the following editorial.

This act provides for the appointment, by
the governor, of a board of examiners con-
sisting of nine members, three of whom
shall serve for one year, three for two years,
and three for three years, in the first in-
stance, and thereafter annually the governor
-shall appoint three members to serve for
three years. The members of the board
shall be graduates of a legally chartered col-
lege or university having power to confer
degrees in medicine. They must also be
citizens of the United States and of Penn-
sylvania, and shall have been in active prac-
tice for a period not less than ten years.
Not more than one shall be appointed from
the same county, and none shall be a
member of the faculty or staff of any medi-
cal school or university. The applicants
shall be examined in anatomy, physiology,
chemistry, toxicology, pathology, hygiene,
materia medica and therapeutics, princi-
ples of medicine, surgery and obstetrics.
Any candidate for examination may choose
the system of materia medica and therapeu-
tics in which he or she shall be examined,
and no one shall be rejected on account of
adherence to any school of practice. The
board shall hold two meetings in each year
— one at Philadelphia and one at Pittsburgh.
The Pittsburgh Medical Review, in com-
menting upon this bill, the birth of the com-

mittee of the presidents of the various allo-
pathic county medical societies, says: "The
proposed bill is, of necessity, not such an
one as the regular members of the medical
profession would desire, and what strict ad-
herence to all that is best, from a humanita-
rian standpoint, would demand, for, in that
case, it would confine the appointing power
of the governor to the ranks of the regular
scientific practitioners" . . . etc. "It
would seem only just, however, that the rep-
resentation on the examining board should
be governed by the percentage that the
members of the sectarian schools bear to
each other. ' ' The members of the homoeo-
pathic school know very well that this bill is
"not such an one" as the trades-union spirit
of the self-styled "regular scientific practi-
tioners" demand. Of course, its apparently
liberal provisions are framed through dire
necessity. Of course, the membership of
the board would have been composed exclu-
sively from their own selfish sect, if they had
entertained a grain of hope that it could
have been forced through the legislature in
that shape. Of this no one entertains the
slightest doubt. Liberal as these provisions
may appear through allopathic spectacles,
they will not do. Homoeopaths have not
forgotten how the members of the allopathic
committee betrayed the trust reposed in them
in 1889 ; consequently, the members of the
homoeopathic profession have no confidence
in the honesty of purpose of the allopaths.
We object to this bill, principally because it
does not definitely fix the composition of
the board. We must have an equal repre-
sentation. The editors of the Review are
in error when they think "that it is only
just that the representation on the examin-
ing board should be governed by the per-
centage of members of the different schools
of medicine." This question is not one of
relative members of the various schools ; the
proposed bill will not affect any physician
now in practice. It is designed to examine
into the fitness to practice of future appli-
cants. Each school should have the right
of absolute control over the members of its
own faith. The schools of medicine stand
before the State as units, and as such should
have equal representation. The homoeopathic
school will have nothing less. The allo-
pathic physicians who framed this bill are
indulging in a bluff ; they are hugging the
fond hope that they will receive the major-
ity of the appointments, and this risk we
will not take. How can we take it, in the

258

Notes and

Comments. - Vol. lxiv

face of their open boast, that once they can
obtain an exclusive examining board they
will stamp out of existence their hated
rivals?

It is the height of folly to place the power
of licensing of homoeopathic physicians in the
hands of a school that libels us by charging
us with ignorance ; and then openly pro-
claims that it will not aid us to knowledge.
This is shown by the recent act of the New
York Polyclinic in refusing to accept homoe-
opathic physicians as students, and the Uni-
versity of Vermont in refusing to acknowl-
edge a homoeopathic diploma as evidence of
attendance on medical lectures. We do not
need the aid of either of the above-men-
tioned institutions ; but we mention these
facts in order to show the animus with which
our enemies are actuated.

Lupus — or Tuberculosis of the Skin.

In a recent lecture, published in the Med-
ical Press, January 28, 1891, Mr. Jonathan
Hutchinson discusses the question : Whether
or not lupus vulgaris is a form of tuberculo-
sis, and how far clinical evidence supports
the hypothesis that lupus vulgaris is of ba-
cillary origin ?

In reference to this he says : Lupus vul-
garis is not a disease which attacks infants
or young children. In exceptional cases it
may occur even to the youngest, but com-
monly it waits until childhood is well ad-
vanced, or even until the period of puberty
is passed. It is said by some never to begin
in old age, but this is a mistake. We often
see it begin at or after middle life, and in a
few instances its subjects are advanced in
years. When the latter is the case, it dis-
plays somewhat peculiar features, and may
probably be ranked with that group of mal-
adies to which Sir James Paget has given the
name "senile scrofula." Although in many
cases it is multiple in its manifestations in
the skin, several, or perhaps very many,
patches being produced, there is, with the
fewest possible exceptions, no tendency to
infect other parts. The lymphatic glands
do not suffer, nor do the lungs, the bones,
the joints, or the intestines ever become af-
fected. Nothing is less common than to see
a lupus patient pass into phthisis. Thus we
may believe that the infective material, be
it what it may, is one which finds a suitable
home only in cutaneous or mucous struc-
tures. If it be a bacillus, it is a selective

one, and it keeps to the tissue in which it
had its first development.

The most typical forms of common lupus
are often coincident with good health on
the part of the patient, and the absence of
any family history of tendency to tubercu-
losis. Of course, there are many exceptions
to these statements, but all observers agree
that they express the general truth. If, in-
deed, it were asked whether the clinical
evidence more favored the belief of the al-
liance of lupus with tuberculosis or with
cancer, I am inclined to think that the reply
would have to express hesitation: Tubercu-
losis and the cancerous process have hitherto
been held to observe towards each other
something of a position of antagonism.
Those who are liable to the one are not-
prone to the other, and the two are but very
rarely found together. Almost all who have
written on lupus have, however, been struck
by the fact that parts affected by it not very
infrequently take on cancerous growth. The
evidence on this point has recently been
collected by Bayha, of Tubingen, who from
his own experience has collected no fewer
than four cases. I doubt much if many ob-
servers could collect from their own obser-
vations as many as four cases of lupus in
which the patients had subsequently suc-
cumbed to any form of internal tuberculo-
sis.

In making these remarks I am far from
wishing to ignore either the general impres-
sions or the collected facts which favor the
belief that there is some bond of connection
between tubercular affections and lupus.
What I contend for is that it is far less close
than is generally believed. The impressions
which most of us have, I expect, formed on
this subject go far ahead of any proof of a
statistical kind which we could supply. If I
may be permitted to anticipate a little what
I shall have to say in my next lecture, I
may here mention the unexpected fact that
statistical results are different in respect to
lupus erythematosus. In this latter no ob-
server has, I believe, succeeded in detecting
the bacillus, yet it is far more frequently in
close association with tuberculous conditions
than is lupus vulgaris. Some light may per-
haps be obtained for the elucidation of this
difficult question by observation of the very
earliest stages of lupus. We are so accus-
tomed to see this chronic malady after it has
been long existent, and when its peculiar-
ities are well declared, that very little has
been done in the attempt to describe, still

Feb. 28, 1 89 1. Notes and Comments.

259

less to depict, its initial conditions. I much
suspect that if we knew them we should
have to acknowledge • that they are often
such as cannot be recognized as lupus at all.
The disease may, and often does, originate
in a condition of chronic or recurrent con-
gestion and swelling not in the first instance
to be distinguished from a chilblain. Or it
may start from what looked like tuberous
acne at the end of the nose, or from patches
in the middle of the cheek, which had been
often congested in the act of blushing or in
the flush which attends indigestion. Slight
injuries, insect stings, bruises, burns, etc.,
may become its starting point. In almost
all cases something not distinguishable from
a chronic papular inflammation is, I believe,
'the earliest local condition which is ob-
served. The apple jelly may form before
the disease is far advanced, but it is never
present at the very first. Nor do we ever
see anything in the least resembling a tuber-
culous ulcer. The early stage is in many
cases insidious and prolonged, but it is not
so in all. In some a tendency to rather
rapid infective spreading is early manifested,
and while it is so the conditions produced
resemble rather those of common inflamma-
tion than anything which could be recog-
nized as specifically lupus.

In concluding, Mr. Hutchinson says : I
have here endeavored to bring in review the
principal facts which, from the clinical
standpoint, appear likely to help us to answer
the question whether lupus vulgaris should
be regarded as tuberculosis of the skin. We
have seen that there is no evidence that it
ever begins from the implantation of tuber-
culous matter, that it is only exceptionally
associated with tubercle in the viscera, and
that it never causes infective gland disease.
We have also seen that there are other affec-
tions of the skin which do not' resemble it,
which are much more closely associated with
tubercle and with scrofula. We have seen
also that its remarkable preference for cer-
tain regions and parts seems to imply that
the influence of cold is by far the most
common of its exciting causes. I may own
that the sum of the evidence seems to me
much in favor of the belief that lupus is a
specialized form of chronic inflammation
rather than the result of infection. In sug-
gesting this I am well aware that it is
merely a negative conclusion which is
liable to be overthrown at any time by the
accumulation of positive evidence. It may
be that in the future the presence of ba-

1

cilli in lupus-products may be demon-
strated in earlier stages, and much more
constantly than has yet been the case. The
results of Koch's injection treatment may
possibly force us to believe that there is
something about lupus which connects it far
more closely with tuberculosis than I have
admitted. I prefer for the present to say
nothing about the results of the treatment
already obtained.

Association of American Anatomists.

The third annual meeting was held Dec.
29 and 30, 1890, in the anatomical lecture-
room of the Harvard Medical School, Bos-
ton, Mass. It was presided over by Dr. F.
D. Weisse, Second Vice-President, and Dr.
Thomas Dwight acted as Secretary pro tern.
Papers were read as follows : Corrosion Prep-
arations, by Dr. S. J. Mixter; Studies on
the Spine, by Dr. Dwight ; A Comparison of
the Fibrin Filaments of Blood-lymph in Mam-
malia and Amphibia, by Prof. S. H. Gage ;
The Semi-lunar Bone, by Prof. Shepherd ;
The Structure of Protoplasm and Mitosis, by
Dr. Carl- Heitzmann ; The Homology of the
Cerebrospinal Arachnoid with the other Ser-
ous Membranes, by Prof. F. W. Langdon ;
The Occlusion of the Rhinoccele ( Olfactory
Ventricle) in the Dog, by Mr. P. A. Fish and
by Prof. B. G. Wilder; The Relations of
the Olfactory to Jhe Cerebral Portion of the
Brain ; The Brains of a Cat and of a Sheep
lacking the Callosum ; Owen' 's Nomenclature
of the Brain, with suggestions based thereon.

With one exception the papers were illus-
trated by specimens, photographs or dia-
grams, and all were fully discussed.

The Committee on Anatomical Nomencla-
ture (Professors Leidy, Harrison Allen, Frank
Baker, Thomas Dwight, T. B. Stowell and
B. G. Wilder) was authorized to publish,
as its second report, "such general and
specific recommendations as may be unani-
mously agreed upon by them."

The following were elected members:
Dr. W. L. Dana, of Portland, Me. ; Dr.
John C. Munro, of Boston, Mass. ; Mr.
Pierre A. Fish, of Ithaca, N. Y.

The next meeting will be held at Wash-
ington, D. C, September, 1 891, at or about
the time of meeting of the Congress of
American Physicians and Surgeons. The
officers for that meeting are as follows :
President, Joseph Leidy ; Vice-Presidents,
1 Frank Baker, F. D. Weisse Secretary and

260

Notes and

Comments.

Vol. lxiv

Treasurer, D. S. Lamb ; Executive Com-
mittee, Harrison Allen, Thomas Dwight
and B. G. Wilder.

Dangerous Lunatic.

The commission appointed to investigate
the mental condition of James M. Dougherty,
the escaped lunatic who returned and killed
Dr. George F. Lloyd at the Flatbush Insane
Asylum last autumn, and who was tried and
convicted of murder in the second degree
in Brooklyn, has just reported.

The commission finds that Dougherty is
suffering from monomania, and the malady
is marked by hallucinations in the different
senses and by delusions or false beliefs ; de-
lusions of commingled persecution and ex-
pansiveness, the patient imagining he has
enemies who conspire against him, or that
he is a man of unusual talent, beauty or
importance. These delusions are always of
great seeming logicality, and as the mem-
ory and reasoning powers are not affected,
while the usual manner and behavior are al-
tered, the patient seems sane enough to those
who suppose that every lunatic is violent,
confused or incoherent.

The commission finds that Dougherty
comprehends the nature and purport of his
trial and was capable of defending himself.
The prisoner presents a case of great medico-
legal importance. Dougherty's delusions
caused him to believe that he was the object
of a conspiracy, and a man of such surpass-
ing personal beauty as to have been re-
garded, at one time, the handsomest man in
the world, and his hallucinations that he saw
Mary Anderson in various places where the
evidence showed she had not been, led him
to the formation of a murderous plan, inau-
gurated by the murder of Dr. Lloyd, which
he acknowledges was wrong in a legal sense,
and which was to have been continued by
killing many others. He firmly believed
that his commitment into the asylum was a
great wrong, for which there was no legal
redress, and determined to call public atten-
tion to it by violent measures notwithstand-
ing that he expected to be shot in the at-
tempt or killed by electricity afterwards.

These hallucinations in nowise interfered
with his understanding the motive and pur-
port of his trial, or prevented him from de-
fending himself. He thoroughly understood
the legal meaning of his trial ; knew his
rights far better than the average citizen ;

knew the legal punishment for his deed ; de-
liberated as to whether he would prefer
death or imprisonment for life or commit-
ment to a lunatie asylum, and in all respects
comprehended the trial with as keen intelli-
gence as though he had been perfectly sane.

The commission and commissioners have
been unable to perceive that his delusions
and hallucinations marred in the slightest
degree an unusually intelligent understand-
ing of the trial, although it is not within its
province to offer an opinion on his compre-
hension of his act in killing Dr. Lloyd. He
is as dangerous a lunatic as it has ever been
the lot of the committee to encounter.

Dougherty will be sent to an insane asy-
lum for insane criminals.

Medical Legislation in Arkansas,

The Journal of the State Medical Society
of Arkansas, January, 1891, says, editorially,
that it is taken for granted that when the
present act to regulate the practice of medi-
cine and surgery in this State was passed by
a former Legislature, and became a law, it
was intended and expected that it would ef-
fectually accomplish the purposes for which
it was put upon the statute books. It is also
believed that if, through certain palpable
defects the law is ineffectual and fails in its
purposes, the present General Assemby will
be fair and just enough to remedy its defects
by amendment of the present, or the enact-
ment of a new law, provided it can be dem-
onstrated to the satisfaction of the members
of the Legislature that the present one is
fatally imperfect.

It then quotes from an earlier editorial,
saying: "The iniquities of the medical
practice act in this State have been so often
discussed, and are so well understood that it
may be deemed almost superfluous to say
•anything further on the subject ; but what is
here written is suggested with the idea that
it may be well at this time to formulate into
more definite shape its defects, that they
may be the more successfully urged in favor
of amendment of the present, or the enact-
ment of a new law. First. The qualifica-
tions and mode of selecting, the members of
the county boards of examiners are objec-
tionable on the ground that in the first place
the appointing power is vested in men who,
as a rule, are wholly incompetent to pass on
the qualifications that ought to be possessed
by professional gentlemen designated as

Feb. 28, 1891. Notes and Comments.

I learned in the sciences of medicine and
surgery, of good moral character,' etc.
Second. No definite standard of qualifica-
tion is prescribed, such as that members of
the boards shall be graduates of reputable
schools or members of some medical organ-
ization, admission to which carries with it
the proof that the antecedents of its mem-
bers and their professional and moral stand-
ing have been investigated. Third. While
the spirit of the law indicates that applicants
rejected by one county board shall not be
licensed by another than the State Board,
the Attorney-General gave it as his opinion
that the letter of the law did not prohibit
rejected applicants from going from county
to county until a board might be found that
would grant them license. It is too well
known that men most ignorant and wholly
incompetent have been rejected by several
competent boards, but still went from county
to county until a board was found the mem-
bers of which, being on a level with the ap-
plicants, have licensed them and they are
to-day plying their vocation at the expense
and to the detriment of innocent parties
who are not competent to judge of the
proper attainments that ought to be pos-
sessed by persons pretending to practice
medicine and surgery.

"To cure these defects in the law, it is
suggested, First, to have one State Board of
Health, which shall have exclusive power to
grant license. Second, to have a board in
each congressional district and a State
Board of Appeals. Third, to amend the
present law so as to require the members
of county Boards to be graduates of medi-
cine in good standing and to prevent a re-
jected applicant from applying for license to
any other board in the State than the State
Board. The idea adopted at the last meet-
ing of the State Medical Society was the one
recommended by the Committee on Medi-
cal Legislation, viz. : 'The appointment of
one board known as a State Board, and the
repeal of all existing laws on the same sub-
ject.' This is undoubtedly the simplest and
best, but whether it could be accomplished
against the opposition of members of the
existing county boards, is questionable. At
any rate the Committee of the State Society
on Medical Legislation ought to commence
to ask for the very best, and then if that
cannot be obtained, substitute the next best,
and so on until one of the proposed reme-
dies shall be accepted by the Legislature
and a law enacted accordingly."

Dirtiest City in the World.

Harper1 s Weekly says that the citizens of
New York are not bashful nor backward in
celebrating the greatness of the city, and
in claiming for it a metropolitan primacy.
They naturally believe that it is the centre
and head of America, and cannot but sus-
pect that foreigners from the effete despot-
isms must greatly exult when at last, after
ages of oppression and suffering, they ar-
rive in the bay dominated by Liberty En-
lightening the World, step ashore at the
Battery, and tread the Broadway of what
must seem to them a kind of New Jerusalem.

It will not deny also that some foreign
places have a certain historic and romantic,
literary and artistic, interest, for which
New York, busy with more important affairs,
has not yet had time. But it will attend to
them presently and outdo the world. Such
is the cheerful complacency of this good
city. Yet it is droll and undeniable that
with all its grandeur and kindly condescen-
sion to other famous towns it cannot keep
itself clean. Greece and Rome and Ger-
many and France and England may strive
in vain to overcome it in renown, but gar-
bage and refuse and litter and dirt of every
kind and degree utterly subdue it. It may
spend millions and millions of dollars for
what it calls its government, and savagely
resent legislative interference, and maintain
thousands of stipendiaries of every grade,
and denounce Dirt in public meetings, and
thunder at it in a free and forcible press,
and swear at it in clubs, and scold at it in
private parlors, but Dirt remains triumphant,
and, proud of its supremacy, compels New
York to be known as the dirtiest city in the
world.

How the Homoeopaths Look at it.

Many readers of the Reporter will doubt-
less be interested to see the following extract
from the Hahnemannian Monthly (ATews
and Advertiser), February, 1 891, which just
now is making common cause with the
Eclectics against a Medical Examiners' Bill
in Pennsylvania and breathing out " threat-
enings and slaughter " against what it calls
the " allopaths." The question, Why are we
Homoeopaths ? this journal says was answered
by Dr. Wells Lefevr (sic) in a paper, read
before the Southern Homoeopathic Medical
Association. He presented the following
conclusions :

262

Notes and

Comments.

Vol. lxiv

Because Homoeopathy has the only known
law for the prescription of medicine. Its
death-rate is the lowest, as is shown in the
following comparative statistics of Homoeo-
pathic and Allopathic treatments, covering
a period of five years. (Compiled by Dr.
Jos. Buchner.)

Homoeopathic Death-rate, per 100 cases
treated: Erysipelas, 0.8 ; diarrhoea, 0.9 ;
fevers, 1.2; typhus, 13 3; pleurisy, 1.3;
inflam. of bowels, 6.1 ; typhoid fever, 8.8;
scarlet fever, 2.9 ; dysentery, 7.1 ; heart af-
fections, 15.5 ; apoplexy, 28.5 ; consump-
tion; 38.6 ; yellow fever, 6.6 ; pneumonia,
5.2 ; duration of illness, 11.75 davs-

Allopathic Death-rate, per 100 cases
treated: Erysipelas, 23.0 ; diarrhoea, 21.2 ;
fevers, 5.3; typhus, 16.0; pleurisy, 15.6;
inflam. of bowels, 41.0 ; typhoid fever, 14.9;
scarlet fever, 20.75 > dysentery, 26.8 ; heart
affections, 51.7 ; apoplexy, 48.3 ; consump-
tion, 48.5 ; yellow fever, 23.5 ; pneumonia,
20.4 ; duration of illness, 28.9 days.

Homoeopathy is chiefly employed among
the well informed and cultured people. Ho-
moeopaths can procure lower rates of insur-
ance, on account of the lower rate of mor-
tality among them.

Our best records have been made in the
South. There is employment for one thou-
sand more homoeopathic physicians in the
South alone.

!*? It was first introduced in America by Dr.
Gram sixty-five years ago. Despite preju-
dice and calumny, it has grown until there
are almost 20,000 homoeopathic physicians
in the United States to-day.

Our fifteen colleges cannot supply the de-
mand, "Send us a Homoeopathic physi-
cian."

Koch's Treatment Condemned.

At a meeting of the Belgian Academy of
Medicine on December 27, M. Crocq (Sc-
maine Medicate, December 31, 1890) denied
"absolutely" that Koch's fluid is of any
value in the diagnosis of tubercle. He had
made injections in a patient suffering from
phthisis, and in another the subject of acute
pleurisy, "without a trace of tuberculous
character;" in both, intense reaction took
place. In other cases of " manifest " tuber-
culosis the injections were followed by no
reaction, while in other cases patients suffer-
ing from non-tuberculous affections reacted
strongly. With regard to its alleged curative
action, M. Crocq has seen nothing of it ; in

his experience the remedy has done nothing
but aggravate the evil. The lymph is, ac-
cording to him, simply a pyrogenic agent,
and he "denies utterly" that it has any
specific effect on tubercule. " It produces a
febrile movement, of variable duration,
which causes an effervescence of the organ-
ism, various congestions in the skin and
internal organs which have no relation to
any tuberculous lesion ; this congestion is
more easily set up in diseased organs which
have previously been attacked by an inflam-
matory lesion of any kind, and form the
pars tninoris resistentia of every organism.
If the patient is attacked by cutaneous or
pulmonary tuberculosis, the inflammatory
process will take place in the affected organs,
skin or lungs." This pyrogenic action may
be useful in certain cases in which "sub-
stitutive inflammation " (such as is seen, for
example, in the effects of nitrate of silver on
a chronic ulcer) is beneficial. This, accord-
ing to M. Crocq, is the whole secret of the
action of Koch's remedy. If the "substi-
tutive inflammation" may possibly have a
favorable effect in some cases, it may do
harm in others, a new inflammation being
added to the pre-existing one, with fatal
results if the affected organ is the larynx
or the lung. In short, M. Crocq says,
Koch's statements as to the diagnostic and
curative value of his remedy resolve them-
selves into simple gratuitous affirmations,
unsupported by any proof. — British Medical
Journal (Supplement), January 10, 1891.

Shaving with Vaseline.

As nurses often are called upon to provide
shaving materials we recommend the follow-
ing : "A friend of mine a few months ago
told me how to shave easily and painlessly,
and I have never shaved in a barber's shop
since. The plan is to use oil or grease in-
stead of soap to prepare the chin and soften
the beard. Vaseline is the most convenient,
and it should be rubbed in quite freely.
Then with a keen razor shaving can be done
quickly and without the suspicion of pain.
At first I couldn't reconcile myself to doing
without the orthodox lather, and used soap
after the vaseline had been applied. But
the soap is really unnecessary, and shaving
with oil or vaseline is cleaner as well as
pleasanter, and what is more to the point
there is no irritation whatever to the skin."
— Druggists' Circular.

Medical and surgical
Reporter

A Weekly Journal.

Established in 1853 by S. W. Butler, M.D

CHARLES W. DULLES, M. D., Editor and Publisher,

Entered as Second-Class matter at Philadelphia P. O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

$5.00 per Annum.
10 Cents a Copy.

Vol. LXIV, No. 10.
Whole No. 1775.

MARCH 7, 1891.

GOISTTEITTS

CLINICAL LECTURE.

Anders, James M., M. D., Philadelphia, Pa.—
Treatment of Typhoid Fever : Two Relapses and
other Complications.— Asthma Associated with
Emphysema and Chronic Bronchitis 263

COMMUNICATIONS.

Benedict. A. L., A. B., M. D., Buffalo, N. Y.—
Practical Use of the Metric System 266 j

Thompson, Lucia Redding, Philadelphia.— Treat-
ment of Club-Foot, Past and Present 270 j

AVeber, M. J., M. D., Lower Providence, Pa.—
Gastric Ulcer 271

Riley , Henry A., Esq., New York.— Recent Med- j

ieal Jurisprudence 273 ;

PERISCOPE.

Koch's Remedy.— New Remedies for Whooping-

, cough.— A Failure with Koch's Remedy— Cre-
mation and its Safeguards.— Treatment of Tu-
berculous Abscesses with Hot Water Flushing. —
Massage as a Cause of Pyemia.— New Remedies
for Ear Diseases.— Lupus and the Koch Fluid-

Internal Lavage.— Copaiba Balsam as a Diu-
retic—Treatment of Hemeralopia with Injec-
tions of Antipyrin 274-280

EDITORIALS.

Hematuria in Typhoid Fever 281

Maternal Impressions 282

Dust and Tubercle Bacilli 283

Deaths in Cold Weather 283

CORRESPONDENCE .

Aseptic Hypodermic Syringe. — Cancrum Oris or
Gangrenous Stomatitis.— Politics and Pension
Examiners 284-285

NOTES AND COMMENTS.

Benzin as an Antiseptic— Sublimate Spray for
Small-Pox Vesicles. — Removal of the Gasserian
Ganglion.— Impure Drugs.— Medical Society of
the State of Pennsylvania. — Warren Triennial
Prize.— Prevention of Narcotic Inebriety. — Py-
oktanin Stains 285-290

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MEDICAL AND SURGICAL
REPORTER

No. 1775.

PHILADELPHIA, MARCH 7, 1891. Vol. LXIV.— No. 10.

Clinical Lecture

TREATMENT OF TYPHOID FEVER
TWO RELAPSES AND OTHER COM-
PLICATIONS. — ASTHMA ASSO-
CIATED WITH EMPHYSEMA
AND CHRONIC BRON-
CHITIS.1

BY JAMES M. ANDERS, M. D.,

PROFESSOR OF CLINICAL MEDICINE AT THE MEDICO-
CHIRURGICAL COLLEGE, VISITING PHYSICIAN TO
THE PHILADELPHIA AND EPISCOPAL
HOSPITALS.

Typhoid Fever.

The case before you is the one of typhoid
fever, which you will recall was presented at
this clinic last Wednesday. Girl, A. A.,
domestic, 23 years old. Her family history
is unsatisfactory. Six weeks before her ad-
mission she was taken, ill in Pittsburgh, im-
proved, came to Philadelphia, and was soon
after admitted to the female wards of the
Philadelphia Hospital and found to be suf-
fering with typhoid fever — most probably a
relapse.

She had, as you will remember, three or
four serious complications, one of which
was hypostatic congestion, the result of a
weak heart, which in turn was due to paren-
chymatous degeneration of the myocardium.
She had had two hemorrhages from the
bowel, and after the second hemorrhage,
one was in a state closely approaching col-
lapse.

About January 1, after recovering from
her first relapse and after having had a sub-
normal temperature for about one week, she
got up at night during the absence of her at-
tendant, and ate heartily of candy, apples and
cake. The next day her temperature was
1040, and this rise of temperature was fol -
lowed by the other symptoms of the second

1 Delivered at the Philadelphia Hospital.

relapse which was attended with moderately
high temperature.

Errors of diet cause a relapse because of
the latent virus still existing in the system.
You will also recall the affection existing in
the leg, which was swollen and painful to the
touch. The swelling was localized over the
middle third of the fibula and outer aspect
of the os calcis, not due to thrombosis, but
most probably to periostitis, or possibly to
a pyemic condition ; as small abscesses un-
der the skin occur after typhoid fever. A
pyemic condition has not, however, been
developed. There exists tenderness only
over the os calcis and outer third of the
fibula. Making pressure over the fibula, we
find it thickened and roughened as com-
pared to that of the other side. There is
pain developed, especially at night. Thick-
ening of the bone, tenderness on palpation
and pain at night are certain evidences of
periostitis. As a rare sequel, it comes on
two or three weeks after convalescence has
set in ; but it may occur during a relapse, as
in this case. During the attack there has
been some bronchitis and, later, pneumonia.
You will recall the previous history; that
there existed a feeble heart, which leads to
hypostatic congestion of the lungs, and that
there was no active bronchitis. The phy-
sical signs were : impairment of resonance
on percussion and, later, crepitant rales.

During the patient's present or second
relapse she developed pneumonia. In her
case, in addition to the physical signs at the
right base, there was rusty sputum, which
indicated a lobar pneumonia. In patients
much exhausted, as this one is, you do not
have all the characteristic physical signs and
symptoms of pneumonia. She has not the
signs of collapse of the lung or broncho-
pneumonia. You are apt to have hemor-
rhagic infarction, especially where there is
a pyemic condition, and when it occurs the
emboli will lodge in the lower lobe of the
right side. This is the result at times of

263

264

Clinical Lecture.

Vol. lxiv

venous thrombosis from feeble circulation,
as you may remember, in her case during
the' former relapse. When pulmonary hem-
orrhage occurs, there will be dulness on
percussion, feeble respiratory murmur and
frequently bronchial breathing, with expec-
toration of a bloody or sooty-looking mat-
ter— not the characteristic sputum of pneu-
monia as in this case — with great pain.
Another complication, which occurs once
in about t£n cases, is the albumin, in the
urine. In this girl's urine, it was found
ten days ago in abundance. During her
first relapse no albumin was found after re-
peatedly testing the urine. When consider-
able albumin is found during the course of
a case of typhoid, it is good evidence of
desquamative nephritis. During her first
relapse the girl had four complications, and
during her second relapse, three. The chief
physical signs of the pneumonia have dis-
appeared, but there still remains here some
dulness and feeble respiratory murmur. The
prognosis in relapse is good, provided the
previous attack has been severe \ but when
the primary attack is mild the prognosis is
bad.

When called to treat a case of typhoid
fever, first place the patient in the largest
and most airy room, with an open grate if
possible ; since this is preferable to a win-
dow as a means of ventilation. See that
the sanitary arrangements are as perfect as
possible. The leading indications calling
for treatment are, to support the vital func-
tions, to control the fever when high, and to
arrest or modify the complications and se-
quelae. As long as the temperature does
not rise above 1030, there is, as a rule, but
one object to fulfil, namely, to support the
bodily functions. Attention must first be
paid to the feeding. Food should be given
at regular intervals of two hours each, and
should consist mainly of milk. Should this
be found to disagree, give it peptonized,
that it may the more easily be assimilated.
If it still disagrees, give, before each feed-
ing, a mixture consisting of two grains of
pepsin and five minims of dilute muriatic
acid in syrup and water. Well-cooked fari-
naceous articles, such as barley, may be
added to the milk ; animal broths, in small
quantities, may also be allowed. The sys-
tem must also be sustained. This is best ac-
complished with quinine. If the tempera-
ture does not run high, two grains four times
daily is sufficient. In the third week, gentle
stimulation should be given, of about one-

half ounce of either brandy or whiskey every
four hours. In the severe forms, we must
also diminish the fever and arrest complica-
tions and sequelae. The reduction of the
fever is sometimes imperative. This is best
accomplished by the cold-water treatment.
Do not be afraid to sponge the patient
freely. Instruct the nurse to sponge in suc-
cession the face, neck, arms and chest as
long as agreeable to the patient. If this
does not suffice to bring down the temper-
ature, use cold compresses, of ice-bags or
cloths wrun'g out of cold water. Often,
when placed to the head, this will reduce
the temperature o'f the whole body, quiet
the delirium and produce sleep.

If this does not suffice to reduce the tem-
perature, place the cooling applications also
on the stomach. Do not use the cold bath,
unless the tub can be brought to the side of
the bed, and only when the temperature is
dangerously high or profound coma exists.
Do not leave the patient in the bath- longer
than eight or ten minutes, and when he is
taken out wrap him well in blankets, giving
stimulants if he be exhausted.

In the way of internal antipyretics, do
not use them unless the morning temperature
is at or above 1030, no matter if the evening
temperature should be 1040. If both morn-
ing and evening temperature is high, or if
there be but slight remissions, you may re-
sort to them early in the attack, if cold
water does not suffice.

A number of remedies are advocated :
antipyrin, antifebrin, phenacetin, salicylate
of sodium, quinine, etc. Sodium salicylate
disorders the stomach and sometimes causes
albuminuria. Don't use it. I have found
antifebrin, given in doses of two grains at
night, to act as effectually as larger doses
(ten grains for instance), and thus have
avoided the danger from collapse. Phena-
cetin is said not to depress ; but do not give
it in large doses. When the temperature is
dangerously high, then you may resort to
heroic measures ; indeed, this may be the
only means of saving your patient. You
may use the bath-tub, or rub the surface with
ice, which answers the same purpose, or as
a dernier ressort, give a large dose of some
internal antipyretic.

The treatment of complications is all-im-
portant. Attend to the most urgent, symp-
toms, one of which is headache j three grains
of phenacetin, with twenty grains of sodium
bromide, given occasionally will mitigate it.
When there is distention of the abdomen,

March 7, 1891.

Clinical

Lecture.

265

do not use the hypodermic needle — use tur-
pentine stupes. If this fails, give turpentine
internally in emulsion. Diarrhoea, when
prominent, should be treated with mild
measures first ; bismuth in full doses will
generally control it, or a mixture of equal
parts of tincture of catechu and paregoric
gives good results. If it is not controlled
in the manner stated, give one-quarter grain
of nitrate of silver with opium, in pills every
three hours, or two grains of acetate of lead
every four hours, or suppositories of tannic
acid and opium.

Of complications, perforation is the most
serious, and requires active and timely treat-
ment. In the books it is generally stated
that opium is to be given in large doses ;
thus, metaphorically speaking, the bowel is
placed in splints and peristalsis is arrested.
This is unnecessary. Enough opium should
be exhibited to relieve pain, and saline laxa-
tives should be administered until a gentle
movement is produced. Rpehelle salts, in
doses of a drachm every two hours, is the
best for this purpose. Should thrombosis
occur, elevate the limb, rub gently with
vinegar and water or laudanum, and give in-
ternally stimulants, especially carbonate of
ammonium. The pneumonia was here
treated in the same way as the hypostatic
congestion, because the indications were the
same, namely, to stimulate and support well
the patient. In this case, for the hemor-
rhages of the bowels, we employed ergotine
hypodermically, and cold externally. As-
tringents may also be used for this accident.

With the above plan of treatment, you
should not forget to disinfect thoroughly the
stools. There is no longer any doubt but
that the disease may be contracted through
the lungs ; hence it is well to have doors,
floors and window ledges washed with some
disinfectant in solution, or better still, after
the patient leaves his room, to have it fumi-
gated.

Asthma and Emphysema.

This man is 48 years old, and a sailor.
His father died of pneumonia at 58, his
mother of paralysis at 85 years. One
brother died of asthma ; another brother,
living, has asthma. As a child this man
had measles and scarlet fever. In India he
had jungle fever. His present trouble began
when he was 5 or 6 years old ; at first the
attacks of dyspnoea always came on at night,
later they would occur during the day, the
paroxysms increasing in severity. Between

the attacks he would feel quite well. When
young he learned the tanning trade, but
early in life he gave it up, as he found it
made his condition worse. Changing his
occupation, he took to the sea and found
the tropics agreed best with him. For
twenty-five years he carried stramonium
leaves with him, which he would steep in a
solution of nitrate of potassium, burn them,
and inhale the fumes. This gave him imme-
diate relief ; later, when the paroxysms in-
creased in number and severity, the remedy
lost its effect, until finally it lost control
altogether. When in ports, he would obtain
remedies from physicians for the attacks.
For the last few years his condition has
grown steadily worse. About the middle of
November, 1890, he was shipwrecked at sea,
where he remained three days without food
and shelter.

Since then the attacks were notably in-
creased, and he had them worse than ever.
He stated that he has tried all the remedies
ordinarily used, but they failed to relieve
him. His last attack continued four hours,
during which time he smoked stramonium
constantly without good effect. January 1 1 ,
when admitted to the Hospital, he was
greatly cyanosed, his face, lips, nails, lids
and eyes were blue, and his chest immov-
able. He was given at once nitrite of amyl
by inhalation, with but momentary good
effect ; later he was given chloroform by in-
halation, with but temporary relief. He
was then directed by one of the residents to
have tincture of conium, f 3 ss, every half
hour until four doses had been taken. When
he had taken the third dose his breathing
grew suddenly better. Obviously, the rem-
edy deserves further trial. On admission
his chest was as you see it now. It is greatly
distended in all directions, is distinctly bar-
rel-shaped. The neck seems short, from the
chest being drawn up by the muscles of the
neck, with marked depressions above the
clavicles. The ribs are prominent anteriorly,
and there is but little -lateral movement of
the chest in respiration. The stomach moves
forward with each inspiration, which indi-
cates a condition far advanced in emphy-
sema. Percussion gives great hyper-reso-
nance, almost tympanitic, while over the
heart we get lung resonance. The cardiac
dulness commences as low down as the
sixth rib. Normally it should begin at the
fourth, and there is only a very limited
amount of dulness on account of the over-
lapping of the lung. The apex impulse is

2 66 Communications.

lower than it should be. Below the costal
border of the right side there is dulness,
owing to the liver being depressed ; and the
lung resonance extends more than one inch
lower than it should. In advanced cases of
emphysema there is a marked degree of
vesico-tympanitic resonance and great dis-
placement of the heart and liver, as in the
present case — a condition which is some-
times mistaken for pneumo-thorax. In the
latter affection, you have, as a rule, the his-
tory of phthisis, of the occurrence of great
pain followed by the signs of air in the
chest. The breathing becomes at once
difficult, the pulse rapid and feeble. Pneu-
mo-thorax generally occurs on one side,
though it may be bilateral, when it is more
difficult to diagnosticate. The pain may
be wanting, in which case, rely only on the
physical signs in diagnosticating between
this disease and emphysema. Inspection
and palpation give the same result in both
affections, except over the seat of effusion in
pneumo-thorax, where vocal fremitis is want-
ing.

Percussion resonance in pneumo-thorax is
more hyper-resonant, is frequently tympan-
itic ; and where effusion occurs, a sharp line
of dulness can be drawn at the level
of the liquid, which line changes with
the position of the patient. Over the
seat of the effusion, there is flatness ; but
there is none in emphysema. On ausculta-
tion we get weak respiratory murmur, or the
amphoric respiration and voice, which does
not occur in emphysema ; also metallic tink-
ling, and, on succussion, the splashing
sound. In pneumo-thorax the heart and
liver are usually displaced more than in em-
physema, but rarely more than you see in
the patient before you, suffering from em-
physema. An enlarged heart may be mis-
taken for emphysema, because the apex is
depressed ; but the presence of clear per-
cussion resonance over the heart, together
with the symptoms belonging to emphysema,
would aid in establishing the diagnosis. I
want to lay stress upon the fact that you may
have cardiac hypertrophy associated, and
not be able to detect it.

The diagnosis of emphysema is almost
certain when asthma is associated with it, as
in this case. Here we have the history of
asthma in the family, it being hereditary,
which, however, is also the case with em-
physema. The man gives us a clear his-
tory of chronic bronchitis, which began
before the emphysema. The latter is prob- 1

Vol. lxiv

ably due to the former disease. The prog-
nosis, as far as immediate danger to life is
concerned, is fair. The patient should be,
saved as much as possible from the exciting
cause of asthma. A residence in a tropical
climate would doubtless give him the best
chance for increase of years.

As to treatment : It is necessary to pre-
vent the degeneration of the air vesicles as
much as possible, by giving iron and arsenic
in small doses, long continued. The ideal
treatment would be to breathe into rarefied
air and inspire condensed air. An instru-
ment for this purpose can be obtained. The
asthma should be treated with stramonium
in cigarettes, and inhalations of chloroform ;
morphia hypodermically is an efficient rem-
edy. Tincture of lobelia, gtt. x, every half
hour, may be given during the paroxysms,
if it do not cause too much nausea. Potas-
sium iodide may be administered during the
intervals, or the following recipe, when there
is more or less active bronchitis and consider-
able expectoration associated with the em-
physema, as in the present case :

R Syr. acid hydriodici f J ii

Syr. scillae 3 iss

■ * Spts. chloroformi ttic

Syr. pruni Virgin q. s. ad. f ^ iv

M. Sig. Teaspoonful every three hours in water.

Communications.

PRACTICAL USE OF THE METRIC
SYSTEM.

A. L. BENEDICT, A. B., M. D.,

BUFFALO, N. Y.

ATTENDING PHYSICIAN, DEPARTMENT OF GENERAL
PRACTICE, FITCH PROVIDENT DISPENSARY.

By an act of Congress, in 1792, a deci-
mal system of currency was formally adop-
ted for this country, necessitating the adop-
tion of conceptions of value to a unit less
than a quarter as great as the English pound,
with which the people are familiar. For the
last few years a decimal system of measuring
drugs, established upon a scientific basis, with
a simple and logical connection with other
systems of mensuration, and already in prac-
tical use in other countries, has been await-
ing recognition by the medical profession in
England and in the United States.

The prime unit of this system is the me-
ter, a line one-tenth millionth of the length
of a quadrant of a terrestial meridian. A

March 7, 1891.

Com m unications.

267

cube constructed on the decimeter (one-
tenth of a meter) is the unit of capacity,
and is called the liter; it differs but little
from our quart. The weight of one cubic
centimeter of pure water at its point of
greatest density, 400 C, and in a vacuum, is
the unit of weight, and is called a gram. A
liter, therefore, contains 1,000 grams of
water and a little calculation will show that
the gram is equivalent to about one-quar-
ter of a drachm, or fifteen and four- tenths
grains. In all metric scales the prefixes
deka, hecto and kilo are used to form the
names of units 10., 100 and 1,000 times the
prime unit. The kilogram, for example, is
equal to 1,000 gsaras, and it is the unit of
weight in small commercial transactions,
being equivalent to two and two-tenth
pounds.

The prefixes deci, centi and milli indi-
cate, respectively, one-tenth, one-hundreth
and one-thousandth of the prime unit.

As far as prescription writing is concerned
we need no other terms than gram, centi-
gram and milligram, omitting the words
decagram, hectogram, kilogram and deci-
gram, just as in speaking of money we dis-
card the words eagle and dime., For ex-
ample, the expression 10.25, referring to
money, would be read " ten dollars and
twenty five cents/' not " one eagle, two
dimes and five cents." Occurring in a pre-
scription, it would be read : " ten grams,
twenty-five centigrams," instead of " one
dekagrame, two decigrams and five centi-
grams." As we have to deal more with lit-
tle things in medicine than in business, the
milligram, unlike its analogue mill, in our
•money, assumes considerable importance.

The cubic centimeter, familiarly abbrevi-
ated and pronounced " c. c," is often used
as a liquid unit, corresponding to the gram.
To avoid confusion with the centigram, it
would be well to drop the expression " cubic- j
centimeter " and to use the word gram or
fluid gram, instead. It maybe remarked in
passing, that the relation between the gram
and cubic centimeter is nearly the same as
exists between the grain and minim ; but
whereas the correspondence between the
gram and cubic centimeter is scientific and
exact, that between the grain and minim is
merely approximate.

Advocates of the metric system often in-
sist upon the dispensing of liquids by weight
instead of volume. There can be no rea-
son why the gravimetric, as opposed to the
volumetric, method should be more closely

linked with the decimal system than with
the apothecaries' system. For purely scien-
tific purposes, the weight of a substance is
a more accurate expression of its quantity
than the space which it occupies. On the
other hand, our conception of the quantity
of a liquid is more naturally connected with
its volume than with its weight. The rela-
tion between the volume and the weight of
a liquid is so little affected by the slight va-
riations of temperature and atmospheric pres-
sure in different drug-stores at different times;
the loss by evaporation so far exceeds the
greatest possible variation due to changes of
temperature and pressure ; the use by the
patient of scales, or even of accurate meas-
ures in taking single doses, is so impracti-
cable ; and, lastly, our estimation of the
proper dose of a drug is so much a matter of
approximation — that an insistence on the
less convenient method of dispensing liquid
drugs by weight is very much like straining
at a gnat after swallowing not only the
camel, but a considerable portion of the rest
of the menagerie.

What are the advantages of the metric S)'S~
tem ? Briefly speaking, the same as those
which our decimal monetary system possesses
over that of Great Britain. In detail they are :

(1). A simplification of the process of
multiplication in constructing a prescription.
(2). A simplification of the process of di-
vision in calculating from a complete pre-
scription the amount of each drug given at
a single dose. (3). The ease with which
the proportion of drugs in antiseptic solu-
tions, liniments, ointments, etc., may be
indicated. (4). The use of units small
enough to express conveniently the doses of
very powerful medicines. (5). A close cor-
respondence between our already existing
conceptions of value as expressed in dollars,,
cents and mills, and the powerfulness of drugs
as expressed by their metric dosage.

It is probable that an Englishman coming
to this country will derive no immediate
benefit from our system of money. Since
he thinks in pounds, shillings and pence, it
is of no advantage to him that cents can be
converted into dollars by moving the deci-
mal point ; for before he can have a clear
conception of the value of an article, cents
must be converted into units with which he
is familiar. So there is no benefit to be de-
rived from the mere writing of prescriptions
with Arabic figures and in terms of French
units with which we are unfamiliar. Not
until we can think naturally in the metric

268

Communications.

Vol. Ixiv

system are we profited by its use. It is sheer
nonsense for a man to write such a prescrip-
tion as this :

B Argenti nitratis 13

Aquu dest. 31-00

He is thinking of " two grains to the
ounce," and it is quite likely that the drug-
gist will fill the prescription, using the two-
grain weight and the ounce measure. Not
only is nothing gained by such "metric"
prescribing, but there is the positive danger
that, in the conversion from one system to
the other, some error will be made. " Two
grains to the ounce" represents a proportion"
of 1 to 240, or near 1 : 250. The prescrip-
tion should, therefore, take the following
form :

B Argenti nitratis .......... .10

Aquae dest 25.00

In writing for medicine which is to be
measured in doses, we must bear in mind
the number of doses needed and the size of
the measure from which the medicine will
be given. The following table shows the
relation between the ordinary dose-measures

and the metric units :

One drop . . -.03

An old and worn teaspoon ........ 3.50

. A new teaspoon 5-°°

A dessertspoon , 10.00

A tablespoon, brimful .......... 15.00

A tablespoon, heaped as- much as the cohe-
sion of the liquid allows ........ 20.00

Suppose that we have to deal with a tran-

sient case of diarrhoea. We first set down
the ingredients of our prescription without
reference to the quantity to be given. We
next decide upon the number and size of
our doses. Ten doses will probably suffice,
and a dessertspoonful (10.00) is a conven-
ient amount for each administration-. We
therefore order enough of the vehicle to
make 100.00. Our prescription is now in
the following form :
B Ext. hcematoxyli
Ac. sulph. arom.
Ol. cajuputi
Mucil. acacice
Syr. simplicem ad loo.oo

To complete the prescription, we multiply
the dose of each ingredient by ten. We
may leave the amount of the mucilage to
the discretion of the pharmacist.'

B Ext. hoematoxyli . 2.50

Ac. sulph. arom 5 00

01. cajaputi 2.50

Mucrl. acacise q. s.

Syr. simplicem ad 100.00

S. Dessertspoonful (= 10 c. c.) every three to six
hours..

Most medicines will be given by the tea-
spoonful, and twenty or thirty doses may be
conveniently dispensed at once. The tea-
spoonful may be reckoned either as four or
five fluid grams. The use of the latter
number is preferable, and, when accuracy is
necessary, five fluid grams can be marked
off on a test-tube by the apothecary. The
ordinary mixture will, then, amount to
100.00 or 150.00 fluid grams.

The following prescriptions may serve as
an illustration of the method of calculating
a single dose :

B Ammonii chlor. 5.

01. eucalypti . . . 10.

Mucil. acaciae q. s.

Syr. pruni Virg. 50.

Aquam ad 1 00.

S. Teaspoonful after meals.

B Calcii lactophos 4.

01. morrhuse

Mucil. acaciae . aa 150.

01. amygd. amar. . 10

S. Tablespoonful after meals.

The first prescription evidently consists of
twenty five-gram doses. One-twentieth of
5 grains is a quarter of a gram, or 25 centi-
grams; one-twentieth of 10 is *4, or 50
centigrams; one-twentieth of 50 is 2)4.
The second prescription contains twenty
doses each of fifteen grams. Half of each
fifteen grams is cod-liver oil. Twenty, cen-
tigrams of calcium lactophosphate are given
at each dose, and half a centigram, or five
milligrams of oil of bitter almonds. The
last is rather a small dose, but the chief use
hof the essential oil in the emulsion is as a
flavor.

Will the reader please contrast mentally'
the foregoing process of multiplying or di-
viding by 10, 20 and 30 with the correspond-
ing multiplication or division by 12, 16,
24, 32, and the conversion of grains into
drachms, and of drachms into ounces, or,
vice versa, by the use of the numbers 60
and 8?

In prescriptions for external use, not only
the amount but the proportion of each in-
gredient is plainly indicated. For example :

B Plumbi acetatis

Tinci sulphatis . aa I.

Ext. hydrastis fl. . . , ■ 25.

Aquam dest. ad 500.

Those who have been accustomed to re-
membering proportions as so many grains
to the ounce should bear in mind that each
grain to the ounce represents a strength of

March 7, 1891. . Communications.

269

about 1 to 500. In making antiseptic so-
lutions, the physician will find in almost
every household a close approximation to
the 1,000 gram measure in the shape of a
quart cup.

Only a few of the recently discovered al-
kaloids and glucosides can be given safely
in doses of more than a fraction of a grain.
The use of fractions is inconvenient in re-
membering the dose, in writing the prescrip-
tion and in compounding it. The metric
system, on the other hand, furnishes a unit,
the milligram, so small that nearly all doses
can be written in integers. To the best of
the writer's knowledge there is no substance
which could not be given to an adult with
safety in a dose of half a milligram.

In our money matters we have not only
the universally recognized unit but other
amounts whose frequent use has elevated
them to the position of auxilliary concepts
of value. Many of these are spoken of in
arithmetics as aliquot parts of a dollar. 2, 3,
5, 10, 12%, 15, 20, 25, 30, 33^5, 50, 662/3,
75, are examples of such values expressed
in cents. 7, n, 19, 47, etc., are examples
of numbers to be avoided both in price lists
and in dosage.

In becoming familiar with the metric
system, it is well to group together, as far as
possible, drugs of the same degree of pow-
erf ulness, and to think of the appropriate
dose of a drug not merely as a quantity or
weight but as a number which assigns to the
drug its place in a scale. For example, if
we pay twenty-five cents for an article we
think of the twenty-five cents not merely as
so much expenditure, but as an index to the
value of the article when compared with the
price of other similar articles. So, if the
dose of a drug is 25 centigrams, we should
think of the 25 centigrams, not as an arbi-
trary quantity, but as an expression of the
powerfulness of this drug when compared
with others. The following table of what
may be termed dose values will prove useful
in estimating the doses of other drugs which
we may from time to time employ and the
strength of which we know to bear a cer-
tain relation to that of the drugs men-
tioned :

.001 — Atropine, hyoscyamine, hyoscine, physotig-
mine.

.002 — Strychnine, picrotoxin, nicotine.

.005 — Concentrated preparations of arsenic, gold
salts, mercuric salts.

.01 — Morphine, apomorphine, emetine, pilocarpine.

.02 — Salts of copper, silver and zinc as nervines.
Most of the poisonous extracts.

.05-. 10 — Most iron salts, codeine.
.15-. 25 — Most volatile oils, lead acetate, caffeine,
acetanilide.

•25--5° — Ammonium carbonate and chloride, qui-
nine, antipyrin, bismuth sub-nitrate and sub carbonate.

1.00 — Most hypnotics, salicylic and benzoic prepa-
rations, many moderately strong tinctures and Cuid
extracts.

2.-5. — Most tinctures and fluid extracts.
10.-15. — Syrups, infusions, etc.
10.-25. — Many saline cathartics, caster oil.

Although the metric system is best learned
independently, those who are already famil-
iar with the apothecary's system will need
a scale of equivalents, and the following is
approximately correct :

lo grain=

3 grains =

4 " =
15 " =

.001

.01

.20

•25
1. 00

Oj

. 4.00

30.

500.

In changing from the old to the new sys-
tem, do not first write the prescription in
the former system and then attempt to
give its equivalent in the latter. After writ-
ing a list of the ingredients of the prescrip-
tion, order the vehicle up to 10, 20 or 30
times 5. c. c. Then translate separately the
single dose of each drug into metric terms,
adding or subtracting a little if necessary to
make the amount an aliquot part of the
gram. Then multiply by the number of
doses in the prescription. In this way — to
borrow an expression from the teacher of
languages — the metric prescription will be
idiomatic and not a literal translation of
one written in the old system.

The writer has been led to present tin's ar-
ticle because he realizes that many of the
suggestions contained in it would have ^aved
him much trouble if they had been available
when he began to learn the use of the me-
tric system. His own experience has been
that one not too long accustomed to the
apothecary's system can learn in a few
weeks to use the metric system naturally and
easily, and that its simplicity more than
compensates for any difficulties which arc
met in the transition from one system to
the other. A practical experience of nearly
two years has shown him that, in Buffalo at
least, pharmacists are invariably as well
equipped to fill metric prescriptions as those
written in the old system ; and that, while the
medical men who use the metric system are
in the minority, the minority is by no means
insignificant, either in numbers or in influ-
ence.

270

Comm unications.

Vol. lxiv

TREATMENT OF CLUB-FOOT, PAST
AND PRESENT.

BY LUCIA REDDING THOMPSON,

PHILADELPHIA.

A retrospective view has led me to com-
pare the past and present treatment of club-
foot, and to note a few of the many pro-
gressive steps which have given this wonder-
ful century its pre-eminence. According to
tradition, the custom of distorting the feet
of Chinese women is a relic of an edict to
render the deformity of an imperial child
less noticeable by making the malformation
common, thus confessing the impossibility
of Cure.

It is well known that Lord Byron aban-
doned any attempt at correcting his de-
formity after years of treatment. Previous
to the time of Stromeyer, the treatment of
club-foot was purely mechanical, and the
orthopedic surgeon stood upon the level of
the mere instrument maker, or upon the bor-
der line of empiricism. In the light of to-
day, we can only pity those "cheated by
dissembling nature deformed, unfinished,
sent into this breathing world scarce half
made up," at a time when men were afraid
of the knife, and such measures as resection of
the tarsus, tarsal osteotomy, open incision, j
tenotomy, etc., were unknown. With the de- i
velopment of antiseptic and aseptic surgery, 1
radical measures have been adopted, and at j
the present time, few surgical procedures are I
more precise in their indications or more
certain in their results. j

The club-foot deformity is usually con- I
genital, but it may be acquired after infan- j
tile paralysis, accident, or that inflammatory \
condition of the fibrous tissues about joints j
covered by the vague term "rheumatism."

Vague and various theories have been j
advanced in explanation of the congenital
varietyof club-foot. Maternal impressions,
compression in the uterine cavity, lesions
of the nervous system, etc. Heredity has
also been strongly declared to be an etio-
logical factor, and as such we must recog-
nize it. At the same time we must admit
that, though living in an age when all the
symptoms of nature are exhibiting their
mysteries, with ample facilities for investi-
gation, the laws of heredity baffle the sci-
entist, and we know no more than we know
how it is that children inherit the features
of their parents. We must admit that we
are ignorant of the causation of club-foot,

and unable to give an explanation of the
phenomena of its development.

This position of the tarsal bones varies
with the variety. In the congenital form,
the scaphoid will be found articulating
with the side of the head of the astragalus,
rather than with the anterior surface. The
cuneiform bones must follow from their
close connection. The os calcis is usually
found in the vertical position. The astrag-
alus is so much distorted that it cannot be
recognized by the most profound anatomist.

The only rational treatment consists of a
combination of operative and mechanical
means. The age at which treatment should
be commenced is a matter of discussion.
Many claim that operation should not be
done before the end of the first year. Dr.
H. Augustus Wilson. Professor of Ortho-
pedic Surgery in the Philadelphia Polyclinic,
advises early operation. As it is well known
that in infancy and early childhood the
ends of the bones are largely cartilaginous,
it is therefore rational to believe that the
sooner the foot is corrected the better.
Prof. Wilson advises tenotomy with subcu-
taneous division of fascia, in mild cases,
followed by some form of mechanical re-
tention, until the bones adapt themselves to
the normal position, and the muscles recover
their tonicity. After operation, the foot
should be placed in the corrected position
by manual force and retained with a light
plaster-of- Paris bandage.

In the New York Medical Record, Dr. A.
M. Phelps reports one hundred and ninety-
six cases treated by direct open incision
since 1888. The advantages of open incis-
ion must be apparent. The surgeon becomes
master of the situation, as he has every fa-
cility for complete division of all contracted
tissues. Arteries can be spared by careful
dissection, or cut and tied. In obstinate or
inveterate cases, the ligaments should be di-
vided ; open incision renders this possible.

Dr. Thomas G. Morton's operation for
club-foot cannot be too highly commended.
He recognizes the astragalus with its forward
dislocation as a check to the action of the
joint, or as a foreign body, and therefore
removes it. His results are good, as his se-
ries* of cases at the Orthopedic Hospital will
prove.

Again, for a moment, I would look back-
wards. Could a man of the last century
have seen in a vision of the future the re-
sults of measures put into execution by men
of this marvelous era, his heart would have

March 7, 1891.

Communications.

271

leaped, his nerves thrilled; for plainly he
would have seen the hereditary curse lifted
from those apparently condemned by nature.
And instead of seeing behind the faint
tinges of an expiring sunset would have seen
all the glory of the daybreak decking the
skies before.

GASTRIC ULCER.1

BY M. J. WEBER, M. D.,

LOWER PROVIDENCE, PA.

I purpose in this paper to call attention
to an affection of the stomach, which, by its
protracted course and the insidious manner
of its development, along with the entire
absence of any characteristic symptoms in
many cases, often destroys life before the
real nature of the malady is even suspected.
I refer to gastric ulcer, the simple round
ulcer of the stomach.

This disease, which is common in some
parts of the continent of Europe and in
England, is, according to Da Costa, com-
paratively rare in this country. Professor
Welch states that he met with six cases of
open ulcer of the stomach in about eight
hundred autopsies. It has been my fortune
to meet with two fatal cases of this disease,
in which the diagnosis was verified by post-
mortem examination ; and two other cases
in which I had diagnosticated gastic ulcer,
one patient recovered under treatment, while
the other passed out of my care and died,
no autopsy being held.

Gastric ulcer may cause death in three
ways : First, from perforation of the walls
of the stomach and escape of its contents
into the abdominal cavity; second, from
perforation or erosion of blood-vessels and
consequent hemorrhage ; third, from gradual
exhaustion.

Inasmuch as each of my two fatal cases rep-
resents one of these modes of death, a short
history of each of them may not be unin-
teresting.

Case 1. Mrs. Y., seventy-two years old,
while sweeping a bed-room was suddenly
seized with a feeling of faintness, and imme-
diately began vomiting bright red blood in
large quantities. She sank to the floor and
was lifted into bed. When I saw her, about
fifteen minutes afterwards, she was vomiting

1 Read before the Montgomery County Medical So-
ciety.

partly coagulated blood profusely. I had
some tincture ferri chloridi with me, which
I gave her in teaspoonful doses, somewhat
diluted, and the hemorrhage soon ceased.
The woman vomited no more blood for four
days, when the hemorrhage began again,
and continued in spite of all treatment for
three days, until she died exsanguine, seven
days after the initial hemorrhage. In the
four days during which she had no bleed-
ing, she passed several dark, tarry-looking
stools, which showed that blood had passed
downward into the intestines.

The autopsy showed the stomach full of
clotted blood, which, being turned out, re-
vealed an open ulcer three- fourths of an inch
in diameter on the posterior surface of the
stomach, one and one-half inches to the
right of the cardiac orifice and near the
lesser curvature. On the anterior surface
was another open ulcer, directly opposite
the one on the posterior surface, and slightly
larger, but not so deep. Close by the ulcer
on the anterior surface, was a large cicatrix,
which no doubt marked the site of an ulcer
that had healed. The ulcer on the posterior
surface had a hole in its floor large enough
to admit a silver probe. This hole opened
directly into the splenic artery^ which was
firmly adherent to the stomach at this point,
and very calcareous. The cause of the hem-
orrhage was thus fully explained. The mu-
cous membrane of the stomach and duo-
denum was thickened and dark red, and
showed everywhere the marks of chronic
catarrhal inflammation. The gall-bladder
was completely filled with gall-stones. Over
four hundred were taken out. This woman
had never complained of anything more
than a little regurgitation occasionally after
meals, and the ordinary symptoms of dys-
pepsia. There had never been any biliary
colic.

Case 2. Mr. K., farmer, sixty-nine years
old, came to my office complaining -of trou-
ble in his stomach. He had walked about
one-third of a mile, and seemed greatly fa-
tigued. His symptoms for the last three
years had been : partial loss of appetite, a
feeling of uneasiness and fulness in the
stomach after eating, constipation, flatu-
lence, heartburn and eructations of gas ; in
short, all the symptom of chronic gastritis.
There had never been any great pain in the
stomach, nor any vomiting or hemorrhage.
His symptoms during the last year had been
gradually growing worse, and during the
last twenty-four hours he complained of

272

Communications.

Vol. Ixiv

considerable pain in the epigastrium, and
felt very ill in general. His tongue was
coated, his pulse was 90. Percussion over
the abdomen elicited great tenderness in the
epigastric, umbilical and right hypochon-
driac regions. This tenderness was so great
that a satisfactory examination could not be
made. I diagnosticated a local peritonitis,
caused most likely by a perforating ulcer of
the stomach or duodenum, and advised the
patient to go to bed, setting forth the grav-
ity of his condition, and prescribing opium
for him. He went home, but did not go to
bed, and the next day I found him sitting
in a chair, vomiting frequently, and com-
plaining of pain over the whole abdomen.
He now had the symptoms of a general dif-
fuse peritonitis. Eight days afterwards he
died. The autopsy revealed a diffuse peri-
tonitis, the intestines being matted together
and adherent to the whole anterior surface
of the abdomen. Examination of the stom-
ach revealed an open round ulcer one and
one-fourth inches in diameter immediately
adjoining the pyloric orifice, and on the
lesser curvature. The edges of the ulcer were
thickened, and a perforation in its floor
communicated with its peritoneal cavity.

The history of these two cases shows how
serious a disease gastric ulcer is, how insidu-
ous and protracted may be its course and
how great is the importance of it's early
recognition.

It is not my intention, in this paper, to
enter into any detailed consideration of this
disease. A short description will suffice.

The characteristic symptoms of gastric
ulcer are pain, hemorrhage from the stom-
ach, vomiting and disturbances of digestion.
Pain is the most constant symptom, and it
usually becomes more acute within a half
hour after- eating. Many cases of ulcer of
the stomach occur, however, which present
nothing but the symptoms of chronic gas-
tritis. Gastric ulcer occurs with greater fre-
quency among women than among men.
According to Dr. Brinton the proportion is
two women to one man.

The cause of gastric ulcer is obscure.
Abercrombie and Cruveilhier believed it to
be the result of chronic gastritis. Rokitan-
sky and Virchow assign- its origin to a local
embolism or thrombosis. Riegel ascribes
the chief cause to a constant state of hyper-
acidity, while Engel held that gastric ulcer
was not due to any one cause, but might
originate in a variety of ways. This was
also Brinton's view.

Gastric ulcers occur mostly on the poste-
rior wall of the stomach, on or near the les-
ser curvature, and usually near the pylorus.
They are usually round, and if recent have
sharp edges and look as if a circular piece
had been cut out with a punch. Old ulcers,
however, become somewhat irregular, the
greatest loss of substance being in the mu-
cous coat.

The duration of gastric ulcer is variable.
It may exist for years before causing much
trouble, and a fatal termination may occur
within a few days after the initial lesion.
Brinton states that he had a case under ob-
servation for thirty-five years, while Nie-
meyer relates the case of a physician who
died from a perforating ulcer of the stom-
ach eight days after he felt the first symp-
toms. Probably from three to five years is
the average duration. In the second of the
cases I have described the ulcer certainly
existed for three years.

In many cases of gastric ulcer the diag-
nosis is easy, while in other cases it is im-
possible or amounts only to a suspicion.
The two diseases with which gastric ulcer is
most likely to be confounded, in the ab-
sence of a tumor, are nervous gastralgia and
chronic gastric catarrh. In case of doubt,
however, it is best to put the patient for a
time on the proper treatment for gastric
ulcer.

What should be the character of the prog-
nosis in this affection ? It seems to me that,
in view of the danger of sudden perforation
or severe hemorrhage, the prognosis should
not be too favorable. Then, too, cases
often relapse after recovery has begun. The
case mentioned above as having ended in
recovery, relapsed about six weeks after
treatment was begun. The patient thought
she was well, went visiting and ate heartily
of beans, cold-slaw and ham, and all her
former symptoms returned. Two months
more of careful treatment cured her.

In treating gastric ulcer, diet is very im-
portant. We should seek to remove all
sources of irritation from the ulcer, so that
the process of repair may go on uninter-
rupted.

This may be accomplished by giving the
stomach complete rest and nourishing the
patient entirely with nutrient enemata. This
method of administering food, however,
presents many difficulties in practice, and I
believe is rarely required. By a proper se-
lection of the diet, the patient can be more
satisfactorily nourished by the stomach,

March 7, 1891. Communications.

273

without interfering with the healing pro-
cess.

The most valuable article of diet in this
disease is milk. Under an exclusive milk-
diet, the pain and vomiting cease and cica-
trization takes place. The patient should
take from one to two quarts a day. Where
plain milk disagrees, peptonized milk may
be tried. This preparation has proved ex-
ceedingly, valuable in the treatment of gas-
tric ulcer. After three or four weeks, meat
broths, farinaceous foods, soft-boiled eggs,
etc., may be given. For at least three
months the patient should be confined to
easily-digested food ; and when there is
reason to believe that the ulcer is healed,
the usual diet may be gradually resumed.

The drugs most used in the treatment of
gastric ulcer are subnitrate of bismuth and
nitrate of silver. I have carried out Trous-
seau's plan of giving these drugs in succes-
sion every two weeks, with success. By
this method the danger of causing argyria
is averted.

The best way of relieving the pain of
gastric ulcer is by the use of opium in some
form; but, in prescribing opium in' this dis-
ease, the physician should not forget the
danger of establishing the opium habit.
Besides this, opium retards digestion and
increases the constipation already present.

The treatment of complications, such as
vomiting, hemorrhage, dyspepsia, etc., is
the same as when they occur under other
circumstances.

For the relief of the constipation, I found
no drug or combination of drugs to answer
as well as maltine with cascara sagrada.

RECENT MEDICAL JURISPRUDENCE.

HENRY A. RILEY, ESQ.,

NEW YORK.

A recent case in New York is of much in-
terest to physicians, as it bears on the ques-
tion of collecting bills. In this case, the
physician seems to have been at fault, and
the Court refused to come to his aid.

The circumstances were as follows : The
mother of a patient went to the physician
and paid him the amount asked for on ac-
count of his services, and received a receipt
w in full for medical services." The mother
had requested the services, and was under-
stood by the physician to be acting for the
patient in making the payment. The latter, 1

however, did not authorize the payment.
The physician afterwards brought a suit
against the patient, to recover a further
amount, claiming that the services were
worth more than he had received. There
was no satisfactory explanation given of the
receipt in full, and the physician did not
show that the receipt was, in fact, for part
of the services, instead of them all. The
Court held, on this point, that the receipt
in full was prima facie evidence of payment
for everything, but was subject to explana-
tion showing a misunderstanding. The phy-
sician failed to show this, but relied mainly
on the testimony of experts to prove that
the services were really worth more than he
had received. The Court refused to be in-
fluenced by such testimony, and said that
when the amount due had been adjusted and
paid, the opinions of other persons, that
the services were worth more than this sum,
could not be considered. I have no doubt
that this decision is good law in other States
than New York, and it certainly is good
sense.

The present cold snap will no doubt cause
many accidents from slipping on the ice and
snow, and the sufferers will certainly be
anxious to sue some one and recover dam-
ages for their pain and grief. Most persons,
in such circumstances, decide to sue the city
or town authorities, rather than the owners
of the properties in front of which the acci-
dents occur. These suits are brought on
the theory that the city or town is respon-
sible for the care of the streets, and must
keep them in a passable condition or suffer
the consequences. The Courts recognize
and enforce this general rule, and, as a re-
sult, there are many actions brought and
many judgments secured. There is a limit,
however, to the responsibility for sidewalk
accidents, and the city cannot be made to
pay for every slip and fall. In a recent case
the limitations are thus stated : " The duty
resting upon municipal corporations to re-
.move accumulations of ice and snow as it
falls from time to time upon their streets is
a qualified one, and becomes imperative only
when dangerous formations or obstacles have
been created, and notice of their existence
has been received by the corporation. Ac-
tual notice to the public authorities is not in
all cases required, and it has been held that
negligence may be inferred from the omis-
sion by the corporation to cause dangerous
obstructions to be removed from the streets,
1 after sufficient time has elapsed to afford a

274

Periscope.

Vol. lxiv

presumption of knowledge of their exist-
ence and an opportunity to effect their re-
moval."

In a late criminal case in Kentucky, the
Court was called upon to decide whether
oral evidence could be introduced to prove
the contents of a written statement made by
the injured man when in expectation of
death. The accused person had in some
way destroyed or concealed the written
statement, and it was held that in such a
case oral evidence was perfectly proper.
The Courts are, however, careful to require
the best evidence to be produced, and this,
in ordinary circumstances, would be the
original statement and not a copy or any
recollection of its contents.

The rules governing expert evidence are
quite strict, and physicians are not allowed
to give their opinions, except upon state-
ments of facts which are clearly given and
cannot well be misunderstood. In a late
New York case, it was held that an expert
could not be asked whether, in his judgment,
" based on all the testimony " and " on the
whole case," a criminal was sane or insane,
as the jury would not be able to tell upon
what facts the witness based his opinion.
The proper course is for the counsel to frame
hypothetical questions stating exactly cer-
tain facts, assumed to be proved, and then
to ask the witness his opinion, based on such
facts. An expert witness cannot be asked
his opinion, founded on what he has heard
other witnesses testify.

Veterinary surgeons are held liable to the
same requirements of care and knowledge
that members of the medical profession are
subject to. A recent suit in Nebraska brings
out clearly the law bearing on such cases.
The Court said: "A veterinary surgeon
impliedly engages and is bound to use, in
the performance of his duties in his employ-
ment, such reasonable skill, diligence and
attention as may be ordinarily expected of
persons in that profession. He does not
contract to use the highest degree of skill,
nor an extraordinary amount of diligence,
but to exercise a reasonable degree of
knowledge, diligence and attention."

The Iowa Code seems to open a .possible
opportunity for injustice to insane persons
by not requiring their presence at examina-
tions into their mental condition. A recent
case states that if the Commissioners of
Lunacy, after preliminary inquiries as to the
condition of one sought to be adjudged in-
sane, shall be of the opinion that his pres-

ence, during the investigation, would be
injurious to him or without advantage, they
may dispense therewith.

There does not seem to be any require-
ment of a personal notice that the examina-
tion is to be held, and it would appear that
a person can be declared insane, who does
not know that any proceedings are on foot
for such a purpose.

Periscope

Koch's Remedy.

The Jphns Hopkins Hospital Bulletin, Jan-
uary, 1891, contains a very discreet report
by Dr. A. C. Abbott of the impressions made
upon his mind by a visit to Berlin, to inves-
tigate the use of Koch's remedy for tubercu-
losis. In this report, Dr. Abbott says : I shall
not* attempt to give in detail an account of
the cases which were seen by me but shall
present the general conclusions at which I
arrived. Judging from the cases which I
had the opportunity of seeing, I feel justi-
fied in concluding that the outlook for those
coming under the head of " surgical tuber-
culosis "is a very favorable, one. In the
lupus cases particularly, one may say that
up to date cure has certainly been effected
in a fair number. These cases, as was
pointed out-by Koch, present altogether the
favorable material for the observation of
both the systemic and local reactions follow-
ing the injections and, as a rule, respond in
an astonishingly rapid manner to the treat-
ment.

In the group of surgical cases coming
under the head of " joint tuberculosis" the
injections of the virus have not rarely been
continued until the systemic reaction prac-
tically ceased to appear even though large
doses may have been reached, and still the
local expression may have improved but
slightly or not at all. In one such case that
I call to mind the joint cavity was subse-
quently opened and it was found a mass of ne-
crotic tissue containing tubercle bacilli.
This tissue wras lying free in the cavity and
had been thrown off from a point on the wall
of the joint which still presented the charac-
teristics of tuberculous tissue.

In a second case which I saw demon-
strated there was every reason for believing
that the condition was identical with that of 1
the joint to which I have just referred.. 1

March 7, 1891.

Periscope.

275

At operation, however, there was a conspicu-
ous absence of anything in the joint that
would lead one to suspect the presence of
offending necrotic tissue. At the point,
however, on the cartilage was an old scar,
evidently of tubercular origin, and it is not
improbable that the irritation of and effu-
sion into, the joint may have resulted from
the local reaction in this bit of scar tissue ;
a reaction analogous to that seen in the scar
tissue of the skin which remains after sur-
gical operations for the removal of under-
lying tuberculous processes.

In the joint troubles of this character the
best results which may be expected will be
those arising from the action of the virus,
combined with the treatment of the joint
by the ordinary surgical measures.

It is as yet impossible to say what the re-
sult of the treatment in the pulmonary man-
ifestations of the disease will be. Evidence
in this department accumulates so very
slowly that one is hardly justified in speak-
ing confidently as to the results.

The employment of the agent in laryn-
geal cases of tuberculous nature should be
conducted with the greatest care, and the
treatment should begin with even a smaller
quantity of the agent than that ordinarily
employed as the minimum dose for other
troubles. The congestion brought about in
the tissues of this organ as a result of the
treatment may plainly be seen to be of a
dangerous, if not a of fatal, nature.

As is well known, Koch has said posi-
tively that phthisical patients in whom the
disease is but only slightly advanced can
be cured by the systematic employment of
the virus. In his experience this class of
patients were in a number of instances pro-
nounced as cured after from four to six
weeks. He claims further that a patient in
whose lungs cavities of limited extent exist
may be very much improved, and indeed
almost cured by this method.

It has not been my province as yet to see
any of the cases which have been reported
as cured, though I have seen a number in
which the tubercle bacilli were said to have
disappeared for longer or shorter periods of
time from the sputum of the patients.

From my personal experience in the
wards in which the pulmonary cases were
being treated, I feel constrained to say that,
in my opinion, it is only with the greatest
conservatism that one should express an
opinion as to the result of the treatment.
There is no doubt that many of these pa- '

tients gave evidence of improvement, but
for one to say positively that they were cured
would, I believe be, at present, a little pre-
mature.

In concluding his report, Dr. Abbott ex-
presses the opinion that the outlook in sur-
gical cases of tubercular nature is good,
particularly in those most superficially lo-
cated ; that, in the lung cases, the outlook
appears to be fair if the cases are treated
sufficiently early. For advanced cases he
thinks it would be premature to do more
than speculate, in view of the existing evi-
dence. The intestinal cases, so far as they
have as yet been observed, he thinks are
unpromising.

New Remedies for Whooping-cough.

In the Deutsche med. Wochenschrift, Jan-
uary 19, 1891, Boas gives an interesting re-
view of some new remedies for whooping-
cough. Antipyrin was first used by Genser,
who reported his experiences with 120 cases.
The average duration of the disease was
twenty-four days, as compared with the usual
sixty to ninety days. Genser gave, as a
dose, one and a half grains for each year of
the child's age. Sonnenberger reported
upon 70 cases. To young children he gave
doses of from half of a grain to one and
one-half grains three times a day ; to older
children, from two and a half grains to fif-
teen grains. He observed marked lessening
of the severity of the attacks and shortening
of the duration of the disease. Antipyrin
is by no means always harmless, it appears,
and there are a number of cases of poisoning
from its use. Rothe, who has observed un-
favorable results from the employment of
antipyrin, uses a combination of tincture of
iodine and carbolic acid, and proclaims its
great advantages. Of a hundred cases upon
this treatment he could recollect none in
which the disease lasted longer than four
weeks. He makes use of the following solu-
tion :

R Acidi carbol gr. iss

Alcoholis : . . rryss

Tinct. iodi gtt x

Tinct. belladonnse gtt xxx

Aq. menth , f ^ ii

Syr. opiat1 TT\xv

M. To children over two years of age, a teaspoonful
every two hours.

Antifebrin has also had advocates. The

1 Contains, according to Ewald, only about I }4 hun-
dredths of a grain of extract of opium.

276

Peris-cope.

Vol. Ixiv

dose is from one- half to four and a half
grains, three times a day, according to the
age of the child.

Heiman employed phenacetin in a case in
which antipyrin had failed, and the result
was so surprising that he employed it in two
other cases. It diminished the number of
the attacks from fifteen to three, and for a
day at a time they ceased entirely, but re-
turned at night if phenacetin was not given.
The dose for a child three years old was
one and a half grains three times a day.

Moncoroo, in 1885, was the first to recom-
mend resorcin locally in whooping-cough.
His results have been confirmed by others.

The fumes of sulphur 'have been recom-
mended by Manby and Weissberger. The
latter speaks enthusiastically of the remedy.
He burns morning and evening one hundred
and fifty grains of sulphur and exposes the
child for an hour to trie vapor. The gas
generated is not concentrated enough to
more than provoke a slight irritation of the
throat and nasal mucous membrane.

Stepp recommends bromoform, which is
given in drop doses in water. A child three
to four weeks old receives one drop three or
four times a day, older children in propor-
tion. One hundred cases are reported and no
disagreeable symptoms have been observed.
Recovery resulted in from two to four weeks.
Care is required on account of the volatility
of the bromoform, because it is easily de-
composed. It should be kept in dark bot-
tles. L6<Venthal confirms Stepp's statements,
and also reports one hundred cases. The
highest quantity taken (during the course of
the disease) was five drachms, the lowest
seventy- five minims; the separate doses were
the same as those employed by Stepp. In
a few cases Lowenthal observed weariness
and sleepiness after giving the drug, and in
one case, probably on account of too large a
dose being given, poisoning occurred, but it
was quickly overcome by stimulants.

Neumann reports that the bromoform has
a favorable influence, but it does not shorten
the attacks decidedly. Louis Fischer's ex-
perience with it has also been very favorable.

Schilling has experimented with chloro-
form water in the form of inhalations : a
teaspoon ful of warm water is put into the re-
ceptacle of the inhalation apparatus and chlo-
roform added in drops according to the age
of the patient. The sitting is ended as soon
as the water, converted into steam by heat,
has been used up. Four sittings are given a
day. These inhalations act favorably upon

the attacks and upon the duration of the
disease. Sixty-two cases are reported.

Manasse recommends, upon an experience
with forty-one cases, 'terpin hydrate, which
is administered according to the following
formula :

R Terpin hydrat gr. viiss-xv

In. pulv. No x.
Sig. One powder three times a day.

Improvement is said to occur with cer-
tainty in four or five days. Manasse reports
a favorable influence especially upon the
bronchitis which is nearly always present.
Digestion is in no way influenced by terpin
hydrate, and it has no systemic action. Tel-
amon recommends tejpin hydrate with anti-
pyrin :

Terpin hydrat gr. xv-xxiii

Antipyrin gr. xv

Syrupi aurantii cort f ^ iss

Aq. Liliae (Linden) f ^ ij

M. Sig. One to two coffeespoonfuls several times a
day for a child from one to four years old.

A very new remedy is ouabame, an alka-
loid obtained from a root used by the Soma-
lis as an arrow poison. It is recommended
in whooping-cough by Gammel. One-twen-
tieth of a milligram is the dose. The results
obtained by its use thus, far have not been
brilliant.

A Failure with Koch's Remedy.

The New York Medical Journal, February
14, says : A significant case was reported at
the last meeting of the New York Pathologi-
cal Society, on Wednesday evening, that
seems to us to go far to exemplify the force
of the cautions inculcated by Virchow's
observations, subsequently re-enforced by
Henoch's, as to the possibility of spreading
or intensifying a moderate tubercular inva-
sion by the employment of the Koch treat-
ment. The case was that of a man presenting
the rational and physical signs of pulmo-
nary tuberculosis, but in whom no pulmonary
cavity could be detected. After he had
been given twenty-four injections of Koch's
liquid, in the usual doses and at the usual
intervals, the number of bacili in the sputum
was found to have increased, and the pa-
tient's condition was decidedly worse. A
cavity was detected in the apex of the lung,
and the patient died shortly after the dis-
continuance of the Koch treatment. After
death, the cavity was found in the lung,
about as large as a lemon, and there was

March 7, 1891.

Periscope.

277

miliary tuberculous disease of the lungs.
The tuberculous foci were surrounded by
intense congestion, and the meninges of the
brain and various organs were also highly
congested. The opinion was expressed that
at the outset the case was eminently a
proper one for testing the efficacy of the
Koch treatment.

Cremation and its Safeguards.

The Lancet, January 31, 1891, says : Un-
fortunate circumstances connected with the
death of the late Duke of Bedford have
brought into prominence an important ques-
tion respecting the procedure of the Crema-
tion Society, of which the late Duke was a
prominent member, in cases of death from
other than purely natural causes. It is clear
that in the case of the Society absolute cer-
tainty as to the cause of death when other
than natural can alone justify the preferen-
tial application of its method. It will there-
fore be interesting to examine the practical
value of the safeguards adopted by the So-
ciety to prevent the chances of fallacy in a
matter so important. These are three —
namely: (1) the certificate of the medical
practitioner in attendance on the deceased
during his last illness ; (2) a second inde-
pendent certificate by another practitioner
after careful inquiry into the circumstances
attending the illness; and (3), should any
doubt remain, the evidence afforded by
necropsy. A further, though possibly less
permanent, security exists in the resolution
of the Society to refuse cremation in any
case where the least doubt exists respecting
the cause of death. Such doubt, as ob-
served by Sir Henry Thompson, could re-
main after necropsy only in an extremely
small number of cases, and would, in fact,
be virtually abolished. Not actually so,
however. There still remains a minimum
.uncertainty, and this, it is apparent, is much
greater where certification even on the very
careful system employed by the Society, is
alone relied upon. The practitioner in at-
tendance might, in spite of diligence and
skill, be misled— for example, in a case
where the signs of poison were obscurely
blended with those of real or supposed dis-
ease. In this connection the case of the
iate Mr. Maybrick is suggestive. Is it then
to be believed that a second medical testi-
mony, which would be independent of the
former, could be relied on to guarantee the
difference of opinion which would necessi-

tate an appeal to the coroner ? We should
rather expect that this latter evidence, di-
vested as it must be of various technical
premises which guided the statements in the
first certificate, would be at best a care-
fully weighed and usually confirmatory as-
sertion of moral certainty. After all it is
probable that the most reliable safeguard
against a too precipitate practice of crema-
tion which we possess is to be found in the
resolutions of the Society above mentioned.
Cremation therefore under its present rules
is certainly a valuable means of promoting
accuracy in certification. As affording an
absolute guarantee of such accuracy it can-
not be depended on, while it must in all
cases destroy every trace of morbid or mis-
chievous agency contained in the tissues.
While therefore we freely admit its practical
security against any miscarriage of justice in
the vast majority of cases, we cannot admit
that it stands in this respect on a level ex-
actly so higrj as the practice of burial.
Moreover, while we also recognize its more
absolute and destructive purity in the dis-
posal of infectious dead, we do not see that
it possesses any such advantage in compari-
son with burial in other cases, provided
that burial be conducted, as it increasingly
is conducted, on a rational or "earth to
earth " system.

Treatment of Tuberculous Abscesses
with Hot Water Flushing.

Mr. Arthur E. Barker, Surgeon to Uni-
versity College Hospital, says, in the British
Medical Journal, February 7, 1891 : Hith-
erto the usual treatment of large tuberculous
abscesses, whether connected with a dis-
eased spine, with broken-down glands, or
in the soft parts, has left much to be desired.
Whether they were simply allowed to burst,
or were opened and dressed antiseptically,
or whether they were aspirated with or
without subsequent injection of germicidal
fluids, the results have often been far from
satisfactory. Either the discharge, how-
ever sweet, has gone on for an indefinite
time through open sinuses, or the abscess
has become infected with saprophytic organ-
isms, and only too often with acute septic
processes.

Having had considerable experience in
the removal of tuberculous material from
widely diseased hip-joints with hot water
flushings applied in a special way, and hav-

278

Periscope.

Vol. Ixiv

ing seen case after case heal completely and j
permanently without any drainage, under
one dressing, after such treatment, I have
been encouraged to apply the same method
to large tuberculous abscesses elsewhere.
The results have exceeded expectation, and
have encouraged to further trial.

The modus operandi is simply this : Take
the case of a psoas abscess, in which the
bone lesion is apparently stationary, or per-
haps healing, but where a large collection
is steadily, though slowly, advanced towards
the skin of the thigh. In such a case a two-
inch incision is made through sound struc-
tures over the lower end of the swelling.
Through this opening a hollow gouge is in-
serted, which is connected with a reservoir
of hot water atio5°to uo° F. by a rubber
tube some 6 feet long. This reservoir (a 3-gal-
lon can) is raised about 5 feet above the oper-
ating table. When the water is now turned
on it rushes through the long gouge to the
fundus of the abscess with considerable force,
and the reflux carries the contents of the
cavity out by the incision. By gently scrap-
ing with the flushing scoop the more solid
caseous matter is dislodged, the hot water
carrying it clear out of the cavity at once.
Then the walls of the cavity are gently
scraped in a methodical manner until the
soft lining is loosened and carried away from
every part of the abscess. In order to effect
this thoroughly I have had these scoops made
of varying length, so- that the deeper parts
can be reached. In the case of a psoas ab-
scess they can be carried up under Poupart's
ligament nearly, if not actually, to the spine.
In using them all violence must be avoided,
lest important structures should be torn, or
lest the fibrous wall of the abscess should
be broken through, and, finally, to avoid
bleeding. With hot water the bleeding is
but slight if the peeling be done cautiously.

When the water runs out clear after hav-
ing been carried to all recesses of the cav-
ity, the instument is withdrawn. Then any
excess of water is squeezed out, and if the
deeper parts are accessible, sponges are used
to dry out the last traces of moisture. Then
two or three ounces of fresh iodoform emul-
sion are poured into the deepest part of the
abscess, and stitches are inserted in the edges
of the incision. Before these are knotted
all excess of emulsion should be squeezed
out of the cavity. The knotting of the
silk sutures then completes the procedure.
As no drain tube is used at all, a simple dry
dressing of salicylic wool is alone required,

j but it should be laid on in considerable
quantity, so as to exert elastic pressure over
the whole area of the abscess when ban-
daged. Such a dressing may be left on for
about ten days, when it is time to remove
the stitches, and the wound should then be
firmly healed. A piece of salicylic wool
secured by collodion at the edges should,
however, be laid over it to keep it from
chafing for a few days longer, and the elas-
tic pressure should also be kept up.

Such a procedure is only demanded for
the larger tuberculous collections, such as,
for instance, psoas, iliac and lumbar ab-
scesses. Of course, for those that can be
fairly isolated, no treatment is better than
to dissect them cleanly out without ruptur-
ing them — a practice I am very partial to.
This can be done in perhaps a much larger
proportion of cases than is commonly sup-
posed, even when the contents are fluid.
Again, in the case of softening tuberculous
glands, it is the proper thing to dissect
round them and remove them entire, and
wounds thus made ought to heal by first in-
tention and without drainage. Some of the
larger abscesses, such as those alluded to
above, may also ultimately be cured by as-
piration of their contents and injection of
iodoform emulsion. But in my own expe-
rience of many such cases this requires con-
siderable time, is uncertain, and is only to
be achieved when the contents are very
fluid. Where there is much solid matter
which will not pass through the needle, I
know no method so reliable and so speedy
as that of mechanical hot water flushing.
I have always called this " flushing," as it is
something totally different to mere irriga-
tion, which does not carry away the mate-
rial one is anxious to have removed.

Massage as a Cause of Pyemia.

In the Vratch, No. 21, 1890, p. 474, Dr.
Petr S. Novitzky, house-surgeon to the
Kazan Military Hospital, records a very in-'
structive case which proves that massage of
a suppurating gland can easily give rise to
the so-called " multiple or metastatic pye-
mia." A shopkeeper fell ill with suppura-
tive inflammation of his right parotid gland.
On the sixth day of the disease, he ener-
getically rubbed into the fluctuating tumor
some gray mercurial ointment. In a few
minutes there appeared severe rigors, while
the swelling markedly decreased in bulk.
In the course of two days there developed'

March 7, 1891.

Periscope.

279

several abscesses (varying in size from a
nut to a pigeon's egg) on the right side of
the scalp and neck and in the right submax-
illary region. On the fourth day (after the
rubbing in), the left major pectoral muscle
became inflamed. On the tenth, a large
abscess on the right calf made its appear-
ance. On the seventeenth, the right lung
was found affected. On the twentieth, the
patient died of exhaustion. According to
Dr. Novitzky's theory, the energetic manip-
ulations, made by the man on rubbing in
the salve, had driven pus from the parotid
abscess into the adjacent lymphatic and
blood-vessels. Pointing to his case, the
author earnestly warns against practicing
local massage in cases of suppurative paro-
titis or mastitis (which method has been
recently recommended by Dr. Zemblinoff,
of Usman, in the Vratch, Nos. 3 and 7,
p. 61).

New Remedies for Ear Diseases.

Dr. Edmund Szenes, an otologist of Buda-
Pesth, lectured before the Imperial Society of
Physicians at Buda-Besth, June 14, 1890,
upon the therapeutic value of some new reme-
dies introduced into the practice of ear dis-
eases, and Dr. Patrzek makes a report upon
this lecture in the Allgemeine med. Central-
Zeitung, January 3, 1891.

Menthol, according to Szenes, has proved
of value in the treatment of furuncles of the
auditory canal. A twenty per cent, solu-
tion of it is used, and a pledget of cotton
wet with it is placed in the canal. A
twenty per cent, solution of aceto-tartrate
of aluminium is likewise of good service.
In using it, patients are directed to fill the
auditory canal every three hours with a
warmed solution, and to keep it in the ear
for some minutes. Kirchner has recom-
mended the following solution for furun-
cles :

R Corrosive sublimate gr- X

Water f|i

Glycerine fgv

He alludes to staphylococci detected by
him in the secretion of the furuncle. Szenes
says the sublimate acts best after incision
or spontaneous opening of the furuncle.
Szenes has also employed acetate of alumi-
nium, which is much prized as a remedy in
furnuculosis of the auditory canal. It is
diluted four times with water. It allays the
pain but does not shorten the course of the

disease process. During the last epidemic
of influenza, in the first stage of acute inflam-
mation of the tympanum, a fifteen per cent,
solution of carbolic acid in glycerine did
good service. Szenes is not enthusiastic over
creolin ; all antiseptic fluids which are not
clear should be banished from ear practice.
Iodol, which has been recommended in place
of iodoform, accomplished no results in
otorrhcea, notwithstanding its daily use for
several weeks ; and salicylate of bismuth
and aristol were of as little service. /

Szenes has the following to say about the
much-used treatment with powdered boric
acid : " When the perforation in the drum
membrane is sufficiently large, and occupies
a convenient position ; when there is no
caries of the ossicles, or of the tympanic
wall ; when, moreover, no affection of the
mastoid exists, and when, therefore, no re-
tention of pus and its effects are to be feared,
then, after proper cleansing and drying of
the tympanum, a little boric acid can be
blown into the deeper parts of the exter-
nal auditory canal."

Lactic acid, even in weak solution, causes
pain and erosions, so that soon it has to be
given up. Cocaine, recommended by Kies-
selbach, for tinnitus, has in no case proved
effective. At the Prague ear clinic of Prof.
Zaufal, Szenes saw massage employed, and
he praises its effect in diminishing pain
and promoting absorption. The hand is
anointed with iodine ointment and the mas-
toid and the region behind the ante-tragus
is stroked downwards, on the side of the
neck, and as far as the clavicle.

Lupus and the Koch Fluid.

After brief references to the enthusiasm
which the first announcements of Koch as
to his remedy for tuberculosis aroused and to
the reaction which has set in, accelerated by
the reports of Virchow, Dr. Hermann Isaac,
of Berlin, in the Deutsche Medizinal Zeitimg,
January 19, 1891, discusses the utility of
the remedy in the treatment of lupus. While
in the case of tuberculosis of internal organs,
the most cautious dosage and careful obser-
vations cannot obviate occasional untoward
results, experience teaches that the remedy
exerts its specific curative influence espe-
cially in tuberculous processes of exposed sur-
faces. In the case of lupus no obstacle is
interposed to the extrusion of the structures
cast off as a result of the action of the in-
jection of. the Koch fluid. An important

280

Periscope.

Vol. ixiv

consideration in the treatment of lupus in
this way lies in the fact that the patients are
usually otherwise robust and healthy. So
striking is this that there are yet distinguished
dermatologists who do not admit the identity
of lupus and tuberculosis. Isaac, however,
considers the reaction with the Koch fluid
to decide the tuberculous nature of lupus.

Dr. Isaac observes the precaution to make
the initial injection one milligram (.001).
A boy of thirteen, with lupus of the left
cheek, reacted typically to a half a milli-
gram (.0005). An elderly woman with lupus
of the upper lip of forty years' standing
was much improved after having received
ten injections. At the same time she was
relieved of distressing dyspncea arising from
emphysema. Marked general reaction oc-
curred in a case of lupus erythematodos after
the injection of eight milligrams (.008). No
local reaction was apparent, although the
efflorescences receded after repeated injec-
tions. Two other cases of lupus reacted lo-
cally to one milligram (.001) of fluid, while
the general condition was but little affected.
In doubtful cases, involving the diagnosis of
lupus from carcinoma, syphilis and some
forms of eczema, Dr. Isaac thinks the rem-
edy is invaluable.

Internal Lavage.

A few years ago, perhaps based on the
fact of the deficiency of chlorides in the
urine in pneumonia, it was proposed to treat
this disease by subcutaneous injections of
large quantities of water containing, in solu-
tion, sufficient common salt to approximate
the specific gravity of the fluid to that of
the serum of the blood. It was found that
these injections were well borne, to say the
least, and a number of the cases thus treated
recovered. Now, M. Sahli, of Berne, in
the Bulletin. Medical, January 25, 1891,
proposes to apply the procedure, which he
calls "internal lavage," to the treatment
of certain morbid states, such as typhoid
fever and uremia, in which auto-infection
plays a prominent role. The theory is that
the tissues are flushed by the fluid, which
carries off the noxious agents through the
kidneys.

The apparatus for this method of treat-
ment consists in a reservoir to contain a
Sterilized saline solution, a rubber tube, and
a large, hollow aspirating needle. The
needle is introduced into the subcutaneous
connective tissue of the thigh or buttock,

and the fluid is placed at a height sufficient
to obtain the desired degree of pressure.
M. Sahli injects a pint of the solution every
day, or even twice a day. Often copious
diuresis results. In some cases the fluid is
taken up and retained by the tissues de-
prived of their normal fluids by the disease
process.

Copaiba Balsam as a Diuretic.

In the Meditzinskoie Obozreriie\ Nos. 13
and 14, 1890, p. 73, Professor Ivan N.
Obolensky, of Kharkov, warmly recom-
mends copaiba balsam as a powerful diuretic
eminently suitable for dispelling dropsies of
cardiac, origin. Having tried this old-
fashioned remedy (in the daily dose of from
20 to 40 grains, in emulsion), in nine cases,
the author has found that, 1. As a diuretic
agent, copaiba is by far superior to digitalis,
convallaria, adonis vernalis, stigmata mai'dis
and calomel. 2. It acts very quickly, an
abundant diuresis being equally established
about the end of the first 24 hours. 3. The
effects are stable and long-lasting, the ^pa-
tient's organism showing no tendency to
habituation towards the remedy (the same
dose producing the same diuretic effects for
weeks). 4. Of disagreeable concomitant
effects, there are occasionally observed heart-
burn with eructations, increased frequency
of micturition, abdominal pain with liquid
stools, and admixture of red blood-corpus-
cles to the urine. 5. Such phenomena,
however, are always mild, no necessity aris-
ing to discontinue the administration of the
remedy. 6« The balsam does not exercise
any influence on the cardiac action, or pulse,
or arterial tension. .7. Its diuretic action
appears to depend upon its directly stimu-
lating the renal secretory nerves.

Treatment of Hemeralopia with
Injections of Antipyrin.

Hemeralopia is a condition ' in which
vision is impaired so that it becomes im-
perfect when the light is not strong. In-
stillations of pilocarpine or eserine have
been used in its treatment. The Wiener
medizinische Presse, January 4, 1891, quotes
three cases reported by Grandelement in
Lyon med., No. 50, 1890, in which good
results were obtained by the subcutaneous
injection of antipyrin on alternate days, for
a long period.

March 7, 1891.

Editorial,

281

THE

MEDICAL AND SURGICAL

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HEMATURIA IN TYPHOID FEVER.

Hematuria, or the passage of bloody
urine, may arise from disease or from trau-
matism of the kidney, ureter, bladder or
urethra. When from the kidney and ureter,
the blood is usually intimately mixed with
the urine ; when from the bladder, the first
urine passed is usually clearer than the last,
and clotting is more common than in the
case of hemorrhage from the kidney. When
the blood comes from the urethra, it is pos-
sible, by passing a catheter into the bladder,
to obtain clear urine. These statements re-
garding the characteristics of hemorrhage
from the different urinary organs must, of
course, be accepted as general truths only ;
exceptions are not infrequent.

A very rare cause of extra-renal hema-
turia is typhoid fever, and to it A. Letienne
directs attention in a communication pub-
lished in La Medecine Modeme, December

18, 1890. It appears from this paper that
Chomel, Andral and Louis carefully noted
in their autopsies on cases of typhoid fever
the condition of the bladder. Subsequently
J. Cossy, in 1843, collected their observa-
tions and published them, adding eight of
his own. Following Cossy, Lecorche, Ho-
molle, Murchison and Griesinger have all
mentioned the condition and dwelt upon it
with more or less detail.

The hematuria occurs frequently without
premonitory symptoms, and without pain.
In the cases observed by Letienne in the
service of Lecorche, the blood was unco-
agulated, and imperfectly mixed with
the urine ; the blood corpuscles were
rapidly precipitated to the bottom of the
vessel. There were no clots, or only small
ones, indicating that there had been no no-
table extravasation in the bladder. The
hematuria may not occur with each mictu-
rition ; it may occur once, then disappear,
to recur several days later, or it may be con-
tinuous. The quantity of blood varies in
different cases.

Hematuria usually appears late in typhoid
fever, though it may occur at the onset of
the disease, as in a case reported by Le-
corche. It has no such effect in reducing
temperature as intestinal hemorrhage has ;
on the contrary, it may be followed by an
elevation of temperature, for the lesion
which causes it may permit of the re-absorp-
tion of septic products.

The prognosis of cases of typhoid fever
in which hematuria occurs is generally
graver, as the passage of blood indicates the
wide dissemination of the infectious agent
and a lessened resistance on the part of the
patient. But, of course, if it constitutes
the only anomalous symptom in a patient
otherwise doing very well, it becomes of no
importance. The lesions which provoke the
hemorrhage appear in the form of ecchy-
moses, of nipple-like prominences, discrete
or grouped ulcerations, and of gangrenous
spots on the mucous membrane.

Hematuria occurring in typhoid fever is

282

Editorial.

Vol. lxiv

admittedly rare, and some may think it not
worthy of serious consideration. It some-
times happens, however, that the cause of a
rare condition affords an explanation of some
other condition not so rare and more im-
portant. It is well known that palsy follows
many of the acute infectious diseases espe-
cially the exanthemata. Many cases are on
record in which palsy has occurred during
convalescence from typhoid fever, scarlatina
and measles, not to mention diphtheria. The
cause of these palsies has not been very sat-
isfactorily determined. Doubtless hemor-
rhage occurs in a number of cases, the spe-
cific poison so acting upon the vessel walls
that the blood can escape. This explana-
tion is borne out and strengthened by the
lesions just described as occurring in typhoid
fever in the bladder, where they are so gross
as to be capable of demonstration ; whereas
in the brain or cord they could be suspected
only, since autopsies upon persons suffering
with such palsies are rare and have been per-
formed for the most part only after the palsy
has lasted a long time and, consequently,
the possibility of detecting the primary le-
sion very slight.

MATERNAL IMPRESSIONS.'

The influence of maternal impressions
upon the fetus in utero is a matter not
only of scientific interest, but also of cer-
tain practical value. From the time of
Hippocrates it has been held by the medi-
cal profession that psychical or physical im-
pressions made upon the pregnant woman
gave rise to marks, deformities and malfor-
mations evident in the child at birth. Such
a view is also firmly implanted in the popu-
lar mind, as perpetuated in the term "moth-
ers' marks." The problem is one difficult
of solution. Though it may not be possible
to explain the occurrence of abnormalities
in the fetus as a result of influences acting
upon the mother during pregnancy, the first
step in that direction would be the collec-
tion and careful analysis of a large number

of records of cases, so as to determine
whether the association be merely acci-
dental or coincident or related as cause and
effect.

The Edinburgh Medical Journal, for Jan-
uary, 1891, contains an address read by Dr.
J. W. Ballantyne before the Edinburgh Ob-
stetrical Society, in which he reviews the
subject of maternal impressions, and reports
four cases. In one, a woman having an
aversion to frogs was terrified early in her
first pregnancy by a dead frog thrown at
her by a friend. At term she gave birth to
an anencephalic child. Becoming pregnant
a second time she was again delivered of an
anencephalic infant. The significance of
this case is lessened by the fact that the
father, by a first wife, had a hydrocephalic
child. In the second case, a woman who
was struck, during the third month of preg-
nancy, by a deaf-and-dumb peddler, gave
birth to a child which at the age of three
was yet deaf and dumb. In the third case,
a mother gave birth to a" child minus three
fingers of the left hand: During her preg-
nancy, she had been alarmed by a wood-
chopper falling heavily on the same three
fingers of the left hand of another child.
In the fourth case, one son resembled phy-
sically, mentally and personally a maternal
uncle, while a second resembled the mater-
nal grandmother. In each instance, the re-
lative in question had been a source of anxi-
ety during the respective pregnancy.

Dr. Parvin, in the second edition of his
work on Obstetrics, also gives four cases of
maternal impressions. To arrive at some
definite conclusions upon this subject, it is
recommended that the following points be
inquired into : The period in pregnancy at
which the impression was made ; the charac-
ter of the impression; the channels through
which the impression was received ; the
mother was conscious of the impression and
anticipated a defect in the child ; the dura-
tion of the impression ; the influence of
heredity.

The "practical deductions to be drawn

March 7, 1891.

Editorial.

283

from this subject, independently of its ex-
planation, are that during pregnancy a
woman should lead a life of tranquillity,
avoiding excitement, relieved of anxiety,
spared depressing emotions and provided
against deprivation and want.

DUST AND TUBERCLE BACILLI*

The question of the dissemination of tu-
berculosis is so interesting and important
that we may call attention to an observa-
tion in this direction by Dr. M. T. Schnirer,
of Vienna, recorded in the Wiener Medi-
zinische Presse, January 4, 1891. One day
in 1888, on rinsing the dust from some
grapes, bought on a warm day, late in
the summer, he found the water afterwards
quite dirty. Struck by the thought of
the large number of phthisical patients who
eject their sputa upon the streets, he in-
jected ten cubic centimeters of this water
into the abdominal cavity of each of three
guinea-pigs. One of the animals died in
two days of peritonitis. The other two
died in forty-five and fifty-eight days re-
spectively. Examination of the bodies dis-
closed exquisite tuberculosis, originating at
the site of inoculation, and partially case-
ous nodules in the peritoneum, in the liver,
in the spleen, with but meagre deposits in
the lungs. Tubercle bacilli were found in the
nodules. Dr. Schnirer concludes that the
conveyance was by means of the dust, as the
water used was the pure spring water of Vi-
enna, and the glass receptacle containing the
water, the doctor's hands and the syringe
with which the injection was made had been
previously sterilized. He assumes, though
without direct evidence, that the vender
from whom the fruit was obtained was
healthy.

The point Dr. Schnirer makes is, that tu-
bercle bacilli may be in the dust of public
streets, and may be attached to fruit or other
articles exposed for sale and afterwards used
for food.

This fear seems to be exaggerated and

contrary to the inferences deducible from
Cornet's investigations; for Cornet failed
to find bacilli in street dust. Still, the ob-
servation of Schnirer is an interesting one,
and its true significance may be estimated
when taken in connection with facts con-
tinually accumulating. The experience of
Schnirer may be open to inferences very dif-
ferent from those which he draws ; but in
any case, it is interesting to record and
worth remembering in studying the import-
ant subject of tuberculosis.

DEATHS IN COLD WEATHER,

The recent cold weather in Europe serves
to strongly illustrate the inability of the aged
to withstand exposure. A recent number of
the London News states that in the second
week of December, 1890, the number of
deaths among persons eighty years old
reached 100, while during the following
three weeks, which were so unprecedentedly
cold, the number increased to 116, 142,
148. In persons afflicted with diseases of
the throat and chest, the average was dou-
bled.

While the fact that such severe weather is
unusual there, and that people were not pre-
pared to meet its rigors, accounts in a de-
gree for the high rate of mortality, reference
to the returns of our Philadelphia Board of
Health shows that the rate here, where cold
weather is not unusual, is decidedly higher
in the colder months (in the months of
January, February and March) than in the
warmer months.

It is of the utmost importance that aged
people expose themselves as little as pos-
sible during extremely cold or inclement
weather, and when necessity compels them
to do so, that they be well protected.
No doubt if the increased dangers were
sufficiently insisted on, in spite of the dif-
ficulty of making the average octogenarian
realize that he is no longer young, the lives
of many aged people would be greatly pro-
longed.

284

Correspondence.

Vol. lxiv

Correspondence

Aseptic Hypodermic Syringe.

To the Editor.

Sir : Will you kindly grant me space
enough to add a few words more upon the
subject of the aseptic hypodermic syringe
devised by me.

In the issue of the Reporter for Decem-
ber 6, you print a wood-cut of the syringe of
Prof. Koch, used in carrying out the treat-
ment of tuberculosis. As you remark, the
two instruments are constructed upon essen-
tially the same principles, the exception be-
ing that the Koch instrument is much the
more complicated of the two, with all that
greater complication implies in increased
liability to get out of order, greater expense,
and difficulty of being kept in a strictly

aseptic condition. The graduated glass
cylinder and the stop-cock features of the
Koch syringe may have a use as yet unex-
plained in the carrying out of the Profes-
sor's ideas, but they are entirely superfluous
in a syringe for all ordinary uses. In the
admirable instrument made at my suggestion
by Messrs. Chas. Truax & Co., of Chicago,
and now for sale by that firm, the needle
is connected directly to the bulb without
'the intervention of a glass cylinder. The
directions for use are of the simplest sort.

The bulb is pressed flat and the needle is
inserted into some water. On releasing the
bulb, the latter fills with water in five sec-
onds or less. The water is discharged into
a teaspoon, a solution is made of the tablet
or powder, and the bulb is again drawn full,
this time with the fluid ready for injection.

This system I have had in constant em-
ployment for nearly two years, using a
roughly improvised instrument, but with
never-failing satisfaction. The instrument
maker now furnishes "so perfect an article
that a fair trial of its merits cannot fail
quickly to place the bulb syringe well upon
the way of superseding the Ordinary form
of instrument. The Koch instrument may
have uses in carrying out the treatment at
present associated with his name, but is not
suitecT to ordinary everyday uses, and must
be shorn of certain features before it can lay
just claim to be an improvement in the di-
rection of greater simplicity and increased
efficiency.

Yours truly,

John J. Thomas, M. D.
Youngstown, Ohio.

Cancrum Oris or Gangrenous Stoma-
titis.

To the Editor.

Sir : On looking over the proceedings of
the Tri-State — Alabama, Georgia and Ten-
nessee— Medical Association, I noticed a
report of a case of cancrum oris, which
called to mind a similar case occurring in
my practice in October 12, 1886. The pa-
tient, a white male, nine years old, lived
eight miles in the country. I first saw the
patient October 12. I made a diagnosis of
typho-malarial fever. The temperature was
high, the pulse rapid, the respiration hur-
ried, and the tongue coated. The bowels
had not moved for two days. The general
condition of the patient, however, was good.
I ordered hydrarg. chlor. mitis, gr. x ; ipe-
cacuannhse, gr. ii ; to be made into four
powders, one to be given every three hours
until the bowels were thoroughly moved.
On October 13, at 10 a. m., the condition
of the patient was much improved ; the
temperature was 1020, the pulse 110, the
respirations 26. I now gave castor oil, and
put the patient on quiniae sulph., two grains
every three hours, until ten grains were
taken. I learned on the next morning that he
had had several bilious actions during the
previous night. I continued the quinine

March 7, 1891.

Notes and

Comments.

285

for several days. Meanwhile all the symp-
toms seemed to have abated ; when suddenly
word came to me that the boy had grown
worse. I saw him on the morning of Octo-
ber 21. His temperature was 1040 ; his
pulse 130; his respirations 30; his bowels
tympanitic, and he was very restless and
complaining of severe pain in the left jaw.
On examination I found a small, circular,
red spot on the mucous membrane. I gave
anodynes to relieve the intense pain, and
used a solution of chlorate of potash locally.
The symptoms continually grew worse,
when, on October 24, the ulceration had
grown to the size of a twenty-five cent coin,
and extended through the whole integumen-
tary surface, the lower molars becoming
loose and dropping out ; and the patient
succumbed on October 26.

I report this case on account of its rarity,
and to ascertain the possibility of its being
cancrum oris, resulting from the fever or in
any wTay the result of the mercury given in
the beginning of the case. It is my opin-
ion, and that of another physician whom I
had in consultation, that it was a genuine
case, otherwise mercurial salivation would
necessarily have occurred, which did not
obtain in this case.

Yours truly,

H. A. Alexander, M. D.

Birmingham, Ala.

Politics and Pension Examiners.

To the Editor.

Sir: I wish to enter a vigorous protest
against the sentiments expressed in an article
copied in the Reporter, February 21, 1 89 1 ,
from the Indiana Medical Journal, entitled
''Politics and Pension Examiners." The
article in question was undoubtedly written
by some red-hot opponent of the adminis-
tration, who takes this method of trying to
create a prejudice in the minds of some
members of our profession who do not take
the trouble of posting themselves in regard
to the workings of our system of govern-
ment. The journal casts truth to one side
as completely as the opponents of the ad-
ministration did in the last campaign. No
member of any Board of Pension Exami-
ners is appointed by the President of the
United States. The Commissioner of Pen-
sions, with the approval of the Secretary of
the Interior, makes all appointments of mem-
bers of Boards of Pension Examiners. The
President has nothing to do with these

appointments. If Elbert has been appointed
on the Board at Indianapolis, it was not the
fault of President Harrison, and the author
of the article in question should have known
this fact before penning such a scandalous
attack upon the man who fills the executive
chair of this great nation with so much
credit to himself- and honor to the loyal
people of these United States. The Indiana
Medical Journal d\so\a\ms> being a ''partisan
paper," but in the opinion of your corre-
spondent, in this editor] al it has descended
to the lowest depths of bitter partisanship.
It has not even kept within the limits of
truth. And the Marion County Medical
Society so far forgot its own dignity (if it
passed the resolutions quoted) as to lend it-
self as an instrument to insult the President,
and prostituted itself to base " partisan pur-
poses " as completely as any rabid, ultra
sore-headed convention of those opposed to
the administration could have done. Politics
is the Science of Government, and this sci-
ence is one of the expressions of Truth.
President Harrison has never appointed an
" incompetent negro " to any. position what-
ever. The Editor of the' Indiana Medical
journal should stick to medical topics, in-
stead of going into partisan politics, if he
wishes to retain the respect of the medical
profession outside of his narrow coterie in
Indianapolis.

Yours truly,

R. L. Moore, M. D.

Lincoln, Neb.

Notes and Comments.,

Benzin as an Antiseptic.

The Cincinnati lancet- Clinic, February
7, 1 89 1, contains an interesting article by
Dr. F. W. Langdon on the use of benzin as
an antiseptic and parasiticide. Dr. Langdon
says :

The substance to which I desire to direct
attention in the present communication is
the ordinary commercial article, obtained
in the distillation of petroleum, and em-
ployed in the arts as a cheap solvent of oily
matters, paints, etc. Partly deodorized and
re-named "rose- oil " it serves for removing
grease spots from gloves and textile fabrics.
It is known to the chemist as a hydro-carbon
of varying constitution, and has, like ail
such bodies, a marked affinity for oxygen.
It is often confounded (in ordinary reading)

286

Notes and Comments.

Vol. lxiv

with benzole or benzene, and I have, there-
fore, exhibited some of the more important
contrasts of the two bodies in tabular form:

BENZIN OR BENZINE.

Distilled from petroleum.

A mixture of hydro-car-
bons of the " marsh -
gas series."

Specific gravity, .670-

.675.
Chemical formulae :

etc., varying in exact
constitution, but within
definite limits.
Commonly used in dis-
solving oils and pig-
ments, cleaning greasy
machinery, textile fab-
rics, etc.

BENZOLE OR BENZENE.

Distilled from coal-tar.
A hydro-carbon of the
" aromatic series."

Specific gravity, .850.

Chemical formula :

C6 H4

Unvarying in constitu-
tion.

Used in dissolving gutta-
percha, India-rubber,
sulphur, phosphorus,
iodine, some resins and
alkaloids, and by mi-
croscopists for dissolv-
ing Canada balsam.

I use the above rather simple method of
contrast in preference to tables bristling
with the hieroglyphic diagrams of atomic
constitution with which modern chemistry
has familiarized ou'r eyes, if not our under-
standings. It is the substance described in
the first column of the table which forms
the subject of the present paper.

Many years since, my attention was at-
tracted to its value as a destroyer of low
forms of animal and vegetable life, and
when a boy it was my favorable application
for the destruction of the larvae of various
parasitic insects (moths and beetles) known
as " museum pests," as well as for the re-
moval of molds and other vegetable para-
sites from bird-skins and insects.

In 1880, during ray service as interne at
the Cincinnati Hospital, and since then in
private practice, it has fallen to my lot to
treat a considerable number of cases of the
skin disease known as tinea ve?sicolor. It
was the custom in the hospital to attack the
fungus, which 'is the essential element in the
disease, with various parasiticides, of which
mercuric chloride was perhaps the favorite.
Thh application (gr. iii to fgi of water) ef-
fected an apparent cure for the time being,
by destruction of the fungus on the surface,
but invariably there would be a relapse in a
few days or weeks — minute brownish spots
re-appearing in the immediate vicinity of
the hair-follicles and thence spreading and
coalescing to form the characteristic pale-
brownish patches, varying in size from a
fraction of an inch to several inches in area.

As it was evident that the relapses were due
to the re-growth of spores situated in the
depths of the hair follicles, where the watery
solutions failed to penetrate, I was led to
consider the advisability of using a more
penetrating agent, and from my experience
elsewhere in its use as a parasiticide, I se-
lected benzin for experimentation.

Selecting a well-marked case, the applica-
tion was made freely, twice a day, for three
days, of a mixture of equal parts of common
commercial benzin and tincture of green
soap. This was applied by means of a small
mop of absorbent cotton. At the same time,
as a control experiment, a second case was
treated with the bichloride solution. The
result was that the growth disappeared in
both cases, but the second case experienced
the usual relapse within a week or ten days.
The benzin mixture being now applied, a
permanent cure resulted. I have since dis-
carded the admixture of green soap as super-
fluous, sometimes diluting the benzin with a
little tincture of lavender or other aromatic.

In numerous cases, in private practice, I
have found it uniformly successful, not only
in this disease, but in the skin diseases of
mycotic origin generally, amongst which the
ordinary furuncle or "boil" belongs. In
the treatment of the latter important, if not
dangerous affection, I have found benzin of
marked value as an abortive agent, equal, at
least, to the subcutaneous injection of car-
bolic acid, without even the small amount
of pain and the slight danger of sloughing,
attending the latter method.

The efficacy of benzin in furunculosis is
easily demonstrated in that class of cases
where one boil is followed, after its rupture,
by numerous "seed boils," immediately
surrounding its site, or by successive devel-
opments of single boils in the same region
of the body. Here the prompt disinfection
of the affected area, including the depths of
the hair follicles, is a most certain method
of arresting their progress towards suppura-
tion.

The method of application is very simple.
At the first appearance of the little, hard,
painful papule, saturate a pledget of absorb-
ent cotton with the remedy and press it
firmly, but not forcibly, over the swelling,
for about half a minute. Repeat this every
hour or two for the first day, after that two
or three times a day, as the swelling and
pain subside. If suppuration has already
taken place, in ever so small an amount,
the only remedies, of course, are the knife

March 7, 1891. . Notes and

Comments.

287

or spontaneous evacuation. Even with a
small amount of pus in the original boil, its
size may be limited and the formation of
"seed boils" entirely prevented by the
prompt use of the parasiticide. Due care
should be taken to avoid the vicinity of a
fire or light while making the application.
No pain attends the application as above
described.

Benzin is also the most useful and effec-
tive application for the destruction of the
troublesome insects known as "jiggers" or
chigoes, which, in many tropical, and some
temperate countries, excite much pain and
annoyance by burrowing into and laying
their eggs in the skin. In the ordinary in-
sect, as it occurs in our Southern States, and
even in some parts of Ohio, I have found
benzin the best remedy, penetrating their
burrows and causing the death of the pests.
The troublesome itching and irritation due
to its movements are largely abated, though
a red indurated area, surrounding its loca-
tion in the tissue, will remain for some days.

Doubtless the remedy would give equally
satisfactory results in scabies, but I have
been unable to test it, for lack of clinical
material.

I would also suggest its use in trichiniasis,
as soon as possible after the ingestion of the
infected meat, since a somewhat similar
body, benzole (see table of contrasts), has
been credited with good results in this dis-
ease. As much as two drachms has been
given daily (of benzole) for from four to
six days. In another recorded case, benzole
was taken in quantity "of one or two
ounces, probably," without dangerous symp-
toms. This would seem to indicate that its
congener, benzin, in moderate doses, gss
to gi, would be safe, and a remedy worth
trying in this fearful and intractable disease.

Finally, the value of benzin as a solvent
of oily secretions should not be forgotten in
the preparation of skin areas for antiseptic
operations. An agent that can penetrate
and disinfect the pores and hair-follicles of
the region to be operated upon, has advan-
tages not possessed by any of the watery so-
lutions in common use.

To summarize, we have in common com-
mercial benzin an agent which is cheap,
unirritating to the skin, not injuring or stain-
ing the finest fabrics, convenient of appli-
cation, and possessing a wide range of use-
fulness as a parasiticide and anti-mycotic ;
its action being greatly aided by its solvent
power over oily secretions, by reason of

which the chief protection of the parasites
is removed.

How it acts, I shall not attempt to explain,
further than to note that its marked affinity
for oxygen may be the key to its modus op-
erandi as a parasiticide. Ignored by physi-
cians generally, though found in every drug
store at ten cents per gallon, and possessing
a chemical ancestry (marsh-gas) identical
with that of numerous remedies in common
use, e. g., ether, chloroform, iodoform, ani-
lin, antifebrin, antipyrin, rhigolene, carbolic
acid, etc., its non-use would seem to furnish
another example of the truth of the adage,
"Familiarity breeds contempt."

Sublimate Spray for Small-Pox
Vesicles.

Dr. Talamon, in an article in the Gazetta
medica Lombarda, 1890, of which an ab-
stract appears in the Journal of Cutaneous
and Venereal Diseases, February, 1 891, says
that, discouraged by the negative results
which he had obtained in the treatment of
small-pox patients with numerous internal
medications which have been recommended
and employed successively by a large number
of physicians, he confined himself exclu-
sively to the external and local treatment of
the pustules. He tried spraying them with
tannin, salol, iodoform and sublimate solu-
tions. The use of internal remedies being,
up to now, unable to cope with the germ of
variola, he thought that by means of local
antiseptics he might be capable of acting
upon the microbes of suppuration, which
cause destruction of the derma, and by a
convenient modification of Lister's proce-
dure abort the greater portion of the pustule
by keeping its surface under the influence of
an antiseptic.

The tannin sprayings were made with a
solution containing one gram of tannin
to ten grams of a mixture of equal parts
of alcohol, ether and water. The tannin
forms a varnish which compresses, flattens
and drys the pustules, but at the same time
it also produces a tension of the face of ex-
treme painfulness, and analogous to that fol-
lowing the application of collodion. The use
of a fifty per cent, ethereal solution of salol,
sprayed on three or four times a day, calmed
the pains, and was agreeable to the patient
on account of the agreeable odor of the
medicine. It was only found useful in the
lighter forms of the disease. Its effects are
nearly nothing in the coherent and confluent

288

Notes and

Comments.

Vol. lxiv

forms, where the suppurative inflammation
of the derma is more deeply situated. Io-
doform as a fifty per cent, ethereal spray and
used under the same conditions gave more
satisfactory results than the salol, but less so
than the use of the sublimate solution, but
the disagreeable odor of iodoform rendered
its employment offensive to the patient. The
sublimate solution was prepared after the
following formula :

Corrosive sublimate Lgm.

Tartaric acid I gm.

Alcohol (90 per cent.) 5 c. cm.

Ether to make 50 c. cm.

This was applied as a spray three or four
times daily ; its use should not be continued
too long, for it may produce a painful vesi-
cation in the form of long streaks. The in-
dividual's susceptibility to the irritant action
of sublimate varies very much. In general
a spraying of one minute is sufficient in
skilled hands ; the skin is seen to become
whitish in color, which change also extends
to the pustule. This coloration is due to a
deposit of sublimate, and is the result which
the procedure should yield. When, how-
ever, the skin is covered by pustules scat-
tered with long interspaces, salol may be
employed in order to prevent the action of
sublimate upon the points not covered by
pustules. Contact with sublimate is well
tolerated ; patients only complain of a sen-
sation of heat, which is accompanied by a
redness of the skin, more or less vivid.
The writer has never observed any signs of
mercurialism, which seems to indicate that
the mercury is not absorbed, but only acts
on the superficial layers of the derma. Dur-
ing the procedure it is necessary to take the
precaution to protect the eyes by covering
them by layers of cotton dipped into a sat-
urated boric-acid solution. The application
of the sublimate spray does not completely
prevent the formation of pits, but they re-
markably diminish in number and depth.
It is best to commence on the first day of
the eruption, after a vigorous washing of the
face with soap, which may be rinsed off with
boric acid and dried with absorbent cotton.
If one commence on the third day of the
eruption the use of soap will then be unne-
cessary. After the spray has been used the
face should be covered with a layer of a
fifty per cent, glycerolate of sublimate in
order to keep the skin continuously antiseptic
and free from outside germs. After the
fourth day only two sprayings are neces-

sary, but the glycerolate should be applied
the same. At the end of the sixth or on
the seventh day the use of the spray may be
left off and the glycerolate used alone. As
soon as the crusts separate the glycerolate
may be substituted for the sublimate-spray,
in connection with borated vaselin or salol.
Dr. Talamon combined, in the coherent,
confluent and grave forms of the disease,
general sublimate-baths, prolonging their
use for three-quarters of an hour to an
hour; these, however, did not seem to have
any well-marked acticTa on the pustules situ-
ated upon the body. Still, those patients
who were thus treated seemed. to be less sub-
ject to the after-complications of convales-
cence so frequently seen. Finally, the buc-
cal and pharyngeal eruption was treated by
borated gargles and lotions.

This medication is absolutely powerless
against the most severe forms — that is, the
very confluent and hemorrhagic types.

Internally the therapy was limited to sus-
taining the strength of the patient by means
of alcohol in doses of one hundred to two
hundred and fifty grams daily, according
to the gravity of the case. The quantity of
alcohol to be consumed by the patient is in-
creased by addition of water up to one litre ;
this mixture may be given continuously in
broken doses.

Removal of the Gasserian Ganglion.

On Thursday, January 29, Mr. Rose
operated for the removal of the Gasserian
ganglion in the theatre of King's College
Hospital. The patient was a female aged
sixty, under the care of Dr. Ferrier, who
had suffered for many years from severe neu-
ralgia affecting chiefly the superior maxillary
nerve on the right side. Chloroform was
given, and after stitching the eyelids to-
gether on that side in order to avoid any
accidental injury to the eye, a flap of skin
was dissected forward, the zygoma was ex-
posed, and, after openings had been drilled
With an electro-motor, divided and drawn
down with the masseter muscle. The coro-
noid process of the lower jaw was next
drilled and divided in a similar manner,
and turned up with the temporal muscle at-
tached. The external pterygoid muscle was
then cut through and the foramen ovale
reached, into which the pin of a half-inch
trephine was inserted, and a disc of bone
surrounding it in this way removed. The
bleeding was troublesome, and persisted for

March 7, 1891. Notes and

Comments.

289

some time. The ganglion was seized by
some specially constructed hooks, one of
which had a cutting edge upon its concave
surface ; by means of these its attachments
were loosened and divided. Bi-chloride of
mercury solution (i in 3,000) was used dur-
ing the operation. The bones which had
been sawn were replaced and secured in po-
sition by wire sutures passed through the drill
•holes previously made, and a drainage-tube
inserted. Cyanide gauze dressing was ap-
plied. The electric illuminator was found
most useful during the deeper dissections.
The patient has progressed most satisfac-
torily since the operation, having had no
return of the neuralgic pain, although it is im-
possible to say at present that the whole of
the ganglion was removed. The sutures were
removed from the eyelids on the third day ;
the eye was healthy, but the conjunctiva in-
sensitive. We hope to. publish fuller details
of this important case later. The operation
which was witnessed by a large number of
members of the profession and students,
occupied about an hour and a half in its
performance. We are glad to be able to
state that the patient on whom Mr. Rose
performed the first operation for the removal
of the Gasserian ganglion in April last by a
different method continues free from pain
and is in good health. — Lancet, February 7,
1891.

Impure Drugs.

The Medical Record, January 31, 1891,
says editorially : The last report of the New
York State Board of Health shows that, while
the sale of impure drugs is decreasing, it is yet
lamentably large. During the year 1889,
807 samples of drugs were bought in the
larger towns and cities of the State (except-
ing New York and Brooklyn) and subjected
to analysis. The results are startling.
Only 410 samples (50.8 per cent.) were up
to the pharmacopoeial standard, while 330
of the samples (40.8 per cent.) were totally
deficient, by being either falsified, adulter-
ated, decomposed, too strong, or too weak.
The remaining 67 samples were of " fair
quality. ' ' In some details the results of the
analysis were as follows : Dilute acetic acid,
40 samples examined ; 9 good, 6 fair, 19
inferior, and 6 of excessive strength ; this is
of unusual importance because of its use in
the manufacture of spirits of Mindererus.
Dilute nitric acid, 4 samples : 1 good, 3 ex-
cessive strength. Dilute sulphuric acid, 53

samples : 9 excessive strength. Hydrobro-
mic acid, 38 samples : 6 inferior and 6 exces-
sive strength. Saffron, 20 samples : 2 good,
1 fair, 17 inferior. Compound spirits of
ether (Hoffman's anodyne), 47 samples : 4
good, 4 fair, and 39 inferior. Strong ether,
66 samples: 40 good, 4 fair, and 22
inferior. Precipitated sulphur, 25 sam-
ples : 6 good, 2 inferior, 1 7 inferior. Be-
sides these, inferior samples of oxalate of
cerium, chloral and chloroform were found.
115 samples of cream of tartar were bought
at grocery stores, and of these only 30 were
good preparations, 6 being fair, and 79
"clearly adulterated or falsified." Also
there were examined 275 samples of alkaloi-
dal preparations, including sulphate of qui-
nine, citrate of iron and quinine, sulphate
of morphine, and tincture of opium. Of
these 177 were good, 13 of fair quality only,
and 85, or 30 per cent., were " unreasonably
deficient."

The object of the work is not so much to
determine the proportion of adulterated to
pure drugs on the market as to expose actual
adulteration, sophistication and careless-
ness ; to inform the public and to caution
dealers. Consequently a great variety of
drugs was not purchased, and only those
were chosen that were likely to be adulter-
ated. But though the frightful showing of
the figures above does not represent the ac-
tual proportion of impure drugs sold, it
shows the deplorable chance to which a phy-
sician in prescribing is subjected. One in-
clined to be facetious might remark, that,
what with the difficulty of making a correct
diagnosis, the furore and trouble the germs
are creating, the chance of getting impure
medicine, and the awful weather, it is a won-
der that any of our patients live.

The practical value of these analyses
comes from the fact that notices are sent
to dealers from whom impure drugs are
bought, notifying them of the impurities.
Rarely does a second notice have to be sent
and the standard of preparations is being
gradually raised to that of the Pharmaco-
poeia. The law is adequate to its purposes.
It simply needs enforcement. After one or
two or three warnings the penalties laid
down should be applied. In the examina-
tion of alkaloidal preparations the bulk of
attention was very properly paid to quinine
preparations, as the report states that some
druggists sell as many as two hundred thou-
sand two-grain pills annually, and that
fifty thousand is the estimate made of the

290

Notes and

Comments.

Vol. lxiv

avarage number sold by a druggist doing an
ordinary business.

Medical Society of the State of Penn-
sylvania.

The forty-first annual meeting of the Med-
ical Society of the State of Pennsylvania
will be held in Reading, on Tuesday,
Wednesday, Thursday and Friday, June
2-5, 1891.

The appointments for 189 1 are, 1. Ad-
dress on Practice of Medicine, Dr. J. Chris.
Lange, Pittsburgh ; 2. Address on Surgery,
Dr. O. H. Allis, Philadelphia; 3. Address
on Obstetrics, Dr. J. Milton Duff, Pittsburgh;
4. Address on Mental Disorders, Dr. Sam-
uel Ayres, Pittsburgh; 5. Address on Oph-
thalmology, Dr. J. A. Lippincott, Pitts-
burgh; 6. Address on Hygiene, Dr. A. B.
Brumbaugh, Huntingdon.

The report of the Committee on the Re-
vision of the Constitution, Dr. W. M. Welch,
Chairman ; and the report of the Commit-
tee on Incorporation, Dr. C. W. Dulles,
Chairmajt, are to be acted upon.

The Chairman of Committee of Arrange-
ments is Dr. Samuel L. Kurtz, Reading, to
whom all applications to read papers at this
session should be sent not later than April 1.

Secretaries t>f County Medical Societies
are earnestly requested to forward at once
complete lists of their officers and members,
giving the post-office address of each.

Every delegate, before admission, shall
present a certificate of delegation signed by
the President or Secretary of his County
Society.

Every permanent member (not a dele-
gate), before admission, shall present a cer-
tificate of good standing in his County So-
ciety.

Railroad facilities will be announced
when obtained. All who desire excursion
orders should notify the Permanent Secre-
tary, Dr. Wm. B. Atkinson, Philadelphia,
stating what railroad must be used.

Warren Triennial Prize.

The Warren Triennial Prize was founded
by the late Dr. J. Mason Warren in mem-
ory of his father, and his will provides that
the accumulated interest of the fund shall
be awarded every three years to the best dis-
sertation, considered worthy of a premium,
on some subject in physiology, surgery or
pathological anatomy, the arbitrators being

the physicians and surgeons of the Massa-
chusetts General Hospital. The subject for
competition for the year 1892 is On Some
Special Subject in Physiology, Surgery or
Pathology. Dissertations must be legibly
written, and must be suitably bound so as
to be easily handled. The name of the
writer must be inclosed in a sealed envelope,
on which must be written a motto corre-
sponding with one on the accompanying dis-
sertation. Any clew given by the disserta-
tion, or any action on the part of the writer,
which reveals his name before the award
of the prize, will disqualify him from receiv-
ing the same. The amount of the prize for
the year 1892 will be $500. In case no dis-
sertation is considered sufficiently meritori-
ous, no award will be made. A high value
will be placed on original work.

Prevention of Narcotic Inebriety.

At a meeting of the American Associa-
tion for the Cure of Inebriety, held Feb. 18,
at the Academy of Medicine, New York,
Dr. J. B. Mattison, of Brooklyn, offered the
following preamble and resolutions:

Whereas, a leading cause of Morphinism,
Chloralism and Cocainism is the facility with
which morphine, chloral and cocaine- can
be procured from pharmacists : and,

Whereas, the refilling of prescriptions
containing these drugs is a potent factor
in the rise and growth of these diseases :

Therefore, be it resolved, as the sense of
this Association, that no retail druggist
should sell morphine, chloral or cocaine,
except on a physician's prescription, and
that no prescription containing morphine,
chloral or cocaine should be refilled except
on the written order, of a physician.

These resolutions were unanimously adopt-
ed, and a committee consisting of Drs.
Mattison, Crothers and Wright was ap-
pointed to secure legislation along the line of
the resolutions.

Pyoktanin Stains.

Merck's Bulletin says that stains with
pyoktanin may be removed from the hands
by washing with spiritus saponatus, or with
a ten per cent, solution of castile soap in
alcohol, or with liqupr sodse chlorinatae.
Pyoktanin pencils, when broken, are mended
by simply wetting the severed surfaces with
water, and pressing them together gently ;
when dry they will cohere.

*1

96<

Medical and surgical
Reporter

A Weekly Journal.

Established in 1853 by S. W. Butler, M. D

CHARLES W. DULLES, M. D., Editor and Publisher,

Entered as Second-Class matter at Philadelphia P. O N. E. COR. 13th & WALNUT STS., PHILADELPHIA

Vol. LXIV, No. 10.
Whole No. 1775.

MARCH 14, 1891

$5.00 per Annum.
10 Cents a Copy.

COZEsTTZETSTTS :

CLINICAL LECTURE.

Pepper, William, M. D., Philadelphia, Pa.— Jaun-
dice Following the Passage of Biliary Calculi.—

Jaundice from Angeiocholitis 291

COMMUNICATIONS.

Hunt, William, M. D., Philadelphia, Pa.— A View
of Koch's Remedy for Tuberculosis 295

Ward, Aaron C, M. D., Newark, N. J. — Veratrum
Viride 297

Free, James E., M. D., Billings, Montana. — Puer-
peral Pneumonia 302

Neall, C. H. M., M. D., D. D. S., Philadelphia.—

Neuralgia from Tooth-Pressure • 304

PERISCOPE.

Dangers of Syringing the Ear.— The Revival of
Venesection.— Beri-Beri.— Chloroform in Trach-
eotomy.— Hyperemesis and its Treatment with
Creosote.— Chromic Acid in Habitual Epistaxis.

—Fissured Nipples 304-308

EDITORIALS.

Concealed Advertisements in Medical Jour-
nals r. ?. 309

Filaria Sanguinis Hominis 310

Digestjpn for Abscess Cavities 311

BOOK REVIEWS.

Penzoldt; Lehrbuch der Klinischen Arzneibe-
Handlnng.— Text- Book of Clinical Therapeu-
tics.—CEuvres Completes de J. M. Charcot.— Com-
plete Works of J. M, Charcot 311-312

NOTES AND COMMENTS.

Congenital Occlusion of the Urethra.— Medical
and Social Aspects of Abortion.— Country Prac-
tice.—New Method of Detecting Tubercle Ba-
cilli.—Trained Nurses.— Control of Sources of
Water Supply.— Parasitic Chylocele in New Or-
leans.—Relationship of the Diseases of Animals
to those of Man.— Infectiousness of Croupous
Pneumonia.— Hemoglobinuria from the Use of
Quinine 312-318

RESOLUTION „

AS THE YEAR IS PARTLY GONE

the dated POCKET RECORDS FOR 1891
which are still on hand

WILL BE SOLD

FOR 50 CENTS EACH

to paid-up Subscribers, or to those who now remit for a
year's Subscription.

MEDICAL AND SURGICAL REPORTER,

P. O. Box 843, Philadelphia.

RELIEF FROM PAIN

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Can be obtained for your patient, by administering

& Bromidia (Battle) 1 ounce.
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Mix. Sig :— One teaspoonf ul, repeated as required.

m~ The above formula is largely used by European and
American physicians, and UNIVERSALLY gives entire satis-
faction, WHEN the Genuine Products of the Laboratory of
the well-known House of Battle & Co, are used.

Burn Brae

A PRIVATE HOSPITAL

FOR MENTAL** NERVOUS
DISEASES.

Founded by the late Robert A. Given,
M. D., in 1859.

Extensive and beautiful grounds. Perfect privacy. A pleasant, safe and healthful
home. Music, games, open-air amusements, The oldest institution of the kind in the
United States. Both sexes received.

ARRANGEMENTS MADE FOR CHRONIC CASES.

Located a few miles west of Philadelphia, at Primos Station, on the P. W. & B. Railroad.

REFERENCES:

Professors H. C. Wood, D. Hayes Agnew, Win. Pepper. Alfred Stille, William Goodell, Roberts Bartholow,
R. A. F. Penrose, J. M. DaCosta, Charles K. Mills, James Tyson, and Dr. Lawrence Turnbull ; Professor Wil-
liam Osier, of Johns Hopkins University; W. C. Van Bibber, M. D., Baltimore, Md.; W. W. Lassiter, M. D.,
Petersburg, Va.

Resident Physicians: J. WILLOUGHBY PHILLIPS, M. D., S. A. MERCER GIVEN, M. D.

For further information address

BURN BRAE, Clifton Heights, Delaware Co.. Pa.

MEDICAL AND SURGICAL
REPORTER

No. 1776. PHILADELPHIA, MARCH 14, 1891. Vol. LX1V.— No. ii.

Clinical Lecture.

JAUNDICE FOLLOWING THE PAS-
SAGE OF BILIARY CALCULI.—
JAUNDICE FROM ANGEIO-
CHOL1TIS.1

BY WILLIAM PEPPER, M. D.,

PROVOST, AND PROFESSOR OF THE THEORY AND
PRACTICE OF MEDICINE AND OF CLINICAL MEDI-
CINE IN THE UNIVERSITY OF PENNSYLVANIA.

Gentlemen : In anticipation of the dis-
cussion of hepatic disorders, which I shall
make in a systematic way within a short
time, I shall, to-day, call attention to some
clinical illustrations of common affections
of the liver.

This man, 60 years of age, was admitted
to the hospital, October 28, four days ago.
He has always been strong and healthy and
temperate in his habits. He had syphilis
20 years ago, but did not have severe con-
stitutional symptoms. For some years, he
has had occasional pain in the region of the
liver, but not marked enough to greatly
inconvenience him. These pains were never
followed by jaundice. His present illness
began October 14, with severe pain in the
pit of the stomach, where it remained fixed
and was controlled only by the hypodermic
use of morphia. Three days later he was
found to be deeply jaundiced. Whether or
not the jaundice began before this time can-
not be stated. The pain continued for about
four days. The bowels were costive at first,
but since taking elaterium, they have been
loose. There is tenderness in the epigas-
trium. The urine contained no albumin or
casts and on October 31, it was amber clear.
It is now more than two weeks since the at-
tack, but yet he is still distinctly jaundiced.
As you observe the skin of the entire body

Delivered at the University Hospital.

is yellow, although not deeply jaundiced.
Probably, the best places to determine the
existence of jaundice, so far as the skin is
concerned, are about the chest, the epigas-
trium and the palms of the hands.

Let 'us now determine the cause of the
jaundice in this patient, where I hope it may
be readily arrived at. It is difficult to say
how much importance is to be attached to
these vague pains that have been mentioned
as occurring more or less for some years.
People often complain of pains about this
region. They may have been rheumatic,
but the last spell of pain was almost cer-
tainly dependent upon the passage of gall-
stones. It is true that the pain was fixed at
the epigastrium and that it did not extend
up towards the right shoulder or through to
the back, as the pain often does during the
passage of gall-stones. It is, however, by
no means constant that the pain of gall-
stones extends in this way. It may be in
the epigastrium, more commonly over the
gall-bladder, and it may remain fixed in one
place, although it is more common for it to
extend upward and through to the back. I
have repeatedly seen the pain connected
with gall-stones referred to the epigastric
region and remain there, as in this case.
There is usually tenderness over the gall-
bladder and about the position of the gall-
duct. This tenderness may last for some
time, as in the present case. It is readily
explained by the irritation of the gall-ducts
due to the passage of a rough or sharp-
edged stone through the canal. Here are
some specimens of average-sized gall-stones.
Even one as small as the smallest of these
with sharp edges, would set up inflamma-
tion of the gall-duct and account for the
tenderness which we find. I call particular
attention to this point as it has a bearing
upon the diagnosis between gall-stones and
simple catarrhal inflammation of the gall-
duct. Very often at the time of the pas-
sage of the gall-stones there is vomiting.

291

292

Clinical

Lecture.

Vol. lxiv

But in this case, the man vomited only
once and that was on the day following the
severe pain. Usually, the bowels are con-
stipated at the time and afterwards, and this
is partly the effect of the pain and partly the
effect of the sedatives given to relieve the
pain, for usually powerful opiates are re-
quired, and these, of course, tend to pro-
duce constipation. The severe pain may
last for an hour, or for several hours, or until
it is controlled by an opiate. In fact, the
pain may last for several days, as in this case.
Immediately after the relief of the pain,
jaundice is observed, or where the pain has
continued for some time, jaundice may come
on while the pain is still present. The pain
sometimes stops abruptly, the little stone
having forced its way through the duct and
slipping into the duodenum ; but you must
not expect in all cases to find this abrupt
ending of the pain. It often gradually sub-
sides, but oftener the way in which it ends is
masked by the fact that the patient has had
a hypodermic injection of morphia or a
suppository of opium or large doses of
opium by the mouth, so that the way in
which the pain ends is not known.

The jaundice is general. The mucous
membranes and the skin are deeply stained.
It is associated with the presence of biliary
coloring matter in the urine. The move-
ments of the bowels which follow the pas-
sage of a gall-stone are very light in color.
Sometimes the stoppage is so brief that the
bile enters the bowel again and mixes with
the feces and there are no clay-colored
stools. If the stoppage is longer, the feces
will be pale. Often it happens, as in this
case, that the patient has no opportunity to
observe the character of the stools.

We note, then, as the symptoms of the pas-
sage of gall-stones, severe pain in the region
of the liver, often extending to the shoulder
and accompanied or followed by tenderness
on pressure and usually vomiting. The
pain comes on abruptly and may end ab-
ruptly, but often ends more gradually, or
its disappearance is masked by the opiate.
Jaundice comes on immediately after the
pain, and sometimes while the pain is still
present, if this lasts for a day or two. The
attack is not attended with fever, but fever
may follow as a result of the inflammation
of the duct caused by the irritation of the
gall-stone. The attack is usually not pre-
ceded by evidences of gastro -intestinal
catarrh. There has not been a spell of
diarrhoea or signs of gastric irritation. Of

course, these may exist ; but in the majority
of cases they will not be found. This
point is of importance in the diagnosis be-
tween gall-stone and catarrhal hepatitis with
spasm. The only way in which the diag-
nosis of gall-stone can be positively verified
is by searching the feces after the attack.
The next or the two next stools should be
secured, tepid water should be poured upon
the fecal mass, which should be stirred with
the whisk of a broom and then passed
through a sieve, so that if any of these
little stones are present they will be found.
The failure to find gall-stones is not posi-
tive proof that there are none. The stone
may have been broken up or disintegrated,
or it may have become lodged in some
pocket of the colon and not be discharged
until some time after the attack. In the
majority of cases, however, you will find it
in the first or the second stool following the
spell. The jaundice will last for a varying
length of time according to the duration of
the obstruction in the duct. If the stone has
been large and has taken a long time to go
through, the jaundice may last for ten days.
If the stone has been small, the jaundice
may pass away in a day or two. It also de-
pends upon the amount of damage to the
duct. If the duct is much irritated and in-
flamed and is swollen, jaundice may con-
tinue for several weeks, dependent not upon
the gall-stone but upon the destructive in-
flammation of the gall-duct. This man has
jaundice lasting rather long. It is now
seventeen days since the attack and he is
still jaundiced and there is distinct tender-
ness over the gall-duct. I take it that this
is due to swelling of the mucous membrane
partially closing the duct.

The diagnosis of gall-stone is usually easy.
I do not know what it could be confounded
with. Not with renal colic : for there the
pain is in the back, running into the geni-
tals with retraction of the testicle and fre-
quent desire to pass urine. The urine is
affected, often bloody and no jaundice fol-
lows. Sometimes gall-stones pass and no
jaundice follows. I have not rarely noticed
that — a sharp spell of pain and gall-stone
found in the feces and yet no jaundice, be-
cause the stoppage was too short to permit
resorption of enough bile to stain the skin,
or because the stone was so small that there
was not complete occlusion of the duct. In
these cases you may be thrown off the track
as the spells of pain may resemble gastralgia.
I would advise you, therefore, if you have

March' 14, 1891. Clinical

Lecture.

293

paroxysmal pains that seem obscure, to have
the feces carefully searched, tl have found
gall-stones even where there was no trace of
jaundice. Sometimes I have secured as many
.as six or eight calculi.

I shall not to-day dwell upon the treat-
ment of gall-stones. The most important
part is prevention. Where you know that
a gall-stone has been passed, you are anxious
to prevent the formation of others. I wish
to emphasize particularly the importance of
getting the mucous membrane of the gall-
bladder and duct in as healthy a state as
possible. A gall-stone passing through the
duct will injure and inflame it ; thus a gall-
stone may lead to inflammation of the duct;
but on the other hand, inflammation of the
duct may lead to the formation of gall-
stones. The mucous membrane, being in a
state of catarrh and more or less swollen,
interferes with the free flow of bile, which
remains in the gall-bladder, causing its dis-
tention, and thus the flow of bile is slow.
The branches of the biliary duct have their
lining thickened and there is a tendency for
the bile throughout the liver to be retarded
in its flow. This slow flowing bile becomes
thick and there is a tendency to the deposi-
tion of the biliary salts or biliary coloring
matter. As a result of the inflammation of
the mucous membrane, little flakes or shreds
of mucus are formed, and may constitute a
nucleus which at once becomes encrusted
with biliary salts and coloring matter, and
we have the beginning of a calculus. I have
no question that in many cases the formation
of gall-stones is invited and favored by the
presence of catarrhal inflammation of the
lining membrane of the gall-bladder and
duct. Therefore, in order to prevent the
formation of other calculi, it is important to
have the condition of the mucous membrane
as nearly healthy as possible. For this rea-
son I like continued counter-irritation over
this region. In this case I shall apply a
series of small blisters, an inch and a half in
diameter, repeating them at intervals of six
or seven days. The man will be kept quiet,
with light diet and a mild saline to keep the
bile free and thin. At the moment of the
attack you have to relieve the intense pain.
The best agents for this purpose are morphia
and atropia hypodermically. Chlorodyne
by the mouth is useful; but as there is some-
times vomiting it is not so prompt as the
subcutaneous injection. Suppositories are
too slow. Frequently one hypodermic in-
jection of a quarter of a grain of morphia

with a one-hundredth of a grain of atropia
will lull the pain, and before the effect is
over the stone has passed. If necessary, the
injection can be repeated. If the attack is
over soon, there is no seriousness about it.
The patient should be kept quiet until the
jaundice has passed away. Then preventive
treatment, to relieve the irritation of the
mucous membrane and to get the bile to
flow freely, should be instituted. In the
present case I shall give the man, in addi-
tion to a small amount of Rochelle salts
morning and evening, a pill three times a
day containing :

R Argenti nitratis gr. \

Ex. opii

Ex. belladonnse . . . . . . . . aa gr.

Jaundice from Angeiocholitis.

I shall now call attention to a young
woman who came to me some weeks ago,
and whom I sent here to watch her case
carefully. She was induced to come because
of the great improvement which followed in
the case of a friend of hers, who came here
with terrible jaundice, emaciated to a skele-
ton, and with a history of repeated spells of
pain with deeper and deeper jaundice. The
spells were also attended with fever and great
soreness in the region of the gall-bladder.
That woman was kept here for a long time.
The diagnosis made was: obstructive inflam-
mation of the gall-duct. We never found
any calculi, although we searched for them
frequently. I cannot assert that the gall-
bladder is not full and practically obliter-
ated, the pain having stopped because the
stones are fixed. It may have been that the
stones were too large to pass through the
gall-duct ; but one might enter and produce
spasm and severe pain with jaundice, and
then slip out. After remaining here some
time, the woman got well and the skin be-
came perfectly clear. In that case recovery
took place because we cured the condition
of the gall-duct.

This patient gives us the following history.
She was admitted to the hospital two months
ago. She has been married four years, and
has had four miscarriages, but no living
child. She was always healthy and could do
the hardest kind of work until after her mar-
riage at the age of 21. Within eighteen
months after marriage she had three mis-
carriages, which she attributes to hard work.
There is no history of venereal trouble. She
has never had any symptoms, and her hus-
band is said to be a strong and healthy man.

294

Clinical Lecture.

Vol. lxiv

Two years ago last March she had her last
miscarriage, which she attributes to cold
taken during " the blizzard." She has not
been well since. She had rheumatism four
years ago and measles in February of this
year. There is no family history of import-
ance. The present illness began in March,
1888, with her last miscarriage. It began
with a sense of distress in the hypochondriac
region and between the shoulders. In June
she began to vomit. Menstruation was
scanty. She had a spell of vomiting lasting
three days, and after that, every month from
June to December she had an attack of vom-
iting for three or four days regularly at the
time of menstruation. The vomiting partly
took the place of the menstrual discharge,
but not entirely. After December the peri-
odic vomiting occurred every two weeks, and
now menstruation stopped until April, 1889.
Then she menstruated. It again stopped in
June, and did not return until November.
While she had the menses regularly the
vomiting was less and occurred only at the
monthly period. When the vomiting spells
came close together and were severe, the
menses disappeared. In June, 1890, she
again missed the monthly sickness, which
has not returned. She has vomited nearly
every day during the past summer, mostly in
the morning. She does not raise much, but
has straining and gagging. Sometimes the
matters vomited are coated with a little
blood. In March, 1889, she began to have
pain in the region of the liver, which has
continued. It occurred over the gall-blad-
der and extended through the abdomen to
the right shoulder. The jaundice has never
left her. The skin is deeply stained all over
the body. The urine is loaded with biliary
coloring matter. She has had more or less
diarrhoea since June, 1889, amounting to
four or five movements a day, thin and of a
whitish color. Her usual weight is 172
pounds, which is now reduced to 105
pounds.

Here then we have a history of periodic
vomiting with marked evidences of intesti-
nal catarrh, lasting since June, 1889, with
severe jaundice beginning in March, 1889,
and continuing until the present time. You
will find nothing more difficult than to make
an exact diagnosis in such cases as this. The
points which strike one most forcibly are, in
the first place, the protracted catarrhal irri-
tation of the gastro-intestinal mucous mem-
brane. I do not see how we can shut our
eyes to that as the most prominent feature,

where you have such a history. It is ex-
tremely probable that the inflammation has
extended from the intestine to the bile-ducts,
and caused catarrhal thickening and ob-
struction of these ducts and consequent
jaundice. This we term catarrhal jaundice.
The jaundice is the result of angeiocholitis
or inflammation of the biliary vessels of the
liver. I have already stated that you cannot
assert that there are no gall-stones. In an-
geiocholitis the obstruction to the flow of the
bile permits the formation of gall-stones,
which may be shut up in the gall-bladder or
may have come out from time to time. In
this case we have not had any spells of pain
indicating the passage of gall-stones. The
woman has had continuous, not paroxysmal
pain. For twenty months, she has had con-
tinuous pain in the region of the gall-blad-
der. There have also been cutting and
knife-like pains at irregular intervals. The
pain has never been severe enough to re-
quire the hypodermic use of morphia. There
has been no great amount of fluctuation in
the jaundice. She has been jaundiced con-
tinually. All of this points to the existence
of some fixed lesion about the liver, and
whether there be gall-stones mixed with it
or not, it cannot be gall-stones only, unless
it is a large gall-stone impacted somewhere.
A large gall-stone entering the cystic duct
between the gall-bladder and the hepatic
duct and being impacted there could give
rise to such symptoms as we have here. Usu-
ally, however, a gall-stone lodged in that
position sets up inflammation and causes ul-
ceration with fever, rigors and sweat. The
ulceration advances until the patient dies
from exaustion or the gall-stone passes by
ulceration into the duodenum and the pa-
tient gets well. I have watched many cases
where the stone has thus slowly advanced
by ulceration until the cystic, duct is oblit-
erated, and the stone enters the common duct
and this is obliterated, and it passes into the
duodenum, with the recovery of the patient
and the finding of a large stone in the feces.
A large stone in the cystic duct which has not
set up inflammation might account for the
symptoms. There has not been much fever in
this case. Lately there has been a temperature
of 10 1°; but the course of the case has not
been marked by much fever.

Turning now to a physicial examination
of the abdomen, I find that the edge of the
liver extends three inches below the margin
of the ribs, showing that the organ is greatly
enlarged. The surface of the liver is quite

March 14, 1891. Communications.

295

smooth, the edge is thin and sharp and at
most the surface is slightly granular. There
are no tumors. I tried to find the gall-
bladder, but cannot discover it.

What I suppose has happened here is that
this woman, broken down by hard work and
repeated miscarriages, the nature of which
we do not know, had a violent gastrointes-
tinal catarrh and the inflammation has ex-
tended into the bile-ducts and set up angeio-
cholitis with obstruction, preventing the es-
cape of the bile. This obstruction has been
almost complete. Then the inflammation
has extended from the mucous lining of the
gall-duct to the peri-vascular connective tis-
sue, setting up that type of cirrhosis which
is known as peri-vascular or hypertropic cir-
rhosis. Around these dilated and chronic-
ally inflamed ducts we have thickening of
the tissue of the liver.

The liver is uniformly enlarged. There
is no reason here to do a laparotomy. One
of the points that we have to settle in refer-
ence to a case of this kind is whether or not
there is an impacted stone which should
be removed with the knife. We have de-
cided against laparotomy because the evi-
dences of stone are not great enough ; while
the evidence that it is a case of this type of
cirrhosis with chronic inflammation of the
gall-duct is very strong. If that is the case,
I cannot help thinking that this woman
should get well.

I need not say that the question of cancer
comes up in every case of this kind. I
think the fact that the disease has lasted so
long, and the fact that there is no distinct
mass and that' there is more or less fever,
with the youth of the patient, would serve to
exclude malignant disease. In older people
it often is a difficult question to set cancer
aside.

Crystal Coating for Wood or Paper. —
Mix a very concentrated cold solution of salt
with dextrin and lay the thinnest coating of
the fluid on the surface to be covered by
means of a broad, soft brush. After drying,
the surface has a beautiful mother-of-pearl
coating, which, in consequence of the dex-
trin, adheres firmly to. paper and wood. The
coating may be made adhesive to glass by
doing it over with an alcoholic shellac solu-
tion. The following salts are mentioned as
adapted to produce the most beautiful crys-
talline coating — viz., sulphate of magnesia,
acetate of soda and sulphate of tin.

Communications.

A VIEW OF KOCH'S REMEDY FOR
TUBERCULOSIS.1

BY WILLIAM HUNT, M. D.,

SURGEON TO THE PENNSYLVANIA HOSPITAL.

It is now time for me to speak briefly of
the great medical event of the past year,
which has attracted the attention and the
hopes of the world at large, as well as of the
profession of medicine and surgery.

Singularly enough, in January, 1883, it
fell to my lot to give the annual oration be-
fore the Philadelphia Academy of Surgery.
In that oration, the orator is expected also
to notice what has occurred of interest to
surgery during the preceding year. Koch
announced his discovery of the bacillus tu-
berculosis in 1882, and that it was the cause
of consumption and other tuberculous dis-
eases. The announcement attracted as great
professional interest as the one of 1890; but
of course it did not create such a public
furore as this one, because naturally the
public are not interested to any extent in
the science of medicine, but they are in-
tensely interested in the cure of disease. It
was a notable occasion in 1883, because we
nad, besides the oration, a microscopic ex-
hibition of micro-organisms, among which
were two or three slides (I think obtained
by Dr. Formad) containing the bacillus tu-
berculosis. These were the first seen in this
city and among the first in the country, and,
of course, attracted much attention.

Now it becomes my duty to notice the
startling announcement of the same inde-
fatigable bacteriologist, that he has discov-
ered a method of destroying tuberculosis
tissue in situ and of thus preventing the
ravages of the most potent enemy of human
life known to mankind. Is it any wonder
that such an announcement was received
with profound astonishment, and on the
part of all with the most respectful, and, I
might say, with the most reverential regard?
Berlin was the centre of attraction, Koch
the object of honor. We all know how the
representatives of science and the victims of
sickness flocked to that city.

It is unnecessary for me to go over the

1 Portion of an address delivered at the last annual
meeting of the Association of Ex-Residents of the
Pennsylvania Hospital.

296

Communications.

Vol. lxiv

history in detail, as it is familiar to all. The
efforts at secrecy, the general and profes-
sional condemnation of this course, the re-
vealing of the composition of the remedy,
the spare granting of small quantities of it
to certain favored ones and the distribution
to different parts of the world of the precious
liquid are equally well known.

And, with it all, no disrespect, no denun-
ciation or no ridicule of the famed discov-
erer. His behavior throughout has been
grand. He never wished for publicity, but
was forced, as it were, by popular and pro-
fessional clamor into exposure. Time, much
more time, was required for laboratory and
test work.

When, then, he announced, "The rem-
edy, therefore, is a glycerine extract of pure
cultivations of tubercle bacilli," he made no
boastful claim, but told us how and when to
use it, and of its dangers as well as of its
benefits. Is its use to end in bitter disap-
pointment or not? Koch, himself, must
have been as interested as any one in that
remarkable lecture — we might say clinical
lecture — of Virchow's, held the 7th of Jan-
uary, 1 89 1, when he discussed Fraenkel's
paper at the Berlin Medical Society. I do
not think Koch was present. The scene
must have been very impressive. The vet-
eran and profound pathologist stood at his
table, and on it were what was worth show-
ing, from twenty-one post-mortem examina-
tions of patients who had died after the in-
jection treatment. Think of this at one
clinic! Of the twenty-one, 16 were cases
of pulmonary phthisis. These were the cases
to the end of December. The lecturer speaks
of 6 or 7 cases in the present year up to Jan-
uary 7, and he says, " in addition to this my
assistants 'have made necropsies in a large
number of similar cases at other hospitals
and in private, and I have seen the most
important results of the examinations." The
crowded audience gazed with intense and
silent interest, as he took up piece after
piece and showed the changes that he
thought were due to the old disease and
those that were brought on by the new
treatment. No word of disapproval or ridi-
cule escaped him. The specimens them-
selves proclaimed their own lessons. A
mere superficial notice of what was shown
and said at that lecture can only be made
here. You may have read it, or if not, you
can read it in the British Medical Journal,
of January 17. He showed extra hyper-
emias in a case of tubercular arachnitis, and

evidently thinks that the fatal result was pre-
cipitated by the remedy.

Again he says, "In particular it was re-
peatedly noted by us, that even the surfaces
of pulmonary cavities showed unusually in-
tense redness of the granulation layers ;
moreover hemorrhagic infiltrations of the
walls were not seldom present, and even
recent hemorrhages were observed in the
cavities."

After describing certain swellings, rapid
proliferations, etc., he says: " These swell-
ings occasionally assume a very dangerous
character. I will only refer to the phenom-
ena which are seen in the larynx, where
even in cases where the ulcerated surfaces
become clean, the adjoining parts swell to
an enormous extent and cause constrictions
of a very critical nature. Together with
these changes there occasionally occur other
more violent forms which take on a phleg-
monous character and remind one of oedema
glottidis erysipelatodes, andretro-pharyngeal
abcess " — and here he showed specimens.

Again : It was noticed that among the
fatal cases of ulcerative phthisis that the
large majority exhibited recent changes of
great extent, more particularly in the lungs,
but also pleurisy and for the most part very
severe pleurisy, simple and tuberculous, fre-
quently hemorrhagic, and not infrequently
bi-lateral. He then, with the fairness of a
fair-minded man, discusses whether the le-
sions exhibited were due to the treatment, or
would have occurred in the natural progress
of the disease. Showing a specimen he
says, "From the most characteristic of one
of these comes this piece of lung, which
shows such extensive caseous hepatization
that I do not remember to have seen any-
thing like it for years." And then, most
important of all, he discusses the develop-
ment of fresh tubercules in these cases, and
gives by observations strong proofs of their
happening, and says: "lam strongly con-
vinced that these fresh eruptions first ap-
peared ex-post." He speaks of the mobi-
lizing of bacilli and setting them free to at-
tack other parts, and gives a characteristic
example. The breaths of the audience
must have almost stopped at the end of this
lecture.

After reading it at the library of the
College of Physicians, I was involuntarily
reminded of the drawings we have in the Mut-
ter Museum, taken from Dr. Weir Mitchell's
cases, and showing the effects of rattlesnake
bites on pigeons. Man often is a stupid

March 14, 1891. Communications.

297

animal. He knew the anatomy and action
of the rattlesnake hypodermic, years before
he invented a little machine for his own pro-
fessional use. This dreadful Virchow lecture
shows that now he can compete with the
snake for results.

Hear the other side ! Is there one to
hear? Has a favorable report been given
anywhere in the world to offset this one of
Virchow's? I can find reports of none, and
I have looked over many reports. Every clin-
ician is in waiting. The editorial in the
same journal that publishes the report of this
clinic is very fair. It says: "That these
observations are of enormous value ; that
any one who thinks that all that is necessary
to practice Koch's method is to have a bot-
tle of the lymph and a hypodermic syringe,
is mistaken ; that he who thinks of carrying
it out should make himself thorough master
of Koch's original statements, which are
calm to a degree and are as unbiassed as
any man could expect those of the author of
such a method to be. The method is still
on trial and those who wish to keep an open
mind can do so only by a careful study of
scientifically observed facts as they are placed
before us."

And so say we all of us — Wait ! That the
present dangers are recognized through the
influence of Virchow's clinic, is shown by
this telegram in our papers dated Feb. 13 —
only four days ago — " An important dis-
covery. Dr. Weyl, an associate of Professor
Koch, has discovered a method of detecting
in the Koch lymph the poisonous elements
described by Professor Virchow, and of
eliminating them so as to produce a lymph
free from bad properties."

There is nothing new. That charming
and learned writer, Benjamin Ward Rich-
ardson, has a short article in the last number
of the Asclepiad, on Pulmonary Consump-
tion, which opens thus: "In many parts of
provincial England it was once a practice,
hardly yet abolished everywhere by the com-
mon people, to treat persons affected with
consumption of the lungs by making them
swallow live snails. The vulgar idea of the
modus operandi of the medicine was that
the snails found their way to the lungs of
the patient and ate the black worms which
lived on the lungs and caused, by their dep-
redations, the disease. The snail treatment
got a great reputation, for which probably
it depended on two collateral causes. The
persons who were benefited by it were led
to seek the remedy in purer air than they

had been accustomed to live in ; and in
addition to the snail, which did neither good
nor ill, they partook freely of new milk and
cream, rich foods likely to be important ad-
juncts in the cure. Of late the idea that
pulmonary consumption is a parasitic dis-
ease is revived. The lungs infested with
hosts of a specific bacillus is supposed to be
destroyed by them or by the secretion which
they eliminate; and the mode of cure is
expected to be found in a lymph or poison
which shall kill the bacillus without injury
to the patient." Further on the writer
shows that he keeps his opinions in reserve
for he says: "But scientific medicine is
conservative and careful before she speaks a
word ; and the more so because, in her too
ready acceptance of speculative practice in
former days, she has reason to become wary
and chary of belief. Some of her children run
after new remedies and false gods fast
enough; and many, no doubt, will run
after this new promise long before there is
sufficient evidence either for its establish-
ment or its delegation to the shades of de-
parted fallacies."

Again we say, Wait !

VERATRUM VIRIDE.1
BY AARON C. WARD, M. D.,

NEWARK, N. J.

A careful study of the pathology of pneu-
monia not only leads to the conclusion that
bleeding does harm, but that the use of all
those agents which have been employed for
the arrest of simple pulmonary inflammation
are contra-indicated strongly. Hence verat-
rum viride, aconite, antimony, calomel, and
all so-called " cardiac sedatives " have been
discarded, for it is evident that they add a
new load to an already over-burdened heart.
They may for a time lower temperature and
pulse rate, but this will be accomplished at
the expense of heart power. " Cardiac in-
sufficiency will therefore appear earlier and
be more profound;" so says Prof. Loomis,
and the principle expressed in this statement
underlies the practice and teaching of a large
class of intelligent physicians, whom we are
wont to look upon as authorities.

That what seems to us an error should
have such a strong foothold is the excuse for
this brief essay. I believe the above position

1 Read before the Practitioners' Club.

298

Communications .

Vol. lxiv

is untenable, and the arguments used in its
support unsound physiologically and physi-
cally. For, first, the circulatory activity
which occurs in pneumonia is not compensa-
tory; that is, it is in no way dependent
upon or proportionate to the obstruction
existing in the lung or the consequent di-
minution of respiratory area. This is dem-
onstrated by the fact that in all cases the
cardiac activity is in excess of the amount
necessary to compensate for the defective
respiration ; by the fact that we find just as
high arterial tension and just as rapid heart-
action when one lobe is involved as when
two are ; and, again, by the fact that the
same condition of the circulation exists in
other inflammatory affections where the res-
piratory surface is neither diminished nor
its functional activity impaired.

In the second place, the amount of com-
pensation which is rendered necessary is
largely accomplished by the increased rapid-
ity of the respiratory acts ; while it would
not be difficult for the respiratory apparatus,
under favorable circumstances, to compen-
sate entirely for its own defect without
making any extra demand upon the heart.
Moreover, such a result is eminently desira-
ble, for the muscular apparatus of respira-
tion can better bear over-taxation than can
the heart.

In the third place, suppose that heart fail-
ure in pneumonia is principally the result
of the effort of the heart to overcome the
increased resistance in the lung, even so
the auxiliary proposition is untenable —
namely, that cardiac depressants increase,
while stimulants decrease, the burden thrown
upon the heart and the venous stasis which
results. The converse proposition is much
more rational and more in accordance with
the facts. For though it is likely that arte-
rial tension alone is not sufficient to produce
exudation in an otherwise normal circula-
tory apparatus, yet it is certain that from
the instant exudation is rendered possible
by pathological changes in the walls of the
vessels, the higher the arterial tension, the
more rapidly the exudation takes place, and
therefore the greater will be the severity and
extent of the local inflammatory process.
Again, if we consider the circulation as a
whole we will see that the blood must com-
plete the circuit of the pulmonary capillaries
in the same space of time that it traverses
that of the systemic capillaries. It follows
that, whatever the pressure, if we could in-
troduce an obstruction to the flow of the

blood through a part of either system, the
circulation in the remaining normal part of
that system would of necessity be more ac-
tive ; in other words, there would occur in
the rest of that system a compensatory or
•active hyperemia. Under such circum-
stances, any pathological condition which
would increase the rapidity of the general
circulation would proportionately intensify
the embarrassment of the defective system,
and vice versa.

Again, the amount of energy necessary to
be expended in injecting a given amount- of
fluid into an elastic reservoir is proportion-
ate to the tension already existing in such
reservoir.

Now the tension of the systemic circula-
tion is normally at least five times greater
than that of the pulmonary circulation.
Therefore, to overcome any given increase
in the systemic arterial tension requires the
expenditure of five times as much of the
heart's energy as a corresponding increase
of tension in the pulmonary circulation ; or,
in other words, it would not be difficult to
prove that the labor thrown upon the heart
by the increased arterial tension of the sys-
temic vessels which exists in pneumonia, is
greater than that which would be caused by
the total obliteration of the circulation
through a whole lobe of the lung. Under
such conditions it follows that we can do as
much to save the heart from exhaustion by
lowering the arterial tension of the system
at large as we could were it possible for us
to remove entirely pathological resistance
existing in the diseased lung.

Again, the rise of temperature which oc-
curs is proportionate to the circulatory ac-
tivity, and is produced by the excessive oxi-
dization and tissue waste which such abnor-
mal circulatory activity makes possible.
" No argument is necessary to convince
you that the vital powers are rapidly ex-
hausted when the heart is driving the blood
through the system at the rate of 120 or 140
beats in a minute." Could anything be
more irrational than to allow the heart to
waste its own energy in destroying the en-
ergy of the system at large, and content our-
selves with alleviating one of the injurious
results of this process when it is within our
power to remove the cause ?

Again, we find the same physicians who
so strenuously oppose the use of veratrum in
pneumonia, in the next breath recommend-
ing other agents, whose value, where any
such exist, rests upon the same basis as that

March 14, 1891. Communications.

of the veratrum they discard. Or we find
them using this same veratrum in other af-
fections, in which practically the same con-
ditions exist, and the same therapeutic indi-
cations are to be met as in pneumonia. For
example, 'Niemeyer says in favor of the
"bath" in pneumonia: " the temperature
declines, and pulse falls and becomes soft and
compressible, the skin grows moist and the
patient feels refreshed," and this same au-
thority, to use his own words, " feels it ne-
cessary to emphasize the evil effect of cardiac
sedatives" administered in this disease.
Or, again, how do those who contend that
veratrum is inadvisable in pneumonia be-
cause it augments venous stasis and increases
the labor of the heart, explain their endorse-
ment of its use in the hypertrophy of the
heart of chronic Bright's, where, practically,
the same circulatory conditions exist?

Finally, we meet in practice several classes
of cases such as chronic interstitial pneumo-
nia, etc., where, as far as the lung is con-
cerned, the circulatory conditions are iden-
tical with those in pneumonia, and yet in
these cases there is no embarrassment of the
heart, no compensatory hypertrophy, and
no venous stasis, even though the disease
has existed for years. Could any evidence
be more conclusive ?

If the foregoing reasoning is sound, I
think I have proved that the rational
treatment of the first stage of pneumonia is
to reduce arterial tension, as far as that is
possible consistently with the performance
of those functions for which the circulation
exists, namely, the distribution of nourish-
ment and oxygen and the elimination of
waste products. The degree of circulatory
activity which may be necessary to attain
these ends may be greatly reduced, on the
one hand by supplying the nourishment and
oxygen in such a form and degree of con-
centration as shall render assimilation more
easy and rapid, and on the other hand by
assisting in the many ways at our disposal
the activity of the other emunctories, that
their increased functional activity may com-
pensate for the impaired elimination through
the lungs.

In the foregoing argument we have spoken
of pneumonia, because it is more easy to treat
anything in the concrete than in the abstract,
and also because pneumonia furnishes one
of the most important applications of the
principles involved. The conclusions at
which we have arrived in the case of pneumo-
nia are equally applicable to almost any other

acute inflammatory process accompanied by
high arterial tension ; for example, pharyn-
gitis, tonsillitis, laryngitis, bronchitis,
bronchial pneumonia, pleuritis, peritonitis,
nephritis, etc. To accomplish the desired
sedative effect upon the circulation, our pro-
fessional ancestors had resource to venesec-
tion, and though this occasionally proved
of great service, yet, unfortunately, it in-
volved an absolute loss of vital power, which
experience has gradually taught us overbal-
anced the advantages to be gained. The
practice has therefore fallen into disuse.

I shall not, however, consume your time in
attempting by comparisons to demonstrate a
proposition which, it seems to me, is beyond
question, namely, that veratrum viride is the
most rapid and most efficient cardiac seda-
tive we possess ; but I will turn immedi-
ately to the consideration of the other ob-
jection raised by its] opponents, namely, that
its sedative effects are obtained at the ex-
pense of heart power.

Any discussion of the physiological action
of the several alkaloids present in this drug
is foreign to our subject. Suffice it to say,
that its physiological action as a whole is due
to the combined effects of at least three dis-
tinct alkaloids, individual actions of which
differ mainly in degree.

The important and characteristic actions
of veratrum viride can all be considered un-
der the two main heads ; its effect on mus-
cular activity and its effect upon the nervous
system. Veratrum diminishes muscular ex-
citability. This is* an important fact, for
while the sympathy of the motor nerves in
this action is not completely disproved, yet
it is demonstrated beyond a doubt that the
action of veratrum viride mainly affects the
muscles, and that its influence on the motor
nerves is comparatively subordinate. A
muscle so poisoned reacts for a long time to
direct or indirect irritation, but this action
is different from that which occurs in its
natural condition. For while the contrac-
tion is performed in the ordinary time, the
relaxation is very much protracted.

Veratrum exerts little or no influence on
the motor and sensory nerves and upon the
cerebral centres. To this statement there
are several exceptions : the vasomotor centre
is powerfully depressed ; the activity of the
pneumogastric is stimulated ; the reflex of
the spinal cord is at first markedly dimin-
ished and finally abolished ; while the effect
on the respiratory centre is in doubt.
Whether or not this centre is affected, it fol-

300

Communications.

Vol. lxiv

lows from what has already been said in re-
gard to muscular activity, that respiration
must be slowed and finally cease. In the
case of the heart, the same reason holds
good, but here another factor enters the
problem. The pneumogastric being more
rapidly affected than muscular activity, the
heart's action is at first slow, without the
force of the individual beats being much
altered. Later, when the muscular tissue of
the heart feels its influence, the force also is
lessened. Larger amounts of the poison
finally produce paralysis of the terminals of
the pneumogastric and of the cardiac mus-
cle. The ultimate effect, therefore, on the
heart is complete paralysis.

In consequence of the powerful depressing
influence upon the vasomotor centres and
the diminished force and frequency of the
heart's action, arterial pressure is progres-
sively and rapidly diminished. The free
perspiration which occurs is another result
of the vasomotor depression. The pulse,
under the combined influences on the circu-
lation, is at first slow and full, though always
soft and compressible ; later its strength is
diminished, the rapidity being at the same
time even further reduced.

The symptoms of a poisonous or excessive
dose are simply an exaggeration of the phy-
siological effects, and are almost precisely
like those produced by tobacco in persons
unaccustomed to its use. Intense nausea ;
incessant and violent vomiting and retching ;
complete muscular prostration with attacks
of dizziness or fainting ; slow and superfi-
cial respiration ; a small, feeble and some-
times almost imperceptible pulse ; an ex-
pression of great anxiety; a cold, clammy
skin — these and associate symptoms present
a condition which is at once distressing and
alarming.

The rapidity with which the effects of
veratrum viride disappear when its adminis-
tration is suspended, and the almost entire
absence of any persistent derangement of
the functions affected, have been matters of
general observation. They follow naturally
as the result of the modus operandi of the
drug and the rapidity of its excretion. The
importance of their practical bearing is ap-
parent. For if the physiological action of
veratrum, as given above, is correct, it re-
futes the second objection raised by our
opponents, and, on the contrary, warrants
the assertion that veratrum is a heart tonic
in the broadest sense of that word. This
error probably arose because, while observ- '

ing phenomena, the fact was lost sight of
that there is a real and positive distinction
between a weak pulse of repressed energy
and that which results from absolute loss of
power.

Just here it is proper to state, and to em-
phasize the statement, that while veratrum
will absolutely and invariably control the
quick, hard pulse of inflammation, it just as
certainly will not reduce a feeble, rapid pulse
of exhaustion, and this for the very simple
reason that you cannot conserve energy
which does not exist. Failure to recognize
this distinction probably accounts for many
of its reported failures.

The next question naturally presents it-
self : Is not the administration of such a
drug so hazardous as to render its general
use undesirable? This I answer in the
negative, without any hesitation or qualifi-
cation. While there are on record numer-
ous cases where the alarming condition of
the patient gave reason to expect a fatal re-
sult, yet in almost every instance we find
that complete recovery has ensued. The
number of fatal cases is small. On the
other hand, the testimony of those who have
given veratrum the most thorough trial and
whose ability to judge is beyond question,
is unanimous to the effect that there is prac-
tically no danger attending its use — abso-
lutely none when intelligently administered.

Referring to the unpleasant symptoms re-
sulting from an overdose, Barker says :
" After an experience of more than thirty
years in the use of veratrum, I feel war-
ranted in saying that these phenomena are
really not dangerous. I have never known
any serious result to follow from its use.
This condition is purely temporary, and pa-
tients pass out of it in a short time, even if
no restoratives be given."

Wood affirms that, "although veratrum
viride is a remedy of great power, capable
of producing the most alarming symptoms,
yet I believe it to be the safest of all cardiac
depressants ; certainly it is far less dangerous
than aconite. It is somewhat doubtful
whether a robust adult could be killed by a
single dose of any of its preparations, espe-
cially if prompt and judicious treatment
were afforded."

The evidence adduced is surely sufficient
to establish the assertion that its intelligent
administration is devoid of danger. It is
no argument against a drug that it is capable
of doing mischief, if, when intelligently and
judiciously administered, its therapeutic value

March 14, 1891. Communications.

301

is available without incurring the risk of
such mischief. To advance such an argu-
ment is to plead ignorance or indolence.

The therapeutist has at hand numerous
drugs which, if not more powerful than
veratrum viride, are yet more singly spinal
depressants. The field of its usefulness in
this direction is therefore limited. I hope
to show, however, that there is one condi-
tion in which its composite therapeutic effect
renders veratrum the most valuable spinal
depressant at our disposal.

However widely authorities may differ in
their theories as to the exact pathology of
puerperal convulsions, or in the remedies
that they may advocate for the treatment of
the same, there is practical unanimity as to
the therapeutic indications to be met. Briefly
these are, to lower arterial tension, to diminish
to the fullest extent practicable the irritation
of the vaso-motor and convulsive centres, and
to restore to the kidneys their normal func-
tion. Venesection meets the first indication
perfectly, by rapid reduction of the volume
of the blood. It meets the second indica-
tion, though partially only, by removing a
part of the toxic ingredients from the circu-
lation, and by both these means it relieves
somewhat the renal embarrassment. The
testimony as to the prompt relief afforded
is overwhelming, and this not only by those
who wrote at the time when venesection was
the orthodox treatment, but to-day, when in
the face of public sentiment we find such
men as Barker, Lusk and others pleading for
the restoration of the lancet, and insisting
upon the unmistakable clinical evidence in
its favor. All admit, however, that because
the arterial tension is rapidly re-established
and the remedy cannot be repeated, the re-
lief afforded is only transient, while the de-
terioration of the blood which ensues cannot
but increase the danger of the disease. Its
employment, therefore, is justifiable only in
a most pressing emergency, on account of
the rapidity of the relief afforded, and as
an expedient to gain time for the action of
other more satisfactory measures.

I . have considered venesection to such
length, principally because its success con-
firms a point which I desire to make,
namely, that the reduction of arterial ten-
sion alone is sufficient to afford relief in this
most distressing malady. The other agents
most generally employed to-day are chloro-
form, chloral, potassium bromide and mor-
phia. These are dependent for their useful-
ness on their antispasmodic power, since in

the quantity which can be administered with
safety they either do not at all influence ar-
terial pressure, or they exert an unfavorable
influence by raising it. They are not with-
out merit, but as in each case this is
qualified or offset by some danger or unfor-
tunate concomitant action, their employ-
ment should, we think, be secondary and
supplementary to the use of that remedy
which theoretically and practically fulfils all
the indications more perfectly than any sin-
gle agent in the pharmacopoeia. This rem-
edy is veratrum. For veratrum is both the
most powerful of arterial and of spinal de-
pressants, and, at the same time, exerts a
specific depressing effect upon muscular tis-
sue in general. In other words, veratrum is
not only a central antispasmodic, but a pe-
ripheral antispasmodic as well ; if I may be
allowed to use such an expression. Its ac-
tion, moreover, is rapid and can be main-
tained almost indefinitely without danger.
As regards the dosage in this condition, all
that can be said is that enough must be given
to bring the pulse down to about 60, and its
administration must be continued for some
time afterwards, and in such smaller doses
as shall be sufficient to keep the pulse at
about this rate. In order to save time, the
initial dose at least is best given hypoder-
mically.

In conclusion, I will cite briefly three
cases to illustrate in practice the principles
for which we are contending.

Case 1. Mrs. H. , 45 years old, strong, well-
nourished, previously well, was seized with a
severe chill, followed by rapid rise of fever
and pain in the side. I was called six hours
later. The patient's face was flushed; pulse,
116, full and strong; temperature, 1040;
stitch-pain in right side; frequent, restrained
painful cough ; pain intensified by full in-
spiration; respiration, 28. There were phys-
ical signs of pneumonia in the first stage, af-
fecting the lower lobe of the right lung. I
gave calomel (gr. x), sod. bicarb, (gr. xx),
and tincture of veratrum viride (n^ iii), fol-
lowed in half an hour by ttl ii, and after-
wards TTl ii each hour. Counter-irritation
was employed, etc. After the third dose of
veratrum the pulse was 56 ; temperature,
1020; slight nausea ; pulse maintained be-
low 60 or 65 for two or three days. The
physical signs persisted, increasing very
slowly. The patient recovered, without hav-
ing had consolidation of the lungs, in about
the usual time. The inflammation seems in
this case to have been held in check, the

302

Communications.

Vol. lxiv

lung never getting beyond the stage of in-
tense congestion.

Case 2. A strong, healthy boy, 10 years
old, had a severe chill with fever, cough,
dyspnoea, etc. Six hours later his tempera-
ture was 1030, pulse about 140, respiration
about 70. There was great dyspnoea; the
skin was somewhat cyanotic ; the cough was
frequent and distressing, without expectora-
tion. Prostration was great. There were
physical signs of intense congestion of the
lungs; the patient was apparently dying.
Veratrum was given in frequently repeated
small doses until the boy was nauseated. After
three hours I saw the patient again ; he was
quiet, dyspnoea was relieved, the skin was
more natural in color, the pulse below
90, and the respiration about 40, the
temperature being 1020. The pulse was
kept between 80 and 90, and recovery was
rapid.

It does not follow that veratrum viride is
to be discontinued after the first stage of
pneumonia. While I am opposed to the
custom of giving stimulants, saline or alco-
holic, as a routine practice, yet I am per-
fectly willing to admit that, from this point
on, their use in greater or, less quantity is
called for in a large proportion of cases.
If at the same time we stimulate, however,
we can so regulate the energy evoked that
it shall be utilized with the least possible
waste, we are doubly at an advantage. This
we can accomplish by giving small doses of
veratrum viride, along with a proper amount
of alcoholic stimulant. For you will remem-
ber that the primary effect of veratrum is to
decrease the rapidity of the pulse without
affecting materially its quality. This pri-
mary effect can be maintained if the dosage
is properly regulated. The administration
of veratrum is not at all incompatible with
the use of alcoholics, as is apparent in the
following case, cited by Dr. Barker: " Ver-
atrum viride alone did not seem to produce
any effect on this case, the pulse remaining
constantly above 130. It was decided to
give brandy. After the first ounce had been
given the pulse fell tp 108 ; after the second
to 86. Continuing the brandy, the veratrum
viride was suspended for a few hours. The
pulse again arose to 130.. After this, it was
curious to note the fact that if either agent
was suspended, the pulse would rapidly in-
crease in frequency, while under the com-
bined influence of the two it was kept be-
low 80 per minute."

PUERPERAL PNEUMONIA.

BY JAMES E. FREE, M. D.,

BILLINGS, MONTANA.

Mrs. S., primipara, was delivered of a fe-
male child weighing six pounds, May 23,
1890. She was a large, lank woman at the
time of her lying-in, had been married about
two years, and was thirty years old. Two
months previous to this time she contracted
the grippe, which did not develop any very
serious symptoms, although it proved to be
a tedious complaint. A slightly annoying
cough was still present when labor set in.
At 1 a. m., the sharp pains having lasted
two hours, delivery was accomplished. It
was an ordinary case, causing less suffering
than is usual where the mother has reached
such a mature age.

Some hemorrhage followed the shedding
of the placenta, and ergot was administered
to make the uterus behave physiologically.
It is rarely necessary in a primipara, and in
this case it might not have been so. How-
ever, it is a bold physician who will face a
lot of old women and tell them to wait on
Nature, when they know that a friend is
bleeding. Two hours after delivery, the
patient having brightened up considerably,
a binder was applied, and the soiled clothing
was removed. The woman's temperature at
this time was 990, her pulse 100. She ex-
pressed herself as comfortable while she re-
mained perfectly still, and thought she could
sleep. Between four and five o'clock in the
morning I was summoned in great haste to
her bedside. I found her suffering acutely
with pain in the back. The pain was con-
stant and located on both sides of the spinal
column in the lumbar and dorsal regions,
and it radiated downward to her feet. Not
having had any similar experience, it was
difficult for me to tell the origin of the trou-
ble. Opium eaters are liable to have attacks
of acute pains when they are in want of the
drug, but here it did not seem as if the ap-
petite was present. Ergot produces tonic
spasm of uterine muscular tissue which is
sometimes painful. Taking into considera-
tion the amount of exercise the organ had
undergone, it was not likely that fatigue
would be the cause of the pain. When a
set of muscles have been sharply used, or
the use has been long continued, they show
signs of exhaustion when moved. Perfect
rest will generally partially relieve even

March 14, 1891. Communications.

303

rheumatic pains. Here the uterus, after a
normal labor, was contracted and at rest.
The neuralgic symptoms were considered to
be indicative of anemia of the cord. The
woman's temperature was 980, her pulse 96.
A Dover's powder was ordered, which in-
duced sleep and free diaphoresis. Several
hours later she was put on Fowler's solution.
The dull, colorless expression of counte-
nance was similar to that of most victims of
the morphine habit, and I thought more or
less of the drug was necessary to a safe get-
ting up.

Nothing of note occurred for several days.
On the fourth day a decided rise of temper-
ature was detected, morning 10 1°, evening
10 20. The uterus was washed out three
times in the next thirty-six hours, and anti-
febrin was prescribed. The patient was
apparently comfortable until the physiologi-
cal effect of the antifebrin became marked,
when remarkable sweating, producing col-
lapse, made it advisable to withdraw the
remedy. Its anodyne effect was similar to
that of the Dover's powder; but the latter
seemed to fill the long-felt want for opium.
Almost everything else nauseated the stom-
ach when she had learned the effect of the
ipecac and opium.

Two weeks after her confinement the pa-
tient was out of bed in a rocking-chair. She
complained of so many troubles and seemed
notwithstanding to be so strong, that she
was allowed to get up. In the afternoon of
this day she had an attack of acute pain in
both legs. Her description of the pain,
following the course of the large blood-ves-
sels, made it probable that phlegmasic alba
dolens was about to complicate matters.
Fowler's solution and Dover's powder did
not check the pain this time. Quinine
could not be retained ; neither could acon-
ite. The temperature again went up to
1020. Lochial discharge was still present.
The uterus was again washed out with warm
water, but without any effect on the fever.
' Next morning a violent rigor, accompanied
by intense internal congestion, came on, and
lasted for two hours. Pain in the right side
at the base of lung made breathing difficult
and shallow. Auscultation and percussion
revealed nothing abnormal. Blood-letting
was indicated at this time as much as ever
in my observation. However, as the lancet
was wanting, also the cups, I concluded to
fight it out with alcohol, mustard and hot
water to the feet.

The next morning there were was almost

complete percussion dulness on the right
side, and an involvement of the lower bor-
der of the left lung. Pneumonia is said to
be a treacherous disease, and if it was all
this time manifesting itself in this case, it
surely is entitled to that reputation.

The patient all along denied that she
knew anything about morphia or opium,
but the word of an habitue of these drugs is
worthless. The temperature was 104^°,
the pulse 150, the respirations 43. The as-
pect of affairs was very serious, and a con-
sultant was asked for.

After an examination the consultant re-
jected the theory of opium eating, and sug-
gested the administration of veratrum viride
and a carbonate of ammonia mixture, with
nothing hypnotic unless the cough was trou-
blesome. The new treatment did not do
well. Regular doses of brandy and cream
and hypodermics of morphia at bedtime, to
secure rest, was thought to be better, and
consequently the consultant washed his
hands of the case, and prophesied a speedy
fatal- issue.

It required eight weeks to establish con-
valescence. The temperature remained near
1040 for seven weeks and then gradually
subsided, and, as the fever left, a desire for
food returned. Most troublesome of all the
symptoms during the period was the dysp-
noea, which showed itself every day, and
threatened to terminate life, at first. Eu-
phorbia pilulifera had recently come under
my observation as a respiratory tonic, and
its use in this case was beneficial. A half
teaspoonful of the fluid extract given at the
commencement of the dyspnoea, generally
relieved it, but did not appear to have influ-
ence over its return. It was administered
regularly latterly, and seemed to prevent the
occurrence of the symptom. When expec-
toration commenced, the euphorbia was still
a valuable remedy, seeming to promote reso-
lution, and to act as a general tonic. While
the difficulty of breathing lasted, its effect
on the heart was analogous to that of digi-
talis, with more of a tendency to brighten
the nervous force, and without any special
action on the urinary function.

By October 1, the patient was in a lum-
ber camp, away from drug stores, and with
no opportunity to get opium. She had not
yet entirely recovered health and strength ;
constipation was troublesome, headache was
common and any kind of exertion was
irksome and produced palpitation of the
heart.

304

Periscope.

Vol. lxiv

NEURALGIA FROM TOOTH-PRES-
SURE.

BY C. H. M. NEALL, M. D., D. D. S.,

PHILADELPHIA.

A gentleman called at my office on Janu-
ary 24, suffering with violent pain over the
region of the left temple. The pain ex-
tended down to the angle of the inferior
maxillary bone on the same side. I found,
on examining the mouth, that he had erupted
all of his teeth except the " wisdom
tooth" on the right side, and upon making
pressure over the gum in this region, that he
experienced a great deal of pain. I found
the gum and parts much inflamed. After
satisfying myself that the tooth was the
cause, I proceeded as follows. I made a
free incision and found that the masticating
surface of the tooth was deeply imbedded in
the calcellated structure and pressing directly
against the inferior maxillary division of the
fifth pair of nerves. I extracted the tooth
with some difficulty, and found that its root
was exostosed. After removing the tooth,
I syringed out the cavity with a 1-1000 so-
lution of corrosive sublimate, and brought the
parts together by means of a stitch. On
January 27, the man returned to my office,
informing me that the neuralgic pain he had
suffered had entirely disappeared.

I have seen a number of cases like this in
my own practice, and believe that we may
many times trace neuralgic affections to cut-
ting of the teeth.

Periscope.

Dangers of Syringing the Ear.

In the Atlanta Medical and Surgical Jour-
nal, February, 1891, Dr. S. L. Philips, of
Savannah, publishes an article in which he
reports the case of a man, 54 years old, in
fairly good health, save when suffering from
bleeding piles, who for some weeks had ex-
perienced dulness of hearing on left side,
and wished, if possible, to be relieved. On
inspection, the canal of that side was found
to be of average size, and containing a con-
siderable amount of hardened wax. With
a small rubber ball syringe, holding about
an ounce and a half of water, filled with
lukewarm water, Dr. Philips began to syr-
inge the auditory canal. Several syringefuls
forced gently into the ear not bringing away

the wax, he used a little more pressure.
Suddenly something seemed to give way.
Water poured from the patient's left nostril,
and he complained of a peculiar sensation
in that ear, though he had no pain worth
speaking of. The wax was loosened and
easily removed from the canal. Dr. Philips
thought, of course, he would find a perfora-
tion of considerable size in the membrane,
the sequel of an old purulent inflammation
of the tympanum, as sometimes wax forms
over the opening, mixing with the secretions
from the diseased mucous membrane, making
quite a hard impervious wall to the secretions
behind. When he looked at the drum-head
he did not find what he expected, but one
almost intact. It was congested in every
part save the posterior superior quadrant.
From the top of the malleus running down
and back to the bony wall was a thin line
of blood indicating the course of a recent
rupture, and scattered here and there in its
immediate region, a few drops of blood,
which were easily wiped off with a piece of
cotton wool. At this time there was no
gaping. Under suitable treatment in two
months the opening had closed, leaving
only a thin line of scar, and hearing had
become normal, he experiencing no incon-
venience. Several months afterwards the
membrane gave way at this point from too
vigorous blowing of the nose, but the parts
soon united without any treatment whatever
than a piece of cotton wool worn in the
canal for a while, since which time he has
been all right.

In looking over the literature of the sub-
ject at his command, Dr. Philips finds but
one case where rupture of the drum mem-
brane took place from syringing the canal.

The above case teaches that one cannot
be too careful in performing even this appar-
ently trivial operation of syringing out the
ear. Very great force is not necessary, and
a powerful syringe is not needed. Some
physicians have claimed that syringing could
never do harm, provided only water was
used, but Dr. Philips cannot agree with
them. Only a short time ago Dr. Philips
saw a little sufferer with chronic catarrh of
middle ear and eczema of canal, the latter
produced by an almost daily syringing for a
year. The physician had diagnosticated wax
accumulation, and given the mother direc-
tions to syringe out ear until she removed
all wax. This treatment she kept up faith-
fully, but she never saw the wax in the re^
turning water, and finally, when the ears

March 14, 1891.

Periscope.

305

had become very painful the child was put
under his care. After the usual treatment
for aural catarrh, hearing was completely
restored, but for a time the tendency to a
recurrence of the eczema remained. While
syringing is a good thing at times, its
indiscriminate use is not good, and when it
is necessary to use it, the greatest care and
gentleness should be exercised. In purulent
troubles of the ear, usually one syringeful of
water will be sufficient to remove all debris,
and when there is impacted wax a weak so-
lution of bicarbonate of soda poured in the
ear will, after several hours, so soften it that
it can be removed without difficulty.

The Revival of Venesection,

The British Medical Journal, January 31,
1 89 1, says editorially:

The discussion which took place at the
last meeting of the Royal Medical and Chi-
rurgical Society of London was in many re-
spects interesting and noteworthy. Dr. Pye-
Smith is to be congratulated on having so
effectually succeeded in directing attention
to a subject which must always have a real,
if even only a historical, interest.

The reflections and conclusions contained
in the paper were based upon the record of
some fifty cases coming under the notice of
the writer, in which venesection had been
resorted to. The range of diseases in which
it was employed included such acute affec-
tions as bronchitis, acute broncho-pneu-
monia, lobar pneumonia, miliary tuberculo-
sis of the lungs, with others of more chronic
nature, such as valvular disease of the heart
with pericarditis, Bright's disease, aneurism
and epilepsy ; its value in other conditions,
such as hemoptysis, apoplexy, uremic coma,
was also considered.

The discussion which ensued was remark-
able, on account of the almost complete
unanimity which the speakers expressed in
favor of the adoption of this method of
treatment in suitable and urgent cases. All
testified to the great and immediate relief
which venesection gave under such circum-
stances— a relief unattended by any ill con-
sequences on the subsequent progress of the
disease.

Considerable differences of opinion, it is
true, existed as to the cases most likely to
be benefited by the treatment, or, rather,
as to the cases which, in the experience of
the various speakers, had most benefited by
the treatment. For it was one of the note-

worthy features of the discussion that there
was a commendable absence of recourse to
theoretical considerations as a basis for the
practice.

In this respect the subject of venesection
occupies a different position from that held
by it in the former " bleeding era," to which
reference was made in such humorous and
instructive fashion by Sir George Humphry
and Mr. George Pollock. The practice was
then based on the humoral pathology which
so long dominated the practice of medicine
— that pathology which ascribes disease to
the presence of deleterious agents in the
blood, and which seemed, therefore, to jus-
tify the withdrawal of a certain quantity of
the noxious blood as one of the best ways
of curing it. As Dr. Broadbent pointed
out, it was because the practice had been
based so entirely on theory that it was car-
ried to excess, and fell into such disrepute.

One of the chief merits of Dr. Pye-Smith's
paper and of his subsequent remarks was to
lay stress on the importance of resorting to
venesection — not for the cure of pathological
conditions as such, but for the relief of dis-
tressing symptoms depending on temporary
alterations in the physiological balance of
the circulation. As to the first indication
laid down for the performance of the opera-
tion— cyanosis with distention of the right
side of the heart depending on pulmonary
or other obstruction to the circulation —
there was a consensus of opinion favorable
to the operation, but Dr. Broadbent did well
to point out that before resorting to vene-
section under such circumstances, there
should be evidence, as shown by the dispar-
ity between the strength of the heart's beat
and the weakness of the pulse, that the right
ventricle was still acting powerfully, and
able to take advantage of the relief afforded
it by the withdrawal of blood.

As to the second indication — the pain of
aortic aneurism — the cases mentioned by
Dr. Pye-Smith and Mr. Hulke, in which
instantaneous relief was thus given, were
very striking ; and evidence of its curative
effect on the aneurism was also incidentally
adduced by Mr. Jonathan Hutchinson.
Nevertheless, as Dr. Stephen Mackenzie
pointed out, it may be doubted whether in
iodide of potassium, nitrite of amy 1 and nitro-
glycerin, we do not possess remedial agents
equally powerful and equally efficacious in
relieving the high arterial tension on which
such attacks of pain depend. The discus-
sion, indeed, brought out the fact that it is

306

Periscope.

Vol. lxiv

in relieving pain that venesection finds one
of its best applications, and more especially
in relieving the intense inflammatory pain
of pleurisy, pleuro-pneumonia, or the severe
pain with threatening onset of cerebral
symptoms following injury to the skull.

To those accustomed, as most now are, to
regard loss of blood, from whatever source,
as an unmitigated evil, the suggestion to
follow up an extensive bleeding from the
lungs by a further bleeding from the arm, is
startling. Nevertheless, something can be
said, and was adduced by one of the speak-
ers, in favor of its adoption in cases in which
the patient is in urgent danger of suffocation
from the reflux of blood into the bronchi.
It is, however, peculiarly open to the objec-
tion brought against the operation of vene-
section generally — that in the present state
of public opinion as to blood-letting, the
discredit of a fatal result is too likely to be
hastily assigned to the venesection. Apart
from such considerations, however, the gen-
eral result of an unusually animated discus-
sion will be to direct attention once more
to the possible advantages attending the
judicious employment of a mode of treat-
ment long condemned as not only useless
but dangerous.

Beri-Beri.

A most interesting account of the nature
and history of beri-beri is given by Dr. F. B.
Sutcliffe in the Occidental Medical Times,
February, 1891, after observations made in
the Sandwich Islands.

Dr. Sutcliffe says : My first patients were
Japanese. When I was asked to see them
they were under arrest for having refused to
work. They claimed to be ill, and the
plantation doctor and the overseer claimed
they were not. They were arrested, tried,
found guilty and sent to the Wailuku jail.
They had been driven about twelve miles
through the dust and heat — not in a wagon,
but a native policeman had ridden his mule,
driving them ahead of him. They claimed
that he had helped them along with the use
of his whip, but I saw no evidence of such
treatment, and did not think they were
abused in that way. I was asked by the
Sheriff to go and see them before they were
locked up, as he thought they looked ill.
When I saw them I did not know anything
of their history. I was asked to examine
them and say whether or not, in my judg-
ment, they were ill. I found six of them

sitting on a bench, looking worn out and
very tired. They all had a temperature
above the normal, and a rapid, full pulse.
The heart was working hard, altogether out
of keeping with the other symptoms. All
were complaining of pain in the legs; one or
two complained of pain in the chest, put-
ting their fingers under the. sternum, and
pulling at it as if to lift it out. I, of course,
pronounced them ill, but of what disease I
only suspected, and refused to make any di-
agnosis until I had watched them for a day
or two. I was then told their history, and
I recommended that they be sent to the
hospital instead of being put into a cell. I
saw them again the same day, and all doubt
as to the nature of the trouble was dispelled.

The further development of the disease
was very interesting to watch. The legs of
all began to swell, and later on this swelling
became quite general, in one or two of
the worst cases. The day after they were
received, three of them were unable to walk
without great effort, while the others were
decidedly unsteady on their feet. The worst
case amongst them assumed the gait and at-
titude of a child, who, in taking its first un-
steady steps, fearing it may fall, puts out its
hands as a safeguard, reels on one foot,
bringing the lifted foot with undue force to
the ground. The gait is peculiar ; it seems
to be an effort to balance and a false judg-
ment as to distances, rather than a shrinking
to ease soreness or pain in the legs or feet.
I never saw a patient who seemed in danger
of falling backwards ; but this may be be-
cause, as I have said, they lean forward and
put out their hands. The case that I have
mentioned as being worse than the others
did not improve. Effusion into the chest
took place, the heart's action became worse,
the kidneys did not perform more than
half the work they should, breathing be-
came more and more labored, and death
took place in about one week from the
time that he was forced to take his long
walk to jail. The other patients gradually
improved till they were able to leave for
Honolulu, at which place I heard that one
of them died and the others made a full re-
covery.

These cases were the most notable that
came under my observation. They had
been on the island but a short time, the
vessel that they came in being still in port.
The ship's surgeon visited them, and con-
firmed my diagnosis ; indeed, they knew
' themselves what the trouble was, and spoke

March 14, 1891.

Periscope.

307

of it as " kakae," the name they give to the
disease.

For the next three years I saw a good
many cases of all degrees of severity,
though, as a rule, of a mild form, and
yielding kindly to treatment. It was a
common thing in visiting a plantation to
find three or four cases of the disease.
Usually the first symptoms of which they
complained were swelling of the legs, pain
along the tibia and shortness of breath. I
would usually find upon examination, palpi-
tation, a quick pulse and marked anemia.
My method of treatment was as follows : I
changed the patient's diet ; where it could
be had, milk was largely used, but it was
scarce, and the Japanese do not like it.
Fresh vegetables were given, and the best of
all that we could get was tomatoes. The
people most affected were in the habit of
eating a deal of rice, salt fish and such oily
preparations as the Chinese delight in.
Where they could be persuaded to follow
out the directions, improvement was the
rule from the first, if the disease was not
too far advanced when first seen. Occa-
sionally a case would grow worse and have
to go the hospital ; some would fail to re-
port for treatment after a slight degree of
improvement, and, getting worse, come
again and again, with the disease in a
chronic form.

The drug that I gave oftener than any
other was digitalis. I often combined with
it the citrate of potash, and when the
tongue had cleaned iron was given, and
sometimes nux vomica. I was much im-
pressed with the good effect of changing
the patient's place of residence, when they
were living in a low, wet locality, to a high
and drier location. Where this could be
done, and when they were well cared for in
the matter of diet, the disease was often
checked without other treatment. I can
recall one case in a woman, a Japanese.
She was ill for some time, but finally re-
covered. She had worked in the field with
the men, and was exposed in the same way
to like influences. I do not see why the
disease should not attack the female, but
this is the only case in a woman that I can
remember. I never saw a child affected, or
a white man, or a native Hawaiian. All
my cases were Japanese or Chinese. If
Kynsey is correct in his observations of the
disease in Ceylon, we must conclude that
it differs from that at Hawaii ; for the
women and children drink of the sam£

water that is supplied to the field hands,
and would be just as apt to receive any
parasite that it might contain, and as likely
to suffer from any disease caused thereby,
and this is equally true of the foreigner and
of the native.

We have seen that research by those who
have had the opportunity of making post-
mortem examinations has not yielded the re-
sults that one might hope to find in a dis-
ease in which so many symptoms point to
grave changes in the great nerve centres. I
think that the paralysis is due to a starved
condition of the cord rather than a changed
one, and that this condition is due, in part
at least to the anemia. The gait, in many
cases, is very much like that of ataxia, and
I cannot believe with Kynsey, that the em-
barrassment in this respect is due to the edema
of the lower extremities, as I have seen it
come on before this was at all marked.

My observation would lead me to con-
clude that the disease is not as severe in Ha-
waii as in other countries, and that the
worst cases seen there are brought into the
country in a more or less advanced stage.
While beri-beri is a disease of other lands,
we have three cases reported by Dr. Seguin,
of New York, in 1888, and I do not see why
cases might not be found on this coast almost
any time. I have inquired of an intelligent
Japanese, of this city, if he had ever seen a
case of beri-beri in this country, and he stated
he had seen two in San Francisco. This
may or may not be so, but to me it seems
very probable, for the Japanese understand
the disease, its symptoms and its gravity
very well.

Chloroform in Tracheotomy.

The Medical Press, January 28, 1891,
says : A curious fatality attaches to the ad-
ministration of chloroform in operations on
the throat, and this has been noticed more
particularly in connection with tracheotomy.
So tangible is the risk to which the patient
is exposed that it really becomes a question
to be seriously discussed, whether the use of
chloroform is justifiable under these circum-
stances. The operation of tracheotomy,
when skilfully performed, is short and not
very painful, and is most frequently neces-
sary in young subjects, the victims of some
laryngeal affection, hence in patients physi-
cally well under control. It is, moreover,
most commonly performed in order to avert
impending asphyxia, and the patient is usu-

3o8

Periscope.

Vol. lxiv

ally already suffering from partial depriva-
tion of oxygen, the effects of which are un-
doubtedly to dull the perception in respect
of pain.

On the same subject the British Medical
Journal (Supplement), January 31, says:
M. Geffrier, of Orleans, has recently pub-
lished {Revue de Chirurgie, December,
1890) a paper on chloroform in trache-
otomy. The views of this author, which are
based on a study of eighty-seven cases, are
summed up in the following conclusions :
(1) Chloroform is of unquestionable service
in tracheotomy on children ; (2) its use is
not attended with any special danger in this
operation, provided that attention be paid
to certain contra-indications ; (3) the fol-
lowing precautions ought to be taken : (a)
everything that might be required in the
course of the operation should be placed
close at hand ; (b) the administrator, who
ought to be experienced in the use of chlo-
roform, should carefully watch the respira-
tion, and, if it be required, excite the res-
piration by speaking to the patient or by
irritating the skin ; (V) if the state of the
respiration become alarming, the inhalation
of chloroform should be discontinued at
once, and the operation be performed with-
out delay. Extreme asphyxia and prostra-
tion from diphtheritic poison are regarded
as absolute contra-indications. Marked cy-
anosis without, and slight cyanosis with im-
peded expiration are both regarded as con-
tra-indications, though not so stringent as
the conditions previously mentioned. Slight
cyanosis without obstructed expiration and
a very early age are not regarded as contra-
indications. In the author's opinion, if the
operation be not contra-indicated by the
age of the infant, neither will the inhalation
of chloroform be contra-indicated.

Hyperemesis and its Treatment with
Creasote.

In the Berliner Klin. Wochenschrift, De-
cember 29, 1890, Dr. Peter Kaatzer has a
short communication on the rationale of the
treatment of hyperemesis with creasote.
He remarks that the therapeutics of this af-
fection have not so far reached definite re-
sults. Starting from the supposition that
the disease is a reflex neurosis, the narcotics
were brought into employment and their
achievements praised. According to Eulen-
burg and Lemaistre, iodide of potash does
excellent service. If one holds Kehrer's

view, that the obstinate vomiting of preg-
nancy is occasioned by severe diseases of
the stomach, then therapeutic measures must
be adopted accordingly.

Kaatzer gives a report of a case in which
a woman was thought to be wasting from
phthisis. Her sputum contained only a few
bacilli, and it came out by and by that the
woman was pregnant, and was vomiting after
every meal. Kaatzer prescribed creasote,.
both for the stomach trouble and the phthi-
sis. After taking two doses, the patient
ceased to vomit and rapidly recovered.
Kaatzer does not know why the remedy did
good. The formula used was the following;

& Creasoti puriss TT^xxx

Alcoholis f|ji

Tinct. gentianae f g iiss

Ext. cafifeae 3 iiss

Aq. destill f ^ iii

M. Sig. Shake well. Tablespoonful in milk.

Chromic Acid in Habitual Epistaxis.

In the St. Petersburg semi-weekly Medi-
tzina, N0.51, 1890, p. 413, Dr. Metchislav
V. Pogorelsky, of Elisavetgrad, relates three
cases of obstinate habitual epistaxis in school
boys, in which, following, Dr. Heryng's rec-
ommendation, he successfully resorted to
cauterizing with crystalline chromic acid,
after all ordinary means had failed. In all
the three patients, a rhinoscopic examina-
tion revealed the presence of a small-sized,
sharply circumscribed highly-vascularized
area situated on the nasal septum. Only this
congested spot was treated with the acid,
the application being repeated once or
twice a week and always followed by wash-
ing out the nasal cavity with a weak solu-
tion of chloride of sodium, or bicarbonate
of soda, or borax. In two of the cases 4 or
5 seances proved sufficient to effect a com-
plete and permanent cure ; in the third a
few more applications become necessary to
obtain the result.

Fissured Nipples.

Scarff recommends for fissured nipples
the following application.

R Balsami Peruviani . . . . . . . . f^ss

Tincturae arnicse aa f 3 ss

Olei amygdalae dulcis f^j

Aquae calcis , . . , . f J ss

M. Ft. Linimentum. S. Apply locally.

— -Journal de Medicine, January 25, 1891.

March 14, 1891. Editorial.

309

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For nearly four years the Medical and
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here to the same principles, and that they
have published matter which had been sent
by advertisers presumably to many of the
medical journals in the United States, and
which was certainly sent to the Medical and
Surgical Reporter, and refused admittance

to our columns. A recent illustration of
this kind was furnished by one of our
contemporaries in November, 1890, which
contained in its editorial columns an
article that the Reporter had refused to
publish, for reasons which we think ought
to have kept it out of the columns of
a journal which is, on most points, of such
high standing. When the Editor of the
journal referred to had his attention called
to this occurrence, he made a courteously
worded reply that the editorial pages of
his journal " are not purchasable," and
that it never publishes anything referring to
a special remedy "unless the article pos-
sesses something of scientific interest."

" With this," his letter concluded, " we
will drop the subject." Now this the
Reporter regretted, and it also regrets to
see in a recent issue of the same journal,
a long article, which we presume was sent
to the Editor — as it was to the Editor of
the Reporter — by one of our most valuable
advertisers. Exactly five hundred powerful
advocates pleaded with us that this article
was "of scientific interest," but we wrote
to the advertiser stating our rule and declin-
ing to relax it.

As the Reporter remarked long ago, in
speaking of this subject, we can understand
how medical journals which have a hard
struggle to maintain their existence may
yield to the pressure of advertisers ; but we
cannot understand how journals which are
supposed to be prosperous and strong, can
publish, in columns supposed to be devoted
exclusively to scientific matter, articles which
are prepared for them by advertisers, and
which are themselves most palpable adver-
tisements. The rule of the Reporter in
this has been invariably to refuse this sort of
matter, taking the ground that its Editor is
unwilling to assume so much for his intelli-
gence and his conscientiousness as that he
could enter upon so dangerous a course with-
out risk of error on his part or deception on
the part of his readers.

We wish that all the medical journals in

Editorial.

Vol. Ixiv

the country would adopt this principle — if
it be admitted to be a correct one — or, at
least, that the strong journals should not do
what makes it harder for weaker ones, which
would like to do right, to resist a very ur-
gent form of temptation.

FILARIA SANGUINIS HOMINIS.

The occurrence of the conditions known
as chyluria, as elephantiasis, and as lymph-
scrotum has long been recognized. It is,
however, only within comparatively recent
years that their common etiological re-
lation has been established. Wucherer, in
1866, found microscopically in the urine of
a patient with chyluria a number of minute
worms. In 1872, Lewis discovered the same
parasites in the blood of man, and gave to
them the name filarila sanguinis hominis.
These were taken to be the embryos of a
nematode or round worm, the parent being
first detected by Bancroft, in 1876. The
literature on the subject has grown to con-
siderable proportions, other contributors
having been Manson, Cobbold, MacKenzie,
Leuckart and recently, Guiteras, Mastin and
De Saussure.

In the New Orleans Medical and Surgi-
cal Journal, for January, 1891, Dr. Ru-
dolph Matas reports a case of chylocele into
the vaginal tunic of the testicle, due to the
presence of filaria sanguinis hominis, and re-
views at length the whole subject.

The parasite is found principally in the
tropics, in Brazil, in Egypt, in the Indies,
in China, in Australia. It has been found
in isolated cases in the Southern United
States. The fully developed worm is from
three and a half to four inches long, and
about a hundreth in diameter, while the em-
bryo is about one hundredth in length and
one thirty-two-hundredth in diameter.

The mature worm gains entrance into the
human organism with the drinking water.
It bores its way through the wall of the
stomach or bowels into the lymphatic system,
at some point of which it becomes inter-

cepted and here propagates its offspring.
These are carried by way of the thoracic duct
into the general circulation, in which they
can be detected during the periods of rest
ordinarily at night, but by day if the pa-
tient is active by night and rests during the
day. The embryos may circulate in the
blood still enveloped in their capsules or
they may be set free. In the former condi-
tion the ova are too large to pass through
the lymphatic system, and are somewhere
detained, giving rise to lymph stasis in the
circulation behind them.

In this way, depending upon the location
of the obstruction, the various conditions of
chyluria or hemato-chyluria, chylous hydro-
cele, lymph-leg or lymph-scrotum may arise.
It seems not impossible that effusions into
the serous cavities may take place, occasion-
ing chylothorax or chylous ascites. The em-
bryos do not attain mature development in
man, but for this require the intermediation
of another host. This office is performed
by the mosquito. In its depredations, with
the blood it removes, it also carries away
some embryo filariae. The mosquito having
hatched its own ova, dies and deposits both
these and the now maturely developed fila-
riae upon the water.

Individuals harboring the filaria may en-
joy a fair degree of health, notwithstanding
the local manifestations. The condition
may exist for many years, even beyond fifty.
It is not itself directly fatal, except by its
complications. Recovery is the rule and
may be spontaneous. As the disease has its
home in warm climates, removal to colder
regions may suffice to effect a cure. The
prophylaxis thus becomes a most important
matter.

The danger is less from running water,
from that obtained from springs and artesian
wells, and greater from still water, in reser-
voirs, cisterns or tanks. In places in which
filariae are known to abound, the water
should always be boiled. Filtering or
straining alone ought not to be relied
upon.

March 14, 1891.

Book Reviews.

3ii

DIGESTION FOR ABSCESS CAVITIES.

At the last meeting of the Medical So-
ciety of the State of New York, Dr. Robert
T. Morris, of New York, in a paper on the
action of trypsin, pancreatic extract and
pepsin upon sloughs, coagula and muco-pus,
stated that the surgeon's resources were ma-
terially enlarged by adding the digestive fer-
ments to his armamentarium, and with them
liquefying putrescible material, like the lin-
ing membrane and lymph coagula and necro-
tic tissues of tuberculous abscesses.

He stated that, contrary to the presup-
posed ideas, pepsin is the best liquefier. This
material, which is perfectly harmless in any
proportions, can be best used in a ten per
cent, solution in water, acidulated with one
per cent, of hydrochloric acid. The pa-
tient should assume a position favorable for
the retention of the solution, and at the end
of an hour the liquefied dead tissues may be
washed out, and the cleaned abscess may be
then easily sterilized with peroxide of hy-
drogen.

Pepsin, Dr. Morris said, will liquefy dead
tissues in the deepest recesses of tuberculous
abscesses, and its action is ended abruptly
as soon as it reaches tissues through which
blood is circulating. Various conditions of
disease tissue suitable for pepsin treatment
were referred to in Dr. Morris's paper, and he
was inclined to expect some advantage from
association of the method he advocated with
the use of Koch's " lymph ;" for he took it
as demonstrated that Koch's lymph would
loosen and throw out masses of necrotic tissue,
and that these could then be reached with
pepsin and peroxide of hydrogen — giving
the surgeon an ideal group of materials rep-
resented by three P's — paratoloid, pepsin
and peroxide of hydrogen.

The first part of Dr. Morris's suggestion
we think deserves careful consideration.
That is, that the solvent power of pepsin
upon dead albuminoid matter may be util-
ized with advantage in the treatment of tu-
berculous abscess cavities and sinuses. The
idea is not a new one but it has never been

carried very far as yet ; and we commend it
to the notice of the readers of the Repor-
ter, for its simplicity and ease of execu-
tion.

Book Reviews.

[Any book reviewed in these columns maybe obtained upon
receipt of price, from the office of the Reporter.]

LEHRBUCH DER KLINISCHEN ARZNEIBE-
HANDLUNG. Fur Studirende und Arzte. von
Dr. Franz Penzoldt, Ordentlichem Professor und
Oberarzt der Medicinischen Poliklinik zu Erlangen.
Zweite veranderte Aufiage. Jena : Verlag von Gus-
tav Fischer, 1890. Royal 8vo, pp. xxii, 268.

TEXT-BOOK OF CLINICAL THERAPEUTICS.
For Students and Practitioners. By Dr. Franz
Penzoldt, Professor Extraordinary and Physician
in Chief at the Medical Polyclinic at Erlangen.
Second revised edition.

The first edition of this work is dated June, 1889,
the present, the second, April, 1890. The book seems
to have supplied a want in the German medical pro-
fession. A good deal of consideration has been given
to the most recent drugs, some of which, it is true,
have already proved themselves valuable medicinal
agents, while, of others, the utility is, as yet, at least
doubtful. The arrangement of subjects is somewhat
different from that to which English readers have be-
come accustomed since the advent of the physiological
method in the study and administration of remedies.
Two great divisions are made : inorganic medicaments
and carbon compounds. Under the former are pre-
sented metals and non-metals; under the latter, in
many subdivisions, the remainder of the subject. The
topics are discussed with regard to the characters and
properties of the drugs, as to their physiological ac-
tions, their toxicology, their therapeutical applications
and their diagnostic value. Many of the opinions ex-
pressed are at least not generally accepted among us,
if not at variance with our views, while some thera-
peutical applications of considerable importance are
quite ignored.

Of bismuth it is said : " Despite its ancient reputa-
tion, its therapeutical utility in various directions is not
above doubt." It is not thought to be efficacious in
gastric ulcer. "Only in certain cases of chronic diar-
rhoea, given in large doses, have certain otherwise
skeptical observers reported good results." It may be
easier to treat acute and subacute attacks of gastro-
intestinal catarrh, with nausea, vomiting and diarrhoea,
by means of opium, but bismuth is certainly the safer
remedy. Chloroform is said to be less dangerous as a
general anaesthetic than ether. Antipyrin is described
as having almost a specific action in acute articular
rheumatism.

The general indication for the administration of
digitalis is persistent cardiac weakness and its conse-
quences. The most important question is : Is the ar-
terial tension subnormal ? Such a condition is usually
associated with a small,, irregular or frequent pulse, but
not necessarily. The pulse may be regular and infre-
quent, yet digitalis may be indicated. The utility of
digitalis consists in the restoration of the ruptured
compensation, the removal of the oedema, of the cya-
nosis and of the dyspnoea.

Strychnine, it is said, may do good in certain am-

312

Notes and Comments.

Vol. Ixiv

blyopias and amauroses, but it has no other significant
therapeutic value. Strychnine i< one of our most reli-
able and active cardiac stimulants, and is useful as a
tonic in asthenic conditions. Nor is atropine given a
therapeutical place as a prompt and efficient cardiac
stimulant.

The claims of gelsemium as a remedy for neuralgia,
especially of the inferior maxillary type, are rejected.
The only indication given for the use of pepsin is
total absence of the gastric ferment, such as occurs in
atrophy of the mucous membrane of the stomach.
Even in these cases, its utility would be doubtful be-
cause of the lessened absorptive activ ty of the mucous
membrane. The good results obtained in erysipelas
by the use of pilocarpus and pilocarp ne are not alluded
to. The preparations of aconite are said to be not use-
ful. The administration of aconitine in neuralgia can-
not be recommended. >

The work may be a true reflex of German thera-
peutics, but it presents many variations from our own.
We have only noted some of the most striding differ-
ences.

CEUVRES COMPLETES DE J. M. CHARCOT.
Hemorragie et Ramollissement du Cerveau; Metal -
lotherapie et Hypnotisme ; Electrotherapie.

COMPLETE WORKS OF J. M. CHARCOT.
Hemorrhage and Softening of the Brain; Metalo-
therapy, Hypnotism and Electrotherapy. Volume
IX. Thirty-four illustrations and thirteen plates.
8vo, pp. viii, 571. Paris: Office of the Progres
Medical, 1 890. Price, 15 francs.

This volume contains Prof. Charcot's writings upon
cerebral hemorrhage, which he believes to be due, in
the majority of cases, to miliary aneurisms of the small
arteries of the brain. Abstracts of eighty-seven cases
are given in support of his opinion. As regards soft-
ening of the brain, he accepts the view which attrib-
utes the softening to an alteration of nutrition follow-
ing upon embolism, atheroma or thrombosis. There
are also important papers on joint-diseases apparently
due to diseases of the brain and cord. The second
part of the book is devoted to metaloscopy, metalo-
therapy and hypnotism. In the third and concluding
part, Prof. Charcot speaks of electrotherapy, and espe-
cially of the use of static electricity in medicine.

The whole book is a mine of information, and will
prove invaluable to students of nervous diseases.

Notes and Comments.

Congenital Occlusion of the Urethra.

An interesting example of congenital ob-
struction to urination is given by Dr. James
Adams, of Eastbourne, in the British Medical
Journal, January 31,1891. Dr. Adams says :
My attention has been directed to this rare
condition by a case which occurred in my
practice in October, 1889. I attended a con-
finement, and after a natural labor a male
child was born at full term, who was well
formed, and in every respect apparently
normal, except he was the subject of hypos-

padias. Two hours afterwards I was sent
for to see the child, because the nurse, who
was a trained and intelligent woman, thought
something was wrong, as the infant, although
he had been bathed and dressed, and had
passed a motion, had not micturated. The
meatus was patent, so I tried to pass a small
blunt silver probe down the urethra, but it
would go only a very short distance. I di-
rected the nurse to give the child a warm
bath and keep him in the water for fifteen
minutes, and to repeat the bath two or three
times during the next twelve hours if no
urine passed.

The next morning, fifteen hours after
birth, I found that no urine had been passed
and the child was beginning to be restless
and uneasy, but without symptoms of dis-
tress. I again tried to pass, with all gentle-
ness, the silver probe, and failed to get it
further than the previous attempt. I now
took a small French catheter, and that seemed
to be brought up at the same distance from
the meatus. Being a non-metallic instru-
ment, I used as much force as it would bear,
but did not succeed in getting beyond the
obstruction. I withdrew the catheter and
tried again, and this time succeeded in pene-
trating what I believe to have been a thin
membranous structure which was occluding
the urethra. The urine came freely through
the catheter, and I had no further trouble
with the case.

It is open to remark that the urethra
might not have been occluded, being merely
narrowed by a congenital stricture, or that
the urethra was of normal caliber, and that
its sides were agglutinated by inspissated
secretion. While I am unable to disprove
either of these opinions, I may say that had
it, been a stricture I should have expected
subsequent trouble, and had it been the other
condition I should have expected the hot
baths externally, and the effect of the warm
urine internally on the vesical side of the
obstruction to have caused its disappearance.
Another point tending to support my view
that it was an organic occlusion of the
urethra is the fact of the infant being a
hypospadias showing some developmental
abnormality of the mesoblast in this region.
And in a case of congenital occlusion re-
ported by Mr. Forster, of Darlington, in
the British Medical Journal of January 3,
1885, the infant was also the subject of
hypospadias.

The only other instance I have met with
of this condition was in 1878. This was a

March 14, 1891. Notes and Comments.

313

premature child, born at seven mouths, and
a weakly specimen for that age. I was un-
able to pass a probe or catheter, and the
child died forty-eight hours after birth, never
having passed any urine. The child was
too feeble to bear any further surgical pro-
ceedings, even if the parents would have
consented.

The literature of this subject is very scanty,
and in several of our English text-books no
reference is made to it. American works
contain the fullest account of it, and I
quote the following by Professor Duplay
from The International Encyclopaedia of Sur-
gery, edited by John Ashhurst, M. D. :

" These occlusions, which result from
gluing together of the two corresponding
halves of the penis, may occupy any point
in the canal, but the meatus urinarius is the
seat of election. Sometimes the mucous
membrane of the glans is seen to pass in
front of the meatus without anything being
seen at this point which could indicate the
existence of an orifice. . . . Most fre-
quently the meatus is well formed, and ends
in a cul de sac at a distance of a few milli-
meters. We have only a very small number
of examples of occlusions situated at other
points of the canal. The diagnosis is espe-
cially easy when the occlusion is in the
meatus or in the fossa navicularis. Deeper
occlusions may escape the first examination,
but the effectual effort of the infant to uri-
nate, and sounding with a curved stylet or
very small catheter will usually render error
impossible."

I will also give the short description
found in Gross's Surgery ;

" The most common of these congenital
vices are first closure or contraction of the
meatus ; and, secondly, absence, contrac-
tion and change of form of the urethra.
Occlusion of the external meatus always de-
mands prompt interference. When it is
caused simply by aduplicature of the lining
membrane forming a sort of hymen, a verti-
cal incision in the direction of the natural
outlet is generally all that is required, the
edges of the wound -being kept asunder by
means of a bougie. When the imperfora-
tion depends upon the presence of fibrous
tissue, and reaches a considerable distance
back, the operation will be more serious,
and will require to be performed with a
trocar. ' '

The diagnosis in these cases is easily made,
for the subjects are newly-born infants who
are unable to pass water, and if the obstruc-

tion is at the meatus the condition is at
once recognized, and if the obstruction is
further down the urethra, the use of the
catheter makes it evident. If the surgeon
is unable to penetrate the obstruction by
means of a soft catheter, he cannot judge
how far the occlusion extends between the
point where the catheter is brought up and
the bladder, as it may involve the whole of
that portion of the urethra, or only a small
part of it.

On the question of treatment the proper
course to adopt is clear where the occlusion
consists of a membranous veil covering the
meatus. This veil must be incised, and the
orifice kept patent by passing a bougie
daily for a week or ten days. Also in cases
similar to mine, where a non-metallic cathe-
ter can be with moderate force thrust through
the soft and easily lacerable membrane oc-
cluding the urethra, this treatment is clearly
the one to follow ; but in those still rarer
cases where the urethra is obliterated for
some distance, it appears to me there pre-
sents itself to the surgeon a most unfavor-
able condition to deal with satisfactorily.

Three courses are open, namely (i) forc-
ing a passage by means of a curved stylet,
or small curved trocar and canula; (2)
perineal cystotomy; (3) suprapubic punc-
ture. The objection to forcing a passage
is that it is an unsurgical and hazardous pro-
ceeding, and that you are working in the
dark and have no guide to rely on. If you
reach the bladder so much the better for
your patient, for your treatment saves his
life and leaves him with a urethra in its
normal position.

Another agument in favor of this course
is that it has been adopted with success,
notably in the case mentioned above, where
the urethra was said to be wholly obliterated.
With regard to perineal cystotomy by the
median method with the finger in the rec-
tum, the distance to reach the bladder is
short, and as it would be distended, one
would feel more certainty of finding it than
by the first plan. But I should give the
preference to suprapubic puncture by small
trocar as being simplest and safest, and I
should fix in a rubber catheter and wait upon
events. Afterwards, when the child was
old enough, the suprapubic opening might
be enlarged, the bladder explored, and a
passage made from its interior by means of
a curved trocar and canula as near along
the normal position of the urethra as could
be ascertained.

3H

Notes and

Comments.

Vol. lxiv

Medical and Social Aspects of Abor-
tion.

At the Third General Meeting of Russian
Medical Men at St. Petersburg, Dr. Natalia
V. Thalberg, a woman doctor of Kiev, read
a communication (Proceedings, No. 8, 1889,
p. 256) on criminal abortion, and a rational
struggle against that steadily progressing so-
cial evil. She says that a considerable num-
ber of cases of artificial abortion give rise
to grave and permanent disturbances in the
woman's health, not unfrequently ending in
death. Both in Western Europe and also
in Russia, criminal abortion has at present
attained great dimensions and manifests un-
mistakably a harmful influence on the health
of the population. A truly regretful cir-
cumstance is the increasing assistance in the
matter rendered to women by the members
of the medical profession ; and its ill-effect
is enhanced by the fact that often medical
art proves powerless to obviate the injurious
effects of the abortion it produces, due es-
pecially to a hasty and clumsy performance
of the operation, and also to the violation
of elementary rules of precaution during the
after- period. Apart from austere views en-
tertained by modern society in regard to
an extra-matrimonial pregnancy, and from
increasing poverty, the main causes of a
progressive increase of abortion are : defec-
tive moral and mental education of women,
and woman's ignorance of the criminality
of abortion, and especially of its harmful
effects on her own health. An indirect but
still powerful cause of the .spread of abor-
tion is found in the defective sense and
principles of those members of the medical
profession who render their assistance in
the matter.

In view of these facts, a rational struggle
against the evil demands joint action by the
authorities and by the medical profession.
The initiative in the matter belongs un-
doubtedly to the profession, since the medi-
cal man, whom both married and single
women solicit to procure abortion, knows
best the consequences of its performance.
Hence, an imperative duty arises for the
profession to draw the attention of the com-
munity to the evil, to elucidate its causa-
tion, and to find out effective means for its
prevention.

Dr. Thalberg suggests the following meas-
ures to restrict criminal abortion : 1. To re-
duce to the lowest point possible the legal
punishment of women who have abortions

performed, since severe laws have not
served to prevent them 'from undergoing the
operation, while they act powerfully in re-
straining them from denouncing the abor-
tionist. 2. To disseminate knowledge of
the injurious effects and dangers of abortion,
by means of pamphlets, public lectures, etc.
3. To establish numerous lying-in hospitals
and homes for foundlings all over the coun-
try. 4. To promote the education of women
tending to elevate their mental and moral
level.

[Our Russian translator suggests that we
may take the liberty to express doubt in
regard to the actual degree of effectiveness of
measures proposed by Dr. Thalberg. Ob-
viously, her measures are nothing else than
mere palliatives. However humane, they
do not touch in the least the cardinal etio-
logical factors of the social evil. Those
factors are (1), in Russia, an appallingly
progressing wholesale pauperism which, on
one hand, makes the establishment of a
'•'legal" family less and less accessible,
because of its expensiveness ; and, on the
other hand, converts the appearance of every
child into a true disaster, and (2), the ethi-
cally immoral moral codex of the modern
"civilized" community, which sentences
to social death every unhappy woman who,
having no possibility or opportunity for
establishing a " legal " home, gives way to
temptation to the performance of her sexual
functions. He says that only those meas-
ures can prove effective against the slaughter
of intra-uterine children, which honestly and
courageously strive to improve the econom-
ical conditions of the community and to
humanize the moral codex of the latter.
None of the great social evils undermining
the modern community can possibly be
remedied by moralizing or by legal and
hygienic trifles which leave intact the
essence of the matter.]

Country Practice.

In the Medical World, March, 1891, there
is a letter from Dr. George R. Robbins, of
Hamilton Square, N. J., which gives a de-
scription of some of the experiences of a
country practice, which we are sure will be
read with interest and sympathy by many of
the subscribers to the Reporter.

Of obstetrical work Dr. Robbins, who has
been in practice twenty-one years, says :
" You will be taught not to approach an ob-
stetericcase without fortifying yourself with

March 14, 1891. Notes and

Comments.

315

an armful of instruments, carboli zed silk to
tie the cord, bichloride for washing hands,
iron, ergot, chloroform, morphine, turpen-
tine, quinine, etc. — a whole bagful of bottles
— all good. They will serve you if you have
the money to buy them. I have attended
. cases of confinement after waiting for hours
asleep in a wood-box behind the stove ; not
a rag to dress the child ; tied the cord with
a piece of my shoe-string, cutting the cord
with an old rusty butcher knife, all with
good results.

"Imagine yourself summoned to attend a
case of labor. You approach the house
with your grained leather obstetrical bag,
containing forceps, craniotomy instruments,
blunt-pointed scissors, spring lancet, carbo-
lized silk, absorbent cotton, drugs as enu-
merated above, etc. You enter the waiting
room', carpeted with brussels, with velvet
plush reclining chair, with foot-rest before
the grate. You are informed that you are
the sole possessor of that room when not
required in the adjoining one. At the proper
time you approach your patient, notice all
silk-lined paraphernalia for little 1 teetsy-
weetsy,' with all kinds of powders, puffs,
pastes, etc. When your blessed one is com-
fortable you are furnished with warm diluted
Florida water and bouquet soap to wash with,
and May-bloom to. complete your toilet.
Splendid. But you may thank your stars if
you do not get your sleep in a wood-box,
and after the earth has been gladdened
with that familiar ' squall,' go down to the
ditch and wash your hands the same as I
have done. I have made my splints for
fractures from barrel staves, shingles, cigar
boxes, leather, pasteboard, anything. I
performed my first craniotomy alone, deliv-
ering the child, weighing sixteen pounds,
saved the mother, all with a jack-knife,
which I borrowed from the woman's hus-
band, and my tooth forceps. Why did I
do it with these tools? Because I had no
proper instruments and was too poor to buy
them at that time."

New Method of Detecting Tubercle
Bacilli.

The Lancet, February 7, says : Dr. Biedert,
of Hagenau, in Alsace, has devised a new and
considerably surer method for the discovery
of tubercle bacilli in sputum. He collects a
tablespoonful or more of the sputum, mixes
it well with a glass rod, takes some of it and
stirs it together with two tablespoonfuls of

water and four to eight drops of solution of
caustic soda according to the density of the
sputum, and then boils it, stirring it the
while in a shallow cup, gradually adding
four to six tablespoonfuls of water till he
gefs a pretty thin fluid mass. This he allows
to stand for two hours in a high glass taper-
ing as finely as possible downwards, and all
the formed particles sink with the tubercle
bacilli to the bottom. Then he pours off
the fluid, retaining the sediment, parts of
which he takes out with a platinum needle
and rubs them fine on a cover-glass. When
the preparation is dry he passes it through a
flame, stains it with a carbolized solution of
fuchsine, and then bleaches it with' 25 per
cent, sulphuric acid. If there are any tu-
bercle bacilli they remain red, and are thus
distinguishable under the microscope. Even
a single bacillus is discoverable in this way,
whereas the older methods yielded a positive
result only if there were many.

Trained Nurses.

In an address delivered before the Boston
City School, an abstract of which appears
in The Nightingale, January 31, 1891, Dr.
Chas. M. Green makes some timely remarks
upon the duties and conduct of the trained
nurse. He says :

The nurse's duty to the patient consists
chiefly in faithfully carrying out the physi-
cian's directions, in accordance with her
previous training, unless the doctor specifies
other methods.

The nurse's manner in the sick-room
should always be cheerful and hopeful. No
matter how grave the case, she should never
betray in her face or manner the anxiety she
may feel. She should hold no long or whis-
pered interviews with the physician, or
members of the family, within sight or hear-
ing of the patient : such conduct always ex-
cites suspicion in the patient's mind that his
case is not progressing favorably, and deep-
ens the forebodings which patients are prone
to cherish. She should never announce in
the sick-room the patient's temperature, or
give other information about the case than
that which is favorable and encouraging.
Her report to the physician should be made
in an adjoining room. Startling news or
private grievances should never be made
known in the sick-room. All medicines
and other appliances of the sick-room should
be kept in an adjoining chamber ; but if
this is impossible, they should be neatly ar-

316

Notes and

Comments.

Vol. lxiv

ranged upon a table, and perhaps hidden
with a screen ; some patients have a horror
of gazing upon the cups, bottles and spoons,
which remind them of their condition.

Unless the continued presence of the
nurse is necessary in the sick-room, she
should leave the physician alone with the
patient during a part of his visit. There
may be some confidences between patient
and doctor which it is desired she should
not share. When members of the family
visit the patient, if that is allowed, the
nurse should withdraw for a time, for obvi-
ous reasons ; this will give her time for rest
and relaxation, and the patient an opportu-
nity for a few minutes' privacy with his fam-
ily.

As the patient enters upon his convales-
cence, he usually begins to take a lively in-
terest in what he can eat, or he may be led
to do so. Then the nurse has an opportu-
nity to use her taste in the serving of his food ;
for we all know how much better everything
tastes when it is daintily served.

Above all things, the nurse should not
gossip. Patients will often listen with the
greatest interest to what she may say of other
cases and people, and then wonder after-
wards whether she will not, at her next case,
portray the scenes of their sick-room. A
high-minded nurse should remember that
she has no right to trifle with the sacred
confidence of the sick-room, or carry be-
yond its walls the private affairs which have
necessarily come to her knowledge. The
nurse should not at first seek to displace
from the sick-room members of the family
who are in attendance upon the patient ;
they are often loath to give up one dear to
them to the care of a stranger, and unwill-
ing to be directed by the nurse. She should,
therefore, manifest her willingness to assist
them, and gradually they will perceive that
she is far better fitted than they for the
duties of the sick-room, and will gracefully
yield to her the position which it is her prov-
ince to occupy. A nurse should be willing
to go beyond the limits of her legitimate
work, if she can do so without neglecting
her proper duties. It always pays to be
obliging in every walk of life; and the
nurse who is willing to wash some needed
article of dress, to bind up a sore finger,
mend a broken shoe string, or sew on a but-
ton, will be popular in any household. All
that has been said about gossiping in the
sick-room applies with equal force in the
household. Family secrets will necessarily

come to the knowledge of the nurse, and
she should guard them as religiously as those
of the patient ; her duty in this respect is the
same with that of the doctor.

The nurse will generally be asked where
she wishes to take her meals; the reply
should be: " Wherever it is most conve-
nient to the family," adding, "in the din-
ing-room, after the family is served, if it is
agreeable." If the family breakfasts late,
however, she may ask to have her breakfast
earlier. It is probably not agreeable to the
nurse to eat with the family, even if she is
asked to do so ; and if so asked, it would
be right for her in a quiet way to mention
one of the many reasons why she had best
not do so. When the patient is very sick,
it may be necessary that the nurse should
be served on a tray in an adjoining cham-
ber. Sometimes the nurse is expected to eat
in the kitchen. It is well to advise the family
that it is best that the nurse should be in the
kitchen as little as possible ; and that if she
has to eat with the servants, it will be hard
for her, without giving offense to them, to
remain loyal to her duty in respect to the
secrets of the sick-room. When, however,
the nurse's duty takes her to the kitchen,
perhaps to prepare some article of food for
the patient, she should always greet the ser-
vants kindly, and assume no superiority. A
nurse can, by her gentleness and tact, so
win the regard of a large corps of servants
that they will almost bow down and worship
her. Such a nurse is never without engage-
ments, and does much to increase the de-
mand for trained nurses in the community.

Control of Sources of Water Supply.

The Engineering Record, February 14,
189T, says :

The question of the control of sources of
water supply is one of great and increasing
importance, and the necessity of obtaining
an abundant supply of pure and wholesome
water for household use is a universal one.
In sparsely settled districts of this country,
or in small communities, it is usually an
easy matter to obtain it from local springs
or properly located wells. But when small
communities have grown into towns, and
towns into cities, many difficulties are en-
countered. Local sources of supply become
contaminated, and the demand being a large
and concentrated one; the supply frequently
has to be sought at considerable distances.
Even then, especially in the more thickly

March 14, 1891. Notes and

Comments.

317

settled portions of the country, it requires
constant care to keep the sources of supply
free from defilement.

The right to the use of water for the sup-
ply of cities and towns must necessarily take
precedence over all individual or corporate
claims to ownership for manufacturing or
other purposes, and it is generally the case
that communities, seeking a public supply,
are authorized by State legislation to acquire,
by the right of eminent domain, any water
that may be needed for this purpose, pay-
ing, of course, for all damages sustained by
mill owners or riparian proprietors from its
appropriation or diversion.

With the danger of this constantly in-
creasing demand producing a scarcity of
wholesome water available for city uses, it
seems important that some steps should be
taken to guard against undue appropriation
of sources of supply by one city, far beyond
its present needs, and at the expense of other
cities in the same State; and still more
against the monopoly by syndicates of all
desirable sources of supply in a State or dis-
trict, for the purpose of ''making a corner"
in water and compelling the cities to buy of
them, in one form or another, at a greatly
enhanced cost. We have constantly advo-
cated the desirability of cities owning their
own systems of water supply when practica-
ble; still we have been willing to acknowl-
edge that there are cases in which private
ownership is admissible, since otherwise, for
various reasons, the construction of the
works would be indefinitely postponed —
and a private supply is certainly better than
no supply at all. The legal incorporation,
therefore, of a private company for supply-
ing water to a given place; endowing it with
the necessary powers to accomplish this ob-
ject, is not a subject of criticism.

This, however, is quite a different matter
from the incorporation of a company with
general powers to appropriate all the water
supplies of a State, and to furnish more or
less water from them to any places it may
see fit to contract with for this purpose. It
is very questionable if the purchase of the
mill powers of a stream or the shores of a
lake or pond by such a corporation entitles
it to the absolute ownership of the water for
any other purpose. In any case, it would
certainly seem as if a city should have the
same right of condemnation of water for its
necessities against any such corporation or
syndicate, as against any private parties, and
that, moreover, it should not be compelled

to pay any fancy price for it — any more, in
fact, than the actual damage which its di-
version may cause to manufacturing or ripa-
rian interests. Speculation in land, which,
it is expected, a city or State may have to
condemn for its own use, seems to be an
unavoidable evil ; but no good reason can
be advanced why a private corporation, for
the same speculative purposes, should be
permitted to monopolize water supplies by
granting it the same absolute ownership
therein as in lands.

This question of the control and conser-
vation of water supplies has been exciting a
good deal of interest recently in the State
of New Jersey, and Governor Abbett seems
to fully appreciate its importance, as is in-
dicated by his recent message to the Legis-
lature.

Parasitic Chylocele in New Orleans.

The filaria sanguinis hominis is a curious
parasite which has been proved to be the
cause of chyluria, chylocele and elephantoid
affections of the scrotum and lower extrem-
ities. These diseases are relatively common
in the East Indies, and are met with in the
West Indies and South America. Dr. John
Guiteras, Dr. William Mastin, and Dr. De
Saussure have also reported cases occurring
in the South Atlantic and Gulf States, es-
pecially in Charleston, S. C. Dr. Rudolph
Matas adds another case to the comparatively
short list in a paper published in the New
Orleans Medical and Surgical Journal, Jan-
uary, 1 89 1. The case is interesting as an
instance of accurate clinical diagnosis, sub-
sequently confirmed by pathological study ;
but it also shows that the filarial diseases
may in future become common in that part
of the country. For while the patient was
a native of Cuba, and in all probability be-
came infected there, yet he had lived in
New Orleans nine months before he came
under observation for chylocele of the testi-
cle. This fact of course proves that the cli-
matic conditions of New Orleans, as those
of Charleston, are well adapted to the de-
velopment of the filaria. In Dr. Matas's
case the embryos of the filaria were found
in the chylous fluid from the testicle and also
in the blood.

Dr. Matas reports his case with great care,
and adds much to the value of his paper by
giving a very interesting account of the first
discovery of the filaria, its life history, and
of the diseases caused by it, with a few re-

3i8

Resolution.

Vol. lxiv

marks on prognosis and treatment. When
the adult female parasite can not be discov-
ered, and usually it can not, Dr. Matas
thinks the most important therapeutic meas-
ure is removal to a cold climate and a high
altitude. Such a radical change in the
environment of the best gradually brings
about the destruction of the parasites.

Relationship of the Diseases of
Animals to those of Man.

The Medical Press, January 28, 1891,
says : The discussions which have recently
taken place as to the causation and preven-
tion of tuberculosis, have invested with a
peculiar interest the question of the rela-
tions of the diseases of the lower animals
to those of man. The subject is one to
which attention has not been long directed,
but even at this early stage, it bids fair to
add considerably to our knowledge in respect
of the prophylaxis of certain transmissible
diseases. The matter, as a whole, has been
assigned a special section in the Congress of
Hygiene which is to take place in London
in August next, and the section will take
into consideration, inter alia, the infectious,
contagious, parasitic, and other diseases com-
municable from animals to man, and vice
versa ; the methods of the propagation of
diseases affecting mankind by means of ani-
mals and animal products ; the infection
of meat, milk and. other comestibles; and
the restrictions to be placed upon the sale
of infected food and the movements of in-
fected animals. On each of these questions
papers will be obtained from the highest
British and Continental authorities as the
basis of the debates, which ought, therefore,
to prove exceedingly instructive and inter-
esting. Though less attractive, the preven-
tion of tuberculosis and kindred diseases
is vastly more important than their cure, and
promises very much more satisfactory re-
sults.

Infectiousness of Croupous Pneumo-
nia.

'In the Bolnitclmaia Gazeta Botkina, No.
29, 1890, p. 714, Dr. Nil I. Sokoloff, senior
house physician to the Alexandrovsky Pavil-
ion Hospital, St. Petersburg, publishes a valu-
able paper in which he brings forward the
following several propositions. 1. Croup-
ous pneumonia represents, most undoubtedly,
an infectious disease, which (in hospitals)

spreads from man to man very much in the
same way as erysipelas. 2. Patients suffer-
ing from typhoid, typhus and relapsing fe-
vers manifest a quite peculiar predisposition
to catch the infection. 3. The mortality
amongst such patients contracting pneumo-
nia is truly enormous (about 65 per cent.).
4. In view of the fact, all hospitals should
be furnished with special wards for pneumo-
nic patients. 5. As soon as a typhoid pa-
tient, when staying in the hospital, develops
signs of pneumonia, he must be at once iso-
lated, and the ward most strictly disinfected.
6. No ward which has been occupied by
pneumonia cases can be subsequently used
for other patients without a preceding
thorough disinfection. 7. In view of a gen-
erally high mortality from pneumonia
(amounting to 1 2 per cent, under best man-
agement of the cases) ; and of the infec-
tiousness of the disease, the appearance of an
epidemic of croupous pneumonia in the town
given should always constitute an imperative
indication for adopting strictest general san-
itary measures. 8. Every one and all of
hospitals should keep special isolation wards
for admitting diagnostically obscure cases of
infectious affections.

Hemoglobinuria from the Use of
Quinine.

Dr. Coromilas, of Calamata, Greece, in
the Journal de Medecinet January 25, 1891,
reports six cases in which hemoglobinuria
repeatedly followed the administration of
quinine. None of the patients could take
the sulphate, two could not take cinchona
in any form, one not the salicylate, one not
the valerianate, one not the hydrochlorate
of quinine, without the occurrence of hemo-
globinuria ; while two could take cinchona,
and one of these the salicylate of quinine
also with safety.

Resolution.

Woman's Medical College of Pennsyl-
vania.
Philadelphia, Pa.

Dean's Office, Feb. 21, 1891.
Resolved, that the Faculty of the Woman's
Medical College of Pennsylvania approves of
the present bill of Hon. Frank M. Riter to
establish a State Board of Medical Exami-
ners and Licensers.

Clara Marshall, Dean.

Medical and surgical
Reporter

A Weekly Journal. Established in 1853 by S. W. Butler, M. D

CLLaRLES W. DULLES, M. D., Editor and Publisher,

Entered as Second-Class matter at Philadelphia P. O N. E. COR. 13th & WALNUT STS./ PHILADELPHIA

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COUTET^TS :

CLINICAL LECTURE. eases of the Lungs.— Local Treatment of Tuber-
culosis of the Larynx 331-336

Goodell, William, M. D., Philadelphia, Pa. —
Malignant Disease of the Pelvis in a Girl under
Fifteen Years of Age.— Operation 319

COMMUNICATIONS.

EDITORIALS.

Koch's Fluid in Non-Tuberculous Persons 337

Treatment of Anemia 338

Treatment op Asthma in Children 339

Dodge, C. L., M. D., Kingston, N. Y.— Membra-
nous Croup 322 BOOK REVIEWS.

Mover, Harold N.. M. D., Chicago, Illinois.— T „, „. _ . .. „ „ . .

Medical Jurisprudence of Railway Surgery 327 Jastrow ; The lime Relations ol Mental Phe-

Shipps. William H., M. D , Bordefitown, N. J. — nonxena -Flint; A Manual of Auscultation

Traumatic Neurosis. -Temporary Insanity fol- and Percussion -Gross ; A Practical Treatise

lowing Operation for Abscess . 328 ! on Impotence, Sterility and Allied Disorders of

& 1 the Male Sexual Organs 339-340

FOREIGN CORRESPONDENCE. CORRESPONDENCE.

Berlin Letter. — The Latest Developments in the Electricity and Pelvic Surgery 340

Tuberculine Question.— Koch Worried and In-

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NOTES AND COMMENTS.

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MEDICAL AND SURGICAL
REPORTER

No. 1777. PHILADELPHIA, MARCH 21, 1891. Vol. LXIV.— No. 12.

Clinical Lecture.

MALIGNANT DISEASE OF THE PEL-
VIS IN A GIRL UNDER FIFTEEN
YEARS OF AGE.— OPERATION.1

BY WILLIAM GOODELL, M. D.,

PHILADELPHIA.

Gentlemen : To-day I have a case for op-
eration. We have been preparing the in-
struments while the patient is being ether-
ized. I have in this tray fifteen of the
smaller hemostatic forceps and four of the
larger. These numbers have been written
down on a piece of paper. In addition, I
have one knife, one teneculum, one grooved
director, scissors, aneurism needle and a
needle holder. These I do not put down,
because they are invariably present, and
they are not likely to get into the abdominal
cavity. We have also marked down the
number of sponges which we have. There
are nine. It is very important to keep the
record of these articles, for I have collected
some thirty cases in which a sponge or a for-
ceps has been left in the abdomen. I shall
not soon forget the great distress and anxi-
ety I had after an operation some years ago.
I went into the country to perform an ovari-
otomy, and having no skilled assistant I had
to supervise everything. I thought I had
the number .of sponges impressed upon my
mind, but after the operation was over I
had forgotten their number, and I was un-
able to say whether I had all the sponges or
not. All that night on the train I was kept
awake by my anxiety in regard to this point.
I knew that when I got home I should be
able to tell by the number of sponges which
remained in their jar. On arriving, I was

1 Delivered at the Hospital of the University of
Pennsylvania.

greatly relieved, indeed delighted, to find
that I had them all. Since then, I always
make it a point to write the number down.

Here is the patient, a girl not yet fifteen
years of age. Last January she noticed that
she was larger than she should be. Men-
struation has gone on regularly. I happened
to be in the town where she lived, to per-
form an abdominal section, and her physi-
cian asked me to see her. I examined the
case carefully, and made up my mind that
she had a tumor, which probably was malig-
nant. Of course the question of pregnancy
was not overlooked. I examined the breasts,
vagina and cervix uteri carefully. I found
the hymen present. But that would not
exclude the idea of pregnancy; for there
are many cases on record in which a hymen
has been unruptured, with perhaps only a
pin-hole opening, and yet pregnancy has
occurred. Day before yesterday I examined
her with the sound, and found the womb
absolutely immovable. It is pushed against
the pubic bone on the left side and flattened.
The tumor comes into the vagina as far down
as Douglas's pouch, so that I am afraid we
have pelvic adhesions. It perhaps is an in-
tra-ligamentary cyst that has formed be-
tween the layers of the broad ligament.
Such a tumor as this cannot escape upward ;
and it grows downward, dissecting off the
peritoneum from the pelvic cavity. In these
cases of apparently firm fixation from adhe-
sions, however, I have sometimes been agree-
ably disappointed. I have found that the
tumor was retained in the pelvis simply by
the suction from close contact with the pel-
vic walls. When boys, you have seen heavy
stones lifted with a wet piece of round
leather to which a string was attached. The
wet leather is pressed upon the stone and is
kept in firm contact with it by asmospheric
pressure through the vacuum under the
leather. This is sometimes the case with
these tumors. They are held down in the
pelvis by this kind of suction and not by

319

320

Clinical

Lecture.

Vol. lxiv

adhesions. Fearing, however, that we may
meet with bad adhesions I have the Paquelin
cautery ready, and have asked Dr. Taylor
to supervise it. The abdomen has been thor-
oughly cleaned, and scrubbed, and washed
with the antiseptic solution.

There is evident fluctuation in this tumor,
which is irregular in shape. After estimat-
ing the thickness of the abdominal wall by
grasping it between my fingers, I make the
incision. I do this boldly, because I am
sure that there are no intestines in front of
the tumor. Reaching the recti muscles I
search for the line of junction and at once
come down upon the prae-peritoneal fat.
Checking the bleeding with forceps, I raise
the tissue with two other forceps, and open
it by cutting between them. Then I come
to another layer, which I catch up and in-
cise in the same way. This opens the peri-
toneal cavity and exposes the tumor, which
has the appearance of a malignant growth.
As it is evident that we shall have bleeding,
I enlarge the abdominal incision freely, in
order to have working room. The walls of
the tumor are extremely thin, and the least
manipulation causes them to burst ; and you
see that the thick substance which is escap-
ing resembles cerebral matter. To the up-
per portion the omentum is attached. This
I separate and catch temporarily. Here is
the left Fallopian tube spread out over the
growth. As I try to turn out the tumor it
breaks at every point. The growth involves
the whole broad ligament, and it is very
difficult to detach it. In order to get rid
of the attachment of the omentum at the
upper portion of the tumor, I tie it en masse
and cut it off. I never met with a growth
exactly like this before. The whole broad
ligament is the seat of disease, and the
bleeding is very free. The diseased mass
is probably malignant, for it extends down
deep into Douglas's cul-de-sac, and has at-
tacked the pelvic walls so that it is impossi-
ble to remove it wholly. All that I can do
is to check the alarming bleeding and re-
move as much of the growth as possible. It
will be necessary to insert. cobbler's stitches
across the whole extent of the broad liga-
ment. This I do, tying the stitches at short
intervals. The womb also is implicated and
it will have to be removed. This is done
by transfixing the cervix, tying it on either
side by a double ligature, cutting off the
uterine body, and then sewing the edges of
the stump to one another by gut sutures.

Considering the nature of this disease and

its extensive ravages, it is surprising how
little this girl has suffered.

As you see, her condition is a very serious
one, for the shock has been great. Her
pulse is extremely weak and there is great
danger of her dying On the table. We have
been giving her hypodermic injections of
strychnia and digitalis. Had I known be-
forehand what would have to be encount-
ered I should not have operated ; but hav-
ing begun, I was forced to continue. I
irrigate the abdominal cavity thoroughly
and insert a drainage-tube and close the ab-
domen. I have been fortunate in controll-
ing the bleeding so easily. These are the
cases in which it is sometimes necessary to
pack the abdominal cavity with gauze and
to leave it there for several days.

The whole back portion of the uterus has
been eaten away by the disease. It looks
as if gnawed by rats. The omentum, broad
ligament and pelvic tissues are also involved.
This is the first time that I have ever re-
moved a womb by abdominal section for
cancer of its body. I have extirpated the
whole organ per vaginam, but that is alto-
gether a different operation. The disease
in this case probably began in the ovaries,
for I came across a cyst which had the
mother-of-pearl appearance found only in
ovarian tumors. I performed the operation
with all the ordinary care and precaution;
but I do not see how it is possible for this girl
to get well, although she may possibly recover
from the operation. This, however, is even
doubtful, for she has lost much blood and
is fearfully collapsed, and may die in a few
minutes.

. You may ask me, Did I ever lose
a patient on the table ? Yes ; I once had
that misfortune. Some years ago I was
called to a distant town to see a woman
with cancer. While there, the physicians
present told me that there was in the town a
poor school teacher who had been bed-rid-
den for months, with obstinate constipation
and vomiting, caused by the presence of an
abdominal tumor. She was frightfully weak,
and emaciated and bed-ridden. I found
that she had two ovarian tumors, and also a
bad stricture of the rectum. I promised
that if the physicians would dilate the strict-
ure and thereby get her into better shape,
I would come and remove the tumors, al-
though it was a very hazardous case, and
that, in her weak condition, if the cysts
were adherent she would most likely not re-
cover from the operation. Well, after the

March 21, 1891. Clinical

Lecture.

321

1 lapse of six or more weeks the physicians
wrote to me that the vomiting had been
; checked to some extent, and that her gen-
eral condition was .better. I therefore went
1 up and performed the operation, although
: she was still dreadfully weak. Only one of
: the gentlemen had ever seen an abdominal
section before, and they all watched the op-
eration with a great deal of interest, and I,

• not having a skilled assistant, was equally
] intent. The tumors were removed after a
' somewhat serious operation, and I was con-
gratulating myself that everything had gone
along so well, and had indeed begun to sew

: up the wound, when the physician who was
i giving ether said that the patient had
stopped breathing. We tried in vain to
resuscitate her. She was dead, and we were
I all greatly shocked. Then came up the
; question who should inform the family, and
the two attending physicians begged me to
do it. I broke the bad news as gently as I
could, but it was a hard task, the hardest I
ever undertook. In a small country town
bad news travels fast, and when we left the
house we were buttonholed at every corner
and had to repeat the sad story over and
over again. Naturally, I did not feel like
remaining in the town any longer than was
possible, but there was no train until even-
ing ; so I telegraphed to the main office of
the railroad company and asked the head
official to let an express train stop for me,
early in the afternoon, which he was kind
enough to do. But while waiting for it at
the station, I had to go over the story again
to some bystanders. One of the attending
physicians was a man weighing some two
hundred and fifty pounds. A few weeks
after the operation his wife wrote to me,
stating that her husband's health was failing,
and she described his symptoms, which were
those of diabetes. I told her to get some
of his urine without his knowledge, and send
it to me. This was examined and found to
contain sugar. I therefore wrote to him,
explaining what we had done, and advising

• him to consult a specialist. He did so, but
got no better. Finally he went to a warmer
part of the country and stayed there, strug-
gling desperately to live, but he finally died.
I believe that he had had a latent tendency
to diabetes at the time of the operation, and
that the shock of our patient's death devel-
oped it at once.

Some years ago a well-known English
surgeon came to this country, apparently
well. While in this country he received a

terrible mental shock, and at once his health
went down. Albumin, I think, was found
in his case ; but I am not sure whether it
was albumin or sugar. He continued to fail,
and that so rapidly that he died at sea while
on his way home.

I do not recollect having had any other
patient die on the table, but we have had
some very close calls. The woman on whom
I operated last Friday in the ward class came
very near dying on the table. We had to
stop twice during the operation, which was
undertaken for the removal of a pus sac.
The patient was greatly reduced and had a
high temperature with a pulse of 130. After
the operation the temperature came down,
and since the operation it has not been over
99°-

I do not think that this girl will live over
forty-eight hours, for in her condition, re-
duced as it is by a malignant tumor, she
probably has not a sufficient amount of vi-
tality to react. I shall at once begin to give
her nourishment by the bowel, with small
doses of whiskey by the mouth. I order
whiskey, because we cannot nowadays get
decent brandy. All the brandy in this
country is a manufactured article. You
can, however, get pure whiskey, if you pay
enough for it. I shall give teaspoonful
doses every fifteen minutes until reaction
sets in. I put in at the lower angle of the
wound a glass drainage-tube, and it will be
examined every half hour. If there is bleed-
ing, I shall inject a little diluted Monsel's
solution. I have never had to resort to this
styptic in this way, but it is a proper thing
under certain circumstances. I have stitched
the stump of the uterus to the lower angle of
the wound. I use the drainage-tube, be-
cause with this malignant tissue in the pelvis
we are almost certain to have septic trouble if
the patient lives forty-eight hours. Whatever
the result may be I shall inform you.

Two weeks later the patient was again
brought before the class, and Dr. Goodell
made the following remarks.

This is our patient of two weeks ago. She
has gained in flesh and in color since the
operation, and is, in fact, a great deal bet-
ter than before it. The glass drainage-tube
has been removed and has been replaced by
a rubber one. To-day I wish to see if we
can remove this. There has been consider-
able discharge. I shall also remove the
stitches that secure the uterus to the lower
angle of the wound. The reason that the
drainage-tube has been kept in so long, is

322

Communications.

Vol. lxiv

the fear that the discharge from the diseased
tissues left behind would set up septic trouble.
I may be mistaken in regard to this being
malignant disease, for she has improved far
more than I should have expected. I have,
however, repeatedly seen in cases of cancer
of the breast, where the disease has been
removed and a clean wound substituted for
the large sloughing wound, great improve-
ment follow. I have seen the same thing
in cancer of the womb where, by removing
the neck, or the womb itself, or by curet-
ting, the patient will greatly improve, be-
cause the hemorrhage has been stopped and
there has been removed temporarily, at least,
the source' of the chronic blood poisoning.
After such an operation the appetite often
improves wonderfully, the color comes to
the cheeks and the patient and her friends
may think that she is cured ; but after a
time the disease returns anew in the old lo-
cality or in adjacent organs. It will, there-
fore, not do to trust too much to the ap-
pearances of the patient. We shall now
have her removed.

A gentleman has just handed me a note,
in which he said that he and Dr. Formad
examined portions of this growth and found
it to be a round- and spindle -celled sarcoma.
That leaves no doubt about it, and acting on
this information I shall take out the drain-
age-tube and allow the wound to heal. For,
if it heals up, the development of the growth
will be inside and therefore unseen, instead
of outside, through the opening.

I once learned a lesson in regard to this
point. I removed a malignant growth and
left the drainage-tube in a long time. The
result was that at the reproduction of the
disease it burst through the opening, making
a horrible mess and stench. I do not think
that it hastened the death of the patient,
but it made everything unpleasant around
her. Her friends, of course, attributed the
bursting forth of the carcinoma to the op-
eration, and, as they were ignorant people,
it was almost impossible to make them un-
derstand the cause of the trouble.

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Communications.

MEMBRANOUS CROUP.1

BY C. L. DODGE, M. D.,

KINGSTON, N. Y.

"The term pseudo-membranous laryn-
gitis, laryngo-tracheitis, or true croup, is ap-
plied to a common and fatal disease, the es-
sential anatomical character of which is in-
flammation of the larynx, or of the larynx
and trachea, with the formation of a pseudo-
membrane upon its surface."2 A generation
ago this was a common disease. It is occa-
sionally met with at the present time, but
most of the cases that we now see are, strictly
speaking, laryngeal diphtheria.

Etiology. — It is now held by some of our
highest authorities that membranous croup
and laryngeal diphtheria are identical. Thus
Northrup 3 tells us that " He believes it is not
possible in the present state of our knowl-
edge to separate purely local croupous laryn-
gitis from laryngeal diphtheria of mild type,"
and that "it seems advisable, therefore, to
consider all cases of pseudo-membranous
laryngitis not of traumatic origin, as local
manifestations of diphtheria, and base the
treatment on that diagnosis." From this
opinion I feel obliged to express my dissent.
Jacobi also says : 4 "In former times which
are unknown to the younger generation of
physicians, when no such epidemics [of diph-
theria] existed, the only form of diphtheria
occurring now and then, was the local laryn-
geal diphtheria called pseudo-membranous
croup. It was then a rare disease, while at
the present time it is of but too frequent
occurrence." This statement I regard as
misleading. Membranous croup was not in
former years so very rare. In 1858, 5 the
year assigned by Jacobi as the time when
diphtheria first made its appearance here —
and I may add that but five cases of death
from this disease were reported that year in
New York — there were 478 deaths reported
from membranous croup. In 1859 there
were reported 622 deaths from membranous

1 Read before the Ulster County Medical Society,
December 9, 1890.

2 J. Lewis Smith.

3 Keating 's Cyclopedia of the Diseases of Children,
vol. ii, p. 521.

4 Pepper's System of \ Medicine, vol. iii, p. 101.

5 Vide article Membranous Croup, by J. Lewis Smith ,
Transactions New York State Medical Association,
vol. i, p. 432.

March 21, 1891.

Communications.

323

croup, which exceeds by 127 the average
number of deaths per year reported from
diphtheria, from i860 to 1873. If the mem-
branous croup of those days was, as Jacobi
asserts, nothing more or less than local laryn-
geal diphtheria, why was it not contagious ?
Why did the diphtheritic process invariably
begin in the larynx and remain there ? Why
did the constitutional symptoms of diph-
theria, the septic poisoning, the enlarged
glands, etc. , never appear ? Why were none
of the sequelae of diphtheria ever observed ?
2 In -short, if it was the poison of diphtheria
that gave rise to the membranous croup of
1 that time, how shall we explain the fact that
it never gave rise to general diphtheria, but
1 invariably manifested itself as a localized
disease of the larynx ? Northrup states that
of the autopsy records of one hundred and
1 fifty-one cases of laryngeal diphtheria, in
' only one case was the membrane found in
( the larynx only, and he further remarks1
I that " The melancholy fact that but one case
had diphtheria of the larynx only, stands out
as a grim reminder of the tendency of the
lesion to invade the regions adjoining it
1 above and below. ' ' In former years this
! " tendency of the lesion to invade the re-
gions adjoining it above and below" was
not observed. How shall we explain this if
the disease was the same as we now see it ?

If there was once a disease called pseudo-
membranous laryngitis that was produced
by other causes than the diphtheritic virus —
which I think few will be disposed to deny
— :then there is now a pseudo-membranous
laryngitis distinct from diphtheria. "It is
well, therefore," as J. Lewis Smith forcibly
remarks, " to briefly recall the evidences
that croup in a certain proportion of cases
results from causes other than diphtheria.
The occurrence of croup in localities where
diphtheria is unknown of course indicates
the operation of some other agency than the
dipththeritic poison." Therefore I main-
tain that, before diphtheria became epidemic
or endemic in this country, there must have
been some other cause for the membranous
croup which prevailed at that time.

In this, as in most other diseases, there
exists a predisposing and an exciting cause.
The chief predisposing cause is heredity :
the truth of this is beyond cavil. Croup,
as the phrase goes, runs in certain families
from generation to generation. This is as
well known among the laity as the profession.

1 Loc. cit, p. 528.

The common exciting cause (exclusive of
the diphtheritic form) is exposure to cold.
Standing by an open window with insuffi-
cient clothing on a windy day, seems fre-
quently to be the starting point of an attack
of croup. This is the history in so many
cases that the relation of cause and effect
seems almost equivalent to a demonstration.
It occurs most often between the ages of two
and .seven years. The anatomical confor-
mation of the larynx in childhood, together
with a peculiar susceptibility at this age,
seem plausible reasons for its greater fre-
quency in the young. One attack seems to
predispose to others.

Symptoms. — In diphtheritic croup we usu-
ally find the symptoms characteristic of gen-
eral diphtheria. In the majority of cases the
membrane appears first in the throat, and
from there descends into the larynx. It is
held by some that in the so-called uncom-
plicated cases the membrane is confined to
the larynx — starts there and stays there.
This is possible but it must be exceedingly
rare, for Northrup, who avows himself a
unicist in this matter, is able to show but
one case of this kind in his statistics. He
gives the autopsy records of one hundred
and fifty-one cases of laryngeal diphtheria,
and states 1 that "in fifty- eight cases diph-
theria of the pharynx antedated the laryn-
geal symptoms, and in nearly all other cases,
the number not being determined, membrane
appeared sooner or later in the pharynx.
In eighty-eight cases there was evidence that
the membrane made its appearance first in
the larynx, or at the same time as in the
pharynx. In only one case was it in the
larynx only '," The admission, "or at the
same time as in the pharynx," robs this
statement of much of its value as evidence
that the laryngeal affection was the primary
one. When true diphtheritic membrane ap-
pears in the throat the question of diagnosis
is settled once and for all.

I wish to remark here that the classical
description of croup, as well as of some
other diseases, notably typhoid fever, is no
longer to be trusted as absolutely correct.
The truth of this statement will be made
apparent as we proceed with the symptom-
atology.

Case 1. This occurred in my own family.,
Boy, two years and three months old, was
taken suddenly about 12 o'clock Monday
night, December 20, 1886, with a harsh,

Loc. cit., p. 525.

324

Communications.

Vol. lxiv

croupy cough, slight fever and dyspnoea. I
gave him small doses of syrup of ipecac and
paregoric, and in less than an hour the at-
tack passed over and he fell asleep and slept
till morning. I considered the case one of
spasmodic croup, and felt no uneasiness re-
garding it. It is proper to state also, in this
connection, that the child had suffered the
previous week from a cold and a slight sore
throat — with no symptoms of diphtheria,
however, — and had so far recovered that no
treatment was required for a day or two be-
fore the attack of croup. The next day, De-
cember 21, he seemed better, but not en-
tirely well. The pulse was slightly acceler-
ated, but the temperature was normal. .
Towards night slight hoarseness appeared,
but the child was up and dressed, playing
around the room. On the '2 2d, the patient
grew worse : he could no longer speak
clearly and distinctly, and the peculiar ner-
vous symptoms began to manifest themselves,
still no fever appeared, the temperature was
taken regularly and it remained normal
throughout ; the pulse was somewhat in-
creased in frequency ; the dyspnoea gradu-
ally increased, cough became hoarse, not
harsh as in the beginning ; voice steadily
grew weaker. The throat was normal, fre-
quent and thorough examinations showed no
membrane or patches at any time. On Fri-
day morning, the 23d, dyspnoea became the
prominent symptom, attacks of suffocation
came on, cyanosis increased till the lips be-
came blue, and the fingers and face dusky.
About six p. m. tracheotomy was performed,
without an anaesthetic, as the child was semi-
unconscious. The operation was rapidly and
skilfully done, the child began to breathe
naturally as soon as the tube was inserted,
and in a few minutes took a drink of water.
He slept well all that night, the tube re-
quired cleaning but few times till morning,
when it began to clog badly. The false
membrane descended into the bronchi, and
the child died from suffocation at 1 o'clock
Sunday. I deceived myself in this case by
supposing — as I had been taught to do — that
because there was no fever there was no in-
flammation, and, logically, if there was no
inflammation there could be no exudation
with false membrane. I now know what I
did not know then, that the formation of
false membrane in the larynx in some cases
at least takes place without fever.

There were no cases of diphtheria in the
neighborhood, the child had not been ex-
posed to that disease, and no case occurred

afterwards among any of those who were with
him. On two occasions, when the tube be-
came stopped up and the little fellow seemed
on the point of suffocation I applied my
lips to the tube and cleared it by suction. If
the case had been one of diphtheria I cer-
tainly would have contracted the disease.

Furthermore, three other physicians of
large experience saw the case and there never
was any question as to the diagnosis. The
medical treatment was the routine one of
calomel, potassium chloride, emetics, al-
kalies, fumigations, etc.

Croup commonly begins gradually and
insidiously, but there are many exceptions to
this rule. The so-called prodromic symptoms
are by no means invariably present. These
symptoms, upon which great stress has been
laid by some writers, consist of slight cough,
with the other evidences of nasal, pharyn-
geal and laryngeal catarrh, with perhaps
slight fever, although this is often so slight
as not to be detected unless special attention
be directed to this symptom. This condi-
tion may last two or three days or a week
in some cases before the attack of croup is
ushered in. This usually takes place in the
night somewhere between nine and twelve
o'clock, when the child is suddenly roused
from his sleep with a loud ringing cough.
At first it is short and sharp, but it soon be-
comes hoarse, and gradually grows weaker
and less barking. The voice is also changed;
it is hoarse and whispering, and gradu-
ally grows weaker and fainter as the disease
advances, until it becomes wholly suppressed.
The characteristic croupy respiration is
present from the onset. Gradually inspira-
tion becomes stridulous. At first expiration
is short and harsh, later on it becomes stridu-
lous also. The breathing now becomes
somewhat quickened and symptoms of ner-
vousness and extreme restlessness appear.
The dyspnoea steadily increases, with occa-
sional attacks of suffocation, from which
the little patient emerges to struggle on a
little longer. Inspiratory recessions now
take place at the supra-sternal notch and the
supra-clavicular regions. The soft parts also
yield at the epigastrium. Cyanosis now
comes on, the blood is no longer fully aerated
and the lips become blue, the fingers and
face dusky. Death takes place from stran-
gulation, sometimes ending in convulsions
and stupor.

Diagnosis. — The diagnosis of membra-
nous croup from laryngeal diphtheria presents
no difficulties when the latter occurs as a

i

March 21, 1891. Communications.

'325

complication of general diphtheria ; it is
only in those cases where the diphtheritic
inflammation manifests itself exclusively in
the larynx that we feel doubtful as to its
true nature. Is it possible, then, to distin-
guish pseudo-membranous croup from laryn-
geal diphtheria? I believe that it is in some
cases, but not always. If a child have croup
after exposure to diphtheria, but with no
symptoms of that disease, further than the
laryngeal disorder, we are warranted in call-
ing it diphtheritic : further, if a child die
with croup without known exposure, and
with no other symptoms of diphtheria, and
shortly after other members of the family
are attacked with unequivocal symptoms of
diphtheria, we are also warranted in believ-
ing the first to be diphtheritic; but, per
co?itra, if a child have a similar attack of
croup and no other member of the family
suffer, there being no history of exposure,
and no epidemic prevailing in the imme-
diate locality, I believe we are warranted in
excluding the diphtheritic virus as the cause
of the croup. The case cited above illus-
trates this point.

The points, then, in favor of diphtheria,
are known exposure to this disease, or prev-
alence of an epidemic ; albumin in the
urine ; prodromic symptoms adynamic. If
favor of croup : lack of exposure, no epi-
demic prevailing; no albumin in the urine;
prodromic symptoms not adynamic.

The ablest practitioners, however, admit
the impossibility of making a positive diag-
nosis in all cases.

It is sometimes quite difficult to distin-
guish between membranous and catarrhal
croup. Membranous croup usually begins
gradually, although there are exceptions to
this rule as illustrated in the case reported
above. Spasmodic croup, that is, the attack
proper, invariably comes on suddenly and
unexpectedly, and in the great majority of
cases in the night.

The severe symptoms of membranous
laryngitis may first appear in the daytime.
The pulse is of no value in the diagnosis ;
the excitement occasioned by an attack
renders it absolutely worthless as an indica-
tion of fever per% se. The temperature, on
the contrary, is of the utmost importance,
and should always be taken. The fever, in
my opinion, is the most important symptom
in the diagnosis. The older writers all tell
us that membranous croup is attended with
fever, and that in spasmodic croup it is
mostly absent. This is one of the points

in the differential diagnosis. In support of
this statement I quote from Niemeyer who
is usually very accurate in his descriptions.
He says,1 of the diagnosis, that " dyspnoea is
rare in laryngeal catarrh, and is never per-
sistent, nor is there much fever, while in
croup, fever never fails. ' ' Now, as a matter
of fact, this statement is almost exactly the
reverse of the truth. To Dr. Jacobi belongs
the credit of setting the profession right in
this matter. He tells us, in positive terms,
that catarrhal laryngitis in the child is a
febrile disease. He also says 2 that uncom- •
plicated sporadic croup has no increase of
temperature or very little ; catarrhal laryn-
gitis is mostly attended with high fever. In
very many cases this symptom has guided
him safely, in spite of the statements of the
books. " There is no fever or very little
except in the cases of generalized diph-
theria." My experience confirms this view.
A case of croup developing suddenly at
night, with high fever and flushed face, is
almost surely catarrhal. Furthermore, in
catarrhal laryngitis, the hoarseness (aphonia)
and harsh croupy cough come on abruptly,
and often subside in an hour or less, although
in some cases the attack may last much
longer — but sooner or later comes a decided
remission. The child is pretty certain, how-
ever, to have a fresh attack the following
night, just as sudden as the first. Neither
the frequency of relapses nor the history of
previous attacks of catarrhal laryngitis war-
rant us in assuming the catarrhal nature of
an individual case, for quite frequently we
meet with cases of true membranous croup
in children who have experienced many at-
tacks of catarrhal laryngitis.

Age also has some bearing on the diag-
nosis. Membranous croup is rare under one
year, while, according to Jacobi,3 twenty per
cent, of all the cases of spasmodic croup met
with are under one year.

When laryngitis is the principal element
in the attack, hoarseness may remain for
several days, but this of itself does not sig-
nify much. The totality of the symptoms,
as the homoeopaths say, is of great import-
ance in discriminating between catarrhal
and membranous croup. " In the latter,"
as Jacobi 4 ably maintains, 11 the main symp-
toms— viz., stenosis, hoarseness (or aphonia)

1 Text-Book of Practical Medicine, vol. i, p. 25.

2 Pepper's System of Medicine, vol. iii, p. 95.

3 Loc. cit., p. 93.

4 Loc. cit., p. 95.

326

Communications.

Vol. lxiv

and cough — will mostly develop simultane-
ously and in equal proportion ; the unpro-
portionality of the symptoms — for instance,
much stenosis and cough, but little hoarse-
ness, or barking cough and hoarseness with
little stenosis — would speak for catarrh."
Laryngismus stridulus is made synonymous
with spasmodic croup by some writers. This
is much to be regretted, as it tends to need-
less confusion. Membranous croup is easily
distinguished from this affection. Laryngis-
mus stridulus is not inflammatory, but purely
spasmodic. It is attended with great dysp-
noea or momentary suspension of respira-
tion, without fever or cough. Furthermore,
laryngismus stridulus is a rare disease in this
country as compared with either catarrhal or
membranous croup.

Prognosis. — The prognosis is unfavorable
in the mildest cases. Diphtheritic croup
has been said to be the most fatal disease to
which childhood is exposed, and true mem-
branous croup in infants and young children
is equally fatal. The rate of mortality is
very high. Authorities differ widely as to per-
centage : some, as Jacobi 1 and Mackenzie,2
set the death-rate, without operation, at
ninety per cent. On the other hand, J.
Lewis Smith,3 Meigs and Pepper 4 and Ag-
new,5 believe that recovery without opera-
tion is more frequent than has commonly
been supposed. According to Lovett and
Munro,6 the experience at the City Hos-
pital (Boston) has been as follows : forty
cases of diphtheritic croup have been treated
medically and every one died. Dr. G. W.
Gay, visiting surgeon, wrote, in 1885: 7 "Not
a single case of pseudo-membranous laryn-
gitis ever recovered in this hospital' without
operation." And he quoted Dr. D. W.
Cheever, senior visiting surgeon, as writing
to him in 1884 : 8 "After reflection, I can-
not recall a case of membranous laryngitis
that I have known to recover without trache-
otomy." Since Dr. Gay's article was writ-
ten there have been two recoveries from
moderate dyspnoea without operation. I
have seen one case of diphtheria, with croup
as a complication — where the voice was

1 Loc. cit., p. 103.

2 Diseases of the Throat and Nose.

3 Diseases of Children, Philadelphia, 1881; also
Am. Joicr. of Med. Sci., April, 1885, p. 319.

4 Diseases of Children.

^ System of Surgery, vol. iii.

6 Amer. four, of Med. Sci., July, 1887, p. 166.

7 Gay, quoted by Lovett and Munro. Ibid.

8 Quoted by Gay : Med. News, July 12, 1884.

faint and husky, with decided dyspnoea, in
a girl five years of age — recover with medi-
cinal treatment alone. I have also met with
one case of membranous croup — judging
from the almost complete extinction of
voice, which at first was hoarse and feeble,
together with the dyspnoea — in a girl six
years old, which recovered without trache-
otomy.

In diphtheritic croup much depends on
the type of the epidemic. When laryngeal
symptoms appear early, the attack is apt to
be more severe than when they occur in the
declining stages. The younger the age the
higher the mortality ; for the younger the
child the smaller the windpipe and larynx,
and the sooner stenosis results. Unfavor-
able symptoms are increasing debility and
cyanosis, feeble and irregular pulse; also
the development of bronchitis or broncho-
pneumonia. When emetics fail to act; or
spontaneous emesis takes place, the case is
generally hopeless. Among the favorable
indications may be mentioned loosening of
the cough, increase of expectoration and
freer respiration.

Treatment. — The medical treatment of
the present day is practically the treatment
for diphtheria, since that disease is respon-
sible for a large proportion of the cases of
croup. The use of mercurials is advocated
in all forms of membranous laryngitis. The
bichloride of mercury is the preparation ad-
vised by most writers in as large doses as are
warranted in each particular case. From one-
sixth to one grain, in divided doses well di-
luted, is given during the twenty-four hours.
Calomel is preferred by some as being just as
efficacious and safer. The tincture of the
chloride of iron is still a favorite with many
practitioners. Potassium chlorate is con-
demned by most modern authors as being
injurious to the kidneys. Formerly alkalies
were much employed in the treatment of
croup, for their supposed solvent action on
fibrin (antiplastics of the older writers).
Now, however, except in the form of inha-
lations with the atomizer, they are rarely
prescribed. In diphtheritic croup I have
obtained the best results from sulphur ap-
plied topically by insufflation and adminis-
tered internally in small doses frequently
repeated.

Unfortunately but few cases yield to medi-
cinal treatment. Nothing then remains but
resort to surgical measures.

We now have the choice of tracheotomy
or intubation. The proportion of recoveries

March 21, 1891. Communications.

327

after tracheotomy, according to Wharton,1 is
about one in every four cases. Intubation
gives about the same, Waxham 2 placing it
at 26.77 Per cent-

MEDICAL JURISPRUDENCE OF RAIL-
WAY SURGERY.

BY HAROLD N. MOYER, M. D.,

CHICAGO, ILLINOIS.

PROFESSOR OF PHYSIOLOGY IN RUSH MEDICAL COL-
LEGE.

'When a suit is brought, the railway sur-
geon, according to my observation, is placed
at a disadvantage in two ways ; first, his
testimony as an expert is always lessened in
its effect by the question, " Are you an em-
ployee of the road ?" Then again his loy-
alty to his principals, and his not infre-
quent detection of malingerers, place him
in an attitude of " expectant attention,"
and he sees in every claimant not presenting
palpable deformities a fraud and cheat. That
this picture is not overdrawn will be appa-
rent to most physicians who have devoted
special attention to the practice of medical
jurisprudence, and that it is one frequently
accompanied by a large verdict for the
plaintiff is a common experience. The rail-
way surgeon should, I think, assume in all
these cases that the person is injured and by
demonstration and reasoning convince him-
self to the contrary if the facts warrant it.
It has always been my custom when acting
for the plaintiff in such cases to assume that
the person was not injured and then by a
chain of reasoning or direct observation to
convince myself if possible of the contrary.
I have so far always been able to make such
conclusions effective on the witness stand.
The human mind is so constituted that we
cannot be too careful in eliminating uncon-
scious bias, which at times may be apparent
to every individual in a croweded court
room, excepting its unfortunate but honest
possessor.

The qualifications that a railway surgeon
should possess have enormously augmented
within a few years. It is but a short time since
anatomy, operative surgery, and a modicum
of pathology was about all that was needed.
In too many instances the older railway sur-
geons have not advanced beyond this, and

1 Keating' 's Cyclopedia, vol. ii, p. 544.

2 Quoted by Northrup. Ibid.

appointments are still made upon these lines.
There never was a time in which extensive
knowledge of pathology and internal medi-
cine was more needed by the railway surgeon.
It is precisely upon these lines that I have
seen the most unfortunate results, in that the
decision of the railway surgeon enforced a
long litigation upon the plaintiff and usually
resulted in the railway company paying a
sum vastly in excess of what the case could
have been settled for originally. In the ma-
jority of cases a meritorious case can be
settled for much less than will be awarded
by the average jury and the plaintiff will be
saved vexatious litigation.

It is apparent that injuries which cause
gross visible defects will never form any con-
siderable part of this kind of litigation.
The loss of a hand, leg or eye will and must
always be measured in damages by the jury.
The cases in which the judgment will turn
on expert opinion will-be those in which the
injuries are obscure, to internal organs or
deep-seated joints, in which the conditions
must be inferred from objective and subjec-
tive symptoms ; those in which the clinical
picture will be the guide in reaching a diag-
nosis. Injuries to the nervous system will
far outnumber those of other tissues and
organs, and in the difficulty of their medico-
legal diagnosis (to coin a phrase). It is in
this class of cases that the railway surgeon
seems to be most deficient. So-called spinal
concussion has furnished a fruitful field of
contention in railway medical circles and
the deliverances upon this subject has not
been altogether what could have been hoped
for scientifically. It is not surprising when
a railway surgeon is invited to meet a col-
league in an examination to have the former
request the patient to bend the body, stand
upon one leg, balance his body with the eyes
closed ; then to percuss the spine, tap the
patellar-tendon and announce that the ex-
amination is closed. When a surgeon who is
accustomed to this kind of work has a de-
liverance upon spinal concussion, is it mat-
ter for wonder that the medical world is not
impressed ? So far as my own experience
extends I have never met a railway surgeon
at one of these examinations who was pro-
vided with an ophthalmoscope or an electric
battery, nor have I seen a complete exami-
nation of the sensibility or of the reflexes
made by a railway surgeon even when every
opportunity was given.

The necessity of the railway surgeon be-
ing an " all round " man in the best sense

328

Communications.

Vol. lxiv

of the word is now more than ever apparent.
Within a few years the testimony of experts
consisted in stating his experience, qualifi-
cations, knowledge and opinion of the par-
ticular case. Now he is called upon to de-
fend this opinion in the face of a cross-ex-
aminer, who may be equally or even better
posted on the exact points at issue than he
is himself.

It is a matter of experience that suits
against corporations for personal injuries
have increased greatly in the last few years
and the amounts recovered have been much
greater. This I think is due to two principal
causes : the rulings of courts on the law of
negligence, and the fact that corporations
have too frequently fought cases in which both
law and facts were against them, relying
largely upon brilliant and well-paid counsel
to tire litigants and defeat a meritorious
claim. This condition of affairs has pro-
duced lawyers who practice this branch of
the law almost exclusively, and it is now
possible for litigants to secure the best of
legal and medical talent by assigning a cer-
tain portion of the prospective judgment.
It has been my experience that these cases
are usually much better prepared, so far as
the medical questions are concerned, for the
prosecution than for the defense. Part of
this preparation consists in posting the coun-
sel on the direct points at issue and thor-
oughly indoctrinating him with the theory
of the case adopted by the medical witnesses.

Cases are frequently injured — and this oc-
curs about as often for the plaintiff as for
the defendant — by calling a witness who
writes M. D. after his name and whose opin-
ion is adverse to the other side, while in fact
Tie cannot sustain the opinion or himself on
cross-examination. A recent case occurring
in the city of Chicago in which a verdict of
$30,000 was returned against a railway com-
pany well illustrates this point and shows
the injury that may be done to a case by a
poor expert witness. The plaintiffs put
three physicians on the stand and the de-
fendant company five. One of the latter,
after airing his erudition on the joints, liga-
ments and muscles of the spine (the in-
jury was to the spine), failed to remember
what muscles were attached to the styloid
process of the temporal bone. Another said
that the spinal cord terminated opposite
the last dorsal vertebra in the " caudal
appendix." A third, when asked to give
the normal order of the polar muscle reac-
tions, said that he had never heard of such

a thing and that the question was absurd
and unanswerable. It must be apparent
that such witnesses materially lessened the
effect of the two remaining good witnesses
and far outweighed the mere ex cathedra
opinion of a larger number. Such witnesses
are only an embarrassment and not a help.

Proficiency in clinical and operative sur-
gery will for obvious reasons furnish the chief
recommendation of the railway surgeon of
the future, yet in my judgment they do not
furnish the best training for the medical ju-
rist. That is almost a separate branch of
study, and requires a thorough kuowledge of
physicial diagnosis, not only surgical but
medical and also pathology. The medical
jurist should perfect himself in all the most
improved methods of diagnosis, in all
branches of medicine, more especially those
methods which furnish us with the objective
signs of disease, for after all it is the objec-
tive signs that determine the status of a case
in court. To these should be added a care-
ful study of the art of medical jurisprudence —
that is, the orderly presentation of facts and
theories, so as to lead up to a logical con-
clusion and all that in plain, non-technical
language and in such fashion as to convince
the average juryman that his position and
judgment are unassailable.

TRAUMATIC NEUROSIS.— TEMPO-
RARY INSANITY FOLLOWING
OPERATION FOR ABSCESS.

BY WILLIAM H. SHIPPS, M. D.,

BORDENTOWN, N. J.

On April 2, 1890, I was requested by a
fellow-practitioner, to operate upon a patient
suffering with a large abscess, situated in
the upper portion of the right breast and
extending to the axilla of the same side.
The patient, a man 40 years of age, stated
that the abscess was the result of an injury
sustained a month before, and had been
gradually developing ever since, causing
him intense suffering. He had been under
the care of two physicians, who had used
both local and internal treatment with the
hope of aborting the abscess. There was
nothing about the general appearance of
the man to attract notice, except, perhaps,
a certain dulness of expression, and a quick,
nervous manner of speech, which at the time
I attributed to individual peculiarity. He

March 21, 1891. Foreign Correspondence.

329

gave me a brief account of the injury and the
treatment employed, and denied ever hav-
ing been the subject of specific disease.
Without further ceremony I freely opened
the swelling, evacuating about eight ounces
of pus and blood, after which an antiseptic
dressing was applied. Immediately the pa-
tient expressed himself as much relieved,
and stated his intention of at once returning
home by rail, a distance of ten miles. From
this, however, he was dissuaded, and urged
to pass the night at a friend's house in this
city, in order that opportunity might be
given me to re-dress the parts in the morn-
ing.

The morning following, I called upon
the patient, and was surprised to learn that,
shortly after entering his friend's house, he
had begun to talk and act strangely, alto-
gether unlike anything which had been
known of him before. During the night he
became at times unmanageable, refusing to
go to bed or take either medicine or nour-
ishment. On entering his room I found
him before the mirror, gazing vacantly at
his image in the glass. He was almost
naked, and had torn every vestige of the
dressing from his body. He seemed en-
tirely indifferent to the presence of others
about him, save that our entrance caused him
more or less uneasiness, which was evidenced
by his continually pacing the room and
peering out of door and window, as if in
search of some avenue of escape. On mo-
tioning him to a chair, he would insist upon
getting on it with his feet, repeating the op-
eration as often as I attempted to make
him occupy it in the natural position. At
times he would insist upon getting out of
the windows, and was only prevented from
so doing by the determined resistance of his
attendants. For two days he absolutely re-
fused all food, and during that period had
not slept an hour. His pulse and tempera-
ture being normal throughout, and careful
inquiry of friends and relatives as to his
family history throwing no light upon his
present condition,. I felt no hesitancy in
pronouncing the case one of temporary in-
sanity. I therefore advised that he be re-
moved as speedily as possible to the State
asylum for the insane. In this I was sec-
onded by Dr. I. D. Young, of Bordentown,
who very kindly saw the patient with me.
Accordingly arrangements were made for the
patient's removal the day following, or the
third day after the case came under my ob-
servation. Early in the morning of the day

fixed for his departure, I called at the house
for the purpose of facilitating his removal.
On entering the dwelling, I was met at the
door by his host, who with smiling counte-
nance informed me that 11 John was all
right now." On inquiry I ascertained that
shortly after midnight he had fallen asleep
for the first time in three days, sleeping
soundly until daybreak, when he awoke
perfectly calm and rational. On meeting
the patient I was happy in being able to
confirm all that had been told me, and
found him sitting up apparently clothed in
his right mind, sensible that something was
amiss, but totally ignorant of the nature of
his attack. In a day or two he returned
home, unaccompanied, and since then has
been in the enjoyment of good health.

The case was doubly interesting to me, be-
cause of the unexpected sequela of the opera-
tion, and secondly because his friends attri-
buted his insanity solely to the operation,
arguing that as the man was sane prior to
the use of the knife, and insane almost im-
mediately afterwards, but one conclusion
could be drawn. The satisfactory termina-
tion of the case, however, quickly put to
flight all such nonsensical reasoning as this.1

Foreign Correspondence.

BERLIN LETTER.

The Latest Developments in the Tuberculine
Question — Koch Worried and Intimidated.
— The Position of the Government in the
Case. — Voices from Hospitals. — Vox Pop-
uli. — Professional Feeling in the matter.

Berlin, February 17, 1891.

The storm of enthusiasm has passed and
the low tide of cold inspection and calcula-
tion has set in. The miracle is — not what
little there is left of the glowing anticipa-
tions of the Koch Chauvinists, but that there
is anything left at all. It required the stern
and pitiless voice of Virchow to restore to
the profession the common sense which ap-
parently had been completely lost. It re-
quired, moreover, unwarrantable sacrifices
of human lives to convince the profession
that the millennium of medicine has not yet

1 [Neuroses following surgical injuries and operations
have of late attracted considerable attention, and this
report by Dr. Shipps is an interesting contribution to
the subject. — Ed. Reporter.]

33°

Foreign Correspondence.

Vol. lxiv

arrived. Virchow, as I have learnt from a
good source, will continue his warfare
against the "lymph ' ' without zeal or malice,
but with a persistence which will ultimately
prove fatal to the young remedy. As to the
deaths caused by tuberculine, I regret to state
that their number is not a small one. Sudden
failure of vital energy caused by the artifi-
cial fever, hemoptysis, and miliary tubercu-
losis are the chief sources of danger from
the exhibition of the remedy. Quite re-
cently a young medical man who had con-
tracted a catarrh of the apex was hurried to
death by a rapidly developing miliary tuber-
culosis under the influence of tuberculine.

Koch's path during the last two months
was not a rosy one. His private residence
in the Thiergarten, formerly an ideal of se-
clusion and privacy, soon became the centre
of attraction. In spite of all possible signs
and inscriptions, such- as "moved out of
town," postmen and telegraph messengers
vied with patients and doctors in besieging
the house. He actually did move tempo-
rarily to a friend's house, but was hunted
and found out by two Western practitioners.
There was nothing left for Koch but to flee.
Those anxious to see him can do so at
Luxor or Ghizeh, near the pyramids which
are fortunately unable to interview the Ger-
man doctor. Koch's flight had, besides,
another reason, viz., the gradual falling off
of his admirers and the steady increase of
his opposers. It is rumored that he left
worried and full of anxiety.

In a still worse fix, however, than Koch,
is the German Government, and especially
von Gossler, the Cultus Minister. It is un-
deniable that von Gossler alone has brought
about the present unpleasant state of affairs
in the matter. Koch yielded unwillingly to
that official's incessant demands to publish
a matter as yet unfinished. Von Gossler
evidently was led by political and national
impulses. The question of emoluments for
the Koch cause has of late changed its
aspects. It is likely that no financial aid
will be extended to Koch personally. As
the matter stands at present, it is more than
doubtful whether the Reichstag would vote
a large money-grant for the purpose. Mean-
while authoritative voices of clinicians con-
tinue to take stand against tuberculine. The
Berliner Jiidische Krankenhaus has had a
sad experience with the' new remedy, and
Prof. James Israel, its famous Chief, has
banished it completely from the wards. I
listened last night to what Sanitatsrath Dr.

Thorner had to say about tuberculine before
the Verein fin* Innere Medizin. He had
used the remedy since November 20, last
year. Thorner censured severely the pres-
ent arrangement in the distribution of the
remedy, which secured for some hospitals
and a few clinicians an actual monopoly of
the remedy. The ordinary practitioner, he
said, ought by all means to be able to ob-
tain the remedy, for he can detect the signs
of initial consumption before even the pa-
tient himself is aware of the affection.
Thorner has had quite satisfactory results
with tuberculine, though in one instance
the remedy killed a patient. In the major-
ity of cases a considerable improvement
took place, as evidenced by a decrease of
subjective difficulties and increase of bodily
weight. In one patient suffering from api-
cal catarrh, the bacilli had left the sputa
under the influence of tuberculine. Thorner
then communicated some interesting obser-
vations he had made in experimenting with
the remedy upon animals. Any animal, he
said, suffering from miliary tuberculosis can
be cured with tuberculine. This statement —
being absolutely new — created considerable
astonishment. Likewise interesting was
Thorner' s statement that, as long as an ani-
mal was subjected to tuberculine injections
it was immune against infection of tubercle
bacilli, and that this state of immunity
ceased as soon as the tuberculine was with-
drawn. Hence it is clear that Koch's rem-
edy can never be utilized as an immuniza-
tion lymph against tuberculosis.

There are authorities like Prof Schroetter
of Vienna — one of the consulting physi-
cians of the late Emperor Frederick, at San
Remo — who deny not only the therapeutic
but also the diagnostic value of tuberculine.
Bardeleben and Bergmann have lowered
their enthusiasm to a minimum, while Ley-
den and Gerhardt still believe in its future.
Henoch, the Nestor of pediatrics, has in plain
words designated the remedy as useless and
dangerous for children.

Possibly it will interest. you also to learn
what the Berlin populace think at present of
the remedy. The common feeling is very
much opposed to the Koch cure, and it is
not too much to say that today no intelli-
gent Berliner would submit to its exhibition
on his own person.

The profession too, on the whole, is an-
tagonistic to the Koch cure. The Berlin
Medical Union at Friedrichstadt, has just
formulated its disapproval of tuberculine and

March 2i, 1891.

Periscope.

33i

is determined to take a firm stand against
the remedy and especially against the present
mode of its distribution.

Periscope.

Tachycardia Cured with Electricity
and Belladonna.

Dr. Thomas Oliver, Physician to the
Royal Infirmary, Newcastle-upon-Tyne, says
in the British Medical Journal, January 31,
1891:

In July, 1890, I was asked by Dr. Far-
quharson, of Newcastle, to see with him in
consultation a young man, aged 28 — a ner-
vous, anxious-looking and emaciated man,
who was slightly cyanosed. There was no
history of rheumatism. Five or six years
ago he met with an accident, and again, two
years ago, when he fell over a " tipping "
with his horse and cart. Though not ma-
terially injured at the time, he felt' as if he
had had a shock. From this date he be-
came extremely nervous, and began to lose
all his energy and pluck ; he became afraid
even of his own horse. He now began to
suffer from attacks of violent palpitation,
which would last for several days, and
within the last three months he has been
seldom free from these attacks of palpita-
tion and a sense of cardiac distress for more
than a week at a time.

When seen first by Dr. Farquharson in
these attacks, the ' pulse-rate was generally
from 190 to 230 in the minute. In his
quiet state the pulse seldom exceeded 90,
and when this was the case there could be
heard a well-marked mitral systolic murmur.
There was no albuminuria, no distended
jugular veins, and no oedema of feet, but the
left pupil was noticed to be smaller than the
right — a condition of things which became
more pronounced, Dr. Farquharson stated,
if the stomach were distended with flatus.
He had lately been the subject of dyspepsia
and constipation and when these were pres-
ent his cardiac distress was increased. Beyond
a sense of discomfort, of precordial pain and
uneasiness which the excited action of the
heart caused, there was no marked dyspnoea.
His sleep was broken and fitful. By his ill-
ness he had been rendered quite unfit for
work.

The slight cyanosis alluded to was noticed
in the lips, on the face and in the finger
ends. The pulse was small and extremely

rapid. I counted up to 240 beats in the
minute and then lost it. It was upwards of
250 on Dr. Farquharson 's reckoning, but
on this point we speak guardedly. Knee-
jerks were slightly exaggerated. The lungs
were perfectly healthy. Heart : the apex '
beat, which was very diffused, was felt two
inches external to the nipple ; there was also
marked epigastric pulsation ; pulsation, too,
was seen and felt to the right of the sternum
at the level of the right ventricle. The
area of cardiac dulness was increased trans-
versely. The tap of the heart could be seen
and heard quite distinctly several inches
from the chest — I thought about two feet.
Over the aortic area — extending up to the
episternal notch and down the sternum to
the xiphoid cartilage — was heard a rough
grating systolic murmur, followed by a well-
marked second sound. It was only by count-
ing the loud second sound of the heart that
we were able to estimate the rate of cardiac
pulsation. In addition to the grating sys-
tolic murmur mentioned above, a soft mitral
systolic could be heard, which was carried
towards the left axilla, and particularly to-
wards the back at the level of the fifth dor-
sal spine. Pressure upon the pneumogastric
nerve in the neck slowed the action of the
heart. The urine was normal ; the internal
organs of the abdomen appeared to be
healthy.

We arranged that he should have 30-
minim doses of tinct. belladonnge, with
small doses of Fowler's solution ; that for a
few days the ether spray should be applied
to the back of the neck, and afterwards the
interrupted current to the pneumogastric,
one pole behind the neck high up, and the
other along the course of the nerve in the
neck. Within a fortnight he was very much
better. His pulse was never higher than 120
a minute, and that only during excitement.
A sphygmographic tracing taken at this time
showed low arterial tension and well-marked
dicrotism. There was still the well-marked
pericardial grating and mitral systolic mur-
mur. The area of cardiac dulness remained
as before; in its lateral diameter it measured
6j4 inches.

It is now seven months since I saw him,
and Dr. Farquharson tells me that the pa-
tient has made an excellent recovery. Only
once since the beginning of July has there
been a return of the very rapid action of
the heart, and on that occasion it only
lasted two or three hours instead of the
three or four days as previously. His pulse

332

Periscope.

Vol. lxiv

at present is never higher than 80 in the
minute. For the last few weeks he has been
taking arsenic and digitalis.

From being an anxious-looking, irritable
and nervous man, unable to follow his em-
•ployment, he has become calm and more
self-possessed, and is now able to carry on
his employment, not so much in the out-door
department as in looking after the financial
concerns of the business. The only un-
pleasant symptom which has been left is
something akin to agoraphobia. In coming
into Newcastle by road or rail he has to
cross the High Level Bridge which spans
the river Tyne, and whether he is in the
train or on the roadway he always experi-
ences, when on this bridge, unpleasant sen-
sations originating at " the pit of the stom-
ach as if a void had been suddenly created."
This is so apt to be followed by increased
rapidity of the heart that knowledge of this
fact prevents him from making the journey
into Newcastle as frequently as he would.

The subject of tachycardia has attracted
considerable attention since Dr. Samuel
West and Dr. Sansom have written upon it,
and latterly our interest in it has been re-
vived by the remarks made by Sir Dyce
Duckworth in the discussion which he
opened at the Birmingham meeting of the
British Medical Association on Functional
Disorders of the Heart. In the absence of
a rheumatic history, the origin of the dis-
order in our patient must be sought for in
some condition of the central nervous sys-
tem induced by the fright and shock, al-
though the pericardial grating, the mitral
systolic murmur and enlargement of the
heart — in the absence of any pronounced
vascular lesion, such as aneurism — must not
be lost sight of. The immediate effect no-
ticed when gentle pressure was applied to
the pneumogastric nerves in the neck, and
the good result which followed electrical
stimulation, point in the main to a central
cause suspending the inhibitory action of
these nerves upon the heart, or to increased
activity of the accelerating branches of the
sympathetic.

Suppuration of the Antrum of High-
more.

In the Indiana Medical Journal, Febuary,
1 89 1, Dr. L. C. Cline, of Indianapolis, has
an interesting paper on suppurative disease
of the antrum of Highmore, in which he
says : The antrum, owing to its size, situa-

tion and its relation to the nasal cavities and
the teeth, is more frequently involved in the
suppurating process than any other of the
cavities of the bones of the face and skull
which communicate with the nasal passages.

This cavity becomes involved principally
from two sources, namely, dental complica-
tions and hypertrophic rhinitis. The in-
flammation does not extend into the antrum
by continuity, but probably by the hyper-
trophy and turgescence of the nasal mem-
brane producing stenosis or complete oc-
clusion of the opening, thus causing hyper-
emia of the mucous membrane of the antrum,
resulting necessarily in an increase of se-
cretion, which accumulates and eventually
degenerates and causes a purulent discharge ;
for it is generally conceded that a catarrhal
secretion in a closed cavity will, sooner or
later, give rise to a discharge of pus. The
symptoms of an acute or recent case are pain
and tenderness, with a sense of weight and
fulness over the antrum and a pressure up
against the eye, with slight hyperemia of
the ocular conjunctiva. If due to dental
origin?<there will be slight pain on pressure
of the corresponding teeth. When due to
occlusion of the orifice from swelling of the
turbinates, there is nearly always severe neu-
ralgic pains, accompanied by more or less
swelling and tenderness of the face in the
region of the antrum. The pain is usually
worse in the morning, and will be increased
by stooping or lowering the head. The for-
mation of pus is announced with a chill
followed with fever, and if the closing of
the opening of the antrum be due to turges-
cence or swelling of the turbinate bodies
from cold, the symptoms may all subside in
a few days, and the inflamed membrane
will return to its normal condition, or the
purulent discharge may continue in a less
quantity indefinitely and all the acute and
painful symptoms subside.

If the opening of the antrum with the
nasal cavity remain free, as in the case of
dental origin, the pus finds its way through
the-opening, and may produce by its con-
stant irritation an obstinate turgescence of
the turbinate bodies and occlusion of the
nasal passages. The pus is usually discharged
at intervals during the day, viz., on rising
in the morning and in the afternoon, and
when stooping. It is thought by some that
when the pus has a dental origin, it is more
offensive than when it is due to colds.

The diagnosis is not difficult, as a rule,
in the recent or acute cases. The history,

March 21, 1891.

Periscope.

333

coupled with pain referable to the antrum
and side of the face, together with the dis-
charge from one side, will determine the di-
agnosis. If the case is chronic, a careful
inspection of the nose will result in finding
pus on the anterior and inferior part of the
middle turbinated body ; or a drop may be
seen protruding between the middle and in-
ferior turbinate bodies posteriorly, which
when wiped away, in either position, can be
made to reappear by changing the position
of the head or pressing on the walls of the
antrum. The discharge of a straw-colored
pus from one side of the nose is always strong
evidence of a diseased antrum.

Dr. Cline says (but we believe it is not so
certain) that Voltolin's method, as improved
by Heryng, is of great value in these cases.
It consists of an incandescent lamp placed
in the mouth, over which the lips are closed.
The patient being placed in a dark room,
the bones of the face become beautifully il-
luminated. A dark shade will outline the
situation of the antrum. If the antrum
contains pus it will be outlined by a dark
spot and a total absence of any illumina-
tion— a marked contrast to the opposite or
healthy side.

A very simple and efficient method of di-
agnosis is to inject a few drops of peroxide
of hydrogen with a small syringe, armed
with a canula, one-eighth of an inch of the
distal end being bent at right angles, so as
to enter the opening of the antrum. The
nose should be well cocainized to avoid pain.
If pus be present, it will boil up and fill the
nose with a white 'foam. . By using this
method, an exploratory puncture will be un-
necessary in the majority of cases.

After we have determined that the antrum
contains pus, how shall we get rid of it and
cure our patient ? There are several methods
of treatment, but I will only give what I be-
lieve to be the best. In recent cases there
may be an effort made to restore the antrum
by first relieving the swollen and turgescent
condition of the turbinates ; then follow
with injections of peroxide of hydrogen, as
before stated, passing the point of the syr-
inge back about half way between the mid-
dle and inferior turbinate bodies. This may
be followed by light astringents such as —
zinc sulphate, 3 to 5 grains to the ounce ;
silver nitrate, 3 to 10 grains to the ounce;
saturated solution of boric acid, or borax ;
listerine ; or a weak solution of the tincture
of iodine.

When the case is chronic, there should

be an opening made at the most dependent
portion of the sinus. Dr. Cline's practice has
been to drill up through the alveolus with a
drill run by an electro-motor, and then to
insert a silver tube, made from coiled wire.
Some prefer entering the antrum in the same
way, just below the gingivo-labial fold, be-
tween the upper portion of the roots of the
second bicuspid and first molar tooth, di-
recting the drill upward and backward at an
angle of forty-five degrees. In either case
the opening should be of sufficient size to
admit of free cleansing and washing out of
the antrum. A tube of sufficient length to
enter the antrum should be neatly fitted, and
guarded from entering the antrum by a
shield of rubber or wired to the adjoining
tooth.

The after-treatment consists of daily or
twice daily, washing out the cavity, first with
peroxide of hydrogen (commercial strength),
followed with a slightly alkaline or carbol-
ized water in quantity sufficient to thor-
oughly cleanse the cavity. Then, every
second or third day, inject a sufficient amount
to thoroughly cover the surface, of one of
following solutions, as the case may seem to
indicate : saturated solution boric acid, 5
to 20 drops of tincture of iodine to 2 drachms
distilled water; sulphite of zinc, 3 to 10
grains to the ounce; nitrate of silver, 10 to
20 grains to the ounce ; iodoform, 20 grains
to an ounce of the oil of sweet almond.

Of these Dr. Cline likes boric acid the
best.

Names of Diseases.

There has, in the course of time, crept
into medical nomenclature a number of
proper names which have been used in con-
nection with certain morbid conditions.
The list has grown so long that a repro-
duction from Jounlal de Medecine, January
11, 1891, of the most common, with their
symptoms, may prove interesting and not
without utility.

Addison's disease — maladie bronzee — dis-
ease of the supra-renal capsules.

Albert's disease — fungoid mycosis.

Aran - Duchenne' s disease — progressive
muscular atrophy.

Argyll - Robertson pupil — one which
changes in accommodation, but does not
respond to light,

Astley Cooper's hernia — femoral hernia
with a multilocular sac.

Barton's fracture — one of the lower end
of the radius involving the joint.

334

Periscope,

Vol. Ixiv

Basedow's disease — exophthalmic goitre.

Baudin's law — antagonism of tuberculo-
sis and malaria.

Bazin's disease — buccal psoriasis.

Beclard's disease — hernia through the
saphenous opening.

Bell's palsy — paralysis of the seventh
nerve.

Boyer's cyst — sub-hyoid cyst.

Bright' s disease — albuminuric nephritis.

Brown-Sequard's combination of symp-
toms— hemiparaplegia with hemianasthesia
of the opposite side.

Cazenave's lupus — lupus erythematodes.

Charcot's disease — amyotrophic lateral
sclerosis.

Charcot's joint — the enlarged joint of
locomotor ataxia.

Cheyne-Stokes breathing — ascending and
descending frequency of respiration.

Cloquet's hernia — perineal hernia.

Colles's fracture — one of the lower third
of the radius.

Colles's law — that of non-infection of
the mother by her syphilitic infant at the
breast.

Corrigan's disease — aortic insufficiency.

Corrigan pulse — water-hammer pulse —
the pulse of aortic regurgitation.

Corvisart's facies — asystolic facies.

Cruveilhier's disease — simple ulcer of the
stomach.

Cruveilhier's paralysis — progressive mus-
cular atrophy.

Bonders' s glaucoma — simple atrophic
glaucoma.

Dressier' s disease — paroxysmal hemoglo-
binuria.

Dubini's disease — electrical chorea.

Duchenne's disease — locomotor ataxia.

Duchenne's paralysis — pseudo-hypertro-
phic paralysis.

Duhring's disease — dermatitis hepetifor-
mis.

Dupuytren's disease — retraction of the
palmar aponeurosis.

Dupuytren's hydrocele — bi-locular (en
bissac) hydrocele.

E. Wilson's disease — universal exfoliative
dermatitis.

Eichstedt's disease — pityriasis versicolor.

Erb's palsy — paralysis of the brachial
plexus.

Erb-Charcot's disease — spasmodic tabes
dorsalis.

Fouchard's disease — alveolo-dental peri-
ostitis.

Friedreich's disease — hereditary ataxia.

Gerier's disease — paralytic vertigo.
Gibbon's hydrocele — that coincident with
hernia.

Gibert's pityriasis — pityriasis rose.

G. de la Tourette's disease — motor inco-
ordination.

Goyrand's hernia — inguino - interstitial
hernia.

Graefe's sign — failure of the upper lids to1
follow the eyes in descent.

Graves's disease — exophthalmic goitre.

Guyon's sign — renal ballottement.

Harley's disease — paroxysmal hemoglo-
binuria.

Heberden's rheumatism — that of small
articulations with nodosities.

Hebra's disease — polymorphous ery-
thema.

Hebra's pityriasis — pityriasis rubra chron-
ica.

Hebra's prurigo — idiopathic prurigo.

Henoch's purpura — purpura with abdom-
inal symptoms.

Hesselbach's hernia — femoral hernia with
a multiloeular sac.

Hippocrates' s facies — that of agony.

Hodgkin's disease — adenitis ; pseudo-leu-
cocythemia.

Hodgson's disease — atheroma of the
aorta.

Huguier's disease — fibromyomata of the:
uterus.

Hutchinson's teeth — notched teeth of he-
reditary syphilis.

Hutchinson's trio of symptoms — notched
teeth, interstitial keratitis and otitis of he-
reditary syphilis..

Jacksonian epilepsy — focal epilepsy.

Jacob's ulcer — cancroid ulcer.

Kaposi's disease — xerodermia pigmen-
tosa.

Kopp's asthma — thymic asthma — spasm
of the* glottis.

Kronlein's hernia — inguino-properitoneal
hernia.

Laennec's cirrhosis — atrophic cirrhosis.
Landry's disease — acute ascending paraly-
sis.

Laugier's hernia — that across Gimbernat's
ligament.

Leber's disease — hereditary optic atrophy.

Levert's law — marginal insertion of the
umbilical cord with a small placenta..

Littre's hernia — diverticular hernia.

Ludwig's angina — infectious phlegmon of
the subhyoid region.

Malassez's disease — cyst of the testicle. >

Meniere's disease — labyrinthine vertigo.

{March 21, 1891.

Periscope.

335

Millar's asthma — laryngismus stridulus-
■ spasm of the glottis.
1 Morrand's foot — one with eight toes.
Morvan's disease — analgesic paralysis of
the extremities.

Paget' s disease — pre- cancerous eczema of
the breast.

Paget' s disease — hypertrophied deform-
ing ostitis.

: Parkinson's disease — paralysis agitans.

Parrot's disease — syphilitic pseudo-paraly-
sis.

Parry's disease — exophthalmic goitre.
Pavy's disease — intermittent albumi-
I nuria.

1 Petit' s hernia — lumbar hernia.

Pott's aneurism — aneurism by anastomo-
sis.

Pott's disease — ostitis of the vertebra.
Pott's fracture — fracture of the tibia.
Raynaud's disease — symmetrical gangrene
1 of the extremities.

Reclus's disease — cystic disease of the
breast.

Richter's hernia — parietal enterocele.

Rivolta's disease — actinomycosis.

Romberg's sign — ataxic swaying in the
' dark or with closed eyes.

Rosenbach's sign — abolition of the ab-
; dominal reflex.

Soesnich's ulcer — infectious ulcer of the
- cornea.

Stell wag's symptom — retraction of the
upper eyelid.

Stokes's law — paralysis of muscles subja-
cent to inflamed serous and mucous mem-
branes.

Storck's blenorrhea — that of the respira-
tory passages.

Sydenham's chorea — chorea minor — com-
' mon chorea.

Thomsen's disease — muscular spasm on
1 voluntary movement.

Tornwald's disease — inflammation of the
pharyngeal tonsil.

Velpeau's hernia — femoral hernia in front
of the vessels.

Volkmann's deformity — congenital tibio-
tarsal luxation.
' Wardrop's disease — malignant onychia.

Weil's disease — abortive typhoid fever
with jaundice.

Werlhoff's disease — purpura hemorrhagia.

Westphal's sign — abolition of the knee
jerk.

Willard's lupus — tuberculous lupus,
Winckel's disease — cyanosis of the new-
born.

New Operation for Spasmodic Wry
Neck.

Dr. W. W. Keen read a paper on this
subject before the Philadelphia Neurological
Society, Oct. 27, 1890; it is published in
the Annals of Surgery, Jan., 1891. The
steps of the operation are as follows :

1. The field of operation having been
shaved and disinfected, make a transverse
incision about half an inch below the level
of the lobule of the ear, from the middle
line of the neck posteriorly, or even slightly
overlapping the middle. This incision
should be two and one-half to three inches
long.

2. Divide the trapezius transversely.

3. Dissect up to the trapezius and find
the occipitalis major nerve as it emerges
from the complexus and enters the trape-
zius. In the complexus is an intra-muscular
aponeurosis. The nerve emerges from the
complexus at a point between this aponeuro-
sis and the middle line, usually about a half
inch below the incision, but sometimes
higher up, and then enters the trepezius. It
is always a large nerve of the size of a stout
piece of catgut, and it is easily found if
sought for at the right place.

4. Divide the complexus transversely at
the level of the nerve. This division should
be made by repeated small cuts, so as not to
cut the nerve which is our guide, after which
dissect the nerve still further down from the
anterior surface of the complexus, where it
arises from the posterior division of the sec-
ond cervical. Cut, or better, exsect a por-
tion of the posterior division before the oc-
cipitalis major arises from it, so as to catch
the filament to the inferior oblique muscle.
This divides the second cervical.

5. Recognize the inferior oblique muscle
by following the sub-occipital nerve towards
the spine. The nerve passes immediately
below the border of the muscle.

6. Recognize the sub-occipital triangle
formed by the two oblique muscles and the
rectus capitis posticus major. In this tri-
angle lies the sub-occipital close to the oc-
ciput. It should be traced down to the spine
itself, and be divided, or, better, exsected.
This divides the first cervical.

7. An inch lower down than the occipi-
talis major, and under the complexus, is the
external branch of the posterior division of
the third cervical to the splenius. When
found, it is to be divided or exsected close
to the bifurcation of the main trunk. This
divides the third cervical.

336

Periscope.

Vol. lxiv

A drainage-tube and horse hairs are to be
inserted, and as the patient lies on the back,
although the wound is very deep, the condi-
tion is most favorable for good drainage.
If desired, the posterior muscles can be
united by buried sutures, independently of
those in the skin. The after-treatment is
the same as for ordinary operations.

Terpene Iodide in Diseases of the
Lungs.

In the New York Medical Journal, Feb-
ruary 14, Dr. William H. Gregg says: For
the past two or three years I have carried on
a series of therapeutical investigations in
search of some antiseptic agent that would
act as a specific against the development of
acute diseases of the lungs, more particularly
acute congestion, pneumonia and those
catarrhal and throat affections which are so
often the premonitory symptoms of more
serious mischief. While I have demon-
strated to my own satisfaction that these
diseases may be cut short, I am not so san-
guine that the remedy will prove curative in
all cases where a disease is once fully devel-
oped, yet further investigation may prove
that it possesses specific properties even in
these cases.

It has been my desire only to suggest some
drug or combination of drugs which will pre-
vent the ravages of the various cocci that
are carried into the lungs through the agency
of those septic storms which are so frequent
in this climate, before an actual disease of
the lungs has been established.

The great disadvantage the physician has
to contend against in the administration of
medicines is the changes they are liable to
undergo when taken into the stomach before
they finally enter the circulation. It would
therefore appear that we ought to administer
all of our remedies hypodermically, and
perhaps this is the more rational way of ob-
taining their full benefit. But this mode
has its objections. In the first place, it
requires more or less skill ; besides, it is
painful and at times is followed by unpleas-
ant effects.

I believe that terpene iodide enters into
the circulation unchanged, from the fact
that it acts as quickly as if it were adminis-
tered hypodermically. It is my judgment
that the remedy offers greater success and
produces happier results than any other of
this class of remedies. While it is a power-
ful antiseptic, it is comparatively harmless,

for, after prescribing it for several years, I
have yet to meet with any unpleasant effect.
In acute affections of the throat it may be
used in spray, while in other cases it may be
given to adults in ten-drop doses, on a tea-
spoonful of sugar, once or twice a day — in
the morning and at bedtime. The morning
dose should be followed by a glass of milk
or bouillon. Larger or more frequent doses I
are apt to excite too great a discharge of I
urine.

I have no doubt that terpene iodide wift
should it come into general practice, find a
wider range of usefulness than that above!
indicated. As to its value in phthisis pul-i
monalis, diphtheria and other zymotic dis-i
eases, I am at present unable to speak.

Local Treatment of Tuberculosis of
the Larynx.

The Journal de Mkdecine de Paris, Jan-i
uary 25, 1891, says that Goris uses various
astringent powders for insufflation in the
treatment of laryngeal tuberculosis, with the
object of coagulating the albumin and form-
ing a more or less protective coating, of
keeping aseptic the interior of the larynx,
and of relieving pain. He uses the follow-!
ing formula of Schnitzler :

R Morphinse acetatis gr. iij

Plumbi acetatis . g ss

Sacchari lactis g v

M. Ft. pulvis.

In addition he prescribes :

R Iodoformi (vel iodol) ........ gr. xv

Sacchari lactis ^ ijss

M. Ft. pulvis.

or •

R Iodoformi (vel iodol) . , gr. xv

Cocainae hydrochloratis gr. iij

Sacchari lactis c . . 3 ijss

M. # Ft. pulvis.

or

R Acidi tannici . . . gr. vijss

Sacchari lactis g ijss

M. Ft. pulvis.

At the same time, he directs inhalations
of the vapor of a three per cent, solution of
sodium benzoate, adding at each inhalation
a half teaspoonful of the following :

R Tincturae eucalypti fgv

Balsami Peruviani ^j

M.

If the laryngeal secretion is excessive, a
drachm of terpinol may be added to the
preceding. I

March 21, 1891.

Editorial.

337

• THE

MEDICAL AND SURGICAL

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KOCH'S FLUID IN NON-TUBERCULOUS
PERSONS.

To determine if injections of the Koch
fluid, within the limits prescribed by Koch,
produce reaction in healthy individuals, Dr.
Erich Peiper {Allgemeine Medicinische Cen-
tral Zeitung, January 31, 1891) injected at
the clinic of Mosler, at Greifswald, twenty-
two persons in whom evidences of .pulmo-
nary tuberculosis were absent. This num-
ber included one healthy medical student,
one case each, of cystitis that had been re-
lieved, of arthritis, of rheumatic pains at the
shoulder, of gastritis already relieved, of
sciatica, of gonorrhoea relieved, of a conva-
lescent from typhoid fever, of eczema of the
face, of tabes dorsalis, of chlorosis and tri-
geminal neuralgia, of carcinoma of the
stomach, six cases of diffuse bronchitis, one
of fetid bronchitis, two of gonorrhoea and
one of cystitis. In every instance the fluid

was fresh or but a few days old, and was di-
luted with a five per cent, solution of car-
bolic acid. The usual precautions were
taken. In no case did any complication oc-
cur at the site of injection. More than one
centigram was only exceptionally used.
Four patients failed to react, or showed but
slight reaction. Four others had tempera-
tures of 100. 70 and a degree of malaise.
The remaining fourteen displayed quite de-
cided reactions. Of nineteen who received
two milligrams each, four presented a gen-
eral reaction, with temperatures of from
1020 to 1040. Of twenty-one who received
five milligrams each, eight displayed evi-
dences of reaction, with temperatures of from
100. 50 to 1040. Of sixteen who received
one centigram each, twelve reacted, four
with temperatures of 100. 40, eight with
temperatures of from 1010 to 104.50. The
reaction was usually ushered in in from six to
ten hours by shivering or a chill. The max-
imum was soon reached and the tempera-
ture slowly fell. On the day following, the
temperature, in some cases, was unusually
low. In one case, after an injection of one
centigram, the fever lasted for two and a
half days. The accompanying symptoms
were pains in the extremities, headache,
flushing, sweating, dyspnoea, irritable cough,
increased expectoration and pains in the side
of the chest, not so decided, however, as in
the reaction of tuberculous patients. Cough
was absent in several cases of bronchitis.
In two cases, the spleen was enlarged.
There was increased frequency of pulse and
respiration in proportion to the elevation of
temperature. In three cases, in which pus
was present, reaction followed upon small
doses. A patient with cystitis, in whom
there was no reason to believe that tubercu-
losis existed, reacted promptly to each of ten
injections, decided improvement in the local
disease taking place.

It is to be regretted that a number of
perfectly healthy persons could not be se-
cured for making the investigations. It
also remains, of course, an open question

338

Editorial.

Vol. Ixiv

if patients who react to the injections may
not have in some' part of the body a latent
tuberculosis — although to assume this is a
pure hypothesis.

It must not be forgotten that the Koch
fluid is a potent agent — for good or ill —
in the administration of which the great-
est discretion should be observed. Extrav-
agant claims should not be made for it, nor
should it be condemned merely because
injudiciously used. Our own opinion is that
it is of no real value as a therapeutic agent,
although — as we stated in our first comment
on it — we would be glad, for the sake of
humanity, if the judgment should prove to
be erroneous. It is a curious fact that in
the only case, so far as we know, which has
been claimed as a " cure " in Philadelphia,
the patient died in the Philadelphia Hospital
on March 6, a hurried post-mortem examina-
tion being made by the attending surgeon
without securing the presence of the Path-
ologist of the Hospital.

TREATMENT OF ANEMIA.

It should always be borne in mind that
anemia is a symptom. When the removal
of the condition which gives rise to it is
possible, this should be the first step in the
treatment, and it alone may suffice to dis-
sipate the anemia. Sometimes, however,
the causative factor eludes detection, or
it may be that the disease to which the
anemia is due is beyond the reach of treat-
ment. Under these circumstances, the ane-
mia, as such, must be directly attacked.
The Deutsche Medicinische Wochenschrift,
January 29, 1891, contains a brief paper by
Dr. Laache, presented to the Section on
Internal Medicine, at the Tenth Interna-
tional Medical Congress at Berlin, in which
are laid down the lines of treatment of the
various forms of anemia.

If worms are present in the intestinal
canal, if hemorrhage or other wasting dis-
charge exists, if digestion is impaired, these
conditions should receive appropriate atten-

tion. For the simple anemias and for chlo-
rosis, in which there is deficiency both of
red corpuscles and of hemoglobin, iron is
the best remedy. A favorite form in which
to administer iron is as Blaud's pill, con-
taining equal parts of dried sulphate of iron
and carbonate of potassium. For cases to
which this is not suitable, or in which it is
not well borne, the lactate or the carbonate
of iron, or a solution of the albuminate, may
be prescribed, or a soluble salt may be in-
jected subcutaneously. A most important
point in the administration of iron is that
it must be continued persistently, for long
periods, it being remembered that the num-
ber of corpuscles is restored to the normal
long before the proportion of hemoglobin.
Next in importance to iron is arsenic, which
has a special application in the treatment of
pernicious anemia, in which there is a dim-
inution in the number of red cells and in
the total amount of hemoglobin, although
the individual red corpuscle contains a rela-
tive excess of hemoglobin. To arsenic is
also ascribed the property of diminishing
the number of white corpuscles, which
ought to make it a valuable remedy in the
treatment of leukemia.

Of other remedies recommended for the
treatment of anemia, many are of doubtful
value, while, of a few, some good may be
expected in individual instances. Among
the latter may be included : transfusion of
blood or solutions of common salt, subcu-
taneous injection of blood, and inhalations
of oxygen. Of all the means proposed, the
most astounding, perhaps, is blood letting,
which, in a few reported cases, is said to
have given satisfactory results.

The general management in a case of
anemia is not to be neglected. Light and
pure air should be provided for. Passive
or gentle active exercise in the open air,
avoiding fatigue, is to be commended in
most cases of ordinary anemia. In perni-
cious anemia, however, rest in the recum-
bent posture should be insisted upon ; while
in intense anemia following hemorrhage,

March 21, 1.891. Book I

and in chlorosis, such rest — at least for a
.time — acts beneficially. In cases in which
heat production has not sunk too low, judi-
cious treatment with cold water has a tonic
effect. Sea-bathing must be undertaken with
extreme caution, and the dietary should not
be arranged with a view to the production
of fat, but should consist largely of meat,
so as to supply the material from which
blood corpuscles can be made.

With these general suggestions, it would
not be hard for any medical man to arrange
a plan of treatment suited to almost any
case of anemia, remembering always that
the end to be accomplished is to lay up for
the patient a stock of vigorous blood which
shall support and not drain the tissues
through which it circulates.

TREATMENT OF ASTHMA IN CHIL-
DREN.

Dr. Blache, in the Bulletin Medical, Jan-
uary 14, 1 89 1, points out the indications in
the treatment of asthma occurring in chil-
dren. At the onset of the attack, inhala-
tions of the smoke from burning leaves of
belladonna, hyoscyamus or stramonium,
from nitre paper, inhalations of oxygen or
of iodide of ethyl, should be tried. These
failing, a hypodermic of a little morphine
will at once relieve the dyspnoea. Mor-
phine, however, must be used with great
circumspection in children. Belladonna,
on the other hand, is well borne, and its
use may be continued for a long time. A
sixth of a grain of the powder or a sixth of
a grain of the extract may be given daily.
The tincture of lobelia is well borne in large
doses. Beginning with twenty drops, the
dose may be gradually increased to three
drachms in twenty-four hours. Good re-
sults have been obtained with the tincture
of grindelia robusta, which has also been
said to be a specific in whooping-cough.
From fifteen to twenty drops may be given
at a dose. Inhalations of the vapor of py-
ridin, as recommended by See, mitigate the
severity of the paroxysm.

evzews. 339

In the curative treatment, the iodides,
and especially the iodide of potassium, hold
the first place. Their efficacy depends
upon an influence upon the brain and
medulla, regulating nervous discharges. If
the iodides are not well borne or if symp-
toms of iodism occasion annoyance, tinc-
ture of grindelia, arsenic, or inhalations of
pyridin or of compressed air, may be sub-
stituted.

If the asthma be the result of a diathesis
of rheumatism, gout or malaria, or due to
disease elsewhere, as in the nose or pharynx,
treatment must first be directed to these eti-
ological factors.

To these suggestions may be added a ref-
erence to the recommendation of euphorbia
pilulifera made by Dr. M. Graham Tull,
in the Medical and Surgical Reporter,
March 16, 1889, and May 18, 1889. This
drug seems to have a powerful influence
upon the course of asthma.

Book Reviews.

(Any book reviewed in these columns may be obtained upon
receipt of price, from the office of the Reporter.]

THE TIME RELATIONS OF MENTAL PHE-
NOMENA. By Joseph Jastrow, Professor of
Psychology at the University of Wisconsin, pp. 60.
Fact and Theory Papers. New York : N. D. C.
Hodges, 1890.

The title of this work is sufficiently indicative of the
nature of the subject discussed. A careful digest of
the literature, with abundant references, is given. The
outcome of investigations of this kind is in the direc-
tion of facilitating and shortening mental processes and
improving methods of education.

The publication will have an interest for physiolo-
gists and psychologists.

A MANUAL OF AUSCULTATION AND PER-
CUSSION. Embracing the Physical Diagnosis of
Diseases of the Lungs and Heart, and of Thoracic
Aneurism. By Austin Flint, M. D., LL. D.,
Professor of the Principles and Practice of Medi-
cine and of Clinical Medicine in the Bellevue Hos-
pital Medical .College, etc., etc. Fifth Edition.
Thoroughly Revised by J. C. Wilson, M. D.,
Lecturer on Physical Diagnosis in the Jefferson
Medical College, etc., etc. 8vo, pp. 268. Phila-
delphia: Lea Brothers & Co., 1890. Price, #1.75.
Little need be said of a book which has passed
through five editions. Of course physical diagnosis
can be taught practically only on the living subject. It
is impossible to convey adequate ideas of sensation or
sound by description, but in conjunction with actual
examination a systematic work renders valuable ser-
vice. Of course, it must never be forgotten that

34o

Correspondence.

Vol. lxiv

physical signs are but evidence of physical conditions.
Alone they do not establish the diagnosis. In illus-
tration, let us quote as to crackling sounds. They
" are not uncommon in healthy persons, at the end of
forced inspiration. The fact of their presence at both
summits, and the absence of other morbid signs, are
the grounds for not considering them as evidence of
disease. They are found in health, especially if the
binaural stethoscope be employed." Let the student
beware of pathognomonic signs and symptoms.

Little is said of functional or hemic murmurs, often
described in the course of anemia.. We cannot recon-
cile ourselves to the commonly accepted explanation
of these as due to changes in the blood ; unfortunately,
however, without being able to present a better one.
A murmur may be generated by certain peculiarities
of the channel through which fluid passes, giving rise
to variations in resistance. It does not seem plausible,
on the other hand, that variations in the density of
the circulating medium should occasion adventitious
sounds. We should look for the explanations of these
so-called functional murmurs in some transient relation
between circulation and respiration.

The little volume commends itself to students and
physicians, and its revision by so careful a diagnostician
and practitioner as Dr. Wilson enhances the value
which is guaranteed by the name of its author.

A PRACTICAL TREATISE ON IMPOTENCE,
STERILITY AND ALLIED DISORDERS OF
THE MALE SEXUAL ORGANS. By Samuel
W. Gross, A. M., M. D., LL. D., Professor of the
Principles of Surgery and Clinical Surgery in the
Jefferson Medical College, of Philadelphia, etc., etc.
Fourth Edition. Revised by F. R. Sturgis, M. D.
pp.173. Philadelphia: Lea Brothers & Co., 1890.
Price, $1.50.

This work of the younger Gross is too well known
to require extended comment. It has already taken
its place among the classics on the subjects of which
it treats. While medical literature teems with treatises
on diseases of the female generative apparatus, prior
to the work of Gross the derangements of the male
sexual organs was by English writers a comparatively
untrodden field. Even yet, probably, the general
practitioner is as uninformed on this subject as though
it were some obscure specialty. The work in question
has done much to clear the medical atmosphere of a
good deal of doubt and uncertainty. The numerous
additions and comments of the reviser have been in-
terpolated in the text in brackets. The general prac-
titioner would be well repaid by a careful reading of a
treatise which handles in a practical way subjects so
common to every-day experience.

Correspondence.

Electricity and Pelvic Surgery.

To the Editor :

Sir : In an article read before the Missis-
sippi Valley Medical Association, 1890, Dr.
Sutton says : "These teachings are rapidly
becoming ancient history, despite the desper-
ate efforts and exaggerated statements of the
advocates of electricity as a curative agent.
In regard to the latter, men who did not
own a battery, and who had never seen a

fibroid tumor removed by an electric cur-
rent, have written elaborate articles on the
subject. Happily for the surgeons, who had
about arrived at a consensus of opinion
in the surgical methods in the treatment of
these cases, these ' lightning bugs ' have
become in recent months less numerous."

This is sensible talk, with which no logical
fault may be found. It is well for the sci-
ence of gynecological electro-therapeutics
that the unfitted and unlettered should drop
out. That a man who never owned a bat-
tery, and who never saw a fibroid tumor re-
moved, should make blatant claims for some-
thing of which he knew nothing, can be
equalled only by the equally blatant con-
demnation of the surgeon who never owned
a battery and who never saw a tumor re-
moved. It is fortunate for medical advance
that such as these should have screamed
themselves so hoarse that their voices are
no more heard in the land.

In the discussion of this paper, Dr. L. S.
McMurtry, of Louisville, said : "Of late,
electricity has been much vaunted in the
treatment of fibroid tumors of the uterus. Dr.
Sutton merely mentioned this agent in his
paper, probably purposely, because he knows
that electricity does nothing towards arrest-
ing or removing these tumors. A peculiar
feature about the application of electricity
in pelvic surgery is that those who a few
years since denied the existence of certain
forms of intra-pelvic disease are now
foremost in the diagnosis and treatment of
these same diseases by electricity. The ap-
plication of electricity by puncture is fraught
with great danger. The speaker has re-
moved a uterine myoma by supra-vaginal
hysterectomy, weighing sixteen and a half
pounds, in which the entire anterior aspect,
which had been accessible to electric treat-
ment, was bound by dense adhesions to
the omentum, intestines and abdominal wall,
etc., etc."

Now there happens to be some peculiar
points in this argument, which are salient
characteristics of all similiar arguments
made by exclusive laparotomists, which are
interesting bits of contemplation. I will
first number the curios, and then take .them
up separately for examination.

1. " Dr. Sutton merely mentioned this
agent," etc., etc.

2. " A peculiar feature about the appli-
cation of electricity," etc.

3. " The application of electricity by
puncture is fraught with great danger."

March 21, 1891. Correspondence.

34i

4. " The speaker has removed a uterine
tumor," etc.

1. Dr. Sutton, if acquainted with the sta-
tistics and history of gynecological .electro-
therapeutics, will not feel flattered at this
surmise. The unimpeachable cases on re-
cord in which tumors have been arrested by
electricity, are numerous and quite as reli-
able as are any statistics ever brought for-
ward by any surgeon. If Dr. McMurtry
does not know this — his argument would be
akin to that of a "lightning bug" who
never owned a battery — if he does know
that such claims are made, but refuses to ac-
cept them because they antagonize pet the-
ories of his own, it is not polite to give ut-
terance to such doubts, since men of equally
honorable standing with himself have seen
and reported such cases. I have seen quite
a number " reduced," and so can any one
else see these cases if he will. I have never
seen a fibroid disappear entirely, but other
men have, and I believe them. It is " foolish
talk ' ' to reiterate all this, because all of it
is a fact.

2. In no branch of medicine has a greater
change taken place then in the pathology of
female pelvic disease. What became of all
of these modern high-sounding diseases, and
of the women who had them, before the
modern laparotomist was incubated ? Who
condemned abdominal surgery, not very
long ago, but the surgeons themselves ? Did
women die of these diseases then, as they are
dying since laparotomy has become a fash-
ionable "fad It is nice of the doctor
to give the "lightning bugs" credit for
recognizing and diagnosticating these trou-
bles, early in their history, and for establish-
ing a conservative system of treatment.

3. This objection is a mere will-o'-the-
wisp of the doctor's fashioning. I am speak-
ing, of course, of a puncture in the hands of
those competent to make use of it. In the
clinic, conducted by Dr. Massey and myself,
cases are punctured, high intensities being
used, and the patients go to their homes one
half hour afterwards. I do not advise this,
but with such absolutely poor people, and
with no beds at our disposal, we have no al-
ternative. I have rttverseen any bad results
following a fibroid puncture, and my experi-
ence has been an ample one. But even
were it possible to show that such a process
is attended with danger, what is the value
of such an objection ? Is not laparotomy —
the alternative — a dangerous operation.

4. Dr. Baldy, than whom no man of
equal age stands higher in the surgical lit-
erature of this country, told me only a few
days ago, that he very rarely if ever had
opened the abdomen for the removal of tu-
mors, without finding extensive adhesions,
and that a large majority of so-called pus
tubes were simply cases of chronic adherent
salpingitis. So that all this rumpus about
adhesions amounts to nothing. Of course
they are adherent — these big tumors — how
could it be otherwise, and by what process of
ratiocination does one reach the conclu-
sion that adhesions are engendered by elec-
tricity?

In the British Medical Journal, Feb. 7,
1 89 1, Drs. Williams and Champneys (see
Medical News, Feb 21, especially the few in-
troductory words of the editor) have an ar-
ticle on "The Operative Treatment of
Chronic Disease of the Uterin e Appendages ' '
which merits careful reading. In the Lancet
of January 31, 1891 (quoted in the Medical
and Surgical Reporter, February 21)
will be found Sir Spencer Wells' reply to
Mr. Lawson Tait. This is also most edify-
ing reading. It might appear to a student
of medicine as if the accusation of exag-
geration, overstating the case, etc., etc., was
really one which applied most directly to the
surgeon. Sooner or later there must be reac-
tion in favor of the protection of a woman's
pelvic appendages. The time is surely near
at hand, for the tread of its march can be
heard even now, when it shall be criminal
for the surgeon to boast of his recklessness
in abdominal work, or to demonstrate before
any society a ' ' bucketful ' ' of ovaries and
tubes. It is a travesty to call this science, it
stultifies intelligence to call it good surgery,
and it outrages refinement and common
sense to make such exhibitions. It is inex-
act to claim that operations of this kind
cure the patient, when just the reverse is
often the case. Many a woman suffers
more acutely for years after such an opera-
tion than she did before it. I am glad of
anything that cries a halt to it, and I am
very especially glad that electricity has arisen
to show us a better, safer and more conser-
vative plan of treatment, and that the
"lightning bugs" have been largely re-
sponsible for stemming the tide and turning
it in another direction.

Yours truly,
Horatio R. Bigelow, M. D.

Philadelphia.

342

Notes and Comments.

Vol. Ixiv

Notes and Comments,

Solution of Shurley and Gibbes for
Tuberculosis.

Dr. J. E. Clark, Professor of Chemistry
and Physics, Detroit College of Medicine,
gives in the North American Practitioner,
February, 1891, the following account of
the manufacture of the solutions recom-
mended by Drs. Shurley and Gibbes.

The main difficulties encountered were
the tendency of the gold solution to re-
duction, and the formation of abscesses fol-
lowing the iodine injection. It was found
that both these obstacles were removed by
scrupulous cleanliness in all manipulations,
and securing absolute purity of the chemicals
used. It is an unfortunate fact that the so-
called C. P. chemicals, are often so only in
name, and that the chemist who wishes to
succeed must be an adept in purifying or man-
ufacturing his own. In toxicological analy-
sis where the purity of the reagents is of su-
preme importance, Dr. Clark has frequently
found chloroform, ether, alcohol, etc.,
bought from good houses, containing im-
purities, which if undetected might easily
have led to erroneous conclusions.

In making the solution of gold and so-
dium, the first step is the preparation of
pure gold. Dr. Clark takes an English gold
coin of recent date, which is composed of one
part of copper and eleven parts of gold,
and thus avoids the trouble of an insoluble
chloride of silver which sometimes interferes
where the alloy consists of part silver ; to
the coin in small pieces he adds eight parts
of nitro-hydrochloric acid (four parts hy-
drochloric to one part nitric acid) chemi-
cally pure. This solution is then evaporated
on the water bath with an excess of hydro-
chloric acid to nearly dryness, it is then
treated with hot water and filtered to sepa-
rate any chloride which might be present.
To this solution is added a solution oc pure
oxalic or formic acid which will cause the
precipitation of any gold which is present,
in the form of a brown or greenish-black
powder, in from one to forty-eight hours.

This powder is collected and boiled in
dilute hydrochloric acid Sp. gr. 1.1, and
then washed and dried. To the powder is
added eight parts of nitro-hydrochloric acid
and the solution evaporated on the water
bath to nearly dryness, and allowed to crys-
tallize. Too much heat here or too long
evaporation is apt to give an aurous or an 1

acid chloride Au CI or Au H Cl2, either of
which must be avoided. The result, if the
manipulation be properly conducted and the
water of crystallization driven off, leaves
ruby red prismatic crystals, and not the
orange red crystalline needles of commerce.

The next step is the manufacture of the
chloride of gold and sodium. The com-
mon salt usually contains portions of Ca
Cl2, Mg Cl2, and Ca S Or Dr. Clark either
makes the sal.t from an anhydrous carbonate
and hydrochloric acid, or dissolves it in four
times its weight of pure water and adds to
the filtered solution first Ba Cl2, and then
Mg Co3, as long as any precipitate falls, fil-
ters and evaporates very slowly, skimming
off the first crystals that form and rejecting
them ; those forming last are the pure salt.

Take of the gold chloride 85 parts, and
the Na CI 16 parts and mix each separately
in a little pure water, stir together and allow
to crystallize at a low temperature, which
will give orange colored rhombic prisms.
Similar - precautions are necessary in the
preparation of the iodine solution, as the
iodine of commerce all contains more or
less impurities, in the shape of graphite,
chlorine, oxide of manganese and crude
antimony. To prepare it perfectly pure on
a small scale, place some in a small deep
porcelain scale or earthenware dish, and
cover it air-tight with a glass matrass filled
with cold water, and apply to the dish a
temperature of about 100 C. for two or
three hours, allow to cool and the sublimate
will be found attached to the under surface
of the matrass. It is best, however, to ex- 1
pose the matrass after about 20 minutes' ex-
posure to the heat and look for acicular
prisms of a white color and pungent odor,
if these are present they should be scraped
off with a glass rod and rejected, afterwards
the sublimation is to be carried on until it
is complete. The fresh iodine is then to
be kept in glass stoppered bottles.

To make a non-irritating solution of the
iodine for hypodermic use it was found ne-
cessary to combine it with water and glycer- j
ine. This is accomplished through the
medium of potassic iodide. A sufficient
quantity, to just produce solution is added j
to the water and iodine. The glycerine is
subsequently added. To purify the potassic 1
iodide which contains a carbonate and I
iodate it is only necessary to dissolve in j
ethylic alcohol and filter. The carbonate
and iodate are both insoluble in this sol- |
vent.

March 21, 1 89 1 . Notes and

Comments.

343

There are details in the way of manipu-
lation which have not been mentioned, but
: these will occur to any one qualified to un-
; dertake their manufacture. Sterilized dis-
: tilled water is used in all operations.

The question may arise as to why so much
: care is required in the manufacture of the
solutions, and what harm can arise from the
1 presence of minute quantities of organic
1 matter or impurities? It has been found
: that the smallest quantity of organic mat-
ter in the gold solution will produce reduc-
tion on its exposure to light, whereas, if
made in this manner it can be exposed to
the light indefinitely. If a solution of ni-
trate of silver be made with like precaution
< it can be exposed in a clear glass bottle to
direct rays of sunlight without change, show-
ing that organic material is responsible for
the reduction.

The chemical impurities in ordinary mix-
tures of these substances appear to me to
have been the cause of much of the irrita-
tion and the abscesses which followed the
primary experiments, as, since greater care
has been exercised in the manufacture of
the solutions, not a single abscess has been
reported. During the last month Dr. Clark
has supplied a large number of physicians,
in the United States and in Canada, with
the solotion, without receiving one com-
plaint.

Pain in some cases is said to follow the
injection. This can be mitigated by being
careful not to inject too deeply, if the mus-
cle is reached pain often follows. Any di-
lution of the gold solution, unless with ster-
ilized water, will produce a precipitate of
the metallic gold.

On Dietetics of Chronic Nephritis.

In a preliminary note in the Vratch, No.
39, 1890, p. 889, Dr. Nikolai S. Zasiadko,
of St. Petersburg, describes a very interest-
ing group of elaborate clinical experiments
which he has carried out in order to eluci-
date the influence of vegetable, animal and
mixed dietary on albuminuria, the arterial
tension, pulse, dropsy, temperature, body's
weight and general nutrition in patients suf-
fering from chronic Bright's disease. In all,
ten patients were selected for the purpose.
In each case the observation lasted a month,
being divided into three equally-long peri-
ods, during one of which the patient was
kept on a pure vegetable diet ; during the
second on an animal diet (with addition of

bread, from 50 to 200 grams a day), and
during the third on a mixed one. The fol-
lowing are the main deductions drawn by
Dr. Zasiadko from his researches.

1. Under the influence of a vegetable di-
etary, the daily quantity of albumin in the
urine considerably decreases, the ' arterial
tension is lowered, dropsy markedly in-
creases, the pulse becomes slower, weaker
and more easily compressible, the patient's
general objective and subjective state grows
worse (there appear general weakness, list-
lessness, disinclination to movements, etc.),
the appetite gradually disappears.

2. Under the influence of an animal diet,
the daily quantity of albumin in the urine
markedly increases, the arterial tension rises,
dropsy decreases, the pulse becomes more
frequent and fuller, the bodily weight de-
creases pari passu with the disappearance of
cedemas, the daily amount of the urine, its
proportion of solid constituents and specific
gravity increase, the patient's general state
markedly improves (the patient becoming
cheerful and stronger, inclined to exercise,
etc:).

3. A mixed dietary stands midway be-
tween a vegetable and an animal one, but
comes nearer to the latter, as far as its influ-
ence on albuminuria is concerned.

4. The most prominent symptom of
chronic nephritis is constituted by a morbid
alteration of the blood which is character-
ized by an increased proportion of water
and a decreased one of proteids, hemoglobin
and morphological elements. Hence, to re-
store the normal properties of the blood and
to improve the patient's general nutrition,
it appears necessary to keep him on a liberal
diet abounding in proteids. All apprehen-
sions concerning the development of uremia
from such regimen are void of foundation.

5. Contrary to various theoretical objec-
tions, brought forward by Lepine and. Sena-
tor, animal food (butcher's meat, etc.,) does
not cause any renal irritation in chronic
nephritis and does not give rise to any ex-
acerbation of the chronic renal .process. In
acute or subacute cases, however, the dietary
can be resorted to only with certain caution.

6. An abundant proteid food usually aug-
ments the proportion of albumin in the urine,
causing the so-called "dietetic albuminuria "
(which, however, swiftly disappears on de-
creasing the proportion of proteids in the
patient's food). In view of the fact, the
said proportion of albumin alone cannot
afford a criterion for appreciating the grav-

344

Notes and Comments.

Vol. lxiv

ity of the renal process. The patient's di-
etary must be always also taken in due con-
sideration.

7. In chronic cases, a moderate exercise
increases albuminuria but to a slight extent.
Hence it can and must be allowed to such
patients.

8. According to modern scientific teach-
ings (Gull and Sutton, Dickinson, Meigs,
Johnson, Rayer, Kiiskoff), chronic Bright's
disease constitutes a general affection of the
vascular system (and not a local lesion of the
kidneys alone, as was formerly thought and
taught). Hence, the practitioner of nowa-
days cannot possibly limit his efforts solely
to. controlling albuminuria, but must strive
to improve the patient's general nutrition
by means of an appropriate diet. Only such
treatment can lead to improvement in the
nutrition of the renal tissues.

9. The best dietery for chronic nephritic
cases consists in a mixed (animal and vege-
table) food. In chronc interstitial nephritis,
accompanied by a general weakness, an ani-
mal food should predominate in the dietary,
while in chronic parenhymatous nephritis
vegetable food articles with milk should be
in a relative excess.

10. Cooked or roasted Italian chestnuts
markedly lower the proportion of albumin
in the urine, which is, probably, dependent
upon their containing tannic acid.

Starvation and Disease.

The importance of nutrition in the treat-
ment as well as in the prophylaxis of disease
has been recognized more especially since
the time of Graves. It has long been known
that hunger and deprivation increase the
predisposition to disease.

The Centralblatt fur die Medicinischeji
Wissenschaften, January 10, 1891, quotes
from Fortschritte der Median, Nos. 18 and
19, 1890, the conclusions arrived at by Drs.
Canalis and Morpurgo as a result of investi-
gations conducted at the bacteriological
laboratory at Rome. Pigeons, chickens and
white rats, which enjoy a relative immunity
to anthrax, were inoculated subcutaneously
with anthrax, food being withdrawn before
or after the operation.

It was found that pigeons normally enjoy-
ing immunity died of anthrax if food was
withdrawn simultaneously with making the
inoculation. Pigeons which had been starved
for six days did not become infected if they

were again fed immediately after inocula-
tion ; but were infected, as a rule, if they
had been starved for a period longer than
six days. If food was withdrawn at the
time of operation and resumed in two days,
the disease was not aborted, though its pro-
gress was retarded. Thus it is seen that in
pigeons the loss of immunity from anthrax
is related rather to interruption in the cir- 1
culation of nutritive material than to mere
wasting of the tissues. If food was with- j
drawn on the eighth day after inoculation i
the animals still died of anthrax, a proof
that the germs introduced may continue to
live for a number of days in the organism
and remain virulent. The loss of immunity
for anthrax in starving pigeons is not to be
explained by the reduction of temperature !
which takes place, as infection does not fol-
low inoculation if the animals are kept in a
bath at a correspondingly low temperature
but at the same time are well fed.

To determine whether profound lesions of
the digestive apparatus had any influence
upon natural immunity, the pancreas, or
portions of it, were removed. In these
cases, the pigeons were, as a rule, suscepti-
ble to anthrax for a short time.

Chickens also became susceptible to an-
thrax by starvation. Most of the animals
died if the inoculation was preceded for
from three to seven days by withdrawal of
food. In contrast to the pigeons, the chick-
ens retained immunity if the starvation was
begun just after inoculation.

White rats remained unsusceptible to an-
thrax infection in spite of starvation.

[These experiments are of a class which
deserve reprobation. The point sought to
be established -is one which any intelligent
man would consider d priori highly likely, I
and which has been abundantly established f
by clinical experience. The experiments of I
Canalis and Morpurgo were useless and j
cruel, and we mention them only to con- j
demn them. — Editor of Reporter.]

Tritopine.

Merck' 's Bulletin, February, 1 891, says:;!
Tritopine (C42 H54 N2 07 ) is a new alkaloid
discovered in opium last year by Dr. Kauder, '|
chemist in E. Merck's Laboratories at Darm- ;
stadt.

Tritopine, a strong base, neutralizing)
mineral acids, occurs in opium in still f
smaller quantities than Protopine, recently :

March 21, i 89 1 . Notes and

Comments.

345

described in that journal. It melts with-
out decomposition at 1820 C. [359 F.]. It
is easily soluble in chloroform, but only
with difficulty in ether. It crystallizes from
alcohol in beautifully formed transparent
prisms — each part of the alkaloid requiring,
for solution, about 40 parts of boiling ab-
solute alcohol.

Most of its salts are very easy soluble in
water and in alcohol, as for instance the
hydrochlorate, sulphate, nitrate and acetate.
The bin-oxalate and hydro-iodate are crys-
talline. The latter is rather poorly soluble
in water.

In regard to the toxic properties of tri-
topine, Dr. Kobert says that, like most of
the opium alkaloids (for instance : The-
baine, Papaverine, and others), it exercises
a spastic action, in the manner of strychnine ;
so that its application as a narcotic appears
to be precluded. When given in lethal dose,
its final action is exactly like that of strych-
nine— that is, tetanic.

Army Medical Board.

An announcement was recently made that
an Army Medical Board would be in session
in New York City during April next for the
examination of candidates for appointment
in the Medical Corps of the United States
Army, to fill existing vacancies. At the
time of that announcement there were only
five vacancies to be filled. Recent Con-
gressional legislation has, however, permitted
the retirement of certain officers, so that
there are now fourteen vacancies in the
grade of assistant surgeon, with the prob-"
ability that the number will be increased to
seventeen by the time the examining board
begins its labors.

As already stated, persons desiring to pre-
sent themselves for examination by the Board
will make application to the Secretary of
War, before April 1, 1891, for the necessary
invitation, stating the date and place of
birth, the place and State of permanent resi-
dence, the fact of American citizenship, the
name of the medical college from which
they graduated, and a record of service in
hospital, if any, from the authorities thereof.
The application should be accompanied by
certificates based on personal knowledge,
from at least two physicians of repute, as to
professional standing, character and moral
habits. The candidate must be between 2 1
and 28 years of age, and a graduate from a
Regular Medical College, as evidence of

which, his Diploma must be submitted to the
Board.

Further information regarding the ex-
aminations may be obtained by addressing
C. Sutherland, Surgeon-General U. S. Army,
Washington, D. C.

Meeting of the National Association
of Railway Surgeons.

At the Kansas City meeting of the Na-
tional Association of Railway Surgeons last
year, it was decided to hold the next meet-
ing at Buffalo May 7, 8 and 9 of this year.
But, on account of the meeting of the Amer-
ican Medical Association being set for the
same time, it has been decided to change
those dates, and to hold the next meeting at
Buffalo April 30 and May 1 and 2. To this
meeting all Railway Surgeons are cordially
invited. Railway Surgeons sending their
names and addresses to the Corresponding
Secretary will have a copy of the Constitu-
tion and Programme sent to them. Those
wishing to read papers should send in the
titles of their papers without delay. For fur-
ther information inquiry should be made of
A. G. Gumaer, M. D., Corresponding Sec-
retary, Buffalo, N. Y.

Lion Flesh for Food.

The lion is eaten by some African races,
but its flesh is held in small esteem. The
Zulus find carrion so much to their liking,
that, according to the late Bishop Colenso,
they apply to food peopled by large colonies
of larvae the expressive word " uborni," sig-
nifying in their uncouth jargon "great hap-
piness." David Livingstone, that keen and
accurate observer, reminds us that the ab-
original Australians and Hottentots prefer
the intestines of animals. "It is curious,"
he says, "that this is the part which ani-
mals always begin with, and it is the first
choice of our men." On this point it may
be well to remind the civilized reader that
the woodcock and the red mullet, or sea
woodcock, are both eaten and relished with-
out undergoing all the cleaning processes
which most animals used for food among us
generally experience to fit them for the
table ; so that our aversion to the entrails of
animals is not absolute, but only one of de-
gree. The hippopotamus is a favorite dish
with some Africans when they can get this
unwieldy and formidable river monster, and
when young its flesh is good and palatable,

346

Notes and

Comments.

Vol. lxiv

but with advancing years it becomes coarse
and unpleasant. The Abyssianians, the
amiable people to whom, according to the
Italian prime minister, his countrymen pro-
posed to teach wisdom and humanity, find
the rhinoceros to their taste : so they do the
elephant, which is also eaten in Sumatra.
Dr. Livingstone describes the elephant's
foot as delicious, and his praises will be
echoed by many travelers in lands where
that sagacious monster still lingers in
rapidly decreasing numbers. "We had the
foot," wrote the doctor, "cooked for break-
fast next morning, and found it delicious.
It is a whitish mass, slightly gelatinous, and
sweet like marrow. A long march to pre-
vent biliousness is a wise precaution after a
meal of elephant's foot. Elephant's tongue
and trunk are also good, and, after long
simmering, much resemble the hump of a
buffalo and the tongue of an ox ; but all the
other meat is tough, and, from its peculiar
flavor, only to be eaten by a hungry man."
— Science, February 6, 1891.

Nu Sigma Nu Fraternity.

The annual convention of the Nu Sigma Nu
fraternity was held at the Wayne Hotel, De-
troit, February 13. The society bears the
same relation to medicine that the Sigma Phi
does to the law, being an under- graduates'
secret order, which has chapters in several
of the larger cities. The business of the
convention in the afternoon, which was pre-
sided over by Dr. Waldo E. Clark, retiring
grand iEsculapius, consisted of some revi-
sions of the constitution and by-laws, and
the election of the following officers for the
ensuing year : Grand ^Esculapius, R. E. L.
Rogers, M. D., Pittsburgh, Pa.; Grand Galen,
John L. Irwin, M. D., Detroit; Grand
Herophilus, Don M. Campbell, M. D., De-
troit; Grand Malpighi, Charles D. Strong,
M. D., Brooklyn, N. Y.; Grand Hippocrates,
F. W. Robbins, M. D., Detroit.

In the evening the Beta Chapter, of De-
troit, gave its first annual banquet, at which
the visiting delegates were present as guests.

Salol and the Naphthols.

The Chemist and Druggist, February 7,
1891, says : V. Demandre, a pharmacist of
Dijon, recently read before his departmental
pharmaceutical association, an interesting
note suggested by what was at first a mere

prescription difficulty. Some time since, he
received the following prescription :

R Salol ' 0.50 grams

Naphthol alpha 0.10 "

For one cachet, send ten such.

On rubbing together the two chemicals in
a mortar, a pasty mass* resulted, turning to a
thick oily liquid. The physician having
been notified of the occurrence, the naph-
thol was left out of the prescription. But
the Dijon pharmacist thought the case was
worth looking into a little further. Instead
of alpha naphthol, he tried beta naphthol
with salol in the same proportion as before,
and observed that the mixture remained a
dry powderv (1) Hence his conclusions
that salol is incompatible in powders with
alpha naphthol, but quite compatible with
the beta variety. (2) That the reaction, a
very simple one, will be found useful to dis-
tinguish the two naphthols, as dealers are
apt to sell one for the other, although their
properties are far from being the same.

Mississippi Valley Medical
Association.

The Mississippi Valley Medical Associa-
tion will hold its seventeenth annual session
at St. Louis October 14-16, 1891. A large
attendance, a valuable programme and a
good time are expected. The members of
the medical profession are respectully in-
vited to attend.

For Painful Hemorrhoids.

One is sometimes sorely tried for the
means of relieving the pain, tenemus and
itching of turgid hemorrhoids. Alvin
(Fortschritte der Krankenpflege , January,
1 891) states that a sponge saturated with
water at a temperature of from 1270 to 1400
F., applied several times daily to the anal
region, will mitigate these symptoms.

Notice to Surgeons of the National
Guard.

Dr. Senn, of Milwaukee, Surgeon-General
of Wisconsin, is desirous of obtaining the
name and address of every surgeon of the
National Guard in the United States for the
purpose of taking the necessary preliminary
steps towards the formation of a permanent
National Association.

MEDICAL and SURGICAL

Reporter

Weekly " Journal.

Established in 1853 by S. W. Butler,

CHARLES W. DULLES, M. D., Editor and Publisher.

tered as Second-Class matter at Philadelphia P. O

N. E. COR. 13th & WALNUT STS., PHILADELPHIA ^

Vol. LXIV, No. 13.
Whole No. 1778.

MARCH 28, 1891,

£5.00 per Annum.
10 Cents a Copy.

CLINICAL LECTURE.

GOITTBlsTTS:

I EDITORIALS.

Randall, B. Alex., A. M., Ml D., Philadelphia,
Pa. — Acute Suppuration of the Middle Ear in
infancy 347

COMMUNICATIONS.

Anderson, M., M. D., Pine Bluff, Wis.— Purpura
Hemorrhagica and Metrorrhagia 350

Reixeklng, H , M. D., Sheboygan, Wis.— Perfora-
tive Appendicitis ." 352

Hatch, J. Leffingwell, B. St;., M. D., Philadel-
phia, Pa.— History of Bacteriology 354

REPORTS OF CLINICS.

Buffalo General Hospital 357

PERISCOPE.

Excision of Lupus with Immediate Skin Trans-
plantation. — Iodoform-Ether-Glycerin Injec-
tions in Septic Cavities.— Early Treatment of
Otitis.— Uratosis.— Etiology of Extra-Uterine
Pregnancy.— The Digestive Troubles of Infants.
—Regulation of Prostitution in Missouri —Meat
Juice and Glycerin Applied Externally.— Nu-
merical Relation of Sexes.— Boric Acid in Otor-
rhea.—Druggists and Venereal Patients —Test
for Albumin in Urine.— Menthol for Vomiting
in Pregnancy 358-364

Physicians' Accounts 365

Abortive Treatment of Syphilis 366

Electricity in the Treatment of Extra-Uter-
ine Pregnancy 366

BOOK REVIEWS.

Starr ; Diseases of the Digestive Organs in Infan-
cy and Childhood.— Pepper ; De la Malaria.—
Gordon ; Inoculation for Rabies and Hvdropho-
bia 368

CORRESPONDENCE.

Repeated Puerperal Convulsions
Years in the Body

-A Pin Eight

-369

NOTES AND COMMENTS.

Tampon in Menorrhagia.— Treatment of Recent
Hernia by Aspiration.— Impure Milk in Large
Cities.— The Vital Statistics of New York State
in 1890.— Diagnosis of Previous Pregnancy. —
Medical Attendance for the Poor in Richmond.
—The Medical Law of Alabama.— Association
of American Physicians of Berlin.— Golden Belt
Medical Society.— State Board of Medical Ex-
aminers 369-

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Dr. E. R. Squibo, of Brooklyn, writes as follows in an article headed "On the Medical Uses of Hydrogen Peroxide {Gaillard's
mfedical Journal, March, 1889, p. 267), read before the Kings County Medical Association, February 5, 1889 :

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MEDICAL AND SURGICAL
REPORTER

No. 1778. PHILADELPHIA, MARCH 28, 1891. Vol. LXlV.—No. 13.

Clinical Lecture.

ACUTE SUPPURATION OF THE MID-
DLE EAR IN INFANCY.1

BY B. ALEX. RANDALL, A. M., M. D.,

PROFESSOR OF OTOLOGY IN THE UNIVERSITY OF
PENNSYLVANIA AND THE PHILADELPHIA
POLYCLINIC.

Gentlemen : This infant with a muco-
purulent discharge from the ear which I
now bring before you, suggests many points
of importance for our consideration. The
coryza, with which its trouble began, is
now largely past, but enough of it remains
to indicate the truth of the history which is
given and to point to the need of nasal
treatment. The skin about the ear, as well
as on the walls of the meatus, is somewhat
excoriated by the discharge ; and gives its
indication for the most scrupulous cleansing
and the use of an emolient and protecting
ointment. The tenacious character of the
discharge tells us that our best efforts will
probably fall short of complete evacuation
of the drum cavity from which it comes —
for I need hardly remind you that only from
the middle ear could this mucus be derived,
since there is no mucous membrane in the
external canal — and the large admixture of
mucus indicates that the alteration of the
tympanic lining is not extreme. From this
it follows that the collection within the
drum- cavity has probably exerted little de-
structive action upon the drum-head, has
forced its way through it only after great
distention, and that the perforation is only
a separation of the fibers, not a clear, clean
hole. A tiny pouting point through which
drops of sticky discharge slowly exude is
what we are to expect to see when we have
cleansed the canal ; and even in this expec-

Delivered at the Philadelphia Polyclinic.

tation we maybe disappointed, for the open-
ing may be so inconspicuous that we shall
fail to discern it through the narrow swollen
canal, into which strong illumination with
mirror and speculum seems to penetrate but
poorly.

Inspection confirms the anticipation.
The perforation is recognizable only by
the bead of discharge which protrudes
from it and stretches into a long string as I
try to wipe it away ; and now, hanging from
it, serves to locate the invisible opening.
Spraying the nares clear with DobelPs solu-
tion, and making an application of weak
glycerole of tannin with the bent applicator
above the soft palate — as much to sweep
away any collections there as to obtain any
astringent effect — we can inflate the tym-
panum with the Politzer bag, unimpeded by
secretion in the naso-pharynx. As a result
we find a new quantity of glairy discharge
mixed with air bubbles in the auditory
canal, and in removing it can draw away
another string protruding from the perfora-
tion ; after which repeated inflation forces
the air through with a fine crackling rale.
Light dusting of the bottom of the meatus
with boric powder furnishes a slightly as-
tringent and disinfecting dressing ; and we
will direct the mother to return to-morrow,
syringing the ear meantime if any discharge
appears. To the excoriated skin we apply
an ointment of calomel in vaseline, and
could do the same to the nasal mucous
membrane ; but will employ the gentler
procedure of spraying with a protective film
of fluid cosmoline, and lightly insufflating
the calomel.

At the next visit we may expect to
find further decrease of the coryza, a less
inflamed auditory canal and perhaps a slight
diminution of the discharge. On this last
we can hardly yet count. The affection
has probably quite a course yet to run ; and
unless we enlarge the opening in the drum-
membrane greatly, so as to gain free access

347

348

Clinical

Lecture.

Vol. lxiv

to the inflamed surfaces or adopt other rather
heroic methods of treatment, we cannot ex-
pect to cut short the attack. With careful
watching these simpler measures will doubt-
less suffice to guide the case to an early and
safe termination; so we will hold the more
energetic measures in reserve unless more
urgent symptoms arise. The nutrition must
be looked to, for upon it the satisfactory
resolution largely depends ; but any medi-
cation that might impair digestion is haz-
ardous. In some of these cases inunction
with cod-liver oil has distinct value, as com-
bining food, tonic and protection against
renewed cold-taking.

Turning a moment from the pathological
aspect of this case, I will ask you to study
with me some important anatomical points
which it brings before us — and this the more
especially because the text-books would gen-
erally lead .you astray. You know that in
the new-born infant the annulus or tym-
panic bone, in the groove of which, as in a
frame, the drum-membrane is set, is a sepa-
rate and distinct bone, forming part of the
lower outer surface of the skull. The drum-
head, therefore, like the fontanelle, is a por-
tion of the surface of the head, as this speci-
men shows. But do not imagine, as too
many do, that it is to be found immediately
within the mouth of the auditory canal.
When I pass the cotton-tipped probe down
into contact with it, you see that it is about
an inch and a quarter in — as deep as in the
adult. The external auditory meatus is
nearly as long, then, in the infant as in the
adult ; and, being usually narrower, it is
more difficult to illuminate its depths and
study the conditions at its bottom. A part
of this difficulty is owing to the fact that in
the absence of a bony canal there is a much
greater tendency of the walls to fall into
contact — a tendency which is present only
in the outer, cartilaginous portion of the
adult canal. To see into the auditory
canal, you are instructed to draw the au-
ricle up, back and outward — this serving to
straighten out the curves which it naturally
assumes in adult life. But you will find this
will not do in the infant : the canal is only
rendered narrower and more curved by such
traction. The drum-head is, at this period,
well under the base of the skull, and the
meatus extends upwards along the curve of
the squama as it passes out. We must draw
the auricle down, then, in the young child,
in order to straighten and dilate the tube
through which we are to see; and many

fail in their study from not doing so. The
auricle must be well drawn down in order
to bring the external orifice to the level of
the drum-membrane ; while in the adult
you will find that the axis of the canal
almost always tends upwards — that the tym-
panic end is the higher.

Here we have an explanation of the
statement made in almost all of the text-
books that the inclination of the drum-
head is greater in the infant — that it is
more horizontal. Politzer alone, so far
as I recall, states the contrary, basing his
view on the careful anatomical studies of the
point made by Pollak and himself, although
Roosa doubtfully accepts this. As you look
again at this infant skull with its drum-
membranes close together under the base,
so that their extreme inclination is con-
spicuous, it is hard to believe that this does
not represent a condition wholly unlike
what we daily see in the full-grown state.
As seen clinically, the drum-head seems
nearly at right angles to the axis of the
canal through which we view it, and we
must constantly disabuse our minds of this
impression. It is hard to believe the dem-
onstration afforded by casts of the auditory
canal, by sections of the entire organ or by
good anatomical preparations — all agreeing
in showing great obliquity of the adult mem-
brane. But it is only by means of a prepa-
ration such as this, where the bony lower
walls of the canals have been removed on
both sides, so that you can see the tym-
panic membranes just as you do in the
infant skull, that their relations to each
other can be appreciated and their inclina-
tion actually measured. Then it is manifest
that, as accurately as we can measure, there
is no difference in the inclination. The
adult membrane is exactly as near horizon-
tal as the infant's. Great development has
taken place in the sphenoid bone, with the
general skull growth, pushing the tympana
farther apart ; the squamous and mastoid
portions of the temporals are far larger, and
even the petrous portions have apparently
grown greatly. How, then, you may well
ask, has it been possible that this relation
has remained unchanged? Are these two
specimens not merely accidentally similar
exceptions, not typical examples.

The true relation is what is here shown.
I can show you other preparations just like
them ; while I have never seen any to the
contrafy. Extraordinary as it may seem,
there are some parts of the body which are

March 28, 1891. Clinical Lecture.

349

of full size at birth. Such are the labyrinth I
and the ossicles of the ear, and the drum-
membrane can probably be included in
the same list. A slight growth is perhaps
usual in each of these structures ; but it is
so minute as to be doubtful ; and it is even
claimed that the ossicles are larger at birth
than in later life. The tympanic membrane
and the annulus in which it is framed under-
go no noteworthy growth in extra-uterine
life — marked as is the growth of adjacent
structures ; so there is no reason to expect
that the inclination of the two membranes
to each other or to the basal plane of the
skull must undergo modification. The as-
sumption of change is gratuitous, and falls at
once to the ground when tested anatomi-
cally.

If, therefore, your examination of an
infant's drum-head is unsatisfactory, the
principal anatomical reason is probably to be
found in the relative, and perhaps the act-
ual, narrowness of the long canal, which is
specially liable to inflammatory swelling.
The tympanic membrane may appear small
because you cannot see the whole of it — it
may seem exceedingly oblique because you
are looking at it from- above rather than be-
low the horizontal line (yet it must also be
remembered that an opaque membrane, es-
pecially if much congested so as to be ill-
defined, always shows its obliquity markedly)
— its posterior portion, if there is secretion
within, is apt to be so bulging as to hide the
malleus-handle and short process — and any
perforation is usually small and recognizable
only by the drop of fluid occupying it and
giving back a pulsating reflection, or by a
protruding bead of more tenacious discharge,
as in our present case. Yet the negative
side of such a study is so important that it
should never be omitted. Polyp formation is
quite common in such cases, and is of the
gravest importance in causing obstruction of
the outflow, with all the consequent dangers
to the mastoid and to ■ the brain. Such
growths must be promptly removed. The
drum-membrane may be somewhat thick-
ened, and the pressure within the tympanum
may rise to a dangerous height from retained
secretion without doing more than distend
yet not rupture it. Paracentesis may then
,be exceedingly important. Cases may pre-
sent all the symptoms of meningitis, with
convulsions, paralysis and high fever, and
yet yield promptly when a protrusion on the
upper back wall of the canal, indicating col-
lection in the mastoid antrum, has been dis-

covered and incised. It is far better to fore-
see such conditions and combat them early,
if possible ; and a great aid to that end will
be furnished by the inspection of which we
have been considering the drawbacks and
their avoidance. And when our inspection
shows none of these conditions of grave
omen, we have fair assurance that the case is
one which can be safely guided by simple
measures to a full and timely recovery.

In such cases, then, as the one before
us, cleansing and protection are our needful
measures. Cleansing sounds rather simpler
and easier than it is in fact. The discharge
is often of the tenacious character shown in
this case, and both syringing and mopping
with cotton are needed to clear the external
canal. Even with the inflation of the
tympanum, that cavity can be but partially
freed of retained secretion ; and the blow-
ing in of air from the nose calls for cleans-
ing of its cavities as a pre-requisite to an un-
obstructed and unpolluted entrance of air
through the Eustachian tubes. The infan-
tile tubes are short and wide, the naso-
pharynx small ; so there is rarely any diffi-
culty in forcing the air into the drum-cavities.
The Politzer bag with the olive-shaped tip
forms the best inflation apparatus ; and the
child in crying will furnish all the aid re-
quired, such as the adult affords by raising
the soft palate in swallowing. After this
air-douche, any discharge is to be wiped
away from the bottom of the external canal
once more — a little mopping with peroxide
of hydrogen may do this most thoroughly
and perhaps penetrate the perforation, how-
ever small; then impalpable boric powder is
to be blown in with the aid of a regular in-
sufflator, or of one improvised from a quill.
This dusting should be but sparing if the
discharge is markedly mucous, for this will
but slightly dissolve the powder ; and the
rule not to use insoluble powders may here
include boric acid. Usually the boric pow-
der may be freely used, even to the extent
of packing the canal as full as this blowing
in will do it; and while some claim that this
method does not carry the powder to the
bottom of the canal, the slightest observa-
tion will demonstrate to you that it does.
This gives us an unirritating, aseptic, ab-
sorbent dressing, mildly astringent as it dis-
solves ; and while little or none of it may
penetrate into the tympanum, it still exerts
no little influence on the inflammation. It
should be renewed, after cleansing, as often
as discharge appears externally. The infla-

35°

Communications.

Vol. lxiv

tions are to be continued after all discharge
has ceased, to further the restoration of the
ear to its normal condition and function ; and
the nasal treatment is also to be maintained
in order to forestall, if possible, a new in-
volvement from this source.

• Communications.

PURPURA HEMORRHAGICA AND
METRORRHAGIA.1

BY M. ANDERSON, M. D.,

PINE BLUFF, WIS.

The case which I report is that of a young
woman, 24 years of age, who is a " bleeder"
in the fullest sense of the word. She
bleeds freely from the nose, the stomach, the
bowels, and from the uterus. She is both
menorrhagic and metrorrhagic. Her skin
is of waxy whiteness and presents ecchy mo-
sis on slightest pressure. I was first called
to see her six years ago, when she was suf-
fering with extreme, profuse uterine hemor-
rhage, and what first attracted my attention
on entering her room, was the purpuric con-
dition of her skin, the arms and legs being
covered with ecchymosis.

From her mother I obtained the following
history. The patient was then eighteen
years old, and had been subject to nose
bleeding from childhood. This frequently
followed a fit of anger or some trifling dis-
appointment. She commenced to menstru-
ate at twelve years of age. Menstruation
was very profuse, and about a week or ten
days before each menstrual period, black
spots, from the size of a pea to that of a
silver dollar, would appear in her arms and
legs, and if she cut, or even pricked her
fingers with a needle, there would be con-
siderable bleeding from the wound. Her
appetite was variable, and her bowels gener-
ally regular, but sometimes the evacuations
were black and of the consistency of tar.
Her general health was good, except a lan-
guid feeling a few days before the appear-
ance of the black spots, and weakness for a
short time after loss of blood, and she slept
soundly about twelve hours out of the
twenty-four. The mother had never suf-
fered any abnormal hemorrhage ; nor had
any other member of the family suffered so,

1 Read before the Central Wisconsin Medical Society.

except an aunt on the father's side, who had (

profuse menstruation, and had been subject 1
to nose-bleed.

The usual time for the menstrual flow with I

this girl was six days, but when I first saw !

her she had been bleeding for five days after [

the menses should have ceased. I immedi- |
ately gave her fluid extract of ergot, and

also a uterine injection of alum water. I '

regarded the case as extremely serious, and 1

saw her again in a few hours, in which time '

she had suffered a slight shock of paralysis. '

I requested counsel, but her parents ob-
jected, at the same time saying they believed 1
I could do all that any one could. I thanked 1
them for their expression of confidence in '
me, but told them their daughter was in a 1
very dangerous condition, and they might ; '
be better satisfied in the end by having had 1
counsel. I at once set aside the ergot ; for, 1
although it had not produced the slightest (
action on the uterine vessels, I feared its '
action on the vessels of the brain, as it was !
evident the paralysis was due to impover- '
ishment of the nerve centres, because, by '
laying her head lower than her body, so 1
that what little blood she had left could
gravitate to the brain, the paralysis was over- 1
come for the time. I then gave her gallic 1
acid, also elixir of iron, quinine and strych- 1
nine, and all the milk she could drink. In '
the meantime Dr. Fox, of Madison, was called, ;
and he pronounced the case almost hopeless, |
saying I might as well try to hold water in '
a sieve, as to try to save her. He, however, 1
suggested that I give her a little more iron, '
which I did, giving her ten drops of the !
tincture of the chloride in lemonade, but the
stomach rejected it. I gave it again two or (
three times, but with the same result. I then 1
discontinued the iron, feeling that I must I
guard the stomach ; for if the habit of vom- t
iting should become established with her, I '
should have very little to depend on. I 1
continued the alum-water injections, and was '
highly gratified at "having the hemorrhage
cease under their use. I thought I had 1
found the remedy in her case.

The cessation of the uterine hemorrhage

was quickly followed by epistaxis. This <

was controlled by pressure, and for a few j t

days I had hope of her recovery, when from {

some cause, probably disappointment in not t
getting what she had her mind set upon,

the uterine hemorrhage returned, and persist- 1

ent vomiting set in. The stomach would (
not tolerate a particle of anything, not e\ en If

a drop of water. The retching was almost :

( March 28, 1891. Communications.

35i

- continuous, so that rectal feeding and med-

- ication were necessary. I again resorted to
my alum-water injection, only to be disap-
pointed in it, although I repeated the oper-

j ation several times. I then tried plugging
L the uterine cavity with cotton saturated with
I tincture of iron, but with no better success.

Then I tried subsulphate of iron, and after
j this, plumbi acetas ; but with no better result;

for each time the tampons were removed
3 from the vagina, there were also six to eight
large coagula to be removed.

The blood in the beginning presented the
usual color, and coagulated firmly, but later
in the attack it became pale -and watery. All
, this time her sufferings were intense, as all
f the tissues of the body were starving, and
her condition was most distressing. The
pupils dilated to their fullest possibility, and
paralysis first of one side and then of the
I other quickly followed. The paralysis was
; transitory in character, but complete while
; it lasted. There was numbness of the ex-
tremities, panting respiration, and an insuf-
. ferable sense of suffocation. Her pulse was
rapid and weak — at times merely a flutter.
I Her temperature was sometimes below nor-
. mal, and her thirst was unquenchable. She
wanted something to drink every five min-
. utes ; but this only provoked vomiting, and
I limited her to half hour time, but this was
almost intolerable. I gave her small doses
of champagne, which the stomach retained
longer than it did anything else ; but for
three weeks starvation seemed inevitable, and
heart failure hourly threatened to close the
scene.

Finally, as a last resort, I gave her all the
champagne she could drink, hoping thereby
to set up a greater state of excitement in the
stomach than there was in the uterus, and
thus attract the blood from the uterus. In
this I acted upon the theory of Dr. I. N.
Danforth, of Chicago, " that the blood will
rush to the place of greatest excitement;"
and in this I was not disappointed, for the
hemorrhage ceased, and from this time she
began to recover.

She progressed well for three weeks, when
epistaxis came again, and she nearly bled
to death ; but she rallied again, and made a
good recovery. I then put her on tonic
treatment and on small doses of ergot, con-
tinued for a considerable length of time. I
recommended careful diet and moderate out-
door exercise, but the nose bleeding came
just as often, and so did the black spots, and
in less than a year she had another attack,

which, in every particular, was as bad as the
first. Unfortunately she had lost her desire
for champagne ; so when stimulants were
needed, they had to be given per rectum.
This time the subsulphate of iron was the
agent which arrested the hemorrhage. After
this I stated the case to our highly esteemed
Professor of Gynecology, the late Dr. By-
ford, and he replied that such cases were of
rare occurrence and very dangerous, and a
cure could not be expected, but said possibly
the trouble might be modified somewhat by
the continued use of small doses of ergot,
and of the mineral acids, especially sulphuric
acid. The patient had become disgusted
with ergot, so I gave her the acids, but de-
rived very little, if any, benefit therefrom,
for in less than six years she has had six of
these terrible attacks, each one, if possible,
being worse than the preceding. The last
attack commenced in May and lasted until
the latter part of June of the present year,
and was more obstinate than any preceding
attack. This, I think, was largely due to
excitement, followed by disappointment,
but she recovered as usual. The restoration
of the lost blood in her case has always been
very rapid.

I have tried everything that suggested it-
self to my mind, as alteratives, tonics and
hemostatics ; but of all the remedies used
locally, Monsel's solution has given better
results than any other. Palliative measures
are of no use in this case ; and it is only by
the most persistent employment of both
mechanical and chemical means that any
good can be derived therefrom. There is
no misplacement or morbid condition of the
generative organs. The uterus and its ap-
pendages, so far as I can determine, are nor-
mal, except at the time of profuse hemor-
rhage ; then there is relaxation and lack of
tonicity ; the cervix is soft and flabby, and
the os is sufficiently open to admit the end
of the finger. I can attribute this strange
condition only to imperfect development of
the blood-vessels, the walls of the smaller
tubes and capillaries being so thin as to be
unable to resist the pressure, and thus readily
allow the blood to be continually oozing
somewhere. But as these spontaneous hem-
orrhages show a marked tendency to occur
from mucous surfaces, because their vessels
are less well supported here than in other
parts, it is the more likely to take place from
the mucous membrane of the uterus because
of the great normal fluctuations in the cir-
culation of that organ. *

352

Communications.

Vol. lxiv

This is a case which, I think, will tax the
patience, the skill and the ingenuity of who-
ever has charge of it. Gladly would I have
given it up years ago, but the patient's
parents would not hear of it. However, a
few weeks ago, I was somewhat surprised by
her father coming in to tell me they had
adopted a new plan of treatment with their
daughter. I asked if they had concluded to
try the hygienic measures I had so long re-
commended, such as moderate exercise,
plenty of fresh air and sunshine, and not
allowing her to sleep more than half her time.
He replied, " No," but they had taken her to
a Roman Catholic priest, who claimed to pos-
sess the power to heal, and after fully stating
her case to him, he positively assured them
he could cure her, and, although he had never
seen this young woman before, he told them
he had cured twenty just like her. He
furthermore said he was the only one in
America that had the "specific" for this
malady. I remarked that it was very singu-
lar that this priest, who is not a physician,
should have had so many cures like hers,
when not one physician in a hundred in ac-
tive practice has seen a case just like it.

Dr. By ford, in his excellent work on
Diseases of Women, in alluding to the
hemorrhagic diathesis, mentions one case
belonging to this class, that came under his
own observation, and the patient died with
her second menstrual flow. He said " these
cases are of rare occurrence."

I asked the father if he knew what the
" specific " was, and he replied, "certain
herbs steeped in whiskey, of which a wine-
glassful is to be taken three times a day."
The family are Catholics, and this young
women fully believes the priest will cure
her ; so I shall have an opportunity of see-
ing, in this case, how far the mind can in-
fluence the body.

PERFORATIVE APPENDICITIS.1

BY H. REINEKING, M. D.,

SHEBOYGAN, WIS.

It is not my purpose, in presenting this
brief paper, to discuss the subject announced
in the title, or even to review to any extent
its literature, but simply to add to the re-
corded clinical data bearing on this subject,

1 Read before the Brainard Medical Society, at Mil-
waukee, Wis., January, 1891.

two cases that recently came under my
observation.

Case 1. Henry C, 12 years old, whose
previous health had been good, was first seen
by me on October 5, 1890. On the evening
of October 2, he took a very hearty supper,
consisting mainly of baked beans. During
the same night he was seized with severe pain
in the abdomen, most intense in the epigas-
tric and umbilical regions. There was great
restlessness, nausea and vomiting of mucus
but not of food. After a dose of castor oil he
had what is said to have been a free move-
ment of the bowels the following night. The
pain, however, continued with lessened se-
verity, gradually shifting more towards the
right side, until it became pretty well local-
ized in the right iliac region, only now and
then extending over the entire abdomen.

On October 5, his temperature was normal;
his pulse 88, full and strong ; his tongue
heavily coated ; and his appetite completely
lost ; his bowels had not moved for forty-
eight hours. His urine was of normal ap-
pearance and readily passed. Vomiting had
occurred very infrequently, not more than
once in twenty-four hours. The pain came
on in very severe paroxysms, commencing
in the right side and extending over the ab-
domen, while tenderness on pressure was
limited to the right iliac region. No indu-
ration or dulness, however, could be de-
tected.

Large injections of water, glycerine and
oil, as well as the repeated internal adminis-
tration of Epsom salts, were resorted to with
a view of removing any irritating material
that might be retained in the intestines, but
failed to bring on any fecal evacuation. To
relieve pain, hot fomentations and small
doses of morphia were used. This treat-
ment was continued for several days, while
the patient's condition remained unchanged,
except that the vomiting ceased entirely, and
the paroxysms of pain became less severe
and frequent, though but very little morphia
was taken. During this time the tempera-
ture and pulse varied but little from the
normal.

October 13. During the preceding few
days dulness and induration had developed
in the right iliac region, together with slight
tympanites over the remainder of the abdo-
men. Now indistinct fluctuation could be
felt. The temperature and pulse were slightly
elevated ; the bowels had not moved since
the third. There was no vomiting.

October 14. An operation was performed

March 28, 1891. Communications.

353

for his relief. An incision about two and
one-half inches long was made, two inches
to the left of the right anterior superior
spinous process, and a pus cavity was
reached without any difficulty. It was in-
tra-peritoneal and contained a large amount
of pus, having a strongly fecal odor; but
no fecal matter or other foreign body was
found. A strong barrier of adhesions pro-
tected the general peritoneal cavity. Thor-
ough exploration with the finger failed to
detect the vermiform appendix, and it was
therefore thought best not to push the search
any further. Thorough drainage and anti-
septic after-treatment were carried out.

For two days after the operation the
wound was in a good condition, the dis-
charge decreased, the pulse and temperature
had been nearly normal ; still it was evident
that the man's general condition had not
improved. His appetite was failing; his
.bowels were just as inactive as before the
operation, failing to respond to injections
as well as to cathartics, though the latter
were not vomited, nor was the pain appar-
ently increased by their use. The man's
pain was not severe ; and he had no chills
or vomiting.

October 17 his temperature was 1010 F.;
his pulse 100-105 ; his general condition
worse ; his tongue dry, red and deeply
grooved. Tympanites was becoming well
marked. The bowels had not moved for
over thirteen days.

Suspecting the existence of some further
collection of pus or .some constriction that
might account for his failing and for the in-
activity of the bowels, a second operation
was decided on, with a view of finding and
relieving such condition if present. The
original opening was enlarged both upwards
and downwards and the adhesions between
the intestines and surrounding parts were
carefully severed with the finger. No addi-
tional pus cavity was found. The adhesions
were quite extensive, but could all be reached
and severed by the finger. The caecum
and ascending colon contained considerable
masses of hard fecal matter, while the small
intestines were filled with fluid feces and
gas. No mechanical obstruction was dis-
coverable. The appendix was closely ap-
plied to the colon along its under or poste-
rior surface, with no perceptible mesentery,
and imbedded in inflammatory exudate, so
as to be distinguishable from the colon
proper only by the touch. On raising it
out of its bed a point was discovered on its

lower surface at which fecal matter was
oozing out through two small openings.

While this perforation formed an urgent
indication for extirpation of the appendix,
the anatomical conditions described were
such as to make this procedure an extremely
tedious and difficult one. Moreover, the
patient showed signs of grave shock, and it
was evident that he would die under our
hands, should we keep him on the table
much longer. The oozing points were there-
fore carefully stitched over with a few Lem-
bert sutures, and the appendix was left. The
wound was partially closed and packed and
an antiseptic dressing was applied. In spite
of all efforts at restoration the patient died
in about two hours.

The post-mortem examination revealed lit-
tle that had not been found during the op-
eration. There was no general peritonitis,
no mechanical obstruction of the bowels,
no leakage, even under pressure, at the point
of perforation. The mucous lining of the
appendix showed several ulcers, one at the
point where the perforation had taken place.
Death was no doubt due to the shock of the
second operation, added to the already ex-
isting exhaustion.

One question that suggests itself in con-
nection with this case is that concerning the
cause of the obstinate constipation. In the
absence of any evidence of mechanical con-
striction, it can only be explained either on
the theory of a so-called septic paralysis of
the bowels, or by attributing it to the exten-
sive inflammatory adhesions and extension
of the inflammation to the muscular coats of
the intestines. Considering the small amount
of morphia taken, and, on the other hand,
the persistent efforts made to bring on a
movement, all in the absence of vomiting,
the total inactivity of the bowels for over
two weeks is somewhat remarkable. Another
question, and one closely allied to the first,
is, whether it would not have been better to
have persisted in searching for the appendix
at the time of the first operation ; as at- that
time the patient's condition was such that
its removal could have been safely accom-
plished. As the origin of abscesses in this
region is almost invariably located in the
appendix, it would seem a good rule not to
rest until it has been found and examined,
unless there are plain contra-indications to
such procedure.

Case 2. Frank B., the patient, was 22
years old and a mason. The following is a
short synopsis of the history kindly fur-

354

Communications.

Vol. lxiv

nished me by the attending physician, Dr.
Schaper.

Pain in the right iliac region was first no-
ticed November 7, 1890, and was soon ac-
companied by vomiting. The bowels were
constipated, but acted after taking a laxative.
On November 10 the temperature was ioo°
F., the pulse 76, the tongue coated and dry,
and there was a small, firm mass and dulness
at the site of the caecum. Treatment con-
sisted of rest, hot fomentations, repeated
small doses of Epsom salts, with sufficient
morphine to relieve pain. The general
symptoms increased slightly in severity,
while the induration and area of dulness
enlarged pretty rapidly until November 17,
the tenth day after the onset of the symp-
toms ; when the man had a severe chill early
in the morning, followed at once by vomit-
ing and a large evacuation from the bowels.
At the same time the temperature rose to
105. 20 F., the pulse to 120. Both were,
however, considerably reduced again in a
few hours.

I saw the case with Dr. Schaper on the
afternoon of November 17. The swelling
in the right iliac region was considerable,
extending to the median line, and indistinct
fluctuations could be detected.

An incision three and one-half to four
inches long, running parallel to the axis of
the caecum and directly over this organ, was
made, and this was followed, on opening
the peritoneum, by the evacuation of a large
amount of pus, having a strongly fecal odor.
At the bottom of the abscess I found an oval
lump of dry, hard feces, about one-half inch
long by one-third inch thick. The appendix
was found floating freely in the contents of
the abscess, and provided with mesentery
only to a limited extent at and near its base.
It felt ragged and very much thickened, and
tore easily. It was tied with two ligatures
close to its attachment to the csecum, and
was removed. Owing to the protective wall
of inflammatory adhesions running trans-
versely across tha lower extremity of the
caecum, this part of the bowel could not be
drawn out sufficiently to sew the peritoneum
over the stump without using undue traction,
hence this otherwise important precaution
was dispensed with. After complying with
all the usual antiseptic precautions, two large
drainage-tubes were inserted and the wound
closed.

In the further history of the case the fol-
lowing points may be worth mentioning.
The temperature and pulse soon came down I

to the normal and remained so. Fecal odor
of the discharge was noted until November
20 — three days after the operation. The
bowels moved normally, under repeated ad-
ministration of Epsom salts. The stitches
were removed on the seventh, and the drain-
age-tubes were left out on the tenth day. On
the twenty-second day a small subcutaneous
abscess was opened near the point where the
drainage-tubes had protruded ; and three
days later two ligatures and a small, hard,
shell-like substance were discharged, after
which permanent closure took place.

HISTORY OF BACTERIOLOGY.1

J. LEFFINGWELL HATCH, B. Sc., M. D.,

LECTURER ON BACTERIOLOGY, AND ASSISTANT DEM-
ONSTRATOR OF MORBID ANATOMY IN THE
UNIVERSITY OF PENNSYLVANIA ; ASSIST-
ANT PATHOLOGIST TO THE PHILA-
DELPHIA HOSPITAL.

The knowledge of microscopical organ-
isms naturally advances hand in hand with
the science of optics, and although the an-
cients believed the air and water to swarm
with beings of such small size as to be invis-
ible to the naked eye, yet it was mere hy-
pothesis and lacked ocular demonstration.
To Leeuwenhoeck, a naturalist of Holland,
was reserved the honor of discovering and
first describing the bacteria. This he did in
his work entitled Arcana Naturce Detecta,
printed at Delphis BataVorum in 1680. His
observations were made with simple bi-con-
vex lenses fixed in a silver mounting. In
order to give a comparative estimate of their
size, he placed a grain of dust one-quarter
of a millimeter in diameter under the same
lens with the bacteria, and thus approxi-
mately measured them. In spite of instru-
ments so crude, he was able to describe sev-
eral species, and point out the great role
that they play in putrefaction and decompo-
sition. He pointed out their presence in
water, in vegetable infusions, in the intes-
tines of flies, frogs and chickens, in the
feces of man, and recognized the fact of
their augmentation in diarrhoea, the first
application of them to human pathology.
He also demonstrated their presence in the
tartar of the teeth and in saliva. It was a
great event for those times and made quite

1 Part of a Lecture delivered before the Philadel-
1 phia College of Pharmacy, December 9, 1890.

March 28, 1891. Communications.

355

a stir in the scientific world. One does not
know which to admire the more— the nicety
of the results announced, or the skill of the
experimenter.

After Leeuwenhoeck, the study of micro-
scopical beings was neglected for nearly a
century. The difficulty met with in their
study, by means of simple lenses, was enough
to turn less hardy observers than Leeuwen-
hoeck to one side, and it was not until the
discovery of the compound microscope that
anything further was done towards investi-
gating them.

It was Otto Frederic Miiller who first ap-
plied the compound microscope to the study
of the lower organisms, and he described
and classified them in his two works. The
first, Vermium Terrestrium et Fluviatilkim
Historia, published in 1774, and the second,
Animalcula Infusoria Fluviatilia et Marina,
published in 1786. It was he who had the
honor to put in order this crowd of micro-
scopical beings, that the great Linnaeus him-
self believed ought to be placed to one side,
and for which he created his genus " chaos,"
a veritable "caput Mortuum," where all
sorts of beings and things are jostled to-
gether.

Miiller divided the bacteria into two gen-
era : "Monads" and "Vibrios," which
names are handed down to us to-day.

The species of the genus Monas, incom-
pletely described and badly figured, are
scarcely recognizable ; two of the ten species
that he includes here are certainly short,
rod-shaped bacteria — bacilli. He described
thirty-one species under the genus Vibrio,
of which, however, only six are true bac-
teria. The other forms are really Algae,
Desmids, and Diatoms. His Vibrio lunula
is a Closterium, his Vibrio acus is an Englena,
one of the flagellate infusoria. Among the
ciliated infusoria to be found in his genus
Vibrio are the Paramoecii, the little slipper
animalcules, and of the Nematodes, the
Anguillulae.

Lamarck, in 1815-1819; Bruguiere, in
1824 ; and Bary de Saint Vincent, in 1824,
have confined themselves in their works to
reproducing, intact or but little modified,
the gifts of the Danish naturalist, so that up
to the year 1833 little progress was made
beyond what Miiller had done in the eigh-
teenth century.

Ehrenberg is the next to attract attention.
Using perfected instruments, he made great
progress in the study of microscopical be-
ings. It was at about the time that the

botanist Schleiden was carrying on his
studies in plant histology, studies the result
of which was to agitate the scientific world,
and form the basis of what is now known as
cellular structure ; I refer to his discovery
of the cell in 1838. These results, as well
as those of Ehrenberg, were due to the rapid
advance of optics and the improvement of
methods of observation.

In Ehrenberg' s grand work, entitled Die
Infusionsthierchen als Vollkommene Organ-
ismen, we find results that are greatly supe-
rior to those of his predecessors. He sepa-
rates those beings which we are considering,
from those that had been associated with
them, although differing so greatly, and re-
unites them in his family of the Vibrionia,
which he describes in the following manner :
" Filiform animals without intestines, naked,
without external organs, united in chains or
filiform series, by the effect of an incomplete
spontaneous division." This family com-
prehends the four following genera :

Bacterium — Little rods, rigid, without
vacillating movements.

Vibrio — Filiform bodies, susceptible to un-
dulatory movements like a serpent.

Spirillum — Filiform bodies in an inflexible
helix.

Spirochcztoz — Bodies in a helix, forming a
long flexible string.

Dujardin takes the ideas of Ehrenberg
and modifies them a little, in his work en-
titled Histoire Naturelle des Zoophytes, In-
fusoires, published at Paris in 1841. Here
we find new and interesting details concern-
ing the development of bacteria in diverse
infusions, and a description of the methods
for obtaining and studying the different
forms. The four genera of Ehrenberg he
condenses into three, fusing the two forms
spirochaeta and spirillum into one, a move-
ment that has since been approved by many
observers, the distinctive characteristics of
the two genera having only a relative value
of order far too slight as a basis for separa-
tion.

The results obtained at this epoch were
weighty and for the most part to be pre-
served ; certain ones have been many times
confirmed, and are still to be found in the
best works.

The achromatic microscope was being
perfected day by day, and in the hands of
such able experimenters as Dujardin an-
nounced conclusions that could be con-
sidered as strongly supported, if everything
was not made certain.

356

Communications.

Vol. lxiv

Up to this time the appearance of these
beings so simple, these animalcules as they
were called, in the infusions, was regarded
as a simple fortuitous phenomenon. At the
same time very appreciable alterations in the
media in question were observed, but they
were far from supposing that there was a re-
lation between these two, a relation of cause
and effect. If indeed they sought to con-
nect one or the other of them with the phe-
nomenon, it was that they might cause the
second to depend upon the first, thus making
a law of the ancient adage : " Corruptio
unius, generatio alterius" And, as Leeu-
wenhoeck had regarded the considerable
augmentation of microscopical beings in the
stools of diarrhoea, so many of the savants,
Linnaeus among others, were borne by the
simple views of their intellect, to consider
these vibrios as the elements of contagion
in many pathological states, although noth-
ing positive had been advanced, and not a
single fact was forthcoming to support the
entirely gratuitous suppositions. The minds
of scientists were so little turned from this
direction, that Devaine and Rayer, in 1850,
pointed out, quite simply and merely as a
curious fact, and without attaching any
great importance to it, the presence of rod-
shaped bacteria in the blood of animals dead
from the curious disease called " sang de
rate. ' '

The auspicious moment at last arrived,
and Pasteur appeared on the scene. He es-
tablished with certainity the close connec-
tion, or the relations of caus'e, which unite
the alterations in certain liquids, certain fer-
mentations, to the development and to the
life in the interior of the most simple living
beings, the bacteria. In his work on lactic
fermentation he has laid the first 'certain
foundation of bacteriology, by the physio-
logical study of these beings. What he de-
monstrated for this fermentation, he extended
to others, and arrived in forming that train
of studies which constitutes one of the most
glorious scientific achievements of France.

Guided by the principles that as master
Pasteur promulgated, Devaine went over the
observations that he had made several years
previously with Rayer upon the blood of
the spleen, and was able to establish by a
series of experiments, and a line of able de-
ductions, that the cause of the malady was
certainly bacteridian, as bacteria were found
in great abundance in the blood of sheep
ill or dead from that disease.

Pasteur has shown the way to follow in '

elucidating in all its details a terrible disease,
the ruin of the raisers of the silk worm, " la
flacherie," as it is called in French, which is
manifestly bacteridian in origin. It was
the first complete study of a contagious af-
fection, and since then from these remark-
able teachings luminous conclusions have
been drawn relative to the study of maladies
recognized to be of the same origin, when
the same question of contagion, of recidiv-
ity, of heredity, of media, which play so
great a role in the etiology, and the path-
ogenesis of infectious diseases arise.

Koch, following in the footsteps of Pasteur,
has made remarkable advances in the science
of bacteriology, introducing certain refine-
ments into the technique which have facili-
tated the study, and laid a basis for a more
exact classification.

We must not forget to mention the names
of Brefeld, Van Tieghem, Prazmowski and
Buchner in connection with Koch, as they
have played a prominent role in work in
which he was the pioneer, and they have
all been followed by able investigators in
many countries. The great feature of
Koch's work was the pointing out of the
advantage of a solid medium, but gelatine
had already been employed by Vittadini in
1852, and potatoes and turnips had been
used in Germany.

Coze and Feltz, in 1872, showed that the
profound changes in the blood, in the infec-
tious diseases of human beings, were also due
to the bacteria,- and they made an exhaustive
study of one of the most terrible of those
affections, viz.: septicemia.

The most beautiful applications of these
fecund ideas are found without contradic-
tion in the researches upon anthrax, where
men like Koch and Pasteur have exerted
themselves to the utmost, and have been able
to make the study of this malady the basis
of the germ theory of contagious diseases.

Since then this science has advanced with
a rapid stride, thanks to the labors of assidu-
ous investigators throughout the' world,
among whom to be noted as the foremost,
besides those already mentioned, are Chau-
veau, Cornil, Chamberland and Roux, in
France; Klebs, Fliigge, Gaffky, Loffler,
Eisenberg in Germany ; Lister, Crookshank
and Klein in England ; Sternberg, Formad,
Shakespeare and a few others in America.

The morphology and the physiology of
the bacteria, after having been in great
honor, has unfortunately been relegated to
a second place, and almost eclipsed by the

March 28, 1891. Reports of Clinics.

interest and splendor of the grand patholog-
ical gifts ; and in spite of the labors of such
botanists as de Bary, Nsegeli, Cohn, Zopf,
and physiologists like Duclaux and Pfeifer,
the progress of bacteriology as a science has
been slow.

Much work has been done that is useless,
and many erroneous conclusions have been
drawn, yet on a whole there has been laid a
solid foundation, and ways have been
opened along which the careful observer can
reap a rich harvest.

Reports of Clinics.

BUFFALO GENERAL HOSPITAL.

GYNECOLOGICAL CLINIC— DR. MANN.

Polypus Uteri.

Dr. Mann presented a woman whose
symptoms were so indefinite that no further
diagnosis could be made than of some pel-
vic trouble. Examination showed a polyp
projecting from the external os and appar-
ently attached by its pedicle at the internal
os. This might be malignant, or an ade-
noma or a mucous polyp. If it were ma-
lignant, Dr. Mann said he would resort to
high amputation of the cervix. Referring
to the relative merits of high amputation of
the cervix and total extirpation of the
uterus, he said that he regarded total extir-
pation as a perfectly justifiable operation.
He had done it four times with one death,
immediately following operation, due to the
growth of the cancer in the broad liga-
ments. It was so soft that its presence in
the broad ligaments could not be diagnosti-
cated at the time of the operation. The
three other patients, however, died within a
year, from recurrence of the cancer. He
had known one patient to live ten years
after high amputation, a longer duration of
life than had occurred after hysterectomy
in his experience. Considering the difficul-
ties and dangers of total extirpation of the
uterus, and believing that the duration of
life was at least as great after the less radi-
cal operation, he preferred high amputation
of the cervix — the general opinion of the
profession.

After a more careful examination, it was
decided that the growth was not malignant,
and it was removed with the chain ecraseur,

357

although Dr. Mann does not consider it a
scientific instrument, not even believing
that it has the advantage of diminishing
hemorrhage. The tumor was somewhat
modulated, irregularly spherical and about
one and a half inches in diameter. After
swabbing out the vagina, it was tamponed
with pledgets of non-absorbent cotton
dipped in hydro-naphthol solution and
sprinkled with iodoform.

Dr. Mann advised the removal of such
pediculated tumors as soon as their presence
was noted. They were almost certain not
to be malignant, and they could be easily
twisted off with polypus forceps, or snipped
off with scissors, and the vagina tamponed.
Any one could do this operation. Dr. Mann
spoke of his chagrin after being summoned
one hundred miles into the country, to op-
erate, to find that the tumor was of this na-
ture.

Although insignificant at the outset, these
tumors may later cause much harm. Dr.
Andrews, of the Buffalo State Insane Asy-
lum, once called Dr. Mann to operate upon
a maniac with the following history. The
patient had a little mucous polyp, which the
late Dr. Miner wished to remove ten years
ago, but operation was refused. The tumor,
as is frequently the case, caused profuse
menorrhagia, on account of the congestion
of the tumor from compression of its pedi-
cle at the menstrual period. These hemor-
rhages resulted in anemia and neuralgia,
the latter affecting the pelvic organs espe-
cially. Narcotics and alcoholics were used
to control the neuralgia, and the woman
acquired both the morphine and the whis-
key habit. Her mind had become utterly
destroyed. Dr. Mann removed the tumor,
the patient made a good recovery from the
operation, and within a year she was restored
to her family and to society perfectly cured,
and she has remained well since.

Dr. Mann advised that after removing a
tumor of this sort, the patient be directed to
return in a week, so that if other tumors
were present they might be removed.

Extra-uterine Pregnancy.

Dr. Mann showed a specimen removed
from the pelvis of a woman by abdominal
section.

The history was apparently that of an
abortion at the third month, but no fetus
had been seen. There was a mass to be felt
in the pelvis, and from its presence and the
history of the expulsion of the decidua with-

358

Periscope*

Vol. lxiv

out a fetus, the probable diagnosis of extra-
uterine pregnancy with rupture was made.

A cyst was found containing several large
blood-clots. It proved to be the Fallopian
tube, which had burst between the layers of
the broad ligament, and the contents of the
cyst had dissected their way into the sub-
stance of the broad ligament. The cover
of the sac was a large piece of omentum,
which was removed. The sac held nearly
a pint of blood clots. The membranes
could be made out indistinctly, but the fetus
had disappeared, probably by absorption.
After removing the sac, drainage was pro-
vided for though the abdominal wound. .

Periscope.

Excision of Lupus with Immediate
Skin Transplantation.

Dr. Geo. Ryerson Fowler, surgeon to
the Methodist Episcopal and to St. Mary's
Hospital, Brooklyn, reports in the British
Medical Journals February, 1891, a very good
result from excision and immediate skin
transplantation for lupus. He says : Mrs.
O'B., aged 65, was kindly referred to me
by Dr. Sidney Allen Fox, of this city, with
a well-marked lupus exedens of the nose.
The entire integument of the nose, with the
exception of a small point at its tip, was in-
volved in the disease, the ulceration extend-
ing upon the cheeks, and to the inner can-
thus of the left eye as well. Beyond the
area of ulceration there were several suspi-
cious tubercles. The patient states that the
disease began many years ago with what
seemed like a small pimple upon the left side
of the nose, which, after several years, began
to ulcerate. This ulceration progressed
slowly, new tubercles making their appear-
ance in the immediate area of the surround-
ing integument, which in their turn would
undergo the ulcerative process. The super-
ficial surface involved at the time of coming
under my observation measured 5 ctm. in a
vertical direction by 7.5 ctm. transversely.

On April 14, 1890, at St. Mary's Hos-
pital, the following operation was performed
under ether : The entire diseased surface
was circumscribed by an incision extending
through the thickness of the skin to the
subcutaneous cellular tissue. This was made
to include all suspicious tuberculous tissue.
By the use of the scalpel and curette the
structures thus marked out were thoroughly

removed, stopping short only of periosteum
and bony structures. By means of hot salt
water compresses and firm pressure the hem-
orrhage was arrested, but one ligature being
required. The patient's left arm in the del-
toid region was then disinfected, and
Thiersch's method of skin grafting followed,
the strips of skin being immediately trans-
ferred to the surface upon the nose and face
from which the lupus tissue had been re-
moved. The strips were laid side by side,
their edges slightly overlapping each other,
until the entire surface was well covered in ;
nine strips were required. The parts were
then dressed by being first basket-strapped
with narrow strips of oil silk until all the
grafts were thus protected. Over this were
then laid several thicknesses of gauze wrung
out of a sterilized salt solution, the whole
being held in place by a moderately firm
gauze bandage.

On the third day the dressings were re-
moved and replaced, the oil silk permitting
of the lifting away of the gauze compresses
without disturbing the transplanted strips.
Every strip seemed to have secured a hold,
and this was confirmed at subsequent dress-
ings, which were repeated at intervals of
two days. The oil silk strapping was found
to act most efficiently as a means of main-
taining a certain amount of moisture of the
transplanted strips, which latter particularly
I have found to be quite essential to success
in this method of skin transplantation.

As the case progressed, the edges of the
transplanted strips, which had been per-
mitted to overlap the healthy skin in order
to allow for shrinkage, were gradually
trimmed, care being taken to still leave suffi-
cient of the strip to prevent the formation
of cicatricial tissue at the point where these
joined the limits of the circumscribed area.
In fourteen days the healing was complete,
but the patient has been kept under obser-
vation until the present time for the purpose
of determining the curative effects of the
skin transplantation upon the lupus. There
has not been the slightest suggestion of a
recurrence of the disease.

The method of treatment here pursued is
that which was introduced to the profession
by Senger, of Krefeld. In order to pre-
vent the recurrence of the disease in those
cases in which the gap cannot be closed by
suturing, and where heretofore it has been
necessary to permit of slow granulation and
cicatrization of the parts following excision,
Senger recommends that skin transplanta-

March 28, 1891.

tion by the method of Thiersch be at once
practiced. He describes a case in which he
employed this method with success, the
disease having made considerable progress
upon the cheek and upper lip.

lodoform-Ether- Glycerin Injections
in Septic Cavities.

Dr. John R. Haynes discusses, in the
Southern California Practitioner, the use of
iodoform dissolved in ether and glycerin as
an antiseptic in gynecological and surgical
practice. There is, of course, nothing new
in this application of iodoform, but Dr.
Haynes cites cases illustrating a valuable
method of treatment. The following was
the formula used :

R Iodoform J|ss

Ether f % i

Glycerin £ ^ iii

A woman was allowed to retain the de-
cidua of a two-months' miscarriage for ten
days, notwithstanding septic symptoms had
developed. On the tenth day Dr. Francis
Haynes saw the case in consultation. The
uterus was held fast by a swollen adherent
tube, rendering the subsequent process some-
what difficult. Under chloroform it was di-
lated with Goodell's dilator, and a large
quantity of decidua removed by the curette.
Copious irrigation. The temperature fell
from 1040 to normal, but in two days rose
again to 102. 6°. After copious irrigation,
a portion of iodoform mixture was injected.

The method of cleaning and disinfecting
the uterus was as follows : The patient was
brought to the edge of the bed, the legs
wrapped in blankets, the bed protected by
oil-cloth, forming a water shed into a tub.
The vulvar hair was clipped, and the vulva
was carefully cleaned. The vagina was irri-
gated with half a gallon of hot water, then
with a quart of 1 : 2,000 sublimate solution,
then with hot water. A double tube, which
had just been boiled, was attached to a foun-
tain syringe and introduced into the uterus
under guidance of the finger, taking care
not to introduce air. Two quarts of hot
water were used; then a pint of 1 : 5,000
sublimate solution, then a quart of hot water.
The fountain syringe was now detached and
a short piece of rubber tubing attached to
the end of the double tube, through which,
by means of a large glass syringe, an ounce
of solution of peroxide of hydrogen was

359

very slowly injected. Next one ounce of
the iodoform mixture was very slowly in-
jected. Of course most of it ran out through
the double tube, which was now removed. A
pad of thick sublimate gauze was now ad-
justed to the vulva. Recovery was rapid.

A man had an abscess near the right lobe
of the prostate. It was feared that it would
break into the bladder or rectum, or both.
With a long narrow bistoury, the abscess
was reached from the perineum. A drain-
age-tube was inserted, passing up four and
one-half inches, and essentially the same
process as that just described was gone
through. This was repeated morning and
night for three days, when the drainage-
tube was removed. Very slight discharge
followed, and the man made a rapid recov-
ery.

A woman had peritoneal abscess reaching
from the left iliac fossa to within two finger-
breadths of the left costal margin, nearly to
the lumbar region on the left side, and to
beyond the linea semi-lunaris on the right
side. It was opened by an incision admit-
ting two fingers; the peritoneum was sewed
to the skin, irrigated and drained. Next
day the process described was repeated. The
temperature, which had ranged from ioo° to
1040, went to 990. On the third day it rose
to 99^2°, and the treatment was repeated.
The treatment in the interval consisted
merely in renewing the sublimate gauze,
dressing occasionally when it became stained
by a thin, yellowish discharge. The patient
was kept in bed a month, and at the end of
two months she was perfectly well, except
that a slight thin discharge continued from
the seat of the abscess.

The aim was to repeat the process only
when a rise of temperature or the presence
of pain indicated that pus was accumulating
in the cavity. During the entire treatment
the process was repeated three times.

Early Treatment of Otitis.

In the Medical Record, February 7, 1891,
Dr. Sexton writes : The medical man who
sees a case of otitis media which has suddenly
developed during the progress of catarrhal
inflammation of the air tract of the head,
whether consequent on scarlet fever, cold in
the head, or other affection, assumes a se-
rious responsibility unless well informed in
its management, since under certain condi-
1 tions a seemingly mild case may speedily

Periscope.

36°

Periscope.

Vol. lxiv

become most painful and grave. I have
recently been reminded of the perplexity,
not to say apprehension, felt by the consci-
entious practitioner when untoward symp-
toms develop, several distressing cases com-
ing under my observation in consultation
with other physicians. The urgency of the
cases seen was no doubt due to the severe
winter weather of late prevailing. I hope I
may be permitted to offer some practical
suggestions drawn from such experience,
since they may be of interest to others when
in doubt as to the best course to pursue.

It would be out of place here to go far
into the pathogenesis of otitis, but we may
assume that acute middle-ear affections are,
generally speaking, divisible into two prin-
cipal groups ; namely, mild and severe. The
mild ones are usually preceded by more or
less earache, which almost wholly disappears
on the occurrence of a discharge from the
ear. The pain is due to inflammation of
the mucous-periosteal lining of the drum
(inflammation limited, indeed, for the most
part to the atrium of the drum) and the con-
finement of secretions, which may be either
moderate or profuse in quantity. Beyond
cleansing the organ by means of cotton-
wool pellets and very gentle syringing while
discharge lasts, these cases had best be let
alone for the most part, inasmuch as they
have a tendency to spontaneous recovery.
Though those cases often get well despite
misguided treatment one should never be
lulled into unguarded security, whereby val-
uable time may be frittered away in useless
treatment when severer symptoms may be
impending. In a severe case it would seem
almost impossible to be mistaken in diagno-
sis if the ear were properly examined even
before the more urgent symptoms fully de-
velop. The pains and headache are soon
unremitting, unendurable, more agonizing,
perhaps, than the pains of almost any other
disease, and they demand instant relief, if
attainable.

Much blame, we fear, for children's
dreadful sufferings specially, not to mention
the imminent danger to life, frequently lies
at the door of writers who fail to differen-
tiate between mild and severe cases, and
who too often recommend for both of
them such treatment as may, for the most
part, be found among the rubbish of ancient
writings called medical ; methods meddle-
some and often brutal when zealously em-
ployed ; liable, indeed, to be followed by
sad results, now and in the future. Waste

no time, therefore, in temporizing measures,
since the relief to be had should be quickly
sought. So soon as the pains are great, no
relief following the discharge, if any occurs,
and the upper edge of the drum-head be-
comes red and bulging, it may be suspected
that the gravity of the symptoms is mostly
due to the confinement of secretions in the
bony chamber comprising the loft above the
main cavity of the drum — the attic of the
drum in fact — a space lying almost entirely
above that part of the drum which is seen
on looking into the ear to be covered by
the drum-head. The swelling of the lining
membrane of this unyielding bony cavity
closes the natural outlet for secretions, which
can now only escape from the attic by dis-
secting their way slowly underneath the
membrana flaccida and finally appearing as
a tumefaction there or further along the
bony portion of the external auditory canal.
Finally, the mastoid process or general outer
surface of the temporal bone may be in-
vaded with formation of abscess of varying
proportions.

The onset of this unfavorable process
must be recognized at once if we would pre-
vent extensive trouble ; puncturing the drum-
head low down, blistering, leeching, poul-
ticing, etc., will do no good ; indeed, quite
the contrary, since they may distress the
patient and increase the local irritation.
As the invasion of the trouble is rapid, so
the remedy should be sure and swift ; no
stabbing the drum-head in the dark or fruit-
less incisions into the canal. Let a careful
examination of the parts (patient narcotized
if unable to remain quiet — which in children
cannot be expected) with the electric lan-
tern worn upon the forehead be made.
Fortunately we may now, if timely, relieve
the symptoms at the start, by thus liberating
the fluids in the attic and establishing drain-
age, an operation based upon the principle
inaugurated in the treatment of these parts
by Wilde, who waited, however, until much
damage had been done before seeking to
give relief by letting out matter' presenting
at the mastoid process.

D.o not, therefore, wait for days while
more and more damage is being done, when
the extension of inflammation from the seat
of the disease may be prevented by a fine
incision through the membrana flaccida, a
proceeding speedily followed by relief in
most cases, and in many by a speedy cure. ■
To make the incision a small, sharp-pointed
bistoury, the shank of which is set at a con-

March 28, 1 891.

Periscope.

361

venieht angle to its handle, should be em-
ployed. The point of the instrument is then
to be advanced through the membrana flac-
cida well up into the attic, and as it is with-
drawn a free incision made through any
bulging or swollen tissues of the canal in
proximity to the membrane.

Any one who has witnessed the immediate
relief following the liberation of confined
secretions, specially from underneath deep
fascia or the periosteum can appreciate the
importance of* this operation. Of the sub-
sequent treatment but little need be said ;
it will depend largely upon the injury already
.inflicted upon the ear ; if done early, usually
no further special treatment will be required.

Uratosis.

The Montreal Medical Journal, January,
1 89 1, says : The term uratosis has been sug-
gested by Sir Wm. Roberts to designate
that disordered state of nutrition character-
ized by the deposition of the crystalline
urates in the tissues or fluids of the body.
By adopting this nomenclature, several ad-
vantages, it is claimed, would follow. First,
a distinction would be clearly drawn be-
tween the effects of an excess of uric acid in
the blood and uric acid precipitated as crys-
talline urate. What, if any, pathological
significance the former condition has was at
present unknown. The serious consequence
following the latter state were well recog-
nized. Excess of uric acid in the blood
was only an exaggeration of a normal state,
while deposition of crystalline urates was,
in any quantity, a pathological condition.
Another advantage claimed is that we would
be better able to estimate the relation be-
tween the different causes that give rise to
uratic deposits. When speaking of " ordi-
nary " gout and "saturnine" gout, we use
terms which, in the opinion of Sir Wm.
Roberts, would be more truly expressed by
" gouty uratosis " and " saturnine uratosis."
It being much more likely that the gouty
diathesis and lead poisoning, while differing
in other respects, had one tendency or vice
in common, viz., the tendency to the de-
position of the crystalline urates or uratosis.

The separation of the effects of the de-
position of the crvstalline urates from simple
increase of uric acid in the blood was of
importance from a therapeutic point of view.
In the former, the danger of precipitation,
especially in the kidneys, was of a very grave
character and called for immediate treat-

ment. By the employment of alkaline rem-
edies, we are enabled to postpone for a long
period this deposition, and thereby gain
time which should be employed in combat-
ing the essential cause.

Etiology of Extra-Uterine Preg-
nancy.

In the North American Practitioner, Feb-
ruary 1, 1891, Dr. Bayard Holmes says: The
subject of etiology in these sad accidents of
reproduction are significant in relation to
1 progress and treatment. The mother is ex-
posed in extra-uterine pregnancy to an im-
mediate and to a remote danger. The im-
mediate danger is fatal anemia when rupture
of a tube takes place, and the remote dan-
ger is sepsis in a limited hematoma or in a
retained dead fetus. In a study of the bac-
terial condition of dead extra-uterine fe-
tuses which I presented to this Society, my
attention was called to the great danger of
sepsis. Hematomata in other parts of the
body are ordinarily removed by absorption
without any febrile disturbance, except that
early and transient rise which has been at-
tributed to "ferment intoxication." The
case is very different in those pelvic hema-
j tomata which are due to extra-uterine feta-
ition. Both the retained dead fetuses and
j the hematomata in this region become in-
fected, in the great proportion of cases,
within six months, and a large percentage
of the remainder by the end of the year.
This fact, I believe, is to be explained by
the cause of extra-uterine fetation, which
there is good reason to believe lies in an an-
tecedent infective inflammation in the tubes
or the endometrium.

In order that an extra-uterine pregnancy
may take place, there must be some malfor-
mation or deformity in the sexual apparatus.
It does not take place in the normal condi-
tion of the tubes and uterus. That it may
be a malformation we can readily see, be-
cause the present condition of the human
uterus is evolved from a very large and di-
vided uterus which is exhibited in the fetus
and the lower animals. We may expect an
occasional reversion to the original type and
hence a risk of extra-uterine fetation. Such
an arrest of development cannot often oc-
cur, because anatomists do not find these
deformities frequently. Nevertheless preg-
nancy in a rudimentary form is not un-
known. A step further and we have a tubal
pregnancy.

362

Periscope.

Vol. lxiv

Dr. Christian Fenger presented at a re-
cent meeting of the Gynecological Society
a tube, in the distal third of which there
was a two-months' fetus. Its passage into
the uterus seemed to have been impeded by
an ovum which had previously attached
itself to the wall of the tube and grown so
far as to occlude its lumen.

Most cases of extra-uterine pregnancy
are preceded by a long term of sterility fol-
lowing an unhealthy puerperium, which in
itself points to some deformity in the sex-
ual apparatus, arising from one cause or an-
other. It is probable that most of these
cases of deformity are due to a process of
inflammation, and that inflammation is due
to sepsis, and sepsis is due to infection ;
that accounts for the presence, in close
proximity to this extra-uterine fetus, of sep-
tic material which converts the hematoma
into an abscess. Of course we must always
consider the possibility of pressure atrophy
between the heavy, dead fetus and the con-
tents of the bowel (hard feces) opening a
communication between the bowel and the
fetus and producing infection in that way.
That must be considered in these cases, but
it cannot well be considered in cases of
large accumulations of blood. We cannot
consider the possibility of suppuration or
any septic decomposition of a large mass of
blood without infection ; that is impossible.
Infection is rare through the circulation,
but it is not wholly unknown. Therefore I
look upon the indications for operation to
be these two : The dangers from hemor-
rhage and the dangers from sepsis. But
the danger from sepsis is imminent on ac-
count of the probable etiology of extra-
uterine fetation.

The Digestive Troubles of Infants.

The Paris correspondent of the Archives
of Pediatrics, January, 1891, gives an ac-
count of Le Gendre's treatment of the di-
gestive troubles of infants. The causes of
these troubles are to be sought in the fact
that the babies are bottle-fed. It would ap-
pear that French mothers will neither nurse
their infants nor employ a wet nurse. When
the troubles occur, instead of diminishing
the supply of food, which ferments and oc-
casions the disturbance, the infant is given
more milk because it cries and is thirsty.
Water or a carbonated water would be bet-
ter. Sometimes the system becomes intox-

icated by the products of fermentation, and
death ensues.

In the early stages it is proper to suspend
alimentation. In the later stages, when
there is much fermenting matter in the bow-
els, empty them with calomel, and then give
the antiseptics — resorcin, benzoate of soda,
salicylate of soda, salicylate of bismuth,
naphthol, etc. If one is called still later,
when there is fever, flat belly, no urination,
or very little, convulsions and coma, then
no purgation or antiseptics are of use ; we
must then use stimulants to the nervous sys-
tem, hypodermic injections of ether, cam-
phor or caffeine, mustard baths, or wine
baths, while friction is used to the skin. By
the mouth, every quarter of an hour, give a
teaspoonful of sherry, port or champagne
which has been mixed with one-half water.
Rectal injections of meat extracts or wine
may be tried also, and, indeed, they should
be relied upon for some hours afterwards
before returning to milk alimentation by the
mouth. Even when the milk is used it
would be well, in serious cases, to give also,
every half hour, before nursing, a rectal in-
jection of one to one and one-half ounces of
meat (soup) containing two and one-half
drachms of dextrin. If the digestion con- j
tinues to be difficult, the following potion |
may be used :

R Pepsin gr. xv

Acid, hydrochl TT^viiss

Sacch i^iiss

Aquae destill f^^v

M. Sig. Teaspoonful after nursing.

Regulation of Prostitution in Mis-
souri.

The Weekly Medical Review, February 21,
1 89 1, says that a bill has been introduced
and is now pending before the Missouri
Legislature, which provides that the boards
of police commissioners in all cities of the
State having the same, are required to make
a complete list of all houses of ill-fame, and
of all fallen women, revising this list as oc-
casion may demand, and furnishing it to the
boards of health, giving the names, aliases,
ages, and former occupation of the women,
together with such particulars as may be of
statistical and sanitary interest, the record to
be kept in the office of the Clerk of the
Board of Health, and to be open to inspec-
tion to the members of the boards and the
Municipal Assembly only.

March 28, 1891.

Periscope.

363

Each keeper of a house of ill-fame shall
be required to furnish complete information
to the board and its agents of the particulars
set forth in section i, to give notice of any
change that may take place in ownership or
with respect to the inmates. Any person
failing to comply with such requirements
shall be guilty of a misdemeanor.

The police boards are to set apart a dis-
trict consisting of not more than one-twen-
tieth nor less than one-fortieth of the total
area of the city, and as far as possible out-
side the residence section, wherein fallen
women may live. This district shall be di-
vided into sub-districts, and for each sub-
district shall be appointed a regular physi-
cian whose duty it shall be to visit at least
once a week each of the houses and women
appearing on the list furnished by the board
for his sole use and inspection. Such phy-
sician shall inquire into the condition of the
women, and make such orders as are neces-
sary. He may cause their removal to the
hospital or hold them under bond of from
$200 to $500. He shall make a weekly re-
port to the Board of Health concerning each
house and the condition of the inmates, and
the keeper of each house shall pay to him
$1 per week for each such inmate, this
money to be delivered to the Clerk of the
Board of Health, subject to the order of the
board. Any person violating the order of
such physician, or in any way obstructing
him in his duty, shall be deemed guilty of
a misdemeanor and fined not less than $20
— provided that any person may within three
days of the issue of the order appeal from it
yi writing to the Board of* Health, which
shall thereupon grant a final hearing.

The Board of Police Commissioners, upon
the request of the Board of Health, shall
have the power to suppress any house of ill-
fame within any locality they may from time
to time designate, or the keeper of which
disobeys any lawful order. A fine of not
less than $20, nor more than $500, may be
inflicted upon any person violating such
conditions by persisting in a course contrary
to the law.

The boards shall, if necessary for the pur-
pose of carrying out the provisions of the
foregoing section, establish a refuge or re-
formatory wherein fallen women who desire
to lead a virtuous life, but are unable to ob-
tain remunerative employment or are physi-
cally unfit to perform work, may be sheltered
until placed in some position where they can
maintain themselves honorably.

Meat Juice and Glycerin Applied Ex-
ternally.

Dr. E. H. Lewis, of Culpeper, Va., writes
to the Virginia Medical Monthly, February,
1 89 1, that he had as a patient, a two months'
old baby, born in the seventh month of ges-
tation. It was very small — weighing after
birth, only about 3^ pounds — clothing and
all. In this puny condition, the child took
cold and appeared to be threatened with bron-
cho-pneumonia. Asa result of its inability to
cough up the secretions, spasms set in, and
life was almost extinct when I responded to
the hasty call. Indeed, for some minutes
after my arrival, no signs of life could be
detected. Yet by vigorous continuous rub-
bing the body with equal parts of whiskey
and water, life was sustained until evidences
of it became apparent.

At this stage Dr. Lewis prescribed a mix-
ture of cod-liver oil and whiskey for friction
purposes, hoping thereby to furnish some
element of nourishment with the stimulant.
But by mistake or misunderstanding in the
hurry, a bottle of - meat juice and glycerin
was substituted, and the contents were
rubbed all over the infant's body. In a few
hours the child recovered enough to swallow,
when the meat juice and glycerin were
given in doses of one, two and three drops
at a time as the stomach would take it. By
this double administration of meat juice and
glycerin — rubbing the body with it and
dosing it internally — in his opinion the
child's life was saved. In thirty-six hours it
was taking milk as usual from the bottle, and
continued to improve until now it is doing
well.

Dr. Lewis says: undoubtedly in this case
the skin absorbed enough of the meat juice
and glycerin to furnish the requisite nourish-
ment for the time being. And the case de-
monstrates the fact that the remedy can be
administered successfully by the skin.

Numerical Relation of Sexes.

The Journal of Cutaneous and Venereal
Diseases, February, 1891, cites a paper by
Dr. C. Dusing, as stating that the relation
of the number of males to the number of
females born is a constant one as regards
man, animals and plants. In man the nu-
merical relation of male to female is 106 to
100. In horses, male and female, it is 100
to 98.

This relationship in man is subject to va-

364

Periscope.

Vol. lxiv

riation to a certain extent. For example,
during war male births predominate. The
absence of a considerable number of men
exerts this certain influence. In favorable
times not alone are a greater number of
children born, but girls preponderate. In
unfavorable times fewer female children are
born and more boys.

Among the first births in the human spe-
cies there are relatively many males. This
excess is especially seen in the children of
those mothers who are advanced in age when
• they become pregnant, and is attributable
to the nutrition of the, mother not being up
to normal.

From the explanations, it is concluded
that the sex is not inherited, but results from
a combined action of causes. These factors
act not only at the time of impregnation,
but at various times after. From the begin-
ning the ovule has a tendency to the devel-
opment of a certain sex, and the semen pos-
sesses the same tendency ; both combine at
the time of impregnation to constitute one
tendency, which determines the sex. Long
after impregnation, when the embryo is al-
ready developed, the nutrition is still of in-
fluence, and can cause, a change of tendency
even if the sexual organs have begun to de-
velop : as for example the occurrence in the
mother of a poor state of nutrition may ar-
rest the development of the female and bring
about the development of male organs.

When this late reactionary influence re-
mains absent or is not exerted strongly
enough to cause a change in the develop-
ment of the sexual organs, then the sex is
definitely decided.

Boric Acid in Otorrhcea.

In the Riis'skaia Meditz'ina, No. 30, 1890,
p. 470, Dr. M. G. Tzitrin, of Simbirsk,
highly eulogizes the treatment of both acute
and chronic otorrhoea by insufflating finely-
powdered, pure boric acid. In such cases,
where the discharge is profuse, the proced-
ure should be repeated twice or thrice daily ;
be the secretion but moderate, one applica-
ti m a day is fully sufficient for all purposes.
On each occasion, the ear should be pre-
viously thoroughly washed out with a tepid
2 or 3 per cent, solution of carbolic or
boric acid, and then carefully dried with
a plug of sublimate or salicylic cotton-wool,
after which as much boric. acid should be
bljwn into as is necessary for covering the

tympanic walls and the remnants of the
drum-head with an equal layer of the sub-
stance. No powder should* be left in the
auditory meatus itself, since the latter toler-
ates any pulverized substances rather badly.
Under the treatment indicated, the purulent
flow is said to cease in from 8 to 12 days.

Druggists and Venereal Patients.

The National Druggist is published in
St. Louis, and it presents in its advertising
column, February 1, 1891, the following
proposition to its readers.

" To retail druggists. Many of you have,
heard more or less of the wonderful curative
properties of the Cook Remedy Company's
Magic Remedy for the Cure of Syphilis.

" If you will mail us names and address of
those people whom you know to be affected
with syphilis, we .will undertake to secure
them for treatment. We guarantee to cure,
or refund all money. We will reimburse
you for postage, and for every patient we
get out of those whose names you give us we
will pay you $2.5 cash. Look us up, if you
will, and see that we are responsible, and
that we will do as we agree. All informa-
tion will be kept strictly confidential. Some
druggists have already been paid by us $125
in a single month.

" Start in at once ; it will pay you."

Test for Albumin in Urine.

A test for albumin in urine, proposed by
Dr. Adolf Jones, of Vienna, is given in the
P/iarmaceutial Record, December, 1890. It *
is as follows : Upon a portion of the sample
of urine is placed an equal bulk of strong
hydrochloric acid without shaking, then from
a glass pipette let two or three drops of so-
lution of chlorinateS lime fall into the tube.
If albumin is present a white ring will be
visible at the juncture of the acid and "the
urine even if present in 1 part to 10,000,
which makes this one of the most delicate and
easily applied tests.

Menthol for Vomiting in Pregnancy.

It is said that the following prescription is
of great value in relieving the vomiting of
pregnancy.

Be Menthol . 15 grs.

Alcohol . 5 fl drachms

Di-tilled water q. s. ad f 5jv

M. Sig. Dose : A tablespoonful every hour.

March 28, 1891.

Editorial.

365

THE

MEDICAL AND SURGICAL

REPORTER.

ISSUED EVERY SATURDAY.

CHARLES W. DULLES, M.D.,
Editor and Publisher.

N. E. Cor. 13th and Walnut Streets,
P. O. Box 843. Philadelphia, Pa.

^^Suggestions to Subscribers :

See that your address-label gives the date to which your
subscription is paid.

In requesting a change of address, give the old address as
well as the new one.

If your Reporter does not reach you promptly and regu-
larly, notify the publisher at once, so that the cause may be
discovered and corrected.

^^Suggestions to Contributors and Correspondents :
Write in ink.

Write on one side of paper only.

Write on paper of the size usually used for letters.

Make as few paragraphs as possible. Punctuate carefully.
Do not abbreviate or omit words like "the" and "a," or
" an."

Make communications as short as possible.

Never roll a manuscript ! Try to get an envelope or
wrapper which will fit it.

When it is desired to call our attention to something in a
newspaper, mark the passage boldly with a colored pencil, and
write on the wrapper " Marked copy." Unless this is done,
newspapers are not looked at.

The Editor will be glad to get medical news,- but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

PHYSICIANS' ACCOUNTS.

The North American Practitioner, March,
1 89 1, says that there recently occurred in
the La Salle County Court of Probate, a case
of important interest to all physicians. Dr.
S. rendered services, medical and surgical,
to a Mr. M. during a period of five years,
when Mr. M. died and his will was pro-
bated. The doctor's bill •(something over
$500) was presented, with affidavit, and ob-
jected to on the part of the administrators.
Upon the hearing, it was shown that the
doctor did not keep a ledger, but relied only
on his pocket record in which he had made
his charges, by signs, such as each individ-
ual physician has the habit of using. The
doctor swore to each item of entry and at-
tempted to explain what each character used
meant. The defense here objected and was
sustained by the Court. Then the doctor
attempted to prove his books by the old

common-law rule, that is : by several wit-
nesses who had settled accounts with him by
these books ; but they could not tell what
charges were indicated by the signs and let-
ters used. Then, by two brother physicians,
the doctor tried to show that all physicians
used the same kind of books ; but they
could not tell, from an examination of the
books, what the services rendered were.

The judge, in deciding the case, totally
excluded the books, and the doctor was de-
feated. The Court and defendants admitted
the equity, that is, that services had been
rendered, but the Court was compelled by
the lata to ignore everything because the
doctor could not show that somebody else
was thoroughly acquainted with his system
of book-keeping.

If it be asked : Why did not the doctor
keep a ledger and transfer his charges to it ?
Here again the law steps in and says that
only books or memoranda of original entry
can be used as evidence to prove a claim.
So the ledger would not help out.

In discussing the case, the judge suggested
two remedies. One that every physician
should have a complete index of characters
used in the book, and second, that the doc-
tor should tell some disinterested persons,
at least two, what his signs meant, so that
they could testify to the same when called
upon. Even this is of doubtful practicabil-
ity, and, we think, of more dubious relia-
bility in litigation. The best way to avoid
such snarls is to avoid suits for professional
services. Where a suit is unavoidable, we
believe that it would be better for a physi-
cian to produce no books in court, and to
rely upon proving his claim without them.
If his books were called for by the defense,
we think they would have more value as evi-
dence than if the physician brought them
forward himself. If — what is not the case —
physicians kept books as merchants do, or
if they kept them with the design of using
them in lawsuits, a different form from that
now almost universal in the civilized world
would have to be adopted. Each item would

366

Editorial.

Vol. lxiv

have to be entered in full — words and figures
indicating plainly the service rendered and
the charge made for it.

But this cannot well be, and physicians
may as well know that there never has been
published a single pocket record or visiting
list which can be used in court as evidence
to establish a claim against a debtor, under
the rulings of courts which are now in force.
This, we believe, is rarely of much conse-
quence, for suits are rare, and in most cases
a physician who cannot collect on such evi-
dences of indebtedness as most physicians
keep, would do well to remember what
Shakespeare makes Dogberry say to the
watchman who asked what he should do if
a suspicious character would not "stand"
when halted in the Prince's name. " Why,
then," says Dogberry, "take no note of
him, but let him go ; and presently call the
rest of the watch together, and thank God
you are rid of a knave."

ABORTIVE TREATMENT OF SYPHILIS.

The diagnosis of chancre from chancroid
is, at times, one of the most delicate, as
well as one of the most difficult, in surgery.
The presence or absence of induration can-
not be relied upon as of infallible signifi-
cance. It is on account of this uncertainty,
that, in the treatment of syphilis, the pre-
vailing method of awaiting the development
of secondary manifestations, without the in-
stitution of measures directed to the removal
of the primary lesion, has found the support
it has. Should the venereal ulcer, by its
course and sequelae, prove to have been a
chancroid, no harm has been done. If
symptoms of syphilis develop, we have the
means of successfully combatting them.

In the Bulletin Medical, February i, 1891,
Dr. Louis Jullien expresses his confidence in
the possibility of aborting or modifying the
course of syphilis, by excision of the primary
lesion, before adjacent glands have become
involved. In his opinion the chancre may
be considered analogous to a malignant

tumor, the thorough removal of which, with
proper antiseptic precautions, is followecl
by primary union, substituting, in a few
days, a process which it would otherwise
take weeks to complete. Two cases are re-
ported in which, after excision of the chan-
cre, in one case for a period of more than
three years and in another for ten years,
there was no subsequent manifestations of
syphilis. In a third, reinfection occurred
after excision. In other cases operated on,
it was thought the symptoms were favorably
modified.

In two cases in which glandular involve-
ment had already taken place, injections of
calomel were made. These were followed
by swelling of adjacent lymphatic glands,
for which the designation hydrargadenitis
has been created. In neither did secondary
symptoms appear.

In one other case of chancre of the glans
penis and adjacent prepuce, with pronounced
induration, which had persisted for a long
period before cicatrization took place, in
which corrosive sublimate was administered,
no cutaneous eruption had been observed at
the 139th day.

In estimating this report, it must not be
overlooked that the evidence adduced is
presumptive and negative. Every medical
man knows that the only infallible sign of
syphilis is the appearance of secondary symp-
toms, and that their absence must always
as fully cast doubt upon the accuracy of the
diagnosis, as suggest the efficacy of the treat-
ment. Abortive treatment has still some who
believe in it; but it is still — in the words of
a well-known U. S. Senator — an " iridescent
dream."

ELECTRICITY IN THE TREATMENT
OF EXTRA-UTERINE PREGNANCY.

The investigations of the last few years
have thrown much light upon the subject of
extra -uterine pregnancy. Fifteen years ago
it was considered a very rare condition, so
rare as scarcely to be of practical interest ;
and when met with, medicine was practically

March 28, 1891.

Editorial*

367

powerless. The physician stood by with
folded hands and saw his patient die of
hemorrhage ; at the most he gave stimulants
and narcotics. Now, it is known that ecto-
pic pregnancy is a common condition, at
least, in urban communities. It is well re-
cognized also that its cause is antecedent
salpingitis, and, best of all, instead of being
almost uniformly fatal, the mother's life can
now be saved almost always by prompt ab-
dominal section, and removal of the product
of gestation.

The history of the use of electricity in
the treatment of ectopic pregnancy is full of
interest. Introduced at a time when ab-
dominal surgery was in its infancy, . and
promising to be a safe and reliable cure for
a condition universally regarded as fatal,
electricity, in this country, became the re-
cognized method of treatment. This was
largely due to the genius of T. G. Thomas.
Every candid man must admit that much
good has resulted from the labors of those
who have advocated the use of electricity in
the treatment of this condition. Study of
the whole subject was stimulated, and the
medical world was prepared for the marvels
which have since been accomplished by sur-
gical interference. With the introduction
of an ideal method of treatment, electricity
is falling into disuse ; and would be quite
abandoned, but for the efforts of its parti-
sans. But now, even its loudest claimants
award electricity only a small field of use-
fulness. It is universally agreed that after
rupture of the gestation sac, with hemor-
rhage into the peritoneal cavity, electricity
is useless. Life can be saved only by prompt
operation. This class of cases embraces al-
most all seen in practice. Where extra-uter-
ine pregnancy is diagnosticated prior to rup-
ture, the advocates of electricity claim that
it should be used as a feticide, and that
operation should not be done. Under these
circumstances, abdominal section yields al-
most perfect results, and in good hands such
cases practically all recover. On the other
hand, evidence has accumulated that elec-

tricity cannot be depended upon to save
life. Cases are on record in which, in spite
of its use, the ovum has continued to de-
velop ; in which death has occurred from
hemorrhage with and without rupture of the
sac, while the. patient was undergoing, or
waiting to undergo, the electrical treatment ;
and in many cases in which the growth of
the ovum has been arrested, a diseased mass
has been left in the pelvis, liable to cause
peritonitis at any time. These facts are un-
doubted, and they amply prove that, in this
class of cases also (sac unruptured), electri-
city must be rejected.

The value of treatment of ectopic preg-
nancy, when extra-peritoneal rupture of the
sac has occurred — rupture into the broad
ligament — is, at the present time, unsettled.
There is reason to believe that this variety
of rupture is infrequent. Those who con-
sider it frequent argue that such cases under-
go a spontaneous cure, as a rule, and only
exceptionally cause trouble when the ovum
continues to develop, and the fetus grows
until term, or when a second rupture occurs,
with hemorrhage into the peritoneal cavity.
In this class of cases electricity might be
used to destroy the fetus, when it survives
the rupture, but the unreliability of the
agent will probably prevent its employment,
and prompt operation will usually be done.

The evidence is plain that, while electri-
city was useful before the modern advances
in abdominal surgery, its employment at the
present time is reprehensible. Its use does
not protect the woman from the dangers of
rupture and hemorrhage ; and, at best, after
its use diseased uterine appendages are left
in the pelvis.

The experience of the writer embraces
nine cases of extra-uterine pregnancy. This
experience helps to confirm the modern doc-
trine that an extra-uterine pregnancy should
be regarded as a malignant tumor requiring
immediate removal.

It is certain that results have been ob-
tained by operative treatment which fully
justify acting on this presumption.

Correspondence.

Vol. lxiv

Book Reviews.

[Any book reviewed in these columns may be obtained upofl
receipt of price, from the office of the Reporter.]

DISEASES OF THE DIGESTIVE ORGANS IN
INFANCY AND CHILDHOOD, with Chapters
on the Investigation of Disease, the Diet and Gen-
eral Management of Children, and Massage in Paedi-
atrics. By Louis Starr, M. D., Late Clinical Pro-
fessor of Diseases of Children in the Hospital of the
University of Pennsylvania, etc. Second Edition —
illustrated. 8vo, pp. 396. Philadelphia : P. Blak-
iston, Son & Co., 1891. Price, $2.50.

The admirable features of Dr. Starr's well-known
book are so familiar that an extended review seems
unnecessary. The first one hundred pages are devoted
to the investigation of disease and the general manage-
ment of children. These pages are worth the entire
price of the book. We wish the second part, on the
general management of children, could be read and
laid to heart by every mother. The third part treats
of massage in pediatrics, and was not contained in the
first edition. The author follows Murrell in his de-
scriptions. A point to be remembered, Dr. Starr says,
is that those cases in which massage is immediately
followed by a sensation of comfort or by refreshing
sleep are most benefited by the manipulation. On the
contrary, those patients who are stimulated by it, de-
rive little benefit and are perhaps positively injured.

The rest of the book deals with diseases of the di-
gestive organs proper. The author has added, in this
edition, sections on alterations in the odor of the breath
in disease, on urine alterations, and a detailed account
of second dentition and its influence on the health in
late childhood : a subject which he thinks has been
greatly neglected hitherto.

The whole book is thoroughly clinical, contains a
large number of useful formulae, and is just what every
one who has much to do with diseases of children will
find helpful every day. -

DE LA MALARIA. By Dr. Edouard Pepper,
Laureate of the Faculty of Paris. Large 8vo, pp.
xvi, 287. Paris: G. Masson, 1891.

Prof. Peter, in his letter prefatory to this volume,
writes of the author, " ' Living in a village of Algiers,
you have not had at your disposition any library,' you
say.- Well, I congratulate you, for you have described
facts in accordance with nature, and free from the in-
fluence of foreign ideas." This sentence furnishes a
key to the characteristics of the book, although it can
hardly be said that one has been uninfluenced by the
views of others, who seems to be so familiar with a
large variety of practical writers, and with a great va-
riety of remedial measures , although it is true that,
living apart from the influence of large- cities, large,
libraries, and educational centres, unusual opportunity
seems to have been furnished him to study the natural
phenomena of the diseases which he describes, and to
report the results of different modes of treatment. Dr.
Pepper's book contains detailed reports of the history
of a good many cases, and a very full exposition of the
reasons for the views he holds in regard to his subject.
The author, as an American living abroad, has retained
his connection with American literature so as to be able
to compare, as he does, the preparations of the Ameri-
can pharmacopoeia, for example, with those of the
French, sometimes decidedly to the advantage of the
former — as in the preparations of phosphorus and
hamamelis. His book contains, also, numerous refer-

ences to American writers and American medical jour-
nals, and altogether it is a very interesting study of
malaria, especially in its relation to other infectious
diseases of cosmic origin. The Reporter does not
furnish, room in which to give any adequate idea of the
exact nature of its contents, but the book may be com-
mended to those who wish to study the views of one
who has devoted much time to a subject of great medi-
cal importance.

INOCULATION FOR RABIES AND HYDRO-
PHOBIA. A Study of the Literature of the Subject.
By Surgeon-General C. A. Gordon, M. D., C. B.,.
Honorary Physician to Her Majesty the Queen, etc.
8vo, pp. xii, 127. London: Bailliare, Tindall &
Cox, 1887.

Surgeon- General Gordon belongs to that class of in-
vestigators who were not carried away by the rush of
professional approval which greeted the announcement
of Pasteur that he had a means of preventing hydro-
phobia. In England, for some time, such an attitude
towards Pasteur made men singular, but it is a singu-
larity which has been shared by some of the most pru-
dent and discreet men of Great Britain. Surgeon -
General Gordon has written several brochures on the
subject of rabies or hydrophobia', and this one is of
great interest and value. Opposing senseless scares, it
attempts to give a rational notion in regard to the actual
manifestations and best treatment of hydrophobia. It
is a sensible book and calculated to be useful to all
who will consider it with judicial fairness.

CORRESPONDENCE.

Repeated Puerperal Convulsions.

To the Editor.

Sir : Will you kindly answer through the
columns of the Reporter or by letter the
following question, which I think important,
and on which I am unable to find any liter-
ature.

Where puerperal convulsions have oc-
curred in first labors, what are the probabil-
ities of their re-occurrence in subsequent,
labors ?

Yours truly,

W. T. Davison.

Canton, Pa.

[It is well known that about eighty per cent, of
eclamptics are primiparae. Nearly one-third of such
primiparse die. Twenty per cent, of eclamptics are
multiparas. This percentage is made up, not only from
those who have recovered from a first attack of puer-
peral convulsions, but also from the great army of
those who have escaped eclampsia in their first labor.
One case of eclampsia occurs with about every four
hundred labors. Hence, in general, it is evident that
if a primipara recovers from eclampsia, the prospect
of a recurrence of the disease in subsequent preg-
nancies is slight.

But while this is true in general, it is not so in par-
ticular cases. If the eclampsia be due to chronic
Bright's disease, which has antedated the pregnancy,
and the first attack does not prove fatal, eclampsia and

March 28, 1891. Notes and Comments.

369

death is almost certain to follow, should pregnancy
again occur. The same is true if th'e eclampsia com-
plicating the first pregnancy be due to acute Bright's
disease, which becomes chronic after labor.

According to Tyson, when the convulsions are of an
apoplectic character, and brain injury results, as hemi-
plegia, etc., should pregnancy again occur, fatal
eclampsia may be confidently expected.

On the other hand, when eclampsia in primiparse is
due to primiposity — irritability of the nervous system,
pressure on the kidneys or ureters caused by the tonicity
of the abdominal wall — and when neither the brain or
kidneys are left crippled by the attack, the probability
of a recurrence of convulsions in subsequent pregnan-
cies is not great. — Ed. Reporter.]

A Pin Eight Years in the Body.

To the Editor.

Sir : Eight years ago, Ella W., a Swedish
girl, fourteen years old, while dressing,
placed a pin in her mouth and accidentally
swallowed it. It lodged in the throat, and
caused considerable pain and uneasiness for
a short space of time — probably an hour —
when all pain suddenly ceased, and no more
trouble was experienced. About four months
ago, while engaged in some culinary work
and in rolling up the sleeve of her dress,
she noticed a small elevated spot over the
internal condyle of the right humerus.
Upon examination, the object was soon re-
cognized as the pin swallowed some eight
years before.

Being called in to examine the case, I
found that the pin was just beneath the skin,
and that the pin's head was nearest the sur-
face ; and upon making a small incision
through the integument, I extracted the pin,
which was in a good state of preservation.

At no time during the period of its pas-
sage from the throat to its location when ex-
tracted has it caused any inconvenience. In
fact, it was entirely forgotten.

Having frequently heard of such cases as
this, I have never had occasion to meet one
until the present occasion.

Yours truly,

H. L. Brush, M. D.

Pleasant Grove, Utah.

Notes and Comments.

Tampon in Menorrhagia.

Dr. W. H. Mays, of San Francisco, has
an interesting article in the Pacific Medical
Journal, March, 1891, in which he advocates
tamponing for obstinate menorrhagia.

He refers to the medicinal agents usually
employed, the styptics and tonics, the hot

douche and the curette, and says that when
all these shall fail, as they frequently will,
to check the propensity to bleeding, when
the physician finds it borne in upon him
that the more he treats the case the worse is
the trouble becoming, there is a remedy at
his command which, fearlessly used, will give
him absolute control over the hemorrhage,
namely, the tampon.

At the threshold we are likely to be con-
fronted with an old prejudice. Would you
dare to arrest the menstrual flow ? In one in-
stance where it was proposed to tampon at
the end of the first twenty-four hours of
mensturation, he was told that the blood
would surely "go to the head" and work
dire results. The function has been hedged
about with a peculiar sanctity, and the
dangers of interfering with it greatly exag-
gerated. Dr. Goodell in a recent paper
says : "I have learned to unlearn the teach-
ing that woman must not be subjected to a
surgical operation during her flux. Our
forefathers taught that the presence of a
menstruating woman would pollute solemn
religious rites, would turn milk sour, spoil
the fermentation of wine, and do much
other mischief in a general way. Influenced
by hoary tradition, physicians generally post-
pone all operative treatment until the flow
has ceased. But why this delay, if time en-
ters as a factor in the case ? I have found
menstruation to be the very best time to cu-
rette away fungous vegetations of the endo-
metrium, for being swollen they are then
larger and more readily removed than at any
other time." While we may not agree with
this writer as to the advantage of curetting
during the flow, the quotation .shows the drift
of gynecological opinion concerning the
supposed danger of interfering with a men-
struating woman. So little importance does
Professor Loewenthal, of Lausanne, attach
to the old superstition, that he advocates the
complete and repeated suppression by artifi-
cial means of the menstrual flow in chlorosis,
and publishes a record of twenty-three cases
so treated, all of them with benefit.

In illustration of the use of the tampon
in menorrhagia, Dr. Mays related the fol-
lowing case, from his practice.

A. B., aged twenty-seven, had been the
subject of menorrhagia for three years before
coming to him. The disorder was gradually
acquired, its origin being ascribable to no
cause that could be gleaned from the pa-
tient's history. No particular excess of pain
accompanied the molimen, but she simply

37o

Notes and

Comments.

Vol. lxiv

bled freely, passing clots after the first day
and soaking napkin after napkin throughout
a period of four or five days. Most of the
period was of necessity passed in bed, owing
to prostration. During the inter-menstrual
intervals she would drag herself around,
weak, pale and nervous, but the exhausting
hemorrhages, repeated with unrelenting reg-
ularity, were sapping her strength and mak-
ing her existence a miserable one. She had
been under treatment the greater part of
this time, and about four months before
coming to him had been carefully curetted.

On examination he found nothing abnor-
mal in the position or shape of the pelvic
organs. The sound revealed some little
elongation of the uterine canal. There was
no endometritis.

He explained to her that the mucous mem-
brane being set bleeding, the tendency was
to keep on bleeding, and, as in the case of
a cut finger, the indication simply was to
stanch the hemorrhage by pressure. This
he proposed to do each month by the aid of
the tampon, after she had lost as much as
in his judgment she could afford to lose.
She readily consented. So at the next men-
strual epoch, after allowing the flow to con-
tinue for thirty hours, he proceded to tampon
the vagina. Drawing back the perineum
with a Sims speculum, pieces of cotton
wrung out of an alum solution were packed
firmly and tightly, first behind and then in
front of the cervix, then at the sides, gradu-
ally building a solid mass occupying the
whole caliber of the vagina, until the vulva
was reached. A compress and T bandage
completed the procedure. Four hours later
the outermost wad of cotton, which pressed
on the urethra, had to be removed to allow
of urination. On removing the tampon
after forty-eight hours, no evidence of fur-
ther hemorrhage was observable, and the pa-
tient rose stronger than had been custom-
ary.

At the next menstrual period, the tampon-
ing, was repeated. For some reason the
packing was not done so solidly as before,
and some blood soaked the tampon and es-
caped from the vulva, though not much. A
month later the tampon, applied on the
second day, proved a perfect means of con-
trol. So also at the next and at several
periods immediately following. The pa-
tient has only been " packed " twice during
the past six months, as the flow rarely now,
with proper care on her part, transcends the
natural limit. She was gaining in color and

weight, and enjoyed better health than for
years previously.

This case is typical enough ; it is not ne-
cessary, Dr. Mays says, to cite others in sup-
port of his argument. The tampon is essen-
tially the thing in what may be called uncom-
plicated cases of menorrhagia. When subin-
volution is acting as the cause, it is often
the best remedy to employ. Even where the
grosser forms of uterine disease are present
it may be recommended, for it should be
remembered that menorrhagia alone, by its
exhaustive waste, its depraving of tissue, and
the nervous and circulatory disturbances it
sets up, will, itself, produce uterine inflam-
mations, vegetations, flexions, etc.

Bearing on this subject, Dr. Mays quotes
from Dr. Gehrung, whose able article is
found in the Journal of Obstetrics, Novem-
ber, 1888.

"Every practitioner will recall a number
of these pitiful cases of broken-down con-
stitution, nervous to the verge of insanity,
complaining of the ills that flesh is heir to,
who under treatment improve for a while
until the next return of the menses merci-
lessly destroys all that has been gained.
The poor woman passes from the hands of
the neurologist to the gynecologist, and then
back again, until exhausted in confidence,
blood and means. Each in his turn has
honestly done his best, each is conscious
that each recurring menstruation destroys
the fruits of his labor. ' '

" The tampon is the remedy which stands
at the disposition of every practitioner,
whereby he may regulate the amount of loss
in menstruation according to the necessity
of the case."

Dr. Bizzell, of Georgia, advocates repres-
sion of the menstrual flow in menorrhagia,
while other agents prove unavailing or are
contra-indicated. Quoting Dr. Taliaferro he
says : " By this method we have a marvelous
therapeutic resource. ' ' Cases that have obsti-
nately resisted other methods yielded
promptly to this. He prefers, however, the
intra-uterine tampon, which consists of a
roll of cotton about the length and thickness
of a lead pencil. This is iodoformed and
carried up through the os to the fundus
with a slender dressing forceps, packing it
in tightly. The vagina is also tamponed.
It is left in situ seven or eight days.

Dr. Mays' s experience is against the intra-
uterine tampon. On the only occasion on
which he tried it, colicky pains of a very vio-
lent character ensued, necessitating a speedy

March 28, 1891. Notes and Comments.

37 1

removal of the offending cause. Dr. Gehrung
states^that in a case in which he resorted to
the intra-uterine tampon it made matters
worse, the uterus relaxing so completely that
blood found its way freely around the plug.

Vaginal tamponing skilfully done .will
prove entirely satisfactory. Dr. Mays adds
that in applying the strips of dampened cot-
ton, it is well to work with two pairs of dress-
ing forceps, one pair to press the tampon in
an opposite direction from where the next
piece of cotton is to be placed with the other
pair.

Treatment of Recent Hernia by
Aspiration.

In the British Medical Journal, February
7, 1 89 1, Dr. John Hern says : On be-
ing called some years since to a case of
recently strangulated hernia which I failed,
under chloroform, to reduce by taxis, find-
ing the tension in and distention of the pro-
truded gut apparently the main obstacle to
reduction, I emptied it by means of my
hypodermic syringe, with the result that re-
duction was at once easily accomplished.
I have since repeated the operation on
thirty-two occasions, in twenty-eight of
which reduction was readily accomplished,
and in the remaining four, three were, sup-
sequent to aspiration, subjected to the usual
operation (with one death, from gangrenous
gut), and one steadfastly preferred death to
further operation, and succumbed on the
tenth day. In neither of the three cases of
herniotomy could any traces be found of the
previous aspiration, due I think, to two
causes, the small size of the needle used and
the arrangement of the muscular fibers in
the wall of the gut.

The class of cases which have appeared
to me most suitable for the operation are
recent cases — 36 to 48 hours or less ; where
the patient or friends refuse to submit to
herniotomy. The simple aspiration can be
designated " doing a little something."
The advantages claimed for this procedure
are :

1. It avoids the delay almost insepara-
ble from the herniotomy, for example,
gaining consent of friends, procuring ade-
quate assistance, etc.

2. It avoids rough and heroic attempts
at reduction by taxis by placing in the
hands of the general practitioner a means
of reduction easy of application, and requir-
ing no extensive surgical skill for its per-

formance, and, moreover, a proceeding,
which, by reducing the tension of the pro-
trusion, lessens the danger of the taxis sub-
sequently employed.

3. It avoids the risks of pyemia and septi-
cemia, inseparable from all operations in
which skin is divided.

Let us consider in how far this operation
is based on a consideration of the anatomi-
cal and pathological conditions present.
We must remember that the internal abdom-
inal ring, the inguinal canal, the external
abdominal ring, the crural ring, the crural ca-
nal and the saphenous opening in the fascia
lata of the thigh are all bounded chiefly, if not
solely, by aponeurotic structures, which have
become thickened and resistant although the
openings have all become dilated. The
margins of these openings forced back and
thickened offer a strong passive resistance,
so that if the protrusion becomes distended
in any way by feces or flatus, the neck or
narrow portion is so wedged into these fas-
cial openings or canals that it becomes com-
pressed, the venous circulation impeded
(both arteries and veins are, of course, com-
pressed, but the thicker coats of, and the
greater force of circulation in, the former
render them less affected by the pressure),
the proportion between the protrusion and
the opening or canal through which it has de-
scended becomes so altered, that the hernia
becomes irreducible. Now, seeing that (in
recent cases, at any rate) it must be the dis-
tention of the protrusion which is the main
obstacle to reduction, there having elapsed
no time for the effusion of lymph or other
inflammatory changes to occur, having failed
to reduce by taxis, it appears to me to be a
perfectly justifiable proceeding to at once
empty the protrusion of whatever fluid- or
flatus it may contain, and having thus les-
sened its bulk, to reduce by taxis.

Impure Milk in Large Cities.

The New Orleans Medical and Surgical
Journal, February, 1891, says editorially :
Persons residing in the country, or in small
towns away from the great centres of trade
and competition, have no idea of the many
frauds perpetuated by the vendors of the
commonest articles of food consumed in
large cities. Not least among these is the
adulteration of milk with dirty water, or
some other substance designed to give it a
creamy appearance and cause it to pass

372

Notes and Comments.

Vol. lxiv

muster before the dreaded lactometer of the
officers of the Board of Health.

It has now become the practice in all
cities to keep dairymen under surveillance,
so that at least the proportion of adulter-
ants added shall be comparatively small.
New York and Chicago and other cities have
regular milk inspectors, whose sole duty is
to procure and analyze samples of this arti-
cle offered for sale, and to prosecute crimin-
ally all persons who sell other than the na-
tural secretion of the cow. Our own Board
of Health has for the past five years made
regular examinations of milk, and, by fol-
lowing up the offenders to the recorder's j
court, has succeded in materially improving
the standard of milk sold in the city of New j
Orleans. Some points of general interest j
were brought forward in a recent report of j
the chief sanitary inspector, and we will j
venture to quote a portion of it, as the con- ,
elusions to be drawn therefrom are obvious. I
We can see from this what an easy thing it
is for the public to be imposed upon and j
cheated by their milkmen, to whom they
are paying the highest prices for the poorest !
quality of milk.

This' is bad enough, but when we consider !
who are the persons consuming this fluid and
what is the character of the adulterant con-
sumed, the question comes home to us more
directly as medical men. We have simply
to refer to our mortuary records for May
and June of any year and study over the
large mortality among children from the
bowel diseases, and then, when we think of
the sour, stale, watered or adulterated milk
that many children are fed upon, we may,
perhaps, be willing to discard the antiquated
idea of " teething " being a cause of most
of -these complaints, and attribute a larger
proportion of the deaths to improper nour-
ishment.

The substances usually used for adulter-
ating milk are starch, sodium, chloride,
borax, chalk, glycerine and bicarbonate of
soda. When milk has been skimmed and
watered its creamy appearance may be re-
stored by the addition of condensed milk
from cans, a common practice in New
Orleans.

But what seems to us to be most injurious
of all the substances added to milk by the
New Orleans dairyman is simple water.
This water is from cisterns or wells situated
in the swamps back of town and is often
teeming with the germs of malaria. Be-
sides, there is the danger to milk from cows

drinking ditch water, from which a number
of apthous diseases are known to have arisen.
Much more might be said upon the danger
of impure milk to young children, partic-
ularly in reference to tyrotoxicon, a poison
generated in stale and sour milk, but we
shall have more to say on this subject at
another time.

In conclusion, we heartily endorse the
following assertions of Mr. J. Lewis Smith :

"In order to obtain milk of the best
quality, it is necessary to procure it from a
dairy remote from the city, where there is
good pasturage, an abundant supply of water,
and the health of the cows is promoted by
out-door life in open meadows. Stabled
cows, in or near the city, fed with distillery
food, hay, and in part by kitchen refuse,
do not furnish good milk. Such cows are
likely to have dirty udders, and their milk,
chemically inferior to that of pastured cows,
becomes in the open pails the receptacle of
bacteria, which are abundant in stables of
ordinary cleanliness. Milk, therefore, that
is suitable for the nursery in the summer
months is obtained at a distance from the
city, where cows have the range of the
fields, and lie at night in the open air upon
the grass."

The Vital Statistics of New York
State in 1890.

The New York Medical Journal, Febru-
ary 7, 1 89 1, says: The annual mortality-
sheet of the New York State Board of Health
has appeared for the year 1890, giving the
total deaths by eight sanitary districts, by
months, and by the usual principal causes.
The deaths for the whole State, with a small
correction for the non-reported mortality in
some rural sections, were 127,6.30, in a pop-
ulation estimated at 6,000,000 ; this is
equivalent to a death-rate of 19.6 to the
1,000. The mortality from zymotic dis-
eases was less than in recent years, a decline
being registered in scarlet fever, diphtheria,
typhoid fever, and diarrhceal disorders.
Measles showed a marked elevation. Small-
pox caused four deaths. Epidemic influenza
is estimated to have caused not fewer than
5,000 deaths in the early months of the
year, but it did not operate to raise the zy-
motic mortality, for the reason that a large
proportion of its deaths was certified under
the head of respiratory and other local causes.
There were 18,000 deaths from respiratory
diseases, a number greatly in excess of

March 28, 1891. Notes and

Comments.

373

former years ; this is non-inclusive of con-
sumption, which was charged with 13,800
deaths. From unclassified causes there were
18,728 deaths.

Diagnosis of Previous Pregnancy.

From a medico-legal point of view it is
sometimes of the greatest importance to de-
termine whether a woman has ever borne a
child or not. According to Dittrich, as
quoted in the Deutsche medizinische Wochen-
schrift, January 29, 1891, from the Prager
medizinische Wochenschrift, microscopical
examination reveals hyaline degeneration
and necrosis of the muscular tissue of the
uterus and, in rare instances, of the muscu-
lar fibers of the tunica media of the arteries
as well, in cases in which a woman has been
pregnant even though the gestation has been
prematurely terminated.

Medical Attendance for the Poor in
Richmond.

The Virginia Medical Monthly, February,
1891, says that Richmond, with its nearly
100,000 population, has no city hospital,
except the hospital wards in its almshouse.
No other city, in Europe or North America,
of anything like its population, so far as we
know, is without its distinctive city hospital
for the cure of its sick or wounded working
classes. The City Council has just voted
$2,000 annually, to be divided among
four physicians, to be elected, located in
different parts of the city, whose duty it
shall be to attend the deserving poor of
their respective four districts of the city,
without charge.

The Medical Law of Alabama.

The Alabama Medical and Surgical Age,
February, 1891, says that the " Penalty
Bill," which recently passed the Legislature,
gives Alabama a model medical law, and
places the State Medical Association on a
safe and sound basis. The penalty bill, as
it passed the Legislature, provides that any
person practicing medicine or smgery in
this State, without having first obtained a
certificate of qualification from one of the
authorized Boards of Medical Examiners of
this State, shall be guilty of a misdemeanor,

and on conviction thereof shall be fined not
less than twenty-five dollars nor more than
one hundred dollars. Provided, that this
act shall not apply to any doctor practicing
medicine in Alabama who is a graduate of a
reputable medical college, and who has com-
plied with the law by having his diploma
recorded by the Judge of Probate in the
county in which he is practicing.

The Age says : " Much credit is due to the
committee appointed by the Montgomery
County Medical Society, consisting of Drs.
Baldwin, Gaston, Blue, Wilkerson, Hill,
Sealy and Andrews, for the work they did
during the session of the Legislature. The
irregulars had one or two men on the floor,
and used the newspapers for all they were
worth, and occasionally resorted to circulars,,
but this committee, faithful to themselves,
their society, the medical profession and the
people of Alabama, was able at every point
to combat the inroads of the demagogue,
upset the schemes and plans' of. the irregulars
and prevent the evils which would have re-
sulted from such vicious legislation as they
desired. We cordially welcome all worthy
physicians to Alabama, and in doing so, we
assure them of fair, just and honest treat-
ment, regardless, of name, school or pre-
vious condition, but the Legislature of Ala-
bama has said that the Medical Examining
Board must protect the people from the im-
position of quacks, demagogues and incom-
petent men, and by the authority invested
and for the sake of suffering humanity, and
for the protection of the people, we promise
that our Boards of Examiners will be equal
to the task. ' '

Association of American Physicians
of Berlin.

About forty American and Canadian phy-
sicians held a meeting on February 19, 1891,
at Berlin, in order to found a permanent or-
ganization such as exists in Paris, London,
Edinburg and Vienna. Prof. Miller, of the
University of Pennsylvania, now Professor at
the University of Berlin, called special atten-
tion to the fact that such an organization
would not only greatly benefit the physicians
who remain here for purposes of study, but
also that it would call the attention of Ger-
many to the forward tendency of American
medical science. He strongly urged the pub-
lication of the transactions of the Associa-
tion every year. Permanent organization was
effected, Dr. JudsonDaland, of Philadelphia,

374

Notes and Comments.

Vol. lxiv

being elected President, and Dr. F. Weber,
of Milwaukee, Secretary,

Prof. Miller, Dr. Amos, of Iowa, Dr. H.
Douglas, of New York, and the President
and Secretary were elected as a Committee
on Constitution.

Dr. H. T. Brooks, of New York City, Dr.
Louis Frank,- of Louisville, Dr. Crystal, of
Baltimore, Dr. Neal Mitchell, of Florida,
Dr. Marple, of New York, and Dr. Kennedy,
of Montreal, were appointed a Committee
on information to new-comers, and organi-
zation of special private courses.

The objects and scope of the society are:

First, The arrangement of medical work
and the formation of special private courses
so that any desired instruction may hence-
forth be obtainable at this University.
. Second, The giving of advice to new-comers
regarding instruction, lodgings, books, in-
struments, etc.

Third, The reading and discussion of pa-
pers of general interest and the exhibition
of patients and demonstration of specimens
in all lines of work taken up by members.

Fourth, The furthering of mutual ends by a
more extended acquaintance of the physi-
cians here.

The society at its first session listened to
an interesting demonstration of specimens
of myocarditis segmentaire and of a blood
cyst of the aortic valve, by Dr. Henry Doug-
las, of New York City. Dr. Weber then
demonstrated specimens of blood of leu-
kemia and pernicious anemia, and talked of
the value of Ehrlich's method of blood-
staining. Dr. Daland talked about malaria
and relapsing fever in Russia, and demon-
strated the pathological micro-organisms of
these diseases. An interesting discussion of
these papers followed.

Drs. Fitzgibbon and Mead, of Wisconsin,
and Navy Surgeon Kenyoun, were present
as visitors. Prof. Miller then offered the
use of the Dental Lecturing Room of the
University, Dorotheenstrasse 40, as a per-
manent meeting room for the society.

New-comers and others desiring informa-
tion will please apply to or address the Sec-
retary, Dr. Fredk. R. Weber, Charite, Ber-
lin.

Golden Belt Medical Society.

The regular quarterly meeting of the
*' Golden Belt District Medical Society"
for the annual election of officers, and mu-
tual entertainment of the profession, will

be held in the club-rooms of the National
Hotel, Topeka, Kansas, April 9, 1891.

The large attendance in the past bespeaks
a thriving condition of the Society, and a
large attendance is desired at this, our most
important meeting of the year.

The programme provides, for the after-
noon session : A Report of a Case of
Nymphomania with Treatment, by L. R.
King, M. D., Junction City; A Report of
Some Cases of Cystitis with Treatment, by
J. H. Garey, M. D., Wilsey; Report of a
Case (not described) by C. H. Guibor,
M. D., Topeka.

For the evening session : A paper on
Some Recent Improvements in Intestinal
Surgery, with Demonstration upon the Dog,
by Emory Lanphear, M. D., Kansas
City, Mo. ; one on Phimosis, Local and
Remote Results, by A. H. Cordier, M. D.,
McPherson ; one on Peri-Uterine Inflam-
mation, by Chas. W. Adams, M. D., Kansas
City, Mo.,. and the Annual Address by the
President, P. Daugherty, M. D., Junction
City.

The officers of the Society are: President,
P. Daugherty, M. D., Junction City; First
Vice-President, W. N. King, M. D., Abi-
lene; Second Vice-President, Z. T. Harvey,
M. D., Council Grove; Secretary, F. B.
Browne, M. D., Salina; Treasurer, T. N.
Gunn, M. D., Chapman.

State Board of Medical Examiners.

The Regents of the University of New
York have appointed State Boards of Med-
ical Examiners as follows :

From the Medical Society of the State of
New York : for three years from September
1, 1 89 1, W. W. Potter, of Buffalo, William
S. Ely, of Rochester, and Maurice J. Levi,
of Albany ; for two years from September
1, 1 89 1, William C. Way, of Elmira, and
George R. Fowler, of Brooklyn ; for one
year from September 1, 1891, J. P. Creve-
ling, of Auburn, and Eugene Beach, of
Gloversville.

From the Homoeopathic Medical Society
of the State of New York : for three years
from September 1, 1891, William S. Searle,
of Brooklyn, Horace M. Paine, of Albany,
and Asa S. Gosh, of Fredonia; for two
years from September 1, 1891, John McE.
Wetmore, of New York, and Jay W. Shel-
don, of Syracuse ; for one year from Sep-
tember 1, 1 89 1, E. E. Snyder, of Bingham-
ton, and A. R. Wright, of Buffalo.

Medical and Surgical

Reporter

k

A Wee

CHARLES W. DULLES, M. D., Editor and Publisher,

Entered as Second-Class matter at Philadelphia P.O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

jekey Journal.

Established in 1853 by S. W. Butler, M. D

Vol. LXIV, No. 14.
Whole No. 1779.

APRIL 4, 1891

B5.00 per Annum.
10 Cents a Copy.

GOITTSUTS

CLINICAL LECTURE.

Hansell, Howard F., M. D., Philadelphia, Pa.—
A Clinical Lecture on Some Every-day Cases of
Diseases of the Eye 375

COMMUNICATIONS.

Thomas, Charles Hebmon, M. D., Philadelphia,
Pa.— Construction and Adaptation of Spectacle-
Frames 377

Leon, Alexis M., M. D., New York.— Unusual
Case of Pelvic Abscess 380

Ring, Frank W., A. M., M. D., New York.— Dou-
ble Optic Neuritis of Malarial Origin 383

Foster, Hal, M. D.. Kansas City, Mo.— Adhesion
of Soft Palate to Pharynx ; Operation ; Cure.... 385

PERISCOPE.

Some New Medicinal Soaps.— Ligation of the
Saphena Yein in Cases of Varicose Veins.—
Vaccination of Children.— Washing in Cold
Weather.— Multiple Herpes Zoster.— Kola Nut of
Africa.— Contagious Diseases / ct —Cotton and
Collodion Dressing for the Chest.— Calomel and
Salt.— Study of Medicine in Thibet 387-392

EDITORIALS.

Pelvic Inflammation and the General Practi-
tioner 393

The Tongue in Scarlet Fever

Epilepsy and Alylene Hydrate

Medical and Surgical College of New Jersey.

BOOK REVIEWS.

Nettleship ; Diseases of the Eye.— Lutaud ;
Etudes sur la Rage, et la Methode Pasteur.—
Wight ; Suggestions to the Medical Witness.. 395

LITERARY NOTES.

394
394
395

-39G

V.W,

NOTES AND COMMENTS.

American Academy of Medicine. — Hiccough
Cured with Nitrate of Amyl.— Simple Treat-
ment of Ingrown Toenail.— Dietetic Employ-
ment of Fat.— Treatment of Stricture of the
Ileo-ciecal Valve.— Jefferson College's New Sur-
geon.—The Law of Periodical Function in
Women.— Teeth in Diabetes.— Druggist's Error
in Germany.— Congress of American Physicians
and Surgeons.— Is Sterility a Disease ?— Infusion
of Roses for Diarrhoea.— Primary Pyemia.—
An Appliance to Facilitate the Insertion of the
Soft-Rubber (Nelaton's) Stomach-Tube.— Frac-
tured Ribs in the Insane— Acetanilid for Chan-
cre and Chancroid.— Foreign Medical Diplomas
in Illinois 396-402

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MEDICAL AND SURGICAL
REPORTER

No. 1779. PHILADELPHIA, APRIL 4, 1891. Vol. LXIV.— No. 14.

Clinical Lecture.

A CLINICAL LECTURE ON SOME
EVERY-DAY CASES OF DIS-
EASES OF THE EYE.1

BY HOWARD F. HANSELL, M. D.,

CHIEF OF CLINIC.

Occlusion of Canaliculi.

Gentlemen : The Professor of Ophthal-
mology in unavoidably absent to-day, and has
requested me to occupy his hour.

The first case is one of acquired occlusion
of the canaliculi. The patient lost her
right eye through scarlet fever at four years
of age. She presented herself at this clinic
several weeks ago, to consult us as to the ad-
visability of wearing an artificial eye. Upon
examination it was found that the commis-
sure of the lids had been shortened by an
obliteration of the inner canthus. The eye-
ball was atrophied, reduced to nearly one-
half the size of its fellow and slightly pain-
ful on pressure in the ciliary region. She
was advised that an artificial eye might light
up an already smouldering inflammation and
induce sympathetic ophthalmia; moreover
the eye was hopelessly blind and unsightly.
The ball was enucleated in your presence
by Prof. Thomson . Healing progressed favor-
ably. • A few days later the inner canthus
was restored to its normal size by a plastic
operation, but the canaliculi were replaced
by cicatricial tissue. She now wears a glass
eye and is greatly improved in appearance,
but complains of constant overflow of tears.
With a Graefe knife I now divide the cica-
trix over the obliterated lower canal, thrust-
ing its point inward as far as the nasal bone.
With a probe the opening is enlarged. The
latter process must be repeated several times

1 Delivered at the Jefferson Medical College Hos-
pital, January 16, 1 890.

during the next week, to prevent the walls
of the new canal from growing together.

Stricture of the Lachrymal Duct.

This patient makes the same complaint
we heard in the preceding case, but here the
epiphora is due to a closure of the duct in
one or more places by inflammatory thick-
ening of the mucous membrane which lines
it. Its cause might be found in some co-ex-
isting nasal catarrh or hypertrophy of the
nasal mucous membrane, but frequently we
are at a loss to establish a cause. As in
the former case, I insert the point of a
Weber's knife into the lower puncture, thrust
it along the canal until it reaches the sac,
and elevate the handle, thus making the
canal a gutter. I then pass the knife down
though the duct, dividing the stricture. This
must be followed through several weeks by
probing.

Lachrymation is a symptom or an accom-
paniment of many eye diseases, such as con-
junctivitis, keratitis. Chronic lachrymation,
or a constant overflow of tears, is unusual,
unless as a symptom of chronic conjunc-
tivitis, an everted lower lid or closure of the
lachrymal canal. In the last condition only
do we resort to the above operation. In old
cases collection of pus and muco-pus con-
stantly form in the sac, and are easily ex-
pressed. In stich cases no doubt as to the
diagnosis can exist. The result of the di-
vulsion of the stricture either by knife or
probe is not always favorable. Indeed I
venture to assert, that few operators have
been satisfied with their experiences. The
treatment is painful, long continued and
often unsuccessful, so that, as a final resort,
a canulated silver style must be worn.

Soft Cataract.

The next case is one of soft cataract.
This patient was treated by me several years
ago for iritis serosa with dense vitreous opaci-

375

376

Clinical

Lecture.

Vol. lxiv

ties in the left, eye without success. A cata-
ract developed in the interval, and he now
returns to have it removed. He is only
twenty- five years old. Therefore, although
the cataract is mature, the lens is soft and
cannot be extracted according to the
method pursued in the treatment of cata-
racts recurring after the age of forty or
thereabouts. It must be needled, and usu-
ally more than once. While this procedure
is extremely simple, it is not unattended
with danger. Some of you may remember
a similar case last winter in a healthy man,
aged 25, who suffered with congenital cata-
ract. After needling, glaucoma developed,
and notwithstanding sclerotomy and iridec-
tomy we were compelled to enucleate the
ball on account of the dangerous condition
to which the man was reduced, having lost
twenty-five pounds in two weeks. I have
warned this patient of the dangers and given
rather an unfavorable prognosis, in view of
the preceding inflammation, and he is will-
ing to take the chances. The ball is free
from injection, light projection is good and
temperature is normal. I introduce a stop
needle half-way between the centre of the
cornea and its periphery, into the pupil di-
lated with atropine, and thrust it into the
lens. By moving the point of the needle in
. various directions the lens is broken up and
protrudes into the anterior chamber through
the ruptured capsule. If the wound in the
capsule remains open, the cataract will be-
come absorbed ; if not, the operation must
be repeated.

Blindness from Neglected Iritis.

The next case is one of great interest,
and I would ask you to give it your particu-
lar attention. Mary N., thirty years old, is
nearly blind in both eyes from the effects
of old iritis. In order that you may have
a clear idea how this sad condition has re-
sulted from an inflammation* which under
proper and timely treatment would have
been cured, please follow me closely in the
brief consideration of the pathological
changes that have here taken place. In-
flammation of the irides, probably of syph-
ilitic origin, developed two years ago, leav-
ing the vision considerably obscured through
exudation into the pupils. The papillary
margins became totally adherent to the lens
capsules, closing the channels of communi-
cation between the posterior and anterior
chambers, compelling retention of normal
secretion in the posterior chambers with

consequent enlargement of those chambers
by bellying forward of the irides and clo-
sure of the angle between the iris and the
cornea. The adhesions or posterior syne-
chias have been constant causes of recurring
attacks of iritis, each of which caused still
further deterioration of vision. To-day we
find the ciliary vessels injected, the anterior
chambers shallow, the pupils almost oc-
cluded, the fields of vision concentrically
limited and central vision greatly deterior-
ated. Secondary glaucoma is threatening
and will certainly develop unless the chan-
nels of communication are re-established by
an iridectomy in each eye. I find the op-
erations difficult, on account of the firm
posterior synechias, but I am gratified to
see that the new pupils are clear, the exuda-
tion being confined to the papillary mar-
gins. _

This case conveys two important lessons
to you as future practitioners. In iritis,
keep the pupils dilated by means of fre-
quent applications of strong solutions of
atropine ; in circular or annular synechias
perform iridectomy.

Internal Strabismus.

I have to show you, lastly, a case of in-
ternal squint. As you are aware nine-tenths
of all cases of this affection are the result of
hypermetropia, and in most of them one eye
is amblyopic. This patient has hypermetro-
pia and astigmatism, which have been cor-
rected during paralysis of accommodation.
The vision of one, the fixing eye, improved
to normal. The other, the squinting eye, to
one-fifth only. The operation is under-
taken chiefly for cosmetic purposes ; for
although the axes of vision should be made
parallel, I have no anticipation of improv-
ing the vision in the amblyopic eye. By
careful division of the conjunctiva of the
tendon at its attachment to the sclera, and
of the tendinous fibers which sometimes
form broad lateral attachments, the effects
of the operation may be safely regulated ;
and hence I always prefer in both high and
low degrees of apparent abnormal conver-
gence to operate on both internal recti. I
will carefully sever each tendon, using the
small hook, suggested by Stevens, rather
than the large one commonly employed.

— Arecoline, the volatile liquid alkaloid
of the areca nut principally affects the heart.
It is excreted unchanged.

April 4, 1 89 1.

Communications.

377

Communications.

CONSTRUCTION AND ADAPTATION
OF SPECTACLE-FRAMES.1

BY CHARLES HERMON THOMAS; M. D.,

PHILADELPHIA.

The treatment of ocular defects by means
of glasses involves, beside the optical correc-
tion, a factor of no less practical importance
— their mechanical adjustment. The pur-
pose of the present paper is to direct atten-
tion to some of the mechanical aspects of
the subject, particularly to the principles in-
volved, and to certain methods of mounting
spectacle-glasses. The results of the most
accurate refractive measurements may be
entirely vitiated by a faulty position of the
correcting glasses ; not only so, but new
sources of eye-strain may be created by the
very means adopted to remove an existing
fault. Correcting glasses are remedial
agents, just as orthopedic appliances are,
and, as such, are powerful for evil as well as
good, and hence everything belonging to
them falls within the duty of the prescrib-
ing physician. The optical centre of a lens
is generally that part of the glass which we
wish to bring before the pupil, as it and the
part of the lens immediately surrounding it
are freest from aberrations of all sorts — dis-
tort least. Occasionally, however, it may
be desirable to displace this point by a de-
finite amount ; in any case, we should insist
on having the optician carry out our direc-
tions as regards the manner of mounting
and the position of the glass with the same
exactness that he employs in making it of
the proper strength.

The purpose of the spectacle-frame is to
hold a pair of glasses before the eyes in a
definite position and with the least possible
annoyance to the wearer. To accomplish
this, I devised a plan about thirteen years
ago (1878) for the construction of spectacle-
bridges, which plan provides especially for
a wide range of adaptability and the conse-
quent accurate adaptation of spectacles to
individual faces of almost every conceivable
form. No account of the principles involved
'has heretofore been published, so far as
is known, although some special forms of
the bridge, as originally made under my di-
rection, have come into almost universal use,

1 Read before the Philadelphia County Medical
Society, February 11, 1891.

being known throughout the optical trade
under the name saddle-bridge.

Previous to the introduction of this bridge
it was not practicable to .obtain spectacle-
frames suitable for persons with unusual
forms of nose or face or with excessively
prominent eyes or long lashes. Then, be-
side the ordinary ' 'regular bridge," there
was nothing better in use than the " X-
bridge" or the equally unsatisfactory "snake-
bridge," in both of which the combined
weight of the glasses and frames was often
borne directly upon the crest of the nose,
besides which they usually failed to place
the glasses in the correct position before the
eyes. Few could wear either of the latter
with comfort, and those who succeeded often
did so only by padding them with wrap-
pings of thread, thus making an unsightly
cushion at the point of contact with the
nose. The bridge (Fig. 1) under the plan

Fig. i.

Saddle-bridge — typical form (back view).

referred to consists of (1) a nose piece of
arched form, of flattened wire and made to
conform accurately to the shape of the nose
at a definite point of selection, crossing the
bridge of the nose at right angles and so
resting saddle-wise upon it — whence its
name. (2) A pair of adjustable return-pieces
or arms, to the extremities of which are at-
tached the rims or clasps carrying the glasses.
These arms are produced by bending out-
ward upon themselves the limbs of the wire
from which the arch of the bridge has been
formed, and are given whatever special
direction may be required to place the
glasses in the desired position before the
eyes of the individual wearer. The bridge
consists, then, of an arch and two adjustable
arms, which, while fixing the glasses in their
proper position before the eyes, should
furnish as nearly an immovable support as
possible.

The bridge of the nose close to its root
being the basis of support, the spectacle-
bridge must be constructed with reference
to this part. The wire of which it is made

378

Communications.

Vol. lxiv

should be wide at the middle and taper to-
wards each end, so as to make the bridge
widest where it takes its bearing on the sen-
sitive part of the crest of the nose. Nar-
rowing the extremities is of special advan-
tage, as it facilitates any necessary bending
at that point in the process of adjustment.
The sides of the arch should embrace the
nose snugly without undue pressure, and ex-
tend well back towards the inner canthus, but
not far enough to press upon the lachrymal
sac. The saddle, or arch, as thus described,
becomes the fixed support when it rests in
its proper position. This position varies
considerably in different persons, though on
every nose there is usually one best point
which should be sought — the point of selec-
tion, it may be termed. Unless the arch
be adjusted to this particular point, the
wearer will be rendered uncomfortable, and
be continually shifting his spectacles. A few
days' wear may be required to determine
this point definitely in a particular case.
The arch of the bridge, when once adapted
to the nose, is not to be altered in position
during any subsequent regulation or adjust-
ment which may be required ; it is to be
considered as a definitely fixed support,
whose situation is determined, once for all,
by the conformation of the wearer's nose.
Hence the position which the lenses are to
take before the eyes does not directly de-
pend upon the arch, but rather upon the
length and direction of the adjustable arms
attached to it, by variations in which the
glasses may be made to take any required
position. The arms are to be made long or
short, they may be set high or low, pointed
inward or outward, according to the require-
ments of any given case.

If the eyes be specially prominent, and
the bridge of the nose be low, thus causing

Fig. 2.

Saddle-bridge, with horizontal arms ; for prominent eyes and
long lashes.

the lashes to project beyond the level of the
nose, the arms must be made relatively long
(Fig. 2) ; or if the bridge of the nose be low
or flat, and the eyes be placed relatively high
it may be required to direct the arms per-

pendicularly upward (Fig. 3) ; or again, if
the bridge of the nose be prominent, and
the eyes sunken, the arms should be short-
ened, or even reduced to the minimum re-
quired for purposes of lateral and vertical
adjustment.

Fig. 3.

Saddle-bridge, with vertical arms for flattened nose ; eyes high.

The height of the eye as related to the
part of the nose on which the arch rests —
the point of selection — determines the
amount of slant, if any, to be given to the
arms. In practice it is found that in by far
the larger proportion of cases the arms are
nearly horizontal, slanting slightly upward ;
in exceptional cases they slant downward
below the horizontal ; and in rare instances
it is necessary to give them an almost per-
pendicular direction upward. The angle
which the arms make with the clamp or rim
carrying the glasses must vary according to
the directions of the arms, in order to keep
the plane of the glasses perpendicular to the
visual lines. The arm, where it is soldered
to the rim, or the clasp of frameless glasses,
is slightly bent in an upward direction. In-
creasing or diminishing these curves changes
the position of the glasses vertically, and so
compensates for any degree of upward or
downward slant of the arms. This may be
necessary where, for example, the point of
selection of the arch is low down on the nose;
the arms must then ascend vertically to raise
the glasses to a level with the eyes ; but this
position of the arms will cause the glasses
to assume an approximately horizontal di-
rection— parallel to the visual lines — if the
arms meet the rim at or about a right angle,
as they usually do ; in such a case, the arm
must be bent so as to join the lens at an
oblique angle or even lie in the plane of the
lens.

The proper adjustment of a pair of spec-
tacles in ordinary cases is largely determined,
as we have seen, by the length and direction
of the arms. In special cases, also, as in
asymmetry of the face, the compensation re-
quired is to be effected by the same means.
In some cases the arms may need to be of
unequal length. It is of frequent occurrence

April 4, 1 89 1. Communications.

379

that the centres of the pupils on the two
sides are unequally distant from the centre
of the arch. When this condition exists it
is to be met by varying the direction and,
it may be, also the length, of the arms. It
is important from the point of view of the
optician, to note that the principle adapta-
tions of the bridge are preferably to be made
extemporaneously and with the patient pres-
ent. In this way, with a variety of sizes of
the typical form at hand, the skilful mechanic
is able to produce any particular modifica-
tion which may be required without spe-
cially constructing the frames, even for atypi-
cal faces. It is often desirable to take the
conformation of the nose at the point of se-
lection. This may conveniently be done
with lead wire, and the outline thus obtained
may — by " rubbing" — be made a part of
the record of the case.

Variations in the size of the lenses em-
ployed will also necessitate modifications in
the lateral adjustment of the arms. To get
the advantages of a large glass in cases where
the distance between the eyes is relatively
small, the arms will have to be bent inward
— made to approach each other. The oppo-
site direction may have to be given them in
cases of unusual width of face. Lateral
supports, or clamps, which take their bear-
ing lengthwise on the sides of the nose near
the base, as in eye-glasses of the best con-
struction, have occasionally been employed
by others in combination with spectacle-
frames, but usually in form and by mechan-
ical means not wholly satisfactory.

I have recently had made by the Fox
Optical Company a combination of the eye-
glass clamps with the saddle-bridge (Fig. 4),
which is neat and simple in construction,

Fig. 4.

Saddle-bridge: with clamps.

and which combines the advantages of both
in great degree. The attachment is so made
as to preserve the adjustability both of the
bridge and the clamps. The special advan-
tage of this combination is that it distributes
the pressure over a larger surface, and upon
parts better able to sustain it than does the
arch of the bridge alone.

The side-pieces, or temples, should be
specially adapted to the ear with as much
care as the bridge is to the nose in each
individual case. They should be hooked
around the ears for constant use and be so
formed as to retain the bridge at the point
of selection on the nose, and thus secure a
fixed position of the entire appliance. The

Fig. 5.

Adapted temple.

curve of temples, as ordinarily made, is of
far too great a radius. It takes its bearing
behind the ear upon a limited surface, and
so is liable to cut ; it fails to secure a
proper hold to prevent its riding upward,
and it often exerts spring-pressure produc-
tive of pain and injurious to ears and nose
alike.

An adapted temple, designed to fulfil the
above indications and obviate these defects,
has recently been constructed under my di-
rections, and has borne the test of use so
well as to justify its continued regular em-
ployment (Fig. 5). The wire of which it
is made passes back in a straight line to the
top of the ear, at which point it is bent
somewhat abruptly downward, and is made
to conform accurately to the posterior sur-
face of the conch close to its junction with
the head, where it rests in contact with the
ear, bubwithout perceptible pressure. Asym-
metry in the height of the ears, causing
tilting of the frames from the level, is to be
met by a compensating adjustment in the
temples, /. <?., bending the temple upward
on the side of the higher or downward on
the side of the lower ear — or both — and so
dividing the result between the two sides.

The glasses should be slightly inclined
from the perpendicular, so as to bring the
lower edges somewhat nearer the face than the
upper, which is to be effected by giving the
temples the appropriate angulation at their
junction with the hinges when it is imprac-
ticable to change the direction of the hinges
themselves.

The material of the frames should usually
be gold of a good quality and of a weight
as light as is consistent with strength and
steadiness. Steel rusts too readily and is

38o

Communications.

Vol. lxiv

not well adapted to the adjustments fre-
quently required — more especially in the
temples. Silver is so soft as to be almost
worthless.

The lenses themselves should usually be
as large as the face of the wearer permits :
seldom less than 28x38 mm. for an adult,
and not infrequently as large as 29x40 or
30x42 mm., in order that the eyes may be
well covered in their ordinary lateral move-
ments. Such large lenses are hardly more
conspicuous than small ones — especially if
frameless glasses be used — because they
allow the eye itself to be easily seen.
The reflections from the edges of frameless
glasses which are so annoying to some
persons may be avoided by slightly dulling
the polish on the lower edge ; the source
of this reflected light being usually at or
above the level of the eyes, the reflection
enters the eye from this edge alone.

The glasses should be worn as close to
the eyes as possible, without touching the
lashes. Occasionally, where the lashes are
especially long, with feathery or uneven
ends, they should be neatly trimmed with
the scissors — a little procedure best prac-
ticed when the eyes are closed. It is also
to be borne in mind that the subject has an
artistic aspect and that by giving proper
consideration to this phase much can be
done to remove the opprobrium which fre-
quently attaches to the wearing of glasses.
The neat, adjustment of a pair of frameless
gold-mounted spectacles is doubtless the
best that can be accomplished with specta-
cles in this respect.

I have limited myself to a description of
no one form of bridge, nor even of a num-
ber of special forms, but the effort has been
made rather to demonstrate the mechanical
principles involved in the construction and
adaptation of spectacle-frames suitable to all
the requirements of practice. By the means
proposed it is practicable to secure the cor-
rect position of the glasses before the eyes,
together with comfort to the wearer and a
satisfactory artistic effect, thus fulfilling the
three principal indications of spectacle-
mounting.

FRENCH ANTISEPTIC ELIXIR.

Carbolic acid, crystallized 5 parts

Tincture of iodine 10 parts

Essence of citron 3 parts

Essence of mint . 5 parts

Alcohol of 6o°, sufficient to make . . 1,000 parts

UNUSUAL CASE OF PELVIC
ABSCESS.

BY ALEXIS M. LEON, M. D.,

NEW YORK.

A collection of pus in the cavity of the
pelvis may be the result of one or more dis-
tinct inflammatory processes. Primarily the
cause may be (1) an injury, (2) a tuber-
cular process, (3) a suppurative inflamma-
tion occurring in an ovarian tumor for hse-
matocele, or (4) a puerperal infection.

Again, its seat may be (1) in the connec-
tive tissue of the broad ligaments, (2) in the
general cellular tissue of the pelvis, or (3),
as a result of peritonitis, it may be en walled
by peritoneum. A pyosalpinx might also be
considered a form of pelvic abscess.

By far the most frequent form of the dis-
ease under consideration is a cellulitis of the
broad ligaments due to puerperal infection.
Authorities have not considered, however,
that the variety or seat of the inflammation
in the pelvis has much to do with the symp-
toms or course of the disease. The diag-
nosis, it is believed, can be easily made by
the symptoms of septicemia and the physical
signs of the existence of a tumor in the pel-
vis. The termination of the cases, if left to
Nature and if the patient survive the septi-
cemia, is said to be in the discharge of the
abscess either (1) "through the abdominal
walls and saphenous openings, (2) into the
pelvic viscera, as the bladder, rectum, vag-
ina or urethra, (3) through the floor of the
pelvis near the anus, (4) through the pelvis
foramina, either obturator or sacro-ischiatic,
(5) through the pelvic roof into the perito-
neal cavity or (6) into the lumbar region in
the position of the kidney." (J. Braxton
Hicks.)

This general view of pelvic abscess em-
braces both the common and unusual forms
of the disease. The cases presenting, to-
gether with marked constitutional symp-
toms, a palpable abscess in the pelvis, which,
in a short time discharges or is relieved by
operation, are of comparatively frequent oc-
currence. But the cases wherein the diag-
nosis is difficult, and no tumor or swelling is
discoverable by examination are rare. Yet,
probably, both classes are produced under
the same conditions^ and are originally lo-
cated in the same parts of the pelvis. The
interest in these latter cases, therefore, lies
in the fact that occasionally a collection of
pus, due to any of the causes of pelvic ab-

April 4, 1 89 1.

Communications.

scess, may reside in the pelvis and 'escape
detection. And this fact does not seem to
have been very generally stated.

The following case illustrates this diffi-
culty in diagnosis. It is unique, also, in its
chronicity, its spontaneous cure, in the un-
certainty of its seat of origin and in the
course or directions of the burrowing of the
pus.

The patient, 29. years old, a native of
Italy, married and the mother of four chil-
dren, was a stout and strong woman, whose
family history was good and who never re-
membered having been sick, with the ex-
ception of an attack of scarlatina some
years before. Two years ago she had re-
sided in a malarial district. Her last child
was born April 8, 1888. Her labor was
managed by a midwife, and is said to have
been easy and natural. During the last
months of her pregnancy, however, she had
not felt perfectly well. She was languid,
complained of headaches and had noticed
slight puffiness about the face and ankles.
After her labor all progressed favorably until
the third day, when, it is said, fever set in.
On April 16, eight days after the confine-
ment, I saw the patient. At this time she
complained of feverishness and loss of ap-
petite ; the bowels were loose ; she was hav-
ing two or three watery passages per day,
and there was a profuse inodorous white dis-
charge from the uterus. Temperature, 1040;
pulse, 120; respiration, 30. She complained
of no pain and there had been no vomiting.

Examination of the heart and lungs was
negative, except that a few rales were heard
at the bottom of the chest, posteriorly. The
liver was not enlarged ; the spleen was some-
what enlarged. Some tenderness was found,
on deep pressure, over the fundus uteri and
to the left of it. The uterus itself was sub-
involuted and the cervix was lacerated. By
conjoined manipulation, no particular ten-
derness and no tumor could be determined
in the broad ligament or in any part of the
pelvic cavity. The uterus was freely mova-
ble, and movement did not cause pain.

On the following day there Was ameliora-
tion of the symptoms. Temperature, 102°;
pulse, no. The discharge still continued —
profuse and inodorous, and the patient de-
clared she felt no pain. During the three
days following the improvement progressed.
On April 20, examination showed the uterus
to be much smaller in size. The tenderness
had disappeared and the discharge had ceased
abruptly. The fever continued, however, to-

gether with the diarrhoea. The movements
from the bowels were large, watery and bad
smelling. The temperature varied from
ioo^° to ioi^° in the morning, from
102^° to 103^° in the evening, when
profuse sweating would set in, often lasting
through the whole night. Occasionally in
the afternoons the patient would complain
of chilly sensations; though no marked chill
occurred. She now became emaciated and
markedly anemic. Anorexia was complete;
so that nourishment was given with diffi-
culty. The urine was slightly albuminous
and showed a few granular casts and renal
epithelia under the microscope. This con-
dition of the patient persisted during the
next three weeks with but little change.
The temperature gradually sank ; so that by
the end of this time it did not rise above
ioo° in the morning, or above 10 1° in the
evening, and was sometimes lower ; and the
pulse-rate fell correspondingly. Antipyret-
ics, it may be stated, had little or no effect,
however. The sweatings, too, became less
frequent and of milder character. Digital
examination showed the uterus to be of nor-
mal size and in proper position, freely mova-
ble and its movements free from pain. No
tumor could be found in the pelvis, and no
tenderness was elicited by bimanual touch.
The result of rectal examination with the
finger was also negative.

By May 15, the albumin and casts disap-
peared from the urine and the morning tem-
perature fell as low as 990. The patient
made efforts to sit up, but was unable to re-
main out of bed. Under treatment the
anemia became less marked and the appe-
tite began to return ; so that occasionally
she could eat a little solid food. She did
not gain strength, however.

About May 23 she called attention to a
stiffness and pain in the left groin. This
was occasioned by straightening out the leg.
There was no swelling or redness about the
parts and no tenderness either about the ab-
domen or leg. The thigh was kept parti-
ally flexed and rotated inwards, and the
pain made it impossible to fully extend the
leg. When standing or attempting to walk,
the pelvis would be tilted to one side and
only the toes of the left foot would touch
the ground. The amount of pain, and
stiffness and the flexure of the thigh varied
from day to day. On June 5, careful ex-
amination (which had been employed daily
since the appearance of the symptoms about
the leg) revealed some fulness in the left

382

Comm unications.

Vol. lxiv

lumbar region, but no fluctuation. Deep
pressure over this spot caused some pain.
This swelling increased during the next four
or five days and could readily be mapped
out — about four inches in diameter, not pro-
jecting far outwards and causing no discolor-
ation of the skin.

It was proposed to introduce an aspirator
needle, and if pus were withdrawn to cut
down upon the needle and drain the ab-
scess. The patient would not consent to
any surgical procedure and even refused to
be aspirated. On this account the case was
out of observation from the nth to the
25th of June. On this day the patient's
general condition was found to be about as
before. The swelling in the back had in-
creased somewhat, and external to the quad-
ratus lumborum. The skin was red and the
tissues hardened and infiltrated. This redness
extended .slowly forwards from day to day
along the abdominal wall, in a line parallel
to the crest of the ilium, until the groin was
reached. The skin here became thin and
on July 3 opened, giving vent to about one
quart of thick yellow pus, which continued
to flow in large quantities for several days.
Again the patient refused surgical aid and
would not allow even probing of the sinus.
At this time her fever disappeared, her di-
arrhoea stopped, her appetite returned and
the flexure of the thigh began to grow less
and less. The abscess continued to dis-
charge for three or four weeks. From its
situation it drained itself, and so was com-
pletely cured in that time. The patient
grew strong and well and the flexure of the
limb, after a while, entirely disappeared,
allowing the patient to stand perfectly
straight and to walk without difficulty. On
June 25, 1889, she was delivered of a
healthy child, after a normal labor.

It will be observed in reviewing this case,
that distinct signs of pelvic inflammation
occurred at no time except during the first
few days, when the discharge from the uterus
was present, and the signs were, then,
more of endometritis than of cellulitis ; that
the abscess was probably in existence six
weeks without presenting any local signs,
s.uch as pain, tenderness, swelling etc., and
at the end of this time the only sign was
the flexure of the thigh and the pain on ef-
fort of extension ; that it was two weeks longer
before the fulness in the lumbar region oc-
curred, and two weeks longer still before the
skin showed positive evidence of the inflam-
matory process beneath it ; and that it was

nearly three months in all before the ab-
scess was discharged. These general feat-
ures may explain why the diagnosis was not
made positive until the appearances in the
loin presented themselves. Previous to this
time the picture was one of continued fever
with diarrhoea, and more or less septic infec-
tion ; and it was recognized that such con-
dition might be produced by typhoid fever,
acute miliary tuberculosis, or an abscess
causing pyemia.

It should be stated that this patient was
several times examined by different consult-
ants, without their being able to locate any
lesion in the pelvis, notwithstanding the
fact that attention was directed at first to the
pelvis as the seat of the disease and repeated
efforts were made to find an abscess whose
existence was suspected. The question of the
exact location of the primary abscess is, on
this account, not settled with certainty.
It is likely, however, that its seat was in the
left broad ligament. Its small size in the
beginning, together with the fact that its con-
tents, were drained through the uterus, would
explain why no tumor could be appreciated.
And there must have occurred early in the
history of the case adhesions between the
abscess and the posterior wall of the pelvis
as high up as the brim, and perhaps higher.
In this manner the tumor, as it grew in size,
was pulled further and further out of reach
by any ordinary examination ; though it is
possible that examination by the introduction
of the hand into the rectum might have
given some idea of its existence. It is con-
jectured, therefore, that the abscess began
in or near the fimbriated end of the Fal-
lopian tube — since, in this location, it could
discharge through the tube (as it seemed to
do at first) and, being movable, could form
adhesions posteriorly.

Cases similiar to this one are reported by
Dr. Skene, in his text book of Diseases of
Women, and reference to them may supply
the actual appearances presented by dissec-
tion. Dr. Skene relates these as cases of
" pelvic cellulitis, with certain complications
which, so far as I know, have not been no-
ticed or described heretofore." The first
patient, 37 years old, and the mother of six
children, got up the fifth day after confine-
ment, and was taken sick on the ninth day.
She was in bed, but without medical attend-
ance for six weeks, when she was seen by a
physician who found all the signs of pelvic
cellulitis of the left broad ligament and
symptoms of septicemia. Four weeks later

April 4, 1 891.

Comm umcations.

383

she was admitted to the hospital for opera-
tion. She was* then in a very enfeebled
condition, her temperature varied from 1000
to 1030, and there was flexure of the left
thigh. The abdominal symptoms had sub-
sided. Laparotomy was done by Dr. Skene,
•< and a most careful exploration of the pelvis
was made by the touch. The left broad
ligament was considerably thickened and
much less elastic than it should have been,
showing the effect of the inflammation,
which had subsided. Not the slightest sign
of any point of suppuration could be found,
but by the bimanual touch, with the fingers
of one hand in the abdominal cavity and
those of the other on the outside, I detected
obscure fluctuation, indicating that an ab-
scess or sinus extended along that side of .the
abdomen. The location of the pus having
been clearly marked, the wound in the ab-
domen was closed and an incision made in
the side down to the pus." The cavity,
which was narrow at its lowest end, was
found to extend to the diaphgram. It
was washed out and a drainage-tube was in-
troduced. The patient passed out of obser-
vation one month after the operation ; at
which time the wound was still discharging
pus.

The second patient, 35 years old, gave a
history of illness (fever) from the day of the
birth of her fifth child. She was seen four
months after confinement, when symptoms
of septicemia were present, and there was
also flexure of the right thigh. The uterus
was apparently normal and movable, but
high up and on the right there were evi-
dences of inflammatory products. Explora-
tions with the aspirator failed to discover pus.
Laparotomy was performed, and pus was
found in the right iliac and lumbar regions.
The patient died three days later. " The
autopsy showed that the abscess cavity ex-
tended from the right broad ligament up-
ward behind the kidney and to the right of
the spinal column to the diaphragm. The
psoas muscle was involved in the abscess, but
therewas.no bone disease, and it was the
opinion of all who attended the autopsy that
the disease began as a cellulitis of the right
broad ligament."

These cases resemble the one I have the
privilege of reporting in the following
points. All began (probably) as a localized
cellulitis of one broad ligament ; sooner or
later adhesions were formed between the ab-
scess and the posterior pelvic wall ; and the
pus, then, tended to burrow towards the sur-

face through and between the muscles. The
track thus made by the burrowing pus, it
will be noted, tended to close up and heal
as the sinus advanced ; so that, by the time
the site of the abscess was upon the psoas
muscle, the suppuration in the broad liga-
ment had ceased.

These cases are certainly rare (I have not
found any others reported), and the lesson
of special interest they teach is, that a pel-
vic inflammation may result in an abscess,
which, even early, may occupy a position out
of reach by any ordinary examination ; and
such a condition may be difficult of diag-
nosis.

DOUBLE OPTIC NEURITIS OF MALA-
RIAL ORIGIN.1

BY FRANK W. RING, A. M , M. D.,

NEW YORK.

MEMBER OF THE NEW YORK ACADEMY OF MEDICINE ;
ASSISTANT SURGEON, MANHATTAN EYE AND EAR
HOSPITAL, ETC.

January 12, 1888, Mrs. F. K. W., fifty-five
years old, consulted Dr. C. W. Packard, of
New York, on account of failing vision. The
patient was referred to me. She complained
of a blur in the upper field. Upon exami-
nation I found moderate peripheric impair-
ment of the field in the left eye. Right
visiou=|J W.+ .75. Left vision, fg-f-W.
-f-1.0. Ophthalmoscopic examination neg-
ative.

January 13. The following morning the
patient was led to my office by a daughter.
R.V.=5 fingers ; L. V.r=perception of light.
She had retired the preceding evening, see-
ing as well as when at my office in the morn-
ing, and awakened practically blind. Right
field with candle, quick and good. Ophthal-
moscope showed marked papillitis, oedema
of the disc, evident infiltration in and near
the optic nerve, veins slightly enlarged, no
pulsation, arteries about normal, outline of
disc somewhat obscure, slight tortuosity of
veins, no retinal changes apparent. Ap-
proximate swelling of 3^ dioptrics of nerve.

Thinking the case of unusual interest, I
took the patient to Drs. Agnew and Webster.
They corroborated my diagnosis and ex-
pressed surprise at the rapidity of loss of-
vision.

1 Read before the New York State Medical Society,
February 3, 1 89 1.

384

Communications.

Vol. lxiv

January 18. Perception of light in each!
eye. January 22. V.=nil.

January 30. Sixteen days from beginning
neuritis, complains of stiffness in knees.
Has more or less difficulty in walking.
When reclining, finds it impossible to turn
over. This affection of the joints came on
suddenly and in four days the patient could
not rise from a chair without assistance. By
being supported she could shuffle along the
floor. On striking her quickly under the
hip, the limb would fly up, and by this action
she could ascend stairs. There was com-
plete paraplegia. Exaggerated reflex, ankle
clonus. In fact, she lost all locomotive power
of the lower extremities. The skin felt thick
and numb. Bladder unaffected.

February 5. Patient for the first time in
fourteen days has perception of light. Has
enough control of her limbs to enable her
to move about with the aid of a chair.

February. 22. Vision improving. R. V.=
10 fingers. L. V.=5 fingers. Color percep-
tion lost as far as could be ascertained. Six
days later can distinguish bright red. Field
good, retinal vessels slightly diminished in
size.

March 7, 1889, thirty-nine days from be-
ginning paraplegia, is able to walk. R. V.=
; L. V.— -gfo-. Field good, color sense
diminished. Nerves pale, otherwise the
fundi are normal, with the exception of slight
decrease in caliber of arteries.

April 7, 1889. R. V.=H ; L- V.=T%V
Color sense varies ; calls red brown. Left
nerve whiter than right.

April 17, 1889. Stiffness in knees en-
tirely gone. Color perception impaired.

February 14, 1890, two years from in-
itial papillitis, R. V.=4fW.+.5 L. V.=
f-g— I-W.-I-.5, which is a return to the origi-
nal vision before the neuritis. Color sense
decidedly impaired.

December 29, 1890, last examination and
nearly three years from beginning neu-
ritis, R. V. =foW.+.75 ; L. V.=f£+W.
4~i.o. Ophthalmoscopical appearance: Rt.
=nerve bluish white, veins normal, arteries
slightly diminished ; no tortuosity ; lamina
cribrosa plainly visible. Left=nerve bluish
white, otherwise the fundus has a nor-
mal appearance. Color sense : pale yellow,
green, or pink, looks drab ; cannot distin-
guish green from blue. Right eye=the
field for yellow is very much contracted. A
little less for red, and less than normal for
blue. Left eye=yellow visible in cen-
tral vision only. Red, field tortuous in out-

I line and very much diminished. Blue, con-
tracted much less than in right, with a large
scotoma in upper field. Field for white
perfect in each.

The patient , received a nutritious diet,
iodide of potash, arsenic and strychnia.

During the entire illness, the patient was
free from pain, slept well, appetite good, no
nausea, no headache. The urine was ex-
amined several times, with negative results.
No specific history. She has had eight-
children, all healthy, no miscarriages.
Passed the climacteric at forty- two years.
Mrs. W. has been a decidedly healthy woman,
with one exception, and that exception is
best expressed by the following extract from
a letter written by Dr. Packard : "So far as
I know, Mrs. W. has no specific taint, but
she has a decided malarial taint. I have
treated her during the past few years for
several malarial attacks, accompanied with
fever, characterized by periodicity, and that
yielded to quinine. At such time she has
suffered from gastralgia and enteralgia that
I believed to have a malarial basis."

Resume. — An apparently healthy woman
consults an oculist because of a slight blur
in. her vision. He finds both fundi normal,
pupils slightly dilated and responsive to
light. During the same night she becomes
practically blind. The only apparent cause
is a marked papillitis. This continues to be
an idiopathic affection for sixteen days, then
she has a paraplegia. The vision becomes
totally lost. In fourteen days, upon a relax-
ation of the paraplegic symptoms, the sight
gradually returns ; and in two years is nor-
mal, with a decided defect in color vision. .

Was the neuritis an idiopathic affection,
or was it concomitant to the paraplegia, and
what was the existing cause of both ?

Optic neuritis is often accompanied with
headache, nausea and vomiting; and it usu-
ally occurs from some intra- cranial disease,
tumor or other adventitious product.

With tumor the progress is inclined to be
slow and the prognosis grave. To be brief,
let us exclude tumor as a cause, also menin-
gitis and sclerosis and Bright's, for palpable
reasons.

Retro-bulbar neuritis (von Graefe). — A
condition in which we may have a sudden
loss of vision. The pupil is usually widely
dilated and not responsive to light. -The
disc becomes slightly elevated. Arteries
small, veins tortuous.

"In retro-bulbar neuritis in the acute
form, we have headache, orbital pain, in-

April 4, 1 89 1.

Communications.

385

creased by movement of the eye and pres-
sure. Serous effusion of the optic disc and
retina due to compression of retinal ves-
sels." (Knapp.)

In Noyes's admirable treatise on the eye
(1890) he describes a toxic retro-bulbar
neuritis, where the atrophy succeeding the
inflammation is due to a lesion of the axial
fibers of the nerve, and cites a case of
Uhthoff's, where he localizes the character
of the lesion in color scotoma. If there is
a retro-bulbar neuritis due to tobacco and
alcohol poisoning, why may there not be a
similar affection due to malarial poisoning?

There are certain affections due to the
action of malarial poison upon the system.
There' is a bacillus malaria particularly af-
fecting the spleen. This bacillus has been
found in the blood during the fever, causing
marked changes in it.

Let us turn our attention to another cause
of papillitis, denied by some, i. e., disten-
tion of the sheath, or hydropsia of the optic
nerve, which is a serous effusion into the op-
tic sheath coming from the cerebral arach-
noid space.

"A fluid effusion into the arachnoid
space and increased intra-cranial pressure
are always associated with an accumulation
of fluid in the intra-vaginal sheath, which
oedema will cause a swelling of the optic
nerve." (Schwalbe.)

"The intra-cranial pressure must force
the fluid from the arachnoid space along
the sheath of the optic nerve into the canal-
like system present in the lamina cribrosa,
causing swelling and congestion of the
disc." (Pagenstecher.)

Bull says, loss of vision from isolated
papillitis alone is never sudden, and that
distention of the sheath alone is not suffi-
cient to produce papillitis, but may inten-
sify it. Hughlings Jackson is of the same
opinion, and the latter also says there is
nearly always a visible stage of neuritis be-
fore sight fails.

Macnamara, in his text-book of disease
of the eye, cites a case precisely similar in
many respects to the one in question. A girl,
aged thirteen, was attacked with intermit-
tent fever, after which she had paralysis of
the lower extremities, and a partial inability
to move the right arm. Pupils dilated and
insensible to light. Optic papillae swollen
and hazy, with serous effusion into the nerve
and surrounding tissue. She became quite
blind. Her recovery was gradual and per-
fect, both as to the paraplegia and vision.

He remarks that this is an example of a class
of cases not very uncommon in India, and
depends upon malarial poison affecting al-
terations in the blood. He gave, as a di-
rect cause, a serous effusion into the optic
thalami and corpora striata. The pressure
thus exerted on these nerve centres, inter-
fering with the volition of the patient over
the affected limbs, and the serous effusion
or exudation into the papilla and pressure
upon the optic nerve fibers causing the loss
of vision.

I offer this paper as a contribution to the
literature on optic neuritis. I am aware
there may be double optic neuritis with and
without loss of vision, also with gradual or
sudden loss of vision. But, as a rule, there
is a stage of neuritis visible before the blind-
ness. Here the fundi were known to be nor-
mal a few hours before an almost total loss
of sight.

101 Park Avenue.

ADHESION OF SOFT PALATE TO
PHARYNX; OPERATION; CURE.1

BY HAL FOSTER, M. D.,

KANSAS CITY, MO.

LARYNGOLOGIST TO ALL SAINTS' AND MISSOURI PACI-
FIC R. R. HOSPITAL.

The patient, a man 40 years old, by oc-
cupation a seaman, and a native of France,
applied to me November, 1889, complain-
ing of shortness of breath. He wanted to
know if anything could be done to restore
his speech. He was able to utter a sound,
but he could not turn this sound into
words.

He had contracted syphilis twenty years
before. He was married, and his wife had
miscarried three times. One child was born
living, and is now twelve years of age, and
apparently in fair health. This communi-
cation was made on paper, as the patient
was unable to talk. His nose was entirely
eaten away down to the nasal bones, so that
all that remained was a small opening in the
face. The nasal fossae would fill up with
large green crusts, which he dislodged with
a hair-pin every morning and evening. The
stench from these crusts was exceedingly
offensive. I took out two, which were fully
ten and a half inches in length, and shell-
like in form. The patient's mouth was so

1 Read before the Medical Society of the Missouri
Valley, December, 1890.

386

Comm unications.

Vol. lxiv

closed up by syphilitic adhesions that I
could pass in my two fingers only with great
difficulty, by stretching the mouth to its
utmost capacity. A laryngoscopic view of
the throat at this stage was impossible.

The first operation I undertook was
enlargement of the mouth, which was done
by means of a knife. Afterwards little
wooden stretchers or gags were inserted, to
prevent the wounded surfaces from growing
together again. After this was accomplished,
I found that the uvula and the lower part of
the soft palate were entirely destroyed, and
the remaining part of the palate was firmly
adherent to the pharynx, so that the upper
pharynx was completely separate from the
lower pharynx. The complete occlusion of
the two pharynges is extremely rare. I have
met with it in only three cases. It is by no
means rare in tertiary syphilis of the throat
to find a partial adhesion of the parts ; but
it is extremely rare to find a complete ad-
hesion. Often a small opening can be dis-
covered, sometimes only large enough to
admit a small probe, but still large enough
to admit a small current of air.

In this case I covered the lower pharynx
with iodoform and filled the nasal fossae with
water. My iodoform was not moistened.

I now determined to liberate the palate
from the pharynx, so that I could give my
patient nasal breathing, and also give the
nasal cavity an outlet into the throat. I first
passed a silver probe down through the nose
to the pharynx, and with a tenotomy knife
cut where the palate bellied. After I had
thoroughly separated the palate from its at-
tachment, with no little difficulty, the parts
were sprayed with a solution of tannin. No
anaesthetic of any kind was used. I now be-
gan to pass the largest sound I could obtain
through the opening into the pharynx. I
afterwards had a sound made after the fol-
lowing description. The body of the in-
strument was about two inches in length,
and it was blunt-pointed at the end, and
gradually as it reached the base, it was some-
what similar to a triangle in shape. The
base was an inch and a half in width. To
the broad end of the instrument was attached
a long handle, so that it could be manipu-
lated in the throat. I found that with this
instrument I could keep the opening the re-
quired size and prevent it from closing. Had
the wound not been treated with sounds after
cutting, the opening would have filled up in
a very short time.

This is a peculiar characteristic of syphil-

itic tissue, where we seek to enlarge an open-
ing, whether it be in the pharynx or nasal
fossae. In a case of nasal stenosis now under
observation, I have seen the parts close com-
pletely after opening the nasal canal three
times, every time giving the patient complete
breathing space, taking out at each operation
a large piece of cartilage at the point of union.
In a short time the parts were firmly adherent
again.

The parts in this operation healed nicely,
and within four days absolutely no pain was
felt from the passage of the instrument. An
examination of the larynx showed complete
paralysis of the abductors of the vocal cords,
and the whole mucous membrane lining the
larynx was in a state of hyperemia. This ac-
counted for the loss of voice. At the be-
ginning of my operations, I had placed my
patient under iodide of potassium ; but I
was compelled to give him 90 grains, three
times a day, before I could produce any ef-
fect. I do not consider this an unusually
large dose in cases of tertiary syphilis of the
throat and nose, and have often given larger
doses and maintained them during a longer
time. This was given in Vichy water ; his
stomach stood it nicely, and I kept this
amount up for two weeks, when it was gradu-
ally reduced. Later I gave him only tonic
doses. Within a month and a half from the
time of the first operation on the- mouth, the
patient had entirely regained his voice, and
had gained something like fifteen pounds
in weight. His voice was now quite clear
and strong. I had an artificial nose made
for him by Tiemann & Co., while I was
attending the Manhattan Throat Hospital
of New York last August, which supplied his
missing member very well. I gave him one
of the sounds above described, and told him
to use it once or twice a week for a year. I
often hear from him, and he reports the
breathing through his artificial member ex-
cellent, and his voice good.

Syphilis from a Bite. — A patient was re-
cently shown to the Berlin Medical Society
with syphilis from the bite of a man. The
bite was on the lip. The wound healed in
two or three days; but in six weeks it re-
opened and the lip became greatly swollen.
Five weeks later there was an ulcer on the
inner surface of the lip with great swelling
and induration round about ; the submaxil-
lary and cervical glands were much enlarged.
After some time a typical syphilitic eruption
made its appearance.

April 4, 1 89 1.

Periscope.

387

Periscope.

Some New Medicinal Soaps.

In its Periscope of Dermatology, the Ed-
inburgh Medical Journal, February, 1891,
says : Eichhoff of Elberfield, who has al -
ready added to the list of medicinal soaps
some of real value, and embodying some
valuable improvements, has continued his
researches into the subject. He reviews the
conditions of the skin in which soap
treatment is to be recommended. This is
specially indicated in cases where the skin is
unctuous. The soap removes the excess of
fat, while the incorporated drug, if suitably
chosen, acts at the same time on the disease
itself, and, as Eichhoff thinks, can chase the
offending organisms from the ducts of the
cutaneous glands. He quotes in support of
this the treatment by medicinal soaps of psor-
iasis, which he regards as parasitic, and of
acne, the pustules in which are now believed
to be due to the pyogenic micrococci. He
praises also the cleanliness, the innocuous-
ness, and the cheapness of this method with
the vigor of a true partisan.

Soaps may be, for convenience, divided
into — 1. Alkaline, containing an excess of
free alkali ; 2. Neutral, in which all the
alkali is combined with the fatty acids ;
3. So-called acid soaps, which are pre-
pared either by the addition of weak acids,
or by being superfatted, and eventually
react faintly acid. The alkaline may be
used to remove masses of scales ; while in
acute inflammations of the skin, or when
it is irritable, the neutral or superfatted
soaps are to be employed. The superfat-
ting of the new soaps consists of 2 per cent,
lanoline and 3 per cent, olive oil, and they
are made by Ferdinand Miihlensat Cologne.
Among these new soaps may be specially
mentioned a menthol soap, containing 5 per
cent, of menthol. The local anaesthetic
influence of menthol on the skin is well
known, and the principal use of this soap
will probably be found in lessening pruritus.
Eichhoff cites some cases where cure resulted
in pruritus senilis and pruritus genitalium.
He recommends that, should the soap be em-
ployed for the head or face, the eyes should
be kept firmly shut, else an unpleasant,
though, he says, not dangerous, coldness of
the conjunctiva is perceived. A 5 percent.
salol soap is one which may prove useful in
psoriasis. The salol when so used with
water breaks up into carbolic and salicylic

acids, and these in their nascent condition
may be expected to act with energy. A
5 per cent, resorcin soap promises to be of
advantage in cases where this valuable drug
is indicated.

Ligation of the Saphena Vein in
Cases of Varicose Veins.

The British Medical Journal (Supple-
ment), January 24, i8oi,says: Professor
Trendelenburg, of Bonn, in a contribution
to the last number of the Beitrage zur klin-
ischen Chirurgie, advocates double ligature
and division of the large saphena vein in the
treatment of varicosity of the lower limb in-
volving both the trunk and branches of this
vessel. In some remarks on the pathologi-
cal anatomy of varicose veins it is pointed
out that the most prominent and dilated por-
tions of the affected vessel are found below,
and not, as is generally supposed, (? Re-
porter) above the valves. The walls of the
vein, being weaker here than at any other
point, yield to the pressure of the blood when
the valves cease to act. According to Tren-
delenburg, most of the blood which fills the
dilated trunk and branches of a varicose
saphena vein is derived from above, and has
descended from the iliac veins and the vena
cava, and but a small portion of it comes
from the capillaries of the foot and leg.
When the subject of varicose veins exchanges
the horizontal for the vertical position a
large quantity of blood at once descends
from the large veins of the abdomen into
the dilated veins of trie lower extremity.
It is this free downward flow of blood along
large and dilated vessels deprived of valves
that causes the profuse and dangerous hem-
orrhage so frequently produced by a breach
of the surface of the leg when in a condi-
tion of varicosity. The conclusion that the
troubles and dangers of those suffering from
varicose veins of the lower limb are due for
the most part to the fact that the varicose
branches of the great saphena, in conse-
quence of associated dilatation of the trunk
of this vein, are no longer separated from
the vena cava by valves, has led Trendelen-
burg to treat varicosity by permanently ob-
structing the saphenous trunk at one point
with the view of preventing the descent of
blo'od from the abdomen, and thus relieving
the veins of the leg and foot from the ab-
normal pressure. After obstruction of the
flow of blood through the main trunk of

388

Periscope.

Vol. lxiv

the great saphena, the venous circulation
will be maintained by communicating
branches between the superficial and deep
veins. Reference is made to a series of
cases in which good results followed such
treatment, which consists in exposure of the
vein near the saphenous opening, in the
application of two catgut ligatures, and in
the division of the vessel between them.
It is acknowledged in this paper that occlu-
sion of the great saphena is by no means a
novel plan of treatment in cases of varicosity
of the lower extremity. It was practiced
by Paulus ^Egineta, and advocated by
Ambroise Pare, and at the end of the last
century Sir Everard Home performed this
operation on twelve cases with very unfa-
vorable results.

Vaccination of Children.

Dr. E. F. Brush, in a paper on Infant
Hygiene, read before the Jenkins Medical
Association and published in the Archives of
Pediatrics, February, 1891, makes some per-
tinent remarks on the subject of vaccina-
tion, saying that this important hygienic
measure, if physicians are not more careful
in regard to the operation, is liable to be
brought into disrepute. In 1883, while Dr.
Brush was occupying the position of attend-
ant physician to the New York Infant Asy-
lum, he examined the arms of one hundred
and ninety-one children who had been vac-
cinated and deemed sufficiently protected.
Of these he found only thirteen with a well-
defined, pitted scar ; only one had two well-
defined, round and pitted scars ; fifty-one
had no scars at all, although they had been
vaccinated ; the remainder had scars in va-
rious forms, shapes and colors ; no vaccina-
tion had been performed for three months
previous to the examination ; nevertheless,
some of the arms were still crusted. The
majority of the older scars contained cica-
trices, long, irregular, varying in dimensions
from one inch to two inches ; some had
purple ridges in the centre, some fed, others
had cavities blue and red with puckering
edges. Many of these children were vac-
cinated sucessfully, showing that, notwith-
standing the severe and destructive processes
that had previously taken place in the arm,
they were not protected. A baby should
be vaccinated at four months old, unless it
is necessary to do so earlier. Physicians
should see the child on the fourth and eighth
day after the operation, and satisfy them-

selves that there is a proper formation of a
vaccine vesicle. Vaccinations are constantly
seen that are reported to have taken because
sores have been generated by the operation
which in no way simulate the vaccine
vesicle.

It is preferable to vaccinate a child at four
months, because this is usually before denti-
tion takes place. In regard to dentition, it
is an exceedingly dangerous thing for the
physician to teach the mother that any se-
vere attack of illness is due to teething, for
she is very apt to delay the physician's at-
tendance on her child that is ill during the
dentition period. Dentition, perse, is not
the cause of any severe attack of illness.
The most severe condition due to teething
alone is a slight ephemeral fever, a cough or
an eruption, not in any way making the
child ill enough to require medical attention.
Of course, the irritation that is sometimes
caused in the gums will make more severe a
disease due to some other cause, and the
child, during dentition, that is at all affected
by this normal process, is more apt to be
attacked by the prevailing diseases.

Washing in Cold Weather.

The Nighti?igale, February 14, 1891,
says : If your face chaps easily and is un-
comfortable in cold weather, try the follow-
ing : Get a fine quality of Indian meal.
Take a handful of this meal and pour boil-
ing water over it. Then add enough cold
water to reduce the whole to a bearable tem-
perature. Take into your two hands some of
the dry meal, wet this in the water as -pre-
pared and scour the face with it, using it
upon the hands as you would use the lather
of soap. Finally, rinse the face in the
specially prepared hot water and dry. Use
the towel, sparingly, so that the face may
dry partly by evaporation. If afterwards
you pass the hand over the face you will be
surprised at the smooth comfortable feel
which has been given to your irritable skin.
You will also find it less sensitive to the
wind and cold.

What is accomplished by this process?
In the first place the skin is thoroughly
cleansed by the handful of uncooked meal,
the little particles of which scour out the
sebaceous ducts as no amount of soap can
do. It is almost impossible to cultivate a
crop of black-heads and adhere to this treat-
ment. In the second place the meal over

April 4, 1 89 1.

Periscope.

389

which the boiling water was poured has
been partly cooked so that a soupy consis-
tency is given to the water in which your
face is bathed. This dries in a film over
the skin, protecting cracks and rendering it
much less likely to catch dust. Try this
method of taking care of your skin. It is
not at the time so enjoyable and does not
seem so clean as the old soap and water
method, but the results are far superior.

Multiple Herpes Zoster.

In a Clinic Report in the Medical Chron-
icle, February, 1891, Dr. James Mackenzie,
of Victoria Hospital, Manchester, says : On
account of the rarity of such cases the follow-
ing appears worth recording.

Mrs. L., aged 51 years, a widow lady in
comfortable circumstances, tall and of full
habit of body, had been attending four days
at a bazaar, when, at times, from over-crowd-
ing, the atmosphere was very impure. Pre-
vious to this she had been in good health.
The second morning, after attendance at
the bazaar, she felt intense smarting pain in
the right armpit. On looking there she ob-
served a few small blisters. A few hours
later a similar pain was felt in the left arm-
pit, and there also a few blisters appeared.
During the night and next day there was
severe pain shooting down the inner side of
both arms, as low as the elbow. Occasion-
ally a feeling of numbness and pain ex-
tended down the ulnar half of the left fore-
arm, and to the two inner fingers. Pain also
appeared to shoot down the chest, as low as
the level of the nipple. There was also
pain, in the throat and in the nose. Shoot-
ing, burning pains were also felt on the
inside of the thighs, and small blisters ap-
peared on both thighs and on the nates.

I examined her on October 19, 1889,
four days after the beginning of the
complaint. In addition to the sensations
which she voluntarily described, I found
pain and tenderness along the whole spinal
column, much aggravated by the slightest
pressure on the separate vertebrae. This was
worst over the two lowest cervical and upper
two dorsal vertebrae. In each armpit there
was a large patch of vesicles occupying the
hollow of the armpit, about three inches in
diameter. On the right side there was a
thin irregular streak of papules descending
on the side of the chest as low as the level
of the nipple. Two days after, these had
developed into small vesicles full of clear

transparent fluid. On the edge of the pos-
terior fold of the axilla and descending for
a few inches towards the inside of the arm
was another streak of papules that likewise
in a couple of days developed into a crop of
vesicles.

On the inner aspect of each thigh, about
six inches below the pubes, there was an
irregular oval patch of vesicles. The patch
on the right thigh measured two inches by
one, while that of the left was somewhat
smaller. The patches occupied similar posi-
tions on each thigh. To the inside of the
right fold of the buttock, two inches from
the middle line and midway between anus
and vagina, was a small irregular red patch,
but no papules nor vesicles. She com-
plained of the same peculiar pain here as
occurred in the armpit, arm and thigh.
She also felt the same pain in the identical
spot on the opposite side, but was extremely
surprised when I said there was no eruption.

There were also two raw sores about the
size of a split pea on either side of the sep-
tum of the nose, about an inch from the
external opening of the nostril. She said
that these had been small blisters, and the
pain had been so annoying that she had
burst them in the hope of getting relief.
The fauces were sore, and looked red in
patches, but there were no vesicles.

The illness pursued a very severe and
painful course for the next two months.
Every few days there would be recurrence
of the pain, causing sleepless nights. The
situation of the pain was most frequently
down the inner half of the left arm, forearm,
hand, and two fingers (little and ring fin-
gers). Less frequently and less severely the
pain would strike down the same places on
the right arm. Occasionally the pain oc-
curred in the face, generally in the cheeks,
both at once and on identical places, and
also on the inner side of the upper part of
the thighs and upper part of the chest.
On all those places there developed, after
an attack of the pain, an eruption, some-
times limited to one or two papules, some
of which developed into vesicles — sometimes
a crop of vesicles covering an area the size
of a florin, sometimes a streak extending
to one or two inches in length.

These attacks gradually diminished in
intensity, and she was progressing favorably
when, on the 4th of April, 1890, she had
a severe attack of pain in the face, followed
by an eruption of vesicles situated on both
upper eyelids, around both nostrils, and on

390

Periscope,

Vol. lxiv

both sides of the lower lip. After this
attack subsided she had no recurrence of
any of the previous severe attacks, but dur-
ing the next six months, after any occasion
when she had any mental bother or worry,
she would feel on both cheeks the same
peculiar stinging pain, which would con-
tinue from five to nine hours and termi-
nate with the eruption of one or two papules.
These would either remain stationary for a
day or two and disappear, or develop into
vesicles. She reckoned there would be at
least twelve such attacks, and they ceased ex-
actly twelve months from the onset.

During the attacks of pain affecting the
left hand, arm, and, in a less degree, the
right also, she complained of the loss of
power in her hand and arms, so much so
that she felt unable to knit or sew. I
could never satisfy myself of any distinct
paresis.

Kola Nut of Africa.

Mr. P. L. Simmonds, in the American
Journal of Pharmacy, December, 1890, gives
the following interesting account of the kola
nut, which is now attracting so much atten-
tion.

This seed or fruit, known under a variety
of names in different parts of Africa, as
kola, gourou, ombene, nangone, kokkoro-
kon and matrassa, has only within a few
years come into important notice as a food
stimulant. Twenty or thirty years ago, it
was incidentally described by Dr. Daniel
and Prof. Attfield, in the Pharmaceutical
Journal, but its extensive employment in
Africa was comparatively little known. Al-
though its use as a stimulant, in the place of
coffee, tea, mate and coca by other people,
had been very general, almost from time
immemorial among the various tribes of
Equatorial Africa, the product was little
known in Europe.

The opening up of Central Africa and
the increase of trade on the West Coast has
demonstrated its importance as a local article
of commerce, and its chemical advantages
have become duly appreciated. There are,
however, two distinct products; one, the
true kola nut, the product of Sterculia acu-
minata, popularly known as the female kola,
and the false, or bitter kola, designated as
the male kola. The true kola tree grows
spontaneously over the range of Western
Africa comprised between the io° of N.
latitude to the 50 S. latitude. This tree, to

which attention has of late years been promi-
nently directed by the authorities of Kew,
has been introduced from time to time into
India, Ceylon, Seychelles, Mauritius and
Cochin China in the East ; Zanzibar and
Sidney, and in French Guiana, British
Guiana, Guadaloupe, Dominica and Jamaica
in the Western Hemisphere.

Incidental mention of this nut has been
already made in this Journal- — 1880, pp. 6
and 7; 1883, p. 27; 1884, p. 166, and
1886, p. 391. The tree commences to bear
at 4 or 5 years, but it is not until 10 years
that it is in full fruit, when it will produce
on the average 120 pounds of seed twice
yearly. Flowering in June, the pods will
ripen in October and November, and a sec-
ond crop will be yielded in May and June
following, The fruits as they ripen have a
yellowish-brown color, and, as the central
suture opens, exposes both red and white
seeds. The women remove the seeds, which
are most appreciated fcnd valued when they
are fresh and moist. To preserve them,
they are placed in baskets, in layers, with
the leaves of Sterculia cordifolia, which are
kept damp. If they are kept, or to be trans-
ported any distance, the nuts are washed and
fresh moistened leaves added every month.
The packages, weighing about 1 cwt., are
sent to the Gambia, Gone and other dis-
tricts. When the nuts become dry, they are
reduced to powder, and taken in this state
by the caravans to the interior. The)' fre-
quently arrive, however, in a fresh state at
Sokoto and Kouka, in the Soudan, and at
Timbuctoo.

Not only are the kola nuts consumed in
Africa, but they are also exported to Brazil
for the use of the negroes there. The seeds
of Sterculia Chica and S. lasiatitha are also
eaten in Brazil.

Sierra Leone is the principal market for
these nuts. Ten years ago, about 750,000
pounds of kola nuts were imported there,
and 600,000 pounds to the Gambia.

The unerring instinct of man, even in un-
civilized countries, has led him to select,
from the many thousands of plants presented
to him in Nature, just four or five, which,
from their alkaloid active principle, theine,
seem to be a necessary rather than a luxury
of life. These nuts contain more theine
(viz., 2.34) than most of the other dietetic
products in use. The properties of the nut
are said to be two-fold. In the first place,
it enhances to many palates the flavor of food
eaten afterwards ; secondly, it possesses the

April 4, 1 891.

Periscope.

39i

more important function of staying the crav-
ings of hunger, and enabling those indulg-
ing in it to endure prolonged labor without
fatigue. Being bitter, they are used as a
stomachic and a tonic.

It is beneficial in periodical and chronic
headaches, in heart complaints and diar-
rhoea ; and, mixed with cocoa, it has been
found a sustaining and stimulating adjunct
in exhaustive and wasting diseases. It is
said to clarify beer and spirits, and, like the
clearing nut {Strychnos potatorum}, to render
drinkable foul water. It is even spoken of
as a cure for drunkenness, from the amount
of theine it contains. Probably other spe-
cies of kola or sterculia may furnish seeds
equally used if they contain caffeine.

The false kola nut has been named Gar-
cinia Kola by Dr. Heckel, but is not yet
well denned, although it resembles the
Eastern Garcinia Morella. These seeds are
employed like the true kola nuts, although
they have not the same properties, being
destitute of the alkaloid. . They are con-
tained in a large berry, like an apple, to the
number of three or four ; oval, cuneiform.
They are chewed generally on the West
Coast, and have a bitter flavor, like green
coffee. They are said to be an effectual
remedy for cold in the head, a few seeds
being chewed in the course of the day.

Contagious Diseases Act.

The effect of the Contagious Diseases Act
in England has been a subject of much dis-
cussion at different times. The latest on the
subject is in the Lancet, February 14, 1891,
where it is stated that, for the purposes of
comparing stations under the Acts with those
not under them, fourteen of the latter were
selected by Surgeon-General Lawson, in a
recent paper, for comparison, and were
called " fourteen stations never under the
Acts." Besides these two sets of stations
was a third, designated "all the stations
never under the Acts." In i860, at the
fourteen stations which came under the Acts
in 1864 and subsequently, the ratio of pri-
mary sores was 146 ; at the fourteen unsub-
jected stations 134, and at all the stations
never under the Acts 131. From these
points all fell, so that in 1862 they stood at
117, 103 and 99 respectively. In 1863 the
admissions at the fourteen unsubjected sta-
tions rose to 117, while those at the four-
teen subjected were 107, and all the unsub-

jected 108. The compulsory examination
began to take effect in 1867, and though
there was an increase of the incidence of
the disease on the country as indicated by
rises in the ratio of 17 per 1,000 in both the
fourteen and whole unsubjected districts, that
at the fourteen stations under the Acts was 4
per 1,000 only ; and from this year the ratios
at the fourteen subjected stations were always
much under those in the whole until 1884,
the last year of the comparison. In 187 1
the incidence of the disease on the country
seemed at its lowest, being 93 for the four-
teen unsubjected stations, 81 for all the sub-
jected and 5 1 only for the fourteen subjected.
The stoppage of pay showed its effects in
1874 by a fall at each class of stations,
which was continued in 1875, and still
traceable up to 1877, after which the ad-
vance of another epidemic wave caused a
rise at the fourteen unsubjected stations of
40 per 1,000, at all the unsubjected of 20,
while at the fourteen subjected it was 4 only.
In 1879 there was a slight reduction of the
ratio at both classes of unsubjected stations,
but a rise of about the same amount at the
fourteen subjected; but in 1880, with the
cessation of stoppage of pay, there was a
general rise, amounting to 39 at the fourteen
unsubjected stations, to 37 on the whole un-
subjected and. to 27 at the fourteen subjected
stations; a portion of this was no doubt due
to an increasing incidence of the disease
over the country, but a large portion also to
the removal of the inducement to conceal
primary forms of the disease by stoppage of
pay. The beneficial effects of the Acts will
be seen by the following figures. In i860
to 1863, when no Acts were in force, the
ratio of primary sores at the stations subse-
quently protected by them was 129.8. In
1870 to 1873, the Acts being then enforced
in all, it fell to 52.5. Secondary syphilis
fell from 39.9 to 20.2; gonorrhoea from
134.6 to 100.3. At all the stations never
under the Acts the fall in primary sores was
from 1 16.3 to 86.0, in secondary disease
from 30.5 to 27.4 and in gonorrhoea from
1 16. i to 95. At the fourteen unsubjected
stations primary sores fell from 120.6 to
107.9 ; secondary syphilis rose from 31.6 to
31.8; gonorrhoea fell from 112. 1 to 71.6.
In 1880 to 1882, stoppage of pay having
terminated, the ratio of primary sores at the
protected stations was 75.6, secondary syphi-
lis 26.6, gonorrhoea 99.0. At all the sta-
tions never under the Acts the ratio of pri-
mary sores was 123.0; that of secondary

392

Periscope.

Vol. Ixiv

syphilis 32.5; gonorrhoea 110. 4. At the
fourteen u.nsubjected stations the ratio of
primary disease was 175.9, of secondary
syphilis 38.9 and of gonorrhoea 128.4.

The Acts were suspended in 1883, and
wholly repealed subsequently ; the separa-
tion of the tables has not been continued
since 1884. The ratios of disease among
all the troops are as follows :

Primary Secondary ^ ,
c J o 1 -t Gonorrhoea.
Sores. Syphilis.

140

In i860, ratio per?

1,000 of admission 3
In 1885, ratio per)

1,000 of admi sion 3 '

36

27

13:

j in a splint, while the free side does the
\ breathing. A first-class non-conductor is
covering the chest. I am not sure but that
the contracting collodion may have some in-
fluence in controlling the blood supply.

4. There is no particular interference, in
one who has a good ear, with physical ex-
amination. Maybe it would be a good
thing if there was; for, having once made
the diagnosis, what is the use of exhausting
the patient every day by trying to find out
whether one-eighth of an inch, more or less,
is involved? The general symptoms will
tell that.

From this it will be seen that the ratio of
disease has returned to what it was in i860
before the first Act was enforced.

There are many other interesting points
in Inspector-General Lavvson's paper which
show immense pains, great research and a
most thorough knowledge of the whole sub-
ject. Enough, the Lancet says, has been
given to show the benefits of the Contagious
Diseases Acts and the disastrous results of
their repeal.

Cotton and Collodion Dressing for the
Chest.

In the Annals of Gynecology and Pediatics,
February, 1891, there is a letter from Dr.
William Hunt, of Philadelphia, on a new
method of dressing the chest in pneumonia,
pleurisy, pleurodynia, etc. Dr. Hunt says :

This is the method I advise to dress the
chest in a case of pneumonia, pleurisy and
pleurodynia. Do it on a large scale, in the
same way that we now dress abrasions and
bruises. If there is to be any cupping or
other preliminary operation, have that at-
tended to ; then all the ingredients wanting
are pure collodion and absorbent cotton in
smooth layers, and a good broad brush,
like mucilage brushes. Apply a very thin
layer over the side affected from spinal col-
umn to sternum, and secure it with collo-
dion smeared thoroughly over it. Then go
on with thicker layers, securing them with
collodion until a good padding is obtained,
paying particular attention to the edges.
In double cases you can act accordingly.
The advantages are :

1. The one dressing, if well applied, will
last throughout the case, and so

2. The fatigue and discomfort of frequent
poulticing are avoided.

3. The side, in single cases, is held as

Calomel and Salt.

The Western Druggist, February, 1891,
says : Calomel and salt are by many be-
lieved to be incompatible on account of the
alleged formation of mercuric chloride.
This theory has often been contradicted,
but Paul Adam has conducted a fresh series
of experiments, the results of which he has
recently reported. He boiled together cal-
omel and salt in open and in closed vessels,
in the presence of gastric juice, and the ex-
tract of beef. He also experimented with
animals. His conclusions are : Boiled to-
gether in open vessels with the alkaline
(especially ammonium) chlorides, calomel
yields mercuric chloride. Under exclusion
of the atmosphere, however, even in the
presence of organic matter, no corrosive
sublimate is formed. Hence there is no
danger in the administration of these two
agents together.

Study of Medicine in Thibet.

The British Medical and Surgical Jour-
nal, February 5, 1891, says: The Buddhist
Lamas' University, in the Transbaikal Prov-
ince of Thibet, has a medical course of ten
years. According to Nature, a traveler
named Ptitsyn has returned from that coun-
try w7ith a collection of medical books and
drugs illustrative of the knowledge and -the
methods of practice in Thibet. Mr. Ptitsyn
remarks that he has found over one hundred
diseases described in the Buddhist literature,
aud of these a mythical origin is ascribed
to only two. Strictly medical subjects are
not studied until the fifth year of the course,
the first four years being devoted to the
study of the languages and theology. The
eighth year is devoted to astrology, and
philosophy is studied in the last two years.

April 4, 1 89 1.

Editorial.

393

THE

MEDICAL AND SURGICAL

REPORTER.

ISSUED EVERY SATURDAY.

CHARLES W. DULLES, M.D.,
Editor and Publisher.

N. E. Cor. 13th and Walnut Streets,
P. O. Box 843. Philadelphia, Pa.

4Sf"SUGGESTIONS TO SUBSCRIBERS '.

See that your address-label gives the date to whLh your
subscription is paid.

In requesting a change of address, give the old address as
well as the new one.

If your Reporter does not reach you promptly 'and regu-
larly, notify the publisher at once, so that the cause may be
discovered and corrected.

^^Suggestions to Contributors and Correspondents :
Write in ink.

Write on one side of paper only.

Write on paper of the size usually used for letters.

Make as few paragraphs as possible. Punctuate carefully.
Do not abbreviate or omit words like "the" and "a," or
"an."

Make communications as short as possible.

Never roll a manuscript ! Try to get an envelope or
wrapper which will fit it.

When it is desired to call our attention to something in a
newspaper, mark the passage boldly with a colored pencil, and
write on the wrapper " Marked copy." Unless this is done,
newspapers are not looked at.

The Editor will be glad to get medical news, but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

PELVIC INFLAMMATION AND THE
GENERAL PRACTITIONER.

The pathology of pelvic inflammation is
settled beyond cavil. Non-puerperal pel-
vic inflammation is peritonitis, non-puerpe-
ral pelvic cellulitis does not exist, or exists
only as a curiosity — resulting from trauma-
tism and infection of the pelvic connective
tissue. These statements are also nearly
true of puerperal pelvic inflammation. Puer-
peral peritonitis is common ; puerperal cellu-
litis is rare. It is also equally well known
that pelvic peritonitis almost invariably
means salpingitis with infection of the peri-
toneum by discharge of the tubal contents
at the fimbriated end of the tube ; and that
recurring attacks of pelvic peritonitis are due
to leaky tubes. Other causes of pelvic per-
itonitis are changes taking place in pelvic
tumors, especially dermoid cysts, traumatism
and perhaps the effect of exposure at the

menstrual periods. These facts have been
known for thirty years, having been dis-
covered by Bernutz, and they have been
demonstrated fully by the surgery of to-day.

It is also equally well known that chronic
pelvic peritonitis does not tend to a natural
cure, and that recurrences of acute perito-
nitis are characteristic of the disease, being
due to leakage from the focus of poison, the
diseased tubes. The natural end of such cases
is invalidism or death during a recurrent acute
peritonitis. Experience has shown that med-
ical treatment, while affording much pallia-
tive benefit, is inadequate to effect a cure.
Ablation of the diseased uterine appendage
or appendages, the focus of the disease, is
the only treatment offering a radical cure.
When operation is done early, before the
patient is a wreck, the immediate risk to life
is slight, less than five per cent., and prompt
restoration to health follows. Operations
done on such diseased structures does not in
any way lessen the fecundity of women ;
they are sterile by reason of the disease.
It restores such sufferers to health and use-
fulness ; saving some from invalidism and
others from death. These facts are now
amply demonstrated and are opposed only
by those in the profession who object to
exerything which has not the stamp of an-
tiquity upon it.

What, then, becomes the duty of the prac-
titioner when called to attend these cases ?
To recommend operation by skilful hands.
No more pressing duty devolves upon him,
and it is time that the matter is brought
home to the practitioner. He should know
and feel that he is neglecting his duty when
he puts such cases to bed, treats the acute
attacks by opium internally and poultices
externally; and between attacks paints the
vagina with iodine and inserts the glycerin
tampon. Such neglected cases are brought
later to the surgeon either as broken-down
wrecks, or as women dying with suppurative
peritonitis. These are the " too late"
cases. Either their nutrition is so profoundly
depraved that they require months to recu-

394

Editorial.

Vol. lxiv

perate, or being past recuperation they re-
main wrecks, or swell the death-list of the
surgeon who is too conscientious to refuse
them a last chance. Hereafter the respon-
sibility for such maltreatment will rest with
the family physician.

The cases in which hesitancy may be felt
are cases of slight or catarrhal salpingitis, in
which the fimbrise are not agglutinated, and
in which accumulation of tubal secretions
has not occurred. These cases are subjects
for watchful care. Such of them as pro-
gress from bad to worse may be referred to
the surgeon. The others are fair subjects
for medical treatment, so long as life is
threatened by attacks of peritonitis.

THE TONGUE'IN SCARLET FEVER.

Authorities differ as to the constancy and
diagnostic significance of the appearance of
the tongue in scarlet fever. Upon the sug-
gestion of Prof. Fiirbringer, Dr. Neumann
made a series of observations on the tongue
in forty-eight cases of scarlet fever at the
Friedrichshain Hospital, at Berlin, and re-
cords in the Dents dies Archiv fiir Klinische
Medicin, January, 1891, the results of his
investigation.

The changes in the tongue presented
themselves in three stages. In the first, the
mucous membrane became swollen, and the
tongue was enlarged and corrugated on its
surface, while the epithelium became cloudy.
The tongue also presented the appearance
of being heavily coated, except at the tip
and margins. In the second stage, desqua-
mation took place. This was most marked
at the surface of the fungiform papillae, and
gave rise to the characteristic appearance of
the strawberry tongue. In the last stage
restoration of the epithelium took place, at
times with such rapidity as to cause the
tongue to again appear coated. Naturally,
deviations from this typical course occurred.
These could be explained by antecedent or
complicating conditions.

The characteristic appeal ances of the

tongue presented themselves in thirty-eight
of the forty-eight cases, carefully inspected
at intervals of two or three days — that is, in
seventy-nine per cent. In six cases, no ap-
preciable changes occurred. In five of these
there had been digestive derangement or
septic intoxication ; while in the remaining
one no complicating condition could be dis-
covered.

In the majority of the cases, desquama-
tion took place from the third to the fifth day
of the disease and left for more than four
days longer the strawberry tongue which, in
twelve cases, was still present on the four-
teenth day. Thus in a third of the cases,
the strawberry tongue disappeared during
the first week ; in another third, during the
second week; while in the remaining third
it was still present at the end of the second
week. There was no relation observed be-
tween the intensity of the changes in the
tongue and those in the skin.

From the foregoing, it may be concluded
that the appearances of the tongue in scarlet
fever constitute a characteristic, though not
a constant feature of the disease.

EPILEPSY AND ALYLENE HYDRATE.

Notwithstanding the fact that many reme-
dies have been from time to time brought
forward for the treatment of epilepsy, the
bromides yet remain the most trustworthy
and most effective at our command. There
are, however, certain cases in which the
bromides absolutely fail to render any ser-
vice, or in which for one reason or another
they are not well borne. For these cases,
it would be desirable to have a remedy that
could at least be used to alternate with, if
not as a substitute for, the bromides. Stimu-
lated by the results recorded by Wildermuth,
in the Neurologisches Centralblatt, No. 15,
1889, from the use of amylene hydrate in
the treatment of epilepsy, especially when
the attacks were frequent, Dr. Richard
Drews, of Altona, determined to try the
remedy in just such a case, and in the Miin-

April 4, 1 89 1.

Book Reviews.

395

chener medicinische Wochenschrift, January
27, 1 89 1, he reports the disappointing and
unfavorable results he obtained. The case
was a typical one of epilepsy, in a woman
thirty-five years old, without other neurotic
history, in whom the attacks had begun at
twenty years of age, and had continued with
gradually increasing frequency. Bromides
and chloral had been used without avail.
Finally, resort was had to amylene hydrate,
twenty-five grains three times a day. The
attacks increased in frequency, one follow-
ing each administration of the remedy, the
appetite failed and there was severe head-
ache and sleeplessness.

In view of this experience it seems as if
amylene hydrate was of little use and that
the bromides are yet the best remedy in the
treatment of epilepsy. Perhaps too much
disappointment should not be felt, and ex-
perimentation with amylene hydrate should
not be wholly .abandoned, because it may
be suited, to some cases, if not toothers;
but the experience of Drews certainly tends
to dampen the ardor caused by Wildermuth's
reports.

MEDICAL AND SURGICAL COLLEGE
OF NEW JERSEY.

In the Reporter for January 10, 1891,
we called attention to resolutions in regard
to the so-called Medical and Surgical Col-
lege of New Jersey, adopted by the Hudson
County Medical Society, and referred also
to the exposure of the methods of this Col-
lege made in the Reporter as long ago as
August 24, 1889. It is pleasant now to be
able to report that — largely through the
efforts of the.State Board of Medical Examin-
ers of New Jersey — the charter of the insti-
tution mentioned has been Repealed by the
Legislature, and the repealing act has been
approved by Governor Abbett.

We heartily congratulate the New Jersey
Board of Medical Examiners upon this fruit
of its labors so soon after it came into
existence. The institution just abolished
was largely made up of electics, who, so far

as we can tell, have somewhat different
standards of professional and general excel-
lence from those which prevail in the
r.egular profession.

Book Reviews.

[Any book reviewed in these columns may be obtained upon
receipt of price, from the office of the Reporter.]

DISEASES OF THE EYE. By Edward Nettle-
ship, F. R. C. S., Ophthalmic Surgeon to St. Thomas's
Hospital, etc. Fourth American from the Fifth
English Edition. i2mo, pp. 500. 164 illustrations.
Philadephia. Lea Brothers & Co.

'This excellent manual, designed as an introduction
to the study of eye-disease, seemed at its first appear-
ance the most concise, direct and practical presenta-
tion of the subject to be found in the English language.
Each edition has showed distinct improvement, and
the present gives evidence that the revisions have
been careful as well as numerous. Much that at first
seemed merely implied and to be read between the
lines, but only by one already familiar with the sub-
ject, is now clearly and explicitly stated ; and, while
brevity gives a dogmatic character to many of the
opinions set forth, there is only gain to the learner in
this. He is not left halting between two opinions ; and
he can accept, as well-grounded, every view of this
careful, experienced and conservative author. A few
errors have escaped elimination in the revision, and a
few statements are open to criticism. Thus under
"optical conditions of clear sight," p. 40, it is stated
that an object must subtend an angle of 5 minutes, in
order that its form may be perceived. This is true of
square letters like Snellen's, as stated on p. 48 ; but
does not hold for simpler forms. Objects and spaces
of 1 minute ought to be distinguished in good in-door
light. In the designation of prisms the numbering by
the actual deviation produced seems to be ascribed to
Maddox, instead of to Jackson ; and no mention is made
of the metric designations of Dennett and Prentice,
which complete the reform which ought to be made.
The "pseudo-coloboma " of the iris may be upward
or in any direction ; so the statement is incomplete
that coloboma " is always downwards." The table
of prisma ic effect of decentering lenses quoted from
Maddox, notes on spring catarrh, pemphigus of the
conjunctiva, corneal transplantation, etc., bring the
work up to date ; and by the substitution of new cuts
and in its general typography this edition seems an
improvement on the last. On the whole, this book
may be said to fully deserve the warm welcome which
it has already received, and to be worthy of hearty
recommendation to the profession.

ETUDES SUR LA RAGE, ET LA METHODE
PASTEUR. Par le Dr. Lutaud, Redacteur en
Chef du Journal de Medicine de Paris. 2d Edi-
tion. 1 2mo, pp. x, 440. Paris. Journal de Medi-
cine de Paris, 1 89 1.

This second edition of Dr. Lutaud's book on hydro-
phobia comes at an interesting time, when' he finds
himself engaged in combating the extravagances of
the claims of Koch's followers. The extremes to
which Pasteur and his disciples have pushed his no-
tions in regard to the so-called protective inoculations
against rabies, have found a curious counterpart be-
yond the Rhine, and as Pasteur's claims found little

396

Notes and

Comments.

Vol. lxiv

recognition there, so in turn have the claims of Koch
been coldly received in France. It may be yet that
Lutaud will devote himself to collating the failures
and fallacies of the Koch method, as in the book be-
fore us he collates the failures and fallacies of Pas-
teur's method. One who reads this book will see in
it, however, intimations of something worse than fail-
ure and fallacy — that Pasteur has been guilty of mis-
representation, and has made the discoveries which
were exploited as humane and scientific, the means of
acquiring wealth as well as universal fame. It will
be seen here, likewise, that nothing, against which
Pasteur has proposed a sure preventive, has been pre-
vented, and that the diseases of the vines, the diseases
of the silk-worms, the diseases of the dogs, the dis-
eases of cattle still ravage France and other lands
formerly exposed to them ; and he who looks for suc-
cess in connection with Pasteur's brilliant claims will
find them principally in the fortune which he has
amassed and the reputation which he has secured.
In this there is no claim that Pasteur has not been in-
dustrious and ingenious, and from the scientific stand-
point a very useful investigator ; but it appears that
whenever he has passed from the field of the investi-
gator and has attempted to make any practical appli-
cation of his theories, the result has been more
brilliant than lasting, and is likely to serve rather as a
warning than as an example.

SUGGESTIONS TO THE MEDICAL WITNESS.
By J. S. Wight, M. D., Professor of Operative and
Clinical Surgery at the Long Island College Hos-
pital, Brooklyn, N. Y. i2mo, pp. 228. Cambridge :
Printed at the Riverside Press. 1891.

Dr. Wight has written a very readable book on a
very important subject. It is so common now for
medical men to be summoned as expert witnesses
that it is as important for them to be as well prepared
for the trying duties of the situation as possible. Un-
fortunately many medical witnesses go on the stand
without any previous experience, and with no better
preparation than a desire to do justice and bear true
witness. While this is the most important prerequisite,
of course, for good testimony, it is, nevertheless, a fact
that the position is often trying because of its mere
novelty, and more often trying because of the harrass-
ment of the witness by the attorneys. To be fore-
warned in regard to the difficulties of the situation
would be, in many cases, to be forearmed ; and the
recorded experience and opinions of a man like Prof.
Wight cannot fail to be helpful.

Literary Notes.

, — P. Blackiston, Son & Co. announce for early pub-
lication, " A Handbook of Local Therapeutics" being
a practical description of all those agents used in the
local treatment of disease, such as Ointments, Plasters,
Powders, Lotions, Inhalations, Suppositories, Bougies,
Tampons, etc., and the proper methods of preparing
and applying them.

The diseases which chiefly require local treatment
are those of the Respiratory Passages, Ear, Eye, Skin,
together with certain general surgical affections, includ-
ing the Diseases of Women. In order, therefore, that
the various uses of each remedy may be thoroughly
set forth the following gentlemen have assumed the
authorship : Harrison Allen, M. D., Emeritus Pro-
fessor of Physiology in the University of Penna. ; Laryn-
gologist to the Rush Hospital for Consumption ; late

Surgeon to the Philadelphia and St. Joseph's Hospitals.
George C. Harlan, M. D., late Professor of Diseases
of the Eye in the Philadelphia Polyclinic and College
for Graduates in Medicine ; Surgeon to the Will's Eye
Hospital, and Eye and Ear Department of the Penn-
sylvania Hospital. Charles B. Penrose, M. D., Sur-
geon to the German Hospital ; Instructor in Clinical
Surgery, University of Pennsylvania, and Arthur Van
Harlingen, M. D., Professor of Diseases of the Skin in
the Philadelphia Polyclinic and College for Graduates
in Medicine ; late Clinical Lecturer on Dermatology
in Jefferson Medical College ; Dermatologist to the
Howard Hospital.

Each remedy will be taken up in alphabetical order,
and after a succinct description of their pharmaceutical
properties, by Dr. George I. McKelway, will be con-
sidered with reference to the local treatment of the
affections above outlined. The authors believe that
the information contained in this work will not be
found elsewhere. The activity in the various lines of
special medicine is one of the most striking phases of
the times, and has materially changed many of the
older methods of treating disease by local means. The
greater part of the literature which has appeared is not
accessible to most physicians. The Handbook, it is
believed, will be of value to general practitioners as
well as to those who, like themselves, are especially
interested in sub-divisions of the clinical field.

The work will form a compact volume of about 40a
pages, arranged in a manner to facilitate reference and
containing, besides the usual index, a complete index
of diseases, that will greatly enhance its usefulness.

— A few months ago the Home-Maker underwent
changes which improved its appearance and intrinsic
value very materially. The number for March, 1 891,
is a very good specimen of the American monthly
magazine. It is well printed on handsome paper, and
fully illustrated, largely by means of process pictures.
It contains articles of great interest, among which
may be mentioned, " Sheep in California," the " Study
of American Republics " and one on the " Burrows of
the Prairie Dog." This magazine is edited by the
well-known writer, " Jennie June," and contains con-
siderable matter especially interesting to women. The
subscription price, $2.00, is so moderate that it ought
to have a large circulation.

Notes and Comments,

American Academy of Medicine.

The Sixteenth Annual Meeting of the
American Academy of Medicine will be
held at Washington, D. C, May 2-4, open-
ing at 3 p. M., May 2.

As it is just previous to the Sessions of
the American Medical Association, members
will be able to attend both meetings.

Hiccough Cured with Nitrate of
Amyl.

Last February a young woman of Shel-
ton, Connecticut, had a prolonged attack of
hiccough which seriously imperilled her life,
despite the physician's efforts. In conse-

April 4, 1 89 1. Notes and

Comments.

397

quence of the circulation given the case in the
newspapers, remedies were sent from all parts
of the country. Many were tried, and that
suggested by Frank W. Mack, of the Associ-
ated Press, New York, was effective. The
remedy was nitrite of amyl, a few drops to
be inhaled from a handkerchief. On Feb-
ruary 10, it was announced that the young
woman was out of danger.

Simple Treatment of Ingrown
Toenail.

The Pittsburgh Medical Review, Febru-
ary, 1 89 1, cites Dr. Puerckhauer (from the
Miinchener med. Wochenshrift*) as recom-
mending a simple, and at the same time
competent treatment for ingrown toe-nail.

A forty per cent, solution of potassa is
applied warm to the portion of the nail to be
removed. After a few seconds the upper-
most layer of the nail will -be so soft that it
can be scraped off with a piece of sharp-
edged glass ; the next layer is then moist-
ened with the same solution, and scraped
off j this must be repeated until the remain-
ing portion is as a thin sheet of paper, when
it is seized with a pincette and lifted from
the underlying soft parts and severed from
the other half. The operation does not
require more than half an hour's time, is
painless and bloodless, while the patient
is delivered from his suffering without being
disabled even for an hour.

Dietetic Employment of Fat.

W. Zuntz has a paper on the dietetic em-
ployment of fat in the Therapeutische M011-
atshefte, October, 1890. He was induced
to put to the experimental test of some con-
ditions of digestion of fat, a preparation of
chocolate suggested by von Mering. The
chocolate is so made that it possesses a suf-
ficient quantity of free fatty acids to form a
permanent emulsion, without in any way
injuring the taste of the chocolate. In or-
der to find out whether the digestibility of
fat is enhanced by the power to form an
emulsion, Zuntz sought to find out what
quantity of cacao butter, with and without
the addition of fatty acids, was appropriated,
when administered to dogs. The result was,
that there was an increase in digestibility,
which was only slight — two per thousand of
the fat — if moderate quantities of cacao but-

ter were cooked with the rest of the food, but
it was considerable if (as is usually the case
with cod-liver oil, in order to avoid stomach
digestion) the cacao butter was given some
time before the rest of the food and in
somewhat greater quantities. In the latter
case, there appeared in the stool 9.9 per
cent, of pure cacao butter, and only 6. 1 per
cent, of the emulsionized.

Corresponding to the result of the emul-
sionizable cacao butter in dogs, the fat of
Mering' s chocolate proved to be very di-
gestible in men. For three days a mod-
erate diet poor in fat, consisting of bread
and lean meat, was given, and, in addition,
a daily quantity of 416 grams of choco-
late containing 87 grams of fat. In the
feces appeared only 4.88 percent, of fat;
whereas Weigmann, in a series of experi-
ments with ordinary cacao butter, adminis-
tering 53 grams, recovered 5.5 per cent.
In comparison with the most used fats, and
those fats prized on account of their being
easily digestible, such as butter, lard, mar-
row, the fat of the chocolate preparation is
seen to be considerably superior. — Deutsche
med. Woche?ischrift, Jan. 1, 1891.

Treatment of Stricture of the Ileo-
caecal Valve.

In the Bulletin Medical, . December 3 1 ,
1890, Prof. Pean has a lecture on the treat-
ment of strictures of the ileo-csecal valve,
in which we are glad to see that he is ac-
quainted with Philadelphia work in this field,
Barton's cases being referred to in some de-
tail. Pean's operation consists in exposing
by an incision the ileum at its junction with
the caecum, and occluding the bowel both
above and below the valve with rubber tubes
fastened with forceps. The tubes serve the
double purpose of preventing hemorrhage
and keeping fecal matter from circulating
in the intermediate portion of bowel during
the operation. The intestinal wall is then
incised longitudinally over the valve for a
distance of three and one-fourth inches.
After washing the interior of the bowel with
a one per cent, solution of carbolic acid,
the condition of the valve is examined. If
it is found transformed into fibrous tissue,
and so retracted as to occlude the bowel, it
is resected down to the muscular coat of the
bowel. This done, the two extremities of
the intestinal wound are brought together
in such a way that the ileum and caecum

398

Notes and Comments.

Vol. lxiv

are brought together. The opening in the
bowel- thus becomes lozenge-shaped instead
of longitudinal, the two upper sides being
formed by the ileum and the two lower by
the caecum ; the sides are then approxi-
mated with the forceps, and are united so
that the line of suture is transverse to the
bowel. Pean thinks this method of operat-
ing possesses a number of advantages, espe-
cially as it establishes an ampullar dilatation
at a point where before there was stricture.

Jefferson College's New Surgeon.

At a meeting of the faculty of Jefferson
Medical College on March 9, Dr. H. Augus-
tus Wilson was elected Lecturer on Ortho-
pedics in the Jefferson Medical College and
surgeon in charge of the Orthopedic De-
partment of Jefferson Medical College Hos-
pital, to succeed Dr. O. H. Allis, resigned.
Dr. Wilson is Professor of General and Ortho-
pedic Surgery in the Philadelphia Poly-
clinic and College for Graduates in Medicine,
Lecturer on Orthopedic Surgery in the
Woman's Medical College. The present
success of the Polyclinic is due largely to
his industry and enterprise, and his present
appointment is probably a tribute to these
same qualities.

The Law of Periodical Function in
Women.

Probably no single function of the human
organism has called forth so many hypotheses
as the menstrual loss of blood, occurring in
healthy women at regular intervals. Though
many ingenious explanations have been pro-
posed,, none is entirely satisfactory. In the
Wiener medizinische Press e, February 8,
1 89 1, v. Ott reports observations, not ex-
clusively upon menstruation, but upon the
various vital processes occurring in women
during the period of generative activity.
These processes correspond in time to the
hemorrhage, are associated conditions, with
a dependent relation to it. Observations
upon temperature, pulse and blood pressure
indicated that vital activity attained its
maximum preceding the menstrual period
and declined at its commencement or im-
mediately before. Sphygmographic tracings,
muscle strength, and excretion of urea suffer
similar variations. Observations were made
at a certain hour each morning during pro-
longed periods, sometimes extending into

the menstrual periods, upon heat radiation,
muscle strength, pulmonary capacity, inspi-
ratory and expiratory force, the tendon re-
flexes, in healthy women placed under the
same condition ; and a physiological func-
tional periodicity of the female organism was
demonstrated. To establish the connection
between menstruation and this periodicity
of function, it is necessary to determine if
the rhythmical variations are independent
of menstruation. A large number of ob-
servations made by Dr. Schichareff, under
the guidance of von Ott, upon pulse, tem-
perature and blood pressure, in girls between
the ages of eight and thirteen years, and in
women between the ages of fifty-eight and
eighty years, showed that no such periodical
variations of physiological functions occur
in females during the periods in which they
are not capable of conceiving, and in which
they do not menstruate.

Teeth in Diabetes.

The importance of early diagnosis in di-
abetes cannot be over-estimated, because the
prognosis may be much influenced by the
institution of early treatment. It is inter-
esting, therefore, to call attention to the fact
that the Wiener medizinische Presse, January
4, 1 89 1, contains a brief abstract of a pub-
lication by Magitot in Bulletin medical, in
which he dwells upon the diagnostic signifi-
cance of alveolar osteo-periostitis as a mani-
festation of diabetes. He has noticed, in this
disease, a deviation of the tooth, which, later,
becomes loosened. At the same time an al-
veolar catarrh exists. Ultimately the tooth
falls out. In the further course of the dis-
ease, the alveolar border of the bone may be
absorbed, and this in turn may be followed
by gangrene of the gum.

Druggist's Error in Germany.

The Che?nist and Druggist, January 31,
1891, says: A singular casein connection
with a mistake in dispensing is now occupy-
ing the attention of the Berlin authorities.
Some time ago a prescription was presented
to the assistant at a Spandau pharmacy order-
ing a draught composed of sodii nitrat.,
•potas. bromid., aq. dest., and syr. mannae,
for a child. The assistant by mistake dis-
pensed spirit of camphor instead of the dis-
tilled water, but the error was discovered
after the administration of the first dose to

April 4, 1 89 1.

Notes and

Comments.

399

the patient, and no ill results followed. But
the father thought he would try to make
some capital out of the mistake, and threat-
ened the pharmacist with exposure, demand-
ing first 3,000 marks as hush money, and,
when that was refused, dropping his price
for secrecy to 140 marks. But the chemist
declined to compromise, and the father wrote
about the mistake to the local press. The
police got wind of the affair, and they are
now killing two birds with one stone. The
chemist's assistant was prosecuted for caus-
ing bodily injury through carelessness, and
fined 50 marks, and the would-be black-
mailer is being dealt with for the more seri-
ous offense of trying to commit illegal ex-
tortion by threats.

Congress of American Physicians and
Surgeons.

Congress of American physicians and sur-
geons will hold its second triennial meeting
in Washington, D. C, September 23-25,
1 89 1, under the presidency of Dr. S. Weir
Mitchell, of Philadelphia. The vice-presi-
dents, ex-offico, are : The president of the
American Surgical Association, Dr. Claudius
H. Mastin, of Mobile, Ala.; the president
of the American Ophthalmological Society,
Dr. Hasket Derby, of Boston ; the president
of the American Otological Society, Dr.
Gorham Bacon, of New York; the presi-
dent of the American Neurological Associa-
tion, Dr. Wharton Sinkler, of Philadelphia;
the president of the American Gynaecological
Society, Dr. A. Reeves Jackson, of Chicago;
the president of the American Dermatologi-
cal Association, Dr. Francis B. Greenough,
of Boston ; the president of the American
Laryngological Association, Dr. William C.
Glasgow, of St. Louis ; the president of the
American Climatological Association, Dr.
Frederick I. Knight, of Boston ; the presi-
dent of the Association of American .phy-
sicians, Dr. William Pepper, of Philadel-
phia ; the president of the American Asso-
ciation of Andrology and Syphilology, Dr.
Fessenden N. Otis, of New York ; the pres-
ident of the "American Orthopaedic Associa-
tian, Dr. Newton M. Shaffer, of New York;
and the president of the American Physio-
logical Society, Dr. Henry P. Bowditch, of
Boston. The chairman of the Executive
Committee is Dr. William Pepper, of Phila-
delphia. The treasurer is Dr. John S. Bil-
lings, of the army. The secretary is Dr.

William H. Carmalt, of New Haven. The
subjects for report and discussion mentioned
in the preliminary programme are as fol-
lows.

Tuesday, September 22, 3 p. m. — Condi-
tions underlying the Infection of Wounds,
including a discussion of Disinfection with
Reference to the Treatment of Wounds, of
the Relation of Bacteria to Suppuration, of
the Resistance of Tissues to the Multiplica-
tion of Bacteria, and of the Effects of An-
tiseptic Agents on Wounds. Referee, Dr.
William H. Welch, of Baltimore ; co-referee,
Dr. Roswell Park, of Buffalo. The discus-
sion will be adjourned if necessary until
Friday afternoon.

Wednesday, September 23, 3 p. m. — The
Late Manifestations of Syphilis. Referee,
Dr. Phineas S. Conner, of Cincinnati ; co-
referee, Dr. Abner Post, of Boston.

Wednesday evening. — The president's ad-
dress, to be followed by a reception.

Thursday, Septe?nber 24, 3 p. m. — Fibroid
Processes (Chronic Interstitial Inflammation,
Scleroses) ; their Pathology and ^Etiology,
with Special Reference to the Influence of
Diathesis and Heredity. Referee, Dr. Al-
fred L. Loomis, of New York ; co-referee,
Dr. William Osier, of Baltimore.

Friday, September 25, 3 p. m. — If neces-
sary, the discussion on The Conditions under-
lying the Infection of Wounds, etc., will be
resumed.

Is Sterility a Disease ?

The Medical Press, February 25, 1891,
says : A civil record has recently been
tried in Dublin before Mr. Justice Holmes
and a jury in which an enunciation of the
law was made by the judge which is of much
importance to the profession, and which
raises very interesting considerations. The
suit was instituted by a Dublin physician to
recover fees to the amount of 19 guineas for
attendance upon the wife of a solicitor.
The lady, it appeared, suffered from no
other disease save sterility, but anxiously de-
sired a cure for this condition and sought
advice with this object, whether with or
without the knowledge and consent of her
husband was not clearly proved. The
physician attended and made many exam-
inations by speculum and sundry applica-
tions of sponge tents and other instruments
for the purpose of dilating the cervix uteri.
The lady's husband refused to pay on the
ground that the treatment of his wife for the

400

Notes and

Comments.

Vol. lxiv

cure of sterility was not a " necessary " for
which the law required, him to pay, and on
the additional ground that the physician's
attendance took place without his knowledge
or consent, but this latter plea may be taken
as formal. The law laid down by Mr.
Justice Holmes in his charge to the jury,
which we regret to say has not been
reported in the newspapers, is as follows :

1. Every man is bound to provide necessary
medical care for his wife in case of sickness.

2. Every husband is liable for payment of
fees in case of such sickness, whether he
knows of the attendance on his wife or not ;
but, 3, Sterility is not a sickness for the
treatment of which a husband can be made
liable. It does not shorten life, nor prevent
the carrying out of household duties, nor
cause physical pain. Therefore medical
attendance for the remedy of such condition
is not a " necessary" within the meaning of
the law, and the physician, in this suit, was
unable to recover the fees due to him. It
should be added, however, that he could
still recover against the separate estate of
the wife, if she had any, for " work and
labor done ' ' though the ' ' work and labor ' '
might not be legally " necessary," as against
the husband. This decision raises a distinc-
tion between a sickness and an abnormal
condition which we have not seen previously
denned in a court of law, and it is interest-
ing to consider how. far the definition
extends. For instance is a naevus, or a wart
on the back, such a condition as the law
would consider to require "necessary" at-
tendance ? None of these shorten life, none
of them prevent the carrying out of do-
mestic duties, and none of them cause phy-
sical pain, and yet they have always been
considered as subjects for medical and surgi-
cal treatment, but, if the dictum of the
learned judge in this case is to be trusted, of
which we have no doubt, practitioners will
find it necessary, in future, to secure them-
selves in such cases, by a definite contract
with the husband before they enter upon
attendance of the wife.

Infusion of Roses for Diarrhoea.

Dr. A. V. Alexeevski (Bolnitchnaia Gazeta
Botkina, December, 1890) says that pre-
parations of rose petals have usually been
used only as vehicles, but never as an inde-
pendent medicament. He found the infu-
sion of flores rosarum an excellent therapeu-

tic agent, especially in diarrhoea. Only
chronic cases were chosen, which did not
yield to any ordinary treatment known for
diarrhoea. The infusion was prepared by
putting a handful of the dried leaves in a
glassful of hot water and keeping the mix-
ture covered in a warm place for about two
hours. To adults from two to three glass-
fuls of the infusion were given ; to children
a glassful in divided doses during the day.
The best results were obtained from flores
rosae rubiae; the infusion of flores rosae centi-
foliae was found weaker in its action. It is
better not to add any sugar to the infusion
as it only gives the infusion an unpleasant
taste.

Three chronic cases are stated to have been
permanently benefited by the above treat-
ment. One patient was a middle-aged
woman, and two were children of three and
a half and two years old respectively.

The beneficial action of the infusion is
due, first, to the presence of tannin, and sec-
ond to the volatile oils, oleum rosarum be-
ing one of them. The latter possesses anti-
putrifactive and anti-fermentative properties.
The preparation of the red rose is recom-
mended to be used for children.

Primary Pyemia.

Primary pyemia, i. e., pyemia without any
apparent focus for the primary supply of in-
fectious matter to the general system, is very
rare. Dr. L. P. Alesandroff, in the Bol-
nitchnaia Gazeta Botkina, October 17 and
24, 1890, relates the history of an interest-
ing case of this form of pyemia in a young
boy who was under his charge.

The boy was ten years old, with a nega-
tive family and personal history. December
2, 1890, he fell on the floor and hit his knee
slightly. It did not give him any pain, even
immediately after the fall. December 4, he
began to complain of slight pain in his knee
and general malaise. He had no special
treatment until December 6, when high fever
was discovered, after which he was sent to
the hospital. On admission the child was
found in a condition of septicemia. The
leg and foot on the side of the injury pre-
sented all the signs of acute infectious osteo-
myelitis, for which Alesandroff immediately
performed an operation. On the following
day the patient was very restless, began to
fail rapidly, and died in the night.

The post-mortem examination disclosed old

April 4, 1 89 1. Notes and

Comments.

401

pleuritic adhesions, hemorrhagic faci in the
lungs and in the cardiac pericardium,
changed in some places into pus, purulent
arthritis, limited osteo-myelitis and purulent
cellulitis in the leg. Air the appearances
were those of acute and recent disease, and
it appeared impossible to regard any of the
pathological points as the original source
through which systemic infection had taken
place.

Alesandroff says that the general septic
condition developed entirely independently
of the slight injury received to the joint.
He supposes that, in this case, a number of
germs found their way into the system, and
having met with little or no resistance of
the tissues caused the general blood poison-
ing. Falls and injuries in children are an
every-day occurrence, and he thinks that, in
similar cases, it is not justifiable to look
upon a slight fall or injury as being the cause
of acute septicemia. He refers to a similar
case reported by Prof. Kohts, in the Deutsche
Medicinische Wochensch., 1887.

Another such case is reported by Dr. R.
R. Ball, in the New York Medical Journal,
February 14, 1891, under the heading "Case
of fatal septicemia following contused injury
to the thumb in a strumous subject."

An Appliance to Facilitate the Inser-
tion of the Soft-Rubber (Nela-
ton's) Stomach-Tube.

Dr. Gustave Liebmann, Attending Physi-
cian to Patients with Stomach Diseases,
North End Dispensary, Boston, says, in the
Boston Medical and Surgical Journal, March
5, 189 1 : In the every-day use of a stomach-
tube the soft elastic (Nelaton's) tube is by
general agreement the one to be preferred.
Although the hard gum tubes enter the
pharynx and oesophagus much more readily,
they are at any rate relegated to the rarer
cases of poisoning with suicidal intent,
where, from obvious reasons, the application
of a soft tube is not feasible. In all appli-
cations of a tube for diagnostic or therapeutic
purposes we use the soft kind, as it is well-
nigh impossible to do any mischief with
them, and they "sit" much easier in the
stomach, giving rise to less irritation or gag-
ging than a hard tube. Still the introduc-
tion of a soft tube is at times, although gener-
ally not difficult, a source of great annoyance
to both physician and patient. And why ?
Because for the passage of the instrument

from the fauces to the beginning of the
oesophagus we have to depend on the intelli-
gence and docility of the patient. He has
to swallow the tube and work it through the
pharynx, and only then are we enabled to
push it down to the cardiac orifice. Should
the patient from some cause (awkwardness,
nervousness, and so on), fail to swallow, as it
happens in some exceptional cases, then we
are helpless and have to give up the job.
Now to overcome this difficulty I have dur-
ing the last three months used a simple ap-
pliance, that served me exceedingly well.

Although I designed the stylet and had it
made to suit my fancy, I must state that the
conception of it I got from a lady patient,
returning from Professor Leube, in Wurtz-
burg, who told me that the doctor used some
sort of a staff to steady the tube. The stylet
is made of rattan, is about thirty-four inches
in length, to fit that of the ordinary Nelaton,
and to project besides one and a half to two
inches at the proximal end, is well smoothed
down, of the thickness of a No. '6-8 Eng-
lish catheter (according to the caliber of the
tube), with one end curved like the beak of
a metallic bougie, but of uniform thickness
from one end to the other.

The curved end of the well-lubricated
stylet is inserted and pushed forward through
the tube, until it arrives at the distal end of
the latter, care being taken that no part of
it protrudes through any one of the open-
ings at the end of the tube. It is advisable
to bend tube and stylet still more into the
requisite curve before inserting in the fauces.
This done, the tube, with the stylet sticking
out at the proximal end, is cautiously in-
serted— like any other hard-gum tube — into
the fauces and pushed forward along the
pharynx to a point corresponding with the
lower border of the cricoid cartilage, or in
other words, to the beginning of the oesoph-
agus, when the stylet is withdrawn, and the
tube slid down to the cardiac orifice with-
out any further trouble. You see the soft
tube is changed into a stiff one but for the
short minute during which it has to pass
the pharynx ; we remove the stylet, and have
to deal with a soft tube during the remainder
of the whole procedure.

I would warn against allowing the stylet
to remain within the tube below the men-
tioned limit, as, in the first place, we don't
want to use a hard tube in the oesophagus,
and second, the withdrawal of the stylet
under this condition would be almost im-
possible. At any rate, our end in view —

402

Notes and Comments.

Vol. lxiv

the overcoming of the difficuly to the pas-
sage of the Nelaton tube — is fully reached
by using the stylet only as far as the pharynx
extends.

I would claim, therefore, that the stylet
fulfils all the requirements of the case, dis-
penses with the co-operation of the patient,
and that there should never be any further
failure, the patient being willing and there
being no organic stricture present, in intro-
ducing a soft-rubber tube into the stomach.

Fractured Ribs in the Insane.

A paper of much interest upon the subject
of fractured ribs of the insane has been
contributed to the last volume of the St.
Bartholomew' 's Hospital Reports, by Dr.
Claye Shaw. It discusses in the first place
how it is that fractures occur. The author
states that the detection of broken ribs in
lunatics is not necessarily proof of violence
on the part of an attendant, because it is
difficult to imagine that attendants who know
so well the consequences of being detected
in any act of violence would deliberately,
and for no reason, commit one so easily
found out. Seemingly, it is right to say
that fractures in the ribs of lunatics are not
caused by hard direct blows, but by a
slighter force which happens to take the pa-
tient when his body is placed at a disadvan-
tage for resisting strain. Hence the absence
of a bruise and the difficulty in finding out
how these injuries occur. Dr. Shaw bases
this opinion upon the fact that prize-fighters
rarely receive any injuries to the ribs, al-
though immense blows may be given upon
the thorax, the explanation being that the
body is in a position to resist the effect of
the blow. After many experiments made
by himself and Mr. Stansfield, Dr. Shaw
ascertained that the breaking weight of a
rib — the eighth — was among males, on the
right side 15 n-i6thlbs., and on the left
16^ lbs. ; among women it was 10^ lbs.
on the right side, and 9^ lbs. on the left.
He summarizes his results as follows : (1)
That a considerable difference is found to
exist not only in the weight of the ribs on
the two sides of the body, but also in the
average breaking weight. (2) That the
lighter rib is often found to bear the heavier
weight, and that there is no proportion be-
tween the weight of the rib and the number
of pounds it is capable of sustaining, whence
it would appear that physical conditions of'

structure have more to do with the strain-
resisting power than has chemical change in
bones. (3) That persons suffering from dis-
ease of the heart or blood-vessels bear less
strain than others. (4) That persons suffer-
ing from advanced constitutional disease,
such as phthisis, may have ribs that support
a strain much above the average, and hence
that there is no direct relation between con-
stitutional strength and that of the ribs. (5)
That when a blow causes a fracture this is
dependent not so much on the weight of the
rib and its power of bearing strain as on
other conditions. Lastly, he remarks that
the dictum that the ribs of the insane are
more brittle than those of the sane is true to
a very limited extent only, and is almost
confined to those affected with degeneration
of the circulatory system. He appends a
table to his paper showing the weight re-
quired to cause fracture of the rib and the
seat of the fracture in forty-five experiments
which he made. — Medical Press, February
25, 1891.

Acetanilid for Chancre and Chan-
croid.

The Journal de Medecine, January 25,
1 89 1, states that Basilevitch reports in Nou-
veaux Remedes, November, 1890, that cica-
trization took place in a short time as a
result of sprinkling acetanilid on the sur-
face of the ulcers in one case of chancre in
a woman and in two cases of chancroid in
men.

In these cases, acetanilid has the advan-
tage over iodoform of being inodorous, and
that large doses do not give rise to toxic
manifestations. It is also less expensive
than iodoform — an important consideration,
especially in dispensary practice.

Foreign Medical Diplomas in Illinois.

The Illinois State Board of Health has
decided that hereafter it will recognize no
foreign diploma unless such diploma confer
the right to practice medicine in the coun-
try in which it was granted. This rule ap-
plies to Austrian, German, Russian and
Swiss diplomas, unless the ' holders have
passed the State examination which entitles
them to practice in those countries. It ap-
plies also to Canadian diplomas unless the
holder be a licentiate of the Colleges of Phyi-
cians and Surgeons, of Ontario and Quebec.

Medical and surgical
Reporter

I

A Weekly Journal.

Established in 1853 by S. W. Butler, M. D

CHARLES W. DULLES, M. D., Editor and Publisher,

Entered as Second-Class matter at Philadelphia P.O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

Vol. LXIV, No. 15.
lole No. 1780.

APRIL 11, 1891

&5.00 per Annum.
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GOUTET^TS

LINICAL LECTURE.

1* isher, John 1M., M. D., Philadelphia, Pa. — Gal-
vanism in the Tre3.txo.6iit of Diseases of the

EDITORIALS.

Presbyterian Hospital in Philadelphia 421

Traumatic Neuroses "423

/

DMMUNICATIONS.

Goodeli, Wm., M. D., Philadelphia, Pa.— Sugges-
tions for Abdominal Operations and After Care.. 408

McAlisteb, Alex., M. D., Camden, N. J.— Lapa-
rotomy in Intestinal Obstruction.— Report of a

BOOK REVIEWS.

Tyson; Guide to the~Practical. Examination [of
Urine.— Newth-Owen ; Post-Mortems 424

LITERARY NOTES 424

Eshnee, Augustus A., M. D., Philadelphia, Pa.—
ERISCOPE.

Use and Abuse of Drainage in Surgery.— Hemate-
mesis in Gastric Ulcer.— Open Operation for
Strangulated Hernia.— Extracts from Tubercule
Cultures.— Vaccination in France 414-419

NOTES AND COMMENTS.

New Method of Treating Enlarged Prostate.— Who
Owns the Prescription ?— Paroxysmal Tachycar-
dia.—Open and Subcutaneous Tenotomy.— La-
parotomy for Disease of the Liver.— Post-partum
Hemorrhage Treated with Caffeine —To Remove
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MEDICAL AND SURGICAL
REPORTER

No. 1780. PHILADELPHIA, APRIL 11, 1891. Vol. LXIV.— No. 15.

Clinical Lecture.

GALVANISM IN THE TREATMENT
OF DISEASES OF THE UTERUS.1

BY JOHN M. FISHER, M. D.

With a view to determine the value of
galvanism in the treatment of pelvic disease
in women, Professor Parvin, one year ago,
gave me a place on the " gynecological
clinic " for the purpose of treating such
cases as I might think proper with the bat-
tery. In spite of serious drawbacks that
attended our earlier work, and of a skepti-
cism which dominated our minds at the
outset, as to its possible value, we must
confess to having verified at least some of
the reported successes of more competent
observers, in evidence of which we have
here living witnesses — many of the patients
themselves, who have undergone treatment
by this means — to testify to its efficacy.

After giving the salient features in the
history of each case, it may be wTell for you
to note the number and time of the sittings,
the pole that was placed in the vagina or
uterus, the intensities as expressed in mil-
liamperes, and the results. A demonstra-
tion of the galvanic apparatus, with an ex-
planation of its mode of action, and the
treatment of a case in your presence, will
occupy our attention at a subsequent lecture.

Case 1. Mrs. G , aet. 21, married.

I removed this woman's uterine appendages
fifteen months ago for- the cure of a septic
salpingitis following a miscarriage. She
made a good recovery. Soon afterwards,
however, she began to have profuse uterine
hemorrhages, recurring at irregular in-
tervals, and continuing from one to three
weeks. Every medical resource known to

1 Delivered at the Jefferson Medical College Hos-
pital, December 9, 1890.

me was tried and failed. On May 13,
1890, after she had bled for more than three
weeks, a positive intra-uterine application
of galvanism was made, 60 milliamperes for
five minutes, with the result of arresting the
bleeding within twelve hours. Since then
she has had a mere " show " but once, ex-
tending over a period of two days. She
'is now in the enjoyment of excellent health.

Case 2. November 18, 1889, I was
called to see Mrs. S , who gave the fol-
lowing history : age forty-two, married, orle
child nineteen years old, no miscarriages. Six
years ago she began to suffer with menor-
rhagia. She continued to grow worse with
time, until within the last two years, she
seldom knew of a day that she was " well,"
the hemorrhage having become almost con-
stant, and at times so excessive that she was
frequently obliged to resort to the use of
tampons, and to take to her bed for weeks in
succession. She stated that she was con-
fined to bed almost half the days of the
year, because of this trouble. At the time I
was first summoned she had been in bed for
more than nine weeks, flooding incessantly,
save when this was temporarily arrested with
tampons. Her weakened pulse, sunken eyes,
blanched face and bloodless appearance of
the local and vaginal mucous membranes,
at once told the story ; and, although she
had been under the care of intelligent prac-
titioners, men of large therapeutical resources,
the bleeding during all of these nine weeks
had not been checked for even a single day.
After the removal of a cotton tampon, and
the vagina being cleared of clots, blood was.
seen issuing from the uterine canal. The
uterus was found to be enlarged, of a glob-
ular form, and freely movable. The anterior
lip appeared to be the seat of a small intra-
mural fibroid. The uterine cavity measured
four inches. Fibroid uterus was diagnosti-
cated. An intra-uterine positive galvano-
chemical caustic application of fifty milliam-
peres of five minutes' duration was made ;

404

Clinical

Lecture.

Vol. lxiv

with the result of arresting the hemorrhage
at once. Four days later a second applica-
tion was made, of seventy milliamperes, for
five minutes. Six days more elapsed and I
found the patient sitting up with no hemor-
rhage. A third application was made, pos-
itive, intra-uterine, seventy-five milliamperes,
five minutes. November 30, slight bleeding
recurred and continued for six days. The pa-
tient was about all the while, attending to
household duties. December 9, positive
cauterization, one hundred milliamperes, five
minutes. This was the fourth and last gal-
vanic treatment until the following May,
when five months had elapsed, during which
she menstruated regularly, the " flow " ex-
tending over periods of four and five days ;
no clots, no pain. At this time — May 2,
1890— she was again seized with hemor-
rhages. I was out of the city, and the bleed-
ing continued three weeks. On my return I
found the patient in bed, blanched from loss
of blood. I made a single positive applica-
tion of galvanism, 100 milliamperes, five
minutes, with the result of checking the
bleeding within six hours. Six months have
elapsed since then, and the patient is in
buoyant health and menstruation has been
regular, lasting three and four days. A bi-
manual examination indicates that the uterus
has been considerably reduced in size.

Case j. Lizzie B , set. 27, single, has

suffered with menorrhagia for four years.
Lately the flow has covered periods of three
weeks and more, with intervals of only seven
and eight days. She suffers with frequent
attacks of frontal headache and vertigo, and
is extremely nervous and apprehensive. The
mucous membranes in general present a
blanched appearance. Within the past few
years she has lost considerably in weight.
Uterus retroflexed but movable, posterior
wall the seat of a fibroid the size of a small
lemon. June 20, 1890, the patient states
that she has been bleeding continuously for
three weeks. An application of galvanism,
negative, intra-uterine, 40 milliamperes, five
minutes, was made. Three days later, still
bleeding ; another negative application, 60
milliamperes, five minutes. Four days more
elapsed, and she came to the clinic paler and
weaker than at any time before, stating that
since the previous treatment she had been
confined to bed because of the excessive
flooding. Blood was still issuing from the
uterus quite profusely. A " positive " ap-
plication, fifty milliamperes, five minutes, was
now made, with the result of arresting the

bleeding within twenty-four hours — after it
had persisted for more than four weeks.

Between June 27 and September 1, twelve
intra-uterine positive applications of galvan-
ism were made, with intensities of from fifty
to one hundred milliamperes, five minutes.
After the last treatment the patient was
taken with colicky pains in the abdomen, at-
tended with nausea, loss of appetite and vio-
lent frontal headache, confining her to bed
for a week. The last application no doubt
excited a certain degree of pelvic inflam-
mation.

This is the only case of all I have had
under treatment in which such an unfortu-
nate complication resulted. The patient has
no symptoms at present that indicate perma-
nent disability as a result of the attack.
She has menstruated regularly since July,
the flow covering periods of eight and nine
days, and being profuse but not painful.
The size of the fibroid has remained station-
ary. She has gained ten pounds in weight,
and the signs of blood deterioration are no
longer present.

Case 4. Mrs. R — — , set. 38, married for
nineteen years, no children. The patient,
on presenting herself at the clinic, had a
large, smoothly-rounded fibroid tumor of the
uterus extending to within an inch of the
ensiform cartilage. She suffered from con-
stant backache, vesical tenesmus, rectal
distress, and a feeling of fulness, tension, and
dull pains throughout the pelvis, shooting
into the thighs — the latter symptom being
especially annoying. From November 1,
1889, to November 26, 1890, twenty-nine
negative intra-uterine applications of gal-
vanism were made; the intensities varying
between 100 and 150 milliamperes, five
minutes. To-day we have a report to make
as follows : She menstruates regularly without
pain, the periods covering from three to five
days, flow not excessive. The sensations of
fulness and tension are very decidedly re-
lieved. The vesical tenesmus, rectal distress
and abdominal pains and the pains in her
limbs, have all disappeared. One year ago
her girth measurement at the umbilicus was
thirty-four inches, at present it is thirty
inches ; and, since this difference obtains with
reference to all the measurements taken, I am
sure you will not consider it extravagant
when I say that this tumor has decreased in
size to the extent of at least one-fourth its
original bulk one year ago.

Case 5. Mrs. N , set. 24, married eight

years, four children, one miscarriage nine

April ii, 1891.

Clinical

Lecture.

405

months ago after six weeks' gestation, to
which she attributes her present ailments.
Ever since she has had a profuse bloody dis-
charge recurring at intervals of two weeks
and less, at times only a few days inter-
vening between the attacks, continuing for
from several days to four and five weeks at
a time. It is clotted and attended with con-
siderable suffering. Sexual intercourse is
painful, and frequently causes bleeding.
She has severe occipital headache during
menstruation. She has constant sacro-in-
guinal pains of a dull character, and a feel-
ing of weight and dragging in the pelvis ;
all of which, as well as the hemorrhages,
when present, are aggravated by exercise.
The uterus is retroflexed and movable, the
cervix enlarged and highly congested, the
uterine canal patulous and measuring three
and a half inches.

The bleeding was arrested within a few
hours after making a positive intra-uterine
application of galvanism, 50 milliamperes,
five minutes. On June 30, 1890, fourteen
days after the first treatment with the bat-
tery, the menses appeared and continued
for three days, profuse, but not painful.
The fourth and last application of galvan-
ism was made August 25, seventy-five mil-
liamperes, five minutes. Since treatment
was discontinued she has menstruated four
successive times, at intervals of twenty-eight
and thirty days, with an alrnost absolute
freedom from symptoms. She is no longer
distressed with the sensations of weight and
bearing down, sexual intercourse provokes
neither pain nor bleeding, and she has been
free from headache since electrical treatment
was first instituted, save an occasional twinge
during menstruation. The uterus is reduced
in size, the canal contracted, but the flexion
remains.

Case 6. Bessie F , aet. 19, married one

and one-half years, never pregnant, menses
at fifteen, regular before marriage, continu-
ing seven days, not painful. Shortly after
marriage menstruation began to recur at
shorter intervals than usual, until it appeared
every two weeks ; it continued from seven to
ten days, clotted-, and attended with excru-
ciating colicky pains in the lower abdomen
and pelvis. This still persists, and is be-
coming more pronounced with each suc-
ceeding period. The inter-menstrual periods
are characterized by a constant feeling of
distress over the hypogastrium, amounting —
at times — to actual pain, severe enough to
keep her awake at night. After five months'

treatment with the dilator, combined with
constitutional and intra-uterine medication
without benefit, she was referred for electri-
cal applications. The uterus was anteflexed
and movable, the os the site of a mucoid dis-
charge, the vaginal vault tender to the touch.
Just before treatment with the battery was be-
gun she had been bleeding almost contin-
uously for more than a month. September
22 to October 10, 1890, four positive intra-
uterine applications of galvanism were made,
the highest intensity administered was sixty
milliamperes, the lowest Torty, for five min-
utes. September 29, three days after the
second treatment, the menses appeared, cov-
ering a period of five days, and painless.
Exactly twenty-seven days had elapsed be-
tween the periods — a thing that had not
occurred for more than a year before. The
menses came at the regular time in Novem-
ber, lasting five days and being painless.
Patient now has neither a pain nor an ache.

Case 7. Mrs. A , aet. 33, married fif-
teen years, two children, third and last preg-
nancy ten years ago, miscarriage after three
months' gestation, which was attended with
excessive flooding. For a period of more
than five years subsequently she suffered from
frequent and profuse uterine hemorrhages.
At present she has what might be termed
her regular menstruation at intervals of
about four weeks, the "flow" continuing
for eight and nine days, profuse, clotted
and painful. The inter-menstrual periods
are characterized by occasional hemorrhagic
discharges, variable in quantity, but not ex-
cessive. Sexual intercourse is painful, and
frequently followed by bleeding. She suf-
fers from constant inguinal and hypogastric,
dull, aching pains, and from a feeling of
weight and distress in the pelvis ; all of
which are aggravated at the time of the
menses and following undue exercise. The
only time at which she enjoys comparative
comfort is while lying in bed. The uterus
is in the first stage of prolapse, movable,
enlarged and rigid. The cervix is of a pale,
ashy color, and enormously enlarged. The
uterine canal is patulous, and the site of an
ichorous, watery discharge. The cavity
measures three and one-quarter inches.

Between July 29 and September 5, 1890
(38 days), five negative intra-uterine appli-
cations of galvanism were made, the inten-
sities varying between fifty and seventy-five
milliamperes, for five minutes. She has men-
struated regularly and has been absolutely
free from pain since August last. She has

406

Clinical

Lecture.

Vol. lxiv

had no bleeding since July. Sexual inter-
course is neither painful nor followed by-
bleeding. The uterus is reduced in size and
the canal measures less than three inches,
and is contracted and free from discharge.
The patient states that she has not been so
well for ten years past.

Case 8. Mrs. C , aet. 45, married 13

years, two children, one miscarriage twelve
years ago, after a six and a half months preg-
nancy, attended with convulsions, and exces-
sive flooding. The convalescence was pro-
longed, several months elapsing before she
was able to resume household duties. The last
child was born five years ago, after a normal
labor. She dates her present trouble from the
miscarriage, after which her menses became
more profuse and painful. She has been suffer-
ing with constant, heavy, dragging and dull^
pains through the pelvis ever since, with pain
in the back and groins, all symptoms being
aggravated on locomotion. At that time
menstruation was continued for a week and
longer, was abnormally free, and very pain-
ful for several days preceding and during
the "flow." Leuchorrhcea was profuse.
Micturition was frequent at the time of the
menses. She had vertical and occipital
headache, with frequent nausea and vomit-
ing. The hypogastrium was tender to pres-
sure. The uterus was low down in the va-
gina, enlarged and movable; the cervix
passively congested, eroded and enormously
enlarged, the uterine canal patulous, measur-
ing four inches, and the site of a profuse
muco-purulent discharge. The vaginal vault
was extremely tender to the touch. The
abdomen was enlarged and pendulous, re-
quiring a binder during the day, and a pillow
to support it at night. The patient has had
twenty-one intra-uterine applications of gal-
vanism, both negative and positive, since Feb-
ruary 3, the intensities ranging from 35 to 75
milliamperes, five minutes. The time elaps-
ing between treatments, owing to the patient' s
inability to come regularly, has varied be-
tween five days and two months. She is
still under treatment.

She has undergone a slow but gradual and
progressive improvement since the day the
battery was first used, both anatomically and
symptomatically. The whole uterus has un-
dergone great diminution in size. The cav-
ity now measures less than three inches,
and there is decidedly less tenderness of the
pelvic floor. The abdominal walls, the pa-
tient herself observes, have regained some
of their lost tone, so that now the pillow

for support at night can be dispensed with.
The menses are regular, continue from three
to five days, and are painless. The general
pelvic distress is much relieved. In her own
words, electricity has done her more positive
good than all other means of treatment
combined for years previously.

Case 9. Agnes F , aet. 27, single, for

a year preceding puberty suffered from fre-
quent attacks of colicky abd ominal pains, and
constant backache. Her menses began at
seventeen, were regular, and continued for
one and a half days, scanty. The very incep-
tion of the " flow " was always attended with
excruciating uterine pains, every moment
contributing to her suffering for from five to
six hours, rendering the free use of morphia,
or whatever narcotic might be at hand, a ne-
cessity. She had been under the constant
care of physicians for years, and was treated
with the battery from Jannaryto July, 1888,
without benefit. She does not know the
kind of electricity that was used, nor how it
was administered. She applied at the clinic
October 28, 1889. The uterus was in the
normal position, and movable, and presented
cervical endometritis. A week later the
cervix was dilated under ether. Four days
subsequently the menses appeared, just as
painful as ever. January 3, 1890, negative
intra-uterine galvanism was used, 45 mil-
liamperes, five minutes. Menses came on in
three days and continued for four days — a
longer period than ever before — with com-
paratively little pain. Two negative applica-
tions preceded the following period, which
began February 6, and continued for five
days, painless. The fourth and last galvanic
treatment was on February 13, 1890, since
which time she has menstruated regularly,
the "flow" continuing for four days with-
out pain.

Case 10. Mrs. G , aet. 28, married two

years and a quarter, no children, complained
of excessive pain on sexual intercourse, the
mere attempt at which excited violent
spasmodic contractions of the muscular
structure of the vagina, and threw her into a
state of nervOus excitement and trembling,
frequently rendering its accomplishment
impossible. The sensibility is of such an
aggravated type, that, as soon as the finger
touches the vulva, this neuro -.muscular
condition supervenes, the patient at the
same time giving evidence of suffering pain,
and evincing great nervous disturbance.
This trouble has been the source of much
unhappiness between herself and husband.

April ii, 1891.

Clinical

Lecture.

407

She was under treatment at this clinic two
- years ago (shortly after marriage) when the

application of cocaine and repeated dila-

lations gave temporary relief. She returned
;with the disease in an aggravated form.

Between September 22 and October 6, 1890,

five applications of galvanism were made,
.vaginoabdominal, 15 to 30 milliamperes,
. five minutes. After the third application
[ the spasm and pain were entirely relieved,
; and coitus was satisfactory. The cure has

remained permanent.

If time permitted I might continue to
j review the histories of ten additional patients

here to-day — cases duplicating some of the
( various forms of uterine disease already

illustrated, and in which the application of

galvanism proved its curative properties to

no less a degree.

j All of these cases had been subjected to
various other modes of treatment previous
; to the employment of electricity, with but
slight benefit in some and none at all in
others ; and in order to be certain that the
i results obtained are the legitimate outcome
of the galvanic applications alone, no other
. means of treatment were resorted to either
; during or subsequent to the use of the bat-
j tery. In some of the cases of chronic par-
enchymatous metritis especially, improve-
. ment would in all probability have attended
1 our efforts much more rapidly, and the end
in view would have been attained with
greater certainty, had the electrical treat-
, ments been supplemented by other thera-
peutic measures — derivative, antiphlogistic
and tonic.

Of six uterine fibroids treated with the
battery, four were more or less hemor-
rhagic in their tendencies ; and in every one
; of them the intra-uterine application of the
I positive pole proved its hemostatic properties
, immediate and remote, and the results ob-
tained have been lasting. In only two of
1 the cases has there been a positive and
indisputable reduction in size. When we
consider, however, that this was the object
in view in but three of the entire number
of cases treated, it certainly speaks well for
the battery. The case in which it failed
was a fibroid of enormous size. The patient
was under treatment about six weeks, during
which the tumor kept on growing at its
usual rate. After the eighth application the
patient ceased coming to the clinic, and was
lost sight of.

Where the object was to arrest hemor-
rhage alone, the tumors being small, and

giving rise to no other untoward symptoms,
the indication being met, the treatment was
discontinued. In none of the latter has
there been any increase in size. On the
other hand, I cannot say that any have
grown smaller; slight changes may have
taken place, but owing to their location,
the sense of touch — a most uncertain means
of measurement — is our sole reliance in
determining their dimensions.

The use of galvanism in the treatment of
pelvic adhesions and uterine displacements,
save in so far that it often corrected con-
comitant diseased conditions of the organ
and relieved symptoms, appears to have
given negative results. But you must not
accept my statements on these questions as
conclusive. I may have failed where others
more skilled in diagnosis, and more dexter-
ous in the use of apparatus, and possibly
less timid than myself in applying heavy
currents, might have succeeded, and with
an increasing experience my views in some
respects may undergo a change.

Not every woman coming to your office
having a chronic endometritis should have
an electrode thrust into her uterus. There
are certain diatheses, and diseased conditions
of other organs, as well as feebleness of
constitution that predispose to the develop-
ment of this disease, so that it often is but
one of several diseased mucous membranes,
the result of a special tendency of a consti-
tutional state. Turn your attention to the
predisposing cause first ; the endometrium
may require attention, but not always. Hem-
orrhage from the uterus even must not be
regarded as an invariable evidence of disease
of the organ per se ; it may be, and often
is, an expression simply of a general vascu-
lar tension, or other constitutional condition,
depending upon alcoholic excess, diseased
state of the blood-vessels, heart, liver or kid-
neys, or of impairment of nervous func-
tion, which simple hygienic measures and
intelligently applied pharmaceutical remedies
may correct without any intra-uterine tinker-
ing whatever. Just so with diseased states of
the parenchyma of the organ ; electricity
should be regarded as an auxiliary in their
treatment, and not as a " cure-all " to be
used in every case, and to the exclusion of
everything else. Always bear in mind that
a chronically inflamed uterus is enlarged,
that it drags upon surrounding structures,
and that, owing to interference with the re-
turn circulation, it is in a state of constant
passive congestion. In conditions like this,

408

Communications.

Vol. lxiv

five things are always in order — rest, tonics,
saline cathartics, hot vaginal injections, and
glycerine tampons. These of themselves,
diligently applied, will often bring about vast
improvement, and effect a cure in not a few
cases. These things considered, we think of
the electrode last, because every intra-uterine
operation carries with it a certain amount of
risk, and nothing should be introduced into
the uterine cavity unless it is specially indi-
cated to obtain a definite object in treat-
ment.

It follows, therefore, that a gynecological
electrician, above all, should be a good, all-
round general practitioner, with special ex-
perience in the treatment of pelvic disease.
A correct diagnosis is of first importance
to successful treatment, and the mere spe-
cialist, who sees nothing except through a
vaginal speculum, who concerns himself
little about the value of drugs and properly
regulated regimen, and whose therapeutic
armamentarium consists of an applicator, a
knife, or an electrode, will frequently fail to
give relief, and often do positive harm.

Gynecological diagnosis, among the most
experienced, is often difficult and obscure.
Dr. Joseph Price reports cases in which ec-
topic gestation has been diagnosticated as
ovarian cystoma, pyosalpirix and fibroid
tumors. Fibroids have been denominated
ovarian cysts and vice versa. Dr. Anna
Fullerton reports a case in which a small
dermoid cyst had been called a prolapsed
ovary, another of " retroflexed uterus fixed
by adhesions with hematosalpinx of one
side, and hydrosalpinx of the other, accom-
panied by hemorrhage, which had been
thought to be in a condition resulting from
miscarriage, and curretting of the uterus
was advised, or the application of electricity
to the endometrium." An error in diagno-
sis, such as the one made in the last case,
might have proved fatal to the patient had
the treatment originally advocated been
carried out.

In the present state of our knowledge of
pelvic disease, great caution should always
be observed lest we do harm by the applica-
tion of local measures hastily adopted.
Founding my convictions upon individual
experience, in connection with what I have
witnessed at the operatftig table, I, to-day,
do not consider it a safe procedure to make
cauterizing intra-uterine applications of gal-
vanism, if evidence of disease of the uter-
ine adnexa is present. That disease of the
appendages exists, is sufficient warning, be-

cause it is no more given to a gynecological
electrician to make an exact diagnosis than
it is to the abdominal "surgeon whose pre-
conceived opinions are often shown to be
erroneous by what he finds on " section."

Communications.

SUGGESTIONS FOR ABDOMINAL.
OPERATIONS AND AFTER
CARE.

BY WM. GOODELL, M. D.,

PROFESSOR OF GYNECOLOGY IN THE UNIVERSITY OF
PENNSYLVANIA.

[The following is. the form of letter pre-
pared by Prof. Goodell, to be sent to physi-
cians for whom he expects to perform an
abdominal section. It furnishes full in-
structions in regard to the preparation for
operation and the after care of the patient,
with the necessary apparatus and appliances.]

Please procure the following articles for
the operation of abdominal section to be

performed , at o'clock, on

your patient, .

Two yards rubber plaster.

Two rolls of raw cotton, which have been
well baked in an oven, and while hot care-
fully wrapped up in clean brown paper.

Two yards and a half of all-wool flannel,,
for two binders.

Two pounds of ether, together with an
Allis's inhaler ; or else a clean towel without
a fringe, and a newspaper, with which . to
make an ether-cone.

Two ounces of Monsel's solution of iron.

One gallon and a half of a 5 per cent,
solution of crystalized carbolic acid.

Half an ounce of iodoform.

Some antiseptic cotton and some tablets
of corrosive sublimate.

Whiskey, with cup, spoon and sugar.

A pin-cushion, with large pins and safety-
pins.

A washstand, with pitcher, basin, slop-jar^
soap and nail-brush.

One china basin for the sublimate solu-
tion.

Two new tin basins, and one tin cup.
A bucket and a pitcher of hot water.
A small tub and an empty bucket.
Two kettles of boiling water, ready on the
range.

Pure cold water in abundance, that has-
been boiled and kept in covered vessels.

April ii, 1 89 1. Communications.

409

Two large platters, or meat dishes, to be
used as trays for trie instruments. Or a tin
tray may be made nineteen inches long,
twelve wide and three deep.

' Six bottles filled with hot water and
tightly corked.

Three clean kitchen aprons for the opera-
tor and his assistants.

One small table for the basins.

Two tables on which to operate, each one
not less than four feet long, and about two
feet wide. Or an operating table may be
made twenty-two inches wide, thirty-one
inches high and six feet long.

One empty wine-bottle for the aspirator.

One clean blanket for patient's lower ex-
tremities.

Clean towels, clean sheets, clean blankets.

Clean comforters and clean pillows.

Have all the foregoing articles in the
room in which the operation is to take place.

Early in the morning of the day preced-
ing that of the operation, let your patient
.get her bowels thoroughly opened — prefera-
bly with Rochelle salts — and afterwards eat
sparingly of liquid food. Next morning her
lower bowels are to be moved with an enema
of soap and water, and the vagina is to be
washed out with a douche of a 1 : 2,000 so-
lution of mercuric bichloride. She should
then take a warm soap bath, be washed clean
by her nurse, put on clean night-clothing
and go to a clean bed.

To avoid ether-vomiting her breakfast
should consist merely of tea and toast, or of
a cup of beef-tea, or of a goblet of milk,
and, thereafter, she must eat nothing more.
She must not get up, but must stay in bed
until the hour fixed upon for the operation,
-when she should put on a flannel sacque and
woolen stockings and drawers. The bed-
stead, on which your patient is to lie after
the operation, should be furnished with a
mattress and not with a feather-bed.

The room in which the operation is to
take place ought to be a separate one, so that
the patient may be etherized in her sleeping-
room, and not be unnerved by witnessing
the needful preparations. Several days be-
forehand, the carpet of this operating room
should be taken up, and the curtains taken
down for good. The closets and bureau-
drawers should be emptied, and the whole
room — floor and walls — be thoroughly
■cleansed and aired. Early in the morning
of the day fixed upon for the operation, this
room must be heated up to at least 700.
After the operation your patient may oc-

cupy whichever of these two rooms she pre-
fers.

Not more than two assistants — viz., your-
self and another physician — will be needed,
and bearing in mind that the most common
cause of danger from this operation is septi-
cemia, let both of you take a soap-bath, put
on clean clothing, and avoid seeing on that
morning any case of zymotic or of conta-
gious disease. Let these precautions be ob-
served also by those medical friends whom
you may invite to see the operation.

The treatment after the operation needs
careful attention. Your patient must be made
warm with the hot-water bottles, and be kept
perfectly quiet. For several days no one
should see her but yourself and the nurse.
For obstinate vomiting, which comes partly
from the ether and partly from the shock,
whiskey or chloral, or the wine of pepsin
may be given in small doses, frequently re-
peated. Sips of very hot water, or a table-
spoonful every hour of a mixture containing
equal parts of lime-water and of cinnamon-
water, are also good remedies. If the vom-
iting is very stubborn, a hypodermic injec-
tion of morphia will often allay it ; so also
will one of atropia. I have seen it yield to
frequently-repeated doses of five grains of
bismuth, one drop of dilute hydrocyanic
acid and three drops of wine of ipecac-
uanha. Flatus is another very annoying
symptom, which, however, can very gener-
ally be dispersed by turning the patient on
her side and inserting a flexible catheter as
high up the rectum as possible. If this fails
to relieve it, or the temperature rises simul-
taneously with its appearance, saline cathar-
tics should be given, aided, if needful, by
turpentine enemata. A very safe rule to
follow is, to open the bowels whenever wind
does not escape per rectum and tympanites
begins to show itself.

For the first twenty-four hours after the
operation nothing whatever should be given
to the patient excepting sips of hot water or
of hot tea without sugar or milk, and an oc-
casional teaspoonful of old whiskey ; but
even these should be given sparingly. After
that time, tablespoonful doses of milk, of
beef-tea, or of barley-water may be given
every two hours. This diet must then be
gradually increased, and especially if wind
begins to escape from the rectum. If, dur-
ing the first twenty-four hours, nourishment
seems indispensable; or if, later on, more
nourishment than that given by the mouth
is needed, you must resort to nutrient en-

Communications.

Vol. lxiv

emata of peptonized milk, or of beef-tea
with whiskey.

Should the patient be able readily to
pass her water into a urinal, it need
not be drawn off. Otherwise, it must be
drawn off regularly every six hours for the
first two or three days. Later than this, the
catheter need not be used so frequently, but
only when the patient wants it. On the
morning of the third or the fourth day, even
earlier if tympanites appears, the bowels must
be opened, preferably with saline cathartics,
and thereafter they are to be moved every
other day. The cathartics which I prefer
are teaspoonful doses of Rochelle salts every
hour, or a Seidlitz powder every two hours.

No anodyne whatever need be given, un-
less called for by great pain, or by excessive
restlessness. Should the body-heat indicate
a temperature of ioi° or over, an ice-cap
or a bladder filled with ice should be kept
on the head of the patient as long as it
does not chill her, and it feels comfortable.
Peritonitis, or other septic symptoms, must
be treated with ice to the pit of the stomach
in addition to that on the head, and with
brisk saline cathartics followed by large
doses of quinia, and by morphia enough to
allay the pain.

If a drainage-tube has been put in, it is to
be sucked out dry every two, three or four
hours, by means of a small syringe to the
nozzle of which a short piece of rubber-
tubing has been attached. Every time this
is done, a fresh piece of sublimated cotton
is to be placed over its mouth. Twice a
day should the drainage-tube be lifted up
half an inch, and turned wholly around on
its axis. Unless this is done fringes of
the omentum, or shoots of organizing lymph
may get into the tube-holes, and by swell-
ing up inside of the tube, prevent it from
being withdrawn without great and danger-
ous violence. The drainage-tube is to be
removed whenever the fluid withdrawn from
it becomes clear and straw-colored likeserum.
The opening left in the wound must be
dusted with iodoform and covered with sub-
limated cotton or gauze.

The dressing, being antiseptic, need not
usually be changed until a/week has passed.
Every stitch may then be removed," and the
wound may be washed with a 1:2,000 mer-
curic solution, dusted with iodoform and
supported with long and narrow strips of
rubber plaster. Over this some sublimated
cotton or gauze should be placed, and over
all a clean binder. For fear of a weak cic-

atrix and the formation of a hernia at the
site of the wound, the patient should not
get out of bed for at least two weeks, and
should for six months more wear some kind
of gored binder, or an abdominal supporter
like "The London Supporter."

If the foregoing directions do not cover
every point or do not meet every contin-
gency that may arise, do not hesitate to con-
sult me by letter or by telegraph as often as
you may wish.

LAPAROTOMY IN INTESTINAL OB-
STRUCTION.— REPORT OF A CASE.1

BY ALEX. McALISTER, M. D.,

CAMDEN, N. J.

The time for operation in cases of intesti-
nal obstruction is when the diagnosis is
made, and before complications and struc-
tural lesions have taken place in adjacent and
remote organs, and when the patient is in
the best possible condition for operation.
Surgery has made rapid strides, and in no
special field has there been more advance
than in intestinal surgery. The mortality
from delay, incorrect diagnosis, timidity, ig-
norance and prejudice in the past has been
very high. We have a safe and reliable,
speedy and accurate method of diagnosis of
intestinal obstruction, namely, Senn's hy-
drogen gas inflation of the intestines. Senn
deserves much praise for his inventive genius,
originality and experimental research in in-
testinal surgery. Keith, in speaking of the
failures in abdominal surgery and hindrances
to its progress, states that most of the in-
jury has been done by the surgeon himself.
Time waits for no surgeon. Delays are dan-
gerous. Formerly, the phrase, "obstructed
bowels " was synonymous with death. To-
day it means : use the test, operate, remove
the cause and let the patient live. When
done early by expert surgeons, and before
structural lesions have ^formed, laparotomy
for intestinal obstruction will have as small
a mortality as ovariotomy. The physician of
the present and future, who is not equipped
to make the special diagnosis of ob-
struction, operate for the removal, or have
a surgeon operate, and before serious tissue
lesions have taken place, is most certainly
highly culpable and derelict of duty.

1 Read before the Camden County Medical Society,
February, 1891.

April ii, 1 891.

Communications,

411

The best time to operate is when the di-
agnosis is made, and made early. Wyeth
states : " Do not wait longer than the le-
sion of intussusception is recognized. Within
the first twenty-four hours the prognosis will
be more favorable, and the danger of a
fatal termination will be increased with each
day thereafter. ' ' If volvulus is not removed
within a few hours by other treatment, ab-
dominal section should be performed, the
hand should be introduced and the loop
should be untwisted. Constriction by bands,
the vermiform appendix, the pedicle of an
ovarian or uterine tumor, the Fallopian tube,
diverticula, strangulation through slits in the
omentum and mesentery and adhesions be-
tween the contiguous loops of intestines, de-
mand early operative interference, as do all
other forms of intestinal obstruction. That
taxis should not be done longer than five or
ten minutes at any one effort. It may be
repeated at intervals of half or one hour,
within the first six hours of the history of
strangulation. After twelve hours, it should
not be practiced. The majority of cases
which end fatally are those in which stran-
gulation has existed twelve or twenty-four
hours or more before surgical interference.
Abdominal section under asepsis and anti-
sepsis in a patient not exhausted by suffer-
ing or disease, is almost free from danger,
when done early by a surgeon skilled in the
technique of intestinal and abdominal sur-
gery.

Scientifically practiced massage and taxis
have a limited range of application in the
treatment of intestinal obstruction. They
are applicable to cases of obstruction due to
a foreign body, an enterolith or fecal accu-
mulations, and should be resorted to only
before inflammatory changes have developed
at the seat of obstruction, and while the pa-
tient is under anaesthesia. The rule now is
not to wait hours, or a day, to do taxis, but
to do it only for fifteen minutes, and never
over thirty.

Senn states : " True intestinal obstruction,
whatever its cause may be, is as strictly
a surgical affection as strangulated hernia,
and remediable only by the same kind of
surgical treatment." To let a patient die
of the consequences of a removable cause of
obstruction, without an operation, is a re-
flection upon the advances of modern ag-
gressive surgery. In doing an abdominal
section for obstruction, the aim of the sur-
geon should be to save life, to operate
quickly, safely and cautiously, and not to

do an ideal operation, but to economize
time, minimize shock, lessen the stage of
anaesthesia, prevent unnecessary extrusion
of the bowels, and protect them with hot
aseptic towels ; to irrigate with hot aseptic
water, and prevent complications, making
all the details of the operation aseptic from
beginning to end.

The technique of this operation has been
much simplified by Senn's intestinal anas-
tomosis, lateral apposition, lateral implan-
tation and intestinal exclusion, and Senn's
modification of Joberts' operation by cir-
cular enterorrhaphy, will greatly lessen the
mortality of intestinal obstruction in the
future.

On July 14, 1890, I was called in consul-
tation by Dr. Kensinger, to see J. S.,
thirty years old, born in Poland, by occupa-
tion a painter. He had been suffering with
symptoms of obstruction for about four days.
His abdomen was distended and tympan-
itic, and there was some dulness in the
right flank. His extremities were flexed ;
and his expression anxious. He had fecal
vomiting and great and frequent abdominal
pain, referred to the umbilicus. His pulse
was 130; his temperature io2-|°; his re-
spirations 30.

I urged immediate operation, which was
readily assented to by the patient and his
relations. I operated, being assisted by Drs.
Kensinger and Sherk. The patient was
etherized, an incision five inches long
was made in the linea alba, between the
umbilicus and the pubes. Several loops of
intestine presented, which were immediately
covered with towels wrung out of hot water.
Passing my hand into the cavity, after care-
ful examination, I found a loop of ileum
about eight inches long, about two inches
below the umbilicus, twisted upon itself from
left to right. The omentum was pushed
firmly against it, and the part of the intes-
tine where the twist existed was very dark
in color, and looked gangrenous. I also
found small spots throughout the small in-
testine which also looked gangrenous, and
the intestines were congested looking, and
very much distended with gas, which
escaped by the rectum, after the twist was
released.

Irrigation was copious and thorough, and
some water was left in the cavity. No
drainage was used. The incision was closed
with silk. The duration of the operation
was about a half-hour. An antiseptic
dressing was applied, and the patient was

412

Communications.

Vol. lxiv

placed in bed. Very little shock followed the
operation, and no vomiting. Reaction was
rapid. The bowels were freely moved. In
less than an hour after the operation the
patient was given drachm doses of sulphate
of magnesia, every two hours, and by the
next morning he had passed a house-bucket-
ful of feces. His temperature was ioo°.
After this convalescence was uneventful.

Two weeks from the time of the operation
he was back at his trade, and he has been
perfectly well up to date.

ARTERIO- CAPILLARY FIBROSIS.

BY AUGUSTUS A. ESHNER, M. D.,

PHILADELPHIA.

Every cell inherits from its parent cell a
certain lease of life, .at the end of which
physiological death occurs. This period,
however, may be influenced by external
conditions. Premature death is pathologi-
cal. We cannot recognize a pathological
longevity. Similar laws apply to the human
individual, the composite of a vast aggre-
gation of cells of widely differentiated func-
tion.

The life of man may be divided into three
periods : that of evolution, of growth, of
development; that of maturity, of perfec-
tion ; and that of involution, of decline.
The first begins with birth, the last ends
with death.

During the period of growth and devel-
opment, tissue-change and destruction —
catabolism — are more than offset by tissue-
construction and repair — anabolism. Nu-
trition exceeds waste. Building-up is more
active than tearing-down. With the activity
of life comes the demand for the highest
differentiation of function of which the or-
ganism is capable. This represents the per-
fect individual. For a time, a condition of
equilibrium is maintained. Sooner or later,
however, the tide begins to turn. The equi-
librium is disturbed. Waste exceeds repair.
The cellular assimilative function becomes
impaired, the constitution of the nutritive
fluids defective. Tissues and organs are
imperfectly furnished with the materials for
their maintenance. Vascular changes occur.
In a vicious circle, one baneful influence
reacts upon another. The entire 'organism

1 Read before the Philadelphia County Medical
Society, March II, 1 89 1.

is reduced to a condition of deterioration.
Finally, the state of nutrition falls to so low
a level as to be insufficient for the purposes
of life, and functional activity comes to a
standstill. This is the physiological pro-
cess, as it occurs at advanced age, and con-
stitutes the condition of senility. Occur-
ring at an earlier period, however, the pro-
cess becomes pathological, recognized clin-
ically by signs and symptoms which may be
conveniently included in the designation
premature senility.

As the component parts of the organism
depend for their sustenance upon the nutri-
tive elements of the blood, so will their
functional stability be governed by the
quality and quantity of the circulating me-
dium. Thus, we would be led to look to the
blood as containing the excitant which in-
duces the earliest changes. The function
of the cell once impaired, the deleterious
action of the blood would be augmented by
the retention of matters which it was the
part of the cell to remove, and the addition
of products from the degeneration of the
cell.

Pathologically, the condition under dis-
cussion may be considered a general fibrous
substitution and hyperplasia, displacing
parenchymatous structures and narrowing
the lumen of arteries and capillaries ; hence
the names arterio-capillary fibrosis, arterio-
sclerosis.

The histological changes may arise in one
of two ways, or in a combination of both.
When tissue degenerates or is destroyed, na-
ture endeavors to make restoration. The
attempt is often only partially successful.
The newly-formed tissue is apt to be of a
lower grade than that which it replaces. The
more highly organized the latter, the wider,
of course, is the variance. In this way, fi-
brous tissue takes the place of vital struc-
ture. This is illustrated in the cicatrix, be
it cerebral or cutaneous or parenchymatous.
Under other circumstances, there occurs a
primary hyperplasia of pre-existing connec-
tive-tissue, perhaps of a subacute or slowly
chronic character, displacing the tissue pro-
per to the organ, and finally leading to its
disorganization. These two processes may
be illustrated by the modern pathological
conceptions of the changes that occur in
certain diseases of the central nervous sys-
tem. In the acute inflammatory disease
known as anterior poliomyelitis, the destruc-
tion of the ganglion cells in the anterior
horns of the gray matter of the spinal cord

April ii, 1891.

Communications.

413

is followed by a reparative process, in which
fibrous tissue replaces that which has been
destroyed. In the systemic scleroses, pos-
terior and lateral ; in the degenerations, as-
cending and descending, primary destruc-
tion of axis-cylinders takes place, with
secondary substitution of fibrous tissue. In
insular sclerosis, on the other hand, there is
at first an increase in the connective-tissue,
followed by gradual destruction of nerve-
elements and interruption of function. The
difference is that between inflammation and
cirrhosis. Solid viscera may be unchanged
in size. They are rarely enlarged, but often
shrunken, from contraction of the fibrous
elements. The coats of the vessels are
thickened, and their lumen narrowed. In
whatever structure the process begins, it is
slowly progressive, especially if the exciting
influence be maintained. The change, as it
affects the arteries, is to be distinguished
from atheroma, with which it may be asso-
ciated. Both are evidences of senile disor-
ganization. In atheroma, however, the
process is one of fatty degeneration of the
intima, giving rise to ulceration, which is in
turn followed by cicatrization and calcifica-
tion. In the one condition, clinically, the
vessel, to the eye and to the examining fin-
ger, is tortuous and resistant ; in the other,
it is rigid and unyielding, like a pipe-stem.
It is the difference between fibrous and cal-
careous infiltration.

The etiological elements concerned in the
production of arterio-capillary fibrosis are
comprised in the group of noxae which we
now know as toxic and infectious, and in-
clude syphilis, alcoholism, lead-poisoning,
gout, rheumatism and infectious diseases in
general. Heredity, too, probably plays
some part in transmitting a predisposition
to the occurrence of fibrous degeneration.

Perhaps the most conspicuous symptom,
and that for which the patient first seeks re-
lief, is shortness of breath on the slightest
exertion. The onset of this condition is so
insidious that the patient is unaware of its
existence, until it is suddenly revealed by a
demand for some special activity. With it is
often associated palpitation, which the pa-
tient is apt to describe as a fluttering of the
heart. The cardiac action is found to be
irregular, perhaps intermittent, with occa-
sional duplication of the second sound or an
abortive first. The second sound is dis-
tinctly accentuated at the base. The pulse
is tense and resistant. The temporal arte-
ries are prominent and tortuous. In addi-

tion, the patient complains of coldness of
the extremities or of numbness or of form-
ication, with, perhaps, some weakness.
There may be vertigo, especially on sudden
changes of posture, lightness in the head, as
the patient says. The memory is impaired,
and there may be headache. The knee-jerk
is frequently exaggerated, but not always.
Often there is tremor, and sometimes nys-
tagmus. In some cases, the complexus of
symptoms approaches that seen in insular
sclerosis, in others that seen in paralysis
agitans, though typical of neither. It may
be that such cases represent incipient stages
of the one or the other of these affections,
which, in their turn, perhaps, may be more
intimately related than we as yet know. Oc-
casionally, we meet with transient paresis and
local paralysis, sometimes ascribed to uremia.
It seems easier to explain the occurrence of
these on the assumption of partial vascular
occlusion. The feef are sometimes swollen.
There is apt to be increased frequency of
micturition of a urine of low specific grav-
ity, but rarely containing albumin or casts.

The train of symptoms here outlined may
be readily explained by the pathological le-
sion. How common it is at autopsies to
find organs the vessels of which gape with
open mouths, while, during -life, the only
condition determinable was such an associa-
tion of symptoms. It is neither nephritis
nor arteritis, neither myocarditis nor cere-
britis, but a diffuse fibroid change, the
manifestations of which are perhaps most
patent in the small arteries. Thus, we see
associated with this condition miliary aneur-
isms in the brain, which we now know to be
so generally antecedent to cerebral hemor-
rhage. In the absence of aneurism, the vas-
cular fibrosis may alone act as a predisposing
cause of rupture. The narrowing of the
cerebral capillaries may become so marked
as to permit of the formation of thrombi
in situ, thus explaining certain cases of
hemiplegia in which cardiac lesion or other
source of embolism cannot be detected. It
is also probably in the thickening of the wall
of the capillary and the narrowing of its
lumen that certain cases of transient or per-
manent loss of power, in which the severity
of the symptoms soon abates, may find ex-
planation. The derangement of cardiac
function is a result of defective nutrition
and innervation. The shortness of breath
is brought about by the cardiac incompe-
tency, by the vascular changes in the pul-
monary structures, and, finally, by lowered

4H

innervation, in some cases aided by concur-
rent emphysema. Other visceral symptoms
are due to changes of a similar nature in the
respective organs. The extremities are cold
because the blood-supply through the nar-
rowed vessels is imperfect.

In the consideration of the treatment of
this condition, not much need be said in
the way of prophylaxis. "All the medi-
cines in the world will not replace right liv-
ing. " It is the secret of longevity.

In the general management of the case,
the individual is to be directed to lead a
tranquil life, to avoid excitement and undue
physical exertion, to partake of a light, nu-
tritious diet, which, with benefit, may in-
clude a liberal supply of milk, and to take
an occasional saline laxative.

Of medicaments, I have personally had the
most gratifying results from the administra-
tion of nitro-glycerin, in combination with
digitalis when the cardiac action is feeble or
its rhythm disturbed. Nitro-glycerin is a
diffusible stimulant, causing dilatation of the
peripheral capillaries, thus permitting a
flushing of the tissues with arterial blood,
and promoting nutrition. By diminishing
the resistance in the vessels, the demands
upon the heart are lessened, while this organ,
being better nourished, is more competent
to carry on its functions. Beginning with
one minim of a one-per-cent. solution three
times a day, the dose is progressively in-
creased one minim every second day, until
physiological effects — flushing of the face,
sensation of a band around the forehead,
headache and , dizziness — are observed.
Probably the most appropriate menstruum is
spirits of nitrous ether, the action of which,
as a nitrate, is synergistic. In administer-
ing digitalis, I like to prescribe two to five
minims of the tincture in two drachms of
the infusion, in this way obtaining the bene-
fit of all the principles of the crude drug
soluble in alcohol and in water.

Strychnine and atropine may prove useful
adjuvants in the treatment. Under certain
circumstances, it may be desirable to substi-
tute strophanthus for digitalis. Caffeine or
cocaine may fulfil certain indications.
Cod-liver oil might be used as a nutrient,
alcohol as a stimulant. Iodide of potassium
is of doubtful utility, except during the ac-
tive stage of syphilis.

The conclusions I wish to record are :
That there is a pathological condition in
which the manifestations of senility occur
prematurely, and that the best means of

Vol. lxiv

combatting it is by improving the general
nutrition and giving tone and stability to
the cardio-vascular apparatus — a healthy
nutritive fluid, with a competent distribut-
ing apparatus.

Periscope.

Use and Abuse of Drainage in
Surgery.

In the Medical Record, March 14, 1891,
Dr. James E. Moore, Professor of Orthope-
dic Surgery in the University of Minnesota,
says : The besetting sin of our profession is
our tendency to go to extremes. We dis-
cover something the judicious use of which
would be of untold value to the human race,
and are not content with its proper use, but
must needs overuse it until its use becomes
an abuse, when a reaction sets in and abuse
is many times followed by disuse. In the
matter of drainage of wounds we are still in
the .stage of abuse. Reaction has already
set in, and inasmuch as proper drainage is
such a vital part of surgery, it is our duty to
study the subject carefully and not allow dis-
use to follow abuse. This reaction first be-
gan in abdominal surgery, and already we
have learned that in a certain class of cases
in which we at one time thought drainage
an essential, we get the largest percentage of
recoveries without drainage. Laparotomists
have pretty nearly arrived at the truth, viz.,
that septic cases and doubtful cases should
be drained, and that aseptic cases are better
without drainage. I fear that in this import-
ant branch of surgery the reaction has a ten-
dency to go too far, and that certain cases
are left without drainage that would be bet-
ter with it. We can also see some reaction
in amputation wounds, where, instead of the
sewer pipes of former days, we use drainage-
tubes of smaller size, or none at all.

We, as members of the grandest profes-
sion on earth, have weighty responsibilities,
and are held strictly accountable for our
deeds and misdeeds, but, being only human
beings, are entitled to the privilege of
changing our views with increase of knowl-
edge. In fact this is the only way we can
advance. The very fact that our responsi-
bilities are such weighty ones should re-
mind us that we should guard against our
besetting sin and avoid extremes. This can
only be done by refusing to accept the ipse
dixit of any man, no matter how exalted his

Periscope.

April ii, 1 891.

Periscope.

4i5

position may be, and by basing our change
of views upon facts, instead of following in
each other's wake like a flock of sheep.

The thorough drainage of wounds has
been considered of primary importance for
many years, but when Chassaignac suggested
the use of drainage-tubes in 1855 his reason
for draining was very different from that of
the surgeon of 1890. He drained to allow
of the free escape of pus. We drain in re-
cent wounds to prevent the formation of
pus. The necessity for drainage in an in-
fected or suppurating wound is universally
understood. The more perfect the surgeon
becomes in his antiseptic methods the less
he needs drainage-tubes and their various
substitutes, and when he arrives at that stage
of perfection in his methods that insures
him an aseptic wound every time he oper-
ates he can dispense with them altogether.
In all recent works on surgery we are ad-
vised to use drainage-tubes to carry off the
excessive discharges from a wound, but we
are not advised to make an opening at the
seat of a fracture to carry off the discharges.
Those who first learned of the value of
drainage in open suppurating wounds, also
learned that Nature took care of the dis-
charges from a subcutaneous wound. When
we have so perfected our methods of wound-
dressing that we can place an open wound in
the same condition as a subcutaneous wound
we will no more think of draining in one
any more than in the other. If a wound is
aseptic Nature will take care of the dis-
charges, just as she does in a subcutaneous
wound. In a simple fracture of the femur
there is much greater effusion of blood and
serum than in any operation wound, and we
never think of draining it off. Nature takes
care of it promptly, the only disturbance
being a transient rise of temperature.

Twenty-five years ago surgeons drained
to carry off the pus. Fifteen years ago they
drained to carry off the discharges so that
they would not putrefy. At the present-
time we drain largely from force of habit.
We no longer believe in spontaneous gener-
ation, or that the discharges putrefy without
first having been infected from without.
Blood in an aseptic wound becomes partly
absorbed and partly organized. Serum
should not be looked upon as something to
be gotten rid of, for it undoubtedly has an
important function to perform in the repa-
rative process. In certain cases that we are
learning more about every day, viz., infected
cases, we must always drain. I maintain,

however, that in aseptic cases drainage by
means of rubber or other open tubes is not
only useless but adds an element of danger.
We learned the value of drainage when sep-
tic surgery was practiced, and notwithstand-
ing the fact that our reasons for drainage
have undergone very radical changes, we
have been using drainage-tubes, too, nearly
like we did at first. The principal differ-
ence is, that we originally allowed the
drainage-tubes to protrude through the
dressings, thereby infecting every wound.
We are now very careful to cover the ends
of the tubes and to allow everything to pass
out, and nothing to pass in through them,
which is an exceedingly difficult matter.
Aside from the fact that a drainage-tube is
a foreign body and interferes with primary
union, the one great danger is that it keeps
an entrance-way open through which germs
may enter and infect the wound.

It is customary to close small wounds in
all parts of the body without drainage with
very satisfactory results. I can see no reason
why a large wound should require drainage
any more than a small one, for the amount
of absorbing surface bears the same propor-
tion to the discharges in the one as in the
other. I believe we have allowed the size of
the wound to influence us too much when
deciding whether to drain or not. The
character and not the size of the wound
should decide the question. I fear that we
have fallen into the habit of draining every
wound without thinking whether it is neces-
sary to drain or not.

I was first led to question the propriety
of draining every large wound by the an-
noyance occasioned by rubber drainage-
tubes after operations upon tubercular joints.
I found that the sinus caused by the drain-
age-tube almost invariably became infected
and prolonged the case unnecessarily. Al-
though I still drain in cases of this kind
when there is a possibility that I may have
overlooked some focus of disease, I never
use rubber rubes, but use strips of iodoform
gauze. In excision of the knee-joint my
happiest results have been in cases where I
have omitted drainage altogether, or have
used a few strands of catgut. I get more
satisfactory results after amputations, after
operations upon breast and axilla, and, in
fact, in all clean-cut wounds, without drain-
age than with it. No one prizes drainage
more highly than I in proper cases, but it is
not necessary in an aseptic wound. Those
who do not work antiseptically must always

416

Periscope.

Vol. lxiv

drain, because blood and serum when not
protected from germs will surely putrefy in a
wound, where all the necessary auxiliaries are
found. The most zealous advocates of drain-
age are those who denounce antiseptic sur-
gery.

It would be amusing were it not such a
serious matter to see how zealous a dirty
surgeon is in the matter of drainage. He
usually carries his rubber tubing in the bot-
tom of his satchel, after taking it from a
dusty drawer in his office, and if he has not
infected his wound earlier in the operation,
always does so when he introduces his tubes.

When carbolic acid was so extensively
used drainage was always necessary, -on ac-
count of the excessive discharge caused by
the acid. Lister, in his address ^before the
last International Medical Congress, said
that it would be a grand thing if we could
do away with drainage altogether, and cited
an instance in which he uses but one tube of
moderate caliber, where he formerly used
four of various dimensions. He speaks of
the time when we shall have found drainage
no longer necessary as the fulfilment of his
early dream. If this great ibenefactor lives
out his expectancy, I feel certain that he
will see this day. The enemies of antiseptic
surgery point to these advances' of Mr. Lis-
ter's as evidence of its decay. But every
fair-minded man knows that there has been
no change of principles.

With all its perfections antiseptic surgery
is far from being perfect yet, and many
changes of detail are necessary, but these
changes instead of being evidences of decay
are certainly advances.

As Mr. Lister suggests, these advances are
all in the direction of the hermetic sealing
of wounds, and this is certainly the ideal
method, as it is Nature's method. The her-
metic sealing of wounds has been faithfully
tried in the past, but the trial was made at a
time when the principle of wound infection
was undiscovered, and it was necessarily a
failure.

Mr. Tait, in his criticism of Mr. Lister's
address, claims everything for drainage. He
says that when all decomposable material is
removed by drainage, germs may be admit-
ted freely. He states that the exclusion of
germs is an impossibility, but does not seem
to understand that perfect drainage is also
an impossibility.

Prof. Erichsen, in some recent remarks
upon this controversy, has certainly sounded
the key-note when he cites the fact that two

elements are necessary for putrefaction in
wounds, viz., putrescible material and in-
fective germs, and says that the disputants
accomplish the same end by different means :
Mr. Tait by removing the pabulum, and Mr.
Lister by filtration of air and by germicides.
He very wisely asks : " Is it wise to be exclu-
sive in the employment of one or the other
of these methods ?"

I am certain that many wounds have been
infected through the drainage-tubes because
it was impossible to keep the ends of the
tubes covered by the dressings. I have
found it very difficult to keep the dressings
close to the wound after radical operation
for hernia, and have gotten much better re-
sults since I began to apply small strips of
iodoform gauze with collodion.

In some operations upon bone and in
Phelps's operation for club-foot, special
effort is made to secure a blood-clot in the
wound, in order that it may become organ-
ized. Ordinarily, however, it is important
to stop all hemorrhage before closing a
wound that we do not wish to drain.

Hematemesis in Gastric Ulcer.

In a very interesting paper on gastric
ulcer — part of which is published in the
Medical Chronicle, February, 1891, Dr.
Dreschfeld, of Manchester, England, says
hematemesis is one of the cardinal symp-
toms, and occurs in about one-third of all
the cases. It may occasionally be one of the
first symptoms, and it does not so rarely
happen, especially in elderly patients, that
hematemesis comes on in apparently good
health. He has seen three such cases within
the last eighteen months. In these cases
large quantities of blood are vomited, some-
times even clots, and melena soon follows.
In cancer of the stomach hematemesis is, he
believes,' never the first symptom, and if in
cases of doubtless cancer, the history shows
that hematemesis was one of the first symp-
toms, we may, he thinks, assume that we
have to do with cancer implanted on an
ulcer. This was seen in two cases under his
care in the Infirmary, and in one case under
the care of his colleague, Dr. Leech, as re-
vealed by the post-mortem in these cases. In
cirrhosis of the liver, and other diseases
causing obstruction to the portal circulation,
hematemesis may be the first or a very early
symptom of the disease ; but the history of
the case, the presence of symptoms point-

April ii, 1 891.

Periscope.

417

ing to alcoholism, and the appearance of the
blood, which is quite liquid and dark col-
ored, help one in the diagnosis. Moreover,
as the blood in these cases is venous, the he-
matemesis is rarely followed by intense ane-
mia, and symptoms of depression. The
hematemesis in these cases acts more like a
venesection, and the patient after the attack
often feels easier than before. The hemate-
mesis in hysteria occurs chiefly in the morn-
ing ; is, as a rule, small in quantity ; and is,
as we know, often due to various artifices
which the patient has recourse to. This is,
however, not as often the case as is generally
supposed ; and as spontaneous hemorrhages
do occur in hysteria, there can be no doubt
that in some cases the blood is really derived
from the stomach. The presence of other
symptoms of hysteria, such as hemi-anaes-
thesia, globus hystericus, hysterogenic zones,
contraction of the field of vision, and so on,
are important aids in the differential diag-
nosis. Such rare cases of hematemesis as
those due to the bursting of an aneurism
into the. oesophagus (the bursting of an an-
eurism into the stomach is extremely rare)
are quickly fatal, whilst hematemesis from
an ulcer is after all rarely followed by death.

When hematemesis is not the first symp-
tom, but occurs, as it often does, only dur-
ing the course of the disease, then the other
symptoms of ulcer such as localized pain
and vomiting, precede it, and the diagnosis
is not difficult.

The vomited matter in hematemesis from
gastric ulcer has occasionally the character
of " coffee-ground vomit," which is gener-
ally looked upon as characteristic of cancer
of the stomach. This occurs at a late
period of the disease, and is due to a slow
and gradual extension of the ulcer, whereby
only minute blood-vessels become eroded,
and the small amount of blood altered by
the gastric juice assumes this peculiar appear-
ance. The vomit is by itself not to be dis-
tinguished from that of cancer, but the
other symptoms present help to distinguish
the one disease from the other.

Profuse hematemesis in gastric ulcer occurs
more especially when the ulcer is situated at
the pyloric end of the stomach, and more on
the posterior than the anterior surface ; this
is due to the arrangement of the blood-ves-
sels. From this follows two important con-
siderations : First, when in gastric ulcer we
get profuse hematemesis, we have, after a
time, from the cicatrization of the ulcer,
contraction of the pylorus, giving rise to

symptoms of dilatation of the stomach.
Second, the ulcer gradually extending in
depth causes, from its position on the pos-
terior wall, adhesion between the stomach
and pancreas, and perforation of the ulcer
in these cases is not likely to happen. It is
different when the ulcer is situated on the
anterior wall, the extension of the tumor in
depth is not likely to lead to any adhesions,
for the constant movement of the abdomi-
nal walls would hinder any such adhesions
to form, and hence the frequent perforation
of such ulcers ; the same holds good if the
ulcer extends towards the lower curvature.
We can thus understand that perforation is
more apt to occur in those cases where there
is no hematemesis, or only slight hemate-
mesis, and where symptoms of pyloric con-
striction are absent.

Open Operation for Strangulated
Hernia.

Dr. Benjamin T. Shimwell, in the Medi-
cal News, March 14, 1891, says :

The classical operation for strangulated
inguinal hernia nas only partly met the re-
quirements. The advance made in surgery,
more especially in that of the abdomen, has
allowed a greater liberty of action, which
seems not to have been properly taken ad-
vantage of in the treatment of this condi-
tion. This paper is written to show the ad-
vantage gained by the open method of op-
erating— that is, cutting directly through all
the tissues of the tumor, including the ex-
ternal ring, internal ring and, if necessary,
the abdominal wall, converting a simple
herniotomy into a hernio-laparotomy. The
condition of the protruding gut is modified
by its pre-existing condition, the size of the
protrusion, the length of time of strangula-
tion and the position of the constriction.
An old incarcerated hernia with a sudden
increase of the protrusion and consequent
constriction gives an abnormality in relation
of structures and their component charac-
ters, that has no resemblance to an acute
case and causes a difference in the ultimate
results of treatment. The size of the pro-
trusion is not so much a factor in causing
constitutional symptoms as is supposed. I
have seen as violent symptoms in a small
protrusion as in one of greater size.

The length of time of constriction also
modifies structural capacities, and directly
influences the result. The point of con-
striction may be at either the external or in-

I-

4i8

Periscope,

Vol. lxiv

ternal opening, or, what is often overlooked,
the true constriction may be the neck of the
peritoneal sac, the inguinal rings acting
merely as a barrier to the return of the gut
and not as a true constrictor.

A careful consideration of these proposi-
tions opens a field of thought that must of
necessity show the inefficiency of the nick-
ing of the external ring from below. The
extension of the incision cannot be said to
complicate matters by increasing the risks.
It is settled beyond peradventure, that care-
ful increase of a few inches in the length of
an incision, whether in the abdomen or any-
where else, does not increase the risks.

Compare the old method with the cer-
tainty of work and view of field, the defi-
nite knowledge of conditions of the injured
gut, and the lessening of risks which were
due to handling of gut by the drawing down
preparatory to reduction. Would an ab-
dominal surgeon operate in a case with
marked adhesions through an opening of
the same size that he would in a simple un-
complicated oophorectomy? Working in
the dark is prolific of bad results. It is not
in the power of any man who operates for
strangulated hernia by the old method to
tell with certainty the condition of the
bowel, and thus it is that many cases end in
death by inflammation of, or ulceration and
necrosis of the bowel at the point of con-
striction. The condition of the congested
bowel is the point always to be regarded in
determining whether it will regain its nor-
mal state. To me it seems that not enough
importance is laid upon the condition of the
tissue at the point of constriction. There is
often an amount of injury done that causes
the most serious results. There is the ques-
tion of necrosis, which is one of importance,
and then also the loss of nerve vitality by
constant constriction, which is often marked.
I have seen this persistent at the end of days,
the obstruction still remaining.

Paralysis of a portion of the bowel pre-
vents fecal circulation ; the bowel forces its
contents to this point, and then is unable to
send them further. Gas and fecal matter will
enter a paralyzed portion. Continuous ac-
tion is a necessity. As a proof of this point,
a patient upon whom I had performed hys-
terectomy died suddenly from tympany pro-
duced by obstruction of the bowels due to
paralysis. The case was one in which every
means were tried to relieve the condition.
The post-mortem examination disclosed the
point of paralysis in the lower portion of the

ileum. The bowel walls were flaccid at this
position for about two inches. , Above this
the whole canal was enormously distended, !
while below to the anus it was entirely
empty. Experiments on dogs have shown
the same results.

It is in the ability to appreciate these
conditions properly that the open incision
has its strongest advantages. A full inspec-
tion of the injured bowel indicates the treat-
ment where special conditions arise, as does
the question of resection when gangrene is
imminent, or in those cases in which it is
apparent that the point of constriction will
not regain its tone. The importance of re-
section in the latter cases has been impressed
upon me by the condition of those that I
have seen. This loss of tone is apt to be
present in old incarcerated hernias, in which
narrowing of the canal by pressure has al- j
tered the structure of the walls, and in such
cases the increased constriction has injured
an already impoverished part. Another ad-
vantage is the certainty of the complete re-
turn of the protruded gut into the abdomen.

The possibility of a radical cure is to be
considered. I have one case that I operated
on nearly two years ago, which seems to ap-
proach a radical cure. This was a case of
true hernio-laparotomy. The internal ring
was carefully sewn together, the floor of the
inguinal canal was curetted and closed by
buried sutures which included the external
ring, the superficial surfaces continuous with
the abdominal wall being brought together
with silkworm-gut. The abdominal cavity
was cut off at once and coaptation was so
perfect that it tolerated the patient's tearing
off all his dressings, walking down stairs and
sitting on the front steps in the early morn-
ing of the fourth day. When I last saw him
he was doing active work and was not wear-
ing a truss.

The closing of the canal can be done, if
so desired, by retention of the sac in the
upper portion of the canal, using any of the
methods suggested. In old incarcerated
cases the adherent sac can be separated from
the surrounding tissues, leaving a good sur-
face for union, while the sac can still be re-
tained at the internal ring, its serous sur-
faces simply in contact, or by the purse- j;
string method. The open treatment, the
value of which is still doubtful, can be tried.
If the abdominal walls have been divided,
care must be exercised to bring into apposi-
tion the peritoneum and transversalis fascia,
also the superficial fascias that make Pou- !

April ii, 1 891.

Periscope.

419

part's ligament. The latter procedure is a
necessity for strength, the sutures entering
well into the pubic side to hold the divided
ligament firmly together. If this is well
done, when union has taken place the liga-
ment can be readily defined and its relations
are found to be continuous. Drainage of the
pelvis is a necessity if exudation is apt to
occur.

Extracts from Tubercule Cultures.

In a paper read at the Boston Society of
Medical Sciences, January 27, 1891, and
published in the Boston Medical and Surgi-
cal Journal, February 19, Dr. J. A. Jeffries
says : I thought it might be of interest to re-
port a few of my results with extracts of
pure cultures of the tubercle bucillus. I
began a year ago to make extracts and study
their effects on guinea-pigs, my ultimate ob-
ject being to produce immunity or find some
form of treatment. At first I used alcohol
(absolute and dilute), ether, chloroform and
benzole, and found that my results were very
variable, not regular. After this, in the
early part of last summer, I began to pre-
pare glycerine extracts, reasoning from the
power of glycerine pepsin extracts. With
glycerine I soon found that more or less de-
finite reactions could be produced by large
doses in healthy guinea-pigs. There would
be swelling at the point of injection, evi-
dent discomfort, an increase of urine and at
times fever, etc.

Owing to sickness in my family nothing
more was done until after Professor Koch's
first publication. I at once found that my
glycerine extracts produced a much more
marked effect in tuberculous than in healthy
guinea-pigs. The former, after a ■ dose of
half a cubic centigram, would in the
course of a few hours become very sick,
huddle up in a corner with hair on end,
shiver, and in some cases pant. Apparently
the amount of urine was increased. Tuber-
culous guinea-pigs, while in the reaction,
could be laid down anywhere and did not
run away.

All my animals, both those inoculated
with the extract alone and those first poisoned
with pure cultures of the tubercle bacillus
were then put under like conditions to note
results as to longevity. Unfortunately a bull-
terrier made a raid on my guinea-pigs during
the latter part of December, and again on
the 8th of January, killed most of my con-
trol animals, and thus ruined the experi-

ments as to final results. So that all I can
affirm is that some of my glycerine extracts
of about forty-five per cent, final strength,
allowed to stand at a temperature of 37^°
C. for one week, contain a substance which
causes a much more marked reaction in tu-
berculous than in healthy guinea-pigs ; and
that for two or three weeks after, the former
appeared better than the simply tuberculous
control animals.

I have not, of course, got far enough to
say if such an extract will invariably work,
or to what extent it will mitigate the action
of the bacilli. Nor do I yet know how old
a culture would be the best medium to grow
it on, nor if the extract should be made
neutral or slightly acidified. I might add
that I found no signs of tuberculosis in a
guinea-pig which had received one and a
half cubic centigram of my extract in
divided doses, and was then inoculated with
tubercle culture in the abdomen. Too much
weight cannot be laid on this, however, as
the animal was very badly crushed by the
dog eighteen days later — other guinea-pigs
inoculated in the same way with cultures died
of tuberculosis in about a month.

In closing, I would state that this is only
read in view of Professor Koch's latest an-
nouncement as printed in the newspapers of
January 15, from which I should judge that,
working in somewhat the same line and stim-
ulated by his first article, I have got some
thing on the same principle, but am not sure,
as I have been unable to procure an atom of
the paratoloid for any purpose.

Vaccination in France.

The . London Medical Recorder, February
20, 1891, says: The French Academy of
Medicine is just now the scene of a struggle
between those who are in favor of a law
making vaccination compulsory, and the
others who think that the present permissive
system goes as far as is consistent with per-
sonal liberty. The general in command of
the "volunteers," that is to say, of those
who object to compulsory protection, is no
less an authority than Professor Leon Le
Fort, and last week he made a vigorous rally
from behind his entrenchments, and, with
heavy artillery in the shape of arguments,
he prevented the further advance of the at-
tacking forces. There are several points in
Professor Le Fort's address which merit
attention, especially as the matter is at

420

Periscope.

Vol. lxiv

present under consideration in this country.
First of all — and the news will come as a
surprise to those who have been in the habit
of regarding France as being at the prow of
civilization — all statistics based on the
mortality-returns, from the different dis-
eases, must be incomplete, and therefore
misleading, for the cause of death is only re-
corded for statistical purposes in the more
important French towns, and, presumably,
not at all in the rural and smaller urban
districts. What the total annual mortality
from small-pox in France may be, can,
therefore, only be matter of conjecture.
Still, the Professor admits that it is certainly
higher than it ought to be or need be.
Another fact, hardly to the credit of French
provincial authorities, is, that nowhere out-
side Paris is any attempt made to isolate the
sufferers from small-pox. He is therefore
compelled to fall back upon the Paris re-
turns, and these show that the mortality has
been steadily diminishing, from 32 per 100,-
000 inhabitants, during the period 1865-76 ;
55 per 100,000 in 1880-7 ; to 5 per 100,000
in 1889. The returns of the Small-pox
Hospital at Aubervilliers testify to the same
diminution, the admissions and deaths hav-
ing been as follows: —

1887 . . 1,400 admissions . .215 deaths.

1888 . . 1,079 " • • 152 "•

1889 . . 706 " . . 63 "
1890. . 363 " . . 37 "

There are no available means of ascer-
taining the proportion of cases of small-pox
per 100,000 inhabitants in the country ; still
less the proportion of deaths to cases of in-
fection. We are, however, told that country
doctors have the greatest difficulty in pro-
curing lymph and the people have the
greatest difficulty in getting vaccinated, even
supposing they were so disposed.

Let us compare these figures with the
German statistics. It must be borne in mind
that vaccination has been compulsory
throughout Germany since 1835, and in
some parts since 181 5. The returns are as
follows : —

In 1834 . . 54 deaths per 100,000 inhabitants.

" 1836 . . 19 "

" 1847 . . 9 " "

" 1856 . . 7 " "

In 1865, the war led to a relaxation of
the stringent rules in respect of isolation,
and forthwith the number of deaths from
small-pox jumped up to 46 per 100,000, and
in the following year to 62. During the
Franco-German war, small-pox was imported

into Germany by the returning soldiers, and
more particularly by the French prisoners of
war, and the mortality from variola in 187 1
attained 59,839, and 77,000 in 1872, equal
to 233 per 100,000 civilians, and 31 per
100,000 of the military population. In
1874, the vaccination law was consolidated,
and a vaccination service founded for the
supply of lymph, and by 1877 the number
of deaths (810 in 1876) had fallen to 88.
This level, however, was not maintained,
for in 1882 the figures had again risen to
1,007. Thereupon the German Govern-
ment enjoined more stringent measures for
isolation, and then the downward tendency
returned, and in 1886 the number of deaths
was 140 only.

In England, the mortality in 1885 — a.
time when vaccination had long been in
full swing, but when isolation was not seri-
ously enforced — the number of deaths from
small-pox in London alone was 1,419. In
1886 the number fell abruptly to 24, in 1888
to 9, and in 1889 to 1 (!). This diminu-
tion coincided with the introduction of
isolation on a large scale, which reached its
apogee with the law for compulsory notifi-
cation in 1889.

Professor Le Fort argues from these figures
that, though vaccination has an undoubted
and valuable influence in affording protec-
tion and in mitigating the severity of the
disease, the most effective and reliable means
of preventing the spread of the disease is
rigorously enforced isolation.

While it is impossible to deny the salutary
influence of isolation, it seems a trifle incon-
sistent to object to vaccination as an in-
fringement of the liberty of the subject,
while rallying to the principle of compulsory
isolation, which is as directly in contraven-
tion of personal liberty as any measure well
could be. To take a patient, non volens,
and shut him up for eight long weeks in a
hospital, is surely as obvious an attack on
his liberty as to insist on his submitting to
the trivial operation of vaccination. This,
question of personal liberty, unfortunately,
does not admit of any categorical reply.
Different people have different ideas as to
what constitutes liberty, and as to what
limits, if any, are to be assigned to its play.
Still, the great object that we have in view,
is to secure cheerful submission to an inflic-
tion imposed by reason rather than by law,,
and if this could be attained by persuasion,
instead of coercive legislation, then the
choice would be easy.

April ii, 1891.

Editorial.

421

THE

MEDICAL AND SURGICAL

REPORTER.

ISSUED EVERY SATURDAY.

CHARLES W. DULLES, M. D.,
Editor and Publisher.

N. E. Cor. 13th and Walnut Streets,
P. O. Box 843. Philadelphia, Pa.

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See that your address-label gives the date to which your
•subscription is paid.

In requesting a change of address, give the old address as
well as the new one.

If your Reporter does not reach you promptly and regu-
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•discovered and corrected.

^^Suggestions to Contributors and Correspondents :
Write in ink.

Write on one side of paper only.

Write on paper of the size usually used for letters.

Make as few paragraphs as possible. Punctuate carefully.
Do not abbreviate or omit words like "the" and "a," or
-an."

Make communications as short as possible.

Never roll a manuscript ! Try to get an envelope or
.wrapper which will fit it.

When it is desired to call our attention to something in a
newspaper, mark the passage boldly with a colored pencil, and
write on the wrapper " Marked copy." Unless this is done,
newspapers are not looked at.

The Editor will be glad to get medical news, but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

PRESBYTERIAN HOSPITAL IN PHIL-
ADELPHIA.

An event of unusual importance occurred
in Philadelphia January 15, when the Pres-
byterian Hospital of this city celebrated the
completion of its new administration build-
ing. With this gift of a rich and generous
citizen of Philadelphia — and the filling
out of a series of gifts, some very large
and some smaller — the Hospital has come
into the possession of a magnificent series
of buildings, fitted with every appliance
necessary for a first-class hospital. In many
respects, it might be taken as a type of
what is best in the development of the Hos-
pital idea in this country ; and happily it is
only a type of many similar institutions
which, bearing the name of some denomi-
nation of the Christian Church, extend their
-charity to all sufferers of every name and
every condition.

The benevolence and the beneficence of

institutions like the Presbyterian Hospital
can hardly be over-estimated. Medical men,
more, perhaps, than any others, know how
far-reaching is the good done by gifts to
such an object. Those who live in cities
know especially how great is the difference
between what can be obtained by the sick
and injured poor in their own houses, and
what they get in such a Hospital as this, as
well as how much to them it is to be spared
the painful alternative of staying at home or
going into the Almshouse Hospital, no mat-
ter how well that may be managed — as is
the one in this city. For this reason, we
may be glad that the Presbyterian Hospital
in Philadelphia has been so prosperous, and
seems likely to be more prosperous and more
useful as time goes by.

PATHOGENESIS OF TETANUS.

The immense strides made in the science
of bacteriology during the few years of its
existence and development are well illus-
trated in the study of the etiology and
pathogeny of tetanus. In 1885, Nicolaier
demonstrated that fatal tetanus could be
produced in mice, guinea-pigs and rabbits
by subcutaneous inoculation with superficial
layers of earth, a slender bacillus being
found both in the earth and at the site of
inoculation. In 1886, Rosenbach found
the same bacillus in wounds in man in
cases of tetanus as a result of injury or of
extreme cold, which reproduced the disease
in inoculated guinea-pigs and mice. It was
not, however, until 1889 that Kitasato, in
the laboratory of Koch, succeeded in iso-
lating and cultivating the bacillus, while
but a few weeks ago from the same source
emanated an announcement as to the con-
ferring upon guinea-pigs of immunity
against tetanus.

Le Bulletin Medical, February 1, 1891,
contains a highly interesting paper on the
pathogenesis of tetanus, by Drs. Vaillard
and Vincent, presented at a meeting of the
Academie des Sciences, January 26.

422

Editorial.

Vol. lxiv

Inoculation of animals with pure living
cultures of the bacillus of tetanus is always
followed by tetanus, but, contrary to what
is observed in men and animals sponta-
neously infected, the pathogenic agent does
not multiply at the site of inoculation in
the blood or in the organs of the body.
This peculiarity is in apparent contradiction
to the prevailing notions concerning dis-
eases of parasitic origin, the evolution of
which is correlative of the pullulation of
the pathogenic organisms. The explana-
tion lies in the fact that inoculations of cul-
tures of the bacillus of tetanus are active
only by the presence of the toxine which
they contain. * The animals succumb to the
intoxication produced by the poison elabo-
rated by the bacilli, and not as a result of
the growth and development of the organ-
isms in the tissues. This may be proved in
two ways. If a number of animals are in-
oculated with a living culture, and an equal
number with the same dose of the culture
sterilized by filtration through porous earth,
all die after the same interval. If, on the
other hand, a susceptible animal, such as
the guinea-pig, be inoculated with even
considerable quantities of pure cultures of
the bacillus of tetanus, deprived of all
traces of toxine, tetanus does not develop.
Thus, the bacillus or its spores in a state of
purity, without toxine, does not produce
tetanus when injected into the tissues of a
healthy animal, but the animal dies if in-
oculated with the products secreted by the
wound in a patient having tetanus or con-
tained in tetanigenous earth. These results
are not contradictory, but depend on con-
ditions which favor or retard infection.

If an ordinary micro-organism, such as
the bacillus prodigiosus, be associated with
the spores of the tetanus bacillus, freed from
toxine, tetanus can be provoked. Another
means, not less certain, is to expose an in-
fected wound to the impurities of the air.
This can be demonstrated by introducing
beneath the skin a small bit of sterilized
cotton, impregnated with some spores, freed J

from toxine. The wound is soon invaded
by adventitious microbes and may suppu-
rate. Fatal tetanus soon supervenes. We
have here reproduced the conditions of
natural infection. Light is thrown on the
part played by the association of micro-or-
ganisms in the pathogenesis of tetanus. A
new point in the history of diseases of para-
sitic origin is established.

The activity of the pathogenic germs
already known is greatest in their pure
state. The primary condition in experi-
mental study, hitherto, has been the perfect
isolation of the virus, and its inoculation in
a state of absolute purity. This is not the
case with tetanus. The pure virus is with-
out effect. Impure, however, it is patho-
genic.

The microbe of tetanus is incapable of
vegetating in the tissues of a healthy ani-
mal, but it pullulates if simultaneously an-
other microbe, which may or may not be
pathogenic, is introduced with it. This ex-
plains the tetanigenous power of earth, rich
in microbes of many species, all of which,
however, do not favor the development of
the bacilli of tetanus in wounds. Other
conditions may facilitate infection. Thus,
tetanus may be produced by inoculating an
animal even tolerably resistant with a mix-
ture of spores, without toxine, and a solu-
tion of lactic acid or a few drops of trim-
ethylamine. The action of certain chemi-
cal agents upon the tissues is favorable to
the development of the germ, which, with-
out this association, would be inactive.
The result is the same if the spores are in-
troduced into a contused muscle. The
bacillus of tetanus or its spores does not
provoke tetanus in a healthy animal, when
injected in a pure state, without toxine, be-
cause of the action of certain cellular ele-
ments or phagocytes. This may be studied
in the anterior chamber of the eye or in the
subcutaneous connective tissue. Interference
with the protective action of the phagocytes
favors infection. Thus, lactic acid repels
the afflux of leucocytes, permitting the

April ii, 1891.

Editorial.

423

spores to vegetate and the bacilli to elabo-
rate their toxine. The bacillus prodigiosus,
on the contrary, attracts the leucocytes, en-
gages their activity, diverting it from the
tetanus spores, is taken up by them, while
the dangerous agents germinate and secrete
the fatal poison. In the case of natural in-
fection the phagocytes are able to exert
their prophylactic influence only at the be-
ginning of the conflict with the invading
microbes. Finally, as the bacilli elaborate
their toxine, the phagocytes are overcome.

TRAUMATIC NEUROSES.

In connection with the case of traumatic
neurosis published in the Reporter, March
21, 1 89 1, it is interesting to note that Bitot
and Lamarque, residents of the Hospital of
Bordeaux, reported, according to Le Pr ogres
Medical, February 14, 1891, a case of what
they call hysteria in a man, after a fall into
the hold of a vessel — a distance of over
sixty feet. The attack began with disturb-
ances on the side of the face, which were
rather hard to understand, but it developed
as glosso-labial hemispasm, or hysteria. He
had also habitual stigmata, hemi-anasthesia
and contraction of the field of vision. The

patient fell upon some casks, which he struck

•

hard with his heel. This was soon followed
by hyperesthesia in the heel, which was at-
tributed to hysteria. An interesting feature
of the case is the fact that the hysterical
manifestations disappeared in a few months,
which does not often happen in traumatic
hysteria, and that the patient was a person
predisposed to manifestations of this kind,
having had nervous ancestors, and having,
himself, always been an odd and excitable
man.

Recent investigations on this subject will
probably throw some light upon the strong
and only obscurely-understood manifesta-
tions of nervous disturbances after railroad
accidents, and accidents which simulate rail-
road accidents in their principal features.
Some difficulty in these cases is experienced

from the fact that many of the cases have as-
sociated with them a moral element, depend-
ing upon the possibility of securing dam-
ages from corporations in proportion to
the real or apparent severity of the conse-
quences of the injury ; but those who have
studied the subject carefully seem to be prac-
tically unanimous that violent physical shocks
make some impression upon the nervous part
of the human system, which may show
itself in very remarkable ways. Dr. Shipps's
case in the Reporter — referred to above —
was regarded as one of temporary insanity,
and so, no doubt, it was in one sense of the
term ; but a more careful classification would
probably place it with what are now called
traumatic neuroses. Many such cases have
been reported recently, and when attention
is generally attracted to the way in which
the subject is now regarded, it is probable
that more will be put on record, and that the
means for securing a good understanding of
the matter will be increased.

EXCISION OF CHANCRES.

The distinct and different individuality
of chancre and chancroid is a compara-
tively modern doctrine, but it is, to-day,
almost universally accepted. There are,
however, some prominent syphilographers
who still claim the unity of these two
lesions, so that any observations in regard
to them from reliable sources are worthy of
careful consideration. Since about fifteen
years ago it has been believed, by certain
syphilographers, that early excision of the
chancre will prevent the subsequent devel-
opment of syphilis. The determination of
this point is a matter of the highest thera-
peutical importance. The Centralblatt fur
die Medici?iischen Wissenschaften, January
10, 1 89 1, contains an abstract of a paper
by Neumann, the eminent syphilographer
and dermatologist of the Vienna University,
in which he details the results of auto-inocu-
lation of syphilitic patients with the secre-
tion from the primary lesion. If, in from

424

Notes and

Comments.

Vol. lxiv

three to five weeks after infection, inocula-
tion with the secretion of a non-suppurating
chancre is followed by any result, which is
not always the case, there appears in the
course of a week a circumscribed redness
which develops into a papule shortly before
the appearance of constitutional manifesta-
tions. The papule grows larger and firmer
with the progress of the eruption, recedes
with this, following the course of an ordi-
nary lenticular papule ; while the primary
lesion grows smaller and softer at the time
the eruption appears. Nor does the inocu-
lation-papule, like the chancre, occasion
swelling of adjacent lymphatic glands or
give rise to the development of firm lym-
phatic cords or to the formation of crater-
like ulcers of cartilaginous hardness. These
papules cannot be considered identical with
the primary lesion, but as manifestations of
■constitutional syphilis, as the result of irri-
tation, to which syphilitic subjects react
with peculiar readiness. If the inoculation
is made with the pus of a chancroid, in
three days a pustule forms, with an erythe-
matous areola, beneath which a deep ulcer
appears, the base of which becomes indu-
rated in a degree in proportion to the in-
tensity of the infection. The same result,
however, may be obtained with the pus from
the pustules of acne, eczema or scabies.

The conclusion to be drawn from these
observations is that syphilis cannot be
■aborted by excision of the primary sore.
Results of a positive nature, as published,
must depend upon errors in diagnosis.

Book Reviews.

[Any book reviewed in these columns may be obtained upon
receipt of price, from the office of the Reporter.]

GUIDE TO THE PRACTICAL EXAMINATION
OF URINE. By James Tyson, M. D., Professor of
Clinical Medicine in thej University of Pennsylvania,
etc. Seventh edition, revised and corrected. 7}4xS/4
inches, pp. 255. Philadelphia: P. Blakiston, Son &
Co., 1891.

The unimpaired popularity of Dr. Tyson's book on
•examination of the urine is demonstrated by the regu-
larity with which one edition follows another. This
popularity is both deserved and insured by the fact that

to the original merit of the book has been added a con-
stant care to keep it fully up to the state of knowledge
in regard to the subject, so that each new edition is bet-
ter than the last. The result is that the book is with-
out an equal — we believe — in the English language
for usefulness to students and practitioners. For the
former it is almost a necessity, and for the latter it may
be a most valuable aid.

In spite of the advanced teachings now given on
urine analysis and examination in the first-class medical
schools, there are still many physicians who know al-
most nothing of the subject and who might profit very
much by getting and studying a plain and practical
book like the one before us. To such physicians and
to all students we heartily recommend Dr. Tyson's ad-
mirable manual.

POST-MORTEMS ; what to look for and how to
make them, with sections on Infanticide, Poisons,
Malformations, etc. By A. H. Newth, M. D.,
London. Edited, with numerous notes and addi-
tions, by F. W. Owen, M. D., Demonstrator of
Anatomy in the Detroit College of Medicine. 1 2
mo, pp. 136. Detroit, Mich. : The Illustrated Med-
ical Journal Co., 1885. (?) Price, $1.00.

This little book begins with directions for the ex-
ternal examination of the body, then follow sections
on signs of death from violence, poisoning, etc., and
on the internal examination of the body. The latter
section is naturally divided into sub-sections containing
directions for the examination of the organs of circula-
tion, respiration, digestion, etc., and brief descriptions
of the post-mortem appearances of the organs and tis-
sues in disease.

The book contains a large amount of useful infor-
mation, but the matter is so condensed and the de-
scriptions are so brief, that one gets from reading them
no helpful picture of pathological anatomy, and no in-
sight whatever into disease-processes as they appear
after death.

Literary Notes.

— F. C. W. Vogel, the well-known publisher of
Leipzig, announce the appearance at this time of a new
journal of neurology called the Deutsche Zeitschrift fur
Nervenheilkunde, six parts to make a volume and to
cost about 15 marks. The editorial management is to
be, in the hands of Drs. Erb, Lichtheim, Schultze and
Strumpell. Their preliminary announcement indicates
that the new journal will be conducted upon lines
which cannot fail to make it a most valuable addition
to medical literature.

Notes and Comments,

New Method of Treating Enlarged
Prostate.

In a paper published in the Edinburgh
Medical Journal, March, 1891, Dr. Marotti
said : To effect a cure of ischury from pros-
tatic strictures one must understand and
meet the diseased condition which produces
the enlargement. In prostatic strictures the
ischury is occasioned by a mechanical ob-

April n, 1891.

Notes and

Comments.

425

stacle to the emission of the urine. Now,
the therapeutic direction must follow . two
indications — Firstly, To increase the ex-
pulsive power, so as to overcome the obsta-
cle ; Secondly, to remove, or at least to les-
sen the obstruction, so as to restore the reg-
ular passage of the urine. The surgeons of
all times have endeavored to carry out the
second, rather than the first, of these two
questions, and have thought of many differ-
ent ways. The apparatus invented by Dr.
Bottini, of Pavia, completely carries out the
idea of making an artificial passage for the
urine in the body of the same prostate. The
passage of the urine being restored, hyper-
trophy of the prostate does not any longer
entail danger to life, therefore it is useless
to take away an organ which, although ab-
normally enlarged, yet does not affect the
general work of the entire body. The
therapeutic idea is not that of melting or
otherwise destroying the prostate, but that
of making a new passage for the urine, to re-
place the passage which has been obstructed
by the abnormal enlargement of the gland.
The way of fusion and incision of the pros-
tate by thermo-cautery in such conditions
seems rational both as to its immediate ef-
fects and as to its ultimate consequences.
We need not only to divide the prostatic
growth, as the prostatic incisor of Mercier
does, but also to keep it open, making at
the same time an aperture inside, which will
not be quickly closed up, but leaves a per-
manent groove through which the urine can
flow.

The instrument of Dr. Bottini resolves
the problem of the practical application of
such an idea. The problem was how to
heat a certain portion of the instrument, so
as to bring it in front of the diseased en-
largement which is to be treated, limiting
the caustic effect to burn a particular spot,
without injuring the urethra and the blad-
der.

After long and diligent experiments on
dead bodies and on living animals, Dr.
Bottini succeeded in making an instrument
which answers thoroughly the object pro-
posed. The " cauterizatore termo-galvan-
ico "• is composed of a metallic tube resem-
bling the catheter of Mercier, internally di-
vided into four compartments for the pas-
sage of the conducting electric wires, and
the tube for the water, which, entering into
one of the canals, runs to its extremity, then
passes to the other canal and flows out at the
free end, keeping the whole instrument at a

constant low temperature. The conducting
wires end in two little plates, one-third of a
centimeter broad and two centimeters long,
placed parallel to each other at a distance of
one millimeter, and joined at the bow to-
wards the beak of the instrument, from the
curve of which they are separated one centi-
meter. These plates must get heated to a
dull red, the only color which insures de-
struction of the tissues without causing a
single drop of blood. The flow of cold
water, keeping all that part of the instru-
ment constantly cold, so that it may not
have a caustic action, prevents the epithe-
lium and the mucous membrane of the blad-
der from being injured, while cauterization
of the part of the prostate is being effected.

It is always better to accustom the patient
to the use of the instrument before the cau-
terization, so that its introduction may be
easily and quickly done, and the enlarge-
ment may be reached at once by applying
the cautery exactly to the designed spot.
The rule of accustoming the urethra to the
passage of the "cauterizatore," so that the
instrument may slip by its own weight into
the bladder, as Civiale happily expresses it,
" C'est l'urethre qui doit avaler la sonde,"
and so that we can bring the heated portion
against the part to be destroyed, is of vital
importance. As the patient has been placed
in the position used for lithotripsy, unless
the bladder be completely empty, we need
not inject water. The operation is not pain-
ful. Dr. Bottini uses chloroform only occa-
sionally; nevertheless we must insure that
the patient will be kept still during the op-
eration, otherwise by a sudden movement
the instrument might get displaced, and
come against parts which ought not to be
touched.

The operative technique consists of three
parts :

Firstly, We introduce the instrument, and
place the cautery against the part of the en-
larged prostate to be burned.

Secondly, We get the cautery heated, and
we cauterize to a sufficient degree.

Thirdly, We withdraw the instrument.

In regard to the first, we introduce the in-
strument into the bladder according to the
classical rules prescribed in urethral cathe-
terism. Then we must turn down the beak,
as we do in the methodic exploration of the
fundus of the bladder, and pulling the shaft
so as to hook the neck, we may carry the
cautery against the proper spot. If any
doubt arises, the position of the instrument

426

Notes and Comments.

Vol. lxiv

may be ascertained by a finger introduced
into the rectum. The instrument being
properly placed we allow the water to come
in, which can be done by suspending a
common pail, or an irrigator of Esmarch, at
a certain height, capable of holding six or
eight liters of water, at a temperature of
about 400 to 500 Fahrenheit.

The battery which Dr. Bottini uses is a
Bunsen's, with two liquids, in the improved
manner of Pischel, and lately again im-
proved by Dr. Bottini, by the introduction
of the accumulators, as he has fully described
in his article in the Lancet of September
20.

The heating of the cautery must not ex-
ceed the dull red ; if it does exceed this,
and becomes white, the tissues will be too
quickly destroyed, and most probably hem-
orrhage will ensue.

With repeated experiments on dead bodies
and on living animals, Dr. Bottini obtained,
in one minute, by the cautery being heated
to the red color, an eschar about the thick-
ness of a centimeter, and the action being
prolonged for another minute, the thickness
has become doubled, when he could raise
the temperature by one degree, changing
the commutator of the battery.

To insure the eschar being formed as in-
dicated, the heated portion of the instrument
must be placed against the part to be burned,
raising the shaft and bending it gradually, so
that the resistance of the diseased tissue
having been overcome the beak can be em-
bedded in it. We must then stop the fur-
ther production of heat by shutting off the
current, and let it remain for two or three
minutes, so as to give time for the plates to
cool, so as to render harmless the withdrawal
of the instrument, which will be done in a
manner the reverse of that used when it is
introduced. We do this in order to prevent
the risk of the eschar being brought away
with the withdrawal of the instrument.

For the after-treatment we use the soft
catheter of Nelaton, always provided that
the patient cannot pass water by himself.
Dr. Bottini wrote me that a few days ago he
had to operate on an old man, suffering from
prostatic ischury for more than five years,
who after twenty-four hours from operation
was able to pass water without artificial assist-
ance. The eschar is completely gone by
the tenth, twelfth or fifteenth day.

Dr. Bottini has operated after this method
on fifty-seven cases, two of which ended
fatally; these, however, were during the

early days of the operation, before the in-
struments had been brought to their pres-
ent state of perfection. In thirty-two cases
a perfect cure had been obtained, in eleven
there was an improvement, and in only
twelve was no benefit observed. These re-
sults in an affection which was so rebellious
to ordinary treatment, form a powerful argu-
ment in favor of the method ; and the author
hoped soon to see it adopted more generally
by surgeons than it had yet been.

Who Owns the Prescription ?

In a paper, on the subject of prescription
ownership, read before the Philadelphia
College of Pharmacy at the Pharmaceu-
tical Meeting, January 20, and published in
the American Journal of Pharmacy, Feb-
ruary, 1 89 1, Mr. Joseph England asks:
To whom, then, does the prescription legally
belong ? To the physician ? Certainly
not. He has been paid for all services
rendered. To the patient ? No ; for in
his recovery to health he has received all
that he paid his medical adviser for. To
the pharmacist ? Yes ; by every right of
custom and law, provided he has accepted
it under certain conditions. If the patient
makes a request for its return on presenting
it, the pharmacist has one of two lines of
action before him. He must either refuse
to compound it under such conditions, or
express a willingness to compound it and
give a duplicate copy. If the latter pro-
posal be refused, he should return the
original prescription without compounding.
On the other hand, if the prescription is
committed to his hands with no primary
request for its returnal after being filled, and
he has affixed his marks of identity and
compounded it, he should retain the original
copy as legal evidence that he has prepared
such a prescription.

As showing the legal value of a prescrip-
tion it may be of interest to state that Mr.
Robert England informs me he has been
subpoenaed in three cases within the last
three years to produce certain original pre-
scriptions for the purpose of : 1, to prove
attendance in a suit for medical services.
Suit was won. 2, to prove that a physician
used drugs, for malpractice. Physician con-
victed. 3, to prove that a medical student
illegally practiced medicine. In this latter
case, the patient dying and the student be-
ing unable to give a certificate of death, the

April II, 1 89 1 . Notes and

Comments,

427

case was examined by the Coroner, and
when confronted with the prescriptions con-
fessed guilt. In each instance, however,
the legal authorities returned the prescrip-
tions, thus tacitly admitting their owner-
ship.

But this whole question of prescription
ownership, to my mind, is essentially one
of law, and viewing it from that standpoint,
it presents some most interesting features.
I have been fortunate in securing for this
afternoon's meeting an expression of opinion
from that eminent authority on civil law,
Richard C. McMurtrie, of this city. He
writes me as follows :

Bullitt Building, January 15, 1891.

Dear Sir : You ask who is the owner of
a prescription, the physician who writes it,
the patient for whose use it is written, or the
apothecary to whom it is handed to com-
pound ?

Evidently the only dispute can exist in a
case in which the physician and the patient
have parted with the possession of the paper,
and it has lawfully come into the hands of
the apothecary, at the instance of the
patient.

The universal practice appears to me to
point where the title is for all purposes but
one. I presume it is the custom to refill a
bottle with a prescription indicated on the
label. The patient is not required to pur-
chase a new prescription every time he
wishes the order filled — Ind this appears to
me plain, from the consideration that he
could secure this by copying the paper be-
fore using it.

Moreover, he has paid for the composi-
tion and skill required for that purpose, and
the delivery to the apothecary is for a
particular object, and there is in that trans-
action nothing implying a transfer of prop-
erty in anything by the patient to the
apothecary.

But the practice certainly is for the
apothecary to retain the documents. I
presume no one ever heard of a prescription
being returned with the dose to the patient.

It is obvious there is nothing indicative
of a sale or transfer of title on that footing
in this transaction. There is something
analogous in respect of a check. The re-
turn of these instruments arises out of
distinct considerations. Accepted bills are
never returned to the drawer if paid.

Then there is a consideration which I
consider conclusive, seeing that the thing is

open to a contract, and the parties have
chosen to make none. If under this view
of the case the usage is not of itself con-
clusive, I think the apothecary has the right
to retain, to warrant himself, if a question
shall arise, as to correctness of conduct.

I may add the claimant must always show
his title — if the title be in equipoise he must
fail.

It also occurs to me that this paper is
merely a substitute for a verbal direction,
and no doubt there are multitudes of verbal
orders filled that might be written.

On the whole, I should think there ought
to be no doubt that the apothecary may, if
he sees fit and is foolish enough to run the
risk, put the paper in the fire. There can
be no half-way measure — he either owns it
absolutely, or not at all. There can be no
duty to produce it for inspection, or to give
copies, while it would be silly to refuse to
do so when reasonably demanded.

It is very unusual in this country to look
to the consequence of a rule. It may be
well to do so. If the patient is the owner —
he may at any time within six years demand
the paper, and if it is not surrendered, sue
as for a tortious conversion of his property.
If he can't do this he certainly has no title.
I would ask if executors ever inquired for
prescriptions given the testator; if they
belong to the testator, they are assets.

R. C. McMurtrie.

Paroxysmal Tachycardia*

Dr. H. C. Wood, in the University Medi-
cal Magazine for March, presents the his-
tory of a case, in a physician, of a perplex-
ing cardiac disturbance to which he has
attached the name, tachycardia. The affec-
tion is one of several forms of " cardiac nerve
storms " which may or may not be associated
with organic lesion of the heart ; and this
lesion, in turn, may or may not be essential
— it may, for example, be trophic or sec-
ondary to a nerve lesion, as in the cases
reported by Teissier, in which the aortic
valves were found to be punched out as
with a perforating ulcer. Whether this
trophic explanation be accepted or not,
Dr. Wood has no remaining doubts that
there are cases of violent nerve storm,
accompanied with excessive pain — nerve
storms similar in character to those that
constitute the "gastric crises" of posterior
sclerosis — in which no lesion of the valves

428

Notes and

Comments.

Vol. lxiv

can be discovered ; and these cases differ
also from the paroxysms of true . angina.
Dr. Wood is inclined to restrict the use of
the term tachycardia. In accordance with
this etymology, it could be made to apply
to any case of rapid action of the heart.
But he regards it as fortunate that there has
not yet been any very frequent use of the
word, sufficient to affix to it any settled
meaning, and he suggests its limitation to
those diseased conditions, marked by violent
action of the heart, that are not dependent
on organic cardiac disease, or on febrile ex-
citation, or on a general constitutional
affection, such as exophthalmic goitre.
He proposes the restriction of the name
tachycardia to cases in which very violent
action of the heart occurs without obvious
reason. The greater number of these cases
resolve themselves into the following three
classes : (i) paralysis, centric or peripheral,
of the pneumogastric or inhibitory nerve ;
(2) cases of reflex disturbance, as from the
irritation of a biliary calculus or of the sex-
ual organs in the female ; and (3) those in
which the affection is a neurosis, as when
it is due to hysteria or allied conditions, or
to exhaustion from privation, or to fright,
or to the too rapid ascent of nights of
stairs.

Carrying the distinction still further,- Dr.
Wood places in a class by themselves certain
rare cases of cardiac motor-nerve storms to
which he applies the title of essential par-
oxysmal tachycardia, several of which cases
have been found by him in the contribu-
tions of Nothna^el. In the most striking
of these cases, the patient was subject to
violent action of the heart that came on
abruptly, even during absolute quiet, with-
out marked pain, but with some sense of
anxiety. In a moment the pulse would go
up to 180, the heart sounds meanwhile re-
maining normal. The duration of the
tachycardial paroxysm varied from a few
minutes to several hours. In the instance
of the physician, already referred to as Dr.
Wood's typical patient, the pulse-rate rises
as high as 160 if the patient remains at rest,
and as high as 200 if he exerts himself, as
in walking. The access of the paroxysm
is abrupt, and so is its cessation. During
rest the disagreeable sensations belonging
to the attack are hardly more than slight
pain and a sense of thoracic fulness. The
patient, Dr. H. C, is now over eighty-five
years of age, and since about his sixtieth
year has had these paroxysms, on an aver-

age, once in every three weeks, although he
has had as many as four in a month. This
was his experience prior to 1888; latterly
the attacks have been more frequent. The
paroxysms may be brief and they may be
broken up by some medicament after a few
minutes — but various forms of treatment
tend to lose their efficacy after a certain
number of trials — or may be protracted to
ten or even twenty-six hours. The patient
has been examined frequently for cardiac
lesion by various physicians of high rank,
both during the attacks and during the in-
tervals, but at no time has any murmur been
found. His health has continued good,
and now, in his eighty-seventh year, he con-
tinues to be sufficiently vigorous to be able
to ride about in his carriage for hours at a
time, and even to walk considerable dis-
tances. The attacks have become very fre-
quent, occurring during the last year almost
every day, but they are often terminated
promptly by the drinking of a glass of cold
water. The pulse now rarely rises above
135, there is little distress, and he can even
write a letter in the height of a severe parox-
ysm without the handwriting showing any
tremulousness or otherwise giving evidence
that it is the work o'f a tachycardiac old
man.

In conclusion, the following is Dr.
Wood's definition, given in his own words,
of essential paroxysmal tachycardia : " The
definition of the disease would be that of a
recurrent paroxysmal neurosis in which at-
tacks of excessively rapid heart action occur
without obvious immediate or disposing
cause, and without pronounced pain or ex-
cessive cardiac distress, the pulse rising to
160 and upward, the sounds of the heart re-
maining normal, and it being frequently
possible to arrest the attacks by drinking a
glass of cold water and certain other pro-
cedures of apparently trifling import, the
disease having apparently no tendency to
shorten life or to develop organic disease,
and being entirely compatible with great
mental and physical activity." In regard
to the influence over this affection of so sim-
ple an act as the swallowing of a small
amount of cold water — which is probably a
characteristic phenomenon of the trouble,
since it has been noted in nearly all the fully
reported cases — Dr. Wood refers to obser-
vations by Dr. S. Meltzer, which show that
swallowing is attended with a loss of tone in
the vagus centre, and with a consequent'
cardiac inhibition, but it is also possible

April ii, 1 89 1. Notes and

Comments.

429

that the swallowing of cold or hot liquid
begets a stimulus to the cardiac centre by
an irritation of the peripheral gastric fila-
ments, since it is well known that an irrita-
tion of the abdominal nerves is competent
to inhibit the heart in a reflex way ; and the
temperature at which the liquids are swal-
lowed is important, since, if the water,
when taken by the patient, is only moder-
ately cold, much larger quantities of it are
required. — New York Medical Journal,
March 14, 1891.

Open and Subcutaneous Tenotomy.

In the Medical Chronicle, February, 1891,
is an abstract of an article by Sabatier on

Open tenotomy and subcutaneous tenot-
omy," published in the Lyon Med., Decem-
ber 28, 1890, which says that since the in-
troduction of antiseptic surgery there has
been a tendency to abandon subcutaneous
tenotomy in favor of tenotomy by means of
an open wound, and that Sabatier discusses
the reasons for and against each method,
taking in turn the tendons which are most
often divided.

The sterno-mastoid. — The reasons given
by those who favor the open method are two :
The absolute security against accidental in-
jury of vessels, and the ease with which one
can obtain complete division. In support
of the first reason, three cases of wounding
of large vessels, such as the internal and ex-
ternal jugular veins, are quoted. In addi-
tion, abnormal vessels may be injured. In
support of the second reason it is argued
that there are various forms of torticollis,
the most simple being limited to contraction
of the sternal head of the muscle. The
clavicular head is, however, almost always
affected, and in the more complex forms the
levator anguli scapulae, splenius, trapezius
and scalenes. There are also fibrous forms
affecting various parts of the cervical fascia.
It is in these cases that subcutaneous tenot-
omy is both incomplete and dangerous.

In reply to these reasons Sabatier contends
that the dangers of subcutaneous tenotomy
have been exaggerated, and that the open
method is unsuitable.

Out of the thousands of subcutaneous sec-
tions of the sterno-mastoid only a few cases
of wounds of large vessels are known, al-
though he admits that perhaps all have not
been published. All danger may be averted
by entering the knife at the internal border

of the muscle, and fifteen to twenty milli-
meters above the clavicle, to avoid the hori-
zontal part of the anterior jugular vein as it
runs beneath the muscle to join the external
jugular. The knife edge must then be turned
against the deep surface of the muscle, and
the division itself effected by pressure, and
not by sawing movements of the blade,
counter pressure being made with the thumb
on the external surface. By this method of
division from behind forwards only the deep
aspect of the skin is in danger ; if per-
formed from before backwards the vessels
may be injured. He therefore concludes
that in ordinary cases subcutaneous tenot-
omy of the sterno-mastoid is not more dan-
gerous with regard to immediate accidents
than open tenotomy.

The great inconvenience of the open
method is the cicatrix left in an exposed re-
gion. Even if it be smooth, it is generally
horizontal, and all horizontal cicatrices are
more visible than vertical ones. Moreover,
it undergoes vertical displacement from be-
low upwards as age advances, so that it may
even reach as high as the middle of the
neck. If the wound suppurates, or keloid
growth subsequently attacks the cicatrix, it
becomes much more unsightly.

For this reason, Sabatier's second conclu-
sion is, that in ordinary cases of torticollis,
it is preferable to practice subcutaneous tenot-
omy. With regard to the very complex
cases, he believes that nearly all of them can
be cured by subcutaneous section, and sub-
sequent continuous extension by means of
some mechanical apparatus, but in very ex-
ceptional cases open tenotomy ought to be
adopted.

Tenotomies of the lower limb. — These are
performed in three regions — at the root of
the thigh, on the adductors and the muscles
attached to the anterior iliac spin us ; at the
knee, on the hamstring tendons ; and at the
foot, on the tendo Achillis, and plantar apo-
neuroses.

At the root of the .thigh. — There are no
advantages whatever in open tenotomy here,
and the subcutaneous method should al-
ways be chosen.

Hamstring tendons. — Sabatier advises open
tenotomy for the biceps tendon, because one
can better avoid the external popliteal nerve.
A cicatrix in this region is not of import-
ance, and the division can be made more
complete. It is also best for the semi-mem-
branosus and semi-tendinosus, because of
the more complete division and the security

43°

Notes and

Comments.

Vol. lxiv

from wounding the deep vessels. Inflamma-
tions of the knee-joint often spread to the
tissues below the knee, and the vessels get
distorted and fixed in unusual positions.

After the operation is completed, he leaves
the wound open, and packs it with iodoform
gauze ; sutures should not be used, because
after forcibly straightening the limb, the
soft parts are extensively lacerated, and a
large quantity of plastic exudation is thrown
out, which causes tension and suppuration if
the wound be firmly closed with sutures.

Tendo A chillis and plantar aponeuroses. —
For the tendo Achillis the subcutaneous
method is the best, and the section from the
deep surface is the easiest, because the flex-
ion of the foot necessary to make the ten-
don prominent, also draws it into close con-
tact with the skin, rendering it difficult to
pass the tenotome between the tendon and
the skin. It is also better to do it from the
inner side, because in some cases of club-
foot the posterior tibial vessels become tor-
tuous and spread over a large surface, and
are thus liable to injury if one punctures
from the outer side. Again, in cases of club-
foot, the tendon is much more visible and
prominent on the inner side, and so more
easily divided from that side. With regard
to division of the plantar aponeuroses, he
thinks subcutaneous section quite sufficient,
and condemns the free, open and extensive
division advocated by Phelps as being in al-
most all cases more than is necessary to re-
duce the deformity.

Laparotomy for Disease of the Liver.

The Paris correspondent of the Medical
Press, February n, 1890, says that recently
M. Routier related an interesting case of
laparotomy for jaundice of a severe type. A
nurse in the hospital was seized with severe
hepatic colic lasting twenty-four hours. In
spite of energetic treatment jaundice set in,
the fecal excretions were discolored and the
urine almost black. The liver was felt below
the false ribs, and the gall-bladder was pain-
ful. For a whole month the condition of
the patient remained unchanged, and at the
end of that time vomiting set in, and the
patient became much emaciated. Believing
that a biliary calculus was obstructing the
bile duct, the surgeon determined to explore
the region, and for that purpose laid open
the parts by an incision on a level with the

inferior edge of the liver. Passing his fingers
through the wound he felt the gall-bladder,
which did not seem in any way distended,
and Consequently was not obstructed. He
passed his fingers then over the inferior edge
of the hepatic organ, but found nothing ab-
normal. Before withdrawing his hand he
felt the head of the pancreas, but no tumor
was discovered there. Finally, he closed the
wound, and, strange to say, the vomiting,
which had been previously uncontrollable,
ceased, and in two days afterwards the jaun-
dice paled, and in a week the urine assumed
its normal color, and the patient speedily re-
covered. The speaker could only explain
the happy result by the fact that the massage
displaced some mucous collections which had
obstructed the flow of the bile.

Post-partum Hemorrhage Treated
with Caffeine.

Misrachi, in the Journal de Medicine,
January 25, 189^ recommends the subcu-
taneous injection of caffeine as more effi-
cient than ergotin in the treatment of post-
partum hemorrhage, especially when there
has already been much loss of blood, and
delay is dangerous. He gives the following
prescription.

R Sodii benzoatis ^ ijss

CafTeinse .^jss-gij

Aquae destillatse f^j

M.

Of this solution, a drachm, which contains
twelve and a half or fifteen grains of caffeine,
is to be injected at once, and subsequently
from a drachm and a half to two drachms
and a half in twenty-four hours. The solu-
tion should always be employed warm.

To Remove Dark Color from Come-
dones.

The British Journal of Dermatology, Feb-
ruary, 1 89 1, gives the following prescription
of Unna and Leistokow for removing the
unsightly "black-heads" which are so often
an annoyance to a patient and a trouble to
the physician.

R Lanolin 10 parts

Vaselin 20 "

Peroxide of hydrogen .... 20-40 "

Medical and surgical
Reporter

A Weekly Journal.

Established in 1853 by S. W. Butler, M. D

CHARLES W. DULLES, U. D., Editor and Publisher,

Entered as Second-Class matter at Philadelphia P. O N. E. COR. 13th & WALNUT STS., PHILADELPHIA

Vol. LXIV, No.

16.

Whole No. 1781.

APRIL 18, 1891.

$5.00 per Annum.
10 Cents a Copy.

CLINICAL LECTURE.

GOITTETSTTS :

EDITORIALS.

Montgomery, E. E., M. D., Philadelphia, Pa.—
Uterine Hemorrhage, — Correct Treatment of
Fibroids.— Enlargement of the Abdomen 431

COMMUNICATIONS.

Eichler, Alfred, M. D., San Francisco, Cal.—
Salol 434

Kxernan, J. G., M. D., Chicago, 111.— Sexual Per-
version as a Phase of Evolution 430

Smith, A. Noel, M. D., Dover, N. H.— Common
Colds 440

PERISCOPE.

Sterility.— Varieties of Hydrocele.— Safety of Hyp-
notism as a Remedy.— Treatment of Chorea.—
Keloid. — Morphine Habit Treated by Gradual
Withdrawal.— The Leprosy Commission.— Extra
Titles.— Gastric Function in Chronic Nephritis.
—Medical Schools in New York 441-448

Electricity for the Diseases of Women 449

Excision of the Vermiform Appendix in Appen-
dicitis 450

Herpes Vacciniforme of Infants 452

University of Michigan 452

BOOK REVIEWS.

Bigelow ; Plain Talks on Medical Electricity and
Batteries.— Seifert-Mui ler ; Manual of Clini-
cal Diagnosis.— Transactions of the American
Orthopedic Association 453

NOTES AND COMMENTS.

Contagiousness of Gonorrhoea.— Pasteur and his
Work.— New Operation for Lacerated Perineum.
—Calomel in Kidney Disease.— Influence of Ex-
ercise on Digestion.— " New Philadelphia."—
Local Sweating of Reflex Origin.— Powder for
Migraine 454-458

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The effects left by La Grippe are marked Physical Prostration for which Pill
Chalybeate Comp. (Warner & Co.'s) is almost a specific. The assimilable iron, acting
as a blood tonic and the Nux Vomica as a stimulant to the spinal cord.

Dose, begin with one pill every four hours and increase to two pills three times a
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The acute symptoms of La Grippe are controlled by (EFF. ANTALGIC
•ALINE), one dessert spoonful of which contains 4 grains Antipyrine and 4 grains
Salicylate Soda. Physicians will not be disappointed in the treatment of La Grippe by
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INDICATIONS.— Chronic and acute affections of the Air Passages, Coughs,

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WILLIAM MURRELL, M.D., F.R.C.P.,

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the Royal College of Physicians of London; Fellow of the Medico-Chirurgical College of Philadelphia,

Says:— "I have used with success 'Goudron de Blount.* The results have
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MEDICAL AND SURGICAL
RE PORTER

No. 1781. PHILADELPHIA, APRIL 18, 1891. Vol. LXIV.— No. 16.

Clinical Lecture.

UTERINE HEMORRHAGE. — COR-
RECT TREATMENT OF FIB-
ROIDS.—ENLARGEMENT
OF THE ABDOMEN.1

BY E. E. MONTGOMERY, M. D.,

PROFESSOR OF GYNECOLOGY, MEDICO-CHIRURGICAL
COLLEGE.

Uterine Hemorrhage.

Gentlemen : This colored woman, forty-
four years old, presents the following history.
Her mother died of dropsy, lasting a year
before her death. The mother had several
children, two of them girls, one of whom
had a uterine fibroid removed some time ago,
the other, the patient under consideration,
has always been healthy. She had two brothers
who died of phthisis. Our patient menstru-
ated for the first time at the age of fifteen ;
the flow was always profuse but painless. She
was married at twenty-two, and had a child
a year later. The labor was long, lasting
thirty-six hours, requiring for its termination
the use of forceps. It was two years before
she menstruated again. Four years later she
had a second labor, again requiring the use
. of the forceps. She has never had an abor-
tion. Three months ago, at her monthly
period, she experienced intense shooting
pains, accompanied with marked bearing-
down sensations. This lasted several days,
and was followed by a leucorrhceal dis-
charge, which persisted until the menses
made their reappearance, when she suffered
from the same pains. Last month severe
flooding from the vagina accompanied these
sensations. She has been constipated for a
month. She is not emaciated, although her
appetite is poor, and her flesh is not espe-
cially abundant. Her heart and lungs are
normal.

1 Delivered at the Philadelphia Hospital.

There are certain conditions which will
produce the symptoms from which this wo-
man is suffering, but it is best not to arrive
at a hasty conclusion.

Although everything at present points to
pelvic trouble, do not at once exclude care-
ful study of every organ, however remote.
Is the trouble due to local or to constitu-
tional causes ? If you should happen to
find some local cause which, in your mind,
is sufficient to produce the condition present,
do not let that fact deter you from studying
all other possible sources.

Before commencing treatment, investigate
all the sources of hemorrhage from the uterus,
or, more broadly, from the vaginal tract.
Disease of the uterine mucous membrane
is frequently an important factor in these
hemorrhages. Long-continued inflamma-
tion of this membrane sets up a granular
endometritis, even producing polyps, which,
in turn, may produce hemorrhage. The
flow may be at the monthly periods, being
called menorrhagia ; or independent of these
times, forming metrorrhagia — or simply hem-
orrhage from the uterus. Again, the walls
of the uterus may produce a condition which
gives rise to hemorrhage. Growths, which
may be fibroid, appear, distend the mucous
membrane, and, being supplied with numer-
ous blood-vessels, rupture easily, producing
the above phenomena. Malignant disease,
involving the cervix or body of the uterus,
is frequently a cause of hemorrhage. De-
generative changes following labor or abor-
tion may cause hemorrhage. Imperfect re-
moval of the placenta favors the growth of
polypi, which in their turn favor the pro-
duction of hemorrhage. Disease in the kid-
neys, liver or heart, the exanthemata, and
typhoid or malarial poisoning, have pro-
duced occasionally, in their course, bleeding
from the uterus. When there is an absence
of heart, kidney, or liver trouble, when
there is no poison in the blood, no fibroid,
no malignant disease, not even inflamma-

43i

432

Clinical

Lecture.

Vol. lxiv

tion of the mucous membrane lining the
uterus — still there may be disease in the pel-
vis which is producing the flow of blood.
Cellular infiltration of the pelvis, exudations
into the tissue of the adjacent parts from
extension through the Fallopian tubes, may-
cause the trouble. The circulation in the
uterus is interfered with, and a hemorrhage,
passive in character, makes its appearance.
Disease of the ovary, especially cystic de-
generation, is particularly prone to produce
this symptom. In the absence of other ap-
parent causes, it is well to remember this
point. The influence of the ovaries upon
the circulation of the blood in the uterus is
most marked. When this cause is operat-
ing, local applications to the uterus will be
made in vain. Bleeding from the vagina
itself may be the real cause of the trouble,
being mistaken for that from sources higher
up. A vaginitis may produce this symptom;
especially granular papillae, which are com-
mon at the vestibule, may tinge the discharge
blood-color.

Women rapidly lose confidence in the
doctor who is unable to stop any such hem-
orrhage. So it is well to study all these
cases with the utmost care. With this out-
line let us take up our present patient. This
woman has severe tearing pains, bearing down
in character. It is possible that this is due
to pregnancy. The presence of menstrua-
tion does not preclude this possibility. I
saw a case, within a few weeks, which illus-
trates this. I examined in consultation with
another physician, a year ago, a woman who
had enlargement of the uterus. This en-
largement was fibroid in character, and I de-
cided that it was areolar hyperplasia. With
this condition, the woman had increased
menstruation. I saw her again a month ago.
The uterus was then enlarged, not symmet-
rically, and it was hard and firm at one
point, localization of the fibroid growth
having taken place. The hemorrhage had
increased in quantity. There was no arrest
of menstruation, on the contrary the flow
was in excess. Two weeks ago, her physi-
cian writes me, she discharged a small fetus.
The retained placenta formed the so-called
fibrous polypus, to which there was enough
blood supplied to prevent decomposition
with its unpleasant results. There was no
fibroid present ; there was distinct thicken-
ing of the uterine walls, but no tumor.

Again, in some women, menstruation is
increased for the first few months of preg-
nancy. In this woman, it may be due to a

fibroid. If the pedicle is long, it may drop
down into the internal os, becoming a valve,
causing severe labor-like pains to produce
the expulsion of the blood.

Fibroids of the Uterus.

With this introduction, let us return to our
patient. She is, as I have said, forty-four
years old, colored. There is a marked
tendency in the colored race to fibroid en-
largements, and less tendency to carcinoma
or epithelioma. With the woman on her
back, her limbs drawn up to relax her ab-
dominal muscles, I introduce two fingers
into the vagina. The cervix is large, hard
and fixed, and projects into the anterior por-
tion of the vagina. The uterus is immov-
able. In the posterior fornix there is a firm,
irregular, dense mass which extends into the
pelvis. This seems like a fibroid growth ;
still, we must not decide too quickly. With
two fingers in the vagina and the other hand
over the abdomen, it is possible with lax
abdominal walls to outline the mass thor-
oughly. Here we find the abdomen hard
and tense. In such cases, insist on the use
of an anaesthetic. Do not commit yourself
without careful search. Bromide of ethyl
acts quickly, requires a small amount and is
less likely to cause sickness than ether, and
its effects pass off speedily, making it the best
anaesthetic for office use.

Fibroids in the uterus begin as the result
of irritation ; there is a simple increase in
the nutritive activity in the muscular layer
of the uterus. The constituent elements of
the normal tissue increase in size, pushing
aside as they grow the adjacent tissue. Be-
ginning in the uterine wall, as either a single
or a multiple growth, as it develops it re-
mains within the walls or intrudes into the
cavity of the uterus, or extrudes towards the
peritoneum ; its direction varying according
to its original position, as it grows in the
direction of least resistance. These three
varieties are called respectively, sub-mucous
or polypoid ; interstitial or in the wall ; and
sub-peritoneal or beneath the peritoneum.
The fundus is well forward, the body of the
uterus is small, and the mass is posterior,
growing either from the back wall of the
uterus or as the result of inflammatory exu-
dation at this point. The uterus is more
fixed on the right side. This is undoubt-
edly a fibroid enlargement, extending into
the broad ligament. We should pass our
finger into the cavity of the uterus to further

April 1 8, 1 89 1.

Clinical

Lecture.

433

determine the diagnosis. This I will not
take time to do now.

What treatment shall we pursue? This
depends somewhat on the variety of the fib-
roid. First, the medical treatment would
consist, naturally, in decreasing the flow of
blood to the uterus. For this purpose strych-
nia, quinine, ergot, antipyrin, etc., may be
tried. Ergot, by its action on the muscular
coats of the blood-vessels and its contrac-
tile action on the entire uterus, may be of
service. But it may drive a fibroid beneath
the peritoneum, making it sub-peritoneal.
On the other hand, it may force it into the
cavity of the uterus and in this way expel it.
Again, the circulation may be so cut off by
the medication that the tumor may be in
danger of sloughing, setting up septic
trouble. Treating the mucous membrane
locally may be of service. Changing the
surface of the uterus cavity, by curetting or
cutting partially through the vessels of the
region, may cause these to contract, arrest-
ing the tendency to bleed. Dilatation or
cutting of the cervix may be followed by
extrusion of the tumor. Electricity has
been a much vaunted agent in these cases ;
the positive pole being placed in the uterine
cavity, the negative on the abdomen. With
high currents cicatricial tissue is produced,
which in its turn contracts. Cases have un-
doubtedly been benefited by this treatment,
but the results are slight and transient,' and
the tumor steadily increases unless electricity
is constantly applied.

Beside these measures, a radical course
can be pursued. If the tumor is in the cav-
ity of the uterus, twisting or cutting it with
scissors or the wire Zcraseur will be of ser-
vice. If the tumor is in the wall of the
uterus, and the cervix is undilated, this is
not easily accomplished. If the hemor-
rhages are severe, so that life or health are
threatened, the removal of the ovaries may
be considered. Menstruation does not al-
ways stop with the removal of the ovaries.
In the case of this woman's sister, whose
ovaries were removed, discharges have not
ceased at all. I believe that this result is
largely avoided by including the round
ligament in the ligation of the pedicle.
This increases the pressure on the ovarian
nerve, which governs the blood supply of
the uterus, and thus tends to reduce hemor-
rhage. These fibroids cease to grow at the
menopause ; they even decrease from this
time on ; but the menopause is generally de-
layed by their presence. A woman may-

die from hemorrhage before this period is
reached. This woman is forty-four, she is
near the normal time for the disappearance
of her catamenia ; but this disappearance
cannot be regarded as a certainty for some
years.

Enlargement of the Abdomen.

The next woman presents an obstinate
case of vomiting and constipation, for the
relief of which many remedies have been
tried. The injection of oil high up into
the alimentary canal has at last succeeded
in bringing away a large amount of hard-
ened feces. Her abdomen is distended, not
quite symmetrically, more to the left than to
the right. She may have a fibroid, an ova-
rian cyst, ascites, or be pregnant. In preg-
nancy there is usually an arrest of menstrua-
tion, and the subjective nervous symptoms
so well known. The white lines on the ab-
domen here seen are not diagnostic of this
condition. They are present in ascites,
obesity, cystic tumor, or any condition by
which the middle layer of the skin is
stretched. The first step is to inspect the
part. Is the swelling regular in shape ? In
pregnancy it is generally spheroidal with its
main axis in the middle line, or rather, gen-
erally a little to the right side. In fibroid
tumors the abdomen may be symmetrical or
a little one-sided. Irregular projections are
common. In cysts and ascites there is
fluctuation as a rule. In a single cyst this
fluctuation is marked ; if the cyst be multo-
locular, it is less noticeable. On palpation
a distinctive sensation is experienced. The
fibroid presents a hard, dense, resisting
mass, firm and irregular in outline. In
the pregnant uterus of this size, although
not by any means at term, irregular, rhyth-
mical contractions may be felt, which do not
easily mislead. Contractions in the abdomi-
nal walls do not imitate this rhythmical con-
traction. The fetal heart sounds can also
be heard at this period in pregnancy. Both
these signs are present in this woman. That
the mass lies to the right side rather than to
the left indicates that this is not this woman's
first child. The uterus is large and there is
a large amount of liquor amnii present, which
allows the fetus to float.

— Sulphuric acid often contains traces of
nitrous compounds which seriously interfere
in the examination of waters. This fact is
not as well known as it should be.

434

Communications.

Vol. lxiv

Communications.

SALOL.

BY ALFRED EICHLER, M. D.,

SAN FRANCISCO, CAL.

Salol is one of the recent additions to our
materia medica, but its merits are now al-
most universally admitted. It was discov-
ered and first used by Swiss scientists, in
1886, and since then its use has spread all
over the world. It is a white, crystalline
powder, obtained by the action of carbolic
acid on salicylic acid, therefore being, in
chemical nomenclature, a salicylate of phe-
nol. In composition, five grains of salol
are equal to about two grains of carbolic
acid and three grains of salicylic acid.
Therapeutically, its effects are entirely dif-
ferent from those of either agent adminis-
tered alone, depending on the fact that its
constituents are united by chemical union,
and represent, therefore, a different body.
Salol possesses an odor similar to oil of win-
tergreen. It tastes' like carbolic acid ; it is
soluble in water only in a very small meas-
ure, therefore watery solutions are imprac-
ticable. In alcohol, ether and oils, salol is
very soluble. Further, it is interesting to
know that this substance, although crystal-
line, cannot be reduced to a very fine pow-
der, because the crystals have a tendency to
adhere. The odor of salol may be noticed,
after its administration, in the excretions as
well as in the expired air. The dose differs,
according to circumstances, from 15 to 120
grains a day. It should be remarked, how-
ever, that a case has been reported in which
a half drachm of salol, administered to a
previously healthy person, and distributed
in five-grain doses over the day, has pro-
duced a severe rash over the whole body,
which disappeared spontaneously in five or
six days {Medical Record, March 3, 1888).
A case of poisoning has also been reported,
in which a young man had swallowed at
once two drachms of salol. The resulting
coma was followed by death. At the au-
topsy, degenerative changes were noted in
the kidneys, as might be expected ; the harm
done was attributed to the carbolic acid con-
tained in salol {Medical Record, October 1 1 ,
1890.)

As regards the method qf administration
of salol, it is best dispensed in pills, com-
pressed tablets, capsules or emulsion. For

external use lanoline, or a mixture of equal
parts of lanoline and olive oil, offers a very
good menstruum ; if used externally in oint-
ment form, it is usually prescribed in the
strength of one part in ten of the ointment
base.

Salol may be looked upon as a very effi-
cient antiseptic, antipyretic and anti-rheu-
matic. When ingested, it is insoluble in
the acid gastric juice, but it is dissolved in
the alkaline intestinal secretion, being per-
haps split up by the alkaline elements of the
bile into its original constituents, which are
then absorbed and taken into the circula-
tion, the carbolic acid being rendered non-
poisonous by the change into a phenate
(carbolate) of soda. This assumption is
corroborated by the fact that salol is readily
decomposed by weak alkalies like bi-carbon-
ate of soda — a point which should be re-
membered in prescribing. After absorption
and diffusion through the system, the origi-
nal constituents may be detected in the
urine, the carbolic acid imparting the char-
acteristic green color of phenoluria. As
salol passes the stomach unchanged, experi-
ments can be made with it in determining
the activity of the stomach in propelling
food. This test has been . taken advantage
of in dilatation of the stomach, and is
available in all diseases where the motor
power of the stomach is thought to be im-
paired. Of course, physiological tests of
this kind depend so much on varying cir-
cumstances that definite conclusions can be
arrived at only when a sufficient series of
control experiments with healthy individuals
is- also carried out.

The antiseptic effects of salol are easily
enough understood on considering that it is
composed of two of the most powerful anti-
septics now in our possession. As an anti-
pyretic, it acts on account of being a deri-
vative of salicylic acid, which itself has great
heat-reducing virtues. Salol, however, is
more easily tolerated by the stomach than
salicylic acid, as it is insoluble and non-irri-
tant ; while the latter is a strong irritant of
mucous membranes, and, therefore, cannot
be tolerated by the stomach for any length
of time in doses sufficiently large to produce
good effects. That the salicylic acid is the
antipyretic factor of salol is readily proved
by the clinical fact that salol acts as an anti-
pyretic only in large doses, twenty to thirty
grains, containing from twelve to eighteen
grains of salicylic acid. Small doses of
salol reduce heat only in a Very small meas-

April 1 8, 1 89 1. Communications.

435

ure. The carbolic acid and salicylic acid,
into which salol is separated in the intestine,
are eliminated mostly through the kidneys,
as carbolate of soda and unchanged salicylic
acid. Thus the urine is made antiseptic—
a fact which has been taken advantage of in
genito-urinary surgery.

The therapeutic action of salol resembles,
to some extent, that of salicylate of soda.
In comparing the action of the two reme-
dies, much similarity may be observed, with
some points in favor of salol. They are both
excellent anti-rheumatics, salol, however,
acting best in subacute rheumatism, espe-
cially when a short course of salicylate of
soda has preceded its use. It will lessen the
fever quickly, cause the pain to disappear,
and the swelling will be reduced. As al-
ready mentioned, it acts better in chronic
cases than in acute. For this purpose, it
should be given in doses of not less than
fifteen grains every three hours, preferably
in wafer or capsule. Salol is especially effi-
cient in those forms of rheumatism called
lumbago. Sciatica, that uncertain disease,
a veritable touchstone for medical skill,
composed so often of neuralgic, rheumatic
and malarious elements, often yields to large
doses of salol.

In diseases of the alimentary canal, salol
is also very efficient. It acts in the stomach
merely as a mechanical antiseptic, similar to
subnitrate of bismuth. In the intestine it
becomes a full and strong antiseptic. This
has been made use of to treat various dis-
eases of the intestine, like dysentery and
diarrhoea. It is advisable here to combine
salol with other suitable agents. For chronic
diarrhoeas, in which a cleansing of the in-
testinal tract may be desirable, it is good
practice to order fifteen grains of salol in an
ounce of castor oil, to be given at a dose ;
or, when pleasanter medication is desired,
one may prescribe :

B Salol ^ £ii

Ol. ricini f % iss

Syr. rhei f 5 ss

Pulv. acaciae gss

Aquae cinnamomii ...... q.s. ad f J iv

M. Fiat emulsio. Sig. A tablespoonful every

hour, until the bowels move very freely.

In typhoid fever salol has been used, but
with no more success than other remedies.
A disease running a regular course like ty-
phoid fever will not mend its ways, or be
aborted, under any one mode of treatment.
Salol, however, has proved quite efficient to
moderate the diarrhoea, and in conjunction I

with other therapeutic means, like cold ab-
lutions and wet packs, with free stimulation
and proper nourishment, it becomes a val-
uable adjunct in treatment.

Diarrhoea infantum offers a good field for
the administration of salol. It is especially
useful when the intestinal canal has been
severely irritated by the products of faulty
digestion. It may be ordered then in small
doses, alternating with antacid remedies,
like chalk mixture and bismuth.
• Affections of the genito-urinary organs
are often improved by the exhibition of
salol. The most common of all, gonorrhoea,
is much more tractable to treatment with
salol than without it. The main good is
rendered by making the urine antiseptic and
unirritating by its administration. It acts
thus considerably better than injections of
antiseptic substances, being practically an
injection from within outward. In treating
a case of gonorrhoea with salol, it can be
given in conjunction with the balsam of co-
paiba, usually prescribed. It may be or-
dered as in the following formula.

R Saloli gvi

Bals. copaibse : . ; . fgiss

Syr. simpl.

Mucilaginis acaciae aa f % iij

Tinct. lavandul. co q.s. ad f^viij

M. Sig. A tablespoonful three times a day, one
hour after meals.

Large doses will prove more efficient for
this purpose than small ones. The good
effects are produced entirely by the action
of the antiseptic and bland urine upon the
inflamed urethra. Weak antiseptic injec-
tions into the urethra from without can also
be used at the same time, and will assist in
securing a speedy cure. It has been shown
that salol, thus used, will shorten the course
of the disease materially. Chronic cases
improve under judicious use of this agent, if
it be used with sufficient persistence. The
urine appears, after the ingestion of these
large doses of salol, in a much darker color,
ranging from olive green to a blackish tint;
this is caused by the carbolic acid contained
in the urine, and need not be feared. Pain-
ful micturition is alleviated early, and the
discharge is lessened promptly; in short, the
acute inflammatory stage subsides much
more quickly with, than without, salol.

In other diseases of the genito-urinary
organs salol also deserves a careful trial. In
operating for stricture of the urethra, it is
advisable to have the patient take it one or
two days before the operation, to render the

436

Comm unications.

Vol. lxiv

whole urethra aseptic. Perhaps the infiltra-
tion of tissues, so feared after operations in
this region, might be rendered innocuous, if
salol were given beforehand.

In diseases of the bladder it also proves
useful. In cystitis it leads quickly to ame-
lioration of the symptoms, and thus proves
valuable in this troublesome and painful
complaint.

Salol is of great value in treating dif-
ferent affections of the air passages. As the
characteristic odor of salol may be noticed
in the expired air, it is quite right to assume
that it exerts a local influence besides the
constitutional impression. It is of great
value in the treatment of acute catarrhal
conditions, for the treatment of which it
may be combined with various other suitable
agents. Terpin hydrate, for instance, acts
well thus combined. The two substances
can be dispensed in small doses in capsules,
and given alternately every two or three
hours. If salol alone is given, it will often
be found to be acting like a charm. It
soothes irritation, stimulates free secretion,
and permits the patient to expectorate freely.
Patients often remark when salol is given,
that the medicine raises the phlegm quickly.
It is also recommended in tonsillitis, as it
will shorten the duration, besides lessening
the fever, quieting the attending pain and
relieving painful deglutition. In this affec-
tion an emulsion would seem to be the best
mode of prescribing the drug.

During the recent invasion of influenza,
salol proved of great benefit to the many
afflicted. It was quite often prescribed, es-
pecially in that form of the disease simula-
ting anginas and catarrhal sore throat. Al-
leviation of the rheumatic symptoms also
quickly followed its use. In the treatment
of other infectious diseases, salol has been
found useful.

As already mentioned, in typhoid fever
salol will assist in procuring asepsis of the
intestines. In scarlet fever, it has also been
prescribed, . and it is believed continued
administration of this drug will aid in
shortening the duration of the disease, by
eliminating the infectious material, besides
reducing the temperature.

Externally applied, salol gives excellent
results in some diseases of the skin. For a
simple erythema, it may be used rubbed up
with starch to a dusting powder. The pow-
der form, however, is not very eligible, as
salol has a tendency to ball together and
form lumps. It is more suited to a paste.

As it is white in color, it may be freely ap-
plied about the face. In sycosis of the
bearded portion, if it is thus applied, it will
cause good results. A good formula is as
follows :

R Saloli gij

Zinci oxidi

Pulv. amyli ...... . . . aa z iv

Lanoline % \

Of course salol may be added to this in
any strength, providing the fatty vehicle is
also increased. It is entirely innocuous
when thus applied, probably not being ab-
sorbed through unbroken surfaces, and acting
only as an antiseptic protective. The lat-
ter quality makes it also an admirable ap-
plication in burns and scalds. It is then
best used by dissolving it in some fatty oil,
preferably olive oil, afterwards pouring it
liberally over the injured surface, which is to
be covered with soft lint.

A summary of all these properties will
show salol to be a very useful addition to our
materia medica. It is to be regretted that
it is, like most other late additions, a pro-
prietary article, imported from Europe and
one which our laws prevent us from preparing
ourselves ; as a consequence it costs more
than it would if it could be manufactured
here.

SEXUAL PERVERSION AS A PHASE
OF EVOLUTION.1

BY J. G. KIERNAN, M. D.,

CHICAGO, ILL.

The hypotheses advanced as to the origin
of the sexual passion have been multiform.
One just now gaining the ascendency was
advanced by Clevenger a little more than
a decade ago in the following language :
" Dollinger and Drysdale have described
fission of the monad preceded by the ab-
sorption of one form by another. One
monad would fix on the sarcode of another,
and the substance of the lesser or under
one would pass into the upper one. In
about two hours the merest trace of the
lower one was left, and in four hours fission
and multiplication of the larger monad
began." Leidy insists that the amceba
is a cannibal, whereupon Michets expresses

1 Abstract of a paper read at the March meeting of
the Chicago Academy of Medicine.

April 1 8, 1 89 1. Communications.

437

the opinion that each cannibalistic act is a
copulative (if the term be admissible) one.
Henry Lawson agrees with Michets.

Among the numerous hypotheses as to
the origin of the sexual appetite none has
referred its derivation to hunger. At first
glance such a suggestion seems ludicrous
enough, but a little consideration will show
that in thus fusing two desires, the meaning
and derivation of the primary one — desire
for food — is not explained. The cannibal-
istic amoeba may, as Dollinger's monad cer-
tainly does, impregnate itself by eating one
of its own kind. Innumerable instances
occur among algae and protozoa, of this sex-
ual fusion, appearing very much like inges-
tion. Crabs confuse the two desires by actu-
ally eating portions of each other while
copulating. The female mantis religiosa
eats the head off the male during conjuga-
tion. Some female spiders find it necessary
to finish the marital repast by devouring the
male, who tries to scamper away from his
fate. The bitings and even the embrace of
the higher animals appear to have reference
to this derivation. Association often trans-
fers an instinct in an apparently outrageous
manner. With quadrupeds olfaction is most
related to sexual desire and its reflexes ; but
not so in man. Ferrier diligently searches
the region of the temporal lobe near its con-
nection with the olfactory nerve for the seat
of sensuality ; but with the diminished im-
portance of the smelling sense in man, the
faculty of sight has grown to vicariate olfac-
tion ; certainly the lust of the eyes is greater
than that of other special sense organs among
bimana.

In all animal life multiplication proceeds
from growth, and until a certain stage of
growth, puberty, is reached, reproduction
does not occur. The complementary nature
of growth and reproduction is observable in
the large size obtained by some animals
after castration. Could the division of an
amoeba be stopped, a comparable increase
in size would be effected. The seeming
grotesqueness of these views is chiefly due to
their novelty. While a primeval origin for
both ingestive and sexual desire seems to
have existed, and each seems a true hunger,
the one being repressible, and in higher
animal life subjected to more control than
the other, the question then presents itself :
What is hunger ? But the reflection serves
to show its potency in determining the des-
tiny of nations and individuals, and what a
stimulus it is in animated life. Most proba-

bly it originated in atomic affinities of inan-
imate nature.

Later biologists have adopted this theory.
Rolph evidently regards the process of fe-
cundation as one of mutual digestion, for he
says: "Conjugation occurs when nutrition
is diminished, whether this be due to want
of light, or the lower temperature of autumn
or winter, or to a reduction of the organism
to minimal size. It is a necessity for satis-
faction of a gnawing hunger which draws
the animal to engulf its neighbor — to iso-
phagy. The process of conjugation is only
a special form of nutrition which results in
a reduction of the nutritive income or an
increase of the nutritive needs in conse-
quence of the above-mentioned condition.
It is an isophagy which occurs in place of
an heterophagy. The less nutritive and
therefore smaller, hungrier and more mobile
organism, we call the male ; the more nutri-
tive, and, as a rule, relatively more quies-
cent organism, the female. Hence it is that
the small starving male seeks out the larger
well-nourished female for purposes of con-
jugation, to which the latter, the larger and
better nourished is, in its motive, less in-
clined.

Westphal has reported an interesting case
of perverted sexual instinct in a thirty-five-
year-old woman, whose father had com-
mitted suicide, and who had been a house-
keeper in a boarding-school for girls. She
learned with difficulty in school. She had
a cleft palate. As a child she had been
fond of boy's games and male attire. From
her eighth year on she had felt drawn
to certain girls. She liked to express her love
for them, kissed them and induced them to
let her touch their genitals, which from her
eighteenth to her twenty-fifth year she had
frequent chances to do. When such chances
did not occur she masturbated, .particularly
just before and just after menstruation, pic-
turing to herself the loved girl. She had
tried to abandon this habit, but when she at-
tempted to control herself, she experienced a
disagreeable odor and taste coming upward
from her genital organs. This perverse ten-
dency was exceedingly obnoxious to her
and she desired to be freed from it. In her
voluptuous dreams she appeared to herself to
be a man. Physically there was no variation
from the feminine type. The patient had
latterly been depressed and apathetic ; then
unsociable and violent, using obscene lan-
guage. These attacks were of regular oc-
currence. Before she came under Westphal' s

438

Communications.

Vol. lxiv

observation, she had been exceedingly de-
pressed, and confessed to her sister her love
for a girl. As she finally manifested vio-
lence, she was sent to Westphal. Men were
repugnant to her. During two months resi-
dence in the hospital she manifested no de-
lusions or hallucinations, but weakness of
judgment was evident. She contracted an
affection for a weak-minded patient in the
hospital. Five years after, the patient had no
more relations with' girls. She still mastur-
bated, exciting her imagination as before by
picturing female forms. She had attacks of
excitement just before menstruation, and
periods of depression just after ; in these last
she suffered from imperative conceptions,
which are far from infrequent in these cases.
Olfactory hallucinations frequently co-exist
with sexual manifestation ; hence their ap-
pearance in this case. That they are really
an atavism will appear obvious when the re-
lation between sexual excitement and olfac-
tion in the lower animals is remembered.

In another case the mother had a neurotic
ancestry, but was brought up in refinement.
She fell in love with a farmer, and married
him against her parents' wishes. The match
proved unfortunate. He was prudent, and
did not give his wife the comforts of life to
which she had been accustomed. She finally
become demonstrably insane, deserted her
home, and was found one morning behind a
pile of wood clasping to her bosom a new-
born babe. The child was taken care of by
friends until the mother died, and grew up
a beautiful girl, but when about seventeen
years old exhibited an errabund tendency.
She displayed a great liking for boyish games
and attire, but a repugnance to suitors. She
was persuaded into a marriage with a man to
whom she became so repugnant that he de-
serted her, whereupon she sought refuge in
a Pennsylvania almshouse, where she met
the second case who came under Dr. Wise's
immediate observation. This last woman
had an insane ancestry on the maternal side;
she preferred muscular sports and labor ; she
was averse to attention from young men, and
preferred the society of her own sex. She
was forced into a marriage with a man to
whom she bore a female child, but who de-
serted her, relations with her husband being
distasteful. On being abandoned by her
husband she went West, assumed masculine
attire, became a hunter, and spent several
years among the Indians. On her return
she published a very quaint description of her
hunting life. Becoming reduced in circum-

stances she sought refuge in the almshouse
with the first patient, who became strongly
attached to her and the attachment proving
mutual, the two took up their abode in the
woods as husband and wife. The second
patient assumed the name of "Joe," and
provided for the two by hunting and trap-
ping. In 1876, the two returned, the wife
introducing her "husband" to her uncle.
She was kindly received, and her "hus-
band " was hired to work about the place.
One day " Joe " was found to be a woman
in disguise, whereupon the uncle was so in-
dignant that he caused " Joe's " arrest. She
was imprisoned for four months, during
which time the " wife " visited her and car-
ried delicacies to her. At length the neigh-
bors prevailed upon the uncle to have the
young woman released. When she came out
of prison she lived with her " wife " again.
At that time the estate of the "wife's"
mother was settled, and real estate valued at
several thousand dollars became hers. This
property she has not claimed, but still leads
her old curious life. Her husband died in
the Willard Hospital for the Insane. She
is about forty-six years old, while her hus-
band was a few years her senior. The hus-
band was admitted to the Willard Hospital
for the Insane in consequence of maniacal
attacks. After admission "Joe" tried to
have sexual intercourse with her associate.
" Joe " said that with her husband she had
never had anything" but repugnant sexual
relations, but with her " wife " sexual sat-
isfaction was complete. She had an en-
larged clitoris, covered with a large relaxed
prepuce. She had periodical attacks of sex-
ual furor.

Blumer reports a case in which psycho-
logical phenomena closely resembling those
of hysterics were manifest. The patient,
a male, loved a man in the purest manner
possible. To gain the affection of the loved
object he wrote poetry rather above the aver-
age of that poured out by enamored youths.
His poetry was so pervaded by the dreamy
sentimentality of the Platonic philosophic
views of the relations of the sex as naturally
to create a suspicion that ' this philosophy
might have the same origin. The pervert
used endearing names and wrote pseudony-
mous letters to his "beloved," scurrilously
attacking himself as a means of drawing at-
tention to his affection.

Sodomy sometimes results from an imper-
ative conception, or from this arising from
a vice or from both conjoined with congen-

April 18, 1 89 1. Communications.

439

ital defect. This last was the case with the
amours of the suicide paranoiac Ludwig, of
Bavaria, and Wagner, of " Tannhauser "
fame. The letters of the great composer to
the King demonstrate this.

One such case came under my own ob-
servation. An insane Bohemian girl was
admitted to the Cook County Insane Hos-
pital without a history. She had a virginal
vagina and hymen, and a funnel-shaped anus.
Subsequently her lover came under my care.
He admitted she was very lascivious, but
feared pregnancy, and had. permitted coitus
only by the rectum. As a result both became
incapable of coitus except when performed
in this manner. The erethism of the girl
finally resulted in an attack of mania-like
sexual furor, from which she died. This
flung her lover into a depression from which
he recovered under treatment, and he finally
made a happy marriage.

Sexual perversion may furthermore reap-
pear in certain races under the influence of
old tribal customs. Paederasty, according
to the oath of Hippocrates, was no more of
a crime in Greece than ordinary lascivious-
ness. The boy loves of the Greeks were
common features. Socrates and Plato in-
dulged in this love. Paederasty, as with the
Pueblo Indians, often had a religious phase.
Campbell points out that both prostitutes
and sodomites were religious attachments
even to the Hebrew temples. There were
consecrated prostitutes and consecrated sod-
omites whose receipts formed part of the
temple income, while the .hire of the promis-
cuous prostitutes and promiscuous sodom-
ites could not be accepted by the temple.
The influence of such customs was shown in
the relative frequency of paederasty in France
(Marseilles) and Italy (Calabria) where col-
onies had been early established by the
Greeks. In tribes where paederastic cere-
monies were part of the religious exercises,
there would be no popular aversion 'to paed-
erasty. Indeed, Schopenhauer views paeder-
astic performances by old men as an illustra-
tion of the beneficence of nature in prevent-
ing the propagation of the defective beings.

All of these manifestations may appear as
phenomena of periodical insanity, as substi-
tutes for epileptic attacks, in paretic de-
mentia, at the onset of puberty and senility
in man, and of puberty, pregnancy, senility
and the menopause in woman. Further-
more, they are frequently produced on the
neurotic soil of the male and female mas-
turbator. The female masturbator of this

type usually becomes excessively prudish,
despises and hates the opposite sex, and fre-
quently forms a furious attachment for an-
other woman, to whom she unselfishly de-
votes herself. The same phenomena may
be observed in male masturbators. These
latter, however, reach insane hospitals early,
as their gaucheries are demonstrable.

The female masturbator has not escaped
the keen eye of Balzac, who depicted her in
his Demoiselle avec les Teux d' Or. Brow-
ordel has reported an excellent case of the
periodical insanity type. The unstable
emotional balance of the periods of evolu-
tion and involution, like puberty, preg-
nancy, the climacteric and senility, explains
the sexual perversions of these periods.

That these abnormal sexual phenomena
may originate in imperative conceptions is
readily demonstrable. A woman in the
sexo-emotional condition produced by preg-
nancy manifests aberrant ' ' longings. ' ' Preg-
nant women have insisted on sexual inter-
course with a husband and have then killed
and eaten him. Recently delivered dogs
and tigers often devour their offspring. In
the male, similar phenomena occur at the
sexual orgasm, when great emotional exalta-
tion exists and the will is in abeyance in
consequence. A man may be then seized
by an imperative conception differing in
character from the voluptuous. Seeing a
woman's shoe he is unable thereafter to ex-
perience sexual emotions without this con-
ception. Ridiculous as this may seem/more
than one victim of this imperative concep-
tion has been tried for theft therefrom re-
sulting.

Lawson has reported such an adjudicated
case. Sprague, the accused, was arrested
immediately after having assaulted a young
lady by throwing her down violently, re-
moving one of her shoes and running away
with it. He made no attempt to steal any-
thing else, although she had on valuable
jewelry. When the trial came on, insanity
was alleged as a defense. Numerous wit-
nesses, the principal of whom was the father
of the defendant, a clergyman of the high-
est respectability, testified to the erratic
conduct of the prisoner. A family history
was elicited which bore most pertinently
upon Sprague's case, his grandfather, grand-
mother, great-grand-uncle, three great aunts
and a cousin having been insane. He
had himself in his youth received numerous
blows and falls upon the head, and within a
year from the last head injury he had devel-

440

Communications.

Vol. lxiv

oped severe headaches, associated with
which his friends noticed a bulging of the
eyes. About this time the prisoner devel-
oped a fondness for stealing and hiding the
shoes of females about the house, and it was
found necessary by his relatives and the
female domestics to carefully conceal or
lock up their shoes to .prevent his abstracting
them. Upon investigation it was discov-
ered that' the act of stealing or handling the
shoes produced in him sexual gratification.

About a decade ago I pointed out that not
a single abnormal sexual manifestation by
itself, could be regarded as evidence of in-
sanity leading to irresponsibility, hence I
most heartily agree with Krafft-Ebing,
Spitzka and Tarnowsky, that the mere ex-
istence of anthropophagy, necrophilism or
sexual perversion, unaccompanied by other
evidences of nervous and mental disease, is
not sufficient proof of insanity.

Between the cannibalistic sexual inter-
course, the expression of protoplasmic hun-
ger in the amoeba and the picture drawn by
•Finck and Maudsley looms a seemingly im-
passable gap, yet evolution has, as demon-
strated by these perversionary atavisms,
bridged this gap, and from and by what
would a priori seem the utmost expression
of egotism, has developed a secondary
' 'ego" which inhibits explosive manifesta-
tions of egotism and hence is an efficient
moral factor.

COMMON COLDS.

BY A. NOEL SMITH, M. D.,

DOVER, N. H.

When an individual has " taken cold,"
as is said, there is certainly a departure from
a healthy or normal condition. Although
most people have contracted a cold many
times in the course of their lives, and had
no structural disease as a consequence ; yet
it is to my mind not only erroneous but
dangerous to entertain a belief, as many,
more especially non-professional people, are
apt to do, that a cold scarcely ever has se-
quels of a serious nature. And this error
in belief has destroyed the lives of many.

No person, it is true, dies merely of a cold,
as long as it is nothing but a cold simply ;
but when, from inattention and neglect, it
results in certain diseases which at once sug-
gest themselves to the mind, a cold may,
and often does, indirectly prove fatal.

" Colds destroy more than plagues," was
the answer of a physician to one of his
friends, who in reply to an inquiry as to his
health, said, "I am very well, having noth-
ing but a cold."

Another error into which many are apt to
fall is, that colds require no treatment ; and
I have heard of individuals who not only
considered colds as free from danger, but
even thought, or pretended to think, them
wholesome and promotive of good to the
organism in some way which they could
not explain. No doubt a man had better
have a cold than a more grievous disease, but
it must be infinitely better to have neither.

It is unnecessary to note the symptoms of
a cold ; all are only too familiar with them.
Colds seem to be of no certain duration or
continuance; and many have been the reme-
dies employed to cut them short in their
course. Large draughts of cold water ; hot
water ; hot brandy ; whiskey ; hot lemon-
ade ; gin; eating heartily, or " feeding the
cold;" fasting, or " starving" it — all have
been tried with variable results.

Neglected colds may be, and are, respon-
sible for many affections which afflict us.
We meet every day in our practice some
form of the many throat troubles, so com-
mon in this changeable climate, which are
brought on by exposure to cold and moist-
ure. Very few people are exempt from ca-
tarrhal affections of some portion of the res-
piratory tract. Perhaps acute bronchitis
most frequently results from taking cold.
Of course every case of such disease does
not have this common origin ; as bronchitis
frequently occurs in connection with other
diseases, and also arises from traumatic
causes.

Not only may colds be responsible for a
catarrhal process in the larger bronchial
tubes, but the process may extend down-
wards, developing catarrhal pneumonia and
caseous phthisis. Then, although croupous
pneumonia depends upon a specific element
for its etiology, and is therefore a self-lim-
ited disease, persons predisposed to this af-
fection by constitutional vice may find ex-
posure to cold acting as an exciting cause at
any time.

So long as the results of a cold are mani-
fest in the larger bronchial tubes only, per-
haps there is not much to fear ; but when
the smaller tubes become involved, there is
everything to fear ; for continuous collapse
of the air vesicles from obstructed bronchi
must end in caseous phthisis.

April 1 8, 1 89 1.

Periscope.

441

Now seeing these things are so, and that
the dangers to the human economy are so
numerous from neglect of the so-called
" common colds," what is the inference to
be drawn ? Evidently this : that we ought
to strive in all possible ways to lessen these
dangers by prophylaxis, living ourselves, and
teaching others to live — especially in this
changeable climate — in such a manner as to
reduce the number of colds contracted from
time to time to the lowest possible number.
This can be accomplished only by giving
close attention to all hygienic rules. In the
first place, a person must have good and
abundant food, at regular intervals, in order
to be well protected against the arrows of
disease. The clothing must be such as will
afford equal warmth to the surface of the
body and the extremities. It must be com-
fortable and easy, and not interfere with
sufficient perspiration over the surface of the
body. The bad results from chilled extrem-
ities and cold feet can scarcely be over-esti-
mated. The importance of proper clothing
and the necessity of changing with the sea-
sons are well illustrated in the lower animals.
The horse changes his coat in the spring and
autumn, and in the winter it might be said
he has a double coat. The birds moult their
feathers in the fall, and the new feathers
thicken as winter comes on. The neck does
not require so much protection as the body
below this point ; neither do the head and
face. It is a mistake to muffle up the neck
too much, especially when walking, as this
part is richly supplied with blood-vessels,
and does not chill easily.

Again, pure air is essential to the mainte-
nance of health. I firmly believe that in
order to enjoy the greatest immunity against
colds, one must accustom himself to be out-
of-doors in all weathers ; and so long as he
is protected so that he will not get wet feet,
or get wet through, always remembering to
keep the mouth closed, and to breathe
through the nose wholly, there is no more
danger of catching cold out-of-doors than
in.

Another prophylactic measure consists in
proper and continuous expansion of the
lungs. As I have intimated above, certain
forms of phthisis and pneumonia will result
from the inflammatory condition established
by collapse of the air cells of the lungs, on
account of obstruction of the bronchial
tubes. Now, this result may be avoided
very frequently by keeping the lungs, espe-
cially at the apices, well inflated with pure

air. I believe this process to be one of the
most valuable in the prophylactic manage-
ment of common colds \ as I have known
persons who, previous to systematic deep in-
halations of air, were afflicted often with
colds, and thereafter were seldom troubled.
And not only is such a course valuable as a
preventive, but an established cold may often
be cleared up by persistent and frequent ex-
ercise of the respiratory muscles.

To conclude, as so many and grave dis-
eases may and do have their origin in the
common cold, and as guarding against and
preventing disease is admitted to be far bet-
ter and more philanthropic than to cure it
when already established, let us endeavor to
educate our communities in every prophy-
lactic measure that experience of ourselves
and others may suggest, and thus assist in
the prevention of suffering, and in the pro-
longation of human lives.

Periscope.

Sterility.

The Archives of Gynecology, January,
1891, quotes Dr. Robert Bell, in the Medi-
cal Press, as saying that while it must be
admitted that impotency in the male oc-
casionally is present, it is of such rare occur-
rence that when it does occur it may be
looked upon as phenomenal ; moreover, it
can generally be accredited to the effects of
some previous gonorrhceal or syphilitic at-
tack. That it may, however, occur idiopath-
ically is also admitted, but the percentage of
such cases is so very small that for all prac-
tical purposes they scarcely deserve consid-
eration. In the female also sterility of an
idiopathic origin may likewise be viewed as
a very rare defect. In short, it may be ac-
cepted as a principle that sterility in either
sex is the sequelum of some diseased as op-
posed to a defective condition of the sexual
organs. I consider the one great factor in
its production to be a diseased condition of
the endometrium. This may be due to va-
rious causes, such as stenosis, catarrh, hydro-
static congestion due to a defective heart
action, or some vascular derangement in-
duced by obstinate constipation. It may,
on the other hand, be aggravated by flexions,
versions or prolapsus. Stenosis as well as
retroflexion and anteflexion are credited
with many evil consequences such as dys-
menorrhea, menorrhagia, etc., but these

442

Periscope.

Vol. lxiv

various pathological conditions would never
co-exist were the endometrium healthy. We
are not sufficiently alive to the fact that en-
dometritis proceeding to metritis is a preg-
nant cause not only of the various affections
of the uterus, but of those of the tubes and
ovaries also. Take stenosis of the cervical
canal for example. In nine cases out of ten
it is due to a hypertropic condition of the
mucous membrane due to chronic hypersemia.
If such is the case it is needless for me to
remark that forcible dilatation, which is so
frequently resorted to, in the circumstances
can be hardly anything more or less than
injurious. If, on the other hand, stenosis is
really the primary affection, it does not
necessarily imply sterility or even dysmen-
orrhea ; that is, if the upper reaches of the
endometrium are healthy ; and for this rea-
son that the spermatozoa can impel their
way through as narrow a canal as a fluid can
escape by, and blood, if not coagulated,
can dribble through a channel of very mi-
nute caliber as quickly as it is thrown off in
menstruation. If, however, it comes in con-
tact with tissue, be it ever so slightly inflamed,
its fluidity decreases and hence the distress
which so frequently accompanies stenosis,
because coagula have to be forced through
the contracted channel by uterine action.
Now, just as in endometritis the caliber
of the cervical canal becomes narrowed, so
does that of the Fallopian tubes, and more
especially does this occur at their outlet into
the uterus where the lining membrane, in
consequence of its hypertrophied condition,
tends to occlude the orifice. In this way
hydrosalpinx and pyosalpinx frequently ori-
ginate. To my mind the one great factor
of sterility is endometritis, and in this I in-
clude endocervicitis.

Not so very long ago it was accepted as
an axiom, that if a woman had ever been-
the subject of inflammation of the womb
she could never become pregnant. Now,
however, it is beyond question that this
hypothesis is false. Nay, more, I have known
of women who have even been the victims
of gonorrheal endometritis to bear children
after that was removed. This is a much
further advance than pregnancy becoming
possible after a simple endometritis had been
cured. Endocervicitis may certainly per se
be the cause of sterility, and doubtless oc-
casionally is, but it is so rarely disassociated
with a similar condition of the endometrium,
and endometritis is never present without
endocervicitis being co-existent. If we ex-

amine the discharge which is secreted so
abundantly in endometritis, we will find that
it frequently consists of a muco-purulent
fluid of an acrid nature. The character of
this fluid is so irritating that its passage over
the vaginal portion of the cervix denudes it
of its mucous surface, giving rise to erosion
and pupillary ulceration, and not infre-
quently to vaginitis as well. The effects of
its acridity, then, being so injurious to the
mucous surfaces over which it passes, can it
be doubted that it will have a destructive
effect upon the spermatozoa when they come
in contact with it ? Though this were not
the case, however, the disorganization pro-
duced by it on the endometrium would cer-
tainly deprive this membrane of the power
of affording a proper nidus for the ovum, if
even it were to become impregnated. If
pregnancy does not follow marriage within
a reasonable time, there must, as a rule, in
the majority of cases, be present some faulty
condition of the generative organs of the
female.

Flexions are frequently accredited with
being factors of sterility. This, however,
is only because they indicate an un-
healthy condition of the uterine lining
membrane and walls. In short, they are
only accessory conditions to, and dependent
upon, the one prime factor of sterility, viz.,
endometritis. Now we know that not un-
frequently unmarried women are the victims
of this disease, and though in many instances
it may not be sufficiently severe to inter-
fere very much with the geueral health be-
fore marriage, the case is very much altered
after that event, and this for obvious reasons.
As time goes on the diseased condition of
the uterus does not tend to diminish, but on
the contrary to increase, in consequence of
the periodical excitement the organ under-
goes. The unhealthy condition, which at
first was trifling, becomes in consequence
more and more pronounced. It is little
wonder, therefore, if sterility is persistent.
If, however, the endometrium, by judicious
treatment, is restored to its normal condi-
tion, I have no hesitation in affirming that
it matters not how long after marriage this
is accomplished, the most powerful as well
as the most frequent barrier to conception
will have been removed. As I have before
stated, endocervicitis may exist for a time
without the endometrium being also in-
volved, but sooner or later, either by con-
tinuity of tissue or by the repeated monthly
efforts of the uterine walls necessary to pro-

April 1 8, 1 89 1. Periscope. 443

pel the menses through the narrow canal, or I
both combined, the endometrium must of I
necessity sooner or later become involved.
The more extensive my experience becomes
the firmer does my conviction grow that
endometritis is the one great cause of ster-
ility, and not only of sterility, but of flex-
ions and oophoritis also. This being the
case the treatment of those affections is not
difficult to conduct and bring to a happy
determination. To carry this out success-
fully, however, it is needless to insist that
during the process complete abstinence from
marital intercourse be enjoined.

Varieties of Hydrocele.

Duplay, in an article in /' Union Medicate,
translated in the Medical JVews, March 28,
1 89 1, mentions a large variety of hydroceles
which may be encountered in the inguino-
scrotal region, together with the means of
differentiating them. It is an easy matter
to distinguish the so-called " hydrocele by
infiltration" from hydrocele with effusion,
since the former is simply an oedema, and is
not accompanied with fluctuation and trans-
parency, while the tissues retain the imprint
of the fingers. More difficult is the diag-
nosis between encysted hydrocele of the tes-
ticle and epididymis and vaginal hydrocele.
The differences here consist in the variable
connections which exist between the sac and
the testicle. The effusion in hydrocele of
the tunica vaginalis entirely surrounds the
testicle, and the latter occupies a postero-
inferior position, aud is a little internal to
the tumor. This is the rule, but it is well
to remember that in cases of inversion of the
epididymis the testicle is found in front of
the effusion. In encysted hydrocele there is
a cyst which takes its origin between the tes-
ticle and the epididymis, either on a level
with the head of the latter or a little lower.
This cyst increases in volume, little by little,
until it conceals the testicle, but it always
remains attached to the head of the epididy-
mis by a point more or less constricted, as
large as the thumb or two thumbs, and it is
always possible to outline the gland, which
is impossible when it is enveloped by an ef-
fusion.

It is necessary to distinguish several vari-
eties of vaginal hydrocele, and to describe
separately congenital hydrocele, and hydro-
cele in Dupuytren's pouch. In the fetus
there is nothing in the tunica vaginalis, and

it is at the time of the descent of the testicle
that a prolongation of the peritoneum is
dragged down, constituting the serous cav-
ity. Congenital hydrocele is that in which
the peritoneo-vaginal prolongation is not
separated from the large abdominal cavity.
The liquid which the sac holds is then very
easily reducible, and returns into the abdo-
men very rapidly when the passage is large.
If, on the contrary, the passage is small, it
may require some time to return all of the
fluid. Hydrocele in Dupuytren's pouch is
a second variety of congenital hydrocele.
It is easy to confound this variety with bilo-
bar hydrocele. The latter is that in which,
owing to the resistance of the fibrous tunic
of the pouch, a bridle is formed which di-
vides the sac into two portions. Hydrocele
in the pouch is a variety in which the peri-
toneo-vaginal conduit, instead of becoming
obliterated after the passage of the cord, is
closed only in its upper portion, this closure
completely shutting off communication with
the peritoneal cavity. If, under these cir-
cumstances, an effusion occurs into the
tunica vaginalis, it will divide into two por-
tions, the one occupying the cavity which
extends from the base of the sac to the ori-
fice of the canal, and the other an intra-
canalicular dilatation. Occasionally the
peritoneum is pushed back, and it then
forms a subperitoneal sac, which may be felt
in the iliac fossa. In some cases, vaginal
hydrocele runs even to the external orifice
of the vaginal canal.

Of hydrocele of the cord there are two
varieties : in one, the cavity presents itself
above the line of the cord, and evidently
consists of the non-obliterated remains of the
peritoneo-vaginal canal. It is seen as a small,
resistant, transparent tumor, at a point more
or less elevated above the passage-way of the
cord. Some cysts of this kind at times de-
scend to the lower portion of the pouch, and
it is then possible to confuse them with or-
dinary hydrocele. On the other hand, the
obliteration of the peritoneo-vaginal canal
may take place in its lower portion, all the
upper portion remaining patulous, and form-
ing a serous cavity which may be taken for
an hernia or an effusion. In this variety,
which is very rare, the effusion descends
along the inguinal canal, and forms a trans-
parent, reducible tumor. This is, if we
adopt the name given by Chassaignac, a
peritoneo-funicular hydrocele.

Finally, there is hydrocele of the hernial
sac, which may extend the length of the in-

444

Pei'iscope.

Vol. lxiv

guinal canal, and even reach to the base of
the pouch. The hydrocele is a serous cavity
filled with liquid ; sometimes the intestine
and omentum are absent, and there is no
communication with the peritoneum, but at
other times an organ is found in the sac
which should be in the abdominal cavity.
Hydrocele of the hernial sac does not de-
scend to the base of the scrotum, and it is
easy to recognize it. Nevertheless, the di-
agnosis between it and peritoneo-funicular
hydrocele, or cysts of the cord, may be quite
difficult.

Safety of Hypnotism as a Remedy.

So much has been written lately of the
dangers of hypnotism that it is interesting
to note a very interesting and remarkable
article on the therapeutic use of hypnotism,
by Dr. Hamilton Osgood, in the Boston-
Medical and Surgical Journal, March 26,
1 89 1. In concluding, Dr. Osgood says: I
wish again to allude to the feeling that
hypnotism is dangerous. If it be applied
with the necessary technical understanding
and the proper suggestions, the causation of
hallucinations being avoided, and if the pa-
tient be treated with the gentleness and con-
sideration which is always shown a patient
under any other circumstances, I distinctly
deny that danger attends the use of hypnotism.
I do not speak from hearsay, but from a
moderately large experience. It is easy to
see how harm could arise where a susceptible
patient is used as a plaything for the crea-
tion of hallucinations, day in and day out,
at the sweet will of medical students and of
physicians indifferent to all else than their
own amusement, indulgence of curiosity or
a desire to watch effects. Charcot's patients
are trained, strained one may say, to the
highest degree and by startling and exhaus-
tive methods. It is no wonder that he sees
nervous disturbance among them, and that
they became mere puppets. Charcot, there-
fore, declares that only hysterical subjects
or persons of what he calls " a peculiar ner-
vous make-up," can be hypnotized, and that
hypnotism will create hysteria. This is cu-
riously refuted by all the statistics published
by men who hypnotize according to the
Nancy methods, men whose united testimony
refers to hundreds of patients to Charcot's
one. This is my experience, and further,
while the larger number of my patients have
been non-hysterical, among them strong
men, those who were hysterical, and have

responded to the treatment, have become
free from the nervous ailment.

Is there no argument in Bernheim's de-
cided assertion, after more than nine years
of large experience, that he never has seen
one case in which harm of any sort has re-
sulted ? He shows how harm could be
caused, but also that it is wholly unneces-
sary. I can show that harm has been caused
by the use of baths ; but does one stop bath-
ing ? Liebeault has used hypnotic sugges-
tion during thirty years of large practice
and he pronounces its proper application
harmless. It is singular that mere prejudice
strikes stronger roots in some minds than
simple truth. The fact is, however, that the
laity is more independent of the opinion of
the physician than once was the case. Peo-
ple will decide for themselves, and the very
results of hypnotic suggestion will be suffi-
cient proof.

A well-known physician, who is a good
hater of hypnotism, but who, of course, has
not used it himself, else he would have
another opinion, said to a relative of a pa-
tient whose case I have mentioned, that
hypnotism was hurtful. " Yes," was re-
plied, " but there is my cousin, who for
twenty years was constantly intemperate
and now cannot be made to touch liquor,
and his health has greatly improved. This
was the result of hypnotism. That is proof
enough for me."

Can any fair-minded man fail to see the
great value of the treatment in view of such
results ? One can merely quietly continue
the use of a remedy which, in many senses,
nothing can replace, and let prejudice take
care of itself. No physician, who practi-
cally has followed the methods of the Nancy
School, confining suggestions to the func-
tions of the organism, will admit that he
has ever seen a result in any sense injurious
to the patient. Consider the vast number
of patients which this statement includes !

One argument against the use of hypno-
tism I cannot leave unmentioned. It is,
that in using it a physician, simply because
this thing has in the past been largely in the
hands of quacks, might injure his practice
or hurt his standing. This needs only one
word of reply : To put it mildly, it is the
argument of a man without courage. Never-
theless, the timid physician, who believes in
hypnotism, doubtless finds reason to be
thankful for the fact that to-day hypnotic
suggestion stands firmly upon scientific
ground, and that it is practiced abroad by

April 1 8, 1 89 1.

Periscope.

445

men whose judgment is ripe and whose med-
ical attainments occupy the first rank. Per-
sonally, I should feel that I were doing
wrong, and were disobeying duty, if I were
unwilling to apply hypnotic suggestion wher-
ever I saw it were likely to aid the patient.
And this is the outcome of my experience
in this branch of therapeutics.

Treatment of Chorea.

The notable improvement in many cases
of chorea during the administration of sed-
atives, such as chloral or bromide of potas-
sium, has long been recognized by the pro-
fession. Dr. J. A. Jeffries has recently pub-
lished, in the Medical News, his experience
with sulphonal. Five of his cases were sim-
ple chorea — that is, first attacks of recent
origin. These all recovered within three
weeks. In two arsenic had failed, in two it
was never used, in the fifth either arsenic or
sulphonal alone failed, but together they
were quickly followed by improvement.
Sulphonal was also employed in five other
cases, which were either of long standing or
second or third attacks ; four were at the
period of puberty. Three of these cases
got well, at least for a month ; in three ar-
senic had failed ; in two it was not used.
Two did not recover with any treatment.
All the cases were also ordered a daily sponge
bath, simple diet and sleep in the middle of
the day. Although the treatment has only
been employed in ten cases, and two of these
have shown no improvement, the results in
the other cases appear sufficiently encourag-
ing. In reports upon simple chorea, how-
ever, it is well to check the results by the
average duration of such cases when not
under medicinal treatment.

The attempt to place any drug or combi-
nation of drugs in the relationship of a
specific to chorea represents a form of gross
and inexcusable empiricism. Simple cho-
rea, so-called, or better, Sydenham's chorea,
is the only possible exception to the above
statement. Certain choreas are of organic
origin (post-hemiplegic), or at least are so
classified at present. Such a form of chorea
is but little affected by drugs which benefit
the simple type. Huntington's chorea, or
the hereditary form of the disease, is noto-
riously obstinate in its resistance to the cura-
tive effects of all drugs. There are forms
of chorea which are distinctly of reflex ori-
gin. The celebrated case, reported by Ham-
ilton, of chorea dependent upon an eczema

of the arm, the chorseic movements begin-
ning with the development of the eczema,
limited to the same arm and disappearing
with the cure of the skin affection, is a strik-
ing example. Other reflex relations may-
exist in affections of the nasal mucous mem-
brane, in defects of ocular muscle accom-
modation, in preputial irritation, or in a
variety of other peripheral causes. Laryn-
geal chorea is almost invariably found to be
associated with a local condition of disease
in the larynx. Two other forms of chorea,
one occurring in pregnant women and dan-
gerous, the other in the aged, are recognized.
Rational therapeusis demands, of course,
the removal of the cause, and a reflex origin
should always be eliminated. Often the
symptom of nervous twitching will afford
no clew to such a cause. In the simple or
idiopathic, or Sydenham's chorea, the fol-
lowing plan of treatment is that observed
with most success in the clinic for nervous
diseases at the New York Polyclinic. The
child is removed at once from school, put
on a nutritious and non-stimulating diet,
freed from all excitement or mental strain,
and given a combination of iron, preferably
the dialised, with Fowler's solution of arse-
nic, 20 minims of the former and 5 to 10 of
the latter, three times daily. If there is
evidence of malnutrition, as is usual, cod-
liver oil and malt is added. If the case
does not improve in one week, or two at
most, it is put to bed and kept there for
three weeks, other treatment being continued
as above. In private practice, galvanism to
the spine, using the continuous current and
small doses at first (5 to 8 milliamperes),
with seances on alternate days, is at times a
valuable adjunct to other methods. Very
few cases will be found which are not
markedly benefited, if not entirely cured, by
the above plan. The arsenic may be in-
creased, if necessary, though the possibility
of arsenical poisoning should always be re-
cognized.— Archives of Gynecology, Obstet-
rics and Pcediatrics, February, 1891.

Keloid.

Dr. Bryson, in the New York Medical
Journal, March 7, cites an article by Dr.
A. F. Plicque, in the Gazette des Hopitaux0
October 11, 1890, assaying that the anatomi-
cal and pathological nature of keloid is
much in dispute. Alibert classifies it with
cancerous dermatoses ; Jacobson considers

446

Periscope.

Vol. lxiv

it a particular variety of sarcoma ; Tilbury
Fox as a tubercular affection ; and Hardy as
a simple deformity of the skin. To account
for it more satisfactorily, Bazin invokes the
aid of a special diathesis — the fibro-plastic.
Erasmus Wilson thinks it a trophic disturb-
ance ; Deneriaz, a microbic infection ; while
Kabler finds a certain relation between ke-
loid and syringomyelia. It has also been
suggested that keloid in general is the de-
velopment on scrofulous soil of what would
otherwise be sarcoma, and that it is an illus-
tration of the antagonism of disease. Patho-
logically, there is no essential difference be-
tween the cicatricial form and the sponta-
neous variety. Embryonic cells penetrate
deeply and congregate about the sheaths of
vessels far beyond the definite limits of the
disease itself. Hence the necessity of exten-
sive ablation in view of total extirpation.
True keloid is covered with the papillary
layer of the skin, which the cicatricial va-
riety is naturally without. There is also a
slight and immaterial difference in the con-
nective fibers of the two forms, but they
both belong to the group of fibro-sarcomata.
Just here lies an explanation of the benign
nature of the disease. As it progresses, the
embryonic cells take on the character of
definite connective tissue which gradually
obliterates the vessels of keloid that in
themselves are few in number. Hence the
slow devolopment and frequent arrest of sar-
comatous elements, of which the essential
cells and their nuclei become more and more
infrequent and gradually disappear. One
close relation to malignant growths, how-
ever, is the chronic tendency of keloid to
return after removal or treatment.

Pain and discomfort are prominent symp-
toms. Anything that will relieve these is
worthy of consideration. The agent now
most in favor is scarification according to
Vidal's method. The scarificator, a small,
sharp bistoury, is held like a pen between the
thumb and index finger. Incisions — per-
pendicular to the skin and not oblique — are
made lightly and rapidly by movements
of the fingers and not from the wrist.
Quadrilateral incisions are best, extending
slightly beyond the area of morbid tissue
into the region of healthy skin. This pro-
cedure causes considerable pain, which di-
minishes with each sitting, owing to further
division of nerve fibers. The slight hemor-
rhage may be arrested by pledgets of absorb-
ent cotton applied with the left hand during
the scarifying process. A Vigo plaster is

then applied. Union is by first intention,
all traces of the incisions disappearing in
three or five days. While the operation is-
slight in itself, antiseptic precautions are
absolutely necessary to avert all possible
danger of consequent erysipelas. Scarifica-
tion can be applied about once a week at
first, and then more frequently if the surface
is extensive. Pain is the first symptom to
disappear under this treatment, two sittings
having been sufficient to relieve it in a case
of Vidal's, where, it was so severe that the
surface had to be protected from the clothing
by a wire breastplate. Brocq recommends
electrolysis by means of needles plunged
into the tumor to the depth of six or seven
millimeters. The current — five milliamperes
— is passed for thirty seconds. The whole
surface is thus gone over, insertions of the
needle being as near together as is possible
without infringing upon the little white
circle that appears upon its withdrawal. On
account of inflammatory reaction, it is wise
to give only weekly or fortnightly sittings.
Perhaps the very best plan of treating keloid
locally is to alternate scarifications and elec-
trolysis. The diathetic condition, whatever
it is, must receive attention. Quinine,
where there has been a malarial element,
and salicylate of sodium, in a lithaemic sub-
ject, have relieved the pain of keloid.

Morphine Habit Treated by Gradual
Withdrawal.

Dr. Cottel, of Portland, Oregon, in the
American Practitioner, states that he has
obtained a positive cure in forty cases of
morphine addiction by means of the follow-
ing " mistura diabolica": Morphine sul-
phate, a variable amount ; fluid extract of
viburnum prunifolium, four drachms ; elixir
of ammonium valerianate, three ounces ;
elixir of sodium bromide, two ounces and a
half. The dose is a teaspoonful as required.
The amount of morphine is a diminishing
one, beginning at a point somewhat below
that which has been taken habitually. Tinc-
ture of opium may be substituted for the
morphine with advantage in some cases, the
size of the dose being proportionately in-
creased. The bromide of sodium is in the
proportion of five grains in each drachm of
the excipient. The mixture can be readily
given up after the morphine is dropped
from it.

This plan of treatment involves the

April 1 8, 1 89 1.

Periscope.

447

gradual withdrawal of the narcotic in cases
where there is a bona fide desire to be cured ;
immediate withdrawal is cruel and unscien-
tific, and it is inapplicable where espionage
and restraint are not within reach. Rapid
withdrawal of the narcotic has the same ob-
jections, and the tendency to relapse is
greater than when the gradual weaning has
been resorted to. The writer adds : "lam
confident that no case is incurable, however
chronic, provided the general health is fair."
The main point will be to win the confidence
of the patient in the physician's power to
cure, and to secure this he is to be taught
that the substitute used by the physician
contains no morphine. If he finds that the
substitute contains morphine his co-opera-
tion will not be given, since nearly all opium
fiends have had a sad and fruitless experience
in regard to the tapering-off process. It is
well not to hurry the reduction of the dose
of morphine ; in chronic cases, or those of
persons who have been taking ten grains or
less daily, the patients will usually not no-
tice the abstraction of a grain each week,
although some must be dealt with even more
patiently than that. In smell and taste this
mixture is truly diabolic, and many patients
will say they can do without the horrible
stuff long before the time estimated as re-
quired for the withdrawal has been con-
sumed.— New York Medical Journal, March
7, 1891.

The Leprosy Commission.

The Indian correspondent of the Medical
Press, March 4, 1891. furnishes the follow-
ing particulars regarding the work of the
Leprosy Commission : The Commissioners
arrived at Bombay in November, 1890, and
at once proceeded with their inquiries in
that city, whence they proceeded to Madras,
the Central Provinces, Hyderabad and
Burma. They have yet to go through Ben-
gal, the North-West Provinces, and the Pun-
jab. This, however, in itself constitutes
little more than half the inquiry, and which
consists in making the round of the several
leper asylums and examining the various pa-
tients confined therein. A good deal of
time was necessarily spent in getting at the
family history and the extent to which mem-
bers of the family suffered from the disease,
and who for the most part are scattered
about. In Burma a rather different course
was taken, the lepers were collected from
the country and from the pagodas. In

Prome a house-to-house visitation was made,
and a number in this way were got at. A
visit was suggested to the mosque at Tolly-
gunge, where on the first Thursday in each
month alms are distributed to about 600
paupers, the great majority of whom are
lepers. This, however, was obliged to be
abandoned, owing to want of sufficient time,
but at Hyderabad an opportunity occurred of
collecting evidence from a very similar gath-
ering of lepers of the district. Here it ap-
pears that a wealthy native gentleman period-
ically distributed considerable sums of money
among the lepers, and hearing of the arrival
of the Commissioners in the city, he at once
let it be known that he would distribute alms
on a certain day, and this proved of great
value. The Commissioners were last heard
of in Calcutta, where upwards of fifty lepers
were thoroughly examined the first day and
their family history carefully ascertained.
After having completed their work there,
they will then proceed to Darjeeling and to
Burdwan, and thence to the orphanage at
Purulia. Of equal, if not in some respects
of greater importance, is the bacteriological
laboratory work which must follow on the
footsteps of the inquiry, and which will have
to be done at Simla, and will, it is believed,
occupy about six months. The work there
will, for the most part, consist of micro-
scopical examination of the various diseased
structures, the separation and cultivation of
the leprosy bacillus, and to what extent it
may prove to be the medium of communi-
cation. On this point some of the members
of the Commission retain a perfectly open
mind.

Extra Titles.

The Medical Record says editorially,
March 7, 1891 : "The use of extraand dis-
tinctive titles for medical men has always
provoked discussion among those who have
and those who have not the coveted appen-
dages. The recent action of the Toledo
Medical Association in resolving to dispense
with all extra insignia of rank brings the
general subject again to notice. While
much can be said on both sides, we confess
ourselves in favor of such extra titles as
guarantee the possession of extra knowledge
or ability. It may sometimes be the ques-
tion which is the greater, the man or his
title, the officer or the office, the professor
or the college, the surgeon or the hospital,
and so on. Few men are so celebrated as
to carry with their work the simple name as

448

Periscope.

-Vol. lxiv

sufficient authority for ex cathedra state-
ments. There are too few Hannibals, Cae-
sars and Napoleons in our profession to make
precedents in such a line. Consequently,
when a man claims a right to speak from his
experience, it is proper to prove his fitness
by stating his position and title. But the
latter must be distinctive, if it adds force to
the arguments and statements of an author
or teacher. We admit that such distinctions
are invidious, but all distinctions are invid-
ious. Because they are so, men are willing
to work and struggle for them, and in so
doing make themselves fit the positions when
they attain them. We are well aware that
the man of mere titles means nothing.
Those of professor are in some quarters so
common that it becomes a real distinction
to be a high private. The fellowships to
societies are too numerous to mention, while
the medical air is literally swarming with
buzzing dispensary assistants. There is a
happy medium between the two extremes of
magnifying an office or of abolishing it al-
together. It becomes after all a matter of
taste with each man when and how to name
his titles. There is as much presumption
sometimes in avoiding their use on the ego-
tistical plea that the name itself is sufficient
as there is in making the tail too heavy for
the kite. At all events, we cannot legislate
on taste or expediency in this matter, and
we very much fear that the resolutions of the
Toledo Medical Association will be whistled
down the wind."

[This is very true. The use of titles is
sometimes ridiculous, but the fact that a
writer holds a position of responsibility as a
teacher or practitioner adds to the force and
value of what he says ; and, until an author
may assume that all medical readers know
this fact, it is proper to use a title which
will acquaint them with it. — Ed. Reporter.]

Gastric Function in Chronic Ne-
phritis.

In the Bolnitchnaia Gazeta Botkina, No.
47-52, 1890, Dr.V. Kravkoff publishes an ex-
haustive paper on the gastric function in
chronic nephritis, giving in a tabulated form
the results of his experiments on the gastric
function of patients with renal affection of
different degrees. He states that free
hydrochloric acid in the stomach of patients
with chronic kidney affections is extremely
variable in different cases, as well as in the
same case at different times. The varia-

tion in different patients is more marked, and
its relation to the general clinical symptoms
is less marked than that in the same indi-
vidual. In the latter case the fluctuation is
relatively less marked, but its relation to the
general condition of the patient is much
more conspicuous. In the majority of cases
the absolute amount of free hydrochloric
acid is lowered, the general acidity remain-
ing the same. In the minority, the amount
is normal or absent, but the general acidity
is lowered. The absorptive power of the
stomach is normal, as a rule. The gastric
motor power is lowered only in especially
cachectic cases, or cases with pronounced
gastro-intestinal catarrh. Sub-acute and
chronic attacks of uremia do not necessarily
interfere with the presence of a normal
amount of hydrochloric acid in the gastric
juice and the normal digestive power of the
latter.

Medical Schools in New York.

The Medical Standard, March, 1891, says :
The recent incorporation of the New York
College of Physicians and Surgeons with Col-
umbia College has very naturally led to med-
ico-historical reminiscences. It appears
that in 1767 Columbia College established
the first medical college in New York State.
In 1769 the graduation of the students
awakened such public enthusiasm that the
New York Hospital was founded. The
Columbia medical department survived
until the outbreak of the revolutionary war
when all college work ceased. The Medi-
cal College remained moribund until 1806
when the College of Physicians and Surgeons
was started. It had no faculty to speak of,
but the Columbia medical department had,
and this medical faculty was transferred to
the College of Physicians and Surgeons
which, however, maintained a separate ex-
istence. In i860 a nominal union was se-
cured. The present union is, however, an
intimate one. The medical college retains
its name, but becomes an integral part of
the university system of Columbia. The
treasurer and trustees of Columbia assume
all financial and other functions hitherto
exercised by the same officials of the medi-
cal college. Dr. McLane becomes dean of
the medical department and one of its rep-
resentatives in the university control. The
income of Columbia is to be drawn on for
the support of the medical department.
The students matriculate as students of Col-
umbia.

April 1 8, 1 89 1. Editorial.

449

THE

MEDICAL AND SURGICAL

REPORTER.

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The Editor will be glad to get medical news, but it is im-
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munications intended for publication.

ELECTRICITY FOR THE DISEASES
OF WOMEN.

Much interest has been felt, by thinking
men, in the question as to the value of elec-
tricity as a curative agency in gynecology.
This question has been kept constantly be-
fore the profession by the electricians them-
selves ; and as the importance of the subject
demanded, a respectful hearing has been
given. It cannot be denied that at the
present time the profession is disappointed
with what has been accomplished by elec-
tricity. Only recently it was claimed that
electricity was a positive cure for ectopic
pregnancy and for many cases of pelvic in-
flammation, including the various forms of
salpingitis and that pelvic adhesions, binding
bowels, uterus, ovaries and tubes together,
melted like the snow before the summer
sun. Now, we hear this no more, or it is
only hinted at, or it is hoped that electricity

will do these things. Practically, the use of
electricity is condemned by conservative
men in the treatment of ectopic pregnancy
and in all the graver forms of pelvic in-
flammation. Electricity has failed to abolish
the necessity for abdominal section in ec-
topic pregnancy, and in the various septic
accumulations in the tubes and ovaries.

It was claimed that electricity would dis-
place hysterectomy and the removal of the
uterine appendages, in the treatment of fib-
roids; that it would cure symptomatically
and anatomically. The proof of this claim
has been anxiously awaited, and it is grati-
fying to record that there is a growth of evi-
dence of the value of electricity — the gal-
vanic current — in the treatment of this dis-
ease. The Keiths have shown, positively,
that electricity will do much for the relief
or cure of fibroid tumors. At the present
time it has not supplanted hysterectomy or
the removal of the uterine appendages ; but
has been established as a method of treating
uterine fibroids. Careful men exclude it in
the treatment of fibroid tumors in which
salpingitis exists — a considerable class, of
soft myomata, and of fibro-cystic tumors.
When it is recalled that most fibroid tumors
do well without special treatment, that the
occasional use of the curette will suffice in
the treatment of many others, and that only
a small percentage have been submitted to
section in the past, it will be admitted that
the field of usefulness of electricity in the
treatment of fibroids is not a broad one.

There is no doubt, however, that the gal-
vanic current, properly used in the treat-
ment of uterine fibroids, will arrest hemor-
rhage, will lessen pain and will, at times,
bring about a diminution in size or even
the disappearance of the tumor. These
facts have been established by thoroughly
reliable men and are incontestable. On the
other hand it must not be forgotten that in
the natural history of fibroid tumors, hem-
orrhage at times lessens or ceases sponta-
neously, that pressure and reflex pains vary
from time to time, and that the tumors

45°

Editorial.

Vol. lxiv

themselves diminish or disappear at times
spontaneously. And also it must be re-
membered that certain dangers attend the
use of the agent. Deaths have been re-
ported ; peritonitis has been caused, and
growth of the tumor has been accelerated.
There is thus a negative side to the ques-
tion.

It is yet to be decided in what class of
fibroids electricity will do the most good,
and what the dangers of its use really are.
Then its advantages and disadvantages in
the treatment of a special class of fibroid
tumors, can be compared with the advan-
tages or disadvantages of hysterectomy in
the same class of cases.

Electricians claim to cure otherwise in-
curable cases of chronic metritis and en-
dometritis. These conditions, as primary,
uncomplicated diseases, are rarely met ;
usually they are found as a minor complica-
tion of salpingitis — perhaps antedating or
causing the salpingitis, but later being kept
up by the tubal inflammation. In the rare,
uncomplicated form of these uterine mala-
dies, and in purulent endometritis some-
times remaining after the removal of the
uterine appendages the use of the galvanic
current is indicated if simpler measures fail.
When the uterine disease is but a complica-
tion of salpingitis, all intra-uterine treatment
is contra-indicated.

It is gratifying to be able to call at-
tention to the lecture by Dr. Fisher, on the
use of " Galvanism in the Treatment of
the Diseases of the Uterus" in the last
issue of the Reporter, which, on the one
hand, adds something positive to the litera-
ture of the subject, and, on the other, serves
as an illustration of the views already ex-
pressed. Dr. Fisher is to be congratulated
on much that is in his lecture. He has
demonstrated something — that in certain
cases the use of the galvanic current has con-
trolled uterine hemorrhage, that in one case
a fibroid became smaller after the use of the
current for a year, and that in another a so-
called vaginismus disappeared. He states,

also, that he has obtained good results in
ten cases not reported.

Dr. Fisher has demonstrated that galvan-
ism will control uterine hemorrhage from
certain cases of fibroid tumor and from
abortion, after the failure of all medical
means. No mention is made of the curette ;
and the question arises : would not these
women have been cured with the curette in
a few minutes, instead of in weeks or months
by the use of electricity. And again, it is
disappointing to those who have hoped
much from the use of electricity, to find that
in a large clinical service, like that at the
Jefferson College, in a whole year's work
but twenty women have been benefited.
How many have been treated without bene-
fit, the reader is left to conjecture. And,
finally, we find that peritonitis has been in-
duced by electricity in the hands of one so
careful as Dr. Fisher.

The subject is certainly in an experi-
mental state at the present time, and what
is needed is careful reports of actual work,
care being taken to make diagnoses as exact
as possible. With full reports of good and
bad results obtained by the workers in this
field, the profession will be enabled to assign
to electricity its true value as a therapeutic
agent in the treatment of the diseases of
women.

EXCISION OF THE VERMIFORM AP-
PENDIX IN APPENDICITIS.

The inflammatory diseases in the region
of the caecum, described usually under the
names typhlitis and perityphlitis, are of
very great interest. Typhlitis is generally
the result of fecal impaction, and it yields
readily to medical treatment. The condi-
tion described as perityphlitis is probably in
nearly all cases due to an inflammation or
rupture of the vermiform appendix ; appen-
dicitis is, therefore, a better name for it. In
it, also, medical treatment is in the majority
of cases sufficient ; but there are a number of
cases in which an operation is the safer

April 1 8, 1 89 1.

Editorial.

451

course to pursue, and a still fewer number
in which the only hope of saving life is to
be found in a successful operation.

The British Medical Journal, February
21, 1 89 1, gives a brief account of four
cases of appendicitis in which Mr. J. B.
Sutton operated and excised the appendix.
The first patient was a man, twenty-two
years old, with unmistakable appendicitis.
Mr. Sutton exposed the caecum by a lateral
operation, and found the appendix lying ad-
herent to the anterior aspect of the caecum.
The middle third of the appendix had
sloughed, and an abscess, containing sev-
eral ounces of pus, had formed as the result
of it. The appendix was removed, the
stump sutured and the peritoneal cavity
flushed with warm water. The patient made
an uninterrupted recovery.

The second case illustrates the difficulty
attending the diagnosis of appendicitis.
The patient had had three previous attacks,
and came under Mr. Sutton's care as a case'
of renal colic ; the disease was really re-
lapsing appendicitis. On exposing the cae-
cum by a lateral incision, Mr. Sutton found
the appendix slightly adherent to the brim
of the pelvis ; its lumen was obstructed, and
below the constriction the appendix was
filled with pus. The appendix was cut off,
and the end was carefully sutured. The
patient left the hospital convalescent on the
fourteenth day.

The third case had also been regarded as
one of renal colic, but Mr. Sutton came to
the conclusion that the patient had a post-
caecal abscess, probably secondary to inflam-
mation of a vertical retro-caecal appendix.
This clever diagnosis was verified at the op-
eration ; the appendix was lying vertically
behind the caecum, and its middle third had
sloughed. The pus was washed away, the
stump of the appendix sutured and a drain-
age-tube inserted. Convalescence was in-
terrupted by an attack of pleurisy, which
suggested that the trouble with the appendix
was tubercular; no bacilli, however, could
be found in cut sections of the appendix.

In the fourth case, the patient had been
admitted with typical signs of typhlitis.
Under medical treatment he seemed to im-
prove, but in the course of three weeks the
presence of pus was clearly indicated. At
the operation, a large quantity of pus was
evacuated from the iliac fossa; the tip of
the appendix had sloughed.

The first, third and fourth of Mr. Sutton's
cases are cases in which death would have
resulted, in all probability, if an operation
had not been performed. There is no dis-
pute as to the propriety of operation in such
cases. In the second case, one of relaps-
ing appendicitis, there is still a wide differ-
ence of opinion as to whether or not an op-
eration is the best method of treatment.
Undoubtedly, in a number of cases, a patient
gets entirely well after repeated attacks of
appendicitis. If the recurrent attacks are not
severe, if they appear to decrease in fre-
quency and lessen in intensity, and if the pa-
tient is so situated that he can go to bed when
they occur, without serious loss or inconve-
nience, it is probably best to employ medical
and hygienic treatment alone. But if the at-
tacks show no tendency to subside spontane-
ously, and at the same time are a cause of
serious loss and disability to the patient, an
operation may be advised. The operation
should be performed in the interval between
attacks.

Unquestionably lives are lost in cases of
typhlitis and appendicitis because an opera-
tion is not done at the proper time and in the
proper way. But, if Mr. Treves is right, the
result would be worse if all cases were sub-
jected to operation. Mr. Treves, who is a
distinguished surgeon in this special field,
says that, at the London Hospital, nearly all
cases of typhlitis recover under ordinary
medical treatment, and that only a few cases
of appendicitis in young persons require op-
eration. Probably no cases, he says, should
be operated on before the fifth day, for cases
of death on the third or even the fourth day
are almost unknown. Contrary to the im-
pressions one receives from reading the opin-

452

Editorial.

Vol. lxiv

ions of many writers on this subject, Mr.
Treves declares that the operation of re-
moval of the appendix is often very difficult
even during a quiescent period. He thinks
that some day a portion of the ureter will be
removed for an appendix.

Approval of medical treatment for most
cases of typhlitis and appendicitis, coming
from such a surgeon as Mr. Treves, means
far more than it would if it came from any
purely medical man; and yet 'Mr. Treves
only gives expression to what is the common
experience of most physicians. The chief
difficulty which the latter encounter is to de-
cide when medical treatment should end
and surgical aid be invoked. The decision
in a doubtful case requires close observation,
large experience and ripe judgment. We
think it would be wise for the physician to
consult with a surgeon while the propriety
of operating is still in doubt, and not to
wait until it becomes clear to every one that
an operation must be performed ; for, in this
as in most other cases, if an operation is re-
quired, the sooner it is done the better the
chances of success.

HERPES VACCINIFORME OF INFANTS.

There occurs at and about the genital
region in infants of three or four months an
eruption, which, at first vesicular, soon ul-
cerates and presents the appearance of a
mucous patch. The condition is a rare one,
and derives its importance from its close
resemblance to the secondary eruption of
heredity syphilis, for which it is commonly
mistaken. Fournier, who describes the af-
fection in the Bulletin Medical, January 28,
1 89 1, has seen only ten cases, and gives the
condition the name of herpes vacciniforme
by which it is, perhaps, best known. The
eruption may appear coincidently in an in-
fant born of syphilitic parents, but in other
cases it is followed by no sequelae. It oc-
cupies usually folds of the skin, where ad-
jacent surfaces come in contact. In the
first stage, the vesicle resembles that of vac-

cinia before the period of suppuration. The
spots may be isolated or occur in groups or
become confluent. In the second stage,
umbilication and rupture take place, with
subsequent ulceration. The resemblance is
strong to a mucous patch. The affection is
usually purely local. Occasionally, how-
ever, there is involvement of adjacent glands.
Without treatment, the eruption may con-
tinue indefinitely. Under appropriate
management, it may disappear in eight
days. Relapses may occur, and the duration
may be prolonged for from a month to six
weeks. The process is thought to be the
result of local infection from the bowel, in
consequence of diarrhoea, which often co-
exists.

The treatment requires absolute local
cleanliness, baths of simple water, of bran,
or of starch, the application of lotions of
boric acid or of diluted Labarraque's solu-
tion, a drying powder of bismuth, of oxide
of zinc, of salol, or of iodoform, and a cotton
dressing covered by some impermeable ma-
terial.

UNIVERSITY OF MICHIGAN.

It is reported that the bill making an ap-
propriation for the Ann Arbor University
during 189 1-2 was tabled in the Senate of
Michigan,, on April 2, to save it from defeat.
It was opposed by the farmer members on
the ground that " a horde of foreign pupils
were being educated at the expense of the
poorer taxpayers of the State."

It is to be hoped that this action will be
but temporary, and that there will be no im-
pairment of the usefulness of the medical
department of the University of Michigan,
which has done such excellent work in pre-
paring men for the practice of medicine.
The fact that its existence and success did
not depend upon the fees of students has
enabled it to take a high stand in regard to
medical education, and to establish and ad-
here to a graded four years' course of study.
We trust that, in their wisdom, the farmers
of Michigan will come after awhile to see

April 1 8, 1 89 1.

Book Reviews.

453

that education is worth paying for, and that,
within certain limits, the larger the class at
their University, the better for it, and the
better for each student ; so that it is no dis-
advantage if some persons outside of the
State come there to get an education without
charge for tuition. It would be easy to
show, from a purely economic standpoint,
that it is a pecuniary advantage to Ann Ar-i
bor and ' the State of Michigan to get as
many students there as possible, and even'
to make no charge for teaching them. Were
this otherwise, it would still be a very good
thing to have large classes at their Univer-
sity, for the good of the people of that and
neighboring States.

Book Reviews.

[Any book reviewed in these columns maybe obtained upon
receipt of price, from the office of the Reporter.]

PLAIN TALKS ON MEDICAL ELECTRICITY
AND BATTERIES. By Horatio R. Bigelow,
Fellow of the American Electro-Therapeutic Asso-
ciation. Small 8vo, pp. 85. Philadelphia: P. Blak-
iston, Son & Co., 1891.

This little book contains a great deal of succinct in-
formation ia regard to a subject about which most doc-
tors have very hazy notions. The first part is occupied
with definitions of terms like, "volt," "ohm," "am-
pere " and " potential," which must sometimes be
troublesome to the general reader, when considering
articles in which electricity is discussed. To know
what they mean is not common, except with electrical
experts ; and so it is no reflection on the readers of
the Reporter to intimate they might get useful infor-
mation in Dr. Bigelow's book. Besides this, the book
contains very fully and well illustrated descriptions
of a variety of electrical machines, and diagrams
showing the .points on the surface to which electricity
is applied for various medicinal purposes, and a thera-
peutic index in which there is given in alphabetical
order a list of diseases and conditions for which elec-
tricity is used, with the form of current and the made
of application.

MANUAL OF CLINICAL DIAGNOSIS. By Dr.
Otto Seifert, Privat-docent in Wurzburg, and Dr.
Friedrich Muller, Assistant der n.; med. klinik
im Berlin. Translated from the fifth German
edition, enlarged and revised, with the permission
of the authors, by William Buckingham Canfield
A. M., M. D. (Berlin), Lecturer on Clinical Med-
icine, and Chief of Chest Clinic, University of Mary-
land, etc. Second edition, revised and enlarged,
with fifty illustrations and one colored plate. Small
8vo, pp. xi, 185. New York and London : G. P.
Putnam's Sons, 1890. Price, #1.50.

This book treats, in successive chapters, of the
^blood, the temperature, the organs of respiration, the

sputum, laryngoscopy and rhinoscopy, the circulatory
system, the pulse, the digestive and abdominal organs,
the urine-producing system, transudations and exuda-
tions, parasites, the nervous system, analysis of the
pathological concrements, and metabolism and nutri-
tion.

Those who expect to find in the book a treatise on
medical or physical diagnosis, will be disappointed.
Relatively little space, f >x example, is given to the ex-
amination of the heart and lungs, and, perhaps for this
reason, some of the statements are unsatisfactory and
others wrong. We object to the assertion that " very
strong bronchophony is called pectoriloquy. In pec-
toriloquy there is not simply exaggerated reproduction
of the voice sounds, but the individual words can also
be distinguished. Again, in saying that heart murmurs
are transmitted ' more easily in the direction of the
blood-current, the authors give expression to a general
and useful rule ; but they are wrong when they say
that the systolic murmur of mitral insufficiency " is
heard most distinctly at the second costal cartilage of
the left side." The systolic murmur of mitral insuffi-
ciency is heard best at the apex, or a little external to the
apex, and it is transmitted to the axilla ; in very ex-
ceptional cases it is most intense at the second left inter-
costal space.

The chapters on the blood, the digestive and ab-
dominal organs, the urine-producing system, parasites
and the nervous system are all very good. The book
as a whole is an excellent one to put into the hands
of a third or fourth year student who already knows
ordinary medical diagnosis. It will also , prove very
valuable to a hospital interne who has a liking for clin-
ico-pathological study ; but it is too advanced to suit
the requirements of the beginner.

TRANSACTIONS OF THE AMERICAN ORTH-
OPEDIC ASSOCIATION. Fourth Session, held
at Philadelphia, Pa., September 16,17 and 18, 1890.
Volume iii, 8vo, pp. xxiii, 242. Philadelphia : Pub-
lished by the Association, 1890.

This volume contains the papers read at the fourth
annual meeting of the Association, at Philadelphia.
It was one of the most successful meetings the Asso-
ciation has held. In addition to an admirable address
by the President, Dr. De Forest Willard, there were
twenty-three papers read. One of the most interesting
features of the programme consisted in a series of
papers on Lateral Curvature of the Spine, by Drs.
Benjamin Lee, of Philadelphia ; Charles L. Scudder,
of Boston; Robert W. Lovett, of New York, and A.
B. Judson, of New York. An extremely interesting
and animated discussion followed^ the reading of the
papers.

The Association is to be congratulated upon its
thriving condition and upon this last volume of trans-
actions, which bears such ample testimony to the pro-
gress orthopedic surgery is making in the United
States.

Insoluble Cement. — It is said that a ce-
ment which is hard enough to withstand even
boiling sulphuric acid may be obtained by
gently melting India rubber and adding '8
per cent, tallow while stirring. Sufficient
slacked lime should be added to give to the
compound the consistency of a soft paste.
Twenty per cent, of vermilion is now added,
which causes the mass to harden immediately.

454

Notes and

Comments.

Vol. lxiv

Notes and Comments.

Contagiousness of Gonorrhoea.

In discussing the contagiousness of chronic
urethral discharges, in the Journal of Cuta-
neous and Genito- Urinary Diseases, March,
1 89 1, Dr. George Emerson Brewer, of New
York, says the practicing physician is fre-
quently called upon to answer inquiries re-
garding the limit of the contagious stage of
gonorrhceal urethritis. The question is a
serious one, especially when considered in
its relation to marriage, and should be
regarded as equal in importance to that of
syphilis.

It has not infrequently been Dr. Brewer's
experience to be consulted by young men, a
few weeks or months before a contemplated
marriage, with a history of one or more at-
tacks of gonorrhoea in former years, and
who believed themselves to be well ; yet
who upon a careful examination presented
the unmistakable signs of a chronic ure-
thritis. The only evidence of disease re-
maining in these cases frequently was the
presence in the urine of small thread-like
bodies, to which the name of Tripperfaden
has been given by the German surgeons,
who first described them and demonstrated
their importance. These minute shreds are
composed of mucus, pus and epithelium ;
and represent the secretions which adhere to
any granular patch or area of chronic in-
flammation remaining on the urethral mu-
cous membrane.

In consulting the standard authors upon
the subject of genito-urinary diseases, one is
impressed by the marked difference of opin-
ion, regarding the contagiousness of chronic
urethral discharges, held by those whose rep-
utation and experience entitle them to the
foremost position in the discussion of this
question. As early as 1785 Kiihn called at-
tention to the fact that the discharges result-
ing from a gonorrhoea remained contagious
so long as they contained pus. The oppo-
site opinion was held by Hunter, who denied
the possibility of contagion from the gleety
discharges of a chronic urethritis. This
view was also shared by Bell and Ricord.
In a paper entitled "Gonorrhoea a Non-
specific Disease," published in the New York
Medical Independent \x\ 1864, A. K. Gardi-
ner strenuously denies the contagious ele-
ment in any, save the discharges from the
most acute stage of the disease ; and says
regarding gleet that it is "allowably benign.

and innocous." * Npeggerath, on the other
hand, in a paper published in 1872, con-
cludes that a man who has once been the
subject of a gonorrhceal urethritis, never
fully recovers, that the disease invariably
lingers in the glands and ducts emptying
into the canal, and may at any time furnish
a secretion which may infect those with
whom he has sexual relations. He also
states that nine-tenths of all women married
to men who have had gonorrhoea, sooner or
later become the subject of incurable and
painful inflammatory disease of the uterus,
tubes or ovaries ; that this infection may
take place rapidly, and manifest itself as an
acute affection, or by means of a slow and
unrecognized process to- which he gives the
name of " latent gonorrhoea." In a subse-
quent paper, read before the American Gy-
necological Association in 1876, the author
reiterates these opinions, and adds that 90
per cent, of all cases of sterility can be di-
rectly traced to gonorrhoea.

Without entering into any discussion re-
garding the correctness of these views, which
have been the object of considerable criti-
cism, the fact remains that these papers had
the effect of calling attention to a source of
female disease and suffering, the importance
of which had not, until their publication,
been adequately recognized. This differ-
ence of opinion upon so important a ques-
tion is hardly to be wondered at, when we
consider that at the time these views were
enunciated, nothing definite was known re-
garding the etiology of this disease. Since
the discovery by Neisser, in 1878, of the
gonococcus, and the (Dr. Brewer thinks)
establishment of its relationship to this dis-
ease, but one opinion can logically be held
by those who accept his theory of gonor-
rhoeal inflammations, and that is, that all
secretions containing this micro-organism
are capable of transmitting the disease un-
der favorable conditions. In his recently
published work upon this subject, Ernest
Finger emphasizes this point and states re-
garding marriage, that it should be abso-
lutely prohibited in all cases where the ex-
istence of a chronic urethritis is evidenced
by the presence of the " morning drop " or
Tripperfaden in the urine, until the follow-
ing facts have been established :

1. That after from two to four weeks of
daily observation, the secretions from the
urethra are found to be free from pus and
made up wholly of epithelial cells.

2. That no gonococci can be detected by

April 1 8, 1 89 1. Notes and

Comments,

455

the microscope, even after a purulent dis-
charge has been established by the employ-
ment of irritating injections of corrosive
sublimate or nitrate of silver ; and

3. That neither prostatis nor stricture ex-
ists.

Dr. Brewer says that upon first becoming
acquainted with the- views expressed by Fin-
ger, he regarded his conditions as unneces-
sarily severe, and his opinion of the danger
as greatly exaggerated. But a somewhat re-
markable case, which came under his ob-
servation, illustrated in a most striking man-
ner the fact, that unless some of the precau-
tions advised by Finger had been insisted
upon, the responsibility of a dangerous ill-
ness would justly have rested upon his head.
The case is reported by Dr. Brewer, and
fully justifies the inferences he draws from it.

Pasteur and his Work.

The American Practitioner and News,
February 14, 1891, says editorially: At a
moment when Pasteur has been apparently
promoted to a secure apotheosis, and new
eligibles are being sought to share with him
the superabundance of divine honors, it
comes like a discord in a grand orchestra for
men eminent themselves to stand out and
boldly declare to the world that the renowned
savant is wearing unearned laurels. But that
is just what has been done by two eminent
Paris physicians, one of them Dr. Lutaud,
editor of a leading medical journal, the Jour-
nal de Medicine de Paris, and the other Prof.
Peter, member of the Academy of Medicine.
They not only charge Prof. Pasteur with ex-
ploiting procedures in themselves worthless,
but with exploiting them for gain, and with
interfering in political matters for the purpose
of unfairly promoting his personal interests.

In a book of some four hundred and forty
pages, a second edition of which has just
been published by Dr. Lutaud, the whole
history of the Pasteur discoveries has been
gone over, as indeed they have been from
time to time in the author's journal. In the
first place, the originality of the discovery
that repeated inoculation may confer immu-
nity is denied to Pasteur.

In 182 1 Magendie published in his Jour-
nal of Physiology a series of experiments
proving that by successive inoculations hy-
drophobia limited itself after the third gen-
eration or repetition in different animals.
These experiments with their results were re-

published in Paris in 1868, in a work en-
titled What to do till the Doctor comes.

In 1879 M. Galtier, professor in the Vet-
erinary School of Lyons, wrote a commu-
nication to the Academy of Sciences an-
nouncing that he had discovered that rabies
is transmissible to rabbits, and that they
thereby become a convenient and harmless
instrumentality for determining the virulence
,or non-virulence of various fluids derived
from rabid animals.

In 1879, in April, Dr. Deboue, of
Pau, communicated to the Academy of Sci-
ences, through M. Bouley, a treatise on hy-
drophobia, in which he declared his convic-
tion that the destination and seat of the rabic
virus is the medulla.

Pasteur is a member of the Academy of
Sciences to which these communications
were made. So much for originality.

Passing over the charges in which Pasteur
is made to take part in the working of po-
litical machinery to promote the election of
Paul Bert over Davaine to membership in the
Academy of Sciences, for the purpose of
securing through M. Bert large government
bounties, and to which there may be two
sides, we come to the actual status of the
several discoveries in the matter of inocula-
tion.

It is shown that Pasteur had made a con-
tract to sell for 1,000,000 francs the total
rights of sale of the modified virus of char-
bon, which fell through because the syndi-
cate could not raise the money, and because
at the time confidence was being lost in it
and the sales were diminishing ; and this
while it was stated by M. Paul Bert in the
Chamber of Deputies that Pasteur had nobly
refused, and declared that since he was re-
ceiving a pension from the State his works
belonged to the State.

It is now a fact current that inoculation
against charbon has gone out of date, the
general impression being not only that it is
not permanently of value, but that it is even
dangerous and destructive. The outcome
in chicken cholera and the rouget of pigs
has been about the same.

The process invented by Pasteur to further
the manufacture of beer of fine quality in
France, and which was in its turn heralded as
a great addition to the sources of wealth
available for France, has been absolutely
abandoned.

His labors with the silk-worm have not
prevented the steady decline of silk culture
in France, the official statistics showing that

456

Notes and

Comments.

Vol. lxiv

from 1 7,000,000 to 18,000,000 of kilograms
of cocoons were produced in 1865, when he
gave out his discovery for the protection of
the silk-worm. The amount has steadily
declined to 3,000,000 or 4,000,000.

But what of the protective measures against
hydrophobia, the crowning task of all the
works of the great chemist ? Dr. Lutaud
shows beyond all cavil,- by government sta-
tistics and hospital statistics that are acces-
sible to all, that from 1850 to 1872 inclusive
there was a total of 685 deaths from hydro-
phobia in France, or an annual average of
30. Seventeen died without treatment in
France in 1886, and 22 with treatment.
From November 1, 1886, to November r,
1887, 27 died under treatment; 23 in the
year ending November 1, 1889, and 21 in
1889 — a reduction from the former average
of about 5 per annum. In the year ending
November 1, 1886, 1,538 persons were
treated for bites by rabid dogs. Claiming
with Le Blanc that 16 per cent, of all per-
sons so bitten become hydrophobic, this
would give for that single year 246 cases of
hydrophobia that would have been but for
Pasteur's treatment. But it happened that
16 of these cases died, so that there were
230 lives saved by the Pasteur treatment !

Dr. Lutaud shows further that the number
of persons dying of hydrophobia has steadily
gone down in all other countries besides
France without treatment, and that in some
of them it has become a thing unknown.
Can we then think Dr. Lutaud too bold in
declaring that Pasteur's system of inocula-
tion actually tends to spread hydrophobia
in France? This apprehension is further
strengthened by the fact that many of these
are cases of paralytic hydrophobia, which is
the hydrophobia, as a rule, of inoculation.

It matters not how much the world may
be dazed by the brilliant name of Pasteur or
how much misled by blinded partisans, there
is no escaping the principal conclusions of
Dr. Lutaud in this matter. For to believe
that, while in all other countries hydropho-
bia is decreasing, in France, beginning ex-
actly with the discovery of a supposed pre-
ventive, there should happen in that country
enough cases to allow nearly three hundred
a year to be cured, and still leave a much
larger number than the statistics of the
country are entitled to when compared with
those of other lands !

We would not rob Pasteur of a leaflet of
his merited laurels. He is one of the great
men of time, whatever critics closer to him

may be led to feel when they see him wear-
ing unmerited honors. He has made dis-
coveries and given a stimulus to discovery
that will resound onward through the years
to come ; but that is no reason why the
whole world should fall down in worship of
men like themselves and be made blind to
the most glaring inconsistencies. And while
we honor Pasteur, we honor Lutaud and
Peter, who, in the glamour of hero worship,
still have the discernment and the courage to
speak what they regard as the truth.

New Operation for Lacerated Peri-
neum.

Dr. Alexander Duke, Gynecologist to
Steeven's Hospital, writes in the Montreal
Medical Journal, March, 1891 :

I wish to bring before the notice of my
gynecological brethren an operation I have
designed for the restoration of a lacerated
perineum, easy of performance, and which
will, when properly executed, form a good
perineal floor, and I might almost say prac-
tically a new perineal body. The patient,
having been prepared by the usual prelimi-
nary steps required for the old operation
when under the influence of an anaesthetic,
is placed in the lithotomy position, the left
index finger being introduced almost its en-
tire length into the rectum, a long, straight,
double-edged bistoury is made to pierce the
tissues in front of the anus at right angles to
the vulva, and, guided by the finger in the
rectum, is made to penetrate the septum for
two and a half inches upwards, the incision
being enlarged laterally to two inches as the
knife is withdrawn. The patient is then
turned on her side, and on the points of
incision being pressed together, a lozenge-
shaped opening will be seen, and when all
sutures required have been introduced and
are properly adjusted and approximated, the
two.cut surfaces are brought into direct ap-
position. The sutures are introduced by a
strong cycle-shaped needle with eye near
point, mounted on a handle, strong silver
wire being the suture preferred. The needle
is introduced at edge of incision, and,
guided by a finger in the rectum, is made
to travel under the cut surface to its full
depth above, describing the arc of a circle;
and on point of needle appearing directly
opposite, it is threaded with suture and drawn
through. On the ends of this suture being
drawn together with the fingers, a good idea

April 1 8, 1 89 1. Notes and

Comments.

457

can be formed of how many additional
stitches may be required. When all con-
sidered necessary have been inserted, passed
through leaden bars perforated at intervals,
and approximated, a finger of each hand
passed into the rectum and vagina will at
once recognize the gain in thickness of sep-
tum, the external* tissue being pushed fully
an inch forward from anus, and forming a
thick' and solid perineal body. The in-
cision being a deep one, on union taking
place between the raw surfaces, a consider-
able amount of support must be afforded in
cases where a pessary is required, or where
there is much tendency to prolapse of uterus
or vaginal walls. My experience of the op-
eration though up to the present time lim-
ited, has satisfied me with the results, and
there being no loss of time whatever, should
the operation fail, it cannot add any diffi-
culty to a subsequent one.

Even should the perineum be lacerated to
verge of anus, what I describe can be done.
I find that leaving the sutures for ten days
is generally sufficient, but if I am in doubt
as to the union being strong, I cut the wire,
but leave it in situ for a day or two longer,
thus affording some support, and relieving
the strain on the edge of suture holes, and
I also support the parts by long strips of ad-
hesive plaster carried from hip to hip over
new perineum. The wire should be stout
and not too tightly twisted.

My friend, Dr. More Madden, has kindly
given my operation a trial, and was much
pleased with the results, especially in one of
his cases where the old plan of operation
had been tried previously but failed owing
to the patient's poor state of health and a
want of healing power.

The advantages of my plan of operation
are briefly these : •

1. The simplest of performance as yet
proposed ; no danger of hemorrhage, the
surface, when dry, being brought together.

2. No danger of sepsis, as the incision is
not open for the admission of any discharge
from either vagina or rectum during healing
process.

3. No loss of tissue, and consequently no
harm done should the operation fail.

Calomel in Kidney Disease.

The general opinion that calomel is con-
tra-indicated in renal dropsy is founded on
the assumption that the drug acts on the

epithelium of the kidney. When, therefore,
the epithelium is considerably affected or
partly destroyed, as in so-called parenchy-
matous nephritis, the mercury, by acting on
the already weakened and scanty epithelium,
would, presumably, do little good and pos-
sibly much harm. Rosenheim's experiments
seemed to prove the truth of this theory.

The Medical Chronicle, March, 1891, as-
serts that Fleiner, in an article on the di-
uretic action of calomel in renal dropsy, in
the Berliner Klinische Wochenschrift, De-
cember 1, 1890, says that he has found that
facts are somewhat opposed to the general
belief. Two years ago Prof. Erb gave a
lecture on calomel as a diuretic, and men-
tioned a case of chronic parenchymatous
nephritis with general dropsy, in which,
after all customary diuretics and diaphoret-
ics had failed, the oedema rapidly gave way
under the calomel treatment, and the pa-
tient finally left the hospital with scarcely
any appearance of anasarca. Fifteen months
later she appeared again, and stated that all
the intermediate time she had been able to
work, and had not had dropsy to any great
extent. Her disease now presented the
characteristics of secondary contracted kid-
ney.

This case made its due impression on
Fleiner, then a student under Erb, and the
case he details here with extraordinary
preciseness and length is, so to speak, a
twin of Erb's. The case was one of Bright's
disease, threatening death from advanced
dropsy. All other remedies proving useless
calomel was exhibited in large doses, and
on two occasions in a few days caused a mar-
velous improvement, the second time the
oedema completely vanishing. Here, as in
Erb's case, the patient, after the second
treatment with calomel, had, as proved by
his urine and the post-mortem (he died sud-
denly two months after), a contracted kid-
ney, chronic parenchymatous and intersti-
tial nephritis.

Influence of Exercise on Digestion.

Dr. Streng, in a lecture before the Medi-
cal Society of Giessen, on the Influence of
Exercise on Digestion, which has been pub-
lished in the Deutsche Medicinische Wochen-
schrift, states that he concludes from his own
experiments that this influence is of a retard-
ing nature. His experiments, however, suf-
fer from the fact that he always injected 300

458

Notes and

Comments.

Vol. lxiv

cubic centimeters of water before obtaining
the contents of the stomach, so that the
proportion between gastric juice and water
continually varied. The first experiments
in the clinic at Giessen were made on two
dogs. Twenty-five grams of meat, sus-
pended in 300 cubic centimeters of warm
water, were twice injected into the fasting
stomach, and after one feeding the dogs were
compelled to remain for three hours in abso-
lute bodily rest, while after the other feeding
they were made to take active exercise.
After the three hours the contents of the
stomach were obtained and analyzed. The
quantity did not essentially differ in the two
cases ; the experiments consequently tended
to prove that exercise does not influence the
time required for digestion. The chemical
analysis also detected no difference. The
same results were obtained by substituting
the white of an egg for the meat. The ex-
periments were then repeated twenty-five
times on three men with healthy stomachs.
Two of these suffered from sycosis, and the
third from insipient muscular atrophy.
They were fed each time with 200 grams
of minced meat, a bun, a plate of bouillon
and three spoonfuls of mashed potatoes, and
the contents of their stomachs were obtained
four hours and a half afterwards. The ex-
ercise after meals consisted partly in gym-
nastics, partly in walking ; absolute rest was
obtained in bed. These experiments gave
the same results as those on the dogs, the
difference resulting from the chemical analy-
sis being especially imperceptible. The
author therefore concludes that the gastric
function is in no way influenced either by
muscular action or by absolute rest. — Lancet,
March 7, 1891.

" New Philadelphia."

" The New Philadelphia " is the title of
a deeply interesting article which will appear
in the May* Cosmopolitan, and is from the
pen of Mr. Henry C. Walsh. To those who
are not entirely familiar with the " city of
brotherly love " of to-day, and who, taking
the joke-maker at his word, entertain
the erroneous idea that this large city is
at best but a sleepy and unenterprising
town, the Cosmopolitan' 's article will prove
a veritable revelation. The great change
that has been wrought during the past
decade in the external appearance of
Philadelphia is ably set forth, and greatly 1

augmented by the splendid illustrations
drawn by Mr. Harry Fenn. A glance at
these masterly drawings shows that, in beauty
of architecture, the solidity and modernness
of construction and design in her homes,
clubs and commercial buildings, Philadel-
phia stands at the very head of flourishing
American cities. The business, social and
intellectual advancement of this, perhaps
the most habitable of cities, is no less marked
that is its mere outward progression. Doubt-
less, too much attention has been paid to
other more ostentatiously progressive cities,
especially of the West, to the exclusion of
the Quaker City and its marvelous growth.
The article in the May Cosmopolitan, how-
ever, places Philadelphia before the public
in its true light as one of the best governed,
most enterprising and socially, commercially
and politically, progressive cities of the
United States.

Local Sweating of Reflex Origin.

The New York Medical Journal, March
28, 1 89 1, quotes from the Journal de mede-
cine et de chirurgie for October, 1890, the
following curious observation by Ducorneau :
A young woman of good constitution had
been confined two months previously. She
had noticed for about two weeks that when-
ever she put her baby to the breast there
broke out suddenly a profuse sweating of the
thigh and leg of the side corresponding to
the breast nursed. The sweating extended
posteriorly from the nates to the foot, and
lasted through the whole time of the nurs-
ing. The same phenomena was observed
when the other breast was given. On chang-
ing the baby from one breast to the other,
the sweating began and ceased always at the
same moment with the flow of milk from the
side in question. The mother had been
considerably reduced by the sweating. Ton-
ics were given and the breasts were rubbed
with belladonna ointment. After a few days
of this treatment the sweating diminished
and finally ceased entirely. Ducorneau at-
tributes the sweating to reflex action, though
the modus operandi is difficult to explain.

Powder for Migraine.

R Citrate of caffeine gr. I y2

Phenacetin • . gr. 2

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MEDICAL bURUlCAL

I A W

Reporter

Weekly Journal.

Established in 1853 by S. W. Butler, M.D

CHARLES W. DULLES, M. D., Editor and Publisher,

Entered as Second-Class matter at Philadelphia P. O. N. E. COR. 13th & WALNUT STS., PHILADELPHIA

Vol. LXIV, N0.-17. APPTT OR 4QCM $5.00 per Annum.

whole no. 1782. ArruL; zo, 1031. io Cents a Copy

CO^TTElsTTS :

CLINICAL LECTURE.

Anders, Jas. M., M. D., Philadelphia, Pa.— The
Diagnosis and Treatment of Catarrhal Dyspep-
sia -159

COMMUNICATIONS.

Dillek, Theodore, M. D., Pittsburgh, Pa.
of the Chronic Insane

Dawson, Byron F., M. D., Kewanna, Ind.
eign Body in the Ear for Nine Years.

Mansfield, Arthur D., M. D., Baltimoi
Hydrogen Peroxide in Otorrhcea.
PERISCOPE.

Treatment of Uterine Tumors with Electricity.—
Health Legislation in California and South
Carolina. — Koch's Treatment. — Menstruating
Nurses.— Treatment of Headache.— Regulation
of Prostitution.— Rupture of Linea Alba.—
Trichloracetic Acid as a Test for Albumin in the
Urine.— Angina Pectoris.— The Fluviograpb. 464-472
EDITORIALS.

Spermine 473

Treatment op Chronic Constipation with
Bokic Acid 474

Philadelphia Polyclinic 475

Training School for Deaf Infants 475

Resignation of Dr. Da Costa 476

arewell of the Editor 476

K REVIEWS.

Edinger ; Twelve Lectures on the Structure of
the Central Nervous System, for Physicians and

Students —Senn ; Principles of Surgery 477

LITERARY NOTES 477

CORRESPONDENCE.

Electricity and Pelvic Surgery 477

NOTES AND COMMENTS.

Partial Excision of Sternum for Melano-Sarcoma.
—Medical Legislation in Missouri.— Albuminu-
ria in Acute Catarrhal Enteritis.— Ways in
which Syphilis may be Spread.— Burial of So-
called Stillborn Children.— -Ichthyol Varnishes.
—Bad Effect of Poultices for Spreading Ulcers.
—Tuberculosis Treated with Hypodermic Injec-
tions of Iodoform and Guiacol.— Diagnosis of
Whooping-cough with a Tube in the Tra-
chea 479-486

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a remedy for DIPHTHERIA ; CROUP ; SORE THROAT,

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Dr. E. R. Squibb, of Brooklyn, writes as follows in an article headed " On the Medical Uses of Hydrogen Peroxide (Gaillard's
Medical Journal, March, 1889, p. 267), read before the Kings County Medical Association, February 5, 1889 :

" Throughout the discussion upon diphtheria very little has been said of the use of the Peroxide of Hydrogen,
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ciently repeated contact. ... A child's nostrils, pharynx and mouth may be flooded every two or three
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For further information address

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MEDICAL AND SURGICAL
REPORTER

No. 1782. PHILADELPHIA, APRIL 25, 1891. , Vol. LXIV.— No. 17.

Clinical Lecture.

THE DIAGNOSIS AND TREATMENT
OF CATARRHAL DYSPEPSIA.

BY JAS. M. ANDERS, M. D.,

PROFESSOR OF CLINICAL MEDICINE AT THE MEDICO-
CHIRURGICAL COLLEGE ; VISITING PHYSICIAN
TO THE PHILADELPHIA AND EPIS-
COPAL HOSPITALS.

This man, A. P., 57 years old, is a
printer. His family history is negative.
His own history before the onset of his trou-
ble is also negative, with the following ex-
ception. Eleven years ago he had a hemi-
plegia. Twenty years prior to this hemi-
plegia he had syphilis, i. <?., chancre followed
by well developed secondary manifestations.
The fact that the hemiplegia followed so
long after the date of the appearance of the
chancre renders it probable that it was due
to cerebral syphilis. You will remember I
told you while lecturing on that subject that
syphilitic palsies were apt to occur from 10
to 20 years after the initial lesion ; also that
unless proper treatment was instituted at the
proper time, changes would take place in the
muscular and nervous tissues, which go on
independently of the original cause and of
specific treatment. Hence, from the history
of this patient's case, I am inclined to think
that the hemiplegia was due to the syphilis,
which was probably not properly treated.
He comes to us to-day for treatment for a
different affection. For the last year he has
vomited, regularly every morning on getting
up, a couple of tablespoonfuls of ropy, tena-
cious mucus ; his bowels have been regu-
lar. After eating he experiences a sense of
burning weight and gastric uneasiness; he
says he has no pain. Pain is not a symptom
so constant in the inflammatory form of dys-
pepsia, from which, as I shall attempt to
show, he is suffering, as one is led to suspect
by writers on the subject.

Between the two forms, atonic and in-
flammatory dyspepsia, there are radical dif-
ferences, hence the treatment must be radi-
cally different also ; and yet there are symp-
toms and leading ones common to both.
He says he has .belching of gas, eructations
causing heartburn, due to acids. On palpa-
tion he complains of tenderness over the
cardiac end of the stomach, percussion
elicits clear tympanitic resonance to the
costal border, indicating no enlargement of
the liver. His tongue has a yellowish white
fur with red tips and edges and enlarged
papillae in the latter situation. This latter
condition is almost pathognomonic of in-
flammatory dyspepsia. The tongue is either
small with red edges and tip or it is broad
and coated, especially in hepatic forms of
the trouble, but the papillae are always bright
red and enlarged. The atonic form is due
to conditions external to the stomach, and
the symptoms are induced by reflex action,
such as debility or anemia. In the inflam-
matory form the symptoms are caused by the
local condition. Alcohol is a potent cause
as well as immoderate eating, especially of
spicy articles of food. He however tells us
that he does not use alcohol and is a mod-
erate eater. Of other causes predisposing
strongly to this form are syphilis, gout, renal
disease, paralysis, weak heart, even though
no murmurs be present. In phthisis, gout,
and syphilis, gastric catarrh is apt to be early
induced. The subacute type of a passive
nature is often produced by a weak heart or
anything interfering with the return current
of blood from the stomach. There is one
symptom which is prominent in this case
and which is not infrequently met with in
chronic forms of inflammatory dyspepsia,
namely, vomiting of ropy mucus in the
morning when the stomach is empty. This
is due probably to sluggish circulation —
passive hyperemia. It is often hard to make
a certain differential diagnosis between func-
l tional and inflammatory forms of the disease,

459

460

Clinical

Lecture.

Vol. lxiv

because many of the symptoms occur in
both. Anemia and neurasthenic states are
frequently associated with or are precursors
of the atonic form ; so too is a sluggish liver
and constipation — in fact, anything which
depresses the vitality of the system ; but you
do not have the history of syphilis, of gout,
of renal, of lung or organic heart disease as
in the inflammatory form. The symptoms
which, though occurring in both forms, are
more aggravated in the catarrhal form, are
more constant. In atonic dyspepsia there
is gastric uneasiness and a feeling of disten-
tion soon after a meal, rather than. pain in
the epigastric region, and this is the case in
the majority of instances of the catarrhal
form, though pain is sometimes patent in
subacute gastritis. There is more acidity
and thirst in the inflammatory variety. The
tongue in the atonic form may be clean, or
it may be coated with a yellowish or white
fur. In the catarrhal form, it is sometimes
small and clean, but is usually red at the
tip and edges with enlarged papillae, as in
this case. The tongue is often broad, flabby,
and coated heavily, but the papillae are
always pointed. Pain, as already intimated,
occurs in both forms, though not in the
stomach. In the atonic variety there is
rarely much pain in the stomach. It may
be between the shoulders or across the chest,
often the pain is at the back of the head or
at the forehead. In the catarrhal form pain
is more apt to be felt in the stomach, but
as a rule, only in the more acute forms,
while in the subacute and chronic forms,
pain in the region of the stomach is rare,
but usually tenderness, as in this case. In
the latter class of cases, pain is generally
referred to the head.

In both forms of dyspepsia, alterations
in the urine occur. Functional dys-
pepsia is attended with the presence of
urates and phosphates in the urine. When
the oxalates are present in abundance, the
condition is often called oxaluria, and is
frequently associated with a depressed state
of the nervous system. In the catarrhal
form, urates are present in large quantities,
the sp. gr. is apt to be high, a condition of
lithemia existing. In both forms the ner-
vous symptoms are well marked, but to a
greater degree in the catarrhal form.
Patients suffering from inflammatory dys-
pepsia are apt to be gloomy, hypochon-
driacal, and suffer from these latter symptoms
more than from those referable to the
stomach. In the atonic form there are in-

tervals of freedom from all symptoms, while
in the catarrhal form the symptoms are con-
stantly present. Drugs used with good ef-
fect in the atonic form will be found to
aggravate the catarrhal.

In conclusion, I may say, to sum up
the points on which to base a diag-
nosis in the catarrhal form, we have the
history of gout, or of syphilis, or renal dis-
ease, or phthisis, or heart disease, as pre-
disposing causes. As exciting causes, over-
feeding, or improper food ; malaria or
alcohol. There is more frequent vomiting,
more thirst, more heart-burn, more tender-
ness on palpation, more marked nervous
phenomena, than in the atonic form. The
condition of the tongue is to be carefully
noted.

The treatment of the subacute inflam-
matory form, from which our patient is
suffering, consists in giving the stomach
rest, so as to save the mucous membrane and
get rid of the waste products. For one or
two weeks we will order milk diet, also
order the time for feeding and quantity of
food to be given. If it don't agree, we will
give it pancreatinized or boiled, and to it a
quantity of lime water may be added.
Soon after feeding, give diluents, because
the patient suffers from thirst ; the best are
mucilaginous substances and water, to which
a few drops of muriatic acid should be
added. Commence their administration
one hour after meals, then every hour or
two till digestion is complete. This allays
thirst and produces comfort. When solid
substances can be added, albuminous sub-
stances are better than farinaceous. After
two or three weeks give one egg in the
morning, a chop and rice or underdone beef
for dinner for two or three weeks longer,
along with the milk. Of remedies, we
should select the alkaline carbonates and
saline aperients. We will give this man
every morning one drachm of Rochelle salts,
to be taken fasting. If the patient can
afford to go to a mineral spring, such as
Carlsbad, so much the better. I shall also
order the alkaline carbonates as per the fol-
lowing.

t£ Bismuth, subcarbonat 3 ii .

Sodii bicarb ^iv

Ft. chart. No. xii.

Sig. One to be taken before each meal.

Attention to the patient's regimen is im-
portant. Order, in all cases, moderate
exercise in the air, warm, clothing, regular
habits. After certain indications are con-

April 25, 1 891.

Communications.

trolled and the local condition is much
improved, enlarge the diet list and give
tonics, beginning with small doses ; other-
wise the condition will be made worse. By
the injudicious use of tonics, especially
bitter tonics, this disease has actually been
frequently produced. Don't forget to
attempt to remove the constitutional cause
that has led up to the case in hand, whether
it be syphilis, gout or other conditions.

Communications.

CARE OF THE CHRONIC INSANE.
BY THEODORE DILLER, M. D.,

PITTSBURGH, PA.

It is to be hoped that the bill recently in-
troduced in the Legislature at Harrisburg,
by Dr. Morton, president of the State Com-
mittee on Lunacy, providing for the erection
of a hospital plant for the chronic insane
will, with certain modifications, be approved
of by the Legislature.

The normal capacity of the five State
asylums combined is about 4,000 ; but they
contain now about 5,250 — or 1,250 more
than their normal capacity. For the past
five years the average annual increase in
population* in the asylums has been 238.
Certainly no further arguments are needed
to establish the fact that prompt and active
measures should be taken to very consider-
ably increase the State Hospital accommoda-
tions. The only question is : How shall the
State build ? In what shape shall the in-
creased accommodations come ?

Two plans have been suggested. 1. The
extension of the present hospital plants by
building additional wings or annexes to
them. 2. By providing two new hospital
plants — one for the chronic insane, the
other for the criminal insane and insane
criminals. (Note distinction.)

The adoption of the first plan assumes
that the present hospital system is so
good that it cannot be improved upon.

The promoters of the second proposition
say : We can improve on the present hospital
system. By our plan we can take care of
2,000 chronic insane better and much cheaper
than they are now cared for. We can pro-
cure accommodations for all the insane crim-
inals and criminal insane in a separate hos-
pital plant at a cost to the State of not more

than $$.66 per week (the present average
rate).

Now if the claims embodied in the second
proposition can be substantiated, certainly it
behooves the Legislature to adopt them with
as little delay as possible. Let us examine
them a little more in detail.

Separation of the acute from the chronic
insane has long been a desideratum. The
great bulk of the insane are incurable. There
are fully 3,000 inmates in tlie State asylums
who are chronically insane beyond the
smallest hope of recovery but who enjoy
good, or at least fair, physical health. 1,500
or 2,000 of the most suitable of these would
be removed to the new asylum. Here they
would be put to work. From 80 to 90 per
cent, of them would engage in profitable, or
at least useful, occupations. A small in-
firmary building would suffice for those who
became ill with intercurrent physical dis-
eases. Those whose mental condition
changed so as to render them no longer fit
for the chronic asylum could be transferred
back to one of the hospitals. Many of the
methods and appliances now in use in the
State Hospitals could be done away with in
the new asylum.

The present State Hospitals were designed
to treat the acute insane. Now, with the
great bulk of the chronic insane and all the
criminal class removed — with their machin-
ery no longer clogged (if I may be permitted
the expression), the existing hospitals would
certainly be in much better working order.
They might then become hospitals in fact as
well as in name.

Now as to cost. The Lunacy Committee
estimates that the new asylum will cost
$600,000 or $300 per bed, and that the
cost of maintenance will be $2.00 per week
for each inmate — or $1.66 less per week
than the insane are now supported for. The
saving in cost of maintenance would in
three or four years pay for the new hospital
plant. The new asylum itself is not to be
built after the fashion of the present hos-
pitals, which the Lunacy Committee say " are
characterized by unnecessarily elegant and
expensive centre or administration buildings
and by long, straight, cheerless wards, having
small lodging rooms and dormitories open-
ing into the same on either side ; having a
small ward dining-room in each corridor,
and in many other particulars- far behind
modern ideas of proper hospital construc-
tion ; being inconvenient to administer, and
so planned as to but partially fulfil the pur-

462

Communications.

Vol. lxiv

poses for which they were erected. They
cost anywhere from $2,000 to $3,000 per
bed, and accommodate, for the sums ex-
pended, a relatively small number of in-
sane."

The proposed asylum is to be several clus-
ters of small buildings, two stories in height,
plain and simple in their construction, con-
veying, as far as possible, the house idea and
making possible a desirable classification.

Concerning the baneful effects of the
chronic on the acute insane who are conva-
lescing I cannot express my ideas better than
to quote the following from the Lunacy
Committee's report :

" The acute are often heard to allude with
horror to the condition of their chronic com-
panions, dwelling most painfully upon the
imminent probability of soon becoming
hopelessly lost to home, friends and society,
and of living the remainder of their lives in
similar seclusion.

"Like begets like, and as the population of
any hospital for the insane is chiefly chronic,
the acute or curable being a relatively limited
number scattered through the various wards,
this enforced evil association must rob so-
ciety of many a useful and productive citizen
by placing him in daily contact with those
who mar his chance for recovery.

"Humanity demands that the most enlight-
ened policy be applied to the restoration of
the curable insane, which would be materi-
ally promoted by separating the chronic
from the curable, in distinctive separate in-
stitutions."

In the five State Hospitals there are 2 26
of the criminal class. The Committee
thinks the House of Refuge in Philadelphia
could be bought and adapted for them. New
York State has for years provided a separate
asylum for this class of insane. It seems to
me the need of such an asylum for our State
is so obvious as to need no further discus-
sion.

I think the second proposition has every-
thing to commend it. If all the readers of
the Medical and Surgical Reporter who
think as I do and who are interested in the
subject would write to their Senators and
Representatives at Harrisburg much strength
would be given to the Committee's recom-
mendations.

— Incipient putrefaction of meat may be
tested with sensitive litmus paper. The acid
reaction of meat is changed to alkaline by
the putrefactive process.

FOREIGN BODY IN THE EAR FOR
NINE YEARS.

BY BYRON F. DAWSON, M. D.,
KEWANNA, ind.

Some time ago, while attending a case of
typhoid fever in a rural family, the mother
informed me that her son had in. his ear a
grain of corn which had been lodged there
several years. The story seemed so improb-
able that I told her she was undoubtedly
mistaken about the foreign body being still
in the ear, and passed the case by without
other thought or examination. Some days
afterwards the subject was mentioned again,
and the mother reasserted that she was sure
the corn had never escaped. I then made
a cursory examination of the organ and
found the auditory canal did contain a for-
eign body of some kind, and directed that
the boy be sent to my office for examination,
but as he was quite bashful, it was arranged
that he should come ostensibly to bring a
report of his sister's case.

He came, and in a very few minutes after
beginning I had removed from his right ex-
ternal auditory canal a grain of hackberry
popcorn, surrounded by a considerable mass
of inspissated cerumen.

The history of the case is as follows : the
boy was twelve years of age in November,
1890. The grain of corn was put in his
ear by himself some time during the winter
in which he was three years of age, and was
removed February 21, 1891, having been
lodged in the canal something over nine
years. During all this time his hearing was
greatly impaired, while he was at times en-
tirely deaf in the right ear.

The only instruments required were a
head-mirror, ear scoop and dissecting for-
ceps, yet he was required to suffer the annoy-
ing presence of this foreign body over nine
years, because the physicians to whom he
was taken were "not prepared to doctor
ears," and made no examinations of the
case. One of them, however, recommended
the use of sweet oil in the ear, with the as-
surance that it would cause the grain to
" work out."

The grain of corn apparently was of its
original size and shape, and notwithstanding
the irritation to which its sharp point might
be expected to give rise, the lining mem-
brane of the ear appeared perfectly normal,
and hearing was found to be unaffected after
its removal.

April 25, 1 89 1.

Communications.

463

HYDROGEN PEROXIDE IN OTOR-
RHCEA.1

BY ARTHUR D. MANSFIELD, M. D.,

ASSISTANT IN THE PRESBYTERIAN . EYE, EAR AND
THROAT CHARITY HOSPITAL, BALTI-
MORE, MD., ETC.

By far the greater number of ear com-
plaints are those in which otorrhcea appears
as the prominent symptom and as the cause
of the patient's being brought for advice and
treatment. The diagnosis of otorrhcea is
easy enough to make, but the trouble is not
always so easy to cure.

The cause of the otorrhcea may, in the
vast majority of cases, come from the mid-
dle ear, generally being an inflammation set
up there by transmission along the Eusta-
chian tubes from the pharynx, and resulting
in final perforation of the tympanic mem-
brane and a discharge externally.

Again, the otorrhcea may result from an
inflammation of the external meatus alone,
when the drum is not involved at all, or, if
so, only externally.

The main indication in suppurative in-
flammation of the ear — no matter whether
from the middle or external ear — is cleanli-
ness ; and, as it is almost impossible to wash
the ear out properly by the ordinary cleans-
ing means, the advent of a substance which
will attack pus, and pus only, is a decided
advance. Such a substance is found in hy-
drogen peroxide.

I have had very good results from the use
of hydrogen peroxide in all otorrhceas,
treated both in private practice and at the
Hospital. My method is usually to wash
out the ear as thoroughly as I can with a
warm alkaline solution — generally a solu-
tion of sodium bicarbonate, and then,
when the ear has been dried with cotton, to
instil hydrogen peroxide and allow it to re-
main in the ear for ten minutes or so. The
action of the peroxide is to decompose the
organic matter present by oxidizing it, giv-
ing up its atom of nascent oxygen which
very readily combines with whatever free
carbon, sulphur, or other element it may
find. This action gives rise to some such
remarks as these from the patients: "it
causes a bubbling," or "it boils," or
" fries." One likened it to soap-suds. The
action is to decompose all the pus present

1 Read before the Medical and Surgical Society of
Baltimore, March 26, 189 r.

and to clean out the external ear much more
efficaciously than water and syringe can do.

After using the peroxide, it is well to again
syringe out the ear, to wash away any epi-
thelial scales or detritus that may accumu-
late from the action of the peroxide. The
ear is now thoroughly cleansed of all in-
flammatory products, and the membrane can
be inspected easily, and its condition ascer-
tained. It has been my custom to dust the
ear with powdered boric acid and to order
the peroxide to be used at home twice or
thrice daily, as this may be indicated. I
usually have the patient recline, with the ear
that is to be treated uppermost, and have
some one fill the ear with peroxide of hy-
drogen. The patient is instructed to allow
the drops to remain in the ear for ten or fif-
teen minutes, then the meatus is wiped out
with clean cotton as well as possible, and
left alone. This is usually done twice a
day, but may be done oftener if deemed
necessary on account of the quantity or du-
ration of the discharge. The action of the
peroxide is not only cleansing, but also
disinfectant, as it has a germicidal effect
upon the pus-producing organisms.

Seeing the cases day after day, and cases
more or less chronic in character, I have
been enabled to note gradual recovery in
cases where the ear has been discharging for
years without cessation.

The time for recovery varies in the differ-
ent cases, and depends upon many factors,
especially upon the zeal and faithfulness with
which the physician's instructions are carried
out. As a fair average I have found a week
or ten days' treatment generally sufficient to
cure a case of otorrhcea, no matter how long
the ear may have been running. In many
of the acute cases, when treatment is applied
in its very incipiency, a few days suffice to
effect healing of the lesions and stopping of
the otorrhcea.

One complication I have noticed, that may
be well worth mentioning, is this : persistent
rawness and pain in the external meatus,
which follows the use of the peroxide in
some cases after all otorrhcea has ceased.
This is of no consequence whatever, and
soon yields to the use of any of the milder
astringents, such as boric acid dusted in the
ear. Hearing is not by any means restored
in all cases ; for, if the case be one of long
standing, the chances are that the drum is
damaged to such an extent that repair seems
impossible.

In conclusion, I may say that I think the

464

Periscope.

Vol. lxiv

use of hydrogen peroxide in otorrhoea sup-
plies a long- felt need and answers the pur-
pose most admirably- It is a drug for the
specialist and for the general practitioner.
It may be kept on hand and is generally ef-
ficacious when needed, or it may be ordered
from the druggist when needed, and instilled
into the ear by the patient.

Hydrogen peroxide is undergoing now a
1 < boom," and I feel that many of its uses
will be forgotten, but that its use in otorrhoea
will remain with us.

Periscope.

Treatment of Uterine Tumors with
Electricity.

The University Medical Magazine, April,
1 89 1, cites Keith as stating in the British
Medical Journal, Feb. 14, 1891, that the
criticisms with which Apostoli's treatment
has been so generally received, give him
now, after two more years of experience, no
concern. He knows some things that it
cannot do ; he knows better what it can do.
Delicacy of manipulation, perseverance,
and a knowledge of electricity are essential
in carrying out this treatment with any hope
of success or improvement to the physician,
or comfort to the patient. The results are
slow, but comparatively certain. The only
quite hopeless cases seem to be fibro-cystic
tumors and fibroids in which hydrorrhcea
exists to a great degree. In these cases
there is improvement up to a certain point,
but it is not permanent. No fewer than
one-half of the cases of fibroid seen during
the last two years were advised to have no
treatment whatever.

Keith regrets no part of his past work so
much as that in which he removed so many
ovaries for small bleeding tumors. During
the last three years and a half he has not
performed a single hysterectomy in soft or
solid fibroids. He has operated three times
for large fibro-cystic tumors, one of thirty-
eight pounds, one of seventy pounds and
another of seventy-six pounds. In two cases
only has he removed ovaries for small bleed-
ing tumors. In one case there was an ovary
as large as a hen's egg ; the other had two
small ovarian tumors.

The electrical treatment is tedious, but may
be shortened by using high intensities, with
puncture. In only one instance has it been

necessary to use an anaesthetic. Till quite
recently Keith saw few cases of small tumors
with symptoms so severe as to need treat-
ment; lately many such presented them-
selves. The following were the seven earliest
cases: (1) Small bleeding fibroid: profuse
and painful menstruation ; cured by electri-
city. (2) Small uterine fibroid : painful
and profuse menstruation ; disappearance of
tumor under electrical treatment. (3) Fib-
roid uterus : almost continuous menstruation;
electricity ; disappearance of growth. (4)
Small uterine fibroid : unusual amount of
pain, with suspicion of ovarian and tubal
disease, and disappearance of tumor under
electricity. (5) Fibroid tumor in posterior
wall of uterus : profuse menstruation ; dis-
appearance of tumor under electricity. (6)
Small uterine fibroid, with profuse hemor-
rhages ; enlargement of ovary ; disappear-
ance of tumor under electricity. (7) Long-
continued bleeding fibroid : cured by elec-
tricity. Thus in five of these cases the fib-
roid entirely disappeared.

After the treatment is stopped, there may
in some cases be no apparent benefit, and
the good obtained may not be seen for
several months. No explanation is given of
the principle of the process which causes
the absorption or diminution of the enlarge-
ments. In these cases it is certainly not
that of electrolysis. It must be looked for
rather in some form of electrical osmosis.
Several of the cases had enlargement of the
ovary ; not only did the fibroid disappear,
but also the ovarian enlargement.

This treatment almost always relieves pain.
It almost always brings about diminution of
the tumor — sometimes rapidly. It almost
always stops hemorrhages — sometimes rap-
idly. The results are almost always per-
manent, and the growth of the tumor, if it
be not lessened, is stopped. The general
health is immensely improved. By almost
always he means nineteen cases out of every
twenty.

Health Legislation in California and '
South Carolina.

Henry A. Riley, Esq., says in The Amer- j ,

ican Practitioner aiid News, February 14, j

1 89 1 : Two curious cases, involving the j

power of communities to legislate for matters |
really or falsely alleged to be against public

health and morals, come to us from California ; j

and South Carolina. The city of San Fran- j

cisco has, as is well known, a large Chinese \

April 25, 1 89 1.

Periscope.

465

population, which is not looked upon with
favor by the rest of the community, and a
resolution was enacted some time since by
the city authorities requiring all the Chinese
either to remove outside the city and county
of San Francisco, or else to a certain de-
signated portion distant from their present
quarters. This excited great indignation
among the Chinese, and the courts were at
once appealed to in order to prevent the
execution of the ordinance.

The United States Circuit Court decided
in very plain and curt language that the or-
dinance was unjust, unconstitutional and
must not be enforced. It said : " The ob-
vious purpose of this order is to forcibly
drive out a whole community of twenty odd
thousand people, old and young, male and
female, citizens of the United States born
on the soil and foreigners of the Chinese
race, moral and immoral, good, bad and
indifferent, and without respect to circum-
stances or conditions, from a whole section
of the city which they have inhabited, and
in which they have carried on all kinds , of
business appropriate to a city, mercantile,
manufacturing and otherwise, for more than
forty years. Many of them were born there,
in their own houses, and are citizens of the
United States, entitled to all the rights and
privileges under the constitution and laws of
the United States that are lawfully enjoyed
by any other citizen of the United States."
The court in this case did not believe that
any "health" or "moral" question was
really involved, and nullified the ordinance.,

In the South Carolina case the inhab-
itants of a town near Charleston wished to
get the advantage of being considered a
health resort, and so passed a resolution
forbidding the cultivation of the soil with-
in the corporate limits, except to the extent
of one-eighth of an acre for each owner of
land, and absolutely forbidding the cultiva-
tion of rice on the part of any one. The
ordinance permitted the cultivation of flow-
ers, vines, fruit and forest trees without in-
terference. As this ordinance excited oppo-
sition, it came up in various courts for con-
sideration, until at last the Supreme Court
decided that it was valid and could be en-
forced. The judges held that the powers of
local authorities to legislate for the general
health could not be- overruled by the courts.

There will be little doubt felt by thinking
persons that the California decision was a
just one, but many will question the South
Carolina one as giving undue power to local

authorities over the use and control of pri-
vate property. There has undoubtedly been
a considerable extension in recent years of
the police and health powers of town and
city corporations, but the limit has appar-
ently been about reached.

Koch's Treatment.

In the Lancet, March 21, 1891, Dr.
McCall Anderson, Professor of Clinical
Medicine in the University of Glasgow,
says : The extravagant laudation with which
the treatment of tubercular diseases by means
of Koch's fluid was ushered in has given
place in many quarters to an equally absurd
depreciation of its merits. Considerable
practical experience of its results having
been gained in the hospitals of Glasgow,
it is right that we should take stock of our
knowledge and compare notes with one an-
other, in the hope that we may arrive at just
conclusions. But as our experience is ne-
cessarily a short one, it follows that what-
ever views may be expressed must be taken
as provisional, and liable to modification
when a large number of cases has been dealt
with, and when they have been under obser-
vation for a longer period of time. Before
bringing any cases under notice, it may be
well to indicate, in a general way, some of
the conclusions which, I think, may be de-
rived from them. When a patient is inocu-
lated for the first time with an appropriate
dose of the fluid, there result in typical
cases — (1) elevation in temperature, (2) a
series of other constitutional symptoms, and
(3) local reaction. But, in a considerable
number of instances, one or more of these
sets of symptoms may be absent, or only
present in a minor degree. Thus it is not
uncommon to find decided reaction at the
diseased part with little, if any, constitu-
tional reaction and fever. Or there may be
an absence of fever, but other well-marked
constitutional symptoms ; or local reaction
may be alone observed. But, as a rule,
the more pronounced the fever and other
general symptoms the more decided is the
local reaction, and vice versa.

With regard to the body heat, the first
effect of the inoculation in many cases is to
produce a temporary lowering of the tem-
perature, but this soon gives place to a rise,
which reaches its maximum generally within
twelve hours — sometimes not until the fol-
lowing day ; or there may be a primary rise

,466

Periscope.

Vol. lxiv

of temperature the day after the inoculation,
and a secondary one the following day,
which may even be greater than the first.
First inoculations are likely to lead to a
slower rise and one of longer duration than
subsequent ones, in which the tendency is
towards a rapid rise and an equally rapid
fall of temperature. It is not, in my opinion,
desirable to encourage an elevation which
exceeds io4°F., and in this connection it
must be borne in mind that an inoculation
frequently produces a greater rise than the
preceding one, although the dose is not in-
creased. The other constitutional symp-
toms observed varied in different cases, but
the most common were chilliness .or rigors,
headache, pains in the back and throughout
the body, sickness, vomiting and prostration.
In two cases what has been described as a
measly, but which is really a roseolous, rash
made its appearance, but in no instance was
a scarlatiniform eruption induced. As re-
gards the local reaction, we can best observe
it when the lesion is on the surface, although
the symptoms arising when internal organs
— such as the lungs — are affected, leave lit-
tle room for doubt that similar changes take
place in them. The first result — in a case
of lupus, for example — is the occurrence
of redness and swelling which are not limited
to the affected part, but spread to the skin
in the vicinity, which often assumes an ery-
sipeloid appearance, and a serous exuda-
tion takes place from the diseased surface
which dries into crusts. Each succeeding
inoculation is followed by less inflammation,
and when serum ceases to exude, the crusts
become very dry, contract, and finally fall
off, leaving a dry, scaly, rosy surface, the
cicatrix being smooth, and less pronounced
than after any other local treatment with
which I am acquainted. When any isolated
lupus nodules lie imbeded in cicatricial tis-
sue, the inoculations may fail to destroy them,
the poison being apparently unable to get at
them ; and what may be done under these
circumstances is to penetrate them with a
pointed stick of caustic, and then to inocu-
late again, when a certain amount of reac-
tion ensues, generally making short work
of them.

From what I have said it may be inferred
that, when the lupus nodules are confluent,
the result is better than when they are dis-
crete, and the best cases of all are those in
which the whole patch is in a state of ulcer-
ation ; that is to say, the worse the case the
more brilliant is likely to be the result. But,

while tuberculin is often in a position en-
tirely to destroy the existing disease, it seems
to have little influence in the way of pre-
venting relapses, which must be warded off
by endeavoring to improve the general
health, especially by giving anti-strumous
remedies — above all, cod-liver oil — just as
we have been in the habit of doing formerly
in connection with the use of local applica-
tions. A patient who cannot take cod-liver
oil in full doses — say, to the extent of 3 oz.
daily — has a poor chance of being perma-
nently cured. As regards phthisis, the time
is much too short to entitle one to formulate
very positive conclusions, but I am quite
sure that it is undesirable to treat advanced
cases in this way. Indeed, I have no doubt
that such treatment is dangerous ; or, at any
rate, it is very apt to leave the patient in a
worse plight than before. But there is
equally little doubt if we get a case at the
very commencement, before excavation, with
a very limited amount of lung tissue in-
volved and the general health not being un-
dermined, the best results may often be ob-
tained. In considering the propriety of
carrying out this treatment in a given case
of phthisis it must never be forgotten that
the extent of the disease is almost invariably
considerably greater than the physical signs
would seem to imply. Indeed, in most of
the patients treated, moist rales, with or
without evidences of consolidation, have
made their appearance at parts where, pre-
vious to the commencement of the inocula-
tions, there were no traces of pulmonary
mischief. These new physical signs cannot
certainly always be attributed to the devel-
opment of new centres of disease, the result
of setting free tubercle bacilli to work mis-
chief elsewhere, because they sometimes ap-
pear immediately after the first inoculation.

With regard to diagnosis, there can be no
doubt that Koch's discovery is a most valua-
ble one, because, although it cannot be as-
serted that the fluid exclusively attacks
tuberculous tissue, it is certain to inflame
parts which are tuberculous when the appro-
priate dose is reached, and it undoubtedly
often ferrets out quite unsuspected foci of
disease.

As to the dose, I think it may be laid
down as a good rule that not more than one
or two cubic millimeters of the 1 in iod
dilution should be given as a first injection,
especially if internal organs are involved, or
if the patient is weakly ; but the appropriate
dose varies in different persons, just as we

April 25, 1 89 1.

Periscope.

467

find in connection with the administration
of medicinal substances. It is much better to
start with a dose which may fail to yield any
result than with a large one which produces
violent local and constitutional reaction, it
being always safer to feel one's way at the
outset. We are all cognizant of the fact
that the system soon becomes habituated to
the use of certain drugs, so that after a
while doses may be taken with impunity
which might have poisoned the patient at
the outset. And there can be no doubt,
with reference to tuberculin, that a remark-
able tolerance is speedily established; so
much so, that we can often ultimately give
an inoculation without any result one hun-
dred times stronger than that which at first
produced well-marked local and general
reaction.

When I commenced to inoculate patients
I made use of the syringes recommended
by Koch, and with which we are all familiar ;
but I found that they were somewhat trouble-
some and uncertain in their manipulation,
especially when not manufactured with the
greatest care. So that most of my inocula-
tions have been made with an ordinary sub-
cutaneous syringe, graduated for the purpose,
which has none of the drawbacks of the
other, and from the use of which I have
experienced no inconvenience, while inflam-
mation at the seat of puncture has never
occurred.

In conclusion, I may be permitted to say
this much, at least, with regard to tuberculin,
that, whatever the ultimate verdict of the
profession may be with regard to the scope
of its utility in diagnosis and treatment, it
is possessed of most remarkable and unique
properties ; and no one who has had much
practical experience of it, can grudge the
encomiums and the honors which have
been showered upon its discoverer.

Dr. Anderson concluded by showing a
series of cases upon the treatment of which
the above remarks were based.

Menstruating Nurses.

That excellent journal called The Night-
ingale discusses in its issue for March 28,
1 89 1, the question whether or not menstru-
ation should be regarded as disqualifying a
woman for surgical nursing. Our contem-
porary says : " About two years ago we re-
ferred to what was then to us a novel sug-
gestion. This suggestion came from a
Chicago surgeon and was to the effect that

the menstrual discharge rendered the nurse
infective and unfitted her for service in an
obstetrical case, that a menstruating nurse,
in other words, should be excluded from
such service. Still more recently a surgeon
in one of our New York colleges has in the
presence of a large class substantiated this
inference. This surgeon says that he re
gards the menstruating nurse as a source of
infection and announces as an < unwritten
law' of his practice the exclusion of men-
struating nurses from all major operations.
Now, if enforced, this rule will be a serious
matter to the surgical nurse as it will mean
incapacity for three months out of the
twelve — it will mean even more than that —
it will mean total incapacity from the im-
possibility of arranging cases so as to accom-
modate her physiological functions. If this
rule be enforced, we say, all women nurses
will be driven from the field of surgical and
obstetrical nursing. Even in the hospital
we are told that it will be impossible to
cover its requirements, that in spite of the
large classes in our training schools there
will come times when not a single nurse will
be available. We are told that the pupils
of the training schools cannot be depended
upon to arrange themselves in single file and
to so distribute their incapacities over the
month ; but that these incapacities will be
apt to occur in groups, that a large group of
nurses will be found menstruating at one
and the same time. Unless women then are
to be replaced by men, in surgical and ob-
stetrical nursing, this ' unwritten law ' must
be inoperative.

" But let us consider the ground of its
adoption. We acknowledge that the vagina
contains bacteria, we acknowledge that the
menstrual blood is already partly disinte-
grated and that it rapidly becomes offensive.
The same, however, is true of the perspira-
tion and other excretions. It would be as
rational to exclude every perspiring man
from the operating room as to exclude every
menstruating woman. The cases are parallel.
Again, if curetting and other operations can
be performed during menstruation with
safety this fact proves the original innocuous-
ness of the menstrual discharge."

Upon this point Dr. William Goodell's
opinions about menstruation which were
cited in an editorial in the Reporter, Feb-
ruary 28, 1 89 1, are quoted, and a letter
from Mr. Lawson Tait is published, in which
he says: "The question of dealing with
menstruating women in relation to my op-

468

Periscope.

Vol. lxiv

erations has never entered my mind for a
moment. It is a suggestion that has never
been made to me till the present moment
and I cannot imagine anything more ridicu-
lous. For years and years of my work, in
every case the anaesthetic was given by a
woman. There are always four or five
nurses about in each operation, and I dare
say that very few of my operations indeed
are performed without some of the female
persons present being in that condition."

Treatment of Headache.

Dr. Dercum, in a lecture published in the
University Medical Magazine, April, 1891,
speaks as follows in regard to the treatment
of headache.

We come now to the treatment. This is
an exceedingly knotty question.. I shall not
spend time in the consideration of the treat-
ment of organic headache. I can indicate
only general principles. If there is a tumor,
it should be removed if possible. If there
is meningitis, it is to be dealt with on gen-
eral principles. If the patient bears the
iodides and mercurials well, they should be
given, while at the same time counter-irrita-
tion should be practiced. Especially is this
treatment applicable in headache following
sunstroke.

A great deal might be said in regard to
the treatment of the cases that belong to the
group of migraine. In the first place, the
patient should be put on such constitutional
treatment as will improve the general con-
dition and bring it up to a high standard.
Every error of diet should be eliminated,
not because the patient has gastric catarrh,
but because he suffers with migraine. These
patients should be given large amounts of
milk in addition to other food. The food
given should be in a digestible form. Exer-
cise is another important factor. This should
be rigidly insisted upon. However, in spite
of what you do, although the attacks may
be less frequent, it is improbable that you
will be able to stop them altogether. I do
not say that this is invariably true, but it is
so in many cases. In addition, it is neces-
sary to practice some decided interference
at the time of the attack. One plan is to
use morphia. Of course, that is a decided
way of dealing with pain due to any cause.
This is, of course, a dangerous method of
dealing with pain, especially where there are
recurring attacks, for the patient inevitably
acquires the morphia habit. Again, espe-

cially where the migraine is associated with
sympathetic spasm, the pain is often relieved
by large doses of whiskey, especially if it
be given hot. Various drugs have in recent
times been given, not only for migraine, but
also for other head pains, notably antipyrin
and antifebrin. Antipyrin is a very valuable
drug, and is a decided addition to our arma-
mentarium. In some way or other the no-
tion has got abroad, and is held by many
people, that antipyrin is a dangerous drug.
An ordinary individual will stand ten, fifteen
and even twenty grains without noticeable
effect on the heart or pulse. t Antifebrin is a
dangerous drug, and should not be given in
large doses. Antipyrin, however, only ex-
ceptionally acts as a depressant. A good
plan is to associate the antipyrin wTith bro-
mides. The depressing effect, if any, can be
prevented by -giving digitalis, or especially
aromatic spirits of ammonia, which is
acceptable to the stomach in this condition.
Cannabis indica also enjoys a reputation in
the treatment of migraine, and a just one.
One-fourth to one-half a grain of the extract
may be given at intervals of four hours.

In the treatment of functional headaches,
due to anemia or chlorosis or to hyperemic
states, general principles, of course, must
guide you. The anemic patient needs the
best hygiene, and especially does he need
iron. He requires the most nutritious diet.
The headache of chronic nervous exhaus-
tion and neurasthenia may also be spoken
of here. The only way in these cases is
to put the patient to bed for a while. Forced
feeding, especially with milk, and massage
and faradization, will cause improvement in
the general health, and the headache will
disappear. You may treat some of these
cases in other ways, but you will make no
impression on the headache until you put
them to bed. If you make the diagnosis
that the headache is due to neurasthenia, do
not hesitate to tell the patient of the neces-
sity for rest, else you will fail in relieving
the headache, and your reputation will suffer.

The headaches due to disorders of nutri-
tion, as the various diathetic headaches, will
call for their special treatment. The uremic,
rheumatic and diabetic headaches suggest
what is to be done. The same is true of the
toxic headaches. I shall here refer to one
point only, and that is in connection with
the malarial headache. This is not, as a rule,
relieved by ordinary doses of quinine, such
as would prevent the recurrence of a chill.
If you do not give large doses, you will fail.

April 25, 1 89 1.

Periscope.

469

Twenty and even thirty grains are required
to make an impression. Where it is neces-
sary to give very large doses, it is well, in
order to avoid irritation of the stomach, to
give the drug in ten-grain doses in capsules
every hour with a quantity of milk, until
the required amount is taken. In that way
the quinine will dissolve slowly in the pres-
ence of the curds of the milk, and there
will not be much irritation of the stomach.
In order to obtain the best effect the remedy
should be administered four or five hours
before the expected attack.

In regard to headaches of reflex origin,
each case will require the appropriate treat-
ment. The eye, nasal and gastric head-
aches suggest their respective treatment.
Gastric headaches are due to chronic
gastritis, and the treatment should be di-
rected to the relief of this condition. Do
not let yourself be turned aside from the
proper thing to do by dabbling with pepsin
and other digestants. Pat the patient on a
bland diet, give him nothing but milk, per-
haps with a few crackers, or stale bread.
To this possibly may be added beef juice
from time to time. If he will consent to
give the stomach a rest he will recover. This
is the most important part of the treatment.
Nitrate of silver is also of service. One-
fourth of a grain of nitrate of silver, with
hyoscyamus or belladonna, may be given
thirty minutes or an hour before meals. It
should be swallowed with as small a quantity
of water as possible. Even if there be
formed, as some assert, an albuminate of
silver, there can be no doubt that the drug
has some alterative effect upon the stomach.
It probably acts as a stimulant and a seda-
tive. It is probable that it rapidly under-
goes chemical change, but we know that
cases improve more rapidly with silver than
without it. During the attack of headache
it is well to give an emetic, and preferably
one that will not irritate the stomach. You
would not, under these circumstances, think
of giving mustard. You could give the
patient warm water until he could retain no
more. The moment vomiting takes place
the headache is relieved. The vomiting
should be followed by the administration of
an alkali, such as bicarbonate of soda, soda-
mint or a tablespoonful or two of lime water
in ordinary water.

If you have an obscure headache, for
which you can find no obvious cause, and
you detect physical signs of cardiac disease,
you must take this into account. Do not

forget, further, the part that the bowel may
play in the production of headache. Uter-
ine headaches will require their special treat-
ment.

Regulation of Prostitution.

The Medical Record, March 28, 1891, says
editorially : The discussion of the subject of
licensing prostitutes and regulating prosti-
tution has again become a subject of present
interest. The Legislature of Missouri has
before it a bill providing for the regulation
of prostitution. At the International Med-
ical Congress, Dr. Thiry read a paper on
the subject which excited much discussion,
and quite recently it has been brought up
before the New York Academy of Medicine.
We notice also that even in so remote aland
as Japan there has been an agitation started,
and the Imperial Diet has been memorialized
by a large number of citizens, who ask for
the abolition of the license system and pre-
sent statistics showing that it is a failure in
Japan.

Those who assert that the licensing system
should be established, produce statistics which
show that it reduces the amount of venereal
disease. For example, in France, M. Com-
menge has recently stated, at a meeting of
the Academy of Medicine of Paris, that he
had collected the statistics of the number of
diseased prostitutes found in the decade from
1878 to 1887 : First, among women regis-
tered by houses or cards ; second, among
those women who — though registered — were
the object of more or less frequent arrests,
and constituted a special class under the
name of femmes du depot ; 'third, and lastly,
among the uninspected, or women that lived
by clandestine prostitution. The results ob-
tained, based on nearly a million visits,
showed the number of cases of syphilis in
each thousand examined to be respectively
3.1, 2.7 and 23.9. Of other venereal dis-
eases 3.0, 2.5 and 14.5.

Thiry, of Brussels, gives similar figures.
The Vienna syphilographers are all naturally
in favor of regulation. Neumann would
have prostitution entirely under government
control. Prostitutes should, according to
him, be regularly examined, and, if diseased,
quarantined. Soldiers, sailors and even fac-
tory hands and wet nurses should also be
regularly examined. Already in Vienna
each prostitute receives a book containing a
description and photograph of herself, and
a copy of the laws relating to prostitution.

470

Periscope,

Vol. lxiv

No one under sixteen can be registered, no
persons afflicted with organic or constitu-
tional disease. Sanitary examinations are
made twice a week, all diseased women are
put into hospitals, primary syphilitic cases
are quarantined for three months, and kept
under treatment for two years. Clandestine
prostitutes are treated in the same way by
their own physicians.

The results of this treatment in Vienna
are not dwelt upon with so much enthusiasm
as the methods. Vienna is rank with vene-
real disease. The idea that continence is
a moral virtue, simply does not exist for men
or for lower-class women, half the births in
the city are illegitimate, and Austria's Crown
Prince shoots himself as the result of a low
intrigue. Statistics are brought forward by
the opponents of licensing which appear to
show that the system is a failure in Paris,
Berlin, Italy and Great Britain. The state-
ment of Lacour, chief of the police of Paris,
that licensing does not protect and that
prostitution cannot be made safe, is also often
quoted.

It seems, therefore, that judgment must
be formed upon general principles, since the
facts are so inadequate. One general prin-
ciple, viz., that the sexual propensity cannot
be regulated by law, seems to be a pretty
safe one. If there is a general desire in a
given community to do a thing, it will be
done. Regulating prostitution, however, is
said to make this indulgence safer. Facts
do not quite prove it. Furthermore, it is
admitted that all attempts to register and
examine prostitutes thoroughly have failed.
And for our part we should dislike to feel
that members of our calling would accept so
low and despicable a position as that of gov-
ernment examiners of prostitutes.

A mistake which advocates of the licens-
ing system make is that of considering the
question solely as a sanitary one. Even if
it were proved that syphilis were reduced five
per cent, in a given community, it would
not prove that the community was a happier
or healthier one. For under the stimulus of
a government assurance that prostitution was
safe, the amount of illicit indulgence might
be doubled, with the result of increased do-
mestic trouble and moral degradation. The
injustice of forcing women to be examined,
and not men, has often been referred to. M.
Thiry considers this a 11 fallacious idea,"
though upon exactly what grounds he fails to
state.

It has seemed to us, taking all the facts

into consideration, that the safest method of
treating the subject of prostitution is the
educational one. Its moral and physical
dangers should be assiduously inculcated,
especially upon the rising generations.

Rupture of Linea Alba.

In the Australasian Medical Gazette, Jan-
uary, 1 89 1, Dr. R. D. Pinnock, of Victoria,
writes: When reading Dr. Monsell's interest-
ing case of this rare accident it occurred to
me that Dr. Dimock, one of the oldest and
most respected members of the profession in
this city, had, some time ago, told me of a
similar experience in his own practice. I
have, therefore, reminded him of our con-
versation, and he has kindly allowed me to
send you the following particulars which he
has looked up from his notes and which, he
informs me, have never been previously
published :

" Mrs. Sharwood, a wheelwright's wife,
aged (at time of birth of fourth child) 35
years; confined on November 5, 187*6.
During labor linea alba ruptured, and the
limbs of the child could be distinctly made
out through abdomen. The late Dr. Nich-
olson also saw this case, and recognized the
nature of the accident. The labor termi-
nated safely with a living child, but she was
very ill for 1 7 days afterwards. Three years
afterwards she had another child and a good
time, and she is still living, but at a distance
from Ballarat."

Dr. Dimock has been nearly 40 years in
active practice, and has had an immense
midwifery experience, but never saw or
heard of a similar case until I mentioned
to him the one published by Dr. Monsell.
He also tells me of another unusual experi-
ence he had in midwifery, which is well
worth recording.

The labor was going on quite normally in
every way, and when the head of the child
was actually visible outside the vulva it sud-
denly retracted, labor pains ceased, and on
examination he found the child had returned
within the uterus, and there was no return of
labor for 38 hours afterwards, when the birth
took place easily and naturally.

During last year I was consulted by a
young man in charge of a country railway
station for severe pains in the abdomen.
He said he had overstrained himself in
helping to push some empty trucks the. day
previously. On examination I found the
linea alba ruptured for a space of three

April 25, 1891.

Periscope.

47i

inches immediately above the umbilicus,
and the contents of the abdomen easily felt
between the separated recti. Pressure in-
wards at this point caused a sickening pain.
Lateral pressure approximating the recti
gave great relief. I strapped the abdomen
firmly and ordered him to go to bed and lie
on his back for a week, but never saw any-
thing of him again. This case was seen
with me by Dr. Whitcombe, who agreed in
the diagnosis.

I do not recollect any similar case being
reported, and therefore mention it in con-
nection with the other.

Trichloracetic Acid as a Test for
Albumin in the Urine.

Dr. Nestor Tirard, Senior Assistant Physi-
cian to King's College Hospital, London,
writes to the Lancet, March 21, 1891 :

"The practical value of trichloracetic
acid as a test for albumin in the urine is so
great that any sources of error in its em-
ployment should be carefully noted. In a
letter from Dr. C. F. Heywood, of New
York, which appears in the February num-
ber of Merck 's Bulletin, the writer, after
speaking in very laudatory terms of the
value of the test, says : ' I have yet to find
that it declares any other ele?nents of sus-
pected urine than albumin,' and he recom-
mends that a saturated solution should be
carried about in the pocket. I have long
been employing this test, both in private
and in insurance examinations, and can
speak very highly of its results. I have
been in the habit of comparing its reactions
with those given by nitric acid and picric
acid, and while I have never found it fail to
react in specimens in which albumin has
been discovered by other tests, it has given
a line of opacity in numerous samples which
have been unaffected by nitric acid or picric
acid. In some of these the trichloracetic
acid appeared to be a more delicate test,
since in cases with a history of an acute at-
tack of nephritis the urine has often given a
line of opacity after it might have been de-
clared free from albumin when the customary
tests were employed. On the other hand,
the need of the warning originally given by
Boymond has been very strongly impressed
upon me by several cases — viz., that when
the urine is rich in urates the reaction may
appear without any albumin being present,
and this possible source of error can only

be avoided by free dilution of the urine be-
fore making the test.

" With regard to the desirability of carry-
ing this reagent in the pocket, the effects of
a crystal on a piece of blue paper or on the
blade of a knife have been sufficient to deter
me from making the experiment. Although
trichloracetic acid may be used either in a
solid or liquid form, it gives the most strik-
ing results when a good-sized crystal is
dropped into the test-tube containing the
urine. The crystal speedily liquefies, and,
if albumin is present, produces a zone of
turbidity in the urine just above it, other-
wise a sharply-defined line marks the junc-
tion of the white acid with the yellow urine.
The zone of turbidity appears immediately
when due to albumin, but when due to
urates it forms more slowly, and is not so
wide."

Angina Pectoris.

The Medical Press, March 18, 1891, says,
editorially :

Angina pectoris is by no means what may
be termed a new disease, yet its phenomena
and its very nature still present so many ob-
scurities that the subject has monopolized
the almost unprecedented number of three
evenings' discussion at the Medical Society
of London. Those who take their medicine
and pathology from text-books will be sad-
dened at finding the divergence of opinion
on the part of authorities with respect to the
precise nature of the morbid process which
gives rise to symptoms designated in their
integrity under the name of angina. It is
but too obvious that under this somewhat
misleading title are grouped conditions of
widely different origin, of very different
nature, and amenable to vastly different
treatment. This must infallibly prove to be
the case when nomenclature is based on
symptoms rather than on pathological ob-
servation, and it justifies the attitude of
those who evinced a desire to dispense with
the use of a term which implies nothing ex-
cept pain and distress in a particular region
of the body. The term angina pectoris is
about as scientifically precise as stomach
ache. Anginal attacks vary immensely, as
is well known, both in severity and in im-
port, but all attempts to group them on a
more scientific and topical plan have proved
unsatisfactory. The most surprising feature
of the prolonged but instructive debate was
the antagonism of views respecting clinical

472

Periscope.

Vol. lxiv

details which one would have supposed
would have been by this time clearly made
out. For instance, is angina, in its princi-
pal variety, a disease associated with high
arterial pressure or not ? At first sight the
evidence in favor of the pain, which is the
most salient symptom, being due to over-
distention of the heart, appears to be over
whelming, and this view is reinforced by
the palliative effects of drugs which lower
arterial tension, such, for example, as the
nitrites, the use of which in medicine is one
of the most striking examples of the appli-
cation of physiological investigation to prac-
tical therapeutics. There is, on the other
hand, evidence which we cannot afford to
overlook that heightened blood pressure is
not an invariable or even an essential con-
comitant of angina, while in many diseases
associated with an abnormally high blood
pressure, anginal symptoms are compara-
tively rare. As to the neurotic hypotheses
according to which angina is referable to an
improved and unprovable neurosis of the
heart, these may for the present be dismissed
with the Scotch verdict of "not proven."
It is worthy of remark that most cases of
angina occur in persons not constrained to
hard work, though the first attack is fre-
quently associated with, and dates from,
some unusual muscular exertion calculated
to throw an unwonted strain upon a heart
which has been enfeebled by senile or other
degenerative or organic structural changes.
It is, moreover, distinctly associated with
the gouty diathesis, and there is much to be
said in favor of the view that what we call
angina pectoris is in many instances only
the manifestation of a gouty heart. This is
not inconsistent with the view that it may
be directly the result of overstrain of the
heart, for it is not unreasonable to infer that
the proclivity which gout shows to attack
damaged tissues generally holds good in
respect of the heart just as in the case of
joints, etc. Then, again, as was clearly
pointed out by Dr. de Havilland Hall, a
certain proportion of cases which are diag-
nosticated to be anginal really belong to
quite another category, and several instances
are on record in which the pain and distress
which were supposed to be pathogenic of
angina have subsequently been shown to be
due to hepatic colic, indeed, the resem-
blance is occasionally so close that it may
be well-nigh impossible to distinguish one
from the other unless suspicion be aroused
as to the veritable nature of the mischief.

The observations and inquiries which can
alone elucidate the moot points in this pro-
tean malady are unfortunately of a kind not
readily accessible to the ordinary practi-
tioner, but it ought not to be difficult for
those whose means of investigation are
more extensive to provide us with accurate
and reliable data to go upon. At present
there is too much surmise, and too little di-
rect observation, and this accounts for the
difference of opinion which the discussion
has elicited on matters of fact.

The Fluviograph.

The Engineering Record, March 28, 1891,
says : At a recent meeting of the Societe
d' Encouragement, Mr. Ch. Mocquery, Chief
Engineer of Bridges and Roads, described
what he termed an electric "fluviograph,"
an instrument designed to register at any de-
sired distance, by means of electricity, va-
riations in the height of water level of a
water-course, and to give timely warning at
sites of dams of impending floods, so as to
enable adequate means to be taken to pro-
vide for heavy rushes of water.

Briefly described, the device consists of a
float about 1 inch in diameter, which rises
and falls in a vertical cast-iron tube, the
latter being in direct communication with
the river whose varying levels are to be re-
corded. This float transmits its motion to a
wheel, whose circumference measures exactly
one meter (3.28 feet), and which gears with
another wheel of such proportions that every
five centimeters of vertical displacement of
the float corresponds to an interval of two
teeth on the smaller wheel. A conveniently
arranged electric contact thus permits of
sending an electric current through a wire at
every such displacement, and gives indica-
tions of the nature of the variation in the
water level. These can be recorded on a
chart. Arrangements can also be made for
electrically sounding a high water alarm.
The device is said to have been in use on
the river Seine since 1882.

— Stern, of Breslau, says that bacteria
sink to the floor within two hours, in a room
perfectly quiet ; and recommends that rooms
vacated by patients be closed for twenty-four
hours, after which the furniture should be
carefully removed and the floor and walls
washed with sublimate solution.

April 25, 1 89 1.

Editorial.

473

THE

MEDICAL AND SURGICAL

REPORTER.

ISSUED EVERY SATURDAY.

CHARLES W. DULLES, M. D.,
Editor and Publisher.

N. E. Cor. 13th and Walnut Streets,
P. O. Box 843. Philadelphia, Pa.

^^"Suggestions to Subscribers :

See that your address-label gives the date to which your
subscription is paid.

In requesting a change of address, give the old address as
well as the new one.

If your Reporter does not reach you promptly and regu-
larly, notify the publisher at once, so that the cause may be
discovered and corrected.

^©"•Suggestions to Contributors and Correspondents :
Write in ink.

Write on one side of paper only.

Write on paper of the size usually used for letters.

Make as few paragraphs as possible. Punctuate carefully.
Do not abbreviate or omit words like "the" and "a," or
"an."

Make communications as short as possible.

Never roll a manuscript 1 Try to get an envelope or
wrapper which will fit it.

When it is desired to call our attention to something in a
newspaper, mark the passage boldly with a colored pencil, and
write on the wrapper " Marked copy." Unless this is done,
newspapers are not looked at.

The Editor will be glad to get medical news, but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

SPERMINE.

The craze over Brown -Sequard's so-called
elixir led to attempts to find an ingredient
in the semen or testicles which would pro-
duce the effects claimed for the testicle-juice
he used. Such a substance has been quite
largely advertised by an enterprising firm of
manufacturing chemists in Detroit, under
the name of " Spermine." This material,
however, is not new. Spermine, as the
Chemist and Druggist, November i, 1890,
says, has been known under various names
since 1851 : as Charcot or Charcot-Neu-
mann crystals, as the asthma crystals of Ley-
den, and as Schreiner's crystals. In 1865,
Boettcher found them in semen, and they
have been obtained from the spleen, the
blood, the spinal cord, the white of egg,
sputum and old anatomical preparations.
In 1 888, Ladenburg and Abel established
their identity with ethylenimine (CH2.-

CELNH.). The alkaloid, properly called
piper-azidine hydrochloride, resembles other
ptomaines chemically, and when free has
the odor of fresh semen, the same odor
sometimes found in sputum being no doubt
also due to its presence.

On this subject, Merck's Bulletin, Feb-
ruary, 1 89 1, states that spermine has not
been shown to be identical with piper-azi-
dine, and that it is as yet not obtainable by
synthesis. Natural spermine has not yet
been obtained pure in any considerable
quantity, and the difficulties so far found
in the way of its isolation have led to at-
tempts at preparing its equivalent synthetic-
ally ; but hitherto these attempts have not
yet led to any definite result.

On a survey of the chemical results pub-
lished up to the present day, it appears that
the synthetic products variously designated
as piper-azine, piper-azidine, ethylene-imine
and di-ethylene-di-amine are mutually iden-
tical ; but that their identity with Schreiner's
natural spermine from spermatic fluid is not
yet established. Ladenburg, who first in-
timated the possibility of his ethylene-imine
being identical with spermine, has taken up
this question anew, and is now engaged in
a comparative investigation of the two sub-
stances. According to Bock, the excitant
properties ascribed to natural spermine are
totally absent from the synthetic compound
above named.

From all this it will appear that chemists
and manufacturers of pharmaceutical pre-
parations feel quite a lively interest in
this substance, which appeals so strongly to
the imagination, and that their efforts have
been more barren of results than have been
those of the experimenting clinicians of
Europe — we say Europe, because the folly
was soon over in this country. In Europe,
we find Brown-Sequard from time to time
reporting brilliant results from the employ-
ment of testicle therapy, and once in awhile
some one else produces seemingly corrobor-
ative evidence to its worth. In Russia, we
are told, Dr. Roschtinin reported, in March,

474

Editorial.

Vol. lxiv

1890, a series of experiments which he had
made with the injection of spermine, and
declared it had proved an excellent stimu-
lant in asthma with heart complications,
paralysis of the extremities, angina pectoris,
diabetes, fatty degeneration of the heart,
and in pneumonia. It is said also that
spermine has been used with good results by
other Russian physicians in delirium tremens,
tuberculosis, and atonic ulcers of the leg.

If it could really do all this it would be but
little inferior as a remedy to some things
which are advertised in the newspapers ; but
after reflecting on the subject, we incline to
the opinion that spermine is an agent better
suited to the use of persons of an imagina-
tive turn of mind and sanguine disposition
than to that of calm and critical practi-
tioners. Its temporary acceptance seems to
be only one of the evidences we have re-
cently seen that the medical profession may
occasionally try to take its bearings from a
meteor instead of from a star.

TREATMENT OF CHRONIC CONSTI-
PATION WITH BORIC ACID.

Chronic constipation may be the result of
stricture of the bowel, or of chronic catarrh,
or be caused by the pressure of some organ,
such as an enlarged or retroverted womb,
which occludes the lumen of the bowel.
But there are a large number of cases of
chronic constipation not to be referred to
any organic or mechanical cause. In many
cases the bowel is in a sluggish, insensitive,
atonic condition, which is due primarily to
neglect on the part of the patient to heed
the first gentle warnings that the bowel needs
to be emptied. As this neglect becomes a
habit, the bowel itself gradually ceases to
make its condition manifest, and chronic
constipation develops. The symptoms and
distressing consequences of the condition
are well known to every physician, and they
need not be mentioned in this connection.

In recent years there has been a tendency
to use purgatives as little as possible, and to

resort to massage, electricity, gymnastics
and baths. These methods can be carried
out when the patient has a skilled attendant
and sufficient means and leisure.

In many cases, glycerine by the bowel is
to be preferred to the administration of pur-
gatives by the mouth, and its use necessi-
tates less loss of time and less change in the
patient's habits of life than when massage,
electricity, etc., are used. A more recent
remedy than glycerine is suggested by Dr.
Flatau, in the Berliner Kli?iische Wochens-
chrift, March 2, 1891. Flatau recommends
powdered boric acid very highly in those
cases in which, as the result of chronic in-
flammation of the rectum, there is sluggish-
ness of the rectal mucous membrane, a cir-
cular border projecting more or less at the
point where the rectal mucous membrane
merges into the anus. In such cases, the
buttock upon one side is strongly abducted,
the parts are carefully washed with cold water
and then dried, and finely-powdered boric
acid is applied to the exposed rectal mucous
membrane. The quantity used by Dr. Fla-
tau is rather indefinitely expressed as a
" good knife-point full," and he uses it
either by dusting it on the part or by press-
ing it upon the part and then rubbing it in.
In the cases in which there is torpor of the
colon, the boric acid must be used by insuf-
flation.

At first, in the rectal cases, the treatment
should be carried out by the physician, but
later it may be entrusted to the patient. In-
sufflation, however, must be done by the
physician. For this purpose, a short tube of
pretty large bore is inserted into the rectum,
and about forty-five grains of boric acid is
insufflated by means of a powder-blower.
In addition to the cold-water bathing of the
anal region before the application, Flatau
has the patient rest for a short time after the
application of boric acid, in order that the
latter may keep its place for a few minutes.
In from one-half to three hours or longer,
after the application, pretty strong peristaltic
movements are set up in the large intestine,

April 25, 1 89 1.

Editorial.

475

and probably the small intestine takes part
in them also. As the result of the increased
peristalsis, the feces are pressed down into
the lower section of the intestine and so are
cast out. The stools are rarely watery.

Flatau says he has not failed to secure
good results from the boric acid treatment
in any of the cases in which he has used it,
provided that it was used in suitable cases.
He has used it in about forty cases. The
most interesting statement of all, is the as-
sertion that the bowel seemed to grow
stronger as a result of the use of the boric
acid, and that a normal condition of
muscular activity of the large bowel was
brought about. Three illustrative cases are
reported in full.

Such a simple and harmless method of
treating ordinary chronic constipation as
Flatau has described, can be carried out by
any physician, and the results may be as
gratifying as those obtained by the use of
glycerine in more acute cases. One need
not dwell upon what a boon a simple but
effective treatment of chronic constipation
would prove to be to many who now seem
doomed to swallow some purgative two or
three times every week. We hope that the
boric acid treatment may obviate this, in a
measure, at least ; and as each of our read-
ers can try it for himself, it should not be
long before wTe shall know definitely its value
in chronic constipation. It is for this pur-
pose that we have called attention to it in
the Reporter.

PHILADELPHIA POLYCLINIC.

The handsome new building of the Phila-
delphia Polyclinic was formally opened
April 2, 1 89 1, with ceremonies which were
interesting to those who took part in them,
and must have been especially gratifying to
the members of the Board of Trustees and
Faculty of this institution, who have labored
so indefatigably to accomplish the result
which they now have attained. The Poly-
clinic has now what is believed to be the
finest building in use by any such institution

in the United States. It is admirably adapted
for the purposes for which it is intended, and
is especially valuable as affording unusually
good opportunities to medical men for the
close observation of medical and surgical
cases. It is an objection to some of the
most prosperous Polyclinics in this country,
that it is almost impossible for medical men
attending them to get much better views of
operations or closer investigations of indi-
vidual patients than is now attainable in first-
class undergraduate medical schools, with
well-supplied clinics. The Philadelphia
Polyclinic affords peculiar advantages in
enabling those in attendance to come very
close to everything which is done, and in
many cases themselves to take part in the
treatment, as well as in the examination of
patients.

It is pleasant to note that the exercises on
April 2 indicated that the Philadelphia Poly-
clinic has the hearty sympathy and good-
will of the undergraduate medical schools of
this city. With its new building in full op-
eration, and its well-known Faculty, it is rea-
sonable to expect that it will now rapidly
increase in prosperity and usefulness.

Medical men living within convenient
reach of Philadelphia, would at any time
find it to their advantage to take a holiday,
and to spend it here, where, with the Poly-
clinic and the active Medical Societies of
this city, and the professional atmosphere
for which it has a widespread reputation,
they could not fail to find advantage and
pleasure.

TRAINING

SCHOOL FOR
FANTS.

DEAF IN-

It has been demonstrated that deaf chil-
dren can be taught speech and lip reading,
be educated and be enabled to communicate
with their families and friends through the
same, and a number of pure oral schools for
such instruction are in existence in the
United States. To the complete success of
the method, however, it is necessary that
these deaf children should be guided and

476

Editorial,

Vol. lxiv

trained to speech from the age when hearing
children begin to learn to talk.

As the majority of these children are poor,
and as all mothers, even of those who are
not poor, do not understand how to train
them to speech, Miss Fuller, Principal of
the Horace Mann Day School for the Deaf
(pure oral), Boston, established, two years
ago, a Home for the training in speech of
deaf children before they are of school age.
The necessary funds for commencing the
good work in New England were raised by
the mother of a successfully trained deaf
child. The children are, of course, under
the care of persons specially trained for that
purpose, and their progress already gives
great encouragement.

It is proposed to establish in the Middle
States, as speedily as possible, such a Home
as Miss Fuller has established in New Eng-
land, and the public are earnestly requested
to contribute to the Endowment Fund re-
quired for the same. The School will be
under the management of Miss Emma Gar-
rett, long known for her skilful and devoted
labor for the deaf, and more recently as
Principal of the Pennsylvania Oral School
for the Deaf, which position she has re-
signed, to take up this new work.

Physicians probably understand the need
for such institutions as well as any class in
the community, and we feel sure that the
readers of the Reporter — many of whom
are familiar with the work already done for
the deaf by Miss Garrett — will approve and
support the proposed Home, which will begin
the work of ameliorating the condition of
these unfortunates at the most favorable
time.

RESIGNATION OF DR. DA COSTA,

The Alumni and friends of the Jefferson
Medical College will receive with regret the
announcement that Dr. Da Costa has re-
signed from the Chair of Practice of Medi-
cine in that institution. The reason for his
resignation, is that Dr. Da Costa desires to
withdraw from the cares and burdens of the

professorial position in order to have more
leisure for his large practice. For twenty-
seven years, in one capacity or another, Dr.
Da Costa has been identified with the Jef-
ferson Medical College, and it is not too
much to say that its present exalted position
is in a large measure due to the admirable
manner in which he fulfilled the duties of
his position, and to the lustre of his repu-
tation, which has so effectively supplemented
that of Meigs, Gross, Pancoast and others,
whose students respected and loved them,
and who were justly esteemed and honored
by the members of our profession all over
the world.

FAREWELL OF THE EDITOR.

On April 30, 1887, Dr. N. A. Randolph
and I leased the publication business of the
Medical and Surgical Reporter for a
period of ten years, with the right to ter-
minate the contract — at our option — at the
end of any current year. Dr. Randolph
lost his life in August, 1887, and since then
the whole work of editing and publishing
has devolved upon me. Now, in accord-
ance with the provisions of the contract
mentioned above, I have decided to give
up this work on May 1, and I must there-
fore take leave, as Editor, of those to whom,
for nearly four years, I have spoken every
week through these columns.

During this time it has been my desire
and endeavor to conduct the Reporter so
as to advance the interests of its readers
and to support the honor and dignity of
the medical profession. More than once I
have acknowledged recognized errors of
judgment, and others unrecognized have no
doubt occurred ; but I trust that, while under
my control, it has helped those who read it,
has supported no unworthy cause and has
opposed no good one. I have felt, while
Editor of the Reporter, a very warm in-
terest in the welfare of those thousands of
its readers whom I have never known per-
sonally, and especially in that of those who
live far from large centres of population.

April 25, 1891. Correspondence.

Ml

For the faithful and laborious practitioners
in the country, I have acquired a respect
and regard which has increased with each
year of my connection with this journal.

To all — in city, town and country — and
to my editorial colleagues throughout the
land, from whom I have always received
courteous treatment, as Editor of the Re-
porter, I now say, Farewell.

Charles W. Dulles.

Book Reviews.

[Any book reviewed in these columns maybe obtained upon
receipt of price, from the office of the Reporter.]

TWELVE LECTURES ON THE STRUCTURE
OF THE CENTRAL NERVOUS SYSTEM,
FOR PHYSICIANS AND STUDENTS. By
Dr. Ludwig Edinger, Frankfort-on-the-Main.
Second Edition. With 133 illustrations. Trans-
lated by Willis Hall Vittum, M. D., St. Paul, Minn.
Edited by C. Eugene Riggs, A. M., M. D., Profes-
sor of Mental and Nervous Diseases, University of
Minnesota, etc. 8vo, pp. xii, 230. Philadelphia
and London: F. A. Davis, 1890. Price, #1.75.

An idea of the scope of this book can best be given
by mentioning the subjects of the twelve lectures
which form it. These subjects are : A review of the
history and methods of investigating the central ner-
vous system ; embryology and comparative anatomy of
the brain ; the general conformation and histology of
the brain ; the convolutions and fissures of the surface
of the cerebrum; the cortex and fore-brain, the white
substance of the hemispheres, the commissures and
the corona radiata ; the corona radiata, the corpus
striatum, the thalamus and the subthalamic region ; the
structures at the base of the brain ; the corpora quadri-
gemina and the origin of the optic nerve; the pons
and the cerebellum ; the roots of the peripheral nerves,
the spinal ganglia and the spinal cord ; the spinal cord
and the commencement of the medulla oblongata ; the
medulla oblongata and the tegmentum of the pons ;
the pons ; final review.

It will be seen that the lectures cover very com-
pletely the subject of the structure of the central ner-
vous system. The illustrations are very clear and help-
ful. In most cases they have the German anatomical
names upon them, but as these are explained beneath
the illustrations, no confusion is created in the reader's
mind ; indeed, to a person with some knowledge of
German, it is interesting to have the exact German
equivalents of well-known English anatomical names.
Altogether we think the book will be valuable to the
specialist in nervous diseases, and especially to one
who is a student of cerebral histology.

PRINCIPLES OF SURGERY. By N. Senn, M. D.,
Profe-sor of Principles of Surgery and Surgical
Pathology in the Rush Medical College, Chicago,
111., etc. Large 8vo, pp. xiii, 611. Philadelphia
and London: F. A. Davis, 1890. Price, cloth,
#4.50, sheep, #5.50.

This handsome and well-illustrated book contains
an exposition of the principles of surgery different

from what has been usual in works on this subject.
The difference is due to the great amount of space
given to discussing the role played by micro-organisms
in the various morbid processes coming within the
domain of the surgeon. Pus, for example, is not de-
scribed by its color, smell and taste, but — in addition
to some of these — by its chemical and microscopical
characteristics. Septicemia is divided under a number
of heads, each of which is identified by the presence
of a definite bacterium. So through the whole list of
subjects considered — it is the bacteriological side
which gets most study. The result is a book quite
different from the general run of books in the English
language on surgery, and a book for which there is a
place in most libraries.

Dr. Senn has done his work well, having jrreat fa-
miliarity with surgical literature, and an abundant
clinical and experimental experience. His book is
bcth interesting and instructive, and has been well
printed by the publisher.

Literary Notes.

— J. B. Lippincott Company will, beginning with
April, issue quarterly thereafter, a work entitled " In-
ternational Clinics." This work will comprise the
best and most practical clinical lectures on medicine,
surgery, pediatrics, gynecology, dermatology, laryng-
ology, ophthalmology and otology, delivered in the
leading medical colleges of this country, Great Britain
and Canada. These lectures have been reported by
competent medical stenographers and thoi-oughly re-
vised by the professors and lecturers themselves. The
object of the work is to furnish the busy practitioner
and medical student with the best and most practical
clinical instruction in concise form. Each volume
will consist of over 350 octavo pages, illustrated with
photographic reproductions of important cases.

Correspondence.

Electricity and Pelvic Surgery.

To the Editor.

Sir: In your impression of March 21
(page 340), Dr. Horatio R. Bigelow makes
some criticisms upon some remarks of mine
touching the harmful effects of electro-punc-
ture in treating fibroid tumors of the uterus.

My remarks were contributed to a discus-
sion upon the treatment of such growths,
which discussion was introduced by Dr.
R. S. Sutton, of Pittsburgh, and afterwards
published. Here are my remarks to which
Dr. Bigelow makes objection: "Of late
electricity has been much vaunted in the
treatment of fibroid tumors of the uterus.
Dr. Sutton merely mentioned this agent in
his paper, probably purposely, because he
knows that electricity does nothing towards
arresting or removing these tumors. A pe-
culiar feature about the application of elec-
tricity in pelvic surgery is that those who a

478

Correspondence.

Vol. lxiv

few years since denied the existence of certain
forms of intra-pelvic diseases are now fore-
most in the diagnosis and treatment of these
same diseases by electricity. The applica-
tion of electricity by puncture is fraught
with danger. The speaker has removed a
uterine myoma by supra-vaginal hysterec-
tomy, weighing sixteen and a half pounds,
in which the entire anterior aspect, which
had been accessible to electric treatment,
was bound by dense adhesions to the omen-
tum, intestines and abdominal walls, etc."

Dr. Bigelow pronounces the above to con-
tain some " peculiar points," which points
he takes up seriatbn as follows :

"(i). Dr. Sutton, if acquainted with the
statistics and history of gynecological elec-
tro-therapeutics, will not feel flattered at this
surmise. The unimpeachable cases on rec-
ord in which tumors have been arrested by
electricity, are numerous and quite as relia-
ble as are any statistics ever brought forward
by any surgeon. If Dr. McMurtry does not
know this — his argument would be akin to
that of a 'lightning bug' who never owned
a battery — if he does know that such claims
are made, but refuses to accept them because
they antagonize pet theories of his own, it
is not polite to give utterance to such doubts,
since men of equally honorable standing
with himself have seen and reported such
cases. I have seen quite a number 4 re-
duced,' and so can any one else see these
cases if he will. I have never seen a fibroid
disappear entirely, but other men have, and
I believe them. It is ' foolish talk ' to
reiterate all this, because all of it is a fact.

"(2). In no branch of medicine has a
greater change taken place than in the path-
ology of female pelvic disease. What be-
came of all these modern, high-sounding
diseases, and of the women who had them,
before the modern laparotomist was incu-
bated ? Who condemned abdominal sur-
gery, not very long ago, but the surgeons
themselves? Did women die of these dis-
eases then, as they are since laparotomy has
become a fashionable ifad?i It is nice of
the doctor to give the ' lightning bugs '
credit for recognizing and diagnosticating
these troubles, early in their history, and for
establishing a conservative system of treat-
ment.

"(3). This objection is a mere will-o'-
the-wisp of the doctor's fashioning. I am
speaking, of course, of a puncture in the
hands of those competent to make use of it.
In the clinic, conducted by Dr. Massey and

myself, cases are punctured, high intensities
being used, and the patients go to their
homes one- half hour afterwards. I do not
advise this, but with such absolutely poor
people, and with no beds at our disposal,
we have no alternative. I have never seen
any bad results following a fibroid puncture,
and my experience has been an ample one.
But even were it possible to show that such
a process is attended with danger, what is
the value of such an objection ? Is not
laparotomy — the alternative — a dangerous
operation ?

"(4). Dr. Baldy, than whom no man of
equal age stands higher in the surgical liter-
ature of this country, told me only a few
days ago, that he very rarely if ever had
opened the abdomen for the removal of tu-
mors, without finding extensive adhesions,
and that a large majority of so-called pus-
tubes were simply cases of chronic adherent
salpingitis. So that all this rumpus about
adhesions — these big tumors — how could it
be otherwise, and by what process of ratio-
cination does one reach the conclusion that
adhesions are engendered by electricity ?' '

In the present state of our knowledge,
with the established results of the surgical
treatment of uterine fibroids, it seems almost
idle to answer such criticisms as the above ;
but the plea of conservatism (so-called) is
so attractive to many, and so very mislead-
ing, that the facts should be stated. Permit
me to call attention to Dr. Bigelow' s first
< 'curio."

In this he says " the unimpeachable cases
on record, in which tumors have been ar-
rested by electricity, are numerous." In the
same paragraph he says, ' ' I have never
seen a fibroid disappear entirely t but other
men have, and I believe them." Further
on, in paragraph numbered 3, Dr. Bigelow
states that " my (his) experience has been
an ample one." So we have his own testi-
mony, in his own words, that with an ample
experience he has never seen a single case
of fibroid tumor, in which the tumor disap-
peared under electrical treatment.

In his second paragraph, numbered 2, he
presents a still greater absurdity. After an-
nouncing the great advance in the pathology
of female pelvic diseases, he says : What
became of all these modern high-sounding
diseases, and of the women who had them,
before the modern laparotomist was incu-
bated ?" The logical sequence of such an
interrogation can be best appreciated if we
would inquire what result was obtained in

April 25, 1891. Notes and

Comments.

479

treating ectopic pregnancy before advancing
surgical knowledge in the hands of laparot-
omists made clear the deadly nature of in-
tra-peritoneal rupture, and a safe and effi-
cient method of treatment? The absurdity
of this mode of reasoning (if it can be so
called) will be apparent if applied to any
great advance in medical or surgical thera-
peutics, or to any scientific improvement,
for that matter, in any department of human
effort.

In paragraph numbered 3, Dr. Bigelow
says he has never seen any bad results fol-
lowing fibroid puncture. In reply to this, I
will say that I have seen the bad results of
such puncture in the form of violent peri-
tonitis and extensive adhesions, directly re-
sulting from electro-puncture in the hands
of those who, like Dr. Bigelow, consider
themselves competent to make use of such
treatment.

In paragraph numbered 4, Dr. Bigelow
would seem to be ignorant of the simple
fundamental fact that intra-peritoneal adhe-
sions are the result of pre-existing periton-
itis. Whatever begets peritonitis will pro-
duce adhesions ; electro-puncture begets
peritonitis at the point of puncture, often
extending widely ; and hence electro-punc-
ture produces adhesions. No one claims
that electro-puncture is the only cause of
adhesive peritonitis. It is well known to
experienced pelvic surgeons that tapping
ovarian cysts with aspirator or trocar always
produced peritonitis and adhesions at the
site of tapping. Since the practice of tap-
ping has been abandoned, this troublesome
complication is much less frequently encoun-
tered in ovariotomy. For the same reason,
electro-puncture is harmful in its results
upon fibroid tumors of the uterus.

Ovariotomy is recognized as the most,
successful major operation in surgery. The
mortality of supra-vaginal hysterectomy for
uterine fibroids has been reduced almost to
the same point. When treated thus, the re-
sults are perfect, the patient being entirely
cured and restored to health and activity.
A distinguished surgeon in Dr. Bigelow's
own city has done thirty-eight consecutive,
unselected, supra-vaginal hysterectomies
without a death, in cases where the supreme
indication was to save life. The operation
of removal of the uterine appendages ar-
rests hemorrhage and brings about atrophy
of the tumor in less extreme cases, and has
a mortality of only two and one-half per
cent.

These results of the treatment of uterine
fibroids upon sound surgical principles are
established facts, demonstrated by the in-
controvertible evidence of individual cases
and personal experience. The harmful ef-
fects in the form, if inflammation and ad-
hesions resulting from electro-puncture, are
equally well known ; and the inefficiency of
the electric treatment has been conceded by
many who intelligently and earnestly applied
the treatment for a long period of time, and
have abandoned it.

Yours truly,

L. S. McMurtry, M. D.
231 W. Chestnut St.,

Louisville, Ky.

Notes and Comments.

Partial Excision of -Sternum for
Melano- Sarcoma.

Dr. Herman Mynter, of Buffalo, N. Y.,
reports, in the Annals of Surgery, February,
1 89 1, an interesting case of operation for
melano-sarcoma of the sternum. He says
that while excision of the sternum on ac-
count of caries of tuberculous or syphilitic
nature has been done quite frequently, excis-
ion on account of malignant growths is so
rarely performed that neither surgical text-
books nor works on operative surgery men-
tion it. On looking over the literature at
his command, he finds only two cases men-
tioned, one by Koenig, and one by Kiister.
Koenig's case was an osteoid chondroma
which occupied the whole sternum with the
exception of the manubrium and the pro-
cessus xiphoideus. The operation was per-
formed in the following way : Long, vertical
skin incision, after which the costal carti-
lages were severed on both sides from second
rib downwards. Thereafter the sternum was
cut through, by aid of a saw, below the first
rib. The sternum, with the tumor attached,
was now lifted up with blunt hooks and
carefully dissected loose from the mediasti-
num. During this proceeding both pleural
cavities were torn open, but the tears were
closed by pressure with antiseptic gauze until
the skin-flap was in position covering the
openings. The tumor was adherent to the
pericardium, which was removed with suc-
cess (?). The patient recovered, but died
two years later from relapse in the lung.

Dr. Mynter's patient was a woman twenty
years old, born in Ireland, who entered the

480

Notes and Comments.

Vol. lxiv

Sisters of Charity Hospital on November
14, 1890, with the following history: She
is a domestic, and has been obliged to do a
great deal of sweeping, during which the
handle of the broom rubbed against her
breast bone. She ascribes her complaint,
a tumor over the sternum, to this cause. The
tumor first appeared eleven months ago, and
has been growing larger steadily until now
it is the size of half an orange, and extends
from below second to below fifth rib. Four
months ago the glands in the right axilla
commenced to enlarge and there is now
found here a conglomeration of glands as
large as two fists, completely filling the
whole axilla, but yet somewhat movable.
Two months ago the glands in the left axilla
commenced to swell, and are now as large
as a hen's egg. During the last few weeks
the glands in both supraclavicular regions
have commenced to enlarge. The tumor
over the sternum is immovable, and presents
a feeling of false fluctuation ; the skin is nor-
mal in color and not adherent. She has
sharp, shooting pains radiating from the tu-
mor in different directions ; has lately com-
menced to lose flesh, but is yet in pretty
good general health. There are no symp-
toms of any growth in the anterior medias-
tinum such as hoarseness, difficulty in breath-
ing or interference with circulation.

On November 15, 1890, an operation was
done under ether-narcosis. Dr. Mynter
made a U-shaped incision, convex down-
wards, from second to sixth ribs, about three
inches wide. The flap was dissected up and
the periosteum loosened transversely from
the sternum above the tumor in healthy tissue,
in order to shell out the tumor from the bone
if possible. The tumor was surrounded by
a strong fibrous capsule. On a line with the
fourth rib the tumor extended into the ster-
num, and the capsule was necessarily opened
here, and there was a discharge of a semi-
fluid, black, grumous substance. The rest
of the tumor was therefore removed from
below upwards, by a similar process. The
sternum was found quite extensively in-
volved, presenting an irregular cavity as
large as a section of a hickory nut, filled
with the black, grumous substance. It was
thoroughly scraped out with a sharp spoon.
During this proceeding, the posterior lamina
of the sternum was perforated. The open-
ing was enlarged with chisels, and from this
opening the posterior periosteum was loos-
ened with a curved elevator, and the sternum
removed piecemeal with cutting pliers from

above the third rib to midway between the
fifth and sixth ribs. About one-half inch of
the third, fourth and fifth right costal carti-
lages were removed too, and the pericardium,
which appeared healthy, was exposed for
about six square inches. The skin flap was
thereafter brought into place, and sutured,
and a drainage-tube inserted from the lowest
point into the cavity left by the removal of
the tumor and the sternum. The enlarged
glands were thereafter removed from both
axillar and supraclavicular regions, drainage-
tubes or catgut drains introduced, sutures
inserted, and antiseptic dressings applied.
The operation lasted two and one-half hours.

The further course was favorable. The
temperature rose for a couple of days to 10 1°
in the evening. The respiration was difficult
and painful for some time until she learned
to use abdominal respiration. The drains
were removed on fifth day, and on the tenth
day the wounds were healed and the patient
allowed to sit up. She left the hospital on
the fourteenth day, and so far, ten weeks
after the operation, has no symptoms of
relapse ; she has gained twelve pounds
in weight, and gone to work again as a
domestic.

The operation performed differs from < the
one described by Koenig. He tried to ex-
tirpate the sternum in toto, and managed by
that proceeding to tear open both pleural
cavities. It is scarcely possible to have this
accident occur when we first trephine the
sternum, and then remove it in pieces with
cutting-pliers. Dr. Mynter could, with the
greatest ease, have removed the whole ster-
num in this way, but he stopped, of course,
when he met healthy bone-tissue. The tu-
mor being a melano-sarcoma, will, of course,
return, and eventually kill the patient, but
if it had been removed half a year earlier,
before the glands were enlarged, there might
have been better prospects of a permanent
result. Dr. Mynter says he was severely
criticized by several physicians for attempt-
ing the removal, they being of the opinion
that such an operation was "little short of
murder."

Medical Legislation in Missouri.

The St. Louis Medical and Surgical
Journal, March, 1891, says: State Legisla-
tures have always been " a source of inno-
cent merriment," as the Mikado puts it.
Our own is no exception to the rule. In
fact, it seems that since the Farmers' Alii-

April 25, 1891. Notes and

Comments.

ance is in practical control of the House of
Representatives, our lawmakers have let
their fancies run riot. They do not
seem to know what law is and they further-
more indulge in the fascinating self-decep-
tion that they can pass such enactments as
seem most pleasing to them, irrespective of
Constitution or any other such small hin-
drances to their untrammelled action in the
premises.

One bright particular star, no doubt, has
fallen into the clutches of a doctor at some re-
mote period of time. This is the only way we
can account for a remarkable action he com-
mitted not long ago in the introduction of
a bill whose chief feature is the amusement
it caused. We want every one to distinctly
understand that this happened in the broad
commonwealth of Missouri, and not in one
of the effete States bordering upon the At-
lantic Ocean. If we are going to have
sample idiots we want them of the monu-
mental kind, and we have one and we want
to keep him as a sample. He imagined that
an idea had struck him and he forthwith
formulated a bill, the principal features of
which provided for the regulation of the
fees of physicians. The schedule is quite a
liberal one, considering the source whence it
emanated. Calls are not to exceed $1.00
each, and office consultations must not be
charged for at a greater rate than fifty cents
each. There are some other equally lucid
provisions to the literary curiosity, but we
forbear from enumerating them.

Our State Board of Health not long since
held its annual meeting and the subject of
medical education came up incidentally.
Some of the members stated it as their firm
and unalterable conviction that no diploma
should be recognized unless the college issu-
ing it required its possessor to have attended
three courses of lectures in one or several
reputable medical schools. Others of the
members of the same Board gave it as their
opinion that an attendance upon two terms
of lectures was all-sufficient. To arrive at a
definite conclusion it was decided to have a
vote. When the result of the ballot was
announced the discovery was made that the
Board was evenly divided upon the question,
with no hopes of obtaining a majority for
either side of the question. What to do in
such circumstances might have puzzled
others, but the Missouri State Board of Health
cut the Gordian knot and solved the diffi-
culty in a very simple manner. The whole
matter was referred to the State Legislature

and it has been resting there ever since. We
presume that it needs a prolonged rest and
will get it. Our Solons are not particularly
anxious to wrestle with the question and
there seem to be indications that it will
quietly slumber into non-existence unless
some vigorous means be pursued to resus-
citate it into the semblance of life.

We are certain that there will be other feat-
ures of a medical character brought out in
this Legislature before it adjourns. The
Social Evil bill has a few ; but what we want
is a good, genuine " way-back " medical
law (that won't hold water). We need it,
as physicians are so thoroughly incompetent
to manage their own affairs that they need
the kindly and protecting care of the farmers
to help them along. .

Albuminuria in Acute Catarrhal En-
teritis.

Dr. A. A. Netchseff (Bolnitchnaia Gazeta
Botkina, states that there is very little said
about albuminuria in acute enteritis in med-
ical literature, although it is a very important
subject. Works of a number of authors are
quoted, one of whom reported twenty-five
cases of cholera nostras, in nineteen of which
there was albuminuria in various degrees,
which disappeared in from two to three days.
Bacteriological investigations revealed the
presence of five different micro-organisms
in the intestinal secretions. As a rule, it is
alleged, it is hard to trace out the provoking
cause of enteritis. Often the patients state
that unwholesome food was taken, but fre-
quently they cannot account for the condi-
tion. It is always unknown, the author
says, what was the condition of the intesti-
nal tract previous to the manifestation of the
series of symptoms and — what is very im-
portant— what was the condition of the
foods thought to be wholesome.

Three hundred and four cases of acute en -
teritis are mentioned which the author
treated in his hospital. In sixty-five cases
of those, the affection was traceable directly
to the quality of the food used, and seven-
teen cases of the sixty-five had decided al-
buminuria. In the cases of enteritis without
any traceable cause, albuminuria was not
marked, in either per cent, or amount; in
cases with chronic kidney affections the al-
buminuria was increased, and there was a
decided acute renal exacerbation during the
attack of enteritis. The number of post-

482

Notes and

Comments.

Vol. lxiv

mortem examinations of the patients who
succumbed to the enteric attacks convinced
Netchseff that the kidneys suffer more or
less, and the food is considered to be the
source of the supply of poison to the sys-
tem in general. In a few cases indican was
found to be present simultaneously with al-
buminuria in enteritis. As indican appears
usually during decomposition of matter es-
pecially in the small intestine, and as the
presence of indican coincides with tempo-
rary albuminuria in enteritis, it is evident
that both are provoked by decomposing
matter in the intestine.

Netchaeff concludes by saying that the
acute exacerbations of renal disease during
an enteric attack rarely passes off without
leaving some impression on the already af-
fected kidneys, and that in some patients
who have not the choice of their food cer-
tain renal affections could probably be traced
to the latter.

Ways in which Syphilis may be
Spread.

Dr. Holcombe writes in the Internatio?ial
Dental Journal: "I recollect an instance
that occurred on board the same ship with
Horace Greeley's wife. Her little child
was taken up by a stranger and kissed. The
mother took the child from him and said :
' Sir, I do not allow you or anybody to kiss
my child.' She took her handkerchief and
spat on it and rubbed the lips off. This
kissing business is often perfectly terrible in
results. Some nurses kiss a child on the
lips, and kiss it on the nose and ears and
kiss it all over : and I have not the least
doubt that syphilis is conveyed to many in-
nocent persons by this habit. I should like
to ask if the dry powder of syphilitic chan-
cre, having been rubbed off, like vaccine
virus, and blown through a room, would,
by being inhaled, be the means of commu-
nicating syphilis. I heard Ricord once say
that many cooks would communicate syph-
ilis to a whole family ; the cook would have
a sore on his lip and would not think any-
thing about it, and he would taste the differ-
ent dishes and put his fingers into them —
and all know the French cook has a habit
of handling the meat with his fingers — and
many people undoubtedly have contracted
syphilis from food handled by cooks. It
was the old-fashioned way in hotels to have
the towels on a roller for the common
use of guests, and I remember once on a

steamboat there was a tooth brush for the
whole crowd. I have no doubt that .tooth
brushes sometimes used by several younger
members of a family have been the means
of communicating syphilis. I have had
many patients come to me and say that
they caught the disease from a water-closet,
and I have no doubt that many cases of
gonorrhoea and syphilis can be thus commu-
nicated. I think they should be under di-
rect sanitary inspection, just as much as the
foul air that comes from the sewer. Not
long ago I was in a cigar-maker's establish-
ment and I noticed that every cigar-maker,
when he finished the end of a cigar, wet the
forefinger and thumb with his lips to point
it nicely. I wondered at the time if he had
a lip-chancre ; and I question if the disease
has not been given to many persons in that
way. I know of a case where, a few days
ago, a lady kissed every female in the room,
and one of the persons in that room I know
had syphilis. Some people make a business
of kissing everything, kissing animals, birds,
dogs and cats, and it is very suggestive of
the transmission of disease. The habit of
putting money into the mouth, that some
people have, is one that might lead to syph-
ilitic infection. A butcher or grocer will
often hold a half dozen bills in his mouth,
and grown people will put silver pieces and
pennies into their mouths ; and I have won-
dered that the habit has not been more pro-
ductive of disease than we have observed. At
all events it is well to have our attention and
that of the public called to the means of
contracting syphilis and other diseases." —
Druggists'1 Circular, March, 1891.

Burial of So-called Stillborn Chil-
dren.

The Lancet, March 21, 1891, calls atten-
tion as follows to a matter of importance in
this country as well as in Great Britain.
" The question recently asked by Dr. Cam-
eron in the House of Commons respecting
the interment of stillborn children, and the
reply of the President of the Local Govern-
ment Board, call for more serious attention
than it is likely to receive. Dr. R. Rentoul
has just issued a pamphlet in support of his
active opposition to the Midwives' Regis-
tration Bill, in which he states that he has
ascertained by personal inquiry that during
the year 1889 there was interred in seventy-
one burial board cemeteries, as stillborn, the
bodies of 6,321 infants; and that there are

April 25, 1 89 1. Notes and Comments.

483

no fewer than 1,100 such board cemeteries
in England, in addition to the parish church-
yards, in which the proportional number of
this class of burials is supposed to be larger
than in cemeteries under the control of
burial boards. Dr. Cameron, knowing the
very loose and unsatisfactory system under
which stillbirths are certified for burial pur-
poses under the Births and Deaths Registra-
tion Act, 1874, asked the President of the
Local Government Board for a return of the
total number of infants interred as stillborn
during 1890 in England and Wales. The
answer to this question obviously suggested
by the facts of the case was that, as there is
no system of registration of stillbirths in
England and Wales, it would be impossible
to furnish the return asked for. It is seri-
ously to be regretted, however, that the im-
portance of this subject, from many points
of view of deep public interest, did not
suggest the possibility of providing some
remedy for an evil which amounts to a grave
public scandal, rather than suggest the as-
sertion of a simple non possumus, a position
too readily assumed by Government depart-
ments as a foil to suggested reforms. It is
needless now to enumerate the many evils
that arise from the present loose system of
certification of stillbirth; but we may point
to one which is but too likely to be over-
looked— its effect upon vital statistics which
constitute one of the most powerful and
stimulating factors of health progress. Vital
statisticians have in recent years been startled
by the constantly rapid decline of birth-rates
and of death-rates. It is obvious that so-
called stillborn children are not recorded
in the birth or death registers, and in the in-
terests of trustworthy statistics, it is there-
fore of real importance to know what truth
there is in the assertion of the amount of
interment of so-called stillborn infants that
is going on around us, practically unknown
and unchecked. The results of Dr. Ren-
tour s private inquiries are striking enough
to call for Government inquiry ; and there
seems to be only one real difficulty in the
way of such an inquiry. This difficulty is
the apathy of the Government in the matter.
All burial grounds and all burial authori-
ties are, it is supposed, under some kind of
control exercised by the Home Office. Why
then should not the inquiry, so urgently
needed and called for, be undertaken by the
Home Office ? and why should not all burial
authorities be required to furnish annual, or
more frequent, returns, showing the number

of burials of so-called stillborn infants, ac-
companied by the actual certificates which
the Births and Deaths Registration Act,
1874, requires, as authority for the burial of
any child as stillborn ? Such a course
would supply the means for a kind of regis-
tration of stillbirths, and would also prove
a real check upon the gross abuses of the
present system, which are very generally
known to exist."

Ichthyol Varnishes.

In speaking of ichthyol as an external
application, a reviewer in the British Jour-
nal of Dermatology, April, 1891, says :
One great disadvantage in regard to the
employment of ichthyol to limited areas
of disease has been the impossibility of
applying it in any way that was at once
easy and efficacious. The pure drug,
apart from its unsightliness and objec-
tionable odor, will not dry, even if spread
in a thin layer, but remains for hours moist
and sticky, and the various combinations
with dextrin, gum and gelatin-glycerine
paint have been found in practice to be in-
efficacious. Ichthyol collodion promised
better, but the irritation which is caused by
removing it is such as to more than counter-
balance its beneficial effects. In the case, of
patients who are only able to follow out
treatment at night the removal of these firm
adhesive layers each morning, therefore,
renders their employment impossible. In
order to overcome this difficulty and to pro-
duce an impermeable layer of ichthyol,
which could be easily and quickly removed
without irritating the skin, Unna instituted
a series of experiments in conjunction with
Dr. Helmers, and arrived at the following
formula, which he finds to answer his pur-
pose fully : —

Ichthyol 40 parts (by weight).

Starch 4° parts.

Albumin solution concen-
trated about I-IJ^ parts.

Water . . ad. 100 parts (z. e., about 20 parts).

The constituents must be mixed in defi-
nite order, the starch must be moistened
with the water, the ichthyol then rubbed
well in, and finally the albumin must be
added. The concentration may be regu-
lated by the thickness of the layer, the first
application being wiped off with a moist
cloth so as to leave the finest possible coat-
ing. Even a thick layer drys very rapidly,
and can be washed off at any moment.

484 Notes and

An ichthyol-carbolic acid varnish having
the same properties can be made in a similar
way, but, of course, with the omission of
the albumin. The formula is : —

Ichthyol .25 parts.

Carbolic acid 2.5 "

Starch. 50 "

Water 22.5 "

The ichthyol and carbolic acid are dis-
solved in the water in a gentle heat, and the
starch then added.

The first preparation, vernisium ichtliyoli,
is recommended in acne where the skin is
irritable, in rosacea seborrhoica, and in ros-
acea simplex, in ulerythema centrifugum
(one form of "lupus erythematosus"), in-
tertrignes, tubercular eczema, seborrhoic ec-
zema and erysipelas. It may with advan-
tage be made a basis of other reducing and
antiparasitic substances, such as chrysarobin
(2.5 per cent.), which may in this form be
applied with confidence to the face, pyro-
gallol, resorcin and sulphur, .for the treat-
ment of parasitic diseases, such as certain
eczemas and psoriasis. But in this case it
is better to mix, for every quantity of new
substance added, an equal quantity of lin-
seed oil, which is at once a reducing agent
and a rapid seccative.

Bad Effect of Poultices for Spreading
Ulcers.

Surgeon R. Ross, of Bangalore, writes in
the Indian Medical Gazette, March, 1891,
that in October and November, 1889, being
then in Upper Burmah, previous to proceed-
ing on the Chin Lushai expedition, he had
the opportunity of treating a large number
of cases of spreading ulcer on the feet of
mule drivers attached to the force. These
ulcers were of an alarming nature, spreading
rapidly sometimes to the size of a saucer
and even burrowing between the bones.
Several deaths occurred in neglected cases,
and in one case amputation of the foot was
necessary. The sores were evidently mi-
crobic, and were of the same nature as the
spreading sores on the backs of some of the
mules. Flies probably carried the infection,
but the mules' hoofs appeared, by the result
of kicks, to be much imbued with the poison.
The sloughing action implicated as a rule
only the true skin, and in one night a quarter
of an inch of tissue would be destroyed. The
treatment was at first the usual — nitric acid,
hot poultices and opium — but in many cases

Comments. Vol. lxiv

Dr. Ross was obliged to leave off the hot
poultices owing to the great pain they
caused. In a few of his last cases he was
astonished to find that the sloughing ceased
when the sore was dressed simply with a wet
piece of, lint placed upon it. At the same
time he was informed by the Veterinary Sur-
geon of the expedition that those mules
whose sores were left undressed often recov-
ered marvellously.

At the end of June last, Dr. Ross was
called to see a woman, sixty-nine years old.
She was suffering from two bruises, one on
the right shin, the other on the inside of the
left ankle. The skin over both bruises had
mortified to the size of a shilling. The
wounds long remained in a quiescent state,
being only lightly brushed with oil. At
last, in order to stimulate them, hot poul-
tices were ordered. The skin now rapidly
broke, showing a foul ulcer beneath. They
were both cleaned out with pure carbolic
acid and poultices were continued. The
upper and slighter wound healed shortly,
but the lower spread in resistance of fre-
quent carbolic acid swabbings. At last,
when the ulcer had become two and one-
half inches in diameter, nitric acid was ap-
plied to the sloughing tissue (there was a
white, evidently microbic, infiltration of the
true skin causing the slough). The neigh-
boring parts were perchloridized, and car-
bolized charcoal poultices were applied.
Next day Dr. Ross found that the sloughing
had continued as if nothing had happened.
Moreover, a minute drop of acid had fallen
from the pipette on to the healthy skin one-
half inch from the edge of the wound. The
sloughing had commenced in this spot also.
This did not argue well for nitric acid.
Finally, in despair, he determined to leave
off the hot poultices ; and the sloughing
action ceased from the moment the last
poultice was taken off, and -the ulcer com-
pletely healed. Dr. Ross thinks that the
nitric acid failed for one or both of these two
reasons: 1, it is known that microbic infil-
tration is often very extensive in the neigh-
borhood of microbic lesions, so that the
destruction of tissue by nitric acid would
have to be very great to be effective, too
great, in fact, for the present case ; 2, many
recent investigations have shown that micro-
organisms which may exist quite harmlessly
in the blood will immediately attack an in-
jured part, say a broken bone. It is obvi-
ously useless, therefore, to apply nitric acid
to a wound when the malignant organism

April 25, 1 89 1. Notes and

Comments.

485

comes from the blood itself. In this case
the fallen drop of acid itself immediately
started a new circle of disease. The reason
why poultices may be bad is that they main-
tain exactly the conditions of warmth and
moisture necessary to the growth of the path-
ogenic organism.

Tuberculosis Treated with Hypo-
dermic Injections of Iodoform
and Guiacol.

Dr. Picot, Physician to the Hopital Saint
Andre, Bordeaux, at a recent meeting of the
Academie de Medicine, Paris, read a long
and highly interesting paper on the above
subject, the following abstract of which is
taken from the Medical Press, March 25,
1891.

For the last two months the author had
been making experiments at his Clinic in the
Hopital Saint Andre, at Bordeaux, on the
treatntent of phthisis, but before proceed-
ing to describe the treatment he followed,
he wished to declare that he did not bring
forward a cure for the disease, for in his opin-
ion, and in that of his colleagues, the day
has not arrived when it might be affirmed
that an infallible remedy for pulmonary tu-
berculosis has been discovered. There are
patients, with whom no treatment will suc-
ceed, for no therapeutic methods could re-
organize lungs that have been destroyed by
the ravages of the disease. Lately an ex-
ample of the absurdity of therapeutic con-
ceptions pretending to cure tuberculosis in a
general sense has been before the world.
Dr. Picot was much more modest in his pre-
tensions, and desired only to relate the re-
sult of his treatment of pulmonary tubercu-
losis and pleurisy of the same origin. He
would remind his colleagues that, as the il-
lustrious Trosseau had affirmed, pleurisy is,
in the large majority of cases, of tubercu-
lous origin. The therapeutic agent which
he was bringing before his colleagues was a
mixture of iodoform, guiacol, olive oil and
liquid vaseline. The solution is perfectly
transparent, and each hypodermic syringe
contained one-fifth of a grain of iodoform
and one grain of guiacol. The liquid as
indicated was employed in subcutaneous in-
jections, and the position chosen was the
supra-spinal fossa as it is a point free from
any compression.

The first condition, said the author, which
imposes itself on the therapeutist in the use

of an agent, is not to do any harm, pri??io
11011 nocere is the old adage, and which ought
to be respected even in this daring age. He
affirmed then at the outset, that the injec-
tions of the liquid gave r^e to no evil con-
sequences, neither locally nor generally. At
the point of injection no redness or swelling
occurs, nor is the part painful. The ab-
sorption of the medicine is proved by the
fact that it appears in the urine not, how-
ever, as iodoform, but as iodide of potas-
sium, on the third day after the injection.
As to the general effects of the injection,
they were never hardly noticed except when
the patient had fever, and then appeared as
profuse sweating over the whole body, which
set in about a half an hour after the injection,
and lasted one or two hours. When past, the
patient felt a Men etre, and the fever lowered
one degree. Examining the therapeutic ef-
fects of these injections, Dr. Picot said that
all his experiments were made openly, be-
fore all his students and several army and
navy doctors, so that all was done above
board. Twenty-five patients were treated
up to the present, of whom fifteen were
men and ten women, of this number three
succumbed, as they were in the last stage of
consumption, the fever in no way being
abated by the injections, but each of them
expressed themselves as better for the treat-
ment, and the expectoration diminished
considerably in quantity. The post-mortem
showed, however, the good effects of the
injections in the fact that the vomicae were
found dried up, the caseous secretion was
entirely absent. All the other patients were
in the second stage of the malady. One of
them, a man, 54 years old, entered the hos-
pital in October last. His father died from
consumption. This man had coughed for
the last year. On examination, the chest
showed dulness in the subclavicular regions
on both sides, and on the right side sibilant
rales ; bacilli were discovered in the expec-
toration. The injections were commenced
in January, and immediately the patient felt
better, the expectoration diminished and the
body gained in weight. At the end of a
month sonosity was well marked at the seat
of former dulness, and all rales had disap-
peared, while the respiration became nor-
mal. A week subsequently the man left the
hospital in a very encouraging condition.
The injections were made every day, at the
dose of three syringes.

Another patient, 35 years old, entered
the hospital in the middle of January, four

486

Notes and Comments.

Vol. lxiv

years previously he had a pleurisy, which
lasted two months, last year he had the in-
fluenza and coughed ever since. He was
very emaciated and suffered from night
sweating and fever. He spit a great deal,
and bacilli were found in the expectoration.
Auscultation revealed the existence of skodic
murmur on the right side and dulness and
rales in the third intercostal space. On the
left side broncophony was noticed and other
symptoms, leaving no doubt of the charac-
ter of the affection. On January 20, the
injections were commenced at the dose of a
syringe a day, forty-eight hours afterwards
the expectoration diminished by two-thirds.
Three injections daily were then practiced
with the result, that in a week the patient
expectorated no more, and the cough had
totally ceased. On February 9, he quitted
the hospital quite satisfied, although the
skodic murmur persisted, all rales had
ceased and sonosity had returned in the
points *of dulness. After passing more
briefly in review several other cases which
terminated in a similar satisfactory manner
Dr. Picot said that, although the results must
be admitted to be very encouraging, he was
far from pretending that he had discovered
a cure for the disease. It is well known
how reserved one ought to be in such cases,
and how difficult it is to affirm that a patient
is cured. In order to be sure of it, the case
should be closely watched for years. But
with the treatment he had been following
for the last three months, he obtained such
results as to lead him to believe that it was
possible to arrest the progress of the disease.
In any case for the thirteen years that he
had been teaching medicine in the Bor-
deaux Faculty, he never arrived at the suc-
cess he has experienced by the treatment he
had just explained. By these injections the
general condition of the patient was greatly
improved, the expectoration and the cough
ceased, as well as the fever and the night-
sweats, and the vomicae in certain cases
dried up, all crepitation disappearing. Is it
a cure, asked, in conclusion, the author?
Time alone can tell, but up to the present
he was happy to have been able to give
some hope to so many unfortunate patients.
The formula used is as follows :

R Iodoform grs. vj

Guiacol grs. xxxij

Olive oil g iv

Liquid vaseline 5 iv

A hypodermic syringe of this solution <
contains one-fifth of a grain of iodoform. ;

and one grain of guiacol. One to three in-
jections daily.

Diagnosis of Whooping-cough with
a Tube in the Trachea.

Dr. James Finlayson, physician to Glas-
gow Western Infirmary, reports in the Ar-
: chives of Pediatrics, April, 1891, the fol-
lowing interesting case. A boy, six years
old, was admitted to the Royal Hospital for
Sick Children, Glasgow, on November 6,
1888. He was in such distress from urgent
dyspnoea, due obviously to laryngeal ob-
struction, that in about an hour after his ad-
mission tracheotomy was performed by Dr.
Hector C. Cameron. The breathing was at
once relieved. After the operation the boy
seemed to do well enough, but he continued
to have a very troublesome cough, which was
supposed to be connected, in part at least,
with the irritation of the tube, etc. On the
eighteenth day the tube was removed, and he
did well enough without it. The cough still
continued. After the removal Of the tube
the peculiar character of the cough began to
excite suspicion, and in three days the re-
semblance to whooping-cough became so
great that his removal to the isolation ward
was ordered ; in another three days the di-
agnosis was complete, and he was removed
to the whooping-cough wards of the Fever
Hospital, on November 30. The report
from there was that the case proved to be a
mild one ; the tracheotomy wound healed in
a few days, and he was dismissed well on
January 12.

Inquiry of the parents elicited the fact
that others in the family, as well as this boy,
were affected with a cough, which, after the
patient's admission, had developed the char-
acter of whooping-cough in them also.

The case was, no doubt, one of whooping-
cough, complicated with laryngitis, suddenly
presenting a grave form of obstruction. The
idea of whooping-cough never entered my
mind till after the tube was removed from
the trachea, although the irritating sound of
the coughing, with the air rushing through
the tube, was heard repeatedly, and its cause
could not be ascertained on physical exami-
nation of the chest. Of course the pres-
ence of a tracheotomy-tube necessarily in-
terfered with any manifestation of the spasm
of the glottis, on which we rely for the most
characteristic sign of this disease. The
effect of the tube completely misled the di-
agnosis.

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THE

MEDICAL AND SURGICAL
REPORTER

No. 1783.

PHILADELPHIA, MAY 2, 1891. Vol. LXIV.— No. 18.

Clinical Lecture.

COMPLETE PROLAPSE OF THE
WOMB, BLADDER AND VAGINA,
TOGETHER WITH AN EPITHE-
LIOMA OF THE LATTER.— PARO-
VARIAN CYST.— ADHERENT PLA-
CENTA.

BY WILLIAM GOODELL, M. D.

PROFESSOR OF GYNECOLOGY, UNIVERSITY OF PENNSYL-
VANIA.

Gentlemen : — The first case I bring before
you is that of a woman who has come from
a distance to see what can be done for her.
She is sixty-three years of age and has been
a sufferer for a longtime. Her condition is
truly distressing. In merely taking a glance
at her, I can see that she has an arcus senilis,
and that the calcareous degeneration of her
blood-vessels is quite marked. Moreover,
she is emaciated and broken down.

Upon inquiring into her history more
closely, I find she has been married,
when she was a young woman ; that her
husband is still living ; that she never has
had any children ; and, that her genital or-
gans have been in this prolapsed- condition
since she was a girl. Cancers of the cervix
generally come from lacerations, which
latter, from being the seats of fun-
gous degeneration, become worse and
worse, until malignant disease is devel-
oped ; so that old maids have fibroid
tumors ; mothers have epitheliometa, and
sterile wives have ovarian or tubal disease.
Of course, these statements are very broad
ones, and are subject to many exceptions.

In the present instance, the facts that the
bladder is completely prolapsed and that the
urine is constantly dribbling over the
vagina are the two main local causes
in the production of the epithelioma here
noticed; but I cannot tell to what extent
they have contributed to this effect, nor why
the growth is situated on the left inferior

wall of the vagina, as it now stands in its
inverted condition.

The pain that she has suffered from this
growth has not been very great nor has it
been constant ; because the vagina is not a
very sensitive part, nor is the cervix uteri.
Therefore, epitheliometa and such growths
on these parts are misleading; they
are often overlooked for a long time,
and the patient may allow them to go
on, until she is aroused to her condition
by the foetor, bleeding, and her more or less
impaired health; she then applies to aphy-
| sician who insists upon a thorough examina-
i tion and finds that the disease has so far
j advanced that he can do but little beyond
! rendering the balance of the patient's life
more comfortable.

When the disease occurs within the
uterus, the amount of suffering occasioned
may be truly distressing, and it is useless to
restrain the patient from the free use of
opium or from anything else that may af-
ford relief. (The patient was here re-
moved.)

In dealing with this woman I told her the
truth and nothing but the truth ; yet I did not
tell her the whole truth, because I was afraid
1 that the shock and the distress occasioned
I thereby would be too great for her. I in-
i formed her that she had an epithelioma, and
that any operation at her age would be
I almost useless.

I My treatment will be to apply to the foul-
; smelliug surface, a piece of lint or cotton,
I wrung out of a one to four thousand solution
of the bichloride of mercury, in order to
lessen the danger of systemic poisoning, and
also, to destroy the fceted odor. The stench
that clings to the hands of the surgeon from
I merely being in contact with such diseased
structures is truly disgusting, and the method
I resort to in my own person to destroy it,
I is this : I begin my course of disinfection by
j washing my hands in soap and water ; I next
wash them in turpentine, ether or alcohol, —
whichever one happens to be most conven-
ient. I then give them another washing in

487 '

488

Clinical

Lecture.

Vol. Ixiv

soap and water, and finish my course of an-
tiseptic cleaning by rinsing them thoroughly
in a one to five hundred solution of the
bichloride of mercury. All these precau-
tions should be taken in going from one
patient to another, lest disease germs be
carried, and we thus become the seat of in-
fection to those whom we wish to cure. The
clothes may also carry germs, so that they
should always be protected during our oper-
ations with gowns or aprons, which have
been rendered surgically clean for this pur-
pose ; or, what is best, let our outer garments,
at least, be changed, before going from an
infected patient to another.

In the present case, I shall advise that
it be suggested to her physician, so soon as
she returns home and is well rested, that he
apply to the ulcerated part, a solution of
fifteen grains of the bichloride of mercury in
one ounce of flexible collodion. This will
cause a slough, leaving a clean surface more
amenable to treatment than is the present
one. She is also to be placed on the use of
arsenic, beginning with one drop of Fowler's
solution and gradually increasing that
amount until she reaches as much as fifteen
minims after each meal, or until the stomach
rebels. The manner in which this drug ex-
erts its beneficial effect is by means of its
alterative action. Of course, I do not prac-
tically understand much about what this
means, but I do know from a long clinical
experience, that the remedy does good ; and
I can here recall the case of a man who sub-
mitted to numerous operations for an epithe-
lioma of the lip, and who was finally perma-
nently cured by a course of this medicine.

PAROVARIAN CYST.

The next case, is that of a woman, aged
forty-two years, who has been married eigh-
teen years, and has given birth to nine
children. Eighteen months ago she suf-
fered with aphonia, which must have been
the result of some nervous trouble. She was
also, a short time since, in bed for four weeks,
during which time she did not suffer much
pain, but, four times she managed to pass,
from the vagina, as much as a bucketful of
clear semen. After each, of the aqueous
discharges, the swelling of the abdomen
became less for a while, at least ; her
other symptoms subsided, and she became
very much better.

There is but one avenue from the abdom-
inal cavity to the vagina, and that is through
the Fallopian tubes. It is impossible to be-
lieve that the growth noticed in this
case is a tubal tumor ; because such tumors

are smaller, and give more pain than this
one has caused. Now, at times, an ovarian
cyst is communicable with the tubes, and
this will explain these repeated emptyings
and refillings, resulting, too, in so little sys-
temic disturbance. But, whatever it is, I
shall now begin a systematic examination, in
order to find out.

In the first place, I must decide whether
the abdomen is enlarged from the presence of
something really within and distending it,
or whether this enlargement be merely
owing to increase of fat in the abdominal
walls. This latter fact is always to be borne
in mind, because it is a rock upon which
young physicians sometimes go astray.
About the climacteric, a woman begins to
dodge her periods, or to miss"them altogether.
She increases in abdominal size, and im-
agines herself to be pregnant ; if she be a
multipara, having the same signs and feel-
ings as she did at her previous pregnancies ;
or, if she be a primipara, experiencing them
with even greater, evidences than ever did her
more fruitful sisters. Arrangements are
made for the birth, which, however, does not
take place. The family is disappointed, and
the young doctor is mortified. This occur-
rence once happened in the life of an English
Queen, much to the disappointment and
even disgust of her political party, which
was looking to her for an heir. How, then,
am I to determine whether this enlargement
is from a distension within the abdomen, or
whether it is merely from a thickening of the
abdominal walls ? It is done in this manner :
I press with one hand deeply on one side of
the abdomen, and then strike the opposite
side with my other hand. I can feel the thrill
of the vibrations as they are transmitted
through the fat. But, by getting my as-
sistant to put his hand between mine, the
thrill that is transmitted only by the fat is
stopped. The vibrations in the substance
below, or through the underlying strata are
still transmitted ; but they are deeper and
they vary from the fat vibrations. The
difference in the time or intensity of the'
transmissions of the vibrations helps me to
tell also whether I am dealing with a fluid
or a solid tumor ; because the speed or fine-
ness of the thrill varies according to the
solidity of the transmitting medium. This
helps me to exclude a solid tumor, apart
from the common senses of touch and of
feeling ; apart from the double touch, or the
necessary consideration of the much more
serious symptoms which a solid tumor of
any kind would cause.

After arriving at the fact that I have a

May 2, 1 89 1

Clinical Lecture.

489

liquid to deal with, I next have to decide
whether there is a cyst or whether the fluid
is loose in the abdominal cavity. I proceed
to find this out by this mode of reasoning:
If the fluid were loose, there would be dull-
ness in the flanks, as the woman lies on her
back, owing to the liquid seeking the low-
est position. On the other hand, I would
find resonance — as I do in this case — in the
umbilical region ; because the buoyant
intestines would be floated up from below.

Examining per vaginam, I find that there
is a small tear on the right side of the
cervix. The womb is freely movable
and measures plus three inches. Therefore,
there is no solid tumor, and not finding any
remnants of an ovarian cyst, I can yet state
that I have made my diagnosis by finding
nothing.

There is but one affection that would pre-
sent itself as the diagnosis in this case, and
that is a parovarian cyst. A parovarian
cyst! you say, and what, pray, is that? As
yet I am unprepared to answer this question
with complete satisfaction to myself ; but I
know that it is thought to be a dropsy of
one or more of the tubes of the parovarian.
This word means near the ovary, and the
name is given to several tubes on each side,
which lie between the ovary and the Fallo-
pian tubes. When one of them becomes
cystic, the tumor may cause some pressure
upon the ovary and give pain. It contains
fluid as clear as spring water. It is highly re-
fractive and greatly magnifies any object
placed in the bottom of the vessel contain-
ing it. Just here I recall the case of a wife of a
physician who had one of these parovarian
cysts. It burst seven different times, causing
a general collapse, together with the dis-
charge of a large quantity of urine. It was
finally removed by me. I would also mention
that the fluid in the case of this tumor was
slightly greenish. When these cysts col-
lapse they generally leave nothing that can
be felt because their walls are so thin. When
tapped they may not return, but gen-
erally they do and in time they have
to be removed. Sometimes this removal
can be effected without disturbing the
ovary on that side ; but usually the ovary
is also implicated and has to be removed at
the same time. The argument advanced for
the removal of this growth is that there is a
tendency in some cases for it to become a
papillary carcinoma, especially when tapt'.

ADHERENT PLACENTA.

The next and last case which I shall
bring before you to-day, is a woman, who
was delivered of a foetus, two months aeo,

and since then she has suffered with met-
rorrhagia, owing to the adhesion of parts of
the placenta, which were not removed at the
time of confinement.

The ^ womb measures plus three inches.
There is now, and has been, since the labor,
considerable bleeding, so I very carefully
introduce my fenestrated forceps into the
cavity of the uterus and upon removing
them, I bring out a piece of the placenta.
This immediately stops the bleeding. I
now re-introduce the forceps and succeed
in getting out another piece of the adherent
membrane.

The placental tissue has had during these
two months a vital connection, and has,
therefore, not undergone putrefactive
changes. I have removed a scroll-like pla-
centa after seven months, and have found it
undecomposed, because it had been all the
time adherent.

My first measurement of the uterus gave
me a plus three inches. It now measures
four inches. The womb is larger than what
it first seemed. Previously, when I intro-
duced my sound, it rested on a piece of the
placenta, which I have now removed.

If it be necessary to tampon in this case,
I shall plug the cervix — not the vagina —
with iodoform gauze, leaving a little piece of
it protruding, by which the tampon can be
withdrawn at any time. I shall not tampon
if I can avoid it, because tamponing inter-
feres with the firm contraction of the uterus.

Be sure to have a fenestrated forceps
among your instruments. It is especially
valuable after criminal abortions, in which
cases, parts of the placenta are so often
left adherent for the following reason : In
natural abortions the ovum becomes, or
rather has become, a foreign body, it has
been detached from the endometrium ; but
in criminal abortions the foetus comes away,
but parts of the membrane remain at-
tached to cause hemorrhage and septicaemia.
I often compare the results of a natural and of
a criminal abortion with the falling off or
dropping of a defective apple, or one that has
been stung by an insect, to the violent tearing
off of a green apple. The one drops off ; the
other is broken off. The one has its con-
nection severed by nature's amputation, dis-
ease ; and is removed so gradually that the
parent stem does not suffer. Whereas in the
latter* case, the fruit is violently torn from
the tree and a bleeding branch is left.

Gum.chewers' cramp is a muscular inco-
ordination similar to the cramp of writers,
telegraphers, etc.

490

Clinical Lecture.

Vol.

XIV

EMPHYSEMA—GRIPPE AND ITS
COMPLICATIONS.— CHRONIC
HYPERTROPHIC CIR-
RHOSIS OF THE
LIVER.

BY FRANCIS DELAFIELD, M. D.

PROFESSOR OF PATHOLOGY AND PRACTICAL MEDICINE
AT THE COLLEGE OF PHYSICIANS AND SURGEONS,
NEW YORK.

Emphysema.

Gentlemen: I present to you to-day a
man 52 years old, a laborer by occupation,
who says that he was in good health and
able to do his usual work until six months
ago, when he began to develop symptoms of
catarrh of the nose and throat, and, also,
some bronchitis. He has a cough, com-
plains of. dyspnoea on exertion, and has pal-
pitation of the heart. From the time he
speaks of, that is six months ago, he has been
getting steadily worse, and has been losing
considerable flesh and strength.

On observing this man, we find that he is
badly nourished, and has the expression of
a person who is suffering from some real ill-
ness. Examination of the lungs gives us
the physical signs of emphysema, with pleu-
ritic adhesions over the top of the left lung.
His heart is distinctly hypertrophied and
dilated, but I can find no murmur present.
He has a large heart, perfectly regular and
forcible enough in its action and, if any-
thing, a little exaggerated. There is some
thickening of the radial and temporal ar-
teries. He has a full and rapid pulse, but
without any increase in tension. His urine
has been examined a number of times, has a
specific gravity of 1017, but contains no al-
bumen.

The diagnosis of this man's trouble is by
no means clear to me. He has evidently
emphysema, but emphysema of itself is not
sufficient to account for his present condi-
tion. There is no apparent change in the
valves to any considerable extent, there is
no evidence of any kidney lesion, no con-
traction of the arteries, nothing in fact very
obvious to account for this marked increase
in the size of his heart.

We might suppose this patient to have a
chronic nephritis, but he should then have a
heart simply hypertrophied, and not dilated
and hypertrophied at the same time. We
might suppose he has a chronic endo-arteritis,
but then also there would be hypertrophy and
not dilatation. Though his heart is increased

in size, his circulatory system is little, if any,
changed. The pulse of this man seems to
me to point to some febrile movement, and
I should be inclined to think the real cause
of his illness is one of those irregular fevers
that belong to New York and its vicinity,
and which sometimes continue for a con-
siderable length of time. I would imagine
the best thing for this man to do would be
to go into some hospital where he would be
put to bed and taken care of. The medi-
cine which we usually give for such cases, if
it should turn out to be one of continued
fever, would be Warburg's Tincture, either
in the form of the tincture or of capsules.

Grippe and its Complications.

The next patient is a man aged 39, who
has evidently been suffering from an attack
of the grippe, which began about a week ago,
and he is not apparently free from it yet.
The form which the disease has taken with
him, has been of the ordinary character. He
had first a fever, with frontal headache,
which is quite characteristic, and an inflam-
mation of the pharynx. He also had a
feeling of depression, and was confined to his
bed for some time. Although the first
symptoms of the attack have passed away,
he is still suffering, as many of those patients
continue to do after the acute stage of the
disease has passed.

The irregularity of this man's heart ac-
tion is, I think, the result of the grippe.
Probably, before the attack, he had a heart
somewhat enlarged and perhaps not per-
fectly regular, but still it was a heart that
gave him no trouble. He was able to work
and felt tolerably well. Just before coming
to this clinic I saw an old gentleman who
had developed the same cardiac condition
from the same cause as this man has. He
was 70 years of age, and previous to the at-
tack had enjoyed good health and had no
idea there was anything the matter with his
heart. He had an attack of the grippe two
weeks ago, and as a result of this, his heart,
which was somewhat large, has been doing
its work very badly indeed, so that he was
unable to lie down in bed without being
propped up with pillows.

This is one of the many disagreeable
features of this particular disease. It seems
to evoke diseases which had been quiescent
and had given the patient no trouble till its
onset. These cases of grippe should, I think,
be handled with a great deal of caution
when the disease manifests itself with any
great degree of severity. I confess that this
year I think very much more seriously of

May 2, 1 891.

Clinical

Lecture.

491

the disease than I did last year when it first
made its appearance in our midst. Of
course, the very worst feature of this affec-
tion is the pneumonia, which accompanies it ;
and, although having all the clinical char-
acteristics of the pneumonia of last year, it
is, however, of so much more fatal character
that I consider it extremely desirable on the
part of the patient, the moment he feels an
attack of the grippe to go at once to bed and
stay there till the fever has entirely disap-
peared ; and even after that to wait a few
days before he undertakes to do any kind of
work. In this way he is less apt to have a
complicating pneumonia than if he were to
be up and about.

The type of the pneumonia that accom-
panies the grippe this year is characterized by
an excess of bronchitis and an inability of
the right heart to force the blood through
the lungs. As a result of this condition of
affairs the patient very soon develops a sibi-
lant and sonorous breathing over both lungs,
then coarse and subcrepitant r&les, and he
does not cough up very much mucus. As a'
result of this, the bronchi soon become filled
with mucus, and the inability of the right
heart to force the blood through the lungs
shows itself in a general venous congestion
which becomes more and more marked, and
the patient's breathing, as a result of these
conditions, becomes worse and worse, and so
he goes on till he finally dies. A great
many patients die in this way the first
twenty-four hours after the attack of the
pneumonia, while others last three days or
more before they succumb to the disease.

Such cases of pneumonia are made even
still more, unsatisfactory for the reason that
the ordinary means of treating this con-
dition are of such little avail. Generally
speaking, a general bronchitis can be re-
lieved a good deal by efficient cupping, but
this procedure is of no use whatever in the
bronchitis of these patients. In ordinary
cases of pneumonia cardiac stimulants have
been found useful while in these cases their
influence counts for nothing. A combina-
tion of venous congestion and feeble heart
is usually beneficially affected by hypo-
dermics of nitro-glycerine, but in many of
these cases of pneumonia nitro-glycerine is
of no use whatever.

So you can readily see why I look upon
this complication of the grippe as such a seri-
ous matter, and why I advise you to take
every precaution against it ; and, as I have
already said, the moment you begin to have
the first characteristic symptoms of this af-
fection, tell your patient to go to bed and

wait there till he gets better, and not expose
himself to the danger of going out of doors.

Chronic Hypertrophic Cirrhosis
of the Liver.

The next patient I present to you came
here, for the first time, last December. Six
months previous to that time he complained
of pains in the back, his urine was yellow
in color and his stools white. He then
began to notice a lump in the hepatic region
and began to lose flesh and to develop some
jaundice. Since that time these symptoms
have become somewhat modified in char-
acter. His jaundice has diminished in in-
tensity and the skin of the face has assumed
that dusky, brown hue that you now see.
The general appearance of the man is not at
all very bad. The increase in size of the
liver is symmetrical and involves both the
right and left lobes, and these project down
into the abdominal cavity to a distance of
some twelve inches from the free border of
the ribs. The liver appears hard and nodu-
lar, but the spleen is of normal size, so that
the liver in its increase has not offered any
obstacle to the circulation of the blood
through that organ. The blood circulates
through the liver as usual and on that ac-
count we have no dropsy, and no enlarge-
ment of the spleen. This man then has a
condition of the liver known by the name
of hypertrophic cirrhosis.

The jaundice in this case is evidently of
an obstructive kind and due to one of three
causes, viz. : A calculus situated in the
common bile duct ; a chronic catarrhal con-
dition of the common bile duct, or a new
growth situated in its wall. We can, how-
ever, exclude a neoplasm as the causative
factor in this case, for he would, no doubt,
present a much worse condition physically
than he at present exhibits. The diagnosis,
therefore, rests between the other two con-
ditions, and we are not now in a position to
make a positive differential diagnosis. The
probability, however, is that this man has
been suffering all this time from a chronic
catarrhal affection of the common bile duct.

The question of treatment next comes up
for consideration. This patient has been
given cold water enemata and put on the
use of alkalies, but with no appreciable bene-
fit. The difficulty seems to lie in our in-
ability to exert a real local influence on the
catarrh of the bile duct. To bring about
that result I would recommend washing out
his stomach systematically and regularly
every morning, and, at the same time, giving
him better food than he has been in the

492

Communications.

Vol. Ixiv

habit of taking A change of climate would
also be very beneficial in his case. There is
one of the mineral waters which if taken in
its native soil, viz.: Ems, in Germany,
would prove of great benefit. If this patient
were able to go there- and take a systematic
course of the waters of Ems, I have not the
least doubt but that he would be very
greatly benefited.

Communications.

THE THERAPEUTIC USES OF
KAVA-KAVA.

BY DAVID CERNA, M. D., Ph. D.

ASSISTANT IN PHYSIOLOGY, UNIVERSITY OF PENN-
SYLVANIA.

Though not commonly employed at pres-
ent by the profession, Kava-Kava has a do-
mestic history suggestive of highly valuable
clinical properties. This entitles the drug
to serious consideration, and it seems that
the results obtained by various observers in
the treatment of a certain class of cases, war-
rant its further and continuous use in prac-
tical medicine.

In a previous experimental study,1 1 have
discussed the general physiological action of
this drug, and found that it powerfully af-
fected the circulation, exercising at the
same time a stimulating influence on the
respiration and nervous system. The most
important properties of the plant, from a
practical point of view, were, perhaps, those
exercised on the mucus membrane, the liver
and the nervous system, the remedy being
especially a general and local anaesthetic
and a depressant of the spinal motor ap-
paratus. These actions have been noticed
also by previous observers.

In the present paper I will treat of the ther-
apeutic uses of the drug, with special refer-
ence to the literature of the subject which,
in itself, is interesting and instructive. I
will in the first place detail the following
cases in which gratifying results have been
achieved. With a view to determine whether
the effects produced would be attributed
solely to the influence of the drug, no
other treatment was applied in some of the
cases observed.

Case I. Gonorrhoea, S. G., age 19, dental
student, of bilious temperament, with good
family and previous individual history.
Contracted the disease four months ago.
Was under treatment since the appearance

1 The Therapeutic Gazette, January 15, 1891.

of the first symptoms. Had taken copaiba
and cubebs internally and for injections had
used solutions of acetate of lead, sulphate of
zinc and nitrate of silver. Very little relief
was obtained ; the painful micturition con-
tinued and the discharge, although not
abundant, was yet a source of much annoy-
ance and anxiety. Under my charge all
other general and local treatment was put
aside and the patient subjected to the use,
internally, of the fluid extract of the Kava-
Kava, fifteen drops three times a day. Am-
elioration was noticed in three days. In
two weeks the patient was entirely well.
The medicine was then suspended and no
return of the disease occurred.

Case H. Gonorrhoea, J. L. F., 24 years of
age, of nervous temperament, salesman bv
occupation, was suffering from a third at-
tack of specific urethritis of a few days'
standing. He said that the two previous "at-
tacks lasted for two and three months re-
spectively, the disease having finally disap-
peared under general and local treatment
and a rigorous diet. He complained of injec-
tions having been extremely painful. When
the patient was first seen by me the dis-
charge was abundant, and there was great
pain in micturition. No stricture was de-
tected, but there was undoubtedly a begin-
ning inflammation of the bladder. He was
immediately placed under Kava-Kava to
the exclusion of all other remedies. Dose,
t wenty drops three times a day. Relief was
experienced by the fourth day, with great
lessening of the discharge and the burning
pain on passing water. Improvement con-
tinued and at the end of the third week the
patient considered himself entirely cured.
There was no return of the malady for over
two months after the suspension of the drug.

Case III. Chronic Gonorrhoea with Cys-
titis. M. A. C, medical student, age twenty-
two, of a nervo-sanguine temperament, had
for nearly two years suffered from an old
case of specific urethritis complicated with
cystitis, as a result of a third attack of the
malady. The disease had never yielded to
the usual remedies. A careful examination
revealed no stricture, but the doubtless co-
existence of prostatitis and a considerable
cystitis. The discharge was scanty and
muco-purulent, and although not always
present there was, at times, great pain in
micturition. The patient was advised to
take Kava-Kava and to discontinue all
other treatment. He began to take the
drug immediately, and in comparatively
large quantities — thirty to forty drops three
times a day. In about two weeks great im-

May 2, 1 89 1.

Com m unications.

493

provement was noticed. All burning sensa-
tions had entirely gone, although the dis-
charge continued. This, however, dimin-
ished gradually, but did not entirely disap-
pear after two months' treatment. It was
noticed that the drug considerably increased
the amount of urine. The remedy was after-
wards combined with sweet spirits of nitre,
and although there was no stricture, the
passing into the urethra, twice daily, of a
sound smeared with belladonna ointment,
was recommended. In about four months
the patient, though not entirely well, re-
ported satisfactory progress. At present
(eight months afterwards) he continues to
take the remedy, with fair chances of com-
plete . recovery. The cystitis had disap-
peared and there was a notable reduction in
the size of the prostate gland. It may be
stated that this patient was somewhat care-
less about diet and regular habits, and this
circumstance, I think, has delayed a final
and more rapid cure. The drug has not
been taken with regularity.

The following two cases were kindly com-
municated to me by a practitioner to whom
I suggested the use of the remedy :

Case IV. A colored boy, eight years of
age, had been troubled with painful and fre-
quent micturition for over six months. Had
been examined carefully for calculous de-
posits, but no stone was found in the blad-
der, nor were there noticed any traces of
gravel. The urine was scanty in amount, pre-
sented a high specific gravity, 1030, and of a
decidedly alkaline reaction, but no albumen
or sugar was found in it. The microscope
revealed triple phosphates and a consider-
able quantity of pus corpuscles. By exclu-
sion the case was diagnosed as one of chronic
cystitis, and accordingly subjected to the
usual treatments. Benzoic acid, benzoate
of sodium and eucalyptol were employed,
but with negative results. No relief being
obtained by these and other measures, the
patient was put under the exclusive use of
Kava-Kava, in ten drop doses, twice a day,
with wonderful results in the course of two
weeks. A cure was effected in one month.
One of the actions of the drug in this case
was the notable increase of the quantity of
urine.

Case V. Vaginitis. A shop girl, twenty-
two years of age, of a sanguine tempera-
ment, single, but who had evidently fallen
from grace, presented all the symptoms of a
typical vaginitis as a probable sequence of a
previous attack of gonorrhoea. History im-
perfect but sufficiently clear. Said that she
had been under treatment by regular phy-

sicians for a long time but had obtained no
apparent relief. Had taken medicine and
used various injections, but all to no avail.
She was placed exclusively under the use of
Kava-Kava in doses of twenty drops, three
times a day. A change for the better was
noticed in about three weeks, and the abun-
dant and fetid discharge had lessened to
about one-half its original amount. The
treatment was continued, and in three
months the patient pronounced herself per-
fectly well. The medicine was then sus-
pended, and she was requested to report if
the disease should return. The case was
not heard of afterwards, and it is presumed
that the trouble did not reappear.

Other cases may be cited, but the short
number reported here, is sufficient, I think,
to corroborate the results obtained by other
practitioners, and to show that the drug pos-
sesses valuable therapeutic properties. Kava-
Kava is unquestionably of great service, es-
pecially in the treatment of the various in-
flammations of the mucus membranes, its
action in these instances being chiefly a
local one. There is no doubt that the drug
is also a general stimulant and tonic.

No deleterious after-effects have been ob-
served under the therapeutic action of the
drug, although in some cases it has been as-
serted to produce a slight constipation. It
further stated1 that when taken in excess as an
intoxicating beverage it produces a peculiar
skin eruption, known in Tahiti as areverea ;
and that, curiously enough, it has been used
with success in erysipelatous eruptions.

In the cases above described, the prepara-
tion used was the fluid extract in doses of
from ten to thirty drops, in water, three
times a day. The drug has no disagreeable
taste. Although other forms have been
used by various observers, the fluid extract
is the most reliable preparation. The remedy
may be given by itself, or in combination
with other drugs, such as sweet spirits of
nitre, glycerine, iodide of potassium, etc., ac-
cording to the indications of individual
cases.

Kava-Kava is not a new therapeutic
agent. Its value in the treatment of disease
has long been recognized by reliable practi-
tioners.

It was first recommended in gonorrhoea
as far back as 18572 and we are told that in
Nukahibi the natives use Kava-Kava, in
small doses and at bed time, in the treat-
ment of bronchitis and phthisis ; and even

1 Phawnaceutial Journal, IX, p. 218.
2Annal. de Therapeutic, 1857, p. 61.

494

Communications.

Vol. Ixiv

in gout, it has been recommended internally
and as a local application1.

An interesting physiological and thera-
peutical study of the drug was made several
years ago by Dupuy2 who found that the
plant was a sialagogue and that it acted
upon the stomach as a bitter tonic, improv-
ing the appetite without producing diarrhoea
or constipation, and acting perhaps as a
prophylactic to catarrhal affections of the
upper part of the digestive canal; that it
was a gentle excitant of the central nervous
system, a powerful diuretic and an excellent
blennostatic. The same author found the
resin of Kava-Kava to be exceedingly val-
uable in the treatment of acute urethritis
and vaginitis, relieving pain and diminish-
ing the secretion.

Leighton Kesteren3 asserts that the most
marked and valuable property of Kava is
its action upon the genito-urinary tract. He
found that the drug readily cured chronic
gonorrheal gleet, and that in chronic cys-
titis it possessed an influence superior to any
other remedy he had ever used.

It has been prescribed with flattering suc-
cess, by Edward Miller4 in suppurative
urethral inflammation. Four cases of cystitis
have been cured by the same author.

The best results in the treatment of acute
and chronic gonorrhoea have been obtained
by C. C. Switzer5 and J. P. Siddall.6 The
latter writer affirms to have cured also sev-
eral cases of leucorrhoea, where other reme-
dies had entirely failed.

A case of secondary gonorrhoeal inflam-
mation and four cases of acute and chronic
cystitis were cured by Kava-Kava after
other remedies had failed, according to the
report of R. A. French.7 The same results
were observed by J. P. Baird8 in a case of
rebellious urethritis, and in one of prostatitis,
accompanied with painful urination.

In cases of painful micturition, from what-
ever cause, no remedy has given better re-
sults in the hands of W. J. Holman.9

The most excellent results have also been

1 Medical Times and Gazette, December, 1854.
2Za Tribune Medicale, April 1879; also Deut.
Med. Wochenschr., No. 1, 1881.

3 The Practitioner, quoted by The Therapeutic
Gazette, May, 1882.-

4 The Lancet, quoted by The Therapeutic Gazette,
April, 1880.

hArew Preparations, April, 1879.

*New Preparations, August, 1879.

''New Preparations, July, 1879.

8 Therapeutic Gazette, May, 1880.

* Medical and Surgical Reporter, Sept. 25, 1880.

produced by the drug, in the treatment of
acute and chronic gonorrhoea, according to
the reports of Boardman Reed,1 W. Semple,!
J. M. Blackberry,3 and of the Charity Hos-
pital of New York City.4

Another observer states that the plant
produces a primary stimulating effect, in-
creasing the secretion of the mucus mem-
branes, afterwards acting as a tonic, improv-
ing the appetite and giving tone to the di-
gestive organs, and in this respect, acting
differently from copaiba and cubebs. This
has been the experience of Alfred Flies-
burg,6 who has successfully treated with the
drug, cases of cystitis and urethritis. He
further asserts to have obtained excellent
results in over a hundred cases of acute,
sub-acute and chronic bronchitis.

Six cases of stubborn nocturnal incon-
tinence of urine, where even belladonna
failed to produce any relief, were cured with
Kava-Kava, by C. N. Palmer.6 In dropsy
it has been employed with success by Her-
bert C. Rogers.7 According to Weinstein8
the good effects of the drug in cases of em-
physema and tuberculosis were manifested
against the dyspnoea. The same author
found it valuable in acute polyarthritis,
gonorrhoea, and catarrh of the bladder,
where the remedy seemed to act as an anal-
gesic. In small doses it was employed with
success in acute and chronic catarrh of the
stomach, in dyspepsia and cardialgia.

In carefully looking over the records of
cases published, I have been able to collect
a considerable number of well authenticated
instances, where not only improvement, but
a permanent benefit has been produced. I
subjoin the following tables in the hope that
they may be of some use to those interested
in the subject. In these tables, among other
features treated, statements are briefly made
especially in regard to the affections for
which Kava-Kava has been employed, to-
gether with the results obtained.

I do not pretend to have exhausted the
literature of the subject, but I have not, so
far, been able to find any other reports than
those referred to in this article.

1 The Therapeutic Gazette, February, 1882.

2 The Therapeutic Gazette, December, 1881.

3 The Therapeutic Gazette, May, 1881.

4 The Therapeutic Gazette, June, 1881.

5 The Therapeutic Gazette, April, 1883.

8 The Therapeutic Gazette, August, 1883.
» The Medical News, October, 1886.
6Z>euts. Medizinal-Zeitung, December, 1887.

May 2, 1 891.

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498

Communications.

Vol. Ixiv

To recapitulate, of the authenticated cases
treated with Kava-Kava, as reported in this
paper, there were :

Relieved — Gonorrhoea, 4 ; Cystitis, 1 ;
Dropsy, 2 ; Gleet, 1 ; in all 8 cases.

Cared — Acute Cystitis, 9 ; Chronic Cys-
titis, 2 ; Gonorrhoea, 6 ; Prostatorrhoea, 1 ;
Retention of Urine, 1 ; Gleet, 4 ; Urethritis,
with Cystitis, 1 ; Incontinence, of urine, 6 ;
Dropsy, 2 ; Vaginitis, 1 ; in all 33 cases.

Total forty-one cases.

It is thus seen that Kava-Kava, from
these statistics, is a therapeutic agent of no
inferior value, and worthy of further con-
sideration. Certainly it does not deserve
the neglect in which the remedy is at pres-
ent held by the medical profession.

THE EXPECTANT TREATMENT IN
CASES OF SUSPECTED SYPHY-
LITIC INFECTION.

BY HENRY BEATES, Jr., M.D.,

PHILADELPHIA.

Basse reau, father of the Dualist School,
wrote :

(1.) " If a person who has been affected with
chancres, followed by constitutional symp-
toms, is confronted with the person who gave
the infection, or with those to whom it has
been communicated, it will be found that all
such, without exception, have been affected
with chancres followed by constitutional
manifestations. The chancre is never purely
local.

(2). " On the other hand, if one who is af-
fected with a chancre which has not been
followed by any syphilitic symptom, be con-
fronted by the person who has caused the
infection, the former will be found to be the
bearer of a chancre which is entirely local
and which does not infect the constitution.
This admits of no exceptions.

" Thus no chancre which is followed by
constitutional symptoms gives rise to a
purely local sore, nor does a local chancre by
infection communicate an ulcer which is
capable of producing syphilis."

These cardinal truths, when first pro-
claimed, enabled clinical distinctions to be
made between the non-syphilitic lesion and
true chancre, and upon the ability to recog-
nize these respective lesions will treatment
be largely determined.

When the clinical characteristics of initial
lesions are typically pronounced, prognosis
and treatment are self-evident, but, unfortu-

nately, like typhoid fever, and, indeed, all
diseases, the departures are often so great
that it is frequently absolutely impossible to
diagnosticate the lesion, and here it is that
we hesitate how to act. To illustrate : A
patient two or three days after a suspicious
confrontation suffers from a multiple ulcera-
tive lesion. The time of development, char-
acter of abrasion, and clinical history, incline
to the belief that we have before us a chan-
croid. The sores are cauterized the patient
is told that he is free from syphilis and is
dismissed with the belief that he is suffering
from a simple ulceration, which, in ten days
will have healed and not be followed by
constitutional trouble. In six weeks this
individual probably returns because of a cold
and an eruption which are recognized as
the secondary phenomena of syphilis. The
practitioner consults works of reference and
consoles his mind with reading about a
mixed sore, and pacifies the unfortunate
syphilitic, and fortifies himself against criti-
cism, by showing the victim the paragraph
which affords such abundant diagnostic lat-
itude. Without further discussion of this
ignis fatuus — the mixed chancre — it is self-
evident that a true description of it is, a
venereal ulcer, the character of which
can not be ascertained ; if followed by
syphilis (and a favorable prognosis had
been given), " it was mixed," if not, " it
was no chancre at all," but what we
believe all chancroids are : Simple venereal
ulcers.

It may not be amiss here to describe the
sores which are not followed by syphilis and
those which are. I will use term simple ve-
nereal ulcer for chancroid, and chancre for
the specific, hard, or Hunterian lesion.

SIMPLE VENEREAL ULCER.

1. No period of incubation.

2. Originates from similar lesion or pus
from bubo.

3. Multiple and confluent.

4. Auto-inoculable.

5. Begins as a vesico-pustule.

6. The lesion is an ulcer, deep, with sharply
cut perpendicular walls or undermined, pu-
rulent base and secretion, and painful.

7. The hardness is around the lesion and
is simply tissue infiltrated with inflamma-
tory lymph.

8. The lymphatic glands are frequently
inflamed, painful and possess a suppurative
tendency. Bubo common.

9. Tendency to progressive ulceration and
invasion of structure.

May 2, 1891,

Cbmm unications.

499

CHANCRE.

1. Period of incubation 10-35 days.

2. Originates from chancre or secretion
of secondary stages like mucus, saliva, or
blood.

3. Single, perhaps never confluent, and
rarely multiple.

4. Not auto-inoculable.

5. Is a simple erosion or a papule.

6. Lesion is saucer-shaped or hollowed
out, superficial, almost clean base, very little
if any secretion, and very little pus.

7. The hardness is limited to the lesion
and is minute in size and suggestive of a
small shot.

8. Lymphatic glands indurated, not very
painful and free from active inflammatory
processes.

9. Chancre is locally a lesion of little suf-
fering and tends to spontaneously heal with-
out treatment.

These characteristics, then, when typically
present, offer no difficulty, but when ex-
ceptions rule what is to be done ? Prominent
schools advise absolutely opposite lines of
procedure. One teaches that the immediate
exhibition of antisyphilitics is a sine qua
non, and any other plan unwarranted ;
the other promulgates the doctrine that
to treat a patient with a doubtful lesion
in any but an expectant plan is wrong. In
the confused light we have of the course of
syphilis this possesses much to recommend
it.

What is the natural history, so to speak,
of syphilis? A fact to which little attention
seems to have been directed is, that in many
instances, just as in any disease, cure occurs
spontaneously. This is to be remembered.
Again it is a prevalent belief that mercury
possesses the power to modify or even pre-
vent the appearance of secondary phenomena,
and, consequently, the so-called tertiary
sequela are also averted. In strong contrast
with this exists the indisputable fact that
very frequently while a patient with chancre
is taking mercury secondary phenomena oc-
cur. It is true sometimes a little late. A
sect of syphilographers teaches that mercury
aggravates the after developments and im-
peratively demands the utter abandonment of
the drug. Another sect holds a contrary
opinion. How is this prominent face-to-
face contradiction of therapeutics explained ?
If the method of treatment be examined the
answer is contained in this statement of
Zeissl : " It is true if an individual suffering
from an early syphilitic eruption is subjected
at once to mercurial treatment, the symp-

toms existing at the time usually disappear
very rapidly, but the syphilitic diathesis re-
mains, and is manifested particularly by
hyperplastic lymphatic glands." It will be
noticed, however, that among one hundred
individuals treated in this way 96 on the
average will be attacked by relapses sooner
or later. In those individuals who have re-
ceived mercurials internally or hypoderm-
ically at the first appearance of a syphilitic
eruption, the relapses occur as often as after
early inunctions. Opaline patches on the
mucous membrane of the tongue, mouth and
pharynx, occur with special frequency after
the internal or hypodermic administration
of corrosive sublimate.

If we make a resume of these facts, it ap-
pears that mercury when given in the ear-
liest phases of syphilis, causes a very rapid
disappearance of the morbid symptoms, but
that relapses occur more frequently than
after other methods. I would also call at-
tention to this : " The favorable results which
may be attributed to mercury, are, that it
usually causes more rapid disappearance of
the symptoms of syphilis than other specifics,
and that, when it is used two or three months
after infection, and the disease has had
time to exhaust itself somewhat, very small
doses suffice to cause the disappearance of
the symptoms." As a matter of course, it
cannot be foretold whether such recovery is
permanent. But we must ask, in the light of
the knowledge we possess of the natural course
of syphilis, whether two or three months' ex-
hibition of mercury is the kind of therapeu-
tics upon which it is proper to base or formu-
late a principle ? It seems that no argument
is demanded. So much for the anti-mercu-
rialists.

A few words in conclusion regarding the
diagnosis of the initial lesion. It is evident
that we have to deal with two, and only
two, lesions in our diagnosis. When the
above characteristics of chancre are typically
developed there is no difficulty, and we can-
not be in doubt as to the proper treatment.
I believe in the cauterization of chancre
for self-evident reasons. It satisfies the pa-
tient and reduces the chances of further in-
fection and enables a line of treatment to be ,
described. As mercury in my opinion is, as
a rule, the specific to be employed, and as
this remedy does not invariably prevent the
manifestations of secondary phenomena, and
as in many instances the diagnosis of the
initial lesion is obscure, it is a rule with me
to not administer the drug until constitu-
tional manifestations occur. By this plan
the condition of the patient is not permitted

5<x>

Special Correspondence.

Vol. Ixiv

to be worse than it would be, if mercury
be given immediately. I refer here to cases
where the diagnosis is certain, for where
there is doubt there should never be in-
stituted specific treatment. Again, where
diagnosis is certain, the clinical fact that
secondary phenomena are an index of the
future course of the disease, and that mercury
modifies, while it does not prevent these, it
is just as imperative to know the type with
which we are to deal as it is to know the
type of pneumonia or typhoid fever. This
is the more important as the treatment is en-
tirely too routine ; so much so that it can be
said with a great degree of truth that the
treatment of syphilis is the exhibition of a
standard mixture of iodide of potassium and
bichloride of mercury or one-fourth to one-
half grain doses of iodide of mercury, no
matter what the mildness or severity of phe-
nomena may be, or structures involved.' It
is just as reasonable to institute the most
active measures in vogue for any disease
because an initial sign or symptom was
present as to blindly exhibit mercury in
case of chancre. Who would introduce a
Dwyer tube or perform a tracheotomy upon
the earliest manifestation of a diphtheria?
Is the one more inconsistent than the other?

What are some of the advantages gained
by waiting until secondaries occur? First,
we have some chancres not followed by con-
stitutional phenomena at all ; just as some
people experience a sore throat in a scarla-
tinous room yet enjoy immunity from con-
stitutional involvement. Second, a rash
occurring within seven weeks indicates se-
verity and places the physician on guard.
Third, the rash occurring on time, its pro-
fuseness and type indicate a greater or lesser
dyscrasia or tertiary future, and in my ex-
perience demonstrates the necessity of early
instituting those remedies which we usually
employ in the tertiary stage. Fourth, a
late appearing rash is indicative of a mild
after-course, this, like the preceding, being
greater or less according to profuseness and
type.

. LETTERS FROM SPECIAL COR
RESPONDENTS.

Paris Letter.

SURGICAL INTERVENTION IN DISEASES
OF THE NERVE-CENTERS.

Paris, April 10th, 1891.
The Fifth French Congress of Surgery

has just completed its work. It was held in
Paris between March 30 and April 4, a
great many eminent surgeons from every
country being present.

The first question which had been given
out last year as a subject for discussion was
on " Surgical Intervention in Diseases of the
Nerve-Centers."

Prof. V. Horsley, from London, who is
well known to the medical profession for his
works in that line, was to open the dis-
cussion, but, at the last moment, he was kept
away and had his paper read by his as-
sistant, Dr. Boyce. The principle part of
the paper referred to the surgical method
used, which consisted of opening the cranium
by means of a very large trephine ; the cuta-
neous flap is very large ; and, the opening
in the bone is also made large. The
way in which the cranial section is made is as
follows : A trephine is applied until it
reaches to about the middle of the depth of
the portion of bone to be removed ; and from
the center of this portion a smaller disk of
bone is removed, the remaining bone up to
the limit indicated by the first cut is re-
moved with bone forceps.

When the convulsions are limited to a
certain portion of the body, it is compara-
tively easy to localize the seat of the trouble
and the part where we are to interfere. If,
however, this is not ascertained accurately,
when the brain is exposed in the suspected
region, the exact part may be found by the
application of an electric current.

As regards the medical treatment of corti-
cal tumors, Dr. Horsley says that one ought
never to use specific treatment longer than
six weeks ; if, after such a time, the case does
not improve, it is a clear case for operation ;
for even after a simple exploratory trephin-
ing, the cessation of the cerebral compres-
sion may be enough to effect a cure, as has
been observed in several cases.

Prof. Lannelongue, of Paris, read a
paper on the " Treatment of Microcephalous
by Craniectomy," he gave the result of 25
operations performed by himself. He called
attention, first, to the fact, that in microceph-
alous patients, one finds an advanced state of
the union of the sutures and narrowness of
the fontanelles. In microcephalic pa-
tients ossification of the fontanelles is an-
ticipated. The affections which can be
benefited by craniectomy, according to Dr.
Lannelongue, are numerous. Obstetrical
compression, in haeinatoina, circumscribed
pachymeninigitis, serous cysts, etc., in hydro-
cephalus hyperostosis of hereditary syphilitic
origin — again, in diseases of the brain -sub-

May 2, 1 89 1. Special Correspondence:

stance itself, in cerebral atrophy of vascular
origin, in diffuse sclerosis, etc.

Two kinds of operations are recommended
by the author: 1st, linear craniectomy;
2d, flap craniectomy.

The first one is made along the superior
longitudinal sinus and can be extended
through the coronal suture, on the motor or
Rolandic zone, towards Broca's center ; he
has also practiced it on the occipital behind,
between the lateral sinus and the occipito-
parietal suture ; again, he has performed a
transversal and symmetrical craniectomy
on the frontal bone by detaching the longi-
tudinal sinus.

By flap craniectomy, he means that opera-
tion which consists in making sections of
the cranium combined so as to allow the
flaps to remain adherent by a more or less
extensive bony base. Sometimes the flap
involves only one bone — the frontal, or
the parietal ; more often it extends over two
bones — the frontal and parietal. The gap
between the cut surfaces varies from 8 to 12
millimeters. The operation is performed by
attacking the bone with a trephine, at one
of the extremities of the wound, and then
doing the rest with cutting forceps. The
dura mater can be left untouched ; if, how-
ever, there exists any trace of pachymenining-
itis, it would be w7ell to puncture it or even
to open it freely; if, however, an incision
has been made in the dura mater, this mem-
brane must be sutured, which is not neces-
sary if only punctures have been made. As
to the periosteum, it can be excised or not ;
both have been done, with no advantage one
over the other. As to the final results — out
of 25 craniectomies, he has had one death
in 48 hours from acute septicaemia and con-
tinuous flowing of the cerebro-spinal fluid.
The youngest child operated on was 8
months old, and the oldest 12? years — as to
the after-results, they were all benefited by
the operation.

Dr. Anger, of Paris, also reported a
case of craniectomy which was performed
on a child 8 years old, who was taken, when
15 months old, with severe convulsions, oc-
curring in the evening, and her intelligence
seemed to cease developing. In fact she
was at the time of the operation, so far as
intelligence was concerned as little ad-
vanced as any 15 months child and did
not even know her alphabet ; she re-
peated words without understanding them ;
she said papa and mamma ; she had no idea
of danger and had several times fallen out of
a window. The operation was made as fol-
lows : A linear incision was carried from

the frontal eminence to the lambdoid
suture; a first disk of bone was removed,
and the cranial excision was then continued
for 12 centimeters (4 inches) ; the dura
mater being prominent, a puncture was
made with a hypodermic needle. The
osseous wound was then enlarged, and
when finished had an oval form of 11 2
centimeters long (4 inches) antero-posteri-
orly, and 4 centimeters (1£ inch) trans-
versely. The skin was finally united.

The day following the operation, the
patient ceased to urinate or defecate in
bed ; she asked to eat ; she began to cry
when any one spoke of her absent parents ;
the athetose movements which existed
ceased ; and, finally, she has been improv-
ing steadily, both physically and intellect-
ually up to date.

Dr. Girard presented an interesting case
of Essential or Idiopathic Epilepsy, cured by
trephining. The patient, aged 29, had been
suffering from epileptic fits, five or six a
day, ever since the age of 14. At 29, in a
fit of anger, she shot herself in the right
temple, and fell in a state of coma ; the left
arm was completely paralyzed. She was
trephined, several pieces of bone and the
bullet w^ere removed and the skin again
closed. It is now five months since the
operation, and the patient has not had a
single fit. She had before her operation six
children, five of them having died from con-
vulsions.

Dr. Duret, from Lille, also presented two
cases of trephining. One was for aphasia of
traumatic origin, the patient having fallen
on his head. On trephining, a large clot was
found in the Rolandic region, and removed ;
the patient was soon able to speak
again, but unfortunately on the 23d day
after the operation, after a rather copious
alcoholic dissipation, he was attacked by
severe cerebral congestion, with convul-
sions of the four extremities, from which he
never recovered.

The second case was that of a young soldier
of 22, who had had a fall at 14, and was sub-
ject to epilepsy. Trephining exposed a
diseased arachnoid membrane in the
parietal region. The epileptiform attacks,
the headache, and vertigo ceased after this
operation.

Dr. Jeannel, from Toulouse, reported a
case of trephining for Jacksonian epilepsy.
The patient had suddenly been seized a year
ago, by an attack of apoplexy which
left behind it a palsy of the right upper
extremity. Two months later he had an-
other attack, followed by spasmodic move-

502

Special Correspondence.

Vol. Ixiv

ments of the right upper extremity ; some-
times these would extend to the face and to
the lower extremity, but still there was a
continuous spasmodic agitation of the right
forearm. There was also more or less
complete aphasia. On the left side of the
cranium no depression could be found. A
small cicatrix existed, however, which was
the result of a punctured wound made at the
age of 15, but the cicatrix was not adherent.
The cranium was opened in the Rolandic
region on that side. When opened Dr. Jeannel
found a violet, flabby mass which was firmly
united with the cerebral substance, and
extended downwards and backwards, so
that the bony opening had to be enlarged.
This diseased mass was curetted out and a
hole, the size of a green almond, was left in
the cerebral substance. The periosteum and
skin were then united.

The day following the operation, all
spasm otic movements had disappeared, but
were replaced by a paralysis of the right
forearm ; the speech returned very slowly ;
no more epileptic fits occurred.

Dr. Regnier, of Paris, presented also a
case of trephining for Jacksonian epilepsy.
The case is an interesting one, as Prof.
Charcot had given the following diagnosis :
Partial sensitive-motor epilepsy, correspond-
ing to a probable lesion at the middle and
inferior regions of the Rolandic convolu-
tions.

At the age of 5, the patient had been taken
with a sensation of pricking on all the mu-
cus membranes of her head and an abundant
lachrymal secretion. In 1888, she fell sev-
eral times on her head, and one finds to-day
a cicatrix in the left parietal region. In
April, 1889, she had her first attack ; her
mouth was strongly twisted to the right four
or five times a day. Convulsions extended
to the head more than to the arms and lower
extremities.

The operation of trephining was resorted
to. A disk was removed from over the Ro-
landic region and the opening enlarged, when
the surgeon found a gray-colored tumor, of
cystic appearance, extending down into the
cerebral substance. This extended further
forward than the margin of the bony section,
so that after having scraped out as much as
possible of its superficial portion, the wound
was closed. The fits, however, returned
again, so that a new operation had to be
performed 4 months later. It was then
found that the tumor had already re-formed
itself, and it was again enucleated with the
curette ; the tumor was a glioma with a cen-
tral cystic cavity, and it was situated at the

inferior extremity of the ascending frontal
convolution and the lower end of the third
frontal convolution.

Dr. Michaux, of Paris, presented a case
of trephining for non-traumatic meningeal
hemorrhage. The patient was an habitual
absinthe drinker and had been so for years.
He was brought to the hospital in a com-
plete state of apoplexy, with left facial
palsy and paralysis of the right upper ex-
tremity. The following days the paralysis
extended to the right inferior extremity ;
epileptiform convulsions occurred, etc. In
addition, the patient did not present the least
sign of external traumatism.

The patient was trephined over the Rolan-
dic region on the left side ; three disks of bone
were removed, making an opening of 2
inches long. The dura mater was next in-
cised and this allowed several large black clots
to escape — the quantity of two table-spoon-
fuls. The symptoms gradually disappeared,
excepting those connected with speech,
which has remained slightly defective even
five months after the operation.

This was a clear case of spontaneous
hemorrhage of alcoholic or ursemic origin
cured by trephining.

Dr. Picque, of Paris, reported another
case of trephining. It was in a young lady,
aged 19, who shot herself with a revolver.
She was in a comatose state for five days and
then gradually and completely recovered
her mental faculties. The attending physi-
cian said there was no penetration, yet there
was a wound at a point between the right
frontal region and the corresponding tem-
poral, a little in front of the coronal suture.
The patient complaining of persistent head-
ache on the right side, the diagnosis of cere-
bral abscess was made, hence trephining was
resorted to. The cerebral surface appeared
intact, except at one part, where the gray
substance protruded. An incision brought
out a great deal of pus, but the bullet could
not be found. To-day the patient has com-
pletely recovered and is doing very well.

Dr. Broca, from Paris, presented three
cases. On one of his patients, there was an
indication of localization : an athetose move-
ment of the upper extremity ; yet in that
case the author concluded at once that
the cortical center of the upper extremity
ought to be exposed, for according to the
history of the disease and the form of the
head of the patient, he has diagnosticated
intra-ventricular hydrocephalus, hence the
first surgical indication was the removal of
part of this liquid, so as to diminish the
compression of the brain. He, therefore,

May 2, 1891.

Society Reports.

503

opened and drained the left lateral ventricle,
using Keen's process of trephining one inch
behind and above the external auditory
meatus.

His second case was an infantile spasmodic
brachial monoplegia. The athetose contrac-
tions of the left upper extremity resembled
the preceding patient's condition, but the his-
tory of the disease, as well as the form of the
head, pointed to infantile cerebral sclerosis.
In addition, for the past four years, the
patient had had fits of Jacksonian epilepsy
starting from the thumb.

On trephining, a cyst was found on the
motor center for the thumb, at the postero-
inferior portion of the center of the upper
extremity. The epileptic fits have not
completely ceased.

Finally, the third case was one of com-
pound fracture, for which the patient had
already been trephined and a small abscess
found ; the operative result was good, but a
few months later the patient returned with a
Jacksonian epilepsy of the lower maxilla
and left upper extremity, presenting a small
cranial fistula. Thinking that a small
piece of bone might be the source of irrita-
tion, this was removed, with great improve-
ment in the patient's condition.

Prof. Verneuil, of Paris, made an inter-
esting communication on a case of "Fistula of
the Sacral Region with escape of Cerebro-
spinal Fluid." The young lady had noticed
sixteen months before she presented herself
at Dr. Verneuil's consultation, that a small
tumor appeared in the sacral region, about
the size of a small orange, which tumor burst
spontaneously four months later, allowing a
great quantity of pus to escape. Dr. Ver-
neuil thinking that a sequestrum was the
cause of the suppuration, operated with the
thermo-cautery, but when he reached the
supposed diseased bone, he found that his
finger came in contact with one of the pos-
terior sacral foramina, the borders of which
appearing roughened were thoroughly
scraped. The day after the operation the
patient was found drenched in her dressings,
this liquid examined and demonstrated to be
cerebro-spinal fluid. Four days after the
operation and this over-flowing, the patient
was found in a state of deep coma and dysp-
noea, but without fever or vomiting. These
comatose states had occurred before when-
ever the abscess opened. The patient is to-
day cured. The lesion was of bony origin,
producing acute abscess, the dura mater hav-
ing been perforated in one of the sacral
foramina, from which occurred the escape of
the arachnoid fluid.

Dr. Bazy, of Paris, also made a com-
munication on exploratory surgical inter-
ference in cases of compression of the spinal
cord, or in cases of uncertain diagnosis. He
reported the case of a woman on whom he
operated for symptoms which were ascribed
to a probable tumor of the cord ; the spinal
canal was opened in the ruptured region, but
with negative results ; the wound healed
without the least trouble. A. C. PL

Society Reports.

GYNECOLOGICAL AND OBSTETRICAL
SOCIETY OF BALTIMORE.

Dr. Neale reported the following case of
" Occlusion of the Os Uteri during
Four Days' Parturition :"

Mrs. K. W., 9Bt. 26 years ; white. Past his-
tory unimportant. Last menstruation early
part of April, 1890. Pregnancy normal up
to Nov. 16th, 1890, when she slipped and
fell violently on her right side on the side-
walk. There was no vaginal discharge at
the time and no discomfort except from the
jar, bruising, etc., and the patient was up
and about all the time. No movements of
the child were felt after the fall.

About Christmas, 1890, an offensive yel-
lowish vaginal (uterine) discharge occurred
and continued for one week.

On the night of January 12th, 1891, her
first labor pains began, and were so severe
as to require morphine being given by her at-
tendant. There was no " show " or dis-
charge of any kind. The pains increased
and the patient was suffering severely when
I saw her for the first time, Friday evening,
January 16th, 1891. She was a large well-
built and well-nourished woman.

I could not distinctly map out the child
by abdominal palpation. By auscultation
gurgling was detected over the entire
uterine tumor, but not a trace of foetal heart
sounds could be heard.

By vaginal examination ; the vagina was
very short and small, there was no cervix
and no os. A continuous layer of mucus
membrane, flush with the vaginal walls,
closed over the entire vault of the vagina,
and a little dimple in its center was the
only indication of where the os ought to be.

The patient was chloroformed, placed in
position, the hand passed into vagina, the
finger pressed firmly against the dimple
when it suddenly yielded or burst open like
a membranous web, permitting a gush of a

5°4

Society Reports.

Vol. Ixiv

' not foul smelling bloody water to escape,
and at once the rapidly enlarging outlines
of the os could be felt, then about as wide
as a silver half-dollar piece. The soft bag-
ging scalp and loose cranial bones came
down upon the enlarging os and as the ex-
pulsive efforts were almost nil, I grasped the
head with a Simpson's cranioclast which
tore away, and then adjusted the blades of a
Tarnier basiotribe over the head and neck
and a thoroughly macerated, but not de-
composed or foul, small child was easily ex-
tracted. The perineum was intact, and the
os fissured slightly. A small placenta ap-
peared within six minutes. There was con-
siderable post-partum hemorrhage, the
uterus acting feebly. The os remained open
about size of silver-half dollar piece, with
thick edges ; the uterus was rather small but
not firmly contracted. Two quarts of a hot
intra-uterine 1-4000 bichloride douche were
injected. The patient rallied well and de-
barring an occasional slight rise of pulse
and temperature, and faintly foetid lochia
which readily yielded to the antiseptic
douche, the puerperum was uneventful and
recovery complete. This case was a novel
one to me. I am quite sure the membrane
I felt was mucus, and not the amniotic sac,
nor do I think the case should be classed
among those of cervical occlusions or stenosis
from endotrachelitis.

Dr. J. Whitridge Williams read a paper

on

"the induction of premature labor in
contracted pelves."

He pointed out that the comparative
neglect of the operation in this country was
due to two causes ; the absence of large
lying-in institutions and the consequent lack,
of large amounts of clinical material, and
the almost total neglect of pelvic measure-
ment.

By the term induction of premature labor,
one understands the artificial interruption
of pregnancy at such a period that a viable
child may be born ; that is, at any period
from the 28th or 30th week to the end of
pregnancy.

Dr. W. after a discourse on the history of
the operation, showed that it was first
rationally employed for this indication in
England, as the result of a conference of the
eminent physicians of London in the year
1756. Within fifty years it was quite gener-
ally employed on the Continent, and soon
enjoyed a popularity which caused it to be
resorted to on the most trifling pretexts, and

which in 1869 called forth Spiegelberg's
forcible denunciation of the operation by
which he showed that the mortality, both of
the mother and children, was nearly three
times greater after the operation than if the
woman went on to term.

This was soon followed by articles .by
Litzmann and Dohrn, who showed that
Spiegelberg had painted the picture in
colors far too dark. Litzmann snowed that
in moderate degrees of contraction, 8.25-7.5
cm. (3|-3in.) the operation was indicated
in the interests of the mother, as shown
by a mortality of 7.4 per cent, after
the operation compared with one of
18.7 per cent, when the woman was
allowed to go on to term. Dohrn
stated that the proper method of appreciat-
ing wThat the operation accomplished, was
not to compare so many cases of induced
labor with so many cases of labor at term,
but to compare the results of premature and
spontaneous labors in the same woman ; by
this method he found that twice as many
children were saved by inducing labor as
by allowing the woman to go on to term.
Consequently, they proved that the operation
was indicated in properly selected cases both
in the interests of the mother and child.
The introduction of antiseptic methods into
midwifery, almost completely robbed the
operation of danger for the mother, as will
be readily seen from the following statistics.
Thus Haidlen reports forty-four cases from
the Stuttgart clinic, with no material deaths
and 72 per cent, of the children saved. In
1889 Korn stated that Leopold lost one
woman in forty-five cases and saved 66 per
cent, of the children, and last July Ahlfeld
stated that he had induced labor one hun-
dred and eighteen times with the loss of
only one mother, and had saved 62 per cent,
of the children. At the Berlin Congress,
Fehling stated that in sixty cases he had
saved all the mothers and 80 per cent, of
the children.

From the above sketch we will readily
see that the maternal mortality in properly
selected cases is very slight. Four hundred
and one cases collected by Korn, showing a
maternal mortality of only 2.9 per cent., or
just a trifle more than normal labor in a
normal pelvis, while the foetal mortality
ranges from 20 to 70 per cent., the average
being about 33£ per cent. So in this opera-
tion we have a means of saving about two-
thirds of the children without any risk of
the mother. On reckoning by Dohrn's
method we save at least twice as many chil-
dren as if we allowed the woman to go on to

May 2, 1891. Society

term, and then resorted to some conservative
operation.

These are the prospects of the operation,
but unfortunately the degree of contraction
within which the operation is justifiable is
very limited, and one can only think of it
in moderate degrees of contraction. Ac-
cording to Litzmann, in flattened pelves
with a conjugata vera of 6.5-8.25 cm. (3-
3.25 in.) ; and to Schroeder, 6.5—9.5 cm.
(2.5-3.75 in.). As pelves with a conjugata
vera above 8 \ cm. (3f in.) offer a reasonable
chance to both child and mother at term,
and those below 7 cm. (21 in.) offer no
chance to the child, I think that the opera-
tion should be restricted to these limits ; that
is between 7-8 J cm. (2f-3f in.) in simple
flattened pelves. In the justo-minor pelvis
a conjugata of 9? cm. (3f in.) or less will
usually be an indication for the operation.
In the >rare forms of obliquely narrowed
pelvis, whatever the cause, we must be guided
almost entirely by the history of previous
labors.

We thus have the operations restricted to
a very small range, 1\ cm. (f in.), which
should only be exceeded when the previous
history tells us that the previous labors have
all ended disastrously. We should not
think of inducing labor in a flattened pelvis
with a; conjugata below 7 em's. (2| in.) for
in that case the prospects for the child are
almost nil and the dangers to the mother
greatly increased. Here we come to the
relative indication for Csesarian section,
when it is best to allow the .woman to go on
to term, and attempt to save both mother
and child by that operation.

With these contracted indications, we
readily see that an accurate idea as to the
exact size and form of the pelvis is an abso-
lute prerequisite for the performance of the
operation ; and the only means by which
we can accurately obtain this information is
by carefully measuring the pelvis. We
should not content ourselves with simply
measuring the conjugata vera, but should
also take the external measurements and
thereby attempt to determine with what form
of pelvis we have to deal. After doing that,
we must carefully examine the interior of
the pelvis to determine its height ; to see if
it is generally contracted, and if contracted,
if the contraction increases as we approach
the outlet, we must look for exotoses of the
pelvic bones and carefully examine the pro-
montory to see if it is double or not. If we
think the pelvis contracted laterally we
should measure the distance between the
tubera ischiorum on each side, as Breisky

Reports. 505

recommended. We should also attempt to
estimate the transverse diameter of the pelvis,
which is most difficult to do, and the most
that can be expected is to examine alter-
nately with each hand and try to stroke the
linea innominata and so relatively to get
some idea as to the transverse diameter.

Having decided that an operation is nec-
essary, the next question is, when shall it be
done? Of course, the younger the foetus,
the smaller will be its size, and consequently
the easier its delivery. But, unfortunately,
the smaller the foetus, the less chance will it
have of living even if it survive the opera-
tion. Generally speaking, we say a child is
viable after the twenty-eighth week, but its
chances of living are almost nil; indeed
children 30-32 weeks old have next to no
chances of living. The later the operation,
the more chances has the foetus of living
after it, but unfortunately its size and con-
sequently the difficulty of its delivery in-
crease with its age. If possible, the opera-
tion should be done about the 34th-36th
week, our object being to operate at the
latest possible period consistent with safe
delivery. To fulfill this object we must at-
tempt to gain an accurate knowledge as to
the size of the child's head. Unfortunately,
we are unable to determine its size with
mathematical precision or even with the
relative precision of pelvimetry ; so we are
obliged to take advantage of every possible
hint on the subject. Some of the following
points may be of assistance in different
cases. We must consider the mother's ac-
count as to the duration of the pregnancy.

Notice the size of the parents, large parents
usually having large children. Inquire
about the previous labors, particularly as to
the size of the head. Endeavor to estimate
the size of the head by abdominal and com-
bined abdominal and vaginal palpation ; and
note the consistency and amount of resistance
to compression that the bones of the head
offer. Try to measure the head with the
pelvimeter through the abdominal walls, and
deduct the estimated thickness of the ab-
dominal walls from the result. Notice the
size of the large anterior fontanelle, average
width 2 cm. ; the width of the sutures ; and
the distance from the anterior to the poste-
rior fontanelle; for as they are larger or
smaller, it indicates a larger or smaller head.
Measure the length of the foetus as it lies in
utero, from breech to vertex, double the
measurement and it gives, according to Ahl-
feld, the length of the foetus. If a foot is
prolapsed, measure it, for Goenner stated
that there is a difference of nearly one centi-

5o6

Society

Reports.

Vol. Ixiv

meter between the length of the foot at term
and one at thirty-two-thirty-four weeks.

One of the most important methods is that
of Mueller who attempts to force the head
down into the pelvis by pressure from above.
As long as he is able to force the head down,
he knows that labor will readily take place,
but when he can no longer force the head
down and when it bulges out over the sym-
physis, then he considers that the time for
operation has arrived. As the great danger
to the mother is from sepsis, one cannot be too
careful in one's efforts to guard against it,
and consequently one should be most partic-
ular in one's preparation for the operation.
For several days previous to operating, the
woman should have a warm bath daily ; and
several times a day be douched with warm
water, 95-98 F., containing salt or borax,
by which the cervix is softened and dilated.
Just before operating, the genitals should be
most carefully washed with hot water and
soap, followed by a 1-1,000 bichloride solu-
tion ; the vagina should also be most care-
fully cleansed.

The hands of the operator should be
washed for at least ten minutes in hot water
and the nail-brush vigorously used, after
which they should be placed for several
minutes in a 1 — 5,000 bichloride solution.
All instruments should be sterilized by steam
or placed in a 5 per cent, solution of carbolic
acid for at least thirty minutes.

The most generally approved method is
that of Krause or the introduction of a dis-
infected flexible bougie between the mem-
branes and the uterine wall. If properly
conducted it is almost entirely devoid of
danger for the mother, and will bring about
the birth of the child in a period varying
from 8-241 hours, averaging about eighty
hours or about three days. To insert the
bougie, the woman is placed on her back or
side as may be convenient, and the cervix
brought down by a pair of bullet forceps
and the cervical canal carefully cleansed
with bichloride on a pledget of cotton ; the
bougie is then carefully inserted so that its
lower end is within the vagina, care being
taken not to wound the membranes or the
placenta. Then the vagina is packed with
iodoform gauze, which serves to hold the
bougie in place. If at the end of twenty-
four hours no labor pains have been pro-
duced, the bougie should be removed and
another introduced at another point under
the same precautions as the first. If this
method fail we may resort to Kiwisch's
method of allowing a current of hot water,
100-110 F., to flow through the vagina sev-

eral times a day for a period of 5-15 minutes.
Or we may puncture the membranes, as ac-
cessory to these, we may loosen the mem-
branes about their lower pole ; tampon the
vagina with iodoform gauze or employ
Barnes' bags. If the pains are weak, Feh-
ling recommends a version by Hick's method
and bring down one leg, whereby increased
contraction is produced and one is afforded
a ready means of ending the labor if one
deems it expedient in the interests of the
mother or child.

Dr. Neale : I regard the chief point in
this very able paper to be the endeavor to
definitely fix the limits for the induction of
premature labor in contracted pelves, not as
opposed to Caesarian section, but as appli-
cable to a distinct and separate class of
cases. This endeavor I strongly advocate,
but at the same time must confess that I do
not believe the plan is always practicable at
the bed-side. There are so many factors
entering into the determination of this
question as stated in my paper, that I can
now only repeat what I there quoted, viz. :
" A given pelvic measurement is useful as
an indication of what has been the expe-
rience of others under similar circumstances,
but is not a final ground for decision."
After the evidence adduced, which doubtless
represents the opinion of the best medical
authorities, I am sure I only voice the con-
currence of this society in accepting the
limits for this operation as stated by Dr.
Williams. This is practically in accordance
with the teachings of Lusk — probably our
strongest American authority — who places
the range for the induction of premature
labor in contracted pelves at a conjugata
vera of from 2f inches (7 cm.) to 34 inches
(8.75 cm.).

Dr. Kelly : The subject is too large to
be discussed formally. What we want
to know for practical purposes is, whether
the children live any time after they get
home. My own experience is but few live.
If they are sent out simply to die soon after
at home, the induction of premature labor
among the poorer classes simply becomes a
species of uterine gymnastics.

A method of my own which I have
found most successful in inducing premature
labor, is taking a flexible whalebone bougie,
introducing it between the membranes and
the uterine wall, high up into the uterus,
and sweeping it gently around for one or
two inches in either direction. This has not
failed me in any instance in bringing on
labor.- — Journal of Gynecology.

May 2, 1 891.

Editorial.

507

THE

MEDICAL AND SURGICAL

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THE MEDICAL AND SURGICAL
REPORTER.

With the present number the editorial
management passes into other hands.

For nearly 40 years the Reporter has held
an exalted position among medical period-
icals. The liberal policy which has always
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the admission of articles to its pages; it

owes no allegiance to any school or faction ;
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competent from practicing medicine.

Notwithstanding the commanding posi-
tion attained by the Reporter we are not
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with the promised co-operation of a large
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are confident the journal will be more
welcome than ever, and its patronage and
influence greatly increased.

In these busy days when every moment
is preyed upon and when thousand's of
presses are offering us the results of an ever-
increasing amount of observation, it becomes
a necessity that for the practitioner to keep
abreast of the times the essential part of this
mass of work should be so condensed and
arranged that " he who runs may read."
AVith an increase of the size of the Reporter
from 28 to -40 pages of reading matter, and
with the aid of a competent corps of as-
sistants we hope to keep our readers posted
in all important progress in medical science
and art. To this end our editorial columns
will be devoted to Leading Articles which
will consist largely of short critical resumes
of the more important and recent advances.
The Periscope will also be modified — it will
follow the editorial columns, and the abstracts
will be arranged collectively for ready ref-
erence according to the special departments
in medicine to which they belong.

The Reporter has always been pre-
eminently a journal for the practicing phy-
sician, and we will spare no effort to keep it
so ; but while the practical will always be
foremost in view we will endeavor to neglect
nothing which promises to be of value to the
clinician or which is of special interest to the
profession.

5o8

Editorial.

Vol. lxiv

Space does not permit us to offer in detail
what we have done or intend to do, but it is
hoped that these few statements will be
sufficient to indicate our position, and our
determination to secure the best material to
be had and keep our readers thoroughly
informed in a concise and practical way of
medical progress.

We ask the indulgence of our readers for
any shortcomings in the present number.
Owing to a misunderstanding with our pre-
decessor, our task was one of exceptional
difficulty.

As we are going to press, it is announced
that Dr. Joseph Leidy, the eminent natural-
ist and Professor of Anatomy in the Uni-
versity of Pennsylvania, is lying critically
ill, and it is not likely that he will live twenty-
four hours.

THE DANGERS OP COCAINE.

The rapid accumulation of cases in which
alarming symptoms followed the local ap-
plication of small quantities of cocaine,
together with the fact that these untoward
effects are due to individual idiosyncrasy
and do not invariably occur immediately, is
a positive warning to the profession that this
powerful substance should not be used in
any case for the first time without proper
antidotes directly at hand and the patient
kept under surveillance for at least a half
hour. We will not attempt to refer to the
cases published in which ordinary thera-
peutic doses administered internally or
subcutaneously caused symptoms similarly
embarrassing.

Nearly three years ago, Satterwhite, as a
result of a study of one hundred cases of
poisoning by this alkaloid, called attention
to the dangers attending the use of even very
small doses, and at about the same time
another author after summarizing the records
of fifty cases made a similar announcement.
That this warning was well founded is evi-
dent by succeeding publications. A case is
reported by Broughton in which uncon-
sciousness ; an irregular, slow respiration ;
and a slow pulse, followed the application of

three minims of a twenty per cent, solution
within the cavity of a tooth. Whistler,
after the application of a four per cent, solu-
tion to the nasal cavity, noted vertigo and
threatening syncope. In a case of glossitis,
Ricket states, that the patient became mori-
bund after the use of a similar solution.
Myrtyle dropped three minims of a three
per cent, solution in each eye, which imme-
diately caused a sense of numbness in the
back of the tongue and throat, palpitation,
threatened syncope and nausea. Bettleheim
records that in one case the hypodermatic
injection of one-sixth of a grain induced
alarming symptoms ; and in another, one-
eighth of a grain similarly injected caused
unconsciousness, congestion of the face,
irregular breathing and trismus. Cotter
found unpleasant symptoms in more than
one instance while using in the nasal cavities
a solution as weak as ten per cent. Thus, in
a young lady there was sprayed into these
fossse six or seven minims of a ten per cent,
solution, and just as he was going to operate,
the breathing became very difficult, the
larynx seemed paralysed, distressing symp-
toms of cardiac and general depression
appeared, and she was unable to walk for
two hours. Hubner dropped about one and
a half minims of a two per cent, solution
into the nostril of a healthy young soldier
previous to the removal of a polypus. This
was soon followed by unconsciousness, an
exceedingly weak pulse and cold. skin. A
case is reported by Ficano of a woman, forty-
three years of age, who had for some time
suffered from intolerable tinnitis, which
accompanied a dry otitis media, with a dimi-
nution of hearing. A few drops of a five
per cent, solution wTere introduced into the
middle ear by means of a catheter, after the
use of the Politzer method of insufflation.
In a short time vomiting came on with
cramps and diarrhoea which lasted for several
hours, there was marked muscular inco-ordi-
nation, and symptoms generally analogous
to those of sea-sickness.

There seems to be no doubt that cocaine
is absorbed with extraordinary rapidity, and
that the stronger the solution which is

May 2, 1891

Periscope.

509

locally applied the greater the danger of
toxic symptoms, but whether the latter are to
be attributed merely to the larger dose or to
some obscure action is not apparent. Falk
has found that the rapidity of absorption
varies in the different tissues — absorption
taking place most rapidly through the con-
junctiva, then in the following order: nose,
larynx, mouth and ear. It is generally con-
ceded that a ten per cent, solution is suffi-
ciently strong for most purposes and robbed
of many of the dangers of those of greater
strength.

The nature of the toxsemic symptoms
varies so greatly that no rule-o'-thumb treat-
ment can be set down : in some cases nervous
and muscular excitement predominates ; in
others, respiration in the function most seri-
ously affected ; in others, the circulation, etc.
Among the agents found useful are nitrite
of amyl, strychnine, atropine, morphine,
alcohol, ammonia, digitalis, chloral, seria-
prisms over the heart and stomach, hot drinks
and artificial respiration.

PERISCOPE,

THERAPEUTICS.

Correspondence.

" Little Liver Pills."

R Calomel gr. %
Podophyllin : "

Extract of Belladonna "

Aloin a a gr Y%.

Oleoresin of capsicum

Ipecacuanha 'a a gr. 1-16

M. Ft. Pill. No. I. Dose : as an aperient,
one pill at night or morning ; as a laxative,
one or two ; as a cathartic and cholagogue,
three or four — (one every two hours until the
desired number has been taken).

This is a reliable anti-bilious remedy,
equal, if not superior, to the compound ca-
thartic pill of the U. S. P. It is an improve-
ment on the popular little " Lapactic Pill,"
the mercury and podophyllin greatly en-
hancing the hepatic tendency of the aloin
and belladonna pill, while the omission of
the strychnia renders it more suitable for
children. Practically, this little pill leaves
nothing to be desired.

Each pill weighs one grain.

B. Frank Humphreys, M. D.

THE EMPLOYMENT OF NAPHTHALINE IN
THE TREATMENT OF TYPHOID FEVER.

Natanson {Rev. Gen. de Clin, et de
Therap., March 11, 1891 ) has communicated
to the Societe de Medecine Pratigue the re-
sults of his experience in the treatment of
typhoid fever by naphthaline. He has em-
ployed the drug in 23 cases, and at different
periods of the malady. The temperature
and the diarrhoea were diminished within
two or three days. The remedy was given
daily three or four times, in doses of 15 cen-
tigrammes for adults, and 10 centigrammes
for children. In order to continue the use
of the medicament the stools and the urine
should be carefully examined. The disap-
pearance from the stools of the microbes,
shows the success of the treatment ; but a
greenish coloration of the urine is a suffi-
cient cause for the suspension of the drug.
The remedy may be given in gelatine cap-
sules or in water. To this treatment may
be added as auxiliary, other tonic measures,
such, especially, as cold-water baths. The
healthy condition of the kidneys must be
watched in order to avoid toxic phenomena.

HYPOSULPHITE OF SODIUM AND SILVER
IN ATAXIA.

Dr. A. Radcliffe in the Therapeutic Ga-
zette writes : Having a case of locomotor
ataxia to treat, and fearing the danger of
argyria from the nitrate of silver, I was in-
duced to use the hyposuiphate of sodium and
silver, thiosulphite of sodium and silver,
from a report published by Curci, in the
Medical News, July 10, 1886, wherein it was
claimed this double salt " did not coagulate
the albuminoids, is very soluble in water, is
not caustic, is diffusible, promptly absorbed
by mucous membrane and connective tissue.
Its taste is sweet, slightly nauseous. Should
be given fasting or hypodermically, by
mouth from 5 to 20 centigrammes daily,
or hypodermically from 1 to 5 centigrammes
daily. Its action is quickly obtained ; the
danger of argyria is avoided."

My patient was a lady, past middle life,
and her trouble had been slow in coming
on. The electric-like pains had been treated
as neuralgia and rheumatism ; the gas-
tric trouble, as dyspepsia, with pepsin and
nux vomica ; while the difficulty in locomo-

5io

Periscope.

Vol. Ixiv

tion was attributed to the rheumatism. She
came under my care early in 1886. The
first symptom she then complained of was
the difficulty she had just experienced in
coming up the stairs, owing to the darkness,
and some stiffness in her limbs. Though
she could walk from her house to the gate
at night with considerable certainty, as she
was familiar with the locality, yet if she
stepped off the walk she would be compelled
to sit down, because on the ground she could
not get her bearings ; that if she did not get
back on to the walk, she would be compelled
to crawl to the house, for on the ground she
felt an uncertainty about her equilibrium.
She does not walk on her heels, bringing the
sole down with a flap ; she walks slightly
bent forward, that she may watch where she
steps, for a very small obstacle, if stepped
upon, is sufficient to cause her to fall.
Though she stands with her eyes closed, yet
there is a slight swaying motion of the body,
such a feeling that she might fall, she does
not like to try it. She stands and walks
wide ; the foot is not carried directly for-
ward with a good knee action, but is held
rather stiff and swung around.

She took at first ergot, to relieve some spinal
congestion that troubled her in the morn-
ings. Belladonna, she thought, gave little
relief to the bladder-trouble (paralysis of
sphincter), and annoyed her by the dryness
it caused in the mouth.

She has taken the sodium and silver salt
at intervals since 1887, or earlier, as high as
15 centigrammes (2i grains) a day, in all
four or five drachms, and has lately com-
menced on another drachm. Soon after
commencing the use of the silver salt her
gait improved, and she walked wTith more
ease and spring. She says the silver helped
the pains in her limbs, that she could walk
better after taking it, but it did not help her
bladder-trouble.

Suspension, which she uses at home, she
claims greatly helps the bladder-trouble;
the only thing that ever did.

With the silver salt and suspension, she
says, she can get along very well, if her
household work is not too great ; that with-
out them she could hardly get along at all.

TREATMENT OF ERYSIPELAS BY
ICHTHYOL.

An elaborate research, clinical and bac-
teriological, has recently been published by
Professor Nussbaum's assistant, Dri Julius
Fessler, on the treatment of erysipelas by
ichthyol, a plan which has been for some

years extensively adopted in Munich. From
laboratory experiments it was evident that,
though ichthyol has only a slight effect in
preventing the development of staphylococci,
it has a very potent deterrent influence on
the multiplication of streptococci, and it is
well known that it is the latter kind of bac-
teria that are the cause of erysipelas. The
method of treatment consists mainly of rub-
bing a strong ichthyol ointment .energeti-
cally, and for ten minutes at a time, into
the affected surface and its neighborhood ;
ichthyol in the form of pills may also be
given internally. Where there is a wound
it must be very carefully disinfected, and an
antiseptic dressing applied. The results of
this treatment, as compared with ordinary
methods, are embodied in several instruc-
tive tables. From these it appears that,
while the mean duration of the cases treated
by other methods from 1880 to 1888 was
about twelve days, in no single year falling
below nine days, the cases treated by ichthyol
from 1886 to 1888 presented a mean dura-
tion of under seven days, while in the first
half of 1889 it fell to 5.6 days.— Lancet

ON THE ACTION OF ATROPINE IN DIS-
EASES OF THE HEART.

Dr. Cardarelli has experimented with
atropine in sixty-five cases* of various forms
of functional cardiac disease, measuring the
pulse with the chromograph of Verdin and
the arterial pressure with the sphygmo-
manometer of Basch. His conclusions,
which appear to be based on a most careful
study, are published in La France Medicale,
January 23, 1891 :

1. Atropine, in doses of T-b to -fa grain,
given hypodermically in man, manifests
itself first in its action on the heart.

2. The action of atropine on the heart
consists in the overcoming to a greater or
less degree of the inhibitory influence of the
vagus nerve.

3. As a consequence of this paralyzing
action on the vagus, there is constant accel-
eration of the cardiac rhythm, which may
be in certain cases accompanied by a slight
transitory slowing.

4. Arterial pressure is reduced under the
influence of atropine in direct proportion to
the acceleration of the rhythm.

The author concludes with the statement
that, when a clinician cannot use atropine in
slight forms of irritation of the pneumogas-
tric, in which there is no slowing of the
pulse, it will be, nevertheless, a great error
not to prescribe atropine in cases where a

May 2, 1 891.

Periscope.

5ii

permanently slow pulse is accompanied by
epileptiform vertigo, and, above all, by syn-
cope.— Therapeutic Gazette.

ARTSTOL IN DISEASES OF THE EYE.

Aristol has been employed successfully by
A. Bourgeois ( Union Med du Nord-Est,
Feby., 1891), in eye diseases, such as ulcers
of the cornea, traumatic keratitis, and
wounds caused by foreign bodies, or the ex-
tirpation of an epithelioma. In a case of
corneal ulceration he recommends the fol-
lowing treatment :

1. — Instillations of cocaine between the
eye-lids.

2. — Frequent washings of the conjunctival
cul-de-sac with a 20 to 1000 solution of the
biniodide of mercury.

3. — Instillation upon the cornea of a drop
of eserine, to be followed by the local apply-
cation of the powder of aristol.

4. — Corrosive sublimate, dressing and
bandaging.

The indications for the use of aristol in
ophthalmology, according to the author, are
those connected with the drying up of sup-
puration, or the cicatrization of wounds. The
drug has advantages over iodoform as well
as in infantile medicine.

DIGITALIS AND STRYCHNINE AS CIRCU-
LATORY STIMULANTS.

Digitalis, caffeine, strophanthus, scoparius,
and adonis vernalis constitute a most useful
group of agents that exhibit an action upon
the circulatory apparatus commonly spoken
of as tonic or stimulant ; but, when the
physiological effects of these drugs are con-
sidered critically from the stand-point of
their application to diseased states, it will be
seen that their use is more limited than is
generally supposed. The concomitant actions
upon parts and functions of the organism,
other than the heart and circulation pos-
sessed by each, frequently present a barrier
to their employment, even where the circula-
tory symptoms would seem to indicate their
prompt administration. The indications for
the use of digitalis in heart affections are
clearly understood, but the reasons for and
against its use in many cases of a weakened
and failing circulation do not appear to be
as firmly established. This view of the ques-
tion, together with strong arguments for the
use of strychnine as a circulatory stimulant,
form a basis of a valuable paper published
by Dr. Bradfute (New York Med. Journ.,
.January 10, 1891), who, in the first place,

maintains that in the class of constitutional
diseases, especially those characterized by a
continuous high temperature, accompanied
by any of the various forms of degenerative
change in the organs and muscular system,
digitalis is not the remedy, and where these
changes affect markedly the cardiac structure
it is conspicuously contra-indicated. The
action of the drug upon the muscular fibre is
one of stimulation, followed by an increase
in its force power, and if the fibre is sur-
rounded by, or contains within, its substance
granules or particles of fatty change, it can
be readily seen that the indications are for
the relief of overwork, and not to compel it
to do what it is already physically incapaci-
tated to perform. For example, in typhoid
fever the condition just outlined is always
present, and the administration of digitalis
in doses sufficient to produce even a slight
physiological effect cannot fail to do harm ;
but that this fact is frequently overlooked,
and by practitioners of eminence, there is
ample evidence. In addition to the ugly
action of digitalis upon diseased heart-tissue,
its property of contracting the arterioles,
causing a rise in the blood-pressure, increases
the total amount of cardiac work necessary
to be done, which is so injurious as to result
sometimes in practically a paralysis of the
entire organ, — a mishap that has occurred
after a sudden change from the recum-
bent to the erect posture in instances of
undue exhibition of the drug where there
was no interference by disease with the
normal function of the heart-fibre. Its
influence upon the inhibitory centres also
offers an obstacle to its use when the above-
mentioned objections may not exist, and on
account of this it is well to remember that, as
a rule, subject to modifications attendant
upon exceptional cases, a weak and slow
heart is not amenable to the curative effects
of digitalis ; rather is it a weak and rapid
heart that presents the most favorable oppor-
tunity for the display of its peculiar action.
Phosphorus-poisoning, typhus and yellow
fevers, atheroma, and fatty heart are affec-
tions presenting a pathological anatomy con-
tra-indicating the employment of digi-
talis, especially in the last stages
of these diseases. Aside from its use
in simple heart-disease, unless very
skillfully handled, digitalis is only effec-
tive in the failing circulation of hemorrhage,
shock, and certain acute affections, especially
when the cardiac movements are very rapid,
where the result desired is a bracing up, as
it were, of the general circulatory apparatus
until nature has time to recover herself. In

Periscope. Vol. lxiv

512

shock following head injuries, when the heart
is slow, nitro-glycerine is the better agent, as
it paralyzes the inhibitory centres and dilates
the arterioles, thus promoting the activity
of the heart and increasing the rapidity of
the blood current. But in these instances
there are no degenerative changes in the
heart muscle to negative violent stimulation
of the fibre. In acute phthisis, accompanied
by an irritative fever and a rapid and some-
times tumultuous heart, digitalis is often
very .useful, but it is manifestly unsafe to
administer it in large doses. The Harveian
lecturer of 1890 calls attention to the inde-
pendence of the systemic and pulmonary
circulations, which opens up a new field for
the study of pulmonary therapeutics ; and
it may be that future experiments and obser-
vations may preclude the employment of
many of the drugs now used in lung-affec-
tions ; but, under our present knowledge,
digitalis is an excellent remedy for the fail-
ing heart of continued pulmonary hemor-
rhage and the gray hepatization stage of
pneumonia. In the latter, digitalis does
good so long as the heart does not beat
below the normal rate; when 'the pulse
drops below 70, some other remedy must be
given. In the first and second stages of
pneumonia, when active inflammation is going
on, digitalis is out of place, as it only causes
the heart to pump mure blood into an
already surcharged area, and can have but
little influence over the temperature. In
myocarditis, where exudative material is
poured out in and around the muscular sub-
stance, digitalis adds insult to injury, and the
interference with function from the disease
is only increased.

From these few remarks it can easily be
seen that some of the contra-indications "that
may be present in disease prohibiting the
use of the digitalis, or a remedy having a
similar action, are congestion and inflamma-
tory obstruction in the pulmonary structure ;
degenerative changes in the muscular sys-
tem, including the heart; general interrup-
tion of the nutritive processes, with accum-
ulation of serum in the tissue ; sudden car-
diac failure ; and all conditions in which the
heart-beats are less than normal. Of course,
no iron-clad rules can be laid down ; but if
the drug is given in maladies characterized
by any of the above-mentioned lesions, it
must be used with great care.

In selecting a remedy to combat a failing
circulation, all the structural changes and
diminished or lost functions must be accu-
rately studied and the influences resulting
therefrom duly considered. Without the I

intelligence accruing from such a considera-
tion of a given case, it is impossible to apply
a proper drug, no matter how well known is
its action. A thorough knowledge of the
normal physiological state of the patient, the
pathological changes that have taken place,
and the physiological action of the drug is
essential to successful therapeutics, and in no
instance is a familiarity wiith these three
points more important than in a case of fail-
ing circulation.

In those protracted diseases in which this
formidable symptom arises, the general con-
dition of the patient may be summarized as
follows,: The muscular system is weak,
flabby, degenerated, and ill nourished ; the
nervous system is reflexly disorganized ; the
nerve-conducting paths, chiefly at the periph-
ery, are partially or entirely obstructed, so
that tissue sensation and motility are inter-
fered with and vaso-motor paresis is marked,
thus checking normal physiological change
in part or even in places completely ; the
secretory structures are either exhausted —
not functionating — or their products are un-
fit for use ; the circulatory apparatus is de-
void of tone and strength ; and the total
area of blood space is increased, owing to
paretic dilatation of the smaller vessels. In
such a condition here presented the failing
circulation is due not so much to the disease
per se as to vitiated anatomical structure
and physiological function, and the indica-
tions for treatment are plain. The prime
object to be desired is the restoration of the
function of the spinal cord, reflex centres,
and nerve-endings. A drug that will do
this causes a cessation in the destruction of
tissue and less waste, thereby minimizing the
the drain upon the nutritive elements of an
already deteriorated blood ; vaso-motor
tonus returns, the arterioles and capillaries
contract, the superabundant vascular space
disappears, and hence a larger amount of
blood passes through the heart at each car-
diac cycle, stimulating its action and pro-
moting its nutrition.

Strychnine seems to fulfill all the indica-
tions in the morbid condition above de-
scribed, for the action of this remedy being
expended upon the spinal cord and this part
of the nervous system in conjunction with
the sympathetic playing so important a role
in repairing' and maintaining the various
processes of organic life, it is natural to infer
that an intelligent stimulation of its func-
tional activity would, under such circum-
stances, be a perfectly logical procedure,
provided no structural lesion existed in it.s
substance. Clinical experience seems to

May 2, 189 1.

Periscope.

513

have established the truth of this reasoning,
and Dr. Bradfute extends this evidence with
the report of several cases in which symp-
toms of profound collapse were overcome by
the use of strychnine. Its administration
must, however, be guided by the effect pro-
duced. eV grain of the sulphate may be
given hypodermically every two hours, or
oftener if nesessary, until there is the desired
response. It is interesting to note that in
such a condition of the system large amounts
are easily borne, especially if the patient
has been taking large amounts of alcohol,
and the author states he has given as much
as four grains in twenty-four hours without
producing toxic symptoms. The failing cir-
culation of diphtheria is a typical one for the
exhibition of strychnine, for in this affection
in its severer forms we have all the conditions
present to which its action is antagonistic' —
Therapeutic Gazette.

THE TREATMENT OF CHRONIC RHEUMA-
TISM.

The following prescription is recommended
in the treatment of chronic rheumatism, by
Fothergill {Prog, mid., Jan. 10, 1891).

I^Kj Arsenious acid 1.20 grammes.

Powdered guiac 12 "

Pulverized capsicum 2 "

Aloes and myrrh 12 "

Make 120 pills. A pill to be given 3
times a day, together with a diet rich in
fatty substances.

MEDICINE.

BRIGHT'S DISEASE FOLLOWING INFAN-
TILE PURPURA.

A Moussous (Rev. mens, des malad. de
Fenfance, Feby., 1891, p. 62) reports two
cases of purpura in children, followed by
Bright's disease. In one of them, that of a
child ten years of age, suffering from a
rheumatoid purpura, with haematemesis, al-
buminuria with oedema of the extremities
and face, and disturbances of sight, came on
two months afterwards. The second case
was fatal. It occurred in a child, aged thir-
teen years, who had likewise gone through
an attack of purpura. Haematuria, albu-
minuria and anasarca followed, accompanied
with petechial eruptions, the patient dying
four months afterwards with uraemic and
dyspnoeic symptoms. Post-mortem examina-
tion showed enlargement of the kidneys, and
under the microscope lesions due to a dif-
fused nephritis were observed.

A CASE OF PERNICIOUS ANyEMIA OF
PARASITIC ORIGIN.

Dr. M. Kotcher (Bolnltcheraja Gazette,
Botkina, November 1st, 1890) quotes a
number of authors who are against and for the
fact of intestinal parasites, especially Taenia
Solium and Botriocephales Latus, often in-
ducing pernicious anaemia with all its symp-
toms and signs. The majority of the quoted
authors submit to the fact that very fre-
quently desperate cases of pernicious
anaemia have been known to occur in prac-
tice which depended immediately upon the
mentioned parasites. In the author's own
case, which was a typical one, of pernicious
anaemia, improvement followed after the
expulsion of the parasite. He believes that
the presence of the taenia and Botriocephalus
does, in many cases, cause the whole train of
signs and symptoms mentioned, as character-
istic of idiopathic pernicious anaemia, and
quotes amongst others,, Dr. Roosevelt (A. Y.
Medical Record, 1888), who believes in the
same.

CAR-DICE NERVE STORMS, OR ESSEN-
TIAL TACHYCARDIA.

Dr. H. C. Wood, in a study of several im-
portant cases of this nature, in the University
Medical Magazine, gives some interesting
points.

The definition of the disease, he writes,
would be a recurrent paroxysmal neurosis,
in which attacks of excessively rapid heart
action occur without obvious immediate or
predisposing cause, and without pronounced
pain or excessive cardiac distress, the pulse
rising to 160 and upward, the sounds of the
heart remaining normal ; and it being fre-
quently possible to arrest the attacks by
drinking a glass of cold water and certain
other procedures of apparently trifling im-
port ; the disease having apparently no ten-
dency to shorten life or to develop organic
disease, and being entirely compatible with
great mental and physical activity.

. The length of the attacks was from a few
minutes to several hours. Sometimes they
would be shortened by the patient taking a
long breath, and whilst still holding his
breath, drinking a glass of cold water.
When about half a glass was taken the
heart would suddenly quiet down, three long
slow beats would follow one another and the
normal beat be attained. Sometimes, how-
ever, the attack, instead of being shortened
by this procedure, would be only moment-
arily interrupted. There was no evidence

5H

Periscope.

Vol. lxiv

of valvular or other heart disease during or
between the paroxysms.

One of the most curious phenomena of
tachycardia is the arrest of the paroxysms
by the swallowing of cold water, which is
probably a characteristic feature of the dis-
ease, since it has been noted in almost all
the elaborately observed and reported cases.
It affords a plausible' argument against the
probability of the rapid pulse being due to
pneumogastric paralysis, since Dr. S. Melt-
zer has shown that swallowing is attended
with a loss of tone in the vagi centre, and
consequent weakening of cardiac inhibition
and increased frequency of the cardiac
beats. It is, however, probable that the ar-
rest of the tachycardiac paroxysms by the
swallowing of hot or cold liquids, is due to
stimulation of the inhibitory cardiac centre,
produced by irritation of the peripheral
nerve filaments of the stomach. It is a
well-known physiological fact that irritation
of the abdominal nerves is capable of reflexly
inhibiting the heart, and in one case it was
found that the best method was to swallow
the water as rapidly as possible and as cold
or as hot as could be taken ; if the water is
only moderately cold, much larger quanti-
ties of it are required.

AN EARLY ATAXIC SIGN.

Weiss, of Vienna, says that an early
symptom of locomotor ataxia is an inability
on the part of the patient to walk back-
wards, while as yet, and in other ways, he may
be able to walk with firmness and rapidity.
Perron, of Bordeaux, has also, as we stated
several weeks ago, recently suggested an
early diagnostic sign, which is simply a
modification of the Romberg test, — namely,
causing the suspected ataxic patient to stand
upon one leg, instead of two, with the eyes
closed. If the patient shows a tendency to
fall, it may be inferred that the spinal
trouble has begun which will lead on to
locomotor ataxia, even if the Romberg test
fails, as it not infrequently does in cases that
are not well advanced. — New York Medical
Journal.

CHLOROSIS AND ITS TREATMENT.

Dr. Frederick Scholz, of Bremen, has
published a remarkable work on chlorosis,
the outcome of observations made during the
last twenty years. Instead of regarding the
deficiency of iron or haemoglobin, or even
that of the red corpuscles, as the primary
affection, he states that contraction of the
vessels is always present in these cases, as

indeed was observed by Bamberger, Rokitan-
sky, and Virckow-; and this, he contends, is
not to be regarded as a complication due to
an altered condition of the blood, but as the
primary condition which is followed by the
morbid change in the blood. As a matter
of fact, the vessels are, he says, too full, or
in the condition termed by the older physi-
cians " plethora ad vasa," the blood being —
or becoming — abnormally serous. Long
ago his attention was struck by the cold and
livid condition of the skin in ansemic sub-
jects, and he was led by this to employ hot
baths, together with gentle friction, in the
treatment, with the view of acting directly
upon the skin, so as to improve the vitality
and nutrition generally. The success of his
first attempts was so marked that he was en-
couraged to persevere in this line of treat-
ment, and he has since had many opportu-
nities of extending his experience with it.
Hot baths diminish the plethora by relaxing
the tension of the vascular system, which is
high, quickening the circulation, and thus
relieving the palpitation, dyspnoea, and
other symptoms. In thirty cases where the
distress of the patient was very great, Dr.
Scholz has gone a step further and supple-
mented the hot bath by venesection. Para-
doxical as this treatment may appear, it was
followed by marked benefit, and if the
theory of the pathology of chlorosis above
mentioned be correct, there can be little
doubt that the novel line of treatment prac-
tised by Dr. Scholz is justifiable. — Lancet.

SURGERY.

SURGERY" OF THE LIVER.

An excellent paper on the surgery of the
liver, based upon nine very careful observa-
tions, is published by Terrillon (Bull.
Gener. de Therapeutique, Feb. 15, 1891).
The subject is studied under the topics of
Puncture and Incisions; Operations upon
the Gall-bladder ; Opening of Hepatic Ab-
scesses; and Resection of the Liver. The
author arrives at the following interesting
conclusions :

1. The surgery of the liver only demands
special precautions which can easily be ap-
plied. Under ordinary antiseptic measures,
punctures of the liver are inoffensive.

2. The gall-bladder can always be opened
and drained. This operation is known
by the name of cholecystectomy. If there is
obstruction of the ductus choledochus, open-
ing of the gall-bladder is a simple palliative.
When it is permeable, the cure is rapid, and

May 2, 1 89 1.

Periscope.

515

no fistula will remain. Nevertheless chole-
cystectomy should not be practiced unless
under special indications. Its utility is
not unfrequently doubtful, whereas simple
incisions with proper drainage give equally
good results.

3. The ablation of a piece of liver is an easy
and benign procedure. To insure hsematoris
a band of caoutchouc may be placed be-
tween the healthy portion and the diseased
part.

THE PROPER TIME OF DAY IN WHICH
TO OPERATE.

Surgeons have been divided in their
opinion as to which part of the day is the
most favorable for the performance and suc-
cessful outcome of operations. The British
Medical Journal discusses the matter in a
recent number, stating that the advocates of
morning operations assert that the patient
is thereby saved the suspense of waiting un-
til the afternoon, and that a better supply
•of sun-light, or its equivalent, can be de-
pended on. Others, instead, say that morn-
ing operations imply an anxious and sleep-
less night for the patient, and that as night
comes on more rapidly when the operation
is performed in the afternoon, better chances
for the patient's rest and sleep are secured.
They also state that long operations seri-
ously tax a surgeon's nerves and strength,
and that for that reason the afternoon is
preferable. In this respect we cannot alto-
gether agree with them, thinking that by
morning operations the surgeon secures the
time at which he is best provided with mus-
cular and nervous force, that have not been
exhausted by the forenoon's work. We
are also inclined to think that whether the
operation be done early or late, its influence
upon the previous night is about equal in
either case. Those who operate frequently
in the afternoon know the discomfort of
finishing their operations by artificial light.

The Journal states that wherever freedom
from noise and plenty of warmth can be
procured, especially in summer, morning is
probably the best time. We are inclined
to think that, as darkness comes early in
winter, morning operations are also indicated
at that season. — International Journal of
Surgery, Feb., 1891.

A NEW METHOD FOR THE TREATMENT
OF INJURIES TO THE SHOULDER.

Dr. Monks reports about twenty-five cases,
including some in which rheumatism un-
doubtedly played a prominent part. In

most of the cases the ordinary methods of
treatment had been tried in vain. The result
was a more or less perfect cure in about two-
thirds of all cases tried, in a period of time
varying from a few days to a few weeks.
The most hopeful cases were those which were
purely traumatic. The principal involved
in the treatment was that the shoulder is
more perfectly in a condition of actual rest
when the arm is supported at right angles to
the trunk, than when the elbow is kept at
the side, because (1) the weight of the upper
extremity is thus entirely taken off the
shoulder; (2) the deltoid and other struct-
ures covering the joints are relaxed ; (3) the
circumflex nerve and other deeply seated
structures are relieved from pressure. In
applying this method of treatment, the
whole weight of the upper extremity is taken
upon the platform-shaped splint, which is
supported by a firm band of webbing passing
over the other shoulder. The cases for which
this form of treatment is especially adapted
are, those where the prominent symptoms are
persistent pain and tenderness in the shoul-
der, or inability to raise the elbow from the
side. — Boston Med. Journal.

THE PREPARATION OF LIGATURES.
Dr. J . Schou ( Ugeslcrifl for Lceger) recom-
mends the following methods of preparation :

1. Sublimate Catgut : Commercial catgut
is wound upon glass spools and placed in 5
per cent alcoholic solution of corosive subli-
mate. This solution is changed repeatedly
until it remains clear (Bergmann). An-
other method is to place the catgut in a 1
per cent, solution of sublimate for twelve
hours, and then to preserve it in a one-half
per cent, sublimate solution containing 10
per cent, of glycerine (Schede and Kummell).

2. Carbolized Catgut : Commercial catgut
is wound upon spools, and placed for forty-
eight hours, in a 5 per cent, solution of car-
bolic acid. It is then transferred to a vessel
containing a fresh solution of the same
strength, when the gut is removed from the
spool, and then again firmly wound upon it
and preserved in a 5 per cent, solution of
carbolic acid in alcohol (Block).

3. Carbolized Silk : The silk is boiled in
a 5 per cent, carbolic solution for a period
varying from ten minutes to an hour and a
half, according to the strength of the silk,
the fluid being renewed every half hour.
The silk is preserved in 2 per cent, watery
solution of carbolic acid (Czernv).

4. Sublimate Silk : The silk is boiled for
two hours in a 1 percent, sublimate solution,
and preserved in a 1 to 1,000 solution

5i6

Periscope.

Vol. Ixiv

(Schede and Kiimmell). — Deutsche Medizin,
Zeitung, Jan. 22, 1891.

Transplantation of Tissue from Lower
Animals to Man.

The case of transplantation from an ani-
mal, recently performed at Charity Hospital,
New York, by Dr. A. M. Phelps, has com-
manded a wide-spread attention, and all sorts
of absurd rumors have been circulated. The
operation is a success in so far as it estab-
lishes the principle that it is possible to grow
large masses of tissue from an animal to man,
and to establish the circulation until the
union takes place between opposite species
without danger to either. It also demon-
strates that a growth of new bone takes place
when a section of bone is transplanted and
its nutrition maintained by the artery of the
animal. This, if continued four or five
weeks, would probably unite a fracture.
Owing to the inefficient dressings which are
apt to occur in early operations, the contact
of the transplanted bone could not be con-
tinued sufficiently long for bone to unite to
bone. Dr. Phelps is confident, after viewing
the specimen, and taking all conditions and
surroundings into account, that bony union
would have taken place if actual contact had
been maintained for a longer period. The
stimulation of the graft, however, has excited
a reparative process in the fracture, and it
now promises fair to unite. The boy walks
with the aid of one crutch, or a cane.

History of the case. — In the month of
November, last year, the patient at Charity
Hospital was sent to Dr. Phelps for operation.
Briefly, the history of the case is this :

The lad, John Gethins, was suffering from
.an un-united fracture of the lower third of
the leg, the result of an operation to remedy
an anterior curve of the tibia, which had ex-
isted and had slowly increased from early
childhood, until he was compelled to go upon
crutches.

There was no paralysis of the limb, neither
was it atrophied, excepting from non-use ;
the muscles were perfect in every respect.

A few months after the operation of osteot-
omy, Dr. Phelps cut down upon the fracture
and wired it, but failed in getting union.
After a few months he again operated, re-
moving all cicatricial tissue, carefully stitch-
ing the periosteum together, and wired the
bone. This failed. A few months later he
again cut down upon the fracture, removed
all cicatricial tissue, and again freshened the
ends of the bone, and engrafted decalcified

bone chips, according to Senn's method.
This failed ; the chips came away from the
wound a few weeks after the operation. He
then resorted to Thomas's method of ham-
mering, damming, and adjusting an appli-
ance for the boy to walk upon. This he
wore for several months, but again he failed
to secure union. In the mean time the boy
had returned to his home.

It seemed a pity to amputate the leg. He
had arrived at that stage of the case where,
so ^far as our present knowledge was con-
cerned, amputation was the last and only
step to be taken. With all of these facts be-
fore him, Dr. Phelps felt justified in attempt-
ing any experiment which would promise to
succeed in restoring the limb to usefulness,
provided the danger to life was not too great.

The brave lad had submitted to every
means known to surgery for the relief of his
condition, and, discouraged and heart-broken,
had returned to his home. When he was
told there was another chance for his limb,
his face brightened, and he said, " Doctor, I
will take that chance." After consulting"
with the members of the Medical Board, ot
Charity Hospital, and several eminent sur-
geons of this city, he decided upon an oper-
ation.

It is a well known surgical fact that an
amputation performed in the growing limb
below the knee, or in the humerus/ frequently
results in what is known as a conical stump..

This necessarily leads to re-amputation,
and many amputations have been performed
from year to year, in the same case, for this
abnormality. This was one of the reasons,
but not the greatest, why he hesitated to
amputate the limb.

A dog two years old was secured and pre-
pared for the operation, carefully cleansed
wTith soap and water, and made aseptic with
a solution of bichloride of mercury.

While the patient was being anaesthetised
and the ends of the fractured bones fresh-
ened, his assistants, Drs. Plimpton and
Mooney, prepared the dog, in the following
manner : She was etherized, and then en-
veloped in a thick layer of absorbent cotton
to the thickness of several inches, while
placed in the natural sitting posture. Over
this soft covering of cotton a few turns of a
plaster-of-Paris bandage were made, to hold
the dressing in place. The dog was not en-
cased in plaster-of-Paris ; the right foreleg
of the animal protruded through the dressing.
This leg was carefully shaved, and again
made aseptic with bichloride of mercury,
and finally with ether. The dog was now
ready for the operatiou.

May 2, 1 891.

Periscope.

517

Two elliptical incisions were made down
to the fracture, four inches in length, remov-
ing the old cicatrix and cicatricial tissue
about the ununited ends of the bone, to-
gether with an elliptical piece of the soft
parts. With a saw the ends of the bones
were freshened, leaving a space about one
inch between them. The portions removed
proved to be eburnated, and more like ivory
than bone.

The limb of the patient was now prepared
for the next step in the operation, by en-
veloping it in a plaster-of-Paris bandage,
commencing six inches above the incision,
and extending to the upper third of the
thigh. The foot and ankle were also covered
with a plaster-of-Paris bandage. While the
surgeons were preparing this part of the dress-
ing, the assistants were preparing the dog. An
incision was made through the skin, for the
purpose of cutting a piece which would
accurately fit the elliptically-shaped wound in
the patient's leg. The elbow was now quickly
excised ; the radius and ulna were severed
one-half inch in front of the elbow-joint, and
the humerus three inches above it, and re-
moved.

The extremity, near the paw, was ampu-
tated, leaving a piece of bone one inch in
length, attached to a branch of the brachial
artery among the soft parts.

The attachment of the biceps tendon was
detached from the bone and loose superfluous
muscular tissue removed. In the dog the
nutrient artery enters the bone one inch in
front of the elbow-joint. Cutting the bone,
as indicated above, saved the nutrient artery
from injury, and secured the nutrition to the
fragment of bone, from which it was hoped
that new bone would be thrown out, and
at the same time stimulate the human bone
to a reparative effort.

The dog was placed by the side of the
patient's leg, the head toward the patient.

An aluminum dowel-pin was passed
through the medullary cavity in the long
axis of the bone. This was though a mistake.
A steel pin inserted into the solid portion of
the bone would not interfere with the circu-
lation so much. The piece of bone was
placed between the ends of the bone of the
patient. The bones were crowded together,
the dowel-pin entering the bones of the
patient above and below. A silver wire
was passed around the entire graft, and se-
curely tied. This held the bone securely in
place. Muscle was stitched to muscle, and
skin to skin, the parts being evenly coapta-
ted. A large drainage tube was inserted for
drainage, which opened posteriorly. A few

turns of the plaster-of-Paris bandage secured
the iron rods to the leg. The wound was
dressed antiseptically.

Through the entire operation the most
rigid antiseptic methods were carried out.
Constant irrigation prevented the possibility
of wound infection. The operation can be
performed in an hour with efficient dressers.
The operation appears difficult and compli-
cated, but is quite simple when understood.

The patients (for we must now say pa-
tients) were put to bed. Both recovered from
the anaesthetic rapidly. Small doses of
morphine were used for both, from time to
time, to allay, not so much the pain, as the
uneasiness caused by the forced confinement.
After three days this uneasiness passed away,
and from that time on the dog and patient
became friends, administering to each other's
comfort — the patient by feeding and playing
with the dog, and the dog by vigorous wags
of the tail which showed her appreciation
of the kindness.

Before the operation was performed the
vocal cords of the dog had been carefully
severed, under ether, to prevent any disturb-
ance of the patient. At the end of two weeks,
however, the cords had again re-united, and
the voice of the dog sounded fully as strong
as before the operation. The only pain
caused to either patient was the twitching ot
the muscles of the dog as she shrank in her
bed from the loss of adipose tissue. This
might have been prevented by a simple pro-
cedure at the time of operation.

On the sixth day the case was dressed.
The wound was found perfectly healed by
primary union, without a single drop of pus.
Only for the difference in the color of the
skin it would have been difficult to detect
the line of union. On the eighth day it was
again dressed and the union was still perfect
and more firm. Finally at the end of eleven
days, there was an apparent shrinkage of the
dog in the dressings. This allowed of mo-
tion, and it became evident that the graft
would be pulled from its attachment within
a few days. Consequently, as much as it was
desired to continue the experiment, Dr.
Phelps concluded as an act of humanity to
sever the bond of union. He was prepared
to do this the moment that he discovered
that any surgical interference would become
necessary, which would inflict additional
pain to either, in order to continue the ex-
periment.

The dog was chloroformed during the
operation.

While the graft was being trimmed, and
the leg of the patient dressed, the artery was

Si8

Periscope.

Vol. Ixiv

secured and nicely stitched up the stump of
the dog's leg. She was then placed in bed
and cared for by the nurse. As the graft
was trimmed down to the parts still attached
a free oozing of blood took place through
the graft, which demonstrated the fact that
union had taken place and that circulation
had been established between the patient
and the dog. Both patients rapidly con-
valesced. The boy spent his time writing
letters to his friends and reading the papers
and postal cards from persons praying that
the effort to save his leg might not be a
failure.

The wound was dressed and the graft ex-
amined daily. At the end of five weeks it
was discovered that the bone showed no
further sign of uniting, and desiring to give
the bby every chance for union of the fract-
ure it was removed. The rods, also, were
removed, and the ends of the patient's bones
placed firmly together, hoping to secure
union because of the stimulation produced
by the graft. The bone graft was irregularly
covered with a new growth of bone, thus
proving, he believed, that an effort had been
made to unite the fracture.

This was the result of eleven days' contact,
whereas at least thirty days are required for
bony union to take place.

The canal of the bone was also filled with
a new growth of bone, excepting where the
dowel-pin passed through.

The average temperature recorded in the
patient was about 99i°, in the dog 99 f#.
The average pulse of the boy was about 95.
The normal temperature of the dog is above
a hundred, that of the human being 98£° F.
The temperature of the dog fell to below a
hundred and that of the boy rose to near a
hundred, or the same as that of the dog,
where it remained for weeks. The pulse of
the boy rose and the dog's fell until they
beat nearly the same number of beats per
minute, varying from ninety to one hundred
and ten. The boy ate, slept, and felt well.
There was no sepsis. Whether this peculiar
condition of temperature and pulse was due
to the interchanging of blood between the
animal and the patient, he was unable to
say ; further observation is necessary to
verify it.

After the eleventh day, owing to the
plaster-of-Paris accidentally getting into the
wound, pus for the first time was seen. This
rapidly disappeared.

The operation had a two-fold object : first,
to establish the fact that large masses of soft
parts could be transplanted from an animal
to man ; second, to unite an ununited fract-

ure by a section of bone from the dog. It
was successful in demonstrating the first
proposition, but partially failed in the
other in so far as the actual growing of
the bone into place is concerned. This was
due entirely to a defect in the dressings.
The principle of transplantation established
means much to humanity ; its application
will be found useful in many cases which now
defy the best efforts of the most skillful sur-
geons in the world.

Among the cases suitable for the applica-
tion of the principle are those cases of fract-
ures which resist all efforts for their union,
and which must necessarily result in ampu-
tation ; ulcers of a particular class which
can be cured by no means known to surgery.
Scalps ripped from the heads of factory girls
by machinery. Months and often years have
been taken to skin-graft back the scalp to
cover the skull, and numerous friends have
been flayed to supply the material.

Thiersch's method of skin-grafting has
been a step in advance of the older methods,
but a martyr must be fo^nd to submit to
the flaying. A dog wTould be found better
adapted for the work as hair could be trans-
planted with the flap. Sloughing, follow-
ing amputations in the upper third of the
tibia resulting in cicatricial contraction with
indolent granulations covering the end of
the stump caused by the bad circulation
from pressure are now cured. But how?
By amputation at the knee-joint or else so
near to it that an artificial limb cannot be
worn without a useful knee-joint. Animal
transplantation should be resorted to before
amputation is performed.

If circulation could be established be-
tween opposite species, the elements of whose
blood differed, without injury to either, a
step would be taken which might lead to the
relief of many a sufferer. Then large masses
of tissue could be grafted from an animal to
man, the circulation of the animal furnish-
ing that which the patient could not supply,
as in bone-transplantation. Or in grafting
of soft parts the circulation of the dog would
keep alive the graft until it had become
firmly united to the patient, then it could be
severed.

In bone-transplantation it was expected
that in four or five weeks the animal would
have thrown out a provisional callus and at
the same time stimulate the fracture to repair.
A dog was selected because the elements of
its blood very closely resemble those of man.
The reparative energy of a dog is very
strong and his power of endurance great.
No unnecessary cruelty is inflicted and aside

May 2, 1 891.

Periscope.

519

from the confinement but little suffering
occurs. Of course, it is useless to reply to
those who have denounced the operation as
cruel and unnecessary. Those who under-
stand the motive which actuates the surgeon,
can comprehend how, with all sympathy for
the brute, his sacrifice of limb may be de-
manded for the good of his master, man.
They, too, can appreciate the reluctance of
the surgeon to inflict wanton suffering,
whether upon man or brute, and can under-
stand how such an operation only seemed
commendable when a more than commensu-
rate benefit was promised. To those whose
eyes are blind to human suffering, and whose
sympathies are all for the brute, we have
nothing to say.

This poor lad personally demanded that
every means should be exhausted which
promised relief before amputation should be
resorted to. He still demands it, and the
demand is one which a humane surgeon
should consider before resorting to an opera-
tion which would involve the loss of a limb
and possibly life.

GYNECOLOGY.

WHAT EXPERIENCE TEACHES ONE TO
UNLEARN.

One of the most respected gynaecologists
of this country, Prof. William Goodell, in
the University Medical Magazine, has re-
cently stated that " every earnest worker in
any field of the inexact sciences finds him-
self compelled to unlearn as well as to learn,"
and on this basis he communicates a sketch
of a . number of things, chiefly traditional
teachings, which he has himself, in his own
experience, learned to unlearn. His sum-
mary, of course, relates to the special branch
of which he has been a distinguished teacher
and practitioner ; but many a general practi-
tioner, if he were as honest and candid,
could teach his professional brethren similar
lessons. Among other things cited by him
are the following :

He has learned to unlearn the grand-
motherly belief that the climacteric is in it-
self an entity, and that, as such, it is respon-
sible for most of the ills of matronhood, and
especially for that of menorrhagia.

He has learned to unlearn that anteflexion
and anteversion in themselves — that is to
say, as displacements merely and without
narrowing of the uterine canal — are neces-
sarily pathological conditions of the womb.

He has long since abandoned the idea
cherished by that class of waistless and wit-

less nurses, now happily obsolescent, that the
parturient woman is to be swathed like a
mummy and to be kept as immovable.

He expresses his disbelief that mammary
abscess comes from " caked " breasts, or from
breasts overdistended from a secretion of
milk too great for the infant's needs. Mam-
mary abscess, in the suckling woman, comes,
in his opinion, from cracked nipples, and
from cracked nipples alone.

He has wholly freed himself from the be-
lief that cellulitis is at the bottom of most
female ailments, and that the hot-water
douche is its cure-all.

He has learned to unlearn the teaching
that woman must not be subjected to a sur-
gical operation during her monthly flux.
Our forefathers, from time immemorial, have
thought and taught that the presence of a
menstruating woman would pollute solemn
religious rites, would sour milk, spoil the
fermentation in wine-vats, and much other
mischief in a general way. Influenced by
hoary tradition, modern physicians very
generally postpone all operative treatment
until the flow has ceased. But why this
delay, if time is precious and it enters as an
important factor in the case?.

Long ago he came to the conclusion that
the womb, like the nose, has its own secre-
tions ; and that, because the cervical canal
is stopped up with mucus, it is not to be
treated any more harshly than a stopped-up
nose. This nasal analogy led him soon to
think that even uterine catarrhs are not of
such paramount importance as to merit
heroic treatment, and that metritis and
endometritis, in so far as symptoms are con-
cerned, are often idle words.

He has learned to unlearn the idea — and
this was the hardest task of all — that uterine
symptoms are not always present in cases of
uterine disease ; or that, when present, they
necessarily come from the uterine disease.
Seemingly urgent uterine symptoms may be
merety nerve-counterfeits of uterine disease.
He has, therefore, long since given up the
belief which, with many, amounts to a creed,
that the womb is at the bottom of nearly
every female ailment. As an outcome of
much that he has learned to unlearn, Pro-
fessor Goodell has arrived at this very short
gynaecological creed : " I believe that the
physician who recognizes the complexity of
woman's nervous organization, and appreci-
ates its tyranny, will touch her well-being at
more points and with a keener perception of
its wants, than the one w-ho holds the opin-
ion that woman is woman because she has a
womb." — College and. Clinical Record.

520

Periscope.

Vol. lxiv

ENDOMETRITIS AND ITS TREATMENT.

Dr. Paul F. Munde, in speaking of a pa-
tient having what is known as a chronic en-
dometritis, said that this is not a proper name
to give it, because there is no inflammation
present. Continuing his remarks he said :

Now, that you may more clearly under-
stand this condition, and the manner in
which this discharge is brought about, I will
try and explain its mechanism to you in as
few words as possible. After confinement
the membrane which lines the cavity of the
uterus is, as you know, shed, and a fresh
mucous membrane is formed beneath it. If
this membrane were shed off at once, it
would leave underneath it a raw, bleeding
surface, which is not mucous membrane at
all. This process of shedding is, however, a
gradual one, and it takes about two months
before a new membrane has been formed
and the uterine mucous membrane has re-
turned to the same condition.

The treatment resolves itself into drainage
and the application of mild astringents or
caustics to the endometrium. I think the
tincture of iodine will answer best in this in-
stance, though iodized phenol for a first
application might be preferable. In apply-
ing this fluid it is necessary to protect the
vagina from injury by a pledget of cotton
or other material, for carbolic acid or iodine
will destroy the epithelium of the vaginal
wall.

This application is made by means of a
cotton wrapped applicator, which after its
introduction into the cavity of the uterus,
should be permitted to remain there for a
minute or so, for by too rapid a withdrawal
of the instrument, you are very apt to tear
away the eschar that may have formed as a
result of the application. Have your tam-
pons of tannin and iodoform ready, so that
you can apply them on withdrawal of the
applicator. Instruct your patient to keep
quiet the rest of the day, and remove the
tampons on the following morning, and use
hot douches at a temperature of 110° or
115° F., with the patient in a recumbent
position. In about four days you may again
repeat this intra-uterine medication, and if
you then find that there is little or no oozing,
you can conclude that you have done enough
cauterization, and apply the compound
tincture of iodine in the same way. The latter
treatment may have to be kept up for several
weeks or months.

There are varidus other ways in which
these applications can be made to the endo-
metrium, besides the one I have just alluded '

to. The practice of injecting iodine or other
fluids by means of a syringe into the uterus
is certainly a much more efficient method,
but it may prove so very efficient that you
will not desire to try it a second time. I
have seen uterine colic follow its use, and
the uterine colic thus induced, is apt to be
so severe as to bring on collapse. There
have been cases of death from peritonitis, oc-
curring as a result of this procedure. I
therefore, warn you against this method of
applying these medicinal agents to the in-
terior of the uterus. Some years ago I
devised a fine syringe with a point no larger
than a sound, perforated with numerous
little holes, with which I made applications
to the uterine cavity. I used a weak solu-
tion of nitrate of silver for this purpose, but
found so much pain followed its employment
that I have refrained from resorting to this
method for the past four or five years.

Another form of making applications to
the interior of the uterus is by means of
pencils of gelatine, containing the medicinal
agents you wish to employ. There is one
great drawback to this procedure and that
is the impossibility of obtaining gelatine
pencils that remain soft and flexible. I have
had a large number of these pencils prepared,
but have discovered that in the course of a
few weeks they become so hard that they act
as irritants, and give rise to severe colic.

Another agent I employ to a great extent
for intra-uterine medication is a fifty per
cent, solution of chloride of zinc. This is a
very effective remedy, but it is necessary to
keep the patient in bed after using it. It
should be applied but once in ten days, and
only a few times in any given case.

The sine qua non for intra-uterine applica-
tions is a patulous uterine canal, with the
external and internal os so wide as to permit
the passage of a good-sized applicator,
wrapped with a large film of cotton, up to
the fundus, if you choose. Of course, in all
instances, the removal of the cause of the
affection by appropriate remedies, if yon can
do so, is the proper course to pursue, whether
that cause be pelvic congestion, prolapse,
constipation, abdominal plethora or some
other condition.

OBSTETRICS.

ANAESTHETICS IN RELATION TO MID-
WIFERY.

W. K. Eeid ( Glasgow MedicalJournal). —
In the course of a discussion on anaes-
thetics at the Glasgow Medico-Chirurgical
Society, observed that chloroform and ether

May 2, 1891,

Periscope.

52i

were equally valuable for securing thorough
anaesthesia in operative midwifery. For the
administration of chloroform he preferred a
single ply of flannel on a small wire frame
used with a drop-bottle. In this way a mild
degree of anaesthesia could be readily kept
up, and deepened in a minute or two if re-
quired. In the case of ether he advocated
the use of Clover's inhaler as the only safe
plan. He had,, indeed, substituted ether by
the open method when a patient seemed very
weak, and no bad result followed. On the
only occasion, however, when he used ether
during a lengthened operation the patient
was ill for a fortnight afterward with bron-
chitis and congestion of the lungs. The
ether was administered on a sponge in a
water-proof cone. Ether had been given in a
recent case by Clover's inhaler with perfectly
satisfactory results. While he always ex-
amined the heart before giving an anaesthetic,
yet the knowledge that heart disease existed
only made him more anxious to use chloro-
form or ether, "because in such cases the
strain of a severe labor is vastly more dan-
gerous without an anaesthetic than with it.
The same holds good with regard to dis-
eases of the kidney." After five-and twenty
years' experience of anaesthetics in mid-
wifery cases, Dr. Reid said he had never
seen a fatal issue. While his experience of
chloroform had been very large, that with
ether had been just as limited. " A lying-in
woman is peculiarly fitted for escaping the
dangers usually connected with anaesthesia.
The left ventricle of the heart is considerably
hypertrophied, and so less likely to weaken
readily in its action. She is kept in the
recumbent position, and so, to that extent,
defended from syncope. The action of the
heart is aided by the alternate relaxation
and contractien of the uterus, and, lastly,
the anaethesia tends to produce anaemia of
the brain, whereas the labor pains give rise
to an engorgement of that organ. These
causes, taken together, seem to me to account
for the great rarity of fatal results in con-
nection with obstetrical anaethesia." He is in-
clined to believe that there is some truth in the
assertion that chloroform may kill a lying-in
woman by inducing post-partum haemor-
rhage. That danger, however, can be quite
set aside by the use of the subcutaneous in-
jection of ergotin and by manual compres-
sion of the uterus. He has good reason for
believing that chloroform has no danger to
the foetus. He admits it is hard to explain
why, with chloroform circulating in the
blood of the mother, the foetus should not
run a good deal of risk. He comes to the

following conclusions : " 1. In severe labor
and the ordinary operations I am content to
use chloroform in view of its convenience
and safety in those circumstances. 2. In
long and severe operations, especially where
there is much loss of blood, I prefer ether,
given by means of Clover's inhaler. This
involves more trouble, but its probable
greater safety ought to turn the balance in
its favor. 3. I hold strongly the belief that
while it is advisable to have two medical
men present when an anaesthic is given, it
would be wrong to enforce this by law. —
Archives of Gynecology.

THE DIAGNOSIS OF PLACENTA PREVIA
BY PALPATION.

Spencer reports in detail seven cases of
placenta praevia in which he diagnosticated,
by abdominal palpation, the presence of the
placenta in, or its absence from, the front
wall of the lower uterine segment, the diag-
nosis being subsequently verified by internal
examination. The cases were head presenta-
tions in multiparae before pains were pres-
ent and before the membranes had rupt-
ured ; no anaesthetic was used.

In three cases the exact site of the pla-
centa on the front wall of the lower segment
was determined ; in two cases the placenta
was felt when by vaginal examination it
could not be found. The absence of the
placenta from the anterior wall was diag-
nosticated in four cases.

The patient should lie on her back for
these examinations, the bladder having been
emptied ; the examination should be gentle,
made in the absence of pains, prolonged for
several minutes, or repeated, if needed.
When the placenta is in front of the head,
it is felt as a spongy mass between the
fingers and the head. Its edge feels like the
segment of a circJe, within which the touch
is obscured ; outside the child is plainly felt.
Impulses to the head through the placenta
are distinctly felt where the placenta is ab-
sent.— American Journal of Medical Sciences.

PEDIATRICS.

THE TREATMENT OF WHOOPING-COUGH.

In a lecture delivered at the Hospital for
Sick Children, Paris, Jules Simon {Journal
de Medicine, 1890, p. 577) remarks that the
treatment of the first period is of great im-
portance, for the future progress of the case
depends upon the care which is given to it at
1 that time.

522

Periscope.

Vol. lxiv

One must be well convinced, contrary to
the method which was followed formerly, of
the necessity of keeping the child indoors ;
it is often even necessary to keep him in bed
as one would do for a serious attack of bron-
chitis'. Archambault has insisted upon the
importance of this fact, and since Simon has
adopted the same plan he has observed al-
most no complications in whooping-cough
in children who were cared for in time.
The pharmaceutical means are not to be
neglected, but at best are only secondary;
belladonna is, perhaps, the best of all. It is
well to employ the following formula :
Tincture of aconite root, tincture of bella-
donna, elixir of paregoric, equal parts— ten,
twenty, or thirty drops a day, according to
the age of the patient ; if there is fever in-
crease the aconite, or if intestinal catarrh
increase the paregoric. Chloral may be
given in the evening and sulphate of quinine
in the morning. These drugs may be used
by injection, the former in 15-grain doses,
and the sulphate of quinine in three- to five-
grain doses, especially if the heart is
agitated. We must combat the catarrhal
secretions if they are too abundant ; under
these circumstances an emetic may be given
once a week; with the infusion of wild
narcissus (daffodil) given every two or three
days one obtains a state of mild nausea
which favors the expulsion of the secretions ;
rhatany will also diminish them ; of this we
may give from three to five grains of the ex-
tract before each meal. Coffee is advised,
to combat the dyspepsia. The treatment
for the third period is that directed to the
bronchial adenopathy ; it consists princi-
pally in the use of tonics, iodine, cod-liver
oil, etc., and later, an outdoor life.

To the remedies referred to above, one
may add, with advantage, in certain cases,
henbane, to combat the meteorisra, in doses
of from two to ten grains a day, warm fric-
tion of the abdomen with chamomile oil,
containing tincture of nux vomica, 4 parts
to 100, combined with digitalis when there
is anuria, a thing that often happens. —
American Journal Medical Science.

TREATMENT IN CONVULSIONS IN
CHILDREN.

In a case of convulsions in a child, if the
patient is cyanotic, a few whiffs of amyl
nitrite, followed by inhalations of chloro-
form to relax spasm, should be given. These
should be followed as soon as possible by
hypodermic injection of tincture of veratrum
viride, one-half drop for each year of age up

to six years. The veratrum may be repeated
in half an hour or an hour, if the convulsions
recur. If the convulsions are ursemic, a
small dose of morphine may be added or
given separately. In all the cases in which
I have employed the foregoing treatment the
effect was remarkably good, and in but one
case have I had to repeat the injection of
veratrum. The convulsions cease, the mus-
cles relax, the pulse becomes slower, the
temperature falls, and the skin becomes
moist. Indeed the danger is over in less
time than by any other means I have seen
employed. Appropriate after-treatment, as
may be indicated, should, of course, be
adopted. — Med. Neivs.

HYGIENE.

AN ANALYSIS OF THE STATISTICS OF
FORTY-ONE THOUSAND, FIVE HUN-
DRED CASES OF EPIDEMIC
INFLUENZA.

Dr. Benjamin Lee, in The Journal of the
American Medical Association, March 14th,
1891, summarizes the replies of 265 physi-
cians to inquiries made, having a practical
bearing on the grippe epidemic of last year,
and furnishes some valuable statistics :

People appeared to look forward to the ap-
pearance of la grippe on 'this side the ocean
as an experience, which, on the whole, would
constitute a mild amusement, rather than an
occasion of suffering, distress, terror and
death. A very few weeks, however, suf-
ficed to convince both the public and the
profession that influenza meant a good deal
more than a bad cold in the head.

Discovering this fact, and observing the
serious involvement of the nervous system
in a large percentage of the cases, the in-
quiry suggested itself to those who were
looking for nothing more than a bronchial
catarrh, " Is this influenza after all, or is it
some other epidemic disease, and if some
other, is it not dengue ?"

The first point of distinction that we may
make is in regard to the mode of extension
of the two affections. Influenza, as we have
had recent demonstration, spreads like a
flood, inundating whole sections in an hour,
w7hile dengue works along gradually, estab-
lishing centres of infection here and there,
enabling its course to be easily traced. In
their sudden onset, intense headache, pain
in the back and limbs, and excessive lassi-
tude they have much in common, but, while
the fever in dengue is invariably of a high
grade, in influenza it is often slight or ab-

May 2, 1 89 1. Periscope.

523

sent altogether. The catarrhal and pneu-
moniae complications of influenza, the dysp-
noea, the feeble piping voice, are very rare
in dengue, while on the other hand, the lat-
ter is characterized by violent and persistent
gastric disturbances.

An erythematous eruption followed by
desquamation, beginning in the face and de-
scending, is rarely absent in dengue, and as
rarely seen in influenza. Dengue very rarely
terminates fatally, influenza, as we know to
our cost, often does. While, therefore, there
are points of similarity between the two af-
fections, especially in regard to their nervous
pnenomena, the distinctions are sufficiently
marked to prevent any misconception, when
large numbers of cases are under considera-
tion.

It is probable that not a single individual
entirely escaped its pernicious effects. Its
manifestations were so various, affecting in
one the bronchial tubes, in another the
nervous system, now the brain and now the
bowels, here peritonitis and there pneu-
monia, that it was a long time, compara-
tively, before physicians, even, recognized it
in its protean forms. It is scarcely con-
ceivable that a disease which spreads with
such astonishing rapidity, goes through the
process of re-development in each person in-
fected, and is only communicated from per-
son to person or by infected articles. And
yet this theory has been maintained by a
few authorities who claim that it is always
more prevalent along lines of travel, and
that it did not progress more rapidly than
modern means of communication would en-
able it to do.

The following is an analysis of the results
obtained :

Number of physicians reporting, . . 265

Number of cases 37,275

Adults, 26,302

Children, 10,973

Number of cases nervous, .... 6,913
Number of cases catarrhal, .... 16,434
.Number of cases inflammatory, . . 5,829
No. of deaths directly caused, 56 "I 9R1
No. of deaths indirectly caused, 205 J
Immediate cause of death, bronchitis, 8
" " " pneumonia, 117

" " " phthisis, . 42

" " " nervous, . 21

Supposing, which there is no reason to
doubt, that the 265 physicians who replied,
represent a fair average of the practitioners
of the State, this would give us 1,120,000
persons as having been sufficiently ill with
the disease to demand medical aid or come
beneath the observation of a medical man,
and 7,879 deaths directly or indirectly
caused by the epidemic influence in the

State of Pennsylvania alone. We know
that there were many who suffered mild at-
tacks who never sought advice, and many
more whom physicians, in their excessive
haste, failed to enter on their visiting lists
although they may have prescribed for
them.

In fact this is exactly the return that was
made in some instances :

"Treated an immense number of cases
but kept no record."

Nearly one-half of the cases reported were
in the city of Philadelphia. As the Phila-
delphia physicians reporting constituted
only about one-third of the whole number,
the disease must therefore have been more
prevalent in large cities than in the country.
To be exact, the average of cases to each
physician reporting was 140; while the
average to each Philadelphia physician re-
porting, was 193.

The disease seems to have been especially
prevalent in mining towns. Two physicians
in Shamokin, a place of about 12,000 in-
habitants, report 950 cases between them.
In Greensburg, a place of about 6,000 in-
habitants, two physicians report 737 cases.
In the little village of Portage, Cambria
County, numbering 650 inhabitants, one
physician reports 400 cases. Ill-fated Ply-
mouth suffered seriously as did the most of
the other mining towns and villages of Lu-
zerne County. Scranton was also severely
visited.

One curious fact developed by the in-
vestigation is that the disease was observed
quite as early in the extreme western por-
tion of the State as in Philadelphia on the
eastern border. Indeed, more observers in
proportion to the population report having
observed cases in November in Allegheny
County than in Philadelphia County : as
though a disease-bearing air current had
passed over the eastern border at a great
altitude and dipped down in the western
portion of the State.

Of the 265 physicians reporting 206 made
the distinction as to the predominant type
of the disease. While it is to be regretted
that all did not, still this number, repre-
senting more than 29,000 cases, is ample for
purposes of deduction.

Nearly 7,000 of these are recorded as be-
longing to the nervous type. This is very
nearly 25 per cent, and does not, of course,
preclude the presence of nervous symptoms
in a large proportion of those set down as
catarrhal or inflammatory. And this takes
us back to the point from which we started,
namely the marked predominance of the

524

Periscope

Vol. lxiv

nervous element and the protean character
of the manifestations in this singular affec-
tion. How shall we account for the produc-
tion of such varied morbid phenomena by a
single morbific agent ?

To the writer, the most probable explana-
tion is, that the morbific influence, whether
germ, microbe or occult meteorological de-
parture from the normal condition, spent
itself directly upon the nervous system, and
more particularly on the vegetative portion
of that system, or to particularize, still
further upon the pneumogastric nerve and
its associated ganglia with partial implica-
tion of the spinal cord. Nearly all phe-
nomena which distinguish influenza from
other similar affections can be readily ac-
counted for by this theory ; the excessive
nervous prostration, so entirely out of pro-
portion to the catarrhal disturbance, the
emotional depression, causing the victim to
weep incessantly without consciousness of
any reason for so doing, the sense of con-
striction about the larynx, the strident
cough, piping voice and occasional aphonia,
the sudden congestions of the lungs, the
pain and stiffness in the dorsal muscles, es-
pecially along the nucha, the gastric and
intestinal disturbances, the intense head-
ache, and transient manias, all can be ac-
counted for by the supposition that the
great balance wheel of organic life has be-
come deranged — and on no other theory so
simply.

The fact that all the remedies which were
found most beneficial in the treatment of
this affection are nervines, such as phenace-
tine, morphia and nux vomica may also be
adduced as strongly confirmatory of this
theory.

MODE OF ENTRY OF THE TUBERCULAR
POISON INTO -THE BODY.

Dr. Bollinger believes that the frequency
of infection through the skin has been
underestimated. Several cases have been
recorded of direct inoculation by wounds
received from broken spittoons, by bites,
operations, earrings, etc. Eczema and im-
petigo increase the susceptibility of the skin.
No case has as yet been attributed to vacci-
nation, and it would appear that the tuber-
cle bacilli are unable to live in the vaccine
lymph. They also appear unable to pierce
the pores of the skin as do some of the
pyogenic organisms. The susceptibility of
the mucous membranes is increased by in-
flammatory processes, such as otitis, rhinitis,
conjunctivitis, and pharyngitis. The poison
travels to the submaxillary glands and those

of the neck, and generally causes local
tuberculosis of the glands. The chief point
of infection is of course the lungs. Local
predisposition is best exhibited by apices
which have been before diseased, but have
undergone a healing process. The move-
ment is deficient both in expiration and in-
spiration, and the liability to reinfection is
increased by anaemia, irritants, constitu-
tional influences, such as diabetes, dis-
turbances of digestion, and unhealthy sur-
roundings generally. The poison may pass
through the lungs and attack the bronchial
glands, under which circumstances the dis-
ease may be very insidious. The predisposi-
tion of the lungs again exhibits itself in
metastasis ; not every tubercular disease of
these organs is due to inhalation of the
bacilli or their spores. As regards primary
tuberculosis of the testicles, joints, and
bones, Bollinger considers that a latent
hematogenic infection must be understood,
which leaves as little trace of its point of
entry as does a primary septic endocarditis
or an osteomyelitis. Tubercular disease of
the larynx depends upon an auto-infection
through the sputum. The rarity of this dis-
ease in children is explained by the infre-
quency of pulmonary cavities in the rapid
forms of phthisis. Primary tuberculosis of
the intestine generally, combined with an
affection of the mesenteric and retroperi-
toneal glands, is usually occasioned by
means of vitiated food and contaminated
feeding utensils. Secondary tuberculosis of
the intestine depends upon an auto-infection.
The tubercular poison passes through to the
intestine unaltered by the juices of the
stomach and attacks the Peyer's patches and
solitary follicles. Tuberculosis of the peri-
toneum, which is three or four times as com-
mon in men as in women, can arise directly
from ulcers of the intestines, from tubercular
abdominal glands, or, especially in women,
from the urogenital tract ; further, through
contagion from the lungs and pleura, .and
finally in the course of miliary tuberculosis,
or from caseus bronchial glands. Primary
tuberculosis of the peritoneum is quite rare.
As regards the infection from milk, this is,
in Bollinger's opinion, undoubtedly due to
the udder of the cow being affected with the
disease. Infection through the milk of
tuberculous women has not yet been proved.
Munchener Medizinische Wochenschrift.

REGULATION OF PROSTITUTION.

Moeller in the Journal des Maladies
Cutanees, December, 1890, makes the asser-

May 2, 1 891.

Periscope.

525

tion that the measures adopted in the regu-
lation of prostitution are inefficient from a
hygienic point of view. While admitting
that the danger of contagion is greatest dur-
ing the primary stage of syphilis, and slightly
less during the secondary period when the
external manifestations of the disease are
present, he claims that during the entire
secondary period the person infected is able
to transmit the disease, even when there are
no external manifestations, as has been
proved by the infection of nurses from in-
fants and vice versa, and by the infection of
women during intercourse. This contagious-
ness of syphilis during the latent stage of the
secondary period, is but little marked if the
body of the infected person does not present
any external solution of continuity ; but the
slightest scratch or laceration of the skin or
mucous membrane considerably increases
the danger of contagion. For this reason
Moeller claims that persons afflicted with
syphilis should abstain from sexual inter-
course not only during the existence of the
primary sore, or when the secondary mani-
festations are present, but in the latent
period as well. This is the duty of every
man or woman affected with syphilis, to
neglect which is culpable. He goes on to
say that our present regulations are based
upon the assumptions of physicians at the
beginning of this century, who believed that
gonorrhoea, soft chancre, and syphilis, were
all of the same nature, and only contagious
in the initial stages. The researches of the
succeeding years have entirely revolution-
ized these views, hence the necessity of alter-
ing the laws governing prostitution to meet
the dangers which have been discovered.

As a substitute for the present laws upon
the subject he suggests a system as follows :
Every person who is convicted of certain of-
fenses relative to prostitution, or who has
committed some infraction of the articles of
the penal code, should be, if he be sentenced
to imprisonment, submitted to a physical ex-
amination at the moment of arrest. This
examination should be repeated at the expi-
ration of punishment. If the physician
confirms the presence of syphilitic lesions,
the patients should be admitted into a hos-
pital for treatment. In addition, they should
be forbidden to resume their trade, and in-
structed not to indulge in sexual intercourse
as long as the dangers of contagion exist.
They should likewise be obliged to submit
to periodical visits during a variable time,
to be determined at the beginning of the
sickness. The advantage which Moeller
claims for this system is, in the first place,

the suppression of the registration of prosti-
tutes ; second, in place of leaving to hazard
or to arbitrary attention the designating of
the prostitutes who should be submitted to
sanitary visits, it is the prostitutes who, by
the infractions they have committed, would
designate themselves, in virtue of a positive
law which they know and which they ought
to recognize. Moreover, the civil authorities
would no longer recognize the right of the
infected prostitutes to continue their busi-
ness, and would interdict them from the prac-
tice of their profession, so long as they could
be dangerous to the public health/ Thus
would disappear that security which the pub-
lic accords, rightly or wrongly, to the regis-
tered prostitutes, who are considered as
healthy in virtue of the certificate delivered
after the inspector's visit. Finally, the pro-
phylactic system thus designed would neither
violate individual liberty nor the moral law.

MEDICAL CHEMISTRY.

CHEMICAL REACTIONS OF KOCH'S TU-
BERCULIN.

In the Farmatzevtitchesky Jurnal, No. 9,
1891, p. 136, Mr. I. Gertel, a chemist, pub-
lishes the result of his examination of a
specimen of Koch's " tuberculin." The
"lymph" forms a cinnamon-brown, odor-
less, viscid fluid, sp. gravity of 1.17 and
of a neutral reaction. Concentrated sul-
phuric acid dissolves it easily and com-
pletely, the solution being at first colorless,
but after a while assuming a cinnamon-
brown color. Concentrated hydrochloric
acid does not manifest any action on the
lymph, while concentrated nitric acid pro-
duces a slight opacity, appearing at the
point of contact between the two fluids.
When immersed in a sulphuric acid solu-
tion of tuberculin, crystals of bichromate of
potassium soon become covered with bub*
bles (which are due to glycerine being
present in the preparation). The following
reagents give considerable precipitates on
being added to a 10 per cent, aqueous solu-
tion of tuberculin : Tannic acid, picric
acid, chloride of gold, nitrate of silver,
sulphate of copper, nitrate of mercuric
suboxide ; but chloride of platinum, neutral
acetate of lead, and chloride of tin,
produce a comparatively slight precipita-
tion ; iodide of potassium and cadimum
(double salt) give a distinct turbidity,
but no actual deposit. The follow-
ing substances behave entirely negatively
toward the solution : Iodide of potassium

526

News and

Miscellany.

Vol. Ixiv

and mercury (double salt), bi-iodide of po-
tassium, chloride of iron, ferro-cyanide of
potassium, chloride of mercury, molibdenate
of ammonia, rhodanide of potassium, chro-
mate of potassium, ammonia, and sulphate
of iron. When heated with acids, the aque-
ous solution assumes an intense yellow
color. Strongly diluted aqueous solutions
give voluminous precipitates with alcohol,
the deposits being re-dissolved on a free ad-
dition of water. A 10 per cent, aqueous
solution, as well as more diluted ones, when
kept at the ordinary room temperature, be-
comes turbid even on the next day. As to
the lymph itself (that is, an undiluted prepa-
ration), it has not undergone any changes
even after 4 months' keeping.

THE DA COSTA LABORATORY OF
BIOLOGY.

It is announced that the trustees of Col-
umbia College have determined to devote
the late Mr. Charles M. Da Costa's bequest
of $100,000 to the foundation endowment of
a laboratory of biology, to be built on the
grounds of the medical school (the College
of Physicians and Surgeous), and that the
professor in charge of the department is to
be designated the Da Costa professor of
biology. This is an early and striking
manifestation of the good likely to result
from the union of the College of Physicians
and Surgeons with Columbia College.

THE PHONOGRAPH OF MEDICINE.
The applicability of the phonograph to
the record and demonstration of defects in
speech has been well illustrated during the
past week at the Royal Medical and Chi-
rurgical Society and at the Hunterian
Society. At the first named, Dr. Hale
White and Mr. Golding-Bird were enabled
by means of this instrument to allow the
Fellows present to hear the curiously defec-
tive speech of two children, and to contrast
this with the improvement effected by treat-
ment, for the subjects were present, and after
the phonograph had given their past utter-
ances, their present speech was demonstrated
viva voce. The papers .read by the above
gentlemen and that by Dr. F. Taylor led to
an instructive debate, which was further
illustrated by some marked cases introduced
by Dr. Hadden. The outcome seemed to be
that these defects in articulation are proba-
bly of central origin, and not due to any
mechanical interference with the organs of
speech. Whether, as suggested by Dr.
Langdon Down and Mr. Spencer Watson's
the defect was primarily one of audition it is.

a question certainly worthy of consideration.
Another point raised was whether the defect
should be considered one of speech or lan-
guage, and some exception was taken by Dr.
Taylor, Dr. Pye-Smith, and others, to the
use of the term "idioglossia," which, however,
was ably defended by Dr. Hale White. The
other phonographic demonstration at the
Hunterian Society was by Dr. Hughlings
Jackson, who thus reproduced the character-
istic speech of a subject of cerebro-spinal
sclerosis. There can be little question that
the phonograph will ultimately prove very
useful, especially in the preservation of cer-
tain anomalies of articulation, and its further
extension to other sound phenomena in the
range of clinical medicine may be justifiably
hoped for. — Lancet.

NEWS AND MISCELLANY.

We are authorized to state that Dr. J.
M. DaCosta is not going to Europe this
year as reported.

Dr. J. M. Baldy has been elected Pro-
fessor of Gynaecology in the Philadelphia
Polyclinic and College for Graduates in
Medicine.

The twenty-sixth annual meeting of the
members of the Michigan State Medical
Society, will he held in Saginaw, Thurs-
day and Friday, June 11th and 12th, 1891,
at Germania Hall, a building so situated as
to be readily reached from all principal
hotels by electric cars, and sufficiently com-
modious to accommodate the work of the
General Sessions, the Committees and all of
the Sections.

The President's Annual Address will be
given by Dr. L. W. Bliss, Saginaw ; subject
to be announced later.

The Address of the Orator appointed by
the Section on the Practice of Medicine, will
be delivered by Dr. Heneage Gibbes, Ann
Arbor, subject, " Phthisis."

The Orator appointed by the Section on
Obstetrics and Gynaecology, .is Dr. J. H.
Kellogg, Battle Creek, and the subject of his
address will be : " The Influence of Dress in
Producing the Physical Decadence of Amer-
ican Women." This address will be appro-
priately illustrated by stereopticon views.

Dr. H. O. Walker, Detroit, will give the
address on Surgery ; subject to be announced
later.

The Medical Society of the State of North
Carolina, will meet at Asheville, Mav 26th,
27th and 28th, 1891.

ENLARGED FROM 28 TO 40 PAGES OF READING MATTER.

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THE

MEDICAL AND SURGICAL
REPORTER

No. 1784. PHILADELPHIA. MAY 9, 1891. Vol. LXIV.— No. 19.

Clinical Lecture.

LEG ULCER— SKIN GRAFTING— KELOID—
LUPUS— DIFFERENTIAL DIAGNOSIS OF
LUPUS AND EPITHELIOMA — SCROFU-
LOUS ULCERATION OF THE CERVICAL
GLANDS-TRAUMATIC INFECTION- ANTI-
SEPTIC POULTICE.

BY ERNEST LAPLACE, M. D.,

PROFESSOR OF PATHOLGOY AND CLINICAL SURGERY,
MEDICO-CHIRURGICAL COLLEGE, PHILADELPHIA;
SURGEON TO THE PHILADELPHIA HOSPITAL.

LEG ULCER.

Gentlemen : — The first case that I bring
before you to-day is one that was operated
upon by me eighteen days ago, and affords
an excellent example of the successful re-
sults obtainable by the modern surgical
method followed in the treatment of these
cases.

A leg ulcer is a necrosis of the epithelium
and underlying tissues. The surrounding
parts are indurated and inflamed, and the
edges of the ulcer are hard and callous. Of
itself, a leg ulcer will not heal, but contin-
ues to increasei n size, until it frequently
reaches entirely around the limb.

The treatment to be followed is, therefore,
to cover this denuded and ulcerated surface
with new skin ; but before attempting this,
we must prepare the surface of the wound
for its reception. So the first step is to
scrape away the necrosed epithelium and re-
move the callous edges. This must be thor-
oughly done, and it matters not if the opera-
tor goes right down to the muscle, or at all
events until healthy and living tissue is
reached. Then leave the wound until
healthy granulations have begun to form,
and you have a surface ready for your skin
graft. Even this preliminary operation
should be conducted with strictest aseptic
precautions.

SKIN GRAFTING.

Let us turn aside from this patient for a
moment to review the question of skin graft-

ing. The process is a comparatively new
one in surgery, dating only a few years
back ; but when skin , grafting was first suc-
cessfully performed, it was thought that only
minute grafts could be transplanted. Ac-
cordingly, it was then the practice to snip off
a tiny piece of skin, no larger than a pin's
head, and to cover the denuded parts with a
number of these. Such little grafts would
form islands of epithelium which gradually
increased in size, and joined one another, un-
til finally the whole surface was covered. It
was argued, however, that if a small graft
would take root and grow, a large one
should do the same, all things being equal.
The total immunity from suppuration af-
forded by modern aseptic surgery, has en-
abled us to prove that this is truly the case.
We no longer transplant minute fragments
of skin, but take strips, or pieces, large
enough to cover the entire denuded surface
at the outset. This is what has been done
in the case before you.

Let us first examine the spot from whence
I took the skin. You see that it is entirely
healed, and covered with new epithelium,
although a large amount was removed. A
valuable lesson may be learned from this.
In no case should we hesitate to take from a
healthy surface all the epithelium we need,
for if we proceed aseptically, new epithelium
is rapidly formed, and the nealingis perfect.
You will notice that the new skin covering
is redder than the surrounding skin ; this is
because, first, it is thinner, and second, be-
cause the blood vessels lie nearer the sur-
face. Ultimately, however, this new skin
will become thicker than that of the sur-
rounding parts, owing to the friction and ir-
ritation caused by the clothing, ^ and a
similar process of epithelial thickening will
take place as that which occurs on the hands
of rowers, where friction primarily wears
away the skin, but where finally additional
epithelial cells are thrown off until the part
becomes materially thickened. Eventually,
this reddened skin, now tender and thin,
will, therefore, become thick, and also of a

527

528

Clinical

Lecture.

Vol. lxiv

darker color than the surrounding parts.

We will now turn our attention to what
eighteen days ago was a very ugly looking
indolent ulcer. You see that its surface is
entirely covered with exceedingly delicate
epithelium, so thin indeed as to be trans-
parent, enabling us to see the underlying
granulations. The operation has been a
success, and nothing further remains to be
done than to keep the part protected with
an antiseptic dressing, and to keep the man
in bed until this new epithelium has become
thick and strong.

Right here let me warn you against a
needless fear, often experienced by the young
surgeon in similar cases. When, a week
after having made the graft, you remove the
dressing, you will find a large slough of dead
epithelium come away with it, and you will
very naturally conclude that the graft has
not taken and that your operation has been
a failure. Not so, however, for below the
dead epithelium you will see the thin and
transparent membrane which we have here.
This is easily explained. In grafting we
can only expect epithelium that is alive and
well nourished to grow upon the denuded
surface. Let me remind you of the anatomy
of the skin. The uppermost layer, the
homy epithelium, is dead, and comes off in
washing as dandruff ; below this are epithe-
lial cells also poorly nourished ; below these
are the papillae with their blood vessels and
surrounded by living epithelial cells; and,
finally, oelow all these is the fibrous tissue.
In taking our graft we cut through these
papillae. We know this because we have
distinct hemorrhage. This living and well-
nourished epithelium we graft on our de-
nuded surface where it grows and new epi-
thelial cells quickly form from around the
papillae and push up the layers of unnour-
ished cells, so that when the dressing is re-
moved it would seem as though the whole
graft had come away, while in reality the
living epithelium has taken root.

KELOID.

The next patient which I will call your
attention to this morning, is also one that
was operated upon about two weeks ago,
and is another example of successful skin
grafting.

A keloid is, as you know, a dense cic-
atricial formation, which causes considerable
contraction. This man came to the hospital
with a dense growth on the ball of the
thumb, which contracted that member into
the hand. The growth was primarily re-
moved, and a week allowed for healthy

granulations to form over the denuded mus-
cles, for both the adductor and flexor pollicis
were laid bare. We then grafted, covering
the entire surface with new epithelium, and
with the gratifying results whichyou now see.
The man's thumb is in a normal position. To
be sure, we had far greater chance for success
than in the case of leg ulcer, for there we were
dealing with necrosed and diseased tissues,
while here the parts were healthy and well
nourished.

Look at the man's fingers. You will re-
member that these also were greatly con-
tracted but are now nearly straight. It is
the tendency of these contractions to increase,
as additional deposits of cicatrical tissue are
formed about the tendon, until finally a
useless hand is the result.

What was done in this case, was to cut
down upon the tendons, and nearly through
them, severing fully three-fourths of their
substance. The remaining fibres acting as a
suture to keep the ends in apposition. The
fingers were then stretched until straight,
and put on splints. The stretched tendons
gradually became strengthened and the
gaping cuts in them healed up, the fingers re-
maining straight.

LUPUS.

The next patient is a man suffering from
lupus who has been treated with Koch's
lymph. One milligramme of the lymph was
injected on Monday, two milligrammes on
Tuesday, and three on Wednesday — none
since (Saturday). The improvement has
been very marked, and healing has already
begun to take place.

I am not prepared to make any definite
statement regarding the value of Koch's
lymph, but am free to acknowledge that its
action upon local tuberculous processes — and
lupus is one of these — is undeniable. What
will be the result of this treatment I cannot
now say. The man may make a complete
recovery, as I have seen many such follow
the use of Koch's lymph ; the disease may,
however, return after a time. Time alone
wil 1 decide the case.

The principal reason for my bringing this
case before you was in order to demonstrate
differential diagnosis between it and a case
of epithelioma.

DIFFERENT DIAGNOSIS OF LUPUS AND
EPITHELIOMA.

Let us first study their similarity. Both
have ulcerating surfaces, and in both the
skin slopes down toward the ulcer, and their
general appearance is not at all unlike. You
will notice, however, that the surrounding

May 9, 1 89 1

Clinical

Lecture.

529

*kin, in the case of epithelioma, is indurated
and hardened, while in the case of lupus the
skin is freely movable over the surface of
the granulations. Often, indeed, a narrow
bridge of skin will stretch across the ulcer-
ating surface. This feature is peculiar to
tuberculous ulcerations. In tuberculous
processes also, the granulations extend under
the skin, while in epithelioma the skin is
destroyed as far as the ulceration reaches.

Under the microscope the difference is still
more marked. In the granulations taken
from a case of lupus we find round cells with
a nucleus, these are tubercular cells. Often
also we fiud much larger cells, containing
three or more nuclei, these are known as
the giant cells of tuberculosis. Their exist-
ence is due to the fact that the formation of
the nuclei occurs more rapidly than the
segmentation of the surrounding protoplasm.

In epithelioma the microscope shows a
totally different picture. Before us lie myr-
iads of epithelial cells of all shapes and
forms.

The most definite and perhaps practical
means for the differential diagnosis of lupus
and epithelioma is afforded us by Koch's
lymph. For it invariably causes a re-action
in all cases of local tuberculosis, while it has
absolutely no effect in cases of epithelioma.
This fact alone is sufficient to make for Koch's
discovery a permanent place in medicine.

SCROFULOUS ULCERATION OF CERVICAL
GLANDS.

The child that lies before you presents an-
other, and a typical form of local tuberculo-
sis. It is a very ill child, and its condition
demands immediate attention. In the neck,
over the region of the cervical lymphatic
glands, is a large dense tumor — very large
for a child who has not seen more than two
summers. Near the angle of the jaw the
growth has ulcerated, and a cheesy matter is
discharged from the opening. We see, also,
that the opening is bridged by a narrow strip
of skin, and this fact gives us an immediate
clue to the diagnosis, as you remember I re-
ferred to this peculiarity as being typical to
tuberculous ulcerations. We find that the
mass is slightly movable and from its ap-
pearance and location, are forced to the con-
clusion that the growth is a scrofulous ulcer-
ation of the cervical glands. This conclusion
is strengthened by an examination of the
patient's temperature chart, which shows a
very high evening temperature. The case,
therefore, demands the immediate removal
of these glands, and were it not for the fact
that the parents' consent to the operation has

not yet been obtained, I would perform it
to-day, but will be forced to delay it. In
the mean time every effort will be made to
improve the child's physical condition, so
that it will be better able to stand the oper-'
ation.

It is in these fair-skinned, blue-eyed
children that we generally find scrofula. In
all probability in this case other glands are
also affected.

TRAUMATIC INFECTION.

The last patient which I shall have the
pleasure of showing you to-day, is this man
who came to us, not long ago, to be treated
for a very painful tumor over the glands in
the neck. The growth is not clearly defined,
but of irregular shape and very painful;
the surrounding skin is also inflamed and
painful. We evidently have an acute in-
flammatory process here and must look
further for the cause. We find that a short
time previously he had received a contused
and lacerated wound of the scalp by being
struck with a rock, but to which he had
paid little attention.

All wounds if improperly dressed or
treated are liable to infection, but contused
and lacerated wounds, where a large amount
of tissue is destroyed, are peculiarly so dis-
posed, the wide-open mouths of the lymph-
atics being always ready to imbibe the poison-
ous germs.

Let me here tell you that nine-tenths of
all acute inflammatory processes are caused
by the pus microbe, the streptococcus
pyogenes aureus, and it is an infection from
this source that we have before us.

Never, gentlemen, never be tempted or
led to apply a hot poultice to such an in-
flammatory process. What could be more
conducive to the propagation of these poi-
sonous germs than the application of heat
and moisture ! What season of the year so
fruitful of infectious diseases as the hot
and wet months of summer? To apply a hot
poultice to such an inflammation is to court
further infection, when the real object in
view is to retard it. What is demanded is,
first, 'an opening up and cleansing of the
wound, which has been the door to the in-
fection, and the removal from it of any in-
fectious matter; it should then be dressed
aseptically. Next, local applications to the
point of infection, of such a nature as will
check the suppurative process and cause the
death of the microbe. For this purpose
antiseptic solutions are alone available. Wet,
if you like, gentlemen, but never hot.

53°

Clinical Lecture.

Vol. lxiv

ANTISEPTIC POULTICE.

Take a solution of 1 : 3000 of corrosive
sublimate, or better still, an acid solution of
1 : 3000 of the same, as it is stronger, and
make a cold poultice with linseed meal, for
the meal will hold the moisture better and
longer than any cloth, and apply this over
the seat of inflammation, and the suppura-
tive process will soon cease, and the pain
and swelling disappear.

The modern poultice is an antiseptic
poultice.

This is the bent of modern surgery, the
prevention of infection, and the maintenance
of aseptic cleanliness. By these means we
may cope with ulcerations on the surface,
and check the process of inflammation even
when hidden deep in the tissues. These are
lessons worthy of your careful consideration
and earnest study.

ACUTE PARENCHYMATOUS NEPHRITIS,
WITH ACTIVE PULMONARY CONGES-
TION.

BY PROF. CHAS. G. STOCKTON.

BUFFALO GENERAL HOSPITAL.

Gentlemen : — The history of this patient
is as follows : Aged 42, married, Canadian,
carpenter. Family history negative. The
patient had measles and scarlet fever when
a child, apart from this he has always been
well and he denies any venereal trouble.
On Wednesday, a week ago to-day, while at
work, he was taken suddenly with a severe
chill, followed by fever and nausea, but he
has vomited only two or three times. The
attacks were also attended by considerable
headache, which has continued with inter-
missions up to the present. He stopped
work, went home and to bed, and he has
been in bed most of the time since. He has
no appetite and the nausea has continued.
Since Thursday he has had griping pain
in the abdomen, and diarrhoea existed from
Thursday until Monday. On Sunday he
' had a second chill. The patient is a moder-
ate drinker and he smokes to excess. On
entering the hospital his pulse was 98,
temperature 103.4°, respirations 38.

The patient, as you look at him, will im-
press you at once by his appearance of
apathy. The man is evidently very sick,
very feeble, and somewhat cyanosed. His
breathing is between 40 and 50 a minute,
his pulse has varied between 100 and 110,
and his temperature between 103.5° and

104.5° since his admission. With these
symptoms and from the man's appearance,
we would say that there was something
wrong with his respiratory apparatus, and,
to follow the symptoms up more carefully,
we find that he has a moderate cough and
considerable expectoration of muco-purulent
matter which is very tenacious, and which
sticks to the bottom of the cup and looks
like the expectoration of catarrhal pneu-
monia. In all probability the prostration
and apathy depend either upon the severity
of the fever, or upon some toxaemia, or the
two combined. The toxaemia may arise
from his lung trouble or from some other
condition.

The tongue, which he protrudes slowly, is
dry, brown and cracked. He says his hear-
ing is good, but you observe that he under-
stands slowly, giving one the impression, at
first, that he is deaf. The condition of the
tongue and the slow cerebration are evi-
dences of a toxaemia.

As we inspect his breathing, we find it
rather shallow, but symmetrical. He
breathes as though his lungs were not
properly filled with air and as though the
bases were particularly involved. This
condition might come about from inflam-
mation of the lung and the exudation of
fluid into the substance of the lung, from ef-
fusion around the lung, or merely from con-
gestion of the lung. I find everywhere,
anteriorly, a feeble respiratory murmur,
with harsh sounds and some so-called dry
rales in the upper part, some moist rales and
a few sibilant sounds lower down. The
vesicular respiration is harsh, superficial and
very imperfect. The same condition is
found behind, the breathing is particularly
obscure and impure at the bases. The
breathing behind is accompanied by more
sounds of disease, such as rales and sibilant
breathing, than in front. I regard the evi-
dences, so far as the lungs are concerned,
both from the history of the case and the
physical examination, to be in favor of con-
gestion of a high clegree with a certain
amount of inflammatory trouble in the
bronchial tubes, the amount of actual in-
flammation being much less than we would
expect to find with the rapid breathing,
high temperature, frequent pulse and the
general prostration of the patient. I do not
find enough trouble in the chest to account
for the general condition and that was what
impressed the house-staff when they first saw
the man.

While the pulse is somewhat ample, it is
very feeble, and still it has more resistance

May 9, 1891.

Clinical

Lecture.

53i

and greater tension than we would expect
in typhoid fever with this temperature. On
examining the abdomen to make sure that
we are right in excluding typhoid fever, we
find it slightly distended with gas. The
skin looks normal, there is no eruption, and
pressure over the abdomen discovers no
points of especial tenderness. There is little
evidence of abdominal trouble and the
bowels have moved regularly since the
diarrhoea. Last night he was given epsom
salts and, as a result, he had three or four
large involuntary stools, not typhoidal, but
of a light yellow color and with a distinct
odor of urine. He has passed three pints
and a half of urine in the last twenty-four
hours. Two days ago there was a very
slight discharge of condensed urine, yellow-
ish red, very acid, containing a large amount
of albumen. The sediment contained a
large quantity of debris, renal epithelium
in abundance, and granular blood and epi-
thelial casts. The blood casts were conspic-
uous by their abundance. There were no
fatty nor hyaline casts.

Now let us look at the case from the stand-
point of the information derived from the
examination of the urine. Here is a man
apparently in good health, suddenly seized
with chill, fever, prostration, vomiting ; who
has been confined to bed for a week, at the
end of which time we find him still very
much prostrated, with a frequent feeble pulse,
high temperature and brown cracked tongue,
with scanty urine, and with evidence of lung
trouble. Which of these two conditions :
the nephritis or the congestion of the lungs,
was primary ? It is not common for an
acute lung trouble to cause an acute nephri-
tis, but it is quite common to have congestion
of the lungs and a certain amount of dis-
turbance of respiration with acute nephritis.
The evidence points, therefore, toward the
conclusion that this man was seized with an
acute nephritis at the time of the initial chill.

If we had not examined the urine we
should say that the man was seized with an
acute lobular pneumonia, and from the high
temperature and prostration we would make
a grave prognosis ; but knowing the con-
dition of the urine and having an explana-
tion of these symptoms of prostration, the
prognosis becomes better though still
guarded. From the examination of the urine
we would conclude that this is a case not of
chronic but acute Bright's disease, from
which recovery is to be expected. The lung
trouble is somewhat secondary to the kidney
lesion. I say " somewhat secondary " be-
cause at the same time that he caught cold

and the nephritis started, the lungs might
have become involved. But the blood
going to the lungs is loaded with excre-
mentitious products which have irritated
the pulmonary tissue, and the condition
of the circulation is depressed and the pulse
frequent. This case would probably result
fatally from the condition in the lungs being
maintained by the disease in the kidneys if
the latter organs were not properly attended
to.

The cause of this attack we do not know
satisfactorily. There is no history of falling
into cold water or other marked exposure.
The measles and scarlet fever occurred too
long ago to have any causal relation. They
might have been followed by a nephritis
which has become chronic and has been
lighted up into an acute exacerbation, but
the condition of the urine as reported to me
does not indicate the existence of such a
condition. The heart is apparently sound,
though excited in its action, there is no evi-
dence of previous cardiac valvular lesion nor
of acute endo-carditis. Although we cannot
account definitely for this nephritis-, we must
remember that it is not uncommon to have
an acute Bright's disease coming on without
any special exposure, just as on the other
hand, exposure to wet and cold is not always
followed by this trouble.

It is important that a case like this shall
receive early treatment. I directed that the
patient's back be thoroughly cupped, that
his feet be bathed in hot water, and, that he
have hot vapor baths. As a result of the
treatment the sweating was induced and the
amount of urine passed increased very
largely. In proportion as the elimination by
the kidneys increases his symptoms will sub-
side. He was also cupped over the lungs
and the essential oil of camphor was used as
a stimulant application. I did not use tur-
pentine because it is a stimulant to the kid-
ney and a kidney already overstimulated by
inflammation should not be exposed to the
danger of further irritation. The treatment
was directed principally to the skin, both to
aid elimination by exciting sweating and to
relieve the kidneys of their engorgement by
bringing the blood to the surface. Magne-
sium sulphate was also given to carry off the
poison by the bowels and to relieve the cir-
culation by depletion. A light diet was
ordered, the nervous symptoms were con-
trolled by bromide of potassium, assisted by
moderate doses of chloral. Internal medi-
cation directed to the kidneys is to be avoided
in such a case as this, although it would be
perfectly safe to give potassium acetate or

532

Com m unications.

Vol. lxiv

sodium beuzoate, which are uh-irritating
diuretics. The former is especially indicated
when the urine is highly acid, the latter usu-
ally increases the acidity of the urine, but it
may often be given with benefit even in cases
of acid urine. Potassium acetate should be
given in doses of fifteen grains once in two
hours with infusion of digitalis. Sodium
benzoate is given in five grain doses every
two hours with or without the digitalis.
Digitalis is given with a view to increasing
the pressure of blood in the kidney.

This is the only medication which I think
should be directed toward the kidneys them-
selves when they are acutely inflamed or
acutely irritated. The purgatives act in-
directly on the kidneys in the most favorable
way possible, lessening their labor of ex-
cretion and removing the effete products
which would otherwise accumulate in the
blood. The necessity of examining the
urine, especially in cases like this of con-
gestion of the lungs, is the most important
lesson to be learned from this case.

CLINIC THREE DAYS LATER.

These are specimens taken from the pa-
tient whom you saw on Wednesday. His
urine was increased in quantity and the con-
dition of his kidneys improved until they
were functionally fairly well, but, contrary
to my expectations, the man did not improve
under the treatment that should have un-
loaded the venous side of his circulation, he
grew weaker, suffered more and more from
dyspnoea, and finally died by failure of res-
piration.

The post-mortem revealed, as the physical
examination two days before had promised,
a very acute congestion of the lungs. The
right lung showed rather more infiltration
than could be classed under the head of
congestion, there was very complete oedema,
particularly of the lower lobe. The upper
portion of the right lung and the left lung
were markedly congested. The lung now
crepitates very feebly and is still dark in
color, though it has bleached out somewhat
since the autopsy.

The examination further revealed that
the kidneys, instead of being healthy
previously to this acute attack, as I sup-
posed from the history of the case and the re-
port of the urine analysis, had been for a long
time diseased, the man having the so-called
large white kidney — the chronic parenchym-
atous form of diffuse nephritis. There was
an acute attack which was superadded to
the chronic kidney trouble. These kidneys
did not appear red and congested as other

organs of the body did, and you see now how
pale they look. But if you examine them
carefully, you will find injected points lying
among large masses of comparatively white
tissue. These are not the red engorged kid-
neys which I expected to find. Does this
mean that the man did not have the acute
inflammation which I described to you ?
Not at all, it means that the kidneys were
congested like the other organs of the body,
but they were pale because their tissues had
become so changed by chronic disease, which
I did not suspect because the report of the
urine analysis misled me — that the areas re-
maining for blood to enter were small.
These kidneys were red and congested for
such kidneys, but yet they contained far less
blood than is normal. It is precisely what
we expected to find, but occurring in the
midst of another change.

The heart was somewhat enlarged but
there was no valvular lesion. On account
of the swollen condition of the lungs, this
enlargement was not manifest at the physical
examination. Although the predominating
inflammation in the kidney was parenchym-
atous, yet there was some fibroid change
which would cause resistance to the onward
flow of the blood and thus produce hyper-
trophy of the heart. There were a few
atheromatous markings just above the cusps
of the aortic valves.

The spleen and liver were congested. The
stomach was large but empty, and held nine
pints of water. The great majority of cases
of dilatation of the stomach, occur in those
who have no stenosis in the alimentary
canal, and there was no stenosis here.
Stenosis below the stomach, however is
quite apt to be a mechanical cause of such a
dilatation.

Communications.

CANCER OF THE RECTUM.1
BY L. L. McARTHUR, M. D.

CHICAGO, ILL.

In my brief experience as a surgeon it has
been my fortune to number among my cases
six examples of this disease in various stages
of advancement, as follows: one, female,
cancer within two inches of anus, colostomy
and excision ; one, female, cancer involving
anus and lower rectum, colostomy, ex-
cision ; one, female, cancer involving

1Read before the Chicago Gynecological Society,
January 16th, 1891.

May 9, 1891.

Communications.

533

anus and rectum, colostomy, no excision ;
one, female, cancer high in rectum, no colos-
tomy, curettage ; one, male, Kraske's oper-
ation, colostomy (Dr. Fenger's case) ; one,
male, no excision, curettage, no colostomy.
With these there were no deaths as a result
of the operations, though Kelsey states that
the mortality for excision is thirty-three per
cent.

Let me, before presenting the history of a
case, call your attention to the following
significant facts : In a careful inquiry —
made by Cripps — into the family history of
a large number of cases of cancer, the per-
centage of mortality by that disease was
found almost identical with that of the gen-
eral population by the same. In a very
large proportion the disease is so situated
that an infection could have been plausibly
possible. Infection of husband from wife
suffering from cancer of cervix has been in
several instances well authenticated by com-
petent observers. A much greater frequency
exists near the sea than inland, and both
Sheurlen, of Munich, and Thoma, of Heidel-
berg, have demonstrated the frequent pres-
ence of micro-organisms (psorosperms),
which, in their opinion have a specific rela-
tion to the causation of this disease.

In relative frequency of type, cylindrical-
celled, flat-celled (epithelioma), and papillo-
carcinoma stand in the order named. Al-
lingham, who, in 1886, had already reported
thirty-nine cases of excision, is authority for
the statement that rectal carcinoma usually
runs its course in twenty-four months. He
notes, however, cases ending in death in from
four months to four years. His experience
had been also (contrary to that usually
noted) that the disease occurs more frequently
in males than in females, and that its most
usual site is within three inches of the anus.
Cachexia appears at a very early period.
The ages of greatest frequency range from
45 to 55, though it has been noted as early
as the age of 6. Cancer in this location fre-
quently escapes the observation of the general
practitioner, being mistaken for hemorr-
hoids ; and, for this reason, too great care
cannot be taken in the examination of mid-
dle-aged people in whom there are symptoms
referable to the rectum.

Treatment. — James Adams urges that in
every case there should be made a colostomy,
saying : " In cases of any but the slightest de-
gree the operation of removal may prove in-
complete and the disease speedily return ;
. . . after complete extirpation of the lower
end of the rectum the subsequent contraction
is often very great, and even at times intract-

able, and in any case the healing of the
wound will be much expedited and the
chances of local recurrence diminished by
diverting the course of the fecal matter."

Allingham justly condemns the making
of a colostomy in every case of cancer of
the rectum, stating that " often neither pain
nor obstruction will ensue in months, or they
may never occur and the patient may die
from some other malady. Of course, if a
surgeon at once persuades all his patients
who have malignant growths in their rectum,
to submit to colostomy under the promise
that life will be prolonged or suffering aver-
ted, he will have many cases to report and
very good but very valueless statistics."

There are four factors which make this
operation justifiable : First, because the mor-
tality of rectal excision can be immensely
reduced by diverting the fecal matter from
the site of the excision. Second, because
there are in some of the cases excruciating
pains, caused by the passage of fecal matter
over the ulcerating carcinoma, which can be
relieved by a colostomy, winning at the
same time for the surgeon the gratitude of
the patient. Third, because in those cases
in which the disease extends higher than the
lower three inches, there is sure to be sooner
or latter a stenosis. This Jessop has dem-
onstrated at the late meeting of the British
Medical Association. He calls attention to
the fact that where the disease is low down
in the rectum complete obstruction seldom
occurs, and that the opposite is true where
the disease is high up. The reasons for this
difference are to be found in the anatomy of
the parts themselves ; for while the rectum,
as it approaches the outlet, becomes more
closely applied to the sacrum and pelvic
wall, in its superior portion it is compara-
tively free. Thus the contractile action of
the colon is exerted with effect in forcing its
contents through the contracted ring when
that ring is fixed and immovable. But
when the narrow portion is freely movable,
as it is when situated in the upper portion
of the rectum, the efforts of the bowel above
succeed only in invaginating or otherwise dis-
placing the growth, and fail altogether to
effect any onward movement of the contents
(Kelsey). Fourthly, it has been the expe-
rience of most operators that the cicatricial
contraction which follows such an operation
is often excessive and intractable, as in any
of the inflammations, specific or simple,
which so frequently result in a stenosis here.
Allingham has found that if he would main-
tain .the gut in a useful and patulous con-
dition, it is necessary to have the patient

534

Communications.

Vol. lxiv

wear a guttapercha tube, which can be re-
moved at will. Finally, an argument which
needs no champion is the fact that thirty-
three per cent, of all cases of carcinoma (as
shown by the researches of Jessop in one
hundred and two cases which were allowed
to follow their course without any surgical
interference) die from obstruction.

To sum up, I would urge that prior to
every excision in every painful case, and in
every case where the disease was situated
high up, that a colostomy be made, the
choice being in favor of the left inguinal.
The method of excision recommended by
the French surgeons has been that which I
have utilized, preceding each excision, how-
ever, by a colostomy two or three weeks
prior to the final operation. In this the
main feature is a deep incision which ex-
poses the posterior segment of the rectum
from the anus to the coccyx, when it is an
easy matter to dissect out the rectal tube
until one comes to the anterior portion.
Here, if it is found that the disease involves
one or more of the coats of the vaginal wall
it is, in my opinion, best to remove a longi-
tudinal segment of the entire thickness of
the same, as it both renders the operation
safer and more easily accomplished, and
does not, as Kelsey would infer, greatly in-
crease the danger. When the sphincters
are involved a circular incision should sur-
round the anal opening, and all be removed
together. Dr. Guerin's suggestion that the
gut be cut through by the ecraseur, modified
by the passing through the normal gut of
several threads for purposes of fixation of
the proximal end after removal, as rec-
ommended by Verneuil, has been the pro-
cedure employed in the excisions I have
made. The proximal end is then to be
stitched to the posterior angle of the perineal
incision or to the left side of the coccyx, and,
after stitching up the vaginal wound in
much the same way as after a posterior
colporrhaphy or laceration, deep transverse
perineal stitches render the making of a new
and extensive perineal body very easy.

When the type of the disease is that of
the cauliflower-like growth known as papillo-
carcinoma, I believe the best practice is to
remove it with the curette rapidly and well
down to the base of the growth. The
hemorrhage, very active and easily provoked
while in the soft tissues of the tumor, is
easily controlled when the base has been
reached. In two such cases I have been
successful in for a time relieving them of
their distressing symptoms, but have not

been able to follow their history for more
than six months after operation.

The case I now report is of interest in
showing the benefit to be derived from
surgical interference.

Case. — After having suffered with what
she believed to be hemorrhage, the patient
came to St. Luke's Hospital a year and a
half ago, with symptoms of absolute stenosis
of the intestine, and requiring immediate
relief. The diagnosis of carcinomatous ob-
struction of the rectum being made, a colos-
tomy in the left lumbar region was done,
with relief to the urgent symptoms. After
the lapse of three weeks, the artificial anus
being well established and healed, an ex-
cision of the rectum was practiced after the
usual methods by a deep posterior incision
from the anus to the left side of the coccyx
well down to the posterior wall of the rec-
tum, which was then dissected laterally until
the vaginal wall was reached, which was
found to be involved to the level of the pos-
terior lip of the cervix in the carcinomatous
growth. The posterior wall of the vagina
was removed, as well as the rectum, to this
level, including the sphincter muscles. The
rectum was stitched to the skin of the left
side of the coccyx, and deep transverse
stitches were inserted to make a new peri-
neal body. There was a speedy union and
rapid convalescence. After the lapse of one
year she returned to me with the artificial
anus presenting a normal rectal mucous
membrane normally attached to the integu-
ment to the left side of the tip of the coc-
cyx, with the artificial anus almost closed
from surgical interference by Dr. John E.
Owens, but with a return in the perirectal
tissue of the original trouble to such an ex-
tent that the line of cicatrix in the vaginal
wall posteriorly and in the anterior rectal
wall was again invaded by the new growth,
which was beginning to cause painful def-
ecation as at first. The patient, being
much frightened with the symptoms of a
return, came to me requesting a repetition
of the operation. This at first I refused to
make, telling her that I did not believe her
longevity could be increased by such a pro-
cedure nor her condition materially im-
proved. She then consulted Drs. Parkes
and Fenger, both of whom, she stated,
promised to operate upon her and offered
her hopes of at least temporary relief. Com-
ing back to me with this history and the
threat that if I would not operate somebody
else would, I had her admitted, in the last
week of September, 1890, to the Michael

May 9, 1891.

Communications.

535

Reese Hospital, where I excised the portion
of the rectum which had been drawn down
and attached to the integument, at a point
on a level with the posterior lip of the cer-
vix. I dissected out laterally, in so far as I
could reach, all indurated tissue. I then
found that it was impossible to bring the
end of the rectum down to the integument,
no matter how far I might extend my pos-
terior incision, and decided that the best
thing I could do would be to suture the end
of the rectum at the top of the vaginal in-
cision after the cicatrix had been removed.
I did this, then united the vaginal mucous
membrane, much as is done for a laceration
or operation for posterior colporrhaphy, and
brought the lateral pelvic tissues together
by very deep, heavy silk sutures, and,
strangely enough, obtained a perfect union.
The patient has, since the second week in
November, been at home, is feeling well,
has gained in weight, and has several times
come to my office, each time stating that she
feels better than she did during the year
which elapsed after the first operation ;
that she now has control of the bowel and is
capable of evacuating its contents without
any artificial assistance — that is, without a
douche, which I advised when she first left
the hospital.

I believe this to be a unique case. I do
not find, in what literature I possess, refer-
ence to a similar operation. I have no
doubt that she will ultimately have a return
of the trouble, because the cicatricial con-
traction which normally occurs with any
inflammatory deposit about the rectum,
whether from specific or simple inflam-
mations, has already produced some sus-
picious induration. (See Society Reports for
discussion.)

AN INCARCERATED RETROFLEXED PREG-
NANT UTERUS, WITH GREAT DISTEN-
TION OF BLADDER— SUCCESSFUL
REPOSITION— RECOVERY. 1

BY CORNELIA KAHN, xM.D.

PHILADELPHIA.

This grave complication of - pregnancy is
comparatively rare, yet the importance of
its early recognition and prompt treatment
is so evident, that a report of every case of
this nature must be of value to the pro-
fession. Gregoire, in France, Sir W.
Hunter, in England, are said to have been
the first to fully appreciate the existence of
posterior displacements of the gravid uterus,

'Read before the Alumnoe Medical Society of
Philadelphia.

and to have called attention to them. They
are far more difficult to manage, and more
serious in their consequences than those met
with in the unimpregnated state, but of less
frequent occurrence, or, at least, fewer come
under the notice of practitioners.

This may be due to the fact that in the
majority of cases, spontaneous cure occurs
about the end of the third month, and the
women have had no symptoms urgent
enough to compel them to seek medical
advice, or a miscarriage occurs, the cause of
it not being traced to this condition. If
this restoration does not take place of itself,
or an endeavor made to rectify the abnormal
position as soon as an augmentation of the
pains and functional disturbances of bladder
and rectum incident to first months of gesta-
tion, give evidence of the nature of the
trouble, grave results may ensue. This
retro-deviation may then end either in abor-
tion, incomplete rectification or incarcera-
tion.

Jaggard says, that " The persistence of
complete retroflexion and consequent in-
carceration must be regarded as exceptional
events ; " but the dangers to be apprehended,
when they do occur are great. Cases have
been recorded of proctitis, peritonitis, cystitis,
sloughing of vesical mucous membrane,
rupture of bladder, rupture of posterior
vaginal wall, as well as of deaths from shock,
exhaustion, uraemia, following these con-
ditions. Other serious complications have
also been noted. In the Lancet of December
31, 1887, page 1311, a case of retroversion
followed by abortion and sloughing of vesical
mucous membrane is reported. Elliott in
" Obstetric Clinic " (1872) describes three
cases at Bellevue Hospital with one death,
and Barnes had four deaths from uraemia,
and De Paul one death.

The sequelae of urinary retention are
of gravest prognostic moment, not only
sloughing of a part or of the whole vesical
mucous membrane, but necrosis of the blad-
der itself and its peritoneal covering has oc-
curred. Haultain, in the Edinburgh Medi-
cal Journal, June, 1890, relates a case of
exfoliation of the entire bladder wall, seven
weeks after the reposition of an incarcerated
gravid uterus. Abortion had been induced
by the manipulations to replace the organ
and incurable incontinence was the result of
the death of the vesical tissue (replaced by
connective tissue growth). The following
are the notes of the case which forms the
basis of the present paper.

C. B., aged 34, German, married, pre-
sented herself on Sept. 8, 1889, at the dis-

536

Communications.

Vol.

XIV

pensary clinic of the Woman's Hospital in
great distress, complaining of intense pain
in the abdomen and that she could not " pass
her water." With great difficulty, she was
placed upon the table for examination. To
lie down seemed almost impossible, so severe
was the suffering occasioned by the effort to
remain in that position. On exposing the
abdomen, we saw immediately that there
was a peculiar tumor to diagnose. The dis-
tension was most marked, the integument
having a bluish thinned-out appearance,
suggesting the presence of a rupture. The
swelling was not uniform, although it ex-
tended to the umbilicus ; for in this region,
there was a pointing or bulging which simu-
lated a hernia.

Palpation and percussion were too painful
for us to elicit any physical signs, and a
vaginal examination (exploration) was
made to ascertain the condition of the pelvic
organs. The cervix was found drawn up
near the symphysis pubis and a round body
was felt in the posterior cul de sac. The os
uteri having the softened velvety character
of early pregnancy, we questioned the woman
and found that the menses had last appeared
in June.

An attempt was made to empty the bladder
with a metallic catheter, preparatory to
more thorough examination, but failing to
draw any urine, although the meatus
urinarius was accessible, we called upon Dr.
Fullerton to assist us. She suggested our
using the flexible English catheter, and as
this instrument did its work, we witnessed
the peculiar tumor progressively diminish
and disappear. The patient's face, relieved
of its suffering and strained look, gave
evidence that the pain had ceased.

This was a striking example of the im-
portance of the use of the long flexible
catheter in diagnosis of vesical complications
in women. Failure to draw urine with the
metallic catheter often misleads the physi-
cian as to the real condition present* and
serious results have been reported.

Three pints of urine were drawn off, but
the bladder was purposely not completely
emptied. The urine was found to be of a
sp. gr. of 1015, neutral reaction, and without
albumen.

Bi-manual examination now confirmed
the supposition that there was a retroflexed,
incarcerated pregnant uterus. Freed from
her urgent symptoms the patient was allowed
to go home with directions to assume the
knee-chest posture often during the day, and
to try to urinate while in this position, or
bending forward, and return to the dis-

pensary in a few days. On the 11th, three
days afterwards, she presented herself again
with no marked improvement in her .condi-
tion, the bladder being again distended,
although not quite to the same size as
before.

Catheterization again relieved the pres-
sure symptoms, but the patient was advised
to come to the hospital for treatment that
could be directed towards correcting the
displacement. On the next day, she was
admitted, and the following history elicited :

Patient had a good family history and had
a healthy childhood. Began to menstruate
when fifteen years old, and although not
painful the flow was always irregular. Con-
stipation was a persistent habit with her.
She was married twelve years before,
in her twenty-third year, — had five children,
the youngest being two-and-a-half years, and
no miscarriages. When, after her first con-
finement, menstruation was again established,
it was painful, although it had not been so
previously. She stated that " bearing down
pains with falling of the womb " and some
trouble with urination had occurred follow-
ing the puerperal periods, w7ith the last
two children.

Both these latter symptoms, however, dis-
appeared gradually without treatment, the
patient having an interval of comparative
comfort. Conception again took place. As
already stated, she ceased to mqnstruate in
June, and began then to experience anew the
" bearing down pains," the sense of weight
and fullness in pelvis. She continued doing
her usual work, including the lifting of heavy
washtubs, etc. In the second month, mictur-
rition became more frequent, effected with
difficulty and accompanied by pains in the
back and down the legs. She was still
of a very constipated habit, although
there does not seem to have been
marked distress with defecation. Vesical
tenesmus gradually increased, micturition
was very difficult, and when she came to us
the pain had grown intense, and the flow of
urine very scant. Every morning there was
swelling at the hypogastrium and inability to
urinate until after moving about for a couple
of hours. Both walking and sitting were
alike painful, and the nervous system was
necessarily affected to a marked degree.

At last voluntary micturition became im-
possible. Dysuria gave way to the " incon-
tinence of retention," and from Saturday
evening to Monday morning, when the pa-
tient came to the dispensary, scarcely any
urine was passed, coming merely "drop by
drop." Her suffering was extreme, the in-

May 9, 1891.

effectual straining was intolerable, and she
was forced to seek relief. Her visits to the
clinic and the treatment received have been
already detailed. Having now entered the
Hospital 5 days after first coming under
observation she was put to bed in the knee-
chest position, in which she lay for an hour,
only to resume it again after resting awhile
on her side. After emptying the bladdar,
Dr. Fullerton, with careful manipulations
(two fingers in the vagina, making gentle
pressure upon the retroflexed fundus through
the posterior cul de sac), succeeded, to some
extent, in disengaging the body of the uterus
from its imprisonment under the promontory
of the sacrum, and the patient gave expres-
sion to a sense of relief and comfort after
this procedure. The vagina was now packed
posteriorly with wool pledgets, and a No. 8
flexible catheter inserted in the bladder and
retained until the next day, so as to prevent
a full bladder from interfering with the cor-
rection of the uterine displacement. The
necessary adjunct to this line of treatment —
the knee-chest position was not forgotten,
and the patient was ordered to lie thus as
constantly as possible — pillows being placed
under her to give her the necessary support.
On the following day, the uterus was found
in a. much better position, the fundus hav-
ing risen into the abdominal cavity. The
pledgets and catheter were now removed and
an Albert Smith soft rubber pessary inserted
— the patient still remaining in bed. She
was now able to urinate without pain. Two
days later, the fundus uteri was anterior, the
cervix posterior. Patient was now in good
condition, gestation not seemingly affected by
either the displacement of the organ or by
the efforts at restoration to its normal posi-
tion. The patient was discharged from the
Hospital with instructions to assume at times
the knee-chest position, to avoid constipa-
tion, to empty bladder regularly, and to re-
turn when six months pregnant to have the
pessary removed, if there should be no occa-
sion, in the interval, to present herself earlier.

From this time forward, she experienced
no further trouble, and succeeded in securing
a daily movement of the bowels, thus avoid-
ing one factor in the causation of uterine
displacements. In due time she was de-
livered, in the Woman's Hospital, of a fine
child, after a normal, easy labor. The re-
covery, in this case, is thus shown to have
been a prompt and permanent one, the dan-
ger that threatened was averted, and the
lives of both mother and child preserved.

In reviewing the history of this case, there
are some points I would comment upon.

537

Authorities differ as to the occurrence of
posterior displacements during pregnancy
and also as to their abrupt or gradual origin.
. Barnes says that -retroflection, pure and
simple, does not take place in an impregna-
ted uterus, but that it supervenes on some
degree of retroversion or prolapse. Accord-
ing to Tyler Smith, " retroflection of the
gravid uterus presupposes retroflexion of
unimpregnated organ."

Meadows " does not see any causative re-
lation between misplacement of the non-
pregnant and pregnant state." Jaggard ad-
mits the possibility of acute retroversion in a
prolapsed pregnant uterus. Many others
might be quoted to show the differences of
opinion. It is also an open question whether
the distended bladder acts as a cause or is a
result of the retro-deviation. Sir W. Hunt-
er's opinion " that retention of urine was the
primary cause seems to be modified now by
the belief that it is an important adjunct in
its production, and an obstacle to its reduc-
tion, rather than the initial cause.

In the case I have reported, the history of
recurrent attacks of bearing down efforts
and difficult micturition, with obstinate con-
stipation and painful menstruation since
birth of first child, would seem to favor the
view of some form of displacement having
existed at times during these years.

The early appearance of severe symptoms
after this last conception would seem to con-
firm this, and such being the case, it is easy
to conceive how the continual straining at
stool, vesical tenesmus and pressure of
abdominal muscles in the heavy lifting,
would act to depress the fundus still more
and thus establish a retroflexion. The resti-
tution of the organ was opposed also by the
distension of the bladder, which acted not
only by pressure, but by its dragging up the
anterior wall of cervix in its ascent into the
abdomen. The uterus, thus crippled in its
natural movements to free itself from its im-
prisonment, remained impacted in the hollow
of the sacrum.

Diagnosis of these retro-deviations says
Parvin, should not he difficult if a thorough
examination be instituted, but errors have
been made. W. S. Stewart lately reported
a case that was diagnosed as a fibroid going
to term with the retroflexion unreduced, and
in danger of serious exhaustion at time of
labor.

In treating this condition of incarceration
much difficulty has been experienced in
many cases in introducing the catheter.
This woman was fortunate in that the
meatus urinarius was not so inaccessible.

Com m unications.

538

Society

Reports,

Vol. Ixiv

Various instrumental methods have been
employed to rectify the malposition ; but
gentle vaginal and rectal taxis in the knee-
chest posture, is thought to cause less trauma,
and must be tried first. It often has
been necessary to administer chloroform
before reduction was possible. Dr. Playfair,
in two cases, effected a cure in twenty-four
hours with continuous elastic pressure by
means of a pyriform India rubber bag dis-
tended with water or air placed in the
vagina. Barnes says, frequent daily cathe-
terization cures in a week. Authorities also
differ in their modes of after treatment.
Bandelocque resorts to the use of the pes-
sary. Cazeaux advises the horizontal posi-
tion up to sixth month of pregnancy. Jag-
gard recommends rest in bed in the latero-
prone position until the uterus is of sufficient
size to retain its position in the abdominal
cavity.

With our patient, the line of treatment
was simple and rational. The first measure
to be resorted to before attempting reposi-
tion of the displaced organ, the evacuation
of the bladder, was promptly done, and its
refilling prevented by the constant drainage
through the retained catheter. The knee-
chest position and packing of the vagina,
after the manipulations, and ridding the
rectum of all fcecal accumulations, were the
elements of successful treatment, which
lasted only three days. The use of the pes-
sary, adjusted before patient left the bed,
with due attention to the functions of blad-
der and intestines, and the frequent employ-
ment of the genu-pectoral posture, assisted
in maintaining the pregnant uterus in the
normal relation to the line of the pelvis.
Rest in bed for any length of time was not
practical, as there was a family of children
to be cared for.

The capacity of the distended bladder, in
the case reported, was about fifty ounces,
but in one of those related by Elliott the
bladder contained the remarkable quantity
of one hundred and forty ounces. Notwith-
standing this fact, the patient did not suffer
as had ours, having no symptoms urgent
enough, even to direct the attention of the
physician to this viscus. In the case, al-
ready cited, of Haultain's the bladder held
as much as one hundred ounces of porter-
colored, offensive urine, even though its
walls were in a state of decomposition
and consequent diminished muscular elas-
ticity.

Dr. E. Richter has found that fresh
urine destroys the bacilli of anthrax, cholera
and typhus.

Society Reports.

THE GYNECOLOGICAL SOCIETY OF
CHICAGO.

Dr. L. L. McArthur read a paper on
(see p. 582).

CANCER OF THE RECTUM.

Dr. C. T. Parkes. — The case as presented
by Dr. McArthur is very interesting to me,
and, I think, he is to be complimented on
the skillful attention he has given to this
patient and the success which has resulted
from his interference. It seems to me, we
must look upon this operation for the relief
of this terrible disease mainly as a palliative
treatment ; it is seldom curative. Certainly
it removes the manifestations of the disease
for a time, and, above all, is desirable, as
Dr. McArthur has said, from the fact that
it relieves the patient from the local distress
caused by the disease, especially from pain,
which is present in all these cases, and the
symptoms of on-coming obstruction which
accompany the later stages. My experience
with it has been rather moderate ; as I
recall the cases I have met, and have
thought a little about them since receiving
the notice of this meeting, there come to
mind nine cases in which operation has
been done for excision of the rectum, two
cases in which simple incision was done, and
two cases which are interesting from the
fact that they accompanied the presence of
ovarian tumors, and one case which was
situated very high in the rectum and no
interference was practiced — in all fourteen.
Of the nine cases in which excision was
done, five were operated upon according to
the plan of Kraske ; in the others success
was attained in the removal of the manifesta-
tions of the disease by merely external in-
cision of the soft parts, without interference
with the sacrum or coccyx.

Of these cases, which represent a period
of work of eight or ten years, some are living
to-day, but most of them are dead. None
of the cases of excision were preceded by an
opening into the colon. I think the statis-
tics which the doctor gives as to the
mortality of the disease as the result of im-
mediate excision is based upon the results of
pre-antiseptic days rather than the present.
I am not one of those who believe that the
contact of fecal matter with the wound is
at all times hurtful, as I have had in my ex-
perience many cases in which wounds have
been bathed in fecal matter without any-
septic condition following.

May 9, 1891.

Society

Reports.

539

I can see readily enough that the previous
operation for an artificial anus can be a
benefit to these cases, and will likely predis-
pose to the earlier and more rapid healing of
the rectal wound, simply because it prevents
the fecal material from passing over the raw
surface. The operation of forming an arti-
ficial anus in itself is of little consequence,
and should be, as a rule, attended with little
fatality. That it is a necessary procedure t
am not inclined to believe ; neither do I
think that it makes very much difference
in the mortality. As far as the relief given
in preventing the discharge from coming
over the wound is concerned, I have to agree
with Dr. McArthur's statements.

The disposition is in all these cases to a
comparatively rapid return of the disease.
We must always remember, in the treatment
of cancer here as well as elsewhere, that the
operation itself may stimulate or produce
infection. In two cases in which the opera-
tion was done by myself, there followed no
local manifestations of return of the disease,
but within eighteen months there appeared
to be general infection of the entire body, as
shown by evidence of disease in the liver and
in the lung, and the presence of cancerous
nodules of different sizes in the integument.

There is no question but that every one
of these patients will be grateful to the sur-
geon for the removal of the manifestations
of this disease; but, as I said before, we
must look at it in the true light and tell
these patients that the relief is only tempo-
rary and cannot often be curative where
the disease is really cancerous in its nature.
Again, we must bear in mind that quite a
number of surgeons of great experience —
men who have seen this disease in all its con-
ditions and ravages — believe that the es-
tablishment of an. artificial anus itself is a
sufficient relief to the case. Dr. Thomas
Bryant, of London, is not an advocate of
excision, but is an advocate of an artificial
anus and relieving the patient entirely of
the necessity of using the diseased portion
of the bowel for the transmission of fecal
matter, and thereby allaying inflammation.

Again, we must remember that other
operations are done besides excision of the
rectum, which is a formidable operation and
leaves disgusting results in many cases.
Some other operations have been done which
surgeons of experience believe to be effica-
cious ; these are local in character — that is,
the complete division of the mass backward
towards the sacrum, in that way providing
for the easy exit of the fecal matter. Of
oourse, theera of operative procedure is upon

us, and particularly is this operation advo-
cated by European surgeons, and also very
largely by American surgeons ; but I think
if all the cases were examined as carefully
as those cases have been which Dr. McAr-
thur has presented to us to-night, and dis-
cussed as coolly and calmly as he has dis-
cussed them, none of us would be very much
in favor of promising a great deal for the
operation.

Dr. Henry T. Byford. — I would like
to emphasize what Dr. Parkes has said, that
this is a palliative operation and not justi-
fiable when it is immediately very dangerous
to the life of the patient. The case related
was very interesting to me, because it is
similar to a case which I have treated, and
which illustrates the principle which should
be carried out in treating cancer of the rec-
tum in women. In this case the sphincter
was not involved, although the rectum from
about two-and-a-half above down nearly to
the sphincter was affected on its anterior and
lateral aspect. I removed portions of the
lateral and anterior rectal walls, and the
posterior vaginal wall. Instead of drawing
the parts together in front of the rectum, I
operated upon the principle that all raw
tissue not covered by mucous membrane will
contract and obliterate the entire tract within
it ; so I endeavored to secure as large a sur-
face of mucous membrane for the canal
as possible by leaving the vagina open
and merely closing up the vaginal entrance.
There is another reason for removing, in
cancer of the rectum, all of the rectum that
we can, viz., that a return of the disease in
connective tissue is not as painful as when
it attacks the viscera. In this case the
patient was able to evacuate the bowels until
the entire pelvis was filled up with a mass
of carcinomatous tissue, without very much
pain. She died finally of exhaustion more
than anything else. The point in all these
cases is to get as much mucous membrane as
possible, using the vagina the same as in any
other operation.

Dr. L. L. McArthur, in closing the dis-
cussion, said : In presenting the patient
this evening, I did not do so to advocate such
an operation, although it does seem to me
that, in cases in the female in which car-
cinoma occurs low down in the rectum, in
reality it would be a procedure more ad-
visable than to make an artificial anus at
one side of the tip of the coccyx, because of
the statement of the patient that she knew
when the bowels desired to move. She had
a peculiar feeling, she says, and has the
power to expel the contents, thus escaping

54o

Society Reports.

Vol. lxiv

the exceedingly distressing symptoms of in-
voluntary discharges, which always occur
with an artificial anus at other points. In
regard to the statistics which I quoted as
collected by Kelsey, in the article which he
wrote on this subject for the " Reference
Hand-book of Medical Sciences," published
in 1886, he stated that the mortality from
the operation of excision was thirty-three
per cent. In Sajous' Annual for 1890, there
is a collection of statistics after Kraske's
operation, and the mortality is stated at
fifty per cent. Kelsey happens also to be a
contributor to this department of Sajous'
Annual, so the mortality has rather in-
creased than decreased for the last year, ac-
cording to the same man's statistics. He
bases this fifty per cent, mortality on seven
cases done by Kraske himself, three by
Schonborn, one by Rinne, and the re-
mainder by Lauenstein, twelve in all, in
which six died as the result of the operation ;
some by septic peritonitis (two), some by
sepsis (two), and some from exhaustion.

As Dr. Parkes says, there are a large
number of surgeons who advocate simpty
making a colostomy and interfering to no
further extent with the case. In some ex-
cellent statistics collected by Cripps, we find
that out of cases which he watched person-
ally in London hospitals and studied care-
fully, life was lengthened on the average
from seventeen months to twenty -two
months — that is, there were five and a half
months added to the longevity by simply
making a colostomy ; which shows that it is
decidedly advantageous. Colostomy, I be-
lieve, will aid in lowering the mortality in
cases of excision, whether done for pain or
for obstruction. As to the operation being
of dubious value, there is much to be said
on both sides; there are, however, some
well-recorded cases in which, the operation
having been performed at an early day, the
life of the patient has been preserved. One
case was living in 1886 that had been living
for seven years since the operation, and no
return wTas to be seen, and five cases in
which no return wTas seen in two years.

It has impressed me that some of the
gynaecologists of the Society would comment
upon the probability of endometritis with
infection through the uterine canal and
tubes as being very likely to occur in such a
procedure, as was exhibited in my patient,
and I would like to ask the President
whether such an inflammation would be
probable in a woman who had passed the
menopause.

EDISON'S EXPLANATION OF THE AMPERE
AND THE VOLT.

During a recent examination a lawyer
put the following question to Thomas A.
Edison :

" Explain what is meant by the number
of volts in an electric current ?" To which
he replied :

" I will have to use the analogy of a
waterfall to explain. Say we have a current
of water and a turbine wheel. If I have a
turbine wheel and allow a thousand gallons
per second to fall from a height of one foot
on the turbine, I get a certain power, we will
say one horse power. Now the one foot of
fall will represent one volt of pressure in
electricity, and the thousand gallons will
represent the ampere or the amount of cur-
rent, We will call that one ampere. Thus
we have a thousand gallons of water or one
ampere falling one foot or one volt or under
one volt of pressure, and the water working
the turbine gives one horse power. If,
now, we go a thousand feet high and
take one gallon of water and let it
fall on the turbine wheel, we will get
the same power as we had before, namely,
one horse power. We have got a thousand
times less current or less water, and we will
have a thousandth of an ampere in place of
one ampere, and will have a thousand volts in
place of one volt, and we will have a fall of
water a thousand feet as against one foot.
Now the fall of water, or the height from
which it falls, is the pressure or volts in
electricity, and the amount of water is the
amperes. It will be seen that a thousand
gallons a minute falling on a man from a
heighth of only one foot would be no danger
to the man, and that if we took one gallon
and took it up a thousand feet and let is
fall down it w7ould crush him. So it is not
the quantity or current of water that does
the damage, but it is the velocity or the
pressure that produces the effect,"

It has been calculated that the electromo-
tive force of a bolt of lightning is about
3,500,000 volts, the current about 14,000,-
000 amperes, and the time to be about wsmw
part of a second. In such a bolt there is an
energy of 2,450,000,000 watts, or 3,284,182
h. p. — Scientific American.

Gunpowder Stains of the Face may
be removed by painting with biniodide of
ammonium, distilled water, equal parts ; then
with dilute hydrochloric acid, to reach the
tissues more deeply affected. — Revue de Ther-
apeutique.

May 9, 1 89 1.

Editorial.

54i

THE

MEDICAL AND SURGICAL

REPORTER.

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THE PRESENT STATUS OF THE
KOCH TREATMENT OP TUBER-
CULOSIS.

The absence of exact science in the
medical knowledge of the day, has perhaps
been nowhere so well exemplified as in the
extreme readiness of both profession and
laity to accept the unproved word of a
single man in relation to a hitherto unan-
swered and weighty question in therapeu-
sis — that of the existence of a specific con-
trol of the tubercular process. Nor is the
precipitate haste on the part of the clini-

cians to condemn the method, as yet not
even half tried, any more evidence of the
development of stable principles in our
methods of combatting disease processes.
From a theoretical stand-point, excluding
from present consideration the general care
and management of the patient, the de-
struction, or modification of the materies
morbi is to be accomplished in four
probable ways, these include : the util-
ization of the antagonism of micro-organisms
toward each other ; the deleterious effect of
micro-organismal products on the growth of
micro-organisms ; the unfavorable effects on
micro-organisms of certain agents of mineral
or organic oiigin ; and the production of
general surroundings unfavorable to the ad-
vance of the infection, both in the indi-
vidual and in the community. To the
second of these groups is to be referred the
method recently proposed by Prof. Koch for
combatting the tubercular process. This
method, which is substantially if not pre-
cisely identical with the measures previously
employed and announced by Dixon of this
city, has for its underlying principle a fact,
the verity of which may easily be recog-
nized by analogy in numerous instances of
the incompatibility of waste products with
productive growths. Thus alcohol, as a
product of vegetable activity manifested as
fermentation, when present in proportions
beyond 20 per cent., is sufficient to retard
and eventually destroy the actions and
vitality of the ferment. Nor is the use of
the products of bacteria as a means of alter-
ing the further growth of bacteria in the
animal tissues by any means a recent one,
as may be noted in relation to the work done
upon the bacillus pyocyaueus by Charrin
and others. Separation of the fluid product
of the growth of this last bacterium from the
culture itself, by means of an unglazed por-
celain filter, and inoculation with this sterile
product has prevented the inception of
pyocyanic disease in animals after subsequent
inoculations with virulent matter. Probably
the same principle underlies the Pasteur
method of hydrophobic prevention ; and

542

Editorial.

Vol. lxiv

the field of preventive medicine glows with
promise of great and near discoveries in
this same line in other diseases.

The substance used by Koch in his ex-
periments and more recently in the treat-
ment of tuberculosis in man, and which, as
already stated, is produced in practically
the same manner by Dixon, is obtained from
cultures of tubercle bacilli exposed to altered
conditions of life by means of extraction
with some such menstruum as glycerine.
This material, from which no definite active
agent has been eliminated by Koch, when
brought into contact with tubercular growth
in the animal economy, is announced to pro-
duce decided lowering of activity of growth
and eventually, if in sufficient proportion,
to permanently stop the morbid process. In
the animal economy, further, as an evidence
of its action, whether by direct action upon
the germ, or by inducing deleterious changes
in the tubercular tissues, there is manifested
a febrile re-action ; and as a result of its
action it is stated that there is a destruction
of the diseased structures and subsequently
their replacement by cicatricial tissue. The
exact mode of operation is not known, vari-
ous theories having been offered in explana-
tion.

Such was the knowledge established by
the researches of Dixon and Koch, and
eagerly seized upon by the entire world in
the expectation of mastering tuberculosis.
In the natural course of the rapid populariza-
tion of so important a discovery, the limits
of its application have been wittingly as well
as ignorantly widely overstepped ; badly
diagnosed cases and cases whose only cure
can be death have been subjected to the
vicissitudes of the treatment. With an eye
singly to the result of the means upon the
tuberculosis, cases have been permitted to
approach the fatal termination because of
the neglect of the true end, the recovery of
the patient ; and too often even the increased
nutritive need of the weakened system has
been passed by in the endeavor to overcome
the process at fault. Clearly, in the method
of action of the substance it was to be recog-
nized that its only safe application could be

found in the most localized forms, and
preferably in foci where elimination of the
products could be performed most thoroughly
and with least severity to the organism ;
nevertheless, in the mad hurry, cases of ad-
vanced degrees of the disease and cases
marked by generalization of the malady
have been permitted the treatment, only to
swell the death list which has been heaping
discredit upon the measure. Where tubercu-
lar foci are numerous and widely distributed,
if each focus is to be the scene of rapid
necrotic processes, each followed by a local
focus of reactive inflammation, what is to be
expected but the effects of an intense toxae-
mia and fever, which are the necessary at-
tendants of such a condition ?

Where the lungs are riddled with the
tubercular changes of late chronic phthisis,
what is to be expected if this new thera-
peutic agent accomplish the best possible
results, and yet leave a great mass of
cicatricial tissue to block up and hamper
the pulmonary tissue? Moreover, what of
that great mass of patients, from whom, the
treatment having failed to produce notable
.external changes, the lymph was withdrawn
and death followed — are there positive
evidences of no palpable changes in the in-
ternal tubercular localities in the line of
change indicated ? How is it possible from
post-mortem appearances to affirm absolutely
the generalization of the tubercular process
in this or that position, within a definite and
brief period? These are the considerations
upon which more information and more
definite knowledge should be demanded
from those who condemn the method. Its
action upon true cases of lupus has been
too decisive to permit, in other localized
forms of tuberculosis, any discredit until
more exact information is had. The con-
flict of reports is too great at the present
date and the tendency of medical opinion
too observant of so-called policy to allow
an absolute decision ; this will and can only
come when the lymph method has fallen
entirely out of injudicious hands and is
left to the investigation of the cautious and
thoroughly interested.

May 9, 189 1.

Editorial.

543

There are other phases of the subject, too,
which cannot fail to attract attention in the
future. How much of the severity of the
reactions, and how much the failure in re-
sults may be due to the presence of sub-
stances other than the essential toxalbumen
in the lymph ? What auxiliary measures are
those best adapted to the furtherance of the
favorable results of treatment ? Finally, if
even in mild cases of pulmonary tuber-
culosis failure should be established, there is
one other point of the utmost importance to
be further examined. In the earliest paper
of Dixon (Med. News, Nov., '89), antedating
Koch's announcement by more than a year,
there were distinct expressions of the de-
velopment of immunity in animal tis-
sues against the tubercular process by this
general method ; and investigations carried
on in rabbits and guinea pigs have with
considerable uniformity confirmed this hy-
pothesis. It is undoubtedly an injudicious
act to inoculate healthy individuals with an
agent of which so little is known as this
mixture of the retrograde products of tu-
bercle bacilli, but it has been and doubtless
will be done more or less frequently for a
time. There are no positive arguments in
relation to tuberculosis refuting the usual
rule of infections to protect against them-
selves ; and there do occur occasional cases
whose clinical histories present features not
averse to this view. For example, within
the knowledge of the writer, a young man
of questionable family history, who for 20
years had had a destructive scrofuloderm
only cured within the past few years, became
accidentally inoculated with tuberculosis,
while performing an autopsy upon a tubercu-
lar body.1 To ordinary observation, the usual
course of inoculated tuberculosis was man-
ifested, the healing of the original wound, the
period of some days' quiescence, the forma-
tion of a nodule at the site of sore, and the
breaking down of the surface into a slightly
purulent fluid to the formation of a tubercu-
lar ulcer. Within more than a month no
lymphatic involvement had become manifest,
and the local node was removed by opera-
tion. Thus far, nearly five months, there is

no evidence of general infection. Such
cases have occurred before and the proc-
ess remained for a long time localized —
yet may not the previous tubercular condi-
tion as manifested by the existence of scrof-
ula, have exerted some limiting influence
upon the inoculated process ? The existence
in otherwise normal lungs of isolated and
calcified nodes of old tubercular processes
may suggest the protective value of the re-
sults of the prior disease ; and where these
are associated with evidences of general ad-
vancement of the process there enters the
question of whether there had not been at
least a temporary protection analogous to
that afforded by vaccination.

This then is the status of the proposition.
The statements denying value to the treat-
ment of tuberculosis by the method of Koch,
whose claim to consideration rests upon what
appear to be general laws, and is corrobora-
ted by laboratory researches, lose their own
force from the numerous faults of omission
and commission met in the widespread and
ignorant application of the method. Even
should it fail as a curative, except in the
localized and superficial variety known as
lupus, there is yet another field for its use-
fulness open to investigation, its possible
preventive power.

Dr. J. T. Eothrock, Prof, of Botany, in
the University of Pennsjdvania, has sent out
his vacation circular for the fourth season.

The Doctor's plan is to take charge of lads
who are below par physically, but who need
moderate, systematic exercise in the open
air, good food, and early hours, rather than
medicine. The plan includes sailing on one
of the safest of vessels, deep-sea fishing, foot-
ball, lawn-tennis, target practice, etc. At
night instruction is given on methods of
prompt action in an emergency — " until the
doctor comes."

Thus far the Professor asserts there have
been nothing but good results from this
novel plan.

Dr. Eothrock is a gentleman of experi-
ence, a physician, explorer and teacher.
Parents may trust their sons in his hands with

544

Editorial.

Vol. lxiv

the assurance that they will be conscien-
tiously and wisely cared for.

Obituary.

DR. JOSEPH LEIDY.

On April 30th, after a brief illness,
passed away, Dr. Joseph Leidy, Professor
of Anatomy and Zoology in the Uni-
versity of Pennsylvania, the most dis-
tinguished naturalist of America, a man
whose lasting achievements secured the high-
est recognition throughout the entire sci-
entific world, whose personal characteristics
won the warmest affection of all who had
the privilege of his friendship.

Joseph Leidy was born in Philadelphia,
Sept. 9th, 1823. His inclination towards
the study of natural history was early man-
ifested, when, as a school boy, he secured
text-books and began the study of mineral-
ogy and botany, thereby laying the founda-
tion of that immense store of knowledge,
which his unaided efforts and ceaseless in-
dustry made his own. As a youth, he also
displayed a remarkable facility for drawing,
a talent which, in after years, rendered his
scientific contributions conspicuous.

After several experiences, it was deter-
mined that he should adopt a profession, in
which his devotion to the natural sciences —
becoming ever more pronounced — would
find opportunities for congenial employment ;
he, therefore, in 1840, entered upon the
study of medicine, under the guidance of
Drs. James McClintock and Paul B. God-
dafd, graduating from the Medical Depart-
ment of the University of Pennsylvania in
1844. His thesis was an admirable essay on
the " Comparative Anatomy of the Eye of
Vertebrated Animals."

During the years of his medical course,
his favorite studies in the domain of more
purely scientific biology were by no means
neglected, for in the same year of his gradu-
ation, he contributed a brilliant chapter on
the " Special Anatomy of the Terrestrial
Molusks of the United States" to Binney's
monograph.

Immediately after receiving his degree, he
became assistant to Prof. Hare, the distin-
guished occupant of the chair of Chemistry
in the University of Pennsylvania at that
time, thus already indicating the broadness
of his scientific interests. In 1845, Dr.
Leidy was appointed Prosector in Anatomy,
thus beginning the services in the anatomical
department of the University, which, with a
slight interruption during the succeeding
year when he was demonstrator in the
Franklin Medical College, have terminated
only with his death. As Horner's successor,
Dr. Leidy became, in May, 1853, professor
of Anatomy in the University of Pennsyl-
vania, to which chair that of Zoology and
Comparative Anatomy was added a few
years ago. In 1871, he became, likewise,
professor of Natural History in Swarthmore
College.

Three years after his graduation, "The
Fossil Horse of America " appeared, the
first of those paleontological contributions
which wTere to make Leidy's name known in
all lands. The most important of these
have been :

Ancient Fauna of Nebraska. 1853.

Memoir on the Extinct Sloth Tribe .of
North America. 1855.

Cretaceous Reptiles of the United States.
1865.

Extinct Mammalian Fauna of Dakota
and Nebraska : together with a Synopsis of
the Mammalian Remains of North America,
1869.

Contributions to the Extinct Vertebrate
Fauna of the Western Territories. 1873.

Description of Vertebrate Remains from
the Phosphate Beds of South' Carolina.
1877.

The preparations of these monumental
works, however, by no means exhausted the
industry of this indefatigable worker, for his
additional contributions during these same
years were numerous and varied.

Among the first in this country to use the
microscope as an instrument of scientific re-
search, Prof. Leidy always delighted in
studying the minute forms of life and the
details of structure it alone revealed. Early

May 9, 1891.

Editorial.

545

in his career, his classic paper on "Re-
searches on the Comparative Structure of
the*Liver," (1848) and other kindred con-
tributions established his ability as an hist-
ologist.

The study of parasites also became a
favorite field with this investigator, whose
numerous discoveries, as recorded in the
Proceedings of the Academy of Natural
Sciences of Philadelphia, bear testimony to
the success with which his labors were at-
tended. It is interesting to note that, in
1846, Dr. Leidy recorded the discovery of a
species of trichina in the hog, and stated
that it appeared to be identical with the
trichina spiralis, which he had met with in
the tissues of the human subject ; later, this
observation materially aided Leuckart in
unravelling the relation between the para-
site in man and in the hog. The appear-
ance, in 1853, of the beautifully illustrated
monograph, " Flora and Fauna within Liv-
ing Animals," added a contribution of per-
manent value to the literature pertaining to
microscopic parasites, to which its author
subsequently made so many important ad-
ditions.

The fondness for the study of the lowest
forms of life, which had always been a source
of never failing pleasure and recreation from
the fatigues of more burdensome duties, led
Dr. Leidy to undertake a systematic investi-
gation of the forms found in this country.
The results of this research appeared in the
quarto volume, " The Fresh-water Rhizopods
of North America", the splendid illustra-
tions of which are the delight of every
student. These plates, charming as they
are, in many instances fall far short in re-
producing the exquisite beauty of the
original drawings from Leidy's skillful pencil
and brush.

As teacher of anatomy in a great med-
ical school — in which capacity not a few
readers of the Reporter have profited by
his learning, during the thirty-eight years
that have elapsed since his accession to the
chair — Dr. Leidy appreciated the burden
imposed on the student by the useless com-
plexity of nomenclature, as well as by the

perpetuation of errors grown classic by the
sanction of precedent. He, therefore, set
about the preparation of a text-book which
should describe the human body as he saw
it, freed, as far as possible, from all cumber-
some terms; in 1861 was published "An
Elementary Text-book on Human Anatomy,"
which for clearness and accuracy of descrip-
tion has never been surpassed ; the second
edition of the book (1890) even more fully
justifies its favorable reception.

Some idea of the achievements of this life
of ceaseless industry 'and untiring devotion
to investigation may be had, when it is
learned that the published communications,
of all kinds, number about one thousand.
While Prof. Leidy's eminence as a great
naturalist has been cheerfully accorded at
home, foreign countries have not been tardy in
expressing their appreciation of the valuable
services he has rendered in the advancement
of those fields in which he has labored, since
the honors conferred upon him by learned
bodies abroad, include honorary member-
ship in almost all the foreign societies of
note devoted to the natural sciences.

The peer of the greatest, Leidy, together
with such men as Owen and Huxley, Johann
Miiller and Agassiz, Koelliker and Henle,
represented a generation of scientists almost
past away — men, whose privilege it was to
be of the van-guard of Biology, to live in
those golden days when, on every side, new
discoveries rewarded the scrutiny of the
keen investigators, whose minds, already
richly stored by broad training, became the
repository of an ever-widening insight into
natural phenomena. Men, whose energies
were engaged in mapping out the salient
landmarks of their science, whose compre-
hensive field was all nature, and on whom
the limitations of an age of specialties had
not been exerted.

Great as our admiration and respect for
the splendid scientific attainments of Dr.
Leidy must always be, it was, however, the
personality of the man that drew towards
him the warmest regard of all who came
within his influence. Who that learned to
know him — majestic in his noble simplicity,

546

Periscopt

Vol. lxiv

unassuming in his greatness, approachable
by all seeking knowledge, to whom the
youngest student turned assured of a. kindly
reception, a patient ear, and sound advice ;
ever the last to allude to his own achieve-
ments, but fearlessly expressing his own
honest beliefs when occasion demanded,
devoting to science his entire life, not for
his personal glory, but for the advancement
of knowledge— could not fail to honor the man
truly great and good ! A nature to which
petty jealousy and conventional circumlocu-
tion were alike unknown. A man whose
tender heart and quick sympathies were
overruled alone by his sense of duty, and by
his absolute, unwavering devotion to the
truth. G. A. P.

Correspondence.

Dr. S. E. Young of Midland, Ga., writes :

Please inform me, (1.) Whether females
experience an orgasm in sexual intercourse,
similar to that experienced by males.

(2.) Give the philosophy of such orgasm.

(3.) You will also oblige me by stating
whether women who are pregnant have any
sexual propensities.

(4.) Advise me as to the probable pro-
creative powers of a man who has twice had
double gonorrheal epididymitis, each epidi-
dymis being left somewhat nodular.

(5.) How can seminal fluid find its way
into the receptaculum seminalis when the
calibre of each vas deferens has been oblit-
erated by adhesive inflammation ?

[(1.) As far as our information goes the orgasms in
the two sexes are essentially identical.

(2.) Not knowing the philosophy of the operations
in the nerve cells we cannot explain.

(3.) Yes, as a rule, but in abeyance.

(4.) Practically nil.

(5.) Of course, if the vasa deferens are obliterated,
the seminal fluid could not find its way into the
receptaculum save by burrowing through the tissues,
which is highly improbable. — Ed.]

PERISCOPE.

THERAPEUTICS.

THE USES OF NITRATE OF SILVER AND
SULPHATE OF COPPER IN OPHTHAL-
MOLOGY.

Grandclement {Lyon Medical, March 8,
1891) carefully reviews the principal rem-
edies used locally in eye affections, with es-
pecial reference to the sulphate of copper
and the nitrate of silver.

He considers the copper salt one of the
best agents in the treatment of granular
ophthalmias, applied either in solution or
in the solid form. The cauterizations are
painful even after the previous use of
cocaine. It, however, is one of the most
serviceable remedies in all the superficial
inflammations of* the eye. The divine or
blue stone is said to be composed of equal
parts of copper, alum, and nitrate of potas-
sium.

The nitrate of silver is extremely danger-
ous in ulcerations of the cornea, as it is very
apt to form, in such cases, disagreeable in-
crustations of chloride and albuminate of
silver. In the treatment of purulent ophthal-
mia the author has been in the habit of
cauterizing the conjunctiva every twelve
hours, neutralizing the strong action of the
salt with a little salt-water applied by
means of a soft brush. Endeavors should
always be made to protect the cornea from
the action of the silver nitrate. The solution
of this salt should be freshly made and
placed in a black bottle, otherwise it will
decompose into the oxide of silver and nitric
acid, this producing deep eschars upon the
conjunction. In spite of these incoveniences,
howrever, nitrate of silver is the best germi-
cide, so far, in the treatment of purulent
ophthalmia. The author has obtained
rapid and beneficial results in the treatment
of crescentic and sloughing ulcers of the
cornea by means of a finely pointed stick of
nitrate of silver, being careful not to touch
the borders of the ulcers.

THE INFLUENCE OF WARM ENEMATA IN
THE TREATMENT OF TYPHUS FEVER.

From a study of the subject, T. K. Geisler
(JEsterr ungar Centrablatt, Feb'y, 1891),
draws the following interesting conclusions :
1. Immediately after the injection the tem-
perature of the whole body is somewhat
raised (maximum 0. 2.° C). 2. Warm ene-
mata exercise a favorable influence upon the
intestines, as they diminish the number and

May 9, 1891.

Periscope.

547

quantity of excreted matters retained in
them. 3. The injections provoke a rapid
fall of temperature and transform a continued
fever into a remittent and intermittent dis-
order. 4. After the administration of the
warm enemata, the pulse immediately be-
comes diminished in frequency, but it returns
to its original rate in about an hour. The
pulse in general is very hard and full and
the cardiac contraction very strong ; the
dicrotism is little influenced. 5. The respi-
ration, soon after the injections, is generally
hurried. An hour afterwards, it be-
gins to get slower. 6. The blood pressure
is increased by warm enemata. 7. Under
the injections the quantity of urine is in^
creased, and its specific gravity diminished.
8. The cutaneous and pulmonary exudations
are diminished.

UNTOWARD EFFECTS OF EXALGINE.

A case of poisoning by exalgine is re-
ported by Buisson {Bull. Genet, de Therap.,
March 15, 1891). A man, 60 years of age,
suffering from influenza, accompanied with
gastric disturbance, was ordered antipyrine
but was given by mistake thirty grains of
exalgine, which he took in the course of
three hours. A similar amount was injected
on the following morning. Symptoms of
vertigo, with extreme dyspnoea and pro-
nounced cyanosis were experienced soon
afterwards, and lasted for two days. The
patient recovered.

ARISTOL IN VENEREAL DISEASES.

Vincenzo Fisichella (Biforma Mediea,
1891, p. 238) has tried aristol in the treat-
ment of simple and syphilitic chancres,
buboes, mucous and gummous patches, and
has arrived at the following conclusions : 1.
In simple or syphilitic chajacres aristol pro-
duces after a certain time allying up of the
ulcer. 2. In phagedenic lesions the drug is
of some use but does not produce a curative
action. 3. Compared with iodoform, it is
less efficacious, and can only be preferred on
account of its odorless properties. 4. It is
easily pulverized and it adheres well. The
author does not believe that aristol is des-
tined to be of much use as a remedy for the
treatment of syphilitic disorders.

NEW METHODS OF TREATMENT IN
TYPHOID FEVER.

Dujardin-Beaumetz (Bulletin Gen. de
TherapeuL, December 30, 1890) studies pro-
phylaxis of typhoid fever, and the use of

intestinal antiseptics, cold baths and diuresis
in the treatment of the disease.

Prophylaxis has been more benefited
than has treatment by the discovery of the
bacillus of Eberth. To purify water, boil-
ing or sterilization is better than nitration.
Rigorous care of typhoid patients is insisted
upon ; a strong solution of sulphate of cop-
per, twelve and a half drachms to the quart,
is recommended for washing sheets, water
closets, etc.; a weaker solution, three
drachms to the quart, is used to disinfect
the nurse's hands and those portions of
patient soiled by ejecta. In studying in-
testinal antisepsis, introduced by Bouchard,
salol is preferable to iodoform, naphthaline,
naphthol, etc., since it is less harmful and
more efficient. Thirty to sixty grains may
be given in twenty -four hours, in combina-
tion with salicylate of bismuth, if this drug
is indicated.

Dujardin-Beaumetz does not regard hy-
perpyrexia as a part of the general condi-
tion of the disease, believing that typhoid
fever can be serious without hyperpyrexia
or that the temperature can be kept normal
by antipyretics without decreasing the
severity of the disease. He believes that
antipyretic drugs decrease urinary secretion
and retard elimination of the poisons pro-
duced. He finds that in sponging, envelop-
ing in wet sheets and tepid baths, he has all
the advantages of cold baths without their
inconveniences. By a tepid bath he means
one with a temperature of 86° to 89.6° F.,
making it about eighteen degrees below the
patient's temperature ; with these baths seda-
tion of nervous phenomena is obtained, to-
gether with sufficient lowering of the tem-
perature. Opposing Brand's systemization,
he treats cases symptomatically ; beginning
with sponging, he gives tepid baths, if the
temperature passes 104° F., one or two a
day, lasting twenty to thirty minutes.
Stimulating drinks are given patients, if
needed, while in the bath. If ataxo-adyma-
nia becomes excessive, wet-packing is used
instead ; this pack is not continued for more
than thirty seconds.

Sulphate of quinine is regarded as the
drug best able to meet the general indica-
tions of typhoid, not more than fifteen grains
a day being given. He does not believe
that the benzoate of soda recommended by
Robins increases the elimination of waste
products ; believing the kidneys are the best
agents he gives abundant drinks, preferably
lemonade made with wine, to favor diuresis.

He calls attention to the remarkable
paper of Brouardel, showing the great in-

548

Periscope,

Vol. lxiv

fluence of typhoid mortality on depopulation
in France, the mortality in women being
twice as great as in men. In studying the
influence of the treatment on mortality, he
finds that the difference under the various
methods is trifling ; in 1889, under sympto-
matic treatment, there was a mortality in
the hospitals of Paris of 11.33 in a hundred ;
by systematized treatment with cold baths,
the mortality was 11.28 in a hundred. The
lowest mortality for the year, 7.33 in a hun-
dred, was obtained by the combined use of
quinine aud tepid baths.

Debove has shown that prudence is neces-
sary in reaching therapeutic conclusions
from the study of statistics, for by the purely
expectant plan without hygienic treatment,
he had a mortality the same year, at the
Andral Hospital, of 9.2 in a hundred.
Beaumetz believes that this success rested
largely on the diuresis obtained by Debove.
— University Medical Magazine.

CARPAINE.

A new alkaloid has recently been detected
in papaw-leaves by M. Greshoff, of the
Chemico-Pharmacological Laboratory at
Buitenzorg, in Java. It was obtained by
digesting the powdered leaves in spirit acid-
ulated with acetic acid, removing the spirit
by distillation, and treating the resulting ex-
tract with water so as to leave behind resin
and chlorophyll. The aqueous solution was
then shaken repeatedly with ether, aud car-
bonate of sodium was added until an alka-
line reaction was evident, The precipitate
thus obtained was readily soluble in ether,
and on evaporation of the ether the " car-
paine " was obtained in colorless rosettes of
crystals to the extent of about .25 per cent,
of the leaves employed. Although the
freshly-precipitated alkaloid is readily solu-
ble in ether, when once crystallized it redis-
solves but slowly, so that the crystals can be
purified and rendered perfectly white by
washing with a little ether, but the percen-
tage obtained is thus reduced to .15 per
ceut. On a large scale, the lime and petro-
leum method gives very good results, about
.19 per cent., and would probably be pre-
ferred on the score of expense. Compara-
tive experiments made on the young and
old leaves, freed from the stalks, show that
the old leaves afford when dried .072 per
cent, of the alkaloid, and the young leaves
.25 per cent., and that, on an average, a
papaw plant can be calculated to afford
thirty grammes of the alkaloid per year
from the leaves. The hydrochlorate of car-

paine, which contains about eighty-two per
cent, of the pure alkaloid, is freely soluble
in water. As yet, com]3aratively little is
known of the physiological actions of the
alkaloid. It appears, however, to act more
especially upon the heart, slowiug its action.
The lethal dose for a fowl of five hundred
grammes (one pound) weight was found to
be about 200 milligrammes (three grains).
In a fowl of three hundred and fifty
grammes weight, no poisonous symptoms
were produced with 50 milligrammes of the
alkaloid; with 100 milligrammes, symptoms
of poisoning occurred in ten minutes after
injection into the breast muscles, but after
twenty-five minutes the animal recovered its
normal condition. The bird lay on its side,
and breathed deeply in a jerky manner,
and showed slight convulsive movements of
the whole body, but no irritability was
noticed. Further observations are neces-
sary to determine the usefulness or other-
wise of the alkaloid in medicine. Should it
prove of utility, there can be no difficulty in
obtaining it in almost unlimited quantity
and in a definite crystalline condition. The
alkaloid is easily precipitated from its solu-
tions by the alkaloid reagents. The most
delicate reaction is with Mayer's reagent,—
iodo-iodide of potassium, — which, in a solu-
tion of 1 in 300,000, gives a turbidity, and
in 80,000 parts an evident precipitate ;
phosphomolybdate of ammonium has its
limit of reaction at 1 in 75,000 parts, picric
acid at 1 in 30,000, and chloride of gold at
1 in 25,000. The alkaloid has a bitter
taste, which is perceptible even in a solution
of 1 part in 100,000. — Pharmaceutical Jour-
nal and Transactions, December 27, 1890.

CASES OF POISONING BY BROMOFORM.

Bromoform has been recommended by
numerous observers, in the strongest terms,
as a remedy in whooping-cough, but Dr.
Nauwelaers {Revue Mensuelle des Maladies
de VEnfanee, February, 1891) reports a case
of poisoning in a child, aged 1 year and 3
months, suffering from whooping-cough, by
2 drops of a solution of 7 drachms to i of
bromoform, dissolved in an equal amount of
alcohol, and given eight times daily.

The symptoms produced were profound
stupor, paleness, coldness, complete muscular
relaxation, tracheal rales, feebleness of res-
piration and circulation, contraction and im-
mobility of the pupil, and insensibility of
the cornea. The case proved fatal, and at
the autopsy there was found slight conges-
tion of the brain, marked injection of the

May 9, 1891.

Periscope.

549

stomach and duodenum, and great increase
in bronchial secretions.

In the Provincial Medical Journal for
February 2, 1891, is a second case reported
by Dr. E. Sachs, of a 4-year old child, in
whom 3 drops of bromoform were ordered
three times a day. In the absence of the
mother, the child — doubtless tempted by the
sweet taste of the mixture — got at the
bottle, and drank what remained in it, —
that is, about 15 minims of bromoform.
Some time after, the child suddenly turned
pale, and, staggering about, was put to bed.
When seen by Dr. Sachs it was lying in a
seemingly lifeless condition, with fixed
dilated pupils, cyanotic lips, imperceptible
pulse, and cold extremities. Injections of
ether (Pravaz's syringefuls) and the appli-
cation of a stream of cold water to the chest
and back, soon brought the little patient
back to consciousness, and the next day it
had entirely recovered.- — Therapeutic Ga-
zette.

A NEW METHOD OF ADMINISTERING
DIG ATI LINE.

A new method for the administration of
dangerous drugs has been proposed by Petit
(Rev. Gener. de Clin, et de Therap., March
1 1, 1891). It consists in the preparation of
a solution to serve as a vehicle, this being
especially recommended for the administra-
tion of crystallized digitaline. It is made as
follows :

Glycerine 133 grammes.

Distilled water .... 147 grammes.
Alchohol 95% .... q. s. to make a litre.

Every cubic centimetre of this solution
represents 50 drops, so that the remedy
may be administered in doses of of a milli-
gramme. For example, digitaline could be
ordered in the following manner :

Crystallized digitaline ... 1 gramme.
Glycerine-alcoholic solution q. s. to make a litre.

One drop of this solution is equal to -h of
a milligramme of the active principle.

This method of administration presents
several advantages. The solution or vehicle
is somewhat viscid and consequently does
not evaporate easily ; it is stable and keeps
for a long time.

THE LOCAL ANESTHETIC ACTION OF
STROPHANTHINE AND OUABAINE.

Panas (Archives d' Ophthalmologic, March-
April, 1890) draws the following conclusions
from his clinical observations : 1. Ouabaine
acts as an anaesthetic in the rabbit's con-

junctiva, but has apparently no such effect
in the human eye. 2. Strophanthine, though
superior to ouabaine in anaesthetic proper-
ties, is so irritating in its effects on the
human eye that it can not take the place of
cocaine.

OIL OF PEPPERMINT IN THE TREATMENT
OF "GRIP."

Dr. Charles L. Hogeboom, has had much
greater success in treating grip when using
full doses of oil of peppermint in addition
to quinine, and full doses of bicarbonate of
soda, than without it. He gives from five
to ten drops three times a day, and some-
times more, till the worst symptoms subside.
The disease may be assumed as microbic,
although the germ has not been discovered!
It is probably many times smaller than the
typhoid bacillus, and, in consequence, may
never be found.

The history of grip indicates a germ
origin. It resembles, in many character-
istics, other well-known germ diseases. He
believes oil of peppermint to be a grip germi-
cide. It acts with the greatest promptness
and speedily dispels the most alarming
symptoms, at least as far as my experience
goes. The oil of peppermint is a powerful
stimulant to the nervous system, particularlv
the vaso-motor, promoting regularity and
decreased rapidity of the pulse, and relieving
local congestion. It is the most diffusive of
all the essential oils. These remarks are
sufficient as hints to all practitioners who
may care to make a trial of the remedy. —
Med. Rec.

NITRITE OF AMYL IN CHLOROFORM POI-
SONING.

Dr. E. Mammen, adds another case of
chloroform poisoning treated successfully by
the inhalation of nitrite of amyl. The facts
are as follows : At about 7 P.M., Dr. M.
received a message to come hastily to M.

P , who had taken chloroform and could

not be awakened. The distance was about
one and a half miles, and he stopped at a
drug store to procure five-drop pearls of
nitrite of amyl. Time of arrival was about
half an hour after being called. He found
the patient in a profound stupor, respirations
shallow, pulse rapid and feeble. A three
ounce bottle was found in his coat pocket,
half full of Squib's chloroform. A tele-
phone message to the druggist revealed the
fact that he had purchased three ounces of
the drug some two hours before. He had

Periscope.

Vol.

XIV

550

swallowed apparently about one and a half
ounce. Air was at once freely admitted to
the room and to the patient, and a pearl of
the nitrite given by inhalation. The effect
was immediate and apparent. After the
lapse of fifteen minutes, pulse again became
rapid and feeble, and another pearl was
used, with the result of deepening the res-
pirations and increasing the vigor of the
pulse. The same thing was repeated at
lengthening intervals eight or nine times.
Meanwhile, hypodermic injections of atropia
were twice given, and towels wrung out of
cold water dashed upon the chest. After
four hours the patient awoke from his
stupor, and in another hour was out of
danger. Recovery was somewhat slow, owing
no doubt partly to the great destruction
of red blood-corpuscles, as evidenced by the
extreme icteric hue of the skin, which per-
sisted for two weeks. In my judgment this
patient could not possibly have survived
without the use of nitrite of amyl. — Med.
Bee.

TREATMENT OF SWEATING FEET.

Dr. I. N. Bloom, at a meeting of the Clin.
Soc. of Louisville, said that in a recent case, '
he had the patient bathe the feet in a solution
of bichloride of mercury, 1 to 1000, morn-
ing and evening. After rubbing the surface
carefully, so as to remove the dead epidermis
macerated by the sweat, he directed the fol-
lowing course, which is partly original : A
plaster sole, partly soaked in a bichloride
solution, 1 to 1000, was put in the shoe.
After drying the sole and placing it in the
shoe, he sprinkled it with powdered boric
acid. As regards the advantage of this
method of treatment, there is much diversity
of opinion. In this case the result was quite
satisfactory. If this treatment were uni-
formly successful, it would point to a micro-
organismic origin for the disease rather than
a neurological. His experience has been too
short to determine, but in many cases, espe-
cially of the lighter forms, it is of nervous
origin. It is much easier to cure simple
hyperidrosis of the feet than of the hands.
Hebra's method, with diachylon ointment, is
the only one promising any hope of success.
He has tried many other means recommended
by worthy men, but always had to return to
the diachylon. The inconvenience of this
latter method is great, but patients bear any
treatment, that will help to get rid of the
disagreeable disease. This is especially true
of women.

COCAINE IN SMALL POX.

Drs. Luton and Ory recommend highly
the internal use of cocaine in the treatment
of variola, having tried it during a severe
epidemic that raged in Algiers, in November,
1889. The good effect of the remedy was
shown almost immediately by a lightening of
the color of the eruption and disappearance
of many of the papules without be-
coming purulent. Even in those cases in
which the papules persisted for some time
there was no suppuration. One of the cases
in which the remedy was tried was one of
black small-pox, from which the patient re-
covered. The cocaine was exhibited in a
five per cent, solution, of which from ten to
twenty drops were given every six hours.
As no pustules were formed, there was no
pitting. — Med. Bee.

MEDICINE.

THE WHITE CORPUSCLES IN DISEASE.

A very interesting communication upon
this subject, by Castellino, appears in the
Gazetta degli Ospitalli, No. 4, 1891. The
author has studied the matter for a period
of three years, on over a hundred patients
and his researches were made in a labora-
tory of Genoa. The following conclusions are
put forth : 1. Along with the destruction of
the red cells of the blood, there is an in-
crease in the white globules in the following
diseases, which are arranged in the degree
of the number of said leucocytes : Pneumo-
nia, erysipelas, scarlatina, pleurisy and
typhoid fever. 2. These leucocytes rise in
number with the temperature, and, except
in the cases of erysipelas and pneumonia,
begin to diminish pari-passu with the decline
of the fever. 3. In these last two cases the
white cells only begin to diminish several
days after the crisis is over. 4. In acute
infections there is a predominance of small
white globules which are finely granular
with one nucleus (the leucoblasts of Lowit).
5. In leuchsemia and chronic infectious dis-
eases, such as syphilis, malaria and lead-
poisoning, there is a predominance of the
large leucocytes with coarse granulations,
having many nuclei without nucleoli (ery-
throblasts of Lowit). Many of these gran-
ules answer to the chemical and microscopi-
cal tests of fatty substances.

A CASE OF ECHINOCOCCUS OF THE LUNG.

An interesting case of echinococcus in the
upper lobe ot the right lung, in a girl, aged
16 years, and of a family history of phthisis,

May 9, 1891.

Periscope.

55i

is reported by L. Revilloid {Rev. Med. de la
Suisse Romande, Feb'y 20, 1891). The
girl had always been delicate, having suf-
fered from pleurisy when she was three
years of age ; when eight years old she had
whooping cough, and shortly afterwards an
area of dullness over the upper lobe of the
right lung appeared and was diagnosed as
tuberculous. The best hygienic measures
were used in treating the patient, but not-
withstanding these precautions, the dullness
continued to spread until amphoric breath-
ing appeared over the whole area of dull-
ness in front and behind. Once, when ap-
parently enjoying fair health, the patient
was suddenly seized with suffocation and un-
controllable cough, which was followed by
expectoration of large quantities of white
viscid fluid. The expectoration continued
for three-quarters of an hour and was fol-
lowed by violent vomiting. The patient
became very ill ; the face and extremities
were cold and blue, and collapse set in. On
recovery from this, the temperature went up
and the pulse increased to 130. The ex-
pectoration continued and the nausea was so
great that no food could be retained in the
stomach. Rectal alimentation was em-
ployed. Two days afterwards rigors, with
cold perspiration, came on and the expect-
orated matters exhibited an excessive foetor.
Then over the area of dullness, physical ex-
ploration showed the presence of a cavity ;
amphoric breath sounds, rales and crepita-
tion were marked. The patient, however,
in such condition, did not present the aspect
of a consumptive person, and the rare smell
of the sputum was that of sulphuretted hy-
drogen. In the sputum, through micro-
scopical examination, were found organisms
in the form of hooklets, but no traces of
tubercule bacilli. The diagnosis was clearly
made then. In the course of time, all signs
of the infectious disease disappeared and the
patient made a final recovery. The treat-
ment consisted of the administration of de-
odorants and the regulation of the patient's
posture in order to insure the evacuation of
the cavity. It was afterwards ascertained
that the girl, when a child, associated largely
with pet dogs, known to be suffering from
taenia, and thus the presence of the echino-
coccus in the patient was explained. About
nine months later the subject of this case
was enjoying apparently the best of health,
no symptoms of tuberculosis having been
observed.

Eleven physicians have each found a
better "lymph" than that of Koch.

THE VISUAL DISTURBANCES IN TABES
DORSALIS ; AN ATTEMPT AT A COM-
PREHENSIVE EXPLANATION OF
. THE SYMPIOM-COMPLEX
OF TABES.

Berger (Arch, of Ophthalmology, xix, 4)
has here presented a very interesting paper.
He finds that tabes occurring in the earliest
and latest periods of life are free from severe
complications. Tabes in syphilitic cases gen-
erally begins with cerebral symptoms and in
non-syphilitic cases with spinal symptoms.
Slight drooping of the upper lid increases
from the beginning of the tabes up to the
paralytic stage. When the lids of a tabetic
patient are closed after a few seconds, fibril-
lar twitching is seen in the orbicular muscle
of the lid. There is no marked difference in
the relative frequency of inequality of the
pupils in the different stages of tabes ; it is
slightly more frequent in the initial stages.
A trace of pupillary reaction to light may be
preserved for a long time, and this reaction
disappears undoubtedly earlier than the re-
action to irritation of the skin. Berger
accepts Mauthner's explanation of the immo-
bility of the pupil in tabes — that the fibres
of the pupillary light reflex, lying in the wall
of the third ventricle, suffer from a chronic
ependymitis and a consequent sclerosis.
Paralysis of accommodation becomes the
more frequent the more advanced is the dis-
ease. As a rule, paralyses of the exterior
ocular muscles are found disproportionately
oftener in cases showing optic atrophy than
in cases not thus complicated. Between the
cases of optic atrophy with paralyses of the
ocular muscles and those without such com-
plications there is no special difference as
regards the duration of the affection before
blindness ensues. Most of the optic atrophies
develop in the pre-ataxic stage ; but should
such atrophy develop later, blindness will
follow the sooner the more advanced is the
tabes. No relation exists between the con-
traction of the visual field, the color-fields,
the disturbances of central vision, and of
color-perception in tabes. Contraction of the
outer portion of the visual field is most fre-
quent, though it may occur in its upper
portion. Syphilitic patients show a greater
tendency to permanent paralyses of the ocular
muscles than non-syphilitic patients, owing to
the fact that they are more subject to multiple
paralyses. Berger draws the following con-
clusions: Many of the symptoms of tabes may
be explained by a lesion of the nerve nuclei
in the fossa rhomboidalis and its continua-
tion into the aqueduct of Sylvius. The dif-

552

Periscope.

Vol. lxiv

ficult closure of the lids may be explained
by a slight functional disturbance of the up-
per nucleus of the facial nerve. The myosis
is paralytic, caused by paralysis of the vaso-
constrictors in the medulla. The reflex
iridoplegia is caused by a legion of the fibres
running in the wall of the third ventricle to
the nucleus of the sphincter pupillse. The
diminished intra-ocular tension sometimes
found is the result of the lowering of the
tone of the vessels. The lacrymation in ta-
betic patients is a vaso-motor neurosis. The
sympathetic nerve is not the cause, but the
medium by which certain ocular symptoms
of tabes are carried from the central ner-
vous system to the eye. In tabes it may be
said in general that the nerve nuclei in the
medulla nearest the median line suffer more
frequently than those farther outward. An
affection of the medulla is indicated by the
development of diabetes mellitus in tabes,
and in this manner may, perhaps, be ex-
plained the febrile symptoms which are
sometimes met with in tabes. It is unneces-
sary to assume the existence of haemorrhages
in the central fibres and in the nuclei in or-
der to explain the transitory paralyses of the
ocular muscles which come on in the begin-
ning of tabes. We know that the antero-
lateral tract, which connects the degenera-
tion zones of the medulla with those of the
cord, contains vaso-motor fibers, and it has
been proved that the lesions of the cord, es-
pecially in tabes, correspond in extent to the
vasculas zones. It may be concluded from
the functional disturbances of the optic
nerve that vascular changes alone cause the
disturbances, and the assumption is admis-
sible that the functional disturbances of the
vascular regions of the optic nerve and pos-
terior columns of the cord are caused by a
disease of the nerve centers in the fossa
rhomboidalis, resulting from an ependymitis
of the medulla.

Berger's experimental investigations, in
which he cut different parts of the medulla,
shows that: 1. Nystagmus may develop.

2. Mydriasis as well as myosis may appear.

3. As a result of injury to the medulla,
haemorrhages are found in particular vas-
cular regions of the cord. 4. After injury
to the medulla, changes in the retinal ves-
sels may come on. — N. Y. Med. Jour.

REFLEX PAIN IN REMOTE REGIONS AN
EVIDENCE OF INTERNAL HEM-
ORRHAGE.

In 1880, a German, aged fifty-nine, while
engaged in playing chess with Dr. H. Engel

complained of an excruciating pain in
his left knee, which had developed a few
hours before and gradually became more in-
tense. He had never suffered with rheuma-
tism or neuralgia of any kind, never, met
with any injury, and never felt any pain in
that knee. An examination gave no result ;
there was neither redness, swelling, nor
tenderness.. He went home promising to
use certain anodynes as directed by me.
Late in the night Dr. E. was sent for, the pain
not having diminished. A hypodermic of
morph. sulph., one sixth grain, gave no re-
lief, and it was followed fifteen minutes later
by a second injection of one-fourth of a
grain, and the pain became less severe. The
next day the pain remained about the same;
he refused another hypodermic, and a blister
applied at 11 A.M. Otherwise his health
was undisturbed, there being no symptom
or sign of any other morbid condition.
Dr. E. was informed later, that the pain
subsided somewhat about five o'clock in the
afternoon, probably from the effect of the
blister still covering the spot. A few min-
utes before 6 P.M. the pain again became
suddenly intense ; he expressed a desire to
use the commode, and while sitting upon it
he was seen to fall forward. An immense
hemorrhage, extending over the entire base
of the brain, had caused the fatal issue be-
fore Dr. E. reached him an hour later.

An Israelite, aged sixty-three, remarka-
bly active and healthy-looking, while visit-
ing, on the afternoon of December 14, 1884,
a lady with whom he had been very inti-
mate for years, complained of a severe pain
in the left leg, a little below the knee. This
pain became so severe that a neighboring
physician, a homoeopath, was sent for. He
had the patient go to bed and administered
various internal remedies. At about 9 P.M.
the pain became easier, when suddenly all
the sympto'ms of the classical apoplectic
seizure developed. In this state he was re-
moved to his home, where Dr. E. saw him
about 11 P.M. Venesection, the application
of croton oil to his tongue, and the internal
use of tartar emetic caused him to regain con-
sciousness ; but when Dr. E. saw him the next
morning his temperature was 102° and the
fatal issue seemed imminent. Later in the
day the haemorrhage recurred and he died
the same night.

October 11, 1886, a man of fifty-three con-
sulted Dr. E. about a severe pain in his back.
The closest examination failed to reveal its
cause. It was not lumbago, for no move-
ment of any kind augmented or diminished
the pain. After several days of fruitless

May 9, 1 891.

Periscope.

553'

medication a blister cured it. The man
then remained well for three months, when
the same pain suddenly returned while he
was at his home on the night of January
16th. ' Nothing seemed to give relief, and a
little after 5 A. M. death occurred from cere-
bral haemorrhage. — Med. News, March 28,
1891.

SURGERY.

STRICTURE OF THE MALE URETHRA.

Dr. J. William White, in the University
Medical Magazine, gives his views in an
able manner as to the treatment of this con-
dition. The following are his conclusions :

1. Strictures of large calibre, that is, of
more than 15 French, situated at or behind
the bulbo-membranous urethra, are to be
treated almost without exception, by gradual
dilatation.

2. Strictures of large calibre occupying
the pendulous urethra are to be treated by
gradual dilatation when very recent and
soft, and by internal urethrotomy when of
longer standing, distinctly fibrous in char-
acter or non-dilatable. It is to be remem-
bered that the great majority of so-called
strictures of large calibre of the pendulous
urethra are merely points of physiological
narrowing.

3. Strictures of the meatus and of the
neighborhood of the fossa navicularis should
be divided upon the floor of the urethra
whenever it is evident that they are real
pathological conditions producing definite
symptoms and not normal points of narrow-
ing.

4. Strictures of small calibre (less than 15
French), situated in advance of the bulbo-
membranous junction, unless seen very early
and found to be unusually soft and dilatable,
furnish the typical condition for internal
urethrotomy, which should be done prefer-
ably with a dilating urethrotome and, in-
variably, with all possible antiseptic pre-
cautions.

5. Strictures of small calibre (less than ] 5
French), situated at, or deeper than, the
bulbo-membranous junction, should be
treated whenever possible by gradual dilata-
tion. In a case of resilient, irritable or
traumatic stricture in this region or of
stricture which, for any reason (as the oc-
currence of rigors), is non-dilatable, external
perineal urethrotomy is the operation of
choice.

6. Strictures of the deep urethra, permea-
ble only to filiform bougies, should be

treated by gradual dilatation when possible,
the filiform being left in situ for some time,
and followed by the introduction of others,
or used as a guide for a tunneled catheter.
If the stricture be not suitable for dilatation,
external perineal urethrotomy should be
performed.

7. Impassable strictures of the deep urethra
always require the performance of perineal
section.

IS CANCER OF A POISONOUS NATURE?

Prof. Adamkiewicz, of Krakau, read a
paper before the Royal Academy of Sciences
at Vienna {Deutsche Med. Zeit). on the above
subject. After formulating the following
questions, he reaches the conclusions given
below in reply thereto : —

1. Is it, in the first place, possible to dem-
onstrate any poisonous property of cancer-
tissue, no matter how developed, upon the
animal organism ?

2. Is the activity of the cancer-poison
upon the animal dependent on the location
of the site of inoculation ?

Experiments upon rabbits have so far fur-
nished the following answers : —

1. There is a poison in recently-removed
and unchanged carcinomatous tissue.

2. This poison can kill animals in a few
hours.

3. It acts only on the nervous system, and
death is caused by paralysis of the brain.

4. Boiling heat and disinfectants (carbolic
acid, etc.) destroy the activity of this cancer-
poison.

5. The micro-organisms which are con-
stantly to be found in cancerous substance
and at the site of inoculation do not, how-
ever, seem to be the carriers of this cancer-
poison.

6. By transplanting cancer-tissue upon a
favorable soil, the latter also acquires poi-
sonous properties ; it cannot be stated
definitely to what extent the micro-organisms
are concerned in the production of these
properties, which develop on this soil at the
same time.

7. No other living tissue, whether of phys-
iological or pathological origin, possesses
(as far as can be determined from his experi-
ments) the poisonous properties of cancer.

8. This poison has been found only in
true carcinomas ; in sarcomas and adenomas
he has not yet been able to prove the exist-
ence of such a poison.

9. The action of the poison is so rapid that
it may be of value as a means of rendering
evident the cancerous nature of a patholog-
ical growth.

554

Periscope.

Vol. lxiv

10. Tissue from the cadaver possesses a
poisonous action very analogous to that of
carcinomatous substance ; this analogy is
so great that it may be positively stated that
malignant growths produce during life a
material having an action similar to that of
the poisons from the cadaver.

Adamkiewicz intends to produce the proofs
of these conclusions in a more extended form.
— Memphis Med. Monthly.

TREATMENT OF ABDOMINAL CONTUSIONS
PRODUCED BY HORSE KICKS.

From an interesting study of the treat-
ment of abdominal contusions produced by
horse-kicks, Moty (Arch, de med. et de
Chirurg. nulit, Feb'y and March, 1891) ar-
rives at the following conclusions: 1. In
one-third of the cases abdominal contusions
of the origin indicated are accompanied by
serious intestinal lesions. 2. The diagnosis
of perforation is impossible. 3. The best
method to use in the treatment of intestinal
wounds is the direct union by means of
sutures. Even if peritonitis exists, intestinal
suturing and laparotomy can be practiced.
4. Meanwhile, an exploratory laparotomy is
not indicated, and in the case of doubt,
medical treatment alone should be resorted
to. 5. In regard to prognosis, this should
be withheld for about a month, for subse-
quent complications may arise as a result of
a latent contusion of the mucous membrane.

TREATMENT OF GLEET AND SEXUAL NEU-
RASTHENIA BY MEANS OF METALLIC
BOUGIES.

Dr. Charles Szadek, of KiefF, Kussia, in the
Atlanta Medical and SurgicalJournal, refers
to the extraordinary difficulty of healing
some cases of gleet is well known. There
are men who have every morning an exuda-
tion, although they have tried every possible
remedy against the evil. Frequently, espe-
cially after coitus or excess in saccho, the
chronic disease becomes acute, which often
leads to disagreeable results.

The product of the chronic inflammation
of the urethra is an infiltration of the cells
of the diseased mucous membrane ; the in-
filtration gradually becomes fibrous tissue,
which, in its turn, produces the cicitrization
called stricture ; the upper cells of this stra-
tum, constantly sloughing, exfoliating and
mingling with the mucous secretion of the
glands, constitute the exudation which char-
acterizes chronic gonorrhoea (gleet) ; the
glands and lacunse of the urethra are also
affected. It is clear that many chronic gon-

orrhoeas already represent the first stages of
stricture, or, as Otis calls them " large sized
strictures," which naturally cannot be cured
by astringent solutions, or even such as are
fatal to gonococci. If they are to be cured
local pressure must be used to remove the
cell infiltration, while medical treatment is
adopted to affect the catarrh. For these
reasons treatment with metallic bougies
against chronic gonorrhoea has been mostly
practiced.

In four years (1887-1890) I have treated
fifty (50) cases of inveterate gleet with most
satisfactory results, by the introduction into
the urethra of Benique's duly curved tin
bougies, anointed with either Unna's

Ol. cacao 1,0

Cerae flavae 2,0-5,0

Bals. Peruv 2,0

Arg. nit 1,0

M . ; f. ung.

Or Sperling's Salve :

Lanolini 20,0

Cerae albae 4,0

Arg. nit 0,1-0,3

M. ; f. ung.

These bougies are slightly conical and
eleven centimeters in length. In nervous or
very sensitive subjects, in whom the asser-
tion of the bougies gives rise to pain and
erection, from 3 to 5 per cent, solution of
cocaine should be previously injected into
the urethra ; during the first sitting the bou-
gie is left in situ not longer than for three
or five minutes, but later on the duration of
the sittting is gradually increased up to fifteen
or twenty min utes. The sittings are repeated
every two or three days, except in very in-
veterate and atonic cases, in which a daily
introduction of the instrument is advisable.
I have used a set of the bougies from No. 18
to No. 30 charriere, commencing with the
least irritating bougies and gradually ascend-
ing to even larger ones. In relatively recent
and in old cases I have usually employed
Nos. 22, 24 and 25, while in more severe
and protracted ones (which, by the way,
constitute a vast majority) I have passed,
following Professor Otis's instance, by de-
grees to No. 28 or even No 30. In patients
with narrowed ureter, I have enlarged the
latter by means of a bistoury. In such cases
where the lesions are situated in the bulbous
or the posterior division of the urethra, his
bougies should be introduced even as far
backwards as the bladder ; according to my
experience, the deep insertion, when prac-
ticed with due caution and carefulness, never
causes any untoward accessory effects (such
as vesical or urethral irritation, urethral
fever, etc.). The therapeutic results which
I have obtained with this treatment are sat-

May 9, 1891.

Periscope.

555

isfactory. My fifty cases of gleet, which
were treated after the mechanical method
in five cases of urethritis posterior, compli-
cated with obstinate vesical affection,
the results were far from being satis-
factory; but in the remaining forty-five
the treatment by metallic bougies proved
highly successful. In thirty of the fifty
cases a complete cure ensued ; in another
case a considerable improvement was ob-
tained, and the only symptom left was a
scanty mucoid discharge recurring from time
to time. In relatively recent or in old cases
from four to eight sittings proved to be suf-
ficient for effecting cure. In a majority of
cases, however, two or three months' course
was necessary for the purpose, while in some
unusually severe case, complicated with
multiple strictures where a relapse took
place, another course was to be repeated
some months later.

The same method in the shape of the in-
sertion of Nos. 20 to 30 gave to me most
gratifying results, also, in fifteen cases of
sexual asthenia, with spermatorrhoea and in-
complete sexual impotence.

I arrive at the following general con-
clusions :

1. The method under consideration proves
very useful ; in many cases of neurasthenic
irritation of the urethral mucous membrane,
and in many cases of inveterate gleet, espe-
cially in those characterized by infiltration
and other morbid changes in the mucous
membrane and submucuous tissues.

2. It proves beneficial further in invet-
erate gleet of an atonic character, or in that
kept up by local nervous disturbances.

3. In some cases, however, the mechanical
treatment must be supplemented by a subse-
quent course of local astringent remedies.

4. The method is free from any untoward
accessory effects ; provided, it is practiced
with due precautions.

THE TREATMENT OF VARICOSE ULCERS.

Dr. J. Braun states that a large experi-
ence with this class of cases has convinced
him of the superior advantages of a 10 per
cent, ointment of zinc in lanoline (zinc oxid.
15.0, lanoline 110.0, ung. emoll. 40.0). This
is applied as follows in cases of ulcer of the
legs : The surface of the ulcer is thoroughly
washed with luke-warm water, carefully
dried with a compress, and the salve spread
on a soft piece of linen applied to the sore
and retained by a handkerchief or strip of
linen. The patient remains in bed until the
sores have cicatrized. The good effects of

this treatment soon become apparent, the
pains and itching disappear, and the profuse
watery secretion is arrested, the greater part
of the transuded fluid being absorbed by the
lanolin which has hygroscopic properties.
The ointment forms a protective covering
under which healing takes place, while the
lanolin by virtue of its antiseptic powers
prevents decomposition of the secretions. In
cases of unhealthy ulcers, the application
should be renewed four or five times daily
for the first few days. After three or four
days, the surface of the sore will be found
much cleaner, and cicatrization will have
occurred at the margins, and then the oint-
ment need only be applied three times daily.
Once a day, and preferably in the morning,
the ulcer should be irrigated with luke-warm
water and dried, and before each application
any remaining secretion is removed with
absorbent cotton. Since employing this
treatment the author has not found it neces-
sary to resort to skin transplantation. — Allg.
Wien. Medisin. Central- Zeitg.

GYNAECOLOGY.

MEDICATED PENCILS FOR ENDO-
METRITIS.

Terrier (L'Union Medicale, Jan'y 8, 1891)
uses the following combination for the prep-
aration of medicated pencils :

I^? . Powdered iodoform 10 grammes.

Tragacanth gum 9.50 "

Glycerine and distilled water each
q. s. to make 10 pencils

These pencils are recommended in the local
treatment of simple endometritis, when direct
exploration of the uterine cavity and dilata-
tion are not necessary. The iodoform may
be replaced by salol or resorcine in the same
doses. If it is desired to use the bichloride
of mercury, the pencils may be prepared in
the following way :

1^? Bichloride of mercury 0.50 grammes.

Pulverized talc 25 "

Tragacanth gum 1.50 "

Glycerine and distilled water each
q. s. to make 50 pencils.

The vagina should at first be thoroughly
washed and disinfected with a one thous-
andth solution of the bichloride of mercury,
after which the pencils are to be introduced
into the uterine cavity and retained there
by the aid of iodoform or salol tampons.

TREATMENT OF FISSURED NIPPLE AND
ENGORGED MAMMARY GLAND.

Dr. Barton Cooke Hirst, in a recent num-
ber of the University Medical Magazine,
says : In the treatment of fissured nipple,

556

Periscope.

Vol. lxiv

when the cracks are at all extensive, the
ordinary remedies recommended from time
to time have been found more or less unsat-
isfactory. Painting with tincture of benzoin,
for instance, while an excellent procedure
for small superficial cracks of the nipple, is
perfectly worthless in more advanced cases.

The writer has found in hospital and pri-
vate practice that excellent results can be
secured in bad cases by the application of
an ointment made up of equal parts of castor,
oil and subnitrate of bismuth. This mixture
makes a very smooth, soft ointment, which
relieves the pain, and is an excellent protec-
tive to the part. Before application, the
nipple and surrounding skin should be care-
fully cleansed and disinfected, and then the
ointment should be smeared on plentifully.
If it is necessary for the child to nurse from
the affected nipple, it can be allowed to do
so without the necessity of removing the oint-
ment from the nipple, as must be done if
tannic acid or the salts of lead are used.
This is a serious disadvantage of many forms
of treatment recommended for fissured nip-
ple, for the irritation of removing the sub-
stance employed as a local sedative neutral-
izes its action.

For the engorgement and pain in the
mammary gland itself, which so often ac-
companies fissured nipple, the writer has had
excellent results from the use of an applica-
tion of lead water and laudanum, which is
applied by means of a cloth covering the
whole breast, renewed at frequent intervals,
and kept in place by a suitable mammary
binder, either that recommended by Rich-
ardson or the Murphy bandage. This not
only retains the dressing, but supports the
breast and exercises even pressure upon it.
With this treatment the development of
mammary abscess is a rare event. If the
child can be nursed from the other breast
alone, it is safer, I think, to draw the milk
from the affected gland by means of a breast-
pump, until the cure is almost complete. If
it is necessary that the child should nurse
from the cracked nipple, a glass nipple shield
with a rubber tip must be employed.

TRENDELENBURG'S POSTURE IN LAP-
AROTOMIES.

The advantage of Trendelenburg's method
of pelvic elevation in suprapubic operations
upon the bladder has been generally recog-
nized by surgeons. In a recent number of
the Centralblatt fur Chirurgie, Dr. Leopold
states that an experience of several years

has convinced him of the value of this post-
ure in intra-abdominal operations on fe-
males, for diseases of the uterus, ovaries and
tubes. By elevating the pelvis the intes-
tines are caused to gravitate toward the
diaphragm, and the pelvic organs are thus
rendered much more accessible to operative
procedures. As is well known the protru-
sion of the intestines into the wound is fre-
quently a source of delay and danger in
laparotomies ; they get in the way of the
operator, and are apt to be wounded. Aside
from this, the posture affords an excellent
view of the pelvic viscera, enabling us to
recognize the presence of adhesions between
the uterus and rectum or bladder ; to diag-
nose the different forms of salpingitis and
ovarian disease, and to determine the rela-
tive position of the organs. In operations
before a class of students, the latter are en-
abled to follow the different steps of the
procedure much more readily than when the
woman is in the ordinary position. It is
often a source of disappointment to those
witnessing a laparotomy that many of the
details of the operation escape observation,
but Dr. Leopold assures us that by the em-
ployment of this posture, many important
points in the technique, such as the manner of
ligating the pedicle and the application of
the sutures can be noted. — International
Journal Surgerg.

H^MOSTYPTICA.
Fritsch (Therapeut. Monatshefte, Jan-
uary, 1891) states that in common with all
gynaecologists he uses ergot frequently in his
gynaecological work. In obstetrical prac-
tice he rarely has occasion to employ it. For
a long time he gave the drug in pill form as
follows :

Powder of ergot 80 grains.

Tragacanth q. s.

Make 60 pills.
Take ten pills daily.

In practice among poor patients this is a
desirable formula on account of its cheap-
ness. For more prompt action he uses the
following prescription :

Powdered ergot 10 drachms.

Alcohol 20 drachms.

Sulphuric acid 2 drachms.

Warm water 4 pints.

Digest to , 1 Vi pints.

Filter and add syrup of cinnamon 4 ounces.

Take two tablespoonsfuls three times daily.

This preparation of ergot, though very-
effective, will disagree with the stomach and
cannot be taken continuously,

Fritsch then advises the use of Denzel'e
ergotine in the following combination.

May 9, 1891

Periscope.

557

Ergotine (Den/el)
Powdered ergot

Make 100 pills.

Take six pills daily.

each 80 grains.

In this way ergot may be given with ex-
cellent effect for a long while.

In cases of menorrhagia the following is
advised :

Jjk Dried extract of hydrastis canadensis ~|

Dried extract of gossypium >of each 80 grains.

Ergotine (Denzel) )
Make 100 pills.

Take three pills three times a day.

I In the form of suppositories ergot seems to
be of little value.

A tincture may be made on the plan of the
decoction given above, of such strength that
one drachm will contain eight grains of
ergot. Of this two tablespoonfuls may be
given daily. Fritsch calls this tinctura hcemo-
styptica.

This tincture is very effective, especially
in menorrhagia after labor, at the climacteric
and in profuse menstruation of the very
young. This remedy should always be
tried before any operative measures are un-
dertaken for the relief of menorrhagia. —
University Med. Magazine.

SEXUAL LIFE OF WOMEN AFTER CAS-
TRATION.

At the Berlin Medical Congress, Dr. F.
Deppler, of Venice, read a paper embody-
ing the results of a study he had made in
the cases of ovariotomy performed by him-
self. He had performed castration forty-six
times, obtaining a cure in thirty-nine. These
operations were performed for the relief of
purulent or gonorrhoeal salpingitis, oophoritis,
fibroid tumors of the uterus, etc. The fol-
lowing were his conclusions, derived from a
study of the physiological consequences of
these operations: 1. When the operation
was performed on account of salpingitis or
other inflammatory process, uterine haemor-
rhage never occurred subsequently. 2. The
conjugata became gradually shortened, and
this was the more marked the younger the
individual was when operated upon. 3.
The uterus became atrophied, the vagina
grew shorter and narrower, its mucous mem-
brane became paler, and the labia majora
were somewhat thinned. 4. The breasts grew
smaller, acquiring a strong resemblance
to the male mammae. 5. The brown pig-
mentation of the nipple, areola, perineum,
and annus disappeared wholly, as did also
pathological pigmentation existing in some
of the cases; the hair also turned white. 6.
The tendency to embonpoint, which is gen-
erally believed to exist after these opera-

tions, was not observed by the author. 7.
No changes were observed as regards the
growth of the hair or the tone of the voice.
8. The sexual desire remained, and was the
more pronouneed the earlier in life the
operation was performed. 9. The opera-
tion offers no impediment to marriage;
three of the author's cases had married and
had lived happily with their husbands for
years. 10. A marriage with a castrated
woman is the ideal Malthusian marriage,
and the only way the Malthusian idea can
be carried out without endangering the
health and happiness of the woman. 11. In
the cases operated upon in early life for in-
flammatory conditions, no neuroses were
seen to develop, which was not the case
when women were operated upon late in life
for fibroid tumors of the uterus. 12. A
favorable influence upon the haemorrhage
was observed after operation for myoma, yet
in no case did the menopause at once set in.
13. In cases of operation for uterine fibroma,
the patients, even those in full maturity, lost
all sexual inclination after the operation. —
Medical Press and Circular.

OBSTETRICS.

INDICATIONS FOR OPERATION IN EC-
TOPIC GESTATION.

Dr. C. A. L. Reed, of Cincinnati, Ohio,
contributed a paper to the Southern Surg,
and Gyn. Assoc., on this subject.

The paper starts with the assumption that
the only proper treatment of ectopic gesta-
tion is by laparotomy, or, more properly,
coeliotomy. While the profession has be-
come practically unanimous that this is the
proper line of treatment, the indications for
operation have been less definitely decided
upon. This conviction is forced upon the
observer, not only by a study of the litera-
ture of the subject, but by encountering
cases which have been advised against
operation by their attending physicians,
until haemorrhage within the pelvis has
threatened a fatality, which is but too fre-
quently realized. The most legitimate ex-
cuse for this dilatory practice is to be found
in the confusion which has arisen with re-
gard to the supposed uniform causal relation-
ship of ruptured ectopic gestation to pelvie
hematocele, and the division of the latter
into " primary " and "secondary" rupture.
These terms are unfortunate, and, as used in
this connection, may be entirely arbitrary.
Primary rupture is made to mean rupture
beneath the peritoneum, instead of first
rupture, as the etymology of the word would

558

Periscope.

Vol. Ixiv

imply, while secondary rupture is made to
mean rupture within the peritoneum, in-
stead of " second " rupture ; whereas an
intra-peritoneal rupture may be, and fre-
quently is, a primary rupture, when spoken
of with reference to the sequence of events
in ectopic gestation. There would be no
serious confusion here if we were not also
taught to leave extra-peritoneal hematoceles
alone, to be taken care of by absorption,
and if we did not add that, as these hae-
matoceles are generally caused by ruptured
ectopic gestation sacs, we are to relegate
these cases also to the expectant plan of
treatment. This conclusion is without war-
rant, and is responsible for hundreds of
deaths annually from this one cause.

The treatment of ectopic gestation pre-
mises the diagnosis of this condition. This is
obviously difficult, and in the majority of in-
stances cannot be arrived at at all, or, if at all,
only presumptively. But in all these cases
conditions can be found in the pelvis, which,
if not conclusive of extra-uterine pregnancy,
yet constitute conclusive indications for ex-
ploratory operation. The presumption of
ectopic pregnancy can be arrived at before
rupture, chiefly by a history of previous
sterility, by a previous amenorrhea, followed
after a few weeks by irregular haemorrhage,
by increased tumefaction at each side, or be-
hind the uterus, and by the existence of
false decidua within the uterus. The latter
fact may be safely determined by the judi-
cious use of the Emmett curett forceps.
The diagnosis after rupture is essentially the
diagnosis of internal haemorrhage. Time
wasted either to determine the cause of that
haemorrhage, or to find out whether it be
primary or secondary, is criminal. The
thing to do is to cut down and operate. The
position has been taken that time should be
taken for the patient to rally from the
shock. One of Dr. Heed's own cases died
simply because he waited twelve hours for
reaction — a lesson which taught him the
fallacy of the old teaching, and which has
since saved lives at his hands. The best
way to overcome shock from internal haemor-
rhage is to stimulate the patient by giving
ether, stop the drain by ligating the bleed-
ing vessels, and arouse the nervous system,
by washing out the belly with hot water.

What shall be done with the appendages
on the other side ? In view of the fact that
tubal pregnancy generally depends upon
desquamative salpingitis, as confirmed by
the recent observations of Formad, before
the American Association of Obstetricians
and Gynaecologists, and in view of the fact

that this disease is almost uniformly bilat-
eral, the question is at once raised, " Is the
woman liable to an ectopic pregnancy on the
other side ?" Herman, in the British Medi-
cal Journal, September 27, 1890, reports
such a case; and Tait reports another, with
death from rupture of the second conception.
Leopold Meyer reports another, and refers to
verified cases by Veit and Olshausen. There
are now at least ten cases on record. From
this Dr. Reed concludes that if the patient's
condition at the time of the operation is such
as to justify further interference, the appen-
dages from both sides should be removed.

He submitted the following conclusions :

(1.) The only proper treatment of ectopic
gestation is that by abdominal section.

(2.) The operation should be done in cases
before rupture as soon as the condition can
be presumptively diagnosed.

(3.) The operation should be done in cases
after rupture, as soon as the evidences of in-
ternal haemorrhage become apparent.

(4.) In cases in which the period of via-
bility has already been reached without
rupture, pregnancy should be allowed to ad-
vance to term before operation, but only
under the closest possible vigilance.

(5.) In all cases the appendages from both
sides should be removed, providing the con-
dition of the patient will justify the exten-
sion of the operation. — Ann. Gyn. Peed.

THE TREATMENT OF ECLAMPSIA.

Dr. Barton Cooke Hirst (Ann. Gyn.
Peed.) in considering the various methods
employed in the treatment of eclampsia, says
that he believes that a careful analysis of
the different plans of treatment will award
the palm to chloral, with diaphoresis, and
catharsis, anaesthetization and occasionally
venesection. Morphia, it is true, gives the
best record — 3.3 per cent. — but this was in
the hands of a single individual, and his re-
port would be more impressive were it more
exact. Thus, he says that in " more than
thirty years " he has had " more than sixty
cases of eclampsia." In that period one's
memory could easily play him false, both as
to the number of cases and the results.
Chloral, on the other hand, has achieved
brilliant results in different, hands aud
places He should like to see veratrum
viride more extensively tried, and would be
glad to unite with others holding hospital
positions to give it a thorough test under
favorable conditions. He believes the re-
sults would be excellent — would, perhaps,
challenge those of chloral. But as the case

May, 9, 1891.

Periscope.

559

stands at present, it seems to me that the
conscientious physician must depend upon
chloral, at least in private practice, until the
equality or superiority of some other plan of
treatment is proved. Perhaps a combina-
tion of chloral and veratrum, one by the
bowel, the other hypodermically, will give
better results than either remedy alone.
This he intends to test at the first oppor-
tunity.

PAEDIATRICS.

INSOMNIA IN INFANTS.
Dr. Jules Simon considers insomnia a
symptom of much importance in infants. In
many diseases it is a sympton of minor im-
portance, and of no special interest. In
others it is one of the chief manifestations of
the disease. The influence of dentition has
been greatly exaggerated. Unless congestion
of the gums or surrounding parts is present,
it causes but little disturbance of the sleep.
Dyspepsia and indigestion are the most com-
mon and universal causes of disturbed sleep,
even without the definite symptoms of vomit-
ing, diarrhoea, or marked constipation. A
discussion of the treatment would involve a
review of the whole subject of dietetics.
Causes referable to the nervous system prob-
ably occur next in frequency. All young
infants may, even in the first year, present
evidences of acute cerebral congestion. Ex-
tremes of either cold or heat may produce
the same result. A child that has been ex-
posed to a strong wind during its daily airing,
or one that has had insufficient protection
from the sun, may pass a restless and un-
comfortable night. This condition must be
distinguished from the insomnia of meningitis
which, in some cases, is for many days the
only sign. In older children, headache due
to overtaxing of the brain is not uncommon.
Anaemia and rapid growth, in conjunction
with over-study, is a fruitful cause of insom-
nia. In children of rheumatic parents this
tendency is especially marked. Among
nervous causes in these older children, hys-
teria, chorea, and epilepsy are the most com-
mon. The young hysterical subject is always
liable to insomnia, with or without headache.
Some attribute all headaches of this period
to hysteria, but the author believes that the
distinction should be carefully made between
such headaches and those due simply to rapid
growth and over-study. The insomnia of
epilepsy is peculiar to itself, and is sometimes
the only symptom for a considerable period.
The child suddenly wakes from profound
sleep, sits up, and begins to cry, but soon lies

back, as if exhausted, and falls into a deep
sleep. These attacks are always accompa-
nied by incontinence of urine. Insomnia
complicating chorea is an exceedingly grave
symptom. Earache is always accompanied
by insomnia, and usually by continuous cry-
ing. Hernia is a cause of pain and sleep-
lessness that is frequently overlooked. In-
termittent fever is in some cases marked
by wakefulness at a definitely recurring-
period. Insomnia and headache are promi-
nent and early symptoms of albuminuria. —
New York Medical Journal.

DIAGNOSIS OF TUBERCULOSIS IN CHIL-
DREN.

In the March No. of the Rev. Mens, des
Malad. de VEnfanee, M. Mirinescn calls at-
tention to the existence of enlarged lym-
phatic glands in various parts of the body,
such as the axilla, groins and others, as af-
fording great assistance in making the diag-
nosis of phthisis in children, especially in
doubtful cases. If the child is in an ema-
ciated and weakened condition, and there
are no superficial lesions to explain the en-
largement of the glands, it may be inferred
that tuberculosis is present. Out of sixteen
cases of this nature examined, the glands of
fifteen were found, by experimental inocula-
tions, to be tuberculous. This " peripheral
polyadenitis " as the author terms, it, may
be observed in children as young as fourteen
or fifteen months.

THE ANTIPYRETIC TREATMENT OF FEB-
RILE AFFECTIONS OF CHILDREN.

In the yearly report of the Children's
Hospital of Berne, Professor Demme pub-
lishes a number of rules as to the selection
of antipyretic measures in the treatment of
various febrile affections in children, and his
results, which are exceptionally valuable, in
that he has rich experience, are published in
the Wiener Medizinische Blatter for January
1, 1891. •

In the first place, Dr. Demme maintains
that he is firmly convinced that, in children,
febrile affections, with moderate fever, from
100° to 101° F., are best treated without any
antipyretics whatever in the way of thera-
peutics, and that the febrile symptoms may
be best controlled by cloths wet in cold
water and wrapped around the trunk. His
experience, he states, has taught him that
such moderate febrile temperatures, with the
accompanying nervous excitement and rest-
lessness and the insomnia, or still more
alarming profound somnolence, can be more

560

Periscope.

Vol. lxiv

satisfactorily overcome by baths of from five
to ten minutes' duration each, administered
twice daily, the temperature of the water
. being from 79° to 82 \° F. When, however,
the temperature reaches 104°, and remains
at this elevation, then antipyretics are nec-
essary, although the author shows that there
is the greatest choice in the selection of a
suitable remedy for this purpose. Regard
must not only be paid to the elevation of
temperature alone, but also the character of
the morbid process and the condition of the
patient's strength must come into consider-
ation. His experience, he states, has taught
him that typhoid fever, acute articular rheu-
matism, and broncho-pneumonia of asthenic
type best respond to the antipyretic thera-
peutics. He rarely, however, employs them,
or only exceptionally when compelled to, in
diphtheria, in the acute exanthemata, such
as scarlet fever and measles, and in simple
croupous pneumonia. What was said above
us to the employment of baths alone applies
also to the combined employment of anti-
pyretic drugs and baths. He only recom-
mends the employment of baths when the
temperature of the body is reduced during
its administration in extremely rare cases
and only when there is an alarmingly high
temperature. In the large majority of cases,
luke-warm baths, of the temperature above
referred to, more or less prolonged in ad-
ministration, will give much more satisfac-
tory results. In cases where the soporific
symptoms are especially marked, and where
there is deep red or light cyanotic color in
the face, luke-warm baths may be used and
are better taken at about 40° F., poured
over the head and neck. As regards the
selection of the individual antipyretics, in
addition to the general observations already
given in every case of acute articular rheu-
matism, when the condition of the digestive
organs permit it, he uses the salicylate of
sodium, or, where there is a tendency to
vomiting or diarrhoea or serious objection to
the taste, he substitutes for it salol. Of the
salicylate of sodium, the following are the
doses to be administered in twenty-four
hours : For children from 2 to 4 years of
age, 7 2 to 15 grains; for children from 5 to 10
years of age, 15 to 30 grains; for children from
11 to 15 years of age, 30 to 45 grains. The
following are the doses recommended of
salol : For children from 2 to 4 years of age,
three times daily, a powder of 4 to 5 grains ;
for children from 5 to 10 years, three to four
times daily, a powder of from 7 s to 12 grains ;
for children from 11 to 15 years of age,
three to four times daily, a powder of 12 to

15 grains; and in typhoid fever he has
found the greatest satisfaction upon the em-
ployment of thallin, administered in the
form of sulphate, giving it every two hours
to children from 3 to four years of age in
doses of \ grain ; from 5 to 10 years of age,
in doses of i grain ; 11 to 15 years of age,
in doses of J to i grain. In cases of
broncho-pneumonia, where the temperature
may often reach 106°, antipyrine is the rem-
edy which Dr. Demme recommends, giving
it dissolved in large quantities of water,
with the addition of a little sugar and a few
drops of brandy. In this mode of adminis-
tration he claims that disturbances of the
appetite or vomiting will be entirely
avoided. He states that this remedy has
rarely failed to give him satisfactory results
where he has attempted to produce marked
reduction of temperature, notwithstanding
cases of broncho-pneumonia, or in the acute
exanthemata, or even in malignant diph-
theria, and he consequently prefers it to any
one of the other antipyretics. He recom-
mends the following doses, to be taken at
hourly intervals : For children of from 2 to
4 years of age, 3 to 6 grains ; from 5 to 10
years of age, 7 to 12 grains ; 11 to 15 years
of age, 13 to 15 grains. Of course, when
the antipyretic effect commences, this dose
must be diminished, while larger doses are,
according to the author, never required. In
cases of broncho-pneumonia in children,
where hectic fever sets in, with high evening
exacerbations and morning remissions, anti-
pyrine, or any of the aromatic order of anti-
pyretics, will be of value. The dose which
he then administers is, for children from 11
to 15 years of age, 12 to 15 grains ; although
the author, as seen, gives the preference . to
antipyrine as an antipyretic, he nevertheless
refers to acetanilide and antifebrin as like-
wise, in cases of erysipelas and acute rheu-
matism and pulmonary tuberculosis, satis-
factory antipyretics, while antifebrin pos-
sesses the advantage over antipyrine in more
seldom leading to the production of exan-
thematous eruption. — Therop. Gaz.

STATISTICS. AND TREATMENT OF DIPH-
THERIA.

Statistics as to the cases .of diphtheria and
croup treated in the Children's Hospital of
Pesth are given by Dr. Johann Bokai
(Wien. med. Woch., No. 10, 1891) for the
years 1889-90. There were 447 cases of
diphtheria, and 32 of "primary laryngeal
croup." Post-diphtheria palsy was noted in
10 per cent, of the cases. The mortality

May 9, 1 89 1.

Periscope.

among the 447 cases of diphtheria, of whom
one quarter were under three years old, was
'234 (54 per cent.) ; in 170 cases the larynx
was not affected, and the death-rate in this
class was only 23 per cent. Laryngeal
croup occurred as a complication of faucial
diphtheria in 237 cases ; 53 cases recovered,
32 without, and 21 after, tracheotomy,
which was performed 159 times. In
the group of 32 cases of uncomplicated
laryngeal croup, 16 cases recovered ; 7 with-
out, and 9 after, tracheotomy, which was
performed 23 times. The treatment adopted
in pharyngeal diphtheria was the internal
administration of chlorate of potassium,
gargling with lime water, and painting two
or three times a day with a 5 per cent, solu-
tion of perchloride of iron in glycerine,
which Bokai believes prevents the occur-
rence of laryngeal complications. After
tracheotomy steam inhalations were con-
tinuously used, and perchloride of mercury
internally. Sulphate of copper was used as
an emetic, and was of great value in the
early stages of laryngeal croup, but the pro-
longed use of emetics was dangerous.
Tracheotomy was resorted to when suffoca-
tion was imminent ; the operation, in Bokai's
opinion is contra-indicated in septic cases,
and in those in which the symptoms point
to involvement of the bronchi. In the dis-
cussion which followed the reading of Bokai's
paper at the Buda-Pesth Society, Professor
Gerloczy stated that 157 cases of diphtheria
had been treated in the Koch us Hospital
with a death-rate of 43.9 per cent. Dr.
Glass spoke favorably of treatment by
Lori's method ; this consists in burning
about three-quarters of a pound of sulphur
in a room, at the end of four hours ventilat-
ing the room four or five minutes, and then
placing the patient in it ; an adjoining room
is then prepared for the patient in the same
way. — Brit. Med. Jour.

INTUBATION OF THE LARYNX IN DIPH-
THERIA.

Dr. J. Mount Bleyer, of New York {Ar-
chives of Pediatrics, March, 1891), gives the
results of 512 cases of intubation of the lar-
ynx for croup and diphtheria operated on
betwreen 1886 and 1890; of these cases, 37
per cent, recovered. The 512 cases included
294 males and 228 females. The ages va-
ied from 6 months to 21 years; 251 cases
were under 3 years of age, with 73 recover-
ies; 260 were over 3 years of age, with 115
recoveries. Of 4 cases, 6 months of age, all
died ; of 7 cases, 9 months old, 4 died ; of 3

cases, 10 months old, 2 died ; of 14 cases, 12
months old, all died ; of 48 cases, 2i years
old, all died. In cases of recovery the tube
was removed on the first day in 5 cases;
second day in 29 cases; third day in 37
cases; three days and a half in 14 cases,
fourth day in 43 cases ; fifth day in 22 cases ;
sixth day in 10 cases ; seventh day in 13
cases ; ninth day in 6 cases ; tenth day in
4 cases ; eleventh day in 3 cases ; fifteenth
day in 2 cases ; twentieth day in 2 cases.
Among the causes of death in the 322 fatal
cases, extension of the false membranes oc-
curred in 67 cases ; bronchitis in 45 cases ;
pueumonia in 41 cases; broncho-pneumonia
in 40 cases ; sepsis in 39 cases ; asphyxia,
due to closure of the tube by membrane, in
2 cases. The author strongly emphasizes
the necessity of making a forced or a normal
laryngoscopic examination before operating,
as the differentiation and diagnostication of
other laryngeal diseases may be made out,
and the extent of the diphtherial or croupous
lesion seen. The tube is to be extracted
daily for the purpose of removing any ac-
cumulation of loose membranes, tenacious
mucus, pus, etc. " When the tube has been
extracted, irrigate the posterior nares,
pharynx, larynx, and entire surface with a
mild solution of bicarbonate of sodium."
Much of the success depends upon the judg-
ment of the operator in selecting a suitable
tube. When loose membranes exist in a
case, a tube of thinner metal and larger cal-
ibre is recommended, and is left in situ for
six hours or more. The tube once in place,
the most vital portion of the treatment must
be next carried out, namely irrigation of the
affected parts. A No. 8 soft rubber catheter
attached to a fountain-bag syringe, is passed
into the nostrils alternately, and a solution
of the peroxide of hydrogen (5 ounces of a
15 volume solution, chemically pure, in 12
ounces of water) is passed through ; after
this has been done, the next step is to wash
out the mouth, pharynx and larynx. If
necessary, a gag must be used ; the patient
is held well forward over a basin for the re-
ception of the returning fluid. For purposes
of comparison, the recorded results of
tracheotomy operations are given as follows:
German authors have obtained 31 per cent,
recoveries in 5,795 cases ; German hospitals
record, 30 per cent, recoveries in 3,063 cases.
French surgeons have tabulated 9,242 cases,
with 24 per cent. cent, recoveries. In the
Boston City Hospital between 1884 and
1887, 327 operations yielded 29 per cent, of
recoveries. Out of 21,853 cases collected
from all sources by Dr. Lovett, of Boston,

562

PeiHscope.

Vol. lxiv

293 per cent, of recoveries were obtained. —
Brit. Med. Jour.

HYGIENE.

THE BACILLI OF MALARIA.

Dr. Andreas has recently published an in-
teresting treatise on the comparative number
of the bacilli of malaria in the air at different
times of the day. His experiments, which
were conducted in the Observatory of Mon-
calieri, and reported in the Medicinische
Neuigkeiten, April 11, 1891, were carried
out by means of small rubber balloons filled
with hydrogen. On to these balloons he
fastened a small box, holding prepared glass
slides, which box he was able to open by
means of a cord, after the balloon had reached
the desired height. Microscopical examina-
tion of the slides showed that in the early
hours of the day the swarms of bacteria were
close to the ground and in large numbers ;
later, at about nine o'clock in the morning
until about three in the afternoon, they
would rise until they reached a considerable
height, and from that time would again
gradually sink to the ground. The number
of bacilli in the air was almost exactly in
proportion to the rise of temperature, while
in direct opposition to the amount of humid-
ity in the atmosphere. It is evident, there-
fore, that the condensation of the watery
vapors in the air cause the falling of the
bacilli, and for this reason the morning and
evening hours are the most dangerous in
malarial districts.

INFECTION THROUGH THE SOIL.

The question is often raised whether there
is any direct or indirect proof of the infec-
tivity of the bodies of those dying from
specific fevers, or whether the soil of grave-
yards may become really dangerously con-
taminated thereby ; but it is also one to
Avhich comparatively little attention has been
given by the experimentalist. One aspect
of the matter has been lately studied by Dr.
Justyn Karlinski, of Konjica, Herzegovina ;
in a series of experiments ( Centralblatt f.
Bakteriol., ix, 13) undertaken to determine
whether the organs of the body undergo any
change in temperature during the natural
process of decomposition after burial in the
earth, and especially whether any differences
in this regard are to be met with in the case
of infected subjects. His results show that
invariably the putrefactive process is ac-
companied by a rise of temperature above
that of the circumjacent soil ; and also that

this rise in temperature is markedly higher
when the parts examined have been taken
'from the bodies of men or animals who have
succumbed to infective diseases than it is in
the case of healthy bodies. He further ex-
amined into the question of the survival of
the pathogenic bacteria in the affected parts,
and states that the typhoid bacilli may re-
tain their vitality in the decomposing spleen
for three months, and are only completely
annihilated by rapid putrefaction and the
presence of a large number of the bacteria of
putrefaction. Dr. Karlinski says that he
had previously shown that typhoid bacilli
could retain their vitality for a period of five
months in soil, but that if the earth were
thoroughly saturated with rain water they
were destroyed in from seven to fourteen
days. The part played by the soil in the
origin of epidemics should not, he thinks, be
underestimated, since typhoid bacilli can
only exist in water a comparatively short
time. — Laneet.

INFECTION FROM MILK.

In the Glasgow Medical Journal, for Oc-
tober, appears an account of an epidemic of
erysipelas and sore throat, occurring among
families supplied with milk from a certain
farm. The most striking symptom was an
intense inflammation of the fauces, resem-
bling erysipelas of the mucous membrane,
with swelling of the glands of the neck, and
in some cases suppuration. In some, true
erysipelas of the skin developed. The tem-
peratures ranged from 102° to 105° during
the first few days of an attack. Convales-
cence was attended by extreme prostration.
No bacterial examination was made, but a
clear connection was traced between the milk
and the epidemic. — {Jour. Amr. Med. Asso.)

THE ETIOLOGY OF TETANUS.

In the last number of the Annales de V
Institut Pasteur, there appears (from the
Bacteriological Laboratory of Val-oVGrace)
a most interesting paper on tetanus by Drs.
Vaillard and Vincent, which appears to
throw very considerable light on the subject
of tetanus, and to clear up a number of points
and observations that have hitherto been
enshrouded in obscurity. After describing
the organism, and identifying it with that
already made familiar through the papers
of recent writers, the authors give it as their
firm opinion that in cases of artificial inocu-
lation of pure cultures it is always the poison
introduced along with the bacillus, and not
the organism itself, that acts upon the animaL

May 9, 1891. Periscope.

563

This indeed seems to be probable, as they are
able to prove that almost inconceivably
minute doses of this poison, which they com-
pare with snake poison, are quite sufficient
to produce all the symptoms of most acute
tetanus; in fact, it was almost impossible,
from some of the cultures that they obtained,
to administer a dose that was not lethal.

An exceedingly interesting feature brought
out in the course of their work is that in no
case was the poison developed as soon as the
organism began to grow ; in fact, gelatine
cultures of the tetanus bacillus were never
capable of producing toxic symptoms until
liquefaction of the gelatine had commenced,
when spores were demonstrated to have been
formed, and when the peculiarly disagreeable
odor so characteristic of tetanus cultures had
become perceptible. They associate both
the odor and the peptonizing power with the
formation of the poison in the cultures. That
it was due merely to the presence of the
spores that the material was poisonous they
demonstrated by heating their cultures to a
temperature of 62° C, for a short time (a
temperature which is quite incapable of inter-
fering with the vitality of the spores), when
it was found that cultures so heated and in-
troduced by inoculation into a rabbit or a
guinea-pig failed to produce any tetanus,
thus proving that although the spores are not
killed the poison has been destroyed by the
heat. The spores were proved to be living
by making fresh cultures from them in arti-
ficial media ; after a time they grew luxuri-
antly, and if left to grow eight or ten days
produced another crop of the poison. By
simply washing away the poison from the
spores with distilled water they also obtained
similar results, for, although the spores could
still develop and form the specific poison in
artificial media, they were, when inoculated,
incapable of giving rise to any symptoms of
tetanus. From the reaction to heat of a
substance they were able to separate, and
from its resemblance to the diastases in other
respects* they conclude that they have ob-
tained from tetanus cultures the true tetanus
poison, a poison, however, that cannot be
formed by the tetanus bacillus in healthy
tissues. The microorganisms are here so
rapidly attacked by the leucocytes that they
are rendered hors de combathefore they have
time to form their poison.

It has long been well known that the
tetanus bacillus could not develop in the
tissues except, apparently, in the presence
of other organisms, and the suggestion is of-
fered that these other organisms act in one
of two ways ; they either paralyze the activ-

ity of the leucocytes, or they draw off, as it
were, their attention and activity from the
tetanus bacillus, thus allowing it sufficient
time to develop its characteristic products.
It is interesting to note that Drs. Vaillard
and Vincent consider that in many respects
the tetanus bacillus is extremely like the
diphtheria bacillus, the method of action on
and in the organism being essentially the
same in the two cases, the above factors in
all probability playing a part in diphtheria
much as-in the case of tetanus ; and it is evi-
dent that in studying the one poison much
light may be thrown on the other. Behring
and Kitasato appreciated this fact, and
combined their forces to work out the ques-
tion of immunity in these two diseases. It
is obvious, however, from a consideration of
some of the points that are indicated in this
paper, that there are many sources of fallacy
that will have to be eliminated before the
ultimate explanation of the condition of im-
munity in protected animals can be given.
The facts that this poison is active in such
extraordinary minute quantities, and that
the microorganisms are able to grow with
such difficulty in the human tissues, allow
us to hope that extremely minute changes
in the blood may be quite sufficient to secure
the alteration or breaking-down of the
virulent poison, even when it has become
diffused throughout the system. So long as
the organism is localized to the wound,
there is, of course, more chance of coping
successfully with the disease, although here,
as in other diseases, there always appears to
be a possibility of the poison exerting such a
paralyzing influence on the cells that usually
take up foreign substances, that secondary
septic conditions may be liable to occur even
when the action of the tetanic poison can be
antagonized so far as its primary effects on
the cells are concerned. One question ap-
pears to be set at rest, and that is, as regards
tetanus and diphtheria, the ptomaines have
had their day, whatever may become of the
products of other organisms. It may be ac-
cepted that here, at any rate, we have some
subtle poison which, although it has not yet
been actually separated, has become so far
isolated that it may be taken as proved that
it is not an alkaloid or basic poison. A
most remarkable feature is that, in pepto-
nizing gelatine with the filtrate from a meat-
broth culture of the tetanus bacillus, the
poisonous properties are lost to a certain de-
gree in direct proportion to the amount of
gelatine that is peptonized ; this, taken in
conjunction with the fact that the properties
are not developed until the gelatine begins

564

Periscope.

Vol. lxiv

to liquefy, has led Drs. Vaillard and Vin-
cent to suppose that the same agent that
peptonizes the gelatine is the active agent
in bringing about the development of the
toxic symptoms of tetanus. — The Lancet.

THE REPUTED CAUSE OF INFLUENZA.

Dr. Tezzier, of Lyons, France, claims that
influenza is produced by a microbe, which
he styles the strepto bacillus, whose habitat
is putrid mud. That Russia is its home is,
in his opinion, due to the fact that bad
drainage, filthy streets and neglected barn-
yards are the rule, a condition particularly
aggravated by swollen rivers and generally
wide plains.

BACILLI IN SYPHILIS.

Dr. von Marschalko, who has been work-
ing in the pathological laboratory of the
Buda-Pesth University at the subject of the
bacteriology of syphilis, has devised a method
of staining by which bacilli may be found
in syphilitic growths of various kinds, such
as papules on the skin, the indurated base of
a chancre, and condylomata, as well as in
the secretion of primary sores, while he has
not been able to find them in non-syphilitic
growths or in the secretion of soft chancres.
Whether they are really inseparably con-
nected with syphilis can, of course, only be
decided by a prolonged series of observations,
but there would at least appear to have been
a prima-facie case made out for further in-
vestigation. The method employed is by
double staining, as follows: — The object,
after having been hardened in alcohol, is im-
mersed for thirty-six hours in an alkaline
solution of. methyl blue; it is then rinsed
well with water, and re-stained by a concen-
trated solution of vesuvin in water. The
bacilli are stained blue, and can be easily
distinguished from the tissues, which are
brown.

HINTS ON DISINFECTION.

Dr. von Esmarch has innumerated some
of the points that should be specially at-
tended to in the use of disinfecting apparatus.
He agrees with most authorities that steam,
either circulating or under pressure, and
without the admixture of air, is by far the
best means of disinfecting clothing and other
articles that will withstand the action of
moist heat. As to whether circulating steam
or steam under "pressure is best, he thinks
that it is entirely a matter of convenience,
but it will be readily understood that where
large chambers have to be constructed it

would be difficult and extremely expensive
to build them of sufficient strength to with-
stand any great pressure from within. Even
in the case of smaller sterilizing chambers, the
expense of obtaining them sufficiently strong
is so great that in most cases their use is
precluded. The main desiderata for a per-
fect disinfecting apparatus are that it shall
be close to the source of the steam-supply ;
that there shall be sufficient steam developed
to fill it thoroughly, and to keep up the tem-
perature for some length of time ; that the
steam shall be sent in at the top and passed
out at the bottom, in order that every crevice
of the apparatus may be filled ; and that
where it is used in large establishments, it
shall be placed between two rooms, into one
of which articles to be treated are to be
taken, and passed in at one door of the ster-
ilizer ; while the other room should be at the
other end of the sterilizer, and into it the
clothes should be passed, so that they shall
not again be brought into contact with un-
sterilized clothing, etc. Articles that are to
be disinfected should not be allowed to re-
main too long in contact with steam, and be-
fore being steamed they should be thoroughly
heated, so that there is no opportunity for the
steam to condense on cold surfaces, and in
the same way they should be well dried by
heat after the steaming process has been
concluded. Twenty minutes is quite long
enough to allow most ordinary articles to re-
main exposed to a moist heat of 212° F., so
that they should be left for this length of
time after the temperature has once been
raised to this point, this being determined
by an electrical contact thermometer, or a
thermometer placed in a tube through which
the steam escapes ; some simple manometer
should be used to determine the pressure that
has been obtained by super-heating the steam.
The greatest attention should be paid to this
point of time of exposure, for it is the ex-
perience of all medical officers of health that
nothing deters people from sending their
clothes to be sterilized so much as the fact
that they are frequently ruined by too long
an exposure to the action of the steam. Dis-
crimination must also be used in determin-
ing what articles can be safely steamed, and
an officer of health who ordered stamped
plush, leather, skins, or waterproof material
to be exposed to heat would render himself
liable to be heartily laughed at by all prac-
tical men. Grease should always be removed
if possible before the articles are put into the
sterilizer, otherwise it becomes fluid and is
liable to spread to other parts. — Hygienische
Rundschau.

May 9, 1891.

Periscope.

565

MEDICAL CHEMISTRY.

THE PHENYL-HYDRAZIN TEST FOR
SUGAR.

Havilburg (Centralbl. fur klin. Medicin,
January 31, 1891), of Rio de Janeiro, pro-
poses a modification of the Fischer-Jaksch
test for the presence of sugar in the urine,
which he considers more reliable. Two parts
of phenyl-hydrazin hydrochlorate and three
of sodium acetate are added to half a test-
tube ful of water, to which a like quantity of
urine to be tested is added. Instead of boil-
ing over a water-bath the mixture is shaken
with chloroform. In a little time the fluids
separate. If sugar be present canary-yellow
crystals appear in the upper layer. The
reaction is more striking if the fluid is boiled

a permitted to cool before the addition of
chloroform. Havilburg suggests that the
procedure might be adapted for use as a
ready means of quantitative determination
of the amount of sugar present. — Amer. Jour.
Med. Sci.

THE PRACTICAL VALUE OF THE ALPHA-
NAPHTHOL TEST FOR SUGAR.
Posner and Epenstein (Berlin, klin.
Wochenschrift, Feb. 23, 1891), reviewing the
details of this test, consider it to be free from
many of the objections raised against other
tests for sugar. It depends upon the fact
that a solution of sugar, in the presence of
pure concentrated sulphuric acid and a solu-
tion of alpha-naphthol, gives a violet-colored
reaction, due, according to Udransky, to the
separation of furfurol. This reaction occurs
not only with sugars but with all carbohy-
drates and certain albuminoids ; hence, the
urine must be free from albumen. The test
is extremely sensitive,showing one-hundredth
of one per cent, of sugar. The reagents
and glasses must be chemically clean. It
was noted that normal urine, i. e., urine
which showed no presence of sugar by any
of the accepted tests, gave with this test the
reaction of such intensity as to indicate the
presence of two-hundredth of one per cent,
of sugar. The authors do not discuss the
cause of this occurrence, deeming it sufficient
to state that if the urine is diluted at least
twenty times, this reaction is not obtained
in normal urine. Hence, in practice the
urine must always be previously diluted.
The quantitive analysis for sugar by this
method does not give perfectly accurate re-
sults in the decimal figures of the percentage.
The authors conclude that the test is a val-
uable addition to practical medicine. — Univ.
Med. Mag.

TEST FOR PURE ANTIPYRINE.

According to Dr. Gille, in the Deutsche
Medizinal Zeitung, April 13, 1891, pure
antipyrine may be tested by the following
methods: (1.) The concentrated watery solu-
tion of antipyrine should have no effect either
upon red or blue litmus paper. (2.) Pure
antipyrine melts rapidly when exposed to
heat, and gives off inflammable gasses, with-
out leaving any un meltable deposit or car-
bonated residue. (3.) One gramme of pure
antipyrine should be entirely taken up by
one gramme of water or alcohol. (4.) Sul-
phurretted hydrogen throws off no deposit in
a watery solution of antipyrine.

A NEW POISON IN CHEESE.

Dr. V. C. Vaughn announces a new
poison found in cheese. A number of samples
of the suspected cheese, which, it was alleged,
had caused nausea and vomiting, were ex-
amined at the hygienic laboratory, of Michi-
gan University. Its poisonous character
was proved in experiments on animals by
its causing death in a few hours, but the
nature of the poison could not be determined
further than that it was not tyrotoxicon and
that it belonged in the list of so-called
poisonous albumens.

A NEW TEST FOR ALBUMEN AND OTHER
PROTEIDS.
Dr. John A. MacWilliam gives in The
British Medical Journal a method of testing
for proteids by salicyl-sulphonic acid. Take
a small amount of urine (for example, 20
minims), preferably in a very small test-
tube, and add a drop or two of a saturated
watery solution1 of the reagent. If the urine
is strongly alkaline, an extra drop or two of
the acid should be added, and if no opales-
cence or precipitate occurs it is well to test
the reaction with litmus paper, and make
sure that the urine has been rendered strongly
acid. On adding the reagent, shake the
tube quickly so as to mix its contents. Then
examine at once. The occurrence of an
opalescence or cloudiness immediately or
within a very few seconds (for example, 2 to 3
seconds), is a test for proteids intermediate
in delicacy between the cold nitric acid test
on the one hand, and the acetic acid and
heat test (in favorable circumstances) on the
other. The development of an opalescence
some time after (for example, J to 2 min-
utes), is a more delicate test than even acetic
acid and heat, and shows the presence of

• 1 It is important to notice that the solution must be
a saturated one in order to obtain the best results.

566

News and Miscellany.

Vol. lxiv

minute traces of proteid, which are probably
insignificant from a clinical point of view as
a rule.

Next heat the tube to the boiling point.
If the precipitate or opalescence is caused by
the ordinary "albumen" (albumen and
globulin) commonly present in albuminous
urine, it does not disappear on heating, but, on
the other hand, becomes markedly flocculent.
But if the precipitate • or opalescence is due
to the presence of albumoses or peptones, it
clears up on heating (before the boiling point
is reached) and reappears when the tube
cools.

NEWS AND MISCELLANY.

OUTSIDE PHYSICIANS CAN ADMIT PA-
TIENTS TO THE PHILA. POLY-
CLINIC HOSPITAL.

As evidence of the liberal spirit with which
the Philadelphia Polyclinic Hospital is man-
aged, it has been decided that the full
privileges of the wards, private rooms and
suite of operating-rooms may be extended by
any member of the staff to physicians not
connected with the institution.

Many physicians who are not attached to
Hospitals have frequently cases that they
would like to have under the auspices of a
Hospital with its resident physicians, trained
nurses and sanitary regime, and yet wish
them under their own observation.

Patients thus admitted to this Hospital are
attended by the physician for whom the case
is admitted as fully as though he were a
member of the staff. The admission blanks
must invariably be signed by a member of
the staff, who thereby assumes the responsi-
bility for the acts of the physician, after
which arrangements and terms may be made
with the matron.

Visitors are cordially invited to visit and
inspect the Hospital, on Lombard street,
west of 18th, on Mondays from 3 to 4 P. M.

MUTTER COURSE OF LECTURES ON SUR-
GICAL PATHOLOGY.

Prof. Roswell Park, of Buffalo will de-
liver the remaining four lectures of the
Mutter Course, in the Hall of the College of
Physicians, of Philadelphia, N. E. Cor. 13th
and Locust Sts., on May 12, 13, 14, and 15,
at 8.15 P.M.

Subject : Surgical Bacteriology. The
medical profession are cordially invited to
attend.

A SIMPLE METHOD OF REMOVING A
NEEDLE.

I think it may be of service to record a
simple means by which I obtained the re-
moval of a broken needle from the heel of a
young girl, aged 12, whom I saw lately
walking about on her toes to avoid her
right heel, into which a needle had been
broken, touching the ground. The buried
end could be felt, but any pressure led to its
further entry. I directed her lo wear a
large thick corn-plaster around the spot,
with a little wet cotton-wool in the center,
and to tread freely on the heel. Within a
week afterwards she showed me the needle,
which had protruded, and she had easily
withdrawn it. Thus no wound was made,
and no scar left to be a tender spot on the
plantar surface. — Chas. Steele, M. D., F. R.
C. S.j in Brit. Med. Jour.

ALCOHOL AND DIGESTION.

From experiments made on himself by Dr.
Eichenberg some further knowledge of the
effect of alcohol on digestion is obtained,
which contrasts strongly with the teetotal
lecturer's experiment showing how digestion
in a glass vessel is retarded by alcohol. Dr.
Eichenberg found that a small dose of strong
alcohol — e. g., brandy — shortens the time
that food in general, whether animal or
vegetable, or a mixture, remains in the
stomach by more than half an hour. A
similar but not quite so marked an effect is
produced by a dose of diluted hydrochloric
acid or mustard. Pepper and condurango
diminish the time the food remains in the
stomach by about a quarter of an hour.
Beer and an infusion of rhubarb had no
effect.

An enterprising lady has been making
investigations upon the question of matri-
mony in regard to her sex. She finds that
the highest marriage rate is among trained
nurses, and impartial observation would
rather tend to support the statement that
this is the best field for matrimony which
the fair sex enjoys.

A French dispensing chemist points out
that a mixture of bromide of sodium and
hydrochlorate of cocaine results in the alka-
loid being precipitated. It will be well to
bear this in mind, for, with the cocaine
merely suspended, a serious and, in an in-
fant, even a fatal accident might easily
result.

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Ext. Nux. Vom., . . . . gr. | absorbed, is nerve tonic and quickly soluble.

The effects left by La Grippe are marked Physical Prostration for which Pill
Chalybeate Comp. (Warner & Co.'s) is almost a specific. The assimilable iron, acting
as a blood tonic and the Nux Vomica as a stimulant to the spinal cord.

Dose, begin with one pill every four hours and increase to two pills three times a

day.

The acute symptoms of La Grippe are controlled by (EFF. ANTALGIC
SALINE), one dessert spoonful of which contains 4 grains Antipyrine and 4 grains
Salicylate Soda. Physicians will not be disappointed in the treatment of La Grippe by
trying this salt followed by PILL CHALYBEATE COMP. as above mentioned.

WILLIAM R. WARNER &, CO.,

1228 Market Street, Philadelphia. 18 Liberty Street, new York.

AVOID SUBSTITUTIONS AND SPECIFY WARNER & CO.
£S=* Tlie Coating: of PIU. CHAU'BEATE CO. is Colored a Delicate I»ink.=®ft

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PHILADELPHIA. MAY 16, 1801. Vol. LXIV.— No. 20.

Clinical Lecture.

ONE OF THE SEQUENCES OF LAPAROTOMY
—RETROVERSION OF THE UTERUS—
THE USE OF PESSARIES.

BY H. MARION SIMS, M. D.,

PROFESSOR OF GYNECOLOGY AT THE N. Y. POLY-
CLINIC, VISITING SURGEON TO SAINT ELIZA-
BETH HOSPITAL, &C, &C.

Gentlemen : — The patient I present to you
now, illustrates a condition following laparot-
omy, which is of a peculiarly trying nature
to both the physician and the patient. This
woman has a very interesting clinical feature
in her history, and as she presents a con-
dition you may be often called upon to treat
in gynaecological practice, I shall give it to
you in detail.

To begin with, this patient's original
trouble commenced with a constant and per-
sistent pain throughout the pelvic organs, of
a most exaggerated character, which was ac-
companied by a very severe dysmenorrhea.
She had, in addition to this, pains in the
back, headache, and all the symptoms such
patients usually have, but in a most aggrava-
ted form. When she first came to this clinic
for treatment, I found that on digital exami-
nation the dysmenorrhea in her case was due
to a diseased condition of the tubes and
ovaries. There existed what is known as an
apoplectic condition of the ovaries, with total
occlusion of both tubes. I sent her to the
Hospital and there performed abdominal
section, under the strictest antiseptic precau-
tions, removing both tubes and ovaries, with
the result of a marked and decided improve-
ment in every respect in her general condi-
tion. She was on the eve of being discharged
from the Hospital, perfectly cured, when
I accidentally discovered a small fistulous
opening in the line of the abdominal incision.
On passing down a probe carefully through
this opening, I found that the instrument
was deflected to the left in the direction of
the former seat of the left ovary, and extend-

ing to a depth of six or seven inches in all.
I immediately suspected the cause of the
trouble to be an attempt on the part of nat-
ure to throw off the ligature that had been
placed around the pedicle of the ovary that
had been removed from that side, and, on
passing a long forceps through this fistulous
openingl very readily grasped something with
its blade which I knew by the sense of touch
to be the suspected ligature. This I then
brought away with the forceps. It was ex-
actly in the same condition as it was when
first introduced. The fistulous opening on
that side healed up immediately.

The fistulous opening on this side of the
abdomen had no sooner healed up than an-
other one developed on the right side, due
to the same cause, but which was not so easily
removed as in the former instance. Through
this opening I passed a small-sized curette
down to the bottom of the sac to the depth
of about eight inches. I could readily make
out by touch the existence of a foreign body,
occupying the same relationship to the
stump of the right ovary as was the case with
the left one. Withdrawing the curette, I
then thrust the forceps down the fistulous
tract and I could readily grasp the ligature
with it. I made traction on the ligature
with the forceps, but this threw the patient
into a paroxysm of such acute suffering that
I was compelled to desist from any further
attempt in that direction, and postpone the
operation for another day. Finally, after
three weeks of futile attempts at this kind of
work, with the patient tired and myself dis-
couraged, I thought I would make another
attempt, in a somewhat different manner, to
remove the offending ligature. I accordingly
put the ligature on the stretch, and with a
small probe for a guide, locating the end of
the ligature, I cut the ligature completely
away with a blunt-pointed bistoury. The
fistulous opening soon afterwards healed
promptly and the patient experienced no
further trouble in that direction.

I mention this incident to you to-day in
connection with the case of this woman be-

567

568

Clinical Lecture.

Vol. lxiv

cause it is not an uncommon occurrence fol-
lowing a laparotomy, and is one with which
you should become familiar. The liga-
ture would never have spontaneously come
away in this case, and there would be as a
result a very disagreeable, running fistula.

Now, the next question that naturally
suggests itself to our minds in this case is,
how are we to get this fistulous opening
healed up as rapidly as possible ? The open-
ing in the case of this woman wTas originally
eight inches in depth, but it is now only
three and a-half, and is gradually filling up
with healthy granulation tissue. She com-
plains of considerable weakness, slight flush-
ing of the face, a tired feeling, and other
symptoms of a like nature. I have told her
that all these symptoms were due to the fact
of the removal of both ovaries and tubes,
and the same condition is brought about by
their removal as if she had undergone a
practical change of life. The proud flesh
you see collected about the margin of this
fistulous tract will have to be removed, and
the simplest and readiest way to accomplish
that is by means of the curette under cocaine.
And when the normal tissue is reached, the
tract will then heal up quite readily. It
may also be packed with iodoform or
bichloride gauze, or what is better still, ap-
plications of pure carbolic acid may be made
to the entire fistulous tract, and the parts
then dressed with bichloride gauze, as I have
done in this case.

I wish to say a word, in this connection,
about the form of ligature that should be
used in these cases. The ligature I gener-
ally employ, is silk, as I consider it the
strongest possible form of ligature that can
be used for this purpose, and is, at the same
time, the most reliable. You can be certain
it will not give away, or be absorbed like
catgut. The only trouble I ever experienced
in my life, was in the .use of catgut in a
patient with a lacerated cervix and peri-
neum. I employed catgut for suturing the
cervix, putting in four stitches, and to my
great surprise, on the third day after opera-
tion, I was called to the patient's bedside
and found her with a profuse and exhaustive
haemorrhage from the circular artery ; the
four catgut sutures having come away,
leaving the wound in the cervix gaping
widely. Since that time I have never em-
ployed catgut in these operations, as catgut
is always apt to come away, but silk never.

RETROVERSION OF THE UTERUS.

The next patient comes to us complaining
of a train of pathological symptoms that one

very frequently hears at clinics of this kind.
She has a constant and distressing backache,
persistent headache, and dragging down
pains across the small of the back, which
have existed for a considerable length of
time. She also complains of a very obsti-
nate form of constipation.

As I examine this woman's uterus, I can
readily understand the reason for the con-
tinuance of these disagreeable symptoms.
She has a uterus that is somewhat retro-
verted, and in making an examination for
this condition, I always first ascertain the

j degree of mobility of that organ, whether it
be freely movable, laterally as well as

j antero-posteriorly, and whether it can be

| lifted out of its position and restored to its

j normal relationship in the pelvic cavity.

j When we have found out these different
conditions, we will then be able to determine
what we can do for the patient.

To ascertain whether a uterus can be
elevated, it is not always necessary to em-
ploy a uterine elevator for that purpose, but
with a cervix so short as this is, I do not
think we can get sufficient leverage man-
ually on the anterior lip, without the use of
an elevator. A good many gynaecologists do
not believe in the use of an elevator for this
purpose, and there are also some who argue
that retroversion is not a disease per se, but
a symptom. I do not, myself, consider dis-
placement of the uterus a disease, but it
gives rise to certain reflex symptoms, which
can be removed by restoration of the uterine
organ to its normal position in the pelvic
cavity. I have seen so many of these
patients benefited by this simple manoeuvre,
that I always have recourse to it when such
a condition is possible. If there be adhe-
sions formed around the uterus, you can
very readily determine to what extent they
are present when you pass your finger into
the rectum of the patient. Under such cir-
cumstances, it may be necessary to break up
these adhesions under ether, and without
subjecting the patient to the risk of a lapa-
rotomy. This can be readily and easily done
by means of the uterine elevator, with the
patient at home in bed. After the operation

I is completed, she should be kept in bed for
from three to six days afterwards. During
that time I always make it a practice to
watch her carefully, and if she complains of

I any pain or tenderness about the pelvic
region,. I treat her for these symptoms by
hot douches, warm anodyne applications,
and other measures appropriated for such
cases. If you are careful in your operations
about the uterus, you will never experience

May 1 6, 1891.

Clinical Lechire.

569

any trouble as a result thereof.

After breaking up the adhesions in this
way, I elevate the uterus a few times, to
educate it, so to speak, towards assuming its
normal position in the pelvic cavity.
Finally, after repeated efforts in this direc-
tion, when the uterus can be readily raised
without giving the slightest pain or discom-
fort to the patient, I then proceed to use
cotton tampons or a pessary, or whatever I
may deem best adapted to the case in hand.

Speaking of pessaries in this connection
reminds me of the fact that twenty years
ago, when I began to first practice the art of
gynaecology, every one was speaking of pes-
saries, while to-day, among gynaecologists,
we very seldom hear a pessary referred to.
I do not think the time will ever come when
this instrument can be safely relegated to
the back shelf in gynaecological practice.
If there is one subject, more than any other,
that has been abused, that subject certainly
is the use of the pessary. The pessary has
undoubtedly, caused a good deal of harm in
many instances, but I contend that this
harm has been due to the flagrant abuse of
this instrument, and not its use. We have
many patients who come to us like this
patient before us, suffering from a chronic
condition of retroversion, who have been
very materially benefited by the reposition of
the uterus and its maintenance in its normal
anatomical position in the pelvis by means
of a well-fitting pessary. A pessary, no
matter of what kind it be, whether it be a
tampon of cotton, or one of tin or rubber,
certainly does give great relief to the patient
in a large majority of cases. In the fitting
of a pessary there is at times as much me-
chanical ingenuity required of the physician
as in the making of any mechanical ap-
pliance. The instrument must fit "just so,"
to be worn with any degree of comfort. It
must neither press back in front nor at the
sides. In fact as much care should be taken
in the fitting of the instrument as a dentist
would take in the fitting of a plate in the
mouth. If the patient complains of undue
pressure or pain caused by the instrument at
any point, it should be removed at once, and
the patient herself should be instructed how
to remove it in case it gives her the least dis-
comfort

In fitting a pessary for displacement the
method I always employ is to first map out
in my mind the exact shape of the vagina,
its length, its breadth and its general out-
line. I then take one of these Sims' block
,tin rings, which, as you see, is perfectly mal-
leable and can be bent into any desired

shape. I recommend these rings to you be-
cause of their ready adaptability to any case
and because you can make almost any one's
pessary out of them ; they are to be further-
more recommended, because if the pessary
is an instrument you need only occasionally,
you will find these rings very much cheaper
than a rubber pessary, and a dozen of them
will answer the purpose of five or six dozen
of the others. They are, therefore, very
much more economical for an ordinary prac-
titioner or a country doctor to carry for
gynaecological practice. I take this medium
sized block tin pessary and mould it in my
hand until I think that this curve I have
given it posteriorly will suit the required
purpose. The width I give it by gently
pressing in the hand and the slight curve
downward which I give it anteriorly, is done
for the purpose of preventing a too firm pres-
sure against the pessary.

I will now proceed to place this pessary in
position, and this is best done with the
patient lying on her back. By making firm
pressure downwards with one index finger
on the perineum, you see that the instrument
is readily slipped into position by the uterine
elevator. The next step is to let your
patient get up and walk around the room,
in other words, to test the instrument fully
before allowing her to leave your office. If
she complains of pain at any point, remove
the instrument at once and find out the exact
point of pressure and where the fault lies
with the instrument. Having made the
necessary alterations in the instrument, re-
place it then and you will find it will be
perfectly comfortable. Never permit a pa-
tient with a newly adjusted instrument to go
away and remain for several days from un-
der your observation. Always instruct her
to return the very next day so that you can
be sure the instrument is doing no harm, or
else, if she lives at too great a distance to re-
turn the following day, then instruct her
how she is to remove it herself in case it
causes her the slightest inconvenience or the
least pain.

Now, this block tin pessary is not to be
applied in this case as a permanent instru-
ment by any means. Being made of block
tin, it is apt to corrode and to cause at the
end of a few weeks sore spots on the mucous
membrane of the vagina. Consequently, I
only use it as a temporary instrument to get
the proper shape of what will subsequently
be a permanent one. When the block tin
instrument fits satisfactorily, as you think it
ought to do, you can then remove it, send it
by mail to the nearest instrument maker and

57o

Clinical

Lecture.

Vol. lxiv

have him make you a hard rubber one, of
exactly similar kind, or, if you have any
mechanical ingenuity about you, you can
take the hard rubber one and with the aid
of a spirit lamp and a little vaseline or sweet
oil, mold one into the required shape.

Having now adjusted this pessary in the
patient before us, you see that it holds the
uterus up perfectly, the patient complains
of no pain whatever, her backache has gone,
and I have no doubt but that after wear-
ing the instrument a few weeks, her general
health will be in every way very much im-
proved. She will be able to go about her
work and attend to her duties as she has not
been able to do for some years past.

The next patient I present to you illus-
trates, very strikingly, the points I have just
given you in regard to the management of
adhesions around the uterus. This patient
came here some months ago with the uterus
bound down on all sides by firm bands of
adhesions, which I have broken up under
ether, in the way I have just pointed out to
you, until the uterus was rendered freely
movable, and after two or three weeks of
local treatment it has been kept in its nor-
mal position in the pelvic cavity by means
of a Thomas Smith pessary. She came here
with exactly the same symptoms and con-
dition as the patient I have just spoken to
you about, and she is now entirely free from
all the symptoms that accompany retrover-
sions. She wears the pessary without the
slightest inconvenience, and is hardly aware
of the fact that she is wearing one at all. A
pessar}^ is worn with advantage only in one
way, and that is when it gives rise to no pain
whatever from its use.

Bear in mind the fact that there is no one
pessary that will fit any two patients, and
each instrument must be molded to suit each
individual case. Mold your instrument to
fit your patient and do not try to mold your
patient to fit the instrument. When you
have fulfilled these anatomical indications
you will then know how to fit an instru-
ment correctly so that your patient will be
able to wear it with a great deal of prac-
tical comfort and satisfaction.

Synthetical Quinine. — MM. Grimaux
and Armaud have succeeded in producing
a quinine by synthesis which is said to be in
every respect identical with the quinine of
vegetable origin. They arrived at this result
by treating a base obtained from the Remijia
Pedunculata (cuprein) with sodium, and
heating the compound thus obtained with
chloride of methyl.

CHRONIC GASTRITIS— GASTRIC ULCER-
ATROPHY OF THE GASTRIC MUCOUS
MEMBRANE.1

BY J. P. CROZER GRIFFITH, M. D.,

PROFESSOR OF CLINICAL MEDICINE IN THE PHILADEL-
PHIA POLYCLINIC ; ASSISTANT PHYSICIAN TO THE
HOSPITAL OF THE UNIVERSITY OF PENNSYL-
VANIA.

Gentlemen. — The first case that I shall
show you is interesting and practically very
useful to study. The man is one of those
individuals from whom it is difficult to ob-
tain an entirely satisfactory account of him-
self. He came here a week ago, with a his-
tory somewhat as follows : He is 39 years
of age, married, and an iron- worker by oc-
cupation. He has had the ordinary dis-
eases of childhood, except whooping cough,
and suffered fiom measles only a few years
ago. With these exceptions he has been
practically well until within a year and a
half. Then, for causes unknown to himself,
he began to feel weak and out of health, and
afterwards to lose flesh. He also began to
experience pain in the epigastrium and a
sensation of distress on eating, but he did
not have much vomiting until last Autumn.
During the summer he imbibed stimulants
in rather large quantities, but it does not
appear clear whether this habit was the
result of fondness for drink or of an effort to
overcome the weakness. In November he
commenced to vomit nearly every day, and
often several times a day. For the past
three weeks he has not been troubled so
much in this way, although he still vomits
frequently. The pain which he suffers
comes on at no regular period as related to
the time of the ingestion of food, although it
appears to be food which produces pain.
Neither does the vomiting occur at any
difinite time. There has been no history of
ejection of large quantities of food, or of
blood ; nor has there been in the vomited
material any particularly dark substance,
further than could be explained by the
character of the food taken. The bowels
have recently been constipated, though for-
merly they were regular. He does not
know what articles of diet disagree with him
most. After a general mixed meal he is
apt to suffer pain and distress. At times he
can restrain the vomiting for hours, but
eventually he is forced to yield to the incli-
nation.

This, gentlemen, is the history in brief.

1A Clinical lecture delivered at the Hospital of the
University of Pennsylvania.

May 1 6, 1891. Clinical

Lecture.

57i

It is not very perfect, but it is the best we
can get out of him. It is not typical of any-
thing, but it is interesting in connection
with the case which was before you last
week.

You probably remember that anaemic girl
who suffered intense epigastric pain, coming
on soon after eating, and shooting through
to the back ; while vomiting occurred very
soon after the ingestion of food. Ulcer of
the stomach was naturally suspected, for this
is apt to occur in females of about her age.

It is quite certain that patients often have
no marked gastric symptoms and yet may
have an open ulcer in the stomach. Again,
it has been found that certain patients, after
suffering from the symptoms of ulcer, ap-
pear to recover entirely, and go on for an
indefinite number of years without further
gastric symptoms, and then relapse. Or
they may evidently die of some other dis-
ease, and at the autopsy an ulcer may be
found in the stomach entirely unhealed. It
has probably been open, but inactive all
these years.

We therefore may have an ulcer without
any characteristic symptoms, and again an
ulcer present with severe symptoms ; the
symptoms later disappearing, although the
ulcer has not healed.

The girl of whom I have been speaking
says that for a long time she has not passed
more than two or three days without vomit-
ing. For the past week she has been at ab-
solute rest in bed, and has been on an ex-
clusive diet of peptonized milk in small
quantities. She has not vomited since she
entered the hospital. She feels better and
her health is improving. This shows what
rest and proper food, in proper quantity will
sometimes accomplish.

A very important matter to be borne in
mind in her case, was the condition of her
blood. We found on examination that
there were 2,900,000 red blood cells to the
cubic millimetre. That is, taking 4,500,000
as the normal number for females, she had
64 per cent, of erythrocytes. The amount
of haemoglobin, however, only equalled 20
per cent. There is therefore a marked con-
trast between the percentages of haemoglobin
and of red blood cells. The girl really has
chlorosis or chloro-anaemia, and it is con^
ceivable that the pain in her case is simply
of the nature of a cardialgia, a common
symptom in chlorosis, and that there is no
ulcer. It is equally possible however, and
much more probable in the light of the very
marked gastric symptoms, that an ulcer

does exist which is the indirect result of
chlorosis ; since it is a very well-known fact
that this disease acts as a powerfully predis-
posing cause of ulcer of the stomach. The
presence of chlorosis modifies the treatment
to some extent. It has been found that in
order to effect the healing of a gastric ulcer,
it is often first necessary to remove the chloro-
sis or anaemia. Consequently in addition to
the rest and careful diet of which I spoke,
the girl has been taking iron. Now nearly
all of the preparations of iron are irritating
to \ stomach in this condition, and it is most
important to choose one which is entirelv
free from this disadvantage. Within a few
years a number of preparations of iron have
been devised for which this property is
claimed. The one which I have employed
in this case is the Liquor Ferri Albuminati,
the solution of the albuminate of iron, made
by Drees, of Bentheim, Germany. It is of
neutral reaction, entirely free from metallic
taste, does not coagulate albumen, and is
usually perfectly well borne by the stomach.
Even in cases in which haematemesis has re-
cently occurred, the use of this preparation
is not contra-indicated. The girl of whom
I have been speaking, takes it readily. It
may be given in doses of 10 drops, three
times a day at first, but a much larger
amount can later be administered.

To return to the case of the man still be-
fore us. You observe that he is consider-
ably emaciated, rather pale, yet with no de-
cided cachexia. He is quite weak and is
able to walk but a short distance. His
other symptoms I have already reviewed.

There are several diseases to be taken
into consideration in the diagnosis of his
case. One is gastric ulcer; a second is
chronic gastric catarrh, or chronic gastritis
which is practically synonymous ; a third is
carcinoma ventriculi, and a fourth is simple
dilatation of the stomach. Gastric ulcer can
be readily excluded by comparing this man's
symptoms with those of the girl. The pain
does not come on so soon after eating, it is
not as intense and is not as localized as in
ulcer. The vomiting, too, is not so prompt,
and there is, indeed, very little connection
in this case between the time of eating and
that of vomiting. There is another very im-
portant matter, — the chemical characteristics
of the gastric contents — to which I shall
allude in a few moments.

Simple dilatation of the stomach, i. e., a
dilatation not due to carcinomatous constric-
tion of the pylorus, may produce a degree of
anaemia and emaciation which is surprising.

572

Clinical

Lecture.

Vol. lxiv

I do not know that I have often seen cases
more emaciated than sometimes after simple
gastrectasia, where the stomach seems for
various reasons to have lost the power of
emptying itself of food and has dilated to a
remarkable degree. This condition can be
recognized in various ways. One plan, pro-
posed by Ewald, rests on the use of salol, of
which 5 or 10 grains may be given at one
time. -Salol is supposed not to undergo de-
composition into salicylic acid and carbolic
acid until it reaches the intestinal juices.
By having your patient pass his urine every
fifteen minutes and testing this with chloride
of iron, you may, by observing the brown
coloration, determine how soon salicylic acid
appears in it. Where the stomach is inac-
tive the salol may remain in it for hours or
days. If, after the administration of salol,
you can in the course of half an hour detect
salicylic acid in the urine, you feel assured
that there is no motor insufficiency. It is
however necessary to say that the value of
the salol reaction is much disputed by
various observers, and is still problematical.
The test may be a help in forming a diag-
nosis, but cannot be relied on as conclusive.
We have not yet had an opportunity of try-
ing it in this patient.

Another method of determining the pres-
ence of dilatation is by percussion. It is,
however, often very hard to be positive as to
the different percussion boundaries of gastric
resonance. The liver covers the lower por-
tion of the right boundary, and the left
border, also, cannot be located with cer-
tainty. The upper border is partially
covered by lung. After all, these bound-
aries usually vary but little in any case.
It is the determination of the lower boun-
dary which is the important matter. It is
this which you wish to find in gastrectasia,
and having found it, the others can be dis-
regarded. You will find in practice that it
is frequently, perhaps usually, not easy to
distinguish the tympany of the stomach
from that of the colon and small intestines.
The ability to do this in any case depends
a great deal upon the respective amount of
gaseous dilatation of the various viscera. By
simple percussion it is often impossible to fix
the lower limit of the stomach. Where
there is great dilatation you may find a loud,
deep-toned tympany in the gastric region,
and you may get the succussion splash on
tapping with the tips of your fingers. Some
writers, indeed, claim that the production
of the succussion splash, and the noticing
the regions in which this ceases, is the best
method of outlining the stomach under all

conditions. I think, however, that you will
find it much more difficult than the descrip-
tion would indicate. The lower boundary
of the stomach could of course, be located
by passing a sound and feeling for it through
the abdominal walls, in the way proposed
by Leube ; but this method is by no means
without danger, and is unpleasant to the
patient. Another plan is that of Penzoldt,
namely, the passage of a tube, the pouring
in of water through this, and the determina-
tion by percussion of the position of the
dullness produced. This method is reliable,
but unpleasant, and not free from danger,
should an ulcer exist. A third method is
that of Frerichs. This consists in allowing
the patient to drink, say, 20 grains of bicar-
bonate of soda, dissolved in a glass of water,
and to follow this by another glassful, con-
taining about three quarters as much tartaric
acid in solution, with a little sugar to take
away some of the sour taste. Chemical decom-
position at once begins, carbonic di-oxide is
set free, the stomach dilated by it, and the
limits of the viscus often very distinctly de-
fined both to inspection and to percussion.
The method is, nevertheless, not entirely
accurate and sometimes disappoints utterly ;
since for its success, is required a decided
ability on the part of the pylorus to restrain
the gas from passing rapidly into the intes-
tine. One must also be prepared to with-
draw the gas promptly with the stomach-
tube, in case unpleasant symptoms arise.
Perhaps the simplest plan, and the one to be
first employed, is that of Piorry, of which
Penzoldt's method is a modification. This
consists in causing the patient to drink
several glasses of water and then in deter-
mining the lower border of the percussion
dullness while he is in the erect position.
This, of course, indicates the lower boundary
of the stomach. On again reclining, this
line of dullness shifts.

The lower border of the stomach varies
considerably in its position, since, as we
know, the stomach itself is a movable organ.
It is however, the very generally accepted
opinion that the lower boundary of the
healthy stomach rarely reaches to the trans-
verse umbilical line, and that, when it ex-
tends much below this line, the viscus is
certainly dilated. In the present case, how-
ever, it is easy to determine that the stomach
is not dilated, and I will not take the time
to go through the examination with you.

The two diseases remaining for us to con-
sider, are chronic gastric catarrh and cancer.

I have said nothing about dilatation from
cancerous constriction of the pylorus, for there

May 1 6, 1891. Clinical

Lecture.

573

is no dilatation in this patient. We have
still to entertain the possibility of the pres-
ence of a carcinoma of some other portion of
the stomach, interfering with health by dis-
turbing the digestion, causing pain and giv-
ing rise to cachexia. It is very difficult in
this case to determine whether the patient is
suffering from gastrititis or from cancer.
There is one sign whose presence would put
the diagnosis beyond doubt. If we were cer-
tain that we could find some increased re-
sistance, some nodular growth in the epigas-
trium, we should be justified in concluding
that we had to do with carcinoma. If
we found it in the region of the pylorus we
could not certainly tell that it was located
in the stomach, for it might be in the left
border of the liver. Growths in the liver
are, however, almost invariably of second-
ary nature, so that if you find severe gastric
symptoms accompanying a growth which
appears to be in the liver it is probable that
you also have to do with a primary tumor in
the stomach, whether you can detect it or
not. In a case in which you were in doubt
whether the tumor felt was in the liver or
the pylorus your diagnosis would be aided
by observing the effect of respiration. The
liver moves a great deal with respiration.
Hence, if such a patient breathe deeply and
the tumor simultaneously move downward
some distance you would be inclined to be-
lieve that it was in the liver. If, however,
you can move it about pretty freely in the
abdominal cavity, and it move but little with
respiration, you would conclude that it was
not in the liver.

To illustrate the difficulties often attend-
ing the recognition of a gastric cancer by
palpation, I may tell you of a case in this
hospital some years ago. The man was ex-
amined by several expert observers. All
agreed that in the epigastrium, and extend-
ing into the left hypochondrium, there was a
distinct mass, undoubtedly a carcinoma ven-
triculi. I examined him also and had no
doubt of the correctness of this diagnosis.
The patient suffered from progressive
emaciation and cachexia and from marked
gastric symptoms. After some months of
repeated observation he died. At the au-
topsy a small growth was found in the colon,
and the rest of the tumor was composed of
fecal accumulation merely. I well recall
the first — I fear not the last — time I failed
to recognize such a mass. It was the case
of a man admitted to the hospital in which
I was then an interne. On examining him
I found what I supposed to be a large

growth extending over the left side of the
abdomen. On the suggestion of a fellow-
interne I administered a large dose of salts
and the growth promptly disappeared. Since
then I have always hesitated to diagnosti-
cate any growth in the abdomen unless I
was sure that the bowels had been opened
regularly, and even unless I felt pretty con-
fident that no hardened fecal accumulation
existed around which softened feces could
pass.

In the case before us there is no evidence
of a tumor at the pylorus. I am not quite
sure that there is not a sensation of increased
resistance elsewhere in the gastric region,
but I think it very probable that this sensa-
tion is purely subjective. It is so easy to
feel something when you are looking for it.

You will find the greatest difficulty in
your practice in palpating the abdomen. It
takes, I think, much more experience than
does the physical examination of the chest.
One of the chief difficulties consists in over-
coming the resistance of the abdominal mus-
cles. Sometimes you find the abdominal
walls lax, and then palpation becomes an
easy matter, when, however, the patient is
very fat, or the muscles very resisting you
are often practically at sea and can deter-
mine nothing. If the case be one in which
a decision is absolutely necessary you might
give ether. This would help greatly, but it
is, of course, not feasible in every case. In
ordinary practice you direct the patient to
draw up his legs in bed, and you may even
prop him up slightly in order to still more
relax the abdominal parieties. Then have
him breathe deeply — sigh — through his
mouth. In this way, and by gentle and
skillful palpation — and only long practice
after all can teach you this — you will usually
succeed in determining the conditions pres-
ent. Sometimes, however, it will be only
after several examinations that you finally
satisfy yourself.

This man has no positive evidence of can-
cer. There is no increased resistance deter-
minable with any certainty, he has no
marked cachexia, and he has been working
very hard though sick, which accounts for
much of his weakness. He could scarcely
have had a cancer for the past year and
a half and be in as good condition as he ex-
hibits at present. Since he has been in the
Hospital he has had no vomiting. He has
been in bed and has been fed on peptonized
milk. We have also given him pepsin with
hydrochloric acid and wine of condurango.
The latter was proposed some years ago as a

574

Clinical

Lecture.

Vol. lxiv

specific in cancer. It is, of course, not such,
but it is an excellent stomachic, similar to
tincture of cardamom.

I think, therefore, that in this patient we
must make the diagnosis of chronic gastritis,
in the production of which, at any rate in
the increasing of which, the excessive use of
alcohol has had some influence.

I have as yet merely referred to the chem-
ical examination of the contents of the
stomach in gastric diseases. This is now-a-
days a most important matter. Many in-
vestigators have maintained — and perhaps
most prominent among these is Riegel — that
in cases of cancer of the stomach free
hydrochloric acid cannot be found by certain
color tests, some of which I shall presently
mention ; whereas in gastric ulcer the secre-
tion of hydrochloric acid is always in excess.
Further, that most cases of dyspepsia, in-
cluding many cases of chronic gastritis, do
not suffer from a diminution in the amount
of acid secreted, but rather from an excess
of it. The whole subject is still in what
might be called a formative stage. What is
stated positively and apparently proved by
one investigator, is as positively contradicted
or disproved by another. A few points,
however, I think, we may depend upon.
First, that in gastric ulcer the amount of
free acid found is almost always in excess,
or at any rate not diminished. Second, that
in cases of gastric cancer free hydrochloric
acid is always absent, or at any rate present
in very small quantities. I do not think,
however, that we are at all justified in con-
cluding that the absence of free acid is met
with only in cancer. Although many cases
of chronic gastritis are characterized by an
increase in the amount of acid secreted, in
other cases of the same disease, and in some
other gastric affections as well, the secretion
is certainly diminished or absent.

The absence of acid, then, only increases
the probability of the existence of cancer in
cases in which the other symptoms point
strongly in that direction. I should, however,
hesitate to make the diagnosis of cancer if
hydrochloric acid were present in normal
amount, or of ulcer if the acid were absent.

Most of you are familiar with the way in
which we procure the contents of the stomach.
The patient is given a mixed meal in the
morning, and, if you wish to be very accu-.
rate, the stomach should be first washed out.
Five to seven hours afterwards syphon out
tflie contents of the stomach with a tube,
using as little water as possible. Some clin-
icians use no water, but simply introduce the
tube and, having the patient lean forward,

press firmly over the epigastrium, and thus
force the contents out. I have never been
able to do this with much satisfaction, but
have always needed a little water. The con-
tents of the stomach, having been secured,
are filtered and examined by various chem-
ical tests. We wish to ascertain several
things. Among these are the presence and
amount of lactic and butyric acids which
indicate the degree of fermentation. Further,
the presence of free hydrochloric acid,as this is
t%o some degree an index of the digestive power
of the stomach. You need not look for pep-
sin, as it has been found that where hydro-
chloric acid is secreted,pepsin is secreted also..
You may, however, readily test the peptic
strength by placing a small cube' of hard-
boiled white of egg in a test tube with some
of the filtered fluid, and setting this in a
warm place for six or eight hours. If the
fluid has no peptic strength the egg does not
change ; otherwise it is, of course, more or
less dissolved.

A very important matter which is, I think,
unduly overlooked by many writers, is the
presence of peptones. It is easily conceivable
that a man may have no excess of pepsin and
hydrochloric acid but.quite sufficient to make
abundant peptones of the food taken. You
may find in such a case no hydrochloric acid
and no peptic strength, but testing with sul-
phate of copper — the biurette test — may
show an abundance of peptones, indicating
that acid and pepsin must have been present
at some time during digestion. A case of
this nature was in this Hospital only a few
weeks ago. I examined the contents of his
stomach and found no hydrochloric acid or
peptic strength, but a decided re-action for
peptones. At the same time there was no
reason to suppose that the patient had a can-
cer of the stomach. An interesting case
showing the value which sometimes attaches
to these newer methods of clinical study was
that of a man who was for a time in the Hos-
pital some years ago. He suffered from
marked and increasing ansemia, emaciation
and gastic symptoms. He was given a very
carefully regulated diet, and his vomiting
and distress ceased, but he continued to fail
in health. The question arose whether or
not a carcinoma ventricoli was at the bottom
of all his trouble. To some who examined
him it seemed that there was increased re-
sistance on palpati6n of the epigastrium.
However, chemical examination of the gas-
tric secretions showed abundant hydrochloric
acid and powerful peptic strength. On this
ground the idea of carcinoma was abandoned.
The case finally developed into one of pul-

May 16, 1891.

Clinical

Lecture.

575

monary tuberculosis, and after death there
was found a duodenal ulcer, but no cancer.

Now, in the patient before us to-day ex-
amination has shown that the free acid is
entirely absent, and that the secretion has no
peptic strength. Are we then compelled to
altar our diagnosis ? I think not. As I
have already told you chronic gastritis is
sometimes without free hydrochloric acid in
the gastric contents. We shall then remain
by our previous diagnosis. We will con-
tinue his treatment and report his progress
on another occasion.

I wish to say a word here in reference to
the tests employed for hydrochloric acid.
There are a number recommended and the
battle over their respective reliability wages
as fiercely as that over the indication of free
acid when found. The tests perhaps oftenest
employed are the methyl-violet, the Congo
red, and the Phloroglucin-vanillin or Gunz-
burg reaction. The latter is rather more
difficult to apply, and I do not know that it
is any more accurate or reliable. The tests
generally used in this Hospital are Congo
red and methyl-violet. If a solution con-
taining free hydrochloric acid, even if very
dilute, be added to a solution of the former
the red becomes a blue. With the latter the
violet becomes blue under the same condi-
tions. A very convenient method is to im-
merse strips of filter paper in the solution
and allow them to dry. One of these can
then be dipped into the solution to be tested.

These tests are so practical and so easy of
application that they are worth remember-
ing. Both of them are very delicate. The
objection urged against them is that certain
other substances, as lactic acid in a concen-
tration not usually found even in a diseased
stomach, will produce the same color change.
Nevertheless, the failure of the change to
take place is an undoubted proof that no
free hydrochloric acid is present. What I
have said is true only in a restricted sense.
It is quite certain that careful chemical tests
made by an expert chemist may show the
presence of acid where these color tests fail.
This I know from personal experience.
Acid has been found in the chemical labo-
ratory of the University in cases in which I
failed to discover it with the color tests.
For clinical purposes, however, I believe
these tests to oe efficient. The reaction for
lactic acid — known as Uffelmann's test — is
applied as follows : Dissolve a small amount
of chloride of iron in a little water in a test
tube, and add a few drops of a strong solu-
tion of carbolic acid until a purple color is
produced. If, now, to this be added some of

the filtered contents the purple color will
become a canary yellow if lactic acid be
present.

This second case is also one of gastric dis-
order, and is one of extreme interest. He
has been kindly brought here by the phy-
sician under whose care he is. Un-
fortunately we have but little time
remaining in which to study it together. The
paient is a man of 43 years of age. His
father and one sister died of phthisis.
He has never drank to excess. Except
for chronic constipation he was always well
and strong until two and a half years ago,
when he found that he was losing appetite.
This was soon followed by discomfort after
eating, with frequent vomiting occurring an
hour or an hour and a half after meals, and
an increase in constipation. One and a half
years ago .he had a great deal of vomiting.
He has been somewhat pale ever since he
came to this country, 24 years ago, and
thinks he has been as pale as at present for
the last two years. His best weight has
been 145 pounds, and his average weight 136
pounds. His present weight is 119 pounds.
Last December he had to give up work on
account of increasing weakness. The dys-
peptic symptoms at that time became more
marked, except the vomiting, which has
been less. He has had ringing in the ears,
accompanied by a sensation of lightness in
the head.

When examined a year ago the skin had
a pale, light-yellow tint, with but little sub-
cutaneous fat. There was marked pulsa-
tion in the vessels of the neck, a soft and
somewhat accelerated pulse, and a blowing
murmur at the apex of the heart with a
sharp second sound. The hepatic and
splenic dullness did not seem to be increased.
No tumor could be found in the abdomen,
even by the most careful examination. The
examination of the blood showed 681,000 red
blood cells to the cubic millimetre, with a
slight increase of the white cells. Five
grains of salol were given and the urine
tested after a half hour and after one and a
half hours, but no salicylic acid was found.
This seemed to indicate a possible motor in-
sufficiency of the stomach. CEdema of the
feet and ankles was first noticed last June.
The urine, however, does not show any evi-
dence of Bright's disease. He improved some-
what through the summer, and the blood-count
made last December showed 2,000,000 eryth-
rocytes, i. e.,40 per cent., with a percentage of
haemoglobin of 50. Thus, as you see, the
percentage of haemoglobin exceeded consid-
erably that of erythrocytes ; a condition

576

Clinical

Lecture.

Vol. lxiv

characteristic of pernicious ansemia. In
January there was great weakness and much
nausea and retching with pain. Lavage
brought up a quantity of foul-smelling mu-
cus. At no time has hydrochloric acid
been found in the gastric contents. His con-
dition has certainly been getting worse, for
some time past. I have been able to read
you only scattered extracts from the elab-
orate clinical history which his physician
has made.

Turning to the patient you notice at once
the excessive pallor, yet without any de-
cided emaciation. The pallor has the pecul-
iar faint lemon tint often attending extreme
ansemia. There has been no growth found
in the abdomen. Moreover, if this were a
case of cancer Ave should probably have had
a fatal issue long before this.

On percussion you notice that the loud
gastric tympany is very extensive, and his
physician has determined, by giving him
water and then examining in the way I have
described, that the lower border of the stom-
ach extends below the umbilicus. We un-
doubtedly have here a dilatation of the
stomach without any constriction at the py-
lorous to account for it. Here is a case in
which there has been no hydrochloric acid
found, yet in which there is no reason to be-
lieve in the existence of cancer.

I have shown you this case because it is a
very possible example of a rare condition, or
at least of one very little understood. It is
probably an example of atrophy of the gas-
tric mucous membrane. I have seen only
one instance of this disease, and that post
mortem, and there are not many cases re-
ported. In this disease you find a combina-
tion to some extent of the symptoms of
chronic gastritis with those of pernicious
anaemia. According to George Meyer? who
has seen several cases and carefully studied
the subject, the symptoms are dilatation of
the stomach, disappearance of the natural
secretion, cardialgia and diminution of the
gastric movements, while at the same time
there is extreme anaemia with fairly good-
general condition and an absence of marked
emaciation. In these cases the microscope
shows that the gastric tubules have almost
entirely disappeared. There is practically
no mucous membrane. You will find a
small-celled infiltration with cysts where
the membrane should be, with scanty re-
mains of glands here and there. The other
layers of the stomach-wall are not much af-
fected, except that the submucosa is thick-
ened. In certain cases an overgrowth of
connective tissue occurs instead of the infil- 1

tration and chokes the glands, as it were.

Fenwick, Nothnagel, Osier and Henry,
Litton, Ewald, Kinnicutt and a few others
have reported cases of this affection, with
pretty much the same symptoms. The dis-
ease is rare — or rather the reported cases
are — and the number of instances of it might
almost be counted on the fingers of the two
hands. The diagnosis is often impossible,
ante-mortem and in the case before us, as in
all others, can only be made provisionally.
Yet I think, with the symptoms exhibited
by this man, we are justified in considering
this as very probably a genuine instance of
atrophy of the gastric mucous membrane.
Review with me once more what may be
gathered from the man's history and appear-
ance. The extreme pallor and the lack of
marked emaciation are characteristic of per-
nicious anaemia. The condition of the blood
is also characteristic of this disease. Then
he has marked dyspeptic symptoms with a
failure of the secretion of hydrochloric acid.
There is evidence of motor insufficiency of
the stomach, and there is gastrectasia. This
combination of symptoms exactly fills the
requirements necessary to justify the diag-
nosis.

Atrophy of the gastric tubules may pro-
duce dilatation, and conversely dilatation
may be followed by atrophy. In the latter
case the tension and pressure on the gastric
wall induces the atrophy. In the former
the food, not being properly digested, lies in
fhe stomach, decomposes with the formation
of gases, and produces dilatation. This pa-
tient at times does not vomit for several days
and then fills a large basin with the contents
of his stomach.

The treatment of this case is practically
what has been already employed ; though,
in fact, very little can be done in the way of
therapy. Arsenic has been given him in
the hope that it might act as an alterative.
He has also had gastrointestinal antiseptics,
such as naphthalin, aromatics, salol and the
like. Bismuth has been tried, as has nitrate
of silver, in an effort to control the vomiting.
Some dependence can be placed on the admin-
istration of predigested foods, in the hope that
in this way the lack of digestive power may
be supplemented.

Lavage at frequent intervals is certainly
indicated, and has been repeatedly tried in his
case. Unfortunately, though it gives de-
cided relief, it exhausts him to such an ex-
tent that it cannot be employed.

It is said that people living out-of-door
lives are hypermetropic.

May 1 6, 1891.

Communications.

577

Communications.

TRAUMATISM OF THE CHEST.

BY J. McFADDEN GASTON, M.D.

ATLANTA, GA.

Ill the course of my investigations on thor-
acic surgery for The Annual of the Universal
Medical Sciences, I have been strongly im-
pressed with the lack of knowledge in re-
gard to the injuries of the chest. While this
subject has been considered somewhat care-
fully in my two contributions to that work,
there are many practical details of great im-
portance, which are not touched upon, owing
to the paucity of data afforded by the very
limited reports in this branch of surgical
experience.

It is not my purpose now to enter into the
minute distinctions of the lesions resulting
from violence to the walls and contained
viscera of the chest. I ask for the attention
of surgeons to the great advantage of
methodic treatment of traumatism of the
chest.

All those inflammatory processes of a latent
or idiopathic nature, which lead to serious ef-
fusions primarily, or to suppuration second-
arily, within the thoracic cavity, are
excluded, as not germain to our present
undertaking. In like manner, the very ex-
tensive lesions involved in operations for the
relief of the above conditions in all stages,
do not come within the scope of this paper.

Foreign bodies entering through the tra-
chea, into the bronchi and causing mechan-
ical obstruction, or inflammatory compli-
cations, call for consideration, under the
general inflammatory impression transmitted
to the pulmonary structure.

Blows upon the parietes of the thorax
which propagate a shock to the lungs or
heart, involving ah impairment of functions,
or subsequent organic changes, come ap-
propriately under the heading of traumatism,
though no superficial contused wound is ap-
parent.

Of course, all violence from without
which produces injury to the structures
within the chest, should be regarded as the
proximate cause of the lesion, whether it be
haemorrhage, congestion or inflammation.

The grosser accompaniments or conse-
quences of violence, consisting in notable
contusion of the soft parts and fracture of
the bony walls of the chest, are frequently

iRead before the Surgical Section of the American Medical
Association, at the meeting in Washington, D. C, May 6th,

the exciting causes of transmitted inflamma-
tion to the vital structures of the thorax.

Among the gravest injuries to the chest
are the wounds by firearms and by cutting
or puncturing instruments. These generally
bring about the entrance of air into the
pleural cavity and thus by pressure upon
the corresponding lung there is serious inter-
ference with the respiratory act. Should the
pulmonary tissue be involved in the wound,
there is likely to occur emphysema, from the
entrance of air into the areolar tissue of its
parenchymatous structure, so as to effectually
prevent the alternate expansion and con-
traction of the bronchial ramifications.

The former condition of pneumothorax
may be a result of air escaping from the
bronchial tubes when wounded, even when
the external incision or puncture may be of
a valvular nature, which does not admit of
the entrance of air from without.

If the external wound is patulous, the in-
gress and egress of air occurs with each act
of expiration and inspiration, inducing the
condition of traumatopnoea. This is a most
unpleasant result, and introduces a grave
complication in the nature of the case.

There is also, most frequently, sanguin-
eous extravasation into the pleural cavity,
from such injuries, and if the lung has not
become collapsed from the entrance of air,
its function of respiration is impeded, if not
obliterated, by the blood pressure.

Should the parenchymatous structure be
involved in gunshot or punctured wounds of
the lungs, there may be emphysema to a
greater or less extent, throughout the cellu-
lar tissue of the thorax and adjacent parts.

The constitutional or systemic effects of
any violence to the thorax depends upon
the amount of shock in the first instance or
the inflammatory process which is devel-
oped subsequently.

The greatest diligence on the part of the
surgeon is requisite to avert the immediate
fatal result of penetrating chest wounds.
Apart from the general manifestations of
chest wounds there are local effects from me-
chanical causes, which require our consider-
ation.

One of the most serious consequences of
violence to the walls of the thorax is rupt-
ure of the lungs. A fall upon some solid
body or the pressure of some heavy weight,
while the lungs are greatly distended by
closure of the glottis, induces rupture of the
pulmonary tissue, with all the serious results
of pneumothorax and hsemoptisis. This may
occur even without an abrasion upon the
surface of the chest ; and the history of such

578

Communications.

Vol. lxiv

an accident is the only explanation of
the grave condition within the thorax. A
forcible impression upon the walls of the
chest may fracture the sternum or ribs and
drive either inward so as to lacerate the
lungs or the heart, leading to immediate or
remote serious effects.

One of the grave consequences of an open-
ing through the chest wall is the protrusion
of a portion of the lung, constituting a
hernia. If this should occur under the
observation of a surgeon, he would find
little difficulty in returning it and re-
taining it within by a compress. But
most frequently it has been exposed for some
hours and has become engorged, so that it is
entirely impracticable to .reduce it without
enlarging the opening in the walls of the
chest. This would seem the most feasible
mode of relief, if the vitality of the tissue
had not been impaired by the constriction.
But it is generally held to be safest, either
to allow the protrusion to remain and slough
away or to assist its detachment by placing
an elastic ligature around the neck of the
hernial tumor. The edges thus, become ag-
glutinated and the lung is occluded. Then
may also occur laceration of the lesser or
greater blood vessels of the thorax calling
for prompt relief, if the injury does not
prove immediately fatal.

It has been proven by subsequent obser-
vation of the effects, that lesions of the heart
have healed and that injury to the coats of
the large arteries are not necessarily fatal.
But there is no instance on record of a
wound of the vena cava without a fatal re-
sult. The thoracic duct, in like manner,
cannot be wounded with impunity, and the
escape of the lymph terminates in death.

While the ligation of the intercostal ar-
teries, the internal mammary and the sub-
clavian is attended with difficulty, the haem-
orrhage from them rarely may be controlled,
and the patient should not be abandoned to
his fate. If blood has accumulated within,
it may be withdrawn by suction or its escape
may be prevented by position.

Those who have had the largest sphere of
observation in this branch of thoracic sur-
gery, will best understand the uncertainty
hanging over pulmonary disorders resulting
from violence. Commencing with the doubts
as to the production of traumatic pneu-
monia, and running through the abscesses of
the parenchymatous structure of the lungs,
it is remarkable how little is finally and
definitely determined as a guide for practice
in thoracic injuries.

It will be found, upon attempting to ana-

lyze the reports of such lesions, that quite a
variety of opinions are entertained by dif-
ferent observers, and that really no meth-
odic treatment has been adopted generally
by the medical profession. I know of no
Avork on surgery which lays down any fixed
rule for the practitioner in the management
of wounds of the chest.

The contributions to the literature of
traumatism of the chest in Holmes's System
of Surgery, Vol. I, in The International
Encyclopaedia of Surgery, Vol. II, in The
Keference Hand-book of Medical Sciences,
Vol. IV, and in The Annual of the Universal
Medical Sciences for the years 1889-90-91,
represent fairly the status of this branch of
surgery. Those who seek to keep abreast
of the recognized data, may learn from these
works what has been accomplished for the
relief of this class of injuries. It will be
noted that there are conflicting views in re-
gard to the proper treatment of some of the
consequences of penetrating wounds of the
chest, dependent, no doubt, to a great extent,
upon the different stand-points from which
observations are made. While there is a
correspondence, for the most part, among
different authorities, in the propriety of
closing the external opening in the wall of
the chest, when the amount of blood in the
pleural cavity is small, contradicting opin-
ions are expressed when it is large.

To define more clearly the attitude of
those who have written upon this topic, I
may state that individual views of the
nature of such injuries, with the steps recom-
mended for their relief, rest very much upon
personal observation and not upon the con-
sensus of general experiences by the pro-
fession.

There are articles upon thoracic wounds in
most of our standard works on surgery, pre-
senting many points of a practical bearing,
as viewed by the author. Yet, with such
material differences in their application,
under the emergency of treatment, as to
avail little for the practitioner.

While we should not overlook the writ-
ings of former days, it may be stated that
little progress has been made in the elucida-
tion of wounds of the chest since the work of
Gross and Agnew were presented, and some
of the more recent authors, as Wyeth and
Koberts, have touched upon chest injuries very
briefly. While Senn ignores, with few ex-
ceptions, traumatic developments of the tho-
rax, many important data, illustrating the
results of gunshot wounds of the chest are
given in The Surgical History of the War,
published by the U. S. Government, and

May 1 6, 1891.

Communications.

579

the statistics of non-penetrating and pene-
trating wounds of the chest, therein pre-
sented, demonstrates the gravity of the
latter as compared with the former in a
most conclusive manner. This, however,
only confirms the results of the records of
military operations throughout the world,
showing that about 1 per cent, of non-pene-
trating wounds of the chest prove fatal,
while over 65 per cent, of penetrating
wounds terminate in death at an early
period after the injury.

One of the practical questions of greatest
moment in regard to the hermetical sealing
of gunshot wounds of the thorax, remains
unsettled.

Experiments upon the inferior animals,
commencing with those of Houston in 1728,
for illustrating the effects of punctures and
incisions into the thoracic cavity, have been
attended with such different results upon
the ' lungs, that it is yet undetermined
whether collapses ensue directly from these
wounds. There is such an intimate relation
of the surface of the lungs to the costal
pleura, that something must separate them
for the occurrence of pneumo-thorax, and
hence it occurs that openings are not always
followed by this result.

It is held that the falling away of the
lung is not a uniform consequence of a
penetrating wound of the chest. If the
wound is small, or if it is at a distance from
the free margin of either lobe, the expanded
lung remains in contact with the costal
pleura.

The adhesion of the two pleural surfaces
is illustrated by an experiment of Surgeon
A. H. Smith, in which, in a recently killed
animal, an opening was made in an inter-
costal space, midway between the sternum
and the spine. The lung did not collapse,
but on making another in the same intercostal
space close to the sternum, the outer surface
of the lung was observed to slide backwards,
though still remaining in contact with the
chest walls, until the edge of the lobe came op-
posite the first opening. Then for the first
time the air entered here, and the pneumo-
thorax became complete.

Gordon and McDonald found that with
small tubes introduced into the chest, the
breathing became quick and laborious, while
the lungs had fallen away from the chest
walls for an inch. After four minutes, they
enlarged the wounds and put in tubes,
whose united calibre was twice that of the
glottis. The respiration then became very
laborious. On closing the wounds, however,
and applying friction to the chest, the

respiration was restored and in ten minutes
the animal was able to walk about. It was
killed on the 5th day aud nothing notable
way found in the chest.

Dr. Northrup reports some experiments on
animals, contradicting the statements of
Samuel West, that the force of cohesion suf-
ficed to maintain the lung in complete ex-
pansion when the parietal pleura was punct-
ured. Further experiments were made in
which a dog's two plurse were fitted with
double-flanged canulse, stoppered with corks.
Until the dog recovered from ether the two
corks were left in place. When fully re-
covered one cork was withdrawn, and the
dog scarcely suffered dyspnoea on moderate
exercise. When both corks were removed
the dog tumbled about for two min-
utes and succumbed to some dyspnoea, which
again entirely disappeared on replacing the
corks.

These results throw some light upon the
practical resort to closure of the external
openings into the pleural cavity as a curative
measure in cases of penetrating wounds of
the chest. .

Howard's proposition to the Surgeon
General of the U. S., during the war, to test
the process of hermitically sealing the ex-
ternal orifices of gun-shot wounds of the
chest, met with so much prejudice on the part
of the surgeons of the Federal army, that it
was used in a limited number of cases. It
is also inferred that the conditions under
which this measure was tried, were not
favorable to its success, as the most grave
cases were the subjects. Judging from my
own experience of the good effects of closing
penetrating wounds of the chest, and from
the records of cases thus treated by others,
it seems unfortunate that hermetical sealing
was not applied on a larger scale, so as to
afford the statistics for a final and conclusive
decision as to its merits. Independent of
the recognized advantages of closure in the
lesser accumulations of blood in the pleural
cavity, it is held by some, with a show of
practical discernment, that in the most ex-
treme cases of thoracic haemorrhages, the flow
of blood externally should be arrested by
plugging the orifice, so as to favor the
coagulation of the blood within, and by com-
pression upon the lung to prevent further
extravasation.

If this course is applicable in the most
aggravated condition of penetrating wounds
of the chest, as well as to the simpler form
in which there is a slight haemorrhage into
the pleural cavity, why may it not prove
serviceable in the intermediate accumulations

58o

Communications.

Vol. lxiv

of blood in the thorax, and thus be applica- 1
ble to every variety of penetrating wounds
of the chest ?

It is not expected that a general rule can
be laid down, without exceptions, for the
immediate and complete closure of all pene-
trating wounds of the chest. There must
be certain preliminaries observed in the prep-
aration of the patient for receiving the
benefits of such procedure, so as to close the
orifice with the least blood in the cavity of
the pleura, that is possible. Placing the
patient so that the opening shall be the most
dependent part, with a firm bandage around
the thorax, and making the occlusion im-
mediately after the expulsion of air and
blood from the wound, by forcible inspira-
tion, should promote a favorable result.

If the case is complicated with emphysema,
involving any considerable * portion of the
surface, plugging the orifice with a condom
stuffed with sponges, as has been suggested
for the arrest of haemorrhage from an inter-
costal artery, will prove efficient in prevent-
ing the escape of air into the cellular tissues,
and at the same time accomplish complete
occlusion of the thoracic cavity.

A comparison of this procedure may be
made with that in which the air enters the
cavity of the pleura and induces collapse of
the lung, thus arresting the flow of blood
from the wounded darenchyma, with a tube
in the opening, as recommended by Packard,
for prevention of emphysema. In this latter,
the air pressure is supposed to arrest the
bleeding. In the other condition, blood
clot presses upon the lung so as to control
the haemorrhage.

The variable influence of the air in the
pleura, with more or less air entering the
lung by the inspiratory act of the sound side,
renders this recourse very doubtful in per-
manently controlling the escape of blood
from a wound of the lung.

On the contrary, the formation of blood-
clot within the pleura keeps up a pressure
which can be relied on to prevent the further
bleeding from the pulmonary lesion. All
those who have observed the relief of dis-
tressing dyspnoea, by closing an open wound
of the chest, concur in its great benefits.

It may be inferred from the favorable
progress of cases in which a large accumu-
lation of blood has remained in the pleural
cavity, that its gradual absorption occurs.
If the air is completely shut off from without,
of course, germs cannot enter to set up de-
composition in the mass, even should there
be a perforation of the bronchia ; as it is

held that air passing through this sieve-like
structure is rendered innocuous.

With the larger death rate from penetrat-
ing wounds of the chest, treated without
special reference to the process of occlusion,
the result is not likely to be more serious
from a uniform adoption of sealing hermeti-
cally all external openings of penetrating
wounds of the thorax. If the worst conse-
quence of this procedure ensues in purulent
development, there is open to the surgeons
such measures of relief as have been adopted
successfully in emphysema from other in-
flammatory processes.

In this connection, a few cases which have
come under my observation, may serve to
illustrate the open and closed methods of
treating wounds involving the thoracic
cavity. Many instances of gun-shot wounds
of the chest were brought to my attention as
Chief Surgeon of Division during the civil
war in this country. But I had no opportunity
of following up the subsequent course of these
injuries ; and would refer to reports of such
cases in The Surgical History of the War for
the results. I will give, however, an outline
of some characteristic cases, occurring in my
own private practice and in consultation
with others, during the past few years.

One case had a pistol-ball wound at short
range between the fourth and fifth ribs, on
the right side, in front, and ranging down-
ward. All the physical signs were present,
indicating a wound of the right lung, with
extravasation of blood into the pleural
cavity. It was kept open for a time but
closed afterwards spontaneously and termin-
ated fatally.

Another case, in which a ball from a
large Colt's revolver, traversed the left side
of the chest, entering through the lower
border of the pectoral muscle and escaping
between the ninth and tenth ribs near their
cartilages, instead the pleural cavity. There
was a discharge of frothy blood from the
posterior wound and the physical signs of
extensive sanguinary extravasations into the
left pleural cavity.

The heart was perceptibly pressed over to
the right, carrying the apex beyond the
median line. While no suture was used
to close the wounds, they were hermetically
sealed by antiseptic dressings ; and, notwith-
standing considerable constitutional dis-
turbance subsequently, the patient made a
good recovery.

A third case was a child, accidentally
shot, the pistol ball entering through the
ensiform cartilage and ranging upwards,

May 1 6, 1891. Communications.

58i

no precaution was used to close the wound,
and the patient died from emphysema. '

The fourth case was from a pistol shot
which entered just below the ensiform
cartilage ranging upwards to the right and
lodging above the eighth rib, thus passing
through the diaphragm and lower portion
of the right pleural cavity. The external
haemorrhage was not pronounced, but the
presence of blood in the chest was inferred
from the physical signs of dullness upon
percussion and diminution of the respiratory
murmur under auscultation.

There seemed to be no indication for oc-
clusion of the external wound and it was
therefore left open. As there may have
existed complications involving the abdomi-
nal viscera, the fatal termination on the
fourth day cannot throw any light upon
the true cause of death.

The fifth case affords an instance of a
pistol ball entering the chest, immediately
over the heart,traversing the mediastinum
and lodging upon the sixth rib of the right
side, just behind the posterior axillary line.

The external wound was occluded, and
the ball was not removed until after the
general shock and slight inflammatory re-
action had passed off. The patient made a
good recovery by the strict observance of
masterly inactivity.

This case, with that preceding, having
the ball lodged superficially for several days
before removal, seem to emphasize the
caution against cutting down and extract-
ing a ball under such circumstances, at the
outset.

Time should be allowed for adhesive in-
flammation to block up the communication
with the cavity, as otherwise a direct counter
opening into the chest must result.

I recall, in this connection, after the first
Manassas battle, allowing a minnie ball,
which was impacted in the clavicle and first
rib, to remain, but by its extraction the
chest cavity should be exposed ; but the
final result of the case is not known.

The practice of removing balls lodged
between ribs, which is inculcated in Agnew's
Surgery, without proper limitation, is more
honored in the breach than by the observ-
ance. It is evident that the immediate ex-
traction of a ball from the border of a rib,
after it has traversed the chest, must leave
an opening into the cavity of the pleura
and aggravate the gravity of the case.

A counter opening in muscular structures
for the removal of a ball which is near the
surface, does not in the experience of sur-
geons of large practices, retard the healing

process along the line traversed by the ball.
But with the conditions presented in a
gunshot wound of the thorax, when an
opening already has been made by the en-
trance of the ball it is not good surgery to
make another for the extraction, until the
wall behind has become solidified.

In illustration of the effects of punctured
and incised wounds of the chest, a few ex-
amples of knife-stabs, which have occurred
in my practice will be added.

A case of stabbing, between the fourth
and fifth ribs, in front of the anterior axil-
lary line on the left side was accompanied
with localized emphysema. While there
was evidence of sanguineous effusions in the
pleural cavity the bleeding was profuse ex-
ternally.

There was a slight dyspnoea upon lying
down which was relieved in the sitting post-
ure. The wound was closed by adhesive
plaster with a compress and bandage and
the patient recovered without untoward
symptoms.

It has not been found necessary to use
stitches in these wounds inflicted by the
thrust of a knife blade, as the coaptation is
effected by the above process, so as to
hermetically close the opening in the chest.
In another case a stab was inflicted between
the sixth and seventh ribs over the left side
near margin of the scapula, from which
blood and air escaped at each inspiration,
with considerable accumulation of blood
in the pleura, and hsemoptysis.

The external wound was closed imme-
diately after a gush of blood and air
from the opening. The patient became
more quiet afterwards. This case was ac-
companied with traumatic pneumonia and
marked constitutional disturbance, but ulti-
mately recovered.

A third case came under my observation
in which a knife blade entered between the
fifth and sixth ribs on the right side, pene-
trating the lungs and attended with the ac-
cumulation of blood in the pleural cavity.
There was no very marked dyspnoea, and as
the flow of blood externally, gradually
diminished with the dependent position of
the wound, it was not thought that closure
of the opening was indicated.

Inflammatory symptoms soon developed,
with subsequent adhesion of the pulmonary
and parietal pleura. In the end suppura-
tion of the lung found its way through the
external opening. A weak solution of car-
bolic acid was daily, injected into the suppu-
rating tract, and the healing process pro-
gressed favorably, so that there remained,

582

Communications.

Vol. lxiv

eventually, but slight impairment of the
lung from the injury.

The inference from these cases goes to
prove that suppuration is more likely to occur
when the incised wound is left open than
when ' it is closed immediately and kept
occluded.

A fourth case was seen some days after a
stab had been inflicted between the seventh
and eighth ribs, and there was a protusion of a
small globular mass of pulmonary tissues
from the wound. As it had occurred shortly
after the injury and was tightly constricted
by the margins of the wound in the thoracic
wall, the neck of the hernial tumor was
encircled with an elastic ligature, as most
likely to effect a prompt and safe detach-
ment of the mass. In a few days it sepa-
rated, and there was no further trouble with
the case. If there was any escape of blood
into the pleura it was most effectually shut
in by the plugging of the opening, and af-
forded an illustration of the favorable issue of
hermetical sealing in penetrating wounds of
the thoracic walls.

A RESUME OF THE HISTORY AND PRAC-
TICAL APPLICATION OF HYDROGEN
PEROXIDE IN SURGICAL AF-
FECTIONS.

BY S. POTTS EAGLETON, M. D.

RESIDENT PHYSICIAN IN THE CHILDREN'S HOSPITAL,
PHILADELPHIA.

Hydrogen peroxide was discovered by M.
Thenard, a French chemist, in the year 1818.
Since which time it has, like many other
therapeutical remedies, laid dormant, occa-
sionally being brought forward by some
"enthusiast " and its virtues highly extolled
for a time. But the drug, unequal to the
task of proving all that had been said in its
favor, was again and again returned to its
stall of oblivion. Within the past few years,
it has been introduced to the notice of
the medical profession, on account of its an-
tiseptic properties, and apparently has awak-
ened into active therapeutic life.

Most of the preparations or hydrogen
peroxide in the market to-day, according to
C. T. Kingzett, 1 are made by the process
which originated with its discoverer. Physi-
cally it is like water, transparent, colorless,
odorless, and generally tasteless ; occasion-
ally, however, a slight metallic taste may be

XC. T. Kingzett, British Medical Journal, London,
1882, vol. II, p. 1087.

noticed. The specific gravity varies, gener-
ally it is about 1,450. It remains liquid at
zero. Chemically, it is one molecule of water
in feeble combination with an atom of oxy-
gen, (H2 0+0— H2 02). That this extra
amount of oxygen does not show a strong
affinity for the water, with which it enters
into combination, is made evident by the
rapid decomposition of the compound into
its original constituents (water and oxy-
gen) when brought into contact with any
surface containing pus. It is this factor of
being readily decomposed and setting free
nascent oxygen which renders it of practical
utility in the treatment of disease.

In looking over the literature of the sub-
ject, I find that Dr. B. W. Richardson, 1 in
1862, called attention to the action of hydro-
gen peroxide in an able article upon the sub-
ject, which excited wide-spread interest in
the profession at that time and has led to
many experiments with the drug, both in
surgery and medicine.

It is my purpose to confine myself in its
study, entirely to the treatment of surgical
affections. Before referring to the results of
my own experience, during the last few
months, I will briefly allude to some o"f the
most important monographs which have
appeared from time to time in our medical
journals. C. T. Kingzett 2 believes that the
substance exhibits striking antiseptic effects
and is capable, even in very small quantities,
of arresting the so-called process of fermen-
tation which is originated by living organ-
isms. He further calls attention to the fact
that care should be exercised in making the
solution neutral before using the same, and
yet admits that neutral solutions are by no
means as staple as are those of a slightly
acid reaction. In closing his monograph he
states that the expectations that the com-
pound would prove of peculiar benefit in the
treatment of wounds have been, amply real-
ized in the practice of several noted surgeons
of France, among whom may be mentioned
M. Baldy, M. M. Reynard and M. Reau.
In summing up his article he further says
that, in his opinion, hydrogen peroxide is
far superior to phenol, and that it has been
demonstrated beyond question that all wounds
treated with peroxide of hydrogen have pro-
gressed well, healing generally by first in-
tention.

A. E. Prince, 3 speaks most favorably of

1B. W. Richardson, Tr. M. Loc. Lond., 1862, vol.
II, pp. 51-53.

2 Ibid.

3 A. E. Prince, St. Louis.il/. and S. Journal, 1884,
vol. XLVI, pp. 246-252.

May 1 6, 1891. Communications.

583

the results obtained with this remedy.

It is as a local therapeutic agent that
it has asserted its supremacy and secured
the attention of medical pioneers in all de-
partments of medicine. Believing, as he
does, that in comparison with iodoform it is
inferior as an antiseptic, but, like the latter,
it produces little or no irritation, when used
about tender organs. C. E. Shelly 1 con-
siders it to possess anaesthetic properties, and
at the same time claiming for the drug, not
only a pus -destroyer, but that it is an actual
stimulant to the surface of wounds. To the
carefully conducted experiments of Dr. P.
Miguet, quoted by W. D. Bizett, 2 we owe
the establishment, on a firm basis, of hydro-
gen peroxide as a positive germicide. The
line of experimentation pursued had the fol-
lowing aim : to determine the quantity of
various substances, commonly used as ger-
micides, which, added to a quart of beef tea,
would prevent decomposition. Miguet found
among a long list of substances used by him,
that only two were more powerful than
hydrogen peroxide. The following table
shows the relative strength, according to his
experiments, of the four most powerful ger-
micides :

Biniodide Mercury 0.025 grains

Biniodide Silver 0.03 grains.

Hydrogen Peroxide 0.05 grains.

Bichloride Mercury 0.07 grains.

The results thus obtained, place hydrogen
peroxide in the lead of bichloride mercury
as a germicide, with the advantage, also, of
being absolutely void of any toxic action,
while the corrosive sublimate is a most viru-
lent poison. Bizett3 claims that when the
pure peroxide, which is syrupy in consist-
ence, is brought into contact with living
tissues, it acts as a direct caustic. Various
experiments were made by H. Gifford4
directly with the disease germs, thus testing
the germicidal action of the peroxide. Two
methods of determining its ability to destroy
germs, were used, that of Koch and his own
well-known method. The preparation of
peroxide used, was that of Chas. Marchand's
(15 vol.). Gifford found that the white and
yellow cocci, as well as the bacilli anthrax,
were killed in exposures of from f to H
minutes. It required but f minute to de-
stroy fully developed anthrax spores. He
further found that the solution exposed
for 40 days, to a temperature of 68-75°

1C. E. Shelley, Practitioner, Lond., 1884, vol.
XXXII, p. 196.

2W. D. Bizett, Atlanta M. and S. Journal, 1888-9,
N. S.

4H. Gifford, Med. Rec, N. Y. 1888, vol. XXXIV,
p. 243.

killed the yellow pus cocci in from 10-11
minutes. The same solution of peroxide,
when diluted with four times its bulk,
requires an exposure of 30 minutes to kill
the pus cocci. If diluted with an equal
volume, it kills within f minute. After
an experience of six months, J. N. Love1
sums up the action of hydrogen peroxide as
follows: It is a most efficient means of
cleansing purulent surfaces, deep cavities,
and sinuses, stimulating the healthy proc-
ess in ulcerating parts. As a destroyer of
microbes, a cleanser and securer of comfort,
it is of great value as a local application.

My own experience with this drug in
surgical affections, during the past ten
months, has been most satisfactory. During
that time I have used the remedy in the
following affections : Abscesses (acute and
chronic, of various kinds), suppurating
glands, sloughing gangrenous wounds, em-
pyema of the chest, necrosis (general and
localized), suppurative otitis media, and
wounds of all descriptions. The ages of the
cases treated, varied from two to thirteen
years. The mode of applying the peroxide
was as follows : All cavities, crevices, etc.,
were syringed with the bichloride of mercury
(1-2000, to 1-6000) and then carefully
cleansed with the hydrogen peroxide (Mar-
chand's).

At first one volume of this solution was
diluted with two to three times its bulk.
Later on, I used the full strength. The
first effect noticed after applying the per-
oxide, was the rapid oxidation of all
purulent or bloody material, which would
cause the distention of crevices, no matter
how minute with the oxygen, which was
eliminated as a frothy (often yellowish, de-
pending upon the quantity of pus present)
bubbling substance. After the oxidation
was completed, the wound was always left in
a clean, sweet condition, absolutely free
from pus. The wounds were then gently
dusted over with iodoform and the usual
antiseptic dressings of gauze, etc., were ap-
plied. On removal of the dressings, a few
days later, it was noticed that the wounds
were in almost every instance cleaner (es-
pecially marked in acute cases), more
healthy in appearance and with a decided
diminution in the quantity of pus secreted.
The thought being suggested, that possibly
the bichloride and not the peroxide was
instrumental in producing the favorable re-
sults noticed, I commenced a series of
control experiments. I would, at onedress-

ij. N. Love, Phila. Med. Times, 1887-8, vol.
XVIII, pp. 362-364.

584

Communications.

Vol. lxiv

ing, use simply the bichloride of mercury,
following this, at the next dressing, with the
peroxide. Thus making actual comparisons
in the same cases. After several alternate
dressings as above, I found without exception
that the hydrogen peroxide perceptably
diminished pus formation to a much greater
degree than simply the bichloride alone.

The belief that iodoform should not be
used in conjunction with the peroxide, for
fear of liberating free iodine, which, as a
direct irritant, would defeat the object in
view, is, I believe, erroneous. I found that
when a quantity of iodoform was placed in
a small receptacle covered with the peroxide
solution and then set aside for periods
varying from three hours to three days, on
being treated chemically for free iodine,
with the ordinary starch test, gave negative
results. Although one drop of a solution
of iodine, on being added to the same solu-
tions, gave a brilliant reaction on addition
of the starch.

In all cases in which the peroxide
was given a fair trial, I have observed a
direct healing effect upon the granulating
tissues. It is therefore evident that owing
to its oxidizing action on the pus and the
diminution of the purulent secretions after
its use, it does, either directly or indirectly,
cause a destructiou of the anthrax bacillus.
In concluding my article, I think from the
clinical as well as the experimental evidence
which has been deduced, we can safely sum
up the action of peroxide of hydrogen in
the treatment of surgical affections, as fol-
lows :

1. Hydrogen peroxide is a positive ger-
micide and a possible stimulant to granu-
lating tissues.

2. Owing to its especial property of
eliminating oxygen, it is of unparalleled
value in the distention of suppurating sinuses
and cavities, especially in the mastoid re-
gion or where it is almost impossible to
reach unhealthy surfaces by other means.

3. The diluted solution is perfectly harm-
less and can with safety be used in any
quantity.

4. The strong concentrated solution, syrupy
in consistence, is a direct irritant to all tissues
and should never be used.

5. It possesses healing and cleansing
qualities as well as those germicidal in
nature.

6. When exposed to light it loses strength ;
care should therefore be exercised in keep-
ing the bottles well stopped with rubber
corks, and in a cool, dry place.

7. Fibrin, cellular tissue and some metals,

instantly decompose it. In contact with
sugar and starch it eliminates carbon diox-
ide (C02). Albumen, gelatine, urea and
cutaneous tissues have no affect upon it,
while ammonia, aconite, tobacco and hy-
drocyanic acid increase its stability.

8. In washing suppurating surfaces, it
should be used until oxidation ceases, thus
showing a complete destruction of all exist-
ing purulent material.1

TETANY. 2

BY E. H. SMALL, M. D.,

PITTSBURGH.

On November 29th, 1890, I was called to
see M. B., a fat, healthy-looking, breast-fed
baby boy, aged 11 months. His hands and
feet were much swollen, oedematous, and of
a cyanotic tinge. His mother said that
they had been " spotted," i. e., ecchymotic,
before I had come. The fingers were
strongly flexed at the metacarpal phalangeal
joints, while the phalangeal joints were as
strongly extended. The thumbs were ad-
ducted and flexed. The feet were extended
at the ankles as in talipes equinus, while the
toes were strongly flexed. Attempts to
straighten out these contractions caused
great pain. The mother said that at first
the child cried a good deal and that his
hands. and feet were tender and painful. So
much were the hands and feet, particularly
the dorsal surface, swollen, that I suspected
nephritis. The urine, however, contained
no albumen. The chiid had always been
strong and healthy, having had no other
sickness.

Two days before, Thanksgiving, the child
had been given some turkey and cranberries
to eat, which had caused indigestion. When
I called he had had no satisfactory move-
ment of the bowels for some time. I gave
him two one-half grain doses of calomel one
hour apart, and twenty drops of the elixir
of bromide of potassium four times daily,
and told the mother to rub his hands and
feet with alcohol and water. The next day
he was much better. I directed hot fomen-
tations to be applied to the hands and feet
instead of the rubbing with alcohol and
water. In a week the child was about as
well as usual.

1 Read before the D. Hayes Agnew Surgical Society
of the undergraduates of the Medical Department of
the University of Pa., February, 1891.

2 Read before the Allegheny County Medical
Society, March 17, 1891.

May 1 6, 1891.

Communications.

585

Four weeks before his gums had been
scored by another doctor. A few days be-
fore my visit, the two first teeth had ap-
peared, i. e.y at eleven months. The anterior
fontanel was larger than normal for his age,
and the costo-chondral articulations were
rather more prominent than normal. He
has an older brother and sister who are per-
fectly healthy.

When I first saw this case, I thought it to
be one of tetany, and its course and termi-
nation have proved it to have been such. I
had never before seen this disease in a child,
but had seen one case in Vienna in a preg-
nant woman.

Although this disease has doubtless
always existed, and although it was de-
scribed as far back as 1831 by a French-
man, M. Dance, as occurring in an adult,
and in 1832 by another Frenchman, M.
Tonnele, as a new convulsive disease of
childhood, yet it is but seldom mentioned in
the more common medical text-books. The
name tetany was first given it by Dr. Cor-
visart, in 1851. Dunglison's Dictionary,
1874, speaks of " Tetanilla " diminutive of
tetanus, saying that this disease is also
called tetany.

Dr. Smith, of New York, defines it as "a
disease in which there is a tonic contraction
of the muscles, commonly those of the ex-
tremities, but sometimes also those of the
face or trunk, produced by causes external
to the nervous system, and usually of tempo-
rary duration." This definition shuts out
true muscular contractions arising from dis-
ease of the brain or spinal cord, in which
the contractions are both but a symptom,
and not the disease itself. Henoch describes
it under the name of " Idiopathischen con-
tracturen " and regards it as a kind of abor-
tive form of convulsions. Dr. Cherdle, of
London, says, " Laryngismus, tetany and
general convulsions are the positive, com-
parative and superlative of the convulsive
state in childhood."

Causes : Cases are recorded between the
ages of six months and sixty-one years.
Most cases occur in infancy and childhood ;
more in males than in females. The most
common cause seems to be disorders of the
digestive system, as diarrhoea, habitual con-
stipation, wrorms, and dentition. Charles
Warrington Earle, of Chicago, gives a case
of a healthy girl two and one-half years old,
in whom tetany occurred on the day after
she had eaten heartily of fried potatoes.
Perhaps my case was caused by the turkey
and cranberry sauce of Thanksgiving, two
days before.

It may arise in persons who are in poor
health from other diseases, as pneumonia,
bronchitis, cholera, typhoid fever and dysen-
tery. Exposure to wet and cold has seemed to
cause it. Hence, some think it a rheumatic
affection. Erb says : " Many physicians
have regarded it as an exquisite example of
rheumatic disease." In adults, commencing
puberty, pregnancy, as in the case I saw in
Vienna, and nursing, may cause it. Rha-
chitis is also regarded as a cause, which may
hold in my. case, on account of the delayed
dentition, large size of fontanel and en-
larged articulations.

Symptoms : In patients old enough to de-
scribe their symptoms, tetany begins with
pain in the head and an uneasy, tingling,
burning sensation in the limbs. In children,
the objective symptoms are those first no-
ticed. The peculiar shape of the hands and
feet, their rigidity, and pain on pressure are
the commonest symptoms. Generally the
fingers and toes are flexed on the palms and
soles, occasionally extended. At times the
joints of the hands and feet are also affected,
or the elbow-joint — so that the fore-arm ap-
pears flexed upon the humerus, the hands
upon the fore-arm, and the foot upwards, or
else toward the sole. The thighs may be
adducted, or flexed, the legs extended or
flexed, and the feet extended as in talipes
equinus. The contractions are always bilat-
eral and symmetrical. Attempts to
straighten out the contractions cause pain.
CEdema, with a cyanotic tinge of the back
of the hands and feet and.occasionally ecchy-
moses, produced according to Henoch, by
the pressure of the contracting muscles on
the intermuscular veins, is oft-times present.
In severe cases the muscles of the trunk and
head may be affected, but this is rare in
children. Trousseau's sign — compression of
the artery and nerve supplying the con-
contracted muscles increasing the contrac-
tions— can be sometimes observed. The
electrical excitability of the nerve supplying
the affected muscles is increased, as is also
the patellar reflex.

Diagnosis : This may be made out by the
peculiar grouping of the symptoms, the char-
acteristic position of the extremities, and the
absence of cerebral and general disturbances.
Tetanus neonatorum and organic disease of
the brain and spinal cord are the principal
diseases with which it may be confounded.
Tetanus generally occurs within a few days
after birth, almost never after the first month ;
tetany is very rare under the age of one
month. In tetanus the muscles of mastica-
tion are early affected ; in tetany the con-

586

Society Reports.

Vol. lxiv

tractions begin in the extremities, and the
muscles of mastication are never, or only in
the last stages, affected. In tetanus the
symptoms tend rapidly to become worse and
worse, generally ending in death ; in tetany
as a rule, the child is soon well. Tetanus is
in some way connected with injury to the
umbilicus, or umbilical cord ; in tetany,
trauma has nothing to do with the case. In
organic diseases of the brain the contractions
are usually limited to one side, with other
symptoms of brain involvement ; in tetany
the contractions are bi-lateral.

Prognosis : In children, tetany, when un-
complicated by grave disease causing it, al-
most always ends in recovery, though it may
recur. The duration is from a few days to
several weeks or months — indefinite.

Pathology : Since tetany in children is so
rarely fatal, and then usually from the com-
plicating or causative disease, but few autop-
sies have been made, and in these no lesions
have been found which seem to bear a causal
relation to the disease. Herz says that clin-
ical phenomena indicate that the disease is
due to ansemia of the cord.

Treatment : When the cause is known,
especially when from diseases of the diges-
tive system, its removal will soon be followed
by the disappearance of the disease. Bro-
mide of potassium in doses according to age
should be used. Chloral and calabar bean
are recommended. Envelope the hands and
feet in hot fomentations, or use massage with
alcohol and water. A child of fifteen months
recovered in one week on gr. \ zinc sulphate
and gr. t¥2 atrophia sulphate, thrice daily.
This is all that is necessary in children. In
adults, canabis indica and morphia hypoder-
mically have been used with good results. —
(For discussion see page 587.)

Society Reports.

ALLEGHENY COUNTY MEDICAL SOCIETY.1

BY W. C. BANE, M. D.

CHLORATE OF POTASSIUM IN PHLYCTENULAR ULCER-
ATION OF THE CORNEA.

It is almost a century since chlorate of
potassium was brought to the notice of the
medical profession as a remedial agent. In
1795 Dr. Garnet,2 of England, used it in the
treatment of disease. At one time it was
lauded as almost a specific in many of the

i Scientific Meeting, March 17th, 1891.
2Duncan's Annals of Med., p. 1797.

maladies to which mortal man is heir. How-
ever, years of clinical experience determined
its real value, and it was assigned a place
among the topical remedies. Though valu-
able when administered internally, in some
conditions of the system, it has its deleterious
effects,1 having already caused 47 deaths.2
Its therapeutic properties may be stated
generally as those suggested by its chemical
constitution and affinities, as a salt excep-
sionally rich in oxygen, it has without de-
composition, the valuable property, per se
by its mere presence apparently, of oxygen-
ating or aerating the blood, and by so re-
storing or exalting this inherent quality of
the circulating fluid, influencing to a corre-
sponding degree nutrition and functional
activity of the various tissues and organs of
the body.3

In ulcerative diseases chlorate of po-
tassium has been thoroughly tested during
the past 40 years both internally and locally.
Under Therapeutics, in the North Am. Med-
ico- Chirug. Review tor March 1858, p. 387,
Dr. Dethan regards chlorate of potash " as
an especial and incontestible remedy in ul-
cero -membranous stomatitis. ... its topical
application is sufficient, and in a short time
the mucous membrane recovers its normal
qualities and functions."

Dr. Gallaher, of Pittsburg,4 lauded chlo-
rate of potash in mercurial stomatitis, stat-
ing that, should there be ulceration of
any portion of the mucous membrane of the
mouth, I direct a weak solution of the salt
to be applied to the denuded part several
times a day ; generally nothing else is re-
quired, the cure being accomplished in a few
days." As a local application in ulcers of
the lower bowel chlorate of potassium in
solution gives excellent results, the ulcers
healing rapidly.

I presume chlorate of potassium has fre-
quently been used as a local application in
diseases of the eyes, but I have only found
one record, that of Dr. Landesberg, of Phila-
delphia, using it as a topical application in
epithelioma of the eye-lids.5

Ulcers of the cornea, especially the phlyc-
tenular variety, are frequently met with,
usually developing as a little papule or pus-
tule on or near the margin of the cornea.
They may develop independently or as a

iBartholow's Mat. Med., 4th Ed., p. 183.

2Dr. Coghill, Trans. Ninth Internat. Med. Cong.,
p. 26.

3 Dr. Coghill, Trans. Ninth Internat. Med. Cong.,
p. 31.

^Am. Journal Med. Science, July, 1857.
s Medical Record, 1882, p. 674.

May 1 6, 1891. Society

Reports.

5^7

complication of some existing ophthalmia or
catarrhal affection of the nares. A large
percentage of the cases are strumous or
scrofulous, consequently suffer from nasal
catarrh.

The symptoms may vary as to their in-
tensity, but we usually find photophobia,
congestion and pain. The variation in the
symptoms being influenced by the number
of phlyctenules and the constitution of the
patient. Constitutional treatment and regu-
lation of the diet, etc., is invariably needed.

The first use I made of chlorate of po-
tassium as a local remedy in ulcers of the
cornea was in a case of serpiginous ulcer in
Jan. 1882. Case— Mrs. S. C. H., aet. 50,
constitution feeble. Having exposed herself
in doing some out-door work while the
weatner was rough, that developed an ulcer
in the upper, outer quadrant of the right
cornea. When I first examined the eye the
ulcer was about 2x3 mm. in size. There
was photophobia, congestion of the con-
junctiva and subjacent tissues; eye-ball,
right side of the face and head painful, con-
stitutional remedies prescribed. Locally
atropia and weak solution of biborate of
soda. One week later the ulcer had doubled
in size and depth. Atropia acted as an
irritant, morphia disagreed, they were both
discontinued. As chlorate of patassium had
served me well in ulcers of other portions of
the body, I determined to test it on the
corneal ulcer, and so directed a 5-grain
solution to be instilled in the eye, as warm
as could be borne, 3 or 4 times daily. From
the time the chlorate was used the ulcer
began to heal. Owing to loss of tissue there
remained an opacity. Instead of the mor-
phia the patient was given hydrate of chloral,
with bromide of potassium, though chloral,
when administered internally, acts as an
irritant to the eyes in some cases, in this
case it did not.

During the past five years of special prac-
tice, nearly four years of which I have had
charge of the eye and ear department of the
dispensary of the Western Pennsylvania
Medical College, some 56 cases of ulcer of
the cornea have come under my care.
About two-thirds of these cases were of the
phlyctenular variety. The chlorate has
rendered good service in different forms of
ulcers of the cornea, but rather better in the
phlyctenular than in the other varieties.
Not all of these cases were treated with the
chlorate, as in some the washed mild chlo-
ride was applied, in others the ointment of
the yellow oxide of mercury, and in a few a
weak solution of the bichloride of mercury.

In the limited experience I have had in
the treatment of corneal ulcers and the use
of the above remedial agents, my convictions
are that the chlorate in about 5-grain solu-
tion, used quite warm 3 or 4 times daily is
the most soothing, and heals the ulcers more
rapidly than any of the other agents tested.
True, the warm water itself is of great ad-
vantage, but the chlorate is a valuable addi-
tion on account of its antiseptic action. It
does not prevent bacterial evolution, but it
does retard chemical decomposition of or-
ganic fluids.

Dr. Lippincott : I never use chlorate of
potassium in such cases. We have so many
old remedies which will answer the purpose.
I have found in my experience, that the di-
rect application of very hot water to the
cornea is a good thing in these ulcers. The
one class to which the doctor refers, generally
extremely obstinate, I have treated by the
direct application of water at a boiling tem-
perature or steaming. I put a drop of water
directly on the exposed cornea so that it
steams as it comes out. One drop of the
water touches the ulcer, and the effect is
marvelous in some cases. The first case I
tried it in was a little boy, aged about six
years, who had been under treatment for a
good while. Treatment had been followed
for about three weeks without any material
change for the better, and it occurred to me
one day to apply the hot water in that way.
Before that time could get no dilatation,
none whatever, but after the first effort with
hot water, the pupil dilated very widely in-
deed. A good recovery was made. Heat is
applied constantly of course, but this was a
new application of heat. This hot wTater
treatment, it seems to me, is milder than ap-
plying a red hot iron to the ulcer. It seems
to destroy less tissues than the hot iron, and
it certainly answers the purpose in so far as
my experience has gone.

Dr. Bane : I simply wanted to bring this
matter out. Hot water is certainly bene-
ficial as Dr. Lippincott has stated, but it
seemed to me that the chlorate shows an ad-
vantage, at least it has done so in my expe-
rience.

Paper by Dr. Small. See page 584.

Dr. Lange: I once saw a tetany follow
diphtheria at the time paralysis usually fol-
lows. The description Dr. Small has given
of his case, fits mine exactly. Tonic contrac-
tions of the muscle, lasting in my case ten
days. The dorso-cervical muscles were not
involved in my case, neither were the muscles
of the lower jaw, and the clinical picture as
a whole is different from tetanus. At that

588

Society

Reports.

Vol. lxiv

time I had not been enlightened by Dr.
Small's researches, and scribed this to some
obscure nervous affection. I am glad to have
heard Dr. Small's pathology, and merely
mention my case as his etiology did not in-
clude diphtheria. Tetany in the infant is
not a very rare disease; it is however in the
adult. I do not remember having seen it in
an adult. The symptoms given by the doctor
correspond to the symptoms in my case.
These cases generally recover without treat-
ment.

Dr. Green: At the present time I have
in charge a case or two of tetany, and one
has been going on a full week. In the first
instance, when I was called to see it, they re-
ported that the child had convulsions. The
child is 19 months old. There were no con-
vulsions and no indications of convulsions
having taken place. None of the usual symp-
toms that follow convulsions. I did not dis-
cover any peculiarity at that time in regard
to the muscular contractions. I saw the
case again in two days ; at that time the dis-
coloration of the hands and feet was wrell
marked. Very tender on pressure, a case
that might well be mistaken for rheumatism.
The general condition of this child, when I
saw her, was slight congestion of the lungs
with slight bronchitis, and I discovered after-
ward that there was some derangement of
the stomach. I used an injection of warm
water, and when the matter had passed from
the bowels, there was a considerable number
of pieces of potato that had been fried be-
fore taken into the stomach. I think my
case corresponds almost exactly with the
case that Dr. Small has described. On my
first visit, I regarded it as tetany, although
I was not able to make a diagnosis. The
case was well marked latterly.

Dr. Rigg : I would like to ask a question :
Whether the doctor has observed any special
contraction of the muscles with reference to
the epidemic that has been prevailing for
the last year or two? I refer to the epidemic
called grip. There has been in my hands
quite a good deal of contraction of the mus-
cles, especially of the limbs, so much so that
persons have been unable to relax themselves,
and would generally require a quarter of a
grain of morphine, and I have had to repeat
that two or three times in an evening before
the muscles would relax so that the patient
could rest. I was very much pleased with
the doctor's paper, and the question came up
in my mind whether there might be some
connection between tetany and the influenza
of which I speak.

Dr. Ayres : This is certainly an . uncom-

mon disease. I have never seen a typical
case of it. The cases of Dr. Rigg are not
due to tetany, they are doubtless of a rheu-
matic character, caused by the cold or influ-
enza, and possibly Dr. Green's case is simi-
lar. In one respect, the doctor's does not
quite agree with the typical cases, and that
is, that it was of brief duration, about a week
if I remember aright. Tetany is paroxys-
mal, coming and going. If I understand
the doctor rightly, his case was just one of
tonic contraction, which relaxed and disap-
peared, and I believe there was no recur-
rence.

Dr. Stevenson: I think there are a
great many diseases that because they are
rare and infrequent are not much written of
or talked about. Now tetany is a disease
that has been very clearly before the pro-
fession for thirty years, yet the fact that per-
haps we do not see this disease and do not
hear it talked about, makes it seem like
something new. Some of the speakers have
got the idea that it occurs almost exclusively
in childhood. I think I will have to differ
from that, for Professor Trousseau, when he
first discussed the disease, described it as a
rheumatic contraction occurring in nursing
women. In his hospital he had seen a num-
ber of cases occurring in the nursing wards,
and he published a description of them.
The paper, as I understand it, did not ex-
actly describe the contraction as I under-
stand the disease. This contraction is a
spasmodic affair that comes on and may last
a few minutes and may last as long as twelve
hours, and relax and come again. A con-
traction that would last twelve hours would
be considered one of unusual duration.
Now then, the paper, as I understand the
question, describes the disease as terminat-
ing in a week. This is possible in a mild
case which may terminate within a week and
not return, though the rule is to have these
contractions repeated frequently during a
day or several days, if they are sick long
enough, in which the patient will seem well,
and the condition will occur and be repeated
again and again, and the whole duration of
the disease is very frequently several months.
I saw a case of this character twenty years
ago. It occurred in a pregnant woman.
She was ten years married ; she had given
birth to seven children, and as a result she
was very feeble and delicate, worn out, ex-
hausted by her frequently recurring preg-
nancies ; she was all the time either carry-
ing a baby or nursing one during these ten
years. In about the sixth month of her
pregnancy this condition occurred. She

May 1 6, 1891

Selected Formula.

589

got spasmodic contractions of the toes, and
then of the ankles, and by and by it involved
two fingers on each hand and the thumb.
She would sometimes have these paroxysms
come on and last for an hour, and relax for a
time, and come again probably for a week,
then perhaps for a week or ten days she
would be wholly clear of the spasms, then
they would recur again, and this condition
contined until after she was delivered of her
child. I saw another case of tetany in a boy,
a colored boy, who lived in a rather destitute
condition ; the family were exceedingly
poor, and lived in a stable simply weather-
boarded with no internal lining. They had
few bed-clothes and were scarce of food.
This boy was driving a wagon and doing
chores of different kinds through the town ;
he was aged about sixteen years. He drove
a milk wagon and was out in very severe
weather, and only partially clothed. I think
the privation and the cold he was subjected
to at home and outside, brought on this te-
tany. He had contractions of his hands and
of his feet and contraction of the abdominal
muscles and the diaphragm, and he died.
He had no lock jaw, he had none of that
sensation around the chest that would indi-
cate tetanus, but this spasm of the diaphragm
occurred at intervals. He had one or two
slight attacks of it on the first day, he had
two or three slight attacks of it in the night,
and the next morning he had a severe attack
of the diaphragm and died.

Dr. Small : As I said in my paper, I do
not think this disease is mentioned in the
common medical text books. The most I
have read on it I have seen in the last two
or three years in the Archives of Pediatrics.
I presume that I so easily made out a diag-
nosis of this case, for the reason that in three
numbers of that journal, Dr. Smith, of New
York, published a very exhaustive article
on the subject, and he had some pictures, one
of which is almost precisely like the appear-
ance of my patient when I first saw her.
His article is very exhaustive, and it maybe
that he got it up simply as regards tetany in
children, and although this article I mention
speaks of it in a child, I think I mentioned
in several places in my paper as to symp-
toms in adults, although it was written with
a view of describing tetany in children. As
to duration, the gentlemen seem not to have
understood me rightly. I stated it may last
a week or a month or indefinitely. As to
diphtheria being the cause, as far as I have
observed, I have not seen that given as a
cause, nor have I seen influenza given.

Selected Formulae.

LOCAL ANESTHESIA FOR SLIGHT OPERA-
TIONS.

For operations upon small abscesses,
opening fistulous tracts, or removing super-
ficial growths, it is recommended that local
anaesthesia be secured by a spray of the fol-
lowing solution :

1^ Chloroform 10 parts

Sulphuric ether 15 "

Menthol 1 part. M.

The ansesthesia which is thus obtained
lasts from two to ten minutes.

— Lon. Med. Record.

POWDER FOR ACUTE ECZEMA.

La Semaine Medical gives the following
prescription of Alexinski for this condition :

IjkJ Oxide of Zinc 15 grains.

Subnitrate of bismuth 30 "

Powdered starch 1% drachms.

Powdered Lycopodium " "

This powder is to be dusted over the parts
which are affected, night and morning.

GARGLE FOR ACUTE TONSILLITIS.

Ammoniated tinct-l

cinchona.

Chlorate of potassium 2 "

Honey 6 "

Powdered gum arabic a sufficient quantity.
Distilled water enough to make 4 ounces.

From one-half to one teaspoonful of this
should be used as a gargle in a little water
every two or three hours. — Journal de Med-
ecine de Paris.

PRESCRIPTION FOR TETANUS.

La Semaine Medicale states thay Mayer
employs the following prescription in the
treatment of tetanus :

Hydrochlorate of morphine... % grain.

Chloral 15 grains.

Bromide of sodium 20 "

Make into one powder, which should be
wrapped in wax paper ; give from three to
six of these powders each day. — News.

INJECTION FOR TUBERCULAR DIAR-
RHOEA.

Ij^ Olive oil 6 drachms.

Guaiacol 10 drops.

Water .... 8 ounces.

r yelk of an egg.

— Journal de Medecine de Paris.

59o

Selected Formula.

Vol. lxiv

ANTISEPTIC GAUZE.

For plugging the uterus, Bar (La Pra-
tique Medicale, Feb. 17, 1891) has employed
with advantage a gauze medicated with
retinol iodoform. It is used as follows :
The gauze, after being boiled in strong car-
bolized water and well dried, is dipped in a
mixture, the formula of which is not yet
very precise ; but the one used in the ser-
vice of Bar consists of —

Retinol...

Wax

Iodoform.

drachms,
drachm,
drachms .

The employment of this mixture, as ap-
plied by means of the gauze, appears to pre-
sent unusual advantages. Tampons made
with gauze, prepared in this manner, are
especially useful, inasmuch as they are apt
to leave a good coating of iodoform upon the
vaginal or cervical service and thus assure
complete asepsis of the mucous membrane.

A GARGLE FOR THE RELIEF OF FCSTID
BREATH.

The Revue Generate de Clinique et de
Therapeutique gives the following prescrip-
tion for the relief of this condition :

J^k? Saccharine,

Salicylic acid,
Bicarbonate of Sodium

Alcohol i ounce.

Essence of peppermint 10 drops.

A teaspoonful of this is to be placed in a
wineglassful of hot water, and used as a gar-
gle, once or twice daily. — News.

FORMULA FOR DYSMENORRHEA.

Monin (27 Union Medicale, March 5,
1891) recommends the following for dys-
menorrhoea of chlorosis :

|-of each...;

5 grains.

R

Spirits of melissa.
Tincture of saffron.
Tincture of iodine

Z'.'.'.'.'. lof

:• I

each, 1% ounces.

Mix. Twelve drops daily, before each of
the two principal meals, for two months.

Every eight days, a warm bath, contain-
ing three and one-half ounces of chlorate of
ammonia.

A PLEASANT VEHICLE FOR CASTOR OIL.

The following mixture is recommended as
an efficient means of disguising the taste of
castor oil. The only disadvantage is its bulk
in proportion to the dose of oil administered.

R

Castor oil 30 parts

Bitter almonds 2 "

Sugar 30 "

Gum tragacanth y2 "

Orange flower water 10 "

Water 120 " M.

■American Druggist.

TOPICAL APPLICATION FOR NASAL

DIPHTHERIA.
Raulin recommends that the membrane
be detached by antiseptic irrigation and the
raw surfaces covered with the following :

Lactic acid gr. xxx

Carbolic acid gr. xlv

Pure glycerine one ounce.

— Revue Gen. de Clin, et de Therap.

ANTIPYRINE IN THE TREATMENT OF

GONORRHOEA.
In the Revue Generale.de Clinique et de
Therapeutique it is stated that Brindisi em-
ploys the following solution as an antiseptic
lotion in the treatment of gonorrhoea :

1^ Antipyrine 45 grains.

Sulphate of zinc 4 "

Rose water

of each 2 ounces.

Cherry-laurel water 1

Label, " To be used as an injection."

FEVER MIXTURE FOR CHILDREN.
The following is an excellent fever mixt-
ure for a child one year old :

I^k? Antipyrine .gr. viij.

Aq. cinnamomi

Syr. aurantii cort aa fSj.

M.^Sig. 5 j. every two hours until fever subsides.

The antipyrine being soluble, goes into
the circulation more rapidly than acetanilide,
and so breaks the fever sooner. — Hollopeter.

NUTRITIVE ENEMA.

Beef broth (fresh made) viii ounces.

Wine iv ounces.

Yolk of eggs ij ounces.

Dry pepsin .j. — iv drachm.

M. Sig. Inject as an enema, in small portions during 'the

R

day.

■M. Jaccouds.

DIPHTHERIA.

Andeer recommends the application every
hour or two, night and day, of the following :

Ijk; Resorcin, ....grain xlviij.

Glycerine fgi. M.

A spray of a five per cent, solution of the
drug should be used in the room and the
following administered internally :

1^ Resorcin grain x.

Syrup terebinth f3i. M.

S. A teaspoonful every three or four hours.

— Centralblatt f. d. Gesammte Therapie H.
9, 1890.

MIGRAINE.

The following powder is recommended in
La Med. Moderne for migraine :

R

Citrate of caffeine 1^ grain.

Phenacetin 2 grains.

Sugar of milk 4 grains. M.

To be repeated, if necessary, in two hours.

May 1 6, 1891.

Editorial.

59i

THE

MEDICAL AND SURGICAL

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^*Oicatioas intended for publication.

LEADING ARTICLE.

RETINOL: A NEW SOLVENT AND ANTI-
SEPTIC.

In several recent communications, Dr. F.
Vigier calls attention to retinol, which prom-
ises to be as valuable an addition to our
pharmacopsea as vaseline. This substance
was discovered by Pelletier and Walter in
1838, but remained without any special
medicinal application until 1890, when Bal-
zar used it successfully in the treatment of
blennorrhagia and in syphilitic and varicose
ulcers of the leg. His pupil, Barbier, con-
tinued his studies and made them a subject
of an inaugural thesis.

Retinol is prepared by the destructive dis-
tillation of rosin by heating rosin in an iron
retort. When rosin is thus acted upon
four principal bodies come off—retinpathe,

isomeric with toluene and benzoene, boiling
108° C ; retinyle, isomeric with cumene,
boiling at 150° C ; retinol, which boils at
238° C ; and metanaphthaline, isomeric with
naphthaline boiling at 235° C.

Retinol has a formula of C35 H16, a
density of 0.900, and is of a brown or yellow
color depending upon whether it is prepared
from brown or yellow rosin. Both possess
the same solvent and therapeutical proper-
ties, but the yellow preparation is preferable.
Retinol is of an oily consistence, greasy,
slightly bitter, of a slightly acid reaction due
to traces of pinic acid ; the odor is faint and
peculiar, approaching that of the fir tree ;
and it burns with a fuliginous flame.

The solvent power of this substance is re-
markable, and in addition to this it is unirri-
tating, antiseptic and desicative, and exhib-
its no tendency to become rancid or in any
way decompose. It is, therefore, singularly
adapted for a large number of pharmaceu-
tical purposes. Among the substances dis-
solved by it are : salol, 1-10 ; iodol, 1-50 ;
naphthol, 1-50 ; aristol, 1-50 ; camphor,
1-20 ; chrysophanic acid, 1-40 ; cocaine,
1-30 ; codeine, 1-40, and strychnine, 1-40.
It is mixable in all proportions with oil of
juniper, carbolic acid, turpentine, alcohol and
ether. Resorcin, if dissolved in glycerine, may
be mixed with retinol, and so may iodoform
if dissolved first in a little ether. Iodol is
dissolved but soon precipitates as a resinous
mass. Phosphorus is also dissolved and the
solution remains unchanged indefinitely.
Retinol mixes readily with fats, oils, vase-
line, lard, lanoline, glycerine, cocoa-butter,
etc., and is thus susceptible of use in the
preparation of a vast number of ointments.
In cases where a liquid is not undesirable,
retinol, owing to its antiseptic properties,
can with great advantage, replace these
bodies. Preparations can be made in the
form of ointments, solutions, capsules, etc.
Vigier exhibited to the Societe de Medecine
Practique capsules of retinol-salol, retinol-
creosote and pure retinol.

It has already afforded in therapeutics
most satisfactory results, and in a large
variety of diseases. Desarenes and Bar-

592

Correspondence.

Vol. Ixiv

bier have experienced great satisfaction
from its use in otology and rhinology,
more particularly in purulent otitis, and to
favor the expulsion of mucus and overcome
the nauseous odor in atrophic rhinitis. In
such cases it can be applied by injection,
with a brush, or on a wad. In gonorrhceal
vaginitis tampons soaked with retinol give
very quick results, and a cure within 12 or
15 days. In gonorrhoea in man the injec-
tion of retinol gives immediate relief and
acts on the discharge better and more rap-
idly than any other substance employed up
to this time. In both affections it acts as an
antiseptic and insulating body and is also
valuable because it causes no pain and is
well supported.

Phosphorated-retinol has been used with
great satisfaction in the treatment of cases in
which phosphorus was indicated. Vigier
refers to over two hundred observations
made by Kassowitz, in the treatment of
rachitis and scrofula; .and to cases of
anaemia, chlorosis, dysmenorrhoea, uterine
haemorrhages, muscular paralysis, pro-
gressive locomotor ataxia, neuralgias, neu-
roses, hysteria, glaucoma and zona, treated
by such men as Delpech, Curie, Gueneau de
Mussy, Brocq and Duhring.

Retinol-salol has been used in urinary dis-
eases ; retinol-creosote in bronchitis, phthisis,
etc. ; and pure retinol in gonorrhoea. In
opthalmology, Hubert has found it of great
usefulness, especially in gonorrhceal con-
junctivitis, and after injuries or operations.
As illustrations of desirable combinations,
the following are suggested :

Retinol 10 grams.

Lanoline 5 "

Bi-carbonate of Sodium. .0.5 "

Retinol 10 grams.

White Wax 4 grams.

Cocoa-butter 6 grams.

Retinol 8 grams.

Rosin 8 "

Lanoline 5 "

Retinol, 1

Rosin, > each... 5 grams.

Lanoline, J

The last is of very good consistency. To
these formulae may be added such other sub-
stances as may be indicated.

In diphtheria the following combination
may be employed as a topical application :

Ijk Retinol 15 grams.

Naphthol 1 gram.

Camphor 2 grams.

In blennnorrhagia in man it may be em-
ployed as an injection, associated with resor-
cine in the proportion of 3 to 100, and it may
also be administered in the form of capsules
alone, or in combination with salol, etc.

In diseases of the skin, as psoriasis, the fol-
lowing prescriptions have been found to be
good :

]J Retinol 20 grams.

Glycerole of starch„30 "

]J Oil of cade,) ,

Retinol, } e(lual Parls-

To stop itching this pomade is recom-
mended :

Jfy Naphthol B 5 grams.

Retinol 50 "

Soft soap 50 "

Prepared chalk 10 "

In conclusion, the following may be con-
sidered the chief points of recommendation
for this substance :

1. It possesses remarkable solvent powers ;
it is not altered by time or light ; it is an ex-
cellent and permanent antiseptic ; its local
application does not give rise to pain or
irritation ; it is very cheap ; and, finally, it
unites by solution or simple mixture with a
large number of the most important sub-
stances employed in therapeutics. These
certainly are sufficient to justifiy the belief
that retinol will soon render important and
extensive service as an antiseptic excipient.

Correspondence.

ELECTRICITY AND PELVIC SURGERY.

To the Editor :

Sir : — Dr. McMurtry's communication, in
your issue of April 25, pleases me. The re-
cent paper of Dr. Keith, of London, which
is commanding the respectful attention of
scientific men on both hemispheres, contains
a most suitable answer to these objections,
which, after all, are mere fragments of self-
delusion.

If electricity in the diseases of women
amounted to nothing, it would have been
moribund long ago. If electricity was not

May 1 6, 1891.

Periscope.

593

steadily gaining a strong following it would
not be met with such enmity by laparoto-
mists. If electricity had not already as-
sumed a place as the greatest of all conser-
vative measures in the treatment of pelvic
disease, it would not evoke such hostility
from those who fear that their own metier
may cease to exist from the encroachments
made upon it.

I reiterate, I have never seen a tumor
anatomically cured, but I am only one out
of many using electrical punctures. Dr.
Keith cures them, so does Marsey — are the
statements of these men to be sneered at by
those who advance statistics of successful
laparotomies and expect to be believed ?

I have never seen a peritonitis result from
a puncture, and I find that the records of
such results in the practices of competent
men are exceedingly rare, Competent men
have no such results, and hence, I repeat,
that all this furor about adhesions set up by
electricity, is " foolish talk," quite on a par
with the statement that " fibroids are caused
by electricity." And yet this strange path-
ological story formed the subject of a strange
address, not long ago, before an enlightened
body of medical men.

It is proven as clearly as any surgical
fact is proven :

1. That tumors have been anatomically
cured.

2. That all painful and dangerous symp-
toms have been arrested.

3. That tumors have been greatly dimin-
ished in size.

4. That many cases of salpingitis have
been permanently benefited.

The doctor stands on dangerous ground
when citing ectopic pregnancy as a shibbo-
leth of the laparotomist. The opinion of
able men, surgeons, too,and big ones, is evenly
divided as to the respective merits of elec-
tricity and the knife in the treatment of these
cases. So I reiterate, what is found written in
paragraph 2 of my letter, to which the doc-
tor makes reply. The doctor has seen bad
results following puncture — hence he con-
demns puncture.

I have seen deaths caused by laparotomy
— so has Doctor McMurtry. Shall we,
therefore, also condemn abdominal surgery?
Dr. McMurtry says, " the operation of the
removal of the uterine appendages arrests
haemorrhage and brings about atrophy of
the tumor in less extreme cases, and has a
mortality of only two-and-one-half per cent."

Electricity will do the same thing, without
endangering life — hence the mortality be-
comes almost criminal.

Why cut a woman up, if you can accom-
plish the same result, possibly a better one,
without this anatomical recreation ?

Incompetent men will practice electricity
and have bad results ; incompetent surgeons
make abdominal sections and have bad re-
sults— shall we say the fault is in the method ?
Horatio R. Bigelow.

Philadelphia.

PERISCOPE.

THERAPEUTICS.

THE INTERNAL USE OF MERCURY IN
BLENNORRHAGIC RHEUMATISM.

Morel Lavallee (Le Progres Medical,
April 11, 1891) reports to the Societe Fran-
caise de Dermatologie et de Syphiligraphie
two cases of blennorrhagia successfully treated
by the internal administration of mercury.
The first patient, suffering from blennorrhagic
arthropathy was only relieved by ordinary
treatment and by the medicinal waters of
Aix. He was cured only after the con-
comitant syphilitic manifestations were com-
bated by the action of protiodide of mercury
administered in pill form. The second case
was one of blennorrhagic rheumatism ac-
companied with muscular atrophy that had
resisted all other treatment, but was entirely
and rapidly cured by the internal use of
mercury. The action of the drug in such
cases must be determined by future re-
searches.

The same author referred to a case of
poisoning produced by the local application
of salol. A patient, with an external otitis
of syphilitic origin, introduced into the
auditory meatus a large quantity of salol.
On next day, pari passu, with the appear-
ance of serious constitutional phenomena, a
swelling of the auricle, accompanied with a
violet hue and vesicles, was noticed, followed
by an (edematous angina, resulting from a
propagation through the Eustachian tube.
The intense dyspnoea produced, was after-
wards checked through the influence of
emollients. Salol, though well borne by the
digestive canal, is, on the contrary, badly
tolerated when applied locally.

PATHOLOGY AND TREATMENT OF SYM-
PATHETIC OPHTHALMIA.

According to Abadie (Le Progres Medical,
April 11, 1891) who has contributed a
paper on the subject to the French Congress
of Surgery, sympathetic ophthalmia is a dis-

594

Periscope.

Vol. lxiv

ease of microbial origin. Following a trau-
matic injury the wounded eye becomes in-
fected. From the borders of the wound the
infection gradually gains entrance into the
deep parts, invading the optic nerve, the
chiasm and finally affecting the opposite eye.
Under such circumstances, the external
wound should be cauterized by means of a
galvano-cautery, and an injection made into
the vitreous of the diseased eye of one drop
of a solution of corrosive sublimate (1 to
1,000). After a few days this injection
should be repeated if necessary. By this
means we are able not only to arrest the de-
velopment of sympathetic opthalmia, but
also to avoid the certain loss of the wounded
eye. This treatment is especially applicable
in the recent forms ot sympathetic ophthal-
mia when the question of saving the primi-
tively wounded eye should be taken into
consideration. When, however, the ophthal-
mia is provoked by the existence of a pain-
ful stump, for example, then, the conserva-
tive treatment presents no advantages. In
such cases enucleation constitutes the best
treatment and should be preferred ; and here,
again, mercurial rubbings in large quantities
and prolonged for a considerable time,
should be associated with surgical interfer-
ence.

HOW TO APPLY SERUM INJECTIONS IN
THE TREATMENT OF TUBERCULAR
PHTHISIS.

Hericourt and Richet have observed that
the introduction of blood from an animal
refractory to tuberculosis, as the dog, into
the economy of one susceptible to the dis-
ease, tends to retard the development of the
malady. Lepine {Lyon Medical, March 1,
1891) has further studied the subject, and
from a series of experiments, especially as to
the method of making the injections, has ar-
rived at the following conclusions, which
have been communicated to the Soc. des Sci-
ences Medicales de Lyon : 1. The liquid
could not be introduced into the peritoneum,
owing to the difficulty of applying asepsis.
2. Other things being equal, injections of 2
or 3 kilogr. can be introduced. 3. The
serum, and not the blood, was the substance
injected as it is the serum which possesses
germicidal powers. 4. The serum of goat's
blood was employed in preference to that of
the dog, as that was less offensive to 'the
human blood-corpuscles. From 50 to 100
grammes, in divided doses, were injected
hypodermatically every two days. This
method was well borne by the patients.

ON SULPHATE OF ZINC IN DIPHTHERIA.

As an experiment, Dr. Kilmer added to a
gargle (an ordinary tumblerful of water)
about fifteen or twenty grains of sulphate of
zinc. Upon my visit the next day, my sur-
prise was great to find that about one-half
of the membrane (diphtheritic) had disap-
peared from a boy's throat, while the diph-
theritic membrane in his sister's throat had
enlarged to about half an inch in diameter,
and the throat in every way looked worse.
There was no sulphate of zinc in the girl's
gargle. The same treatment was continued
another twenty-four hours, at the expiration
of which time the exudate had entirely dis-
appeared from the boy's mouth and
throat, while in the girl's throat it had
again at least doubled in quantity, and the
general appearance of the throat was much
worse. Believing then that the zinc sul-
phate was entitled to credit for the boy's
rapidly improved condition, the girl was
supplied with a gargle identical with that
which the boy had been using, and twenty-
four hours later not only had the diph-
theritic membrane disappeared entirely, but
all the swelling and distress had gone also,
and both patients were now convalescent,
and speedily recovered. — Med. Record.

DANGERS OF SULPHONAL.

Although sulphonal is probably one of the
safest, as it is one of the most efficacious,
among the hypnotics recently introduced,
the series of cases published by Bresslauer
of Vienna show clearly that it has certain
dangers. The degree of peril is difficult to
estimate, as the patients were lunatics, and
were also apparently feeble ; but the fact is
significant that out of seventy-seven patients
who were treated with the drug, no less than
seven showed serious symptoms, and in five
of these there was a fatal termination. It
ought to be mentioned that the patients had
been taking the drug for a considerable
time in good doses, and had borne it well
until symptoms of disturbance set in, these
being great constipation, dark-brown urine,
slow, or in some cases rapid but feeble pulse,
discolored patches resembling purpura on
the limbs, and great prostration. In the.
cases which ended fatally the cause of death
was heart failure, with oedema of the lungs.
— Lancet.

THE ACTION OF HYDRASTIN UPON THE
VASCULAR SYSTEM AND THE UTERUS.

Authorities are divided upon the mode of
the action of hydrastin on the vascular sys-

May 16, 1891.

Periscope.

595

tern. Some have observed an increased
blood-pressure and slowing of the heart's
action, whilst others affirm that the drug
paralyzes the vascular system. The uterine
contractions provoked by hydrastin are due,
according to some, to the direct stimulation
of the muscles and of the cardiac nerves ;
according to others, to the stimulation of
the central nervous system. It was for this
reason that Serdsteff had undertaken new
experimental researches upon frogs (sixty-
two experiments) and upon warm-blooded
animals (fifty-seven experiments). These
are* the results obtained by this experi-
menter :

Given in a small dose hydrastin provoked,
in frogs and in warm-blooded animals, slow-
ing of the heart's movements, owing to a
stimulation of the inhibitory apparatus, both
peripheral and central. Small doses always
increased blood-pressure ; by larger doses it
was lowered.

These differences depended upon the state
of the vasomotor centre. Small doses were
not followed by convulsions, and did not
paralyze either the respiration or the heart.
He thinks, then, that if some observers have
verified the paralyzing action of hydrastin
upon the vascular system, it must be those
who have given larger doses of the remedy.
Kegarding the influence exercised by hy-
drastin upon the uterus, the voluntary or
rhythmic contractions of this organ would
be increased in their strength, their number,
and their duration.

Hydrastin does not act directly upon the
neuro-muscular apparatus of the uterus, but
indirectly by the intervention of the central
nervous system, and that very probably by
way of the vasomotors.

In sustaining these obtained results the
experimenter counsels the use of hydrastin
in all those cases of haemorrhage where it
would be, for one cause or another, unwise to
await strong contractions of the uterine
muscles, and where, it is of the greatest im-
portance to attack the bleeding through the
vessels of the uterus. — Les Nouveaux Re-
medes.

IODOFORM IN CHRONIC EYE CONDITIONS.

Dr. G. Walter Barr says : The use of
iodoform as a dry antiseptic dressing has
always had a tendency, in my hands, to pro-
duce exuberant granulations. This sugges-
ted the use of the same substance in cases
where it is desired to stimulate cell-growth,
and naturally some chronic conditions of the
eye offered an attractive field for investiga-
tion.

It seemed evident that to attain antisepsis
and the stimulating effect of the drug, seen
in open wounds, it must be continually kept
in contact with the part ; this ruled out of
the question the almost discarded use of
iodoform pencils as rapid, repeated applica-
tions; the pure iodoform is much too irri-
tating for use in the eye ; and an ointment
of proper strength best fulfils the conditions.
The strength of the ointment should vary
with the amount of stimulation desired
and the susceptibility of the eye, for there
is an individual factor of susceptibility which
is far from constant. From 1 to 5 grains of
iodoform to the ounce of vaseline has been
found most often of greatest use. En passant,
it is hard to find vaseline now which is free
from some irritating substance (probably
acid) left in it in the process of refining.
This applies to unguentum petrolei, under
whatever trade-marked name it is sold.

The first case in which I used the iodoform
ointment was a girl aged 15, who had barely
light perception in one eye and an anterior
staphyloma in the other. There had been
conjunctivitis from infancy, and the entire
cornea was opaque in the eye which did not
have the staphyloma. Before operating on
the latter, it was highly desirable to get the
best possible vision in the other eye. The
ordinary practice had been exhausted, and a
4-grain iodoform ointment was placed in
the eye three times a day. In a fortnight
the vision was perceptibly improved, and in
three months she could count fingers. This
eye never got much better, perhaps partly
due to a pathological condition of the optic
nerve from a long disuse — from early in-
fancy— although the cornea became grad-
ually clearer. The staphyloma was operated
upon, leaving a triangular piece of cornea,
about 1.5 millimetres in dimensions on each
side, and an iridectomy performed behind it.
The corneal remnant at once became opaque
in the process of healing ; there was total
blindness in the eye. A 4-grain iodoform
ointment was applied twice a day, sufficient
being placed on the everted upper lid to
last until the next application. In three
months the corneal remnant had so cleared
up that she could recognize faces in her
limited field of vision. I have never had
any but the most gratifying results in treat-
ing pannus, however deeply the cornea is
affected, by the use of iodoform ointment ;
the sight has not always been completely
restored in the worst cases, but vision has
been doubled or improved even more. The
length of the period of treatment seems to be
in direct ratio to the age of the pannus, but

596

Periscope.

Vol. lxiv

several mouths are nearly always required
in cases of long standing. The ointment
should be applied often enough to keep the
cornea constantly covered with it.

In trachoma, the efficacy of iodoform oint-
ment depends on the amount of stimulation
required and the strength of the ointment.
By varying the strength of the ointment, it
seems to me that greater nicety of effect can
be obtained than in any other way. Tra-
choma of years' standing with large granu-
lations, ' which are best adapted to the
compression treatment, quickly succumbs to
a 4-grain ointment, applied twice a day. In
trachoma and chronic conjunctivitis the
iodoform ointment may be used to advantage
in conjunction with other treatment, where
stimulation is not contra-indicated, by apply-
ing it at bed-time ; the result is a cessation
of the gummy or postulating condition of
the lids in the morning.

In indolent ulcers, the results have been
as encouraging as in pannus. Sometimes it
has been necessary to touch the ulcer with
cupric sulphate, but in two cases nothing
but the ointment was necessary. In all the
ulcer healed much more rapidly when the
iodoform ointment was used, and usually
without cicatricial cloudiness. Continued
use of the ointment soon removed all marks
of the ulcer and left the cornea perfectly
clear.

The above is a generalization of the re-
sults in over a hundred cases of trachoma
(mostly of very long standing), thirty cases
of pannus, and a dozen cases of corneal ulcer.
They seem to me to justify a further trial by
others. The points to be remembered are,
that much depends on a proper strength of
ointment in each case, and that it is not
adapted to acute conditions.

Regarding the modus operandi, those who
are not confirmed microbe maniacs will at-
tribute the action to the cell stimulation seen
in the use of iodoform in chronic ulcers and
like conditions. Of course, in trachoma and
chronic conjunctivitis, something may be
due to the antiseptic action of the iodoform,
but hardly in pannus, or, perhaps, in corneal
ulcer. — Ther. Gaz.

HYPERKINETIC ACTION OF CAFFEINE
IN LARGE DOSES.

In the section of Pharmacology of the
Tenth International Congress held at Ber-
lin, Dr. Petreskn, of Bukaresh, made an in-
teresting communication on the subject of
the hyperkinetic action of caffeine in large
doses. He prescribes the drug in . the fol-
lowing formulas :

J# Caffeine 1-0-2 0 gram.

Ag.melissae 140-0 "

Spiriti Vini

Syrupi simplicis....aa....30-0 "
M. Sig. One tablespoonful every half hour.

If necessary, this amount may again be
taken within twenty-four hours. The for-
mula for hypodermic injection of the drug
used by Dr. Petreskn is as follows :

Jjfc Caffeine

Natr. Salic, vel benzoica...aa...0'25 gram.
Ag. destill 1-0 "

The solution can be made with the aid of
heat, and the whole amount should be used
for one injection. In the majority of cases,
the author prefers to give the drug by the
mouth, never having observed any digestive
disturbances to follow its use. Subcuta-
neous injections were only resorted to in ex-
treme cases where an immediate action of
the drug was desirable, and in which other
injections were also called into use.

Petreskn classes caffeine among hyper-
kinetics of the greatest value for the nervous
and muscular systems ; it is also a stimulant
to the vagus, and its action is allied to digi-
talis in this respect. He has used the drug
successfully in typhoid fever, pneumonia,
acute articular rheumatism, erysipelas, in-
fluenza, measles and several cardiac affec-
tions. His experience lead him to the fol-
lowing conclusions :

1. 'The therapeutic dose of caffeine is from

2 to 4 grammes daily, by the mouth, or 2 to

3 grammes subcutaneously in doses of 0.25
every two hours.

2. Given in these doses, caffeine is a pow-
erful hyperkinetic both for the nervous and
muscular systems. The effect of such a dos-
age shows itself in a strengthening of the
cardiac contractions, together with a slight
acceleration, the pulse becomes fuller, Ihe
arterial tension increases, the temperature
decreases, diuresis increases, and the general
feelings of the patients are greatly improved..

3. By means of its hyperkinetic action on
the heart and vessels, caffeine becomes the
most valuable substitute for digitalis. In
certain cases caffeine is undoubtedly prefer-
able to digitalis, and for two important rea-
sons : first, its rapidity of action, especially
when given hypodermically, and secondly,,
on account of the absence of accumulative
effects, which permits of its continued use
for a long period.

4. Caffeine is invaluable in the treatment
of primary or consecutive heart failure. It
is also valuable in nervous prostration or in
congestive conditions in which the nerve

May 16, 1891.

Periscope.

597

entres are affected, and which are caused

y disease or intoxication.
5. The diuretic action peculiar to caffeine,
akes it valuable in the dropsies incident

0 heart failure, as well as those of a purely

enal origin. — Wiener Med. Presse.

HE TREATMENT OF PULMONARY TUBER-
CULOSIS BY HYPODERMIC INJEC-
TIONS OF IODOFORM.

Gavoy, in the Gazette Medicate de Paris,
etails his method of treating pulmonary
uberculosis with iodoform. Morning and
night, a hypodermic injection of 30 minims
of the solution, of 1 part to 100 of iodoform
in oil of sweet almond, is given.

No febrile reaction occurs, and the results
are very good. The cough diminishes rap-
idly, and the characteristic muco-purulent
catarrh first becomes more liquid and then
ceases. The character of the voice is also
improved, and the lungs become more per-
meable to the air. Inspiration is increased
in depth, and the rales become more moist.
Other symptoms showing the favorable in-
fluence of this treatment are a decrease
in the night-sweats and a renewal of the
appetite. The therapeutic influence of iodo-
form over carious bone and pus-corpuscles
seems to point to the fact that it exercises
an analogous action upon tubercular proc-
esses accompanied by resolution and necrosis
of the lung. — Med. News.

TREATMENT OF MALARIAL HEMATURIA.

Dr. B. W. Mason has treated five cases of
malarial hematuria, two of these cases were
very bad, one died, the other three cases
were seen early and all recovered.

One patient was a girl nine years old,
who had been having chills for more than
a year. Skin very yellow, pulse 135, tem-
perature 102, bowels had been moved by
a dose of salts, the bladder acting every
hour or two, passing dark blood. The child
complained of pain in head, back and bones
of lower extremities. She was vomiting al-
most incessantly, and the dyspnoea was so
great that she had to be raised to a sitting
posture and fanned frequently ; this was, to
him, an alarming symptom. He at once put
her upon one grain doses of calomel every
two hours until the bowels were acted upon ;
for the nausea gave Horsford's acid phos-
phate, which acted nicely. He gave tinct-
ure of iron three drops, Fowler's solution one
drop every two hours, and spirits turpentine
four drops every two hours. This treat-

ment was commenced Tuesday at 11 o'clock
A. M. At 8 o'clock P. M., the urine began
to look more natural, the skin to clear up,
the nausea to subside. The last trace of
blood in the urine disappeared at 9 o'clock
A. M. Wednesday. Not a trace was to be
discovered in discharge from the bladder
two hours later. The patient began to im-
prove and was discharged on Saturday, so
far recovered as to sit up a little. He left
a tonic for her and she made a quick and
nice recovery. He thinks the iron and arse-
nic treatment will do. — Atlanta Med. and
Surg. Jour.

TREATMENT OF BRIGHT'S DISEASE.

The Rev. de Clin, et Therap. publishes
the following methods for the treatment of
Bright's disease ;

(1.) Classic Method. — The climateric pre-
scription consisted in the avoidance of damp-
ness and sudden changes of temperature.
As to diet, rich or irritant articles of food
were avoided, as were also eggs. A pure or
mixed milk regime was followed, and such
articles as wine, whiskey, liquors and beer
were entirely prohibited.

(2.) Senator's Method. — All white meats
and pork are allowed, and the use of vege-
tables and starchy articles of food, fruits,
fats and milk advised. Senator also recom-
mends the employment of wine mixed with
water.

(3.) Semmola's Method. — The author ob-
serves the preceding treatment and besides
advises the employment of the following
solution to be given in the course of twenty-
four hours :

Iodide of potassium 15 grains.

Phosphate of sodium 30 grains.

Chloride of sodium 75 to 90 grains.

Water 20 ounces.

(4.) Bamberger s Method. — Besides a milk
diet, tonics and ferruginous remedies are
employed. The author highly recommends
the following preparations : (I) Pills of per-
chloride of iron. Of these pills three to six
are given per day. Each one contains :

Perchloride of iron l/3 of a grain.

Pulverized menyanthe (Buckbean)...% of a grain.
Extract of gentian, a sufficient quantity.

— Univ. Med. Mag.

MEDICINE.

SOME REASONS IN FAVOR OF THE NON-
SPECIFIC PROPERTIES OF GON-
OCOCCUS.

Erand, of Lyon (Le Progres Medical,
April 11, 1891) gives some reasons to sus-

598

Periscope.

Vol. lxiv

tain the non-specific properties of gonococ-
cus. According to the author, there exists
in the normal urethra, a diplococcus, which,
under the influence of coloring materials,
behaves like the so-called gonococcus. Both
secrete a diastase, which, injected into the
cellular tissue, produces no deleterious effects ;
but which, introduced into the testicle of an
animal, gives rise to orchitis, to a suppura-
tion of the vaginal sac, followed by atrophy
of the testicle. The interference of microbes
is not absolutely necessary for the produc-
tion of the suppuration. From a number of
experiments performed, to determine this
point of specificity in regard to gonococcus,
Erand concludes that it is the ground, so to
speak, and not a special property, upon
which the virulence of the so-called gonor-
rhoea! germ depends.

ALBUMINURIA IN BLENNORRHAGIA.

In a communication upon this subject,
presented to the Societe Fran, de Derm, et de
SyphiL, Balzer (Le Progres Medical,
April 11, 1891) has sustained that in acute
blennorrhagia, whether simple or complicated
with cystitis or orchitis, the co-existence of
albuminuria is frequent, generally in the
proportion of 12 per cent., although this
may be caused also by previously existing
complications. This albuminuria may as-
sume an intermittent type, and only lasts a
few days. In such condition, the balsamic
medication seems to exercise an unfavorable
action. It is possible that many of these
cases of albuminuria may be due to the ex-
istence of venal lesions, but they also form a
part of infectious processes. It is, therefore,
of the utmost importance to examine the
urine for albuminuria in all cases of blennor-
rhagia.

1'HE ASSOCIATION OF SYDENHAM'S CHO-
REA AND RYTHMICAL CHOREA IN
A HISTORICAL FEMALE.

J. Seglas {Le Bulletin Medical, April 12,
1891) reports to the Societe Medicale de Paris,
the case of a young girl, who, at fifteen
years of age, suffered the first stroke of
Sydenham's chorea. At nineteen she had a
second attack of the same malady. The
disorderly movements were general, but
most prominent on the left side of the body.
On this side the sensibility was diminished,
as shown by simple contact and even prick-
ing ; the same thing was noticed with regard
to muscular sense. There was a slight ova-
rian hypersthesia, but no symptoms of pre-
vious rheumatic nature were observed. The

heart was apparently intact. Two months
afterwards, the choreic movements, greatly
improved, were scarcely noticeable on the
left arm. It was noticed at the time that
these movements had changed in character :
they were no longer inco-ordinate but had
assumed a small rythmical amplitude, so to
speak. Eight days later, these movements
of the left arm exhibited the type of a mal-
leatory chorea. In the intervals, the patient
suffered from nerve crisis, such as left hemi-
anasthesia, ovarian hypersthesia and a pos-
sibility of being hypnotized.

To sum up, this patient was laboring un-
der Sydenham's chorea, accompanied with
some hysterical symptoms. Afterwards this
chorea was replaced by the rythmical form,
the hysteria becoming, at the same time, pro-
nounced. The author does not believe that
in this case we had to deal with two diseases,
but only with one affection, the hysteria
having assumed, successively, the two differ-
ent types of the original disease, that is,
that of Sydenham's and that of the rythmi-
cal chorea.

EFFECTS OF TUBERCULIN ON MONKEYS.

M. Henocqtje (Rev. de Ther. Med Chir.,
March 15, 1891) has recently tried the effect
of tuberculin in a monkey which presented
no symptoms of pulmonary phthisis. Two
days after the first injection the animal,
which had exhibited the characteristic re-
action, presented dullness and a few rales at
the right apex. After the third injection
the dullness was more marked on the right
side, and began to be perceptible at the left
apex. Soon all the symptoms of acute
phthisis manifested themselves with intense
fever, the animal dying ten days after the
last injection after losing a tenth of its weight
during that time. The total amount used
was 6 milligrammes of the diluted fluid.
On post-mortem examination, four tubercu-
lous nodules of the size of a pea were fouud
in the right lung, and caseous pneumonia
involving two-thirds of the organ in the left.
In both cases the tuberculous lesions were
surrounded by a zone of very intense red
hepatisation. Pieces of the caseous tissues
were injected into two guinea-pigs, in one
after mixture with sterilized water, in the
other with diluted tuberculin. Both animals
showed signs of cutaneous and glandular
tuberculosis. — Brit. Med. Jour.

Grass juice, and bottles of electricity, are
the agents which a Paris quack announces
as a certain cure for tuberculosis. — Exchange.

May 16, 1891.

Periscope.

599

CONTRIBUTION TO THE STUDY OF HYS-
TERICAL BLUE OZDEMA.

Dr. Emile Boix (Nouvelle Icon. Salpe-
triere) recently reported a case of this nature,
which is of much interest :

L. G., aged 35, cook, Dec. 13, 1890.
Headache, but no alcoholism in family. The
patient had incontinence ' of urine in bed
until he was 14 years old; had rheumatism
when in the army and twice erysipelas of
the face. This was his fourth attack of blue
oedema.

The patient is a blonde with blue eyes,
and a feminine expression. He says that
his natural disposition is very lively, but
that his present trouble has made him
melancholy.

Sensibility to the brush completely lost on
the right side ; sensibility to pain and heat
very much diminished. The anaesthetic
zone was more marked at the level of the
right scapula.

There was a concentric retraction of the
visual field on both sides, more marked in
the right eye. Eight, 55° on the outside,
40° on the nasal side ; a second examination
gave us 40° on the outside ; the left eye is
70° on the outside and normal on the nasal
side.

The. first thing observed was the exag-
gerated oedema of the patient's right hand.
It has the aspect of a total phlegmon of the
hand. The oedema occupies the whole hand,
but especially the dorsal aspect which is
enormous. The coloration of the hand is
habitually violaceous with deeply colored
places and others whiter ; it has the appear-
ance of marble. The cyanosis is much more
marked towards the end of the fingers, but
it varies very much in the course of the day,
without apparent regularity in its variations,
and without being altered by external in-
fluences ; the hand becoming dark-red .with
places more or less light, and cyanotic
points ; at other times very pale, at others
entirely cyanotic ; at other times it is rosy.
The position of the hand makes no difference
either in the oedema or in the coloration.

The tumor was hard, but the finger made
some depression, from which the swelling
recovered with great rapidity, the depressed
point being white and the coloration, violet
or red, being deepened after removal of the
pressure.

The affected (right hand) was colder than
the sound hand, the difference in tempera-
ture varying greatly. On Dec. 13, at night,
the temperature of the affected hand Avas
64° F., that of the sound hand being 81° F.

at the same time, On the afternoon, how-
ever, of the same day, the conditions varied,
the affected hand having registered 94° F.
and the sound hand 76° F. This elevation
of temperature was not accompanied with
any special redness. This elevation was but
for a short time ; an hour after we find the
right hand colder than the other. The pa-
tient called this a stroke of madness in his
hand.

The anaesthesia in the right hand was
absolute for all methods, even deep sensi-
bility was abolished. This anaesthesia was
arrested at the wrist-band. The prick of a
pin on the oedematous part produced a small
drop of black blood, but the flow did not
persist.

The arm-pit was the seat of an exag-
gerated secretion of sweat; in a few hours
the night shirt of the patient on that side
would be soaking to the waist.

If we analyze the stigmata presented by
L. we cannot have any doubt as to the exist-
ence of hysteria in man ; the narrowing of
the visual field and the ease with which
hypnotism can be produced show this.

In conclusion: the chief singularity we
observe was in the temperature of the pa-
tient's right hand; an extreme variation,
compared with the left hand, of 16.4°
(29.5° F.). It is true that this variation
was not produced at once under our eyes,
but we have had the man at our disposition
only three days. We intended to employ
various measures — such as the electric cur-
rent, etc., for the cure of our patient, and
we did, in fact, hypnotize him, hoping to get
some effect from suggestion. The next day,
however, L. insisted upon leaving the hos-
pital at once and would give no reason for
his departure.

We believe he was afraid that his oedema
would disappear — for we had given him
assurance that we were perfectly able to cure
him — and he would be deprived of an in-
firmity which rendered his entrance to a
hospital easy.

Two days after the above disappearance
he entered the Pitie, and we find, also, that
he has been in the Charite.

It is possible that L. can make his oedema
appear at will, as a patient of M. Fereol
can, who produces when he pleases various
imitations of diseases of the skin, such as
scarlatina, variola, etc., which mislead the
physicians.

L. did not stay long at the Pitie, he did
not think they showed enough solicitude for
his case there ; and that is worth something
as a hysteric note.

6oo Periscope. Vol. Ixiv

PATHOGENY OF DIABETES.

Bouchard has stated that there are no
fewer than twenty-seven theories of the cause
of diabetes. None are entirely satisfactory.
The most important fact discovered in recent
years is that diabetes follows extirpation of
the pancreas in animals (V. Mering and
Minkowski), and numerous clinical obser-
vers have since then noted pancreatic dis-
ease in conjunction with glycosuria. V.
Mering and Minkowski, with most praise-
worthy scientific reserve, have abstained from
formulating any theory to explain the un-
doubted fact they have put upon record, and
Lepine (Rev. Scientifigue, February 28, 1891)
has discovered an additional fact in relation
to pancreatic extirpation and diabetes,
which must be taken into account wThen the
true explanation of these phenomena is forth-
coming. Healthy blood possesses what he
terms glycolytic powers. Fresh blood con-
tains a certain percentage of sugar ; if the
same blood be allowed to stand at the body
temperature for an hour before it is exam-
ined, a very considerable portion (20 to 40
per cent.) of this sugar has disappeared.
This number (20 to 40) may be taken as the
glycolytic power of healthy blood. It is
considered that this sugar-destroying power
is due to a ferment present in the corpuscles,
but especially in the white corpuscles, as the
glycolytic power of the chyle is as great as
that of the blood, and the portions of the
blood richest in leucocytes are richest in the
ferment, which may be dissolved out from
them by salt solution. In cases of diabetes
the clycolytic power of the blood falls to 5,
2, or even 1. In animals without a pancreas
there is a similar drop. The pancreas thus
appears to be the chief source of the ferment.
Lepine believes that the activity of a pan-
creatic cell is bipolar ; by its internal ex-
tremity it pours the pancreatic juice into the
ducts of the organ, and by its basal ex-
tremity it pours into the venous blood and
lymph the glycolytic ferment. The absence
of diminution of the sugar-destroying power
of the blood dependent on pancreatic ex-
tirpation or disease is thus a factor, and per-
haps an important one, in the causation of
an over-abundance of sugar in the blood,
and will certainly have to be reckoned with
before the true pathogeny of diabetes is un-
derstood.— Brit. Med. Jour.

Dr. Caius, some four hundred years ago,
when an old man, tried to regain his youth
by sucking the breast of a woman.

SURGERY.

MICROCIDINE: A NEW ANTISEPTIC.

In representing Berlioz, of Grenoble,
Polaillon has presented to the Academie de
Medecine (Journal de Medicine de Paris,
April 12, 1891) an experimental and clini-
cal study of the new antiseptic : Mierocidine.
Berlioz believes that all the known antisep-
tics possess more or less disagreeable proper-
ties, and cannot be manipulated carefully
enough, owing to their insufficient solubility
in water ; they are such as the salts of mer-
cury, phenol, naphtol, thymol, salicylic
acid and boric acid.

He has thus found, from a research upon
the subject, a new medicament which, while
it possesses feeble toxic properties, is a true
caustic, perfectly soluble in water and has
no odor or taste. Such a drug is mieroci-
dine, a combination of naphtol and soda.

It destroys the staphylococcus alb us and
the microbes of anthrax in solutions of 0'20
grammes per 1000 ; it acts similarly on the
bacilli of Eberth and the baccillus coli-
communis in the strength of 0"25 grammes
per 1000. It also kills in the course of one
minute, in solutions of 5 grammes per 1000,
the microbes of saliva, of the pus of osteo-
myelitis and of puerperal septicaemia. Its
antiseptic power is ten times greater than
that of phenol, and twenty-eight that of
boric acid.

Its minimum fatal dose for rabbits and
guinea-pigs, is 0"164 grammes administered
intravenously and 0'35 grammes by hypo-
dermatic injection, per kilogramme of the
body-weight. It is, therefore, less toxic than
naphtol itself.

The solubility of mierocidine in water is
very pronounced ; one gramme of it is read-
ily dissolved in three cubic centimetres of
water. In ordinary therapeutics, and even
in very large doses, mierocidine does not
exercise a powerful caustic effect; it does
not irritate wounds, and as, on the other
hand, it has no odor, it may be employed
for toilet purposes. Neither has it any
deleterious action on surgical instruments
or on clothing.

Mierocidine lowers rapidly in animals
both normal and febrile temperatures, and
is eliminated by the kidneys, rendering the
urine non -putrefactive.

Mierocidine has been employed with suc-
cess in a large number of infected and sur-
gical wrounds. It may be used in solutions
varying from 5 to 3 parts per 1000.

May 1 6, 1891.

Periscope.

601

THE TREATMENT OF SYPHILIS.

The following is the therapeutic method
which I ordinarily employ in the treatment
of syphilis :

As I have already stated, I do not gener-
ally give mercury until the onset of the sec-
ondary symptoms, although I have care-
fully used the mild mercurial preparations
in the local treatment of the primary lesion.

According to the intensity of the phenom-
ena observed, I prescribe to the patient daily
mercurial rubbings, in doses varying from
two to four grammes (30 to 60 grains) for a
period of fifteen days ; then I allow the
patient to rest from two to three weeks, ac-
cording to the case, and I continue in this
manner during the first ten months.

In the course of the periods of treatment
and similarly during the intervals, I am
careful as regards the local treatment of
syphilides by means of the mild prepara-
tions of mercury. For cutaneous syphilides,
I employ the drug in the form of ointments,
solutions or lotions.

In certain forms of rebellious cutaneous
syphilides, I advise general baths, in each
of which may be put seven grammes (105
grains) of corrosive sublimate. It will be
unnecessary for me to say that I particu-
larly insist in the observance of mouth
hygiene, on cleanliness, general hygienic
measures, and that I always endeavor to
build up, as much as possible, the system of
my patient. In well-to-do cases, I advise a
sojourn in the country or by the sea-shore.

At the end of from six to ten months, I
do not prescribe the mercurial frictions for
a longer period than ten days, and I then
advise my patient an interval of repose vary-
ing from three to six weeks or even two
months, according to the case. This method
of treatment is followed to the end of the
first and during the second year of the
disease.

I am in the habit of administering sudor-
ifics, purgatives and out-door exercise, in
order to make the mercury, as it were, cir-
culate through the economy and thus avoid
cumulative effects. In exceptional cases,
where the patient suffers from persisting
headaches or pains in the bones (osteocoes),
and where the symptoms do not yield to
mercurial medication, I prescribe for the
time being, from two to three grammes (30
to 45 grains) of iodide of potassium in com-
bination with from fifty decigrammes to one
gramme (J\ to 15 grains) of bromide of
potassium.

From the end of the second year my
treatment varies greatly, according to the

case. If after a certain time the individual
is free from syphilitic troubles, I observe
the custom of ordering every three months,
and during a period of ten days, rubbings
of mercurial ointment two to three grammes
(30 to 45 grains), and for a few weeks after
the inunctions, I administer two to three
grammes of potassium iodide, generally after
the principal meal, or at night in a glass of
milk.

I need not say that when syphilitic phe-
nomena have manifested themselves, I have
resorted to a treatment sufficiently adequate
to combat the severity and duration of the
accidents observed. If at the beginning of
the third or fourth year, my patient remains
free from all syphilitic manifestations for
more than a year, I am in the habit, by
way of precaution, of prescribing twice a
year, that is, in the spring and fall, mercu-
rial rubbings for a period of ten days. One
month after this operation, I order my
patient to take, for a space of three weeks,
iodide of potassium in thirty grain (two
gramme) doses.

If he comes to me after the fourth year,
having apparently, for a long time, escaped
from syphilitic phenomena, I recommend,
by way of precaution, a continuance of the
same method of treatment ; but if there is
the least suspicion of any syphilitic phenom-
ena, I advise him to consult a specialist.

In a general way I try to avoid, as far as
possible, the pushing of the treatment by
mercury and potassium iodide, the effects of
which I have reason to fear. I have many
times seen alterations of the economy follow-
ing the abuse of these therapeutic agents,
and, as a consequence, serious neurasthenic
phenomena.

I have, likewise, often observed that these
neurasthenic symptoms, with or without the
presence of dilatation of the stomach, have
been mistaken for phenomena of cerebral or
cerebro-spinal syphilis. I have also noticed
that the continuance of this mercurial and
iodated treatment, which has been the very
cause of these nervous troubles, has gradually
increased the severity of these. Serious con-
sideration of the subject, at such moments,
has led me to make the following observa-
tions : An individual contracts syphilis. He
consults a syphilographer and is by this well
treated. Vexation, excesses, bad hygiene,
the abuse of mercurial and iodated prepara-
tions, all contribute to produce in the patient
the neurasthenic symptoms referred to, chief
among which are headache, vertigo, change
in the individual's character, and disordered
memory. Under such circumstances the

602

Periscope.

Vol. lxiv

physician is liable to diagnose the case as
one of cerebral syphilis. Once made, this
diagnosis is followed by a simple and natural
consequence. The specific treatment has
been insufficient, and, therefore, it is further
pushed. Iu spite, however, of this measure,
the nervous phenomena do not diminish ; on
the contrary, they are increased. The
patient again consults his physician and
this, in turn, increases the doses of the rem-
edies. Thus, the undue persistance of the
specific medication renders worse the neu-
rasthenic condition, a condition which has
been produced, in many cases, by the abuse
of such a treatment, an error of diagnosis,
and by the non-observance of the common
rules of hygiene.

I have at length treated of the danger re-
sulting from the abuse of the specific treat-
ment, and of the diagnosis of neurasthenia
which is frequently mistaken for cerebral
syphilis, chiefly because I am now author-
ized to say that I myself have, at some time,
labored under the same errors.

I have afterwards made up for my faults
in many instances where 1 have entirely
subdued neurasthenic phenomena by the
simple suppression of a specific treatment
instituted for a pretended cerebral syphilis.

Such are the principles which have guided
me. . *

I will conclude by saying that I do not
prescribe the internal administration of mer-
cury when I can use this remedy otherwise,
as that method, as has been shown by Jul-
lien, is more apt to produce digestive, and
hence, neurasthenic, disorders, than the ex-
ternal application of the remedy.

I employ the drug internally in those
cases where, owing to various causes, the
rubbings are repulsive ; in those, where it is
advisable to keep secret the ingestion of the
drug, as, for example, married women ; in
those that owing to an irritable skin, can
not tolerate the local applications (generally
this inconvenience can be avoided by em-
ploying mercurial ointment newly prepared
with fresh benzoated lard, cleansing the
part twelve hours after the application,
afterwards washing and powdering it) ; in
those where it is absolutely necessary to
conceal the treatment, and finally in those
cases that, like commercial travellers for
example, will not submit themselves to the
local use of the drug.

In regard to the hypodermatic injections
of the soluble or insoluble salts, I only em-
ploy them in hospital practice, especially in
the case of public women, since these, as a
general rule, do not take the medicament in

other forms prescribed. — Prof. H. Leloir, in
Journal de Medecine de Paris.

ZINC PASTE AS A DRESSING.

Drs. Cordua and Glum have experimented
with Unna's modified zinc pastes as a sur-
gical dressing (the thicker paste consists of
zinc oxide 10 parts, gelatine, glycerine and
water each 30 parts, and the thinner one, of
zinc oxide 10 parts, gelatine 20 parts, glyce-
rine 30 parts, and water 40 parts). They
found this application especially useful in
the treatment of granulating cavities and
wounds. After the skin has been disinfected
with a 1 to 2,000 sublimate solution and
dried, the paste, which has been warmed over
a water-bath, is applied in a broad streak
around the wound at a distance of 1 to 2
centimeters from the margins, with a thick
brush, and then a thick layer of iodoform
gauze is pressed with moderate firmness upon
the wound surface and the surrounding area
covered by the paste. According to the
situation of the wound, the layer of gauze
and surrounding skin may be brushed with
the thin zinc paste, and thus made to adhere
firmly, or the dressing may be secured by
one or two turns of a bandage, and the paste
applied over both. Immediately after, and
before the paste has become dry, its surface
is lightly covered with cotton, which will
thus prevent adherence of the clothing. In
this way a perfectly fixed dressing is ob-
tained, which has proved especially useful
on the neck, chest, shoulders, hips, the upper
third of the arm and thigh, where dressings
are usually retained with difficulty. In
cases of ulcers of the leg, after disinfection,
the sore is covered with iodoform gauze, and
the leg enveloped firmly in a mull bandage,
over which is applied a layer of paste and
then another bandage. This dressing may
be left in place for eight or more days. If
applied to hairy parts of the body the
hairs must be shaved off for a wide distance
around the wound. — Wiener Medizin Presse,
1 and 2, 1891.

ACETANILID FOR CHANCRE AND CHAN-
CROID.

The Journal de Medecine, January 25,
1891, states that Basilevitch reports in Nou-
■veaux Remedes, November, 1890, that
cicatrization took place in a short time as a
result of sprinkling acetanilid on the surface
of the ulcers in one case of chancre in a
woman and in two cases of chancroid in
men.

May 1 6, 1891: Periscope.

603

In these cases acetanilid has the advan-
tage over iodoform of being inodorous, and
that large doses do not give rise to toxic
manifestations. It is also less expensive
than iodoform — an important consideration,
especially in dispensary practice.

GYNECOLOGY.

SUBCUTANEOUS INJECTIONS OF ETHER
IN PUERPERAL ECLAMPSIA.

An interesting supplement to the treat-
ment of puerperal eclampsia, is offered by
Dr. Perron, and quoted in the Wiener Medi-
cinische Wachenschrift, April 12, 1891. The
case recorded was that of primipara, twenty
years old, who was seized with eclamptic
convulsions two hours after delivery. Chloral
in liberal doses, blood-letting, and even in-
halations of chloroform, had been tried with-
out avail. The convulsions, which had be-
gun at eight in the morning, continued with
unabating severity to return every half hour
until noon and then became almost unre-
mitting. The patient lay convulsed with
severe dyspnoea and deeply cyanosed, her
breathing was labored and stertorous, and
death was momentarily expected. Dr. Perrin
then injected subcutaneously a syringeful of
ether, and in a few minutes the respirations
became more regular and less labored.
Fifteen minutes later, another similar injec-
tion was made, and a third injection two
hours later. After the second injection the
convulsions ceased entirely, and the patient
made a speedy recovery. It is to be noted
that no albumen was found in the urine.

PORRO'S OPERATION: PUERPERAL HYS-
TERECTOMY.

Dr. Joseph Price, in the Annals of Gynec-
ology, calls attention to the present success
in supra-vaginal extra-peritoneal hysteroc-
tomy for fibroids which has greatly confirmed
our confidence in the Porro operation over
the Cesarean.

The present low mortality has induced
many operators to do the Porra— a com-
plete -and perfect operation and a wise prac-
tice— as it saves the patient from the risk of
a subsequent section, taking away from the
Cesarean section the most important factor
in its dangers — the succulent uterus with its
incision.

In his discussions on supra-vaginal hys-
terectomy, he has endeavored to show that
an uncomplicated operation of this sort, with

the extra-peritoneal treatment of the stump,
is, under the improved technique, an opera-
tion of comparatively little danger. He had
no deaths from this procedure in his last
forty consecutive cases, including two Por-
ros. The operation, in the hands of all
trained men, accords with my experience.

The complications of hysterectomy, when
no important viscus is involved and the ad-
hesions are simple, are not to be feared. In
the Cesarean section the danger of haemor-
rhage is ever present ; in the Porro opera-
tion the uterus is strangulated at once, thus
obviating this complication. The Porro
operation clearly has the advantage in these
essential points : first, in absence of danger
of haemorrhage from uterine incision ; second,
in the extra-peritoneal treatment of the cut
uterus; third, in the greater rapidity of
operation. The results in the Porro opera-
tion should surpass those of ordinary hys-
terectomy for the following reasons : first,
there are very rarelv adhesions unless elec-
tricity has been used ; second, there is no im-
plication of any important viscus, and, ac-
cordingly, less haemorrhage ; third, less
shock. In the Cesarean section the sutur-
ing of the uterus greatly prolongs the opera-
tion, making a time consideration that is one
of the most important in abdominal surgery.
The factors of uncertainty in the healing of
the uterine incision put our established ideas
of exact surgery at sea ; it is impossible to
put it at rest. The uterine tissue is not sta-
ble, but is undergoing metamorphoses and
degeneration ; in no other part of the
body do we find such a condition, creating
such dangers of leakage and consequent per-
itonitis. This is all done away with in the
extra-peritoneal treatment of the succulent
stump ; here the use of the serre-noeud is the
ideal treatment, as it can be contracted upon
the shrinking stump and haemorrhage ab-
solutely controlled.

Considering the sociological side of the
question : Have we a right to sterilize a
woman? We have not, if she is simply a
propagating organism. If we take a higher
view, she has the right to the best she can
attain to, physically as well as mentally and
morally. We should not leave her in jeop-
ardy from a future peril. Again, the chil-
dren from this class of women — deformed,
rachitic, illy developed — often die young,
and are at best but illy fitted for the battles
of life.

Nearly one-third of the inmates of the
New York hospitals are well able to pay for
medical attendance. — Ex.

604

Periscope.

Vol. lxiv

OBSTETRICS.

APPARENT GROWTH OF THE PLACENTA
AFTER LABOR.

Dr. W. P. Chunn related to the Gyn. and
Obs. Soc. of Bait., an instance of a patient
who was twenty-eight years old, and had
been married five years, She had had no
children at full term, but had had three
miscarriages. The first and second mis-
carriages occurred at about the fourth
month of gestation. The last miscarriage
occurred about May 10th, 1890. She
had missed one period, and believed herself
to be about six weeks pregnant. On the
10th of May she began to have bearing
down pains and haemorrhage with the ex-
pulsion of blood clots, lasting some three or
four days. Then the pains subsided, the
haemorrhage ceased and I regarded the
uterus as empty. On the 12th of June,
however, she was again seized with violent
pains, and during the night was delivered of
a placental mass larger than a man's fist,
which I saw the next morning ; the patient,
as well as myself, was surprised. The foetus
was searched for but no sign of it found.

THE POLYURIA OF PREGNANCY.

Dr. Voituriez (Arch, de Tocol., December,
1890) concludes, after a study of this sub-
ject, that, in the course of gestation, polyuria
of a type entirely confined to pregnancy is
sometimes observed. In such cases the
urine is clear, slightly acid, and of normal
composition, excepting that the proportion
of water is greatly increased, so that the
specific gravity is low. Sugar and albumen
are alike absent, and no cystitis is present
in cases of this affection. Polyuria of preg-
nancy is probably more common than is
generally believed. The only way of au-
thenticating a case is carefully to collect all
the urine passed every twenty-four hours.
The disorder is not usually detected until
the middle of the pregnancy. It rapidly
disappears after delivery. In nature it is
exceedingly mild, and it appears to endanger
neither the mother nor the child. Dr.
Voituriez describes a case where a pregnant
woman was compelled to make water over
twenty-four times in twenty-four hours,
passing over seven pints of urine daily. She
suffered from slight thirst, Yet she was
safely delivered of a living (first) child,
which weighed nine pounds. Tarnier's for-
ceps had to be used. Directly after delivery
polyuria ceased and never recurred. The
secretion of milk was normal. Bromides

and belladonna had been administered, but
proved useless. — Albany Med. Ann.

PAEDIATRICS.

SALICYLIC ACID FOR THE PREVENTION
OF SCARLET FEVER.

Sticker reports the observations of G. de
Rosa, who administered salicylic acid, in
doses of one to five grains daily, to sixty-six
children exposed to infection during an epi-
demic of scarlet fever. Twenty-seven cases
of the disease existed in the building, when
administration of the drug was commenced.
Only three of the sixty-six contracted the
disease, the failure in these being ascribed
to a longer exposure to infection. — Central-
blattfur klin. Med.

ANTIPYRETICS IN CHILDHOOD.

Demme (abstract in fherapeutuche Mon-
atshefte, Feb., 1891) believes that a moder-
ate elevation of temperature of a few days'
duration is best treated without any antipy-
retic drug. When, however, a temperature
of 104° F. is reached and maintained, these
drugs are of decided importance, as in
typhoid fever, rheumatism and broncho-
pneumonia. In diphtheria, the acute exan-
thems and croupous pneumonia, on the other
hand, they are to be avoided.

Salicylate of soda he employs in rheuma-
tism, in daily doses of 71 to 45 grains for
children of between 2 and 15 years ; and
salol in about the same doses. He recom-
mends thallin sulphate in typhoid fever in
doses of 7 to f grains for children from 3 to
15 years ; antipyrine in the first stage of
broncho-pneumonia in several hourly doses
of three to fifteen grains ; in later stages of
the same disease quinine in equal doses.
Acetanilide is efficient in the high tempera-
tures of pulmonary tuberculosis, one to three
times daily, in doses of f to 4£ grains.
Phenacetin, he thinks, is best given in sev-
eral full doses, such as H to 7i grains, ac-
cording to age. — Univ. Med. Mag.

TREATMENT OF CONVULSIONS IN CHIL-
DREN.

T. G. Davis recommends, if the patient is
cyanotic, a few whiffs of amyl-nitrite, fol-
lowed by inhalations of chloroform and
hypodermic injection of tincture veratrum
viride — one-half drop for each year up to
six years.

May 16, 1891.

Periscope.

605

HYGIENE.

A RETROSPECT OF THE SUCCESSIVE EPI-
DEMICS OF CHOLERA IN EUROPE
AND AMERICA FROM 1830
TO 1890.

Dr. Willoughby, in a paper before
the Epidem. Soc., after alluding to the
doctrine of epidemic influences, telluric and
atmospheric conditions, and other unknown
agencies as at one baseless and needless, and
to the opposite delusion, prevalent in the
south of Europe, of its being infectious in
the same sense as small-pox, asserted that
all the independent and scientific students
of the subject in Europe and America were
now agreed that the vehicle of contagion was
contained in the evacuations, that it was
thus carried by fomites as soiled clothing,
etc., while persons suffering from the disease,
even in unrecognized and mild forms, infec-
ted the soil and water of places through
which they passecf. Insanitary conditions
favored its development, but the most in-
sanitary towns — as Rome, Seville, and
others — had escaped, since they had been
provided with pure water supplies. The in-
cubation period he believed to be as a rule
from one to two days, four being an ample
limit for quarantine purposes. Its trans-
portability and conveyance wholly and solely
by human intercourse was proved not only
by the progress of every epidemic having
followed the great routes of trade and pil-
grimages, but by the rapidity of this progress
having corresponded to the facilities for
travel, whether by caravans, river boats,
railways, or ocean steamers, quoting in this
connection Dr. de Renzy and others as to
the altered corcumstances of travel in North-
ern India ; and he thus explained the im-
munity of Australia and Chili, virtually the
most isolated communities in the civilized
world. It was, he said, in 1821 that cholera,
so far as was known, first advanced from
India westward, reaching Astrakhan in 1823,
but subsiding until 1827, when a fresh wave
swept over Persia, entering Russia in 1 829.
In 1830-31 it was fomented by the war in
Poland ; in 1831-32 it spread over the whole
of Europe; and in 1832-33 over North
America, lingering in each continent for
about two years longer. It was remarkable,
and totally inconsistent with the theory of
conveyance by winds, that, though some
cases had occurred on board ships in the
Medway as early as July, 1831, it did not
reach London till February, 1832, having
effected a landing at Sunderland and travel-

led via Newcastle, Edinburgh, Glasgow,
Belfast, Dublin, and Cork, whence it was
at length brought to London. A wave rolled
over Persia, Arabia, and Syria between 1836
and 1839, but retired again. In 1840 it en-
tered China, then passed westward through
Central Asia, re-entering India from Afghan-
istan and through North Persia, reaching
the Caspian and Black Seas in the summer
of 1847. Following the military road then
in course of construction from the Caucasus
to Moscow and the river highway of the
Volga, it was intensified and spread by the
fair at Nijni Novgorod and the massing of the
Russian, Austrian and insurgent Hungarian
armies on the Danube, and in the course of
1848-49 had attacked every country in
Europe except Denmark and Greece, which
were saved by stringent quarantine. It ex-
tended to America in 1849, but died out in
the course of the following year. The epi-
demic of 1854 was not strictly a separate
invasion, but rather a resuscitation of the
last, which had lingered in the south and
east of Europe and the west of Asia until
called into fresh activity by the Crimean
war. Every country in Europe and America
was again invaded. The incidents of the
outbreaks in America threw great light on
the ' conveyance of the disease by fomites.
The epidemic of 1865-66, which was the
first to come wholly by the Red Sea, spread
rapidly over Europe and America ; but had
scarcely subsided when a fresh explosion oc-
curred at the Hurdwar fair in India in
1867, whence it was carried to Persia and
Russia, being reintensified en route by the
pilgrimage at Great Mesched in 1868 and
the fairs at Nijni Novgorod in 1869 and
1870.

At the close of the Franco-German war,
every country in Europe was attacked ex-
cept Great Britain, and America succeeded
in averting its importation until 1873. By
1874 it had, however, disappeared every-
where on this side of India. In 1881-83 it
prevailed in Arabia and Egypt ; in 1884 it
made its appearance in France, and soon
raged throughout Italy and Spain. The in-
fluence of pure water supplies was brought
into special prominence, not only in the
case of single towns in Italy and Spain, but
in the almost complete immunity enjoyed by
Germany, which had previously suffered
heavily in every epidemic. Cholera lingered
in the south until the end of 1885, since
which date it had been absent from the
continent of Europe until the isolated out-
break in Spain in 1890. This, Dr. Wil-
loughby was convinced, was not imported

6o6

News, and Miscellany.

Vol. Ixiv

from the East, but was a recrudescence of
the epidemic of 1884-85, brought about by
excavations in infected ground. Still cholera
had, since 1888, been slowly but^steadily ad-
vancing by the Persian Gulf and the exten-
sions of that route. It had last year reached
the shores of the Caspian and Black Seas,
and had raged at Mecca, though Egypt had
almost miraculously escaped, and it had
persisted at Aleppo and the Syrian ports
certainly as late as January of the present
year. He had little doubt that, as its march
had closely corresponded with that in 1845-
47 we might expect history to repeat itself
in an invasion of Southern and Eastern
Europe during the coming summer, unless,
as in 1823 and 1839, it should retire, after
having thus approacned the confines of
Europe. If, however, it had not already
really died out, the vast increase of com-
munication between the two continents ren-
dered such recession less probable than it was
fifty years ago. The paper was illustrated by
a number of maps showing the great routes
and the course of each epidemic in Asia, Eu-
rope and America. Sir W. Moore gave his
experience of an outbreak at Aden following
the unloading of a cargo which was proved
to have been soiled with cholera excreta at
Bombay, the crew remaining healthy ; and
Mr. Murphy alluded to Dr. Simpson's hav-
ing traced ' the occurrence of cholera on
board certain ships moored in the Hooghly
to an infected milk supply. Surgeon Daw-
son argued in favor of epidemic influences,
but Dr. Willoughby, in reply, urged that
in the case of the ships at sea quoted by Mr.
Lawson, the crews who must have been most
exposed to atmospheric influences escaped,
the steerage passengers only being attacked;
while such negative evidence as that of the
Southampton and Theydon Bois outbreaks
in 1865 was worth nothing. It was more
probable that some one suffering from mild
and unrecognized cholera had crossed over
from France, and, leaving the infection be-
hind, had perhaps returned, than that Mr.
Groombridge had inhaled it with the sea
.breezes on Weymouth pier. Such difficul-
ties were incident to all cases even of small-
pox, the source of which no one doubted.
The President complimented Dr. Wil-
loughby on having brought within the com-
pass of a single paper a mass of information
hitherto inacessible, and on having by his
demonstration of the almost " postal regular-
ity " with which the late epidemic followed
the routes of travel by road, rail and steam-
ships, regardless of prevailing winds, but re-
fusing to cross the Scandinavian and Carr

pathian mountain ranges in mid-winter,given
the coup de grace to the doctrine of atmos-
pheric waves, which, in the case of this dis-
ease, he had until that evening accepted. —
Lancet.

MEDICAL OHEMSTRY.

H^EMATO PORPHYRIN IN THE URINE.

A number of cases have recently been re-
corded in which the iron-free derivative of
haemoglobin, called hsematoporphyrin, has
been described in the urine. The first re-
corded observations of this occurrence were
made by MacMunn in J une last, and the
most recent, by Salkowski, are published in
the Centralb.f. d. med. Wiss., 1891, No. 8, p.
129. The three cases mentioned by Salkow-
ski were in women, and one case ended fa-
tally. The cause of the occurrence of this
abnormal substance in the urine is supposed
by Salkowski to be the administration of
sulphonal. This is, however, an abnormal
action of the drug, and therefore appear to
be due to individual idiosyncrasy.

TESTING FOR IRON IN ORGANS.

Zaleski (Die Vereinfachung von makro-
und mikrochem. Eisenreaction, Zeitsch. f.
phys. Chemie, xiv., p. 274, 1890) gives a
simple method for detecting histologically
the presence of iron in organs. Small pieces
of the organ are hardened first in 65 per
cent, alcohol, and then in 60 per cent, alco-
hol, to which a few drops of yellow ammo-
nium sulphide are added. In twenty-four
hours, if iron be present, the tissue has a
greenish appearance, and on making a sec-
tion the exact distribution of the particles
of iron sulphide is readily detected by the
color reaction.

NEWS AND MISCELLANY.

Experiments recently made in France
with a view to discovering the amount of
vitality in specimens of trichinae show that,
though they be subjected to a temperature
of 25° below zero for two hours, they again
become as lively as ever on a return of a
normal amount of light and heat.

The University of Bonn is stated by the
correspondents of the London papers to have
ordered that the use of the Koch injection
shall be discontinued in all the clinical hos-
pitals under its jurisdiction.

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No. 1786. PHILADELPHIA, MAY 23, 1891. Vol. LXIV.— No. 21.

Clinical Lecture.

CONVULSIONS DEPENDING ON RICKETS-
VARICELLA— SPECIMEN FROM A CASE
OF CEREBRO-SPINAL MEN-
INGITIS.

BY L. EMMET HOLT, M. D.,

PROFESSOR OF DISEASES OF CHILDREN AT THE N. Y.
POLYCLINIC, ETC.

CONVULSIONS DEPENDING ON RICKETS.

Gentlemen : — Our first patient this morning
is a little boy, six months old, who, his
mother states, was perfectly well until about
two months ago. Without any premonitory
symptoms he was then taken with general
convulsions, which were repeated during the
following twenty-four hours, the child pass-
ing, at short intervals, from one convulsion
into another. After this attack, he was ap-
parently well, until about two weeks later
when the same symptoms were repeated, the
second series of convulsions being more severe
than the first ones had been.

Ten days before he came here he had a
third series of convulsions, similar to those
which had preceded. The intervals between
these different attacks were, however, free
from symptoms of any kind, and since the
last attack he has been apparently well.

At first sight, this boy seems to be well
nourished and healthy ; he is plump and
weighs about 20 pounds, is not anaemic, holds
his head up, has no evidence of paralysis,
no fever, he is bright and apparently notices
everything. What causes of convulsions
are we to consider in such a case as this ?
Organic disease of the brain is apparently
excluded, first, because his symptoms were
not noticed until some months after birth,
and second, because the labor was a natural
one, no forceps were used, there is no rigidity
of the neck, no spasms of the extremities and
intellectually the child seems to be very
well developed. The probabilities are that

in a case like this the convulsions are of re-
flex origin, and the* first thing to suspect as
the source of such irritation in a child is the
gastro-intestinal canal. The mother states,
when questioned about this, that she now is
nursing her child exclusively, but that about
the time of the first attack of convulsions,
she gave him coffee, soup, toast, and some
other varieties of solid food. At the present
time, however, these have been discontinued
altogether. Could the same cause have been
operative in both instances, or are we to look
further for the cause of these convulsions ?

In many cases of convulsions in infancy
no cause can be found clinically, and the
convulsive habit becomes finally established,
the attacks recurring at shorter and shorter
intervals, until the patient passes into a stage
of confirmed epilepsy. Is this case to be
looked upon in such a light?

Constipation is another cause of convul-
sions in children, but the mother states that
this child's bowels have been always regular.

There is one strongly pre-disposing cause
to convulsions in infants, and one that must
never be overlooked by the physician, and
that cause is rickets. The nervous system
of young children is exceedingly prone to
convulsive attacks, and in rachitic children
this proneness is very much exaggerated.
Never permit a young child, after recurring
attacks of convulsions, to pass through your
hands without first of all making a careful
and exhaustive examination for the earlier
signs of rickets.

What signs are we to look for in a child
of this age? First, examine the head. What
do we find here? The head of this child is
of 'normal size, but the anterior fontanelle
measures two inches and a half in one diam-
eter by one inch and a half in the other.
The sutures have not united, and over the
posterior part of the parietal bone I can feel
several soft spots in the cranium about the
size of a nickel. These are spots of cranial
tabies, and are, of themselves, almost con-
clusive proof of rickets. Their position on
this part of the head shows that they have

607

608 Clinical

been produced by pressure, the osseous ele-
ments of the skull being here absorbed and
the membranous portions alone remaining
intact. The bony deformities, such as beaded
ribs, enlarged epiphyses, pigeon-breast, bow-
legs, etc., belong to a later period of this dis-
ease, and are not to be expected here.

One other point in the history should be
inquired into, namely, as to the presence of
head-sweats. The mother states, upon in-
quiry, that for several months past, while
the child has been asleep, she has noticed a
profuse perspiration of the head and neck,
sufficient to wet the pfllow considerably.
There seems, then, to be very little doubt
that this child who, upon first sight, seemed
so fat and healthy, is the subject of rickets.
Rickety children are often fat, but their tis-
sues are usually flabby. This child's tissues
are not especially so, nor is he anaemic. There
is to my mind no doubt that the underlying
and predisposing cause for the convulsive
seizures is rickets. In such children we find
that a very slight exciting cause is sufficient
to bring on attacks of convulsions, second
attacks always move easier than the first
ones, and subsequent attacks from still more
trivial causes. The exciting cause of the
first attack, I judge in this case, was the im-
proper food the mother gave the child, but
what the particular thing has been that has
excited the subsequent attacks, from the ab-
sence of details in the history of the case, I
am unable to say.

The treatment of convulsions in children
involves two distinct points : First, the
treatment of the seizures, and second, the
treatment of the child's general condition in
the intervals, in order to prevent subsequent
attacks. During the seizures, no single
remedy has been in my hands so successful
as the use of chloral by the rectum. To a
child of this age, that is six months old, it
is safe to give six grains as an initial dose,
and repeat this in half an hour, and again
at the end of an hour unless the attacks are
controlled in the meantime. It is to be
given preferably in warm milk, and we can
generally count upon producing an effect in
fifteen or twenty minutes after the adminis-
tration of the first dose. It is often neces-
sary to give chloroform for the first few
minutes, while waiting for the effect of the
chloral. Another valuable remedy in the
convulsions of children, is morphia given
hypodermically. There is a strong prejudice
in the minds of the profession against the
use of morphia in the case of young chil-
dren, but its injurious effects have been
owing to the overdose that has been adminis-

Lecture. Vol. lxiv

tered rather than to the use of the drug
itself. It is certainly a drug that we can ill
afford to do without in this connection.
One-eightieth of a grain . can be safely given
to a child as old as this one, and the dose
repeated in half an hour if no beneficial
effects are produced. It is always best in
giving morphine to children, to give small
doses repeatedly, rather than a single large
one at once. Ice, or iced cloths should also
be applied to the head, and the child kept
as quiet as possible during the attack. I
will say, in this connection, that I have seen
very little good result secured by the com-
monly employed treatment of mustard baths.
Harm is often done by the unnecessary dis-
turbances of the child. If constipation has
preceded the attack, or there is a history of
the child having eaten any indigestible
food, the colon should be irrigated in the
first instance, and in the second instance,
the stomach should be washed out, whatever
other methods you employ, for these pro-
cedures generally allay the attack. In the
interval, in ordinary cases, it is sufficient to
keep the child under the influence of the
bromides for several weeks, or longer, if the
attacks have occurred several times. In the
case of this child, you will have to do some-
thing more. In order to control this ten-
dency to convulsive seizures, Ave must give
prompt and immediate attention to the
rickets. To this end, we will give cod liver
oil and 2<ro of a grain of phosphorus, three
times a day, dissolved in the oil. These
remedies are to be kept up for several
months, the child to be taken as much as
possible into the open air, and regular
habits of nursing and sleep enforced.

VARICELLA.

The second patient now I present to you for
diagnosis. He is five years old, and is gener-
ally well developed. We will first make an
examination of his skin and afterwards get
a history of his disease from the mother.

In making an examination of a cutaneous
disease in a child, it is always well to strip
him completely and examine his .entire
body. An eruption may present very pecul-
iar features upon one part of the body so as
to render a diagnosis very doubtful ; while
in another part it may be perfectly typical.
In adults it is not always possible for the
physician to do this, but there is that ad-
vantage in paediatrics that the physician has
at least, the privilege of examining the entire
body of the patient.

As the child's body is now completely ex-
posed to view, you notice it is covered with

May 23, 1 89 1. Clinical

Lecture.

a sparsely scattered eruption. . It is discrete
everywhere, a little more abundant over the
shoulders and trunk than over the ex-
tremities, and rather less upon the face,
than upon the body. In some parts we see
vesicles, iu o'thers, papules, and in others
still, you will notice that vesicles have dried
and form small crusts with a slightly de-
pressed centre. In other parts, there are
found simply macules. All these varieties
are found in pretty close proximity to one
another. There has been considerable itch-
ing of the skin, as is evident by the amount
of irritation we see about some of the older
spots. Nowhere do you see any of the
patches coalescing.

In calling upon the members of the class
to make a diagnosis of this condition, Dr.
A. says scabies ; Dr. B. papular eczema ;
Dr. C. erythema and Dr. D. varicella.
The last diagnosis is certainly the most prob-
able one. There is one point by which we
can make a differential diagnosis of vari-
cella from any of the skin affections sug-
gested by the gentlemen of the class, and
that is by an examination of the mouth of
the patient. I find on looking into this
child's mouth, a typical vesicle on the hard
palate, and another one upon the inside of
the cheek. Under these circumstances this
point is enough to settle the question of
diagnosis. The appearance or non-appear-
ance of the spots in the hair is not of any
special diagnostic value. One .other point
by which we may differentiate varicella
from many other forms of eruptive fever is
the great diversity of lesions seen at the
same time on the patient. This is due to
the fact that the eruption comes out in suc-
cessive crops every two or three days. So
we may have all the different stages of the
disease represented in a given part of the
body.

Ordinarily, varicella is so mild a disease
that it scarcely needs any treatment. A
diagnosis, however, is always desirable ; and
in this case one fact in the history is suf-
ficient to diagnosticate it from papular
eczema or scabies, viz. : that it made its
appearance within the last three days. It
should be remembered that varicella may
be serious and even fatal. When such is
the case, it is most frequently in institutions
where many children are congregated, and
then usually a fatal result is brought about
by complications. I have on two different
occasions seen a fatal result follow an attack
of varicella from a complicating erysipelas
developing about the pustules. Occasionally
a localized gangrene is seen, forming a dis-

tinct variety of this disease known by the
name of varicella gangrenosa. Nephritis
has also been observed as a complication of
this disease and in a few instances, broncho-
pneumonia. So that in institutions prac-
tically all cases of varicella should be iso-
lated with promptitude, as the disease is of
quite a contagious character, and during the
period of desquamation, warm baths should
be given daily to the patient, and this
should be followed by inunction with car-
bolized vaseline, or a one per cent, ointment
of ichthyol. Continued disinfection of the
skin during the period of desquamation is
always advisable.

SPECIMEN FROM A CASE OF CEREBRO-
SPINAL MENINGITIS.

I will now pass around the class for in-
spection a specimen of a brain removed
from a child who died two days ago of
cerebro-spinai meningitis. The child was
perfectly well until four days before his
death when he was suddenly taken ill with
a temperature which ranged from 104° F.
to 105-2° F., throughout the day. He vom-
ited twice in the morning and had one large,
normal stool. A physical examination
failed to reveal any evidence of disease
either in his throat or lungs. On the fol-
lowing day the temperature range was be-
tween 103° F. and 105° F.. and pulse from
150-160, respiration regular, and the child
showed some signs of restlessness. There
was no more vomiting. During the night the
patient was quite restless and on the morn-
ing of the following day he developed
marked signs of nervous irritability. He
bit his fingers and rolled about restlessly in
his crib. Muscular twitchings developed at
the extremities during the afternoon, and
there were noticeable signs of general hyper-
esthesia. The pupils were dilated and re-
sponded imperfectly to light, but there was
no rigidity or any evidence of paralysis.
The child looked pale, occasionally uttered
low screams and prostration gradually began
to increase.

On the evening of the following day some
rigidity of the muscles of the neck were for
the first time noticed, with slight rigidity of
the extremities. The abdomen was rounded
but soft and natural. The pulse rose to 200,
was very feeble, and almost imperceptible
at the wrist. During the night he passed
from a half-drowsy state into a condition of
semicoma. On the morning of the next day
he was comatose with the right hand re-
maining quiet and the left hand constantly
moving. Twitchings of the right hand and

6io

Clinical

Lecture.

Vol. lxiv

face were noticeable at this time and death
took place at 11 A. M. that day, the tem-
perature being 105^° a few hours before
that event.

No cause could be assigned for this illness
save that the child had had a discharge
from both ears, which, however, had ceased
six weeks previous to his death. On further
inquiry it was found out that the child had
sustained a fall 2 \ weeks previous to his
fatal illness, but this was followed by no im-
portant symptom at the time. It is doubt-
ful if either of these factors, the fall or the
otorrhcea, played any part in bringing
about the death of this child.

The autopsy showed all the organs essen-
tially normal, except the brain and spinal
cord. The anterior half of the brain, you
will see, is covered with a thick layer of
lymph and pus, giving to it a yellowish-
green hue, and concealing the normal brain
substance. This is found in greatest abund-
ance over the convexity. At the base of the
brain it follows the line of the Sylvian fis-
sures, and in the posterior half, this exudate
is seen in patches, but nowhere does it cover
a continuous surface. It is generally found
distributed along the course of the bloodves-
sels. There are no tubercles present, and the
ventricles are not distended. There is no
softening of the cerebral substance.

The cord is normal, except at its lower
portion, where a small collection of pus was
found. There is no lymph coating the mem-
branes of the cord.

The diagnosis of this case was exceedingly
obscure until the night before the death of
the child. Up to that time he presented
simply the symptoms of an acute febrile ill-
ness, with very high temperature and marked
prostration. Please note in the history the
absence of the common and classical symp-
toms of meningitis, viz. : persisting vomiting,
constipation, retraction of the abdomen,
photophobia and early opisthotinos. It is
extremely difficult in these abrupt cases of
meningitis to make a diagnosis. They much
more resemble cases of acute pneumonia
than those of meningitis. It is only by care-
ful and repeated examination of the lungs
in this case that pneumonia was excluded.

A great deal of light has been thrown on
the etiology of the cerebro-spinal meningitis
within the past few years. Many of these
cases of meningitis are found to depend upon
the pneumo-coccus of Fraenkel. This germ
has been found more frequently than any
other in this particular disease. In a case
of my own, recently studied bacteriologically
by Dr. M. Prudden, of this city, cultures of

pneumo-coccus were found in the exudate.
This case is the more interesting from the
fact that the symptoms were largely pul-
monary.

NEURALGIA SECONDARY TO LA GRIPPE-
CHRONIC BRONCHITIS — PLEURISY
WITH EFFUSION.

BY JOSEPH M. PATTON, M. D.,

PROFFSSOR OF CLINICAL MEDICINE IN THE CHICAGO
POLYCLINIC, CHICAGO, ILLINOIS.

- Gentlemen : — This lady came to the clinic
about a week ago complaining of neuralgia
of about two weeks' duration. Now, we
know that the ordinary person terms every-
thing that is painful neuralgia, but when she
describes the pain by running the finger
down the line of the sternomastoid, down the
anterior border of the trapezius, over the delt-
oid and over the extensor muscles of the fore-
arm, of course we begin to doubt its being neu-
ralgia. Neuralgia is an acute pain which is
located along the course of one of the nerves. \
If it is neuralgia you can determine the exact 1
nerve to which the trouble belongs. For
instance, if an individual has neuralgia of
one of the branches of the 5th nerve, it will
be located over the portion supplied by that
nerve. If it is the first branch you will
have pain over the temple and around the
ear, over the top of the head ; if it is of the
second branch of the trigeminus you will j
have pain over the malar bone, down along
the affected side of the nose, and perhaps
extending down to the jaw. If it is the
third branch you will have pain in the jaw
radiating down under the chin. If there be
neuralgia of the cervical nerves you will
have pain radiating from the back of the
neck around towards the front or down
towards the shoulder ; and if it is the inter-
costal nerves, or the nerves of the arm, you
will have pain following the course supplied
by these nerves. If the neuralgia is due to
an affection of the nerve, an inflammatory
condition of the nerve, you will generally be
able to locate some sore spot. In neuralgia
of the second branch of the 5th, if it is due
to an inflammatory condition of the nerve,
you will find a sore spot in front of the ear
or immediately below the eye or just below
the center of the malar prominence. If you
touch these branches of nerves you will
have severe pain ; there will be some tender
spot ; you may have just as severe pain in
one of these nerves without any sore spot
whatever. When you place your finger in

May 23, 1 89 1.

Clinical

Lecture.

611

the region of the affected spot there is sore-
ness, which extends along the muscles of the
neck and shoulder. She complains of severe
pain when we put the cervical muscles on
the stretch. It has the appearance of a
rheumatic affection of the muscles rather
than of neuralgia. She tells us that some
two or three weeks ago she had an attack of
the grip, and after recovering in a measure
from that she became afflicted with this
pain. Now, neuralgias and rheumatic pains
in the muscles and tendons are often second-
ary consequences of the grip. I have seen
two or three most severe neuralgias second-
ary to attacks of the grip this winter. They
are not what you might call true neuralgias,
that is, they are not due to an inflammatory
condition of the nerves ; they are apparently
rheumatic in character, and are relieved by
rheumatic remedies. One case was under
my care two or three weeks ago, following a
moderately severe attack of the grip. It
was a case of neuralgia of the second branch
of the 5th nerve, with no tender spots espe-
cially. The face was sore over the nervous
foramina and was entirely unrelieved by
any of the neuralgic remedies.

All those remedies which are said to be
efficacious in neuralgias of the 5th nerve, such
as gelsemium, aconite, aconitine, cimicifuga,
the ordinary neuralgic pills — all of those reme-
dies from which you would expect effect in neu-
ralgias of the 5th nerve, were entirely inef-
fectual. You will find that the pain is re-
lieved temporarily, but not sufficiently so to
do any good. The pain in this case was re-
lieved by salicylate of soda administered in
large doses, twenty grains every two hours.
The pain disappeared promptly, and under
its continued use for two. or three days,
failed to return. There were no unpleasant
effects from its use. Ordinarily, such large
doses of salicylate of soda will cause unpleas-
ant effects in most patients, such as dizzi-
ness, tinnitus aurium, headache.

Now, the point to bear in mind in these
neuralgic and rheumatic pains that result
from the grip, is that they are not, as a rule,
true neuralgias, they do not result from in-
flammatory conditions of the nerve, but are
systemic conditions, and are best relieved
by some anti-rheumatic remedies. This
woman has been taking bromide of quinine
and phenacetine, two grains of quinine with
five or six grains of phenacetine, every two
or three hours. While that relieves the
pain while she takes it, the soreness of the
muscles is much better, but still persists.

In using these synthetical remedies for
pains, as a rule, if you do not get response

to the administration of them within a few
hours it is best not to expect any result from
them ; if they do not promptly relieve the
symptoms they fail, and if they afford re-
lief at all it is within a few hours. As this
soreness still persists, I think this patient
will do better on salicylates than anti-rheu-
matic remedies. I would prescribe for her
to-day, ten grains of the salicylate of soda,
every two or three hours, according to the
way in which her stomach will bear it. In
some people it is an irritating medicine to
administer as far as the stomach is con-
cerned, and you have to be careful, espe-
cially in women, and give it largely diluted
in water. I expect that will relieve her
trouble better than anything else.

This lady is another victim of the current
affliction. She had the grip about two or
three weeks ago — a slight attack of it, and
since that time has been complaining of
weakness. She feels almost too weak to go
about — no ambition. She also has some
pain in her limbs and arms and in the back
of her neck. You will notice in regard to
the pains that are complained of in these
attacks of the grip, barring the headache,
that they are, as a rule, confined to the ten-
dons of the cervical region and the lumbar
region, with some pains in the limbs. These
pains are sometimes very severe in the cer-
vical region, and also in the lumbar region,
with no special stiffness of the muscles. Her
trouble now is probably the weakness that
is complained of. It is somewhat surprising
the amount of physical weakness which will
follow a comparatively slight attack of the
grip. This year the name influenza would
hardly seem to apply to the disease, as there
are very few cases that have exhibited any
marked trouble with the mucous mem-
branes ; it is not the characteristic coryza or
sneezing, or the suffused condition of the
eyes or pharynx that is complained of, nor
the mucous membrane of the larynx, and
there is not so much bronchial inflammation
in the start, though that may follow as a
secondary matter. This year the symptoms
of influenza are entirely wanting, and the
trouble consists generally in high tempera-
ture, great weakness and pain. The weak-
ness which follows these attacks is not at all
consistent with the amount of temperature
or with the length of the attack. I have
seen several cases where the temperature
did not go above 101°, and where there was
very little pain, and yet the secondary ex-
haustion following the attack would last
from one to three weeks. Again, you see
cases with a temperature of 103° or 104° with

6l2

Clinical

Lecture.

Vol. lxiv

not very much pain, which seem to be well
in a few days after the temperature goes
down, so that the exhaustive effects depend
upon the condition of the system of the
patient, and not on the height of tempera-
ture or severity of attack.

The administration of remedies for the
acute stage of this trouble may have some-
thing to do with the exhaustion which fol-
lows. It is fashionable to give antipyrine,
acetanilid, phenacetine, antiferbrin with, or
without quinine, both because that is the
fashion of the day, and because they are
very efficient remedies for reducing fever
and pain,- at the same time they leave a de-
pressing effect. Any of you who have ad-
ministered antipyrine in marked doses in
typhoid fever or pneumonia, or any of the
acute exhaustive diseases, will have noticed
that you get a more depressing effect from
its prolonged use, than in those cases in
which these drugs are not used. These pa-
tients will take quinine for three or four
days, and if they do not get much better they
will go to a physician, and he gives them as
much antipyrine or acetanilid as they will
stand, and by the time they are beginning
to get well they complain of great exhaus-
tion due, perhaps in part, to the administra-
tion of these remedies ; at any rate, there
seems to be a great deal more exhaustion
following the grip this year than I ever
noticed before.

Another marked feature of the disease
this year, is the tendency to bowel trouble —
catarrhal inflammation of the bowels. As a
rule there is not much difficulty with the
stomach ; the trouble seems to be with the
intestines. The diarrhoea will begin with
the active symptom of the disease, or will
follow as the patient begins to get better ; it
is accompanied by considerable fermenta-
tion, a good deal of flatulence. The pas-
sages are frequent, thin, slightly greenish as
a rule, showing evidences of imperfect diges-
tion. That has been the case also with
pneumonia. I have hardly seen a case of
pneumonia this winter that has not been ac-
companied by diarrhoea — even the asthenic
cases of pneumonia all have it, and in the
other cases which occurred in people who
were weak and feeble, they were also af-
flicted with it. For instance, a woman was
under my care a short time ago who had
had chronic bronchitis for years ; she was
very much run down in health ; she had a
croupous pneumonia of one lung, which got
along fairly well, but the attack in her case
was accompanied by diarrhoea during the
course of the trouble. Another case, a

strong, active young man of 20, with double ;
pneumonia, respiration 45, and pulse 140,
temperature 104°, a very severe one, also
developed diarrhoea about the time that the !
temperature began to drop. And so it ran
through all the cases. I lost a case of pneu-
monia this morning in a young man of 27, I
where the trouble began as a gastritis, which
I succeeded in relieving, when pleuro-pneu-
monia developed wTith an active diarrhoea \
all the time. This diarrhoea is not depend-
ent upon what you feed the patient. I
have kept them on an exclusive milk diet. J
I have fed them on beef peptonoids and j
beef extracts, and on broths ; I tried every |
manner of diet, and it makes no difference.
It seems to me some atmospheric condition.

As regards treating the exhaustion which
follows attacks of the grip, of course much
depends on the patient, the character of the 1
attack, and the amount of food which they
are able to take. They should be put on
tonic treatment, and among the best things
to feed these patients with are some of the
tonic wines. Coca wine or Tokio wine,
which is a good deal used just now, is very
beneficial. The coca wine pf Mariana &
Co. is a nice preparation — one which I have
used a good deal in these cases, one glassful \
two or three times a day. They respond to
it nicely. It has a tonic action on the
mucous membrane of the throat and larynx
where there is troublesome cough, or hoarse-
ness of the voice. They should be fed on
light diet, that is a diet from which the I
starches, sugars and fats are excluded, so j
that you will not have much transformation
of sugar into glycogen, and therefore there
is not much chance for fermentation. For i
the tendency to fermentation and diarrhoea j
the best remedies are those which prevent
intestinal fermentation, intestinal antiseptics.
The old remedies, bismuth, or dilute mineral
acids are good. It is more fashionable now
to use salol, napthol, napthaline, thymic
acid, or some such preparations. Salol is a
nice remedy, and should be given in 5-grain
doses in the form of a sugar coated pill, one
every three or four hours. You can use
napthol and napthaline if you so desire
Where there is fermentation in the stomach, j
one of the best remedies is a grain, or a
grain and a half of thymic acid, with five
grains of charcoal in a capsule ; it relieves
fermentation nicely.

This patient complains principally now of
flatulence, and not so much of diarrhoea.
She says her bowels are not loose, at the pres-
ent time, but that the flatulence is the only
trouble that bothers her. I would put her j

May 23, 1 89 1. Clinical

Lecture.

613

on one of these remedies — salol, for instance,
with one of tonic wine, and expect her to
regain strength quite rapidly.

CHRONIC BRONCHITIS.

This lady comes to us from the throat
clinic. She complains of hoarseness. This
hoarseness she has had for two or three
years, mostly in winter. Professor Brown
has referred her to us for examination of her
chest in order to determine whether there is
any condition there which would add to the
permanency of this hoarseness. She says
she has some cough nearly always in winter,
and that it bothers her more in the evening
than at any other time. That fact which she
states of her own accord,that the cough is more
troublesome at night than in the morning,
would probably exclude the stomach as a
cause of the cough or laryngeal irritation,
for the reason that coughs which arise from
the stomach, as a rule, are more trouble-
some in the morning than at any other time.
If the reflex trouble of the stomach is the
cause you will find the coughs are more
troublesome ; immediately after getting out
of bed, they cough a long time until they
raise a little mucus, then perhaps they will
not cough but once or twice during the day
to amount to anything. That is not only
characteristic of stomach cough, but it is
characteristic of trouble with the stomach
in any chronic cough. Where you find the
coughing spell is in the morning you may
look at once for some trouble with the
stomach. She says her cough is worse in
cold, damp weather, sufficiently so to make
her quite short of breath at times.

Expansion of the lungs is good ; vocal
fremitus is unchanged, and the percussion
note is unchanged. The only thing I find
wrong with her lungs is a slight harshness
about the breathing over the upper portion
of the lungs in front, produced by a little
chronic inflammatory condition of the bron-
chial lining. Occasionally through her lungs
during the first one or two deep inspirations
you find solitary rales which disappear after
deep inspirations, showing that there is a
little adhesive mucus which is displaced by
deep breathing. This may have something
to do with her hoarseness, as the bronchial
coughs which are worse in winter and during
damp weather, which clear up during dry
weather, are due to a little swelling of the
mucous membrane with increased secretion
of mucus, nd are very apt to cause conges-
tion of the vocal cords or of the larynx from
the constant coughing and hacking which
they produce, and you frequently see these

conditions of the larynx clear up after hav-
ing cured the condition existing in the
bronchial tubes.

Now, for the relief of that condition. You
want something slightly expectorant with
an alterative, especially in old women. One
of the best combinations is five to ten grains
of iodide of potash with two or three drops *
of tincture of belladonna, and about the
twelfth of a grain of tartarized antimony.
In children and young people, one of the best
remedies is the syrup of hydriodic acid
which contains a certain percentage of free
iodine, and is a most excellent way to give
iodine. It is very palatable. I have seen
localized bronchitis, both in children and in
adults, which would resist all kinds of cough
mixtures and all kinds of tonics, clear up
promptly after the administration of a little
iodine in this way. It is especially valuable
in those chronic coughs which follow whoop-
ing cough and measles in children, and it is
an excellent remedy for these conditions.
To this woman I should give five grains of
iodide of potash, or you may give iodide of
soda, either one, I prefer iodide of potash in
this case, with a little tartarized antimony,
and no belladonna on account of the tendency
to an inflammatory condition of her throat,
because if she got enough to affect the mu-
cous membrane at all, it would make her
throat and larynx dry. She would cough
more and experience more difficulty with
her throat, so that we will leave the bella-
donna out.

PLEURISY WITH EFFUSION.

This boy, aged 15, we aspirated last week.
I brought him here to-day for you to see
whether there is any change in his condition
or not. He says he feels much better in
every way. Although we removed three
quarts of fluid from him at that time, there
were fully three pints left. You remember
that his heart was much displaced, almost to
the right nipple and the lung very much
compressed. As to the amount of fluid
which you should remove in these cases, it
depends a good deal on the nature of the
effusion and on the case. Where the chest
has filled rapidly, and where there is a great
deal of effusion, especially in young sub-
jects, I see no objection to removing at least
three-fourths of what is there in the chest or
more if you can do so without causing any
dyspnoea. This boy, after he got off the
table last week, as soon as he began to move
around, began to cough, which was quite
severe, hacking, and irritating, and was
forced to lie down and rest until his lung

614

Communicatio7ts.

Vol. lxiv

had accommodated itself to the greater
amount of room before he could move around.
Where the patients begin to cough or com-
plain of some constricting pain in the side
while withdrawing the fluid it is about time
to stop.

I want you to look at the difference in
the spine. You remember how much lateral
curvature there was of the spine last week.
That is nearly straightened out now, and it
was supposed to be due to the weight of the
fluid in the left side, which caused it to
gravitate in that direction. You notice a
little prominence on the left side of the
sternum, at the costo-cartilaginous junction,
it has not disappeared, and that is probably
due, as we had previously supposed, to some
bending of the junction of the ribs and the
cartilage from pressure, and was doubtless
there from infancy, — one of the slight forms
of what is called pigeon breast — which is
due to some interference with the respiratory
conditions which produce pressure on the
ribs at the time when the cartilages are soft
and bend very easily. You will find these
conditions developing in children who are
the subjects of enlarged tonsils for a long
time and have difficulty in breathing ; you
will find them developing a prominence
along the sternum due to pushing out of the
ribs, from increased pressure in the lungs
made by the efforts at respiration — efforts to
get the air out of the lungs, caused by the
small amount of room in the throat where
the tonsils are quite large. You will find
that if the tonsils are removed in the early
stages of these slight deformities, they will
generally disappear, or at least will not
grow worse.

The next thing we notice is that there is
absence of pulsation in the right mammary
region, where it existed last week, and that
pulsation has moved over to the left of the
sternum, and has almost regained the natural
area of cardiac pulsation. We can now
feel the action of the heart in the natural
area. You notice there is some motion of
that side, it is not as good as it ought to be,
but it is better than it was. The percussion
note is vesicular in quality down as far as
the 7th rib, from that point it is more or less
flat. You can hear the respiratory murmur
all over the left side down to the present
line of flatness and behind below the angle
of the scapula. You may occasionally,
when he takes a deep inspiration, hear the
rubbing of the pleural surfaces over each
other at the end of each inspiration — a dry,
grating sound. There is still a slight amount
of fluid in the left cavity.

As to the likelihood of these cases filling
up again, in a case like this, a young boy
who has developed that amount of fluid
within a comparatively short space of time,
if the fluid is taken out inside of a week or
so of its development, as a rule there is little
danger of the pleura refilling ; but if the
condition be left alone for several weeks,
and the patient is very much run down in
strength, you are apt to have the pleura
refill again. This is especially likely in old
people. In patients who are 60, 70, or 75
years old you will find pleurisy develops
quite rapidly, and even though it may be
removed if there is marked compression of
the lung, you will find that such cavities
will fill up again, so that you are apt to tap
them two or three times. But as a rule
after two or three tappings they cease to
refill, and you have no further trouble with
them. It is probable that the small amount
of fluid which remains at the end of a week'
in the left side of this boy will not compro-
mise the lower portion of the lung or the
pleural surface before it is absorbed, so that
it is hardly worth while to attempt to with-
draw it ; the expansion of the lung has suf-
ficiently increased and circulation is good
enough to take it up without much difficulty.
I expect at the end of two weeks to be able
to get a dry friction sound clear to the bot-
tom of the lung ; this sound will disappear
as the pleura becomes healed, and there will
probably remain a slight thickening of the
pleura which will probably do him little
or no injury.

Communications.

THE RELATION OF CONCUSSION OF THE
BRAIN AND SPINAL CORD TO IN-
FLAMMATORY AND OTHER MOR-
BID CONDITIONS IN THESE
ORGANS.

BY B. A. WATSON, A. M., M. D.,

CONSULTING SURGEON TO THE BAYONNE HOSPITAL,
SURGEON TO JERSEY CITY HOSPITAL, ETC.

It is certainly apparent to all members of
the medical profession that brain and spinal
surgery has received during the last quarter
of this century an unusual and likewise un-
precedented amount of attention. It is like-
wise equally apparent that great progress
has been made by those who are devoted to
this branch of surgery ; it therefore becomes

May 23, 1 89 1.

Communications.

highly necessary, that he, who is about to
enter this field of medical literature, should
first discover some dark spot or disputed
question, on which he thinks he may possibly
throw a few rays of scientific light. The
traumatisms of the brain and its membranes
have been more fully studied than those of
the spinal cord. Undoubtedly this may be
accounted for in part by the fact, that the
first-mentioned organ is much more
frequently the seat of these lesions than the
latter.

1 shall therefore direct the greater por-
tion of my attention especially to any lesions
following traumatic injuries of the spinal
cord and its membranes.

It seems necessary to call attention to cer-
tain errors as a preliminary to the consider-
ation of our first inquiry.

One of the most important of these has
been expressed by Mr. Erichsen, in the fol-
lowing language : 1 " The consideration
of the effects that may be produced
on the spinal cord by slight blows,
whether applied to the back or to a distant
part of the body, is not altogether a matter
of modern surgical study arising from the
prevalence of railway accidents, but had,
long antecedent to the introduction of mod-
ern means of locomotion, arrested the atten-
tion of observant practitioners." Since the
above statement was made it has been clearly
demonstrated to be erroneous by anatomical
and experimental investigations. The an-
atomical studies have shown that the spinal
cord is the best protected organ in the body,
and experimentation has fully confirmed this
position. The experiments which I made on
dogs — the total number being 141 — which
were arranged and conducted for the especial
purpose of producing concussive lesion in
the spinal cord and its membranes fully con-
vinced me that it required a very severe blow,
which must even be delivered on certain
limited areas of the body, in order to accom-
plish this object. I am likewise satisfied
that this conclusion must ueccessarily follow
a careful study of my report entitled : "An
Experimental Study of Lesions Arising from
Severe Concussions."2

It should be further stated that the lesions
produced in the spinal cord and its mem-
branes are rarely apparent to the unaided
eye, but were readily revealed under the
microscope. This statement, however, does
not apply to those cases in which there were

" 1 On Concussion of the Spine. A New and Re-
vised Edition. London, Longmans, Green & Co.,
1882.

2 P. Blakiston, Son & Co., Philadelphia, 1890.

either fractures or dislocations involving
the vertebrae ; since the lesions here were
comparatively coarse.

The statement that a rupture of the spinal
membrane has occurred, or that there has
been a gross haemorrhage into the substance
of the spinal cord, or between the cord and
its membranes, is certainly not entitled to
credence unless coupled with the acknowl-
edgment of either a fracture or dislocation
of a vertebra. This statement is based on
my examination of the lesions found in the
spinal cord and its membranes, and I am so
thoroughly convinced on this point, that I
feel warranted in making this positive state-
ment.

The so-called "railway spine" includes
true concussion arising from blows, falls,
gun-shot wounds, lightning strokes, electric
shocks, etc., likewise contusions on the back,
sudden flexions of the spinal column, sprains,
wrenches and twists. Dr. John A. Lidell
says, in discussing the consecutive effects of
some of these injuries that : 1 "Among the
remote effects of sprains, wrenches and hvists
of the spinal column, are chronic inflammation
of the vertebral joints that are implicated,
which is often suppurative in character,
destruction of the articular cartilages and the
intervertebral substances that are involved,
and caries or necrosis of the adjoining verte-
bral bodies. In such cases, the destructive
process begins more frequently at the junc-
tion of the vertebrae with the intervertebral
substances than in the intervertebral sub-
stances or vertebrae themselves, because, as
Mr. Hilton has pointed out, we know that in
accidents, at least as far as we have been
able to discover, "the most frequent lesion
in injury to the spine is a partial severance
of the vertebrae from the intervertebral sub-
stance."

A number of illustrative examples have
already been presented, and inasmuch as
this topic has already been pretty thoroughly
discussed, no apparent need exists for pre-
senting any additional instances of the same
sort. I will, however, take space, to present
a very instructive case, in which there simul-
taneously occurred lumbo-sacral abscess and
suppurative spinal meningitis,in consequence
of a blow on the spinal column :

The following abstract made from the re-
port of the history of this case supplies the
essential points : A healthy lad, of fifteen
years, was struck by his playmate on the
back with the fist. He thought little of it

1 International Encyclopaedia of Surgery, Vol. IV,
p. 870 et. seq. 'Edited by John Ashurst, Jr., M. D.,
Wm. Wood & Co., New York, 1884.

6i6

Communications.

Vol. lxiv

at the time, but was admitted to Guy's Hos-
pital nine days afterwards ; was treated
with leeches and somewhat recovered, but
the pain soon returned and fever ensued.
" An abscess formed on the right side of the
sacrum, which was opened, and continued to
discharge, the flow of pus being increased by
pressure on the abdomen. He continued to
get worse daily, having much irritative fever
and severe pain in the back. During the
last week of his life he was exceedingly rest-
less, and often delirious ; and he complained
of pain in all parts of his body, but par-
ticularly in the extremities. On one or two
occasions he had loss of power over the
bladder and rectum, but had no other symp-
toms of parapelgia, and could move freely in
bed." He died twenty-two days after the
casualty,

Autopsy: — An aperture in the integu-
ments at the right side of the sacrum led
into a very extensive abscess, external to the
peritoneum, which occupied the forepart of
the sacrum behind the rectum, and external
to the ilia on both sides behind the psoas
muscles. The bones were exposed but not
diseased. Although the abscess had dis-
charged externally on the right, it was most
extensive on the left. It had burrowed up
to the left side of the last lumbar vertebra
and the sacrovertebral foramen into the
spinal canal. When the theca was opened,
it was found to contain a quantity of green-
ish pus, spread over its inner surface and
over the cord itself. The spinal dura mater
(theca) at the point indicated, was softened
and destroyed, and the cauda equina was
lying bathed in pus which filled the sacral
canal. The membranes of the cord were in-
flamed throughout the whole extent, and
there was purulent effusion as high as the
dorsal region. The spinal dura mater was
thickened, and its inner surface had lost its
smoothness and transparency, and was of a
dull green color. Pus could be squeezed out
from beneath the visceral arachnoid in con-
siderable quantity. The spinal cord itself
was firm, and the microscope revealed no
morbid condition in its substance. On open-
ing the cranium, cases of acute arachnitis
were found over the whole surface of the
brain, greenish-colored lymph being effused
into the sub-arachnoid tissue, especially at
the base. The inner surface of the dura
mater, around the foramen magnum and on
the adjacent part of the occipital fossa, was
of a greenish color, from lymph effused upon
it, Bronchial tubes filled with tenacious
mucus. Lumbar and bronchial glands
slightly enlarged. All other jrgans entirely

healthy.

The purulent infiltration of the spinal
meninges which was observed in this case,
occurring coincidently with the formation
of a lumbo-sacral abscess, but without the
production of paralysis, could scarcely have
happened unless the sacrovertebral articula-
tion had previously been opened, both ex-
ternally and internally, but disease of the
articulation itself in such a manner as to
allow the products of inflammatory action to
flow freely out of, as well as into, the
spinal canal. ' Otherwise, the suppurative
meningitis would pretty certainly have
caused paralysis by compressing the spinal
cord with its inflammatory products.

The clinical history of this lad's case,
interpreted by the post-mortem appear-
ances, appears to have been as fol-
lows : The blow on the back wrenched the
sacro-vertebral articulation and caused a
suppurative inflammation to be lighted up
therein, particularly on the left side, and in
consequence of this, purulent matter escaped
in an outward direction, and led to the
formation of an immense lumbo-sacral ab-
scess ; it likewise escaped in an inward direc-
tion, and caused the theca vertebralis to be-
come softened and perforated, and exten-
sively destroyed, and a diffuse suppurative
inflammation which extended upward to the
brain, to be kindled in the spinal arach-
noid. It has been aptly said that " in all
science, error precedes the truth, and it is
better it should be first than last."1 I
have cited the case reported by Dr. Lidell,
with all its details, in order that I might
bring forward some of the results of my ob-
servations, made during my recent experi-
ments, which afford a correct and rational
explanation of the condition, revealed by
that post-mortem examination. There will
be found in the report of my experiments,
eleven cases, in which there was rupture of
the ligaments of the sacro-lumbar articula-
tion. There were marked pathological
changes in the organs and tissues within the
pelvic and abdominal cavities in six of these
cases, which were immediately connected
with the rupture of the ligaments of the
sacro-lumbar articulation. Let me here
present the following abstracts from post-
mortem examinations for the purpose of giv-
ing a correct idea of the character of the
lesions :2 " Autopsy. — This examination re-

iWalpole.

2An Experimental Study of Lesions Arising from
Severe Concussions, by B. A. Watson, A. M., M. D.,
p. 32, Exp. 4.

May 23, 1 891.

Commtmications.

617

vealed, a rupture of the ligaments between
the last lumbar and the first sacral vertebrae,
deep and extensive ecchymoses over the en-
tire post-sacral and right lumbar regions.
A profuse extravasation of blood into the
abdominal cavity, marked engorgement of
the kidneys. Brain apparently normal,
slight increase of the cerebro-spinal fluid in
the cavities, and the cord was congested, to
the middle of the dorsal region."

"Autopsy.1 — This examination revealed
the following lesions : Both kidneys con-
gested ; ecchymosis in the connective tissue
covering the anterior surface of the last
lumbar and the upper sacral vertebrae. The
brain and spinal cord apparently hypersemic.
The removal of the integument over the
sacral and lumbar regions showed an ec-
chymotic condition of the muscles. There
had been a rupture of ligaments between
the last lumbar and upper sacral vertebra?."

"Autopsy.2 — This examination revealed
the following lesions: Both kidneys con-
gested ; bladder distended with urine ; ex-
tensive ecchymoses in the lumbar and pelvic
regions involving psoas muscles ; brain per-
fectly normal ; the spinal cord was hyperaemic
downward from the lumbar enlargement,
including a portion of the caucla equina;
rupture of the ligaments between the last
lumbar and the first sacral vertebrae."

The essential point which Dr. Liddell has
overlooked in his comments on the case
which he has reported, are the pathological
conditions of the organs and tissues within
the pelvic and abdominal cavities. It was
the existence of these lesions which gave rise
to the inflammation and suppuration within
these cavities. The post-mortem examina-
tion of Dr. Lidell's case sufficiently demon-
strates this position. Dr. Lidell says:3
" The blow on the back wrenched the
sacro-vertebral articulation, and caused a
suppurative inflammation to be started up
there." The autopsy in the case fails to
show that there is any erosion of the bones
or cartilage within this articulation, and its
history reveals the fact, that it was only im-
mediately before death that there was the
slightest indication of paraplegia, It is
therefore certain that the wrench which he
mentions consisted in producing a rupture
of the ligaments of the sacro-lumbar articu-
lation and likewise, as very frequently hap-
pens in those cases, some pathological
lesions within the pelvic and abdominal

lib., p. 35, Exp. 10.
21b., p. 40, Exp. 24.
3 Previously cited.

cavities. The simple wrenching of any
joint in a healthy subject — unattended with
pathological lesions, has been amply shown
to be a comparatively trivial injury, which
does not lead to serious inflammatory com-
plications or death.

The one hundred and forty-one experi-
ments, which I made on animals, does not
afford a single example which justifies the
conclusion that injuries to the vertebral
articulations are a whit more serious than
those produced in the carpal and tarsal
articulations; and, consequently, analogous
reasonings may be here employed with entire
propriety. We can not pass over the his-
tory of Dr. Lidell's case without pointing
out a glaring absurdity, which may possibly
have had its origin in carelessness. In this
report, we are informed that a healthy boy,
aged fifteen, "while playing with another lad,
received a blow on the back with the fist,"
and in the absence of any additional state-
ment bearing on this injury, we are left to
infer that the pathological changes and even
the death of the patient were directly caused
by this blow.1

He who has examined the anatomical
structure of the spinal column will readily
perceive the absurdity of this statement.
The blow inflicted was entirely inadequate to
the production of the results which followed,
unless there has been omitted from this re-
port the most important factor in the history
of this case. It is true that the force of the
blow might cause the lad to fall — and if at
this point, the history of the case showed
that the boy fell across a bar, raised a few
feet from the ground, in such a manner that
his feet remained on one side, while his
head was on the other, then the very im-
portant factor of leverage having been
added, which would result under these cir-
cumstances in the production of a sudden
flexion of the spinal column, would cer-
tainly bring within the limits of possibility
the occurrence of the injuries which are re-
ported in the autopsy.

It is scarcely necessary to mention the
fact, that nearly all the injuries grouped
together under the unfortunate cognomen of
" railway spine " — so far as their remote
effects are concerned — take their origin,
either directly or indirectly in inflammatory
processes. Consequently the consideration
of the following queries assume importance :

1. Do inflammatory and other morbid
changes take their origin in traumatic in-
juries of the spinal cord and its membranes

Previously cited.

6i8

Communications.

Vol. lxiv

as frequently as the writings of Mr. Erich-
sen imply ?

2. Do inflammatory and other morbid
changes ever arise from traumatic injuries
which are entirely uncomplicated by imme-
diate symptoms ?

3. How soon are the inflammatory and
other morbid changes developed after the
receipt of traumatic injuries in the cord,
etc.?

In our consideration of the first question
it is scarcely necessary to give a negative
reply to those who have perused the writ-
ings of Mr. Erich sen on this subject ; since
they have already reached this conclusion.
Furthermore, the mere assumption that
serious results frequently arise from wholly
unimportant injuries is not sustained by
clinical observations or experimental inves-
tigations. However, Mr. Erichsen, in writ-
ing of those cases in which the patient has
received no blow or injury upon the head or
spine, but in wrhich the whole system has
received a severe shake or shock, in con-
sequence of which an immediate lesion,
probably of a molecular character, is sus-
tained by the spinal chord and disease of an
inflammatory character, or of a disorganizing
nature is developed in it, the inflammatory
action eventually creeping up to the mem-
branes of the brain, says that the cases1
" although necessarily more frequent in rail-
way than in other injuries, do occasionally
occur as a consequence of ordinary acci-
dents." A perusal ot Mr. Erichsen's writ-
ings has completely failed to convince me
that he has supplied any basis for the sup-
port of the ©pinion advanced in the -above
statement.

In order, to demonstrate the correctness
of this opinion which conflicts with all posi-
tive knowledge we possess on this subject —
and which can not be supported by anal-
ogous reasoning — he should clearly estab-
lish the following facts, viz. :

(1) That no disease of the brain or
spinal chord existed at the time of the occur-
rence of the alleged accident. (2) That the
consecutive inflammation did arise from the
traumatism, and was not due, in part, or
wholly, to a vitiated constitution.

This evidence is entirely wanting ; and,
consequently we must maintain that Mr.
Erichsen's statement should be excluded in
cases of medico-legal evidence.

We have now devoted our attention to
the consideration of the material points in-
volved in our first query, but it would seem

10n Concussion of the Spine, Nervous Shock, etc.,
p. 95. New York. Wm. Wood & Co. 1875.

proper in this connection to give some
additional thought to the consecutive results
of concussive accidents.

Mr. Erichsen says1 : " Whatever may be
the nature of the primary change that is
produced in the spinal cord by a concus-
sion, the secondary effects are clearly of an
inflammatory character, and identical with
those dependent on chronic meningitis of
the cord and sub-acute myelitis." The
term concussion as employed in the above
quotation evidently refers only to trau-
matism of the spinal cord and its mem-
branes, but elsewhere the same author in
speaking of sprains, twists and wrenches of
the spinal column, says2: " It is important
to bear in mind that the vertebral column
is more apt to suffer in these strains of the
spine than in the other forms of injury that
we are discussing, and that in serious cases
the full force of the mischief appears to be
expanded in the spine itself independently
of its contents which escape uninjured."
The views expressed by Mr. Herbert Page
on this subject are as follows8 : " Happily,
there is no doubt of the exceeding rarity of
spinal meningitis, as an immediate result of
localized injury to the vertebral column ;
and I know of no case in which meningeal
inflammation has been caused by injury of
some part of the body remote from the
spine." The experimental study of concus-
sion of the spinal cord has satisfied me on
the following points: (1) True concussion
of the spinal cord from blows, falls, light-
ning strokes, etc., is an exceedingly rare
occurrence. (2) Secondary results, such as
inflammation, suppuration, etc., very seldom
follow the traumatism, owing to the fact,
that the punctate haemorrhages, etc., are
generally widely diffused in various parts of
the spinal cord, while the pathological
lesions are so slight as not tft supply inflam-
matoru foci. However, the danger arising
from a true concussion of the spinal cord
produced by gun-shot injuries, the lodgment
of a musket or rifle ball in the spinal col-
umn is attended with much more danger
from consecutive inflammation, etc., than
those traumatisms which have been pre-
viously mentioned because of the following
peculiarities: (1) The pathological lesions
are more concentrated — resembling in this
respect the ecchymoses arising from a con-
centrated contusion. (2) The lodgment of
a ball in the spinal column is very liable to

nh. p., 157.

2Ib. p., 128.

3 Railway Injuries, p. 21. Philadelphia. P. Blak-
iston, Son & Co. 1891.

May 23, 1891.

Communications.

619

give rise to a septic inflammation, pus forma-
tion, diseased condition of bone, extention
of the inflammatory products to the spinal
membranes, and even the cord itself. It
must be universally admitted, that gun-shot
wounds, fractures and dislocations involving
the spinal column are very serious trauma-
tisms, frequently producing death imme-
diately, or within a few hours. Even when
this result does not follow, the danger is
very great from the consecutive sequelae.

Let us now take up the consideration of
the second query. " Do inflammatory and
other morbid changes ever arise from trau-
matic injuries which are entirely unaccom-
panied by immediate symptoms ?" The con-
clusions reached by a careful analysis of the
above question must depend to some extent
on the interpretation which we give to this
query. The fact must be admitted that it is
not only possible for a patient to receive,
under certain circumstances, severe trau-
matic injuries of which he remains a longer
or shorter period wholly unconscious, but that
these occurrences are by no means very rare.
I can now recall a number of instances of
this character occurring to officers and
soldiers during the excitement of battle,
while I was serving with the army. It also
occasionally happens that drunkenness dulls
the sensibilities in certain cases to such an
extent as to render the patient oblivious to
an injury, which he may have received,
while the same condition will more or less
embarrass, and sometimes even deceive, the
surgeon who is attempting to make an ex-
amination. These statements possess only
an indirect bearing on the question under
consideration. The question relates to the
immediate existence of symptoms and not
to the observance of the same. A critical
examination of this question in the same
direction indicated in the above sentences,
brings us to the following query : " Are re-
sults ever produced without causes ?" — i. e.,
" Do inflammatory and other morbid changes
ever arise from traumatic injuries, which
have failed to produce any lesions ?" My
experimental studies of the lesions of the
cerebro-spinal axis have clearly demon-
strated the fact, that pathological changes
are occasionally produced in this centre —
some of which are even apparent to the un-
aided eye — while others required the aid of
the microscope ; but which were not fol-
lowed by any symptom indicative of these
lesions during the life of the animal. The
question will now be naturally asked with
reference to these cases': Would they not

have developed inflammatory changes at a
later period ? f have not before me the
data which would justify me in positively
asserting that a result was absolutely im-
possible ; but I can aver that, in all these
experiments— one hundred and forty-one —
there is not a single case which warrants
giving an affirmative answer. Surgical obser-
vations and analogous reasoning fully sup-
port the results obtained by our experi-
mental research, not only with reference to
the brain and spinal cord, but likewise in
other organs of the body. Mr. Erichsen
says in his recent work, " On Concussion of
the Spine1*' : " There is a continuous chain of
broken ill health, between the time of the oc-
currence of the accident and the development
of the more serious symptoms. It is this that
enables the surgeon to connect the two in
the relation of cause and effect. This is not
peculiar to railway injuries, but occurs in
all cases of progressive paralysis after spinal
concussion." It would appear from this
quotation that Mr. Erichsen fully concurs
with us in the opinion, that the production
of a traumatic pathological lesion is always
indicated by immediate symptoms when the
degree of injury has been sufficient to
entitle it to our consideration. Observation
has taught us that the existence of a patho-
logical lesion affords insufficient proof that
this injury will be followed by inflammation
or other morbid changes. In fact, every
surgeon can recall to mind cases of severe
traumatic injuries of the brain in which
there were extensive larcerations or contu-
sions of this organ ; but, in which the sec-
ondary changes were entirely absent or very
slight.

The same remark may also be made in re-
gard to gross injuries in other parts ; since the
same general physiological and pathological
principles prevail in the cerebro-spinal axis
as in the other organs of the body. It is
therefore entirely proper to introduce in
connection with discussions of injuries of
the cerebro-spinal axis, in many cases anal-
ogous reasoning drawn from studies and
observations made in other parts of the
body. It must be admitted as a general
rule in surgery, that the more extensive and
the more destructive the primary trauma-
tism, the greater will be the danger from
secondary disorganizing processes. Does it
not therefore seem absurd to attribute to a
single punctate haemorrhage or even a half
dozen of these little pathological lesions the

JA new and Revised Edition, p. 158. London,
Longmans, Green & Co., 1882.

620

Com m unications.

Vol. lxiv

power of exciting a disorganizing process in
a healthy spinal cord which may ultimately
produce the death of the patient ?

Is there a single well authenticated case
in which such a result has followed from
such a cause ?

Let us now proceed to the consideration
of our third question — which has a very
important bearing on medico-legal cases and
likewise on the diagnosis and treatment of
myelitis arising from syphilitic disease. Mr.
Erichsen says1 : " It would appear that sur-
geons and writers on diseases of the nervous
system have included four distinct patho-
logical conditions under this <^ne term,
" Concussion of the Spine," viz. : 1. A jar
or shake of the cord, disordering, to a
greater or less degree, its functions without
any lesion perceptible to the unaided eye.
2. Compression of the cord slowly produced
by the extravasation of blood. 3. Com-
pression of the cord by imflammatory exu-
dations, serum, lymph, or pus within the
spinal canal ; and 4. Chronic alterations of
the structure of the cord itself as the result
of impairment of nutrition consequent on
the occurrence of one or other of the pre-
ceding pathological states, but chiefly on
the third."

We have already paid our respects in full
to those subjects included under the head-
ings 1 and 2 ; but we have yet to deal with
those embraced under headings 3 and 4.

There exists no reason to doubt that in-
flammation, having its origin in the spinal
cord or in its membranes, may be either
acute or sub-acute, or that the former need
be developed at an earlier day than the lat-
ter. The important question before us for
our consideration, however, is, How soon do
traumatic inflammations arise after the re-
ceipt of the traumatism ? This question can-
not be definitely answered — the answer must
necessarily be a mere approximation. Nev-
ertheless, I think that observation and ex-
perimentation fully justify the statement
that traumatic inflammation commonly
makes its appearance within four days after
the receipt of the injury. In support of the
above, I will here present a series of experi-
ments which consisted in fracturing the
right leg of twenty rabbits2 : " This was done
without producing a single compound fract-
ure. The temperature details were as fol-
lows : -Average temperature before the fract-

10n Concussion of the Spine, p. 16. London,
Longmans, Green & Co., 1882.

2 Amputations and their Complications, p. 525.
By B. A. Watson, M. D., Phila., P. Blakiston, Son.
& Co., 1885.

ure 102*6 ; average temperature two hours
afterwards 102' 6 ; subsequent daily average
temperature, first, 102*6 ; second, 102*6 ;
third. 103*1; fourth, 103*1; sixth, 103;
eighth, 103*1 ; tenth, 102*8 ; twelfth, 103 ;
fifteenth, 102*8 ; seventeenth, 103*2 ; nine-
teenth, 103 ; twenty-second, 103."

In the case of the brain and spinal cord,
when there is no open wound communica-
tion with these organs, the danger of inflam-
matory action is greatly diminished. Fur-
thermore, the trivial character of lesions
produced by concussion, and also the exceed-
ing rarity of the traumatism — except when
it is produced by lightning strokes, electric
shocks or gun-shot wounds — all combine to
impress me with grave doubts in regard to
its being followed by inflammation. In fact,
there is not sufficient proof to justify the con-
clusion that any case of traumatic myelitis,
or meningo-myelitis, has ever had its origin
from molecular disturbances or any patho-
logical lesions which were invisible to the
unaided eye, in an otherwise healthy spinal
cord or its membranes.

Let us now briefly examine the history of
concussion, in order that we may, if possible,
discover how these troublesome errors were
engrafted on the profession. The history of
concussion dates from 1705, when M. Littre
published his famous observations. A pris-
oner struck his bowed head against the wall
of his cell and fell dead. The inspection of
the head failed to reveal a contusion, tumor
or wound in the scalp or a fracture of the
skull. The cranium was opened when it
was discovered that the brain did not nearly
fill the interior of the skull, while the entire
brain substance seemed harder to the touch
— more compact than usual. This observa-
tion has been reported hundreds of times,
and it was long claimed that it demonstrated
the fact that a violent shaking of the sub-
stance of the brain was capable of producing
death without any appreciable lesion. Per-
mit me here to call attention to the fact that
in the report before me there is no evidence
to show that there was any post-mortem ex-
amination made of any portion of the body
except the head. The autopsy of the head,
viewed in the light of modern science, is
entirely worthless; while the position in
which the head was placed at the moment
the injury was inflicted, suggests the possi-
bility of a fracture or dislocation in some
portion of the cervical region of the spine.
It may be well to call attention to the fact
that in this case, and all other cases of con-
cussion reported prior to the middle of the
present century, the microscope was not em-

May, 23, 1 89 1. Communications.

621

ployed to aid in the discovery of the patho-
logical lesions. Post-mortem examinations
were very rarely made, even in cases of con-
cussion of the brain, and consequently the
case reported by M. Littre was accepted as
a typical one. M. Littre, at the time he re-
ported this case of so-called concussion of
the brain, had become famous in the medi-
cal profession and, therefore, the following
may be very properly applied to him :
*' Great errors seldom originate but with
men of great minds." — Petrarch.

Mr. Erichsen in writing on concussion of
the spine, in 1875, remarks i1 " There is
little opportunity, reason, or excuse for a
post-mortem investigation of that structure,
which is probably the one that is least fre-
quently examined in the dead-house, viz.,
the spinal cord, as it is the one, the correct
pathological investigation of which, is at-
tended by more difficulties than that of any
other organ of the body. So rare are post-
mortem examinations of these cases, that no
instance has occurred to me in hospital, or
in private practice in which I could obtain
one ; and, with one exception, I can find no
record in the transactions of societies or in
the periodical literature of the day of any
such instance. The only case, indeed, on
record with which I am acquainted, in
which a post-mortem examination has been
made of the spinal cord of a person who had
actually died from the remote effects of con-
cussion of the spine from a railway col-
lision, is one that was published in the
' Transactions of the Pathological Society,'
by Dr. Lockhart Clark. He had been in a
railway collision, and without any sign of
external injury, fracture, dislocation wound,
or bruise, began to manifest the usual nerv-
ous symptoms. He very gradually became
partially paralyzed in the lower extremities,
and died three years and a half after the
accident." There is no reason to believe
that this man died from even the remote
effects of the traumatism. The history of
this case entirely fails to connect the disease
from which the patient died with the rail-
way collision. Therefore it may be prop-
erly said of those who base an argument on
this and all similar cases :

" When people once are in the wrong,
Each line they add is much too long;
Who fastest walks, but walks astray
Is only farthest from his way."

— Prior.

1 Concussion of the spine, nervous shock, etc., p.
177, et seq. New York. Wm. Wood & Co., 1875.

A NEW OPERATION FOR HARELIP.

BY CHRISTIAN FENGER, M. D..

CHICAGO.

In all forms of harelip we find not an ex-
cess, but rather a defect of labial tissue — mu-
cous membrane, prolabium and skin. The
two portions of the upper lip, when brought
together, are too small to form a lip of nor-
mal shape ; it would require the interposition
of a triangular piece of lip with apex to-
wards the nose and base toward the border
of the lip to obtain at once a lip of normal
shape. The tissue defect is greatest in the
skin, less manifest in the mucous membrane
and prolabium ; still in the majority of cases
of complete harelip, the defects in these tis-
sues also may be considerable.

It would thus seem natural to select a
method of operating by which no tissue
should be lost. In all the older methods the
so-called "freshening" of the surfaces to be
united requires the removal of at least a
part of the prolabium, in some more, in
others less, at the best as in the method of
Nelatonl,for small harelip, a displacement
downward, to form a projection which must
either disappear by retraction and atrophy
or be removed, if present in excess, by a
secondary operation.

About five years ago I was led to consider
this question in a case of double harelip with
rather defective lateral portions, in which I
operated after the old method, and suppura-
tion with consequent non-union took place.
At the next attempt at union, the increased
defect of tissue made union still more diffi-
cult than at the first operation. I therefore
concluded to operate in my next case without
the removal of any tissue, so as to have, at
least, not lost anything in this respect if sup-
puration and non-union should make one or
more later operations necessary. When I
commenced to operate in this way I found
it necessary to apply a separate row of
sutures to the prolabium before bringing the
edges of the skin together, thus closing the
wound toward the mouth, and I soon tound
this to be a protection against infection. I
have since that time never had any reason
to abandon this method for any of the older
methods.

I. OPERATION FOR UNILATERAL HARELIP.

1. Incision. — The incision is made at the
border of the skin and prolabium, four to six
millimeters or two to three lines deep, care
being taken to guard against opening through
the mucous membrane into the mouth.

622

Communications.

Vol. lxiv

It is necessary to draw the lip down in
order to procure sufficient tension for the
knife to divide the tissues ; this traction
causes anaemia of the border of the lip, mak-
ing the line between the white skin and red
prolabium indistinct. It is necessary to be
careful to have the incision precisely in this
line, because a small margin of prolabial
tissue left with skin will, as I have seen in
one case, leave a red brim along the line of
union, necessitating a secondary operation
for cosmetic reasons.

The length of the incision downward and
outward depends upon the shape of the two
portions of the separated lip. It is unneces-
sary, at the beginning of the operation, to
estimate t«he length correctly, as the incision
can be prolonged later on after some of the
sutures have been applied and tied, accord-
ing to the requirements of the shape of the
lip when united.

2. Sutures of the Prolabium. — Interrupted
sutures of fine silk are applied or inserted
from the mucous surface so as to place the
knot of the suture in the mouth, the first
suture close to the top of the triangle as
shown. The ends of the sutures are left?
long and held together with an artery forcep
which is left hanging down. The succeed-
ing sutures are applied in a similar manner
at a distance of from three to five millimeters
from each other in a number corresponding
to the extent of the line of prolabium to be
united. These prolabial sutures should in-
clude the mucous membrane and sub-mucous
tissue only, or as little tissue as will suffice
to keep the prolabial edges together. There
must be no tension whatever at the line of
union ; if tension exists from shortness of the
labial flabs, it must be overcome by the ten-
sion sutures which will be described later.

When, apparently, a sufficient number
of these sutures have been applied, they are
tied from above downward, or from the nose
to the prolabium, the upper or nasal suture
first, the forceps being held up toward the
forehead. The united line must be long
enough to give sufficient length to the lip
and permit the lowest point of union to be a
little lower down (toward the lower lip) than
the sides of the lip and the corners of the
mouth. The wound to be united is now
closed against the mouth — is made a sub-
cutaneous wound.

3. Sutures of the Skin. — (1.) Tension Su-
tures. According to the size of the defect,
one or two tension sutures become necessary.
I have entirely discarded the figure-of-eight
suture with hairlip pins and also the button
and shot sutures, and always employ an in-

terrupted suture, using silk a little heavier
than that used for the coaptation sutures of
the prolabium and skin. In ordinary cases
of single harelip one tension suture is suffi-
cient. This suture enters the skin at a dis-
tance of one-quarter to half an inch from the
cutaneous margin of the wound and is passed
deeply down into the tissue of the lip. Care-
is taken not to have it pass through to the
mouth, but to have it take in about two-
thirds of the tissue of the lip, as this tension
suture should be placed at or near a point
where the margins of the wound are the
greatest distance from each other — that is,
near to the prolabium of the undivided por-
tion of the lip. The tension suture is left
with long ends held by artery forceps, and
should not be tied until all the cutaneous
coaptation sutures have been inserted.

(2.) Coaptation Sutures : These sutures for
which common silk twist (which may be
bought in dry goods stores, and disinfected
in the usual manner by boiling it from
fifteen to thirty minutes in a five per cent,
solution of carbolic acid) is used, are applied
from above downward, or from the nasal
angle of the wound to the prolabium, at a
distance of three to five millimeters. Three
to five sutures are usually required. The
lowest suture is passed through the ununited
borders of the prolabium.

The wound is now carefully cleansed by
small aseptic sponges and is finally touched
with a sponge wrung out from a two and a
half per cent, carbolic acid or a 1 to 2,000
sublimate solution.

If any haemorrhage is present, it is
stopped by continuous pressure, with an asep-
tic sponge, for a few minutes ; if the haemor-
rhage is slight it will cease upon tying the
sutures.

The closure of the sutures should begin
with the tension suture, so as to prevent the
coaptation sutures from tearing through, as
they would be liable to do if tied before all
tension was done away with.

If, in drawing the sutures together, it is
found that the middle of the lip does not
come down low enough, or that there is still
an indentation in the prolabium at the line
of incision, it is advisable to prolong the
cutaneo-prolabial incision a little on one or
both sides, as the shape of the lip may require,
and then apply an additional cutaneous
coaptation suture.

When the cutaneous sutures are tied, the
united wound should present the appearance
shown.

4. Dressing of the Wound. — After care-
ful cleansing of the line of the wound with

May 23, 1 89 1.

Communications.

623

saturated solution of boracic acid, a layer of
finely powdered boracic acid is dusted on,
and a cotton-collodion dressing applied.
When I began to use this method, I plugged
the nostril with borated cotton, but on ac-
count of its inconvenience to the patient,
have now discontinued this practice. I do
not use iodoform-cotton or iodoform-collo-
dion dressing, for fear of iodoform poisoning ;
I prefer to have .the nurse or mother dust
finely powdered boracic acid into the nostril
every three or four hours during the day.

A single or double strip of rubber adhe-
sive plaster extending from ear to ear
is applied over the collodion dressing in
such a manner as to draw the two cheeks
somewhat together, for the purpose of immo-
bilizing the cheeks and lips when the child
cries or nurses.

The dressing may be changed once a day,
or every two or three days, if it remains dry.
If, however, the dressing becomes soaked by
nasal secretion, or milk when the child is
nursed, it should be changed according to
the necessity of the individual case.

5. Removal of Sutures. — The cutaneous
coaptation sutures are removed after a week :
the tension suture is allowed to remain two
to four days longer, if it has not been loos-
ened by pressure atrophy or pressure necrosis
of its canal. After removal of the sutures,
the borated cotton-collodion dressing and
adhesive straps are re-applied to be con-
tinued until the suture canals have entirely
healed, which takes place toward the end of
the second or third week.

At the junction of the two lateral corners
of the wound, there often remains after the
suturing, a small quadrangular ununited
:space one to two millimeters in diameter
where it may have been impossible to ap-
proximate the edges of the wound. A very
tine suture may help to close this little de-
fect. If, as is often the case, this little
suture cuts through, the small defect heals
by aseptic granulation, requiring only very
little more time than the primary union of
the remainder of the wound. It leaves at
most a small cicatrix in the line of union at
the border of the skin and prolabium and
does not result in permanent disfigurement.

The prolabial sutures will sometimes cut
through and peel off if the process of heal-
ing goes on undisturbed, or some of the
sutures may remain and be removed after
the end of the second or third week, at a
time when union is strong enough to tolerate
the manipulations necessary for their re-
moval.

II. OPERATION FOR DOUBLE AND COMPLI-
CATED HARELIP.

The operation for double and complicated
harelip is performed on the same general
principles, namely :

1. Incision. — The incision along the
cutaneo-prolabial border should be of suf-
ficient length to cover the space of defect.
A second incision should be made along the
cutaneo-prolabial border of the median
peninsula of labial tissue below the nasal
septum, if this peninsula is so situated as to
be avilable for use in the information of the

1!p-

2. Suture of the Prolabium. — The prolabial
sutures are applied as just described for the
unilateral harelip, to be tied on the oral
surface of the wound. The sutures should
be first inserted on both sides of the nasal
peninsula until this is wholly covered and
until both lateral halves of the prolabium
come together at the median point of its
lower border. When this point is reached
these two rows of sutures are tied.

The lateral prolabial borders are now
united in the median line as low down or as
far out as required to give to the lip the
necessary length, as described in the opera-
tion for single harelip. These prolabial
sutures are tied in the mouth usually with-
out any tension, because the prolabium,
when loosened from the skin and retro-
verted, furnishes a flap of sufficient size and
elasticity to permit of ready approximation.

It is important, as before stated, that the
linear incision should not penetrate into
the mouth. When, as is often the case,
the cleft extends through the nostril or
nasal cavity, there is a lack of prolabium
near to and in the nostril, and the prolabial
sutures cannot be applied high up. It is
usually possible by careful dissection and
separation of the mucous membrane at the
oral fornix of the lateral half of the upper
lip, to displace the mucous membrane to
some extent laterally, so that the uppermost
suture may be applied reasonably high up
toward the nostril.

When the prolabial sutures have been
tied, the wound presents the appearance
represented.

3. Sutures of the Skin. — Tension and co-
aptation sutures are now applied as follows :

(1.) Tension Sutures : For these sutures
somewhat heavier silk should be employed.
The upper suture should be inserted at the
lower border of the nasal peninsula, the
lower one near the lower border of the lip.
They should be passed in and out at a dis-

624

Communications.

Vol. lxiv

tance of, a quarter to half an inch of the
border of the skin, and should include one-
half, or a little more than one-half of the
thickness of the lip. The ends should be
held by artery forceps and should not be
tied until all the skin sutures have been ap-
plied.

(2.) Coaptation Sutures : The coaptation
sutures are now inserted from above down-
ward. The first two or three sutures are in-
serted on both sides, between the lateral
skin flap and the skin of the peninsula until
this is united to the side flap throughout
its entire circumference. The lateral flaps
uniting in the median line just below the
nasal peninsula, forms the upper portion of
a Y-shaped line of union. Then the lower
portion of the wound is united by two or
three sutures, and a lower fourth suture is
inserted through the two halves of the pro-
labium.

After thorough cleansing and disinfection
of the wound, the sutures should be tied ;
first, the tension, and then the coaptation
sutures.

4. Dressing of the Wound. — The wound
should be dressed with borated cotton-col-
lodion or in older patients, with iodoform-
collodion. The nostrils, especially in older
patients, should be loosely packed with
borated or iodoform cotton. Over this, two
straps of adhesive plaster should be applied.
In older patients a strip of iodoform gauze
should be laid in the mouth along the line
of union of the prolabium. In new-born
children the nostrils need not be packed
with cotton and no iodoform gauze should
be used : but these localities should be fre-
quently dusted with finely powdered boracic
acid. The dressing should be changed ac-
cording to the amount of discharge, never
more than once daily.

5. Removal of Sutures. — The coaptation
sutures of the skin may be removed at the
end of the first week ; the tension sutures
according to the amount of tension remain-
ing, usually late in the second week ; finally,
what may remain of the prolabial sutures
should be removed still later when the
union is so solid that the upper lip is able to
tolerate manipulation.

. It is immaterial how narrow the new
upper lip may appear to be immediately
after the operation. Konig remarks (in
speaking on plastic operations on the lips —
keiloplastic operations following the extir-
pation of labial carcinomas) that the shape
of the mouth, however deformed it may ap-
pear, on account of unequal size of the lower
and upper lip in the first weeks after the

operation, that in the course of some months
the shape of the oral orifice and lips be-
comes more and more normal, surprisingly
so when a sufficient time, from three to six
months, has elapsed.

The all-important feature of the opera-
tion is to make the upper lip long enough
in a sagittal direction, and to have exact
union of the lower portion of the prolabium.

Apparatus to draw the cheeks together
for the sake of immobilization or to diminish
tension I have up to this time found super-
flous.

CONCLUSIONS.

The two main points in this harelip
operation are the incision and the prolabial
sutures.

1. The incision, a linear incision, is similar
to that made in the operation for laceration
of the perineum as proposed by Lawson
Tait, and by him termed "flap-splitting."
As stated above, this possesses the advan-
tage of not sacrificing any tissue of the parts
already more or less defective ; on the other
hand, repeated denudations made necessary
by unsuccessful attempts at union would
tend to make the lateral portions of the lip
smaller and smaller. Furthermore, the
linear incision, by loosening the everted
prolabium (which is readily converted into
mucous membrane by the simple change of
position into the oral cavity) furnishes so
much tissue for the posterior surface of the
lip that union of the prolabial borders is
easy, even before any tension sutures have
been applied.

2. The prolabial sutures should be ac-
curately applied. Fine curved needles
should be used, the sutures made of fine silk.
Interrupted sutures should be employed, in
sufficient number and at sufficient intervals
to furnish exact union. These sutures close
the wound against the mouth and make the
wound, so to speak, cutaneous instead of
visceral, and thereby prevent infection from
the ever-present multitude of microbes in
the mouth. I believe that this suture will
prove to be a potent factor in securing uni-
form results by preventing suppuration and
non-union of the wound.

3. The cosmetic results have been all I
could desire. If a slight indentation at the
line of union of the prolabium has existed
immediately after the operation, it has gen-
erally disappeared after a few months, pro-
vided the lip has been made long enough at
the time of the operation.

4. I think that this method is applicable
in all cases and should take the place of all
the numerous older methods of operating.

May 23, 1 89 1. Society

Reports.

625

Society Reports.

AMERICAN MEDICAL ASSOCIATION.

FORTY-SECOND ANNUAL MEETING, HELD IN WASH-
INGTON, D. C, ON TUESDAY, WEDNESDAY, THURS-
DAY AND FRIDAY, MAY 5, 6, 7 AND 8, 1891.

The Address of Welcome. — The proceed-
ings of the general session were opened at
Albaugh's Opera House, with an address of
welcome to the members and delegates by
the Hon. J. W. Ross, one of the Commis-
sioners of the District of Columbia. He
characterized the association as representing
a constituency more numerous and powerful
than any other on the face of the globe and
one whose influence could not be over esti-
mated. No similar organization ever occu-
pied the vantage-ground held by the associa-
tion for the discussion of topics calculated
to enlarge its usefulness and power. One of
the primary objects at which it was aiming
was the promotion of such legislation as
would tend to strengthen the profession in
the performance of its duties. As a mem-
ber of the bar he had often marveled at the
fact that the common law, which respected
the confidence that should exist between
counsel and client, did not extend the same
privilege and protection in the case of the
physician and his patients. If any com-
munication should be absolutely sacred
and beyond the inquisition of the witness
stand, it should be the statements made by
an individual to his medical adviser. He
thought that the time had come when any
suitably expressed statements of the rights
and requirements of the medical profession
in this matter to the great body of law-
makers in Congress would be treated with
the most profound respect.

The President's Address. — In the course
of his address the President reminded his
hearers that they were met solely for the
promotion of science and for the good of the
human race, to maintain the honor and dig-
nity of the profession, and to hold aloft the
flag of honorable medicine. They were
there to lay their contributions, the results
of study and observation, upon a common
altar for the common good ; to worship at
the sacred shrine of medicine and to renew
their fealty to the noble profession to which
they had devoted their lives and linked
their fortunes. As physicians they had an
almost superhuman mission to fulfil. ' The
chief object of their professional work was
to preserve life and insure health. The
goal of their ambition and desire was almost

at the end of human capacity. It was their
province as well as desire to know all the
secrets of natural organization. They would
have the formative crystal and the germinal
spot made transparent. They would enter
the microscopic world and witness the won-
ders therein revealed, and would, if possi-
ble, search into and unravel the very myste-
ries of the vital principle. To this perfect
knowledge did they aspire. It was doubtful
if man's intellect, great as it was, could ever
compass all that he so earnestly desired ;
yet, by constant and faithful work, he might
approach nearer and nearer to its consum-
mation. In .every part of the habitable
world, blessed with the light of civilization,
active, busy members of the profession, en-
dowed with high culture and incited by the
noblest resolves, were enthusiastically en-
gaged in unraveling the mysteries of dis-
ease and seeking means and methods of
treatment for the mitigation and relief of
suffering and the prolongation of life. That
the full benefit of the labors of American
physicians might be attained and utilized, it
was essential that the members of the pro-
fession, scattered over an area of country of
almost inconceivable magnitude, should be
brought into associated action and be organ-
ized into a body whose influence might be
exerted over the length and breadth of the
land, until a correct and noble sentiment
was engendered in the mind of every mem-
ber of the profession.

One of the great benefits conferred by the
association was the establishment of an
esprit de corps in the profession by the prep-
aration and adoption of a code of ethics
which comprised the great principles of
truth, honor, and justice in regulating the
relations of physicians to each other, to
their patients, and to the public. This
should be and was the written law, clearly
defined, and of acknowledged force and
effect, that prevailed from one end of the
country to the other. It formed an impas-
sable barrier between the sheep and the
goats, the clean and the unclean, the physi-
cian and the charlatan. The strict observ-
ance of this code had done more than any-
thing else to maintain harmony in the pro-
fession and to elevate it in the public esti-
mation. It embodied the true spirit of the
golden rule. Every one who entered the
profession should be provided with a copy
of the code, and should make it the guide
of his medical life. It would serve as a
talisman to the young physician, and would
be the best safeguard against snares and
pitfalls. It would seem that every honor-

626

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able and high-minded member of the pro-
fession would be willing to indorse and be
controlled by this code. It was to be re-
gretted that there were some, who undoubt-
edly possessed a high order of talents and
were justly distinguished, who had still an
utter repugnance to the observance of cer-
tain parts of the code, and who held them-
selves aloof from the association in conse-
quence. These gentlemen were probably as
proud of the noble profession to which they
belonged as any others were, and were
equally anxious for the advancement of its
interests, but could they censcientiously
affirm that the motives by which they were
influenced were pure and unselfish ? Should
these members put their opinion against the
unbiased and unselfish judgment of the
wisest and most experienced in the profes-
sion, nine-tenths of whom were guided in
their actions by the spirit and letter of the
code?

The fundamental and chief object of those
who had originated the association was the
improvement of the American system of
medical education, and the elevation of the
standard of requirements for the profes-
sional degree. Never had there been a
greater expenditure of effort illumined with
genius and learning to accomplish these two
great objects, and, though many of the
ideas were, in a country so diversified in
character and extent, probably somewhat
Utopian, there had been a gradual eleva-
tion of the standard of education fully
equal to the progress of the country in
every other department of human learning.
The speaker was ready to maintain that the
advantages and facilities for medical in-
struction in this country, even at the pres-
ent time, were quite equal to those of any
other, and that the medical colleges had pro-
duced as able, learned, and successful prac-
titioners as had ever been graduated from
other institutions. While he was willing to
admit that our trans-atlantic brethren had
excelled in experimental work, this country
had taken the lead in all the practical de-
partments'of medical science.

Now that the Medical College Associa-
tion had adopted all the requirements for
improved medical education which this
association had been so long urging, and for
which in fact it was established, it was
eminently proper and important to pass a
resolution that after the changes contem-
pleted had gone into effect no medical man
who had received a degree-from a college
that had not adopted the improved method
of teaching, and no professor or attache of

such college, should be eligible as a delegate
or member of the association. This great
moral support was due to those colleges
which had so heartily taken up the burden
that the association had for nearly half a
century carried on its own shoulders.

It might be well to call attention to the
fact that original research and experimental
investigation had not received the attention
from American physicians which their im-
portance demanded. The government, while
the most liberal and best in the world, had
never seemed to comprehend that the cause
of science would be greatly advanced and
its own honor increased by the establish-
ment of schools for original investigation
and experimental research. It had not
kept pace with other enlightened govern-
ments in scientific enterprises. Such work
must in the very nature of things be left,
for the present at least, to the progressive
spirit that animated the universities and to
private laboratories which were being estab-
lished in different sections of the country.
It would probably be advisable to establish
a Section in Experimental Research, which
would tend to advance science and be
greatly to the interest of the work of the
association.

It had been a happy conception of one
of their most distinguished presidents to
make the establishment of an association
Journal the burden of his inaugural address,
and so powerfully had he impressed the
minds of the members that a journal had
sprung into existence which had in a short
time given evidence of its power in the ad-
vancement of its purposes. It might re-
quire years to bring it to the desired stand-
ard. To effect so desirable an object it was
necessary to make provision for an ample
annual income. Nothing less than from
seventy-five to a hundred thousand dollars
should be considered ample. Next in im-
portance to its financial needs was the selec-
tion of an editor, able, learned, and highly
endowed with editorial tact and business
qualifications, who would devote all his
time and talent to his editorial duties. He
should be empowered to spend money liber-
ally in obtaining scientific material, original
communications, translations, and reviews
from every part of the world. He should
have absolute control in the selection of
matter for the journal. To such an editor
a salary should be given that would render
him independent. The sum should be not
less than ten or fifteen thousand dollars a
year. The necessary funds could, by
proper exertion, be easily raised, and would

May 23, 1 89 1. . Society

Reports.

627

not only sustain the journal in the best
style, but afford a sum in addition which
could be used in many ways to the advan-
tage of the association. The future loca-
tion of the journal was a matter of such
importance as to require careful considera-
tion. Its weal or woe might depend upon
the action taken at the present meeting. It
had been suggested that the Journal of the
American Medical Association should be
moved to Washington, and it had been
determined to submit the question to the
members and delegates present at this ses-
sion. He would beg the delegate's and
members of the association to consider well
every side of this question before commit-
ting themselves to a vote. The Journal had
now its home in Chicago, and had been
there for eight years. It had already be-
come the peer of many of the great week-
lies of the country, and, if properly sus-
tained by the profession and wisely and
energetically conducted by its managers, it
would become the recipient of the best
thoughts of this country and the worthy
exponent of the American profession. It
had been proved that it could be more
economically published in Chicago than in
Washington, which latter city was by no
means an important scientific or professional
center. But it was the great center of
American politics, to which everything was
made subordinate, and it would be impos-
sible, if the Journal was published in that
city, to prevent its becoming contaminated
by the political air.

The Relations of Contract Surgeons to the
General Profession. — A special committee,
appointed last year by the Medical Society
of West Virginia to consider this subject,
memorialized the association and appealed
for its active co-operation to effect the re-
dress of alleged abuses. The memorialists
asked consideration of the question as to
how far the rules adopted by railroad cor-
porations for the government of the sur-
geons in their service infringed upon the
rights of the profession at large as set forth
in the code of ethics of the American Med-
ical Association. It was well known that
large bodies of men were in the employ of
these corporations, and that these men lived
in widely-scattered communities. The cor-
porations had established systems of employ-
ing contract surgeons to attend to employees
and passengers injured by accidents. It
was also well known that these corporations
had adopted rules for the government of the
surgeons and of those injured which de-
manded that these surgeons should assume

entire charge of such employees or pas-
sengers when injured, regardless of the
rights of any outside medical men who
might have been summoned and be in at-
tendance upon the injured prior to the
arrival of the company's surgeon, even
though the physician first in attendance
might be the family physician of the injured
person. Notice had been given in most
cases by the railroad companies waiving all
responsibility in respect of injuries treated
by non-contract men. It was assumed by
the memorialists that this condition of
affairs placed the contracting surgeons in
direct conflict with the spirit of the code of
ethics, and was an infringement upon the
rights of the physician first called. The
practice of accepting passes as compensa-
tion or in lieu of the regular fees was detri-
mental to the profession's interests by lower-
ing the standard of surgical services, and
was further demoralizing. It gave to these
wealthy corporations services at far lower
rates than the profession charged to indi-
viduals. It seemed that if members of the
profession were at liberty to make contracts
to furnish an unlimited service of the kind
referred to for passes, and in some cases for
small fixed money payments, without affect-
ing their ethical standing, all stigma of un-
ethical or unprofessional conduct should be
removed from those of the profession who
contracted with private individuals to fur-
nish medical or surgical services, including
medicines, by the month or year for fixed
sums. A special committee was voted to
sift the facts in respect to the points alleged
in the memorial.

The Rush Monument Fund. — This subject
was again brought before the association by
Dr. A. L. Gihon, who for the seventh time
reported slow progress toward the accumu-
lation of the required fund. He made an
earnest appeal for more enthusiasm in the
matter, and propounded certain schemes
that might be adopted for the purpose of
raising the necessary money, which were ap-
proved.

The Address in General Medicine. — Dr.
E. L. Shurly, of Detroit, delivered this ad-
dress. He said he should present for con-
sideration some points bearing on the rela-
tion of micro-organisms and toxines to the
so-called zymotic or infectious diseases.
Though laboratory work had done more
than any other branch of science toward
clearing up many vexed questions about
physiological and pathological activities,
yet, to be of lasting value and guidance, it
must agree with general and clinical obser-

628

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Reports.

Vol. lxiv

vation, and there were instances where
laboratory and clinical observations had
crossed swords. He was aware that it was
generally accepted that bacteria or their
spores were the essential cause of most, if
not all, of the infective diseases, and the re-
sults of bacteriological investigation during
the last few years would seem to support
such a doctrine for the following reasons:
1. They could be isolated by color reactions
and thus directly connected with the dis-
eased body when found. 2. They required
a certain time for development, correspond-
ing to the period of incubation of such dis-
eases, many of them being ectogenic and
saprogenic, anaerobic or aerobic. They
could thus live until the opportunity for in-
vasion offered. Being endowed with life
and multiplying enormously, they could
resist destruction, Being protoplasmic and
microscopic, they could more readily affiliate
with animal fluids, cells, and tissues existing
in a passive or quiescent state as well as in
an active one. They could behave like
vegetable seeds or spores, and preserve a
long period of latency. For these and other
reasons that might be adduced, we were led
to believe that bacteria must be the cause
in some way or other of the zymotio infec-
tious diseases. But the question arose, How
did they effect this result ? Was it by mere
local growth as parasites, or by the secre-
tion of a material from themselves? In
other words, were they secreting cells or did
they induce at once chemical changes or
fermentation of a destructive character with
the formation of poisonous substances ? It
would be seen that many observers who
were strong in their faith in the microbic
origin of disease had not in every instance
looked fairly at the question. The state-
ment that no case of genuine cholera had as
yet been reported in which the comma
bacillus was absent had been disproved. In
what bacteriological life were exemplified
certain effects that had been observed con-
nected with development ? The career of
bacteria ad interim, from one animal to an-
other, was not well known. In the case of
many of them, spores had never been dem-
onstrated or their behavior formulated.
Most of the species were destroyed by the
healthy fluids or tissues, and hence their
destiny depended upon a favorable nidus or
pabulum, which meant disease. It was ob-
vious that artificial culture in media outside
the body or in the lower animals could only
approximately reflect their real natural
growth and development, for in no instance
was it possible to transfer the artificially

cultivated micro-organisms to an animal
with the absolute certainty that nothing
else accompanied the bacteria. The certain
species only appeared to be pathogenic im-
plied a state of specialization analogous to
that of living nucleated cells. That their
action was local primarily in all cases might
be assumed, because their behavior in no
way showed that they themselves invaded or
maintained their existence in the blood or
lymph. Therefore it was possible that
pathogenic bacteria developed only where
previous disease or an abnormal state of the
body suitable to them existed ; that, having
found such, they took root, as it were, and
by their catalytic action primarily, and
secondarily by giving rise to a particular j
toxine, which in turn acted selectively as a
tissue poison. If the bacilli of tuberculosis I
immediately produced the several diseases
known as tubercular, why should any pre- !
viously prepared nidus be necessary? If
they or their still un demonstrated spores
were constantly invading us, which was un-
doubtedly true, they must at once be de-
stroyed, or, by gaining access to the fluids ;
of the body, must set up, mechanically or
otherwise, inflammation and their peculiar
effects as any other foreign body would.
But, as such micro-organisms must find just
the proper conditions for development or
not develop, we might assume that such a
result implied previous disease, such as case-
ation, whether tuberculous or not. Com-
plex and delicate processes attended the
changes' of proteids, and by radical or
atomic substitution one might be changed
readily into the other. We could see how
probable it was that these micro-organisms
might operate by a peculiar property wdiich
enabled them to decompose or exercise a
catalytic action on certain states and kinds
of proteids. It was manifest that diseases
arising from the presence or entrance of
micro-organisms must be therapeutically
treated by attacking the cause or neutraliz-
ing its operation. The bacteria produced
for themselves, or from the organic sub-
stances which they attacked, a poison which
could be cultivated outside the body in some .
instances. Pathological chemistry had not
demonstrated with exactness the nature of
all these poisons, or classfied them, but it
was fair to believe that this would be done
in the near future. Although it was gener-
ally supposed that inorganic chemicals were
not tissue poisons, but acted only upon the
functions through the nervous system, still
this view did not obtain when we observed
the changes produced by iodine, bromine,

May 23, 1891.

Society

Reports.

629

phosphorus, arsenic, and the silver, gold,
platinum, and cupric salts, besides some of
the vegetable alkaloids. In consideration
of the changes that many of the remedies
underwent in the stomach and intestines by
oxidation or other processes before their
absorption, it seemed to the speaker that the
rational mode for the administration of
drugs was to give them hypodermically, and
in this way it was possible to command ef-
fects which could not otherwise be attained.
Dr. Lauderer had obtained beneficial effects
in phthisis from hypodermic injections of
balsam of Peru. Behring had recently
found that a number of chemical substances
used hypodermically — such as aurochloride
of sodium, naphthaline, and trichloride of
iodine — were capable of neutralizing the
poision of diphtheria in guinea-pigs, the
latter substance being the most active of all.
The same observer had also practiced in
diphtheria, and with good effect, the inocu-
lation of animals with bacillus cultures.
Better effects had been obtained from the
administration of bromide of gold by injec-
tion than from the bromide given in the
ordinary way. The prompt results in the
treatment of erysipelas with carbolic-acid
injections were well known. The superior
effects of the treatment of syphilis by the
hypodermic injection of cyanide and bichlo-
ride of mercury and chloride of gold and
sodium were striking. The hypodermic in-
jection of chlorodyne in profuse diarrhoea
was superior to its administration by the
mouth. Ergot administered, even in con-
siderable quantities, by the mouth would
often fail, whereas one, or at most two, hy-
podermic injections of one-tenth or one-fifth
of a grain of ergotin would generally stop a
severe attack. Digitalis also acted upon
the cells and vascular system more certainly
"when so administered. He might also men-
tion the beneficial effects of strychnine used
in the same manner in typhoid conditions.
That animal poisons could be neutralized in
the body he believed would soon be gener-
ally demonstrated. The recent experiments
of Tyndale, of New York, for the cure of
tuberculosis by vaccination promised well.
Hemmeter,had stopped the diphtheritic proc-
ess by the inoculation of the patient with
an erysipelas toxine, and it was stated that
persons suffering from tinea tonsurans were
proof against diphtheria. This would seem
to show that there must be a sort of antag-
onism between animal and chemical poisons.
Why could not more universal application
be made of this principle with a view to ob-
taining more specific therapeutic agents?

His object in choosing this subject had been
to awaken a more general interest in physi-
ological and pathological chemistry, and
thus hasten the period of release from em-
piricism.

The Address in Surgery was on Stricture
of the Rectum ; its ^Etiology, Pathology,
Symptomatology, Diagnosis, and Treatment,
by Dr. J. H. Matthews, of Louisville. He
said he realized that in discussing this sub-
ject he should take positions contrary to the
accepted teachings of the day, but assumed
that the one great object of the meetings of
this association was to elucidate and dis-
cuss subjects that were in doubt, those that
were mooted. In considering the classifica-
tion of the varieties of stricture of the rec-
tum as given by Dr. Kelsey, he said that
the idea intended to be conveyed by the
term was that of a pathological change in
the tissues, a deviationTrom the natural state
brought about by disease ; hence he objected
to the consideration of congenital malfor-
mations of the rectum, or to defining them
under the head of strictures of the same, for
the reason that it was misleading to do so.
It would be more to the point to call them
atresias of the gut. Exception could also
be made* to the term acquired, stricture, and
it was very easy to understand how one
could acquire a stricture as the result of
venery, but difficult to understand how one
could acquire a spasmodic or cancerous
stricture. He would adopt, for the sake of
discussion, the classification into —

1. Spasmodic. — To this form of stricture
he should prefer two objections. First, if it
was true that such a condition ever existed,
which he doubted, then it should not be
classed as stricture at all, for the reason that
no pathological change was manifest such as
was necessary to constitute a stricture, and
no treatment could be given in per se. In
other words, it would be a symptom of some
lesion or trouble outside the one called strict-
ure. Secondly, he believed that, from the
anatomical construction of the rectum, it
would be utterly impossible for its lumen to
be so constricted by spasmodic contraction
of its muscular fibers as to be perceptible as
an obstruction. In all his examinations of
this part of the gut he had never seen a
spasmodic contraction that could be called a
stricture.

2. Dysenteric. — Although it was fre-
quently stated that dysentery was a common
cause of stricture of the rectum, he had
never seen a case that convinced him of the
truth of the statement or that it was a cause
at all. He had many times seen patients

630

Society Reports.

Vol. Ixiv

who gave him a history of having had dys-
entery ; and who were treated for a long
time for the affection ; but close scrutiny of
the case had revealed the fact that the so-
called dysentery was caused by an already
existing stricture and ulceiation. Dysen-
tery was the result, not the cause, of strict-
ure. If a long-continued irritation was
kept up in the rectum from any cause, the
result would be, of course, an inflammatory
exudate, resulting, perhaps, in ulceration
and stricture ; but, in searching for this as a
cause, the road to a conclusion had not been
plain enough for him to put dysentery in
the list as a cause at all for stricture of the
rectum.

3. Tubercular. — Since the discovery of
the tubercle bacillus it was self-evident that
tuberculosis was often met with in the mu-
cous membrane and other structures of the
rectum. If stricture and ulceration was the
term used, he could make no objection to
the classification of tuberculosis as a cause
of ulceration. That ulceration frequently
resulted from this diathesis or dyscrasia no
one could doubt, or that the coincident
stricture followed as from other well-known
causes — notably syphilis — he could not
agree. The disposition of tuberculous tissue
everywhere was to break down. Before the
capacious rectum was filled with tubercular
deposit sufficient to stricture it, it would
have broken down from ulceration, and so
on ; and it must be by deposition only that
we could conceive of stricture from this
cause, because cicatrization was so rare and
so feeble in these parts that it would be the
rarest accident to find it. In no instance
had he ever seen a stricture of the bronchial
tubes the result of tuberculosis. There
would be just as much reason to expect it
here as in the rectum ; indeed, more.

4. Inflammation. — This term was so broad
and comprehensive that we must admit
inflammation as a cause of stricture of the
gut — indeed, as the one grand and common
cause. In no other way could a stricture
be formed. It might be argued that a lesion
or wound existing in the bowel, by the re-
parative process healed and left cicatricial
tissue, and that the stricture was the result
of the cicatrix, and not of plastic infiltra-
tion of the tissue. But there could have
been no cicatrization if there had been no
inflammatory process. If he were asked
what was the prime cause of stricture of the
rectum, he would answer, Inflammation.
What caused the inflammation in many
cases he did not know, but, ordinarily, it
wTas syphilis, cancer, or trauma — if by

trauma was meant a wound or lesion from
any or many causes. Outside of the two
first named, cancer and syphilis, he was
satisfied that no one could tell the cause that
originated the stricture. He wished to re-
iterate that, outside of these two well-recog-
nized causes for stricture of the rectum, he
was not prepared to admit any other as a
well-known, recognized, indisputable cause.

After elaborating the points in the diag-
nosis and pathology of stricture, the speaker
went on to deal with the question of treat-
ment, premising that he should adhere in
the strictest sense to the pathological con-
dition— namely, a stricture. This entirely
ruled out the treatment of proctitis or the
subsequent ulceration, which was one cause
of stricture, and brought him directly to
the means of treating that which was the
result of said causes. It must be granted
that many times ulcerations wThich would
otherwise end in stricture were cured before
that condition resulted. This could not hold
in cancer, and possibly not in syphilis. The
methods practiced to-day for treating strict-
ure of the rectum were : first, dilatation ;
second, incision ; third, electrolysis and rac-
lage; fourth, excision ; fifth, colotomy. Of
course, under the division he had made,
general treatment was ruled out, and the
gradual dilatation of the stricture was ob-
jectionable for the reason that by this form
of repeated irritation, more plasma ^as
thrown out and the stricture surface in-
creased. It might be true that some tem-
porary relief w7as afforded, but upon the
contraction of the tissue more was lost than
had been gained. He did not hold the view
that by the passing of bougies through the
strictured surface absorption of the tissue
was caused, but believed that the converse
was true. Why forcible divulsion was sel-
dom applicable in these cases he could not
understan d. If a fibrous stricture existed, for-
cible divulsion was the best method. To-day
we did not fear haemorrhage, because we un-
derstood how to control it. He was very pos-
itive, then, in saying that, if dilatation of a
stricture of the rectum was decided upon, it
should be a forcible and a radical one. He
was very partial to incision or incisions for
the relief of stricture of the rectum. Of the
two operations recommended, internal and
external posterior linear proctotomy, he pre-
ferred the internal. It was urged for the
external, which consisted in not only cutting
through the strictured surface but also in
dividing the sphincter muscle, that it was
all-important to get the necessary drainage.
He did not think so — and if he did, he be-

May 23, 1 89 1. Selected

Formula.

631

lieved the ill effects of dividing the sphinc-
ters outweighed the matter of drainage. His
plan was to introduce a three- or four-valve
speculum and, after dilating sufficiently for
the purpose, a long, sharp knife was used to
divide the constrictions of fibrous tissue
down to a healthy base — not only in the
median line, but in several places around
the circumference of the gut. He then
placed a tampon, through which was in-
serted a metallic tube for drainage and the
escape of gases. This tampon was aseptic
and usually dusted with powdered persul-
phate of iron. On the fourth day it was
removed and the rectum was irrigated with
the mercuric solution. If the operation was
done effectually, he had never seen the
necessity of employing the bougies afterward
for the purpose of dilatation.

Excision. — He thought a better term to
employ here would be extirpation. Excis-
ion of a stricture of the rectum conveyed
but little idea of the operation. He could
not appreciate the idea of excising a benign
stricture. Extirpation of the rectum for
malignant disease was an ideal operation.
It was an axiom in surgery that in operat-
ing for cancer the whole growth must be
removed, together with the glands that were
involved. If the growth extended beyond
the point where it was prudent to operate,
it was best not to attempt its removal, ex-
cept, perhaps, for total obstruction, not with
any idea of cure. Kraske's operation was
admirably suited to cancerous stricture. It
consisted in resecting the diseased part
through an opening made at the left side of
the sacrum. This operation was only appli-
cable in a certain class of cases. If the sig-
moid flexure was involved,, it would be of no
use. According to this method, the soft
parts were divided in the median line from
the second sacral vertebra to the anus. The
muscular attachments to the sacrum were
divided as far as the edge of the opening on
the left side. The coccyx was removed, the
attachments of the two sacro-sciatic liga-
ments to the sacrum were cut, and the soft
parts were drawn to the left side. If still
more room was necessary, it might be gained
by removing a part of the lower left side of
the sacrum. If the bone was divided on a
line beginning on the left edge, at the level
of the three posterior sacral foramina, and
running in a curve with the concavity to the
left through the lower border of the three
posterior sacral foramina, and through the
fourth to the left lower border of the sa-
crum, the more important nerves were not
injured and the sacral canal was not opened.

In this way the lower part of the rectum as
far as the sigmoid flexure might be resected.
It would be found in this operation that the
dissection was a very. difficult one.

As to colotomy, he was forced to conclude
that none of the arguments in its favor, in-
stead of other methods for cancerous strict-
ure, could be substantiated in fact. If he
were asked when colotomy was justified in
cancer of the rectum, he would answer, Not
at all. But if there was a total obstruction
of the sigmoid flexure from a cancerous
mass, colotomy would be justifiable. When-
ever a stricture other than malignant, espe-
cially when caused by syphilis, was located
in the movable part of the gut or in the sig-
moid flexure, either causing total obstruc-
tion or about to cause it, colotomy should be
done. By this we prolonged life indefinitely.
If, then, it was decided to do colotomy,
which of the two operations was preferable--
the lumbar or extra-peritoneal, or the iliac
or intra-peritoneal ? He thought the ana-
tomical phrase used in designating the two
should decide it.

The Association's Journal. — The vexed
question as to whether the publication of the
Journal of the association should continue
in Chicago or be removed to Washington,
which it was supposed would form the sub-
ject of warm debate, was settled by an over-
whelming vote to maintain the present
arrangements.

Eecommendations for change in the edi-
torial and business management of the Jour-
nal were rife. — JSf. Y. Med. Jour.

Selected Formulae.

TREATMENT OF ACUTE CORYZA.

According to Dr. Tissie, in the Revue de
Laryng., d' Otolog. et de Bhinolog., May 1,
1891, acute coryza may be dependent upon
certain difficulties of the general nutrition.
In such cases, to effect a cure, these symp-
toms as well as the local manifestations
should receive the physician's attention.

Locally, Dr. Tissie claims efficacy for in-
halations of a few drops of the following
mixture, poured upon absorbent paper :

Jjkf Carbolic acid 5 grammes.

Water of ammonia 5 "

Water 15 "

Alcohol .....10 "

M. et Sig. For inhalation.

Antipyrine will be found valuable in re-
lieving the headache accompanying acute
coryza. Finally, the author advocates the

632

Selected

Formula.

Vol. lxiv

use of the following snuff, five or six times a
day:

Ij^ Sub-nitrate of bismuth 6.00 grammes.

Powdered benzoin ..6.00

Carbolic acid 4-°° "

Menthol 0.20

Morphine 0.03 " M.

Donna, in the Province Medicale, speaks
highly of the value of ichthyol similarly
used.

METRORRHAGIA.

JHtf Ergotini 10. 00 grammes.

Aq. dest 7°-°°

Glycerini 20.00

Acid salicylici 0.20

M. et Sig. One teaspoonful in three teaspoonfuls of water
for rectal injection.

— Keinstadier, in the Raccoglitore Medico,
April 30, 1891.

ARISTOL IN GYNECOLOGY.
Swieciki, in the Raccoglitore Medico, April
30, 1891, gives the following formulae for
aristol, which he claims to have found most
efficacious in twenty cases of metritis, hyper-
plasia of the cervix, parametritis and eczema
of the vulva.

I. Aristol 5 grammes.

Powdered gum arabic 9.5 "

To make 5 pencils about 5 centimetres long.

II. Aristol 0,50-1,00 grammes.

Cocoa butter 9.5 "

To make 10 vaginal suppositories.

III. Aristol..... 5. 00 grammes.

Sugna 5,00 "

Lanolin 1.80 "

M. et fiat unguentum.

SALICYLATE OF MERCURY.
For hypodermic injections Vacher uses
the following solution :

1^? Hydrarg. chloridi corrosiv 1 part.

Sodii salicylici 2 parts.

Aquse destil 100 parts. M.

In this solution each cubic centimeter
contains one centigram of salicylate of mer-
cury. For use by the mouth a 1-1000 to
1-5000 solution should be used. — Deutsche
Medicin. Wochenschrift.

CHRYSAROBIN FOR HEMORRHOIDS.

Kossubudski (Bui. Gen. Ther.) has used
with success this remedy proposed by Unna.
For external haemorrhoids this ointment is
used :

5^kJ Chrysarobin gr. viij.

Iodoform gr. iij.

Ext. belladonna? gr. vj.

Petrolati 5 iv.

Ft. ung.

For internal use, a suppository :

Ijfc? ' Chrysarobin gr. j.

Iodoform gr. J^.

Ext. belladonna? gr. %.

Olei theobromae gr. xxx. M.

For one suppository.

DYSMENORRHEA.

Monin (JJ Union Medicale) recommends
the following for dysmenorrhoea of chlorosis:

Alcohol of melissa ~|

Tincture of saffron j» aa i% ounces.

Tincture of iodine I

M. Twelve drops daily, before each of
the two principal meals, for two months.

Every eight days, a warm bath, containing
three and one-half ounces of chlorate of am-
monia.— Univ. Med. Mag.

PRURITUS.

The following are given by La Semaine
Med. for pruritus :

1^ Pureresorcin Jjjj,

Glycerin 5 ij.

Water 3 iv. M.

Sig. — For external use.

t^? Menthol 5 iij.

Glycerin 5 ij.

Water g iv. M.

Sig. — For external use.

APPLICATION OF ICHTHYOL

According to the Revue Generale de Clin-
ique et de Therapeutique, Unna employs the
following preparation of ichthyol in the
treatment of diseases of the skin :

Ijk? Ichthyol 25 parts.

Starch 50 "

Carbolic acid 2^ "

Water 22 "

The ichthyol and carbolic acid are dis-
solved in the water while hot, and the starch
added.

CHRONIC BRONCHITIS.

U Union Medicale recommends the follow-
ing pill for chronic catarrhal bronchitis :

Turpentine \
Tar f" "

Balsam of Peru.

.aa 5ss.
ojss.

Benzoate of sodium, a sufficient quantity
to make 80 pills.

Two of these pills may be given three
times a day, in cases in which there is a
marked catarrhal exudation into the bron-
chial tubes.

May 23, 189 1.

Editorial.

633

THE

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Leading Article.

CURRETTING OF THE UTERUS IN PUER-
PERAL FEVER.

It is a surprising fact that while the micro-
bic origin of puerperal fever has been recog-
nized for some time, the use of the curette in
these cases has only recently received any
extensive consideration. If simple cleansing
or irrigation of the parts proves insufficient
to remove the cause of infection, one would
surmise' that the surgeon, at least, would at
once attempt bolder and more efficacious
means.

Fortunately, asepsis in child-birth has
almost entirely done away with the possi-
bility of puerperal infection, and this bug-
bear of obstetricians of a few years ago, has

almost sunk out of existence. Yet, from
varied causes, including carelessness from
either physician or nurse, or pre-existing
suppurative process, child-bed fever still
manifests itself occasionally both in Hospital
and private practice, and its prompt treat-
ment is a serious question.

The rapidity with which death frequently
follows the first symptoms of puerperal infec-
tion is remarkable, and brooks of no delay
in treatment. Hecker reported a case, not
lqng ago, wherein death occurred so quickly
that a diagnosis of apoplexy seemed justifia-
ble. The number of deaths from puerperal
infection reported as occurring within the
first twenty-four or forty-eight hours after
the appearance of untoward symptoms, is
startlingly large.

Could the physician know of the moment
when infection has taken place, prompt re-
moval of the infectious matter, by irrigations
and douches, would surely prevent general
infection. But this, unfortunately, is impos-
sible.

In laparotomies, a prognosis may be ad-
vanced very early, for, if infected, the patient
will usually show, within a few hours after
the completion of the operation, signs of fear,
restlessness, weakness and depression, before
any objective symptoms have manifested
themselves. It is not to be wondered at,
therefore, that within a comparatively short
time an incurable puerperal infection may be
developed. Even in Hospitals, where the
patient's temperature is taken three times a
day, the attending physician is often forced
to confess that he has come too late to render
any help, or to stay the infectious process.

The question naturally arises as to whether
— even although we have come apparently
" too late," — there is not some more energetic
means than mere washing out of the womb,
at our command, and can we not, by means
of these more heroic measures gain what we
have lost in time ?

If, in general surgery, the operator arrives
too late to effect primary healing or to per-
form a primary operation, cannot a more ex-
tensive operation be equally successful ?
The surgeon cuts, scrapes and cauterizes

634

Editorial.

Vol. lxiv

until all dangerous substances are removed
from the- wound. Logically speaking, a
similar therapeusis is surely applicable in
puerperal infections. If irrigation and douch-
ing have failed, it is because by these means
a removal of the infectious matter has not
been effected. There may be two reasons for
this. Either the patient has already become
septic, and is, perhaps, lost ; or, within the
womb, there is still a colony of microbes, or
in other words, a culture of streptococci.
Should the former be the case — as subse-
quent symptoms in spite of all our efforts
will show — the patient's fate is sealed, and
it would only be cruelty to subject her to
further operative interference. If general
sepsis has not yet supervened, a thorough
scraping out, or curretting of the womb, will
frequently stop the infectious process.

It was in the above lines that Dr. E.
V. Braun argued the feasability of the
method advocated. The justification of
the procedure will be better understood if
puerperal fever is divided into three classes,
viz., Pyseruic, Septicemic and Saprsemic. In
the last two classes, we are dealing with a
process of decomposition in the womb ; we
find that saprophytes, and their ptomaines
absorbed into the circulation have given rise
to fever. There is no doubt but that a com-
plete removal of this decomposing mass will
effect a complete cure. As these saprsemic
cases are usually light, and their prognosis
good, there need be no question as to the
justifiability of curretting.

So much for theory. Let us now review
the practical value of the method, summed
up from the experiences of operators both
here and abroad.

Dr. Braun, in the Arch, fur Gynakologie,
stated that this practice was adopted by him,
especially in cases of saprsemic endometritis
in child-bed. He used the method in 101
cases with the following results : Ninety-six
of the cases were cured, and five died, but
three out of these had already symptoms of
general infection, a fourth died of purulent
peritonitis attributed to escape of pus out of
ostia of the tubes, and the fifth sank from
haemorrhage with septic symptoms ten days

after the scraping. In over two-thirds of the
101 cases; the labor had proceeded normally,
and there had been no visible evidence of
any damage to the placenta, yet the curette
never failed to bring away necrosed and pu-
trid tissues, which, on microscopic examina-
tion, proved to be fragments of placenta or
decidua. The procedure, according to Braun,
is only to be undertaken in cases of rise of
temperature in child-bed, due to endometritis.
This complication can be recognized by the
distinct arrest of involution of the uterus,
fcetor of the lochia, and fever coming on early
in child-bed without signs of pelvic inflam-
mation outside the uterus. When signs of
an extension of the inflammatory process
are present, and, above all, where general
infection is evident, scraping is contra-indi-
cated. A rise of temperature sometimes
occurs during the first week after the use of
the curette, but Braun has never seen any
parametritic exudation in his cases.

Both Braun and Dr. Heinrich Fritsch —
who has of late given the subject careful at-
tention, and contributed an interesting arti-
cle in the Deutsche Med. Wochenschrift,
April 16, 1891 — agree that the operation is
one comparatively free from danger.
Haemorrhages are seldom observed, neither
is the procedure very painful. The uterus
is washed out with a 1 in 1 ,000 solution of
thymol before and after the scraping. The
patient should be placed in the lateral posi-
tion, the anterior portion of the os hooked
carefully forward, and the vagina and peri-
neum protected with a Sims speculum. In
this way the womb may be scraped out with-
out much inconvenience to the patient.
That the womb may thus be thoroughly
curretted has been shown by autopsies, and it
is only in the folds of the cervix that the
operation is not thorough. Braun, therefore,
advocates a cauterization of this part. After
the scraping and subsequent washing of the
womb, an iodoform point is passed into the
uterine cavity. Any abrasions of the vaginal
mucous membrane are painted with pure
tincture of iodine. The cervix and vagina
are plugged for twenty-four hours, with,
iodoform gauze.

May 23, 1 89 1. Correspondence.

635

The danger of perforating the womb is but
• slight, especially if a broad, dull curette is
used, and during the first days the womb is
hard and firm: Here, however, we have
varying opinions. Lohlein, at a post-mortem
examination of a woman nine days after
parturition, found the uterus soft and
doughy. Liebman, of Triest, has also shown
that in consumptives, and patients greatly run
down, the uterus is easily perforated. Gen-
erally, however, in skilled hands, the opera-
tion may be safely performed, the uterus re-
maining firm until the fourth week.

Fritsch, while admitting with Braun the
theoretic value of curretting for the removal
of puerperal infection, nevertheless strongly
condemns the general adoption of the
methods, for the following reasons : first,
because the differential diagnosis between
saprsemic and streptococcic infection is most
•difficult at the outset ; second, Fritsch asserts
that the seat of the infection is neither in the
decidua, nor in the contents of the womb;
neither can we look upon the case in the
light of a septic wound. The disease has a
deeper seat, usually in the parametrium.
Fritsch believes that the infection starts from
the cervix, because this part suffers most
severely in parturition, and as microbes may
easily be deposited here, where lacerations
are so frequent. The parametritis at the
base of the broad ligament, is in the imme-
diate vicinity, indeed, is almost a continua-
tion of the wounded cervix. If the infectious
matter is deposited on the surface of the
dilated cervix, and this part is subsequently
drawn together, the infection is thus mechan-
ically carried to the deeper tissues, and is,
therefore, undisturbed by irrigation. This
infection is rapidly carried further in the
loose tissue of the parametrium, and suppu-
ration ensues. If the surgeon wishes to re-
move the seat of infection, large cuts should
l)e made in the parametrium to facilitate the
•discharge of pus, or else the entire septic
uterus should be removed. This, says
Fritsch, would be rational. A partial re-
moval of the decidua will certainly not ac-
complish the desired end.

If Fritsch, and others who argue similarly,

are right, how do we account for the evi-
dences of Braun's statistics which show a
fall of temperature after curretting in 100
cases of puerperal infection ? Perhaps, be-
cause all these cases were light, or it may be
even that the subsequent irrigations and cau-
terization were productive of the good results
and not the curretting.

Finally, it may be asked whether the
method is ever positively indicated in these
cases. To which it can only be answered
that if the contents of the womb can be
safely diagnosed as the cause of the trouble,
it should be removed, and the procedure is
as justifiable as the removal of a retained
shred of the placenta. Further than this
we cannot now go. The question is one,
however, which critic and anti-critic will in
time settle, and in the meanwhile these dis-
cussions and experiments may be watched
with great interest.

Correspondence.

COCAINE POISONING.

To the Editor M. and S. Reporter. —

Your editorial to-day raises anew the
warning note touching cocaine and its dan-
gers— one which the writer has sounded
again and again, with a clinical support de-
tailing nearly 300 cases, including 13 deaths.

In 1886, Dr. Wm. A. Hammond said, " he
did not believe any dose of cocaine that could
be taken was dangerous." That statement
— mistaken and misleading — was promptly
challenged by the writer, and that challenge
so sustained by clinical facts in a paper :
" Cocaine Dosage and Cocaine Addiction,"
read before the Med. Soc. of the Co. of Kings,
Feb. 13, 1887 ; and another : " Cocaine
Toxemia," read before the Amer. Assoc. for
the cure of inebriety, Nov. 8, 1887, that the
British Med. Journal was impelled to say,
editorially, "If it were needful to produce
more proof of the unsoundness of Dr.
Hammond's statement, Dr. Mattison has
effectually done this."

In discussing my paper on "Cocainism,"
read before the D. C. Med. Soc, Washington,
Dec. 24, 1890, Dr. Hammoiid confessed that
he was wrong, and that nearly fatal results
from cocaine had been noted under his own
care. •

636

Periscope.

Vol. lxiv

In a fourth paper, " Cocaine Poisoning,"
by myself, read before the N. Y. Med. Legal
Soc, March 9, 1891 — to appear in The Re-
porter— the toxic record of cocaine was
continued, making the most extensive re-
sume of the subject ever presented.

Four words tell the story, Cocaine is a
Poison. Verbum Sap.

J. B. Mattison.

Medical Director, Brooklyn Home for
Habitues.

185 Brooklyn Avenue, May 2, '91.

PERISCOPE.

THERAPEUTICS.

HUMAN LYMPH IN THERAPEUTICS.

E. Magnat (Le Bull. Medicale, April 8,
1891) read a note to the Academie de Mede-
cine on the employment of human lymph in
the treatment of disease. The serous exhu-
dation of blisters, which the author has
designated as human lymph, was injected in
cases laboring under a variety of diseases,
such as ulcers of the leg, pulmonary tuber-
culosis, typhoid fever, and others. The
results obtained were good.

CHLOROFORM IN TYPHOID FEVER.

In the treatment of typhoid fever, excel-
lent results have been obtained by Stepp
(La Clinique, Brux. Jan'y 15, 1891) with
the internal administration of chloroform.
The drug was given according to the fol-
lowing formula :

5? Chloroform i gramme.

Water 150 "

M. To be given in three doses, in the course of the
twenty-four hours. The bottle should be shaken before using.

The influence of this treatment in the
course of typhoid fever was certainly favor-
able. In the worst cases, insomnia and
delirium, and the dryness of the mouth dis-
appeared under the use of the remedy, while
general amelioration was invariably ob-
served. In from eight to ten days the fever
diminished and convalescence began. In
all the cases treated with chloroform the
duration of the febrile period varied from
nine to thirty days, eight being the minimum.
The total amount of chloroform ingested to
each patient varied from ten to twenty
grammes. No untoward effects were ever
observed in the course of the treatment.
According to the author the favorable in-
fluence of chloroform in typhoid fever, is,

due to the germicide properties possessed bv
the drug. Recent researches show that the
remedy passes through the circulation as
chloroform, and as such is eliminated by
the organism. In the second place, chloro-
form administered in the way and in the
doses indicated above, acts as anaesthetic
and thus aids to control excitability.

HYOSCINE IN MANIA AND INSOMNIA.

Malfilatre and Lemoine report in the Gaz.
Med. de Paris the result of a trial of hyoscine
on some sixty-two patients, chiefly' of the
maniacal class (Practitioner, xxxvii, p. 321).
The results obtained were very favorable.
In the great majority of cases they found
that they had either an immediate and con-
tinued hypnotic effect from very small (three
to five-tenths cmm.) or moderate (1 cmin.)
doses administered hypodermically, and in
only a very were few larger doses required :
and also that there did not appear to be such
uncomfortable lasting after-symptoms as
sometimes contra-indicate the employment of
other hypnotics. These investigators feel
justified in affirming that in hyoscine we
have an excellent palliative in all conditions
of insomnia with agitation, but they decline
to commit themselves as regards its curative-
effects. Its inconveniences are the tem-
porary intoxication it produces in some very
sensitive individuals, and the necessity of
steadily increasing the dose to produce the
hypnotic action in some few others. — The
Dublin Journ. Med. Science.

THE THERAPEUTIC USES OF EXALGINE.

The effects of this new remedy, exalgine
or methylacetanilide, have been carefully
studied by Desnos (Bull, general de Thera-
peutique, Feb. 15, 1891). After reviewing
the literature of the subject, Desnos gives-
the results of his experience in the treatment
of disease by the new drug.

Exalgine was tried in the treatment of
affections essentially characterized by pain,,
particularly in facial neuralgias, due to
lesion of the trigeminal, and even to those-
of the occipital nerve. Congestive neural-
gias, due to cold or a rheumatic condition,
usually yielded to moderate doses ; but if re-
lapses occurred, the medicament was con-
tinued for a long time in large doses. A
case is reported of a woman suffering from
neuralgia, in whom enucleation of the eye-
ball was not successful in relieving pain.
She was given exalgine in doses of from 3
to 22* grains, with the result that she was
discharged cured in the course of thirteen
days.

May 23, 1 89 1.

Periscope.

637

It was observed that the drug acted most
favorably in neuralgias due to anaemia and
syphilis. In diffused headaches and mi-
graine, the results were negative or doubt-
ful. In intercostal neuralgias the effects
were generally satisfactory.

A persistent, very painful - neuralgia of
the brachial plexus was completely subdued
by a dose of 22 \ grains. In this case a pro-
nounced tingling, which soon passed away,
was experienced along the branches of the
plexus. In neuralgias of the ileo-lumbar
region, of a uterine origin, the drug did
good ; but relapses, due to the persistence of
the lesion in the genital organs, only yielded
to large doses.

Sciatic neuralgias were also checked by
exalgine, one truly remarkable case being
reported. The author has likewise obtained
good results with the drug in the treatment
of visceral neuralgias, the acute pains of
locomotor ataxia, and has known exalgine
to be of benefit in the pains of menstrual
hysteralgia. A case of paralysis agitans,
due to emotional causes, was cured by exal-
gine, and the drug was found of great ser-
vice in certain cases of rheumatism.

In conclusion, Desnos considers exalgine
a therapeutic agent of great value — an anal-
gesic which is neither a hypnotic nor an anti-
thermic in the proper sense of the word.
To obtain the good effects of the drug, it
should be given in full amounts. The usual
dose is 3f grains, but 15 to 26 grains may
be given without producing deleterious
effects. — Univ. Med. Mag.

OF

AGARICINE IN THE TREATMENT
NIGHT SWEATS.

This drug has been used by Bocquillon
{Province Med., Jan. 10, 1891) in the treat-
ment of pulmonary phthisis. In these cases
the remedy diminished the diarrhoea, lessened
the cough and produced a more quiet sleep.
Doses of from 5 to 8 milligrammes were
given hypodermatically from 5 to 6 hours
before the appearance of the sweats. Sei-
furt employs for hypodermatic use, the fol-
lowing solution :

Agaricine 0.05 grammes.

Absolute alcohol 4.50 grammes.

Glycerine 5.50 grammes.

M. This is a % per cent solution of which a syringefull can
be given 5 hours before the appearance of the sweats.

THE THERAPEUTIC EFFECT OF STRYCH-
NINE IN CARDIAC AFFECTIONS.

The Medicinisch-chirurgische Rundschau,
February 1st, has an extended notice of a
recent paper by Professor Baldo Zaniboni,

of Padua, on this subject. Zaniboni's article
is based on a large number of clinical ob-
servations, with sphygmographic tracings,
and appeared originally in the Revista veneta,
Nos. 2 and 3, 1890. The following are his
most important conclusions :

Strychnine is without question a very effi-
cient exciter of cardiac activity. By its use
the systolic impulse is strengthened, the dias-
tole is prolonged, and attacks of arhythmia
are cut short ; subsequently the arterial ten-
sion is increased and the pulse-rate, if rapid,
is slowed ; if retarded, is accelerated. Acute
dilatation and the dangers of heart failure,
especially of the right side, are removed.
Respiration becomes freer, and attacks of
dyspnoea are completely relieved. Only in
cases in which the nervous and muscular
elements of the heart are no longer suscep-
tible of stimulation does strychnine remain
without effect. (Edema, even when it has
resisted treatment with digitalis, disappears
quickly, and there is free diuresis without
the occurrence of albuminuria, such as fol-
lows the use of strophanthus. The bodily
temperature is not noticeably affected. The
appetite improves and the action of the
bowels is regulated in consequence of in-
creased persistalsis. The contractility of
the arteries is heightened by the vaso-motor
action of the drug. The hypodermic in-
jection of strychnine is well borne, and with
careful antisepsis causes no local reaction.
Beginning with one-sixty-fiffch of a grain,
the dose may be increased to one-thirtieth
of a grain three or four times a day, with-
out producing subjective or objective dis-
turbances. The treatment may be stopped
abruptly, even when the largest doses are
being given, without causing any unpleasant
symptoms. The effect of the salt is seen
very quickly (in about ten miuutes) after
the injection, and lasts for several hours.
Even after the long-continued use of strych-
nine no symptoms were noticed that pointed
to any cumulative action of the drug. — N.
Y. Med. Jour.

BRONCHITIS PRODUCED BY THE VAPORS
OF PICRIC ACID.

A peculiar form of bronchitis produced
by the vapors of picric acid is described
by Regnault and Sarlet (Annales d'hygiene,
March, 1891). The malady is characterized
by paroxysms of dyspnoea, frequency of respi-
rations, and of cough and the absence of a
glairy expectoration at the end of the crisis.
The paroxysms come during the day and also
during the night. Death is rarely produced.

638

Periscope.

Vol. lxiv

In a fatal case, observed by the authors, the
patient's' death was due to an intercurrent
malady: la grippe. A chemical analysis
showed the presence of picric acid in the
urine, the blood and the liver. The patient,
poisoned by the picric acid vapors, exhibited
a condition of anaemia and a yellowish color-
ation of the skin, of the hairs on the surface
of the body and of the parts, especially,
mostly exposed to the toxic emanations.
The diagnosis of the peculiar dyspnoea and
asthma was easily made, especially after the
analysis of the urine, which usually contained
picric acid.

MEDICINE.

NEURASTHENIC STIGMATA.

Recent issues of the Union Medieale con-
tain a resume of Dr. Bouveret's lectures on
neurasthenia. While the symptoms of this
interesting disease are extremely varied and
numerous, according to Dr. Bouveret's view
there are certain distinct manifestations
which are sufficiently constant to be called
the stigmata of neurasthenia. These are
headache, insomnia, muscular weakness,
vertebral pain, atonic gastro-intestinal dys-
pepsia, to which are frequently added
habitual dilatation of the pupil owing to
feeble reaction to light, together with dis-
coloration and objective and subjective cold-
ness of the hands and feet.

While the headache is more or less per-
sistent, the pain is not particularly severe,
the sensation being more that of heaviness,
fulness and constriction, as of a hand or cap
pressing upon the scalp, giving rise to what
Charcot calls the helmet symptom. In event
of intense headache, which sometimes exists,
it is circumscribed, may be limited to the
forehead, one temple or both, to the occiput,
or the back of the neck. Aching and weari-
ness in the neck are common, and in them-
selves are rather good signs of neurasthenia.
The neurasthenic headache is increased by
work, intellectual effort, noise, and sudden
emotion. During these exacerbations vertigo
is not infrequent. True migraine may com-
plicate this cephalalgia and render the con-
dition doubly trying. Insomnia is of the
persistent order, and is rebellious to treat-
ment. It may be absent in women. In cer-
tain rare cases, irrespective of sex, the
fatigue of work is followed by attacks of
irresistible somnolence. Dreams are com-
mon, and more or less distressing. Sleep
may come only toward morning, or it may
visit the patient early in the night, leaving
him to the horrors of wakeful visions after
an hour or two. In either case the sufferer

rises unrefreshed, in a condition of extreme
weariness, without energy and without hope,
and as thoroughly sapped as if he had been
up all night.

Mental depression in neurasthenia ex-
presses itself as exhaustion of all the mental
faculties. There is loss of memory, of judg-
ment, of will, inability to fix the attention
for any length of time, and to resist suffi-
ciently the influence of psychic impressions.
Impairment of will is the keynote to the
psychic state in neurasthenia. It is impos-
sible for the patient to pursue the even tenor
of his way. The character changes. The
thousand and one petty annoyances of daily
life are converted into so many excuses for
irritability, anger, and exhibitions of bad
temper. General weakness exists, and a
notable diminution of muscular force is
usually present. After slight emotion,
moderate physical fatigue, sometimes with-
out assignable cause, there will come a sud-
den feeling of profound prostration and com-
plete loss of strength; together with painful
fatigue in the calves, knees and thighs. Ver-
tebral pain is almost as common as headache.
It is a sensation of heat, burning, lassitude,
and strain along the spine. This has favor-
ite points of location : the seventh cervical
vertebrae, the lumbar vertebrae, and the
sacral region. It may exist in the coccyx
alone.

There are two forms of neurasthenic gas-
tro-intestinal atony. In the first, only
functional disturbances appear. In the
second, the patient emaciates, loses strength,
and objective symptoms are present. Ab-
dominal examination reveals prolapse and
dilatation of the stomach, flabbiness of the
anterior abdominal parietes, together with
descent of the kidneys and liver in certain
instances, completing the anatomical com-
plexus that Glenard has described under the
title of enteroptosis. There are cases, not so
rare either, where, after the earliest develop-
ments of neurasthenia, the patient passes
progressively and rapidly from functional
gastro-intestinal atony to interoptosis of
serious moment.

A chemical hypothesis to account for
neurasthenic phenomena has recently been
proposed by Professor Kowaleski, of Char-
kow, of which mention appears in. the
American Journal of Insanity, January,
1891. Acquired neurasthenia may be di-
vided into two principal varieties : one
where there is excessive mental strain or
exertion without sufficient nourishment.
The brain is starved with the rest of the
body, and naturally fails to perform its
functions. The other form of the disease is

May 23, 1 89 1.

Periscope.

639

found in those who lead lives of intense
mental activity within a narrow field, and
who have bat little physical exercise. The
tendency of modern civilization to specialism
leads to the restricting of mental activity to
a limited range of topics, tending to local
exhaustion of the brain. This exhaus-
tion may come about in spite of an
abundant supply of food. In conse-
quence of the sedentary lives led by
persons engaged in intellectual pursuits,
food may aggravate the evil, poisoning the
brain by imperfectly assimilated material.
Alcohol, tobacco, tea, and coffee taken to
stimulate flagging energies, together with
late hours to make good the losses of the
day, serve to render bad matters worse. The
congenital form of neurasthenia, when not
connected with anatomical anomalies of the
nervous system that can be demonstrated,
must be considered due to defect of organi-
zation that conjecture may reasonably
ascribe to its abnormal chemical constitu-
tion. In view of the frequent appearance of
neurasthenia and allied disorders among
children of drunkards, it seems probable
that poisoning of the nervous system of the
parent may result in defective chemical
composition of the nerve-elements in the off-
spring, this being latter-day retribution fol-
lowing the eating of sour grapes by modern
fathers. — Med. Rec.

GLYCOSURIA AND DIABETES.

Moritz (Munchener med. Wochenschrift,
Jan. 6, 1891) considers it probable that
grape sugar is present in normal urine from
the fact that the characteristic reaction with
phenolhydrocine can be demonstrated.
There are a great many cases where grape
sugar appears in the urine which are not
real diabetes mellitus ; this may be called
simple glycosuria. This symptom is com-
paratively harmless in the absence of all the
severe general symptoms — emaciation, loss
of strength, thirst, furunculosis, etc. A
combination of these general symptoms with
sugar in the urine determines a diagnosis of
diabetes mellitis, but it is not safe to exclude
the disease in all cases where sugar appears
without the general symptoms, for there are
certain instances where a small amount of
sugar constantly present in the urine is the
only symptom until a sudden outbreak of
a general character occurs.

It is impossible to fix upon any one symp-
tom which distinguishes simple glycosuria
from true diabetes mellitus, but simple gly-
cosuria" may be said to be an increase of the

normal amount of sugar, which disappears
with the cause, while diabetes mellitus is a
true disease, chronic in nature, its charac-
teristic being the persistence of the glycos-
uria. The author divides all cases into two
groups — glycosuria occurring under patho-
logical conditions, and glycosuria occuring
under physiological conditions. He then
quotes many pathological conditions give
rise to glycosuria — injury to ihe floor of the
fourth ventricle, extirpation of the pancreas,
cirrhosis of the liver, and apoplexy, being
among the number. Among the physiolog-
ical conditions he considers the puerperium
as the most import. Eighty per cent of all
lying-in women have from *8 per cent, to 1
per cent of sugar in the urine. The so-
called alimentary form of glycosuria occurs
after the ingestion of a large amount of
sugar. Some authors consider that this ten-
dency to excrete sugar shows a disposition
toward diabetes mellitis. Where this ten-
dency to glycosuria is noticed only after the
ingestion of sugar it may be considered phy-
siological, bnt where it is found after a meal
of starchy foods it may be considered patho-
logical.

For clinical purposes diabetes mellitus
may be divided into a mild and a severe
form. In the first the sugar is taken from
the carbohydrates of the food ; in the latter
this is not the case. In suspected cases the
urine should be examined some hours after a
meal of carbohydrates with little or no
sugar. If sugar is present in the urine a
diagnosis of diabetes mellitus may be made ;
if it is absent the disease may be excluded.
In certain cases where a large amount of
urine of low specific gravity is excreted, it is
necessary to examine the urine passed
shortly after the meals, and not a specimen
of the mixed urine.

The 'author considers the fermentation
test the only entirely reliable one. He ad-
vises the following simple apparatus: A
test-tube is filled with a mixture of urine
and yeast and is stopped with a gum cork
perforated with a U-shaped tube. Two
control tubes are rilled, one with normal
urine and yeast, and another with the sus-
pected urine with yeast, and a little sugar
added. Care must be taken that the urine
is not rendered antiseptic by the adminis-
tration of salol or salicylic. acid to the pa-
tient. If the urine contains sugar, carbonic
acid gas will collect in the upper part of the
tube. He advises the combination of this
test with one of the reduction tests to make
the diagnosis absolutely sure. — Univ. Med.
Mag.

640

Periscope.

Vol. Ixiv

SURGERY.

INSTANCES OF FOREIGN BODIES LODGED
IN THE BODY.

Francis L. Haynes. gives in the Annals
of Surgery a collection of cases of this nature
which is of much interest :

I. A TOOTH IN A BRONCHUS PRODUCES A
PULMONARY ABSCESS. IT IS EXPELLED

SPONTANEOUSLY AND THE PATIENT
RECOVERS.

A middle-aged man presented all the
symptoms of a copiously suppurating cavity
in the apex of the right lung, and was sup-
posed to be afflicted with consumption.
After I had attended him for three months,
during which he improved greatly, he ex-
pelled a tooth from the lung during a severe
paroxysm of coughing. Recovery from all
symptoms of pulmonary disease was rapid
and complete.

A minute cross-examination now showed
for the first time that, one year1 previously,
the man had, as he supposed, swallowed a
tooth immediately after its extraction, and
that his illness had dated from that time.

II. A PIECE OF SHEEP'S VERTEBRA IN THE
LUNG PRODUCES AN ABSCESS WHICH,

AFTER ONE YEAR, RESULTS IN
DEATH.

A woman, set. 50, while hastily swallowing
some soup, felt that a hard substance had
passed into the air passages. An immense
cavity rapidly developed in the lower lobe
of the right lung. After six months, during
a severe paroxysm of coughing, a large piece
of the body of a sheep's vertebra, the shape
of a maltese cross (measuring 1 by i by i
inch) was expelled. The cavity, however,
continued to suppurate and the woman died
about a year after the date of the accident.
Prof. S. D. Gross examined this case but
did not suggest any operative procedure.

III. A BEAN IN THE AIR PASSAGES CAUSES

SPEEDY DEATH.

A boy, set. 5, while holding some beans in
his mouth, suddenly exclaimed that one
had " gone down the wrong way." Suffoca-
tive symptoms were at once noted and con-
tinued until death 36 hours afterward.
Physical examination showed that no air
entered the right lung. The parents would
not permit an operation.

IV. REMOVAL OF THE TIP OF A HARD RUB-
BER SOUND FROM THE PREGNANT

UTERUS.

A healthy woman, two months pregnant,
while inserting a hard rubber sound into the '

uterus, broke off a piece two inches long,
which remained in the organ. Dr. E. A.
Follansbee was consulted, and asked me to
assist in the management of the case. With
the metallic sound the body could readily
be felt, but it lay across the uterus, and its
ends seemed to be embedded in the mucosa;
it could not be removed until the cervix
was dilated, which was at once accomplished
by Goodell's dilator, under ether narcosis.
The body was now readily removed by a
slender pedicel forceps guided by the finger.
As the membranes had been raptured by the
patient's probing, the uterus was emptied by
the finger, and washed out.

V. A GLASS DISC REMAINS IN THE VAGINA
FOR TEN YEARS, CAUSING A STRICT-
URE, WHICH REQUIRES TO BE

INCISED, THAT THE DISC MAY
BE REMOVED.

A woman, set. 60, had worn a glass disc in
the vagina continuously, for the relief of pro-
lapsus, for ten years. As it finally produced
a purulent discharge she asked me to remove
it. One and a half inch up the vagina a
stricture barely admitting the index tip was
felt. It was incised in the median line pos-
teriorly and a disc two inches in diameter
removed. Unfortunately hsemostasis was
carelessly made, and the patient bled for two
days before she thought it worth her while
to send for me. It took two months to cure
the resulting ansemia. After six months the
patient reported that she was well and that
the prolapsus had not recurred.

VI. A CHILD IS TREATED FOR NASAL
CATARRH FOR FOUR YEARS, AND RE-
COVERS ON THE REMOVAL OF A

SHOE BUTTON FROM THE NOSE.

A girl, set. 8, had received much unavail-
ing treatment for the relief of a profuse pu-
rulent discharge from the right nostril. On
inserting a probe I distinctly felt a smooth
hard body buried in a mass of rotton tissue
between the inferior and middle turbinated
bones about one inch behind the tip of the
nose. The body, which was supposed to be
dead bone, was easily removed, and proved
to be an ordinary gaiter button. Recovery
was rapid and complete.

FRACTURE OF THE LARYNX.

An interesting case of fracture of the lar-
ynx is reported by Dr. Sokolowski, in the
Centralblatt fur die med. Wissenschaften,
April 11, 1891. The patient was a mill-
hand, twenty years old, who was caught in
the driving wheel of a machine, by her apron,
which was fastened about her neck, and

May 23, 1891. Periscope.

641

thrown some distance. She immediately
experienced severe pain in the larynx, diffi-
culty in breathing, and expectorated a consid-
erable quantity of blood. The neck was
greatly swollen and crepitation over the lar-
ynx was distinctly felt, and a considerable
depression of the cartilage on the left side to
be seen. The laryngoscope showed two in-
flamed swellings immediately below the epi-
glottis. Tracheotomy being indicated, an
incision over the larynx was made and the
fracture found. One fragment of cartilage
was pushed into the windpipe. This was
removed, and breathing at once became
easy. Still the extent of the fracture was
such that a tube was inserted and left in
r>lace. The patient ultimately recovered.

SUFFOCATING GOITRE.

The following interesting case of extirpa-
tion of a goitre, is reported in the Revue de
Laryngologie, d' Otolog. et de Rhinolog.,
May 1, 1891. The patient was an Italian,
seventeen years old, and Dr. Arthur Berti,
of Modene, the operator. The man came
from a district where goitre was very rare.
His previous family histories were negative.
Up to his thirteenth year he had always en-
joyed good health. At this time a tumor
appeared, of about the size of a small nut,
a little to the right of the median line of the
throat. The growth was freely . movable,
hard, and indolent. Soon after the tumor
began to rapidly increase in size, until, when
the patient presented himself at the hospital,
it had attained the size of a large orange.
Respiration was difficult and deglutition
impossible. Extirpation was performed only
with great difficulty, as the growth com-
pletely surrounded the trachea, nevertheless,
its entire removal was effected. His wound
healed up within six days, and no subse-
quent trouble was experienced by the
patient.

GONORRHCEAL EPIDIDYMITIS.

Drs. Martin and A. C. Wood, in The
University Medical Magazine in a study of
this, the most frequent complication of
gonorrhoea, reach the following conclusions :

1. Gonorrheal epididymitis occurs most
frequently in those who have received no
treatment for the original urethritis. Its
outbreak is frequently determined by violent
or long-continued physical exertion, or by
venereal excess.

2. The resultant induration of a gonor-
rhoea! epididymitis does not cause oblitera-

tion of the convoluted duct in the majority
of cases. Statistics on this point are mis-
leading, from the fact that it is practically
only the few sterile patients who are subse-
quently observed by surgeons, and hence
these form the greater number of the re-
ported tabulations.

Of four cases of double epididymitis ob-
served by us, not under treatment for
sterility, there was an abundant discharge
of spermatozoa in three.

3. Unilateral epididymitis may, in excep-
tional cases, cause permanent sterility. Du-
ring the acute attack very few spermatozoa
are found in the semen.

4. Obliteration of the duct does not cause
atrophy of the testicle.

5. Pain, tenderness and swelling in the
groin, dependent on funiculus, practically
always precede gonorrhoeal epididymitis.
Prompt treatment at this stage may abort
the inflammation of the epididymus.

6. The development of gonorrhoeal epi-
didymitis is, in a great measure, avoided by
the use of antiseptics by the mouth, and the
application of a suspensory bandage to the
scrotum.

7. The pain and disability usually at-
tendant cm gonorrhoeal epididymitis are
promptly allayed by puncture, or aspiration
of the serous exudate contained in the tunica
vaginalis and the cellular tissue placed be-
hind and above the epididymus, followed by
the application to the scrotum of a thick
layer of cotton, over which is placed a
Mackintosh suspensory, so made that it
presses the inflamed organ upward against
the pubes, and, by means of lacings at the
side, can be so drawn in that uniform lateral
support is secured. Punctures are neces-
sary only in the most acute cases.

8. The subsequent induration after the
acute stage is most quickly resolved by a
continuance of the dressing above described,
together with the local application of bella-
donna and mercury ointment, and the inter-
nal administration of iodide of potassium.

GYNAECOLOGY.

CANCER OF THE BREAST TREATED BY
INJECTION OF METHYL-VIOLET.

Dr. Edw. T. Grim, in the Brit. Med.
Jour, writes : The patient, whose case is
described below, presented herself suffering
from a well-marked circumscribed indurated
tumor of the breast, about the size of a
small egg. The case was considered a par-
ticularly suitable one for testing the efficacy

642

Periscope.

Vol. lxiv

of Dr. Mosetig's treatment by injection of
methyl-violet.

The treatment having been explained to
the patient, her consent was readily ob-
tained, and a course of twenty injections
was prescribed. This treatment was' com-
menced with a dose of 10 minims of 1 part
of methyl-violet in 300 parts sterilized
water; administered February 7th, 1891.
The injections were given daily. The first
ten injections produced no pain and no in-
flammation of the breast, but, after the
tenth injection, a slight redness of the skin
became apparent, which increased after
each injection. On the fifteenth day of
treatment some suppuration of the breast
tissue was present, masking, to a great ex-
tent,, the tumor. The injections were still
continued. After the twentieth injection,
on careful examination, the tumor being
still present, it was decided to remove the
breast in the ordinary manner.

The operation was performed by Dr.
Hugh Fenton, with strict aseptic precau-
tions, after the manner of Dr. Edgar Kurz,
of Florence, described in the Deutsche medi-
einische Wochenschrift of November 20th,
1890, and, although considerable suppura-
tion was present in the breast, the wound
healed by first intention at the end of seven
days, the only application to the breast hav-
ing been dry Gamgee tissue, carefully steri-
lized previous to the operation in the hot
air sterilizer, as were all the instruments
used in the operation, no carbolic acid or
iodoform being used at any time during or
after the operation.

The breast, on examination after removal,
was found to contain a typical tumor of the
scirrhous cancer variety. The growth pre-
sented no alteration that could be attributed
to the methyl-violet, even when examined,
after hardening and staining, by very high
microscopic power, such as the y^th and Ty;h
oil emersion. No degeneration of the cancer
structure could be observed around the
growth. Considerable suppuration of the
glandular tissue of the breast had taken place,
which, no doubt, under ordinary antiseptic
dressing, would have considerably retarded
pimary union. The result of the treatment
by methyl-violet must, in this case, be re-
garded as purely negative. The rapid heal-
ing of the wound speaks greatly in favor of
the aseptic sterilized dressing, now so largely
adopted on the Continent with such good
results, Dr. Kurtz giving a mortality of 2
in 169 cases of operations, of amputations,
resections, laparotomies for perforation in
typhoid fever, and other major operations.

WOUNDS OF THE URETERS IN LAPA-
ROTOMIES.

During the last session of the French
Congress of Surgery, Dr. Pozzi read a paper
on wounds of the ureters in laparotomies.
Pozzi has succeeded in finding the histories
of several cases, including one observed by
Gusseron and one occurring in his own ex-
perience.

If the wound of the ureter is lateral it is
possible to make a suture. In one case thus
treated the patient died. In another re-
ported by Gusseron recovery followed the
operation. Wounds of the ureters are most
likely to be produced during the removal of
retro-peritoneal cysts.

The case reported by Pozzi was that of a
woman fifty-three years old, with an intra-
ligamentous cyst. The tumor had been of
rapid growth, and the patient's general con-
dition was very poor. Laparotomy was per-
formed, and revealed a large red tumor with
a rough surface. The tumor was enucleated
with great difficulty, being firmly adherent.
During the course of the operation one of
the ureters, which was attache*d to the tumor,
was cut through. The operation was com-
pleted, a Mickulicz tampon being used and
the end of the ureter sutured to the abdom-
inal wound. Subsequently, nephrectomy was
performed, and the patient made a good re-
covery.

OBSTETRICS.

OVARIAN PREGNANCY.

At a recent meeting of the Royal Medical
Society of Vienna, reported in the Wiener
Med. Presse, April 12, 1891, Dr. Herzfeld
told of an interesting case of ovarian preg-
nancy. The patient was a multipara, thirty-
three years old, and on March 12, gave
birth to a child at the normal end of gesta-
tion. After delivery the abdomen remained
distended, and a second foetus was clearly
definable above the empty womb. The
patient did not come into the hospital until
the foetus was dead. Dr. Herzfeld performed
laparotomy and removed the' foetus with
ease, it being attached to the adnexa of the
uterus by a small pedicle. The question of
tubal pregnancy could be set aside as the
right tube could be traced in its entire
length. The uterus was empty and the left
adnexa normal. An anatomical examina-
tion proved the case to be one of ovarian
pregnancy. This case is not only of interest
because it occurred in conjunction with a
normal pregnancy, but especially so as it

May 23, 1 89 1. Periscope.

643

definitely proves the possibility of a pure
ovarian pregnancy, and because it continued
until full term.

EPILEPSY FROM A DEPRESSED FRACTURE
PRODUCED WITH THE OBSTETRIC
FORCEPS.

A boy, sixteen years old, came under Mr.
Lane's care for epilepsy {Lancet, Jan. 17,
1891). He had been subject to these fits for
two years, or from the age of fourteen years.
When he was about to have a fit he noticed
a twitching at the junction of the middle
and lower thirds of the leg on its outer as-
pect, and his foot and knee then jerked in a
manner that resembled ankle clonus and
knee-jerk. A pain then ran up the outer
side of the leg and thigh, through the left side
of the trunk to the arm, then to the left side
of the face, and, when the fit was severe, to
the right arm.

On examination, a groove three inches
and a quarter long was found on the right
side of the head, extending from an inch be-
hind the coronal suture to about the same
distance in front of the lambdoid suture.
Its anterior extremity was vertically above
the external auditory meatus, and its lower
limit reached just below the temporal ridge.
From this it extended downward and back-
ward toward the external occipital protu-
berance. The left arm was the smaller and
weaker, its muscles were less firm and its
movements were clistinctly clumsy. There
was no difference in the appearance of the
muscles of the legs, but the patient had never
had the same confidence in the left that he
had in the right leg. By simply raising the
left foot to a right angle, a very rapid clonus
could be obtained. By using more force a
clonus could be produced in the right ankle.
The plantar, knee, and abdominal reflexes
were exaggerated on both sides, but most
decidedly on the left. The depression on
the right side of his skull was said to have
been noticed immediately after birth, the
delivery having been effected with the for-
ceps with much difficulty. It had become
less conspicuous as he had grown older. The
depressed area of bone was finally removed.
It was found to be very thin and vascular,
and appeared to encroach but little on the
cranial cavity. The dura and subjacent
brain appeared healthy. The wound healed
by primary union. Since the operation, fits
have occurred at longer intervals and are
much slighter. He has gained power in
the left arm and leg, and never suffers from
headache, and has become mentally much
brighter.

PEDIATRICS.

OBSTETRICAL PARALYSIS IN THE NEW-
BORN.

Not a year passes but what several cases
of paralysis, dating from birth, are brought
before the various surgical clinics of the
continent. Most of these cases are children
suffering from paralysis of the upper extrem-
ities, and are the results of injuries sustained
during dfficult labors.

These paralyses, which are directly due to
obstetrical proceedures, such as version, the
use of forceps, traction on the limbs, etc.,.
have been recognized by the profession for
some time. Dr. Comby, of the Societe medi-
cale des hopitailx, has been recently engaged
in investigating their origin and prognosis,,
and a report of his work is given in the
Revue Medicale, March, 1891. The facial
paralysis, he claims, is due to compression
by the forceps; likewise, frequently, the para-
lysis of the lower extremities. Rarely are
the latter caused by injury to the spinal col-
umn or the cord.

The paralysis of the upper extremities,
called " radiculary paralysis " by Comby, is
directly due to a stretching or compression
of the brachial plexus, caused either by ap-
plication of the forceps, version, or hooking
the shoulders of the foetus, by means of the
operator's finger or by an instrument.

Erb has demonstrated that all these vio-
lences cause a lesion of the fifth and sixth
cervical nerves ; nearly always the paralyses
occur in the same muscles : the deltoid, the
sub-scapular, the biceps, and the coraco-
brachial.- The radicular paralysis may,
however, be complete and include all the
muscles of the upper extremities.

The prognosis of such paralyses is always
serious. Duchesne holds that unless active
treatment is instituted very early, a hopeful
prognosis cannot be entertained ; and the
child, which in other respects may be strong
and healthy, will surely remain a cripple.

According to Duchesne, the treatment
includes Faradisation — applications of the
current being made two or three times a
day, and continued for five or ten minutes —
also the application of the continuous cur-
rent ; and finally these means may be aug-
mented by massage, stimulating frictions
with turpentine, and salt baths. Dr. Gof-
froy recommends strongly electrization by
means of the galvanic current, not in a
continuous current, but interrupted. For
the ultimate success of the case, it is, of
course, of utmost necessity that the treat-

644

Periscope.

Vol. lxiv

ment should be instituted as early as possi-
ble, and most carefully regulated.

A CASE OF TRISMUS NEONATORUM
TREATED WITH SULPHONAL.

Dr. Julius Berenyi {Pester mediz.-chirurg.
Presse, No. 7, 1891 ; Therapeut. Monatsh.,
March, 1891) reports the case of a child,
eight days old, who had tetanus on the fifth
day after birth. On examination he found
the internal organs normal, the pulse 148,
the respirations 50 and quiet. The par-
oxysms were initiated by crying fits and
great restlessness. The skin assumed a bluish
color, and around the root of the nose the
integument was thrown into thick folds. The
nostrils became distended, the buccinators
were rigid, the mouth was slightly opened,
but would not admit the tip of the little
finger. The abdominal wall was hard and
tense, the upper extremities were crossed in
a flexed position over the chest, the thumbs
were spasmodically flexed inward, the
vertebral column was perfectly rigid.
From nine o'clock in the morning to two
o'clock in the afternoon the little patient
had five attacks, of which the fourth lasted
an hour. Berenyi administered twenty
centigrammes (3 grains) of sulphonal in an
enema, and also gave the drug by the
mouth. After the fifth attack, which was
less intense than the others, the child began
to take the breast. On the same day three
attacks of diminished severity occurred. On
the following day the paroxysms became less
frequent and intense, and on the sixth day
of treatment had disappeared completely.
Altogether, ten grammes of sulphonal were
employed, without the occurrence of somno-
lence or disagreeable after-effects.

HYGIENE.

ON THE RELATION OF ATMOSPHERIC
ELECTRICITY, MAGNETIC STORMS,
AND WEATHER ELEMENTS TO A
CASE OF TRAUMATIC
NEURALGIA.

R. Catlin, U. S. Army, writes in the
Medical JSFvws : In the relationship of atmos-
pheric electricity to pain, it is shown that
by a comparison of 120 daily curves taken
on neuralgia periods with the mean of the
same number for ten consecutive days of each
month, pain seeks identity with both lower
positive curves and with the negative, and
with fluctuations of great amplitude.

For the influence of May storms on pain
the maximum auroral period of 1882-83

was selected ; of this period, seven of the
greatest magnetic storms were chosen.
Accompanying each was pain, and in the
majority of cases pain of unusual intensity
prevailed. The great storm of November,
1882, the greatest of which we have a
record, shows the relationship to be une-
quivocal. In the other cases the magnetic
storm was coincident with other causes,
which may or may not have had something
to do with pain, but in four cases no dry or
wet cyclone was in any way connected with
the trouble.

The comparison of the weather elements
— such as pressure, temperature, force of
wind, humidity, relative and absolute, days
of rain, depth of rain, hours of sunshine,
number of storms, and ozone — with pain —
covers a period in no case of less than five
years. Of these the increasing temperature
curve,the hours of sunshine curve, and the
absolute vapor curve, operate to diminish
pain, while all the others are identified more
or less with pain. In the monthly products
for fourteen years it appears that the " depth of
rain," ozone, and " number of days of rain,"
in this order, but almost equally, constituted
the best standards for pain measurement.
By generalizing on the extremes through
all these years, by taking the twelve months
of greatest pain and the twelve of least
pain, the above conclusions are verified, and
the law stated in general terms, as follows :

Maximum pain bears a direct proportion
to storm frequency, and an inverse propor-
tion to temperature and elastic force of
vapor ; and minimum pain bears an inverse
proportion to storm frequency, and a direct
to temperature and elastic force of vapor ;
while depth of rain accompanies the num-
ber of storms and maximum pain. Charts
of relative stonn frequency and geographical
pain charts are thus related.

What are known as " spells" or " types"
of weather, lasting from one to three weeks,
probably due to the relative position of the
great anti-cyclone areas, having their influ-
ence on pain condition. This fact was rec-
ognized early in the history of this case, in
1869. Increased amount and intensity of
pain accompany these " spells," particularly
at their beginnings. Covering a period of
fifteen years the relative ratios of the monthly
products of pain were as follows : February,
176; March, 175; January, 174; Decem-
ber, 168 ; November, 164 ; April, 161 ; May,
160; July, 159; June, 154; September,
153 ; and October, 153. The ratios were
determined by dividing the total number of
hours of neuralgia of each month by the

May 23, 1 89 1.

Periscope.

645

total number of hours in the month for the
whole period of fifteen years.

Perhaps the most difficult and complex
part of the problem is in offering an expla-
nation of the diurnal fluctuations of pain.

The record of hourly beginnings of pain
covers a period of more than eighteen years ;
and the curve of the record of hourly begin-
nings of storms and the amount of rain of
each covers a period of sixteen years.

The daily pain curve exhibits 3 pain max-
ima ; the first at 11 A. M., the second at 2
P. M., and the third at 7 P. M. The part of
the curve at 6, 7, and 8 A. M. has almost
an inverse counterpart in 8, 9, and 10 P. M.,
but in the curve from 9 A. M. to 7 P. M.,
there is a very important minimum at 12
M. and 1 P. M., then a subordinate mini-
mum at 3 P. M., very like that at 10 A. M.,
followed at 5 and 6 P. M. by a distinct min-
imum.

By placing on the pain curve the storm
curves for the sixteen-year period, it becomes
manifest that while the absolute values of
the rain depths and number of storms on
the |ain curve do not show a full corre-
spondence, it is, however, clear at once that
there is a relative value between the two
and the pain.

In all the discussions of this subject to
this time, only instrumental records, such as
synoptic charts, thermograms, etc., have
been brought into use, but it is clear that
the physical effects produced by the temper-
ature on the southeast side of a cyclone is
very different from the same record-tem-
perature on the west or the northwest side.

It is found that the eastern edge of the
neuralgic cresent lies more than six hundred
miles, or about twenty-three hours to the
east of the centre of the " lows," but no two
cyclones or rain conditions are exactly alike,
and have different kinds of rain, and when
we consider that there are two atmospheres —
one of a dry, gaseous air, and another one
distinct, of aqueous vapor, with the latter
never thoroughly intermixed . with the for-
mer, and never in a state of equilibrium —
we partially realize how impossible it is in
any given storm to get a complete record by
instruments, or of those which are the best
pain-producers, for without apparent instru-
mental cause they vary much in this respect.

No local hygrometric reading can give
anything more than a vague approximation
of the quantity of vapor or its mixture in a
vertical column of air.

A typical neuralgic atmosphere, antici-
pating a cyclone, may be a dry air with a
diminishing light, variable wind, and a

pale, delicate, bluish whiteness in the atmos-
phere, more marked toward the horizon, and
in the first stage more marked in the west-
ern horizon. The sickly whiteness may in-
crease for from twenty to sixty hours, with
an increasing discomfort when exposed to
the peculiarly penetrating power of the sun's
rays, but during all this typical condition
there is nothing which has measured the
changing aspect of the air, nor its changing
condition of heat permeability, nor the abso-
lute vapor, except at the surface, nor the
distinctive character of the cyclone heat in
the southeast quadrant, nor the direction of
the upper and cross currents of wind, nor,
above all, the modifications of the diurnal
and " semi-diurnal " effect superimposed on
the cyclone movement. It therefore seems
important, in studying the hourly phases of
pain, that meteorological charts should be
supplemented by a descriptive narration to
complete the record, and a closer study of
the effect of diurnal change on weather.

HYGIENE IN FRANCE.

Recently the French Chamber of Depu-
ties have considered a general law govern-
ing workers in factories, child labor, etc,
M. de Mun proposed an amendment provid-
ing that women should not be allowed to
work the first four weeks after confinement.
The proposition created a lively discussion,
the general tenor of which was to the effect
that the private life of citizens should not
be interfered with to the extent proposed,
and that the fixing of an arbitrary limit of
four weeks was not wise, as many would be
able to be at work long before that time,
while others would be incapacitated far be-
yond the limit. One member proposed that
compensation by the State be given to the
extent of one franc per day. The amend-
ment was finally tabled by a decisive vote. —
Le Bulletin Medicale.

MEDICAL CHEMISTRY

PRESERVATION OF HYDROGEN
PEROXIDE,

For this purpose, Kingzett recommends
the addition of a small amount of ether.
Experiments conducted by the author show
that pure hydrogen peroxide lost, in twenty-
eight days, ten per cent. ; in ninety-eight
days, 27.4 per cent. ; in two hundred days,
thirty-nine per cent. ; and in four hundred
and ninety days, 89.2 per cent. The ad-
dition of sulphuric acid reduced these
figures to 9, 23, 271, and 68.3, respectively.

646

News and Miscellany.

Vol. lxiv

Alcohol reduced them to 1, 7, 4, 7.4, and

22.8, respectively, while ether still further
jeduced them, showing a loss of the peroxide
in the times mentioned of 0, 1.3, 2.4, and

15.9, respectively. — Med. Bee.

NEW REACTION OF HYDROCHLORATE
OF COCAINE.

M. Schell, student of pharmacy at Mul-
house, states, in the Journal de Pharmacie
d' Alsace Lorraine, that if a minute quantity
of a mixture of calomel and hydrochlorate
of cocaine be moistened with distilled water
a deep grayish coloration at once takes
place. Care must be taken to avoid too
great a quantity of water. No other alka-
loidal salt gives this reaction, though if free
atropine be heated with calomel and water
to about 212°F. a black or blackish colora-
tion ensues. The same result is obtained
when a mixture of calomel and atropine is
treated with very dilute alcohol. It is
rather remarkable that cocaine (the base)
in the one case, and the salts of atropine in
the other, do not yield the results above
mentioned. — Nat. Druggist.

TO DETECT COPPER COLORING MATTER
IN TEA.

Sometimes worthless and exhausted tea-
leaves are restored to their natural color
and made to look like a superior article of
green tea by coloring with copper or drying
on copper plates. The addition of a little
aqua ammonise to an infusion of tea thus
colored will at once produce a blue color,
more or less intense, according to the
amount of copper present. The presence
of copper coloring matter in pickles, pre-
served vegetables, etc., may be similarly de-
tected.— Nat. Drug.

THE ALKALINITY OF THE BLOOD WHEN
CONCENTRATED BY THE ACTION OF
LARGE DOSES OF SODIC SUL-
PHATE.

J. Swiatecki (Hoppe-Seyler's Zeitschr. f.
physiol. Chem., November, 1890) discusses
this question. In 1850, C. Schmidt made
the observation that in the algid stage of
cholera the blood loses its alkalinity so
markedly that in many instances it may
even redden blue litmus paper — an observa-
tion that has often since been confirmed, as,
for example, by the French Commission
during the cholera in Egypt in 1883. Mya
and Tassinari, who have investigated the

different diseased processes which affect the
alkalinity of the blood, have also studied its
behavior under the influence of certain
purgatives, such as infusion of senna, mag-
nesia, and sodic sulphate, but without ob-
taining any positive results. The author
accordingly pursued in the University of
Warsaw a series of researches upon dogs
with Glauber's salts, and as the result of
them he concludes that the alkalinity of the
blood increases when its specific gravity is
raised by means of large doses of these
salts ; that this rise can be explained by the
increased transudation of acids, as well as
alkalies, from the blood into the intestine
in accordance with the laws of osmose ; and
that the attempt to explain the increased
alkalinity after the use of mineral waters
exclusively through the passage of basic
salts out of the intestine into the blood is
not satisfactory.

NEWS AND MISCELLANY.

TUBERCLE

BACILLI AT THE
INFECTION.

POINT OF

By inoculation on guinea-pigs and rabbits,
Tangl has established (Monatsh f. prakt.
Derm., No. 4, February, 1891) the fact that
tubercle bacilli cannot penetrate the body
without producing tuberculous changes at
the point of entry. He infers, therefore,
that in primary tuberculosis of the lymphatic
glands, or of the bones, if after even a con-
siderable time there is no tuberculous change
externally, the tuberculosis could not have
been produced by external infection. — Brit
Med. Jour.

IMPORTANT IMPROVEMENT IN MICRO-
SCOPIC LENSES.

It is stated that an immense improvement
has recently been effected in the manu-
facture of glass for optical instruments by
means of the addition to the ordinary ma-
terials of phosphorus and chlorine, which in
some as yet unexplained way cause the glass
to be very much more transparent, and en-
able it to receive a much higher degree of
polish than any optical glass hitherto manu-
factured. Thus microscopes can be made
which will render objects of the diameter of
only the one-eighth millionth of a millimeter
visible, whereas with the best instruments
now in use the diameter of the smallest
object that can be seen is one-sixteenth thou-
sandth of a millimeter.

:

p:

ENLARGED FROM 28 TO 40 PAGES OF READING MATTER.

whole No. 1787.] MAX 30, 1891 CV0L- LXIV> No 22-

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No. 1787-

PHILADELPHIA, MAY 30, 1

Vol. LXIV.— No. 22

Clinical Lecture.

THE ETIOLOGY AND THERAPY OF WEAK
LABOR IN PRIMAPAR^E OF ADVANCED
AGE.

BY ERNST BORNER, M. D.,

PROFESSOR OF OBSTETRICS, UNIVERSITY OF GRAZ.

Gentlemen : — The subject of to-day's lect-
ure, namely, the Etiology aud Therapy of
Weak Labor in Elderly Primaparse, is one
that is but very meagerly dealt with in the
text-books. Only a few monographs of very
recent date show that this subject has re-
ceived any attention or study at the hands
of specialists.

During the last summer, cases have been
brought to this clinic, that have forced upon
us the study of labor and confinement in
primaparse of advanced age, and it is high
time that we should have a thorough under-
standing of the subject. Before going into
the special subject under consideration, let
me call to your mind the characteristic
peculiarities, acknowledged by other observ-
ers, to be found in the confinement of
elderly primaparse. The majority of authors
agree on many points, and a resume of their
opinions is, therefore, not difficult.

It is of primary importance to fix the
dividing line between what may be justly
termed young or old primaparse. Ahlfeld
places this age at thirty-two years, being —
as he expresses it — the middle of the " ovu-
lation-period" (15-50 years). Hecker is
of the opinion that fifty years of age does
not constitute the average age for " change
of life" but is too old, and I agree with
him. He, as well as Cohenstein, Rumpe,
Stein mann, and other writers, take the age
of thirty as the dividing line. Glancing at
the tabulated records of various observers,
we find that Cohnstein reports his observa-
tions at the parturition of 393 old prima-
parse, Ahlfeld, 102, Hecker, 422, Rumpe,
100, Steinmann, 645, and it is from the re-

sults of these observations that we will form
our resume.

It will be of interest to you to know that
Cohnstein reports the cases of women becom-
ing primaparre at the advanced age of fifty
years ; while the oldest primaparse on rec-
ord is one reported by Steinmann, the
patient's age being fifty-two. The recorded
observations, however, show that child-birth
rarely occurs, for the first time, in women
over forty years of age. The influences of
a late appearance of menstruation upon late
conception, the course of pregnancy, and
peculiarities in parturition, in the sex of the
foetus, and in the lying-in period, are ques-
tions which are answered similarly by the
majority of observers. The following table,
compiled by Hecker, showing the age of the-
appearance of the menses in a number of
primaparse, speaks for itself :

In 39 cases menstruation began at 20.

«. 14 " << << « 21.

" 13 " " " " 22.

" 3 " " '« " 23.

" 4 " " " " 24.

" 3 " " " " 25.

" J " . " " " 26.

Late sexual development is, therefore,
according to Hecker, the principal factor of
late parturition.

Regarding the causes of delayed concep-
tion, Rumpe, while agreeing with Hecker in
the importance of retarded sexual develop-
ment, recognizes also three other possible
causes. First, and very naturally, delayed
cohabitation, until a late period of life ;
second, a hindrance to conception by some
local disease, for which a suitable treatment
should be instituted ; third, a hindrance to
conception caused by some unrecognized
trouble or ailment, which, after years of
cohabitation, yields voluntarily to concep-
tion. Such local anomalies have been re-
ported by Cohnstein, and include rigidity
of the vagina and of the vaginal entrance,
rigidity of the orificium externum, closure
of the external orifice resulting from long
I continued catarrh, and fibroids or sarcoma

647 .

648

Clinical

Lecture.

Vol. lxiv

of the uterus. He concludes, that patho-
logical changes in the vaginal orifice, the
vagina, or the external os, which prevent,
or render difficult the accomplishment of
coitus, or render the introduction of the
seminal fluid into the uterus difficult, are
among the most frequent causes of sterility.
For a time also, it was erroneously held that
a narrow pelvis should be considered one of
the etiological causes of late conception.
This, however, is totally unwarrantable.
Regarding the peculiarities following the
Course of pregnancy in old primaparse,
Winckel has called attention to their pre-
disposition to kidney troubles.

The researches of Deventer, Dionis, v.
Siebold, Wigand and Michaelis, show that
the rigidity of the sexual organs in old pri-
maparse, cause increased difficulty in child-
birth, and result frequently in lacerations of
the perinenum. E. v. Siebold has observed
repeatedly delayed and painful labor, and
considerable trouble in passing the after-
birth, owing to the weakness of the uterine
contractions. Mauriceau speaks of diffi-
culties occurring from the position of the
os coccygis, and Neubeck, of the unyield-
ingness of the pelvic cartilages generally.
The text book of Nsegele-Grenser speaks of
the inclination of old primaparse to eclamp-
tic convulsions. Valenta's experiences have
shown him that in these cases a change of
the foetal condition very frequently occurs
during the last month of pregnancy, causing
a premature rupture of the bag of waters.
This, he asserts, occurs with great frequency
in primaparse between the ages of thirty-six
and forty years. Hecker calls attention to
the frequency of extra-uterine pregnancy.

In connection with this brief historical
resume, it will be well to go a little deeper
into the subject. The principal character-
istic, acknowledged by the authors men-
tioned in the first part of this lecture, is the
weakness of labor in old primaparse. This
weakness and tardiness of the contractions,
may proceed throughout the entire course
of labor, or else may show itself as a sec-
ondary symptom, the initiatory labor hav-
ing been normal.

Curiously enough, this weakness of labor
is accompanied by an utter disproportionate
amount of pain, this being frequently of an
agonizing nature. These convulsive pains
occur most severely in cases when there has
been a premature flow of the amniotic fluid,
the os remaining hard and unyielding.

Rigidity of the soft parts in general is
another factor, acknowledged by nearly all
observers. Rigidity of the cervix tends to

give trouble, and lacerations of the cervix
occur frequently.

I have already spoken of the frequency
of a premature rupture of the amniotic sac.
Cohnstein observed this in over eleven per
cent, of his cases.

All these unnatural conditions very nat-
urally tend to produce a tedious course of
labor for old primaparse, and this may be
regarded as an almost inflexible rule. This
tediousness is especially marked during the
"dilatory stage," while the "expulsion
stage," is generally hastened by instrumen-
tal interference. Finally, also, the " after-
birth stage " is generally delayed ; Rumpe's
cases showing that tediousness in this stage
of parturition occurs in 10 per cent, of
primaparse.

Bidder claims that the average duration of
labor in primaparse is 17.8 hours, while
Ahlfeld holds thta 20.8 hours is a just aver-
age. Beumer and Peiper have found that the
average duration of labor in old primaparse
is 25 hours, and Ahlfeld claims that it is
27.6 hours. Regarding the use of instru-
ments, the general opinion is that, in old
primaparse, forceps will be used five times as
frequently as in general cases. Operative
interference for the removal of the after-
birth is also frequently necessitated ; Cohn-
stein reports 26 cases in which he was com-
pelled to use instruments in the removal of
an adherent placenta, and Hecker reports
15 similar cases.

Another point, on which all writers on
this subject seem to agree, is the frequent
occurrence of puerperal eclampsia. An-
other frequent complication is post-partum
hsemorrhage, caused either by atony of the
uterus, adherent or retained placenta.

I have thus briefly given you the chief
characteristics acknowledged to be of fre-
quent occurrence in old primaparse, but be-
fore leaving this chapter of peculiarities,
must not fail to call your attention to one
more, and one which, if met with, is likely
to cause grave fears on the part of the ob-
stetrician. When we have indications for
the use of the forceps in these cases, we not
only find a weak foetal pulse, but Very fre-
quently also an abnormal weakness, and ex-
haustion of the patient. In two cases re-
ported by Rumpe, death, which occurred
during labor, could only be attributed to
exhaustion. One of these cases was that of a
primapara, age 35, who died after 60 hours
of weak labor, and the other who died after 24
hours of labor, her age being 43 years. On
the- other hand, Ahlfeld reports 9 cases in
which the patients evinced great excite-

May 30, 1 89 1.

Clinical

Lecture.

649

ment, which gradually increased to a vio-
lent delirium. This, Ahlfeld claims, is
due to an abnormal excitability of the nervous
system, caused by the long and painful
labor. 1 hold it to be of great importance
to watch most carefully for these signs of
nervous depression or excitability.

The number of still-born infants is, on an
average, far greater in old primaparse than
in other parturitants. This is frequently
caused by asphyxia of the foetus, and this
in turn, due to the tedious bi,rth.

An interesting fact is that the number of
male infants born by old primaparse,
far out-numbers the number of female in-
fants. Finally, complications, and even
death, during the lying-in period, are more
frequently met with in old primaparse than
in others.

While experience has taught us the
existence of these various complications, yet
our scientific knowledge is still unable to
definitely give the etiology of these symp-
toms, but in my opinion, these questions can
still be answered by means of the results of
extended pergonal experiences. The history
of a case which I intend calling your atten-
tion to to-day, is calculated to throw light
upon, at least, one of ithese questions viz.,
the significance of the different grades of
modified labor in old primaparse and its'
possible significance.

The history of the case is briefly as follows :
The patient, Mrs. H., was a primapara, 35
years old, and of healthy parentage. Her
family history is good. The patient herself,
was a healthy child, and menstruated at the
age of 12 years. During her married life
she was always strong, healthy, and a good
walker. Three years previously she had a
slight increase of menstruation, and between
the periods, she passed a slimy secretion
from the vagina. Upon examination, I
found a slight papillary erosion around the
external orifice, and a slight hypertrophy of
the anterior lip, which occasioned some
contraction of the vaginal orifice. The hy-
pertrophy was excised, the erosion subjected
to the usual treatment and the patient soon
recovered completely.

After her recovery, the patient shortly be-
came pregnant for the first time during her
married life. Pregnancy proceeded normally,
and on December 24, the first foetal move-
ments were felt. At the end of March, I
took the measurement of the pelvis and
found it normal. In the middle of April
the foetal head was in the lower pelvis. Ac-
cording to my calculations the birth should
have taken place about the first of May, but

on the twenty. fifth of April, uterine contrac-
tions were felt, and the bag of waters broke.
The foetal head was well down in the pelvis,
in the second occipital position. The foetal
heart was distinctly audible on the right
side. The pains gradually increased, and
were, to all appearance, normal.

During the entire day following (April
26), light labor continued, without produc-
ing any effect upon the position of the foetus
or dilating the cervix. The patient is up
and about. April 27, the foetal head still
lower, but the cervix only dilated to the
size of a finger. April 28, the condition
unchanged, except that the contractions are
becoming more and more painful, and a
" sawing " pain appeared in the small of the
back. At night no rest can be obtained,
and the patient's appetite, which, until now,
has been excellent, begins to fail.

April 29, no change.

April 30, great weakness in consequence
of loss of sleep and appetite. The painful-
ness and also the inutility of the pains,
which are growing shorter, continues. The
only change is a slight swelling of the os.
The patient is greatly discouraged.

Up to this time the treatment consisted in
the application of active measures, calcu-
lated to increase the severity of the uterine
contractions, and for this purpose two baths
were given daily, tepid vaginal douches
used three times a day, four litres being
used at each douche, with the addition of a
little carbolic acid. Also as much exercise
as possible, such as walking about the room,
etc. All this supplemented by a nutritious
diet, wine and brandy. The intensity of the
suffering was relieved somewhat with anti-
pyrine, and suppositories containing laud-
anum.

As no advance was being made, and as
the situation seemed a most hopeless one, I
attempted a slight dilatation of the os,
although it was evident that the cause of the
trouble did not lie in this direction. The os
was soft and smooth, and normal contrac-
tions would have caused speedy dilation;

On the first of May, after five days of
labor, the patient had an attack of delirium.
She threw herself wildly about on the bed,
rolled up her eyes, and called out unintelli-
gibly, as if in the greatest fear. I was at
once called, and found the patient somewhat
quieter, but otherwise about in the same con-
dition. I now made several incisions in the
os, without, it must be confessed, expecting
much from them. In the evening of the
same day it was seen that the procedure
had been ineffectual. Practically, the local

650

Clinical Lecture.

Vol. lxiv

condition showed that the patient was still
in the first stage of labor, while her dangerous
weakness and exhaustion were most alarm-
ing and the altered frequency of the foetal
heart sounds, showed that the situation was
a most critical one. Calling in a colligue,
we agreed that the immediate extraction
of the foetus was necessary to the mother's
life, and, accordingly, perforation, with Lev-
ret's shears, and extraction was speedily
performed. The pains did not even prove
sufficient to expel the after-birth, although
energetic massage was performed for about
an hour, and finally this had to be removed
manually. The foetus was that of a large
child, weighing 3,500 grammes, and of nor-
mal development. Post-partum haemorrhage
did not occur, and the patient subsequently
recovered after a normal lying-in period.

The peculiarities characteristic to old
primaparse, as observed in this case, included,
first, abnormal lack of energy and effective-
ness of the pains, which, although they re-
curred at regular intervals, only dilated the
os to the size of about a nickle ; second,
that in the face of an apparently normal
physical condition, a so heroic method of de-
livery was necessitated.

In this case, no existing physical abnor-
malities justified the weakness of the labor,
and the only etiology which could be ad-
vanced was the patient's age. The physical
strength does not seem to have anything to
do with it. Indeed statistics show that in
old prima-parse of vigorous constitution the
labor is apt to be weaker than in constitu-
tionally delicate patients of the same age.
The question of etiology is, therefore, a most
difficult one to answer, but one which I sum
up in the following sentence :

The mechanism of parturition — if I may
use this expression — loses its power of exact
work with the increased age of the patient.
This loss of power is caused principally by
inaction, due to long sterility, and increases
with the age of the patient.

Regarding the treatment of these cases, no
definite rule can be laid down. Everything
depending upon the severity of the case. If
symptoms of extreme exhaustion or excita-
bility are present, the mother's life is In
great danger, and the foetus should be at once
mechanically removed. Until then it should,
very naturally, be the aim of the physician
to save both lives if possible. It should,
however, always be endeavored to save the
mother from danger, andtany operative pro-
cedures which would imperil her life for
the sake of the child's, are not to be enter-
tained.

Incisions into the os may, or may not, be
effective. More heroic measures have been
offered, such as Diihrssen's method of cutting
deeply into the external orifice until the
vaginal wall is reached, in order to render
the application of forceps possible. Such
procedures, even if undertaken with every
precaution, including strict asepsis, cannot
be regarded as anything but dangerous, yet
the operation has proved successful in ex-
perienced hands. Tamponing the cervix
and vagina with iodoform gauze is another
rational method often valuable in strength-
ening the pains and dilating the os.

Regarding the operation of Caesarian sec-
tion, in my opinion, the risk run by this
operation, although it has reached so high a
grade of perfection, is too great to warrant
it, when by sacrificing the child's life, an
extraction per vaginam can be easily effected.
Still, the operation is one for every operator
to consider in such cases.

Experience is, after all, the best teacher
in these cases, and at the same time the
hardest teacher, and in this lecture I can
only hope to have forewarned you, so that
you may not be dismayed when meeting a
case of the kind.

CARDIAC HYPERTROPHY AND DILATA-
TION— BRONCHITIS — RETRO-PERITON-
EAL SARCOMA— ENLARGED GALL
BLADDER.

BY FRANCIS DELAFIELD, M. D.,

PROFESSOR OF PATHOLOGY AND PRACTICAL MEDI-
CINE AT THK COLLEGE OF PHYSICIANS AND
SURGEONS, NEW YORK.

CARDIAC HYPERTROPHY AND DILATATION.

Gentlemen : — You have here a man 22
years of age, a laborer by occupation, who
was apparently in good physical health until
about one month ago. At that time he was
taken sick, complained of a good deal of
pain about the right shoulder joint, with
frontal headache, cough with expectoration
and vomiting, and great physical depression.
After suffering with these symptoms for a
day or so, he was compelled to take to his
bed, and remained there for a couple of
weeks. At the end of this period he got up
again, the pains in his head disappeared, his
strength gradually returned, and he felt in a
position to be able to go back to work again.
He remained at his work this time for about
four days when he suddenly, and without any
appreciable cause, began to experience great

May 30, 1 89 1. Clinical

Lecture.

651

shortness of breath and palpitation, and these
symptoms persisted up to the time of his
coming to this clinic for the first time, which
was five days ago.

Physical examination of this man then
showed a condition of the heart the same as
he at present has. He had then some rales
over both lungs, giving us the physical
signs of a general bronchitis, and he had a
pulse of 140. He was advised to go home,
remain perfectly quiet, and was put on the
use of iodide of soda. We find him now not
looking particularly bad, and he feels well
enough to go back to his work, although he
still has dyspnoea. The bronchitis has appar-
ently disappeared and there are no physical
signs of anything wrong with the lungs at
the present time.

When we examine this man's heart we
find it considerably hypertrophied and dila-
ted,but without any murmer, and one, though
laboring under, excitement that is quite
marked, still, when he is quiet, acts fairly
well. We find a pulse showing no evidence
of increased arterial tension.

This is all the clinical knowledge we can
obtain in this man's case, and though it is
easy enough to give the cause of his illness
a month ago, which was due to the prevailing
epidemic, it is not now so easy to say why he
has a heart that illustrates one of the ex-
amples of hypertrophy and dilatation, with-
out valvular lesion, developing suddenly.
Why such a pathological condition should
develop in this case we do not know, but we
do knjw that this young man, in ordinary
physical health, began to complain of an
abnormal cardiac sensation, with dyspncea,
and presenting all the physical characteristics
of a heart hypertrophied and dilated, in the
course of a day or so. Patients who develop
in this way this form of cardiac hypertrophy
and dilatation have a very extreme and dis-
tressing dyspnoea, and in many cases the
heart's action cannot be brought under
control.

There can be no question as to the pro-
priety of keeping this man absolutely quiet
until his heart's action is a little better than
it is at present. Though he feels physically
better than he has been, he still should not
be permitted to go to work for the present.
He should still continue the use of the iodide
of soda, as he has been apparently improving
under its administration, but should he not
keep on improving, it would then be a ques-
tion for us to determine whether he would
not do better under the administration of
the chloride of barium or aconite. The
iodides, chloride of barium, and aconite, are

the three drugs I would especially recom-
mend for his use. This condition is not, by
any means, a common one, and is an ex-
tremely interesting one of its sort.

BRONCHITIS.

The next patient is a boy, 16 years of age,
who was brought to us from the country.
He was in apparently good health until
within the past seven months. During this
period, however, he has complained of very
little in particular, but his mother notices
he has been steadily losing flesh and
strength. He has had some cough, and a
headache. He has now a temperature of
101° F.

On physical examination of this boy's
lungs, I am able to detect the signs of bron-
chitis of the larger- tubes, and he has, at the
apex of the left lung, as compared with the
right, resonance of a higher pitch and shorter
duration, which pathologically denotes thick-
ening of the pleura and consolidation of the
lung on that side. Over the lower part of the
right lung behind, I find a localized area of
subcrepitant rales, without any marked
change in the percussion note, which would
mean either a localized pleurisy or inflam-
mation of the lung substance at that point.

This is all the history we have of this case
and these are all the physical signs that we
can obtain, but they are not of sufficient
clinical significance to wTarrant us in giving
more than a probable diagnosis. I should
be quite unwilling to say positively what is
the nature of this boy's trouble, but from the
absence of any marked symptoms and from
this steady wasting away, I should be in-
clined to regard it as tubercular in origin.
We have not as yet had an opportunity to
examine microscopically this boy's sputa
to determine the presence or absence of
bacilli.

I should be inclined to put this boy on the
use of cod liver oil and creosote, if he is
able to bear it, and note its effect on his
physical condition.

RETRO-PERITONEAL SARCOMA.

The next patient I present to you, is a
man TO^years of age, who tells us that he was
in his ordinary health up to three months
ago, at which time his bowels became con-
stipated, and this constipation has persisted
up to the present time without any ameliora-
tion in its character. The form of constipa-
tion he has is that the bowels moved every
two or three days, and then they had to be
moved by the use of purgatives. He then
passed hard fecal matter and he gives us no
history of an inter-current diarrhoea, nor is

652

Clinical Lecture.

Vol. lxiv

there a history of the passage of fecal matter
diminished in size.

Besides this symptom of constipation this
man complains of, he has been evidently
losing flesh and strength, and has lost ten
pounds in weight, he tells us, since the com-
mencement of his present illness. His appe-
tite has, however, continued good, and he
has had no gastric symptoms until within
the past few days, when nausea suddenly
presented itself. He has also had, of late, a
slight oedema of the feet, but more marked
on one side than on the other. His urine
has a specific gravity of 1,007, but contains
110 albumen.

Now, as we look at this man, we can at
once notice his loss of flesh and strength.
We notice also, as he lies on the table, an
unnatural fulness about the centre of the
abdomen, and we also observe that there is
increased peristalsis, with a marked depres-
sion below the ribs laterally. I find on
palpation a solid mass at about the middle
of the abdomen, which is apparently as large
as an orange, and hardly movable with my
fingers. At the lower portion of. the abdo-
men, and in the vicinity of the left groin is
another but smaller mass which appears to
have some movement on palpation. You
can notice very distinctly the outlines of the
larger mass in the abdomen change with the
movement of the diaphragm.

Looking at this large mass in that way,
it would seem that it was made up of a num-
ber of coils of intestine which are more or
less matted together, and it would further
seem as if these coils of intestine are more or
less in motion all the time, changing their
position continually from side to side.

With this history of this man's case, and
the pathological condition of his abdomen,
at the present time, the question naturally
suggests itself to our minds : What is the
nature of this tumor? One gentleman calls
it a carcinoma of the peritoneum. That
diagnosis might be possible, but this tumor
is not evidently attached to the anterior
wall of the abdomen, nor does it seem to be
attached to the omentum, nor to the intes-
tines, and these are the ordinary positions
of a neoplasm that originates in the peri-
toneum. It is not a movable tumor and is
attached to the posterior wall of the abdo-
men. Tubercular infiltration of the glands,
another gentleman states this trouble to be.
That is not very probable in this case, for
the man has no history of tuberculosis.
There are such pathological conditions as
tubercular infiltration of the glands of the
mesentery, but this diagnosis would hardly

apply to the case before us. Chronic intes-
tinal obstruction of some kind, is the answer
of another gentleman. That would account
for the constipation this man complains of,
and for the increased peristalsis, but in what
way are we to account for the presence of
this hard mass ? If there is a fecal mass in
the colon, that intestine usually is movable.
It would be very proper, indeed, to think of
incomplete obstruction of the colon to ac-
count for a large part of this man's trouble,
but, as to the exact nature of that obstruc-
tion it would not be so easy to say. WTe
might suppose that a new growth existed in
the wall of the colon, and there are curious
examples of chronic inflammations that ob-
struct the colon in one way or another.
Some sort of obstruction of the colon un-
questionably exists here, but still this is not
a case of ordinary obstruction. He gives up
the clinical evidence of obstruction of the
colon, and he also gives us evidence of this
solid tumor which is attached to the pos-
terior abdominal wall.

A gentleman says that this tumor is a
retro-peritoneal sarcoma. With this diag-
nosis I am inclined to agree, and this tumor
is evidently of that character. This man
has had, at some time, a peritonitis, and this
peritonitis has matted together the intes-
tines, offering in this way interference, to a
certain extent, to the passage of fecal matter
through the intestine.

The way to treat this case is evidently to
try and keep this man's bowels as freely
active as we can. He has no pain, the
tumor is not of a large size, and I see no
reason why he should not be able to get
along very well for a considerable length of
time, providing we can get his bowels to
move regularly.

ENLARGED GALL BLADDER.

I will now relate to you the particulars of
a case I saw in consultation a few days ago
in the hope that it may prove of some prac-
tical interest to you. I was called to see in
consultation, a young man, who gave me
the following history. He was 35 years of
age, and of somewhat intemperate habits of
life. He sustained, while under the in-
fluence of liquor, a traumatism over the
region of the liver. This injury did not at
first trouble him in any way, but, in the
course of a day or so, pain developed over
the region of the liver, some fever set in,
and the patient felt so very sick that he was
compelled to take to his bed. He remained
in bed for some time, the pain and fever
continuing, and he began to waste gradually

May, 30, 1 89 1.

Communications.

653

away. After suffering in this way for some
weeks, an enlargement was noticed over the
liver, and this enlargement persisted up to
the time I was called to see him. When I
came to the bedside of the patient he was
vomiting constantly, appeared to be very
much emaciated, and had that peculiar ex-
pression suggestive of septic poisoning.

The attending physician thought of the
possibility of abscess of the liver in his case,
and on aspirating that organ drew out no
pus. The most noticeable feature of the
man, besides this change in his general con-
dition, was the appearance of the liver.
The upper border of that organ was a little
higher than normal, while its lower border
beginning at the left side, came down
symmetrically and regularly into the abdom-
inal cavity as low down as the umbilicus.
The liver was not only enlarged downwards,
but also forwards, so that the anterior ab-
dominal wall was pushed up, presenting all
the characteristic outlines of an enlarged
liver.

The physician who was in attendance
made a diagnosis of amyloid degeneration
of the liver, but this seemed to me to be
altogether out of the question. I thought
that the man had either a suppurative
process going on in the liver, or a rapid neo-
plasm of that organ, though the appearance
of the man was strongly suggestive of sup-
puration. I was embarrassed from the fact
that aspiration had been done and no pus
withdrawn. I was furthermore embarrassed
from the fact that the patient, when I was
called to see him, was so sick that I did not
deem it right to aspirate the second time,
and obtain positive evidence of the exist-
ence of pus in the liver, for I thought that
the doctor, in aspirating, had not penetrated
the liver substance sufficiently deep.
Whether he had one or more abscesses of
the liver, or diffuse suppuration of that
organ, a pathological condition that some-
times occurs, I was not certain.

This morning I received a note from his
physician, stating that the man had died,
that his liver had been examined, and no
suppuration existed. The tumor was an en-
larged gall bladder, and instead of enlarg-
ing after the manner of the normal gall
bladder, which is pear-shaped in form, it
spread out under the under surface of the
liver, so as to form a symmetrical and con-
tinuous tumor with that organ, and this is
what gave, on physical examination, the ap-
pearance of an enlarged liver. The gall
bladder, on examination, was found dis-
tended with pus. This fact never entered

into my mind on arriving at the question of
diagnosis. There was no cause for this
pathological condition, except the blow he
received over the region of the liver.

Communications.

RESECTION OF THE OPTIC NERVE.

BY L. WEBSTER FOX, M. D.
• (second paper.)

Shortly after my first paper made its ap-
pearance on the above subject, I again had
the opportunity of putting to a test the effi-
cacy of this operation. The immediate dis-
appearing of all sympathetic symptoms, the
freedom from pain, the rapid recovery, the
saving of an eyeball, make me give the de-
tails of the following interesting case.

Mrs. Kate Guest, age 25, of Palmyra,
N. J., at the age of three years, had her
left eye punctured by a fork. The tine
entering at the lower and inner quadrant,
close to the corneo-scleral margin in the cil-
iary bodies. This accident was immediately
followed by an attack of sympathic ophthal-
mia, in which the sympathizing eye — the
right — became totally blind, the left passing
through the attack none the worse ; the vis-
ion remaining good until November of
1886, when the right eye became irritated
and inflamed causing the left one to become
the seat of sympathetic iritis. It is inter-
esting to note that the eye which was origi-
nally the seat of injury now became the
attacked eye, seventeen years after the primal
wound ; in other words, the right was now
the starting point of the migratory ophthal-
mia and the fulmination taking place in the
apparently healthy one. At this stage the
patient came under my care at the German-
town Hospital. The diagnosis was simple,
although the left eye did not present any
untoward symptoms. The patient com-
plained of a " mist before her eye." An
examination revealed iritis, the iris having
become attached to the anterior capsule of
the lens ; having seelusio pupillae.

The patient had very little or no pain
during the fading away of the vision. It
was a case of " slow iritis," where the vision
was blurred and the patient did not realize
her danger until too late.

I immediately performed an iridectomy
on the nasal side of the left eye ; first to
prevent further progress of the iritis, and
second, to give a better pupil for vision.

654 Communications. Vol. lxiv

The internal treatment was hydrarg, bi-
chlor. and potassa iodidi, pushed to their
fullest limit. The eye rapidly grew better
and useful vision was obtained. (I# J. §» )
glasses did not improve sight, owing to a
slight deposit of iritic pigment on the ante-
rior capsule of the lens. The patient was
married in 1887, and during her pregnancy,
which followed shortly afterwards, she had
a mild attack of dimness of sight, but
attributed it to her physical condition.

In the latter part of 1889, the third attack
came on, which materially lessened her
definition of objects for distance. Having
removed from the city, shortly after her
marriage, she did not seek the professional
advice of a medical man during the attacks,
but depended solely upon such domestic
remedies as hot water, tea leaves, etc., etc.

In February of this year she had a fourth
attack, which caused, vision to fall very rap-
idly to which so alarmed the patient
that she sought my professional advice im-
mediately. The attacks all seemed to start
from the right eye, blind one, which was
sensitive to pressure, with at all times some
lachrymation, the tears being scalding and
coming on in floods, ■ at intervals ; these
symptoms always being the precursor of
hazy vision in the left eye. At this exami-
nation I found in the right eye, which was
partially atrophied, pain on slight pressure,
but not at all angry looking. The left had
a diffused Descemitis ; iris musty and
scarcely any reflex to be obtained through
the artificial pupil which I made in 1886.
Vision was very defective, fingers could be
counted at about five feet against a black
back-ground.

In 1886 I suggested the removal of the
right eyeball, but owing to the young
woman having hopes of a speedy marriage
such advice was not entertained. The
operation of resection of the optic nerve
was suggested and when it was explained
that the eyeball could be preserved, while the
source of the migratory ophthalmia cut off,
her consent to a resection was given and the
operation was performed, under ether,
March 15th, 1891. Vision began to clear
on the second day following, and so con-
tinued from day to day until May 6th (last
examination), when vision had returned to
-££0-. Very little or no discomfort followed
the resection, in fact the patient returned
home in ten days. At present the scar vis-
ible in the operated eye is nothing more
than one would find after an advancement
or tenotomy of a muscle.

I have recently been making experiments

upon rabbits to decide whether the nerve
should be severed immediately at its bulbar
attachment or further down the trunk. My
experiments prove that it is safer to cut the
nerve as close to the eyeball as possible ; by
so doing one lessens the chances of a re-
union. In the rabbit the optic nerve enters
the eyeball at a right angle to its basilar
end, which lies under the anterior lobe of
the brain. As soon as the nerve is severed
the ocular muscles turn the eyeball on its
equatorial axis, and in consequence the
nerve becomes displaced down and in, in
some cases one-fourth of an inch.

The above figure represents a post-mor-
tem drawing of an eyeball of a rabbit five
weeks after a resection operation. 1, repre-
sents the optic nerve entrance turned out
from its original position ; 2, the optic
nerve-end down and in, which was attached
to the eyeball by organized tissue. The
relative position of optic nerve entrance and
nerve-end has been accurately preserved.
The illustration is life-size. The fundus
oculi was examined with the ophthalmo-
scope immediately after the resection. The
arteries were found empty, while the veins
retained sufficient blood to show their out-
lines very distinctly and so remained until
the death of the rabbit five weeks later.
In the rabbit the distribution of the blood-
vessels is unlike that in the eye-ground of the
human subject, while opaque nerve fibres
extend beyond the equator in a narrow
ribbon-shaped band, exceedingly bright and
silvery, across the horizon. The eyeball did
not change in appearance, the cornea re-
maining bright and clear ; no change in the
color of the iris nor crystalline lens. I am
convinced that where the operation for re-
section of the optic nerve is carefully
carried out, we have a better substitute than
enucleation, and with proper instruments it
becomes a very simple procedure.

I can only repeat what Dr. de Wecker
has said, " that the only way to prove con-
clusively that resection of the optic nerve
I can take the place of enucleation is that a

May 30, 1 891.

Communications.

655

large number of resections shall be made
and the results noted."

The above case, which I have described
carefully and somewhat at length, is one in
which I feel sure a resection of the optic
nerve is as safe a prophylactic measure as
enucleation, and in addition I have saved a
particularly morbid woman from the dis-
agreeable necessity of wearing an artificial
eye.

1304 Walnut St.

TYPHOID FEVER.1

BY DR. RIGG,

ALLEGHENY, PA.

Typhoid fever, gastric fever, typhus ab-
dominalis, enteric fever and infantile remit-
tent fever are a few of the terms used to
designate a peculiar continued fever of long
duration, usually attended with diarrhoea,
and characterized by peculiar intestinal
lesions, an eruption of small rose spots, and
enlargement of the spleen. In common
with other continued fevers, typhoid fever is
due to the introduction from without of a
specific poison into a system more or less
predisposed to the disease.

The nature and origin of the poison, and
the modes in which it is propagated, are
questions of interest and importance. Two
distinct views have been held with regard to
the origin of the poison, one that it is specific
in its nature, and derived only from some
pre-existing case of the disease. The other,
while usually produced in a person suffering
from fever, it may also be generated anew
by the decomposition of sewage and perhaps
other forms of animal filth.

It is accepted on all hands that typhoid
poison is reproduced in the system during
the fever, and that its chief, if not exclnsive
outlet is the intestinal discharges.

There is no evidence that it is conveyed
by the breath, perspiration or urine, but
while it is in the intestinal discharges it is
not as virulent when first avoided as after it
has been allowed to stand awhile. Warmth,
stagnation and seclusion from open air in-
tensify the poison.

There is now very little opposition to the
above theory — Murchison, of the older, and
Harley, of the more recent writers, excepted.
The former supporting the sewage gas origin,
anb the latter the effect of derangement of
function, he denies the infectious nature of

!Read before the Allegheny County Medical So-
ciety, March 17th, 1891.

the disease, and holds that a chill or wetting
is sufficient to determine congestion and the
resulting phenomena of enteric fever. With
the above exception, the mind of the profes-
sion seems to be almost a unit as to the spe-
cific cause of typhoid or enteric fever.

The mode through which the poison may
find an entrance to the human body is still
a question in the minds of many able investi-
gators. As it stands to'day, we might say
the probabilities are in favor of the follow-
ing in the order in which they are named :
First, Infected water. Second, Infected
milk. Third, Infected ice. Fourth, Air
being infected with the dried spores through
dust. Fifth, Digital infection. Sixth, In-
fected meat. With reference to the first, or
water source, there seems to be no limit to
the evidence that might be collected were
one disposed to spend the time and labor to
collect it ; we will therefore only refer to a
few cases in which that seems to be the
cause.

Mr. Charles V. Chapin reports on the epi-
demic fever in Providence, E. L, in its rela-
tion to the public water supply. It was
! found that the fever had prevailed at
Natick, three and one-half miles above the
pumping station which supplied the reser-
voir. It was learned that the excrement
had been thrown on the river bank. The
time between a heavy rain which would
wash the excrement into the river and the
outbreak was about fifteen to twenty days ;
deduct from this three days which would be
required to get from river to consumers, and
we have about twelve to seventeen days as
the time of incubation.

This is in accord with the report given by
Dr. Taylor in 1885, to the State Medical
Society of the Plymouth epidemic, which
was clearly traced to a case in the mountains
on the bank of a stream that supplied the
reservoirs.

The time which this got into the reservoir
was, if I remember correctly, March 26th,
and the outbreak April 9th to 15th, at which
time it was in full force, also, in accord with
a report by myself in 1884, to the West-
moreland County Medical Society, of an
outbreak at Alice mines, in which one case
was brought to a house where the closet was
located just above a spring. About the
third wreek there was a heavy rain, causing
the vault to overflow, at which time I went
to the superintendent and asked that the
spring be closed up, when he informed me
that it was the best water on the place and
could not do it.

After trying to explain to him the reason,

656

Communications.

Vol. lxiv

and failing, the matter was dropped, and in
about seventeen days typhoid fever began
to develop, we had in all twenty -four cases,
all except one got their water supply from
the above spring.

At this time the company ordered the
spring closed, and the trouble ceased. Dr.
Anderson reports a peculiar teat eruption in
the milch-cow, in connection with an out-
break of enteric fever among the* consumers
of the milk, at Dundee. There is also a re-
port from Leeds, showing milk to be the
probable source of infection. I have been
unable to find any well authenticated cases
traceable to ice, but. the fact that a low tem-
perature does not destroy the germ, makes
it a possible source of infection.

The air may be the source not so much by
carrying the germs themselves, as by carry-
ing the particles of dust, or other matter, .
that may contain the special poison.

It is impossible for a current of air to de-
tach bacteria from moist surfaces, they must
first dry. I think it possible to account for
many isolated cases, that could not be ac-
counted for in any other way.

As to digital and meat infection, they, in
my judgment, are only possible and not
likely means of communicating the disease.

As to diagnosis we will say but little, as
the disease is too well known to you to jus-
tify taking your time, only a few points will
then be noticed :

The invasion is usually insidious, more or
less headache, muscular weakness, general
depression, with pains more or less through
the body, slight chills, as a rule not severe,
loss of appetite, epistaxis, yellowish white
coat on tongue, bowels confined or relaxed,
if confined, usually open freely from slight
purge, urine high colored and diminished in
quantity, pulse and temperature above nor-
mal. The patient will have the appearance
of more depression than will be accounted
for by the temperature or duration of illness,
the face is often a very useful guide in mak-
ing an early diagnosis. One very important
thing to do is to exclude any local inflam-
mation as a cause of the pyrexia. The ab-
domen may be tumid with some tenderness
of right iliac fossa, but the abscence of this
does not exclude enteric fever. The gradual
and continuous rise in temperature together
with above symptoms and abscence of local
inflammation, will leave us fairly sure of
the character of the trouble. Then if we get
a free yellowish green stool from slight
purge, we may feel sure of our case, the rose
spots will soon begin to make their appear-
ance, a short cough is often present, some-

times severe with sibilant rales, If the pulse
is much above one hundred per minute, you
can look for a severe case, — if below eighty
or ninety most likely a mild one.

Relapses are common in enteric fever ;
this if a true relapse is not simply a return
of pyrexia, but a return of all the phenomena
of fever. I have seen the third relapse with
all the symptoms well marked, with a period
of five to ten days between the ending of one
and the beginning of the other.

As to the special symptoms and complica-
tions hemorrhage is perhaps the first to at-
tract our attention. This occurs in about
eight per cent, of cases, usually after the
fourteenth day.

Perforation also may occur, andis a very
fatal complication.

Peritonitis without perforation may occur,
and in typhoid fever may exist without any
very great tenderness, but with a good deal
of tympanites.

If great tympanites occur early in the dis-
ease, say the first week, it is an unfavorable
indication. Diarrhoea is usually present
though not often hard to control, and if not
excessive not especially dangerous. The
urine usually contains albumen in the early
stage, and by some is looked on as a diag-
nostic sign. Ehrlich's urinary test is also
regarded as of great diagnostic value. This
is the characteristic red coloration of the
urine, and is made by adding 25 parts of a
solution of sulphanilic acid in dilute hydro-
chloride acid, 1 to 20 to 1 part of a 5 per
cent, solution of sodium nitrite, and the
whole mixed with an equal part of urine.

I have had no experience with this test
and cannot speak of its usefulness. Pneu-
monia is very apt to develop in the later
stage if the patient is exposed to any draft.
It has been my rule for the past eight years
to have the bed so placed that the door
would open and shut without a draft passing
over the bed. The windows should be just
as carefully watched. It cost one man his
life to teach me that lesson. Pulmonary
gangrene, pleurisy, thrombosis and embolism
may occur in the course of the fever or at its
close. Parotitis going on to suppuration
occurred once in my hands ; there was no
fistulous opening left after recovery.

Phlebitis has several times appeared as a
sequela to enteric fever. Arteritis is also
reported in which the femoral artery was oc-
cluded and amputation was necessary.

Sudden death may occur in typhoid fever
from bulbar paralysis, capillary hemorrhage
in brain, and from the much used and abused
heart failure. There is nothing in the early

May 30, 1 89 1. Society

Reports.

657

state of a typhoid patient to indicate that
the fever will assume the abortive form ;
this, however, will most likely become mani-
fest, by about the eighth or tenth day. The
scope of this paper will not admit of the con-
sideration of either the abortive or irregular
forms of typhoid fever. In enteric fever the
prognosis should be guarded oh account of
the long time the case will most likely run,
and the risk to some of the complications ;
very high temperature or rapid pulse indi-
cate a severe and possibly a dangerous type.

The treatment should be largely symptom-
atic. The patient should be placed in a
large room, well lighted and well ventilated,
any unnecessary articles of furniture should
be removed. The body should be sponged
off night and morning in tepid water ; if the
skin is hot and dry a little bicarbonate of
sodium should be added to the water ; if
sweating is profuse a little vinegar. The
patient should be handled with care, all
traumatism to the abdomen should be dis-
pensed with. Either violent or unnecessary
palpation or food that is not in a liquid
state. The great tendency of typhoid pa-
tients to develop tuberculosis should cause
them to be protected from any possible ex-
posure in that line. In the early state a few
doses of the mild choride q. s. to empty the
bowels and put them in an aseptic condition,
will be good treatment ; this may be given
with naphthalin in three or four grain doses.
Naphthalin is said by some to be more of a
destroyer of the typhoid bacteria than calo-
mel, but the latter would receive my con-
fidence in the first few days. It lessens the
subsequent diarrhoea and leaves the bowels
in a better and more healthy condition. The
statistics show that cases receiving the mild
chloride at the onset of the disease run their
course in about two days less time than those
not receiving the same.

As to the antipyretic treatment, high tem-
perature in any specific fever is an indication
of danger, not the cause of it. Temperature
is only a part of a specific fever. Sub-nor-
mal temperature is due like elevation of
temperature to disorder of the thermotaxic
centers. Perhaps the best antipyretic we
have is the cold pack or the spray of cool
water as practiced by Hiller and others in
sun-stroke.

Antipyrine, antifebrin and phenacetine
should not be used as antipyretics in typhoid
fever. It has been my experience also, that
large doses of quinine given throughout the
disease had the effect of prolonging the dis-
ease, and I have failed to see any good in
any way from its administration.

Carbolic acid and tincture of iodine, resor-
cine, turpentine, the acids, etc., have all been
used with more or less success. The im-
portant thing in my mind is to keep the
stomach in as good condition as possible, the
bowels aseptic, patient quiet and well nour-
ished with liquid food, and you will give
your patient the best chance to get well.
Complications must be treated as they arise.

Society Reports.

ALLEGHENY COUNTY MEDICAL SOCIETY,
MEETING MARCH 17TH.

Dr. Rigg read a paper on Typhoid Fever.
(See page 655.)

Dr. Kcenig: I am pleased to see the
prominence that Dr. Rigg has given to .in-
fection through air. I believe that is a
source of infection frequently overlooked by
city physicians. The infection -to which I
refer is found only in cities in which there
is a system of sewerage. I am perfectly
clear in my mind that 1 have seen a number
of cases of typhoid fever the infection of
which could be traced to sewer pipes, in
which there were no traps, that led directly
from the underground sewers in which the
intestinal discharges of typhoid fever cases
are thrown throughout the year. We can
readily understand that the germs will
multiply there and that they will rise with
the vapors, for if odors can rise from the
sewers into sleeping apartments, certainly
these minute germs to which I believe we all
consider the disease to be due, can also rise,
and I think it is the duty of all physicians
to inspect the sewage of a house in which
cases of fever have occurred, and to prevent
any one sleeping in an apartment in which
there is no trap to the waste pipe, and I be-
lieve, furthermore, that the air saturated writh
the germs of the disease which have deleteri-
ous influence on the course of the disease,
and the removal of the patient from such a
room would be judicious. I wish also to say
a word in favor of the drug that Dr. Rigg
has recommended, namely, napthalin. I
have used it in a few instances, perhaps not
sufficiently often to decide regarding its
merits with absolute certainty. I have used
it where there was considerable tympanitis,
with uniform success. It is an extraordinary
germicide, and in repeated doses of two or
three grains will disinfect the intestinal
canal. It seems to me rational treatment to
administer a remedy like napthalin if fur no

658

Society Reports.

Vol. lxiv

other reason than to destroy the fermentative
germs in the intestinal tract.

Dr. Kearns: This subject is so old and
trite that it is perhaps difficult to raise pro-
found interest in it, but perhaps there is no
subject that should engage our attention
more thoroughly and more carefully than
typhoid fever. When I commenced to
practice, over thirty years ago, it was the
great disease, requiring more attention than
was given to the treatment of almost any
other disease, but now it has lost that inter-
est, owing partially to the fact that other
ailments have grown to occupy a large share
of the professional attention. I think Dr.
Rigg's paper was a fine resume of practical
points in which he dwelt principally on
causation, diagnosis and prognosis. Of
course it is unnecessary to go into the an-
atomical and clinical condition, neither is it
necessary to dwell on causation. However,
I am not prepared to admit that this is due
exclusively to outside influences communi-
cated by microbes. That it has no other
source of generation I am not prepared to
admit and never have been. I agree with
some of the old authorities who studied this
disease many years ago and saw it in its true
type. I never come across a case now such
as I came across twenty-five years ago. At
that time whole families would be taken
down, four and five one after the other.
Now it is seldom that more than one in a
family is afflicted with the disease at the
same time. Then, these cases were invaria-
bly characterized by a peculiar tongue, and
by symptoms of the locality of the disease,
the ulceration of the glands. I admit that
in all my experience and careful study of
typhoid fever, it is a difficult matter at the
present time to diagnose a case of typhoid,
especially at the first time I visit it. I
never report a case to the board of health
until I have made two or three trips.
Formerly, typhoid fever was supposed to
come on slowly and gradually. The cases
we have now come on abruptly, and I
always defer my report until I am certain
about the fever. I believe it is to a certain
extent auto-genetic. I am borne out in this
supposition by men who have studied the
matter much more than I have. I believe
that great mental worry and strain on a
system partially prostrated will throw that
patient into typhoid fever. I believe, there-
fore, that is not dependent upon germs.
However, I believe that germs will come in
and infect, as in the excretions from the
sewers through the cess-pools, but I have no
doubt that we can have typhoid fever come

on auto-genetic. Having started out many
years ago with a treatment which was suc-
cessful, I have never changed it. I never use
any of the recent remedies. I think the
systematic, scientific treatment of typhoid
fever is by preparations of acids. Quinine in
small doses is required. The great remedy
I have always relied upon is turpentine.
Half a drachm every two or three hours. I
have no confidence in the treatment that
will reduce typhoid fever by reducing the
the fever. I would be afraid to use cold
douches. Strong stimulants are necessary
to keep up the vitality.

Dr. Batten : I agree with the paper
and of course I have no criticisms to make,
but there are conditions in the treatment of
typhoid fever that requires us to move very
carefully. These conditions we do not meet
in a mild case of fever. I have treated a
mild case of typhoid fever in an old lady
sixty years of age without any medication
and she did excellently and recovered.
About fifteen years ago I had a very malig-
nant case of typhoid fever, pregnant about
three months, and she ran on very badly
until the third week, when miscarriage took
place and she lost an immense amount of
blood in the miscarriage. There was no de-
composition in the foetus. I had some
trouble in getting the placenta delivered,
but after it was delivered, and she had lost
this blood, the whole type of the fever
seemed to have changed, and she made a
fine recovery. I do not mean to say that
blood-letting in her case would have been
the proper thing. Another case that came
under my notice. Some of you will recol-
lect that about twenty-five years ago mor-
phia was recommended in cases of delirium
to make the patient sleep. This case I saw
had been under the care of a physician in
Pittsburg, and the patient was delirious,
and it had taken three men to hold him.
He was taken to Passavant's hospital. It
was about the time cold packs were intro-
duced. I put him in a cold pack twenty
minutes and afterward gave him a good
dose of whisky. It lowered his temperature
and changed his condition and he went to
sleep and slept for eight or ten hours soundly,
and the disease went on without difficulty
to a good recovery. I should state that
his temperature when he came into the hos-
pital was about 104.

Dr. Lange: I was very much pleased
with Dr. Rigg's paper and the society cer-
tainly is indebted to the doctor for the brief
but comprehensive resume presented. There
was one point which struck me as being a

May 30, 1891. Society

Reports.

659

little incomplete, and which it is profitable
to consider a little more in extenso than Dr.
Rigg did and this is the occurrence of pneu-
monia which Dr. Rigg ascribed solely to
changes of the temperature of the atmos-
phere in the sick-room. Now, there are two
kinds of pneumonia occurring in typhoid
fever, one of which is very fatal, and the
other not so. The pneumonia which is not
very fatal and which occurs in typhoid fever
frequently is croupous pneumonia. I be-
lieve with Dr. Rigg that croupous pneu-
monia occurs frequently in typhoid fever
from change of temperature of the atmos-
phere, and Dr. Rigg has with him, probably,
the majority of the profession, in ignoring
the pneumococus. The other form of pneu-
monia which is very fatal in typhoid fever
is catarrhal pneumonia. It frequently is
the direct result of the dirty mouths of
patients and comes when the patient is late
in the disease. It has been called for this
reason deglutition and inhalation pneu-
monia and is a preventable complication.
On the other hand croupous pneumonia
comes about the second week. These ca-
tarrhal pneumonias are as a rule preventa-
ble, and it is the catarrhal pneumonias which
make a large death rate in typhoid. It is
difficult to keep the mouth clean. In a re-
cent report from Germany where they use
the cold bath so extensively, there were re-
ported one hundred cases of typhoid fever
without one death, no medicines being used,
nothing but the cold bath and scrupulous
cleanliness of the mouth. When I had
typhoid fever, five or six years ago, I was
treated to a cold bath with very bad result.
It was followed by an aggravation of an
already existing mild bronchitis and coryza.
We must conclude that the Germans are a
different race ; they are more rugged and
hearty than the people who live here.
They are more rugged than the people we
have to treat. You can see that in the emi-
grants ; you can see their full habits and
faces, their cheeks red with blood, and their
lips scarlet.

Dr. Green : I wish to compliment Dr.
Rigg on the paper. His treatment is almost
parallel to that which I followed for a num-
ber of years with regards to the disinfect-
ing of the intestinal canal. I wish to speak
more especially about a remark offered by
Kearns to the effect that the typhoid fever
of the present day is not the typhoid fever
of twenty years ago. I cannot conceive
why it is not and I think we would be mis-
taken were we to conclude that the doctor
is right. I think the typhoid fever of the

present day is as severe as the disease ever
was. Of course we have had epidemics of
a mild type of typhoid, but that is no argu-
ment in favor of a different type of typhoid
to what we formerly had. It is well proven
that the typhoid germ exists in typhoid
fever, and I think it is acknowledged at the
present time and I have no doubt that the
germ existed previous to the discovery a
considerable length of time, and I think
that what causes the apparent change in
type of typhoid fever is the treatment at
the present time. The sanitation and medi-
cation, I think is due to them.

Dr. Thomas: I expected to hear more
said with regard to the prophylaxis of
typhoid fever. I am in the habit of telling
patients who have typhoid fever the fact
that they have taken into their mouths
something to cause the disease. I think the
greatest thing we can do for typhoid fever
is its prevention, and no one can use a
greater influence in bringing about that
condition than the medical profession. On
the South Side we get it once in a while,
and we get it under certain conditions just
as sure as the sun rises. The circumstances
are these: If the river remains low for a
number of weeks and the water gets below
the combs of the dams, we have stagnant
water. In the pool from which we draw
our water we have the sewerage- of the entire
South Side above the lock. What do these
sewers carry ? Fecal matter ; they are con-
structed to carry fecal matter. In addition
to that, we have all the sewage and refuse
of Soho, from Minersville, trom Hazelwood,
and in addition to that, we get the sewage
from Homestead, Braddock, and so on. As
sure as we get these conditions, we have
typhoid, and the epidemic generally comes
on within three or four days. We will have
to-day three or four patients with symptoms
of fever, to-morrow four or five and the
next day six or seven, it gets all over the
town and that condition lasts until we get a
big freshet to sweep out the pool. So far as
the medical profession of the South Side is
concerned, we have resolved, and have had
the resolutions published in the prints of
Pittsburg, that the entire cause of the
epidemic is bad water. It is said that in
Berlin at the present time typhoid is rare,
simply because they have a good water sup-
ply. Before, it was very common. They
tell me that in Johnstown, where the water
is gotten from the mountains free from con-
tamination by these germs, they do not
know what a case of typhoid fever is, only
through cases that come there from other

66o

Society Reports.

Vol. lxiv

places. We might talk a good deal about
typhoid fever ; the proper thing is to stop
the fever.

Dr. Stevenson : The paper was a very
comprehensive, full and truthful statement
of the knowledge of typhoid fever to-day.
The discussion has covered a number of
points embodied in the paper, but there are
others, enough left untouched to keep this
society talking a long time. I was a little
surprised at the statement of Dr. Kearns
that certain conditions of depression and
nerve disturbances could produce typhoid
fever. I presume the doctor would admit
that a case of fever originating in that way
would transmit the disease to other people.
Now, how could nervous disturbance and
mental strain originate a specific disease
, and transmit it to another person ? I am
unable to understand how to expect this. I
think this much is true ; that the conditions
have a depressing effect and a patient in that
way is more exposed to the germs and is
more apt to contract the disease. Another
of the speakers seemed to be at a little loss
to explain the recovery that followed an ex-
haustive haemorrhage occurring in an abor-
tion in a pregnant woman with typhoid
fever. I think the secret is that he had a
patient who had a complication. He had a
patient who was pregnant, undergoing
typhoid fever. The patient lost the preg-
nancy, the haemorrhage did not happen to
kill her and she was in a better condition to
get well. It has occurred to me that it is a
little curious that both in the paper and in
the discussion that has followed, there has
not been a single word dropped as to typhoid
fever in children. The profession are cer-
tainly well aware that typhoid occurs with
great frequency in children. It is estimated
by the best authorities that one in six of
the total number of cases is in children.
The diagnosis in children is probably the
most important, part of the matter. As a
rule, typhoid fever in children is mild, but
it has been very often mistaken for other
diseases.

I do not know that the paper specifically
mentions the condition of the tongue in ty-
phoid, but I think this one of the most
characteristic symptoms. A moist, heavily
coated tongue, with a red area and a red
tip. I am not aware that the condition
comes in any other disease. In regard to
the treatment of typhoid : Typhoid is a self-
limiting disease ; it has a certain course to
run, and the only danger is some complica-
tion or some mismanagement that changes
the type and character of the disease. Dr.

Kearns thinks there is a great difference
between the cases of typhoid which he saw
earlier, and which we now see. I think the
main difference is in the way they are man-
aged. I saw a case in consultation not very
long ago in which I found the patient* un-
conscious, with the abdomen like a barrel,
tongue dry, lips all cracked and covered
with sores. I asked the doctor what he had
been doing. Well, he had put the patient
on half grain doses of calomel every four
hours. " How long did you keep that up ?"
Five days. " Why did you stop ?" The
patient had had diarrhoea. " What did you
do then ?" The patient was put on sugar
of lead and opium, grain and a half of
sugar of lead, and half a grain of opium.
This for four days. The patient's mouth,
tongue and lips were all very dry. " What
did you do then ?" Put him on turpentine
and have him on turpentine now. He is
no better. I said, " Doctor, put this man
on an ounce of whisky every hour and
three pints of milk a day, and give him
nothing else, he will get well." And he
did. It looked to me as if that physician
had been treating a disease he had produced.
He gives calomel which causes diarrhoea ;
then he gives sugar of lead and opium to
stop the complaint. Then he turns around
to remove the effects of the sugar of lead
aud opium by the use of turpentine. I
think there is very little danger in typhoid
fever when the temperature is under 104.
If the temperature does not exceed 104, it
is well enough to let it alone. If it gets
above that it is over the danger line. I
think about all there is to it in typhoid is to
see that the temperature does not get beyond
this danger line, and to see that we do not
lose our patient through some complication.

NEW YORK SOCIETIES.

NEW YORK ACADEMY OF MEDICINE.

Meeting of April 16, 1891.
The President, Dr. Alfred Loomis, in the Chair.

Is Embryotomy of the Living Fcetus Justi-
fiable f — A paper by Dr. Egbert H. Grandin
opened the discussion on this question. He
thought that, in view of the great progress
in abdominal surgery during the past decade,
the time had come when the question of the
justifiability of foeticide should receive ear-
nest consideration. Ten "years ago, when
the mortality from the Cesarean section was
forty per cent on an average, embryotomy
had been a beneficent necessity. To-day..

May 30, 1 89 1. Society

however, when sepsis had been practically
banished as an after-complication of abdom-
inal surgery, when we knew how to effect-
ively suture the uterine wound so as to
guard against gaping and internal haemor-
rhage, when the fear of opening the perito-
neal cavity had been proved groundless, the
time was at hand when the physician had
the right to question if, under all conditions,
he was called upon to mutilate the living
foetus. On moral grounds the speaker would
not discuss the question. Theologians could
not decide the point for obstetricians. If
the latter could once prove that the risk to
the woman from the Csesarean section was
no greater than from embryotomy, their
duty as well as their pleasure would be to
save two lives instead of, as in the past,
destroying the lesser. If our data concern-
ing the Csesarean section continued to im-
prove over those of the present time, the
choice of operation would lie purely with the
physician and not at all with the laity, who
would always claim precedence for embryo-
tomy over the Csesarean section. One im*
portant factor lacking toward the desired
end was more thorough education of the
student in pelvimetry. The Csesarean sec-
tion should be elected, even as an ovario-
tomy or a hysterectomy was. The operation
should never be left as a dernier ressort. A
difficult embryotomy subjected the woman
to as great risks as the elective Csesarern sec-
tion. Shock was the element to be feared
chiefly after both operations, and the
speaker had witnessed greater shock after
embryotomy than after the Csesarean section.
We must learn, further, not to rest our con-
clusions on the statistics at present at our
disposal. These were very fallible, seeing
that they included many instances where
the section was not elected. The record of
individual operators from the elective Csesa-
rean section gave a fair estimate of the re-
sults obtainable in the future. Thus, certain
German operators had a mortality as low as
six per cent. Hertsch had reported seven
cases with no deaths ; Cameron, ten cases
with one death. At the New York Mater-
nity Hospital the record for the past two
years' was four elective sections, all success-
ful as regarded both the mothers and the
children, while during the same period there
had been four craniotomies with one death.
The speaker trusted, therefore, that surgeons
to maternity hospitals would with one accord
cease doing embryotomy, and perform the
Csesarean section under the relative as well
as the absolute indication, deliberately elect-
ing it. His belief was thus, in the near

Reports. 661

future, the maternal mortality could be low-
ered at least five per cent, while fully ninety-
five per cent of the children could be saved.
These results would pave the way for the
election of the Csesarean section in private
practice.

Dr. H. J. Garrigues thought that the sta-
tistics by no means warranted the assump-
tion that the Csesarean section, even with the
improvements of modern surgical technique,
was an operation of less danger than cranio-
tomy. The chances of saving the mother
were five times as great in craniotomy. The
only measure that seemed to him to offer a
pretty good chance of success to the mother
was the induction of premature labor, and
where the case was seen in time, he thought
that this was the proper thing to' do.

Dr. R. A. Murray was in favor of elective
Csesarean section. When the deformity of
the pelvis was such that no other operation
could be done, the question of previous un-
successful results was not to be considered.
In the hands of the ordinary operator he
thought that the Csesarean section would
probably yield as good results as embryo-
tomy.

Dr. W. T. Lusk did not admit that the
dangers of craniotomy were of so grave a
character as those of the Csesarean section,
and he thought that it was an error to allow
the idea of an equality in the dangers of the
two operations to be promulgated. In large
hospitals it was true that the results of the
section had been good, but in the same hos-
pitals there had been no deaths from cranio-
tomy. While he disliked extremely to do a
craniotomy, and would always avoid it if he
could, his experience with the Csesarean sec-
tion had been such that he would do the
former operation in preference, other things
being equal.

Dr. C. Jewett, of Brooklyn, would perform
embryotomy on the living foetus : 1. As an
alternative of other means of delivery by
the natural passages in certain rare emer-
gencies for the rapid termination of the
labor in the interests of the mother. 2. As
an alternative of the Csesarean section : (a)
When the mother was exhausted or her
condition otherwise unfavorable for the
abdominal operation ; (6) when the condi-
tions were not favorable for the child ; (c)
in disproportion between the pelvis and the
foetal head, but with a conjugate of from two
inches and three-quarters to three inches or
more, provided the mother so elected, after
a full knowledge of the facts.

The life-saving capacity of the modern
Csesarean section for the mothers could not

662

Society Reports.

Vol. lxiv

be estimated at more than from seventy-five
to eighty per cent. The average maternal
mortality in embryotomy was about ten per
cent, and was less in proportion as the pelvis
was more roomy.

The choice of operation must take into
account the skill and experience of the oper-
ator in abdominal surgery. The Csesarean
section was an operation for the expert,
embryotomy for the general practitioner in-
experienced in abdominal section. It was
not true that the two operations were equally
within the skill of every practitioner.
Every physician became more or less famil-
iar with the operating field of the obstetri-
cian. Few had any practical knowledge
of the surgery of the abdomen. The rights
of the child must be ignored, but the rights
of the mother must be paramount.

SECTION IN GENERAL SURGERY.

Meeting of April ij, 1891.
Dr. William T. Bull in the Chair.

Lumbar Nephrotomy. — Dr. Robert Abbe
presented a patient who, five years before,
had begun to suffer from renal colic and
haemorrhage. This condition had become
continuous during the last two years. Six
weeks since, the patient had come to him for
advice, and was at that time suffering from
hsematuria. Examination with the cysto-
scope distinctly demonstrated that the
bloody urine came from the right ureter.
Nephrotomy was accordingly performed.
The kidney was found perfectly normal on
palpation. It was stripped free of the sur-
rounding fat. Fifteen punctures were made.
At only one of them was the operator able
to feel anything apparently abnormal. It
seemed as if the needle struck something
gritty. An incision was made, enabling the
speaker to pass his finger well into the pel-
vis of the kidney, but there no stone was
found. The finger had come in contact
with the gritty point before mentioned,
which might have corresponded in feeling to
a papilla of one of the pyramids. The
wound was accordingly closed. There was
no trouble resulting from the operation and
no escape of urine from the wound. The
interest seemed to lie in the fact that since
the operation the patient had remained free
from pain and there had been, so far, no
return of the hsematuria.

Dr. R. F. Weir said that there was a
class of lesions sometimes found in the kidney
which, though trifling enough in itself,
caused a tendency to bleeding from the
organ. It was at present too soon to form
any conclusion as to whether a cure had

been effected in the present case or whether
the diseased condition was of the class he
referred to.

The Treatment of Hernia by means of the
Hank Truss. — Dr. S. E. Milliken in a
paper on this subject, referred to the danger
of producing excoriation or at times severe
sloughing with the ordinary trusses of the
shops. If this condition was brought about
it made the treatment of hernia in young
and delicate children exceedingly tedious
and occasionally impossible. The hank
truss, of which the speaker thought too little
was known, was constructed from a loop of
zephyr of the best quality containing from
twenty-five to thirty strands. It was made
of sufficient length to encircle the pelvis be-
tween the anterior superior spinous process
and the trochanter major, with enough left
to make a perineal strap. On one end a
double tape was attached, corresponding to
the affected side, and passed through the
loop coming from the opposite side. Con-
siderable care should be given to the adjust-
ment of the loop. The method might be de-
scribed as follows : With the index finger of
the left hand passed through the loop and
allowed to rest perpendicularly on the me-
dian line of the abdomen, ordinary tension
should be made. The tape was now passed
through the loop and the additional force
necessary to bring the point of the crossing
to the inguinal region would usually give
sufficient support to retain the hernia. The
free or tape end was then carried under the
thigh of the affected side and tied to the
band going around the pelvis. Where a
double hernia existed, the second hank
should be applied irrespective of the first.
The truss might be worn a week or ten days
without changing if the proper use of ab-
sorbants was made, and the best of these
was sudiodide of bismuth. This powder
might be renewed daily after giving a
sponge bath. During the first few weeks
no change of the apparatus should be at-
tempted by the mother or nurse, for only
after considerable technique had been
acquired could protrusion be prevented,
especially when dealing with a restless child.
When the truss was worn as he explained,
and was not changed more than once a week,
and no protrusion was allowed to take place,
at the end of two months it might, as a rule,
and in the absence of contra-indications, be
discontinued. Only one case of recurrence
had come under the speaker's notice after
cure by this truss, and in this the hernia
had only recurred on one side, whereas a
double hernia had formerly existed. He

May 30, 1 89 1.

Society Reports.

663

was able to report some two hundred and
sixty-eight cases treated by this method, and
to present to the meeting a large number of
patients in various stages of the process of
treatment. He had concluded that among
the advantages of the hank tress were : 1.
Easiness of manufacture, no delay being
encountered in the beginning of treatment.
2: Absence of spring pressure or severe elas-
tic pressure and a lessened liability to pro-
duce excoriation or sloughing. 3. The
pressure could be regulated without re-
moving the truss. 4. Less weakening of
the tendinous and muscular structures,
which so frequently followed the use of or-
dinary trusses. 5. There was no danger of
adenitis from pressure on the inguinal
glands.

Dr. Abbe said he had at one time made
an unsuccessful attempt to make use of this
truss and had abandoned it, as it had seemed
to cause pain. From what he had seen of
its application in the cases presented, how-
ever, he thought it was a most seductive
form of treatment, and he should certainly
take it up again.

Dr. W. B. De Garmo desires to protest
against a return to what appeared to him a
relic of the past. For the practitioner
located where he could not procure a suita-
ble truss at once, this was a very convenient
bandage for temporary use, but he should
not consider himself justified in leaving it
on as a permauent appliance. At this day,
when we had many good trusses that could
be worn by the most delicate infant, if prop-
erly applied, he felt that we had no excuse
for using something that was neither cleanly
nor efficient. It was true that many child-
ren were readily cured, even by the crudest
appliance, but it was equally true that many
others were allowed to go by the curable
age by the use of a " makeshift " of this
kind. A well-known institution where these
bandages had been applied had recently
furnished his clinic at the Post-graduate
Medical School with abundant evidence of
the unreliability of this so-called hank truss.
According to the histories given, these child-
ren were all worse when they came to the
clinic than when the bandage had been ap-
plied, and in most instances the yarn was in
a filthy condition. Cleanliness, simplicity,
and durability seemed to him the essential
points in selecting trusses for infants. All
these features were combined in the rubber
and celluloid covered truss, with which the
country was well supplied. These, fitted by
the lead tape diagram method, appeared to
leave little to be desired in the way of ap-<

pliances of this kind. Nine-tenths of all
hernias occurring in children under five
years of age could be cured by a suitable
truss ; this implied the proper fitting of the
truss and the keeping of the patient under
observation until he was cured. If mechan-
ical treatment failed, he should consider an
operation justifiable.

The Curative Effect of Operations per se. —
This was the title of a paper read by Dr. J.
'M. White, of Philadelphia, in which he
considered an elaborately complied aggrega-
tion of the reported experiences of others,
supplemented by his own, as to the palpable
or possible evidence, immediate or remote,
of the relief of symptoms, or the subsidence
of concrete indications of pathological con-
ditions, resulting from surgical interference,
stopping short, however, of radical proced-
ures. There was no lack of both startling
and amusing data upon which to establish a
theory that operations per se were sometimes
productive of curative results, even where
investigation could determine no macro-
scopic or microscopic physiological disturb-
ance to account for the existing symptoms.
The acceptance of this evidence, of course,
landed the investigator upon that terra
incognita in which such ambiguous phrases
as hysterical manifestations, psychic influ-
ences, and reflex phenomena were the only
terms left for the description of an unknown
quantity.

Dr. Abbe was of the opinion that certain
growths might be the result of mental in-
fluences producing changes in the circu-
lation, disturbance to the physiological equi-
librium, and ultimately a pathological pro-
duct. When an exploratory operation was
of benefit in these cases, it was because a
change was brought about in the tissues by
the manipulation of the lymphatics, the
nerve filaments, and the vascular structure
of the tumor itself. He thought, however,
that the acceptance of the theory might
lead to mischievous results from reckless
operating for experimental purposes. Such
cases should only be undertaken by those
able to accurately weigh the chances of
benefits to the patients. He did not believe
that many instances of cure would be re-
corded.

Dr. H. J. Boldt did not believe that any
malignant disease of the abdomen would
disappear upon simply opening the region.
In cases in which this result had been
affirmed he considered the diagnosis had
been incorrect.

Dr. Weir pointed out the fact that the
tumors which disappeared after surgical in-

664

Society

Repoits.

Vol. Ixiv

terference were generally situated in the
abdominal cavity. He had never seen a
tumor in the leg disappear under like con-
ditions. In the abdominal cavity it must
be borne in mind that there was an immense
sympathetic nervous system. The inter-
ference with such a region, might set up
such disturbance as would bring about
changes in the circulation, and thus influ-
ence the nutrition of any existing neoplasm.
He was, however, very skeptical as to the
curative effect of operations per se.

The further opinions expressed were in the
same vein. It was conceded that psychic
influences might be potent, but that they
could not at present be demonstrated. For
the most part the benefits which were de-
rived from operations per se were due to
retrograde metamorphoses in existing
growths or to the irritative disturbances of
existing conditions of malnutrition.

SECTION IN GENERAL MEDICINE.

Meeting of April 21, i8gi.
Dr. R. C. M. Page in the Chair.

American Childhood from a Medical Stand-
point—-Dr. Henry Ling Taylor read a paper
with this title. The human organism, he
said, was pre-eminent in its marvelous adap-
tability to the most varied surroundings and
conditions of life. It had complex mechan-
isms for the reception, conveyance, storage,
modification, and discharge of the showers
of impressions constantly received through
the sense organs and through the nerve end-
ings in the skin, membranes, and tissues.
We recognized that different individuals
and races reacted somewhat differently ; they
had inherited or acquired special character-
istics of mind and body, probably largely
due to habits evoked by special surround-
ings and ingrained by frequent repetitions,
either in themselves or in their ancestors.
Which way did life in New York push the
children ? We knew that the city children
with whom the physician was brought inv
contact got too little light and air, did not
take enough of the right kind of exercise,
were often overfed or underfed, lived in
houses that were kept too hot, were often
urged too much in their studies and espec-
ially in their emotions, and frequently, with
shortened childhood, became little men and
women before emerging from pinafores and
knickerbockers, The children had, as a
rule, the following characteristics: Weak
ankles, strong legs, weak waists, shallow
and inelastic chests, and weak shoulders
and arms. The pale countenance and cold
extremities gave evidence of a. faulty circu-

lation. The feelings and will might be in-
tense or flabby, but in either case betrayed
the lack of discipline. There was precocity
in knowledge of people and social relations,
and there was the darkest ignorance with re-
gard to most natural objects and processes.

If the parents were in easy circumstances,
the children were, as a rule, produced with
difficulty from an overtaxed and undernour-
ished stock, not from the superabundant
vitality of robust natures. The mother
rarely had vitality left to nurse her infant,
and it was brought up on some substitute,
which at best was only a makeshift. What-
ever modern life had done for women, it did
not seem to have prepared them for the in-
telligent care of their offspring. If our city
life was so artificial that we required gym-
nasia, field sports, and outings to keep a de-
scent physical equilibrium, we still needed
to give some attention to vascular gym-
nastics, and the culture and development of
the unstriped fibers which played so funda-
mental a part in our vital economy, by plac-
ing some reliance on the adjustive and re-
sisting powers, and by a systematic and
judicious exposure of the skin to cold water,
air, and the vicissitudes of weather. The
city child, instead of soil with its diversified
coverings, had hard and mostly level floors
or pavement ; instead of grateful greenish,
bluish, or brownish tints, the patchwork
surface of our houses and streets ; and in-
stead of restful silence or simple, harmonious
sounds, the irritating jar of complicated
noises. Young city children of the primary-
school classes had the most extraordinarily
distorted ideas about the commonest natural
objects, and much of this mass of misinfor-
mation remained in adult life. On the
other hand, they were abnormally precocious
in their knowledge of men and social rela-
tions and in general " knowingness." That
the modern methods of school education
produced many bad results was seen in the
nervous condition of many children, in their
headaches and ocular and other troubles.
Nature was a good schoolmistress, and her
lessons were the fundamental ones, no mat-
ter how much we might supplement them at
school or university. The infant was learn-
ing his lesson when he was kicking out his
legs, waving his arms, or bumping his head,
the child playing tag or batting ball, or the
youth working with his carpenter tools, or
riding a bicycle, just as truly, perhaps more
truly, than the university student burning
midnight oil over Greek and calculus.
Nature was never systematic in the school
sense, and, however much we might system-

May 30, 1891.

Society Reports.

665

arize, we roust at the same time cultivate
our powers and round our individuality by
keeping in close touch with so much of
nature as lay within our horizon in a rest-
ful, informal way. Family life was perhaps
the most important factor of all in the
child's development, physical as well as j
mental and normal. The system of flat
housekeeping prevented our women from
being good house-wives, and the high-pres-
sure work for the mighty dollar rendered
the men anything but agreeable fathers ; so
that children really saw but little of what
ought to go to make up a home for their
training. Much of what had been said ap-
plied to certain classes in certain localities,
and it might be thought that the physique
of the children that were now growing up
under our eyes was not, on the whole, satis-
factory, and that it was a difficult matter to
bring up wholesome, hearty children in New
York. If this was so, it was well to recog-
nize the fact.

The Chairman thought that the children
in the cities were subjected to dangers
which were overlooked. One was that their
bowels were constantly neglected, and an-
other was that they were allowed to go
about with wet or damp shoes.

Dr. F. A. Castle argued that if attention
to the bowels was neglected by children, it
was the result of the present bad arrange-
ment as to school-hours. Social usages had
gradually pushed the hours for meals — that
is to say, for dinner — later and later in the
day, but the nine o'clock school-hour never
changed, and children were often rushed off
to school without adequate food or any
other attention to natural requirements. He
also deprecated the whole system adopted in
the primary schools. All that the children
did was to shout some nonsense in concert.
The schools were simply bedlams ; the sys-
tem adopted not only served no purpose,
but actually did damage to those who had
to undergo it.

Dr. C. E. Quinby thought that to meet
the requirements of the age, and especially
of city life, it was necessary to turn out
specialized men and women ; and, this being
admitted, there was a tremendous advantage
in city life, which would put a child at
twelve years of age where a person of twenty
would not be in the country.

Fel Bovis Inspissatum as a Therapeutic
Agent. — Dr. W. H. Porter read a paper on
this subject. He made a most emphatic ap-
peal to his hearers on behalf of what he had I
decided to be the great therapeutic utility of I
fel bovis inspissatum in all diseases which 1

had for their source, or were under the in-
fluence of, pathological conditions of the
digestive economy. He stated that the con-
clusions which he was urging had been ar-
rived at after ten years of persistent use and
careful observation of the drug. Adequate
! confirmation of the speaker's view of the
matter was given by other observers, special
emphasis being laid on the advantages ac-
cruing from administration of the ox-gall
throughout cases of typhoid fever.

The Value of Auscultatory Percussion as a
Method of Diagnosis. — This was the title of
a paper by Dr. F. W. Jackson.

Dr. J. West Roosevelt complimented the
author on the integrity of the work done
and the conclusions drawn so far. He
thought that the paper ought to show the
value of auscultatory percussion and serve
to make the method more popular. He
was, however, sorry to hear that throughout
the series of observations the nipple had
been used as a landmark. Its position upon
the chest was not constant, relatively, in
any given number of subjects, and it was an
utterly unreliable factor in measurements.
The mid-clavicular line was very much to
be preferred.

SECTION IN OBSTETRICS AND GYNECOLOGY.

Meeting of April ^j, i8gi.
Dr. Egbert H. Grandin in the Chair.

Birth of a Viable Child at Six Months and
a Half — Dr. H. Collyer reported a case of
this nature. The woman was thirty-three
years of age, had been married eleven years,
and had had four children at term and one
miscarriage. She had been under the
speaker's care for chronic pelvic peritonitis,
which fact had given him opportunities for
observation in the case that he might not
otherwise have had. On July 5, 1890, she
menstruated as usual. On August 6th there
was a scanty flow for three days. During
the third week in August changes were
noticed in the uterus characteristic of the
earlier weeks of pregnancy. The woman
stated that conception must have occurred
on July 13th, denying its possibility before
that date. On January 4, 1891, while she
was working a sewing-machine, there was
sudden and profuse hemorrhage. All at-
tempts to prevent labor were futile, and on
February 3d she was delivered of a small
male child weighing two pounds and two
ounces. The child cried at once, and, wrap-
ping it up warmly, the speaker waited for
I some five minutes till pulsation in the cord
I had ceased before separating the child from
1 its mother. The placenta gave some

666

Society Reports.

Vol. lxiv

trouble, and there was found attached to it
an independent lobule. The bones of the
child's skull were soft and overlapping.
The testes had not descended, and the finger
nails were only just showing. The infant
was wrapped in wool and put into a basket,
which was placed near a fire kept continu-
ally burning. At first the child was fed
with milk and water from a spoon every
two hours, and subsequently from the breast.
It had since continued to thrive in every re-
spect. The date at which the child was
born and the general condition of its de-
velopment would indicate the period of ges-
tation as six months and a half.

The Association of Rectal and Pelvic Dis-
ease in Women. — Dr. R. A. Murray read a
paper with this title. When the anatomical
connection between the genital organs and
the rectum was considered, it wras not
strange, he said, that many diseased condi-
tions of the one set of organs reacted on the
other, and, further, that they sometimes had
a causative relation. The vascular supply
of the uterus, ovaries, and tubes was indi-
rectly connected with the lower third of the
rectum. The veins on the left side empty-
ing into the left renal vein, the varicose con-
dition of these veins was oftentimes the
cause of symptoms of ovarian hyperemia,
and even of acute oophoritis. Constipation
was not absolutely a disease confined to the
rectum, but in a large proportion of cases it
was a symptom which, if not the cause, was
surely a concomitant of uterine trouble.
The inflammatory diseases of the uterus and
its annexa, tube, ovary, and ligaments, were,
of all uterine diseases, by far the most fre-
quently seen by the specialist. The first
symptom present in almost every case was
pain in the left side, over the ovary ; next,
flatulence and constipation. When the
anatomical relations of the tissues in these
parts were remembered, the cause of this
condition of things was easily accounted for.
In chronic displacements of the uterus —
retroversion of retroflexion — the long-con-
tinued pressure of habitual constipation ob-
structed the circulation to such an extent
that haemorrhoids resulted, and the para-
metritis generally fixed the uterus on the
rectum so that the use of cathartics only ex-
cited the inflammatory symptoms and made
the patients afraid to take the remedies. In
such cases the uterine symptoms were most
prominent, and no relief was experienced
until the communication between the portal
and genital circulations was made freer.
This was to be done first by correcting the
displacement, secondly by relieving the con-

stipation. For the constipation, enemata
were to be preferred. Another result of
chronic constipation was pouching of the
lower third of the rectum. This condition
was found frequently in virgins and gave
rise to pain in the back, discomfort in stand-
ing, and the sensation of dragging and full-
ness, with a feeling that the parts would
fall, due to the distention and varicosity of
the vaginal and uterine veins caused by the
formation of proctocele, which pressed the
vagina forward. The author had seen fis-
sures in the vaginal entrance which were
painful and intractable, and which could
only be cured by relieving the constipated
habit and correcting the proctocele. In
chronic retroversion, where the uterus was
pressing on the rectum, and in chronic fixa-
tion of the uterus in any position, from
pelvic peritonitis, the author had found that
with constipation, and even without it, many
patients complained of a discharge of glairy
mucus from the bowels, with a sensation of
burning during and after the act of defeca-
tion. This mucus was often stringy and in
links. Following this, there might be a
bloody discharge, particularly at the men-
strual period.

On the relief of this catarrhal proctitis by
aseptic injections of boric acid or mild
astringents, the complaints of pelvic pain
were often very materially lessened, although
the uterine disease was not cured. Haemor-
rhoids and painful fissures of the anus were
frequently associated with uterine disease,
either inflammatory in nature or due to the
pressure of tumors. Where haemorrhoids
were due to uterine pressure, the reposition
of the displaced organ was called for.
Where this could not be done, much might
be accomplished for the patient by keeping
the bowels regular and relieving the pelvic
circulation by rest in bed. The vaginal
douche was indicated. The author had
found benefit from the reduction of the
haemorrhoids after each action of the bowels,
by pressure, wThile the patient was in the
recumbent posture. It was noticed that
most of the symptoms that patients com-
plained of when suffering from prolapsus
uteri were the same as those presented in a
case of haemorrhoids, the exception being
the pressure of the tumor forward by the
pile, the haemorrhage, and the intense pain
on defecation. This suggested that the
trouble was really the same congestion of the
pelvic veins. Fissures of the rectum often
caused dyspareunia, which might be mis-
taken for vaginismus, and relief of the cause
was quickly followed by disappearance of

May 30, 1 89 1. Special Correspondence.

667

the symptoms. Any and all of these con-
ditions might be exaggerated, going on to
abscesses in the recto-vaginal septum if the
cause persisted, and finally producing a
general breaking down of the health. In
this paper the author's endeavor was merely
to outline this subject, as there was so little
said by authorities in regard to this par-
ticular question. If its consideration di-
rected more attention to closely contiguous
and related organs, he believed that rnany
errors in diagnosis would be avoided and
much more benefit result to patients.

Dr. H. J. Boldt said there was no doubt
that this subject had been much neglected,
and that the presence of rectal disease was
too often overlooked by gynaecologists. In
four-fifths of his uterine cases the patients
were examined per rectum and obscure
symptoms very often cleared up thereby.

The opinion expressed by Dr. Boldt was
that of the speakers who followed him, and
the author of the paper was thanked for
bringing before the Section points full of
practical suggestiveness. — N. Y. Med. Jour.

Special Correspondence.

London Letter.

THE LONDON UNIVERSITY SCHEME.— DE-
GREE FOR LONDON STUDENTS AT LAST.
THE KOCH CRAZE— DR. SYER BRIS-
TOWE'S VERDICT.— MR. STEAD
AND THE CURE FOR CANCER.
THE EDINBURGH PROFES-
• SOR'S TIE.

After years of wearisome delay and dis-
cussion, a scheme has been drawn up where-
by the London students may have a chance
of getting a degree upon reasonable terms.
The proposed alterations have raised a
storm of opposition throughout the country.
The provincial schools offer the most de-
termined resistance at the very outset to the
constitution of the new Senate, and not
without some show of "sweet reason," for
the provinces are allotted four only out of
forty-two seats. The Dean of the Birming-
ham medical faculty points out the " calm
assumption of the metropolitan teachers
that, at their mere desire, a great imperial
institution like the University of London is
to be made a narrow parochial undertaking."
Then the present graduates are fearful of
the lowering of the value of the degree they
have so hardly won. However, the matter
may be finally settled, medical students are
likely to reap the benefit. The London

degree has been so fenced in with high
standards and other conditions' so as to be
practically prohibitic to the greater number
of students. As a result, those who want a
degree on reasonable terms are forced away
to the provinces. Thus the policy of the
London school for many years past has
driven a regular exodus of students to
Edinburgh, Durham, Glasgow and other
University towns. Of late there has been
a growing tendency to recognize the fact
that very high standard examinations are a
snare and a delusion, calculated to foster
cunning rather than brains. It certainly ,
looks rather like beginning at the wrong
end of the stick to send a man out into the
world so crammed with details that he has
had no time to inquire into the principles
of his art.

The Koch craze is about over. After
waiting a sufficient time to get reliable re-
sults various meetings have been held in
different parts of the country to consider
the matter, and the verdict has been every-
where alike unfavorable to the remedy.
Perhaps the most calm and philosophical
summing up of the whole affair from be-
ginning to end has been made by Syer
Bristowe. He remarks that " collective re-
sults go to show that the use of Koch's fluid
tends to cause more or less intense and
widespread inflammation round the tuber-
culous deposits; that this inflammation in
no degree tends (as Koch assumed to be the
case in order to explain the supposed cura-
tive action of his remedy) to envelop and
imprison the living bacilli in caseous cocoons,
and so to prevent them doing further mis-
chief ; but that, as happens in the case of
lupus, the inflammation in some cases be-
comes, from its very severity, a source of
serious danger. " There can be no doubt
that tuberculin is a very potent poison.
The present writer has given it up to doses
of a decigramme in a case of lupus erythe-
matosus of seventeen years standing, in
which the scalp was extensively affected.
At first considerable improvement was
effected, but at the end of three months
things are very much as they were at start-
ing. This result gives a fair echo of the
general report, which tells of nothing but
vexation and disappointment. And thus
we come to the end of one of the most extra-
ordinary chapters in the history of modern
medicine. If we were to seek a parallel in
outside affairs we could find nothing more
nearly resembling it than the tale of the
South Sea bubble, when society of all sorts
and conditions lost its head over the fabled

668

Selected

For mu Ice.

Vol. lxiv

treasures of the islands of the Southern
Seas.

In the now famous journal, the Review of
Reviews, Mr. Stead has taken up the cudgels
for Count Mattei, the " Italian nobleman,"
who advertises all over the world cures for
cancer. Unfortunately, the medical journals,
with one exception, think it beneath their
dignity to attempt to interfere in the matter,
in spite of the immense harm that must result
to the public at large. With his usual
energy Mr. Stead has started a test ward of
five beds at a small Hospital in London. He
has a small committee of supervision, con-
sisting of Sir Morel Mackenzie, Mr. Lawson
Tait, and a Dr. Potter, sub-editor of a nurs-
ing journal. With regard to these proceed-
ings the Medical Press and Circular has a
slashing article, calling Mr. Stead's atten-
tion to the commercial aspect of the ques-
tion, and to the fact that Mattel's advertise-
ments appear largely in his own paper. It
also remarks that a layman is about as
likely to throw fresh light on the therapeu-
tics of cancer as an ordinary man would be
to add to our knowledge of the differential
calculus. The Count professes to work his
cures by means of differently colored elec-
tricities. Recent examination by a distin-
guished London analyst has shown his
" green fluid " to be absolutely negative in
all its properties, and to correspond to no
known substance in nature except water.
If that be the case, this old Italian cynic
beats the record by making a huge fortune
out of the springs of his native country.
There is something extremely ludicrous in the
idea of retailing water all over the world in
small phials at a high price. Some of the
details of the Hospital, where the experi-
ments are to take place, are suggestive. The
matron is a firm believer in Mattel's powers
and -is said frequently to have proved the
reliability of the " green fluid " in arresting
haemorrhages, indeed, for that purpose she
uses nothing else. Of course, average medi-
cal men will wonder why on earth the
matron of a Hospital should go about stop-
ping haemorrhages, nor will they be silenced
by the assurance that the lady in question
is the widow of a Bank of England director.
Nurses are made, they will reflect, not born.
Then we are told that the Hospital is looked
after by two medical men, father and son,
one of whom for a long time past has been
in the habit of dispensing the Mattei remedies
in the out-patient department. All this is
taking place in good old conservative
England. An editor who has cheerfully
faced imprisonment in the cause of social

purity, and whose pronounced religious
views are of the strongest, is persuaded that
an Italian layman has discovered the secret
of curing a disease that admittedly baffles the
efforts of legitimate surgery. Mr. Stead has
the courage of his opinions when he backs
this Italian advertiser to do what many
thousands of his own countrymen, earnest
men, trained in the study of disease, have
hitherto failed in doing. Verily, nemo
omnibus horis sapit — a proverb that is especi-
ally true of editors in quest of sensational
copy.

The following is told of the Professor of
Surgery at Edinburgh. In the course of a
clinical demonstration he turned to a student
who had just commenced his studies, with
the question : Now, Sir, can you tell me
what is wrong with my dressing?" The
ingenious youth turned red, and preserved
a discreet silence. Mr. Chiene, however,
was not to be put off, and repeated the ques-
tion. After a long pause the youth stam-
mered out in a fit of desperation: <fWell,
Sir, if you insist on my telling you, I should
say your tie is not quite straight." As might
be surmised this unexpected answer quite
" brought down the house."

D. W.

Selected Formulae.

OINTMENT FOR ALOPECIA.

The following combination is recom-
mended in the treatment of alopecia (Poitou
med., Jan. 1, 1891):

Gallic acid 3 grammes.

Essence of lavender . ... 1 gramme.

Vaseline 30 grammes.

Castor oil 20 grammes.

M. This ointment is used by means of friction upon the

scalp.

CREASOTE IN THE VOMITING OF PREG-
NANCY.

Kaatzer, in the Berliner Klin Wochen-
schrift, gives the following formula for crea-
sote in the treatment of obstinate vomiting
of pregnancy :

1^? Creasoti pur., 2.0 grammes.

Spirit-vini rect., 30.0 grammes.

Tinct. gentianse,

Extr. coffeae, aa 10. o grammes.

Aquas des-t., 100.0 grammes.

M. et Sig. To be well shaken. Dose: One tablespoonful
two or three times a day in a little milk.

The effect of this mixture will be found
most gratifying.

May 30, 1 89 1 .

Selected Formula,

669

FORMULA FOR SULPHATE OF QUININE.

The Revue Internationale de Biblio-
graphie Medicale, April 25, 1891, gives the
following formula in which, it is claimed,
the bitter taste of the quinine is entirely
absent :

B

Sulphate of quinine 0.5 gramme.

Dilute, sulphuric acid 0.5 gramme.

Essence of menthol 5 drops.

Saturated solution of sugar 10. o grammes.
Distilled water 90.00 grammes.

VOMITING OF PREGNANCY.

The following is highly recommended by
an exchange :

Ijk Menthol , grs. xv.

Alcoholis 5 v.

Aq. dest 5 iv. M.

Sig. — <§ ss every hour.

ERGOTINE IN GONORRHOEA.

Roicki, in the Viadomosci Lekarski, speaks
highly of the efficacy of ergotine in the
treatment of gonorrhoea. He gives the drug
both internally as a pill, and locally as an
injection, using for the latter the following
formula :

B Ergotine 0.30 gramme.

Dist. water 300.00 grammes.

M. et Sig. For injection.

The injections should be made several
times a day. The drug is well tolerated,
and a speedy cure usually obtained. — Jour-
nal de Med.'de Paris, April 26, 1891.

TREATMENT OF SENILE PRURITUS.

Resnier, in the V Union Medicale, recom-
mends the following treatment for senile
pruritus :

B

Acid carbolici 4.0 grammes.

Acet. aromat., 200.0 grammes.

Two tablespoonfuls of this solution should
be added to a quart of water and the body
washed with it every night before retiring.
After drying, the body should be dusted
with either of the following powders :

B

B

Bismuth, salicyl., 20.0 grammes.

Amyli pulv., 90.00 grammes.

II.

Acid salicyli pulv 20.0 grammes.

Amyli pulv., 180.0 grammes.

EPILATORY PASTE.

Unna, in the Allgemeine Med. Central-
Zeitung, gives the following for an epilatory :

1^ Baryii sulphur, 10.0 grammes.

Amyli pulv.,

Tine, oxyd., aa 5 o grammes.

M.

Enough water should be mixed with this
powder to make a stiff paste, which should
be spread over the parts where a removal
of hair is desired. The paste dries in about
ten minutes, and then may be lifted off.
The skin beneath will be found to be smooth
and hairless. The paste will not irritate
unless used again the next day over the
same spot.

MOUTH-WASH.

The Apotheker-Zeitung, May 15, gives the
following formula for an anitseptic mouth-
wash:

B

Salol

Menthol.

2 gram mes .

. 3 grammes.

Ul. menth. piper 3 grammes.

Spirit Anisi..... 9 grammes.

Alcoholi 200 grammes.

The mixture may be colored with a little
cochenille. It is very popular in Germany.

FISSURES OF THE TONGUE.

The Allgemeine Med. Central- Zeitung re-
commends the following formula for fissures
of the tongue : ■

5? Acidi carboi., 2.5 grammes.

Tinct. jodii,

Glycerini, aa 12.5 grammes.

M. et Sig. To be painted over the fissures.

FOR CHAPPED, ROUGH, OR FISSURED
HANDS.

The following formula is claimed bv the
Wiener Med. Wochenschrift to be the" most
efficaceous application in cases of chapped,
roughened or fissured hands :

Ijk? Tinct. benzoes,

Glycerin, aa 5.0 grammes.

Lanolin 30.0 grammes.

M. et fiat unguentum.

Wash the hands in tepid water, then with-
out having dried them, but merely shaking
the water off, apply the salve and rub it in
morning and evening. Gloves should be
worn during the night.

TREATMENT OF OBSTINATE CORYZA.

B

Salicylate of soda,

Syrup of orange:peel, aa 15.0 grammes.

Peppermint water .90.0 grammes.

M. et Sig. One dessertspoonful every three or four hours.

— Journal de Med. de Paris, April 26, 1891,

670

Selected Formula.

Vol. lxiv

PRESCRIPTIONS FOR FLATULENCE.

Journal "de Medecine de Paris gives the
following prescriptions for the relief of flat-
ulence :

JY Napthol 1 dram.

Carbonate of magnesium 1 dram.

Powdered charcoal 1 dram.

Essence of peppermint 2 drops.

This is to be divided into 15 powders, and
1 taken at the beginning of each meal.

When the flatulence is accompanied by
constipation the following may be used :

3^ Magnesium i dram.

Flowers of sulphur i dram.

To be made into 15 powders, 1 of which
is to be taken at each meal.

When diarrhoea accompanies the flat-
ulence :

Ijk; Bicarbinate of sodium 30 grains.

Prepared chalk 15 grains.

Powdered nux vomica 3 grains.

May be made into 10 powders, 1 of which
is given with each meal.

In still other cases, where neuralgia of
the stomach or true gastralgia accompanies
the tympanites :

Ijk Hydrochlorate of cocaine 4 grains.

Quinine sulphate 6 drams.

Cinnamon water 8 ounces.

A teaspoonful every two or three hours.

EARACHE DROPS.

Ij^ Camphor chloral m v.

Glycerin tn xxxiij.

Almond oij... m xxx.

M. Three drops of this mixture on absorbent cotton to
be placed in the ear twice a day.

— Chemist and Druggist.

LINIMENT FOR GOUT.

The Lyon Medicate states that the follow-
ing liniment is useful in the treatment of
gout :

ft

icid > of each.
:id j

Collodion

Sulphuric acid y of each 1 drachm.

Salicylic acic"

Hydrochlorate of morphine 15 grains.

This is to be painted over the part affect-
ed every few hours.

SEAT WORMS.

ft

Tincturae rhei 30 drops.

Magnesia carbonat 3 grams.

Tincturae zingiberis 1 drop.

Aquae q. s. add 4 ounces.

M. Sig. Warm and use as injection three times daily.

—The Doctor.

OINTMENT FOR PHTHISIS.

& Union Medicale states that the follow-
ing ointment is useful in the treatment of
pulmonary phthisis :

ft

Creasote 2% drams.

Lanolin 1

Olive oil >of tach 1% ounces.

Lard J

This ointment is to be applied with* fric-
tion each night to the thorax, and the
absorption of the creasote from the skin will
be of value to the patient.

PRESCRIPTION FOR WHOOPING-COUGH.

Von Genser is said to use the following
prescription in the treatment of whooping-
cough :

-f^k? Carbolic acid 1% grains.

Rectified spirit 2 drops.

Tincture of iodine 5 drops.

Tincture of belladonna 10 drops.

Peppermint water.... 2 , ounces.

Simple syrup 1 drachm.

To a child of two years a teaspoonful of
this mixture may be given every two hours.

— Medical News.

CORDIAL FOR INFANTILE DIARRHEA.

ft

ft

Syr. Rhei Aromat.
Syr. Brom. Comp. Peacock

Listerine (Lambert) aa * j.

Sig. One teaspoonful as needed.

WARTS.

Acid salicylic gr. xv

Alcohol mxvj

Ether 5j

Collodion 5ij

M. Sig. Apply daily to the warts.

SOLUTION FOR THE REMOVAL OF
FRECKLES.

-Ejk^ Chloride of ammonium 1 drachm.

Hydrochloric acid 1 drachm.

Glycerin 1 ounce.

Fresh milk 2 ounces.

Dissolve, and apply night and morning to
the part of the skin which is affected.

COPPER IN CHLOROSIS.
Luton has recommended the following
formula, from the use of which Dr. Liegeois
has obtained excellent effects in chlorosis :

ft

meal

Neutral acetate of copper gi. 1-6.

Crystallized phosphate of sodium.. gr. 5-6.

Liquorice powder

Glycerin aa q. s.

M. ft. tal. pil. No. 12.

Sig. One pill immediately before morning and evening

-St. Louis Medical and Surgical Journal.

May 30, 1 89 1.

THE

Editorial.

671

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Leading Article.

HABITUAL CONSTIPATION.

Habitual constipation is one of the com-
monest and, very frequently, one of the most
rebellious affections with which the prac-
tioner is called upon to cope. Recently a
number' of foreign journals have devoted
considerable space to the discussion of this
subject. Notable among the contributions
are Nothnagel's, in the Wiener Med. Presse,
and an editorial treatise in the Revue Medi-
cate, of Louvain, in which we have collected
much important information.

Defecation depends upon the regular con-
traction of the colon, and especially of the
rectum. In the small intestine the fecal
matter moves very rapidly (according to
Bauhin the entire length of the small intes-
tine is traversed in six or eight hours) while
in the large intestine the fecal mass moves
much more slowly. Intestinal peristalsis is
largely influenced by the nervous system,
and only in part depends upon a direct ex-
citation of the muscular walls and the con-
tained nervous mechanism. Innervation of
the small and large intestines does not nec-
essarily occur synchronously or similarly —
the one is almost entirely independent of the
other.

Intestinal contractions, which give rise to
the expulsion of feces, occur normally
periodically, one defecation occurring every
twenty-four hours. This, however, depends
largely upon the individual. Some having
two or three movements daily, others but
one movement in two or three days. Cases
are occasionally met with where defecations
occur only once in eight or twelve days, and
others have been recorded in which defeca-
tion occurred from six to ten times in a year !
These anamolies are, however, morbid, not
physiological, and cases] of this kind consti-
tute the affection termed habitual constipa-
tion.

The causes of habitual constipation are
varied. It may be the result of intestinal
innervation, or of atrophy of the muscular

672

Editorial.

Vol.

xiv

coat of the colon — a condition found by
Nothnagel in post mortem examinations. The
usual cause of habitual constipation is, how-
ever, enforced retention of feces, due to a
persistent disregard of the call of nature,
which is particularly the case in women.
Such a state of affairs may be instituted
during a long journey by stage or rail, where
a false modesty on the part of the sufferer
prevents his obtaining relief, or it may occur
. from willful disregard of the natural recur-
rent hour for defecation. Again, habitual
constipation may be caused by indigestion,
the 'result of a change of diet. An acute
attack of intestinal catarrh, not infrequently
leaves the patient with this trouble. Noth-
nagel does not attach the importance to
atony of the abdominal muscles, as a factor
in habitual constipation, as do other writers.
Sedentary habits frequently lead to the
trouble, while in some individuals it is hered-
itary.

The consequences of this condition are
also varied, and are not necessarily iden-
tical in any two cases. In a certain num-
ber of instances haemorrhoids, with all
their well-known inconveniences, are the re-
sult. In a majority there is a loss of
appetite, the digestive functions of the
stomach being for the time depressed, as are
also the same functions of the intestines ; or
it may be that the ptomaines formed in the
stagnant intestinal contents, have, by means
of their toxic actions, directly affected the
digestive powers. Finally, it is by no means
rare to find troubles of the central nervous
system resulting from this disorder. This
may be due either to a reflex action exer-
cised upon the vaso-motor mechanism, or to
a veritable poisoning by ptomaines. In the
latter the troubles take the form of hypo-
chondria, inaptitude for work, dizziness and
vertigo ; even cases of temporary insanity
have been recorded.

A recent opinion, which has found exten-
sive support among English physicians, has
been advanced, claiming that habitual con-
stipation in certain cases causes chlorosis.
How far this may be true we are not in

contestable fact that many cases of chlorosis
have been cured by purgatives alone.

In the treatment of habitual constipation
we must largely disregard the symptoms
produced, and direct our attention to the
treatment of the main point at issue: the
trouble with intestinal peristalsis.

In this respect intestinal massage, and
especially massage of the colon and rectum
is the least used but the most valuable
remedy. This procedure not only strength-
ens the muscular coats of the intestines, but
also mechanically hastens the movement of
the fecal masses within the intestines. In a
similar manner faradization of the abdomen
will be found valuable ; more rarely a gal-
vanic current is .used, one electrode being
inserted into the rectum. In the same line
of treatment regular exercise and' home
gymnastics are to be recommended.

It is well, at the outset of the treatment to
send the patients to some watering place,
where there are mineral springs, and to keep
them there during the course of treatment if
practicable. I-f the patient cannot leave
home, or as he in this country is not sur-
rounded by mineral springs, as he would be
in Germany, any of the many bitter mineral
waters, which are mildly purgative, may be
given regularly with advantage. Rectal
enemata are also very valuable, as well as
rectal injections of glycerine, or glycerine
suppositories. As a rule, it is best to avoid
the use of purgatives, but in a large number
of cases this k impossible.

Purgatives may be divided under two
heads : laxative purgatives and drastic pur-
gatives. The former merely accelerate the
peristaltic movement without irritation, the
latter cause a greater or less amount of irri-
tation of the intestinal mucous membrane.

In the first group may be included acid
fruits, manna, tamarind, castor oil, calomel,
etc., also saline purges. The latter, however,
should not be usecl habitually. Among the
drastic purges valuable in the treatment of
habitual constipation are principally aloes,
rhubarb and podophyllin. The three may
be advantageously combined as in the follow-

a position to say. It is, however, an in- 1 ing formula :

May 30, 1 89 1. Correspondence.

673

JP» Podophyllini gramme 0.30

Extr. aloes

Extr. rhei aa grammes 3.00

Extr. tarax q. s. ad. pil.no. xl .

Sig. One, two or three pills to be taken at
night.

Colocquinth is also a very energetic drastic
purge, but it is not well to employ it longer
than for eight consecutive days. Jalap in
large doses is equally useful, but should be
avoided as it frequently causes nausea and
vomiting. French writers recommend most
highly cascara sagadra. The Revue Medi-
cate giving the following formula :

Jtj^ Extr. fluid, cascarse sagad.

Syrup, cort. aurant aa, grammes 20.00

M. et. Sig. One or two teaspoonsful every
two or three hours.

In cases complicated with bleeding haem-
orrhoids, compound liquorice powder, will be
found useful. When all other purges fail,
senna leaves or croton oil will prove
effectual.

If purgatives are used for a long period,
it is advisable not to use the same drug, but to
change occasionally. Thus Nothnagel be-
gins with the administration of aloes, and
follows this by several weeks' treatment with
purgative mineral waters ; after this com-
. pound liquorice powder is given, and finally
simple syrup.

Regarding enemata, the continued use of
rectal injections of either water, a decoction
of chamomile with a little flaxseed, or soap
and water, or, finally, of pure glycerine, are
frequently productive of excellent results.

Hiinerfauth, in his work on the subject of
habitual constipation, recognizes only three
curative methods : electricity, massage and
hydrotherapy.

For the electrical treatment he prefers the
faradic current, if, however, the affection is
accompanied by pain, the continuous current
should be substituted. For the application
of electricity the patient should assume the
dorsal position with the lower limbs flexed.
The current is then applied over the abdo-
men and rectum, or else within the rectum
and over the abdomen, finally, over the sac-
rum and in the rectum.

Regarding massage, this treatment con-

sists principally of frictions, pinching pres-
sure, kneeding and striking, coupled with
careful exercises, such as walking, riding,
hunting, shooting and especially mountain
climbing.

The hydrotherapy of habitual constipa-
tion consists, according to Hiinerfauth, in
douches over the abdomen, with friction,
cold shower baths, and, finally, the applica-
tion of a wet-pack at night over the abdo-
men.

In summarizing the various treatments of
value in this affection, we must not omit the
" cannon-ball treatment," which is, however,
fortunately less heroic than its name might
lead one to suppose, and consists in a kind of
vigorous massage, the cannon-ball being
rolled about over the abdomen, and occa-
sionally even raised a few inches up and
brought down with considerable force. These
novel seances should last from five to ten
minutes, and be repeated daily.

Finally, Nothnagel bases a further treat-
ment on the hypothesis that a weakness of
the abdominal muscles is one cause of habit-
ual constipation. Dr. Ewer, for example,
prescribes a system of gymnastics tending to
strengthen these muscles, as an efficient
remedy for the trouble. Dr. Enlenberg
recommends Sweedish movements, or gym-
nastics for the same purpose.

In massage of the abdomen, the patient
should lie upon his back with the abdominal
muscles relaxed and masseur, both in kneed-
ing and rubbing, use considerable force and
pressure, following, however, always the
course of the bowels, especially of the colon.

Correspondence.

THE TREATMENT OF LOCOMOTOR ATAXIA
WITH TUBERCULIN.

Ed. Medical and Surgical Reporter. —
The treatment of Locomotor Ataxia has
hitherto been so unsatisfactory, both to
patient and physician, that anything tend-
ing to throw light upon it is welcomed.
This, then, is my ground for begging a few
moments consideration. I do not write to

674

Book Reviews.

Vol. lxiv

herald a new discovery, for I know not that
it is new, nor that it is a discovery at all,
but to stimulate further experimentation,
and to obtain an interchange of experiences.
I will briefly give my experience :

On the twelfth day of last March, Henry
W., aged thirty-six years, a carpenter, a
man of good habits and of good family his-
tory, consulted me for " rheumatism," which
he "stated had troubled him for over four
years, and for the past year he had not
been free from pain though " doctoring all
the time."

Upon examination I found him suffering
from well marked Locomotor Ataxia.
Though he could walk after a fashion there
was marked inability to co-ordinate, slug-
gishness of pupils, girdle-like sensations,
darting pain in the limbs and complete
absence of the knee-jerk. I told him there
was nothing to do for him in the medical
line, but that as I was using Koch's Lymph
in the Hospital I would be pleased to try it
in his case, as an experiment. Fully under-
standing that . nothing was promised, he
readily gave his consent, and the lymph
was injected the same day. Reaction fol-
lowed and the injection was repeated in two
days. His pains at first increased, then
rapidly diminished, under repeated injec-
tions, until at the end of three weeks, they
had entirely gone. His co-ordination was
much improved and his strength greatly in-
creased. He has had as yet no return of
pain, he can work at his trade, walks wrell,
can run and is correspondingly happy.

Meanwhile another case, Ernst F., was
under treatment. His sickness was of six
years duration. He was entirely unable to
walk unless supported, and his pain at night
in the abdomen was so severe as to prevent
his resting, obliging him to set up a great
part of the time. The loss of co-ordinating
power was very marked. Soon after re-
• ceiving injections he became comfortable,
could sleep all night, and his strength was
markedly increased. He is now practically
free of pain and can walk for twenty-five
minutes without assistance. He has received
no other treatment in the Hospital. At
present I have three other cases in Trinity
Hospital in which treatment has just begun.
Reaction follows regularly. I have no
theory to offer in regard to these cases. Can
any one suggest one ? Trusting to hear from
any interested, I am, respectfully, W. H.
Neilson, M. D., Milwaukee, Wis.

It is better to work for nothing than to be
idle.

Book Reviews.

SURGICAL BACTERIOLOGY. By N. Senn, M.
D., Ph. D., Professor of the Principles of Surgery
and Surgical Pathology, Rush Medical College,
Chicago, Illinois. Second Edition. Thoroughly
Revised and Illustrated. Octavo, pp. 271. Phila-
delphia. Lea Bros. & Co., 1891.

The subject of Surgical Bacteriology is
one of such universal interest to medical
men of the present day, that any book
which presents the status of the subject as
it exists to date, based not largely upon
mere personal prejudices, but upon the
broader basis of incorporating, in compact
form, the general outcome of scientific work,
cannot fail to be popular with physicians.

The value of Dr. Senn's- work and its
appreciation by the profession, is shown by
the appearance of a second edition within a
short space of time.

This noted surgeon and investigator has
given to the profession, in this volume, a
resume of the work of standard authorities
on the various subjects which are therein
discussed. When occasion demands, he does
not hesitate to state his own convictions re-
garding disputed points ; and, as the views,
so expressed, are the result of careful clin-
ical observation as well as independent origi-
nal research, they add materially to the
value of the treatise.

In the present edition, the arrangement of
the work into chapters, not only renders it
more useful as a text-book for ready refer-
ence, but also permitted the author to better
classify the subject-matter.

As the former edition of this work has
been fully reviewed in these columns, we
will not occupy needless space by a repeti-
tion of the merits of the book, suffice it to
say that the volume will prove a needed and
valuable addition to any physician's library.

SAUNDER'S QUESTION COMPENDS: ESSEN-
TIALS OF SURGERY. By Edward Martin,
A. M., M. D. Fourth Edition. Illustrated, Re-
vised and Enlarged, with an Appendix of Pre-
scriptions, etc. Philadelphia. W. B. Saunders,
1891.

This is one of the best compends upon
surgery that has been placed before the pro-
fession for a long time. Dr. Martin's large
experience with medical students, as lecturer
and instructor, has enabled him to appre-
ciate their needs, and to amply supply their
wants in his " Essentials of Surgery."

In fact, the book, in its present form, will
prove not only a valuable aid to the student
in systematizing his knowledge, but it also

May 30, 1 891.

Book Reviews.

675

will be found to be a bandy work for easy
reference to the busy practitioner.

In this edition the author has added an
exceedingly useful appendix, which con-
tains several hundred prescriptions appli-
cable to the treatment of the numerous sur-
gical affections, and, in addition, a list of
drugs and materials used in antiseptic sur-
gery, together with very full directions for
the preparation of the various dressings,
solutions, etc., for antiseptic procedures.

TRANSACTIONS OF THE NEW YORK STATE
MEDICAL ASSOCIATION. Seventh Annual
Session, held at New York City, New York, 1890-

This volume of more than 600 pages, con-
tains a very full account of the transactions
of the association at the meeting held during
October of last year. A series of very inter-
esting papers are included in the report ;
among which may be mentioned : — ' Some
Personal Observations Upon the Claims of
Hypnotism, and Its Employment in Certain
Diseased Conditions," bv H. Ernest Shmid,
M. D., of Westchester Co., N. Y. ; " Inter-
cranial Lesions," a discussion by Drs. W.
W. Kern, Chas. K. Wills, and John B.
Roberts, of Philadelphia ; Jas. J. Putnam,
of Massachusets ; Chas. Phelps, Fred. S.
Dennis, Jos. D. Bryant, Thos. R. Manley
and John A. Wyeth, of New York County;
" A New Method of Surgical Treatment of
Certain Forms of Retro-Displacement of the
Uterus, with Adhesions," by A. Palmer
Dudley, M. D., of New York County ; and
The Physician as a Witness," by M. Cav-
ana, M. D., of Madison County, N. Y.

Many other entertaining papers and dis-
cussions are contained in the volume, all of
which are a credit to the scientific and lit-
erary activity of the association.

INTERNATIONAL CLINICS. A quarterly col-
lection of Clinical Lecture^ on Medicine, Surgery,
Gynaecology, Paediatrics, Neurology, Dermatology,
Laryncolo^y, Ophthalmology and Othology. By
piofessors and lecturers in the leading Medical Col-
leges of the United States, Great Britian and
Canada. Edited by John M. Keating, M. D.,
and J. P. Crozer Griffith, M. D., of Phila-
delphia, and T. Mitchell Bruce, M. D., F. R.
C. P., and David W. Finlay, M. D., F. R. C. P.,
of London. Illustrated. J. B. Lippincott Co.,
Philadelphia, 189L

In placing " International Clinics " upon
the market, the Lippincott Co., have de-
vised a new and valuable scheme for sup-
plying to ,the profession medical literature
both of the latest and best. This " Journal,"
if so it may be styled, is to be issued quar-
terly, and is to consist entirely of clinical

lectures which have been delivered by the
leading clinicians in the United States,
Great Britian and Canada. These lectures,
reported by competent medical stenog-
raphers, are carefully revised by the lect-
urers themselves before being placed in the
hands of the editors. The object of the
work is to place in the busy practitioner's
hands a journal which shall contain " the
very cream of practical medicine and the
most recent phases of clinical instruction,"
as they are given to students and the work-
ing physicians in our schools by prominent
teachers throughout the English-speaking
world.

The initial number for April contains 34
complete clinical lectures upon subjects per-
taining to the various departments of medi-
cine, of which the journal takes cognizance.
Each lecture is in the form in which it was
delivered to the .class, and deals with the
etiology, symptoms, diagnosis, treatment and
prognosis of the subject in hand. Treat-
ment is particularly elaborated in every
article, so that all the latest and best meth-
ods are presented to the reader at a glance.

In the department of Medicine proper,
with which the present issue opens, among
other articles are lectures upon " Acrome-
galy," by Ross, of Manchester, Eng. ; upon
" Polysemia or Plethora," by Porter, of New
York ; on " Angina Ludovici in Its Relation
to Diptheria," from Finlayson, of Glasgow ;
" Sore Throat," by Sir Christopher Heath, of
London ; " Pneumonia," by Loomis, of New
York, and upon " Uremic Convulsions,"
by Shattuck, of Boston.

The department of Surgery contains lect-
ures upon " Modern Methods in Surgical
Operations," by Keen, of Phila.; "Ulcers," by
Cheever, of Boston ; " Schirrus of the Breast,"
by the late Dr. Parkes, of Chicago ; " Chole-
lithiasis," by Robson, of London ; and " Ab-
dominal Nephrectomy for Pyolenephrosis,"
by Nancrede, of Ann Arbor.

In Obstetrics and Gynaecology are the
teachings of Mann, of Buffalo, upon " The
Early Diagnosis of Pregnancy ;" of Cam-
eron, of Montreal, upon " Elevation of the
Temperature During the Puerperal State;"
of H. T. Byford, of Chicago, upon " Ure-
thritis ;" and of Goodell, of Philadelphia,
upon " Cancer of the Vagina."

Paediatrics contains " Tonsellar Diph-
theria," by Forcheimnier, of Cincinnati ;
"Different Types of Paralysis in Young
Children," by Gray, of New York ; and
" Chorea," by Sir Dyce Duckworth, of
London.

In the Neurological department, H. C.

676

Periscope.

Vol. Ixiv

Wood, of Philadelphia, contributes a clinic
upon " The Remote Effects of Traumatisms
as seen by the Neurologist ; " Sachs, of New
York, one upon " Functional Nervous
Troubles and Neurasthenia Mills, of Phil
adelphia, upon " Myotonia and Athetoid
Spasm ;" Ferrier, of London, upon " Alco-
holic Paralysis ;" and Weir Mitchell, of
Philadelphia, upon " The Treatment of
Obstinate Sciatic Pain by Splint-Rest and
Cold."

J. Solis Cohen, of Philadelphia, contri-
butes to Laryngology a clinic upon " Strict-
ure of the Larynx."

In Dermatology appear lectures of Fox,
of New York, upon " Psoriasis ;" of Ohmaim
Dumesnik, of St. Louis, upon " Infantile
Eczema ;" and of Hyde, of Chicago, upon
" Xarthema Lichen Planu, etc."

Ophthalmology and Othology are re-
spectively considered by Chisolm, of Balti-
more, and Buck, of New . York, in lectures
upon " Astigmatism an Often Unrecog-
nized Cause of Headache," and " Stubborn
Inflammations of the External Auditorv
Canal."

Of necessity, in the limits of a book
notice such as this, it is impossible to give
even a short synopsis of the foregoing lect-
ures, and, indeed, where all are equally
good the task would be a difficult one.
The profession is, however, to be heartily
congratulated upon the fact that within the
covers of " International Clinics " the re-
sults of the work of the ablest teachers of
medicine appear so condensed and arranged
as to be most easily available and useful.

The journal contains 350 pages, whose
typographical make up is excellent. Nu-
merous wood-cuts and photographic repro-
ductions assist greatly in elucidating the
text. In these lectures are to be found just
what the practitioner wants in the way of
the latest theories as to causation of disease,
with the newest methods of therapeusis as
taught by the ablest clinicians of the day.

CREOLIN IN ALOPECIA.

Creolin Pearson ^ gr.

Hydrarg. bichlor 1-64 gr.

Aq. rosse 31^ f oz.

Aq. dest 13% f oz.

M. Sig. Wash the scalp with the solution.

— Swalowaski.

The physicians of this country do more
missionary work without charge than all the
other professions put together. — Ex.

PERISCOPE.

THERAPEUTICS.

COPAIBA AS AN EXPECTORANT.

Recently balsam of copaiba has been
found to be an excellent expectorant in cases
of chronic bronchitis. The dose, as advised
by the Allgemeine Med. Central-Zeitung ,
April 4, 1891, is 7 grammes daily, to be ad-
ministered with 30 grammes of malt extract.

PIPERAZIN.

W. Epstein and C. Sprague publish a pre-
liminary report of their investigations with
piperazin, in the Wiener Med. Presse, April
19, 1891. The drug, which is a new one,
has the property of dissolving large quanti-
ties of uric acid at the body temperature, and
also — what is of greater value — even when
a very large excess of uric acid existed, only
the neutral and easily soluble uric acid salt
would be found. One part of uric-pi perazin
is soluble in fifty parts of water at 17° C.
When it is considered that the solubility of
uric-lithion is only 1 to 368 at 19° C, it will
be seen that piperazin is seven times more
soluble. Piperazin is neither irritating or
toxic and is therefore of great value in cases-
where a dissolution of uric acid is to be ac-
complished. Experience has shown that the
result is well tolerated. The drug is admin-
istered hypodermically.

GIBBES-SHURLY METHOD OF HYPODERM-
IC MEDICATION AND CHLORINE
INHALATION FOR PHTHISIS
PULMONALIS.

HYPODERMIC INJECTIONS,

As chemicals may cause considerable pain
to some people when injected under the skin,
the site chosen may be previously treated by
the application, for two or three minutes, of
a wad of flannel which has been saturated
with a mixture of ether and chloroform
(equal parts), or, ether (two parts), chloro-
form (two parts), and menthol (one part), or
better still, one of these mixtures may be
sprayed upon the part. With many people,
however, the pain is only momentary, and
they will not require such preliminary treat-
ment. The injection may be made at any
time of day and without reference to temper-
ature of the body. The evening will be
found generally acceptable to the patient.
Although the fluids may be injected at
almost any convenient region of the body,

May 30, 1 89 1. Periscope.

677

the gluteal region will be found preferable
on account of the loose cellular and adipose
tissue of the part, and because there is less
danger of abscess or sloughing of the skin.
The chemicals used should be pure, or trouble-
some abscesses will be likely to occur.

THE HYPODERMIC SYRINGE.

Any hypodermic syringe can be used.
Care should be taken to keep the syringe
clean. It should be washed with hot water
and then with alcohol, or a five per cent,
solution of carbolic acid, directly after its use.
Drawing a little kerosene oil in occasionally
will prevent the packing from getting too
dry.

IODINE.

To commence with, the dose of the iodine
solution should be about (1-12) one-twelfth
of a grain, gradually increasing daily until
one-half (1-2) or perhaps one grain is reached,
when it may be gradually diminished or
substituted at once for the gold and sodium
solution. The temperature is likely to go
higher for at least the first week, and as the
chemical becomes diffused its effects may be
shown in increased mucus secretion from the
bronchial tubes, sensation of dryness of the
throat, redness of the eyes, and coryza,
characteristic erythema of the skin, diminu-
tion of urine or of diarrhoea, and loss of
appetite. During this period there is gener-
ally loss of weight. In susceptible patients
these symptoms may supervene after two or
three injections only, in which case the gold
solution should be used. In a few instances,
after thorough diffusion, the characteristic
reaction of iodine with starch may be ob-
tained in the urine, and even in the perspi-
ration.

CHLORIDE OF GOLD AND SODIUM.

The chloride of gold and sodium solution
causes less pain than the iodine, in fact, in
the majority of instances no pain save the
sting of the hypodermic needle. The dosage,
like that of the iodine, should be gradually
increased, beginning with about (1-30) or
(1-20) grain and increasing up to (1-5) or
(1-3) grain. The more immediate effects
noticeable from the larger doses are vertigo,
nausea, sensation of constriction at lumbar
region, and headache, and lowering of pulse
tension. With many persons the continued
use of this solution will cause profuse per-
spiration, which, however, is soon stopped
or checked by lowering the dose or stopping
the use of the chemical. When hectic fever
is not broken up by these injections, hypo-
dermic injection of bisulphate of quinine

from three to six grains, alternately with
the iodine solution, may be given with great
benefit.

CHLORINE.

Chlorine may be administered either by
directly diffusing the gas in the atmosphere
of a small room, or spraying chlorine water
through a face-shield inhaler. In either
case it must be freely mixed with chloride of
sodium. The gas may be evolved from chlo-
rinated lime, by the addition of dilute hydro-
chloric acid, using from one-half to three
drachms of the lime for a sitting, in a room
about 8x9 feet and 9 to 10 feet height of
ceiling.

Previous to this, however, it will be nec-
essary to diffuse through the atmosphere a
spray of a saturated solution of chloride of
sodium, which spray should be kept up
during the sitting. The patient may be
allowed to remain in the room from ten to
thirty minutes, according to the effects
observed. While so placed the patient
should be instructed to breathe through the
nose, keeping the mouth closed, and to re-
frain from talking. If coughing supervene
to any great extent the sitting should ter-
minate. One, two or three inhalations may
be given daily.

The chlorine water should be carefully
made according to the U. S. P. It may be
administered as a spray, mixed with a satur-
ated solution of chloride of sodium, in the
proportion of one-third to one-half. From
one-half to two ounces of the mixture may
be used at a sitting, once, twice or three
times a day. In some cases after a time a
general soreness of the throat may be com-
plained of, when this happens the treatment
should be suspended for awhile. Chlorine,
by either of these methods, should not be
administered where there is danger of
hemoptysis.

HYPEROSMIC ACID FOR SUBORBITAL
NEURALGIA.

Luciani, in the Allg. Med. Central- Zeit-
ung, April 22, 1891, reports a case of sub-
orbital neuralgia, in which hyperosmic acid
was used with great success. The patient
was a woman who suffered intensely from
neuralgia of the right eyelid, and right
cheek. All the usual anti-neuralgics had
been resorted to without the least relief
being obtained. Hypodermic injections of
a one per cent, solution of hyperosmic acid
gave prompt and lasting relief. The solu-
tion was given in syringeful doses, and re-
peated as required.

6y8

Periscope.

Vol. lxiv

EXPULSION OF GALLSTONES.

The treatment of gallstones by large doses
of olive oil is a subject that has received
almost universal acknowledgement of late,
and has been used so extensively that many
other means, useful in accomplishing the
same results — viz. : the expulsion of the
gallstones — have been temporarily over-
looked.

Foremost among these are the methods
advanced by Prof. Harley, of London. He
advises the administration of belladonna,
and placing the patient in a hot bath.
During the crisis inhalations of the follow-
ing anaesthetic mixture may be given :

Alcohol, 4 grammes.

Chloroform, 8 "

Sulphuric Ether, 12 "

M. • . • , *\ *ft* rt|;> 1

Further, it is well to administer an emetic
or purgative. Although opiates are gen-
erally used, Harley considers them contra-
indicated in the majority of cases of affec-
tions of the liver. If, however, the pain
should become unbearable, a hyperdermic
injection of morphine should be given over
the epigastric region. Still he has the
greatest confidence in the efficacy of bella-
donna not only taken internally, but also
in the form of liniment, plaster and sup-
pository. An alkaline water should also be
given the patient, composed of say a tea-
spoonful of bicarbonate of soda in a glass
of water, or half milk and half water. It
is impossible, says Harley, to give the
patient too much of this mixture, since it
lessens the irritability of the stomach, facil-
itates vomiting, and favors the secretion of
bile, thus materially aiding the expulsion of
the calculi. It ' should not be neglected,
also, to administer a mercurial purgative,
the following being recommended :

Hydragyr. cum cretse, 0.40 gramme.

Pulv rhei, 0.20 "

Magnesia?, 1.50 "

M.

Finally, Harley also claims to have
achieved excellent results by digital manipu-
lations and massage of the abdomen, as a
means of causing the expulsion of gall-
stones.

The treatment of hepatic collie, as advo-
cated by Prof. Lemoine, of Lille, and
quoted in the Revue Medicate, March, 1891,
is almost analogous with the above.

Internally, in the absence of emetics, he
advocates potions containing ether or chlo-
roform. Locally, over the seat of the
trouble, he applies heat in the form of cata-
plasms. These should be very large, very

hot, and renewed every hour. Frictions
and rubbing with belladonna and chloro-
form over the hepatic region are also useful.
Contrary to Harley, however, Lemoine has
found that prolonged or oft-repeated baths
produce a calmative effect which tends to
hinder the expulsion of the calculi.

The following suppositories will be found
most useful :

Ijk? Ext. belladonnae,

Ext. opii, aa 0.02 gramme.

But. cacao, 6.00 "

These suppositories should be. inserted
every hour or half hour as occasion de-
mands. The surest and most rapid method
of relieving all pain is, however, by hypo-
dermic injections of morphine ; the pain
disappearing in from five to fifteen minutes.
About half a centigramme should be in-
jected and repeated in half an hour if
necessary.

For a purgative, Lemoine prescribes atro-
pine with morphine in the following for-
mula:

Mix.

Chlorhydrate of morphine, 10 gramme.

Neutral sulphate of atropia, 01 "

Cherry-laurel water, 20.00 "

Lemoine condemns the practice of inhal-
ing chloroform or ether, claiming that it is
apt to cause more harm than good. Neither
should chloral be administered internally,
it being badly tolerated.

THE THERAPEUTIC EFFECTS OF
DIURETIN.

Keissler ( Vratch, Nos. 46, 47, 1890, Bull.
Gen. de Theap.) — The author has studied
the diuretic effects of diuretin in healthy
men, and he paid particular attention to its
effect on the renal tissue ; and he also
studied its effects on the pulse and blood
pressure. His experiments were made on a
normal man, on four with heart disease, two
with nephritis and one with cirrhosis of the
liver. He arranges his observations into
three divisions — before, after, and during
the administration of the drug. The dose
given in each case was one gramme, repeated
to six grammes a day. The following re-
sults were obtained :

1. Diuretin acts incontestibly on the
blood-pressure, raising it.

2. It is not solely a diuretic, but has a
cardiac action.

3. The drug gives remarkable results, es-
pecially in those cases of asystole, which do
not depend on insufficiency of the valves.

4. When the muscle of the heart is dis-

May 30, 1 89 1.

Periscope.

679

eased the effects of diuretin are less marked,
especially its diuretic effects.

5. In acute nephritis its diuretic effects
are more marked than in chronic nephritis.
The albumen is never augmented even if
the administration of the diuretin be con-
tinued.

6. In hepatic cirrhosis diuretin augmented
the quantity of urine.

7. In healthy men the drug does not in-
crease the diuresis.

ABORTIVE TREATMENT OF HERPES BY
APPLICATIONS OF PURE ALCOHOL
OR OF ALCOHOLIC SOLUTIONS.

Leloir {La Pratique Medicate, Feb. 17,
1891) has been able, in a number of cases,
to completely abort herpetic eruptions of the
lips by the local application of carbolized
alcohol, in the form of compresses. This
treatment, however, has not given satisfac-
tory results in herpes of the genitals. The
vesicles of herpes zoster are acted upon fav-
orably, but the eruption does not disappear
except in rare cases.

The influence of the treatment by alco-
holic solutions is remarkable. Whether
applied at the erythematous or at the vesic-
ular period, the herpetic eruption is gener-
ally aborted, and this is accomplished very
rapidly, usually in the course of a few hours.

Leloir employs alcohol in different forms.
For example :

Ijk? Alcohol , 90 per cent 25 drachms .

Pure resorcin 30 grains.

He often replaces the resorcin by thymol
(15 grains), menthol (15 grains) or phenic
acid (3f grains).

Other formulae are employed by the
author, as follows :

_L>? Alcohol, 90 per cent 25 drachms.

Resorcin 30 grains.

Chlorhydrate of cocaine 7^2-30 grains.

Ijk Alcohol, 90 per cent 12^ drachms.

Tannin .. 1% drachms.

In private practice Leloir uses this prep-
aration :

Ij^ Alcohol, 90 per cent 25 drachms.

Extract of cannabis indica....2*/£ drachms.

Chlorhydrate of cocaine 15 grains.

Essence of peppermint 2% drachms.

Compresses, moistened with one of these
mixtures, are applied upon the eruption,
and are fixed by means of pieces of adhesive
plaster, or, for the same purpose, collodion
and medicated gelatine may be employed.

— Univ. Med. Mag.

HYDROCHLORIC PHENOCOL.

Dr. Hertel, in the Wiener Med. Presse,
April 19, 1891, reports of the value of
hydrochloric phenocol, a new antipyretic
and antirheumatic. The drug is a white,
micro-crystalline powder. Chemically, it is
produced from phenacetin, which, by the
introduction of the saline amido-group, is
rendered soluble in an acetyl residue. Hy-
drochloric phenocol is soluble in water,
forming a clear solution. The fresh solution
is' of neutral reaction. Solutions, two days
old, show a slight alkaline reaction which
increases with the age of the solution.

So far, the drug has not been found
to produce any unpleasant effects upon
the heart, lungs, or digestion, even when
given continuously in daily doses of 5
grammes. Hydrochloric phenocol does not
have any effect upon perspiration, neither
producing nor increasing it. As a test for its
antipyretic properties, Dr. Hertel used it
in a number of cases of phthisis with
irregular hectic fever. Single doses of 0.50
gramme will cause a fall of temperature of
about i° C. Doses of 0.5 gramme to 1.5
grammes, given hourly, will generally bring
the temperature down about 1° C. but only
for a short time. Single doses of 1 gramme
will cause a fall of 1-1*° C. within a few
hours. The fall of temperature usually
begins within an hour after the exhibition
of the remedy, and lasts for about two
hours. Five grammes, in divided doses
during the day, will generally suffice to
keep the temperature down. It seemed,
however, to rather lack in efficacy in con-
trolling high evening temperatures. In
severe cases of acute muscular rheumatism,
often accompanied with serious after-com-
plications, the drug is frequently of value
in relieving pain, when other remedies,
such as antifebrin, antipyrin, salicylate of
sodium and phenacatin have failed. The
dose given was 5 grammes daily. In these
cases, however, the drug entirely lacked any
antipyretic action, the temperature not sink-
ing to the normal until the rheumatism and
the accompanying symptoms began to im-
prove. In cases of severe gonorrhceal rheu-
matism the drug has no influence either upon
the course of the disease or upon the fever.
Hydrochloric phenocol exerts no deleterious
influence upon the kidneys, although after
the ingestion of 5 grammes the urine be-
comes reddish-brown in color, or even dark
brown. This discoloration increases mate-
rially if the urine is left exposed to the air.
Liq. ferri sesquichlor. added to the urine
causes a still darker coloring, which is con-

68o

Periscope.

Vol. Ixiv

siderably lessened, although not dispelled
by the addition of concentrated sulphuric
acid. The drug is eliminated with great
rapidity, since twelve hours after its exhibi-
tion it can be no longer traced in the urine.
The technical name of the drug is amido-
acet-para-phenetidin.

MEDICINE.

TREATMENT OF ERYSIPELAS WITH SALI-
CYLATED GLYCERINE.

For the past six years Dr. S. C. Inglessis
has been treating erysipelas successfully with
a solution of salicylate of soda in glycerine.
A four to six per cent, solution is used as a
lotion, and rubbed into the affected parts
every two or three hours, after which the
parts are covered with salicylated cotton.
Simultaneously, if there is no heart weakness
or albumin in the urine, the author advises
the exhibition of 0.2 grammes of salicylate
of soda daily. In all, he has treated thirty-
six cases with this method, and all success-
fully. The application of the salicylated
glycerine caused an immediate disappear-
ance of pain and itching, and considerably
lessens the couise of the disease. When
instituted at the outset of the disease the
treatment will frequently abort it, and cause
an almost immediate recovery. — Semaine
Mcdicale.

CRYSTALS IN NASAL POLYPI.

At the meeting of the Society for Internal
Medicine of Berlin, held April 21, 1891, and
reported in the Medicine Modeme, April 30,
1891, Dr. Lewry reported the results of the
microscopical examination of a large number
of polypi of the nasal mucous membrane.
The polypi contained large quantities of a
fluid rich in albumin, in which, after a
variable length of time, but usually within
a few days, there appeared crystals of a
double pyramidal form, and resembling in
every particular the crystals found by Dr.
Leyden in the sputa of asthenatics. The
formation of these crystals seems due to a
necrotic process, since they only appear some
time after the removal of the growths, and
increase in number. The theory has been
advanced that these crystals, forming in
nasal polypi, might find their way down the
respiratory tract, and act as a mechanical
irritant, thus producing asthma. Lewry's
experiments however, have confirmed be-
yond doubt, that the crystals do not exist in
the polypi until some time after their re-
moval. It is, however, very possible that

their fundamental elements existing in the
blood act as an irritant. The same crystals
have also been found in non-asthenatic cases,
but this is most rare. They have never been
observed in the tonsils or uvula.

ON AMICRABIAN FEVER FOLLOWING
ARTERIAL OBLITERATION.

It has been frequently observed by Gan-
golphe and Courmont {Le Bull. Medical,
April 8, 1891) that arterial obliteration,
without external lesion, is followed by a rise
of temperature even above 40°C. In order
to explain the cause of this phenomenon
they have instituted a series of experiments
upon the lower animals. The investigators
have thought that the fever is due to a re-
absorption of the products resulting from
the cellular desintegration occurring in the
parts deprived of blood, but in which a new
circulatory process has been started and,
thus enhanced, the taking up of these
cellular products formed during the anaemic
condition of the part. When, however,
these products are not absorbed, as for in-
stance in the case of elastic ligatures ap-
plied in the course of the experiments, no
hyperthermic phenomena occur: These
elastic ligatures were tried in the scrotum of
the animals used, and were allowed to re-
main for three days, during which, no
changes in the body temperature occurred.
At the end of this time the ligatures were
removed, and of course the new cellular
products would find their way into the gen-
eral circulation, with the result that the
temperature was considerably elevated.

In some instances the organism in a state
of necrobiasis, or degeneration, were removed
and from them was extracted a substance
insoluble in alcohol but soluble in water, es-
pecially glycerinated water. This substance
was found to possess a pyretogenic power.

From the researches made, the authors
have drawn the following conclusions :

1. The existence of amicrobian fever is
proven, clinically and experimentally, in
cases of vascular obliteration.

2. This fever seems to be due to the reab-
sorption of the soluble pyretogenic products
resulting from cellular desintegration of the
parts in state of necrobiosis.

3. The subsequent decline of tempera-
ture, occurring at the time of elimination, is
due to the diminution of the necrobiotic
process and to the lessening of the vascular
interference.

4. These pyretogenic products "exist in
large quantities in degenerating tissues ; they

May 30, 1891.

Periscope.

are piecipitated by alcohol but are soluble
in glycerinated water.

SURGERY.

PLASTER OF PARIS BANDAGES.

According to the Medicinische Neuigkei-
ten, April 18* T891, the proper preparation
of plaster of Paris for bandages is not gener-
ally understood, and, therefore, the results
obtained are frequently unsatisfactory. The
fluid used should be filtered rain-water, or
still better, sour milk. Either will make an
extraordinarily hard plaster. The addition
of fine marble dust will also add to the
hardness. An addition of 33£ grammes of
alum and 33? grammes of sal ammoniac to
each i kilogramme of the plaster is also
recommended. The following directions
for mixing are given : The plaster should
be put in a dry basin and formed into a
cone, and then water or sour milk slowly
added until the fluid has been drawn up to
the tip of the plaster cone, then begin to stir.
In this way the best results are obtainable.

Vigues strongly recommends the direct
massage of the conjunctiva with applications
of boric acid, and his statistics show that he
has achieved brilliant results by this method,
a few days sufficing to produce a marked
improvement in every case. — All. Med. Cen-
tral-Zeitung, April 22, 1891.

TREATMENT OF TRACHOMA.

At a recent meeting of the Ophthalmo-
logical Society of Paris, the question as to
what was the most efficaceous treatment for
trachoma was extensively discussed. Darier
abvocates a thorough breaking up of the
granulations by an operation under chloro-
form. The operation consists in a deep
scarification of the conjunctiva and a sub-
sequent scraping with the curette, and finally
a brushing off" with a very stiff brush soaked
in a strong solution of bichloride of mercury.
Within one or two weeks a fine cicatrical
tissue is formed, without causing any deform-
ity of the lids. Abadie has also used this
surgical method for the treatment of tra-
choma with extraordinarily good results,
such as he has never observed to follow any
other treatment for this disease.

Gillet de Grandmont, was opposed to any
surgical treatment, claiming that it sacrificed
the continuity of the mucous membrane.
He advocates the use of acetate of lead in
the following formula :

1^ Plumb acetic 2.0 grammes.

Glycerin, pur, anhydr .10.0 grammes.

M.

This mixture should be applied by means
of an antiseptic ivory spatula, and under its
influence the .trachoma disappears. This
collyrium has no caustic action and there-
fore does not injure the conjunctiva or
cornea.

THE TREATMENT OF COLD ABSCESSES.

The treatment of cold abscesses by the
antiseptic puncture is advocated by Pie-
chaud (Le Bull. Medicate, April 8, 1891).
The results of this simple procedure have
been entirely satisfactory, no complications
having followed the cures accomplished.
The size of the abscesses treated has been
variable, but the largest collections were
met in the thigh and buttocks of children.
The liquid of some of these abscesses
showed, under the microscope, the presence
of the streptococus and the staphylococus.

Twenty cases were treated as follows :
After the puncture washing of the sac was
ordered, and then the application of a solu-
tion of corrosive sublimate (1 to 1000) was
made. This method usually brought about
a very rapid cure, even in cases where the
skin had become so thin as to threaten a
rupture of the abscess. The author never
observed untoward effects following the use
of the mercurial solution employed.

GYNECOLOGY.

SALOL AS A DEODORIZER OF THE
FCETED DISCHARGES OF UTERINE
CARCINOMA.

Drs. Marty and Plowezky, of Toulouse,
recommended, in a recent number of the
Semaine Medicale, the internal use of salol
as a deodorizer of the fceted vaginal dis-
charges in cases of internal carcinoma. The
remedy is of especial value in cases when a
vesico-vaginal fixtula exists, as the stench of
the discharges of these cases is most sicken-
ing. The authors, arguing that in the
organism salol would be split up into its two
component parts, viz., salicylic acid and
.carbolic acid, gave the drug internally
hoping to render the urine antiseptic. The
results of their experiments exceeded their
| hopes, -for in two cases, in which all the
| usual methods, such as vaginal injections of
disinfectants, and tampons, had been tried
in vain, salol given internally caused a com-
plete disappearance of the foeted odor. The
drug was given in doses of from two to four
grammes daily. If this quantity was not

682

Periscope.

Vol. lxiv

sufficient as much as six to eight grammes
may be given daily without producing any
unpleasant symptoms. Its action in cases
complicated with vesico-vaginal fistula is
most marked, the dribbling of the antiseptic
urine over the carcinoma causing a continual
process of disinfection.

INTRA - UTERINE G ALV ANO-C AUTERI ZA-
TION IN GYNECOLOGY.

Apostoli {Bull, et Mem. de la Soc. de
Med. Prat, de Paris, Feb. 15, 1891), in sup-
port of his electrical treatment, lays down-
briefly the following propositions ; The gal-
vanic current finds its principle indication
in gymecology in endometritis and fibromata ;
it is sovereign in circulatory and painful
affections (amenorrhoea, dysmenorrhea and
metrorrhagia), and it is of powerful assist-
ance in arresting the evolution of benign
neoplasms, and in aiding in the reabsorption
of peri-uterine exudations. It exercises a
very salutary resolutive action in many of
the peri-uterine phlegmasia and in catarrhal
ovaro-salpingitis ; but it is inefficient, and it
may be even harmful in strong intensity,
especially if the intra-uterine pole is nega-
tive, in the suppurating phlegmasia? of the
appendages.

In his justification of the application of
high intensities, he claims that electro-
therapy, as well as general therapeutics,
should be essentially seasonable in its
employment, and that its dose should be
modified according to clinical indications,
which vary in each instance. It has been
necessary to employ the galvanic current in
various degrees of intensity, in order to
arrive at the most beneficial strength neces-
sary to accomplish the desired object. In
certain conditions high intensities of the gal-
vanic current must be employed where weak
currents will have no effect. The current
should be increased in power progressively
and with due warning to the patient. Every
fluid collection, suppurating or bloody, uter-
ine or peri-uterine, absolutely contra-indi-
cates high intensity, while it calls for an
evacuation more or less speedy, or for surgi-
cal extirpation. The current, however, in
such cases acts as a valuable means of diag-
nosis, since relief not following its applica-
tion, it will lead to the suspicion of a cystic
condition which further examination will
reveal. The positive pole of the constant
galvanic current has, in addition, a powerful
action in destroying microbes, especially the
destructive bacteria.

The intra-uterine application facilitates
the penetration en masse of the current,,
because the uterine mucosa of feeble resist-
ing power will be readily traversed by the
current. In cases of peri-uterine affections
(para- and peri-metritis), if there be any
resistance offered to the purely intra-uterine
application, he claims immediate relief for
the peripheral vaginal gajivano-puncture.
Patients thus treated have said that while
" galvano-puncture has been the most pain-
ful operation, it has been followed by the
most complete amelioration of the symp-
toms."

There is no danger of ultimate sterility
from the intra-uterine treatment, since Apos-
toli has collected thirty observations of pa-
tients so treated who have gone to full term
in a subsequent pregnancy.

During the eight years, from July, 1882?
to July, 1890, Apostoli has treated 912 cases,
consisting of 531 fibromata, 133 simple en-
dometritis, and 248 endometritis complicated
with peri-uterine phlegmasia? (peri-metritis,
para-metritis, or inflammation of the ap-
pendages). Eleven thousand four hundred
and ninety-nine galvanic applications, were
made as follows :

8,177 positive galvano-caustics, intra-uterine.
2,486 negative " *' " "

222 positive vaginal galvano-purtctures.

614 negative " " "

During this time he has had three deaths,
the first due to a galvano-puncture made too
deeply into the peritoneal cavity upon an
extra-uterine fibroid ; the second due to a
puncture of an ovaro-salpingitis, probably
suppurative (no autopsy was made). There
had been an intestinal perforation. The
third was due to a grave diagnostic error,
where an ovarian cyst w7as mistaken for a
fibroma and improperly treated. — Univ. Med.
Mag.

OBSTETRICS.

THE ELIMINATIVE TREATMENT OF
PUERPERAL SEPTICEMIA.

From a study of infectious diseases in
general, and from observations on the meth-
ods of elimination of toxic substances from
the organism by the natural emunctories,
Heliodor de Swiecicki ( Gazette hebdomadaire
de medecine et de chirurgie) advises the em-
ployment of these means to rid the system
of poison in puerperal septicaemia. Of
course, the early treatment of this disease, if
the case is seen in time, is, first, by asepsis
and antisepsis by means of uterine irriga-
tion, etc.; and, secondly, by the use of alcohol
and every means to prevent the poison from

May 30, 1 89 1. Periscope.

683

overpowering the organism. But, if the
morbid germs and their products have
surcharged the blood, the author says, the
production of exaggerated diuresis and
diaphoresis would be a rational method of j
eliminating the morbid elements. The
treatment consists of subcutaneous injections
of pilocarpine and the drinking of large and
frequent draughts of sterilized chloride of
sodium solution. If there is any difficulty
in the patient's swallowing the solution, it is
to be introduced directly into the stomach
by means of a tube. The author reports the
success of this method of treatment in several
grave cases of puerperal septicaemia. The
amelioration of the symptoms was prompt,
the temperature falling, the pulse becoming
less rapid, and the rigors disappearing in a
very short time. The patient must be
watched closely for any sign of heart failure,
in the event of which small doses of alcohol
are to be given.

HYDRASTIS CANADENSIS IN UTERINE
HEMORRHAGES.

Jules Bataud refers to the paper by
Schatz, and to the recent theses by Cabanes
and Pigache, which contain a resume of the
recent literature upon hydrastis. Bataud
himself has studied the effects of hydrastis
in four cases of uterine haemorrhage which
occurred in the wards of the Saint-Lazare.

The first case was that of a prostitute,
twenty-seven years old, with secondary
syphilis, ^who was unexpectedly arrested
while street-walking, and was taken to
Saint-Lazare. She was of a very nervous
and impressionable temperament. Menstru-
ation was regular, scanty, and accompanied
with dysmenorrhoea. The patient had never
had a child or a miscarriage, and, though
she had been at the hospital a dozen times
before, had never had uterine haemorrhage.
At the time of admission it was found that
she had an enormous papulo-hypertrophic
syphilide of the vulva and anus. On the
night of admission she wras seized with pro-
fuse hemorrhage from the uterus, preceded
by dysmenorrhoeal pains, though she had
menstruated only fifteen days before. The
cause of the haemorrhage was thought to be
congestion of the ovaries and uterus, induced
by the shock of her sudden arrest— such an
effect is said not to be uncommon in patients
brought to Saint-Lazare. An examination
of the uterus and ovaries showed no cause
for the haemorrhage. The patient was given
ten drops of fluid extract of hydrastis thrice
daily, and the haemorrhage ceased nine days

after its first appearance. It is not clear
from the text whether she took the hydrastis
from the beginning of the haemorrhage or
not. The drug was continued for twelve
days after the haemorrhage had ceased. The
following menstrual period continued only
three days, and the flow was scanty as
usual.

The second patient, a woman, twenty-one
years old, was admitted for gonorrhoeal
urethritis and vaginitis, with discrete vege-
tations about the anus and vulva. Men-
struation was regular and painless, lasting
four or five days. She had had neither
children nor miscarriages. While descend-
ing the stairs, one day after admission, she
fell, striking her side over the region of the
kidney. Two hours later she was seized
with acute pain, and was obliged to go to
bed. The same night very profuse and
painful haemorrhage from the uterus came
on. There was a large ecchymosis in the
left lumbar region. Forty drops of fluid of
extract of hydrastis were given daily, in
four doses. The next day pain and haemor-
rhage were less, and in five days from the
beginning of the administration of hydrastis,
and in six from the time of the accident, the
haemorrhage had ceased.
, In the third case, a woman, twenty-three
years old, was admitted for syphilitic erosions
of the mouth. Her menstruation had always
been regular, scanty and painless, lasting
four or five days. She had had neither
children nor miscarriages, and never had
menorrhagia or pain in the abdomen until
three months before admission, when she
rolled down stairs. This accident was fol-
lowed by a sensation of heat and weight in
her abdomen. Two days later menstruation
set in, and was painful and much more pro-
fuse than normal, and continued ten days.
In the interval between her menses the pains
continued, and leucorrhoea developed'. The
last menstruation before admission was sim-
ilar to the one just described. The uterus,
vagina, and vulva were intensely congested.
The dull curette disclosed no lesion of the
endometrium. At the next menstruation the
patient was kept in bed, and was given forty
drops of fluid extract of hydrastis a day, be-
ginning on the second day after the appear-
ance of the flow. Menstruation lasted only
seven days, and was less painful. The
hydrastis Avas continued until the next men-
struation appeared, which was not painful,
lasting only five days, and was not as profuse
as before. The congestion of the uterus is
said to have been completely cured.

In the fourth case, a woman, thirtv-nine

684

Periscope.

Vol. lxiv

years old, had been curretted eight months
before for metrorrhagia due to an endome-
tritis following abortion. The patient was
cured by the operation, and menstruation
became normal as to quantity and duration.
On the second day of one of her menstrual
periods,she had intercourse with her husband.
Instead of the flow ceasing on the fourth day
as usual, it continued for eight days longer,
the patient suffering at the same time from
sensations of heat in the pelvic organs.
Bataud saw the patient on the tenth day of
the haemorrhage, and gave her four one-grain
pills of hydrastin a day. The sensations of
heat and the haemorrhage diminished from
the first, and ceased on the second day. Since
then she has had two periods, each lasting
only four days. Absence of endometritis
was proved by curretting the womb.
Hydrastin was used instead of the fluid
extract of hydrastis, because of the
disagreeable taste of the latter. — Revue
Medico- Chirurgicale des Maladies des Fem-
mes.

PEDIATRICS.

MEDICINES TO NURSING MOTHERS; IN-
FLUENCE OF THE MILK UPON THE
INFANT.

Schling (Gazette de Gynecologic, Feb. 15,
1891 — Paris Medical) has made a series of
investigations with various medicines, and
obtained the following results:

Sodium Salicylate. — Dose, fifteen to thirty
grains. When the child was not put to the
breast for an hour or more after the admin-
istration of the drug to the mother, it was
always found in the infant's urine and dis-
appeared in twenty-four hours. If the in-
fant nursed very soon after administration,
there was no trace of the drug in its urine.

Potassium iodide. — Similar results. Analy-
sis of the milk gave the characteristic re-
action. Elimination in the infant lasted
seventy-two hours ; in the mother, forty-four
hours. After twenty-four hours the milk
contained the drug.

Potassium Ferro-cyanide. — Reaction very
plain in the mother's urine. None in the
infant's.

Iodoform. — Employed as applications to
the vagina and vulva. After a rather pro-
longed use, as a rule, iodine was found in the
milk and the mother's urine, but never in the
urine of the infant.

Mercury. — Its transmission through the
milk was always very feeble and irregular,
and depended upon the quantity of milk
absorbed.

Narcotics. — (a) Tincture of Opium, in
doses of twenty to thirty drops. Thornhill
has observed in the infant prolonged sleep.
Fehling has noted neither prolongation of
sleep nor constipation, (b) Morphine Hy-
drochlorate. — Solution 1-30; doses, gr. f*$.
No ill effects upon the child, (c) Chloral. —
Dose, gr. xv.-xlv. Mean duration of ma-
ternal sleep, two hours. No action was noted
upon strong and vigorous infants. When
the child is feeble or premature there should
always be an interval of at least two hours
between the administration of the drug to
the mother and nursing, (d) Atropine Sul-
phate.— Solution, 1-100. Subcutaneous in-
jections, gr. 1-200 — 1-120. Pronounced
symptoms were observed in the mother.
Dilatation of the pupils was noted in the
infant, which disappeared after twenty-four
hours. The drug should not be given to
nursing mothers except in very small doses.

Influence of Maternal Fever. — In an im-
mense majority of cases the milk has no ill
effects upon the child. When the mother
was the subject of a grave disease with a per-
sistent temperature of 104°, the fever curve
of the infant presented the same characters
as that of the mother. In a* case of mastitis,
Bumm has demonstrated the presence of
micrococci in the milk and gastro-intestinal
disturbance in the child. — Univ. Med. Mag.

ADMINISTRATION OF ANAESTHETICS TO
CHILDREN.

Dr. Ness, in a discussion published in the
Glasgow Medical Journal, reports 1080 cases
in which anaesthetics were employed at the
Hospital for Sick Children. In all these
cases careful notes were taken, and there
were at least a thousand more of which no
record was kept. Chloroform was almost
invariably used, ether being employed only
in exceptional cases. No death has ever oc-
curred during the administration of an
anaesthetic. The mode and details of ad-
ministration are not given. — N. Y. Med. Jour.

THE PREVENTION OF OPHTHALMIA IN
THE NEW-BORN. .

Simeon Snell, in the Lancet says, this it
appears established that the ophthalmia of
the new-born is a disease which permits of
distinct prevention, and that even careful
cleansing with plain water is sufficient.
There may be reasons against entrusting
such a strong solution of nitrate of silver as
Crede advocated to nurses, but a much
weaker solution would suffice. It may,
however, be perhaps as well to use some

May 30, 1 89 1. Periscope.

685

antiseptic with the water employed for
cleansing, in the manner used at the Jessop
Hospital. Directions are now freely given
to nurses and midwives as to the employ-
ment of antiseptics for the lying-in woman,
and the sublimate solution freely ordered
will do excellently for bathing the infants'
eyes. Some of us who see the terrible effects
of the disease are earnestly impressed with
the importance of doing all we can to pre-
vent its occurrence. As far as we are able
we must spread knowledge as to the dangers
of delay and the benefit resulting from
early treatment. The obstetrician has, how-
ever, the opportunity of preventing the dis-
ease. The teacher can find occasion to
bring the subject before his pupils, and the
writers of text-books, whether for medical
students, midwives, , or monthly nurses,
should urge the importance of the affection
and give directions as to the means neces-
sary for prevention. No text-book should,
he thinks, be published without some such
teaching. The disease is particularly met
with among the poor — much less frequently
among the well-to-do. Hence the impor-
tance of midwives, who by degrees are ac-
quiring a better* and more recognized status,
receiving thorough instruction in the sub-
ject.

HYGIENE.

CORROSIVE SUBLIMATE AS A DISINFECT-
ANT AGAINST THE STAPHYLOCOCCUS
PYOGENES AUREUS.

Dr. A. C. Abbott, in a study of this sub-
ject in the Bacteriological Laboratory, in
the Johns Hopkins Hospital, believes that
the following conclusions are justified :

L Under the most favorable conditions a
given amount of sublimate has the property
of rendering inert only a certain number of
individual organisms. That is to say, the
process is a definite chemical one, taking
place between the protoplasm of the indi-
vidual bacteria and the sublimate in the
solution.

2. The disinfecting activity of the subli-
mate against organisms is profoundly in-
fluenced by the proportion of albuminous
material contained in the medium in which
the bacteria are present.

3. The relation between the golden
pyogenic staphylococci and sublimate is not
a constant one. organisms from different
sources and of different ages behaving dif-
ferently when exposed to the same amount
of the disinfectant, for the same length of
time.

3. The organisms which survive the ex-
posure to the sublimate, may experience a
temporary attenuation. This attenuation,
however, may be caused to disappear by
successive cultivation in normal media.

IMMUNITY FROM INFLUENZA OBTAINED
BY VACCINATION WITH CALF LYMPH.

The Medicinische Nenigkeiten, April 18,
1891, speaks of the interesting researches of
Dr. Julius Goldschmidt, regarding the im-
munity from influenza, or grippe, afforded
with recent vaccination with calf lymph.
Dr. Goldschmidt's attention was first called
to the fact, when during the epidemic of
influenza of 1890, there occurred also a
good deal of small-pox in Madeira, and he
was surprised to find that those whom he
vaccinated escaped from the epidemic. In
all he vaccinated 210 patients, in 112 of
which the lymph took. Of the remaining
98, only 15 were seized with grippe, and
then only in a very mild degree. In one
household of twenty-six members, all who
were not vaccinated had the influenza, and
two of them nearly died, while twelve who
had recently been vaccinated escaped. The
author claims that the immunity to in-
fluenza shown by the majority of children
is due to the fact that they have been more
or less recently vaccinated.

At these times when the influenza seems
again to be premeditating an extensive tour,
these facts are not only of interest, but war-
rant our careful consideration.

MEDICAL CHEMISTRY

CONVENIENT URINE TESTS,

To test for albumin, Raabe uses trichlo-
racetic acid in the following manner. (Merles
Bulletin.) About one cubic centimetre" of
urine, previously filtered, is poured into a
narrow test tube, and a small crystal of
trichloracetic acid is dropped into it ; it is
then set aside for a while, without shaking.
The acid soon dissolves in the bottom of the
test tube, and at the plane of contact of the
two layers of fluid a distinctly visible and
sharply defined turbid zone forms, if albu-
min be present. Even the slightest quantity
of albumin can be detected with certainty
and promptness, because the contrast be-
tween the turbid zone and the supernatant
clear fluid is very distinct. According to
this author, trichloracetic acid produces no
precipitation in normal urine. Only when
the latter abounds in urates, a slight haze
develops after some lapse of time ; — this can

686

News and Miscellany.

Vol. Ixiv

be avoided, however, by gently warming the
urine, or by diluting it with three times its
volume of distilled water. He ascertained,
by comparative tests, that trichloracetic acid
is decidedly more sensitive, as a test for al-
bumin, than either nitric or metaphosphoric
acid.

According to Roch sulpho-salicylic acid
is a very sensitive and reliable reagent for
albumin. It is a product of the action of
sulphuric anhydride on salicylic acid. By
its means, the presence of egg-albumin can
be proved with certainty in a solution of
one part of the latter in 20,000 parts of
water. To test urine for albumin, all that
is necessary is to add a few crystals of the
readily soluble sulpho-salicylic acid to a few
cubic centimetres of clear urine and shake.
The appearance of turbidity indicates, with
certainty, the presence of albumin ; for all
the other constituents of urine — such as pep-
tone, glucose, urea, uric acid, etc., remain in
solution ; the albumin alone being precip-
itated by this reagent.

Certain substances which may be present
in urine, such as arsenic, salicylic acid etc.,
may interfere with the test for sugar, by
either the fermentation method or with
Fehling's solution. In order to eliminate
this source of error Bishop advises treating
the urine as follows : The urine is first
shaken with animal charcoal. As soon as
the fluid appears colorless, add baryta water,
boil, allow to cool, and filter. To the fil-
trate add cautiously a weak solution of
cupric sulphate in moderate excess, allow to
stand for one hour in a covered vessel, de-
cant and filter. To the clear solution add
H2 S water in excess, or better, transmit H2
S gas through the solution. Then filter,
apply a gentle heat to expel the H S which
may be present and again filter. The solu-
tion is now practically free from everything
which would interfere with the determina-
tion of sugar, and the operation may be
finished by either of the usual methods.

Nothnagel communicated at a recent
meeting of the Vienna Medical Association,
a paper received from Dr. Becker, of Cairo,
on a simplified test for sugar, which depends
upon the fact that the paper used for the
manufacture of visiting cards contains' a
large quantity of potash to make it heavier
and fuller. When this paper is brushed
over with a concentrated solution of sul-
phate of copper and then dried, the salt is
crystallized on the surface. If the urine
containing sugar is then added by means of
a bit , of wood and allowed to dry by the
action of the air, or by holding it over an

Argand burner (without browning the sul-
phate of copper), the latter is liquefied by
the water contained in the small crystals,
and the alkaline paper immediately pro-
duces the sugar browning reaction. The
more sugar the urine contains the darker the
color produced. The author considers the
test highly sensitive.

NEWS AND MISCELLANY.

HIGHER MEDICAL EDUCATION.

At the meeting of the Board of Trustees
of the University of Pennsylvania, held
May 21st, Dr. Pepper made an offer of
$50,000 towards an endowment fund of
$250,000, and of $1000 annually towards a
guarantee fund of $20,000 annually, for five
years, conditioned upon the establishment of
an obligatory graded four-year course of
medical study. This was accompanied by
a communication from the Medical Faculty,
pledging themselves to carry out this pro-
posal, and to enter upon the four-year
course in September, 1893. It was also re-
ported that the members of the Medical
Faculty had themselves subscribed{$10,000
annually for five years to the endowment
fund. The Board of Trustees expressed
warm approval of the proposed advance in
medical education, but postponed their
assent until the success of both funds had
been demonstrated.

The approaching completion of the fine
Laboratory of Hygiene, built by Henry C.
Lea, Esq., will render the medical facilities
of this school unequaled. It is to be hoped
that the neccessary pledges will be secured
promptly, as the interests of the entire com-
munity are deeply involved in the success
of this great advance, which will enable
medical students to obtain a thorough prac-
tical education in every branch of their pro-
fession.

THE SUPPRESSION OF QUACKERY IN
ITALY.

During the first half of 1890 the number
of complaints of " illegal exercise of the
healing arts " brought before the authorities
was 843. In 325 of these a conviction was
obtained ; in 145 the accused were acquitted.
What the result was in the remaining 373
cases does not appear, but it is satisfactory to
see that at least a considerable proportion of
the offenders were brought to justice. It is
to be hoped that the penalties inflicted will
be sufficient to deter not only the guilty per-
sons themselves, but others from pursuing
their evil ways. — British Medical Journal.

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THE

MEDICAL AND SURGICAL
REPORTER

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FOR TABLE OF CONTENTS, SEE PAGE V.

ARISTOL.

While possessing all of the virtues of iodoform, and many properties not claimed for the latter ARISTOL has
NO TOXIC INFLUENCE AND NO DISAGREEABLE ODOR.

The efficacy of ARISTOL has been widely tested by physicians and surgeons. As a simple dressing it now
HEADS THE LIST OF LOCAL REMEDIAL AGENTS, and the results obtained in the GREAT VARIETY
OF MORBID LESIONS for which it has been employed, have been wholly satisfactory.

ARISTOL has been widely commended for its special adaptability to all surgical and pharmaceutical
requirements. It may be used in the form of OINTMENTS, CRAYONS, SUPPOSITORIES, BALLS, OILS,
SPRAYS, COLLODIONS, POWDERS, PLASTERS, Etc., while it is equally suitable for TAMPONS, BAND-
AGES, GAUZE, and other topical appliances. Used as a powder, it forms AN IMPERVIOUS ANTISEPTIC
COATING, which gives it an exceptional value in ULCERATIONS, BURNS, Etc.

ARISTOL has been used with unqualified satisfaction by able and experienced clinicians in DERMATOLOGY,
SYPHILOLOGY, GYNECOLOGY, OPHTHALMOLOGY, Etc., and in all of those diatheses in whose course
such lesions supervene as call for ACTIVE, LOCAL MEDICATION.

ARISTOL is demonstrated to possess EXCEPTIONAL EFFICACY AS A CICATRISANT. In ULCERA-
TIONS, of whatever character they may be, in BURNS, and in ALL OPEN LESIONS, the efficacy of ARISTOL
cannot be overestimated.

Hence its great value in the DERMATOSES, the SOLUTIONS OF CONTINUITY dependent upon
PHTHISIS, SCROFULOSIS, SYPHILIS, VARIX and accessible TRAUMATISMS, and in the SUPPURATIVE
LESIONS following many inflammations. Its value in BURNS, as in all the operations of MINOR SURGERY,
is exceptional, while in DENTAL SURGERY it has given very valuable results.

Applied to the MUCOUS SURFACES of the NATURAL CAVITIES, in such conditions as PHARINGITIS,
RHINITIS, OTITIS METRITIS, URETHRITIS, etc., etc., ARISTOL gives the same excellent effects as in
tissue lesions.

^•sf** Physicians are respectfulty requested to test for themselves the accuracy of these statements, while reading
in our pamphlet of the results obtained by others. Pamphlet mailed to applicants.

The preparation of ARISTOL, theoretically simple, involves the greatest care and experience, and the word
<( ARISTOL" is the registered property of The Farbenfabriken, vormals Friedr. Bayer &= Co., in Elberfeld. In or-
der, therefore, to secure the desired effect of ARISTOL, it is important that the physician be certain that the
article used bears the name of these manufacturers, together with the name of W. H. Schieffelin & Co.

7f. H. Sc7iieffeli?i & Co.,

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THE

MEDICAL AND SURGICAL
REPORTER

No. 1788. PHILADELPHIA, JUNE 6, 1891. Vol. LXIV.— No. 23.

Clinical Lecture.

AMPUTATION BELOW THE KNEE— ARTI-
FICIAL ANUS-SARCOMA OF SHOUL-
DER—RADICAL CURE OF HERNIA-
CARCINOMA OF BREAST; RE-
MOVAL TUBERCULAR AR-
THRITIS OF KNEE-JOINT;
EXCISION OF KNEE-JOINT.

BY J. WILLIAM WHITE, M. D.

PROFESSOR OF CLINICAL SURGERY, UNIVERSITY OF
PENNSYLVANIA, PHILADELPHIA.

AMPUTATION BELOW THE KNEE.

Gentlemen : — Our first case this morning
is an old one, which I operated upon in last
Wednesday's clinic. I bring the patient
before you to-day merely to show you the
result of the operation, which — as you will
remember — was an amputation of the leg,
below the knee.

You see the results, so far, are perfect.
Not a drop of pus has formed ; and from
the one remaining drainage tube there has
been only a slight serous discharge. The
largest part of the wound has healed by first
intention. The flaps are also of good color,
and apparently well nourished. The
patient has only had an immaterial rise of
temperature, has a good appetite and looks
well. Had this been an ordinary amputa-
tion, these results would naturally have been
expected, since the operation was conducted
antiseptically. But the young man you see
before you was brought here for operation
in an apparently moribund condition, suffer-
ing from an aggravated case of gangrene
following a crush of the leg, and to get my
flaps I was forced to go dangerously near
the diseased parts. The results are a sur-
prise to me, for at the time of the operation
the patient's chances for recovery were very
slim. Even now we cannot feel justified in
giving an absolutely favorable prognosis,
although the probabilities are that a com-
plete ultimate recovery will be the result.

This case is an example of the value of anti-
septic surgery even in cases already gravely
infected. Not only can we almost invari-
ably prevent septicaemia or gangrene — but
even when those conditions pre-exist, can
frequently check their course. Such results
as these are always most gratifying.

ARTIFICIAL ANUS.

I shall as quickly as possible show you
the results of the other operations I per-
formed at the last clinic. I am glad to be
able to report that all are doing excellently
well ; not a drop of pus in a single case.

This man was operated upon for car-
cinoma of the colon. His condition was
truly a pitiable one. Besides the colon
being carcinomatous in almost its entire
length, he also had a recto-vesical fistula,
and was passing fecal matter through his
bladder. His sufferings were intense. I
performed colotomy, opening an artificial
anus in the left groin. The patient is now
doing well ; he has had several large and
comfortable stools through the artificial
anus, and the fecal matter in the urine is
growing less. What is now in the urine is
probably from feces that were in the lower
part of the colon before the operation, and
will soon disappear.

Of the course this can at best be only
considered a palliative operation, but it pro-
longs life and alleviates suffering.

SARCOMA OF SHOULDER.

This is also an old case, and has been
doing remarkably since the operation, which
was performed a week ago. The case was
one of sarcoma of the shoulder. The growth
was an enormous one, involving the shoulder
joint and humerus, necessitating a very
large wound and making the operation a
formidable one. To-day you see that the
wound has entirely healed by first intention
with the exception of one point in the track
of a drainage tube. There has been no pus,
and no material elevation of temperature.
The patient's condition is excellent, and she
is now practically out of danger.

687

688

Clinical

Lecture. t Vol. lxiv

RADICAL CURE OF HERNIA.

The last of the cases operated upon last
week was that of this man, over 70 years
old, who had a very large irreducible hernia.
It was undoubtedly the worst case I ever
operated upon. The results of the operation
can be fairly called perfect. Healing has
been entirely by first intention, and there is
no evidence of any return of the hernia.
This slight swelling over the wound is due to
oedema, not to a return of the hernia.
Whether or not the operation will prove
itself truly a " radical cure " remains yet to
be seen, but the prognosis is undoubtedly
good.

CARCINOMA OF BREAST.

The first case for operation to-day is one
of carcinoma of the breast. The patient is a
woman fifty-four years old. Before proceed-
ing to the operation let me tell you that the
two kinds of growths most frequently met
with in the breast, are sarcoma and car-
cinoma. The following points are valuable
for differential diagnosis. Sarcomata are
soft ; they occur before or during the middle
of life; the skin is free and not involved,
except that there is usually a venous en-
largement. Carcinoma, on the contrary,
usually occur late in life ; the skin is ad-
herent ; the growth is hard, and frequently
nodular, and the nipple retracted.

The latter symptoms are all present in
the case before us.

The first step of the operation is to make
two superficial incisions across the growth
in the form of a crescent. We then proceed
to dissect out the growth. One of the super-
ficial incisions should extend well down into
the axilla to facilitate the cleaning out of
this part. Never run the risk of including
diseased tissues in your flaps, or in your fear
of removing too much and leave infected
tissues behind. Also never fail to remove
such portions of the pectoral muscles as are
attached to the tumor.

One part of this operation which, fjr a
subsequently successful result, requires the
utmost care, is the thorough cleaning out of
the axilla. In these cases the neighboring
lymphatics are always infected and should
therefore be carefully removed. This part
of the operation is also by far the most dif-
ficult. Over the pectoral region we are com-
paratively safe, no large blood vessels being
near, but here, in the axilla, we are working
among a net work of large veins and arteries.
You see I not only remove the lymphatic
glands, but also any loose pieces of fat or
tissue ; in fact clean the whole axilla out,

leaving nothing that might act as a seat for
further infection.

Having now removed the growth, I bring
the edges of skin together, and find that they
approximate nicely. The wound is now
closed with a row of sutures and dressed an-
tiseptically, all bleeding points, which dur-
ing the course of the operation have been
caught by hsemostats, having been tied.

Before going to the next case, let me
reiterate the necessity of removing all dis-
eased tissue. It matters but little whether
the wound is entirely covered by skin or not,
but it is of the greatest importance that every
particle of diseased tissue be removed,
whether it be muscle, or gland, or skin.
Unless this is accomplished, your operation
will be worse than useless.

TUBERCULAR ARTHRITIS ; EXCISION OF
THE KNEE-JOINT.

The history of the young woman before
us is one of tuberculosis. Several members
of her immediate family have died of con-
sumption. The patient herself has been
suffering from an enlargement of the knee
for some time, and has faithfully tried
various methods of treatment, including the
rest cure. But to no avail, and she is now
practically a cripple, being unable to use
the limb in any way. From the family his-
tory and the local evidences, the case is
evidently one of tubercular arthritis of the
knee-joint and we will excise the joint.

You see I elevate the limb as high as pos-
sible to render it bloodless. This is often a
more satisfactory procedure than applying
an Esmarch bandage in such cases, as forci-
ble pressure could very possibly rupture a
distended capsule and drive tuberculous or
purulent material into the tissues above the
joint. Indeed, I have not unfrequently
seen this to be the case, and serious suppu-
ration follow in consequence. Then again,
there is nothing to be gained by the appli-
cation of the bandage, since the limb can
be rendered equally bloodless. This being
accomplished we now place an Esmarch
tube above the knee to control all possible
haemorrhage.

The operation of excision of the knee-
joint consists in making a straight incision
across the joint, turning up the flaps; re-
moving of the patella ; sawing off of the
condyles ; a thorough cleaning out of the
joint ; drainage ; an antiseptic dressing, and
the application of a suitable splint.

After having made my superficial incision,
and having removed the patella by sever-
ing its tendenous attachments, I find that

June 6, 1 89 1.

Clinical Lecture.

689

the under surface of this bone is necrosed.
The head of the tibia is also badly diseased,
as are also the condyles of the femur. I
find a large mass of synovial tissue and
other evidence of tuberculosis. This con-
firms our initial diagnosis of tubercular
arthritis of the joint. I am careful to re-
move all these infiltrated tissues, since if left
behind they would undoubtedly be new foci
for an extension of the disease. I divide
the lateral ligaments freely. I saw off1 a
good deal of bone from both the head of the
tibia and condyles of the femor, three quar-
ters of an inch at least, on account of the
necrosed and softened areas which extend
beyond the surfaces of the bones. You see
these fresh bone surfaces look healthy, and
straightening the leg, I find that they fit
snugly together, leaving the limb in a more
normal position. This operation is now
practically completed, care being taken that
all loose tissue is removed. Personally I
prefer to ligate all bleeding points, but many
operators depend merely upon pressure and
elevation for the arrest of haemorrhage.
The wound may now be closed, an antiseptic
dressing applied, and the limbs placed in a
well-padded Gooch's splint. The prognosis
is good.

THE TREATMENT OF SYPHILIS.

BY R. W. TAYLOR, M. D.

CLINICAL PROFESSOR OF VENEREAL DISEASES AT THE
COLLEGE OF PHYSICIANS AND SURGEONS, NEW
YORK.

Gentlemen: — I will now present to you
a man with the characteristic rash of a sec-
ondary syphilis. He is 24 years of age,
who had a gonorrhoea, a few months ago
for the first time, and a chancre seven
weeks ago, with no history of the period of
incubation.

I wish now to speak to you a few words
on the proper way of treating syphilis. In
the first place, do not treat the initial lesion
by the use of strong caustics, cold water
dressings, lead water, lime water, or the
black or yellow wash. Always bear in
mind that absolute cleanliness is the true
foundation of all treatment. When there is
any tendency to ulceration in the lesion, by
burning the parts vigorously you only cause
the inflammatory areola to break down in
ulceration at a later period. The very best
remedy to use for the initial lesion of
syphilis of all that I know of is iodoform,
and you get that in the pleasantest form

possible, under the name of Merck's iodo-
form. I wish to give you a point in this
connection. We hear a great many people
say that they cannot use iodoform on ac-
count of its odor, and it will be smelled by
everybody. If you use iodoform carefully,
and in small quantities, people will not be
able to detect its presence. In other words,
when you are dressing a chancre with iodo-
form, be careful that the iodoform does not
get on the clothes of the patient, put on
only sufficient to cover the sore, place a
piece of cotton over that, and then draw
the prepuce forward over the cotton. Then
you can use iodol or aristol, if you choose,
instead of iodoform, but neither of these is
as good for this purpose as iodoform.
Aristol is a good remedy to employ where
there is not a very active stage of ulceration
present.

If there is a good deal of hardness present
and the chancre is " lumpy " it is well to
wash the parts first with soap and water,
and then with a five per cent, carbolic acid
solution, dressing it with blue ointment.

When a man comes to you like this one,
it is your duty to make the unpleasant fact
known to him that he has syphilis as gently
as you can, but with all the seriousness that
the case demands. Impress upon him the
necessity of his continuing under treatment
for the next two years at least, and, in the
majority of cases, you will find, if they
start in with a good constitution, they
will come out cured of their trouble at
the end of that time. The idea that
syphilis is an incurable disease is based upon
the information that there is a diathesis be-
hind all the stages of this affection which we
are powerless to treat, and that our thera-
peutic measures are utterly useless in this
respect. There are some cases, however, that
will act badly, but by care and attention,
and with a knowledge of the proper remedial
agents, you will be able to tide them over
their difficulties in time. Then again, there
are other cases that, even with the best of
care and attention, this diathesis seems to get
the better of them and obtain complete mas-
tery for a long period of time. You must
bear in mind that syphilis is a constitutional
disease, the tendency of which is to lower the
vital powers and develop certain lesions
which may be the means of producing inva-
lidism in your patient and perhaps death.
It behooves people, therefore, who have syph-
ilis, to put their house in order, so to speak,
and keep their health up to the highest pos-
sible standard of development. This is in
reality the keynote of successful treatment

690

Clinical

Lecture.

Vol. lxiv

in these cases of syphilis. A man came to
my office the other day with a minute chan-
cre of the upper lip, so slight as to be hardly
recognized from a herpes. He had enlarged
submaxillary glands also. He told me he
had a project by which he could make a
large amount of money, and he wanted to
know if I thought he would be able to un-
dergo a certain amount of mental strain
which this scheme would devolve upon him.
I told him practically no, and informed him
that he was in a condition in which he was
not warranted to draw upon either his
physical or mental resources. That it was
his duty to husband his vital forces and not
draw upon them for present use. If a man
worries and bothers himself about the busi-
ness and cares incident to a financial life,
while under the influence of the syphilitic
infection, you can well understand that this
strain upon his nervous system is going to do
him harm, and your treatment of his case by
the therapeutic measures at your command
will not result in much practical benefit to
the patient. In treating a patient with
syphilis put him into as good a mental and
physical condition as possible, for, bear in
mind this one fact, that the effect of the
mind on the malignity of syphilis is very
great indeed.

If your patient be a drinking man he must
stop this habit, but it does not follow because
a man has syphilis, you shonld teach him
prohibition doctrines. There are a good
many of those men who are accustomed to
the use of a glass of beer or ale, and there is
no valid reason that they should not be per-
mitted to take a glass or two a day, if they
want to. They should be advised to go to
bed as early as practicable, avoid catching
cold and over-fatigue. In other words they
must not put their mental or physical
qualities to the test in the way of over-
fatigue or over-exertion. Time and time
again can I look back and see children grow
up to puberty vigorous and healthy, both
mentally and physically, whose parents I
have treated for syphilis years ago. It is
always well to impress these patients with
this hope of an ultimate cure, because there
are some whom you will find it difficult to
keep under treatment and observation for a
proper period of time.

If a patient with syphilis has some little
functional trouble, as for instance, a bron-
chitis, look out for that trouble. Having
this chronic infectious disease he is very
liable to have some pulmonary trouble added
thereto. It is always well for a patient with
syphilis to guard himself against exacerba-

tions or development of that infection and
in that way he will avoid the complications
of the disease.

Some of you, no doubt, have read in the
books that syphilis is largely a mathematical
problem, and by regarding it as an abstract
factor, they compute in figures the amount
of mercury required for this abstract prob-
lem. This is a very routine way of treating
this disease. Every case of syphilis is a law
unto itself, and a dose which affects one man
favorably, will affect another man unfavor-
ably. A dose which will remove the poison
in one patient will prove utterly powerless
in another.

In the case of this man before us who pre-
sents with the first general manifestations of
the disease you would not give him iodide
of potassium. This drug is contra-indicated
in the earlier stages of syphilis, except there
be some severe trouble of the brain or peri-
osteum. The proper way to treat this man
would be to give him a pill of the proto-
iodide of mercury, for of all preparations
of this drug for internal use the proto-iodide
of mercury is the best.

There is no necessity for the use of any
tonic in this case, though in a good many
patients you will find it very essential. As
a general formula you will find the follow-
ing a very good one : —

Ij^ Hyd. protoiodidi viii gr.

Ferri et quin. cit 5 jss

Ext. Hyoscami vi gr.

M. ft. Pill xxxii. S. Three a day.

If under the use of this medicine the
glands are going down the remedy is doing
your patient good, and you ought to keep
him on this treatment for a month at least,
but, if on the contrary, the remedy was not
acting properly and your patient was not
showing any signs of improvement under its
use, then you can increase the dose of mer-
cury to be given each time. You will
rarely have to give more than three grains
of the protoiodide of mercury a day and
four grains will be the maximum amount
you should give in the twenty-four hours,
for if you do not produce the desired effect
with that dose, you are not going to produce
it all. At the onset of the disease it is well
to give large doses of this drug and always
inquire of your patient how it is acting.
Ask him how he is feeling, whether he is
losing or gaining in weight, whether his
thoughts are clear and capable of the same
amount of mental strain as before the onset
of the disease, and these points in the treat-
ment of syphilis will be a guide for you in
your medication of the patient.

June 6, 1 891.

Clinical Lecture.

691

Some people will tell you that the guide
to the availability of mercury depends
entirely on the mouth. Such a view as that
is erroneous. If, after the use of mercury
for two or three weeks, you observe the con-
dition of the gums and find any trouble
there, touch them with the solution of iodine
and keep up the use of the mercury. The
mouth often becomes irritated by reason of
defect in it, and the mercury will be well
borne and produce its physiological effect if
you keep the mouth in a good state. It is
always a good plan to make peace with the
mouth under these circumstances. The tests
of the efficiency of your mercurial treatment
is then the rapidity with which the lesions
of syphilis vanish. It is well to give your
patient for the first two or three months the
protoiodide of mercury and then stop for a
while, giving him the iodide of potassium
and the tincture of gentian for a week or
two. If in the early stages of the disease
you cover four, five or six months with your
treatment, you are going to cure your
patients more efficiently than by giving
them an interval of rest in the early stages
of the disease. Every day during the first
year of syphilis is a matter of vital im-
portance, for during this time the disease is
more amenable to treatment than at any
other period of its history. Keep these
patients as persistently and as constantly as
you can during the first six months under
the use of the mercury. Old Ricord used to
say that he could cure syphilis in six months.
In many cases he no doubt would, because
he would keep the patient continuously
under observation and treatment.

There is a limit to the use of the proto-
iodide of mercury in syphilis. It is well to
give it for the first month or two and then
to use inunctions of the mercurial ointment
And here let me in this connection say a
word about the use of the pill, hydrargyri.
The blue pill is about as uncertain and
capricious a remedy as you can get. It
simply amounts to this, that when it is
pushed on the patient, it will produce saliva-
tion as rapidly as possible, but when it is
acting blandly, it is doing nothing at all.
It is one of those drugs that you do not know
in what way it is going to act. I have
studied this subject with great care for
many years, and I may say this, that the
therapeutic effect of the protoiodide of
mercury after two months of the disease is
absolutely nil. It seems to develop in the
system of the patient a tolerance for the
drug, and possesses for no longer period the
power of dissolving, destroying, or burning I

up these small round cells which constitute
the evidence of syphilis. Therefore, after
having given these pills for the time I have
stated, then begin with your inunctions of
the mercurial ointment. Take thirty, forty
forty-five grains of mercurial ointment and
have it thoroughly rubbed into the arm,
having previously washed it with soap and
water and then with a solution of car-
bolic acid. As the disease commences around
the blood vessels in its permeation through
the system and the lymphaties are its chief
channels of distribution it is, therefore,
always well to act on the glands whenever
you can do so. Therefore, have the axilla
well washed out and the ointment well
rubbed in there. If you see any irritation
over the parts cover it with Laselle paste
which is composed of two parts of starch,
two parts of oxide of zinc, with four of
vaseline, to which may be added four or
five per cent, of carbolic acid. In that way
you will keep down the dermatitis. In giv-
ing the ointment, it is a good thing to
have the whole neck up to the scalp rubbed
in with these inunctions, for in that way
you bring the mercury in contact with the
whole surface of the body. You are in this
way accomplishing two things, you are de-
stroying those small cells that develop in
the skin, and you are, at the same time, per-
meating the skin with the mercury which
is producing its effect on the glands. It has
been shown that by excising portions of the
skin near the genitals in parts remote from
the seat of the initial lesion you find small
cells in the skin under the microscope.
Therefore, you should bring your mercurial
ointment into direct contact with the whole
skin. You can cover the whole body in
seven or eight rubbings, but these rubbings
must be done faithfully and intelligently.
Having gone over the wThole body it is well
to give the patient rest for three or four
nights, and while he is taking the inunc-
tions it may be advisable to ask him if his
mouth is sore, if he has a diarrhoea, or pain
in the stomach, does he sleep well at night,
and is he nervous or depressed. If he re-
plies no to these inquiries, then that is all
right, and you are treating his syphilis
efficiently. Continue with your inunctions
till you have given your patient forty or
fifty rubbings, and as a general thing,
thirty-five or forty grains of mercurial
ointment, will be sufficient. In this
city, however, a patient cannot stand that
amount of mercurial treatment, but if he
were out in the open air with noth-
ing to do and free from care and busi-

692

Communications.

Vol. lxiv

ness, he can stand a good deal more of
this kind of treatment than if otherwise
situated. There is no law regulating the
amount of mercurial inunction you use in a
given case to guide you but your own judg-
ment. If your patient be a poor, weak, in-
dividual, perhaps twenty-five grains of the
mercurial might be enough, and if he be a
robust, vigorous man, he may require as
many as sixty grains. It is always well to
wait, before giving these inunctions, till the
secondary symptons begin, so that you may
know where you are, except where the
lesion may make its appearance on the
mouth or face of the patient and proves to
be a menace to the health of those that sur-
round him. While you are giving these
inunctions, you can make use of the stomach
for the purposes of tonic treatment. In
giving these patients treatment, impress
upon them the absolute necessity of rest
and recreation. During the summer -have
them go away to the country as long as pos-
sible, and as an aid to the inunction treat-
ment, let them take very hot baths in order
to produce free diaphoresis, or have them go
to the Turkish baths. Stimulating the cir-
culation and producing diaphoresis in this
way seems to scatter the mercurial ointment
throughout the system.

In some cases you will find that regional
treatment is necessary, and it may be neces-
sary to have certain parts covered with the
ointment all the time. Push this treatment
on for the first year with the mercurial.

But suppose that your patient cannot
use mercurial inunctions, what then is to be
done? In such a case as that you have a
sovereign remedy in the injections of mer-
cury. There is no preparation that I have
found, and I have been using it now for
over 23 years as an injection, that has given
me better results in this respect than the
bichloride of mercury. Get an ordinary
hypodermic syringe, keep it in the cleanest
possible condition, cleanse the surface of the
body you are going to inject, and then inject
under the skin one-sixth, one-eighth or one-
twelfth of a grain of bichloride of mercury
in ten minims of water, and in that way
where the stomach fails, where the inunc-
tions are inadmissible, you will find that
you have a remedy that will not disturb the
stomach, and will affect the syphilitic in-
fection favorably, while at the same time
preserving the stomach for the use of medi-
cines that will build the patient up. I
never experienced so much difficulty in the
treatment of these cases as I have had this

winter, and have found great help from
these injections.

Now to sum up the treatment of these
cases, I would say push on for the first year
your mercurials, giving your patient a
couple of weeks rest after the first six
months, and then toward the end of the first
year you can use your combination of mer-
cury and iodide of potassium, or the so-
called mixed treatment. The following for-
mula you will find very satisfactory :

Ijk^ Hyd. Iodidi, iij to ix grains.

Potass. Iod., iv 5 to vi 5.

Aquae, ad, 5 iv.

M. and S. A tablespoonfull three or four times a day as
the case requires.

Push this treatment on the second year,
and you will generally find that your pati-
ent will be cured. In the vast majority of
cases you will have the best result follow
such a treatment as I have here given you
in cases of syphilitic infection.

Communication.

THE SPECIFIC AND THE NON-SPECIFIC
TREATMENT OF PULMONARY
CONSUMPTION.1

BY THOMAS J. MAYS, M. D.

PROFESSOR OF DISEASES OF THE CHEST IN THE
PHILADELPHIA POLYCLINIC.

It goes without saying that the successful
treatment of pulmonary consumption de-
pends entirely on a correct and rational
view of its origin. On this ground, there
can be no division of opinion. Unfortu-
nately, however, one part of the profession
holds that the tubercle bacillus is the sole
cause of the disease ; while the other part
believes that the disease depends on numer-
ous other causes, and that the bacillus is
merely one of its products or concomitants.

Now, it must be confessed that diametri-
cally opposite opinions on a question of such
tremendous practical and public importance,
is no great credit to a profession which is
justly proud of her logical conquests, and
which rightfully rejoices in her scientific
achievements, and in her work of philan-
thropy. Especially is this a misfortune
when we consider that the whole difficulty
rests on an erroneous interpretation of the
fundamental terms which are involved in

1 Read before the meeting of the Pennsylvania
State Medical Society at Reading, June 3rd, 1891.

June 6, 1 891.

Communications.

693

the question ; and in endeavoring to prove
this, I desire it to be perfectly understood
at the outset, that I yield to no one in my
admiration of, and I might even say in my
veneration for those pains-taking explorers
who so patiently and assiduously devote
their life and energies to the investigation
of this fearful malady. But I do not re-
gard this as a question of personal reverence.
It is one which must determine the true re-
lation of the consumptive to his family, to
his friends and to society ; whether or not
he is to be looked upon as a center of infec-
tion, a source of danger, and liable to spread
the disease among those who are well.

Where then lies the fundamental misap-
prehension? It is (1) in affirming that, be-
cause a disease is capable of being commun-
icated from one animal to another through
inoculation, that, therefore, it must be con-
tagious or infectious among the human spe-
cies ; (2) in holding that the disease (tuber-
culosis) which is produced artificially in ani-
mals through inoculation, is the same as that
(consumption) which is naturally produced
in man ; and (3) in assuming, that, because
an immunity can be created in animals by
inoculations with a modified form of the
tubercle virus, the same can be done in
man. Furthermore, there is no warrant for
believing that a disease can be cured by an-
tagonistic inoculation unless it is clearly infec-
tious or propogated from man to man through
contagion.

The whole inception and progress of the
infectious theory of consumption rests on
animal experimentation, and recent history
still reverberates with the assurances that
the key to the cure of this disease was lying
waiting in the lap of the experimentalists,
whose dicta were to be blindly accepted
whether they accorded with clinical experi-
ence or not. I am a firm and positive be-
liever in the immense good which comes
from well conducted laboratory research,
and I think I have given sufficient practical
evidence of my high appreciation of such
work ; but I also recognize the fact that the
great bane of modern medicine is the ten-
dency to subscribe to the premature con-
clusions of experimentalists which are wholly
unsupported by bedside experience.

Professor Semmola of Naples, Italy, well
strikes the key-note of this error, when he
says {Med. Press and Circular, Feb. 25, 1891,
p. 195) : " It is painful to see these men car-
ried away with this enthusiasm of Koch's
fluid when they know that such a wide gulf
exists between theory and practice, and
when the very laws of scientific pharmacol-

ogy and rational therapeutics are violated.
The mistake exists in neglecting to see the
gulf that lies between the laboratory and
the clinic where all such fine dreams are
blasted."

I am free to say that the mortification of
professional pride, and the shock to public
confidence recently perpetrated in the name
of a specific cure for consumption, would all
have been, saved if we had raised our stand-
ard of treatment higher than the walls of
the laboratory, and planted it on the solid
and rational ground of practical experience.

I am not unmindful, however, that those
who indorse the contagion theory claim that
aside of experiments on animals, there is
ample clinical evidence to justify their belief.
Let us briefly examine these claims. Their
chief argument is the work of Cornet, who
investigated the death-rate from consump-
tion among the nursing members of the Cath-
olic convents and monasteries in Prussia,
and found that this disease causes 62.88 per
cent of all their deaths (Zeitschrifte fur Hy-
giene, vol. vi, p. 65). This is, indeed, a high
death-rate, but it does not demonstrate the
contagious nature of consumption. It mere-
ly shows, what was well known before, that
this disease prevails largely amoug those
who lead indoor and confined lives. Ac-
cording to Dr. Baer's research (TJeber das
Vorkommen von Phthisis in dem Gefdugnis-
sen, 1884) the death rate from consumption
among German prisoners is greater — rang-
ing from 64 to 90.9 per cent. Another
point Avhich destroys Cornet's conclusions
entirely, is forcibly brought out by Dr.
Baer's statistics. These show that prisoners
who suffer solitary confinement, and who
have, of course, no personal contact with
any outside sources of the disease are more
vulnerable to consumption by 20 per cent,
than those who are allowed to associate with
each other.

Another argument is that houses in which
consumptives died are centers of infection.
This is principally based on the research of
Dr. Flick, who believes from his investiga-
tions, that 20 per cent, of the houses in the
fifth ward of the city of Philadelphia are so
infected. It is interesting to observe, how-
ever, that Dr. Flick's conclusions are not
corroborated by other observers equally com-
petent who have studied the question of
house infection. Dr. Langerhans, who prac-
tised medicine for nine years in Madeira,
an island which is visited every winter sea-
son by about 400 consumptives, states (Zur
Aetiologie der Phthisie, Virchow's Arch i v.
1884, vol. 96. p. 289) that these invalids are

694

Communications.

Vol. lxiv

lodged, boarded, and in great part nursed
by English colonists, varying from 210 to
250 in number, who live in about 100
houses. The rooms which are occupied by
consumptives in the winter, are reoccupied
by the resident families during the summer
— thus insuring the closest intermingling of
the well with the sick. House infection
should certainly make its influence felt here,
but the health records which have been accu-
rately kept since the year 1836, show that
only four of the English colonists died from
consumption during all this time, and that
one of these suffered from the disease before
he came on the island.

Dr. Adams, of Colorado Springs, states in
a private communication to me, that Colo-
rado Springs has been a health resort for
about seventeen years, and comprises about
11,000 inhabitants, and that the majority of
the rooms in the boarding houses are, and
generally have been constantly occupied by
consumptives. Yet, after a diligent search
among the physicians of that place, some of
whom resided there from the first, he could
only find a record of seven cases of consump-
tion which originated there during this time ;
and so far as he could ascertain, none of
these were especially exposed — at least none
were husband, wife or sister who had charge
of another consumptive.

Dr. Haupt, one of the resident physicians
of Soden — a beautiful watering resort for
consumptives, in Germany, says that there
are one hundred and one families, whose
members with the aid of servants, lodge and
nurse consumptives and other invalids dur-
ing the summer seasons. During the win-
ter the same rooms are reoccupied by the
members of the landlord's families. This
has been going on for 33 years, and during
this time there were exposed to this contagion,
if so it may be called, 653 persons, fifteen of
whom died from consumption, but in most
of these the source of the disease was trace-
able to inheritance, to colds and exposure,
but none of them to contagion.

Now when these facts are connected with
other well known facts, such as the statistics
of the Brompton Hospital for Consumption
in London, and the Friedrichshain Hospital
in Berlin, which fail to show a single case of
contagion among 262 physicians and clinical
assistants, and 1017 nurses — the former dur-
ing 36 years and the latter during 16 years ;
the declaration of Dr. Detweiler, that dur-
ing 14 years not a single case of consump-
tion was contracted among the nurses and
employees in his hospital for consumptives
at Falkenstein ; or the fact that among a

collection of sixteen hundred and twenty-six
cases of consumption among married people
(for particulars I refer to my address on
Hygiene published in last year's Transac-
tions of this Society) the same disease ex-
isted in both couples only in 44 instances.
I think no further proof is needed to demon-
strate that consumption is not propagated
from person to person through contagion.

I hope I shall be the last one to deny to my
colleagues on the other side, the same honesty
and conscientiousness of purpose as I ascribe
to myself; but should this make me willing to
brush aside this weighty mass of clinical tes-
timony which is diametrically opposed to the
contagion doctrine, and to accept as my
guide, principles of treatment which are con-
ceived in theory and born of fancy, and
which have nothing to support them in bed-
side experience ? He who has been a diligent
observer during the last ten or fifteen years,
must be aware by this time that every specif-
ic measure which has been proposed for the
cure of consumption, from benzoate of soda,
and hot air inhalations to tuberculin, has
been a dismal failure, in spite of the fact
that they have all been shown to possess
strong anti-bacillary powers. Glance at the
beggarly results which have been obtained
from tuberculin. According to recent offi-
cial reports,1 fifty-five in number, issuing
from the clinics, polyclinics, and pathologi-
cal institutes of the Prussian University,
only about one per cent. (10) of 932 con-
sumptives, who received the specific treat-
ment were cured. This is, indeed, a very
diminutive proportion of cures when we re-
flect that all but one of the latter were in
the first stage of the disease. There cannot
be the least question that so far as the treat-
ment of consumption is concerned, the bacil-
lus theory leaves the profession exactly on
the same level wmich it occupied ten years
ago. Not only did it not advance the inter-
ests of pulmonary therapeutics, but it de-
flected research into channels of error, and
served as a barrier to an investigation of the
true causes of consumption.

Let us now relinquish the gloomy side of
this picture and turn to the hopeful ex-
periences of those who practically disregard
the teachings of the bacillus theory, and
treat the disease according to its clinical in-
dications. First of all I shall refer to the
experience of the late Dr. Brehmer in his
world renowned institution at Gorbersdorf, in
Germany. In 1887 he gives the statistics of

1 Die Wirksamkeit des KocJis schen Heilmitteh
gegen Tuberculose.

June, 6, 1891.

Communications.

695

150 cases of consumption which he treated,
12 of whom were in the first ; 80 in the sec-
ond ; and 58 in the third stage. Of these,
15.3 per cent, were cured, and 11.3 per
cent, in whom the disease was arrested. Of
those in the different stages he cured 50.
per cent, in the first, 20. per cent, in the
second, and 1.7 per cent, in the third stage
of the disease.

In 1888, he gives the statistics of 554
cases which he treated, of whom 49 were in
the first, 310 in the second, and 195 in the
third stage. Of those in the first stage he
cured 36.1 per cent., in the second, 9.7 per
cent., in the third, 0.5 per cent.

The results reported in the Sixth Annual
Report of the Adirondack Sanitarium, under
the supervision of Dr. Trudeau are not less
encouraging. Fifty-two patients were treat-
ed in the following stages : 21 in the first,
18 in the second, and 13 in the third. Of
those in the first, 13 or 61.90 per cent. ; in
the second, 2 or 11.11 per cent.; in the
third none were apparently cured1 — showing
a total of 28.84 per cent, cures. Besides
these it is shown that there are 11 cases, or
21.15 per cent, in whom the disease is
arrested, that is, in whom all constitutional
disturbance has disappeared for several
months, but in whom the bacilli, cough and
expectoration are still present. It may not
be too much to hope that a number, and
possibly most of the arrested cases will in
time go to swell the list of the cures.

Similar favorable testimony concerning
the non-specific treatment of consumption is
also attested by other institutions of a like
character, notably by that of Dr. Detweiler,
of Falkenstein. In fact such institutions
demonstrate that the successful treatment of
pulmonary consumption is no longer to be
disputed, and they show that no chronic
medical disease is so amenable to treatment
as pulmonary consumption.

A most interesting point in this question
is the fact that there is a consensus of opin-
ion as to the methods which bring about the
best results in the treatment of this disease.
The first is an institution in which the
patients are under the immediate and direct
supervision of intelligent physicians and
nurses. In regard to these Brehmer in no
uncertain tones says (Therapie der Chron-
isehen Lungenschivindsucht 1887, p. 93),
" Special institutions for the treatment of
consumption give the greatest promise of

1By apparently cured is meant when the rational
signs of the disease and the bacilli have been absent
for at least three months. I think it is but reasonable
to assume that sucli cases are cured.

cure." Dr. Trudean states (Transactions of
American Climatological Assoc., 1889, p.
168), " If anything is to be done for those
who are both poor and consumptive, it can-
not be done outside of an institution."
Many other physicians who have had ex-
perience of this sort are equally emphatic
in their opinion on this subject.

The second is rest, or at least a rigid con-
trol of the physical movements of patients.
On this subject Brehmer says (Mittheilungen
aus Dr. Brehmer' s Heilanstalt, 1889, pp. 43
and 45,) 'k This much I can assert that all
fatigue is an injury and a poison to the con-
sumptive. * * * The healthy individual
rests because he is tired, but the consumptive
must rest so that he cannot become tired."

One of the important instructions in Dr.
Trudeau's Sanitarium is, " When feverish,
patients will do well to make as little ex-
ertion as possible. Fatique, when induced
in persons still having active disease is sure
to be followed by loss of appetite, fever, ex-
haustion, and even sweating." (Trans.
American Climatological Assoc.,1889, p. 174.)

Dr. Detweiler, in his report for 1886,
states that every patient who is not confined
to bed must repose in the open air on a re-
clining chair throughout the greater part of
the day.

Dr. Volland, of Davos, who has had ex-
tensive experience in the high altitude treat-
ment of consumption declares (Die Behand-
lung der Lungen-schwindsucht im Hochge-
birge, p. 18) that rest in the open air is the
first duty of the consumptive patient, and
that, if he is able, he is allowed to sit out-of-
doors, and if not, he is confined to bed in a
wTell ventilated chamber.

This feeling to regard rest as such an im-
portant element in the successful manage-
ment of consumption is not confined to these
and other public institutions, but is also
shared by private practitioners, and it is
based on the sound pathological reason that
consumption is not a local disease of the
lungs, but one w7hich implicates the whole
constitution. A consumptive must be looked
upon as one verging on physiological bank-
ruptcy. His whole strength is already ab-
sorbed in the performance of the necessary
functions of life, frequently carried oq im-
perfectly. His digestion is weak, his bowels
may be disordered, sleep is restless and dis-
turbed there is a waste of tissue owing to the
fever, and his muscular power is impaired to
such a degree that a short walk or a small
amount of physical exercise saps his strength,
and may wholly disable him. Yet strange
and paradoxical as it seems, weak as he is,

696

Communications.

Vol. lxiv

he persists in the belief that exercise is the
one thing needful for his restoration. This
feeling is not confined to consumptives,
but lives in behest of a strong public senti-
ment. It is builded on the knowledge that
in health exercise gives strength. But what
an enormous difference between the body in
a normal state, and when suffering from a
chronic wasting disease like consumption !
The two conditions may be illustrated by
comparing a business man who is threatened
with insolvency wTith one whose credit is
good. If the former pays out as much as
he takes in, his finances will always be
in a crippled state, and he will be in
constant danger of going to the wall;
but if he halts — that is, if he diminishes his
expenses and maintains or increases his in-
come— his capital will accumulate, and in
time he will be able to compete with other
capitalists. But the business man whose
credit is unimpaired goes on and invests all
his surplus capital — that is, he exercises his
financial strength to the utmost limit of pru-
dence— and thereby enhances and improves
the integrity of the institution which he
represents. So it is with the taking of ex-
ercises. If this is to be beneficial, a certain
amount of strength must be possessed by
the individual before he begins it, and by
putting this strength to proper use it will
grow and accumulate ; but he who has no,
or very little strength at the outset, must
reduce his expenditures, or his waste, and
enlarge his income, or else go into physio-
logical bankruptcy. We must realize that
with the consumptive, it is wholly a question
of constitutional resistance ; that when he is
weak the disease is strong and advances ;
that when he is strong the disease is weak
and recedes; and that the force which he
expends in performing exercise deducts so
much from his total vitality, and allows so
much less for the body to cope against the
disease, and to perform the essential func-
tions of life.

Moreover, there is a perfect agreement in
these institutions in regard to the great
utility of supplying nutritious food in the
most concentrated form ; of reducing high
temperature with antipyrin, phenacetin, and
antifebrin ; of checking the waste which is
occasioned by cough, expectoration, sweats,
and diarrhoea ; of employing pneumatic and
climatic treatment; and in fact of every-
thing which goes to enhance the vigor and
vitality of the body.

I think I am justified in saying that
hard, cold, positive facts are the best crucial
tests to which a theory can be submitted in

order to ascertain its correctness. The
specific cure for consumption is utterly con-
demned, when compared with the general
treatment of this disease on such a basis.
How would mercury rank as a specific in
syphilis, or quinine in ague, if their cura-.
tive results were as hapless as those of tuber-
culin ? Even if a specific cure for consump-
tion were possible, it is difficult to see its
need in view of the large number of cures,
as I have shown, are annually made by
other means. From my own personal ex-
perience, I can testify that there is no
chronic disease which responds more readily
and more promptly to persistent and well
directed general treatment than pulmonary
consumption ; and there is no reason to
doubt that with the advance of the scientific
study of the disease the percentage of cures
will increase. A specific cure for consump-
tion is not of so much consideration now as
a study and a development of the lines of
treatment which have been shown to hold
out such a magnificent measure of enduring
success.

One more thought and I am done. Ever
since the failure of tuberculin became gen-
erally palpable, there arose a feeling in the
minds of many of his followers, that Dr.
Koch had made a serious mistake in the
practical application of his theory, and that
eventually great therapeutic results are
bound to flow from it. Dr. Koch is not in
error, but is more consistent than many of
his disciples who follow him in the distance.
He has a logical belief in his theory, and
knows what the practical application of
tuberculin implies better than any other
living being. There cannot be the least
question concerning his ability to cure by
inoculation, the disease which he artificially
induced in animals; and if consumption in
man were caused through contagion or inoc-
ulation, or was of the same nature as the
disease which he produced in animals, it
would be perfectly reasonable to hope that
he could cure the consumption in the human
family. But the disparity which exists be-
tween that which is and that which seems,
is a vortex which has stranded and annihi-
lated many an idea. This is not. the first
time that the contagion theory of consump-
tion has come to grief. A century ago the
government of Naples concluded that con-
sumption was an infectious disease, and
practised the most rigorous isolation of those
who suffered from this disease, for more than
fifty years. The results were abominable.
Reliable historians inform us that besides
causing untold misery, these laws were not

June 6, 1 89 1. Communications.

697

of the slightest service in diminishing the
death rate from this disease.

Should we not profit by these dearly
bought experiences ? Is it not high time that
we take an account of our bearings and begin
to recognize that he who hugs the delusion
that consumption will be cured or prevented
through the miraculous operation of some
anti-bacillary agent or process, will only live
to reap " from the hopes which around him
he sows, a harvest of barren regrets ? "

THE ELECTRICAL TREATMENT OF FI-
BROID TUMORS— WITH AN ANALYSIS
OF FORTY-SIX CASES. *

BY G. BETTON MASSEY, M D.;

PHILADELPHIA.

The progress of the Apostoli method of
treating fibroid tumors of the uterus presents
both analogies and contrasts to those of some
of the recent theapeutic claims that have
been widely investigated by the medical
world. Recognized at last owing to the per-
sistent agitation of its originator, it was, like
the Brown-Sequard and Koch remedies, en-
thusiastically adopted by those pioneer ad-
vocates who often make up for crudeness of
training and inexactness of observation by a
debt of stimulated progress laid upon subse-
quent workers. In contrast to the theories
alluded to, it has since borne the test of ca-
pable exj3eriment to an extent that even
exceeds the original claims, and with the
broadened use of electricity in other allied
conditions, has made a new departure in
gynaecology. Unlike them, also, it has en-
countered an opposition of unparallelled
fierceness, an opposition, nevertheless, that
has been as healthy as it has been fierce. The
cause of this unusual attitude towards a new
remedy is easily seen in the recent extension
of abdominal surgery, and this highl 7
favored disease has heretofore been treated
to a rivalry of methods that cannot be other
than productive of the best results. Far
from regretting this rivalry, I indeed point
to it as an important index of medical de-
velopment, and cannot but regret that other
therapeutic efforts now blindly accepted are
not subjected to similar tests. I do regret
the intemperate statements of certain extreme
opponents. Undermined in their wholesale
and indiscriminate resort to dangerous oper-
ations by the attention bestowed upon a
milder and non-dangerous method of en-
forced atrophy, they have been invariably

* Read in the Obstetrical Section, American Med.
Assoc., May 7, 1891.

the aggressors in controversy, condemning
in unmeasured terms a method of which they
knew nothing. This is in striking contrast
to the position of electro-therapeutists, who
willingly concede to surgery certain cases
unsuited to electrical treatment yet demand-
ing active help.

Experience is alone the final arbiter, and
in view of the many cases of symptomatic
cure and reduction, and the considerable
number of those who that have disappeared
under electrical treatment, now on record,
it is in order for those who advocate an ex-
clusively surgical treatment to come forward,
not with wet specimens just removed from
patients who may die subsequently, nor even
mere reports of recoveries and deaths from
the operations, but with full reports of the
ultimate results in each case that withstood
the operation of oophorectomy arid hysterec-
tomy. The profession is not simply inter-
ested in the average mortality of these oper-
ations for comparatively benign tumors, but
wishes to know also the results in the resto-
ration of health and comfort to these pa-
tients. For instance, some careful operator
should tell us how often removal of the ap-
pendages for bleeding myomas fail to con-
trol the haemorrhages ; how often this pro-
cedure in patients approaching the meno-
pause is followed by mental disturbance ;
how often a successful hysterectomy is fol-
lowed by abdominal fistulas, intestinal ad-
hesions, hernias and other sequela? that are
as troublesome and painful to the patient as
the benign tumor itself had been. Until
such statistics are collected there can be no
true comparison of surgical and electrical
methods, as the latter refer only to results
that are always more or less remote from the
remedial procedures.

As an illustration of the results of electri-
cal treatment of these growths I have an-
alysed the histories of forty-six cases treated
consecutively by myself, in which I have
considered the conditions present at the be-
ginning of treatment, the nature of the treat-
ment, and the results as ascertained at various
periods after the cessation of treatment.

A study of these cases will show that seven
cases should be eliminated from considera-
tion in this paper because two were polypoid
and their delivery per vaginam was merely
assisted by the electrical applications made,
and five were treated for so short a time or
were so soon lost sight of that it is impossi-
ble to use them in demonstration.

This leaves thirty-nine cases that had more
or less thorough treatment and in which the
results have been ascertainable. These are

698

Communications.

Vol. Ixiv

divisible into five classes in the matter of re-
sults attained :

Class I. Cases of complete anatomical and
symptomatic cure, the tumors disappearing
and the patient being restored to health. Of
this class there were five cases.

Class II. Cases in which the tumor was
considerably diminished in size and all other
symptoms were cured. Of this class there
were twenty-three.

Class III. Cases in which the tumor was
not diminished in size but all the symp-
toms were relieved, or in which the tumor
was reduced but the symptoms were not re-
lieved. Of this class there were eight.

Class IV. Cases in which the tumors were
not diminished nor the symptoms relieved.
Of this class there were two.

Class V. Cases made worse by the treat-
ment. Of this class there was but one.

PERCENTAGES.

Based upon the thirty-nine cases of
thorough treatment, therefore, it will be
seen that 12.8 per cent, resulted in a com-
plete cure and disappearance of tumor ; 79.4
per cent, in symptomatic cure with or with-
out reduction in size ; 5.3 per cent, were un-
affected ; and 2.5 per cent, were made worse.
Omitting the case that was made worse
since it was fibro-cystic and should not have
been treated, the successes amount to 95 per
cent, and the failures to five.

The prevalence of the several varieties of
tumor in the series is shown in the following
table :

I. Complete disap-

pearance

II. Symptomatic

cure and
reduction.

III. Symptomatic
relief without

reduction.

IV. Unaffected by
treatment.

V. Made worse.

Intra-mural.

Intra-mural.

Subperitoneal.

and sub-

5

peritoneal.

15

3

6

1

THE FAILURES.

Of the two cases unaffected by the treat-
ment, one was that of a patient who had
two painless, movable, subperitoneal growths
attached to the uterus by long pedicles.
There was absolutely no symptom whatever
of these tumors, beyond the mere fact of
their physical presence, and as they were
not situated favorably for electro-puncture
and were giving no trouble anyway they
were left alone, after a thorough trial of
mild intra-uterine applications. No. 33 was
a large, kidney-shaped subperitoneal tumor
attached to the anterior surface of the

uterus and lying between the latter organ
and the bladder. As the bladder was spread
out in front of it, preventing puncture,
resort was had to long continued vaginal
galvanic alternatives. Under these the
tumor was released from the pelvis, but the
patient was not sure that she felt any better.

The case made worse was No. 3, a large
intra-uterine fibrocyst which was treated be-
fore it was pointed out by Apostoli that this
form was liable to be made worse by elec-
tricity. The death from septicaemia did
not occur until sometime after the cessation
of treatment and during attempts to extract
the mass surgically by piece meal. The
case resembled closely the one described by
Emmett at page 587, of his work on the
Diseases of Women, in which it is stated
that death also occurred during attempts at
extraction. Though sent to me by an ex-
pert surgeon my own case would have been
far better treated by hysterectomy than by
any form of electricity.

METHODS.

It will be noticed that six cases were
treated by puncture. The greater number
of these punctures were of the kind that has
been designated as " buried " — a variety of
puncture that was originated by myself, and
one that I think more powerful and safer
than that described by Apostoli. Unlike
the Apostoli needle, which is only insulated
by a movable sheath up to the point at
which the puncture is made, my own needle
is insulated by vulcanized rubber to within
one centimeter of the end, with a view of
preserving the track made by it through
healthy tissue from an electrolytic softening
that would prevent immediate union. Punc-
tures made in this way have been proven by
me to heal in three days in spite of the use
of 150 ma. at the point within the fibroid
tissue, while the older form of puncture
usually remains unhealed for a week or
more.

No unpleasant reactions followed any of
the punctures, which were sometimes ex-
ceeding an inch in depth, and while I do
not think that any but those skilled in it
should attempt this method, I do not hesi-
tate to employ it myself in those rare cases
that are adapted to it. None of the cases in
which the tumors disappeared were punc-
tured, but this was merely because their
intra-mural situation neither required nor
permitted it.

The intra-uterine method is certainly the
method of choice, and with gentleness, and
especially the use when possible of the

June 6, 1 89 1. Society

elastic electrode devised by me, is free from
risk in all cases except those complicated by
acute inflammatory conditions. I have
been disposed of late to increase the intervals
between these applications to five or more
days, interspersing one or more vagino-ab-
dominal treatments for their contracting
effect.

The vagino-abdominal galvanic alterna-
tives that have been advocated by Danion
of Paris have a considerable value when
neither of the two better methods are avail-
able. I have seen reduction occur during
the use of this method in several cases, and
can testify to its power over inflammatory
conditions in the pelvis.

As will be seen from the notes of some of
the cases, persistent treatment has at times,
been the keynote of success, though the best
results were often attained in a short time.

Society Reports.

NEW YORK NEUROLOGICAL SOCIETY.

Meeting of May 5th, i8qi.
The President, Dr. L. C. Gray, in the Chair.

The Bach in Railway Spine. — Dr. F. X.
Dercum, of Philadelphia, read a paper with
this title. He said that it seemed to him
in discussing railway injuries, the physical
condition of the back had not been suffi-
ciently dwelt upon. It was certain that
more had been said pro and con upon in-
juries of the spinal contents, and far more
still upon the subject of traumatic neuroses.
It had been the speaker's fortune to examine
a large number of railway and allied in-
juries, and it had appeared to him, that the
condition of the back was often poorly
understood and often unappreciated, while
important points were sometimes entirely
overlooked. Further conditions were occa-
sionally observed which were difficult of ex-
planation, and it was to these he wished to
call attention. It was well known that pain
of various kinds was met with in railway
cases, but he wanted to exclude from the
discussion all pains, the existence of which
could not be confirmed by any physical evi-
dence and which rested solely upon the un-
supported statements of the patient. On
the other hand all pain, signs of which were
evoked without previous warning or sug-
gestion should be rigidly admitted. He
strongly advised the thorough examination
of all such patients by superficial and deep
pressure and by blows, as by this means in-
formation of decided character, might be

Reports. 699

gained in cases otherwise obscure. Another
important method of test was by motion.
In regard to pain elicited by voluntary
motion, the objection might be urged that
here an opportunity was presented to the
malingerer. There were, however, so many
other means of ascertaining the truth that
difficulty in arriving at definite conclusions
would rarely be experienced. Much de-
pended upon the manner in which the
various tests for motion were applied.
These tests consisted of flexion forwards,
lateral flexion, torsion and transmitted
shock. Having first practiced palpation and
pressure, and gleaned such information as
could be obtained from these sources, with
the patient standing before us the back
should be closely inspected. Following this
the tests for motion should be gone through.
After having briefly considered the various
tests for eliciting pain, he said that not only
was it possible with due care to settle the
question of the genuineness of the symptoms
by any one of the methods detailed, but it
was also evident that there must be a gen-
eral correspondence in the results of all the
methods. We should expect fijr instance
that the area of pain upon deep pressure
would correspond, other things being equal,
to the area of pain on motion, or that the
region of pain elicited by percussion would
correspond to the region of pain elicited by
transmitted shock. The speaker then de-
tailed the histories of six cases bearing upon
the question. The various symptoms pre-
sented by these cases could be conveniently
grouped as follows : first, those due to the
physical condition of the back ; secondly, the
symptoms of functional derangements and
asthenia; and, thirdly, those that presented
psychic and hysterical symptoms. To the
first group belonged : first, pain on deep
pressure; secondly, pain on motion and
transmitted shock ; thirdly, muscular spasm
and rigidity ; fourthly, muscular weakness.
Now the pain elicited by pressure, motion,
or shock, was evidently the result of a deep
seated injury, either to the ligaments of the
spinal column, or to the muscles, probably
to both. Practically, it was impossible to
differentiate between the two, nor was it im-
portant to do so. To muscular spasm and
rigidity were to be assigned the same value,
which was assigned to the muscular spasm
observed in a sprained, dislocated or broken
limb. The muscular weakness resulting
occasionally in lordosis, was to be ascribed
to the general weakness resulting from the
shock, and also to the direct effect of the
trauma upon the muscles themselves. To

700

Society Reports.

Vol. Ixiv

the group of symptoms of functional de-
rangements and asthenia, belonged the
various symptoms of general weakness, both
mental and physical, tremor, sweating,
inability to properly expel or to retain the
urine, etc. To the group of psychic and
hysterical symptoms was relegated the
hypochondria, the night horrors and the
convulsions. One important problem, how-
ever, still presented itself, and that was why
it was that some of these cases did not at-
tain their maximum severity for days and
weeks after the accident. It was thought
exceedingly probable that there was a
direct extension of inflammation from the
original site of the trauma along the sheaths
and tendons of the muscles. It was difficult
to escape from this inference, inasmuch as
there was a marked spread in the area of
pain on deep pressure. Hand in hand with
this, there was, beyond doubt, a radiation in
the muscular spasm, a radiation too which
might reach not only muscles immediately
adjacent, but those even relatively remote,
such as muscles of the abdomen or of the
shoulder. As to the question of duration
of the symptoms it was impossible to give a
definite answer. It was a question of
probability, and of degree, and therefore one
in which legitimate differences of opinion
might obtain ; however, taking the cases the
speaker had seen, it was evident that chro-
nocity must be admitted as established be-
yond cavil. In regard to the disappearance
of so-called "litigation symptoms" made so
much of by Page and others, the speaker's
observations had been that when a claim for
damages had been settled, the mental con-
dition improved very much. A man who
perhaps was poor, was suddenly raised to a
condition of relative wealth. No wonder
that hypochondria often disappeared and
was replaced by buoyancy and exhaltation,
it would be strange indeed if it were other-
wise. After a while, however, he had seen
the old mental condition partly re-establish
itself, while the physical condition had
undergone no change save that which could
be accounted for by the slow repair of time.
Lastly, the cases which had been presented
were selected because of the marked and
pronounced condition of the back. He did
not wish to create the impression that every
case should present the back symptoms to
an equal degree in order to be considered
genuine. As a matter of fact, in a large
number of instances of bona fide railway
back, the symptoms were far less evi-
dent than is the cases detailed. Finally

he repeated that careful application of the
various tests for eliciting pain and spasm
could not fail to evoke a reply if trauma be
really present.

Dr. G. M. Hammond called attention to
a train of similar symptoms to those de-
scribed by Dr. Dercum to be found in a
modified form among athletes. This was
especially the case with those who practiced
jumping and running. He had seen several
instances in which the patients complained
of pain in the back and deep seated pain on
pressure, and on stooping forward. There
would also be exaggerated reflexes. These
symptoms would persist for months while
the individual was practicing his exercises.
In jumping the foot struck the ground in
the take-oft' with considerable force. In
running long distances the repeated jar from
the foot striking the ground would be trans-
mitted to the spinal cord. Indeed it was
his opinion that the symptoms he had met
with were due to long continued transmitted
concussion to the cord. After examining a
great number of athletes he had invariably
found that the knee-jerk was exaggerated,
particularly among those who ran and
walked.

Dr. E. C. Spitzka referred to some prac-
tical features of the paper and particularly
to the tests used to locate the sprain. Con-
clusions drawn from a large number of
cases were contradictory and the matter to a
certain extent still obscure. Lateral flexion
and torsion and transmitted concussion were
of the utmost value. Within a year the
speaker had seen one case of almost fatal
collapse from severe transmitted concussion.
The spinal deformity was often very slight
and escaped observation while producing
serious nervous symptoms due to slow hyper-
trophic changes.

Dr. A. D. Rockwell said that concussion
of all kinds might be immediately followed
by complete paralysis. When he was sur-
geon in the United States Cavalry in the
late war, one of the men was injured while
his horse was jumping a ditch. There was
complete paralysis at once, the man being
carried for several days in an ambulance.
Partial recovery gradually took place. The
speaker saw the man again a short time ago
learning that he had always been more or
less of an invalid, suffering from pain in
the spine on pressure, melancholia and neu-
ralgic symptoms. This condition had been
present ever since the time of the injury.
As to the treatment of cases such as the
author had described he thought that the

June 6, 1 89 1. Selected Formulce.

701

actual cautery when properly applied gave
the best results. He had used it in the in-
stance narrated with direct benefit.

Dr. Dercum thought the tendency was to
look for some other cause for these symp-
toms, other than the right one. If the phy-
sician would examine the spinal columns
more carefully in patients complaining of
the symptoms he had described diagnostic
points would usually be determined.

Selected Formulae.

FORMULA FOR WHOOPING COUGH.

Talamon, in the Med. Moderne, gives the
following formula for whooping cough :

Ijk? Terpini hydrati r.0-1.5 grammes

Antipyrini 1.0 gramme

Syr. aurant. cork 50.0 grammes

Aquae Tiliae 60.0 grammes

M. eft. Sig. One-half to one teaspoonful frequently during

the day, for a child from one to four years of age.

ANTI-DYSPEPTIC POWDER.

Dujardin-Beaumetz, in the Union Med.,
gives the following formula, which he calls
an " anti-dyspeptic " powder :

JJk? Magn. sulph

Cret. praepar

Calc. phosphor aa 10. 0 grammes

M. et. div. in chart No. xl.
Sig. One powder before meals.

NITRATE OF SILVER IN CATARRHAL
ICTERUS.

Dr. Niecechi, in Medicina, claims that
nitrate of silver is specific in catarrhal
icterus, checking all symptoms immediately.
He gives the following formula :

J^k£ Arg. nitr 0.06 gramme

Aquae dest 180.00 grammes

Sig. One tablespoonful three or four times a day. The dose
may be repeated if not efficaceous. A rigorous anti-catarrhal
diet should be enforced.

SUMMER DIARRHOEA.

i^k; Resorcin... gr. iss,— gr. iij

Infus. chamomil ounces ij

Tr. opii. gtt. ij

Tr. cascarill gtt. xv

M. Sig. Teaspoonful every two hours.

— Kinder-Arzt.

PILLS FOR DYSENTERY.

The following pills used in the treatment
of dysentery have given satisfactory results :

Powdered ipecac gr. iv

Calomel gr. jss

Extract of opium...., gr. j

Make into three pills, and give one each hour, in the treat-
ment of diarrhoea or dysentery due to exposure to heat.

— Medical News.

APHRODISIAC PILLS.

According to the Journal de Medecine de
Paris, Lutaud employs the following for the
purpose of producing sexual stimulation :

-E^? Powdered nux vomica % grain

Bromide of iron , 15 grains

Phosphorus % grain

Excipient a sufficient quantity.
Make into twenty pills and take one each night.

In addition to this treatment the patient
should resort to hot and cold douches and
gymnastic exercise, massage, and systemic
tonics, and frequently coca will be found
of value, as in the opinion of Lutaud this
drug possesses very distinct aphrodisiac
powers.

SALICYLATE OF' MERCURY.

This remedy is one which has been largely
neglected, despite the fact that it is useful
to a high degree. One of the great draw-
backs which attended its use was the impos-
sibility of dissolving it in water without the
addition of alcohol or of chloride of sodium.
Otherwise this salt has antiseptic powers
equal to corrosive sublimate, and is devoid
of the latter's bad qualities. M. Vacher
has overcome the difficulty of making a
solution (Medicine Moderne) by obtaining
salicylate of mercury through the double
decomposition of a mixture of corrosive sub-
limate and salicylate of soda in water. In
addition to the salicylate of mercury, a
chloride of sodium is formed wl?ich makes
the solution a stable one. This solution is
not irritating, contains no alcohol, and may
be used for various purposes according to
its strength.

For external use the following formula
may be employed :

Ijk? Hydrarg. bichlorid gr. iv

Sodii salicylat gr. viij

Aquae oz. viij M.

If a weaker solution is desired, the follow-
ing way be ordered :

Ij^ Hydrarg. bichlorid gr. j

Sodii salicylat gr. ij

Aquae oz. x M.

For hypodermic injections in the treat-
ment of syphilis, M. Vacher injects one
cubic centimeter of the following solution,
which has given him the best results :

Ijkj Hydrarg. bichlorid gr. v

Sodii salicylat gr. x

Aquae destillat oz. j M.

One cubic centimeter contains three-twen-
tieths of a grain of salicylate of mercury.
The injection is not painful, and is never
followed by abscess. Internally, a table-

J02

Selected

Formula.

Vol. lxiv

spoonful, or slightly more, of a one to a
thousand solution may be administered. — St.
Louis Med. and Surg. Journal.

OINTMENT FOR ECZEMA.

1^ Thymol \ Top grains T

Oxide of zinc, ) , ,

Starch, ) °* eacn ° drachms

Lard \y2 ounce

Apply twice a day to the affected part.

— Journ. de Med. de Paris.

WHOOPING COUGH.

For use at time of the paroxysm, Wilde
recommends the following mixture, a tea-
spoonful of which is to be poured upon a
compress and cautiously held near the child's
mouth :

1^ Chloroformi f * j

^Ether. sulphuric, purif. f. g ij

Ess. terebinthinae rect f. 5. Hss

— M Union Medicate.

FOR EXTERNAL HEMORRHOIDS.
Washing them with a solution of corrosive
sublimate the strength of 1 to 1,000 or of
carbolic acid, 1 to 50. After this the fol-
lowing salve may be applied :

Iodoform grS- v

Extract of belladonna grs. viij

Vaseline g j

SUBINVOLUTION OF THE UTERUS.

Professor Barton Cook Hirst, of the Uni-
versity of Pennsylvania, recently gave the
following as the best combination to use :

1^ Strychnine sulphatis gr. 1-20

Quininae sulphatis gr. ij

Extract ergotae gr. j

M. ft. pil. No. 1.

Sig.— At one dose. To be repeated thrice daily.

UTERINE WAFERS.

1^ Hydrarg bichlor gr. 1-16

Sulphate zinc grs. v

Sub nit. bismuth grs. xv

Pulv. gum arabic grs. v

Carbolic acid grs. iij

M. Pulverize the zinc ; then add the rest of the ingredients,

with q. s. water to make into a conical shape for a vaginal

suppository.

This formula is offered to the profes-
sion as practically duplicating the Micajah
medicated wafers. This formula, with the
exception of the bismuth and acacia, has
been used by the medical profession for a
long time for onychia, etc. U. S. Dispensa-
tory, 12th edition, Wood & Bache, page
1,115 ; used by Drs. Perkins and Physick.

TREATMENT OF BALANITIS.

Dr. W. R. Chichester states that he has
obtained good results from the employment
of the following (Med. Bee.) :

Ij^ Atropiae sulphatis gr. i

Zinci sulphatis gr. ij

Acid, boracic... gr. v

Aqua? destillat 5 j

M. Sig. Ayply two or three times a day with a brush.

He further states that this is open to any
modification which the case suggests.

OX-GALL.

The following prescriptions containing ox-
gall are recommended :

Ijk^ Fellis bovis purificati,

Magnesii carbonatis, aa c.

Ol. menth. pip., mj.
M. et ft. capsulse No, xx. Sig., a pill three or four times a
day, after meals. Use in dyspepsia and constipation.

Ijkj Fellis bovis purificati 5j

Ext. nucis vomicae gr. j

Aloini , gr. j

01. cinnamomi m]

M. et ft. pil. No. xx. Sig., two pills between meals. Ser-
viceable in torpor of the liver and in dyspepsia.

—Med. Bee.

INFANTILE CONVULSIONS.

J^k? Choral hydratis gr. iv

Potassii bromidi gr. viij

Aquae

Syrupi aa dr. j

M. Sig. One dose for a child, aet. two.

— Jacobi.

2^ Pepsinae gr. xii lo xxiv

Hydrarg. chlor. mit gr. ss to j

Sacch. lactis q. s.

M. et ft. chart. No. xii.

Sig. One powder every three hours after nursing.

-1^ Ex. Pancreatis ...5ss to j

Hydrarg. chlor. mit gr. ss. toj

Sacch. lactis q. s.

M. et. ft. chart. No. xii.

Sig. One powder every three hours immediately before or
after nursing.

— Annals Gyncecology and Paediatrics.

TREATMENT OF WHOOPING COUGH.

Loffler recommends the following solution
to be used in the treatment of whooping
cough :

1^ Freshly prepared chloride of

silver 1% grain

Water ..7. 2 pints

Hyposulphite of Sodium, a saturated solution.

Use by an atomizer, the liquid being
directed into the pharynx. Kepeat the ap-
plication every two or three hours. This
treatment is both prophylactic and curative.

June 6, 1 89 1. Editorial.
THE

MEDICAL AND SURGICAL

703

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Leading Article.

INTRA-UTERINE STEM PESSARY.

During the past few years, very little has
appeared in current literature concerning
the intra-uterine stem pessary, and it is evi-
dent that its use is being more and more
restricted. Not many years ago the stem
pessary was regarded as an indispensable in-
strument in the treatment of certain forms
of flexions and versions of the uterus. Now,
it is equally true that to most of the present
generation the instrument is known only by
having seen a cut of it in a text-book. In-
troduced and abandoned by Velpeau, re-
introduced and abandoned by Amusat, it
was forced upon the notice of the profession
by Simpson, in 1848. For twenty years it
was lauded or condemned by gynecologists
of prominence, but gradually experience in
its use, and new discoveries in pathology
have limited its field of application and
demonstrated the dangers arising from its
employment. Views upon the pathology of
flexions have undergone a revolution, and
the conscensus of opinion to-day excludes
the stem pessary in the treatment of flexions
and versions.

In the treatment of atrophy of the uterus,
and of the so-called infantile, or poorly
developed uterus, with or without flexion,
the use of the stem pessary, in connection
with dilitation of the cervix, has its advo-
cates. The stem pessary is advised also,
especially by Wylie, to keep the cervix
patulus after dilatation, and for the purpose
of drainage. But inasmuch as the necessity
for this procedure is felt only by a decided
minority of operators, it may be assumed
with safety that its omission would be a small
loss.

Practically the stem pessary is used to-day
for the treatment of the so-called infantile
uterus, and of super-involution of the uterus
— a very restricted field. The prognosis of
super-involution of the uterus is notoriously
bad ; and when improvement does take place,
it is usually but temporary. It is an open
question as to whether super-involution of

704

Correspondence.

Vol. lxiv

the uterus is not equivalent to an early
menopause. The infantile uterus is the re-
sult, as a rule, of a partial development of
the sexual organs, and accompanies small
ovaries — not infrequently cystic or cirrhotic
— and small tubes. Menstruation in such
cases is absent or imperfect. The reason why
treatment directed to the uterus in such
cases yield poor results is not far to seek.
When, fortunately, the partial development
is confined to the cervix or even to the
uterus, and the tubes and ovaries are more
perfectly developed, the prognosis is better.
But in this field the stem pessary comes in
competition with dilitation of the cervix, the
use Of electricity, and roborant medication
combined with judicious exercise. It seems
probable that the intra-uterine stem will con-
tinue to be used in certain cases of imperfect
development of the sexual organs, not so
much because of the positive good which its
use will accomplish, but because this con-
dition, when marked, is very rebellious to all
treatment, and such unfortunate patients,
especially when desirous of marriage, will
demand that everything offering a reason-
able hope of benefit shall be employed. But
the practioner must remember the teachings
of the past, and warn his patient of the dan-
ger of salpingitis and peritonitis from the
use of the stem ; and be prepared at any
time to see the poor prospect for sexual de-
velpment, previously possessed by his patient,
absolutely destroyed by the occurrence of
serious pelvic inflammation.

Correspondence.

OUR INADEQUATE HOSPITAL FACILITIES
FOR THE MANAGEMENT OF MILD
CASES OF CONTAGEOUS
DISEASES.

To the Editor of the Medical and
Surgical Reporter.

Dear Sir : — I desire to relate a recent ex-
perience, not with the intention of fault-find-
ing, but rather with the hope that benefit
may result from its consideration.

On Thursday, May 14, I was called to see

a servant girl, Kate M., who, I was informed
had been ailing since the previous Tuesday
evening. Upon examination I found her
to be suffering from a well-marked follicular
tonsillitis, this being the eighth case of the
kind I had seen in our square during the
week. As she did not properly carry out
the measures I suggested, and was rather
troublesome to wait upon, the family, by
whom she was employed, desired her removal.
I accordingly arranged to have her admitted
to the Philadelphia Hospital, as she said she
could not afford to pay board anywhere.

Just as she was about to start for the Hos-
pital, however, I detected for the first time,
a profuse rash over her neck, breast, arms,
legs and slightly on her face. There was no
exacerbation of general symptoms, and my
knowledge of her condition for the previous
two days enabled me to conclude promptly
that the eruption was not due to scarlet fever
but to Rotheln. I so pronounced it, and had
her conveyed, in the carriage hired by her
friends, to the Philadelphia Hospital.

Upon arriving there she was refused ad-
mittance because of the contagious nature of
her disease. Not having any place to go_
she had the driver bring her to my office for
advice. Thinking it probable that a mistake
in diagnosis had been made and scarlet fever
suspected from the combination of sore
throat and a rash, which certainly resembles
the eruption of scarlet fever at times, I de-
cided to accompany the girl to the
Hospital, to make explanation, and ac-
cordingly had her taken there for the
second time. Unfortunately the Hospital
officials informed me that they could not re-
ceive a case of Rotheln and that the proper
place for such a patient was the Municipal
Hospital. We then proceeded to that in-
stitution where she was received and placed
in a vacant ward, as I was particularly
anxious that she should not contract a
trouble more serious in nature than the one
she had upon entering. After the arrival of
the physician of the institution, after my
departure, the case was diagnosticated as
scarlet fever, and she was placed in a ward
with some patients who were convalescing
from that disease. These facts I learned
upon visiting her on Monday morning, about
36 hours after her admission to the Hospital.
Examining her at this time I found her
throat decidedly improved, no secretion in
the follicles of the tonsils and the inflamma-
tory action greatly subdued. The rash had
disappeared. Temperature was 98° F., hav-
ing rapidly come down from 102° F., which

June 6, 1 891.

was the record upon admission, and which I
am quite sure was largely due to nervousness,
its her temperature had been normal that
morning.

So much was I impressed with the correct-
ness of my original diagnosis, and so greatly
did I feel the dangers she incurred from
contact with her contagious surroundings,
that I called upon the physician in charge
of the Hospital and asked if she could not
be removed to safer quarters. I was informed
that even granting a mistake had been made
by him in the diagnosis of the case it was
not possible to do any better for the girl than
keep her where she had been placed, that
they did not have any room where cases of
such mild contagion could be separately
"cared for, and that the nurse who would be
obliged to wait upon her, had charge of
cases of scarlet fever .and diptheria ; and
finally that as long as she had been for over
24 hours in the scarlet fever ward, she would
not be apt to escape that disease by removal
from the ward.

Whether this particular case is one of
Rotheln or of scarlet fever matters little as
far as my purpose in this communication is
concerned. While freely admitting my
liability to err in diagnosis, I, however,
feel justified in holding my original opinion
respecting the nature of this girl's illness,
and I also greatly fear that she will be the
victim of a much more serious malady,
due to her incarceration in a room poisoned
by scarlet fever patients. Several questions
have presented themselves as a result of this
experience :

1st. Is it just to Philadelphia citizens that
the city's Hospital for contagious diseases
should have no ward or wards set apart for
the reception of contagious diseases of such
a mild character as Rotheln, when patients
may be cared for by nurses not on duty
amongst cases of a more serious character?

2nd. Is it just to the physicians who may
be obliged to do as I did and allow their
patients to run the risk of contracting a
more serious affection in the place they are
confined for safety ?

3d. Might not a physican be caused much
annoyance if a patient felt disposed to pros-
ecute him in case a more serious disease were
contracted while at the Hospital ?

It would seem that the claims of economy
would demand better facilities for the
management of the mild contagious diseases
at the municipal Hospital, when we consider
the relatively greater period of time patients
must be boarded when afflicted with a grave

705

disease. Certain it is that the claims of
humanity demand such attention.
Respectfully,

Wm. A. Carey,
1947 North 18th Street.

Ed. Medical and Surgical Reporter.

Dear Sir: — Will you or some of your
readers please give through the columns of
your valuable journal, a remedy, or remedies
to allay the itching following the hypodermic
use of morphia, and oblige. Yours,

R. C. Spear, M. D.,

Mt. Gilead, O.

Ed. Medical and Surgical Reporter.

Dear Sir: — Speaking of Hydrogen Per-
oxide ; I used it recently to wash out a foul
suppurating abscess in the roof of the
vagina, after previously cleansing it with a
bichloride solution. The abscess held about
half a teacupful of pus, and had been ex-
istent for twenty years. Result was com-
plete cure after one application.

Wm. H. Burr, M. D.,

Wilmington, Del.

Book Reviews.

BLAKISTON'S QUIZ COMPENDS. A COM-
PEND OF DISEASES OF CHILDREN, ESPE-
CIALLY ADAPTED FOR THE USE OF
MEDICAL STUDENTS. By Marcus P. Hat-
feild, A. M., M. D., Professor of Diseases of
Children, Chicago Med. College, etc. One colored
plate. Phila., 1890.

This epitome of the diseases of children
consists of the condensed annual course of
lectures delivered at the Chicago Medical
College by the author. The lectures in
turn, the author states in his preface, were
founded upon Dr. Ernst Kormann's " Com-
pendium der Kinderkrankheiten," which
was translated by him in cooperation with
Dr. E. J. Doering, at the University of
Berlin. The frontispiece consists of a very
good colored diagramatic sketch of the foetal
circulation, which is a wise provision in a
book intended " especially for the use of
medical students." We believe the book is
admirably suited to the requirements of
students, being clearly written, and consist-
ing chiefly of definitions and short explana-
tory passages. This arrangement enables
the small size so valuable in a quiz-compend,
while allowing the work to embrace all of
the chief affections of childhood. It is an
excellent synopsis of the diseases of children
and as such we commend it to the students
for whom it is intended.

Book Reviews.

yo6

Periscope.

Vol. lxiv

ORIGIN PURPOSE AND DESTINY OF MAN
OR PHILOSOPHY OF THE THREE ETHERS,
By William Thornton. Boston. Published by
the author, 1891.

In this little book of one hundred pages,
the author continues the thoughts expressed
in his " Rationalism in Medicine " published
in 1885. This philosophical essay will not
be of any use to the busy practitioner of
modern medicine, since one of the con-
clusions reached, is, that all drugs now com-
monly administered are positively harmful
to the organism, since according to the
theory advanced by the writer, nothing
should be given in disease except those sub-
stances which are normally found in the
body. To those who are interested in phi-
losophy, especially as it bears upon the
science of medicine, this volume will be
found worth a careful reading, particularly
the chapters devoted to the " philosophy of
the three ethers " and " how to make medi-
cine a science." In fact the whole essay is
written in graceful language, and the
theories of which the author treats and
applies to medical science, are extremely
enticing. The writer also devotes a chapter
to the subject of the immortality of the Life,
which his philosophy separates from its
"material environment." To thoroughly
appreciate the idea of the book, it must be
carefully perused, since space will not here
permit even a clear synopsis of thought
advanced.

KOCH'S METHOD TO CURE TUBERCULOSIS,
POPULARLY TREATED BY DR. MAX
BIRNBAUM. Translated from the German by
Dr. Fr. Brendecke. Milwaukee, Haferkorn,
1891, pp. 95.

This brochure consists for the greater part
of a popular resume of our knowledge of the
tubercular process in its various manifesta-
tions ; its consideration of Koch's method of
treatment is limited to the republication of
Koch's first communication in the medical
papers. There is little in the pamphlet that
is not much better treated elsewhere ; and
the success of the translation is extremely
doubtful from an English point of view, the
failure to dispose of the many Germanisms
rendering the text rather unpleasant to
readers unaccustomed to such idioms.

Considered as a medical wTork it is worth-
less because of the unsoundness of many of
its statements and the brevity of the consid-
eration of important points. As a popular
presentation of tuberculosis, it is about what
might be expected from a writer who con-
founds lupus with ring-worm, as is repeat-

edly done in its pages. As a review of
Koch's work in the treatment of the tuber-
cular process, there is everything to desire,
little or nothing to be found, as the pam-
phlet was published before Prof. Koch had
announced the character of the matter he
employs and its manner of manufacture.

PERISCOPE.

THERAPEUTICS.

THE THERAPEUTIC VALUE OF CETRA-
RIN.

Cetrarin is the name which has been
given to the active principle of Iceland
Moss. The drug is one having several
valuable therapeutic properties. Recent
experiments show that it stimulates the
stomach and also the intestinal peristalsis,
it also increases the number of both red and
white corpuscles in cases of ansemia, and,
finally, acts as a tonic to the nervous system.
Kobert, in the Journal de Med. de Paris,
April 19, 1891, states that he has found
cetrarin of great value in cases of chlor-
anamaia complicated with constipation and
loss of appetite. The dose employed was 10
centigramme in any convenient vehicles.

SOZOIODOL.

The comparatively new antiseptic, Sozo-
iodol has already been brought to the notice
of the readers of The Reporter some time
ago. It will be remembered that its chemi-
cal name is bi-iodo-para-phenyl-sulphuric
acid. It is obtained by the action of fum-
ing sulphuric acid on bi-iodide of benzine,
which is saturated with carbonate of lead
and filtered. The lead salt is decomposed
from the mixture by sulphuretted hydrogen,
and the aqueous solution allowed to
evaporate. The crystals which are then
formed are those of Sozoidol. The prepara-
tion contains 42 % of iodine.

Recent investigations have confirmed the
valuable antiseptic properties of this drug.
It is similar, yet in many Avays far superior
to iodoform. Its odor is not unpleasant,
and its healing properties more marked.
Its action in tuberculous or scrofulous ulcer-
ations is excellent, and it has been used
with success in both gonorrhoea and syhphil-
itic sores of the generative organs. A
rapid curative action has also been seen to
follow its use in various chronic cutaneous
affections, in ozena, and in laryngitis. As
in antiseptic in surgery, it is very useful,

June 6, 1891.

Periscope.

707

promoting rapid healing, and keeping the
parts free from infection. It may be ad-
vantageously dispensed in connection with
starch, vaseline, or cerate. — Journal de
Med. de Paris, April 19, 1891.

TREATMENT FOR VARICOSE LEG-ULCERS.

Basing his opinion upon numerous ex-
periments and a large number of successful
cases, Dr. J. Braun, in the Allgemeine Med.
Central- Zeitung, May 6, 1891, advocates
most highly the treatment of leg ulcers with
the following formula :

Jfy Zinci oxyd 15.0 grammes

Lanolini 100.0 "

Unguent, moll 40.0 "

M.

The ulcer should first be carefully washed
and dried and the above salve, thickly
spread upon a piece of linen, applied, and
covered with a light bandage. The patient
should be kept in bed. Almost immediately
after application of the ointment all pain
ar i itching will disappear, and the copious
discharge will soon lessen.

According to Braun this salve forms a
protective covering over the ulcer, and the
lanolin absorbs the purulent discharge, while
further suppuration is checked. The ulcer
will therefore become dry and heal. In dis-
colored ulcers the salve should be applied
four or five times a day. In about three or
four days the ulcerated surface will assume
a healthy appearance and cicatrization will
begin. The author has even seen deep and
extensive varicose ulcers heal in this way,
without any transplantation of skin being
necessary. After healing, the author advises
that an elastic bandage should be worn for
some time over the seat of the ulcer.

This same salve has been found by Braun
to be of great service in eczema, and as an
application to any granulating surface. In
eczema capillittii the addition of a little
bichloride of mercury will be found ex-
cellent.

BROMIDE OF ETHYLENE IN EPILEPSY.

The Munchner Med. Wochenschrift, May
5, 1891, contains the description of a new
anti-epileptic, reported by Dr. J. Donath,
of Budapest. The remedy advocated is
bromide of ethylene (sethylenum bromatum).
The drug is of a light brown color and
smells something like chloroform. Its taste
is sweet, but it leaves a burning sensation
in the mouth. At 0°C. it freezes to a snow-
white crystalline mass, and it boils at 131°

C. Its specific gravity is comparatively
high, being 2.163, at 21°C. Bromide of
ethylene contains 90.9 per cent, of bromine.
The fluid is insoluble in water, but is solu-
ble in any proportion of rectified alcohol,
and forms a perfectly clear solution in any
of the fatty oils, such as oil of sweet
almonds.

The drug is best given in the following
5 per cent, oily emulsion :

1^ Aethyleni brom 5.0 grammes

Ad. emuls, oleos 100.0 "

M. Sig.

Thirty drops in a little sugar and water
two or three times a day for adults. On
the third day the dose should be increased
to 40 drops ; in three days again to a coffee-
spoonful, then to a teaspoonful. In child-
ren from eight to ten years of age, the in-
itial dose should only be 10-20 drops. The
dilution of the emulsion in water or milk is
necessitated on account of its irritating prop-
erties, and any gastric irritation is to be
avoided. In patients with extremely irrita-
ble stomachs, gramme 0, 1-0,2 of the aque-
ous extract of opium should be added to
the above formula. Toxic symptoms fol-
lowing the use of the drug were never
observed.

Another simple form for its administra-
tion is :

Ijk? Aethyleni brom. aromati.

Spirit vini rect aa 5 o grammes

M. Sig. 5, 10 to 15 drops well stirred in yz glass of milk
two or three times a day.

Very sensitive persons may take the drug
in gelatine capsules, associated with almond
oil ; each capsule containing three drops of
bromide of ethylene and six drops of almond
oil. Two to four of these capsules to be
taken daily.

Dr. Donath has used the drug in twenty-
one cases of epilepsy, and reports fully the
history of ten of these cases which were
under observation for along period. It was
observed that under the remedy's influence
the convulsions occurred more seldom, that
they were of shorter duration, and milder.
Frequently the disease becomes of a much
milder type and the period of immunity from
the convulsions increased. In some cases the
improvement was so great, that the convul-
sions only amounted toslightmusculartwitch-
ings without loss of consciousness. The
general condition of the patients was also
greatly improved by the treatment. In
many respects the drug's actions are far more
favorable than those of bromide of potas-
sium.

708

Periscope.

Vol. lxiv

IODOFORM IN BURNS.

Rottenberg, in the Munchener Med. Woch-
enschrift, May 5, 1891, speaks of the great
efficacy of iodoform in all kinds of burns,
and especially those caused by molton iron.
His method of treatment is as follows :
Through the punctured blisters he pulls a
silk thread soaked in a bichloride solution ;
he then covers the entire surface of the
wound with a thick layer of the following
salve :

T> Iodoform 10 parts

Jljli Vaseline 100 "

This is then covered with rubber or a pro-
tective. The salve should be freshly applied
daily.

This treatment not only results in a speedy
cure, but also relieves almost like magic the
burning pains.

THE TREATMENT OF PNEUMONIA BY
LARGE DOSES OF DIGITALIS.

We have already on one or two occasions
called attention to the mode of treatment
recommended by Dr. Petresco of combating
pneumonia with large doses of digitalis, and
in the Therapeutische Monatshefie for Feb-
ruary, 1891, this author publishes an addi-
tional communication on this subject, in
which he offers a number of arguments and
reports of a number of cases to support his
position as to the value of very large doses
of digitalis in this disease. The dose which
this author recommends is simply enormous
in contrast to that which is ordinarily re-
garded as the safe dose of digitalis, Pro-
fessor Pretresco stating that he does not
hesitate in single doses to give as much as
180 grains of digitalis-leaves in twenty-four
hours, although he admits that ordinarily
the dose for twenty-four hours does not ex-
ceed 25 grains. He prefers the infusion
made with 4 parts of digitalis-leaves in 200
of water, and then adding 40 parts of syrup
of orange-peel, the dose then being a table-
spoonful every half hour. He states that
in general this dose is very well borne, and
that he has never met a single case of poison-
ing. Dr. Petresco meets the incredulity
which has been expressed as to the tolerance
of these large doses, with the explanation that
he can only have employed inferior quality
of digitalis-leaves, with a denial, and states
that he has employed the leaves obtained
from all the best pharmacists in Europe,
with, as a rule, the same results. He states
that he has obtained the best results in gen-
uine fibrous or croupous pneumonia. In
infectious pneumonia he has usually com-
bined it with antiseptic methods. He also

states that he has obtained satisfactory re-
sults in cases of pneumonia complicated
with bronchitis and pleurisy, and he claims
in the most positive manner to have cut
short undoubted cases of croupous pneumo-
nia, so that within twenty-four to forty-eight
hours — the time necessary for the effects of
the digitalis to be demonstrated — he has
succeeded in obtaining sudden and almost
absolute reduction of the temperature to the
normal, accompanied with reduction of the
pulse, while at the same time this disappear-
ance of fever is accompanied by general im-
provement in the j:>atient's condition, pain
and cough being diminished, the tempera-
ture becoming normal, while the healing
process rapidly goes on to completion. These
large doses, with the exception of but rare
cases, are without effect on the digestive
canal, although sometimes he has met with
vomiting as the result of this method of
treatment. The most evident symptom de-
tectable as to the effect of this medication is
the marked slowing in the pulse, with in-
creased tension. The author publishes a
number of sphygmograms, illustrating the
effect of digitalis on the pulse in cases of
pneumonia, and concludes his paper with
the following deductions :

1. Digitalis has an important antiphlo-
gistic action only in its special therapeutic
dose.

2. Its specific therapeutic dose of digitalis
amounts to from 75 to 150 grains of digitalis-
leaves administered as an infusion in twenty-
four hours.

3. This dose may be administered in from
two to four days continuously, according to
the severity of the case. In some cases from
300 to 375 grains of digitalis-leaves being
given in four or five days without symptoms
of nausea, or in fact, any toxic effect.
Treated with this dose, the temperature in
cases of pneumonia falls from 1° to 3° C.
after a single dose, and from 5° to 6° C.
after three doses, while the pulse is slowed
from 40 to 60 beats in the minute after six
doses. This reduction in the pulse-frequency
and in the temperature lasts from ten to
twelve days, by which time the normal con-
dition has been gradually obtained.

4. Simultaneously with this diminution in
the rate of circulation and respiration, disap-
pearance of all the local symptoms of pneu-
monia can be noted.

5. The value of this method of treatment
is proved by statistics, the mortality of cases
of pheumonia so treated with high doses of
digitalis being much less than that observa-
ble when any other method is employed.

June 6, 1 891.

Periscope.

709

6. The value and harmlessness of this
therapeutic dose of digitalis is established by
the author's numerous individual experi-
ments and by the cases reported by his
scholars.

7. From studies as to the value of this
method of treatment the author concludes
that the expectant method of treating pneu-
monia is not only irrational but even danger-
ous ; that the assumption that there is a
definite cycle of progress in pneumonia is
not warranted ; that pneumonia may be cut
short by an energetic rational mode of treat-
ment, especially if the method is inaugurated
at the onset of the disease, and that, finally,
the claim is supported that the treatment of
pneumonia with large doses of digitalis fur-
nishes better results than that obtainable by
any other mode of procedure. — Ther. Gaz.

THE TREATMENT OF RHEUMATIC HYPER-
PYREXIA.

Dr. Herbert C. Male, in the Practitioner
says: The occurrence of hyperpyrexia in
acute rheumatism, though happily rare, is a
complication of grave import, and demands
most active and immediate treatment.

Previous to 1870, cases of Cerebral
Rheumatism with extreme pyrexia were
mostly regarded as hopeless. In this year
however Meding, published a case of rheu-
matic fever, in which a temperature of
108.6° was successfully reduced by means of
cold affusion and iced enemata ; and in the
following year Wilson Fox further drew
the attention of the profession to the subject
by his treatise on Hyperpyrexia, and de-
scribed very fully two cases of extreme
pyrexia (temp. 107.3° and 110°), where the
treatment by the external application of
cold wras carried out with success. Since
that time the value of this method of treat-
ment has been universally recognized.

It has been abundantly proved that ex-
cessive rises of temperature, in rheumatism
at all events, cannot be kept in check by
drugs alone. Quinine has been given in
large doses, as much as 120 grains in six
hours. In the case reported below, the pa-
tient was saturated with quinine ; he had
been taking 12 grs. per diem for a fortnight
previously, and on the approach of hyper-
pyrexia large doses were given and con-
tinued without any apparent effect on the
temperature. Salicylic acid and its salts
are powerless, and the complication has
often arisen in patients who have been
throughout their illness treated by full doses
of this drug. Antipyrin and antifebrin are

transient in their effects, and are dangerous
to continue from their depressing effect on
the heart, which is probably already
weakened by the disease. Antifebrin was
given to the patient A. H. on November 4 ;
the temperature did not rise during its ad-
ministration, and it certainly had the effect
of causing some moisture to appear on the
skin which was previously harsh and dry.
Delirium was not relieved. It was not
thought advisable, in his weak condition, to
continue its use.

Relying therefore solely on the employ-
ment of cold in reducing excess of tempera-
ture, we must decide at what temperature
this treatment must be commenced. Wilson
Fox has never seen a case of rheumatic
fever recover unbathed after a temperature
of 106° has been attained. Merchison has
known a case recover after a temperature of
106.5°, but he states that this must be ex-
tremely rare.

In other diseases, such as typhoid fever
and pneumonia, a temperature of 108° has
been reached and recovered from, without
special treatment, but Wilson Fox thinks
that the " power of sustaining life in acute
rheumatism after excessive temperature is
less than in other diseases"; therefore we
cannot afford to wait so long.

Some ten years ago the Committee of the
Clinical Society of London made an exhaus-
tive inquiry into this subject, and in their
Report they show the necessity of not al-
lowing the temperature to exceed 105°. In
six out of eleven fatal cases (unbathed) the
temperature did not reach 106°, and they
have shown that the treatment by cold is
more successful the earlier it is commenced.
Moreover the temperature may rapidly rise
when once it begins: in a case mentioned
by Fox the temperature ran up from ordi-
nary to 109° in two hours.

There are practically but two methods of
applying cold to the surface of the body
with the view of reducing temperature ; by
means of the bath, and by the cold pack.

When the bath is used, it is recommended
that the patient be lowered into it in a sheet,
at a temperature of 90° — 100° F., and that
it be cooled down by adding cold water, or
preferably pieces of ice, till it is reduced to
60° or 70°.

He should remain in the bath till the
thermometer, placed in the rectum, has
fallen to 101° — 102°, unless any symptom
of faintness or shivering require it to be dis-
continued earlier. In many cases the pa-
tient's temperature continues to fall after
his removal from the bath. He must be

710

Periscope.

Vol. Ixiv

rubbed dry, and placed in bed lightly
covered with blankets; if the temperature
fall too low, or the patient is shivering, hot
bottles and stimulants are required.

The cold pack is best applied in the fol-
lowing way: — The patient remains in his
bed; he is stripped of all clothing and a
mackintosh is placed under him. Towels
are wrung out of iced water and applied to
the trunk, head, and limbs. These are
changed frequently, and the body sponged
over with lumps of ice. An ice-bag should
also be applied along the whole length of
the spine. The temperature must be care-
fully watched as before, and the pack dis-
continued when its reduction has been
effected.

The choice of method to be employed must
depend on the circumstances of the case.

In hospital practice where sufficient as-
sistance and all appliances are at hand, the
bath is generally preferred. It is doubtless
a more thorough method, and appears to be
attended by no greater shock or risk to the
patient. On the other hand in private
practice it is seldom that the bath can be
satisfactorily employed, and for several
reasons the pack may be preferred. It can
be applied at once, it is less alarming to the
friends, it does not necessitate the moving
about of the patient, it can be carried out
by one intelligent attendant without con-
stant medical supervision, and its effect on
the patient can be more readily watched.
Moreover it has been proved to be thor-
oughly successful even in extreme cases of
hyperpyrexia. Temperatures above 110°
F. have been recovered from after treatment
by the cold pack, as well as by the bath.

In some cases one bathing is sufficient to
effect reduction of temperature, no further
excessive rise taking place. In others it
has required to be repeated, and it has been
used as often as twenty-six times on the same
patient with ultimate success.

The length of time required for reduction
varies considerably, and bears no proportion
to the severity of the case. In the case re-
ported, the time that the pack required to
be used varied from half-an-hour to three
hours.

The following facts will give some idea of
the proportion of recoveries that may be
looked for after this treatment.

Wilson Fox collected a series of twenty-
two cases from 1867 to 1871, temperatures
ranging between 106° and 111.7°; eighteen
were treated by ordinary means without the
application of cold, and all were fatal ; the
remaining four were treated by the cold

bath and three of them were successful, the
highest temperature being 110°.

The Committee of the Clinical Society of
London collected a series of sixty-seven
cases during the ten years ending 1879. In
thirty-nine of these the temperature exceeded
106°, and in thirty-four the treatment by
cold bathing was adopted, and fourteen re-
covered, the highest temperature being
109°— 110°.

Of the more moderate temperatures among
these (viz. between 106° and 107°), eight
out of eleven cases recovered, over two-
thirds. All the cases that were unbathed
died.

In the ten years ending 1890 many cases
of recovery have been reported from time to
time in the journals, and I have been able to
find a record of sixteen cases with thirteen
recoveries ; temperatures ranging from 106°
— 110.4°. The pack was used in eight of
these with two deaths, and the bath in the
remaining eight with one death.

It is not possible of course to form an ac-
curate idea of the proportion of recoveries
from the study of published cases alone, as
it is probable that many unsuccessful ones
have not been published, while the majority
of successful cases have been put on record.
Still there is ample evidence of frequent re-
covery after extreme temperatures, which
under other conditions must certainly have
been fatal.

While however recognizing the success
that often follows the employment of cold in
rheumatic pyrexia, we must ascertain if
there are any dangers attending its use.

Bristowe, records a case where the cold
bath on two occasions produced such serious
faintness, after five minutes' immersion, that
it had to be discontinued.

At Guy's Hospital,2 during 1874 and
1877, death took place on two occasions
during immersion ; but in these cases the
bath was probably too long delayed, and
the heart and tissues had suffered too much
from the excessive heat to stand the shock.

In several cases violent purgation has re-
sulted after immersion.

In a case previously reported by the
writer, tetaniform convulsions, which oc-
curred after the first application of cold,
were so exaggerated on the attempted repe-
tition of the pack, that it was impossible to
apply it. The patient eventually died as-
phyxiated during a convulsive spasm.
Another case of a similar kind has also been
recorded.

These difficulties, however, appear to be
exceptional, and it is well to note that the

June 6, 1891.

Periscope.

711

various visceral lesions, such as pericarditis
and pneumonia, so common in acute rheu-
matism, are no coatra-indications to the use
of cold. Indeed, as Wilson Fox asserts,
intense pyrexia predisposes to congestion of
internal organs, and the physical signs of
such have been frequently observed to clear
up during treatment by cold.

The following case is recorded, not un-
fortunately, as an example of a cure after
cold packing, but to show the marked effect
of this treatment in keeping the tempera-
ture within bounds over a prolonged period,
its reduction being effected on each of the
eight occasions on which it was used. It
further shows that, on the discontinuance of
the treatment, there followed a rapid rise of
temperature, with exaggeration of all the
symptoms until the fatal termination. The
oase also illustrates the variability of the
time required to effect a reduction of tem-
perature.

The spinal ice-bag was chiefly of service
when used in conjunction with the iced
towels. When employed alone, it appeared
on the first occasion to delay for several
hours a threatening rise, and the second
time, when the bag was allowed to remain
after the removal of the towels, the tempera-
ture continued to fall for three hours, and
rose again slightly after it was removed.
On another ocasion, the afternoon of Novem-
ber 5, the temperature rose rapidly in spite
of it.

There was little doubt the patient's life
was lengthened for some days by the treat-
ment. It prolonged a period when the
efforts of nature might have brought about
a change for the better, had other conditions
been favorable.

Previous to the onset of hyperpyrexia,
the patient's strength was already exhausted.
He had been ill for over five weeks, with
constant pain and want of sleep. Pericar-
ditis had existed long enough to cause such
local organic change as seriously hampered
the action of his heart, and this further
lessened his chances of recovery.

Such a case impresses upon us the neces-
sity of making a most careful record of tem-
perature in all cases of acute rheumatism,
and of recognizing at once the earliest signs
of approaching hyperpyrexia.

Should the temperature show an undue
rise, we should not waste valuable time by
the administration of drugs, but endeavor
to check it at once by the prompt applica-
tion of cold.

The result of such treatment in a favor-
able case, is most gratifying. The patient

may be dying from excess of temperature
one hour, and the next may be in compari-
tive comfort, and with prospects of a speedy
recovery. One bathing has frequently
turned the scale. The treatment may be
applied readily both in private and in hos-
pital practice, and should not be withheld
from any patient, in whatever circumstances
he may be placed.

MEDICINE.

SALICYLATE OF MERCURY AS AN ANTI-
SEPTIC.

At a recent meeting of the Surgical Soci-
ety of Paris, Dr. Vacher, of Orleans, read a
paper on the antiseptic qualities of salicylate
of mercury, which is quoted in the Bulletin
Medical. He considers the drug an admi-
rable antiseptic, and superier to Van Swie-
ten's solution because solutions of salicylate
of mercury need not contain alcohol. Solu-
tions of any strength are perfectly stable
and will keep indefinitely. It is non-irrita-
ting and a powerful antiseptic. In the
treatment of syphilis Dr. Vacher has found
it to be of great service, particularly when
given hypodermically. The injections pro-
duce no pain and cause no local inflamma-
tion. The author has used the drug in solu-
tion hypodermically in over one hundred
cases of syphilis and with the best results.
Salicylate of mercury is always well toler-
ated.

NOVEL TREATMENT OF GONORRHOEA.

Dr. Hanicka, in the Beichs-Medicinal-
Anzeiger, May 15, 1891, speaks highly of
the following novel treatment for gonorrhoea :
A powder composed of equal parts of tannin,
iodoform, and sulphate of thallin is applied
to the urethra by means of a catheter-like
instrument until the former is entirely full
of the remedy. Prompt healing is said to
take place in every instance.

NINETY CASES OF PARETIC DEMENTIA.

Dr. G. K. Trowbridge, in the Alienist and
Neurologist, writes: The very fact that
this disease was practically unrecognized in
this country forty years ago, and to-day
ranks among the worst forms of insanity, is
sufficient reason to make statistics on the
subject both of considerable interest and
value. In all probability there were cases
of paretic dementia before the time of Bayle,
and although he is credited, I believe, with
first having accurately described the signs

712

Periscope.

Vol. lxiv

and symptoms of it about the year 1825, it
is scarcely probable that the inhabitants of
this world were exempt from it though it
was not recognized and understood as it is
to-day.

History is indirectly contradictory to this,
and if we are to believe the facts as recorded
there were certainly sufficient causes in the
Middle Ages to produce a generous supply
of paretic dementia, and I have not the least
doubt but that it existed to a considerable
extent among the so-called nobility of
France, England and other European
nations, whose ideas of morality and moder-
ation were somewhat at a discount. The
same causes which are producing it to-day
were in working order then, though perhaps
not to so great an extent; and granting
that the mental, moral and physical condi-
tions of two centuries ago were practically
the same as those of the nineteenth century,
it is fair to conclude that this age is not en-
tirely responsible for this disease.

That paretic dementia is increasing in
this country with alarming rapidity there is
no room for doubt, as the reports of our in-
stitutions for the insane show. It is, however,
only another indication of the " fast " age in
which we live ; and this yearly increase of
the disorder is not a thing of which the
American citizen should be proud, but on
the contrary, it should be looked upon as a
veritable curse, as it only proves that those
vices and immoralities which are the corner-
stone of general paresis, are increasing and
causing the moral, physical and mental
wreck of our fellow-citizens. No one can
realize the truth of this better than the med-
ical officers in our hospitals for the insane.
In a large number of cases of paretic demen-
tia admitted to hospitals for the insane,
causes for the disease are given which are
ridiculous in the extreme; and though
either through ignorance or unwillingness on
the part of friends, or delicacy on the part of
the physician, the real and true cause can-
not be ascertained, yet in three cases out of
five it would be a comparatively easy matter
to guess it, as the real causes of paretic de-
mentia can be sifted down to an extremely
small number.

The following statistics of ninety cases
were compiled from the registers of this hos-
pital, and though they are more or less de-
fective, they present some interesting points.

Of the 3,518 admissions to this hospital,
90 were cases of paretic dementia ; 77 of
these being males and 13 females. This is
about two and one-half per cent of the entire
number admitted.

In the State Hospital for the Insane, at
Independence, Iowa, of 3,700 admissions, 40,
or a little over one per cent, were cases of
paretic dementia.

Of 2,297 male patients at the Pauper
Asylum of N. Y. City, 284, or a little over
twelve per cent, were paretic.

First among exciting causes is the exces-
sive use of alcohol. This is acknowledged,
I believe, by the majority of writers to be a
great producer of general paralysis. In
close relation to it, both socially and as an
exciting cause, is syphilis. It is claimed by
some that syphilis is not an exciting cause
of paretic dementia, but there are cases of
general paralysis which cannot be traced to
any other source, and the symptoms of this
form are so identical with the regular gen-
eral paralysis that it is stretching a point to
claim another name for the disease. It is a
distinction without a difference. This, how-
ever, does not mean that syphilis always
produces paretic dementia to the exclusion
of other insanities.

The excessive indulgence of vicious
habits, as a rule, is likely to produce some
impairment of the mental faculties, and in
the majority of cases of paretic dementia,
were the truth known, alcohol and syphilis
would occupy the first place as exciting
causes.

Here, again, the question reverts to one of
social standing. Alcohol and syphilis are
luxuries which are placed within the reach
of everybody, from the laborer to the mill-
ionaire, but we find in my ninety cases, on
a close comparison, that as the number in
the exciting causes lessens, the cause itself
becomes more respectable. I found that in-
temperance was given as a cause, especially
among laborers and miners, and the same
was true of syphilis, whereas the occupation,
being a little better, the cause appeared as
overwork, or was unknown.

Paretic dementia, as a rule, does not
attack vigorous and well-balanced minds,
unless, perchance, heredity plays a part, but
is found among the class whose morals are
of such a low grade that regard for them-
selves or others is completely destroyed, and
they give themselves up to immoralities and
vices which are the exciting causes of the
disease. Thirty-four of the seventy-seven
cases were due to either alcoholism, syphilis
or heredity, or a combination of two or
more, and I venture to say that in the twen-
ty-six cases in which the cause was un-
known, these three factors w7ould be in the
majority. Heredity plays an important
part in the causation of paretic dementia,

June 6, 189 1. Periscope.

7!3

though I do not think as important a one as
alcohol and syphilis, as it acts more as a
predisposing cause.

The disease, as a rule, does not attack
either extreme age or youth, but on the con-
trary seems to select individuals in the
prime of life. In summarizing these ninety
cases, I find that among the men, the
youngest case when attacked was 26 years
old, and the oldest 63 years ; the average of
the 77 cases being 41 years and 8 months.

Among the 13 females, the youngest was
21 years of age, and the oldest 56 years, the
average being 41 years and 6 months.

In regard to duration, my cases show that
among the males (50 cases) the longest time
for the disease to run its course was ten
years; the shortest, six months. Average
of the fifty cases, two years and seven
months; and among the females (8 cases)
the longest was six years ^ the shortest, one
year and six months; average, two years
and eight months. Average of fifty-eight
cases, male and female, two years, eight and
one-half months.

I have here only taken those cases in
which the disease has completed its course,
i. e., resulted in death, as some are still here,
and others were, for various reasons, dis-
charged.

I think a fair average of the course of
the disease is from two and one-half to three
years, though, as we have seen, the course
in single cases may be varied to either
extreme.

The time spent in the hospital by these
patients is as follows — and here, again, I
shall only consider those cases resulting in
death, omitting those which are still here,
and those which have been discharged.
Among the fifty male cases, the longest resi-
dence in the hospital was seven years, the
shortest, eight days ; average, one year and
nine months. Among the eight female
cases, the longest residence was three years
and two months, shortest, three months;
average one year and six months. Average
for the fifty-eight cases, one year and seven
and one-half months.

The average duration before admission
was, males, one year and one month ; females,
one year and two months.

The ages at deaths were as follows : Males,
oldest, 65 years ; youngest, 29 years ; aver-
age, forty-four years, th ree months. Females,
oldest, 58 years ; youngest, 26 years ; aver-
age, forty-four years and two months.

I shall not draw any conclusions from
these cases, as I would only repeat those of
other writers, but leave that to my readers.

We must realize that if this disease con-
tinues to gain ground, and go on increas-
ing, we will have another powerful factor
which will aid in the mental, moral and
physical deterioration of the American peo-
ple as a whole.

There is room for improvement in our
mode and manners of life, and the sooner we
realize it the better it will be for this and
future generations.

THE STATUS EPILEPTICUS.

Dr. Robert T. Edes, in the Virg. Med.
Month., says : The name " status epilepti-
cus," is, or was, applied to a continuous suc-
cession of epileptic fits, coming so rapidly
that one does not end before another begins ;
that is, if we count as a fit not only the
period marked by active convulsive move-
ments, but the stage of unconsciousness suc-
ceeding it.

This is the usual condition, but it is prob-
able that the same, or a similar, patholog-
ical state prevails, and may very properly
bear the same name where the convulsions
are not all very well marked, but are indi-
cated, or at least some of them are so, simply
by muscular twitchings not developing into
general convulsions.

Rise of temperature, pulse and respiration
are characteristic symptoms ; and some
others noted in my case, as the extremely
dirty tongue, and the rapid supervention of
sloughing of the nates, have been commented
on before.

In the more typical cases, the status epi-
lepticus is divided into two stages — one
marked by the severity of the convulsions,
and a second comatose, delirious, or collaps-
ing, which has been termed, though im-
properly, the meningitic stage.

In looking over the recommendations of
authors for treatment, one finds that they
agree chiefly on one point, the uselessness of
a large number of drugs.

Nitrite of amyl, however, seems to have
been of considerable value. It was tried,
but not very successfully, in our case first
reported. In the other, it was of decided
advantage. Amylene hydrate has also been
highly spoken of.

In one case he was confident that ether
had a decided effect in postponing the at-
tacks, and chloral hydrate, in not excessive
doses, by the rectum, was even more effica-
cious. How far chloral, if used early and
freely, might have been efficient, not merely
in checking the convulsive movements, but
in preserving life, is not so easy to say. It

7H

Periscope.

Vol. lxiv

certainly seems to me that, either alone or
combined with bromide, it gives the best
chance of attaining this object.

It is not, however, so easy to be certain of
this, for the reason that in some cases, and
some fatal cases, the severe muscular con-
tractions are not the most prominent feat-
ures, but the coma and fever, with a few
well-marked convulsions, and a more or less
constant, but not violent muscular twitching,
seems to constitute the disease.

In the comatose stage, or that of collapse,
chloral would certainly not seem indicated.
He was surprised not to find it even men-
tioned in either of two monographs * founded
on an apparently thorough study of the
subject.

A phenomenon, which is sufficiently often
seen to have been considered by some writers
essential, or even diagnostic, is a moderate
and usually evanescent hemiplegia. This
has been wrongly attributed to some gross
permanent lesion in the brain, which by no
means invariably exists.

In one case, nothing of the kind could be
observed, although repeatedly and carefully
looked for. The only possible indication of
any unilateral affection was the turning of
the eyes and head to the right for a few
seconds at the beginning of a fit.

In another case, there were differences of
sensation and slightly of motion in the two
sides, but the only gross lesion noted was in
the median line.

A CASE OF PSEUDO-CHOREA.

When first seen at the out-patient depart-
ment the most conspicuous features about
the case were clonic movements of some of
the muscles of his trunk, which jerked the
latter forcibly to the right side, the dia-
phragm being affected at the same time, so
that a grunting inspiratory sound was pro-
duced which often interrupted his speech in
a quite characteristic manner. His gait was
hemiplegic and the muscular strength was
found to be distinctly subnormal on the en-
tire right side, the movements were confined
to the trunk and followed each other in
quick succession. The motions of the limbs
were found only to be communicated. The
man was totally unable to walk alone.

As regards his family history, we were
told that the patient's father had died with
an acute brain-trouble, the exact nature of
which, however, could not be ascertained.
The patient had been well and strong. No

* Hertz. — Status Epilepticus. Inaug. Dissert.,
Bonn, 1877. Lorenz, op. cit.

excesses in Baccho aid Venere. No syphilis.
In 1888 he entered the army. In 1889 he
was in Washington Territory with his regi-
ment and much exposed to wet and cold.
During the next summer, following a good
deal of exposure, he was attacked with
severe pain in his back, which shot down
into his legs, especially the right one to the
toes. The joints were neither swollen nor
red, but the attack was of considerable
severity, so that, as he states, he was unable
to walk for between two to three months.
While still at the hospital, he had an attack
of the same nature as the present one, which
persisted for four months and gradually dis-
appeared. With the exception of a very
slight return m the spring of 1890, he re-
mained perfectly well until 15 days before
he was first seen. While driving a wagon
the axle broke and he was thrown out. He
was not hurt, but two hours later the jerk-
ing movement referred to above suddenly
appeared.

Two days after presenting himself at the
dispensary he was admitted to the hospital,
the condition was then slightly better. A
more careful examination was made. The
latissimus dorsi., the rhomb., the serrat.,
were found to be especially affected. The
pectoralis less so. Of the abdominal muscles
the rectus. The diaphragm as stated above.
The weakness of the right side still well
marked. Some tenderness over the errect.
spinae.

About the movements the note, which was
dictated by Dr. Lafleur, says : " the move-
ments are of great rapidity and have
almost a rhythmic character jerking his
body to the right in a manner which re-
minds one somewhat of the canine chorea."

The viscera showed no changes.

He was found to have dulling to sensation
of pain (not of touch or of heat) in the
whole right side with the exception of the
face. There is diminution in the reflexes on
that side. The perimetric fields of both
eyes were equal and normal. The special
senses are in no way affected. Electrically
there was no change found.

The patient was placed in a room by him-
self and no medication save a placebo was
given.

The improvement was rapid and remark-
able. He slept comfortably, the jerks
diminished in frequency and four days later
only occasional movements were observed,
and still three days later they had almost
completely ceased. Now the only features
remaining are the sensory changes and the
changes in the reflexes. The resemblances

June 6, 1 89 1.

Periscope.

715

to Sydenham's chorea exist of course only
in a rough way. The points which are un-
like the true chorea, are : (1) the almost
rhythmical character of the movement ; (2)
the electric-like character of them ; (3) the
fact that they were confined to the trunk ;
(4) the sensory changes ; (5) the fact that
in a quite short time the movements reach
the greatest severity.

The case, therefore, must be classed under
the head of Pseudo-chorea, which belongs
under the large heading of Hysteria. — Dr.
Hoch in the Johns Hopkins Hosp. Bull.

SURGERY.

MICROCIDIN— A NEW ANTISEPTIC.

At the meeting of the French Academy
of Medicine, held in Paris, April 28, and re-
ported in the Bulletin Medicale, April 29,
1891, Dr. Polaillon read a paper on the sub-
ject of microcidin, a new antiseptic which
has recently been discovered by Dr. Berlioz.

A quantity of B naphthol is heated to the
melting point, and the half of this quantity
(by weight) of caustic soda is added and the
mixture allowed to cool. The result will be
a white powder composed largely of naph-
thol and soda, but besides this composites of
naphthol and phenol, which give the sub-
stance peculiar properties which seem to
justify the name of microcidin, which Berlioz
has given it.

The substance is soluble in three times its
weight of water. Concentrated solutions are
of a brown color, while the weak solutions
are almost colorless. It is but very slightly
toxic. Its antiseptic properties are weaker
than those of bichloride of mercury and
naphthol, but it is ten times as strongly anti-
septic as carbolic acid in solutions of similar
strength. The toxicity of microcidin is less
than that of naphthol, and, of course, in-
finitely less than that of bichloride of mer-
cury. The substance is almost entirely
eliminated through the urine.

Regarding the clinical value of the prepa-
ration, Polaillon has used a 3 per cent, solu-
tion of microcidin with excellent results in
leg ulcers, various suppurations and suppu-
rating wounds. The solution is non-irritating,
promotes healing, and keeps the wound
clean.

SURGICAL AND CLINATIC TREATMENT
OF PHTHISIS.

An interesting monograph on the above
subject has been recently published in Ger-

man, by Dr. C. Spenglar, of Davos (Switz-
erland).

The author claims that neither cavities,
empyeman or pyo-pneumo-thorax can heal
unless the necessary mechanical conditions
are brought about. Arguing from this point
Spengler advocates the establishment of an
open pneumo-thorax, by a free resection of
ribs. In advocating this procedure he
places himself on the same stand as Schede
and Immermann. In young subjects the
method promises better results than in older
patients. The principle consists in the
hypothesis that the atmospheric pressure on
the lung would cause a shrinking of the
thorax. Of course, there is always more or
less displacement of the organs of the chest,
especially the heart, but not enough to cause
any untoward effect. This treatment should
be supplemented by a careful dietary,
hygienic and climatic treatment — high alti-
tudes being preferable. Finally, Spengler
cites many cases which show the efficacy of
the treatment, although in many cases suffi-
cient time had not elapsed to warrant a more
than improved condition. — Centralblatt fur
Chirurgie, April 25, 1891.

SURGICAL TREATMENT OF APPENDICITIS.

Dr. Randolph Winslow, in approaching
this subject from a surgical standpoint,
states that there was great difficulty ex-
perienced from the confusion in the nomen-
clature applied to the inflammatory troubles
in the right iliac fossa, and that this con-
fusion in nomenclature meant an equal ob-
scurity in our ideas of the pathology of
these affections.

The terms typhlitis, perityphlitis, and
paratyphlitis, are used more or less indis-
criminately for painful inflammatory affec-
tions of the right flank, which may be
widely different in character.

Typhlitis is an inflammation of the
caecum, which may be limited to its mucous
coats, or may penetrate more deeply, until
the peritoneal coat is reached, when the re-
sulting peritonitis, with its accompanying
exudation, is called perityphlitis ; and if pus
forms, a perityphlitic abscess is said to be
present.

It was supposed until quite recently that
the caecum was only partially covered by
peritoneum, leaving a large part of its walls
with no peritoneal coat, and in immediate
relation with the post-csecal connective
tissue. This is an error, the caecum has a
distinct mesentery in the vast majority of
cases, and floats quite freely , within the

716

Periscope.

Vol. lxiv

peritoneal cavity. And when an abscess
forms, it is almost invariably found to have
its primary seat within the peritoneal sac —
the diffusion of the pus being prevented by
adherent coils of intestines. Sometimes, as
a secondary result, the peritoneum is de-
stroyed and the pus escapes into the post-
peritoneal connective tissues. It would be
much better to use the terms caecitis and ap-
pendicitis to describe inflammations of the
caecum and vermiform appendix, and to dis-
card such expressions as typhlitis, peri-
typhlitis, and paratyphlitis, as being obscure
and obsolete. Coecitis or typhlitis is a dis-
ease amenable to medical measures, and but
seldom calling for surgical treatment, whilst
para- and peri-typhlitis, meaning thereby an
inflammation of the post-caecal connective
tissue, but seldom occurs.

As the various inflammatory conditions
within the female pelvis are usually found
to depend upon disease of the Fallopian
tubes, so the inflammations found in the
right iliac fossa usually have their origin
in diseased conditions of the vermiform pro-
cess. It is very important, therefore, that we
should have correct ideas about this very
troublesome and apparently useless bit of
anatomy.

The vermiform appendix varies in size,
length, and position ; sometimes it has quite
a distinct mesentery, but generally it is quite
free, and may be found occupying almost
any relation to the caecum. Its tip may be
found in the pelvis or turned upwards and
attached to the abdominal wall or some of
the viscera, or the whole process may be
found behind the caecum, or in fact occupy-
ing almost any relation to this gut.

It is probable that the appendix is fre-
quently diseased without producing very
decided or distinct symptoms, and that re-
coveries occur both with and without treat-
ment.

When, however, acute appendicitis sets in,
the symptoms are generally quite character-
istic ; but it is not every case of acute appen-
dicitis that demands operative treatment.
When the symptoms are not very severe, the
pain not intense, and the fever not high, and
especially if no tumor is to be felt, reliance
should be placed upon medical treatment ; a
careful watch should, nevertheless, be kept
for evidences of the development of more
threatening symptoms. Even where there
is a swelling found in the right iliac fossa, it
does not necessarily demand operation. He
has seen a number of cases recover after a
decided exudation had occurred, without
operation or any appeciable discharge of pus.

It has been recommended, and in many
cases carried out, to aspirate the suspected
region. Whilst this method has yielded
good results, he is unable to approve its em-
ployment, as it is excessively hard to pro-
perly disinfect an aspirating needle, and a
serious accumulation may become converted
into a purulent one, besides the risk of pen-
etrating the intestines or some blood vessel.
When the diagnosis must depend upon the
detection of fluid within a circumscribed
space, it will be less dangerous to make an
incision down to the seat of disease, than to
aspirate.

When a decided lump is found in the right
iliac fossa, which is hard, tender, and pain-
ful, and the fever keeps up, and especially
if this lump increases in size, an incision
should be made both for purposes of explo-
ration and treatment. This incision should
not be too long delayed, as the pus may
break through the adhesions which circum-
scribe it, and set up a general suppurative
peritonitis. It is not safe to wait until the
sign of fluctuation can be detected, as this
may never occur, or may occur only at a
late deriod. The earlier the operation is
performed the greater the probabilities of a
successful termination. It may be stated
that operations, when indicated at all, ought
to be made as early as the fifth or even the
third day.

When the symptoms of perforation come
on, as sudden and intense pain with col-
lapse, operation ought to be performed as
soon as there is sufficient re-action to justify
it ; otherwise a generalized peritonitis will
probably set in and terminate fatally.
Thex*e are a few cases of perforative ap-
pendicitis, which present such obscure symp-
toms, that the nature of the disease is not
suspected until a fulminent peritonitis is set
up, with pus-bathed intestines and viscera,
when it is too late to save the patient by
laparotomy.

Dr. Winslow thinks we should emphasize
the fact that the exudation, or pus, in a case
of suppurative appendicitis, is found within
the peritoneal cavity, and not in the post-
peritoneal connective tissues ; hence, the
great danger that the adherent coils of in-
testines may become separated, and fatal
general peritonitis occur.

Having determined to operate, the seat
of incision is usually over the swelling,
as thereby the most ready access to the
abscess cavity is gained. The tissues
are divided by a straight or curved
incision in the right flank until the trans-
versalis fascia is reached, when an aspirating

June 6, 189 1.

needle or hypodermic needle may be thrust
in various directions into the swelling, if
there is any doubt about the presence of
pus, or the tissues may be cautiously divided
until the peritoneal cavity is opened, when
the exudation of pus or serum will be
reached. If the appendix is perforated, or
even if it is manifestly diseased, it should
be ligated close to the caecum and cut off.
Sometimes the appendix will not be found —
it has sloughed off and disappeared. It is
usually better not to irrigate the abscess
cavity, as there is danger that by so doing
pus may be forced into the general perito-
neal cavity. Free drainage should be
secured, and as far as practicable, antiseptic
treatment adopted ; but this will be difficult,
as the discharge is of an especially septic
character.

As surgeons, we are also called upon to
open the abdomen in those cases where the
pus has set up a general peritonitis, though
with but slight hope of success. Here the
incision should be placed in the linea alba,
with perhaps incision for drainage for one
or more other points. The peritoneal cavity
should be thoroughly cleansed, the intestines
sponged off or washed, and free, and if pos-
sible, continuous irrigation with warm water,
or a weak antiseptic solution kept up —
several drainage tubes being placed in fav-
orable situations. One or two cases have
been recorded of recovery after continuous
irrigation for several days.

A certain quite large number of cases of
appendicitis recur after having apparently
healed, and not only give rise to consider-
able local reaction, but even to danger.

Treves, of London, and Senn, of Milwau-
kee, recommend the removal of a diseased
appendix during the intervals of quietude
from acute outbreak, and report several suc-
cessful operations in such cases. Dr. Win-
slow is strongly inclined to the opinion that
this is correct surgical doctrine, notwith-
standing the protest of Dr. Dennis, of New
York, against it ; and he will certainly
carry it out in practice in appropriate cases.
Dr. Winslow referred to a patient who has
had two attacks of painful febrile affections
on the right side of the abdomen, the first
of which was recovered from under medical
treatment, and the last, after incision, who
is determined to have the more radical ope-
ration performed if he has another re-
currence.

In conclusion Dr. Winslow submits the
following propositions :

1st. Inflammatory affections in the right
iliac fossa are atmost invariablv due to dis-

Periscope.

717

eased conditions of the appendix verini-
formis.

2nd. When an abscess forms in the course
of such affections, the pus is found, pri-
marily, within the peritoneal cavity, and
not in the post-csecal connective tissue.

3rd. Many mild, and some severe attacks
of appendicitis are recovered from without
operation.

4th. When there is severe localized pain,
tenderness, and a tumor present in the right
iliac region, with the constitutional suppu-
rative inflammation, an early operation is
demanded to evacuate the pus. This should
be done as early as the third day when pos-
sible.

5th. Delay is more dangerous than opera-
tion, as the adhesions circumscribing the
pus may give way, and a rapidly fatal peri-
tonitis may be set up. — Virg. Med. Month.

GYNAECOLOGY.

INCISION VERSUS RAPID DILATATION
FOR STENOSIS OF THE CERVICAL
CANAL.

Dr. James H. Keilly in a paper before
the Vermont Medical Society said : I feel
that I owe the society an apology in
claiming that better results can be ob-
tained in the treatment of constriction of
the cervical canal for dysmenorrhoea and
sterility than by the more modern proced-
ure, rapid dilatation, as advocated by
Goodell and other eminent gynaecologists ;
but after an experience in the treatment of
forty cases, my statistics force me to take
the stand that I have taken.

When cases of this kind first came under
my direct observation for treatment, I re-
sorted to the operation by means of rapid
dilatation as a means to produce a radical
cure. I assisted at the operation a great
many times during my service as hospital
interne, and whilst I looked upon the opera-
tion as a barbarous procedure, it evidently
accomplished the dilatation to such a
marked degree that I reconciled myself with
the idea that the end justified the means.
That the canal could contract again to the
same degree as before operation appeared at
that time to me an impossibility, but it was
not my privilege to watch the progress and
termination of these cases after leaving the
hospital, and, not hearing of any unsatis-
factory results, I concluded that the opera-
tion must have been very gratifying to the
operator as well as to the patient. After
entering practice, when cases of this nature

Periscope.

Vol. Ixiv

presented themselves to me, the first opera-
tion that suggested itself was that of rapid
dilatation ; and after meeting with cases
where, after dilatation to the maximum ex-
tent (suggested by enthusiastic advocates of
the operation), and carrying out the after-
treatment in the manner advocated by them,
the contraction was as marked as before the
operation, if not to a greater extent, I have
concluded that the operation does not over-
come, to a permanent degree, the contrac-
tion of the cervical canal.

The causes for which we are called upon
to do this operation generally are dysmenor-
rhea and sterility. When I say dysmenor-
rhea and sterility, I do not mean to say that
all cases of painful menstruation are due to
a constriction of the cervical canal, nor that
all cases of sterility are due to this condi-
tion. I have only reference to those cases
where every other reason is excluded and a
stenosed condition of the cervical canal ex-
ists. When called upon to treat a case of
sterility, I think we are justified in operating
if this condition is found to be present,
although history of dysmenorrhea is not as-
sociated with the case, a condition not at all
uncommon ; in fact, the only case of sterilitv
which I have successfully treated by rapid
dilatation is that of a woman who presented
herself to me for treatment with the follow-
ing history : She had been married eight
years, was twenty-one years of age when
married, and had never had any serious
sickness. She was very anxious to have
children, and stated that if the fact that she
had none was due to any condition that
could be corrected she wanted to have it
done. She menstruated regularly, and
never had severe pains immediately before
or during this period. There was no ulcer-
ation around the external os. On passing
the sound it met with, considerable resistance
at the internal os, and was forcibly passed
through. The uterus was found to be in its
normal position. The only condition about
her that I found to which her sterility could
be attributed was this apparent constriction
at the internal os. I dilated this rapidly
under ether, passed a sound at short inter-
vals for a month, after which I did not see
her for four or five months, when I was
called to see her for some of the disagreeable
symptoms of pregnancy, and in a year from
time of operation I delivered her of a
twelve-pound boy.

Of the forty cases that I have operated
upon, ten were for sterility and thirty for
dysmenorrhea. On the first ten cases that
came under my observation for dysmenor-

rhea I operated by rapid dilatation, and of
these but four were relieved permanently.
The condition of six others, after periods
varying from three months to a year, was as
bad, and in two cases worse, than before
operation. They underwent a secondary
operation by incision, and after a period of
from one to two years I have yet to hear of
an unfavorable result. Of the remaining
thirty cases operated on by incision, perma-
nent relief followed in every instance.
Within the last six months I have operated
on three cases which I have not included in
my statistics, as I do not regard a case per-
manently relieved until they pass a period
of one year without a recurrence of the
trouble. Of the ten cases operated upon for
sterility, six underwent the rapid dilatation
operation. This operation proved effectual
in but one case, and that as reported. After
one year's time the contraction was as
marked as before the operation. They
underwent a secondary operation by incision.
Two of them have borne children, and one
other is well advanced in pregnancy, and in
one the constriction is as marked as before
the operation. The other patient passed
from under my observation about six
months after the operation. She was not
pregnant at the time. On four patients I
have done the operation by incision during
the past year ; two are now pregnant — one
two months after the operation, and the
other four months. On two I have operated
within the past three months, and they are
still under my observation.

The constriction in every case that came
under my observation has been at the
internal os. In not a single case have I
met with any resistance with the ordinary
sound until I came to the internal os, and
in every instance the constriction has been
so marked that an ordinary probe could not
be passed unless considerable force was
used. What we accomplish by dilatation is
a paralyzation of the sphincter muscle sur-
rounding the internal os, but it is only a
temporary paralysis, and will gradually re-
sume its functions again in the same man-
ner as the sphincter ani, and after forcible
dilatation for diseases peculiar to the
rectum. The great tendency for this muscle
to contract again after dilatation is not at all
surprising. Very true, the muscular fibres
that are ruptured by the dilatation lose their
power of contractility, but it is almost an
impossibility to rupture them all with the
instruments devised for rapid dilatation,
and I doubt whether we will rupture any of
the fibres if only carried to the extent

June 6, 1 89 1. Periscope.

719

advocated by some authors. When we re-
flect and consider how soon after labor,
where the muscle surrounding the internal
os is put upon a stretch to an extent of six
times as great as can be accomplished by any
of the dilatation instruments now in use,
and how soon after it resumes its power of
contractility, it is inconsistent to expect to
deprive the same muscle of its function
under the force of the instruments devised
for that purpose. The operation by incision
is not attended with any more danger than
by rapid dilatation. A number of instru-
ments, called hysterotomes, or metrotomes,
have been devised to do the cutting. The
objection to these instruments is that they
do not incise deep enough. In my hands
the long, blunt-pointed bistoury has accom-
plished the desired result without any
trouble.

Pelvic peritonitis or cellulitis is a contra-
indication for the operation ; in fact, it is
essential that any inflammatory trouble
peculiar to the pelvis should not exist to
have the operation successful. If the opera-
tion is done and any inflammatory trouble
exists, the operation is certain not to be a
success, but the inflammatory condition
aggravated. This does not include endome-
tritis ; but, on the contrary, when this dis-
ease exists, which it does very often in con-
sequence of a stenosed condition of the inter-
nal os, the cure of it is facilitated by the
opening of the os.

The operation should be done as soon
after the menstrual period as possible. This
will give the tissues sufficient time before
the next period to become completely healed.
If the tissues are in an inflamed condition
at the subsequent period, contraction is very
sure to follow; for this reason a patient
should not be operated upon close to a men-
strual period.

A mild cathartic is given the night before
the operation. If this does not prove effect-
ual by time of the operation, the bowels are
unloaded by means of a rectal enemata. A
vaginal douche is given the morning of the
operation ; this leaves the parts in a proper
condition for the operation. The various
steps in the operation are as follows :

The patient is anaesthetized and placed on
a table, and a bivalve speculum introduced,
or a Sims, whichever is preferred by the
operator. The cervix is grasped by the for-
ceps tenaculum and held in a fixed position.
A dilator is passed to open the os up to a
degree large enough for the bistoury to
enter. After passing the bistoury, the next
step is to make the incisions. I resort to

the crucial incision, one anterior and one
posterior and two lateral incisions. A blunt-
pointed, double-edged bistoury has been
devised to simplify the operation by avoid-
ing turning the instrument. I use the sin-
gle-edged one, and do not experience any
difficulty in turning it from one wall to
the other. The depth of the incision is gov-
erned by the experience of the operator.
The danger of a deep incision lies in the
severing of the circular artery. As near as
I can determine, the depth of the incision I
usually make is about three-eighths of an
inch. The haemorrhage is controlled by
compression with absorbent cotton passed
into the canal on an applicator. Occasion-
ally I have found it necessary to resort to
applications of the persulphate of iron to
control the bleeding. A douche of hot
water is again given, a stem pessary intro-
duced and held in place by tampons satu-
rated with a solution of glycerine and car-
bolic acid (ten grains to the ounce), a hypo-
dermic given, and cold applications are
kept over abdomen for about four days. A
vaginal douche is given once a day for
about ten days. If symptoms of pelvic
inflammation develop, the pessary is taken
out and a sound or dilator passed every few
days, and hot applications are to be made
instead of cold. It is the -exception for in-
flammatory symptoms to develop. The
patients generally make uninterrupted re-
covery, and are able to be around the tenth
day. The pessary can generally be left in
for three weeks before removing. If the
period is due before that, it will be essentially
necessary to remove it at the expected time.
The patients are instructed how to place
tampons themselves. If the operation is for
dysmenorrhoea, sounds should be introduced
a few days before the expected period ; if
for sterility, I generally wait until after the
period before their introduction. If the
patients are not carefully observed and dila-
tation kept up for a year after operation, it
is certain not to prove effectual.

DRAINAGE OF THE ABDOMINAL CAVITY
AFTER LAPARATOMY.

While the majority of German gynaecolo-
gists practice the immediate and complete
closure of the abdominal wound after laparot-
omies, a number of the foremost operators,
both in England and America, speak in favor
of abdominal drainage. Dr. M. Sanger,
has recently performed fourteen laparotomies
in which he has used drainage, and he
1 claims to be forced to the conclusion that the
> course of such cases is much safer and less

720

Periscope.

Vol. lxiv

critical than when drainage is omitted.
Finally, the danger of poisoning by blood
ferments is entirely obviated. There are
three forms of abdominal drainage : first, the
tubular drainage, with straight or bent glass
tubes ; second, the intra-abdominal tampon,
with absorbent gauze ; third, a combination
of the glass tubes and absorbent gauze.

In eleven of the cases reported by Sanger,
in the Deutche Med. Wachenschrift, the last
named method was employed. A most
carefully cleaned and sterilized bent glass
drainage-tube was used, its sides being per-
forated with a number of small holes. After
closure of the abdominal wound, several
strips of absorbent gauze were placed in the
tube by means of a similarly bent copper
sound. Over all this an antiseptic and if
possible an hermetically closed bandage
dressing was applied. The dressings were
renewed in twenty-four hours.

OBSTETRICS.

STRYCHNIA AND THE HOT DOUCHE IN
THE PROPHYLAXIS OF PROTRACTED
LABOR.

The following observations on the use of
small doses of strychnine, given for a period
prior to labor, may prove interesting. From
a therapeutic point of view they are certainly
useful.

I have given strychnine in one hundred
cases, and the effects, as far as the children
were concerned, were very gratifying. Out
of the entire hundred births there were only
two children still-born. One of these had
evidently been dead in utero for some con-
siderable time, and was quite macerated and
softened. The other was lost by the twisting
about the neck of a short cord.

With regard to the mothers, the strych-
nine acted as a bitter tonic and improved the
appetite ; its use stimulated the movements
of the bowels, and to some extent prevented
the constipation that is so general in preg-
nancy. At the time of labor not one of the
patients treated with the strychnine had con-
vulsions, so that it cannot be regarded as
unsafe for this reason. Its action on the
uterus was satisfactory, the contractions be-
ing regular and normal, and entirely free
from any tetanic condition, as is sometimes
seen after the administration of ergot during
labor.

The state of uterine tone was improved by
the strychnine. The contractions of the
uterus were longer maintained, more regular

and satisfactory, than in the case of those
to whom the strychnine had not been given.
The after-contraction of the uterus was better,
and after-pains were greatly lessened, as the
firm condition of the uterus prevented the
formation of clots and the occurrence of
jerky, twitching, clonic uterine action that
is often so distressing to the patient. The
amount of haemorrhage was reduced. There
is an impression in the minds of many that
the bleeding after labor is arrested by the
formation of clots in the uterine sinuses.
Such, however, is not the case. The uterine
vessels are surrounded by the interlacing
muscular fibres of the uterus. It is the
steady, firm contraction of this muscular
tissue that must be regarded as the true
haemostatic, and not dead, inert clots.

Another feature w7ell noted in the cases
where strychnine had been given was that
the recovery was quick and better than the
average. There are several reasons for this.
The shorter period of labor must have had
some influence. Then the fact that there
was less blood loss is important. The firm
tone of the uterus, effecting speedy and good
involution and controlling the after-pains,
also had its share in aiding the recovery.
Good, firm uterine tone lessens the risk of
septic absorption, and by so much favors the
patient's recovery.

Concerning the duration of labor, the fol-
lowing figures may assist in conveying an
idea of the general usefulness of the drug.
It should be remarked the treatment was
adopted in cases where previous labors had
been protracted owing to uterine inertia,
irregular and crampy pains. Primiparse
were excluded in all cases. The one hun-
dred cases treated with the strichnine gave
an average of nine hours, whereas the aver-
age of the previous protracted labors, in the
same one hundred patients, was seventeen
hours. Here we have an average gain of
eight hours on previous tardy deliveries, the
second stage being much shorter.

The dose of the drug varied with the sus-
ceptibility of the patient. One could not
tolerate more than the sixtieth of a grain.
A number had reached their maximum
dosage when taking one-fortieth three times
daily. About one-half of the entire number
bore the thirtieth of a grain well. The largest
dose given in any case was the sixteenth of
a grain three times a day. This amount
was administered to one patient, who. during
two prior labors, had almost complete
uterine inertia.

It is quite possible that other tonics, such

June 6, 1891.

Periscope.

721

as iron and quinine, would exert a beneficial
influence where there was anemia and de-
bility.

As a means of prophylaxis against a pro-
tracted first stage caused by a rigid and un-
dilatable os, I strongly recommend a hot
douche. All are familiar with the excellent
effects of this measure in the first stage of a
lingering labor, but it has not been used as
prophylactic against a tedious first stage due
to rigidity of the maternal tissues. The plan
I have adopted is to take a new tin pail
holding about two gallons, and have a small
spout put on the side near the bottom. To
this are attached a few feet of rubber tubing
carrying a good vaginal nozzle. The pail is
filled with water at 105° to 110° F. The
patient sits over a receiving vessel ; the
nozzle is then introduced and the flow started.
In this way the cervix and vagina are
thoroughly douched. One caution is needed
— that the hydrostatic pressure be not too
great. All that is requisite is just enough
to make the water flow.

It may be said that the use of the hot
water will induce labor before* the full term
has been reached. Such, however, has not
been the case in my experience. But grant
that it should come on a few days sooner
than it would if the douches had not been
used, what harm could there possibty arise
from such a circumstance ? If there is not
too great force in the water flow, so as to
■effect some separation of the membranes,
there need be no fear on this score.

The douche ought to be used twice a day
for a short time before labor, a week or ten
days being sufficient to soften and relax a
very rigid os. The local application of the
hot water stimulates the blood supply of the
pelvic viscera, increases the activity of the
glands, and allays much of the sensitiveness
of the cervix. When labor sets in the os
yields sooner, is less tense and less liable to
tear. The first stage is in this way very ma-
terially shortened. The abundant secretion
of mucus aids the second stage. The second
stage is also shortened by the relaxing action
of the douches on the perineum ; it, like the
os, is found to yield to the pressure of the
advancing head, and time and suffering are
saved.

These douches may be ordered with ad-
vantage in all cases where rigidity and slow
dilatation is probable, as in primiparse, or
where previous tedious labors have been
known to be due to tense and rigid structures.
Many patients of this latter class have gone
through subsequent accouchements with com-
parative ease and rapidity after the use of

the hot water for ten days prior to term. —
Dr. John Ferguson, in Amer. Jour. Ob-
stetrics.

RETAINED PLACENTA IN MISCARRIAGE-
HOW SHALL WE TREAT SUCH CASES ?

Dr. A. J. Swaney in the Southern Prac-
titioner writes :

The reasons given for active interference
are the frequency of these dangers in pro-
longed delivery of the placenta. The almost
constant possibility of manual extraction
which at once assures the woman's safety
from the dangers of haemorrhage and septic
poisoning, Simpson, Munde and Grandin
are perhaps the most active partisans for
interference. Simpson directs if the cervix
is dilated, or patent to act at once, if it is
not dilated, he dilates at once. The woman
is first anaesthetized, the uterus depressed as
much as possible by the external hand and
with the index finger of the other hand, he
removes the placenta and membranes. If
he cannot sufficiently depress the uterus
with the hand, he does not hesitate to
forcibly drag it down by a double tenaculum
fixed in the cervix. Munde and Dr. E. H.
Grandin, of New York, go still further, and
currette the cavity of the uterus with special
instruments made for the loosening of adhe-
rent placenta and its removal from the
uterus. These curettes have no cutting
edge and are applicable to cases where there
is a large mass to remove, and where in
consequence nearly always the cervical
canal is open and will admit them. When
dealing with shreds and the os is less patent,
the dull curette of Thomas answers every
purpose. They place the woman in the left
lateral position and the removal is through
a Sim's speculum. Dr. Grandin then di-
rects, after the removal of the placenta, that
the cavity of the uterus should be carefully
dried by cotton applicator and tamponed
by a slide applicator, the cotton on which
has been saturated with the compound
tinct. of iodine. The compound tinct. of
iodine is used as a gentle styptic and dis-
infectant, or if there is much fetor iodoform
is preferable. The authorities who counsel
waiting for serious complications before
interfering are just as many. We mention
Ramsbotham, Davis, Burns, Fleetwood
Churchill, Grailey Hewitt, Charpentier, and
many others. Charpentier, in his Cyclopaedia
of Obstetrics and Gynaecology, says :

" If the woman miscarries in two stages,
if the foetus has been expelled and the
placenta remains, what is to be done?
Usually nothing : nature can do the work.

722

Periscope.

Vol. lxiv

The placenta may remain days before being
expelled ; whilst there are no complications,
wait at least till the placenta is engaged in
the cervix and detached from the uterus,
and then extract. If the placenta is not
engaged and the cervix is closed, wait, and
in case of haemorrhage tampon, give ergot,
never the ergot alone. If the placenta is
still adherent, and is in part engaged in the
cervix, give ergot, for the cervix cannot
contract, since its canal is filled by the
placenta. If the placenta is at the fundus
and adherent, w-ait in case there are
no complications, but interfere in case of
accident. If it be haemorrhage, the tampon
and ergot. If it be putrefaction of the
placenta, recognize this and extract at once ;
we must not hesitate, but we must im-
mediately extract the placenta or secudines,
and this, it is understood, is all the more
difficult, the more completely the cervix has
closed. If the cervix is permeable to the
finger or instruments, the operation is easy.
If closed, then we must dilate at once with
sponge, branched steel dilators, or with
Barnes' bags. Dilatation once accom-
plished, we must proceed to extraction, and
this must be done by the finger or instru-
ments, according to the case. He directs
after the cervix has been dilated, and the
woman on her back, to depress the uterus
with the left hand as much as possible, and
with the index finger of the right hand in-
troduced into the cavity of the uterus, or as
deep as possible, the adherent remnants are
detached and brought away. If this does
not suffice he resorts to instruments."

Septicaemia being one of the dangers from
putrefaction of the retained placenta, how
are we to recognize this. The first sj^mptom
is fetor of the lochial discharge. The
discharge further loses its normal character
and diminishes in quantity, becoming in
color black or brown. It is no longer
bloody or sero-sanguinolent, but is com-
posed of reddish-black detritus, the debris
of the retained mass, involution ceases and
the uterus becomes sensitive to pressure.
At times tympanitis supervenes with or
without diarrhoea. The woman has chills.
Sometimes the chills are violent and single,
at other times many, separated by intervals
of one or two days. There is fever, the
temperature rising to 104°, 105° F. The
pulse ranges to 120 or more. The tempera-
ture shows a marked remission, but the
pulse remains high, and thus it may be day
after day until the woman dies, or the fever
may be continuous. The general condition
alters for the worse. The eyes are sunken,

anorexia and vomiting exist, the woman
grows weaker, and if we cannot suppress
these symptoms, dies of septic poisoning.

Has the physician any business to allow a
woman wTith retained placenta to enter such
a state as this ? Is he doing his duty to sit
calmly waiting for the onset of sepsis ? He
knows what he ought to do in case of sepsis,
but action then, no matter how prompt, may
fail, and the woman die of septicaemia.
Then, as we cannot tell in any given case of
retained placenta or secundines whether or
not sepsis may develop, which is the wise
course to pursue? To sit calmly waiting
for the approach of these dangers, as ad-
vised by Charpentier, Ramsbotham, and
others ; or to act promptly, as advised by
Munde, Grandin, and others ? I believe
with Munde and Grandin, that active inter-
ference in the removal of the retained
placenta is safe, easy, and forthwith guaran-
tees the woman against sepsis. Active inter-
vention does not mean unnecessary inter-
vention. Nature is ever to be given a
chance, but when we see her efforts are
futile, certainly it is but rational to assist
her, and this should be done as directed by
Munde and Grandin, by placing the woman
in the left lateral position, and w7ith a dull
wire curette remove the placenta or any
part of the secundines that may remain
through a Sims speculum. This is far
better and easier than the method advised
by Simpson, of dragging or pressing down
the uterus and introducing the finger into
the uterine cavity. The uterine cavity
should then be washed out with hot water
slightly carbolized through a Jamson uterine
douche, and repeated every six or eight
hours until all fetor disappears from the
lochial discharge.

I am painfully aware of the fact that a
very large majority of physicians follow
and practice the expectant or do-nothing
plan, being satisfied with giving ergot and
vaginal injections. It would doubtless be a
surprise to many if we could ascertain the
number of valuable lives that have been
lost and the amount of suffering entailed
upon women from the neglect of removing
the retained placenta. Who of us with
much experience has not seen such cases ?

Shall we give ergot in retained placenta ?
This is another practice which should be
relegated to the past. Engleman says never
give ergot until the uterine cavity is cleared.
The contractility evoked by ergot is notably
different from that which is peculiar to the
uterus ; it is a species of tetanic contraction
which, when it affects the cervix, not only

June 6, 1 89 1. Periscope.

723

does not cause dilatation, but produces
rigidity. Ergot may then act directly
opposite to the end desired, and by inter-
fering with dilatation of the cervix shut up
the uterine cavity. Haemorrhage after mis-
carriage, even when we believe the placenta
and membranes have been removed, invari-
ably means retention of a part of the pla-
centa or secundines. Profuse haemorrhage
may occur for weeks from this cause. In
such cases we should boldly explore the
uterine cavity and remove any offending
matter that may be present.

In the first twelve weeks of pregnancy,
the dangers from haemorrhage and septicae-
mia are not so great, and the expectant plan
is more justifiable. After the third month
it is criminal negligence to wait and subject
a woman to the dangers arising from
retained placenta, when she can be relieved
by an operation, which, if properly done,
can do no harm and spare her the risk of
haemorrhage and septic poisoning.

Again, with Munde and Grandin, I
repeat. The early removal of the secun-
dines is easy, safe, and forthwith guarantees
the woman against the dangers of haemor-
rhage and sepsis.

It has been said that necessity is the
mother of invention. I now show you an
instrument improvised and made fifteen
years ago by Dr. Thomas M. Woodson, of
Gallatin, Tenn. As you see, it is simply a
wire doubled and twisted together, leaving
an open space at the end, as the wire is
brought back. This opening is about one-
half to three-quarters of an inch wide and
two inches long, and is then again bent to
resemble a spoon. This is as good a curette
as Tieman can make, and was devised and
used by Dr. Woodson to extract a retained
placenta in a miscarriage of five months
pregnancy. He has used this frequently
and successfully, and in case of emergency
it will answer every purpose. Some months
ago I saw a lady who had miscarried at five
months. Five days after the foetus passed,
a retained placenta was passed by the
unaided efforts of nature ; four days after
this, I saw her in a dying condition with
septicaemia. Was it proper to allow the
placenta to remain such a length of time?
Was this a wise course to pursue? Who
can say : " This valuable life might not have
been saved by the early removal of the
retained placenta?" This case prompted
me to present this paper for your thought
and consideration.

TREATMENT OF POST-PARTUM ECLAMP-
SIA.

Dr. Strisover contributes a most interest-
ing article on the treatment of post-partum
eclampsia in a recent number of the Journal
de Med. de Paris. The treatment advocated
by him, and used successfully in every case
(ten) in which he has had occasion to try it,
consists in hypodermic injections of the fol-
lowing solution :.

T> Chlorhydrate of Pilocarpine, gramme o. 05

XV Water 4. 00

Each injection to consist of a Pravaz
syringeful of the solution.

The author closes his article with the fol-
lowing conclusions :

I. Chlorhydrate of pilocarpine is un-
doubtedly a trustworthy remedy in post-
partum eclampsia.

II. Cardiac weakness is not a contraindi-
cation for the repetition of the injections of
pilocarpine if the eclamptic spasms reappear.

in. A return of the pupils to the normal
size is an indication that the morbid process
has not yet been conquered, and that the
convulsions are about to recur.

PEDIATRICS.

ETHERIZATION IN CROUP.

Dr. F. Betz contributes an article to the
current issue of Memorabilien, which, though
founded on only one case where etherization
was tried as a treatment for croup, is yet of
sufficient interest to merit notice. He com-
menced by pointing out that in croup the
tendency towards death is by no means
commensurate always with the morbid
condition of the larynx anatomically consid-
ered, the nervous system often playing a
considerable role. The case he describes
was that of a child thirteen months old, to
whom he was called by another practitioner
in order to assist in the performance of
tracheotomy. The child was breathing with
the greatest difficulty, expiration and inspi-
ration being equally noisy; the hypochon-
driac regions were strongly drawn in at each
inspiration, also the lower intercostal spaces
anteriorly ; the alae nasi were working
strongly, and the child kept clutching at its
throat, where the larynx was very promi-
nent, and at its ears, and twisting its head
round as if there were both pain and a sense
of obstruction. It would not drink or stay
in bed, the face wore an anxious expression,
and the head was retracted. No membrane
could be detected in the throat, and there
was no sound of air entering the lungs when
auscultated from behind. On the left side

724

Periscope.

Vol. lxiv

percussion was dull from want of expansion
of the lung. Altogether the case was appar-
ently hopeless. Notwithstanding the danger-
ous character of tracheotomy in children so
young, preparations were made for its per-
formance, when the writer suggested that
ether inhalations should first be tried. A
mixture was ordered of three parts sulphuric
ether, one part acetic ether, and one-tenth
part menthol, of which three drops wrere
given as an inhalation on a folded handker-
chief every quarter of an hour. The idea
was by means of the vapor of ether and
menthol to act on the mucous membrane of
the larynx, which, as is well known, lies
somewhat higher than usual in croup, and
thus to contract the bloodvessels, to lower
the temperature of the part, to decrease the
oedema, to lessen secretion, and to allay the
irritation in the larynx by the production of
some amount of local anaesthesia. In addi-
tion to these, Dr. Betz had the further object
in view of inducing partial general anaesthe-
sia so as to give the child rest, and to allay
the spasmodic contractions of the muscles
connected with respiration. In a couple of
hours a decided change for the better had
taken place, the child being quieter, and
some air evidently entering the lungs. The
inhalations were continued, therefore, but at
intervals of half an hour. Six hours later
the respiration had become much less noisy,
the contractions less, and the dyspnoea far
less urgent, enabling the child to drink.
The face had regained its proper color, and
the child was apparently pretty comfortable,
so that there was no longer any need to
think of tracheotomy. The regular admin-
istration of the inhalation was stopped, but
another mixture of somewhat similar char-
acter, containing three-tenths of a part of
menthol, was ordered, in case of any recur-
rence of the alarming symptoms. Fortu-
nately the subsequent progress was so
uniform that no recourse to this was required.
The object of increasing the menthol was to
obtain greater refrigeration and to enable it
to penetrate further into the air passages.
The writer remarks that Trousseau used to
prescribe chloroform inhalations in croup,
but he is disposed to prefer his own mixture
of ether and menthol. Whether such ether-
ization has any power to loosen false
membranes further experiments must show ;
but when tracheotomy or intubation is for
any reason inadmissible in undoubtedly
membranous croup, this treatment may, he
thinks, very fairly be tried. The inhala-
tions ought not to be continuous, but intermit-
tent, and the medical man should for the

first hour or two administer them himself. —
Brit. Med. Jour.

HYGIENE.

PROGENY OF LEPERS.

In an analysis of 118 cases of leprosy
in the Tantaran Asylum, in the Punjab, re-
ported by Gulam Mustafa and read before
the Epidemiological Society of London, by
Dr. Phineas S. Abraham, we find the fol-
lowing relative to the progeny of lepers :
Seventy-three of the total number appear to
have been married before the onset of the
disease, viz., forty-three males and thirty
females ; and whilst still in the healthy con-
dition, the males are credited with seventy-
one children, now or lately living, and in
most cases free from the disease, and the
females with sixty-five; total, 136. Only
four females are stated to have given birth
to offspring, five in all, after the disease had
declared itself. Until recently, it was the
custom to allow the patients to intermarry.
Thirty-nine of those whose histories are re-
corded, viz., sixteen males and twenty-three
females — availed themselves of the privilege,
and seven of them married more than once ;
thus, one man united himself with no less
than five leper wives, one after the other,
and several other patients were married two
or three times. Altogether, the number of
marriages contracted by the men in the list
amounts to twenty-six, and those of the
females to twenty-nine. Only five of the
men proved prolific, with a result of ten
children and eight of the women with a
result of fifteen children. Four of the
children are dead, so that we have left
twenty-one as the progeny of fifty-five mar-
riages. As the notes give no information
as to the names of the leper or lepers which
each man or woman married, it is impossible
to say whether the children and the marriages
are not counted twice in the above collection.
It is probable that the actual sterility is even
greater than these figures indicate. — St.
Louis Med. and Surg. Jour.

TRANSMISSIBILITY OF SYPHILIS.

As published in his magnificent Atlas
of Venereal and Skin Diseases, Prof. Morrow's
conclusions in reference to the hereditary
transmissions of syphilis are :

1. A syphilitic man may beget a
syphilitic child, the mother remaining ex-
empt from all visible signs of the disease ;

June 6, 1 891.

Periscope.

725

the transmissive power of the father is, how-
ever, comparatively restricted.

2. A syphilitic woman may bring forth a
syphilitic child, the father being perfectly
healthy ; the transmissive power of the
mother is much more potent and pronounced,
and of longer duration, than that of the
father. When both parents are syphilitic,
or the mother alone, and the disease recently
acquired, the infection of the foetus is almost
inevitable ; the more recent the syphilis, the
greater the probability of infection, and the
graver the manifestation in the offspring.

3. While hereditary transmission is more
certain when the parental syphilis is in full
activity of manifestation, it may also be
effected during a period of latency when no
active symptoms are present.

4. Both parents may be healthy at the
time of procreation, and the mother may
contract syphilis during her pregnancy, and
infect her child in utero. Contamination of
the foetus during pregnancy is not probable
if the maternal infection takes place after
the seventh month of pregnancy.

MEDICAL CHEMISTRY.

SOLUBILITY OF IODOFORM IN OLIVE-OIL.

The solubility of iodoform in the fixed
oils is stated somewhat variably. Squire
gives 1 to 30 of olive-oil ; Martindale " 1 in
60 of vaseline and oil of almonds, and about
the same in fats and other fixed oils.', F.
Klingmann (Apoth. Zeit., 18 31, 70) has re-
cently determined the factor with care.
Five grammes of iodoform were added to 30
grammes of olive-oil, the whole been shaken
for twelve hours by means of a small tur-
bine. Then it was filtered, and the saturated
oil wTas found to contain between 2 J and 3
per cent, of iodoform. With due allowance
for specific gravity, this shows the solubility
of iodoform to be 1 part in 39 fluid parts of
olive-oil.

UROLOGY IN CONNECTION WITH INFAN-
TILE DISEASES.

Albuminuria. — The citro-picric acid re-
agent of Esbach is approved. First, filter
the urine, then pour a few centimeters of it
into a tube, and then an equal quantity of
the reagent. If there is albumen the mix-
ture will become opalescent, or there will be a
precipitate. Frequently it may be neces-
sary to reach the boiling point before the
precipitation will take place. Examinations
for albumen were made in two hundred and

fifty cases. In twenty-seven cases of pneu-
monia and broncho-pneumonia, albumen
was found in large or small quantity. Albu-
men is usually associated with febrile oligu-
ria; it disappears with defervescence and
increases in the urine. It is a characteristic
of all infectious diseases, though the rule is
less absolute in children than in adults. In
measles, albuminuria was present in 33 out
of 34 cases, in scarlet fever in 34 out of 43,
in erysipelas in 4 out of 5, in febrile roseola
in 1, in typhoid fever in 5, in diphtheria in
36 out of 40 ; it was absent in 1 case of
mumps and 2 of false croup. Albuminuria
is transitory and not intense in most dis-
eases with the exception of diphtheria,
though in scarlatina it is present in a serious
and rather permanent form in the second-
ary nephritis, which may occur as a compli-
cation. The albuminuria of diphtheria has
no relation to the existence or intensity of
the fever. It is present in fifty to seventy-
four per cent of cases. In 10 cases of pul-
monary tuberculosis albuminuria Avas pres-
ent in 5, and in 4 out of 6 cases of tuber-
cular meningitis. In 6 cases of whooping-
cough it was found only once, in 1 case out
of 3 of athrepsia in very young children, in 2
out of 3 cases of scrofulous cachexia with
adenitis, in 1 case of acute perityphlitis, and
in 1 of extensive burning. In 21 cases in
which there was suppuration, especially in
connection with carious bone, there was
albumen in 11. Of 27 cases of nephritis,
21 occurred with infectious diseases, and 6
as chronic nephritis.

Peptonuria. — The peptones are hydrated
albumens, soluble in water, diffusible, dialyz-
able, and not precipitated by heat, nitric
acid, ferro-cyanide of potash, and acetic acid.
They are easily precipitated by most of the
reagents which precipitate the alkaloids, the
precipitate being redissolved by heat and
reappearing with cold. The reagents which
are most frequently employed are phospho-
tungstic acid, phospho-molybdic acid, tannin,
iodo-iodurateot solutions, iodo-mercuric
and citro-picric solutions. The search
for this substance is made in the same
way as for albumen. If a precipitate
is obtained it may consist of albumen,
peptones, alkaloids, or urate of sodium.
If it should be albumen, it will not be dis-
solved when heat is applied. If it should
consist of alkaloids or peptones, heat will
dissolve it, but the alkaloids, and quinine in
particular, will respond to particular reac-
tions for such substances. The acid urate
of sodium forms a finely granular precipitate

726

News and Miscellany.

Vol. lxiv

which appears more slowly than a precipitate
of peptones ; the latter will also give an
opalescent appearance.

If there is any doubt remaining, it may
be settled by the murexide test. If the
urine is albuminous, the albumen may be
eliminated by Hoffmeister's method." Eich-
wald and Gerhardt were the first to deter-
mine the presence of peptonuria, in cases of
pneumonia,diphtheria, phosphorus poisoning,
tertiary syphilis, petechial typhus, and doth-
inenteritis. Jaksch discovered it in certain
conditions in which there was change in the
blood, scorbutus being one of these condi-
tions. In the general infectious diseases it
is usually absent. Peptonuria has been
divided into the following groups : nephro-
genic, pyrogenic, puerperal, hematogenic,
enterogenic, hepatic, and urogenic. The
blood normally contains no peptones, hence
its presence indicates a non-assimilable ma-
terial which the kidney should eliminate.
Peptones were sought by the author in 248
cases of disease in children, and were found
in 34. It was found in 5 cases out of 28 ot
pneumonia and broncho-pneumonia, in 1
case out of 2 of purulent pleurisy, in 1 case
of severe febrile roseola, in 10 cases out of
37 of diphtheria, in 3 cases out of 21 in
which there was suppuration, in 1 case out
of 6 of athrepsia, in 13 out of 23 of nephritis.
In the 34 cases of peptonuria there were
32 in which there was also albuminuria.
The methods of investigation now in use are
not yet sufficiently exact.

Diaceturia. — If to normal urine a solution
of perchloride of iron is added, there will be
a precipitate of phosphate of iron ; if per-
chloride of iron is still added, the precipitate
will be dissolved and the urine will assume
an amber color, or, in other cases, the color
of red wine, which will become less marked
by boiling, and will disappear if acids are
added. These reactions will not take place
if the urine is first submitted to prolonged
boiling. Jaksch considers this reaction due
to aceto-acetic acid or its ethers, and he has
given the name diaceturia to the elimination
by the urine of its acetic acids, its salts, and
its ethers. He has determined its presence
in diabetes and in several febrile diseases,
and has also found that it might exist as the
expression of a particular auto-intoxication.
Febrile diaceturia is of frequent occurrence
but is not of serious prognostic significance.

In diabetes it is a grave symptom, and
frequently announces the advent of coma.
In 150 examinations the author determined
diaceturia in 69. It was found 19 times in
23 cases ot pneumonia and broncho-pneumo-
nia, in 16 out of 26 of measles, in 27 out of

34 of scarlet fever, in 4 cases of erysipelas,
in 11 out of 31 of diphtheria, in 2 out of 13
cases of suppuration, in 2 out of 4 of typhoid
fever, in 2 out of 4 of tubercular meningitis,
in 1 of acute perityphlitis, in 1 of extensive
burning, in 2 out of 15 of acute nephritis, in
1 of solid tumor of the iliac fossa. Diace-
turia maybe considered as of frequent occur-
rence in infectious febrile diseases, and par-
ticularly in scarlet fever. It occurs excep-
tionally in uncomplicated diphtheria. —
Binet's — Rev. Mens. Mai. Enf.

NEWS AND MISCELLANY.

Result of Koch's Treatment. — Ac-
cording to the British Medical Journal, 708
cases have been treated in external tubercu-
losis, 15 cured, 148 substantially improved,
237 improved, 298 unimproved and 9 died.

MODERN DISCOVERIES OF NEW CURES.

With painful and patient pen we record
the birth of a new treatment for phthisis,
the sixth in four months. The hopeful
author and discoverer this time is Dr. Tran-
jen, of Sistow, Bulgaria. He doesn't seem
to have any front name, but that may be
the fashion in Sistow. Professor Dr. C. A.
Ewald writes a supplement to Dr. Tranjen's
communication and also publishes the details
in all their rosy tabulated promise in the
Berliner Klinische Wochenschrift, an organ
for practical doctors. The refrain which
Dr. Tranjen plays upon Professor Ewald's
organ is like that of other discoverers. We
are having prepared a lithographed form for
the benefit of future ingenious therapeutists
in this same line. It will read like this :

" Form I. — Dr. has discovered a new

remedy for phthisis. He reports . . . cases.
The results have so far been very satisfac-
tory. In early stages it produces decided
improvement and sometimes cure. In later
stages it does not do so much good, but
sometimes causes remarkable improvement

before the patient ultimately dies. Dr. 's

new treatment promises to be a useful addi-
tion to our therapeutic armamentarium, and
deserves further trial."

We shall be very glad to furnish " dis-
covery blanks" of the above type to our
clinical workers.

But meanwhile we had almost forgotten
to say that Dr. Tranjen's new discovery con-
sists in the hypodermic injection daily, for
seven to ten days, of a solution of thymolo-
acetate of mercury, at the same time giving
the patient iodide of potassium. The results
are accurately described in Form I, as given
above. — Med. Rec.

Whole No. 1789.

juwb id, loyi.

10 Cents a Copy.

THE

MEDICAL AND SURGICA
REPORTER

A Weekly Journal.

Established in 1853 by S. W. BUTLER, M. D.

EDWAKD T. BEICHEBT, M. D., Editor and Manager,

Entered as Second-Class matter at Philadelphia P. 0. N. E. Cor. 13th & WALNUT STS., PHILA.

■33

CLINICAL LECTURES.

Charles G. Stockton, M. D., Buffalo, N. Y.
Syphilis with Lesions of the Heart and

Kidneys 727

R. C M. Page, M. D., New York, City.

Chronic Phthisis 739

COMMUNICATIONS.

J. C. Wilson, M. P., Philadelphia, Pa.

Caries of Costal Cartilage Following Enteric
Fever — Persistence of Sinus after Operation —

Treatment by Methyl-Violet — Cure

D. W. Cadwallader, M. D., Philadelphia, Pa.
Report of a Case of Fibro-Papilloma of the

Bladder, with Recovery 734

J. M. Thomas Chapman, Bessemer, Ala.

The Mechanical Treatment of Umbilical Hernia

in Children 735

SOCIETY REPORTS.

State Medical Society of Pennsylvania. . . . 730

SELECTED FORMULAE. 747

EDITORIALS.

Infantile Malaria 749

CORRESPONDENCE 751

BOOK REVIEWS.

A Guide to the Clinical Examination of the
Urine — Historical Sketch of The University of
Maryland — The Diseases of Personality. . .751

PERISCOPE.
Therapeutics.

The Employment of Guaiac as a Purge —
Radlauer's Antisepsine — The Treatment of
Lupus — Action of Antipyretics — Jambul in the
Treatment of Diabetes — Treatment of Tuber-
culous Bronchitis by Hypodermic Injections of
Iodoform — On the Utilization of the Food in

Cases of Gastric Diseases — Chloralamid — Diph-
theria, with Special Reference to its Treatment

Avith Hydrogen Peroxide .

Medicine.

Albuminuria Caused by Antipyrine — Treat-
ment of Phthisis by Artificial Atmospheres
Under Pressure — Angina Pectoris: Its Nature
and Treatment — "Traumatic Neuroses" — The
Diagnosis of Motor Insufficiency of the
Stomach — The Diagnostic Significance of Ve-
nous Hum in the Neck ; a Study in Statistics
— .Etiology of Bright's Disease — A Form of
Gingivitis Common to Men and Dogs in India.
Surgery.

Temporary Resection of the Cranium — The
Treatment of White Swellings — The Indica-
tions for Surgical Intervention in Traumatic
Hysteria i.

Gynaecology.

An Enormous Ovarian Cyst — Bagot on Mass-
age as Applied to the Treatment of Incon-
tinence of Urine in Females

Obstetrics.

Iodoform Gauze in Post-P^tum Haemorrhage —
Fetid Milk in Human Mammary Glands —
Duration of Pregnancy

Pediatrics.

The Prevention and Treatment of Scarlet
Fever

Hygiene,

The Transmissibility of Hydrophobia from
Man to Man — Voluntary Constipation. . . .
Medical Chemistry.

Isolation of a Cholera Toxine

NEWS AND MISCELLANY

r.56

759

ARISTOL.

While possessing all of the virtues of iodoform, and many properties not claimed for the latter ARISTOL has
NO TOXIC INFLUENCE AND NO DISAGREEABLE ODOR.

The efficacy of ARISTOL has been widely tested by physicians and surgeons. As a simple dressing it now
HEADS THE LIST OF LOCAL REMEDIAL AGENTS, and the Jesuits obtained in the GREAT VARIETY
OF MORBID LESIONS for which it has been employed, have been wholly satisfactory.

ARISTOL has been widely commended for its special adaptability to all surgical and pharmaceutical
requirements. It may be used in the form of OINTMENTS, CRAYONS, SUPPOSITORIES, BALLS, OILS,
SPRAYS, COLLODIONS, POWDERS, PLASTERS, Etc., while it is equally suitable for TAMPONS, BAND-
AGES, GAUZE, and other topical appliances. Used as a powder, it forms AN IMPERVIOUS ANTISEPTIC
COATING, which gives it an exceptional value in ULCERATIONS, BURNS, Etc.

ARISTOL has been used with unqualified satisfaction by able and experienced clinicians in DERMATOLOGY,
SYPHILOLOGY, GYNAECOLOGY, OPHTHALMOLOGY, Etc., and in all of those diatheses in whose course
such lesions supervene as call for ACTIVE, LOCAL MEDICATION.

ARISTOL is demonstrated to possess EXCEPTIONAL EFFICACY AS A CICATRISANT. In ULCERA-
TIONS, of whatever character they may be, in BURNS, and in ALL OPEN LESIONS, the efficacy of ARISTOL
cannot be overestimated.

Hence its great value in the DERMATOSES, the SOLUTIONS OF CONTINUITY dependent upon
PHTHISIS, SCROFULOSIS, SYPHILIS, VARIX and accessible TRAUMATISMS, and in the SUPPURATIVE
LESIONS following many inflammations. Its value in BURNS, as in all the operations of MINOR SURGERY,
is exceptional, while in DENTAL SURGERY it has given very valuable results.

Applied to the MUCOUS SURFACES of the NATURAL CAVITIES, in such conditions as PHARINGITIS,
RHINITIS, OTITIS METRITIS, URETHRITIS, etc., etc., ARISTOL gives the same excellent effects as in
tissue lesions.

JS*§t' Physicians are respectfulty requested to test for themselves the accuracy of these statements, while reading
in our pamphlet of the results obtained by others. Pamphlet mailed to applicants.

The preparation of ARISTOL, theoretically simple, involves the greatest care and experience, and the word
" ARISTOL" is the registered property of The Farbenfabriken , normals Friedr. Bayer &> Co., in Elberfeld. In or-
der, therefore, to secure the desired effect of ARISTOL, it is important that the physician be certain that the
article used bears the name of these manufacturers, together with the name of W. II. Schieefelin & Co.

7f. H. Schieffelin & Co.,

NEW YORK.

JOHN C. BAKER & CO.'S

Standard Preparations.

Messrs. John C. Baker & Co.

Gentlemen :

It affords me pleasure to have the opportunity of recommending your Cod
Liver Oil to the medical profession.' I feel satisfied that a purer and more efficacious
article can not be obtained in the market.

Yours, with respect, JOSEPH LEIDY,

Professor of Anatomy in the University of Pe

Baker's Fure Norwegian
Cod Liver Oil.

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THE

MEDICAL AND SURGICAL
REPORTER

No. 1789. PHILADELPHIA, JUNE 13, 1S91. Vol. LXIV.— No. 24.

Clinical Lecture.

SYPHILIS WITH LESIONS OF THE HEART
AND KIDNEYS.

BY CHARLES G. STOCKTON, M. D„

PROFESSOR OF THE THEORY AND PRACTICE OF MED-
ICINE, UNIVERSITY OF BUFFALO — VISITING
PHYSICIAN TO THE BUFFALO GEN-
ERAL HOSPITAL.

§.v —

This is not an easy case to diagnose by
exclusion, and I shall, therefore, go directly
to the ultimate cause of his difficulty and then
we will try to account for his more immedi-
ate troubles.

A few months ago, this man acquired
syphilis, and he is now suffering with the
secondary manifestations of that disease,
feverishness, weakness, mucous patches in
the mouth, and specific pharyngitis and
laryngitis. You have seen him in the wards
and you understand that while these are
manifestations of importance, they are con-
ditions that can usually be readily relieved
by the use of mercury, and the symptoms
pass off under a careful administration of
this drug in a comparatively short time,
particularly if the patient is, at the same
time, well cared for, well fed, not allowed to
worry, not allowed to drink alcoholic bever-
ages, and compelled to keep regular hours.
Under this treatment the man has done
badly, he very soon showed tenderness of the
gums and salivation, so that the mercury had
to be withdrawn, and his throat trouble be-
came worse. Then mercury hypodermically
was tried and injections of the bichloride
were made once daily until the effects in the
mouth were shown and then it was discon-
tinued to be tried again after three or four
days. Once in two or three days is often
enough for hypodermic injections of mercury
if you use large enough doses. We used in
this case one-eighth of a grain daily. You
may give a half a grain and allow two or

three days to elapse before the next dose.
Under this treatment the man has gotten
the good effects of mercury but he has had
considerable throat trouble, and one night
he had indications of oedema of the glottis, a
croupy cough, the symptoms of laryngismus
stridulus, and we felt it necessary to have
means at our disposal for relief if the con-
dition became worse. The O'Dwyer tubes
were put in readiness, but under the use of
an alkaline steam-spray, he improved, and,
while he is yet voiceless and yet suffers to
some extent from cough, he is decidedly bet-
ter. Not getting any relief for his throat
symptoms by the use of Gross's mixture,
which we gave first, nor by the use of mer-
cury hypodermically, I began giving him
mercury in the form of the green iodide by
the mouth, and under that, I think, he is
doing better, so far as his throat is concerned,
than he did under the hypodermatic use of
mercury — a matter of therapeutic interest
because it is contrary to what is generally
stated in regard to the relative value of dif-
ferent modes of employing mercury.

I bring the man before you this morning,
not in regard to his ultimate disease, but on
account of certain manifestations of the dis-
ease in the viscera. He is very anaemic ; he
is eating and digesting very little. He has
great prostration and I discovered some time
since that he had a curious pulse. It was a
pulse suggesting the Corrigan pulse and yet
not well enough sustained in the beginning
to make a true Corrigan pulse. It was fre-
quent, very compressible and vibratory. My
attention was naturally directed toward the
heart and I found that the man was suffering
from a present endocarditis which showed
itself by the soft bruit, the somewhat tumult-
uous action of the heart as well as the
curious character of the pulse. This endo-
carditis was located in the left side of the
heart where it almost invariably occurs in
adult life, and affecting especially the mitral
and aortic orifices. Later I found that this
man was suffering from oedema. His hands
are somewhat puffy, the fingers seem large

728

Clinical

Lecture.

Vol. lxiv

in proportion to the size of the hand and the
skin is distended and glossy. Before saying
that this was the result of the disease of the
heart alone. I asked that the urine be ex-
amined with a view to learning whether
there was also kidney disease present and it
was found that there was a large amount of
albumen in the urine. We have here not
only secondary syphilis with serious throat
trouble, but a present endocarditis and
nephritis. The form of nephritis which h«
has, I cannot state to you without making a
careful microscopic examination of the
urinary sediment, estimating the urea,
studying the relation between the quantity
of urine and the albumen, but in all proba-
bility it is an acute desquamative nephritis,
coming on, as the heart trouble has come on,
since his entrance into the hospital, and,
therefore, secondary to the attacK of
syphilis. Why do I make a diagnosis of
acute desquamative nephritis ? The large
amount of albumen and the brevity of the
duration of the symptoms make me think
that the case is an acute one, and if so, it is
probably of the parenchymatous form.

Let us look at the patient generally, be-
fore we study more carefully the condition
of his heart and kidneys. The oedema is
seen very plainly in his legs, his feet are
swollen and are quite red, showing a con-
gestion which is unusual in oedema. There
is no dermatitis, either simple or syphilitic
and it is not a temporary condition, due to
the recent application of heat. The con-
gestion of the capillaries is probably due to
some affection of the sympathetic system.

The oedema is undoubtedly due to the
heart and kidney lesions. The state of the
blood might add to the condition. You
may ask if the liver may not have some-
thing to do with causing the oedema. That
is possible, although general anasarca we
refer, as a rule to disease of the heart, kid-
neys or blood. Dropsy due to the liver, is
usually an ascites, and not a general ana-
sarca, unless the hepatic trouble acts to
interrupt the general circulation in some
very marked way, or unless it gives rise to
serious blood changes such as take place in
cancer of the liver. An acute neuritis
might give rise to an oedema, but our
patient has no evidence of neuritis. Ana-
sarca may also be due to the obstruction of
the flow of blood through the lungs by dis-
ease of the lungs, but this man shows no
further trouble in the lungs than the over-
filling of the vessels with blood, which is
readily explained by the heart disease.

The endocarditis, being acute, will prob-

ably get better in course of time ; just how
much deformity of the valves will remain,
it is impossible to say. The apex-beat is in
the fifth intercostal space, about an inch and
a quarter below the nipple and a trifle to
the right of the nipple line. At the apex
I find a bruit which precedes the ordinary
systole of the heart, and is, therefore, a- pre-
systolic bruit. It is accompanied by a con-
siderable thrill at the apex and just above
it. The presystolic sound is heard in the
same locality with the greatest intensity. It
is caused by an obstruction and narrowing
of the mitral orifice due to swelling, possibly
©edematous, of the leaflets of the valve. If
the man improves, this condition may en-
tirely subside, or it may leave behind a per-
manent narrowing of the mitral orifice. It
may leave merely a shortening of the valves
and an insufficiency. There is also a
systolic bruit. The presystolic bruit ends
in the systolic bruit in the somewhat excited
state of the heart at present. The blood is
forced down by the contraction of the
auricle making the presystolic sound and,
on account of the insufficiency of the valve,
some of the blood is immediately returned
by the contraction of the ventricle giving
rise to the systolic sound. Both the presystolic
and the systolic sounds are soft and cooing in
character, and when the patient is lying
dowrn at rest there may be heard very dis-
tinctly, three sounds at the apex instead
of two. The first two sounds come nearer
together. The first sound is the murmur
produced by the contraction of the left
auricle ; the second the regurgitant murmur
produced by the contraction of the left
ventricle, and the third sound is the ordinary
second sound of the heart caused by the
closure of the aortic valves. None of the
heart sounds have their natural accent, they
are all obscure and have a certain blunt-
ness, a certain muffled character which is
the result of the oedema, which is present in
the heart. The systolic sound is carried up-
ward and to the left as we would expect,
and, while I can not hear the sound behind,
it is simply because it is not distinct enough
to be propelled to that distance.

The man has also disease at the aortic
orifice and that I know by the character of
the sounds at the base of the heart. There
is heard, with the first sound of the heart, a
soft bruit, which travels upward into the
vessels of the neck and which is also muf-
fled and obscure. The second sound of the
heart is nearly normal. There is a sharp
accentuation to it now because the man is
somewhat excited and his arterial tension is

June 13, 1891.

Clinical Lecture.

729

higher than normal. When he is in bed
this sound, too, is muffled and with it there
is a slight murmur of insufficiency. He
has disease at the mitral and aortic orifices,
both obstructive and insufficient in char-
acter, which may be entirely temporary,
which is produced by an acute endocarditis
and also by a profound anaemia which causes
softness and relaxation of the cardiac tis-
sues.

This man has an acute inflammatory
degeneration of the kidneys as the result
of syphilis. I have no doubt of the syphilis
possibly involving the blood-vessels of the
kidney, and also directly attacking the
epithelium and giving rise to a cloudy
swelling and softening and desquamation of
the epithelium. Tube casts are produced,
epithelial, hyaline, granular and, probably,
to a certain extent blood-casts. The amount
of urine is doubtless small and the urea is
decidedly diminished. Those waste prod-
ucts which are normally formed in the
blood and which are formed to an abnormal
degree in this man's case, are not thrown
off properly by the kidneys and the man
has a uraemia, strictly speaking, and other
toxaemias also.

What are we to do for the patient ? We
must deal with the cause certainly. The
syphilis must be treated and the most im-
portant remedy in the treatment of the sec-
ondary stage of syphilis is mercury. He
does not bear mercury well and he already
has the mercurial breath which you will
learn to recognize instantly so that you can
tell it on first entering a house in which
there is a patient with mercurial stomatitis.
It is my belief that we will have to over-
come the syphilis by the moderate use of
mercury. It does no good to force mercury
beyond the point of tolerance. The present
tenderness about the teeth will pass away
in a few days and we must continue with
such a dose of mercury as to keep his gums
slightly tender.

We must attend to his fever and relieve
it, especially by baths. We must nourish
most carefully, avoiding alcoholic stimulants
if possible. The patient's diet will be
chosen from the following list : milk, eggs,
peptonized beef, peptonized milk punches
with just enough whisky to give a flavor,
oyster broth or oysters themselves pepton-
ized, forcing nutrition as far as we can.

The utmost attention must be paid to the
bowels. While we are doing this we must
bear in mind that what he takes must come
out of him in some way. If he takes food
and it is assimilated, it passes into the blood

and the waste products from the blood pass
out chiefly through the kidneys normally,
but in his condition, the waste products will
not pass off through the kidneys. This is
one of those cases which tax the skill of the
physician and on which physicians so often
go wrong. We must treat this man as being
sick, as having syphilis, as a patient with
Bright's disease, not forgetting that he has a
heart trouble.

How shall we treat him for the Bright's
disease? Would there be any objection to
giving this man vapor baths to stimulate
the skin to the utmost and thus get rid of
the waste and relieve the kidneys ? There
is only one objection to that and that is the
possible effect on the heart. I shall put this
patient upon a treatment of the skin by diaph-
oretics and diaphoretic measures rather than
diaphoretic drugs. He shall have sweats,
he shall be kept still in bed, we will try to
unload this accumulation of fluid in the sub-
cutaneous tissue and when we get rid of the
oedema, we shall know we are helping the
kidneys. In the meantime, is it right to
force the nourishment as hard as we can ?
No, we must not force the nourishment till
we can provide for getting rid of the waste.
The first thing to be thought of after the
mercury is not so much forcing nutrition as
looking after the kidneys. Many a case of
Bright's disease is lost for the reason that
nutrition is looked after to the conclusion of
the waste products.

With reference to the heart. It is not
always a good plan to produce diaphoresis
and relaxation of the skin when the heart is
weak, because thereby, blood pressure is
lowered and the patient feels the worse for
it. I should, however, advise moderate
diaphoresis here for reasons already stated
and should attempt to sustain the heart by
cardiac tonics. The heart tonics are in no
way antagonistic to syphilis and some of
them are irritating to the kidneys. In this
form of Bright's disease, by maintaining the
blood pressure, we shall relieve to some ex-
tent the congestion of the kidneys and we
shall enable the urine to pass out in larger
quantities and get rid of urea and other
toxic principles in large measure. What
heart tonic shall we administer in this case ?
I should say digitalis in the form of the
infusion given in teaspoonful doses and
repeated every three or four hours, gradu-
ally increasing it if necessary till we have a
steady quiet action of the heart and at the
same time keeping up the diaphoretic
measures.

If his urine is at all irritating owing to

730

Clinical

Lecture.

Vol. lxiv

the large amount of acid it contains, I
should give him alkalies. An alkaline
diuretic is the only one that should be given
in a case of acute Bright's disease. Stimu-
lating diuretics are altogether inadmissible
since they irritate and damage the kidney.
Potassium acetate or a mixture of potassium
nitrate, sodium bicarbonate and the double
tartrate of potassium and sodium given
twice a day will produce alkalinity of the
urine quicker than almost any other combi-
nation.

If we find that the urine is still scant in
quantity, that the amount of urea given off
is very small, we will often afford greater
relief by giving the acetate of potassium
than by giving this alkaline mixture.

Such patients are disturbed by iron. The
liver is irritated, the appetite is diminished,
the patient becomes despondent and de-
pressed by the use of iron. When his
digestion is restored to normal, I should
give iron in the form of the tincture of the
chloride. In cases of rather chronic Bright's
disease, the acid preparations of iron are
more useful than the carbonate, albuminate
or the other preparations which we select in
common cases of anaemia. We _ may give
him bitter tonics, such as quinine and
strychnine by and by.

So far as the fever is concerned, aside
from the baths already mentioned, we will
control that entirely by the diaphoretics.

CHRONIC PHTHISIS.

BY R. C. M. PAGE, M. D.,

PROFESSOR OF DISEASES OF THE CHEST AND GEN-
ERAL MEDICINE AT THE NEW YORK POLY-
CLINIC— VISITING PHYSICIAN AT THE
NORTHWESTERN DISPENSARY, ETC.

Gentlemen : — The patient I present to you
this morning is a man 47 years of age, who
is a laborer by occupation. He was, he says,
in good health up to a period of some six-
teen months ago, when he began to have a
cough, and to lose flesh and strength. He
has now some dyspnoea and nightsweats.

As you look at this man and listen to the
tone of his voice your suspicions are at once
directed to either tubercular or syphilitic
laryngitis as present in his case. We sus-
pect, from the subjective symptoms of the
patient, as related by himself, that he has
phthisis, but to what stage this disease has
progressed in his case, physical examination
will alone enable us to determine.

Phthisis, as now generally understood
and accepted by the profession, not only
means tuberculosis, but it also signifies pul-
monary tuberculosis. It may be acute or
chronic, but whatever form it may assume,
whether it be slow or rapid in its progress,
it is in every case tubercular.

Acute phthisis may commence as a lobar
pneumonia, and instead of resolution taking
place, as usual, there are signs of softening
in the lungs, followed by excavation, rapid
emaciation and death in the course of a few
weeks. Acute phthisis may also be a part
of that form of the disease known by the
name of general tuberculosis, affecting the
various organs and tissues of the body at the
same time. The physical signs of pulmonary
disease are those of bronchitis. This disease
is nearly always secondary to some tubercu-
lar lesion from which the bacilli are absorbed
into the blood, the circulation of the blood
in the lung favoring their lodgment in that
organ, as the tubercle bacilli do not prolif-
erate readily in the circulatory fluid.

Chronic phthisis may be reduced to two
varieties, though variously described under
different forms, and these two varieties are
known by the name of the catarrhal and the
fibroid. Catarrhal phthisis is that form of
chronic phthisis most frequently met with
in practice, and usually appears at the apices
of the lungs. It begins in the apices of the
lungs, because those parts are the most liable
to traumatism from exposure, and injury to
the vessels from imperfect circulation and
stagnation of blood. There is also less respir-
atory motion in this portion of the lung and
consequently imperfect ventilation, and less
tendency to the absorption of exudation and
disturbance of the bacilli.

Fibroid phthisis, the second variety of the
chronic disease, is in reality a tuberculous
interstitial pneumonia. Like chronic in-
terstitial pneumonia, it leads to bronchiectasis
and shrinkage. Before the discovery of the
bacillus by Koch, in 1882, chronic inter-
stitial pneumonia and fibroid phthisis were
regarded as the same disease. After the
discovery of the bacillus these two diseases
were separated, one being considered as a
form of phthisis, and the other as a chronic
pneumonia.

Tii ere are, as you know, three stages of
phthisis, and a thorough appreciation of
these three stages is essential to a knowledge
of what you can do for your patient. To this
end it is well, then, for us to determine the
earliest signs of phthisis. What, then, are the
earliest signs by which we can recognize
this disease ? If the top of the left lung be

June 13, 1891.

Clinical

Lecture.

73i

affected, it is easier to make an early diagno-
sis than if it be the top of the right lung,
since in health the patient has exaggerated
fremitus and pectorophony on the right side,
as well as slight dullness on percussion and
rude respiration.

Frequency of the pulse and loss of appetite
are also among the earliest signs of phthisis.
But shall we rely in this connection upon
the discovery of the bacillus in the sputum ?
Or are we justified in waiting before resort-
ing to improved methods of treatment until
we find this micro-organism ? Unquestion-
ably no. The cough of chronic phthisis is
at first dry and hacking. Expectoration is
scanty, and even that does not contain the
bacilli, as a rule, because these bacilli are
few in number and are not readily removed
by expectoration. Furthermore, every gen-
eral practitioner has not the means or oppor-
tunity of determining the existence of the
bacilli in the sputum, even if they could be
found.

Now the question comes up for con-
sideration how are we to determine the pres-
ent condition of this man ? and to that end
let us see what conclusion we can reach in
the way of diagnosis by a physical exami-
nation of his chest.

First, on inspection we notice that the
chest is more or less retracted on the right
side in the neighborhood of the clavicle, and
the heart is somewhat displaced to the left.
In perfect health we know that the apex of
the heart ought to be normally about \\
inches below, and somewhat within the line
of the left nipple. This is, however, a very
uncertain landmark for us to follow. It is
a safer guide for us to find the middle point
of the clavicle, and a line dropped from this
point will determine the nipple line in
health. Now, what has caused this man's
heart to occupy this abnormal relationship ?
Pleurisy with effusion would tend to pro-
duce this condition ; enlargement of the
liver and spleen would cause an upward
displacement of the heart ; enlargement of
the heart itself would also tend to displace
that organ ; but in this case we conclude
from the physical signs present that this
displacement of the heart is due to contrac-
tion from pleuro-pericardial adhesions. On
inspection, we notice the apex beat of the
heart carried outward from such causes.

After inspection we come to palpation,
and note the amount of vocal fremitus pres-
ent over this man's lungs. We get no
vocal fremitus in this case from impairment
of voice, but as we ask the man to cough we
get more tussile fremitus over the left side

than we do over the right. Fremitus is
increased in two ways, by consolidation of
lung tissue, or by connection along the
tubes.

After palpation, we come to percussion.
If this man were in a state of perfect health,
you would get a slight difference in the per-
cussion note over the right and left lung.
In the case of right handed people we get a
little more dullness over the right lung and
vice versa on account of the difference in
the thickness of the muscles. On per-
cussion we get marked dullness over the left
lung, as compared with the right in this
man's case.

From these physical signs we can, there-
fore, conclude that there is something wrong
with this man's left lung. There is present
there, more or less consolidation of the lung
tissue, and a thickened pleura.

This now brings us to auscultation and
this subject brings up the question, What
do you listen for when you place your ear
to a chest like that? You are simply
listening for the respiratory murmur, and
this respiratory murmur may be vesicular,
bronchial or cavernous breathing. Having
satisfied yourself about the character of the
respiratory murmur and the vocal reso-
nance, we listen lastly for what are called ad-
ventitious sounds, viz., sounds produced in
the chest by disease. Of these adventitious
sounds there are three classes, viz., rales
(rattles), frictions and splashing. We have
three varieties of rales, dry, moist and
indeterminate.

As I listen over this man's chest under
the left clavicle, I get on auscultation the
physical signs of a cavity. When we per-
cuss over a cavity, we get dullness as a rule,
but in certain exceptional cases we may get
tympanicity. In the third stage of
phthisis, the pathological lesion is gener-
ally a complicated one, and you are likely
to have fluid in the cavity, a thickened
pleura, and other morbid conditions that go
to produce dullness on percussion.

Having now gone over this case thus
briefly, and having decided upon the diag-
nosis of phthisis as the cause of this man's
trouble, the question comes up, What can Ave
do for him in his present condition ? The
treatment of phthisis to-day, it must be
borne in mind, is still purely symptomatic.
We do not use depleting remedies now, as
formerly, but we nourish the patient as well
as we can. Keep him in the fresh air, give
him plenty of milk, cod liver oil, and easily
digested food, and treat each symptom as it
develops. Filleau thought that he had dis-

732

Clinical

Lecture.

Vol. lxiv

covered the cure of phthisis by injecting
carbolic (phenic) acid into the patient's
body, to be exhaled by the lungs. Seiler
claimed that hydrofluoric acid fumes did the
same thing. Then came the Bergeon
method. Iodoform, arsenic and creosote
have all been tried, but without avail.
However useful they may be, no one claims
that they can cure phthisis. Recently, the
whole world has been moved by the well-
known discovery of Koch. Sufficient time
has not elapsed to pass upon the therapeutic
value of this discovery in the cure of
phthisis. But, supposing all is true that is
claimed for it, the importance of an early
diagnosis, and the prompt application of the
remedy is at once apparent.

Now there are certain complications that
may arise in the course of phthisis which it
may be well for you to know how to treat
promptly and efficiently, for these complica-
tions may sometimes exhaust our patient's
strength to such a degree as to utterly defeat
any measure of relief or comfort he may be
otherwise likely to obtain. Of the compli-
cations that attend phthisis, perhaps the
most alarming and, and at the same time,
the most dangerous is haemorrhage. Sup-
pose you were treating a patient in this stage
of phthisis wrho was troubled with haemor-
rhage. What would you do to arrest it?
You may have a profuse haemorrhage from
the lungs before any physical signs of pulmo-
nary phthisis present themselves. This may
be the first objective sign of phthisis that you
get, and it is usually a very bad sign. At
other times, during the progress of the mal-
ady a large artery running across a cavity
may rupture and give rise to a profuse
haemorrhage by aneurismal dilatation.
Now, every one has a different remedy for
haemorrhage in phthisis. It is well to have
but one, and that a safe and ready one. Er-
gotine with morphia is the one remedy I
would recommend you to use for this patho-
logical condition, and you will generally
find it very efficient.

Ergotine acts by contracting the fibres of
the capillaries, but how morphine acts in this
connection I am unable to say, but I know
from clinical experience that it does good,
it allays nervousness, keeps the patient
quiet and prevents restlessness. We know
in intestinal haemorrhage due to typhoid
fever, morphine stops peristaltic action of
the intestine and favors the formation of a
clot.

I saw lately at the Brompton Hospital
in England, a case of pulmonary
haemorrhage where everything was tried in

vain to stop haemorrhage in a patient with
phthisis and the physician in charge had
finally to have recourse to morphia to keep
the patient quiet, and 1-3 grains of ergotine
hypodermically. This succeeded in arrest-
ing the haemorrhage. Twenty-five years ago
at Bellevue Hospital the drinking of a satu-
rated solution of common salt was used
with very good result in arresting the
haemorrhage of phthisis, and Dr. Alonzo
Clark used to say if that remedy did
not stop haemorrhage from the lungs
nothing will. How does salt and water act
in this connection? Salt simply acts by
drying up the blood, and as it is well to
have a reason for everything we do, I give
you this reason for the use of salt in pulmo-
nary haemorrhage.

There is another complication of phthisis
I wish to speak to you to-day about, and
that is night sweats. These night sweats,
we know, weaken the patient considerably,
and are a very distressing symptom to have.
I wish to tell you that because your patient
is in the third stage of phthisis, it is no rea-
son why you should abandon him hopelessly.
I have seen such people, when sent to a
suitable climate, do very well indeed.
When a patient has night sweats, you must
do something to stop them, but what medi-
cine are you to give to produce this effect?
It is a common practice with dispensaries in
this city to give one dram of the tincture of
belladonna, in a two ounce mixture of
Stokes's expectorant, for this purpose. In
private practice it may not be desirable to
give this remedy, as it has a tendency to
produce hoarseness in your patient, and this
is a rather unpleasant thing to happen. I
had a very bad case of night sweats in a
private patient the other day and the very
first dose I gave of this mixture stopped
them at once. If this remedy should, how-
ever, fail in arresting these sweats, then you
may try agaricin in doses of \ of a grain
three times a day and increase this amount
till you have given the i of a grain three
times a day ; or better still give your
patient the oxide of zinz according to the
following formula :

1^ Pulv. zinci ox iij gr.

To be taken on going to bed at night.

These three remedies are the most efficient
that I know of in arresting the night sweats
of phthisis.

There is another good thing about the use
of balladonna in this connection, and that is
in all cough mixtures for the relief of phthisis
we have to give opium to a greater or less

June 13, 1 891. Communications.

733

extent. Belladonna mixed in with the
cough mixture containing opium counteracts
the bad effects of the latter drug.

There is another point I wish to speak to
you about in this connection, which may
prove to you of some practical interest, for
though phthisis is a pretty threadworn sub-
ject, I think we can learn something new
every time we go over this matter. Suppose
your patient has a hectic fever every after-
noon, how are you going to treat this com-
plication satisfactorily ? Hectic fever, you
know, is a very disagreeable complication in
the course of phthisis, it keeps your patient
emaciated, ruins his appetite and renders
him absolutely uncomfortable. I remem-
ber the time when these patients used to be
given quinine in very large doses for this
condition, but without producing any good
effect whatever. Quinine will not lower
the temperature to any appreciable extent
in phthisis, pneumonia, pyaemia, or any
other similar affection. It is, besides, a
very dangerous drug to use in large doses,
as I have seen it given in the case of phthisis.
Antipyrine is a good remedy to employ for
reducing temperature but it produces diaph-
oresis iu your patient, and that is a condition
you do not want to develop in a patient
with phthisis. Antifebrine is a better rem-
edy to employ for reducing temperature in
these cases, as it does not give rise to so
much diaphoresis as does antipyrene. By
giving five grains of antifebrine in the form
of tablets, in the afternoon, at about one
o'clock, and five grains more at five o'clock
in the evening, your patient will be enabled
to spend quite a comfortable night. It is a rule
at Bromptom Hospital to let the temperature
alone unless it went over 102° F., though I
often bring it down below 101° F., because
such a temperature as that gradually ex-
hausts your patient's strength and vitality.

You should not forget to supplement this
treatment, as I have now outlined it to you,
by sending your patients to some climate
where they can pass the greater part of the
time out of doors in the open air.

Goldbeater's Skin for Cracked Nipples.

M. J. Blechmann {Paris Medical) advises the
treatment of cracked or fissured nipples by means of
goldbeater's skin. Over the nipple affected after
wetting with simple clean water, there is applied a
round piece of goMboater's skin, of about ten centi-
metres in diameter. The center of the skin is first
pierced by a number of fine holes with a needle.
The skin takes the form of the nipple and adheres
like a second epidermis. It should then be moistened
and after each nursing a new piece applied. — Ex.

Communications.

CARIES OF COSTAL CARTILAGE FOLLOW-
ING ENTERIC FEVER— PERSISTENCE
OF SINUS AFTER OPERATION-
TREATMENT BY METHYL-
VIOLET— CURE.

BY J. C. WILSON, M. D.,

PHYSICIAN TO THE JEFFERSON HOSPITAL, ETC.

The following case is briefly reported, (1)
as an example of a sequel of enteric fever
rare in this country though relatively fre-
quent in Europe, and (2) on account of the
result of the treatment :

A gentlemen 32 years of age consulted
me on October 9th, 1890, in regard to an
open sinus in the lower part of his right
chest, near the mammillary line.

He stated that during the summer of
1889 he had, suffered from a severe and un-
usually prolonged attack of typhoid fever,
from which he had, however, made as regards
his general health, a satisfactory recovery.

In the early days of his convalescence he
had experienced distressing pain, localized
in the lower part of the right chest. The
painful area was extremely tender upon
pressure. In the course of a short time an
abscess formed at this point which ruptured
spontaneously. The resulting sinus refused
to heal and continued to discharge a small
amount of thin pus.

The diagnosis of caries of the cartilage of
the rib was made and some months later an
operation was performed. This procedure,
however, failed to give relief, and the sinus
continued to discharge thin pus as before,
though in smaller amounts ; its outlet occa-
sionally closing, only to reopen in the course
of a few days under the pressure of the accum-
ulated secretion.

Upon examination the opening was found
to be surrounded by pouting granulations ;
it was somewhat retracted ; the neighboring
tissues for a distance of an inch or two were
infiltrated; the skin congested and bluish.

A probe introduced, passed in a direct
course upward and backward a distance of
about an inch and a half. Being introduced
with the tip bent, it passed behind the carti-
lage of the sixth rib near its costal articula-
tion. The cartilage was distinctly felt to be
roughened.

The patient stated that he had recently
been advised to have the affected portion of
the cartilage excised. In this I fully con-
curred. Upon further conversation, the

734

Communications.

Vol. lxiv

patient's disinclination to an operation being
very great, I proposed the treatment of the
wound by methyl- violet, a small quantity of
which had been sent-me a few weeks before
by Dr. Johnstone of Brooklyn who had re-
ceived it directly from Professor Stilling.
It was agreed that the patient should regard
this as a clinical experiment.

A small quantity of a five per cent,
aqueous solution of the blue pyoktanin was
injected by means of a curved dental syringe
introduced to the cul-de-sac of the sinus
behind the cartilage. Upon the withdrawal
of the syringe, the orifice was closed by
a pad of absorbent cotton which was held
in place by strips of adhesive plaster. This
maneuvre was repeated on five occasions, at
intervals of three or four days. During this
period the infiltration of the skin surround-
ing the fistula rapidly diminished ; the
neighboring skin lost its livid hue ; the
pouting granulations underwent resorption
and the discharge practically ceased.

Two weeks after the last injection, namely
on the 17th of November, the patient re-
turned. The sinus had closed ; the infiltra-
tion had disappeared and the slightly
indurated, but healthy cicatrix alone re-
mained. A distinct loss of the substance of
the cartilage, or its inferior border could
be felt. Whether this was the result of the
caries or of the scraping at the operation,
cannot be determined.

To-day— May 25th, 1891— the patient re-
ports that he has had no further trouble.
The cicatrix is thin, pliable and movable.

I desire to call attention to the fact that
the solution of methyl-violet used in this
case was very much stronger than those
usually recommended, and to the fact that
the outlet of the orifice was immediately
closed by a small pad of tightly rolled
cotton with a view of retaining the solution
in contact with the walls of the sinus.

The treatment was almost painless, and
resulted in a cure which now promises to be
permanent, without the loss of a single
hour's time on the part of the patient, and
without the annoyance incident to a surgical
operation.

In view of. these facts the treatment of
small sinuses, resulting from carious proc-
esses, by strong solutions of methyl-violet
should be tentatively instituted as a pre-
liminary measure prior to a surgical opera-
tion.

Maygrier reports an instance of a female
foetus weighing thirteen and -a half pounds.
Its total length was 58 cm.

REPORT OF A CASE OF FIBRO-PAPILLOMA
OF THE BLADDER, WITH RECOVERY.

BY D. W. CADWALLADER, M. £>„

GYNECOLOGIST TO ST. AGNES HOSPITAL, PHILA-
DELPHIA.

M. Q., age 30, was admitted to St. Agnes's
Hospital, November 20th, 1889, with the
following history :

Has been married 13 years and given
birth to eight living children ; labors all
easy ; made good recoveries and never had
any miscarriages. In March, 1889 her
"sickness" ceased and did not return until
June, w7hen she began to have "bearing
down " pain and a slight discharge of blood
each day. This continued up to August
10th, on that day she passed a -mass, which
on examination by her, proved to be clotted
blood ; a similar clot was passed a week
later, and about this time she began to have
occasional haemorrhages, which wrere profuse
and which continued to present date ; has had
over thirty in all, and lost as much as a pint
and a half of blood at one time. All this time
(from March until June) she had no signs
of pregnancy other than a cessation of the
menstruation.

On admittance she was extremely faint
from loss of blood ; was terribly emaciated—
in fact, reduced to a mere skeleton — and had
the appearance of one suffering from some
malignant disease. She, however, suffered
little or no pain, with the exception of occa-
sional vesical tenesmus, which latter symp-
tom was only elicited by the closest ques-
tioning, and which she thought very trivial.
At this time she had not noticed any blood
in the urine.

She had been under the care of two able
physicians, one telling her that she need not
expect to recover ; the other saying she had
a miscarriage, and would require a curvetting
of the womb to insure relief from the haemor-
rhages. On examination I found the uterus
in a normal condition in every respect, with
the exception of a slight laceration of the
cervix. There was no evidence that a mis-
carriage had taken place, or that the haemor-
rhages had their origin in the uterus. The
ovaries and tubes were in a healthy condi-
tion. I, therefore, excluded the uterus as
the origin of the profuse haemorrhages,
which had now continued for several months.
The urethra at its external orifice presented
a laceration a quarter of an inch in extent ;
and by passing the index finger along on
the anterior wall of the vagina, there was

June, 13, 1891.

Communications.

735

detected a mass the size of a large English
walnut; it was somewhat flattened, and to
the finger in the vagina was quite firm. It
appeared to be on the interior surface of the
bladder, extending from the fundus to the
neck of the bladder.

Introducing carefully a metallic catheter
and drawing off a small quantity of urine —
free from blood — the growth could be
easily felt with the instrument, in the loca-
tion already indicated. The growth here —
in the bladder — felt softer, with somewhat
ragged edges, was not pedunculated but on
the contrary, appeared to have a broad at-
tachment to the posterior vesical wall.

I asked my assistant to feel the growth with
the instrument, already in the bladder, and
to use extreme gentleness in its manipula-
tion, as these growths frequently bleed pro-
fusely. He, however, made undue pressure
on the growth, when, suddenly, a profuse
haemorrhage occurred ; the patient must
have lost at least three pints of blood, some
fragments were also passed.

She was put to bed, with the hips elevated,
and measures were taken to counteract the
shock. These consisted in the application
of ice over the hypogastrium, and in the
vagina ; and hot water bottles to the ex-
tremities, and the administering of a small
quantity of whiskey. The haemorrhage
ceased, and but a short time ensued till re-
action occurred. For a number of weeks
large quantities of milk, with other nutri-
tious diet were given ; chalybeates and
vegetable tonics employed, and absolute rest
in the recumbent position enforced.

A microscopic examination of the frag-
ments passed from the urethra, proved the
growth to be Fibro- Papilloma of the Bladder.
I therefore decided to make no operative
interference for the present, preferring la
medecine expectante, as there seemed a de-
cided tendency for nature to expel the
growth.

On November 24th, another haemorrhage
occurred ; more fragments were passed. The
urine was found to contain blood occasion-
ally; at other times, perfectly free from
blood.

These fragments continued to come from
the bladder every few days, for a period of
about four weeks. No severe bleeding oc-
curred after November 24th, and the patient
continued to improve. The examinations
which were made from time to time proved
the growth to be gradually diminishing in
size until she was discharged, January 30th,
1890, much improved. On that date the
only traces of the vesical growth was a

slight thickening of the posterior vesical
wall.

She menstruated naturally the latter end
of December ; again in January, and con-
tinued regular. I saw her in December '90,
when she informed me she had been in per-
fect health since leaving the Hospital. Had
not had any haemorrhages of any kind ; had
continued to menstruate regularly up till
October. On examination I found her
about three months pregnant and no traces
of the vesical growth.

I report the foregoing case, firstly, be-
cause there are not any reported cases, to
my knowledge, where these vesical growths
of the bladder, have been expelled by nature
through the urethra, and thus resulting in a
cure, without the intervention of an opera-
tion ; secondly, because until recently there
has been but little said or written on the
subject, and have been considered extremely
rare, while there is but little doubt they are
frequently overlooked, especially in the
female.

THE MECHANICAL TREATMENT OF UM-
BILICAL HERNIA IN CHILDREN.1

BY J. M. THOMAS CHAPMAN,

BESSEMER, ALA.

These varieties of hernia of late have
caused considerable discussion from the
medical profession. More able men than
myself have handled the subject.

The treatment as recommended has not
met with general approvement. To me it
seems a little presumptuous that I should
advance any new treatment but following
the old adage, "In unity there is strength,"
by combining our ideas as we are working
and tending in the same direction, by co-la-
boring together we may yet reach the goal
for which we are striving.

In some of these cases the hernia yields
readily to mechanical appliances, it matters
not of what kind, so there is pressure enough
to keep the intestines within the abdominal
cavity. Other cases are more obstinate, and
give physicians considerable annoyance.

The treatment recommended by our most
able men is not satisfactory.

The cork pad of Erichsen is very serious-
ly objected to for this reason, the pressure is
not equal, the resisting force is so great as
to cause the aperture through which the
hernia has escaped to assume less circular

JRead before the Amer. Med. Assoc. May 6, 1891.

736

Society Reports.

Vol. lxiv

outline, and the aperture to enlarge, as its
natural tendency is to be displaced.

The treatment of Ashurst being very sim-
ilar, I will not dwell on it as a whole, his
treatment but call special attention to
certain points, viz. : He used wax instead
of cork, it is to be stripped on with
adhesive plaster, and removed from time
to time when detached by washing. In
children where the cuticle is so delicate
plaster of any kind that remains on for
any time, abrases the surface and causes
the child to cry and fret to such an
extent that this treatment is unsatisfactory.
A child aged nine months was brought to
me for treatment, founded with unbilical
hernia. From inquiry I found that the
hernia made its appearance in the child
when two months old. I tried the various
modes of treatment as recommended.

My case did not seem to improve, but, to
the contrary, get worse. The family of
which the child was a member was very
much discouraged, they were unwilling for
any operation.

I tried a number of appliances that I con-
structed with negative results, but one idea
leading on to another with the same end in
view resulted in making the following,
to wit : —

I made a jacket, about 6 inches wide, of
silk fabric, nicely padded with sixteen eye-
let holds on either side. I used absorbent
cotton for padding, as it takes up all the
impurities that may arise from the cuticle.
It is a disinfectant, and makes the jacket
soft and light. I attached anteriorly, and
posteriorly over both right and left
shoulders, strips two inches wide; these
strips are padded the same as jacket, their
use is to hold the jacket in place, as its
natural tendency is downward. I used a
round silk elastic for lacing the jacket, this
cord will give easily and is stout enough to
adjust itself.

If the flatus in the bowels is excessively
abnormal I give a simple laxative which
will generally relieve them. I take the pad
from the water truss, remove the metallic
plate from the silk gauze over the exposed
surface by means of silk threads, I then
adjust the pad to the hernia and attach the
pad to the jacket while in position.

The beauty of this pad is its lightness,
and softness, and yet it is sufficiently stout
to hold parts in place, without enlarging the
aperture.

It does not abrase, and can be worn with-
out any discomfort to the child. When the

child is asleep, I recommend that it be re-
moved, and replaced on awakening.

I have used this truss in about fifteen
cases, the results have been satisfactory.

I have recommended the use to a number
of my brother physicians, and in every case
the results were gratifying. I had one made
under my own supervision, for my esteemed
and honored friend, Dr. W. E. B. Davis, of
Birmingham, Ala. He was so much pleased
with it that he requested me to prepare a
paper on the subject, which I have done.
This is only a synopsis, so not wishing to
consume too much of your valuable time, I
will sum up the advantages of this simple
little appliance.

1. I claim that it is light, and yet stout
enough to hold parts in place without dis-
comfort to the child.

2. The water pad is such that it will not
produce force enough to enlarge the aper-
ture, as we know its natural tendency is to
be displaced.

3. It will not abrase, and can be worn, if
the bowels should be enlarged, from accumu-
lation flatus, as the silk cord will, give to
such an extent as to adjust itself to the sur-
roundings.

4. And last, but not least, if it does not
obliterate the hernia, it facilitates subse-
quent retention.

Society Reports.

STATE MEDICAL SOCIETY OF PENNSYL-
VANIA—FORTY-FIRST ANNUAL
MEETING,

READING, PENNSYLVANIA, JUNE 2, 3, 4,
AND 5, 1891.

First Day — Morning Session.

The meeting was called to order by the
President, Dr. Alexander Craig, of Columbia,
Pa., and prayer offered by the Rt. Rev. M.
A. De Wolfe Howe, D. D., LL. D., Bishop
of the Diocese of Central Pennsylvania.
Hon. T. P. Merritt, Mayor of Reading, being
introduced by the President, delivered an
address of welcome on behalf of the city of
Reading.

ADDRESS OF WELCOME.

The Mayor said it had been forty years
since the State Medical Society of Pennsyl-
vania, then in its infancy, had met in Read-
ing. Since then the progress of the medical

June 13, 1 89 1. Society Reports.

737

sciences had been very great, and deserved
the warm appreciation and earnest support of
the community at large. In his opinion the
medical profession was above all others the
most self-sacrificing. In the life of a true
physician, all thoughts of personal conven-
ience were laid aside. This was especially
true of the country doctor.

Many of the members present, continued
the Mayor, had not only gained name and
fame in their professional careers, but had
also won well-earned laurels by active ser-
vice during our late war. He hoped that the
stay of the visiting physicians in Reading
would be a pleasant one, and that they
would carry pleasing memories away with
them. They would be taken over the moun-
tain railways and be shown landscape
pictures of nature's own production, that
rival any in America, and that when once
seen can never be forgotten.

In addressing this assembly of physicians
the names of many came to his mind;
among the dead being Pancoast, Wood, Gross,
Leidy and others, and among the living,
Agnew, Pepper, Tyson and Keen.

The Mayor then extended an invitation
to the visitors to visit the leading manufac-
tories and industries of Reading, and in
closing said : "We are a growing town. We
have three Hospitals, one Old Woman's
Home, and several other charitable institu-
tions, all well supported. Our schools
thrive, our churches are everywhere in the
city, and our industries are daily increasing.
I sincerely hope that your meeting will be a
most profitable one, and trust only that
your pleasant relations with us, and the
enjoyment you may partake of while here,
will be ever linked in your memories among
the happiest recollections. Again, in the
name of the citizens of Reading, I bid you
a hearty welcome."

Then followed an address of welcome by
Dr. S. L. Kurtz, Chairman of the Committee
of Arrangements, on behalf of the Berks
County Medical Society.

ADDRESS OF WELCOME.

Dr. Kurtz said : " Forty-two years have
elapsed since your last meeting in this city.
A generation of people has been born and
died in the interval. Of the members of
the Berks County Medical Society, who
greeted your organization on that occasion
not one is with us to-day, and of the mem-
bers of the State Society in attendance then,
there are but five survivors." Dr. Kurtz
then spoke most forcibly on the urgent need
and desirability of having the Legislature

enact a law governing the practice of med-
icine in Pennsylvania. The speaker then
gave a brief but interesting description of
Berks County, which, he said, was an emi-
nently agricultural and manufacturing
district. The population of Reading at the
date of the former meeting was about 12,000,
while to-day it exceeds 60,000. In the
meantime the city's manufacturing establish-
ments have also greatly multiplied in num-
ber, increased in capacity, and are of a most
diversified character. Dr. Kurtz then re-
ferred to several things in which he claimed
Berks county excelled, mentioning among
others the Brown-Segment wire gun, and the
Carpenter steel projectiles. He then gave
a vivid and interesting description of Mounts
Penn and Neversink, Klapperthal, the
Highland House, Mount Penn Tower and
the Mineral Spring Park, points of interest
which the visitors would have the opportu-
nity of seeing. In closing he said that the
members of the Berks County Society de-
sired that every visiting member and dele-
gate should not only feel that he had
garnered the golden fruit of knowledge and
experience during his stay in Reading, but
also that his social enjoyment might ever
remain as a bright and enjoyable remem-
brance.

It was then announced that the Postal
Telegraph Co. had established an office in
the hall for the convenience of the visitors.

Dr. Charles W. Bachman then read the
programme, and immediately after, Dr.
Charles W. Dulles moved that the report of
the Committee on Incorporation, of which
he was Chairman, be inserted here instead of
during the proceedings of the second day,
where it had been placed. The motion was
carried and Dr. Dulles proceeded to read the
report, which stated that a charter had been
obtained and that the present meeting was
the first the Society had ever held as an
incorporated body. Dr. Dulles presented
the charter to the President, who delivered
it to the custody of Dr. Atkinson, the Perma-
nent Secretary.

On motion of Dr. Jackson, Thursday
morning (third day) was set apart for the
consideration of amendments to the consti-
tution, during the time allotted to unfinished
business.

The report of the Treasurer, Dr. Dunmire,
was then presented, and the assets of the
Society shown to be $809.88. During the
year $2,709.00 had been received from the
various county societies, and $2,097.64 ex-
pended.

Dr. Edward Jackson then presented the

738

Society Reports.

Vol. lxiv

report of the Committee on Publication, re-
garding the publishing and distribution of
the Society's transactions. The report was
received, and the bills incurred ordered to
be paid.

It was moved by Dr. Dulles that the Per-
manent Secretary be authorized to hold the
treasurer's bond for $1,000. Heretofore
while the bond has been required, no cus-
todian for the same had been appointed.
The motion was carried.

The President then appointed an auditing
committee to audit the treasurer's account.

Dr. Murray Weidman, of Reading, offered
a resolution providing for the appointment
of a committee to consist of one member
from each county to collect funds for the
erection of a monument in Washington, D.
C, in memory of the late Dr. Benjamin
Rush, of Philadelphia. The resolution was
adopted, and each county asked to nominate
one of their members to serve on this com-
mittee. Dr. Weidman then presented to the
Society a copy of the proceedings of the
meeting at which the Society was organized,
Oct. 11, 1848. In accepting this gift, the
Permanent Secretary stated that these pro-
ceedings were extremely rare and that the
gift perfected the archives of the Society,
none of the proceedings being missing. A
vote of thanks was tendered to Dr. Weid-
man, and the session then adjourned for
the morning.

The Afternoon Session — 2 P. M.

The afternoon session was opened by Dr.
J. Chris. Lange, of Allegheny, who delivered
the annual

ADDRESS ON MEDICINE.

This address showed careful preparation
and was well received. Dr. Lange stated
that a golden era was being entered upon by
the Medical Profession, and that great things
were promised in the near future. He spoke
of the growing inclination of the profession
to use proprietary medicines, and vehemently
denounced this tendency. He declared that
the introduction of such remedies was merely
a scheme to make money for their owners,
and that their success was a detriment to
the profession. There are many reliable
and effective medicines being used which are
standard, yet many reputable physicians
desert these well-tried therapeutic agencies
for proprietary medicines which have ema-
nated from the laboratory of the chemist
instead of from the clinical experience of the
physician. From a medical and ethical
standpoint, such conduct is inexcusable.

There being no discussion, Dr. A. B.
Brumbaugh, of Huntingdon, delivered the
annual

ADDRESS ON HYGIENE.

During the course of his address, Dr.
Brumbaugh said that less attention was be-
ing paid to ventilation than was proper, and
that the most important questions a physician
was called upon to answer were embraced
in hygiene. Dr. Brumbaugh also advanced
the assertion that no case of consumption
exists that has not been brought on by dys-
pepsia, and that many cases are directly
traceable to the use of tobacco, which may
justly be looked upon as an exciting agent
of this disease. Could tobacco, together with
its ally, the liquor traffic, be rooted out, one
of the most infectious diseases would be
greatly mitigated. The licensing of tobacco
and liquor, and securing revenue from these
sources, is like sending out an army of fiends
to mutilate and destroy, and then sending
out another to bind up the wounds of the
sufferers. Dr. Brumbaugh also spoke at
length on the danger of water pollution by
cemeteries near the banks of streams in large
cities, and spoke of this as a potent factor of
disease.

Dr. Wm. F. Waugh was then called upon
for his paper on typhoid fever, but failing to
respond, Dr. John M. Batton, of Pittsburg,
read a paper on the subject of

TAPE WORM.

Dr. Batton cited several interesting cases
in which he had been able to remove entire
worms, measuring from 2 to 7 yards in length,
by the use of turpentine and cocoanut.

Dr. James Tyson, of Philadelphia, in the
discussion that followed the reading of this
paper, said that cases of tape worm were
very rare, and that he only met about one
case a year in his practice. The subject was
fully discussed by several members.

Dr. John B. Roberts, of Philadelphia, pre-
sented a resolution to the effect that the bond
of the treasurer be placed in the hands of
some reputable Trust Company, to guaran-
tee the faithful performance of his (the
treasurer's) duty, and that the annual pre-
mium be paid by the Society. The resolu-
tion was laid on the table.

An invitation from the Wyomissing Club,
tendering the visitors the use of the club-
house during their stay, was, on motion of
Dr. Ulrich, accepted, and a vote of thanks
tendered the club. The session adjourned
for the day at 4 P. M.

Later in the afternoon a visit was made

June 13, 189 1. Society

Reports.

739

to the Reading Hospital, where the visitors
were received and entertained by the Ladies'
Auxiliary, and lunch served. The location
and excellent equipment of the Hospital
afforded the visitors much gratification.

In the evening, at 8 o'clock, the members
again assembled in the Academy of Music,
where the entire meeting was held, in order
to hear the

president's address.

The Academy not only contained mem-
bers of the Society but also a large number
of ladies and guests, so that the large audi-
torium was well filled. Dr. Craig, the Pres-
ident, was introduced by Dr. S. L. Kurtz,
chairman of the committee of arrangements.

At 9 P. M. a reception and banquet was
tendered the visiting physicians by the mem-
bers of the Berks County Medcal Society of

Second Day — Morning Session.

The meeting having been called to order
by the President, the following physicians
were named for the Committee on Nomina-
tions : Allegheny, A. Koenig ; Armstrong,
J. F. Henry ; Berks, H. Landis ; Bradford,
C. L. Stephens ; Bucks, J. N. Richards ;
Butler, J. C. Cort ; Chester, W. R. Perdue ;
Dauphin, W. T. Bishop ; Delaware, W. B.
Ulrich ; Elk, J. J. Finerty ; Green, J. M.
Williams ; Huntingdon, A. B. Brumbaugh ;
Indiana, A. B. Ansley ; Lackawanna, L. M.
Gates ; Lancaster, M. G. Motter ; Lebanon,
J. R. Bucher ; Lehigh, M. F. Early ; Lu-
zerne, L. H. Tabor ; Lycoming, J. G. Mc-
Cormick ; Montour, C. B. Mayberry ; North-
ampton, W. L. Estes ; Philadelphia, Ber-
nard R. Lee ; Schuylkill, J. F. Bronson ;
Warren, M. S. Guth ; Washington, J. B.
Donaldson, and York, S. J. Rouse.

Dr. Ziegler, of Columbia, opened the
business by moving a vote of thanks to the
President "for his able address. The motion
was unanimously carried. The first paper
of the day was the

ADDRESS ON MENTAL DISORDERS.

Read by Dr. Samuel Ayres, of Pittsburg.
Dr. Ayres dwelt principally upon gastro-
intestinal catarrh as a cause of insanity.
He said that melancholia and disorders of a
similar nature were in the majority of in-
stances attributable to a derangement of the
digestive organs, or the stoppage of the pas-
sage of some duct. A healthy, vigorous
body, he regarded as essential to a sound
mind. Many other derangements of the
nervous system were also due to intestinal

troubles. In his opinion many of the men-
tal disorders found in adults begin in child-
hood, and are due to injudicious feeding.
Hot bread, cakes, sweets, and so forth, were
the cause of many digestive derangements
which result in serious disorders as age in-
creases.

The liver normally acts as an obstruction
to, and destroyer of, the poison which enters
the system, but when this organ becomes
weakened by vicious living, it is no longer
able to discharge its duties, and cannot
throw off all the poison. There are three
recognized forms of gastro-intestinal poison-
ing. The first by sulphurretted hydrogen,
formed by putrifying matter within the
stomach and bowels. This condition may
justly be called a gastro-intestinal sewage
poisoning. The second form is by pto-
maines, and the third is a toxaemia. Al-
these may result in both mental and nervous
derangements. In passing cases where the
exciting disease is neither aggravated nor
chronic, these symptoms may take the form
of vertigo or insomnia, and are directly due
to the absorption through the digestive tract
of some morbid element. If these symp-
toms become intensified by chronic gastro-
intestinal troubles, melancholia or even
suicidal mania may be the result. The
absorption of toxic matter may frequently
occur through the kidneys, and we often
find forms of insanity supplementing renal
disease — especially Bright's disease. In such
cases the uremic disease is not the primary
cause of the mental condition, but it causes
a discharge of poison into the blood, and
this in its turn, gives rise to the mental
symptoms. Science has, unfortunately, not
yet advanced sufficiently to enable us to
ascribe any one definite cause for insanity,
neither has it yet shown us that it is
the work of a microbe. The speaker
believed, however, that some specific would
be found for insanity, and that at no dis-
tant day some lymph would be found, the
inoculation of which would effectually coun-
teract the poison that diseases the mind.

At present prophylaxis promises more
than therapeusis, and the preventive or
active treatment of dyspepsia in children is
of great importance in this respect. Even
cases of melancholia and other forms of
insanity have yielded when, by means of
active medication, the digestive disturbances
have been cured. In such cases all food or
drink which is likely to cause rapid fer-
mentation should be avoided. Diuretic
elimination is also frequently of great value.

740

Society

Reports.

Vol. Ixiv

Finally, in children of weak digestion all
starchy or saccharine foods should be care-
fully restricted.

Dr. Israel Cleaver, of Reading, then read
a paper entitled :

HISTORY OF THE MEDICAL PROFESSION IN
BERKS COUNTY.

The reading of this paper was followed
by Dr. H. G. McCormick's

REPORT OF THE LEGISLATIVE COMMITTEE.

This report related to the bill for the
appointment of Board of Medical Exam-
iners, which was defeated by the last Legis-
lature. The report showed that the bill
was defeated by the members of the Society
themselves, and detailed the energetic efforts
of the committee to secure legislative pro-
tection for the medical profession.

Dr. E. E. Montgomery moved a vote of
thanks to the Legislative Committee. The
motion was carried.

Some discussion ensued upon the sugges-
tion that the committee should be continued
bo as to make another effort to secure legis-
lation at the next session. Action was de-
ferred until the time allotted for new busi-
ness was reached.

Dr. J. M. Anders, of Philadelphia, read
a paper entitled :

THE TREATMENT OF SUBACUTE PLEURITIS.

Dr. Anders related the histories of many
cases successfully treated by himself, and
also spoke of the various methods employed
in the treatment of this disease. He
strongly advises light gymnastics for the
development of the chest. The paper was
discussed at some length by Drs. J. B.
Roberts and James Tyson, of Philadelphia,
and Dr. Carpenter.

Dr. Wm. F. Waugh then read his paper

on

TYPHOID FEVER,

This being the third paper on the subject
which Dr. Waugh has read before the
Society. It embraced a large number of
cases successfully treated.

Under the head of New Business, Dr. W.
B. Ulrich, of Delaware, presented a resolu-
tion authorizing the appointment of a com-
mittee of seven, to continue the effort to
have the Legislature pass a bill for the
appointment of a board of Medical Exam-
iners, and appropriating $200 for the ex-
penses of the said committee during the
year.

The resolution was adopted.

Drs. Early, Richards and Cleaver, who
had been appointed to audit the report of
the Treasurer, found it correct.

Dr. Hiram Corson, of Conshohocken, then
presented the following preamble and reso^
lution :

" In view of the fact that insanity seems
to be on the increase in a ratio greater than
the ratio of increase of population, and that
just about one-half of the thousands of in-
sane in our hospitals are females, it appears
to me that it is desirable to have both sexes
represented in our Board of Public Char-
ities, and also in our Boards of Trustees of
Hospitals for the care and treatment of our
insane. And in the presence of the fact
that the zealous, unaided efforts of a single
woman — the well-known and greatly be-
loved Dorothea Dix — has had more effect
in improving the condition of the insane in
our State, and indeed in the whole country,
than can be claimed of any one of us, there-
fore,

" Resolved, That a committee be appointed
by the President of this Society, to appeal
to His Excellency, the Governor, to fill the
first vacancy which shall occur in the Board
of Public Charities by the appointment of
an enlightened and philanthropic woman."

The presentation of Dr. Corson's resolu-
tion and preamble, provoked some discus-
sion.

Dr. Ulrich, of Delaware, heartily en-
dorsed its language and paid a high tribute
to women.

Dr. Bishop, of Harrisburg, suggested that
the Society approach the subject with some
care. He was in favor of the resolution, but
the preamble, if adopted;' would mean an en-
dorsement of its language, which, however,
he was not prepared to accept because he
did not believe the ratio claimed was jus-
tified by facts. It was explained that the
preamble was simply intended to represent
Dr. Corson's personal views on the subject,
and the resolution was then adopted, minus
the preamble.

Afternoon Session — 2 P. M.
The first order of business was the

REPORT OF THE COMMITTEE ON
NOMINATIONS.

The Committee reported that they had
unanimously elected Dr. S. L. Kurtz, of
Reading, to the position of President. The
announcement was warmly greeted. The
remainder of the officers were elected as
follows :

June 13, 1 89 1. Society

Reports.

74i

First Vice President, Dr. John B. Rob-
erts, of Philadelphia ; Second Vice Presi-
dent, Dr. H. H. Whitcomb, Norristown ;
Third Vice President, Dr. I. C. Gable,
York ; Secretary, Dr. Wm. B. Atkinson,
Philadelphia ; Assistant Secretary, Dr.
Charles W. Dulles, Philadelphia ; Treas-
urer, Dr. George B. Dumire, Philadelphia.

Delegates to the American Medical Asso-
ciatiou, Drs. A. M. Miller, Lancaster; H.
O. Whitman, Dauphin ; J. C. Biddle,
Schuylkill; O. J. Stephens, Bradford; E.

E. Montgomery, Philadelphia ; T. M. Liv-
ingstone, Columbia ; M. A. Rhoads and
Henry Landis, Reading ; A. B. Brum-
baugh, Huntingdon ; W. B. Ulrich, Dela-
ware ; W. F. Stewart, Wilkesbarre ; J. J.
Finnerty, Erie; H. D. Gardner, Lacka-
wanna ; J. M. Baldy, Philadelphia ; R. G.
McCormick, Williamsport ; J. N. Richards,
Bucks ; Jacob Price, West Chester ; A. A.
Woods, Erie ; J. C. Cort, Butler ; Dr.
Nutt, Williamsport ; Hiram Corson, Mont-
gomery ; W. Murray Weidman, Berks ; A.

F. Bronson, Schuylkill.

Delegates to State Societies : Drs. J. W.
Richards and W. L. Esters, to New Jersey ;
Dr. Taylor, of Wilkesbarre, to New York ;
Drs. M. G. Motter and T. C. Detweiler, to
Maryland ; Dr. M. L. Herr, of Lancaster,
to the International Conference at Rome.

Dr. Thomas J. Mays then read the paper
entitled :

THE CONTAGION THEORY AND TREATMENT
OF CONSUMPTION.

(See Reporter, June 6, 1891.)
This was followed by a paper read by
Dr. Hugh Hamilton, of Harrisburg, en-
titled :

THE PHYSIOLOGICAL BEHAVIOR OF KOCH'S
REMEDY.

Then followed a discussion of the subject
of consumption which was to have been
opened by Dr. Traill Green, of Easton.
This gentleman, however, being absent, the
discussion was opened by Dr. Charles W
Dulles, of Philadelphia.

Dr. Dulles said that it was over 200 years
since Sir Thomas Brown, in his admirable
work, which every physician can peruse with
advantage, spoke of the curability of con-
sumption, and in a letter to a friend cited a
severe case which had entirely recovered.
Dr. Dulles went on by briefly touching upon
the works and experiences of various med-
ical writers from the science's very earliest
history, all showing that even at those times
the possibility of the cure for consumption

was recognized. To be sure, the death rate
from consumption is still enormous, about
60,000 deaths occurring yearly from this
disease in British countries alone. The
idea that consumption is incurable is very
deeply rooted in the minds of the public.
This belief is not new, yet consumption has
been cured even during the time of Hypo-
crates, who refused to regard the disease as
necessarily fatal. All through the history
of medicine we find cases reported in which
this dread disease has been cured. Hilda-
nus tells of a most severe case, resulting in
recovery.

Christian Bennett, who was born in 1617,
was himself affected, and his work in which
he describes his own cure, is well worth
reading. This writer said that it was well
to continue the curative means for some
time after an apparent cure. The late Dr.
George B. Wood claimed that consumption
was often cured, or at least ended in complete
recovery, while the cases of Dr. Joseph
Parrish, and Bowditch, are familiar to all
the profession. Dr. Dulles said he doubted
not but that many of his hearers could report
cases illustrating the curability of consump-
tion from their practices. He said that he
had at present several patients who were
entirely free from cough and walking about
well, who had unmistakably come to him as
consumptives. The speaker then proceeded
to cite several illustrative cases.

Dr. Dulles laid great stress upon the
importance of properly conducted institu-
tions for the treatment of the disease.
While many patients may be well treated at
home, they would surely do better in a
properly conducted hospital where every
facility for proper treatment would be at
hand. He also called the Society's attention
to the fact that such a hospital had been
recently established in Philadelphia, called
the Rush Hospital, and he hoped that this
hospital would prove to be a more lasting
and suitable memorial to the late Dr. Ben-
jamin Rush, than monuments in bronze or
marble.

Dr. W. T. Bishop continued the discus-
sion by saying that while he had great admi-
ration and profound respect for investigators,
yet in his own mind he classed them with
pharmacists. Both, in a large measure, do
their work in the laboratory. After all, the
treatment of consumption must be a rational
treatment, in spite of surroundings and
and whether the disease be produced by a
bacillus or not. Study and experience will
surely show us still more, and in destroying
one scientific idol we may find a new point

742

Society

Reports.

Vol. lxiv

of value in the treatment of the disease. At
present he believed that too much was
claimed for new remedies, and also that too
much was claimed for the disease.

Dr. Bishop agreed with Dr. Mays's asser-
tion that consumption was neither infectious
nor contagious. The immunity gained by
inoculation of man or animal is still dis-
puted, and in Dr. Bishop's mind, has yet to
be proved. The finding of a single tubercle
bacillus in any one of these cases destroys
the entire theory.

Regarding specifics, whether for consump-
tion or any other disease, he does not believe
in their existence. The enthusiastic inves-
tigator claims far too much, and wastes
much time and energy in a search for some-
thing which does not exist. They seek to
rob the grave of its lawful victim. The
physician can at best only direct, it remains
for the patient to accomplish the rest, and
so long as this is true there will be no spe-
cifics. The apparent results of delusive
tables would be greatly modified if compared
with family histories and surrounding cir-
cumstances, and if all these points were
clearly elucidated many would change their
opinion.

Dr. Lewis H. Taylor said that if he were
compelled to believe all he had recently
read and heard regarding the contagiousness
of consumption his life would be surely very
miserable. A few weeks since, he had the
pleasure of hearing the reading of a very
valuable paper on the subject, in which it
was claimed insomuch as molasses candy
might be handled by tuberculous subjects it
could also become infected, and it was there-
fore dangerous to give it to children. Again,
insomuch as oyster openers might be tuber-
culous, raw oysters are dangerous ; likewise
milk, also meat. You are in mortal danger
in any public conveyance; in fact it is a
real wonder that with all these menaces to
human life the human race still exists!
Surely in such theories there is much
absurdity.

We are, however, longing for light upon
this dark subject, and we shall ever strive
to find it. If we can dispel from the minds
of over fearful subjects, the useless fears of
continual menace, as well as the theory of
incurability, we shall do well ; while on the
other hand, equal good can be accomplished
by teaching the reckless the possibilities of
evil which their rashness is likely to incur.

Suitable institutes and hygienic surround-
ings are, of course, of inestimable value, but
unfortunately are not obtainable for all
classes. In such cases what shall we do?

We shall do as best we can, of course ; we
will remedy the unhygienic condition of the
surroundings as far as possible, and we will
ever seek to inspire our patients with that
most important factor pertaining to subse-
quent recovery, hope. Let them know that
they are not necessarily doomed to an early
death, but that with care an ultimate recov-
ery is very possible.

While rushing ever onwards in our search
for knowledge, it is well to also hold fast to
what we do know. Were it possible to sift the
good, and only the good, from the great
mass of treatments, theories, and remedies
that have been reported to the profession, a
great good might be done, and we might
justly hope for great things.

Dr. L. F. Flick then said, in continuing the
discussion, that for many years he had taken
great interest in the subject of consumption,
and had done considerable original work.
At this meeting theories had been advanced
that he felt called upon to challenge. He
claimed that many had very erroneous ideas
regarding the primary and fundamental
truths concerning consumption. Many
think because it is not contagious in the
sense that small-pox is contagious, it is there-
fore not contagious at all. Even the advo-
cators of the contagion theory do not claim
this. On the one hand small-pox is a
quickly contagious disease ; on the other
hand consumption is a slowly contagious
disease. Again, the contagiousness of tuber-
culosis is confined within certain limited en-
vironments, namely, pus or sputa, and it
cannot get about except by pus or sputa.
The idea that our lives are in constant
danger may be absurd without the fact
of the contagiousness of tuberculosis being
denied. Consumptives may indeed expec-
torate sputa laden with bacilli in the street
with but very little possibility of any conta-
gion arising therefrom. The bacilli do not
live forever, and the sputa may either be
washed away or trodden into the earth.

Dr. Flick said that his own clinical expe-
rience had taught him that the disease only
showed its contagiousness in cases of pro-
longed contact, such as exist when nursing
a patient during the last stages of the disease.
As a point illustrating the non-contagiousness
of tuberculosis Dr. Mays claimed that the
tuberculosis caused in animals by inocula-
tion was not the same as that occurring in
man. Clinical evidence, however, is of
greater value than experimental, and it has
been clinically proved beyond all doubt that
tuberculosis is contagious. He then cited a
series of cases coming under his own obser-

June 1 3, 1 89 1 . Society Reports.

743

vation in which the inmates of certain
houses in a given locality, were one after
another attacked with the disease. In the
houses observed the deaths from consump-
tion all occurred in 20 per cent, while in 80
per cent of these houses the disease did not
occur. Scrapings from the walls of such
infected houses have been innoculated into
animals and have caused tuberculosis. It
has repeatedly been proved that prisoners
placed in cells previously inhabited by con-
sumptives, will themselves develop the dis-
ease. The disease when once introduced into
a locality becomes endemic.

It is a well-known fact that certain
Indian tribes which have been infected with
the disease have been completely extermi-
nated by its ravages, while other tribes in
which the disease has not been introduced
remain entirely free from it.

Regarding the value of the prophylactic
measures that have been recently introduced
in Europe for the prevention of tuberculosis,
in Italy alone, where the disease has been
indeed a scourge, the death rate from con-
sumption has be^en reduced seventy -five per
cent, since the rigid enforcement of these
measures, and at present in the southern
part of Italy, when at one time not long
since, consumption raged the worst, the
death rate from this disease is now as low as
to per cent., or practically nil.

"Regarding specifics, I not only believe in
them, but use them with the best possible
results. My own treatment consists of in-
unctions of a solution of iodoform in olive
oil, together with larger doses of the drug
internally. By this treatment I have cured
a large number of cases. The gain in
weight has been from six to twenty pounds,
and the cough and other symptoms have
disappeared. Of course I do not pretend to
claim any infallibility for this treatment.
The case may be too far advanced or so
complicated as not to be more than benefited
by this treatment."

That the treatment is of great value you
will acknowledge when I tell you that my
present results are from 50 per cent to 75
per cent better than they were prior to my
using this method of treatment.

Dr. Ulrich, of Delaware, after telling an
amusing anecdote regarding the infectious-
ness or contagiousness of disease, said, that
after forty-five years' experience with con-
sumption in his practice he could come to
no other conclusion but that the disease was
contagious. He had noticed this particu-
larly in married couples, where the husband
had consumption the wife was almost sure

to develop the disease, and, indeed, fre-
quently succumbed before the husband.
The reverse was, however, seldom the case.
What the means of propagation were he did
not know, but that it was propagated could
not be denied. Dr. Ulrich regarded poverty
as a great source of consumption, due possi-
bly to the bad hygienic surroundings of our
poorer quarters.

Dr. Mays, in closing the discussion, ex-
pressed his pleasure in seeing such a general
interest manifested in this important subject
of pulmonary consumption; but would have to
take exception to Dr. Flick's statement that
while this disease was contagious it was not
so in the same sense as are small-pox or
measles. If it is contagious then it becomes
a question of exposure, whether there may
be a difference in the length of the incuba-
tion period or not. In the case of small-pox
and measles those who are most exposed to
the contagion are more liable than those
who are not, but if it is true, as the speaker
has shown, that those who are exposed to the
bacilli are not more liable than those who
are not, the plea of contagion, so far as con-
sumption is concerned, must fall to the
ground.

Dr. Flick's home infection theory rests on
equally false premises. It shows a coinci-
dence, and nothing else. Dr. Formad said,
in discussing Dr. Flick's paper, some time
ago, before the Philadelphia County Medical
Society," Who knows that affections which are
universally regarded as being non-contagious
do not show a similar relationship?"
Probably if Dr. Flick had investigated the
localities in which the abortions and mis-
carriages of the fifth ward occurred, he
might have found that these were confined
to certain houses. Dr. F. P. Henry, in dis-
cussing the same paper, said : " Sailors are
very subject to syphilis, and they live chiefly
at sea, therefore, from Dr Flick's premises,
we would be justified in concluding that the
syphilitic poison was lurking in the fabrics
of ships, and not on land Avhere the disease
is contracted.

In regard to the statistics of Naples,
which Dr. Flick says show such a marked
diminution in the death rate of consumption,
in consequence of the rigorous measures of
isolation which were enforced in that king-
dom from 1782 to 1860, he would say that
he has known a number of authorities who
have thought and written on this subject,
but none who take such a distorted view
of it as is done by Dr. Flick. By what
means does he arrive at this conclusion ?

By quoting the statistics of 1887, wThich

744

Society

Reports.

Vol. lxiv

show that Naples had a low death rate from
consumption during that year. But does
he know that the death rate was the same
in 1860, when these measures went out of
force, as it was in 1887 ? If he had referred
to the speaker's paper on the subject, he
would have found that Dr. de Kenzi, whom
Dr. Flick quotes so frequently, "Marvels
greatly (in 1863) that the City of Naples is
fully as much liable to consumption, as
either London or Paris, though the salutary
condition of the climate should render it far
less common," and that Drs. Spatuzzi and
Somma, who have paid great attention to
the mortuary returns in Naples, about 1860,
affirm that one-sixth or one-seventh of the
whole mortality was due to consumption ; a
mortality which compares very unfavorably
with countries where isolation of these poor
victims had never been dreamed of.

After the conclusion of Dr. May's remarks
the session adjourned for the day. Later in
the afternoon the visitors were taken over
the gravity railroad to the summit of Mount
Penn, where some time was spent in the tower,
1200 feet above the sea. The time was well
chosen, the air cool, and the sky clear, so
that the magnificent view, embracing six
counties, and the Schuylkill Valley, was un-
obstructed.

In the evening the visiting physicians
were entertained at a reception, given by
the Mayor of Reading, and at another given
by Ex-Congressman Hon. Daniel Ermen-
trout, at his residence.

During the afternoon the exhibitors pre-
sented Dr. Howard Reeser with a complete
case of obstetrical and emergency instru-
ments, as a token of their appreciation of his
disinterested labors on their behalf. The
pharmaceutical firms contributed to this
gift with a large collection of valuable
drugs.

Third Day — Morning Session.

The third day's proceedings opened with
the annual

ADDRESS ON SURGERY,

By Dr. O. H. Allis, of Philadelphia. Dr.
Allis gave his paper the title of Problem's
in Surgery, and discussed at length the sub-
ject of amputations. He is not in favor of
amputation unless it become absolutely
necessary. No man is so poor that he can-
not be made poorer, and physicians should
not be in haste to take a limb from a
man. In these days of antiseptic surgery, a
crushed limb can be treated in such a man-
ner, that even if amputation becomes neces-

sary, it can, at least, be deferred for a few
days, until the patient has recovered from
the shock of the accident. The speaker
illustrated with the aid of charts the
methods of amputating the foot. If an
amputation had to be performed, it should
be the chief aim of the surgeon to give his
patient a good stump.

Fractures and abscesses were then re-
ferred to and suggestions made as to their
proper treatment by the speaker.

The discussion of this paper was opened
by Dr. Packard, of Philadelphia, who said
that he favored prompt amputation when
any is necessary, but allowing as much of
the limb to remain as possible.

Dr. Mordicai Price, of Philadelphia, who
suffered an amputation of the right leg in
1863, said that he could carry as heavy a
rifle, and do as much climbing as any
hunter in West Virginia. He could not
understand why in some amputations an un-
sightly stump was allowed to remain, and
that he would consider the surgeon who left
more than five inches of stump below the
knee, one worthy of prosecution.

The discussion was continued by Drs.
Flick, Brumbaugh, Bishop, and the Presi-
dent, Dr. Craig.

Dr^E. E. Montgomery then read a paper
entitled :

CONDITIONS REQUIRING ABDOMINAL SEC-
TION IN PARTURITION.

In this paper Dr. Montgomery gave a
brief outline of the cases operated upon by
him in the Philadelphia Hospital, drawing
special attention to the various indications
for abdominal section in parturition.

In the discussion which followed, Dr.
Duffy, of Pittsburg, endorsed Dr. Mont- *
gomery's views. The discussion was con-
tinued by Drs. Price and DaCosta, of Phila-
delphia.

The two following papers on the pro-
gramme, " Insanity following Operations in
General Surgery," by Dr. Joseph Leidy, Jr.,
of Philadelphia, and " Hare Lip," by Dr.
DeForrest Willard, of Philadelphia, were
omitted, owing to the absence of these
gentlemen.

The next paper read, was one by Dr.
Edward Jackson, of Philadelphia, entitled :

WHAT TO DO FOR INSIPIENT CATARACT.

Dr. Jackson, while giving various means
by which relief could be approved, spoke of
the bad effects the blacksmith, puddling
and glass-blowing trades have upon the
eyes, and the great relief afforded by dark

June 1 3, 1 89 1 . Society Reports.

glasses to persons whose eyes are exposed to
great heat and brilliant light.

The paper was discussed by Drs. Thomas,
Barr, and Taylor. The

ADDRESS ON OPHTHALMOLOGY

was then delivered by Dr. J. A. Lippincott,
of Pittsburg. The speaker dwelt princi-
pally on the subject of trachoma, which he
said, prevailed to a great extent in orphan
asylums, public institutions, and among
imigrants.

A number of proposed amendments to the
constitution and by-laws were then pro-
posed, after which the session adjourned.

Afternoon Session.

Dr. Milton Duff, of Pittsburg, opened the
session by the annual

ADDRESS ON OBSTETRICS

which embraced an interesting history of,
and the present standing of, our knowledge
of this subject. He was followed by Dr. S.
Solis-Cohen, of Philadelphia, who read a
paper entitled :

NEWSPAPERS AND PATENT MEDICINES.

He said : " The subject is a delicate one,
and when agitated the parties who advance
any opinion against the pernicious evil, are
accused of having a personal interest in
some similar scheme, or that they desire
to choke off all competition.

" There exists in every community a
palpable and glaring evil, which reaches
high and low. rich and poor. We desire to
ask the publishers of the newspapers whether
they are willing, in the sight of God, to con-
tinue to lend their aid to this fearful evil,
the advertising of patent medicines. The
miserable newspaper that goes to the poor,
and the higher class of reviews and maga-
zines which cater to the rich, both contain
column after column of advertisements,
testimonials, and certificates which are
fraudulent and lying upon their faces.

" No man, be he editor or journalist, be-
lieves that a clothing store that only pos-
sesses one suit of clothes can perfectly fit
anyone. Any physical! who advances one
effort to produce an abortion, is ignorant of
the first principle of his art. In the news-
papers we find column after column of
advertisements promising to cure diseases of
the blood, skin, and lungs if the patient will
only swallow these money-making remedies.
Men who put forth these advertisements,
use the newspapers as a net to catch the
poor, deluded creatures who eagerly en-

deavor to cure themselves by placing faith
in these advertisements, written in the blood
of thousands who have already become their
victims.

" Have newspaper publishers a legal
right to publish such advertisements? The
answer unfortunately must be, that there is
no Legislature to prevent it. But we all
deny their moral right. They say that
they do not guarantee the nostrums which
they advertise. But the editor does guar-
antee, and is personally responsible for all
editorials, and therefore he carefully con-
siders and balances all which goes into the
columns of his paper. Why not consider
the health and happiness of the people to
whom he caters ? They say that one is not
compelled to buy them, but this is only a
secondary consideration, and the use of
these quack nostrums is, in a large measure,
due to the promiscuous advertising received
from the newspapers. Our postal author-
ities forbid all newspapers, containing the
announcement of any lottery, the privilege
of the mails, yet, where is there a lottery
half go bad as these vile mixtures which
bear the name of patent medicines ? These
mixtures cause patients to lose valuable
time in their desire to procure health, and
often result in causing death. Many a
child has been soothed to death by the use
of soothing syrup; many a drunkard has
been driven to death by the use of so-called
substitutes for whiskey, and many a mor-
phine eater has been killed by the use of
substitutes more dangerous than morphine
itself. We all have among us, either as
patients or friends, editors and newspaper
men, and let us go to them, not indignantly,
but calmly and in a friendly manner, and
put the subject before them. If I were an
editor and should insert such an advertise-
ment, I would consider every dollar that I
received from such a source as so much
" blood money," and as if stamped with the
skull and cross bones."

The discussion of this paper was opened
by Dr. F. W. Muhlenberg, of Beading, who
said that the speaker had omitted to state
that religious journals and orators were
guilty of the same offence.

Dr. J. L. Zeigler, of Mount Joy, stated
that before the discussion went any further
he wished to say that it was a case of
" Physician Heal Thyself ;" and that before
the doctors raise a cry against patent
medicines they must see that medical col-
leges turn out better material, and not
allow certificates to be given by so-called
colleges, which are the worst frauds in the

746

Society

Reports.

Vol. lxiv

country. The legislature is perhaps some-
what responsible for this state of affairs, by
not acceding to the demand for a Board of
Examiners, and thus allowing one of the
most glaring frauds which has ever been
perpetrated upon the people.

Dr. C. E. Early, of Ridgeway, read a
paper on

CATARRH.

The paper dealt chiefly with the therapeusis
of catarrh, and many interesting cases were
cited.

The last speaker was Dr. John Aulde, of
Philadelphia, who read a paper on the

PHARMACOLOGY AND THERAPEUTICS OF
ENPHORBIA PILULIFERA.

The speaker claimed many new and
interesting properties for the drug, and gave
brief histories of a number of cases in which
it had been successfully employed.

AMENDMENTS.

Dr. Solis-Cohen, of Philadelphia, moved
that the chairman of the Committee on
Publication receive the same salary as
before, viz., $150, which was adopted.

Dr. Solis-Cohen also offered an amend-
ment to the by-laws and constitution, to the
effect that the record of each member in-
clude the name of the college where he
studied, and the date of graduation. Carried.

The following resolution, offered by Dr.
J. A. Lippincott, of Pittsburg, was unani-
mously adopted :

"Resolved, That a committee be appointed
on 'Contagious Ophthalmology in Public
Institutions,' whose duty shall be to com-
municate with those who exercise super-
vision or control over orphan asylums,
orphan schools, reform schools, and kindred
institutions, with a view of ascertaining
what means, if any, are exerted to prevent
the introduction and spread of the various
forms of contagious eye disease among the
inmates. The committee shall also devise
such means, as shall in their opinion seem
best calculated to lessen the evils which flow
from these diseases."

There being no further new business the
day's session closed.

Later in the afternoon the visiting phy-
sicians paid a visit to St. Joseph's Hospital,
where a lunch was served ; and at 6 P. M.
started on a trip over the Neversink Moun-
tain Railway, stopping at the Highland
House and Klapperthal, and enjoying a
supper, dance, and music.

FOURTH DAY.

The fourth day's session was merely a
formal one and occupied but a few hours.
The following list of censors was elected :

1st District. — Drs. S. P. Bartleson, Dela-
ware ; J. W. Walk, Philadelphia ; James
Fulton, Chester.

2nd District— Drs. J. B. Walter, Bucks ;
Traill Green, Northampton ; W. B. Erdman,
Lehigh.

3rd District. — Drs. Hiram Corson, Mont-
gomery ; W. Murray Weidman, Berks ; A.
F. Bronson, Schuylkill.

4th District. — Drs. J. M. Deaven, Lancas-
ter; H. O. Orris, Perry; H. L. Orth,
Dauphin ; A. M. Smith, Snyder.

5th District. — Drs. S. P. Ziegler, Cumber-
land ; J. W. C. O'Neil, Adams; D. K.
Gotwald, York ; J. Montgomery, Franklin.

6th District. — Drs. A. B. Brumbaugh,
Huntingdon ; Crawford Irwin, Blair; John
Lowman, Cambria ; H. M. Lichte, Somerset.

7th District. — Drs. J. O. Robertson, West-
moreland ; J. S. Hackney, Fayette ; William
Anderson, Indiana ; J. A. Armstrong, Arm-
strong.

8th District. — Drs. James McCaen, Alle-
gheny ; Jesse L. Scott, Washington ; W. S.
Throckmorton, Greene.

9th District— Dm. S. D. Bell, Butler ; E.
Griswald, Mercer; D. S. Margins, Beaver;
J. A. Richey, Venango; J. Cresswell,
Clarion.

10th District. — Drs. A. A. Woods, Erie ;
W. V. Hazeltine, Warren ; R. B. Brown,
Jefferson ; A. M. Straight, McKean.

11th District— Drs. D. A. Hogue, Clear-
field ; G. T. Harris, Centre ; P. H. Detweiler,
Lycoming.

12th District— Drs. S. C. Newbaker, Mon-
tour ; E. R. Meyer, Luzerne ; J. H. Vastine,
Columbia , L. M. Gates Lackawanna.

13th District— Drs. J. W. Lyman, Brad-
ford ; S. Birdsall, Susquehanna.

Then followed the inauguration of the
President-elect, Dr. Kurtz. After a vote of
thanks being tendered the retiring officers,
and the disposal of unfinished business, Dr.
Kurtz, the President-elect, adjourned the
forty-first annual meeting of the State
Medical Society, of Pennsylvania, until the
second Tuesday in June, 1892, at Harris-
burg.

The State Society has at present a mem-
bership of 2,172. At this meeting 300 phy-
sicians registered.

The committee of arrangements to whom
the success of the meeting was so largely
due, included Drs. Samuel L. Kurtz, Chair-

June 13, 1 89 1. Selected Formula.

747

man, James Y. Shearer, C. W. Bachman,
H. S. Reeser, M. A. Rhoads, Samuel C.
Ermentrout, and A. S. Raudenbush, all of
Reading, Pa.

Selected Formula.

IRRITABLE BLADDER.

Potassium citrate 3 iv.

Fluid ext. triticum repens

Tinct. of hyoscyamus aa 5 j.

Fluid ext. of buchu .5 ss.

Water, sufficient to make % iij.

M Sig. One teaspoonful in a wineglassful of water, three
or four times daily.

— Med. Summary.

TREATMENT OF DYSENTERY.

Minorbi, in U Union Medicale, describes
a method of treatment which he has followed
in twenty-three cases of dysentery. In one
case a cure was obtained in a very few days.
The treatment consisted in the insertion
into the rectum of suppositories made in the
following manner :

f& Naphthalin 5 ijss.

Cocoa butter 5 ijss.

Where there is ulceration or any other
condition which tends to make the use
of a suppository painful or dangerous, he
has recourse to the following injection :

Naphthalin.
Olive oil....

.grs. Ixxv.
■ 5 vj.

At the beginning of an attack, when there
is a good deal of tenesmus, the injections
should be given every half hour, but ordi-
narily it is sufficient to repeat them three or
four times in the twenty-four hours. The
advantage of this method is that it does
not cause constipation, which opium is apt
to produce.

WHOOPING-COUGH.
^Germain See in Jour, de Medecine) :

Ify Powdered belladonna root gr. 1-5.

Dover's powder gr. ss.

Sublimed sulphur gr. iv.

White sugar gr. x.

M. Sig : Take in one dose from two to ten times a day, ac-
cording to age of patient and effect produced.

— Am. Pract.

ONE MINUTE LIGHTNING DROPS.'

01 sinapis gtt. v.

Chloroform gtt. x.

Spts. terebinth gtt. iij.

Spts. vini. rect , 5 ss.

— Pharmaceutical Era.

FOR INTERNAL HEMORRHOIDS.

-E^ Chrysarobin grs. xv.

Iodoform grs. v.

Extract of belladonna .grs. viij.

Cocoa butter 5 vj.

Of this are made ten suppositories, and
one suppository ought to be inserted into
the rectum each day. After five or six
hours the pain and the tumor diminish.
The treatment may continue for several
months without harm.

INTESTINAL FLATUS.

Many young children are irritable, and
cry because they have intestinal flatus.
Instead of using opiates which are the basis
of most of the soothing syrups, Prof. Bar-
tholow gives the following as a valuable
remedy :

1^ Misturae assafoetidae fgj.

Sodii bromid., gr iij-v.

M. This is a dose for a child from one to four months old.

— College and Clin. Record,

PURGATIVE PILLS.

Aloes 15 grains.

Resin of scammony 7 "

Resin of jalap 7 "

Calomel 7 "

Extract of belladonna 3 "

Extract of stramonium 3

Make into twenty-five pills and give one to two a day.

COUGH MIXTURE.

The following is said by the College and
Clinical Record to be Dr. E. G. Janeway's
favorite cough mixture :

i^k? Syrup, tolu

Syrup, pruni Virginian

Tinct. Hyoscyami

Spirit, aetheris comp

Aquae aa gj.

M. Sig. — Dose a teaspoonful.

TREATMENT OF GONORRHOEA BY BI-
CARBONATE OF SODA.

According to the Journal de Medecine de
Paris, Casselan during the past four years
has employed a solution of bicarbonate of
soda in the strength of 1 : 100 in the treat-
ment of gonorrhoea. He has treated thirty-
three cases and obtained thirty-three cures
in from two to three weeks by the employ-
ment of injections of the solution named.
He bases his treatment on the belief that the
virulence of the disease is in direct propor-
tion to the acidity of the secretions.

748

Selected Formula.

Vol. lxiv

DIPHTHERIA.

Andeer recommends the application every
hour or two, night and day, of the follow-
ing:

Ijk" Resorcin gr. xlviij.

Glycerine.. f f 5 i.

M.

A spray of a five per cent, solution of the
drug should be used in the room and the
following administered internally :

Ijk Resorcin gr. x.

Syrup terebinth f 5 i.

S.— A teaspoonful every three or four hours.

— Centralblatt f. d. Gesammte Therapie.

INHALATION FOR WHOOPING-COUGH.
Beall recommends the following formula :

Jjt? Thymol gr. xx.

Acid carbolic, ]
Ol. sassafras,

01. eucalypti, }- aafSij.

Reis liq idae, |
Ol. terebinthinse, J

/Etheris, f 5 iv.

Alcoholis, q. s., ad. fg iij. M.

S. Put about thirty drops upon a pad of such size as to be
cotiveniently hung around the child's neck, renewing the
application every two or three hours.

— Daniel's Med. Jour.

SUBACUTE OR CHRONIC DIARRHOEA.

The following is recommended in the
Southern Med. Record :

Ify Acacise pulv 5 iss.

Creasoti (beechwood) gtt. xxxii.

Aqua? 3 iv.

Fiat emuls. Sig. A teaspoonful in water (for adults) every
4 to 6 hours.

THE TREATMENT OF TYPHOID FEVER.

Smakovsky, during the space of two and
a half years has treated 700 cases of
typhoid fever in the following manner:

Calomel grain.

Sugar 4 grains.

This to be made into ten powders and one
powder given each hour until the evacua-
tion from the bowels becomes copious and
soft. The patient is also given a gargle,
composed of a solution of chlorate of potash,
to prevent mercurial stomatitis. If there
are evidences of feebleness of the heart, the
calomel is stopped and small doses of the
infusion of digitalis are administered. After
the calomel has produced its antiseptic and
alterative influence the diarrhoea, if it has
become excessive, may be controlled" by the
use of the following powders :

Ijk? Subnitrate of bismuth 2 grains.

Naphthalin y2 grain.

Sulphate of quinine 1 grain.

One of these powders to be given four times a day.

For the cough Smakovsky recommends :

Ijk" Aqua ammonia 1 drachm.

Tincture of eucalyptus 1 ounce.

Essence of peppermint 10 drops.

Ten drops to be given every two hours.

This prescription is also of advantage in
acting as a disinfectant of the mouth. The
Russian investigator just named is con-
vinced that the mortality of typhoid fever
under such treatment is very much lessened.
— 1? Union Medicate.

SOOTHING SYRUP FOR CHILDREN.

We do not recommend any narcotic sooth-
ing syrup, although such are much used ;
the employment of opiates in these prepara-
tions is unsafe, and should be discouraged as
far as possible. The following is effectual
and perfectly safe :

JjE* Treacle i*lb.

Distilled water 1^ pints.

Stronger tincture of ginger % tl oz.

Oil of cloves 20 min.

Oil of sassafras 30 "

Oil of caraway 5 "

Oil of aniseed 10 "

Rectified spirit 5 fl ozs.

Dissolve the oils in the spirit, then add the treacle with the

water, and mix Dose, from half to one teaspoonful.

— Era.

ACUTE URETHRITIS.

Professor J. William White, of the
University of Pennsylvania, recommends
the following mixture*, in capsules. In
about two-thirds of his cases the discharge
ceased within a week. In the majority it
was necessary also to use an injection, and
for this he recommends two to ten grains of
sulpho-carbolate of zinc in a ten to fifteen
per cent, solution of peroxide of hydrogen :

Ij^ Salol 3% grains.

Oleoresin of cubebs 5 grains.

Balsam of copabia (Para) 10 grains.

Pepsin 1 grain.

VOMITING OF PREGNANCY.

Cocain with Acetanilid is recommended
in the vomiting of pregnancy, also in acute
gastralgia, in this proportion :

1^ Cocain. mur gr. iii.

Acetanilid 5 ss.

Aquse 3 v.

Sig. A teaspoonful hourly.

\

June 13, 1891.

Editorial.

749

THE

MEDICAL AND SURGICAL

REPORTER.

ISSUED EVERY SATURDAY.

EDWARD T. REICHERT, M. D.,

Professor of Physiology, University of Penna.,
Editor and Manager.

N. E. Cor. 13th and Walnut Streets,
P. 0. Box 843. Philadelphia, Pa.

THE MEDICAL AND SURGICAL
REPORTER.

Terms : Five dollars a year, strictly in advance,
unless otherwise specifically agreed upon. Sent 3 months
on trial for $1.

At the termination of the period of subscription, we
will promptly discontinue sending The Reporter unless
directed to the contrary by the subscriber.

Remittances should be made by draft, check, postal
note, or money order payable to Edward T. Reichert.

THE POCKET RECORD AND YIS-
ITING LIST.

Two sizes. Prices to subscribers of The Reporter :
For 30 patients a week (with or without dates), $1.00.
For 60 patients a week (without dates), . . $1.25.
Prices to non-subscribers, $1.25 and $1.50 respectively.

THE MODEL LEDGER.

Physicians who keep their own books will find this of
great value. Sample pages sent on application. Price,
$5.00.

J8®""SuGGESTIONS TO SUBSCRIBERS t

See that your address-label gives the date to which your sub-
scription is paid.

In requesting a change of address, give the old address as
well as the new one.

If The Reporter does not reach you promptly and regularly,
notify the publisher at once, so that the cause may be dis-
covered and corrected.

^"Suggestions to Contributors and Correspondents.
Write in ink.

Write on one side of paper only.
Write on foolscap or legalcap paper.

Make as few paragraphs as possible. Punctuate carefully.
Do not abbreviate or omit words like "the" and "a," or
" an."

Make communications as short as possible.

Never roll a manuscript ! Try to get an envelope or
wrapper which will fit it.

When it is desired to call our attention to something in a
newspaper, mark the passage boldly with a colored pencil, and
write on the wrapper " Marked copy." Unless this is done,
newspapers are not looked at.

The Editor will be pleased to get medical news, but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

THE TABLE OF CONTENTS.
In response to what we believe is the gen-
eral wish of our readers, the table of contents
is permanently restored to the title page.

Leading Article.

The lack of attention given by the podi-
atrist as well as the general practitioner to
the subject of infantile malaria, is surprising.
Both, in meeting intermitting febrile symp-
toms in very young children and infants,
are prone to advance any other diagnosis
rather than that of malaria. Recent statistics
show that intermittent fevers occur with
greater frequency in the early years of life,
than at any other period, and that the ages
showing the greatest susceptibility to mala-
rial infection are the first and second years.

The chief reason for the failure to rec-
ognize intermittent fevers in infants, is
owing to their atypical course, which in
comparison with the symptomatic picture
of intermittent fever in adults, seems an
almost totally different disease. It is for
this reason that, in all probability, even
eminent podiatrists, failing to recognize the
real trouble, have treated the manifestations
of infantile malaria as other affections.

In infantile malaria the initial chill is
absent, perspiration is seldom observed, and
the intermissions between the febrile attacks
are usually not clearly defined. In the ma-
jority of cases the temperature between the
attacks will be \ to 1$° C. above normal ;
and in this respect the disease resembles a
remittent rather than an intermittent fever.

The infantile organism reacts so strongly
to any infectious febrile disease, that it is
not long, in cases of malaria, before the
digestive and respiratory systems become
involved. The child rapidly falls away, the
facial color becomes bad, and anseinia is
rapidly established. Unless the case occurs
in a well-recognized malarial region, the
attending physician is almost certain to
make a wrong diagnosis. The attending
complications will seem to justify a diagnosis
of gastric or intestinal catarrh, or even a
mild form of typhoid fever, bronchial catarrh

75 o iidito

or possibly even phthisis. If the disease
occurs during the teething period it is very
frequently called " dentition fever." If, in
such cases, after having exhausted almost
every therapeutic means, the physician tries
quinine, he will be greatly surprised at the
rapid recovery of his little patient.

Light cases of infantile malaria often re-
cover spontaneously, and for this reason
escape notice ; indeed, even in the severer
forms, a change of air or climate will fre-
quently be productive of excellent results.

In this article, necessary brevity forbids
our giving a detailed account of the symp-
tomatology of the various forms of infantile
malaria. The subject is one so extensive,
and of such interest, as to be a worthy the me
for a lengthy monograph. We would, how-
ever, state that the greatest stumbling block
in the physical diagnosis of these cases has
been, the peculiarity and atypical nature
of the temperature curves, and the rela-
tive condition of spleen and skin. The
regular rise of temperature, coupled with
restlessness and various nervous symptoms
is of great diagnostic value. If such symp-
toms are present in a child in a district
where malaria is known to exist, even
although slightly, a diagnosis may safely be
advanced. Large doses of quinine — 0.5 to
0.8 gramme, pro die, according to the age of
the child — may be given with impunity, and
are productive of excellent results. In
such parts of the country in which mala-
ria is unknown, to adults, at least, cases of
intermittent fever in children can frequently
be shown to be of a malarial nature, apart
from their tendency to yield quickly to
quinine.

It is not long ago since Laveran and
Marchiafava-Celli discovered the hcemo-
plasmodium malarioz to be the germ of
malaria. Since then, Dr. Carl Hochsinger,
of Vienna, who has made the subject of in-
fantile malaria a special study, has been able
to trace this plasmodium in the blood of a
number of cases of intermittent fevers in
children, when otherwise, from the locality,
such a diagnosis would seem unwarrantable.
Dr. Hochsinger contributes a most interest-

rial. Vol. lxiv

ing article on the subject in the Wiener
Medizinische Presse, April 26, 1891, in
which he states that during the past year he
has found these germs in every one of twenty-
four cases of infantile intermittent fever,
which have come under his observation. The
youngest child in which these germs of ma-
laria were found was only three months old.

In searching for the plasmodium in the
blood, Dr. Hochsinger makes use of a solu-
tion of methylen-blue and eosin. Taking
100 grammes of a strong, but not concen-
trated, aqueous solution of methylen-blue, he
adds to this a few drops of absolute alcohol,
and then £ gramme of soluble eosin. The mixt-
ure is' then bottled and sterilized by boiling
and will keep for an indefinite length of
time. A small quantity of this solution is
poured into a shallow dish, and the slides,
containing a dry preparation of the blood,
are allowed to float in the solution for ten to
fifteen minutes, then rinsed off and sealed.
Under the microscope the red blood cor-
puscles will be found stained a deep red, the
nuclei of the leucocytes a deep, dark blue,
and the hsematozcese of malaria a delicate
sky-blue.

In every case examined by Hochsinger
large quantities of these plasmodia were
found, varying in number, form and kind,
with the intensity of the disease. In all cases
and all stages of the disease, Laveran's so-
called corps segmentes were observed. These
were seen as large groups of closely packed
corpuscles of protoplasm of ajdelicate blue
color, and about as large as i to \ of a red
blood corpuscle. In three cases the flagelats
form were found, and in one case of severe
cachexic malaria, terminating fatally, well
defined crescent forms were also visible. The
segmented variety were present in every case,
and in especially large numbers in the
youngest subjects.

Examination of the blood is, therefore, of
the highest importance in cases where the
possibility of malarial infection in infants
and young children is suspected, and also in
those cases of intermittent fever in children,
of an uncertain origin. The diagnostic value
of such an examination is especially great, as

June 13, 1891.

Book Reviews.

75i

these plasmodia are only found in cases of
malarial infection.

With the extreme susceptibility and pre-
disposition of the infantile organism to ma-
larial poisoning on the one hand, and the
comparatively easy, and at once positive
diagnostic method on the other, the practi-
tioner should not rest content with an
uncertain diagnosis in any case of infantile
fever of obscure origin, without having first
precluded the possibility of a malarial infec-
tion by the above simple yet unerring test.

Correspondence.

ED. MEDICAL AND SURGICAL REPORTER.

Dear Sir: — I would like to place on
record a brief note of two cases, which I
have recently done, both of which are cases
of abdominal tumors complicating preg-
nancy. I will in time make full reports
of both.

On April 1st, I removed a large intra-
ligamentous ovarion cyst from a lady from
Butler Co., Pa., who was pregnant 3£
months. She has gone home, pregnancy not
disturbed.

On May 23, I removed from a lady,
resident of East Liverpool, O., a fibro-
cystic tumor, growing from the fundus of
the uterus, weighing 22 pounds, with the
uterus pregnant 5 months. The child was
living, but died. She is in her sixth day,
pulse and temperature normal. The first
Porro operation in the State, outside of
Philadelphia, so far as I know.
Very truly yours,

R. Stansbury Sutton.

419 Penn Ave., Pittsburgh.

Book Reviews.

A GUIDE TO THE CLINICAL EXAMINA-
TION OF THE URINE. By Farrington H.
Whipple, A. B. (Harv.) Boston, Damrell and
Upham, 1891; pp. 206.

Had there been an urgent demand for
any condensation of the already existing
works upon urinary examination, possibly
Mr. Whipple would have had an excuse for
rushing into print with this volume. As it
is, however, there is no reason for its exist-
ence, even were it a first-rate compilation.
Moreover, the book is exceedingly in-
sufficient, both in clearness and accuracy,
and in the presentation of the more recent

additions to our knowledge of urinary
matters.

There can scarcely be a necessity for a
systematic consideration of the entire work
after such an introduction ; and, in fact,
sufficient illustrations may be cited from
random pages to prove the above assertion.
For example, in the consideration of the
subject of albumen in the urine, the only
tests mentioned are those by heat and
acetic acid, and by nitric acid ; there are no
quantitative tests, not even the popular
Esbach's tube. None of the newer albumen
reagents are considered : picric acid, the
ferrocyanide test, trichloracetic acid, Tan-
ret's or Millard's. In the estimation of
sugar the same fault may be cited — there
are none of the newer tests, and those as
a rule are badly put. For example, the
following covers the subject of the fermen-
tation test for sugar (excluding reference to
the differential density method) : " Fermen-
tation Test. — By fermentation, sugar is
broken up into alcohol and C02; there-
fore it is only necessary to cause fermen-
tation in the urine, which can be done
by the addition of a little yeast-cake.
The CO 2 as it forms is passed through baryta
water." As a guide for those who need
directions, such guidance must be regarded
as exceedingly meagre.

In the study of hematuria, the urinary
symptom is used as an excuse for leading
the author into an entirely irrelevant
biological study of the blood with a con-
sideration of the differences between the
blood of the different animals. The author's
test for iodide of potassium in the urine,
which substance he recognizes by a brown
ring between the layers of nitric acid and
urine in the ordinary application of Heller's
test for albumen, would be greatly improved,
if, after freeing the iodine by any of the
stronger mineral acids, some characteristic
color reaction were added, as seen, for in-
stance, in the solution of the iodine by
chloroform.

The author states that when H2S exists
in the urine in conditions unassociated with
disease of the urinary system it is to be re-
garded as a favorable symptom. Hydro-
thionuria is, however, a condition which is
rarely recognized in the freshly passed
urine, except as a phenomenon of bacterial
invasion of the urinary system, or of some
connection between the intestinal canal and
the urinary apparatus, and in either case is
exceedingly unfavorable ; beyond this, as a
demonstrably free substance in the urine,
H2S practically does not exist.

752

Book Reviews.

Vol. lxiv

In the optical appearance of calcic oxalate
crystals Mr. Whipple entirely forgets the
very characteristic refractive property of
these bodies ; hence in his separation from
similarly shaped crystals of phosphate he
must have recourse to chemical tests. On the
subject of casts he states that only in a few
isolated cases have these been detected in
non-albminous urine ; in our experience in
cases of interstitial nephritis it is quite a
common occurrence to meet specimens of
urine presenting typical casts, in which with
the tests mentioned by Mr. Whipple, abso-
lutely no traces of albumen can be discovered.
His simile that a waxy cast " bears some-
what the same relation to a hyaline cast that
a fat drop does to an abnormal blood disk"
seems exceedingly indefinite and nondescrip-
tive. He states that " pus casts may occur in
the course of acute inflammatory conditions.
In pyelitis and pyelonephritis the pus cor-
puscles are frequently agglomerated in
masses which are suggestive of casts and
may come from the straight tubules. They
are usually of considerable size — much larger
than the renal casts."

The view announced by Mr. Whipple that
active hyperemia of the kidney is identical
with parenchymatous degeneration (" cloudy
swelling," large white kidney) may account
for his failure to notice pus casts in cases of
Bright's disease that are not to be regarded
as distinctly acute processes. Both these
views are, however, contrary to * the truth.
Pus casts, casts to which pus corpuscles are
intimately attached, in urines showing few
free pus corpuscles, may be taken as an indi-
cation of tubular inflammation ; and the pus
cells possess the same significance so far as
the nature of the process is concerned as do
renal tubular epithelial cells. Such casts
may be found in varying amounts in almost
every case of catarrhal nephritis from the
first to the last stage.

Such instances may serve to point out the
general character of Mr. Whipple's book ;
almost every page is, however, open to some
objection when he does not adhere strictly
to the teachings of the older works upon
which his book is based. The present
edition cannot possibly be regarded as a suc-
cess from a scientific point.

HISTORICAL SKETCH OF THE UNIVER-
SITY OF MARYLAND. By Eugene T. Cor-
dell, M. D., of the class of 1868, Baltimore.
Press of Isaac Friedenwald, 1891.

This octavo volume, of some two-hundred
and fifty pages, contain a history of the
school of medicine from the year 1807 to

1890, inclusive, together with an introduc-
tory chapter, in which are recorded events
preceding the founding of the college of
medicine of Maryland in 1807 ; — also notices
of the schools of Law Arts and Sciences,
and Theology, and the department of Den-
tistry, and a general catalogue of medical
alumni. There are likewise included some
twenty illustrations and portraits and about
seventy memoirs.

Special emphasis is laid upon the necessity
of endowing the university, especially the
medical department, and the author does
well when he states that in order to make
the rank of medical schools in this country,
of the highest standard and their graduates
worthy of the title "Doctor of Medicine," it
is essential that the schools be fully endowed ;
for the scientific requirements of modern
medicine demand a large outlay which cannot
always be met by the mere fees of students,
fluctuating and hence uncertain as they
necessarily are, and without which support,
most of the medical colleges as now con-
ducted, would cease to exist.

The book is more than a sketch, as the
author modestly titles his work, — it is a
complete record of the medical school of the
Maryland University, and therefore will re-
ceive undoubtedly a cordial welcome at the
hands of the many alumni of the institution.

THE DISEASES OF PERSONALITY. By Th.
Ribot, Professor of Comparative and Experimental
Psychology at the College of France, and Editor of
the "Revue Philosophique." Authorized Ameri-
can Translation, Chicago. The Open Court Pub-
lishing Company, 1891.

For the student of Psychology, this small
volume contains much of interest. The
contents are embraced in an introductory
and five chapters. The titles of the latter
are : 1. Organic Disorders. 2. Emotional
Disorders. 3. Disorders of the Intellect.
4. Dissolution of personality ; and finally
the Summary.

The author is a well-known writer on
Psychological subjects, as well as editor of a
periodical devoted entirely to this study,
which account for the masterly manner in
which the difficult subject of the present
volume is handled.

FOR SOFTENING EAR-WAX.
La Clinique recommends the following :

1^7 Acid. Boric grv.

Glycerini

Aquae aa ad Sj

M. Ft. sol

Sig : Warm the solution and put 5 to 10 drops in the ear
twice a day.

June 13, 1891.

Periscope.

753

PERISCOPE.

THERAPEUTICS.

THE EMPLOYMENT OF GUAIAC AS A
PURGE.

Murell (Rev. Therap, Med. Lhirurg., Paris,
Jan. 15, 18111) attributes to guaiac laxative
and purgative properties, believing it to be
a stimulant to the liver and intestines. He
has employed it with satisfactory results in
several cases of biliousness and constipation.
The drug was administered as a purge, in
combination with honey, in doses of 60 centi-
grammes. This quantity was generally suf-
ficient to produce a purgative effect. He
reports a case in which the remedy produced
a well-marked eruption of the arms and legs,
accompanied with intense itching, but these
symptoms disappeared on the suspension of
the drug.

In order to avoid the disagreeable griping
sensations which the medicant sometimes
produces, Murell recommends a combination
of the drug and extract of malt. The author
believes, also, that if this preparation is tritu-
rated with cream of tartar, sugar of milk, or
other inert substance, its efficacy may be
observed when administered in small doses.

RADLAUER'S ANTISEPSINE.

According to the Inter. Nat. Pharm. Gen.
Anz., Jan. 30, 1891, this substance is a com-
bination of iodate of zinc, zinc, and thymolic
borax, brought about by treating these agents
with antiseptic measures. Antisepsine pro-
duces the same antiseptic effects as iodol,
thymol, boric acid, and the salts of zinc ; it
entirely supplements iodoform, carbolic acid
and corrosive sublimate. Its advantages
areas follows: 1. While it is a powerful
antiseptic it does not possess toxic proper-
ties, nor are its marked effects ever of a
poisonous nature. 2. It is free from bad
odor, and it exercises no local irritant action.
3. It is easily soluble in absolutely clear water
It is a whitish powder, its price being
reasonable, more so than that of iodoform,
iodol or aristol.

THE TREATMENT OF LUPUS.

H. Leboir (Journal des Maladies Cutanees
et Syphilitiques, Jan., 1891) divides the
treatment of lupus into two great classes :
The local and the internal treatment. The
first he again divides into the surgical, the
medical and the mixed treatments. This last I

one is preferred by the author in the
majorfty of cases.

In the surgical treatment five methods are
employed, as follows : ablation, scraping,
scarifications, cauterizations, and electrolysis.
In the application of all these methods, local
and general anesthetics are used. With
regard to the employment of germicidal
and caustic agents, the latter are preferred.
In general, the local medication is not re-
garded favorably by the author; on the
contrary, the mixed treatment, chiefly made
up of cauterizations and the local applica-
tions of iodoformed ether should be the base
for the general treatment of lupus.

The general treatment should be looked
upon as an adjuvant to the local one. That
treatment may be reconstructive and specific,
in the first case, cocl liver oil, arsenical prep-
arations, sulphur, and other alteratives may
be administered, and in the second, iodoform,
iodol, and creosote may be employed together
with subcutaneous injections of iodoform. In
regard to the Koch remedy, the author has
formed no definite opinion, but as that agent
appears to possess an elective action towards
lupus, it may be employed for the present,
as an element of diagnostic value.

ACTION OF ANTIPYRETICS.

The action of antipyretics may be sup-
posed to be due to the limitation of the oxi-
dation processes and consequent lowering of
heat development, or to an increase in the
heat radiation from the surface of the body.
Moreover, they may have a purely local
action, — i.e., on the cellular tissue, — or they
may influence the nerve-centres, regulating
the development or radiation of heat.
Messrs. Sawodowsky and Podanowsky con-
sider that they have proved that the lower-
ing of temperature produced by antipyrine
and antifebrine is attributable exclusively to
their influence upon the brain-centres regu-
lating the temperature, which are believed
to exist in the corpus striatum (Apot. Zeit,
February 11, p. 87). The authors cut the
brain of an animal through close behind the
corpus striatum and thalamus opticus, so
as to isolate the organism from the heat-
centres, while the connection with the
respiration and vasomotor centres was re-
tained. Although the animal so treated
lived for some time, and the arterial blood-
pressure and breathing remained unaltered,
the body temperature fell continuously.
Even injections of the most powerful
pyretics, such as putrescent matter, caused
not the slightest rise of temperature,

754

Periscope.

Vol. lxiv

although all the other symptoms of putres-
cent infection were present. Equally power-
less were antipyrine and antifebrine to hinder
in the slightest degree the fall of tempera-
ture. The skin temperature also remained
entirely unchanged, although in the case of
normal animals this rises considerably after
the injection of antipyretics. An apparent
exception was noticed in the case of quinine
hydro-bromide, but this was attributed to
the known action of bromine. The conclu-
sion drawn by the authors is that the action
of quinine salts — resorcin and thallin — in
lowering the temperature is dependent upon
their specific influence upon the temperature
regulating centres situated in the anterior
part of the base of the brain. — Pharmaceuti-
cal Journal and Transactions, February 28,
1891.

JAMBUL IN THE TREATMENT OF
DIABETES.

Among the newer drugs which have been
suggested for the treatment of diabetes mel-
litus, the seeds of Eugenia jarubolana,
Lamarck, a tree of the family myrtacese,
growing in Java, the Molucca and Phil-
lipine Islands, and in parts of India, have
been most favorably commended by several
English and American writers, most notably
by Scott (British and Colonial Druggist,
1887). The chief advantage of the drug, as
expressed by these observers, was the possi-
bility of controlling the excretion of sugar,
without the necessity of restricting the diet.
A careful study of the subject has recently
been undertaken by Villy (Bulletin general
de Therapeutique, Jan. 30, 1891), whose
observations throw considerable light upon
the chemistry and clinical action of this
drug. Although as large a dose as an ounce
to an ounce and a half of the seeds has been
given to the adult in twenty-four hours, no
case of poisoning has been recorded ; and the
author finds that a rabbit may be given its
own weight of the drug within twenty-four
hours without disturbance of its nutrition.

Contrary to the observations of Scott, it
was demonstrated that jambul favors and
hastens saccharine fermentation at a temper-
ature of 70°. The same result was noted in
experiments made at the normal tempera-
ture of the human body, but the process was
somewhat more slow. Judged, therefore,
simply by the result of experiments outside
of the body, the drug would appear to be
ill-suited to the indications of the disease.

His clinical observations are interesting,
and seem to show that the applicability of

this drug is quite limited. As long as the
ordinary diet is permitted, the use of jambul
is dangerous, as favoring the persistence of
polyuria and increasing the excretion of
sugar and urea. In cases of moderate
degree, with or without azoturia, in stout
and gouty patients, jambul seems to be of
value, provided that at the same time an
exclusive diet is maintained. In this
respect the drug does not differ from other
therapeutic agents employed in this disease.
Most frequently sugar disappears rapidly
from the urine, but reappears almost as soon
as the medication is suspended.

In grave cases, where regulation of the
diet appears to be without effect, jambul,
like other remedies, is of no value. The
powdered seed is well borne by the stomach
to the amount of 150 to 320 grains, in
divided doses, in the twenty-four hours. —
Univ. Med. Mag.

TREATMENT OF TUBERCULOUS BRON-
CHITIS BY HYPODERMIC INJEC-
TIONS OF IODOFORM.

Influenced by the action of iodoform on
pus globules, Dr. Gavoy announces in the
Gazette Medicale de Paris for February 28,
1891, that in 1887 he was led to test this
remedy in pill form in tubercular bronchitis,
but the gastric distress and nausea caused
by the administration of the remedy com-
pelled him to substitute enemata for the
internal administration in the pill form, and
he has now, for various reasons, substituted
for these methods the hypodermic method.
He states that at the outset he employs,
morning and evening, a hypodermic injec-
tion of a quarter of a syringeful of a solu-
tion of 1 part of iodoform in 100 parts of oil
of sweet almonds. In very few cases, he states,
is any febrile reaction produced, and the re-
sults obtained in the majority of cases are
excellent. He maintains that in his use of
this remedy the cough rapidly diminishes ;
muco-purulent expectoration, so character-
istic of this specific catarrh, becomes more
fluid, and finally ceases almost entirely ;
alteration in the character and hoarseness of
the voice disappear ; the lungs become more
permeable to air ; inspiration becomes
deeper ; the vesicular murmur acquires an-
other character, and subcrepitant moist rales
disappear, nocturnal sweats cease, the appe-
tite returns, and the patient's general health
improves. In fact, he states, that progres-
sive improvement in the majority of cases
indicates in the most positive manner arrest
of this broncho-pulmonary catarrh of phthisis.

June 13, 1 89 1. Periscope.

755

He states that the examination of the spu-
tum for bacilli is not an indispensable crite-
rion for this therapeutic process, for the pres-
ence of the bacilli can only be exceptionally
located at the onset of tubercular bronchitis,
and, although the bacilli may exist in small
closed cavities in the lungs, they only appear
in the sputum when the ulceration has com-
municated with the bronchi. Further,
iodoform is said to have the power of lique-
fying the more or less solid obstruction in
the alveoli. He suggests that the therapeutic
action of iodoform on caries of bone and on
pus globules permits of the supposition that
it may exert an analogous action on yellow
tubercle and during the stage of softening, a
condition which might be described as a
caries of the lung. Although iodoform is an
active antiseptic agent, it does not appear
to have any direct action on the bacilli of
tuberculosis other than in modifying the
character of the tissues in such a manner as
to delay or prevent the reproduction of the
bacilli, and in aiding the elimination of the
results of tissue breaking down, and favoring
the cicatrization of ulcers seated in the
alveoli. He recommends in the warmest
terms further tests with this remedy in this
connection. — Therap. Gaz.

ON THE UTILIZATION OF THE FOOD IN
CASES OF GASTRIC DISEASES.

Dr. C. Noorden (Ztschr. f. Kl Med., Bd.
xvii.) has made some experiments to de-
termine what becomes of the food in func-
tional gastric disorders after it has left the
stomach. He selected seven patients in
whom the production of hydrochloric acid
had been reduced to a minimum, and in
whom the food was so rapidly carried into
the intestine that even if lactic acid fermen-
tation had occurred, it could not have at-
tained a degree sufficient to peptonize
albumen in the stomach. Propepsin was
formed in all of the cases in abundant
quantities. These experiments demonstrate
that even in cases where no pepsine or
hydrochloric acid is secreted the intestine is
capable of completely fulfilling the office of
the stomach. The reduction of the bodily
weight observed in cases of chronic gas-
tric disease is attributed by the author to an
insufficient supply of food, since the two
other factors which might be held respon-
sible for it, viz.: the formation of toxines,
and the excessive decomposition of the albu-
minous substances in the intestines, owing to
fermentation resulting from the diminished
disinfectant power of the abnormal gastric

juice, can be excluded. The hydrochloric
acid secreted in the stomach does not exert
any disinfectant properties beyond the
boundaries of that organ, and has no part
in intestinal disinfection. The theory of
motor insufficienpy of the stomach in gastric
catarrhs is controverted by the author, on
the ground that this condition rapidly dis-
appears as soon as fermentation in the
stomach is arrested. The delay in stomach
evacuation is attributable to the action of
organic acids in producing spasms at the
pylorus. Noorden recommends in the
therapy of chronic gastritis the administra-
tion of a regulated quantity of albumen, fats
and carbohydrates, sufficient being given
only to maintain the general nutrition, and
states that by the avoidance of all super-
fluous nutriments we will favorably in-
fluence the local affection. The lack of ap-
petite should be overcome by the patient's
own will power. Stimulant stomachics,
especially orexin, should not be given, on
account of their harmful effects. Rest in
bed is indicated, for the reason that less
food will be consumed and the stomach less
taxed. The food which is best adapted to
supply the body with fats and carbohy-
drates is milk, especially if fortified by the
addition of butter and lactose. — St. Peters-
burger Medic. Wochenschr. No. 1, 1891.

CHLORALAMID.

Dr. W. G. Killebrew, in the Memphis
Medical Monthly, states that he has used
chloralamid in hysteria, acute mania, mono-
mania, typhoid fever, also in surgical opera-
tions, and when unattended with much pain,
with as good results as could be hoped for in
all cases. He has used it in cases of insomnia
and neurasthenia, and found that it produced
all the sleep necessary, patients feeling much
refreshed the following morning, with no
after effects that he could discern. He noticed
only two instances of delayed action, and in
these two cases the hypnotic effect was con-
tinued into the next day, a result so fre-
quently noticeable in the administration of
sulfonal. His deductions were these : That
in any case, almost without exception, un-
attended with pain, it would produce sleep.
That its analgesic power,though slight, would
meet a good per cent, of cases attended with
pain.

Compared with chloral :

1. It is more agreeable to the taste and
consequently more easily administered.

2. Rarely causes digestive disorders.

3. Does not depress heart or circulation

756

Periscope.

Vol. lxiv

4. Seldom produces cerebral disturbances.
As compared with sulfonal :

1. Much more prompt in its action.

2. Being more soluble it can be adminis-
tered more easily.

3. Sleep nearly always passes away by
morning.

4. It is only about one-half as expensive.

DIPHTHERIA, WITH SPECIAL REFERENCE
TO ITS TREATMENT WITH HYDROGEN
PEROXIDE.

Whether the false membrane in the
throat be the primary source of infection or
the local manifestation of a constitutional
disease, says Dr. Dickey, all agree that it is
an element of great danger, and has to be
removed as quickly and as thoroughly as
possible, and at the same time doing as little
violence to the surrounding healthy tissue
necessary. The poison invades very
quickly any denuded or abraded surface,
consequently much care should be exercised
in whatever remedies we may use.

Peroxide of hydrogen is a colorless, taste-
less liquid, and when applied to a diseased
membrane, causes little or no pain, and Dr. D.
knows of nothing in the whole materia
medica that will dissolve the diphtheritic
membrane so quickly and thoroughly, and
yet leave the healthy mucous membrane
intact.

Dilute it twenty-five per cent, (although
it can be used full strength), and apply with
an atomizer. This can be repeated until
effervescence ceases, when the membrane will
be found to have practically disappeared,
leaving a whitish surface. If the nose is
invaded, it can be applied there with equal
satisfaction. Absorb all the watery secre-
tions from the nostrils with blotting-paper
or absorbent cotton, and then apply the
peroxide. After using the peroxide, use a.
solution of chloral hydrate, glycerine, and
water, either as a gargle or with an atomizer.

At the same time, bichloride of mercury,
tincture of the chloride of iron, with or with-
out chlorate of potassium, or such other
remedies as may suit the judgment of
the individual prescriber, or be applicable
to the case in hand, may be used. The
writer prefers the bichloride.

Coupled with this should be given good
digestible food at regular intervals, of which
milk should form the basis, and such stimu-
lants, from time to time, as the individual
case may demand. The constitutional treat-
ment is not less important than the local,
and consequently must be attended to from
the outset. When the temperature exceeds

103 5°, sponge the entire body with tepid
water as often as may be necessary to bring
it below this point. Pellets of ice internally
will allay thirst and relieve very materially
the turgid condition of the blood-vessels, and
should not be omitted. Ice may also be ap-
plied to the throat in a rubber bag or a
bladder, relieving greatly the inflamed
glands. — Ann. Gyn. Peed.

MEDICINE.

ALBUMINURIA CAUSED BY ANTIPYRINE.

Dr. E. L. Thompson, in the Virginia Med,
Monthly, calls attention to a case of albumin-
uria caused by antipyrine.

A gentleman from New York came to
Dr. Wm. A. Hammond's Sanitorium for
Diseases of the Nervous System with loco-
motor ataxia. His urine was so heavily
loaded with albumen that it almost solidified
on boiling. There was so much oedema of
the lower extremities that he could hardly
put on his shoes ; and there was also con-
siderable puffiness under the lower eye-lids.
Dr. Thompson found that he had been taking
for some time, nearly every night, large
doses of antipyrine — often as much as sixty
grains a night. This would always stop the
ataxic pains. Dr. Thompson examined his
urine twice a day, and found much albumen
in the morning, and very little or none in
the evening discharge. It was then, on
questioning, he found out about the antipy-
rine. It was suspected that the antipyrine
caused it, on account of there being no albu-
men in the evening. The antipyrine was
stopped, and since then, the albumen has dis-
appeared, and the oedema is much less.

TREATMENT OF PHTHISIS BY ARTIFICIAL
ATMOSPHERES UNDER PRESSURE.

A paper by M. Germain See on the sub-
ject of the treatment of phthisis by continued
inhalation of medicated air under pressure,
appears in the Bulletin de V Academic de
Medicine, No. 15, 1891. The drugs used
were creosote and eucalyptol, their origin
and action being fully referred to in the
paper. The patients were placed in a closed
chamber into which air was forced to an in-
creased pressure of about half an atmosphere,
after passing through a solution of the drugs.
The pressure was increased gradually, and
the sittings were prolonged to two, three, or
more hours according to the patient's feel-
ings. They took place every day, and the
effect upon the general health was beneficial

June 13, 1 89 1. Periscope.

757

rather than the reverse, whilst a very marked
improvement was noted in the symptoms of
the disease. Cases of phthisis in early as
well as advanced stages were treated with
satisfactory results. In two cases of foetid
bronchorrhcea of two years' duration, a com-
plete recovery was brought about in the
course of five weeks. M. Germain See
claims for this method of prolonged inhala-
tion under pressure that the actual absorp-
tion of the antiseptic drug is more complete,
and approaches more nearly to the point at
which it is assumed that morbific organisms
may be annihilated. It is harmless in itself,
and gives rise to no unpleasant consequences
such as may follow the continued introduc-
tion of creosote subcutaneously or by the
stomach. Inhalation of creosote vapor at
ordinary atmospheric pressure has long since
been proved to be insufficient for the purpose
of checking the progress of tubercle. Im-
provement of appetite, gain of weight, dim-
inution of cough and expectoration, and
subsidence of fever would appear to be the
most striking of the changes brought about
by the treatment. — Brit. Med. Jour.

ANGINA PECTORIS: ITS NATURE AND
TREATMENT.

Dr. R. Douglas Powell, in The Prac-
titioner, argues that angina pectoris is a dis-
turbed innervation of the heart or vessels,
associated with more or less intense cardiac
distress and pain, and a general prostration
of the forces, always producing anxiety, and
often amounting to a sense of impending
death, and concludes that:

1. In its purer forms we observe disturbed
innervation of the systemic or pulmonary
vessels causing their spasmodic contraction,
and consequently a sudden extra demand
upon the propelling power of the heart,
violent palpitation or more or less cramp
and paralysis ensuing according to the re-
serve power and integrity of that organ —
angina pectoris vasomotoria.

2. In other cases we have essentially the
same mechanism but with the extra demand
made upon a diseased heart — angina pectoris
gravior.

3. The trouble may commence at the
heart through irritation or excitation of the
cardiac nerves, or from sudden accession of
anaemia of cardiac muscle from coronary
disease — penary cardiac angina.

4. In certain conditions of blood or under
certain reflex excitations of the inhibitory
nerves, always, however, with a degenerate
feeble heart in the background, we may ob-

serve intermittence in its action prolonged
to syncope — syncopal angina.

"TRAUMATIC NEUROSES."

" This is a convenient term, but, like
other terms which are convenient, it is apt
to include far too much. In this country the
most important traumatic neurosis which is
met with is no doubt the so-called, 'railway
spine,' and it may be that cases placed in
this category are as varied as those which
Hoffman (Berlin, klin. Woch., No. 29)
found among a series of twenty-four cases of
' traumatic neurosis.' Of those twenty -four,
ten were found to have undoubted signs of
organic mischief; in six the symptoms were
partly the result of exaggeration and partly
of simulation ; in eight there was malinger-
ing, proved to be so after careful observation
for several weeks. The author protests
against the use of the term for such varied
conditions, pointing out that in a so-called
traumatic neurosis we may have to deal
with organic nerve injury, with hysteria,
the result of injury, with shock to the
cerebro-spinal system, with neurasthenia,
or even with a true psychosis." — Lancet.

THE DIAGNOSIS OF MOTOR INSUFFI-
CIENCY OF THE STOMACH.

Leo Silberstein (Deutsche medicinische
Wochenschrift, February 26th) has recently
made a series of experiments in Senator's
clinic to determine the value of the salol
test in estimating the motor activity of the
stomach. The test is based upon the fact
that salol when given by the mouth, is not
absorbed in the stomach, but passes on un-
changed to the bowel. There meeting an
alkaline fluid, it is split up into phenol and
salicylic acid, which latter is absorbed^ and
afterward secreted in the urine. Its pres-
ence in the urine is detected by its violet re-
action with chloride of iron.

Ewald's method was to give 15 grains of
salol after the principal meal. Then in
thirty minutes the urine was tested for
traces of salicylic acid. He found that in
healthy individuals the reaction always ap-
peared in an hour at the latest. Any delay
beyond this time indicated a slow passing of
the salol into the bowel, or, in other words,
a motor paresis of the stomach. Brunner,
however, showed that Ewald's method was
unreliable. His investigations proved that
there was no fixed physiological time for the
first appearance of the salicylic acid in the
urine In the same individual under like
conditions the interval may vary greatly

758

Periscope.

Vol. lxiv

from time to time. These statements of
Brunner were confirmed by Huber, who at
the same time observed that in some persons
the urine continued to show the presence of
salicylic acid for a remarkably long time
after the ingestion of the salol. This led
him to think that perhaps the time of disap-
pearance of the reaction might be more im-
portant than that of its first appearance in
the urine. And, in fact, some experiments
based upon this idea enabled Huber to state
that an abnormally long duration of the
salicylic-acid reaction pointed to a disturb-
ance ot the motor activity of the stomach.
This theory, in turn, has been attacked by
Decker and Pal, who believe that atonic
and catarrhal conditions of the bowel may
cause the prolonged reaction, though the
stomach may be normal in all respects.
Silberstein therefore proposed to repeat
Huber's experiments, but on a much larger
scale, and with special reference to the
points raised by Decker and Pal. He made
his first test of the urine twenty-four hours
after the salol had been taken, and repeated
it at intervals of six hours until he was sat-
isfied that the drug had been entirely
excreted. He insists upon the necessity of
this procedure, stating that in some cases of
marked motor disturbance of the stomach
there was no reaction at the end of twenty-
four hours, and yet after thirty or more
hours had elapsed the reaction appeared.
He made upward of 148 different experi-
ments upon 76 individuals, and the follow-
ing are his conclusions :

1. In healthy persons salol is entirely
eliminated from the body within twenty-
four hours.

2. In gastrectasia the elimination of the
salol is always delayed, the reaction being
invariably found after thirty-six hours.
This" is not the case when the stomach is
simply displaced, hence this test serves to
distinguish the dilated from the displaced
organ, conditions which are easily con-
founded with each other.

3. In atonic conditions of the stomach
there is also usually a delay in the elimina-
tion of the salol, but not to the extent noted
in gastrectasia. It is the exception to find
the reaction after thirty-six hours in cases
of atony, whereas it is the rule in dilatation
of the stomach. Here, again, this method is
of diagnostic importance.

4. The condition of the bowels does not
impair in any way the value of the salol
test as modified by Huber.

Silberstein admits that Leube's method of
examining the gastric contents two hours

after a test breakfast is without doubt our
best means of judging of the motor activity
of the stomach. There are cases, however,
in which, for one reason or another, it is im-
practicable to introduce a tube into the
stomach, and in these the salol test may be
relied upon as entirely trustworthy. — N. Y.
Med. Jour.

THE DIAGNOSTIC SIGNIFICANCE OF VE-
NOUS HUM IN THE NECK; A STUDY
IN STATISTICS.

Dr. Bewley said he had been induced to
collect statistics bearing on this subject by
reading a paper by Dr. E. Apetz, " On the
Significance of Venous Humming Mur-
murs for the Diagnosis of Anaemic Condi-
tions," in Virchow's Archiv., vol. 107. He
called attention to the differences of opinion
held on this subject — some writers attrib-
uting considerable diagnostic importance'
to the presence of a murmur ; others believ-
ing the phenomenon to be one of no import-
ance. Dr. Bewley then related the details
of his investigation. He examined only
healthy individuals ; he only examined in-
dividuals between the ages of 16 and 26,
because age has a very important influence
on the production of these murmurs. All
the cases were examined in an upright posi-
tion, either sitting or standing. He divided
his cases into three classes : — 1. Ansemic.
2. Slightly or doubtfully ansemic, i. e., cases
which presented no appearance of anaemia,
but yet suffered from some of the symptoms
of this condition, or vice versa. 3. Not
anaemic. He examined in all 51 young men
and 149 young women. Of these 22
belonged to the anaemic class, 31 to the
slightly anaemic, and 147 to the not-anaemic.
In 22 ansemic there were 19 murmurs, equal
86*4 per cent. In 31 slightly anaemic there
were 27 murmurs, equal 87*1 per cent. In
147 not-anaemic there were 85 murmurs,
equal 57'9 per cent. Dividing up the not-
anaemics into male and female — in 104
females there were 64 murmurs, equal 6T5
per cent. In 43 males there were 21 mur-
murs, equal 48*8 per cent. The conclusions
Dr. Bewley drew from these statistics were
the following : — 1. Murmurs are more com-
mon in the anaemic than in the not-anaemic.
2. More than half of those young persons
who are not-anaemic have a venous hum in
the neck. 3. The presence of a hum is not
of any diagnostic importance in any indi-
vidual case. The loudness of murmurs is
not a matter of much diagnostic importance.
In his cases Dr. Bewley noticed 15 very

June 13, 1 891.

Periscope.

759

loud murmurs, distributed as follows : — -In
22 anaemic, 3 loud murmurs, equal 13'6 per
cent. In 31 slightly anaemic, 5 loud mur-
murs, equal 16*1 per cent. In 147 not
anaemic, 7 loud murmurs, equal 4*8 per cent.
He had noted some of the loudest murmurs
in particularly rosy and full-blooded per-
sons, and therefore did not attribute any
diagnostic value to even the loudest mur-
mur. He added that Dr. Apetz's conclu-
sions based on very elaborate statistics,
were almost identical with his own. — Med.
Press.

AETIOLOGY OF BRIGHT'S DISEASE.

Dr. Agnes Bluhm has studied the apparent
causation of all the cases of morbus Brightii
and albuminuria that were treated in the
Cantonal Hospital of Zurich, from the be-
ginning of 1884 to July 1, 1889. The cases
numbered in all 8,442, and after a careful
analysis lead to the following conclusions :
1. The chief causes of acute Bright's disease
are the acute specific fevers, and nearly all
of these are liable to be complicated by
nephritis. 2. The apparently uncommon
occurrence of chronic Bright's disease as a
sequel of acute infective diseases is due partly
to non-pathological causes, but also in some
measure to the latent and therefore unde-
tected course of chronic nephritis. 3. The
occurrence of nephritis as a complication
does not depend on the intensity of the pri-
mary specific disease. 4. The course of the
primary affection and that of the nephritis
complicating it are not mutually related. —
DeuUches Archiv fur klin. Medicin, Janu-
ary 8, 1891.

A FORM OF GINGIVITIS COMMON TO MEN
AND DOGS IN INDIA.

Surgeon J. R. Roberts, of the Indian
Medical Service, describes gingivitis which
is often mistaken for a symptom of scurvy,
but which has distinct characteristics of its
own, and is entirely a local disease. It is
characterized by a bright red velvety condi-
tion of the gums ; its almost invariable limi-
tation to the front of the mouth ; the ulcera-
tion that surrounds the bases of the teeth,
generally the incisors, which process in ad-
vanced cases continues to extend, destroying
the alveolus and exposing the fangs, until
the teeth remain but loosely attached or drop
out ; the tendency to haemorrhage on pres-
sure or the slightest injury ; the occurrence
of an exactly similar process in dogs, re-
markably limited in them to incisors and
canines, whereby their small front teeth are

frequently lost ; the acid reaction of the
mouth and the fetid odor given off.

Microscopic examinations of scraping show
a large number of different micro-organisms.
The disease is not limited to natives, but is
common enough among British soldiers. Its
worst effects are seen in a hot moist climate.
The disease is essentially a slow chronic proc-
ess. The treatment indicated is a light
scraping of the ulcerations, touching them
with strong carbolic acid or other antiseptic,
and an alkaline mouth-wash. — Boston Med.
Surg. Jour.

SURGERY.

TEMPORARY RESECTION OF THE CRA-
NIUM.

Wagner (Centralblatt f. Chirurg., 1891,
No. 2) describes two cases in which he has
used his method of " temporary resection of
the cranium," first described in No. 47 of the
above for 1889. Both cases, given somewhat
in detail, demonstrate that the operation is
very easy to do, and that the resected piece
reunites both quickly and without reaction.
In both instances the part resected was about
one-fifth of the entire cranial vault, which
leads the author to believe that a still greater
amount will heal in the same way, and he
would not fear to resect two-fifths or more if
necessary. Naturally the isthmus of the flap
must be correspondingly broader. Just as
we have trephined, sometimes, the skull in
different places, so we can make this tempo-
rary resection in one or more places. First,
corresponding to the piece of bone to be re-
moved, a curved incision is made whose ends
converge toward each other. This flap
must overlap the bone to be raised one-fifth
to two-fifths of an inch. The soft parts re-
tract, and the incision gapes in a sickle-
shaped way, with the point toward the base
of the flap. The flap is now firmly pressed
upon the cranial surface, and the pericranium
smoothly cut through along its border. With
a small, fine chisel a little trough is made in
the bone along the line of the incision. For
the further steps of the operation, a moder-
ately thick but small chisel, abruptly beveled
on one side, is used. This is applied in an
oblique manner. One can work his way
through the cranium most quickly with this.
When all the bone is chiseled through, a
small, thin chisel is used to cut through that
part of the bone covered by the isthmus of
the flap. The skin and bone are now raised
together with the aid of a small elevator.
The replacing later on is very easy to effect.

Periscope. Vol. lxiv

760

When the chisel is applied obliquely, the
inner circumference is naturally less than
the outer. The soft parts are then sewed
together with fine sutures, and one of the
under angles of the wound left open. The
suture line does not correspond with the
bony defect, but is somewhat removed from
it, the soft parts overlapping this, in accord-
ance with the plan of the incision above
mentioned. In this way an adherent scar
between bone and skin is avoided.

Regarding the indications for " temporary
resection," or " osteoplastic trepanation," the
author regards it, in general, indicated
wherever in the uninjured bone the cranial
vault is to be opened, not only in cases where
we expect with certainty or probability to
find removable alterations, but where we
only suspect them ; for instance, many cases
of epilepsy of doubtful traumatic origin.
This form of exploratory opening of the
cranium the author regards fully as justi-
fiable and no more dangerous than explor-
atory laparatomy. — Buffalo Med. and Surg.
Journal.

THE TREATMENT OF WHITE SWELLINGS.

Under this title, Lucas-Champonniere has
written {Journal de Medecine et de Chir-
urgie, Nov. 25, 1890) a very interesting
paper, giving his views, based on a wide ex-
perience, as to the treatment of this variety
of tubercular disease. He considers that
the methods of treatment have been much
modified by modern improvements, both as
to therapeutic and operative measures.
Topical treatment he regards as particularly
happy in children, upon the development of
whose bones operative interference exercises
a disastrous influence. Immobilization he
has found not to possess the beneficial in-
fluence generally attributed to it, and he
thinks that while there are a certain number
of cases in which it ought to be employed,
it is, as a rule, abused. Its principal object
should be to prevent deformity.

Care of the general health plays a prin-
cipal part in the treatment, and the value of
country or sea air must not be overlooked.
As to the medicines to be relied upon, the
iodide of potassium is mentioned as the one
par excellence, while tonics, cod liver oil,
quinine and arsenic are also useful. Iron is
not spoken of with favor, and the iodide of
iron does not, according to the writer,
possess the virtues of iodide of potassium.

As to the direct treatment of the aflfected
joint, revulsion, by means of the thermo-
cautery, superficially applied, is considered

a measure of the greatest value. The
cauterizations are repeated about every fort-
night, and are made to extend beyond the
limits of the joint. Next to cauterization
in importance, compression is mentioned.
This is to be effected by means of flannel
bandages firmly applied, and renewed as
often as they become loose. Before the
bandage is applied, the joint is first en-
veloped in a layer of either peat wadding
(which has been found to best answer the
purpose), oakum, tow, or wool, all of which
are superior to cotton.

Of topical applications, mercury is con-
sidered the best, the use of iodine or turpen-
tine being characterized as a mistake.' The
mercury is employed in the form of cerate,
made according to an old formula of Scott,
of Dublin, which is as follows : Soap
cerate, one ounce ; double mercurial oint-
ment, one ounce ; powdered camphor, one
drachm. Champonniere regards mercury
as the principal source of success in the
treatment, the absorption of the drug into
the tissues of the part making possible its
microbicidal action. Previous to the ap-
plication of the cerate the skin is thoroughly
cleansed and then rubbed with camphor-
ated spirit.

After the dressing is made, if fixation is
required, it is accomplished by means of a
plaster bandage. If abscesses form in the
course of the disease, they are not interfered
with unless large, in which case they are
opened under anaesthesia and washed out
with a 5 to 8 per cent, solution of chloride
of zinc. Sinuses are injected with the same
solution, sometimes with an emulsion of
iodoform, and, as a substitute for the latter,
naphthol-camphor is mentioned.

Continuous extension is regarded as most
seaviceable in the case of hip disease, and is
employed, not only because of the relief of
pain which it secures, but because it pro-
motes the conditions which favor the possi-
bility of cure.

As to operative treatment, when neces-
sary, the view is taken that it should be
complete, Arthrectomy is considered as
hazardous and incomplete, while resection is
spoken of as "the only and true operation
for articular and osseous tuberculosis."

The paper concludes with an epitome of
eighty-one resections, the results of the
operations upon the knee-joint being particu-
larly excellent. In no less than forty ex-
cisions of this joint cure was effected without
the occurrence of any suppuration what-
ever. Antisepsis was rigidly carried out,
and in order to prevent injury to the silver

June 13, 189 1. Periscope.

761

wire employed to appose the ends of the
femur and the tibia, carbolic acid solutions
were substituted for those of bichloride
generally used. — Univ. Med. Mag.

THE INDICATIONS FOR SURGICAL INTER-
VENTION IN TRAUMATIC HYSTERIA.

In an interesting article on the relations
of hysteria to surgery, by Georges Guinon
(communicated by Dr. Baaz), the author
states that surgical interference in this affec-
tion is only indicated in cases of old con-
tractures with formation of fibrous tissue,
and also in persistent monoplegias with
severe trophic disturbances. As a general
rule, the surgeon is not called upon to inter-
fere in hysteria, for the fact that a lesion
sine materia is the cause of the symptoms and
warrants us, in a certain sense, of expecting
a favorable prognosis. The prognosis is
never certain, however, as regards the possi-
bility of a cure of the attacks, but we know
that even when contractures have persisted
for many years, we are not justified in giving
up all hope of a cure. If the contractures
are of spasmodic origin, they will sometimes
disappear spontaneously during an attack,
or may be relieved by massage, electricity,
magnetism, or hypnotic suggestion. In all
these conditions no surgical interference is
demanded. The question comes up whether
we are to interfere in cases where the con-
tracture is associated, for example, with a
shortening of tendons, with muscular atrophy
and various trophic disturbances. On this
subject opinions are still much divided. We
may be tempted to divide the fibrous bands
formed in a limb affected by contractures,
but whether this is permissible must depend
upon each case, and no general rule can be
formulated. As long as a spasmodic con-
diton persists, no operation is warranted.
To make sure whether a contracture is due
to spasm or a shortening of muscles and
tendons, the patient is placed under chloro-
form anaesthesia, which will show to what
extent the contracture depends upon spasm
and shortening. The surgeon is not justified
in interfering until all spasm has ceased.

In his lectures, Charcot reports a case in
which attempts were made to affect a cure
by stretching of the nerves. The result was
not satisfactory. Sometimes these patients
request from their physicians procedures of
much greater severity. Thus one of Debove's
patients, in whom a spasmodic contracture
of the arm had resulted from application of
a splint, urgently demanded an amputation,
on the ground that the limb was perfectly

useless. The extremity presented a deplor-
able appearance, the muscles had atrophied,
but gave no degeneration-reactions, the nails
had deeply penetrated the palm of the hand
in consequence of the spasm, and had pro-
duced unhealthy ulcers. Debove brought
the case before the Societe Medical des
Hopitaux, and asked the advice of the
members regarding its treatment, and most
of those present spoke against an operation.

In general we may say that, in hysterical
subjects, the surgeon is only called upon
to intervene when he has to deal with the
sequelae of a former neurosis. He should not
attempt to treat the hysterical affection by
surgical means. The relations of hysteria to
surgery are numerous, and may be illustrated
in the following conclusions :

1. Traumatisms which do not require the
direct intervention of the surgeon, but are
capable of evoking a number of surgical
affections, may, in persons predisposed
thereto, produce hysteria and hysterical
manifestations which may bear a deceptive
resemblance to diseases belonging to the
domain of external pathology.

2. On the other hand, the surgeon may
give rise to hysterical seizures by operations
undertaken for curative purposes.

3. The surgeon may be inclined to inter-
fere in conditions of hysterical character,
but the indications and contra-indications to
operation should be based upon a thorough
knowledge of hysteria. — Wiener Mediz.
Presse.

GYNECOLOGY.

AN ENORMOUS OVARIAN CYST.

There has recently been a patient in the
obstetric ward of St. Thomas's Hospital,
under the care of Dr. Cullingworth, suffering
from an enormous ovarion cyst. She was a
widow aged forty-five, who had had no chil-
dren, and who had been the stewardess on a
well-known line of Channel steamers for
many years. The swelling of the abdomen
was first noticed nine years ago ; for three
years and a half it had been so large that
she had been unable to go beyond her own
garden ; for two years she had not left her
room, and for six months she had not been
out of bed. She had persistently refused
operation until recently. After admission
on April 9th the abdomen was found to be
uniformly and enormously distended by a
fluctuating swelling, consisting of one large
cyst, distending the lower part of the thorax,
and hanging down, as she sat in bed, as far

762

Periscope.

Vol. lxiv

as the knees, completely concealing the
thighs. The girth H in. above the um-
bilicus was 67 ins.; the measurement from
the ensiform cartilage to the symphysis
pubis was 38 ins. The body was greatly
emaciated ; she presented a most remarkable
appearance, but was very cheerful. There
was some albuminuria. On April 13th,
preparatory to operation and in order to
diminish the shock, the abdomen was punct-
ured by a fine trocar, attached to a long
India-rubber tube, with the lower end placed
under a measured quantity of solution of
carbolic acid, and the fluid from the cyst
allowed to flow away for seven hours.
Seventy-four pints of thick grumous choco-
late-colored fluid escaped, containing much
altered blood. The day after this an at-
tempt was made, under ether, to remove the
tumor. The whole of the anterior surface
of the cyst was adherent to the abdominal
wall. There were comparatively few ad-
hesions posteriorly, but more in the pelvis.
At the end of half an hour the patient be-
came seriously collapsed and the cyst was
quickly extracted. It was a large thick-
walled single cyst of the left ovary. The
patient died before the closure of the ab-
dominal wound had been completed, in
spite of persistent efforts at resuscitation.
The total weight of the tumor and its con-
tents— including that of the fluid removed
on the previous day — was 1541 lbs., or 11 st.
£ lb. The weight of the patient was not
ascertained, but must have been much less
than this. This is probably the largest ab-
dominal tumor of which there is any record ;
the largest mentioned in the series of 1,000
by Sir Spencer Wells did not weigh more
than 125 lb. — Lancet.

BAGOT ON MASSAGE AS APPLIED TO THE
TREATMENT OF INCONTINENCE
OF URINE IN FEMALES.

A full account is given of the treatment
of this affection by Brandt's method, by
Sanger's method (which consists in dilata-
tion of the vesical sphincter and massage),
and also by distension of the bladder with
warm water, as practiced by Nissen and H.
Marion Sims. The author has cured three
cases by the use of Brandt's system, omitting
some of the steps which he considered useless.
The most essential part of this method of
treatment was the direct treatment of the
neck of the bladder by the finger in the rec-
tum or vagina. In children the finger was
used in the rectum.

The first patient had suffered more or less

from incontinence of urine since her last con-
finement, eighteen months ago, but had
become much worse during the last nine
months. She was treated at first every day
for four days by Brandt's system, omitting
" the lifting of the bladder." After this she
was treated sometimes every second and
sometimes every third day for twenty-nine
days. At the end of this time a permanent
cure was effected.

The second case, an unmarried woman of
twenty-four, had suffered from incontinence
from childhood. She was treated by Brandt's
method, omitting the " exercises for the ad-
ductors of the thighs " and the " bladder
lifting," every second day for five weeks, at
the end of which she declared herself quite
w7ell, and was discharged.

The third case was a woman of forty, who
had ten children, and had suffered from in-
continence for three years. The treatment
in this case lasted four weeks. Dr. Bagot's
reason for discarding the " bladder lifting,"
altogether, was because, from what he had
seen during laparotomies, he knew that it
would be impossible to sieze hold of the blad-
der when in an empty state, and elevate it
by the manoeuvre described by Brandt. The
"exercises for the adductors " might be of
use in those cases where the pelvic floor was
greatly relaxed, and even in these, though
it was probably of use in bracing up the
parts, it was not an essential in the cure of
either enuresis or of uterine displacements.
The chief part of this method, as applied to
enuresis, was the direct treatment of the neck
of the bladder. The method of Sanger was
one to which the author wished to draw
special attention. Dr. Sanger considered
that the basis and cause of this affection
consisted in a weakness or paresis of the
vesical sphincter, and perhaps a certain
tenuity of the muscular bundles. This method
was not indicated where there was very great
dilatation of the bladder neck and whole
urethra. In these cases, artificial removing
of the urethra in some way was more likely
to succeed. Dr. Bagot had treated two cases
by Sanger's method.

Massage, by distension of the bladder with
warm water, was of use in case of contraction
of the bladder, following long-continued in-
continence of urine from any cause, the hold-
ing capacity of the bladder being then dimin-
ished.

While recommending these treatments,
Dr. Bagot urged the necessity of careful
diagnosis in every case, and that the cysto-
scope should be more generally used. — Med.
Press.

June 13, 1891. Periscope.

763

OBSTETRICS.

IODOFORM GAUZE IN POST-PARTUM
HEMORRHAGE.

Dr. Velitz, of Buda-Pesth ( Orvosi hetilap,
1890, Nos. 10 to 12) describes thirteen cases
where he employed plugs of iodoform gauze
for flooding, during and after delivery, and
(in two cases) in the course of the puer-
perium. He finds that iodoform gauze is a
perfectly aseptic medium in obstetrics. It
is of permanent value as a haemostatic in
flooding from atony of the uterus. Only a
small amount of the gauze should be packed
in the uterus, so that retraction of that
organ may not be hindered. Iodoform
gauze is useless, and indeed dangerous, in
uterine haemorrhages due to abnormal con-
dition of the blood. Being hygrometric it
promotes haemorrhage. In this form of
flooding weak solutions of perchloride of
iron act best. Haemorrhage from high lac-
eration of the cervix can only be safely checked
by aid of the suture. When bleeding
occurs after delivery or late in childbed,
through the presence of a fibroid, the only
effectual check is a thorough plugging of
the uterine cavity with iodoform gauze ; the
cavity must be well stuffed with that
material. — Brit. Med. Jour.

FETID MILK IN HUMAN MAMMARY
GLANDS.

Dr. Jorissenne had under his care in 1874
a patient of slightly tuberculous aspect,
though now, in 1891, she is in good health.
On October 5, 1874, she was delivered by
forceps. She suckled her child freely till
December 7th, when she was absent from it
for seven hours and a half. This space of
time included a drive one hour long, five
hours and a half walking, and one hour's
rest for refreshment. Immediately on her
return home she gave her child the breast.
The milk was horribly fetid — like rotten
eggs. It made her feel ill, and her relatives
could not stay in the same room with her.
Yet the infant sucked with avidity ; how-
ever, it was violently sick. Next day the
milk was sweet, and the child and also the
mother quite well. The breasts showed no
sign of hardness, engorgement, etc. The
nipples were healthy. The patient told Dr.
Jorissenne that on several previous occa-
sions she had noticed that when she delayed
giving the child the breast at the usual
times the milk became fetid. Dr. Joris-
senne had no further opportunity of observ-
ing this putrefaction of milk, as it did not

recur. The patient was red-haired ; but he
has carefully examined the milk of many
red-haired women since 1874, and failed to
find that it showed any special tendency to
putrefy or even turn sour, in the open air or
in a close room, more quickly than the milk
from a black or fair-haired woman. The
avidity with which the infant imbibed the
putrid milk was remarkable ; its stomach
was more sensitive than its nose and tongue.
Evidence as to the acuteness of taste in the
infant is imperfect. During the first few
days of extra-uterine life the sense seems
undeveloped. The child will take solutions
of raw salines without syrup, though a few
weeks later it will reject the same com-
pounds nicely flavored. The sense of sweet-
ness is early developed. At the end of a
few weeks an infant likes sugar, and dis-
likes cow's milk unless sweetened artificially.
Children of six months, or older, will lick
ill-tasting colors off their toys. In Dr.
Jorissenne's case, the child liked a milk
that smelt intensely fetid and must have
tasted nasty, according to an adult's idea of
taste. — Archives de Tocologie.

DURATION OF PREGNANCY.

Oliver concludes, after very careful obser-
vation, that the duration of pregnancy in
the human female varies as much as it does
in the case of many of the lower animals.
Issmer, reckoning only cases in which the
foetus was well developed, asserts that the
duration ranges from 260 to 304 days. But
Oliver believes there must be some error in
this statement. If we reckon from the last
menstruation, we must be careful to ascer-
tain the exact date of the cessation of this,
for it will be remarked that where the dura-
tion of the discharge varies little, the woman,
when asked, is more likely to give the date
of beginning than the date of cessation of
the last menstruation, and in this way mis-
takes may arise in our calculation to the
extent of four or more days. The majority
of authors are agreed that in reckoning the
duration of pregnancy in woman, we ought
to fix the probable date of delivery on the
278th day from the cessation of the last
menstruation. He is of the opinion that the
best results will be obtained by ascertaining,
first, the date of the cessation of the last
menstruation, and then the usual duration
of the inter-menstrual period in each given
case ; the number of inter-menstrual days
should then be divided by two, and it will
be found that the 260th day from the middle
of the inter-menstrual period will most

764

Periscope.

Vol. lxiv

probably be the date of confinement. —
Liverpool Medico- Chirurg. Journal.

PAEDIATRICS.

THE PREVENTION AND TREATMENT OF
SCARLET FEVER.

Dr. W. Bezly Thorne, in the Lancet, says,
the prevention, treatment, and, perhaps, the
cure of scarlet fever are of so great importance
to the medical profession and the public at
large that he ventures to offer for publication
the following brief notes of a case which was
under his care at the commencement of this
year. If it stood alone, he would be com-
pelled to admit that no practical conclusion
could safely be drawn from it ; but he has
since gathered, from the perusal of a paper
read before the Epidemiological Society by
Mr. J. Brendon Curgenven, that many other
cases of the same disease have been some-
what similarly treated with the like striking
results, and he thinks that it cannot fail to
serve a useful purpose to invite others who
have practiced the treatment advocated by
Mr. Curgenven to bring forward the results
which they have obtained.

The patient, fourteen years of age, but of
the physical development of ten, was seen
within little more than an hour of the ap-
pearance of the rash, and was reported to
have been " bilious and shivering over the
fire " for something more than two days.
The face was flushed and dotted with a scar-
latiniform rash ; the eyes were red and suf-
fused, and both tonsils swollen, inflamed and
ulcerated ; the pulse was 120 and the tem-
perature 103°. She was immediately ordered
to take internally every four hours five
minims of the oil of eucalyptus globulus
emulsified with powdered acacia, to use every
hour a gargle of carbolic and tannic acids
suitably diluted, to undergo daily inunction
with an emulsion of eucalyptus oil of the
strength of half a drachm to the ounce, and
made up of glycerine, to promote adhesion
to the skin, and to have the scalp and hair
daily sprinkled with a spirit lotion contain-
ing eucalyptol, with a small quantity of
almond oil. On the following morning —
that is, in rather more than twelve hours —
Dr. Thorne found that the rash had receded
from the face. He inquired of the nurse
whether any was to be seen on the chest,
which she had washed and anointed two
hours previously, and was informed that it
was " well out," but on examining that re-
gion found that it presented absolutely none.
It was at that time making its appearance

on the lower extremities, was well marked
in the evening, and on the following morn-
ing had entirely disappeared. No desqua-
mation followed. The chart tells the rest
with sufficient detail. It should be added
that although the house was occupied during
the illness and up to the departure of the
patient to the seaside on the twenty-second
day by six full-grown adults and four
younger persons whose ages range from nine-
teen to six, besides the sick one, the infection
has not spread. A sheet, which was from
time to time moistened with a dilution of
sanitas, was fixed by the nurse to the door of
the sick room in accordance with the instruc-
tions of the institution from which she was
sent.

HYGIENE.

THE TRANSMISSIBILITY OF HYDRO-
PHOBIA FROM MAN TO MAN.

The fact that no instance is on record of
hydrophobia having been transmitted from
man to man has given rise to a doubt as to
whether the saliva of human beings suffering
from the disease possesses the same virulent
properties as that of the dog similarly
affected. In not more than five or six of
the ten thousand patients treated at the
Pasteur Institute was the lesion due to bites
inflicted byliuman beings, and it is evident
that statistics bearing on so small a number
of cases are of no value one way or the
other. It has, however, been proved ex-
perimentally, that the saliva of human
beings, having succumbed to hydrophobia,
produces the disease in animals by inocula-
tion, though the incubation period is some-
what prolonged. It may, therefore, be
taken as proved that the disease may be
transmitted in this way from man to
man. It is hardly possible as yet to affirm
categorically the possibility of curing hydro-
phobia after the characteristic symptoms
have made their appearance, but recent ob-
servations throw a doubt on the incurability
of the disease even under these circum-
stances.— Med. Press.

VOLUNTARY CONSTIPATION.

In an article in the Revue de VHypnotismc,
entitled "Voluntary Personal Uncleanli-
ness," Dr. Galippe calls the attention of the
authorities to the necessity of reforming the
sanitary arrangements obtaining in most
French educational establishments. Some
facts related by him in this connection will
be read with astonishment by those who are

June 13, 1891.

Periscope.

765

not familiar with the horrible filthiness of
most French closets. He says, " We need
hardly remind the reader of the disgusting
filthiness of most (school) closets, and I have
known sensitive children who refuse to re-
pair to these places until they were abso-
lutely obliged to do so, such is their horror
of the stench that there assails their nostrils,
and the dirt they may bring away with
them. I have known of many children who
have suffered much from this voluntary
constipation, and of others who, affected with
diarrhoea, have for a whole week passed
their motions into their clothing." Dr.
Bourneville, in a notice of this article {Prog-
res Medical, February 14th) says that he
has for years urged the necessity of endow-
ing not only schools but also hospitals and
barracks with decent closets. He has en-
deavored to convince the French public of
the feasibility of such a stupendous feat by
having constructed for his idiot and imbecile
child-patients at the BiceStre closets, the
cleanliness of which strikes the French
visitor with astonishment. M. Bourneville
also demands for each school a complete set
of bath-rooms, and calls for regulations ren-
dering the use of a bath obligatory on the
scholars. — Paris Correspondence of The
Lancet.

MEDICAL CHEMISTRY.

ISOLATION OF A CHOLERA TOXINE.

Hermann Scholl {Berlin, klin. Woch.,
October 13th, 1890) communicates an inter-
esting paper giving the results of some
experiments with a poisonous body isolated
from cultivations of the cholera bacillus.
He thinks it curious that in all previous
investigations on the nature of the cholera
toxine cultivations should have been used
which had been grown in the presence of
air, whereas, in his opinion, in order to
imitate the conditions under which the
cholera bacillus grows in the human intes-
tine, the most essential point is that the
culture be grown in the absence of air. In
this assumption he follows Hueppe and
Cartwright Wood, who, he considers, have
satisfactorily shown that the cholera bacilli
grow in the small intestine in the absence of
oxygen, and that their extreme virulence or
rapidity of poison production depends chiefly
on this anaerobic growth. Other observers,
among whom Petri may be cited, think that
this point requires more rigorous proof than
has yet been afforded. To obtain this an-
aerobic growth the author used the method

introduced by Hueppe of growing the
bacilli in raw eggs, by which means he
holds that oxygen is completely excluded.
The inoculated eggs were kept for eighteen
days at a temperature of 36° C. When
opened the contents were found to give off a
very powerful smell of sulphuretted hydro-
gen, differing in this from cultures grown in
air. He describes the white of the egg at
this period as being fluid and watery, the
yolk firmer in consistence and black in
color. In order to test the toxicity of the
egg contents 5 cubic centimetres of the fluid
part were injected into the peritoneal cavity
of a guinea-pig. The animal at first showed
signs of paralysis, then convulsive move-
ments, and died at the end of forty minutes.
This proved that the fluid egg albumen was
very poisonous. The author then proceeds
to describe his method of isolating the
poison. Shortly, it is as follows : The fluid
part of the egg contents, which amounted to
150 cubic centimetres, was dropped into ten
times its volume of absolute alcohol. The
white precipitate thrown down was col-
lected and digested with 200 cubic centi-
metres of water at 40° C. The effect of this
was to dissolve only a very small quantity
of the precipitate, which was then removed
by filtration. Eight cubic centimetres of
the transparent filtrate were then injected
into the peritoneal cavity of a guinea-pig,
and caused death in one minute and a half.
This fluid entirely lost its poisonous proper-
ties on being boiled in the steam sterilizer
for half an hour, whilst a short heating to
75° C. had no such effect. On the other
hand, when placed at 40° C. in vacuo, over
chloride of lime, the fluid was found next
day to be completely inert. The author
then subjected the poison to the usual
chemical tests, and came to the conclusion
that it was no ptomaine, but a peptone,
differing, however, from the toxo-peptone
isolated by Petri from aerobically grown
cultivations. This peptone could be obtained
in a solid form by dropping the watery
solution into 8 to 10 times its volume of a
mixture of the ether and alcohol, rendered
faintly acid by acetic acid. The resulting
precipitate was found to be insoluble in
pure water, but soluble on the addition of
an alkali. After repeating this precipita-
tion and re-solution several times, pure
ether was substituted for the mixture of
ether and alcohol, and the peptone obtained
after evaporation as a white bulky sub-
stance. A very small quantity of this dis-
solved in water was then injected into the
peritoneal cavity of a guinea.pig. The

766

News and Miscellany.

Vol. lxiv

animal at once became totally paralyzed.
After half an hour convulsive movements of
the head and extremities set in, and, at the
end of five hours the guinea-pig died. The
author concludes, as the result of his experi-
ments: 1. That the poisonous peptone,
elaborated by the cholera bacilli under
conditions of anaerobiosis from the albumen
of the egg, is different from the toxo-peptone
of Petri, since the latter was not decomposed
on boiling, while the former was. 2. That
this cholera pepto-toxine is much more
poisonous than the toxines found by Brieger
and Petri in cultures grown under aerobic
conditions, since the poison obtainable from
a single egg was capable of killing ten
guinea-pigs in the space of ten minutes. 3.
That these experiments are in favor of the
contention of Hueppe and Wood that the
cholera bacilli, when grown anaerobically,
form a greater quantity of, and a more
powerful, poison than when grown aerobi-
cally. — Brit. Med. Jour.

NEWS AND MISCELLANY.

THE MEDICAL NEWS.

Dr. Geo. M. Gould has succeeded Dr.
Hobart A. Hare as editor of the Medical
News.

VALEDICTORY ADDRESS AT THE YALE
MEDICAL SCHOOL.

Dr. John S. Billings will deliver the
annual address at the Yale Medical School
on the Tuesday before the commencement.

RESIGNATION OF PROF. H. W. WILLIAMS.

Dr. Henry W. Williams has resigned the
Professorship of Opthalmology in the Har-
vard Medical School, which position he has
held for twenty years.

THE NEW HAMPSHIRE MEDICAL SOCIETY.

The New Hampshire Medical Society will
hold its one-hundredth annual meeting at
Concord on the 15th, 16th and 17th of June.
The first two days will be devoted to literary
worK, and the third day to general business.

LEPROSY IN RUSSIA.

The rapid extension of leprosy in Russia
has excited the alarm of the authorities, and
the Town Council of Riga has voted a sum
of 60,000 roubles to establish a Hospital for

lepers, which is to be inaugurated in July.
—Ex.

JOURNAL OF THE AMERICAN MEDICAL
ASSOCIATION.

The Trustees of the American Medical
Association have elected Dr. J. C. Culbert-
son editor of the Journal. Dr. Culberlson
was for many years editor of the Cincinnati
Lancet- Clinic. He assumed his duties on
May 14th.

THE PROPOSED PAN-AMERICAN MEDICAL
CONGRESS.

The proposition made at the last meeting
of the American Medical Association by Dr.
Chas. A. L. Reed, for a Pan-American
Medical Congress, has met with much ap-
proval, and it now seems likely that this
worthy project will be carried out.

THE JEFFERSON MEDICAL COLLEGE.

Dr. J. M. Da Costa and Dr. Roberts
Bartholow have been elected Emeritus Pro-
fessors in the Jefferson Medical College.
Although Dr. Da Costa has given up the
ehair of Practice he will continue his valua-
ble clinical lectures in the Jefferson College
Hospital.

THE INTERNATIONAL HYGIENIC CON-
GRESS, 1893.

A movement is on foot, at Buda Pesth, to
have the meeting of the International Hy-
gienic Congress, in 1893, held in that city.
Professor Fodor is taking an active part in
furthering the scheme, and the Hungarian
Government has already been approached
unofficially on the subject. — Ex.

THE CROONIAN LECTURES.
Dr. Burdon Sanderson will deliver the
Croon ian Lectures of the Royal College of
Physicians " On the Progress of Discovery
relating to the Origin and Nature of Infec-
tious Diseases during the last Twenty-five
Years." The lectures will be given on June
9th, 16th, 23rd and 30th, at the Examina-
tion Hall, The Savoy, London. Consider-
ing the reputation of the author and the sub-
ject, these lectures will doubtless prove of
exceptional interest.

Vol. LXIV, No. 25.
Whole No. 1790.

JUNE 20, 1891

10 Cents a Copy.

THE

MEDICAL AND SURGICAL
REPORTER

A Weekly Journal. Established in 1853 by S. W. BUTLER, M.

EDWARD T. REICHERT, M. D., Editor and Manager,

tefed as Second-Class matter at Philadelphia P. 0.

N. E. Cor. 13th & WALNUT STS., PHILA.

769

CL'IXICAL LECTURES.

William Pepper, M. D., Philadelphia, Pa.
Consumption and Emphysema— Pleuritic Efiu-

sion— Rheumatic Neuritis 1

F. Loeffler, M. D., Griefswald, Germany.

The Therapy of Diphtheria

COMMUNICATIONS.

Charles P. Noble, M. D., Philadelphia, Pa.
The After-Treatment of Cases of Abdominal

Section ,'.,*'

Augustus P. Clarke, A. M., M. D., Cambridge,
Mass.

Some Points in the Surgical Treatment for the

Radical Cure of Hernia

JCIETY REPORTS.

Philadelphia County Medical Society. . . .

'ECIAL CORRESPONDENCE

ELECTED FORMULAE

ITORIALS.

Tracheotomy Versus Intubation 1 °o

IRRESPONDENCE <S7

>0K REVIEWS 790

'ERISCOPE.
Therapeutics.

Arsenite of Cooper in Diarrhoea— Acetanilid
in the Treatment of Hard and Soft Ulcerating
Chancres — The Analgesic Action of Electric
Light— The Treatment of Pneumonia— Methyl-

776

779
782
783

Blue as an Anaesthetic — Strychnine in the

Treatment of Chronic Alcoholism 792

Medicine.

A Carcinoma Disappears with the Develop-
ment of Phthisis — Infectious Eye-Lotions —
Some Notes on the Present Epidemic- of

Influenza 794-

Surgery.

Some Practical Points in Abdominal Surgery —
Excision of Portions of the Lungs of Dogs. . 796

Gynaecology.

Salicylate of Soda as an Emmenagogue —
Ichthiol in Diseases of the Genitalia of Females
— Tachycardia at the Menopause 797

Obstetrics.

Unconscious Parturition in a Primipara — The
Necessity for Immediate Surgical Interyention
in Lacerations of the Perinaeum 799

Pediatrics.

Treatment of Diphtheria by Mercurial Inunc-
tions—Quinine in Whooping-Cough — The Scar-
let Fever Tongue 800

Hygiene.

Dr. Klein on Bacteria 802

Medical Chemistry.

The Alkalinity of the Blood Under Normal
and Pathological Conditions — Estimation of
Nitrates and Nitrites in Water by Electrolysis. 801
NEWS AND MISCELLANY . 804

CH. MARCHAND'S

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can always oe relied upon. This remedy is not a Nostrum.
a remedy for DIPHTHERIA ; CROUP ; SORE THROAT,

AND ALL INFLAMMATORY DISEASES OF THE THROAT.
OPINION OF THE PROFESSION.
E R Squibb, of Brooklyn, writes as follows In an article headed -'On the Medical Uses of Hydrogen Peroxide ( Gaillard's
Medical' Journal March i88q, p. 267), read before the Kings County Medical Association, February 5, i8»9-

» Th^ghouMh; discission upon diphtheria very little has been said of the use of the Peroxide of Hydrogen,
or hydrogen dioxide ; yet it is perhaps the most powerful of all disinfectants and antiseptics, acting both chem-
ically and mechanically upon all excretions and secretions, so as to thoroughly change their character and
reactions instantly. The few physicians who have used it in such diseases as diphtheria sparlatma small-pox.
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action so little understood.

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as it really is, an albuminoid substance, it may and will be destroyed by this agent upon a sufficient and a suffi-
ciently repeated contact. ... A child's nostrils, pharynx and mouth may be flooaed every two or tffree
hours,oroftener, from a proper spray apparatus with a two volume solution without force, and witr 1 very little
discomfort; and any solution which finds its way into the larynx or stomach is beneficial rather than harmful,
and thus the effect of corrosive sublimate is obtained without its risks or dangers. . . . p^
T Further on Dr. Squibb mentions that Charles Marchand is one of the oldest and best maker, of Peioxide
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THE

MEDICAL AND SURGICAL
REPORTER

No. 1790. PHILADELPHIA, JUNE 20, 1891. Vol. LXIV.— No. 25.

Clinical Lecture.

CONSUMPTION AND EMPHYSEMA— PLEU-
RITIC EFFUSION— RHEUMATIC
NEURITIS.

BY WILLIAM PEPPER, M. D., PHILA.,

PROFESSOR OF CLINICAL MEDICINE NIVERSITY OF
PENNSYLVANIA.

CONSUMPTION AND EMPHYSEMA.

Gentlemen : — The first case that I shall
call to your notice to-day, is that of a man
of about forty years old. Until two years
ago he has enjoyed fairly good health, when
he caught cold, and had a persistent cough
which lasted for several months. He also
expectorated a large amount of purulent
sputa, of a yellowish color. These symp-
toms, however, began to improve until in
January of this year he took a fresh cold.
The symptoms all became aggravated. The
patient's cough increased, he raised a con-
siderable amount of blood, his appetite
failed him almost completely, and he grad-
ually grew weaker and weaker. There were
no night sweats.

Regarding the physical signs of this patient,
we first notice that the color of his face is
good. His finger nails are somewhat large
and bulbous. This point alone has consider-
able diagnostic value, for these peculiar fin-
ger nails are often met with in cases of long
standing lung trouble, and more frequently
in chronic phthisis than in any other disease.
The patient says that the trouble has always
been on the left side. His sputa contains
tubercle bacilli. In comparing the move-
ments of each side of the chest, it will be
seen that the right side expands more than
the left.

You see that with very little effort we
have already observed several important
physical signs which will materially assist
us in forming a diagnosis, as well as prog-
nosis. These are the good color of the com-

plexion, the peculiarity of the finger nails,
and the decrease of chest expansion on the
left side.

I cannot too strongly impress upon you
the vast importance of carefully noting even
the apparently most insignificant physical
signs. The very one which we will perhaps
regard as the least important, may be the
very one that will ultimately give us a clue
to the diagnosis. Physical diagnosis is,
therefore, of the greatest importance, and
cannot be too carefully studied. After your
student life is over and you are well on in
active practice, you will find that each year
will unfold new truths to you, you will
learn to attach greater importance to each
physical sign, and you will after all feel
convinced that nature is only beginning to
unfold her mysteries to you.

Note once more, therefore, these physical
signs. The right side of the chest moves
more freely than the left. To make sure of
this we practice palpation : laying our open
hands over the chest. We can in this way
feel the difference of expansion even more
distinctly than we can see it. Our attention
is also called to a marked pulsation in the
epigastric region, which strongly simulates
the thrill of an aneurism. Auscultation
shows us that the pulsation is stronger here
than over the heart. All these signs are
most deceptive, the chances that they are
due to real aneurism being not more than
one in fifty. In all probability it is merely
an abnormal pulsation of the healthy aorta.

In such cases we have no right to con-
clude that the patient is suffering from
aneurism unless, also, there are evidences of
tumor. But why have we this pulsation ?
Such a pulsation is likely to occur in cases
of enlarged heart, when the right ventricle,
which may be either over-charged, dilated
or hypertrophied, rests against, the dia-
phragm. In pleuritic effusions this same
epigastric pulsation is observed. In this
case, when the patient leans forward I can
hear his heart pulsate in its normal region,

767

768

Clinical

Lecture.

Vol. lxiv

but when the patient is erect the epigastric
pulsation is strong and the heart over its
normal region becomes almost inaudible.

This shows that while the heart is acting
feebly, yet that it is not displaced to the
right. The probabilities are, in this case,
that this epigastric pulsation is due to an
enlarged right ventricle. We will now see
what percussion will develop. There is a
great deal of resonance here, the liver dull-
ness does not begin until some distance be-
low the normal line. On the left side we
find an area of impaired lung reaching from
the nipple to the heart dullness. Posteriorly,
there is resonance everywhere. Let us now
try auscultation. We find interesting tuber-
cular breathing over the position of the
primary bronchus. Over the area of dull-
ness there is marked bronchial breathing
both in expiration and inspiration. There
are a few rales.

The patient has a pleural effusion on the
left side. This would be the usual conclu-
sion also from the visible examination, but
it is disproved by finding a distended right
heart laying on the diaphragm. Percussion
over the right side was negative ; but over
the left nipple an area of dullness was found,
thai is to say, that the lower portion of the
upper lobe, and the upper portion of the
lower lobe is affected. Dullness in this re-
gion is rare ; what can it be ? I have seen
similar dullness between the outside of the
pericardium and the lung, but in this case
no such condition exists. Here we have
partial consolidation, increased respiration
and increased vocal fremitus. Percussion
and auscultation have elicited also another
interesting symptom, namely, an enlarged
right bronchus, in fact there is a cavity in
the right bronchus caused by its enlargement.
Without doubt this man's trouble was at first
merely bronchial. You will remember, also,
that we found his liver displaced downwards.
The right lung is emphysematous and its
limits are increased. Since January last,
the man says, that he has been steadily losing
flesh and growing worse, he having taken
fresh cold — in other words he became tuber-
culous. This is the reason why, although ill
so long, he still looks comparatively well,
namely, he has not been affected with tuber-
culosis prior to last January. I think that
it is a good thing for this man that his lung
trouble is where it is and not at the apex of
the lung, for, for some unknown reason, the
apex heals much more slowly than any other
part of the lung. Let me, however, warn
you against making any too favorable prog-
nosis in cases of this kind. Emphysema is

not such a bad thing for a tuberculous sub-
ject to have. It is an undoubted fact that
tuberculosis does not spread so rapidly in
emphysematous subjects as in others ; but the
presence of the emphysema is often apt to
mislead us, and lead us to believe that the
lung is healthy where it is really diseased.
The mistake is made by the emphysema
giving rise to resonance or percussion over
portions of the lung where really there may
be nodules or even partial consolidation.
And so while the apparent physical signs of
your patient may be favorable, yet extensive
disease may exist and you will be surprised
at the sudden way in which your patient
will grow worse and finally die. It is well,
therefore, always to add, in these cases, a
possible 33 per cent, to the extent of the pul-
monary disease. Therefore, be guarded in
your prognosis.

PLEURITIC EFFUSION.

The next patient is a young man suffer-
ing from pleuritic effusion. About two
months ago about 55 fluid ounces of serum
were drawn off. The patient's breath smells
strongly of decomposed pus. His tempera-
ture has been very eratic, a hectic fever
existing most of the time. He had been
discharged but came in again a short time
since with new evidences of pleuritic effusion.
He coughs a good deal, and spits up a large
quantity of pus. This time there is an
effusion on both sides of the chest, but the
contents of the chest is pus, and not serum.
This pus has caused a softening of the
pleura and a fistula communicating with
the lung has formed. This accounts for the
pus in the sputa. But as the pus goes out
through this fistula, the air comes in, and
we therefore have a case of pyopneumo-
thorax. Since the patient has been in the
Hospital this time, 48 ounces of pus have
been drawn from the right side. There is
still a large amount of liquid in the chest,
capable of producing flatness and tympani.
As I move the patient about I can hear the
pus splashing with a metallic splash, that
only exists when there is air in the pleural
cavity. While the case is undoubtedly one
of pyo-pneumo-thorax, we also observe that
his finger nails are bulbous, and that the
flesh is livid around the matrix. As I have
said before in this lecture, this condition of
the finger nails is of great diagnostic value.
But, while the indications in this patient
point toward tuberculosis, yet no tubercle
bacilli have been found in his sputa. After
all, while we may have many symptoms
pointing toward tuberculosis, yet, its actual

June 20, 1 89 1. Clinical

Lecture.

769

existence can be always proved by the
presence of the tubercle bacillis.

The patient's left side is best let alone,
but what can we do for his right side ? If I
felt certain about subsequent healing, I
would insert a drainage tube in this side,
but the condition of the left side makes me
hesitate. I shall therefore wait awhile. In
this case the prognosis is, of course, very un-
favorable.

RHEUMATIC NEURITIS.

This woman is forty-two years old ; she is
married, and has three children. Until five
years ago she has always been well, indeed,
her general health is good, even now, and
she is robustly built. She says that for the
last four or five years she has been hoarse,
and that she has had severe pains in the
knee, and that her legs became swollen.
Lately her arms have also swollen, become
stiff and given her much pain. The case
has been one of rheumatic peri-neuritis.
You see that her elbow joints are very stiff.
This patient should have daily movements
of these limbs so that mobility may be re-
stored. My movements of the arm cause
the patient evident pain, and the procedure
looks cruel ; but in reality it is not cruel,
for if this were not done thejoints would in-
crease in stiffness, and finally an atrophy of
the muscle takes place, leaving the woman
with a useless limb. On examining her
limbs, I find on the left side of the tibia a
thickened lesion. This can only be of a
specific origin, and the laryngitis that she
complains of, confirms this. Regarding the
best treatment to be followed, we will give
an ointment composed of equal parts of
lanolin, nitrate of mercury, and cosmoline.
Internally we will give her iodide of mer-
cury.

THE THERAPY OF DIPHTHERIA.
BY F. LOEFFLER, M. D.,

PROFESSOR OF DISEASES OF CHILDREN, UNIVERSITY
OF GRIEFSWALD, GERMANY.

Gentlemen: — The number of remedies
which are recommended in the treatment of
diphtheria have, during the course of the
last few years, become truly legion. Nitrate
of silver, mercurial salts, chloride of iron,
carbolic acid, chlorine, bromine and iodine,
chlorate of potash, permanganate of pot-
ash, lime water, turpentine, chinolin, papai-
otin, and even yeast, are among the reme-
dies for which their several upholders have

claimed superiority ; and yet, in the face of
all this, there is no one remedy that has
merited a general acknowledgment, or found
general use.

The majority of physicians have used this
or that remedy with good results and have
become accustomed to it. By good results
I mean that their patients have recovered.
Until sooner or later they come across a
severe case in which their remedy fails them
completely, and they then bestir themselves
to find some other curative agent of greater
efficacy. The cure of diphtheria still re-
mains a problem of medicine waiting to be
solved.

How comes it, we ask ourselves, that the
therapy of diphtheria has not yet been placed
upon a firm basis ? The answer is easily
given. Up to the present time an accurate
knowledge of the cause of diphtheria is
wanting, and, therefore, systematic, scientific
and experimental tests of the various reme-
dies recommended in the treatment of this
disease are impossible. The only test we
have for the value of these various remedies
is a statistical one, and in no disease so much
as diphtheria, are these statistics so little to be
depended upon. Many conscientious physi-
cians frequently report under the name of
diphtheria, simple inflammation of the ton-
sils and pharynx with a slight exudation.
Granted that many of the successful cases
reported are of the above class, it will at
once be appreciated how delusive and mis-
leading such statistics are.

The problem before the investigator is to
find the disease germ or cause. This prob-
lem has now finally been solved. The
morphologically- and biologically-character-
istic bacillus, I have found, is the etiological
germ of diphtheria.

In this bacillus of diphtheria we have the
object upon which the various remedies may
be tried. "Not with human beings, but
with the parasites in pure cultures should
we experiment," said Koch in his address
before the Tenth International Medical
Congress in Berlin. So, guided by this
thought, I for some time studied the actions
of various chemicals on the bacillus of diph-
theria, and those which I found experiment-
ally successful have also been of great serv-
ice to me in treating the disease in the
human subject, and it gives me pleasure to
briefly report the results to you to-day.

The chemical actions of various agents
upon the bacillus of diphtheria, have been
already studied by many investigators.
Their methods of procedure have been
varied. D'Espine and de Marignac, placed

770

Clinical Leclure.

Vol. lxiv

4 cubic centigrammes of the solution they
wished to test in a test tube, after previous
sterilization of the solution, then a portion
of a pure culture of the bacilli was added
and the contents of the test tube and shaken
up. Portions of this culture, thus treated, were
then placed in blood serum in order to see
whether the germs which had come in con-
tact with the chemical agency were dead or
not. One drop of the solution was always
placed in the serum with the culture. The
contact of the bacillus with the solution
was longer than five minutes.

Babes has a different method. In one
series of experiments he would allow the
coagulated surface of blood serum to come
in contact for several minutes with various
chemical substances, and then inoculate the
surface with diphtheria bacilli. In another
series he would first inoculate the serum
from a pure culture of the bacilli, and then
half an hour later, would wash the surface
of the serum with various antiseptic sub-
stances for the space of five minutes.

Boer and Behring chose a weakly alka-
line beef bouillon, prepared with peptons
and salt, and inoculated this with the
bacillus. They confirmed, first, in what
quantity of bouillon would one gramme of
the fluid that was being tested, after the
mixture had stood two days, cause a de-
crease of the bacilli; secondly, in what
quantity of freshly inoculated bouillon, and
in what quantity of bouillon which had been
inoculated for 24 hours, would one gramme
of the fluid to be tested cause the death of
the bacilli in the culture.

The results obtained by these various in-
vestigations differ materially, on account of
the varied methods employed. At the out-
set of my experiments, I endeavored to
make them of as practical value as possible,
so that the results might be directly appli-
cable to subsequent practice.

In our fight against this microbe in
nature, two points are always before us :
Frst, to guard against the colonization of
the bacillus, in healthy subjects on the in-
tact mucous membranes, and in diseased in-
dividuals on the mucous membrane that has
not been as yet infected. This colonization can
be hindered if we bring the healthy mucous
membrane into contact with some substance
which will prevent the growth of the bacilli,
or better still, which will kill them, as soon
as it is brought into contact with them. Of
course these substances cannot be of a
nature calculated to injure the mucous
membrane, or such that even a continued
use of them could give rise to toxic or

other unpleasant symptoms. Second, the
clusters of developed bacilli in the super-
ficial layers of the pseudo-membrane must
be killed, so that no spreading of the infec-
tion to parts of the mucous membrane, as
yet intact, can take place, and also that no
living bacillus may be expelled from the
patient's mouth, so that the spread of the
disease in other persons may be avoided.

In experimental work the bacilli should
be placed in a nutritive substance congenial
to them, and in which they will increase
rapidly, as is the case when they are in the
human mucous membrane. The tempera-
ture of the culture should also be such as to
facilitate the growth of the germs. I have
found the following mixture especially
favorable to the growth of the bacilli : 4
parts of beef-blood serum, one pint of neu-
tralized bouillon, 1 per cent, of peptone, 1
per cent, of grape sugar, 0.5 per cent, of
common salt, at a temperature of 37.5°C.

Ten cubic centimetres of this serum mixt-
ure is placed in a test-tube. The tube is
held at an angle so as to allow a larger sur,
face to the serum to be exposed to the air-
until it coagulates. This tube was now in-
oculated superficially with a fresh culture
of the bacillus. In eight hours small col-
onies could be seen, and in twenty-four hours
the whole surface of the serum was covered
with a thick layer of the bacilli. Into the
freshly inoculated tube, enough of the rem-
edy to be tested was poured to cover the
surface of the serum — about 10 to 15 cubic
centimetres. The fluid was either imme-
diately poured off again, or else allowed to
stay in contact with the serum for ten sec-
onds. The act of gargling can seldom be
continued longer than 10 or 30 seconds, and
therefore this time was chosen in order to
prove the efficacy of the drugs to be em-
ployed. The pouring in and out of the fluid
did not work off the bacilli.

If a blood-serum culture is allowed to
remain undisturbed for several days, jt will
be found that a thick layer has formed over
the serum. This layer corresponds with the
colonies of bacilli in the superficial mem-
branous layers in the human subject. After
the remedy had been tested upon the super-
ficial culture of the bacilli, it was also
tested in cultures several days old, in a sim-
ilar manner. The time allowed for contact
being 20-30 seconds. After the fluid had
been poured off, tests were made both from
the superficial, and deep layers of the culture.

I discovered, in this way, that while some
remedies cause the immediate death of the
bacilli in superficial cultures, they have

June 20, 1891.

Clinical Lecture.

771

comparatively little or no effect when the
cultures have become thick layers, even
when the contact is prolonged,- and that in
order to produce any effect the remedy had
to be used in a concentrated form.

These comparative experiments seem to
me, to be of great practical value. They
teach us that a prophylactic treatment with
weak solutions is not sufficient, but that we
must combine these with concentrated appli-
cations which will also cause the immediate
destruction of the bacilli in the deeper
layers.

The remedies which I have tested com-
prise most of those which have found, or still
find, therapeutic application in diphtheria,
and also other antiseptics. Some I have
subjected to a most careful study, others I
have only been able to pay passing atten-
tion to.

They are as follows : Bichloride of mer-
cury, cyanide of mercury, metallic mercury,
nitrate of silver, chloride of silver dissolved
in sub-sulphurate of soda, permanganate of
potash, chlorate of potash, saturated lime
water, aqueous chlorine solutions, aqueous
bromine solutions, aqueous iodine solutions,
trichloride of iodine, chlorate of lime solu-
tions, double iodide of potash solutions, alco-
hol, allyl-alcohol, benzyl-alcohol, ether,
chloroform, carbolic acid, salicylic acid, re-
sorcin, hydrochinon, tropasolin, benzol,
brenzcatechin, the xyloles, toluol, anisol,
phenetol, pseudocumol, oil of turpentine,
anilin, thymol, the creosoles, creosol-sul-
phonic acids, and thirty-eight etheric oils.

The majority of the organic preparations
were placed at my disposal by Dr. Lim-
pricht, of our chemical institute, and my
thanks are due him.

Bichloride of mercury proved its powerful
antiseptic qualities also in killing the tuber-
cle bacillus. Solutions of 1: 10,000 caused
immediate sterilization of a superficial cult-
ure, and even a solution of 1: 20,000, when
brought into contact with the cultures caused
the death of nearly all the bacilli, the few
remaining ones, however, formed themselves
into colonies within a few days. A 1: 2,000
solution, even, when kept in contact with the
cultures for twenty seconds, failed to exert
any lasting influence upon the deeper layers
of the culture. The employment of a 1:1,000
solution caused the disappearance of nearly
all the bacilli, and any stronger solution
than this caused their complete extermina-
tion, even in the deepest layers.

My experiments with the cyanide of mer-
cury were particularly interesting. This
drug has been used in the treatment of diph-

theria by Hugo Schulz, Erichsen, Rothe, and
others. Sellden, of Sweden, has, perhaps,
had the most extended experience with it.
He has used it in 156 cases of diphtheria,
and only lost four, three of which he came
too late to relieve.

His treatment consisted in giving a spoon-
ful of the following formula every hour,
day and night :

3^ Hydrag cyan gramme, 0.02.

Tinct. aconiti granrfmes, 2.00.

Mel. crud " 50.00.

Ag. dest " 150.00.

M.

For young children 0.1 to 0.4 milli-
grammes of thecyanide mercury was the dose
employed. Then, two to four times during
an hour the following gargle was employed:

IjkJ Hydrag cyan grammes, 0.04

Ag. menth. pip " 400.0

Either of these solutions have a strength
of 1:10,000. My own experiences have
shown that solutions of 1:10,000 exterminate
nearly all the germs, although the contact
may only be momentary. In solutions of
1:8,000, the sterilization is absolutely com-
plete. The thick cultures were not, however,
sterilized even by twenty seconds contact
with a 1:1,000 solution, this result being
obtainable only when a solution of 1:200
was used. All the same, repeated applica-
tions of a 1:1,000 solution will cause subse-
quent sterilization. Sellden's method of
using the solutions every fifteen minutes or
half hour, would surely hinder the growth
of the bacilli. This treatment, however,
will not cause a destruction of the bacilli
within the membranes. In one case of
diphtheria I was able to trace the bacilli in
the membranes (by cultures) after the cyan-
ide of mercury solutions had been used for
three weeks.

In my opinion preparations of silver
promise excellent results. Nitrate of silver
in solutions of 1:1,000, when brought in con-
tact with cultures for one to ten seconds, had
a decided action. The serum would remain
apparently sterile for about twTenty-four hours,
then, however, colonies would begin to form
again. Stronger solutions of 1:150 caused
complete destruction of the bacilli. The
same solution had no effect upon cultures,
even when kept in contact for twenty sec-
onds.

Fresh chloride of silver, dissolved in sub-
sulphurate of soda, was found by Behring to
be very destructive to the gonococcus of
gonorrhoea in solutions of 1:7,500. Personally
I brought four cases of whooping cough to a

772

Clinical

Lecture.

Vol. lxiv

speedy termination by inhalations of a 1:10,-
000 solution of the chloride. Solutions stronger
than 1:5,000 are very irritating. In experi-
menting with this drug on serum infected
with the bacillus of diphtheria, I found that
ten seconds contact with solutions of strengths
varying from 1:600 to 1:4,000, rendered the
serum sterile, while the tubes tested with solu-
tions of 1:5,000 to 1:10,000, developed small
colonies the subsequent day. But on the
third or fourth day, all the tests contained
bacilli. In the tube treated with the 1:600
solution, the colonies were very markedly
disseminated, but in the weaker solution a
coating of the bacilli had formed over the
serum. Indeed this drug showed no superi-
ority to nitrate of silver.

Permanganate of potash in a 1 per cent,
solution left enough bacilli to form new
colonies within the course of a day. A 2
per cent, solution sterilized the surface of the
serum. In order to positively destroy cult-
ures within twenty seconds, a 5 per cent,
solution was necessary, although the 3 per
cent, solution was very active.

Chlorate of potash, 5 per cent., saturated
lime water, peroxide of hydrogen 1 per
cent., sulphuric acid 1.25 per cent., and
lactic acid 1 per cent., were entirely inactive
when kept in contact for 10 seconds.

Iodine in aqueous solutions was inactive,
but a solution composed of 5 parts of iodine,
10 parts of iodide of potash, and 300 parts
water, sterilized cultures in 20 seconds.

Bromine in 1:300 to 1:500 solutions,
sterilized the serum in 10 seconds. The
bacilli in cultures were only destroyed after
a 20 seconds contact with a 2.5 per cent,
solution of bromine.

Chlorine water, containing 0.009 gramme
of CI. to the cubic centimeter (1: 112.7) de-
stroyed the bacilli on the serum, even in
weaker solutions (1: 1100) in 10 seconds.
The first named solution also sterilized cult-
ures in 20 seconds, but the weaker solutions
had but little effect.

Although saturated lime water had been
proven inactive, saturated solutions of
chlorate of lime were most effective. Fifty
parts of chlorate of lime were mixed with
200 parts of water. The filtrate, destroyed
the bacilli on the serum, even when diluted
twenty-five times. The cultures, however,
were only destroyed by the undiluted
filtrate, in 20 seconds. Weaker solutions
were almost inactive.

Behring has recently used trichloride of
iodine successfully in treating diphtheria
in animals, in a 1:1000 solution. Even a
1:2000 solution has a decided action. My

own experiments showed that a 1 per cent,
solution exterminates the bacilli in cultures
in 20 seconds.

Absolute alcohol destroyed nearly all the
germs on the serum surface upon momentary
contact, and even a 5 per cent, solution was
decidedly active. A mixture of alcohol and
ether is especially valuable, and the follow-
ing mixture I have proved to be most
serviceable :

Ijk? Alcohol 50 parts.

Ether 25 parts.

Water 25 parts.

On cultures, however, both alcohol and
ether gave negative results.

Allyl-alcohol gave negative results, while
benzyl-alcohol sterilized the inoculated
serum in 10 seconds completely. Chloroform
water was equally as effectual.

Carbolic acid gave negative results in a 1
per cent, solution. A 3 per cent, or 4 per
cent, solution will sterilize the inoculated
serum. The addition of a 20-40 per cent,
of alcohol, greatly intensified the action of a
2 per cent, solution. Cultures were de-
stroyed in 20 seconds by a 5 per cent, solu-
tion. The same results could be accom-
plished by a 3 per cent, solution, with the
addition of 30 per cent, of alcohol.

Lysol, which has been recently introduced
into commerce, proved very efficacious.
Two per cent, solutions sterilized the inocu-
lated serum in 10 seconds. Cultures, how-
ever, were not positively sterilized, even by
20 seconds contact with a 5 per cent, solu-
tion.

The kresols were but slightly active.
Salicylic acid while active in sterilizing
serum inoculations, gave negative results in
cultures. Two and five per cent, solutions
were employed.

The action of the etherial oils was espe-
cially interesting. The majority of these
strongly odorous oils contain carbo-hydro-
gen in the form of C10 H16 and a few contain
oxygen. These actions were extremely
varied. The majority of them, however,
seemed to check the growth of the bacilli,
even by their fumes. Anisol in a five per
cent, solution of equal parts of ether and
alcohol wras very effective. Thymol in
steam form was inactive, but in a mixture
with 20 per cent, of alcohol, it killed all the
bacilli upon contact — even in solutions of
1:500. The direct application of watery
solutions of anilin, were active on the serum
surfaces. Anisol solutions were inactive.
Oil of turpentine, even with the addition of
50 per cent, of alcohol, gave negative re-

June 20, 1 891. Communications.

773

suits, but the addition of 2 per cent, of car-
bolic acid rendered it very active.

Metallic mercury in vapor form, was ef-
fective in sterilizing serum surfaces.

So much for my experiments, which, how-
ever, are far from being complete. Many
of the most active agencies, are unfortu-
nately unsuitable for practical use, on
account of their toxic qualities.

For prophylactic treatment of persons
exposed to diphtheria, gargling every two
or three hours, for 5 or 10 seconds with a
suitable solution, is recommended. For this
purpose, I have found the following very
useful : Bichloride of mercury 1 : 10,000, or
1 : 15,000, or better still, cyanide of mercury
in a 1:8,000 solution, or 1:10,000. The
taste of the latter preparation is less un-
pleasant than that offhe former. Chloro-
form water, or thymol 1 : 500 in 20 per
cent, of alcohol, are also useful and agree-
able. It is of great importance that the
gargling should be done properly and
thoroughly. In vapor form, oil of orange
peel, lemon oil, eucalyptus oil, anisol,
phenetol, benzol and toluol are of service.
These are best used, according to Feld-
bausch's method. A small metallic tube,
containing absorbent cotton, moistened with
the oil, is inserted in each nostril, and the
patient is therefore continually breathing
the fumes. These tubes should remain in
place as long as the patient is in an atmos-
phere probably victated with the bacilli of
diphtheria. The same oils might also be
sprayed or vaporized in the sick room with
material advantage. In this way the air
would be more or less saturated with the
fumes, and, certainly, an atmosphere in
which orange peel oil, or lemon oil is sus-
pended, is both pleasant and refreshing.

Regarding the treatment of patients
actually suffering from this dread disease, I
advocate gargling every one or two hours
with weak solutions, and gargling every
three or four hours with solutions which
will positively destroy the bacilli, even in
thick cultures. For the latter purpose I
have found the following most practicable :
Bichloride of mercury, 1:1,000; carbolic
acid 3 per cent, solution in 30 per cent, of
alcohol, finally equal parts of alcohol and
oil of turpentine, with 2 per cent, of carbolic
acid. Between the appointed hours for
gargling, the parts might be painted wTith a
5 per cent, solution of carbolic acid, 2 per
cent, of bromine, 1 per cent, of chlorine, or
with a concentrated watery solution of the
kresols, especially o-kresol and p-kresol.

Bichloride of mercury has been used with

the most excellent effects, and also the 3 per
cent, solution of carbolic acid in 30 per cent,
of alcohol. Under the treatment described
above the membranes can be proven to be
steril within a few days. The general con-
dition of the patient improves rapidly.
Gargling with the carbolic acid solution
will at first be unpleasant to the patient, but
this soon passes off, and the patient soon be-
comes accustomed to it. It is to be noted that
in diphtheritic scarlet fever the above
method of treatment is also very successful.

I trust, that in this brief lecture I have
been able to set forth clearly the prin-
ciples of the modern therapy of diphtheria,
based on the most recent researches and ex-
tensive experience, and that with the advance
of medical knowledge this bete noir of med-
icine may lose many of its horrors, and be
able to claim but few victims.

Communications.

THE AFTER-TREATMENT OE CASES OF
ABDOMINAL SECTION.

BY CHARLES P. NOBLE, M. D.,

SURGEON IN CHARGE OF KENSINGTON HOSPITAL FOR
WOMEN, PHILADELPHIA.1

According to Oliver Wendell Holmes, to
successfully treat an individual one should
begin with the grandfather. The same prin-
ciple applies to the successful after-treat-
ment of cases of abdominal section. When-
ever possible, careful preparatory treatment
should be carried out. Nutrition should be
improved, where depraved ; the emunctories
should be made active, especially the bowels
and skin. Operation should be rapid, care-
ful and thorough. Diseased, and especially
suppurating, structures should receive most
careful attention, and unless vital organs,
be completely removed. Asepsis in clean
operations, and irrigation and drainage in
dirty operations are essentials. Under such
conditions, unless operations have been made
a last resort, or the vital organs of the in-
dividual are seriously crippled, proper after-
treatment of cases of abdominal section will
insure a successful result, quite uniformly.

That which is accomplished by after-
treatment in cases of abdominal section is
principally of a negative character. The
object is to protect the patient from all

1 Read by title before the Section on Obstetrics
and Gynaecology of the American Medical Associa-
tion, at Washington, D. C.

774

Communications.

Vol. lxiv

sources of harm, while nature does her per-
fect work. The most positive ends accom-
plished are : to sustain the power of life to
enable the patient to pass a crisis ; to keep
the emunctories active; and to prevent
wound secretions from becoming a source of
poison.

The after-treatment of typical cases of
abdominal section is extremely simple. By
typical cases I mean those in which the
operation has been done satisfactorily, with-
out special loss of blood, and in whieh the
patient goes to bed without marked shock.

The room in which the patient is to re-
main should be airy, well lighted, and ven-
tilated. The bed, preferably, should be
single, and of such a height that the woven
wire matress is two feet above the floor. A
hair matress is the best. The bed should be
made warm during the operation by having
hot water cans or bottles placed in it.
These should remain about the patient until
reaction is complete — care being taken to
avoid burning the patient.

Diet. — During the first twenty-four hours
nothing should be given. Rinsing the
mouth with water will relieve thirst partly.
If thirst is excessive, enemas of beef tea,
eight ounces or a pint, may be given every
four hours. This should relieve systemic
thirst ; but it will not relieve thirst due to a
dry mouth or throat. On the second day
one or two drachms of water every hair hour
may be given, to be increased or withheld
according to the tolerance of the stomach.
After thirty-six or forty-eight hours beef
tea, one or two drachms, or an equal
amount of milk and lime water or soda
water, may be given ; and increased if well
borne, the frequency of administration being
decreased. If all goes well, on the fourth
or fifth day water practically ad libitum
may be given. After a week, soft diet may
be given, and after two weeks full diet.

Drainage tube, and the abdominal wound.—
In my judgment the drainage tube should
be used unless there is some special contra-
indication. If the drainage is not excessive,
nor bleeding going on, it is best to surround
the tube with sterilized cotton ; with the
bandage over all. In this way the tube is
protected against infection between dressings.
A rope of bichloride-wet gauze should be
passed down the tube to Douglass's pouch,
and externally into the absorbent cotton.
Used in this way most of the fluid poured
out into the pelvis will escape by capillary
action, and draining the tube will beunnec-
cessary more than twice or three times in
twenty -four hours. In this way the tube can

be managed by the surgeon. All soiled cotton
should be removed at each dressing, and the
outside of the tube be kept aseptic by wash-
ing with sublimate solution. It is well also
to keep the gauze over the wound wet with
bichloride solution until the tube is removed.
In draining the tube, the rope of gauze is
removed, a pledget of aseptic cotton is seized
with an aseptic forceps and passed down the
tube. This is repeated until all fluid is
removed. When the pelvis has been made
dry, it is well to pass one pledget saturated
with sublimate solution. The wet sublimate
gauze drain is next inserted, and the cotton
and bandage readjusted. This method of
managing the tube has given perfect satis-
faction in typical cases.

Where drainage is excessive or haemor-
rhage is going on, it is better to use the rub-
ber dam about the tube, having it project
through the bandage. In this way it is
more accessible for draining. The chances
of infection are also greater. In this class
of cases the tube must be drained often —
even every fifteen or thirty minutes in case
of bleeding. The piston syringe may be
used to remove fluid ; but I have found it
unsatisfactory. It will not remove all fluid
from Douglass's pouch.

The tube should be removed when the
drainage ceases to saturate the gauze rope
in the tube, especially if the drainage has
become serous. In most cases the tube will
remain in from one to three days. When
the tube is removed early, the wound should
be closed by tying a provisional stitch intro-
duced during the operation. If for any
reason it has been necessary to use the tube
five or six days or more, it should be elevated
from day to day, perhaps a shorter one sub-
stituted, and finally a plug of gauze, in-
serted through the abdominal wound, be used.
In this way a sinus can at times be pre-
vented. In such cases the judicious use of
sublimate solution, and the peroxide of
hydrogen solution within the tube track is
of great value. These agents should be
on cotton carried down the tube in the
grasp of a forceps.

The hands of the surgeon must be made
aseptic before each dressing of the tube,
and the tube forceps must be kept aseptic.
By having the forceps well nickel plated it
can be washed before use in sublimate solu-
tion. After use it should be carefully
washed with soap and water. With a little
practice the surgeon can drain the tube with
but little use of his fingers. Only the thumb
and forefinger of the left hand need come in
contact with the cotton or that part of the

June, 20, 1 89 1.

Communications.

115

tube forceps which passes down the tube.
The method employed is as follows : Small
rolls of absorbent cotton are wrapped in
tissue paper, and sterilized in the steam
sterilizer. A roll of cotton partly un-
wrapped is held by the nurse, the tissue
paper serving to keep her finger from touch-
ing the cotton. A pledget of cotton is
seized by the tube forceps, lightly wrapped
about the forceps by the thumb and index
finger of the left hand, and then passed
down the tube. It may or may not be
necessary to steady the tube. The process
is repeated until the pelvis is dry. It is
manifest that if special care is taken in
cleaning one thumb and forefinger that
asepsis can be maintained. And this can
he done with little expenditure of time.

A satisfactory method of dressing the
wound is to use a wet sublimate gauze dress-
ing until the tube is removed, and then to
apply a powder consisting of iodoform one
part, and boric acid seven parts. The deep
sutures should be removed on the seventh or
eighth day ; at which time the wound should
be supported with adhesive straps. Some
days later the superficial stitches may be
taken out.

The Bladder. — It is best to encourage the
patient to void urine. When necessary
the catheter must be used. Every care
should be taken to avoid catheter cystitis.
This is best accomplished by using a glass
catheter, having it carefully washed in run-
ning water after use, and kept in sublimate
solution until needed again. Before the
catheter is used the vestibule should be
wiped dry with absorbent cotton. Then the
catheter, properly lubricated with vaseline,
should be introduced, the parts being ex-
posed.

The Bowels.-— The bowels should be moved
early — the second or third day. I believe
that the pain after abdominal section is
largely intestinal — due to flatus, or to irreg-
ular peristalsis — and that the best way to
relieve it, is to open the bowels. The plan
of giving a brisk cathartic shortly before
operation so as to secure an early evacuation
of the bowels, commends itself to my judg-
ment, though I have not employed it. On
the second or third day an enema is given ;
and should this fail, calomel in twelfth-grain
doses, every half hour, or concentrated
citrate of magnesia solution. (Four ounces
equals one pint of the official.) Epsom and
rochelle salts have proved too nauseating
for my patients.

As an enema the following is used :

mJd Magnesia sulphat 2 S

01. terebrinth % 5

Glycerini 2 5

Aquse, q. s. ad 4 5 M.

This mixture is a very reliable purgative
enema.

The bowels should be kept open at least
on alternate days throughout the convales-
cence. Special care should be taken to pre-
vent the accumulation of scabious masses.

General care, especially by the nurse. —
During the first few days, or period of thirst
and pain, the patient should be encouraged
to bear up, and be told that pain is quite
the rule after abdominal section. Nervous,
fretful patients must be impressed with the
fact that nothing will be given that is not
thought good for them, and that personal
teasing appeals will avail nothing. As a
rule, a good morale can be thus established.
The nurse can do much to promote the
comfort of the patient. During the period
of thirst the face and hands should be
bathed frequently with ice water, or cold
water and alcohol, and the mouth should be
rinsed frequently with ice water or a weak
solution of permanganate of potassium, or
of peroxide of hydrogen. Glycerine and
ice water will at times relieve " dry mouth,"
but generally the sweet taste of the glycerine
is objectionable. The nurse should be
given the rectal tube, and should use it
whenever pain from flatus is present.

The bed ought to be kept strictly clean,
and the sheets be kept smooth. The draw
sheets and the bandages should be changed
at least twice daily. The patient's back
should be rubbed well with alcohol or soap
liniment two or three times daily. She
should be allowed to flex the legs and thighs,
when the legs can be comfortably supported
by placing a small pillow under the knees.
Cotton-wool pads or an air cushion should
be provided to ease the back. Attention to
these details adds much to a patient's
comfort.

I believe that it is best to keep patients
on their backs for two weeks after abdom-
inal section. During the first week comfort
is best attained by avoiding all motion.
After eight or ten days the use of the bed
rest permits sufficient change in position.
After three weeks the patient may be per-
mitted to sit up out of bed. Hernias are
best avoided by careful suturing, and by
rest until firm union has occurred.

COMPLICATED CASES.

Shock. — Shock is best met by the applica-
tion of external heat, the use of strychnia,

776

Communications.

Vol. lxiv

digitalis, caffeine, and whiskey hypodermi-
cally, and of decoction of coffee or beef tea
by rectal enema. Within eight hours,
thirty minims of the tr. of digitalis, one
eighth of a grain of sulphate of strychnia,
and two or three grains of the citrate of
caffeine may be given. If recovery is not
prompt, one-half of a grain of the sulphate
of strychnia, and one drachm of tr. of
digitalis may be given in twenty-four hours,
and enema of beef tea, eight ounces to one
pint with whisky one or two ounces may be
given every two or four hours. This treat-
ment can be continued for some days. If
much blood has been lost, large amounts of
fluid will be absorbed from the rectum. A
saline solution, also, may be injected into
the areolar tissue under the skin. After
one or two days, if recta) feeding is nec-
essary, a more nutritious mixture should be
substituted. I have used the following :

One egg ; milk eight ounces, peptonized ;
and add whiskey one or two ounces. This
quantity can be given by enema every six
hours. If rectal feeding is kept up for
many days, it is well to wash out the rec-
tum daily with soap suds, so as to remove
decomposing material and prevent proctitis.

Vomiting. — Vomiting from ether cures
itself. When vomiting continues more than
two days, some other cause must be sought.
If not excessive, vomiting will usually cease
if no fluids are given by the mouth. A
mustard plaster over the epigastrium, or a
tumbler full of hot water will at times
arrest it. If simple means fail, it will be
found that the vomiting is due to perito-
nitis, or to impending obstruction of the
bowels. In either case the bowels should
be moved at all hazards. This is accom-
plished best by the use of the purgative
enema already noted, given, if necessary,
through the rectal tube into the colon.
Broken doses of calomel can be given
when other purgatives are rejected. Con-
centrated solution of citrate of magnesia,
and Seidlitz powders also can be used. The
continued use of these agents usually will
open the bowels. Secondary abdominal
section for the relief of obstruction should
not be undertaken too quickly, as not infre-
quently the bowels are moved only after re-
peated efforts ; and, moreover, the results of
the secondary operation are not encouraging.

Fever. — When fever occurs the bowels
should be kept freely open, and the body
be sponged freely with cool water. The use
of antipyretics is of doubtful value. When
to re-open the abdomen for peritonitis, and
when to trust to medical measures is a very

difficult problem. In general, when the skin
is dry, the face flushed, and the pulse full
and bounding, secondary operation will be
unnecessary ; but when the skin is " leaky,"
the extremities cool, and the pulse rapid
and feeble, absorption of septic material
is going on and operation is indicated.
Unfortunately the result usually is death.

Opium. — The use of opium in any form
in typical cases of abdominal section is un-
necessary. A little encouragement during
the first day or two will enable the patient
to stand the pain, and later it is quite bear-
able. Occasionally morphia is useful when
a nervous patient becomes much excited,
and cannot otherwise be controlled. I feel
convinced that the experience of the past
few years has demonstrated the fallacy of
the doctrine that opium is curative in peri-
tonitis ; and that it finds its legitimate field
in abdominal surgery in combating extreme
nervous excitation, and in easing the last
hours of the dying. Occasionally it may be
used temporarily to relieve extreme pain.

Asthenia. — Asthenia must be combated
by the systematic use of nutritive enemas
with whiskey, together with the administra-
tion of such liquid food as the stomach will
bear. Champagne can often be given with
advantage where other stimulants are re-
jected. Less can be done by alimentation
and medication after abdominal section|than
after other operations to combat asthenia,
because, as a rule, the stomach is not
available. The fate of the patient is decided,
in general, when the operation is completed.

SOME POINTS IN THE SURGICAL TREAT-
MENT FOR THE RADICAL CURE OF
HERNIA.

BY AUGUSTUS P. CLARKE, A. M., M. D.,

CAMBRIDGE, MASS.

One of the most important features in the
surgical treatment for the radical cure of
hernia is the selection of the proper material
for sutures. The sutures in all cases should
be aseptic. The wound made by the incision
should also be kept aseptic. The operator
should have knowledge of the manner in
which the sutures have been made, and in
order to have such knowledge he should su-
perintend their final preparation. Sutures
which have been prepared and are sold in
shops should in no event be trusted, notwith-
standing the careful manner in which they
may seem to have been prepared. No one,

June 20, 189 1.

Communications.

777

except the surgeon, or his immediate assist-
ants who are to use them, and who have
taken occasion to make most careful obser-
vation, is at all likely to appreciate this ne-
cessity, and to carry out in every detail
measures necessary for assuring their prepa-
ration in such a manner that they can be
relied upon as being surgically clean and
perfectly free from germs. Experience has
demonstrated that the best material for
buried sutures is that obtained solely from
animal substances. Cat-gut and tendon,
when properly prepared, afford the best
material as is yet known for such sutures.
Considerable experience is required in chrom-
icising them. If the sutures remain long in
the acid they become hard and offer too
much resistance to the action of the tissues.
The same effect occurs when the quantity of
acid is in excess of the due proportion. If,
on the contrary, the sutures are not suffi-
ciently chromicised they undergo absorption
before complete union of the coapted parts
of the wound takes place. Silk ligatures,
however carefully prepared, should not, as a
rule, be employed in operations on hernia ;
their substance is not akin to those of the
tissues into which they are to be inserted ;
they are liable to be the medium, either
directly or remotely of sepsis, and are rarely,
if ever, absorbed. In cases in which they
have been used, it has been necessary, for the
most part to establish some means of drain-
age. Such expedients serve to prevent the
occurrence of immediate adhesion of the
tissues, and to render the line of union weak
and yielding, and consequently to afford but
little protection against a return of the
hernia. The same may be said when horse-
hair and certain other materials are used for
such sutures. It is true that for affording
immunity against the recurrence of the
hernia the internal ring, may be embossed
by the inverting of the sac on its peritoneal
surface. This measure may, for the time
being, be of some service especially in a case
in which a well fitted truss is worn. Such
unnatural coaptation of parts is liable, how-
ever, to yield before the superincumbent
pressure of the abdominal viscera and thus
to cause a return, at length, of the hernia.
Application of quilled sutures fail far short
of accomplishing what is most to be desired,
for the adoption of this method of procedure,
when silk, or like substance is employed
has to be supplemented by some special pro-
vision for drainage to the wound. One of
the features which I here insist upon to be
achieved is that the several different tissues
be coapted, each in its proper order and that

direct and immediate union be secured with-
out the necessity of having to resort to any
method of drainage whatever. Another im-
portant feature to be secured in the opera-
tion is the restoration of the obliquity or the
valve-like form of the inguinal canal, and
also of the internal and external abdominal
rings. Attention has been called to the
importance of this measure, but as yet, I
believe, it has not been generally appreciated.
This may be effected by free dissection pro-
ceeding from the internal ring. In cases in
which the tissues have undergone serious
changes, or the parts have become distended,
deformed, thickened or attenuated much dif-
ficulty will be encountered in accomplishing
such restoration. Every effort, however,
should be made to bring back the canal as
near as possible to the typical one, as regards
length, diameter and obliquity. In those
cases in which the canal has become tortu-
ous, or in which the opening is formed at an
undue angle to the parietes of the abdomen,
and the parts are not reformed but are left
in abnormal condition, the operation under-
taken for the radical cure will prove to be
of temporary benefit only. Statistics are
sometimes offered by different operators to
show that certain methods of practice are
attended with unusual success. Statistics
can be of but little value when the individ-
ual operators select cases with the view of
showing favorable results of their special
methods of operating. In a case in which
the sac is to be removed the cord should be
freed as high as possible even if the perito-
neum has to be impinged upon. The sac
should be sewed off by means of aseptic
animal sutures ; and if the other steps in the
operation have been properly taken there
will be scarcely any danger of a return of
the hernia. There are several advantages
in the method of removing the sac. Promi-
nent among them is the greater facility for
inspecting its'' contents and for guarding
against the possibility of reducing parts
which may be in a state of inflammation.
Such a condition of the parts is particularly
apt to occur in cases of strangulated hernia,
after prolonged taxis or other measures for
relief have been undertaken. When the
hernia has been properly reduced, the sac
should be regarded only as an unnecessary
incumbrance. The sac is formed originally
from the parietal peritoneum, which
frequently becomes distended and thick-
ened. The various changes in its nu-
trition and vascularity often lead to
irritation, inflammation and adhesion, ac-
cording to circumstances and accidental

778

Communications.

Vol. lxiv

conditions. In all cases after opening the
sac the surgeon should see whether the
circulation returns. If the parts have been
too long compressed and there is much
danger of sloughing, it will be advisable to
resort to resection of the necrosed portions,
and not to assume risks of returning them.
After opening the sac and relieving the
constriction, and before making reduction,
the contents of the sac should be carefully
examined. If there is evidence of inflam-
mation or an effusion of lymph, free irriga-
tion, with mercuric bichloride should be
had recourse to. The sac should then be
sowed across at its neck with animal suture
and be excised. Different methods of
operating for the radical cure of hernia
from time to time have been reported.
Emphasis is often laid upon the adoption of
the most careful antiseptic precautions. A
more particular examination of such reports
almost invariably reveals the fact that some
method of drainage has been employed. The
failure on the part of the operator to keep the
wound aseptic, must necessarily render the
line of union weak, the parts in large meas-
ure devoid of vitality, and thus incapable of
overcoming the pressure which is the cause
of the recurrence of the hernia, This is the
reason, no doubt, why so many different
methods for the radical cure of hernia have
been devised, and why each method of
operating, for the most part, undertaken by
a different surgeon, so often proves unsatis-
factory. In some cases of femoral hernia,
excision of the sac is almost imperatively
demanded. In those cases in which
Macewen's method is adopted, the thickened
mass is liable to set up more or less irrita-
tion, and to become the source of much
inconvenience.

When the sac is removed the ring and
canal can be narrowed and sutures can be
introduced, in close proximity to the vessels
without causing injury or disturbance to the
circulation. Another advantage, according
to Mr. Poland,1 is that it allows the closure
of the neck of the sac,- and thus effectually
prevents all hemorrhage from the wound
into the peritoneal cavity. After the sac
has been removed the loose folds in the
vicinity can be more nearly approximated,
the exudation of plastic lymph readily
closes the wound effectually from any com-
munication with the abdominal cavity.
After the edges of the pillars have been re-
freshed they may be brought together and

ijohn Poland, F. R. C. S. Braithwaite's Ret.
Part 98, page 124.

retained by aseptic sutures. By this means
the canal is reformed but narrowed, and
becomes an effectual barrier against the re-
currence of hernia. This method is evi-
dently of far more importance than the one
which seeks to utilize the sac by invaginat-
ing it in the canal, and by converting it
into a pad, or fixing it as a boss over the
internal ring. Of course in cases of chronic
hernia, in which there has been much
inflammation, considerable difficulty will
be experienced in separating the sac from
the surrounding parts. If, however, much
care be exercised, and a liberal use of the
aseptic sutures be resorted to, the sac can
be separated and be removed, to a certain
extent without incurring the risks of
gangrene, suppuration or inflammation,
and the operation will therefore not appear
so difficult or dangerous as some writers
would lead us to believe. In a recent case
in which the hernia is quite small, the sac
and hernia may have passed into the abdo-
men and so have disappeared. These cases
may be operated upon without our inter-
fering with the sac. The edges of the pillars
should in such cases be refreshed, and ap-
proximated by aseptic animal sutures. The
other parts are sewed together according to
the method already referred to. In con-
genital cases the cord and sac are frequently
found so blended with each other that to
separate the one from the other is often
most difficult and tedious. In such cases,
when there is no appearance of recent
lymph, portions of the sac may be left. The
remaining fibres for the most part, usually
undergo absorption or degeneration. This
measure in the operation is quite different
from the one which, as said before seeks
to plug the canal and internal ring, by
means of the retained or inverted sac that
is liable to form a painful or hardened mass
in connection with the ring and canal. In
operations for the cure of hernia, the use of
wire sutures is unnecessary, and should not
be encouraged. The use of wire sooner or
later, becomes the source of inconvenience,
if not of serious trouble, and notwithstand-
ing the efforts made in other respects to keep
the wound aseptic, their presence is followed
by irritalion or ulceration, conditions that
will necessitate their early removal and
thus compromise the usefulness and advan-
tages that should be derived from the
surgical measures undertaken. Other
methods of treating the sac have been pro-
posed. The cases in which the method by
torsion of the sac, can, with any degree of
safety, be resorted to are too few for general

June 20, 1 89 1.

Society Reports.

779

considerations. In every such case the
operator of course must be law unto himself
In conclusion I would say that every
operation, for the radical cure of hernia, in
which the wound is kept strictly aseptic in-
cluding the employment of thoroughly
aseptic animal sutures the results will be
most satisfactory, and but little danger is to
be apprehended of a return of the hernia.
These favorable results may be expected to
follow in the cases in which the sac has, as
far as possible, been excised, without injury
to the cord or other parts. In all cases ex-
pected to be successful the operation
should be so conducted that no drainage,
however simple in its details, should
in any way be required. The necessity
of observing this principle in operations
for the cure of hernia, has been urged by
my friend, Dr. H. Q. Marcy. He1 says the
" Coapted surfaces held aseptically at rest,
readily tolerate the limited effusion which is
utilized in the process of repair. The
elimination of the drainage tube, renders
the complete closure of an aseptic wound
possible, and prevents its further extraneous
contamination. Repair ensues as in a sub-
cutaneous wound. The advantages of this
method in the treatment of the wound, is
the assurance of non-infection. By every
method of antiseptic dressing with drainage
all surgeons have admitted the great diffi-
culty, and, in children the well nigh im-
possibility of retaining the wound aseptic."
The results of the operations in the
hernia cases, occurring in Dr. Marcy's
practice, with which I have been connected,
and also in those in my own for the past
twenty years fully justify the conclusion here
reached. By the observance of these prin-
ciples of aseptics inoperative treatment for
the radical cure of hernia, Dr. Marcy has,
according to my judgment, attained a success
that has scarcely been paralleled.

Society Reports.

PHILADELPHIA COUNTY MEDICAL
SOCIETY.

Stated Meeting, May 29, 1891.
The President, John B. Roberts, M. D., in the Chair.

DR. FRANK WOODBURY SUBMITTED A PAPER ON
NITROGEN-CONTAINING FOODS AND THEIR
RELATIONS TO MORBID STATES.

In connection with the paper of the
evening, by Professor Chittenden, upon the

lTreatise on the Radical Cure of Hernia, page 87.

" Food-value of Beef-preparations," I have
been invited by the Honorable Board of
Directors to contribute a few remarks upon
" Nitrogen-containing Foods and their Re-
lations to Certain Morbid States." Under
the circumstances, it is proper that what I
have to say shall be made as brief as possible.

At the outset, our attention is drawn to
some fundamental physiological facts which
must be kept in mind during the discussion
of this subject. The human body is now re-
garded as a unit composed of an aggregation
or community of cells. These anatomical
elements differ from each other in some
respects, but agree in this: each cell con-
sists of two parts, one living and one non-
living, corresponding with cell-nucleus and
formed material. What is visible to us is
the non-living part, or the formed material ;
the real living part of the organism is
hidden from view. Just as in vegetable
tissue, the parts that are permanent and
solid are composed of the cell-walls, which
may remain long after the essential living
part or protoplasm of the wood-cell has
dried up and disappeared — in a similar way,
in the human subject, the various organs
and tissues which give it form and substance
are not living ; the only part exhibiting
vital phenomena is the soft, shapeless, and
colorless cell-nucleus, consisting of proto-
plasm or bioplasm. This living substance,
in its chemical composition, resembles the
various tissues, varying somewhat according
to function, but it contains one essential
ingredient which is so characteristic as to
confer its name upon the whole class — this
element is nitrogen. The celebrated dic-
tum, " Without phosphorus, no thought,"
might be paraphrased " Without nitrogen,
no life." Viewed from the physiological
stand-point, the name " Azote," applied to
this element by Lavoisier, appears remark-
ably inappropriate.

As a necessary constituent of the tissues,
therefore, nitrogen, in a state of combination,
is always present in the human body. Since
it is found in considerable quantity and in
various forms in the excretions, some two
or three hundred grains being discharged
daily by the kidneys alone besides what is
lost by the intestinal tract and the skin, it is
evident that in order to maintain life the
supply must be kept up from outside sources.
There are two principal directions in which
we may look for the supply of nitrogen, (1)
the atmospheric air, and (2) the food.

Although the atmospheric air contains
about eighty per cent, of nitrogen, we may-
dismiss this at once as not available, beyond

780

Society Reports.

Vol. lxiv

a very limited extent. Experiment has
shown that it is not consumed or absorbed
in the act of respiration ; but a certain
amount of air is always swallowed with the
food and passes into the stomach, where it
may become absorbed by the gastrointes-
tinal mucous membrane. It is possible that
a small quantity is introduced by this
channel, especially since it has been demon-
strated that a moderate amount of gaseous
nitrogen is excreted or exhaled by the skin.

Nitrogen-containing food must, therefore,
be regarded as practically the only source
of the constant supply of nitrogen which is
so essential to the maintenance of the body
in a normal condition. In fact, due atten-
tion has already been given to this by
Liebig, Fick, Wislicenus, Parkes, Pavy,
Flint, and others ; and the proper relation
of the two great divisions of proximate
principles of organic origin, the nitrogenized
and the non-nitrogenized, have been pretty
closely determined. As their results are to
be found in all the text-books, I will not
refer to them in detail. I may remark,
however, in passing, that from the clinical
standpoint there appears to be a fallacy
underlying all these calculations of dietaries,
where food values are expressed in grains of
nitrogen and carbon, inasmuch as no allow-
ance is made for waste ; the entire quantity
ingested is supposed to be digested and as-
similated. In practice we know ^hat the
feces contain considerable nitrogen, which is
not excretory, properly speaking, but repre-
sents the excess of consumption, part of the
food having escaped digestion. In nursing
infants the feces consist largely of undigested
casein. Even adults are not able to entirely
digest milk, and if so simple an article of
food as milk is not completely assimilated,
what warrant have we for assuming that the
nitrogenized constituents of peas and beans,
or of anirnaj tissue, will yield their full
equivalent of potential force to the organ-
ism ? On the contrary, we know it to be a
fact, that much food-stuff passes through the
alimentary canal without having its proxi-
mate principles extracted by the digestive
organs and the absorbents.

We may, however, both clinically and by
physiological experiment, making due al-
lowance for the personal equation, determine
with sufficient exactness the kinds and pro-
portion of different foods required to main-
tain the body in a normal condition. Pro-
ceeding on the same lines, we may discover
the effects of an excess, actual or relative, of
nitrogen ; or, on the other hand, we may

ascertain the results of deprivation either
partial or complete. We may also be able
to see some therapeutic applications of the
knowledge thus gained.

From the time of Hippocrates, and even
earlier, it has been known that health and
disease are largely influenced by food, and
that the effects of an animal diet are dif-
ferent from those of a diet exclusively of
vegetables. A distinction was even made
between leguminous and other forms of
vegetable food. It was not until our own
day, however, that the practising physician
possessed sufficient knowledge of the chem-
istry of food and of metabolism in health
and disease to enable him to direct the diet
of his patients upon scientific principles.
Following the definition given by Hippo-
crates, " Medicine consists in addition and
subtraction, the addition of the things which
are deficient and the subtraction of those
things which are redundant ; he who prac-
tises this is the best physician, but he whose
practice is farthest from it is the farthest re-
moved from a knowledge of the art " — we
can now prescribe viands suited to a
deficiency of nitrogen in the system, or
substitute others if there is an excess. To
the therapeutic aspect of the, subject I will
now very briefly ask your attention.

Taking up the latter instance first, we
find that a diet poor in nitrogen is useful in
the several forms of rheumatism, in gout
and lithasmia, and also in recurring attacks
of biliousness and bilious headache. Scurvy
appears to be caused by an absolute, as well
as a relative, excess of nitrogen in the food,
and I have seen it caused by the use of an
excessive amount of fresh meat among chil-
dren in an orphan asylum. In its treat-
ment, vegetable food relatively poor in
nitrogen is usually employed. Some skin
diseases, possibly of lithsemic character, are
only to be cured by withholding nitrogenized
food. It seems possible that a liberal use of
meat in the diet may have some connection
with the development of cancer, a disease
which appears to be on the increase, as was
pointed out by Dr. R. A. Cleemann, of this
Society, in his " Address on Hygiene," de-
livered before the Medical Society of the
State of Pennsylvania a few years ago. Dr.
W. Mattieu Williams, in a little work on
the " Chemistry of Cookery/' pointedly
directs attention to the large consumption of
meat as a cause of various forms of cancer.
In families where a hereditary tendency of
this kind exists, it is possible that it might
be overcome by vegetarianism. Some

June 20, 1 89 1. Society Reports.

781

nervous affections, notably epilepsy and
chorea, are greatly benefited by abstention
from meat in the food.

Owing to the writings of Roberts, Fother-
gill, and others, a causative between a diet
rich in nitrogen and some forms of kidney
inflammation or degeneration is now gener-
ally recognized. And in the treatment of
the various forms of Bright's disease, atten-
tion to the diet is generally admitted to be
of prime importance. There is a widely
spread opinion that nitrogenized food is
favorable to the occurrence of inflammation,
and for this there seems to be a scientific
foundation. Parkes has shown that a non-
nitrogenized diet causes lowered blood-
pressure and diminished arterial tension.
Meat, therefore, is ordinarily prohibited
under the antiphlogistic treatment, as it was
formerly called. In acute inflammations of
mucous surfaces, especially in plethoric sub-
jects, the use of animal food is usually for-
bidden. This should not be applied too
strictly, however, for in some cases of sub-
acute or chronic character, a generous and
nourishing diet is necessary.

On the other hand, nitrogenized food may
be prescribed where there is, from any
cause, a deficiency of albuminous principles
in the blood, for example in anaemia or
chlorosis. In phthisis, this condition is
sometimes quite marked and good results
have been obtained from the " beef and hot-
water " plan of treatment, and also from the
use of fresh bullock's blood, or haemoglobin,
which requires less digestive capacity and is
more easily assimilated than muscle-tissue.

Children frequently suffer from a de-
ficiency of nitrogen. Where an infant is
reared upon condensed milk entirely, the
limbs are plump but the tissues are flabby,
on account of anaemia. Such children are
late in getting their teeth and have little
power of resistance against disease. The
addition of oat-meal, barley, or rice to the
milk will often bring about marked im-
provement and may prevent the develop-
ment of rickets. Just here I might stop to
point out the fallacious character of some
of the arguments based upon the compara-
tive chemical composition of woman's milk
and other foods. Leeds found in a number
of specimens of woman's milk that the
nitrogenous constituents varied from 4.86 to
0.85 per cent. So that one specimen of
mother's milk may have six times the
amount of albumious material contained in
another.1 This shows the necessity when

Quoted by Starr in his Hygiene of the Nursery,"
Philadelphia, 1888.

the child does not thrive at the breast, of
examining the milk to find out if it be de-
ficient in nitrogenized constituents. If so,
the addition of beef-meal, bovinine or other
nitrogen-containing food in an easily assim-
ilable form is advisable.

Eczema in infants, or in sewing woman, is
often traceable to a deficiency of nitrogen in
the food, and Dr. Rohe, of Baltimore, ad-
vises the addition of meat-broth and eggs to
the diet as an essential part of the treat-
ment. Similarly, in many syphilitic erup-
tions upon the skin, in broken-down sub-
jects, good food is a necessary preliminary
to any specific treatment. Neurasthenia
and atonic dyspepsia, which are so often as-
sociated in the same patient, especially if he
is at the same time anaemic, can only be re-
lieved by nitrogenized and fatty food, ad-
ministered in a form easy of assimilation
and at comparatively short intervals. On
the other hand, in diabetes and in obesity,
the diet may be largely nitrogenous, but in
this case it is because there is a desire to
reduce the carbo-hydrates and not because
an excess of nitrogen is particularly sought
after.

To return to the children, I wish to call
attention to the fact that during the period
of growth and development more nitrogen
is needed than after the body has assumed
its full stature. Hence, school-children
should have a due allowance of meat, and.
should be encouraged to eat oat-meal, corn,
beans, peas, and other vegetables known to
contain this valuable constituent.

In the foregoing brief resume of an im-
portant and interesting subject, I have not
made any distinction between the nitrog-
enous, proximate principles of animal and
vegetable origin. Chemically and physio-
logically they are nearly identical ; but
practically there are minor differences of
palatability, digestibility, an/l relative
utility, which, at present, our limits will not
permit us to consider.

— Sanitary administration means not only
personal comfort and health in the family, but
economy to the state and family. Two hun-
dred and fifth thousand lives lost, three mil-
lion cases of sickness and $20,000,000 in
money are traced, in one decade in England
alone, to neglect of sanitary care. The sword
and musket are terrible ministers of death,
but even in armies, where battles kill one per-
son, disease kills at least three. — Ex.

782

Special Correspondence.

Vol. lxiv

Special Correspondence.

London Letter.

LATE SPRING AND THE INFLUENZA-
REJECTION OF THE NEW SCHEME OF
THE LONDON UNIVERSITY— SIR
WALTER FOSTER ON PROFES-
SIONAL POLITICAL POWER-
LESSNESS— PROFESSOR
GAIRDNER'S LITTLE
ANECDOTE.

Spring is late in coming this year. Hail
storms have been reported all over the
country, varied with snow and sleet, while
every now and then a warm, genial day is
dovetailed into the midst of this backward
season. The cold has swelled the Registrar
General's returns in no small degree. In
London alone there is an increase of 433
deaths above the average number for the last
ten years. The deaths from diseases of the
respiratory organs were 584, or 240 in excess
of the average ; of these 230 were attributed
to pneumonia, and 302 to bronchitis. In-
fluenza rose to 148, or 21 in excess of the
highest weekly number of deaths in the 1890
outbreak. The death rate for the Metropolis
amounted to 24.0 per 1,000. In some of the
provincial towns, however, the rate has been
brought up to fever pitch. Sheffield, for
instance, has shown the following figures for
the last three weeks during the influenza
epidemic : 57.8, 70.5, 59.3 ; Leeds, 27.9, 36.1,
48.3 ; Manchester, 29.8, 35.1, 43.6. A more
intimate acquaintance with this mysterious
disease is impressing on us the important
lesson that fatalities are largely influenced
by surrounding insanitary conditions. The
smoky atmosphere of Sheffield, together with
the dusty workshops, render its inhabitants
especially liable to chest affections. The
other day a member of the House of Com-
mons solemnly warned the Commissioner of
Works that by leaving the windows of the
House open he was admitting the influenza.
If closed windows would exclude the mi-
crobes our difficulty in dealing with those
obtrusive vegetable organisms would be ma-
terially lessened, but, alas, they are not so
easily given the cold shoulder.

The revolutionary spirit of the age seems
to have at last invaded the domain of medic-
al education. Two of the most conservative
and autocratic of the London powers have
lately received a sharp reminder that gov-
erning boards cannot for ever ignore the
wishes of their constituents. The new scheme
of the Senate for providing a degree on
" reasonable terms " has been rejected by an

overwhelming majority at the meeting of the
Convocation of the University of London.
The chief opposition has-been raised by the
provincial schools, which were barely allowed
a voice in the proposed future Senate. Then
the Council of the College of Surgeons sanc-
tioned the scheme without consulting its
members and fellows. At a general meeting
of the College a formal censure was passed
on the Council for having taken that step,
and a further resolution declared it
undesirable that that body should have in-
creased power over medical education. Mr.
Lawson Tait carried another motion that no
amalgamation scheme would be perfect that
did not include the Society of Apothecaries,
which the Senate had entirely ignored. And
thus there is every prospect of a lively strug-
gle. However, there can be no doubt that
the student will get his London degree in a
not very distant future without being forced
to seek it in the Provinces. Some of the
journals do not mince matters, but say in
so many words that it is the instinct of self-
preservation only that has forced the hands
of the London Senate. The Scotch news-
papers openly acknowledge that the estab-
lishment of a teaching London University
will be a great blow to their own Universi-
ties.

Notwithstanding the attempt of the Lon-
don Senate and of the London teachers to
ignore the Provinces, there is no question
that many of our most able men are in the
Provinces, although in the natural course of
events a goodly number of them are drafted
on the Metropolis. One of the first men to
call attention to the existence of such a
thing as a democracy in the medical profes-
sion was a Privincial physician, Sir Walter
Foster. In 1883 he made a famous presi-
dential speech before the Birmingham branch
of the British Medical Association. In that
address he pointed out the political powerless-
ness of the profession, and started the wave of
thought that is now sweeping against various
ancient barriers. Sir Walter has lately re-
signed his appointment as honorary physician
to the Birmingham General Hospital, which
he has held for upwards of twenty years.
Five years since he was elected direct rep-
resentative on the General Medical Council,
and is a member of the House of Commons.
On the occasion of his first entering on pub-
lic life, he says that Sir Andrew Clark wrote
him a word of warning to the effect that
" Medicine is a jealous mistress," to which
reminder he replied that the best antidote
was unbroken lovalty. Sir Walter struck a
key-note in the further remark that in all his

r June 20, 1891

public work he never had, and hoped he
never should lose sight of medicine, for he
believed their profession was interwoven
with the highest and best legislation and
with the future welfare of mankind. This is
very much the conclusion that is arrived at
by most philosophical thinkers, and may be
otherwise expressed in the formula that
medicine is one of the most progressive, as it
is the most comprehensive, of all professions.
After waiting all these centuries, the outside
world seems to be waking up to pretty much
the same conclusion. Peerages, however, are
as yet reserved for such men as soldiers,
bankers, brewers, diplomats and successful
politicians. Sir James Paget has often been
mentioned as our coming peer, but Ministers
have not yet made up their minds.

Professor Gairdner has revived an old
story that went the round in Edinburgh
many years ago, of which it can be said, Se
non e vero 'e ben trevate. He asks whether
it is better to test a harmless remedy by
giving it all round, or to adopt the more
scientific plan of giving it to one-half of our
patients (reserving the other half as a con-
trol experiment). The story refers to the
former method. "A lady, finding in her
prescription something unwonted and as she
thought uncanny, turned back to get a
further explanation from the Professor, who
was by that time fully occupied with some-
one else. But the man at the door was equal
to the occasion. Taking the prescription
into his hand he ran it over with a practised
eye, inured even to Latin formulae by long
and faithful service in a medical man's
house. He returned the paper to the lady
and showed her to the door again with the
remark," Ou aye, mem, it's a'richt ; they're
a'gettin' that 'the now." The Professor had
been experimenting all round, more or less,
with some of the more unwonted metallic
salts, such as titaninm, cadmium, tellurium,
palladium and so on, most of which turned
out to be tonics, with the exception of one,
which had the awkward peculiarity of caus-
ing the patient to shed abroad such a peculiar
and disagreeable perfume or stink (if you
will pardon the word) that it had to be forth-
with abandoned on that account." As Dr.
Gairdner remarks, the anecdote did not de-
tract from the world-wide fame of the Pro-
fessor in question, nor was it known to have
emptied to any extent his over-flowing wait-
ing-room. D. W.

Selected Formulce.

Selected Formulae.

783

BLENNORHAGIA.

Creasote gtt. x.

Fl. ext. of hamamelis

Fl. Ext. of hydrastis canadensis. ..aa... gtt xv.

Rose Water 60.0 grammes.

Water 200.0 '•

Journal de Med. de Paris, May 10, 1891.

TREATMENT OF FISSURED HANDS.

After having washed the hands in tepid
water, apply a small quantity of the follow-
ing solution to the fissures, and let it dry :

1^ Tannin i.o gramme.

Glycerin 20.0 grammes.

Water 100.0 "

M.

At night, on retiring, the following salve
should be applied :

Ext. of ratanhia „ 2

Lanolin.

o grammes.

.50 o grammes.

M.

Vanillin o. 10 gramme.

Rose oil gtt ij.

fiat, unguentum.

Gloves should be worn at night.
— Journal de Med. de Paris, May 10, 1891.

WHOOPING COUGH.

Von Genser is said to use the following
prescription in the treatment of whooping
cough :

Carbolic acid grains.

Rectified spirit 2 drops.

Tincture of iodine.... 5 drops.

Tincture of belladonna 10 drops.

Peppermint water 2 ounces.

Simple syrup 1 dram.

To a child of two years a teaspoonful of this mixture may
be given every two hours.

INSOMNIA.
Dr. E. C. Hooved, of Dayton, Ohio,
gives an efficient preparation for#use in the
insomnia following alcoholic excesses, etc.,
which is permanent, contains no alcohol, is
perfectly miscible with water and can be
readily prepared by any pharmacist. His
formula is as follows :

Ijk Chloral hydrat

Potass, bromid aa 5iv.

Ex. cannabis ind

Ex. hyoscyami aa grs. xvj.

Chloroform i 5ij.

Aquae (bullientis) ad Oij.

Dissolve the cannabis in the chloroform
and add the chloral. Pour the boiling
water on this and then add the bromide and
the hyoscyamus. When cold filter. A
clear amber-colored solution results, con-

784

Selected Formulcz.

Vol. lxiv

taming a dram to the ounce of the chloral
and of the bromide, which is in ever)' way
as efficient as proprietary preparations like
bromidia, chloro-anodyne, etc., and which
has the advantage of our knowing just what
is in it and how much. — Lancet and Clinic.

THE TREATMENT OF HICCOUGH.
The Gazette Hebdomadaire gives the fol-
lowing treatment for hiccough. The local
treatment is to compress the phrenic nerve
and the pneumogastric in the neck by pres-
sure with the index finger, which will often
cause immediate cessation of the spasms.
The medicinal treatment consists in the
administration of a coffee-spoonful of vine-
gar mixed with a little powdered sugar, or
the following formula may be used :

jfjk Subnitrate of bismuth 45 grains.

Oxide of zinc 1

Valerianate of zinc >-of each...i drachm.
Powdered calumba I

Powdered Opium y2 grain.

Essence of anise, a sufficient quantity.
Mix thoroughly, and give half a teaspoonful of this powder
in a wineglassful of sweetened water.

TREATMENT OF PARASITIC DYSENTERY
AND OXYURUS.

C. Minerbi employs naphthalin (Medecine
Modeme) suppositories and oily enemata,
the suppositories being made as follows :

Naphthalin
Butyr. cacao.

.aa Jijss.

When the ulcers are seated higher up
than can be reached by suppositories, the
author has recourse to oily enemata :

M.

Naphthalin gr. lxxv.

01. olivarum 5v.

At the beginning of the dysentery the
injections cannot be held much longer than
a half-hour, on account of the tenesmus.
They should be repeated three or four times
every twenty-four hours at this period.
Later, the patients succeed in retaining
them longer and longer so as to last five or
six hours, or even be absorbed. Besides
this the enemata do not bring about con-
stipation.

For oxyurus the same method has been
successfully employed, children infested with
this parasite being cured in less than a
week. The formula employed is as follows :

.gr. xv-gr. vxy.
.5x-5xv.

Naphthalin

Ol. olivarum ,

M.

Sig. For one injection.

For an adult the enema should be made
stronger such as :

M.

Naphthalin gr. lxxv-5jss.

Ol. olivarum §xv-!5xx.

Sig. For one injection.

COCAINE IN ASTHMA.
C. R. D. Sylva reports a case in which
very severe attacks of asthma were in a few
minutes entirely relieved by the following
subcutaneous injection :

Cocaine hydrochlor
Morph. sulph.
Aquae destil

•aa % gr.

q. s. M.

-Ind. Med. Gaz.

ALOPECIA FOLLOWING CONTINUED
FEVERS.

ijk? Ext. jaborandi f

Tr. cantharidis aa 5 ss.

Glycerine

Olei vaselin aa % i.

M. Sig. — Apply locally with a sponge at night.

— Barthlouu in Col. and Clin. Bee.

PRESCRIPTION FOR ECZEMA OF THE
ANUS AND GENITAL ORGANS.

Lustgarten advises, in La Semaine Medi-
cale, the following ointment:

1^ Oleate of cocaine 15 to 30 grains.

Lanolin 1 ounce and 2 drachms.

Olive oil 2% drachms.

Use externally.

Make an application of this ointment
twice daily, and after each application pow-
der the affected part with any absorbent
powder whatever. Warm soap baths will
aid in curing the disease. In pruritus ani,
suppositories of cocaine can be employed
with advantage.

TREATMENT OF ERYTHEMA OF THE
EYELID.

Brocq, in the Revue oV Ophthalmologic,
states that he employs the following oint-
ment in the treatment of erythema and
swelling of the eyelids :

Ijk? Salicylic acid 7 grains.

Lactic acid 7 "

Resorcin . . ...10 "

Oxide of zinc... 30 "

Pure vaseline 5 drams.

Care should be takerr that none of the
ointment enters the eye.

In other cases the following ointment may
be applied :

Salicylic acid 15 grains.

Pyrogallic acid 30 grains.

Vaseline. ...15 drams.

This treatment is to be applied at night,
and it may be alternated with that contain-
ing resorcin just given. — L' Union Medicale.

June 20, 1 89 1.

THE

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TRACHEOTOMY VERSUS INTUBATION.

Tracheotomy and intubation are the two
recognized surgical procedures for the relief
of tracheal and laryngeal obstruction. One
or the other of these operations may be re-
quired to relieve the dyspnoea dependent
upon membranous laryngitis or diphtheritic
laryngitis, growths in the larynx or trachea,
growths exterior to these organs causing
pressure upon them, oedema of the mucous
membrane of the larynx or trachea from
inflammation, from the inhalation of irri-
tating gases, from the swallowing of corrosive
liquids or from burns or scalds, etc.

For many years, tracheotomy had been
the only method employed for surgical inter-
ference in these cases. In 1880, Dr. Joseph
O'Dwyer, of New York, began a series of
experiments which, later on, resulted in the
perfection of the operation, now known as
intubation. It is certainly an ingenious
plan and the contrivances for its performance
reflect more than ordinary credit on the
inventor and investigator.

Kegarding the utility of intubation in gen-
eral practice, it is the object of this paper to
discuss, as well as to show the relative value
of the operation as compared with that of
tracheotomy.

The advocates of intubation, claim that on
account of the simplicity of the operation and
the avoidance of the use of the knife, it is
the procedure that commends itself most
highly to the profession and is the operation
that will be allowed most readily by the
laity.

True, the operation of intubation is a
knifeless procedure, and so far as the general
public are concerned, is the one they would
select, if the choice were theirs. But, on the
other hand, is intubation a simple surgical
operation ? If it is, then it certainly, in
this respect, possesses a decided advantage
over tracheotomy. Unfortunately such is not
the case, for not only is the operation, as
well as the removal and replacement of the
tube very difficult procedures, but the

y86 Ratio

requisite manipulations require a degree of
manual dexterity which the average physi-
cian is not apt to acquire, who is called upon
to practice the operation only on rare occa-
sions.

Furthermore, the re-introduction of the
tube, which is a frequent necessity in cases
of intubation, is a source of constant annoy-
ance to the patient, occasioning all the fright
of the primary operation, together with
nervous and physical exhaustion of the child,
induced by its alarmed condition and attend-
ing struggles. The exhaustion hereby pro-
duced, is, in diptheria, above all things, to
be avoided.

Among other complications, accompanying
or following the operation, may be named :
1. Loosened false membrane may become
wedged in the lower end of the tube, and re-
quire its instant removal ; or worse still, the
membrane may be forced downward by the
entering tube into the trachea, and, before it
can be coughed up or the passage cleared
for the patient to breath, cyanosis may de-
velop, respirations cease and death ensues ;
no time being afforded for the performance
of tracheotomy. 2. Owing to the presence
of tenacious or ropy mucus, or from the
formation of loose membrane — which the
child, in its weakened condition, is not able
to expectorate — the tube may require re-
moval at any time, and in the absence of the
physician and the inability of other persons
to remove it, symptoms of an alarming
nature may occur. 3. The liability of
liquids finding their way into the air pas-
sages, and pneumonia following as a result.
This is a source of great danger, which is to
be kept in sight, especially as an inordinate
desire for fluids exists in these cases, the re-
sult, not of actual thirst but of uncomfortable
sensations caused by the presence of the tube.
4. In a certain few cases (estimated to be
about one per cent.), ulceration from pres-
sure of the tube and alterations in speech
have been met with ; the aphonia being par-
tial or complete, but always amenable to
treatment. 5. The danger of the tube be-
coming loosened during a paroxism of
coughing is by no means slight. In such a'

vial. Vol. lxiv

case, it may become lodged in the oesophagus,
or else be gotten out through the mouth, if
prompt assistance be rendered. In either in-
stance, the child is in a serious condition,
especially in the absence of a medical at-
tendant. The larynx, after such an accident,
is liable to behave in one of two ways : either
the swollen tissues will occlude the entrance
of air, or the relaxed vocal cords will fall
together and give rise to immediate severe
dyspnoea.

From the above observations we are forced
to admit that intubation of the larynx is by
no means a simple surgical procedure, nor
is it an operation devoid of dangers. These
facts beiug accepted, our next step is to show
the relative value of intubation and trache-
otomy, and to prove wherein one is superior
to the other.

In the operation of tracheotomy, the phy-
sician is able to see his work and to meet
such complications as may arise in a cool
and calm manner — for he is not working
in the dark. Such is not the case when in-
tubation is performed. There the surgeon
is obliged to work unaided ' by sight,
trusting entirely to his sense of touch.

In tracheotomy the pain is momentary
and the subsequent treatment of the tube can
safely be entrusted to the nurse or the child's
attendant. Not only so, but the operation
once performed, is finished, and the patient
is not harassed by subsequent surgery. Un-
fortunately, intubation is not attended with
these results. The presence of the tube may
at any moment become a source of danger,
and in the absence of the physician, even a
cause of death. The operation itself is often
as trying to the patient as that of trache-
otomy, and the subsequent removal and re-
introduction of the tube— which is of daily
necessity, at least — repeats all of the suffer-
ing, be it mental or physical, of the primary
procedure. Furthermore, the operation of
intubation has frequently to be followed by
that of tracheotomy.

Finally, in spite of the fact that trache-
otomy is regarded as one of the most difficult
of surgical procedures, it is our belief that
any country practitioner, who possesses some

June 20, 1891. Correspondence.

787

acquaintance with anatomy, and has a cool
head together with some surgical experience,
can perform it.

Glancing for a moment at the statistics
showing the relative mortality and recoveries
of the operations, we are confronted with
the fact that they are largely in favor of in-
tubation. But when we consider that in-
tubation is frequently followed by trache-
otomy, and that the latter operation is often
performed when the patient is in a moribund
condition, the apparent discrepancy in the
results of the operations is explained.

In conclusion, we think we can draw the
following deductions :

1. That in cases of equal gravity, trache-
otomy is not, in itself, a cause of greater
fatality than intubation.

2. That the operation of tracheotomy in-
volves less suffering to the patient, because
once performed, it is done, and the patient
is not annoyed by subsequent steps, as in
intubation, which operation in its repetition,
involves all of the harassment of the primary
procedure.

3. After a tracheotomy, the patient usually
falls into a quiet slumber ; such is not the
case when intubation has been done. Clearly
showing that the presence of the tube, in-
serted between the vocal cords and into the
larynx, is a cause of greater and more pro-
longed irritation than is the case in trache-
otomy, where the tube is placed lower down
into the trachea.

4. Intubation involves a great risk of
foreign bodies, liquids, etc., entering the
trachea and setting up a pneumoni'a.

5. In tracheotomy, the subsequent cleans-
ing of the inner tube, can safely be intrusted
to the nurse. In intubation, the doctor
alone can give the tube its needed attention.

6. The physician who is able to perform
properly an operation of intubation, is just
as competent to do a tracheotomy, and in the
latter case, with less liability of dangerous
sequelae following.

Hydrogen peroxide made into a paste with
chalk or cuttle-fish bone is an efficient agent
for whitening discolored teeth.

Correspondence.

BERMUDA.

Editor of The Medical and Surgical
Reporter. —

Dear Sir: — Seven hundred miles from
New York lies a land quite unfamiliar to
most Americans, yet having within its
borders much to charm, and above all, pos-
sessing in large degree that which nature
has provided to restore those giving way
before our over-active life.

Bermudians assert their climate the most
equable in the world, and temperature
tables, high and low, largely support this
claim, the record for 1889-1890, as com-
pared with several other winter resorts,
being :

Nov. Dec. Jan. Feb. Mar. Apr.

Bermuda 77-62 73-58 71-50 72"49 72"-5° 74-56

Los Angeles 82-43 68-40 67-34 81-35 81-40 94-42

San Diego.... 83-46 69-40 66-35 77-38 74-41 85-45

Jacksonville 86--30 80-35 80-40 83-44 85-27 88-47

St. Augustine 84-35 76-43 79-43 81-45 87-28 86-51

The present season has been : Nov., 79-
56 ; Dec, 73-51 ; Jan., 71-48 ; Feb., 74-52 ;
Mar., 72-49. As a rule, November, April
and May are most agreeable. During
December, January and February last, how-
ever, the weather most of the time was charm-
ing. March is the worst month, when east
winds, low barometer and thermometer and
frequent showers are apt to prevail. The
porous soil admits of outings soon after a
heavy rain. As in England, mornings often
betoken a stormy day, but the clouds roll by
to a beautiful afternoon. July and August
for the "outside barbarian" are not to his
liking ; and September, with its sultry breeze-
less days, is most oppressive of all. May and
June, as regards climatic conditions and the
floral beauty of forest and field, offer special
attractions; but fashion at present decrees
that during March the full tide of travel
shall crowd steamers, hotels and boarding-
houses to discomfort. The highest pleasure
in these sunny isles will never be found till
this senseless fad has had its day.

These islands, once called the Isle of
Devils, were discovered in 1515 by Juan
Bermudez, and, though many in number,
only the five largest are tenanted. Their
shape is that of a shepherd's crook ; their area
about twenty-one miles. They form a ring
of coral reefs round a lagoon, the coral
structure resting on a sub-marine mountain
of volcanic origin — a lonely cone rising three
miles from the ocean bed. Until the placing,
last summer, of the cable to Halifax, they
formed the most isolated spot on the globe,
save, possibly, St. Helena. The population

788

Correspondence.

Vol. lxiv

is 16,000, of which three-fifths are black.
Hamilton, the capital and leading town, con-
tains 2,000.

The soil is red and rich — composed of
peroxide of iron, alumina, silica and earthly
phosphates — and, fertilized, is largely pro-
ductive. The climate being semi-tropical,
vegetables and southerly fruit abound. The
former comprise all known in our northern
gardens, the onion, of course, leading the
list. This typifies the acme point of Ber-
mudian excellence, according to Mark
Twain, who declares that the fond Ber-
mudian father, sending his noble scion of a
noble sire out to battle the world, breathes a
parental blessing, and — as tending towards
the highest attainable — this parting injunc-
tion : " My son, be an onion !"

The houses in Bermuda are, almost with-
out exception, built of coral, white, and so
soft that it can be cut and trimmed by saw
and 0111861,* but promptly hardens on ex-
posure. The roofs are thin slates of the same
material. These are annually whitewashed,
and, rising mid their emerald surroundings —
the islands are perennially green — give a
charm to the landscape that must be seen to
be appreciated. Each dwelling is required
by law to be provided with a tank for rain
water taken from the roof, which, with the
yearly whitening, insures its purity. There
are wells, but the water is too blackish to
drink. Last year the supply was largely in-
creased by several artesion wells, the water of
which is good.

Of fruits, bananas, oranges, lemons and
the paw-paw are most abundant. The
bananas are of the yellow sort — sweet — but
too small to compete in northern markets
with those from more southern climes. The
oranges and lemons are too inferior for use.
The paw-paw is essentially a local delicacy,
mostly used by the natives. There are no
apples or peaches. There is a cherry, but it
is not toothsome. On a former visit, in
January, strawberries were abundant and
good. Since then their culture has largely
fallen off ; but it has been thought that, with
selected plants, extra care and added market
facilities— quicker transit and cooling rooms on
the steamers — they might be made an export of
no little value. So, too, might the valleys and
sheltered places produce figs, pineapples and
other fruit; but the Bermudian planter
seems to let his ambition tend mainly to
potatoes and onions.

The cedar is the tree of Bermuda ; but the
palm-tree, the palmetto and bamboo rearing
their stately heads, vary forest and field.
Flowers bloom the year round, roses — some

of which are found only here — the most.
The oleander and geranium, fullest in May
and June, hedge the highways. Lilies, at
best in April, fill whole fields, making a
picture beautiful and unique. The varied
floral adornings, and so abundant, form one of
Bermuda's greatest charms.

The health of these islands is almost
always good. A healthy October presages a
healthful winter. There has been no epi-
demic since 1853, when yellow fever made
havoc — sparing neither sex, state nor condi-
tion. A sort of pessimistic writer hinted last
summer that enteric fever was rather rife, but
it was not true. The greatest mortality is
under five, and, among the blacks, largely
due to neglect. Long fives, 85 to 95, are not
uncommon. There are nine resident regis-
tered medical men, all graduates of American
colleges except two — Dr. Eldon Harvey,
M.R.C.S., L.R.C.P., England, and Ettore
Sarzana, M.D., Italy, L.S.A., London. There
are ten army and five naval surgeons. There
is a branch of the British Medical Associa-
tion, before which the writer, by invitation,
had the honor of making an address on
narcotic inebriety. A general board of
health is composed of the governor, and
council — the latter, nine, leading non-pro-
fessional men of the colony. There are two
health officers — a post-surgeon at St. George
and a local physician at Hamilton ; services
paid by fees. Two coroners, non-medical
men, are paid in the same way. Gaol sur-
geons at these places get $200 per year.
Quarantine regulations are careful and com-
plete.

The insane asylum here is a large building,
once intended for college purposes, and con-
tains forty beds. The attending physician is
Dr. Hinson, the Senior practitioner of Ber-
muda— salary $1,100.

Through the effort of Dr. Harvey, a hand-
some hospital cottage has been erected about
half a mile from Hamilton. It may prove of
much value should contagious disease occur
among visitors. Nine-tenths of its cost was
given by Americans. Great credit is due to
Dr. Harvey for this good work. A new
army hospital is being constructed at Camp
Prospect, the central military post, two miles
from town. It will admit one hundred.

The leading death cause is tuberculosis,
mainly among the blacks. Forty cases oc-
curred year before last ; 40 last year. The
mortuary report for 1890 included, debility
25, enteric fever 20, heart disease 20, whoop-
ing-cough 20, diarrhoea 18, pneumonia 15,
old age 14, tetanus 10, still-births 28. There
is much rum drinking, but little open drunk-

June 20, 1 89 1 . Correspondence.

789

enness. There were two deaths each from
alcoholism in 1889 and 1890.

Births and deaths are fully recorded.
The former lead, making an annual increase
in population — last year 241. Death cer-
tificates are not prerequisite for burial, but
must be presented within a fortnight. The
illegitimate births are many — -during the
last decade 953, of which 909 were black.
The number last year was 84, the lowest,
save once, since registration was adopted,
twenty-five years ago — a hopeful index of
bettering morals among them. There are
six drug stores — one of them at St. George,
twelve miles from Hamilton. Druggists
are not examined. Any one, on payment
of five shillings, can set up shop.

Climate has been thought, hitherto, the
leading remedial factor for invalids in Ber-
muda, but a new Richard has lately entered
the field. A band of Kickapoo Indians (?),
made up of half-breeds and others from
Quackland and elsewhere, swooped on the
islands — an unheard-of visitation — some
weeks ago. They pitched their tent hard
by the town, posted walls and waste places
with pictures of the noble red man in vari-
ous attitudes of Samaritan ministration,
" laid low " during the day, and at night,
by dint of so-called music, tight-rope antics,
acrobatic acts, juggling feats and other
"fetching" performances, drew the dusky
natives in droves, and actually depleted
them of $1,500 in one week — a big amount
for those no better off in the world's wares
than they are. Having dearthed this field,
they stole away to St. George, worked that
place for all it was worth — to them — and
are now at Somerset for a season, after which
they purpose a parting raid on Hamilton,
and then set sail for the land of wooden
nutmegs, whence they came.

An event so rare as to be the only one in
the annals of Bermuda, was the recent trial
— on an indictment for manslaughter for the
alleged killing of a patient by overdosing
with opium and belladonna — of one of the
two colored physicians. The facts, as
brought out at the inquest and trial, were
that the doctor was called to a middle-aged
colored man, ill with painful bowel obstruc-
tion, and prescribed :

1^ Tincti. opii

" belladon

Spts. chloroform

" ammon aromat aa gtt.v.

to each teaspoonful, with instructions to re-
peat every ten minutes till relieved. This
was repeated, more or less regularly, and —

to shorten the story — in thirty-six hours the
man was narcotized, and, in forty-eight,
gathered to his fathers. The doctor, a very
intelligent-looking fellow, graduate of a
western medical college, frankly stated in
his certificate that death was due to bowel
obstruction and over-dosing with opium ;
but the gossips got in some fine work, a hue
went up, and an indictment followed. He
plead not guilty. Expert evidence for the
prosecution was given. A question by a
juror disclosed the fact — vital for the de-
fence and made the most of by his counsel
— that the teaspoon used held nearly double
the usual amount. There was little ques-
tion that the man died from narcotic poison-
ing, but the evidence failed to prove crim-
inal lack of medical care. The trial lasted
five days. The jury was out twenty min-
utes. The doctor was acquitted.

It seems to us strange more medical men
do not visit Bermuda. We have noted less
than a dozen, and most of these from
Brooklyn. Physicians might well set their
patients an example in this regard, and by
so doing induce many more to spend an out-
ing here. The fact is few realize that less
than sixty hours from New York is a lovely
land, an evergreen isle, where roses bloom
the year round out of doors, and the high
tide of rose time is December ; where mala-
ria never comes ; where frost and the white
mantle of winter are unknown ; and where
the sleep-giving, health-bringing breezes, the
panoramic beauty of sea and shore, and the
quiet, restful life, combine to make halcyon
days.

,For insomnia, Bermuda is unique to do
good. It is not the place for consumptives,
nor for one far advanced in any wasting
disease. It is a happy land for the neu-
ralgic, and those coming back to health
from acute disease. For the weary and
worn, for the tired pilgrim along any line —
be it brain or brawn — it is indeed a Mecca
to which he may go with high hope of get-
ting rest and relief.

Bermuda is, too, good for those not ill.
Let the busy American doctor take a fort-
night off, and a ten-days sojourn in these
sun-lit isles, and our word for it, if condi-
tions favor, he will lay in a stock of happy
memories for many days to come.

The writer has been presenting a series of
letters from Bermuda in a Brooklyn daily.
One object was to induce those who might
read them to visit this favored land. He
will be glad to tell any . one what he knows
about this charming resort, and if, in so

79o

Book Reviews.

Vol. lxiv

doing, more of his confreres shall share in
the pleasures he has enjoyed, he will be con-
tent.

J. B. Mattison, M. D.

Editor of the Medical and Surgical
Reporter. —

My Dear Doctor : — I have been suffering
the past fall and winter with gall-stone colic,
the attacks coming on every three or four
weeks. I could get relief from the usual
remedies such as morphine, belladonna, chlo-
roform, etc., but what I wanted to find was
a remedy to prevent the formation of the
gall-stones. I was advised by my old friend
.Dr. Job Bell, of Tennessee, to take gum
guaiac and whiskey in the following propor-
tions: Gum guaiac ^ii, whiskey, Oj, and
take one tablespoonful in water after each
meal. I commenced taking the prescrip-
tion and the result is I have gone five weeks
longer without having an attack than I
have since my first attack about six months
ago. Before taking the remedy I would
have a spell of billions colic every four
weeks at the furthest, but usually every
three weeks. It has now been nine weeks
since the last attack.

The remedy improves the appetite, keeps
the bowels open, and produces a copious
flow of bile each day.

Dr. Bell is very enthusiastic about the
merits of this drug. He says he has treated
many cases in this way and has had excel-
lent results.

The Dr. thinks it best to give the guaiac
in whiskey as whiskey is less objectionable
than alcohol for obvious reasons.

I write this feeling confident it will be of
great use to the profession, and a boon to
those who are suffering with this fearful
malady.

Very truly,

J. F. Bagwell, M. D.

Book Reviews.

A TEXT BOOK OF PRACTICAL THERAPEU-
TICS, WITH ESPECIAL RFFERENCE TO
THE APPLICATION OF REMEDIAL MEAS-
URES TO DISEASES AND THEIR EMPLOY-
MENT UPON A RATIONAL BASIS. Second
edition. Enlarged and revised. By Hobart Amory
Hare, M. D., B. Sc. Philadelphia, Lea Brothers
& Co., 1891.

The evidence of the popularity of this
work is shown by the fact that the first
edition was exhausted within six months of
its publication. Its value as a Practical

" Therapeutics " is demonstrated by its adop-
tion as a text book in a number of medical
schools.

The present volume consists of 658 pages,
and is divided into four parts. Part one is
devoted to general therapeutic considerations,
such as modes of administering drugs, dosage,
idiosyncrasy, absorption of drugs and their
duration of action, incompatibility, etc.

Part two takes up the consideration of the
drugs of the pharmacopoeia (U. S.), and such
other remedies as are in general use, or are
entitled to notice in a work on general thera-
peutics. Each agent is treated in alphabeti-
cal order, separately, and is discussed first,
by a brief description of the drug, followed
by an account of its mode of action, its appli-
cation in disease, the methods of administra-
tion, and when occasion requires, the contra-
indication to its employment. In the case of
the more powerful drugs, the toxicological
symptoms and the treatment are given. Ex-
cellent tables are appended in some instances
as a means of differential diagnosis between
the actions of certain remedies and the symp-
toms of particular diseases, as in the article
on alcohol, in which three tables are given
differentiating alcoholism from opium poison-
ing, apoplexy, and the general paralysis of
the insane. In this section (page 72), the
author directs particular attention to the
prevalent abuse, or rather misuse, of arsenic
in the treatment of skin diseases — no distinc-
tion usually being made by the general prac-
titioner between the moist and the dry varie-
ties of these affections. It is only in the lat-
ter cases that the drug is indicated or does good.
Arsenic is contraindicated in lesions associated
with much proliferation of new cells and the
exudation of serum, etc.

An important detail is not mentioned in
the article on cocaine, in the description of
its use in minor purgery as a local anaesthetic
(p. 141). It is not alone necessary to employ
a ligature in such instances, in order to con-
trol the circulation and to prevent undue
absorption of the drug, but it is equally im-
portant to allow free bleeding at the comple-
tion of the operation, but before the sutures
are tied, so that any excess of the cocaine
may be washed out. The neglect of this
point is a frequent cause of the untoward
results, so often reported as following the em-
ployment of the drug in surgical practice to
produce local anaesthesia.

In the respective articles, ergot (page 159)
and eucalyptus (p. 166), notice might have
been made of the therapeutic value of the
first drug in the relief of eneuris, and in the
second instance, of the relief afforded patients

June 20, 1891.

Book Reviews.

791

suffering from sub-acute or chronic bronchitis,
pharyngitis, etc., by the employment of the
oil of eucalyptus as an inhalation.

Part third treats of remedial measures
other than drugs, and also includes a val-
uable addition in the shape of an article on
" Foods for the sick."

The fourth part consists of articles upon
the treatment of diseases and symptoms ; a
table of doses and remedies ; tables of relative
weights and measures in the metric and
apothecaries' systems ; an index of drugs and
remedial measures, and an index of diseases
and remedies.

With this brief summary of Dr. Hare's
book, we would close our remarks by restat-
ing a fact mentioned in the earlier part of
this notice — that the work is essentially
"practical" in every particular and, there-
fore, can be heartily recommended as a book
for the student and general practitioner.

DIABETES: ITS CAUSES, SYMPTOMS, AND
TREATMENT. By Charles W. Purdy, M. D.
Philadelphia and London: F. A. Davis, 1890,
pp. 184.

•

Among the monographs which are destined
to uphold the dignity and repute of the med-
ical profession in America, the work of Dr.
Purdy must be granted a prominent position.
Its excellence does not depend simply upon
the practical and concise form of presentation
of the subject, but as well upon the value of
the original matter which is contained in the
book.

The first consideration which excites the
attention of the reader is the prominence
accorded the features of the disease and its
climatological study in the United States, the
observations in these relations being based
upon the personal experiences of the writer
and upon data obtained from the census of
1880 of this country. From the statistics
detailed Dr. Purdy concludes that there is a
definite factor exerted upon the aetiology of
this affection by the influence of climatic cir-
cumstances. Diabetes mellitus reaches its
highest proportion in those parts of the coun-
try in which there is the lowest mean temper-
ature, combined with a low barometric regis-
tration ; on the contrary, its least proportion
coincides with those portions of the country
where the mean temperature is highest and
the barometer is relatively high. A rare
atmosphere, in Dr. Piirdy's opinion, is favor-
able to the establishment and perpetuation of
a glycosuria, in that it directly contributes to
a lowered possibility of oxidation. On the
contrary, the marked barometric pressure in-

duced by dampness of the air is not without
some deleterious influence, the conditions of
excellence demanding a warm or moderate
climate with high barometric registration and
dry air. In the United States the highest
mortality from diabetes is reached in the
north-eastern hills and plateaus, especially in
the state of Vermont, in which region the
mean temperature is from 35° to 45° F. and
the mean elevation 1500 feet; the lowest
mortality is shown to be found (and from
these studies this region is regarded as the
most favorable climate possessed by the Uni-
ted States) in the South Atlantic coast, the
southern interior plateau and the south-west
central region. This range embraces, in part
or in whole, the states of North Carolina,
South Carolina, Georgia, Alabama, Missis-
sippi, Louisiana, Arkansas and Texas. This
region, in Dr. Purdy's view, furnishes, not
only climatological ly but also in the constant
supply of foods suitable for the diabetic, the
most striking advantages for the treatment of
the disease to be found in any part of the in-
habited globe.

The author looks upon diabetes niellitus as
essentially a disturbance of the glycogenic
function of the liver, by which there occurs
an arrest of the transformation of certain
forms of the food (the ultimate transformation
being probably into fats) whereby these sub-
stances, because of their ntfn-assimilability,
are thrown out of the body in an intermediate
form, sugar. In this hepatic disturbance
there occurs a hypersemic condition of the
liver and a more or less engorged condition
of the chylo-poietic viscera. Recently ascer-
tained facts point also to an influence exerted
by. disturbance of the pancreatic function, in
connection, however, with the hepatic disturb-
ance ; further, pathological states of certain
portions of the central nervous system which
preside over the hepatic vascular area may
induce phenomenon of glycosuria.

Among the causes of the disease the author
places heredity in a prominent position.
Among the instances narrated under this
head it is interesting to note, in view of the
recent query of Schmitz as to the possibly
infectious nature of this disease, the occur-
rence of diabetes in the father and the
mother of one of the writer's cases. Richard
Schmitz in the past year has discussed the
possible transmission of diabetes mellitus
from husband to wife or vice versa, and has
pointed out the not infrequent occurrence of
such instances. Besides heredity, as causa-
tive influences the author mentions the
greater frequency of the disease in the male

792

Periscope.

Vol. lxiv

sex, in the middle portions of life, the influ-
ence of over-eating, climate, various diseased
conditions, and mental emotions.

In treating of the symptoms of the affec-
tion, the various phenomena are taken up
as presented by the different systems of the
body. Dr. Purdy calls attention to a very
valuable modification of Fehling's reagent
for the detection of urinary sugar by which
he is enabled to keep the cupric sulphate
solution indefinitely without change, and
which consists briefly in the substitution of
potassic or ammonium hydrate for the bitar-
trate in Fehling's solution and the addition
of glycerine to the solution.

The work is particularly complete in the
treatment of the disease. Dr. Purdy con-
demns all the common diabetic breads and re-
lies upon ordinary home-made wheaten
bread, preferring to diminish its quantity
rather than to replace it by an unlimited
amount of an article which may, and in
most cases probably does contain a greater
proportion of starch than the patient's usual
home diet. He refuses his patients such
beverages as tea and coffee, finding from ex-
perience that they contain a notable amount
of sugar ; and permits only the following
list of drinks — water (including all mineral
waters) Rhine wine, California Rislings and
Chablis, New t York and Ohio Catawbas,
Rudai Imperial, Schreiber's "diatetic wine,"
whisky and gin. Of medicinal agents,
arsenic, jambul, iodoform, ergot, the alkalies
and opium are regarded favorably ; anti pyrin
witl^ others of its class isseverly condemned.

Following the general consideration of
the disease there occurs a section of clinical
cases, detailed for the purpose of illustration
of the statements made in the previous por-
tions of the book. Finally, there is a chap-
ter upon diabetes insipidus, which is more
briefly considered and serves as a back-
ground for the more important disease, to
the literature of which the author has in this
work contributed a really valuable addition.

TREATMENT OF ERYSIPELAS.
Dr. Koch treated numerous cases of
erysipelas with the following ointment :

Creolin 3 i.

Iodoform 3 iii.

Lanolin g i.

This ointment is spread as an even,
smooth layer over the affected skin and its
surroundings, on an area of at least two to
three inches to the outside of the inflamed
parts. The whole is covered by a piece of
mackintosh.

PERISCOPE.

THERAPEUTICS.

ARSENITE OF COPPER IN DIARRHOEA.

Dr. F. Hinz, in the Journal de Med. de
Paris, May 3, 1891, strongly advocates the
use of arsenite of copper in diarrhoea. He
prescribes the drug in the following formula :

I^? Arsenite of copper gramme 0.05.

Water grammes 90.0.

M. et sig. Half a teaspoonful every hour.

During the next day the remedy is only
given four times. Recovery is usually rapid.

[We strongly suspect that Dr. Hinz has
taken his idea from Dr. John Aulde, of
Philadelphia, the latter gentleman having
used the drug similarly for some time and
having written extensively on the subject.
Ed. Reporter.]

ACETANILID IN THE TREATMENT OF
HARD AND SOFT ULCERATING
CHANCRES.

Basilvitch, in the Journal de Med. de
Paris, May 10, 1891, reports three cases of
ulcerating chancres — one hard, in a female,
and two soft, in males — .that he successfully
treated with local applications of acetanilid.
Healing was both rapid and complete. The
drug's action was equally as good, if not
better, than that of iodoform in similar cases.
It possesses, also, two material advantages
over iodoform, first, it is inodorous, second,
it is comparatively cheap.

THE ANALGESIC ACTION OF ELECTRIC
LIGHT.

Dr. Th. V. Stein, of Moskan reports in
the Deutsche Medicinal Zeitung, April 6,
1891, fourteen cases illustrating the analgesic
action of electric light. The results obtained
are claimed to have been remakable. The
electric light was applied by an especially
devised reflector, designed by the author.
In cases where the pain was located in the
head or neck, these parts were illuminated
for only 10 or 15 seconds, but other parts
of the body were subjected to an illumina-
tion lasting five minutes or over, or until the
patient complained of the intense heat. In
a stubborn case of intercostal neuralgia in a
woman one treatment resulted in a complete
and lasting cure. The same results were
observed in a case of lumbago, one of severe
cough, one of rheumatism, etc.

June 20, 1 891.

Periscope.

793

THE TREATMENT OF PNEUMONIA.
Dr. W. Soltan Fenwick gives in the Lancet
for January 31 and February 7, 1891, an
analysis of a thousand cases of acute primary
lobar pneumonia which were treated at the
London Hospital between the years 1880 and
1890. Those cases in which the temperature
ranged above 103° are for convenience classi-
fied as " sthenic," those in which the tempera-
ture remained below 103° are considered as
" asthenic " in character. The treatment of
the sthenic cases was of three kinds : 1. Ex-
pectant, consisting of the application of hot
poultices to the chest and the internal use of
expectorant and tonic remedies. Of the 493
cases in this class, 116 were fatal, or 23 per
cent. 2. With quinine, consisting entirely of
the use of quinine in large doses, 12 to 40
grains a day. Of 52 cases, 11 died, or 21
per cent. 3. Antipyretic. These cases were
combated upon general antipyretic principles,
similar to those employed in the treatment of
other acute specific fevers. Only 10 cases
ivere treated with antipyrine and phenacetin,
hence the inquiry is confined to the results
which attended the systematic efforts to con-
trol the symptom of fever by direct abstrac-
tion of heat. The various measures resorted
to were the use of —

1. The ice bag. Of 26 patients so treated,
4 died, or 15 per cent.

2. The cold pack*. Of 26 patients, 4 died,
or 15 per cent.

3. Cold sponging. Of 65 patients, 8 died,
or 12 per cent.

4. The ice-cradle. Of 43 patients, 3 died,
or 7 per cent.

There were 285 cases of asthenic pneu-
monia. Of these, 240 were treated in the
ordinary way with poultices, stimulants, and
tonics ; the deaths were 76, or 32 per cent.
In 45 cases the treatment was supplemented
by large doses of quinine ; the mortality was
20 per cent.

In summing up the foregoing results, Dr.
Fenwick observes that the termination in the
fatal cases was almost invariably directly due
to failure of the heart. There are two
factors which are capable of producing the
condition of cardiac insufficiency — an in-
creased resistance to the propulsive action of
the heart, and a progressive deterioration of
its muscular substance. In acute pneumonia
both these factors are present ; the former in
the increase of tension in the pulmonary
circuit consequent on the consolidation of a
portion of the lung, and the latter as a direct
result of high temperature. The action of
these two forces is to compel the heart to beat
more forcibly and more quickly, while at the
game time it is steadily deprived of the power

to do either. Treatment should therefore be
directed to one special object — viz., to econo-
mize cardiac force by minimizing the in-
jurious influences of fever. He believes that
this is the best accomplished in the sthenic
cases by the use of cold sponging or the ice-
cradle.

In pneumonia of the asthenic type cold
should not be employed, but the treatment
should be stimulating.

Dr. Fenwick adds, in conclusion, that the
quantity of albumin in the urine during the
first three days is of considerable prognostic
value ; of patients with a quarter albumin, 32
per cent, died ; of those with a third, 52 per
cent, died ; and of those with a half, 82 per
cent. died. — N, Y. Med. Jour.

METHYL-BLUE AS AN ANESTHETIC.

Pietrowski has verified the statement of
Ehrlich that methyl-blue is possessed of
anaesthetic power to a remarkable extent.
He has administered it both by way of hypo-
dermic injections and by the mouth, to ten
cases, including patients suffering from acute
rheumatism and neuralgia of the intercostal,
supra-orbital and sciatic nerves, as well as
from lumbago. In all of these cases the
urine became first green and then blue.
After these injections there was some redness
and tumefaction and perhaps some pain. In
every case the pain was diminished.— -ifeime
Internationale de Bibliographie.

STRYCHNINE IN THE TREATMENT OF
CHRONIC ALCOHOLISM.

Dr. V. N. Ergolski reports in Vrateh for
March 7, 1891, ten cases of chronic alcohol-
ism treated with more or less marked suc-
cess by means of strychnine. The following
are two of the cases reported in this article:
The first was that of a gardener, thirty-four
years of age, who often drank to excess,
but did not regard himself as intemperate,
claiming that he drank only when he had
plenty of money and was in good company.
At the solicitation of his mother, however,
he submitted himself to treatment. On the
first day he received a hypodermic injec-
tion of grain of nitrate of strychnine, ?o
grain on the next day, and 2V on the third
and following days. During the entire
course of treatment, and for two weeKS after-
ward, the patient did not drink anything,
giving as his excuse that he had no money ;
but his mother said that he had never gone
for so long a time without liquor in twelve
years. Finally he thought he would try
once more how vodka tasted. But after
taking two glasses he became very drunk,

794

Periscope.

Vol. lxiv

had a violent headache, vomited profusely,
and had to be taken home and put to bed.
He tried the experiment again in a week or
two, with the same result. He insisted, how-
ever, on resuming his old habits, saying that
he did not want to lose his taste for drink,
and began taking vodka, a few drops at a
time, gradually increasing the dose until he
could take his usual allowance without
trouble. The second case was that of a rail-
road worker, who had been for ten years
strongly addicted to brandy, so that every
day he would take from a half to one bottle
or more, feeling, unless he took this allow-
ance, a great restlessness and a sense of
drawing in the region of the stomach. He
was anxious to overcome his habit, but had
not the will-power to do so. The first day
after coming under treatment he received a
hypodermic injection of ?V grain of nitrate
of strychnine. Upon presenting himself
the next day, he reported that he had had
none of the restlessness or dragging at the
stomach, although he had not touched a
drop of vodka. Dr. Ergolski administered
tu grain subcutaneously this and the seven
following days, after which he dismissed the
patient, giving him 1 grain of the remedy
divided into sixty pills, of which he was in-
structed to take one a day every alternate
week. On the fifth day of treatment the
man attended the name-day festival of a
relative, where he was pressed to ioin the
others in drinking the health of the host.
He felt, however, a loathing for liquor, and
would not touch it although the company
made sport of him for refusing. The patient
reported to Dr. Ergolski at the end of fifteen
months, at which time he was perfectly
cured. The eight other cases were similar
to these, in all of which there was some good
effects noted — in some a permanent cure,
though in a few there was a relapse from
one cause or another. The author regards
the remedy in the nature of a specific for
chronic alcoholism, and declares, as his
belief, that it is possible to cure even the
most obstinate cases by means of it, although
in cases of relapse it may be necessary to
repeat the course of treatment once or
twice. — Med. Bee.

MEDICINE.

A CARCINOMA DISAPPEARS WITH THE
DEVELOPMENT OF PHTHISIS,

As yet we know little of the analogy of
various diseases, except as the history of
iome interesting case affords us some evidence

and furnishes us with material for speculation.

Dr. Sigg, of Andelfingen, Switzerland, has
recently reported the following interesting
case, which is quoted in the Wiener Medi-
cinishe Presse, May, 10, 1891. The patient
was a woman 33 years old, who had a pain-
ful swelling of the left breast. The growth
was hard, nodulated, partly adherent to the
skin, and painful on pressure ; the axillary
glands in the left side were swollen and hard.
In August of 1883, the growth was removed,
and axilla cleaned out. In November of the
same year a new growth appeared, below
the cicatrix of the old growth, which rapidly
increased in size, necessitating the removal
of the remaining portions of the mammary
gland. This was done February 28, 1884.
On August 31, 1884, a third operation was
rendered necessary, owing to the appearance
of new growths. In January 1885, several
new nodules made their appearance, and in
April of the same year, had increased so
rapidly, that the left side, from the sternum
to the scapula, and into the axilla, was in-
filtrated, and covered with a flat growth,
which rendered every movement of the
shoulder, or elbow, impossible. Over the
region of the left breast there were also
several nodules, some as large as a man's
fist. At this time the patient developed a
cough, and gradually the typical picture of
pulmonary phthisis presented itself. Bacilli
were found in the sputum. With the ap-
pearance of the cachectic stage, the carcino-
matous infiltration began quickly to disap-
pear, and within a few days before the
patient's death, no sign of the carinoma re-
mained, except a small growth the size of a
nut. A microscopical examination proved
this to be an epithelical-carcinoma.

INFECTIOUS EYE-LOTIONS.
Dr. Franke, at a recent meeting of the
Medical Society of Hamburg, called atten-
tion to the fact, that the instillation of solu-
tions of atropin, eserin, and cocaine into
the eye, frequently gives rise to acute
conjunctivitis. The reason of this is, he
claims, that these solutions are not antiseptic,
and generally contain mould or fungi.
Franke has found that if these remedies are
added in the desired proportion to a 1 : 10,000
solution of bichloride of mercury, they will
be kept antiseptic for an indefinite period,
and not give rise to any irritative symptoms.
In practice the addition of 2 drops of a 1 per
cent, solution of bichloride of mercury to 10
grammes of any ordinary eye-lotion, will have
the desired effect. — Deutsche Med.-Zeitung,
May 4, 1891.

June 20, 1 891.

Periscope.

795

SOME NOTES ON THE PRESENT EPIDEMIC
OF INFLUENZA.
Dr. Allen Greenwood states that the fol-
lowing observations are taken from his notes
of a number of eases, and from his own un-
pleasant acquaintance with " Grip " in Walt-
ham.

The attack usually begins with a feeling of
depression, followed by dull pains, often be-
coming severe in the limbs and back, and
often with chilly sensations. In almost every
case these symptoms have been followed in
twenty-four hours by a severe headache and
a feeling of soreness in the throat, with pain-
ful deglutition. The inflammatory process
aoon extends to the larynx, and the patient
becomes hoarse or loses the voice entirely ;
and it is here that the most painful part of
the attack (to myself and several others) has
been, for the pain about the region of the
larynx has been intense, resembling the pain
of a bad toothache or earache.

In about twenty-four hours after the be-
ginning of the throat symptoms, the patient
begins to cough, and soon there comes a feel-
ing of tightness and soreness about the chest,
the feeling of tightness often amounting to a
suffocative sensation that is very distressing.
The cough is accompanied by a varying
amount of expectoration of a white or
yellowish-white frothy material, which is
occasionally streaked with blood. The ex-
pectoration becomes much less on the second
or third day after the cough begins, and the
dry cough remaining may last a week or
more.

There is often more or less coryza, and
there was in most of the cases a symptom I
had never seen before, namely, a severe, dull
pain over the frontal sinuses, probably due to
a congestion of the membrane lining the
sinuses. In my own case this pain lasted
several days, and was accompanied by a
marked swelling and tenderness of the in-
tegument over the sinuses.

The evening temperature when first taken,
usually after the throat symptoms were well
established, varied between 100° and 103° F.
It remained about the same for twenty-four
or forty-eight hours, with morning remissions
of one or two degrees, and then fell by lysis
reaching normal on the fifth or sixth day.
Two of the cases were followed by acute
otitis media, requiring paracentesis and the
usual after-treatment for such cases.

The attack usually leaves the patient very
weak, and it is often several weeks before
full health is regained.

Physical examination of the chest did not
show much beyond the few usual signs of a

acute bronchitis of the larger tubes. In ex-
amining the throat I was struck by the
absence of any follicular deposits, the ap-
pearances being invariably those of acute
inflammation of the tonsils and pharynx,
the surface of the whole region posterior to
the anterior pillars of the fauces looking
like raw beef.

In speaking of treatment, I shall only
mention those things which in my few cases
have given the most relief.

In no case has treatment been begun on
the first day ; but for the severe headache
of the second day antipyrine, in fifteen-grain
doses, has served me well, and given much
relief to patients.

For the sore throat and painful laryngitis,
hot, moist applications are indicated, either
in form of poultices or cloths rung out of
hot water ; and the relief thus afforded, as I
can testify, is very grateful.

For the feeling of soreness and tightness
in the chest, nothing gave so much relief as
a clear mustard paste to the front of the
chest, left on fifteen or twenty minutes till
the skin was well reddened.

At night the patient should take ten
grains of Dover's powder, which will prob-
ably ensure a good night's rest ; and this
may be repeated the following night.

As the expectoration ceases, the cough
becomes useless and distressing to the patient,
and to relieve this one of the anodyne cough
mixtures may be given. I have had very
good success with a combination of morphine
and hydrocyanic acid, as in the following :

l^kJ Morph. sulph gr. ii.

Ac. hydrocyan, dil 5 i.

Syr. tolu 3 ii.

Syr. simp ad 3 iv. M.

Sig. Teaspoonful every three hours, for cough.

This will usually stop or relieve the cough
so that it need not be taken more than two
or three times a day after the first few doses.
One patient did not follow directions, but
continued the medicine after the cough had
stopped until such marked physiological
effects of the hydrocyanic acid appeared as
to frighten her.

For the painful congestion in the frontal
sinuses, clothes rung out in hot water and
laid on the forehead gave relief, as did also
antipyrine used in fifteen-grain doses.

From other physicians here I learned
that the type of the disease as given above
is similar to that observed by them. — Boston
Med. and Surg. Jour.

In Tokiyo over 12,000 bodies were incin-
erated last year at a cost of $19,000.

796

Periscope.

Vol. lxiv

SURGERY.

SOME PRACTICAL POINTS IN ABDOMINAL
SURGERY.

Dr. Jno. H. Mclntyre,in a paper read before
the State Medical Association of Missouri,
states that in his opinion, among anaesthetics,
the safest and best is bichloride of methylene
used in Junker's Inhaler. He has used it in
laparotomy work for the past ten years with-
out a single untoward sympton, and with the
greatest satisfaction, and upon many occa-
sions has put it to as severe a test as it is
possible to put an anaesthetic.

By its use, anaesthesia can not only be
promptly induced, but safely maintained for
any desirable length of time, and it is rarely
followed by nausea and vomiting.

By the use of the inhaler of Junker, over-
dosing is next to impossible, in reality the
patient takes inspired air, charged with the
vapor of bichloride of methylene, and it is
surprising what a small quantity is required
in doing a prolonged operation.

Short incisions constitute another point of
excellence, and should never be extended
beyond the point of necessity in removing a
growth of given size without bruising the
tissues. In removing the ovaries or fallopian
tubes, or both, it is rarely that the ventral
incision need be over two inches in extent.

In dealing with adhesions, perseverance
by well directed effort will always succeed ;
remembering, however, that violence is
always harmful, and the necessary force
should be that of gentle momentum.

Intestinal adhesions, should be separated
as far from the gut as possile, for by so doing
the danger of haemorrhage is much lessened ;
they should be carefully examined after-
ward, as the placing of a Lembert suture in
the proper place at the opportune moment,
will prevent the mortification of a future
fecal fistula.

In the management of the pedicle he
always uses Japanese cable silk, transfixing
the tying the ordinary surgical knot, when
dealing with large tumors ; for removal of
the appendages, he is partial to the Stafford-
shire Knot of Tait.

Drainage. — " When in doubt " he always
drains, and prefers the Keith tube to all
others, and he is a thorough believer in flush-
ing the abdomen with a large quantity of hot
distilled water ; it is marvelous sometimes to
see how many blood clots can thus be washed
out, even after careful sponging, besides it is
one of the best methods of relieving shock.

Closure of ventral wound can best be done

with silk worm gut ; it is the ideal suture, as
it is round, smooth and very strong, and can
be rendered perfectly aseptic. As it is rather
stiff, it should be steeped for a few hours be-
fore using, in a solution of some kind, so that
it can be tied tightly. It should be threaded
at each end upon straight or slightly curved
veterinary needles. The needle being held
in the grasp of the Spencer- Wells needle
holder, should be passed from within out-
ward, always including the peritoneum.
Sutures should be placed five or six to the
inch. The frequent cause of ventral hernia
following abdominal section, is an insufficient
number of sutures.

After Management. — For the first twenty-
four hours, nothing should be taken into the
stomach, except a little hot water, bits of ice
chewed or swallowed do not relieve thirst.
The second day a little barley water may be
allowed, and on the third day she can be
promoted to a chicken wing, when after-
wards, if everything goes well, almost any
light diet may be allowed.

When pain is present, he uses but little
morphia, on account of its tendency to arrest
secretions ; and thereby prevent the elimina-
tion of morbid material, but in its stead, for
more than a year past, has used antikamnia,
with happy effect. It soothes and tranquil-
izes, and lessens the tendency to rise of
temperature.

Stitch-hole sinuses can best be obviated
by early removal of the sutures. It is rarely
that he allows sutures to remain in the
ventral wound longer than the eighth day,
and he often removes them as early as the
sixth.

He who essays to do abdominal and pelvic
operations, should by previous observation
and training, be so fitted for his work, that
when he comes into "action" he will be
"ready for anything, and surprised at
nothing."

The best place in which to obtain the
highest grade of success, he thinks, is not in
large general hospitals, neither is it in " the
cottage by the wayside," but in a small
especially prepared establishment, under the
absolute control of experienced management.

EXCISION OF PORTIONS OF THE LUNGS
OF DOGS.

In view of the universal interest excited
in relation to tuberculosis in all its now rec-
ognized manifestations by the announcement
that Koch's tuberculin acted upon tuber-
culous tissue, causing its death in situ, but
not rendering the necrotic tissue innocuous,
it occurred to the members of the Stille

June 20, 1 89 1.

Periscope

797

Medical Society to undertake the following
research, which was performed by Bolgiano,
Patek and Sailer in the Physiological Labora-
tory of the University of Pennsylvania :

A certain number of dogs were set aside
for experimental research. The general
plan of operation first adopted was to resect
one or more ribs, draw out and ligate a lobe
of the lung, cut off a portion and return the
lung into the cavity. A catgut drain was
then introduced into the thoracic cavity, and
the pleura, intercostal muscles and skin was
sutured. Of four animals experimented
upon one died upon the table, two on the
second day after the operation, and one not
until the fifth day. Autopsies showed gan-
grene of the stump and empyema.

A different operative technique was then
adopted. The sight of operation, previously
selected in accordance with results obtained
on the cadaver under forced respirations,
was shaved and carefully disinfected. An
incision about two inches long was made
down to the intercostal muscles, and the
tissues were dissected back a short distance
on each side. A quick cut, about one and a
half inches long, was then made through the
intercostal muscles and pleura. Retractors
were immediately inserted, and the ribs were
drawn apart by an assistant, while the opera-
tor thrust in a pair of haemostatic forceps in
the direction previously determined, seized
the lobe of the lung, drew it out and trans-
fixed it with a sharp probe. As soon as
this was accomplished the retractors were
withdrawn, allowing the ribs to close upon
the lung tissue, the probe preventing re-
traction during inspiration. The external
portion of the lung was now removed by a
V-incision. A needle, threaded with anti-
septic gut, was passed through the inter-
costal muscle, pleura and tissue of the lung
beneath the incision, and out through the
pleura and intercostal muscle of the other
side. These sutures were repeated about
one-eighth of an inch apart until the wound
in the thorax was closed, the wound in the
lung being closed at the same time. A cat-
gut drain was now laid over the wound, and
the edges of the skin were brought together.
Owing to the difficulty experienced in con-
trolling the dogs, it was found necessary to
dress the wound with a solution of collodion
and iodoform in ether upon a matrix of
cotton.

By this method three dogs were operated
upon with most satisfactory results. During
the operation shock was not experienced,
and but little haemorrhage occurred. In
each case the dogs reacted well. Respira-

tions were at first somewhat rapid, and there
was an insignificant rise of temperature
during the twenty-four hours following the
operation. The appetite was good through-
out.

One dog was killed and examined on the
tenth day after the operation, the trachea
being ligated previous to the opening of the
thorax to prevent collapse of the lungs.
The lung was found to have healed perfectly
to the thoracic wall without the occurrence
of circumjacent pleurisy. The pneumotho-
rax had been wholly absorbed and the func-
tion of the lung restored.

Three weeks after operation the second
dog was killed and the thorax opened under
forced respiration. The wound in the lung
had healed completely, leaving a small
white cicatrix, and the lung itself had be-
come detached from the thoracic wall. The
pneumothorax had been wholly absorbed
and the function of the lung completely re-
stored. Indeed, the result may be looked
upon as a perfect cure. In both instances
about 0.5 gram of lung tissue was removed
from the lower lobe of the right lung.

From the third dog the whole of the
upper lobe of the left lung was removed —
a piece about three inches long, and weigh-
ing 5 grams. It was necessary in this case
to ligate the bronchial artery, but the opera-
tion was performed without further compli-
cations. The dog recovered promptly and
is now living in excellent condition.

We think that we may fairly consider
these results as indicating a thoroughly satis-
factory method of excising portions of the
lung from dogs. Whether it is equally
applicable to human beings, experience
alone can demonstrate. Reasoning a priori
it would seem that this technique might be
adopted in surgery, for none of the steps
depend upon any anatomical peculiarity of
the subject. What result it promises it is,
of course, impossible to say, but the bene-
ficial results of operative interference in
tubercular peritonitis strongly indicate that
much good may come from surgical inter-
ference even when such important viscera
as the lungs are involved. — Univ. Med. Mag.

GYNAECOLOGY.

SALICYLATE OF SODA AS AN EM MEN A-
GOGUE.

Dr. C. Mettenheimer speaks highly of sali-
cylate of soda as an emmenagogue. He bases
his opinion on a series of cases, one of

798

Periscope.

Vol. lxi'v

which is reported in the Allgemeine Med.
Central-Zeitung, May 6, 1891.

The patient was a married woman, 35
years of age, and of vigorous constitution.
During the prevalency of the grippe she
caught cold, and complained of chills, pains
in the limbs, headache, loss of appetite, pain
in the eye-balls and great lassitude. The
symptoms were not severe, and the febrile
symptoms were very slight. The following
prescription was given :

Ij^ Natron, salicyl 6.0 grammes.

Aq. dest 75.0 grammes.

Syr. aurant. cort 25.0 grammes.

M. et Sig. One tablespoonful every hour until perspiration
occurs.

After the patient had taken two doses she
began to perspire, and also her monthly
period appeared, which had been delayed for
over a week. Otherwise she had always
been most regular. The menses followed
their normal course, and the patient made a
speedy recovery.

ICHTHIOL IN DISEASES OF THE GENITA-
LIA OF FEMALES.

Dr. Richard Bloch, in the Journal de Med.
de Paris, May 10, 1891, speaks most highly
of the value of ichthiol in the treatment of
various inflammatory diseases of the female
genitalia. He considers it far superior to
nitrate of silver, creolin or carbolic acid.
Dr. Bloch bases his conclusions on a long list
of cases in which the drug has proved itself
of signal service. It seems to have a specific
action in diseases of genital mucous mem-
branes, but produces no local or general re-
action, and is not in the least toxic. Intra-
uterine injections of a 10 per cent, solution of
ichthiol in glycerine are of great value and
produce no untoward symptoms.

The application of pure ichthiol to the
vaginal mucous membrane produces slight
erosions, and therefore occasion some pain.

The drug diminishes both vaginal and
uterine discharges. In acute inflammations,
whether blennorrhagic or not, it is most effi-
cacious. In metritis of the cervix it is most
valuable, and in cervical erosions the appli-
cation of the pure drug will cause prompt
healing.

TACHYCARDIA AT THE MENOPAUSE.

It is not many weeks ago that the subject
of rapid pulse received attention in our
columns, but of the numerous authors cited,
none had studied the pnenomenon in connec-
tion with the climacteric. This study has
occupied the attention of Professor Kisch, of
the Prague faculty, a resident of Marienbad,

and he has made it the basis of an able arti-
cle in a recent number of the Prager Med-
icinische Wochenschrift. Marienbad is a
well-known resort for women approaching
the change of life, and the author has had
ample opportunities for studying the varied
and complex nervous and circulatory dis-
turbances of that period. As his conception
of tachycardia differs somewhat from that of
other reliable observers, it may be well to
give his definition of it. He defines it as a
purely nervous affection, not dependent upon
any organic disease of the heart and blood-
vessels, manifesting itself in a change of the
motor fuction of the heart, and making itself
evident in a decided, at times extraordinary,
increase of the frequency of the heart's con-
tractions. Although the various morbid
phenomena attendant upon the change of
life have received apple attention, this func-
tional affection of the heart has gone almost
unnoticed. Stokes, however, in his well-
known work on Diseases of the Heart, men-
tions a form of palpitation at the menopause
that is at times attended with paroxysmal
attacks of great rapidity of the pulse.

Kisch's clinical picture of the affection is
as follows : At the time of the menopause,
occasionally after the cessation of the menses,
but most frequently between the ages of
forty and fifty years, when the menstrual
flow is beginning to show signs of change,
paroxysmal attacks of palpitation may occur
in women whose heart's action has previously
been quite normal. These attacks sometimes
come on without any provocation, and at
other times they are evoked by slight causes,
such as would have no effect in a normal
state of health. The attacks may come on
while the patient is in any posture — walking,
sitting, or lying down, and even during sleep.
The subjective symptoms accompanying the
attacks are a feeling of oppression and of
anxiety, throbbing in the carotids and in the
abdominal aorta, severe headache, and fugi-
tive sensations of heat and of a rush of blood
to the head. Occasionally there are noises in
the ears, flashes of light before the eyes, and
dizziness, and, in rare cases, syncope may
occur. Objectively, it is found that the
pulse numbers from 120 to 150, and may
even reach 200. In most cases ^it is full,
powerful, and regular. The sphygmographic
tracings show a high pulse wave, a rapid and
abrupt rise of the ascending line, and an
equally rapid and abrupt fall of the descend-
ing line. Redness of the face, neck, and
chest is the contrary, there was a tendency
to plethora, and the patient had a dread of a
stroke of apoplexy. The duration of the

June 20, 1 89 1 . Periscope.

799

affection may vary from a few weeks to two
years and even longer.

In the tachycardia of the menopause the
author thinks the etiological facor is hyper-
plasia of the ovarian stroma. This increase
of connective tissue in certain predisposed
individuals, acts in some way, unknown as
yet, upon the terminal nerves of the ovarian
tissue and, through them, in a reflex maimer
upon the sympathetic nerve — the accelerator
of the heart. This assumption receives sup-
port from the fact that tachycardia is fre-
quently seen after the operation for the
removal of the ovaries, which is followed by
a shrinking process of the internal genital
organs. In the way of treatment, the author
has obtained the best results from a syste-
matic course of mild purgatives, suitable
dietetic and hygienic regimen, such as mount-
ain air, a bland diet, and active bodily exer-
cise, and wet applications to the lower part
of the abdomen. A course of some wTeeks at
Marienbad is usually followed by improve-
ment. Small doses of the bromides gener-
ally afford relief from the unpleasant
sensations attending the attacks. — N. Y.
Med. Jour.

OBSTETRICS.

UNCONSCIOUS PARTURITION IN A PRIMI-
PARA.

A case of high obstetric and medico-legal
interest is to be found in the Archives de
Tocologie for November. Physiologically
painless parturition isfrare. Tarnier has re-
lated some cases, including one instance
where a Canadian woman occasionally
dropped a baby on the ground, at term,
without noticing it. In Howard's case labor
took two hours; the patient was reading a
book till a quarter of an hour before the
child was delivered, which event occurred
after some straining, not sufficient to make
her cry out. In Dr. Brunon's case, neAvly
reported, a married woman, aged twenty-two,
had a troublesome cough one day shortly be-
fore term. The coughing was accompanied
with lumbar pains, which increased. At
eleven o'clock in the evening the patient
tried to pass a motion. She sat over one
hour in the closet, believing that her pains
signified painful defecation. Then she went
to bed. At half-past one o'clock she woke
up feeling a desire to pass a motion, with
lumbar pains such as she had felt before
when constipated. As she rose to go to stool
a smart lumbar pain occurred, and she felt
something between her thighs. On handling

it she found, much to her surprise, that it
was the head of her first-born. She declared
to Dr. Brunon that the pains were entirely
lumbar, she had no colicky sensations, and
none of the expulsive pains usually so severe,
especially in primiparse. The desire to defe-
cate was strong, and she stated that the child
might have been born into the pan of the
closet without her recognizing the truth of
her condition till the moment of its delivery.
The patient was an intelligent well-educated
woman, free from any neurosis. This case
proves that in the case of an inexperienced
person an infant might be expelled into the
water in the pan of a closet without any in-
tention of infanticide on the part of the
mother. — Epitome.

THE NECESSITY FOR IMMEDIATE SURGI-
CAL INTERVENTION IN LACERA-
TIONS OF THE PERINEUM.

The misfortune which has just happened
to an unfortunate practitioner, who was
mulcted damages to the amount of nine
hundred dollars and costs by the Superior
Court for neglecting a lacerated perinaeum,
should be a lesson to every accoucheur in this
country. It was shown that the laceration
was complete, extending into the rectum,
and had been followed by procidentia of the
uterus and other distressing accidents.

The duty of attending to all extensive
lacerations of the perinaaum at the time when
the lesions are fresh is insisted upon by the
best obstetrical writers, and it is certainly
the practice of the most successful obstetri-
cians in this country to immediately put in
three or more deep stitches, thus approxi-
mating and keeping in apposition the lacer-
ated parts till union takes place. It matters
little what material is used for the sutures ;
some use chromacized catgut, and make a
deep continuous suture, and certainly cat-
gut has in many instances proved to be suf-
ficiently enduring; others prefer silk, others
silver wire. Every physician has, or ought
to have, in his pocket-surgical-case, ligatures
and curved needles, and if a sufficiency of
interrupted sutures are inserted immediately
after confinement, the old-fashioned quilt
suture may well be dispensed with. It will
not always be necessary to give the patient
ether in order to insert the stitches, though
some nervous and susceptible subjects may
require it. It is true that after a long and
difficult confinement case, the medical
attendant is generally tired out and shrinks
from another operation, especially where
anaesthesia is required, but he must muster
strength and nerve for the occasion if he

8oo

Periscope.

Vol. lxiv

would escape liability to a suit for malprac-
tice ; and if he inserts a few stitches he will
save himself from the imputation of igno-
rance or carelessness. Modern juries have
not the name of being very tender to the
feelings, reputations or pockets of physicians,
and it goes without saying that the most
vigilant and attentive will be the least likely
to be " caught napping."

There are one or two errors that should
be cleared away, lest they should be subter-
fuges for the careless. The one is that tying
the knees of the patient together will answer
the same end as sutures. " Only a very
credulous person," says Lusk, "really be-
lieves that he has witnessed union by first
intention in extensive ruptures as the result
of tying the knees together, and enjoining
rest upon the side. The action of the trans-
versi-perinei muscles tends to draw the torn
surfaces apart. Moreover, the necessity of
separating the knees in passing urine, and
to enable the nurse to clean the genitalia,
makes it impossible to keep them in contact
for any lengthened period."

The other mistaken notion is that pri-
mary perineorrhaphy rarely succeeds, " that
the perinseum is not merely torn but is con-
tused and mangled, and that the previously
cedematous and infiltrated tissues are pre-
disposed to gangrene, and consequently are
in the worst possible condition for immedi-
ate union " (Charpentier). Moreover, it is
said that the lochial discharge will always
be an obstacle to the union by first intention.

According to the experience of very many
who have tried the immediate operation, and
who have seldom or never failed to obtain
good union, if due pains toward cleanli-
ness and antisepsis are taken, no such un-
favorable result as Charpentier points out
need ever be feared. Certainly, Charpen*
tier's American editor warmly favors the
immediate repair of any laceration beyond
the first degree, for the reason that thus a
possible entrance sight for septic matter' is
prevented, and also because the operation is
a simple affair after delivery, and more
extensive and complicated, the longer we
wait. He recommends that in case of lac-
eration to the second degree only one deep
silk or wire suture should be used ; if the
rent be deeper, three to five will be needed.
In any event, the patient should be placed
on her side, a wad of absorbent cotton in-
serted into the vagina to catch the dis-
charges, the wound carefully washed and
trimmed of jagged shreds, and then, guided
by the finger in the rectum, the suture is
passed deeply around, at one-half inch from

the margins. The line of suture should be
dusted with iodoform, and a narrow strip
of cotton laid along the perineum and the
posterior vaginal wall. The after-treatment
will consist in dusting with iodoform twice
daily, and replacing the strip of cotton by
a fresh piece till the sixth or seventh day,
when the sutures may be removed. — Bost.
Med. Surg. Jour.

PAEDIATRICS.

TREATMENT OF DIPHTHERIA BY MERCU-
RIAL INUNCTIONS.

Smakowsky, in the Allgemeine Med. Cen-
tral-Zeitung, May 13, 1891, reports three
cases of diphtheria, which recovered after in-
unctions of mercurial ointment. Every hour
4 grammes of mercurial ointment were rubbed
into the skin of different parts of the body,
as in the treatment of syphilis. In this way
the patient got, in all, about 30 grammes
daily. The only other treatment that was
used was gargling with a solution of chlorate
of potash. The treatment lasts for one day
only. If there is any relapse it may be re-
peated. Unfortunately the treatment is of
little value in the treatment of infants, since
they cannot gargle. The patients treated
were from seven to eight years of age.

QUININE IN WHOOPING-COUGH.
Professor Emil Ungar, advocates the free
use of quinine in whooping-cough (Deutsche
medicinische Wochenschrift, No. 18, 1891),
having used it with much success during
several epidemics in the last six years. He
attributed the great differences of opinion
as to its value which have prevailed amongst
previous observers to the difference in the
dose employed. Large doses are necessary,
and, suiting the exact quantity to the age of
the patient, he advises the use of from 16 to
22 grains per diem, in divided doses. Even
to children below three months of age he
would administer | of a grain at each dose.
These large quantities are only given for a
few days, and as improvement begins the
dose is diminished, and is given twice or
only once a day instead of three times.
This diminution should be effected slowly.
Dr. Engar believes that children will bear
relatively larger doses than adults, and has
had no experience of the deafness or dis-
turbed digestion which the drug is said to
have produced in the hands of other observ-
ers. In his cases the vomiting, after the
paroxysm, was rapidly stopped, and appetite

June 20, 1891.

Periscope.

801

and digestive power seemed to be improved.
The recorded cases of aural disturbance are
for the most part in adult persons, and not
in children. No untoward results of the
treatment occurred in his practice, the only
symptom presumably attributable to the
equinine being the occurrence of very rapid
cardiac action in one case. The main diffi-
culty in the way of the administration of
quinine to very young children is its bitter
taste. Perseverance in many cases was re-
warded by the children actually becoming
fond of it, although almost all rebelled at
first. The struggle induced during the
swallowing of the medicine is apt to pro-
duce a fit of coughing, followed by retching
and vomiting. In order to avoid this occur-
rence it is advisable to give the quinine
directly after a paroxyism has taken place.
To older children the quinine may be given
in capsules. Administration per rectum is
not satisfactory. By subcutaneous injection
good results may be obtained, a neutral
hydrochlorate being used, which is fairly
oluble in water. The curative effects of
quinine, however administered, are not ap-
parent immediately, except in a few in-
stances. As a rule, from three to six days
elapse before the severity of the attack
begins to diminish and the vomiting to cease.
The disease then appears to run a milder
course, and at the end of a fortnight the
attacks are slight and infrequent. The ten-
dency to complications, broncho-pneumonia,
etc., is lessened, and improvement may be
looked for in the large majority, though not
in all cases. — Brit. Med. Jour.

THE SCARLET FEVER TONGUE.

The method followed by Dr. Newman was
to sketch the tongue as soon as the diagnosis
of scarlet fever was made, and after two or
three days to compare its condition with the
sketch already made.' This was done in
forty-eight cases, the chief symptoms of the
disease being noted at the same time. The
mucous membrane of the tongue passed
through three stages: 1. Swelling and
cloudiness of the epithelium ; 2. desquama-
tion ; 3. regeneration of the lost epithelium.
The first thing noted in the scarlet fever
tongue is a swelling of the entire mucous
membrane, giving rise to longitudinal folds
and channels, easily distinguished from the
folds noted in bulbar paralysis by the con-
sistency of the tongue. The cloudiness of
the epithelium gives rise to the changed
color of the tongue ; it appears grayish-
white, white, or yellowish-white — that is, the

tongue is coated. The back of the tongue is
chiefly affected, the sides and tip being red.
The desquamation does not take place as
uniformly over the tongue as the other
processes. It commences on the papillae
fungi-formes. These latter appear as sub-
miliary or milary round, dusky-red dots,
surrounded by a white area. Thus the tongue
gets its strawberry appearance. In the third
stage the sides of the tongue, and more par-
ticularly its tip, retain their red appearance
and strawberry aspect longer than other
parts of the tongue. The new epithelial
layer may be so thick that the tongue appears
coated anew. The swelling gradually goes
away. The above is the usual course, but
there may be departures from it. In two
cases the dulling of the epithelium was ab-
sent, and the desquamation excessive, so that
the longitudinal muscle bundles were seen.
In another case, the epithelium was only
detached in part, and a new layer developed
quickly, so that the tongue appeared coated
throughout. It resembled a dyspeptic
tongue. The author says that the fungiform
papillae appeared round and erect ; whereas
in the dyspeptic tongue they are elongated,
and slope toward the tip of the tongue.
Generally speaking, the digestive troubles
cause the tongue to be coated before the
scarlet fever process has had time to affect it.
If scarlet fever be combined with a septic
condition, the latter determines the condition
of the tongue. As the new infection appears
early or late, so is the scarlet fever process
interrupted. Generally speaking, the tongue,
after losing its epithelium, developesa straw-
berry appearance, and then becomes dry.
Bleeding cracks may be seen, which can lead
to deep ulceration, or true diphtheritic mem-
brane may appear. Out of the 48 cases the
tongue was typical in 38. In 4 cases, one
or two of the stages were only very slightly
developed ; and in 6, the typical scarlet
fever tongue was altogether absent. Of
these 6, there was severe gastric disturbance
in 2 ; another case was in a chlorotic girl ;
in the fourth case there were symptoms of
septicaemia, and death on the fourth day;
and in the fifth and sixth cases the tongue
was quite unaltered. Thus it would certainly
appear that the scarlet fever tongue is a
tolerably frequent occurrence in the disease,
and that when absent, complication or pre-
vious illness has altered the tongue in other
ways. The tongue recovers its normal state
with the cessation of the fever. In the ma-
jority of cases the tongue had lost its epithe-
lium, and had become strawberry in three
to five days. There is no proportionate rela-

802

Periscope.

Vol. Ixiv

tion between the intensity of the scarlet fever
poison as it affects the skin and tongue.
Both processes are probable brought about
in the same way, as their tolerably equal
occurrence and their appearance much about
the same time would suggest ; and again,
certain departures from the ordinary have
shown a peculiar resemblance. Thus in one
case with a puerpuric rash, the same was
noted on the tongue ; and in another, where
syphilis was present as well, pustules were
seen on the tongue as well as on the skin.
Thus this condition of tongue, though not
always present, is observed in many cases.
It is, however, of less value than it might be,
as it does not appear before the fourth day
or so, and it may certainly be present in
other illnesses. — Deutsches Archiv fur
Klinische Medicin.

HYGIENE.

DR. KLEIN ON BACTERIA.

The first of a series of three lectures on
Bacteria ; their Nature and Functions, was
delivered at the Royal Institution on Tues-
day last by Dr. E. Klein, F.R.S. He said
that perhaps in no branch of biological
science had advances in the methods of re-
search within the last twenty -five or thirty
years been so enormous as in this subject.
In 1828 Ehrenberg recognized the exist-
ence in water of minute mobile organisms
which he considered to belong to the group
of animalcule known as infusoria, an as-
sumption which was now known to be
erroneous. In 1837 Schwann demonstrated
the presence in atmospheric air and in dust
of living microscopic beings, which he
showed by direct experiment to be endowed
with the power of producing in certain
fluids those chemical changes termed alco-
holic fermentation or putrefaction. Pasteur
fully established the proposition that the
different fermentations, such as alcoholic,
butyric, acetous, mucous, and lactous fer-
mentations, and also the decomposition of
putrescible matter, were caused by definite
and different species of such minute living
beings — microbes, — and that without them
such changes did not occur. This proposi-
tion implied that these changes were de-
pendent on and ultimately bound up with
the life and growth of these microbes, and if
these were prevented from gaining access to
such fermentative matters, they would re-
main unchanged or sterile. This was the
principle which Sir Joseph Lister had ap-
plied in surgery, with the well-known

brilliant results. The role of these microbes
in atmospheric air had been minutely
worked out and beautifully illustrated by
Professor Tyndall, whose share in finally
establishing that with these simple organisms,
belonging almost to the world of the infinitely
small, the same fundamental principle
obtains as in other living organisms of plant
and animal life, be they ever so large and
complex — namely, that each organism had
descended from an antecedent parent organ-
ism, and that no such thing as their origin
from non-living matter occurred. Within
comparatively recent times it had been
shown that a variety of the most important
and extensive processes of oxidation and
reduction occur in nature, such as the oxida-
tion and resolution of dead animal and
vegetable matter, the breaking up of com-
plex nitrogenous materials — such as albu-
minous substances, and their ultimate change
into nitrites and nitrates, so essential to the
life and growth of plants ; that specific fer-
mentation, so important in food stuffs and
articles of diet, and many other processes are
caused by, and intimately connected with,
the growth and life of microbes. Though
the importance of some species as useful
agencies in nature is recognized, the import-
ance of other species, as being the cause of
disease affecting plants, animals, and man, is
not less. The term micro-parasite is given
to this latter group. Amongst the microbes
there is one great group to be dealt with in
particular, called "bacteria," because it pos-
sesses more or less the shape of a minute rod.
Like the true or higher fungi, they are free
from chlorophyll, and are composed of cells,
a cellular membrane with living matter or
protoplasm within, and they multiply by
fission, for which reason they are called
" fission fungi." Bacteria could then be
defined as microscopic elementary organisms,
composed of a cellulose investment of the
protoplasmic contents, and which multiply
by simple fission. They are classified into
micrococci or cocci, bacilli and spiral vi-
briones, according to whether they are spher-
ical, cylindrical, or curved and spiral. The
lecturer exhibited a large number of micro-
photographs of bacteria, prepared by Mr.
Andrew Pringle and Dr. Bousfield.

All these organisms, when they have
found suitable nidus, multiply with enor-
mous rapidity. It has, for example, been
found from observation — all conditions of
moisture, medium, and temperature being
favorable — that some multiply in twenty
minutes, others in thirty minutes, and
others in forty minutes. Staphylococcus

June 20, 1 89 1.

Periscope,

803

aureus, which in its growth produces a
peculiar golclen-colored filament, grows with
great rapidity when sown in a medium-
like, faintly alkaline broth at a temperature
of 37°C. Into a sterile broth tube a
definite number of organisms are put — say,
eight cocci per cubic centimeter. If placed
in an. incubator for twenty-four hours at
37 °C. and then counted, it is found that
1 cc. contains 640,000 — that is to say, one
organism has multiplied eighty thousand-
fold in the first twenty-four hours. It
would not be expected that the same rate
would obtain in the second twenty-four
hours, because the material had been used
up. After forty-eight hours' growth the
counting yielded 248 millions per cubic
centimeter — that is, only four hundredfold.
In seventy-two hours it was found that there
were 1184 millions per cubic centimeter —
that is to say, during the last day each had
multiplied only fivefold. As the material
is used up the rate of multiplication de-
creases. Another instance of the rapidity
of growth was given. A rabbit was inoc-
ulated subcutaneously with 20,000 bacilli of
fowl cholera, and died in twenty-four hours.
It was found that 15,150,000 microbes were
contained in 1 cc. of the blood of the
animal. The whole of the blood contained
twelve hundred millions, showing that each
bacillus in twenty-four hours had multiplied
sixty thousand times. Those organisms
which have their habitat in ordinary tem-
peratures grow very rapidly. Professor
Ferdinand Cohn was the first to study the
rate of multiplication on the hay bacillus.
He calculated that in two days the number
of these would be so great that the whole
Atlantic Ocean would be densely peopled
by them if there was sufficient nutriment,
which, fortunately, there is not, and there-
fore many of them had to go to the wall.

By the motility of bacteria is understood
active locomotion. They spin round, they
dart to and fro, and pass rapidly over the
field of the microscope, and that is on
account of their possessing one, two, three,
or even a multitude of fine hairs. The
organism of typhoid fever possesses several
of these flapellse. It has been shown that
for retaining this motility a plentiful sup-
ply of oxygen is required. If, in a chamber,
at one end oxygen is supplied, and at the
other nitrogen or hydrogen gas, the organ-
isms will all move towards the end where
the oxygen is. If the oxygen is replaced
by nitrogen or hydrogen the movement
gradually ceases. If water is covered with
a scum, it is most probably a motile bacillus

which grows in the fluid, and which is
driven to the surface, where it can derive
the best supply of oxygen. In many cases
the motility of the organisms is interfered
with by their own chemical products.

Within certain of these organisms, but not
in all, are formed peculiar corpuscles, which
bear the same relation to the organisms as the
seed does to the plant. This spore formation is
almost entirely limited to the order of bacilli,
and in this group there are very many spe-
cies which do not possess this power. In a
number of different species of bacilli, some
of which are capable of forming spores and
others not, those which have this power may
look on very quietly, while those that do not
will exhaust all the nutritive material
present, growth and multiplication will then
cease, and they will gradually die away.
Those which form spores have a much bet-
ter chance of bringing forth new generations
than the others.

When organisms do not find suitable
materials for their growth, certain changes
are brought about called "involution
changes." When the bacillus ceases to
possess that high degree of vitality that the
normal typical bacillus possesses, it gradu-
ally undergoes changes which lead to its
death. Illustrations were given of what had
been described as involution changes, but
which were not so. For instance, tubercle
bacilli grown under not very favorable con-
ditions may be swollen, and others may
appear branched. Some observers took
these changes to indicate the death of the
organism, but the lecturer was not quite sure
that such were "involution changes."

In all these considerations, particularly in
reference to the formation of spores, there
were a number of facts of very considerable
practical importance. The germination of
those organisms which form spores takes
place on the same principles as the germi-
nation of the spores in the higher fungi.
The envelope is broken, the protoplasm con-
tained within it shoots out in the shape of a
rod, which when it is fully formed elongates,
divides and multiplies as in the case of the
parent. In this way one bacillus, by
repeated multiplication, forms a new crop.
When these have reached a certain phase of
development they again form spores which
go to start a new generation. These spores
have a much greater power of resistance
than is possessed by the non-spore-bearing
organisms, and can withstand high tempera-
ture, dryness and the influence of light, so
much so that it has become almost a recog-
nized method of determining whether a par-

8o4

News and Miscellany.

Vol. lxiv

ticular species of bacilli forms spores by
subjecting the suspected organism to a tem-
perature of 95° C. or 100° C. If they sur-
vive this exposure, and if they survive dry-
ing, it may be taken as established that the
growth is spore-forming. — Lancet.

MEDICAL CHEMISTRY.

THE ALKALINITY OF THE BLOOD UNDER
NORMAL AND PATHOLOGICAL
CONDITIONS.

E. Pieper (Arch.f. Pathol. Anal, 116, 337 ;
Ber. Deut. Cliem. Ges., 23, 666) found that
the alkalinity of the blood varies within
narrow limits. The blood of children is less
alkaline, in reaction, than that of adults ; of
women, less alkaline than of men. The
alkalinity of the blood is increased during
digestion, muscular activity and vomiting.
The spasms of strychnine poisoning cause a
decrease.

The author states that in leukemia, dia-
betes mellitus, arthritis deformans, chronic
articular rheumatism, anemia, cancerous
cachexia uremia, and in fevers the alkalinity
of the blood is, as a rule, decreased, while in
chlorosis it is increased.

ESTIMATION OF NITRATES AND NITRITES
IN WATER BY ELECTROLYSIS.

At the recent annual meeting of the
Bristol (Eng.) Pharmaceutical Association,
G. F. Schacht, presented a paper on this
subject. After alluding to the importance
of being able to determine the wholesome-
ness of potable water, he discussed as his
special point in such determination a recent
suggestion to employ a " couple " of alumi-
nium and mercury for the evolution of the
hydrogen in the well-known process for the
estimation of nitrogen existing as nitrates
and nitrites in the sample. Messrs. Ormandy
and Cohen had published this suggestion,
and their paper had appeared in the Jour-
nal of the Chemical Society for September of
last year. He had taken some pains to as-
sure himself of the accuracy of the method,
and, with the modifications to which he
would presently refer, it became so easy
of execution that he recommended its
adoption with confidence. Mr. Schacht
then proceded to show the process in detail,
and to describe it thus : Measure 100 c. c.
of the sample into a plain upright glass
vessel of capacity equal to about 130 c. c. ;
take a strip of aluminium foil (about three
inches of ordinary ribbon= 0.4 gram), clean
both surfaces by rubbing with tow dipped in

liquor sodse, wash thoroughly and dip it into
a solution of mercuric chloride (half a satur-
ated solution and half water) for one minute.
A deposit of mercury takes place upon the
aluminium, and a " couple " is formed.
Wash it well under the tap, put it at once
into the 100 c. c. of the sample, and cover
the glass vessel loosely. Let these react until
the metals become a deposit and no more gas
is evolved. Gently stir the mixture and allow
the deposit to subside. Take 10 c. c. of
the clear supernatant liquid, dilute
with 90 c.c. of pure water, and add 1 c.c. of
Nessler's solution. Note the color. Per-
form a comparison experiment in the usual
way with standard solution of ammonium
chloride 0.0001 gram of NH to each c.c.
Then x being the number of c.c. of solution
required 0.0001 x x x 10 x 700=grains per
gallon of ammonia, and this figure multi-
plied by 0.828=grains per gallon of nitro-
gen. In experiments which aim for exact
results, it is better to close the mouth of the
vessel with an india rubber stopper through
which passes a glass tube, bent so as to
allow the gasses to pass through a small
quantity of water, which should be mixed
with the sample before the final stirring.
The author submitted a table of results of
experiments, which showed that great accu-
racy could be attained by this process.

NEWS AND MISCELLANY.

ANATOMY AT OXFORD UNIVERSITY.

A grant of $35,000 has been asked by the
Convocation to procure permanent accom-
modation for the teaching of anatomy.

DR. LASSAR.

The French Government has conferred the
Order of the Legion of Honor on Dr. O.
Lassar, the General Secretary of the Tenth
International Medical Congress, held in
Berlin in 1890.

THE CHICAGO MEDICAL RECORD.

This is the title of a new medical monthly
edited by Dr. Archibald Church. It is
well printed and contains a number of
valuable original articles, together with
society reports, etc.

THE MEDICAL DEPARTMENT OF THE
UNIVERSITY OF TEXAS.

The Medical Department of the University
of Texas, will open its doors in the Autumn

June 20, 1 89 1.

News and

Miscellany.

805

of this year. Dr. Thos. D. Wooton, of
Austin, is the Kegent. A large Hospital
will be adjacent to the school, and every
effort is promised to make the school one of
yery high standard.

RESIGNATION OF SURGEON-GENERAL
JOHN B. HAMILTON.

Dr. John B. Hamilton, Surgeon-General
of the Marine Hospital Service, has resigned
to accept the chair of Surgery and Surgical
Pathology, in the Rush Medical College, of
Chicago. Dr. Walter Wyman, who has
been his chief assistant, has been promoted
to the vacant position.

THE NEW YORKf POST-GRADUATE MED-
ICAL SCHOOL.

At a recent meeting of the Directors of
the New York Post-Graduate Medical
School and Hospital, H. J. Boldt, M. D.,
was made Professor of Diseases of Women ;
William James Morton, M. D., Professor of
Electrotherapeutics, and Aug. Caille, M. D.,
Professor of Diseases of Children.

A NEW CREMATORY.

The incineration of the dead becomes
more and more popular. Crematories are
rapidly increasing in number in all civilized
countries. One of the most important
structures of this kind will be at Heide-
burg, a site having been given by the
municipality for the purpose. The cost of
erection is estimated to be over $10,000.

THE UNIVERSITY OF PENNSYLVANIA.

The Trustees of the University of Penn-
sylvania have elected — Dr. George A. Pier-
sol, Professor of Anatomy ; Dr. Harrison
Allen, Professor of Comparative Anatomy ;
Dr. John B. Deaver, Assistant Professor of
Applied Anatomy ; Dr. Edward Martin,
Clinical Professor of Genito-urinary Sur-
gery ; and Dr. Holmes, Demonstrator of
Anatomy.

THE LEHIGH VALLEY MEDICAL ASSO-
CIATION.

The eleventh annual meeting of the Le-
high Valley Medical Association will be held
at the Mansion House, Mauch Chunk, Pa.,
on Thursday, June 25, 1891.

During the morning business will be trans-
acted and papers read. At 3 P. M. the

Society will take in an excursion on the
" Switch Back."

UNIVERSITY OF BUDA-PESTH.

A festal commemoration of the 111th
anniversary of the University of Buda-Pesth
was held on May 12th.

Prof. Koranyi, on the 14th inst., celebra-
ted the twenty-fifth anniversary of his ap-
pointment as Professor, and received over
200 congratulatory telegrams.

The Medical Society has decided to build
itself a house which will probably cost about
$20,000.

FOOT-BALL CASUALTIES.
The last foot-ball season in England has
been noted for the casualties recorded.
Among the injuries noted in the Lancet,
which ended fatally are, asphyxia, caused
by paralysis of the muscles of respiration,
acute peritonitis, injury to the brain, rupture
of the intestine, rupture of the right kidney
and abdominal injuries. Is it not time that
this game should be so modified as to relieve
it of the unnecessary dangers now attend-
ing it ?

WHO OWNS THE PRESCRIPTION ?
The British Medical Journal says that the
question of the ownership of prescriptions
has been settled by law in New York, Mas-
sachusetts, and a few other States. In all
the cases it has been decided that the drug-
gist is the owner of the prescription. The
following is the text of a judicial pronounce-
ment lately delivered on the subject : "The
question before the Court appears to be sim-
ple indeed. A patient applies to a physician
and receives from him certain advice for
which he tenders a fee. The physician hands
a piece of paper to the patient, purporting to
be a written order for certain goods, called
drugs, which order is filled by a merchant
or apothecary. The payment of the fee and
the delivery of the goods or drugs terminates
the verbal contract, and the druggist keeps
the prescription as an evidence that the con-
tract has been fulfilled so far as he is con-
cerned. The druggist can, if he so please,
on his own responsibility renew the drugs,
for he is but a merchant, and has a perfect
right to sell drugs to anyone and in any
shape. He need not keep the prescription,
nor is he bound to give a copy ; but should
error occur, he has no protection in case of

8o6

News and Miscellany.

Vol. lxir

suit." It is said that some time ago a de-
cision in the same sense was given by the
judge of a court in Berlin.

The Journal adds in comment on the
above : "The opinion here quoted does not
seem to be sound ; the patient receives the
prescription in return for the fee which he
gives to the physician, but he is under no
obligation to give up the prescription to the
druggist. He is bound to show it to him,
or else he cannot get the drugs he wants, but
the document belongs to the patient, who
could, if he choose, enforce its return by
action. A publisher might as well claim to
keep an author's manuscript as evidence
that he had correctly printed it, as a drug-
gist to keep the prescription as evidence that
he had fulfilled his contract to supply the
drugs ordered of him. Such a claim on the
part of a tradesman against his customer is
not recognized as valid by English law,
whatever may be laid down by the courts of
other countries.,,

In a paper recently read by Mr. Joseph
England, before the Philadelphia College of
Pharmacy, this question of ownership was
discussed, the writer taking decided ground
in favor of the druggist being owner of the
prescription. He cited a long legal opinion
furnished by an experienced lawyer, Mr. R.
C. McMurtrie, in support of his view.

" If the patient is the owner," says Mr. Mc-
Murtrie, " he may at any time within six
years demand the paper, and if it is not sur-
rendered, sue as for a tortious conversion of
his property. If he can't do this he certainly
has no title." Various instances are cited
also showing the necessity to the druggist of
owning and keeping the prescriptions. —
Med. Bee.

JOHNSTOWN CORRESPONDENTS
ASSOCIATION.

The representatives of the great daily
papers who worked in Johnstown during the
days following the dreadful flood of May 31 ,
1889, have formed an organization known as
the Johnstown Correspondent's Association.
On the anniversary of the great disaster they
meet and renew the friendships formed then,
and recount the stirring scenes of those event-
ful months. This year they met in Johns-
town and were delightfully entertained by
the Cambria County Medical Society and the
citizens generally. There were present rep-
resentatives of the New 7ork World, Her-
ald, Times and Mail and Express, of the
Philadelphia Times, Record, Press, Inquirer
and Public Ledger, and of all the Pittsburgh

papers. The entire party numbered about
seventy-five persons. The different parties
arrived in special cars on Saturday, May 30,
and were at once taken in charge by a com-
mittee of citizens and by the following med-
ical men : Drs. A. R Wakefield, W. B.
Towman, L. 1ST. Mayer, G. W. Wagoner and
E. S. Miller. The party were provided with
carriages and driven to all the points of in-
terest in the historic valley. The rooms of
the Medical Society were used as the head-
quarters of the party and had been hand-
somely decorated for the purpose. An
elegant lunch was served, during the entire
day, in the rooms, and all enjoyed this feature
of the entertainment very much. The mem-
bers of the Medical Society turned out in
full force and took special pride in receiving
the guests at their rooms because they had a
magnificent library to show them. The large
and valuable collection of medical and liter-
ary works was recently given to the Society
by Dr. Joseph M. Toner, of Washington, D.
C. It comprises a large portion of a col-
lection, to the acquirement of which this
distinguished and learned gentleman has
devoted his life and fortune, hence one can
readily fancy how valuable it must be.
There are nearly 5,000 titles, and among
them are all the famous medical works of
the last 150 years. Dr. Toner passed his
boyhood days in Johnstown and entered
upon the study of medicine many years ago,
in the office of Dr. John Lowman, who was
then, as he is now, one of the most distin-
guished practitioners of medicine and surgery
in Western Pennsylvania. Dr. Toner has
never forgotten the early home or his old
preceptor, and now in his declining years he
has manifested his affection by enriching the
medical profession of the community where
he first imbibed medical knowledge. The
Toner Library contains many volumes
which could not be duplicated. The mem-
bers of the Medical Society are justly proud
of the splendid library and the many other
articles of interest and value which Dr. Toner
has donated to their use, and took very great
pleasure in exhibiting their possessions to the
visitors. The Toner Library is the first
public one established in the city since the
flood and was therefore a centre of interest.
It is well cared for in one of the principal
business blocks of the new city. At the close
of their day of sight-seeing the visiting re-
porters were given a banquet at a hotel, by
the citizens, and left the city surprised at the
wonderful progress it had made since the
flood, and delighted at the elegant manner
in which they had been entertained.

Vol. LXIV, No. 26.
Whole No. 1791.

JUNE 27, 1891.

$5.00 per Annum.
10 Cents a Copy.

THE

MEDICAL AND SURGICAL

REPORTER

A Weekly Journal.

Established in 1853 by S. W. BUTLER, M. D.

EDWARD T. REICHERT, M. D., Editor and Manager,

Entered as Second-Class matter at Philadelphia P. 0.

N. E. Cor. 13th & WALNUT STS., PHILA.

CLINICAL LECTURES.

William Goodell, M. D., Philadelphia, Pa.
Double Oophorectomy — Supravaginal Hyster-
ectomy 807

Dr. Grvox, Paris.

Diagnosis of Vesical Tumors — Hematuria and
Endoscopic Examination of the Bladder. . . 809

COMMUNICATIONS.

J. J. Thomas, M. D., Youngstown, Ohio.

Strychnia as a Heart Stimulant in Pneumonia. 811
H. F. Byers, M. D., Caruthersville, Missouri.

Three Cases of Hystero-Epilepsy 812

Joseph E. Hoffmax, M. D., Philadelphia, Pa.
The Relation of Imperfect Surgery to the
Sequelae of Pelvic and Abdominal Operations. 814

SOCIETY REPORTS.

Philadelphia County Medical Society. . . . 819

SELECTED FORMULAE 823

EDITORIALS.

In the Preparation of Sponges for Surgical
uses, which is the Safest Sterilizing Fluid : A
Solution of Carbolic Acid or one of Corrosive
Sublimate? 825

CORRESPONDENCE . 827

BOOK REVIEWS 828

PERISCOPE.
Therapeutics.

Treatment of Pneumonia with Large Doses of
Digitalis — The Action of Cocaine on the Cir-
culation— Treatment of the Night Sweats of
Phthisis — Variation in the Caustic Action of
Carbolic Acid — Piperazidine as a Solvent for

Uric Acid— Treatment of Hyperphoria — The
Action of Saccharine on the Heart — Thallin. . 829
Medicixe.

On the Etiology of Tinnitus Aurium— Cirrhosis
of the Liver and Nervous Symptoms — The
Influence of Tobacco on Gastric Digestion and

Acidity of the Urine 832

Surgery.

Remarks on Five Hundred Cases of Stricture
of the Urethra— A Method for Removing Tattoo
Marks — Nerve-Grafting 834

Gynaecology.

Effect of Leeches in the Uterine Cavity — The
Total Extirpation of the Uterus — Defective
Development of Genitals 835

Obstetrics.

On the Treatment of Breech Presentation —
Anatomy of Tubal Pregnancy — Tonic Spasm
of Parturient Uterus Overcome by Antipyrin. 836

Paediatrics.

Infantile Cerebral Palsies — Spinal Paralysis in
Children — Notes of an Epidemic of Measles —
Bromoform in Whooping Cough 838

Hygtexe.

Influenza Bacteria — Compulsory Notification
of Infectious Disease — The Suppression of Juve-
nile Smoking 840

. Medical "Chemistry.

The Quantitative Estimation of Sugar with
Roberts' Fermentation Test. 841

NEWS AND MISCELLANY 843

Index.

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THE

MEDICAL AND SURGICAL
REPORTER

No. 1791. PHILADELPHIA, JUNE 27, 1891. Vol. LXIV.— No. 26.

Clinical Lecture.

DOUBLE OOPHORECTOMY— SUPRA-
VAGINAL HYSTERECTOMY.

BY WILLIAM GOODELL, M. D.,

PROFESSOR OF GYNECOLOGY, UNIVERSITY OF PENN-
SYLVANIA.

DOUBLE OOPHORECTOMY.

Gentlemen : — The first case that I shall
operate upon before you to-day, is that of a
woman, forty years old, whose ovaries I shall
remove. The history of her ease is as fol-
lows : She has been married a good many
years, and has born several children. For
the past few years she has been constantly
suffering with a dragging, gnawing pain in
her left side, which has been steadily grow-
ing worse until now she is a constant sufferer,
wholly unfit for any work — an invalid, in
fact. Her pain is evidently of an ovarian
origin, and my diagnosis is that the left ovary,
which is much enlarged, is the one princi-
pally affected. At this woman's age, especi-
ally as her maternal instincts have already
been gratified, we should feel no compunc-
tion in removing her ovaries, feeling con-
fident— as we do in this case — that they, or
at least one of them, is the cause of her
present pitiable condition. These organs can
no longer be of any material service to her,
but are capable of doing infinite harm, and,
perhaps, eventually causing the woman's
death. You see she is emaciated, and shows
unmistakable signs of years of suffering.

Before being brought into the clinic the
patient's abdomen has been thoroughly
washed and scrubbed and covered with an
antiseptic bandage. This, we now remove,
and again thoroughly wash the parts with a
strong mercuric solution — 1:1,000 — and
shave off the pubic hair, in order to ren-
der the field of our operation absolutely
aseptic. Another point, which I have already

drawn your attention to before now, is to
keep your instruments immersed in water.
Dust, or dirt, laden with infection, will not
reach or adhere to submerged instruments.
Finally, be most careful to count your in-
struments, and especially your haemostatic
forceps, both before and after the operation,
writing their number doAvn on paper and not
trusting to your memory. This precaution,
while apparently superfluous, is of great im-
portance, since it renders the accidental leav-
ing of a hsemostat or other instrument in the
wound impossible.

I first make a superficial incision about
four or five inches long and about midway
between the umbilicus and symphysis pubis,
down to the linea alba or uniting line of the
sheaths of the recti muscles. Tearing the
muscles apart, I come to the preperitoneal
fat, and under it to the peritoneum. This
membrane is caught up with a pair of
dressing forceps, and nicked open. Taking
good care beforehand to feel whether a loop
of intestine is in the fold. The bleeding
points in the skin and muscle are caught
with haemostatic forceps. Having now
opened the peritoneum I am able to introduce
my fingers into the abdominal cavity. I
can now feel the womb and, following the
course of the Fallopian tube, find the left
ovary which is adherent, but not so firmly
as to cause any great difficulty in loosening
it. This is the ovary in which she has suf-
fered so much pain. After firmly ligating
the tube I proceed to remove it. I now
bring out the right ovary. This is also ad-
herent, but very slightly so. But now that
I have removed it I see that it, as well as
the left, is diseased. The condition of the
ovaries before us is quite sufficient to ac-
count for the woman's sufferings during the
past years,for they are much enlarged by cys-
tic degeneration. You see that the removal of
these ovaries has occupied only a few
minutes. To be sure the case is a simple
one ; there has been no pus, and but few ad-
hesions.

We shall now proceed to close the wound.

807

8o8

Clinical Lecture.

Vol. lxiv

I first place a hot, wet, aseptic sponge in the
wound over the intestines. Now I intro-
duce deep silk sutures which include every
layer of tissue. Next the linea alba are
brought together by a continuous and buried
gut suture. Before drawing up these sutures,
and tying them, we remove the sponge
which has been protecting the intestines.
This row of buried gut sutures is most im-
portant and should never be neglected. Its
value is in preventing subsequent hernia,
and I have seen ugly looking hernias, even
in very small incisions, resulting from a dis-
regard of this proceedure. The deep silk
sutures are now tied, and all that remains to
be done is to apply the usual antiseptic
dressing and binder. You see that the
closing of the wound has occupied more
time than the operation, but in operations of
this kind every detail must be performed
with equal exactness, in order to ensure sub-
sequent successful results.

FIBROID TUMOR OF THE WOMB ; SUPRA-
VAGINAL HYSTERECTOMY.

The patient now before you is a woman,
thirty-nine years old, and married, but has
never born any children. For several
years back she has had both menorrhagia
and metrorrhagia, and now copious bleeding
occurs every two weeks. These came from
a large fibroid tumor of the womb. This
long continued bleeding has greatly pros-
trated the patient, so that she is a confirmed
invalid although very fat, as you see.- The
fat, however, is pale and flabby. Strange
to say, bleeding in women very frequently
acts as a fat producer, as it has done in this
case.

What the operation will be, I cannot yet
say. If I can get at the ovaries I shall re-
move them ; if not, I shall have to remove
the womb, making the operation a hyster-
ectomy.

You see I make a much freer and bolder
incision in this case than in the previous one,
on account of the abundant fat. These
fatty cases are always difficult to operate
upon, and I, for one, do not like them.
After cutting through this first thick layer
of fat, we come to the tendenous sheath of
the two recti muscles. Separating them,
another layer of flabby fat is revealed
which I also cut through, and with it the
peritoneum. I find the omentum adher-
ent to the abdominal wall. This is stripped
off to get into the peritoneal cavity.

I now have my hand on a large fibroid
tumor of the womb, and I cannot reach the
ovaries. The case is a bad one — worse in- 1

deed than I at first expected. First of all
we must enlarge this incision considerably
in order to give ourselves more room, and to
get the tumor out. The necessarily large
incision is the principal objection to fat
cases; but here the unusual size of the
tumor would call for a large opening any-
how.

Notice how that the catch in the breath-
ing of the patient throws the intestines for-
ward and make them protrude from the
wound. This is another unpleasant feature
of the case.

I find the tumor adherent to the anterior
wall of the abdomen, but think I can get it
out. We are dealing with a large tumor of
the womb, evidently a fibroid, and our open-
ing is still too small to permit of its removal
and I therefore enlarge it. Through the
incision you may now get a glimpse of the
growth. See these angry and tortuous veins
running over its surface ; some of them are
as large, almost, as my index finger.

At last, by breaking up adhesions, I have
succeeded in bringing one end of the tumor
into the womb, you see it is as large as the
head of an adult ; but I am still unable to
get at the tumor, which is very voluminous
and has no neck. I must, therefore, again
enlarge the wound. Dr. Taylor will now
push up the womb per vaginam, so that I
may be able to get a better idea of the limits
of the growth. It is bound down by adhe-
sions everywhere, and while I might now be
able to forcibly bring it out into the wound,
I dont like to break up adhesions that I can-
not see or get at. This time, in enlarging
the wound, I have cut through and far
above the naval. By screwing a corkscrew
into its upper portion I get a good strong
purchase and deliver all but the pelvic por-
tion out of the wound.

As it has no neck, the lower portion being
as large as the upper, I shall have to enucle-
ate it out of its uterine capsule, and convert
the flaccid capsule into a nedicle. To do
this safely I place two rubber tubes tightly
around the lowest portion of the tumor, to
arrest haemorrhage. I use two rubber tubes
as I care not to trust to one alone. Remember,
that if during the course of enucleation these
tubes should break, we should have a terrific
haemorrhage which could with difficulty be
arrested, perhaps not soon enough to save
the patient. Practically, therefore, the
patient's life hangs upon the strength of these
rubber tubes, and I therefore take the
precaution of using two instead of one.

Let me now proceed to the enucleation,
which I begin by making a circular incision

June 27, 1 891.

Clinical

Lecture.

809

around the growth about 3 inches above the
tube constrictors, and gradually dissect the
capsul free from the tumor. This is difficult
because, by inflammatory action, the tumor
has cohered to the uterine walls. By the
aid of knife and scissors the lower portion of
the tumor, through very slow enucleation
which is unusual, has decreased from about
eight inches in diameter to about four, and
when I have completed the enucleation, the
pedicle will be only as large as my wrist. I
then replace the rubber tubes with this wire
^craseur, which is kept from slipping off by
two transfixing pins. The redundant portion
of the stump is cut off.

I now close the abdominal wound, first by
sewing, with gut, the peritoneal surface of
the stump below the wire of the ecraseur to
the peritoneal edges of the wound. Next,
deep sutures are passed through all the dif-
ferent layers of the abdominal wall. Then
the tendonous fascia divided at the linea alba
is, as in the former operation, united by a
continuous and buried gut suture. The deep
silk sutures are now tied, and the wound
dusted with iodoform and covered with cor-
rosive sublimate gauze. To avoid putrefac-
tion of the stump it is buried in boric acid.
This has been a formidable operation, but
the outlook is by no means a bad one.1

DIAGNOSIS OF VESICAL TUMORS.— HE-
MATURIA AND ENDOSCOPIC EXAMIN-
ATION OF THE BLADDER.

BY DR. GUYON,

PROFESSOR OF CLINICAL SURGERY AT THE NECKER
HOSPITAL, PARIS.

Gentlemen: — To-day I will operate on a
case of vesical neoplasm, but before bringing
the patient before you, I wish to give you
some practical points regarding the diagnosis
of vesical tumors, and in doing so, will pay
particular attention to the subjects of hema-
turia, and the direct examination of the
bladder by means of the endoscope.

The patient in question is a man 65 years
old, who, for the last three months, has with-
out an apparent cause, been suffering from
hematuria. Nearly every time he urinates,
he also passes more or less blood, both at the
beginning and at the end of micturition.
Sometimes his urine is clear, but then even it
will usually deposit a few blood clots. Apart
from this symptom, the patient's urinary

1 Two weeks later this patient was exhibited to
the class. She had done extremely well, having had
a temperature which reached 100° only on one day.

organs are normal. Urination is neither ab-
normally frequent nor painful, and is always
accomplished with ease, and especially so
when the urine is free from blood, it is then
clear, limpid, and free from sediment. Direct
examination shows that the urethra is norm-
al and that the bladder is not sensitive to
moderate dilatation. The injected fluid will
pass out of the catheter entirely clear, except
the last few drops, which will be colored
with blood. The quantity of the blood will
be materially increased if the catheter is
allowed to remain in the bladder for a few
moments, before the expulsion of the liquid.
The prostate, seminal ducts, and testicles
are normal.

If, before resorting to an endoscopic ex-
amination, we make an examination by pal-
pation, one finger being inserted into the
rectum, and the other hand over the bladder,
we will find an enlargement on the right
side. This growth, if such an examination
will warrant us calling it such, is neither
hard nor clearly defined. The sensation ex-
perienced by palpation is, rather, as though
this portion of the bladder was of a syrupy
or gluey consistency. The patient's general
condition is good, and an examination of the
kidneys is negative.

This examination alone, is sufficient to
warrant the assumption that we are here
dealing with a versical neoplasm, but then
among the diagnostic signs, that of hema-
turic is the most important.

In all such cases hematuria is always
present. The urine will become bloody
without any attributable reason ; the patient
has not been suffering either from any great
exhaustion or from any traumatism ; there
is never any alteration in either the fre-
quency or mode of urination, and the act is
accompanied by no pain. In brief, to all
appearances we are dealing with a healthy
and absolutely normal bladder, with the ex-
ception of this one symptom — hematuria.

If such a hematuria has lasted for three
months, accompanied by these characteristics,
there is only one diagnosis for us to assume,
viz., that of vesical neoplasm. In my
opinion, a neoplasm will exist for some
time before the appearance of the hematuria.
This is the weak point in this important
diagnostic symptom. For, if the hematuria
set in as soon as the tumor began to develop,
we might accomplish much by an early
treatment. Unfortunately, however, the
symptom may not appear until the growth
has obtained considerable size. In fact, the
appearance of this symptom has no connect-
ion to the size or growth of the tumor ; it

8io

Clinical

Lecture.

Vol. Ixiv

may appear comparatively early, or not
until the growth has been present for some
time.

One might reasonably suppose that the
amount of the haemorrhage depended upon
the size of the tumor, but unfortunately
this is not the case, and the diagnostician is
liable to fall into grave error if he gauges
the size of the tumor by the extent of the
haemorrhages. A small tumor will not in-
frequently give rise to enormous haemor-
rhages, so severe, indeed, as to materially
effect the general health of the patient,
while, on the other hand, tumors of a very
large size will only occasion trifling haemor-
rhages ; but, as you see, that the size of these
haemorrhages have nothing to do with the
volume of the tumor, it is quite different
regarding their frequency. The haemor-
rhages due to neoplasms are always fre-
quently recurring.

It has been said, and I have said it my-
self, that vesical tumors sometimes exist
without causing any haematuria. I believe,
however, that on this point it will be well to
make one observation, viz. : that in order to
be positive of the absence of this symptom,
a most careful examination of the urine is
necessary. Let me cite a case.

About two weeks ago, I operated upon a
^case of enormous vesical tumor, so large in-
deed that the operation only resulted in
being a palliative. The patient, however,
had had apparently no haematuria. He
claimed never to have passed blood to his
knowledge. The urine, upon superficial ex-
amination seemed clear and limpid enough
but a closer examination revealed the exist-
ence of several minute clots at the bottom
of the vessel. Without doubt, these would
have been overlooked by many, and the case
declared to be one of vesical tumor without
haematuria.

While the quantity of the haemorrhage is
entirely independant of the size of the
tumor, it is, however, of considerable diag-
nostic value in determining the nature of
the growth. Certain hard carcinomatous
growths found in the bladder do not bleed,
while epitheliomae bleed easily.

If the haematuria is insufficient to allow
an accurate diagnosis, we must use other
means in determining the nature of the
growth, viz. : direct examination of the
bladder by means of the endoscope. In the
case which serves as the object of this lesson,
it is very probable that an examination of
the bladder one year ago would have con-
firmed a diagnosis of vesical tumor, and, in
that case, the operation could have been

promptly performed and the patient's
chances wTould have been far more favor-
able than they are now. It would, however,
have been necessary for the patient to con-
sider himself ill enough at the time to need
medical advice, which w7as not the case.
But even if he had come to a surgeon, there
would have been no symptom which could
have warranted an examination of the
bladder by means of the endoscope.

The symptom of haematuria appears too
late to assist in the diagnosis of the disease
at its outset, and at the same time, it is the
first symptom that we have to indicate the
presence of any abnormality. The result is,
that the endoscope is rarely, if ever, the
means of the primary diagnosis of vesical
tumors.

But may not the endoscope confirm an
uncertain diagnosis? Certainly, yes. It
will tell the surgeon whether he is dealing
with a small tumor, surcharged with blood,
or with a large growth. By its aid we
can also frequently confirm the nature of
the tumor ; whether epithelial, or a papil-
loma, or benign. Very frequently a simple
variety of epithelioma is met with and un-
fortunately the endoscope is for many
reasons rarely of any practical value in these
cases.

Even if a bladder is sensitive and will not
permit of an endoscopic examination on ac-
count of the pain produced, its inflation with
a liquid will frequently enable the direct
examination to be made. But these con-
ditions are often only intensified in patients
suffering from vesical tumors. With these
even chloroform sometimes fails to allow the
bladder to be distended sufficiently to permit
of an examination with the endoscope.

In the patient before us, and upon whom
I am about to operate, distention of the
bladder was accompanied with ease. But
we here have another trouble confronting us.
We counted on the urine in the bladder be-
ing clear, and not disturbing the trans-
parency ; but on the contrary, so soon as we
introduced our endoscope into the distended
bladder, we found the instrument surrounded
by an opaque liquid, which rendered the
attempt at an endoscopic dilation unfruitful.
To remedy this we endeavored to keep a
continual stream of water running through
the bladder, but this did not sufficiently
clear its contents to enable us to get any
view of the tumor.

Another frequent difficulty attending the
successful use of the endoscope, is the size of
the tumor. If by the endoscope we cannot get
a view of the limits of the growth, the examin-

June, 27, 1 89 1. Communications.

811

ation will accomplish but little more than
palpation. In short, the value of the endo-
scope as a diagnostic means in cases of
vesical tumors at least, has been much over-
rated. Nevertheless, in cases of small
growths, when it is possible to clean the
contents of the bladder, so as to obtain an
unobstructed view, the instruments may
often be of great service. Its use will also
tell the operator whether he is dealing with
an old or recent growth.

So, you see, that while the endoscope
may be applicable for the examination of
vesical tumors, it does not fulfil all the re-
quirements that one might a pr iori suppose
it to do. It is perhaps well for me thus to
draw your attention to its weak points, in
order that you may be guarded against the
exaggerated enthusiasm of many eminent
genito-urinary surgeons. Still, in cases where
its successful employment is possible, it is
undoubtedly of very great value to the diag-
nostician. It is a great mistake to imagine
for a moment that an endoscopic is called
for in every case of vesical disease, but it is
an equally bad a blunder to dispense entirely
with its use. It was for this reason that I
attempted such an examination in the
patient before you, but unfortunately with
negative results. We will now proceed to
the operation itself.

While the diagnosis of vesical tumor is
confirmed, I am largely ignorant of either
the size or nature of the growth, and there-
fore must run the risk of finding a very ex-
tensive disease, perhaps infinitely worse than
the general symptoms would indicate. Do
not forget, however, that in this case we
have no history of abundant hemorrhages,
but on the contrary, the bleeding has only
been slight, but it has occurred every day.
Yet such operations are frequently attended
by severe haemorrhages. In one of such, I
have seen an anaemic patient die on the
table. In these bleeding tumors the ultimate
success of the operation is also greatly
jeapardized. That we have here a tumor
which bleeds easily has been shown by the
fact that we have been unable to free the
bladder sufficiently from blood to enable us
to make an endoscopic examination.

An operation having been decided upon,
a final question arises, and this is, the possi-
bility of a recurrence of the disease. With-
out doubt, in this case, where the indications
are towards a vesical cancer, recurrence is
probable, but the operation will, more the
less, be of great value to the patient. I
could quote you the histories of a number of
si miliar cases upon which I have operated,

and the results, while perhaps only tempo-
rary, are nearly always encouraging and
satisfactory to the patient. At present the
tumor is increasing in size, already his
general health is beginning to suffer, and
the hematuria is a constant drain upon his
system. I will endeavor to remove the
entire growth, if possible, and in all prob-
ability the man will be able to return to
his work, and his health will greatly im-
prove. A case I operated upon in Sep-
tember 1889, — a very aggravated case — is
now doing well, and apparently in excellent
health.

The patient before the class was then
operated upon. The case was found to be
one of cancer. The growth was removed by
means of the galvano-cantery and the cur-
rette. The patient made a rapid and excel-
lent recovery from the operation. — Trans-
lated from Le Bulletin Medical.

Communications.

STRYCHNIA AS A HEART STIMULANT IN
PNEUMONIA.

BY J. J. THOMAS, M. D.,

YOUNGSTOWN, OHIO.

In St. Bartholomeiv's Hospital Reports,
vol. xxii, there is to be found a paper by
S. Herbert Habershon, M. B., on the use of
strychnia by hypodermic injections in heart
failure, particularly that of pneumonia.
The Reporter of Dec. 10th, 1887 contains
an editorial upon the paper in question.
Habershon places strychnia in the front rank
as a cardiac tonic and claims to have seen
from its use better and more lasting effects
than froni ether, ammonia or alcohol. Dig-
italis even, he considers to be secondary in
value to strychnia in all cases of exhausted
heart muscles, particularly in cases of disease
of the mitral and aortic valves and in pneu-
monia with Cheyne-Stokes respiration and
marked cyanosis. He advocates the use of
the drug hypodermically and in larger than
ordinary doses, citing cases which appear
strongly to support the conclusions of his
views. The matter made a more than pass-
ing impression upon the mind of the writer,
and it was determined to give this use of
strychnia a trial in every appropiate case
occurring during a period of sufficient dura-
tion to make any deduction one of value.

Several years have passed by since the
publication of Dr. Habershon's paper and

8l2

Communications.

Vol. lxiv

numerous opportunities have been afforded
me of putting his views to the test. My ob-
servations have been made chiefly upon cases
of pneumonia, giving the remedy hypoderm-
icaliy in all cases of unusual severity, espe-
cially where heart failure threatened. I have
kept no record of cases for publication, but
while penning these lines my mind reverts to
occasions whereupon the hypodermic admin-
istration of 2V gr. doses of sulphate of strych-
nia, repeated every six hours, certainly ap-
peared to act with wondrously tonic effect
upon the o'er wrought and jaded heart, turn-
ing favorably the tide of life in seemingly
hopeless cases.

Recent studies of the modus operandi of
heart stimulants and tonics appears to sup-
port the validity of the claims made by
Habershon in favor of the value of strychnia.

The Harveian oration of Dr. James
Andrews of St. Bartholomew's, delivered
Oct. 18, 1890, consists largely of a critical
comparison of the actions of this class of rem-
edies in question upon the pulmonary and
systemic circulations. It is shown that
strychnia "produces, in both carotid and
pulmonary arteries, a rise in pressure, espe-
cially marked in the pulmonary artery" In
this particular respect the drug compares
very favorably with the best, ordinarily and
heretofore commonly resorted to in threaten-
ing heart failure.

It is universally conceded that heart ex-
haustion is a common and direct cause of
death in pneumonia, and however practi-
tioners may differ as to the use or non-use of
venesection in the early stages of that dis-
order there is none to dispute the propriety
and the necessity, in many cases, of applying
to the flagging heart the whips and the spur
ere the crisis is reached.

Dr. Andrew H. Smith has contributed to
the American Journal of the Medical Sciences
an extremely valuable article on "Acute
Obstructive Diseases of the Lungs," in which
he calls renewed attention to the fact that it
is the right heart that bears the chief burden
in pneumonia ; though he makes no mention
of the peculiar properties of strychnia in
furnishing to that particular side the needed
stimulus. He emphasizes the importance of
making a daily study of the pulmonary
circulation by observation of the pulmonary
valve sound.

Dr. Bradford, in the New York Medical
Journal, of Jan. 10, 1891, compares the
the actions of digitalis and strychnia, his
article being at once elaborate and scientific.
He prefers the latter in conditions of en-
feebled heart muscle, for the reason that its

action is indirect, being expended chiefly and
primarily upon the spinal cord and sympa-
thetic system. It imparts tone to the func-
tions of the entire muscular system and is a
tonic in the truest sense of the term. He
reports cases of collapse restored by strychnia
given freely, and urges its use, particularly
in pneumonia and diphtheria.

It is altogether probable that to some, if
not to a marked extent, strychnia acts
directly upon the muscles of the right side of
the heart and in the same manner that digita-
lis acts. This with its wider influence in im-
parting a better nervous tone makes it the
ideal heart stimulant in pneumonia. In
critical cases I give it in doses of *V gr. every
4 or 6 hours, and can ask no better illustra-
tion of the resources of therapeutics than that
afforded by the quick response which almost
invariably follows. Hypodermically appears
to be the best mode of administration.
Whatever may be the rationale of its opera-
tion, I have, within the last few years, wit-
nessed too many illustrations of the value of
this article to be at all hesitant in pronounc-
ing it an invaluable resource in pneumonia,
and one that will often and often be found to
justify the confidence reposed in it. A tol-
erance of the drug appears to obtain in pneu-
monia, and to secure good effects the dosage
must be decided and frequent.

THREE CASES OF HYSTERO EPILEPSY.

BY H. F. BYERS, M. D.,

CARUTHERSVILLE, MISSOURI.

On June 26, 1889, I was called to attend
Mrs. H. B., a married lady, 26 years of age,
the mother of two children. On my arrival
the lady was found lying dressed upon the
side of the bed engaged in conversation with
several neighbors. Her husband stated that
she had had several very hard "fits " with
no preceding or apparent cause whatever,
her health was usually excellent, but that on
several previous occasions she had had
" spells " of greater or less severity, the first
happening shortly after the birth of her elder
child, some four years ago. The thermometer
was placed in the axilla and showed a tem-
perature of 99° F. The pulse was normal,
skin moist and natural, bowels constipated.
She answered readily and intelligently all
questions, and complained of hot flashes and
various pains. When asked to describe any
symptoms that advised her of the approach
of a spasm, she said that they always Came

June 27, 1 891. Communications.

813

011 with a violent sense of cramping and a
drawing in of the big toe of the right foot, and
that something seemed to rise from that
point and choke her. While engaged in
conversation with her she suddenly ex-
claimed : " There, doctor, one is coming on
now." The big toe of the right foot, of
course, claimed my immediate attention, it
was found to be forcibly flexed, while the
foot was extended to the utmost, in rapid
succession all the muscles of the right limb,
and then of the whole body, became involved
in tonic convulsions. The head was thrown
back and to the left, the eyes rolled back so
that the whites alone were visible, and there
followed a convulsion in all respects, save
only one, like those of puerperal eclampsia —
the tongue was not bitten. Two more con-
vulsions occurred in rapid succession, when
they were controlled by the hypodermatic
injection of morphias sulphatis gr. i, and
atrophias sulphatis gr. rio. A prescription
of potass, bromidi gr. xx, chloral hydrat,
gr. x, morphine sulph. gr. %, to be given at
intervals varying from one to four hours,
p. r. n., controlled the spasms for twenty-
four hours, when the hypodermatic injection
was repeated, with only temporary relief.
After exhausting my therapeutical resources,
and a considerable amount of patience, and
being out of the reach of consultation, I gave,
with a view of its relaxing effect, as well as
the mental impression, 2 grains of the yellow
sub-sulphate or mercury and a pint of warm
water. The lady began in about fifteen
minutes to alarm her husband and friends
by assuring them that "death had struck
her," and by giving directions as to the dis-
position to be made of her effects. This was
followed by copious emesis and immediate
permanent relief, so far as the " fits " were
concerned. This lady is in robust health and
had had no return of the convulsions in
almost two years, and so far as is known to
the writer, no other manifestations of
hysteria.

' Case No. 2. — Miss E. P., aged 19 years,
first seen on August 2, 1890. She had had
before my arrival eleven spasms similar to
those described in case No. 1. Except that
she gave no manifestations of consciousness
in the interium until after my arrival, when
it was found that she was aware of all that
happened in the room. The globus hysteri-
cus was a well marked feature, the girl tear-
ing frantically at her throat as the convul-
sions came on. The treatment, consisting
of morphia and atropia, hypodermatically,
chloral per rectum and by the stomach,
bromides in large doses, clearing the alimen-

tary canal by large doses of castor oil, and
an emetic of powdered ipecac, all failed to
afford permanent relief. Four ounces of blood
were taken from the arm, with some benefit,
(caused possibly by the mental rather than
the physical impression made by its abstrac-
tion.) As a last resort, on August 6th, two
grains of the yellow sub-sulphate of mercury
were given, followed by copious draughts of
hot water, immediately after its physiological
effects secured most prompt and permanent
relief, the patient having had no return of
the symptoms as late as a few months ago,
when she removed with her family to an
adjoining state.

Case No. 3. — Miss J. C, aged 20 years, of
nervous temperament, though of ordinary
good health. There is no history of any
previous attack of the kind. There had
been, shortly before her illness from derange-
ment of the catamenia incident to exposure
to draughts or cold. On the 21st of March,
1891, she complained of headache across the
brow and afterwards of alternate flushings
of heat and cold sensations, with some pain
in the lumbar region. On the 22d she was
apparently well, making no complaint what-
ever until about 6 P. M., when she had a
" fit." These " fits " continued at shortening
intervals until the 24th, when the writer was
called. The patient was found propped up
in bed with pillows, perfectly conscious and
able to answer all questions intelligently.
She said there was some pain in her back
and general muscular soreness and also a
" curious pain in her tongue." When asked
if she knew when a spasm was coming on
she said " yes, they come on by an appear-
ance like smoke before my eyes and then I
smother." While still engaged in conver-
sation with the writer she began to spit and
slabber,when several bystanders immediately
seized her and held her in anticipation of
the spasm which came on immediately; the
whole frame was convulsed, the eyes rolled
back and alternately opened and shut very
rapidly, (something I have not noticed in
any other case,) the jaws were fixed at first
and then came to with a sharp click or snap.
Consciousness during the fit was abolished.
The tongue was not bitten. There was no
blood in the saliva that escaped from her
mouth. The duration of the spasm was pro-
bably 30 seconds. In exactly 15 minutes,
during which time complete consciousness
was regained, another convulsion occurred.
They were controlled by chloroform, and
a hypodermatic injection of morphia; sulph.
gr. J, atropise sulph. gr. h, with the effect
of stopping them until the next day,

814

Comm unications.

Vol. Ixiv

when I was re-called. During my absence
some of the neighbors, who had collected,
suggested the idea of hydrophobia from
a dog bite she had gotten two years ago.
It was not known that she had heard the
conversation but soon afterwards she began
to have a hoarse cough and to try to bite
those around her as well as to lap the water
which was given her to drink. It should
have been mentioned that her appetite was,
during the whole of her illness, voracious,
and that there was no difficulty whatever in
swallowing. On my second visit I found
her raving, she did not appear to remember
my name, calling me " Moad," (the name of
a neighboring farmer,) but knew my business
perfectly well, begging me to "keep the smoke
away." She bit at her father who was sup-
porting her head, and had a convulsion
exactly like those described above. I talked
to her and told her that her biting and lap-
ping was all nonsense, then holding her head
and placing a cup of water to her mouth
bade her drink, she lapped. Throwing her
head back the cup was pressed between her
teeth and its contents were swallowed with-
out difficulty. Her arm was corded and an
ounce or two of blood drawn with no effect
except to slightly increase the interval be-
tween the spasms. Two ounces of castor oil
were given which caused a large dejection in
a short time. Chloroform, bromides, morphia,
gelsemium, and chloral, were all tried with
temporary relief, lasting only during the sleep
which was produced. There had been occa-
sional vomiting from over-loading the
stomach with food and water which had been
given her without stint during my absence.
I had been unable to make a positive diag-
nosis up to the second visit when the pseudo-
hydrophobic symptoms manifested them-
selves. The neighbors were sent away and
quiet secured. The emetic used in both the
other cases was given with the happiest re-
sults, the snapping, lapping and fits all stop-
ping as the deathly sickness caused by the
emetic came on, and a quiet sleep supervened
as it went off. On the next day she said she
felt very well and wanted to get up. The
temperature which at my first visit had been
99° F. was on the day after the trouble was
ended but normal, the thermometer in the
axilla registering 97° F., attributable, no
doubt, to exhaustion. A small amount of a
stimulant with a liquid diet and a general
tonic were ordered.

A talent may be developed in the cloister ;
character can only be perfected in the world.

THE RELATION OF IMPERFECT SURGERY
TO THE SEQUELAE OF PELVIC AND
ABDOMINAL OPERATIONS.1

BY JOSEPH E. HOFFMAN, M. D.

So touch has lately been said and written
relative to the results and, therefore, to the
justifiability of abdominal and pelvic opera-
tions that it is necessary for the candid
critic and honest operator to stop and con-
sider what on the one hand is the exact
status of the repentant critics and of their
changed attitude toward the position and
merits of surgery, and on the other how far
inexact methods are accountable for some of
the failures and misfortunes of what would
otherwise be a field of almost unprecedented
brilliancy and encouragement in the results
that have been obtained in this branch of
surgery.

In the first place it is to be noted that of
all the men who have gained prominence in
any of the various domains of surgery in
general, not one has abandoned that specialty
from a surgical standpoint in order to treat
it empirically by any other method. Sir
Henry Thompson, for instance, has not de-
parted from the exact surgery of the blad-
der in order to destroy its calculi by solvents
or electricity ; Mr. Mace wen, bone surgery ;
or Schaeffer, orthopaedics. What is meant to
be here illustrated is that when a man has
once chosen a specialty and worked up to
that specialty by an experience gained by
natural selection and application, his spec-
ialty has become so much a part of him that
its abandonment is just as impossible as the
negation of the laws of gravity. His train-
ing makes it the law of his mental gravity,
and the same laws apply to it as to weight
and inertia in the physical world. The
greater his experience, the longer his train-
ing, the more certain is he in regard to the
limitations, the requirements, the possi-
bilities of his work, and as a result of all
this his position, when taken, is an en-
trenched one, from which he is not to be
moved and made a weathercock of every
shade of opinion, whether of madmen, fools
or philosophers, for none of these are apt to
speak from a practical experience, in sur-
gery at least, and practice, not theory, has
made surgery what it is.

That there are specialties in surgery has
come about by the consensus of opinion
among surgeons in general, and physicians,
strictly so-called, that there is need of them.

1 Read before the Phila. County Med. Society,
May 27, 1891.

June 27, 1 89 1.

Comm unications.

815

The specialist in any branch is the living
embodiment of the necessity of his work.
To whom then is the title of " specialist " to
be applied ? In each branch confessedly,
to those who work conformably with their
expressed sentiment, or if not teachers whose
line of procedure is uniform and the result
either of their own experience wrought out
by laborious painstaking, or conforms with
that of other expert workers in the same
line.

To that class of see-saw workers who anon
are this and anon are that the name special-
ist should be applied. For accurate exact
surgery, we cannot look to the electrician or
the dabbler in it. If one condemns a pro-
cedure to-day and extols it to-morrow we
are brought to the point of inquiry, Which
view is correct, which has the vantage of
observation? or perhaps, Is either expres-
sion of any value whatever, or is the change
made like that of the slight-of-hand man to
puzzle his audience and bring in a set of
new admirers to be pleased by the rare and
startling exhibition of surgical acrobatics, a
surgery in which the constant is differ-
entiated out of sight by the variable. ?

These inquiries and lines of thought are
suggestive of some of the causes we have to
consider in the relation of imperfect work to
the sequelae of abdominal and pelvic sur-
gery. What has been said of experience as
a necessity for a firm faith in the necessity of
any special branch of work, is true with just
as much force when the ability to do such
work is considered. The appalling eager-
ness with which men with only a diploma as
a justification and a safeguard from the hand
of the law to do abdominal surgery is one
of the startling features in the history of this
work. In no other branch of the art has
there ever been any approach to such audac-
ity. That fools rush in where angels fear to
tread has never been more aptly illustrated.
Training has been, nay still is, rejected,
while the work is sought, and if the case is
found willing to be offered up an offering to
the prurient itch of a surgical pretender, the
case is at once reported as a wonderful cure
in the hands of the youthful aspirant, or if
unsuccessful is recorded, heralded, and posted
up as a warning against all surgery in gen-
eral, and against that sugeon in particular
who has been rash enough to loan both his
instruments and experience to a neophyte
with no other experience than ingrown toe-
nails and vaccination, now hiding and ex-
cusing himself and his failure behind the ex-
perience of the too easy friend, who by a
mistaken kindness has martyred both him-

self and surgery and done both an irrepar-
able injury. I take it that it should be the
rule of all surgeons to assist no one who has
not studied, observed and assisted in such
work. There is no excuse or reason here for
a man to begin with all the faults and errors
of the early operators, and again work out
the technique of this branch of si&gery in a
series of failures and calamities that once
well-nigh led to its abandonment. The work
of such men cannot be other than imperfect,
and must reflect upon surgical interferences
in these affections in the minds of the un-
critical and unthinking. Another class of
operators to be carefully watched, is those
who, by fair means or foul, are bound to
obtain prominence. These men have lain in
wait for operations, as the moonshiners for a
cloudy night, to bring themselves into prom-
inence, let us say notoriety. These men
have opened abdomens, not to operate, but
to do the first step of an operation. I can
this moment put my hands on such a case,
in whom nothing was found wrong, but
there was a chance to perpetrate a pet fad,
and the woman is now dragging out an ex-
istence after three subsequent operations, all
the result of the first unnecessary tinkering.
If we are to criticise abdominal surgery, let
us not do so with the results of such opera-
tors and their methods before our eyes. Let
us rather criticise the crude methods and
cruder morals, or if you please the code that
tolerates apprentices and dabblers to do with
the bodies of our patients for the like of
which we would ruin the reputation of our
tailor or well-nigh mob a cobbler. That
such surgery has been overdone is just as
true as it is that it has no right to be con-
sidered surgery at all. And just here it is
to be said that among men of this dass, I
mean those who have done the kind of work
just referred to, we are bound to find our
latter-day conservatives and repentants. Of
all those who have gained and kept a name
as foremost in the rank of abdominal sur-
geons, we find no recanters. These are
almost always to be found in the lines of
failure or discouragement or embarrassment.
If a man has made blunders he is a fool not
to perceive them, or if the real spirit of sur-
gery is beyond him and he feels it, he alike
is bound on the one hand to retrieve past
misfortune by so-called conservatism, sitting
on the pons asinorum watching the stream
of surgery flow by, and with it the hopes
that he no more has chance of realizing. On
the other, having neither the spirit of sur-
gery within him nor the courage to attain
it by drill and application, nothing is left

8i6

Com m unications.

Vol. lxiv

for him but to be a dissenter, to decry all
surgery as mutilation, nothing justifiable but
conservatism. From this standpoint I make
the plea that each one of us, before he con-
demns surgery, its justifiability or its results,
shall judge of them all. As sensible men
and women, saying that we are in need of
surgical attention, to whom shall we go?
To the apologists for their work, to those
who have operated themselves into repent-
tance, who have made an experience only to
regret it ? Certainly not. Experience and
judgment in this work is no more to be
gotten in lumps, than can knowledge be
bought by the wagonload of books.

If there has not been an antecedent ex-
perience from which special knowledge has
been differentiated, this special knowledge,
though it may be wide enough theoretically,
practically is cramped and dwarfed. The
wider the general experience, the more exact
will be the special. Having considered the
class of operators we must look to for errors
and repentance, let us look at the work as
surgery simply, not in the light of miracles it
is supposed and often promised to work.
Miracles nothing human can perform. No
surgeon has a right to promise an absolutely
certain result in every case. I have too fre-
quently heard promised, " The operation will
make you a well woman." Patients are per-
suaded into operation when they should be
left to choose it for themselves. I have noth-
ing but condolence, may be contempt, for the
surgeon who has to persuade his patients to
be operated upon. Herein comes a great
deal of the blame of surgery in the abdomen
and pelvis. Who ever heard of a surgeon's
having to persuade a patient to put a splint
upon a broken leg or a ligature around a
bleeding vessel? The indications for every
operation should be plainly stated, and the
patient or her responsible friends be re-
sponsible for the decision for or against
operation.

The disasters of operation, on the other
hand, ought not to be attributed to the inhe-
rent danger of abdominal or pelvic inter-
ference. We are to remember that, as a rule,
except in extreme haemorrhage and in dis-
eases implicating the kidneys, bladder, or
uterus, abdominal operations ought to be, as
a rule, successful. It is well for all aspiring
operators, and for many who consider them-
selves established, to ponder well the words
of Savage. He says : " I think we ought to
get into our minds, as a prominent idea, the
view that after an abdominal operation a
death should be considered to an extent as
preventable, and that when one does' occur

we should hold with ourselves a moral in-
quest as to the cause, how it might have been
prevented, and whether in any way it was
associated with aught relating to ourselves."
As time goes on, I am more persuaded that
in the question of success or failure, less and
less depends on the patient, her conditions
and surroundings, and more and more on
ourselves and the attention to certain details
which have been found to be essential."
With such a standard as this a man cannot
fail to do the best possible work. High
ideals, though they never be quite realized,
are a safeguard against the nauseating com-
placency with which certain operators con-
template their woeful results, blaming either
Providence or the nurse, allowing themselves
to escape unscathed.

It is well iust here to consider Mr. Savage's
expression when he says " Less and less de-
pends upon the patient, her condition and
surroundings," for this is at once too wide
and at the same time widely true. It is just
as evident that patients go on suffering time
and time again, until they are hopelessly ill,
as it is that, if taken earlier, no matter what
their surroundings, they could have been
cured. This fact must stand out a perpetual
contradiction to those who in charity adver-
tisements for private aggrandizement laud in
season and out the over-laudatory achieve-
ments of hospital surgery. Right here I
want to say that the best results that have
ever been gotten in this city in a wide series
of cases have been done in private houses,
many oT them have none of the recognized
conveniences either for comfort or ideal
cleanliness. The room that the patient oc-
cupied was often the only clean one in the
house, and yet, as a rule, all of these patients
get well. We, as operators, have no business
to scare a patient into a hospital for our own.
convenience.

By doing so we bring into the chances of
her recovery an additional element of doubt.

In estimating the importance of the sequelae
of any surgical operation, we must compare
them with the gravity of the condition for
which the operation was done. Generally
speaking, promptitude in ridding a patient of
any surgical disease is a step toward avoiding
after complications as well as primary im-
pediment to rapid satisfactory work. If a
patient is suffering from suppurative ab-
dominal disease, which by its presence
threatens life primarily by septicaemia, or
indirectly by secondary implication of vital
organs, the fact that a hernia or fistula re-
mains after operation is no argument either
against the advisability of operation nor

June 27, 189 1. Communications.

817

against the results of the operation. The
argument rather rebounds against the critics,
and should convince them that early opera-
tion, while giving the patient a better primary
chance for life, secondarily would leave him
in better condition to resist the influences
that tend to prevent prompt healing and,
therefore, conduce to fistula and hernia for-
mation. To appreciate these and other
pathological points, a thorough appreciation
of the pathology of pelvic inflammation is
necessary. A devotee of the ancient doc-
trines of pelvic cellulitis, has no hope of be-
coming either a skillful diagnostician in or a
surgeon of pelvic disease, since his supposed
pathology does not agree with the actual con-
dition of affairs, and hence he is handicapped
from the start and the incubus of tradition
must be fatal to his progress

In advanced cases of tubal and ovarian
disease, theory will tell him to treat the dis-
ease by derivative measures, aiding himself
possibly by closure of a cervix, when lo ! the
patient grows worse in his hands, and is only
rescued by the merest chance by final resort
to the abdominal section. In such cases it is
no uncommon condition in which there is
such a generally vicious condition that
healthy tissue in which to place a ligature
can scarcely be found, and the result is a
fistula, through which a ligature ultimately
is passed. Here only the most careful
technique, of making a good stump, cleaning
out the necrosed tissue for this purpose, and
diligence in using accurately all precautions
against infecting the ligature while it is being
placed around the pedicle, will prevent the
formation of fistula, or at least of the condi-
tions that will result therein. Hernise are
cited as a perpetual menace against the pro-
priety of abdominal operation. Women are
said to be worse from them than from their
original trouble. In these cases the value of
personal opinion goes very little to announce
the true condition. The surgeon or the critic
of surgery who estimates the value of either
medicine or surgery by the reports of the
patient will argue from very uncertain and
worthless data. Some patients will complain
more from a slight hernia than originally
they did at the trouble necessitating opera-
tion, or at least their complaints are very
distinct. In the first they groaned in
anguish, begging relief, while at last they
repudiate all surgery because they no longer
suffer torture at each menstrual period. To
this they are frequently encouraged by meddle-
some women who, never having suffered, can-
not appreciate the tortures of disease, or by
malevolent professional rivals who descend to

such indecent methods in order to compass
the ruin or professional distrust of the com-
munity against the operator. As a rule,
hernise and fistulae especially should be rare.
Hernia is a constant danger in fat women,
both as primary owing to the uncertain heal-
ing of the fat, and secondarily as a result of
weakening the abdominal support. Hence
the rule should be in all such cases to keep
the patient in bed much longer than is re-
quired to heal the incision, and after getting
up constantly to wear an abdominal support.
A failure so to advise is just as culpable as to
admit the elastic support over a dislocated
patella, and can only occur as the result of
sheer carelessness or ignorance of the require-
ments of this special class of cases. Fistulse
besides resulting from ligatures, may have
their origin in lesions of the intestine result-
ing from the freeing of adhesions. Fecal
fistulse are rarely persistent, almost never so,
and in the great majority of cases can be
avoided if a careful watch is had over the
bowel involved in the adhesions. Here the
result of bad work must result disastrously,
both so far as perpetuating the fistula is con-
cerned and in doing damage to the intestine.
To obtain perfect results the intestine is so to
be mended, not only to prevent leakage of its
contents, but also to avoid adhesions com-
promising its function and conducing to ob-
struction. In this relation the deaths from
intestinal obstruction after operation are to
be considered. In the hands of experienced
operators this rarely if ever happens, and if
it occurs it is recognized and relieved. One
death occurring from such cause coming
under my knowledge was the direct result of
placing the patient shortly after operation in
the care of a physician without any experi-
ence whatever in a surgical way. The com-
plication accordingly was not understood,
and by the time surgical aid was sought the
woman was practically dead. Imperfect
after-attention of surgeons eager only to
operate, has been and will continue to be the
cause of much reproach to surgery. Until
his patient is out of bed and moving about
freely, the surgeon has no right to dismiss
her as cured. If a hernia occur after opera-
tion it is the duty of the surgeon to explain
its nature and make early effort to cure it.
The earlier it is cured the less will be the
obstacles in the way of permanent relief. To
have a patient die of operation for hernia,
the result of the surgeon's own operation,
ought to be a calamity almost unheard of.
Nevertheless it ought to be understood that,
owing to the size of the sac, and the conse-
quent extent of the adhesions, some herniie

8i8

Communications.

Vol. lxiv

are practically incurable unless at a great
risk. One such case is still fresh in my
memory, in which, after a long relief, the
hernia again returned. The woman was
very fat, and with the difficulties of a former
operation fresh in my mind I refused another.

There is no use in operating and reopera-
ting in unfavorable cases until at last the
patient is lost. Surgery nor the surgeon re-
ceives credit, while the patient receives no
benefit. Imperfect knowledge of how to
drain is at the bottom of many failures in
the surgery of the abdomen. I once knew
the question to be asked by a man following
up the matters of abdominal surgery, very
far oif to be sure, "-How long does the tube
stay in — till it smells ? " I have seen a tube
removed containing more than an inch of
coagulated serum, this last in the hands of
an operator who ought to know better than
now to advise the cleansing of the tube once
every twelve hours, or some such long inter-
val. A drainage-tube that needs cleansing
or emptying only once in twelve hours had
better be kept clean in the bag until it is
wanted. Such advice as to the use of the
tube is worse than worthless. To be valu-
able, information must come from those who
are informed not from those who are guess-
ing or using the tube under protest or be-
cause some one else uses it. It is better not
used than badly or carelessly used. Drain-
age and the conditions that require it must
always remain a disputed question, but one
fact alone must forever keep its opponents
on the defensive, and that is that those who
advocate it most have had the most experi-
ence with it, and that their cases so treated
run a most uneventful course, even in most
serious antecedent conditions. One point
negativing its advantages in some cases
urgently needing it, is the semi-delirious con-
dition of the patient during the first few
days immediately following operation.
These patients are unruly and their unrest
will disturb the position of the tube and
render it at once irritating and useless. I
have two patients in mind in whom I believe
the tube on this account would havs been a
serious disadvantage. In another in whom
I considered it advisable, I removed it at
once when it had become displaced. I shall
never forget the anxiety with which I
watched over this patient through several
days, fearing the oncoming of peritonitis and
dreading the necessity of reopening the
abdomen.

But if the proper use of the drainage-tube
is essential to success, it is to be remembered
that crevices created by desultory breaking

up of adhesions at the bottom of the pelvis,
having no common outlet by which they
may drain, are beyond the reach of a single
tube; hence, in appendicitis, for example,
the careful placing of an additional rubber
tube often gives security when otherwise, at
best, the end would be doubtful. A case of
my own is here vividly before me and brings
out the theory justified by results.

When it is sought to break up adhesions
on either side of the pelvis because
one side seemingly presents less diffi-
culty than the other, the more difficult
should not be abandoned when once
begun, unless it is plainly evident that
by freeing the simpler side a vantage-point
is gained from which to attack the other.
Going from side to side but gives two diffi-
culties where but one before existed, and
in event of prolonged operation, when com-
pletion for the patient's sake must be aban-
doned or postponed, adds additional com-
plication and takes away some of the chances
of recovery. Such methods are common to
inexperienced workers, and must be aban-
doned if good results are desired.

Incomplete operations are at the bottom of
much of the criticism made as to the useless-
ness of abdominal or pelvic surgery. When
an operator removes but one ovary and tube
for hemorrhage of a fibroid he confesses to
the knowing critic his incompetency to deal
with the conditions he meets. He is as
likely to cure such haemorrhage by such sur-
I srery as to raise chickens from china e££s.

By this it becomes manifest that a lack of
resources is fatal to ideal surgery. The sur-
geon who deserves the name is a man of
emergencies. The surgeon in masquerade,
like the journeyman actor, tears, not his pas-
sion, but his patient to tatters. By every
operation so done a certain number of
women whom surgery might save are fright-
ened and so hindered from receiving the
benefits of real surgery.

The easier operations are the bane of the
would-be surgeon. Suceeding in one of
I these, he imagines he has conquered the
whole field and at once rests easy in his
assurance. To such men, and their patients
generally, absolute failure in their first
attempts is a distinct gain, for it frightens
them away from the possibility of doing
further harm.

Many other points leading to and illustra-
ting the same idea, and showing conclusively
where mal-operation and needless operation
are most likely to occur, and why, could be
multiplied. But this is not necessary. It is
plain that that operator only is safe who has

June 27, 1 89 1.

Society Reports.

819

first learned by a long and painstaking
apprenticeship, thoroughly and patiently,
the principles of the work he is to perform ;
who, grounding himself in the principles,
has applied them at the side of capable in-
structors ; who, when he operates, does so for
the patient's good and not for his own glory.
Such a man — such men— must both give
their patients their best hope and be the
saviors of surgery from its false exponents,
who only disgrace it.

The men who get the best results are those
who work along the safe lines, departing
from them as necessity compels according to
the exigencies of each individual case ; not
those who from the threading of a needle to
the cleansing of a tube or the washing of
their hands strive to be original. Such
originality hides real surgery in a multi-
plicity of details and paraphernalia, and
risks the sufferer to exalt the operator.
(For discussion see Society Reports.)

Society Reports.

PHILADELPHIA COUNTY MEDICAL
SOCIETY.

Stated Meeting, May 21, 1891.

The Vice-President, De Forest Willard, M. D., in
the Chair.

DR. JOSEPH E. HOFFMAN SUBMITTED A PAPER ON THE
RELATION OF IMPERFECT SURGERY TO THE
SEQUELAE OF PELVIC AND ABDOMINAL
OPERATIONS. — (See p. 814.)

Dr. M. Price : I am fully in accord with
the belief that most of our deaths can be
accounted for by some want of care on the
part of the operator before, during, or after
operation. I recall two cases in which the
previous care before the operation had every-
thing to do with the result. In one, the
woman was sent into the house to be oper-
ated on. The patient declared that the
bowels had been freely moved fifteen or six-
teen times on that day. The operation was
done, and it was found that the patient had
not had the bowels opened for two weeks.
She had an impermeable stricture, which
would permit the passage of nothing but the
watery contents of the bowels. The fatal
result might have been avoided if the patient
had been under the care of a trained nurse
before the operation. I have seen this acci-
dent twice.

Many men who profess to be abdominal
surgeons will go to a case of supposed tumor,
or some other condition, prepared to do only
that operation. They go to do an ovari-

otomy and a hysterectomy is required. The
result is a death. The surgeon must carry
with him everything that can be needed. I
have seen many hundreds of abdominal sec-
tions, and have seen about as many mistakes
as most men, and that, too, in the most com-
petent hands.

As to the success of abdominal surgery.
Does any one pretend to say that when a
surgeon amputates a leg, giving the patient
a useful stump, that is not a success? I
hold that it is. If we had subjected an
abdominal case to such a risk of life, and
had left it in such a crippled condition,
what a howl there would be on the part of
the medical profession ! You take a woman
who has been lying around, unable to assist
herself in the slightest, and you remove the
disease and allow her to move around with
some little pain, some little crippling of her
gait. You cannot expect to make a perfect
cure. Many of the objections, and many of
what are called sequelae are the fault, not of
the surgeon, but of the patient's delay.

Dr. G. Betton Massey : The attempt has
apparently been made to make an apology
for surgery. I think that from some points
in view the surgery of the abdominal cavity
needs an apology. By some we are told that
the bad results are due to improper opera-
tions, and by others that they are due to
the diseases themselves. I would take no
exception to that class of bad results in
those cases of abdominal disease incapable
of being cured in any other way than by
surgery. I have been much impressed with
the mistake which is the keynote of Dr.
Hoffman's paper — that is, the mistake made
by surgeons persuading women to be oper-
ated on who do not require any operation.
I have seen a number of these patients who,
fortunately, have failed to take the advice
given by the surgeon. I have now under
observation a lady who was persuaded to
have the ovaries removed in order that the
cervix might be repaired. A little reduc-
tion of the congestion and enlargements of
the parts in a rather stout patient showed
that the whole trouble came from a subin-
voluted uterus and a hypoplastic enlarge-
ment of one side, which was rapidly im-
proved.

Dr. O. H. Allis : It seems to me that a
good deal depends upon who gives the ad-
vice whether an operation should be done
or not. A patient comes with sarcoma of
the jaw, where nothing but the removal of
the entire jaw, or at least half, will save
life. Although the surgeon urges operation
with earnestness, the patient goes away and

820

Society

Reports.

Vol. Ixiv

nothing is done. The delay is fatal. The
same is true in strangulated hernia. The
patient should be urged to undergo immedi-
ate operation.

Dr. William E. Ashton : The question of
hernia following abdominal section is one of
great importance. The surgeon who says
that he never has a hernia does not follow
up his cases. The majority of hernias are
due to a failure in properly uniting the
sheath of the rectus. I do not believe that
fat women are especially liable to this acci-
dent. The integrity of the abdominal wall
depends entirely upon the sheath of the rec-
tus muscle, and this should be sutured in all
cases. I believe, also, that a large number
of hernias are due to getting out of bed too
soon. The patient should not get up under
three weeks. There is not much benefit in
an abdominal support. I have found it im-
possible to keep any bandage closely enough
applied to relieve the ordinary strain. If
the patient is doing heavy work, an abdom-
inal support may be of service.

In regard to fistula caused by a ligature,
I might mention a clever device told to me
by a doctor from Texas. He takes a num-
ber of horse-hairs, doubles them over upon
themselves and ties them together, and passes
them into the fistula and turns them around.
In this way he often succeeds in bringing
away the ligature.

I believe it to be a good plan to have the
patient in a hospital, if possible, in order
that she may be under observation and con-
trol. I do not believe that there is more
danger of sepsis in cases operated on at
home than in those in hospitals. Sepsis
does not come from the atmosphere. Bar-
ring the question of control, there is little
difference, so far as results are concerned,
where we operate.

Dr. J. Price: Dr. Allis has given an in-
teresting point in reference to the selection
of cases and the importance of promptitude.
The whole experience of abdominal sur-
geons is in favor of promptitude in pelvic
abscess and in small tumors of all kinds. I
may say in regard to mortality that if my
mortality equalled the number of cases that
I find dead when I arrive at the house, I
should cease to operate. A man to do ab-
dominal surgery should serve an apprentice-
ship, not only that he may know what to
recognize, but that he may, with specimens
in hand, compare them with the histories.
With a pair of pus tubes or a pelvic abscess,
you can almost demonstrate the number of
attacks of pelvic peritonitis that the woman
has suffered.

It is very nice to talk about the sequela?
of abdominal sections, but the sequela? ante-
date the operation in many cases. I saw to-
day, a large cystoma, probably complicated
with fibroid. The patient had been coun-
selled by many not to have the tumor re-
moved. I sometimes wish that the general
practitioner and general surgeon were like
the eye and ear men — they attend to their
business and say nothing about anything
else.

Dr. J. M. Baldy : Unquestionably many
of the so-called sequela? occur before the sec-
tion has been performed. Many, also, are
due to incomplete operations. I do not
think that any one cause is a fault. I have
not found that fistula? and hernia? are more
apt to occur in fat women, nor have I found
that suturing of the fascia will prevent it.

In regard to hospitals, I believe in rail-
roading patients into hospitals, if you have
wTell-appointed ones. You have there a bet-
ter chance to do good work and to watch
the patient. Some of my best work, how-
ever, has been " alley work," but it has been
most anxious work. In these cases I have
been forced to permit them to get up in two
weeks. In hospitals you can keep the
patient in bed. I think that four weeks is
not too long.

As to the cause of death, I have seen one
death from shock in the hands of another
gentleman. I have seen one or two deaths
from hemorrhage, but the one great cause
of death is septic peritonitis. In some of
these cases I have thought that the tube was
at fault, but in others there was no drainage.
In regard to early operation, if it is an
operative case, the operation cannot be done
too soon.

Dr. Charles P. Noble : In regard to the
cause of death after abdominal section, I
may say that in my own experience the
deaths, with two exceptions, were due to the
fact that the patient was operated on when
she was almost dead from disease. I have
had three deaths from kidney trouble. In
two the condition was not discovered prior
to operation. Serious kidney disease is a
positive contra-indication to abdominal sec-
tion involving any considerable manipula-
tion.

I think that our facilities for managing
patients are much better in hospitals than at
home, and I think that there is every in-
ducement, both on account of the patient
and ourselves, to urge her to go to a hospital.

In reference to cellulitis. Most men who
do abdominal surgery say that they never
see cellulitis. I have seen it but do not

June 27, 1 89 1. Society

Reports.

821

think that it is a common condition. I do
not believe that we meet with it as a non-
puerperal condition. Cellulitis in the pelvis
occurs as does cellulitis in other parts of the
body — from infection. I have knowledge of
four abdominal operations in which the tubes
were examined and found free from pus ac-
cumulations. Of course it was not possible
to say that catarrhal salpingitis was not
present. Large quantities of pus, however,
were evacuated through an incision over the
ramus of the pubes. They were undoubted
cases of pelvic abscess. I believe that this
accounts for the fact that certain women re-
cover and bear children after they have had
pelvic inflammation complicating labor.

In regard to drainage, it has become my
practice to drain in almost every case, and I
have seen no reason to regret it. Unless
there is a special reason to the contrary, I
drain every case. It is often said that unless
the tube is cleaned every half hour to two
hours the surgeon does not understand drain-
age. At the Kensington Hospital for
Women there has been a series of as many
as sixty cases, with one death, where this
principal of drainage was not used. In the
last thirty-three cases (without a death) the
drainage-tube was not evacuated oftener
than three times in twenty-four hours. My
experience with the capillary drain, running
over one hundred cases, enables me to say
that it is a most efficient form of drainage,
and that it is the exception, even in bad
cases, to find more than a drachm of fluid in
the pelvis when the tube is drained. By
this measure the pelvis is continually
drained.

Dr. Hoflman : While a capillary drain
will remove the liquid, it will not remove
clots. The syringe will. All that my point
stated was that cleaning the drainage-tube
once in twelve hours is not cleaning it.

In regard to hospitals, I can control my
patients better in their homes. The hospital
is not a sine qua non, and it is not free from
danger.

In speaking of advice in surgery, I did
not object to real advice. We, however,
compromise ourselves by seeking operations,
although those things are done. If an
operation is necessary we should say so, and
tell why it is. If the patient does not
accept it, the result does not lie at our door.

The Bacteriological World is the title of a
monthly illustrated magazine for the study of
microbes and diseases of bacterial and par-
asitic origin, edited by Dr. Paul Paquin, of
Columbia, Mo.

Dr. W. W. Keen then read a paper en-
titled :

A FURTHER COMMUNICATION ON A NEW
METHOD OF COMPRESSING THE SUB-
CLAVIAN ARTERY : WITH THE
REPORT OF TWO CASES.

He said, I desire to call the attention of
the Society to the method which I proposed
some time since for controlling the circula-
tion in the upper extremity by elastic com-
pression of the subclavian artery. ( Trans-
actions Philadelphia County Medical Society,
February, 1890.) This, it will be remem-
bered, was effected by a pad over the sub-
clavian, held in place by the ordinary rubber
bandage of the Esmarch apparatus ; the
elastic bandage being carried from the chest
over the back, and then alternately between
the thighs and in the opposite armpit.

Not long after I made the suggestion I
made a trial of it for my friend Dr. Hearn,
in the clinic at the Jefferson Medical College
Hospital. In this case the application was
a failure. The failure, I think, arose from
two reasons. First, the man had a very
prominent clavicle and a deeply-seated first
rib ; and, secondly and chiefly, the pad used
was the ordinary roller bandage. The
conical graduated pad, as suggested by Dr.
Parkes below, is far better.

I received a letter from the late Professor
Charles T. Parkes, of Chicago, dated Oct.
24, 1890, recording his use of it in another
case in which the absolute control of the
subclavian was almost a sine qua non for the
perfect operative procedure, and in which
the method, submitted to such a crucial test,
succeeded so well that I venture to quote
from his letter. I need scarcely point out
that all our former methods for controlling
the artery would not have given such com-
mand of the circulation as to make the
deliberate dissection and ligation practised
by Dr. Parkes a possibility :

" Allow me to congratulate you on the
perfect success of the plan recommended by
you for the control of the circulation in the
upper extremity. The adoption of it yester-
day enabled me to carry to a successful issue
an operation for the relief of an immense
traumatic aneurism of the axillary space,
following a laceration of the axillary artery
by a bullet from a heavy 45-caliber revolver.
After the application of the rubber band in
the manner you recommend with a compress
over the subclavian artery, I laid the
aneurism wide open, cleaned out all the
clots, and finally found a large tear in the
artery, and applied a ligature above and

822

Society Reports.

Vol. lxiv

below it without the patient losing any
blood. Twelve hours after the operation
circulation was so far restored in the limb as
to make a successful termination almost cer-
tain. I attribute the ease and readiness with
which the difficult procedure was accom-
plished, to the perfect control of the circula-
tion permitted by the adoption of your plan.
It is certainly of great value. If an ampu-
tation at the shoulder-joint had been re-
quired it could have been without the loss of
a drachm of blood.

" No more trying test could be given to
the method than the case in which I used it.
A traumatic aneurism in the axillary space
from a large wound in the artery is certainly
one of the most difficult things we have to
deal with. The application of the bandage
in this case enabled me to work deliberately
and with perfect ease. No motion on the
patient's part can displace it.

"I think the character of the pad used
under the bandage and over the artery has
much to do with the success of the method.
This pad should be somewhat in the nature
of a graduated compress, small enough at its
apex into the interval between the clavicle
and the first rib, and yet thick enough and
firm enough to reach well above the clavicle
and the side of the neck, so as to take all the
pressure off the rubber."

To answer this purpose I have had made
a wooden pad, the bevelling of the top is for
the purpose of enabling the rubber bandage
to hold it in place and prevent its slipping
either inward or outward. There are two
holes at the sides and end for a removable
handle, resembling a two-pronged fork, with
which to hold it while applying it.

I have tried a similar but larger pad for
the iliac arteries, but so far its experimental
use has not been satisfactory.

DISCUSSION.

Dr. Miller: We are certainly indebted to
Dr. Keen for his valuable contribution to
the technique of operations in which the
subclavian artery is concerned. It often
happens that while under ether the patient
is difficult to manage or vomiting occurs,
and then there is liability of displacement of
the key if we rely upon that to control the
hemorrhage. Several years ago I amputated
at the shoulder-joint in a very muscular
man. The patient began to struggle, and
there was considerable difficulty in control-
ling the artery. In that case I should have
been much more comfortable had I had the
apparatus described by Dr. Keen.

I noticed that the subject on whom Dr.

Keen demonstrated the application of the
apparatus expressed considerable pain. This
is probably due to the length of the pad,
which pressed upon some branches of the
brachial plexus. If this pressure were con-
tinued for twenty minutes it might lead to
considerable injury.

Dr. O. H. Allis : The one to whom the
care of the artery is given in these operations
about the shoulder-joint has no enviable
position. I do not know when I have been
more alarmed during a surgical operation
than when I assisted a friend in amputating
at the shoulder-joint. It was my duty to
control the artery. I passed my thumbs
underneath the flap, and as he cut the mus-
cles they contracted so forcibly that it was
with difficulty that I controlled the vessel.
In compressing the artery to-night Professor
Keen probably used more force than was
necessary, and this will probably account for
the pain.

Dr. A. Hewson : I should like to ask Dr.
Keen, in reference to the effect of motion of
the vertebral column on the apparatus.
Would not this interfere ? I have this even-
ing seen a friend compress his own axillary
artery so as to stop the radial pulse. The
pressure seems to be made by the lower part
of the trapezius muscle acting 'on the spines
of the scapulas, and the latissimus dorsi on
humerii, the humerii being rotated inward
and drawn downward and backward. The
individual was a spare medical man, and
locking his hands behind him and then
straightening the whole upper extremities,
he was able to prevent pulsation in the
radial arteries.

Dr. Keen : This is the first time that I
have seen pain caused by the application of
this apparatus. I think that the pressure
was too great. It is possible that India-rub-
ber would be better than ebony.

I do not see how movements of the spinal
column or of the clavicle would have any-
thing to do with the position of the pad,
which presses directly on the first rib.

I have never seen a case like the one
detailed by Dr. Hewson, and should not
have thought it possible that the artery
could be controlled in this way if I had not
his testimony to that effect.

Dr. John B. Roberts reported, a

CASE OF EXOSTOSIS OF HUMERUS SIMU-
LATING AXILLARY DISLOCATION.

He said, there is nothing especially inter-
esting about the patient, whose photograph
he presented, except the situation of the
bony growth.

June 27, 1891.

Selected Formula?.

823

The boy, who is about eight years old, fell
from a pair of steps, and struck upon his
shoulders. As he was supposed to be hurt,
his clothing was removed, and the condition
shown in the photograph observed. The
physician who first saw him at once took it
for granted that the deformity was due to
the fall, and that an axillary dislocation
existed. He made unsuccessful attempts to
reduce the supposed luxation. Shortly after-
ward he examined the boy, and found that
the prominence, mistaken for a displaced
head of the humerus, was an exostis situated
at about the epiphyseal line, between the
shaft and the head. This, curiously, had
never been noticed before by the child or his
parents.

Some weeks subsequently he removed the
little tumor by means of chisels, and found
it to be cancellated bone partly covered by
cartilage. The wound healed promptly
under the usual antiseptic treatment.

It is needless to say that the symptoms of
dislocation were absent, except that there
was a rounded mass of bone to be seen and
felt in about the situation occupied by the
humeral head in subcoracoid luxation.

Selected Formulae.

NASAL DIPTHERIA.
Raulin recommends that the membrane
be detached by antiseptic irrigation and the
raw surfaces covered with the following :

WHOOPING COUGH.

Lactic acid gr. xxx.

Carbolic acid gr. xlv.

Pure glycerine 3 i

—Revue Gen de Clin, et de Therap.

OINTMENT FOR INTERTRIGO.

Boric acid 7 grains.

Lanolin 12 drachms.

Vaseline 3 "

Terpin gr. xv.

Antipyrine gr. xv.

Syrup aurant. cert 3j 3vj.

Mucil. acac '.

M. Sig. 3j to 5ij several times a day for a child under four.

— Talaman, Times and Register.

This ointment is to be applied to the dis-
eased area, which is first cleaned by the use
of a mild soap.

CROUP.

J. B. Johnson uses the following :

Hfy Aquae destillat f I i.

Potass chlorat

Potass iodid aa 3 i.

Emuls. arabicae 5 ij.

Mucilag. acaciae

Ext. ipecac, fl

Olei capaibae aa 3 i. M.

S. Shake well. Dose, a teaspoonful every ten minutes, to
an infant of 8 months, till free vomiting ensues ; and then con-
tinue the same dose every half hour or hour until the disease is
cured. The dose must be given according to the age of the
child.

— New England Med. Monthly, 1891.

MIXTURE FOR DISSOLVING DIPTHERITIC
MEMBRANES.

Caldwell is stated by the Medical Neive to
recommend the following solution for this
purpose :

1^ Papain Sijss.

Hydronaphthol grs. ij.

Acid muriatic gtt. xv.

Aq. destillat 3iij.

Glycerini 3jj.

M. Sig. Apply to the affected parts every half hour by
means of an atomizer.

DIARRHCEA.

tjt; Tr. opii camph % j,

Mistura cretae 3Hj.

Ol. menthaepip Mx.

A teaspoonful for an adult every three
hours until diarrhoea is checked. For in-
fants the following prescription will be more
appropriate and more easily retained on the
stomach :

J^kJ Vin. Pepsini 3 ij.

Bismuth subnitratis 5iij.

Glycerini 3j.

Aquae.. 3iv.

Give one drachm at a dose every two or three hours.

LARYNGITIS.

Moure recommends the following to be
used in the treatment of laryngitis :

J^kJ Crystallized carb. acid gr. vij — xv.

Hydrochlorate of cocaine gr. vij.

Opium 3 jss.

Distilled water 3x

This may be applied by means of a brush
three times a day, or

Boric acid 5j.

Crystallized resorcin 3ss.

Cherry-laurel water 3jss.

Distilled water 3x.

This mixture may be used in an atomizer
for from three to five minutes morning and
night, or three or four times a day, if the
condition of the throat issubacutely affected.
— La Tribune Medicale.

BED SORES.

Prof. Rosenbach recommends that lanoline
be rubbed into the red spots indicating an
impending bed sore. He has had unvary-
ing success with it. — Pacific Medical Journal.

824

Selected

Formulae.

Vol. lxiv

CREOLIN IN ACUTE GASTROENTERITIS.

Schwinz has employed this drug with suc-
cess in the following formula:

Ijk Creolin M\%

Syrup althaea f 3 y.

Aq. cinnamonii, q. %., ad fSiij. M.

S. To a very young child a small teaspoonful hourly. To

older children the drug may be given in a powder.

Ijk Creolin Mxv.

Sacchari alb gr. lxxv. M.

Divide in Chart No. X.

S. One or two powders daily.

— Wiener Medizinische Wochenschrift,
No. 3, 1891.

DYSENTERY.

Rossbach employs naphthalin in the fol-
lowing manner in this condition :

I^k; Naphthalin grs. x.

Boiling water 5 iv.

Decoction of marshmallow O j.

This is to be used as an injection at the
temperature of 100°. In children who suf-
fer from diarrhoea dependent upon the pres-
ence of parasites in the lower bowel, the
quantity of naphthalin which is employed
should not be more that 15 grains in 4
ounces of oil.

COCAINE FOR PAINFUL TEETHING.

-I^k? Cocaine hydrochlorate i % grs .

Syrup 2 fl. 5.

Tinctute of conium 20 gtts.

M. Sig. To be rubbed on the gums several times a day.

— Merck's Bulletin.

BETOL AS AN INTESTINAL ANTISEPTIC.

M. Yvon states that betol or naphtalol
or salinaphtol is valuable in children's dis-
eases where an intestinal antiseptic is indi-
cated. As is well-known betol is a salicy-
late of naphtol. The following is a good
formula in cases of the character mentioned
above :

1^ Betol ....gr. xv,

Syr. aurant flor 5j.

Aquse acaciae 5 v.

M. Sig. In dessertspoonful doses.

The total amount above given may be
taken in twenty-four hours. The betol may
also be given alone in milk in the doses in-
dicated above. As the taste is very slight it
is not difficult to administer.

TREATMENT OF ECZEMA.

I should like to call the attention of the
profession to the value of a method of treat-
ing certain cases of eczema. It has been

highly lauded by Prof. Unna, and my atten-
tion was called to it by a friend, Dr. D. W.
Montgomery, whom I called in consultation
for a case of eczema equamosa of both lower
legs, attended with terrible and uncontrol-
lable itching. The pruritus was of such a
character as to resist all the ordinary treat-
ment, and it was rapidly breaking down the
patient's strength. In a very short time
after using the formula given below, a most
marked change took place in the trouble-
some symptom, and in fact the disease is
being conquered :

Ijk Gelatine 5 iv.

Zinc, oxide 5 ijss.

Glycerine 5 ss.

Aquae 5 vj.

Heat the water, and dissolve in it the gela-
tine, then add the glycerine and zinc, stir-
ring until cold.

This makes a stiff jelly. When used it
is to be heated sufficiently so that it may be
painted with a small varnish brush all over
the affected parts, and a thin layer of cotton
placed over it at once. This acts like a pro-
tecting scab which the patient is unable to
tear off with the finger-nails ; in fact it has
such a soothing effect that the desire to
scratch is of little moment.

It is quite unnecessary to say that the
general health received due attention. The
purpose of this correspondence is to call
attention to the treatment. — Dr. C. C. Ven-
der beck, in Pac. Med. Jour.

WARTS.

Hydrarg. chlor. corros 1 part.

Collodion 30 parts. M.

S. Apply once daily about the base of the wart.

— Cincinnati Lancet- Clinic, February
21, 1891.

AN EXCELLENT HAIR TONIC.

Ify Acid carbolic 5 ss.

Tinct. nucis vom 5 ij.

Tinct. cinchonse rubrse 5 j.

Tinct. cantharidis 5 ss.

Aq. coloniensis J q s ad 5 iv.

Ol cocao \
M. Sig. Apply once or twice a day to the scalp by means
of a soft sponge. This will prevent the hair from falling out if
it does not produce a" luxuriant crop.

HANSON'S MAGIC CORN CURE.

A good corn cure that is similar in every
respect to Hanson's Magic Corn Cure is
made by taking of —

R

Simple cerate 1 oz.

Salicylic acid 1 dr.

Mix intimately.

— Indiana Pharmacist.

June 27, 1 89 1. Editorial.
THE

MEDICAL AMD SURGICAL

REPORTER.

825

ISSUED EVERY SATURDAY,

EDWARD T. REICHERT, M. D.,

Professor of Physiology, University of Penna.,
Editor and Manager.

N. E. Cor. 13th and Walnut Streets,
P. 0. Box 843. Philadelphia, Pa.

THE MEDICAL AND SURGICAL
REPORTER.

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Remittances should be made by draft, check, postal
note, or money order payable to Edward T. Reichert.

Leading Article.

IN THE PREPARATION OF SPONGES FOR
SURGICAL USES, WHICH IS THE SAFEST
STERILIZING FLUID: A SOLUTION
OF CARBOLIC ACID OR ONE OF
CORROSIVE SUBLIMATE ?

THE POCKET RECORD AND VIS-
ITING LIST.

Two sizes. Prices to subscribers of The Reporter i
Por 30 patients a week (with or without dates), $1.00.
Por 60 patients a week (without dates), . . $1.25.
Prices to non-subscribers, $1.25 and $1.50 respectively.

THE MODEL LEDGER.

Physicians who keep their own books will find this of
great value. Sample pages sent on application. Price,
$5.00.

■^^Suggestions to Subscribers :

See that your address-label gives the date to which your sub-
scription is paid.

In requesting a change of address, give the old address as
well as the new one.

If The Reporter does not reach you promptly and regularly,
notify the publisher at once, so that the cause may be dis-
covered and corrected.

^^Suggestions to Contributors and Correspondents.
Write in ink.

Write on one side of paper only.
Write on foolscap or legalcap paper.

Make as few paragraphs as possible. Punctuate carefully.
Do not abbreviate or omit words like "the" and "a," or
"an."

Make communications as short as possible.

Never roll a manuscript ! Try to get an envelope or
wrapper which will fit it.

When it is desired to call our attention to something in a
newspaper, mark the passage boldly with a colored pencil, and
write on the wrapper " Marked copy." Unless this is done,
newspapers are not looked at.

The Editor will be pleased to get medical news, but it is im-
portant that brevity and actual interest shall characterize com-
munications intended for publication.

The surgery of to-day demands the most
rigid antiseptic precautions to be taken, even
in matters of minor moments ; consequently
the subject under discussion is well worthy of
consideration.

Few of the ordinary needs of a surgical
operation are in more general and frequent
requisition than sponges. No other sub-
stance possesses in itself all the physical
qualities of a sponge ; and, therefore, there is
no known article that, from a surgical stand-
point, can take its place. Such being the
case, it is essential that the utmost care and
attention be given by the operator to their
preparation and purification.

The meshes of a sponge can readily be-
come a lodging place for septic germs, and it
behooves the surgeon to be on the alert less
he infects his patient by one which is poorly
disinfected.

In the present article we shall have nothing
to say about the routine preparation of
sponges for the market ; nor of their purifica-
tion for surgical use — up to the point when
they are ready for immersion and preserva-
tion in the solutions of carbolic acid or of
bichloride of mercury. We will take it for
granted, for the purposes of discussion, that
they have been carefully prepared thus far,
and will now occupy ourselves with the con-
sideration of the subject of this article, viz. :
the relative value of the sterilizing qualities
of the two antiseptics upon sponges.

In a recent article " On Sponges and their
use in Surgery," (Annals of Surgery,) A.
Ernest Waylard, M. B., of Glasgow, details
some interesting experiments which he made
upon this subject. We will record the gist
of these experimental tests, with their
results :

Experiment One : — Two new sponges — a
Cuban wool, (which is an open textured
sponge) and a Cuban fine, (which is a close

826

Editorial.

Vol. lxiv

or dense textured sponge) were thoroughly
rinsed in hot water and then placed in a
solution of carbolic acid (1 to 40) and kept
there over night. The following morning
the fluid was changed. Each of the sponges
was now squeezed by the hand as free as
possible of the carbolic solution, and then
divided by a sterilized pair of scissors. From
the center of the sponges so divided, small
pieces were removed by another
pair of sterilized scissors, and separately
inserted into tubes of Koch's beef-peptone
jelly, previously liquified. The tubes — two
of each specimen — were placed in the incu-
bator and left at a temperature of 37° C. for
forty-eight hours. Examination of the con-
tents of the tubes at the expiration of this
time showed a muddy appearance of the two,
containing the dense or close textured sponge,
while those containing pieces from the open
textured one, were quite clear. A micro-
scopical examination of the muddy jellies
showed them to be loaded with microbes.

Thus experimentally, the author shows
that 12 to 18 hours immersion in a 1 to 40
solution of carbolic acid had not asepticised
the close textured sponges, but apparently
had done so in the case of the open textured
ones — although in each instance the sponges
had been prepared with considerable care
and with every intention that the / should
be clean, and after sterilization, fit for sur-
gical use.

Experiment Two : — The above experiment
was repeated, except that the preparation
of the sponges was attended to by Mr. Way-
lard. After this had been done, the two
sponges were placed in 1 to 40 carbolic solu-
tion, where they were allowed to remain
twenty-four hours. Each sponge was then
divided and pieces removed from the centers
and placed in jelly tubes, in the same man-
mer as in the first experiment. The tubes
were now placed in the incubator, where
they were left for forty-eight hours. Develop-
ment of microbes took place in the tubes
containing the pieces from the dense textured
sponge, but none appeared in those contain-
ing pieces from the open textured one.

Experiment Three : — The above experi-

ment was repeated, only this time with
pieces of the dense textured sponge above,
and with the same result — an extensive
development of microbes : rapidly in those
placed in the incubator and more slowly in
those left in the room at the ordinary tem-
perature.

The author states that these experiments
seem to prove, with little room for doubt, the
inefficiency of solutions of carbolic acid of
a strength of 1 to 40, to sterilize the central
part of close textured sponges.

This failure on the part of carbolic acid
led me to try the sterilizing power of solu-
tions of bichloride of mercury. The principal
reasons for not testing stronger solutions of
the acid was that sponges used direct from
such solutions would be inconvenient, if not
sometimes harmful ; and at all times an ex-
pensive procedure from the quantity of solu-
tions required.

Since the experimentor's object, therefore,
was a practical one, he made use of solutions
that could be used in large quantities, and
for this purpose choose a 1 to 2,000 solution
of bichloride of mercury such as is in com-
mon and constant use in surgical practice.

Experiment Four : — The Cuban fine or
dense textured sponges were alone used. The
sponges were prepared as in former instan-
ces. They were then placed for twenty-four
hours in the solution of mercury, at the end
of which time pieces were removed from their
centers and inserted in jelly-tubes as before.
Two tubes were placed in the incubator and
two in the room. No development of mi-
crobes occurred at any time in either set of
tubes. Thus it appeared that the mercury
solutions had succeeded, where the carbolic
acid had failed.

For the purposes of testing more surely
the relative sterilizing power of the two solu-
tions— bichloride of mercury and carbolic
acid — and to eliminate a possible objection
against the last experiment, that no control
had been made and that therefore the
sponges may have been aseptic from the first,
the following experiment was performed :

Experiment Five : — A Cuban fine sponge
was placed immediately over the orifice of a

June 27, 1 89 1 . Correspondence.

827

discharging sinus, situated in the thigh of a
patient suffering from necrosis of the femur.
When removed from the wound on the fol-
lowing day, it contained a quantity of ex-
cessively foeted pus. The sponge was placed
in a glass receptacle and kept until the fol-
lowing day, and when then exposed its odor
was about as bad as it well could be. The
sponge was now taken from the jar, rinsed
and squeezed several times in hot water.
After this washing it still maintained an
offensive smell, which was especially marked
in the center of the sponge, after it had been
divided.

Each half was now placed into a separate
jar, the one containing a solution of carbolic
acid of a strength of 1 to 40, the other in a
solution of bichloride of mercury of a strength
1 in 2,000. They were left in these solutions
for eighteen hours, at the expiration of
which time tube cultivations were made in
the manner already described in former ex-
periments. Two tubes of each were placed
in the incubator. On the following day the
two tubes containing the carbolized frag-
ments had each a dense opaque scum upon
their surfaces, while the two tubes containing
the mecurialized fragments were perfectly
clear.

The practical deductions to be drawn from
these experiments are :

1. That a solution of the bichloride of
mercury is the safer, and, therefore, the better
sterilizing medicine for sponges. It is, also,
the cheaper drug.

2. That sponges with open, somewhat
coarse nestwork, are least likely to be septic
from causes connected with their preparation.

3. That large sponges and thick, dense
ones, should be prepared with special care,
especially after contact with foeted pus or
other infected substances.

Correspondence.

To the Editor.

Dear Sir: — Your editorial on Curetting
the Uterus in Puerperal Fever, draws atten-
tion to an ever interesting subject. While
all will agree in the main with the author-

ities referred to in your article, it seems to
me that in some respects the teachings
inculcated can be modified or added to with
advantage. I wish to speak of several
practical aspects of the subject.

Some years ago, in the capacity of Assist-
ant at the Philadelphia Lying-in Charity, I
had the opportunity of studying a series of
cases of puerperal septicaemia. My obser-
vation would lead me to believe that the
proportion of cases dying within twenty-four
hours of the onset of the disease is small. I
have seen but one such case — a woman
having a contracted pelvis who was delivered
by the high forceps operation. In this case
there is reason to believe that infection was
introduced within the cavity of the uterus.
In all other cases coming under my notice I
have been impressed with the fact that the
observant physician will find symptoms to
warn him of the impending danger, and
enable him to institute treatment before the
life of the woman is endangered by the
progress of the local inflammation, or the
system is poisoned by the absorption of
septic material. This point cannot be in-
sisted upon too strongly ; and broadly speak-
ing, the obstetrician who recognizes septi-
caemia in his patient only after it has
progressed to its full development must be
considered culpable, not only for the exist-
ence of the malady, but for negligence or in-
competence in failing to recognize its early
manifestations. The physician who daily
palpates the hypogastrium and notes the
progressive involution of the uterus, who
watches the functions of the bladder, who
notes the state of the lochia, and who care-
fully observes the state of the pulse and
temperature will almost never be confronted
without warning with a full blown puerperal
septicaemia.

With reference to the thoroughness M'ith
which the curette will remove septic material
from the uterus, I am disposed to differ with
Braun. Cases are on record in which care-
ful men have curetted the uterus to remove
the supposed remnants of a miscarriage, in
which, after this supposed emptying of the
uterus an abortion, foetus and all, has
occurred. So experienced a man as Goodell
absolutely rejects the curette for the removal
of particles of placenta, and holds that it is
impossible to determine the absence of
foreign bodies in the uterus by the use of the
curette. Were it necessary it would be easy
to collect positive proof that the curette can-
not be depended upon to do what is claimed
by Braun and Fritsch. The only way to
determine whether the puerperal uterus is

828

Book Reviews.

Vol. lxiv

empty is to introduce the index finger to the
fundus, under anaesthesia. If no small frag-
ments of placenta are present, the use of the
curette will remove the infected, softened
decidua.

Anaesthesia, necessary for the proper
examination of the puerperal uterus, will
greatly facilitate the subsequent curetting.
My own experience warrants me in doubt-
ing whether American women will consider
the procedure comparatively painless, as
claimed by Braun.

Again, in ordinary cases of labor the
cavity of the uterus is not invaded by the
fingers or instruments of the attendant.
Hence, when septicaemia results, the pro-
cesses usually have their origin in the
vagina, and when treatment is instituted
promptly, the uterus may escape infection.

It seems to me that if the principles of
asepsis and antisepsis were fully appreciated
by the practitioner that puerperal sepsis
would be encountered but seldom in private
practice. It is now well ascertained that
puerperal septicaemia is caused by the intro-
duction by the physician or by the nurse of
septic germs within the genitals of the puer-
pera, at the time of or shortly after labor, or
it is caused by the activity of germs already
present within the vagina at the time of
labor.

It has been positively proved that the
vagina swarms with germs. Inasmuch as
they do no harm as a rule, it may be assumed,
until our information is more definite, that
under ordinary conditions the germs present
are non -pathogenetic. But when vaginitis,
with an imitating leucorrhcea is present, we
may well question the innocence of the
germs. It has been a rule in my practice
for a long time to question women in the latter
months of pregnancy, as to the existence of
vaginitis, and when there has been the least
reason to suspect it, an examination has
been insisted upon and the vaginitis vigor-
ously treated with suppositories of alum and
irrigations with alum^ and with sublimate
solutions. No one who is at all familiar
with modern bacteriology will expect to dis-
infect such a vagina by giving a sublimate
douche at the beginning of labor. Hospital
experience apparently has shown that the
routine use of vaginal antiseptic douches at
the beginning of labor is to be avoided. It
will be interesting to watch this point in
practice in the future, influenced as it will be
by more definite knowledge concerning the
efficient use of germicide. Undoubtedly, in
the past, asepsis of the vagina has not been
obtained.

Practically, the most important point —
although every step is important — in obstet-
rical antisepsis is to secure asepsis of the
hand of the physician. My views upon that
point can be found in The Reporter for
February 28, 1891. The reason why many
men do not employ rigid methods for clean-
iug the hands is that certain practitioners of
large experience have not done so, and yet
have not had sepsis in their practice. Doubt-
less these men have been cleanly in their
person, and their work has not brought their
fingers in contact with septic matter. But
let such men dress erisipelatous wounds, or
wounds discharging pus !

Lardj as commonly used, has kept many a
woman from puerperal sepsis, by covering
over the germs on her physician's fingers ;
but after all it is a frail banner of defence.
Should it be depended upon by the con-
scientious physician, when five minutes use
of the nail brush, with soap and water,
especial attention being given to the examin-
ing finger, followed by a sublimate, both for
three minutes, will go so far to ensure his
patient against the dreaded "child-bed
fever ?" Very Respectfully Yours,

Charles P. Noble,

Philadelphia.

Book Reviews.

STUDIES OF OLD CASE-BOOKS. By Sir
James Paget, Bart. London : Longmans, Green
& Co., 1891. Philada.: Blakiston & Co.

If we could imagine a physician ignorant
enough not to be acquainted with the writ-
ings of the eminent surgeon and teacher —
Sir James Paget, F. R. C. S., and surgeon to
St. Bartholomew's Hospital — we might sup-
pose that the title, " Studies of old case-books,"
would give to such an one the impression
that the present volume was a mere recital
of dry cases used as a basis for a book and
of no practical interest to the general
practitioner.

To one, however, at all familiar with this '
writer's versatility, sound judgment, quick
perception, and, above all, his power of
imparting to others the knowledge he has
gained by years of observation and study, the
book is picked up and perused with evident
pleasure, with an assurance to the average
reader, that as each page is scanned informa-
tion has been gained.

The volume is replete with so much
knowledge and so many practical suggestions
that to do justice to a review we would be
obliged to extend our remarks beyond the

June 27, 1891.

Periscope.

829

limit of the space at our command. We,
therefore, content ourselves with saying that
we have read through the seventeen chap-
ters comprising the book without losing, for
a single instant, the interest awakened at the
beginning.

In conclusion, we would add that the busy
physician will find in "Studies of old case-
books," several hours of pleasant and profit-
able reading.

SAUNDERS'S QUESTION COMPENDS. ES-
SENTIALS OF PHARMACY. By Lucius E.
Sayre, Ph. G., Professor of Pharmacy, and Mate-
ria Medica, of the School of Pharmacy of the Uni-
versity of Kansas. Phila. : W. B. Saunders, 1890.

The writer of this epitome of chemistry,
pharmaceutical and practical, deserves credit
for having embraced in one small volume so
much which is necessarily frequently referred
to by physicians in general practice. Of
course the book is specially intended to aid
the students in craming for examination,
but as the majority of medical institutions
are not at present insisting upon such a
preparation in pharmacy, as a careful study
of this compend would impart, it is probable
that a large portion of its usefulness will
consist in its being a handy-book for the
general practitioner, who can readily find
any ordinary question clearly answered.
The work is arranged in the form of ques-
tions and answers. The questions are
printed with bold-faced type, and the book
is finished in the neat manner which char-
acterizes this series of quiz-books. Besides
definitions of the terms in pharmacy, and a
thorough " quiz " upon the mode of prepara-
tion of all the various officinal mixtures, the
booK also contains a complete review of all
the substances ordinarily used in medicine,
as well as much pure chemical knowledge.

TREATMENT OF AMENORRHEA.

Bichloride of mercury 3 grains.

Arsenite of sodium 3 "

Sulphate of strychnine 1%. "

Carbonate of potassium f of each, 45 «
Sulphate of iron | ' TJ

Make into sixty pills and give one pill after each meal.

— Revue Med.-chir. des Med. des Femmes.

INFANTILE CONSTIPATION.
Bouchut employs the following syrup :

1^ Podophyllin gr. i.

Alcohol f 5 iss.

Syrup althaea f 5 Iv. M.

S. Dessertspoonful daily.

— Union Medicale, 1890.

PERISCOPE,

THERAPEUTICS.

TREATMENT OF PNEUMONIA WITH
LARGE DOSES OF DIGITALIS.

At the last International Medical Con-
gress Professor Petresco of Bucharest read a
paper on this subject. He makes an infusion
of sixty grains of powdered digitalis leaves
to six ounces of water, a little syrup of
orange being added to sweeten it. A table-
spoonful of this mixture is given every half
hour. In spite of the largeness of the dose,
he says that he has never met with a case of
poisoning, and maintains that these doses
are therapeutic, and not toxic. The best
results are obtained in fibrinous or croupous
pneumonia. The author states that if used
in the way he describes digitalis will fre-
quently cut short an attack of true croupous
pneumonia. In from twenty-four to forty-
eight hours after taking the drug a certain
fall of temperature occurred, from 104°F. to
98°F.; this being accompanied by a decrease
in the frequency of the pulse and respiration.
The digestive tract was little affected. The
most marked changes were noticed in the
pulse, which became slow, full, and of high
tension. The conclusions to which Professor
Petresco has come are published in the
Therapeutische Monatshefte,Feb. 1891. They
are as follows : 1. When given in thera-
peutic doses digitalis has a direct antiphlo-
gistic action. 2. The dose may be raised as
high as from 60 to 120 grains of the leaves
given as an infusion within twenty-four
hours. 3. This treatment may be continued
for from two to four days if the severity of
the case requires it. 4. When improvement
takes place in the circulation and respira-
tion, this is speedily followed by a disap-
pearance of all local signs and symptoms.
5. The success of this treatment is confirmed
by the statistics. In an elaborate table of
statistics Professor Petresco shows the
superiority of digitalis over the other
methods. Thus the highest mortality in
pneumonia (34'5 per cent.) occurred when
bleeding was practised, and the lowest (3 per
cent.) when tonics, alcohol, &c, were em-
ployed. When digitalis, however, was ad-
ministered the mortality sank as low as 2*06
per cent. 6. From an experience of a very
great number of cases, both of his own and
of other medical men, he maintains that the
doses, as given above, are perfectly harm-
less. 7. After a comparison of the various
methods of treating pneumonia, Professor

Periscope.

Vol. Ixiv

Petresco affirms that the expectant plan is
not only without reasonable foundation, but
even dangerous ; and his experience has
demonstrated that an attack of pneumonia
may be aborted if the treatment is com-
menced at the very earliest stages of the
disease. — Lancet.

THE ACTION OF COCAINE ON THE CIR-
CULATION.

Dr. Edward T. Reichert, in the American
Lancet, from a careful study of the actions
of cocaine on the circulation in animals, de-
duced the following conclusions:

1. The discrepancies in the testimony
offered by different experimenters, in their
investigations of the action of cocaine on the
circulation, are almost wholly due to varia-
tions in the absolute doses employed, and to
the individual susceptibility of the animals.

2. The minimal fatal dose, when injected
intravenously in divided doses in the form of
a one per cent, solution, varies from 0.004 to
0.03 gramme to the kilo of the body weight.
Owing to the great differences in the sensi-
tiveness of different dogs to the poison, a
moderate dose in one animal might prove a
small or a large one in another of similar
weight.

3. When the full train of effects on the
heart-beat is slowly developed by the
repeated injection of very small doses (0.001
gramme to the kilo of body weight) the
pulse-rate is at first decreased, then increased,
and finally decreaseed. A single very small
dose causes a decrease, a small to a moderate
dose an increase ; large doses a transient de-
crease followed by an increase ; very large
doses a more or less permanent decrease.
The primary decrease which only can be de-
veloped by very small doses, is due to a
stimulation of the cardio-inhibitory centres ;
the secondary increase to a depression of the
same centres, and which may be assisted by
a similar action on the cardio-inhibitory
peripheries ; and the final decrease to a de-
pression either of the accelerator or automatic
motor-ganglion in the heart. The height of
the pulse-curves during these changes is
always in inverse relation to the frequency
of the beat.

4. The cardio-inhibitory centres are inva-
riably affected, being primarily stimulated,
and secondarily depressed ; but the action on
the peripheries is of a very inconstant char-
acter, although a primary stimulant action
is never manifest, the depressant action is
sometimes present to a profound degree very

early in the poisoning, and, at others, abso1
lutely absent up to the time of death.

5. The arterial pressure is always in-^
creased, unless it be after large doses, when
it may temporarily be diminished, followed
by a rise above the normal ; or after very
large doses, be permanently lowered. The
iucrease may be decided long after the
development of the third stage of the actions
on the heart, and, therefore, may outlast the
period of the acceleration of the heart's beat.
The increase is chiefly due to a stimulation
of the vaso-motor centres in the medulla
oblongata ; to a slight stimulation direct of
the vessel-walls ; and to the acceleration of
the pulse. The final fall of pressure is chiefly
dependent upon a depression of the heart,
and partly to vaso-motor depression.

6. The effects of cocaine in normal and
curarized animals are identical, unless, in the
latter, the curare has been used to excess.

7. Cocaine is a decided circulatory stimu-
lant.

TREATMENT OF THE NIGHT SWEATS OF
PHTHISIS.

Huchard reports in the Rev. Gen. de Clin,
et de Therap., February 4th, the results with
many medicaments tried for the relief of the
sweating of phthisical patients. Among
these may be mentioned lead acetate, tannin,
phosphate of lime, ergot, atropine, and mus-
carine. Of these the two first are unreliable,
and are seldom used, and probably atropine
sulphate is the most valuable (one-half to
one milligramme at night). Phosphate of
lime should be given in large doses (one to
two drachms daily) to produce anhidrotic
effects, and even in these doses it has several
times failed. Ergot (fifteen to twenty-two
grains of the powder at night) is much more
reliable. When the sweats co-exist with more
or less marked fever, the author recommends
the use of quinine combined with ergot.

I^k Quinse sulph gr. xvi.

Pulv. ergotse 5 ss.

Divide into four cachets — two or three to be taken daily.

This formula is specially valuable in phth-
sis with haemoptysis. Lastly, powdered agaric
is an excellent remedy, not equal to atropine,
but parfectly harmless, and never causing
derangement of digestion. It may well be
combined with tannin or belladonna, given
in doses of three or four grains.

The same writer speaks very highly of
antipyrin in the initial fever of tuberculous
patients. The older drugs, quinine, tartar
emetic, salicylic acid, all fail, or have but

June 27, 189 1.

Periscope.

831

slight effect. It is specially in this initial'
fever that antipyrin is of great service. One j
must, however, distinguish between an anal-
gesic and an antipyretie dose of the drug.
To obtain the former effect, one would give
a large dose (say fifteen to thirty grains) in
a short time, but this must not be done if its
best action as an antipyretic is desired. It is
well for this purpose to use constantly de-
creasing doses (say sixteen grains, twelve
grains, eight grains), taken care to divide
them so that at no time during the twenty-
four hours is the patient not under the influ-
ence of the drug. Used in this way, Hu-
chard declares that antipyrin seems to have
a special action on the tuberculous lesion, and
to greatly retard or to arrest its progress.

Professor Combemale has used tellurate of
sodium, in phthisical and other sweating. It
was first recommended by Neusser who gave
one-third or two-thirds of a grain in pill once
daily. Combemale gave it up to nearly one
grain per dose, and tried its effects in eleven
cases. His conclusions are : It is a powerful
anti-sudorific; a dose of nearly one grain
gives rise to digestive troubles, and especially
to a strong garlic odor in the breath. All
the compounds of tellurium cause a very dis-
agreeable odor in the breath, and this must
always be a bar to their employment, as it is
very persistent and disagreeable.

In addition to the list sulphonal has been
used with success by a few 'reporters. — Bost.
Med. and Surg. Jour.

VARIATIONS IN THE CAUSTIC ACTION OF
CARBOLIC ACID.

It is claimed on the authority of Dr. Char-
les that carbolic acid, if dissolved in glycerine
or alcohol is not caustic, wrhatever be the de-
gree of concentration. An aqueous solution
or even a small per ceut. of water added to
the alcohol or glycerine solution will act as a
caustic to the skin and mucous membrane. —
Le Bui. Med.; Weekly Med. Review.

PIPERAZIDINE AS A SOLVENT FOR URIC
ACID.

It is stated in a German pharmaceutical
journal that piperazidine dissolves urid acid
more readily than any other substance of a
basic nature. Urate of lithia requires 368
times its OAvn weight of water to dissolve it,
but urate of piperazidine dissolves in fifty
times its weight of water. It may therefore
be expected that this drug will become a
fashionable, let us hope too an efficient, rem-
edy in gout and allied diseases. — Lancet.

TREATMENT OF HYPERPHORIA.

Dr. H. F. Hansell (American Journal of
the Medical Sciences) says :

That hyperphoria is a real affection, and
that, while it may exist without causing
symptoms, it is in some cases of the highest
importance :

That it may produce reflex disturbances
in an oversensitive or exhausted system :

That reflex functional disorders are found
in patients with hyperphoria, which are not
caused by hyperphoria :

That it is not dependent upon errors of
refraction :

That it should be sought for in every case
of asthenopia :

That the degree can be determined only
after repeated examinations:

That tenotomy, and not prisms, is the
treatment for hyperphoria :

That in most cases the tendons should be
completely divided.

Of the six cases reported above, two pre-
sented symptoms of hyperphoria when no
want of equilibrium of the verticle muscles
could be detected ; one had hyperphoria
with asthenopia, which w7as entirely relieved
by the correction of the refractive error.
Three had local and reflex symptoms due to
hyperphoria, and were cured by tenotomies.

It may be objected that the cases are too
few to enable one te deduce therefrom laws
for general acceptance. No such deductions
are made, Nothing more has been attempted
than a truthful recital of the histories and a
careful observation of the points presented
to my own mind. They furnish so much
data from which the reader may form his
own opinion and draw his own deductions.
The subject is new, attractive and important,
and deserves more partial investigation and
study than it has hitherto received.

THE ACTION OF SACCHARINE ON THE
HEART.

Loutzensko has studied the action of sac-
charine upon the heart of the frog, and finds
that when 1 \ grains of a two-per-cent. solu-
tion of saccharine with bicarbonate of
sodium is injected into a frog the animal in
one hour appears to be better. It is in-
sensible to the touch, but pinchings provoke
feeble reflexes. The heart is finally ar-
rested in diastole, but if pinched will once
more begin to contract. Electrical stimula-
tion also produces these contractions of the
heart. In doses twice or thrice as large as
that named, Loutzensko found that sac-
charine causes irregular cardiac movements.

Periscope.

Vol. Ixiv

The effect of the drug upon the vagus nerve
after such doses is very feeble. — Revue
General de Clinique et de Therapeutique.

THALLIN.

Thallin is an oily liquid, perchloride of
iron imparts to it an emerald green color.
The following salts are known : Sulphate of
thallin, tartrate of thallin, and hydrochlorate
of thallin. Concentrated solutions have a
bitter, salty, and piquant taste. The weaker
solutions have an aromatic and agreeable
taste. The sulphate is soluble in five times
its weight of water, and the tartrate in ten
times its weight of water. The salts have
marked antiseptic properties, since they
retard the fermentative processes of am-
monia and alcohol, and also of milk.

Therapeutic properties: — The sulphate is
the most active. It may be employed with
advantage in solution as an injection in
cystitis. It is also given internally as an
antipyretic. By its use, in nearly 100 cases
of various fevers, including intermittant fever,
rheumatic fever, measles, erysipelas, fever
during the puerperim, pneumonia, and tuber-
culosis. Dr. Jacksch, reports (in the Journal
de Med. de Paris, May 3, 1891) to have been
able to reduce the temperature to normal,
without the occurrence of any untoward
symptoms.

In intermittant fevers the drug seems of
especial value. If the drug is given two or
three hours before the regular time of the
rise of temperature, the febrile attacks will be
lessened both in intensity and duration.
Yet, when a curative action is desired we
must return to sulphate of quinine. The
remedy, therefore, while being a powerful
antithermic, is not. an antiperiodic. In
typhoid fever, and espedially in rheumatic
fever, the drug is prompt in acting ; yet it
neither lessens the course of the disease, nor
relieves the pain. When the thallin salts are
used the fall of temperature is always ac-
companied with abundant perspiration. The
secondary rise of temperature following the
exhibition of the drug, occurs within four or
five hours, and is frequently preceded by a
chill. No digestive disturbances, cyanosis or
any unpleasant symptoms seem to be caused
by the drug.

MEDICINE.

ON THE ETIOLOGY OF TINNITUS AURIUM.
Dr. H. MacNaughton Jones read a paper

on the subject named above in the Section
of Otology, British Medical Assocsation, 1890.
(Reported in Medical Press and Circular.)

The paper is based upon two hundred and
sixty cases of tinnitus aurium, taken from the
author's private note-book. Of these, 127
were males, and 133 females. The ages
varied from under ten years (3) to eighty
years. The youngest patient was three years
old. The right ear was the seat of tinnitus
36 times, the left ear 53 times, and both ears
171 times. The ascribed causes were ceru-
men, 30 ; naso-pharyngeal catarrh, 28 ; nasal
turbinate congestion and obstruction, 19 ;
mental worry and over-strain, 14 ; sea-bath-
ing, 12; scarlatina, 9 ; heredity, 8; effects of
tropical climate, 8 ; the menopause, 8 ; inju-
ries, 7 ; hypertrophied tonsils and tonsillitis,
7 ; abscess or inflammation of meatus, 7 ; car-
diac disease, 7 ; gout, 5 ; uterine disorders,
5 ; measles, 4 ; syphilis, 4 ; alcohol, 4 ; rheu-
matic fever and rheumatism, 3 ; pregnancy,
2 ; Bright's disease, 2 ; ozoena, 2 ; decayed
teeth, 2 ; facial paralysis, 1 ; puerperal septi-
cemia, 1 ; quinine, 1 ; adenoid growths, 1 ;
from gun-concussion, 1 ; pneumonia, 1 ; paro-
titis, 1. In the remaining cases no cause was
assigned.

The clinical conditions of the ear found in
these cases were chiefly: catarrhal changes in
the tympanum, 102 ; the same with closed Eu-
stachian tube, 38 ; making really 140 cases of
associated tympanic disease.

The hearing distance was normal in both
ears in 18 cases. In 185 cases tinnitus and
deafness alone were complained of ; in 22
cases aural vertigo was also present. In 7
cases only were there any accompanying
ocular symptoms. Attention is called to
Ferrier's statement, that "the sense of hear-
ing is in greater part situated in the tem-
poral lobe, and more especially in the
superior temporal gyrus of this lobe." Dr.
Ferrier also is quoted as saying that "tinnitus
may occur in both ears as the result of unilat-
eral irritation, the effect of the intimate con-
nection of the auditory nerves and centres."

Very slight causes may underlie tinnitus
aurium, as for example : A fine membranous
husk of a hay-seed resting on the membrana
tympani. -

The following is a basis for a classification
of the different causes and varieties of tin-
nitus aurium, condensed from the original :

1. Impulses originating in the temporal
lobe or superior temporal gyrus, the cerebel-
lum, or the auditory nuclei (in the medulla
or pons), and referred as impressions to
various situations — as the labyrinth or cer-

June 27, 1891.

Periscope.

833

tain parts of the head. Such acoustic im-
pressions may or may not be attended by
deafness.

2. Impulses due to irritation, direct or re-
flected, in any portion of the auditory nerve.

3. Impulses originating in the peripheral
ends of the auditory nerve (perhaps the
most numerous class.)

4. Irritation arising from interference
with the intra-tympanic muscles.

5. Irritations transmitted by altered con-
ditions of equilibrium of the air in the
tympanic cavity.

6. Irritations due to disease in the middle
ear and labyrinth.

7. Irritations arising in the external ear.

8. Some aural hallucinations, subjective
impressions arising in the psycho-sensorial
brain-centres, and having no objective cere-
bral or aural source of origin. Such hallu-
cinations may become insane hallucinations.
The latter may be divided into two distinct
forms: (a) Hallucinations which arise sub-
jectively in the brain when the auditory
apparatus and nerves are healthy, (b)
Hallucinations which are secondary to objec-
tive changes in the aural apparatus, and in
which a tinnitus is developed that leads up
gradually to a fixed illusion.

9. Therapeutical causes of tinnitus au-
rium. — Amr. Jour. Med. Sci.

CIRRHOSIS OF THE LIVER AND NERVOUS
SYMPTOMS.

In the St. Bartholomew's Hospital Re-
ports, vol. xxvi., Dr. Ormerod directs atten-
tion to a curious and important class of cases
in which extreme cirrhosis of the liver is
present, and in which the symptoms are
mainly nervous. He relates the particulars
of one which was under the care of Dr. Gee.
The patient was a boy of ten, who had
three or four months before admission de-
veloped weakness with cramped position of
right hand and arm, and difficulty in speak-
ing. This condition became more pro-
nounced, and was accompanied by gradual
mental impairment, difficulty in swallowing,
and finally some affection of the left arm
and hand. During the time he was in
hospital, his condition was characterized by
severe attacks of pain, extreme noisiness,
and idiotic appearance. The electrical con-
dition of the muscles remained unchanged
in spite of the contractures and weakness.
During the last three months of life he had
occasional attacks of pyrexia, sometimes
with profuse sweating, he developed bed-
sores ; the urine became alkaline and phos-

phatic, and mental hebetude became ex-
treme. The optic discs and fundi under-
went no change. At the necropsy the liver
was found to be in a state of extreme cir-
rhosis, and the only lesions found in the
nervous system were two small, almost sym-
metrical patches of softening in each lenti-
cular nucleus, and two minute points ap-
parently also of softening in the pons. Dr.
Ormerod in his comments on this case, men-
tions one or two similar cases, of which, how-
ever, he is unable to give full notes ; but
reference is particularly made to set of cases
recently published by Professor Homen in
the Neurologisches Centralblatt. These cases
were three in number, and the patients were
all members of the same family. Their
symptoms were giddiness, headache, mental
failure, unsteady gait, and difficulty of
speech, together with contractures of the
limbs, and in two of them there were found,
in addition to slight changes in the cortex
cerebi, softening in both lenticulnr nuclei
and well-marked cirrhosis of the liver.
These cases offer a new problem in sympto-
matology, for, whatever may be the relation
of the slight changes found in the nervous
system to the symptoms produced during
life, there seems to be little room for doubt
that the fundamental morbid coudition is
the cirrhosis of the liver. — Lancet, Mar. 7,
1891.

THE INFLUENCE OF TOBACCO ON GAS-
TRIC DIGESTION AND ACIDITY OF
THE URINE.

Dr. J. Ydan-Pouchkine reports a number
of experiments which he has made in this
connection on seven healthy individuals who
were not habituated to tobacco-smoking, and
his results are reported in the Bulletin Gene-
ral ale Therapeutique for February 15, 1891.

He first examined the effects of tobacco on
the gastric juice and the motility of the
stomach and on degree of absorption and on
the acidity of the urine. For three days the
author examined the gastric juice and motil-
ity of the stomach, noting the degree of
motion of the stomach by salol, according
to the process of Ewald and the rapidity of
absorption with the iodide of potassium,
according to the method of Zweifel, during
a second period of three days each, in which
the individual smoked, respectively, twenty-
five cigarettes daily. For three days after
this period the author continued the ex-
amination of their gastric juice in order to
determine the after-effects of the tobacco.
His conclusions are embraced in the follow-
ing statements :

834

Periscope.

Vol. lxiv

L Tobacco increases the quantity of gas-
tric juice, but diminishes its acidity.

2. The quantity of free hydrochloric acid
of the gastric juice is diminished under the
influence of tobacco.

3. Proportionately to the decrease of the
amount of hydrochloric acid there is an
equal diminution of the digestive power of
the gastric juice.

4. Tobacco likewise slows the action of the
gastric ferments.

5. These modifications in the gastric juice
produced by tobacco last for a period of
several days.

6. As regards the motility of the stomach
and its power of absorption, tobacco is
stated to produce an increase of these func-
tions.

7. Tobacco has no influence on the acidity
of the urine. — Therap. Gaz.

SURGEBY.

REMARKS ON FIVE HUNDRED CASES OF
STRICTURE OF THE URETHRA

Desnos (Annales des Maladies des Or-
ganes Genito-Urinaires, Jan. 1891) records
his observations upon the etiology and treat-
ment of stricture of the urethra, derived from
500 cases.

In the immense majority of the cases the
strictures were of gonorrhoeal origin ; in two
instances they were caused by the cicatriza-
tion of urethral chancres; and four cases re-
sulted from traumatism, such as falls and
kicks. He draws attention to what he calls
"slight traumatism of the canal," which
sometimes takes place during coitus, and
sometimes follows a prolonged erection during
the course of an attack of gonorrhoea. He
believes that these little ruptures of the mu-
cous membrane are more frequent than one
would suppose, and that they play a consid-
erable part in the genesis of stricture.

His experience goes to show that gonorrhoeal
strictures are of slow development, having
never seen one in which a year and a half, at
least, had not elapsed since the beginning of
the urethritis. A traumatism, on the con-
trary, whether slight or extensive, leads to
the rapid formation of a contraction.

He points out as a remarkable fact the
degree to which a stricture may attain before
the patient experiences functional troubles.
Many patients do not seek relief for difficult-
ies of micturition, but for such complica-
tions as cystitis, fever, digestive disturbances,
etc.

As to the locality of the stricture, an anal-
ysis of the cases showed that almost all
the constriction was in the bulbous portion
of the urethra. In nearly one-half of the
cases the strictures were multiple, the tight-
est ones being in the bulbous region. He
never met with an instance in which the
stricture was impassable, but always, even
in the most difficult cases, after patient and
repeated efforts, has succeeded in passing a
bent filiform bougie.

The methods of treatment employed by
him, and the number of cases treated by
each, were :

Cases. Deaths.

387

78

0

I

0

500 2

With regard to gradual dilitation, he in-
sists upon the necessity of proceeding with
extreme slowness and patience, avoiding all
violence, rapidity of movement, and press-
ure, however slight. Of the employment of
cocaine in the urethra, he says that he rarely
uses it. Outside of the dangers inherent to
the drug, he has found a disadvantage in
the fact that the cocainized urethra offers a
certain degree of resistance to the passage of
sounds. He insists in a most positive man-
ner upon the association of antiseptic and
aseptic measures with the instrumental treat-
ment of the urethra, cleansing the external
parts with a boric acid solution, and irri-
gating the urethra with it as well. The in-
struments to be employed should be steril-
ized. To the patient he administers salol or
biborate of sodium. His experience goes to
prove the value of these precautions, since he
met with urethra fever in but two per cent,
of his dilatations.

As to the question whether dilatation
really leads to the cure of stricture, the
writer is unable to adduce a sufficient num-
ber of facts, less than one-half of his patients
having remained long enough under obser-
vation.

Passing on to the operation of internal
urethrotomy, Desnos expresses his prefer-
ence for the Maissoneuve urethrotome, hav-
ing employed it in all but two of his seventy-
eight cases. He uses a small blade, and
thinks that a division of the stricture to a
calibre of twenty-one or twenty-three is quite
sufficient. He thinks that when it can be
easily introduced, a catheter should be left
in the bladder after the operation, for the
purpose of preventing contact of the urine
with the wound ; but when difficulty is met

June 27, 1891.

Periscope.

835

with, he believes that the attempts to pass
the catheter will be of more serious import
than the omission of its use.

External urethrotomy he regards as an
operation required only iu exceptional cases.
Of the three patients upon whom he per-
formed it one had multiple perineal fistula,
another had a calculus impacted behind a
tight stricture, and the third suffered from
stricture resulting from rupture of the ure-
thra.

Desnos's conclusions as to the several
methods of treatment show that he strongly
favors gradual dilatation as being applicable
to the greatest number of strictures. He
calls attention to the advantage which it
possesses of not confining the patient to bed,
and its freedom from serious risks, and be-
lieves that it should undoubtedly be em-
ployed if the dilatation progresses regularly,
and no complication arises. If, during the
course of treatment, cystitis, prostatitis,
fever, or hemorrhage, should be met with ;
or if, after dilatation, the contraction speedily
returns, the operation of internal urethrot-
omy is indicated. He is of the opinion that
the final results of the operation will advan-
tageously bear comparison with any other
mode of treatment. — Univ. Med. Mag.

A METHOD FOR REMOVING TATTOO
MARKS.

Variot {Jour, de Med. et de Chirurg. Prat.,
January 10, 1891) details the procedure
which he adopts for the removal of these
disfigurements. The skin to be decolorized
is first washed with a concentrated solution
of tannic acid, and is then closely punctured
with a set of needles, such as tattooers use.
A crayon of nitrate of silver is next thor-
oughly rubbed over the area, and after a
moment the skin is dried off, when it will be
found that the punctures are deeply black-
ened by the formation of the tannate of
silver in the superficial layers of the skin.
The cauterization is said to result in an in-
flammatory reaction for a couple of days,
and subsequently in the formation of a crust
or thin eschar, which separates spontaneously
in from fourteen to eighteen days, leaving
beneath it a superficial red cicatrix, which
gradually loses its color, and at the end of a
few months, M. Variot states, is scarcely
perceptible. He does not consider it expe-
dient to attack at one sitting an area larger
than a dollar, lest the inflammation pro-
voked should be too severe, and interfere
with the pursuance of the daily duties of the
individual. The only dressings which he

employs after the little operation consists in
keeping the part powdered with tannin.

NERVE-GRAFTING.

Atkinson has recently reported a number
of successful cases of nerve-grafting to the
British Medical Association. It is impor-
tant to bear in mind that the substitution of
a new piece of nerve for a piece that has
been lost (nerve-grafting) is a totally differ-
ent thing from the uniting of a nerve (nerve-
suturing). In one case the median nerve
had been divided in an operation. Two and
one-half inches of the tibial nerve from an
arm that happened to be amputated at the
same time, was transplanted to the forearm
of his patient. Healing occurred by first
intention, and sensation began to return in
thirty-six hours, and in five weeks was com-
plete. The muscles partly recovered their
poAver. A number of other cases were re-
ported with similar results. Strict asepis is
important, though union may occur follow-
ing suppuration. Return of sensation occurs
before motion. Better results are obtained
when the grafting is performed immediately
after the injury.

GYNECOLOGY.

EFFECT .OF LEECHES IN THE UTERINE
CAVITY.

Dr. Montane (Nouvelles Archiv. d' Obst. et
de Gynec., March, 1891) states that he is not
accustomed to plug the os with wool when
applying leeches to the cervix, but simply
catches each leech with forceps with large
teeth, places it against the cervix, and lets
go of it when it has taken a firm hold of the
tissues. He has never seen a leech shift its
position. Once, when he was applying
leeches, the patient sneezed violently, so that
the Ferguson speculum was shot out of the
vulva. When reintroduced three leeches
were found still adherent to the cervix, and
a fourth rapidly escaped up the cervix, and
ensconced itself in the uterine cavity before
it could be seized with a forceps. A red
rubber sound was passed up the cervix, and
a small amount of warm carbolised water
thrown into the uterus. The water came
back in intermittent jets, and at length a
black body appeared, which was seized with
forceps ; it was the cephalic end of the leech,
which was easily extracted. The patient
knew nothing of the misadventure. Dr.
Montane's colleague, Dr. Arrango, de-
scribes another case where a leech could not

836

Periscope.

Vol. Ixiv

be displaced so speedily from the uterine
cavity. It set up intense pain, which, it
is remarkable to note, was referred to the
region of the right ovary. Violent con-
vulsions followed, and lasted for nearly half
an hour, leaving the patient in a most dis-
tressing state of excitement, the pain being
unabated. The fits returned. Three hours
after the beginning of the pain the patient
was seized with violent uterine contractions,
compared by her to the sensations expe-
rienced daring an abortion, the leech, per-
fectly gorged with blood, escaped from the
vulva, the pains and convulsions thenceforth
ceasing entirely. — Brit. Med. Jour.

THE TOTAL EXTIRPATION OF THE
UTERUS.

Fifty-seven cases are reported in which the
author has removed the entire uterus ; for
carcinoma, 53 ; sarcoma, 2, and prolapse, 2.
In favorable cases of carcinoma one should
hope for complete cure. Partial extirpation
is rarely indicated. In one case a partial
operation was performed upon a woman who
was seven months pregnant, a wedge-shaped
excision of the cervix being performed with-
out interruption of the pregnancy. In only
two of the above series did death result from
the operation, the cause in one being uraemia
after ligation of the left ureter and wounding
of the bladder. In two cases it was subse-
quently necessary to perform kolpo-kleisis on
account of vesico-vaginal fistula. In three
cases the patients were more than 60 years
of age. The suturing of the peritonaeum and
disinfection salicylic and boric acid are
deemed very important. In twenty-five of
the carcinoma cases a year passed without
recurrence of the disease. Recovery from
the operation was usually rapid. In cases
in which there was recurrence the thermo-
cautery and chloride of zinc were used. In
none of the operations was there severe
haemorrhage, and in one case a vesico-vaginal
fistula was cured by the operation upon the
uterus. — Jour, de Med.

DEFECTIVE DEVELOPMENT OF GENITALS.

Dr. von Swiecicki (Der Frauenarzt,
April 1, 1891) was consulted recently by a
robust woman, aged 30. She had always
been healthy as a child. After the age of
20 the menstrual molimen was noticed every
four weeks, and the hands and feet then
became swollen to a marked degree. A little
blood passed from the anus; at the same

time there was nausea and headache. All
these symptoms lasted for about four days.
Early in January a severe attack of haemat-
emesis set in during the presence of the
menstrual molimen, and the vomiting of
blood recurred four times within a week.
Nearly a pint of blood was lost during each
attack. On this occasion it was remarkable
that the breasts became swollen, which was un-
usual, though the ordinary oedema of the hands
and feet did not occur. The patient was
perfectly feminine in mind and in general
confirmation. The hymen, like the vulva,
was normal, but there was an impassable
septum above it. After very careful recto-
abdominal and recto- vesical exploration it
was concluded that the vagina, uterus, and
left ovary were entirely absent. A small
right ovary could be distinctly defined. Dr.
von Swiecicki quotes Kline's case, where the
uterus and vagina did not exist, but both
ovaries were present. Molimen with epi-
staxis for two days occurred every three
weeks. OEdema of the extremities has been
observed in other cases, and may accompany
menstruation otherwise normal. Borner re-
fers it to vasomotor disturbances. — BriL
Med. Jour.

OBSTETRICS.

ON THE TREATMENT OF BREECH PRES-
ENTATION.

Winter (Deutsche Medicinische Wochen-
schrift, February, 1891) contrasts the differ-
ent line of treatment to be adopted in breech
and foot presentations, and the more favor-
able prognosis offered by the former variety.
Expectancy is the attitude to be adopted in
footing cases, but interference is necessary if
in breech presentations delay becomes dan-
gerous to mother or child. The indications
for bringing down a foot in breech cases and
completing delivery are complications endan-
gering the life of mother or child, such as
slowing of pulsation in the cord, impending
asphyxia, haemorrhage, septicaemia, &c. In
prolapse of the cord, eclampsia and con-
tracted pelvis, this method of procedure
may also have to be adopted. The writer
quotes the opinions of various authors as to
the particular form of contracted pelvis in
which the operation can be performed with
beneficial results. He considers that in nor-
mal conditions it is wrong, because it is un-
necessary, and while not entirely harmless
for the mother may be very detrimental to
the child. In eighteen cases where delivery
speedily followed drawing down of the foot,

June 27, 1891.

Periscope.

837

seventeen of the children survived, while in
nine cases, where delivery was more tediously
accomplished, four of the children were lost.

The writer advocates bringing down a
foot in preference to traction with the fingers,
loop or blunt hook, all of which are either
tedious or dangerous. If these were so safe
an instrument for the breech as forceps for
the head, there would be no necessity for
bringing down the feet. All the breech for-
ceps invented have been failures.

If the foot cannot be brought down, the
author recommends traction with the finger,
inserted between the thigh and abdomen of
the child, and if this be unsuccessful, a skein
of worsted or silk may be employed ; but
this is often difficult or impossible of appli-
cation. Poppel advocates introducing it by
means of a Bellocq's sound. Winter strongly
recommends an instrument invented by
Bunge, and called a " loop carrier." It con-
sists of a curved metal staff, grooved on its
concave surface, and containing a thick
hempen cord covered with gutta-percha, and
about eighteen inches long. The latter is
passed by means of the staff between the
thighs and abdomen of the child, the staff is
withdrawn, and the loop can then be used as
a tractor.

His conclusions are : — (l.)Normal cases
to be treated by the expectant method. (2.)
Bring down a foot in cases of prolapse of
the cord, eclampsia and contracted pelvis,
but not, as a rule, before the os is well
dilated. (3.) Complete the labor in breech
cases where desirable by bringing down a
foot, and proceed at once to extraction of
the child. If the breech is too low in the
pelvis for this operation, use the finger as a
tractor, and should this prove unsuccessful,
employ Bange's instrument or a skein of
wool. — Dublin Jour. Med. Sei.

ANATOMY OF TUBAL PREGNANCY.

Two cases are recorded occurring in the
practise of Dr. Landau. In the first case
the patient died in a few minutes after
the arrival of the physician. In the second
the patient's condition was so poor that
no operation could be attempted. But
in spite of rupture the patient rallied and
made an excellent recovery. In Case I. the
autopsy revealed a rupture of the right tube.
The deeidua was removed from the uterus.
In Case II. pieces of deeidua came away.
Careful microscopic examinations were made
of these specimens, and from these the follow-
ing are formulated :

In tubal pregnancies occurring in the fourth
and fifth week we find :

1. That the endometrium is about to be-
come changed into a deeidua. The compact
layer, the so-called layer of Friedlander, is
not fully formed.

2. The superficial epithelium ofthe deeidua
uterina is intact as late as the middle of the
second month, although its form is materially
changed.

3. The vessels which are found in the
superficial layers of the deeidua uterina are
in all probability arteries and veins.

4. The ovary and tube on the uni impreg-
nated side remain unchanged. The ovary
containing the gravid corpus luteum is en-
larged.

5. The cause of tubal pregnancy may be
assumed to be due to a diverticulum in the
walls of the tube or a marked tortuosity of
the same.

6. That portion of the tube not included
in the impregnated sac usually remains
unaltered.

7. A deeidua tubaria vera is formed upon
the mucous membrane of the tube, having
its greatest amount of development at the
poles of the ovum. The superficial epithe-
lium of the deeidua serotina disappears, and
is replaced by the endothelium of the freely
communicating capillary vessels.

8. In the majority of the cases no deeidua
tubaria reflexa is formed. If one is formed
it differs entirely from the uterine
reflexa, owing to its small number of vessels.

9. The attachment of the chorionic villi to
the deeidua tubaria is extremely loose in
the beginning ef the pregnancy, but in some
situations a complete union between the two
is found.

10. The epithelium of the chorionic villi
is of the three varieties. The maternal capil-
lary endothelium lies external to a double
layer of fetal epithelium.

11. The intervillous spaces are composed of
dilated maternal capillaries, whose walls are
not penetrated by the chorionic villi.— Archiv.
fur Gyndkologie.

TOXIC SPASM OF PARTURIENT UTERUS
OVERCOME BY ANTIPYRIN.

Dr. Wright, of Toronto (Archives of
Gyncecol., New York, April, 1891) reports
the case of a primipara, aged 22, of seden-
tary habits. The pelvic outlet was slightly
narrow ; pregnancy was normal. The os
was rigid, and the membranes ruptured
prematurely, so that the first stage of labour
lasted over twenty-four hours, although

838

Periscope.

Vol. lxiv

three 15-grain doses of hydrate of chloral
were given to relax the os. The head then
descended rapidly half down the vaginal
canal, but then the progress of labour be-
came slow. At the end of forty hours the
head was well down in the perineum, but
the rigidity of external parts rendered the
pains ineffectual. Symptoms of exhaustion
then began to appear. The pains became
shorter and more frequent, the pulse in-
creased to over 100, and the patient com-
plained of nausea and thirst. It soon be-
came impossible to make out distinct inter-
vals between the pains, and, on examination,
the uterus was found retracted, and in a
state of tonic contraction. Three 15-grain
doses of antipyrin, to be taken at intervals
of one quarter of an hour, were prescribed.
Before the second dose had been given the
patient felt easier ; after the third the pains
were about three minutes apart, and the
tetanic contractions had disappeared. The
head, being very large in proportion to the
outlet, was delivered with forceps under
chloroform. The uterus took three-quarters
of an hour to contract properly after the ad-
ministration of ergot in drachm doses. Dr.
Wright considers that this case shows the
value of antipyrin in uterine tetanus. It
might more beneficially be used before the
muscular fibres and nerve centres are ex-
hausted by prolonged tonic contractions. —
Brit. Med. Jour.

PEDIATRICS.

INFANTILE CEREBRAL PALSIES.

Professor Sachs, in a paper read before
the New York Neurological Society {New
York Med. Journ., May 2nd, 1891), dis-
cusses the pathology of the cerebral paralyses
of infancy. He divides them into the con-
genital cases, that is, those occurring before
birth and due to gross cerebral defects ; birth
palsies, the result of protracted labour, where
meningeal, or more rarely intracerebral,
haemorrhage has taken place; and those
acquired after birth, in which in agreement
with the majority of recent writers on this
subject, he considers vascular lesions as by-
far the most common cause ; next to these
he places chronic meningitis and hydro-
cephalus ; and lastly, Striimpell's primary
encephalitis. This last condition he be-
lieves to be excessively rare, and he holds
that the theory should be accepted with
some reserve. The diagnosis of the different
kinds of vascular lesion, that is, embolism,
thrombosis, and hemorrhage, he admits to

be sometimes very difficult, but when haemor-
rhage can be diagnosed, he thinks that
surgical interference is imperatively called
for. If the symptoms point to the forma-
tion of a large clot over the motor area of a
child otherwise healthy and strong enough
to endure the operation, he recommends that
an attempt should be made to remove the
clot in order at once to relieve pressure upon
the given area, and to prevent secondary
degeneration. This latter point would be
certainly well worth attaining, but the diag-
nosis of intracranial haemorrhage in the
young is by no means so easy. Still, where
it can be made, there is no objection to the
use of the trephine. — Brit. Med, Jour.

SPINAL PARALYSIS IN CHILDREN.

Several cases of this disease are reported
by Professor Charcot in a recent number of
the Journal de medecine et de chirurgie. In
examining into the antecedents of these cases
a family history of nervous disease is fre-
quently found. Hysteria, epilepsy, insanity,
and various other nervous affections are not
uncommon. This is, however, in contra-
diction of Cordier and others, who have
seen the disease occur epidemically. In one
case reported by the author fatigue seemed
to play an important aetiological role. On
the third day after excessive fatigue the
child became delirious and one of the legs
was found to be paralyzed. The case was
peculiar from the fact that but one limb was
attacked at the outset. The paralysis did
not change from place to place and finally
locate itself in one member, as is frequently
the^ case. It was confined to the sciatic
region and was very severe. Complete loss
of all electrical reaction indicated that all
hope of cure was gone. A second patient
was attacked without apparent cause. Chilli-
ness was the only symptom at the onset, and
was followed in the evening by paralysis of
the left leg. On the following day the left
hand also was involved. The bladder was
soon affected, which resulted in retention of
urine for several days. This is a symptom
of frequent occurrence in children.

NOTES OF AN EPIDEMIC OF MEASLES.

Dr. Frederick Stanbro says : I write these
notes, not because Kubeola is such a rare
disease, but in order to put on record certain
irregularities observed during this epidemic,
which I trust, will be of interest, and may
be of service to the general practitioner.

Beginning in the last week of January,
1891, and continuing seven weeks, there has

June 27, 1891.

Periscope.

839

been a severe epidemic of measles in this
region. No such epidemic has been observed
here in fifteen years, both as regards severity,
numbers attacked, and small mortality.

All unprotected persons have been at-
tacked, and six authentic cases I have ob-
served which have suffered a second attack.
These six persons had measles before, under
the observation and care of physicians in
this vicinity, and there can be no mistake.
Three had mild attacks from three to ten
years ago, and three had severe attacks
seven years ago. Each of these six cases
had measles under my observation this
season, and all had it in the severest form,
the prodromes, rash, catarrhal symptoms, all
being typical. I lay special stress on these
cases, as there seems to be some doubt on
this subject among medical minds, as well as
among the laity.

Of the 110 cases observed and treated, I
find sixty males, and fifty females ; of these,
twenty-four were adults and six were infants
under the age of nine months.

The period of incubation was about nine
days, but the eruptive stage was wonderfully
delayed, the rash not appearing until a week
had passed, in the majority of cases, and in
two cases of young ladies, aged respectively
sixteen and eighteen years, the rash did not
appear until nine and fourteen days had
passed, during which time they were confined
to the bed with the usual symptoms of the
prodromal stage — viz., malaise, headache,
bone-ache, slight fever, etc.

During this period of " invasion " the pa-
tients were all ill and suffered from aching
bones and muscles, constipation, nausea,
headache, and other symptoms similar to
those of *' la grippe " of last year. A slight
rise of temperature would be observed, and
for about three days before the appearance
of the rash the coryzal symptoms and the
peculiar hacking cough would appear.

The temperature was extremely high as a
rule, being 103° F. in most of the cases, 104°
F. in twenty cases, 105° F. in ten cases, and
10550 F. in three cases.

The pulse was correspondingly high, run-
ning from 120 to 160 in the severest cases.
Slight congestion of kidneys occurred in
most of the days before the appearance of
the rash, and delirium was a common
symptom.

In a few cases, earache was so severe as to
call for local, treatment.

Sequelm. — Catarrhal pneumonia attacked
one patient weakened by the measles, and
whooping cough occurred in nine cases.
The severe coughing caused a direct inguinal

hernia in a young man about sixteen years
of age. Otherwise all the -cases recovered,
not one of the 110 dying, and only one is
now under my observation.

Treatment. — The simpler cases demanded
no treatment, except light diet and some
calming expectorant.

The more severe cases were kept in warm,
darkened rooms on strictly milk diet. High
fever was relieved or controlled by tr. aconite,
quinine and tepid baths. Constipation re-
lieved only by warm enemata. Dysuria, or
suppression of urine, by spirits of nitre and
other simple diuretics.

The conjunctivitis required nothing but
warm lotions, and the general pruritus was
relieved by inunctions of vaseline or lard.

Only a few required any tonic treatment
during convalescence. — Exchange.

BROMOFORM IN WHOOPING COUGH.

Recently The Reporter has several
times found occasion to speak of the efficacy
of bromoform in whooping cough. Perhaps
the most recent experiences with the drug are
those of Dr. Naurcelsers, of Brussels, which
are referred to in the Wiener. Med. Wochen-
schrift, May 10, 1891. The author gives the
drug in the following formula :

Ijk? Bromoform xx gtt.

Alcohol 10.0 grammes.

Sol. gum. trag

Syr. tolu, aa 60 o grammes

M. One coffeespoonful every hour.

The mixture should be well shaken before
administration, and should be kept in a well
corked bottle. The solution of gum facili-
tates an equal distribution of the remedy in
the mixture and the large quantity of syrup
marks its unpleasant taste, so that children
take the dose without murmuring.

In adults, ISTauweloers gives the drug in
capsules, each containing gramme 0.50 of
bromoform. He gives the patient 14 cap-
sules during two or three days. In children
the dose should vary with the intensity of the
attack and the strength of the child. At first
8-1 0 drops daily is usually a sufficient dose
but in a few days this may be increased to 20
drops, if found necessary.

Bromoform has one drawback ; it is apt to
cause diarrhoea. In order to hinder such an
action, the drug may be combined with opium
or astringents. If, however, the diarrhoea
still persists, the drug must be discontinued
for a few days. In 74 cases in which the
drug was tried, it only failed once. Three
greatly weakened children died of broncho-
pneumonia, but all the rest recovered rapidly,

840

Periscope.

Vol. lxiv

the direct action of the drug being admirable.
In many cases a cure was accomplished
within 5-6 days. No other remedy has, as
yet, shown such abortive properties in this
disease.

HYGIENE.

INFLUENZA BACTERIA.

A recent number of the Progre.s medical
contains an abstract of an article by Pro-
fessor Babes, which appeared in the Central-
blatt fur Bakteriologie und Parasitenhunde,
on the subject of bacteria in influenza. The
author has succeeded in isolating two varie-
ties of micro-organisms to which he thinks
that in all probability the pathological ele-
ment in the causation of influenza may be
attributed. Those of the first variety form
short chains, are immobile, and are not
stained by Gram's method. Their colonies
are small in dimensions, transparent, and
developed through the entire culture media.
They have been proved capable of produc-
ing active pulmonary inflammations. The
bacteria of the second class produce on agar-
agar colonies that present a dark centre and
a whitish periphery. They are also immob-
ile, but, unlike the first variety, are colored
by Gram's method. In mice, the inocula-
tion of this culture produced fatal pneu-
monia, the bacilli being found in the blood-
vessels; and in rabbits a local inflammation
resulted. — N. Y. Med. Jour.

COMPULSORY NOTIFICATION OF INFEC-
TIOUS DISEASE.

In criticising the notification bill of last
year, one of the reasons which we urged
against its enactment, was that it must
always be impossible to enforce such law,
or to impose the penalties provided for
omission to notify. You may bribe an un-
scrupulous practitioner by half-a-crown to
report an infectious case, but you can never
punish him for omitting to do so, because
you can never prove that he knew the case
to be infectious and yet concealed it. The
most careful and conscientious practitioner
may be in doubt as to the nature of the
disease for a week or ten days after its onset,
while an ignorant or stupid man may fail to
recognize it even when the symptoms were
tolerably clear. But he could never be
punished for mere ignorance, nor could a
prosecution be successfully maintained if he
met the accusation by denying that the case
was infectious, and by asserting that the

Medical Officer of Health was all wrong in
his diagnosis. Our anticipation of the work-
ing of the Act in this respect has been fully
realized, for the only attempt at prosecution
which, as far as we know, has been made
since the Act became law has completely
failed, and a judgment has been given by
the Court which makes successful prosecu-
tions almost impossible. The worst of this
is, that the law offers every inducement for
the trickery of unscrupulous practitioners,
while it handicaps truthful and conscientious
persons. The unscrupulous doctor certifies
every case which is not worth half-a-crown
to him in private fees, and he conceals every
case which is worth more than that sum. If
he meets wdth a pauper who has shivered
and has a headache, he at once concludes
that the patient is in for an infectious attack,
and he reports him forthwith, at a profit of
half-a-crown, whether the case is really in-
fectious or not, and the patient goes to swell
the half-yearly earnings of the notifier and
the total of infectious notifications, to the
great satisfaction of the Medical Officer of
Health. But if the patient happens to be
worth more than half a crown, the practi-
tioner is slow to diagnose infective disease,
pronounces that it is nothing but a bad cold,
and keeps the case concealed to the end of
the chapter. An Act of Parliament which
imposes penalties which it is impossible to
enforce, is ridiculous, and its apparent re-
sults totally unreliable, and, therefore, we
shall attach no confidence to the supposed
beneficial results from the compulsory notifi-
cation system until we see whether a de-
creased death-rate from zymotics is the out-
come of it. — Med. Press.

THE SUPPRESSION OF JUVENILE SMOKING.

It is doubtless desirable to place some
check upon the use of tobacco by juveniles —
a practice which is every day becoming
more general, or at any rate, more flagrant,
but we know by sad experience that ine-
briety, whether of alcoholic or other source,
is not easy to control by legislative enact-
ment. The experiment is being tried in cer-
tain cities in the United States, but we are
not yet in possession of any reliable data as
to the effect of the police regulations. The
labors of the ubiquitous policeman will be
materially added to, if, in addition to pre-
venting juveniles playing tipcat in crowded
thoroughfares he be expected to stop every
offender against an anti-juvenile smoking
law. It was suggested at a recent meeting
on the subject at Manchester that lads take

June 27, 1891. Periscope.

up with the habit " ignorantly supposing
they will be benefited thereby," but this we
venture to doubt, as also the proposed edu-
cational remedy based on that assumption.
It is the imitative faculty which is mainly
responsible for the spread of the habit among
young people, and parental example is a
potent factor in its promotion. The best
plan would be to authorize municipalities to
make and enforce tentative regulations of
this kind, for an inoperative general law
would only prove a barrier to such modifica-
tions as experience might suggest. The first
step would necessarily be to make it an
offence to sell the weed to persons below a
certain age, as has been done in regard to
spirits. — Med. Press.

MEDICAL CHEMISTRY.

THE QUANTITATIVE ESTIMATION OF
SUGAR WITH ROBERTS' FERMEN-
TATION TEST.

Dr. Moms Manges, in the Medical Record
refers to two inherent important advantages
in this process, which deserve notice. The
one is that fermentation is the only absolute
test for determining the presence of glucose ;
it is the chemist's crucial test to absolutely
distinguish it from allied substances, some of
which may have a similar chemical composi-
tion, or may reduce Fehling's solution, or
may have a right rotary action on polarized
light.1 The other is that none of the usual
reducing substances (albumin, uric acid, etc.)
can interfere with its action.

The principle upon which all the fermen-
tation tests are based is the well-known split-
ting up of glucose by yeast into alcohol and
carbon dioxide. C6H1206=2C2H60 + 2Co,.
Another reaction occurs which is not ex-
pressed in the formula ; that is, the specific
gravity of the fermenting fluid is lessened in
direct proportion to the amount of grape-
sugar present. This loss of weight is due not
alone to the disappearance of the sugar, but
also to the presence of the generated alcohol ;
it is the presence of the latter which some-
times, though rarely, causes the specific
gravity of the fermented liquid to sink below
1,000.

From the above we see that there are
several factors which may be utilized in
quantative estimations by this method. 1.
The carbon dioxide, usually estimated by

1Leo has isolated such a substance, which has the
same chemical formula, reduces Fehling's solution,
and rotates polarized light to the right, yet differs
from glucose in not fermenting.

volume, as in Einhorn's method. 2. The
alcohol; is too complicated and unreliable.
3. The difference in the specific gravity of
the unfermented and fermented fluids ; may
may be estimated (a) by actual weighing
with accurate balance, as is done by chemists ;
is not adapted for general use ; (b) by taking
specific gravity, as in Roberts' method.

For clinical purposes we are thus reduced
to the methods of Einhorn and of Roberts.
Einhorn's method being too well known to
need description here we shall at once pro-
ceed to consider the test proposed by William
Roberts of Manchester ; and so well has its
distinguished author done his work, that,
although thirty years have almost elapsed,
the method stands practically as originally
proposed. The only requisites for the test
are a sufficiently wdde cylindrical urinometer-
jar of about two to three ounces capacity,
and two good urinometers, one reading from
1.000 to 1.025, the other, 1.025 to 1.0 ,0 ;*
large subdivisions of the scale are essential.
Urinometers with thermometers are desir-
able, but by no means absolutely necessary.
The tests of a good instrument are that in
distilled water at the temperature for which
it is corrected, the instrument should stand
at 1.000, and in a dilution of any salt solu-
tion with an equal volume of distilled water
the reading should be one-half of the gravity
of the original salt solution.

The procedure is carried out as follows :
Having accurately taken the specific gravity
of the specimen of urine, and noted the
temperature, about four ounces (if quantity
is small, one-half this amount will suffice)
are poured into a twelve ounce bottle, " a
lump of compressed yeast about the size of
a walnut " (half a cake will be found suf-
ficient) is added and thoroughly stirred up ;
the bottle is then closed with a nicked cork,
to prevent the escape of the CO gas gen-
erated. A standard is then prepared by
filling a two or four ounce bottle with some
of the same urine, and is securely corked
without having added anything. The two
bottles are now put aside in a warm room
for eighteen to thirty-six hours, when the
fermentation will have been completed, as is
shown by the cessation of the formation of
bubbles in the fluid, and also by the clear-
ing off or subsidence of the scum. The
bottles are removed to a cool place so that
they may acquire the same temperature as
at the beginning of the test ; a portion of the
fermented fluid is decanted and the specific

lShould the specific gravity be above 1 050, the
specimen should be diluted. This is uncommon,
however.

842

Periscope.

Vol. lxiv

gravity and temperature are again noted. It
is also well to note the gravity of the " stand-
ard," to see if it is identical with the original
reading. The difference in the two readings
of the specimen, before and after fermentation,
multiplied by 0.23 will give the percentage
of sugar in the specimen. Or we may express
it thus : each degree of specific gravity lost
in fermentation represents one grain of sugar
to the ounce of urine. The total amount for
twenty-four hours being known, the total
amount of sugar can be calculated.

Roberts gives two examples. A specimen
showed 11.36 per cent, sugar by titration
with Fehling's solution, (— 49.64 grains to
the ounce). The specific gravity was 1.0535 ;
after fermentation it fell to 1.0045 ; it lost
49°, i. e., 49 grains to the ounce; or, x 0.23
= 11.27 per cent.

A second specimen had 5.68 per cent,
sugar (=24.82 grains to the ounce) as shown
by titrating with Fehling's solution. The
original specific gravity was 1.03032 ; after
fermenting it fell to 1.01356 ; the difference
was 24.76°, i. e., 24.76 grains to the ounce ;
or, x 0.23 = 5.69 per cent.

Jaksch says, after trying the method on
eight cases of diabetes, that " it gives thor-
oughly reliable results for clinical purposes,
and is one which is to be commended, espec-
ially to busy physicians, on account of the
simplicity and ease of its application." He
quotes four cases which were examined with
a special apparatus designed to prevent
evaporation (which, however, is superfluous),
the control-examinations having been made
by polarization.

Guttman highly commends the method
after having used it in over one hundred
cases. He has simplified the method as fol-
lows : In a three to four ounce cylindrical
glass vessel the specific gravity is taken ; a
quarter of a cake of compressed yeast is
added and thoroughly stirred up ; the ves-
sel is covered with a piece of paper and set
aside at 15° C. (59° F.) for twenty-four
hours. Then the yeast has settled, and
the specific gravity is taken in the same
vessel at about the same temperature as
the original observation. He has ascer-
tained that the temperature changes exert
slight differences in the result if the per-
centage of sugar is over one per cent. ; and if
over two per cent, it is reduced to iV per
cent, to tV per cent. The exact difference is
3° C. (5.4° F.) =1°; thus a reading of
1.022 at 12° C. would be 1.021 at 15° C,
and 1.020 at 18° C.

Dr. Manges has tried Roberts's method in
a fair number of specimens and the results,

from a clinical point of view, have been very
satisfactory. Comparisons were made with
Einhorn's method, and the specimens were
also titrated with Fehling's solution as modi-
fied by Munk.

Dr. Manges's observations agree with those
of the other observers in proving that there
is no constant source of error, but that the
result may be more or less than the actual
amount. What the cause of this error is he
has been unable to ascertain. That it is not
due to the urinometer is shown by Wonn-
Miiller's figures, who also obtained higher
and lower results although the pyknometer
was employed to determine the difference in
the specific gravity. Possibly we may find
the cause in subtle changes of temperature,
or in the secondary fermentation which
occurs in the yeast itself. Whatever these
influences may be, they are surely not of
very great importance, nor do they detract
from the claims of this procedure of being
called the " Clinical Method," as proposed
by Roberts.

The advantages of the method may be
summed up thus : It is simple ; it requires
no special apparatus nor special experience ;
dilutions are unnecessary, and hence the
multiplication of an error is avoided ; im-
purities in the yeast have very little effect
on the result. The disadvantages, besides
that inherent in all the fermentation tests,
that they are slow, are, that it does not show
amounts of sugar below 0.4 »per cent., and
also that it requires a larger amount of urine.
The latter, however, is more apparent than
real, for in Einhorn's method we must also
have enough urine to estimate the specific
gravity.

There are also certain disadvantages pres-
ent in Einhorn's method from which this
method is free. In the first place, gases are
much more affected by differences of tempera-
ture and atmospheric pressure than are
liquids. Then the necessary dilution is a
cause of inaccuracy ; Einhorn gives definite
rules as to the proportions, as if certain
ranges of specific gravity must correspond
with approximate amounts of sugar, for he-
directs that " diabetic urines of a straw color
and a specific gravity of 1.018-1.022 may be
diluted twice; of 1.022-1.028, five times;
1.028-1.038, ten times." There are other
ingredients, however, in urine which may
markedly affect the specific gravity, i.e.,
urea, phosphates, chlorides, etc. The analy-
ses already quoted show this very forcibly ;
thus, Nos. 8 and 9 of the last table both have
specific gravity of 1.0315, yet the one has
4.37 per cent, sugar, and the other, 1.92 per

June 27, 1891.

News and Miscellany.

843

cent. Furthermore, a high specific gravity
does not necessarily mean a large amount of
sugar, nor a low specific gravity indicate a
small percentage. Thus No. 3 of Guttman's
cases has specific gravity of 1.011, yet has
1.495 per cent, sugar, and Nos. 11 and 12
of my own series, each with a specific grav-
ity of 1.028, have only two per cent, and
1.38 per cent, sugar respectively. If we do
not dilute enough, the gas will pass up into
the bulb ; if we dilute too much, the amount
of gas will be so small that a large error is
unavoidable, because of the subsequent mul-
tiplication.

Guttman has also shown that only a small
part of the carbon dioxide remains in the
long arm of the saccharometer, while the
greater part escapes into the air through
the bulb. Thus 10 c.c. of a one per cent,
saccharine urine ought to give off 24 c.c. of
CO at ordinary temperature and atmos-
pheric pressure ; of this only 5 c.c. are reg-
istered, while 19 c.c. are lost. (A small
amount of the gas may also be absorbed by
the fluid.) This objection, however, may
be more theoretical than practical, for even
Guttman comes to the conclusion that for
saccharine urines under one per cent., Ein-
horn's method gives reliable results.

Dr. Manges would go even further than
this, and say that with most urines it gives re-
sults which are sufficiently accurate for clin-
ical purposes ; but, at the same time would as-
sert that Roberts's method is in many respects
superior to it. Neither method, however, gives
absolutely accurate results. But this applies to
every test which has yet been proposed for
this purpose, even to the most delicate of them
all, polarization and Fehling's test. For the
right rotation of polarized light may be par-
tially neutralized by the presence of oxy-
butyric acid, which rotates polarized light to
the left. As for Fehling's test, we are all
familiar with the difficulty of telling exactly
when the blue color has disappeard, and we
all know how its results may be affected by
the reducing action of albumin, uric acid,
kreatinin, etc.

News and Miscellany.

ITALIAN PHARMACOPGEA.
The first national Italian formulary is
about to be published.

RESIGNATION OF DR. FRANCIS MINOT.
Dr. Francis Minot has resigned from the
Chair of Practice in the Harvard Medical
School.

DEATH OF DR. JOS. P. LOGAN.

Dr. Joseph P. Logan, editor of the
Atlanta Medical and Surgical Journal, died
at Atlanta, Ga., on June 2nd.

THE JOHNS HOPKINS HOSPITAL.

The Johns Hopkins Hospital accommo-
dates one hundred and twenty patients and
cost over two millions of dollars.

FOUR YEARS' COURSE AT HARVARD.

Beginning with September, 1892, the reg-
ular course in medicine at Harvard to obtain
the degree of M. D., shall be four years.

DR. J. MADISON TAYLOR.

Bar Harbor, Maine, will be fortunate this
summer in having at command the pro-
fessional services of this distinguished phy-
sician.

A NEW JOURNAL OF GYNECOLOGY.
A monthly Journal of Gynaecology, Ob-
stetrics and Abdominal Surgery has appeared,
and is edited by Dr. Charles N. Smith, of
Toledo, Ohio.

THE METRIC SYSTEM.

Russia is the latest to make the study of
the metric system compulsory by all med-
ical and pharmaceutical students, and has
made it also compulsory in prescriptions and
pharmacy.

TULANE UNIVERSITY.

The Medical Department of the Tulane
University has been made the recipient of a
donation from Mrs. T. G. Richardson of
$100,000, which is intended to be used in
erecting a new college. Mrs. Richardson is
the wife of Dr. T. G. Richardson, an eminent
physician and Dean of the College.

THE VIRCHOW TESTIMONIAL FUND.

October 13th will be the seventy-fifth
birth-day of Professor Virchou, and on that
occasion it is proposed that the profession
pay a suitable tribute in appreciation of his
invaluable labors for medical science. Five
dollar subscriptions are being raised all over
the world, and already a large amount has
been subscribed in this country

MEDICAL AND SURGICAL REPORTER.

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II

MEDICAL AND SURGICAL REPORTER.

ARISTOL.

ARISTOL, a combination of iodine and thymol, manufactured by the Farbenfabriken, formerly Friedr.
Bayer & Co., Elberfeld, Germany, is a valuable, inodorous and non-toxic antiseptic remedy, said to be
superior to Iodoform, Iodole and Sozo-Iodole.

ARISTOL is insoluble in water and glycerine, and very sparingly in alcohol, but is very easily soluble
in ether and chloroform. The ether solution is precipitated .by the addition of alcohol. ARISTOL is
very freely soluble in fatty oils. The solution must be made in the cold, by stirring, as the use of heat
causes a decomposition. For the same reason it is necessary to protect the body from light and keep it in
opaque bottles. It very readily adheres to the skin, and can thus be used as a powder strewn over wounds
and burns.

In cases of mycosis it also acts well, and more quickly than any other known remedy, and does not
cause irritation, like so many drugs.

The effective use of ARISTOL in psoriasis is of great interest, as our Materia Medica has hitherto
supplied us with no non-poisonous drug, save only chrysarobin, the use of which is associated with a deep
skin coloration and conjunctivitis — drawbacks from which ARISTOL is absolutely free.

In cases of lupus it is said to surpass even the best known remedies.

The value of ARISTOL can scarcely be over-estimated, as we have in it a drug possessing the good
properties of Iodoform, but free from its toxic qualities. Its freedom, too, from any suspicious odor will be
at once appreciated, both by the physician and his patient.

ARISTOL, prepared by the Farbenfabriken, formerly Friedr. Bayer Co., Elberfeld, is supplied by
us in ounces.

SULFONAL-BAYER.

The value of Sulfonal in children's diseases, — Dr. William C. Wile sent a paper
with this title to the American Medical Association, in which he stated that Sulfonal was the ideal hypnotic.
It was without the bad effects of opium and the uncertainty of the bromides. It could be given in ten-
grain doses. It quieted reflex irritability. It did not constipate nor disturb the stomach. In one case in
which a drachm was taken accidentally in ten-grain doses, there was a deep slumber lasting twenty-four
hours, slight fever, but a normal pulse and respiration. — Medical Record, New York.

Dr. Henry M. Field, in a paper presented to the American Medical Association, says: — " Clinically
observed, we recognize in Sulfonal a mild calmative, a slowly, but progressively acting hypnotic ; it has no
other action, and its operation is attended by no complications, near or remote. It is therefore a pure
hypnotic, and, we submit, it is the only pure hypnotic we possess, up to date." — New England Medical
Monthly.

Sulfonal- Bayer, prepared by the Farbenfabriken, formerly Friedr. Bayer <Sr» Co., Elberfeld, is supplied
by us in ounces and in the form of Tablets of J, 10 and 15 grains, put up in bottles of 10 and 100 tablets
each.

We also offer Sulfonal- Bayer in the form of our soluble pills, containing 3 grains each.

PHENACETINE- BAYER.

Phenacetine in Insomnia. — Dr. F. Peyre Porcher, of Charleston, S. C, writes : " I desire
to call special attention to the extreme value of Phenacetine as a remedy for insomnia. Given at night in
a little water it is tasteless, innocuous, and induces sleep. I am confident, also, after repeated trials, that it
is the best and most unobjectionable substitute for morphia. It causes sleep when, of course, pain is in
abeyance, unless the pain be more than ordinary, and morphia hypodermically may then be required. The
remedy may be repeated and the dose increased to seven or ten grains.

" Suffering from chronic rheumatism of the forearm, I have tested it repeatedly in my own person, and
have given it to many who have suffered from insomnia, or inability to sleep from any transient cause,
atigue, nervousness, excitement, etc., in either sex." * * * * * — Medical Record, New York.

Phenacetine- Bayer, prepared by the Farbenfabriken, formerly Friedr. Bayer dr» Co., Elberfeld, is sup-
plied by us in ounces and also in the form of our soluble pills and compressed tablets, containing two, four
and five grains each. Either form may be obtained of any reputable apothecary.

It gratifies us to be able to announce that PHENACETINE, SULFONAL and SALOL have been incorporated into the
new German Pharmacopoeia just issued, and have been proposed by the General Medical Council of Great Britain for intro-
duction into the forthcoming Addendum to the British Pharmacopoeia. This action confirms and endorses our judgment in
introducing these valuable remedies to the medical profession of the United States, and is a natural sequence of the favorable
results experienced in their employment, and of the brilliant and conclusive testimony thereof, which had been so freely fur-
nished by the most talented of the profession both in Europe and in the United States.

W. H. Schieffelin & Co.,

170 & 171 William Street,

NEW YORK

MEDICAL AND SURGICAL REPORTER.

Ill

SCOTT'S EMULSION

r VERSUS -

PLAIN COD LIVER OIL.

Plain Cod Liver Oil is indigestible, deranges the stomach, destroys the appetite
is not assimilated, and in a majority of cases is detrimental to the patient.

SCOTT'S EMULSION

Can be digested in nearly all cases, is assimilated, does not derange the stomach,
nor overtax the digestive functions, and can be_ taken for an indefinite period when the
plain cod liver oil cannot be tolerated at all, and with most marked results in Anaemia,
Consumption and all wasting conditions. It also contains the Hypophosphites of JLime
and Soda with Glycerine, which are most desirable adjuncts.

WHEN PHYSICIANS TRY IT THEY INVARIABLY USE IT
in preference to the plain cod liver oil or other so-called Emulsions that invariably separate,
and hence their integrity and value is destroyed. Scott's Emulsion is palatable and
absolutely permanent hence its integrity is always preserved.

The formula for Scott's Emulsion is 50 per cent, of the finest Norwegian Cod Liver Oil, 6 grains
Hypophosphite of Lime and 3 grains Hypophosphite of Soda to the fluid ounce, Emulsified, or digested
to the condition of assimilation with chemically pure Glycerine and Mucilage.

We also wish to call your attention to the following preparations :

CHERRY MALT PHOSPHITES.

A combination of the tonic principles of Prunus Virginiana, Malted Barley, Hypophosphites of
Lime and Soda, and Fruit Juices. An elegant and efficient brain aud nerve tonic.

BUCKTHORN CORDIAL (Rhamnus Frangula).

Prepared from carefully selected German Buckthorn Bark, Juglans Bark and Aromatics. The
undoubted remedy for Habitual Constipation.

Be sure and send for samples of the above — delivered free.

SCOTT & BOWNE. 132 South Fifth Avenue, NEW YORK.

FRELIGH'S TABLETS,

(Cough and Constituent),

FOR THE PREVENTION AND CURE OF

PULMONARY PHTHISIS.

m m m —

Cough Tablets.

EACH TABLET CONTAINS.

Morph. Sulph. gr.), Atropise Sulph. gr.),
Codeia (,& gr.), Antimony Tart. & gr.), Ipecac,
Aconite, Pulsatilla, Dulcamara, Causticum, Graph-
ite, Rhus-tox, and Lachesis, fractionally so ar-
ranged as to accomplish every indication in any
form of cough.

Constituent Tablets.

EACH TABLET CONTAINS.

Arsenicum gr.), Precipitate Carb. of Iron,
Phos. Lime, Carb. Lime, Silica, and the other
ultimate constituents, according to physiological
chemistry (normally) in the human organism,
together with Caraccas. Cocoa and Sugar.

PRICE, THREE DOLLARS PER DOUBLE BOX.

Containing sufficient Tablets of each kind to last from one to three months according to the condition of the patient.

SPECIAL OFFER.

While the above formulae have been in use. in private practice, over 30 years, and we could give testimonials
from well-known clergymen, lawyers and businessmen, we prefer to leave them to the unbiased judgmen of the
profession with the following offer : On receipt of 50 cents, and card, letter-head, bill-head, or other proof that the
applicant is a physician in active practice, we will send, delivered, charges prepaid, one of the regular (double)
boxes (retail price, Three Dollars), containing sufficient of each kind of Tablets to test them three months (in the
majority of cases) in some one case. Card, letier-head, or some proof that the applicant is a physician in active
practice, must accompany each application. Pamphlet, with full particulars, price-list, etc., on request.

As we furnish no samples through the trade, wholesale or retail, for samples, directions, price-list, etc., address,

88 Maiden Lane,

I. O. WOODRUFF & CO.,

MANUFACTURERS OF PHYSICIANS' SPECIALTIES,

New York City.

IV

MEDICAL AND SURGICAL REPORTER.

CHARLES LENTZ & SONS,

MAKERS OF

Surgical Instruments and Orthopaedic Apparatus

18 NORTH ELEVENTH STREET, PHILADELPHIA.

WE HAVE EVERYTHING IN PHYSICIANS' SUPPLIES, Medical 1»y c—

MICROSCOPES

FOR

Urinary Analysis

A SPECIALTY.

$28.00 AND UPWARDS.

Send for catalogue of Micro-
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Lentz's Aseptic Catheter.

The above is a modification of Jennison's Uterine Douche, for intra-uterine injections.
Any bulb or fountain syringe can be attached.

Price, with Rubber Tubing, Net, $2.00.

Send for descriptive Circular.

Our No. 10 Operating Case,

complete set in the market for any ordinary operation. Price,
for circular.

SEND FOR SPECIAL LIST OF NEW

of which so much
has been said, is
having large sale
yet. It is the most
#18.75, and upward. Send

NSTRUMENTS.

ANTISEPTIC DRAINAGE TUBES.-Glass.

These Tubes have large holes, one-half inch apart, arranged alternately on opposite sides.
They are carefully finished, especial care being taken to make them smooth.

In addition to the drainage-holes, each tube has at one end two smaller holes for the insertion o* aafefr-Pin, through
which it is prevented slipping into the wound.

FURNISHED IN SEVEN SIZES.

No. 1, 81.25 per doz. No. 4, $1.55 per doz.
No. 2, 1.25 " No. 5, 1.70 "

No. 3, 1.40 " No. 6, 1.90 «

No, 7, $2.10 per dozen.

RAW CAT-GUT. Ipnt this up in coils of 10 feet, 10 ar difierent

sizes, Nos. 1, 2, 3, 4 (4 is thickest). Nos. 2 and 3 are the most useful sizes.
No. 1 Coil, 10 Cents; No. 3 Coil, 12 Cents; No. 3 Coil, 14
Cents; No. 4 Coil, 16 Cents. Full directions with each coil for
making it absolutely aseptic. •

WILLIAM SNOWDEN,

Manufacturer, Importer and Exporter of Surgical Instruments,

No. 121 SOUTH ELEVENTH STREET, PHILADELPHIA.

MEDICO-CHIRURGICAL COLLEGE

OF PHILADELPHIA.

Winter Session will begin Wednesday, October 1st, and
continue until April 16th. Preliminary Session begins Sep-
tember 8th. Spring Term, April 20th, 1891.

The curriculum is graded, and a preliminary examination
and three Annual Winter Sessions are required. Laboratory
instruction in Chemistry, Histology, Pathology, Hygiene,
Physiology, with Bedside instruction in Medicine, Surgery and
Gynecology, is a part of the regular course.

Fees : Matriculation $5.00. First and second years, each
$75.00. Third year $100.00. Fourth year free to those in
attendance three sessions ; to all others $100.00.

For Announcement or information apply to

E. E. MONTGOMERY, M. D„

1818 Arch Street, Philadelphia, Pa.

DR. MASSEY'S

PRIVATE SANITARIUM

212 South Fifteenth Street

PHILADELPHIA

This institution, in addition to complete arrangements for
the treatment of Nervous Diseases by rest, electricity, mass-
<ge, etc., under comfortable surroundings, is specially equipped
ior the treatment of cases of Fibroid Tumors and other intract-
tble diseases of the pelvic viscera, by the conservative use of
strong electric currents. For particulars, address

DR. G. BETTON MASSEY,

Physician in Charge.

MEDICAL AND SURGICAL REPORTER. V

A BRIEF SUMMARY

OF

HYPODERMIC MEDICATION".

will be sent, with our compliments, when application is made and the name of this journal is
mentioned. It quotes Profs. Dujardin-Beaumetz, Bartholow. Anstie, Erb, Echeverria, Mays
and others. It contains important and the most recent suggestions on the technique of hypo-
dermic medication, and gives the composition, properties, doses, etc., of our

SOLUBLE HYPODERMIC TABLETS, E±Ei

•

which are quickly and perfectly soluble in cold or warm water, combining accuracy of dose
with perfect preservation of the active ingredient, and the base of which is perfectly harm-
less and unobjectionable. They will cause no abscesses and will not become insoluble by
age. They may also be administered by the mouth, and are

ALWAYS READY FOR INSTANT USE.

We respectfully solicit a trial of these tablets, and will mail samples of them free to
readers of this journal.

That the several objections to
hypodermic medication might be
obviated, we have had manufac-
tured expressly for us a line of

HYPODERMIC SYRINGES, S, & DA,

which have all the latest improve-
ments, are most accurately made
of the best materials and so con-
structed as to allow the

MAKING OF A SOLUTION IN THE
SYRINGE.

They are sent to any address
at the following prices :

Syringe, in leathered-covered case, two tubes of tablets net, $2.50

" metal case, latest improved style, two tubes of tablets " 2.50

" " " four tubes of tablets " 3.50

" flexible leather case, as shown by cut 3.50

SHARP & DOHME,

MANUFACTURERS OF
Standard Medicinal Fluid and Solid Extracts; Soluble Hypodermic Tablets; Soluble
Gelatin and Sugar-Coated Pills and Granules; Granular Effervescent Salts;
Compressed Lozenges and Tablets; Fine Chemicals, &c, &c.

ESTABLISHED 1860. 3 . BALTIMORE, MD.

VI

MEDICAL AND SURGICAL REPORTER.

RABUTEAU'S DRAGEES of IRON

laureate of the Institute of France— Prize in Therapeutics.

The studies made by the Physicians of the Hospitals have
demonstrated tliat the Genuine Dragees of Iron of
Rabuteau are superior to all other preparations of iron
in cases of C dorosis, Ansemia, Leucorrhcea, liebility, Exhaustion,
Convalescence, Weakness of Children, and the maladies caused
by the Impoverishment and Alteration of the blood alter
periods of fatigue, watching, and excesses of any kind.

TAKE 4 to 6 DRAGEES DAILY.

Rabuteau's Elixir of Iron is recommended to those
persons who may be unable to swallow the Dragees. Dose
— A small wineglassful with meals.

Rabuteau's Syrup of Iron is specially designed for
children. Chalybeate medication, by means of Rabuteau's
Iron, is the most economical and the most rational known
to therapeutics.

No constipation, no diarrhoea, complete assimilation.
Take only the GENUINE IRON OF RABUTEAU of
CHiIST dc CO., :E=>a,ris.

SOLUTION OK

THE SALICYLATE of SODA
OF DOCTOR CLIN.

Laureate of the Paris Faculty of Medicine
(MONTYON PRIZE).

Dr. Clin's Solution, always identical in its composition,

and of an agreeable taste, permits the easy administration
of pure Salicylate of Soda, and the variation of the dose in
accordance with the indications presented.

"The Salicylate of Soda used by Clin is of perfect purity,
"and is prepared with the greatest care; it is a medicament
"in which we may have every confidence."

—Paris Society of Medicine, Meeting of Feb. 8th, 1879.

Clin's Solution, very exactly mixed, contains: 2
grammes of Salicylate of Soda per tablespoonful, 50 centi-
grammes of Salicylate of Soda per teaspoonful.

Paris- OX-iUST" CO.-Paris

AND BY ALL DRUGGISTS.

CAPSULES

MATHEY-CAYLUS

WITH THIN ENTELOPE OF GLUTEN.
CONTAINING COPAIBA AND ESSENCE OF SANTAL:
COPAIBA, CUBEBS, AND THE ESSENCE OF SANTAL;
COPAIBA. IRON, AND THE ESSENCE OF SANTAL.

"The Mathey-Caylus Capsules, of the Essence of
uSantal, associated with the Balsams, possess an incontesta-
ble efficaciousness, and are employed with the greatest
"success for the rapid cure of old or recent Discharges,
"Gonorrhoea, Blenorrhcea, Leucorrhcea, Cystitis of the Neck,
M Urethritis, Catarrh, and other diseases of the bladder, together
"with all affections of the Urinary Passages."

" Thanks to their thin envelope of Gluten, which is essen-
" tially assimilable, the Mathey-Caylus Capsules are digested
" by the most delicate persons, and never weary the stomach."

— Gazette des Hopitaux de Paris.

aHaX±T cSc CO., IF>a,ris,

AND OP ALL DRUGGISTS.

N E U R ALG I AS

PILLS OF DR. MOUSSETTE.

The Moussette Pills of aconitine and qninium, calm or
cure Gaslralgia, Hemicrania, Headache, Sciatica, and the
most obstinate Neuralgias.

"The sedative action exerted by the Moussette Pills
"upon the apparatus of the sanguineous circulation by the
"intermediation of the vaso-motor nerves, indicates their
"use in neuralgias of the trigemini nerves, (fifth pair), con-
"gestivc neuralgias, and painful and inflammatory Bheumatismal
" affections."

"Aconitine produces marvelous effects in the treatment
"of facial neuralgias when tbey are not symptomatic of
"intracranial tumor." — Society of Biology of Paris, Meeting
"of the 28th February, 1880.

Dose— Take 3 to 6 pills during the twenty-four hours.
ACCEPT ONLY THE GENUINE MOUSSETTE PILLS OF
CX-iI2ST <5c CO.,— IFa,ris.

GRAND NATIONAL PRIZE OF 16,600 FRANCS,

Ouina-Laroche

This meritorious Elixir,
QUTNA-LAROCHE, is
prepared from the three
Cinchonas ; it is an agreea-
ble and doubtless highly
efficacious remedy,

— The Lancet.

VINOUS ELIXIR,

A STIMULATING
RESTORATIVE

AND

ANTI-FEBRILE TONIC.

QUINA-LAKOCHE

under the form of a vinous
Elixir contains the totality
of the numerous principles,
of the three Cinchona
barks. It is a preparation
which renders great serv-
ices to Therapeutics. — Ex-
tract of the Gazette des
Hopitaux, Paris.

FAR SUPERIOR TO ALL ORDINARY CINCHONA WINES.

LAROCHE'S QUINA, tried by the Academy of Medicine of Paris, is a specially prepared Compound Extract of
Quinquina, a careful analysis, confirmed by experience, has shown that most of the wines and syrups hitherto used have not-
contained all the properties of this precious bark, of tnese some, although beneficial, are altogether lost, while many preparations,
contain but half the properties of the bark in varying proportions.

Mr. Larochk, by his peculiar method, has succeeded in extracting all the active principles of the quinquina, combining these
with Catalan Wine forming an Elixir free from the disagreeable bitterness of other similar preparations. Practitioners have
found triple advantages in the use of this Elixir, it is a strong tonic, is easily administered, and perfectly harmless, being free
from the unpleasant effects of Quinine.

THE FERRUGINOUS QUINA-LAROCHE is the invigorating tonic par excellence, having the advantage of being
easily assimilated by the gastric juice ; without, in any way, deranging the action of the digestive organs, proving itself to be a most
efficacious remedy in cases of impoverishment of the 'blood, Anemia, Chlorosis, Intestinal Hemorrhage, Castralgia,
Exhaustion, Etc., Etc.

PARIS. — 22 RUB DROUOT. — PARIS.

E. FOUGERA & CO., New York,

Sole Agrents for the United States for the above Preparations.

MEDICAL AND SURGICAL REPORTER.

VII

ESTABLISHED 1855.

DBS. STRONG'S SANITARIUM,

SARATOGA SPRINGS, NEW YORK,

Receives persons recommended to it by their home physicians for Treatment, Change, Rest or Recreation, and places them
under well-regulated hygienic conditions so helpful in the treatment of chronic invalids or the overtaxed.

For Treatment : In addition to the ordinary remedial agents, it employs Turkish, Russian, Roman, Sulphur, Electro-
Thermal, the French Douche (Charcot's), and all Hydropathic Baths; Vacuum Treatment, Swedish Movements Massage,
Pneumatic Cabinet, Inhalations of Medicated, Compressed, and Rarelied Air, Electricity in various forms, Thermo-Cautery^
Calisthenics, and Saratoga Waters, under the direction of a staff of educated physicians.

tor Change: This Institution is located in a phenomenally dry, tonic, and quiet atmosphere, in the lower arc of the
Adirondack Zone, and within the ''Snow Belt."

tor Rest: The Institution offers a well-regulated, quiet home, heated by steam and thoroughly ventilated, with cheer-
ing influences and avoiding the depressing atmosphere of invalidism.

For Recrraiion: To prevent introspection, are household sports at all seasons of the year, and in Winter, toboggan-
ing, elegant sleighing etc.; in Summer, croquet, lawn-tennis, etc.

Private professional references furnished upon application. Physicians are invited to inspect the Institution at their con-
venience. A liberal discount to physicians and their families.

For further information, address, DRS. S. S. & S. E. STRONG.

For Sale.

A TOEPLER-KOLTZ
STATIC BATTERY, in
case, as good as new. 16
inch revolving plate.

Address

Medical and Surgical Reporter,
P. O. Box 843, Philadelphia.

for our Patent Barley CRYSTALS,
fd Cereal Food,for Breakfast Tea
there, write us for free sam-
fLOUll and SPECIAL i)IA-
are invaluable waste-repairing
>sia,Diabetes,Debilitj &Cnil-
i bran ; mainly free from starch,
jothing equals our HEALTH
circular offering 4 lbs. free.
FAK.WELL <& RHlNES,Props.,Watertown,N.Y

OF PHILADELPHIA,

The 66th Annual Session of the Jefferson Medical College
begins October 1st and continues nearly 7 months.
Preliminary Lectures will be held from
22d of September.

EACH student is immediately and personally taught in Ob-
stetrics and Gynecology, Physical Diagnosis, Laryngol-
ogy ..Ophthalmology, Medical Chemistry, Pharmacy, Materia
Medica, and Experimental Therapeutics, Histology and Ex-
perimental Physiology, Minor Surgery, Bandaging, Operations
on the Cadaver, Pathology, Neurology, and Electro-Thera-
peutics.

Three annual regular sessions are required. Bedside in-
struction in Medicine, Gynaecology, Surgery and Obstetrics
is a part of the third year course. No extra fee.

The Annual Announcement will be sent on applica-
tion to J. w. HOLLAND, m. D„ Dean.

Mellin's Food

FOR INFANTS AND INVALIDS

A SOLUBLE DRY EXTRACT, prepared from Malted Barley
and Wheat, consisting of Dextrin, Maltose, Albuminates, and Salts.

The SUGAR in MELLIN'S FOOD is MALTOSE. MALTOSE is
the PROPER SUGAR for use in connection with cow's milk.

The sugar formed by the action of the Ptyalin of the Saliva and the Amylopsin of
the Pancreas upon starch is MALTOSE. In the digestive tract MALTOSE is absorbed
UNCHANGED.

— Landois and Sterling.

MALTOSE is a saccharose, not a glucose, and is a form of sugar which does not ferment.

— Materia Medica and Therapeutics, Dr. Mitchell Bruce.

" I have never seen any signs of fermentation which I could attribute to the influence
of MALTOSE."

— Eustace Smith, M.D., F.R.C.S.

MELLIN'S FOOD, prepared according to the directions, is
a true LIEBIG'S FOOD and the BEST SUBSTITUTE for Mother's
Milk yet produced.

IT REQUIRES NO COOKING.

THE DO LIBER- GOO DALE CO.,

BOSTON, MASS.

VIII

MEDICAL AND SURGICAL REPORTER.

BOOKS FOR OUR SUBSCRIBERS

BY SPECIAL ARRANGEMENT with the publishers we are able
at this time to offer the following- first-class and very valuable
books (last editions) at a very low price, when taken in connection with
paid-up subscriptions. Subscribers will see that we have put in this
list thoroughly good books. See Adv. Page ix.

For

$10.00

REPORTER for one year, . $5.00

HEATH'S DICTIONARY OF PRAC-
TICAL SURGERY. Cloth,. . . $7.50

For

$9.00

REPORTER for one year,

S5.00

LEIDY'S HUMAN ANATOMY. By

Joseph Leidy, M. D. Cloth, . . $6.00

For

$0.50

REPORTER for one year,

and any one of the following books —

f. — BYFORD'S DISEASES OF WO-
MEN. Cloth,

$5.00

. $5.00

2.— FOWLER'S DICTIONARY OF PRACTICAL MEDICINE, $5.00

3 JACOBSON'S OPERATIONS OF SURGERY, . . $5.00

4. — CAZEAUX & TARNIER'S MIDWIFERY. With Appendix by Munde, . $5.00

5. — THOMAS'S MEDICAL DICTIONARY, $5.00

These works are all in cloth binding, but can be supplied in leather binding for $1.00 additional.

For

$0.00

we will send the REPORTER for one year,
and any two of the following books :

$5.00

1.— THE NURSING AND CARE OF
THE NERVOUS ANDTHE INSANE.

By Chas. K. Mills, M. D., .... $1.00

2. — MATERNITY ; INFANCY; CHILDHOOD. By John M. Keating, M. D., . . $1.00

3. — OUTLINES FOR THE MANAGEMENT OF DIET; or, The Regulation of Food

to the Requirements of Health and the Treatment of Disease. By E. T. Bruen, M.D., . . $1.00

4. — FEVER NURSING. Designed for the use of professional and other Nurses. By J. C.
Wilson, A. M., M. D., $1.00

5. — DISEASES AND INJURIES OF THE EAR : Their Prevention and Cure. By Chas.

H. Burnett, A.M., M.D., $1.00

Or, For $6.00, any one of the above Nursing Books and THOMSON'S (Sir Henry)
SURGERY OF THE URINARY ORGANS. Some important points connected with
the Surgery of the Urinary Organs. Illustrated. Cloth, . . $1.25

MEDICAL AND SURGICAL REPORTER.

IX

Books for our Subscribers.

WHAT IS THOUGHT OF THEM.

HEATH'S DICTIONARY OE PRACTICAL SURGERY.

C. B. Porter, M. D., Boston. Mass., says ; "A most excellent book for the library of the surgeon, and especially for the
country practitioner ; as a book of reference it is so concise and at the same time so complete."

M. Senn, M. D., College of Physicians and Surgeons , Milwaukee , says ; "Asa means of ready reference for the student
and busy practitioner this book stands unexcelled."

Prof. E. h. Gregory, St. Louis Medical College, St. Louis, says : " I have examined the book, and find it a most valuable
addition to my library. 1 am sure it will meet the favor of the surgical profession."

EEIDY'S HUMAN ANATOMY.

The Lancet- Clinic, Cincinnati, O., says : " Professor Leidy again presents to medical practitioners and students a treatise
on human anatomy that at once commands the attention and admiration of all who are at all familiar with the subject. Most
of the plates are original, and in common with the text are very beautiful to behold. The work is a complete illustration of
the method of teaching anatomy adopted by a leading scientist, and one of America's best known professors of anatomy. This
is one of the books that should be in the library of every practitioner of medicine and surgery."

The Medical Advance, Ann Arbor, Mich., says : " The student can master and retain a practical knowledge of anatomy
in a shorter time and with less hard work from this text-book than from any other work extant, and it has been our privilege to
teach anatomy for several years."

BYFORDS DISEASES OE WOMEN.

The Boston Medical and Surgical Journal says : " It is a satisfaction to observe the discussion of certain topics which
are often neglected by writers, notably of the sympathetic symptoms of organs apparently disconnected with the uterus, for
which he will receive the thanks of the younger members of the profession. Another topic very widely treated is that of Con-
stipation in its relation to uterine diseases. All the other topics which should have a place in a work of this kind have been
fully and properly treated."

The Cincinnati Lancet- Clinic says : " The book is eminently practical and instructive. Its suggestions for treatment are
well up with the times, mostly judicious, conservative, and valuable, and the whole amply repays for thorough perusal."

The St. Louis Courier of Medicine says: " The work of a representative Western practitioner and professor, and is a
thoroughly practical work." »

The Virginia Medical Monthly says : " We take pleasure in recommending it to every student and physician desirous of
obtaining a standard work on Gynaecology."

The Chicago Medical Journal and Examiner says: "The chapter on puberty should be carefully studied by every
physician, teacher, and mother in the land. . . . Its style is clear, but concise, and always practical, and shows the author to
be, as we all know, an experienced teacher. The work as a whole is most valuable, both to the student and practitioner."

Gaillard's Medical Journal says : " It is replete with good judgment, broad and practical views. . . . The illustrations
are excellent."

FOWEER'S DICTIONARY OE PRACTICAL MEDICINE.

The Medical News says : " For those who do not wish to purchase the much larger book of Quain, or who wish compara-
tively recent information concerning medical subjects in a somewhat narrow space, the book will certainly prove of value, and
we heartily recommend it as one which will give a full return for the money invested in the purchase."

The London Lancet says : " What the writers know they tell simply and plainly, and generally manage to put it in a short
compass, and, what is more, the treatment that is recommended is clearly and sufficientiy set forth. . . . We can heartily
congratulate the editor and his colleagues on having admirably fulfilled their purpose, viz., to produce a first-rate dictionary of
medicine, at once scientific and practical, which well deserve the success we have no doubt it will meet with."

JACOBSON'S OPERATIONS OE SURGERY.

The Medical and Surgical Reporter says : " This handsome book is one of the most admirable works on operative surgery
which we have seen for a long time. The author has brought to its preparation a large observation and experience, and a very
thorough acquaintance with the methods of other surgeons. His book is comprehensive and his directions are clear and reli-
able. It is gratifying to an American reader to find that full justice is done to the work of American surgeons by Mr. Jacobson,
and that his book bears no marks of the distance which stretches between his land and ours. This is as it should be, and is no
less an element in the excellence of the technical worth of his book than it is an evidence of the cosmopolitan character of good
scientific work."

CA2JEAUX & TARNIER'S MIDWIFERY. With Appendix t>> MUNDE.

The Memphis Medical Monthly says : "Cazeaux's Obstetrics was authority during our student life, and has been gener-
ally recognized as authority from the publication of the first edition to the present. We cannot do more than to fully endorse
the following from the pen of T. Gallard Thomas, M. D ; 'I have examined the last edition of Cazeaux & Tarnier's Theory
and Practice of Obstetrics, and pronounce it practical, and just what is needed by every practitioner. I highly recommend the
work. This work should be prominent in every library.' "

Dr. Wm. L. Lusk says : "Cazeaux's Midwifery will always remain an inexhaustible mine of information, and I rejoice to
see it once more accessible to the profession in a new and attractive dress."

Dr. Wm. Goodell says : "I deem Cazeaux & Tarnier's Obstetrics the best yet published."

The Denver Medical Times says ; " It is needless to say anything in praise of this work. Cazeaux's Obstetrics is a clas-
sical work, and Tarnier is one of the best known French writers on Obstetrics. The whole has been brought up to date by the
appendix of Prof. Munde, and altogether it makes a very complete and practical treatise on the subject, unsurpassed if not
unequalled by any work with which we are acquainted. Especially valuable are the signs of delivery in the dead body and of
Live and still-births. The chapter on antisepsis and on puerperal septicemia are a'so worthy of mention."

THOMAS'S MEDICAL DICTIONARY.

Prof. A. F. Patton, College of Physicians a?id Surgeons, Boston, Mass., says : " It is just the book for a medical or any
other student, and it should be in the office of every physician. This dictionary supplies a place that has never been filled. I
have looked it through and find all the new words that I have sought."

The St. Joseph Medical Herald says : " No better testimonial to the value of the work can be given than the following
from Dr. J. Gibbon Hunt, the distinguished microscopist : ' To me the work is invaluable. I am astonished at its fullness of
all recent words which the modern advance of medical science has introduced. Of course, I cannot conceive the learning and
great labor which could edit such a complete, thorough, and admirable volume.' We can add nothing further save that the
book should be in the hands of every physician and every student in the land."

X

MEDICAL AND SURGICAL REPORTER.

INHALATION APPARATUS

FOR

THE THERAPEUTIC ADMINISTRATION OF OXYGEN.

In the treatment of lung troubles by Oxygen its exhibition by inhalation is preferred. The apparatus herewith shown ts
• modification of the Nitrous Oxide apparatus which we have supplied for many years. It is made in the best manneff
throughout, and is the outcome of years of experience in the manufacture of gas apparatus. It will be found to meet all

the requirements.

We supply the gas in two sizes of cylinders, containing respectively forty and one hundred gallons, either pure Oxygen,
9t a mixture of Oxygen and Nitrous Oxide in definite proportions of 20 per cent., and forty per cent, of Nitrous Oxide.

Whether pure or mixed the gas is sold at the uniform price of 5 cents a gallon. The cost of the cylinders will be refunded
Mi their return empty with the waives in good condition. Full description of Inhalation and Enema apparatuses with directions-
fer use accompany each apparatus, or will be supplied on application.

PRICES.

Inhalation Apparatus ••••••••••»••• $5.00

Cylinder, 40 gallons' capacity • 6.00

40 gallons Gas, either pure Oxygen or mixed Oxygen and Nitrous Oxide . . • . 2.00

Complete Apparatus, Cylinder, and 40 gallons Gas $13.00

Inhalation Apparatus ........«••.. $5.00

Cylinder, 100 gallons' capacity 15.00

100 gallons Gas, either pure or mixed . . . . ..««••••••••••». 5.00

Complete Apparatus, Cylinder, and 100 gallons Gas .•«•••«•••••• .$25.00

THE S. 3. WHITE DENTAL MFG. CO.

PHILADELPHIA, NEW YORK, BOSTON, CHICAGO, BROOKLYN.

MEDICAL AND SURGICAL REPORTER.

XI

THE BEST ANTISEPTIC

FOR BOTH INTERNAL AND EXTERNAL USE.

antiseptic, H imyy g— fl H&9 Bl^T I N0N-T0XI0'

Prophylactic, fl M v-*^ h | j Bp" Mlwff H B^TOffl H"" non-Irritant.
Deodorant. fibgraa Q ^hiiijrar B PL« gj ^ g gj ^jjg ShHI > Non-escharotio.

FORMULA — Listerine is the essential antiseptic constituent of Thyme, Eucalyptus, Baptisia, Gaultheria and
Mentha Arvensis, in combination. Each fluid drachm also contains two grains of refined and purified
Benzo-boracic Acid.

DOSE — Internally: One teaspoonful three or more times a day (as indicated) either full strength, or di'/uted,
as necessary for varied conditions.
LISTERINE is a well -proven antiseptic agent— an antizymotic— especially adapted to
internal use, and to make and maintain surgical cleanliness— asepsis— in the treatment of
all parts of the human body, whether by spray, irrigation, atomization, or simple local
application, and therefore characterized by its particular adaptability to the field of

PREVENTIVE MEDICINE -INDIVIDUAL PROPHYLAXIS.
1

X>i»e^«o» of tlie XJrio Acid 13xtit:ixo»i».

LAMBERT'S

LITHIATED HYDRANGEA

KIDNEY ALTERATIVE— ANTI-LITH I C.

FORMULA — Each fluid drachm of "Lithiated Hydrangea" represents thirty grains of fresh Hydrangea and
three grains of chemically pure Benzo-Salicylate of Lithia. Prepared by our improved process of
osmosis, it is invariably of definite and uniform therapeutic strength, and hence can be depended
upon in clinical practice.

DOSE — One or two teaspoonfuls four times a day (preferably between meals).

Urinary Calculus, Gout, Rheumatism, Bright's Disease, Diabetes, Cystitis, Hema-
turia Albuminuria, and Vesical irritations generally.
We have ranch valuable \ General Antiseptic Treatment, | To forward tt Physicians

literature upon \ Lithemia, Diabetes. Cystitis, etc.* upon request:

LAMBERT PHARMACAL CO.. ST, LOUIS, MO.

FRENCH, CAVE & CO.

(SUCCESSORS TO FRENCH, RICHARDS & CO.),

PHILADELPHIA,

WILL continue the manufacture of the Fine Pharmaceutical Products
made by the late firm at the present laboratory, 16 and 18 North
Tenth Street, Philadelphia.

Physicians who have prescribed these preparations can rest assured that
the high standard of quality which has made for these products a reputation
for consistent strength and purity will be strictly maintained in the future, and
the physician can always prescribe our preparations and depend on uniform
results.

To those physicians who have not yet prescribed our products, we request
them to send to us their address and we will forward by EXPRESS, PRE-
PAID, a line of samples free for trial.

Physicians' Price-list and Formulary sent by mail on application.

FRENCH, CAVE & CO.,

Factors ok Fine Pharmaceutical Products,
Nos. 16 and 18 NORTH TENTH STREET, PHILADELPHIA,

XII

MEDICAL AND SURGICAL REPORTER.

Champagne

Of Interest to all Medicai Practitioners.

WHAT IS SAID BY

ANALYZED

THOMAS KING CHAMBERS, M.D.,F.R.C.P.
R. OGDEN DOREMUS, M.D.
F. W. PAVY, M.D., F.R.S.

" Champagne, with a minimum of alcohol, is by far the wholesomest, and possesses
remarkable exhilarating power." — THOMAS KING CHAMBERS, M.D., F.R.C.P.

" Having occasion to investigate the question of wholesome beverages, I have made
a chemical analysis of the most prominent brands of Champagne. I find G. H. Mumm
& Co.'s Extra Dry to contain, in a marked degree, less alcohol than the others. I
therefore most cordially commend it not only for its purity but as the most wholesome
of the Champagnes."— R. OGDEN DOREMUS, M.D., Professor of Chemistry, Bellevue
Hospital Medical College, New York.

"Champagne, while only possessing the alcoholic strength of natural wines, is
useful for exciting the flagging powers in case of exhaustion." — F. W. PAVY, M.D.,
F.R.S. , Lecturer on Physiology at Guy's Hospital, London.

The remarkable vintage of 1884 of Q. H. MUMM & CO.'S EXTRA
DRY CHAMPAGNE, tne finest for a number of years.

Pronounced by connoisseurs unsurpassed for excellence and bouquet.

PREPARED FROM THE GENUINE CAROLINA TAR.

DOSE.— One fluid drachm four or more times a day (as indicated), either full

strength, diluted, or, in combination.
INDICATIONS.— Chronic and acute affections of the Air Passages, Coughs,

Colds, Bronchitis, Asthma and Consumption.

Lecturer on Pharmacology and Therapeutics at the Westminster Hospital ; Examiner in Materia Medica to
the Royal College of Physicians of London; Fellow of the Medico-Chirurgical College of Philadelphia,

Says:— "1 have used with success 'Goudron de Blount.' The results have
been good, and the preparation is popular with patients."

R. E. BLOUNT, 33 RUE ST. ROCH, PARIS.

WHOLESALE AGENTS FOR UNITED STATES AND CANADA,

FRED'K DE BARY & CO., New York:,

SOLE AGENTS IN THE UNITED STATES AND CANADA.

WILLIAM MURRELL, M.D., F.R.C.P.,

BATTLE

at

CO

MEDICAL AND SURGICAL REPORTER.

XIII

17,670,000 BOTTLES FILLED IN 1890.

Apollinaris

"THE QUEEN OF TABLE WATERS."

" The APOLLINARIS SPRING yields enough water not only
for PRESENT REQ UIREMENTS but also for those of a FUTURE
which is STILL REMOTE.

" The EXISTING SUPPLY is ADEQUATE for FILLING
FORTY MILLION quart bottles YEARLY.

" The VOLUME of GAS is so GREAT that it is dangerous to
.approach the SPRING on a windless day!' — The Times, London,
20th September, 1890.

THE BEST NATURAL APERIENT.

THE APOLLINARIS COMPANY, LIMITED, London, beg to announce that, as
numerous Aperient Waters are offered to the public under names of which the word
Hunyadl forms part, they have now adopted an additional Label comprising their
Registered Trade Mark of selection, which consists of

This Label will henceforth also serve to distinguish the Hungarian Aperient Water
SOLD by the Company from all other Aperient Waters.

DEMAND THE ^■■1 DIAMOND MARK,

And insist upon receiving the Hungarian Aperient Water ot the APOLLINARIS

Company, Limited, London,

XIV

MEDICAL AND SURGICAL REPORTER.

BoupAULT's Pepsi ne

The only Pepsine used in the Hospitals of Paris for the last Thirty Years,

Unlike the various substitutes which, in most'cases, are but7unscientific or incompatible compounds, forced upon the'Medicai
Profession as aids to digestion by extensive advertising, but which, when submitted to the proper tests, are found to be useless ae
digestive agents, Pepsine is constantly gaining in the esteem of the careful practitioner.

Since the introduction of Pepsine by Boudault and Corvisart in 1854, the original BOUDAULT'S PEPSINE HAS BEEN
AT ALL TIMES CONSIDERED THE BEST, as is attested by the awards it has received at the Expositions of 1867, 1868, 187
1873, in 1876 at the Centennial Exposition of Philadelphia, and in 1878 at the Paris Exposition.

The most reliable tests, carefully applied, will satisfy everyone that BOUDAULT'S PEPSINE HAS A MUCH HIGHER
DIGESTIVE POWER than the best Pepsines now before the Profession, and is therefore especially worthy of their attention.

BOUDAULT'S PEPSINE is prepared in the form of Pepsine Acid and Pepsine Neutral. It is sold in bottles of one ounce,
with a measure containing exactly five grains; also in bottles of four, eight/and sixteen ounces for dispensing.

BOUDAULT'S WINE OF PEPSINE

FORMULA OF DR. CORVISART.

The taste of Pepsine being perfectly disguised in this Wine, it may be recommended to persons who have difficulty in taking
Pepsine in the form of Powder. This Wine is tested so that a tablespoonful of it is equal in digestive power to ten grains of
Boudault's Pepsine in powder. Sold only in bottles of eight ounces.

TAN RETS PELLETI ERI N E

For the Treatment of Tape-Worm (Taenia Solium).

This New Tsenifuge, the Active Alkaloid of Pomegranate Bark, has of late come into extensive use In irance for tb»
treatment of Tape-Worm (Taenia Solium). The results of numerous experiments with it at the Marine Hospitals of Toulon,
St. Mandrier, etc., and in the Hospitals of Paris, St. Antoine, La Charite, Necker Beaujon, etc., have all been most satisfactory.
Doctor Dujardin Beaumetz, Member of the Academy of Medicine, and Professor Laboulbene, in their report to the Society of
Therapeutics, have given it their unqualified approval, after the most searching experiments. This preparation is pleasant to
administer, and, if certain preliminaries are observed, success will be insured.

Sold only in bottles containing one dose.

DUCRO'S ALIMENTARY ELIXIR

A Combination uniting the properties of Alcoholic Stimulants and Raw Meat

This preparation, which has been used with great success in the hospitals of Paris since 1868, is adapted to the treatment •
All diseases requiring administration, in a small volume, of a tonic able to stimulate and support the vital forces, as Puhnonar
Phthisis, Depression and Nervous Debility, Adynamia, Malarious Cachexia, etc.

Prepared by EMILE DUBIEZ & CO., Successors to DUORO & OIE, Paris.

KIRKWOOD'S INHALER

This is the only complete, reliable, and effective inhaler in use, arranged for the direct application of Muriate of Ammonia
and other remedial agents in the state of vapor to the diseased parts of the air-passages in the treatment of catarrh and disease*
of the throat and lungs. No heat or warm liquids required in its use.

It is entirely different from the various frail, cheap instruments that have been introduced.

KIRKWOOD'S INHALER is accompanied by testimonials of the highest professional character, together With carenUS}?
prepared formulas for use.

K3ETATL PRICE, COMPLETE, $3.50.

4®" A liberal discount allowed to the trade and profession. For descriptive pamphlet or other information addresi

E> FOUGERA & CO., 30 North William St., New York.

Sole Agents for the^above Preparations.

MEDICAL AND SURGICAL REPORTER.

XV

■ JX" % % % $% J% % X %

sir " " ^ : ^ ^ ^ |^

% Constipation. X

I 1

£p Pavara Pills are prepared especially for the

^ treatment of Constipation. They are tasteless, harm- ^%

' less, and produce natural movements of the bowels, *

'^M without pain, nausea, or any inconvenience whatever. %<0

l*i Physicians are requested to test these pills in those 0i

„ < cases which they think to be incurable, also, in cases of >

^ constipation during pregnancy. Thousands %0

of physicians now use and prescribe them.

Physicians will see by the formula (on the outside '% 4

0^ label) that each medicinal ingredient is absolutely 0

harmless.

& Prices : small bottle (25 pills), 25c. ; large, (150 pills), ^

p| $1.00. Liberal discount to physicians. ^

, * A large bottle will be mailed to any physician, \ \

for trial, on receipt of 25 cents in postage stamps. ^

M Prepared by C. L. Topli^f, New York. Depot, 115 ^

Fulton Street. % 4

Please mention this Journal.

FRAUD.

Unscrupulous parties are selling an inferior Wine, calling
it Royal Tokay, thus profiting by the numberless Medical
Editorials written about our genuine product. The Wine
cannot be used as a substitute for ours, and many physi-
cians have unjustly blamed us for damage done, imagining
they were securing our Wine, which they had already tested
with complete satisfaction. Your patients will not secure
the Wine you prescribe unless you specify CALVICO
TOKAY, by which name it will hereafter be known.

CALIFORNIA VINTAGE CO.

21 Park Place, N. Y.

BOSTON, MASS., Theo. Metcalf & Co., 39 Tremont St.
PHILADELPHIA, PA., Showell & Fryer,

Juniper and Market Sts.
ST.LOTJIS, MO., John W. Howard, 307 Garrison Ave.
LOUISVILLE, KY., Geo. A. Newman,

Walnut St. and 5th Ave.
INDIANAPOLIS, IND., Geo. W. Sloan,

22 West Washington St,

EVANSVILLE, IND., H. J. Schlaepfer,

Main and 2d St.
SCHENECTADY, N. Y., Andrew T. Veeder & Son.
NEWHAVEN, CONN., E. A. Gessner, 821 Chapel St.
HARTFORD, CONN., C. A. Rapelye, 321 Main St.
NEW BRITAIN, CONN., E. W. Thompson,

181 Main St.
NEWPORT, R. I., Hazard, Hazard & Co.

PROVIDENCE, R. I., E. F. Mattison, 277 Westminster St.

XVI

MEDICAL AND SLRGICAL REPORTER.

A CASE WITH A LESSON IN IT.

We have frequently referred to the neces-
sity of keeping the pregnant woman supplied
with those chemical substances which she
must give to the child in the formation of
its little frame, and the dire effects which
may result from a deficiency of those sub-
stances. The headaches, neuralgias, spinal
tenderness, and some of the many disorders
of digestion, and even mental failure, may
be all prevented or relieved by supplying to
the mother the chemical food her system
demands.

We have noticed a few cases where the
most serious results have occurred to the
mother by such a deficiency, one of which
is well worth relating.. Mrs. M., aged 30,
pregnant with her third child, suffered from
the second to the fifth month of her preg-
nant term with gradually failing strength
and health, and nervous irritability. She
was very restless nights for three or four
days, the peculiar restlessness of complete
nervous "exhaustion, and was irrational for
more than a week.

At this time I advised that she have a
teaspoonful of Murdock's Liquid Food
every hour in milk, and a little wine every
four hours. The third night she had fifteen
drops of hydrobromic acid dil. every three
or four hours, which was continued for a
week. The liquid food after a week every
two hours, and all other medicines were dis-
continued. Her bowels were moved with a
mild laxative at first, and afterward became
regular. Her tongue cleaned quickly and
her skin assumed a more natural appear-
ance.

At this writing, less than three weeks
from our first visit, the patient is able to sit
up an hour at a time, is quite rational and
cheerful, has a good appetite, the bowels
are quite regular, there is no headache, and
but little spinal tenderness. She sleeps
reasonably well if fed frequently. She is
allowed to suit her taste in her diet. The
child is quite active, and the mother is pro-
gressing so nicely that it is hoped that she
will pass safely through her confinement,
which is nearly at hand. She will be kept
on the liquid food and the phosphates
until her confinement after which, the con-
dition will suggest the treatment. This
is the most marked case of a starved
nervous system we have ever seen, and
the benefit derived from the treatment

proves the theory as to the cause of the
trouble.

Apropos with the above, comes the ques-
tion of the selection of nutritious foods for
those many cases which demand strong and
immediate nourishment. The food used in
the above case has produced marvelous re-
sults for us in some of those extreme cases
in which we have used it.

In one case of nervous exhaustion the
insomnia was absolutely painful. When
the exhaustion forced the patient to sleep
there was an immediate sense of falling or
approaching death, or there were hallucina-
tions which were appalling, rendering the
nights unbearable. One teaspoonful of
Murdock's Liquid Food so nourished the
system the first night it was given that the
patient sank into a quiet, refreshing sleep
which lasted, with a single awakening, until
morning, and the improvement the patient
obtained was most striking.

One case of mitral regurgitation with
leucocythemia and nervous exhaustion im-
proved more rapidly on this food than on
all other measures combined. In cases of
nervous exhaustion and brain tire, its effects
are most marked, as we have experienced
many times in the past five years* in the
frequent personal use of the agent. It con-
tains the principles of pure, healthy blood
and nerve tissue ready for immediate as-
similation. Fourteen per cent, of the entire
quantity is uncoagulated albumen, as we
have demonstrated by actual analysis.

We have tided babies over critical periods
often with a few drops in its usual diet.
We have given it to dipsomaniacs with or
without non-alcoholic stimulants with su-
perb results. The sole objection our pa-
tients have to it is its odor. Its taste is not
disagreeable ; it has the odor and appear-
ance of blood. All objections are soon for-
gotten, however, in the results of its action
upon the nutrition of the system, and the
patient soon learns to like it, and often
craves for it, drinking it from the bottle or
a glass readily, like any beverage. It
ought to be the food par-excellence for
rapid appropriation in all conditions of ex-
haustion.

P. S. — Phosphates act well with the Liquid
Food.

Editorial of the Chicago Medical Times,
June, 1890.

MEDICAL AND SURGICAL REPORTER.

XVII

CELERINA

NERVE TONIC, STIMULANT AND ANTISPASMODIC.

FQEt§V8ULA.""Ev®ry Fluid Drachm represents FIVE grains EACH— Celery
- ^— - — Coca, Kola, Viburnum and Aromatics.

INDICATIONS.— Loss of Nervo Power (so usual with Law-
yers, Preachers, Writers and Business Men), Impotency.
Spermatorrhea, Nervous Headache, Neuralgia, Paralysis,
Hysteria, Opium Habit, Inebriety, Dyspepsia, and ALL
LANGUID conditions of the System.

Indispensable to restore a patient after alcoholic excess,

DOSE ."On® or two Teaspoonfuls three or more times a day, as directed
by the Physician.

ALETRIS CORDIAL

UTERINE TONIC AND RESTORATIVE.

PREPARED FROM THE ALETRIS FARINOSA OR TRUE UNICORN.

INDICATIONS.— Amenorrhea, Dysmenorrhea, Leucorrhea,
Prolapsus Uteri, Sterility, to PREVENT Miscarriage, Etc.
DOSE. -O"® Teaspoonful three or four times a day.

Unrivaled as a Uterine Tonic in Irregular, Painful, Suppressed and Excessive Menstruation.

It Restores Normal Action to the Uterus, and Imparts Vigor to the
Entire Uterine System.

Where Women have miscarried during previous pregnancies, or in any
case where miscarriage is feared, ALETRIS CORDIAL is indicated, and
should be continuously administered during entire gestation.

S. H. KENNEDY'S

CONCENTRATED EXTRACT OF

PINUS CANADENSIS

■ dark. A NON-ALCOHOLIC LIQUID. white.

A MOST VALUABLE NON-IRRITATING MUCOUS ASTRINGENT.

INDfCATIONS.-AIbuminuria, Diarrhea, Dysentery, Night-
Sweats, Hemorrhages, Profuse Expectoration, Catarrh,
Sore Throat, Leucorrhea, and other Vaginal Diseases, Piles,
Sores, Ulcers, Burns, Scalds, Gonorrhea, Gleet, Etc.

Wnen Used as an injection, to Avoid Staining ol Linen, tne WHITE Pinns snonld He used,

RECOMMENDED BY PROMINENT EUROPEAN AND AMERICAN PHYSICIANS.

The above preparations are prepared exclusively for Physicians' Prescriptions, and a
sample of each or all of them will be sent to any Physician who wishes to test them, if
he will pay the Express Charges.

RIO CHEMICAL CO., St. Louis, Mo., U. S. A.

London. Paris. Calcutta. Montreal.

XVIII

MEDICAL AND SURGICAL REPORTER.

TERTIARY SYPHILIS.

"Your preparation, IODIA, is an excellent altera-
tive, and is the most agreeable of any preparation of
Iod. Potas., as it does not cause the cramps in stomach,
which are often intolerable.

" I have employed IODIA in two cases of Tertiary
Syphilis, in which, after five weeks' treatment, the mani-
festations disappeared.

" In a case of Syphiltic Eczema it was also successful.
— Dr. Sam Petite ait, Garches, France, Nov. 10, 1890.

BATTLE & CO., Chemists' Corporation,

St. Louis, Mo., U. S. A.

BRANCHES :

76 New Bond Street, London, W.

5 Rue de la Paix, Paris.

9 and 10 Dalhousie Square, Calcutta.
80 Montague-de-la-Cour, Brussels.
28 Nieuwe Hoogstraat, Amsterdam.

MEDICAL AND SURGICAL REPORTER.

XIX

The Atmospheric Tractor.

IT ENABLES parturition to be ren-
dered almost PAINLESS, and RE-
DUCES the expulsive stage to minutes,
instead of hours.

Powerful for good, and powerless to in-
flict injury on either the mother or the
child.

LIGHT, DURABLE AND ASEPTIC.

INDISPENSABLE TO EVERY PHYSICIAN.

Price, $3.00.

Sent free by mail or express on receipt of
$3.00. Address

The Atmospheric Tractor Co.,

607 Chestnut Street,

PHILADELPHIA.

P. O. BOX NO. 1202

XX

MEDICAL AND SURGICAL REPORTER.

PHILADELPHIA POLYCLINIC AND COLLEGE FOR GRADUATES IN MEDICINE.

THE POLYCLINIC HOSPITAL,
Northwest corner Broad and Lombard Sts.
REGULAR SESSIONS RECOMMENCE SEPT. 15th.

Pupils may beg-in at any time. Tickets good for Six Weeks' Daily Clinics
from date of issue or One Clinic Weekly, for three months.

PRACTICAL, INDIVIDUAL INSTRUCTION, TO PHYSI
CIANS ONLY, IN ALL BRANCHES OF MEDICINE

AND SURGERY.

For Announcement, Address,

SOLOMON SOLIS-COHEN, M. D.

Secretary.

NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL

SESSIONS 1890.91.

The Autumn and Winter Sessions of the Post-Graduate Medical School opened on September 15. The Hospital is fully
utilized for clinical purposes. There are ninety beds, including thirty for babies in the adjacent building. No Post-Graduate
Medical School in this country can offer such opportunities for seeing important surgical and gynaecological operations under
its own roof as does this institution. Besides, regular clinics, medical and surgical, are held by professors and instructors in
those general and special hospitals with which they are connected, which comprises nearly all the great hospitals of the city.
The dispensary of the school and other large dispensaries furnish ample means of instruction in every class of walking cases.

Instruction is given in every branch of medicine and surgery. The laboratory is large and well equipped. Surgical
anatomy and operative surgery are thoroughly taught. The instruction is personal, the practitioner being brought in direct
contact with the patient. No other courses in any department will be required if those to be had in the Post-Graduate School
are taken. The faculty were the first in the United States to organize private courses for practitioners of medicine, and they
pledge themselves to leave nothing undone to make graduates in medicine profit by the unrivalled clinical advantages of the
City of New York.

For catalogue and schedule, address

CLARENCE C. RICE, M. D., Secretary,

D. B. St. JOHN ROOSA, M. D., LL.D., President. 226 East 20tli St., New York City.

F. E. FARRELL, Superintendent.

COLLEGE OF MEDICINE. SYRACUSE UNIVERSITY.

FACULTY.

GAYLORD P. CLARK, M. D., Anatomy.
WILLIAM H. DUNLAP, M. D., Dermatology.
JOHN L. HEFFRON, M. D., Materia Medica and Thera-
peutics.

HENRY B. ALLEN, M. D., Obstetrics.
A. CLIFFORD MERCER, M. D., Pathology.
HENRY L. ELSNER, M. D.. Clinical Medicine.
FRANK W. MARLOW, M. D., Ophthalmology.

JOHN VAN DUYN, M. D., Surgery.

HENRYD. DIDAMA, M. D., Practice and Clinical Medicine
WILLIAM T. PLANT, M. D., Diseases of Children.
ALFRED MERCER. M. D., State Medicine.
WILLIAM MANLIUS SMITH, M. D., Chemistry.
DAVID M. TOTMAN. M. D., Clinical Surgery,
NATHAN JACOBSON, M. D., Clinical Surgery and Laryn-
gology.

Three Years' Graded Course. Year begins October 7tn, 1890, ends in June, 1891.

FIRST YEAR: Anatomy, Physiology, Chemistry, Histology, Materia Medica.

SECOND YEAR: Anatomy, Physiology, Chemistry, Therapeutics, Pathology, Practice, Surgery, Clinical Medicine and
Surgery.

THIRD YEAR: Therapeutics, Practice, Surgery, Children, Clinics, Obstetrics, Gynaecology, Forensic Medicine, Ophthal-
mology, Hygiene.

An experience of seventeen years has demonstrated that a three years' graded course is superior in every respect to an
ungraded, unnatural, and cramming course of two winters.

Tuition, $80.00 for each Year. Perpetual Ticket, $200.00. Diploma, $35.00.
For circulars with full information, address

W. H. DUNLAP, M. D., Registrar, SYRACUSE, N. Y.

UNIVERSITY OF PENNSYLVANIA. — Medical Department

The 125TH Annual Winter Session will begin Wednesday, October 1st, 1890, at 12 M., and wilfcontinue seven months.
The Preliminary Session begins September 22d, 1890, the Spring Term early in May, 1891.

The curriculum is graded and three annual winter sessions are required. Practical instruction, including laboratory work
in Chemistry, Histology, Osteology and Pathology, with Bedside Instruction in Medicine, Surgery and Gynecology are a part
of the regular course and without additional expense.

FACULTY.

JOSEPH LEIDY, M.D., LL.D., Professor of Anatomy.
D. HAYES AGNEW, M.D , LL.D., Honorary Professor of Clin-
ical Surgery.

WILLIAM PEPPER, M.D., LL.D., Professor of Theory and
Practice of Medicine, and of Clinical Medicine.

WILLIAM GOODELL, M.D., Professor of Gynecology.

JAMES TYSON, M.D., Professor of Clinical Medicine.

HORATIO C. WOOD, M.D., LL.D , Professor of Materia Medica,
Pharmacy and General Therapeutics.

THEODORE G. WORMLEY, M.D., LL.D., Professor of Chem-
, istry and Toxicology.

JOHN ASHHURST, Jr., M.D., Professor of Surgery and of
Clinical Surgery.

EDWARD T. REICHERT, M.D. Professor of Physiology.

WILLIAM F. NORRIS, M.D., Honorary Prof.of Ophthalmology
BARTON COOKE HIRST, M.D., Professor of Obstetrics.
J. WILLIAM WHITE, M.D., Professor of Clinical Surgery.
JOHN GLTTERAS. M.D., Professor of General Pathology and

Morbid Anatomy.
GEORGE A. PIERSOL, M.D., Professor of Histology and Em

bryology.

SAMUEL G. DIXON, M.D., Professor of Hygiene.

For Catalogue and announcement containing particularsi
apply Jo

DR. JAMES TYSON, Dean,
36th and Woodland Avenue, Philadelphia*

MEDICAL AND SURGICAL REPORTER. XXI

XXII

MEDICAL AND SURGICAL REPORTER.

GOLD MEDAL, PARIS, 1878.

I W.Baker A Co.'s

Breakfast
Cocoa

from -which the excess of
oil has been removed, is

Absolutely JPure
and it is Soluble.

No Chemicals

are used in its preparation. It has
more than three times the strength of
Cocoa mixed with Starch, Arrowroot
or Sugar, and is therefore far more
economical, costing less than one cent
a cup. It is delicious, nourishing,
strengthening, easily digested,
and admirably adapted for invalids
as well as for persons in health.

Sold by Grocers everywhere.

W. BAKER & CO., Dorchester, Mass.

WESTERN PENNSYLVANIA MEDICAL COLLEGE

CITT PITTSETJEGH.
SESSIONS OF 1890—91.

The Regular Session begins on the last Tuesday of Sep-
Cember, and continues six months. During this session, in
addition to four Didactic Lectures, two or three hours are daily
allotted to Clinical Instruction. Attendance upon two regular
courses of lectures is requisite for graduation. A three years'
graded course is also provided. The Spring Session embraces
recitations, clinical lectures and exercises, and didactic lectures
on special subjects; this session begins the second Tuesday in
April, and continues ten weeks.

The laboratories are open during the collegiate year for
instruction in chemistry, microscopy, practical demonstrations
in medical and surgical pathology, and lessons in normal his-
tology. Special importance attaches to "the superior clinical
advantages possessed by this College." For particulars, see annual
announcement and catalogue, for which, address the Secretary
of Faculty, Prof. T. M. T. McKENNAN.

Business correspondence should be addressed to

Prof. W. J. ASDALE, 2107 Penn Avenue, Pittsburgh.

Walnut Lodge H ospital,

HARTFORD, CONN.

Organized in 1880 for the special medical treatment of

A.LCOHOL AND OPIUM INEBRIATES.

Elegantly situated in the suburbs of the city, with every ap-
pointment and appliance for the treatment of this class of
cases, including Turkish, Russian, Roman, Saline and Medi-
cated Baths. Each case comes under the direct personal care
of the physician. Experience shows that a large per cent, of
these cases are curable, and all are more or less benefited from
the application of exact hygienic and scientific measures.
This institution is founded on the well-recognized fact that
Inebriety is a disease, and curable, and all these cases re-
quire rest, change of thought and living, in the best sur-
roundings, together with every means known to science and
experience to bring about this result. Applications and all in-
quiries should be addressed

T. D. CROTHERS, M.D.,
Sup't Walnut Lodge, Hartford, Conn.

"The Hygeia"

A PRIVATE HOME HOSPITAL,

SITUATED IN A PLEASANT AND CONVENIENT PART OF

SAN FRANCISCO.

Furnished in ELEGANCE and fully
EQUIPPED WITH EVERY
APPLIANCE required for
the Treatment and
Comfort of
Patients.

Correspondence Solicited from physicians send-
ing patients to this coast. References from the highest
in the profession in this city. Special advantages for
genito-urinary and rectal diseases, and for mild nar-
cotic habitues.

C. C. VANDERBECK, M. D., PH.D.,

PHYSICIAN IN CHARGE,

216 Leavenworth Street.

Consultants and References —Dr. J. Rosenstirn,
Surgery ; Dr. J. D. Arnold, Throat Diseases ; Dr. D. W.
Montgomery, Skin Diseases and Microscopist ; Dr. Martin
Regensburger, Genito-urinary; Dr, Alfred Perry, General
Medicine; Dr. Chas. Von Hoffmann, Gynecology; Dr. B.
Marshall, etc.

St, Vincent Homo Maternity Hospital.

70th Street and Woodland Avenue,

(pASCHALL STATION) PHILADELPHIA.

Conducted by the Sisters of Charity.

INFANTS and Children under two years of age
received.
Patients for Maternity Department ac-
commodated according to their means.

IN THE WARDS terms range from $5.00
to $8.00 per week.

IN THE PRIVATE ROOMS terms range
from $10.00 to $20.00 per week.

For further information apply to or address

THE SISTER 1ST CHARGE,
PASCHALVILLE,

PHILADELPHIA, - PA.

MEDICAL AND SURGICAL REPORTER.

XXIII

GARDNER'S

rap of Hydeiodic Acid,

Introduced in 1878 by K. W. GAKDNER.

The Reputation which Hydr iodic Acid has Attained During the
past Eleven Years was Won by this Preparation.

Numerous Imitations prepared differently, and weaker in Iodine, are offered, from the use of
which the same therapeutic effects cannot be obtained.

Caution. — Use no Syrup of Hydriodic Acid which has tmrned red. This shows decomposition
and free Iodine. In this state it acts as an irritant and fails to produce desirable results.

Unprincipled apothecaries substitute imitations when Gardner's Syrup is prescribed, and physi*
ians, failing to get desirable and promised results, attribute the fault, unjustly, to Gardner's Syrup.

THERAPEUTIC INDICATIONS.

Hay Fever; Hose Cold; Poisoning by Lead, Mercury or Arsenic; Acute and Chronic Rheuma-
tism; Asthma; Chronic Bronchitis ; Catarrh; Congestion of Lungs in Children; Adenitis; Eczema;
Lupus; Chronic Malarial Poisoning; Lumbago; Acute Pneumonia; Psoriasis; Scrofulous Diseases;
Goitre; Enlarged Glands ; Cold Abscesses ; Indolent Sores ; Excessive Fat ; Fatty Degeneration of the
Heart ; to absorb non-malignant Tumors ; and in the latter stages of Syphilis ; Syphilitic Phthisis.

Details of treatment furnished physicians upon application to undersigned without charge.

Gardner's Chemically Pure Syrups of Hypophosphites.

Embracing the separate Syrups of Lime, of Soda, of Iron, of Potassa, of Manganese, and an Elixir
of the Quinia Salt ; enabling physicians to accurately follow Dr. Churchill's method, by which thou-
sands of authenticated cases of Phthisis have been cured. The only salts, however, used by Churchill
in Phthisis are those of Lime, of Soda, and of Quinia, and always separately according to indications, —
never combined.

The reason for the use of single Salts is because of antagonistic action of the different bases, injuri-
ous and pathological action of Iron, Potassa, Manganese, etc., in this disease.

These facts have been demonstrated by thirty years' clinieal experience in the treatment of this
disease exclusively, by Dr. Churchill, who was the first to apply these remedies in Medical practice.
Modified doses are also required in this disease; seven grains during twenty -four hours being the
maximum dose in cases of Phthisis, because of increased susceptibility of the patient to their action, the
danger of producing toxic symptoms (as hemorrhage, rapid softening of tubercular deposit, etc.), and
the necessity that time be allowed the various functions to recuperate simultaneously ; over-stimula-
tion, by pushing the remedy, resulting in crisis and disaster.

A pamphlet of sixty-four pages, devoted to a full explanation of these details and others, such as
contra-indicated remedies, indications for the use of each hypophosphite, reasons for the use of abso-
lutely pure Salts, protected in Syrup from oxidation, etc., mailed to physicians without charge upon
application to <

R. W. GARDNER, 158 William St., N. Y. City.

W. H. SCHIEFFELENT & CO., Sole Wholesale Agents, New fork.

XXIV

MEDICAL AND SURGICAL REPORTER.

Mgp> The only prominent Emulsion of Cod- Liver Oil introduced directly to the medical profession.

It is advertised exclusively in medical journals.

Produces rapid increase in Flesh and Strength*

TTORMUIiA.— Each Dose contains : I I Recommended and Prescribed by

Pnr. Cod Uv,r Oi. 80 m. (drop,) | Sod -. ,-3 GnUn. \MM\ ""^J ^IlSESto^S \l ,T? lEf-"*

Di«tm«i Water 35 " Salicylic Add -...-..,..1-4 " •g/aV^| It is pleasant to the Taste and

Soluble Pancreattn s Grains. | Hyochoiic Acid :..i-so *• I i | acceptable to the most delicate Stomach,

J

IT IS ECONOMICAL IN USE AND CERTAIN IN RESULTS.

gj YDROLEINE (Hydrated Oil) is not a simple alkaline emulsion of oleum morrhuae, but a hydro-:

"~" pancreated preparation, containing acids and a small percentage of
soda. Pancreatin is the digestive principle of fatty foods, and in the soluble form here used, readily converts
the oleaginous material into assimilable matter, a change so necessary to the reparative process in all wasting^

diseases.

The following are some of the diseases in which HYPH.OIiEIJg'B is indicated:,

Phthisis, Tuberculosis, Catarrh, Cough, Scrofula, Chlorosis,
General Debility, etc.

TO BRAIN WORKERS of all classes, H YDROLEINE is invaluable,- supplying as it does, the>

true brain-food, and being more easily assimilated by the digestive organs than any other emulsion.

The principles upon which this discovery is based have been described in a treatise on " The Digestion and
Assimilation of Fats in the Human Body," and "Consumption and Wasting Diseases," by two distinguished
London physicians, which will be sent free on application.

SOLD BY DRUGGISTS GENERALLY.

SOLE AGENTTOR THE UNITED STATES. I 15 FULTON STREET, N. Y.

A Sample of Hydroleine will be sent free upon application, to any physician (enclosing business card) in the U. 8.

LIQUOR SANTAL FLAV,

CUM

BUCHU et CUBEBA.

(ORIGINAL FORMULA.)

This elegant preparation has been very successfully used in the treatment of
long-standing Gonorrhoea and chronic Gleet.

If given in the early stages of Gonorrhoea, it will usually arrest the progress
of the disease.

It is especially effective in all inflammations of genito-urinary mucous
membranes.

It is perfectly miscible in water. Dose, iZi to f3ij, three times a day in water
or milk. When prescribing, please specify Liq. Santal Flav. cum Buchu et Cubeba
(Ogden's).

croHisr oo-iDiEisr,

CHEMIST,
WALNUT & THIRTEENTH STREETS,

PHILADELPHIA.

mi

B

ft

I

kr,

I

THE GENUINE IMPORTED NATURAL

CARLSBAD SPRUDEL SALT

AND

CARLSBAD MINERAL WATERS

r c

o c <o ixx m ended for

ignly

1. Diseases of the Stomach — Chronic catarrh of the stomach,
cardialgia,. ulcer of the stomach.

2. Diseases of the Intestines — Chronic constipation, chronic
diarrhoea.

3. Diseases of the Spleen— Chronic hyperaemia of the spleen,

tumors of the spleen, arising after inter-
mittent fever, typhus, etc., and the effects
of a residence in marshy districts or hot
climates.

4. Liver Diseases — Hyperaemia of 1 he
liver, resulting from agglomeration of the
blood in the veins, if it does not originate
in organic defects; fat liver, jaundice, pro-
duced by catarrh of the passages of the
bile, or by liver complaint in consequence
of violent emotions; gallstones.

5. Diseases of the Kidneys and
Bladder — Gravel, nephritic stones, sand,
stone in the bladder — chronic catarrh of
the kidneys and bladder — albuminuria.

6. Diseases of the Prostate —
Chronic hyperaemia of the prostate, result-
ing from interrupted circulation in the
bowels, constipation, hemorrhoids, etc.

7. Chronic Catarrh of the Womb,
produced by menstrual disturbances, hem-

i orrhoids, and the different consequences of
interrupted circulation in the bowels.

8. Gout, especially in the early stages.

9. Diabetes Mellitus — By the use of
the Carlsbad Thermal Waters, not only the
clinical phenomena of this disease (the tor-

The genuine imported Carlsbad Sprudel ai • • 1 . i i c

Salt is put up in round bottles like the above menJing thirst, violent hunger, dryness of
cut. Each bottle comes in a paper cartoon tne skin) disappear in a very short time, but

with the seal of the Citv of Carlsbad, and . ' i 1 i- — • i •

signature of " Eisner & 'Mendelson Co.," it also considerably diminishes the secretion
^ASd?^^ °f every b°ttle and of sugar in the urine, and frequently causes

it to disappear altogether.
Diseases of the stomach are best treated with the Carlsbad Water,
whereas the Carlsbad Sprudel Salt (powder form) is to be preferred in dis-
eases of the viscera, such as intestinal canal, spleen, kidneys, inadiposis, etc.
PAMPHLETS MAILED ON APPLICATION.

EISNER & MENDELSON CO.,

SOLE AGENTS,
6 BARCLAY STREET, NEW YORK.

i
I
1
1
1
1
1
1
1
1
p

t!

1

For the Physician to watch the character and
quality of the remedies used in his prescrip-
tions. Responsibility does not cease when the
patient leaves the office ; for impure, stale, or
inferior preparations may be used without his knowledge. Personal examination of remedies prescribed —
is the best check upon substitution.

It is Important

FERRO-SALICYLATA

LIQUID.

MERRELL.

An eligible combination of
Methyl Salicylate and Tinct.Citro-
Chloride Iron, in a pleasant and
permanent form.

EACH FLUID DRACHM CONTAINS

True Salicylic Acid— from Oil
Wintergreen (Methyl Sali-
cylate), - - - - 5 grs.

Tinct. Citro-Chloride Iron, 5 minims.

Not Sold, in Bulk:.

ELIXIR

Pinus Compositus

MERRELL.

Each Fluid Drachm Contains

White Pine — fresh bark, 2% grs.

Balm Gilead Buds, 2 grs.

Spikenard, 2 grs.

Cherry Bark 1% grs.

Ipecac, 1-4 gr.

Sanguinarina Nitrate, 1-64 gr.

Morphine Acetate, i-i6gr.

Ammonium Chloride, 1-2 gr.

Chloroform, 1-2 minim.

Not Sold, in Bulk.

FERRO-SALICYLATA-^-^

Ferro-Salicylata is especially valuable in that shade of dis-
ease peculiar in anaemic, delicate, poorly nourished or broken-
down patients — usually aged people — children or youth — but
met with in all ages. In adults, and often in children when
the disease is not plainly chronic, there will be a long series of
recurrences with intervals of doubtful health. It may also be
employed in acute articular rheumatism, and in some cases of
acute tonsillitis, especially where the diagnosis is at first in
doubt between rheumatic angina and diphtheria; also, in
acute rheumatism and rheumatic affections generally.

Ferro-Salicylata may be used in combination with the Iodides
and Bromides of Potassium and Sodium. Associated with the
former, it will prove an admirable alterative and tonic in second
syphilis attended by a debilitated condition of the general
system. It also combines well with Chlorate Potassium, the
Hypophosphites, with Fowler's Solution, the vegetable bitter
tonics, either in Fluid Extract or Tincture Form.

Ferro-Salicylata and all other preparations of this Company
reach the laity through professional channels only. We there-
fore avoid entering into the minute details of their application,
leaving the physician to make such practical use of our thera-
peutic notes as in his judgment may be best suited to individual
cases.

Ferro-Salicylata may be obtained of wholesale druggists
throughout the United States, of our Eastern Office, 96 Maiden
Lane, New York City, or direct from the Laboratory.

Please designate " Ferro-Salicylata — Merrelir

ELIXIR PINUS COMPOSITOS.-^-^

An admirable combination of well known and highly ap-
proved medicinal agents; recommended in acute, chronic, and
capillary bronchitis — in ordinary coughs and colds, and wher-
ever a "routine" expectorant is suggested. In the troublesome
cough following the recent epidemic " La Grippe," it proved
invaluable — many of our correspondents looking upon it as a
" specific" in this stage of the disease.

CAUTION. — Physicians are reminded that the Elixir Pinus
Compositus of this manufacturer is wholly unlike the many
syrups, etc., under similar names, and the difference will be
readily appreciated when tried. In testing the physical prop-
erties of the Elixir Pinus, note especially its delicate taste and
perfect freedom from the odor of rank syrup, the drastic, harsh,
and repulsive characteristics of the erude blood-root, and other
coarser ingredients characteristic of competing preparations.

"Merrell Co.'s" "Green Drug," Fluid Extracts, True Salicylic Acid, Salts of
Hydrastis, Fluid Hydrastis, and Specialties may be obtained of wholesale druggists
throughout the United States, at the Home Office at Cincinnati, or the New York Office,
96 Maiden Lane, New York City, Richards Drug Co., San Francisco, Agents for Pacific
Coast. Prices-current and printed matter cheerfully supplied.

The WM. S. MERRELL CHEMICAL CO.

CINCINNATI. NEW YORK.

MEDICAL AND SURGICAL REPORTER.

I

THE STANDARD COCOA OF THE WORLD,
A SUBSTITUTE FOR TEA & COFFEE.
Digested-

HICHEST AWARDS AT
PRINCIPAL EXHIBITIONS,

" Best & Goes Farthest— Largest Sale in the World— Once Tried, Always Used.£

IJTJTJXnrUTJUOJTnJTJlJTJ^^

Vaccine Virus

FOR SALE.

SOUND and SAFE.

Address.

MEDICAL AND SURGICAL REPORTER, P. O. Box 843, Philadelphia.

MESSRS. SNOW, CHURCH & CO.,

LAW AND COLLECTION OFFICES,

608 & 61 0 Chestnut Street,

PHILADELPHIA. t

Gentlemen : — Your management of the collections of the
Medical and Surgical Reporter during the past year has
been so admirable and so much more successful than that of
any agency with which I have dealt heretofore, that I renew
my contract with you for the coming year with great pleasure.
The Publisher of the Medical and Surgical Reporter.
Philadelphia,

September 25, 1890.

MEDICO-CHIRURGICAL COLLEGE

OF PHILADELPHIA.

Winter Session will begin Wednesday, October 1st, and
continue until April 16th. Preliminary Session begins Sep-
tember 8th. Spring Term, April 20th, 1891.

The curriculum is graded, and a preliminary examination
and three Annual Winter Sessions are required. Laboratory
instruction in Chemistry, Histology, Pathology, Hygiene,
Physiology, with Bedside instruction in Medicine, Surgery and
Gynecology, is a part of the regular course.

Fees : Matriculation $5.00. First and second years, each
$75.00. Third year $100.00. Fourth year free to those in
attendance three sessions ; to all others $100.00.

For Announcement or information apply to

E. E. MONTGOMERY, M. D.,

1818 Arch Street, Philadelphia, Pa,

CAPITAL,

$1,000,000

Ike Guarantee Trust ad Sale Deposit Company,

316, 318 and 320 CHESTKUT STEEET, Philadelphia,

RENTS SAFES in its ABSOLUTELY
FIRE AND BURGLAR PROOF
VAULTS.

ALLOWS INTEREST on deposits
of money, acts as Registrar and Transfer
Agent of Corporation Stocks, and exe-
cutes Trusts of every kind under appoint-
ment of States, Courts, Corporations, or
individuals, holding Trust Funds sepa-
rate and apart from the assets 0/ the
Company.

COLLECTS INTEREST OR IN-
COME.

RECEIVES FOR SAFE KEEPING,
under Guarantee, VALUABLES of every
description.

Receipts for and safely keeps , Wills
without charge.

For further information, call at the
office, or send for a circular.

MANAGEMENT.
Richard Y. Cook, President.
Geo. H. Earle, Jr., Vice-President.
Harry J. Delany, Treasurer.
John Jay Gilroy, Secretary.
Richard C. Winship, Trust Officer,

DIRECTORS.
Thomas Cochran.
Edward C. Knight.
Thomas MacKellar.
John J. Stadiger.
Clayton French.
W. Rotch Wister.
Alfred F.tler.
J. Dickinson Sergeant
Aaron Fries.
Charles A. Sparks.
Joseph Moore, Jr.
Richard Y. Cook.
George H. Eerie, Jr.

II

MEDICAL AND SURGICAL REPORTER.

SULFONAL-BAYER.

A CORRECT METHOD OF ADMINISTRATION, ESSENTIAL TO OB-
TAINING ITS HYPNOTIC EFFECT.

Inquiries have been made of us from time to time as to the best method of administering Sulfonal-
Bayer. These inquiries indicate that various methods of administration have been employed, and this,
without doubt, accounts for those cases where the results obtained were not wholly satisfactory. We call
special attention to the following :

" Clinically observed, we recognize in Sulfonal a mild calmative, a slowly but progressively active
hypnotic. // has no other action, and its operation is attended by 710 complications, near or remote. Jt is,
therefore, a pure hypnotic ."

" The essential conditions of success in the exhibition of Sulfonal depend on first, the time when the
remedy should be administered ; second, the method of administration ; third, the dose."

" is a fact, perhaps wholly unprecedented in what we observe of other neurotic materials, that
Sulfonal demands from two hours to one hour for its physiological incubation ; often quite two hours elapse
between ingestion and the first accession of sensible medicinal energy. With the untried subject it is wise
to stipulate for two hours." — [Extracts from articles by Prof. H. M. Field, New England Medical
Monthly ; I herapeutic Gazette. ,]

According to the experience of Prof. A. Kast, of Freiburg University, Sulfonal- Bayer should be
administered in a plate of soup, a cup of hot tea, milk or broth, at least two hours before retiring, or with
the last meal early in the evening, between 7 and 8 P. M., at which time the stomach contains considerable
amount of muriatic acid, mineral salts and peptones, and the most favorable conditions for the absorption
are satisfied.

Sulfonal has just been incorporated into the Addendum to the British Pharmacopoeia.

Sulfonal-Bayer, prepared by the Farbenfabriken, formerly Friedr. Bayer & Co., Elberfeld, is supplied
by us in ounces and in the form of Tablets of 5, 10 and 15 grains, put up in bottles of 10 and 100 tablets
each.

We also offer Sulfonal-Bayer in the form of our soluble pills, containing 5 grains each.

ARISTOL.

In order to secure the desired effects of Aristol, it is important that the physician be certain that the
article used bears the guarantee furnished by the continuous scientific control and the name of the manu-
facturers, the " Farbenfabriken, vormals Friedr. Bayer 6° Co., in Elberfeld." This firm are the only
manufacturers of this article, and the word "Aristol" is their registered property.

The preparation of Aristol, theoretically simple, involves the greatest care and experience.

Aristol, a combination of iodine and thymol, manufactured by the Farbenfabriken, formerly Friedr.
Bayer & Co., Elberfeld, Germany, is a valuable, inodorous, and non-toxic antiseptic remedy, superior to
iodoform, iodole, and sozo-iodole.

The general specific action of Aristol is similar to that of iodoform, iodol, and the sozo-iodol com-
pounds, but in addition it has the valuable property of forming an absolutely unirritant covering over the
surfaces on which it is placed, under which the processes of granulation and cicatrization proceed with
extraordinary rapidity.

Aristol is indicated in Mycosis, Lupis, Psoriasis, Syphilitic diseases generally, etc., etc.

Descriptive pamphlet mailed on application.

PHENACETINE-BAYER.

Antineuralgic- Antipyretic.

Much valuable testimony regarding Phenacetine, furnished by the medical profession of other countries,
as well as our own, has, from time to time, been collated by us, and the same has been put before American
practitioners.

The scope of Phenacetine having widened, we have brought together in pamphlet form, classified in
respect to diseases indicated, the results of the latest experience as reported chiefly by American physicians.
This pamphlet mailed to applicants.

W. H. Schieffelin & Co.,

170 & 172 William Street,
NEW YORK.

MEDICAL AND SURGICAL REPORTER.

Ill

HENRY LEFFMAN, M. D.,

Analytical Chemist and Expert,

715 Walnut Street,

Philadelphia, October 26, 1889.

Messrs. Eisner & Mendelson :

Sirs : — In response to inquiries made concerning the relative merits of the Johann
HofPs Malt Extract, and that sold under the name of Tarrant's HofT's Extract, I may
state as follows :

11 That I have, during the past eighteen months, made a number of examinations
of the principal forms of Malt Extract in the market, and have, among other matters,
satisfied myself that the Johann Hoff 's Malt Extract, as imported by you, is a Genuine
Extract of Malt."

The judgment of the value of a liquid preparation of Malt will be largely based on
the percentage of Alcohol, and the presence of any preservative, especially Salicylic
Acid. It may be justly said that the less Alcohol found the better, provided its place is
not taken by some more objectionable substance. Under such considerations, the
Johann Hoff 's Malt Extract possesses decided advantages over the preparation sold
under the name of Tarrant's HorT's Extract, in the fact that the former contains three
and one-half per cent, of Alcohol, while the latter has yielded, in two samples, four and
three-quarters and five per cent, respectively.

Further, I have noted in a number of examinations of the latter article — Tarrant's
Extract — the presence of Salicylic Acid, while I have never, in repeated examinations
of the Eisner & Mendelson Johann Hoff 's Extract, found any trace of such preserva-
tive. The effects of Salicylic Acid have been extensively studied, and the unanimous
opinion of sanitary chemists is, that it is very objectionable as an addition to any form
of food or drink, and especially objectionable in Malt Extract. From some observations
made in my own laboratory, and published in the Polyclinic in May, 1888, it appears
that not only does Salicylic Acid wholly suspend the action of Diastase, to which Malt
owes its starch-converting power, but that the starch-digesting power of the pancreatic
secretion is also wholly suspended by it. It thus appears the addition of this body is to
render the Extract not only inactive so far as its own function is concerned, but it
introduces into the system an injurious substance, and one which interferes with an im-
portant function. Sanitary authorities, in various parts of Europe, have given from time
to time much attention to the now indiscriminate use of this acid, and have all, so far
as I am aware, condemned its employment in any article of food or drink. For this
reason, among others as above noted, I am of the opinion that the Genuine Johann
Hoff 's Malt Extract, as imported by Eisner & Mendelson, is to be preferred. I may say
that all the examinations were made on samples obtained in the open market, and in the
bottles as originally imported. Yours,

HENRY LEFFMAN, M. D.,

Professor Chemistry Woman's Medical College, and
Penna. College Dental Surgery; Food In-
spector9 Pennsylvania Board of
Agriculture.

IV

MEDICAL AND SURGICAL REPORTER.

BOOKS FOR OUR SUBSCRIBERS

BY SPECIAL ARRANGEMENT with the publishers we are able
at this time to offer the following- first-class and very valuable
books (last editions) at a very low price, when taken in connection with
paid-up subscriptions. Subscribers will see that we have put in this
list thoroughly good books. See Adv. Page v.

For

$10.00

REPORTER for one year,

$5.00

HEATH'S DICTIONARY OF PRAC-
TICAL SURGERY. Cloth,. . . $7.50

For

$9.00

REPORTER for one year,

S5.00

LEIDY'S HUMAN ANATOMY. By

Joseph Leidy, M. D. Cloth, . . $6.00

For

$8.50

REPORTER for one year, . $5.00

and any one of the following books —

1 — BYFORD'S DISEASES OF WO-
MEN. Cloth, $5.00

2 FOWLER'S DICTIONARY OF PRACTICAL MEDICINE, $5.00

3 JACOBSON'S OPERATIONS OF SURGERY, ....... $5.00

4. — CAZEAUX & TARNIER'S MIDWIFERY. With Appendix by Munde, . $5.00

5. — THOMAS'S MEDICAL DICTIONARY, ........ $5.00

These works are all in cloth binding, but can be supplied in leather binding for $1.00 additional.

For

$6.00

we will send the REPORTER for one year,
and any two ofthe following books :

$5.00

1.— THE NURSING AND CARE OF
THE NERVOUS ANDTHE INSANE.

— — — — — - By Chas. K. Mills, M.D., .... $1.00

2. — MATERNITY ; INFANCY; CHILDHOOD. By John M. Keating, M. D., . . $1.00

3. — OUTLINES FOR THE MANAGEMENT OF DIET; or, The Regulation of Food

to the Requirements of Health and the Treatment of Disease. By E. T. Bruen, M.D., . . $1.00

4. — FEVER NURSING. Designed for the use of professional and other Nurses. By J. C.
Wilson, A. M., M. D., $1.00

5. — DISEASES AND INJURIES OF THE EAR : Their Prevention and Cure. By Chas.

H. Burnett, A. M., M. D., $1.00

Or, Fop $6.00, any one of the above Nursing Books and THOMSON'S (Sir Henry)
SURGERY OF THE URINARY ORGANS. Some important points connected with

the Surgery of the Urinary Organs. Illustrated. Cloth, $1.25

MEDICAL AND SURGICAL REPORTER.

V

Books for our Subscribers.

WHAT IS THOUGHT OF THEM.

HEATH'S DICTIONARY OK PRACTICAI, SURGERY.

C. B. Porter, M. D., Boston, Mass., says; "A most excellent book for the library of the surgeon, and especially for the
country practitioner ; as a book of reference it is so concise and at the same time so complete."

N. Senn, M. D., College of Physicians and Surgeons, Milwaukee , says ; "Asa means of ready reference for the student
and busy practitioner this book stands unexcelled.''

Prof. E. H. Gregory, St. Louis Medical College, St. Louis, says : " I have examined the book, and find it a most valuable
addition to my library. I am sure it will meet the favor of the surgical profession."

EEIDY'S HUMAN ANATOMY.

The Lancet- Clinic, Cincinnati, O., says : " Professor Leidy again presents to medical practitioners and students a treatise
on human anatomy that at once commands the attention and admiration of all who are at all familiar with the subject. Most
of the plates are original, and in common with the text are very beautiful to behold. The work is a complete illustration of
the method of teaching anatomy adopted by a leading scientist, and one of America's best known professors of anatomy. This
is one of the books that should be in the library of every practitioner of medicine and surgery."

The Medical Advance , Ann Arbor, Mich., says : "The student can master and retain a practical knowledge of anatomy
in a shorter time and with less hard work from this text-book than from any other work extant, and it has been our privilege to
teach anatomy for several years."

BYFORD'S DISEASES OE WOMEN.

The Boston Medical and Surgical Journal says : "It is a satisfaction to observe the discussion of certain topics which
are often neglected by writers, notably of the sympathetic symptoms of organs apparently disconnected with the uterus, for
which he will receive the thanks of the younger members of the profession. Another topic very widely treated is that of Con-
stipation in its relation to uterine diseases. All the other topics which should have a place in a work of this kind have been
fully and properly treated."

The Cincinnati Lancet-Clinic says : " The book is eminently practical and instructive. Its suggestions for treatment are
well up with the times, mostly judicious, conservative, and valuable, and the whole amply repays for thorough perusal."

The St. Louis Courier of Medicine says: " The work of a representative Western practitioner and professor, and is a
thoroughly practical work."

The Virginia Medical Monthly says : " We take pleasure in recommending it to every student and physician desirous of
obtaining a standard work on Gynaecology."

The Chicago Medical fournal and. Examiner says: "The chapter on puberty should be carefully studied by every
physician, teacher, and mother in the land. ... Its style is clear, but concise, and always practical, and shows the author to
be, as we all know, an experienced teacher. The work as a whole is most valuable, both to the student and practitioner."

Gaillard 's Medical Journal says : " It is replete with good judgment, broad and practical views. . . . The illustrations
are excellent."

FOWLER'S DICTIONARY OE PRACTICAL MEDICINE.

The Medical News says : ¥ For those who do not wish to purchase the much larger book of Quain, or who wish compara-
tively recent information concerning medial subjects in a somewhat narrow space, the book will certainly prove of value, and
we heartily recommend it as one which will give a full return for the money invested in the purchase."

The London Lancet says : " What the writers know they tell simply and plainly, and generally manage to put it in a short
compass, and, what is more, the treatment that is recommended is clearly and sufficiently set forth. . . . We can heartily
congratulate the editor and his colleagues on having admirably fulfilled their purpose, viz., to produce a first-rate dictionary of
medicine, at once scientific and practical, which well deserve the success we have no doubt it will meet with."

JACOBSON'S OPERATIONS OE SURGERY.

The Medical and Surgical Reporter says: " This handsome book is one of the most admirable works on operative surgery
which we have seen for a long time. The author has brought to its preparation a large observation and experience, and a very
thorough acquaintance with the methods of other surgeons. His book is comprehensive and his directions are clear and reli-
able. It is gratifying to an American reader to find that full justice is done to the work of American surgeons by Mr. Jacobson,
and that his book bears no marks of the distance which stretches between his land and ours. This is as it should be, and is no
less an element in the excellence of the technical worth of his book than it is an evidence of the cosmopolitan character of good
scientific work."

CA2JEAIIX & TARNIER'S MIDWIFERY. With Appendix toy MUNDE.

The Memphis Medical Monthly says : ' ' Cazeaux's Obstetrics was authc-rity during our student life, and has been gener-
ally recognized as authority from the publication of the first edition to the present. We cannot do more than to fully endorse
the following from the pen of T. Gallard Thomas, M. D. ; 'I have examined the last edition of Cazeaux & Tarnier's Theory
and Practice of Obstetrics, and pronounce it practical, and just what is needed by every practitioner. I highly recommend the
work. This work should be prominent in every library.' "

Dr. Wm. L. Lusk says : " Cazeaux's Midwifery will always remain an inexhaustible mine of information, and I rejoice to
see it once more accessible to the profession in a new and attractive dress."

Dr. Wm. Goodell says : " I deem Cazeaux & Tarnier's Obstetrics the best yet published."

The Denver Medical Times says ; " It is needless to say anything in praise of this work. Cazeaux's Obstetrics is a clas-
sical work, and Tarnier is one of the best known French writers on Obstetrics. The whole has been brought up to date by the
appendix of Prof. Munde, and altogether it makes a very complete and practical treatise on the subject, unsurpassed if not
unequalled by any work with which we are acquainted. Especially valuable are the signs of delivery in the dead body and of
live and still-births. The chapter on antisepsis and on puerperal septicemia are also worthy of mention."

THOMAS'S MEDICAE DICTIONARY.

Prof. A. F. Patton, College of Physicians and Surgeons, Boston, Mass., says : " It is just the book for a medical or any
other student, and it should be in the office of every physician. This dictionary supplies a place that has never been filled. I
have looked it through and find all the new words that I have sought."

The St. Joseph Medical Herald says : " No better testimonial to the value of the work can be given than the following
from Dr. J. Gibbon Hunt, the distinguished microscopist : 'To me the work is invaluable. I am astonished at its fullness of
all recent words which the modern advance of medical science has introduced. Of course, I cannot conceive the learning and
great labor which could edit such a complete, thorough, and admirable volume.* We can add nothing further save that the
book should be in the hands of every physician and every student in the land."

vc

MEDICAL AND SURGICAL REPORTER.

CHARLES LENTZ & SONS,

MAKERS OF

Surgical Instruments and Orthopaedic Apparatus

18 NORTH ELEVENTH STREET, PHILADELPHIA.

WE HAVE EVERYTHING IN PHYSICIANS' SUPPLIES. Medica' 3KS2r£SL ISLSgr Cas"'

MICROSCOPES

FOR

Urinary Analysis

A SPECIALTY.

$28.00 AND UPWARDS.

Send for catalogue of Micro-
scopes, 100 pages.

Lentz's Aseptic Catheter.

The above is a modification of Jennison's Uterine Douche, for intra-uterine injections.
Any bulb or fountain syringe can be attached.

Price, with Rubber Tubing, Net, $2.00. .

Send for descriptive Circular.

Our No. 10 Operating Case,

complete set in the market for any ordinary operation,
for circular.

of which so much
has been said, is
having large sale
yet. It is the most
Price, #18.75, and upward. Send

SEND FOR SPECIAL LIST OF NEW INSTRUMENTS.

ANTISEPTIC DRAINAGE TUBES.-Glass.

These Tubes have large holes, one-half inch apart, arranged alternately on opposite sides.
They are carefully finished, especial care being taken to make them smooth.

In addition to the drainage-holes, each tube has at one end two smaller holes for the insertion o* Safety-Pin, through
which it is prevented slipping into the wound.

RAW CAT-GUT. I put this up in coils of 10 feet, lour difierent
sizes, Nos. 1, 2, 3, 4 (4 is thickest). Nos. 2 and 3 are the most useful sizes.
No. 1 Coil, 10 Cents; No. 2 Coil, 12 Cents; No. 3 CoU, 14
Cents; No. 4 Coil, 16 Cents. Full directions with each coil foi

making it absolutely aseptic.

WILLIAM SNOWDEN,

Manufacturer, Importer and Exporter of Surgical Instruments,

No. 121 SOUTH ELEVENTH STREET, PHILADELPHIA.

FURNISHED IN SEVEN SIZES

No. 1, $1.25 per doz. No. 4, $1.55 per doz.
No. 2, 1.25 " No. 5, 1.70 «

No. 3, 1.40 " No. 6, 1.90 "

No. 7, $2.10 per dozen.

OK PHILADELPHIA,

The 66th Annual Session of the Jefferson Medical College
begins October 1st and continues nearly 7 months.
Preliminary Lectures will be held from
22d of September.

EACH student is immediately and personally taught in Ob-
stetrics and Gynaecology, Physical Diagnosis, Laryngol-
ogy, Ophthalmology, Medical Chemistry, Pharmacy, Materia
Medica, and Experimental Therapeutics, Histology and Ex-
perimental Physiology, Minor Surgery, Bandaging, Operations
on the Cadaver, Pathology, Neurology, and Electro-Thera-
peutics.

Three annual regular sessions are required. Bedside in-
struction in Medicine, Gynaecology, Surgery and Obstetrics
is a part of the third year course. No extra fee.

The Annual Announcement will be sent on applica
tion to J. W. HOLLAND, M. Dean.

DR. MASSEY'S

PRIVATE SANITARIUM

212 South Fifteenth Street

PHILADELPHIA

•lliis institution, in addition tocomplete arrangements for
the treatment of Nervous Diseases by rest, electricity, mass-
age, etc., under comfortable surroundings, is specially equipped
for the treatment of cases of Fibroid Tumors and other intract-
able diseases of the pelvic viscera, by the conservative use of
strong electric currents. For particulars, address

DR. G. BETTON MASSEY,

Physician in Charge.

MEDICAL AND SURGICAL REPORTER.

VII

IN GYNAECOLOGICAL PRACTICE

For Subinvolution, Congestive Dysmenorrhoea, Chronic Metritis, &o.

m PJECTKDi

For Hemorrhoids, Relaxation of Sphincter, Prolapsnsof Rectum, &c.

For Congestion of Mucous Membranes as in Conjunctivitis,
Cervicitis, Pharyngitis, Gonorrhoea, <&c.

fflyFOOTFIIOlLlY

Or by the mouth, for Aneurisms, Dilatation of Heart, Acute and Chronic Dysentery,
Haemoptysis, Hsematuria and other Hemorrhages ; Chronic Arteritis, Incontinence,
Spermatorrhoea, Varicocele, Varicose Veins, Diabetes Insipidus ; with the Bromides for
Spinal Meningitis, Acute Myelitis and Congestion of Meninges and Cord, and in obstetric
practice, especially when Post-Partum Hemorrhage is threatened,

ERGOTOLE s,&d

.'s

has been most successfully employed. When given hypodermically, more prompt action and
the best results are usually obtained.

Ergotole is a new preparation of Ergot of Rye. It is specially made for hypodermic use
by a new process ; representing all the active principles of Ergot in a very concentrated
form, and entirely freed from all inert and irritating constituents.

It causes neither pain nor abscess, and keeps perfectly without precipitation
for any length of time. It has been extensively tried in hospital and private practice,
hypodermically and administered by the mouth, proving uniformly efficacious, and it has
been pronounced

THE MOST EFFICIENT PREPARATION OF ERGOT IN USE

One minim representing the full therapeutic strength of about 2^ grains of the best Spanish
Ergot. Administered by the mouth, it will prove itself divested of all irritating and nauseat-
ing properties, which are so objectionable in the officinal fluid extract.

An eminent physician of Baltimore states that he has had uniform and satisfactory re-
sults in over fifty cases of various diseases from a supply of our Brgotole, which was prepared
over two years ago, and kept in a cork-stopped bottle partially filled.

10$* SPECIAL CIRCULAR AND SAMPLE SENT TO PHYSICIANS WHO MENTION THIS JOURNAL.**^

SHARP &, DOHME,

MANUFACTURERS OF
Standard Medicinal Fluid and Solid Extracts; Soluble Hypodermic Tablets; Soluble
Gelatin and Sugar-Coated Pills and Granules; Granualr Effervescent Salts;
Compressed Lozenges and Tablets; Fine Chemicals, &c, &c.

ESTABLISHED 1860. 1 BALTIMORE, MD.

VIII

MEDICAL AND SURGICAL REPORTER,

RABUTEAU'S DRAGEES of IRON

Laureate of the Institute of France— Prize in Therapeutics.

The studies made by the Physicians of the Hospitals have
demonstrated that the Genuine Uragees of Iron of
Kabuteau are superior to ail other preparations of Iron
in cases of Chlorosis, Ansemia, Leucorrhcea, Debility, Exhaustion,
Convalescence, Weakness of Children, and the maladies caused
by the Impoverishment and Alteration of the blood alter
periods of fatigue, watching, and excesses of any kind.

TAKE 4 to 6 DRAGEES DAILY.

Rabuteau's .Elixir of Iron is recommended to those
persons who may be unable to swallow the Dragees. Dose
— A small wineglassful with meals.

Rabuteau's Syrup of Iron is specially designed for
children. Chalybeate medication, by means of Rabuteau's
Iron, is the most economical and the most rational known
to therapeutics.

No constipation, no diarrhoea, complete assimilation.
Take only the GENUINE IRON OF RABUTEAU of
OX-.I2S7 <3c CO., ZFa,ris.

SOLUTION OK

THE SALICYLATE of SODA
OF DOCTOR GLIN.

Laureate of the Paris Faculty of Medicine
(MONTYON PRIZE).

Dr. Clin' s Solution, always identical in its composition,

and of an agreeable taste, permits the easy administration
of pure Salicylate of Soda, and the variation of the dose in
accordance with the indications presented.

"The Salicylate of Soda used by Clin is of perfect purity,
"and is prepared with the greatest care; it is a medicament
"in which we may have every confidence."

—Paris Society of Medicine, Meeting of Feb. 8th, 1879.

Clin's Solution, very exactly mixed, contains: 2
grammes of Salicylate of Soda per tablespoonful, 50 centi-
grammes of Salicylate of Soda per teaspoonful.

lE^ris— CIjIIjT <Sc CO.-Paris

AND BY ALL DRUGGISTS.

CAPSULES

MATHEY-CAYLUS

WITH THIN ENVELOPE OF GLUTEN.
CONTAINING COPAIBA AND ESSENCE OF SANTAL:
COPAIBA, CUBEBS, AND THE ESSENCE OF SANTAL;
COPAIBA. IRON, AND THE ESSENCE OF SANTAL.

"The Mathey-Caylus Capsules, of the Essence of
*'Santal, associated with the Balsams, possess an incontesta-
ble efficaciousness, and are employed with the greatest
"success for the rapid cure of old or recent Discharges,
"Gonorrhoea, Blenorrhcea, Leueorrhoea, Cystitis of the Neck,
" Urethritis, Catarrh, and other diseases of the bladder, together
" with all affections of the Urinary Passages."

" Thanks to their thin envelope of Gluten, which is essen-
" tially assimilable, the Mathey-Caylus Capsules are digested
44 by the most delicate persons, and never weary the stomach."

— Gazette des HopUaux de Paris.

CXjUST <Sc CO., IF>a,ris,

AND OF ALL DRUGGISTS.

N EU R ALG IAS

PILLS OF DR. MOUSSETTE.

The Moussette Pills of aconitine and quinium, calm or
cure Gastralgia, Hemicrania, Headache, Sciatica, and the
most obstinate Neuralgias.

"The sedative action exerted by the Moussette Pills
"upon the apparatus of the sanguineous circulation by the
"intermediation of the vaso-motor nerves, indicates their
"use in neuralgias of the trigemini nerves, (fifth pair), con-
"gestioe neuralgias, arid painful and inflammatory Rhewmatismal
" affections."

"Aconitine produces marvelous effects in the treatment
"of facial neuralgias when they are not symptomatic of
" intracranial tumor." — Society of Biology of Paris, Meeting
"of the 28th February, 1880.

Dose— Take 3 to 6 pills during the twenty-four hours.
ACCEPT ONLY THE GENUINE MOUSSETTE PILLS OF
CLI1T 6c CO.,-Paris.

GRAND NATIONAL PRIZE OF 16,600 FRANCS.

Ouina-Laroche

This meritorious Elixir,
QUINA-LAROCHE, is

prepared from the three
Cinchonas ; it is an agreea-
ble and doubtless highly
efficacious remedy.

— The Lancet.

VINOUS ELIXIR,

A STIMULATING
RESTORATIVE

> AND

ANTI-FEBRILE TONIC

QUIN A - L ABO CHE

under the form of a vinous
Elixir contains the totality
of the numerous principles
of the three Cinchona
barks. It is a preparation
which renders great serv-
ices to Therapeutics. — Ex-
tract of the Gazette des
HopUaux, Paris.

FAR SUPERIOR TO ALL ORDINARY CINCHONA WINES.

IARO CHE'S QUINA, tried by the Academy of Medicine of Paris, is a specially prepared Compound Extract of
Quinquina, a careful analysis, confirmed by experience, has shown that most of the wines and syrups hitherto used have not
contained all the properties of this precious bark, of these some, although beneficial, are altogether lost, while many preparations
contain but half the properties of the bark in varying proportions.

Mr. Laroche, by his peculiar method, has succeeded in extracting all the active principles of the quinquina, combining these
With Catalan Wine forming an Elixir free from the disagreeable bitterness of other similar preparations. Practitioners have
found triple advantages in the use of this Elixir, it is a strong tonic, is easily administered, and perfectly harmless, being free
from the unpleasant effects of Quinine.

THE FERRUGINOUS QUENA-IAROCHE is the invigorating tonic par excellence, having the advantage of being
easily assimilated by the gastric juice ; without, in any way, deranging the action of the digestive organs, proving itself to be a most
efficacious remedy in cases of impoverishment of the 'blood, Anemia, Chlorosis, Intestinal Hemorrhage, Castralgia,
Exhaustion, Etc., Etc.

PARIS. — 22 RUB DROUOT. — PARIS .

E. FOUGERA & CO., New York,

Sole Agents for the United States for the above Preparations.

MEDICAL AND SURGICAL REPORTER.

IX

DANDRUFF

LASSAR'S TREATMENT *

includes Shampooing the head thoroughly for ten
minutes every day with Packers' Tar Soap. — f.f.

*Reprint from Dr. Jackson's paper— Gaillard's Med. Jour., May— sent with sam-
ple of our Pine Tar Soap on receipt of 4 stamps. Address

THE PACKER MFG. CO., 100 Fulton St., New York.

AND

BALDNESS

PLANTER'S

CAPSULES

Known over 50 years for " General Excellence."

H. PLAMTES & SQMT Estate* 1836. flfiW York.

STERILIZED INJECTION-SYRINGE

After Professor DR. KOCH , for the treatment of tuber-
cular consumption, latest model, with first rate German silver
mountings, M. 5 each, M. 50 per dozen, forwarded on receipt
of price by

IB. IB. CASSEL,

Manufacturer of chirurgical instruments, FRANKFORT-
ON-THE-MAIN (Germany). Price Current about 3000
chirurgical instruments gratis and post free.

SOFT AND PADCm CQ FILLED OF
HARD LArOULLO ALL KINDS.

Ninesizes : 3, 5,io,andi5 Min., and 1,2%, 5, 10, and 15 Gram.

SPECIALTIES :— Sandal Pure, Compound Sandal, Apiol,
Erigeron, Creosote, etc.

IMPROVED EMPTY CAPSULES.

POWDERS, 8 sizes; LIQUIDS, 8 sizes;

RECTAL, 3 sizes; VAGINAL, 9 sizes;
HORSE, 6 sizes; VETERINARY RECTAL, 3 sizes.
CAPSULES FOR MECHANICAL PURPOSES.
New Articles, and Capsuling Private Formulae a Specialty.
4®- SOLD BY ALL DRUGGISTS. SAMPLES FREE.

Specify PLANTEN'S on all Orders.

HOME FOR HABITUES.

OJPITJMI, CHLORAL, COCAINE.
DR. J. B. MATTISON,

Continues to receive at his residence, 314 State Street, Brook-
lyn, N. Y.,a limited number of these habitues, to whom he
devotes his exclusive professional attention. Patients Six.
and Select. Attractive apartments, liberal cuisine, desirable
privacy, cheerful society, and personal professional attention,
based on several years' experience in the treatment of this
disease. Details on application.

EXCELLENT OPENING

FOR

YOUNG PHYSICIAN.

Office of recently deceased physician to let, with practice,

1816 Christian St., Philadelphia.

Mellin's Food

FOR INFANTS AND INVALIDS.

A SOLUBLE DRY EXTRACT, prepared from Malted Barley
and Wheat, consisting of Dextrin, Maltose, Albuminates, and Salts.

The SUGAR in MELLIN'S FOOD is MALTOSE. MALTOSE is
the PROPER SUGAR for use in connection with cow's milk.

The sugar formed by the action of the Ptyalin of the Saliva and the Amylopsin of
the Pancreas upon starch is MALTOSE. In the digestive tract MALTOSE is absorbed

UNCHANGED. _ . . ......

— Landois and £>terling.

MALTOSE is a saccharose, not a glucose, and is a form of sugar which does not ferment.

— Materia Medica a?id Therapeutics, Dr. Mitchell Bruce.

" I have never seen any signs of fermentation which I could attribute to the influence
of MALTOSE." _Eustace Smiih> i FR C S

MELLIN'S FOOD, prepared according to the directions, is
a true LIEBIG'S FOOD and the BEST SUBSTITUTE for Mother's
Milk yet produced.

U ^ IT REQUIRES NO COOKING.

THE DOLIBER-GOODALE CO.,

BOSTON, MASS.

X

MEDICAL AND SURGICAL REPORTER.

TERTIARY SYPHILIS.

"Your preparation, IODIA, is an excellent altera-
tive, and is the most agreeable of any preparation of
Iod. Potas., as it does not cause the cramps in stomach,
which are often intolerable.

"I have employed IODIA in two cases of Tertiary
Syphilis, in which, after five weeks' treatment, the mani-
festations disappeared.

" In a case of Syphiltic Eczema it was also successful.
— De. Sam Petite ait, Garches, France, Nov. 10, 1890.

BATTLE & CO., Chemists' Corporation,

St. Louis, Mo., TJ. S. A.

BKANCHES :

76 New Bond Street, London, W.

5 Rue de la Paix, Paris.

9 and 10 Dalhousie Square, Calcutta.
80 Montague-de-la-Cour, Brussels.
28 Nieuwe Hoogstraat, Amsterdam.

MEDICAL AND SURGICAL REPORTER.

XI

SYRUP OF FIGS.

(Syr. Fici Cal.)

In order to meet the almost universal demand for a safe, reliable and elegant
liquid laxative, the

CALIFORNIA FIG SYRUP CO.

OF

SAN FRANCISCO, CAL.
LOUISVILLE, KY. NEW YORK, N. Y.

is utilizing the delicious blue Fig of California in the preparation of

SYRUP OF FIGS,

an agreeable and effective laxative or purgative, according to the dose and manner of
administration.

Syrup of Figs is delightful to the taste, and may be taken by every one, from
infancy to old age.

Syrup of Figs does not debilitate, and is perfectly safe.

The dose as a purgative for an adult is from one-half to one tablespoonful and
may be repeated in six hours if required. As a laxative, one or two teaspoonfuls may be
given at bed-time or before breakfast.

For children the dose may be regulated according to age and desired effect.

SYRUP OF FIGS

is recommended and prescribed by prominent physicians in all sections of the United
States, and gives general satisfaction.

In addition to the blue Figs of California, we use the juice of true Alexandria
Senna, representing the laxative and purgative principles without its griping properties,
also pure white sugar and an excellent combination of carminative aromatics.

Devoting our entire attention to the manufacture of Syrup of Figs after a
thorough study of the results to be accomplished and of the best methods to produce a
perfect laxative, and with complete manufacturing facilities especially adapted to the
purpose, we are enabled to offer to the medical profession, in Syrup of Figs, a laxa-
tive which, though simple in itself, cannot be produced in all its excellence by other
parties, and we believe and trust that physicians will not permit imitations to be used
when they prescribe Syrup of Figs (Syr. Fici Cal.).

SYRUP OF FIGS

is manufactured only by the

CALIFORNIA FIG SYRUP CO.

OF

SAN FRANCISCO, CAL.
LOUISVILLE, KY. NEW YORK, N. Y.

It is sold to the drug trade in bottles of two sizes only : the smaller bottles con-
taining full four ounces and the large size about ten ounces.

XII

MEDICAL AND SURGICAL REPORTER.

DISEASES IN WHICH

Oxygen and Nitrogen Monoxide

HAVE BEEN EMPLOYED.

(See " Therapeutic Uses of Oxygen and Nitrogen Monoxide," which can be obtained upon

application.)

Anaemia, Dyspnoea, Nephritis,

Asphyxia, Emphysema, Pulmonary, Nervous Affections,

Asthenia, Epilepsy, Nervous Prostration,

Asthma, Formication, Neuralgia,

Atonic Conditions, Headache, Paralysis,

Briglit's Disease, Hemorrhage, Pulmonary, Phthisis, !

Bronchitis, Hypochondriasis, Pleuritic Adhesions,

Catarrh, Hysteria, Pleurisy,

Croup, Indigestion, Pleuro-Pneumonia,

Cyanosis, Insomnia, Pneumonia,

Diabetes, Laryngitis, Rheumatism.

Diarrhoea, Lithiasis, Scarlet Fever,

Diphtheria, Melancholia, Tuberculosis,

Dyspepsia, Menstrual Irregularities, Uraemia.

-AJ30TTT GKA.S TRBATMBHT.

We make and sell oxygen and nitrogen monoxide for therapeutic use, and we guarantee them pure.
They are put up in compact form. (A cylinder containing 100 gallons of nitrogen monoxide or 40 gallons
of oxygen measures 12 inches in length, has a diameter of 3^ inches, and weighs 10^ lbs. A cylinder
containing 450 gallons of nitrogen monoxide or 100 gallons of oxygen measures 25 inches in length, has a
diameter of \]/2 inches, and weighs 34 lbs.)

Insomnia. Dr. Allan McLane Hamilton states that nitrogen monoxide, N20 (nitrous oxide of the old
nomenclature) has no equal in the treatment of this difficulty.

Melancholia. A short course of nitrogen monoxide is said to change the face of nature for such
patients.

Anemia. Where iron is not tolerated or proves inefficient, the addition of oxygen or a combination
of oxygen and nitrogen monoxide has proven very beneficial.

For those who should, but cannot, go from home for rest or a change of air, or for those who, from any
cause fail to get air enough into their lungs, the inhalation of one or other of these gases, or both in com-
bination, promises great benefit. The testimony is that in cases of

Asthma, more than fifty per cent, of the cases yield to oxygen treatment, others are very greatly
relieved, and a very small per cent, are not improved.

Indigestion and Constipation are said to be greatly relieved and very often conquered by continued
treatment.

A highly esteemed New York physician has used more than twenty thousand gallons of nitrogen
monoxide in his private practice. The letters received from his patients, largely from those who were
afflicted with nervous disorders, are enthusiastic in their testimony as to the benefit received.

Regular practitioners who are using gas treatment testify that when pure oxygen and pure nitrogen
monoxide, or a mixture of these, is used, no therapeutic agents are more uniformly successful when intelli-
gently prescribed.

For descriptive circulars, and term for gas outfits, address

The S. S. White Dental Manufacturing Company,

AT EITHER OF THE BELOW NAMED PLACES;

Twelfth and Chestnut Sts., Philadelphia, Pa. 160 Tremont St., Boston, Mass.

767 and 769 Broadway (cor. 9th St.), New York, N. Y. 151 and 153 Wabash Ave., Chicago, 111.

1260 and 1262 Broadway (cor. 32d St.), New York, N. Y. 444 Fulton St., Brooklyn, N. Y.

MEDICAL AND SURGICAL REPORTER.

XTII

THE BEST ANTISEPTIC

FOR BOTH INTERNAL AND EXTERNAL USE.

ANTISEPTIC, H ^Hr^ pP8™ B fflk H | NON-TOXIO.

PROPHYLACTIC | H 9 ^QGK M BBB BBf ■ &■ NON-IRRITANT.

Deodorant. raSSB 9 ^bmr B BflB B m. fl 9 HGHB ' NoN'EscHAROTI0-

FORMULA — Listerine is the essential antiseptic constituent of Thyme, Eucalyptus, Baptisia, Gaultheria and
Mentha Arvensis, in combination. Each fluid drachm also contains two grains of refined and purified
Benzo-boracic Acid.

DOSE — Internally: One teaspoonful three or more times a day (as indicated) either full strength, or di2uted,
as necessary for varied conditions.
LISTERINE is a well -proven antiseptic agent— an antizymotic— especially adapted to
internal use, and to make and maintain surgical cleanliness— asepsis— in the treatment of
all parts of the human body, whether by spray, irrigation, atomization, or simple local
application, and therefore characterized by its particular adaptability to the field ol

PREVENTIVE MEDICIXE-DfOIVIBUAI. PROPHYLAXIS.
*

LAMBERT'S

LITHIATED HYDRANGEA

KIDNEY ALTERATIVE— A NT I - LITHIC.

FORMULA — Each fluid drachm of "Lithiated Hydrangea" represents thirty grains of fresh Hydrangea and
three grains of chemically pure Benzo-Salicylate of Lithia. Prepared by our improved process of
osmosis, it is invariably of definite and uniform therapeutic strength, and hence can be depended
upon in clinical practice.

DOSE — One or two teaspoonfuls four times a day (preferably between meals).

Urinary Calculus, Gout, Rheumatism, Bright's Disease, Diabetes, Cystitis, Hema-
turia Albuminuria, and ^Vesical irritations generally.

We have much valuable \ GENERAL ANTISEPTIC Treatment, l To forward tt Physicians

literature upon j LlTHEMIA, DIABETES. CYSTITIS, EtcJ ^request:

LAMBERT PHARMACAL CO.. ST, LOUIS. MO.

FRENCH, CAVE & CO.

(SUCCESSORS TO FRENCH, RICHARDS & CO.),

PHILADELPHIA,

WILL continue the manufacture of the Fine Pharmaceutical Products
made by the late firm at the present laboratory, 16 and 18 North
™— - Tenth Street, Philadelphia.

— Physicians who have prescribed these preparations can rest assured that

the high standard of quality which has made for these products a reputation
for consistent strength and purity will be strictly maintained in the future, and
the physician can always prescribe our preparations and depend on uniform
«,» results.

To those physicians who have not yet prescribed our products, we request
them to send to us their address and we will forward by EXPRESS, PRE-
PAID, a line of samples free for trial.

Physicians' Price-list and Formulary sent by mail on application.

FRENCH, CAVE & CO.,

Factors of Fine Ph a rmaceutical Products,
Nos. 16 and 18 NORTH TENTH STREET, PHILADELPHIA.

XIV

MEDICAL AND SURGICAL REPORTER.

FOE TIHEIE] CUEE OIF1

NERVOUS HEADACHES

SEDATIVE EFFERVESCENT EFFERVESCENT ANODYNE

(WARNER & CO.) ^

R Caffein 1 grain, Bromide Potash 20 grains
in each heaping teaspoonful.

Useful in Nervous Headache, Sleeplessness, Excessive Study,
Migraine, Nervous Debility, Mania, as a Remedy
in Seasickness and Epilepsy.

4®=* Physicians desiring the Potash Salt can obtain the
same by ordering or prescribing Bromo-Potasli (Warner
& Co.), the composition of which is :^Brom. Potash 20 grs.,

Caffein 1 gr.

The composition of the above effervescent salts is such as physicians can use with confidence, and you will please
specify BrOIIlO-SotlS or Bromo-Potash, Warner & Co., when ordering or prescribing to avoid the
substitution of other " Bromos." Prepared only by

WILLIAM R. WARNER & CO.,

4*0Mo

(WARNER &, CO.)

B Caffein 1 grain, Broin. Soda 30 grains in
each heaping teaspoonful.

Useful in Nervous Headache, Sleeplessness, Excessive Study,
Migraine, Nervous Debility, Mania, as a Remedy
in Seasickness and Epilepsy.

Dose and Composition.— A heaping teaspoonful, con-
taining Bromo-Soda 30 grs., and Caffein 1 gr., in half a glass
of water, to be repeated once after an interval of thirty min-
utes if necessary

1228 Market street, Philadelphia.

18 Liberty street, New York.

THOMAS'S MEDICAL DICTIONARY.

A Complete pronouncing Medical Dictionary, embracing the Terminology of Medicine
and Kindred Sciences, with their Signification, Etymology, and Pronunciation.
With an Appendix. By Joseph Thomas, M. D., LL. D. Imperial 8vo. 844 pages.
Extra cloth. $5.00. Sheep. $6.00.

" For the daily use of the student or the practitioner, it is superior to any other
Medical Dictionary in the language." — Canada Medical Record.

" We can add nothing further save that the book should be in the hands of every
physician and every student in the land."— St. Joseph Medical Herald.

" This dictionary supplies a place that has never been filled. I have looked it
through and find all the new words that I have sought." — Prof. A. F. Patton, College

of Physicians and Surgeons, Boston, Mass.

For sale by all Booksellers, or will be sent free of expense, by the Publishers, on
receipt of price.

J. B. LIPPINCOTT COMPANY,

715 and 717 Market St., Philadelphia.

MEDICAL AND SURGICAL REPORTER.

XIX

CELERINA

NERVE TONIC, STIMULANT AND ANTISPASMODIC.

FORMULA*— Every Fluid Drachm represents FIVE grains EACH-Celery
— — ^— — Coca, Kola, Viburnum and Aromatics.

INDICATIONS. -Loss of Nerve Power (so usual with Law-
yers, Preachers, Writers and Business Men), Impotency.
Spermatorrhea, Nervous Headache, Neuralgia, Paralysis,
Hysteria* Opium Habit, Inebriety, Dyspepsia, and ALL
LANGUID conditions of the System.

Indispensable to restore a patient after alcoholic excess,
DOSE.-0"» or two Teaspoonfuls three or more times a day, as directed
*" " by the Physician.

ALETRIS CORDIAL

UTERINE TONIC AND RESTORATIVE.

PREPARED FROM THE ALETRIS FARINOSA OR TRUE UNICORN.

INDICATIONS.— Amenorrhea, Dysmenorrhea, Leucorrhea,
Prolapsus Uteri, Sterility, to PREVENT Miscarriage, Etc.
DOSE.~One Teaspoonful three or four times a day.

Unrivaled as a Uterine Tonic in Irregular, Painful, Suppressed and Excessive Menstruation.

It Restores Normal Action to the Uterus, and Imparts Vigor to the
Entire Uterine System.

Where Women have miscarried during previous pregnancies, or in any
case where miscarriage is feared, ALETRIS CORDIAL is Indicated, and
should be continuously administered during entire gestation.

S. XX. KENNEDY'S

CONCENTRATED EXTRACT OF

PINUS CANADENSIS

— - - ■ — WHITE.

DARK.

A NON-ALCOHOLIC LIQUID

A MOST VALUABLE NON-IRRITATINB MUCOUS ASTRINGENT.

INDICATIONS.— Albuminuria, Diarrhea, Dysentery, Night-
Sweats, Hemorrhages, Profuse Expectoration, Catarrh,
Sore Throat, Leucorrhea, and other Vaginal Diseases, Piles,
Sores, Ulcers, Burns, Scalds, Gonorrhea, Gleet, Etc.

Wnen Used as an Injection, to Avoid staining oi Linen, the WHITE Finns snonld De nsed,

RECOMMENDED BY PROMINENT EUROPEAN AND AMERICAN PHYSICIANS.

The above preparations are prepared exclusively for Physicians' Prescriptions, and a
sample of each or all of them will be sent to any Physician who wishes to test them, if
he will pay the Express Charges.

RIO CHEMICAL CO.. St. Louis, Mo., U. S. A.

London.

Paris.

Calcutta.

Montreal.

MEDICAL AND SURGICAL REPORTER.

LIQUOR SANTAL FLAV.

CUM

BUCHU et CUB KB A.

(ORIGINAL FORMULA.)

This elegant preparation has been very successfully used in the treatment of
long-standing Gonorrhoea and chronic Gleet.

If given in the early stages of Gonorrhoea, it will usually arrest the progress

of the disease.

It is especially effective in all inflammations of genito-urinary mucous
membranes. •:;-V^:«5f •

It is perfectly miscible in water. Dose, iZ\ to f3ij, three times a day in water
or milk. When prescribing, please specify Liq. Santal Flav. cum Buchu et Cubeba
(Ogden's).

vJOHIlsr OGKDEILT,
CHEMIST,
WALNUT & THIRTEENTH STREETS,

PHILADELPHIA.

Every Physician in THE WORLD should Read This Advertisement.

THE RIP VAN WINKLE RECLINING ROCKER.

OFFICE AND GYNAECOLOGICAL CHAIR COMBINED.

Special Inducements and Extra Discount Given to Physicians.

It is the most wonderful Chair in the world. You
can sit in the Chair with your feet on the foot-rest and
rock yourself, and it is impossible for a beholder to
tell what makes the Chair rock. It is the finest in-
valid's Chair in the world.

As an Invalid's Chair, aperson can recline
the back by quarter-inches until he lies straight or hori-
zontally, and without taking his weight from the back
of the chair in the least, and CAN ROCK AS WELL
LYING DOWN AS SITTING UP. Upholstered in
Plush, Leather or Wilton Rugs. This Chair has over
200 changes of position, and sells for #25.00.

No. 1.

This Chair can be converted from a splendid
Office Chair (see cuts Nos. 1 and 3) into one
of the most complete Gynaecological Chairs
in'a half minnte, (see cuts 2, 4, and 5).

As a Gynaecological Chair it will take all
the positions of the high-priced chairs costing
two and three times what this one does.

The Rip Van Winkle Chair has over 200
changes of position. Every chair fully war-
ranted.

No. 2.

This Chair is sold with or without the Gyn-
aecological attachment, as desired. It is un-
questionably the most complete and comfort-
able Reclining or Lounging Chair ever made.
I make a special price to physicians, and also
give them a handsome commission on all orders
I receive through them for Chairs for their
patients. No Chair in the world is so well
adapted to ladies suffering from female weak-
ness, and the commission I give on your orders
will soon pay for your own Chair.

No. 4.

No. 3.

The Chair makes 5 pieces of Furniture.

I have attachments by which it can be con-
verted into an Invalid's Rolling Chair in one
minute. Parties can get these attachments from
factory at any time. Send for full particulars,
price-list, and illustrated catalogue showing the
principal positions and changes. The Catalogue
contains the " Legend of Rip Van Winkle."
Without the Gynaecological Attachment these Chairs

No. 5-

Make an Elegrant Wedding* or Holiday Present.
Manufactured by p. C. LEWIS, 154, Catskill, W. Y.

MEDICAL AND SURGICAL REPORTER.

XXI

The Atmospheric Tractor

SOME PRACTICAL POINTS ABOUT ITS USE.

In using the Atmospheric Tractor, it will be found that after the head has been
properly flexed, its extraction will be facilitated more by continuous moderate traction
for a number of seconds, than by exerting at once the greatest power possible.

It is well known that all sphincter muscles readily relax to gentle, continuous,
persuasive pressure, but if abrupt great force be employed they contract spasmodically,
and will often become ruptured or lacerated before relaxing.

Continuous pressure, of a trifling amount, will tire out the strongest muscles. A
man may be able to pick up fifty pounds or more with one hand and hold it extended
for a brief period, but he could not support a weight of five pounds in the same manner
for many minutes. The muscles employed would become tired out and relax. In a
similar manner, the pelvic muscles and the muscular tissue of the vagina may resist for
hours the intermittent pressure of the head driven against them by the abdominal and
uterine muscles, but they will become tired out and relax in a few minutes to a much
less pressure exerted against them continuously through the medium of the Atmospheric
Tractor.

It is not to be supposed that delivery will be completed invariably by one extractive
effort. The extrusion of the head is a complex process which can be better accomplished
in three moves than in one. The Tractor should, therefore, be detached when necessary,
and reapplied' in the desired position. If it becomes detached during traction, no alarm
need be felt, as no injury has or can be done by its separation, and its reapplication only
requiring a few seconds of time.

Flexion and rotation may be made at any time with the Atmospheric Tractor, but
direct tractile efforts should not be made during the moment intervening between the
relaxation of the abdominal muscles and the inward rush of air into the uterus. During
this lightning-like interval our efforts should be directed only to hold the head in the
position which it has gained until the column of air has rushed past it and broken up the
uterine vacuum. At all other times, whether between pains or during their continuance,
direct traction may be exerted with great and immediate relief.

P. McCAHEY, M. D.

UPrlce, $3.00-

Sent free by mail or express on receipt of $3.00. Address the ATMOS-
PHERIC TRACTOR CO.,

219 NORTH 22d STREET, PHILADELPHIA.

P. O. Box 1202.

XXII

MEDICAL AND SURGICAL REPORTER.

PHILADELPHIA POLYCLINIC AND COLLEGE FOR GRADUATES IN MEDICINE.

THE POLYCLINIC HOSPITAL,
Northwest corner Broad and Lombard Sts.
REGULAR SESSIONS RECOMMENCE SEPT. 15th.

Pupils may begin at any time. Tickets good for Six Weeks' Daily Clinics
from date of issue or One Clinic Weekly, for three months.

PRACTICAL, INDIVIDUAL INSTRUCTION, TO PHYSI-
CIANS ONLY, IN ALL BRANCHES OF MEDICINE

AND SURGERY.

For Announcement, Address,

SOLOMON SOLIS-COHEN, M.D.

Secretary.

NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL

SESSIONS 1890-91.

The Autumn and Winter Sessions of the Post-Graduate Medical School opened on September 15. The Hospital is fully
utilized for clinical purposes. There are ninety beds, including thirty for babies in the adjacent building. No Post-Graduate
Medical School in this country can offer such opportunities for seeing important surgical and gynaecological operations under
its own roof as does this institution. Besides, regular clinics, medical and surgical, are held by professors and instructors ia
those general and special hospitals with which they are connected, which comprises nearly all the great hospitals of the city.
The dispensary of the school and other large dispensaries furnish ample means of instruction in every class of walking cases.

Instruction is given in every branch of medicine and surgery. The laboratory is large and well equipped. Surgical
anatomy and operative surgery are thoroughly taught. The instruction is personal, the practitioner being brought in direct
contact with the patient. No other courses in any department will be required if those to be had in the Post-Graduate School
are taken. The faculty were the first in the United States to organize private courses for practitioners of medicine, and they
pledge themselves to leave nothing undone to make graduates in medicine profit by the unrivalled clinical advantages of the
City of New York.

For catalogue and schedule, address

CLARENCE C. RICE, M. D., Secretary,

D. B. St. JOHN ROOSA, M. D., LL.D., President.
F. E. FARRELL, Superintendent.

226 East 20th St., New York City.

COLLEGE OP MEDICINE. SYRACUSE UNIVERSITY.

FACULTY.

GAYLORD P. CLARK, M. D., Anatomy.
WILLIAM H. DUNLAP, M. D., Dermatology. I
JOHN L. HEFFRON, M. D., Materia Medic* a»d TIms*-

JOHN VAN DUYN, M. D., Surgery.

HENRY D. DIDAMA. M. D., Practice and Clinical Medicine.
WILLIAM T. PLANT, M. D., Diseases of Children.
ALFRED MERCER, M. D., State Medicine.
WILLIAM MANL1US SMITH, M. D., Chemistry.
DAVID M. TOTMAN, M. D., Clinical Surgery,
NATHAN JACOBSON, M. D., Clinical Surgery and Laryn-
gology.

peutics.

HENRY B. ALLEN. M. D., Obstetrics.
A. CLIFFORD MERCER, M. D., Pathology.
HENRY L. ELSNER, M. D., Clinical Medicine.
FRANK W. MARLOW, M. D., Ophthalmology.

Three Years' Graded Course. Year begins October 7th, 1890, ends in June, 1891.

' 3. Medica.

Pathology, Practice, Surgery, Clinical Medietas and

FIRST YEAR: Anatomy, Physiology, Chemistry, Histology, Materia Medica.
SECOND YEAR: Anatomy, Physiology, Chemistry, Therapeutics, I
Surgery.

THIRD YEAR: Therapeutics, Practice, Surgery, Children, Clinics, Obstetrics, Gynaecology, Forensic Medicine, Ophthal-
mology, Hygiene.

An experience of seventeen years has demonstrated that a three years' graded course is superior in every respect te aa
ungraded, unnatural, and cramming course of two winters.

Tuition, 880.00 for each Year. Perpetual Ticket, 8300.00. Diploma, 835.00.
For circulars with full information, address

W. H. DUNLAP, M. D., Registrar, SYRACUSE, N. Y.

UNIVERSITY OF PENNSYLVANIA.— Medical Department

The 125TH Annual Winter Session will begin Wednesday, October ist, 1890, at 12 M., and will continue seven months.
The Preliminary Session begins September 22d, 1890, the Spring Term early in May, 1891.

The curriculum is graded and three annual winter sessions are required. Practical instruction, including laboratory work
in Chemistry, Histology, Osteology and Pathology, with Bedside Instruction in Medicine, Surgery and Gynecology are a part
of the regular course and without additional expense.

FACULTY.

JOSEPH LEIDY, M.D., LL.D., Professor of Anatomy.
D. HAYES AGNEW, M.D., LL.D., Honorary Professor of Clin-
ical Surgery.

WILLIAM PEPPER, M.D., LL.D., Professor of Theory and
Practice of Medicine, and of Clinical Medicine.

WILLIAM GOODELL, M.D., Professor of Gynecology.

JAMES TYSON, M.D., Professor of Clinical Medicine.

HORATIO C. WOOD, M.D., LL.D., Professor of Materia Medica,
Pharmacy and General Therapeutics.

THEODORE G. WORMLEY, MJ>., LL.D., Professor of Chem-
* istry and Toxicology.

JOHN ASHHURST, Jr., M.D., Professor of Surgery and of
Clinical Surgery.

EDWARD T. REICHERT, M.D. Professor of Physiology.

WILLIAM F. NORRIS, M.D., Honorary ProLof Ophthalmology
BARTON COOKE HIRST, M.D., Professor of Obstetrics.
J. WILLIAM WHITE, M.D., Professor of Clinical Surgery.
JOHN GUITERAS. M.D., Professor of General Pathology and

Morbid Anatomy.
GEORGE A. PIERSOL, M.D., Professor of Histology and Em

bryology.

SAMUEL G. DIXON, M.D., Professor of Hygiene.

For Catalogue and announcement containing particulars.

apply to

DR. JAMES .TYSON, Dean, ' i
36th and Woodland Avenue, Philadelphia.

MEDICAL AND SURGICAL REPORTER.

XXIII

XXIV

MEDICAL AND SURGICAL REPORTER.

GOLD MEDAL, PARIS, 1878.

W. Baker & Oo.-s

Breakfast
Cocoa

from which the excess of
oil has been removed, is

Absolutely Pure
and it is Soluble.

No Chemicals

are used jn its preparation. It has
more than three times the strength of
Cocoa mixed with Starch, Arrowroot
or Sugar, and is therefore far more
economical, costing less than one cent
a cup. It is delicious, nourishing,
strengthening, easily digested,
and admirably adapted for invalids
as well as for persons in health.

Sold by Grocers everywhere.

W. BAKER & CO., Dorchester, Mass.

WESTERN PENNSYLVANIA MEDICAL COLLEGE

CITT ©3? PITTSBTO&SI.
SESSIONS OF 1890—91.

The Regular Session begins on the last Tuesday of Sep-
tember, and continues six months. During this session, in
addition to four Didactic Lectures, two or three hours are daily
allotted to Clinical Instruction. Attendance upon two regular
courses of lectures is requisite for graduation. A three years'
graded course is also provided. The Spring Session embraces
recitations, clinical lectures and exercises, and didactic lectures
en special subjects ; this session begins the second Tuesday in
April, and continues ten weeks.

The laboratories are open during the collegiate year for
Instruction in chemistry, microscopy, practical demonstrations
in medical and surgical pathology, and lessons in normal his-
tology. Special importance attaches to "the superior clinical
advantages possessed by this College." For particulars,see annual
announcement and catalogue, for which, address the Secretary
atf Faculty, Prof. T. M. T. McKBNNAN.

Business correspondence should be addressed to

Paor. W. J. ASD ALE, 2107 Penn Avenue, Pittsburgh.

Walnut Lodge H ospital,

HARTFORD, CONN.
Organized in 1880 for the special medical treatment of

ALCOHOL AND OPIUM INEBRIATES.

Elegantly situated ia the suburbs of the city, with every ap-
pointment and appliance for the treatment of this class of
cases, including Turkish, Russian, Roman, Saline and Medi-
cated Baths. Each case comes under the direct personal care
of the physician. Experience shows that a large per cent, of
these cases are curable, and all are more or less benefited from
the application of exact hygienic and scientific measures.
This institution is founded on the well-recognized fact that
Inebriety is a disease, and curable, and all these cases re-
quire rest, change of thought and living, in the best sur-
roundings, together with every means known to science and
experience to bring about this result. Applications and all in-
quiries should be addressed

T. D. CROTHERS, M.D.,
Sup't Walnut Lodge, Hartford, Conn.

SYAPNIA

PURIFIED OPIUM

St. Vincent lone Maternity Hospital,

70th Street and Woodland Avenue,

(PASCHALL STATION) PHILADELPHIA.

iWTFOR PHYSICIANS USE ONLY.'

Contains the Anodyne and Soporific
Alkaloids, Codeia, Narceia and morphia.
Excludes the Poisonous and Convulsive
Alkaloids, Thebaine, Narcotine
and Papaverine.

Svapnia has been in steadily increas-
ing use for over twenty years, and
whenever used has given great satis-
faction.

To Physicians of repute, not already
acquainted with its merits, samples
will be mailed on application.

Svapnia is made to conform to a uni-
form standard of Opium of Ten per
cent. Morphia strength.

JOHN FARE, Manufacturing Chemist, New Yori.
C.N. CRITTSNTON, Een?l Agent, U5 Fulton St, , N. Y

To whom all orders for samples must be addressed.
SVAPNIA IS FOB SALE BY DRUGGISTS QENEBAUY.

Conducted by the Sisters of Charity.

T NFANTS and Children under two years of age

J received.

Patients for Maternity Department ac-
commodated according to their means.

IN THE WARDS terms range from $5.00
to $8.00 per week.

IN THE PRIVATE ROOMS terms range
from $10.00 to $20.00 per week.

For further information apply to or address

THE SISTER IN CHARGE,
PASCHALVILLE,

PHILADELPHIA, • PA.

MEDICAL AND SURGICAL REPORTER.

XXV

a-EirriTH <sc co:s

Compound Mixture of Guaiac, Stillingia, etc.

For Acute and Chronic Rheumatism, Bout, Lumbago, Neuralgia, ani Kindred Complaints,

TO PHYSICIANS, — Gentlemen : We would respectfully draw your atten-
tion to our COMPOUND MIXTURE OF GUAIAC, ST1LL1NGIA, ETC.

THIS is not a new preparation, but has been in constant use by many prominent practitioners of medicine for several
years, and its beneficial results in the treatment of the diseases indicated, including Syphilitic troubles, have been fully
established.

When ordering this Preparation, in order to avoid delay or misunderstanding, Physicians will please specify
4< GRIFFITH A CO.'S," or Physicians in the city can send their patients direct to our pharmacies, at No. 67 Third
Arenue, cor. 11th St., or 9341 Third Avenue, cor. 12 2d St., New York, where, at any time, further infor-
mation will be cheerfully furnished. Out of town Physicians can order through their druggists or direct from us.

WE have hundreds of testimonials from prominent physicians who have prescribed and personally used
this mixture. It is manufactured for PHYSICIANS' PRESCRIPTIONS only. Always specify
Griffith & Co.'s. If you have an obstinate case of Rheumatism under treatment, inclose One Dollar and
receive, by express, a regular size bottle, or we will send, upon request, a sample bottle providing you will
pay express charges. Wholesale Price-List — 8-ounce size, $10.50 per dozen ; 16-ounce size, $20.00 per dozen.
In lots of one dozen and upward, we prepay express charges to any point east of the Rocky Mountains. (Do
not overlook this offer, for you may be pleased and possibly surprised at the results.)

P. S. — The advertising of this article is confined strictly to Medical Journals, and the general verdict of physicians is
that if this mixture does not act on a case, it is a difficult matter to find something that will.

Very respectfully,

GRIFFITH & CO., (Mists and Pharmacists,

67 Third Ave., cor. 11th St., and 2241 Third Ave., cor. 122d St., NEW YORK.

Carried in stock by the principal Wholesale Druggists in the IT. S.

Pocket Record

AND

Visiting List

FOR 1891.
BETTER THAN EVER.

TWO SIZES. PRICE TO SUBSCRIBERS TO REPORTER :

For 30 Patients a week (with or without dates), .......... . $1.00

For 60 Patients a week (without dates), . . . 1.25

SEND MONEY WITH ORDER

XXVI

MEDICAL AND SURGICAL REPORTER.

** What a boon it would be to the Medical Profession if some reliable
Chemist would bring out an Extract of Malt in combination with a well-
digested or peptonized Beef, giving us the elements of Beef and the
stimulating and nutritious portions of Ale." — J. Milner Fothergill, M.D.

file & Beef

"PEPTONIZED"

(EXTRACT:— Bovis Cum Malto.)

Is the identical combination suggested by the late eminent Fothergill

EACH BOTTLE REPRESENTS 1-4 POUND
OF LEAN BEEF THOROUGHLY PEPTONIZED.

It is the only Mild Stimulant combined with a Perfect Food known.
It is very palatable, aids digestion, is retained by the most delicate stomach,
and the purity of its ingredients is guaranteed.

THE "PEPTONIZED" BEEF

is manufactured by Prof. Preston B. Rose, of Chicago, late of the faculty of the

University of Michigan.

THE ALE USED
IS THE PUREST AND BEST MADE IN AMERICA

Especially brewed for this purpose, and guaranteed to be equal to
the best imported ales, as only the best Canada Malt and the
choicest new hops are used in its manufacture.

IT ISA REAL FOOD; NOT A MERE STIMULANT,

as it contains all the albumen and fibrin of the beef as well as the nutritive
qualities of the malted barley.

It is most useful during the period of Gestation, in allaying all vom-
iting, and invaluable to Nursing Mothers ; also in Typhoid Fever and
Dysentery.

Prof. G. A. Liebig says : "A careful chemical examination of the
Peptonized Ale and Beef shows a much larger per cent, of nitrogenous
blood and muscle-making matter over all other malt extracts, and that
it is also rich in Diastase, giving it the power to digest Starch Foods."

The Ale and Beef Company,

DAYTON, OHIO, U. S. A.

Two full-sized bottles will be sent FREE to any physician who will pay express charges.
Please mention this journal

Wyeth'sBeef J uice

A Liquid Preparation of the Choicest Beef, containing the Nutritious
Albuminous Principles in an unaltered and soluble form.

Physicians have, for a long time, had their attention called to the fact that
beef extracts, made by the Liebig process, are utterly devoid of the valuable and
nutritious albuminous constituents of meat, as these are coagulated and filtered out
in the process of manufacture. In consequence, the most advanced class of medical
practitioners to-day, merely use the commercial extracts of meat as stimulants,
and not for any nutritious properties they may possess. Realizing thisfect, we
have after continued and exhaustive experiments, succeeded in preparing the article
which we offer as Wyeth's Beef Juice, and for which we make the following claims :
FIRST. — That it contains all of the albuminous principles of beef in an active
and soluble form. This may be proven by mixing a small portion of Beef
Juice with an equal part of water in a test-tube or any convenient vessel,
and gradually heating to the boiling point, when the albuminous principles
will be coagulated.

SECOND.— That it contains the Haemoglobin of the meat unaltered, as is evi-
denced by the bright arterial color of the preparation, and by the fact that it
loses this color upon boiling, as the Haemoglobin is precipitated with the
albumen.

THIRD —That it will be found upon trial to possess the nutritive properties of
the choicest beef to a higher degree than any extract of meat yet offered to
the profession.

Physicians will find Wyeth's Beef Juice of great value as a strengthening
diet in cases of convalescence, consumption, nervous prostration, and similar
diseases ; also, in typhoid fever, debility, etc. Beef Tea prepared from it, contains
more nourishment than any other liquid preparation of meat, and, when properly
seasoned, is more grateful and appetizing to the patient. Professional men who are
suffering from over-work, mental anxiety, etc., will find that one-half teaspoonml
in about half a glass of iced water, taken at intervals during the day, and upon
retiring, will relieve fatigue,— both of mind and body.

Directions— In cases of debility, nervous prostration, convalescence, etc.,
one-half to one teaspoonful in a half tumblerful of iced or luke-warm water.

CAUTION —As the valuable albuminous elements are rendered insoluble by extreme
heat, this preparation should only be mixed with iced or LUKE-WARM water, and never
with water at the boiling point.

MANUFACTURED BY

JOHN WYETH & BROTHER

PHILADELPHIA, PA.

Therapeutic Points.

Use McArthur's Syrup (Syrup Hypophos. Comp., C. P., McArthur) for
Consumption, as it rapidly repairs the waste and restores vigor to the system.

For Tuberculosis in all forms, as it invigorates the tissue cells and enables
them to overcome and expel the disease germs.

For Scrofula, as it builds up the tissue walls and thus breaks up the various
inflammatory and suppurative processes incident to this diathesis.

For Inflammatory Diseases of the Throat, Bronchial Tubes and Lungs, as its
tonic and healing properties are nowhere better manifested than in this class of

diseases.

For Rachitis, and all osseous degeneration, as it rapidly repairs bone tissue.

For Teething of Infants, as it furnishes food to the growing teeth. For the
same reason you should give it to the nursing mothers and those whose teeth and
bones are suffering during pregnancy.

For Chronic Diarrhea, Leucorrhea, Suppurating Discharges and Sores.

For Chronic Alcoholism, the Morphine Habit, Brain Exhaustion, Loss of
Memory, Neurasthenia, Spermatorrhea, Impotence, and all derangements of the
nervous system. Here, by building up and restoring the nerve tissue it effects a
permanent cure, raising the patient from despondency to renewed hope and
confidence, from weakness to strength and vigor.

For Uterine Fibroids and all forms of perverted nutrition, where it restores
the normal processes of nutrition, and effects a recovery at once gratifying to the
patient and satisfactory to the physician.

To obtain the best results, the Syrup should be given for a long time — weeks,
months and even years — until the disease is entirely eradicated and the patient no
more susceptible to its return than if it " never had occured."

As it is made only for Physicians' prescriptions there are no labels, &c, on the
bottle.

We will send our valuable treatise on "The Curability and Treatment of
Consumption," free to any physician.

McARTHUR HYPO PHOSPHITE CO.,

BOSTON, MASS.

XII

MEDICAL AND SURGICAL REPORTER.

iiflfc JifiiuiSlkjiiSllrjIk jfflk^huJkjJSk jriUfcaflk adtfc jdfik jiilllulliiiuiiSlufc Juf!iiiUillliLj|Iijuil!5ac jifflk Jiifcjfflirjtfk jUIunjiHHncjoffJiic jd!kjfl||

Nourishment f

5

There is no

in Tea or Coffee, but plenty in

COCOA

especially in

VAN HOUTEN'S

THE DRINK QUESTION

is ever coming to the front. What beverage shall we drink to quench thirst? The most popular non-intoxicant is
cocoa, which is rapidly supplanting tea and coffee as a national beverage. There are many excellent cocoas, but in
advance of all other preparations stands Van Houten's which is universally declared to be perfectly pure, free from
fat, easily digested, delicious to the taste, nutritious, and a stimulant without any depressing after-effects.

Van Houten's Cocoa was introduced into the household of the late Emperor of Germany upon high recom-
mendation. The senior physician of the London Court Hospital has used this brand of Cocoa for many years. It
is strongly recommended to Students and all whose duties involve much wear and tear, whether mental or physical.
For these reasons it has earned the highest encomiums of the leading analysts of the day.

What shall we drink to raise the spirits high?
Van Houten's Cocoa, is the universal cry !
The purest and most delicious ;
The best and most nutritious.

M VAN HOUTEN'S COCOA BEST &, GOES FARTHEST." |

4®=* It only needs a single trial to convince any one of the superiority of Van Houten's Cocoa. Please insist Q
<0k upon your grocer or storekeeper ordering it for you, and take no substitute. It is put up in one-quarter, one-half,

2 and one-pound cans. 4®=" If not obtainable, enclose 25 cents in stamps or postal note to either Van Houten & H

Zoon, 106 Reade Street, New York, or 45 Wabash Avenue, Chicago, and a can will be sent by mail, if you mention M

0 this publication. Prepared only by Van Houten & Zoon, Weesp-Holland. J*

\ VAN HOUTEN'S COCOA "ONCE TRIED, ALWAYS USED." f

fll«lEF '^"IiF^IF^'lF anpt-^muL jiipiiL japic Tupripriiiprjnpnr ^cy^px0rss^. ^r^rs^cv^. upi juyuL jigp. jqypr ^jpmipic 102 Tqjoqjg

Mellin's Food

FOR INFANTS AND INVALIDS.

A SOLUBLE DRY EXTRACT, prepared from Malted Barley
and Wheat, consisting of Dextrin, Maltose, Albuminates, arfd Salts.

The SUGAR in MELLIN'S FOOD is MALTOSE. MALTOSE is
the PROPER SUGAR for use in connection with cow's milk.

The sugar formed by the action of the Ptyalin of the Saliva and the Amylopsin of
the Pancreas upon starch is MALTOSE. In the digestive tract MALTOSE is absorbed
UNCHANGED. r _ ■ . . w _,

— Landois ana Sterling.

MALTOSE is a saccharose, not a glucose, and is a form of sugar which does not ferment.

— Materia Medica and Therapeutics, Dr. Mitchell Bruce.

" I have never seen any signs of fermentation which I could attribute to the influence
of MALTOSE."

— Eustace Smith, M.D., F.R.C.S.

MELLIN'S FOOD, prepared according to the directions, is
a true LIEBIG'S FOOD and the BEST SUBSTITUTE for Mother's
Milk yet produced.

IT REQUIRES NO COOKING.

THE DOLIBER-GOODALE CO.,

BOSTON, MASS.

MEDICAL AND SURGICAL REPORTER.

THE BEST ANTISEPTIC

FOR BOTH INTERNAL AND EXTERNAL USE.

ANTISEPTIC, M SL^fr yi g gE^S »^ I N0N-T0XIO.

PROPHYLACTIO, If H ^SQB^ Bn HriF H BtoH 01 NON-IRRITANT.

DEODORANT. g| | BLi g Q |§ I NON-ESCHAROTIO.

FORMULA — Listerine is the essential antiseptic constituent of Thyme, Eucalyptus, Baptisia, Gaultheria and
Mentha Arvensis, in combination. Each fluid drachm also contains two grains of refined and purified
Benzo-boracic Acid.

DOSE — Internally: One teaspoonful three or more times a day (as indicated) either full strength, or diluted,
as necessary for varied conditions.
LISTERINE is a well -proven antiseptic agent— an antizymotic— especially adapted to
internal use, and to make and maintain surgical cleanliness— asepsis— in the treatment of
all parts of the human body, whether by spray, irrigation, atomization, or simple local
application, and therefore characterized by its particular adaptability to the field of

PREVENTIVE MEDICINE -ECDIVIDIJAE PROPHYLAXIS.
♦

I>i»o^.«o» of tlie TJrio Aoidl Diatliesis.

LAMBERT'S

LITHIATED HYDRANGEA

KIDNEY ALTERATIVE— A SMTI- LITH I C.

FORMULA — Each fluid drachm of "Lithiated Hydrangea" represents thirty grains of fresh Hydrangea and
three grains of chemically pure Benzo-Salicylate of Lithia. Prepared by our improved process of
osmosis, it is invariably of definite and uniform therapeutic strength, and hence can be depended
upon in clinical practice.

DOSE — One or two teaspoonfuls four times a day (preferably between meals) .

Urinary Calculus, Gout, Rheumatism, Bright's Disease, Diabetes, Cystitis, Hema-
turia Albuminuria, and ^Vesical irritations generally.

We have much valuable \ GENERAL ANTISEPTIC Treatment, l To forward to Physicians

literature upon | LlTHEMIA, DIABETES, CYSTITIS, Etc. » upon request:

LAMBERT PHARMACAL CO.. ST3 LOUIS, MO.

FRENCH, CAVE &, CO.

(Successors to French, Richards & Co.),
PHILADELPHIA,

WILL continue the manufacture of the Fine Pharmaceutical Products
made by the late firm at the present laboratory, 16 and 18 North
Tenth Street, Philadelphia.

Physicians who have prescribed these preparations can rest assured that
the high standard of quality which has made for these products a reputation
for consistent strength and purity will be strictly maintained in the future, and
the physician can always prescribe our preparations and depend on uniform
results.

To those physicians who have not yet prescribed our products, we request
them to send to us their address and we will forward by EXPRESS, PRE-
PAID, a line of samples free for trial.

Physicians' Price-Last and Formulary sent by mail on application.

FRENCH, CAVE & CO.,

Factors of Kiism Ph a rm AOEUTicAii Products,
Nos. 16 and 18 NORTH TENTH STREET, PHILADELPHIA.

X

MEDICAL AND SURGICAL REPORTER.

INHALATION APPARATUS

FOR

THE THERAPEUTIG ADMINISTRATION OF OXYGEN.

In the treatment of lung troubles by Oxygen its exhibition by inhalation is preferred. The apparatus herewith t&OWB !•
ft modification of the Nitrous Oxide apparatus which we have supplied for many years. It is made in the best manner
throughout, and is the outcome of years of experience in the manufacture of gas apparatus. It will be found to meet all
the requirements.

We supply the gas in two sizes of cylinders, containing respectively forty and one hundred gallons, either pure Oxygen*
or a mixture of Oxygen and Nitrous Oxide in definite proportions of 20 per cent., and forty per cent, of Nitrous Oxide.

Whether pure or mixed the gas is sold at the uniform price of 5 cents a gallon. The cost of the cylinders will be reftmdea
#B their return empty with the valves in good condition. Full description of Inhalation and Enema apparatuses with directioof
for use accompany each apparatus, or will be supplied on application.

PRICKS.

Inhalation Apparatus 56.00

Cylinder, 40 gallons' capacity 6.00

40 gallons Gas, either pure Oxygen or mixed Oxygen and Nitrous Oxide • . . . 2.00

Complete Apparatus, Cylinder, and 40 gallons Gas •••••••••••••• $13.00

Inhalation Apparatus ••••••••• $5.00

Cylinder, 100 gallons' capacity 15.00

100 gallons Gas, either pure or mixed ...«•••••••••••••••• 5.00

Complete Apparatus, Cylinder, and 100 gallons Gas • • $25.00

THE S. 3. WHITE DENTAL MFG.

PHILADELPHIA, NEW YORK, BOSTON, CHICAGO, BROOKLYN.

CO,

MEDICAL AND SURGICAL REPORTER.

IX

Books for our Subscribers.

WHAT IS THOUGHT OF THEM.

HEATH'S DICTIONARY OK PRACTICAL SURGERY.

C. B. Porter, M. D.\ Boston, Mass., says ; "A most excellent book for the library of the surgeon, and especially for the
country practitioner; as a book of reference it is so concise and at the same time so complete."

N. Senn, M. D., College of Physicians and Surgeons, Milwaukee , says ; " As a means of ready reference for the student
and busy practitioner this book stands unexcelled."

Prof. E. h. Gregory, St. Louis Medical College, St. Louis, says : " I have examined the book, and find it a most valuable
addition to my library. 1 am sure it will meet the favor of the surgical profession."

EEIDY'S HUMAN ANATOMY.

The Lancet- Clinic, Cincinnati, O., says : " Professor Leidy again presents to medical practitioners and students a treatise
on human anatomy that at once commands the attention and admiration of all who are at all familiar with the subject. Most
of the plates are original, and in common with the text are very beautiful to behold. The work is a complete illustration of
the method of teaching anatomy adopted by a leading scientist, and one of America's best known professors of anatomy. This
is one of the books that should be in the library of every practitioner of medicine and surgery."

The Medical Advance , Ann Arbor, Mich., says : " The student can master and retain a practical knowledge of anatomy
in a shorter time and with less hard work from this text-book than from any other work extant, and it has been our privilege to
teach anatomy for several years."

BYFORD'S DISEASES OK WOMEN.

The Boston Medical and Surgical Journal says : " It is a satisfaction to observe the discussion of certain topics which
are often neglected by writers, notably of the sympathetic symptoms of organs apparently disconnected with the uterus, for
which he will receive the thanks of the younger members of the profession. Another topic very widely treated is that of Con-
stipation in its relation to uterine diseases. All the other topics which should have a place in a work of this kind have been
fully and properly treated."

The Cincinnati Lancet- Clinic says : " The book is eminently practical and instructive. Its suggestions for treatment are
well up with the times, mostly judicious, conservative, and valuable, and the whole amply repays for thorough perusal."

The St. Louis Courier of Medicine says: " The work of a representative Western practitioner and professor, and is a
thoroughly practical work."

The Virginia Medical Monthly says : " We take pleasure in recommending it to every student and physician desirous of
obtaining a standard work on Gynaecology."

The Chicago Medical Journal and Examiner says: "The chapter on puberty should be carefully studied by every
physician, teacher, and mother in the land. . . . Its style is clear, but concise, and always practical, and shows the author to
be, as we all know, an experienced teacher. The work as a whole is most valuable, both to the student and practitioner."

Gaillard's Medical Journal says : " It is replete with good judgment, broad and practical views. . . . The illustrations
are excellent."

FOWEER'S DICTIONARY OK PRACTICAE MEDICINE.

The Medical News says : " For those who do not wish to purchase the much larger book of Quain, or who wish compara-
tively recent information concerning medical subjects in a somewhat narrow space, the book will certainly prove of value, and
we heartily recommend it as one which will give a full return for the money invested in the purchase."

The London Lancet says : " What the writers know they tell simply and plainly, and generally manage to put it in a short
compass, and, what is more, the treatment that is recommended is clearly and sufficiently set forth. . . . We can heartily
congratulate the editor and his colleagues on having admirably fulfilled their purpose, viz., to produce a first-rate dictionary of
medicine, at once scientific and practical, which well deserve the success we have no doubt it will meet with."

JACOBSON'S OPERATIONS OK SURGERY.

The Medical and Surgical Reporter says: " This handsome book is one of the most admirable works on operative surgery
which we have seen for a long time. The author has brought to its preparation a large observation and experience, and a very
thorough acquaintance with the methods of other surgeons. _ His book is comprehensive and his directions are clear and reli-
able. It is gratifying to an American reader to find that full justice is done to the work of American surgeons by Mr. Jacobson,
and that his book bears no marks of the distance which stretches between his land and ours. This is as it should be, and is no
less an element in the excellence of the technical worth of his book than it is an evidence of the cosmopolitan character of good
scientific work."

CA25EAUX & TARNIER'S MIDWIFERY, *Witn Appendix toy MUNDE.

The Memphis Medical Monthly says : "Cazeaux's Obstetrics was authority during our student life, and has been gener-
ally recognized as authority from the publication of the first edition to the present. We cannot do more than to fully endorse
the following from the pen of T. Gallard Thomas, M. D. ; 'I have examined the last edition of Cazeaux & Tarnier's Theory
and Practice of Obstetrics, and pronounce it practical, and just what is needed by every practitioner. I highly recommend the
work. This work should be prominent in every library.' "

Dr. Wm. L. Lush says : "Cazeaux's Midwifery will always remain an inexhaustible mine of information, and I rejoice to
see it once more accessible to the profession in a new and attractive dress."

Dr. Wm. Goodell says : "I deem Cazeaux & Tarnier's Obstetrics the best yet published."

The Denver Medical Times says ; " It is needless to say anything in praise of this work. Cazeaux's Obstetrics is a clas-
sical work, and Tarnier is one of the best known French writers on Obstetrics. The whole has been brought up to date by the
appendix of Prof. Munde, and altogether it makes a very complete and practical treatise on the subject, unsurpassed if not
unequalled by any work with which we arc acquainted. Especially valuable are the signs of delivery in the dead body and of
live and still-births. The chapter on antisepsis and on puerperal septicemia are also worthy of mention."

THOMAS'S MEDICAE DICTIONARY.

Prof. A. F. Patton, College of Physicians and Surgeons, Boston, Mass., says : " It is just the book for a medical or any
other student, and it should be in the office of every physician. This dictionary supplies a place that has never been filled. I
have looked it through and find all the new words that I have sought."

The St. Joseph Medical Herald says : " No better testimonial to the value of the work can be given than the following
from Dr. J. Gibbon Hunt, the distinguished microscopist : ' To me the work is invaluable. I am astonished at its fullness of
all recent words which the modern advance of medical science has introduced. Of course, I cannot conceive the learning and
great labor which could edit such a complete, thorough, and admirable volume.' We can add nothing further save that the
book should be in the hands of every physician and every student in the land."

VIII

MEDICAL AND SURGICAL REPORTER.

BOOKS FOR OUR SUBSCRIBERS

BY SPECIAL ARRANGEMENT with the publishers we are able
at this time to offer the following- first-class and very valuable
books (last editions) at a very low price, when taken in connection with
paid-up subscriptions. Subscribers will see that we have put in this
list thoroughly good books. See Adv. Page ix.

For

$10.00

REPORTER for one year,

$5.00

HEATH'S DICTIONARY OF PRAC-
TICAL SURGERY. Cloth,. . . $7.50

For

$ 9.00

REPORTER for one year,

$5.00

LEIDY'S HUMAN ANATOMY. By

Joseph Leidy, M. D. Cloth, . . $6.00

For

$8.50

REPORTER for one year, . $5.00

and any one of the following books —

1. — BYFORD'S DISEASES OF WO-
MEN. Cloth, . . $5.00

2 FOWLER'S DICTIONARY OF PRACTICAL MEDICINE, $5.00

3 — JACOBSON'S OPERATIONS OF SURGERY, . $5.00

4. — CAZEAUX & TARNIER'S MIDWIFERY. With Appendix by Munde' . $5.00

5. — THOMAS'S MEDICAL DICTIONARY, $5.00

These works are all in cloth binding, but can be supplied in leather binding for $1.00 additional.

For

$6.00

we will send the REPORTER for one year,
and any two of the following bpoks :

1.— THE NURSING AND CARE OF
THE NERVOUS ANDTHE INSANE.

By Chas. K. Mills, M.D.,

2.— MATERNITY ; INFANCY; CHILDHOOD. By John M. Keating, M. D., .

3 — OUTLINES FOR THE MANAGEMENT OF DIET; or, The Regulation of Food
to the Requirements of Health and the Treatment of Disease. By E. T. Bruen, M.D., .

$5.00

$1.00
$1.00

$1.00

.—FEVER NURSING.

Wilson, A. M., M. D.,

Designed for the use of professional and other Nurses. By J. C.

$1.00

5.— DISEASES AND INJURIES OF THE EAR : Their Prevention and Cure. By Chas.

H. Burnett, A.M., M.D., $1.00

Or, Fop $6.00, any one of the above Nursing Books and THOMSON'S (Sir Henry)
SURGERY OF THE URINARY ORGANS. Some important points connected with

the Surgery of the Urinary Organs. Illustrated. Cloth, $1.25

MEDICAL AND SURGICAL REPORTER.

VII

ESTABLISHED 1853.

DBS. STRONG'S SANITARIUM,

SARATOGA SPRINGS, NEW TORE,

Receives persons recommended to it by their home physicians for Treatment, Change, Rest or Recreation, and places them
under well-regulated hygienic conditions so helpful in the treatment of chronic invalids or the overtaxed.

For Treatment : In addition to the ordinary remedial agents, it employs Turkish, Russian, Roman, Sulphur, Electro-
Thermal the French Douche (Charcot's), and all Hydropathic Baths; Vacuum Treatment, Swedish Movements Massage,
Pneumatic Cabinet, Inhalations of Medicated, Compressed, and Rarefied Air, Electricity in various forms, Thermo-Cautery,
Calisthenics, and Saratoga Waters, under the direction of a staff of educated physicians.

For Change: This Institution is located in a phenomenally dry, tonic, and quiet atmosphere, in the lower arc of the
Adirondack Zone, and within the "Snow Belt."

For Rest: The Institution offers a well-regulated, quiet home, heated by steam and thoroughly ventilated, with cheer-
in°- influences and avoiding the depressing atmosphere of invalidism.

" For Recreation: To prevent introspection, are household sports at all seasons of the year, and in Winter, toboggan-
ing, elegant sleighing, etc. ; in Summer, croquet, lawn-tennis, etc.

Private professional references furnished upon application. Physicians are invited to inspect the Institution at their con-
venience. A liberal discount to physicians and their families.

For further information, address, DPS. S. S. & S. E. STRONG.

JOSEPH ZENTMAYER,

OPTICIAN,

209 South 11th Street, PHILADELPHIA.

HISTOLOGICAL MICROSCOPES, $65.00.

REPAIRING- OF ALL SCIENTIFIC INSTRUMENTS.

STUDENTS' MICROSCOPES $38.00 TO $46.00 COMPLETE.

ILLUSTRATED CATALOGUE ON APPLICATION.

Walnut Lodge H ospital,

HAKTF ORD , CONN.

Organized in 1880 for the special medical treatment of

ALCOHOL AND OPIUM INEBRIATES.

Elegantly situated in the suburbs of the city, with every ap-
pointment and appliance for the treatment of this class of
cases, including Turkish, Russian, Roman, Saline and Medi-
cated Baths. Each case comes under the direct personal care
of the physician. Experience shows that a large per cent, of
these cases are curable, and all are more or less benefited from
the application of exact hygienic and scientific measures, j
This institution is founded on the well-recognized fact that j
Inebriety is a disease, and curable, and all these cases re- |
quire rest, change of thought and living, in the best sur- j
roundings, together with every means known to science and j
experience to bring about this result. Applications and all in- |
quiries should be addressed

T. D. CROTHERS, M.D.,
Sup't Walnut Lodge, Hartford, Conn.

EXCELLENT OPENING

YOUNG PHYSICIAN.

Office of recently deceased physician to let, with practice,

1 8 16 Christian St., Philadelphia.

St. Vincent Boise Maternity Hospital,

70th Street and Woodland Avenue,

(PASCHALL STATION) PHILADELPHIA.

Unmarried Physician,

Age 24, graduate of Jefferson Medical College, '89,
and now taking post-graduate course, desires position
as assistant.

Address H. W.,

Care Medical and Surgical Reporter.

Conducted by the Sisters of Charity.

INFANTS and Children under two years of age
received.
Patients for Maternity Department ac-
commodated according to their means.

IN THE WARDS terms range from $5.00
to $8.00 per week.

IN THE PRIVATE ROOMS terms range
from $10.00 to $20.00 per week.

For further information apply to or address

THE SISTEK IN CHARGE,
PASCH ALVI LLE,

PHILADELPHIA, - I\A.

VI

MEDICAL AND SURGICAL REPORTER.

RABUTEAU'S DRAGEES of IRON

laureate of the Institute ofFrance— Prize in Therapeutics.

The studies made by the Physicians of the Hospitals have
demonstrated that the Genuine Uragees of Iron of
Rabuteau are superior to all other preparations of Iron
in cases of Chlorosis, Ansemia, Leucorrhcea, Debility, Exhaustion,
Convalescence, Weakness of Children, and the maladies caused
by the Impoverishment and Alteration of the blood after
periods of fatigue, watching, and excesses of any kind.

TAKE 4 to 6 DRAGEES DAILY.

Rabuteau's .Elixir of Iron is recommended to those
persons who may be unable to swallow the Dragees. Dose
— A small wineglassful uoith meals,

Rabuteau's Syrup of Iron is specially designed for
children. Chalybeate medication, by means of Rabuteau's
Iron, is the most economical and the most rational known
to therapeutics. #

No constipation, no diarrhoea, complete assimilation.
Take only the GENUINE IRON OF RABUTEAU of

CXjIS^T cSc CO,, IFstris.

SOLUTION OK

THE SALICYLATE of SODA
OF DOCTOR CLIN.

Laureate of the Paris Faculty of Medicine
(MONTYON PRIZE).

Dr. Clin' s Solution, always identical in its composition,
and of an agreeable taste, permits the easy administration
of pure Salicylate of Soda, and the variation of the dose in
accordance with the indications presented.

"The Salicylate of Soda used by Clin is of perfect purity,
"and is prepared with the greatest care; it is a medicament
"in which we may have every confidence."

—Paris Society of Medicine, Meeting of Feb. 8th, 1879.

Clin's Solution, very exactly mixed, contains: 2
grammes of Salicylate of Soda per tablespoonful, 50 centi-
grammes of Salicylate of Soda per teaspoonful.

Faris— <Sc CO.-Paris

AND BY ALL DRUGGISTS.

CAPSULES

MATHEY-CAYLUS

WITH THIN ENVELOPE OF GLUTEN.
CONTAINING COPAIBA AND ESSENCE OF SANTAL;
COPAIBA, CUBEBS, AND THE ESSENCE OF SANTAL;
COPAIBA. IRON, AND THE ESSENCE OF SANTAL.

"The Mathey-Caylus Capsules, of the Essence of
" Santal, associated with the Balsams, possess an incontesta-
ble efficaciousness, and are employed with the greatest
"success for the rapid cure of old or recent Discharges,
"Gonorrhoea, Blenorrhcea, Leucorrhcea, Cystitis of the Neck,
" Urethritis, Catarrh, and other diseases of the bladder, together
"with all affections of the Urinary Passages."

" Thanks to their thin envelope of Gluten, which is essen-
" tially assimilable, the Mathey-Caylus Capsules are digested
" by the mo*st delicate persons, and never weary the stomach."

— Gazette des Hopitaux de Paris.

CTJTUT <Sc CO., IFaris,

AND OF ALL DRUGGISTS.

N E U R ALG I AS

PILLS OF DR. MOUSSETTE.

The Moussette Pills of aconitine and quinium, calm or
cure Gastralgia, Hemicrania, Headache, Sciatica, anrt the
most obstinate Neuralgias.

"The sedative action exerted by the Moussette Pills
"upon the apparatus of the sanguineous circulation by the
"intermediation of the vaso-motor nerves, indicates their
"use in neuralgias of the trigemini nerves, (fifth pair), con-
"gestivc neuralgias, and painful and inflammatory Eheumatismal
" affections."

" Aconitine produces marvelous effects in the treatment
"of facial neuralgias when they are not symptomatic of
"intracranial tumor."— Society of Biology of Paris, Meeting
"of the 28th February, 1880.

Dose — Take 3 to 6 pills during the twenty-four hours.
ACCEPT ONLY THE GENUINE MOUSSETTE PILLS OF
CHiX^T <Sc CO., — Paris.

GRAND NATIONAL PRIZE OF 16,600 FRANCS,

Ouina-Laroche

This meritorious Elixir,
QUTNA-LAROCHE, is
prepared from the three
Cinchonas ; it is an agreea-
ble and doubtless highly
efficacious remedy.

— The Lancet.

VINOUS ELIXIR,

A STIMULATING
RESTORATIVE

AND

ANTI-FEBRILE TONIC

QUINA - LAKO CHE

under the form of a vinous
Elixir contains the totality
of the numerous principles,
of the three Cinchona'
barks. It is a preparation
which renders great serv-
ices to Therapeutics. — Ex-
tract of the Gazette des
Hopitaux, Paris.

FAR SUPERIOR TO ALL ORDINARY CINCHONA WINES.

IiARO CHE'S QUINA, tried by the Academy of Medicine of Paris, is a specially prepared Compound Extract of
Quinquina, a careful analysis, confirmed by experience, has shown that most of the wines and syrups hitherto used have not
contained all the properties of this precious bark, of tnese some, although beneficial, are altogether lost, while many preparations
contain but half the properties of the bark in varying proportions.

Me. Laroche, by his peculiar method, has succeeded in extracting all the active principles of the quinquina, combining these
With Catalan Wine forming an Elixir free from the disagreeable bitterness of other similar preparations. Practitioners have
found triple advantages in the use of this Elixir, it is a strong tonic, is easily administered, and perfectly harmless, being free
from the nnpleasant effects of Quinine.

THE FERRUGINOUS QUTNA-IAJROCHE is the invigorating tonic par excellence, having the advantage of being
easily assimilated by the gastric juice ; without, in any way, deranging the action of the digestive organs, proving itself to be a most
efficacious remedy in cases of impoverishment of the 'blood, Anemia, Chlorosis, Intestinal Hemorrhage, Castralgia,
Exhaustion, Etc., Etc.

PARIS. — 22 RUE DROUOT. — PARIS.

E. FOUGERA & CO., New York,

Sole Agents for the United States for the above Preparations.

MEDICAL AND SURGICAL REPORTER.

V

LAPACTIC PILLST s &D.s

(PILUUE LAPACTIC/E.)

Aloin 1-4 gr.

Strychnine 1-60 gr.

Bxt. Belladonna .1-8 gr.

Ipecac 1-16 gr.

An elegant and most efficient combination introduced by us and found in practice

to possess superior advantages over similar formulae for the relief of

HABITUAL CONSTIPATION, ATONIC DYSPEPSIA, BILIARY ENGORGE-
MENT AND MANY GASTRIC. DISORDERS.

J^gf* Since we introduced our Lapactic Pills — some four years ago — a number

of manufacturers have adopted the same formula and have furnished these pills under the
same name. Should Physicians fail to obtain satisfactory results from Lapactic Pills not of
our make (and we have received a large number of such complaints) , we shall be glad to
furnish a sample of our Ivapactic Pills on application. We feel confident that they will fully
substantiate our claims.

Please use the term "Lapactie Pills, S. & D.'s " when prescribing these pills.
Dose : One to two pills when going- to bed.

PAN-PEPTIC TABLETS, s.&d.'s.

Pure Pepsin

Pure Pancreatin

Pure Caffeine

Acid L,acto-Phosphate of Calcium
Celery.

The Pepsin and Pancreatin used in these tablets possess highest digestive power,
and cannot fail to promptly start and accomplish

THE DIGESTION OF FOOD.

Whilst the Caffeine, by its stimulant tonic action on stomach and bowels, assists and
quickens the normal digestion and assimilation of food, the Acid Liacto-Phosphate
of Calcium contributes to the tonic action of the tablets, and aids to build up the
general system, and a small quantity of that refreshing aromatic nerve stimulant, Celery,
imparts a pleasant flavor and acts as an appetizer.

^ SAMPLE SENT TO PHYSICIANS WHO MENTION THIS JOURNAL^m

SHARP & DOHME,

MANUFACTURERS OF

Standard Medicinal Fluid and Solid Extracts; Soluble Hypodermic Tablets; Soluble
Gelatin and Sugar-Coated Pills and Granules; Granular Effervescent Salts;
Compressed Lozenges and Tablets; Fine Chemicals, &c, &c.

ESTABLISHED 1860. 2 BALTIMORE, MD.

1 gr.

IV

MEDICAL AND SURGICAL REPORTER.

CHARLES LENTZ & SONS,

MAKERS OF

Surgical Instruments and Orthopaedic Apparatus

18 NORTH ELEVENTH STREET, PHILADELPHIA.

WE HAVE EVERYTHING \l PHYSICIANS' SUPPLIES, Medica' ISSS«. Mr Cases'

MICROSCOPES

FOR

Urinary Analysis

A SPECIALTY.

$28.00 AND UPWARDS.

Send for catalogue of Micro-
scopes, 100 pages.

Lentz's Aseptic Catheter.

The above is a modification of Jennison's Uterine Douche, for intra-uterine injections.
Any bulb or fountain syringe can be attached.

Price, with Rubber Tubing, Net, $2.00.

Send for descriptive Circular.

Our No. 10 Operating Case,

of which so much
has been said, is
having large sale
yet. It is the most
Price, $18.75, and upward. Send

complete set in the market for any ordinary operation
for circular.

SEND FOR SPECIAL LIST OF NEW INSTRUMENTS.

ANTISEPTIC DRAINAGE TUBES.-Glass.

These Tubes have large holes, one-half inch apart, arranged alternately on opposite sides.
They are carefully finished, especial care being taken to make them smooth.

In addition to the drainage-holes, each tube has at one end two smaller holes for the insertion o* Safety-Pin, through
which it is prevented slipping into the wound.

FURNISHED IN SEVEN SIZES.

No. 1, 81.25 per doz. No. 4, $1.55 per doz.
No. 2, 1.25 " No. 5, 1.70 «

No. 3, 1.40 " No. 6, 1.90 "

No. 7, $2.10 per dozen.

RAW CAT-GUT. I put this up in coils of 10 feet, lour difierent
sizes, Nos. 1, 2, 3, 4 (4 is thickest). Nos. 2 and 3 are the most useful sizes.
No. 1 Coil, 10 Cents; No. 2 Coil, 13 Cents; No. 3 Coil, 14
Cents; No. 4 Coil, 16 Cents. Full directions with each coil for
making it absolutely aseptic.

WILLIAM SNOWDEN,

Manufacturer, Importer and Exporter of Surgical Instruments,

No. 121 SOUTH ELEVENTH STREET, PHILADELPHIA,

DR. MASSEY'S

PRIYATE SANITARIUM

212 South Fifteenth Street

PHILADELPHIA

•fhis institution, in addition tocomplete arrangements for
the treatment of Nervous Diseases by rest, electricity, mass-
age, etc., under comfortable surroundings, is specially equipped
for the treatment of cases of Fibroid Tumors and other intract-
able diseases of the pelvic viscera, by the conservative use of
strong electric currents. For particulars, address

DR. G. BETTON MASSEY,

Physician in Charge.

WESTERN PENNSYLVANIA MEDICAL COLLEGE

SESSIONS OF 1890—91.

The Regular Session begins on the last Tuesday of Sep-
tember, and continues six months. During this session, in
addition to four Didactic Lectures, two or three hours are daily
allotted to Clinical Instruction. Attendance upon two regular
courses of lectures is requisite for graduation. A three years*
graded course is also provided. The Spring Session embraces
recitations, clinical lectures and exercises, and didactic lectures
on special subjects; this session begins the second Tuesday in
April, and continues ten weeks.

The laboratories are open during the collegiate year for
instruction in chemistry, microscopy, practical demonstrations
in medical and surgical pathology, and lessons in normal his-
tology. Special importance attaches to "the superior clinical
advantages possessed by this College." For particulars, see annual
announcement and catalogue, for which, address the Secretary
Of Faculty, Prof. T. M.T. McKENNAN.

Business correspondence should be addressed to

Prop. W. J. ASDALE, 2107 Penn Avenue, Pittsburgh,

MEDICAL AND SURGICAL REPORTER.

Ill

i^^iiiiiiiiiiiiiiiiii^iiiiiiii^

THE GENUINE IMPORTED NATURAL

CARLSBAD SPRUDEL SALT

AND

CARLSBAD MINERAL WATERS

JS_ r o H ighly Recommended for

■Chronic catarrh of the stomach,
■Chronic constipation, chronic

1. Diseases of the Stomach

cardialgia, ulcer of the stomach.

2. Diseases of the Intestines

diarrhoea.

3. Diseases of the Spleen — Chronic hyperemia of the spleen,

tumors of the spleen, arising after inter-
mittent fever, typhus, etc., and the effects
of a residence in marshy districts or hot
climates.

4. Liver Diseases — Hyperemia of the
liver, resulting from agglomeration of the
blood in the veins, if it does not originate
in organic defects; fat liver, jaundice, pro-
duced by catarrh of the passages of the
bile, or by liver complaint in consequence
of violent emotions; gallstones.

5. Diseases of the Kidneys and
Bladder — Gravel, nephritic stones, sand,
stone in the bladder — chronic catarrh of
the kidneys and bladder — albuminuria.

6. Diseases of the Prostate —
Chronic hyperemia of the prostate, result-
ing from interrupted circulation in the
bowels, constipation, hemorrhoids, etc.

7. Chronic Catarrh of the Womb,
jJL produced by menstrual disturbances, hem-
orrhoids, and the different consequences of
interrupted circulation in the bowels.

8. Gout, especially in the early stages.

9. Diabetes Mellitus — By the use of
the Carlsbad Thermal Waters, not only the
clinical phenomena of this disease (the tor-

SaitkpuTupTnVoundtott^ thirst, violent hunger, dryness of

cut. Each bottle comes in a paper cartoon tne skin) disappear in a very short time, but

with the seal of the City of Carlsbad, and . , ' . , rr, { , ' .

signature of " Eisner & Mendelson Co.," it also considerably diminishes the secretion

Mth1gomSdrcartooTk °f every boUle and of su£ar in the urine> and frequently causes

it to disappear altogether.
Diseases of the stomach are best treated with the Carlsbad Water,
whereas the Carlsbad Sprudel Salt (powder form) is to be preferred in dis-
eases of the viscera, such as intestinal canal, spleen, kidneys, inadiposis, etc.
PAMPHLETS MAILED ON APPLICATION.

EISNER & MENDELSON CO.,

SOLE AGENTS,
6 BARCLAY STREET, NEW YORK.

P
i

1

1

1

i
p

I

iHmHiHiiiiiiiiimiiiiiiiiifE!

II

MEDICAL AND SURGICAL REPORTER.

SULFONAL-BAYER.

A CORRECT METHOD OF ADMINISTRATION, ESSENTIAL TO OB-
TAINING ITS HYPNOTIC EFFECT.

Inquiries have been made of us from time to time as to the best method of administering Sulfonal-
Bayer. These inquiries indicate that various methods of administration have been employed, and this,
without doubt, accounts for those cases where the results obtained were not wholly satisfactory. We call
special attention to the following :

" Clinically observed, we recognize in Sulfonal a mild calmative, a slowly but progressively active
hypnotic. It has no other action, and its operation is attended by no complications, near or remote. It is,
therefore, a pure hypnotic"

" The essential conditions of success in the exhibition of Sulfonal depend on first, the time when the
remedy should be administered ; second, the method of administration ; third, the dose."

" // is a fact, perhaps wholly unprecedented in what we observe of other neurotic materials, that
Sulfonal demands from two hours to one hour for its physiological incubation ; often quite two hours elapse
between ingestion and the first accession of sensible medicinal energy. With the untried subject it is wise
to stipulate for two hours." — [Extracts from articles by Prof. H. M. Field, New England Medical
Monthly ; Therapeutic Gazette. ~\

According to the experience of Prof. A. Kast, of Freiburg University, Sulfonal- Bayer should be
administered in a plate of soup, a cup of hot tea, milk or broth, at least two hours before retiring, or with
the last meal early in the evening, between 7 and 8 P. M., at which time the stomach contains considerable
amount of muriatic acid, mineral salts and peptones, and the most favorable conditions for the absorption
are satisfied.

Sulfonal has just been incorporated into the Addendum to the British Pharmacopoeia.

Sulfonal-Bayer, prepared by the Farbenfabriken, formerly Friedr. Bayer & Co., Elberfeld, is supplied
by us in ounces and in the form of Tablets of 5, 10 and 15 grains, put up in bottles of 10 and 100 tablets
each.

We also offer Sulfonal-Bayer in the form of our soluble pills, containing 5 grains each.

ARISTOL.

In order to secure the desired effects of Aristol, it is important that the physician be certain that the
article used bears the guarantee furnished by the continuous scientific control and the name of the manu-
facturers, the " Farbenfabriken, vormals Friedr. Bayer dr3 Co., in Elberfeld." This firm are the only
manufacturers of 1 his article, and the word "Aristol" is their registered property.

The preparation of Aristol, theoretically simple, involves the greatest care and experience.

Aristol, a combination of iodine and thymol, manufactured by the Farbenfabriken, formerly Friedr.
Bayer & Co., Elberfeld, Germany, is a valuable, inodorous, and non-toxic antiseptic remedy, superior to
iodoform, iodole, and sozo-iodole.

The general specific action of Aristol is similar to that of iodoform, iodol, and the sozo-iodol com-
pounds, but in addition it has the valuable property of forming an absolutely unirritant covering over the
surfaces on which it is placed, under which the processes of granulation and cicatrization proceed with
extraordinary rapidity.

Aristol is indicated in Mycosis, Lupis, Psoriasis, Syphilitic diseases generally, etc., etc.

Descriptive pamphlet mailed on application.

PHENACETINE-BAYER.

Antineuralgic- Antipyretic.

Much valuable testimony regarding Phenacetine, furnished by the medical profession of other countries,
as well as our own, has, from time to time, been collated by us, and the same has been put before American
practitioners.

The scope of Phenacetine having widened, we have brought together in pamphlet form, classified in
respect to diseases indicated, the results of the latest experience as reported chiefly by American physicians.
This pamphlet mailed to applicants.

W. H. Schieffelin & Co.,

170 & 172 William Street,
NEW YORK.

MEDICAL AND SURGICAL REPORTER.

I

GOLD MEDAL, PARIS, 1878.

W. Baker & Co/s

Breakfast
Cocoa

from which the excess of
oil has been removed, is

Absolutely JPure
and it is Soluble.

No Chemicals

are used in its preparation. It has
more than three times the strength of
Cocoa mixed with Starch, Arrowroot
or Sugar, and is therefore far more
economical, costing less than one cent
a cup. It is delicious, nourishing,
strengthening, easily digested,
and admirably adapted for invalids
as well as for persons in health..

Sold by Grocers everywhere.

W. BAKER & CO., Dorchester, Mass.

"The Bygeia"

A PRIVATE HOME HOSPITAL,

SITUATED IN A PLEASANT AND CONVENIENT PART OF

SAN FRANCISCO.

Furnished in ELEGANCE and fully
EQUIPPED WITH EVERY
APPLIANCE required for
the Treatment and .
Comfort of
Patients.

Correspondence Solicited from physicians send-
ing patients to this coast. References from the highest
in the profession in this city. Special advantages for
genito-urinary and rectal diseases, and for mild nar-
cotic habitues.

C. C. VANDERBECK, M. D„ PH.D.,

PHYSICIAN IN CHARGE,

216 Leavenworth Street.

Consultants and References — Dr. J. Rosenstim,
Surgery ; Dr. J. D. Arnold, Throat Diseases ; Dr. D. W.
Montgomery, Skin Diseases and Microscopist ; Dr. Martin
Regensburger, Genito-urinary ; Dr. Alfred Perry, General
Medicine ; Dr. Chas. Von Hoffmann, Gynecology ; Dr. B.
Marshall, etc.

CAPITAL

$1,000,000

\\\ (jutee hi ani Sale Deposit Company,

316, 318 and 320 CHESTNUT STEEET, Philadelphia,

RENTS SAFES in its ABSOLUTELY
FIRE AND BURGLAR PROOF
VAULTS

ALLOWS INTEREST on deposits
Of money, acts as Registrar and Transfer
Agent of Corporation Stocks, and exe-
cutes Trusts of every kind under appoint-
ment of States, Courts, Corporations, or
individuals, holding Trust Funds sepa-
rate and apart from the assets of the
Company.

COLLECTS INTEREST OR IN-
COME

RECEIVES FOR SAFE KEEPING,
under Guarantee, VALUABLES of every
description.

Receipts for and safely keeps Wills
without charge.

For further information, call at the
office, or send for a circular.

MANAGEMENT.
Richard Y. Cook, President.
Geo. H. Earle, Jr., Vice-President.
Harry J. Del any, Treasurer.
John Jay Gilroy, Secretary.
Richard C. Winship, Trust Officer.

DIRECTORS.
Thomas Cochran.
Edward C. Knight.
Thomas MacKellar.
John J. Stadiger.
Clayton French.
W. Rotch Wister.
Alfred F tier.
J. Dickinson Sergeant.
Aaron Fries.
Charles A. Sparks.
Joseph Moore, Jr.
Richard Y. Cook.
George H. Earle, Jr.

MEDICAL AND SURGICAL REPORTER.

XVII

XVIII

MEDICAL AND SURGICAL REPORTER.

The Atmospheric Tractor

SOME PRACTICAL POINTS ABOUT ITS USE.

In using the Atmospheric Tractor, it will be found that after the head has been
properly flexed, its extraction will be facilitated more by continuous moderate traction
for a number of seconds, than by exerting at once the greatest power possible.

It is well known that all sphincter muscles readily relax to gentle, continuous,
persuasive pressure, but if abrupt great force be employed they contract spasmodically,
and will often become ruptured or lacerated before relaxing.

Continuous pressure, of a trifling amount, will tire out the strongest muscles. A
man may be able to pick up fifty pounds or more with one hand and hold it extended
for a brief period, but he could not support a weight of five pounds in the same manner
for many minutes. The muscles employed would become tired out and relax. In a
similar manner, the pelvic muscles and the muscular tissue of the vagina may resist for
hours the intermittent pressure of the head driven against them by the abdominal and
uterine muscles, but they will become tired out and relax in a few minutes to a much
less pressure exerted against them continuously through the medium of the Atmospheric
Tractor.

It is not to be supposed that delivery will be completed invariably by one extractive
effort. The extrusion of the head is a complex process which can be better accomplished
in three moves than in one. The Tractor should, therefore, be detached when necessary,
and reapplied in the desired position. If it becomes detached during traction, no alarm
need be felt, as no injury has or can be done by its separation, and its reapplication only
requiring a few seconds of time.

Flexion and rotation may be made at any time with the Atmospheric Tractor, but
direct tractile efforts should not be made during the moment intervening between the
relaxation of the abdominal muscles and the inward rush of air into the uterus. During
this lightning-like interval our efforts should be directed only to hold the head in the
position which it has gained until the column of air has rushed past it and broken up the
uterine vacuum. At all other times, whether between pains or during their continuance,
direct traction may be exerted with great and immediate relief.

P. McCAHEY, M. D.

UPrlce, $3.00-

Sent free by mail or express on receipt of $3.00. Address the ATMOS-
PHERIC TRACTOR CO.,

219 NORTH 22d STREET, PHILADELPHIA.

P. O. Box 1202.

MEDICAL AND SURGICAL REPORTER.
«

XIX

PARTURITION.

Aletris Cordial (Rio), given in Tea-
spoonful doses every hour or two
after parturition, is the best agent
to prevent after-pains and hemorrhage.
By its direct tonic action on the
uterus, it expels blood clots, closes the
uterine sinuses, causes the womb to
contract, and prevents subinvolution.
In severe cases, it can be combined
with ergot in the proportion of one
ounce of fluid Ext. Ergot to three
ounces Aletris Cordial. It is the ex-
perience of eminent practitioners, in
all cases where ergot is indicated, that
its action is rendered much more
efficacious by combining it with Aletris
Cordial in the proportions above stated.

XX

MEDICAL AND SURGICAL REPORTER.

FRELIGH'S TABLETS,

(Cough and Constituent),

FOR THE PREVENTION AND CURE OF

PULMONARY PHTHISIS

Cough Tablets.

EACH TABLET CONTAINS.

Morph. Sulph. gr.), Atropise Sulph. gr.),
Codeia gr.), Antimony Tart. 5V gr.), Ipecac,
Aconite, Pulsatilla, Dulcamara, Causticum, Graph-
ite, Rhus-tox, and Lachesis. fractionally so ar-
ranged as to accomplish every indication in any
form of cough.

Constituent Tablets.

EACH TABLET CONTAINS.

Arsenicum gr.), Precipitate Carb. of Iron,
Phos. Lime, Carb. Lime, Silica, and the other
ultimate constituents, according to physiological
chemistry (normally) in the human organism,
together with Caraccas. Cocoa and Sugar.

m-

m

PRICE, THREE DOLLARS PER DOUBLE BOX.

Containing sufficient Tablets of each kind to last from one to three months according to the condition of the patient.

SPECIAL OFFER.

While the above formulae have been in use, in private practice, over 30 years, and we could give testimonials
from well-known clergymen, lawyers and business men, we prefer to leave them to the unbiased judgment of the
profession with the following offer : On receipt of 50 cents, and card, letter-head, bill-head, or other proof that the
applicant is a physician in active practice, we will send, delivered, charges prepaid, one of the regular (double)
boxes (retail price, Three Dollars), containing sufficient of each kind of Tablets to test them three months (in the
majority of cases) in some one case. Card, letter-head, or some proof that the applicant is a physician in active
practice, must accompany each application. Pamphlet, with full particulars, price-list, etc., on request.

As we furnish no samples through the trade, wholesale or retail, for samples, directions, price-list, etc., address,

88 Maiden Lane,

I. O. WOODRUFF & CO.,

MANUFACTURERS OF PHYSICIANS' SPECIALTIES,

New York City.

LIQUOR SANTAL FLAV.

CUM

BUCHU et CUBEBA.

(ORIGINAL FORMULA.)

This elegant preparation has been very successfully used in the treatment of
long-standing Gonorrhoea and chronic Gleet.

If given in the early stages of Gonorrhoea, it will usually arrest the progress
of the disease.

It is especially effective in all inflammations of genito-urinary mucous
membranes.

It is perfectly miscible in water. Dose, f3i to f3ij, three times a day in water
or milk. When prescribing, please specify Liq. Santal Flav. cum Buchu et Cubeba
(Ogden's).

CTOHUnT ogkdieilt,

CHEMIST,
WALNUT & THIRTEENTH STREETS,

PHILADELPHIA.

MEDICAL AND SURGICAL REPORTER.

XXI

TERTIARY SYPHILIS.

" Your preparation, IODIA, is an excellent altera-
tive, and is the most agreeable of any preparation of
Iod. Potas., as it does not cause the cramps in stomach,
which are often intolerable.

" I have employed IODIA in two cases of Tertiary
Syphilis, in which, after five weeks' treatment, the mani-
festations disappeared.

" In a case of Syphiltic Eczema it was also successful.
— Dr. Sam Petite au, Garches, France, Nov. 10, 1890.

BATTLE & CO., Chemists' Corporation,

St. Louis, Mo., IT. S. A.

BRANCHES :

76 New Bond Street, London, W.

5 Rue de la Paix, Paris.

9 and 10 Dalhousie Square, Calcutta.
80 Montague-de-la-Cour, Brussels.
28 Nieuwe Hoogstraat, Amsterdam.

XXII

MEDICAL AND SURGICAL REPORTER.

OF PHILADELPHIA.

The 66th Annual Session of the Jefferson Medical College
begins October 1st and continues nearly 7 months.
Preliminary Lectures will be held from
22d of September.

EACH student is immediately and personally taught in Ob-
stetrics and Gynaecology, Physical Diagnosis, Laryngol-
ogy, Ophthalmology, Medical Chemistry, Pharmacy, Materia
Medica, and Experimental Therapeutics, Histology and Ex-
perimental Physiology, Minor Surgery, Bandaging, Operations
on the Cadaver, Pathology, Neurology, and Electro-Thera-
peutics.

Three annual regular sessions are required. Bedside in-
struction in Medicine, Gynaecology, Surgery and Obstetrics
is a part of the third year course. No extra fee.

The Annual Announcement will be sent on applica-
tion to J. W. M I>., Dean.

MEDICO-CHIRURGICAL COLLEGE

OF PHILADELPHIA.

Winter Session will begin Wednesday, October ist, and
continue until April 16th. Preliminary Session begins Sep-
tember 8th. Spring Term, April 20th, 1891.

The curriculum is graded, and a preliminary examination
and three Annual Winter Sessions are required. Laboratory
instruction in Chemistry, Histology, Pathology, Hygiene,
Physiology, with Bedside instruction in Medicine, Surgery and
Gynecology, is a part of the regular course.

Fees: Matriculation $5.00. First and second years, each
$75.00. Third year $100.00. Fourth year free to those in
attendance three sessions ; to all others $100.00.

For Announcement or information apply to

E. E. MONTGOMERY, M. D„

1818 Arch Street, Philadelphia, Pa.

NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL

SESSIONS 1890.91.

The Autumn and Winter Sessions of the Post-Graduate Medical School opened on September 15. The Hospital is fully
utilized for clinical purposes. There are ninety beds, including thirty for babies in the adjacent building. No Post-Graduate
Medical School in this country can offer such opportunities for seeing important surgical and gynaecological operations under
its own roof as does this institution. Besides, regular clinics, medical and surgical, are held by professors and instructors in
those general and special hospitals with which they are connected, which comprises nearly all the great hospitals of the city.
The dispensary of the' school and other large dispensaries furnish ample means of instruction in every class of walking cases.

Instruction is given in every branch of medicine and surgery. The laboratory is large and well equipped. Surgical
anatomy and operative surgery are thoroughly taught. The instruction is personal, the practitioner being brought in direct
contact with the patient. No other courses in any department will be required if those to be had in the Post-Graduate School
are taken. The faculty were the first in the United States to organize private courses for practitioners of medicine, and they
pledge themselves to leave nothing undone to make graduates in medicine profit by the unrivalled clinical advantages of the
City of New York.

For catalogue and schedule, address

CLARENCE C. RICE, M. D., Secretary,

D. B. St. JOHN ROOSA, M. D., LL.D., President. 226 East 20th St., New York City.

F. E. FARRELL, Superintendent.

COLLEGE OF MEDICINE. SYRACUSE UNIVERSITY.

JOHN VAN DUYN, M. D., Surgery.

HENRY D. DIDAMA. M. D., Practice and Clinical Medicine
WILLIAM T. PLANT, M. D., Diseases of Children.
ALFRED MERCER. M. D., State Medicine.
WILLIAM MANLIUS SMITH. M. D., Chemistry.
DAVID M. TOTMAN, M. D., Clinical Surgery,
NATHAN JACOBSON, M. D., Clinical Surgery and Laryn
gology.

FACULTY.

GAYLORD P. CLARK, M. D., Anatomy.
WILLIAM H. DUNLAP, M. D., Dermatology. I
JOHN L. HEFFRON, M. D., Materia Medica and Thera-
peutics.

HENRY B. ALLEN. M. D., Obstetrics.
A. CLIFFORD MERCER, M. D., Pathology.
HENRY L. ELSNER, M. D., Clinical Medicine.
FRANK W. MARLOW, M. D., Ophthalmology.

Three Years' Graded Course. Year begins October 7th, 1890, ends in June, 1891.

FIRST YEAR: Anatomy, Physiology, Chemistry, Histology, Materia Medica.

SECOND YEAR: Anatomy, Physiology, Chemistry, Therapeutics, Pathology, Practice, Surgery, Clinical Medicine and
Surgery.

THIRD YEAR: Therapeutics, Practice, Surgery, Children, Clinics, Obstetrics, Gynaecology, Forensic Medicine, Ophthal-
mology, Hygiene.

An experience of seventeen years has demonstrated that a three years' graded course is superior in every respect to an
ungraded, unnatural, and cramming course of two winters.

Tuition, $80.00 for each Tear. Perpetual Ticket, $300.00. Diploma, $35.00.
For circulars with full information, address

W. H. DUNLAP, M. D., Registrar, SYRACUSE, N. Y.

UNIVERSITY OF PENNSYLVANIA. — Medical Department

The 125TH Annual Winter Session will begin Wednesday, October ist, 1890, at 12 M., and will continue seven months.
The Preliminary Session begins September 22d, 1890, the Spring Term early in May, 1891.

The curriculumis graded and three annual winter sessions are required. Practical instruction, including laboratory work
in Chemistry, Histology, Osteology and Pathology, with Bedside Instruction in Medicine, Surgery and Gynecology are a part
of the regular course and without additional expense.

FACULTY.

JOSEPH LEIDY, M.D., LL.D., Professor of Anatomy.
D. HAYES AGNEW, M.D , LL.D., Honorary Professor of Clin-
ical Surgery.

WILLIAM PEPPER, M.D., LL.D., Professor of Theory and
Practice of Medicine, and of Clinical Medicine.

WILLIAM GOODELL, M.D., Professor of Gynecology.

JAMES TYSON, M.D., Professor of Clinical Medicine.

HORATIO C. WOOD, M.D., LL.D , Professor of Materia Medica,
Pharmacy and General Therapeutics.

THEODORE G. WORMLEY, M.D., LL.D., Professor of Chem-
' istry and Toxicology.

JUHN ASHHURST, Jr., M.D., Professor of Surgery and of
Clinical Surgery.

EDWARD T.REICHERT, M.D. Professor of Physiology.

WILLIAM F. NORRIS, M.D., Honorary Prof.of Ophthalmology
BARTON COOKE HIRST, M.D., Professor of Obstetrics.
J. WILLIAM WHITE, M.D., Professor of Clinical Surgery.
JOHN GUITERAS, M.D., Professor of General Pathology and

Morbid Anatomy.
GEORGE A. PIERSOL, M.D., Professor of Histology and Em

bryology.

SAMUEL G. DIXON, M.D., Professor of Hygiene.

For Catalogue and announcement containing particulars,
apply to

DR. JAMES TYSON, Dean,
36th and Woodland Avenue, Philadelphia

MEDICAL AND SURGICAL REPORTER.

XXIII

PHILADELPHIA POLYCLINIC

HAS MOVED TO

EIGHTEENTH AND LOMBARD STREETS,

AND OCCUPIED ITS

New College and Hospital Building,

The Finest Structure of the kind in America.

Practical instruction in all branches of medicine, utilizing
its own rich out-patient service, its indoor accommodation of
50 beds, and the best facilities of the other hospitals of Phila-
delphia. Six weeks' courses may begin at any time.

fCgr^ Write for announcement and full particulars.

XXIV

MEDICAL AND SURGICAL REPORTER.

SYRUP OF FIGS.

(Syr. Fici Cal.)

In order to meet the almost universal demand for a safe, reliable and elegant
liquid laxative, the

CALIFORNIA FIG SYRUP CO.

OF

SAN FRANCISCO, CAL.
LOUISVILLE, KY. NEW YORK, N. Y-

is utilizing the delicious blue Fig of California in the preparation of

SYRUP OF FIGS,

an agreeable and effective laxative or purgative, according to the dose and manner of
administration.

Syrup of Figs is delightful to the taste, and may be taken by every one, from
infancy to old age.

Syrup of Figs does not debilitate, and is perfectly safe.

The dose as a purgative for an adult is from one-half to one tablespoonful and
may be repeated in six hours if required. As a laxative, one or two teaspoonfuls may be
given at bed-time or before breakfast.

For children the dose may be regulated according to age and desired effect.

SYRUP OF FIGS

is recommended and prescribed by prominent physicians in all sections of the United
States, and gives general satisfaction.

In addition to the blue Figs of California, we use the juice of true Alexandria
Senna, representing the laxative and purgative principles without its griping properties,
also pure white sugar and an excellent combination of carminative aromatics.

Devoting our entire attention to the manufacture of Syrup of Figs after a
thorough study of the results to be accomplished and of the best methods to produce a
perfect laxative, and with complete manufacturing facilities especially adapted to the
purpose, we are enabled to offer to the medical profession, in Syrup of Figs, a laxa-
tive which, though simple in itself, cannot be produced in all its excellence by other
parties, and we believe and trust that physicians will not permit imitations to be used
when they prescribe Syrup of Figs (Syr. Fici Cal.).

SYRUP OF FIGS

is manufactured only by the

CALIFORNIA FIG SYRUP CO.

or

SAN FRANCISCO, CAL.
LOUISVILLE, KY. NEW YORK, N. Y.

It is sold to the drug trade in bottles of two sizes only : the smaller bottles con-
taining full four ounces and the large size about ten ounces.

MEDICAL AND SURGICAL REPORTER.

XXV

GARDNER'S

YBCP OF IfDEIOBIC ACID,

Introduced in 1878 by R. W. GARDNER.

The Reputation which Hydr iodic Acid has Attained During the
past Eleven Years was Won by this Preparation,

Numerous Imitations prepared differently, and weaker in Iodine, are offered, from the use of
which the same therapeutic effects cannot be obtained.

Caution* — Use no Syrup of Hydriodic Acid which has twrned red. This shows decomposition
and free Iodine. In this state it acts as an irritant and fails to produce desirable results.

Unprincipled apothecaries substitute imitations when Gardner's Syrup is prescribed, and physi*
ians, failing to get desirable and promised results, attribute the fault, unjustly, to Gardner's Syrup.

THERAPEUTIC INDICATIONS.

Hay Fever; Hose Cold; Poisoning by Lead, Mercury or Arsenic; Acute and Chronic Kheuma-
tism; Asthma; Chronic Bronchitis ; Catarrh; Congestion of Lungs in Children; Adenitis; Eczema;
Lupus; Chronic Malarial Poisoning; Lumbago; Acute Pneumonia; Psoriasis; Scrofulous Diseases;
Goitre ; Enlarged Glands ; Cold Abscesses ; Indolent Sores ; Excessive Fat ; Fatty Degeneration of the
Heart ; to absorb non-malignant Tumors ; and in the latter stages of Syphilis ; Syphilitic Phthisis.

Details of treatment furnished physicians upon application to undersigned without charge.

Gardner's Chemically Pure Syrups of Hypophosphites.

Embracing the separate Syrups of Lime, of Soda, of Iron, of Potassa, of Manganese, and an Elixir
of the Quinia Salt ; enabling physicians to accurately follow Dr. Churchill's method, by which thou-
sands of authenticated cases of Phthisis have been cured. The only salts, however, used by Churchill
in Phthisis are those of Lime, of Soda, and of Quinia, and always separately according to indications, —
never combined.

The reason for the use of single Salts is because of antagonistic action of the different bases, injuri-
ous and pathological action of Iron, Potassa, Manganese, etc., in this disease.

These facts have been demonstrated by thirty years' clinical experience in the treatment of this
disease exclusively, by Dr. Churchill, who was the first to apply these remedies in Medical practice.
Modified doses are also required in this disease; seven grains during twenty -four hours being the
maximum dose in cases of Phthisis, because of increased susceptibility of the patient to their action, the
danger of producing toxic symptoms (as hemorrhage, rapid softening of tubercular deposit, etc.), and
the necessity that time be allowed the various functions to recuperate simultaneously ; over-stimula-
tion, by pushing the remedy, resulting in crisis and disaster.

A pamphlet of sixty-four pages, devoted to a full explanation of these details and others, such as
contra-indicated remedies, indications for the use of each hypophosphite, reasons for the use of abso-
lutely pure Salts, protected in Syrup from oxidation, etc., mailed to physicians without charge upon
application to

R. W. GARDNER, 158 William St., N. Y. City.

W. H. SCHIEFFELIN & CO., Sole Wholesale Agents, New York.

XXVI

MEDICAL AND SURGICAL REPORTER.

ESTABLISHED t6 YEARS.

BEWARE OF IMITATIONS.

A\D IN

p**cn

ORIGINAL

COLDEN'S LIEBIG'S LIQUID EXTRACT OF BEEF AND TONIC INVIGORATOR.

[ESSENTIALLY DIFFERENT FROM ALL OTHER BEEF TONICS,
ENDORSED BY LEADING PHYSICIANS.

UNIVERSALLY/

This preparation, consisting of the Extract of Beef (prepared by Baron Liebig's process), the best Brandy
bbtainable, soluble Citrate of Iron, Cinchona and Gentian is offered to the Medical Profession upon its own
merits. ^ It is of inestimable value in the treatment of Debility, Convalescence from Severe Illness
Anaemia, Malarial Fever, Chlorosis, Incipient Consumption, Nervous "Weakness, and maladies
requiring a Tonic and Nutrient. It is quickly absorbed by the Stomach and upper portion of the Alimentary
Canal, and therefore finds its way into the circulation quite rapidly.

COLDEN'S LIQUID BEEF TONIC appeals to the judgment of intelligent Physicians in the treatment of
AUL, CASES OF GENERAL DEBILITY.

By the urgent request of several eminent members of the medical profession, I have added to each wineglassf ul of
this preparation two grains of Soluble Citrate of Iron, and which is designated on the label, '* Witlt Iron, No. I j"
while the same preparation, 'Without Iron, is designated on the label as '* No. 2."

In prescribing this preparation, phvsicians should be particular to mention "COLDEN'S," viz.. "Ext. Carnis
Fl^Comp. iColdenu" A Sample of COLDEN'S BEEP TONIC will he sent free on application, to any physician
(enclosing business card) in the United States. Sold by druggists generally.

C. N. CRITTENTON, General Agent, 115 Fulton St., New York.

GLENN'S SULPHUR SOAP.

BEWARE OK COUNTERFEITS.

Physicians know the great value of ihe local use of J
Sulphur in the Treatment of Diseases of the Skin.

Constantine's Pine-Tar Soap.

THE BEST SOAP MADE.

, Has been on trial among physicians for very many years
as a healing agent. By far the Best Tar Soap

Wholesale Depot, O. KT. C?F8.I«X"I»E;3Xr,X'0 ISJ, 115 Fulton St, New York.

Samples of above Soaps SENT FREE» on application, to any Physician enclosing care!

SCOTT'S EMULSION

— VERSUS ~

PLAIN COD LIVER OIL.

Plain Cod Liver Oil is indigestible, deranges the stomach, destroys the appetite
is not assimilated, and in a majority of cases is detrimental to the patient.

SCOTT'S EMULSION

Can be digested in nearly all cases, is assimilated, does not derange the stomach,
nor overtax the digestive functions, and can be taken for an indefinite period when the
plain cod liver oil cannot be tolerated at all, and with most marked results in Anosmia,
Consumption and all wasting conditions. It also contains the Hypophosphites of Lime
and Soda with Glycerine, which are most desirable adjuncts.

WHEN PHYSICIANS TRY IT THEY INVARIABLY USE IT
in preference to the plain cod liver oil or other so-called Emulsions that invariably separate,
and hence their integrity and value is destroyed. ScoWs Emulsion is palatable and
absolutely permanent hence its integrity is always preserved.

The formula for Scott's Emulsion is 50 per cent, of the finest Norwegian Cod Liver Oil, 6 grains
Hypophosphite of Lime and 3 grains Hypophosphite of Soda to the fluid ounce, Emulsified, or digested
to the condition of assimilation with chemically pure Glycerine and Mucilage.

We also wish to call your attention to the following preparations :

CHERRY MALT PHOSPHITES.

A combination of the tonic principles of Prunus Virginiana, Malted Barley, Hypophosphites of
Lime and Soda, and Fruit Juices. An elegant and efficient brain aud nerve tonic.

BUCKTHORN CORDIAL (Rhamnus Frangula).

Prepared from carefully selected German Buckthorn Bark, Juglans Bark and Aromatics. The
undoubted remedy for Habitual Constipation.

Be sure and send for samples of the above — delivered free.

SCOTT & BOWNE, 132 South Fifth Avenue, NEW YORK.

FELLOWS'

HYPOPHOS-PHITES

(SYR: HYPOPHOS: COMP: FELLOWS)

Contains The essential elements to the Animal Organization — Potash and

Lime.

The Oxydizing Agents — Iron and Manganese;

The Tonics — Quinine and Strychnine,

And the Vitalizing Constituent — Phosphorus,
Combined in the form of a Syrup, with slight alkaline reaction.

It Differs fn Effect from all others, being pleasant to taste, acceptable
to the stomach, and harmless under prolonged use.

It has Sustained a High Reputation in America and England for
efficiency in the treatment of Pulmonary Tuberculosis, Chronic Bronchitis, and
other affections of the respiratory organs, and is employed also in various ner-
vous and debilitating diseases with success.

Its Curative Properties are largely attributable to Stimulant, Tonic, and
Nutritive qualities, whereby the various organic functions are recruited.

In Cases where innervating constitutional treatment is applied, and tonic
treatment is desirable, this preparation will be found to act with safety and
satisfaction.

Its Action is Prompt; stimulating the appetite and the digestion, it
promotes assimilation, and enters directly into the circulation with the food
products.

The Prescribed Dose produces a feeling of buoyancy, removing depres-
sion or melancholy, and hence is of great value in the treatment of Mental
and Nervous Affections.

From its exerting a double tonic effect and influencing a healthy flow of
the secretions, its use is indicated in a wide range of diseases.

Prepared by JAMES I. FELLOWS, Chemist,

-38 VESEY STREET, NEW YORK.
Circulars sent to Physicians on Application.

FOR SALE BY ALL DRUGGISTS*

PHILLIPS' COD LIVER OIL

EMULSION.

A TRUE EMULSION WITHOUT SAPONIFICATION.

T? „ 1

In all essential features, it represents the highest degree of perfection in the Emul-
sionizing of Cod Liver Oil.

This preparation is not advertised to the public, and enjoys Professional popularity
because of its high standard of excellence, uniformity and reliability.

(A pamphlet, with formula, Photo- Micrographic illustrations, etc. , mailed upon appli-
cation.^) .

PHOSPHO-MURIATE OF QUININE,

COMPOUND.

A RELIABLE ALTER ATO-COW STRUCT! VE,

Particularly indicated in conditions of disturbed nutrition and tissue retrograde.

An easily appropriated general tonic, promoting digestion, and safe under prolonged use.

A permanent combination of the soluble Wheat Phosphates, with Muriate of Quinine, Iron and Strychnia.
Of greater strength than the various Hypophosphite compounds.

DIGESTIBLE COCOA.
WHEAT PHOSPHATES.
MILK OF MAGNESIA.

THE CHAS. H. PHILLIPS CHEMICAL CO.,

77 PINE STREET, NEW YORK.

CH. MARCHAND'S

Peroxide of Hydrogen

(MEDICINAL) H2 02

(Absolutely Harmless.)

Is rapidly growing; in favor witii the medical profession. It is tli<
most powerful antiseptic known, almost tasteless, and odorless.
Can be taken internally or applied externally wails perfect safety.
Its curative properties are positive, and its strength and purity
can always be relied upon. This remedy is not a Nostrum.

a remedy for DIPHTHERIA ; CROUP; SORE THROAT,

A'^y^^^^^^^^W $0 AND ALL 1NFLAMMAT°RY DISEASES OF THE THROAT.

OPINION OF THE PROFESSION.
Dr. E. R. Squibb, of Brooklyn, writes as follows in an article headed "On the Medical Uses of Hydrogen Peroxide {GaillarcP
Medical Journal, M irch, 1889, p. 267), read before the Kings County Medical Association, February 5,

" Throughout the discussion upon diphtheria very little has been said of the use of the Peroxide of Hydrogen,
or hydrogen dioxide ; yet it is perhaps the most powerful of all disinfectants and antiseptics, acting both chem-
ically and mechanically upon all excretions and secretions, so as to thoroughly change their character and
reactions instantly. The few physicians who have used it in such diseases as diphtheria, scarlatina, small-pox
and upon all diseased surfaces, whether of skin or mucous membrane, have uniformly spoken well of it so far a
this writer knows, and perhaps the reason why it is not more used is that it is so little known and its nature and
action so little understood. . . . Now, if diphtheria be at first a local disease, and be auto-infectious ; that
is, if it be propagated to the genera] organism by a contagious virus located about the tonsils, and if this virus be,
as it really is, an albuminoid substance, it may and will be destroyed by this agent upon a sufficient and a suffi-
ciently repeated contact. ... A child's nostrils, pharynx and mouth may be flooded every two or three
hours, oroftener, from a proper spray apparatus with a two volume solution without force, and with very little
discomfort ; and any solution which finds its way into the larynx or stomach is beneficial rather than harmful
and thus the effect of corrosive sublimate is obtained without its risks or dangers.

Further on Dr. Squibb mentions that Charles Marchand is one of the oldest and best makers of Peroxide
of Hydrogen, and one who supplies it to all parts of the country.

CAUTION. — By specifying in your prescriptions "Ch. Marchand's Peroxide of Hydrogen (Medicinal)," which is sold
only in %-lb., ji-\b., and i-lb. bottle.-., bearing my label aud signature, you will never be imposed upon. Never sold in bulk.

PREPARED ONLY BY _

Chemist and Gradual
of the liEcole Centrale
des Arts et Ma?tnfac
tures de Paris''

( Fra?tce )

A book con

peutical appl

PREPARED ONLY BY A

itaining full explanations concerning the th;ra- / V (/,_-— — fT" Jl V~ ""-^L ^

lications of both ( h. Marchand's Peroxide of L^Ta M Y n k h / L M a + A\. '•

Medicinal) and Gl.YCOZONE, with opinions of the /^CwM&Q »W WLC\VXM*<\>

'ill be; mailed to Dhysi Jans free of charge on ~==1£& "^^r — "3 t

JKW Mention this nubheation. — C. < >

lYDROGEN (

profession, v

application. J3G§= Mention th

i>OLD BY LEADING DRUGGISTS.

publication.

Laboratory,

IO West Fourth Street, New York

MEDICAL AND SURGICAL REPORTER.

XV

17,670,000 BOTTLES FILLED IN 1890.

Apollinaris

"THE QUEEN OF TABLE WATERS."

" The APOLLINARIS SPRING yields enough water not only
for PRESENT REQ UIREMENTS but also for those of a FUTURE
which is STILL REMOTE.

" The EXISTING SUPPLY is ADEQUATE for FILLING
FORTY MILLION quart bottles YEARLY.

" The VOLUME of GAS is so GREAT that it is dangerous to
approach the SPRING on a windless day!' — The Times, London,
20th September, 1890.

THE BEST NATURAL APERIENT.

THE APOLLINARIS COMPANY, LIMITED, London, beg to announce that, as
numerous Aperient Waters are offered to 'the public under names of which the word
Hunyadi " forms part, they have now adopted an additional Label comprising their
Registered Trade Mark of selection, which consists of

A DIAlVEOlSro.

This Label will henceforth also serve to distinguish the Hungarian Aperient Water
sold By the Company from all other Aperient Waters.

DEMAND THE

DIAMOND MARK.

And insist upon receiving the Hungarian Aperient Water ot the Apollinaris

Company, Limited, London.

XVI

MEDICAL AND SURGICAL REPORTER.

Boudault's Pepsi ne

The only Pepsine used in the Hospitals of Paris for the last Thirty Years.

Unlike the various substitutes which, in most'cases, are but/nnscientific or incompatible compounds, forced upon the'HedkaS
Profession as aids to digestion by extensive advertising, but which, when submitted to the proper tests, are found to be useless M
digestive agents, Pepsine is constantly gaining in the esteem of the careful practitioner.

Since the introduction of Pepsine by Boudault and Corvisart in 1854, the original BOUDAULT'S PEPSINE HAS BEEN
AT ALL TIMES CONSIDERED THE BEST, as is attested by the awards it has received at the Expositions of 1867, 1868, 187
1873, in 1876 at the Centennial Exposition of Philadelphia, and in 1878 at the Paris Exposition.

The most reliable tests, carefully applied, will satisfy everyone that BOUDAULT'S PEPSINE HAS A MUCH HIGHEB
DIGESTIVE POWER than the best Pepsines now before the Profession, and is therefore especially worthy of their attention.

BOUDAULT'S PEPSINE is prepared in the form of Pepsine Acid and Pepsine Neutral. It is sold in bottles of one ounce,
with a measure containing exactly five grains ; also in bottles of four, eight,*and sixteen ounces for dispensing.

BOUDAULT'S WINE OF PEPSINE

FORMULA OF DR. CORVISART.

The taste of Pepsine being perfectly disguised in this Wine, it may be recommended to persons who have difficulty ia taking
Pepsine in the form of Powder. This Wine is tested so that a tablespoonful of it is equal in digestive power to tea grains of
Boudault's Pepsine in powder. Sold only in bottles of eight ounces.

TANRET'S PELLETI ERI N E

For the Treatment of Tape- Worm (Taenia Solium).

This New Tsenifuge, the Active Alkaloid of Pomegranate Bark, has of late come into extensive use lu jfrance for th©
treatment of Tape- Worm (Taenia Solium). The results of numerous experiments with it at the Marine Hospitals of Toulon,
St. Mandrier, etc., and in the Hospitals of Paris, St. Antoine, La Charite, Necker Beaujon, etc., have all been most satisfactory.
Doctor Dujardin Beaumetz, Member of the Academy of Medicine, and Professor Laboulbene, in their report to the Society of
Therapeutics, have given it their unqualified approval, after the most searching experiments. This preparation is pleasant to
administer, and, if certain preliminaries are observed, success will be insured.

Sold only in bottles containing one dose.

DUCRO'S ALIMENTARY ELIXIR

1 Combination uniting the properties of Alcoholic Stimulants and Raw Heal

This preparation, which has been used with great success in the hospitals of Paris since 1868, is adapted to the treatment •
Jdl diseases requiring administration, in a small volume, of a tonic able to stimulate and support the vital forces, as Puimonar
Phthisis, Depression and Nervous Debility, Adynamia, Malarious Cachexia, etc.

Prepared by EMTLE DUBIEZ & CO., Successors to DTJCRO & OIE, Paris.

KIRKWOOD'S INHALER

This Is the only complete, reliable, and effective inhaler in use, arranged for the direct application of Muriate of Ammonia
«nd other remedial agents in the state of vapor to the diseased parts of the air-passages in the treatment of catarrh and disease*
of the throat and lungs. No heat ot warm liquids required in its use.

It is entirely different from the various frail, cheap instruments that have been introduced. , _

KIKKWOOD'S INHALER is accompanied by testimonials of the highest professional character, together With OareftUIf
-prepared formulas for use.

K.ETAEL PRICE, COMPLETE, $2.50.

A liberal discount allowed to the trade and profession. For descriptive pamphlet or other information addreffl

E. FOUGERA & CO., 30 North William St., New York.

Sole Agents for the^above Preparations.

MEDICAL AND SURGICAL REPORTER.

XVII

LASSAR'S TREATMENT FOR BALDNESS.

Wash out the lather with plenty of warm water

Shampoo the head thoroughly for ten minutes with Packer's tar soap,
followed by cold water. Dry the hair and apply :

-p Lassar's Treatment and a half-cake of Packer's Tar Soap will be mailed to

any Physician on receipt of four stamps. Address

TH E PACKER M FG CO., 100 FULTON ST., New York.
" The whole process is said to take about fifteen minutes, and to be very agreeable. Let me stimulate you to try this plan
of treatment by telling you that I have seen it cause the scalp of one physician to take on a revigorated growth of hair." —
George Thomas Jackson, M. D., Chief of Dermatological Clinic, College of Phys. and Surg., New York etc. (Gaillard's
Med. Jour. , May, i8qo) .

HOME FOR HABITUES.

OFITJ3VI, CHLORAL, COCAINE.
DR. J. B. MATTISON,

Continues to receive at his residence, 314 State Street, Brook-
lyn, N. Y.,a limited number of these habitues, to whom he
devotes his exclusive professional attention. Patients Six.
and Select. Attractive apartments, liberal cuisine, desirable
privacy, cheerful society, and personal professional attention,
based on several years' experience in the treatment of this
disease. Details on application.

for our Patent Barley CRYSTAIiS,
fd Cereal Food, f or Breakfast Tea
. there, write us for free sam-
iOUlt and SPECIAL DIA-
are invaluable waste-repairing
»sia,Diabetes, Debility & C'hil-
bran ; mainly free from starch.
es\iothing equals our HEAJLTHL
circular offering 4 lbs. free.
FARWELE&RHINES,Props.,Watertown,N.Y

ANTISEPTIC DRAINAGE TUBES.-Glass.

These Tubes have large holes, one-half inch apart, arranged alternately on opposite sides.
They are carefully finished, especial care being taken to make them smooth.

In addition to the drainage-holes, each tube has at one end two smaller holes for the insertion o* fciafety-Pin, through
which it is prevented slipping into the wound.

FURNISHED IN SEVEN SIZES.

No. 1, $1.25 per doz. No. 4, $1.55 per doz.
No. 2, 1.25 « No. 5, 1.70 «

No. 3, 1.40 " No. 6, 1.90 "

No. 7, $2.10 per dozen.

RAW CAT- GUT. Iput this up in coils of 10 feet, lour difierent
sizes, Nos. 1, 2, 3, 4 (4 is thickest). Nos. 2 and 3 are the most useful sizes.
No. 1 Coil, 10 Cents; No. 2 Coil, 12 Cents; No. 3 Coil, 14
Cents; No. 4 Coil, 16 Cents. Full directions with each coil for
making it absolutely aseptic.

WILLIAM SNOWDEN,

Manufacturer, importer and Exporter of Surgical Instruments,

No. 121 SOUTH ELEVENTH STREET, PHILADELPHIA.

CH. MARCHAND'S

PEROXIDEofHYDROGEN

(MEDICINAL) H2O2 (ABSOLUTELY HARMLESS.)

Is rapidly growing in favor with the medical profession. It is the most
powerful antiseptic known, almost tasteless, and odorless. Can be taken
internally or applied externally with perfect safety. Its curative proper-
ties are positive, and its strength and purity can always be relied upon.
This remedy is not a Nostrum.

a remedy for DIPHTHERIA ; CROUP ; SORE THROAT,

AND ALL INFLAMMATORY DISEASES OF THE THROAT.
OPINION OF THE PROFESSION.
Dr. Geo. B. Hope, Surgeon Metropolitan Throat Hospital, Professor Diseases of Throat,
University of Vermont, writes in an article headed, ' ' Some Clinical Features of Diphtheria, and
the treatment by Peroxide of Hydrogen " (N. Y. Medical Record, October 13, 1888). Extract :

. . On account of their poisonous or irritant nature the active germicides have a utility limited par-
ticularly to surface or open wound applications, and their free use in reaching diphtheritic formations in the mouth
or throat, particularly in children, is, unfortunately, not within the range of systematic treatment. In Peroxide of
Hydrogen, however, it is confidently believed will be found, if not a specific, at least the most efficient topical agent
in destroying the contagious element and limiting the spread of its formation, and at the same time a remedy which
may be employed in the most thorough manner without dread of producing any vicious constitutional effect. .

" Inasmuch as the efficacy depends upon the ozonized oxygen in solution, it has seemed desirable to rely on
the full strength of the officinal preparation of fifteen volumes, especially when used in the fauces, where any slight
irritation from its acidity is not apparent. In all the cases treated (at the Metropolitan Throat Hospital), a fresh,
standard Marchand preparation of fifteen volumes was that on which the experience of the writer has been based. . .

"An equally important element is in making the application in such a manner as to produce the most deter-
mined effect on the diseased tissues with as little local disturbance as possible. ... A steady, coarse spray,
with an air pressure of twenty pounds or more, will, in a few moments' time, produce a more positive action than
prolonged efforts to reach the fauces by means of cotton applicators. . . . How frequently the treatment is to
be followed up depends to a considerable extent on the density, as well as the area, of the surface involved. ; "

CAUTION.— By specifying in your prescriptions " Ch. Marchand's Peroxide of Hydrogen (Medicinal)," which is sold
only in %-lb., %-lb., and i-lb. bottles, bearing my label aud signature, you will never be imposed upon. Never sold in bulk.

PREPARED ONLY BY

fl . J Chemist and Graduate

V a^i\. °f the "Ecole Cent rale

jWifyUX} des Arts et Mannfac-

. tures de Paris"

$2 — <4tf. ^> (France).

A book containing full explanations concerning the thera-
peutical applications of both Ch. Marchand's Peroxide of

vdrogen (Medicinal) and Glycozone, with opinions of the
profession, will be mailed to physicians free of charge on
application. Mention this publication.

SOLD BY LEADING DRUGGISTS.

Laboratory, lO West Fourth Street, New York.

XVIII MEDICAL AND SURGICAL REPORTER.

A CASE WITH A LESSON IN IT.

We have frequently referred to the neces-
sity of keeping the pregnant woman supplied
with those chemical substances which she
must give to the child in the formation of
its little frame, and the dire effects which
may result from a deficiency of those sub-
stances. The headaches, neuralgias, spinal
tenderness, and some of the many disorders
of digestion, and even mental failure, may
be all prevented or relieved by supplying to
the mother the chemical food her system
demands.

We have noticed a few cases where the
most serious results have occurred to the
mother by such a deficiency, one of which
is well worth relating. Mrs. M., aged 30,
pregnant with her third child, suffered from
the second to the fifth month of her preg-
nant term with gradually failing strength
and health, and nervous irritability. She
was very restless nights for three or four
days, the peculiar restlessness of complete
nervous exhaustion, and was irrational for
more than a week.

At this time I advised that she have a
teaspoonful of Murdock's Liquid Food
every hour in milk, and a little wine every
four hours. The third night she had fifteen
drops of hydrobromic acid dil. every three
or four hours, which was continued for a
week. The liquid food after a week every
two hours, and all other medicines were dis-
continued. Her bowels were moved with a
mild laxative at first, and afterward became
regular. Her tongue cleaned quickly and
her skin assumed a more natural appear-
ance.

At this writing, less than three weeks
from our first visit, the patient is able to sit
up an hour at a time, is quite rational and
cheerful, has a good appetite, the bowels
are quite regular, there is no headache, and
but little spinal tenderness. She sleeps
reasonably well if fed frequently. She is
allowed to suit her taste in her diet. The
child is quite active, and the mother is pro-
gressing so nicely that it is hoped that she
will pass safely through her confinement,
which is nearly at hand. She will be kept
on the liquid food and the phosphates
until her confinement after which, the con-
dition will suggest the treatment. This
is the most marked case of a starved
nervous system we have ever seen, and
the benefit derived from the treatment

proves the theory as to the cause of the
trouble.

Apropos with the above, comes the ques-
tion of the selection of nutritious foods for
those many cases which demand strong and
immediate nourishment. The food used in
the above case has produced marvelous re-
sults for us in some of those extreme cases
in which we have used it.

In one case of nervous exhaustion the
insomnia was absolutely painful. When
the exhaustion forced the patient to sleep
there was an immediate sense of falling or
approaching death, or there were hallucina-
tions which were appalling, rendering the
nights unbearable. One teaspoonful of
Murdock's Liquid Food so nourished the
system the first night it was given that the
patient sank into a quiet, refreshing sleep
which lasted, with a single awakening, until
morning, and the improvement the patient
obtained was most striking.

One case of mitral regurgitation with
leucocythemia and nervous exhaustion im-
proved more rapidly on this food than on
all other measures combined. In cases of
nervous exhaustion and brain tire, its effects
are most marked, as we have experienced
many times in the past five years in the
frequent personal use of the agent. It con-
tains the principles of pure, healthy blood
and nerve tissue ready for immediate as-
similation. Fourteen per cent, of the entire
quantity is uncoagulated albumen, as we
have demonstrated by actual analysis.

We have tided babies over critical periods
often with a few drops in its usual diet.
We have given it to dipsomaniacs with or
without non-alcoholic stimulants with su-
perb results. The sole objection our pa-
tients have to it is its odor. Its taste is not
disagreeable ; it has the odor and appear-
ance of blood. All objections are soon for-
gotten, however, in the results of its action
upon the nutrition of the system, and the
patient soon learns to like it, and often
craves for it, drinking it from the bottle or
a glass readily, like any beverage. It
ought to be the food par-excellence for
rapid appropriation in all conditions of ex-
haustion.

P. S. — Phosphates act well with the Liquid
Food.

Editorial of the Chicago Medical Times,
June, 1890.

MEDICAL AND SURGICAL REPORTER.

XTX

MESSRS. SNOW, CHURCH & CO.,

LAW AND COLLECTION OFFICES,

608 & 610 Chestnut Street,

PHILADELPHIA.

Gentlemen : — Your management of the collections of the
Medical and Surgical Reporter during the past year has
been so admirable and so much more successful than that of
any agency with which I have dealt heretofore, that I renew
my contract with you for the coming year with great pleasure.
The Publisher of the Medical and Surgical Reporter.
Philadelphia,

September 25, 1890.

GrESWrJXKTJS BLAUD'S PILLS.

These pills, which have been inserted in the new French
Pharmacopoeia, have been employed with the greatest success
for more than fifty years by most French and foreign physi-
cians, to cure anemia, chlorosis, and all chlorotic affections in
which iron is indicated.

Here is the opinion of men most eminent in medical science
who have employed them:

" For thirty-five years, in which I have practised medicine, I
have recognized the incontestable advantages of BLAUD'S
PILLS over all other ferruginous preparations, and I regard
them as the best anti-chlorotic." — Dr. Double, Ex-President of
the Academy of Medicine.

" Of all the ferruginous preparations, which have given good
results in thetreatment of chlorotic affections, BLAUD'S PILLS
appear to us to deserve to hold the first rank." — Diclionnaire
universel de medecine, Vol. II, p. 99.

These pills, prepared according to the genuine formule of
the originator, by his nephew, Aug. Bland, Pharmacist of the
Faculty of Paris, are sold only in bottles of 200
pills and half bottles of 100 pills, at a cost of 5
and 3 francs ($1.00, and seventy-five cents), and
never in smaller quantities. See that his name is
stamped on each pill. PARIS, 8 RUE PAYENNE,
and at every Pharmacy. (Beware of imitations.)

irmacist of the

GOLD MEDAL, PARIS, 1878.

W. Baker A Ccs

Breakfast
Cocoa

from which the excess of
oil has been removed, is

Absolutely JPure
and it is Soluble.

No Chemicals

are used in its preparation. It has
more than three times the strength of
Cocoa mixed with Starch, Arrowroot
or Sugar, and is therefore far more
economical, costing less than one cent
a cnp. It is delicious, nourishing,
strengthening, easily digested,
and admirably adapted for invalids
as well as for persons in health.

Sold by Grocers everywhere.

W. BAKER & GO., Dorchester, Mass.

SCOTT'S EMULSION

= VERSUS -

PLAIN COD LIVER OIL.

Plain Cod Liver Oil is indigestible, deranges the stomach, destroys the appetite
is not assimilated, and in a majority of cases is detrimental to the patient.

SCOTT'S EMULSION

Can be digested in nearly all cases , is assimilated, does not derange the stomach,
nor overtake the digestive functions, and can be taken for an indefinite period when the
plain cod liver oil cannot be tolerated at all, and with most marked results in Anmmia,
Consumption and all wasting conditions. It also contains the Hypophosphites of Lime
and Soda with Glycerine, which are most desirable adjuncts.

WHEN PHYSICIANS TRY IT THEY INVARIABLY USE IT
in preference to the plain cod liver oil or other so-called Emulsions that invariably separate,
and hence their integrity and value is destroyed. Scott's Emulsion is palatable and
absolutely permanent hence its integrity is always preserved.

The formula for Scott's Emulsion is 50 per cent, of the finest Norwegian Cod Liver Oil, 6 grains
Hypophosphite of Lime and 3 grains Hypophosphite of Soda to the fluid ounce, Emulsified, or digested
to the condition of assimilation with chemically pure Glycerine and Mucilage.

We also wish to call your attention to the following preparations :

CHERRY MALT PHOSPHITES.

A combination of the tonic principles of Prunus Yirginiana, Malted Barley, Hypophosphites of
Lime and Soda, and Fruit Juices. An elegant and efficient brain aud nerve tonic.

BUCKTHORN CORDIAL (Rhamnus Frangula).

Prepared from carefully selected German Buckthorn Bark, Juglans Bark and Aromatics. The
undoubted remedy for Habitual Constipation.

Be sure and send for samples of the above — delivered free.

SCOTT & BOWNE, 132 South Fifth Avenue, NEW YORK.

XX

MEDICAL AND SURGICAL REPORTER.

The Atmospheric Tractor

SOME PRACTICAL POINTS ABOUT ITS USE.

In using the Atmospheric Tractor, it will be found that after the head has been
properly flexed, its extraction will be facilitated more by continuous moderate traction
for a number of seconds, than by exerting at once the greatest power possible.

It is well known that all sphincter muscles readily relax to gentle, continuous,
persuasive pressure, but if abrupt great force be employed they contract spasmodically,
and will often become ruptured or lacerated before relaxing.

Continuous pressure, of a trifling amount, will tire out the strongest muscles. A
man may be able to pick up fifty pounds or more with one hand and hold it extended
for a brief period, but he could not support a weight of five pounds in the same manner
for many minutes. The muscles employed would become tired out and relax. In a
similar manner, the pelvic muscles and the muscular tissue of the vagina may resist for
hours the intermittent pressure of the head driven against them by the abdominal and
uterine muscles, but they will become tired out and relax in a few minutes to a much
less pressure exerted against them continuously through the medium of the Atmospheric
Tractor.

It is not to be supposed that delivery will be completed invariably by one extractive
effort. The extrusion of the head is a complex process which can be better accomplished
in three moves than in one. The Tractor should, therefore, be detached when necessary,
and reapplied in the desired position. If it becomes detached during traction, no alarm
need be felt, as no injury has or can be done by its separation, and its reapplication only
requiring a few seconds of time.

Flexion and rotation may be made at any time with the Atmospheric Tractor, but
direct tractile efforts should not be made during the moment intervening between the
relaxation of the abdominal muscles and the inward rush of air into the uterus. During
this lightning-like interval our efforts should be directed only to hold the head in the
position which it has gained until the column of air has rushed past it and broken up the
uterine vacuum. At all other times, whether between pains or during their continuance,
direct traction may be exerted with great and immediate relief.

P. McCAHEY, M. D.

IFrlce, $3.00-

Sent free by mail or express on receipt of $3.00. Address the ATMOS-
PHERIC TRACTOR CO.,

219 NORTH 22d STREET, PHILADELPHIA.

P. O. Box 1202.

MEDICAL AND SURGICAL REPORTER.

XXI

WESTERN PENNSYLVANIA MEDICAL COLLEGE

CXT-LT OUT PITTSBTJE&H.
SESSIONS OF 1890—91.

The Regular Session begins on the last Tuesday of Sep-
tember, and continues six months. During this session, in
addition to four Didactic Lectures, two or three hours are daily
allotted to Clinical Instruction, Attendance upon two regular
courses of lectures is requisite for graduation. A three years'
graded course is also provided. The Spring Session embraces
recitations, clinical lectures and exercises, and didactic lectures
on special subjects; this session begins the second Tuesday in
April, and continues ten weeks.

The laboratories are open during the collegiate year for
instruction in chemistry, microscopy, practical demonstrations
in medical and surgical pathology, and lessons in normal his-
tology. Special importance attaches to "the superior clinical
advantages possessed by this College." For particulars, see annual
announcement and catalogue, for which, address the Secretary
af Faculty, Prof. T.M.T. McKSNNAN.

Business correspondence should be addressed to

Peof. W. J. ASDALE, 2107 Penn Avenue, Pittsburgh.

Walnut Lodge H ospital,

HARTFORD, CONN.

Organized in 1880 for the special medical treatment of

ALCOHOL AND OPIUM INEBRIATES.

Elegantly situated in the suburbs of the city, with every ap-
pointment and appliance for the treatment of this class of
cases, including Turkish, Russian, Roman, Saline and Medi-
cated Baths. Each case comes under the direct personal care
of the physician. Experience shows that a large per cent, of
these cases are curable, and all are more or less benefited from
the application of exact hygienic and scientific measures.
This institution is founded on the well-recognized fact that
Inebriety is a disease, and curable, and all these cases re-
quire rest, change of thought and living, in the best sur-
roundings, together with every means known to science and
experience to bring about this result. Applications and all in-
quiries should be addressed

T. D. CROTHERS, M.D.,
Sup't Walnut Lodge, Hartford, Conn.

EXCELLENT OPENSNC

FOR

YOUNG PHYSICIAN.

Office of recently deceased physician to let, with practice,

18 16 Christian St., Philadelphia.

For Sale. %

A TOEPLER-HOLTZ
STATIC BATTERY, in
case, as good as new. 16
ch revolving plate.

Address

Medical and Surgical Reporter,
P. O. Box 843, Philadelphia.

DR. MASSEY'S

PRIVATE SANITARIUM

212 South Fifteenth Street

PHILADELPHIA

This institution, in addition to complete arrangements for
che treatment of Nervous Diseases by rest, electricity, mass-
age, etc., under comfortable surroundings, is specially equipped
for the treatment of cases of Fibroid Tumors and other intract-
ible diseases of the pelvic viscera, by the conservative use of
strong electric currents. For particulars, address

DR. G. BETTON MASSEY,

Physician in Charge.

Mellin's Food

FOR INFANTS AND INVALIDS.

A SOLUBLE DRY EXTRACT, prepared from Malted Barley
and Wheat, consisting of Dextrin, Maltose, Albuminates, and Salts.

The SUGAR in MELLIN'S FOOD is MALTOSE. MALTOSE is
the PROPER SUGAR for use in connection with cow's milk.

The sugar formed by the action of the Ptyalin of the Saliva and the Amylopsin of
the Pancreas upon starch is MALTOSE. In the digestive tract MALTOSE is absorbed

UNCHANGED. — Landois and Sterling.

MALTOSE is a saccharose, not a glucose, and is a form of sugar which does not ferment.

— Materia Medica and Therapeutics, Dr. Mitchell Bruce.

" I have never seen any signs of fermentation which I could attribute to the influence
Of MALTOSE." -Eustace Smith, M.D., F.R.C.S.

MELLIN'S FOOD, prepared according to the directions, is
a true LIEBIG'S FOOD and the BEST SUBSTITUTE for Mother's
Milk yet produced.

" * IT REQUIRES NO COOKING.

THE DOLIBER-GOODALE CO.,

BOSTON, MASS.

XXII

MEDICAL AND SURGICAL REPORTER.

TEE mil MEDICAL USE

■ OF PHILADELPHIA.

The 66th Annual Session of the Jefferson Medical College
begins October 1st and continues nearly 7 months.
Preliminary Lectures will be held from
22d of September.

EACH student is immediately and personally taught in Ob-
stetrics and Gynaecology, Physical Diagnosis, Laryngol-
ogy, Ophthalmology, Medical Chemistry, Pharmacy,- Materia
Medica, and Experimental Therapeutics, Histology and Ex-
perimental Physiology, Minor Surgery, Bandaging, Operations
on the Cadaver, Pathology, Neurology, and Electro-Thera-
peutics.

Three annual regular sessions are required. Bedside in-
struction in Medicine, Gynaecology, Surgery and Obstetrics
is a part of the third year course. No extra fee.

The Annual Announcement will be sent on applica-
tion to J. W. HOLLAND, M Dean.

MEDICO-CHIRURGJCAL COLLEGE

OP PHILADELPHIA.

Winter Session will begin Wednesday, October ist, and
continue until April 16th. Preliminary Session begins Sep-
tember 8th. Spring Term, April 20th, 1891.

The curriculum is graded, and a preliminary examination
and three Annual Winter Sessions are required. Laboratory
instruction in Chemistry, Histology, Pathology, Hygiene,
Physiology, with Bedside instruction in Medicine, Surgery and
Gynecology, is a part of the regular course.

Fees : Matriculation $5.00. First and second years, each
$75.00. Third year $100.00. Fourth year free to those in
attendance three sessions; to all others $100.00.

For Announcement or information apply to

E. E. MONTGOMERY, M. D.,

1818 Arch Street, Philadelphia, Pa.

NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL

SESSIONS 1890.91.

The Autumn and Winter Sessions of the Post-Graduate Medical School opened on September 15. The Hospital is fully
utilized for clinical purposes. There are ninety beds, including thirty for babies in the adjacent building. No Post-Graduate
Medical School in this country can offer such opportunities for seeing important surgical and gynaecological operations under
its own roof as does this institution. Besides, regular clinics, medical and surgical, are held by professors and instructors in
those general and special hospitals with which they are connected, which comprises nearly all the great hospitals of the city.
The dispensary of the school and other large dispensaries furnish ample means of instruction in every class of walking cases.

Instruction is given in every branch of medicine and surgery. The laboratory is large and well equipped. Surgical
anatomy and operative surgery are thoroughly taught. The instruction is personal, the practitioner being brought in direct
contact with the patient. No other courses in any department will be required if those to be had in the Post-Graduate School
are taken. The faculty were the first in the United States to organize private courses for practitioners of medicine, and they
pledge themselves to- leave nothing undone to make graduates in medicine profit by the unrivalled clinical advantages of the
City of New York.

For catalogue and schedule, address

CLARENCE C. RICE, M. DM Secretary,

D. B. St. JOHN ROOSA, M. D., LL.D., President. 226 East 20tli St., New York City.

F. E. FARRELL, Superintendent.

COLLEGE OF MEDICINE. SYRACUSE UNIVERSITY.

JOHN VAN DUYN, M. D., Surgery.

HENRY D. DIDAMA, M. D., Practice and Clinical Medicine.
WILLIAM T. PLANT, M. D., Diseases of Children.
ALFRED MERCER, M. D., State Medicine.
WILLIAM MANLIUS SMITH, M. D., Chemistry.
DAVID M. TOTMAN, M. D., Clinical Surgery,
NATHAN JACOBSON, M. D., Clinical Surgery and Laryn-
gology.

FACUI/TY.

GAYLORD P. CLARK, M. D., Anatomy.
WILLIAM H. DUNLAP, M. D., Dermatology.!
JOHN L. HEFFRON, M. D., Materia Medica and Thera-
peutics.

HENRY B. ALLEN, M. D., Obstetrics.
A. CLIFFORD MERCER, M. D., Pathology.
HENRY L. ELSNER, M. D„ Clinical Medicine.
FRANK W. MARLOW, M. D., Ophthalmology.

Three Years' Graded Course. Year begins October 7th, 1890, ends in June, 1891.

FIRST YEAR : Anatomy, Physiology, Chemistry, Histology, Materia Medica.

SECOND YEAR: Anatomy, Physiology, Chemistry, Therapeutics, Pathology, Practice, Surgery, Clinical Medicine and
Surgery.

THIRD YEAR: Therapeutics, Practice, Surgery, Children, Clinics, Obstetrics, Gynaecology, Forensic Medicine, Ophthal-
mology, Hygiene.

An experience of seventeen years has demonstrated that a three years' graded course is superior in every respect to an
ungraded, unnatural, and cramming course of two winters.

Tuition, $80.00 for each Tear. Perpetual Ticket, $200.00. Diploma, $25.00.
For circulars with full information, address

W. H. DUNLAP, M. D., Registrar, SYRACUSE, N. Y.

UNIVERSITY OF PENNSYLVANIA. — Medical Department

The 125TH Annual Winter Session will begin Wednesday, October ist, 1890, at 12 M., and will' continue seven months.
The Preliminary Session begins September 22d, 1890, the Spring Term early in May, 1891.

The curriculum is graded and three annual winter sessions are required. Practical instruction, including laboratory work
in Chemistry, Histology, Osteology and Pathology, with Bedside Instruction in Medicine, Surgery and Gynecology are a part
of the regular course and without additional expense.

FACULTY.

JOSEPH LEIDT, M.D., LL.D., Professor of Anatomy.
D. HAYES AGNEW, M.D , LL.D., Honorary Professor of Clin-
ical Surgery.

WILLIAM PEPPER, M.D., LL.D., Professor of Theory and
Practice of Medicine, and of Clinical Medicine.

WILLIAM GOODELL, M.D., Professor of Gynecology.

JAMES TYSON, M.D., Professor of Clinical Medicine.

HORATIO C. WOOD, M.D., LL.D , Professor of Blateria Medica,
Pharmacy and General Therapeutics.

THEODORE G. WORMLEY, M.D., LL.D., Professor of Chem-
, istry and Toxicology.

JOHN ASHHURST, Jr., M.D., Professor of Surgery and of
Clinical Surgery.

EDWARD T. REICHERT, M.D. Professor of Physiology.

WILLIAM F. NORRIS, M.D., Honorary Prof.of Ophthalmology
BARTON COOKE HIRST, M.D., Professor of Obstetrics.
J. WILLIAM WHITE, M.D., Professor of Clinical Surgery.
JOHN GUITERAS. M.D., Professor of General Pathology and

Morbid Anatomy.
GEORGE A. PIERSOL, M.D., Professor of Histology and Em

bryology.

SAMUEL G. DIXON, M.D., Professor of Hygiene.

For Catalogue and announcement containing particulars!,
apply to

DR. JAMES TYSON, Dean,
36th and Woodland Avenue, Philadelphia.

MEDICAL AND SURGICAL REPORTER.

XXIII

PHILADELPHIA POLYCLINIC

THE PHILADELPHIA POLYCLINIC

HAS MOVED TO

EIGHTEENTH AND LOMBARD STREETS,

AND OCCUPIED ITS

New College and Hospital Building,

The Finest Structure of the kind in America.

Practical instruction in all branches of medicine, utilizing
its own rich out-patient service, its indoor accommodation of
50 beds, and the best facilities of the other hospitals of Phila-
delphia. Six weeks' courses may begin at any time.

Write for announcement and full particulars.

XXIV

MEDICAL AND SURGICAL REPORTER.

O-EIFFITH CO.'S

Compound Mixture of Guaiac, Stillingia, etc.

For Acute and Chronic Rheumatism, Gout, Lumbago, Neuralgia, and Kindred Complaints,

TO PHYSICIANS. — Gentlemen : We would respectfully draw your atten-
tion to our COMPOUND MIXTURE OF GUA1AC, STILLINGIA, ETC.

THIS is not a new preparation, but has been in constant use by many prominent practitioners of medicine for several
years, and its beneficial results in the treatment of the diseases indicated, including Syphilitic troubles, have D«en fully
established.

When ordering this Preparation, in order to avoid delay or misunderstanding, Physicians will please specify
'* GRIFFITH & CO.'S," or Physicians in the city can send their patients direct to our pharmacies, at No. 67 Third
Avenue, cor. 11th St., or 2241 Third Avenue, cor. 123d St., New York, where, at any time, further infor-
mation will be cheerfully furnished. Out of town Physicians can order through their druggists or direct from us.

WE have hundreds of testimonials from prominent physicians who have prescribed and personally used
this mixture. It is manufactured for PHYSICIANS' PRESCRIPTIONS only. Always specify
Griffith & Co.'s. If you have an obstinate case of Rheumatism under treatment, inclose One Dollar and
receive, by express, a regular size bottle, or we will send, upon request, a sample bottle providing you will
pay express charges. Wholesale Price-List — 8-ounce size, $10.50 per dozen ; 16-ounce size, $20.00 per dozen.
In lots of one dozen and upward, we prepay express charges to any point east of the Rocky Mountains. (Do
not overlook this offer, for you may be pleased and possibly surprised at the results.)

P. S.— The advertising of this article is confined strictly to Medical Journals, and the general verdict of physicians is
that if this mixture does not act on a case, it is a difficult matter to find something that will.

Very respectfully,

GRIFFITH & CO., Chemists anil Pharmacists,

67 Third Ave., cor. 11th St., and 2241 Third Ave., cor. 122d St., ISEW YORK.

Carried in stock by the principal Wholesale Druggists in the U. S.

SVAPNIA

PURIFIED OPIUM

St. Tincsnt Home Maternity Hospital,

70th Street and Woodland Avenue,

(PASCHALL STATION) PHILADELPHIA.

«TF0R PHYSICIANS USE ONLY.

Contains the Anodyne and Soporific
Alkaloids, Codeia, Narceia and Morphia.
Excludes the Poisonous and ConrulsiTe
Alkaloids, Thebaine, Narcotine
and Papaverine.

Svapnia has been in steadily increas-
ing nse for over twenty years, and
whenever used has given great satis-
faction.

To Physicians op repute, not already
acquainted with its merits, samples
will be mailed on application.

Svapnia is made to conform to a uni-
form standard of Opium of Ten per
cent. Morphia strength.

JOHN FARE, Manufacturing Chemist, New York.
C.N. CRITTENTON, Gen?l Agent5115 Fulton 5tMN. Y

To whom all orders for samples must be addressed.
SVAPNIA IS FOR SALE BY DRUGGISTS GENERALLY.

Conducted by the Sisters of Charity,

T NFANTS and Children under two years of age

Patients for Maternity Department ac-
commodated according to their means.

IN THE WARDS terms range from $5.00
to $8.00 per week.

IN THE PRIVATE ROOMS terms range
from $10.00 to $20.00 per week.

For further information apply to or address

THE SISTER IN CHARGE,
PASCHALVILLE,

PHILADELPHIA, PA.

XXV

SYRUP OF FIGS.

(Syr. Fici Cal.)

In order to meet the almost universal demand for a safe, reliable and elegant
liquid laxative, the

CALIFORNIA FIG SYRUP CO.

OF

SAN FRANCISCO, CAL.
LOUISVILLE, KY. NEW YORK, N. Y.

is utilizing the delicious blue Fig of California in the preparation of

SYRUP OF FIGS,

an agreeable and effective laxative or purgative, according to the dose and manner of
administration.

Syrup of Figs is delightful to the taste, and may be taken by every one, from
infancy to old age.

Syrup of Figs does not debilitate, and is perfectly safe.

The dose as a purgative for an adult is from one-half to one tablespoon ful and
may be repeated in six hours if required. As a laxative, one or two teaspoonfuls may be
given at bed-time or before breakfast.

For children the dose may be regulated according to age and desired effect.

SYRUP OF FIGS

is recommended and prescribed by prominent physicians in all sections of the United
States, and gives general satisfaction.

In addition to the blue Figs of California, we use the juice of true Alexandria
Senna, representing the laxative and purgative principles without its griping properties,
also pure white sugar and an excellent combination of carminative aromatics.

Devoting our entire attention to the manufacture of Syrup of Figs after a
thorough study of the results to be accomplished and of the best methods to produce a
perfect laxative, and with complete manufacturing facilities especially adapted to the
purpose, we are enabled to offer to the medical profession, in Syrup of Figs, a laxa-
tive which, though simple in itself, cannot be produced in all its excellence by other
parties, and we believe and trust that physicians will not permit imitations to be used
when they prescribe Syrup of Figs (Syr. Fici Cal.).

SYRUP OF FIGS

is manufactured only by the

CALIFORNIA FIG SYRUP CO.

OF

SAN FRANCISCO, CAL.
LOUISVILLE, KY. NEW YORK, N. Y.

It is sold to the drug trade in bottles of two sizes only : the smaller bottles con-
taining full four ounces and the large size about ten ounces.

XXVI

MEDICAL AND SURGICAL REPORTER.

" What a boon it would be to the Medical Profession if some reliable
Chemist would bring out an Extract of Malt in combination with a well-
digested or peptonized Beef, giving us the elements of Beef and the
stimulating and nutritious portions of Ale."— J. Milner Fothergill, M.D.

Ale & Beef

" PEPTONIZED"

(EXTRACT :-Bovis Cum Malto.)

Is the identical combination suggested by the late eminent Fothergill.

EACH BOTTLE REPRESENTS 1-4 POUND
OF LEAN BEEF THOROUGHLY PEPTONIZED.

It is the only Mild Stimulant combined with a Perfect Food known.
It is very palatable, aids digestion, is retained by the most delicate stomach,
and the purity of its ingredients is guaranteed.

THE " PEPTONIZED" BEEF

is manufactured by Prof. Preston B. Rose, of Chicago, late of the faculty of the

University of Michigan.

THE ALE USED
IS THE PUREST AND BEST MADE IN AMERICA

Especially brewed for this purpose, and guaranteed to be equal to
the best imported ales, as only the best Canada Malt and the
choicest new hops are used in its manufacture.

IT IS A REAL FOOD; NOT A MERE STIMULANT,

as it contains all the albumen and fibrin of the beef as well as the nutritive
qualities of the malted barley.

It is most useful during the period of Gestation, in allaying all vom-
iting, and invaluable to Nursing Mothers ; also in Typhoid Fever and
Dysentery.

Prof. G. A. Liebig says: "A careful chemical examination of the
Peptonized Ale and Beef shows a much larger per cent, of nitrogenous
blood and muscle-making matter over all other malt extracts, and that
it is also rich in Diastase, giving it the power to digest Starch Foods."

PBEPiLHED IB 72"

The Ale and Beef Company,

DAYTON, OHIO, U. S. A.

Two full-sized bottles will be sent FREE to any physician who will pay express charges.
Please mention this journal.

The Genuine Imported

Mann Hoffs Malt Extract

is put up in this style only.

This has been the first Malt Ex-
tract introduced to the Medical Pro-
fession ( 1847). No preparation of
Malt has been so long and exten-
sively employed as a Medical

Food Nutrient and Tonic.

The following is an abstract from the work ion the Pul-
monary Diseases published by Prof. PROSPER DE ■
Pietra Santa, at Paris:

"Asa large number of patients lack the neces-
sary power to digest solid food, and would through
the use of stimulants be merely excited and weak-
ened, therefore I regard it of immense value to
the practitioner to bring to his aid a nutritious
tonic and remedy like the Johann Hoff's Malt
Extract, which will act not only as a tonic, but as
a nutrient as well, and which is less exciting than
wine as a stimulant."

" I have, during the past eighteen months, made
a number of examinations of the principal forms
of Malt Extract in the market, and have satisfied
myself that the Johann Hoff's Malt Extract, im-
ported by Eisner & Mendelson Co., is a genuine
Malt Extract, free from Salicylic Acid or other
objectionable substances."

Henry Leffmann, M.D., Phila.

Please Specify

JOHANN HOFF'S" MALT EXTRACT.

Imported by " EISNER,"
When ordering the Genuine Article.

The Genuine has the signature of" Johann Hoff

CAUTSON: A preparation bottled in
New York is being sold as " Hoff 's " Malt
Extract. To obtain the genuine, original
article, please specify "JOHANN HOFF'S
MALT EXTRACT, imported by Eisner,'*
which will prevent substitution.

and " Moritz Eisner" on the neck of every bottle-

EISNER & MENDELSON CO., Sole Agents for the U.S.,
6 Barclay Street, New York.

25

eutzc Points.

Use McArthur's Syrup (Syrup Hypophos. Comp., C. P., McArthur) for
Consumption, as it rapidly repairs the waste and restores vigor to the system.

For Tuberculosis in all forms, as it invigorates the tissue cells and enables
them to overcome and expel the disease germs.

For Scrofula, as it builds up the tissue walls and thus breaks up the various
inflammatory and suppurative processes incident to this diathesis.

For Inflammatory Diseases of the Throat, Bronchial Tubes and Lungs, as its
tonic and healing properties are nowhere better manifested than in this class of

diseases.

For Rachitis, and all osseous degeneration, as it rapidly repairs bone tissuec
For Teething of Infants, as it furnishes food to the growing teeth. For the

same reason you should give it to the nursing mothers and those whose teeth and

bones are suffering during pregnancy.

For Chronic Diarrhea, Leucorrhea, Suppurating Discharges and Sores.

For Chronic Alcoholism, the Morphine Habit, Brain Exhaustion, Loss of
Memory, Neurasthenia, Spermatorrhea, Impotence, and all derangements of the
nervous system. Here, by building up and restoring the nerve tissue it effects a
permanent cure, raising the patient from despondency to renewed hope and
confidence, from weakness to strength and vigor.

For Uterine Fibroids and all forms of perverted nutrition, where it restores
the normal processes of nutrition, and effects a recovery at once gratifying to the
patient and satisfactory to the physician.

To obtain the best results, the Syrup should be given for a long time — weeks,
months and even years — until the disease is entirely eradicated and the patient no
more susceptible to its return than if it "never had occurred."

As it is made only for Physicians' prescriptions there are no labels, &c, on the
bottle.

We will send our valuable treatise on "The Curability and Treatment of
Consumption," free to any physician.

Mc ART H U R HYPOPHOSPHITE CO.,

BOSTON, MASS.

iherap

1

PURE.
SOLUBLE.
Delicious

THE STANDARD COCOA OF THE WORLD,
A SUBSTITUTE FOR TEA & COFFEE,
Easily Digested— Made Instantly.

HICHEST AWARDS AT
PRINCIPAL EXHIBITIONS*
The Original— Take no other.

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Vaccine Virus

FOR SALE

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Address, MEDICAL AND SURGICAL REPORTER, P. O. Box 843, Philadelphia.

JOSEPH ZENTMAYER,

OPTICIAN,

209 South 11th Street, PHILADELPHIA,

HISTOLOGICAL MICROSCOPES, $65.00.

REPAIRING- OF ALL SCIENTIFIC INSTRUMENTS.
STUDENTS' MICROSCOPES $38.00 TO $46.00 COMPLETE,

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RENTS SAFES in its ABSOLUTELY
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VAULTS.

ALLOWS INTEREST on deposit*
of money, acts as Registrar and Transfer
Agent of Corporation Stocks, and exe-
cutes Trusts of every kind under appoint-
ment of States, Courts, Corporations, or
individuals, holding Trust Funds sepa-
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Company.

COLLECTS INTEREST OR IN-
COME.

RECEIVES FOR SAFE KEEPING,
under Guarantee, VALUABLES of every
description.

Receipts for and safely keeps Wills
•without charge.

For further information, call at the
office, or send for a circular.

MANAGEMENT.
Richard Y. Cook, President.
Geo. H. Earle, Jr., Vice-President.
Harry J. Delany, Treasurer.
John Jay Gilroy, Secretary.
Richard C. Winship, Trust Officer.

DIRECTORS.
Thomas Cochran.
Edward C. Knight.
Thomas MacKellar.
John J. Stadiger.
Clayton French.
W. Rotch Wister.
Alfred F.tler.
J. Dickinson Sergeant.
Aaron Fries.
Charles A. Sparks.
Joseph Moore, Jr.
Richard Y. Cook.
George H. Earle, Jr.

II

MEDICAL AND SURGICAL REPORTER.

SULFONAL-BAYER.

A CORRECT METHOD OF ADMINISTRATION, ESSENTIAL TO OB-
TAINING ITS HYPNOTIC EFFECT"

Inquiries have been made of us from time to time as to the best method of administering Sulfonal-
Bayer. These inquiries indicate that various methods of administration have been employed, and this,
without doubt, accounts for those cases where the results obtained were not wholly satisfactory. We call
special attention to the following :

" Clinically observed, we recognize in Sulfonal a mild calmative, a slowly but progressively active
hypnotic. It has no other action, and its operation is attended by 710 complications, near or remote. It is,
therefore, a pure hypnotic"

" The essential conditions of success in the exhibition of Sulfonal depend on first, the time when the
remedy should be administered ; second, the method of administration ; third, the dose."

" is a fact, perhaps wholly unprecedented in what we observe of other neurotic materials, that
Sulfonal demands from two hours to one hour for its physiological incubation ; often quite two hours elapse
between ingestion and the first accession of sensible medicinal energy. With the untried subject it is wise
to stipulate for two hours'' — [Extracts from articles by Prof. H. M. Field, New England Medical
Monthly ; 1 ' herapeutic Gazette, ,]

According to the experience of Prof A. East, of Freiburg University, Sulfonal- Bayer should be
administered in a plate of soup, a cup of hot tea, milk or broth, at least two hours before retiring, or with
the last meal early in the evening, between y and 8 P. M„ at which time the stomach contains considerable
amount of muriatic acid, mineral salts and peptones, and the most favorable conditions for the absorption
are satisfied.

Sulfonal has just been incorporated into the Addendum to the British Pharmacopoeia.

Sulfonal-Bayer, prepared by the Farbenfabriken, formerly Friedr. Bayer & Co., Elberfeld, is supplied
by us in ounces and in the form of Tablets of 5, 10 and 15 grains, put up in bottles of 10 and 100 tablets
each.

We also offer Sulfonal-Bayer in the form of our soluble pills, containing 5 grains each.

ARISTOL.

In order to secure the desired effects of Aristol, it is important thai the physician be certain that the
article used bears the guarantee furnished by the continuous scientific control and the name of the manu-
facturers, the " Farbenfabriken, vormals Friedr. Bayer <Sr» Co., in Elberfeld?' This firm are the only
manufacturers of this article, and the word u Aristol" is their registered property.

The preparation of Aristol, theoretically simple, involves the greatest care and experience.

Aristol, a combination of iodine and thymol, manufactured by the Farbenfabriken, formerly Friedr.
Bayer & Co., Elberfeld, Germany, is a valuable, inodorous, and non-toxic antiseptic remedy, superior to
iodoform, iodole, and sozo-iodole.

The general specific action of Aristol is similar to that of iodoform, iodol, and the sozo-iodol com-
pounds, but in addition it has the valuable property of forming an absolutely unirritant covering over the
surfaces on which it is placed, under which the processes of granulation and cicatrization proceed with
extraordinary rapidity. * *

Aristol is indicated in Mycosis, Lupis, Psoriasis, Syphilitic diseases generally, etc., etc.

Descriptive pamphlet mailed on application.

PHENACETINE-BAYER.

Antineuralgic- Antipyretic.

Much valuable testimony regarding Phenacetine, furnished by the medical profession of other countries,
as well as our own, has, from time to time, been collated by us, and the same has been put before American
practitioners.

The scope of Phenacetine having widened, we have brought together in pamphlet form, classified in
respect to diseases indicated, the results of the latest experience as reported chiefly by American physicians.
This pamphlet mailed to applicants.

W. H. Schieffelin & Co.,

170 & 172 William Street,
NEW YORK.

MEDICAL AND SURGICAL REPORTER.

Ill

IV

MEDICAL AND SURGICAL REPORTER.

SOMNAL.

RADLAUER.

CHEMICAL FORMULA: CH12C1803N.

SOMNAL is a new soporific which produces sound sleep within
half an hour after taking, and the effect lasting six to eig-ht hours. The
dose is 2 or 3 grammes (half a teaspoonful) ; it is best administered
with extract of licorice or with syrup of raspberry. Somnal does not
affect either digestion, respiration, or the temperature of the body.

Dr. Guttman, Surg. Director of the City Hospital Moabit, in Berlin, states
that he has applied " Somnal " in 60 to 70 cases at the hospital. Doses of 2
grammes have produced a quiet, refreshing sleep, lasting from 6 to 8 hours, with-
out any unpleasant symptoms following its use.

The British Medical Journal says : " Somnal" when given in doses of half a
teaspoonful, will produce sleep in thirty minutes. The sleep is described as sound
and natural, lasting from 6 to 8 hours, and followed by no unpleasant effects.

Somnal does not disturb the digestion, has no influence over the pulse or tem-
perature, and, in fact, has the excellent qualities of both chloral and methane
without their disadvantages.

Dr. Knyy of Strassburg, prefers Somnal to Sulfonal, and claims that it pro-
duces deep sleep within half an hour after its administration, and that it
has but little influence on the heart's action.

Dr. J. S. Ridge, of Kingston, R. I., writes : " I have used Somnal on three
cases of insomia, in middle aged and quite old ladies, with beautiful results, having
used Sulphonal, Bromidia, Chloralamid with little or no result. I gave a lady 80
years old suffering from Insomnia 3 grammes of Somnal at bedtime in a little
Syrup of Raspberry, with splendid effect, she getting, so the nurse says, 6 hours
sound sleep. This is the best soporific I have used yet."

S. RADLAUER, - BERLIN.

NEW YORK ADDRESS:

EISNER & MENDELSON CO.,

IST2SW YORK.

Samples Free 011 Application by mentioning this Journal.^a

MEDICAL AND SURGICAL REPORTER.

V

IN GYNAECOLOGICAL PRACTICE

For Subinvolution, Congestive Dysmenorrhea, Chronic Metritis, &c.
For Hemorrhoids, Relaxation of Sphincter, Prolapsus of Rectum, &c.

For Congestion of Mucous Membranes as in Conjunctivitis,
Cervicitis, Pharyngitis, Gonorrhoea, &c.

Or by the mouth, for Aneurisms, Dilatation of Heart, Acute and Chronic Dysentery,
Haemoptysis, Hematuria and other Hemorrhages ; Chronic Arteritis, Incontinence,
Spermatorrhoea, Varicocele, Varicose Veins, Diabetes Insipidus ; with the Bromides for
Spinal Meningitis, Acute Myelitis and Congestion of Meninges and Cord, and in obstetric
practice, especially when Post-Partum Hemorrhage is threatened,

ERGOTOLE

has been most successfully employed. When given hypodermically, more prompt action and
the best results are usually obtained.

Ergotole is a new preparation of Krgot of Rye. It is specially made for hypodermic use
by a new process ; representing all the active principles of Ergot in a very concentrated
form, and entirely freed from all inert and irritating constituents.

It causes neither pain nor abscess, and keeps perfectly without precipitation
for any leng-th of time. It has been extensively tried in hospital and private practice,
hypodermically and administered by the mouth, proving uniformly efficacious, and it has
been pronounced

THE MOST EFFICIENT PREPARATION OF ERGOT IN USE

One minim representing the full therapeutic strength of about 2)4, grains of the best Spanish
Ergot. Administered by the mouth, it will prove itself divested of all irritating and nauseat-
ing properties, which are so objectionable in the officinal fluid extract.

An eminent physician of Baltimore states that he has had uniform and satisfactory re-
sults in over fifty cases of various diseases from a supply of our Ergotole, which was prepared
over two years ago, and kept in a cork-stopped bottle partially filled.

SPECIAL CIRCULAR AND SAMPLE SENT TO PHYSICIANS WHO MENTION THIS JOURNAL.*®*

SHARP & DOHME,

MANUFACTURERS OF
Standard Medicinal Fluid and Solid Extracts; Soluble Hypodermic Tablets; Soluble
Gelatin and Sugar-Coated Pills and Granules; Granualr Effervescent Salts;
Compressed Lozenges and Tablets; Fine Chemicals, &c, &c.

Established i860.

BALTIMORE, MO.

VI

MEDICAL AND SURGICAL REPORTER.

RABUTEAU'S DRAGEES of IRON

Laureate of the Institute of France.— Prize in Therapeutics.

The studies made by the Physicians of the Hospitals have
demonstrated that the Genuine Dragees of Iron of
Kabuteau are superior to all other preparations of Iron
in cases of Chlorosis, Ansemia, Leucorrhcea, Debility, Exhaustion,
Convalescence, Weakness of Children, and the maladies caused
by the Impoverishment and Alteration of the blood after
periods of fatigue, watching, and excesses of any kind.

TAKE 4 to 6 DRAGEES DAILY.

Rabuteau's .Elixir of Iron is recommended to those
persons who may be unable to swallow the Dragees. Dose
— A small wineglassf ul with meals,

Rabuteau's Syrup of Iron is specially designed for
children. Chalybeate medication, by means of Rabuteau's
Iron, is the most economical and the most rational known
to therapeutics.

No constipation, no diarrhoea, complete assimilation.
Take only the GENUINE IRON OF RABUTEAU of

OXjI^T <Sc CO, ZFeuris.

^Ql^UTlON OK 1

THE SALICYLATE of SODA
OF DOCTOR CLIN.

Laureate of the Paris Faculty of Medicine
(MONTYON PRIZE).

Dr. Clin's Solution, always identical in its composition,

and of an agreeable taste, permits the easy administration
of pure Salicylate of Soda, and the variation of the dose in
accordance with the indications presented.

" The Salicylate of Soda used by CHn is of perfect purity,
"and is prepared with the greatest care; it is a medicament
"in which we may have every confidence."

— Paris Society of Medicine, Meeting of Feb. 8th, 1879.

Clin's Solution, very exactly mixed, contains: 2
grammes of Salicylate of Soda per tablespoonful, 50 centi-
grammes of Salicylate of Soda per teaspoonful.

£=a,rls— OX_.I2nT <Sc CO.-Parii?

AND BY ALL DEUGGISTS.

CAPSULES

MATHEY-CAYLUS

WITH THIN ENVELOPE OF GLUTEN.
CONTAINING COPAIBA AND ESSENCE OF SANTAL;
COPAIBA, CUBEBS, AND THE ESSENCE OF SANTAL:
COPAIBA. IRON, AND THE ESSENCE OF SANTAL.

"The Matbey-Caylus Capsules, of the Essence of
"Santal, associated with the Balsams, possess an incontesta-
ble efficaciousness, and are employed with the greatest
"success for the rapid cure of old or recent Discharges,
" Gonorrhoea, Blenorrhcea, Leucoirhcea, Cystitis of the Neck,
" Urethritis, Catarrh, and other diseases of the bladder, together
" with all affections of the TJrinary Passages."

" Thanks to their thin envelope of Gluten, which is essen-
M tially assimilable, the Mathey-Caylus Capsules are digested
M by the most delicate persons, and n ever weary the stomach."

— Gazette des Hopitaux de Paris.

CHjIZEnT <Sc CO, IE=a,ris,

AND OP ALL DRUGGISTS.

N E U R ALG 1 AS

PILLS OF DR. MOUSSETTE.

The Moussette Pills of aconitine and quinium, calm or
cure Gaslralgia, Hemicrania, Headache, Sciatica, and the
most obstinate Neuralgias.

"The sedative action exerted by the Moussette Pills
"upon the apparatus of the sanguineous circulation by the
"intermediation of the vaso-motor nerves, indicates their
"use in neuralgias of the trigemini nerves, (fifth pair), con-
"gestivi neuralgias, and painful and inflammatory Eheumatismal
" affections."

"Aconitine produces marvelous effects in the treatment
"of facial neuralgias when they are not symptomatic of
"intracranial tumor." — Society of Biohgy of Paris, Meeting
"of the 28th February, 1880.

Dose — Take 3 to 6 pills during the twenty-four hours.
ACCEPT ONLY THE GENUINE MOUSSETTE PILLS OF
cSc CO.,— Paris.

GRAND NATIONAL PRIZE OF 16,600 FRANCS,

CHE

This meritorious Elixir,
QUINA-LAROCHE, is
prepared from the three
Cinchonas ; it is an agreea-
ble and doubtless highly
efficacious remedy.

— The Lancet.

VINOUS ELIXIR,

A STIMULATING
RESTORATIVE

AND

ANTI-FEBRILE TONIC

QU1N A - LAROCIIE

under the form of a vinous
Elixir contains the totality
of the numerous principles
of the three Cinchona,
barks. It is a preparation
which renders great serv-
ices to Therapeutics. — Ex-
tract of the Gazette des
Hopitaux, Paris.

FAR SUPERIOR TO ALL ORDINARY CINCHONA WINES,

IiAROCHE'S QTJINA, tried by the Academy of Medicine of Paris, is a specially prepared Compound Extract of
Quinquina, a careful analysis, confirmed by experience, has shown that most of the wines and syrups hitherto used have not
contained all the properties of this precious bark, of tnese some, although beneficial, are altogether lost, while many preparations
contain but half the properties of the bark in varying proportions.

Me. Laroche, by his peculiar method, has succeeded in extracting all the active principles of the quinquina, combining these
With Catalan Wine forming an Elixir free from the disagreeable bitterness of other similar preparations. Practitioners have
found triple advantages in the use of this Elixir, it is a strong tonic, is easily administered, and perfectly harmless, being free
from the unpleasant effects of Quinine.

THE FERRUGINOUS QUINA-L.AROCHE is the invigorating tonic par excellence, having the advantage of being
easily assimilated by the gastric juice ; without, in any way, deranging the action of the digestive organs, proving itself to be a most
efficacious remedy in cases of impoverishment of the blood, Anemia, Chlorosis, Intestinal Hemorrhage, Castralgta,
Exhaustion, Etc., Etc.

PARIS.— 22 RUE DROTJOT. — PARIS.

E. FOUGERA & CO., New York,

Sole Agents for the United States for the above Preparations.

MEDICAL AND SURGICAL REPORTER.

VII

ESTABLISHED 18515.

DBS. STRONG'S SANITARIUM,

SARATOGA SPRINGS, NEW YORK,

Receives persons recommended to it by their home physicians for Treatment, Change, Rest or Recreation, and places them
under well-regulated hygienic conditions so helpful in the treatment of chronic invalids or the overtaxed.

For Treatment : In addition to the ordinary remedial agents, it employs Turkish, Russian, Roman, Sulphur, Electro-
Thermal, the French Douche (Charcot's), and all Hydropathic Baths; Vacuum Treatment, Swedish Movements Massage,
Pneumatic Cabinet, Inhalations of Medicated, Compressed, and Rarefied Air, Electricity in various forms, Thermo-Cautery,
Calisthenics, and Saratoga Waters, under the direction of a staff of educated physicians.

tor Change: This Institution is located in a phenomenally dry, tonic, and quiet atmosphere, in the lower arc of the
Adirondack Zone, and within the Snow Belt."

For Rest: The Institution offers a well-regulated, quiet home, heated by steam and thoroughly ventilated, with cheer-
ing influences and avoiding the depressing atmosphere of invalidism.

For Recreation: To prevent introspection, are household sports at all seasons of the year, and in Winter, toboggan-
ing, elegant sleighing, etc. ; in Summer, croquet, lawn-tennis, etc.

Private professional references furnished upon application. Physicians are invited to inspect the Institution at their con-
venience. A liberal discount to physicians and their families.

For further information, address, DFS. S. S. & S. E. STRONG.

For Sale.

A TOEPLER-HOLTZ
STATIC BATTERY, in
case, as good as new. 16
inch revolving plate.

Address

Medical and Surgical Reporter,
P. O. Box 843, Philadelphia.

i for our Patent Barley CRYSTAJLS,
;real Food,for Breakfast Tea
there, write us for free sam-
TliOUR and SPECIAL 0IA-
are invaluable waste-repairing
»sia,Diabetes, Debility & Chil-
> bran ; mainly free from starch,
jothing equals our HEALTH
circular offering 4 lbs. free.
FARWEIiC&RHINES,Props.,Watertown,N.Y

WINDSOR HOTEL,

(fronting East on Windsor Park.)

Winter Resort,
JACKSONVILLE, FLORIDA.

Open DECEMBER TO MAY. Board $4.00
per day. One hundred pleasant rooms at $21 per
week, each person. p. H . ORVIS.

4®= Dogs Not Taken.

Mellin's Food

FOR INFANTS AND INVALIDS.

A SOLUBLE DRY EXTRACT, prepared from Malted Barley
and Wheat, consisting of Dextrin, Maltose, Albuminates, and Salts.

The SUGAR in MELLIN'S FOOD is MALTOSE. MALTOSE is
the PROPER SUGAR for use in connection with cow's milk.

The sugar formed by the action of the Ptyalin of the Saliva and the Amylopsin of
the Pancreas upon starch is MALTOSE. In the digestive tract MALTOSE is absorbed
UNCHANGED.

— Landois and Sterling.

MALTOSE is a saccharose, not a glucose, and is a form of sugar which does not ferment.

— Materia Medica and Therapeutics, Dr. Mitchell Bruce.

" I have never seen any signs of fermentation which I could attribute to the influence
of MALTOSE."

— Eustace Smith, M.D., F.R.C.S.

MELLIN'S FOOD, prepared according to the directions, is
a true LIEBIG'S FOOD and the BEST SUBSTITUTE for Mother's
Milk yet produced.

IT REQUIRES NO COOKING.

THE DO LIBER- GOO DALE CO.,

BOSTON, MASS.

VIII

MEDICAL AND SURGICAL REPORTER.

Books for Subscribers.

BY SPECIAL ARRANGEMENT with the publishers we are able
at this time to offer the following first-class and very valuable
books (last editions) at a very low price, when taken in connection with
paid-up subscriptions. Subscribers will see that we have put in this
list thoroughly good books. See Adv. Page ix.

For

$10.00

REPORTER for one year,

$5.0O

HEATH'S DICTIONARY OF PRAC-
TICAL SURGERY. Cloth,. . . $7.50

For

$9.00

REPORTER for one year,

S6.00

LEIDY'S HUMAN ANATOMY. By

Joseph Leidy, M. D. Cloth, . . $6.00

For

$8.50

REPORTER for one year,

and any one of the following books —

1. — BYFORD'S DISEASES OF WO-
MEN. Cloth, ....

$5.00

$5.00

2. — FOWLER'S DICTIONARY OF PRACTICAL MEDICINE, $5.00

3. — JACOBSON'S OPERATIONS OF SURGERY, $5.00

4. — CAZEAUX & TARNIER'S MIDWIFERY. With Appendix by Munde' . $5.00

5. — THOMAS'S MEDICAL DICTIONARY, $5.00

Th3se w:rks are all in c!o:h binding, but can be supplied in leather binding for $1.00 additional.

For

$6.00

we will send the REPORTER for one year, $5.00
and any two of the following books :

1.— THE NURSING AND CARE OF
THE NERVOUS ANDTHE INSANE.

By Chas. K. Mills, M.D., .... $1.00

2.— MATERNITY ; INFANCY; CHILDHOOD. By John M. Keating, M. D., . . $1.00

3 — OUTLINES FOR THE MANAGEMENT OF DIET; or, The Regulation of Food

to the Requirements of Health and the Treatment of Disease. By E. T. Bruen, M.D., . . $1.00

4. — FEVER NURSING. Designed for the use of professional and other Nurses. By J. C.
Wilson, A.M., M.D., $1.00

5. — DISEASES AND INJURIES OF THE EAR : Their Prevention and Cure. By Chas.

H. Burnett, A.M., M.D., . $1.00

Or, For $6.00, any one of the above Nursing Books and THOMSON'S (Sir Henry)
SURGERY OF THE URINARY ORGANS. Some important points connected with
he Surgery of the Urinary Organs. Illustrated. Cloth, $1.25

IX

WHAT IS THOUGHT OF THEM!

(BOOKS FOR SUBSCRIBERS TO REPORTER.)

H6§r*See adv. page viii.

HEATH'S DICTIONARY OK PRACTICAL SURGERY.

C. B. Porter, M. D., Boston, Mass., says ; "A most excellent book for the library of the surgeon, and especially for the
country practitioner; as a book of reference it is so concise and at the same time so complete."

N. Senn, M. D., College of Physicians and Surgeons, Milwaukee , says.; "As a means of ready reference for the student
and busy practitioner this book stands unexcelled.''

Prof. E. JH. Gregory, St. Louis Medical College, St. Louis, says : " I have examined the book, and find it a most valuable
addition to my library. I am sure it will meet the favor of the surgical profession."

I.EIDVS HUMAN ANATOMY.

The Lancet- Clinic, Cincinnati, O., says: " Professor Leidy again presents to medical practitioners and students a treatise
on human anatomy that at once commands the attention and admiration of all who are at all familiar with the subject. Most
of the plates are original, and in common with the text are very beautiful to behold. The work is a complete illustration of
the method of teaching anatomy adopted by a leading scientist, and one of America's best known professors of anatomy. This
is one of the books that should be in the library of every practitioner of medicine and surgery."

The Medical Advance, Ann Arbor, Mich., says : " The student can master and retain a practical knowledge of anatomy
in a shorter time and with less hard work from this text-book than from any other work extant, and it has been our privilege to
teach anatomy for several years."

BVFORD'S DISEASES OE WOMEN.

The Boston Medical and Surgical Journal says : " It is a satisfaction to observe the discussion of certain topics which
are often neglected by writers, notably of the sympathetic symptoms of organs apparently disconnected with the uterus, for
which he will receive the thanks of the younger members of the profession. Another topic very widely treated is that of Con-
stipation in its relation to uterine diseases. All the other topics which should have a place in a work of this kind have been
fully and properly treated."

The Cincinnati Lancet- Clinic says : " The book is eminently practical and instructive. Its suggestions for treatment are
well up with the times, mostly judicious, conservative, and valuable, and the whole amply repays for thorough perusal."

The St. Louis Courier of Medicine says: " The work of a representative Western practitioner and professor, and is a
thoroughly practical work."

The Virginia Medical Monthly says : " We take pleasure in recommending it to every student and physician desirous of
obtaining a standard work on Gynaecology."

The Chicago Medical Journal and Exajniner says: "The chapter on puberty should be carefully studied by every
physician, teacher, and mother in the land. ... Its style is clear, but concise, and always practical, and shows the author to
be, as we all know, an experienced teacher. The work as a whole is most valuable, both to the student and practitioner."

Gaillard 's Medical Journal says : " It is replete with good judgment, broad and practical views.