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Hºº § sº §§§ § ºğº 㺠ºś ºf t - - - *** - º § º #º § º:* $º §: ºº:: §: Fº § § §§§ : i : §§ º § ºº: #}; §: ſº yº # § - ; § - º tºº ºś §§ :::::::::::::::: º º ############# # # ######## § - :::::::: - ; fº º § & º; ; # ºº §§ § º º º §: º ºrºrºº º º º ºwºº º - sº ºr tº: ºwººººº. f i § # s $ §§ º OF ation * 30ci #3 LY BE USED SUBJ w A- HE * H To T ASSOCATION UNIVERSITY MEDICAL MAGAZINE EI) ITED UNI) ER THE AUSPICES OF THE ALUMNI AND FACULTY OF MEDICINE OF THE UNIVERSITY OF PENNSYLVANIA. ADVISORY COMMITTEE : william PEPPER, M.D., BARTON COOKE HIRST, M.D., HORATIO C. WOOD, M.D., CHARLES B. PEN ROSE, M.D., J. WILLIAM WHITE, M.D., SAMUEL D. RISLEY, M.D., JAMES TYSON, M.D., HORACE JAYNE, M.D. E DITO RIAL COMMITTEE : ALFREL) C. WOOD, M.D., ARTH U R A. ST EVENS, M.D., VOLUME VII. OCTOBER, 1894, TO SEPTEMBER, 1895. PHILADELPHIA : UNIVERSITY OF PENNSYLVANIA PRESS, 1895. COPYRIGHT BY UNIVERSITY OF PENNSYLVANIA PRESS, 1895. PRINTED BY J. B. LippincorT CoMPANY, PHILADELPHIA, U. S. A. CONTRIBUTORS TO VOLUME VII. ALLEN, A. R., M.D., Carlisle, Pa. ALLEN, HARRISON, M.D., Philadelphia, Pa. ALLYN, HERMAN B., M.D., Philadelphia, Pa. ARNOLD, JOHN P., M.D., Philadelphia, Pa. ASHMEAD, ALBERT S., M.D., New York, N. Y. BILLINGS, JOHN S., M.D., Washington, D. C. BLOOM, HOMER C., M.D., Philadelphia, Pa. Booth, ARTHUR W., M.D., Philadelphia, Pa. BROWN, JAMES M., M.D., Philadelphia, Pa. BURR, CHARLEs W., M.D., Philadelphia, Pa. CARTER, WILLIAM S., M.D., Philadelphia, Pa. CATES, BEN. B., M.D., Knoxville, Tenn. CHANDLER, SWITHIN, M.D., Wilmington, Del. CLEEMAN, RICHARD A., M.D., Philadelphia, Pa. CLEVELAND, A. H., M.D.. Philadelphia, Pa. CURTIN, ROLAND G., M.D., Philadelphia, Pa. DEAVER, JOHN B., M.D., Philadelphia, Pa. DILLER, THEODORE, M.D., Pittsburg, Pa. DOCK, GEORGE, M.D., Ann Harbor, Mich. DORLAND, W. A. N., M.D., Philadelphia, Pa. DUNN, THOMAs D., M.D., West Chester, Pa. EDWARDS, WILLIAM A., M.D., San Diego, Cal. D'ESTRíº Es, DEBOUT, M.D., Contrexéville, France. FLICK, LAWRENCE F., M.D., Philadelphia, Pa. FOSTER, BURNSIDE, M.D., St. Paul, Minn. FREEMAN, WALTER J., M.D., Philadelphia, Pa. FRESE, CARL, M.D., Philadelphia, Pa. FUSSELL, M. HowARD, M.D., Philadelphia, Pa. GILLILAND, A. BERTRAM, M.D., Van Wert, Ohio. GRIFFITH, J. P. CROZER, M.D., Philadelphia, Pa. HARTZELL, M. B., M.D., Philadelphia, Pa. HENRY, FREDERICK P., M.D., Philadelphia, Pa. HENRY, T. J., M.D., Apollo, Pa. HINSDALE, GUY, M.D., Philadelphia, Pa. HIRST, BARTON COOKE, M.D., Philadelphia, Pa. HoPKINS, GEORGE G., M.M., M.D., Brooklyn, N. Y. HUBBARD, THOMAS, M.D., Toledo, Ohio. iii 2 H. C. Wood. which there is blindness, not of the whole eye, but of half of the eye. This can be determined by means of a simple test which I use continu- ally in my office; the test, however, is not sufficiently accurate for scientific investigation. (The Professor, sitting in front of the patient at a distance of about two and a half feet, directed the sight of left eye of the patient at his (the Professor's) nose, and then brought a pencil rapidly from above, below, and the side, into the field of vision.) You see what I am doing. I am comparing this patient’s field of vision with my own, using my own as a standard. In her left eye there is no hemianopsia; if there were, she would not see the pencil equally upon both sides of the field. In her right eye vision is alto- gether gone. Upon inquiry I find she has had very bad headaches accompanied with giddiness. Let us now take up the investigation of her special senses. Her hearing can be tested with a watch, as you see me do. I find no distinct disorder of her hearing ; in fact, there is no disorder of any of her special senses other than that of vision. In regard to her motor conditions, you will notice that when she walks she does so with short steps, with the feet not widely straddled. She walks backward fairly well, but upon putting the heels closely together, you notice she can hardly stand up, and, strange to say, she stands in this position better with her eyes shut than when they are open. The nurse informs me that this woman’s gait was the same while she was in the ward. We learn from the patient that there is a little tendency to staggering from one side to the other. The next step in our investigation is that of reflexes, especially of the patella, and we find exaggeration of both reflexes. Further, we find no loss of sensation. What did this case at the outset suggest to your minds 2 Hysteria. What other point was not brought out in the history which is essential in our diagnosis? The steadiness of the symptoms. - Hysterical symptoms usually shift continually. If you get a history of a patient being blind to-day and seeing to-morrow, the chances are 99 out of IOO that you have a case of hysterical blindness to deal with. This patient states, however, that there have been no alternate periods of blindness and vision ; she has had no laughing and crying spells; the numbness in her hand and arm have been steady, not going and coming, and she has persistent motor weakness in the right arm and leg. You notice that it is the right eye that is blind and the right arm and right leg partially paralyzed. We sent her to the eye dispensary, and got a report of albuminuric retinitis. We had the urine examined repeatedly, however, and it was A Case of Multiple Brazm Zesions. 3 always found normal, and when you take a young girl like this and find her urine normal to tests, you can practically lay aside kidney- disease, especially if there be no pronounced general symptoms of Ridney-disease. We then sent her to Professor Norris himself, telling him that we found no signs of kidney-disease. He said that the condition of the eyes resembled very closely in appearance albuminuric retinitis, but was really different, and the outcome of brain pressure. - Here we have conditions of the retina and nerve, due to organic brain disorder, so closely resembling albuminuric retinitis that experts of the first class are deceived, and no ordinary neurologist, let alone general medical practitioner, would be able to make a diagnosis between the two conditions. To-day that condition has passed away, the ede- matous swelling of the nerve point has given way to contraction, with white nerves and atrophy, so common a proof of the existence of a chronic brain lesion. This girl must, therefore, have some form of chronic brain-disease, and the difficult point to be decided is where the lesion is located. - When we come to study the brain for the purposes of cerebral localization, we find that it divides itself naturally into three parts. The first of these, the anterior, or frontal, lying in front of the ascend- ing convolution, the portion of the brain whose function to-day is unknown. It is probably connected in some way with intellectual action ; it is, pathologically, the inert portion of the brain, and a tumor may exist in this part without the production of a single symptom. Indeed, I have seen a clot, the size of a pigeon's egg, cause no symptom in a case under hospital supervision until secondary softening brought out evidences of failing brain power. In the most favorable case all that we can do is to suspect the existence of a tumor in this region. The second part of the brain is that of the motor tract, which lies on the side of the fissure of Rolando following the ascending convo- lutions deep down into the region of the fissures of Sylvius and island of Reil. Posteriorly to this is the sensory region, embracing the whole posterior brain, with the sense of hearing having its function localized in temporal gyri or convolution, and the function of vision localized especially in the extreme back end of the occipital region; both of these functions are probably capable of being disturbed by lesions in the central region, provided these lesions are so situated as to cut fibres which connect the sense centres with the outer world. If you remember these facts, you have the map before you which will enable you to understand any brain subject. First, anteriorly, is the frontal region, then the fissure of Rolando with the ascending frontal and parietal convolutions; then posteriorly we have the sense 4. F. C. Wood. region, with sight located in the cuneus, and hearing in the superior temporosphenoidal convolution. We find the region of speech memory in the island of Reil and fissure of Sylvius. It is plain that in the present case the only special sense brain region which can be affected is that connected with vision, since all other special senses are intact. What portion, then, of the visual cerebral tract is implicated 2 Plainly not the cuneus, nor yet the corpora quadri- gemina, nor yet the optic-nerve fibres between the corpora quadrigemina and the optic chiasm, nor yet the optic chiasm, because any tumor or other lesion situated posteriorly to the optic chiasm must produce a hemianopsia for anatomical reasons; whilst a lesion of the optic chiasm itself would almost of necessity produce some hemianoptic symptoms. It is plain that the lesion which produces this loss of sight must be situated in, under or near the base of the frontal lobe, in such a posi- tion as to directly affect the nerves of the eye. It is possible that the 1oss of sight is due to an optic neuritis, the inflammation of the nerve naving gone on to such a degree that it is no longer functionally capa- ble. Remember, however, that one eye is much more affected than the other, and that this one eye was completely paralyzed as to its func- tions months before the other was discovered to be affected at all. This is not a history of a neuritis due simply to a general increase in the brain pressure. In balancing the probabilities we are forced to the conclusion that the greater probability lies on the side of the theory that the loss of sight in the right is due to a tumor, to an exudation, or to some lesion directly affecting by contact or otherwise the optic nerve in front of the chiasm. It is possible, or at least conceivable, that a tumor situated under the frontal lobe might produce this disorder of vision and affect the motor area in the middle brain region by proximity, by pressure, or by disturbance of circulation. Unfortunately for this theory, the right eye and the right side of the body are each paralyzed, whereas, if the situation was as has just been suggested, the right hemisphere being the site of the lesion, the paralysis should be on the 1eft side of the body. In all cases of organic brain-disease presumably of the nature of tumor, in which the symptoms have existed for months, beware of being misled by the development of secondary brain lesions which in their turn may give rise to symptoms so prominent as entirely to over- shadow the manifestations of the original disease. I cannot, however, conceive of any lesion of the brain directly secondary to the one which produces the ocular disturbance here present that should cause the paralytic symptoms and the disturbance of co-ordination which exist. Let us, therefore, examine a little more carefully these motor disturb- a11CeS. A Case of Multiple Brain Lesions. 5 Testing her knee-jerks you see at once that the reflexes are grossly exaggerated. Asking her to walk, you note that her gait is peculiar, resembling somewhat but differing essentially from that of true loco- motor ataxia. To my sight she seems to have an imperfectly developed titubation. Titubation, you remember, is the name applied to the peculiar gait produced by disease of the cerebellum. It differs from the true ataxic gait especially in the fact that the patient does not stand with the feet widely apart, as in posterior sclerosis, and does not throw the feet out violently, almost choreically, as occurs in the latter disorder. In titubation the patient takes short steps and has a lateral uncertainty of movement which is the basis of staggering. In some cases of cerebellar disease there is a tendency to run backward ; no such tendency exists in the girl before you, but notice her short steps, and notice her excess of lateral movement amounting at times to a true staggering gait. This gait is not ataxic. It is not absolutely typical titubation, but it approaches the latter much more than the former gait. Another symptom, as you well know, commonly seen in cerebellar tumor is violent and apparently causeless vomiting. Again, here we find indication of the cerebellar symptom without its full development. This girl has from time to time vomited without gastric disease and without apparent cause, but the vomiting has not been very violent nor very often repeated. One strange symptom which is shown in our patient, and which is commonly thought of as of spinal origin is the gross exaggeration of the knee-jerks. In the vast majority of cases of nervous diseases any disturbance of the knee-jerks is spinal in its origin, but we may have in the case of cerebellar tumor loss of reflexes, or an increase of reflexes, or the reflexes may be normal. Moreover, in typical cases we may have a shifting condition of the reflexes which I believe to be characteristic of cerebellar disease, or, at 1east, of some disease in the immediate neighborhood of the cerebellum. In such a case, starting from the primary normal reflex, we find the knee-jerks diminishing until they disappear, and then in the lapse of weeks or months beginning to return until they become normal, and then continuing in their upward tendency until finally they are grossly exaggerated. The explanation of this remarkable series of phenomena seems to me to be possible through our knowledge of the inhibitory functions of the so-called Setschenow centres, which are situated somewhere in the base of the brain. These centres, as you well know, have for their function inhibition of the motor cells of the spinal cord. When an impulse reaches these spinal motor cells from the periphery, it is due to Setschenow's centre with its subordinate, inhibitory centres, that the response to this impulse is confined to the cells which it first reaches, 6 A. C. Wood. whilst these cells themselves are prevented from responding with exces- sive activity and feeling by the checking power of the inhibitory cen- tres. If a tumor commences to develop close to but not in immediate contact with Setschenow's centre, this centre before it is paralyzed by pressure feels the irritation of the growing mass, and by this irritation is thrown into functional exaltation. There is, therefore, a condition of excessive spinal inhibition with consequent functional depression of the motor spinal cells, and lessening or complete loss of the reflex activity. As the tumor increases in size irritation of the near-by in- hibitory centres more and more merges itself into paralysis from pressure and increasing inflammation, and as this process goes on in the Sets- chenow centre functional exaltation gradually changes into func- tional depression. There is a time when the two antagonistic conditions, failing irritation and growing paralysis, completely balance, and the spinal cord is left to its normal self. At such time the reflexes come back practically to the norm. As the change in the Setschenow centre deepens, however, paralysis gains the upper hand of functional excitement, until at Tast the inhibitory centre is completely paralyzed and the whole restraining force removed from the motor cells of the spinal cord. At such times gross exaggeration of the knee-jerks must be present. In the case before us I do not believe that the exaggeration of the reflexes is of spinal origin. In the presence of a form of titu- bation, of vomiting, of headache, and of other evidences of gen- eral disturbance of the cerebral mass, there is demonstration of morbid growth or other progressive organic lesion within or in the neighborhood of the cerebellum. It would seem, therefore, most probable that the girl before us has multiple lesions within her cere- brum, one anterior and one posterior. It may well be, also, that she has a third lesion affecting the motor tract of the middle portion of the hemisphere, situated in the left hemisphere and causing the motor palsy. * I may say here I have usually very little faith in a diagnosis of cerebral disease which necessitates or supposes the presence of two 1esions ; sometimes, however, multiple brain lesions do occur. What diseases of the brain commonly gives rise to multiple lesions 2 Tuber- culosis and syphilis. Therefore, there is at once the suggestion that you have to deal in this case with tuberculosis or with syphilis. There is nothing in this girl’s past history which tells us of syphilis; she comes from a family which seems above suspicion. I do not for a moment believe that she is impure and has an acquired syphilis; there is, there- fore, every moral reason to believe that syphilis does not exist. At the same time, when it comes to practical medicine, never take it for granted Phenolic Substances in Tuberculosis. 7 that syphilis cannot exist in any one. I have seen it in the pew and pulpit, in the dens of infamy and in the high places of the earth. It often crops out where least expected. If in any individual like this young woman the symptoms point strongly towards a specific disease, keep your own counsel, do not even make inquiries, but act; try the therapeutic test. In accordance with this, without stirring up the past, a few days ago I put this girl on mercurials. She insists that she feels better and is better. Her gait does seems to be a little improved. Moreover, she has been for several days now without an attack. Nevertheless, it is hard to come to a positive conclusion, because the history of her past shows that the symptoms vary in their intensity from time to time, and because her epileptoid attacks have been so irregular, now in groups, now coming on at long intervals. I shall, However, continue the trial, and report to you the result. [This case was mercurialized and shown to the University class from time to time for several months. The symptoms began to abate before ptyalism appeared, and under the continuous use of mercurials and afterwards of the iodide of potassium, the patient lost her head- aches, the reflexes became normal, the paralytic arm regained its power, and the patient was finally discharged from the hospital, having had no epileptoid attacks for several months and seemingly entirely well. As stated by the lecturer, when she was finally shown to the class, the result seemed in every way to justify the original diagnosis that the 1esions were the outcome of a tardily-developed hereditary syphilis.] PHENOLIC SUBSTANCES IN TUBERCULOSIS (NASCENT PHENIC ACID, CARBOLIC ACID, CREOSOTE, GUAI- ACOL, AND BENZOYL OF GUAIACOL)." BY ROLAND G. CURTIN, M.D., Philadelphia. My principal object in reading this paper at this meeting is to elicit a general and full discussion on the use of the phenolic substances in the treatment of pulmonary tuberculosis. Two papers have been published by the association, one by Dr. Glasgow on Creosote in Pulmonary Diseases in 1891, and one by Dr. Jacoby on Guaiacol in the Treatment of Pulmonary Tuberculosis in * Read before the American Climatological Association at Washington, May 30, 1894. 8 A'oland G. Curtin. 1892. We have never had a full discussion of the subject at a large meeting, and I am sure the opinion of our members will be received by the outside medical world with gratitude. DeClat’s Syrup of Mascent Phemic Acid.—I have been using De- Clat’s syrup of nascent phenic acid more or less for fifteen years. The directions for its proper use include the administration of the syrup by the mouth, a gargle for the throat, and a preparation for hypodermic use. After repeated attempts to use the remedy hypodermically I aban- doned it altogether. The injections were followed by great suffering, and it was a rarity to find a patient that would allow the subcutaneous treatment to be used for more than a few days. One patient said that death would be preferable to the treatment; another said that he was more content to be comfortable than to be improved by the painful treatment. The pain was severe at the point of puncture, and often radiated along the course of the nerves towards the body. It was not uncommon to have a painful numbness in the whole limb lasting for hours. The most of my patients were treated by the syrup administered by the mouth. To be brief, I will simply state in a general way that the results in the improved cases were shown by the following evi- dences: an increase in weight, diminished cough and expectoration, less dyspnea, and more strength and appetite. One woman had been inca- pacitated for work for years, owing to weakness, a result of a chronic lung disease she had had for six years. She had a cavity at the left apex. She had come into the hospital to die. In two weeks after the administration of the syrup she had gained six pounds, and had im- proved in every respect. At the end of two months she left the hos- pital, and took a position as a domestic, and was there a month later, still improving. The improvement in this case was the most marked of any I had under treatment. It illustrates the kind of cases which are most benefited by the internal use of the phenic acid, viz., chronic phthisis with slow emaciation and low temperature and poor assimila- tion of food. Carbolic Acid.—I have tried the ordinary carbolic acid in a number of cases, but it did not seem to do as well as the nascent form (in DeClat’s syrup). Creosote.—Another article of the phenolic class that has long been used by the profession in the treatment of consumption is creosote, but not to the extent it has been since the introduction of Beechwood creosote. This was found to contain a larger amount of guaiacol, and this discovery led to the extensive use of guaiacol in tuberculosis; then followed the experiments with the carbonate, iodate, benzoate, Ahenolic Substances in Tuberculosis. 9 and salicylate. These last-mentioned preparations have been used both hypodermically and by the stomach, but the results have not been universally satisfactory. Creosote has been administered in large doses, one physician hav- ing given as high as 150 drops a day for months without any ill-effects, but, on the contrary, followed by marked good results, results not ob- tained by smaller dosage. I have given fifty drops a day continuously for over a month with improvement which decreased upon diminishing the dose, and in the same ward and with the same creosote other patients were injured by doses of five drops, as shown by unpleasant eructations and disordered digestion. If the stomach is disturbed by the creosote no good results need be expected from its use. Occasion- ally, though rarely, the use of this remedy is followed by renal irrita- tion, and sometimes by hematuria. I have not observed these symp- toms in hospital patients, but have now and then observed them in private practice. It has occurred to me that the ill-effects might be due to an impure, adulterated, or substituted article. (A druggist once said to me, “It don’t make any difference which you put in a mixture, carbolic acid or creosote. They are the same,”) X- The following are the conclusions arrived at by Dr. J. T. Whit- taker : * (1) When pure creosote is harmless. (2) It has no direct action upon the tubercle bacillus. (3) Tuberculosis pulmonum is chiefly a secondary affection by streptococcus. (4) Creosote has no direct action on this streptococcus, hence none whatever on hectic fever. Guaiacol.—After long and repeated observations, I am satisfied that following the administration of guaiacol in tuberculosis, or catarrhal disease of the lungs with high temperature, no material benefit is to be expected. The class of cases that seem to be most improved by the use of this medicine is the one in which we have slow progress, slight rise of temperature, slow digestion with fermentation, and poor nutri- tion. The improvement noticed in these cases may be summed up as follows : improved digestion and nutrition, and diminished breaking down of the pulmonary tissue, and consequently less expectoration. Guaiacol, creosote, carbolic acid, and phenic acid have been used suc- cessfully in the past in the treatment of simple fermentative dyspepsia. I have observed that guaiacol obtained from different sources is followed by varying results. I am also convinced that some pharma- cists substitute creosote where guaiacol has been called for. I have been using guaiacol in the encapsulated and the compressed pill form 1 Therapeutic Gazette, July, 1893, p. 438. IO Roland G. Curtin. - for the last three years. The benefits of this method of administration are the absence of taste, and it is less irritating to the stomach, and is less liable to be followed by unpleasant eructations. From my experience I should say that guaiacol is beneficial in chronic ulceration of the lungs, no matter whether associated with the tubercle bacillus or not. From this fact I am satisfied that the guaiacol has no specific effect upon the tubercle bacillus. I have had ample oppor- tunity to observe in the cases of influenzal phthisis the action of this drug, and I am satisfied that the improvement following its use in these cases was about the same as the tubercular cases. The best re- sults were obtained in patients where the destructive process was slow and the symptoms were mild, very much the same as were reported under the head of creosote. When we take into consideration the chemical composition of these articles they are found to be much the same, and when used in the treatment of tuberculosis they all seem to act much the same way. In my hands guaiacol has appeared to be the most reliable. Conclusions.—Guaiacol is not irritating to the stomach, nor is it so liable to produce irritation of the kidneys or hematuria as creosote. It has no specific action on the tubercle bacillus, but seems to act beneficially on the digestive tract, improving nutrition, and thereby assisting repair. Among the advantages of guaiacol over creosote are, - (1) It is more easily taken. (2) The process of manufacture insures purity. (3) You know the exact quantity of the medicinal substance you are administering. • Benzoyl of Guaiacol.—Professor Winkle, a German physician, has written an article and given statistics highly extolling the use of ben- zoyl of guaiacol. A number of cases of advanced phthisis were treated by him, and for the first two or three months they all increased in weight; some continued to improve after that time, while others re- mained stationary or lost. After reading this paper I used the article quite extensively. Theoretically this combination should be more suc- cessful than simple guaiacol, but I must confess that I found no advantage over the simple guaiacol. I found that in almost all cases where the patient eructated the taste of guaiacol the same disagreeable taste fol- lowed the use of benzoyl of guaiacol, which upon reaching the stomach changes into the substances of which it is composed. It is certainly much pleasanter in taste, and is readily made into a compressed pill. The high price is an objection to this drug, as in full dosage the patient would be at considerable expense. My results were not as good as those reported by Dr. Winkle, and the improvement was usually not as marked as after the use of simple guaiacol. Prophylaxis in the 77-eatment of Tuberculosis. I I PROPHYLAXIS IN THE TREATMENT OF TUBERCULOSIS." By LAWRENCE F. FLICK, M.D., Philadelphia, Pa. WITH the demonstration of the parasitic nature of tuberculosis began a new era in its treatment. In the past the medical profession has had no resources in its struggle with this disease except such as it could draw from empiricism, but in the future its combat will at least be founded upon a rational basis. All that has been found useful in the past can now be used more intelligently and more effectively because we can give a reason for its use, and can discriminate in its application ; and the new light has already enabled us to discover pathways which promise to lead us to the E1 dorado in which will be found the precious substances that will cure. From the organic theory of tuberculosis we can learn many valu- able lessons in treatment. The organic theory as now elucidated can be briefly summarized as follows: (1) Tuberculosis is a parasitic disease due to the implantation and development of a vegetable organism in the tissues of the body. (2) For the successful implantation and development of this organ- ism the tissues of the body must constitute a proper soil, which may either mean that they contain a certain something conducive to the development of the organism, or they lack a certain something which would interfere with the development of the organism. (3) The symptoms which we recognize as constituting the disease we call tuberculosis are partially due to the irritating presence of the parasite, partially due to the destruction of tissues which takes place during the effort of nature to cure, and partially to the absorption of poisonous products of the organism. (4) When death takes place from tuberculosis it is usually due to the ptomaines produced by the organisms causing the disease, but may be due to destruction of tissue, or to the inflammation set up by the parasite. (5) The severity and rapidity of progress of a case of tuberculosis is in proportion to the fertility of the soil and the number of organ- isms implanted. (6) The soil for tuberculosis is not exhausted, but, on the con- trary, is enriched by the growth and development of the organism pro- ducing the disease, and is likewise enriched by the growth and develop- ment of organisms producing other diseases. * Read before the Pennsylvania State Medical Society, Philadelphia, June, 1894. I 2 Alazvrence F. Flick. (7) Fertile soil for the development of tuberculosis can be trans- mitted from parent to offspring, and can be produced by mode of living and by occupation. - (8) Tuberculosis cannot exist without the organism which pro- duces the disease, and therefore no new case can arise without having an old one to spring from. A most valuable lesson taught by the organic theory of tubercu- losis, and one hitherto unrecognized, is prophylaxis in the treatment of the disease. Tuberculosis is strictly a parasitic disease, and as such is always a local disease. It is local, however, only in its cause, for the absorption of the products of the tubercle bacillus sets up constitutional symptoms, and death usually results from the absorption of those pro- ducts. It might therefore be termed a constitutional disease with a local cause. Nature makes a strong effort to get rid of all parasites, and in tuberculosis this effort manifests itself in the formation, break- ing down, and casting off of the tubercular nodule. Unfortunately, this very process may be the means of extending the disease. When a tubercular nodule breaks down the escaping organisms are liable to find their way back into the circulation, and to form new deposits. Re-en- trance into the circulation may take place at the seat of ulceration where the broken-down tissue seeks exit, through a denuded surface in the mucous membrane of the respiratory tract, through the peribronchial glands; and through the stomach. Were it not for auto-infection or re-entrance of the organisms into the system all cases of tuberculosis would get well. It is very rare that the first invasion of the organism is powerful enough to produce death. In those cases which are called acute tuberculosis, and in which death ensues in a few weeks, it is quite probable that the large number of organisms which are capable of producing such a result are not taken into the system at one time, but have been grown in the system in some gland, and have suddenly been set afloat in the circulation by the breaking down of that gland. Most cases of tuberculosis are simply a prolonged series of invasions of the organism in which each new invasion is the outcome of a former abortive effort at cure. This accounts for the long duration of tuberculosis, and also for the variation in its duration in different persons. Where the resisting power of the individual is good, the various invasions are apt to be mild and the breaking-down process slow, making the intervals between the invasions longer. The sanitary environments, and the habits of life also, are pregnant factors in determining re- infection, and consequently the duration of the disease. Hence we have the duration of tuberculosis ranging from a few months to many years. And yet the disease is the same in all persons, differing only Prophylaxis in the Treatment of Tuberculosis. I3 in the rapidity of the breaking-down process, and in the number and size of the invasions. A clear knowledge of the nature of tuberculosis and a full appre- ciation of the influences which bear upon its development are of pri- mary importance in its treatment. Auto-inoculation, whilst it cannot be absolutely prevented, can be, to a great extent, controlled, and the rapidity of the breaking-down process can in many cases be materially checked. Along this line lies all scientific treatment of tuberculosis so far known, and along this line all future effort in search of remedies or modes of treatment must be made. When we can absolutely stop all auto-inoculation we can cure the disease, and until we can do that deliberate and unfailing cure is impossible. In those cases in which recovery takes place this is the process by which it is brought about, and as far as we are now able to see it is the only process by which it is possible. Auto-inoculation can be largely controlled in two ways, by build- ing up the system of the patient so as to enable it to resist new deposits, and by preventing the readmission of the organisms into the system. For the building up of the system every possible resource must be drawn on, and the food-supply, the digestion, the assimilation, and the elimi- nation all carefully studied and corrected, where faulty, so that the larg- est possible amount of nutrition may be obtained with the smallest pos- sible consumption of force and energy. Increase in weight and strength and the restoration of the normal functions of the different organs of the body is the best evidence we can have that this is being accom- plished. Improvident expenditure of force must be guarded against. Violent or prolonged exercise, depressing mental influence,—anything, indeed, that makes an unusual demand upon the muscle or nerve re- sources of the body should be scrupulously avoided. Forced nutrition should be practised as far as it is compatible with the maintenance of a healthy condition of the stomach. Ample sleep should be taken, and the nervous system always kept in a good vigorous condition. The re-entrance of the tubercle bacillus into the system can be prevented to a large extent by the sterilization of all broken-down tissue as soon as it is given off. Of course re-entrance at the seat of exit, if there are broken blood-vessels at the place of ulceration, cannot be protected against; but fortunately the channel through which a broken- down nodule empties itself is frequently a non-absorbing surface. Re- entrance through denuded mucous membrane of the trachea and through peribronchial glands is also difficult to guard against. But when the broken-down tissue has once made its exit from the body, it is compara- tively easy to prevent it from again infecting the patient. This can be accomplished by immediately sterilizing it whilst still in a moist condi- I4 Alazerence F. Flick. tion. All sputa of tuberculous subjects should be ejected into a sputum cup, containing a liquid and, if possible, a germicide, and where this is not practicable into a paper handkerchief. Handkerchiefs made of other material should not be used, because the sputum dries too readily in them and the patient is very apt to rub it up or scatter it in pulling his handkerchief apart. When handkerchiefs are used they should not be allowed to become saturated, and should, after using, be burned. Under no circumstances should tuberculous matter ever be allowed to remain and dry on bedclothing or upon furniture, carpets, etc. In short, all tuberculous matter given off by a patient should be devitalized at the earliest possible moment after it has made its exit from the body. It is quite likely that reinfection sometimes takes place through the stomach. Tubercular matter is frequently swallowed by patients voluntarily and still more frequently by accident. Broken-down tuber- cular matter is apt to adhere to the pharynx and to be swallowed with food in eating. The living organisms in such matter may meet their death in the stomach through the agency of the gastric juice, but may also run the gauntlet of the stomach if the secretion of gastric juice is deficient or if protected by undigested food, and be carried into the cir- culation with the chyle, finding lodgement in whatever part of the body best fitted to receive them. It is therefore of the greatest importance that patients be instructed not to swallow sputa. Where the expectora- tion is profuse, it is well to have the patient gargle the throat with an astringent before eating. Sometimes the hands and mouth are smeared with sputa, and for this reason the precaution of washing these ought to be taken before eating. Where a patient is living in a room in which preventive measures have not been practised, such room ought to be carefully disinfected. This disinfection does not consist of burning sulphur or whitewashing, but in completely renovating the room. The walls should be scraped and then washed with a five-per-cent. solution of carbolic acid. If the walls have been painted they should be rubbed down with bread and then washed with carbolic-acid solution. The floor should be scrubbed with a carbolic acid solution, and every particle of furniture, carpet, bedding, etc., in the room should be either subjected to a temperature above 158° F., or disinfected with a five-per-cent. solution of carbolic acid or a one-tenth-per-cent. Solution of corrosive sublimate, to which must be added some tartaric acid, citric acid, hydrochloric acid, or muriate of ammonia, to prevent the coagulation of albumen. I have more than once seen the improvement of a patient date from his removal from infected quarters, and I have no doubt but that some of the benefit which is usually credited to change of climate is really produced by removal from infected homes. Correction of Æefractive Brror in Alastic /ritis. I5 The importance of prophylaxis in the treatment of tuberculosis cannot be over-estimated. Whatever brilliant results may be obtained temporarily by drug treatment, upon prophylaxis must depend to a great degree permanent results. No case of tuberculosis should be called cured until it has withstood new invasions of the disease for four or five years. I am convinced that for fully that length of time a case of tuberculosis which has apparently recovered may carry the slumbering embers of the disease in a partially broken-down gland or secreting cavity, and is prone to new invasions of the disease. It has been shown that the tubercle bacillus can maintain its vitality for a very long period, probably a year, at least in dried-up broken-down tissue. A room containing such dried-up tissue is, therefore, a source of danger to the patient for a long time after he has apparently recov- ered from the disease, and may be the means of precipitating a fresh attack. The only safe thing for the patient in the light of modern science is, (I) To make his surroundings absolutely free from danger from infection, (2) and to prevent him from reinfecting himself by keeping him in the best possible state of health, so as to be able to resist the disease, and by inhibiting the reintroduction of ejected organisms into the system. SOME ADDITIONAL STUDIES UPON THE CLINICAL VALUE OF REPEATED CAREFUL CORRECTION OF MANI- FEST REFRACTIVE ERROR IN PLASTIC IRITIS." By CHARLEs A. OLIVER, A.M., M.D., One of the Attending Surgeons to Wills Eye Hospital; one of the Ophthalmic Surgeons to the Presbyterian Hospital of Philadelphia, etc. SINCE the publication of the writer's paper upon this subject, in the transactions of this Society for 1892, he has been able, by a number of fortuitous circumstances both as to material and proper assistance, to make a series of additional studies in order to determine the causal factor of the apparent and transitory increase of ametropia in the same variety of cases as he then had the privilege to study. Ignoring, as he then did, any cases where there were objective evidences of corneal opacity, lenticular haze, or even the faintest visible disturbances in the aqueous or vitreous humors; excluding all instances where there were any perceptible tags of adhesion between the iris and 1 Paper read before the American Ophthalmological Society, May 31, 1894, at the Third Tri- ennial Meeting of the Congress of American Physicians and Surgeons. I6 Charles A. Oliver. the lens; and limiting the work to those eyes where the pupils were seemingly dilated ad maximum, a number of experimental studies were instituted to determine, if possible, the cause of the ametropic increase. (1) To discover whether there is a forward displacement of the lens. This was shown not to occur, objectively, in two ways. The first plan consisted in studying the plane of the iris by the use of ordinary inspection through a corneal loupe upon a brilliantly illumi- nated area. In this experiment, it was found that in nearly every instance the anterior plane of the iris was either vertically placed or was dragged backward. The second method was accomplished by means of the estimation of the relative positions and sizes of the catoptric images, especially of the two lenticular reflexes. Here it was found that by either roughly testing by a candle-flame or, as in several instances, more scientifically, by recourse to an ophthalmometer of Helmholtz, that whilst the anterior capsular reflex moved forward and became smaller, the posterior one moved slightly backward. (2) To endeavor to determine clinically whether the index of refraction or whether the actual amount of either the aqueous or the vitreous humor is increased during the inflammatory process. This in measure was shown not to be the case; first by careful and repeated study of the objective appearances of successive layers of these two media, by both oblique illumination, and the ophthalmoscope. No thickening, no visible sign of increase of density of the fluids, as might be evidenced by planes of increased reflection, and even no distortion of any of the gradually deepening meridional reflexes could be con- scientiously asserted; second, by reference to the fact that in nearly every case which was carefully studied, the distance between the ante- rior and the posterior lenticular reflexes was, as before shown, unduly increased. Thus, these two plans to a great degree invalidated the possibility of either any increased amount of the density of the fluid contents or augmentation of the contained material in the two large intra-ocular chambers." (3) To make certain that the temporary increase of the index of refraction in the type of eases here under special consideration is dependent upon either spastic tonicity of the fibres of the ciliary muscle or congestion with rigidity of the ciliary bodies. In addition to the great number of experiments pursued to formulate the conclusions given in the writer's first paper upon the subject, a number of control tests, with both mydriatic and myotic agents, were made in such a manner as to set aside any confusion or disturbing influence that might 1 Vide article upon “The Proximate Cause of the Transient Form of Myopia associated with Iritis,” by A. Schapringer, M.D., in the New York Medical Journal for October 21, 1893, and edi- torial, “Poor Vision after Iritis,” in the May 12, 1894, number of the Philadelphia Polyclinic. Zeucocytosis. 17 be supposed to have arisen from the first two categories of cases. This was done by first obtaining the exact corrective lens that was necessary to bring a subnormal vision to normal, care being taken to choose intel- ligent patients with but slight refractive error. This done, three instillations of two drops each of strong solutions of either atropine, cocaine and atropine, or eserine were made at three-minute intervals, and the ametropia was immediately re-examined, when, in every case in which the inflammatory process had not absolutely subsided, the use of the cycloplegic reduced the apparent amount of the refractive error (ordinarily one-fourth to three-fourths diopter), whilst the myotic, in every instance tried, increased the apparent amount of the ametropia. To recontrol these tests, all of the eyes whilst in a condition of sur- charged dosage, as it were, were re-submitted to a few of the most important of the objective tests, when in every instance where the mydriatic was used, the lenticular reflexes were shown to be more greatly approximated, whilst in those cases where the nuyotic was employed, the lenticular reflexes became further separated. The conclusion, therefore, is in every instance of this third variety of study not only is so-called “spastic accommodation” proved, but the supposition of the forward displacement of the lens is, in a great meas- ure, denied, and both real and relative increases of aqueous and vitreous humor are confuted." LEUCOCYTOSIS.” By WM. S. CARTER, M.D., Assistant Demonstrator of Pathology, University of Pennsylvania; Pathologist to the Children’s Hospital. LEUCOcyTES may be classified according to their morphology or according to their avidity for certain stains. According to their mor- phology they are classified into, - (I) /./mphocytes, which are small cells with large nuclei, staining intensely, and almost completely filling the entire cell, leaving only a very small ring of protoplasm. They vary in size from that of a red 1 A most interesting and instructive example of this group of cases is given by Dr. John T. Carpenter, Jr., of Philadelphia, in the Philadelphia Polyclinic for May 5, 1894, where he cites an instance in which he inadvertently too early ordered a minus correction in a case of plastic iritis at the time when the refractive apparatus was in a condition of functional myopia. Complaints of the patient as the plasticity of the ciliary muscle lessened and the lens regained its normal refractive curvatures soon set matters aright by the substitution of a much weaker correction. 2 Read before the Philadelphia Society for Clinical Research, May 22, 1894. 2 I8 Wm. S. Carter. blood-corpuscle or less up to others, being considerably larger, and having a clear ring of protoplasm. These corpuscles do not possess the power of motion, and constitute about 20 per cent. of the leucocytes of the blood. (2) Large mononuclear leucocytes having a round or oval vesicular nucleus and a large amount of clear protoplasm. These cells are sev- eral times the size of red blood-corpuscles. 3. (3) Transitional leucocytes, with indentations of the nuclei, so that they have no constant shape. They are usually spoken of as a further stage of the large mononuclear cells. The large cells do undergo this change, but beside these we also find other smaller cells, with nuclei staining intensely, showing this same change in the shape of their nuclei, -indicating a beginning division of this body. The proto- plasm of these cells may or may not contain granules, and they have the power of motion. According to Ehrlich the large mononuclear and the transitional leucocytes constitute 6 to 8 per cent. of the leuco- cytes. (4) Multinuclear leucocytes containing several deeply-stained nuclei, which are often joined together by a thin filament, and not entirely separated. The protoplasm of these cells frequently contain a consid- erable quantity of granules. Ameboid movements are seen very largely in these cells, and they are chiefly the ones which wander through the vessel-walls in inflammation. The size of these cells is extremely vari- able, some being but little larger than the small lymphocytes, others being as large as the mononuclear cells. They constitute 70 to 80 per cent. of the leucocytes of the blood. The other classification of leucocytes, based upon the affinity for certain stains possessed by granules in their protoplasm, is as follows, for human blood : g (I) Eosinophiles, those cells with coarse granules in their proto- plasm which take the acid stains. They are called eosinophiles because they stain best with eosin. They may be either mononuclear or mul- tinuclear, and constitute from I to 2 per cent. of the leucocytes. It is said that these cells are never phagocytic. (2) Basophiles, those cells with granules which stain by dyes, in which the base has the staining power. We know so little of these that as yet they have no practical value. They occur in large mononuclear cells, but are seldom found in the blood of man. (3) Neutrophiles, those whose granules stain by a neutral mix- ture of a staining base and a staining acid. These granules are very fine. They occur in the vast majority of leucocytes, and, generally speaking, we may say that, in health, the multinuclear leucocytes con- taining granules, which do not stain by eosin, are neutrophiles. Aleucocytosis. I9 Several distinct varieties of cells depending upon the kind of granulations have been separated in different animals. One cell never contains more than one kind of granulations. Those found in man are mentioned above, and these are also the most important in other ani- mals. In the rabbit there is a small proportion of amphophiles, those staining by either the acid or basic stain. Leucocytes have their origin in the lymphoid structures of the body, chiefly in the lymph-glands, and also from the spleen and bone mar- row. As to the development of these corpuscles the conclusions reached by Howell' are, perhaps, correct. This observer believes that all leu- cocytes originate as mononuclear cells or lymphoid cells, and that subsequent changes occur in the circulatory stream or in the tissues of the body. The lymph coming from glands contains these small mononuclear cells, and does not contain the other forms to any extent. It cannot be said positively that the large mononuclear corpuscles do not originate as such, but we often see in the blood colorless cor- puscles apparently standing between the lymphocytes and the large mononuclear cells, some with considerable protoplasm and a deeply- stained nucleus ; others with a vesicular nucleus, but a smaller amount of protoplasm ; and still others with a moderate amount of protoplasm and a semivesicular nucleus. Concerning the multinuclear form, it is true that scrapings from spleen or bone marrow have shown these cells in considerable number, but when these tissues were fixed and sectioned, these cells were found only in the blood-vessels and not in the tissues (Uskow). It is highly probable that many multinuclear colorless cells of bone marrow are not the white corpuscles of the blood. It seems perfectly clear that if mul- tinuclear corpuscles originated as such from the lymph-glands, then we should find them in large quantities in the lymph leaving these glands. The leucocytes, then, probably all originate as mononuclear cells, and the different morphological forms observed in the blood are only the same cells at different periods of their life-history. The multinu- clear form is the oldest of the leucocytes, and it is at this period that most of the cells are destroyed. One scarcely ever sees the mononu- clear cells breaking up in the blood. In examining fixed preparations, and also in counting blood (especially in infections, or any condition in which the leucocytes are being destroyed in considerable numbers), one constantly sees a great many multinuclear cells breaking up and liberating their granules and their nuclei. When the destruction is * Journal of Morphology, July, 1890. 2O Wm. S. Carter. going on very rapidly great masses of these granules are seen surround- ing many liberated nuclei, -this is not the grouping of leucocytes due to faulty technique. As the cells grow old, peculiar changes occur in their protoplasm, and, as a result, we have granules which show certain staining peculiari- ties. All cells, of course, do not undergo the same change. These granules have been shown to be albuminous in nature. The granules staining by eosin have been considered a secretory product. Concerning the physiology of the leucocytes we know even less than we do of their origin and life-history. They are unquestionably greatly concerned in many obscure metabolic processes occurring in the tissues of the body, but as yet we do not know how they act in these changes. * We know that certain fibrin factors of the blood arise from the disintegration of the white blood-corpuscles, and we observe rapid de- struction of these cells in the clotting of shed blood or in the clotting of blood within the vessels under pathological conditions. We also know that leucocytes are phagocytic, swallowing foreign bodies, and that they are attracted by substances which are positively chemotactic. The multinuclear leucocytes are especially concerned in phagocytosis and also seem to be the most sensitive to chemotactic reactions. As it has been stated that certain forms of leucocytes arise from the spleen, the writer removed the spleen from dogs to determine the effect on the leucocytes. - ExPERIMENT I.-Large healthy dog weighing I2.698 kilos. February 22, 2 P.M. . . . . . . . . . . . . R. B. C., 7,950, OOO W. B. C., 31,250 2.30 P.M. . . . . . . . . . . . R. B. C., 7,825,000 Hb = II.4 per cent. (by Gowers's app.) . . . . W. B. C., 25, OOO 5 P.M. Removed spleen while dog was under ether. Operated with antiseptic precautions. February 23, dog seemed very dull. Hb = I2O per cent. I P.M. . . . . . . . . . R. B. C., 8,800,000 W. B. C., 65,600 February 24 . . . . . . . . . . . . . . . . R. B. C., 8,375,000 - W. B. C., 51,000 February 25 . . . . . . . . . . . . . . . . R. B. C., 8,875,OOO W. B. C., 43,750 February 26 . . . . . . . . . . . . . . . . R. B. C., 7,662,000 W. B. C., 35,000 ExPERIMENT II.-Old mongrel, weighing 7.480 kilos. February 22, 3 P.M. . . . . . . . . . . . . . R. B. C., 7,325,000 * W. B. C., 25,000 3.30 P.M. . . . . . . . . . . . R. B. C., 7,575,000 Leucocytosis. 2 I Hb = I IO per cent. . . . . . . . . . . . . . W. B. C., 28, IOO 4 P.M. Etherized and removed spleen, using all precautions of antisepsis in operating. February 23, seems dull. Wound clean. 3 P.M. . . . . . . . . . . . . . R. B. C., 7,625,000 Hb = IO6 per cent. . . . . . . . . . . . . . W. B. C., 50,000 February 24 . . . . . . . . . . . . . . . . R. B. C., 7,825,000 W. B. C., 43,750 February 25 . . . . . . . . . . . . . . . . R. B. C., 7,675,000 W. B. C., 46,850 A third experiment gave practically the same result as the above, —a slight increase in the number of red blood-corpuscles and a leuco- cytosis which undoubtedly arose from the injury to the peritoneum, for every precaution was taken to prevent pyogenic infection. The differential count was as follows: EXPERIMENT I. One Day after Two Days after Normal. Removal of Removal of February 22. Spleen. Spleen. February 23. February 24. Lymphocytes . . . . . . . . . 8.0 per cent. 2.8 per cent. 2.6 per cent. Large mononuclear . . . . . . 4. O ( & I. 2 { { 2. O & & Transitional . . . . . . . . . . 4. O { { 2. O { { 4.4 { { Multinuclear . . . . . . . . . 83. O & 4 94.O { { 9I.O & ( Eosinophile . . . . . . . . . . I.O “. . . . . . . . . . . . . . . . . EXPERIMENT II. One Day after Two Days after Normal. Removal of Removal of February 22. Spleen. Spleen. February 23. February 24. Lymphocytes . . . . . . . . . I2.0 per cent. 4.3 per cent. 6.4 per cent. Large mononuclear . . . . . . 2. O { { I. O & 4 I. O & 4 Transitional . . . . . . . . . . 5.o “ 4.3 ( & 6,o “ Multinuclear . . . . . . . . . 8o.o ( & 90.O & 4 85.2 & 4 Eosinophile s e e s e e º is a • I. O { { O.5 & & I.5 ( & This shows that the leucocytosis was produced by a dispropor- tionate increase of the polynuclear. Of course, the other varieties are relatively less abundant, but not absolutely so. None of them disap- peared entirely, but the large mononuclear cells seem to be least abun- dant after the removal of the spleen. THE LEUcocytosis OF PHYSIOLOGICAL STATEs. By leucocytosis let us understand a condition in which the total number of leucocytes in the blood is increased, usually being due to a 22 Wm. S. Carter. disproportionate increase of the multinuclear variety, although excep- tionally one of the other varieties found in normal blood may be increased. rº I. Digestion Leucocytosis.-In a series of experiments on thirty- five different individuals made by Dr. Hermann Rieder," it was found that a distinct leucocytosis made its appearance about two hours after the ingestion of a meal, reaching the maximum, in three to four hours, and gradually disappearing in six to seven hours. The degree of leu- cocytosis during digestion is quite variable, sometimes being absent altogether. It does not seem to be affected by the time of fasting before the meal. That it is not due to the physical process of flushing out the lymph-spaces by the fluid absorbed from the alimentary tract is shown by the fact that it is not constantly present and that tea and coffee, or very weak soups, or a meal of carbohydrates, in which the digestive process is an active one, all fail to cause leucocytosis. A mixed diet will cause slight leucocytosis, while a meal of proteids show the greatest increase. Dogs fed upon a pure meat diet show double the normal number of leucocytes, while men on mixed diet show an increase of about one-half the normal number. It is said that vegeta- rians do not show any digestion leucocytosis. Children show a more pronounced digestion leucocytosis than adults, but it is questionable if this is as marked as mentioned by some writers. To determine the effect of different food-stuffs the following experi- ments were made : ExPERIMENT I.—Dog ; weight, Io.231 kilos. Fasted one day before experiment. I2.45 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6,150,000 W. B. C., I2,500 I. I5 P.M. . . . . . . . . . . . . . . . . . W. B. C., 15,600 I. I5 P.M. Was given large quantity of fresh lean beef (uncooked). Ate very freely. 4 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 6, IOO,OOO - W. B. C., 28,200 ExPERIMENT II.—Young pup; weight, 4.988 kilos. I P. M. . . . . . . . . . . . . . . . . . . . R. B. C., 5,800,000 W. B. C., 18,750 I.3O P.M. . . . . . . . . . . . . . . . . . R. B. C., 6,000,000 2 P.M. Ate freely of fresh lean beef (uncooked). 4 P.M. . . . . . . . . . . . . . . . . . . . R. B. C. B 6, IOO,OOO W. B. C. 37,500 ?y 1 Beiträge zur Kentniss der Leukocytose, Leipzig, 1892. Zezzcocytosis. 23 EXPERIMENT III.-Dog ; weight, 9.514 kilos. I2.3O P. M. . . . . . . . . . . . . . . . . . W. B. C., 17, 18O I P. M. . . . . . . . . . . . . . . . . . . . W. B. C., 20,300 I. I5 P.M. Injected into stomach (by means of soft catheter) I25 cubic centimetres of a 50-per-cent. emulsion of cod-liver oil. 2.30 P.M. . . . . . . . . . . . . . . . . . W. B. C., 34,370 3. I5 P.M. . . . . . . . . . . . . . . . . . W. B. C., 40,600 4. I5 P.M. . . . . . . . . . . . . . . . . . W. B. C., 31,250 II A.M. . . . . . . . . . . . . . . . . . . W. B. C., I2,500 I2 M. . . . . . . . . . . . . . . . . . . . W. B. C., 18,700 I P.M. Injected into stomach IOO cubic centimetres of 50-per-cent. emulsion of cod-liver oil. 3 P.M. . . . . . . . . . . . . . . . . . . . W. B. C., 28, 150 6 P.M. . . . . . . . . . . . . . . . . . . . W. B. C., 36,000 ExPERIMENT V.-The writer having breakfasted at 8 A.M. found his leucocytes at I P.M. to be 7,800. I.30 P.M. . . . . . . . . . . . . . . . . . W. B. C., 6,250 I.40 P.M. Ate one pint of corn-starch pudding (made without milk) and drank some tea. 3 P.M. - . . . . . . . . . . . . . . . . . . W. B. C., 6,250 4.30 P.M. . . . . . . . . . . . . . . . . . W. B. C., 7,800 ExPERIMENT VI.--Small rabbit, fasted one day before experiment. 4.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 4,700,000 W. B. C., 4,700 5 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 5, IOO,OOO W. B. C., 3,900 6–8 P.M. Ate a large quantity of lettuce, cabbage, and green grass. IO P. M. . . . . . . . . . . . . . . . . . . R. B. C., 5,475,000 W. B. C., 4,700 These experiments confirm the experiments of others in that carbohydrates fail to produce leucocytosis, and that a diet of proteids produces the greatest leucocytosis, amounting to double the normal number. It has been stated that fats do not produce leucocytosis, but to this the writer cannot agree. In my experiments the degree of leucocytosis after the administration of fats wās quite as great as after a diet of proteids. As the fats are absorbed largely through the lacteals, one would naturally expect some alteration in the leucocytes. W. B. Hardy' has studied the white blood-corpuscles of daphnia very carefully, and found that when fats were given within a few hours fat droplets were found within the cells, and that even ten to twelve hours afterwards almost every white blood-corpuscle of these animals con- tained fat droplets. 1 Journal of Physiology, Vol. XIII. 24 Wm. S. Carter. The leucocytosis after a meal of proteids has been thought to be a means of disposing of the peptones after their absorption,-of converting them back into coagulable albumens. From the fact that peptonuria frequently occurs in diseases in which leucocytes are being destroyed rapidly (e.g., pneumonia), and that peptones are often found locally in areas in which there is an extensive destruction of leucocytes, it has been supposed that these cells are rich in peptones. Hofmeister has observed that many karyokinetic figures occur in the lymphoid collections of the intestine during the absorption of nitrogenous foods, and we must also remember that leucocytosis is by no means constant after a mixed diet, and may even be absent after a diet consisting very largely of proteids (Rieder). These facts would indicate that the leucocytes are probably not concerned so much in handling the products of normal digestion as in dealing with some form of intoxication which is apt to occur from this digestion. II. The Leucocytosis of Pregnancy.—The writer has had no experi- ence in examining the blood of pregnant women, but it would appear that the frequency of leucocytosis in this state is overdrawn. According to the results given by Rieder, about one in every five or six cases fails to show leucocytosis, and when it does occur is not at all pronounced, never amounting to double the normal number. The time of gestation and the number of the pregnancy appear to bear no relation to the degree of leucocytosis. The number rapidly returns to the normal after delivery in most cases, although there may be a temporary increase immediately after delivery, probably the result of the loss of blood. III. Leucocytosis of the New-Born.—Almost all children seem to show some leucocytosis when born. This lasts a variable time, and then gradually subsides, usually disappearing in a few days. It is interesting to note that the fractional counts show a relative excess of eosinophiles and also a great abundance of lymphocytes. IV. Leucocytosis after Massage.—You are all familiar with the results recently published by Dr. John K. Mitchell." Examining the ten cases in which a count of the leucocytes was made, we find a decided leucocytosis in four, a slight increase (too slight to be called leucocytosis) in three, and no alteration at all in three, although in two of these three there was a distinct increase in the number of red blood- cells. On the other hand, in one case there was a distinct increase of the leucocytes, although the number of red blood-corpuscles was not affected. f V. The Leucocytosis after Cold Baths.—Professor Winternitz first pointed out that patients treated by cold baths, as in the Brand treat- ment of typhoid fever, showed a leucocytosis which comes on very 1 American Journal of the Medical Sciences, May, 1894. Zeucocytosis. 25 shortly after the bath and lasts several hours. This same condition is produced in normal individuals by cold bathing. Since his first com- munication Winternitz has studied the effects of thermic and mechanical measures (douches, cold pack, friction) applied to the surface of the body. The maximum increase of red blood-cells was 2, OOO,OOO per centimetre, the Hb was increased 14 per cent., while the leucocytes were trebled in number. The maximum was not always seen at once after the treatment, but often an hour afterwards. The colorless cor- puscles began to increase at a time when the red blood-corpuscles were beginning to decrease. Applications of cold to the lower extremities were followed by a diminution of leucocytes in the upper extremities, while blood from the parts to which cold was applied showed an increase of the leucocytes. General application of gentle heat was followed at first by a diminution and, later, by an increase in the number of red blood-corpuscles. Dr. W. S. Thayer has reported twenty cases of typhoid fever treated by the Brand method in Professor William Osler's wards in the Johns Hopkins Hospital, in which the number of leucocytes after a cold bath was about double the normal number. There was no change in the normal proportion of the different varieties of leucocytes. It would appear that the application of cold, like massage, produces leucocytosis in a mechanical way,+the invigorating influence upon the heart, vessels, and tissues causing the stagnant blood of the tissues to hasten back into the blood-vessels. THE LEUCOcyTOSIS OF PATHOLOGICAL STATES. I. The Leucocytosis of Cachexias.-Malignant growths usually cause a leucocytosis, but quite often it is absent. Just what relation the location or kind of growth has upon the leucocytosis cannot be positively stated. In twelve cases with malignant neoplasms examined by Rieder, eight showed leucocytosis, while four (two cancers and two sarcomas) failed to show it. In nineteen cases examined by Dr. R. C. Cabot,' twelve showed leucocytosis and seven did not, most of the latter being either small tumors or cases in which cachexia had not yet developed. So far as we can judge from the cases reported, those with cancers situated at the pyloric orifice of the stomach seem to show the most pronounced leucocytosis, while those of the uterus or of the lip do so less frequently. However, the number of cases studied is entirely too small to warrant any positive conclusions. The size of the growth does not seem to affect the number of 1eucocytes, for Cabot gives two cases of very extensive growth which did not have any leucocytosis. 1 Boston Medical and Surgical Journal, March 22, 1894. 26 Wm. S. Carter. A case of rapidly-growing, small, round-cell sarcoma in a child of 2 years, which was seen in Dr. H. R. Wharton’s wards of the Children’s Hospital, confirms this. The child was admitted, with a mass in right iliac fossa, late in the summer of 1893. It was operated upon, found to be a new growth, and was not disturbed except to remove small piece for examination. Early in December there was moderate disten- tion of the abdomen, child fairly nourished. R. B. C., 3,125,000 ; W. B. C., 22, ooo. February 5, 1894. Child greatly emaciated, abdomen enormously distended, and superficial veins very prominent. There are marked Secondary growth in the orbit, on the left arm near the elbow, and over the scapula. R. B. C., 2,800,000; W. B. C., 18,700. March 15, 1894. Abdomen even more distended. Secondary growths increasing in size very rapidly. Symptoms of metastasis to lung. R. B. C., 1,300,000 ; W. B. C., 48,000. Child died March 30, 1894. No necropsy allowed. Cabot attributes the leucocytosis to the cachexia, for in two of his cases, in which it was absent at first examination, it was present later, when the cachexia became pronounced. On the other hand, some of Rieder's cases show the usual disturbance of the red blood-corpus- cles seen in cachexias without any leucocytosis. That it is not due to the physical state of the blood seen in these conditions (such as hydre- mia, lessened alkalinity, or altered isotonic equivalent) is evidenced by the fact that in chlorosis, in which these conditions are present, leuco- cytosis is usually absent. Further, in animals in which the , normal condition of the blood has been altered experimentally, there is no change in the leucocytes, as is shown by the following: ExPERIMENT I.—Dog ; weight, 9.070 kilos. I2 NOON. . . . . . . . . . . . . . . . . . R. B. C., 7,025,000 W. B. C., 18,750 I P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 7,400,000 W. B. C., 25,000 2. I5–2.20 P.M. Injected, per jugular vein, 250 cubic centimetres normal saline solution at body temperature. 2.35 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6, 125,000 W. B. C., 12,500 3.00–3. Io P.M. Injected 250 cubic centimetres saline solution. 3. I5 P.M. . . . . . . . . . . . . . . . . . . R. B. C., 6,000,000 W. B. C., I2,500 Urinated very freely. ExPERIMENT II.-Dog ; weight, I2.698 kilos. I2 NOON . . . . . . . . . . . . . . . . . . R. B. C., 7,525,000 Hb = IOO per cent. . . . . . . . . . . . . . W. B. C., 35,600 I P. M. . . . . . . . . . . . . . . . . . . . R. B. C., 7,800,000 W. B. C., 31,250 Aleucocytosis. 27 4.25–4.35 P.M. Injected, per jugular vein, 2Io cubic centimetres distilled water at the body temperature. 4.40 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6, I25, OOO Hb = 82.0 per cent. . . . . . . . . . . . . W. B. C., 4O,OOO 5.OO P. M. . . . . . . . . . . . . . . . . . R. B. C., 6,660,000 W. B. C., 31,250 Hb = 90 per cent. 5.25 P.M. . . . . . . . R. B. C., 6,575, OOO W. B. C., 31,250 EXPERIMENT III.-Dog ; weight, II.7.91 kilos. 3 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 7,350,000 * W. B. C., I4, ooo 3.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 7,250,000 W. B. C., I7, 18O 3.40—3.45 P.M. Injected slowly, per jugular vein, thirty cubic cen- timetres of tartaric acid solution (75 grammes in 1000 cubic centimetres). 3.45 P.M. . . . . . . . . . . . . . . . . . . R. B. C., 7,750,000 W. B. C., I2.500 3.55–4.oO P. M. Injected forty cubic centimetres. 4.05 P.M. . . . . . . . . . . . . . . . . . R. B. C., 5,950, OOO W. B. C., I5,625 4. IO-4.25 P.M. Injected fifty cubic centimetres. 4.25 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6,8oo, Ooo W. B. C., 28, Ooo While injecting a larger quantity dog died suddenly,–apparently from direct action on the heart. From what has been stated, it seems highly probable that the leu- cocytosis of cachectic states depends upon some special intoxication, which probably arises from the neoplasm causing the cachexia. As it is most marked late in the disease, it may be that it sometimes arises from septic infection, or from metastatic involvement of the lungs or serous membranes. II. The preagonal leucocytosis, observed in many patients who die slowly, can probably be attributed to the same cause,_i.e., some tox- emia, for it is not present in all cases of slow death, and cannot be produced experimentally by chloralizing animals, and causing them to die slowly, as has been shown by Rieder. III. The post-hemorrhagic leucocytosis, observed in man, is quite constant, and usually proportionate to the loss of blood. I have had no opportunity of studying the blood of men after a severe hemorrhage, but have failed to produce leucocytosis in dogs by bleeding experi- mentally. This is in accord with the experiment of Rieder, for in his experiments, in which he removed about one-half the estimated total quantity of blood of an animal and did not follow it by Saline transfu- sion, there was no leucocytosis. In one of my experiments (Experi- ment I) the red blood-corpuscles were reduced to one-half the normal number, with an actual diminution of the white blood-corpuscles. 28 Wm. S. Carter. ExPERIMENT I.—Dog: weight, 8.163 kilos. 2.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 5,830,000 t W. B. C., 21, ooo 3 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 5,700,000 W. B. C., 29,8oo 3.40–4.00 P.M. Bled from external jugular vein, about 450 cubic centimetres in all. 4.05 P.M. . . . . . . . . . . . . . . . . . R. B. C., 4,260,000 W. B. C., I6,000 5 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 4,230,000 W. B. C., 30,000 5.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 4,200,000 W. B. C., 4o, ooo Next day, dog very weak. 5 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 2,460,000 W. B. C., I5, IOO Second day. I P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 2,480,000 W. B. C., 15,600 Died during night. ExPERIMENT II.—Very large, old, fat dog; weighing 36.280 kilos. 3 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 7, Ooo,000 - W. B. C., I7,200 3.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 7,300,000 W. B. C., 21,8oo 4.45 P.M. Started bleeding from external jugular. 4.58 canula occluded by clot. Has lost very nearly 900 cubic centimetres. 5.OO P.M. . . . . . . . . . . . . . . . . . . R. B. C., 7,000,000 - W. B. C., I2,500 5. IO-5. I3 P.M. Bled about Ioo cubic centimetres. 5. I5 P.M. Blood very dark. Respiration sighing. 5. I5 P.M. . . . . . . . . . . . . . . . . . . R. B . C., 5,800,000 W. B. C., 31,000 5.20 P.M. Sighing continues. 5.25 P.M. Could get no blood from sticking the ear. Blood of vein is almost black, and shows . . . . . R. B. C., 4,400,000 W. B. C., 24,000 5.35 P.M. Died. ExPERIMENT III.-Dog'; weighing Io.800 kilos. Has leucocytosis from a pleuritis produced experimentally. 3.OO P.M. . . . . . . . . . . . . . . . . . . R. B. C., 7,600,000 W. B. C., 34,375 3.30 P.M. . . . . . . . . . . . . . . . . . . R. B. C., 7,200,000 W. B. C., 37,250 4.30 P.M. Bled freely from vein until sighing respiration was observed. Loss of Orethra, and Vesico- Vaginal Septum. 29 5. IO P.M. . . . . . . . . . . . . . . . . . . R. B. C., 5,500,000 W. B. C., 25, OOO Dog is very weak. 5.30 P.M. Appears to be dying. Chest opened. Heart still beating. Blood from right ventricle shows . . . . . . . . . . . . . . . . . R. B. C., 4,500,000 W. B. C., 21,800 These results show that hemorrhage, even when sufficiently severe to cause death, does not produce in dogs (at least in a few hours) a dis- tinct leucocytosis. The very pronounced leucocytosis, which Rieder produced in dogs by copious bleeding, and then transfusing the same quantity of normal salt solution, probably explains the cause of post-hemorrhagic leucocy- tosis. Very probably, the leucocytosis seen in man after a hemorrhage, even without transfusion, can be explained by the fact that the tissues of man are richer in the juices of the body, and hence more lymph is available in sudden emergencies. It has been shown by Dr. Wm. E. Hughes and the writer that the absorption of subcutaneous injections of large quantities of saline solution in man, made at the time of copious bleeding, which we recommend in uremia,” takes place with a rapidity that is truly astonishing. MEMORANDUM. A CASE OF ENTIRE LOSS OF THE URETHRA AND VESICO-VAGINAL SEPTUM. LILLIE S., aged 33, married, was delivered of her first child in December, 1893. The labor was prolonged beyond twenty-four hours. The attend- ant's patience having become exhausted, he applied the forceps, and after pulling until he got tired, put the forceps in the hands of her hus- band, and had him pull. Between the two the child was delivered. When she came under my observation, March 1, 1894, in my ser- vice at St. John's Hospital, I found her in a most pitiable condition. She had undergone three operations, but without benefit. The entire urethra was gone, and the under surface of the pubic bone was devoid of muscular tissue, and only covered with a thin membranous tissue. The base of the bladder was gone to the vagino-cervical junction. The 1 Boylston Prize Essay, American Journal of the Medical Sciences, September, 1894. 3O Memorandum. upper surface of the uterine cervix was constantly bathed in urine, and all the parts were excoriated and very friable, The whole interior of the bladder was visible to the naked eye, a more distressing condition can scarcely be imagined. On account of her menstrual period we were unable to operate until March I I. Assisted by Drs. Simmons, Search and Stuart, ether having been administered,—the operation was undertaken. & Profiting by the former three unsuccessful operations, which were from behind forward, we determined to pursue a middle course. The operation was designed to form a strong band of tissue, near where the base of the urethra should be, and extending as far into the vagina as seemed practicable, and as far forward as possible. We intended to leave a fistula posteriorly, so that the bulk of the urine would pass out that way, giving a better prospect for union of the coaptated parts. On either side of the vaginal wall strips were dissected up, and denuded of mucous membrane, about an inch in length. Six silkworm-gut sutures were introduced and drawn tightly together. We thus very materially lessened the opening, and had a very fair beginning for a urethra. * March 23, 1894. Twelve days after the operation the stitches were removed, and all had taken well except the anterior one, which had not held perfectly. For the first three days after the operation—the vagina being packed with iodoform gauze—the patient held her urine, and passed it voluntarily. By this operation we secured a good firm connecting band of tissue from which to work both ways in our future operations. We had also gained very materially in the strength and healthfulness of the sur- rounding tissues. April 5, 1894. Anesthetic, ether. Assisted by Drs. Simmons and Wood, we proceeded to close the vesico-vaginal fistula, not desiring to do more to the urethra until this was closed. The previous operation bad secured to us about three-quarters of an inch of solid tissue from which to work. To get the parts better into view, we carried a braided silk thread through the uterine cervix. With this arrangement we were able to draw the parts well down and denude them with much greater ease. The parts having been denuded, ten Chinese silk sutures were introduced as deeply as possible, and avoiding the mucous membrane of the bladder. All antiseptic precautions were observed throughout, and the vagina again packed with iodoform gauze. April 17. We removed the stitches; all had done their work but Clinical Department. 3I one. But from this cause there was no leakage of urine, it all being passed every two hours by the short urethra. By distending the bladder with Tiersch's solution we found a small opening into the vagina about one-sixteenth inch in diameter. April 24, 1894. Under ether, assisted by Drs. Simmons, Search and Panton, we attempted to close the small fistula, but were not suc- cessful. May 27, 1894. Under ether, assisted by Drs. Search and Pan- ton again operated. We first closed the very small fistula. We then extended the urethra forward, and narrowed it to about a quarter of an inch in diameter, this time completing the operations as designed in the beginning. June 9. Stitches removed. The wall of the bladder is complete. The patient can hold her urine while walking or standing, but there is some leakage from the urethra when reclining. This is not to be won- dered at when we consider that our only means of closing the meatus is in the hope of contraction of non-muscular tissue. Few cases have ever came under my care that presented the diffi- culties that this one did in the beginning. So we made no promises, only said we would try. Modern methods, which in a word are summed up, cleanliness, during the operation and night and day after the operation, had a large share in the success of this series of operations. This woman’s life is now tolerable; before, it was intolerable, GEORGE G. HOPKINS, A.M., M.D. (Univ. Pa.). CLINICAL DEPARTMENT. UNIVERSITY HOSPITAL. (Service of J. W.M. WHITE, M.D.) DISLOCATION OF THE FIFTH CERVICAL VERTEBRA, witH DISPLACEMENT OF THE INTERARTICULAR CARTILAGE BETWEEN THE FIFTH AND SIXTH CERVICAL VERTEBRAE. HUGH O'D., aged 24 years, was brought to the hospital apparently intoxicated, with the history of having fallen into a cellar. An exami- nation disclosed a trifling scalp wound, which did not expose the skull. There was no evidence of fracture at the seat of the wound or of injury 32 Clinical Department. elsewhere. After the wound had been dressed the patient complained of weakness of his limbs, and upon investigation it was found that there was distinct loss of power in both legs and both arms. He was put to bed and given one-sixth grain of calomel every two hours with two grains of Dover's powder. The following morning there was complete paralysis of both limbs and the left arm, slight power being still retained in the right arm. The right hand, however, was almost helpless; there was loss of sensation of the entire body below the third rib ; the temperature rose to IO4°F., the pulse remaining at 76. Later in the day the paralysis of the right arm increased ; the temperature rose to IOG” F. ; the pulse was, however, slow and full; the respirations assumed the Cheyne-Stokes type. The patient complained of moderate pain in the spine between the scapulae. From the symptoms, Dr. Martin, who saw the case, suspected intraspinal hemorrhage, and the advisability of an operation was considered, but there was no lesion which could be detected by external examination that would serve as a guide to the exact seat of trouble, and it was thought best to defer an operative attack. By evening the conditions were worse, the tem- perature remained above IO6°F., the respirations began to fail, stupor developed, and death in coma soon followed. Post-Mortem A^xamination.—Brain : The sinuses contained currant- jelly clots; the veins in the velum interpositum, in the ventricles, and over the entire surface of the brain were distended with blood ; no other lesions were detected. Spinal Column. On cutting down upon the spinal column a distinct separation was noticed between the fifth and sixth cervical vertebrae. After having removed the laminae and cord, the fifth vertebra was found freely movable, the interarticular cartilage between this and the sixth was loosened, and had attached to its surface a small fragment of bone which was torn from the surface of the latter. Beneath the periosteum there were small hemorrhages above and below the seat of injury, not large enough, however, to cause pressure; there were also small extradural hemorrhages anteriorly and posteriorly. On removing the dura mater there was found a trans- verse depression on the cord corresponding to the dislocated cartilage; there were also hemorrhages into the substance of the cord above and below the seat of depression. Sections of the cord at this point showed the gray matter to be dark and distinctly soft, so that its sur- face presented an exudation. No other lesions were found. CHARLES H. SCHOFF, Resident Surgeon. Alumn? AVotes. 33 ALUMNI NOTES, THE Appleton prize, consisting of twenty-five dollars’ worth of medical publications, offered annually by the firm of D. Appleton & Co. to the candidate passing the best examination before the Board of Medical Examiners of the State of North Carolina, was won this year by Dr. Hubert A. Royster, of the class of '94, whose percentage was 98.93, which was the highest in the history of the board. Dr. W. H. Nicholson, of the class of '93, has been elected by the board of managers to fill the vacancy in the resident staff of the Penn- sylvania Hospital caused by the resignation of Dr. Thomas F. Branson. NECROLOGY. Dr. Charles D. Dare, of Bridgeton, N. J., died on August 25, 1894. His death was sudden, and caused by a rupture of the aorta, the result of aneurism. Dr. Dare was one of the most popular physi- cians of the country, and was for seven years County Physician of Cumberland County. He was 47 years of age. Dr. Frank Muhlenberg, one of Lancaster's best known physicians, died on September 8, 1894, in the fiftieth year of his age. He was a graduate of the Lancaster High School, Pennsylvania College at Gettysburg, and the University of Pennsylvania. After studying some time in Germany he returned to America, and began practising in Philadelphia. About ten years ago he removed to Lancaster and con- tinued the practice of his profession. Dr. Thomas Barr McBride, of Philadelphia, died suddenly, of heart-failure, on September 13, 1894, in the thirty-fourth year of his age. He graduated from the University in May, 1884. INTERNATIONAL OBSTETRICAL CONGRESS. The International Congress of Gynecology and Obstetric Medicine will be held for the second time at Geneva, in September, 1896. The questions proposed for discussion are: (1) The treatment of eclampsia. (2) The surgical treatment of retroflexion and retroversion. (3) The relative frequency of the various forms of narrowing of the pelvis in different nations. (4) The best method of suturing the abdominal walls for the pre- vention of hernial protrusion. (5) The treatment of pelvic suppurations. 3 EDITORIAL. THE TEACHING OF THE ART OF SURGERY. ATTENTION has recently been called from a number of sources to the subject of the teaching of surgery. In an able address at the recent annual meeting of the British Medical Association, J. Greig Smith spoke on the art of surgery. He dwelt on the thoroughness with which the science of surgery is taught, and contrasted in a forcible manner the lack of instruction in the art. This condition he very much deplores, and he hopes that a reform may soon be inaugurated. There can be no doubt of the general truth of the statement which the author. makes, nor of the necessity for the reform for which he is striving. Commenting on this address, the American Lancet publishes the following editorially: “The teaching of the physician and obstetrician is quite perfect in practical details at the best medical schools and hos- pitals. Is the student learning anatomy P A demonstrator stands over him and points out the defects in his work and shows how to prac- tically remedy them. Is he studying physiology 2 The teacher is at hand to direct in moments of doubt. Does he study practical medicine? The teacher shows how to auscultate a chest, and corrects mistakes of observation until the truth is mastered in a practical manner. So in urine-analysis, bacteriology, microscopy, the recognition of separate diseases, the varied phrases, and their practical management. In all these and allied portions of medical art, modern methods have brought the pupil and teacher into the closest relationships. As a result, the student on his graduation has become familiar with actual practice as it will present itself to him during his professional career. The physi- cian is, or may be, fully trained, not only in the science but in the practice of his art. He can learn to make examinations with the skill and deftness of a master before he has attended his first private patient. “But with the surgeon there is an obvious lack. He is taught the science but not the art. This art is, or should be, like that of a painter or sculptor, perfect in the training of brain and hand so that every touch shall aid in completing the perfect picture in the operator's brain. The painter and sculptor apply long and patient labor, under the direct training of a master, before they acquire the art of this combined hand- and brain-work called painting and sculpture. If the surgeon were 34 The Teaching of the Art of Surgery. 35 trained in like manner he would be able to operate upon the living subject under the direct tutelage of a master surgeon. His mistakes would be pointed out at the time of operating, and his correct move- ment approved. This is the only method of practically teaching surgery. “We know of no place in the world at which surgery is taught after this method. It is not regarded as proper for an undergraduate to operate ; yet the graduates know less than their superiors. It must be also considered that the older surgeons cling rather too tenaciously to the glory and reward attendant upon the successful training of them- selves in the art.” To the latter part of the quotation from the Lancet we partic- ularly desire to call attention. While it is manifestly impossible to fur- nish each aspirant for surgical honors with an abundance of operative material in every department, it is at least possible to give the under- graduate a considerable experience in the personal contact with patients, and to at least inculcate the fundamental principles which underlie the art of surgery. The large classes which now throng our medical col- leges preclude the opportunity for this personal contact to as great a degree as we could all hope. It has been, however, the custom in the department of Clinical Surgery in the University of Pennsylvania, during the past few years, to utilize this principle to the fullest possi- ble extent. In addition to the class being divided into small sections, which allows each member to see and hear to the best advantage, the students are called down in regular order, and personally take the his- tory and make the diagnosis of the cases as they are presented, being guided, of course, in the examination by the Professor of Clinical Sur- gery, and receiving such assistance as is necessary; the object being to teach the proper method of examination, and of handling cases by this personal contact. No amount of attention from the benches will adequately supply the knowledge thus gained. In cases that require minor operations the student is asked to perform the operation under the guidance of and with the assistance of Professor White; in the major operations the student acts as the chief assistant, and is thereby benefited to but a slightly less degree than if really performing the operation. In this service, a rich supply of material is available, being drawn both from the hospital wards and from the out-patient depart- Inent. The same is true with regard to the use of anesthetics; the students in turn personally administer the ether, under the supervision of a skilled anesthetizer. During the anesthetization instruction is given in the proper methods of administration, in the dangers to be appre- bended, and in the proper treatment to be instituted in the event of an 36 Salicylic Acid in the Treatment of Pleurisy. accident. It must be repeated that such a course does not pretend to graduate a proficient surgeon, but it at least prepares the way for those who expect to continue further in the study of this branch of medicine, and gives others sufficient training to handle intelligently surgical cases in an emergency until they can be transferred to other hands. Another feature of this course is the constant endeavor to teach the students the art of close observation, and to use the senses of sight and of touch to the fullest extent. The crowded condition of the medical curriculum will scarcely allow of more time being devoted to the teaching of clinical surgery than is now given to this branch in the University, and for further work in this line post-graduate instruction must be depended upon. We feel, however, that this course is one in which the University may justly take pride. This will be particularly appreciated when it is remem- bered that in the address before alluded to, Mr. Smith indicates that such instruction is not to be had in England, and, according to the Lancet, teaching of this kind is unknown in this country. SALICYLIC ACID IN THE TREATMENT OF PLEURISY. SALICYLIC ACID was first employed as an antiferment, Kolbe, Bucholz, and Meyer having demonstrated that solutions as weak as o.4 per cent. had the power of destroying most bacteria. However, the superiority of the drug over carbolic acid and corrosive sublimate was never established, and now it is rarely employed as an external anti- septic. Ewald and Justi first called attention to its antipyretic action, which they proved to be quite pronounced ; but other drugs having fewer disadvantages than salicylic acid soon displaced it as an anti-. pyretic, and at present it is seldom employed in pyrexia, excepting in that accompanying acute articular rheumatism. In the treatment of rheumatism the salicyl compounds still hold the same exalted place in the confidence of the profession that they ever did, and as yet they are without formidable rivals. New uses of the drug continue to multiply. We find it recommended as an anthelmintic, intestinal antiseptic, anal- gesic, cholagogue, and mild caustic. w * A few years ago the treatment of pleurisy by salicylic acid was insti- tuted in Germany, and since that time the method has found numerous followers in Europe. Although the usefulness of the drug in pleural effusions has been frequently demonstrated by foreign authorities, it seems to have attracted but little attention in this country. Dock, we believe, is the only American authority who has contributed any- thing to the literature of the subject. In the Therapeutic Gazette for Salicylic Acid in the Treatment of Pleurisy. 37 February 15, 1893, will be found an elaborate article by the above-men- tioned author, in which it is concluded that salicylic acid and its salts are among the most effectual agents in the treatment of pleurisy with effusion. During the last two years we have prescribed the salicylates in many instances, and always with the most happy effects. As a rule, a drachm of sodium salicylate a day is sufficient, but in some instances it is necessary to increase the amount to a drachm and a half. Under this treatment we have found that serous effusions in the pleural sac are much more rapidly removed than by the administration of absorb- ents, diuretics, and cathartics. When employed early in simple pleurisy, the drug relieves the pain, lowers the temperature, and often arrests the progress of the disease. In tuberculous pleurisy the remedy is of little value, and in empyema, as one would expect, it is absolutely useless. No explanation of this favorable action of the salicylates has yet been given. It is true that they act as diuretics, but it cannot be that they accomplish their good results solely in this manner, for drugs having a more decided influence on the flow of urine are not nearly so effective. LARGE INCREASE OF LUNACY IN GREAT BRITAIN. The forty-eighth report of the British commissioners in lunacy, just issued as a Parliamentary paper, says there were in the kingdom, on January 1, 92,067 lunatics, idiots, and persons of unsound mind, according to the various returns to the commissioners. This number is 22.45 in excess of the corresponding returns from the previous year, and shows the largest increase in the number of lunatics yet recorded. The report says: “This large increase calls the more for some special consideration, because it follows an increase of IO/4 in the preceding year, that being far above the average for the ten years, 1882 to 1892, which was only 1300. The increase seems to have been fairly general throughout England and Wales, but the predominant feature of the figures is the great increase shown in the county of London, its pauper lunatics numbering on January I, 800 more than they did a year pre- viously. It is perhaps right in this connection to point out that from the administrative county of Middlesex, which is fast becoming metro- politan, there is shown from last year an excessive increase of 103, against an average for the previous ten years of 42. From one of the tables attached to the report it appears this state of affairs, though alarming, is not quite so serious when considered in conjunction with the increase of population, the ratio being one insane person in 326, as against one in 331 for the previous year.”—Medical Record. MEDICAL PROGRESS. N/IEDIC IN E. |UNDER THE CHARGE OF WILLIAM PEPPER, M.D., LL.D., AND JAMES TYSON, M.D., ASSISTED BY M. HOWARD FUSSELL, M.D. THE FREQUENCY OF RENAL. ALBUMINURIA, As SHOwn BY ALBUMIN AND CASTs, APART FROM BRIGHT's DISEASE, FEveR, OR OBVIOUS CAUSE OF RENAI, IRRITATION. SHATTUCK (Boston Medical and Surgical Journal, June 21, 1894) has exam- ined the urine of patients seeking his advice for various ailments. He has used boiling with additions of nitric acid and the Heller test, and considers them the most satisfactory. He concludes his article as follows: (1) Renal albuminuria, as proved by the presence of both albumin and casts, is much more common in adults quite apart from Bright's disease or any obvious source of renal irritation than is generally supposed. (2) The frequency increases speedily and progressively with increasing age. (3) This increase with age suggests the explanation that the albuminuria is often an indication of senile change. (4) Though it cannot be regarded as yet absolutely proved, it is highly prob- able that faint traces of albumin and hyaline and finely-granular casts of small diameter are often, especially after 50 years of age, of little or no practical importance. THROMBOSIS OF CEREBRAI, SINUSES IN CHLOROSIS. KockEL (Deutsches Archiv für klinische Medicin, Vol. LII, Parts 5 and 6, 1894) reports two cases of thrombosis of the cerebral sinuses. Case I had been chlorotic for a long time. Three days before admission to the hospital she was seized with severe headache, and became unconscious on the third day. There were no paralyses, and the patient died unconscious in a few hours. At the post-mortem the ventricles were found distended with fluid. The vena magna Galeni was found plugged with a clot which had its origin in a clot in the left lateral sinus. The white brain-substance was pale; the ganglia rather red, but nowhere any sign of a hemorrhage. Case II had exactly the history of the first case. At the section the vessels at the base of the brain were found filled with fluid blood. On opening the lateral ventricle a large area of softening was found covering its borders and the ganglia. The vena magna Galeni was found filled with a clot which sprang from a thrombus in the right cerebral sinus. In the softened parts of the brain were 38 Medicine. 39 punctiform hemorrhages. A great number of the small vessels were filled with clots, and these vessels were surrounded by small-celled infiltrations. The picture in this case is very like the primary hemorrhagic encephalitis described by Strüm- pell, but it must have its cause in the plugged sinus and is not primary. He believes that some of the cases of primary hemorrhagic encephalitis are really softening due to sinus thrombi, and that the term should be limited to those cases without such thrombi. Some fifteen cases of thrombi of the lower extremities in chlorosis are mentioned, and three of thrombosis of the pulmonary arteries. PRIMARY NASAL DIPHTHERIA. TownsenD (Boston Medical and Surgical Journal, May 24, 1894) reports seven interesting cases of nasal diphtheria, and draws the following conclusions: (1) Primary nasal diphtheria may occur of a very mild type. (2) These cases are especially dangerous, as they are likely to go unrecognized for the following reasons: (a) The resemblance of these cases to ordinary coryzas, a membrane not being noticed in some cases except by careful scrutiny. (b) The normal or only slightly elevated temperature often present, with but little constitutional disturbance. (c) The intermittent character of the nasal discharge, absent for a few days and then starting up again. - (d) The apparent recovery, even the cessation of nasal discharge, while Klebs- Löffler bacilli are still present. (e) The fact that these bacilli have not lost their virulence; or, in other words, the fact that the patient having bacilli in his nose, although apparently well, may transmit the disease in a fatal form to others. - (f) The difficulty of always finding the bacilli in the nose, even when they are present. (3) The importance of bacteriological examinations in all suspicious cases of nasal discharge. (4) The importance of prolonged isolation, together with a refusal to consider a case cured until several consecutive negative cultures have been obtained. THERAPEUTIC VALUE OF LYSOL IN INTERNAL MEDICINE. MAAss (Deutsches Archiv für klinische Medicin, Vol. LII, Parts 5 and 6) first experimented with animals, administering lysol to them in different doses. He found it entirely harmless, and then administered it to men. Cases of catarrh of the stomach where there was interference with digestion were observed. The stools of these patients were examined for bacteria, and in all cases the colonies of bacteria decreased after the use of the lysol. He discovered, however, that it is necessary that the intestinal contents be fluid in order that they may be dis- infected. The urine of a man with advanced phthisis was found to contain a large amount of indican. During the use of lysol, the blue coloration due to indican entirely disappeared. The amount of sulphuric acid was not increased in the slightest degree by the use of lysol. Neither did its use either increase or diminish the amount of urine excreted. The dose of the drug is from one to six grains given in solution or in capsule. He believes it will prove of value where a direct disinfectant is needed for the mucous membranes. He has used it as a gargle, 5 parts to IOO, in angina, and in a 1-per-cent. solution as a nasal wash. 4O Medicine. LEPROPHOBIA. LUTZ (Journal of Cutaneous and Genito-Urinary Diseases, December, 1892) describes a curious mental condition among neurasthenic individuals who have a history of leprosy in the family, or who have lived with lepers, or who perhaps have simply come in contact with lepers. They believe themselves to be lepers, and go from physician to physician until one is finally found who gives leprosy as a possible diagnosis. For a while the patient is satisfied, but he soon sinks into the deepest depression. The author admonishes the physician to be very certain in his diagnosis of leprosy, and to make a diagnosis only on the most positive points. That the transmission of the disease from man to man among civilized nations is very rare, and that the teaching of the long incubation stage is largely a fable. THE TREATMENT OF LEPROSY witH EUROPHEN. GOLDSCHMIDT (Therapeutische Monatsheft, April, 1893) has used europhen in five cases of leprosy. In one he used it for fifteen months, and the case recovered. In this patient there were leprous patches on the angle of the mouth, chin, eyelid, point of the nose, and on the leg. A 5-per-cent. europhen oil was used and rubbed into the spots three times daily for five minutes at a time. After four weeks of treatment the patient was better, and after fifteen months the point of the nose was alone somewhat reddened. HEMATOPORPHYRINURIA AND ITS TREATMENT. MüLLER (Wiener élinische Wochenschrift, 1894, No. 14), after inveighing against the too general use of the coal-tar products as a probable source of much more mischief to the economy than good, quotes some cases of sulphonal-poisoning, and gives their treatment. Sulphonal, as well as trional, acts after long use in a deleterious manner upon the red corpuscles, destroying the coloring matter and causing hematoporphyrin (iron free hematin) to be excreted. If the excretion of this substance is continued for any length of time the case becomes incurable, notwithstanding the with- drawal of the sulphonal, and the patient dies. As a rule, this symptom of sulphonal poisoning, the excretion of hematoporphyrin, follows a series of symptoms, and it may be accompanied by them,--to wit, vertigo, failure of memory, sleepiness, staggering gait, ataxia, and disorders of speech. By further use severe obstipation appears, with severe colicky pains and periodical vomiting. At this point the urine becomes dark-blue red, and in severe cases becomes the color of cherry juice. Before the color of the collected urine can be noticed there are sometimes discolored spots on the bed-linen or on the underclothing of the patient. Unexceptionally the urine has a highly acid reaction, and shows the charac- teristic absorption bands for hematoporphyrin by the spectroscope. If the drug is still continued, the patient becomes bedridden, and is the picture of extreme prostration. One patient showed all the above symptoms who had taken sixteen grains of sulphonal daily for five months. The writer, taking into consideration the high degree of acidity, administered a drachm and a half of bicarbonate of soda daily. After four days the urine became neutral and then alkaline. After three weeks of this treatment the urine had lost its color, but upon the cessation of the use of the alkaline treatment it again became of the characteristic color. Four months after the beginning of the treatment, however, the patient had lost all the bad symptoms, and had apparently recovered. Medicine. 4. I A second case showed these symptoms with less intensity after having used sulphonal for two months in the dose of eight to fifteen grains. The author concludes that sulphonal should never be given continuously for a long time unless there is obtained daily a large bowel movement, and at the same time an alkali is administered. THE TREATMENT OF WHOOPING-COUGH witH QUININE. BARON (Berliner klin ische Wochenschriſt, No. 48, 1893) reports on fifty cases of whooping-cough treated after the old manner of Benz-Ungar, which they advo- cated in 1868. In a few children the good action of the quinine was noticed in two or three days, but in most of the children the results were shown after several days. The first evidence of value is the lessening of the night attacks. The improve- ment continues until health is restored, unless the dose be too suddenly reduced. The author continues the administration of the quinine for three weeks. Relapses do not occur in children treated with quinine. In spite of the fact that the quinine was not given as regularly as directed in more than half the cases, there were only two failures noted. The treatment is of unusual value in the cases of acute inflam- mation of the lungs caused by the whooping-cough. Since the thorough trial of quinine, whooping-cough has lost all its terrors to the author. The proper dose of quinine is one-sixth of a grain for each month of the child’s age, and one-and-a-half grains for each year, given three times in the day, at six A.M., and two and ten P.M. More than six grains three times daily is not necessary for older children. As the case improves, the number of daily doses is decreased. ANTISEPTIC TREATMENT OF TUBERCULAR PHTHISIS. Foxwel. L (Birmingham Medical Review, July, 1894) gives a general review of the different substances now employed in the treatment of phthisis. He lays great stress upon the free use of iodoform. He believes this drug the most satis- factory of the various antiseptics used in phthisis. He quotes one case at length, and arrives at the following conclusions: (1) We should never give up hope in a case of phthisis. (2) The case bears out Gosselin's experiments of 1887, in which he inoculated animals with tuberculosis, and afterwards injected iodoform. He found the disease delayed but the bacilli alive. (3) The remedy should be continued for a long time after all symptoms of the disease have disappeared. (4) A daily dose of twenty to thirty grains can be taken for a long time without any ill results, and such a dose should be administered. The dose should be six grains daily in the beginning, and increased every other day until thirty grains are taken daily. º MEGALOGASTRIA AND GASTROECTASIA. RIEGEL (Deutsche medicinische Wochenschriſt, April 12, 1894) reports a case of a man with a slight valvular lesion of the heart in which the physical examina- tion showed great dilatation of the stomach. There were no symptoms of any dis- order of digestion whatever. The muscular strength of the stomach, and its 42 Surgery. powers of digestion, as proved by the various methods, were both perfect. He claims that gastroectasia should not be applied to such cases, but prefers the term megalogastria, believing it to be virtually a congenital condition. There are three ways in which the motor strength of the stomach can be determined in relation to its size. The motor power is lessened,— (1) When the size of the stomach is normal, and in spite of this the contents are retained in the stomach for digestion longer than the normal time. This is the true atony or insufficiency of the stomach. (2) When the contents of the stomach are retained longer than normal, and there is at the same time dilatation. This is gastroectasia, or the so-called atonic ectasia. (3) If the contents are digested in the normal time, and the stomach is still dilated. The case belongs to the group of megalogastria or congenitally enlarged stomach. In this last group the stomach may readily become atonic if prophylactic measures are not undertaken. The fluids should be lessened, and meal times should be so regulated that there will be a normal relation between the work and rest of the stomach. SUFG EFY. |UNIDER THE CHARGE OF J. WILLIAM WHITE, M.D., ASSISTED BY G. G. DAVIS, M.D., M.R.C.S., AND ELLWOOD R. KIRBY, M.D. APPENDICITIS. J. WILLIAM WHITE (Therapeutic Gazette, June 15, 1894) discusses some of the unsettled points in reference to appendicitis, particularly as to its treatment. The following is a summary of his views: (1) The explanation of the great frequency of inflammation of the appendix is to be found in the following facts: (a) It is a functionless structure of low vitality removed from the direct fecal current. It has a scanty mesentery so attached to both cecum and ileum that it is easily stretched or twisted when they become distended. It derives its blood- supply through a single vessel, the calibre of which is seriously interfered with or altogether occluded by anything which produces dragging upon the mesentery. (6) In addition, there is almost always present a micro-organism, the bac- terium coli commune,—capable of great virulence when there is constriction of the appendix or lesions of its mucous coat or of its parietes. (2) The symptoms in a case of mild catarrhal appendicitis—general abdom- inal pain, umbilical pain, localized pain, and tenderness on pressure in the right iliac fossa, vomiting, moderate fever, and slightly-increased pulse-rate—cannot at present, with any certainty, be distinguished from the symptoms, apparently Surgery. 43 precisely identical, which mark the onset of a case destined to be of the very gravest type. (3) It must be determined by future experience whether or not operation in every case of appendicitis, as soon as the diagnosis is made, would be attended by a lower mortality than would waiting for more definite symptoms indicating unmistakably the need of operative interference. At present such indication exists in every case if the onset is sudden and the symptoms moderately severe, and whenever in a mild case the symptoms are unrelieved at the end of forty-eight hours, or, a ſortiori, if at that time they are growing worse. (4) It must be determined by future experience whether cases seen from the third to the sixth day, which present indications of the beginning circumscription of the disease by adhesions and which tend to the formation of localized abscesses, will do better with immediate operation with the risk of infecting the general peritoneal cavity, or with later operation when the circumscribing wall is stronger and less likely to be broken through. At present, operation is certainly indicated whenever a firm, slowly-forming, well-defined mass in the right iliac fossa is to be felt; or, on the other hand, when a sudden increase in the sharpness and the diffusion of the pain and tenderness points to the perforation of the appendix or breaking down of the limited adhesions. (5) In the beginning of general suppurative peritonitis operation offers some hope of success. In the presence of general peritonitis with septic paresis of the intestines operation has thus far been useless. (6) Reeurrent appendicitis of mild type, like acute appendicitis, frequently results from digestive derangements. Several attacks may occur followed by entire and permanent recovery, but it is as yet impossible to differentiate these cases accurately from those which do not tend to spontaneous cure. Operation is certainly indicated whenever the attacks are very frequent. (7) Chronic relapsing appendicitis is characterized by the persistence of local symptoms during the intervals and by more or less failure of the general health. It usually indicates operation. (8) In either the recurrent or the chronic relapsing variety operation should "be advised according to the following indications formulated by Treves. When- ever— (a) The attacks have been very numerous. (6) The attacks are increasing in frequency and severity. (c) The last attack has been so severe as to place the patient’s life in con- siderable danger. (d) The constant relapses have reduced the patient to the condition of a chronic invalid, and have rendered him unfit to follow any occupation. (e) Owing to the persistence of certain local symptoms during the quiescent period, there is a probability that a collection of pus exists in or about the appendix. EXTRAGENITAL SYPHILITIC INFECTION. KREFTING (Archiv für Dermatologie und Syphilis, Band xxvi, Heft 2) has reported 539 cases of extragenital syphilitic infection ; 4.3 per cent. of the cases were in men, and 32.8 per cent. were in women. About three-quarters of all the cases seen were infected by drinking-glasses. Fifty-one per cent. the chancre was located upon the hip; 20 per cent. in the throat; 3.5 per cent. On the tongue. The author says many children are infected through the breast. 44 Surgery. PRACTICAL MANAGEMENT OF STRICTURES OF THE URETHRA. COLE (New York Medical Journal, March 3, 1894) advises the following course in treating urethral strictures: (I) When the symptoms point to urethral difficulties, accurately determine the conditions present, using for this purpose the hard-rubber, olive-pointed bougies of small size, or the bulbs of larger size, or the urethrometer. (2) If, a contracted meatus or constriction within an inch of the meatus obtains, immediate meatotomy and a careful subsequent examination of the whole urethra. (3) For resilient or pliable strictures in the penile urethra, divulsion under cocaine; in the bulbo-membranous urethra, the passage of sounds and massage; and in aggravated cases perineal incision under general anesthesia; and in either case anesthesia is permissible. (4) For tough (fibrous, etc.) strictures, urethrotomy (internal) in the penile urethra; perineal section in the bulbo-membranous, always under an anesthetic in either case. - (5) Careful and continuous after-treatment by the passage of sounds and massage at the site of the exudation while the sound is in the urethra. (6) In all cases scrupulous cleanliness, a clear conception of the case from beginning to end, and a frank statement to the patient of what it is proposed to do. TENOTOMY FOR CONTRACTED TENDONS FOLLOwing INFANTILE PARALYSIS. Phºtºs (Nezw York Medical Journal, February 24, 1884), in certain cases of contracted tendons resulting from infantile paralysis, advises division of the ten- don instead of attempting to stretch the parts. He gives the case of a boy with contraction of the tendo Achillis in which it was impossible to bring the feet to a right angle. The patient had been told by a prominent English surgeon that he should “allow no American surgeon to operate on his tendons, else his feet would surely be ruined.” Conservative measures were also advised by three other sur- geons, but the child recovered quickly and satisfactorily after the operation, with. a perfect functional result, thus demonstrating the correctness of the treatment pursued. REMOVAL OF FIBROUS OR NASO-PHARYNGEAL POLYPI. ANNANDALE (Lancet, February 17, 1894) submits the following as his conclu- sions on the removal of naso-pharyngeal polypi: (I) That unless the tumor is seriously interfering with the respiration during the administration of the anesthetic, preliminary tracheotomy is not re- quired. (2) That chloroform is the best anesthetic. (3) That the position of the head should be dependent, that is, hanging well over one end of the operating table. (4) That the following method of operating allows the tumor to be sufficiently exposed and rapidly removed : (a) The chloroform having been administered, and the head placed in the dependent position, the mouth is kept open by an efficient gag. (b) A loop of strong silk is passed through each side of the soft palate, exter- nally to and about one inch above the uvula. These loops are left long, and are held by an assistant, so as to steady the soft palate. t Suzgery. 45 (c) The soft palate is then rapidly divided in the middle line with a sharp knife along its whole extent, and through both of its layers of mucous membrane, and its two halves are drawn apart by pulling upon the thread loops. (d) The tumor is now quickly enucleated or separated from its surrounding connections down to its attachment to the bone with a blunt periosteal elevator, assisted by the finger. (e) Thereupon, the neck of the growth is seized with a pair of strong forceps close to its attachment to the bone, and wrenched or twisted off. If the attach- ment passes up into the nasal passages, this portion will be most readily separated by introducing the same strong forceps through one or the other anterior nostril, the working of the forceps being assisted by the fingers of one hand passed up behind the soft palate. (f) When the tumor has been thus removed the nasal cavities should be plugged with iodoform gauze, and the halves of the soft palate stitched together. The thread loops may be retained until this stitching has been done, as they are useful in steadying the palate ; after this they should be removed. A CASE OF DILATATION OF THE STOMACH CURED BY MEANS OF A HEINEKE- MIKULICZ OPERATION. LöwenstEIN (Mitnchener medicinische Wochenschrift, May 22, 1894) says the most common cause of dilatation of the stomach is stenosis of the pylorus. In the surgical treatment of gastric dilatation two methods are to be considered,— (1) That which deals with the obstruction alone (gastro-enterostomy). (2) That which removes the obstruction, and at the same time decreases the size of the dilated organ by a partial gastrectomy. Of eighteen cases of gastro-enterostomy, collected by the author, there were six deaths; of twenty-two cases of resection of the pylorus, there were seven deaths. The exact number of cases that have been treated by the Loreta operation could not be collected. THE TREATMENT OF CYSTITIS BY INSTILLATIONS OF BICHLORIDE OF MERCURY. CoLIN (Thèse de Paris, 74 pp., 1894) reports thirty-four cases treated by subli- mate instillations, twelve were cured, nine greatly improved, nine improved, while no change was noticed in the remaining four. The good results noted in cases of ordinary cystitis have been likewise seen in cases of tuberculosis and gonorrhea of the bladder. In the tubercular variety of cystitis, the instillations give almost immediate relief from pain and tenesmus. The instillations are to be made by Guyon's method. At first the injections should be made at intervals of two days, but later every day, and the strength of the solution gradually increased. * The strongest solutions required are I : IOOO to 1 : 500. As to the quantity of fluid that should be injected, the author recommends five to ten grammes should be injected into the bladder, and ten to fifteen drops should be deposited near the neck of the bladder and in the posterior urethra. Guyon, in 1891, made some experiments as regards the strength of a bichloride solution that could with comfort be injected into the bladder. He found that when the bladder was irrigated with a solution stronger than I : 4ooo, there was great pain and tenesmus. If, however, the solution was used in much smaller quantities as strong as I : 500 might be used without any disagreeable after effect. 46 - Surgery. A NEw TREATMENT For CHRONIC EMPYEMA. DELORME (Gazette de Hôpitaux, No. 11, 1894) describes a new operation for the treatment of chronic empyema, which is intended to do away with the Estlander operation. The pleural cavity should be exposed by a large flap opening in the chest. The skin flap should reach from the third to the sixth rib, the ribs and inter- costal muscles are now divided to correspond with the skin flap, and also turned back. Through this opening the entire lung may be stripped of its pyogenic membrane. The rib and skin flaps are now turned down and sutured in place, complete long union always takes place. In this operation the lung can be readily freed from the pyogenic membrane. This is a rational operation and is more conservative than the Estlanders, and permits in most cases of a complete restoration of the respiratory functions of the compressed lung. TUMOR OF THE BLADDER. GUYon (Annales des Maladies des Organes Génito-Urinaires, January, 1894) gives the following operative technique in the removal of vesical growths: The incision should be a longitudinal one and extend two or three fingers’ breadths above the bladder. This latter should be entered at its highest point. From this point it can be prolonged to the symphysis or even to the neck of the bladder. He has done symphyseotomy in the removal of a large growth. The growth being seized with forceps it can be removed with the cautery knife or the galvanic loop. The principal thing is to see well, therefore it does not suffice to have a long incision, suitable retractors, a good light, and the aid given by raising the pelvis, but one must do the removal as already indicated by a bloodless method. To remove the stumps they are to be transfixed with a tenaculum and drawn upward towards the wound in the abdominal walls, then treated. If preferred, the bistoury can be used and the vessels ligated with catgut. The wound made in the bladder walls by the removal of the base of the tumor can be approximated by a few catgut sutures. The line of incision in the bladder is then sutured shut, as is also that in the abdominal walls. A NEW CYSTOSCOPE. BoISSEAU DU RocBER (Annales des Maladies des Orgames Génito-Urinaires, January, 1894, p. 51) describes a new instrument which is designed to give a better and more complete view of the interior of the bladder than those heretofore used without the necessity of removing or reintroducing it. The apparatus consists of a hollow tube bearing the lamp. This lamp has two fenestra instead of only one, as in the Leiter instrument. At the angle of the beak on its convexity is a window, and on the shaft on the opposite side near the beak is another window. A stylet or mandril is used in the tube when it is introduced. This closes the two windows. The instrument once in place the mandril is removed, and another tube bearing the optical apparatus introduced. Different tubes are used for the windows on each side. The different parts of the bladder can thus be inspected without the necessity of using different cystoscopes, or even of reintroducing it. If bleeding occurs the optical tube is removed, and the bladder washed out through the tube bearing the lamp, and the optical tube then reinserted. Different eye-pieces can also be adopted to the instrument. The diameter of the instrument at its largest part is No. 22, French scale. Therapeutics. 47 THE FA E2 EUTICS. UNIDER THE CHARGE OF HORATIO C. WOOD, M.D., LL.D., AND ARTHUR A. STEVENS, M.D. THE DIETETIC TREATMENT OF PHTHISIS. Loom IS (Practitioner, No. 3 II, 1894) makes the following suggestions regard- ing the dietetic treatment of phthisis: (1) Never take cough mixtures if they can possibly be avoided. (2) Food should be taken at least six times in the twenty-four hours; light repasts between the meals and on retiring. (3) Never eat when suffering from bodily or mental fatigue or nervous excite- 1ment. (4) Take a nap or at least lie down for twenty minutes before the mid-day and evening meals. r (5) The starches and sugars should be avoided, as also all indigestible articles of diet. (6) As far as possible each meal should consist of articles requiring about the same time to digest. (7) Only eat so much as can be easily and fully digested in the time allowed. . (8) As long as possible systematic exercise should be taken to favor assimila- tion and excretion ; when this is impossible, massage or passive exercise should be undergone. (9) The food must be nicely prepared and daintily served,—made inviting in every way. The following diet-sheet is suggested for the early stage : On awakening, eight ounces of equal parts of milk and seltzer, taken slowly through half an hour. Breakfast: oatmeal and cracked wheat with a little sugar and an abundance of cream, rare steak or loin chop with fat, soft-boiled or poached egg, cream toast, half pint of milk, and small cup of coffee. Early lunch : half pint of milk or small tea-cup of squeezed beef juice with stale bread. Mid-day meal: fish, broiled or stewed chicken, scraped meat-ball, stale bread and plenty of butter, baked apples and cream, and two glasses of milk. Afternoon lunch : bottle of Koumyss, raw, scraped beef-sandwich, or goblet of milk. Dinner: substantial meat or fish. soup, rare roast beef or mutton, game, slice of stale bread, spinnach, cauliflower, fresh vegetables in season (sparingly). EFFECT OF MERCURY ON THE KIDNEYS. WELANDER (Hygeia, LVI, 2, 1894) has had the opportunity of observing ninety- seven cases of syphilis before treatment with mercury, and during the administra- tion of the drug. He found that its elimination was accompanied by a greater or less irritation of the kidneys, manifested by casts in the urine. These casts in- crease in proportion to the length of the treatment, gradually decrease after its essation, and generally disappear within a month or six weeks. No injury to the Ridneys, either temporary or permanent, was observed. (Universal Medical Journal.) 48 Therapeutics. THE TREATMENT OF ENTERIC FEVER witH KILLED CULTURES OF BACILLUS PYOCYANEUS. KRAUS AND BUswer,I, (Wiener klin ische Wochenschrift, July 12, 1894) have made some experiments to determine the antagonism between pyocyaneus products and the typhoid bacillus in the body. Instead of thymus extract cultures, they used bouillon cultures heated to between 60° and 80°C. for twenty minutes. These higher temperatures were used, as one animal injected with an apparently steril- ized culture died of the pyocyaneus infection. Enteric fever in man is not a simple infection, but a middle form between infection and intoxication. Three guinea- pigs were inoculated with one-half cubic centimetre of sterilized pyocyaneus cul- ture, and a week later with 3 cubic centimetres virulent typhoid culture. The three control animals died within twelve hours, whereas the others not only lived but were active and lively on the next day. The action really lies in an increase in the natural resistance. Toxalbumins are destroyed at 70° C., and the poi- sonous toxines have little significance in this relation. The bacterial protein, how- ever, preserves its powers even after being heated to 120° C. ; it constitutes the most important part of sterilized bacterial fluids. The authors believe that the real object to be aimed at in the injection of bacterial protein is to make the inflammatory and febrile reaction more marked. GLYCERIN IN HEPATIC COLIC. FERRAND (L' Union Médicale, May 8, 1894) states that he has obtained good results with glycerin in the treatment of hepatic colic. On the appearance of an attack he administers by the mouth from one-half to one ounce of glycerin. He believes that the drug is rapidly conveyed to the liver where it exerts a marked cholagogue effect and thus aborts the attack of colic. One to three drachms of glycerin daily, in some alkaline water, it is stated, is sufficient to prevent a recur- rence of the attacks. PARA- AND ORTHO-CHLORPHENOI, IN TUBERCULOUS AND OTHER DISEASES. N. SIMANOFFSKI (Vratch, No. 8, 1894) has used solutions of monochlorphenol in glycerin in the strength of 5 per cent., Io per cent., and 20 per cent., and points out as special features of these very powerful disinfectants that they do not irritate the mucous membrane, even if applied in a 20-per-cent. solution ; that they form no stable combination with the tissue albumens, and that they are, therefore, able to penetrate into the depth of the diseased organ. The tuberculous cases treated were mostly very advanced and serious affections of the throat with impairment of voice and difficulty in swallowing. In one case there was, besides these symp- toms, a tuberculous ulcer at the root of the tongue; in another a similar ulcer on the whole posterior wall of the pharynx and part of the naso-pharyngeal region, All cases without exception, even including the last one in which there was a very advanced affection of the lung, improved quickly under the local treatment with monochlorphenols; the ulcers became clean and showed a tendency to heal, and all the accompanying symptoms disappeared. Equally good results were obtained in chronic thickening and hyperplasia of the mucous membranes, which disap- peared after a few applications of the same solutions. Simanoffski is of opinion that the monochlorphenols will find a large field of application in diphtheria, etc., and he unhesitatingly recommends them in laryngological practice in preference to iodoform, pyoktanin, menthol, etc., especially as they also possess anesthetic properties. Therapeutics. 49 ERGOT IN THE NIGHT-SWEATS OF PHTHISIS. GOLDEN DACH (Deutsche medicinische Wochenschrift, No. 20, 1894) states that, from a knowledge of the action of ergot on the vaso-motor nerves, he was led to employ it in the colliquative sweats of phthisis. He first administered one or two five-grain powders at bedtime. The results were excellent, the remedy rarely failing to do good. Lately he has substituted ergotin for the powdered drug, and claims that its action is even better and more constant than that of the latter preparation. The ergotin is administered hypodermically, and is prescribed as follows: B Ergotin, 3 parts. Diluted alcohol, Glycerin, | of each 5 parts. Distilled water, One cubic centimetre every evening. THE ANTITOXIN TREATMENT OF DIPHTHERIA. KATZ (Lancet, II, 1894) has obtained excellent results with Aronson’s antitoxin in diphtheria in the Emperor and Empress Frederick’s Children Hospital, under Professor Baginsky's superintendence. In the last three years, 1891–1893, Io81 cases of diphtheria have been treated in the hospital, of which 421, or 38.9 per cent., died, the mortality in the respective years being 32.5 per cent. in 1891, 35.4 per cent. in 1892, and 41.7 per cent. in 1893. From the commencement of this year up to March 14, 86 cases have been treated, with 38 deaths, or a mortality of 41.8. On the latter date the antitoxin treatment was commenced and employed in I28 out of 151 cases admitted to the hospital, 23 cases not being subjected to it for various reasons. In the 128 cases so treated only 17 deaths occurred, the mor- tality thus falling from 41.7 to 13.2 per cent. In all his clinical observations Dr. Katz is able to say that on no occasion could any deleterious effect be ever attrib- uted to the employment of the antitoxin solution. If renal inflammation did occur, it followed quite a normal course, no bad effect could be observed upon the rhythm or tone of the heart and pulse. Katz also inoculated 72 children exposed to the disease in order to deter- mine the prophylactic value of the remedy. Of the 72 inoculated, only 8 were attacked, and so slightly as to be free from any evil consequences. The author states that in the records of the hospital there has never been so favorable a result in a series of diphtheria cases since the introduction of the antitoxin treatment. THE HyPod BRMIC INJECTION OF MAGNESIUM SULPHATE. As A PURGATIVE. FINcKE (Medical Nezvs, August 25, 1894) has made some experiments to test the purgative properties of magnesium sulphate when hypodermically administered. In September, 1893, Rohé and Wade reported that they had employed the drug in , this manner in forty-six cases, with the following results: The number of injec- tions made was Ioo. In 67 per cent. the injection was successful, in 33 per cent. it failed. The dose varied from I.86 grains to 4.5 grains. It was found that small doses acted as efficiently as slightly larger doses. In only one case was the dose (4.5 grains) employed. The shortest time for the injection to produce an evacua- tion was three hours, the longest fourteen. Fincke's results have not been so satisfactory. Twenty-five cases were selected, 4 5O Obstetrics. and fifty injections of from one to six grains were made. The average dose was 2.78 grains. In the majority of cases the results were negative. In order to com- pare with the foregoing the action of magnesium sulphate given in the usual doses by the mouth, eleven cases were selected, and in these, with one exception, the results were negative with hypodermic administration. The results obtained in all cases by the two methods of administration were as follows: Hypodermically: success, 18 per cent. ; failure, 82 percent. By the mouth : success, 72.7 per cent. ; failure, 27.3 per cent. While the author does not consider the number of hypo- dermic injections as conclusive, he still believes that the foregoing results cast considerable doubt upon the purgative property of magnesium sulphate exhibited hypodermically in small doses. O ESTETRICS. UN DER THE CHARGE OF BARTON COOKE HIRST, M.D., ASSISTED BY RICHARD C. NORRIS, M.D., AND FRANK W. TALLEY, M.D. RUPTURE OF THE SINUS LONGITUDINALIS IN FORCEPS DELIVERY. J. C. WEBSTER, of Edinburgh (Edinburgh Medical Journal, January, 1892), reports, in a demonstration of the skull, a case of labor in which from flat pelvis of three and a quarter to three and a half inches conjugate, the transversely-present- ing head was delivered from the superior strait with the axis-traction forceps, The child was asphyxiated, and died. There was a considerable blood extravasation on the convexity of the cerebrum reaching below to the base of the medulla. The sinus longitudinalis was ruptured through the great degree of telescoping of the skull bones in fronto-occipital direction. A CASE OF CERVICAL PREGNANCY. SIEGFRIED STOCKER, of Luzerne (Korrespondenzblatt für Schweizer Aerzte, Jahrgang XXIII, No. 23), describes a case of primary cervical pregnancy with cer- vical placenta formation in a 37-year-old III-para. The case presented the following peculiarities: (1) There existed no connection with the cavity of the uterus. 8 (2) There was throughout strong adhesion of the ovum with the cervical wall. (3) The separation of the ovum was attended with copious hemorrhage that continued after the removal of the ovum, as the cervix was without power to contract. (4) The external os was so dilated that, from the absence of a pedicle, the ovum must have been expelled through the force which dilated the external os had there been no union of the chorionic willi with the cervical mucosa. (5) There was an elevated decidual formation to be felt in the cervical canal, in the right side of which was the location of the placentar attachment. (6) The cavum uteri was perfectly empty and smooth. Obstetrics. 5 I TREATMENT OF ASPHYXIA BY TRACTION UPON THE TONGUE. LABORDE (Abeille Médical, 1893, No. 3) believes that asphyxia is to be com- bated by strong rhythmical traction upon the tongue. Apart from the good results in asphyxia of the new-born, Laborde has applied the method with good results in an adult poisoned with bromidia, who was pulseless and without appreci- able movement of heart. The action of this method is referred by Laborde to the primary excitation of the sensitive nerves and transferrence of this excitement to the motor nerves of the respiratory muscles, especially excitement of the nervus laryngeus superior, then the glosso-pharyngeus and lingüalis, finally, the phrenic. ANTISEPTIC OBSTETRICS. C. GoDSON, of London (Lance!, April I, 1893), refers to the improvement in the mortality of his hospital. In the year 1870 the mortality was 4 per cent. ; from 1873 to 1883 average yearly mortality over 2 per cent. In the four years from January, 1880, to January, 1884, over 3 per cent. In the last six years, from January, 1887, to January, 1893, the mortality was O.31 per cent. The ground for this lowering of mortality lay in the thoroughly practised antisepsis. For disin- fection of the hands sublimate was used. Every parturient patient received a vaginal douche, I : 2000 sublimate, and a second after the termination of the labor. During the puerperal state, for the first six days, a similar douche twice daily; later a douche of permanganate of potash or carbolic acid. Poisoning by absorption of sublimate so used Godson has never observed. INTRA-UTERINE INFECTION OF THE FETAL LUNGS. M. LEGRy (Bulletin de la Société Anatomie de Paris, December, 1893) exhibited the lungs of a child which had lived but ten hours, and had suffered from insuffi- cient respiration. The pleura showed fibrinous deposits and false membranes. In the pleural cavities was about a half coffeespoonful of sero-sanguineous fluid. The examination of the membrane and the fluid showed the presence of streptococci chains. The mother had been well during her pregnancy. Only in the last month she had had a strongly irritant white discharge, which had occasioned a violent vaginitis. The membranes had ruptured three days ante partum, from which Legry believed that there had been an ascending infection of the child. The result of the examination of the vaginal section was not at the time of writing ready for report. A RARE LESION CAUSING THE DEATH OF A NEW-BORN CHILD. NEGRI, of Venedig (Annali di Ostetrica e Ginecologica, 1893, No. 4), refers to a case in which a child weighing 3490 grammes and 51 centimetres long was extracted by forceps asphyxiated, but was easily resuscitated by immersion in a Hot bath. Two days later, in absolute appearance of health, it suddenly grew pale and died. The autopsy revealed a bursted liver hematoma as cause of death. Negri believes that the cause of the hematoma was the increased tension of the abdomen from the asphyxia. In this case there was no swinging of the child, and it was not clothed, but had been removed from the warm bath and loosely covered. - The case is certainly a proof that the swinging by Schultze’s method is not always to be regarded as the cause of hematoma of the liver. 52 Obstetrics. IDENTICAL BACTERIA FOUND IN TWO CASES OF MELENA NEONATORUM. GARTNER (Archiv für Gynākologie, Band xIV, Heft 2) refers to the fact that the etiology of melena neonatorum is based upon manifold hypotheses. Rehn and Neumann have referred to a bacteriological cause. Gärtner observed two cases, and was able to identify a bacillus with the cause of the condition. The bacillus has the following peculiarities: The temperature required for its growth is that of the blood. The motion in hanging-drops is peculiar and lively, the bacillus turning about its transverse axis. The multiplication is by division. In agar, and espe- cially in gelatin, it shows characteristic culture forms and the formation of gas. It is, during the disease, found in the intestinal cóntents and in the blood, and by section in the liver and spleen. The intestinal hemorrhages are to be regarded as the consequence of the wandering of the bacilli through the walls of the gut from the serosa, and thereby the destruction of the glandular layer. The petechia upon the serous coat of the intestine and the peritoneum, the lesser and greater hemor- rhages found in the liver and the spleen, are caused by the stopping of a vessel from the 1arge numbers of melena bacilli. The resemblance of the condition on section between animals inoculated with melena and by melena neonatorum is identical. The best results in the inoculation of animals were afforded by the infection of new-born animals through the umbilical cord, or by intraperitoneal injection. Also in human beings, the entrance portal is the umbilicus. All investigations of fresh cases have shown that at first there is peritonitis, following this the infection of the intestines. The bleeding and infection of the rest of the body follow. A CASE OF SPONTANEOUS INTRA-UTERINE RUPTURE OF THE UMIBILICAL CORD. FUNcKE, assistant to the obstetrical Clinic of Freund, in Strasburg (Central- blatt für Gynākologie, No. 31, 1894), reports the following case occurring in the clinic : Patient, a II-para, was admitted to the house five hours after the sponta- neous rupture of the membranes, and had passed abnormal quantities of amniotic liquor. The movements of the child at the time of admission were plainly per- ceptible, as were also the heart sounds, 128 to the minute. The portio was high above the promontory, and with difficulty reached. The external os was closed. Nine hours later the heart sounds were weak, ninety to the minute. During this time, especially in the last three hours, there had been weak pains, and the mother had felt the motion of the child. Three hours later the fetal heart sounds were no longer to be recognized. About eight hours later the patient rose to uri- nate, and during the act a long cord fell from the vagina, which was recognized as the umbilical cord by the vessels in its torn end. The piece of cord hanging from the vagina was twenty-five centimetres long. By vaginal examination, the cervix was found about one centimetre long, and the cervical canal just admitted one finger. The breech was found presenting. The torn, prolapsed cord was cut off at the inner os in order to prevent sloughing in case of prolonged labor. After administering a hot bath weak pains were experienced, and some dark blood was expelled from the vagina. The dilatation of the os was accomplished with a colpeurynter, and after a slow labor the child was delivered. The child was dead, weighed 1000 grammes, forty-eight centimetres long, and smelt slightly. The placenta was expelled a half hour after. The umbilical cord had been torn directly from the abdominal insertion in the fetus without opening the abdominal cavity. There was no blood in the peritoneal cavity of the fetus. To the placenta Gynecology. 53 was attached a piece of cord fifteen centimetres long, making the entire length of the cord forty-eight centimetres. The cord was fresh, without maceration or tor- sion or other injuries. Funcke refers the rupture of the cord possibly to spontaneous intra-uterine rup- ture in closed or slightly dilated cervix during the first period of labor. A METHOD OF EXTRACTING THE AFTER-COMING HEAD NOT PREVIOUSLY DESCRIBFD. - J. PULVERMACHER, of Breslau (Centralblatt für Gymäkologie, No. 29, 1894), refers to the fact that in many cases the head of the child is found in such posi- tion that the occiput, resting partly or wholly upon the pelvic wall, is bent at an angle to the neck, and that the hand can only feel an ear and the presenting part of the cheek or the zygoma. The other parts of the face, forehead, eyes, nose, mouth, and chin cannot be felt. The known methods partly cannot be applied, and do not bring about the desired results. In such cases, Pulvermacher applies the following procedure : * A dull double hook is guided by the hand to the region of the zygoma, some- what beneath the infra-orbital margin, and the blunt end of the instrument, which is hook-shaped, is with the hand in the vagina firmly pressed against the head, while on the other hook-shaped end, which projects from the genitals, a firm trac- tion is made by the other hand. The nurse makes traction during this time with one hand on the legs of the child directing it downward, and presses with the other hand through the abdominal walls upon the head. The face turns imme- diately towards the sacral hollow, and the child's head will rapidly be delivered. The part of the face upon which the hook has pressed shows no injury, hardly an abrasion of the skin. Pulvermacher recommends this methed in cases where the head is in the above-described position. G-YN ECOLOGY. UN DER THE CHARGE OF WILLIAM GOODELL, M.D., AND CHARLES BINGHAM PENROSE, M.D., ASSISTED BY WILLIAM A. CAREY, M.D., AND H. D. BEYEA , M.D. ACUTE ENDOMETRITIS. THE future advances in the treatment of pelvic inflammatory diseases must be in the direction of prophylaxis. All such diseases originate in an acute endo- metritis. Labors and abortion, followed by a distinct rise of pulse and temper- ature, together with fetid discharges, must be treated first by intra-uterine antiseptic irrigations, to be followed in half a dozen hours, if not cured, by the free use of the sharp curette, antiseptic irrigations, and iodoform-gauze packings. Gonor- rheal endometritis should be treated at once by the sharp curette, antiseptic irri- gations, and gauze packing. Anything short of this is unwarranted procrastina- tion. [Abstract of paper read by Dr. J. M. BALDY at the recent meeting of the Pennsylvania State Medical Society.] 54 Gynecology. LIGATION OF THE BASE OF THE BROAD LIGAMENTS PER VAGINAM FOR UTERINE FIBROIDS. GoFLET (American Medico-Surgical Bulletin, June 1, 1894) states that this operation has given very satisfactory results in controlling uterine hemorrhage and diminishing the size of the fibroid growths. He prefers this operation to hysterectomy when the major operation is likely to be attended with any con- siderable risk. It is also appropriate as a preliminary measure, with a view to obviating the necessity for the more radical operation. He has observed marked decrease in the size of some tumors after this operation, particularly in those cases where no extensive and vascular adhesions are present. The author’s method of operating consists not only in the ligation of the uterine artery on each side on a level with the internal os, but also in the introduction of a second or a third liga- ture in such a position that the uterine artery will be encircled by each ligature as it ascends along the cervix. This results in the cutting off of the compensating blood-supply from the ovarian artery to the lower part of the uterus. The credit of priority is given to Martin, of Chicago, although Goelet states that in January, 1889, he ligated the uterine artery on one side of the uterus per vaginam, in a case of a large fibroid (size of seven months’ pregnancy) with adhesions, in the hope that the size of the tumor might be diminished. Six months after this oper- ation he was pleased to note that the tumor was two-thirds its original size and was giving no inconvenience. THE ABUSE OF TRACHELORREIAPHY. WILLIAM R. PRYoR (American Journal of the Medical Sciences, June, 1894) believes that the operation of trachelorrhaphy is commonly misapplied. The procedure should be limited, in the author’s opinion, to the immediate opera- tion for hemorrhage and to those cases of tear through the cervix from internal os out to the vaginal junction, cases of true extraperitoneal rupture of the uterus. Slight lacerations, it is claimed, are not productive of erosions, cervical hyper- trophy, cystic degeneration, sterility, and subinvolution, nor of “reflex symp- toms,” except to a very limited degree. Indeed, lacerations of moderate length are said to be beneficial, and the author “can but believe that Nature has intended this lesion as a safeguard.” Unless there were a certain amount of tearing of the cervix (which has the sphincter function of the uterus) there would be danger of a retention of the afterbirth or lochial discharge. It is feared that in case of no 1aceration the normal elasticity of the cervical tissues would be so quickly regained and the contraction of the cervix after delivery would be so rapid that sufficient time for drainage would not be given, and that, therefore, the tear is of special importance. “When our modern woman so far advances that she will cease to discharge her placenta, that she will cease to have a lochial discharge, she may have all tears in her cervix united. Until that time arrives, she has need for a 1acerated cervix ; it is essential to her safety.” Probably the most frequent cause for the operation of trachelorrhaphy is sub- involution. The author contends that such a condition is not the result of a tear in the cervix, but is due to the injury which is sustained by the uterus in a pro- tracted labor. Cystic degeneration of the cervix should not be treated by puncturing the cysts and uniting the torn surface of the cervix, because of the probability of epithelioma developing in such tissue. Thorough removal of all such tissue should be performed. Gynecology. 55 The author states that during the past twelve years the operation of trachelor- rhaphy has been performed more frequently than ever before, and often as a pre- ventive measure against the development of cancer, and yet he finds cancer of the uterus on the increase. Laceration of the cervix is not held responsible for cancer, but rather the sudden onsets of developmental activity and equally sharp retrograde processes. Not by seeking for its local causes can we expect to check it, but by a critical study of every condition under which the disease occurs may we hope to arrest its inheritable tendencies. Women who have by heredity any tendency to cancer should remain sterile, inasmuch as repeated childbirths more than anything else conduce to it and disseminate it. “If we operate to prevent the possible occurrence of cancer in those who may reasonably expect it, assuredly trachelorrhaphy is not indicated, but a more radical procedure which will remove the entire cervix.’’ A pathological laceration of the cervix requiring trachelorrhaphy the author defines as any tear which is of sufficient severity and degree to implicate the circular fibres of the cervix sufficiently to cause a modification in shape or position of the uterus. A tear to do this must sever most of the sphincter fibres of the cervix at one or more points. The lesions found associated with a lacerated cervix are best treated by either a curettage of the uterus or by some form of amputation of the cervix which provides for the maintenance of a cervical mucous membrane. The great objections which the author urges against trachelorrhaphy are that it does not give a cervical canal of dimensions equal to the requirements of a woman who should continue to bear children with increasing ease as years pass by ; it does not remove sufficient tissue when the operation is indicated, and it does not appear to him as a rational procedure, because he believes that most of the cases subjected to it require no operation on the cervix, inasmuch as a generous lacera- tion is normal and necessary. THE TECHNIQUE OF SUPRAPUBIC HYSTERECTOMY. Joseph EASTMAN (American Journal of Obstetrics, May, 1894) states that during the last four years he has been trying to reduce the number of ligatures to the minimum. He presented a specimen to the Marion County Medical Society recently, which, with the exception of the ligatures used in tying off ovaries and tubes, was removed without any ligature at all ; the uterine arteries, being left with the woman, were neither tied nor cut, and cannot be seen on the tumor. The necessity for ligating vessels is overcome by separating the tumor from its capsule and then uniting the flaps of the capsule. For this purpose the author devised an instrument with serrated edges, somewhat resembling a Simon's spoon. After opening the abdomen and tying off the broad ligaments sufficiently to secure the ovarian arteries, the tumor is girdled by button-pointed scissors below the place where the elastic ligature is usually placed, drawing up the capsule anteriorly and posteriorly. The instrument, described above, is then employed to peel down the capsule of tumor and cervix, as a glove finger would be pushed down and off with a spatula. The hysterectomy staff is then introduced into the vagina, and the vaginal tissues are punctured into the groove of the staff, and through this opening is passed a strip of dermatal gauze, which is drawn down into the vagina to act as drainage. The upper end of gauze is packed into the pocket, and the flaps of the capsule are folded and united with silkworm gut so as to secure sero-serous approximation with drainage from the vagina. * 56 Pathology. PATHOLOGY. UNIDER THE CHARGE OF JOHN GUITÉRAS, M.D., ASSISTED BY JOSEPH McFARLAND, M.D THE OCCURRENCE OF EOSINOPHILE CELLS IN HUMAN BLOOD. ZAPPERT (Zeitschrift für klinische Medicin, Bd. xxIII, Heft 3 und 4) made a large number of studies of human blood to discover the occurrence of the eosin- ophile cells in health and disease. He found that in afebrile pulmonary tuberculosis there was a frequent diminu- tion of the eosinophile cells. In a number of skin-diseases their number was con- siderably increased. In most febrile conditions, during the pyrexia, a diminution of the eosinophile cells was observed, which soon returned to the normal when the fever subsided. Injections of tuberculin with marked reaction caused a diminution during the febrile stage, an increase in the number of eosinophile leucocytes. A NOTE ON A NEW METHOD OF PREPARING CULTURE MEDIA. SMITH (British Medical Journal, June 21, 1894) speaks of the difficulties in the way of preparing artificial culture media that will approximate the juices and tissues of the human body, and suggests their preparation on the principle dis- covered by Lieberkühn, that the addition of potash to white of egg would give a very solid and insoluble proteid substance in the form of solid, insoluble, clear jelly. Lieberkähn also pointed out that if this be washed till the free alkali is completely removed, it has a neutral reaction to litmus. The method suggested by Smith is as follows: “Add to ox cerum o.1 per cent. to o. 15 per cent. caustic soda, and heat the solution to 120° C. in the auto- slave, when the desired jelly will be obtained. “In the case of the hen’s egg the following method has been found reliable: Break up the white with an egg-beater till it loses its consistency. Add to it 4O per cent. of water, and mix well. Pass the mixture through a muslin to remove any shreds of insoluble material, or let it stand over night in a cylinder till these settle to the bottom. Add O. I per cent. caustic soda, and solidify in the autoclave. Egg-white is naturally more free from pigment than serum, and with a little care in clearing it a jelly can be obtained closely resembling gelatin in transparency. Substances like glucose may be added as desired. THE GONOCOccuS OF NEISSER : ITS OCCURRENCE IN URETHRITIS AND BARTHOLINITIS. CARI, HAssE (Inaugural Dissertation, Strasburg, 1893), after many experi- ments, gives the following as the best method of staining the gonococcus. (1) The prepared cover-glass is drawn but once through the flame. (2) Stain thirty seconds in a saturated solution of methylene-blue in 5-per- cent. solution of permanganate of potassium. Pathology. 57 (3) Wash off in water and decolorize in suitable weak solution of acetic acid until the blue color disappears and is replaced by violet. (4) Wash out the acid in water. (5) Stain in picro carmine until a rose color occurs, when the specimen is held over white. This generally occurs in five to eight minutes; if not, the specimen may be warmed. (6) Wash in water for a minute. (7) Dry and examine in glycerin or Canada-balsam. The cocci appear blue, the nuclei of the cells red, the protoplasm light blue, while that of the epithelial cells appears a trifle yellowish. Hasse studied the urethral and Bartholinic secretions of 625 cases, and found in nineteen cases bacilli only, in twenty-seven cases cocci alone, and in I47 both together. In the secretions of the Bartholini glands he found cocci and bacilli constantly together. In general, it may be stated that in acute gonorrhea no other lbacteria than the gonococci were to be seen, but that with the disappearance of the gonococci and the increase in the epithelium, other bacteria, both cocci and bacilli, occurred in great numbers. ON VACUOLATION OF THE NERVE-CELL OF THE HUMAN CEREBRAI, CORTEX. ALFRED W. CAMPBELI, (Journal of Pathology and Bacteriology, February 1894, Vol. II, No. 3, p. 380) has collected and tabulated the various cases in which vacuolation of the nerve-cells was found. The conclusion reached as the result of the research is that vacuolation of the nerve-cells of the cortea cerebri is in all cases induced by a toacemic condition. He found that vacuoles may form either (I) in the nucleus, or (2) in the sur- rounding granular protoplasm of the cell body, or in both together. Vacuolation of the cortex alone is most frequent in the superficial layers. *. (1) Vacuolation of the Nucleus.—The initial visible alteration is a slight uni- form swelling of the whole of the nucleus, accompanied by an alteration in its normal reaction to the staining material. Subsequently to these alterations one or more minute, circular, clearly-refractive, oily droplets form, either in the nucleo- lus or in the other altered portion of the nucleus; these multiply, enlarge, and may coalesce, until finally the whole nucleus is converted into one large cavity filled with lustrous oily material. At a later stage the envelope bursts, allowing the contents to escape and a well-defined non-lustrous vacuole is left. (2) Vacuolation of the surrounding protoplasm is more frequently observed in the more deeply-situated and larger cell,—namely, those of the large pyramidal and multipolar cells. The process of formation is similar to that in the nucleus. In the cells in which protoplasmic vacuolation occurs, the adjoining protoplasm is almost always seen to be in a condition of granular degeneration. Pigmentary degeneration often coexists; the number of cell processes is not uncommonly diminished; and in the altered outline of the cell one can often distinguish the rent through which the oily material which formerly filled the vacuole has escaped. There is one change the existence of which the writer has observed with the greatest constancy and regularity in the cases which he examined,—namely, fatty degeneration of the fusiform muscle nuclei and of the non-striped muscle fibres of the small vessels supplying the cortex and distributed throughout it. Vacuolation of cortical nerve-cells have been observed in the following dis- eases: Epilepsy; diseases produced by metallic poisoning, such as arsenic, phos- 58 Dermatology. phorous, etc.; chronic insanity; dementia and senile cerebral atrophy; in chronic pulmonary affections; and in acute infective fevers. In the concluding summary the probabilities in favor of the toxic theory of the vacuolation are given as follows: (I) I have shown that in all the conditions in which vacuolation has hitherto been described as occurring, there is such a poison at the root of the disease. Epilepsy (idiopathic) cannot be excluded from this class. (2) I have demonstrated the existence of vacuolation in phthisis pulmonalis and acute lobar pneumonia, and in cases of certain acute infective fevers, these being all instances of toxemic diseases. (3) I have proved that vacuolation of the cortical cell is almost invariably asso- ciated with acute vascular degeneration. - (4) I have pointed out that vacuolation of the nerve-cell is probably an acute fatty change, analogous to that occurring in the cells of other organs, in the case of individuals dying of toxemic diseases. Appended to the paper there is a table of the microscopical examination, etc., of the cases of phthisis, pneumonia, and infective conditions, upon which these observations are based. DE, F&NMATOLOGY. TJN DER THE CHARGE OF LOUIS A. DUHRING, M.D., ASSISTED BY M. B. HARTZELL, M.D. CONCERNING THE ETIOLOGY OF ECZEMA. A. RAvogLI (Medical Nezºs, January 13, 1894) regards eczema as entirely dis- tinct from dermatitis, due to varied local causes. He would emphasize the obser- vation that dermatitis is not eczema, although dermatitis may produce eczema. Both affections are based upon an inflammatory process. Experiments made upon rabbits with a pure culture of the staphylococcus pyogenes albus went to show that this microbe was a cause of eczema, its development under the epidermis produc- ing the disease. But a fertile soil for its development is necessary, which is often wanting. The contagiousness of eczema is entirely dependent upon the condition of the epidermis. “Scratching scatters the staphylococci about the skin and pre- pares the epidermis for their culture.” Dr. Ravogli concludes his article by stating that eczema is a local affection of the epidermis of a chronic inflammatory character, contagious under favorable circumstances; and that it is caused by pyogenic micro-organisms (staphylococcus pyogenes albus) developed upon a previous inflammation of the skin. [The abstractor cannot regard the conclusions, drawn from the experiments, as war- ranted. There remains much to be proved, clinically and experimentally, before the contagiousness of the disease can be accepted. There is a difference between the contagiousness of a secretion or fluid, as found upon the surface of the skin after the disease has existed for some time, and the contagiousness of the disease per se,_that is, independent of adventitious microbes.] Dermatology. 59 THE EMPLOYMENT OF OPTICAL METHODS IN THE CLINICAL STUDY OF CUTANEOUS ERUPTIONS. BRocA recommends (La Presse Médicale, July 7, 1894) the employment of photography or, as more practicable, blue light in the study of various cutaneous eruptions. By the elimination of the red rays of the spectrum greater differentia- tion is obtained, and in this manner features not visible to the naked eye become apparent. LUPUs ERYTHEMATOSUS AssociateD witH SUPPURATING CERVICAL, GLANDs ; PRESENCE OF TUBERCLE BACILLI IN THE PUS. At the séance held June 14, 1894, of the Société Française de Dermatologie et de Syphiligraphie, LEREDDE (Annales de Dermatologie et de Syphiligraphie, No 6, 1894) presented a woman, 67 years old, the subject of an erythematous lupus of the face of seven or eight years’ duration, associated with suppuration of the cer- vical lymphatic glands. The softened glands were punctured with a sterilized syringe, and the pus thus obtained was stained according to the methods of Zielh and Kühne ; great numbers of tubercle bacilli were found. THE TREATMENT OF FURUNCULOSIS. sº VAN Hoorn (Monatshefte für praktische Dermatologie, Bd. XIX, No. 1), con- vinced that infection in furuncle takes place from the outside, employs a method of treatment based upon general disinfection of the skin as well as isolation and disinfection of the disease foci. This method is as follows: The entire skin is cleansed in a warm bath with soft soap, and the furuncle and the parts around it washed with a 1: IOOO solution of corrosive sublimate. After drying, the furuncle is covered with mercury and carbolic acid plaster-mull, and the patient puts on clean linen. Every day or, preferably, twice a day, a new plaster is applied, and where perforation has occurred the furuncle is lightly pressed out and disinfected anew with sublimate solution. The results of this treatment are said by the author to be brilliant, and, what is especially important, new lesions are seldom observed. THE RELATION OF ECZEMA TO THE MUCOUS MEMBRANES. Von SEHLEN calls attention (Momatshefte fºr praktische Dermatologie, Bd. xIx, No. 1) to the relation which exists between eczema of the skin and certain diseases of the adjoining mucous membranes. Inflammation of the nasal mucous membrane, chronic catarrh of the external ear, conjunctivitis, balanitis, inflam- mation of the anal mucous membrane with the formation of fissures, are some of the affections which may arise from the extension of an eczema. In the treatment of these the author has found ichthyol of great service. The paper concludes as follows : - (1) Chronic eczema of the skin may attack the adjoining mucous membranes, and produce upon them apparently independent affections. (2) Eczema of the lips, catarrh of the external ear, eczema of the lids, and a certain form of conjunctivitis are to be regarded as special localizations of the eczematous process, and are to be treated accordingly. (3) Certain inflammatory conditions of the anal mucous membrane, and of the genitalia in both sexes seem to stand in close, if not causal, relationship to eczema of the skin. - . V. 6O Miscellaneous. MISCELLANEOUS. DEATH OF PROFESSOR HELMEIOLTZ. PROFESSOR HERMANN LUDWIG. FERDINAND VON HELMHOLTz, the celebrated physiologist and physician, died on September 8, 1894, from apoplexy. He was born in Potsdam, August 31, 1821. The works of Helmholtz have reference principally to the physiological con- ditions of the impressions of the senses. After studying medicine in the Military Institute at Bertin, and being attached for a time to the staff of one of the public hospitals there, he returned to his native town as an army surgeon. In 1848 he was appointed Professor of Anatomy in the Academy of Fine Arts at Berlin ; in 1855, Professor of Physi- ology at Königsberg, whence he removed, in 1858, to Heidelberg, where he also filled the Chair of Physiology. He was appointed Pro- fessor of Physiology at Berlin in 1871, and in October, 1877, was installed as Rector of the University of that city. His first great production was a treatise “On the Conservation of Force,” which was published in 1847, and set forth, clearly and indis- putably, for the first time, the interchangeability and indestructibility of all the manifestations of force in nature, such as light, heat, elec- tricity, chemical action, and animal vitality. His investigations of the phenomena of light led to the discovery of the reason why the pupil of the eye appears black, and why we can- not, without mechanical agency, see into the interior of the eye. This course of investigation led him, in 1851, to the invention of the ophthal- ſmoscope. His further researches in the field of optics resulted in the publica- tion, between 1856 and 1867, of several exhaustive works on the sub- ject, in which he established the so-called empirical theory of vision, and included the whole range of optics, from the investigation of the limits of human power of perception to that of the details of vision, and the analysis, combination, and appreciation of colors. In 1862, the versatility of Helmholtz was further shown by the publication of a work on “Sensations of Tone, as a Physiological Basis for the Theory of Music,” in which he threw the light of natural science upon the fundamental principles of music and esthetics. In 1870 he was admitted to foreign membership in the French Academy of Sciences, a prominent member of which body, on the occa- sion of his election, characterized him as “the foremost and greatest naturalist of the age,” and adding that “nothing is wanting to his glory, but he is wanting to ours.” In 1883 Dr. Helmholtz was raised Correspondence. 6 I to the rank of noble by Emperor William I, in recognition of the fame he had brought to Germany. During the World's Fair, Dr. Helmholtz visited this country to attend the Electrical Congress held at Chicago. CORRESPONDENCE. VAGINAL HYSTERECTOMY WITHOUT CLAMPS OR LIGATURES. Bditors of UNIVERSITY MEDICAL MAGAZINE : GENTLEMEN : A paper by the above title was read before the Missouri Valley Medical Society, March 15, 1894, describing a method of bloodless enucleation of the uterus similar to the first method described by Pratt. Q The operation consists in incising the mucous membrane surround- ing the os, the incision completely encircling the cervix. The tissues are then separated by the ends of blunt scissors, clipping fibres here and there where too firmly attached to be freely torn through. “As little cutting as possible should be done, the prime object of the oper- ation being to enucleate the uterus by suturing the loose tissue sur- rounding it, the tissue in which the terminal branches of the uterine artery ramify ; and by careful work to denude the uterus of its areolar tissue, pressing aside every important blood-vessel uninjured. The only points where separation cannot be quickly done are at the internal os, where the connective tissue is quite dense, along the sides of the organ, and at the entrance of the Fallopian tubes.” This method appears to have nothing to commend its preference to that by ligature except the fact that the peritoneal cavity is not opened and the blood-vessels are not wounded. It would seem that the peeling of a uterus by blunt dissection from its enveloping peri- toneal coat and from the areolar tissue at its sides, in which the large blood-vessels ramify, without puncturing the peritoneum or wounding the blood-vessels, would constitute a much more delicate and tedious operation than the application of from four to six ligatures to the broad ligaments. I do not believe that this classic enucleation without leaving uterine tissue behind is, in the great majority of cases, possi- ble. The writer of the paper admits that in only one of the cases upon which his paper was based the operation was bloodless and no ligatures were employed. Should there exist any reason for removing the ovaries and tubes, the writer states, the peritoneum may be cut 62 Correspondence. when the operator is ready to sever the tubal attachment. The impor- tance of the removal of the adnexa seems not to have been properly estimated. The especial indication for vaginal hysterectomy is incip- ient cancer. The uterus and its appendages should then be removed as thoroughly as the condition will permit. The leaving of ovaries and tubes under these circumstances is fraught with extreme danger of the early return of the growth. This method the writer advocates for the removal of small intra- mural fibroids, procidentia, and for early cancer of the cervix. I do not believe that small intra-mural fibroids are indications for hysterec- tomy. Should the fibroid tumor be of such small size that it can be safely removed through the vagina, the proper operation would be either that of myomectomy, by which a uterus, capable of performing its function, will be left the patient, or oophorectomy, which is a simpler operation, of shorter duration, attended with less risk to the patient and less mutilation. I also do not agree that the uterus should be removed for procidentia, especially if the woman be still in the child- bearing period, any more than we would agree that the arm should be amputated for luxation. In early cancer of the cervix it is the method and not the opera- tion that we would criticise. The teaching of surgery has been and still is that carcinomatous growths should be removed freely, with as much surrounding tissue as will insure their complete removal. Who would enucleate a cancerous nodule from the breast 2 The operator who would leave connective tissue from the sides of the uterus, peri- uterine, peritoneum, and Fallopian tubes, which are prolongations of uterine tissue, in a case of cancer, for the reason that the operation is less difficult and the hemorrhage is less, is not giving his patient the best prospect of a cure. I could sanction no method that did not freely extirpate the uterus, tubes, and ovaries. At our present age there is an unfortunate tendency to devise methods and to improvise departures from the regular methods in order that operators’ may step prominently before the profession. This is unfortunate, because by the practical application of many such depart- ures, conceived in theory, the laity suffer. Our previous methods of performing vaginal hysterectomy by the ligature, in which the uterus, ovaries, and tubes are removed entirely, the stumps of the ligaments drawn into the vagina and the wound in the vaginal vault closed by suture, is so perfect a surgical procedure, and its mortality in the hands of skilful operators has been so small, and the convalescence so rapid as to leave no excuse for a less surgical procedure. FRANK W. TALLEY, M.D. A'ook AVoffices. 63 BOOK NOTICES. CLINICAL DIAGNOSIs. By ALBERT ABRAMs, M.D., Professor of Pathology, etc., Cooper Medical College, San Francisco, Cal. Third edition, revised and enlarged. Illustrated. New York : E. B. Treat, 1894. The fact that two editions of this book have already been exhausted is sufficient proof of its favorable reception. The work consists, for the most part, of well arranged selections from the best authorities on clinical diagnosis. In the present edition the author has added many synoptic tables, a chapter on insanity, and a summary of recent methods of diagnosis. There are some statements to which but few clinicians would be willing to subscribe, namely, that unilateral dilatation of the chest is observed in croupous pneumonia, and the following, refer- ring to the method of distinguishing between pneumonia and pleurisy in children : “It is not infrequent, especially in children, that a pleu- ritic effusion may yield the same physical signs as a pneumonia, in which case a differentiation may be necessary without having recourse to the exploratory needle. If the upper line of dulness is marked and then an hypodermic injection of pilocarpine is given, the line of dul- ness on percussion will be lower after than before the injection.” Notwithstanding a few inaccuracies, the work contains a vast amount of valuable material, which has been carefully classified, and condensed within a small compass. BIOGRAPHY OF EMINENT PHYSICIANS AND SURGEONS. Illustrated with Photo-engraved portraits. Edited by R. FRENCH STONE, M.D., Author of “Elements of Modern Medicine,” Surgeon-Gen- eral National Guard, State of Indiana, etc. It has been eighteen years since the last work of this kind ap- peared under the title of “Physicians and Surgeons of the United States.” This is not only out of print, but even if this were not the case, almost a new generation of physicians has come to the front since that time, so that the necessity of rewriting American Medical Biography has resulted in the present volume. Every physician must be interested in familiarizing himself with the histories of distinguished men in the profession. And yet few have time to seach out the dusty biographies from the shelves of the library and plod through long pages of minutiae. The value of having the pith of such works ex- tracted and put in a form available to all will be appreciated by a large number of the profession. Dr. Stone has confined his work entirely to members of the regular profession, and while it is not as complete as could be desired, still this defect is not due to any lack of energy on the part of the editor, to whom much credit is due for the painstaking care in its compilation. $ 64 Book AVotices. The work begins with an introductory chapter containing an out- line review of the progress and condition of medical science and medi- cal practice from an early period in our country's history to the present time. The biographies occupy upwards of 7oo pages. There is an index of portraits and of names arranged alphabetically and also accord- ing to cities and towns. ANTISEPTIC THERAPEUTICs. By Dr. E. L. TROUESSART, Paris, France. Translated by E. P. HURD, M.D. Two volumes. De- troit: George S. Davis, 1893. These two small volumes belong to the series known as the Physi- cians' Leisure Library. In the first volume are considered systematically the various drugs which are employed as antiseptics, and in the second volume is discussed the antiseptic treatment of disease. All the impor- tant advances made in this department of therapeutics have been included. In view of the increasing prominence given to antiseptics in medicine, surgery, and obstetrics this work ought to have an extended circulation. TO CONTRIBUTORS AND SUBSCRIBERS. All Communications to this Magazine must becontributed to it exclusively. Reprints will be furnished free to authors of articles published among the original commu- nications, provided the order is distinctly stated upon the manuscript when sent to the Editorial Committee. Typewritten copy preferred. Contributors desiring extra copies of their articles can obtain them, at reasonable rates, by applying to the General Manager immediately after the acceptance of the article by the Editorial Staff. Contributions, Letters, Exchanges, Books for review, and all Communications relating to the editorial management, should be sent to the Editorial Committee, 214 South Fifteenth Street. Alterations in the proof will be charged to authors at the rate of sixty cents an hour, the amount expended by journal for such changes. Subscriptions and all business to UNIVERSITY OF PENNSYLVANIA PRESS, 716 Filbert Street, Philadelphia, Pa. UNIVERSITY MEDICAL MAGAZINE. NOVEMBER, 1894. THE INFLUENCE OF THE HABITUAL INCLINATION OF THE PELVIS IN THE ERECT POSTURE UPON THE SHAPE AND SIZE OF THE PELVIC CANAL. BY BARTON COOKE HIRST, M.D., Professor of Obstetrics in the University of Pennsylvania. FROM the last quarter of the eighteenth century, when Müller first called attention to it, the inclination of the pelvis received much atten- tion from obstetricians, until the observations of Naegele, Weber, and Meyer showed how the pelvic obliquity varied greatly, not only in different postures, but even in the erect posture, under the influence of abduction, adduction, and rotation of the thighs. Thus, in a single individual, the pelvic obliquity, normally about 45°, can be practically obliterated in a squatting posture Qr can be increased to IOO’ by strong abduction and rotation of the thighs. Because the pelvic inclination can be decreased or increased at will, it is generally argued that the pelvic obliquity is a negligible quantity in the act of childbirth. While this view is correct, it has led to a general neglect to consider the influence of the habitual inclination of the pelvis in the erect pos- ture upon the development of the pelvic bones and upon the evolution of the pelvic canal. If there is an exaggerated inclination of the pelvis in childhood, as in rachitis, dislocation of the femora, double club-foot, lordosis, etc., the direction in which the trunk weight is received by the sacrum increases the rotation forward of that bone upon its transverse axis, diminishing the antero-posterior diameter of the inlet and diminishing the depth of the pelvic canal. Further, the exaggerated pull of the rotative muscles of the thigh, put constantly upon the stretch, separates 5 65 66 Barton Cooke Hºrst. the tuberosities of the ischia more widely than common, and thus widens the pelvic outlet. - On the other hand, if the pelvic inclination is much diminished, as in kyphosis from caries of the spine, rachitis, or certain forms of osteo- malacia, the top of the sacrum is pushed backward, so that this bone is lengthened and straightened, thus making the antero-posterior diameter of the inlet greater and increasing the depth of the pelvic canal. Further, the pull of the ilio-psoas muscles, put upon the stretch in the erect posture, drags the iliac bones apart, and by a compensatory movement approximates the ischia, thus diminishing the transverse diameter of the pelvic outlet. * The habitual inclination of the pelvis in the erect posture is there- fore one of the chief factors in the production of the most important pelvic contractions. Consequently its effect upon the progress of labor should not be ignored. These general propositions are well illustrated by the cases figured in the plate. - - Figs. I, 2, 3, and 4 represent a young woman, aged 19, whose spinal extensor muscles became paralyzed as the result of an attack of measles when she was about 13 years of age. The unopposed pull of the ilio-psoas muscles produced the extreme lordosis that may be seen in the illustrations. The pelvic inlet in this case looked actually downward and the pelvic outlet directly backward. The external measurements were: iliac spines, twenty-two and a half centimetres; iliac crests, twenty-six centimetres ; external conjugate, fifteen and a half centimetres; tuberosities of the ischia, ten centimetres (a large measurement compared with the others). The extreme rotation of the pelvis on its transverse axis carried the external genitals with it so that they looked almost directly backward. Coitus in the usual posture would have been impossible. The upper edge of the pubic hair was more than five centimetres above the upper edge of the symphysis, the skin of the lower abdomen being unable to follow the pelvis in its backward movement. No position which this girl could assume would have much diminished the pelvic obliquity, so that, were she in labor, the process would be seriously retarded by the pelvic obliquity itself as well as by the influence of this obliquity upon the development of the pelvis. - Figs. 5, 6, and 7 represent an Italian woman, 25 years of age, who Had had three children, all destroyed in labor. She had been in this country about seven years, and all her children had been born here; the first four and a half years ago. The osteomalacia, from which she suf- fered, had begun after the birth of the first child. In the last four years she has lost more than six inches in height, and now her trunk is so much shortened that the floating ribs are telescoped within the false ... *** * * *- * : * *-* - * Influence of Habitual Inclination of Pelvis on Pelvic Canal. 67 pelvis. The spinal column has bent so far backward in the dorsal region that the same result is produced upon pelvic obliquity and, to a degree, upon pelvic form as though there had been a true kyphosis since childhood. The external pelvic measurements were as follows: Iliac spines . . . . . . . . . . . . . . . 24% cm. Iliac crests . . . . . . . . . . . . . . . 27% “ Trochanters . . . . . . . . . . . . . . . 29 { { e / { { External conjugate . . . . . . . . . . . . I7% Transverse of Outlet . . . . . . . . . . . 9% “ Ensiform cartilage to symphysis . . . . . I5% ‘‘ { { Posterior superior spinous processes of ilia . 7 The upper edge of the symphysis was a considerable distance above the upper edge of the pubic hair. The anterior wall of the pelvis was sensitive, and the bones yielded to pressure. The sacrum was twisted on its longitudinal diameter so that the right side of the bone was much more prominent than the left. On an internal examination, the pubic rami were so closely approximated that it was difficult to insert a finger between them. The sacral curve was exaggerated, as in rachitis, but the angulation was more pronounced. The pelvis, in short, presented a queer combination of the rachitic and the kyphotic types. I did an oophorectomy on this patient in the hope of arresting the progress of her disease, but unfortunately she became wildly maniacal after the operation, tossed about in the most violent fashion, and at length pulled the stump on one side from its ligature and bled to death. It has been repeatedly asserted that deformed pelves are rare in this country, but this assertion, as regards our larger cities, is refuted by my own experience and by that of every one who takes the trouble to observe the pelves in his pregnant and parturient patients. During the past twelve months I have had under my care, in labor, two rachitic dwarfs, two women with obliquely contracted pelves, some half-dozen cases of rachitic pelvis and a larger number of generally contracted and of simple flat pelves. A MUTUAL DISSECTION SOCIETY. The Société d’Autopsie Mutuelle, founded by Dr. Condereau in 1876, is now presided over by Dr. F. Laborde. The membership is limited to IOO. The Society has a museum which contains the brains of several distinguished men, such as Broca (of “Convolution” fame), Bertillon, Fauvelle, Gambetta, and Eugène Véron. We are not aware, however, that the disinterested labors of the Society have as yet added much to our knowledge of the higher nerve-centres.—British Medical Journal. 68 De Forest Willard and Guy Hinsdale. ANTERIOR POLIOMYELITIS." BY DE FOREST WILLARD, M.D., Clinical Professor of Orthopedic Surgery in the University of Pennsylvania, Surgeon to the Presbyterian Hospital, etc. AND GUY HINSDALE, M.D., Physician to Out-Patient Department, Presbyterian Hospital ; Assistant Physician to Orthopedic Hospital, etc., IT is probable that anterior poliomyelitis will be relegated in the near future, in common with many other diseases of the nerve-centres, to the class of infectious diseases of microbic origin. As yet we have little proof to offer in support of such a proposi- tion, but the surgical pathology of to-day is nothing if not bacterial. One affection after another is analyzed in the laboratories of the world ; the organism is finally isolated by the refinement and higher powers of the pathological technique of these last years of the century. In these days we could fill a veritable Pandora's box with the scourges of the universe, the pure cultures would be marked with the names of anthrax and tubercle, relapsing fever and glanders, cholera and typhoid, diphtheria and leprosy, pneumonia and tetanus ; with the names of Neisser and Laveran and Pasteur, and with all the toxines and ptomaines in an ever-lengthening list. The plagues that have escaped to the ends of the earth are now collected within the walls of Our modern institutes of hygiene. We have already alluded to the probability of the infectious origin of Sclerosis of the spinal cord, and a recent observation indi- cates the microbic origin of chorea. Dana also infers from his studies of the pathological anatomy of paralysis agitans that its cause is toxic, and he would therefore classify the disease as a “chronic toxic dis- order.” & With regard to poliomyelitis the evidence as yet is meagre. The disease is being scrutinized with reference to this point, and evidence will no doubt be forthcoming. A very pertinent observation has been recorded by Cordier in a report of thirteen cases of infantile atrophic paralysis. These cases occurred as an epidemic in the months of June and July, 1885, in a district containing fourteen to fifteen hundred in- habitants, affecting children from ten months to two and a half years old. Previously healthy, they were seized with fever of variable degree without premonitory symptoms. Convulsions occurred in half 1 One of the Mütter Course of Lectures delivered before the College of Physicians of Phila- delphia, 1893. Anterior Poliomyelitis. 69 the cases, but without reference to the gravity of other symptoms. . Profuse sweating was noted during the febrile period as a rule, but was absent in four cases that terminated fatally. Paralysis appeared in several cases after the third day in the lower extremities, or in all four at the same time, and in some cases involving the neck mus- cles. Paralysis did not disappear with equal rapidity in all ; it would reappear in summer, and remain stationary in winter. The presump- tion is reasonable that these cases which presented the symptoms of acute poliomyelitis were of infectious origin ; and if such were their origin, the discovery of the microbe might not have been beyond the range of possibility. Another epidemic of infantile spinal paralysis was recorded in 1891, by Medin,” of Stockholm. In five months forty-four cases were observed. In the febrile stage there was somnolence, dyspepsia, occasional vomiting ; diarrhea in some cases, constipation in others. Facial monoplegia was observed in three cases; facial paralysis, abdu- cens paralysis, and polyneuritis in others. Heubner regarded these cases as infectious. In our own country, Dana, Putnam, and Welch stand out boldly as the champions of a newer pathology in nervous disease. They strike down deep underneath the foundations of the old pathology, = the phlogistic conception of nervous diseases, and replace them with the words toxemia and degeneration. Inflammation is construed simply as the reaction of the system to a poison or irritant; the irritant is a toxine, and in most cases the product of a microbe. When the irritant consists only of dead cells, as occurs after an aseptic injury, we have a reparative process, call it inflammation, if you like ; but in the other forms the irritation is of a microbic or, perhaps, sometimes diathetic origin. It acts espe- cially upon the blood-vessels, connective tissue, and lymphatics, and it calls into play the defensive cells (phagocytes) and defensive proteids of the body. There is always a something which sets the organism into an active warfare against the invader. That is the doctrine which we have received ; it is the miner's lamp guiding him as he works in new veins that promise richer treasures than have yet been brought to light. Just now the funda- mental principles of inflammation are being studied anew. The theo- ries of Virchow, Cohnheim, and Stricker have been successively held ; Grawitz,” of Griefswald, and his pupils have taken advanced ground 1 Centralblatt für klinische medicin, Leipzig. * Recent Progress in Pathology and Bacteriology, Boston Medical and Surgical Journal, February 23, 1893. 7o De Forest Willard and Guy Hinsdale. f along the line of Stricker's researches. Grawitz gave an extended description of his views at the Twenty-fifth Congress of the German Surgical Association in Berlin, June, 1892, but it is impossible even to review them here. The tendency of all these studies is to attribute all inflammation to poisons generated within the system. Thus it is not surprising to read that “acute poliomyelitis ante- rior has been shown to be inflammatory, and primarily a connective tissue and vascular trouble. It is probably of toxic or microbic origin also’’ (Dana). & Déjerine believes that a review of the facts will show that Du- chenne’s “acute anterior spinal paralysis,” and his “general subacute spinal paralysis” are due in reality to a peripheral neuritis, and, as is usually the case in the latter, ‘‘probably dependent on infectious or toxic agents of an undetermined nature.” The most recent studies, as, for instance, those by Williamson,’ of England, go to show that in adult spinal paralysis there are both cen- tral and peripheral lesions. His own efforts to detect micro-organisms have as yet given negative results. The sudden appearance and the complete extent of the paralysis in some cases of infantile paralysis leaves but little reason to doubt a sudden hemorrhage into the substance of the cord as the immediate cause of the difficulty. In cases of slow development the changes are largely due to the effusion of serum ; but in the rapidly-developing cases there is speedy and extensive nerve alteration. These symptoms are largely confined to the motor branches, but the sensory branches are at times also involved. While post-mortems can rarely be obtained at this early part of the disease, yet there seems to be but little doubt that the anterior cornua are the portions chiefly involved. Following this hemorrhage, as a direct result from the presence of a foreign body, inflammation occurs. This may be moderate in extent, or it may be of high degree. The loss of power probably results from a combination of sequelae, both of the initial hemorrhage and of the subsequent inflammation. There is seldom or ever any suppuration, but sclerotic atrophy of the column is nearly always present. In a case reported by Nonne, where death occurred two years after an attack, there were decided changes of the anterior horn and column with great reduction in the number of the ganglionic cells; there was also degeneration of the anterior root and peripheral nerves, and degenerative atrophy of the muscles. Nonne describes three forms of poliomyelitis: (1) A circumscript form, which seems to remain stationary at a certain period of its development. 1 Medical Chronicle, Manchester, 1893. Anterior Poliomyelitis. 7 I (2) A form in which rapid involvement of the muscles occurs and subsequent tendency towards recovery. (3) A form of slow but steady progress, with secondary atrophy of the peripheral nerves, with evolution and primary atrophy of the ganglionic cells. Rokitansky has also called attention, in a report of a case of polio- myelitis, to the trophic changes in the skin and to lesions in the periph- eral nerves, as well as in the cord." In the case referred to the cause was a definite poison, carbonic acid gas. Death occurred on the ninth day. The autopsy revealed bilateral pneumonia and edema, interstitial and peritoneal hemorrhages, thrombosis of the left popliteal, crural, and iliac veins, cerebral hyperemia and edema, anterior poliomyelitis, a perineal hyperemia, and edema of the sciatic nerve. The patient had had a continuous fever and wasting of the lower extremities. Peripheral neuritis, whose relation to anterior poliomyelitis is thus claimed, has been frequently shown to be of toxic origin. Baret” has just reported three interesting cases of this affection produced by infec- tion. One was the result of typhoid infection, another one from alcohol, and another from infection of syphilis and erysipelas. This case was just convalescing from the last disease, and his symptoms simulated those of poliomyelitis. There was weakness together with slight wasting, numbness, tingling in the lower extremities, with anal- gesia of the soles of the feet and enfeeblement of the knee-jerk. Pressure on the muscles gave rise to a disagreeable sensation, while pressure on the nerve-trunks caused severe pain. The muscular sense was preserved. In the upper extremities weakness and wasting were less marked, while paresthesia and anesthesia were pronounced. There was also slight convulsive tremor of the fingers. The knee-jerk became entirely abolished, and the muscular sense in the lower extrem- ities totally lost. A left pleural effusion also occurred. Antisyphilitic treatment was followed by improvement. Multiple neuritis occurred in a series of nine cases at Hamburg in 1886, and were considered by Eisenlohr, who reported them as of infectious nature. Lowenfield argues, on theoretical grounds, that there is an infectious form of multiple neuritis, and cites three cases in proof. Rosenheim records a well-observed and accurately-reported case of acute infectious multiple neuritis which terminated fatally in seventeen days. Infantile paralysis is, however, a disease which is rarely fatal, and post-mortem examinations are not very often made. We are in great 1 Wiener medicinische Presse, December 29, 1889. * Archives de Méd. et de Pharm. Milit., 1893, No. 7, p. 49. 72 Aſomer C. A/oomz. need of post-mortem investigations by modern methods in early cases. In the late cases the disease has progressed so far that even gross sections of the cord made at different times under a low-power micro- scope show the cells of the anterior cornu shrunken, and the original condition replaced by chronic sclerosis. * In lieu of autopsies physiologists have recently been making experimental studies in this direction. Herter, of New York, produced myelitis by shutting off the blood-supply in the cord. Acute myelitis has also been produced artificially in rabbits by Bourges," who published his successful experiments in this direction. Five days after inoculating the animals with the coccus of erysipelas the myelitis was developed, and after fourteen days death occurred. The myelitic degeneration of the cord was most pronounced in the lumbar region. *. - Rodger produced muscular atrophy in rabbits by infection with the staphylococci of erysipelas. It was followed by degeneration of the cells and of the anterior horns, although the peripheral nerves remained intact. In the degenerative atrophy of the muscles the fibrous groups split up and gradually disappeared, frequently undergoing fatty degeneration. [To BE continue D.] A PLEA FOR MORE PATIENCE IN THE CARE AND TREAT- MENT OF INFANTILE REPRODUCTIVE ORGANS IN THE FEMALE, WITH NOTES OF THREE CASES. BY Hom(ER C. BLOOM, M.D., Instructor of Gynecology in the Philadelphia Polyclinic; Out-door Surgeon to the Gynécéan - Hospital. No more fruitful cause of non-congeniality, unhappiness, and even misery is to be met with than want of development of the female repro- ductive organs. When we remember the train of symptoms that must necessarily follow in the wake of such a condition, this state of affairs can readily be accounted for. It is not my intention to enter into the special etiology of this con- dition, but more especially to deal with the practical application of such means and measures as have been found of greatest value in a number of cases. Nothing new is to be offered in the way of the treatment of these i Bulletin Médicale, February 22, 1893. Care and Treatment of Infantile Reproductive Organs in Pemale. 73 cases. The same methods, the same means, that are being used every day have been employed ; but it is to emphasize the great importance of persistently following for at least two years, if no improvement re- sults, the procedures which will presently be discussed. In considering, first, the etiological condition which enters into this defective development of the special organs of generation in the female, we are met at its very threshold with the same obscurity that marks so frequently the infantile development of other organs not in any way connected with these. We may have, and do have, in certain individual cases, a fully-devel- oped uterus with infantile ovaries and appendages, and, vice versa, we may have an abnormally small uterus with fully-developed ovaries, etc. With conditions like these to deal with, there are no certain etiological factors which cannot arbitrarily be construed in one way or other. To say that a hypoplasia uteri is a purely congenital condition is at once a contradiction of the well-established laws that an unhealthy systemic state during infancy or childhood retards cell-proliferation or cell- development, and consequently a faulty development of certain organs in which this retardation of cell-development is most manifest. This proves that there is no certainty as to the special factors which enter into this arrested development. It is clear to any one who studies this condition that it can be due not only to some disturbing or restricting element in embryonic life, but to some malnutrition during infancy and childhood. In discussing the symptoms, let us first take up the rational symp- toms, as given by certain individual cases. It is not the ill-looking, the poorly-developed physique that seeks our aid for this condition in the greater number of cases; but, on the contrary, many of these women have every appearance of a fully-developed organism. If she is a married woman, among the first prominent complaints will be ster- ility and lack of sexual desire ; these, too, she will tell you are the woes of her life. To deny these, is to deny that the desire for offspring is one of the strongest of maternal instincts. No class of patients, as a rule, is so unhappy, so much disappointed with the results of married life, as these unfortunate women who are being and have been denied the rights of maternity. No one can view these cases in a moral and social way without feeling the great responsibility resting upon us in the treatment of them. In connection with these two most prominent symptoms, she will tell you she has either amenorrhea or severe dysmenorrhea with scanty menstruation ; that puberty, as far as menstruation is concerned, has been delayed four or five years beyond the expected time, or is entirely absent. These patients will often complain of flushes about the face 74 Aſomer C. Bloom. and head. Frequently they will have, if the menses are absent, peri- odical pains in the lower part of the abdomen and in the lumbo sacral region, menstrual molimina. - - Some of them will complain of mammary irritation at periodical intervals, proving that there is, even in the juvenility of these organs, certain nervous phenomena, which have more or less to do with the function of menstruation; and in some cases these very nervous symp- toms are the most pronounced of all the manifestations they complain of Occasionally a case will present itself with a certain amount of leucorrhea. At first, in cases of this kind, we are led to suppose that, probably, it is vaginal in its origin ; but, in a number of these cases, if we investigate, we will find it is intra-uterine, a species of endome- tritis, probably due to a phlegmatic or relaxed condition of the organ dependent upon a lack of normal stimulation, the result of faulty development. * In studying the physical signs of such cases, we are not dealing with cases in which there is an absence of one or more organs dependent upon some other for their normal and physiological functions. It is with the infantile condition of one or more of these organs that we are interested. Noting first the external genital organ, we find, as a rule, these are normal. The vagina is, as a rule, smaller than normal. In excep- tional cases it is fully developed. If it is the uterus that is infantile, and, indeed, in most of the cases it is not only this organ that is smaller, but there seems a faulty development of all the reproductive organs, the cervix is usually pointed, and at once you are struck with the abnormal smallness and conical shape of this part of the uterus; or, in a few cases, you may find the cervix large and the body of the uterus Small, or the body and cervix may be of equal size, but all are rudi- mentary in their development, the uterus being less than one and a half inches in length. There is often an anteflexion either of the cer- vix or body, or each may be bent one upon the other. The position in the larger number of cases is anterior; but occasionally we meet with a posterior non-developed uterus. We find, as remarked above, a faulty development of the uterus is accompanied by the same condition of the ovaries and tubes. These are very hard to outline without anesthesia. I doubt whether we can map out in most of the cases with any satis- faction the true condition without giving an anesthetic. Upon the diagnosis of the true state of these organs will depend largely the cor- rectness of our views as to the ultimate success or non-success of our treatment. If we have satisfied ourselves that the ovaries and tubes are present, and not excessively atrophic or rudimentary, there is hope of the successful issue of the case. - Care and Treatment of Infantile Reproductive Organs in Female. 75 Let us not lose sight of the fact that we are dealing with conditions in which all the genital organs are present, through which the conjoint functional activity of the ovaries, tubes, and uterus is necessary to accomplish the physiological process, the beginning of life. With a uterus and its allied organs present with no malformation, so far as these individual organs are concerned, except their infantile or non- developed condition, we can feel justified in giving a favorable prog- nosis in the large percentage of cases, only, however, with the under- standing that it will require in most cases a long time. As remarked before, the methods which we will now study are not new. Having made our diagnosis, and presumably under an anes- thetic (this being the only satisfactory way), while your patient is under the anesthetic, introduce through the cervix a dilator, and gradually dilate the canal until you have it sufficiently patulous to readily admit a good-sized sound. At the same time we can make considerable mas- sage, and often free some slight adhesions about the tubes and ovaries, making the entire pelvic organs more tolerant for our subsequent treat- ment and manipulations; for we recognize the fact that these organs are not unlike others in this, that the more they are treated the less suffering is experienced. Indeed, I have been impressed with the great tolerance that many of these cases display during what in other indi- viduals would be treatment unbearable without an anesthetic. Having accomplished this much at our first visit, and having en- joined on our patient rest in the recumbent posture for twenty-four hours, we allow further treatment to go over for five or six days. At the end of this time a steel sound is introduced into the uterus, first immersing in a half strength of tincture of iodine. This can be done several times at each visit, followed by the introduction of a light pair of dilators, which are gently and continuously dilated for a few minutes. At the same visit we can make our massage and manipulations of the organs of generation. Always insist upon patients, after these treatments, remaining perfectly quiet for an hour or two ; for by this we will often save ourselves trouble, and our patients an attack of uterine colic. This simple plan of treatment is along those lines where we will find the most practical results, and at the same time be able to give a scientific solution for the results which must surely follow a persistent patient carrying out of the principles we have been studying. To more forcibly present the plea for the long continuance of treatment in these cases, notes of three cases will be given showing the results. Mrs. R., aged 27; married five years. Sterile, with scanty, irreg- ular, painful menstruation, sometimes absent for three or four months. 76 . A/omer C. Bloom. Menstruation lasting twenty-four hours, and only a mere show. Some slight albuminous leucorrhea. Flushes about the head and face. Periodical manifestations of a nervous character, calling as it were for that force which nature had failed to supply the reproductive organs sufficiently with for their normal functional activity. Bowels con- stipated. Urinary organs normal. General appearance that of per- fect health. Sexual congress repugnant. On physical examination the uterus and, indeed, all the reproduc- tive organs were more or less infantile, the uterus measuring scant two inches. The treatment before indicated was carried out in every detail; for the first few months the apparent results were anything but en- couraging, but by perseverance in six months the uterus had a depth of two inches plus. The menses were now more normal, lasting two days, and her nervous phenomena were becoming less and less. At the end of eighteen months this patient was practically well; and a few weeks since I had the pleasure of being told by her family physi- cian that he had delivered her of a nine-pound boy a few days before. The second case was that of a young woman, 21 years of age; single. She had never menstruated, and the strongest possible nervous phenomena were present at her periods. Indeed, hers was one of those cases in which the nerve element predominated. Often the only relief this patient had was a vicarious hemorrhage, and when the forces of nature were not sufficient to bring on this hemorrhage other means {} looking to the depletion of a vascular system overcharged by that physiological process whose function is menstruation had to be resorted to. The physical signs were those of faulty development of all the reproductive organs. The same treatment referred to was diligently and patiently followed for over a year with the successful establishment of the menses, and entire relief from the nervous phenomena which had been so pronounced. - The third and last case is one now under care at the Gynécéan Hospital. This case has been carefully examined by Dr. Charles B. Penrose and Dr. J. M. Baldy, both of whom fully corroborated the juvenility of her reproductive organs. - She is 27 years of age; married five years; sterile. Saw a mere show of menstruation at 18 years of age, but had had menstrual moli- mina since she was 14 years of age. Since the first appearance or show of her menses, there was no time in which she soiled even so much as one napkin, and frequently she would pass six or eight periods without a show ; but at the proper time for the periods she would have the nerve-storm incident to the unfulfilled function. Coitus was revolting to her, with this a desire of maternity, upon her part as well as her Care and Treatment of Infantile Æeproductive Organs in Female. 77 husband’s, foreshadowed impending woe, and she was willing to undergo any treatment which was likely to be instrumental in estab- lishing a normal condition. Physical examination revealed a small infantile uterus whose length was but one inch, All the other reproductive organs were cor- respondingly small, and, indeed, the rudimentary condition of her organs was such that, in connection with an absence of any menstrua- tion for nine consecutive months, made the outlook anything but favorable; but with an anxious and willing patient the treatment which we have indicated was adopted and carried out twice each week to the present time, dating over one year. At first, and for weeks, it was most discouraging, but after the lapse of a few months the successful establishment of a mere show of the menses resulted. Each month proved that progress was being made along these lines. The last report of menstruation dates the fourth day of August of this year, lasting three full days with sufficient flow and normal in every way. In the presence of Dr. Robert LeConte, assistant surgeon to the out-patient department, the uterus was measured and found to be two and one-half inches deep. This result, with the others above mentioned, is most encouraging, and shows what can be done under adverse circumstances if the treat- ment is patiently followed out. As to the rational therapy of this class of cases there seems to be one that is based upon scientific reasoning, that of cell-therapy. It is obvious that the increased development following the pro- cedures used in these cases is nothing less than that of the stimulation of cell-metabolism which takes place in the growth and development of any tissue or organ. It is not the intention of this article to enter into a discussion of cellular therapy, but there seems to be no other rational explanation. With electricity I have had very little experience. FRENcHwoMEN AND THE MEDICAL PROFESSION. According to the Progrès Médical, the medical profession does not seem to have much attraction for Frenchwomen. Of 165 female stu- dents registered in the Paris Medical Faculty at the beginning of the present academic year, only sixteen were French. On the other hand, of a total of 164 female students in the Faculty of Letters 141 were French. There were seven French female students in the Faculty of Science and three in that of Law. - 78 William Campbell Posey. THE Association OF A PARTIAL coloBOMA of THE MACULAR REGION WITH A SUPER- NUMERARY TOOTH. BY WILLIAM CAMPBELL Pos Ey, * Philadelphia, Assistant Surgeon, Wills Eye Hospital; Ophthalmologist to the Norristown Insane Asylum. COLOBOMA of this region have not been of rare occurrence, and the literature of ophthalmology contains the description of the clinical appearances of many fully reported cases. Opportunities, however, for their pathological study have been but few, so that explanatory state- ments regarding their formation must be largely hypothetical, being based upon the consideration of the pathological changes of coloboma occurring elsewhere in the ocular tissues, and of the physiological evolution of the embryonic eye. The coloboma which is cited in this article is of unusual interest on account of the occurrence of a super- numerary incisor. The association of these two anomalous condi- tions is, I believe, quite unique, the only instance of malformations or anomalies occurring in conjunction with coloboma of the macula which have been reported having been those connected with the bones of the calvarium, the anterior fontanelle remaining patulous in one instance, whilst in another a too early union of the sutures had produced microcephalus. According to the statement of the patient, his mother had a dental anomaly which corresponded exactly with his own, but as she died a short time before he came under observation, an examina- tion to prove the coexistence of the two anomalies in her and the possible transmission of the ocular as well as the dental peculiarity was impossible. The patient was a man, 25 years old, of good family and personal history. The right eye was normal, and the left, that in which the anomaly occurred, was also unaffected by any pathological change other than the coloboma. After the correction of a slight amount of compound hypermetropic astigmatism vision equalled # in both eyes. Corresponding to the colobomatous area in the fundus there was a triangular-shaped positive scotoma in the visual field. The apex of the scotoma embraced part of the fixation-point, and extended up and in to a distance of about ten degrees. The rest of the field was normal. The colobomatous area, which is well shown in the accompanying chromo-lithograph, was situated two and a half discs’ diameters down and out from the disc, and had an oval form with its long axis at an angle of 45°. The ground of the coloboma was of decidedly lighter tint than that of the surrounding fundus. There were two rounded Aartial Coloboma of the Macular Region. 79 masses of pigment lying in the space, the one near the disc being about one third the size of the other. They consisted of blackish pigment, which was stippled here and there with whitish bodies, giving a peculiar “pepper-and-salt” appearance to them. The edges of the pigment-masses were quite regular and sharply cut, and were much denser than their central portion, which presented somewhat of a honey- combed appearance. A few of the finer terminal branches of some of the retinal vessels ran over these masses, whilst some of the larger choroidal vessels and part of the pigment of this layer, which was seen lying in the bottom of the space, were obscured by them. The borders of the coloboma were sharply cut, showing no tendency to blend with the tissues surrounding it, whilst its edges and the uninterrupted course of the retinal vessels passing over it gave evidence that it was not in the slightest degree ectasic. The sketch gives an excellent idea of the appearance of the acces- sory tooth. This was placed in the median line somewhat obliquely between two well-developed incisors, and did not project anteriorly or posteriorly to them. It was about half the size of either incisor, but appeared to be fully developed. There were no other anomalous con- ditions in the body. - In regard to the genesis of coloboma of the macular region, several hypotheses have been advanced. Some investigators view the condition as being a true abnormality, as a lack in the development of the ocular tissues in this particular region. Others, again, believe that the cause must be sought for in some interference to the proper closure of the fetal fissure, which is occasioned by an inflammation of the choroid in that position, whilst others think that this hinderance is due to a local- ized inflammation on the borders of the cleft. There are certainly well- authenticated instances where coloboma of this region have occurred in eyes in which there were no traces of inflammation, but there are cases in which well-marked choroidal and retinal change place the inflammatory origin of the affection beyond question. It is a matter of experience that nearly all the ocular changes that can be traced to an intra-uterine source lie either directly below or to the temporal side of the disc, or in a position between these, at various distances and angles from it, whilst congenital pathological areas in the other three quadrants of the eye are but rarely seen. The explanation of this must be sought for in a consideration of the fetal fissure. This region is prone to inflammation above all other parts of the ocular tissues, in the first place, by reason of the greater quantity of pigment that is found on its borders, and, secondly, by the ready transmission of any pathological process to it by the retinal vessels as they enter the eye at that point. The variety in the location 8O William Campbell Posey. of these changes is explained by the external rotation in the globe which occurs during intra-uterine life, whereby the cleft is caused to occupy different angles at different periods of fetal development. By knowing the angle which the cleft occupies at certain months, the position of the inflammatory areas would be of value in indicating the time at which the obstruction to its closure occurred. Thus, coloboma of the macula, being a consequence of the patulency of that part of the fissure that is last to close, must be regarded as being due to a disturbing influence which has operated very late. An instance of coloboma of the iris associated with a similar condition in the macular region has not been recorded as yet, the 'failure of association of the two condi- tions being probably due to the fact that coloboma of the former mem- brane are dependent upon those of the choroid, and occur as the result of some early interference to the closing of the fissure. - The origin of macular coloboma from the fissure is further attested to by their shape, as they are usually triangular with their apices directed towards the disc, and again, by the frequent association of large trunks of the retinal vessels with them, instances having been reported where they were seen to leave the eye through these coloboma- tous areas. Their color and appearance are dependent upon the number of layers of the ocular tissues that have been affected, and also upon the extent to which they have been involved. . The appearance of the coloboma (Fig. 1) would give the impres- sion that all the coats of the eye had not been involved, choroidal vessels and pigment, and the retinal arteries running partially over it, being quite discernible. The case therefore has been viewed as being an instance of a partial coloboma of the eye, one in which the pigment layer of the retina was alone disturbed. - In all cases of this affection where a microscopic examination has been made, the pigment layer has been the one that has been the more usually absent. Pause, indeed, has made a histological examination of a coloboma of the choroid and iris in which all the layers of the retina were present except that one. The explanation of the frequent involvement of this to the exclu- sion of the other retinal layers is made easier by the researches of recent observers. Scherl has shown that in birds where there is no vascular system in the interior of the eye, the first deposition of pigment is on the external surface of the proximal layer of the vesicle, whereas in all mammals, where there is an internal system present, the pigment appears first on the internal surface of the proximal layer. This would seem to prove that the pigment is a derivative of the blood, and is dependent upon the presence of a vascular layer. Any inter- ference with the vascular supply would therefore retard or prohibit Fig. FIG, 2. Zeucocytosis. 8 I its development. In addition to this, Salzman has pointed out that any hinderance to the proper closing of the fetal cleft has a most decided effect upon the pigment layer and its overlying capil- laries. In the case that has been reported in this article, it would seem that there had been some obstacle offered to the proper closure of the cleft, which had disturbed its posterior extremity alone, by operating after the more anterior portion had united. Whether this disturbing factor resided in the vascular system, or whether there was a transmis- sion of the defect from the mother, as suggested by the inheritance of the dental anomaly, it is impossible to say. It is of interest, however, to note a lack of development in one part of the fetal cleft, and an excess in another. It is much to be regretted that an ophthalmoscopic examination of the mother was not possible, as the discovery of the same condition in her, as well as in her son, would have proved that the existence of the two anomalies in the same individual was not accidental, whilst it would also have been strong evidence in favor of the non-inflammatory origin of coloboma of the macular region. LEUCOCYTOSIS." By WILLIAM S. CARTER, M.D., Assistant Demonstrator of Pathology, University of Pennsylvania ; Pathologist to the Children’s Hospital. g (CONTINUED FROM PAGE 29.) THE LEUCOcyTOSIS OF PATHOLOGICAL STATES. IV. Zeucocytosis from /mflammation of Serous Membranes.--It is a well-known fact that inflammation of serous membranes are attended with leucocytosis. The nature of the inflammatory process (whether serous, fibrinous, or purulent) does not bear any relation to the degree of leucocytosis. There are certain cases which fail to show any leuco- cytosis, although there may be an extensive inflammation of a serous membrane. The extent of the inflammation does not determine the degree of leucocytosis. A localized inflammation about the appendix may cause as great a leucocytosis as a general peritonitis. Dr. R. C. Cabot, of the Massachusetts General Hospital, has re- cently counted the leucocytes in twenty-four cases of appendicitis. In all except two where pus was found leucocytosis was present, but the 1 Paper read before the Society for Clinical Research, Philadelphia, May 22, 1894. 6 82 Wm. S. Carter. degree of leucocytosis bore no relation to the amount of pus present. In three cases, which at operation proved to be catarrhal, leucocytosis was absent. The two cases with pus, which failed to show leucocy- tosis, had a general peritonitis, and died within twenty-four hours. These cases did not suffer from pain, and this fact, together with the point that they all showed a feeble systemic reaction, are brought for- ward to account for the absence of leucocytosis. The absence of leu- cocytosis in these septic conditions is, probably, an unfavorable prog- nostic sign just as it is in pneumonia ; but there is also another class of cases in which there may be extensive involvement of either the peri- toneum, pleura, or meninges, and yet leucocytosis is absent. I refer to tuberculosis of these membranes. In these cases leucocytosis is absent oftener than it is present, if we may judge of the cases reported ; and, indeed, when we consider the extent of the tuberculous involve- ment in some cases which fail to show any leucocytosis, the ques- tion arises, Does tuberculosis per se ever produce leucocytosis, or is this condition, when present, due to secondary infection by the ordinary pyogenic micro-organisms? Tuberculous appendicitis may be more common than we suspect at present. The writer has recently had an opportunity to count the blood in two children in the Children's Hospital with tuberculous meningitis. CASE I.—H. P., aged 6 months; sick eight days; great emacia- tion ; rolling the head ; general convulsions; paralysis; bulging fontanelle; high temperature; catarrhal pneumónia. Blood count a few days before death showed red blood-corpuscles, 4,580,000; white blood-corpuscles, 15,600. At the necropsy we found a general acute miliary tuberculosis involving the whole of both lungs, the mediastinal and bronchial glands, the spleen, kidney (right), liver, peritoneum, with one ulcer in the ileum, and some enlargement of the mesenteric glands. There was a very extensive lepto-meningitis. Over the entire under surface of the cerebellum, crura, and all about the circle of Willis, the membrane was greatly thickened, and contained a yellowish inflammatory exudate and vast numbers of tubercles. These were dis- tributed all along the basilar, the posterior and middle cerebral arter- ies, extending along the latter almost to the great longitudinal fissure. There were also vast numbers of tubercles over the upper surface of the cerebellum and the under surface of the occipital lobes. CASE II.-R. B., aged Io months. Had been ill ten days. Seems very sick; considerable temperature; marked retraction of head; char- acteristic cry; convulsions of right side followed by paralysis; strabis- mus; Cheyne-Stokes respiration. Blood count two days before death ; red blood-corpuscles, 4,800,000; white blood-corpuscles, 9,400. No necropsy allowed. Zeucocytosis. 83 Many cases of pleuritis and peritonitis have been reported by dif- ferent writers which show leucocytosis to be present. Several have stated that the leucocytosis is greatest when the temperature is at its maximum. Although my own observations have been limited in num- ber, they are strictly in accord with the results obtained by Rieder, i.e., that the leucocytosis seen in inflammations of the serous membranes bears no relation to the body temperature in those conditions. To determine whether or not an inflammation of the serous mem- brane which is not bacterial in origin would produce as great a leuco- cytosis as a specific inflammation of such a part, the following experi- ments were performed : EXPERIMENT I.-Healthy young dog ; weighing II.327 kilos. Rectal temperature, 40° C., I P.M. . . . . . R. B. C., 8,250,000 W. B. C., 7,750 I.3O P. M. . . . . . . . . . . . . . . . . . R. B. C., 6,650, OOO W. B. C., I2,OOO 2.15 P.M. Injected twelve drops of oil of turpentine into right pleural cavity with sterilized syringe. 2.18 P.M. Is profoundly shocked and cannot stand when untied. 2-25 P.M. . . . . . . . . . . . . . . . . . R. B. C., 5,300,000 W. B. C., I5,600 Had several convulsions. 2.45 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6,600,000 - W. B. C., I2,500 Is still very sick, but is better than he has been. 3.05 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6,300,000 W. B. C., I5,600 Seems much easier. ' Rectal temperature, 36.7°C., 3.50 P.M. . . . R. B. C., 6,250,000 W. B. C., 50,625 6 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 6,850, OOO W. B. C., 43,750 Gave morphia subcutaneously. Next day . . . . . . . . . . . . . . . . . R. B. C., 7,500,000 W. B. C., 34,500 Animal bled to death. Right pleural cavity showed an extensive sero-fibrinous inflammation. ExPERIMENT II.-Rabbit of medium size. 2 P. M. . . . . . . . . ſº tº & º & © º º . . R. B. C., 6,600,000 W. B. C., 7,800 2.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6,500,000 W. B. C., Io,900 4.45 P.M. Injected .5 gramme of calomel suspended in glycerin into the peritoneal cavity. The material was prepared with aseptic precautions, and the syringe sterilized and bacterial infection avoided. 5 P.M. Animal seems very sick. Appears to be in a condition of shock. 84 Wm. S. Carter. 7 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 6,450,000 W. B. C., 21,8oo 8 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 6,700,000 W. B. C., 28, IOO I2 midnight, found dead. These experiments indicate that the leucocytosis seen in inflam- mation of serous membranes is not due solely to the absorption of bac- terial products, which occurs more readily here than in other tissues, but that it may also be produced by chemical substances, which are posi- tively chemotactic and capable of setting up an active inflammation. From the present state of our knowledge of this subject, it seems highly probable that all inflammations of the serous membranes (pleu- ral, meningeal, and peritoneal) are attended with a distinct leucocytosis, unless the process is tuberculous in origin. This fact may often be utilized in making a diagnosis in obscure cases in which involvement of these membranes is suspected, and especially those in which inflam- mation about the appendix is suspected. From the experiments cited above, it would appear that leucocytosis is present early in the course of such cases. - Q The prognostic value of leucocytosis in troubles about the appen- dix still remains to be determined. As bearing on this subject of inflammation of serous membranes, it is very interesting to consider for a moment the extraordinary phe- nomenon to which Professor John Guitéras first called attention,-viz., that the sudden removal of fluid from the large serous cavities is fol- lowed at once by a diminution in the number of leucocytes in the blood, this reduction amounting, on the average, to half the number present before the operation. By the courtesy of Dr. W. E. Hughes, I was able to study six different cases in his wards at the Philadelphia Hospital, in which either the pleural or peritoneal cavity was tapped. In every case there was a diminution of at least one-half the number present before the tapping, and sometimes even a greater reduction took place. This came on at once, and was present whether there was an increased or a normal number of leucocytes before the operation. Dr. Guitéras attributes this curious change to a reversal of the lymph current, i.e., that it is directed to the serous cavity, which has been suddenly emptied, instead of flowing into the veins. V. The Leucocytoses of Infections.—(a) Pneumonia. As a rule, there is a distinct leucocytosis in cases of pneumonia, usually amount- ing to several times the normal number of leucocytes, coming on with the onset of the disease, and changing very slightly from day to day, disappearing suddenly with the crisis of the disease. Zeucocytosis. 85 The statements that the leucocytosis is in direct proportion to the extent of lung involvement, and that the leucocytosis is greater the day before the crisis, are not borne out by facts. If we combine the cases reported by Rieder (26), by Ewing' (100), and by Cabot (72), we have a series of 198 cases. Of these, at least 48 died (Cabot does not state how many died of his last series of 24 cases); 13 cases did not show leucocytosis, and all of these died, ex- cepting one (Cabot's case), and this one was apparently moribund, and remained so for a time, but when he began to improve, his leucocytes increased in number. Of Ewing’s cases (IOO), 3 I died with leucocy- tosis present, but of this number 13 were complicated by some other inflammatory process (pericarditis, endocarditis, nephritis), or by senil- ity or alcoholism ; I I of the 31 cases showed such a slight increase (averaging but 9000 per cubic millimetre) that they do not deserve the name of leucocytosis. As Ewing points out, the prognosis of pneumonia seems to depend upon the amount of poison generated, and the vigor of the systemic reaction, rather than upon the extent of lung involvement. In con. sidering the relation between the degree of leucocytosis and these two factors, he divides his cases into three classes, as follows: (1) Those in which the reaction of the system was vigorous, the rectal temperature having reached IO 5° F. or more, the pulse retaining its force until the lesion was well advanced, and when the condition was markedly sthenic, and a fatal issue seemed to result from some complication. (2) Those cases in which the systemic reaction was moderate, the temperature amounting to 104°-IO5° F., and other symptoms were less Severe. (3) Those cases in which the reaction was slight, +the temperature never reaching IO4° F., with only moderate prostration. In 47 cases coming under the first class, -i.e., vigorous reaction,- the average number of leucocytes was 31,000 per cubic millimetre. In 27 coming under the second class, +7.e., moderate reaction,-the average number was 20,000. Of 27 cases characterized by slight or deficient reaction, and coming under the third class, the average was 90oo. In this last group there were placed II asthenic cases, in 6 of which the number of leucocytes was subnormal. - Cabot contends that there is no relation between the degree of leu- cocytosis and the systemic reaction, stating that he has seen high counts in sthenic cases and in fatal cases. He does not say, however, whether or not there was any complication in these fatal cases. It would appear that leucocytosis of lobar pneumonia may be 1 Ewing, New York Medical Journal, December 16, 1893. 86 Wm. S. Carter. slight (a) in mild cases, and (b) in those severe cases in which there is little reaction. - A well-marked leucocytosis does not always assure us that the dis- ease will pursue a favorable course, but it is generally a favorable sign, PNEUMONIA. NO. Case. Age. Day of Disease. Result. R. B. C. II III IV VI VII VIII IX XI XII Io years. 4 years. 3 years. I6 months. 2% years. 2% years. 2 years. 2 years. 2% years. 2% years. 2% years. 6th 2 weeks. 3d 5th 7th 9th I2th 4th 7th Death. Recovery. Death. Recovery. { { Death. Recovery. 4,945, OOO 3,975, OOO 4, I25, OOO 4, O25, OOO 4,775, OOO 4,550, OOO 4,475, OOO 4,850, OOO 4,750, OOO 4,800,000 4, OOO,OOO W. B. C. 38,000 3I,250 34,400 3I,OOO I7,2OO I5,6OO 46,000 23,500 25,000 48,400 I2,500 4,450,000 29,700 Remarks. Very ill; high tem- perature; necropsy showed extensive catarrhal pneumo- nia, fibrinous pleu- ritis, and purulent peritonitis. Few areas in both lungs; moderate se- verity; temperature IoI°–103.0°F. Very sick ; extensive consolidation upper lobe right lung; tem- per a ture Iog.o"— IO5.5° F.; pulse 150; respiration 50–55. Extremely ill; high temperature; rapid pulse and respira- tion ; convulsions; necropsy showed few areas bron cho- pneumonia in both lungs. Not very sick; slight temperature. Moderate tempera- ture; pulse I2O ; re- spiration 44; recov- ery in few days. Moderate severity. ( ( & 4 & & 4 & Extremely ill; high temperature; rapid pulse and respira- tion. Pneumonia at base of right lung; temper- ature Io.3° F.; pulse and re spiration rapid ; seems quite sick. Quite ill attime; pulse I5O ; temperature Iogº—IO5° F.; respi- ration 40–50. Zeucocytosis. 87 provided there is no complication. On the other hand, the absence of leucocytosis seems to unmistakably indicate a fatal termination. That the leucocytosis does not occur because we have a patholog- ical process involving that delicate epithelium lining the alveoli, which closely resembles the endothelium of serous cavities, is evidenced by the fact that the leucocytosis disappears suddenly with the crisis of the disease before resolution has taken place. This would also indicate, together with the fact that leucocytosis is present from the first onset of the disease and remains at a certain point until the crisis, that the character of the inflammatory exudate, which occurs later in the course of pneumonia, leucocytic has nothing to do with the increase in the number of leucocytes in the circulation. On preceding page there are twelve cases of catarrhal pneumonia. They clearly demonstrate that the extent of pneumonic involvement bears no relation to the degree of leucocytosis. Death occurred in three cases. In one there was fibrinous pleu- ritis, purulent peritonitis, and extensive catarrhal pneumonia, and clinically this case presented a distinct leucocytosis. In the other two, death occurred without complications, and yet distinct leucocytosis was present in one (Case IV); the other (Case XI) showed less leucocytosis than any other of the series. (b) Tuberculosis.-The number of leucocytes in tuberculosis is extremely variable. As a rule, it may be said that tuberculosis does not produce leucocytosis. Chronic cases with long standing suppura- tion, or more acute cases with a secondary or mixed infection may show a leucocytosis. As already stated, the extensive tuberculosis seen in many cases without leucocytosis causes one to incline to the opinion that leucocytosis, when present in this disease, may not be due to the tuberculosis itself, but some other cause. Even acute miliary tubercu- losis does not usually present leucocytosis. Cabot has only been able to collect four cases of acute miliary tuberculosis in which a blood count was made, and in all of them leucocytosis was absent. . This was also the condition in his own case. The case mentioned above, in speaking of tuberculous meningitis, showed a slight leucocytosis (15,600). It may be stated, then, that leucocytosis in tuberculosis is the exception rather than the rule. (c) Typhoid Fever.—The leucocytes in this disease have been care- fully studied by different men, and they all seem to agree with Thayer, who has given especial attention to this subject, and reached the con- clusion that there is no increase in the number of leucocytes in typhoid fever, but, on the contrary, there is a distinct diminution in number. There is, however, a characteristic alteration in the fractional count. 88 - Wm. S. Carter. The multinuclear variety is decreased, but the pale mononuclear form is increased. It is especially the young cells of this variety of leuco- cytes that is increased,—those standing between the small lymphocytes, on the one hand, and the very large pale mononuclear cells, on the other. This seems to be a well-established clinical fact, and may be of great use in the diagnosis of certain obscure cases. (d) Erysipelas.-It is said that erysipelas constantly produces a distinct leucocytosis. My own experience with this disease has been limited to a few cases, in all of which there was a distinct leucocytosis. (e) Measles.—It has been stated by various writers on leucocytosis that this disease is unattended by an increase of the leucocytes. The writer has counted the blood in seventeen cases of measles, at all stages of the disease, and in eleven of them failed to find any increase in the number of leucocytes. In six cases the number varied from Io, OOO to 15, ooo per cubic millimetre, and of this number one case developed diphtheria in a malignant form two days after the count, and another had an unusually severe rhinitis. The other four did not show any complications by physical examination, although the catarrhal symp- toms in all of them were unusually severe. Of course, there might have been a slight broncho-pneumonia which was not demonstrable at the time by physical signs. In one case (Case XIII) there was a slight leucocytosis, and although there were no signs of pneumonia at that time, two days later catarrhal pneumonia was clearly demonstrable. These results are confirmatory of the conclusions reached by others, viz., that leucocytosis is absent in measles. (f) Diphtheria.-The blood of patients with diphtheria has been said to contain a greater number of leucocytes than in any other in- fection, and it has been stated that the greater the leucocytosis the worse the prognosis. The writer gives below the result of blood exam- inations in thirteen cases of diphtheria. The cases are entirely too few to draw any positive conclusions, but a careful examination of the cases shows the following : (1) Those cases which were very mild, and made a rapid recovery without ever having been very sick, show a leucocytosis. (Cases II, III, VI, VIII, and X.) The average of these five cases is 24,600 leuco- cytes per cubic millimetre. Only one showed a pronounced leucocy- tosis (Case II), and in that one there was a mixed infection, strepto- cocci being associated with the Klebs-Löffler bacillus in the membrane. (2) Those cases which were very sick or moderately so,-i.e., showed considerable toxemia,--but recovered eventually, showed the highest degree of leucocytosis, the five cases averaging 46,280 per cubic millimetres (Cases VII, IX, XI, and XII). Zeucocytosis. 89 MEASLES. NO. Day of Case. Age. Result. Rash. R. B. C. W. B. C. Remarks. I 5 years. Recovery. 3d 4,725,000 || 7,8oo Moderate severity. II Io years. 2d 4,4OO,OOO 6,250 | Severe. III 9 years. { { ISt 4,800,000 6,250 Severe; high temper- ature. IV 5 years. { { 2d 4,600,000 || 4,700 Extensive rash ; high temperature; had diphtheria 2 weeks later. V 3 years. { { 2d 4,812,000 Io,900 Moderate. VI 5 years. { { 5,000,000 15,600 | Slight eruption ; Se- 3d vere cough. VII 5 years. Death. 2d 4,300,000 12,500 Developed diphtheria 3 days later while rash out, and died in 2% days. (See Case IV of diphtheria.) VIII 2% years. | Recovery. Ist 4,4OO,OOO 7,800 Mild. IX 4 years. 3d 4,350,000 || 9,370 || Moderate. X 234 years. . . . . . . . . . . 4,44O,OGO IO,900 { { J) XI 3 years. Recovery. 2d 4,700,000 || 9,300 Severe. XII (15 months. & ( 3d 5, OOO,OOO I2,500 & & XIII 2 years. & C 3d 4,900,000 | I 2,500 Catarrhal pneumonia, shown by physical examination 2 days | 1ater. XIV 5 years. * { 2d 4,825,OOO 8,600 Moderate severity. XV 5 years. ( & 2d 4,500,000 5,475 Mild. XVI 2 years. { { 3d 4,800,000 4,700 ( & XVII || 4 years. { { 3d . . . . . 3,900 { { (3) Four cases died (Cases I, IV, V, and XIII). The average number of leucocytes in these cases was 32,3oo per cubic millimetre. One case that died showed a pronounced leucocytosis (Case IV). This patient had a very malignant form of the disease coming on while the measles rash was still out. The membrane rapidly filled the pharynx, and extended into the larynx, making tracheotomy necessary. The blood count was made several hours after the tracheotomy. An autopsy could not be obtained, and it could not be determined whether or not there was any complication, such as pneumonia. Although these cases are few in number, they appear to indicate that we have in diphtheria a condition analogous to that in pneumonia, —viz., that there is a slight leucocytosis in,- (a) Mild cases with slight intoxication, and (b) In cases which end fatally, in which there is an unusually severe intoxication or a feeble resistance on the part of the patient. The greatest leucocytosis obtains in those cases which are subjected to a severe toxemia, but are able to withstand it and recover. This will be referred to again when speaking of experiments with diphtheria. - DIPEITHERIA. & Age. #. Culture. §: º; i. Blood Examination. Remarks. I 5 yrs. || 4th. . . . . . . . . . . . . . Severe. D. R. B. C., 3,500,000 | No culture. Croup symptoms. Great pallor, W. B. C., I4, OOO prostration, and moderate temperature. Died two days after count. II Io ‘‘ 2d. K.-L." and | Extensive. Mild. R. R. B. C., 4,237,500 | But slight prostration. * strepto- W. B. C., 40,600 cocci. + III | 2% “ 5th. K.-L. Extensive. Mild. R. R. B. C., 3,800,000 | Never very sick. W. B. C., 18,750 IV 5 “ 2d. K.-L. Extensive. Very D R. B. C., 4,000,000 | Profound toxemia. Membrane in larynx. Trache- malignant. W. B. C., 56, OOO otomy several hours before count. Death twelve hours later. V | 3 “ 2d. K.-L. Extensive. Very D. R. B. C., 3,737,000 | Convalescing from scarlet fever when diphtheria malignant. W. B. C., 23,400 developed. Death fifteen hours after blood examination. VI 5 “ 3d. R.-L. Slight. Mild. R. R. B. C., 5,02O,OOO || Rapid recovery. W. B. C., I8,750 VII 6 ‘‘ | Ist. K.-L. Slight. Severe. R. R. B. C., 4,550,000 | Pulse rapid. Considerable hebetude and pros- W. B. C., 28,000 tration. Appears very ill. VIII | 3 “ | 1st. K.-L. Slight. Mild. R. R. B. C., 4,2OO,OOO Became quite ill later. W. B. C., I8,3OO IX | 7 “ 3d. K.-L. Consider- Severe. R. R. B. C., 4,000,000 || Considerable membrane on both tonsils, which - able. W. B. C., 78,000 extended into the nose. Very ill for a time. X | 5 ‘‘ 5th. K.-L. Consider- Mild. R. R. B. C., 4,700,000 | Membrane on both tonsils, but no great prostra- able. W. B. C., 26,500 tion. XI 6 “ || 4th. K.-L. Consider- || Moderate. R. R. B. C., 4,600,000 able. W. B. C., 31,250 XII 2% “ | 8th. . . . . . . Slight. Moderate. R. R. B. C., 4,750,000 W. B. C., 50, ooo XIII | 3 ‘‘ 5th. . . . . . . Extensive. Severe. D. R. B. C., 4,200,000 || Membrane extended to nasal mucous membrane. W. B. C., 36,000 Cervical glands greatly enlarged. Severe tox- emia. i K.-L. indicates that the Klebs-Löffler bacillus was found by culture. 3 Leucocytosis. 9I (g) Scarlatina.-A series of eleven cases of scarlet fever shows a pronounced leucocytosis. There was a moderate leucocytosis in all but two, -one of these was very ill, and three days later showed moderate leucocytosis (Case I). He developed diphtheria while desquamating, and died in three days. The other one without leucocytosis was scarcely affected by the disease,_except the slight fever. All the others were mild cases, and show from 12,000 to 30,000 leucocytes per cubic milli- metre of blood. While there is only a moderate increase in the number of leuco- cytes, there seems to be a departure from the normal, in the relative proportion of the different forms. This consists in an increase of the eosinophiles. All who have examined the blood in scarlet fever seem to agree on this point. I give a fractional count of the leucocytes in four cases, only 500 leucocytes being counted in these cases. SCARLATINA. Case II. Case VIII. Case IX. Case X. Lymphocytes . . . . 5.0 per cent. II.3+percent. 3.0 per cent. I3.0 per cent. Large mononuclear . 3.0 { { 3.3+ “ 2. O { { 3. O { { Transitional . . . 6.3 * { 6.3 { { 7.O { { 4. O { { Multinuclear . 82.o { { 76.o C & 86.O ( & 76.o ( { Eosinophiles . 3.6–H “ 3. O { { 2. O { { 4. O { { (h) Septic Infection.—The presence of pus in the body will produce a leucocytosis, unless the pus be tuberculous in origin. All are agreed that pus in the body is attended with leucocytosis, and this fact may often be made use of in diagnosis. Thus Cabot has found 1eucocytosis in fifteen cases of pus-tube or pelvic abscess, and suggests that this may be made use of in differentiating between this condition and many other affections likely to be confounded with it. We have already spoken of the importance of leucocytosis in the diagnosis of pathologi- cal conditions about the appendix vermiformis. Cabot suggests that pus under tension is more apt to produce leu- cocytosis than when free. He found well-marked leucocytosis in patients with felons, in which there was a small amount of pus, while in paronychia with great pain but no pus, there was no increase in the number of leucocytes. The same observer examining two scalp wounds, in one of which the tissues were water-soaked and boggy but contained no pus, and in the other, which contained plenty of pus, found leuco- cytosis in the latter, but not in the former. This would indicate that the presence of pus rather than the condition under which it exists determines the condition of leucocytosis. It may be that all pyogenic SCARLET FEVER. No. Desquama- Case. Age. Rash. tion. Sore Throat. Result. Blood Count, Remarks. I 3 yrs. . . . . . . Marked. Slight D. R. B. C., 4,562,500 | Count, March 31, 1894. W. B. C., 6,250 I 3 “ . . . . . . . . . . . . . . . . . . . . . R. B. C., 4, Ioo,000 || Count, April 4, 1894. Few patches. Catarrhal W. B. C., 15,600 pneumonia. Developed diphtheria next day, and died in three days. (See diphtheria table, Case V.) II Io “ Very bright| . . . . . . Moderate R. R. B. C., 4,700,000 | High temperature, April 15, 1894. Ist day. patches. W. B. C., 17, 18O II IO ‘‘ | . . . . . . Distinct. . . . . . . R. B. C., 5, 120,000 || Much improved. Has slight fever. April 22, W. B. C., 18,700 I894. III 7 “ 3d day. | . . . . . . Slight R. R. B. C., 4,52O,OOO | Mild case. W. B. C., 15,600 IV I6 “ 3d day. | . . . . . . Slight R. R. B. C., 4,312,000 | Covered by rash, but does not seem sick, and W. B. C., 6,200 has only slight temperature. V 7 “ . . . . . . . 7 days. | . . . . . . R. R. B. C., 5,200,000 || Desquamation well advanced. Boy seems per- W. B. C., I5,600 fectly well. VI 3% “ . . . . . . . Beginning None R. R. B. C., 4,940,000 | Very mild. - W. B. C., I4,060 VII I}4 “ . . . . . . . 5 days. None R. R. B. C., 5,200,000 || Extremely mild. - W. B. C., I2,500 * VIII 5 “ 3d day. | . . . . . . Slight R. R. B. C., 3,350,000 | Covered with rash. Slight fever. W. B. C., I4, Ooo IX 4 “ 2d day. | . . . . . . Slight R. R. B. C., 4,700,000 || Has vaccination at same time. Much sicker - W. B. C., 18,750 than others. X 5 “ 2d day. | . . . . . . Slight R. R. B. C., 4,750,000 || Moderately severe. W. B. C., 29,000 XI 8 “ 9th day Marked. None R. R. B. C., 4,525,000 || Mild case. . W. B. C., II,720 S Aleucocytosis. 93 bacteria do not produce leucocytosis. The variable degree of leucocy- tosis in the different specific infections indicates that all micro-organisms do not produce this condition to the same degree. In regard to the different ordinary pus-producing organisms this still remains to be determined. To determine whether or not a chemical substance which is posi- tively chemotactic could produce leucocytosis when injected subcuta- neously, the following experiment was performed : Medium-sized rabbit. Has an abscess on side from inoculation in a previous experiment. 3 P. M. . . . . . . . . . . . . . . . . . . . R. B. C., 5,300,000 W. B. C., 21,900 3.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 5,500,000 W. B. C., 28,OOO 4.30 P.M. Injected subcutaneously .5 gramme calomel sus- pended in glycerin. Used sterilized syringe. 7.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6,000,000 W. B. C., 72,600 I2 midnight . . . . . . . . . . . . . . . . R. B. C., 5,600,000 W. B. C., 59,300 This indicates that other substances than bacteria or their products are capable of producing leucocytosis, when thrown into the cellular tissues. In closing the subject of the infections, I would like to mention the following case of noma or gangrenous stomatitis: S. S., aged 3 years. Had been sick several days before admission. Admitted to the wards of Dr. Samuel Ashhurst, Children's Hospital, March 27, 1894. Child very sick. Gangrenous area has been thor- oughly curetted and treated with antiseptics. There is a slight perfora- tion of cheek; red blood-corpuscles, 3,500,000 ; white blood-corpuscles, 25,000. March 29, 1894. Child very sick, evidently moribund. Gan- grenous condition has extended rapidly in last two days, until nearly the entire cheek is destroyed. Blood count two hours before death, red blood-corpuscles, 1,375,000; white blood-corpuscles, 28, IOO. [TO BE contLNUED.] 94 Clinical Department. CLINICAL DEPARTMENT. UNIVERSITY HOSPITAL. MEDICAL DISPENSARY. PLEURAL EFFUSIONS. THE following cases of pleural effusions have been selected from the great number which presented themselves at the dispensary during the past year, to illustrate the different varieties and as a basis for a few remarks upon the etiology, symptoms, and treatment of this inter- esting phase of disease. CASE I.—Frank K., aged 64; laborer; family history indefinite; never had rheumatism ; a moderate drinker. Four weeks before appli- cation at the service, November 1, 1893, he was seized with a severe attack of dyspnea. Careful questioning developed the fact that he had been constantly dyspneic with palpitation of the heart on exertion for some months. Physical Examination.—Apex-beat of heart not visible, but felt in fifth interspace, nipple-line. The superficial cardiac dulness is bounded by the fourth rib, left border of sternum and nipple-line. Cardiac action is extremely irregular. At the aortic cartilage the heart-sounds are accompanied by a faint systolic murmur, and are irregular and weak. Lungs.—On left side there is dulness below sixth rib. There is good tactile fremitus at both bases. The breath-sounds are harsh and accompanied by fine crackling rāles. A diagnosis of fatty degeneration of heart with edema of lungs was made, and strychnine and digitalis ordered. Patient did not return for three months, February 24, 1894,-when there was marked flatness at both bases. The dulness was movable, and puncture with needle showed the presence of a clear liquid. He again disappeared for two months, to answer again April 20, 1894. At this time he had general anasarca, urgent dyspnea, a scarcely perceptible pulse, and a large amount of effusion in both chests. He was taken into the ward, put to bed, and given digitalis and strychnine. In four weeks he was as well as he “ever was,” and was up and about. The effusion entirely disappeared with the strengthening of the heart. CASE II.—July 7, 1894. William C., aged 23. Father, mother, and one sister living and well. In infancy he had asthma ; but health was good until one year ago. At that time he caught cold, and lost thirty-three pounds of weight in two weeks, but has kept the same Clinical Department. 95 weight since. Yellow expectoration; no night-sweats; appetite good ; pain in back ; urgent dyspnea, and palpitation on the least exertion. Aºxamination.—Much emaciation ; marked depression, especially under left clavicle. The left shoulder droops. Tremendous distention of the entire right chest, measuring two inches more than left side. Flat note on percussion ; slight tactile fremitus; at the extreme apex the tactile fremitus is greater than at any other point on right side. Blowing breathing at extreme right apex. Over the entire right chest there is hollow, prolonged expiration. The whispered voice can be heard well over whole right chest. The voice and breath-sounds are exag- gerated over the left chest. The apex-beat of the heart is in the sixth interspace and axillary line. So great is the distention of the right chest that the right edge of sternum is tilted forward. There was a slight fever. A puncture was made and pus withdrawn. Aspiration was then performed, and at two sittings six quarts of pus were withdrawn from the chest. The patient bore the tappings very badly, and went into collapse after the last one. Two days after the last tapping permanent drainage was established by means of aspiration drainage. Patient was etherized. A large trocar and canula, three-eighths of an inch in diameter, were inserted in the seventh interspace. The trocar was re- moved and a gum tube, which fitted the canula exactly, was pushed into the chest through the canula. The canula was then withdrawn and the tube allowed to remain in chest, and retained there by silk passed through the tube and tied around the body. The free end of the tube was then attached to a glass tube inserted through the cork of a bottle and extending to the bottom of a boracic acid solution contained in the bottle. A second opening was made in the cork for the ingress and egress of air. Immediately after the withdrawal of the last of the pus both sides of the chest measured the same, the heart came back to its normal position. Breath-sounds were heard over the whole right chest, and at the apex were fairly normal in character. During his stay of one week in the hospital the temperature ranged between normal and IoI* F., usually, however, about 99.5° F. Various examinations of both sputum (which was very scant) and the pus were made for tubercle bacilli, but none were found. The patient went about carrying the bottle in his pocket and at- tached to his tube. He eats well; walks without dyspnea. Some weeks after the tapping the sputum became more profuse, and was found to contain myriads of tubercle bacilli. About the same time the exudation became extremely fetid, and, in spite of careful washing of the cavity, remained so until death. 96 Clinical Department. CASE III.—John B., aged 28 ; single ; salesman ; family history is good. He was perfectly well until spring of 1891, when he began to cough blood. One and a half years ago he developed cough. Has lost much flesh ; his appetite is poor. He has night-sweats, and hectic. On examination there is seen to be much less movement on left side than on right, with the cardiac impulse somewhat to right of sternum. The whole left chest is hyper-resonant, the cardiac dulness being lost. On 1eft the tactile fremitus is entirely lost. The breath-sounds are feeble and distant. The expiration is prolonged and hollow. August 9, 1894. Three months after the first visit he returned with flatness on percussion at left base. The dulness is movable, and accom- panied with a marked succussion splash. The breathing above the dulness is amphoric with tinkling rāles. There is marked bell tym- pany. - October Io, 1894. At the base there is still movable dulness, but the signs of pneumothorax have entirely disappeared. The case was to return for resection, but failed to put in an appearance. CASE IV.-Wm. R., aged 27 ; white; married. Family history excellent, there being no trace of phthisis in the family. No serious illness until three and a half years previous to visit, March 26, 1894. At that time he had a slight cough, which continued. He gradually lost flesh and strength. He spat blood in September, 1892, and again in June, 1893. In October, 1893, he started for Denver, Colorado. On boarding the train at Chicago, he was seized with a pain in the left side so severe that he was rendered unconscious, and did not become entirely conscious until he reached Denver. He was there admitted to the hospital, and soon afterwards the side was tapped, and what the patient described as pure serum removed. He was again tapped January, 1894, but without result. He returned to Philadelphia, March, 1894, and immediately came to the University Medical Dispensary. He was slightly short of breath. On examination the left chest was found much distended, and a marked pulsation between the second and fourth right intercostal spaces. Apex- beat absent from its normal position. Spinal column bowed to the right. There was absolute dulness of entire left chest, except at the extreme apex. Over the area to the right of sternum, where the pul- sation was seen, there was dulness. Voice-sounds were absent over the left chest, as were the breath-sounds. Tactile fremitus, but over the dulness. The chest was tapped, and three quarts of bloody fluid removed. After the tapping, dulness still persisted over the left side, the apex beat of heart felt in normal position, and the pulsation and dulness had disappeared from the upper part of chest to the right of sternum. Breath-sounds could be fairly well heard in the left chest. Clinical Department. 97 On April 9, 1894, the fluid had reaccumulated, and he was again tapped. The fluid was sero-purulent in character, and had lost its bloody characteristic. He was again tapped, and one quart of liquid removed ; the heart was just to the right of sternum. Tubercle bacilli were found in sputum and exudate. On May 25, the fluid having again accumulated, the chest was opened and aspiration-drainage performed, as in Case II. The case did fairly well until August, 1894, though there was always a great deal of tenderness about the tube. The liquid also became extremely fetid in this case as in the other one of drainage. In the latter part of August a rib was resected, and the patient at present is doing well. CASE V.—Annie S., aged 12 ; has had cough and pain in right chest for several weeks. The patient is dyspneic ; has much palpita- tion of heart; the lips are blue and hands cold. On examination the left chest is found to have less movement than right. There is dul- ness on percussion below the fourth rib, and this dulness is movable. The apex-beat of the heart is almost in the nipple-line in the fifth inter- space. Over the entire area of percussion dulness the breath-sounds are feeble, and accompanied by a loud, dry friction sound. The chest was tapped and sixteen fluid ounces of serum removed. There has been no return of the liquid, and the child is much improved. CASE VI.-Clarence S., aged 17; barber. Family history good. No serious disease previous to the present illness. Two weeks before the first visit at the dispensary, July, 1894, he was suddenly seized with pain in the lumbar region, which did not radiate down the groin or around the abdomen. Appetite was good. It was difficult for the patient to inspire deeply. No cough. Temperature IOoº F. On examination the patient was pale and ill-nourished. Slight curvature of the upper third of the spinal column. There was pulsation in the second interspace to night of sternum. Movement of chest-wall less on left than on right. On percussion there was dulness on the left side, beginning at the third rib anteriorly and the spine of scapula posteriorly. Tactile fremitus was entirely lost over the left base. Over the area of pulsation to the right of sternum there was dulness, and the heart-sounds are well heard in this position. The chest was immediately tapped, and one quart of serum re- moved. The heart immediately resumed its normal position, and the dulness on percussion disappeared. He returned several times, and on the last visit was in an entirely normal condition. Since writing the above, this patient has returned with a pleural effusion in right chest. This was tapped, and the patient is again well. Case I is a good example of a double effusion occurring in the 7 98 Clinical Department. course of heart-disease as a result of the faulty action of that organ. The case is traced from the first symptoms of water-logging of the lungs themselves to the filling of both pleural cavities with liquid. The treatment followed in this case, absolute rest, light diet, combined with digitalis and strychnine, gave prompt and prolonged relief. It can be confidently relied upon to relieve in almost all cases of like character. Purging may in still more extreme cases be a necessary measure. Tap- ping is comparatively seldom demanded. Cases II, III, and IV are examples of empyema, the result of tubercular pleurisy. Case II is especially remarkable for the unusual amount of liquid removed and the length of time the effusion existed. The patient had visited several hospitals, but the condition remained unrecognized, doubtless by reason of a rapid and cursory examination, all too frequently made in the out- wards of our various hospitals. The presence of prolonged hollow expiration and whispered voice sounds over the liquid disprove the infallibility of Baccelli’s theory that these signs occur only over a serous effusion. The great displacement of the heart was the sign which next to tapping decided the diagnosis. Both this and Case IV are examples of aspiration drainage done and treated under careful precautions, both of the cases became fetid, and in the last was promptly relieved by resection of a rib. It would seem to be strongly indicated by both of these cases that resection of one or more ribs is much preferable to aspiration drainage as a permanent operation. The tube irritates the chest-wall, becomes loose, and allows infection of the pleural contents. Case IV is an example of the frequency of bloody exudates in tuber- cular pleurisy. The presence of a bloody serum as a pleural exudate is pretty good evidence of either tubercular or malignant disease. Case III is an unusual instance in which the steps of pneumothorax, pyopneumothorax, and pyothorax are observed in the same patient. On his first visit he had a pure pneumothorax, and it will be noticed that the heart was displaced. On his third visit he had a typical pyo- pneumothorax, and on his last visit simply a pyothorax. Case V illustrates the necessity of an exploratory puncture for a sure diagnosis between effusions and consolidations or thickened pleurae. In this case the presence of loud friction sounds heard over the entire effusion made us hesitate as to the presence of a liquid, though the displacement of the heart more than any other sign made us suspicious. The explanation in this case must be that the liquid being small allowed the friction to occur in the upper part of the chest. The sounds were so loud that they were well heard over the effusion. Both Cases V and VI are examples of the beneficial effects of early tappings. It seems absurd to allow a lung to be compressed, and a patient distressed by a pleural effusion when such a simple and harm- Alumn? Notes. 99 less operation will at once give relief, which in simple pleurisies is usually permanent. We have come to look upon displacement of the heart as the most valuable physical sign of pleural effusions as distinguished from con- solidation. Case II shows how the voice sounds and breathing may simulate consolidation, and Case V how friction may be heard Over a liquid. Distention of the side and movable dulness, of course, are valuable signs, but the chest may be so full or the effusion so bound down that it is immobile, while an effusion insufficient to cause disten- tion will invariably cause dislocation of the heart more or less marked. M. H. FUSSELL, Physician in Chief. ALUMNI NOTES, IN order to increase the usefulness of the Society of the Alumni of the Medical Department of the University of Pennsylvania, a brief appeal has recently been issued to a large number of those graduates not already members of the association. In the past the Society has been forced to content itself with, – (a) The publication of an annual report. (b) The awarding each year of a bronze medal to the student receiving the highest general average at graduation. (c) The preparation of an annual banquet, at which the cost of entertaining the graduating class has, for several terms, been equally divided between the Faculty of the University and the Supper Com- mittee. A decided increase in the membership will enable the Society to add $50 as an accompaniment of the bronze medal, or provide for the casting of the same in gold, if desired. Other prizes might also be established as funds permitted, and the complete graduate catalogue pushed to early completion. Thomas Hubbard, M.D., of 205 Ontario Street, Toledo, for two years secretary of the Ohio State Medical Society, has recently com- pleted his labors on the Transactions of the same, to be reviewed elsewhere in this journal. APPOINTMENTS. Dr. I. B. Hamilton, Class of 1883, who last winter was located at Tombstone, A. T., and who collected antelope for Dr. Harrison Allen, has been appointed surgeon to the Congress Gold-Mining Company. : : . 3. : : : : IOO Alumn: Motes. Dr. Hamilton is now engaged in making a mineral collection for the University of Pennsylvania. Dr. Charles A. Oliver has been appointed Ophthalmic Surgeon to the B. & O. R. R. The following Consultants have been appointed to St. Agnes’s Hospital : Dr. Michael O’Hara, Sr., Consulting Physician, and Dr. John Grove, Consulting Surgeon. Dr. Burton K. Chance, of the Class of '93, has been elected Res- ident Physician to the Wills Eye Hospital. Dr. A. A. Stevens, of the Class of ’86, has been appointed Visiting Physician to St. Agnes’s Hospital. NECROLOGY. Dr. Abraham Rothrock died at McVeytown, Mifflin County, Pa., September 9, where he had practised medicine for almost sixty-five years. He was born in Derry township, Mifflin County, Pa. In 1826, when 20 years of age, he commenced the study of medicine, and entered the Medical Department of the University of Pennsylvania in the fall of 1828. After one course of lectures he commenced practice at McVey- town ; returning later he graduated from the University in 1835, since which time he continued in practice at McVeytown until some three years ago. During his many long years of work, his practice was both large and arduous, and located in a field entailing great hardships and exposure. He was a great reader, and an earnest student, thus keeping him- self abreast with all that pertained to his profession ; although situated at a distance from medical schools, or the source of professional sup- plies, yet his patients received promptly the benefit of any advances or discoveries in the healing art. He was a member of both the County and State Medical Societies; the first vice-president of the latter in 1878. During the late Civil War he was appointed to the office of Examining Surgeon to the Board of Enrolment in the Seventeenth Congressional District of Pennsylvania. His conscientious efforts and impartial decisions in this important work proving his peeuliar fitness for this office, and his report to the Surgeon-General’s Department at Washington, was most highly commended. He was a man of irreproachable character; his name standing for everything that was substantial or good in the com- munity. . In May, 1837, he married Phoebe Brinton, daughter of Joseph Trimble, of Delaware County, Pa., whose life fully supplemented his own. He was the father of Joseph T. Rothrock, M.D., formerly Pro- ; : º : ; : : : : : Alumn? AVotes. IoI fessor of Botany in the University of Pennsylvania, who with two sisters survive him. Dr. William A. Culpeper died on the 4th inst., at Barbadoes, West Indies. He graduated from the Medical Department of the University of Pennsylvania with high honors in the class of 1883. He after- wards served as resident physician in the Philadelphia and University Hospitals, Dr. C. W. Coleman died at Williamsburg, Va., September 15, 1894. After graduating from the University of Pennsylvania, he began the practice of his profession in Richmond, but soon removed to his native town, with which place he remained intimately identified, pro- fessionally and socially. LABOR AND HEART-DISEASE. TARNIER (Journal des Sages-Femmes, January 16, 1894) notes that in heart-disease all great and sudden efforts put the patient in peril, and labor is no exception to the rule. Running up-stairs, racing to catch an omnibus or train, and sexual intercourse may all cause fatal syncope. The danger of labor is not special in this sense; it is dangerous in heart-disease simply because it involves much effort. Tarnier induced premature labor in a lady who was subject to advanced heart-disease. Notwithstanding all precautions, she became moribund in the course of the labor. Directly she died, he turned and delivered a live child, which survived. A woman was brought into Tarnier's wards in Janu- ary, 1894, in labor, with advanced heart-disease and asystolism ; she was apparently dying. Immediately about 300 grammes of blood were withdrawn, and the symptoms of suffocation diminished. The patient grew calmer. As it was extremely advisable to bring on labor quickly, as the forceps is apt to fatigue the patient, and as, in particular, the child was dead, the basiotribe was applied and delivery effected. A few days later the mother was doing very well.—British Medical Journal. EDITORIAL. APPENDICITIS. IT is hardly too much to say that at the present time no subject connected with medicine is demanding more attention than appendicitis. This is due not only to the fact of its great relative frequency since we have been able by a better understanding of its symptoms to recognize its presence, but also because there exists such marked diversity of opinion in regard to the proper treatment of the disease. The time is quite within the recollection of many physicians when appendicitis was rarely heard of, the affections in the right iliac fossa being usually con- sidered typhlitic. Then came the period when the inflammations in this region were said to involve the cecum, the tissues around the cecum, and the appendix, the affections being designated typhlitis, perityphlitis, and appendicitis. This time is so recent that even the youngest practitioner of to-day received this teaching as a student. At present typhlitis and perityphlitis are scarcely referred to in current literature, unless it be to call attention to the confusion which existed in the professional mind concerning these conditions a few years ago. It cannot be denied that typhlitis may and does occasionally exist, but it is so overshadowed in frequency by appendicitis that the latter deservedly claims almost undivided attention. The views which are at present held on the subject of appendicitis are of such recent origin that only the most modern text-books give anything like a satisfactory account of the affection, and there is such a great variety of opinion respecting the treatment of the disease in the literature of to-day that the student and even the physician is often quite puzzled after reviewing the diverse theories to form a definite idea of the proper course to pursue. Of all the characteristics of appendicitis, none stands out so prom- inently as the sudden and fatal change which is likely to occur even in what has appeared to be a mild case. There is absolutely no way to foreshadow this change, and the only safety for the patient lies in a keen appreciation of this fact by the physician, in having the case con- stantly under the observation of a skilled attendant, and in being pre- pared for such an emergency by having the assistance of a surgeon from the beginning, who is thus familiar with the details of the individual IO2 The Hygiene of the Mouth. IO3 case, and consequently prepared to operate at any time that such a course seems indicated. It is not an infrequent experience for the sur- geon to be called to see a case of appendicitis when the patient is almost moribund. There are several reasons for this occurrence. The physician at his morning visit may have found the patient in a satis- factory condition ; soon after his departure a perforation may occur, and unless the attendant is experienced in this class of troubles, and is able to discern the signals which should excite alarm, some hours may be passed over before the change is noted. This delay may, and con- stantly does, make the difference between life and death to the patient. Even if the change has been promptly noted, the physician may not be at once accessible, and some hours may elapse before his next visit, or before he can be found ; then, if he concludes to send for a surgeon another delay is incurred, and the hasty preparation for the operation still further robs the patient of precious moments. On the other hand, so many primary cases recover without oper- ation that a correct view of the abortive treatment is most desirable. Equally important are the better understanding of the measures neces- sary to bring about permanent recovery, and the better discrimination between the cases that may be expected to recover without operation and those that will need such interference. There can be no doubt that there have been many needless operations for appendicitis. It is gratifying to learn that a recent effort has succeeded in plac- ing at the disposal of patients having appendicitis a number of beds in the University Hospital, notice of which will be found in another part of the MAGAZINE. The ward is to be under the care of Professors William Pepper and J. William White, who are engaged in a special study of the symptoms, treatment, and pathology of this affection. The medical and surgical features of the disease will be studied together from the outset. Especial features of the investigation will be the studies in the morbid anatomy and the bacteriology of the dis- ease, which will be conducted in special laboratories connected with the University. In addition to affording this class of patients the care and attention which could not be secured outside of an institution of this kind, it is hoped that the results may aid materially in settling the disputed and doubtful points which now exist. THE HYGIENE OF THE MOUTH. WITH the development of bacteriology has come the knowledge of the presence of microscopic life everywhere. This very fact tends to lessen the full appreciation of the dangers of their presence if favorable IO4 Aditorial. conditions should develop for their growth. The rôle played by micro- organisms in many morbid processes has now been established, and the list of these diseases must constantly be added to. In a recent lecture before the Wistar Biological Association, entitled “The Bacterio-Pathology of the Mouth and its Significance in its Relation to General Diseases,” Professor W. D. Miller, of Berlin, stated that thirty-two distinct species of germs had been found in the mouth, and directed attention forcibly to the need of careful attention to this cavity. Galen, who lived in the second century, was the first person to record the poisonous qualities of human saliva of which we have record. Since that time the observation has been frequently repeated both by early medical writers and those of the present day. It is now known that these poisonous properties depend upon the presence of micro-organisms, some of which are quite virulent, while others are harmless. One of the most important of the buccal bacteria is that which causes caries of the teeth. The first effect of decayed teeth, if not attended to, is, of course, imperfect mastication, and as a consequence indigestion with its usual train of symptoms. In some cases, an abscess forms at the root of the tooth ; as a result of this necrosis of the jaw may follow, and either septicemia or pyemia may develop. Dr. Miller has collected 200 cases in which death has resulted from one of these conditions, which began as caries of the teeth. Among these were several instances of necrosis of the jaw, abscess of the lung, and other parts, etc. It is thought that many of the abscesses whose cause cannot be explained, and other infections, the origin of which is not apparent, may be due to the invasion of germs, the latter having entered the body through a carious tooth. It has been found as a result of a large number of observations that enlargement of the lymphatic glands at the angle of the jaw constantly accompanies carious teeth. It is not unlikely that decayed teeth may furnish a ready means of entrance for the tubercle bacillus. Experience certainly shows that the cervical lymphatic glands are very frequently the seat of tuberculosis. It is probable, at least, that if pathogenic organisms do not find entrance into the body through this channel, the irritation of the gland resulting from the decayed teeth so dimin- ishes its powers of resistance that disease is much more likely to fol- low. It was also pointed out that the diplococcus of pneumonia, which is thought to be the cause of croupous pneumonia, was identical with the micrococcus of sputum septicemia. The coccus described by Fried- länder evidently is not inspired, in as much as it cannot survive long in the air; whereas its presence in great numbers in the mouth renders A Bust of Dr. Zeidy. IO5 it an easy matter for the lungs to become infected whenever the usual powers of resistance are sufficiently diminished. The tonsils are also apt to contain a variety of micro-organisms. Their richness in crypts and follicles, together with a weakened resist- ance which supervenes upon the frequent inflammatory attacks, so common with many people, offers a particularly suitable soil for germs. The collections of yellowish offensive matter that sometimes occur in the tonsils have been found to consist almost entirely of micro-organ- isms. A number of authors have now described diseases in which the tonsils are supposed to have been the port through which the germs found their way into the body. The list has recently been augmented by the addition of rheumatism. The practical deduction is that increased care should be devoted to keeping the mouth perfectly healthy. This will be one of the features of “preventive medicine,” the dawn of which is evidently approaching. A BUST OF DR. LEIDY. GRADUATEs of the University of Pennsylvania will be pleased to learn that a suitable memorial of the late Dr. Leidy is to be placed in the library of the institution. Dr. Leidy held the professorship of anatomy for thirty-nine years, and his services and labors have given imperishable fame to the University. The memorial will be in the form of bust modelled from a death-mask, obtained by the sculptor, Mr. John J. Boyle, and from various enlarged photographs. The work, which is already finished and awaiting final acceptance by the Committee of Trustees, is to cost $800, all of which sum has been contributed by the friends of Dr. Leidy. THE WISTAR BIOLOGICAL ASSOCIATION. THE first meeting of this organization was held in the lecture-room of the Wistar Institute of Anatomy, on the evening of October 12, 1894. Dr. John Macfarland, Professor of Botany, delivered a lecture on some recent botanical investigations. Although the association has but recently been organized, it has a membership of 150. The purpose of the organization is to promote scientific investigation, and to enable the laity to keep in touch with the advances made in biological sciences. The officers of the association are: Mr. Isaac Jones Wistar, President; Dr. Horace Jayne, Vice-President ; and Dr. Milton J. Greenman, Sec- retary and Treasurer. MEDICAL PROGRESS. NME DIC IN E. UNIDER THE CHARGE OF WILLIAM PEPPER, M.D., LL.D., AND JAMES TYSON, M.D., ASSISTED BY M. HOWARD FUSSELL, M.D. ASTHMA IN CHILDREN. DAUCHEZ (Revue des Maladies de l’Enfance, July, 1894) thus concludes a val- uable article on the above subject. (I) Infantile asthma is in the greater number of cases a reflex symptom. Being symptomatic of some excitation on the cutaneous or mucous surface, or sometimes due to visceral trouble. In the beginning, if the cause is recognized and combated, it is easily curable. Later the cure is much more delayed. (2) Sometimes the symptomatic and reflex asthma is hereditary and consti- tutional. In these cases it is a true asthma due to arthritism in neuro-arthritic subjects with a spasmodic tendency. In these cases it is often persistent. (3) Recovery is frequent when there is no asthma in the antecedents, if the hygiene is good and the treatment climatic. (4) When asthma develops in the younger children, it is most curable. (5) Asthma is a disease of adolescence and adult age. (6) The frequency of occurrence in the child is between 5 and Io years. ACUTE DISSEMINATED MYELITIS. DRESCHFELD (British Medical Journal, June 2, 1884) reports the following case : J. R., aged 23, had enjoyed good health until April 20, 1893. He was espe- cially fond of athletics. There was no syphilis, and his habits had been regular. In the middle of April he fell into a pond, and had to walk two miles to change his garments. In two weeks he suffered severe pain on the right side of the head and rapidly lost the sight of his right eye. Examination showed optic neuritis. Soon after he was confined to bed with pain and swelling of right leg, and on at- tempting to go about found he could not use his left leg. Soon after he had numb- ness in both legs. Complete loss of power of left leg, and a girdle pain at the region of the xiphoid. He had incontinence of urine, followed by retention. May 20, 1893, he was in bed, unable to walk. He had no pain. He had a right optic neuritis, all other cranial nerves normal. The radial and triceps reflexes were increased. The upper part of the trunk appeared normal. About two inches below the xiphoid there was a line of anesthesia on the right and paresthesia on the left. The anesthesia affected the whole right half of the body below this point ; the paresthesia the left half. There was complete loss of power of left leg, and weakness of right leg. The knee reflexes were increased. Ioé * Medicine. IO7 The symptoms rapidly grew worse, and he died from asphyxia on July 27. Post- mortem.—Greatemaciation. Brain normal but edematous. Optic nerves presented red points on transverse section. Spinal cord. Dura distended with fluid, but there was no pus or blood; the pia was not thickened; the upper part of cord from the second cervical to the end of the cervical enlargement was almost diffluent; the dorsal and lumbar portions were free. On hardening and staining after Weigert there were found,- (1) Irregularly distributed patches of myelitis. (2) In some places the patches occupied one-half of the cord, in others they could be recognized only by the microscope. (3) The changes were most marked around the blood-vessels. (4) There was marked distention of the perivascular sheaths with leucocytes and compound granular cells. (5) There was well-marked ascending degeneration of the posterior columns. Sections of the optic nerves showed patches of degeneration. BONE-MARROW IN THE TREATMENT OF PERNICIOUS ANEMIA. FRASER (British Medical Journal, June 2, 1894) reports one case of per- nicious (?) anemia treated with all the symptoms due to extreme anemia. The blood count was 1,860,000 reds, with 30 per cent. hemoglobin, and I,460,000 reds, with 28 per cent. of hemoglobin, with much distortion of the corpuscles. During the administration of full doses of arsenic and iron the corpuscles fell to 843,000, and the hemoglobin to 18 per cent. Ox-bone marrow, uncooked, was then added to the treatment, three ounces daily, with almost immediate improve- ment. Thirty-two days after beginning the bone-marrow the corpuscles were 3,400,000, and the hemoglobin 75 per cent. The patient was discharged after about three months with his blood in this condition, and feeling “as though he 11ad been made over again.” SCLERODERMA. EULENBERG (Wiener medizinische Wochenschrift, No. 93, 1894) cites several cases of this disease, one of which ran a fatal course in two years, and began with symptoms of tabes. Later the diagnosis was trichinosis, due to the swelling of the eyelids and the muscles. Still 1ater the diagnosis was polyneuritis. Errors in diag- nosis are especially frequent when the disturbance begins in the proximal ends of the limbs. Then the characteristic signs of the disease, the tense pain, the pares- thesia, the cold sensations, etc., are looked upon as signs of a nervous disturbance. In a fully-developed diffuse scleroderma, of course, there can be no doubt of the diagnosis. In the beginning of the disease the marked stretching of the skin, the mark-like condition of the features, and the enlargement of the hands and feet are characteristic. The disease is rare, occurring between 20 and 52 years in the cases observed. The clinical symptoms are marked by disturbances of sensation. Sometimes there is motor disturbance, but this is seldom. There are many trophic disturbances, however. The face may become atrophied, and spots of ulceration occur. In the small joints there may be enlargement of the ends of the bones. The excretion of sweat is sometimes but not always diminished. The general symptoms which occur in the most severe cases are loss of flesh and strength. There are no pathological lesions found in either the cord or the peripheral ganglia or nerves. IO8 Medicine. THE ETIOLOGY AND TIME OF INCUBATION OF Fol.I.Icur,AR TonSILLITIs. WOLBERG (Archiv für Kinderheilkunde, Vol. xv.1, Parts III and Iv, 1894) reports some observations upon the above disease, and concludes,— (I) That follicular tonsillitis can doubtless be communicated from person to person. (2) The duration of the diseases varies from three to four days. A SIMPLE METHOD OF INCREASING THE DOUBLE CRURAL, MURMUR IN AORTIc INSUFFICIENCY, LANNOIS (Lyon Médical, June 17, 1894) noticed in examining certain patients with double aortic disease that strong pressure on the crural artery caused a to-and- fro movement in the artery above the point of pressure, and a very marked diastolic thrill. Auscultation of the artery made above the point of compression showed the diastolic sound very marked. If it could not be heard in the artery usually, then compression caused it to become audible. ANTITOXIN IN DIPHTHERIA. KATZ (Berliner klinische Wochenschrift, July 16, 1894) reports for Baginsky the result of treatment of diphtheria in the Children's Hospital in Berlin with Aronson’s antitoxin. In four years 1081 cases of diphtheria were treated, with a mortality of 38.9 per cent. In the three and a half months immediately preceding the beginning of treatment by antitoxin there was a mortality of 41.8 per cent. During the three months in which antitoxin was used there were I28 cases so treated, with a mortality of 13.2 per cent. Adding to these cases 15, which for good reasons were not treated with antitoxin, the mortality was I6.5 per cent. Nephritis was no more common in the cases on whom antitoxin was used than on the others, and was not of so severe a type. Once there was an abscess at the seat of the injection. Nine times an eruption appeared either at the region of the injection or on the extremities. There was no constitutional disturbance with these exanthemata, however. Sometimes the rash resembled scarlatina, sometimes measles. Four times urticaria appeared. The exudation was not influenced in an unusual way, but in not a single case of the I28 treated was the larynx affected after the use of the remedy. There was no effect on the swelling of the glands. Indeed, the course of the disease was generally affected, and no special symptom was marked. g Eighty-two healthy children were injected with a diluted solution of anti- toxin for the purpose of vaccination. Eight of these became slightly ill, but none seriously. At the time of writing none of these children were sick with diphtheria. He believes it is too soon to state a positive conclusion, but thinks the treat- ment is the best so far suggested, and awaits further trials. EASTEs (British Medical Journal, July 21, 1894) reports one case of diphtheria in which all the usual methods of treatment were used, and the child steadily grew worse. On the third day the writer injected five cubic centimetres of Aron- son's antitoxin, when an immediate effect was noted. Four days after the injection the patient was well. -- - HEUBNER (Jahrbuch für Kinderheilkunde, Vol. xxxviiI, Parts II and III), in a paper read at Rome at the International Congress, compares the result of the treatment of three groups of cases of diphtheria. The first group was treated entirely without the serum,_113 cases, with a Surgery. IO9 mortality of 64.6 per cent. The second group, 129 cases, 79 of which were treated with the serum, had a mortality of 42.6 per cent. The third group of II8 cases, none of which received the serum, had a mortality of 45.7 per cent. The cases treated in the serum period were of about the same as those treated in Period III. During the time which the writer could get the serum to use, 96 cases came under observation. Seventeen of these were mild and were not injected. Comparing these 96 cases with 96 from each of the other periods, the percentages stand as follows : Period. Cases Treated. Mortality. I (without serum) . . . . . . . . . 96 62.5 per cent. II (79 with serum) . . . . . . . . 96 38.5 { { III . . . . . . . . . . . . . . . . 96 49. O { { As will be seen, a slight change in favor of the serum period. The cases which required operation were in no way affected by the use of the serum, nor was the percentage of cases requiring the serum materially lessened. The author found that the cases which were treated with the serum of greatest power did better than those treated with weaker serum. There were no bad results observed, never any abscesses or induration at the seat of injections, and there was never any carbolic acid poisoning observed, notwithstanding the considerable amount of acid injected with the serum in some of the cases. He concludes that in his experience the serum used, while it had a marked influence on the course of diphtheria, did not act as a specific. It should be given further trial in a larger number of cases. In the Congress at Rome the following remarks were made : Ränke (Munich) can report no good result from the use of antitoxin. Malinowski (Warsaw) knew of no bad result from the use of the remedy. Baginsky (Berlin) believes that a positive conclusion in regard to the “heil- serum” can be reached only after some years. SU F. G E RY. UN DER THE CHARGE OF J. WILLIAM WHITE, M.D., ASSISTED BY G. G. DAVIS, M.D., M.R.C.S., AND ELLWOOD R. KIRBY, M.D. MODIFICATION OF LITHOLAPAXY IN CASES OF ENLARGED PROSTATE. CHISMORE (Journal of Cutaneous and Genito-Urinary Diseases, August, I894, p. 325) advocates the following modification of Bigelow's method of operating for stone in the bladder when the prostate is enlarged : - (1) Substituting local for general anesthesia in cases where an anesthetic is required. (2) Short sittings. Continue crushing only so long as fragments can easily be found. Wash out the pieces, and stop the moment symptoms of exhaustion, spasm of the bladder, or undue distress occur. I IO Surgery. (3) Remove remaining pieces after symptoms due to previous operation have subsided so soon as they can be felt by the searcher,-usually within a week, -and repeat the process until the bladder is cleared. The author in his office empties the bladder and injects one to two fluid ounces of a 4-per-cent. solution of muriate of cocaine, and introduces the lithotrite and crusher. If there is any difficulty in finding a fragment, further procedures are ceased, and the bladderwashed out with warm boracic solution until the fragments cease to come. The patient is then sent home, with orders to keep quiet and warm, send for the operator if needed, and if all goes well to come back in three or four days. He has had 52 cases. The youngest was 51 and the oldest 74 years, an average of 66.36 years. Of the stones, 22 were phosphates, 24 oxalates, 5 urates, and I mixed oxalates and tirates. The smallest weighed, when dry, 7 grains, and the largest IOOO grains; average I49 grains. There were no deaths and no serious complications attributable to these operations. . The author concludes that, in all cases of stone in the bladder where senile enlargement of the prostate gland exists, the operation described affords a reason- able probability of success, provided the urethra is, or can be made, large enough to admit the instruments; that in such cases it is possible by this method, with less suffering and danger to the patient, to remove any stone that can be gotten through a perineal incision ; that the results are quite as good, both as to relief or recurrence, as those obtained by cutting, either high or low, and that, as a rule, the time required to clear the bladder is not greater than that which is necessary to recover from a suprapubic lithotomy. [In the surgical abstracts of the August issue, p. 779, is a case of death from cocaine reported by Reclus to the Paris Société de Chirurgie, and recorded in their Bulletin of May, 1894, p. 276. In this case, to facilitate catheterization, twenty grams (five fluid drachms) of a 5-per-cent, solution, (fifteen grains) of cocaine, were injected into the urethra. Reclus stated that one should never exceed fifteen to twenty centigrammes (two and a half to three and a third grains) of cocaine at an injection, and not use a stronger solution than I per cent. Three other deaths are cited. In the discussion which followed, Bazy stated that the passage of the drug into the bladder favored absorption. Sée suggested slight tears in the canal might have contributed to the fatal effect, while Tuffier attributed it to the direct passage of the solution into a ruptured vein in the vicinity of the bulb. A well-known death occurred some time ago in this city from a urethral injection of cocaine.— ED.] SPLINT FOR FRACTURE OF THE HUMERUS. ALBERS (Centralblatt für Chirurgie, 1894, p. 593) describes his method of treating fracture of the humerus with a plaster bandage. It is best applied when the patient is seated on a chair. Two rolls of a plaster bandage four metres long and twelve centimetres wide are needed. The arm is placed parallel to the side, and the forearm flexed at a rightangle, and in a supine position. The parts are slightly greased to prevent the plaster from sticking. The plaster bandage having been moistened in water is applied up and down from the neck and outer side of the arm and forearm to the knuckles. When eight or ten layers have been applied they are fixed in place with a bandage which encircles the arm and then goes around the neck and through the opposite axilla. The part of the plaster bandage on the neck which projects above the muslin bandage is turned down over it like a collar, whence the name collar bandage. The arm is placed in a handkerchief sling (Mitella), and when dried the splint is re- Surgery. I I I moved, trimmed, and replaced with a light layer of cotton between it and the skin. The splint is bandaged to the arm with muslin or flannel bandages, turns being taken over the shoulder and through the opposite axilla. A sling is then added. Ten patients were so treated. The average time of consolidation in eight of these cases was twenty-two days, only one went over four weeks. TECHNIQUE OF MAKING URETHRAL INJECTIONs. GUIARD (Annales des Maladies des Organes Génito-Urinaire, June 1894) gives the results of his investigations concerning the urethra and its medication. The capacity of the urethra had been stated by Jarnin and Leprévoct to be from five to eight grammes, therefore it was held that a urethral syringe should not hold more than five or six grammes, equal to about one and a half drachms. Later it was shown that posterior urethritis, particularly late in the disease, was far more frequent than formerly supposed. The author by experimenting on the living subject found that the urethra would always hold eight toºten’ grammes (two to two and a half fluid drachms), and more often twelve to fifteen grammes, and some- times sixteen to seventeen. As the patient could tell when the sphincter was forced, this was avoided. These deep injections are only called for when definite symptoms have already demonstrated that the posterior region of the urethra is already affected. In order to administer these deep injections, the author uses a syringe of twenty grammes (five drachms) capacity. When it is desired to overcome the sphincter, gen- tle pressure is made when the liquid will enter. In an experience of ten years he has never had any accidents, and only encountered one case in which the sphincter would not relax. It is better to give the injections when the patient is lying down than when he is standing up. The requirements of an effective injection is that it shall reach all the diseased parts. To do this a syringe of twenty grammes (five fluid drachms) capacity should be used, and the injection of its entire contents, if carefully done, is easy, and causes no inconvenience. CORRECTION OF DEFORMITY AFTER REMOVAL OF HALF THE Low ER JAw. McBURNEY (Annals of Surgery, July, 1894, p. 35), after excision of a half of the lower jaw, inserted immediately after the operation an interdental splint to prevent, for the time being, its displacement by the unopposed muscles. Later a spring was inserted, one end being fastened to the divided lower jaw, and the other to the upper posterior molar teeth of the side operated on. This was soon replaced by a set of artificial teeth, with a piece of gutta-percha sufficient in size to fill out the cheek at the site of the removed bone. These appliances were made by a dentist, Dr, Westlake, from casts. The author has applied this method with success to three patients. The spiral spring is essential but a short time. During its use these patients, even the one most recently operated on, have acquired such control over the half of the jaw that they can now articulate and masticate when the spring is not in place. The essential part of the method is the application, immediately after the operation, of the simple interdental splint, and its constant use until complete cicatrization has taken place. As soon as the interdental splint is removed, and the spiral wire spring applied, the patient begins at once to culti- vate the muscles, and rapidly acquires voluntary control of the jaw. [This subject has been worked up by some of the French surgeons, and a communication appeared in reference to it in one of their journals a year or so ago.—G. G. D.] II 2 Surgery. TREATMENT OF GANGRENOUS HERNIA. In the Bulletins et Memoires de la Société de Chirurgie, xx, p. 381, is given a discussión on the treatment of gangrenous hernia. Chaput having advised resection with circular enterorrhaphy, Segond, on the contrary, advised the making of an artificial anus. His three cases had all died of shock. Of eight cases in which an artificial anus had been made, four died in three or four days, and the other four in the course of several weeks, one of renal and three of pulmonary complications. In these latter cases he claims that the operation had nothing to do with causing death, and says that the septic and shocked condition of this class of patients prohibits the employment of such a long operation as circular enteror- rhaphy. Terrier said that the operation of circular enterorrhaphy, as usually practised, was too prolonged and severe to be used as a rule in this class of cases, but that Murphy, by means of his anastomotic buttons, had obtained seven recoveries in eight cases. A trial of this method was recommended. Kirmisson agreed with Terrier that circular enterorrhaphy was difficult, long, and grave, and therefore he always made an artificial anus. This he had done with some success, having subsequently closed the artificial anus in two cases. Championnière agreed with Segond that enterorrhaphy is long, difficult, and serious, and does not often give good results. An artificial anus is much less grave. Chaput in closing said 80 per cent. was the mortality of artificial anus, and 30 per cent. of the remainder subsequently succumbed. He offered the following conclusions: (1) Make the resections large in extent. (2) Don’t employ any method which narrows the 1umen of the gut. (3) Leave the intestine outside between two layers of iodoform gauze. (4) Do not use chloroform. Miculicz only lost 30 per cent. of his cases, Murphy had the success already stated, and Delbet also has had two successful cases. Two CASES OF RUPTURE OF THE SEMILUNAR CARTILAGES OF THE KNEE. LARDY (Revue de Chirurgie, June Io, 1894) excised two semilunar cartilages for rupture. The first was in a foot-ball player, aged 34 years. While playing foot-ball, fifteen years previously, he was suddenly seized with great pain on the inner side of the left knee. It swelled rapidly, and the patient was kept abed for several months and treated for tumor albus. He had the typical symptoms of 1oose cartilage, which came out while walking, only to be replaced by manipulation. A hard mass could be felt beneath the skin; it appeared to engage in the articula- tion on movement. A transverse incision was made and the anterior two-thirds of the affected meniscus removed. Union by first intention and perfect cure. Case two was in a man, aged 50 years. About a year previously he slipped on a stone and twisted his knee. The joint immediately inflamed. The external meniscus, when the limb was extended, could plainly be felt enlarged and promi- nent. A transverse incision at the interarticular line allowed the removal of the anterior two-thirds of the external meniscus. It only remained attached by a thread-like filament posteriorly. This case also resulted favorably. The author also observed another case which declined operation, and a fourth in whom the cartilage had been removed ten years previously with absolutely perfect functional use of the joint. Surgery. II 3 COMPARATIVE SAFETY OF SUPRAPUBIc LITHOTOMY, OF LATERAL LITHOTOMY, AND OF LITHOLAPAXY IN YOUNG MALES. BARLING (British Medical Journal, May 5, 1894) investigated the results of these three operations during the five years from 1888 to 1892. The inquiry was limited to six hospitals in London and six in the provinces. Of 44 cases of suprapubic lithotomy under Io years of age, Io died; of 28 cases between the ages of Io and 20 years, 5 died. Total, 72 cases, 15 deaths. Deducting 3 deaths in which either litholapaxy or lateral lithotomy had been attempted 1eave 69 cases, 12 deaths, a mortality of 17.4 per cent. Of 39 cases of lateral lithotomy under Io years, 2 died; of 20 cases between Io and 20 years, none died. Total, 59 cases, 2 deaths. To this add 1 death from suprapubic section after an uncompleted lateral operation, and it makes 60 cases with 3 deaths; a mortality of 5 per cent. Of 43 cases of litholapaxy under IO years of age, I died ; of 16 cases between Io and 20 years, none died. Add 2 deaths from suprapubic operation after uncom- pleted litholapaxy, and it makes 61 cases with 3 deaths; a mortality, of 5 per cent. The causes of death in the suprapubic operation were as follows: Four were due to shock, one of the four being an uncompleted lateral operation, and another an uncompleted litholapaxy. Two were due to infiltration around the bladder, one of these followed an uncompleted litholapaxy. Three were due to various conditions of the kidneys, pyonephrosis, hydronephrosis, and calculus. One death each occurred from pyemia, septicemia, bronchitis, and pneumonia. The author gives the following results in one children’s hospital : from 1870 to 1887, of 70 cases of lateral operation only 2 died, or 2.8 per cent. At the same hospital, from 1888 to 1893, 15 lateral operations were all followed by recovery, while 4 out of 7 cases of suprapubic operation died. One of these, however, followed an incompleted lateral operation. The author regards litholapaxy in children for small stones as a very facile and attractive operation, and it will probably run the 1ateral operation hard as the routine operation for young males. The high opera- tion will probably be reserved for large stones unsuitable for removal by the other methods. STERILIZATION OF CATGUT By BOILING IN OLIVE OIL. EASTMAN (Annals of Surgery, Vol. xx, No. 1, p. 56) experimented with the sterilization of catgut by means of hot olive oil. The following are his conclusions: Catgut can be rendered sterile by heating in oil to a temperature of 212°F. for three hours. The method is reliable, cheap, and rapid. The quality is not impaired, and gut so treated is more satisfactory as to strength and smoothness than if subjected to the ether-alcohol-bichloride process. A higher temperature than 212°F. is not necessary for sterilization, and is an injury to the gut. The material should be wound on reels or cylinders and not on anything with sharp edges. DEVICE TO FACILITATE MICTURITION IN PATIENTS WITH SUPRAPUBIC URETHRAE. LYDSTON (Journal of Cutaneous and Genito-Urinary Diseases, Vol. xII, p. 347) suggests that, in order to avoid soiling the clothes, patients who, after supra- pubic cystotomy, have some control over the urine should use a small glass funnel. The large end of this is pressed against the suprapubic opening and a small pad of absorbent cotton held beneath. By this means any little excess of urine is caught, and wetting of the clothing prevented. 8 II.4. Therapeutics. THERAFEUTICS: TJNDER THE CHARGE OF HORATIO C. WOOD, M.D., LL.D., AND ARTHUR A. STEVENS, M.D. THE PHYSIOLOGICAI, ACTIONS OF ALCOHOL. CERNA (Therapeutic Gazette, May and June, 1894) draws the following con- clusions from an elaborate study of the actions of alcohol: (1) Alcohol in small amounts excites and in large doses depresses both the peripheral motor and sensory nerves. (2) Excessive quantities cause a spiral degeneration of the axis cylinder of nerve-fibres. - (3) Reflex action is at first increased and afterwards diminished by an influence exercised by the drug upon the spinal cord and the nerves. (4) In small amounts the drug stimulates the cerebral functions; it afterwards, especially in large quantities, depresses and finally abolishes them. (5) Alcohol causes lack of co-ordination by depressing both the brain and the spinal cord. (6) In toxic doses alcohol produces hyperemia of both brain and spinal cord, especially of the lumbar enlargement of the latter. - (7) Small doses of alcohol produce increased rapidity of the cardiac beat; large amounts, a depression of the same. In either case the effect is brought about mainly through a direct cardiac action. - (8) The drug in small quantities causes a rise of the arterial pressure by a direct action upon the heart; in large amounts it depresses the arterial pressure similarly through a cardiac influence. (9) In large doses alcohol enhances coagulation of the blood; in toxic quan- tities it destroys the ozonizing power of this fluid, causing a separation of the hemoglobin from the corpuscles. - (Io) Alcohol in small doses has little or no effect on the respiratory function ; in large amounts it produces a depression of both rate and depth of the respiration through a direct action on the centres in the medulla oblongata. (II) The drug kills by failure of the respiration. (12) On the elimination of carbon dioxide alcohol exercises a varying action, sometimes increasing, sometimes decreasing, such elimination. (13) The action of alcohol on the amount of oxygen absorbed also varies, and may be said to be practically unknown. (14) The drug lessens the excretion of tissue-waste, both in health and disease. (15) In small amounts alcohol increases the bodily temperature; in large doses it diminishes the same. The fall of bodily temperature is due mainly to an excess of heat-dissipation caused by the drug. * (16) Alcohol, in sufficiently large amounts, has a decided antipyretic action. (17) In moderate amounts alcohol aids the digestive processes. (18) Alcohol diminishes the absorption of fats. (19) The drug exercises a varying influence on the amount of urine secreted, but it probably increases the activity of the kidneys. (20) In 1arge doses, or when continuously used for a long time, alcohol pro- duces cirrhotic changes, of hepatic tissues especially, and paralysis of spinal origin. It also causes insanity, epilepsy, and other maladies. Therapeutics. II 5 (21) Alcohol is mainly burnt up in the system when taken in moderate quan- tities, but when ingested in excessive amounts it is partly eliminated by the breath, the kidneys, and the intestines. (22) Alcohol is a conservator of tissue, a generator of vital force, and may therefore be considered as a food. HYPNOTICS IN MENTAL DISEASE. EvKNSEN (Norsk Mag. for Laegez/idenska/ben, No. 5, May, 1894) draws the following conclusions from his experiments with the various hypnotics in mental disease : Sulphonal was given to seventy-six patients in doses of I to I.5 grammes. It was found to be very reliable, but its protracted use was sometimes followed by unpleasant symptoms. It was most efficient in acute cases, mania, alcoholism, and active delirium. To avoid poisoning it is well to alternate it with some other hypnotic, such as chloralamide. Amylene hydrate is a mild hypnotic, especially useful in cerebral anemia. The sleep following its use is natural, but the drug is rather uncertain in its action. The dose is two to five grammes. Paraldehyde in doses of two to eight grammes, when employed for a short period, is without deleterious effects, but its continued use is sometimes followed by prostration and various nervous disturbances. Trional and tetronal are similar in their action to sulphonal. The dose of either drug is one gramme. Chloralamide in doses of two grammes was administered to forty-five patients. Although not very certain in its effect, it does not depress the circulation as much as chloral, nor does it often cause headache, vertigo, or vomiting. It acts favorably in senile dementia, but is valueless in conditions of great excitement. Somnal was employed in doses of from two to six grammes, but was very unreliable. Hyoscine was pre- scribed in seventy-six cases. Its action was prompt and reliable. When injected subcutaneously it induced sleep within half an hour, lasting five hours. It is useful in all conditions of excitement, and may be advantageously combined with sulphonal. It has little or no effect when administered by the mouth. It is harm ſess in doses under a milligramme. Its long use, however, is followed by cachexia. Duboisine in doses of one milligramme resembles hyoscine in its action, although it is less powerful. It sometimes causes hallucinations of sight. TRIONAL IN DELIRIUM TREMENS. BELLAMY (AVew York Medical Journal, No. 60, 1894) reports twenty-five cases of alcoholic delirium in which trional was used with advantage. The adjunct treatment consisted in the employment of a hot bath, a calomel purge, and in all cases forced feeding, the diet including milk, eggs, and soup. On admission twenty grains of trional mixed in water, with ten minims of tincture of capsicum, were administered. If the delirium still continued, ten grains more of trional were given in thirty minutes, and if this proved ineffective, twenty grains addi- tional were given in an hour. In nearly every instance sleep followed the admin- istration of fifty grains, and the pulse and respiration were stimulated. The author concludes as follows: (1) Delirium was controlled with greater rapidity and safety by trional than by other hypnotics. (2) In the majority of cases a marked stimulant effect was observed, possibly on account of the methylic and ethylic elements whichenter into the composition of the drug. II6 Therapeutics. (3) On account of the low temperature noted in all cases, trional must possess antipyretic properties, thereby simulating its allies of the phenol group. (4) It was always well borne by the stomach, and in one case was rapidly absorbed when administered per rectum. (5) No unpleasant after-effects were observed. STRYCHNINE IN WEAK LABOR-PAINS. DUFF (Wiener Medicinische Presse, No. 35, 1894) has obtained excellent results with strychnine as a prophylactic remedy in weakness of the uterine contractions attending parturition. When there is general debility, or a history of post-partum hemorrhage, or of feeble uterine power, he begins to administer strychnine six to eight weeks before the expected time of parturition. Up to the last week the dose prescribed is one-sixty-fourth of a grain thrice daily, during the last week this amount is increased to one-fortieth of a grain. THE THERAPEUTIC USES OF SPARTEINE. CERNA (AWeze, York Medical Journal, May 26, 1894) concludes from his own experience, and from a careful review of the literature of the subject, that spar- teine is a medicament of considerable power as a cardiac and renal stimulant, second only, it appears, to digitalis. The drug does not produce, as a general rule, any serious ill after-effects. It is best given by itself, though it may be advisable sometimes to administer it in combination with other remedies. Julliard calls at- tention to the fact that sparteine and sodium iodide are incompatible. Another important point is that of dosage. In this matter authors differ materially. Sée puts down the dose as two grains a day; Prior, from one-sixth to one-third of a grain several times daily; Tyson employs one-fourth of a grain every two hours, or one-half of a grain every four hours; Clarke gave it in amounts of one-six- teenth of a grain every four hours, and increased it to twelve grains a day without causing toxic effects. The writer believes in an emergetic method of administra- tion, using in some instances as high doses as one-half of a grain every three hours. He believes that large quantities must be used in order to insure the good effects of sparteine; small doses generally leading to disappointment. MALAKIN. GERMANI (Gaz. d. Ospedal, July 24, 1894) reports eight cases of acute artic- ular rheumatism in which malakin acted very favorably. He concludes that it is a useful antirheumatic remedy; that it is an excellent complement of the salicyl compounds, being unattended by the disadvantages of the latter preparations; that it has marked antipyretic properties, but is less powerful than antipyrin or antifebrin; that as an antineuralgic malakin is sometimes serviceable in sensitive subjects, but that generally it is much inferior to the older analgesics, antipyrin and phenacetin. FERRATIN. GERMAIN SAEE (Presse Méd., August 25, 1894), in a communication to the Académie de Médecine, states that even after prolonged use ferratin causes neither gastric nor intestinal derangement in men or animals. It acts as a slightjastringent without causing injurious stimulation, and it never causes the development of Obstetrics. I 17 H2S as the result of putrefaction in the intestine. Its local effect on the gastro- intestinal tract shows itself constantly in restoration of appetite and improvement in the quality of the stools. It is absorbed slowly, but animals weighing from five to seven kilos. have had to take from five to twenty litres of milk in order to absorb the same quantity of iron as could be conveyed in one-tenth to two-tenths gramme of ferratin. The dosage should be so regulated that the intest1ne shall always con- tain an excess of ferratin, which the organism can use according to its needs. There is no reason to fear the accumulation of an excess of iron in the organs; ab- sorption and elimination appear spontaneously to balance each other. Ferratin is, therefore, in the first place, an alimentary substance, and can be employed in men apparently healthy, or in children and chlorotic subjects, as the curative action is not interfered with by injurious secondary effects, as is often the case when ordinary ferruginous preparations are used. The dose of ferratin is from five centigrammes to one and a half grammes two or three times a day. Each dose contains about 7 per cent. of iron. ANTIPYRIN AS A VESICAL ANALGESIC. VIGNERON (Annales des Maladies des Organes Génito. Urinaires, No. 5, 1894) is convinced from its employment in three cases that antipyrin will prove to be a valuable vesical analgesic. Injected into the bladder the remedy is free from harmful effects, even when employed over a protracted period. As an antiseptic the author believes it to be superior to solutions of boric acid. When the solution of antipyrin is allowed to remain in the bladder, it not only relieves the pain but checks spasmodic contractions. A 4-per-cent. Solution left in the bladder for ten minutes is sufficient to diminish the pain attending subsequent washing or instilla- tion. Antipyrin may be employed in all cases of cystitis in which local treat- ment induces pain. When the bladder is not distended, two and a half to five drachms of a 4-per-cent. solution, left in the bladder for ten minutes, is sufficient. When the bladder is much distended, fifteen to thirty drachms of a 1- or 9%-per- cent. solution should be injected and allowed to remain in the bladder. O ESTETRICS. UN DER THE CHARGE OF BARTON COOKE HIRST, M.D., ASSISTED BY RICHARD C. NORRIS, M.D., AND FRANK W. TALLEY, M.D. ERYTHEMA AFTER THREE SUCCESSIVE DELIVERIES. GAERTIG (Centralblatt für Gymäkologie, No. 30, 1894) reports three labors in the same patient, all followed by severe erythema, although antiseptic precau- tions were taken. No intra-uterine injections were used. The first confinement occurred when the patient was 26 years old. The child presented by the breech. Delivery was followed by post-partum hemorrhage; the placenta was adherent, and had to be detached under chloroform. On the third day an erythematous rash I I3 - Obstetrics. set in, first appearing on the abdomen and spreading over the extremities. Itching was intolerable. There was neither sore throat, nor albuminuria, nor fever. One year and seven months later the patient was again confined. The placenta was again adherent and extracted as in the previous confinement. Very severe flooding occurred. On the following night the rash appeared again, accompanied with high temperature, but no sore throat nor albuminuria. The eruption became severe over the entire body, vesicles developed at some points, and recovery was slow; the patient became very enemic from the flooding. - The third delivery occurred sixteen months after. The period of pregnancy had passed uneventfully. She was delivered of a large, healthy, male child, and a similar post-partum hemorrhage and adherent placenta complicated the labor. Two days after the erythema appeared, and upon the abdomen as before. It spread to the legs and arms. The patient recovered at the end of nine days. On this occasion there was no fever. Gaertig insists that both erysipelas and scarlet fever must be excluded even in the second attack where fever alone occurred. UTERUS SEPTUS ; SIX PREGNANCIES. TARNIER (Journal des Sages-Femmes, March I6, 1894) has under observation a case in her sixth pregnancy, whose previous history is as follows: First preg- nancy, live child delivered in seventh month ; it died in a few minutes. Second delivery at beginning of seventh month; child lived three months. Third delivery in seventh month ; child is living. Fourth delivery at term ; child lived six months. Fifth pregnancy (twins); abortion in the fourth month. The patient was sent into Tarnier's wards in the sixth month of her sixth pregnancy. Flood- ing had set in, and placenta previa had been diagnosed. Vertex presentation was discovered, and the fetal heart-sounds were audible. There was prolapsus vaginae. A thick ridge ran down the anterior vaginal wall. A prominent swelling could be felt in the left fornix, which had been taken for placenta. On careful exploration a distinct opening was detected in it. The finger could pass nearly one inch up this orifice, which was separated by a distinct septum from the dilated os of the pregnant half of the uterus. Next day a clot was expelled from the non-pregnant cavity, and it as rapidly contracted. The pregnancy continues. In short, the flood- ing was simply menstruation continuing in the non-pregnant half of the uterus. Tarnier suspects that many cases of menstruation continuing during pregnancy can be explained in this way. When the vagina is double as well as the uterus, diagnosis will be difficult. Tarnier was once called in by a colleague to see a patient in labor. The cervix seemed like that of a non-pregnant uterus. At the consultation the vagina was found to be double, and a well-dilated cervix was dis- covered. The same observer has seen pregnancy alternately in the right and left half of a double uterus. The non-pregnant uterus appeared like a cyst. Twin pregnancy in one cavity and simultaneous pregnancy in both cavities of a double uterus have been recorded. SYMPHYSEOTOMY IN PRIVATE PRACTICE. The feasibility of performing symphyseotomy without special apparatus or trained assistants is shown in the report of a case by WALLICH (Annales de Gymé. cologie et d’Obstetrique, August, 1894). The patient was 32 years of age, V-para, under medium height, and stout. She gave no history of rachitis, nor were there physical signs of such disease. In her first pregnancy she was delivered at term of a living child, weighing 1750 grammes, after twelve hours labor. The second Obstetrics. I IQ pregnancy terminated in a miscarriage at two and a half months. In the third pregnancy she was delivered spontaneously of a living child, weighing 2250 grammes, after a labor lasting two and a half hours. Her fourth labor was instru- mental, the forceps being applied after forty-eight hours at the superior strait. The child, weighing 3300 grammes, lived. The present labor had existed twenty- four hours when she was seen by Wallich, the dilatation being, at that time about the size of a five-franc piece. The membranes then ruptured, and the amniotic liquor was noticed to be greenish in color, the heart above the brim, and showing no tendency to descend. On the following day the patient was again seen by Wallich, and found very excited, the pains vigorous, and the fetal heart-sounds good. The fetus was presenting by the vertex with Naegele's obliquity. The anterior aspect of the sacrum was accessible, but the promontory could not be reached on account of the fetal parts. Three hours later, the dilatation being complete, the patient was placed in the obstetrical position upon a case of drawers. Two physicians, a nurse, and the husband assisted the operator. The patient was anesthetized and forceps applied under antiseptic precautions upon the head still above the pelvic brim. Not securing descent after his first effort, Wallich performed symphyseotomy at once. The cartilage and subpubic ligament were divided while the forceps was in position. The pubic bones separated four centimetres at once, and during traction upon the resisting head separated five and a half centimetres. The head readily descended, was delivered living, and weighed after extraction 3810 grammes. The placenta was next extracted, and an intra-uterine douche administered. During the delivery of the placenta and the douche the wound had been plugged with iodoform gauze. This was removed and the edges sutured when the pelvis was encircled with a plaster-of-Paris bandage. During the night the patient was left upon the chest of drawers. Next day she was removed to her bed. Scrupu- 1ous cleanliness and antisepsis were practised, the wound being dressed twice a day, while the external genitals were douched after every micturition and defeca- tion. On the eighth day the deep sutures were removed, and on the following day the superficial ones. The plaster of Paris belt was removed on the thirteenth day. On the twentieth day the patient was able to rise, and walked without pain. The child was suckled from the first, and six weeks after the operation both were flourishing. The sacro-subpubic diameter was found to be Io.7 centimetres. The promontory was very high. The fetal head measurements were as follows: Biparietal, 9.4 centimetres; bitemporal, 18.2 ; suboccipito-bregmatic, 9.9; sub- occipito-frontal, II.6; occipito-frontal, 12. I ; occipito-mental, 14 The operation was indicated by Naegele's obliquity, the volume of the head, and the contraction of the pelvis. Wallich thinks that persistent attempts at ex- traction with forceps would have injured the child's skull. LActATION ; ATROPHY OF THE UTERUS. ENGSTRöM (Centralblatt für Gynākologie, No. 38, 1894), referring to the simple general anemia common in lactation, especially if protracted, states his belief that this accounts for the overinvolution of the uterus, or practically uterine atrophy. He is not a believer in special tropho-neurotic action of the act of suckling on the pelvic organs. That function, he claims, does not set up con- traction of the uterine fibres, and consequent absorption of its tissues. I 2G) Gynecology. GYNECOLOGY. UNDER THE CHARGE OF WILLIAM GOODELL, M.D., AND CHARLES BINGHAM PENROSE, M.D., ASSISTED BY WILLIAM A. CAREY, M.D., AND H. D. BEYEA, M.D. SENILE ENDOMETRITIS. A. J. C. SCENE (American Journal of Obstetrics, April, 1894) considers this condition quite different from the endometritis of early life. While in some cases it probably is a continuation of an inflammation which existed prior to the meno- pause, it is not so in the majority of cases. The disease may be limited to the cervical canal, but usually it includes the entire mucosa. It is usually suppura. tive, the discharge being sero-purulent, and when it begins as a catarrh it usually progresses to the suppurative form. The epithelium of the endometrium becomes almost entirely lost; granulations of low vitality spring up ; minute extravasation of blood are seen with small pigmentspots, atrophy of the muscular tissue was present and caused inversion of the mucous membrane; laceration of the cervix frequently existed; stenosis of the internal or external os was often present; pus would be discharged and again accumulate. When the disease had existed long enough to destroy the mucous membrane it might end in cicatrization, but it could scarcely be called self-limiting. Displacement, 1aceration of cervix, and a continuance of endometritis existing from early life are some of the causes of this tribute. Inat- tention to cleanliness, also fibroma, may cause it. The treatment consists of the use of the douche of the solution of borax or sulphate of zinc if the inflammation is confined to the cervix. Medicated tampons, astringent and alterative applica- tions are helpful, but no caustics. Iodoform applied in the uterine cavity is very efficient, but its odor is objectionable. Complete closure must be overcorne when it exists, and dilatation and drainage performed. Dilatation must be done gradu- ally by graduated dilators. The complete removal of the uterus may be justi- fied after other measures have been tried and failed, and when complete prolapsus exists vaginal hysterectomy is the proper treatment. O ENDOMETRITIS OF THE MENOPAUSE. JAcOBS (Archives de Tocologie et de Gynekologie, November, 1893) describes the pathological steps in this process as an arterio-sclerosis, followed by a diffuse sclerosis, causing atrophy of the unstriped muscle-fibre, which gradually becomes absorbed and replaced by fibro-cellular tissue. The uterine mucosa diminishes in thickness after the climacteric, its cells atrophy and undergo changes in shape, and the protoplasm is occupied by fatty granules. These conditions may cause ar, endometritis or some malignant degeneration. In endometritis the uterus is found to be hard and somewhat enlarged, with a hypertrophied, granular cervix, having swollen, everted lips. The mucous membrane of the vagina and vulva is apt to be inflamed and sensitive, and there is rectal and vesical tenesmus. The cervix is sometimes occupied by polypi which cause abundant hemorrhage. These inflammatory disorders may have originated independently of the menopause, or may have come on at that time or soon afterwards. It is quite certain that the sudden and premature cessation of menstruation is a predisposing Gynecology. I 2 I cause of inflammation, and many other causes combine to produce it, particularly if there be a rheumatic, arthritic, or diabetic diathesis. The symptoms of this condition are at times quite misleading, and cause mistakes to be made in favor of cancer, from the fact that the general health deteriorates quickly, and there is in some cases a fetid discharge alternating with hemorrhages, which may become alarming. The fetid discharge of the endometritis is due to the fact that the leucorrhea is discharged slowly and has difficulty in escaping, and thus has time to decom- pose. The discharge is muco-purulent, while in carcinoma it is serous, limpid, and abundant. Hemorrhages are the rule in carcinoma, while in endometritis the bleeding is infrequent. The pain in endometritis may be quieted by rest, whereas everything fails to quiet it when due to cancer. Endometritis may last for years with continued 10cal and general aggravation of the symptoms, which, of course, would not obtain in cases of malignant disease. The characteristic induration of the cancerous cervix is absent in endometritis. The vegetations on the cervix in papillary cancer are soft and bleed readily upon the slightest touch, while the hypertrophied cervix of endometritis is somewhat elastic. In certain cases the diagnosis can be made only through the aid of the microscope. In reference to treatment, the author's advice is to pay particular attention to the upbuilding of the general health, after thoroughly curetting the endometrium, which should be followed by rational local treatment. THE ADVANTAGE OF ATMOSPHERIC DISTENTION OF THE RECTUM, WITH DIS- LODGEMENT OF THE SMALL INTESTINES, IN THE BIMANUAL ExAMINATION OF UTERUS, OVARIES, AND TUBES. HowARD A. KELLY (American Journal of Obstetrics, May, 1894) suggests a procedure for overcoming the embarrassment experienced by the crowding of the small intestines down into the pelvis and the consequent liability of making a false diagnosis of pelvic disease. Coils of small intestines in the pelvis containing fluid often feel tense and fluctuating, and thus readily impose themselves upon the examiner as large cystic ovaries, or leave him in doubt as to their true nature. The complete removal of these impediments may be satisfactorily effected in the following manner: The patient is placed in the knee-breast posture, with shoulders on the table and hips high and thighs vertical. The anal orifice is opened by a small speculum or tube, allowing the air to rush into the rectum. The explanation of this phenomenon is that, upon assuming the knee-breast posture, the small intes- tines gravitate along the anterior abdominal wall into the upper abdomen towards the diaphragm, creating a suction at the most elevated portion, which is the pelvic extremity, by means of which the whole ampulla and rectum balloon out with air as soon as the anus is opened, and the distended rectum applies itself broadly over the posterior surface of the uterus and left broad ligament. Before making such an examination, both rectum and bladder must be thoroughly emptied. Immedi- ately after filling the rectum with air the tube is removed, the patient placed in the ordinary dorsal position with limbs flexed upon the abdomen, and the bimanual examination made per rectum and abdomen. The index finger introduced within the anus experiences at once the sensation of entering a large cavity filled with air, in which the customary resistance is absent. The communication with the upper bowel between the utero-sacral folds is, under these circumstances, readily found, and the finger is conducted behind the broad ligament, when, on using the outside hand in assistance, uterus, broad ligaments, ovaries, and tubes are at once palpated directly through the rectal wall, without resistance and with startling I 22 Gynecology. distinctness. The true pelvic viscera thus seen, as it were, to be skeletonized in the pelvis, lying so clearly exposed to touch that the minuter surface peculiarities, fissures, and elevations, and changes in consistence, can be detected, and a diag- nosis made more satisfactorily, more rapidly, and with far less effort than under ordinary conditions. PERIVAGINITIS SIMPLEX J. J. E. MAHER (Medical Record, March 31, 1894) gives the above title to a condition which he considers a new disease of the vagina. The patient was 23 years old, married one year, and had been delivered of her first child nineteen days before the author saw her. He was called on account of “puerperal hemor- rhages and painful sitting.” The bowels were liquid and very offensive, and had been moved daily since the third day after labor. The patient’s temperature was Ioo” F., pulse I2O, and skin clammy. She was pale, weak, and had an anxious, worried expression. There were restlessness, insomnia, painful sitting (as though she were sitting upon an apple), and a disagreeable succession of liquid in the pelvis on moving suddenly in the horizontal position, with a discharge of blood from the vagina on assuming the erect posture. The physical signs are thus de- scribed : The entire perineal body possessed a brawny hardness and was lacerated about a centimetre. The laceration presented thickened, everted, indurated lips that could not easily be approximated. The labia in coaptation presented nothing unusual ; but when separated, the visual field beyond was astonishing. The vagina formed a rigid tube, all agape, with the cervix and os uteri distinctly visible at its upper end. One would have thought an invisible speculum held the walls of the vagina apart. The mucous membrane was apparently unaltered. Pressure on the perineum caused pain and was identified with the painful sitting. The same pain was produced by pushing the uterus towards the vulva; but the uterus could be pressed into other quarters without causing any pain. Exploration per rectum discovered a fecal tumor which was pressing upon the uterus, chiefly on the cervix. This was removed and was excessively fetid. The uterine cavity was gently curetted, following which the bleeding ceased and the laceration of the perineum was treated as an ulcer by the placing of glycerin tampons. No speculum was required for these manipulations as the vaginal walls were rigid and separated. Three days later the vaginal walls had collapsed at the upper end to such an extent as to almost hide the cervix from view. The remainder of the induration melted away in a few days and the patient gradually convalesced. The etiology of the disease, in this case at least, can be apprehended and demonstrated only on the assumption that the fecal mass existed before delivery, and that the child's head was forcibly dragged over it. This mechanical extreme distribution of either the rectum or vagina, considered sep- arately, might be easily regarded as within the scope of the functional laws of either organ, and thus be reckoned as within physiological bounds; but if it is possible for either organ to be distended beyond the natural limit, the distention of the two organs synchronously rarely exceeds the restrictions of physiology and enters the domain of pathology. The recto-vaginal cellular tissue becoming over- strained and being subjected to the infecting influences of the decomposing fecal mass, is overstimulated in the process of repair. The ensuing proliferative exu- dation, exceeding the normal limits of repair, spreads to the contiguous elements surrounding the vagina, induces thickening to a remarkable degree, and thus establishes the inflammation under consideration, Pathology. I 23 |PATH OLOGY. UNIDER THE CHARGE OF JOHN GUITÉRAS, M.D., ASSISTED BY JOSEPH McFARLAND, M.D. THE CULTIVATION OF THE GONococcus, AND ARTIFICIAL GONORRHEA. TURRO (Centralblatt für Bakteriologie und Parasitemkunde, July 2, 1894, Vol. xv.1, No. 1) in an important paper comprehends the following three subjects : (1) The Cultivation of Gomococci in Acid Culture-Media.-Gonorrheal urine is alkaline, but speedily becomes acid when the contained pus sediments. Turro noticed that when such urine is placed in the incubator for twenty-four hours, the clear supernatant fluid contains an almost pure culture of gonococci, while the sedimented pus is in a part of the liquid where luxuriant growths of streptococci and other bacteria take place. This is described as dependent upon the acidity of the urine, for it is said that as soon as the urine is neutralized the growth of gono- cocci ceases. The vegetative value of the urine for gonococci can also be much improved by the addition of 4 per cent. of Catillon's peptone-powder, provided the acid is not neutralized. Fresh sterilized urine, with or without the addition of peptone, makes an excellent culture media for the gonococcus. The gonococcus also grows well in Io per cent, gelatin, if acid, especially if A to I per cent. of peptone is added. The growth appears as a white line, never associated with liquefaction. Plate cultures are perfectly characteristic. The colonies appear as white points, which later elevate themselves like ivory hemispheres above the surface of the gelatin. The gonorrheal pus is a powerful poison for the gonococci, causing cessation of growth and involution forms. Pus twenty-four hours old does not grow any better upon acid gelatin than upon neutral or alkaline, so that for the cultivation of the organism absolutely fresh pus must be selected from new cases. It is to be observed that the rapid development of alkalinity following the growth of the gonococcus is an aid to the contamination of the culture by allowing the development of such streptococci, etc., as grow best in alkaline media. (2) Artificial Gomorrhea.—Gonococci cultivated in acid media, as described, unlike those cultivated in neutral or alkaline media, are highly virulent for dogs. Such is the peculiarity of the virulence of this organism that neither an injury to the mucous membrane of the urethra, nor actual introduction into the urethra are necessary for the production of the disease. All that is required is that the culture used for inoculation be touched to the meatus urinarius. It is, in fact, the only microbe capable of causing disease and entering the body without any breach of tissue continuity. - (3) Microscopic Examination of the Gonococcus of Dogs.—The organism appears as a diplococcus, which absorbs ordinary dyes like a sponge, but imme- diately decolorizes when treated with iodide of potassium, iodine, and alcohol. Its size and, indeed, all its peculiarities are identical with the gonococcus of Neisser. I24 Aathology. THE INJECTION IN PNEUMONIA AND TYPHOID FEveR of SERUM FROM CONVALESCENTS. HUGHES and CARTER (Therapeutic Gazette, June 15, 1894), following the line of experimentation suggested by the Klemperers and others, injected fourteen cases of pneumonia and three of typhoid fever with the serum obtained from patients convalescent from the same disease. All the cases from which the serum was obtained were carefully selected, and of unquestionable diagnosis. All the cases of pneumonia exhibited numbers of pneumococci in the sputum, the viru- lence of these organisms always being tested. It would be expected that cases treated in the same manner with serum from such cases as described, none of them being more than two weeks past the crisis, would give results of comparative uni- formity. Such, however, was not the case. Some showed success, others decided failure. Of ten selected cases only five can be claimed as distinctly proving any success due to the immune serum. In one case crisis followed the injection, but was probably not due to it. In three of the cases where no effect was produced, the failure is explained by the fact that one of them was a negro (in the negro's sputum the diplococci seem to be distinctly more virulent than in the sputum of a white man, the same probably being true of the lungs, where a larger dose of the antitoxic serum would be required); in another the pneumonia proved at autopsy to be of a peculiar character, more resembling broncho- than lobar pneumonia; while the last case remained inexplicable. The lack of action of the immune serum in certain cases is ascribed to (1) A duality of diplococci causative of pneumonia. (2) Variation of the toxines. The toxines, however, are constant concomi- tants of the growth of bacteria, and while under differing conditions of inherent qualities or environment, it is possible that the toxines are secreted in varying pro- portions, yet it is not likely that the average proportions would ever be so rudely disturbed as to lead to total failure of a neutralizing agent to act. The toxines must always be the same, therefore this hypothesis is not to be entertained. (3) The inadequacy of the antitoxic theory. Neutralization of the toxines is not necessarily cure. Neutralization is merely a step in the production of immu- nity, and its causes must be sought deeper down. While, therefore, it cannot be doubted that immune serum may have a most pronounced effect, yet the irregu- larity of its action certainly suggests strongly that there are important factors other than the antipneumotoxine concerned in the production of the crisis, and the subsequent immunity,+factors probably to be found in some condition of the cells rather than that of the blood serum. From a therapeutic stand-point the results were disappointing. In the ten cases where perfect serum was used there were three deaths, about the ordi- nary death-rate from pneumonia. While disappointing, they are harmless, no bad effects following them. s º Three cases of typhoid were tried, all recovering in an unusually short time, but as all the experiments were made upon very mild cases, it is difficult to esti- mate the value of the serum-therapy. THE MANUFACTURE AND USE OF THE DIPHTHERIA ANTITOXINE. EHRLICH, KossEL, and WASSERMANN (Deutsche medicinische Wochenschrift, April 19, 1894, No. 16). For the preparation of diphtheria antitoxine these exper- imenters prefer the goat to all other animals, because of the considerable natural resistance which the animal shows to the disease. The goat is first rendered immune by the injection of increasing quantities of dead diphtheria bacilli, until Miscellaneous. I25 it becomes accustomed to the toxines, and is able to overcome them. When this condition is developed gradually increasing doses of live bacilli are injected, until considerable quantities of exceedingly virulent cultures can be tolerated without injury. In order to have a definite standard by which to judge the value of the goat's serum as an antitoxic, the investigators made use of the discovery of Behring and Kitasato, that when the micro-organismal toxines and antitoxines are mixed in a test-tube, the proper relative amounts produce a neutral compound devoid of toxic properties. Most previous observers making use of the antitoxic principle injected it simultaneously, but separately, into the control animals. Ehrlich, Kossel, and Wassermann, however, observed that when this is done considerable time elapses before the antitoxine circulating through the system is able to act upon the toxine, thus being an inferior method of its employment to the mixed solution. In order to obtain a standard toxine, 9% per cent. of phenol is added to an old bouillon culture of the diphtheria bacillus. A toxine so virulent may be thus obtained that in doses of O.3 per IOOO grammes of body weight, it is constantly fatal. The value of the antitoxine is determined by the addition of O.4, O.3, O.2 grammes of the serum from the prepared goat to the dosis lethalis for a guinea-pig, diluting the mixture to four cubic centimetres, by adding physiological salt solu- tion, then injecting it into guinea-pigs. Upon the next day the occurrence or absence of induration at the seat of inoculation, as well as the consideration of the weight of the animal, must be the key to the amount of the antitoxine neces- sary to neutralize the toxine. t Ehrlich found that the antitoxine is present in the milk as well as in the serum of the goat, but that a relatively greater quantity of it must be used to neutralize the toxine. Two hundred and twenty children, in various Berlin hospitals, were subjected to the antitoxine treatment, the results being such as to indicate a distinct value of the serum-therapy. It is essential that the cases chosen for treatment shall be in the early days of the disease, as less improvement was observed in old than in fresh cases. MISCELLANEOUS. FOR THE SCIENTIFIC STUDY OF APPENDICITIS. AT the last meeting of the Board of Managers of the University Hospital the Director was authorized to set aside certain beds to be used by Professors William Pepper and J. William White for cases of appendicitis, those gentlemen being engaged in a special investigation of the symptoms, treatment, and pathology of that disease. Each case admitted to these beds will thus be studied from the outset with refer- ence to both its medical and its surgical features. It is hoped that the results may aid in clearing up the prevalent differences of opinion as to this malady. I26 Book Motices. CORRESPONDENCE. Bditors of UNIVERSITY MEDICAL MAGAZINE : DEAR SIRS : For the purpose of securing reliable statistics on the subject of the marriage of syphilitics, I desire to enlist the assistance of those of your readers who have had experience which will be of value in determining the period when this disease ceases to be commu- nicable and inheritable. I shall therefore esteem it a great favor on the part of any physician who will send me answers to the following ques- tions, and due credit will be given in a future publication to those who desire to aid me in this work. (1) What is the latest period from the date of the initial lesion that you have known the disease to be communicated by a patient who has been from the first under your observation ? (2) What is the latest period from the date of the initial lesion that you have known : (a) a syphilitic man, or (b), a syphilitic woman to become the parent of a syphilitic child 2 - (3) Have you ever known syphilis to be either communicated or handed down at a later period than four years from the date of initial lesion by an individual who has been constantly under your observa- tion during that time 2 In answering these questions I should like a brief but complete history of each case, and an account of the treatment that has been pursued. - I hope by this means to obtain the experience of a large number of observers, and to reach a fairly reliable conclusion as to the time when we may safely permit our syphilitic patients to marry. Yours very truly, BURNSIDE FOSTER, M.D. LowRY BUILDING, ST. PAUL, MINN. BOOK NOTICES. A SYSTEM OF GENITO-URINARY DISEASEs, SYPHILOLOGY AND DER- MATOLOGY. By various authors. Edited by PRINCE A. MOR- Row, A.M., M.D., Clinical Professor of Genito-Urinary Diseases in the University of New York, etc. Vol. III. Dermatology. New York: D. Appleton & Company, 1894. . This, the concluding volume of Dr. Morrow’s system, fully main- tains the general excellence of the two which preceded. The work is Book AVotices. 127 devoted entirely to dermatology, the subject having been divided between twenty-seven contributors well known in connection with this branch of medicine. Part I is devoted to general considerations of the subject. The first article, naturally, treats of the anatomy of the skin. This is followed by a brief consideration of the physiology; both of these por- tions are from the pen of Louis Heitzmann and show the marks of care and thoroughness in their preparation. Semeiology has been well pre- sented by Prince A. Morrow, and Etiology and Diagnosis by William A. Hardaway. The perplexing subject of classification has also been contributed by Dr. Morrow. Crocker’s modification of Hebra’s classi- fication has been adopted, with some changes. The list will be found very comprehensive, many new diseases appearing in the table. The acute specific eruptive fevers receive brief but sufficient notice, inasmuch as these diseases usually come to the physician rather than to the dermatologist. Hyperemias have been dropped as a sepa- rate affection and have been grouped under “inflammations.” The dis- tinction between hyperemia and inflammation is, however, maintained by ‘‘erythema hyperaemicum seu simplex” and “erythema exudativum.” The division of erysipelas into “idiopathic” and “traumatic” has been also dropped, it being considered that the streptococcus of Fehl- eisen is the only cause of the disease. In the treatment of erysipelas, local medication is most depended upon, especial preference being given for ammonium ichthyol. The results “appear to be immediately and surprisingly beneficial.” “Erysipeloid” will be new to many readers. It is defined as an erysipeloid inflammation of the skin, which develops in a wound as the result of its infection with certain special micro-organisms found in dead or decomposing animal matter. The specific germ probably belongs to the family of the cladothrix. Rosenbach has succeeded in producing typical erysipeloid by inoculation of pure cultures. The symptoms developed usually within forty-eight hours. Erysipelas, rysipeloid, and other sections were contributed by George T. Elliot. Furunculosis, carbunculosis, anthrax, etc., has been assigned to S. Politzer. He expresses the modern views on these subjects. It would seem, however, that some mention should have been made of the auto-inoculability of “boils,” and of the value of antiseptic appli- cations, which is not referred to, except in the cases where incision has been practised. In “hot cataplasms” the addition of an antiseptic would be valuable. In the treatment of carbuncle, the author says excision is most to be commended. The only other methods to be recommended at all are incision and parenchymatous injections. We are in accord with the statement that a poultice actually favors the spread of a carbuncle, while the use of ice is no more serviceable. The sections on impetigo, impetigo contagiosa, ecthyma, and dermatitis herpetiformis were written by H. W. Stelwagon. The latter subject has been particularly ably treated, while the former concisely represent what is known of those diseases. Eczema is likewise exhaustively considered by H. G. Pifford, and is justly called the most important affection of the skin. Psoriasis is very satisfactorily pre- sented by William Thomas Corlett. In this disease, arsenic was I 28 Book AVotices. formerly considered the most efficient remedy, but we are now told that local treatment plays the more important part in the medication. The chapter on dermatitis medicamentosa is from the pen of the editor. No less than seventy-six drug eruptions are described. The articles on lentigo, chloasma, keratosis, callositas, verruca, ichthyosis, scleroderma, elephantiasis, etc., by James Nevins Hyde, are worthy of praise. A prominent feature is the exhaustive bibliography following the different subjects. & We cannot pretend to have exhausted in any sense the valuable contributions of the many other distinguished authors, which is pre- cluded by the size of the work. Suffice it to say that each one has performed his part well, and the more than two hundred subjects have received thorough consideration without the introduction of any superfluous matter. The numerous plates and chromo-lithographs throughout the book illustrate many rare and typical conditions. Dr. Morrow has accomplished the task of arranging this vast mass of mate- rial with much credit. The mechanical execution is all that could be desired. This is one of the most valuable systems that has appeared, and will doubtless remain the standard work on the subjects of which it treats for some time to come. RECHERCHES ETHNOLOGIQUES SUR LE MORVAN. Par A. Hov E- LAcquE et G. HERVí. Paris: Librairie, Georges Masson, 1894. The Mémoires de la Société d'Anthropologie de Paris are examples of the excellent work done by French scientists, shown in the com- prehensive view of the field under investigation, thorough examina- tion of the matériel, accurate description in detail, concise summary of results, with philosophic deductions from recorded data and practical applications for improvement. - An instance of this is the above-mentioned publication concerning the district Morvan, whose population is essentially the same as that of the central plateau of France, with which it is contiguous. The volume contains some two hundred and fifty pages, with appendices and notes, bibliographic, geologic, geographic, pre-historic, historic, linguistic. To aid in the comparative study of the Morvan inhabitants, a sufmmary of the general ethnology of France is given, as established by a series of observations made on exhumed crania, et al., during the last sixty years. From these it results that the basic race is Keltic (alias Gallic), to which has been added elements from the Kimric (alias Anglo-Saxon), a people allied to those of Indo-European speech in various lands. Part First treats on the territorial limits of the region in question, topography, geology, flora, fauna, and its politico-economic conditions under previous régimes, as to the manner of living of the inhabitants, government, agricultural and commercial products, etc., with tables making known the increase and decrease in population from 1801 to 1891. The advent of the indigenous race is fixed at the fourth century, B.C., the periode celtigue, which corresponds to the bronze age. A wondrous change has been brought about during the last fifty years through the opening of new and good roads. This, however, tends to Avok AVotices. I 29 destroy the purity of the race, by affording the natives means of egress from their mountain home, and facility of approach for those of the world outside. The Second Part refers to portions of the country in detail, touching archeology, ancient ethnology, statistics of population, with descrip- tions of the various parts of the human body, color of the hair, eyes, —e.g., as ascertained in the different localities. In Chapter Seventh (of this part) are remarks on physiognomy, psychology, language, and the influence of communication with foreign races in modifying this people so long isolated as regards the various phases of social life. From numerous observations and comparisons the authors conclude that the population of Morvan, with that of France in general, has lessened as the conditions of existence were ameliorated. This seems to be explained by certain social features. In making up the ethnic diagnosis they think that the stature of the original Morvandeaux has been increased in height by the admixture of Kimric elements. Stature is generally recognized as a typical racial manifestation. This volume contains also various illustrative maps, tables of measurements from different observers, photographs of typical faces, etc. Numerous quotations and notes show Latin of 1676, and forms of French at successive stages of evolution. The authorities given as references are both old and recent : Latin, Italian, German, Russian, in which may be found further bibliographic information. The name Morvan (referred to in an appendix) has its origin, possibly, in mor, meaning black, and van or vand, meaning mountain, being thus equivalent to black hills. A similar country in Scotland is called Morven ; both these languages and peoples are Keltic. How- ever, there is a region in Eastern Russia, near the upper Volga and the Oka, whose inhabitants, of Finnish race, are called Mordvin. More- over, the photographs given in this work resemble the faces of Asiatic Muscovites; and our authors state that in Morvan the equine race is almost identical with the horses of to-day on the Siberian steppes. Tacitus says that a people of Gaul, the Boii, passed into Italy, and thence into Germany, where they gave their name to Bohemia [v. Tacitus et Vellei). Inasmuch as the Bohemians are a Slav race, this may be another presumptive evidence indicating the common provenance of Gaul and Russian, and help to explain the name Morvan. Under the Romans some Sarmatians (Russians to day) were settled in Morvan. Camper states that he noticed a similarity in form, stature, etc., between the women of Holland and those of Oriental countries. One of the references is to a paper by Bogdanov, entitled, “Which is the Oldest Race in Russia P’’ an extract from the first volume of the Transactions of the International Congress for Archeology, Anthro- pology, etc., Eleventh Session, Moscow, 1892. Such things make one hesitate ere forming a judgment, and suggest a similarity of origin in the far away antiquity. L’Esprit de critique is well exemplified by the comparisons and opinions given in various portions of the volume. The work of Gaston Boissier and others (in the Université de Prance) may be cited as illustrative of similar productions in linguistics. I3O Aook AVotices. THE JEWISH METHOD OF SLAUGHTER COMPARED WITH, OTHER METHODS FROM THE HUMANITARIAN, HyGIENIC, AND ECONOMIC PoſNTS OF VIEw. By J. A. DEMBO, M.D., Physician to the Alex- ander Hospital, St. Petersburg; Member of the St. Petersburg Med- ical Society; Member of the Society for the Preservation of Public Health, etc. Translated from the German with the Author’s Amendments. Published by the trustees of the late J. A. Frank- lin. London : Kegan Paul, Trench, Trubner & Co., Limited, I894. It cannot be questioned that slaughtering animals for food pos- sesses considerable interest for the sanitarian. The subject has been discussed from time to time from a scientific stand-point, as well as that of personal preference, but we believe it has never before been so carefully studied, and so impartially presented. The question is considered under the following heads: (a) From the point of view of humanity. (b) From the point of view of hygiene. (c) From the point of view of economy. The observations are based upon the killing of nearly 4ooo animals by different methods, and reveal some inter- esting points. The conclusion is reached that in the Jewish method of slaughter the minimum amount of suffering is inflicted, while the keeping qualities and the healthfulness of the meat are much in- creased. The book cannot fail to interest all who are concerned in the promotion of hygiene. ESSENTIALS OF PRACTICE OF PHARMACY. By LUCIUs E. SAYRE, Ph.G., Professor of Pharmacy and Materia Medica in the School of Pharmacy of the University of Kansas. Philadelphia : W. B. Saunders, 1894. This is one of the question compends, and is made to conform to the 1890 revision of the United States Pharmacopeia. Among the additions in the present volume may be mentioned the following: An Outline of Drug and Plant Analysis, Structural Formulae of Organic Carbon Compounds used in Medicine, Pharmaceutical Testing of In- organic Chemicals, and Problems in Allegation and Specific Gravity. The student of pharmacy will find this a useful book in reviewing the didactic and practical instruction. TO CONTRIBUTORS AND SUBSCRIBERS. All Communications to this Magazine must becontributed to it exclusively. Reprints will be furnished free to authors of articles published among the original commu- nications, provided the order is distinctly stated upon the manuscript when sent to the Editorial Committee. Type-written copy preferred. Contributors desiring extra copies of their articles can obtain them, at reasonable rates, by gºing to the General Manager immediately after the acceptance of the article by the Editorial Contributions, Letters, Exchanges, Books for review, and all Communications relating to the editorial management, should he sent to the Editorial Committee, 214 South Fifteenth Street. Alterations in the proof will be charged to authors at the rate of sixty cents an hour, the amount expended by journal for such changes. Subscriptions and all business to UNIVERSITY OF PENNSYLVANIA PRESS, 716 Filbert Street, Philadelphia, Pa. UNIVERSITY MEDICAL MAGAZINE. DECEMBER, 1894. THE WORK OF THE GYNECOLOGICAL CLINIC OF THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA, 1893–1894.' BY CHARLEs B. PENROSE, Professor of Gynecology in the University of Pennsylvania. I HAVE presented this paper to the college not to give a number of statistical tables and reports of cases, but because several general con- clusions can be drawn from the work of the clinic, which I hope will be of interest to others than specialists in gynecology. The cases which seem best suited for the instruction of a large number of students are those which require the operation of celiotomy, and for this reason nearly all the operations performed at the gyne- cological clinic have been of this character. The various plastic opera- tions upon the perineum, the vagina, and upon the uterus through the vagina can be seen with advantage by but a few students at one time, and, consequently, all these minor operations are reserved for ward- class instruction. Many physicians and a good many students, at first, have the im- pression that a clinic at which repeated celiotomies are performed pre- sents nothing of interest beyond the mere details of the operation, and that instruction in such clinics covers only the general and special operative technique. This is a mistake. The instruction in the operative technique of celiotomy is of very minor importance to undergraduate students; and cannot compare in value to the instruction derived by viewing, through a celiotomy, diseased structures in place, or their examination when fresh, immediately after removal. The students have an opportunity of observing the history of the patients before the operation,-in many 1 Read before the College of Physicians, Philadelphia, November 7, 1894. 9 I31 I 32 Charles B. Penzose. * cases of examining them in the ward classes beforehand; and after this introduction the study of the pathological specimens removed at the clinic has much increased interest and value ; confirming or upset- ting the diagnosis, and shedding light on all the objective and subjec- tive symptoms which the patient had presented. A clinic of this kind instructs in a way analogous to an autopsy. The particular technique of the operation is of value only to specialists. It is remarkable what a great variety of diseases of women are pre- sented for study through the operation of celiotomy even in a limited number of cases. Forty-six celiotomies were performed at the clinic last winter, and these are some of the diseases which were studied : extra-uterine pregnancy, oëphoritic, paroëphoritic, and papillomatous cysts. All the various forms of ovaritis and salpingitis, tuberculosis of the internal genitals, fibroid disease of the uterus, myxomatous degeneration of the uterus, cancer of the uterus, -both of the fundus and cervix, etc. t Clinical instruction by means of celiotomy is not given at the expense of an increased mortality. The mortality, after celiotomy, in the general clinic-room of a clean hospital is not necessarily any greater than the mortality in the best-equipped private operating-room. I am aware that there is still a prejudice in the minds of many physicians against the performance of the operation of celiotomy in the general hospital clinic, but I feel convinced that this prejudice is unwarranted at the present day. g A few simple preparations will render the clinic-room as suitable for an aseptic operation as any place can be made ; and the presence of a number of unsterilized medical students does no harm as long as they and their dust are kept from contact with the patient. Infection undoubtedly takes place from contact. Infection from the atmosphere must be very rare. My series of forty-six cases, though small, still goes to sustain this view. For in this number there was no case of sepsis or peritonitis. The only death which occurred fol- lowed almost immediately after the operation from shock and hemor- rhage, in an uncompleted operation for a large, densely-adherent, retro- peritoneal dermoid. -" The aseptic technique is very simple and easily followed. Before the clinic, the amphitheatre is scrubbed, and the railing separating the amphitheatre from the benches is covered completely with large cotton sheets wrung out of a bichloride solution. All the tables, stands, and chairs are covered in a similar way. The operator and assistants are clothed in white cotton shirts and trousers, which are washed for every clinic. Operator, assistants, and nurses are covered with large ster- ilized aprons. Dressings and silk ligatures are sterilized in a steam Work of Gynecological Clinic of the AHospital of the University. 133 sterilizer, and the instruments are boiled in a solution of bicarbonate of sodium. Distilled water is used for all purposes throughout the operation. No one is permitted in the amphitheatre except those persons who are directly engaged in assisting at the operation, and these are limited to the minimum number. The wound is usually closed with buried sutures,-of silk and catgut, -and with an intracutaneous suture of silk. By such simple means perfect asepsis can be attained. I have found that the practical and scientific work of the clinic is very much assisted by having facilities for making bacteriological examinations on the spot during the operation. And it seems that such association of bacteriology and surgery would be of much advan- tage in other branches besides abdominal surgery. In the gynecological clinic the question of drainage after celiot- omy is—except in rare cases, as of suspected hemorrhage—determined absolutely by bacteriological examination of any suspicious fluid which may have escaped into the peritoneal cavity. The result so far, not only at the University of Pennsylvania, but outside, has confirmed my faith in this method. These bacteriological examinations have shown that the pus in very many cases of pelvic abscess—of ovarian, tubal, or some other origin—contains no micro-organisms; it is sterile and harmless, inca- pable of producing sepsis or peritonitis. The pus containing gonococci alone, at least in limited numbers, seems also to be harmless when brought in contact with the peritoneum. The practical value of this application of bacteriology is very great. It enables us to follow a median course between the extreme advocates of drainage in celiot- omy and the extreme opponents of drainage ; and the course is deter- mined not by prejudice, but by scientific reasoning. In all cases where the bacteriologist finds no micro-organisms in the purulent or other material which escapes into the peritoneum, the abdomen is closed without irrigation and without drainage. When staphylococci, strep- tococci, or the bacterium coli commune are found, both irrigation and drainage are employed. The examinations are made very quickly—within five minutes— and in no way interfere with or delay the progress of the operation. It is very inaccurate to speak of flooding the pelvis and abdomen with pus and of saving the life of the woman by irrigation and drainage, simply because a sac containing purulent-looking material has been ruptured during removal. The purulent material is only dangerous if it contains septic or pathogenic germs, and the surgeon has no way of determining this fact without the aid of bacteriological examination. Most of the irrigation and drainage which is done in a routine way without such examination is unnecessary, and consequently harmful. I34. Charles B. Penrose. The result of the clinical experience of the past winter is to con- firm my opinion of the value of the procedure of removing the uterus in many cases in which formerly we had been contented merely with the removal of tubes and ovaries. In cases of pelvic abscess it enables us to make the most complete removal of the abscess sac and to per- form a neat, clean operation ; and in many cases of ectopic gestation and pelvic inflammatory trouble it enables us to check hemorrhage, otherwise very embarrassing. In Septic cases accompanied by disease of the endometrium the relief is immediate and permanent. The operation of ventrofixation or suspension of the uterus has also given most satisfactory results in retroversion, retroflexion, and prolapse of the titerus. A subject of special investigation last winter was that of tubercu- losis of the Fallopian tubes. All the Fallopian tubes and ovaries re- moved for the general condition designated pelvic inflammatory trouble were submitted to a most thorough microscopical examination by Dr. Beyea, who found a large proportion of them tubercular. The number of cases is too small to warrant the assumption that this proportion will be constant in any series of similar cases. It is, however, greater than any yet reported. We found that in our series of pelvic inflam- matory cases 20 per cent. were tubercular. The tubercular process seems to begin in the distal third of the Fallopian tube, and thence to spread to the ovary and peritoneum or to extend to the uterus. The results in the tubercular cases were all good and seem to be permanent. The relief from pain was immediate, and there has been progressive increase of weight and strength. CELIOTOMIES PERFORMED AT THE GYNECOLOGICAL CLINIC OF THE HOSPITAI, OF THE UNIVERSITY OF PENNSYLVANIA.—(1893–1894.) A/ysterectomy—Intra-Abdominal Method. Number - of Cases. Fibro-myoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Calcareous degeneration of fibroma . . . . . . . . . . . . . . . . . . . . I Salpingitis and endometritis . . . . . . . . . . . . . . . . . . . . . . . . 6 Extra-uterine pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . I Cancer of cervix and body of uterus . . . . . . . . . . . . . . . . . . . . I Myxomatous degeneration of uterus, salpingitis . . . . . . . . . . . . . . I Tubercular salpingitis, endometritis, peritonitis . . . . . . . . . . . . . . I Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I4 Ovariectomy. Papillomatous paroëphoritic cyst . . . . . . . . . . . . . . . . . . . . . 2 Dermoid cyst (retroperitoneal) . . . . . . . . . . . . . . . . . . . . . . I Work of Gynecological Clinic of the Hospital of the University. 135 Salpingo-Oophorectomy. Number of Cases. Chronic salpingitis and ovaritis . . . . . . . . . . . . . . . . . . . . . . 6 Hystero-epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Tubo-Ovarian abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Tuberculosis of Fallopian tubes . . . . . . . . . . . . . . . . . . . . . . I Pyosalpinx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Hematosalpinx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Hydrosalpinx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Ventrofixation of uterus for retrodisplacement with or without salpingo- oöphorectomy . . . . . . . . . . . . . . . . . . . . . . . . . . II Celiotomy zwithout A’emoval of Structures. Tuberculosis of tube and ovary and general tuberculosis of peritoneum . . . I Cancer of fundus of a double uterus . . . . . . . . . . . . . . . . . . . . I Epilepsy (suspected ovarian disease) . . . . . . . . . . . . . . . . . . . . I Papillomatous cyst of ovary, general peritoneal papilloma . . . . . . . . . I Ventral hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 It is impossible to tabulate, in a perfectly satisfactory way, any series of cases of pelvic disease in women because we always find a variety of pathological conditions together. In the preceding series I have divided the cases according to the form of the operation, and have mentioned the most conspicuous pathological condition present. The cases of hysterectomy for salpingitis and endometritis include those cases in which there is purulent inflammation of the Fallopian tubes, generally of gonorrheal or post-puerperal origin, with chronic purulent endometritis and a friable degenerated condition of the body of the uterus. The operation of hysterectomy is a complete removal of all diseased structures. After simple salpingectomy in these cases the woman continues to suffer for an indefinite period with a virulent form of leucorrhea, which, if of gonorrheal origin, may not yield to any plan of treatment. In the operations of ventrofixation of the uterus, the primary object was the correction of a retrodisplacement. If in any case there were marked tubal and ovarian adhesions, salpingo-oophorectomy was performed. The operation of ventrofixation was always preceded by perineorrhaphy if there was present laceration or relaxation of the perineum. Drainage was employed six times in this series of cases for the following conditions: Tubo-Ovarian abscess, -where streptococci, staphylococci, or bac- terium coli commune were found in the pus. Papillomatous cyst, with infection of the peritoneum. Tuberculosis of the peritoneum. Extra-uterine pregnancy. I36 * W. E. Hughes. A CLINICAL STUDY OF EMPYEMA IN CHILDHOOD." By W. E. HUGHES, M.D., PH.D., Professor of Clinical Medicine in the Medico-Chirurgical College; Physician to the Philadelphia Hospital; Physician to the Medical Dispensary of the Children's Hospital; Pathologist to the Presbyterian Hospital. EMPYEMA was formerly considered rather as an accident occurring in the course of sero-fibrinous pleurisy brought about by poorly-con- ducted attempts at exploration or operative interference, or if found with- out any previous violence as caused, on the one hand, by some inherent tendency in the system of its victims towards a conversion into pus of such serous exudations, or on the other, by an acquired dyscrasia, which again predisposed to pus-formation. As its origin was shrouded in mystery, so was its prognosis uncertain and its treatment along lines which were necessarily indefinite. Now that careful bacteriological investigation has shown its true nature, we are able to discuss it more definitely and to recognize it as entirely separate and distinct from any other variety of pleurisy. While the empyema of childhood is not at all to be thought of as constituting a separate variety of the disease, yet it presents here certain peculiarities which make a special study well worth while. Disease processes are much less complex at an early age than in later life, and the actual causes of empyema existing then are much more easily and definitely determined. My somewhat elementary treatment of the subject, and a possibly prolix statement of facts already well established, may be pardoned when it is remembered how little the true nature of empyema is appreciated by the profession at large. Two points cannot be too strongly accentuated here, that empyema is much more common in childhood than is often supposed, and that it is a distinct entity, is primary, and has no direct relation- ship with sero-fibrinous pleurisy. Having these facts clearly in mind it becomes difficult to escape a correct diagnosis, and the diagnosis is made at a time when it will be of the most service. But, having recog- nized the condition, other considerations are of essential moment in prognosis, and become of paramount importance in treatment. Bacte- riological study has shown that in the pus of all empyemas micro- organisms are present ; these constituting the cause, at the same time serving to divide the disease into distinct varieties, the recognition of which, while not always possible, is yet of great importance. The micro- organisms concerned may be divided into three classes: pneumococci, tubercle bacilli, and pus organisms, and these produce empyemas as 1 Read before the Philadelphia Society for Clinical Research. Ampyema in Childhood. I 37 distinct in their nature and symptoms as in their etiology. The in- troduction of these micro-organisms into the pleural cavity takes place undoubtedly in the vast majority of instances by way of the lungs, but there is a small, yet still appreciable, number of cases where the lym- phatics, or even the blood-vessels, are the pathway and the lungs are un- involved. Even where introduction takes place immediately from the lungs the initial lesion in them may be so trifling as to be unrecogniza- ble and thus unavailable for diagnostic purposes. The condition of the pleura would seem to be of much importance. It is certainly an open question whether a healthy pleura would not destroy any ordinary irruption of germs, and whether it is not, in most instances at least, necessary to have a previously existing abnormal state of this mem- brane before we can have a soil suited to the development of the specific germs of empyema. In those scattered cases where a serous effusion has spontaneously become purulent, either the germs were introduced subsequently to the pleurisy and thrown upon a soil pre- viously fitted for them by disease, or they, in the beginning, had not sufficient virulence to produce pus, but merely a serous exudate. The first of these two hypotheses certainly seems the more tenable. In the greater number of cases in children the pneumococcus is the causative germ. Almost of necessity introduced by way of the lungs into the pleural cavity, it is still not necessary that we should have a preceding pneumonia, though those cases which have been carefully watched from the beginning will generally be found to have thus event- uated, and in the others, the history will, as a rule, point quite strongly to an initial pneumonia. So frequent is this that it is of diagnostic importance, and will alone serve to point strongly towards a metapneu- monic empyema, though microscopic examination is always necessary to an absolute determination of the variety. While the entrance of the pneumococci into the pleural cavity is probably coincident with the height of the pneumonia, yet the symptoms of the empyema rarely develop at this time, the pneumonia will run its course, there will be an interval of some days, or sometimes a week or more, during which the condition, if not wholly satisfactory, is at least such as to make us believe that the trouble has passed before the empyema begins to manifest itself. The amount of lung involved has little to do with the incidence of the empyema, often the physical signs and the trifling nature of the symptoms are such as to suggest rather than a lobar a slight broncho-pneumonia. Metapneumonic empyema being the com- monest form in childhood accounts for the comparatively favorable prognosis at this age, and determines the somewhat peculiar course, as will be pointed out further on. In addition to the presence of the pneumococcus there must be another element which determines the I38 W. E. Hughes. incidence of empyema, for it is well known, that there may be pneumo- cocci present when the effusion is not purulent. What this element is, is doubtful, but it must be some condition antedating the entrance of the pneumococcus, for this form of empyema is invariably acute and primary and never follows a sero-fibrinous pleurisy. Tubercle bacilli may, unaided, produce empyema ; at least in a certain number of cases these organisms, and these alone, have been found in the pus. The commonest form of tuberculous pleurisy in childhood is, of course, that in which the exudate is sero-fibrinous. It is interesting to note here that, while in the serous exudate it may be impossible to find the bacilli, and whenever they are present their num- bers are few, in empyema they exist almost constantly and usually in considerable quantities, rendering the differentiating of this variety comparatively easy. This form of empyema is apparently rare in child- hood, yet clinical facts lead me to believe that more careful investiga- tion will show that it is more common than is now apparent. When it does occur it seems to be a sequence of tuberculosis of the bronchial lymph-glands, rather than of the lung, and is not likely to lead to a secondary pulmonary involvement, but to a generalized miliary tuber- culosis. It is necessary to bear this fact in mind, as this form of empyema is very likely to be localized. In the last variety, that produced by any one, or more usually, several of the pus organisms, most prominent among which are strepto- cocci and staphylococci, we have to deal with a form whose etiology is less clear than that of either of the others, and whose symptoms and prognosis are less definite. It is possible that the organisms may, like the pneumococci, gain access to the pleura by way of the lungs, but this is here only exceptionally the case and the lymphatics are the common path. This variety is the one which usually follows the infec- tious fevers, resulting either from the germ, which is their cause, or from any of the numerous swarm which follows in their wake. Not at all infrequently a nidus for the germ is formed by a serous effusion, so that in this form we find best exemplified the changing of a serous into a purulent exudate. Of the predisposing causes of this variety, scarlet fever seems to be the most frequent, though it may follow any other of the fevers or, in fact, any lesion which will admit pus-producing organisms. Finally, while I have spoken of clearly-marked varieties, yet it must be recognized that in most cases we have to do, to a certain extent, with a mixed infection where the micro-organism present in greatest numbers determines the type. It is to be doubted that even the most typical examples of metapneumonic and tuberculous empyemas are really due wholly to their respective specific germs. There is, Bmpyema in Childhood. I 39 probably, in all of them a rôle of a certain importance played by the pus organisms. However, though these organisms may play a part, it seems but a secondary one; where the pneumococci or tubercle bacilli are prominently present they determine the type of their respective varieties and have most to do with their course and termination. But whether or not we concede the existence of specific varieties, the impor- tant fact still remains that an empyema is invariably due to micro- organisms; that it is a disease in itself, and is primarily empyema or has, at least, the potentiality of becoming an empyema. Symptoms and Diagnosis. Clinically, two well characterized divi- sions may be made, and the line of demarcation between them is more sharply drawn in childhood, owing to careless inattention to symptoms on the part of the parents, and to the fact that children are not acute observers of their own physical condition, or too young to give expres- sion to symptoms which would attract attention to their ailment. It is this very fact that a serious disease in childhood so often lacks expres- sion, that should suggest the possibility of the occurrence of empyema, when conditions are favorable and symptoms indefinite, and keep us on our guard against mistaking it for some less serious disorder. These divisions are, first, that in which the disease is pronounced from the beginning, and where attention is attracted immediately to the chest by prominent symptoms; and, second, that in which the onset has not been noticed and the progress of the disease has been marked only by a general deterioration, on a superficial examination no symptoms of any respiratory trouble presenting themselves. The difference between the two clinical forms is an artificial one and not real ; it depends partly on the etiological variety of the disease, and partly, as was said, on lack of observation or of expression of symptoms, thus, in those cases which are least urgent, leading to a minimizing of the gravity of the condition. For diagnostic purposes this division is of a certain amount of importance, for when the onset has been insidious, pneumonia could with certainty be excluded, and we should have to deal only with a question of the nature of the fluid. Considering empyema of both types, we have first to differentiate between pneumonia and pleural effusion, and then, when the fact of the existence of an effusion is established, the determination of its nature. In the first form, which may be called acute, in contradistinction with the second or latent, the attack will very likely have been ushered in by the symptoms of pneumonia, for it is the metapneumonic empy- ema that is most frequently sharply marked and acute. It is for this very reason that a mistake is likely to be made here in diagnosis. Pneumonia has been clearly recognized, and when the child's condition I4O W. E. Hughes. fails to improve satisfactorily after a proper lapse of time, the tendency is towards regarding the case as one of retarded resolution in pneu- monia rather than of empyema. The close similarity between the physi- cal signs makes this mistake the easier. A point of distinct value in diagnosis here is this, when empyema has supervened upon a pne:1- monia it will generally be found to have commenced after the case bas advanced some steps towards recovery, and there will have been then a period of amelioration of symptoms with a subsequent increase in gravity. If, on the other hand, there has happened not an empyema, but simply delayed resolution, or even abscess of the lung, there will have been no such temporary improvement. If the empyema has supervened during the acuteness of an attack of pneumonia the general symptoms will be of little use and sole reliance will have to be placed upon physical signs. Even when an effusion has come on during the course of, or subsequent to, a pneumonia it is not necessarily purulent, and the diagnosis has still to be made between empyema and sero- fibrinous pleurisy. When there has been no antecedent pneumonia, and this acute form of empyema has been primary, a variety which is likely to be not metapneumonic, but that due to pus organisms, the Symptoms are so like those of pneumonia, as to make a diagnosis based wholly upon them difficult or altogether impossible. These symptoms—and this applies equally to pleurisy and empyema for whether the effusion be serous or purulent the symptoms in the beginning of an acute case are practically identical and indistinguishable from each other—are sharp pain, fever, distressing constant cough, dyspnea, manifested by rapidity of respiration and by play of the alae nasi, and such general disturbance as would be due to the increase of temperature. The fever in such a case is almost uniformly high, with no more fluctuations than would be the case in pneumonia. It is only much later that distinct remissions may occur, and even then they are the exception rather than the rule. When they do occur they would point strongly towards empyema rather than pneumonia or serous effu- sion. Profuse sweating is only uncommonly present and is of little importance. As between pleural effusion and pneumonia, for, as has just been said, whether the effusion be serous or purulent the symptoms in a marked and acute case are the same, the only symptoms which have seemed to me to have any diagnostic importance are dyspnea and pain. In empyema the dyspnea has often seemed to be more sharply accentuated than in pneumonia, the respirations are no more rapid, but there is a more noticeable play of the alae nasi, a more evident sense of discomfort. Pain, too, is greater, and this pain is to be gauged not by the expression of the child, but by a hyperesthetic condition of the affected side of the chest. It is probable that this hyperesthesia is Empyema in Childhood. I4 I accountable for the more pronounced dyspnea. But these symptoms are merely suggestive and not of any convincing importance, they serve only to accentuate the results of physical examination. When the empyema is latent, a condition which finds its best type in the tuberculous variety, though it may exist in either of the other two, symptoms pointing towards disease of the respiratory apparatus may be few and indistinct, even when they are carefully and intelli- gently sought for. The superabundant vitality of a child, with the enormous activity of its reparative processes, leads it to bear, with sur- prising equanimity, the most deadly inroads of disease, if these be but made slowly, and this form of empyema exemplifies this most fully. I have seen a child playing about and to all appearances not seriously ill, with a pleural cavity full to the apex with pus. While the heart is not too much embarrassed there will be but little dyspnea, and strangely the pus seems to have little effect upon the system. There is always some dyspnea, but this is shown only by the nose. Fever may be entirely absent, or present in such slight degree as to attract no atten- tion. In the earliest childhood, if there be fever, it is likely to be of a continuous type. It is in older children that distinct remissions show themselves and hectic begins to become evident. When such remittent temperatures are encountered, they are, of course, of extreme impor- tance diagnostically. From the nature of the symptoms and the course of the disease there can be no pneumonia, and where it is a question solely of the nature of a pleural effusion, a hectic temperature will point almost unfailingly to empyema. Sweating is a symptom which is fre- quently present, and, though it is not usually profuse, yet it is probably the most important of all as indicating very strongly an empyema. Seeing, then, that in the latent form the symptoms are so poorly marked, and in the acute form so closely similar to those of pneumonia, it is evident that our only valuable diagnostic guide is that furnished by physical signs, but even here we are often at fault, since the chest- walls in a child are so thin and elastic that the physical signs of an effusion may exactly simulate those of consolidation. The physical signs upon which we rely for a diagnosis between empyema, or any other pleural effusion, and pneumonia in a child are, of course, the same as those we have at our command in an adult, but while in an adult this diagnosis is easy and sure, in childhood it is gen- erally difficult and occasionally impossible. The physical signs of effu- sion may be so clearly marked as to indicate at once the nature of the case. Most notably is this true where we can demonstrate movable dulness or displacement of neighboring organs, though there are many cases where, while these signs cannot be elicited, the others are still distinctive. When, on the other hand, they are not clearly marked I42 W. E. Hughes. and simulate almost perfectly those of pneumonia, the one on which most reliance can be placed for a diagnosis is the breath-sound. In effusion the tubular breathing differs slightly, it is true, but signifi. cantly from that of pneumonia in being sharper, more metallic, more superficial, but not so loud, there being an accentuation of character at the expense of volume. Râles are next in importance. When they are present they are more metallic and distant, they give the impres- sion of being conducted from a distance. The voice-sound, too, is of some importance, it is a trifle more metallic and higher pitched than in pneumonia. Tactile fremitus cannot be relied upon at all in a young child as a diagnostic sign. It is difficult to elicit it satisfactorily enough for accuracy, and when it can be elicited it is very likely to be as promi- nent in empyema as in consolidation. As between serous and purulent effusion the diagnosis is even more difficult, and I have been accustomed to rely here upon the history of the case and the general appearance of the chest rather than upon physical signs. In acute cases the history will furnish no definite diagnostic hints, but where the fluid has remained unabsorbed for some time, and, more important, where there has been marked deterioration of general health, a diagnosis of empyema is to be made, and this is strengthened, if in addition there is present an irregular fever with sweating. Of more moment still than the history is the appearance of the chest. In empyema the affected side looks rather fuller, the superficial veins are more prominent, and, most distinctive of all, there is often a peculiar glossy appearance of the skin, which indicates pus. This is not an edematous condition of the chest-wall, but resembles edema closely in appearance, though the tissues do not pit on pressure. Physical signs, as was said, are unreliable in the diagnosis of the nature of the effusion. The S-shaped line of the upper limit of the effusion, and the freedom with which the area of dulness changes its position with the change of position of the child are dependent on the amount and tension of the fluid, and not on its character. Bacelli’s sign, whispering pectoriloquy, is not reliable. Whether it be absent or present probably depends altogether on the tension of the fluid. In two of the cases cited below this whispering pectoriloquy was present, even though the effusion was thick pus. In adults I have had the same experience; here, too, it is not to be relied upon. As the diagnostic symptoms and signs may be so indefinite it be- comes necessary to make in many cases an exploratory puncture. This in a child can be easily and harmlessly done. Even though the needle may be plunged into lung-tissue, no danger is to be apprehended. This exploratory puncture is often our only means of making a definite diag- nosis between pneumonia and effusion, and oftener still the only way Fmpyema in Childhood. I43 we have of determining the kind of fluid present. It may be made with an ordinary hypodermic syringe, but better with an aspirator, so that if fluid be found its immediate evacuation may follow. As has been said, an empyema is sometimes formed on a basis of a simple serous effusion, so when the progress of the case is not satisfactory a . series of punctures must be made extending over a series of days, and sometimes such persistence will be rewarded by the eventual discovery of pus. This empyema must not be attributed to the exploratory punctures, for if made with proper precautions they are absolutely harmless and incapable of producing pus. The diagnosis of the variety of empyema can be made with cer- tainty only by a microscopic examination of the pus, but there are some clinical facts often prominent enough to warrant a tentative diagnosis in the absence of opportunity to make such examination. Pneumo- coccus empyema usually follows or accompanies a pneumonia, is acute in its character, with prominent but not very serious symptoms. It has a tendency to perforate the lung and evacuate itself through a bronchus. The pus is creamy and thick. Tuberculous empyema is essentially latent, slow in its accumulation, may be irregularly localized, and may eventually perforate the parietes. Its pus is thin and often flocculent. Empyema due to pus organisms is frequently latent, or when acute has prominent and grave symptoms. It is not likely to perforate. It frequently follows the specific fevers or some demonstrable pyogenic lesion. The temperature may be remittent. The pus is thinner than in the first variety, but thicker than in the second. The following cases are introduced because they have recently been under observation, and because they illustrate quite well the course and termination of metapneumonic, the commonest form of empyema : CASE I.—Girl, aged 7 months. Five weeks before coming under my observation, the child, well nourished at the time and in remarkably good health, had been taken suddenly with a markedly febrile attack attended with severe general symptoms, constant harassing cough, and very rapid breathing. The diagnosis made at this time by the attend- ing physician was pneumonia, and, from what I was able to gather from the history of the case, as detailed by the parents, I have no doubt was the correct one. The subsequent history is necessarily in- definite, but with all its indefiniteness still remarkably characteristic of pneumonia. At the end of a week the symptoms ameliorated, the temperature declined, but there was at no time a perfect restoration to health. Soon what little improvement had been gained was lost, ema- ciation progressed, appetite failed, and, finally, in the eyes of her parents, the child was more seriously ill than in the initial attack. When I first saw her she was extremely emaciated, appetite poor, I 44. W. E. Hughes. stomach not always retentive, and bowels often irregular. Respirations were shallow and rapid, ranging from 60 to 70 in the minute with free play of the alae nasi. The heart's action was quick, weak, and labored, the apex beat in the fifth interspace, just outside the nipple line. The general surface was a little cyanotic, and the finger-tips be- ginning to be clubbed. The temperature was irregular, occasionally normal, but oftener above, sometimes reaching Iog” F. There was abso- lutely nothing regular about the temperature curve, the exacerbations occurring quite as frequently in the morning as at any other time, and on alternate days there might be almost apyrexia and sharp fever. The right chest was distinctly fuller than the left and showed less movement. The interspaces were thought to be somewhat prominent. The cuta- neous veins were certainly fuller than those upon the opposite side, and there was a general glossy appearance of the skin, though there was no edema. From apex to base this side was perfectly dull, with a distinct sense of doughy resistance, tactile fremitus was poor, and breathing tubular. As well as can be gotten in a child of this age the voice sound, as determined by the cry, was that of a nasal pectoriloquy, and when the cry was almost suppressed and partly sobbing, what might answer to whispering pectoriloquy could be plainly heard. At no point could any signs be located which might serve to indicate beneath, the existence of a compressed lung. It was impossible at first to gain the consent of the parents to aspiration, but this was at last obtained, and, with the assistance of Dr. W. S. Carter, I drew off seven ounces of thick, creamy-yellow pus, blood stained at the last from 1aceration of adhesions by the end of the canula. The child’s condition immediately before aspiration was interesting; we were as- sured positively by the mother that almost twenty-four hours previously the child had become suddenly and distinctly easier, and that this im- provement had been coincident with the establishment of a loose cough with free expectoration. The inference, of course, was that the empyema had ruptured into a bronchus and was discharging. Careful physical examination, however, failed to show any change in the physical signs, and the results of the aspiration most definitely negatived any commu- nication with a bronchus. It is interestin g, too, to note how the lung— compressed absolutely as it must have been for at least a month—be- haved after aspiration. Immediately after all the pus had been with- drawn the lung filled fully the pleural cavity, everywhere a good respiratory murmur could be heard replacing the previously existing tubular breathing, and over the whole side was a clear tympanitic per- cussion note. For a few days after the aspiration, fluid, presumably pus, slowly reaccumulated, then it was slowly absorbed, and a month afterwards the lung was apparently perfectly normal. From the time Ampyema in Childhood. I4.5 of the aspiration the temperature was normal and the bodily condition of the child steadily improved. CASE II.—Girl, aged 4 years. Seen in consultation with Dr. F. H. Milliken. Two weeks previously she had had a mild attack of pneu- monia involving the lower lobe of the right lung. The symptoms were not at all grave and the physical signs rather those of broncho-pneu- monia. There were spots of imperfect consolidation scattered through lung-tissue apparently unaffected. The temperature fell by crisis at the end of a week, and for a few days she was apparently rapidly re- turning to perfect health, when the original symptoms returned. When I saw her, her fever was moderately high and continuous. There was irregular but not marked sweating; face a little dusky; cough con- stant ; dyspnea marked. Complained greatly of pain in the left side, which was tender to the touch. Left chest was dull from apex to base; breath-sounds tubular ; whispering pectoriloquy. Twenty ounces of thick, creamy pus were withdrawn immediately, with prompt relief to the symptoms. Within three days the pleural effusion had partially reaccumulated, there was still some fever, but the symptoms were no- wise as urgent as before the aspiration. At this time she passed out of Dr. Milliken's care and the subsequent history is indefinite. She is said to have been ailing for some weeks, and at one time to have expec- torated large quantities of purulent matter. However, she eventually made a good recovery without any further operative interference. CASE III.-Boy, aged 6 years. Two weeks before coming under observation had what was said to be grippe, but what was really, in all probability from the symptoms, a mild pneumonia. He did not recover from this, and when I saw him was emaciated, had a distinctly hectic temperature, coughed incessantly, with little expectoration, and complained bitterly of pain in the right side. Physical examination showed over the lower half of the right chest immovable dulness and absence of breath- and voice-sounds. Tactile fremitus over the dull area was exaggerated as compared with the corresponding area on the left side. Exploratory puncture showed pus. The parents refused to permit aspiration. A week 1ater he began to expectorate freely large quantities of pus containing pneumococci. Coincidently with this there was a distinct improvement in his symptoms, and a week later a marked decrease in the area of dulness could be demonstrated. His improvement progressed uninterruptedly, and in six weeks from the first purulent expectoration he was apparently perfectly well. At this time there could be detected nothing wrong in the right lung. CASE IV.-Boy, aged 2 years. Had a severe attack of pneumonia with complete consolidation of the upper lobe of the right lung. Was discharged at the end of ten days apparently perfectly convalescent. I46 W. E. Hughes. Two weeks later, when I was again called to see him, there was dulness throughout the whole of the right chest, tubular breathing, distant metallic rāles, exaggerated tactile fremitus. The right chest was enlarged, the veins dilated, the skin glossy and a little dusky. Ex- ploratory puncture showed pus. The general symptoms were not pro- nounced. The child was evidently not well, was peevish and fretful, but walked about and made occasional attempts to play. There was neither fever nor sweating. The parents refused aspiration, and the child was placed upon supporting treatment, with occasionally a seda- tive to relieve the cough, which was not very troublesome. For some months there was no change in the general condition nor in the physical signs. Then a gradual improvement began, and the fluid in the chest lessened. Nine months after the beginning of the empyema the fluid had apparently been all absorbed, but the pleura was much thickened generally, and the breath-sounds so harsh as to suggest quite an extensive fibroid change in the lung. During the next four months the lung gradually cleared up, till at the end of that time the respira- tory murmur was perfectly normal, and there was no evidence of any thickening of the pleura. In these cases will be noticed two methods of the termination of empyema. The first is by penetration of the lung and evacuation through a bronchus, and is shown in Case III and possibly in Case II. This method is unquestionably more common in childhood than in adult life; but why this should be so cannot be determined, nor is the exact process by which it is accomplished at all understood. That discharge through a bronchus is in some manner connected with the nature of the effusion is evidenced by the fact that this event is much the most common in metapneumonic empyema. In fact, from the frequency with which it occurs in this form, this would seem to be here the normal termination of empyema. The amount of effusion seems to have little to do with it, small localized empyemas not infrequently terminating thus. It can easily be supposed that the pneumonic lung, which has given rise to the empyema, will by virtue of its condition yield more readily to the entrance of pus. Or the reason may still lie in the condition of the lung and yet be a purely mechanical one, the consolidated portion being incompressible may offer an easy outlet. This attempt on the part of nature to heal not always results in a per- fect success, and is too often abortive. When in addition to pneumo- cocci, pus organisms are present in any considerable number, extensive destructive lesions of the lung may be set up by their introduction into its tissue, vitiating the good done by the liberation of the pus. If the organisms be not inimical to the health of the lung, a small fistulous tract may be formed, through which the pus is forced principally by Aºmpyema in Childhood. I 47 coughing, and the lung, readily expansible as it is in childhood, easily follows the lowering fluid till it finally is closely reapplied to the parietes throughout the whole pleural cavity, and a cure results. During this process air is rarely admitted, the pressure of the effusion more than counterbalancing that of the inspired air. The other method of ter- mination referred to is absorption of the pus. This must in itself be an event of great rarity, but that it may occur is proven by the case cited. While this termination is of little importance as a curative measure, yet secondarily in connection with other processes it becomes of great service. From the nature of the pleural cavity it is practically impossible that it should be thoroughly drained except after the lapse of such time when the assistance of the expanding lung is brought into play. But if we grant that the contents of an empyema may be spon- taneously absorbed, it will at once be seen why a single aspiration may be successful, or an empyema may heal a very short time after the perforation of a bronchus. The pus is here by no means all drained off. Merely enough is abstracted to permit of the rapid absorption of the remainder. So we get a more hopeful prognosis, but at the same time we must not permit ourselves to rely too much upon this assist- ance of nature. The third method of cure, and one which must be spoken of, as on it is based all operative procedures, is by perforation and evacuation by channels other than the lungs. The most common point of perforation, and fortunately the one most likely to lead to cure, is the chest-wall. Many other points of perforation have been recorded, but none of them are favorable, and little likely to lead to fortunate results. In childhood, when perforation of the chest-wall takes place, this usually occurs high up, often in the second interspace, and yet the discharge of pus takes place at this point as freely as though it were at a point more favorably situated for free drainage, showing that the pus is really forced out by the expanding lung and not drained away. That this perforation is not more frequently followed by perfect cure is due to the condition of the lung and to the variety of empyema in which it occurs. If the lung, in addition to being col- lapsed, is partially consolidated or has undergone any degree of fibroid change, its expansive power will be so slight as to be of little use in forcing out the effusion. Tubercular empyema is the form which is most frequently followed by perforation, and here from the nature of the process the outcome can be nothing but disastrous. In empyema due to pus organisms perforation is uncommon. When it does take place it is through the chest-wall, with the possibility, though not probability, of ultimate perfect cure. In this form the lung would seem to be seriously crippled, probably by a dissemination throughout its structures of the pus organisms, and consequently less able to IO I48 * W. E. Hughes. expand, and so aid in the drainage of the pleural cavity. If the case be left wholly to nature, long-continued suppuration is likely to result, with its necessarily bad termination. For some time after the existence of an empyema the lung is simply compressed, there is no organic change in its structure. The pyogenic membranes covering its surface do not seem to organize and contract as early as in an adult, so that expansion easily follows removal of the pus. But eventually a fibroid change takes place in the pulmonary tissue, seriously impairing its elasticity. This is most marked and earliest brought about where pus organisms are present, and seems to be the result of the presence of these organisms, rather than of the mechanical collapse of the lung. The process is inaugu- rated by a widely-scattered catarrhal condition of the vesicles and finer bronchi. Eventually this involves the fibrous tissue, and a thickening and contraction result. Treatment.—Prompt evacuation of the pus as soon as its presence is recognized is the only measure that can be taken which promises any good result. In metapneumonic empyema a single aspiration may, and undoubtedly often does, effect a cure. The chest must be emptied as thoroughly as possible, the only precaution being taken to proceed slowly with the evacuation in order to give the lung plenty of time to expand, and to run as little risk as possible of the oozing of blood from the congested pleura. There will always, even in favorable cases, be some reaccumulation of pus, but this ought to subside shortly by absorption. If it does not subside, or if there is any excessive reaccumulation, a second evacuation is necessary, and this is to be repeated, till it is positively demonstrated that a cure will not thus result before more radical measures are adopted. While it may be necessary to eventually introduce a drainage-tube, yet temporizing by means of aspiration does no harm. I cannot deprecate too strongly from my own stand-point the placing of all empyemas in children in the hands of a surgeon, for I am certain that in a notable number of cases simple aspiration is perfectly competent to effect a cure. Where the case has existed for a long time, or where pus organisms are the exciting cause, or where repeated aspirations have failed, the introduc- tion of a drainage-tube is necessary. There is only one class of cases where resection of ribs is to be advised,—that is tuberculous empyemas. In all the others it is not necessary to go further than aspiration or a drainage-tube. Anterior Poliomyelitis. I49 ANTERIOR POLIOMYELITIS." By DE FOREST WILLARD, M.D., Clinical Professor of Orthopedic Surgery in the University of Pennsylvania; Surgeon to the Presbyterian Hospital, etc., AND GUY HINSDALE, M.D., Physician to Out-Patient Department, Presbyterian Hospital ; Assistant Physician to Orthopaedic Hospital, etc., (concLUDED FROM PAGE 72.) THE inequality of muscular power following an attack of anterior poliomyelitis renders the limbs (especially those of the lower extrem- ities) subject to deviation, alteration, and deformity, not only of the muscular and fascial systems, but also of the osseous structures. These deviations are not due to the fact that a particular set of muscles acts too vigorously, but simply that the inactivity of another particular set permits the stronger muscles to draw the limb in their direction ; weight-bearing soon adds to the deformity, permitting shortening of the fibres and inclination of the member in the direction of the greatest power, which is usually at the hip and knee that of flexion. At the ankle the alteration in form will be either inward or outward, according as the peroneals or tibials have been weakened. As has been stated, locomotion in the deformed position soon alters the shape of the bones and produces serious distortion, from stretching of ligaments and partial dislocations may even ultimately result, especially when the child rolls about the floor and exerts itself with the natural eager- ness of childhood. A large majority of these deformities can be prevented by care and attention on the part of the surgeon. Immediately after the primary attack frequent manipulations and stretching should be employed to retain the natural length of the stronger muscles, while the weaker ones should receive persistent and long-continued massage and elec- tricity. This method of prevention of deformity should be continued for years. The process is a discouraging one, and little or no results will be visible for a long time, although great gain will actually have been accomplished by perseverance, not only in preventing atrophy but also in obtaining real increase of power. As soon as the child has acquired sufficient power to walk, the tendency to deformity will greatly increase any existing deviation from the normal line ; weight-bearing should, therefore, be immediately as- sisted by a properly-applied apparatus, which, ifscientifically constructed, 1 One of the Mütter Course of Lectures, delivered before the College of Physicians of Phila- delphia, 1893. I5O De Forest Wºllard. will not interfere with nutrition or development, but, on the contrary, will greatly aid these conditions by encouraging muscular action. The muscles should be stimulated to do the utmost they are capable of per- forming, and stop-joints, lock-joints, and elastic assistance to the muscles should be judiciously, but only temporarily, applied, and should be removed just as speedily as the muscles acquire power for themselves. No positive rules can be laid down for the construction of appa- ratus; this is a matter which requires much thought and ingenuity, and the adaptation of an appliance should be done only by a skilful surgeon. In no instance should an instrument-maker be allowed to apply an apparatus; he will simply adapt the case to his particular form of brace, instead of constructing the apparatus according to the needs of the individual. Massage, electricity, stretching, and manipulation should practically never cease until the individual has fully acquired his growth, and some of these cases demand attention throughout their lives, requir- ing frequently skilled operative and mechanical assistance. The conditions which demand surgical relief are the late deformi- ties, usually in the direction of flexion. These deformities often incline to a severe degree of distortion of the bones, stretching of the liga- ments, contraction of the fasciae, muscles, etc., particularly at the hip, knee, and ankle. An extreme degree of lateral curvature of the spine is also present in certain serious cases. In flail-limbs, where there is complete loss of power, and where the child has been constantly on the floor in peculiar positions, there is frequently distortion of the head and neck of the femur with relaxation of the capsule and round ligament. Even when flexion is overcome, this deformity seriously interferes with locomotion. Bone distortion at the hip, however, can be seldom over- come by surgical procedures, except by removal of the limb. Ampu- tation, however, is rarely to be considered, as the majority of individ- uals prefer to retain even a helpless member rather than to sacrifice it, even though its removal would relieve them of an incubus. Even when there is great deformity at the knee and ankle ampu- tation is not advisable except when the distortion is extreme ; but with a good limb upon the opposite side an artificial foot can be adapted and made to render good service. As a rule, however, the foot and leg can be brought into such line that with proper apparatus it can be made a useful member for weight-bearing service. At the knee, when the deformity is great and accompanied by par- tial dislocation, an excision of the knee and fixation of the extremity, so as to give a stiff walking member, is frequently advisable. Many cases, however, will refuse to submit to this procedure, as it necessarily involves a slight risk of life. Aft The principal surgical procedures will be myotomy, tenotomy, fasci- Anterior Poliomyelitis. I5 I otomy, etc., and these frequently require to be multiple and extensive. At the hip, division is made of the tensor vaginae femoris, the fascia lata, the long head of the rectus, the anterior fibres of the gluteus, and sometimes the sartorius; occasionally the psoas and iliacus need divi- sion. While it is perfectly possible to divide the former muscles sub- cutaneously, the latter cannot be attacked without open section, and when the fascial contractions approach the anterior crural nerve or the vessels, open division is always judicious. In minor cases, however, the subcutaneous method is advisable, as an open incision always leaves a large gaping wound which heals slowly. At the knee, if the contractions lie solely in the semimembranosus semitendinosus, and biceps, subcutaneous section is preferable. When the fasciae, especially in the mid-popliteal space, is contracted, open incision is demanded. The peroneal nerve should, of course, be care- fully avoided. The bony distortions at the knee are exceedingly difficult to over- come. When tenotomy fails, excision is demanded with subsequent fixation of the bone. At the ankle serious distortions occur, but they are usually remediable without bone removal. Extensive fasciotomies and tenotomies are, however, demanded, all the contracted tissues being divided. The same rules will be observed as are followed in the rectification of club-foot, -that is, the application, after section, of powerful stretching, so as to bring the foot as nearly as possible into its normal position, thus accomplishing complete ratification while the patient is under ether and avoiding subsequent pain and difficulty. Tissues which have been long contracted cannot be extended by mechanical processes without much loss of time and the infliction of pain. To attempt to relieve these difficulties by apparatus is unjusti- fiable when surgical procedures are safe, sure, and effective. Of course, mechanical appliances, which have already been alluded to, must be applied after operation in order to prevent relapse of the deformity. In slight cases these appliances may be very simple, but in feeble cases, flail-limbs, etc., apparatus demands much thought, as it is an essential help to walking powers. The legs are used for the attach- ment of what are practically artificial limbs. By the judicious combi- nation of stop-joints, elastic straps, springs, etc., together with the use of axillary crutches, perineal crutches, or wheeled crutches, locomotion becomes possible, and under its stimulation many cases which other- wise would be condemned to a helpless life upon the floor can be bene- fited, so that they will be able to walk for miles as the muscular power is slowly regained. Action is the best stimulation for the muscles; massage and electricity are helpful, but locomotion is the best aid. I52 James M. Brown. A CASE OF MULTIPLE SARCOMA OF THE ABDOMEN, FOLLOWING TRAUMATISM, WITH AN INTER- ESTING MEDICO-LEGAL SEQUEL. By JAMES M. BROWN, M.D., Assistant Aural Surgeon, University Hospital; Aural and Ophthalmic Surgeon, Western Temporary Home. DURING my daily visits to Thomas M., on January 3, 1890, my attention was called to his son, a boy aged 8 years, of short stature, but otherwise well developed, of lymphatic temperament, who I was told had been assaulted some two or three hours previous by a neighbor, who struck him about the head, kicked him in the left side, and other- wise in a general way roughly maltreated him. At the time of my visit he was lying in bed, pale, nervous, weak, with a staring, frightened expression, easily startled, showing every evidence of nervous shock. Examination showed but little positive evidence of injury other than some slight abrasions of the skin about the side of the face and neck, some tenderness on pressure in the left hypochondriac region, which later seemed confined more particularly to the abdominal wall. He complained of constant pain in the head; pain and soreness on movement in the left hypochondriac and lumbar regions. There had been no loss of consciousness nor any evidence of any cerebral lesions; general functions well performed, though at the time of the alleged assault there had been involuntary discharge of the contents of both bowel and bladder, loss of control over these organs being more the result of fright than of injury. By reason of an attack of la grippe in my own person, I did not again see the patient for four days, when he had so far recovered as to be able to sit up and move a little about the room. His mother at this time said that his sleep was fitful, easily broken, attended by moaning, and that he frequently awoke crying out in fright, appealing for help from supposed harm. •, - He still complained of pain in the head, but more of pain in the left hypochondriac and lumbar regions. These symptoms gradually ameliorated until about February 21, when my visits to the family became less frequent, and the case passed from my notice until April 1, when I was called to see him suffering with acute suppurative inflam- mation of both middle ears. He had lost flesh, was weak, nervous, and anemic, and though still present there was subsidence in the severity of the former subjective symptoms. The inflammation of the middle-ear cavities quickly responded to appropriate treatment, and having placed the patient on tonic remedies, Multiple Sarcoma of the Abdomen. I53 he again passed from my immediate notice, being able to visit my office to receive the last several ear treatments. The mother’s imagination, awakened by a keen sense of the wrong done, or the injury inflicted to her child, together with his still occasional frightful starting from sleep, now led her to think he had heart-disease, to which, after careful exam- ination, I could not assent, and tried to explain to her the resulting existence of a purely functional derangement of that organ. This apparently did not satisfy her, and as she left my office I could see there was little hope of her instituting the treatment I had outlined. In the course of some ten days or two weeks after, abdominal swelling having manifested itself, he was taken to a physician in a distant portion of the city, who rendered a diagnosis of ascites, and referred him to a physician nearer home for treatment, who, on learning of my connection with the case, returned him to me, with the suggestion that he had abdominal dropsy and would need tapping at once. On exam- ination at this time I found the abdomen evenly distended to its utmost apparent capacity. Tympanitic resonance marked only in the umbilical and right lumbar region; dulness with distinct wave-like fluctuation in both inguinal and hypogastric regions, while in the left lumbar and left hypochondriac regions there was decided flatness on percussion, with presence of a large solid tumor-like mass, which could be distinctly felt through the abdominal wall, and which I believed to be in relation with the spleen. The superficial veins of the abdomen were enlarged and distended, the patient was greatly emaciated and in great distress, owing to the abdominal and thoracic pressure. The respiration very shallow, and averaged about 35 to the minute; pulse 140. Impressed with the fact that we had a more serious condition than abdominal dropsy to deal with, I very reluctantly consented to tapping, which was done in the presence of the physician last spoken of, selecting the median line about the upper border of the hypogastric region, using a simple canulated trocar, removing about twenty-four ounces of sero-sanguinolent fluid and pus, to the great relief of our patient. The distressful breathing giving way to comparative comfort soon followed by refreshing sleep. Flow from the opening left by the trocar continued about twenty hours, discharging in that time probably twenty ounces more of the same sero-sanguinolent fluid. At the end of this time tympanitic distention of the abdomen recurred, attended by a renewal of all the distressful symptoms relating to breathing, etc. Dr. John B. Deaver was then asked in consultation, together with whom and his brother, Dr. H. C. Deaver, laparotomy, splenotomy, or splenectomy were discussed. Physical examination now showed pulse I6O ; respiration 4o; temperature IO4° F.; abdomen generally distended, favoring in fulness the left side; no fluctuation, but marked tympanitic I54 James M. Brown. resonance everywhere, excepting within an area marked by a line com- mencing anteriorly between the tenth and eleventh ribs at junction of posterior axillary 1ine, extending upward and backward for five inches to the spine of the eleventh dorsal vertebra, bounded in front and below by a line from same starting-point, obliquely downward and backward to midway between the last rib and crest of ilium, thence more directly backward to about the fourth lumbar vertebra; elsewhere resonant excepting a circular area two inches in diameter in front of the anterior axillary line at the upper left border of the umbilical region, thus making the two areas of flatness with well-marked intervening per- cussion resonance, which is held by some as diagnostic of spleen FIG. I. abscess. (See accompanying diagrams.) After due consideration it was decided to first use the aspirating needle in exploring the left lumbar region, which resulted in finding about an ounce and a half of this same sanguinolent fluid and pus. An incision was then made through the skin and lumbar fascia down to and laying bare the spleen, which organ was seen to make regular excursions upward and downward, corresponding to the movements of the diaphragm in respiration. Exploration disclosed a nodular mass, involving and uniting the several tissues and organs of the locality, so that further operative procedure was not to be thought of. A drainage-tube was Multiple Sarcoma of the Abdomen. I55 inserted and the wound closed by interrupted sutures. With the patient under ether the operation lasted but a few moments, and was done rigidly aseptic. Death, already imminent, took place about two hours after, no doubt hastened by surgical shock and by ether. On post-mortem examination, twenty-two hours after death, the abdomen was greatly distended by gas, and the presence of the drain- age-tube was noted externally, in the left lumbar region, on the outer side of the erector spinae muscle. On cutting through the tissues of the chest and abdomen, there was free flow of malignant odematous fluid. The great omentum was much thickened from malignant Odema FIG. 2. and purulent infiltration, and shows many small nodules from a pin- head to a pea in size, some soft and friable, others more firm and pro- tected by the layers of the peritoneum, and are apparently due to infil- tration from the new growth which was found later in connection with deeper structures. Surrounding the spleen was a large amount of lymph, partly purulent, partly organized into firm nodular masses about the size of a marble, with connecting bands and trabecula, firmly adherent to the stomach, liver, and other surrounding parts; the mass just alluded to is a neoplasm, evidently of sarcomatous character, and involved also the peritoneum, pancreas, stomach, liver, and dia- 156 James M. Brown. phragm, and possibly all the lymph-glands. On section, it proved to contain an abscess cavity, which at the point of adhesion to the stomach communicated with it through a large perforating ulcer posteriorly, and by a smaller opening through its anterior wall with the peritoneal cavity; the necrotic change, having taken place in the neoplasm pri- marily and subsequently by a process of ulceration, involved the cavi- ties just mentioned ; that portion of the new mass containing the abscess was in intimate union with the spleen ; dissection showed, how- ever, that this organ was not involved primarily, its capsule was thick- ened, and even where not attached to the mass, was irregularly covered with deposits of lymph ; the organ was slightly hypertrophied and of softer consistence than normal, its pulp pale red or pink. The nodes of the tumor mass surrounded the spleen and were attached to its cap- sule, and extended along the common duct to the cystic and hepatic ducts, over the surface of the gall-bladder, hepatic vessels, and ducts, and infiltrated the tissues of adjacent portions of the liver about one inch or more in depth. The liver is not otherwise involved, except that there is cloudy swelling ; kidneys not involved, and normal with the exception of cloudy swelling; whole peritoneum is studded with deposits from the tumor growth, it is much thickened, and its cavity contains several ounces of grumous bloody fluid ; it is not perforated by the incision at point of operation, and the drainage-tube does not enter the peritoneal cavity. Lymph-glands are but slightly involved, and generally exhibit cloudy swelling. Alimentary canal throughout presents nothing abnormal. The diaphragm is infiltrated and fully four times its usual thickness; the new growth extending through and beyond it into the mediastinum and anterior chest-wall, especially involv- ing that part of the pleura covering the under surface of the lungs, or lining the anterior mediastinum and anterior chest-wall, with nodular masses and organized lymph patches uniting the pleural surfaces. Both pleural cavities and the pericardium contained a large amount of turbid fluid. Pulmonary tissue Odematous, boggy, and congested. Heart slightly dilated, stopped in diastole, both sides filled with dark clots; muscular tissue, orifices, and valves normal. Pericardium thickened with patches of recently-deposited lymph here and there over its surface. The death of Dr. Formad, who conducted the autopsy, resulted in losing all trace of the specimens, and thus prevented a further study microscopically. Interesting as proved the study of the various conditions of this case in life, or of the lesions revealed post-mortem, it continued to attract unusual attention by what seemed very contradictory phases in its medico-legal aspect. - The alleged perpetrator of the abuse having been arrested imme- diately on its infliction, and placed under bond for appearance at court, Multiple Sarcoma of the Abdomen. I57 charged with aggravated assault and battery, was now, on the death of the child, rearrested on the more serious charge of murder, and after languishing in prison about a month, brought to trial,—where a strong chain of evidence was adduced establishing the commission of an assault and injury, and its relation to the death of the child. The unexpected change of attitude, on cross-examination, by the defence, of one whose testimony wholly related to the post-mortem dis- coveries, the nature, cause, and origin of sarcomatous growths, led the district attorney to ask an abandonment of the case; the learned judge concurring, holding that, while the testimony just adduced in relation to such growths, show that they are considered to be of unmistakable inflammatory origin, associated with a history of traumatism, yet the impossibility to always trace them to such origin, or preclude their pos- sible prenatal existence, would give room for such a reasonable doubt as to their cause in this case, as to justify an abandonment of the prosecu- tion. Or again, though it might be shown that in a pre-existing growth or structure, in itself necessarily fatal, at a more or less remore period, there had been set up as a result of the injury inflicted, a new, and more or less separate train of morbid changes, which hastened the fatal termi- nation, it would not constitute murder, and the charge must fall. The former charge of aggravated assault and battery, being in no way annulled by this decision, and remaining still in force, was at a subsequent term of court pressed to trial, resulting in a verdict of “not guilty.” Such a verdict being due in a measure, perhaps, to lack of interest by the prosecuting officer after the disastrous result of the former trial. The broken-hearted condition of the parents of the child, grieving not only at his untimely end, but also at their inability to secure re- dress for the great wrong perpetrated, awakened a friendly interest in one who had heard their sad story, and who, through sympathy re- ferred them to his own attorney, asking his kindly offices in their behalf, who, after a careful investigation of the facts of the case, brought suit for damages. Viewed in the light of the results of the former trials the ground on which such an action could rest was, perhaps, too narrow and insufficient to be grasped by other than a legal mind. An aggressive suit was maintained, which, though sharply contested, re- sulted in a verdict for damages in the amount of Iooo dollars. Sin- gular to relate, this sum was the amount by which the defendant was held in bond by reason of his absence in a distant State, his personal presence not being an absolute necessity at the time of trial. The writer desires to acknowledge his indebtedness to Wendell P. Bowman, Esq., for a careful and critical review of the medico-legal portion of this article. 158 - William S. Carter. LEUCOCYTOSIS." By WILLIAM S. CARTER, M.D., Assistant Demonstrator of Pathology, University of Pennsylvania; Pathologist to the Children's Hospital. (CONCLUDED FROM PAGE 93.) UNDER the last heading (that of infections) we found that leucocy- tosis exists in all of the common infectious processes, except tubercu- losis, typhoid fever, and measles. In the case of typhoid fever there may be an actual diminution in the total number of leucocytes, but there is a characteristic alteration in the proportion of the different forms, Hthe large mononuclear leucocytes, and especially the younger ones, being increased, while the multinuclear forms are decreased in number. In scarlet fever there is also a difference in the fractional count,- the eosinophiles being more abundant than in normal blood. The question naturally arises, What is the cause of the leucocy- tosis of infections? The first thing to suggest itself is that we have some localized inflammatory process in these conditions. While this is true, it must be borne in mind that the extent of the inflammation bears no relation to the degree of leucocytosis, as has been stated in pneumonia and in peritonitis. Further, we find extensive localized cellular infiltrations in tuberculosis and typhoid fever, and less severe catarrhal inflamma- tions of the mucous membranes in measles. - In all the infections there is more or less change in the lymphoid structures of the body, particularly the lymph-glands, which show a distinct hyperplasia. This condition is also present in measles, and is probably no more marked in any infections than in tuberculosis and typhoid fever. Let us consider other conditions present in infections which might be causal of leucocytosis. - - A very constant condition is that of pyrexia; there is commonly an altered degree of coagulability of the blood ; there is often an alter- ation in the alkalinity of the blood ; in all of the infections we have bacterial products entering the blood in variable quantities. These last may be grouped under the general term toxines. Considering first the question of pyrexia, we do not find the degree of leucocytosis bearing any relation to the body temperature in any of the infections. Fever may be present in tuberculosis and measles, with- * Paper read before the Society for Clinical Research, Philadelphia, May 22, 1894. Zeucocytosis. I59 out any alteration in the number or kinds of leucocytes, while typhoid fever with its marked tendency to pyrexia shows no leucocytosis, unless there be some complication of an inflammatory nature. It has, however, been stated by Rorighi, and also by Ischlenoff, that fever experimentally produced in animals causes a diminution in the number of leucocytes. In order to determine what effect pyrexia itself, independent of bacterial poisons, has upon leucocytes, the following experiments were undertaken : EXPERIMENT I.—White rabbit of medium size. 2 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 6,800,000 Rectal temperature = 40.2°C. . . . . . . . W. B. C., Io, Ooo Placed in hot box, with dry air at temperature of 60° C. 3 P.M. Rectal temperature 42.0°C. Placed in hot box again, at temperature of 65.5°C. 3.45 P.M. . . . . . . . . . . . . . . . . . . R. B. C., 6,900,000 Rectal temperature = 42.5°C. . . . . . . . W. B. C., I4,Ooo Many free nuclei were found grouped together in masses. Placed in hot box, temperature 54.5°C. 5. IO P. M. . . . . . . . . . . . . . . . . . . R. B. C., 8,000,000 Rectal temperature = 42.8°C. . . . . . . . . W. B. C., 17,ooo 5.45 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 7,850,000 Rectal temperature = 42.3°C. . . . . . . . W. B. C., II,000 Next day . . . . . . . . . . . . . . . . . R. B. C., 6,800,000 Rectal temperature = 40.8°C. . . . . . . . W. B. C., I2,400 HºxPERIMENT II.--White rabbit. I P.M. Rectal temperature = 40.8°C. . . . R. B. C., 6,330,000 W. B. C., 4,OOO 2. I5 P.M. Placed in hot box, temperature 49°C., gradually in- creased to 65.5°C. (dry air). 3 P.M. Rectal temperature = 42.2°C. 3.50 P.M. Rectal temperature = 43.2° C. 4.30 P.M. . . . . . . . . . . . . . . . . . . R. B. C., 4,420,000 W. B. C., 5,33O 5.og P.M. Rectal temperature = 43. I* C. 5.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 5,040,000 - W. B. C., 7,300 Many free nuclei in the field. Next day . . . . . . . . . . . . . . . . . R. B. C., 4,250,000 |B . C., 6,375 I P. M. . . . . . . . . . . . . . . . . . . . R. B. C., 4,725,000 Hb = 55 per cent. (Gowers's apparatus) . . . W. B. C., 9,375 I. 3O P. M. . . . . . . . . . . . . . . . . . R. B. C., 4,775,000 Rectal temperature = 39.8° C. . . . . . . . W. B. C., 5,250 Placed in hot box (moist air). I6O William S. Carter. 2 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 4,750,000 Rectal temperature = 41.8° C. . . . . . . . . W. B. C., 6,250 2.45 P.M. Rectal temperature = 39.2° C. Placed in hot box again. Air saturated with moisture. 3. O5 P.M. . . . . . . . '• • * * * . . . . . R. B. C., 4,225,000 Rectal temperature = 42.5°C. . . . . . . . W. B. C., 6,250 Hb = 48 per cent. EXPERIMENT IV.-Maltese rabbit. 2 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 5,900,000 Hb = 58 per cent. . . . . . . . . . . . . . W. B. C., 6,26o 3 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 5,550,000 Rectal temperature = 40.0° C. . . . . . . . W. B. C., 9,3OO Placed in hot box (moist air). 4. I5 P.M. . . . . . . . . . . . . . . . . . . R. B. C., 4,637,000 Rectal temperature = 43.0°C. . . . . . . . W. B. C., 6,250 Hb = 54 per cent. ExPERIMENT V.-Dog ; weight, 9.01o kilos. 2 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 3,8oo, OOO Rectal temperature = 39.5°C. . . . . . . . W. B. C., 5, IOO 3 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 4,700, OOO W. B. C., Io, Ooo 3.45 P.M. Placed in hot box (dry air) at temperature of 58° C. 4.20 P.M. Rectal temperature = 40.0° C. Respiration very rapid. 4.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 4,460,000 Rectal temperature = 40.5°C. . . . . . . . W. B. C., 9,300 ExPERIMENT VI.—Same dog as in Experiment V. I2 flood . . . . . . . . . . . . . . . . . . R. B. C., 5, 160,000 Rectal temperature = 39.5°C. . . . . . . . W. B. C., II, ooo 12. I5 P.M. Placed in hot box (dry air). Temperature gradually raised from 48° to 65.5°C. tº I.OO P.M. Rectal temperature = 39.7° C. I.45 P.M. & © { { 40.2° C. 2. I5 P.M. & £ { { 40.5° C. 3.OO P.M. ( & ( & 4I.o° C. 3. I5 P.M. . . . . . . . . . . . . . . . . . R. 5,570, OOO Placed in hot box again. 4. I5 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6,000, OOO Rectal temperature = 42.0° C. . . . . . . . W. B. C., 15,8oo 5. I5 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6,250,000 Rectal temperature = 41.0°C. . . . . . . . W. B. C., 22,500 – To determine whether or not there was any distinct alteration in the proportions of the different varieties of leucocytes, fractional counts were made of the leucocytes of the dog used in Experiments V and VI. An examination of these results will show that the simple exist- Aleucocytosis. I6 I ence of pyrexia does not cause leucocytosis. The acceleration of circulation is probably greater in thermic fever than in the specific infections, and the vaso-dilatation was very pronounced in all of the animals experimented upon. Experiment V. is e 5 P.M., after being Experiment VI. Experiment V. in Box I Hour 4.15 P.M., after 2 P.M., Normal. Temperature' Production of j Io C. Thermic Fever. Lymphocytes . . . . . . . . . I5.0 per cent. 7.0 per cent. 8.0 per cent. Large mononuclear . . . . . . 5. O { { 6.o { { 4. O { { Transitional . . . . . . . . . . 2. O ( & 7.O { % IO.5 { { Multinuclear . . . . . . . . . 78.o { { 80.0 & 4 78.o { { A very curious condition of the blood was observed in these experi- ments. There were many free nuclei grouped together in masses through- out the field when the blood was examined in the febrile state. It was not observed after the fever had disappeared. This occurred too constantly to be due to coincidence or to faulty technique. The leucocytes which remained intact seemed quite equally distributed throughout the field. These bodies stained fairly well, and gave the appearance of nuclei which had been liberated from leucocytes. They could not have been blood plaques, because they took the stain more readily than these bodies, and because they were observed while counting the blood-cells, —a procedure which would cause blood plaques to disappear. The blood plaques would certainly undergo rapid disintegration when the blood is drawn into the capillary tube of the hemacytometer pipette. This fact would indicate that there is an unusual destruction of leucocytes going on, and we have further evidence of this in that the number of the lymphocytes (the youngest of the leucocytes) appears to be diminished while the transitional forms are increased in number. The proportion of the multinuclear leucocytes need not be altered, provided the death-rate of these (the oldest of the leucocytes) keeps pace with the rate of premature senility of the younger ones. An interesting observation, although without any bearing on leucocytosis, is that in two experiments the amount of hemoglobin was diminished by the fever. The count of the red blood-corpuscles was not of sufficient accuracy in these cases to determine whether or not this was out of proportion to the change in the number of these cells. Having failed to find any numerical change in the leucocytes in simple thermic fever, it seemed desirable to study the blood of some other fever not accompanied by the presence of bacteria in the organism. For this purpose peptone fever was selected, and the following experi- ments performed : I62 William S. Carter. EXPERIMENT I.-Large black dog. 2 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 7,450,000 W. B. C., 21,8oo 3 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 7,800,000 Rectal temperature = 39.0° C. . . . . . . . W. B. C., 18,750 3.45 P.M. Finished injecting 2 grammes peptone (Witte's) into jugular vein. 3.50 P.M. . . . . . . . . . . . . . . . . . . R. B. C., 8,400,000 Rectal temperature = 39.0° C. . . . . . . . W. B. C., 6,250 4. I5 P.M. . . . . . . . . . . . . . . . . . R. B. C., 8,500,000 Rectal temperature = 40.4° C. . . . . . . . W. B. C., 3,500 4.45 P.M. . . . . . . . . . . . . . . . . . . R. B. C., 7,300,000 - W. B. C., 12,000 5.45 P.M. . . . . . . . . . . . . . . . . . . R. B. C., 7,640,000 Rectal temperature = 40.9°C. . . . . . . . W. B. C., Io,250 9 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 8,000,000 Rectal temperature = 4o.o° C. . . . . . . . W. B. C., 18,300 ExPERIMENT II.-Dog of medium size. I2 noon . . . . . . . . . . . . . . . . . . R. B. C., 7,650,000 W. B. C., 20,300 I2.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 7,900,000 Rectal temperature = 39.2° C. . . . . . . . W. B. C., 18,750 I.O5 P.M. Injected into jugular vein, I.5 grammes peptone (Witte's). & 2.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 8,730,000 Rectal temperature = 40.7° C. . . . . . . . W. B. C., 9,375 3.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 8,200,000 Rectal temperature = 40.6° C. . . . . . . . W. B. C., f2,500 5.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 7,400,000 Rectal temperature = 40.3°C. . . . . . . . . W. B. C., 9,300 This dog seemed very sick for a time. The intoxication was much more severe than in any other experiments in which peptone was injected. ExPERIMENT III.-Small dog. 2 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 7,400,000 Hb = IIo per cent. . . . . . . . . . . . . W. B. C., II,000 3 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 8,000,000 Hb = 108 per cent.; rectal temperature = 38.8° C. W. B. C., 40,000 3.20 P.M. Injected into jugular vein I gramme peptone (Witte’s). 4.30 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 8,200,000 Rectal temperature =39.5° c.; Hb = 108 per cent. W. B. C., 14,000 5.2O P.M. . . . . . . . . . . . . . . . . . R. B. C., 8,350,000 Rectal temperatur = 39.4° C. . . . . . . . W. B. C., 12,500 Next day . . . . . . . . • - - - - - - - R. B. C., 6,750,000 Hb = IO5 per cent. . . . . . . . . . . . . . w. B. C., 18,750 Zeucocytosis. I63 EXPERIMENT IV.-Small dog. , I2.30 P.M. . . . . . . . . . . . . . . . . . R. B. C., 7,400,000 W. B. C., I8,750 I P. M. . . . . . . . . . . . . . . . . . . . R. B. C., 7,050,000 W. B. C., 25,000 2 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 7,200,000 Rectal temperature = 38.0° C. . . . . . . . W. B. C., 22,000 5.05 P.M. Injected into jugular vein I gramme peptone (Lehn and Fink's). 5.Io P.M. Severe purging, great prostration. This peptone seems much more toxic than the other. 5.2O P. M. . . . . . . . . . . . . . . . . . . R. B. C., 6,675,000 W. B. C., 9,400 6 P.M., . . . . . . . . . . . . . . . . . . R. B. C., 8,000,000 W. B. C., I2, ooo 9 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 7,800,000 Rectal temperature = 38.8° C. . . . . . . . W. B. C., 23,400 Dog still seems ill, but is not as weak and sick as he was imme- diately after the injection. These experiments show a fever without any increase in the number of leucocytes. There is a very pronounced reduction in the number of leucocytes immediately after the injection, from which there is a gradual return to the normal. This is in accord with the experi- ments of Wright. The fever appears to bear no relation to the number of leucocytes, as it comes on while these cells are diminished in num- ber, and is not altered as they return to the normal number. It seems highly probable that this diminution of the leucocytes is the result of the injection of highly toxic albumoses contained in commercial pep- tone, or at least is not caused by the pyrexia. It has been found by Kanthack and Hankin that the injection of micro-organisms causes a fever in a very short time, and that leucocy- tosis appears later when the fever is falling. I have confirmed this by experiments which will be mentioned later. The second condition existent in infections, mentioned above, as a possible factor in the production of leucocytosis is that of altered coag- ulability. * The experiments made with different peptones show us how the blood of an animal may have its coagulability greatly lessened by peptone without any increase of the leucocytes and only a transient diminution of these cells. Clinically we find that those diseases which present the greatest increase in the coagulability of the blood (pneumonia, diphtheria, and erysipelas) show a very decided leucocytosis. It is found, however, that the increase in the fibrin factors is much more constant than the increase in the number of leucocytes. II I 64 William S. Carter. The following experiments were made to determine what effect the injection of nuclein and calcium chloride would have on the leucocytes. The time was so fully occupied by counting corpuscles that the degree of coagulability could not be determined in all the experiments. a well-established fact, however, that the injection of these substances causes an increased coagulability of the blood. When given, the method recommended by Wright" was employed. ExPERIMENT I.—Pup weighing 4.988 kilos. 2 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 6,450,000 W. B. C., I2,500 2.30 P.M. . . . . . . . . . . . . . . . . . W. B. C., I2,500 3 P.M. Injected (slowly) per jugular vein, 15 cubic centimetres nuclein, diluted with normal salt solution. 3.05 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6,400,000 No white corpuscles could be seen anywhere in counting the corpuscles. In a stained, fixed preparation a few were found, the multinuclear predominating and other forms being present. 3.2O P. M. . . . . . . . . . . . . . . . . . R. B. C., 6,500,000 W. B. C., 6,250 3.45 P.M. . . . . . . . . . . . . . . . . . W. B. C., 4,700 4. I5 P.M. . . . . . . . . . . . . . . . . . W. B. C., 6,250 ExPERIMENT II.--Small dog; weight = 7.256 kilos. I P.M. . . . . . tº ſº e a e e e < e a s a e e R. B. C., 7,250,000 W. B. C., 18,750 2 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 7,500,000 Rectal temperature = 38.7°C. . . . . . . . W. B. C., 21,800 3.30 P.M. Coagulation time = I minute I5 seconds. 3.55 P.M. Injected, per jugular, Io cubic centimetres nuclein,” diluted with 20 cubic centimetres normal salt solution. 4 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 5,210,000 W. B. C., Io,900 4. IO P.M. Coagulation time = I minute 15 seconds. 4.25 P.M. . . . . . . . . . . . . . . . . . R. B. C., 6,900,000 W. B. C., Io,900 4.55 P.M. Rectal temperature = 39.0° C. 5. Io P.M. Coagulation time = I minute I5 seconds. 5. I5 P.M. . . . . . . . . . . . . . . . . . R. B. C., 7, I50,000 W. B. C., 18,750 ExPERIMENT III.—Dog ; weight = Io.23 kilos. I2 floofl . . . . . . . . . . . . . . . . . . R. B. C., 5,650,000 --- - - W. B. C., 15,600 I2.30 P.M. . . . . . . . . . . . . . . . . . . R. B. C., 5,700,000 Coagulation time = 1 minute 45 seconds . . . W. B. C., 17,000 1 British Med. Journ., July 29, 1893. 2 I am indebted to Dr. John H. Musser and to Dr. S. Solis Cohen for this nuclein, which was prepared and given to them by Professor V. C. Vaughan, of the University of Michigan. < Zeucocytosis. I65 3.35 P.M. Injected into jugular vein, 25 cubic centimetres 2-per- cent. solution calcium chloride. 3.40 P.M. . . . . . . . . . . . . . . . . . W. B. C., 25,000 3.45 P.M. Injected 25 cubic centimetres (slowly). 3.52 P.M. Coagulation time = I minute 15 seconds. 4 P.M. Injected 30 cubic centimetres. 4. O5 P.M. . . . . . . . . . . . . . . . . . R. B. C., 5,800,000 W. B. C., 23,450 4. Io Coagulation time = I minute IO seconds. 4.45 P.M. . . . . . . . . . . . . . . . . . R. B. C., 5,500,000 Coagulation time = 58 seconds . . . . . . . W. B. C., 28, IOO ExPERIMENT IV.-Dog ; weight = Io.203 kilos. 2 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 6,600,000 W. B. C., 15,600 4 P.M. . . . . . . . . . . . . . . . R. B. C., 7, OOO,OOO Coagulation time = I minute 15 seconds . . . W. B. C., I2,500 4. I5–4.25 P.M. Injected slowly, per jugular, 150 cubic centimetres of 2.5-per-cent. solution of calcium chloride. 4.25 P.M. . . . . . . . . . . . . . . . . . . W. B. C., 17, 18O 4.30-4.45 P.M. Injected 62 cubic centimetres 5-per-cent. Solution calcium chloride. 4.45–4.50 P.M. Injected 38 cubic centimetres 5-per-cent. Solution. 6 P.M. . . . . . . . . . . . . . . . . . . . R. B. C., 6,700,000 Coagulation time = I minute . . . . . . . . W. B. C., I2,500 These experiments, though too few in number to state positively just what effect nuclein and calcium chloride have upon leucocytes, are sufficient at least to show that the injection of these substances does not cause leucocytosis. When nuclein was injected there was a temporary diminution in the number of leucocytes with a gradual return to the normal, while the coagulability was not materially changed; when calcium chloride was injected the coagulability was distinctly increased with scarcely any change in the number of leucocytes. When the alkalinity of the blood is changed in the infections, it is usually diminished. We have already considered this question of les- sened alkalinity of the blood when speaking of the leucocytosis of cachectic states, and found that this condition, produced experimentally, fails to cause any leucocytosis. Having failed, therefore, to find an explanation of leucocytosis in any of the conditions mentioned above, we are narrowed down to the effect of the toxic substances produced by the micro-organisms causing the disease. As negative evidence, however, fails to carry conviction, we must try to find position and direct evidence on this point. Everard, Demoor, and Massart," working in the University of 1 Annales de l'Institut Pasteur, February 25, 1893. I66 . William S. Carter. Brussels, have made an elaborate study of the modifications of the leucocytes in infection and immunity. Their experiments were made upon guinea-pigs and rabbits. The changes which they observed occurred chiefly in the multinuclear forms, and unless otherwise stated it will be understood these are the leuco- cytes affected. In the following summary of their work the terms hypo- and hyperleucocytosis are used (as in the original paper) to designate a diminution and increase of the leucocytes respectively: I. VIBRIO of METsch NIKoff. (a) Injection of cultures heated to roo° C. (I) In fresh guinea-pigs there is first a hypoleucocytosis soon followed by hyperleucocytosis. (2) In guinea-pigs vaccinated against the vibrio of Metschnikoff there was hyperleucocytosis. (b) Injection of cultures filtered but not heated. (I) In fresh guinea-pigs there was a transient hypoleucocytosis followed by hyperleucocytosis. (2) In vaccinated guinea-pigs there was hyperleucocytosis from the first. (c) Injection of virulent, living micro-organisms. (I) Of four fresh guinea-pigs two died and two recovered. The two which recovered showed a hypoleucocytosis followed by hyperleucocytosis. One that died showed hypoleucocytosis up to death. The other showed hypoleucocytosis followed by hyperleucocytosis. (2) Four guinea-pigs vaccinated against the disease showed distinct hypo- leucocytosis followed by a great hyperleucocytosis. w II. BACILLUS OF HOG CHOLERA. Virulent living cultures. (I) In fresh rabbits hypoleucocytosis was observed increasing up to death. In fresh rabbits which withstood the inoculation and recov- ered there was seen a hypoleucocytosis followed by hyperleucocy- tosis. (2) In vaccinated animals there was hyperleucocytosis in a short time after inoculation. The blood was observed to be rich in multinuclear leucocytes before the inoculation. III. STAPHYLOCOCCUS PYOGENES AUREUS. (a) Rabbits. (1) In those in which death was caused there was little change for twenty- two hours, except a decrease of multinuclear forms. Then there was hypoleucocytosis. (2) In those resisting the infection there was hyperleucocytosis in eight hours. - (b) Guinea-pigs. Total number not changed. Aleucocytosis. 167 IV. ANTHRAX BACILLUS. (a) Rabbits. (1) Fresh rabbits, hypoleucocytosis till death. (2) Immunized rabbits. Before the injection there was a hyperleucocy- tosis. Following the injection there was a transient hypoleucocytosis which rapidly disappeared, and blood returned to condition present before injection. (b) Guinea-pigs. (1) Fresh. Hypoleucocytosis alternating with slight hyperleucocytosis up to death. (2) Animal immune to the vibrio of Metschnikoff. Blood rich in multi- nuclear forms before injection. Hypoleucocytosis alternating with hyperleucocytosis up to death. Death occurred when blood was rich in multinuclear forms. V. BACILLUS OF TETANUS. (a) Fresh rabbits injected with attenuated culture. There was immediately a diminution of the multinuclear forms, but no change in number. Later, hyperleucocytosis appeared, lasted two days, when the blood returned to normal. (b) Guinea-pigs. (1) Fresh : Hypoleucocytosis alternating with hyperleucocytosis until death. (2) Animals immune to vibrio of Metschnikoff. Blood rich in multinuclear leucocytes. There was a temporary hypoleucocytosis followed by hyperleucocytosis which lasted almost till death. At time of death the multinuclear leucocytes were abundant. VI. BAcILLUS MycoTDES (NoN-PATHOGENIc). (a) Rabbits. Slight hypo- followed by a slight hyperleucocytosis. Proportion of multinuclear leucocytes increased. (b) Guinea-pigs. Slight hypo- and hyperleucocytosis. From these results they conclude that, in case the animal succumbs to the infection, there is generally a distinct hypoleucocytosis, increasing up to death. In animals not completely immune this is not strictly true, for there is then a fluctuation between hypo- and hyperleucocy- tosis, -a struggle between the disease and the resistance of the animal, Hyperleucocytosis is present when the animals survive the injection,-- whether the material injected be living cultures, filtered products free from bacteria, or cultures heated to Ioo” C. Hyperleucocytosis is most marked when virulent cultures are used, and least marked when non-pathogenic bacteria are injected. In all cases of hyperleucocytosis there are observed many multinuclear I68 William S. Carter. cells breaking down, liberating granules and nuclei, which show a tendency to become grouped together. In animals made immune in any way there is a decided hyperleuco- cytosis, with a great preponderance of the multinuclear forms. Subse- quent inoculation in such animals shows only slight hypoleucocytosis. Animals made immune to one disease and later infected with another exhibit the same phenomena as a fresh animal, except that death takes place at a time when there are many multinuclear leucocytes in the blood, La condition never seen in fresh animals when death comes on. Kanthack" and Hankin have found that following the injection of the bacillus pyocyaneus or its bacterial product separated from the bacilli, and the vibrio of Metschnikoff, there is immediately a diminution of leucocytes in the blood. Following this, leucocytosis appears at a time when the fever is falling, and often continues after the temperature has fallen to the norm. They also claim that the eosinophiles are greatly increased, while the neutrophiles are scarcely at all increased. These eosinophiles are not phagocytic, and hence an increase in the number of these cells must be for some other purpose than that of phagocytosis. Rieder and others have also shown a transient diminution with a subsequent increase of leucocytes following the injection of bacteria. The following experiments were undertaken with the bacillus pyo- cyaneus and with the bacillus diphtheriae in order to determine what effect fatal and non-fatal doses would have, and also what effect im- munity has upon the leucocytes: I. EXPERIMENTS WITH BACILLUS PVOCYANEUS. Ba:periment I.-Rabbit of Medium Size. February 8, 1894. II A. M. . . . . . . W. B. C., 4,680 3.30 P.M. . . . . . R. B. C., 5, 137,500 3 P.M. . . . . . . . R. B. C., 5,080,000 W. B. C., 8,000 W. B. C., 4,680 4 P.M. . . . . . . . R. B. C., 5,050,000 9 P.M. . . . . . . . W. B. C., 6, ooo W. B. C., 9,375 I2 midnight . . . . R. B. C., 5,200,000 4.20 P.M. Injected subcutaneously I W. B. C., 6,250 cubic centimetre bouillon culture ba- February Io, 1894. . cillus pyocyaneus, three days old in Io A.M. . . . . . . R. B. C., 5,025,000 incubator. * W. B. C., 3,900 8 P.M. . . . . . . . R. B. C., 5, I2O,OOO 3 P.M. . . . . . . . R. B. C., 5,075, OOO W. B. C., 7,OOO W. B. C., 5,400 IO P.M. . . . . . . R. B. C., 5, I25,000 February II, 1894. W. B. C., I,600 Io A.M. . . . . . . R. B. C., 5, 125,000 February 9, 1894. - . - - - - W. B. C., 18,750 I.30 A.M. . . . . . R. B. C., 5,025,000 February 12, 1894. W. B. C., 3,900 I2 M. . . . . . . . R. B. C., 5,050,000 8 A.M. . . . . . . . R. B. C., 5,300,000 Died during night . W. B. C., 21,8oo 1 British Medical Journal, Vol. 1, 1892, p. 1301. Zeucocytosis. I69 Fæperiment II.-Large Rabbit. February 8, 1894. 2.3O P. M. . . . . . R. B. C., 5, 18O,OOO W. B. C., Io,900 3 P.M. . . . . . . . R. B. C., 5,450,000 W. B. C., 7, OOO 3.30 P.M. Injected subcutaneously I cubic centimetre bouillon culture ba- cillus pyocyaneus, three days old in incubator. 3 P.M. . . . . . . . R. B. C., 5,200,000 W. B. C., 3, I25 9 P.M. . . . . . . . W. B. C., 4,700 I2 midnight . . R. B. C., 5,400,000 W. B. C., 4,700 February IO, I894. IO.30 A.M. . . . . . R. B. C., 5,350,000 W. B. C., 4,690 2.3O P. M. . . . . . R. B. C., 5,300,000 W. B. C., 6,000 February II, 1894. 9.30 A.M. . . . . . . R. B. C., 5,350,000 W. B. C., 7,800 February I5, 1894. 8 P.M. . . . . . . . R. B. C., 5,400,000 W. B. C., 6,250 February 20, 1894. R. B. C., 5,450, OOO W. B. C., 30,000 Recovered. Used again in Experiment IV. Fæperiment III.-Large Rabbit (Fresh). 4.3O P. M. . . . . . R. B. C., 5,000, OOO W. B. C., 7,500 7.30 P.M. . . . . . R. B. C., 5,000, ooo W. B. C., 4,700 9.3O P. M. . . . . . R. B. C., 5, I75,OOO W. B. C., I4,060 February 9, 1894. I A. M. . . . . . . . R. B. C., 5,2OO,OOO W. B. C., 4,700 7.30 A.M. . . . . . R. B. C., 5,250,000 W. B. C., Io,900 II A. M. . . . . . . W. B. C., 7,800 February 20, 1894. IO. 3O A.M. . . . . R. B. C., 6,050,000 W. B. C., 28, Ioo II A. M. . . . . . . R. B. C., 5,850, OOO W. B. C., I5,6OO Rectal temperature = 38.8° C. II.35 A.M. Injected into jugular vein 4 cubic centimetres bouillon culture bacillus pyocyaneus, two days old in incubator. R. B. C., 5,500,000 W. B. C., 13,28o Rectal temperature = 40.6°C. February 21, 1894. I A. M. . . . . . R. B. C., 5,700, OOO W. B. C., 6,250 Rectal temperature = 41.1° C. II A. M. . . . . . . R. B. C., 5,8oo, OOO W. B. C., 4,68o IO P. M. . . . . . . R. B. C., 5,900,000 W. B. C., 7,800 Rectal temperature = 39.0° C. Rabbit has aborted; is lying on side and cannot stand up; is apparently mori- bund; 12 midnight found dead. Baºperiment / V.—Large Rabbit used in Experiment II. I2.45 P.M. . . . . . R. B. C., 5,640,000 W. B. C., 3, I25 2 P. M. . . . R. B. C., 5,400, OOO W. B. C., I,560 Rectal temperature = 41.4° C. 4 P.M. . . . . . . . R. B. C., 5,000,000 W. B. C., I7,OOO February 20, 1894. I2.3O P. M. . . . . . R. B. C., 5,450,000 W. B. C., 43,750 I P.M. . . . . . . . R. B. C., 5,550, OOO W. B. C., 26,560 Rectal temperature = 37.5°C. 1.20 P.M. Injected into jugular vein 5 cubic centimetres bouillon culture bacillus pyocyaneus, two days old in incubator. . 2.4O P. M. . . . . . R. B. C., 5,350,000 W. B. C., 14,060 17o William S. Carter. Experiment IV.-Large Rabbit used in Experiment II. 4.20 P.M. . . . . . R. B. C., 5,400,000 W. B. C., 7,810 8 P.M. . . . . . . . R. B. C., 5,600,000 W. B. C., 6,200 February 21, 1894. I A.M. . . . . . . . R. B. C., 5,300,000 W. B. C., I5,600 Rectal temperature = 39.7°C. II A.M. . . . . . . R. B. C., 5,600,000 W. B. C., 25,000 Rectal temperature = 39.8°C. February 22, 1894. R. B. C., 5,500,000 W. B. C., Io,900 Rabbit very ill; lying on side, cannot stand. Rectal temperature = 37.2° C. I2 noon. Convulsion. I2.30 P.M. Died. * @ s sº a tº Experiment V.-Large Rabbit. - February 13, 1894. 5 P.M. Normal . . R. B. C., 5,400,000 W. B. C., I2,500 5.30 P.M. . . . . . R. B. C., 5,050,000 W. B. C., 18,000 6 P.M. Injected subcutaneously 2 cubic centimetres bouillon culture bacillus pyocyaneus, heated to 65° C. for one hour. Culture three weeks old at room temperature. February 16, 1894. R. B. C., 5,000,000 W. B. C., IO, I5O Injected 5 cubic centimetres three weeks old culture, heated to 68° C. for one hour. February 17, 1894. R. B. C., 4,900,000 W. B. C., Io,850 Injected 5 cubic centimetres bouillon culture bacillus pyocyaneus, heated to 68°C. (as above). February 18, 1894. R. B. C., 4,090,000 W. B. C., 9,400 Injected 2 cubic centimetres of above culture, heated to 68° C. for one hour. February 20, 1894. R. B. C., 5,087, ooo W. B. C., 7,800 Injected 3 cubic centimetres of above culture, heated to 65.o°C. for one hour. Axperiment VI.-Small Rabbit (Fresh). February 26, 1894. 4 P.M. . . . . . . . R. B. C., 5,875,OOO t W. B. C., 9,250 4.30 P.M. . . . . . R. B. C., 4,787,000 W. B. C., 7,800 5.50 P.M. Injected subcutaneously 2 cubic centimetres bouillon culture bacillus pyocyaneus, heated to 60° C. for one hour. Culture six days old at room temperature. February 27, 1894. R. B. C., 5,225,000 . W. B. C., 17,200 Injected 2 cubic centimetres culture used above, heated to 65° C. for one-half hour. w February 28, 1894. R. B. C., 5,080,000 W. B. C., II, ooo March I, 1894. R. B. C., 5,300,000 W. B. C., I3, Ooo Injected 2 cubic centimetres eight days old culture, heated to 65° C. for one hour. - Found dead next morning. As two other rabbits were found dead in the cage at the same time without any apparent cause, it is doubtful if the animal died as a result of the experiment. Zeucocytosis. 171 Experiment VII.-Zarge White A’abbit. February 26, 1894. R. B. C., 4,600,000 3 P.M. . . . . . . W. B. C., 7, IOO 3.45 P.M. . . . . . R. B. C., 4,800,000 W. B. C., 9,200 5 P.M. Injected subcutaneously 2 cubic centimetres bouillon culture bacillus pyocyaneus (six days old), heated to 60° C., one hour. February 27, 1894. . . R. B. C., 5, 150,000 W. B. C., 7, OOO Injected 2 cubic centimetres, culture heated to 65° C. for thirty minutes. February 28, 1894. R. B. C., 5,250,000 W. B. C., 7,8oo March I, 1894. R. B. C., 5,375, OOO W. B. C., 6,200 Injected 2 cubic centimetres eight days old culture, heated to 65° C. for one hour. * * * * g e º dº e e March 5, 1894. 3.3O P. M. . R. B. C., 5,300,000 W. B. C., 4,700 4 P.M. . . . . . . . R. B. C., 5,000,000 A. W. B. C., 9, 200 4.30 P.M. Etherized. Injected into jugular vein 5 cubic centimetres bouil- lon culture bacillus pyocyaneus culture five days old in incubator. R. B. C., 5,350,000 W. B. C., I7,2OO Rectal temperature = 38.4° C. 8 P.M. . . . . . . . R. B. C., 5,087, OOO W. B. C., II, Ooo Rectal temperature = 40.0° C. II P. M. . R. B. C, 5,2OO,OOO W. B. C., I4, OOO Rectal temperature = 39.7°C. I2 midnight . . R. B. C., 4,950, OOO W. B. C., I2,500 March 6, 1894. IO A. M. . . . . . . R. B. C., 5,038,OOO W. B. C., 18,000 3 P.M. . . . . . . . R. B. C., 5,2OO,OOO . B. C., 34,000 Rectal temperature = 39.4° C. 7 P.M. . . . . . . . R. B. C., 5,300,000 W. B. C., 23,500 12 midnight . R. B. C., 4,900,000 W. B. C., 28,900 March 7, 1894. IO A. M. . . . . . . R. B. C., 5,300,000 W. B. C., 20,500 Seems well. March 8, 1894. Animal found dead. Experiment VIII.—A’abbit of Medium Size. March 20, 1894. 3.30 P.M. . . . . . R. B. C., 6,200,000 W. B. C., 6,400 4 P.M. . . . . . . . R. B. C., 5,800,000 W. B. C., 7.8oo 5 P.M. Injected subcutaneously 5 cubic centimetres bouillon culture bacillus pyocyaneus one month old at room temperature, solution heated to 55° C. for fifteen minutes. March 21, 1894. R. B. C., 5,500,000 W. B. C., 6,250 Injected 3 cubic centimetres as above, heated to 55° C. for fifteen min- utes. March 22, 1894. R. B. C., 5,600,000 W. B. C., Io,200 Injected 5 cubic centimetres as above, heated to 55° C. for fifteen minutes. March 23, 1894. . R. B. C., 6,000,000 W. B. C., 6,250 Injected 3 cubic centimetres as above. March 24, 1894. R. B. C., 5,600,000 }; W. B. C., 7,8oo Injected 5 cubic centimetres as above. March 25, 1894. R. B. C., 5,650,000 W. B. C., I2,500 Injected 7 cubic centimetres as above. * * * * * * * * * * tº e º e s we e s ∈ e * * * * * * * * * * 172 William S. Carter. March 26, 1894. Io:30 A.M. . . . . . R. B. C., 5,825,000 W. B. C., I2,500 II A. M. . . . . . . R. B. C., 5,950,000 W. B. C., Io,900 Rectal temperature = 39.8° C. II.30 A.M. Injected into jugular vein 3 cubic centimetres bouillon culture bacillus pyocyaneus. I2.30 P.M. R. B. C., 6, Ioo,000 W. B. C., 3,280 Rectal temperature = 41.0° C. Coagulability of the blood appears to be greatly increased. - © tº * * Temperature 39.8°C. I2 noon . . . . . . R. B. C., 5,700,000 W. B. C., 21,8oo 8 P.M. . . . . . . . R. B. C., 5,500,000 W. B. C., 18,8oo March 28, 1894. * * * * * s e e º e R. B. C., 5,350,000 W. B. C., Io,900 March 29, 1894. IO A. M. . . . . . . R. B. C., 6,000,000 W. B. C., 20,300 IO.30 A.M. . . . . . R. B. C., 5,300,000 W. B. C., 28, Ioo I.30 P.M. Injected subcutaneously 2.5 cubic centimetres bouillon solution of bacillus diphtheriae on blood serum, one week old at room temperature. 5 P.M. . . . . . . . R. B. C., 5,240,000 W. B. C., 20,300 1O.30 P.M. . . . . . R. B. C., 5, 125,000 W. B. C., 21,875 March 30, 1894. 8 A.M. . . . . . . . R. B. C., 5,350,000 W. B. C., 6,250 II A. M. . . . . . . R. B. C., 5,650,000 - W. B. C., 9,350 4 P.M. . . . . . . . R. B. C., 5,400,000 W. B. C., 7,800 IO P.M. . . . . . . R. B. C., 5,300,000 W. B. C., I4,000 March 31, 1894. IO A. M. . . . . . . R. B. C., 5,575,000 W. B. C., 12,500 2 P.M. . . . . . . . . . & e s e e o e e W. B. C., I2,500 II. ExPERIMENTs witH BAcILLUs DIPHTHERIAE. Experiment I.—Half-grozem Rabbit. 2 P.M. . . . . . . . R. B. C., 6,000,000 W. B. C., 8,500 Rectal temperature = 41.1° C. 3 P.M. . . . . . . . R. B. C., 6,200,000 - W. B. C., 26,500 Animal lively and eats freely. 4.3O P.M. . . . . . R. B. C., 5,050,000 W. B. C., 38,120 Rectal temperature = 40.1° C. 6.30 P.M. . . . . . R. B. C., 5,600,000 W. B. C., 74,200 Rectal temperature = 39.8°C 8 P.M. . . . . . . . R. B. C., 5,555,000 W. B. C., 72,OOO Rectal temperature = 39.9°C II.30 P.M. . . . . ‘. R. B. C., 5,700,000 W. B. C., 79,700 Rectal temperature = 39.8°C. March 27, 1894. 8 A.M. . . . . . . . R. B. C., 6,000,000 W. B. C., 35,900 II A.M. . . . . . . R. B. C., 4,800,000 W. B. C., I2,500 II.30 A.M. . . . . . R. B. C., 4,900,000 W. B. C., I5,600 2.30 P.M. Injected subcutaneously four cubic centimetres of bouillon solution of bacillus diphtheriae on blood se- rum, one week old ; takeri from very malignant case of diphtheria. 5 P.M. . . . . . . . R. B. C., 4,500,000 W. B. C., 7,800 IO P.M. . . . . . . R. B. C., 4,650,000 W. B. C., I2,500 Next day found dead. Leucocytosis. I73 Baºperiment II.-Half-grown Rabbit. I2 11OO11. . . . . . R. B. C., 4,300,000 W. B. C., 25,000 I2.30 P.M. . . . . . R. B. C., 4,600,000 W. B. C., 29,8oo I.30 P.M. Injected subcutaneously 2.5 cubic centimetres bouillon solution of bacillus diphtheriae, as in Experiment Experiment III.-Rabbit of Medium Size. March I5, 1894. 3.30 P.M. . . . . . R. B. C., 6,325,000 W. B. C., 7,81o 4 P.M. . . . . . . . R. B. C., 6,250,000 W. B. C., I2,500 6 P.M. Injected subcutaneously 5 cubic centimetres bouillon culture of bacil- lus diphtheriae, two days old, in incu- bator. 5 P.M. . . . . . . . R. B. C., 4,400,000 W. B. C., IO,93O 8 P.M. . . . . . . . R. B. C., 4, IOO,OOO W. B. C., I5,6OO Died during night. March 17, 1894. 3 P.M. . . . . . . . R. B. C., 5,000, OOO W. B. C., 6,250 March 18, 1894. 3 P.M. . . . . R. B. C., 5,000, OOO W. B. C., 6,250 Animal showed no symptoms up to this date. March 22, 1894. R. B. C., 5,000,000 W. B. C., I5,000 This is the first time the animal has shown any effect from injection. Was found lying on side at this time, very weak, and completely paraplegic. R*spirations very rapid. March 24, 1894. Found dead this morning. * & © a g g Experiment / V.—Rabbit of Medium Size. IO P. M. . . . . . . R. B. C., 5,750,000 W. B. C., 7,800 March 16, 1894. IO A.M. . . . . . . R. B. C., 5,400,000 W. B. C., 3, I25 5 P.M. . . . . . . . R. B. C., 4,650,000 W. B. C., 6,250 March I5, 1894. 2 P.M. . . . . . . . R. B. C., 5, 175,000 W. B. C., 9,400 2.3O P.M. . . . . . . R. B. C., 4,900,000 W. B. C., I4,OOO 5.30 P.M. Injected subcutaneously five cubic centimetres bouillon culture of bacillus diphtheriae, two days old, in incubator. (The micro-organism had been shown to be pathogenic by pre- vious injection of guinea-pigs.) March 16, 1894. IO.30 A.M. . . . . . R. B. C., 4,500,000 W. B. C., 7,000 5.30 P.M. . . . . . R. B. C., 4,525,000 W. B. C., 3, IOO March 17, 1894. 3 P. M. . . . . . . . R. B. C., 4,250,000 W. B. C., 9,000 March 18, 1894. 3 P.M. . . . . . . . R. B. C., 4,300,000 W. B. C., March 22, 1894. Io P.M. Found dead. Had shown abso- lutely no symptoms previous to this date, and could not have been sick for a very long time, as he did not attract attention when seen in the morning of this date. 7,800 I74 William S. Carter. Ea:periment V.—Large White Rabbit. March 2, 1894. Normal . . . . . . R. B. C., 5,040,000 W. B. C., 7,000 Normal . . . . . . R. B. C., 4,840,000 W. B. C., 7,800 Injected subcutaneously 2 cubic centi- metres bouillon solution of bacillus diphtheriae on blood serum, three weeks old (in dark). March 4, 1894. s e e º 'º e s e º e R. B. C., 4,500,000 W. B. C., 25,000 March 5, 1894. e e º 'º e º 'º e º e R. B. C., 4,300,000 W. B. C., I7,000 March 6, 1894. * * * * * * e º is s R. B. C., 4,600,000 W. B. C., 18,000 Recovery. Faperiment VI. March 2, 1894. Normal . . . . . . R. B. C., 4,600,000 W. B. C., Io, Ioo Normal . . . . . . R. B. C., 4,750,000 W. B. C., II,000 Injected 2 cubic centimetres bouillon solution of bacillus diphtheriae on blood serum, three weeks old (in dark). - March 4, 1894. * @ tº e º e s e º e R. B. C., 4,000,000 W. B. C., 60,600 March 5, 1894. s e e º e s is a s a R. B. C., 4,200,000 W. B. C., 25,800 March 6, 1894. * * * * e s = e e R. B. C., 4,275,000 W. B. C., 16,500 Recovered. Ea:periment VII.—Medium Sized Rabbit. March I, I894. O Normal . . . . . . R. B. C., 5, I50,000 W. B. C., 6,250 Normal . . . . . . R. B. C., 5, IOO,OOO W. B. C., 7,000 3 P.M. Injected subcutaneously culture of bacillus diphtheriae on blood serum (two days old). March 2, 1894. as e º e º e º e º tº R. B. C., 5,2OO,OOO W. B. C., Io, I60 March 3, 1894. e e s & © tº . . R. B. C., 4,875,000 W. B. C., I2,500 March 4, 1894. & º e º 'º & tº e º & R. B. C., 4,850,000 W. B. C., 18,700 March 7, 1894. • . . . . . . . . . . R. B. C., 4,212,000 W. B. C., 9,350 Very lively. * * * c e e º e º e R. B. C., 4,125,000 W. B. C., II,7oo 5 P.M. Injected subcutaneously 2 cubic centimetres bouillon solution of bacil- lus diphtheriae, five days old on blood serum. (Same culture killed a guinea- pig in forty-two hours.) March 8, 1894. e e s e º e s e 8 º' R. B. C., 4,875,000 W. B. C., 28, Ioo March 9, 1894. * * * e s e º s e e R. B. C., 4,900,000 W. B. C., 22,600 March Io, 1894. * * * * g e º 'º e ſº R. B. C., -— W. B. C., 25,8oo March II, 1894. * * * g e g º 'º gº e R. B. C., 5,200,000 W. B. C., 18, ooo March 13, 1894. . . . . . . . . . . R. B. C., 5,000,000 W. B. C., 8,650 Recovered. *: Leucocytosis. I75 Faperiment VIII.-Small Rabbit. March I, I894. Normal . . . . . . R. B. C., 5,750,000 W. B. C., 6,250 Normal . . . R. B. C., 5,480,000 W. B. C., 5,450 3 P.M. Injected as in Experiment VII. March 2, 1894. R. B. C., 5,225,000 W. B. C., 21,900 Some edema at seat of inoculation. March 3, 1894. R. B. C., 5,700, OOO W. B. C., 21,850 March 4, 1894. R. B. C., 5,000, Ooo - W. B. C., II,7oo March 7, 1894. . R. B. C., 5, I4O,OOO W. B. C., 8,600 I2 11OO1] * * * @ e º 'º e e a 5 P.M. R. B. C., 5,2OO,OOO W. B. C., 7,800 Injected 2 cubic centimetres bouillon solution, same culture as used in Experiment VII. March 8, 1894. • tº e s - e º 'º e = Earperiment IX.—Full Grozem Rabbit. March I, I894. R. B. C., 4,950,000 W. B. C., 4,OOO R. B. C., 5,090,000 W. B. C., 5,470 Inoculated as in Experiment VII. March 2, 1894. . R. B. C., 4,800,000 • * * * * * * * * * W. B. C., 23,400 Edema at point of inoculation. March 3, 1894. tº e º tº º e o e º e , R. B. C., 4,612,OOO W. B. C., 25, ooo March 4, 1894. • * * * * * * * * * R. B. C., 4,725,000 W. B. C., 49,2OO Seems quite ill; edema persists. March 5, 1894. s º e º ſº tº s s e e R. B. C., 4,525,000 W. B. C., 15,600 Earperiment X. —Rabbit of Medium Size. April 2, 1894. R. B. C., 5,025,000 W. B. C., I4,000 . B. C., 5, 125,000 . B. C., I2,500 R W 4 P.M. . . . . . . . R. B. C., 4,837,OOO W. B. C., II, Ooo March 9, 1894. • * a v * * e e º 'º' R. B. C., 5, IOO,OOO W. B. C., 34,300 March IO I894. • s • * * * * * * * R. B. C., -— W. B. C., 25, OOO March I2, I894. e e s e e s e e º is R. B. C., 5, O75,000 W. B. C., 21,000 Recovered. March 7, 1894. º e º º ſº e e º º º R. B. C., 4,475,000 W. B. C., 6,250 5 P.M. Injected 2 cubic centimetres, same solution as used in Experiments VII and VIII. March 8, 1894. R. B. C., 4,575,000 W. B. C., 23,450 March 9, 1894. e e s e e º e o e a R. B. C., 4,800,000 W. B. C., 36,700 March Io, I894. * * * * * * * * * * R. B. C., -— W. B. C., 54,700 March I 2, 1894. e - e º 'º - e. e. . R. B. C., 5,000,000 W. B. C., 2O,3OO Recovered. 5 P.M. Injected 4 cubic centimetres bouillon solution of bacillus diph- theriae, two weeks old on blood se- rum. Solution heated to 68° C. for one hour. º William S. Carter. Experiment X—Rabbit of Medium Size. April 3, 1894. R. B. C., 5,000,000 W. B. C., 22,650 April 5, 1894. R. B. C., 4,850,000 W. B. C., 8,600 Injected 3 cubic centimetres as above, heated to 68° C. April 6, 1894. * * * * * * e s e a R. B. C., 5,000,000 W. B. C., 9,400 • * * * * * a s a s Injected 3 cubic centimetres as above, heated to 68° C. - April 7, 1894. R. B. C., 4,950,000 W. B. C., 8,000 Injected 2 cubic centimetres buillon so- lution of bacillus diphtheriae on blood serum three weeks old. Solution heated to 68° C. April 9, 1894. . . R. B. C., 4,600, OOO W. B.C., 12,500 * * * * * g g g g tº tºs e †e ge gº g * © Earperiment XI.-Large White Rabbit. April 2, 1894. Normal . . . . . . R. B. C., 5,000,000 W. B. C., 17,000 Normal . . . . . . R. B. C., 4,700,000 W. B. C., 12,500 5 P.M. Injected 4 cubic centimetres bouillon solution, heated to 68° C. for one hour. April 3, 1894. R. B. C., 4,800,000 W. B. C., I2,500 April 5, 1894. . R. B. C., 4,875,000 W. B. C., Injected 2 cubic centimetres as in Ex- periment VIII, heated to 68° C. II,7OO April 6, 1894. - R. B. C., 5,000,000 W. B. C., II,7oo Injected 3 cubic centimetres buillon so- lution, as in Experiment X, at the same time. • * * * e s e s e e April 7, 1894. R. B. C., 4,900,000 W. B. C., II,7oo Injected 2 cubic centimetres, heated to 68° C. as in Experiment X. April 9, 1894. R. B. C., 4,800,000 W. B. C., Io,900 e is e º 'º e º e o e s & e º e s e e º & Baºperiment XII.-Large Healthy Rabbit. April Io, 1894. Normal . . . . . . R. B. C., 4,350,000 W. B. C., 7,800 Second count . . R. B. C., 4,325,000 W. B. C., 9,37O 7.30 P.M. Injected 2.5 cubic centimetres bouillon solution bacillus diphtheriae from blood-serum tube three weeks old. Solution heated to 55° C. for fif- teen minutes. Blood serum culture was very malignant, killing a small rabbit in twenty-four hours. April II, 1894. - R. B. C., 4,700,000 W. B. C., 6,250 5.30 P.M. Injected 2.5 cubic centimetres as above, heated to 55° C., for fifteen minutes. Q: g te c º e º e º e April 12, 1894. 6 P.M. . . . . . . . R. B. C., 4,400,000 W. B. C., 6,250 April 13, 1894. IO A.M. . . . . . . R. B. C., 4,650,000 W. B. C., 7,800 Injected 2.5 cubic centimetres as above. April I4, 1894. P.M. . . . . . . . R. B. C., 4,500,000 W. B. C., 9,3OO Injected 2.5 cubic centimetres. * April 15, 1894. Io P.M. . . . . . . R. B. C., 4,800,000 W. B. C., 6,250 April 16, 1894. IO A.M. . . . . . . R. B. C., 4,700,000 W. B. C:, 4,7oo Leucocytosis. 177 Experiment XII.-Large Healthy Rabbit. Injected 3 cubic centimetres bouillon solution as above, heated to 58° C. for thirty minutes. April 17, 1894. R. B. C., 4,600,000 W. B. C., 7,800 Injected 2.5 cubic centimetres solution, heated to 58° C. for thirty minutes. April 18, 1894. IO A.M. . . . . . . R. B. C., 4,400,000 W. B. C., II, OOO IO.30 A.M. . . . . . R. B. C., 4,775, OOO W. B. C., I7,OOO Io.35 A.M. Injected 5 cubic centimetres bouillon solution virulent diphtheriae cultivated on blood serum. Culture four days old. Proved to be patho- genic by injection of half-grown rabbit. R. B. C., 5,050,000 W. B. C., 4,7OO Coagulability of blood increased. I P.M. . . . . . . . R. B. C., 4,450,000 W. B. C., I5,6OO 4 P.M. . . . . . . . R. B. C., 4,325,000 W. B. C., Io,900 Seems very ill; will not eat. 8 P.M. . . . . . . . R. B. C., 4,375,000 W. B. C., 25, OOO IO.30 P.M. . . . . . R. B. C., 4,325, OOO W. B. C., 2O,3OO April 19, 1894. 8.30 A.M. . . . . . R. B. C., 4,550, OOO W. B. C., 3I,2OO II.30 A.M. . . . . . R. B. C., 4,500,000 - W. B. C., 46,800 2 P.M. . . . . . . . R. B. C., 4,475, OOO W. B. C., 34,370 6 P.M. . . . . . . . R. B. C., 4, IOO,OOO W. B. C., 28, Ooo April 20, 1894. 9 A.M. . . . . . . . R. B. C., 4,275,000 W. B. C., I 7,300 2 P.M. . . . . . . . R. B. C., 4,025,000 W. B. C., I8,750 9 P.M. . . . . . . . R. B. C., 4,050, OOO W. B. C., 20, ooo April 21, 1894. I2 11OO11 . . . . . . R. B. C., 4,325,000 W. B. C., I2,500 5 P.M. . . . . . . . R. B. C., 4,075, Ooo W. B. C., Io,900 Animal recovered. Ba:periment XIII.-Zarge Healthy Rabbit. April Io, 1894. R. B. C., 4,425,000 W. B. C., I7,OOO R. B. C., 4,825,OOO W. B. C., II, OOO 7.45 P.M. Injected 2.5 cubic centimetres, same solution as used in Experiment XII, heated to 55° C. for fifteen min- utes. * @ 9 - Q & April I º 1894. II A.M. . . . . . . R. B. C., 4,900, OOO W. B. C., I2,500 5.45 P.M. Injected 2.5 cubic centimetres solution used in Experiment XII. April 12, 1894. R. B. C., 5, IOO,OOO * * * * * * * * * * W. B. C., I4, OOO April 13, 1894. • a e e s a s e a e R. B. C., 4,900,000 W. B. C., 18,700 Injected 2.5 cubic centimetres as above. April I4, 1894. R. B. C., 5,200, Ooo W. B. C., 2 I, OOO Injected 3 cubic centimetres as above. April 15, 1894. R. B. C., 5,000,000 W. B. C., 12,500 April 16, 1894. R. B. C., 4,850,000 W. B. C., IO,900 Injected 3 cubic centimetres bouillon solution as above, heated to 58° C. for thirty minutes. April 17, 1894. R. B. C., 4,725,000 W. B. C., 9,40O Injected 2.5 cubic centimetres as April I6, 1894. April 18, 1894. R. B. C., 5,075, OOO W. B. C., 9,400 178 William S. Carter. Experiment XIII.-Large Healthy Rabbit. 9.30 A.M. . . . . . . R. B. C., 4,800,000 I.30 P.M. . . . . . . R. B. C., 4,500,000 W. B. C., I4,000 W. B. C., 28, Ioo Io.40 A.M. Injected 5 cubic centimetres 5 P.M. . . . . . . . R. B. C., 4,550,000 bouillon solution virulent bacillus W. B. C., 46,8oo diphtheriae, as in Experiment XII. 8 P.M. . . . . . . . R. B. C., 4,600,000 12 noon . . . . . . R. B. C., 5,200,000 W. B. C., 31,200 W. B. C., 3, I2O April 20, 1894. I.2O P.M. . . . . . R. B. C., 5,050,000 9 A.M. . . . . . . . R. B. C., 4,425,000 W. B. C., 25,000 W. B. C., 58,600 3.30 P.M. . . . . . R. B. C., 4,850,000 Appears to be better; eats freely. W. B. C., 21,900 2 P.M. . . . . . . . R. B. C., 4,500,000 Seems very sick. W. B. C., 23,600 7 P.M. . . . . . . . R. B. C., 4,700,000 8 P.M. . . . . . . . R. B. C., 4,800,000 W. B. C., 17,200 W. B. C., 20,300 IO P.M. . . . . . . R. B. C., 4,700,000 April 21, 1894. W. B. C., I5,600 I2 noon . . . . . . R. B. C., 4,650,000 April 19, 1894. W. B. C., I5,600 8 A.M. . . . . . . . R. B. C., 4,850,000 5 P.M. . . . . . . . R. B. C., 4,475,000 W. B. C., 29,700 W. B. C., 9,37O Seems sick. Animal recovered. II A.M. . . . . . . R. B. C., 4,850,000 W. B. C., 39,000 Experiment XIV.-Same Rabbit as used in Experiment XIII (Immune to Piphtheria). April 30, 1894. II P.M. . . . . . . R. B. C., 5,700,000 9 A.M. . . . . . . R. B. C., 5,650,000 W. B. C., 96,000 W. B. C., 12,500 Rectal temperature = 40.1° C. 9.30 A.M. . . . . . R. B. C., 5,780,000 12 midnight . . . . R. B. C., 5,650,000 W. B. C., 17, roo W. B. C., Ioo, Ooo Rectal temperature = 39.5° C. & May I, I894. II.30 A.M. Injected per jugular vein 3 9 A.M. . . . . . . . R. B. C., 5,675,000 cubic centimetres bouillon culture W. B. C., 67, Ioo bacillus pyocyaneus, two weeks old. Temperature = 39.9°C. I P. M. . . . . . . . R. B. C., 5,750,000 I P.M. . . . . . . . R. B. C., 6,050,000 W. B. C., 31,200 W. B. C., 26,500 Rectal temperature = 40.7° C. II P.M. . . . . . . R. B. C., 5,775, OOO 5 P.M. . . . . . . . R. B. C., 5,550,000 W. B. C., 14, Ioo W. B. C., I9,000 Temperature = 40.6°C. Rectal temperature = 40.4° C. Animal recovered. R. B. C., 6,000,000 W. B. C., 26,500 Rectal temperature = 40.2°C. From the foregoing experiments it will be seen that the leucocy- tosis of infection is due to the micro-organisms causing the disease, or to some product or constituent of the same. While the bacillus pyo- cyaneus may be diffused throughout the animal, the bacillus diphtheria remains at the local focus of infection, with rare exceptions. Zeucocytosis. I79 Animals inoculated with either micro-organism in such a way or of such virulence as to cause death, may show either a subnormal number of leucocytes up to death, or there may be periods in which leucocytosis is present, alternating with this condition. A diminished number of leucocytes is the immediate result of all the inoculations. When the animal resists the disease, a more pronounced leucocy- tosis is present than is found in those cases terminating fatally. Immunization by repeated injections of heated cultures fails to cause any change in the number of leucocytes. Subsequent inoculations in such animals show a much greater leucocytosis than animals resisting the infection without having been immunized. - When immunization had not been complete so that injection of bacillus pyocyaneus into the vein caused death, there was decidedly a greater leucocytosis than in ordinary fatal cases in animals not at all protected by immunizing materials, evidence of a struggle between the infecting material and the resistance of the animal economy. An animal immunized to bacillus pyocyaneus showed very slight change in his leucocytes when inoculated with diphtheria (except a diminution in number soon after the injection). An animal immunized to diphtheria and afterwards injected with bacillus pyocyaneus showed a more pronounced leucocytosis than when inoculated with a virulent culture of bacillus diphtheriae. At first sight the facts that leucocytosis is present in fatal cases in man and is absent in fatal cases in rabbits may seem discordant. In the rabbit the poison was overwhelming, and death occurred very rapidly, while in man the cases were of longer duration, the resistance was greater, and hence we would expect leucocytosis. Perhaps it would have been better had guinea-pigs been used for the experiments with the bacillus diphtheriae, but rabbits were selected because a greater number of blood examinations could be made from these animals. The clinical and experimental facts are in harmony:-Mild infec- tions with easy recovery show slight leucocytosis; severe cases termi- nating fatally either because the infecting agent is unusually severe or because the resistance is slight, show feeble leucocytosis; severe in- fections with a powerful resistance show the greatest leucocytosis. The writer regrets his inability, on account of other duties, to make fractional counts in the case of immunity and infections, as it has been found that the former condition produces a great excess of the multinuclear forms (Everard, Dernoor, and Massart), and that the latter causes an increase of the eosinophiles (Kanthack and Hankin). What does the leucocytosis of infections signify It was claimed I2 I8O William S. Carter. by Werigo that the diminished number of leucocytes immediately after the injection of bacteria was due to an accumulation in the internal organs of the leucocytes which had swallowed up the bacteria. This cannot be, for bacterial products alone or dead bácteria containing these poisons produce this same condition. Non-pathogenic bacteria, and, indeed, inorganic particles in the blood, will cause some slight leucocytosis; but this is entirely different from the leucocytosis caused by pathogenic substances. Too much praise cannot be given to Metschnikoff, the founder of the School of phagocytosis, for his splendid work, nor, indeed, would any one question for a moment the fact of phagocytosis. But the great mystery of immunity cannot be explained by phagocytosis alone. The other school, holding that blood-serum is the only factor in the explanation of resistance and immunity, have gone to the other ex- treme. No one has explained satisfactorily the source of the immu- nizing and bactericidal substance of blood-serum. The theory has been advancd that the resisting power of an animal arises from the spleen, but positive confirmatory evidence of this fact is 'still wanting. An interaction between blood plasma—and indeed all the juices of the body—and the white blood-corpuscles is going on constantly. This has been clearly demonstrated in the formation of the fibrin factor. Cells are constantly being destroyed, liberating granules which, by their staining peculiarities, show difference of chemical composition, and great numbers of nuclei, all of which pass into solution in the fluid containing them. This is not simply the death of the cell because it is of no further use in the economy, the conditions which effect this destruction of cells, and the modifications seen in these cells in many of these conditions suggest that the increase in number and in the destruction of leucocytes has a definite purpose. The action is not phagocytic entirely, or we would not have this effect by such diseases as diphtheria which operate chiefly by the poisons produced and not by the bacteria themselves, and experimentally it has been found that bacterial products entirely free from the micro-organisms cause the same change. It must then be a chemical action, and it seems that, as the leucocytes suffer first and to the greatest extent when infection takes place, these cells are probably concerned in elaborating chemical antidotes to the toxic substance. .* - This is rendered the more probable by the experiments of Vaughan and McClintock," which show that the germicidal action of blood-serum is probably due to nuclein in solution. While nuclein may be derived * Medical News, December 23, 1893. Leucocytosis. I8 I from many sources, it seems that the great destruction of the leucocytes in infections must liberate a considerable quantity of it. To recapitulate, the conclusions reached in this paper may be summarized as follows: (1) That leucocytes originate in lymphoid structures, chiefly lymph- glands. They are all mononuclear at first, and as they grow may take on changes in shape and may show granules in their protoplasm, these alterations in the protoplasm being from some metabolic change. (2) Extirpation of the spleen does not cause any particular form of leucocyte to disappear from the blood. There is a leucocytosis produced from the injury to the peritoneum. (3) Digestion leucocytosis is present after a meal of proteids or hydrocarbons, but not after a meal of carbohydrates. (4) The leucocytosis seen during the digestion of proteids is probably active in preventing auto-intoxication and not solely in dealing with normal products of digestion. (5) The leucocytosis of pregnancy is by no means constant and bears no relation to the time of gestation or the number of the pregnancy. (6) New-born children show a leucocytosis for a time. (7) Massage and cold baths produce leucocytosis, probably by hastening the circulation of fluids through the tissues and emptying the stagnant fluids of the tissues into the blood-stream. (8) Cachectic states are often attended by leucocytosis. This may be due to some special intoxication or to septic infection or to involve- ment of serous membranes by secondary growth. (9) The preagonal leucocytosis is due to some toxemia and not to the method of death. (IO) Post-hemorrhagic leticocytosis is much greater in man than in dogs. It is marked when transfusion is practised, but may be absent without transfusion. In man it is usually present because the tissues are more juicy than those of the dog. * (II) Inflammations of serous membranes cause leucocytosis, unless the disease be of tuberculous origin. Chemical irritants produce the same effect as bacteria. (I.2) Sudden removal of fluid from the serous cavities causes a sudden diminution of the white blood-cells of the blood. (13) Infections show leucocytosis, with the exception of measles, typhoid fever, and tuberculosis. The most pronounced leucocytosis is seen in pneumonia and diphtheria, the degree of leucocytosis depending on the virulence of the infecting agent and the resistance of the animal economy. The extent of the local lesion in the disease has no effect on the degree of leucocytosis. I82 William S. Carter. (14) There is a change in the kinds of leucocytes in typhoid fever and in Scarlatina, -the large mononuclear forms being increased in the former and the eosinophiles in the latter. (15) Substances positively chemotactic, other than bacterial poi- Sons, cause leucocytosis when injected into the subcutaneous connective tissue. - (16) In infections, the fever, increased coagulability and altered alkalinity are insufficient to account for the leucocytosis. Thermic fever does not cause an increase in the number of leucocytes, but apparently they are being destroyed more rapidly. Peptone fever causes a diminished number, but no increase. Injections of nuclein and calcium chloride do not cause any distinct change in the number of leucocytes. (17) The cause of the leucocytosis in infections is the action of some toxic substance, whatever it may be, and not the mere presence of bacteria either in the tissues or in the blood. (18) Leucocytosis is slight: (a) In cases terminating fatally either because there is a feeble resistance or because there is a very severe toxemia (b) In mild cases recovering readily. (19) Severe infections with strong resistance cause pronounced leucocytosis. (20) Following the injection of bacteria into the blood there is a transient diminution in the number of leucocytes. (21) Immunization does not cause leucocytosis. (22) The greatest leucocytosis is seen in animals which have been inoculated after they have been immunized. (23) The object of the leucocytosis in infections is probably to elaborate some chemical substances, which pass into solution in the juices of the body, and antagonize the “action of the toxic substance causing the disease. THE HORACE WELLS ANNIVERSARY. ATTENTION is called to the notice in the Miscellaneous column of the celebration of the fiftieth anniversary of the discovery of the anesthetic properties of nitrous oxide by Dr. Horace Wells. Members of both the medical and dental professions are invited to unite in making the event a notable one, as it is a subject in which both are interested. Quite a rivalry has existed in regard to whom the honor of first directing attention to the anesthetic properties of nitrous oxide should be awarded. It is generally believed, however, that the intro- duction of nitrous oxide into dental practice was entirely due to the work of Dr. Wells, and it is hoped the coming celebration will be made in every way worthy of the importance of his discovery. A Case of Typhus Fever. 183 MEMORANDA. A CASE OF TYPHUS FEVER. JULY 19. D. M., aged 23; single ; sailor; born in Nova Scotia. Family history negative ; previous history negative. Present history : Left Boston some time in June on a cattle steamer bound for Liverpool. Stopped one week in Liverpool ; and on July 7 started on return voyage in same steamer. The third day of the voyage he felt sick, aching all over. Blotches appeared on the abdo- men and thighs like hives, and itched considerably. The fourth day out he was obliged to give up, and went to bed. About July 12 had nose-bleed and diarrhea. The steamer arrived in Boston July 17. The man was obliged by the captain to stand in line on deck with the other sailors while the health officer made his inspection. His condition was not noticed. His friends took him to his boarding-house in Cambridge, where he was treated for typhoid fever. On the 19th he was admitted to the Cam- bridge Hospital. The next morning, July 20, the diagnosis was thought to be a possible case of typhus, and the patient was removed at once to the isolation building. A hysical AExamination.—Face and eyes congested. Tongue clean at tip, moderately coated with a thin yellow coating. An eruption entirely over trunk, anteriorly, of a scattered papular character, of a rose-red color, and disappearing on pressure. Here and there are spots irregular in shape, blue in color, the size of a ten-cent piece. The same blue spots appear on legs and thighs. The upper part of thigh having a blue tinge. Below knee same tinge, but less distinct. These same spots are numerous over the back. The whole skin has a dingy red hue. Coarse rāles over chest pos- teriorly; a few anteriorly. Heart-sounds are normal. Pulse weak and compressible, –slightly reduplicated. No gurgling or tenderness in right iliac fossa ; slight tympany. Has slight cough. Nose filled up ; mouth-breathing. July 20. Subsultus tendinum ; Carphologia ; rash increasing ; papular red spots spreading to hands. July 21. Tongue fissured and red,—brown coating in centre. Movements from bowels like pea-soup. Has nose-bleed frequently. July 24. Nervous symptoms very pronounced,—carphologia, and twitching of shoulders. Gets out of bed. July 25. Nervous symptoms still worse. At times perfectly rational. Not deaf. He is unable to speak above a whisper. Face dark ; fingers livid; spots less conspicuous. I84 A Case of Typhus Fever. July 26. Mutters to himself. Reaches out his hand. Gets out of bed. - 20 | 21 22 || 23 24 ||25 || 26 || 27 28 29 || 30 2 || 3 || 4 || 5 || 6 || 7 || 8 9 10 || 11 12 || 13 || 14 | 15 16 || 17 | 18 || 19 || 20 21 |22, 23 24 ||25 || 26 28 29 -* til -l < O (ſ) so E Lal * > 22 |al ſº == « St ul º: :-} Hº < ſº ſº fl. :: |al |- July 27. Tongue moist; mind clear. Asks for paper, etc. Strong odor always noticeable, and still present. ZXiaphragmatic Æernia. I85 August 2. About six o'clock each evening seems to become con- fused, and tells about imaginary objects. August 14. Discharged well. N. VAUGHAN SHANNON. CAMBRIDGE, MASS. DIAPHRAGMATIC HERNIA. THE following case is interesting on account of the large extent of abdominal viscera in the thoracic cavity. The patient was a man about 40 years old. His family history negative. - His previous personal history was as follows : A well man until ten years ago. At that time he fell from a tree, injuring himself so severely that he was confined to his bed for six weeks. The extent and location of injury could not be positively ascertained, but when he started to walk he complained of a sharp pain, deep in the left hypo- chondriac region. This pain continued more or less severe until the present attack. . With the exception of this pain, he was apparently as well as before the injury ten years ago, The present attack commenced while serving milk with haste in the morning. About 8 A.M. he suddenly felt the pain in the left hypochondriac region to a greater extent than usual. At 6 P.M. the pain spread to the umbilical region. At this time nausea and retching developed. At 8 P.M. he was given mustard and warm water by the family. This caused much retching and a bilious vomiting. The pain now became very severe all over the abdomen. He passed per rectum some hard fecal matter. At I I P.M. there was great abdominal tym- panites, dyspnea, and tenesmus. The skin was cold and clammy; pulse 90, and very weak; heart-sounds muffled. At 2.30 A.M., he was assisted to a commode, contrary to orders, and while there suddenly died. - - At the post-mortem we found the following : Kidneys were flat and flabby, but in the normal position. Liver was dragged to the centre of the abdomen. Its borders were dark and congested. The spleen was congested, pressed upward, and back. The esoph- ageal opening in the diaphragm was ruptured, so as to admit a ball one and a half inches in diameter. Through this protruded the stomach and all the small intestines above a point eight inches above the ileo- cecal valve. Also that part of the large intestines included between the hepatic flexure and a point eight inches above the sigmoid flexure. The intestines were almost coal black, and were distended with gas. 186 - Alumn? AVotes. The heart and thoracic aorta were bloodless. The heart and lungs were pushed to the right side of the thoracic cavity. The heart was twisted, probably due to the pressure of the accumulated post-mortem gas. The lungs were entirely collapsed, and contained no blood. WILMINGTON, DEL. SWITHIN CHANDLER, M.D. SAND-BATH TREATMENT. IN Bungo, Japan, near a town of a thousand homes, and 5000 inhabitants, on the coast of Kiushiu, at the foot of an old volcano, there is a warm-spring watering place much frequented by poor people. They crowd there between the barley harvest and the June rice planting. Eighty-two springs belong to the place. A pecu- liar way of taking this treatment is the sand-bath, and this is the manner of it: Some of the springs, all of them hot, are so near the beach that they are covered by the full tide. When the waters recede, basins are dug in the sand, heated by these, and frequenting patients bury themselves in these holes up to the neck. Some of these places are so hot that the inhabitants of the town cook vegetables and rice in them. The hotter the spring the purer the water. Those of lower temperature are sulphurous. Those who use the sand-baths usually remain for several hours in them, umbrellas being held over their heads to protect them against the sun. In cold weather, a num- ber of boys spend there the whole day. - ALBERT S. ASHMEAD, M.D. ALUMNI NOTES, A NEW PRIZE FOR BEST SCHOLARSHIP. The Society of the Alumni of the Medical Department of the Uni- versity of Pennsylvania has decided to offer $50 as an accompaniment of the bronze medal given to the student receiving the highest general average at graduation. If the student wishes, a gold medal will be given in place of the customary bronze medal. SURGEON F. B. Stephenson, U.S.A., having finished a cruise of three years on the Asiatic Station,-from Wladivatok and Japan to Singapore and Java, is now on duty at the United States Recruiting Rendezvous, Boston. ...” Alumn? Notes. 187 Dr. N. L. Johnson, of the class of 1891, has been appointed visit- ing physician to the City Hospital, Williamsport, Pa. Dr. Horace G. Morton, class of 1880, has been appointed visiting physician to the Mercer Hospital, Trenton, N. J. Dr. William Elmer was at the same time made consulting physician. The other Univer- sity graduates on the staff are Drs. I. M. Shepherd, F. H. Adams, H. G. Wetherill, N. B. Oliphant, and William Clark. A MUNIFICENT GIFT TO THE STUDENTS’ HALL FUND. At a meeting of the Trustees of the University of Pennsylvania, held on November 6, 1894, the gift of Mr. and Mrs. H. H. Houston, of $100,000 to the Students' Hall Fund, was announced. In recogni- W. tion of the interest shown by Mr. and Mrs. Houston in the University, it was unanimously resolved that the hall should bear the name of their son, Howard Houston, who was a student at the University at the time of his death. NEWS OF DR. DONALDSON SMITH's ExPLORING ExPEDITION. The first news of the scientific expedition headed by Dr. Donald- son Smith, who graduated from the Medical Department of the Uni- versity in 1889, has just been received. Dr. Smith started in June last to explore the unknown region lying 200 miles west of Berbera, Africa, and extending to Lake Rudolph, where traces of ancient civilization were believed to exist. Soon after his arrival at Berbera, he found a caravan of I IO camels, and, accompanied by two Englishmen, early in September reached a 1arge stream believed to be the Erer. The expe- dition was greatly delayed after beginning its march, owing to defects in the transportation arrangements. The party explored the unknown country west of Milmil, and surveyed several rivers. During the prog- ress of the work had a narrow escape from death by being charged by a rhinoceros. The country explored was full of interesting features. All the members of the party are in good health. NECROLOGY. Charles P. Keichline, of the class of 1835, died October 28, in the 85th year of his age. Born in Bucks County in 1810, Dr. Keichline spent his youth there, but came to Philadelphia about 1830, and en- tered the University of Pennsylvania, from which institution he was graduated with honor as a doctor of medicine in August, 1835. He came of a long line of distinguished ancestors, and was a lineal descend- ant of John Peter Keichline, who immigrated from Heidelberg, Ger- I88 Alumni AVotes. many, and settled in what is now Bucks County as early as 1740. The three sons of the latter took a prominent part in the War of the Rev- olution, and by their courage, bravery, and loyalty to the cause left to their descendants a heritage of which they may justly be proud. After spending the first three years of his professinal career at Bellefonte, Pa., Dr. Keichline returned to Philadelphia, where he had been actively engaged in the pursuit of his profession until within a short time of his death. Dr. Reid Alexander, a graduate of the Medical Department, Uni- versity of Pennsylvania, class of 1885, died at his home of perforation of the bowel, October 8, 1894, aged 33 years, II months. At the time of his death, Dr. Alexander was Assistant Chief Sur- geon C. R. I. & P. Railway, Local Surgeon Missouri Pacific Railway, Medical Referee for the Mutual Life Insurance Co. of New York in the State of Kansas, Treasurer United States Pension Examining Board, Chairman Stormont Medical Library, and President of the Topeka Academy of Medicine and Surgery. Dr. Alexander arrived in Topeka eighteen days after graduation, and commenced the practice of medicine at once, forming a partnership with Dr. D. W. Stormont, which existed until the latter's death, in 1887. His success was phenomenal from the start, and during the nine years of active professional life in this city he built up one of the finest and largest practices in the State, enjoying the honor and respect of both profession and laity. He leaves a wife and three little girls to mourn the loss of a kind and loving husband and father. EDITORIAL. THE ANTITOXIN TREATMENT OF DIPHTHERIA. THE fate of tuberculin as a remedy for tuberculosis naturally makes one somewhat chary in accepting at the present stage of inves- tigation the statement recently made by Duranton that, with the intro- duction of antidiphtheritic vaccine as a curative agent, “ diphtheria has been vanquished, and croup has lost its terrors.” It can be truly said, however, that the most favorable reports of the new treatment of diphtheria continue to be received from divers European sources. In a recent report, edited by the United States consul at Havre, the follow- ing statistics, furnished by the director of the Hôpital des Enfants Malades, of Paris, give the result of Dr. Roux's treatment. During the years 1890–1893 there were 3971 children treated in the diphtheria annex of the hospital, with the following death-rate for each year : 1890 . . . . . . . . . . . . . . . . . . . . . 55.80 per cent. 1891 . . . . . . . . . . . . . . . . . . . . 52.45 & 4 1892 . . . . . . . . . . . . . . . . . . . . . 47.64 & C 1893 . . . . . . . . . . . . . . . . . . . . . 48.47 { % This makes an average of 51.09 per cent. for the four years. When Dr. Roux and his co-workers entered the hospital (February 1, 1894) they at once began the new treatment of injecting the antitoxic serum, and of 448 children treated only 109 succumbed,—a death-rate of 24.33 per cent. As every other part of the treatment of the patients was the same as during the four years above cited, the difference between 51.09 and 24.33 per cent. is a fair representation of the advantages derived from the serum treatment. - In the British Medical Journal there have lately appeared reports of 39 cases of diphtheria treated by various observers with antitoxin, with an average mortality of 7.6 per cent. Of 200 cases of diphtheria treated by antitoxin by Behring, Was- sermann, Eslich, and Kossel, in Germany, 168 recovered, and 52 died, —a mortality of 30.95 per cent. In Budapesth, the antitoxin treatment has yielded excellent results in the hands of Bokai. This authority states that in 35 cases of diph- theria in children under 12 years of age (the majority under 4 years), the mortality under the new treatment was only 14.33 per cent., the average mortality in the same hospital for the corresponding periods of the last three years was 53.8 per cent. I89 I90 Aditorial. Katz (Berliner Ælinische Wochenschrift, July 16, 1894) reports for Baginsky the result of the treatment of diphtheria in the Children's Hospital in Berlin with the antitoxin. In four years Io&I cases of diphtheria were treated, with a mortality of 38.9 per cent. In the three and a half months immediately preceding the beginning of treatment by antitoxin there was a mortality of 41.8 per cent. During the three months in which the antitoxin was used there were 128 cases so treated, with a mortality of 13.2 per cent. The exudation was not influenced in an unusual way, but in not a single case of the 128 treated was the larynx affected after the use of the remedy. Eighty-two healthy chil- dren were injected with a diluted solution of antitoxin for the purpose of vaccination. Eight of these became slightly ill, but none seriously. At the time of writing none of these children were sick with diph- theria. In this country the first significant report of the value of the anti- toxin treatment was made by Dr. Muehleck, in a communication to the Surgical Section of the College of Physicians of Philadelphia, held on November 9; the results of this observer have been summarized in the Medical AVews as follows: “The cases reported by Dr. Muehleck were five in number, occurring in the same family in children from II months to 6 years of age. All the injections were made in from twenty-four to thirty- six hours after the beginning of the attack. For immunization, one cubic centimetre, and for therapeutic purposes from one and a half to two cubic centimetres of Aronson’s serum were used. Of the five children four were attacked. Two of these (one II months, one 6 years of age) were not treated with the antitoxin, owing to inability to obtain it, and these two, although treated by the hitherto generally-accepted rules of practice, died. One child that had mingled freely with the other cases, and in whose throat typical bacilli were found, was inoc- ulated with the antitoxin as a prophylactic measure, and was not at- tacked by the disease. In all of the cases except one the bacteriologic tests proved the presence of the Klebs-Löffler bacillus. Of the two cases injected with the antitoxin both recovered; in one tracheotomy was indicated, owing to involvement of the larynx, but the stenosis was markedly ameliorated within twenty-four hours after the injection; in the other the mucous membrane of the tonsils, the soft palate, and the pharynx was involved, but without stenosis. After the injection there was a rapid fall of the temperature within twenty-four hours, the membrane became fatty and pultaceous, and came away in four or five days.” It will be seen, therefore, that the reports from all sources are suffi- ciently encouraging to warrant an extended trial of the new remedy. On account of the great variation in the severity of different types of The Status of Intercollegiate Foot-Ball. I 9 I diphtheria the true value of the antitoxin treatment can be determined only after a most exhaustive study. To Professor Behring belongs whatever credit is to be attached to this discovery. It was he who first demonstrated that successive inoculations of the horse with cultures of the Klebs-Löffler bacillus of increasing virulence finally rendered the animal immune, and that its blood-serum injected into other animals proved antidotal to the toxine of diphtheria. The Paris Figaro, of Oc- tober 12, 1894, publishes the following method adopted by Dr. Roux in securing the antitoxin. The first injection under the animal's skin is an attenuated culture of diphtheritic bacilli. After the lapse of some days, this injection is renewed at fixed intervals, and is continued for six weeks; finally, the pure toxin is injected, and the horse is hence- forth in readiness to furnish the serum on being bled. This operation can be performed every twenty days, after the lapse of which time the animal can supply, without injury or fatigue, 2.05 quarts of blood, which furnishes enough serum for the inoculation of forty children attacked with diphtheria. The effective dose of antitoxin varies with the age of the patient, the severity of the type, and the stage of the disease in which the treatment is instituted. The amount usually employed varies from five to twenty-five cubic centimetres. Even in large amounts the serum seems incapable of producing deleterious effects. The injections are not followed by rise of temperature, abscess formation, or enlargement of the lymph-glands. In a few instances an urticarial or erythematous rash has been produced by the injections. THE STATUS OF INTERCOLLEGIATE FOOT-BALL. IN the face of some adverse criticism—partly valid and just, but largely invalid and unjust—a greatly increased interest is manifested each year in the intercollegiate foot-ball contests. These games are looked forward to not only by the players themselves, but by the students generally, and even by the teachers. That the public shares this interest is attested by the very large numbers of spectators that invariably attend the important matches. Whether or not foot-ball is a proper exercise for college students to indulge in is still being debated, but it seems to us that the arguments are largely on the affirmative side. The two objections urged against foot-ball are, first, the liability of injury to the players, and, second, that it affords exercise to but a limited number of students. That accidents occasionally occur is not to be disputed, but that their frequency and severity are exaggerated by those who oppose foot-ball, in their over-zealous efforts to fortify their positions, is equally certain. The serious accidents that occur I 92 Bditorial. usually befall the “green’’ men. At the University of Pennsylvania there are between one hundred and one hundred and fifty men playing foot-ball, including the regular team, the substitutes, and the various class teams, and there has not been a single serious mishap this year, nor does the writer know of any grave accident having befallen the University team in past years. It is to be understood that football is a science, and the men who are to play in hard games must be carefully trained for their work. It would be as reasonable to condemn naviga- tion as too dangerous to follow if an inexperienced pilot had wrecked his vessel because he lacked the skill necessary for his position, as to condemn foot-ball because players are injured by entering contests for which they are not prepared. Then, the extent of the injuries is constantly exaggerated. This statement has been made before, but it will bear repetition. Every one who has had any intimate connection with the men has repeatedly observed this, although it is not accepted by that small number who object to foot-ball on account of its “brutality,” and who get all their information from the newspapers. - It has been said that foot-ball affords exercise to but a few students. The most ardent advocates of the game have hardly thought of making it a compulsory branch in the colleges as yet. There are other sports that may be taken up by those who have a taste for milder exercises, but, on the other hand, we see no reason why those who prefer foot-ball may not be allowed to follow their inclination. The actual players are not the only ones benefited, however; those who attend the games undoubtedly share this influence. The advantages of foot-ball over other forms of athletic sports has been dwelt upon at great length by various writers. Colonel O. N. Ernst, Superintendent of the West Point Military Academy, in his recent annual report, discusses at considerable length the advantages and disadvantages of foot-ball. His conclusions are that foot-ball as controlled there has been a benefit to scholarship and an aid to dis- cipline, and should receive a proper degree of encouragement. He states that any innocent amusement which during the hours set aside for recreation will take the mind of the cadet absolutely away from his books will benefit him. Foot-ball accomplishes this object more com- pletely than any other game. Its effects in this respect are not confined to the actual players, but extend to practically the entire corps of cadets. The enforcement of a well-regulated life such as is lived up to while in training, the concentration which is necessary, the strict discipline, the increased courage, and the ability to exert one's entire force to the accomplishment of an object must be of the greatest service as a part of an educational scheme. The Status of Intercollegiate Foot-Ball. I93 Our Alumni will be particularly interested in hearing of the excellent work which is being done by the University team this season. It is only within a few years that an interest has been manifested in the game at the Pennsylvania. During this time, however, the improvement has been most marked. The present season has been one of uninter- rupted victories, and only once has the opposing team been allowed to score. The game with Princeton, which resulted in a score of 12 to O, in favor of Pennsylvania, was, it is said, the finest exhibition of foot- ball ever witnessed. The game with the Cornell team, more recently, was equally brilliant, for although they played the best game in their history, they were not able to score, although they made twelve points in the game with Harvard and six in that with Princeton. The Uni- versity team is scheduled to play but one more game this season, which is with Harvard at the University grounds on Thanksgiving Day, November 29. This event is being looked forward to with keen interest, and if the weather is fair it is predicted that 25,000 people will be present. & Too much praise cannot be bestowed upon coach Woodruff and upon the team individually for their excellent record. The enthusiasm over the game reaches its height in the medical department, which furnishes not only the staunchest undergraduate admirers and the most loyal and earnest supporters among the Alumni, but also some of the very best players, including in this team, as it did in the winning team of 1892, the captain. THE RELATIVE STANDING OF THE GRADUATES OF THE VARIOUS MEDICAL COLLEGES. THE following table indicates the relative standing of the grad- uates of the various medical colleges in the examination held by the State Board of Medical Examiners, June 11–14, 1894. Medical College from which g NO. Per ct. *ś. Applicants º Fia. raiſies ºge University of Pennsylvania . . . . . . . . 76 I I.32 87.76 Woman’s Medical College . . . . . . . . . 18 2 II. II 83.44 Jefferson Medical College . . . . . . . . . 67 5 7.46 83.29 Medico-Chirurgical College . . . . . . . . 26 3 II. 54 82.48 Western Pennsylvania College . . . . . . 44 3 6.82 81.13 College of Physicians and Surgeons (Balt.). 3 I 33.33 8O.68 Baltimore Medical College . . . . . . - 8 5 62.50 75.81 Miscellaneous Colleges . . . . . . . . . . 26 9 34.61 74.77 | --- - - | -— Total . . . . . . . . . . . . . . 268 29 Io.82 82. 18 Medical AVezys. MEDICAL PROGRESS. N/[EIDIC IN E. UN DER THE CHARGE OF WILLIAM PEPPER, M.D., LL.D., AND JAMES TYSON, M.D., ASSISTED BY M. HOWARD FUSSELL, M.D. DIGESTIBILITY OF STERILIZED MILK. BENDIx (Jahrbuch für Kinderheilkunde, Vol. xxxv.111, Part Iv) has made researches upon sound and sick children as to the digestibility of both sterilized and non-sterilized milk. He concludes: - (1) That in healthy children there is no difference as to the digestibility of the two milks. (2) In sick children the sterilized is digested just as well as the unsterilized, notwithstanding the fact that the absorption of fat and nitrogen is so much reduced in such children. * (3) The taste and smell of milk, while they may be changed by sterilization, are not materially so, and sterilized milk is readily taken by children. (4) He has never seen the health of children badly affected by the use of sterilized milk. On the other hand, they eat well, grow, and their stools are normal, and they never have vomiting. (5) The transmission of severe diseases from animals to men is prevented by the sterilization of milk. (6) Sterilization is much preferable to Pasteurization, and heating the milk to 212°F., while it does not hinder its digestion, absolutely kills all bacteria and spores. QUININE IN CHOLERA. FULLERTON (Nezw York Medical Journal, August 18, 1894) gives a table of statistics, in which he claims to show that cases of cholera treated with quinine have a much lower death-rate than when treated in any other way. This he attributes to the high inhibitory power of quinine, and believes that the very fact that medicines are not absorbed from the intestinal tract favors the curative action of the quinine by allowing it to inhibit the cholera spirillum in the intestinal. tract. It must be given in comparatively large doses. In ordinary cases ten grains must be given every hour until twenty to forty grains are given; afterwards pro re nata. In collapse the same dose should be given half-hourly. Besides the administration of quinine, hypodermoclyses, appliances for supplying heat, and morphine hypodermics to relieve pain should be used where necessary. Enteroclyses of quinine should be used where the quinine is vomited. He believes that the early administration of quinine will reduce the mortality to 4 or 5 per cent. I94 Medicine. I 95 TANNIGEN, A NEw INTESTINAL ASTRINGENT. MEYER (Deutsche medicinische Wochenschrift, No. 31, 1894), in this article calls attention to the inefficiency of most astringents upon the lower bowel because of their destruction in the stomach or upper bowel, the large dose in which they must consequently be exhibited, and the deleterious effect of this large dose upon the stomach itself. The new compound is a pentacetate of tannin. It occurs in yellowish-gray powder, is tasteless and odorless, and is slightly hygro- scopic. It can be heated to 330° F. without change. It is insoluble in cold water, and only slightly soluble in hot water. The action of this drug was first tried on cats. It was found that relatively large doses could be taken without interfering with the stomach in any way, and that it had a decidedly constipating effect. MüLLER (Ibid.) has tested “tannigen” on some of his patients, with the following results: The patients take the powder without any ill effects either upon the appetite or the stomach. The drug was so harmless that a definite dose was not ordered, but a knife-pointful was directed three to eight times daily. It was used in chronic diarrhea, chronic intestinal catarrh, and in some cases of recurring dysentery, and in cases of intestinal disturbance in phthisical patients. In most cases the number of stools was decreased on the day after the drug was begun. In some, as in phthisical cases, the good results lasted only so long as the drug was continued. But as soon as the drug was again commenced the diarrhea stopped. Some of the patients took the drug for several weeks without ill effects or lessening of the good effects. The drug was also tried in a small epidemic of acute diarrhea, and the disease in all the cases was brought quickly to an end. In the acute and subacute diarrheas of children the drug is valueless except the diet be changed. It is also without good effect in the atrophic cases of nursing infants. He concludes that it is of most value in chronic diarrhea, and is actually curative in these cases. He thinks that it is also of great value in the diarrhea of phthis- ical patients, where it can be given for a long while and will not interfere with the appetite or digestion. DENTAL MANIFESTATIONS OF GOUT. KIRK (Zancet, June 30, 1894). The co-existence of certain forms of suppura- tive gingivitis and gouty diathesis has long been known. Dr. Peirce, of Philadel- phia, has shown that the calcareous deposits taken from the roots of teeth lost from pyorrhea alveolaris contain, besides the usual calcium carbonate, considerable uric acid and urates of calcium and sodium. He concludes that the deposits upon the roots of such teeth are not salivary, but hemic in origin, and that pyorrhea alveolaris is simply a local manifestation of gout. As further evidence of the cor- rectness of these conclusions, the author has found that, after thorough local treat- ment, the gingivitis will disappear, and have no tendency to return. He has found a marked acidity of the secretions of the mucous glands of the mouth in such cases, which brings about local decalcification of the enamel. He first used cream of tartar to correct this acidity. He afterwards had a lithium tartrate prepared, which gave much more satisfactory results than any other alkali used. The promptness with which it acts is sometimes astonishing. After three doses of five grains each all symptoms sometimes subside. TYPHOID FEVER. A report on typhoid fever in the District of Columbia, made to the United States House of Representatives by the Medical Society of the District of Columbia, I3 196 Medicine. contains several instructive maps as to the causation of typhoid fever in cities. Some important conclusions are formulated, among which are the following : (1) Typhoid fever increases in proportion to the saturation of the soil with decomposing organic matter, especially human excreta, and to the drinking of infected well-water. (2) Typhoid fever decreases in proportion as a city is well sewered, and in proportion to the abandonment of the drinking of well-water, and of all contami- nated water. SOME STATISTICS OF DIABETES MELLITUS. DAVIS (reprint of a paper read before the Illinois State Medical Society, May I5–17, 1894) has observed that there is a reasonable variation in the occurrence and severity of cases of diabetes mellitus. The observations were made upon fifty- five cases. He has observed that glycosuria has occurred three times as often in March and April as in January. Four times as often in July and three times as often in November. It occurs least frequently in December, January, and February. It is notably less common in May than in April and July. It gradually diminishes through August, September, and October to rise abruptly in November. Further study of the records shows that in mild cases variations in the amount of sugar in the urine in the same month are great, though the same diet and the same treat- ment be persisted in. It was also noticed that there was no relation between the specific gravity of the urine and the percentage of sugar it contains. The feelings of weakness and malaise so characteristic of the diabetic state are correlated with the amount of sugar eliminated, but very different amounts will produce the same results in different individuals, THE PRODUCTION OF DISEASES BY SEw ER AIR. JACOBI (AVezw York Medical Journal, August 4, 1894) concludes his article upon the above subject with the following sentences: (1) The atmosphere contains some specific disease-germs, both living and dead. - (2) They are frequently found in places which were infected by specific diseases. * (3) In sewer air fewer such germs have been found than in the air of houses and school-rooms. (4) Moist surfaces,<-that is, the contents of cesspools and sewers, and the walls of sewers, while emitting odors, do not give off specific germs, even in a moderate current of wind. (5) Splashing of the sewer contents may separate some germs, and then the air of the sewer may become temporarily infected, but the germ will soon sink to the ground again. (6) Choking of the sewer, introduction of hot factory refuse, leaky house- drains, and absence of traps may be the cause of sewer air ascending or forced back into the houses. But the occurrence of this complication of circumstances is certain to be rare. - - . --- — - - (7) Whatever rises from the sewer under these circumstances is offensive and irritating. A number of ailments, inclusive, perhaps, of sore throats, may origi- nate from these causes. But no specific diseases will be generated by them except in the rarest of conditions. For specific germs are destroyed by the processes of putrefaction in the sewers, and the worse the odor the less is the danger, particu- larly from diphtheria. Medicine. I 97 (8) The causes of the latter disease are very numerous, and the search for the origin of an individual case is often unsuccessful. * (9) Irritation of the throat and naso-pharynx is a frequent source of local catarrh ; this creates a resting-place for diphtheria-germs, which are ubiquitous during an epidemic, and thus an opportunity for diphtheria is furnished. (IO) Of the specific germs, those of typhoid and dysentery appear to be the 1east subject to destruction by cesspools and sewers. These diseases appear to be sometimes referable to direct exhalation from privies and cesspools. Very few cases, if any, are attributable to sewer air. (II) A single outlet from a sewer would be dangerous to general health, because of the density of odors (not germs) arising therefrom. Therefore a very thorough and multiple ventilation is required. TREATMENT OF PRURIGO IN CHILDREN. The Jarhöuch für Kinderheilkunde, Vol. xxxvi II, Part Iv, quotes the follow- ing: Iw ANOW (Westnik Obschtschetszwennoj, July; 1892) recommends the following treatment for prurigo : For the increase of nourishment of the skin he uses an especially fat diet. He adds a tablespoonful of lard to a glass of milk, and for older children gives cod-liver oil. For the itching he uses a 3- to 5-per-cent. solu- tion of carbolic acid, or a 5- to IO-per-cent. solution of glacial acetic acid in water or glycerin. The watery solution is used only in severe cases, frequent baths being harmful, but baths once or twice a week lasting ten or fifteen minutes and followed by the use of the glycerin solution readily effect a cure. After the itching disappears inunctions of glycerin are used twice a day for two months. SPINAL THROMBOSIS AND HEMORRHAGE. WILLIAMSON (Lancet, July 7, 1894) reports the following case : A man, aged 28, was admitted to the infirmary September 22, 1893. One month previously he began to suffer with pains in the back and under the left scapula. The pain was not severe. He noticed difficulty in passing urine September 20. In the evening his gait was unsteady. On awaking in the morning he found both legs entirely paralyzed. There was no pain and no girdle sensation. After the 20th there was loss of control over the rectum and retention of urine. Five days afterwards he had complete loss of all the reflexes of the thigh and legs. There was loss of sensation in the legs and on the trunk as high as the sixth intercostal space. After admis- sion rigors occurred. There was a history of syphilis two years previously. On examination, post-mortem, brain congested. The spinal cord showed no signs of softening. The meninges were congested, but there were no other naked-eye evidences of disease of the cord. On section a hemorrhage was found about the middle of the dorsal region. The vertical length of this, hemorrhage was about one and three-fourths inches; it was situated in the gray matter. It extended across the gray commissure into the gray matter on the right side, the greater hemorrhage being on the left side. There were a few white points seen in the white matter on both sides. In the upper dorsal and cervical regions there were signs of ascending degeneration. The vessels were enormously dilated, they were packed full of red corpuscles, and very many were thrombosed, and there was extensive endarteritis. The vessels of the meninges also showed distinct syphilitic changes. I98 Surgery. TABORDE's METHOD FOR ASPHYxIA IN THE NEw-Born. * This author (Gazette Médicale de Paris, January 14, 1893) treats this condition by seizing the tongue of the child with forceps and making rhythmical traction upon it, alternating this by allowing the tongue to fall back. By this method natural breathing is established in ten minutes. One case is quoted where, in spite of the use of ordinary methods for one hour and a half, breathing was not established. In the last moment Taborde’s method was used, and in a short time the child breathed naturally. SUF GERY. UN DER THE CHARGE OF J. WILLIAM WHITE, M.D., ASSISTED BY G. G. DAVIS, M.D., M.R.C.S., AND ELLWOOD R. KIRBY, M.D. NOTES UPON THE PATHOLOGY OF TENDON CONTRACTURES. Doyon (Province Medical, No. 14, 1894) says that in previous experiments as to the mechanism of the contractures of tetanus, the cause was claimed by authors to be a reflex one, and whether the reflex curve involves the sensory or the motor tracts is yet to be proven. With this object in view, the author carried out a series of experiments upon dogs, and first studied the contractures in the immediate neighborhood of the point of infection. . The reaction produced by the irritation of a mixed nerve in relation to the arterial pressure was the same on both sides. As a result of the experiments, the author says, in conclusion, that the ptomaine of tetanus acts only on the sensory nerves. These experiments also explain the fact why even the slightest peripheral irritation produces such widespread contractures. THE USE OF ANTIPYRIN IN Cystiris. VIGNERON (Ann. des Malad. des Org. Genito-Urim., 1893) has found that in many cases of cystitis no local treatment can be carried out on account of the intense pain produced by such manipulations. The author is now in the habit of injecting a solution of antipyrin into the bladder and then continuing with the local treatment. The effects of the antipyrin are similar to cocaine, but has the advantage that it may be used for a long time without any constitutional effect. -- ---- If the bladder be not dilated, ten to twenty grammes of a 4-per-cent. solution of antipyrin should be injected into the bladder at least ten minutes before the local treatment is carried out. In dilated bladders the local treatment may be carried out first, and then from sixty to one hundred and twenty grammes of a 34- or I-per-cent. solution of the drug may be injected into the bladder and allowed to remain. Surgery. I99 THE FUNCTION OF THE STOMACH AFTER RESECTION OF THE PYLORUS. IMREDx (Wiener medicinische Presse, No. 13, 1894) has made a series of experiments as to the function of the stomach after pylorus resection, with the following results: Dilated stomachs after the removal of the stricture usually recover their normal function. The normal contractions of the organ likewise return to normal. CONTRIBUTIONS TO THE STUDY OF APPENDICITIS. JAcob (Thèse de Paris, 1893) examined eighty cadavers and found no traces of appendicitis, and that the usual position of the appendix is to the outside of the cecum and in a horizontal position. In all the cases of appendicitis in which the location of the appendix was diagnosed it was found to be behind the cecum or extending down into the pelvis. This position the author thinks rather predisposes to inflammation of these parts because of the necessary stagnation of feces. THE INOCULABILITY OF CANCER. GEISSI.ER (Centralblatt filr Chirurgie, No. 27, 1894) says that Adamkiewicz claims the cancer cells to be living organisms and similar in character to parasites. Geissler repeated the experiments of Adamkiewicz upon twenty-five rabbits, and found that if pieces of aseptic cancer-tissue were placed in the brains of these animals, no reaction resulted, and all the pieces were absorbed like any other animal tissue. Only in those cases in which septic material was introduced did the results correspond to those of Adamkiewicz. PAINFUL PERITONEAL ADHESIONS. NICAISE (Revue de Chirurgie, 1894) states that the use of antiseptic methods and the consequent development of antiseptic surgery have made surgeons better acquainted with peritoneal adhesions, and have led to their successful treatment by operation. These adhesions may give trouble by disturbing the function of implicated organs, and by exciting pain. The pain varies in character and inten- sity in different cases. It may be caused by displacement of organs to which the adhesive bands are attached, or by constriction of the intestinal canal. The pains in the latter condition are often very severe, and of a similar nature to that of hepatic and renal colic. The diagnosis of peritoneal adhesions is often very difficult. In some cases their existence can only be assumed by the process of exclusion, while in others their certainty can only be demonstrated by an exploratory operation. The author is of the opinion, however, that a diagnosis can be made in many cases by close inquiry concerning such details as previously occurring abdominal inflam- mation, the seat of pain, and the relation to the seat of any previous inflammation, the time when the pain comes on in regard to the taking of food. As many peritoneal adhesions become longer and thinner and have a tendency to disappear, there should be no great hurry in having recourse to an operative procedure. When, however, they cause great pain, a laparotomy should be per- formed and the adhesions broken up. The cure that will thus be effected will be permanent and complete. • 2OO Surgery. THE CAUSE AND RELIEF OF Post-OPERATIVE NEURALGIA, ESPECIALLY IN AMPUTATION STUMPS. WITZEL (Centralblatt für Chirurgie, No. 29, 1894) claims that the cause o the neuralgia in stumps after amputation is not the result of growth in the nerve but from the fact that the nerve is caught in the scar. Socin claims that he never has stump neuralgia after amputation, and, as he says, it is due to the fact that before the wound is closed strong traction is made on the nerve so as it can be cut off as high up as possible. For the relief of such a condition when once developed, Witzel recommends resection of the nerves. •. PLASTIC SURGERY OF THE SCALP. MESSNER (Centralblatt für Chirurgie, No. 32, 1894) says that in many opera- tions about the head it is often necessary to remove considerable portions of the scalp, leaving large defects which often remain open granulating wounds for years. Volkmann's method consisted in a dividing up of the large defects into a number of small granulating areas by the following method : In the ordinary round defect four tongue-like flaps are dissected up around the margin of the defect, and then all turned on their axes towards the middle point of the defect, and the ends of the flaps sutured together. Gangrene of the flaps is seldom to be expected on account of the size of the base of the flaps. The author reports two cases in which large defects were completely closed. BONE-DISEASE IN TYPHOID FEVER. KLEMM (Archiv für klinische Chirurgie, Bd. XLVI) says the most frequent bone complication in typhoid fever is limited generally to the cortical layer. This inflammation may end in resolution, caseation, or liquefaction. This form of bone inflammation is generally accompanied with suppuration of the medulla, and is due to the mixed infection with two species of micro- organisms. An examination of the exudate showed the bacillus of Eberth and the typhoid bacillus. In those cases in which suppuration resulted the staphylococcus and the streptococcus were found. Occasionally in certain cases no pus organisms were found in the exudate, even though suppuration had taken place. The author claims this to be the result of the persistence of the typhoid bacillus. Experiments were carried out upon rabbits, a pure culture of typhoid organisms being injected in the veins of the ear. In five of the ten animals experimented upon a positive result was obtained in from ten hours to twelve days, the organisms being found in the medulla of the femur. - - - - -- - - - - - - - ---- In several animals the typhoid infection was followed by an injection of a pure culture of the staphylococcus. As a result of this double infection, those animals that lived developed an acute osteomyelitis with separation of the epiphyses. Therapeutics. - 2O I THE FAPE UTICS. UNDER THE CHARGE OF HORATIO C. WOOD, M.D., LL.D., AND ARTHUR A. STEVENS, M.D. ERYSIPELAS STREPTOCOCCUS IN ANTHRAX. EMMERICH (Münchemer medicinische Wochenschrift, July Io, 1894), having previously demonstrated that anthrax bacilli in the tissue gave evidence of disin- tegration in the presence of erysipelas streptococcus, the bacillus of Friedländer, and the bacillus pyocyaneus, gives a further account of his experiments in this field, in connection with Most, Scholl, and Isuboi. He first cites a case in which a rabbit suffering with severe anthrax was cured by the injection of a virulent culture of erysipelas streptococcus. A pure culture of streptococcus, obtained from a case of facial erysipelas, was injected into rabbits, and the blood-serum freed by filtration from the erysipelas streptococcus was used in the treatment of anthrax. Three rabbits were injected with this serum, one, four, and eleven and a half hours respectively after being inoculated with anthrax. Two recovered com- pletely, and the third (pregnant) lived twenty-four hours longer than the control animal. This serum treatment must be continued during five days. The serum of sheep's blood prepared in a similar way is even still more efficient. Two experiments are reported in which rabbits infected with anthrax were so treated with complete success, the control animals dying rapidly. The author concludes with the hope that the same treatment may be successfully applied in cases of anthrax in man. CANNABIS INDICA. MACKENZIE (Semaine Médical, No. 14, 1894) speaks highly of cannabis indica in all forms of cephalalgia. He has found it act favorably even in the severe head- ache attending cerebral growths. In chronic uremia, where opium is contra- indicated, it is especially serviceable. He has found the remedy to be almost a specific for that continuous form of headache which begins in the morning and lasts all day. In these cases the pain is generally dull and diffuse, but marked by occasional exacerbations. While it is rarely severe enough to interfere with occupation, yet it constitutes a source of constant annoyance to the patient. In such case the author administers morning and evening from one-twelfth to one- half grain of the extract in pills. If these doses are not sufficient, he gives one grain in the evening and one-half grain in the morning. In very obstinate cases the dose is still further increased, the larger dose always being taken in the evening, until relief is afforded or toxic symptoms become manifest. In some instances Mackenzie combines gentian, cinchona, or hydrobromate of caffeine with the cannabis indica. In various neuralgic affections, gastralgia, enteralgia, the pains of tabes the drug often proves very useful. In skin-diseases associated with intense itching, particularly senile pruritus, where local applications fail to relieve, cannabis indica is often used with great benefit. The author has rarely observed any untoward effects from its use, never- theless, to avoid toxic manifestations, the drug should be given at first in small doses, the latter being gradually increased. 2O2 Therapeutics. CHLORINATED LIME IN PRURITUS ANI. BERGER (Zemski Vratch, No. 13, 1893) speaks highly of the treatment of pru- ritus ani by inserting into the orifice (for about one inch) a piece of cotton wool soaked in liquor calcis chlorinatae. When slight turning or smarting is felt, the plug should be extracted, and the anal region washed out with the same lotion, after which the parts should be left to dry spontaneously. The itching is said to vanish instantaneously, while after a few applications of the remedy any accompa- nying symptoms (such as swelling, eczema, etc.) also disappear. * - - - - - TREATMENT OF ATONIC GASTRIC DILATATION. WEGELE (Münchener medicinische Wochenschrift, March 28, 1894, and Brit- ish Medical Journal) deals with the severer forms of this disease, and not with such as accompany any gastric affection lasting over any considerable time. For the practical distinction of mild from severe cases, the test break- fast is useful; in marked cases remains of food are found in the water used for washing out the stomach on the following morning, whereas in mild cases the stomach is able to deal with such moderate demands. Pronounced atonic dilatation is not, in the author’s opinion, such a rare event as is sometimes represented. At first the dry diet was employed, and for slighter cases it sufficed ; but a rigorous carrying out of this regimen was often of disadvantage. Washing out the stomach proved a great advance, as in this way the stomach was freed of every acid and fermenting contents. Here, however, a consid- erable amount of nourishment is withdrawn, and the patient's nutrition and weight may suffer. Rectal alimentation must in addition be had recourse to ; either water alone or the desirable food stuffs may be thus used. The amount of urine passed is a practical measure of the gastric insufficiency. By a strict dry diet and supplying the necessary water by the rectum, the patient's condition may be very greatly improved. Clysters containing grape sugar are apt to ferment and to produce diarrhea, and the same is true of those containing peptone frequently repeated. The diet must be suited to the condition of the gastric chemistry. If hyperacidity is present, large doses of alkalies are indicated. Washing out the stomach is, according to the author, best done in the morning. Raising the foot of the bed is said to be useful in helping to empty the pyloric antrum. If fermen- tation is present, harmless antiseptics should be added to the water, and salicylic acid, creosote, bismuth salicylate given internally. If the abdominal walls are lax, a belt should be used. The author says that the prognosis is considerably improved by the use of the dry diet, and supplying fluid by the rectum. Bon E-MARRow IN THE TREATMENT OF PERNICIOUs ANEMIA. FRASER (British Medical Journal, No. 1744, 1894) reports a case of pernicious anemia in which he employed bone-marrow with considerable success. The patient was a man, aged 60 years, suffering from dyspnea, swelling of the feet, frequent spells of vomiting, diarrhea, great weakness, and slight pyrexia. Ex- amination of the blood revealed : hemocytes, 1,860,ooo to 1,460,000 per cubic millimetre; hemoglobin, 28 to 30 per cent. Three ounces of uncooked bone- marrow from the ox were given by the mouth daily. After twenty-seven days the hemocytes numbered 3,900,000 per cubic millimetre, and the hemoglobin amounted to 78 per cent. DANFORTH (Chicago Clinical Review, Vol. IV, No. 1, 1894) reports a very Gynecology. 2O3 severe case of pernicious anemia in which good results attended the use of bone- marrow. The anterior extremities of calves’ ribs were comminuted so as to expose the cancellated tissue, and the fragments were placed in a jar and covered with glycerin, to the influence of which they were exposed for three or four days, being occasionally agitated. At the end of this time the liquid was strained through flannel, and the resulting fluid presented a reddish, syrupy appearance, without pronounced odor, and with the taste of glycerin. At first a teaspoonful of this extract was administered thrice daily, together with five drops of Fowler’s solu- tion, but as the sweetish taste of the preparation excited nausea, the following combination was substituted : Solution of potassium arsenite . . . . . . . . . . 2% drachms. Acid sodium phosphate . . . . . . . . . . . . . 3 ounces. Extract of bone-marrow . . . . . . . . . . . . . 8 ounces. A dessertspoonful of this mixture after each meal proved entirely satisfactory. The patient steadily gained in strength and spirits, and in a short time presented every indication of restoration to former health. The hemoglobin rose from 35 to 80 per cent., and red blood-corpuscles increased proportionately. G-YN ECOLOGY. UNDER THE CHARGE OF WILLIAM GOODELL, M.D., AND CHARLES BINGHAM PENROSE, M.D., ASSISTED BY WILLIAM A. CAREY, M.D., AND H. D. BEYEA , M.D. SALPINGITIS NODOSA. WERTHEIM (Centralblatt für Gymážologie, No. 18, 1894), at a recent meeting of the Obstetrical and Gynecological Society in Vienna, reports a case and describes salpingitis nodosa. This form of salpingitis was first described by Schauta and Chiari. It is characterized by the presence of nodes in the tube-wall, which vary in size from a pea to a hazel-nut. They are always found in relation with the proximal third of the tube, and are associated with inflammation at the ampulla and other portions of the genital tract. These nodes were formerly believed to be fibromyoma, but Chiari, through careful microscopic examination, found that the form of growth was not constant, but that the greater number were due to inflam- matory hyperplasia of the muscular wall of the tube. The columnae epithelium of the tube mucous membrane is usually “in tact.” Frequently, as the disease advances, the tube lumen becomes narrowed at short intervals, and, finally, numer- ous small cysts are produced,—follicular salpingitis. Wertheim's case differs from those described by Schauta and Chiari, in that the nodes, which were the size of small walnuts, on section were found to be small abscesses containing thick yellow pus. On the right side each abscess communicated with the uterine cavity by means of a minute canal. The tube canal on both sides was filled with pus, and the ostium closed. Schauta, in his discussion of the report of this case, concluded that it represents an advanced form of salpingitis nodosa. 2O4 Gynecology. TACHYCARDIA FOLLOWING LAPARoToMy. NEGRI (Annali di Ost. e Gin., 1893, No. 6) calls attention to a condition of tachycardia following laparotomy. He has observed two cases where, unassociated with fever, the pulse became very much accelerated following perfectly aseptic laparotomy. The rapid pulse continued for many days, the patient in both instances slowly recovering. Negri’s cases differ from those reported by Mangia- galli, in that the attack was not abrupt or paroxysmal, and both patients finally recovered. He believes the condition to be wholly a nervous phenomenon. THE STERILIZATION OF CATGUT. KRONIG (Centralblatt für Gynākologie, No. 27, 1893) discussed the methods of sterilization of catgut by disinfection or heat, and advises a new method of sterili- zation by means of boiling in cumol. A hydrocarbon compound which has a boiling-point of 168° to 178° C. He believes, as shown by the experiments of Geppert, that the disinfection of catgut with watery and alcoholic solutions of the bichloride of mercury does not kill the germs, but simply inhibits their growth. As long as the catgut retains the bichloride no organisms will grow, but if it be treated with a solution of the sulphide of ammonium destroying the bichloride organisms will soon appear. The method of Reverdin, the application of dry heat at a temperature of I40° C. for four hours, he believes is positive, but that the method requires too much time and apparatus. The application of dry heat at a temperature of 130° C. for one hour, as advised by Döderlein, does not render the catgut sterile. The method of Brunner, boiling it in xylol at a temperature of I36° to 140°C. is ordinarily positive, but the writer has observed that certain spores which much resemble anthrax are not destroyed by this method, even though the boiling be continued for several hours. Kronig advises the following method : Each strand is made into a ring four fingers' breadth in diameter and held loosely in place by three or four turns of thread. The object of this being to allow con- traction of the catgut during sterilization, and also, when wound upon rollers, it is usually very difficult to remove. After being thus prepared it is placed in a dry sterilizer at a temperature of 70° C. for one hour so as to drive off the hydroscopic water, then direct into a beaker containing cumol which is two-thirds buried in a sand bath. The vessel containing the sand should be seventeen centimetres (six and a half inches) in diameter and fourteen centimetres (five and a half inches) deep. Heat is then applied with two Bunsen burners, or a round burner. And wire gauze is placed over the beaker to prevent the cumol from catching fire. When the cumol has reached a temperature of 155° C. the flame is removed, as ordinarily the temperature continues between 155° and 165° C. for an hour. A thermometer is not necessary, the boiling-point of the cumol being the guide. After thus heating for one hour the catgut is removed with sterilized forceps and placed in a previously sterilized beaker containing petroleum benzine (G. P.). In this petroleum benzine it may be kept until used, or after three hours it may be removed and placed in sterilized Patri cups. The catgut kept in Patricups remains sterile for many weeks. Where a dry sterilizer is not at hand the catgut may be placed in a beaker or the sand bath, for two hours the temperature in the beaker would be between 70° and Ioo° C. A temperature of more than 100° C. dry heat destroys the catgut. Catgut previously infected with spore-forming bacilli and sterilized after this method was found to be sterile. The infecting spore-forming bacilli were shown to be particularly resisting in that, after being subjected to two hours' steam, sterilization gave many colonies on agar-agar plates. Cumol, as pre- pared by Dr. Grübler, of Leipzig, is a fatty, light-yellow, non-explosive liquid. Gynecology. 2O5 EARLY DIAGNOSIS OF CANceR OF THE CERVIx UTERI. DR. ERNEST HERMAN (British Medical Journal) says that as secondary growths occur later and less frequently in the uterus than in any other part of the body, the early recognition and removal of the diseased area is of the utmost importance. The readiness with which the vaginal portion of the cervix may be examined makes it possible to detect diseases early, and to gain successful results from treatment. The early diagnosis of cancer is so important that we are justified in making an unusual hemorrhage or discharge in a woman who has borne chil- dren, a reason for a vaginal examination. The use of the microscope in estab- lishing a diagnosis of cancer has decided limitations, and while it will occasionally reveal cancer in doubtful cases, negative evidence of cancer by microscopical examination should not be relied upon, and an opinion had better rest upon the local and general symptoms. As a rule, the first signs of cancer are hemorrhage and leucorrhea ; pain and loss of flesh come later. Cancer that begins as an out- growth from the surface of the cervix resembles a growth of warts, papillae, or granulations, and the surface feels uneven or rough. The disease may start as an ingrowth beneath the surface. It may be detected by an angry, livid, red spot, the surface of which is at first quite smooth. This angry color depends upon the vas- cularity caused by the new growth, and upon its tendency to break down, which leads to minute hemorrhages into the growth before the breaking down is exten- sive enough to make a breach of the surface. The livid surface of a cancer spot blee is on being rubbed, so that a smooth, dark-red spot, bleeding on contact, is very suspicious. This is the earliest stage of cancer, and if a nodule can be felt, the suspicion is stronger. When the cancer has advanced to a cauliflower-like growth the diagnosis is quite certain. THE RESULTS OF VAGINAL HYSTERECTOMY FOR AFFECTIONS OF THE UTERINE ADNEXA AS COMPARED WITH ABDOMINAL BILATERAL OVARIO-SALPINGECTOMY. JAcOBS (Brussels) (Centralblatt für Gynākologie, No. 18, 1894), at the Inter- national Congress in Rome, relates the results of his own experience, and quotes the statistics of others regarding vaginal hysterectomy and ovario-salpingectomy as compared with the abdominal operation. He says that since the first Interna- tional Gynecological Congress in Brussels, the question regarding total castration per vagina has progressed very much, and he believes that to-day there is ground for the argument that it will substitute the abdominal operation. He has per- formed vaginal castration in 184 cases, with I79 recoveries, a mortality of 2.71 per cent. This proves that the danger in the vaginal method is not greater than the abdominal, but is very much less. The combined statistics of Terrier, Terrillon, Doyen, Schauta, Chrobak, Zweifel, Martin, Jacobs, Lawson Tait, Dubois, and Gallot, with 1540 operations per abdomen, show a mortality of 5.7 per cent., while those of Richelot, Doyen, Péan, Segond, Rouffart, and Jacobs, with 690 operations per vagina, show a mortality of 4.49 per cent. It also must be remembered that frequently the vaginal operation was performed only because the abdominal was impossible. Therefore, with the same class of cases the mortality in the vaginal operation would be even less than these statistics show. The objection to this method has been that where the operation is once begun it must be completed ; as in cases where during the operation only one side is found diseased. Jacobs says this is not justified, that the operation should be begun by opening Douglas's pouch, and immediately seeking with the finger for the adnexa. If both sides are affected, a total castration should be performed, but if only one side is found dis- eased, a unilateral vaginal ovario-salpingectomy is performed. 2O6 Gynecology. A SUGGESTION IN THE OPERATION OF VESICO-VAGINAL FISTULA. E. R. CORSON (American Journal of Obstetrics, August, 1894) describes a method of bringing the parts for operation well into view and within reach of the knife. The device is very simple and yet proved of great service in two cases, one of which had had two previous unsuccessful attempts at closure. A small hollow rubber ball, such as is found in toy-shops, is cut in half and a strong silk ligature is passed through the dome of this disk with the knot tied on the concave surface. The disk is pared down to such a size that it will enter the fistulous opening by drawing on the ligature, the vesical tissues are made tense and brought down into better view. This arrangement resembles in its effect the “goose egg” used by women in darning stockings. Through the counter-pressure of the disk the paring of the edges was greatly facilitated, especially in checking hemorrhage, which is so apt to blur the way of the knife. The introduction of the stitches is made very much simpler and is more quickly accomplished. After the sutures are placed the disk can be removed by separating the sutures and compressing the disk by a pair of forceps, gently withdrawing it. THE USE OF THE ABDOMINAL DRAINAGE-TUBE DETERMINED BY BACTERIOLOGICAL, EXAMINATION. C. B. PENROSE (American Zancet, August, 1894) states that the use of the drainage-tube depends too often upon the caprice of the operator, rather than upon sound scientific principles. Some operators never used drainage at all after any operation, and yet ob- tained exceedingly good results; while others obtained equally good results, and their statistics showed that they employed drainage in a proportion of their cases which varied, according to the individual taste of the operator, from 5 or Io per cent. to 75 per cent. The general advice given by the advocates of drainage was, “When in doubt, drain.” It was this element of doubt which caused the diver- sity of practice. Everything which increases our knowledge in regard to the facts which determine drainage diminishes our doubt, and brings about more unifor- mity of practice. The necessity for drainage in cases of hemorrhage lessens with the increasing experience of the operator, the use of the Trendelenburg posture, careful inspection of the area of operation, etc. The other reason for drainage is the septic character of the material which escapes or is retained in the abdomen. Knowledge in regard to this fact is of great importance in deciding about drainage in any case, and with the hope of gaining definite information touching this sub- ject, the author during the past winter, at the University Hospital, had an imme- diate bacteriological examination made of the contents of every tubal and ova- rian tumor, which was ruptured during removal. The report of the pathologist regarding the septic or aseptic character of the contents has determined his deci- Sion in regard to the use of the drainage-tube. The results of this plan have been most satisfactory, for out of a series of forty-six celiotomies, in which drainage was used but three or four times for hemorrhage, and only once because the microscope showed the material which escaped to be septic, there has been no case of peritonitis or sepsis. Reference is made to the report by Shauta (Archiv fºr Gynecologie, 1893, No. 44) of 192 cases of salpingitis, in 144 of which the contents were sterile, in 33 there were gonococci, and in 15 streptococci or staphy- lococci. Prior to the adoption of this method of bacteriological examination Penrose inserted a drainage-tube in every case of tubal or ovarian abscess, where the contents escaped into the peritoneum. Now he neither irrigates nor uses a Gynecology. 2O7 drainage-tube unless the microscope shows these contents to be septic. The pres- ence of gonococci in small numbers does not necessitate drainage. Recently, the value of this method of practice was demonstrated by two cases operated on consecutively. Each woman had a tubo-ovarian abscess, caused by sepsis at labor. In each case the abscess ruptured during removal, and the pelvis filled with pus. In the first case the pus was found to be sterile, and the abdomen was closed without irrigation or drainage. In the second, the pus contained streptococci, and staphylococci, and the coli commune; consequently, the pelvis was thoroughly irrigated and drained. Both women recovered without peritonitis or sepsis, but the convalescence of the first was much easier than that of the second. Cover-glass preparations of the material to be examined are made and fixed in the flame of an alcohol lamp, and stained with carbol-fuchsin. The microscopic examination is made with a Leitz one-twelfth immersion lens. THE TREATMENT OF VESIco-VAGINAL FISTULA By OPERATION FROM WITHIN THE BLADDER. C. J. BOND (Annals of Surgery, October, 1894) reports two successful cases operated upon by this method which had defied previous attempts through the vaginal route. The cases specially suitable for this plan of operating are those in which there has been extensive cicatricial contraction. In such cases the vaginal roof is often tightly stretched across the pelvis and the neck of the uterus cannot be drawn down ; if, under these conditions, the fistula be extensive and situated high up near the uterus, considerable advantage is obtained by choosing the new method. The steps of the operation are as follows: * First inject the bladder, while an assistant’s finger blocks the fistulous open- ing; if this is impossible, it may be opened by a vertical incision above the pubes on a sound, the peritoneum being carefully drawn out of the way. The abdominal wall is incised either vertically or transversely, and the incision in the bladder is parted by three long curved metal retractors, and by these means and the upward pressure of the bladder by the assistant's finger in the vagina the fistula and field of operation are brought well within reach. The thin cicatricial junction of the two mucous membranes is now incised all around, and two flaps of vesical mucous membrane are raised, one on either side the rent, with their edges turned in- ward towards the bladder, and are sutured with catgut on a doubly-curved needle, such as is used for cleft palate suture; at this stage, also, the rectangular knives and long forceps are also useful, and care must be taken at the angles to extend the separation of mucous membrane beyond the actual limits of the fistula. A few silver-wire sutures are afterwards used to draw the edges of the vaginal mucous membrane together, these having been already freshened on their vesical surface by the operation within the bladder. # In the after-treatment it is very important to avoid the development of cys- titis, and for that purpose continuous irrigation, day and night, with warm boric acid solution is advised. The method of irrigation is as follows: After closing the fistula, a piece of rubber tubing is passed through the urethra and up into the bladder and out through the suprapubic wound. To the upper end of this tube is attached an irrigator, and as the water flows down it escapes into the bladder through a few small holes which had been cut in the sides of the tubing, and the lotion then passes through these holes again, after washing the cavity of the bladder, and passes out through the lower end of the tube into a receptacle provided. By compressing the tube below the urethra, the bladder may be filled and 2O8 Pathology. flushed at will, the rate of flow can be easily regulated by pressure-clamps and the irrigator kept constantly warm by being wrapped in a cotton-wool jacket. The irrigation can be continued as long as desired, and the tube may be gradually dis- pensed with, by first drawing it within the bladder and allowing the suprapubic opening to close, and then removing it entirely. There are two reasons which make the suprapubic method as reliable a means of closing fistulous openings in bad cases. (I) The vesical flaps are raised and turned inward and thus have their surfaces opposed to the direction of the current of urine flowing through the fistula, and are thus more tightly closed by its press, ure, unlike the flaps formed by vaginal mucous membrane; the vesical flap is the valuable agent in closing the opening. Moreover, in most cases of extensive loss of substance, the vesical mucous membrane has grown over the edge of the fistula, projecting into the vagina, and is more voluminous than the vaginal mem- brane. (2) The suprapubic opening, especially where combined with the urethral drain and constant irrigation, insures complete drainage, that is, the absence of all tension within the bladder. This is a most important factor, and is in itself sufficient in some cases to bring about a cure without further operation. PATHOLOGY. |UNDER THE CHARGE OF JOHN GUITÉRAS, M.D., ASSISTED BY JOSEPH McFARLAND, M.D. ExPERIMENTAL RESEARCHES UPON THE PRODUCTS OF THE TUBERCLE BACILLUS. MAFFUccI (Annals of Surgery, Vol. xx, No. 5, November, 1894, p. 556), being convinced by experiments upon foul embryos that the general wasting in tubercu- losis is due to the destroyed protoplasm of the bacilli acted upon by the embryos, secured a proof of this by experiments upon the sea-hog. Observing that sea- hogs inoculated with dead tubercle bacilli into the cellular tissue died marasmatic, with local and general symptoms, such as abscesses at the point of inoculation, hyperemia of the lungs, catarrhal pneumonia, endobronchitis proliferans and with hemorrhage, with parenchymatous and interstitial nephritis, atrophy of the liver, degeneration of the muscular fibre of the heart, and atrophy and pigmentation of the spleen. Death followed in from a few days to a month after inoculation. As in these diseased animals there were no tubercles, he concluded that a toxic sub- stance capable of producing inflammatory and necrobiotic processes existed in the protoplasm of the dead bacilli capable of producing the described lesions. Numerous experiments, showing the influence of temperature, desiccation, sun- light and high temperatures (100° F. for two hours), digestive juices, etc., upon the tubercle bacillus to be without influence upon its toxicity, were made. The researches prove the original idea that the dead tubercle bacillus contains a toxic product zvhich has a great resistance against very potent physical agents. Pathology. 2O9 * METHOD OF SECURING GERM-FREE BLOOD-SERUM. KUPRIANow (Centralblatt für Bakteriologie und Parasitenkunde, Band xv. Nos. 13–14, 1894) recommends those who desire to secure germ-free blood-serum to introduce a small sterile canula into the jugular vein of the animal and draw off the blood without allowing it in any way to come in contact with the air. THE Occur RENCE OF BACTERIUM COI, I COMMUNE IN LIVING BLOOD. LITTMAN AND BARLow (/Deutsches Archiv für klin ische Medicin, Band LII, Heft. 3 und 4, S. 252, ff.) found in a case of miliary abscess of the kidney a bacillus similar to the bacillus coli communis, not retaining the color when stained by Gram’s method. Upon all culture media it grew exactly like the bacillus men- tioned. Experiments upon animals, however, failed to produce lesions similar to that from which it was secured. Sixteen hours before death puncture of the vena mediana showed the presence of the bacilli in the blood of the living individual. A NEW PATHOGENIC MICRO-ORGANISM FROM PNEUMONIA SPUTUM. BUNZE-FEDERN (Archiv für Hygiene, Band xIx, Heft 3, S. 326) secured from the rust-colored sputum of a pneumonia patient a micro-organism pathogenic for mice and rabbits. It possesses a variable form both in culture and in blood. In the blood of the rabbit and guinea-pig it occurs as a short, somewhat thick rod, which in consequence of polar coloring much resembles a diplococcus. In the blood of the white mouse it is longer, though of the same thickness, often double. In pigeons it is shorter with rounded ends. It does not color by Gram’s method, grows slowly in gelatin without liquefaction, in bouillon causes cloudiness, but later transparency through precipitation to the bottom of the tube. No spores were observed, and the individual does not seem mobile. When inocu- lated subcutaneously rabbits die in from twelve hours to three days from septi- cemia. The bacteria can be demonstrated in the blood, in the transudation, and in sections of the tissues. Autopsies discovered enlargement of the spleen and hemorrhages. PREPARATION OF DIPHTHERIA ANTITOXINE. ARONSON (Berlin klinische Wochenschrift, Nos. 18 and 19, 1894) finds that the antitoxic serum can be manufactured by immunizing calves, goats, sheep, horses, and dogs. He begins the immunization by injecting the animals with bouillon cultures of the diphtheria bacillus which have been exposed for one hour to the temperature of 70° C. After this, cultures exposed to 60° C. are used, then cul- tures to which trikresol has been added, the bacteria killed, and the cultures pre- served. He found that the virulence of the cultures could be greatly increased by the application of oxygen to the cultures. It seems difficult to immunize large numbers of animals, as they may be lost through too active treatment, and sometimes die without distinct pathological lesions, under which circumstances the greater the number under treatment, the greater the number lost. To estimate the exact value of the serum of such prepared animals he uses the method of Behring and Ehrlich, and mixes with the toxine the smallest possible amount of the antitoxic serum required for its neutralization, determining the neutralization by inoculation into animals. 2 IO Pathology. { A CASE OF PNEUMONOMYCOSIS ASPERGILLINA. KOHN (Deutsche medicinische Wochenscriſt, 1893, No. 50) describes a case of aspergillus infection of the lung occurring in a man 58 years old. He suffered in January, 1893, with severe hemoptysis, after which he had double pleurisy. (?) in May, 1893. Three weeks later he entered the hospital suffering from severe dys pnea, and died June 17. The sputum was examined for tubercular bacilli with continuous negative result. The autopsy showed a round necrotic patch in the apex of the left lung, about four to five centimetres in diameter, surrounded by a dense infiltration. In the right middle lobe a similar small area surrounded by considerable edema was found. Examination showed these areas to be filled with fungous threads which Kohn recognized as aspergillus fumigatus. No cultures were made. PATHOLOGICAL CONSIDERATIONS ON SURGICAL INTERFERENCE FOR PERFORA- TIVE ULCER OF THE STOMACH AND DUODENUM. KELYNACK (British Medical Journal, October 27, 1894, p. 914) examined the records of 3471 post-mortems made at the Manchester Royal Infirmary, finding 159 cases of acute peritonitis among them. Of these the number due to perfor- ating gastric and duodenal ulcers is comparatively small,—six from each. Of the 157 cases nine were due to appendicitis. Surgically the ulcers are divided into (I) gastric; (2) pyloric; (3) duodenal. (I) Gastric Ulcer.—It is usually stated that gastric ulcers are most frequently met with on the posterior wall near the pylorus and towards the lesser curvature. The position, however, varies considerably, a fact of moment to the surgeon who finds the lesions accessible, non-accessible, or accessible zeyith difficulty. Sometimes the ulcers are situated on the anterior wall near the greater curva- ture, accessible ; sometimes on the anterior wall near the lesser curvature, accessi- ble with difficulty; sometimes near the smaller curvature and close to the esopha- gus, inacesssible. The ulcers are usually single. The edges of the ulcer are almost invariably thickened, rounded, and elevated. The surrounding tissue is often for some little distance extensively infiltrated. Sometimes the mucous membrane is undermined at the edges so as to produce a distinct cyst-like cavity. In one case the whole mucous membrane was thickened, evidently from a long-standing gastritis. (2) Pyloric ulcers are of importance from the possible stenosis which may result. - (3) Duodenal Ulcers.-In the post-mortem reports of the Manchester Royal Infirmary on medical cases since the year 1867 only ten cases of undoubted primary duodenal ulcers appear,<-all associated with burns and gall-stones, etc., being ex- cluded as secondary. It is of interest to observe that all the cases recorded occurred in males. In seven the exact age being obtained, gave an average of thirty-three years. Miscellaneous. 2 I I MISCELLANEOUS. DR. WILLIAM GOODELL. WE present with this issue of the MAGAZINE an excellent repro- duction of a photograph of the late Dr. William Goodell. Graduates of the University do not need to be reminded of the great loss which the profession has sustained in Dr. Goodell's death. His professional skill, rare literary attainments, and amiableness of character were such as to render the filling of the vacancy caused by his death wellnigh impossible. Although the history of his life is familiar to most of our readers, it seems proper that a brief record of its most important events should be made here. He was born on the Island of Malta on October 17, 1829, being the son of the Rev. William Goodell, D.D., who was at that time engaged in missionary work in Turkey. When twenty years of age he entered Williams College, from which he graduated in 1851. Shortly after this event he entered Jefferson Medical College, and received his diploma in 1854. He first practised his profession in Constantinople, where his father was still laboring, but in 1861 he returned to this country, and located in West Chester. In 1865 he was appointed Physician-in- Charge of the Preston Retreat, which position he retained for twenty years. In 1874 he was appointed Lecturer on Obstetrics and Diseases of Women in the University of Pennsylvania, and two years later Clinical Professor of Gynecology in the same institution. The 1atter position he held until about two years ago, when failing health com- pelled him to resign. On his retirement from active work he was elected Honorary Professor. His health grew steadily worse, and after an acute illness of several weeks, he died on October 27, in the sixty-fifth year of his age. MINUTE ADOPTED BY THE FACULTY OF MEDICINE OF THE UNIVERSITY OF PENNSYLVANIA ON THE DEATH OF DR. WILLIAM GOODELL. THE following minute was adopted by the Faculty of Medicine at its meeting, November 19, 1894 : The Faculty of Medicine of the University of Pennsylvania, at this its first meeting since the death of its late member, Dr. William Goodell, honorary professor of gynecology, hereby makes record of the sincere respect and affection entertained for Dr. Goodell by all his col- leagues, and their deep sense of the great loss sustained through his I4 2 I 2 Miscellaneous. death by the University, by the medical profession, and by society at large. - Dr. Goodell became a member of this faculty on April 4, 1876, and at once took rank as a teacher of the highest order—a skilful operator, an admirable lecturer, and a most brilliant and forcible writer. During the whole period of his connection with the University, his name was a tower of strength to its medical school, while his personal qualities secured for him the admiration and respect of all who knew him, and the sincere love and friendship of those who became associated with him in his daily work. - In evidence of its feeling, the Secretary is instructed to enter this minute upon the records of the faculty, and to send a copy to Dr. Goodell's family, and to publish it in the UNIVERSITY MEDICAL MAGAZINE. JOHN MARSHALL, Dean. THE WISTAR BIOLOGICAL ASSOCIATION. A REGULAR meeting of the Wistar Biological Society was held at the Wistar Institute on November 9, 1894. General Isaac J. Wistar presided. There was a discussion of the subject of “The Purification of Drinking Water, with Special Reference to the Water-Supply of Phil- adelphia,” which was participated in by Dr. William Pepper, Dr. A. C. Abbott, and Dr. Henry Leffmann. After a brief introductory address by General Wistar, Dr. Abbott spoke of the natural" methods of filtration of water through the soil, and said that the deeper the soil the poorer it was in bacteria. This change, however, was not the only one, as there was a marked change in the constitution of the water as found by its passage through the soil. Organic matter will have been found to have disappeared. Sur- face water in going through soil undergoes not only bacteriological but chemical purification, and the most desirable water is that obtained from the deepest strata. It becomes important, he said, to know how nature can be imitated so as to obtain this water, and the method is that of filtration by sand, passed through large stones, then gravel and sand to a fine sand at the top of the filter. The first waters passed through such a filter simply wash away the bacteria. This method, he said, was pre-eminently a biological one. It is nature's way, and is not only satisfactory, but meets sanitary requirements. -- - - - - Dr. Abbott then alluded to the cholera epidemic in Hamburg and a neighboring city in 1892, both of which obtained their water from the river Elbe. Hamburg supplied its people with water directly from the river, and with a population of 635, OOO there were 18,000 cases and Miscellaneous. 2 I 3 8Ooo deaths, while in the other city, which filtered its water, in a pop- ulation of 145,000 there were but 516 cases, with 316 deaths. There were 283 deaths to every 10,000 people where unfiltered water was used, and only 36 to every IO,OOO where the water was filtered. The biological phase of the question, he said, was to consider the effect that impure water may have on health. In this connection he discussed the prevalency of typhoid fever, which, he said, was very high in Philadelphia, the average being 6.31 to Io, OOO of the popula- tion. This is lower than that of Chicago, but higher than that of New York, Boston, Berlin, and Paris. It looked, he said, as if this disease should be charged to something used in common in the community,+ air and water, and the latter, by common consent, is believed to be the one that causes typhoid fever. The places where the deaths are fewer are where the water-supply has been purified. He showed how in Chicago the death-rate from the disease had been reduced by putting the in-take further out in the lake, and similar results had been obtained in other large cities, both in this and in foreign countries. If steps are taken here to correct the water-supply, he believed that it would result in a reduction in the mortality that would exceed the most sanguine expectations. Dr. Leffmann, who followed, pointed out that the main object of the precipitation methods is to economize the filtering area, and that, by introducing in the water some ingredient which will collect the suspended matter in a coagulum, the operation of filtration takes place with greater rapidity. The best substance used to day in the purifica- tion of water, he said, is aluminum sulphate, as such or in the form of alum. In explaining the operation of this material, he said it removes any color from the water, as well as any turbidity, etc. Dr. Leffmann also discussed the sand method of filtration, and that by the use of iron turnings. In the latter process the small pieces of iron are placed in a cylinder about as large as a hogshead, through which the water constantly passes. The iron is ground up slowly by the friction and rubbing, and by the chemical change that takes place the water is purified. He stated that he had had considerable expe- rience with the iron method of filtration, and was satisfied that it was capable of doing good work, especially in waters decidedly turbid. In reference to the subject of typhoid fever, Dr. Leffmann said that from the records of the board of health he found that in 1893 there were 453 deaths from the disease in the city proper. The district sup- plied by the East Park Reservoir, which includes Kensington, is toler- ably free from typhoid fever, while in Kensington, when it received its water-supply from the station at Otis Street wharf, the mortality was much greater. In fact, the disease has mostly disappeared from the dis- 2 I4. - • Miscellaneous. trict, while in the district west of Broad Street, which receives its water-supply direct from the river, the disease is more prevalent. In Girard College, which is in this district, and which has about 2000 boys, there is scarcely a case of typhoid fever, because filtered water is used. Dr. Pepper said that no community was in more urgent need of purified water than Philadelphia, where water is used to a larger extent than perhaps any city in the world. It was quite important, he said, that a method of filtration that had been shown to be so economical should at least be tried, pending a determination of the question of the ultimate water-supply of the city. He complimented the stand taken by Mayor Stuart and Director Windrim in advocating purification of the water by asking Councils for an appropriation for a filtering plant at Belmont, and urged the members of the Society to use their influence in promoting the scheme. For himself, he said, he did not permit his family to drink Schuylkill water unless it had been boiled, and the amount of drinking waters purchased by people, he said, was enormous and scandalous. - ALVARENGA PRIZE OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA. THE College of Physicians of Philadelphia announces that the next award of the Alvarenga Prize, being the income for one year of the bequest of the late Señor Alvarenga, and amounting to about one hundred and eighty dollars, will be made on July 14, 1895, provided that an essay deemed by the Committee of Award to be worthy of the prize shall have been offered. Essays intended for competition may be upon any subject in Medi- cine, but cannot have been published, and must be received by the Secretary of the College on or before May 1, 1895. Each essay must be sent without signature, but must be plainly marked with a motto and be accompanied by a sealed envelope having on its outside the motto of the paper and within it the name and address of the author. It is a condition of competition that the successful essay or a copy of it shall remain in possession of the College ; other essays will be returned upon application within three months after the award. The Alvarenga Prize for 1894 has been awarded to Dr. G. E. de Schweinitz, of Philadelphia, for the essay entitled, “Toxic Ambly- opias.” - CHARLES W. DULLEs, Secretary. Miscellaneous. 2 I 5 THE EXAMINATION OF GYNECOLOGICAL SPECIMENS. IN order to extend the usefulness of the Pathological Laboratory of the Gynecological Department of the University of Pennsylvania, the following plan has been adopted : Any physician may send to the Pathological Laboratory any speci- men for examination on which the diagnosis or the prognosis of a gynecological case may depend. A fee of five dollars will be charged for such examination in case the patient is able to pay. If the physi- cian states that his patient is too poor to pay, the examination will be made free. The necessity for some arrangement of this kind, especially in making an early diagnosis of malignant disease of the uterus, is widely felt. This offer applies to private, not to hospital, patients. The speci- men should be placed in 95 per cent. alcohol, and directed to the Pro- fessor of Gynecology, Hospital of the University of Pennsylvania, 34OO Spruce Street, Philadelphia. A brief history of the case should be sent with each specimen. A report will be returned to the physician within two weeks after the receipt of the specimen. • ERRATUM. IN the article on Otomycosis, p. 527, May issue of the MAGAZINE, fifteenth line from the bottom, for “chrysolene salicylate” read “chin- olene salicylate.” © THE HORACE WELLS ANNIVERSARY CELEBRATION. At the recent meeting of the American Dental Association at Old Point Comfort, Va., it was decided to hold a national celebration of the fiftieth anniversary of the discovery of the anesthetic properties of nitrous oxide, by Dr. Horace Wells. The celebration will be held in Association Hall, Fifteenth and Chestnut Streets, Philadelphia, on Tuesday, December 11, 1894, at 2 P.M. The banquet will take place at the Union League the same evening. Professor Thomas Fillebrown, of Boston, will read a paper upon the “History of Anesthesia,’’ and Professor James E. Garretson, of Philadelphia, will deliver an address on the “Benefits of Anesthesia to Mankind.” A full report of the celebration, including the papers and addresses, will be printed and issued as a permanent souvenir of the occasion. To cover the expenses attending the celebration, the fee for admis- 2 I 6 - Book AVotices. sion to the banquet has been placed at $6.o.o. It is necessary that the committee shall have ample notice of the number who will be in attend- ance, in order that places may be provided for all who may desire to attend. Subscriptions will be invited later for the souvenir volume, at a price sufficient to cover the cost of publication. You are cordially invited to participate in this event, which should enlist the enthusiastic support of every member of our profession. To that end you are requested to send your check and notify the chairman of the Anesthesia Committee, at the earliest date possible, in order that an official invitation may be sent to you. It will be proposed at the meeting that subscriptions be invited for a permanent memorial, to take such shape as the meeting shall decide. Signed, LOUIS, JACK, S. H. GUILFORD, E. T. DARBY, WM. CARR, C. N. PEIRCE, A. L. NORTHROP, D. N. McQUILLEN, H. B. NOBLE, E. C. KIRK, JAS. McMANUS. J. D. THOMAS, Chairman, - 912 Walnut St., Philadelphia. BOOK NOTICES. WHERE TO SEND PATIENTS ABROAD FOR WATER CURES AND CLIMATIC TREATMENT. By DR. THOMAS LINN. This little volume is one of the Physicians' Leisure Library. It contains in the first part some general remarks upon the various “cures” and baths and some good advice upon travel and diet. The last half of the book is occupied by an alphabetical list of the various diseases, each disease being followed by a list of the places at which such conditions are best treated. Each paragraph contains usually Some general remarks upon the various methods of treating disease at the places mentioned. If the volume be used as an index to the different health resorts, as the author evidently intends it to be used, it will be found of use. Book AVotices. 217 AN INTERNATIONAL SYSTEM OF ELECTRO-THERAPEUTICs: for Stu- dents, General Practitioners, and Specialists. By HoRATIO R. BIGELOW, M.D., and Thirty-eight Associate Editors. Thoroughly illustrated. Philadelphia : The F. A. Davis Co., 1894. This is certainly the most exhaustive work on medical electricity ever published in this country. The physics of electricity is treated of in numerous articles, all written by competent men of science. When we come, however, to electricity as a therapeutic measure, the book is somewhat unsatisfactory because too much is proven and too much is accepted without proof. If all that all the contributors write were true, electricity would be the most potent therapeutic agent we have. Indeed, it would be almost a panacea, would cure almost all diseases except the acute infectious fevers. It is a curious fact that so soon as a man becomes a deep student of electro-therapeutics, he loses that proper spirit of scepticism necessary to the man of science. The proof of this is shown everywhere throughout the work. The book also shows the lack of unity necessarily met with in a work composed by many authors. Notwithstanding the defects to which we have alluded, the work is a very valuable contribution to the literature of the subject, and ought to be owned by all who use electricity. ANNUAL OF THE UNIVERSAL MEDICAL ScreNCEs. Edited by CHARLES E. SAJOUs and Seventy Associate Editors. Philadelphia : The F. A. Davis Co., 1894. The present work marks the seventh annual publication of what has come to be an indispensable possession for those who desire to keep fully abreast with the medical literature of the day. The previous vol- umes have, in the main, been worthy of much commendation, but in the present work a distinctly higher tone is noticeable. This is to be explained by the valuable experience of the editor and his distinguished collaborators in bringing out the previous parts. In a work of this magnitude, there is an enormous amount of machinery to superintend, and the experience of each year adds greatly to the general improve- ment of the work, while it diminishes the mistakes and weak points. It would be impossible to produce a similar work with a corps of new editors without this previous experience. There are no new features in its publication, and the general plan and scope continue to be uni- form with the previous volumes. It is impossible to mention all of the numerous reviews of the medical sciences, but those of Griffith on cholera and diseases of the intestines and peritoneum, of Wilson and Eshner on fever, of Lepine on diseases of the kidneys, etc., of Pilcher and Lloyd on surgery of the brain, spinal cord, and nerves, and others may be taken as representative of the work in general. The section on syphilis, by White and Furness, is of particular excellence. Numer- ous other reviews of merit are passed over, although equally worthy of mention. An important feature of the work is the excellent index, which at once refers the reader to any given disease, to treatment, or to the authors of publications upon any medical subject. 2 I 8 Book Motices. TREATMENT OF TYPHOID FEVER. By D. D. STEwART, M.D. This monograph, published by George S. Davis, at Detroit, in 1893, is a complete résumé of the present treatment of this important disease. The description of the cold-bath treatment is especially good. The chapter devoted to the specific and antiseptic treatment leaves nothing to be desired except, perhaps, the mention of salol, which is certainly an important and useful drug in the disease. The book is well worth reading, and deserves a place in the library. CHEMISTRY: GENERAL, MEDICAL, AND PHARMACEUTICAL, INCLUD- ING THE CHEMISTRY OF THE U. S. PHARMACOPEIA. A. MAN- UAL ON THE GENERAL PRINCIPLES OF THE SciENCE, AND THEIR APPLICATIONS IN MEDICINE AND PHARMACY. By JOHN ATTFIELD, F.R.S., Professor of Practical Chemistry to the Phar- maceutical Society of Great Britain, etc. This work has long been a standard, and will need no introduction now. It occupies a unique position, for, although it is a complete manual of chemistry, it has been arranged and especially adapted to the needs of the physician and pharmacist. It also stands apart in these particulars : (1) The exclusion of matter relating to compounds which at present are only of interest to the scientific chemist; (2) in containing more or less of the chemistry of every substance recognized officially, or in general practice as a remedial agent; (3) in the para- graphs being so cast that the volume may be used as a guide in study- ing the science experimentally. The work is made to correspond with the last edition of the United States Pharmacopeia. Among other chapters of particular interest are those relating to the chemistry of substances, met with in vegetables and animals, and chemical toxi- cology. The present edition contains such alterations and additions as seemed necessary for the demonstration of the latest developments of chemical principles, and the latest applications of chemistry to phar- macy. The fact that this work now appears in its fourteenth edition is abundant proof that it supplies a distinct want. TO CONTRIBUTORS AND SUBSCRIBERS. All Communications to this Magazine must becontributed to it exclusively. Reprints will be furnished free to authors of articles published among the original commu- nications, provided the order is distinctly stated upon the manuscript when sent to the Editorial Committee. Type-written copy preferred. Contributors desiring extra copies of their articles can obtain them, at reasonable rates, by applying to the General Manager immediately after the acceptance of the article by the Editorial Staff. - Contributions, Letters, Exchanges, Books for review, and all Communications relating to the editorial management, should be sent to the Editorial Committee, 214 South Fifteenth Street. Alterations in the proof will be charged to authors at the rate of sixty cents an hour, the a mount expended by journal for such changes. Subscriptions and all business to UNIVERSITY OF PENNSYLVANIA PRESS, 716 Filbert Street, Philadelphia, Pa. UNIVERSITY MEDICAL MAGAZINE. JANUARY, 1895. STRONTIUM SALICYLATE. By H. C. WooD, M.D., LL.D., Professor of Therapeutics in the University of Pennsylvania. THE medical world everywhere recognizes that the salicylates are valuable in the treatment of rheumatic and gouty affections, and that their usefulness is often interfered with by the great tendency which they have to derange digestion. In common, I suppose, with most practitioners of medicine, for some years I have been trying to find some way of getting the general action of the salicylates without gas- tric disturbance. At one time most of my patients reeeived oil of gaul- theria, which certainly in many cases is less disturbing to the gastric mucous membrane than is the salicylic acid or the sodium salicylate. Subsequently, however, I found that the ammonium salicylate, given in milk, was usually much better borne than was even the oil of gaul- theria. In the earlier editions of my Treatise on Therapeutics it was recommended to dissolve salicylic acid in water by the cautious addi- tion of ammonia, but this crude method of preparing ammonium sali- cylate was in turn replaced by the use of the ammonium salicylate as made by the manufacturing chemist. In Philadelphia at least, and pre- sumably in other places, the ammonium salicylate has come largely into use. It is a freely soluble salt, which is rapidly absorbed, and rap- idly produces, when given in sufficient amount, the cinchonism that marks the salicylic action. Strangely enough, it was not only not made official in the late revisions of the British and United States Pharma- copeias, but is not even mentioned in the recent editions of the United States Dispensatory, nor in the new National Dispensatory; an omis- sion which is the more strange, at least so far as the United States Dispensatory is concerned, because I daily prescribe the salt. Hith- I5 2I9 22O A. C. Wood. erto it has certainly offered the best method of administering the salicylates for ordinary purposes, and I believe that when an immediate powerful impression is desired, it still remains the best remedy of its class. My own clinical experiments closely accord with the statements of Laborde, that the haloid strontium salts agree with the human diges- tive apparatus very much better than do the corresponding salts of sodium and potassium ; and it occurred to me that very possibly the strontium might be able to overcome the disagreeable effects of salicylic acid. At my request, Rosengarten & Sons, manufacturing chemists, very kindly prepared for me the salt, which occurs in an irregularly, coarsely crystalline powder, or, as it was furnished to me by the chem- ists, finely pulverized. According to the determination of Professor Wormley, it is soluble in 31.25 parts of cold water, but by means of heat a permanent 6-per-cent. solution can be made. In the proportion of its salicylic acid it compares with the sodium salicylate as 1.4 does to I (161 parts of sodium salicylate equalling 138 parts of salicylic acid). When given intravenously in fatal dose to the dog it produces death through the respiration, followed almost at once by an extraordinary post-mortem rigidity. In some instances there was vomiting, but never purging. - In order to determine whether it has any distinct depressing influ- ence on the circulation, experiments upon dogs were made with it; and also, for control, with the sodium and ammonium salicylate. Axperiment Z.-Dog, weighing 28.6 kilos Sodium salicylate, 6-per-cent, solution. The arterial pressure was not distinctly affected by the intravenous injection of Ioo cubic centimetres; after 40 cubic centimetres more there was a rise of Io millimetres in the arterial press- ure, which was maintained for between one and two minutes, when under the influence of another 20 cubic centimetres the pressure began to fall slowly. Another 20 cubic centimetres being given the rate of fall was increased ; when the arterial pressure had decreased from 18O, the norm, to 52 millimetres, the respiration ceased ; the heart contin- uing to beat for half a minute longer. Experiment II.-Dog, weighing 21.4 kilos. Ammonium salicylate, 6-per-cent. solution. The rapid injection of 20 cubic centimetres of the solution into the jugular was followed by a pronounced imme- diate fall of pressure followed in a few seconds by a rise; after repe- tition until 80 cubic centimetres had been injected the pressure rose to 20 millimetres above the norm. This rise was increased 16 millimetres by the further gradual injection of 80 cubic centimetres of the solu- tion. During the very slow injection of 40 cubic centimetres more the Strontium Salicylate. 22 I pressure remained about the same until the whole had been given, when violent tetanus developed, and the arterial pressure rose to 56 milli- metres above the norm, only to rapidly fall a half minute later, when the muscles relaxed during quiet to II 2 millimetres below the norm. Ten seconds after this respiration ceased, the heart continuing to beat for twenty seconds, and the arterial pressure gradually descending to Ze1 O. A study of these experiments will show that with the sodium sali- cylate there was a slight rise of pressure, which was followed by a fall when 5.6 cubic centimetres of the solution per kilo. had been injected; with the ammonium salicylate a great rise of pressure occurred, fol- lowed by a fall when the injected solution amounted to 9.5 cubic centi- metres per kilo. A study of these results brings into relief the stimu- lating influence of the ammonia in contrast with the inertness of the soda. It is evident that in the Salicylates the physiological properties of the base are not without influence upon the paralyzing action of the toxic dose of the salicylic acid. As I am not aware that any experiments of the strontium salicylate upon the circulation have been made, I record two experiments in greater detail than those just given. ExPERIMENT. Dog ; weight, 20 kilos. ; 3-per-cent. solution of the strontium salicylate, given by intravenous injection into the jugular. Time. h. m. Dose. Pulse. Pressure. Remarks. O. . . . . . . 22O I28–138 O. I IO C. C. a • * | * * * * * * O. 3O IO “ s º º e º n < * * O.4O | . . . . . . 2O4 I3O—I5O I.4O IO C. C. s s = | * * * * * * I-55 | . . . . . . e e º I3O-I5O 3.OO 2O C. C. s e a * * * * * * 3.55 . . . . . . is e e I3O-I4O 5. OO 3O C. C. * * * | * * * * * * 5.4O | . . . . . . tº $ tº I3O-I4O 6.OO IO C.C. e is © | a e < * * * 6. Io IO ‘‘ 6O 130–160 | Pulse suddenly altered in character. 6.25 2O ‘‘ a * * | * * * * * * 6.35 | . . . . . . differs somewhat from that of Dr. Rotch in shape, but holds the same amount. Its cost is nominal and it is very convenient. In using it the sugar should be scooped up with gentle pressure against the side of the box containing it, and then levelled off. This insures the measure being actually full, without being over-filled by packing or shaking down. The soda solution is made of the strength of one grain of bicar- bonate of soda to the half-ounce of water. Analyses kindly made for 452 J. P. Crozer Griffith. me under the supervision of Dr. Marshall, of the University of Penn- sylvania, show that the amount of this salt of soda, equivalent in alka- linity to a half-ounce of ordinary lime-water, equals very nearly one grain. A dozen packages of bicarbonate of soda, each containing one drachm, may be obtained from the druggist at very slight cost. One of these dissolved in a quart of water makes a solution of the proper strength. As the dozen packages are sufficient to alkalinize 768 eight- ounce bottles of the milk mixture, and as the soda solution will keep indefinitely, it is readily seen that the use of this solution is both cheap and simple. We may now consider some of the reasons why a soda solution is decidedly to be preferred to lime-water. In the first place it is a mis- taken idea that lime must be added to the food for the sake of the lime salts required for the baby. Cow's milk, as the tables show, is decid- edly richer than woman's milk in mineral matter, including lime, and its dilution does not reduce the salts below the proper amount. The sole object of the lime-water is to render the mixture alkaline, and soda does this just as well. I hasten to say that the use of soda is in no way original with me. Dr. Jacobi, for one, long ago sanctioned it. Another objection to lime-water is that when added to milk in the quantity sometimes advised, its taste is quite evident and may be unpleasant to the baby. Another count against it is that when the milk mixture is heated a chemical reaction takes place between the sugar and the lime and a brownish color is produced. This is perhaps only an objection on an esthetic ground, but there seems no good reason for producing the offending color unless it is necessary. A fourth and more vital objection is that when the milk mixture is sterilized after lime-water has been added, the lime is precipitated in 1arge measure, and the desired alkalinity is reduced or destroyed. Finally, in the effort to overcome the latter objection, the difficulties of sterilizing are largely increased. It has been proposed, for instance, that the milk, water, sugar, and cream be mixed in the proper propor- tions and sterilized, and that the lime-water then be added. We can only do this with safety, however, just before the mixture is to be used, since an earlier removal of the cotton plug allows germs to enter. Con- sequently the proper amount of lime-water must be added to each bottle when the child is about to be fed. With the varying amounts of nourishment which the baby takes at different ages it is evident that the calculation of just how much lime water is to be added on each occasion is a matter not altogether simple. It will certainly seem to the mother to add greatly to the trouble in using sterilized milk; and it must be our object to make the process as easy as possible. With regard to the amount of cream to be employed, the formula Remarks on the Hygiene of Children. 453 given allows a certain latitude, since the cream is a variable substance. In using the mixture the whole amount needed for the twenty-four hours should be prepared in the morning when the milk arrives, the proper amount placed in each bottle according to the age of the child, and the bottles placed in the sterilizer and heated to the degree of tem- perature desired. With regard to the practice of sterilizing, it is undoubtedly true that the process often in some way makes the caseine more difficult to digest. On this account Pasteurizing has been proposed to take its place, as it does not materially alter the digestibility. The studies of Koplik and others show, however, that Pasteurizing in the strict sense of the term—i.e., heating to 75° C. (167° F.)--is not a safe method to be intrusted to mothers, since it does not satisfactorily kill the germs, which will develop in less than twenty-four hours. On this account a modified sterilizing is to be preferred. If the sterilizer is employed with the hood removed and the lid set slightly ajar and a brisk but not too hot fire is employed for about forty-five minutes, the tempera- ture of the milk does not go above 80° or 90° C., -a temperature which does not materially affect the digestibility of the milk, yet which is sufficient to render the milk practically safe for twenty-four hours. I have myself tested the milk with the thermometer while it was being heated in this way. Where predigestion of the food is to be combined with sterilizing, as is very often necessary in cases of illness, we may employ the fol- lowing formula : STERILIZED PEPTONIZED MILK MIXTURE. Water . . . . . . . . . . . . . . . . . . . 8 ounces. One-half of a peptonizing tube OT One peptonizing tablet Dissolve. Add milk . . . . . . . . . . . . . . . . . . 8 ounces. Peptonize. Then use, - Peptonized milk . . . . . . . . . . . . . . 2 Olli106 S. Cream . . . . . . . . . . . . . . . . . . I}% to 2 ounces. Milk-sugar . . . . . . . . . . . . . . . . . I [I] ea Slire. Water enough to make . . . . . . . . . . . 8 ounces. Sterilize as already described. This formula contains the same proportions as the preceding one, with the exception of the soda, which is increased in amount. No soda solution need be added, since the soda in the peptonizing powders or tablets more than takes its place. In concluding remarks upon feeding, I beg leave to exhibit this food warmer, which will be found very convenient, and which is not as 454 J. P. Crozer Griffith. tº widely known as it deserves. When a baby wakes in the night crying for its bottle, the tedious warming of the milk to the proper tempera- ture is, to say the least, a dreary process. This food-warmer, called the Penniston, consists practically of a hot-water bag with an outside pocket. One or more bottles of prepared milk, sterilized and corked, may be placed in the pocket on retiring, the compartment for water filled, and the whole covered with a woollen cloth. The bottles are thus kept ready for immediate use. To change the subject altogether, I desire to call the attention of the College to the importance of proper foot-covering for children. Almost always shoes are improperly made. It is often supposed that a baby’s foot, because plump and well rounded, is therefore shapeless. Attention has been called to the proper shape of the shoe by various writers, but, although the interest of many mothers is awakened, that of most shoemakers is still dormant. Shoes are constantly seen which clearly are cramping the baby's toes, with the natural result of pro- ducing ingrowing toe-nails and the like. In the effort to incite needed reform in this direction, I have made a considerable number of foot tracings of children of different ages, some of which I would exhibit to the College. (Fig. 2.) They were prepared by painting the sole with a mixture of lamp-black, turpentine, and sweet oil, and then pressing it upon a piece of blotting-paper. They serve to show better than any words can tell that a child’s foot, even at a very early age, is, of course, of the same shape as the adult's. The conclusion nat- urally drawn is that the earliest shoes should be rights and lefts. I came across a shoemaker in London who does make infants' shoes of this shape properly conformed to the foot. Unfortunately he is such an enthusiast that he goes to extremes, and produces a shoe which, excellent as it is, is not pretty, and can consequently not hope to find a sale, in this country at least. I purchased a pair from him, which I present for your inspection. After submitting a number of foot-tracings to a leading shoemaker of this city, I have received the promise that shoes will be kept in stock which are rights and lefts, and which are Remarks on the Hygiene of Children. 455 conformed as far as possible to the shape of the feet of children, even of the youngest age at which shoes are needed. In concluding these remarks upon various matters relating to children, I may call attention to the importance in many cases, as well as the scientific interest, of knowing how rapidly any baby is increasing in length. The determination of weight is simple enough, but the holding and measuring of a child against the wall is an awkward and inaccurate method for measuring its length. I wish to exhibit to the College this apparatus which I have devised to facilitate the measuring. (Fig 3.") There is absolutely nothing original about it, and the same device has probably been employed repeatedly by others, although I FIG. 3. # --> - º ------- I – ––––––––– – ---- gº I––º" ºx= -- -: * ~ * * >== -: ... -- ==== - - - - - ~~~~ Eºmºlº jººn, = **-----— — — --- —-º" - ----— — — E-ITI I —-- - - T --— — ==ºl L- have not happened to meet with a description of it. It is, as you see, similar to the foot-measures used by shoemakers, but much enlarged. It is four feet in length, and the pieces which run transversely to the length are eight inches long and are lined with felt. To use it the baby should be laid on its back upon a firm mattress. The end piece can then be placed above the head and the sliding piece moved along until it touches the foot, both toes and heel. The apparatus can be constructed by any clever carpenter. It can easily be made to fold into a comparatively small space to be easily portable. ICHTHYOL IN THE TREATMENT OF ERYSIPELAs. ZELEWSKY has found ichthyol efficacious in every form of erysipelas, and in his opinion it is superior to other remedies. In some cases of migratory erysipelas affecting both sides of the patient’s body, he painted one side with Trousseau's solution (acidi tannici, camphorae, ââ 2.0 grammes, 31 grains; aether, sulph., 15.0 grammes, 3% flui- drachms) and the other with ichthyol, the morbid process subsiding much more quickly under the latter treatment than under Trousseau's solution. He prescribed the drug as follows: Ammon, sulpho-ichthyol, spir. aether., áà I part; collodi. elastici, 2 parts.-Zugno-russkaya medic. gazetta. 1 The cuts appearing in this article have been electrotyped from plates made for Dr. Griffith's new work, “The Hygiene of Infants,” and kindly loaned by Mr. W. B. Saunders, the publisher. 456 B. Alexander Randall. CONCERNING TEST-TYPE." By B. ALEXANDER RANDALL, M.A., M.D., Ophthalmic and Aural Surgeon to the Children's Hospital; Professor of the Diseases of the Ear in the University of Pennsylvania and the Philadelphia Polyclinic, etc. INNUMERABLE test-types—good, bad, and indifferent—have been presented by many ophthalmic surgeons and perpetuated or travestied by numerous opticians, so that any one desirous of having an accurate measure of his patients' vision will have much apparent room for choice and have to look far for a satisfactory publication. The name inscribed upon a test-card is no guarantee that it has met the approval of that ophthalmologist, since its use has often been unauthorized, as the writer knows to his personal cost. One who wishes a chart which is really correct must know the principles and practice of test-type con- struction and apply them to his own or other cards. These principles are simple and their application easy; and it is a great pity that so much ignorantly or perversely erroneous work has been put forward. Empiricism in these tests gave place to scientific experiment and demonstration when Snellen utilized the data obtained by Helmholtz and other physiologists in measuring the minimum visi- ble, and constructed letters subtending at definite distances an angle of five minutes, and with parts and interspaces one-fifth of this height. He adopted the Roman block-letter as fairly satisfying the conditions of science and practice; and most of the deviations later made from his standard have been for the worse. This one-minute standard was gained by tests with gratings of rods of equal widths and interspaces, which were found to be discern- ible by the normal eye if subtending an angle of about fifty seconds, This does not mean that one or perhaps several wires or rods cannot be distinguished under a far smaller angle, or that points of light like stars must have an appreciable breadth to be perceived. The test rests upon the well-ascertained fact that for accurate and ready recognition of the letters, their strokes and interspaces must subtend about one minute, since the parts have never the considerable length which makes wires distinguishable under a smaller angle. And, further, it has been found that when circular dots are used as test-objects, about a half dozen being grouped irregularly with interspaces equal to their breadth, a much larger angle, more than two minutes, is requisite. Snellen chose the “block Roman” capitals for his test-letters, and undertook to inscribe each in a square subdivided into twenty-five * Read before the Ophthalmic Section of the Philadelphia College of Physicians, December 18, 1894. Concerning Test. Type. 457 one-minute spaces. He exaggerated the broadening of the foot and other adnexa of the letters, -additions which have their raison d'être in combating the effect of irradiation in apparently reducing the size of extremities not thus reinforced,—as shown in Fig. 3. Some of his letters are perfect in their exemplification of the principle, as the E (Fig. 2); but the A and H had to be broadened to seven spaces in order to have one-minute interspaces, and even then remained difficult letters to decipher (Fig. 1). His gradations in the sizes of the letters were rather violent and disproportionate, although fairly meeting clinical needs. An improvement was attempted by Dr. John Green, of St. Louis, in working out a more evenly progressive series of sizes, in which each line was on a scale of O.795 of the preceding ; but he used the simple Gothic letter without foot or other adnexa, which constitutes a far easier test-object than the block Roman, since its interspaces are always more than one minute. Hence, Wallace has put forward a four-minute letter as a truer empirical standard, as shown in Fig. 6. Later Green adopted a new letter having, as a rule, adnexa of one-half instead of FIGS. I 2 3 4 5 6. one-minute dimensions. This furnishes these parts of a size adequate to fulfil their intent and to complicate sufficiently their recognition, while inconspicuous enough to hamper little the employment of almost any letter of the alphabet. While not wholly free from objections, this letter has fewer drawbacks than Snellen's, and it is a pity that it has not been more generally adopted. (Fig. 4.) Drawn in this or in any other way, there will always be much difference in the legibility of the various letters. I and J will be so much the easiest as to exclude them from use,_B, K, and R will be among the hardest. Yet it is very important that no very limited selection shall be alone employed, since they are too easily learned ; while the real test consists in showing that the patient can distinguish intervals and strokes of one-minute size in any direction, as proved by distinguishing Y from T or V, F from P, and C from G or O. As to these last letters, they should be excluded as too easy in their general rounded form, unless offering just this element of small contrast. Yet the mere break in the side does not constitute the full difference between C and O,-the former needing its upper stroke to complete it (Fig. 5); so a patient seeing the broken circle offered by some test-cards is equally incorrect whether he calls it O or C, for it is neither. 458 B. Alexander Randall. * Dr. Dennett has worked out a card which employs most of the letters and well succeeds in equalizing their recognition by reducing the easy and enlarging the difficult from the accepted five-minute letter; yet the employment of the Gothic form leaves them too empirical and FIG. 7. LX C P L. O A T G Y D F A V H U D L. o E c N c P A R G E o L A T H Y E v. k U FD v1.1% O F : U N C L. D. E. B V H P G R o L D U c v H T E u e v H + n w = c Fo 1|| D A O N C E U H. W. L. T. P. imperfect exponents of the one- minute principle. The card presented by the writer some ten years ago fol- lowed Dr. Green's work closely as to the form and series of the letters, holding to the VI-metre distance for testing. So many seem to be using other distances now that it seems no longer well to keep this rather awkward con- vention. A more decimal series has been adopted, therefore, with close maintenance of the propor- tional sizes of the letters. The chart (Fig. 7) now contains sets subtending the standard angle at distances of LX, L, XL, XXX, XXV, XX, XV, XII+, X, VII+, V, IV, and III metres. The more-used lines XII and lower, contain ten or twelve let- ters each, so that a full test of the patient's vision can be made with small element of chance; no let- ter unless the N offers too difficult a task, so that the deciphering of every letter of a line should be insisted on. As normal eyes have usually more than a bare 5 V vision in good light, the V-metre line will remain a good standard for those who prefer to adhere to the six-metre distance,—none of its letters being really as difficult to decipher as some of the imperfect letters of Snellen's VI. The order of the letters has been carefully adjusted so as to bring the con- fusion-letters into some alternation; while the easier ones have been Concerning Test-Type. 459 placed at the first of the line, that the patient may begin correctly and thus indicate at once which line he is attempting. The larger letters have been placed as usual at the top of the card, since no advantage has been found in the inverted arrangement. On the con- trary, when illuminated by daylight, as is more common, the best sky-light falls on the bottom of the card, where nine-tenths of our work is done among the smaller letters. The color of the card has some importance; a cream-color verging on the India-tint giving better definition through lessening of irradiation, as is easily seen on compar- ing a new with a time-stained card. The delineation of the squares in which the letters are inscribed has a value as an object lesson to those ignorant or forgetful of the principle of construction, and as a demon- stration of its due employment in the card in hand. For the larger letters it is unobjectionable, but at or below the XII line it begins to encumber the letters and detract from their clearness. It should be omitted in the lower half of the chart therefore ; but I regret that in the present card it has been wholly left out, through a mistake. It may seem invidious to point out the advantages of these types by showing the shortcomings of others; but the illustrations offered may suffice to indicate those which I have sought to avoid. Other tests have value, often great; yet I believe these will be found to better answer the scientific and practical needs. Strange as it may seem, the majority of publications do not afford the accurate dimensions of the letters, being based upon the tangent of the angle 5* = .oO1454, instead of twice the tangent of half the angle = .oO1425. Slight as is this dif- ference, it makes the letters for LX metres 87.24 millimetres, instead of 85.5 millimetres in height; so they really subtend the standard angle at 61.22 metres. All too often, through the carelessness of author or publisher, the errors are still more conspicuous. FREQUENCY OF BILIARY CALCULI. HALK (Bibliothek for Zäger, p. 51 1, 1893), in a series of 414 autop- sies upon patients between 50 and 90 years of age, found biliary con- cretions in 29 per cent., the percentage in the female being 40, and in the male 19. In I 12 cases the stones were lodged in the gall-bladder alone, in three cases in the bile-ducts or intestines as well, and in four cases in the ductus choledochus only.— The C/niversal Medical Journal. 46O Charles A. Oliver. A DESCRIPTION OF SOME OF THE MOST IMPORTANT OPHTHALMIC METHODS EMPLOYED FOR THE RECOGNITION OF PERIPHERAL AND CENTRAL NERVE DISEASE. BY CHARLES A. OLIVER, A.M., M.D., Attending Surgeon to Wills Eye Hospital; Ophthalmic Surgeon to the Philadelphia Hospital ; Consulting Ophthalmologist to the State Asylum for the Chronic Insane of Pennsylvania. (Concluded from page 395.) OBJECTIVE STUDY OF MOTOR CONDITIONS. LEAVING the methods for the recognition of the sensory disturb- ances, the observer is brought to what at first sight seems one of the easiest portions of the examination,-that is, the objective study of the motor conditions of the visual apparatus. The muscular movements, however, are so varied in monocular and binocular fixation, and the association of nerve action is so complex in the different physiological acts of the two organs, that the examiner must be mentally well equipped to fully understand the significance of what to the uninitiated may appear to be an indeterminate commingling of movement and action. Most important are the procedures for the determination of iris movement. The comparative sizes and shapes of the pupils should first be gauged, the former being accomplished by one of the many forms of pupillometer, and the latter by the use of a twelve- to sixteen- diopter convex lens in the sight-hole of an ophthalmoscope. Should the pupil be round, as it seldom is, the horizontal width should be carefully estimated in millimetre lengths. If the pupil be oval, the lengths of the long and short axes should be determined, and the degree of direction of the long axis should be noted. These deter- minations are to be made during both monocular and binocular expo- sure, whilst the eyes are gazing directly ahead at a distance, and whilst they are fixed upon some near object, situated at about thirty-five centimetres’ distance from the patient's face. This should be done both immediately in front of the singly-exposed organ and on the median line when both eyes are simultaneously exposed. The patient should be made to face a window or some other source of diffuse day- light. If artificial light be employed, a ground glass shade over the source of illumination will be conducive to better results. The significance of the size of the pupil itself, although fre- quently unlike in the two eyes of the same subject, may often be taken advantage of for diagnostic purposes. For example, in myopia it is, by reason of relaxation of accommodation and consequent want Recognition of Peripheral and Central Nerve Disease. 46 I of impulse of the sphincter muscle of the iris, as a rule, larger than ordinary. It is also large in most of the various forms of so-called amblyopia and amaurosis. In sympathetic irritation, as may be found in the earlier stages of aneurismal pressure on the nerve, it is large. In paralysis of the third nerve, in glaucoma, cerebral compression, neu- roses of functional type, peripheral irritations, it generally becomes dilated. Local application and internal administration of certain drugs, ordinarily known as mydriatics, cause it; moreover, it must be remembered that it is larger in childhood and in youth than it is in adult life and in old age. On the contrary, it is small in hyperme- tropia. Especially is this so in cases where the patient is continuously using the eyes for close work. In retinal hyperesthesia, in meningeal inflammation, in cerebral irritation, and in certain stages of convulsive seizures, it becomes contracted. It lessens in size during the local and general action of certain drugs popularly known as myotics. Decrease of the area is an almost certain accompaniment of increasing age. Frequently, as is so often seen in the early stages of posterior spinal sclerosis and general paralysis of the insane, it will be found to assume all manner of bizarre shapes and irregularities of size. A11 of these conditions should be noted most carefully. For the better differentiation of pathological or artificial pupillary disturbances, some one of the numerous mydriatic and myotic agents, such as cocaine, atropine, eserine, etc., can, at times, be employed to advantage. Having thus roughly determined the equilibrium of the iris series of muscles, the actions of the sphincter muscles of these membranes are next to be studied. As these movements are associated ones, the procedures for their determination must be made under definite condi- tions. The first and the most important impulse or reflex-act is that known as iris-response to light stimulus thrown upon the retina. To study it properly, the patient is made to face Some source of diffuse day- light or artificial illumination. He is then to be directed to keep both eyes open and to gaze directly ahead into space. The two organs are then to be covered and alternately exposed to the entering light stimu- 1us until surety is made that there is muscular response or not. If there be any response, it will evidence itself by a more or less complete contraction of a portion or of the entire pupillary area upon exposure of the organ to the source of light. Frequently, in neuroses of degen- erative type, a series of slowly-decreasing secondary clonicisms may be noticed. These can be best studied by a magnifying lens which has been preferably placed behind the sight-hole of an ophthalmoscope. The next so-called pupillary reflex act, or better, iris reflex act, to study, is that existing between the ciliary and the iris muscles. Either of 462 Charles A. Oliver. these muscles, as can be determined experimentally, contracts its fibres when its fellow is broughtinto play. When the reflex movement of theiris, producing pupillary contraction, is brought into action by the contrac- tion of the ciliary muscle so as to allow the lens to increase its power of focussing for near vision, the impulse is known as pupillary response to accommodation. To determine whether this reflex motion is in proper working order, one eye is to be covered from use and the other is first made to gaze directly ahead at a distance. When the pupil of the gazing eye has become comparatively fixed in size, an object, such as the finger-tip or a pencil-point, is to be quickly placed at about thirty- five centimetres in front of the exposed eye, and the patient is requested to look directly at the object. If the reflex be in proper working order, the pupil will immediately contract, to dilate when the fixation- object is removed and the eye is made to regaze into space. A third pupillary response (better, iris response) is where the two eyes are made to accommodate synchronously upon a near object, situated upon the median line. Here, in addition to the relationship of impulse between the ciliary and the iris muscles, there is another factor, known as simultaneous contraction of the internal recti mus- cles, added. This compound reflex act, which is ordinarily, though improperly, known as the pupillary reaction to convergence,” is ob- tained in exactly the same way as it was during the previous method, except that here the fixation object is situated upon the median line and both eyes are coetaneously exposed. A fourth response is that in which the pupil dilates when the skin of the back of the neck is pinched. By some it is known as Parrot's sign, and is said to be present in some cases of meningeal inflammation. A11 of these examinations should be repeated frequently, often, —taking care in many cases to totally withdraw any form of stimulus from the eyes by temporary bandaging of both eyes, until certainty of result can be vouchsafed. This cannot be too strongly insisted upon, as nowhere in all of the methods of ocular precision, when the reflexes are carefully or properly studied, can so much information be gained as to deep-seated nerve and vascular disorder of motor type as in these most delicate and evanescent tests. One of the most important methods of diagnosis is that known as the hemianopic iris inaction sign, or what is popularly known as the Wernicke sign. Here, by the study of the peculiarities of movement of the iris in certain types of hemianopsia, much localizing data can be had as to the position of intracranial mischief. As is well known, the reflex arc for iris movement, when light stimulus is thrown upon the 1 It would be more fitting to say iris reaction to convergence, as the pupil, being a void, cannot have a reaction. Recognition of Peripheral and Central Merve Disease. 463 retina, extends back along the in-going optic nerve-fibres, until when about in mid-brain it associates with the out-going motor nerves of the iris. This, as has been proven anatomically, takes place before the position of the corpora quadrigemina has been reached. This being so, it is certain that, should some break occur within this reflex sen- sory-motor loop back of the optic nerves themselves, that is, in the optic chiasm or in the optic tracts, the want of proper physiological act to any appropriate external stimulus would immediately manifest itself by a failure of response of iris movement, should light stimulus be thrown through the pupil upon the retina. Knowing these facts, so here in hemianopsia, or, in fact, any related field defect, should the lesion be situated in the chiasm or optic tracts anterior to the corpora quadrigemina, the iris muscle will fail to respond when light stimulus is carefully thrown upon the non-receiving portions of the retina. To produce the symptom satisfactorily, many plans have been urged. In the writer's experience, the easiest and most practical method consists in simply having the patient placed in the ordinary ophthalmoscopic position, except that the source of light is so situated that the rays will come from over his head. One eye should be tried at a time, it being made to gaze straight ahead into a darkened space. The fellow eye is to be excluded from the entrance of all rays of light into it. The observer, standing in front of the patient, is to faintly illuminate the iris that he wishes to study by means of a piece of plain looking-glass such as is employed in the fundus-reflex test. This can be done by some permanent arrangement of mirror or by holding a glass in the hand. An ordinary concave ophthalmoscopic mirror is to be held in the other hand and a narrow beam of concentrated light is to be thrown upon the pupil from the periphery of the blind area of the field of vision. This beam is then slowly moved in towards the position of the line of fixation. If the sign be present, there will not be any iris movement until the edge of the retained field area has been reached. At this point, an immediate pupillary contraction will take place. This contraction will persist as long as the light stimulus is kept within the persistent field area. Should the lesion be situated posterior to the corpora quadrigemina, pupillary contraction will ensue, even though the stimulus be presented from the blind portion of the visual field, thus showing that the motor-sensory arc is untouched and unharmed. Another sign, known as the Knies pupil-symptom, is well worth searching for. It consists in a hemianopic inaction without a hemi- anopic field-defect, and shows that there is some localized disturbance in the different pupillary reflex path between the third-nerve nucleus of one side and its related tract. In some cases of grave nerve-disease, 464 Charles A. Oliver. especially where there is coexistent pupillary dilatation, and no an- swers can be obtained from the patient, much valuable data as to the condition of the ciliary muscle can be objectively obtained by the so-called catoptric test. As is well known, if a small beam of extraneous light be allowed to fall very obliquely upon the pupillary area, and this area be properly magnified and looked at, three images of the beam will be plainly seen. These images, in their order of succession, are formed upon the anterior convex surface of the cornea, the anterior convex surface of the lens, and the inner concave surface of the posterior portion of the lens. The first two images are large and upright, whilst the third image is small and inverted. In the act of accommodation, which necessarily means a contraction of the ciliary muscle, the con- vexity of the lens increases. This increase in the strength of the lens shows itself by a separation and a change in comparative size of the 1enticular reflexes. The lenticular reflex, which is the second reflex seen in the test, becomes larger and slightly moves anteriorly. The posterior lenticular reflex, which is the third reflex of the test, becomes smaller and markedly recedes posteriorly. At times, when the pupil is small and when it is impossible to properly study the catoptric images, the plain mirror can be employed to advantage to determine the degree and the amount of accommodative action of the ciliary muscle. If, whilst the instrument is being used to study the play of the movements of the lights and shadows in the fundus-reflex test, it be gradually approached to the patient's eye, there will be a point that is dependent upon the degree of accommodative power possessed by the organ, at which the movements of the reflexes will be reversed. This point, measured from the anterior surface of the eye, will determine both that there is ciliary muscle action and its degree of power. The objective study of the equilibrium, and the determination of the visible motions of the extrinsic muscles of the two eyes, next de- mand attention. In many instances, principally in the incipient and in the irritative stages of nerve-disease, the recognition of minor de- grees of disturbances of these muscles is extremely difficult. Hidden from view, associated in the most complex way in their normal actions, and so readily compensated for among themselves in their faults, their peculiarities of balance and the disturbances of their action are much less readily recognized upon mere inspection than the peculiarities of their related interior groupings, Often, however, a quick observer may notice abnormalities of facial expression, and take advantage of peculiar movements of the head and trunk muscles when certain ocular motions are attempted. Should the patient complain of double vision, one eye will often be found unable A'ecognition of Peripheral and Central Nerve Disease. 465 to fix upon some object held at about occupation distance (such as reading or sewing) upon the median line. The clinical demonstration of this sign, which can be very readily determined by alternately ex- cluding one of the eyes whilst its fellow is made to gaze at an object, such as a pen-point, held directly ahead of the patient at about thirty- five centimetres’ distance, is ordinarily known as the method by exclu- sion. If desired, the degree of deviation of the faulty eye can be esti- mated by the aid of a strabismometer, held in front of each eye. This experiment can be repeated in any meridian of the field of vision that may be desired. In fact, if due allowance for situation be taken, it may be tried in any position of muscle equilibrium that may seem to be desirable. Again, the degree of rotation, effected by the globe and the character of the movement when the eye is made to follow the up- raised finger, is of the greatest importance as an objective test. If there be an irritated or hypertrophied muscle, the movement of the eye- ball in the direction of the muscle will be greater than the movement of the opposite eyeball in the direction of the corresponding muscle. Should there be a paresis of the affected muscle, the movement of the globe to which it is attached will be limited in the direction of the pull of the muscle. An excellent routine in the determination of these conditions is to first consider the monocular movements in the hori- zontal meridian. This is to be followed by a study of the movements in the vertical meridian and at oblique angles. These observations should be repeated with the two eyes simultaneously, taking care in all instances to add the associated physiologic movements, as, for instance, the two interni in maximum convergence and the related external and internal groupings in conjugate deviation. If these tests be properly and intelligently conducted, they will often, especially if the observer be quick and certain in his finger movements, bring to light many minor discrepancies of both peripheral and central type that otherwise might escape attention. Watch should be made for slight ataxic movements during extreme action of the suspected muscle. Here the eyeball seems to succes- sively recede several times back along its excursional route and regain for a second or two its point of limitation of movement, before being able to accurately and steadfastly fix upon the observer's upraised finger. In all of this work, it should be remembered that the degree of movement in different directions of any two or more groups of muscles is greatly at variance, not only in respect to the individual strength of the muscles, but also as to the physiological acts that are being re- quired of the muscle-grouping at the time of action. For instance, the lateral movements of the globes, both separately and combinedly, are 34 - 466 Charles A. Oliver. far greater than the vertical, whilst the utmost degree of the movement of the two interni during the effort for binocular convergence is far less, especially in hypermetropes and in old subjects, than it is when these muscles are separately employed in association with the externi during conjugate deviation. Again, the observer should remember that errors of refraction may so mask the apparent results of the most care- fully performed work that, at times, the most bizarre and seemingly incongruous findings may be obtained. For this reason, therefore, no tests for muscle-balance and motion, unless so marked that they cannot be mistaken by the merest novice, should ever be undertaken until all or as much refractive error as possible has been expunged. If the observer be an adept in the art of ophthalmoscopy, and knows so well how to handle the instrument that it offers no inconven- ience in any way, or even if its use in this particular connection is repeated sufficiently often until all technique has been thoroughly mastered, the presence of muscular deviation may often be objectively decided. To do such work properly, the patient is to be seated in the ordinary ophthalmoscopic position. The light is to be placed directly over and back of his head. The observer is to stand directly in front of the patient and to face him. The patient should now be made to gaze steadily at the sight-hole of the instrument or the forehead of the observer. The observer is to gaze alternately at the two eyes of the patient and study the relative situations of the bright light-reflex upon the patient’s corneae. The feeblest nystagmic motions may ofttimes be brought to view by recourse to one of these methods. If the mirror be not at hand, a candle-flame so shaded from the observer that it does not interfere with the sight of the patient’s corneae, may be substituted. This latter plan, although somewhat more difficult and necessitative of more practice, has several times served the writer at the bedside. A spasmodic action of the superior elevator muscle of the upper lid, known as Abadie's sign, may, at times, be distinguished in cases of Basedow's disease. Poisoning of the palpebral fissure, described by Jacobson as sympathetic ptosis and probably due to paralysis of the sympathetic, may appear during the course of posterior spinal sclerosis. Imperfect action of the orbicularis muscle with pilullary movements dependent upon a minor degree of facial palsy, which has been called attention to by Berger as appearing in the same disease, should be sought for in suspected cases. At times, in exophthalmic goitre, the upper lids lag when the eyes are made to direct their gaze downward. This, known as the “von Gräfe sign,” has, in the hands of the writer, been the easiest recognized, whilst the patient is made to lie flat upon his back, with his head slightly elevated and inclined forward upon a firm, hard pillow. A'ecognition of Peripheral and Central Nerve Disease. 467 While the patient is in this position, he should be made to gaze with his two eyes at the observer's finger-tip, which is to be held at about seventy centimetres directly above the patient’s face. The observer is then to slowly move his finger in a curvilinear direction towards the patient's breast. If the sign be present, the upper lids will lag, whilst the eyeballs will follow the finger. Dalrymple's sign, or Stellwag's symptom, which consists in an abnormal widening of the fissure be- tween the lids, can often be seen in the same disease. In some instances, a valuable clinical guide as to the degree of smoothness and evenness of the movements of the extra-ocular mus- cles through their tendinous sheaths and coverings, can be obtained by the employment of auscultation. The writer has sometimes felt that he has thus added an additional diagnostic factor in so-called muscular paralyses that later have been found to have been mere mechanical impediments to muscle-action. This he has several times observed in cases of rheumatism and gout. SUBJECTIVE STUDY OF MOTOR CONDITIONs, The last grouping of studies of the motor series of ocular symptoms (the subjective motor) is in reality the most vague, and frequently the most confusing. Here, not only must the answers depend upon the patient’s assertions, which often are the sequences of incomprehensible questions to his uneducated mind, but frequently, especially in the seriously ill and the mentally unfit, the apparent results are useless and valueless. When properly obtained, however, and fortunately, as a rule, in subjects whose disease is in its very incipiency, the results are most valuable. Brief training of the patient with a couple of the pro- cedures, and explanation of what is to be expected in a few of the easiest methods, before any attempts at examination are made, have, in the writer's experience, saved much subsequent useless labor upon his part, and given answers that have been eminently satisfactory. Commencing with the easiest and the most easily comprehended, the plan for the determination of the disturbances of the extra-ocular muscular groupings will be taken first. The muscles should be tested both when they are used to fix the eyes upon near and when they are made to have them gaze upon distant objects. In every instance, care must be taken to note the circumstances under which the test is being performed. Taking the study of the deviations where the eyes are gazing at a distance first, the simplest and easiest plan to render any disturbance apparent, and one which can be accomplished without the employment of any delicate or complicate apparatus, is to have the patient placed in a darkened room. He should then be made to gaze at a minute point of light, situated at about five metres' distance from 468 Charles A. Oliver. his eyes and upon a level with them. A ten-degree prism, base up or down, is next to be placed before one of his eyes. Preferably, as a routine, the left eye should be the one chosen. The relative positions of the false light thus produced and the true one are then to be ascer- tained. For example, if the prism be placed base up before the left eye, the false image thus produced and seen by the left eye, will be thrown below the true light. Should the inferiorly-situated false light be also thrown to the right, there is, by reason of the left false light having been crossed over to the right of the true right light, a condi- tion known as crossed or heteronymous diplopia. This shows that the patient has either an enervation of the left internus muscle or a spas- modic contraction of the right externus muscle. So, similarly, with any series of muscles, the position of the false image as compared with the true one will always give immediate and almost certain answer as to the character of the fault and the determination of the muscle that is disturbed. These obtained, the degree of apparent variation can then be readily determined by the superposition of increasing strengths of correcting prisms with their apices placed towards the supposed affected muscles. Should the false light, when the prism is placed either base up or down before one eye, appear upon the side towards the eye before which the prism is placed, the double vision, or diplopia, as it is termed, would then be known as homonymous. If, under the same circum- stances, the two lights be situated immediately in vertical line, there is said to be orthophoria or perfect binocular equilibrium in that meridian. If desired, a gauged card can be substituted for the correcting prisms, and the amount of apparent deviation can be readily designated by the patient. To assist in the determination of the relative positions of the two images, the true one can be made to appear as “red” to the patient by placing a piece of plain red glass before the eye that has not any prism before it, thus more readily differentiating it from the false one that has been produced by the prism-bearing eye. In vertical deviation obtained by horizontally-placed prisms, the prism-strengths must be necessarily greatly increased. This is so, by reason of the preponderant powers of the lateral muscle-groupings over the vertical muscles to overcome stronger prisms. In this series of experiments, the faulty findings are to be estimated by vertically-placed correcting prisms. If, during such experiments, a tendency for vertical deviation of one of the visual lines be found, hyperphoria is said to exist. Another rough and ready test for the determination of muscle- balance that is peculiarly applicable to the sick-room is what is known by Duane as the parallax-test. After having placed the patient and a Recognition of Peripheral and Central Nerve Disease. 469 distant light upon a proper level, he is to be requested to alternately expose the two eyes whilst he endeavors to steadfastly gaze at the light. If muscle-balance exists, the right and the left image of the light will not apparently undergo any movement. If any muscular deviation be present, the images of the lights will appear to jump into a new position the moment that the covered eye is exposed. If desired, the degree of muscle disturbance can be easily estimated in this test by means of correcting prisms. With properly-constructed apparatus, the tests for the determina- tion of muscle-balance become more beautiful and more certain. Com- mencing with the simplest,-the glass-rod test of Maddox,-much important data, especially from previously instructed and intelligent subjects, can be obtained. The contrivance essentially consists of one or more short cylinders of clear glass that distort the image of the light into one or more lines that are situated at right angles to the direction of the placing of the rod. The image of the lines is so different in out- line and shape from the untransformed image of the light as seen with the opposite naked eye, that it cannot be confounded or fused with the undisturbed image of the fellow eye. Consequently, if no impulse for fusion exists, the muscles of each eye will assume their individual state of equilibrium. This is immediately shown by the relative positions of the projections of the two series of images. Should any deviation exist, its angle and its degree can easily be estimated, just as in the previous test, by the addition of the prismatic strengths that are neces- sary to superimpose the lines exactly upon the untransformed candle- flame. If the patient can be seen at a consultation room, where more deli- cate contrivances can be employed, some one of the better grade pho- tometers and revolving prisms, such as Prince's, Risley's, Jackson's, or Stevens's, may be used. Where greater delicacy or where scientific accuracy is necessary, some more complex and more expensive contri- vance, such as Brayton's optomyometer, may become useful. The above-mentioned simpler tests, when used in their various forms by an accurate observer, can hardly fail to elicit adequate data as to almost all forms of muscle discrepancy, after sufficient repetition and due explanation have been given to the patient. In many of the grosser and more marked cases, the mere superposition of a plain red glass before one of the eyes will be all that is necessary to study the kind and the degree of diplopia. In numerous instances, the writer has found that it is a good plan to estimate one faulty meridian, as, for example, the horizontal, and then, after this has been corrected, to search for any disturbance in the opposite meridian and to estimate this. By this plan, the combined 47O Charles A. Oliver. correction frequently evinces a less difference of necessary strengths in each of the two meridians than would be found were they to be sepa- rately estimated. This should always be remembered, as it is a plan of procedure that may be of the utmost etiological importance and even of subsequent therapeutic value in special cases under study. Another method that may at times be adopted, is to estimate the amount of prism-deviation that the different extra-ocular muscles can overcome. This is done by having the patient look at a distant light with his two eyes, and then substituting stronger and stronger prisms before one eye with their apices pointed towards the muscle of that eye which is desired to be studied, until double vision is complained of. As a rough guide, the internal rectus muscles are said to generally overcome about forty to fifty degrees of prism strength ; the external rectus muscles about eight degrees; the inferior rectus muscles about four degrees; and the superior rectus muscles about three degrees. In all cases, the subjective determination of the degree of the power of the ciliary muscle, thus evidencing the amount of consequent lenticular action, is necessary. To do this properly, one eye should be tried at a time. It is always best to commence with the supposed more affected one. A series of small test-words are to be first approxi- mated so closely to the patient’s face that he cannot recognize any of the type. By now slowly moving the card away from the eye, the dis- tance of the point of the first correct naming of the letters or spelling of the smallest words upon the card away from the eye is to be noted in centimetres. This distance or measurement gives the near point or punctum proximum (p.p.) as it is termed. This represents the utmost strength of the accommodative or focussing apparatus of the eye, and shows the amount of action of the ciliary muscle. After this has been registered, the card of type is to be removed beyond the limit of dis- tinct vision for the same size of letters that has been used to obtain the near point. The letters are then to be slowly approached towards the patient’s eye until another similarly-sized word or combination of letters is correctly read. This gives the farthest point, or the punctum remotum (p.r.). The two series of findings are to be noted in the fol- lowing manner: for example, “Acc. (accommodation) = type o.5o D (the size of one series of letters), 20–35 c.m. (centimetres).” Where presbyopia is supposed to exist, or where there are high and extreme degrees of ametropia, the superposition of correcting lenses, taking care to specify them in the notings, should be employed to enable the patient to read the test-words. In addition to these four varieties of procedures for the determina- tion of the motor and sensory symptoms of the visual apparatus, the observer should never fail to obtain a clear and a concise history of any Recognition of Peripheral and Central Nerve Disease. 47 I pre-existing and present ocular symptoms. A brief record of the gross objective condition of the organ should be noted. The deeply-seated and the more superficial vascularity of the sclera and overlying con- junctiva should be studied. Fatty degeneration areas around the periphery of the cornea should be searched for. The state of the lacrymal apparatus should be determined. Marks of inflammatory thickenings, and the degree of intra-ocular tension, should both be recorded. If to these the relative prominence of the eyes be gauged, and palpation and auscultation be practised for the detection of orbital bruit, the work will be more complete. At times, it must be remem- bered that patients may either intentionally or unwittingly feign cer- tain ocular symptoms. The determination of the truth or falsity of their assertions can be accomplished by experiments and procedures which are intended to either actually deceive or confuse the patient. Plans of all kinds, dependent upon the ingenuity of the examiner, can be tried for this class of subjects. In parting, the writer can give no better advice to the reader than to study every ocular symptom that may appear of importance to the elucidation of the cause of any related neural disturbance. The examiner should understand that it is the entire grouping of the ocular conditions that alone can furnish proper data. This must be done repeatedly and sufficiently often to allow an understanding of the course taken by the symptoms, and to formulate some generalization as to their significance. In fact, if in all of his work the reader should con- stantly employ the most careful and painstaking technique, and exer- cise proper judgment as to the meaning of the findings, he will soon realize that the reputation and certainty of his results will far more than repay him for his trouble and his care. 472. - - Charles W. Burr. THE SPINAL CORD LESIONS AND syMPTOMS OF - PERNICIOUS ANEMIA. By CHARLEs W. BURR, M.D., clinical Professor of Nervous Diseases in the Medico-chirurgical College; Pathologist to the . Orthopedic Hospital and Infirmary for Nervous Diseases. THE following study is based upon seven cases of pernicious anemia, a case of profound anemia secondary to chronic dysentery, and one of ataxic paraplegia occurring in a phthisical subject with intense anemia. I shall discuss the frequency of lesions in the spinal cord, their localization, their causation, and the symptoms they produce. I shall not consider at all the hemorrhages that sometimes occur in the cord, since they bear no relation to the lesions found in my cases. CASE I.*—(Courtesy of Dr. Morris J. Lewis.) Many of the notes have been lost, and I am only able to give the report of the patient's condition on admission to the Infirmary in November, 1889. Middle- aged white woman ; bedridden; skin sallow, with a peculiar yellow tinge; no dark spots; pressure causes no change in color. Her body has a peculiar musty odor. Spleen not enlarged; area of renal dul- ness not increased ; lungs normal. Apex-beat is in the fifth inter- space in nipple line. The impulse is a trifle extended. A systolic bruit is heard over the body of the heart and at the apex, at which point it is loudest. It is perfectly soft and low. There is a venous hum in neck. Slight general edema. The veins in the arms are not very marked. There is no tenderness over sternum or clavicle. The back is very tender to touch. No periosteal nodes are found. There are no glandular enlargements in the groins or axillae. There is no increase of liver dulness. Blood Examination.—Red corpuscles I, I5O,OOO ; hemoglobin, 25 per cent. Three weeks later red corpuscles 860, Ooo ; hemoglobin, 12 per cent. A few days before death red corpuscles 650,000; hemoglobin, Io per cent. The urine contained a little pus and a trace of albumin, but no casts. The patient gradually grew weaker, vomited so frequently that rectal feeding had to be resorted to, developed an acute bedsore, and was at times delirious. A short time before death there was slight transient paresis of the left face and arm. Death in coma. Clinical diagnosis, pernicious anemia. - On post-mortem examination I found the subcutaneous fat rather 1 Read at the meeting of the Society for clinical Research, January 29, 1895. 2 Reported briefly by me in Transactions of the Philadelphia Pathological Society, Vol. xvi., 1893, • , - T- T FIG. I.-Case I (Dr. Lewis). Lower level of medulla, show- Fig. 4.—Case I (Dr. Lewis). Lower dorsal region. ing degeneration in the postero-median and postero-external columns with a band of normal tissue between. Fig. 2.-Case I (Dr. Lewis). Cervical swelling, show- Fig. 5-Case II (Dr. Lewis). Cervical swelling. ing the degeneration in the postero-median and postero- external columns. Fig. 3.-Case I (Dr. Lewis). Upper dorsal region. Fig. 6.-Case II (Dr. Lewis). Middle dorsal region. Fig. 7–Case III (Dr. Packard). Upper dorsal region. Fig. 9–Case III (Dr. Packard). Upper lumbar region. FIG. Io-Case VI (Dr. Ireland). Cervical swelling, Fig. 11.-Case VI (Dr. Ireland). Upper dorsal region. Fig. 12–Case VII (Dr. Parke). Dorsal cord. Aermicious Amenia. - 473 abundant and orange-yellow in color. The heart was large, flabby, and contained a little liquid blood. The muscle-substance was fatty; lungs normal ; liver fatty. Mucous membrane of the stomach showed no atrophy. Within the suprarenal capsules were cavities. The tibial marrow was blood-red and resembled currant-jelly. On microscopical examination quite a number of nucleated red blood-corpuscles were found. Absolutely no fat was present and the bony trabeculae had en- tirely disappeared. Macroscopically the brain and cord appeared nor- mal. The liver gave Quincke's iron reaction. The spinal cord was hardened in Müller's fluid. On section the form of the cord was shown to be well preserved, there being no shrink- ing of the posterior columns. The gray matter was well marked off from the white. The only morbid condition seen was a very lightly- stained area in the posterior columns, very marked in the cervical re- gion, and becoming less and less down the cord, until in the lumbar region it was scarcely visible. Microscopical Examination.—Lower Level of Medulla (Fig. 1).- In the postero-median column is a wedge shaped area of degeneration, greatest at the periphery and extending along the posterior median fissure, the apex not reaching to the posterior commissure. On the left the degeneration reaches the septum between the postero-internal and postero-external columns. On the postero-external column, on either side, is a club-shaped area of degeneration, the head towards the periphery, the handle extending inward and dorsally towards the median fissure. Between the outer and inner area of degeneration is a W-shaped area of normal tissue. The degeneration does not reach the periphery anywhere, nor does it extend to the edge of the gray matter. The lateral tracts and, indeed, the whole antero-lateral region is normal. The gray matter is normal. A few of the fibres in the posterior peripheral nerve-roots are degenerated. Cervical Swelling (Fig. 2).-The same condition obtains, except that the posterior columns are, of course, greater in extent, and the areas of degeneration are on a larger scale, but the relative positions are the same. The posterior peripheral roots are affected to a very slight degree. - - - Upper Dorsal Region (Fig. 3).-There is a W-shaped band of de- generation between the postero-median and postero-external columns, involving both, the apex being about one-third the distance from the bot- tom of the posterior longitudinal fissure. In the middle of the pos- tero-median column there is an area of degeneration reaching to the apex of the first. Here also the periphery and the white matter bor- dering on the gray are normal. - Mower Dorsal (Fig. 4).-There is a W-shaped area, base out, in 474 * Charles W. Burr. the central part of the postero-median columns, greatest along the edge of the fissure. Dumbar Swelling.—There is a small area of degeneration just visible to the naked eye, because it is more deeply stained by carmine between the postero-internal and external columns on one side, about half-way between the centre and periphery. Lower Lumbar Region is Normal.—At no level is the degeneration complete, there being in every section more or fewer normal nerve- fibres, but it is distinctly visible to the naked eye. The cervical swell- ing is the seat of greatest insult, and from there down the lesion con- tinuously decreases in extent and intensity. The affection of the posterior peripheral nerve-roots is confined to the cervical region and is very slight. The gray matter is nowhere diseased. There is no meningitis. Histologically the picture varies. In certain areas there is a dense net-work of fine fibrous tissue with an increase in the number of nuclei. In others the net-work is much more open, and here and there are empty spaces as if a nerve-fibre had fallen out. Many of the present nerve-fibres are much smaller than normal, the transverse area of the sheath being much diminished. There is no increase in the number of blood-vessels, but the walls look somewhat glassy and are apparently thicker than normal. CASE II.-(Courtesy of Dr. Morris J. Lewis.) A. B., female; aged 35 years; admitted to the Pennsylvania Hospital July 19, 1890. Com- plained of great weakness, diarrhea, and vomiting. Two days before admission she thought herself well enough to be about, but fell from weakness on crossing the floor. Two years before, just after her hus- band's death, she was first taken ill with indefinite symptoms. She was wearied and exhausted, and was in a sanitarium for some weeks. Men- struation is regular. For several months she has suffered from bleeding - piles when constipated. * ..., Bxamination.—No emaciation ; skin yellowish and anemic ; lungs, liver, and spleen normal. Heart: systolic murmur, loudest over base. No evidence of organic disease. Pupils equal, normal in size, and react well to light and with accommodation. Disks pale. No retinal hern- orrhages. All the skin reflexes are slight. The knee-jerk is absent, and not reinforcible. Ankle-jerk is absent. There is no chin-jerk. Slight muscle-jerk is present on thighs. Pulse is weak and thready, 14o per minute. Temperature 103** F. Tongue not coated, but reddish. There are brownish blotches on right side of face and the right thigh resembling very large freckles. There are no periosteal nodes nor glandular enlargements. Blood examination reveals hemoglobin 25 per cent.; red blood-corpuscles 2,075,000. No leucocytcsis. On a second A'ernicious Anemia. 475 examination, made on the day of death, July 22, hemoglobin was reduced to 24 per cent., and the red corpuscles to 1,750,000. Clinical diagnosis, pernicious anemia. The post-mortem was negative except that the tibial marrow was red and contained many nucleated red cells, and fat was absent. The liver responded to Quincke's iron reaction. Microscopic Bºxamination of the Cord.—Cervical swelling (Fig. 5). — In the postero-median column there is a wedge-shaped area of degen- eration, base towards the periphery, and extending half-way to the posterior commissure. Outside this is a narrow W of normal tissue, covering which again is a narrow band of degeneration, mainly in the postero-external column. In some sections the two areas of degener- ation are fused into one mass. The degeneration is least at the cir- cumference of the cord, and in some sections there is in that situation no lesion at all. The degeneration nowhere reaches to the border of the gray matter. The gray matter and the anterior and antero-lateral tracts are normal. The peripheral nerve-roots are normal. Opper, Middle, and Zozver Dorsal Regions (Fig. 6).-There is a small, wedge-shaped area of degeneration with the base posteriorly on either side of the middle of the posterior median fissure, extending neither to the periphery nor to the commissure. There is no involve- ment of other parts of the transverse area of the cord. Azembar Aegion.—Perfectly normal, unless the rather less deep staining of the postero-median columns visible macroscopically, and an apparent very slight thinning out of the fibres microscopically, indicate beginning disease, which I doubt much. CASE III.-(Courtesy of Dr. F. A. Packard.) J. F., male; white; aged 43 years; car-conductor. Previous health good. No alcoholic excess. Gonorrhea admitted. Onset of present trouble in 1887. First symptoms: anorexia, discomfort after eating, frequent vomiting, usually about an hour after eating, and marked constipation. Axamination.—First seen in 1890, Weight I 19 pounds. Skin pale lemon-yellow; mucous membranes almost colorless ; conjunc- tivae clear ; no edema; no jaundice. There is a loud venous hum in neck. Loud blowing, systolic murmur at pulmonary area, and a soft blowing murmur at apex. Very marked upward pulsation in cer- vical veins. No enlargement of the glands about the clavicles. Lungs normal. Liver somewhat diminished in size. Spleen of normal dimen- sions. Knee-jerk absent. In July the blood-count gave red corpuscles 681,250, white corpuscles Io97; hemoglobin 25 per cent. In Decem- ber the body weight increased to 148 pounds. Red corpuscles rose to 2,000,000, and the hemoglobin to 50 per cent. Later profuse serous diarrhea and edema set in, and he was removed to the Presbyterian Hospital, where he died, September 10, 1891. 476 Charles W. Burr. Post-mortem revealed no emaciation. Marked general edema. Not very much subcutaneous fat. Heart enlarged, flabby, and with thick- ened walls and dilated cavities. The muscle was reddish-brown. Valves normal. The tibial marrow was red, and contained many nucleated red blood-cells. The liver gave Quincke's iron reaction. There was much clear straw-colored fluid in the abdominal and pleural cavities. The lungs were hypostatically congested, but otherwise normal. Examina- tion of the kidneys was negative. The dorsal and lumbar cord only were sent me for examination. Macroscopically there is a distinct area of degeneration visible, after hardening in the postero-median columns. Microscopical Examination.— Upper Dorsal Region (Fig. 7).-There is an irregular triangular area of degeneration in the posterior columns, the apex reaching almost to the commissure, and the periphery being free. The remainder of the transverse area of the cord is perfectly normal. The peripheral nerve-roots are normal. Zower Dorsal Region (Fig. 8).-There is a thin band of degenerated tissue on either side the posterior longitudinal fissure, running parallel with it, and about half-way between it and the border of the gray matter, and reaching neither periphery nor commissure. Upper Lumbar (Fig. 9).-The band spoken of above becomes Here a spot about as big as a pin's head, situated at the middle of either posterior column. Lower Zumbar Region.-Normal. • CASE IV.-(Courtesy of Dr. F. A. Packard.) A. S., female; white; mill-hand; aged 42 years; admitted to the Episcopal Hospital Sep- tember 4, 1894. Onset three years ago after much grief. Began with loss of appetite. Later weakness, palpitation of the heart, dyspnea, puffiness under the eyes, and edema of feet. Examination.—Hemoglobin 23 per cent. ; red corpuscles 872, ooo; poikilocytosis; macrocytes present. Urine: Clear amber-color; acid ; specific gravity IOO7; a little pus; no albumen. Lungs : Resonance good except at apices. At right there are subcrepitant and on left a few crackling rāles. Posteriorly resonance is impaired at angle of scapula on left side, and expiration is prolonged on both sides. There are a few crackling rāles at the base. On the right side posteriorly the crackling and sibilant rāles are general. Heart : Dulness in parasternal line at upper border of third rib, and laterally at fifth rib extends to right sternal border. Apex-beat not palpable. Wavy impulse at lower end of sternum and in epigastrium. At apex systolic murmur trans- mitted into axilla. At aortic cartilage systolic murmur transmitted into carotids. At pulmonary cartilage second sound sharp and rasping. Aliver: Dulness at upper margin of sixth rib, extending slightly below costal margin. Spleen is enlarged downward, and tender on palpation. Aerºzicious Anzemża. 477 General appearance : Skin discolored a light yellow-brown. Face somewhat flabby. A little puffiness under the eyes. Conjunctivae pale. Tongue and mucous membranes pale and dry. On a later examination, made October Io, 1894, the following condition was revealed. Skin very dark yellow, almost mahogany; conjunctivae clear and bluish; pannic- ulus good ; tongue very white ; lips and gums pale; vessels of neck pulsate very visibly ; pulsation of the large veins, which is stopped by pressure below. Slight impairment of pulmonary resonance with harsh broncho-vesicular breathing and prolonged expiration. All over pre- cordium a soft blowing systolic murmur, most marked at apex and at xiphoid. Second sound at pulmonary very valvular. Splenic dulness enlarged to costal margin. Knee-jerk is slightly diminished, but still marked. Hemoglobin 25 per cent. ; red corpuscles 668,000; poiki- locytosis; microcytosis. Death October 30, 1894. Aost mortem.—Body well nourished ; much subcutaneous edema ; muscles red ; spleen plainly visible on opening abdomen. Much straw- colored fluid in peritoneal cavity. Pericardial sac moderately filled with clear fluid. Both pleural cavities contain a large quantity of clear amber-colored fluid. The heart is arrested in systole. All cavities filled with partly fluid, partly clotted blood. Right auricle stuffed with chocolate-colored post-mortem clot; foramen ovale closed. Tricuspid orifice admits four fingers and thumb. Right ventricle contains ad- herent, pale-red post-mortem clot. Endocardium of right side normal. Wall measures one-fourth inch. Tricuspid and pulmonary valve leaflets normal. Left auricle contains a pale red post-mortem clot. Mitral orifice admits two fingers readily. Aortic valves apparently incom- petent. Left ventricular wall measures three-fourths inch in thickness. Some tabby-cat mottling seen through endocardium. In general endo- cardium normal in appearance. Mitral valve leaflets distinctly thick- ened and rigid. Aortic valve leaflets normal. Weight of heart, opened and freed from clots, thirteen and one-half ounces. Bronchial glands slightly enlarged. In left pleural cavity a few old adhesions, one par- ticularly thick, stretching from parietal layer to an area of putty-like infiltration in upper periphery of left lung. General appearance of left lung good. Posteriorly and laterally in upper portion of upper lobe is a pea-sized mass of putty-like material distinctly encapsuled. Be- tween middle and lower lobes of right lung numerous cobweb-like adhesions. Areas of collapse in both upper and lower lobes. At inner angle of lower lobe posteriorly an area of pneumonic consolidation one and a half inches in area. Spleen ... Weight fifteen ounces; pulp red and firm. Gall-bladder moderately full of bile; duct patulous; duo- denum normal; pylorus normal ; stomach normal in size; walls slightly thin. Towards pylorus marked corrugation of mucous mem- 478 - Charles W. Burr. brane. Intestines normal except for punctiform hemorrhages in jejunum. Suprarenal capsules normal. Kidneys rather pale, otherwise normal. Liver. Weight sixty-two and a half ounces, pale, flabby, and distinctly fatty. Bone-marrow red. - The dorsal and lumbar cord of the above case was kindly given . me for examination. It is normal throughout. CASE V.—Ataxic Paraplegia, possibly due to Amemia and Secondary to Phthisis. (Courtesy of Dr. Wharton Sinkler.) B. H., male; married; house-painter, but has not worked at his trade for years. Applied for treatment at the Infirmary for Nervous Diseases October 17, 1892. In brief his history is as follows: Family history negative. Habits good. Syphilis and gonorrhea denied. Pneumonia, as he calls it, many years ago. Never had painter's colic or wrist-drop. Has had cough (phthisis). for a long time, and has lost much, flesh. The present trouble began in January, 1892, with prickling and tingling in the fingers and hands, which later extended over the entire body. Soon stiffness and weak- ness in walking developed. He has at times a sensation of a tight band around the waist. There is occasional slight vertigo. He passes water without difficulty, but with little feeling. Bowels are moved only by injection ; appetite poor; sleeps fairly well; mental condition good. Æxamination.—Extreme emaciation. The skin is of a waxy, lemon-yellow color. The mucous membranes very pale. Station is very bad, the eyes being either open or closed. Gait is ataxic and at the same time spastic. This together with his general weakness makes it impossible for him to walk more than a few yards or, indeed, even feet. The knee-jerk is much increased in amplitude, and is spastic. There is no ankle clonus. The pupils are equal, moderately dilated, and react well to light and with accommodation. All movements of the hands are markedly ataxic. Touch sense in the hands is slightly delayed; pain sense is normal. The tendon- and muscle-jerks in the arms are all increased. There is a slight chin-jerk. Slight edema of feet. No blue line on gums. Blood: Red corpuscles, 1,050, OOO ; hemoglobin, 25 per cent. ; no leucocytosis; poikilocytosis present ; no nucleated red corpuscles. - The symptoms both pulmonary and nervous gradually grew worse after his one visit to the infirmary, and he died October Io, 1893, of chronic phthisis. On post-mortem examination I found : Extreme emaciation; al- most no subdermal fat. Advanced chronic phthisis involving both lungs. Stomach, heart, liver, kidneys, and spleen showed nothing noteworthy. Marrow of the tibia normal. Brain not examined. The posterior columns and crossed pyramidal tracts pearly gray in color. tº, Aermicious Anemia. 479 Microscopical Examination of the Spinal Cord.—/Lower Cervical A'egion : Complete degeneration of the posterior columns, except a very narrow band along the edge of the posterior commissure. Com- plete degeneration of the lateral columns back of a line drawn through the central canal. At some levels there is degeneration at the periphery of the cord almost as far forward as the anterior direct tracts. The direct pyramidal tracts are degenerated completely on both sides. The gray matter and peripheral nerve-roots are normal. There is no menin- gitis. Dorsal Region : The same condition obtains. Lumbar Region : Complete degeneration of the posterior columns. There is a triangular area of degeneration in the lateral column just outside and in contact with the posterior horns. The direct pyramidal tracts are degenerated even at this level. A few of the bundles of the posterior peripheral nerve-roots are markedly degenerated. The greater number are normal. Histologically there is a very wide-meshed net-work of fibrous tis- Sue. In many places there are apparently open spaces as if nerve- fibres had dropped out. Here and there are what look like much swollen and granular myeline sheaths with a scarcely visible or invis- ible axis cylinder. There are also sharply-stained points that look like naked axis cylinders. There are quite a number of scattered nuclei. There is no increase in the number of blood-vessels, and those present have walls but little if any thicker than normal. The diseased area is much more visible than in those cases in which the sclerosis is dense. CASE VI.—(Courtesy of Dr. Weir Mitchell.) I abstract the his- tory from one of Dr. Mitchell’s clinical lessons." E. S., female; single; 50 years old. Admitted to the infirmary March 2, 1894. In 1887, “nervous exhaustion.” In 1889, influenza, after which she was in bed for a year on account of weakness. Never well since. In 1890, marked hysterical symptoms. In June, 1893, had a severe attack of dysentery. On August I, red blood-corpuscles, 581,000; on September I the count had risen to 950, Ooo reds ; October 18, 1,62O, ooo. Has never menstruated since October, 1893. The skin was then lemon-yellow, conjunctivae bluish, mucous membranes almost colorless. The apex- beat is in the fifth interspace. No thrill is felt. Area of cardiac dulness normal. There is a soft, hemic, systolic murmur, low in pitch, transmitted into the axilla, accompanying but not obliterating the first sound at the apex. There is also a higher-pitched systolic murmur (probably hemic) heard in the pulmonary area. Hemoglobin 15 per cent. ; red blood-corpuscles, 930, Ooo. There were poikilocytes, macro- cytes, and microcytes in abundance, while macroscopically a drop of * Medical News, July 7, 1894. 48O Charles W. Burr. blood looked like slightly-tinged muddy water. She improved greatly. On admission there was marked motor ataxia in the hands and legs. Numbness and tingling in hands and feet. Could not stand alone. Plantar, epigastric, and abdominal reflexes are normal. Knee-jerk normal and reinforcible. Elbow-jerks normal. Muscle-jerks through- out the body normal. Touch and temperature sense normal. Areas of analgesia varying in situation from day to day are present. Muscu- lar response to faradism normal. de Schweinitz and Thomson report both disks gray. Arteries too small; veins normal. Pupils normal. Color-fields (red and blue) typically reversed. Form-fields contracted. The blood count rose to 3,200,000 red corpuscles with 60 per cent. hemoglobin. Many of the hysterical manifestations I have omitted. For a time she did very well and improved greatly, so that she was able to walk, to feed herself, and even to sew, but later she relapsed and became bedridden. The corpuscular count fell to 1,600,000 ; hemoglobin 20 per cent.; and she died September 1, 1894. At post-mortem I found quite marked emaciation. Skin lemon- yellow. Subcutaneous fat small in amount, orange-yellow in color. Muscles very dark red. Blood liquid throughout the body. Heart normal in size. Cavities contain a little semi-fluid blood ; walls average thickness; muscle brownish ; very slight old thickening of mitral valves. Liver slightly fatty. Lungs, kidneys, and spleen showed nothing noteworthy. No gastric atrophy. Tibial marrow currant-jelly color, broken-down cancellated bone tissue. No fat. Many nucleated red corpuscles. Cerebral membranes and brain normal; spinal membranes normal. On cross-section of the spinal cord the posterior columns are pearly gray. Microscopical Examination, Highest Zevel of Cervical Cord.—Very marked degeneration of the posterior columns except a narrow level along the edge of the gray matter. In the lateral columns in the region of the crossed pyramidal tracts, but not confined strictly to them and not in contact with the posterior gray matter, is an area of much slighter but still quite marked degeneration. Running round the periphery of the lateral columns and reaching quite far forward is an irregular band of not very marked degeneration. The intensity of the lesion varies much. It is patchy, worse here, better there. The remainder of the white matter and the gray matter normal. Peripheral nerve-roots normal. No meningitis. Cervical Swelling (Fig. Io).—The same condition obtains. Opper Dorsal Region (Fig. II).-The condition is the same except that the band of healthy tissue between the gray matter and the pos- terior columns is wider, and there are quite a number of healthy fibres A ermicious Anemia. 48 I in the periphery of the latter. Marked degeneration of the crossed pyramidal tracts. Cerebellar tract fairly normal. Alower Dorsal Region.—The same. Ilumbar Sztelling.—Slight degeneration of the postero-internal column; very slight of postero-external. A small area of degeneration in the crossed pyramidal tract, Aſistological Examination.—There is a very fine and very dense net-work of connective tissue. No increase of blood-vessels and slight thickening of their walls. There is no histological difference between the lesion in the posterior and that in the lateral columns. Median and sciatic nerves normal. CASE VII.-(Courtesy of Dr. William E. Paike.) Mrs. E., 60 years old ; has had much grief in recent years. Began to feel weak in 1atter part of 1890. Lost appetite. Some diarrhea. No vomiting till just before death. Dyspnea; palpitation ; no emaciation ; no cutaneous hemorrhages. Towards the end edema beginning in the legs and ascending. Skin lemon-yellow. The blood was examined by Dr. J. P. C. Griffith, who reported hemoglobin 20 per cent. ; red cor- puscles 528, ooo. Macrocytes and microcytes were present. At the autopsy the tibial marrow was found to be red and contained nucleated red corpuscles. The liver gave Quincke's iron reaction. The dorsal (Fig. 12) cord was sent me for examination. It revealed an irregularly V-shaped area of degeneration in the middle of the postero- internal columns along the border of the posterior longitudinal fissure and a small area on one side in the crossed pyramidal tract. The remainder of the white and the gray matter normal. Peripheral nerve- roots normal. CASE VIII.—(Courtesy of Dr. John Musser.) Anemia secondary to dysentery. A. C., female; white; married. Admitted to the Presbyterian Hospital September 13, 1892. Previous history negative. In July, 1892, chill followed by bloody stools. Was delirious for three weeks, has grown weaker ever since. Bowels are very loose and movements are involuntary. She complains much of abdominal pain. Since in hospital no blood or mucus in stools. Much nausea and vomiting. Red blood-corpuscles 2,000,000. $ Post-mortem.—No emaciation ; general edema ; subcutaneous fat one inch thick; viscera pallid; muscles pale ; tibial marrow pale yellow. Heart enlarged; much surrounding fat. Muscle pale yellow- brown in color. Slight atheroma of the aorta; valves normal. Liver large, pale-yellow. Spleen not enlarged, soft, brownish-red on section. Kidneys negative. Lower part of small intestine and large intestine chronically inflamed. Numerous dysenteric ulcers. 35 482 Charles W. Burr. The dorsal and lumbar cord were sent to me, and on examination proved normal. * CASE IX. —(Courtesy of Dr. F. P. Henry.) J. M., male; 64 years old ; laborer. Admitted to the Philadelphia Hospital, April 26, 1894. He has been slowly growing weaker for several years. Complains of slight dyspnea upon exertion. During his entire stay in the hospital he complained only of weakness. Aºxamination.—Soft systolic murmur at apex. A more distinct systolic murmur at aortic cartilage transmitted into the vessels of the neck. Slight edema of the feet which disappeared when he was put to bed. The skin was desperately pale. At the first examination of the blood, made by Dr. Henry, there were 1,275,000 red blood-corpuscles. At a later examination, made by Dr. Daland, the hematokrit being used, there were 25 per cent. of the normal number of red blood-corpuscles. Fleischl's hemoglobinometer gave 20 per cent. of hemoglobin. Dr. de Schweinitz examined the eyes and found numerous old and recent retinal hemorrhages. | The knee-jerks are abolished. Urine contains neither sugar nor albumin. Liver, lungs, spleen, and kidneys give neither signs nor symptoms of disease. There is a freckle-like pigmentation over the entire body except the palms and soles. The patient died May 13, I894. Post-mortem examination was largely negative. There was only a small amount of intensely yellow subcutaneous fat. The tibial mar- row was slightly tinged with red. The spinal cord was given me for examination. At the lowest level of the crossing of the pyramids there is degeneration of the poste- rior columns, but not extending to the border of the gray matter. In the lateral columns there is a small area of degeneration at the periphery just outside of the posterior horns. In the cervical swelling there is a patchy degeneration affecting the whole transverse area of the posterior columns and much more pro- nounced in some fields than in others. In the lateral tracts there is a wedge-shaped area (base out) of degeneration just external to the pos- terior horns. The same condition obtains in the dorsal region. The lumbar cord was not examined. The gray matter and the posterior peripheral nerve-roots were not affected. Histologically, nothing was seen but a very dense net-work of very fine connective tissue, a large number of corpora amylacea, and an apparent slight increase in the number of blood-vessels in the affected white matter. Pernicious Anemia. 483 The first study of the spinal cord in pernicious anemia was given in a paper by Lichtheim." In his two cases there was degeneration in the posterior columns with slight changes in the lateral and anterior columns. He holds that some toxic substance may affect both blood and cord. The process differs from that of true tabes in the absence of shrinking of the posterior columns, the numerous granular cells pres- ent, and the involvement of other parts of the white matter. In a later paper” he remarks that the localization is unlike that in tabes, being greatest in the cervical cord. Clarke's columns, Lissaur's zone, and the peripheral nerves are intact. In referring to the toxic origin of the degeneration he speaks of syphilitic tabes, disease of the cord occurring in diabetes mellitus, and of four cases of long-standing icterus observed by Minick, three of which showed changes in the posterior columns. The history of Von Noorden’s “case is in brief as follows : Fe- male, 59 years old. A progressive and apparently causeless anemia began to develop about ten months before death. There was weakness in the legs. The knee-jerk was absent. There was diminished sensa- tion in the legs. The white blood-corpuscles were relatively increased but absolutely decreased. There were lymphocytes of small size. There were no nucleated red corpuscles. Poikilocytosis was present. The red corpuscles numbered 700,000. On microscopic examination, section through the lower third of the olive was normal, as was the rest of the medulla, except a small area in the left lateral border posteriorly to the roots of the vagus. The long fibres in that situation had in great part disappeared, those remaining being much thickened. In the upper part of the decussation of the pyramids there was distinct degeneration of the cerebellar lateral tracts. In the lower part of the decussation there was degeneration of the lateral pyramidal and lateral cerebellar tracts, and of the posterior columns except where they border on the posterior horns. In the cervical region there was degeneration in the direct and crossed pyramidal tracts, the cerebellar tracts, and the posterior columns. The nerve-roots were very slightly affected. As the sections were made lower and lower down the diseased areas became less and less in extent. Histologically there was a disappearance of the nerve fibres, leaving a connective- . tissue net-work. The blood-vessels were filled. There were no ac- cumulations of nuclei nor hemorrhages. There were no changes in the crural nerves, but in the tibials and peroneals there was a moderately high grade of degeneration. 1 Congress für innere Medicin, 1887. 2 Centralblatt für allgemeine Pathologie und pathologische Anatomie, 1890–91, p. 20. 8 Charité Annalen, 1891, xv.1, p. 26o ; a second paper, Charité Annalen, 1892, xv.11, p. 202. 484 Charles W. Burr. Minick" reported six cases, of which two had been previously reported by Lichtheim and one was given to Minick by Valentine. CASE I.—Duration four months. General weakness and anemia. Paresthesia of arms and feet. Slow, insecure gait and swaying. No paresis; no objective sensory symptoms. The knee-jerk was normal. In the spinal cord there was symmetrical degeneration of the col- umns of Goll in the cervical and upper dorsal region. There was a diffuse degeneration in the columns of Burdach in the lumbar cord principally around the septum of the middle root zones. The pos- terior peripheral roots were without change. The degeneration was of two forms. In the one there were small foci in the middle root zones in the entire length of the cord except the so-called sacral portion. The second was a compact degeneration occupying the greater part of the columns of Goll in the upper dorsal and cervical regions. CASE II.-About two years’ duration. General motor weakness. The knee-jerk absent. Numbness of the feet and hands without ob- jective sensory disturbance, with later a general diminution of sensa- tion. No ataxia. Post mortem there was found symmetrical degenera- tion of the greater part of the columns of Goll, with the exception of the base, from the cervical to the middle dorsal cord. There were foci of degeneration in the central part of the columns of Burdach through- out the entire length of the cord. The posterior roots were intact. CASE III.—Symptoms of pernicious anemia for ten weeks before death. Legs felt weak and paresthesiae were present. Ataxia of all extremities. Knee-jerk lost. Anesthesia in legs. Reflex inactivity of pupils. Death from pneumonia. - There were irregular foci of degeneration in the posterior columns from the cervical to the lumbar region of the cord, less and less in ex- tent as it descended. There was slight beginning irregular dengenera- tion in the postero-lateral white matter. The posterior roots and peripheral nerves were intact. - CASE IV.-While this case did not present all the symptoms of pernicious anemia, lacking the typical blood condition, and not pre- senting the fatty heart muscle, post mortem, yet Minick classes it among the essential anemiae. Male, 36 years old. During the progress of a severe general sickness there appeared paresthesiae in the arms and legs, with motor weakness and difficulty in walking. Later ataxia, spastic gait, increased tendon-jerks, slight paresis of bladder and rec- tum. No fixation of the pupils. Retinal hemorrhages. No poikilocy- tosis. Systolic murmur. Death from broncho-pneumonia. Aost-mortem.—There were found in the cord extensive foci of fresh degeneration around the septum of the posterior columns, decreasing 1 Zeitschrift für klinische Medicin, 1892, v.1, p. 25. Aernácious Anemia. 485 as one passed down the cord. Similar degeneration of like inten- sity in the posterior part of the lateral columns extending to the lower dorsal region. Scattered myelitic foci in the anterior white matter in the cervical and upper dorsal cord. The posterior roots and peripheral nerves intact. CASE V.—Male, 58 years old. General fatigue. Weakness in legs and arms with slight pains. Ataxia in legs. Disturbance of mus- cle sense. Partial loss of sensation in all extremities. Leg- and arm- jerks present. Some weakness of bladder. Later there was almost total loss of pain sense in the legs. In the arms diminution of touch, temperature, and muscle sense. Knee-jerks weak. No immobility of the pupils. There was total degeneration of the posterior cord, with the ex- ception of a small zone by the gray substance, in the cervical and dor- sal region. Irregular degeneration principally in the middle root zones in lumbar region. Extensive disease of the postero-lateral white matter extending as low down as the lumbar region. Similar changes along the septum in the anterior white matter in the middle cervical and upper dorsal region. Posterior roots intact. CASE VI. —Male, 42 years. Leg-pains. Inability to walk or stand, though, when supported, all movements could be properly per- formed. Obstinate constipation. Sensation in all qualities diminished. Knee-jerk increased. Incontinence of urine and feces. There was degeneration of the columns of Goll in the cervical and upper dorsal cord. Foci of degeneration in Burdach’s column extend- ing to the sacral region. Extensive marginal degeneration at the base of the posterior columns and in the lateral tracts to the lumbar cord. Irregular foci of sclerosis along the anterior median septum. Roots free. From a study of these and other cases Minick concludes that the cordal lesions cannot be the direct result of the changes in the blood condition, but the two are the result of the same cause, which is un- doubtedly a poison. Eisenlohr' reports the following case. There first appeared weak- ness in the arms and legs accompanied by formication and vertigo. Marked anemia, some but not great poikilocytosis. Atrophy of the small hand muscles. Gait spastic, ataxic. Knee-jerk absent. Sensa- tion not much disturbed. Incontinence of urine and feces. Delirium. There was atrophy of the mucous membrane of the stomach and intestine. Throughout the whole length of the cord there was degen- eration in the posterior and lateral columns. The condition resembled 1 Deutsche medicinische Wochenschrift, 1892, p. 1105. 486 - Charles W. Burr. somewhat that of true tabes, attacking the columns of Goll and Bur- dach, and especially the posterior root zones. The degeneration was least marked in the lumbar cord, most intense in the upper regions. There was degeneration in a branch of the right saphenous nerve. The author concludes that the primary condition was atrophy of the mucous membrane which caused the anemia, and this, in consequence of the associated tissue-change disturbance, caused the cordal disease. Nonne" reports two cases. - CASE I.—Male, 48 years old. About three months after the onset moderate pains in the legs, gradual weakness, knee-jerk absent; ataxia; no sensory trouble ; pupillary reactions slow; transient paralysis of bladder; paroxysms of clonic contractions in arms. Later knee-jerk returned. No spastic symptoms. Oligopoikilocytosis. Retinal hem- orrhages. Death from phthisis. In the cord there were scattered foci of degeneration in the pos- terior region throughout its whole extent. The middle root zones were especially affected. From the upper dorsal upward secondary degeneration in the columns of Goll. In the lateral tracts small and irregular foci of degeneration. In the upper cervical region there was marginal and central degeneration in the lateral tracts. On histological examination foci, in different stages of degenera- tion, were found in the cervical cord. The fibre-sheaths were sometimes swollen. Under a high power there is a honeycombed appearance. A clear homogeneous mass fills up the spaces. In other spaces only the axis cylinders are seen. Many spaces are empty. The capillary walls are thickened and hyaline. The lymph-sheaths of the capillaries were filled up with flakes and detritus in places and one was obliterated. In the lateral and anterior pyramidal tracts only fresh foci were found scattered amidst the healthy tissue. In the posterior columns the lesion was greatest in the cervical and dorsal cord, least in the lumbar region. CASE II.-Without apparent reason paresis and moderate pains developed in legs with ataxia. Later girdle sensation, gastric disturb- ance, paresthesia in arms, knee-jerk diminished. Diminished touch- and pain-sense in legs; normal pupillary reaction. After two months the ataxia disappeared ; knee-jerk normal; sensory trouble doubtful. There then developed a bad progressive anemia that was fatal in ten months. No return of cordal symptoms. There were found post mortem slight adhesions between pia and dura in brain and cord. There was scattered degeneration in the entire length of the posterior columns. Numerous small isolated foci in the lateral column. Posterior roots free. The sheaths and axis cylinders 1 Archiv für Psychiatrie und Neuenheilkunde, 1893, XXV, 421. Aermicious Amenza. 487 were swollen or shrunken. There was much space formation. There was a secondary neurogliar growth and increase of the nuclei. No change in the peripheral nerves. Bowman' reports the following case : Female, aged 53 years. Ail- ing about three years. Weakness but no paralysis. Gait not observed because of weakness. No ataxia. Some diminution of sensation. Knee-jerk brisk; wrist-jerk readily obtained; no clonus ; pupils nor- mal; retinal hemorrhages. Red corpuscles 19.5 per cent. ; hemoglobin 20 per cent. Later ataxia in hands, sensation became normal, and then relapsed again under treatment. Legs became semiflexed and rigid, passive extension causing pain. Clonus developed and ataxia became marked. There was found in the sacral cord a small patch of degeneration at the outer and posterior margin of the lateral columns. In the upper lumbar there was a patch of degeneration, in the lateral columns and in the posterior column marked degeneration of Goll's tract. In the dorsal region extensive degeneration in both the lateral and posterior columns. In the cervical region less degeneration in the lateral tracts. Almost complete in the columns of Goll. The anterior columns af. fected in the anterior and median margins. At the lower level of the decussation there was a wedge-shaped area in the posterior columns, chiefly along the median septum, with a small peripheral area of degen- eration in the lateral columns. In the most recent areas a few isolated fibres are found with swollen sheaths, the axis cylinders being normal. Some empty spaces are found where the fibres have dropped out, probably in the cutting and staining. There was no change in the interstitial substance. In the more advanced parts the proportion of healthy fibres is much smaller, and, in addition to the above change, the interstitial tissue was thick- ened and a number of nuclei were found. In the most advanced parts there was a large excess of interstitial substance. The vessels have proliferated nuclei in the sheaths of the smaller arterioles in the early stages, while in the later stage the sheaths are crammed with cells, the 1umen remaining normal. In the most advanced parts the lumen is diminished. The posterior roots and horns were free. The author concludes, the process, it may be inferred, is a primary one, though the denser degeneration found in the crossed pyramidal tracts at the lower levels and in the columns of Goll above the mid- dorsal region are probably of the nature of secondary descending and ascending degenerations. The change resembles that found in the combined sclerosis unassociated with anemia, especially the ataxic paraplegia of Gomes. 1 Brain, Summer Number, 1894, p. 198. 488 Charles W. Burr. ‘‘It is unwise to be too positive as to the relation of the nervous symptoms to the altered blood state, though I am inclined to regard the anemia as primary and probably the cause of change in the cord.” Quite recently Lichtenstein" has reported a case of tabes dorsalis, during the course of which the complete symptom complex of an es- sential anemia developed and was the cause of death. Post-mortem proved the correctness of the clinical diagnosis. Lichtenstein believed the anemia to be due to the tabes. Lloyd presented to the Philadelphia Pathological Society, a few meetings ago, a report of a case of pernicious anemia, not yet published, in which there were marked changes in the posterior columns. CONCLUSIONS. The evidence given above certainly proves that the coexistence of pernicious anemia and certain lesions of the cord is not accidental. The cord was normal in only one (Case IV) of my seven cases, and these cases were successive, were not examined post mortem because it was hoped they would show cord changes, but with the intention of getting as large a mass of material for study as possible. I have been unable to find in the literature any case in which an anemia, any- thing like so intense as that of Case IV, has been unaccompanied by distinct and positive cord lesions. - The localization of the cord lesion in pernicious anemia is fairly characteristic and constant. The cervical swelling is always the seat of greatest insult, and the lesion progressively decreases in intensity and extent at lower and lower levels of the cord till, in the lumbar region, there is either no disease at all or it is extremely slight. There are some exceptions to this rule of the non-involvement of the lumbar cord. Thus in Bowman's case it was the seat of marked postero-lateral degeneration. ſº The only parts of the cord ever affected are the posterior columns, the lateral columns in and near the crossed pyramidal tracts, the direct pyramidal tracts, and rarely a band running forward along the circum- ference of the cord (the direct cerebellar tracts). The gray matter is never affected seriously and rarely even slightly. The degeneration of the posterior peripheral roots, when present, is ordinarily so slight as to be of no importance. In the greater number of cases there is marked posterior degeneration with some, but much less marked, degeneration of the lateral columns in and around the crossed pyramidal tracts. The posterior columns may be affected alone, the lateral never alone. Al- most invariably there is a band of normal white tissue separating the diseased area in the posterior columns from the gray matter. Not 1 Deutsche medicinische Wochenschrift, 1894, p. 849. A'ernicious Anemia. 489 very rarely there are two distinct areas of degeneration in the posterior columns in the cervical region, one in the postero-internal, the other in the postero-external column, the two being separated by a band of normal or almost normal white matter. In the lower dorsal and lumbar cord the most frequent seat is midway between the posterior median longitudinal fissure or septum and the posterior gray matter. Almost always there is normal white matter between the posterior horn and the diseased area in the lateral columns. The lesion is always sym- metrical in the two halves of the cord, often absolutely so, but some- times descending farther on one side than on the other. The de- generation never produces gross deformity, alterations in the shape of the cord. There is never, for instance, shrinking in the posterior columns. Histologically my results have not been very fruitful. I think, how- ever, that the lesion will probably be proven to be primary in the nerve- fibres themselves, and not in the blood-vessels. At all events, in the cases I have examined there has not been any evidence of marked vascular disease. I also have not been able to make any histological distinction between the process taking place in the posterior and that in the lat- eral columns. The condition is not systemic, -that is, it is not strictly confined to any one tract or set of tracts, but overlaps boundaries. In the lateral tracts it is more strictly limited than in the posterior columns, but even there it overflows. The cause of the cordal lesions is not as yet definitely deter- mined. The simplest explanation, that the lesions are due directly to the anemia, -are, if one may so express it, the evidences of a local starvation, –is simple rather than satisfactory. In other anemias comparable changes are not found. We would not expect to find such limited changes in a starvation process. Rather, the whole transverse area of the cord would be affected. The supposition that normally the posterior columns have a poorer blood-supply than the remainder of the cord has not been proven. Another theory, and one that has much evidence to support it, is that both the anemia and the cordal lesions are due to a common cause,_a poison or poisons. As to the anemia, there is much to be said in favor of the view that it is the result of an intoxication from a poison or poisons originating either within or without the body, and that poisons can act upon the spinal cord is, of course, well known. The result of such intoxication is seen, for instance, in the posterior degeneration occurring after diphtheria, studied only recently by Bickels." In pellagra there are always distinct changes in the lateral and quite frequently in the posterior columns, most marked in the cervical region. In the allied disease–ergotism— 1 Obersteiner's Arbeiten, Part II. 490 Charles W. Burr. there are also definite and constant cord lesions. According to Tuczek there' is disease of the posterior columns, especially Burdach's tract, including Westphal’s root zone, extending throughout the whole length of the cord to the posterior pyramidal nucleus in the medulla. Histo- logically there is an atrophy of the nerve-fibres with proliferation of the neuroglia, but without any affection of the vessels, together with the occurrence of granular cells and amylaceous corpuscles. Our knowledge of the spinal cord in other diseases in which anemia is a prominent symptom is very limited. I have examined cords from chronic Bright's disease, phthisis, and cancer of the stomach, but so far have never found anything more than a slight diffuse increase in the connective tissue. Paraplegia, usually motor only, but sometimes ac- companied by hyperesthesia, occurs in quantitative anemia due to hem- orrhage, usually from the stomach, kidneys, or uterus. It may come on within a few hours of the hemorrhage or not until one or two weeks later. According to Gowers most cases recover. We know nothing of the condition of the cord. Gowers speaks also of the occurrence of paraplegia in chlorosis, but so far as I know no autopsies have been made. Spinal symptoms of any kind are not common in chlorosis, and I cannot find any authoritative statement even as to the condition of the knee-jerk. Opinions vary much. I have never seen it abolished nor spastic. That extreme secondary anemia may coexist with a nor- mal cord is proven by Case VIII. It is quite curious, and possibly may prove to have some meaning, that a patient of Tizzoni, whose supra- renals were removed, developed changes in the cord, and that a case of Addison's disease quoted by Lichtheim showed post mortem marked changes in the posterior columns. - - The spinal symptoms of pernicious anemia are usually so over- shadowed by those of the blood condition that they are apt to be neg- lected, and not rarely in cases carefully examined the lesions found post mortem are much greater than the symptoms would indicate. Though the ataxia may be extreme there is never a perfect picture of tabes dorsalis. The condition present could not cause it. The knee- jerk is very often abolished, but it may be much increased. Ankle- clonus is rarely present. The presence of a true paraplegia is often difficult to determine on account of the great general weakness. Any local palsy is, of course, due to some complication, as, for example, cerebral hemorrhage. Though paresthesias are very frequent, and delayed or diminished sensation not infrequent, absolute anesthesia almost never occurs. There are never the lancinating pains char- acteristic of tabes, nor the girdle feeling. There may be slowness Pellagra, Ergotism, Tuke's Dictionary of Psychological Medicine. Aºernicious Anemia. 49 I in the pupillary reactions, but Argyll-Robertson's pupil never OCC111’S. The diagnosis of the two diseases is therefore ordinarily easy, but there is one condition in which a knowledge of the occurrence of spinal symptoms in pernicious anemia is of great importance. Not very rarely patients present themselves complaining of dyspeptic troubles, weakness, numbness, and tingling in the extremities and slight trouble in walking and in using the hands; and on examination we find more or less ataxia, absent knee-jerk, and possibly diminished sensation, but not the other signs of tabes. Blood examination will often show marked anemia and give us the clue to the real trouble. I, of course, do not mean that this is a common thing, but it does occur. One must remember, however, that not very unfrequently a secondary anemia develops late in tabes. Again it seems to me possible that some of the cases presenting tabetic symptoms beginning in the arms, which are apt to run a very aberrant course, may be due to pernicious anemia. In the only two cases I have ever seen there was a history of a pro- found anemia coming on before the ataxic symptoms appeared, but untoward circumstances prevented a blood examination. In a few cases (Bowman's, and Case V of my series, for example) there have been in life the symptoms of ataxic paraplegia, and in death the proper lesions. I am strongly inclined to believe that my case does not properly belong here at all, but that the anemia developed after the cordal trouble and was merely a coincidental complication. At the autopsy there was marked emaciation, the liver did not respond to Quincke's iron test, and the marrow was normal. All this is against pernicious anemia. Whatever the truth may be, it is certain that symptoms referable to the posterior columns are much more frequent than those due to disease in the lateral tracts. I must thank Dr. Florence H. Watson, the resident pathologist at the State Hospital for the Insane, at Norristown, and Dr. J. H. Rhein, for much valuable assistance. I owe the photographs to the skill of Mr. Middleton. I327 SPRUCE STREET, PHILA. 492 - G. Oram Ring. EVISCERATION OF THE EYEBALL, WITH INSERTION OF ARTIFICIAL VITREOUS." BY G. ORAM RING, A.M., M.D., Ophthalmic Surgeon to the Episcopal Hospital, Philadelphia; Ophthalmic and Aural Surgeon to the Samaritan Hospital, Philadelphia. No matter to what extent the ophthalmic surgeon endeavors to minimize the formidable character of the operation of enucleation, it will probably ever continue to be regarded by the laity as one of the most to be dreaded of the so-called major operations. We are indebted to Fröhlich for bringing to our notice an opera- tion in the nature of a substitute. In 1881, while attempting to remove a foreign body from the interior of the eye, he, in a purely accidental way, emptied the globe of its contents; the ball shortly becoming quiet. He applied the term excochleation, or “scooping out,’’ to the procedure. It is a curious coincident that the thought-seed sown at that time should have germinated three years later in three different brains. Mr. Mules, of Manchester, tells us in his address before the Ophthal- mological Society of the United Kingdom, March 12, 1885, that he, for the prevention of sympathetic ophthalmitis, Professor Graefe, of Halle, for the prevention of purulent meningitis, a very rare compli- cation, and Mülder, in his experiments upon rabbits and upon the cada- ver, performed the operation of evisceration or excochleation, each without the knowledge of the other's views. During the same year, at the suggestion of the latter, Dubanton performed a similar series of experiments, arriving at conclusions similar to Graefe's, namely:- That the procedure equalled in value enucleation in sympathetic disease, was safer as regards danger of purulent meningitis, can be per- formed in panophthalmitis, and that whenever done a better stump is always secured. Graefe eviscerated eyeballs with success in advanced cases of iridocyclitis and conditions which follow it, in staphyloma, in glaucoma, in cysticercus, in old hemophthalmus, and in many beginning and established cases of panophthalmitis. r Meyer says of the ordinary operation of evisceration that he fre- quently has seen severe and lasting reaction, but always with subse- quently good results. He prefers the classical enucleation which under strict antisepsis he thinks is not attended with more danger than evis- ceration. He gives Noyes the credit of having first suggested the operation, and advises the use of iced sublimate solution for controlling hemorrhage. 1 Read, by invitation, before the Ophthalmic Section of the College of Physicians of Phila- delphia, January, 1895. “I’Ivºittaeſ º HL 10 NOILy （1）10SIAGI A visceration of the AEyeball. 493 de Schweinitz notes that the operation is followed by considerable pain, edema, and swelling of Surrounding tissues, to avoid which a horse-hair drain is suggested. Noyes mentions that reaction will al- ways be greater than after enucleation, and that some orbital cellulitis is always present, but thinks it most desirable to avoid the removal of the globe, if possible, especially in cases of staphyloma where a yawn- ing chasm is left which an artificial eye cannot suitably fill. Fuchs questions whether evisceration of the suppurating eye is a less dangerous procedure than enucleation, since cases of death after this operation have been noted in a paper by Schulek. It must, however, be observed that some cases have been known in which fatal meningitis has succeeded a panophthalmitis without any operative interference. * It is especially in a suppurative panophthalmitis that Henry D. Noyes' objects to the substitution of evisceration for enucleation, upon the ground that, in the event of orbital inflammation of sufficient severity to compel deep incisions of the tissues, the presence of the eviscerated ball would have distinctly hindered the escape of fluid, and, under such circumstances, the effusion growing greater he had more than once been obliged to cut through the back of the open globe to give vent to the fluids behind. He does not regard the enucleation as contributing to the risks of meningeal disease, much less, responsible for the cerebral symptoms. In a total of 4000 enucleations, including the Vienna Clinic, Moor- field's, the clinic of Dr. Knapp, and that of the New York Eye and Ear Infirmary, but one death occurred, and if it is possible for purulent panophthalmitis and death to follow the extraction of cataract, anti- septically performed, as reported by Webster, nothing more having been done to the globe, Dr. Knapp concludes that enucleation is justi- fiable and preferable, notwithstanding the notes of alarm that have reached us from Von Graefe and Bunge. Dr. F. C. Hotz, of Chicago, in an exceedingly interesting paper upon “A Case of Sympathetic Neuritis after Evisceration of the Eye- ball,’’ presented before the Ophthalmic Section of the 44th annual meeting of the American Medical Association, reported in the Trans- actions of 1893, reviews a portion of the literature of evisceration. Schuleck, of Buda-Pesth, lost two cases among thirty-six eviscerations (Otto Becker, “Enucleation and Exenteration”), and the cases reported by Dr. Cross” are also quoted. The above cases were thought to be due to the presence of the glass ball, but in the case of Dr. Hotz no artificial vitreous was inserted, the operation being an ordinary evis- 1 Transactions of the American Ophthalmological Society, Vol. v. 2 British Medical Journal, July, 1887. 494 G. Oram Ring. ceration. The eyeball had been pierced by a penknife at the corneo- scleral junction into the vitreous, and was lost as the result of an irido- cyclitis followed by atrophy. Two weeks after the operation an optic neuritis of the good eye developed, which did not subside until all signs of inflammation in the eviscerated eye disappeared. Dr. Hotz notes that violent reaction is not unusual, even after perfectly smooth operations, and that we, therefore, have conditions which may possibly lead to sympathetic inflammation. He opposes the procedure, in addi- tion, because of the severity of the pain and the slowness of recovery following it, and because he questions the superiority of the cosmetic effect over that of enucleation. Dr. Bunge's cases of evisceration averaged nine days, and Dr. Hecht's, in Sehweigger's clinic, ten and two-fifths days. Dr. Hotz is in the habit of discharging his cases after enucleation in three or four days. The perimetric measurements of outward and inward rotation by reflection of the candle-flame upon the glass cornea have, so far as I am aware, not been repeated, but will be in a series of cases now being performed in this city. Equally good rotation is claimed by Dr. Hotz after enucleation as after evisceration, the latter, however, being without the insertion of an artificial vitreous. Mr. Mules is a warm advocate of evisceration. He regards it as less formidable, as not disturbing the normal relation of the parts out- side of the sclera, as not evidencing any tendency to the formation of cicatricial bands, and as certain to produce a stump with fair move- ment. His modification of the operation—the introduction of an arti- ficial glass ball into the cavity of the sclera—was purely for cosmetic reasons. This he suggested ten years ago. The details of the operation I shall discuss later. Of his first nine cases, six suppurated more or less, and in each of four, -thinking the irritation due to the presence of the ball, the latter was removed. This, he is convinced by his later successes, was unnecessary, and with im- proved technique and thorough antisepsis regards the reaction as trivial and the success as guaranteed. An experience of over Ioo cases, with almost uniformly fine results, has tended to render him exceedingly enthusiastic. That his enthusiasm is not more generally shared by ophthalmic surgeons seems to be due to want of care in carrying out the details of the operation, or because of an unwillingness to risk its performance. w Mr. Mules believed it adapted to all cases except those of malig- nant disease. It has been modified by Mr. Keall, of Bristol, in the introduction of a hollow, silver ball, and in its details by Mr. Brudenell Carter, of London, and by T. H. Bickerton, of Liverpool. Avisceration of the AEyeball. 495 Mr. W. P. Keall, of Bristol, reports two cases of evisceration with introduction of a silver artificial vitreous, before the Ophthalmic Society of the United Kingdom, both of which were entirely success- ful; the one, a case of opaque anterior staphyloma, the second, an opaque cornea from gonorrheal ophthalmia. The details of the opera- tion were similar to those advised by Mr. Mules, except that the sclerotic was stitched horizontally and the conjunctiva perpendicularly. In both of these cases a smart blow upon the eye with a stick a short time after the operation resulted only in producing a black eye. Mr. Keall is of the opinion that had a glass ball been introduced it would have been broken, rendering enucleation necessary. Mr. Keall has particularly noted that the disagreeable muco-purulent discharge, so common after enucleation, was absent after evisceration. Prince,” of Jacksonville, Ill., expressed the opinion that the pain resulting from the operation was due to the effect of tension, pressure, and inflammation ; that there was probably irritation of the long ciliary nerves left exposed by the operation, as they run forward in grooves in the concave surface of the sclera, he therefore cauterized the whole in- terior of the sclera at the completion of the operation with pure car- bolic acid, regarding the process as at once anesthetic and antiseptic. While his immediate results were good, later on in five out of six cases absorption of the tissues along the line of union was followed by the expulsion of the glass ball, and the contraction of the cavity as it be- came filled with granulations. Even then the ultimate results were better than were obtained without the use of something to replace the vitreous. He had therefore substituted the use of powdered iodoform packed loosely into the cavity of the sclera for the glass globes. After some weeks the iodoform mass was expelled, and there seemed to be the same gain in the final stump ; there was no suppuration. Cross” reports eight cases of evisceration with artificial vitreous. In five of these cases the glass ball was used, and in three the hollow silver ball; while in all but three very marked reaction occurred, three were successful, five unsuccessful (ultimately). In one case, the patient having left the hospital at the end of the thirteenth day, the glass eye was worn from May until October, when the conjunctiva became inflamed resulting in an abscess, later the ball was found slightly exposed with black tingeing of the tissues. The ball was removed. In one case sympathetic ophthalmia is said to have resulted from an eight days’ exposure of the ball, and seventeen days after operation, the ball was removed. In the last, sympathetic ophthalmia came on 1 Journal of the American Medical Association, October 12, 1889. 2 Transactions of the Ophthalmological Society of the United Kingdom. 496 G. Oram Ring. twenty-one days after operation, directly after exposure to sunlight, and the ball was removed. . In Cases V and VI the ball was at once removed through an exist- ing fistula. The stumps in four cases were excellent, the mainte- nance of a deep inferior sulcus at the fornix conjunctiva is, in the opinion of Mr. Cross, the essential factor in keeping the proper posi- tion of the false eye. He notes that the movements of the stump were distinctly superior to those of the false eye upon it. Lang' suggested a modification of Mr. Mules's operation by the introduction of the artificial vitreous into the capsule of Tenon, claim- ing as its advantages, L (I) Less local and general reaction. (2) More rapid recovery. (Average stay in hospital in Mules's operation having been in his experience twenty-four days.) (3) The eyeball is of use for anatomical or pathological purposes. (4) In Mules's operation the inability to remove the lamina fusca from the sclerotic rendered the operation useless as a preventive of sympathetic ophthalmia. - - These conclusions were based upon eight eviscerations with inser- tion of glass balls. He afterwards substituted celluloid for glass globes, and in private operations preferred Mr. Keall's hollow silver globes. Mr. Lang reported sixteen cases, all having done well but two. Frost” independently advocated a similar procedure, agreeing with Mr. Lang as to the slight reaction compared with the Mules opera- tion, but was less enthusiastic over the results; one great objection being the difficulty of controlling hemorrhage as compared with evis- ceration. In some cases for this reason it was impossible to insert the artificial vitreous. This modification has not come into general favor, although Nettleship reports five cases upon which he operated with two successes, in one of which the ball afterwards became displaced. The case upon which I have recently performed the Mules opera- tion was one of increasing anterior staphyloma of the left eye. Florence R., aged Io, had been for three years past subject to attacks of severe ulcerative keratitis dating from scarlet fever. Perforation, prolapse of iris, with, from time to time increasing attenuation of the corneal wall, the outcome of the increased pressure, had produced a total spherical corneal staphyloma. When I first saw the child it was not possible to close the lids over the protuberance, and it had not been for one year. Naturally the circumcorneal and con- junctival injections were marked. No progress was made under the 1 Transactions of the Ophthalmological Society of the United Kingdom, Vol. v11. 2 Paper before the British Medical Association at Brighton, 1886. Bvisceration of the AEyeball. 497 use of eserine and pressure bandage, but despite both the projection increased, and on several occasions she complained of moderate dread of light in the good eye. Operation was advised and performed on December 16, 1894, with the kind assistance of my colleague, Dr. Heyl. The patient was kept as quiet as possible for several days previous to the operation. The face was washed four times each day with soap and water, followed by a solution of bichloride of mercury (I-2OOO), and the conjunctival sac treated at the same intervals with a bichloride solution (1-5000). The nostrils were carefully cleansed by atomization three times daily with an antiseptic solution, and after etherization the operation was per- formed as follows: A stop-speculum was introduced and the conjunctiva well dissected from its corneo-scleral attachment in all directions to the equator of the ball, the muscles, of course, not being touched. The ball was trans- fixed and an upward section made with a Graefe cataract knife at the corneo-scleral junction, involving the upper third of the cornea. The corneal section was then completed with a small scissors. The entire interior of the globe was next removed with a scoop, and the sclera left absolutely white and clean. The hemorrhage, which is apt to be considerable, was controlled by the constant application of a hot astringent antiseptic solution, consisting essentially of bichloride of mercury and sulphocarbolate of zinc. Several times during the operation it was necessary to pack the scleral cavity with sterilized gauze saturated with the solution to which reference has been made. As the operation was done in the operation- room of the Episcopal Hospital, it was possible to condense a very powerful artificial light into the scleral cavity in order to ascertain that every particle of its contents had been removed. A small cut, four millimetres in length, was made in the sclera at the upper and lower corneo-scleral margins to permit the easier intro- duction of the hollow sterilized glass ball. A size smaller was selected than one which could have been inserted with a slight effort. In my judgment, want of care at this juncture is the probable cause of failure in several reported cases in which the scleral stitches have broken. This procedure (the introduction of the ball) is accomplished with an ingenious instrument, especially devised for the purpose by Mr. Mules. º Brudenell Carter inserts a rubber bulb which he inflates within the cavity of the Sclera for the purpose of producing pressure upon the central retinal vessels, and thus controlling hemorrhage. This I did not use, but am told by Dr. Risley that it has been entirely successful in Dr. Carter's hands. 36 498 G. Oram Ring. The sclera was stitched vertically, the conjunctiva horizontally. In order to secure a satisfactory approximation of the concave- scleral edges after the central suture was inserted, the overlapping borders were trimmed. Five sutures were used in uniting the sclera and five in uniting the conjunctiva. The eye was now flooded with the bichloride and sulphocarbolate of zinc solution, dusted with iodo- form, and a sterilized compress and bandage applied. All instruments were sterilized, and just before using were placed in absolute alcohol and finally in boiling distilled water. The diet was confined to liquid. The bandage was removed daily, and a bichloride wash and powdered iodoform applied. The case made an almost uninterrupted recovery. There was scarcely any reaction. The lids were not at any time swollen, and the conjunctiva but very slightly chemotic. The temperature on the second day reached 99%. F., falling to normal on the third day, and there remaining. On the fourth day one of the conjunctival sutures ulcerated out. This I attributed to failute to keep the good eye band- aged on the second and third days, thus permitting too much rolling of the eye operated upon. The case was ready to be discharged on the tenth day, but, in order to make assurance doubly sure, was kept an extra week. The artificial eye was inserted January 12, 1895. The result is most gratifying, cosmetically considered, wellnigh perfect. The artificial eye stands out satisfactorily, the movement is excellent, all secretion is absent, and the lachrymal puncta are kept in proper contact with the artificial eye. There will be unquestionably a better development of the left side of the face than would have been possible after enucleation. It seems probable, as suggested by Mr. Jessup, that no tissue in the body, because of its low vascularity, will as well withstand the pressure of a foreign body as the sclerotic. - The ball is embedded in soft and yielding tissues, and any direct violence that would rupture the artificial vitreous would doubtless rup- ture the normal eyeball. However, should such an accident occur, immediate enucleation would be necessary. R. Brudenell Carter' reports thirteen cases, the operations having been done in two eyes for intra-ocular tumor, one for chronic glaucoma, four for loss of sight by chronic inflammation, five which had sustained injury, and upon one disorganized by acute inflammation supposed to have been connected with Sunstroke. - Carter washes the conjunctival sac with 20-per-cent. solution of boroglyceride, and, in addition to the use of the scoop and rubber bulb, removes every vestige of ciliary body and choroid by a very small 1 Medical Press and Circular, August 17, 1887. A visceration of the Eyeball. 499 sponge fixed to a handle. He unites the opening horizontally with stout silk sutures, three usually being sufficient, the silk first being soaked in a solution of one part of salicylic acid, one part of glycerin, and nine of alcohol, and the needles are passed through all structures (conjunctiva, subconjunctival tissues, and sclera) at a “good distance from the margin.” He then, following Mr. Mules's later suggestion, makes a scissors-cut through the conjunctiva, and introduces a drain of three horse-hairs back to the equator of the ball between conjunctiva and sclera. If there is much subsequent swelling, and the conjunctiva pro- trudes between the lids, he paints the protruding part with cocaine and freely punctures with a cataract-knife. Sutures are removed in from a week to ten days. Of his original series, four were unsuccessful as regards union and two partially suc- cessful. In one of the latter a smaller ball had to be inserted. The remaining seven were entirely successful. He prefers silk to catgut, and regards the stump even in the unsuccessful cases as infinitely superior to those secured by enucleation. In his experience, the statement of Dr. D'Oench, of New York, in connection with the report of 500 cases of enucleation in Knapp's clinic, that the eviscerated stump will contract and its movement become more and more restricted, is never true. The limit of contraction is usually reached in a short time, and, certainly when an artificial vitreous is inserted, the size of the stump is determined by the size of the ball. Mr. Carter uses the method even in intra-ocular growths, except gliomata, claiming in the case of sarcomata that the tendency to recur- rence is not in the orbit but in distant parts, especially in the liver, and that, as the eye tumor is situated in the uvea, there is no tissue passing out of the eyeball with which it has any structural connection. He believes Mr. Cross's two published cases of sympathetic ophthalmitis were not due to insertion of the glass ball, as in each of these cases the scleral edges did not unite and the horse-hair drain was not used. In none of Mr. Carter's cases had the slightest irritation been produced, and at the time of this article the first case had been operated upon nineteen months. He has since done the operation a number of times, and is quite as enthusiastic as when he originally stated, “we are indebted to Mr. Mules for one of the most remarkable and valuable improvements in modern ophthalmic surgery.” Dr. L. Webster Fox,” of this city, reports four cases, the former two done in 1885, in which the reaction was so intense (temperature in one Iosº F., and in the second IOS.5° F.) that he removed the glass 1 Codex Medicus, December, 1894. 5OO David A'iesman. balls and later enucleated ; the results in the last two being entirely satisfactory, the highest temperature being Io2° F. and IoI* F. respec- tively. Dr. Fox is enthusiastic over the results, and has seen several cases operated upon by Mr. T. H. Bickerton, of Liverpool, that are equally gratifying. As the two special instruments and the ball necessary for the oper- ation had not reached me from London at the time the child presented herself for treatment, I am indebted to Dr. Fox for generously placing his supply at my disposal. REPORT OF A CASE OF CANCER OF THE PYLORIC END OF THE STOMACH, ASSOCIATED WITH GALL- STONES, AND A PEDICULATED TUMCR OF THE PERITONEUM (ANGIO- LIPOMA)." By DAVID RIESMAN, M.D., Assistant Demonstrator of Pathological Histology, University of Pennsylvania; Instructor in Clinical Diagnosis, Philadelphia Polyclinic; Attending Physician for Nervous Diseases, Northern Dispensary. THE case here reported was seen with Dr. Clark, of Philadelphia, to whom I am indebted for the history and for the privilege of making the autopsy. Mrs. C. W., aged 44 years, German, married, had always been in good health until the beginning of her present illness. Her parents died of kidney disease. She has had five children ; no miscarriages. Early in March of the present year (1894) she fell over a chair, and was seized almost immediately afterwards with an attack resembling acute gastritis. It was characterized by sharp, cramp-like pain in the epigastrium, and by the vomiting of a dark liquid, which, as far as she could judge, did not contain blood. She was in bed for two weeks, but the vomiting did not cease, and it has since occurred quite regularly, two or three times daily, sometimes soon after the meal, at others not until several hours had elapsed. The bowels were constipated. There was some tenderness at the pit of the stomach. The urine was pale, acid, and had a specific gravity of IOIO ; there was a trace of albumin ; sugar was absent. On microscopic examination a few granular and hyaline casts and some epithelial cells were found. 1 The substance of a paper read before the Philadelphia Pathological Society, September, I894. Cancer of the Pyloric Bnd of the Stomach. 50 I I saw the patient in June. She was a woman of medium height, very obese, weighing, according to her own statement, nearly 200 pounds. The skin was of a uniform pale color, with a faint suggestion of yellow. The abdomen was large and flabby; there was no tender- ness anywhere ; a tumor could not be felt ; the liver and spleen were not enlarged ; the heart-sounds were weak, probably on account of the overlying fat interfering with their transmission. The knee-jerks were present ; there was no ankle-clonus. She was then vomiting several times daily, usually about an hour or two after meals. Her chief complaint was an intense, prostrating weakness, which prevented her from leaving the bed. She also had pain in the back, to the right of the lower dorsal spine. The striking features of the case at this time were the persistent vomiting, without the presence of epigastric tenderness, the extreme debility, and the absence of emaciation. In discussing the diagnosis, malignant disease of the stomach, Addison’s disease, and pernicious anemia were considered. The last was soon abandoned. By administering predigested food in small quantities Dr. Clark was able to diminish the frequency of the vomiting. The patient, however, continued to lose strength. When I saw her again, in the latter part of August, she was very feeble, but had no pain, and the vomiting was less frequent. She had lost but little flesh in the two months during which I had not seen her, yet she was now distinctly cachectic, the skin being yellowish, waxy, and opaque. At the junction of the fore- head and the hairy scalp there was a narrow, pearly-white line, which contrasted ráther strikingly with the yellowish pallor of the remainder of the face. An extensive subcutaneous edema of the trunk and lower limbs was also noted. The abdomen was not tender ; a tumor could nowhere be detected; auscultatory percussion of the stomach showed that the organ was not dilated. During the last few days of her life the patient manifested a mild delirium, which was occasionally interrupted by loud, piercing cries, particularly at night. In her lucid moments she complained of dyspnea. A blood count (Thoma-Zeiss) gave 3,512,500 red corpuscles in the cubic millimetre. A diagnosis of carcinoma of the stomach was made, and in view of the absence of dilatation, the growth was assumed to be a diffuse infiltrating cancer. - The patient died on August 28, 1894, approximately six months after the beginning of her illness. The necropsy was made nine hours after death. Body of a middle-aged woman of medium height, cachectic in appearance, not much emaciated. 502 David Riesman. Abdomen.—A large amount of subcutaneous fat of normal color; liver not enlarged ; stomach not dilated ; the appendix is short and overhangs the pelvic brim. Just beneath the transverse colon, pendent from its posterior surface, and lying in contact with the mesentery, is a peculiar, flat, fleshy, lobulated body, the size and shape of a small fig, three centimetres in diameter, and about three millimetres thick. It is attached to the transverse colon by a slender pedicle, which seems to give passage to and chiefly to consist of a blood-vessel. (Fig. 1.) The body is dark-red in color, soft, and by drawing on the serous coat of the transverse colon, with which the stalk is directly contin- uous, has produced a small fold on the peritoneal surface of the bowel. FIG. I. Rºº- ~~~~~~ ºs---t- azºº ºzzº, - *~~~~ zzº-º-º-º-ºr- ~ 2: 3 & - - sº º 2T _º 3. caº gº *...” _T a 2-ºr-º-rº fºº -º-º: --- * ºrmºsº.º. agº-ºº ºl zºº º Pediculated tumor of the transverse colon, a little smaller than natural size. The fold produced on the peritoneal coat by the traction of the growth is shown. The mesentery and omentum are extremely fatty. The pyloric end of the stomach is the seat of a firm, elastic growth, feeling not unlike a thick piece of tendon. On opening the organ the tumor is found to encroach very decidedly on the lumen of the pylorus, without, however, completely occluding it. Water flows from the stomach into the duodenum quite readily. The growth extends completely around the stomach, and in a longitudinal direction infiltrates fully two-fifths of the walls of the organ. The infiltration, on the internal surface, measures seventy-three millimetres in a line from the pylorus to the fundus, and on section is twelve millimetres thick. Cancer of the Pyloric Fnd of the Stomach. 5O3 In section three concentric zones are visible with the naked eye, - (1) The mucous membrane, which over the growth is apparently the same as elsewhere in the stomach. (2) A dense, opaque, whitish layer, and (3) A translucent zone, just beneath the peritoneum, yellowish in color, and resembling colloid, but firm to the touch. The three layers are nearly of equal width. The internal surface of the tumor presents only a small erosion ; there are no evidences of Hemorrhage; the peritoneum corresponding to the tumor is normal in appearance, as is also that covering the remaining part of the stomach. Secondary cancer-nodules are disposed along the lesser and greater curvatures of the stomach, particularly the former. The fundus shows several prominent veins and a few ecchymotic spots. The liver is ap- parently normal; there are no metastatic deposits. The gall-bladder is sausage-shaped, ten and a half centimetres long, and almost com- pletely filled with gall-stones of varying sizes, the largest being as big as a small cherry. Its walls are slightly thickened; there is no bile present, but only a little glairy mucus. The ducts are patulous. A few small stones were lost ; those collected numbered 605, and weighed IO. 23 grams. The pancreas and spleen are normal. On each side of the middle lumbar vertebrae there is a small tumor, apparently an enlarged and cancerous lymphatic gland. The kidneys show slight interstitial changes. The uterus contains a small, intra- mural fibroid. Beyond the existence of extensive pleural adhesions, the thoracic organs present nothing abnormal. Pathologic Diagnosis.-Cancer of the pyloric end of the stomach, with secondary deposits along both curvatures and in the deep abdom- inal lymphatic glands; gall-stones; a pediculated tumor attached to the transverse colon ; early interstitial nephritis; chronic pleurisy; uterine fibroid. Microscopic Examination —Sections of the growth, taken from the neighborhood of the pylorus, show a total absence of the glandular structure proper to the stomach, the cancer coming directly to the sur- face. There is considerable degeneration, probably mucoid, both of the stroma and of the cancer-cells. On account of this, the type of the growth is not readily determined. The secondary nodules, however, show very perfectly the features of a columnar-celled carcinoma, the so- called cylindrical epithelioma. Resting on the connective-tissue stroma is a row of tall columnar cells with large vesicular nuclei; upon this row a few smaller cells, also columnar, are irregularly disposed, leaving a central lumen. The general arrangement is suggestive of adenomatous structure, the nests resembling sections of the peptic glands of the stomach. 504 David Riesman. In the sections from the gall-bladder we find here and there in the submucous tissue small collections of round cells. Macroscopically, the organ presented, aside from a slight degree of uniform thickening, nothing abnormal, in spite of the presence of gall-stones. Attention has been called by Carter to the existence of these small inflammatory foci in the walls of gall-bladders containing concretions. They may be found when the naked-eye appearance of the organ is normal. The histologic structure of the peritoneal polyp is as follows: The ground-work is ordinary, reticulated adipose tissue, after the type of the omental fat, with very large fat-cells. Permeating the section in all directions are numerous dilated blood-vessels, filled with red cor- puscles. The vessels, which appear both in longitudinal and in trans- verse section (see Fig. 2), are quite regular in outline, and have walls FIG. 2. Microscopic section of the peritoneal tumor, showing the features of an angio-lipoma: blood- vessels and fat. Tissue preserved in Müller's fluid, hardened in alcohol, imbedded in cel- loidin, stained with hematoxylin. Magnifica- tion 90 diametres. of fibrous connective tissue in which but few cells are visible. In some parts of the field the vessels occur singly, in others a large number are aggregated as represented in the sketch. There are also areas in which the blood is not confined in vessels, but is effused into the sub- stance of the tumor in the nature of a hemorrhage, probably from diapedesis. Cancer of the Pyloric End of the Stomach. 5O5 At the periphery there is a thin layer of delicate fibrillar tissue, forming a sort of capsule for the tumor. It is in part stained blue by Weigert’s fibrin-stain, and, hence, is probably fibrin deposited from the peritoneal fluid. - The growth is, then, a fatty tumor in which the blood-vessels have undergone telangiectatic change, and is properly termed an angio-liftoma. The uterine tumor has the structure of the ordinary fibroid. A’emarks.—There are a few features in this case that merit a brief discussion. First, the abrupt development of symptoms of gastric dis- order after an injury. It is not possible to say what relation, if any, the trauma bore to the incidence of the malignant disease, the exist- ence of some connection cannot be entirely denied. We know that in cases of tumors on or near surfaces, there is not rarely a history of an antecedent injury at the site of the growth. What part traumatic lesions play in the etiology of primary visceral tumors remains as yet a very obscure problem. Secondly, the absence of emaciation, notwithstanding the pro- found malassimilation produced by the long-continued vomiting. No forms of cancer give rise habitually to such extreme loss of flesh as those of the digestive tract. This is pre-eminently true of the tumors located at the cardia and at the pylorus. In our case, although the debility was most pronounced, the wasting was of light degree. The loss of tissue in carcinomatous disease, according to Von Noorden, affects especially the muscles. Generally, there is a proportionate diminution in the subcutaneous fat, but there are, as he states, and as is illustrated by the present instance, exceptional cases, in which, for some undetermined reason, the patients become prostrated without suf- fering any marked decrease in the adipose tissue. The third point of interest is the coexistence of cancer and gall- stones, an occurrence to which attention has been called by several writers, and of which an instance was reported some years ago, by Henry,” to the Philadelphia Pathological Society. There is, however, a differ- ence of opinion as to the frequency of this association. Williams’ main- tains that gall-stones are more common in persons perishing of cancer than in those dying of other diseases. This is particularly the case in cancer of the breast. Beadles," on the contrary, holds the opposite view ; he found gall-stones only three times in sixty-eight autopsies on cases of malignant disease. The question is of some importance; it could readily be settled by a collective study of autopsy records. 1 Lehrbuch der Pathologie des Stoffwechsels, p. 456. 2 Transactions of the Philadelphia Pathological Society, 1874–75, Vol. xxv.11. 3 W. Roger Williams, British Medical Journal, August 26, 1893; Medical Chronicle, March, 4 Beadles, British Medical Journal, 1893, II, 555. 1893. 506 David Riesman. Of greatest interest in this case is the peculiar pediculated growth hanging from the transverse colon. The tumor, which is a rare type of peritoneal neoplasm, bears a strong resemblance to, if it is not an early stage of, the free bodies that are occasionally found in the abdominal as well as in other serous cavities, and of which a considerable number have been reported. In some instances both a stalked and a free tumor have been present in the same case. Thus Greenhow" records a case in which a small tumor, the size of a hemp-seed, was found attached to the great omentum by a fine pedicle, while a free mass as large as a hen's egg was lodged in a pouch formed by an invagination of the stomach. He also describes a specimen,” preserved in St. Bartholomew's Hospital Mu- seum, which resembles the writer's very closely. It was a small, oval tumor, about the size of an almond, attached to the surface of the large intestine by a narrow pedicle that had the appearance of being twisted. In a case recorded by Van der By1° the tumor, which was attached to the transverse colon, consisted of an altered epiploic appendix, and was dark in color from the presence of blood, being similar in the latter feature to the one here reported. It is generally accepted that the majority of free bodies, at least those found in the abdominal cavity, were at one time attached, and that the pedicle was disrupted through friction, torsion, or traction. In some cases it is possible to find on the tumor a roughened place indicating the point of attachment of the stalk. The tumors vary in size from minute nodules to bodies as large as a pigeon’s or hen’s egg. They are generally smooth, shining, and hard, and on section are, as a rule, seen to consist of three concentric zones, (I) an outer fibrous coat, which some hold to be fibrin deposited from the peritoneal fluid ; (2) a middle layer of calcareous, gritty material; and (3) a central nucleus of a structureless substance, chiefly fatty. When found unattached, the bodies usually lie loose in the abdominal cavity; in some cases they were found in hernial sacs; in one of Greenhow’s “ cases the body occupied a cul-de-sac formed by an invagination of the cardiac end of the stomach. Virchow" has found them situated in depressions on the surface of the liver. They have been met with in other serous cavities; Wardrop" found them in the pleural sac. Many of the floating bodies in joints, but not all, are analogous to the loose bodies occurring in the peritoneal cavity. Occasionally they are seen 1 Greenhow, Transactions of the London Pathological Society, 1872, xxLII, 241. 2 Greenhow, loc. cit. 8 Van der Byl, Transactions of the London Pathological Society, v1.11. 4 Greenhow, loc. cit. 5 Virchow, Die Krankhaften Geschwiilste, 1863, Vol. I, p. 382. ° Wardrop, quoted by Greenhow, loc. cit. Cancer of the Pyloric End of the Stomach. 5O7 in the tunica vaginalis testis, in the arachnoid and the ventricles of the brain (Rokitansky'). The only free body that I have seen was found at an autopsy, per- formed by Dr. Cattell at the Philadelphia Hospital, some years ago. It lay loose in the peritoneal cavity, was oval, smooth, about the size of a cherry, and had the appearance of a hard fibroma. Free tumors of large size are occasionally found in the abdomen of the horse. The point of the attachment of the stalked tumors is generally to the colon, but they may be connected with the omentum or the small intestine. Regarding the origin of the tumors, both the free and the attached, the explanation advanced by Virchow” and by Rokitansky” is the most plausible. The tumors are primarily developed within the subserous cellular tissue; as they continue to grow they push the peritoneum before them, and in time become polypi, the pedicle being formed by peritoneum. The stalk gradually lengthens and thins out; the vessels atrophy. Finally the pedicle breaks, and the body falls loose into the peritoneal cavity. In many instances the bodies are either transformed epiploic appendices or are developed within them ; according to Wilks," from lymphatic glands, which he believes to exist in some appendices. Subperitoneal fibroids of the uterus may become stalked and eventually, from rupture of the attenuated pedicle, free. The origin of our tumor was clearly not from an appendix epiploica, since it was attached at a considerable distance from and above the line of the appendices. It is most reasonable to suppose that the body originated as a lipoma in the wall of the intestine, probably in the subserous tissue, and became pediculated in the manner described. The majority of tumors present calcareous infiltration. This is wanting in our case, presumably on account of the free blood-supply to the tissues of the growth. 1 Rokitansky, New Sydenham Society's Translation, Vol. III, p. 41. 2 Virchow, loc. cit. 8 Rokitansky, loc. cit. 4 Wilks, Transactions of the London Pathological Society, v1.11, p. 214. Tumors of this kind flave also been reported by Nesbitt, Transactions of the London Pathological Society, xII, p. 89; Murchison, Ibid., xv, p. 96; Show, Ibid., v.1, p. 204; Ogle, Ibid., VI, p. 208; Van der Byl, Ibid., VI, p. 211 ; Hughes Bennet, Ibid., vi II, p. 212 ; Brown, Ibid., VIII, p. 214; Canton, Lancet, 1850, I, p. 187; Eve, Transactions of the London Pathological Society, xxx1, p. 31 I; and by others. 508 - Memoranda. MEMORANDA. ISCHIOPAGUS. [Presented to the Wistar Museum by DR. E. W. Cook, Plattsmouth, Nebraska.] THE two bodies in ischiopagus are joined by the coccyges and Sacra. The spinal columns have about the same axis. The composite pelvis is composed of the four innominate bones, by the junction of the right pubic bone of one infant to the left pubic bone of the other on one side, and the left to the right on the other. The two bodies are distinct and separate, each possessing its normal parts and organs, but the pelvic viscera are likely to be fused, and the external genitalia lying between the limbs on each side of the pelvic region are composed of the right half of one infant’s genitalia and the left half of the other. Thus, in the female, the right and left labia majora belong not to one individual, but one to each. So with the two halves of the penis and scrotum, although the symmetrical and normal appearance of the parts would not suggest their dual ownership. The lower limbs, also, on each side, although symmetrical in appearance, and lying naturally together, are supplied on the right and left sides by the corresponding bodies. The lower limbs are not usually equally well developed, but even so they are symmetrical. Thus, on one side, there will be two well-formed legs each belonging to a separate body, and on the other the two limbs will be fused into a single ill-developed one (ischiopagus tripus). In this case the genitalia are, of course, lacking on the ill-developed side. In other specimens there will be two legs on one side, none on the other (ischiopagus dipus). In many specimens there is atresia of the urethra and anus, at least on one side, and very likely on both. It is mainly on this account that the ischiopagi do not long survive birth. 4 In exceptional cases there seems to be no reason why long con- tinued existence is impossible; but, as a matter of fact, I know of but one ischiopagus which lived beyond the first year. The delivery of these infants is usually easy. The head, shoulders, and trunk of one child are born ; then the legs of both, and, lastly, the trunk, shoulders, and head of the remaining infant. There is only one cord and umbilicus. Ischiopagi are not very rare. Twenty cases were collected by Förster, Ahlfeld adds a number of others, and there are nine references to the subject in the Index Medicus since 1879. The specimen presented by Dr. Cook, however, is the only one the IschioPAGus. (Front view.) Ischiopagus. (Rear view.) Memoranda. 5O9 museum possesses, and it is consequently of great value to the collec- tion. As appears in the illustration, the double monstrosity had scarcely reached the fourth month of intra-uterine development. It is a very unusual example of the deformity in that the junction of the two bodies is exceedingly slight. I know of no other example, indeed, in which there is not more intimate fusion of the pelves. The junction is not bony at all, but is confined to the structures of the buttocks and of the perineums. The common anus, too, occupies a very unusual situation. It is in the median line behind, and it is not displaced to one side, as it almost always is in an ischiopagus. BARTON COOKE HIRST, M.D., Professor of Obstetrics, University of Pennsylvania. CLINICAL EVIDENCE OF THE IDENTITY OF THE STREP- TOCOCCUS ERYSIPELATIS AND STREPTOCOCCUS PYOGENES. DR. J. M. S., a resident physician of the Presbyterian Hospital, while looking on at an operation for empyema in a child, was struck in the face by a fragment of rib as it was cut off by the bone-cutting forceps. He sustained a slight abrasion of the right cheek, which was not at the time noticed. Twenty-four hours later there was considerable redness and some induration about the wound. It was thoroughly cauterized with nitrate of silver. About twelve hours later, as he induration and redness had increased, the wound was freely incised, washed with I : IOoo bichloride of mercury solution, and cauterized with a 12-per-cent. solution of chloride of zinc. The next morning, May 1, the patient felt some malaise and had a slight fever. In the evening at eight o'clock the temperature was IO2.4°F., and the redness was rapidly extending over the right cheek. The redness and swelling continued to increase, and he ran through a typical course of facial erysipelas. The inflammation involved both sides of the face and the entire scalp. The temperature reached IOA.4°F. The urine on May 5 contained blood, albumin, and casts. The attack lasted two weeks. On the fourth day a distinct systolic murmur was present at the mitral area and was transmitted into the axilla. Recovery was complete. Cultures made from the empyema at the time of operation by Dr. Ravenal, of the Laboratory of Hygiene of the University of Pennsyl- vania, showed only the streptococcus pyogenes. The empyema was in a child, 4 years of age, who apparently made a rapid and complete 5IO Memoranda. recovery in about seven weeks. It has since, however, been readmitted (September 9, 1894) with a reaccumulation of pus small in amount. The above case is interesting from the fact that the infection was direct and clearly from the pus of the empyema, yet Dr. S. developed a typical case of facial erysipelas. The bacteriologic examination of the pus from the empyema showed only the streptococcus pyogenes. The case seems to me to afford very strong clinical evidence of the identity of the streptococcus erysipelatis with the streptococcus pyo- genes. JOHN P. ARNOLD, M.D., Superintendent, Presbyterian Hospital, Philadelphia. SPASMODIC STRICTURE OF THE ESOPHAGUS CAUSED BY NASAI, POLYPI. J. H., German, aged 69 years, of splendid physique and formerly of excellent general health, was examined December 31, 1893. He had been afflicted with a cough for some years, due no doubt to laryn- gitis caused by nasal stenosis. Snuff-taking had been doubtless a factor in causing naso-pharyngeal catarrh. For many years his voice had lacked nasal resonance, and he had felt something flopping about in his nose. Of late nasal respiration was entirely shut off. For six weeks he had noticed difficulty in swallowing, which had gradually increased until it amounted to inability to swallow solids of any kind. If fluids were taken, part would be returned into the mouth almost invariably. There was considerable pain in the upper part of the gullet, not only at the time of deglutition, but in the interval as well. He having been a moderate but steady whiskey-drinker and having seen several cases of cancer of the esophagus recently that might be rationally attributed to taking whiskey “straight,” I was inclined to think that this was a neoplastic stricture. His condition was becoming serious, and weakness and anxiety pronounced. The operation for removal of polypi was made to relieve him of his headaches and the discomforts incident to mouth-breathing, but without real hope of influencing the esophageal trouble. One very large polypus occupied the whole of the left nasal cavity, and it had to be removed piecemeal. A few small ones were found in superior meatus. The left side was blocked by hypertrophies. He was given a cleansing douche, and snuff and irritant drinks were interdicted. In two days he announced that he could swallow quite as well as ever, solids and fluids alike. Pain disappeared, and also the frontal Alumni AVotes. 5 II headache and mental hebetude incident to the congested frontal and ethmoidal sinuses. The pathology of this case of spasmodic stricture is apparently simple. The nasal stenosis was complete. No air could be forced through. Consequently the volume of air in the mouth and throat at the time of attempted deglutition was forced downward with the bolus of food instead of escaping through the naso-pharynx and nares. This so disturbed the normal co-ordinated action of the muscles of degluti- tion that the result was rejection of solids and a portion of the liquids. It was the more remarkable that such disturbance of co-ordination should have occurred in a man of phlegmatic temperament. THOMAS HUBBARD, M.D. TOLEDO, OHIO. CURIOUS OBSTETRIC COINCIDENCE. ON January 17, 1895, I was called to attend Mrs. Nicholas B. in confinement. On the same day my brother, Dr. F. E. Henry, was called to attend Mrs. John B., also in confinement. Each gave birth to a girl ; one was born at I I A.M., the other II. 25 A.M. Nicholas B. and John B. are brothers; their wives are sisters; the children are of the same sex, and were born within half an hour of each other; and the physicians who were in attendance are brothers. T. J. HENRY. APOLLO, PA. ALUMNI NOTES, THE MEETING OF THE PHILADELPHIA ALUMNI SocIETY OF THE UNIVERSITY OF PENNSYLVANIA. ON Saturday evening, March 2, 1895, the Philadelphia Alumni Society gave an enjoyable “ smoker” at the Colonnade Hotel, Phila- delphia. The University Glee-Club furnished a number of selections. Among the speakers were Dr. William Osler, of Johns Hopkins Uni- versity, Dr. Horatio C. Wood, Dr. J. William White, Dr. John H. Musser, and Dr. John H. Chestnut. Dr. Reginald Fitz, of Harvard University, was present as a guest. THE DORMITORIES. DURING the month of February $30,000 were contributed to the University, to be applied to the erection of the new dormitories. Messrs. 512 Alumni Motes. Cope and Stewartson, architects, have announced that the working plans for the new buildings have been almost completed, and the con- tract will be shortly awarded. Work will begin on the triangle, west of the old athletic grounds, not later than June 1, and in a year from then the first part of the new dormitories will be ready for occupancy, and will accommodate 3oo students. THE RELATIVE STANDING OF UNIVERSITY GRADUATES IN THE NEw JERSEY STATE BOARD ExAMINATION. THE figures in parentheses give the relative standings of the schools in the respective branches. !, ºn * { Chem- Physi- |Obstet- §§ Sur- | Prac- || Anat- || || § College. istry. oldgy. rics. ## gery. tice. omy. #: * }. §: University of Pennsylvania . . . 82.2 (1)| 85.1 (1)| 94.6(1)| 93.6(1)| 87.1 (2) 69.9(2), 91.4 (3)| 86.3 Jefferson . . . . . . . . . . . . . 71.9 (5), 79.7 (4) 85.1 (5) 92.6 (4) | 84.2 (4) | 668 (5) 86.6(5) 80.98 University of New York . . . . 81.6(2) º 92.8 (3) | 92.8 (3) | 83. I (5) 67.7 (4) 88.7 (4) 83,64 Bellevue . . . . . . . . . . . . 82.2 (3) §§ 88.8 (4) || 91.3 (5) 86.2 (3) | 69.3 (3) 92.2 (2) | 84 88 Columbia . . . . . . . . . . . . 80.5 (4) 80.9 (3 93.7(2)| 93.6 (I) 87.2 (I) | 73.4(1) g2.6(1) || 85.98 Average . . . . . . . . . . 79.7 81.7 9I.O 92.8 85.8 69.4 90.3 DR. S. PALMER LLOYD, Class of 1893, was elected City Physician of Savannah, Ga., January 28, 1895. DR. DAVID CERNA, Class of 1879, formerly Demonstrator of Ex- perimental Therapeutics and Lecturer on the same at the University of Pennsylvania, and more recently Demonstrator of Physiology and Lecturer on the History of Medicine in the Medical Department of the University of Texas, has resigned from his positions in the latter insti- tution, and will hereafter reside upon estates in Mexico, recently inher- ited by the death of his father. NECROLOGY. DR. ROBERT RANDOLPH TAYLOR died February 26, 1895, in Philadelphia, in the 70th year of his age. Dr. Taylor was born in Edgewood, Hanover County, Virginia. He studied first in the Uni- versity of Virginia, and after graduating from that institution came to the University of Pennsylvania, where he received his medical degree. At the outbreak of the war he enlisted in the Fourth Iowa Cavalry, and did active duty in the field. Towards the close of the struggle he was in charge of both the Hestonville and Federal Street Hospitals, in Philadelphia. At the end of the war he resumed the practice of his pro- fession in the latter city, and continued it uninterruptedly until his death. EDITORIAL FUTURE LINES OF DEVELOPMENT IN MEDICAL EDUCATION. At the meeting of the Philadelphia Alumni of the Medical De- partment of the University of Pennsylvania on February 24, Professor William Osler, of Johns Hopkins University, spoke of the splendid stand for higher medical education which had been made by the Uni- versities of Pennsylvania and Harvard, and by the College of Physi- cians and Surgeons of New York City. At one time, he said, it was feared that lengthening of the course from three to four years would result in a large reduction in the number of matriculates ; now it is evident that the profession is so ripe for the longer course that the schools which have been prominently identified with it will have more students than can be accommodated under existing conditions. Dr. Osler predicted that within ten years it would become the custom, about this time every year, to send out notices to the effect that the University was ready to receive applications from those desiring to enter as students in the Medical Department. The number applying would be so great that a preliminary weeding-out would be necessary. Regarding the student’s qualifications, Dr. Osler declared that he should have had beforehand all his general chemistry and biology, including comparative anatomy and physiology, so as to be able at once to enter his medical studies proper. A medical school should not be asked to teach non-medical subjects. Under this system the student will come to his fourth year fully prepared for exclusively clinical work. This brings us to the most interesting part of Dr. Osler's subject, —namely, how shall we deal with the enormous classes which soon will demand bedside instruction ? One way would be to have a very large hospital and a large corps of instructors and use the patients over and over again, which would be hard upon them and not so satisfactory to the students. Dr. Osler expressed his preference for the plan which has for many years been in successful operation at Edinburgh. At that University a physician may apply to the University Court for ap- pointment as an extra-academical professor in a particular branch. If his qualifications and hospital material are deemed sufficient he may be appointed. Any student is privileged then to take this professor's 37 5I3 5 I4. t * Editorial. course, the fees go to the professor, and the latter's card entitles the student to present himself for examination. At Edinburgh there are six extra-academical professors in surgery, and five in medicine, be- sides the regular university professors in these branches. The result- ing competition is good for the younger men, who see ahead of them the full professor's chair; and it is still better for the professor, who is stimulated to do his best. But, most important of all, it opens up to students a vastly larger supply of clinical material than could be ob- tained in any other way. Of the enormous hospital population of Philadelphia, Dr. Osler thought that not more than ten per cent. were utilized for clinical pur- poses. By the plan suggested much of this waste material could be saved, to the great benefit of our students, and also of the patients themselves; for, as a rule, a patient in a hospital in which there is teaching is better cared for and more intelligently treated. Dr. Osler truly said that the adoption of the Edinburgh plan would involve some sacrifice of pride and pocket on the part of our medical faculties. This may be an obstacle in some institutions, but we are persuaded that it will not be in our own, where self-denial and self- sacrifice in the interest of medical advancement are not new. The apparent difficulties at present are two : first, in obtaining the consent of hospital authorities to clinical teaching in their wards, and, second, the fact that our hospitals are scattered over such a vast extent of ter- ritory that much time would be lost in travelling from one to another. But neither difficulty is insuperable. Hospital authorities could, in time, be brought to see that it is to the highest interests of the com- munity and of their own patients to aid to the utmost in the acquisi- tion of medical knowledge. It seems to us, also, that it would be per- fectly proper that the State, when applied to for aid to hospitals, should couple the grant with a proviso that clinical teaching should be per- mitted in the wards under suitable regulation. The State has already, in its passage of the bill establishing a State Board of Medical Exam- iners, insisted that future practising physicians must have higher attainments in knowledge and skill, and by encouraging clinical teach- ing in hospital wards it would provide the means to this end. THE PREVENTION OF MYOPIA. THE large number of children and young adults who are wearing glasses at the present time has been a source of constant wonder to the older portion of our population. If any justification for the army of spectacled children were needed, the findings of a score of skilled ophthalmologists in the public schools of this and other countries Aditorial. 5 I 5 would seem to amply suffice. Without exception, all observers found a very large percentage of the children in the schools with errors of refraction. The fact, however, which attracted most attention was the progressive increase in the number and degree of the myopic eyes as the higher grades were reached. The reforms that have been introduced to remedy many of the commonly-assigned causes are now so well known that they need not be repeated here. It was found, however, that improvements in the hygiene of the school-room did not result in any diminution in the number of near-sighted eyes nor in the grade of the myopia. The cause of the steady rise in the degree of near-sight in school-children was, therefore, sought within the eye itself. It was thought that those children who entered school with congenital anomalies of refraction would be found later to have developed the progressive myopia which was so uniformly found, and that the early optical correction of these defects would save the eye from further pathological change. If this theory be correct, we should expect to find after a number of years of uniform correction of these defects a reduction both in the number and grade of myopic eyes. With this thought in mind, Dr. S. D. Risley undertook a study of the percentage of myopia and of myopic astigmatism present in those applying for treatment during the past twenty years (Archives of Ophthalmology, No. 3, 1894). The observations include the records of his private case-books and the prescription files of two manufac- turing opticians, and embrace nearly 200,000 eyes. The cases were grouped not only according to the degree of myopia, but also into the following periods: 1874 to 1880, 1881 to 1883, 1884 to 1886, 1887 to 1889, and 1890 to 1893. The result shows a marked decrease in all the higher grades of myopia for each successive period. After making allowance for all fallacies that might affect the conclusions, the effect of treatment and glasses is shown unmistakably to have saved innumerable eyes and untold discomfort, not to mention the dis- advantages overcome in the competition in school, or later in business or professional pursuits. It is obvious from the study of this large number of cases that the impression gained in individual experiences is correct, “that we have first the asthenopic eye with hypermetropic astigmatism, then the mixed form, which, if neglected, passes into the simple myopic, and finally into compound myopic astigmatism and progressive near-sight.” Considering “the grave peril which ever waits upon the higher grades of near-sight because of the serious pathological conditions so frequently present,” it should be necessary only to mention the subject to awaken the public to a proper appreciation of the importance of the prevention of myopia. MEDICAL PROGRESS. NMEDICINE. UNDER THE CHARGE of WILLIAM PEPPER, M.D., LL.D., and JAMES TYSON, M.D., ASSISTED BY M. HOWARD FUSSELL, M.D. DISCUSSION ON ANTITOXIN. In the Berlin Medical Society Dr. Schiem mann warned general practitioners against employing the antitoxin, which he thought should as yet be left to the hospitals. Professor O. Liebreich criticised the Berlin statistics on serum therapy. He believed that the Berlin hospitals had so much larger mortality because they received the worst cases, but since serum had been used they received light as well as severe cases, and this lowered the mortality. Dr. Hansemann believed that antitoxin could not be considered a specific against diphtheria. TRANSMISSION OF TYPHOID FEVER BY OYSTERs. BROADBENT (British Medical Journal, January 12, 1895) cites nine cases of typhoid fever where he believes the disease was communicated by oysters. They were all cases seen in consultation. All of the cases lived where typhoid was not prevalent. The hygienic surroundings were perfect. In all of the cases oysters had been partaken of freely by the patients. No remarks are made upon the drinking-water. Apropos of this subject the reader is referred to a humorous article in the Wezy York Medical Record of January 19, 1895, by Dr. J. Early-Hustler. PURPURA IN CHILDHOOD. GRosz (Archiv für Kinderheilkunde, Vol. xv.1II, 1894) reports fifty-three cases of purpura which occurred in the Stephanie Children's Hospital among a total of 90,556 cases of disease. He concludes,<- - (1) In childhood a hemorrhagic diathesis occurs in which hemorrhages appear in the skin, the subcutaneous connective tissue, and various other parts of the organism. (2) The attacks of purpura can be divided into two groups, those in which involvement of the joints occur, and those in which there is no joint involvement. (3) The name purpura comprises cases of purpura simplex, hemorrhagica, and rheumatica. The course of the attack is only exceptionally accompanied by fever, and is usually without danger to life, though sometimes death occurs through severe anemia, cerebral hemorrhages, etc. 516 Medicine. 5 17 FERRATIN IN THE TREATMENT OF ANEMIA. KüNDIG (Deutsches Archiv für klinische Medicin, Vol. LIII, Parts 5 and 6, 1894) describes the preparation of ferratin and some experiments on animals, which go to show that the preparation is absorbed into the organism. He reports twenty- five cases. In all the cases the appetite improved, and in cases where there was complete anorexia the appetite was regained. This was especially noticeable in cases of phthisis. The drug was easily administered, and did not cause vomiting. The digestion was not interfered with, and it was especially noticeable that the movement of the bowels remained regular. In all cases the anemic symptoms dis- appeared more quickly than they did after use of other iron preparations. The actual blood condition improved less markedly than the general condition of the patient. ANTISPASMIN IN WHOOPING-COUGH. FRüHwALD (Archiv für Kinderheilkunde, Vol. xvi II, 1894, Parts I and 2) describes antispasmin as a chemical body in which one molecule of narcein sodium is united with three molecules of salicylate of sodium. It is a hypnotic and sedative, and is of especial use in diseases where there is a severe painful spasm. It is a hygroscopic powder easily soluble in water. He has treated about 200 cases of whooping-cough in individuals from the age of a few months to adults. In every case the results were highly satisfactory. The number and intensity of the attacks were lessened. The course of the disease was shortened. The drug was administered in a 5-per-cent. solution. At the age of six months three to five drops were given four times daily; at the age of one year, five to eight drops; and at three years, fifteen to twenty drops four times daily. VARICES OF THE ESOPHAGUS. FRIEDREICH (Deutsches Archiv für klinische Medicin, Vol. LIII, Parts 5 and 6, 1894) says that the veins of the esophagus are divided into two groups, one of which enters the superior cava, and the other the portal vein. In the anastomosis about the esophagus these veins far outnumber the arteries. There is an inner plexus in the submucosa and an outer plexus on the periphery. Both these plexuses anastomose freely. There is a free anastomosis between the portal vein group and the superior cava group, which gives a direct communication between the portal and general venous system. In most of the cases of varices of the esophagus the liver has been the organ affected as the primary cause of the dilata- tion of the vessels. He reports the following case : A girl, 6 years old, began to be sick when 2% years old. She began to get weak and pale, and complained of pain in the head and in the region of the liver. There were signs of indigestion. One year before, 1892, the child had a sudden vomiting of blood with continued vomiting and diarrhea. In the following summer the child had another attack of vomiting and diarrhea. October 13, 1893, the child was admitted to hospital with vomiting of blood. There was no abnormality of heart or lungs. The abdomen was distended but not tender. It was thought that the child was suffering from an ulcer of the stomach. In five days another severe attack of hematemesis occurred, this time followed by bloody stools. This was followed in ten days by a typical attack of chorea, which gradually improved as the child gained strength. There were no stomach symptoms after this until the child died of a third attack of bemoptysis. # 518 Surgery. At the section the ventricles were dilated and the muscle soft. The endocar- dium was flecked with spots and stripes of intense yellow color. The pericardium and lungs were normal. The peritoneal cavity contained about a pint of milky fluid. The peritoneum and glands were normal. The liver and the much-enlarged spleen were the seat of fatty degeneration. Section of the portal vein, thoracic duct, and vena azygos were negative. The only positive lesion was an extensive varicose condition of the esophageal veins. They were knotted and thickened and some almost as large as a lead-pencil. The point of bleeding could not be discovered. TOXIC EFFECTS OF DIPHTHERIA ANTITOXIN. SEIBERT (Mezºy York Medical Record, January 19, 1895) records the following case : Lizzie, aged 6% years, was inoculated with ten cubic centimetres of anti- toxin from Pasteur Institute. Nine days after the injection, and after she had entirely recovered from the diphtheria, from which she had previously suffered, she was suddenly covered with a rash, which resembled measles in some spots, and scarlatina in others. Temperature 98.5° F. The next day the erythema dis- appeared. On the next day, eleventh after the injection, there were nausea, chill, headache, malaria, pains in back of the head. Temperature IoA.5° F. The poste- rior cervical glands were enlarged. There were no throat symptoms. Next day better. On the following day temperature IO4.8°F. A new eruption over the face ; marked edema of eyelids; face, neck, and extremities covered with small blotches; larger ones over the trunk. All the large joints swollen and tender. On the sixth day the patient was practically well. - This case resembles exactly three others reported by Lublinski and by Scholz in the Deutsche medicinische Wochenschrift, November 8 and 15, 1894. The author believes the symptoms were entirely due to antitoxin, for the following Tea SO11S . e - (1) No local disturbance appeared at the point of injection, thereby excluding the possibility of an unclean syringe. (2) The erythema appeared exactly ten days after the injection of the anti- toxin, exactly the time given in two of the cases quoted. (3) Swelling and pains in joints and tenderness of muscles and tendons were well marked in all the cases. (4) The affection persisted in all the cases from four to seven days. SU F.G. E. F.Y. UN DER THE CHARGE OF J. WILLIAM WHITE, M.D., ASSISTED BY G. G. DAVIS, M.D., M.R.C.S., AND ELLWOOD R. KIRBY, M.D. OPERATION FOR DEPRESSED NOSE. ELLIson (Lancet, February 17, 1894) gives the history of a case of depressed nose, in which a metal plate was inserted. He describes the procedure as fol- lows: An incision with a tenotomy knife was made on either side and across the nose a couple of lines below the lower part of the depression. The flap of integ- Suzgery. 5 I 9 ument thus marked out was raised sufficiently to permit the plate to rest in the position desired on the subjacent tissues. There was very little bleeding, which was easily stopped with hot water. The flap of integument was then drawn over the plate and carefully sutured with horse-hair along the line of the incision ; a thread of catgut as a drain was inserted in the lower portion of the incision, and removed after twenty-four hours. Collodion, except over the catgut drain, and gauze was applied as a dressing. Healing occurred by primary union. The pa- tient seven years later stated that she had no inconvenience from the plate what- ever, thus establishing the complete success of the operation. TREATMENT OF GOITRE BY EXPOSURE TO THE AIR (Exoth YROPEXIA). PONCET (Le Mercredi Médical, February 7, 1894) advocates his method of treating goitre by exposing it to the air by means of an incision through the over- lying soft parts. He has done this fourteen times and obtained a cure in each case. The operative technique is given in the Zyon //&dical, March 12, 1893, and the Bulletin Médical, March 19, 1893. Subsequent interference with the exposed growth, as cauterization, ablation, excision, curetting, etc., has not been found desirable. The exposed tissue is insensible to pain, but its irritation readily gives rise to fever. It is also liable to suppurate, and in that case healing is long delayed. The exposed gland exudes serum very abundantly for a few days after the opera- tion. The sheaths of the large blood-vessels, however, remain dry. The large veins enlarge and become turgid ; soon the color of the goitre darkens, indicating venous stasis. The circulation then stops : until this time the goitre is swollen as if it was distended with blood. On the second day the large veins begin to diminish in size, and on the eighth day their atrophy is complete. Granulations then cover the goitre and the skin becomes adherent around the edges. This may take quite a time to cicatrize and is the only objection to the method. The constitutional symptoms improve as the gland atrophies. This procedure is curative in itself alone, without any adjuvant. It can be done as an operation of urgency in suffocative cases. It can also be the first stage of an excision, thus permitting that operation to be done with much less loss of blood. It is applicable to all varieties of goitre, and, perhaps, it may be found to be a suitable procedure in Basedow's disease. CURE OF GRANULATING SURFACES BY TRANSPLANTATION OF LARGE FLAPS. WM. B. HoPKINs showed two cases before the Philadelphia Academy of Sur- gery, at its meeting on December 3, 1894, of granulating surfaces cured by trans- plantation of large flaps. One case was a man, aged 32, with a granulating surface, from laceration, ex- tending from the middle of the arm to the middle of the forearm, about ninety-six square inches. It was covered by a vertical flap five inches wide and nine inches long, consisting of skin and superficial fascia, the base of which occupied the upper left pectoral region, and the edges of which were nearly parallel. The limb was retained in the Velpeau position. At the end of four days the basal attach- ment was divided ; some epidermal sloughing took place, but the result was excel- lent. The patient remained in the hospital 279 days, leaving with a soft pliable integument. The wound on the chest was closed as much as possible by approx- imating its edges. The other case was in a man, aged 33 years, with a flayed foot. A flap two 52O Therapeutics. inches wide was dissected from the sound limb, from the lower portion of the thigh to the lower third of the leg, a distance of fourteen inches; it was left at- tached at its lower part. Carrying the lower portion along the outer side of the foot from before backward, the flap was reflected upon itself around the heel, and its remaining portion carried forward on the inner side of the foot to the toes. The foot was retained by a splint devised by Dr. Ferguson, fixed to the calf of the leg on the sound side for twenty-two days. Before dividing the flap it was dissected off a little farther down the leg. The patient was in the hospital 657 days. The result was excellent. The plantar surface of the foot had hairs on it. The patient worked as a fireman. THE FAPEUTICS. UNDER THE CHARGE OF HORATIO C. WOOD, M.D., LL.D., AND ARTHUR A. STEVENS, M.D. OPIUM IN EPILEPSY. COLLINS (Medical Record, September 22, 1894) has employed the treatment suggested by Professor Flechsig, of Leipsic, in about fifty cases of epilepsy. Briefly, the plan is as follows: The patient is first given one-half to one grain of opium, and this is rapidly increased until at the end of the first week he is taking fifteen grains or more a day, in doses of from one to four grains. At the end of six weeks the opium is entirely suspended, and potassium or sodium bromide (one-half drachm four times daily) is substituted. After these large doses of bromide have been continued for some time, the amount is gradually lowered, until the patient is taking less than forty grains a day. It is important that the bromide should immediately follow the suspension of the large doses of opium. The writer con- cludes as follows: (1) The plan suggested by Flechsig is not a specific in the treatment of epilepsy. (2) In almost every case in which this plan of treatment has been tried there has been a cessation of the fits for a greater or less time. (3) A relapse generally occurs in a period varying from a few weeks to a few months. - (4) The frequency of fits after the exhibition of opium is, for the first year at least, 1essened more than one-half. (5) The attacks occurring after the relapse are much less severe in character than those that the patient has been accustomed to having. (6) This plan of treatment is particularly valuable in ancient and intractable CaSeS. (7) In recent cases of idiopathic epilepsy it cannot be recommended. (8) The opium plan of treatment is an important adjuvant to the bromide plan as ordinarily applied. (9) The opium acts symptomatically, and merely prepares the way for and enhances the activity of the bromides and other therapeutic measures. (Io) This plan of treatment permits the use of any other substances which are Rnown to have a beneficial action in epilepsy. Therapeutics. 52 I CHLOROFORM IN GASTRIC AFFECTIONS. STADNItzky (Vratch, No. 43, 1894), from his experiments with chloroform administered internally to seven young men, concludes that the drug markedly improves all the functions of the stomach, which fact suggests its value in dys- pepsia. In each instance the experiment lasted fourteen days, being divided into two equally long stages, during the second of which the subject was given three to ten drops of the drug three times a day. TRIONAL. CLAUS (International klinische Rundschau, No. 45, 1894) speaks highly of trional in the insomnia of children. He believes that it should be avoided in the insomnia of organic brain disease, as meningitis, etc., but finds it especially useful in chorea, convulsions, and night-terrors. Trional is of little service in insomnia due to pain. The doses used by the author were o.2 gramme to o. 4 gramme for infants from I month to I year, increased to 1.2 to 1.5 grammes for children from 6 to Io years. In the insomnia due to toxic influences chloral is more effective. QUININE IN CHOREA. KNAPP (Boston Medical and Surgical Reporter, February 28, 1895) reports eight cases of chorea in which quinine was administered in doses of from six to eighteen grains a day, the doses being somewhat smaller than those recommended by Dr. Wood. In addition to the quinine the ordinary hygienic measures and regimen ordinarily recommended in chorea were employed. No other medicinal treatment was given, not even cod-liver oil or any malt preparation. The author sums up the results as follows: “In one case there was complete recovery in a week after treatment was begun, and in a second in three weeks, but, although this is rather a short time, it is not very remarkable for chorea to recover in that period. The third case recovered after being under treatment ten weeks. In five cases the quinine treatment proved ineffectual, and arsenic was substituted, with distinct benefit in the majority of cases. With the exception of one case, which recovered in a week, the results are neither remarkable nor satisfactory.” The writer does not believe that the use of quinine in chorea can be justified on the hypothesis of its action in stimulating the inhibitory motor functions of the spinal cord, and believes that the good it accomplishes results from tonic properties or to some influence which it exerts on the toxine of the disease. Chorea, he asserts, cannot be regarded as a spinal disease. The pronounced cere- bral symptoms, and the distribution of choreic movements, which are so often found to affect one side or even one limb predominantly, would of themselves point to the cerebral origin of the disease, even without the evidence afforded by autopsies, which have shown the most marked changes in the cerebral cortex, although the basal ganglia and the cord itself have not been exempt. Choreic movements are not uncommon as a result of structural brain-disease, but they are rarely, if ever, seen as a symptom of disease of the cord. In canine chorea, on the other hand, which is not proven to be the same as human chorea, the changes are chiefly in the cord. The hypothesis, the writer states, on which quinine is recommended for the treatment of chorea seems to him untenable, and the therapeutic results are based thus far on too few cases to warrant us in ascribing greater virtues to this drug than to arsenic. 522 - - Therapeutics. VIRCHOw’s VIEW OF THE NEw TREATMENT OF DIPHTHERIA. In the Berlin letter to the Medical Press and Circular (Therapeutic Gazette), , of October 17, 1894, the correspondent states that Virchow's opinion of the efficacy of the new treatment of diphtheria by blood-serum may be thus summarized : The serum exercises a strong protective effect for some weeks, perhaps for even three or four months; but it remains to be seen whether this effect is permanent, and whether—and this is the cardinal question—it is really possible to cure diphtheria by this remedy. Much, however, is gained if we succeed in protecting even one child in a family in which three or four are ill of this malady; and that we may accomplish this appears extremely probable. - THE EFFECT OF LEVULOSE ON PATIENTS SUFFERING FROM DIABETES MELLITUS. HAYCRAFT (Medical Chronicle, September, 1894), from experiments on rabbits and observations made on three patients with diabetes to whom levulose was administered, draws the following conclusions: - - (1) A patient suffering from chronic diabetes can utilize fifty grammes or more of levulose daily. . (2) In some acute cases a part of the levulose taken with the food is excreted as such, a part is utilized in the body, and a part is transformed into glucose. (3) In rabbits, glycogen is formed from the levulose taken, and is stored up in the liver. Hale White records the result of a number of careful experiments on eight diabetic patients with regard to the effect of giving levulose and inulin. Levulose prepared by Von Schering was employed, and inulin in the form of dahlia tubers was given. The following are the conclusions at which he arrives: (I) If large amounts of levulose are given, some of it appears in the urine. (2) In none of these cases did levulose have the pernicious effect—often seen with ordinary carbohydrates—of increasing the output of sugar beyond the extra quantity given. - (3) When levulose is given, the excretion of sugar is usually increased, but it may be diminished. (4) In most cases much less sugar is passed in the urine after giving 1evulose than would have been excreted if the previous excretion of sugar had remained stationary and all the levulose had appeared in the urine. This result seems to indicate that in these cases some of the 1evulose given was retained and used up in the body. (5) There is some evidence that the larger the amount of levulose the less will be the increase of sugar in the urine. (6) While, therefore, some of these cases show that levulose can be utilized better than dextrose, none of them show that dextrose can be utilized better than levulose. - (7) None of the patients felt worse for taking levulose; indeed, some felt better and gained in weight. (8) Probably a moderate amount of dahlia tubers, taken as a vegetable by patients suffering from diabetes, would do no harm. (9) The effect of levulose on the excretion of urea is unimportant. (Io) The amount of urine passed when levulose is given varies with the quantity of sugar passed. Obstetrics. 523 URICEDIN. LANGSTEIN (Prager medicinische Wochenschrift, No. 45, 1894) concludes from his experiments with uricedin as follows: (I) In the form of cakes it is not unpalatable. (2) It has no unpleasant after-effects, even when given in daily doses of I50 grains. (3) It may, sometimes, act as a cathartic, but this is not undesirable in the lithic acid diathesis, especially as the effect is not disagreeable or painful. (4) Even after prolonged use it does not irritate the heart or kidneys, as do most remedies for gout. (5) It has a pronounced diuretic effect. (6) The action of the drug is somewhat more certain, but not always more rapid, than that of other remedies which favor the elimination of uric acid. It first increases the uric acid in the urine, then lessens it, and, finally, the urine becomes alkaline. (7) Uricedin also relieves pain. SALOPHEN IN CHILDREN'S DISEASES. DREws (Allgemeine medicinische Central Zeitschrift, November, 1894) states that salophen is well taken by children, and does not produce the untoward effects of sodium salicylate. In fifteen cases of acute rheumatism in children of 7 to I4 years of age, he gave three to five grammes per diem. The pain abated at the end of the first day in most cases, and subsided in three or four days. In twelve out of fifteen cases the administration of the drug was followed in half an hour by copious perspiration, which, however, had no bad effects on the general condition of the patients. Equally good results were obtained in five cases of acute muscular rheumatism of the neck muscles. In a case of chorea in a girl 13 years of age, in which a slight murmur was present, in twelve days the movements had ceased, and the murmur had disappeared. In this case five grammes per diem were given. He also obtained good results in a case of purpura rheumatica, in several cases of migraine, and in cases of fever (Scarlatina, typhoid, croupous pneumonia, etc.) where he employed it as an antipyretic. Drews concludes that salophen has very good antirheumatic properties, and deserves a trial in preference to other drugs; that it is a useful antipyretic and a very good antineuralgic. O ESTETRICS. UN DER THE CHARGE OF BARTON COOKE HIRST, M.D., ASSISTED BY RICHARD C. NORRIS, M.D., AND FRANK W. TALLEY, M.D. CONCEPTION THROUGH AN ACCESSORY OSTIUM. SÄNGER (The Lancet, February 16, 1895) reported the following remarkable case where ectopic pregnancy occurred on the right side, and two years later the woman was delivered of the product of a uterine pregnancy by Cesarean section. The products of inflammation around the extra-uterine sac formed a firm resisting 524 Obstetrics. mass, preventing the descent of the head, although the bony pelvis presented normal measurements. After the section the incision in the uterus was closed, and the parts around it were then carefully examined. The right tube ended in a mass of inflammatory products, which evidently represented the fetal sac. The ostium was lost in old, firm adhesions, and the right ovary could not be found. The meso- salpinx was buried in membranous bands. The left ovary, however, was found, and close to it lay a large, well-fimbriated, accessory ostium. The patient made a good recovery. Sånger maintains that the normal ostia of the tubes were obliter- ated by the changes caused by ectopic gestation. The patent accessory ostium, however, readily allowed of the passage of ova from the left ovary into the left tube. WANDERING OF THE STREPTococcus FROM THE MOTHER TO THE FETUS IN THE BEGINNING OF PREGNANCY. CHAMBRELANT and SUBRAzEs (Journal de Médecine de Bordeauaº, 1893) inserted into the ears of a pregnant rabbit a bouillon culture of the streptococcus. Some time after pure cultures of the streptococcus were obtained from the heart, blood, liver, and spleen of the mother and the interior of the embryos. The embryos were the size of lentils and about twelve days old. They were infected with chains of streptococci, as was shown by the examination of sections after hardening in alcohol and staining with picro-carmine. A SIGN OF DEATH By ExhAUSTION FROM INSUFFICIENT NOURISHMENT OF YOUNG CHILDREN. C. SEYDEL (Vierteljahrsschrift für gerichtliche Medicin, 3 F., Band v1.1, Heft 2) says the narrowing of the stomach and the intestines is, from reference to anatomical variations, not great enough to afford a conclusion of starvation with certainty. Further, there frequently is found in the alimentary tract of such children material which shows that at least-shortly before death there has been reception of food. In all cases of death from exhaustion Seydel found a diminu- tion of the thymus gland: frequently its disappearance. If there is at the autopsy no organic disease, and there is found a high grade of emaciation and diminution of the inner thoracic glands, this is, according to Seydel's opinion, a sure sign of exhaustion through insufficient or improper feeding. RUPTURE OF THE UTERUS DURING LABOR. - L. M. BOSSI, of Genoa (Nouvelle Archives d’Obstetrique et de Gymécologie, No. 7, 1893), describes two cases of rupture of the uterus during labor. Both cases occurred in multiparae with narrow pelves, the fetus presenting in the one case by the shoulder; in the other there was placenta previa, and the rupture took place during version by the feet. The first case, in which the child was already in the pelvic cavity and was operated upon in bed under unfavorable circumstances, terminated favorably; the second case died. Upon the experience of these cases Bossi concludes that the Porro operation, with dropping of the pedicle into the pelvic cavity after previous ligature with an elastic ligature, offers the best chance to end the operation quickly and safely. He rejects the suture of the uterus, as it requires too much time and in deep jagged tears is often difficult to make. Obstetrics. 525 TREATMENT OF APPARENT DEATH IN THE NEW-BORN. BERNHEIM (AVouvelle Archives d'Oöstétrique et de Gymécologie, 1893, Nos. 9 and IO) mentions the much-used methods of Schultze, Marshall-Hall, Sylvester, etc., and refers to the exceptionally good results which have been obtained by the method of Laborde after the failure of the usual methods. It consists simply in the drawing forward of the tongue, which should be carried out with regular inter- missions similar to the rhythm of respiration. The action Bernheim refers to reflex irritation which is referred to the respiratory centre through the motions of the base of the tongue. THE RELATION BETWEEN THE HEAD OF THE MOTHER AND THAT OF THE CHILD, AND THEIR OBSTETRIC IMPORTANCE : witH REGARD ALSO TO THE PELVIS OF THE MOTHER. GöNNER (Zeitschrift für Geburtshillſe und Gymákologie, Band xxvii.1, Heft 2) has measured the pelvis, the head, and the height of Ioo pregnant women, and compared them after labor with the measurements of the child’s head and its weight. The results were as follows: A relation between the head index of the mother and that of the child does not exist. In only 29 per cent. did the head of the child belong in the same cate- gory as that of the mother. In deformities of the pelvis one cannot estimate ſrom the size of the mother's head that of the child’s, and thereby prognosticate an easy or a difficult labor. With increased height of the mother the weight of the child increases. Regarding the absolute measurement of the child's head, in 28 per cent. 1arge heads were found associated with children having the usual measurements, and these comprised nineteen male and nine female children. Large heads, therefore, belong to children with usual-sized bodies. In 15 per cent. there was narrow pelvis of unimportant degree, which was to be referred to smallness of the entire skeleton and caused no obstetric hinderance. THE TREATMENT OF ASPHYxIA NEONATORUM. RoSENTHAL (7 herapeutische Monadschriſt, November, 1893) recommends the following method on account of its being less tiresome to the operator than the swinging method of Schultze and more gentle towards the child, yet affording in asphyxia as good results without disadvantages. The child is laid upon a table with the neck supported by a roll. The operator seizes the feet so that the thumbs are in contact with the soles, the index-finger with the back of the feet and the ring-finger resting upon the tendon of Achilles; the remaining two fingers are closed. In regular movements the knees, hips, and spine are bent, so that the knees touch the breast. In this manner the abdomen is compressed and expira- tion follows; by stretching the body out inspiration follows. The larynx is not compressed by this method, as is possible for it to be by the Schultze method. This method may also be employed where fracture of the arm or of the clavicle is present. Another mode consists in the suspension of the child by the legs. The advan- tage of this is the discharge of the inspired amniotic liquor and blood from the nose, mouth, trachea, and bronchi. At the same time the operator seeks to favor the removal of the aspirated fluid with the finger, causing attempts at vomiting, which compress the lungs. By this means aspirations pneumonia is safely avoided. The legs should never be held in the naked hand, but with a towel, in order that they may not slip. 526 Obstetrics. THE CURETTE IN PUERPERAL INFECTION. FERRíº (AVouvelles Archives d’Obstátrique et de Gymécologie, November 25, 1894) strongly advocates the use of the curette in puerperal infection, after a long experience of irrigation of the uterine cavity, a procedure which lowered mortality but did not save several bad cases. At the same time he never had recourse to the curette after labor except when placental remains required removal. Since using the curette six bad cases had been treated by Ferré with only one death. The fatal case, it must be noted, was a private patient, and symptoms of infection immediately followed natural labor at term. She was left without assistance for five days, and the curette was employed as a last resource. The patient died on the seventeenth day. In a second private case the curette was used on the second day immediately after a rise in temperature with rigors. The symptoms of infec- tion at once vanished. In a third, a live child was born ; a twin then presented by the shoulder. Embryotomy had to be performed. Fever set in on the same evening; next day large blunt curettes were used, without anesthetic, the uterine cavity was swabbed with glycerin of creosote and plugged with iodoform gauze. All bad symptoms disappeared at once. The three remaining cases were in the Pau Lying-in Hospital, and had all the advantages of treatment in a public institu- tion. They resembled the second above described except that in one case para- metritis set in before the curette could be used. All recovered. THE ACUTE INFECTIVE DISEASES AND ABORTION. KLAUTSCH (Münchener medicinische Wochenschrift, December 26, 1894) asserts that pregnancy may here be terminated either by the death of the fetus or, as less frequently happens, by premature uterine contractions. The fetus may die owing to (a) deficiency of oxygen ; (b) alteration in temperature; or (c) direct transmis- sion of the infection. These conditions may be combined. The inconstancy of the transmission of the infection Klautsch explains by the circumstance that it can occur only when the normal connection between the maternal and fetal circulation is disturbed. Premature pains may be caused by (a) increased bodily temperature; (6) altered blood; (c) changes in the uterine mucous membrane, as an endometritis exanthematica; or (d) toxines present in the blood. If the deficiency in oxygen occurs rapidly, the fetus dies; if more gradually, pains are induced. In typhoid fever abortion occurs in more than half the cases, and the fetus is mostly born dead, usually from the transmitted infection. Cholera is not transmitted to the fetus, the death being here ‘due to the altered blood, to an endometritis, to a dis- eased fetal placenta, and to temperature variations. In measles the fetus rarely dies. In severe malaria the fetus is more often born alive but soon dies of mala- rial cachexia. In pneumonia the death of the fetus is not uncommon and is due to asphyxia. Variola frequently kills the fetus, yet many are born alive. As regards the pains, the fetus may be expelled in variola, even during the suppurative stage; in malaria after the paroxysm; in erysipelas most often when the eruption appears; in cholera during the transition stage; in influenza soon after the onset of the febrile symptoms; in pneumonia on the third or fourth day. In typhoid fever the abortion may be accompanied by much hemorrhage or strong contrac- tions and little hemorrhage. In cholera the hemorrhage is profuse and the con- tractions are violent. The fetus is mostly much more threatened by the altered temperature, disturbed circulation, and pathological changes in the endometrium than by the transmission of the infection. Oösſefrics. 527 THE LOWER UTERINE SEGMENT. REGNOLI, of Rome (Centralblatt fºr Gymäkologie, No. 49, 1894), has investi- gated this subject upon the bodies of two pregnant women and six who died in the puerperal state. He draws the following conclusions: The vena coronaria may always be recognized at the end of pregnancy and in the beginning of the puerperium. It is placed sometimes higher and sometimes deeper than the contraction-ring. It indicates always the upper boundary of the lower uterine segment. In those cases in which the contraction-ring was recognized it did not always correspond to the attachment of the abdominal tissue; it was shown by a thicken- ing and shortening of the muscle-fibres on that position where the lower uterine segment begins to become thinner and is marked on the outer as on the inner wall. The outer wall is always thinner than the inner. The lower uterine segment may be clearly recognized as a part of the uterine body in pregnancy as well as in the puerperium, and the cervix may be recognized through the arrangement of the muscle-fibres and through the scarcity of the cer- vical glands. NORMAL PREGNANCY AFTER ABDOMINAL HYSTEROPEXY. FRAIPONT (Annales de la Société Médico-Chirurgicale de Ziège, 1894) reports four cases where pregnancy and labor were practically normal, though the uterus of each patient had been fixed to the abdominal walls. In two of the cases the hysteropexy had been performed over five years before the pregnancy occurred, and, although the bands of adhesion between the fundus and the parietes must have become very tough after so long a period, no special difficulty was encoun- tered. In two of the cases the forceps was used, but not on account of uterine inertia ; the fetal head was voluminous, and in one of the two cases internal rota- tion was delayed. The placenta was always expelled easily, and no serious post- partum hemorrhage occurred. Fraipont observed the progress of pregnancy in several of these cases. The uterus does not increase specially in its posterior part, but quite uniformly, so that, as might be expected, the fundus gradually detaches itself from the abdominal wall. Even if the adhesions were not broken down they would of necessity be so stretched as to be useless for their original purpose after delivery. Bands of adhesion could not share in the process of involution. As, however, the uterus undergoes perfect involution, it is restored to its original con- dition before the onset of the disease which rendered hysteropexy necessary. PREGNANCY AND WARTS ON THE VULVA. PoRAK (Bulletins et Mémoires de la Société Obstetrique et Gymécologique de Paris, October, 1894) reported a case demonstrating the necessity of removing during pregnancy warts which develop exuberantly on the vulva. The patient was 22 years old, and a II-para. During the fourth month of her pregnancy she suffered from a free discharge and much dysuria. In the second half of pregnancy warts began to develop, and at delivery they were abundant, covering the outer side of the 1abia majora and the vulvar orifice. She was delivered of a small male child somewhat before term. Although the delivery was conducted with the most care- ful antiseptic precautions, and the child's eyes were carefully washed with a 1 : 50oo sublimate solution, the infant was soon attacked with severe purulent ophthalmia. After daily cauterizations with nitrate of silver and frequent bathing with boric 528 Gynecology. acid solution the eyes recovered. The lochia remained free for ten days, and con- tinued purulent for a few days longer. The warts were left untouched for exactly two months, iodoform being used, and cocaine ointment being applied, as there was much pain. The vagina was plugged all through this treatment. Since the growths remained unchanged they were removed under chloroform. The end of this clinical history shows the fallacy of the idea that warts disappear sponta- neously after pregnancy. The discharge was clearly gonorrheal, as the ophthalmia in the child amply proved. G-YN ECOLOGY. UNDER THE CHARGE OF CHARLES BINGHAM PENROSE, M.D., ASSISTED BY WILLIAM A. CAREY, M.D., AND H. D. BEYEA, M.D. CELIOTOMY IN THE TREATMENT OF PUERPERAL SEPTICEMIA. E. P. DAVIS (American Journal of Obstetrics, February, 1895) gives the fol lowing summary of a paper on this subject: * When the uterus and vagina have been thoroughly disinfected by curette and douche, and the lymphatics of the pelvis and peritoneum have been well drained by saline purgations, if the patient does not improve the question of celiotomy must be considered. If an infective focus can be distinctly outlined under anes- thesia it must be, if possible, extirpated. Vaginal celiotomy will often drain a pelvic abscess with the least disturbance and give valuable time for an improve. ment in the general condition. If vaginal hysterectomy with removal of tubes and ovaries can be performed it may supplement the vaginal drainage of an ab- scess. If it cannot be performed suprapubic celiotomy, with amputation or ex- tirpation of the uterus and appendages and vaginal drainage, is indicated. Celi- otomy, flushing with saline solution, and drainage are also indicated in beginning infection of the general peritoneal cavity. THE TREATMENT OF MYOMATA COMPLICATING PREGNANCY. F. B. JASSATT (British Gynecological Journal, November, 1894) concludes an interesting paper upon this subject as follows: (I) In those cases of subperitoneal myoma which are either pedunculated or situated in the body of the uterus, if growing rapidly or of large size, the surgeon would be justified in opening the abdomen and enucleating the growths. (2) In cases where there are a large number of subperitoneal and interstitial myomata of considerable size studded over the uterus, and these are found to be increasing, the whole organ and tumor should be removed. (3) In cases of interstitial or submucous fibromyoma complicated with preg- nancy, statistics seem to show that the risk to the patient is greater if 1eft to go to the full period than if abortion is produced or the organ removed. (4) Cases in which the cervix is the seat of the disease may be allowed to go their full term, as the growth, if presenting in the vagina, may be either enucle- ated or removed morcellement at the end of gestation. Gynecology. 529 STATISTICS RELATIVE TO FIBROMYOMA OF THE UTERUS. The British Gymedological Journal, November, 1894, abstracts an article writ- ten by TERRILLON, from which the following conclusions were drawn : During the past thirteen years Terrillon examined and kept himself informed about the condition of 235 cases of this disease. Of this number 122 cases were subjected to operation. Eighty abdominal hysterectomies were done, forty-five having the pedicle treated intraperitoneally and thirty-five extraperitoneally. Thirty cases had the ovaries removed, with no death. There were twelve vaginal hysterectomies with two deaths. In none of the cases in which the ovaries were removed was there any dimin- ution of the size of the tumor. Of the cases not subjected to operation the writer considers the best treatment to be rest in bed with an abdominal binder in posi- tion. While a few cases were benefited symptomatically by the use of electricity, he never observed any diminution in the bulk of the tumor in ninety cases which he examined with special reference to this question. He believes that neither electricity, mineral waters, nor the menopause ever has any effect in lessening their growth, but that they may grow up to or beyond 60 years of age. THE PNEUMOCOCCUS IN THE PUS OF AN OVARIAN A BSCESS. Von RosTHORN (Prager medicinische Wochenschriſt, No. 2, 1894) reports a case where he found the pneumococcus in the pus of an ovarian abscess, and writes that he has been able to find only two cases reported in the German litera- ture (Sweifel and Frommel), and one case in the French literature (Morax), where this organism was found in the pus of a pyosalpinx. The first case (Sweifel) was in a girl, 18 years of age, who had had neither pneumonia nor tuberculosis. She recovered after operation. The second case (Frommel) occurred in a woman 38 years of age, who was suffering with phthisis pulmonalis. The pyosalpinx ap- peared after a puerperium associated with fever. The patient died with sepsis, and at the post-mortem, made sixty hours after death, Fränkel himself procured an almost pure culture of the organism. Inoculations from this culture into animals proved rapidly fatal. This case proved that the pneumococcus is excessively virulent. The history of the writer's case is as follows: A servant girl, 28 years of age, had complained of pain in the lower abdomen, since a puerperium associated with fever six years before. On making a vaginal examination a very painful and immovable tumor, the size of an orange, was felt in the right ovarian region. After many weeks of conservative treatment and rest without the least benefit, the tumor was removed by abdominal incision. At the operation the growth was found so universally covered with adhesions that its anatomical parts could not be recognized. The complete separation of the growth from the lateral wall of the uterus and pelvis was impossible, and it was therefore amputated with the thermo-cautery. The site of the growth was packed with iodoform gauze, and the stump sutured to the abdominal wall. The tumor was the shape of an egg, twelve centimetres in length, and on section was found to be an abscess containing a thick greenish pus. The walls were composed of very dense tissue, and its in- ternal surface was covered with a membrane, which at first sight appeared like mucous membrane, but was truly an abscess membrane. Microscopical sections showed the abscess wall to contain the tube wall, ovarian tissue masses of casea- tion. An inoculation taken from the pus gave a pure culture of the pneumo- coccus. The patient recovered. - 38 53O Gynecology. PLACENTA PREVIA. CUMSTON (Annals of Gynecology, September, 1894) gives the following direc- tions for preparing the tampons used in the treatment of placenta previa. Sterilize good absorbent cotton by placing in a sterilizer and boiling for ten minutes, draining in a sterilized, perforated steel box for twenty-four hours. Hav- ing sterilized the hands, make the cotton into tampons, and place about forty into a medium-sized sterilized glass jar. Pour into the jar the following solution : Iodol . . . . . . . . . . . . . . . . Alcoholis absolut., q. s. ad perfect sol. Glycerin pur. . . . . . e s m e º e s e s e a e 2OO. O. Before introducing the tampons into the vagina, cover them with a thin layer of 3 per cent. carbolized vaseline, which forms a sort of cement not penetrated by blood. Insert fifteen or twenty of these tampons, about the size of a walnut, into the vagina, in such a way that the cavity is transversely dilated and reaches the walls of the pelvis. $ GESTATION COMPLICATED BY APPENDICAL, ABSCESS. McARTHUR (American Journal of Obstetrics, February, 1895) reports two cases of pregnancy complicated by abscess of the vermiform appendix. One case was advanced to four and a half and the other case to five months. Both cases were operated upon and the abscess cavity drained before general peritonitis had occurred. - -- - Abortion resulted in the first case the morning following operation, and in the other case not for two days later. The lessons of the cases detailed may be set forth in the following propositions: (1) That the largest proportion of all cases of acute suppurative appendicitis are seen by the surgeon only forty-eight hours or more after their onset. (2) That in the great majority of such cases an abscess exists outside of the appendix and whose walls are made up of the structures which surround the ap- pendix at the onset of inflammation, and which are held together by plastic lymph. (3) That profound sepsis, either chemical or bacteriological, will sooner or later induce fetal death and miscarriage. (4) That after the third month of gestation a portion of the wall of the ap- pendical abscess is usually formed by part of the right wall of the uterus. From the fact that after opening the abscess and draining its cavity there is a shrinking of its wall and a disturbance of the relationship of parts which existed prior to operation, with the risk of infection from such cause, and as it seems most likely, for reasons mentioned, that the fetus cannot be saved, it seems good practice to lend every effort to save the mother, and to, therefore, before closing the abdominal wound, empty the uterus and establish those relations of the struct- ures which we desire to maintain after closure of the abdomen. REMOVAL OF THE APPENDAGES AND LIGATION OF THE UTERINE ARTERY AT THE UTERO-CERVICAL JUNCTION. - BYRON RoPINson (The Journal, February 16, 1895) reports thirty cases of this operation with two deaths, one from suppression of urine on the sixth day and one apparently from shock. The technique of the operation consists in ligating and removing the append- ages and then passing an aneurism needle armed with a double ligature through Gynecology. 53 I the broad ligament at the cervico-uterine junction on the inner side of the uterine artery. One of these ligatures is tied along the side of the uterus including the per- pendicular arteries of the uterus, the Fallopian tube, round and ovarian liga- ments. The other ligature is tied on the broad ligament, including the ligamentum infundibulo-pelvicum. - The author prefers this method to the simple ligation of the uterine artery once or twice as it courses through the broad ligament, as the first method atro- phies not only blood-vessels but nerves and ganglia. In nearly all the cases operated upon the uterine artery has been ligatured down to the cervico-uterine junction. No indications have yet appeared of tissue death in the uterus. In some cases pain is severe for about fifteen hours, but it has been allayed by one-sixteenth-grain doses of morphia given once or twice during this period. The operation is presented as one having wide application in gynecology. It produces sufficient shock on the circulatory and nerve apparatus to quickly atrophy growing uterine myomata. The effect of ligating the uterine arteries as they course through the broad ligament is to atrophy the endometrium rapidly,–checking endometrial secretions and hemorrhages. The pelvic floor is preserved intact by this operation, obviating the danger of vaginal hernia. This operation brings on the menopause early, it followed in two months in one case. The operation leaves a functionless, atrophic, normal-positioned uterus, which so far as has been observed in this series of cases, dating back two years, has caused no trouble. The utility of the operation consists in the following points: It checks hemorrhage. It arrests menstruation. It elevates the uterus. It shrinks the uterus. It avoids the removal of uterine myoma. It avoids vaginal hernia. - The author claims that he has proved many times, by subsequent examina- tions, that this operation will cause a shrinking and atrophying of large, hard, metritic uteri. It also elevates a retroverted uterus and maintains it in position. It is superior to hysteropexy, as it leaves a movable uterus. Two objections might be raised against the operation,-the danger of gangrene and the ligation of so much tissue, –but so far as is known no trouble has come from such conditions. Care must be exercised in regard to penetrating the blad- der and including a ureter in the ligature. It is suggested that the ligature which includes the broad ligament should not embrace the Fallopian tube with its mu- cous membrane, as that might enhance the chances for suppuration. The needle could be passed just beneath the tube, and this method would not protract the operation many minutes. 532 Pathology. PATHOLOGY. UNDER THE CHARGE OF JOHN GUITÉRAS, M.D., ASSISTED BY JOSEPH McFARLAND, M.D. A CASE OF TUBERCULOSIS IN A LION. STRAUSS (Archives de Médecine expérimentale et d’Anatomie pathologique, Tome VI, 1894, p. 645) had the opportunity to make a post-mortem examination upon a 5-year-old lion, which had been four years in captivity and had emaciated almost to a skeleton. A sister lion which had been kept under the same conditions died with similar symptoms. The autopsy showed a fibroid phthisis of both lungs, with numerous small vomicae in whose contents tubercle bacilli were found. THE ACTION OF HIGH PRESSURE ON MICROBEs. RoCER (Semaine Médical, December 5, 1894) reports the results of the first ex- periments made to determine the effects of high liquid pressure applied to growing bacteria. The streptococcus of erysipelas and bacillus coli communis and anthrax bacilli were found in the first series of experiments to withstand 1000–3000 kilos successfully. A second series showed that non-sporiferous anthrax bacilli are killed in 1arge numbers by a pressure of 2000 but especially 3000 kilos (967–2900 atmospheres), and that those which continue to live are diminished in virulence. THE SUPPOSED ANTAGONISM BETween THE CHOLERA SPIRILLUM AND THE BACTERIUM COLI COMMUNE. g KEMPERER (Centralblatt für Bakteriologie und Parasitemkunde, January Io, I895, Band XVII, No. 1), after a series of careful experiments with mixed cultures and egg-inoculations, shows that the absence of the bacterium coli commune from the stools of cholera patients, which some have thought due to some contra effect of the products of the cholera organism upon the colon bacillus, is not due to an antagonistic action of the cholera spirillum, but is due to the fact that the profusion of the stools and the rapid development of the spirillum in the intestine cause the colon bacilli to be outgrown. TUBERCULOSIS OF THE HUMAN PLACENTA AND ITS RELATION TO CONGENITAL INFECTION witH TUBERCULOSIS. SCHMOOL and KOCKEL (Beiträge zur pathologische Anatomie und allgemeine Pathologie, Band xv.1, p. 313–339) describe three cases of placental tuberculosis. Two of the women suffered from general miliary tuberculosis, the other from a chronic pulmonary and laryngeal tuberculosis. All the women died. In only one case was the fetus diseased. It was seven or eight months old, and exhibited in the capillaries and vessel walls, as well as in the hepatic lymphatics, tubercle bacilli. In the placenta from the chronic case slight. tuberculous changes were observed. In all three placentas the changes were slight. Pathology. 533 PLACENTAL, TUBERCULOSIS IN COwS AND FETAL TUBERCULOSIS. Kock.EL and LUNGwitz (Beiträge zur pathologische Anatomie, Vol. XVI, Heft 2) report the examinations of two bovine feti, one six, one four and a half months old, both taken from the bodies of cows with distinct tuberculous lesions. Both feti showed microscopical as well as macroscopic tuberculous lesions of the liver, portal and bronchial lymph-glands, etc. In both cases there was extensive tuberculosis of the uterine mucous membrane, and in the first case tubercle bacilli were found, though in small numbers, in the chorionic villi. In the second case no bacilli could be found in the tissues of the chorion, though a considerable number were seen in the epithelium and also between the epithelium and membrane of the chorion. The writers think these cases confirm the view of Birch-Hirschfeld that the tubercle bacilli enter the fetus by growing through the placenta. THE TREATMENT OF INOPERABLE MALIGNANT TUMORS WITH THE TOXINES OF ERYSIPELAS AND BACILLUS PRODIGIOSUS. CoLEY (Medical A’ecord, January 19, 1895, Vol. XLVII, No. 3) gives the following comprehensive method of preparing the toxines for injection : To make the toxines of erysipelas and prodigiosus, ordinary peptonized bouillon is put into small flasks containing 50 to IOo cubic centimetres, which after proper sterilization are inoculated with the streptococci of erysipelas and allowed to grow for three weeks at a temperature of 30°–35° C. The flasks are then inoculated with bacillus prodigiosus, and the cultures allowed to grow for another ten or twelve days at room temperature. At the end of that time, after being well shaken up, the cultures are poured into sterilized, glass-stoppered, one- half-ounce bottles, and heated to a temperature of 50°-60° C. for an hour, suffi- ciently to render them perfectly sterile. After cooling, a little powdered thymol is added as a preservative, and the toxines are ready for use. The toxines when prepared in this way are very much stronger than when filtered through a Pasteur, Chamberland, or Kitesato filter. . . . If, as is sometimes the case, the preparation is found to be too strong for use with safety, it can be diluted with glycerin or sterilized water. The method for preparing the bouillon in which the bacteria are grown is identical with that in ordinary use, except that it is always made from meat and is not neutralized, the acid reaction normal to the meat bouillon being better for the growth of the erysipelas coccus. In order to keep up the virulence of the cultures, they are put through rabbits in the following way : The hair of the ear is clipped close with a pair of scissors, and the skin washed with a weak carbolic acid and then sterilized water. A minute quantity of a bouillon culture, forty-eight hours old, is then injected sub- cutaneously in four or five different places in the ear. Forty-eight hours later, after again washing the ear with carbolic acid and sterilized water, a flat needle, sterilized in the flame, is inserted under the skin at or near a point of inoculation, and the layer of the skin cut off with a sharp sterilized scalpel. The piece of skin is then rubbed well over the surface of an agar-tube with a thick platinum wire needle. After twenty-four hours in the incubator the colonies of streptococci will show as minute white specks, and from them a pure culture can be obtained. If the agar is made with 75 per cent. of bouillon and 25 per cent. of urine, the strep- tococci will grow more freely than if bouillon alone is used. The dose varies from one to eight minims, and causes a distinct febrile reaction. 534 Permatology. THE PERMANENCE OF CHOLERA SPIRILLI IN FECES. ABAI, and CLAUSSEN (Centralblatt für Bakteriologie und Parasitenkunde, January 31, 1895, Vol. XVII, No. 4, p. II8) report an elaborate investigation upon this subject, and conclude: - (1) The cholera spirilli are, as a rule, destroyed in feces in from twenty to thirty days. (2) In many stools no spirilli can be demonstrated after the first three days. (3) The peptone-solution method of determining their presence seems to be about the best. THE PERSISTENCE OF THE BACILLUS OF LOEFFLER AFTER REcovery FROM DIPHTHERIA. SCHAFER (British Medical Journal, January 12, 1895, p. 61) reports several cases of diphtheria which recovered after the antitoxin treatment, in the throats of which virulent diphtheria bacilli remained for an unusually long time. A sample taken from the throat of one of the boys showed bacilli in the degenera- tion stage as long as five weeks afterwards, which was thought remarkable; but a sample taken from the throat of another was found to contain virulent bacilli Sezen months and a half after the attack. Parke and Beebe found live virulent bacilli five weeks after convalescence. Washbaum and Hapwood (British Medical Journal, January 19, 1895, p. 121) found them sixty-three days after the disappearance of the membrane. DERN/[ATOLOGY. UN DER THE CHARGE OF LOUIS A. DUHRING, M.D., ASSISTED BY M. B. HARTZELL, M.D. GALLANOL IN PSORIASIS. Josh PH, of Berlin (Momatsheft für Praktische Dermatologie, Band xx, No. 1, p. 35) regards chrysarobin as occupying the first place in the local treatment of this disease, but, unfortunately, it often produces severe inflammation, and discolors the skin, hair, and clothing. Cazeneuve and Rollet, about two years ago, first called attention to the value of gallanol. This drug, which is gallic-acid-anilide, exists as colorless crystals, with a slightly bitter taste, and is soluble in hot water, ether, and alcohol, and insoluble in benzine and chloroform. It acts less rapidly than chrysarobin. It is especially to be recommended in mild psoriasis, particularly of the face and scalp, on account of its not discoloring the skin and hair. It may be used with liquor gutta-perchae or as an ointment, in Io per cent. 'strength, which never produces inflammatory reaction. In eczema the drug does not prove of special value, but it is useful in tinea circinata and in eczema marginatum, and in the latter affection especially, in that it does not dis- color the underclothing. Permatology. - 535 J. CHRISTIAN BAY, of Iowa (Journal of American Medical Association, Jan- uary, 1895, p. 31) concludes from a series of investigations concerning the specific organisms of vaccinia and variola that the organistris in the spore stage found by him, and named “dispora variolae,” are identical with the organisms described by others as “micrococcus vaccinae,” “micrococcus variolae,” “microspheria vac- cinae,” and the like. The dispora variolae was found with three exceptions in sixty- five cultures from vaccine points and in forty cultures from the lymph of confluent small-pox. He believes that these spores are the main source through which variola as well as vaccinia is reproduced. HISTOLOGICAL STUDY OF MYCOSIS FUNGOIDES. E. LEREDDE (Annales de Dermatologie et de Syphiligraphie, Vol. v., No. 5, May, 1894) finds that histologically the disease bears no relation to any of the well- known pathological processes. It may be recognized by the following micro- scopical characters: proliferation of connective-tissue cells about the vessels, presence of “mash” cells, the formation of perivascular masses made up of a net- work containing connective-tissue cells and lymphocytes, invading the subpapil- 1ary layer and later the papillae; peculiar giant-cells, together with vascular changes and endothelial proliferation. ADENOMO-CARCINOMA OF THE SKIN ORIGINATING IN THE COIL-GLANDS. J. A. ForpycE (Journal of Cutaneous and Genito-Orimary Diseases, Febru- ary, 1895) describes an instance of this rare form of disease, and enters in particu- lar upon the anatomy of the structure. Certain sections of excised portions of the growth represented in a striking manner the adenoma-like structure of the new growth, together with the intra-canalicular proliferation of the basement cells. The cavities were lined by a double row of cubical cells, which were united in places by connecting bands, thus dividing the tubes into cavities. There was no tendency to cell-nesting. Other parts of the skin were not invaded by the cancer- ous process. ADEPs LANAE IN PRACTICE. UNNA (Momatsheft für Praktische Dermatologie, January, 1895, Band xx, No. 1) gives his experience in experimenting with lanolin and adeps lanae, cover- ing a period of two years. Reference is made to the fact that the adeps lanae of to-day is a much more desirable product than that made a year or two ago. The authors favor adeps lanae rather than lanolin, not only because it is cheaper but because of its intrinsic superiority. The following formula for a good cold-cream ointment is given : B. Adeps lanae, IO.O : Olei amygdalarum, IO.O; Aq. naphae, 2O. O. He concludes that adeps lanae may take the place of lanolin with advantage in all fatty ointments and cooling salves. It is also useful in the preparation of “salve-sticks,” pastes, and salves for mucous membranes, and especially in the manufacture of plasters. For hospitals and dispensaries, on account of its com- parative cheapness, it is in particular worthy of recommendation. Free chlorine, which some observers claim to have ſound in adeps lanae, Ur na, Mielck, and Tro- plowitz state does not exist in this substance. - 536 Dermato/ogy. EARLY BACTERIOLOGICAL DIAGNOSIS OF LEPRA. MARCANo and WURTz (Archives de Médecine Expérimentale et d’Anatomie pathologique, January, 1895) conclude from their studies that lepra often first ap- pears in the form of an isolated “spot,” or macule, having no specific character- istics, except anesthesia on its surface and around it. The proof of the presence of the bacillus of lepra in these insidious cases is of therapeutic importance. The lesion, where the disease is suspected, should be excised, care being taken to include tissue beyond the anesthetic zone. In a case examined by the writers nothing was found in the blood. The bacilli should be sought for in the derma, the entire thickness of which should be excised and examined. EPITHELIOMA OF THE SKIN OF THE FACE. From the point of view of treatment LAGOUTTE (Lyon Médical, No. 51, 1894) distinguishes two forms: (a) superficial epitheliomata; (b) deep epitheliomata. The first are curable by the most diverse medication (chlorate of potassa, resorcine, aniline dyes, etc.). The numerous observations published of such cures justifies the employment of these remedies in the beginning of the treatment. If the lesion persists, recourse should be had to destructive methods. Caustics should, according to the author, be absolutely rejected, and the sharp curette, or, prefer- ably, the knife, be used. As to the deep and grave forms, only free ablation accompanied by extirpation of the ganglia is justifiable. In cases in which the limits of the disease cannot be passed considerably, the treatment should be limited to palliation. THREE CASES OF PEMPHIGUS VEGETANS. H. KOEBNER (Deutsches Archiv für klinische Médicin, Band LIII) gives the notes in full of three cases of this rare and malignant variety of pemphigus, first directing attention to the several diseases from which it is to be distinguished; these are aphtha of the mouth and vagina, herpes of the genitalia, herpes iris, dermatitis herpetiformis, impetigo herpetiformis, and especially syphilis of the skin and mucous membrane. It is usually mistaken for syphilis. It has been carefully described and figured by I. Neumann, of Vienna, Crocker, of London, and Hyde, of Chicago. In the differential diagnosis Koebner dwells especially on the resemblance of some of the lesions to confluent syphilitic mucous patches (“condylomata lata”). Two of the cases ended fatally, the usual course of this variety of the disease. A photograph and a chromolithograph illustrate the paper, which is a valuable contribution to the subject. THE ETIOLOGY OF ECZEMA. In the Dermatological Section of the Congress of Russian Physicians, 1894, ABRAMITcHEFF (Journal des Maladies Cutamées et Syphilitiques, November, 1894) reported the following cases of eczema: (1) A woman, aged 30 years, who had had an eczema for thirteen years, which did not yield to treatment, was found to have a movable kidney. The patient was provided with a belt, and the eczema disappeared. If the belt was left off for some days the eruption reappeared. (2) A patient affected with an eczema for six years was cured after the expul- sion of a tape-worm. In two other cases the eczema was due to strong emotion. Dermatology. 537 A CASE OF FOOT AND MOUTH DISEASE IN MAN. ScHEYER (Dermatologische Zeitschrift, Band II, Heft I) reports an instance of the transferrence of this disease to man. After briefly reviewing the literature of the subject, the author reports the following case: A laborer, 43 years old, was employed in taking care of cattle affected with foot and mouth disease. Two weeks before coming under observation he was compelled to give up his work, having moderate fever, angina, headache, and constipation. About the same time an eruption appeared upon the upper lip and the hands. This eruption appeared as vesicles filled with a sero-purulent fluid. At the time of observation these had disappeared, being replaced by pale-violet nodules, some of which were slightly scaly, others exuded a small quantity of serum from small erosions on their sum- mits. These lesions were not painful nor sensitive to pressure. Lymphangitis and swelling of the axillary glands accompanied the eruption. Upon the upper lip was a hard lesion covered with a bloody crust. This was, like the others, pain- less. In most of the lesions healing took place with the formation of smooth scars; but in a few instances wart-like growths formed, under which healing Occurred 1ater. THE PLURALITY OF FAvLS. In an etiological, clinical, and mycological study of favus (Annales de Der- matologie et de Syphiligraphie, No. II, 1894), pursued in the laboratory of M. Besnier, BoDIN arrives at the following conclusions: - Among the etiological factors, contagion, mediate or immediate, through one affected with favus, occupies the first place. Transmission from animals occurs, but much less frequently. The saprophytic existence of the achorion is possible, and man may meet with it free in nature. From the clinical point of view one may properly distinguish divers forms of favus (impetiginous, atypical favus, etc.). Nevertheless, a careful examination of the elementary lesions shows that the disease is always the same, the differences which separate the clinical forms being due to accessory characters. Neither the unity nor the plurality of favus can be proved by the microscope in the present condition of our knowledge. The study of cultures of the achorion demonstrates the following facts: (I) The culture medium plays a most important rôle, and unless one recog- nizes this importance, the results which one obtains lack experimental exactness. (2) In the cultures of the achorion, as in those of the trichophyton with large spores, cryptogams are found, and that in four-fifths of the cases. The associated fungi do not play any pathogenic rôle. Undeniable varieties of the achorion exist. They are not numerous, and are closely related, but they seem absolutely distinct from one another. In fifty cases of favus the author found five varieties of fungus, as follows: (I) The achorion Schonleinii, as described by Kral. (2 and 3) Two undescribed varieties. (4) The achorion enthytrix of Unna. (5) The achorion atakton of Unna. The true form of fructification of the achorion being as yet unknown, its place in the classification of the fungi remains yet to be fixed. 538 Miscellaneous. THE TREATMENT OF RHINOscLEROMA. SToukov ENKoRF (Journal de Maladies Cutamäes et Syphilitiques, November, 1894) reports a case of rhinoscleroma treated with injections of Fowler's solution. The patient was 21 years old, and the disease had lasted three years. The strength of the injections was gradually increased from 1 per cent. up to 12 per cent. At first one gramme was injected, but at the ninth injection the quantity was increased to four grammes. The injections were made daily, at first superficially, then more deeply. After the eighth injection improvement began ; after the twenty-third, atrophy; and after the forty-fifth the nodules disappeared. In the course of fifteen months 222 injections were made. Six months later the patient’s health was perfect. MISCELLANEOUS. THE QUESTION OF PRIORITY IN CASTRATION FOR PROSTATIC HYPERTROPHY. IT is not two years since J. William White communicated to the American Surgical Association the results of his experiments for inducing atrophy of the prostate in dogs by removing their testicles, and pointed to the marked and speedy diminution of the prostate thus uniformly induced as suggesting the probability that in the hyper- trophied prostates of men an equally marked shrinking would follow the same procedure. Search in literature had enabled him to marshal in addition a very limited number of observations in comparative anatomy, recorded by Hunter, Owen, and Griffiths, that lent additional weight to his own investigations. To these could be added certain observations upon the atrophied condition of the prostate in eunuchs and in one case where the growth of the external genitals had been arrested in boy- hood. This was the sum total of recorded knowledge of the influence exerted upon the prostate gland by the testicles that at the time of the publication of White's memoir was in the possession of the medical profession. The effects of the removal of the ovaries upon the uterus and upon uterine myofibromata were well known generally, and it is doubtless the fact that the similarity in structure between these uterine growths and the prostatic growths awakened in the mind of White the idea that it might be possible to affect the latter through the testicles as favorably as the former were affected through the ovaries that prompted him to his experiments. The final suggestion of the therapeutic application of castration for the relief of prostatic hypertrophy, with which his memoir was concluded, was, evidently, not a haphazard idea, but was Miscellaneous. 539 a logical deduction from an adequate and well-considered series of already established facts. The novelty of the proposition made its proposer show proper caution in recommending it to the attention of the profession, even after he had worked it out, and he forestalled unfavorable criticism by stating that he himself had not then formed definite and final convictions on the subject, but advanced the sugges- tion for the purpose of provoking discussion and trial. It is quite evident that the Philadelphia surgeon, previous to the inauguration of his personal experiments early in 1893, had knowledge only of facts that were the common property of surgeons generally. Possibly the existence of a relation between the testicles and the pros- tate gland, similar to that known to exist between the ovaries and the uterus, had independently occurred to the minds of some surgeons before the publication of White's memoir. Mansell-Moullin has since stated, in his little book on “Enlargement of the Prostate,” that in November, 1892, he had discussed with a patient the advisability of trying such an operation, but that the patient declined to have the experiment made upon himself. Even this date was six months after the beginning of White's investigation of the subject, and at any rate Mr. Moullin seems to have himself considered the proposition as a passing caprice, and to have dismissed it from serious consideration, for, notwithstanding the large number of cases of prostatic overgrowth that are continually demanding surgical relief for the most urgent suffering, he does not claim to have considered the subject again until after the publication of White's memoir, nearly a year later, since which time he has unreservedly advocated the operation. Perhaps no surgeon ever received a greater compliment from another than Mr. Moullin has given Dr. White in the opening sentence of the chapter (XI) in the book referred to, p. 154, which is as follows: “Removal of the testes is followed in a large proportion of cases, if not in all, by complete and rapid absorption of the enlarged prostate. This has now been proved conclusively. The gland entirely disappears; nothing is left but a little fibrous mass.” It is true that in the later paragraphs of this chapter the author does not specifically state that White had first demonstrated this fact by an elaborate series of experiments upon the lower animals under- taken for the express purpose of determining whether or not such an influence could be exerted upon the prostate by removal of the testicles, and whether, if so, it was sufficiently certain to justify the adoption of the procedure as a therapeutic resource in the prostatic overgrowths of men. It is to be presumed that Mr. Moullin did not think it necessary to restate in so many words what he knew that all the surgical world already knew. An implied compliment is always greater than a badly- 54O Miscellaneous. stated one, and, although it would have been a much more graceful thing for the London surgeon to have fully and specifically stated the real character of the work that had been done by his Philadelphia colleague, it was not necessary, for its omission could not detract from the well-earned credit which is universally ascribed to the latter for his masterly work. An undue sensitiveness has been displayed by some of the American medical journals as to the way in which Mr. Moullin has chosen to speak of White's work, as if in some way the credit of the latter had been assailed, and an important question as to priority had been raised. There is certainly no ground for any of this feeling. As to actual priority of performance, three months after the pub- lication of Dr. White's memoir a Norwegian surgeon, Ramm, of Christiania, published (September, 1893) the statement that in April of that year, before the reading of White's paper, he had removed the testicles from an old man as an experiment for the purpose of producing atrophy of an enlarged prostate. - In some English and American journals there has been of late quite a number of communications upon various phases of this subject. Not the least interesting is the statement by Harrison, of London, that years ago a patient had requested of him that he would remove his testicles in the hope that it might benefit his prostatic disease ! This the surgeon refused to do, and contented himself with subcutaneously dividing the vasa deferentia of his patient, and then “thought nothing further of it” until the fact was recalled by reading White's paper. Here, as far as information goes up to date, would seem to be the real father of the operation. For this man not only conceived the idea, but offered his own body for the performance of the experiment. It is to be regretted that Mr. Harrison did not take advantage of the offer, for, with the light of after events, it is quite apparent that he missed a great opportunity. These questions of priority of mental conception, of suggestion, or even of actual performance are of little importance. As far as the surgical world is concerned, the fact is undeniable that the general serious consideration of the possible value of the removal of the testicles as a therapeutic measure in the treatment of prostatic hypertrophy dates from June 1, 1893, when J. William White read his paper upon “The Present Position of the Surgery of the Hypertrophied Prostate” before the American Surgical Association. Without this work of White, the subsequently-published cases of Ramm would have attracted but little attention; the operations of Haynes and of many other surgeons which have since been reported would not have been made, and Chapter XI of Mansell-Moullin's book on “Enlargement of the Prostate’’ would never have been written. (L. S. PILCHER, in the Annals of Surgery, March, 1895.) Book Notices. 54. I AMERICAN MEDICAL PUBLISHERS’ ASSOCIATION. THE Annual Meeting of the American Medical Publishers’ Asso- ciation will be held in Baltimore on May 6, convening in the parlors of the Eutaw House at 9.30 A.M. An interesting programme is being prepared. CHARLEs WooD FASSETT, Secretary. SIXTH AND CHARLES STREETS, ST. Jose PH, MO. BOOK NOTICES. THE PRINCIPLES OF SURGERY AND SURGICAL PATHOLOGY. General Rules Governing Operations and the Application of Dressings. By DR. HERMANN TILLMANNs, Professor in the University of Leipzig. Translated from the third German edition by JoHN ROGERs, M.D., New York, and BENJAMIN TILTON, M.D., New York. Edited by LEWIS A. STIMSON, M.D., Professor of Surgery in the University of the City of New York. New York: D. Apple- ton & Co., 1894. It is now recognized that for the proper appreciation of surgical diseases and their successful treatment a thorough knowledge of sur- gical pathology is essential. The plan of the present work is an inno- vation in surgical text-books in this country, and is, we think, a distinct advance. Doubtless, future works will be made to conform to this method of presentation, which is now common in Germany and to a less extent in France. The first section of this work deals with the general principles gov- erning surgical operations. Under this heading are included the prep- aration for an aseptic operation, anesthesia, the prevention of loss of blood during an operation, general rules for performing an aseptic oper- ation and for the after treatment of the patient, the different ways of dividing the tissues, the methods of arresting hemorrhage, drainage of wounds, the method of uniting the tissues, general considerations concerning amputations, disarticulations and resections, and plastic operations. The details for carrying out an aseptic operation are given with a minuteness that leaves nothing to be desired. The splendid achieve- ments of modern surgery have been made possible by the demonstration of the circulation of the blood, the discovery of the anesthetic properties of ether and chloroform, and, lastly, the perfection of aseptic methods. The second section deals with the methods of applying surgical dressings, and is one of the most valuable in the book, not only on ac- count of its completeness, but because it is a subject that rarely receives proper attention in systematic works. The section includes general principles governing antiseptic or aseptic dressings, the most common 542 Book AVotices. antiseptic and aseptic dressings for wounds, the preparation of the differ- ent dressings, the conditions that call for a change of dressings, and the rules for performing the same, general rules for the application of bandages, the sick-bed of the patient, immobilization appliances and dressings. The third section opens with a chapter on inflammation. The subject is treated according to the most recent views thereon. A long step forward is taken by the author in the statement, “Of the various inflammatory irritants or causes of inflammation, micro-organisms and the products of their metabolism should be looked upon as the most im- portant.” This fact has not been accepted by surgeons as generally as its importance demands. Throughout the work due prominence is given to the influence of micro-organisms, and the practical lessons to be drawn from a knowledge of their power for harm are many. For example, “From a prophylactic stand-point it is best to treat every injury, no matter how trifling it may be, on antiseptic principles.” Syphilis, the author says, “according to recent investigations, is most probably caused, like tuberculosis, by a characteristic fungus.” Upon this ground he advocates extirpation of the primary lesion ; in fact, he treats every suspicious ulcer in the same way, even when its syphilitic character has not been rendered certain. This view, although not commonly accepted, is probably correct, and corresponds with what is known of the origin of constitutional disease from a primary focus of infection. Tillmanns also advocates the removal of infected glands in suitable cases, in addition to the excision of the primary lesion, as recommended by Bäumler. Chapter II of this section takes up injuries and surgical diseases of the soft parts ; Chapter III discusses injuries and surgical diseases of bone; and Chapter IV the same conditions affecting joints. Chapter V is occupied by a brief review of the subject of tumors. Tillmanns's reputation as a surgeon and the intrinsic value of his book commend it to all interested in this branch of medicine. The translators deserve especial credit for the manner in which they have performed their task. The paper, press-work, and binding are of the highest order. Illustrations have been freely enployed throughout the work. FLINT’s PRACTICE of MEDICINE. A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Prac- titioners of Medicine. By AUSTIN FLINT, M.D., LL.D., Professor of the Principles and Practice of Medicine and of Clinical Medi- cine in Bellevue Hospital Medical College, New York. New (7th) edition, thoroughly revised by FREDERICK P. HENRY, M.D., Pro- fessor of the Principles and Practice of Medicine in the Woman's Medical College of Pennsylvania, Philadelphia. In one very handsome octavo volume of II.43 pages, with illustrations. Phila- delphia : Lea Brothers & Co., 1894. The first issue of this now classic work appeared in 1866, after its author had enjoyed an experience of some thirty years as a teacher and Aook AVotzces. 543 physician. Dr. Henry has succeeded in bringing this last edition fully abreast with the times. The work has not suffered at the editor's hands, but is fully up to the best. All or most of its distinguished author's inimitable descriptions of the course and symptoms of disease are retained. Only where recent investigations have thrown light upon the etiology and treatment are changes made. However, the section on dyspepsia is entirely replaced by one written by Professor Henry. In this section exception may, perhaps, be taken to such expressions as “peristaltic unrest” and “incontinence of the pylorus,” as intro- ducing new and rather confusing terms without any definite results. In late years clinicians have universally come to consider peritonitis, at least in the vast majority of cases, as a symptom of a local disease rather than an idiopathic disease. The editor has allowed the author’s views of this condition to remain, possibly to the detriment of the work. The same may be said of the retention of the chapter on typho-malarial fever. His note—“The only positive criterion of the nature of the false membrane (diphtheritic)—and hence of the disease—is afforded by a bacteriological examination of the exudate”—is undoubtedly correct, but its force is lost by being placed as a small foot-note instead of heading the section on the diagnosis of diphtheria. It is manifestly a most difficult task to edit a work of such reputation and worth with- out impressing too glaringly the editor's personality. Dr. Henry has performed this task excellently, and should receive the thanks of all physicians for retaining the great work among the current literature. A MANUAL OF MODERN SURGERY, GENERAL AND OPERATIVE. By JOHN CHALMERs DA COSTA, M.D., Demonstrator of Surgery in the Jefferson Medical College, etc. Philadelphia : W. B. Saunders, I894. - This is one of Saunders's ‘‘New Aid Series,” and is intended ‘‘to stand between the complete but cumbrous text-books, and the incom- plete but concentrated compend.” In its preparation the author has culled from a great mass of surgical literature, as the frequent quota- tions and references in the text attest. A vast amount of information has been condensed within the limits of the present work. The task of epitomization is a difficult one, as there is always the danger that, in the desire to abbreviate, the funda- mental principles of a subject will either be lost sight of or be imper- fectly presented. These the author has in most instances avoided. A chapter is devoted to the discussion of bacteriology, which is now considered an essential preliminary to a surgical training. Among other bacteria of surgical interest mentioned is the “gonococcus or Neisser's bacillus.” The latter term seems inappropriate, as this germ is a typical coccus. It is stated that the bacterium coli communis is the supposed cause of peritonitis. The author might have added caries and necrosis, metastatic abscesses, etc., occurring in the course of typhoid fever, as well as some other suppurative processes. A work intended for the use of “the student and busy practitioner'’ should be specific in its teachings. In this particular we think Dr. 544 Aook Motices. te Da Costa has occasionally erred. We note, for example, in speaking of the treatment of traumatic spreading gangrene, that “stimulants must literally be poured into the patient.” Again, among other measures to be employed in treating the paroxysm of hydrophobia, it is recom- mended to “saturate [the patient] with morphia.” Such advice would be properly interpreted by the surgeon, and, perhaps, by some students, but we believe that, if the doses were specifically given in each instance, the purpose of the work would be more fully accomplished. After describing the symptoms of the first stage of hip-joint dis- ease, the author says, “The diagnosis in this stage is more or less prob- lematical.” We are inclined to take issue with the writer on this state- ment. We think the diagnosis of this disease should almost invariably be made in the first stage, and the proper treatment instituted at once, as it is at this time that our efforts are followed by the best results. Note the symptoms of the second stage. The child limps; the adductor muscles are rigid ; the hip is broadened by an effusion in the joint; the thigh muscles are atrophied ; the extremity is pushed forward, abducted, and everted ; the fluid effusion may be absorbed, or may find its way ex- ternally by means of sinuses; the bones are worn away and destroyed,” etc., “and the third stage is established,” all of which should have been prevented by diagnosis and treatment in the first stage. We note some lack of care in reading the proof. Ashhurst is misspelled “Ashurst,” five times on page 494, three times on the pre- ceding page, and twice in the preface. Deaver is misspelled “Dever” (p. 626). The binding and general get-up of the book are not up to the usual standard of the publisher. PRACTICAI, URANALYSIS AND URINARY DIAGNOSIS. A Manual for the Use of Physicians, Surgeons, and Students. By CHARLEs W. PURDy, M.D., Queen's University. With Numerous Illustrations, Including Photo-Engravings and Colored Plates. Philadelphia: The F. A. Davis Co., 1894. This work is divided into two parts: In Part I, Analysis of Urine, are considered theories of secretion and excretion of urine, composition of normal urine, abnormal urine, proteids, carbohydrates, urinary sedi- ments, chemical sediments, anatomical sediments, and gravel and cal- culus; in Part II, Urinary Diagnosis, are considered diseases of the urinary organs and urinary disorders, and the urine in other diseases. Finally, an excellent appendix has been added upon the subject of Urinary Examination for Life-Insurance. Under the above headings the author, in a volume of 350 pages, has presented the essential features of our knowledge of the urine and urinary diagnosis in a most systematic, practical, and concise form. He has evidently labored—and with considerable success—to demon- strate the relations of the chemistry of the urine to physiological pro- cesses and pathological facts. In dealing with normal urine, each con- stituent has been considered, so far as at present is known, in the following order: Its chemical nature and composition, its source in the economy, Aook Motices. 545 the significance of its increase or decrease in the urine, with the rela- tions of these to metabolic processes, food-supply, physical surround- ings, and tendency towards disease, and, finally, the most approved methods of its detection and determination have been described. In dealing with abnormal urine each morbid constituent has been consid- ered in the following order: Its chemical nature and composition, its source in the economy, the clinical significance of its appearance in the urine, and, lastly, the most approved methods of its detection and determination have been described. Due consideration is given to the examination of urine by the aid of the centrifugal method, the advantages of which the author has done much to set forth. We heartily coincide with the conclusions which the author has reached after a critical examination of the newer deli- cate tests for albumin, -namely, “While many of these later tests are exceedingly delicate reagents for albumin, greatly exceeding in sensi- tiveness the older methods, yet their increased sensitiveness is nearly always obtained at the expense of trustworthiness. Without excep- tion the tests named give a reaction with substances in normal urine, or with substances in abnormal urine other than albumin.” The most common sources of fallacy, of course, being with mucin and nucleo- albumin. We regret that a little more space has not been allotted to the bacteriological examination of urine, a subject of growing importance. The general make-up of the book, including the type, paper, and illus- trations, is praiseworthy. In conclusion, we believe the work to be one of considerable merit, and heartily recommend it to the profession. LABORATORY GUIDE FOR THE BACTERIOLOGIST. By LANGDON FROTH- INGHAM, M. D.V., Assistant in Bacteriology and Veterinary Science, Sheffield Scientific School, Yale University. Philadelphia: W. B. Saunders, 1895. After a preliminary chapter on bacteriological technique, the manner of preparing specimens and the important staining methods are briefly described. The formula for making the various stains is given, and each step in the staining process is described without the introduction of any irrelevant matter, so that the desired information is seen at a glance. Instructions are also given for preparing the various nutrient media and for embedding tissues for cutting sections. The book cannot fail to be useful to every student in bacteriology. SYLLABUS OF LECTUREs on HUMAN EMBRYOLOGY. By WALTER PoRTER MANTON, M.D., Professor of Clinical Gynecology and Lecturer on Obstetrics in the Detroit College of Medicine. Phila- delphia : The F. A. Davis Co., 1894. The object of this work is to furnish to students of medicine and practitioners an outline of the principal facts in human embryology. Details and theories which tend to confuse the mind of the student have been omitted, as they are out of place in a work of this kind. The 39 546 Book Notices. matter has been so arranged that it may be used in the class room. The book is interleaved to afford an opportunity to make notes and additions. There is a large number of outline drawings which serve to elucidate the text. A chapter is devoted to a description of the prac- tical work which is usually performed by the student. A glossary of the common terms used in embryology is appended, and will be found useful in Saving the time necessary to consult a dictionary in regard to doubtful words. The author has given in a small compass a faithful outline of human embryology, which both the student and the physician will find profitable reading. The printing and binding are all that could be desired. LATIN GRAMMAR IN A NUTSHELL. Lebanon, Ohio; March Brothers. A four-page card, of convenient size to slip into any text-book, giving in condensed form all declensions of nouns and adjectives; a complete list of conjunctions and prepositions, with meanings; preposi- tions governing special cases; interrogative words, with uses; a com- plete synopsis of the verb in all conjugations, voices, modes, and tenses; participles; special note on the gerund and gerundive; rule for preposi- tions in composition ; special rule for the ablative and genitive; and concise note on the subjective, denoting purpose or consequence. With this card in hand, the student saves the time and annoyance of turning through the grammar in search of the information wanted. All is had at a glance. THE PRINCIPLES OF BAcTERIOLOGY. A Practical Manual for Stu- dents and Physicians. By A. C. ABBOTT, M.D., First Assistant, Laboratory of Hygiene, University of Pennsylvania, Philadelphia. Second Edition. Philadelphia : Lea Brothers & Co., 1894. In this book the principles of bacteriology are more clearly deline- ated than in any other work now before the profession. That the object * £ 4-1- c. ~ -- 4-1- - - - -- ~~~~~~~ +3 - ~ * 1- ºr rers, 1 r. A rer, aſ rºss rºl- ºr res-45 as: rs ºf +1+ r. ~~-r-, Wºº-º-Lº-E-º-vºzºzºº- º-Es-º-º-º-º-º-º-º-º-º- wº-ºº-º-º-º-º-z-z-z- ***) Jöe 22 º 27ty Diagrams of the visual fields after the second attack of hemianopsia. The small central white area represents the limits of the preserved field (macular vision); the shading where vision was 10st. floor, but he can see only short words at ordinary reading distance. Although he has driven over the town and walked about with an at- tendant almost daily, nothing has been gained of the lost sense of locality. Two points show slight improvement in this respect in his own home. After coming from a walk, if he is led to the front door and stands face inward, he can walk to a smoking-room at the opposite end of the thirty-foot hall; if, however, his face is turned outward, or even a quarter around, he cannot find his way. In his sitting-room, he fixes his position by the tick of the clock and can find his way out of one door to a bath-room, or out of another to the hall, where the banister enables him to descend the stairs to the dining-room. The aphasia Double Hemiplegia with Double Hemianopsia. 583 has nearly disappeared, though some words are still recalled with difficulty. - His general condition is fair, and he discusses his case with much interest and intelligence. This case presents many points of unusual clinical interest to the ophthalmologist, neurologist, and general practitioner. Double hemi- plegia with double hemianopsia is rare, and a single instance deserves a careful record. The reported cases of double hemianopsia will be briefly referred to, and thanks are due to Dr. de Schweinitz for his assistance in obtaining references. Förster’s” patient had a right hemianopsia, which, with the excep- tion of a slight headache, began without cerebral symptoms. The line of division was not perpendicular, and defects were noticed both above and below the horizontal line and in the region of the macula. At first vision was one-third normal, soon it became normal, and afterwards there was total blindness. Still later a small central field was restored with one-third vision. Color-sense was lost. The loss of recollection of locality was also a prominent feature of this case. The patient, after remaining a long time in his room, could not tell where anything was, and could not move about as well as a blind person. No positive improvement in this respect was recorded. Schweigger’s’ case developed a sudden left hemiopic defect in September, 1888, without loss of consciousness or hemiparesis. Cen- tral vision was unchanged. In August, 1889, the right visual field failed as suddenly as the left had done before. A small central field was preserved. Unlike Förster’s case, his memory and sense of 1ocality were undisturbed. Groenouw “observed left hemiplegia in a man in January, who had left homonymous hemianopsia the following April. Ten months later, after an attack of apoplexy, there was a remarkable loss in orientation. Field of vision was very narrow in all directions, but central vision about normal. A month later there was improvement in vision, but total loss in right inferior quadrants. Color-sense not destroyed cen- trally. The loss in sense of locality was accounted for by the loss of recollection of optical images. - Vorster" has described a case of apoplexy in a man who had had an attack four years previously with loss of sensibility of right half of body, and indefinable sensations of loss of sight. He subsequently had a third stroke with loss of consciousness, left facial palsy and paralysis of left extremities and total loss of sight. Eight days after- wards there was a return of vision in right fields. Four weeks later he had hallucinations, and was unable to find his way about in familiar places. The left half of field was totally lost and right contracted. 584 Thomas D. Dunn. Four months later, vision in right was one-third ; left, one-fourth ; color-sense restored. Both halves defective, with the exception of central zone about fixation point. Gaffron” reports a patient, aged 14 years, who received a fracture of the skull in December, 1890, and was seen by him January Io, 1891. The fracture began six and a half centimetres above the right mastoid, five centimetres behind the ear, and extended two centimetres to the left of the median line, four centimetres above the occipital prominence. Vision was nearly lost at first, but later it improved so that the patient could go about. A small, central, visual field was restored, which enabled her to read small words on a large white surface. The pupillary reaction was normal. No mention is made of loss of sense of locality. Gaffron accounted for the symptoms by the theory of a cortical lesion from the pressure of a hematoma involving the cortical visual area in the occipital lobes of both sides. Hoche" (quoted by Kneis") reports a very interesting case of double hemianopsia, inferior, in which there were hallucinations in the seeing field of vision, and similar phenomena in the blind. The case was only clinically observed, but the lesion was referred to the occipital lobes. Edinger” (also referred to by Kneis) relates a case that was con- sidered one of double softening of the occipital lobes. Suddenly there appeared a bright flash followed by complete blindness. This was thought to be a half blindness, the result of embolism, hemorrhage, etc., occurring alternately on both sides or at the same time. Schmidt-Rimpler's" case was a man of 51 years who received a scalp wound in 1873. The right homonymous hemianopsia in this case was preceded by headache and paresis of the right extremities, with clonic spasms. A year later a contraction of the field was observed, followed by sudden total blindness. A small central field was subse- quently restored, but later it was reduced to a minimum. No loss of the sense of location was noticed. The autopsy showed that the right hemianopsia was due to a hematoma of the dura mater. The right paresis was the result of the extensive cicatricial contraction in the posterior central convolution. The later loss of left visual field he ascribes to a cheesy focus in the region between the gray and white substances in the posterior portion of the right posterior lobe. Swanzy" and Werner's case was first seen several months after an attack of apoplexy. He had paralysis of left arm and right-side hemianopsia. The fundus was normal, but vision was confined in each eye to the left upper quadrant, the other quadrants being wanting. No record was made of loss of orientation. Double Hemiplegia with Double Hemianopsia. 585 Magnus” reports the case of a man, aged 52 years, who thirteen years before had a sudden attack of left hemiparesis and left homon- ymous hemianopsia. Ten years after first attack the second appeared, in which there was loss of consciousness, but no paresis. Three years after the second attack he had a third without paralysis, but there was complete blindness. After a few days he could see small objects, and when the presbyopia was corrected the small central field could recog- nize No. III Snellen's test-types. He was unable to find anything in his room, and loss of memory of recent events was noticed. There was no further improvement in vision in thirteen weeks after the attack. Color-sense was normal. Nineteen weeks later there was no gain in sense of locality. Förster' explains the preservation of the small central field in these cases on the hypothesis that the small portion of the occipital lobe which serves for the most acute perception, the direct vision, is supplied by the anastomosis of two or more vessels. If the main vessel which nourishes the cortex of the occipital lobe is thrombosed, and the cortex is cut off from its blood-supply, the region of most acute vision might receive its blood-supply from the second vessel. He also offers this hypothesis as an explanation of the frequent deviation, in hemi- anopsia, of the line of demarcation towards the defective side. The cases of bilateral hemianopsia that were at first totally blind and in which central vision was subsequently restored, such as the Schmidt- Rimpler,” Vorster," Gaffron," and the one herein related, support the view that the macular region has a bilateral vascular supply. This view is supported by the cases with autopsies reported by Wilbrand.” The physiological importance of this region, the anatomical size of the macular nerve-fibre, as well as all the reported cases, are considered by Schmidt-Rimpler as supporting Förster's theory that the macular cor- tical region has a double vascular supply and is capable of much resist- 3.11Ce. In nearly all the recorded cases the absence of the hemiopic pupil- lary reaction was noted, which places the lesion beyond the reflex curve, either in the optic radiations or the cortical visual area. In the absence of positive information as to the position of the lesion, much speculation might be indulged in as to the cause of all the symptoms of my patient. Only brief reference, however, will be made to a few points. In the attack of 1891, in addition to the cortical lesion causing the right hemianopsia, it must have involved the posterior portion of the internal capsule to account for the aphasia and transient right hemianesthesia and paresis. It is not probable that a double lesion existed in the first attack, for the second attack, in 1893, was identical with the first, the only difference being that the left side was affected, and, instead of aphasia, there was loss of the sense of locality. 586 Thomas D. ZDunn. An embolus was probably the cause of each attack, a clot having been whipped off the roughened valve during the heart-disturbance attending the attack of acute indigestion. * It seems that the loss of sense of locality is an important, if not a characteristic symptom of double hemianopsia. It was present in the cases reported by Förster, Groenouw, Vorster, Magnus, and myself. Schweigger did not observe this symptom, but the hemiopic defect in his patient was incomplete. The loss of sense of locality was not recorded in the Schmidt- Rimpler case, but he confused right and left and his memory was poor. No reference is made to the loss of locality in Swanzy’s case, but a quadrant in each field was partially preserved. No mention is made of this symptom by Kneis in his brief references to Hoche and Edinger, and it was not observed in Gaffron’s patient. Groenouw ascribes the loss of the sense of locality in double hemianopsia to the loss of recollection of optical images, which seems at least a plausible explanation. My patient, however, could recollect persons and could describe correctly their appearances. This would suggest a different place in the brain for the record of such images. The loss in my patient accompanied the second attack in 1893, when the left hemianopsia was accompanied by the left transient hemiparesis and anesthesia. This suggests a centre (which may, for convenience, be named the geographical centre) on the right side of the brain for the record of the optical images of locality, analogous to the region of Broca for that of speech on the left side in right-handed persons. Nearly four years have passed since the first attack of motor aphasia, transient right hemiplegia, and right hemianopsia. The hemianopsia has not improved, but the power of articulate speech has been nearly restored, as is usually the case with aphasia. Cºver two years liãve passed since the second attack, and thcre has been practically no improvement in the sense of locality, except that which has been gained through the sense of hearing,<-for example, the tick of the clock in the sitting-room fixing the position of two doors. In the case of his aphasia, restoration of the power of speech would come largely from the perceptions received through the senses of sight and hearing. His central field of vision is so limited that there is no opportunity, from the small optical images received, to conceive the relation objects bear to each other. In the absence of better reasons, this may be offered as an explanation of so little improvement in this symptom. The Treatment of Diphtheria by Antitoxin Serum. 587 REFERENCES. * Förster. Von Graefe’s Arch., 1890, xxxvi, I, p. 94. * Schzweigger: Archives of Ophthalmology, 1891, Vol. xx, p. 83. * Groenouzy. Archiv für Psych. und Nervenk., Bd. xxIII, p. 339. * Vorster: Allgemeine Zeitschrift f. Psychiatrie, Band XLIX, p. 227. * Gaffrom : Deutshmann's Beiträge zur Augenheilkunde, 1892, v, p. 59. * Hoche : Arch. für Psych., xx1II. * Aneis: Die Beziehungen des Sehorgans und seiner Erkrank., pp. 62 and 63. * Balinger: Deutsche Zeitschr. für Nerv., I, p. 265. * Schmidt-Rimpler: Archiv. of Ophthal., 1893, xx11, p. 313. * Swanzy and Werner: Trans. Oph. Soc. U. K., Vol. x1, p. 183. * Magnus : Deutsche med. Wochenschrift, January 25, 1894. * Wilbrand: Die Hemianopschien Gesichtsfeld-Formen, 1890, p. Io9. THE TREATMENT OF DIPHTHERIA BY ANTITOXIN SERUM, witH REPORT OF Twenty- FIVE CASES.” BY ALExANDER MCALISTER, M.D., Camden, N. J. THE method of preventing and curing diphtheria by antitoxin serum continues to attract the attention of the medical world. Now that the first moments of excitement caused by this marvellous discov- ery have passed by, scientific medical men are devoting themselves to a calmer and more practical examination of the subject. It has been regarded by some as a mere experiment, but it has passed that stage. In the treatment of diphtheria it is as valuable an agent as vaccine is in the prevention of small-pox ; no one will doubt this after having read the remarkable results obtained by Professor E. M. Roux, of Paris, in the treatment of his cases of diphtheria during the last three years, reported by him in September, 1894, at the Eighth Session of the Inter- national Congress of Hygiene and Demography, held in Budapesth. The principle of the method has opened a new field for work in infec- tious diseases. At a recent meeting of the Berlin Medical Society, Dr. Hansemann read a paper condemning serum therapy; in the discussion which took place after the reading of Dr. Hansemann’s paper, Pro- fessor Virchow stated that he was quite in accord with the views of his assistant, Dr. Hansemann, in denying any specific value to the Klebs- Löffler bacillus in the causation of diphtheria. He acknowledged, however, that the statistics, so far produced, were very favorable to 1 Read before the District Medical Society of the County of Camden, February 12, 1895. 588 Alexander McAlister. the curative power of the antitoxin serum. For instance, from about the 15th of March last, Behring's serum had been injected into 303 out of 533 children admitted to the Frederick Hospital for Diphtheria; in the 303 injected children the mortality was 13.5 per cent. ; in the 230 who did not receive serum, the mortality was 47.82 per cent. Pro- fessor Virchow concluded that Behring's serum is really efficacious, and that every physician ought to use it in spite of certain drawbacks with which it is charged. Drs. Von Bergmann and Holff supported the specific character of the Klebs-Löffler bacillus in the causation of diphtheria. The former had tried serum in several cases, but had not yet sufficient data to form a definite opinion. In tracheotomy for all causes, an operation which he had done 2586 times, his mortality had been 52 per cent. Dr. Korte remarked that the results obtained by serum therapy are much supe- rior to those obtained by the ordinary means of treating diphtheria; out of thirty-six patients treated for diphtheria he had lost nine, and three of these were moribund when brought to the hospital. Of the thirty-six, eight only were lightcases. With regard to the albuminuria, resulting from the serum, Dr. Korte admits the soundness of the charge, but he does not consider that a sufficient reason for giving up a treat- ment which has produced results altogether remarkable in a very serious disease. The last meeting of the Medical Society of Greifswald, in Ger- many, was entirely taken up with the consideration of serum therapy in diphtheria. Dr. Borger gave the results of his treatment of thirty patients who had diphtheria, five of whom had been tracheotomized; he had two deaths, or a mortality of about 7 per cent. In former years, with other plans of treatment, the mean mortality was 14.5 per cent. With regard to the effect of the injections, Dr. Borger noted the improvement of the local conditions in from twelve to twenty-four hours, with lowering of the temperature in from two to four days; albuminuria was pretty frequent, but transient. Dr. Beumer cited two facts in favor of the prophylactic value of the serum. In a family in which five children were attacked with diphtheria, the sixth was treated with serum ; he did not take the disease, though continually in contact with his sick brothers. In a boarding-school, three pupils caught diphtheria, fourteen others were treated with serum, and did not contract the disease. Dr. Polienctoff reported to the Society of Pediatrics of Moscow that he had treated nine cases of diphtheria, two with Aronson’s serum and seven with that of Dr. Roux, and lost only one. Professor Filatoff added a tenth case treated successfully by himself. In England, Dr. Campbell White” gives a report of twenty cases, of which fourteen had 1 Medical Recorder, November 17, 1894. The Treatment of Diphtheria by Antitoxin Serum. 589 croup, requiring tracheotomy in five cases. Aronson's serum was used. The mortality was 25 per cent.; four deaths in fourteen cases of croup, one death in six uncomplicated cases. Among the isolated cases reported in the British Medical Journal, we notice three cases by Dr. Simpson, with two deaths; one case of cure by Dr. Lees; one case of cure by Dr. Christie, and also one successful case by Dr. Phillips. At a meeting (December 14) of the London Clinical Society, Dr. Washbourne read a paper showing that out of seventy-two cases of undoubted diphtheria treated by him with serum, fourteen died, showing a mortality of 19.44 per cent. Of nine tracheotomized cases three died; six cases only showed postdiphtheritic paralyses, no instance of which was of a serious character. Dr. Herringham had used serum in eighteen cases of diphtheria, in children ranging from 2O months to 2% years of age, seven were light cases and eleven were serious; all the light cases recovered ; in the serious cases tracheotomy was required in ten and intubation in one; seven recovered, which is rather a favorable showing when we recollect the serious character of tracheotomy in nurslings. Dr. Lennox Brown had used serum in five cases; two children died with symptoms of anuria; in one of the other cases a well-marked oliguria was observed. A statistical report, compiled by Dr. Peyron, was sent last De- cember to the “Comité Consultatif d'Hygiene” of France, in which he shows the comparative figures of the results obtained before and since the new treatment was begun at the Sick Children’s Hospital and the Trousseau Hospital, Paris. The following table shows the results obtained from the years 1887 to I893 : DIPHTHERIA. 1887. I888. 1889. 1890. 1891. 1892. 1893. Cases: Sick Children's Hospital . . . 802 || 874 || 873 || Ioo2 957 997 || IoI5 Trousseau Hospital . . . . . 775 | 909 | IoS5 IIo5 946 IO/3 | 862 1577 | 1783 || 1928 2107 || 1903 || 2070 I877 Deaths : Sick Children's Hospital . . 508 || 601 || 569 560 502 || 475 492 Trousseau Hospital . . . . . 451 552 615 648 || 519 563 47I * II53 II84 || I2O8 IO2.I . Io98 || 963 Mortality, per cent. : 959 Sick Children's Hospital . . . 63.34 | 68.76 65.18 55.81 52.45 47.64 || 48.47 Trousseau Hospital . . . . . 58. 19 || 60.72 58.28 58.64 54.86 52.47 54.63 Average . . . . . . . . 60.81 | 64.66 61.4I 57.33 || 53.65 50. I4 || 51.30 590 Alexander McAlister. The second table shows the results of the new treatment, which was inaugurated February 1, 1894, at the Sick Children’s Hospital, and on September 18 at the Trousseau Hospital; results considered at first separately in each of these hospitals, and afterwards in both taken together : DIPH THERIA. Cases. Deaths. Yº. Sick Children’s Hospital . . . . . . . . . . . . . 78o I64 2I. OO Trousseau Hospital . . . . . . . . . . . . . . . 247 39 I5. O2 Sick Children's Hospital and Trousseau Hospital taken together . . . . . . . . . . . tº e 4 Io27 2O3 19.76 —a Early on Wednesday morning of January 2, 1895, the matron of the West Jersey Orphanage called at my office and informed me that five of the children were complaining of sore throat; on my arrival at the Orphanage I examined the children and found them suffering from diphtheria ; adjoining the Orphanage, about twenty-five feet distant, there is a frame building one story high used for a school-house. I had this building cleared of desks, etc., and thoroughly cleaned, had beds placed in it, and isolated the five cases, and the following day, January 3, seven other cases developed, January 4, four cases, January 5, one case, and January 7, two cases. Having read of the success of antitoxin in diphtheria I decided to use it, after being granted permis- sion by the managers. I called upon Dr. William M. Welch, at the Municipal Hospital, in Philadelphia, to find out where I could obtain antitoxin ; he said he did not think I could get the German serum in this country, as the Philadelphia Board of Health had sent to CY ~~~~~~~~~ --~~~ 4. ~ *-41- - - -- ~~~~ 1- ~ + --~~~~~~~~! ~ * ~~~~1-- 4- Germany over two months ago and had received no reply ; I then despaired of getting it. Dr. Welch referred me to a Philadelphia drug- gist, whom he said had some that was manufactured at the Pasteur Institute in New York. Dr. Welch said he had only used the German serum and knew very little about the American ; he stated, also, that he had at this time used it in seventeen cases, with one death ; he spoke very conservatively about the use of it. I gave the Philadelphia druggist an order for five bottles; the following morning a manager of the Orphanage, Mr. B. C. Reeve, went to New York, but succeeded in getting only two bottles; he arrived home very late that evening ; I was absent from home when he returned, and did not use these two bottles of serum until early Friday morning. One of the first five cases, L. S., aged IO years, had laryngeal diphtheria, and died January 3, in thirty-two hours after I first visited The Treatment of Diphtheria by Antitoxin Serum. 59 I him. He was the first child that complained of sore throat, and was given ferri bichloridum, Strychnine, liquid diet, and stimulants in- ternally, locally 50-per-cent. Solution of lime and sulphur; his death occurred the day before I received the antitoxin, and he was the only child that died during the epidemic; all the other children received the injection. Judging from the malignancy of this case, I was well aware that prompt and energetic measures were necessary to stamp out this epidemic. I gave each child twenty-five cubic centimetres as soon as the disease was apparent. On Friday afternoon I received the other five bottles, which were injected at once; on Saturday I received one dozen bottles, and then injected all the children. On Sunday six more bottles were telegraphed for, to be used for re-injecting ; this was necessary in only two cases,<-in one case that had been immunized, J. S., and in one of the laryngeal cases, E. McC. I injected the cases of greatest severity first. CASE I.—J. S., male, aged II years, colored, was taken sick Jan- uary 2. At 11 A.M., January 4, injection of twenty-five cubic centi- metres of antitoxin serum (Dr. Roux's formula), prepared in New York. At the time of injection the patient had a well-developed case of laryngeal diphtheria,-hoarseness, croupy cough, laryngeal stenosis, difficult swallowing ; child restless and anxious, dyspnea, lymph-glands enlarged, purulent discharge from nose and mouth ; tonsils, uvula, and pharynx heavily covered with membrane. Pulse IOO, weak and thready ; temperature IOO’ F. ; respiration 26, noisy, resembling snoring. In twenty-four hours after the injection the false membrane began to lose its grayish appearance and became whiter; it soon became detached, and a simple irrigation caused it to be expelled, and it did not reappear. The lymph-glands underwent a simultaneous improve- ment; at the end of a week one could scarcely tell that they had been enlarged. On January 12, erythema, with some irritation of skin, which lasted about three days. Examination of urine, January 8, showed no album in ; January II, trace; January I5, 2 per cent. ; January 25, trace; February 5, none. Discharged, cured, February 5. CASE II.-E. McC., female, aged 3 years, taken sick January 2. Laryngeal diphtheria. Injection of antitoxin serum January 4, 6 P.M., twenty-five cubic centimetres. Well-developed case, croupy cough, entire loss of voice, enlarged 1ymph-glands, swallowing difficult, mem- brane abundant on roof of mouth, soft palate and pharynx, and in nares. January 5, 9 P.M., chill. On January 7 a large piece of mem- brane came from nares, almost a complete cast. This child did not show as much improvement as the former case. On January 8, at 11.30 A.M., I gave her ten cubic centimetres more of antitoxin ; the improvement in her case was noticeable in about twenty-four hours, 592 - Alexander McAlister. Pulse in beginning was 124, at time of second injection 140, very weak; respiration 28; temperature 102° F. Erythema January 1o. Membrane had entirely disappeared by eighth day. Examination of urine, January 8, showed 2 per cent. albumin; January II, 2 per cent. ; January 18, trace; January 25, none. Sequela, paralysis of soft palate. Discharged cured. CASE III.-J. W., male, aged 9 years, taken sick, January 2, with faucial diphtheria. Injection of antitoxin serum January 4, 6 P.M., twenty-five cubic centimetres. Redness of soft palate; swollen tonsils; inner surface of same and arch of palate covered with grayish-white membrane; enlarged lymph-glands; croupy cough. Pulse I Io; tem- perature 103}. F.; respiration 44 at time of injection. Patient began to improve in about twenty-four hours; membrane disappeared in about five days. Erythema January 20. Examination of urine, January 8, gave no albumin; January II, none; January 15, trace; January 25, none. Sequela, paralysis of lower limbs; gait uncertain and tottering, patellar reflex gone; no loss of sensation. Still under treatment for paralysis; general condition good. CASE IV.--D. S., male, aged 3 years, taken sick, January 2, with faucial diphtheria. Injection of antitoxin serum January 4, 5.5o P.M., twenty-five cubic centimetres. Soft palate and fauces covered with membrane ; tonsils swollen ; lymph-glands enlarged ; voice husky. Began to improve in twelve hours; membrane disappeared in four days. At time of injection pulse Io8; temperature Ioo” F. ; respira- tion 24. Erythema January 14. Examination of urine, January 8, showed no albumin ; January II, trace; January 15, trace; January 25, none. Sequela, abscess of middle ear. Discharged, cured, Febru- ary 8. CASE V. —C. M., male, aged IO years, taken sick, January 3, with faucial diphtheria. Injection of antitoxin serum January 5, Io.20 P.M., twenty-five cubic centimetres. Membrane on tonsils and in fauces ; slight enlargement of glands; croupy cough ; nasal inflammation ; pur- ulent discharge. Improvement in twelve hours; membrane disappeared in five days. At time of injection pulse 96; temperature 98%? F. ; respiration 28. No erythema noticed in this case. On examination of urine, January 8, II, 15, and 25, no albumin was found. CASE VI.-H. B., male, aged ten years, taken sick, January 3, with laryngeal diphtheria. Injection of antitoxin serum January 4, at II. I5 A.M., twenty-five cubic centimetres. Patient well-nourished ; swallow- ing difficult; lymph-glands enlarged ; dyspnea; purulent discharge from nose and mouth ; membrane abundant on tonsils, uvula, and pharynx. Pulse 130, weak; temperature Io2°F. ; respiration 28, croupy sound on coughing, marked hoarseness; membrane disappeared in five days. * The Treatment of Diphtheria by Antitoxin Serum. 593 Urine examined January 8, II, I5, and 25, trace of albumin; February 5, none. Sequela, paralysis of soft palate. February 5, discharged well. CASE VII.-L. F., male, aged 9 years, taken sick, January 3, with laryngeal diphtheria. Injection of antitoxin serum January 5, Io P.M., twenty-five cubic centimetres. At time of injection temperature IoI3° F. ; pulse I Io; respiration 26. There was marked laryngeal symptoms; stridor; hoarse, croupy breathing ; croupy sound on cough- ing ; membrane on tonsils, uvula, pharynx and Soft palate ; lymph- glands enlarged; voice husky; nasal inflammation with purulent dis- charge. Beginning laryngeal stenosis. Improvement noticed in forty-eight hours; membrane disappeared in five days. Examination of urine, January 8; found a trace of albumin ; January II, none; Janu- ary 15, trace; January 25, none. Sequela, paralysis of soft palate; nasal tone. Discharged, cured, February 8. CASE VIII.-J. B., male, aged IO years, taken sick, January 3, with faucial diphtheria. Injection of antitoxin serum January 5, Io. 25 P.M., twenty-five cubic centimetres. Small amount of membrane on tonsils and in fauces; hoarseness; slight enlargement of lymph-glands. At time of injection temperature IO2$º F. ; pulse IOO ; respiration 29. Examination of urine, January 8, II, I5, and 25, no albumin. Erythema January 14. Improvement in twelve hours; membrane disappeared in three days. Discharged, cured, February 3. CASE IX. —J. R., male, aged 9 years, taken sick, January 3, with laryngeal diphtheria. Injection of antitoxin serum January 4, 6. Io P.M., twenty-five cubic centimetres. Laryngeal huskiness; croupy cough ; signs of beginning laryngeal stenosis. Pulse I2O, weak ; tem- perature Io2.É? F. ; respiration 24. Very restless; soft palate; uvula, tonsils, and pharynx covered with a grayish membrane ; nasal inflam- mation, with purulent discharge ; lymph-glands enlarged. Improve- ment noticed in twenty-four hours; membrane disappeared in four days. Examination of urine, January 8 and I I, showed no albumin ; January 15, trace; January 25, none. No erythema noticed ; no sequela. Discharged, cured, February I. CASE X.—T. M., male, aged Io years, taken sick, January 3, with faucial diphtheria. Injection of antitoxin serum January 5, Io.3o P.M., twenty-five cubic centimetres. Membrane on tonsils; small amount in fauces ; croupy cough ; some hoarseness; unilateral enlarged lymph-glands. At time of injection pulse IOO ; temperature 99° F. ; respiration 24. Examination of urine, January 8, 15, and 25, showed no albumin ; membrane disappeared in two days. No erythema ; no sequela. Discharged, cured, January 24. CASE XI.-E. E., male, aged 9 years, taken sick, January 3, with 594 Alexander McAlister. 1aryngeal diphtheria. Injection of antitoxin serum January 4, 6.15 P.M., twenty-five cubic centimetres. Membrane abundant on soft palate; tonsils, uvula, and pharynx grayish-white in color; lymph-glands en- larged ; nasal inflammation and purulent discharge; superficial ulcers at edge of nostrils; hoarseness; croupy cough ; child restless and anxious. Pulse IOO ; temperature IO2}* F. ; respiration 30. Improvement noticed in twenty-four hours; membrane disappeared in five days. Ex- amination of urine, January 8, showed no albumin ; January II, trace; January 15, 2 per cent. ; January 25, I per cent. ; February 5, none. Erythema. Sequelae, paralysis of the soft palate, which came on two weeks after, and of laryngeal muscles and esophagus; hypoder- mics of strychnine and rectal alimentation had to be resorted to in this case for three weeks. Child now convalescent. CASE XII.—E. J., female, aged 7 years, taken sick on January 4 with faucial diphtheria. Injection of antitoxin serum January 5, 10. I5 P.M., twenty-five cubic centimetres. Small amount of membrane on tonsils and in fauces ; croupy cough ; hoarseness; slight enlargement of lymph-glands. At time of injection pulse I I2; temperature 99%% F. ; respiration 30. Examination of urine, January 8, II, 15, and 25, showed no albumin. Erythema absent. CASE XIII.-C. M., male, aged 6 years, taken sick on January 4 with faucial diphtheria. Injection of antitoxin serum January 5, Io.40 P.M., twenty-five cubic centimetres. Small amount of membrane on tonsils and in fauces ; voice husky ; croupy cough ; enlarged lymph- glands. At time of injection pulse I2O ; temperature IO4° F. ; respi- ration 28. Examination of urine, January 8, II, 15, and 25, showed no albumin. Membrane disappeared in three days. No sequela. Dis- charged, cured, January 26. CASE XIV.—M. B., female, aged 4 years, taken sick, January 4, with 1aryngeal diphtheria. Injection of antitoxin serum January 5, Io.o5 P.M., twenty-five cubic centimetres. Croupy cough ; laryngeal buskiness, and stenosis. Pulse 14o, weak; temperature Ioo” F. ; res- piration 26. Child restless; soft palate ; uvula, tonsils, and pharynx covered with grayish membrane; nasal inflammation with purulent discharge ; lymph-glands enlarged. Improvement noticed in thirty- six hours; membrane disappeared in five days. Examination of urine, January 8 and II, showed no albumin ; January 15, trace; January 25, none. No erythema noticed. Sequela, small abscess at point of injec- tion containing about one teaspoonful of pus incised; closed in a week. Discharged, cured, January 27. CASE XV.-N. H., male, aged 3 years, taken sick, January 4, with faucial diphtheria. Injection of antitoxin serum January 5, Io. 15 P.M., twenty-five cubic centimetres. Membrane on tonsils and in fauces; The Treatment of Diphtheria by Antitoxin Serum. 595 hoarseness; slight enlargement of lymph-glands. At time of injection pulse 98; temperature 98%. F.; respiration 24. Membrane disappeared in two days. Examination of urine, January 8, II, 15, and 25, showed no albumin. Erythema January 7 ; no sequela. Discharged, cured, January 25. CASE XVI.—E. R., male, aged IO years, taken sick, January 5, with faucial diphtheria. Injection of antitoxin serum January 5, Io. 20 P.M., twenty-five cubic centimetres. Small amount of membrane on tonsils and fauces ; croupy cough ; hoarseness; lymph-glands slightly enlarged. At time of injection pulse IOO ; temperature 99%. F.; respi- ration 24. Examination of urine, January 8, II, I5, and 25, showed no albumin. Membrane disappeared in four days. No erythema ; no sequela. Discharged, cured, January 26. CASE XVII.-W. P., male, aged Io years, taken sick, January 7, with faucial diphtheria. Injection of antitoxin serum January 7, 11.30 A.M., twenty-five cubic centimetres. Slight amount of membrane on tonsils and in fauces ; hoarseness; croupy cough ; enlarged lymph- glands. At time of injection pulse IO8; temperature 99$º F. ; respi- ration 26. Examination of urine, January 8, II, I5, and 25, showed no albumin. Membrane disappeared in two days. Erythema January 17; no sequela. Discharged, cured, January 28. CASE XVIII.-J. S., male, aged II years, taken sick, January 8, with laryngeal diphtheria. Injection of antitoxin serum January 7, II A.M., twelve and a half cubic centimetres; second injection January II, I 1.30 A.M., twenty-five cubic centimetres. Croupy cough ; hoarse- ness; beginning stenosis. Pulse I2O, weak; temperature Io2°F.; respi- ration 26. Membrane on palate, tonsils, and in pharynx ; some nasal discharge ; lymph-glands enlarged ; membrane disappeared in four days. Examination of urine, January II, showed a trace of albumin ; January 15, trace; January 25, none. No sequelae. Discharged, cured, January 24. One case of Dr. W. A. Kensinger, of North Cramer Hill, one of Dr. H. A. Wilson, of Woodbury, one of Dr. J. A. Stanton, of this city, and four cases in my own practice constitute this series. CASE XIX. —Dr. W. A. Kensinger sent for me on January 17 to see Mrs. S., aged 35 years ; laryngeal diphtheria. She was at this time suffering from the effects of an abortion and inflammatory rheu- matism. Her soft palate, tonsils, and pharynx were covered with a grayish-white membrane. I advised an injection of antitoxin serum, which was given on January 17, at 8.30 P.M. Pulse IO3; temperature 1ooš’ F. ; respiration 28. The doctor wrote me that he visited her the following morning ; upon examining the throat he found the membrane whiter, and beginning to loosen around the edges. He again visited 43 596 Alexander McAlister. her the same evening, and found that a large portion of the membrane had disappeared. On the following afternoon no membrane could be seen ; this was thirty-six hours after the serum was injected. I re- garded the high temperature at the time of injection due to the abor- tion and inflammatory rheumatism. The urine contained albumin. She died seven days after the injection. This case being complicated with abortion and rheumatism was not a fair test-case of the antitoxin Serú111. CASE XX. —Patient of Dr. H. A. Wilson's, of Woodbury, N. J. He was called to see E. W., aged 8 years; complaining of sore throat and headache. Upon examining the throat, he found both tonsils and fauces covered with a grayish-white adherent exudation; tongue coated; breath fetid. Pulse I2O ; temperature IoI#°F. ; respiration 28. Sub- maxillary and cervical glands enlarged and tender. From these symp- toms, together with the fact that I had during the preceding month treated four cases of diphtheria in the same family, my diagnosis of laryngeal diphtheria was readily made, and I determined to try the antitoxin treatment. The doctor telephoned me in regard to this, and he requested me to come to Woodbury and administer the antitoxin, which was done at 6.15 P.M. At time of injection pulse 130 ; temper- ature Io.2%% F.; respiration 26. The membrane by this time had made its appearance on the uvula and posterior wall of the pharynx ; no other treatment was employed except to swab the throat with sterilized solution of boracic acid. On the morning of the 20th, the temperature had fallen to Iooš’ F. ; pulse 108; respiration 18 ; condition of throat unchanged. On the 21st I was surprised to see the patient sitting up, and said he felt well. Temperature 98.3° F.; pulse 94; respiration 18. The membrane appeared thin, and showed in spots the mucous surface belieaii, ; appeiiie good ; bowels regular. January 22 membrane aimost entirely gone ; few small spots on tonsii. Temperature 97%. F.; pulse 76; respiration 22. January 23 condition of throat about same. Tem- perature 99;? F. ; pulse Ioo; respiration 20. Erythema was present about point of injection. On the 24th there was a well-marked erythema all over the body. Temperature Ioo}* F.; pulse 96; respiration 21. January 25 temperature 98°F. ; rash disappearing. Patient entirely recovered. CASE XXI.—Patient of Dr. J. G. Stanton, of this city. Was called to see A. B., female, aged II years, January 26, 5 P.M., and found her suffering with laryngeal diphtheria. I at once began the regular treatment for same ; next morning found her symptoms much aggravated. Pulse I2O ; temperature Io2#. F.; respiration 36. I sug- gested the use of antitoxin serum, as I believed the patient would succumb to the disease on the regular treatment; the doctor asked me The Treatment of Diphtheria by Antitoxin Serum. 597 to meet him in consultation at 4.30 P.M.; and in the presence of Dr. Grier and myself the patient was injected with twenty-five cubic cen- timetres of antitoxin serum ; three days after the injection the mem- brane came away, leaving the throat clear. On February 3, the eighth day after the injection, an erythema appeared ; the patient did well until February 7; when I called on February 7 found her suffering with pain in the region of her heart. She died suddenly Friday, 2.15 A.M., of paralysis of the heart. CASE XXII.-E. W., female, aged 25 years, called at my office January Io, complaining of Sore throat. On examination I found mem- brane on tonsils and in fauces ; diagnosis faucial diphtheria. I ordered her to bed on the following morning at 9.30 A.M. I injected twenty-five cubic centimetres. At time of injection pulse 96; temperature Ioo? F.; respiration 22. Enlarged lymph-glands; hoarseness. Examination of urine, January 12, showed trace of albumin; January 20, none. Mem- brane disappeared in three days. Erythema appeared January 19; no sequelae. Discharged, cured, January 31. CASE XXIII.-Was called to see C. P., female, aged 17 years. January 12, complaining of sore throat. On examination found tonsils and fauces covered with a grayish-white membrane. Diagnosis, faucial diphtheria; hoarseness; enlarged lymph-glands. Suggested the use of antitoxin, which was not consented to until the following day. At time of injection temperature IoI* F. ; pulse Ioo; respiration 22. Examination of urine January 13, showed trace of albumin ; January 2O, none. Erythema appeared January 21, lasted for three days. Dis- charged, cured, February 3. No sequela. CASE XXIV.-Was called to see F. W., female, aged 17 months. January 15, 4 P.M. Mother said the child had been sick about forty- eight hours, but she did not think it anything serious. I noticed the child had enlarged lymph-glands. On examining the throat I found membrane on soft palate, uvula, tonsils, and pharynx; nasal inflamma- tion, purulent discharge. I suggested the use of antitoxin, which was consented to by the parents, and at 8 P.M. that evening, in the presence of Dr. J. F. Walsh, I injected ten cubic centimetres of anti- toxin serum. The doctor agreed with me that this was a well-marked case of laryngeal diphtheria. At time of injection temperature IoI* F. ; pulse I2O, respiration 24. Thirty-six hours after injection tem- perature was normal, and, by January 20, membrane had entirely dis- appeared. Erythema appeared on lower extremities January 26, disappeared three days after ; reappeared again on January 31, disap- peared February 3. The child's lymph-glands are still slightly enlarged on right side, otherwise she is in good condition. Examination of urine, January 18, showed no albumin. 598 Alexander McAlister. CASE XXV.-M. W., female, aged 31 years, mother of the above case, was seized with a chill at noon January 18. The following day she complained of sore throat. On examination found membrane on tonsils and in fauces. Diagnosis, faucial diphtheria. Gave injection of twenty-five cubic centimetres at 4 P.M. Temperature IoI°F. ; pulse 74; respiration 20 at time of injection ; slight enlargement of lymph- glands; membrane disappeared in three days. Erythema appeared in ten days after injection, lasting forty-eight hours. Examination of urine, January 27, showed no albumin ; no sequelae; patient fully re- covered. There were two other children in this family, one aged four, the other six years. I gave each one an injection of two cubic centi- metres on January 15. They have, up to this time, shown no evidence of the disease. I immunized four children at the Orphanage; injecting twelve and a half cubic centimetres ; one child had a temperature of Ioo” F. at the time, he subsequently developed diphtheria; the other three have not developed it; they all had slight elevation of temperature and the erythematous rash appeared in six days. I also immunized three other children, using two cubic centimetres; they all had been exposed to the disease, none have shown any signs of diphtheria. The longest time in which it is thought to be protective is six weeks; all the chil- dren that were taken sick before antitoxin was received were given Ferri bichloridum and strychnine internally, locally 50-per-cent. solu- tion of lime and sulphur. No medicine was given after injection. I had used, locally, steril- ized solution of boracic acid five times daily. Pulse and temperature were taken every six hours; liquid diet and stimulants; Basham's mixture was given after the first week, five of the children were given strychnine on account of weak hearts, some were given quinine on account of malariai Coimplications. In Case XI, rectal enemata of peptonized milk and stimulants, and hypodermics of strychnine were kept up for three weeks. Eleven of the above cases were laryngeal diphtheria, two died, one the result of paralysis of the heart, the other was complicated with abortion and rheumatism ; the other fourteen cases were faucial diphtheria; they all recovered. This makes a total of twenty-five cases treated with anti- toxin serum, with two deaths. Postdiphtheritic paralysis followed to a mild degree in seven of the cases; all have recovered from this, excepting one case; he is improving rapidly. Dr. Ravenel, of the Department of Hygiene of the University of Pennsylvania, made cultures in blood serum of secretions, of cases at the Orphanage, and inside of twelve hours pure cultures of diphtheria Memoranda. 599 bacilli were produced. The urines in these cases were examined by Dr. L. B. Hirst, of this city. No local reaction followed the injection of antitoxin, general reaction in some of the cases, a rise of one or two degrees in temperature; pulse somewhat accelerated. In the mild cases, improvement was noticed in ten hours, in the others from twenty-four to thirty-six hours; membrane changes in color and becomes detached. I had a small abscess follow only in one case, it was incised and healed rapidly; it contained about one drachm of pus. Erythema followed in a number of my cases in from eight to ten days after injection. According to a report by Mr. Frank M. Mason, Consul-General at Frankfort, in which he says it has also been found that age has an important salutary effect upon antitoxin. In the earlier experiments, when the supply of antitoxin was small and temporary, freshly-prepared serum was mainly used, and produced in some cases a slight eruption on the skin ; this was the outward sign of a disturbance, the ultimate consequences of which caused some anxiety, but later experience has shown that this eruption is not caused when the serum which has ripened a few weeks is used ; instead of degener- ating, therefore, antitoxin improves with age, at least, during the first two months, and the best German practitioners no longer use freshly- prepared antitoxin, when that which has undergone the ripening process can be obtained. MEMORANDA. THE SUCCESSFUL TREATMENT OF TWELVE CONSECU- TIVE CASES OF DIPHTHERIA WITHOUT THE USE OF ANTITOXIN. DURING the past few months I have had in hospital and private practice twelve cases of diphtheria in whom the Klebs-Löffler bacillus was clearly demonstrated,—and all of whom recovered. In none of these was the antitoxin used for various reasons, not because it was distrusted. At first during the autumn it was unattainable and the later cases were of a kind to scarcely demand extreme measures, which are still in the experimental stage. Had any of these been very severe, I would have at once resorted to antitoxin when obtainable. My reason for reporting these cases is that since it was not convenient to use the new and promising remedy, it is only fair to our older measures that they should be compared with the new, and this very satisfactory 6OO Memoranda. series gives Ioo per cent, recoveries. I admit the severity was not in- tense, though some were far from mild. Most of the twelve cases were children and out-patients at the Children’s Hospital. In some there was every clinical evidence of the disease; in some it was barely sus- pected, and the result of the bacteriological examination caused surprise. There were others not counted in this series in whom the state of the throat was most suspicious, but negative results were reported by Dr. Lainé and Dr. Carter who so efficiently aided me. What astonished me most was the smallness of the constitutional disturbance in those reported upon as showing abundant bacilli,-taken in certain instances from throats showing mild follicular tonsillitis. The treatment employed was careful cleansing, with absolute rest, judicious feeding (not starving), tonics and alteratives, iron and bi- chloride of mercury, and in certain cases, when the membrane formed abundantly, trypsalin dusted on. This gave great satisfaction in apparently eating away the growth in a couple of hours, at which time it was again used,—nor was it disagreeable to the patient. In one in- stance I tried powdered acetanilide along with stearate of zinc,+with what good effect was not clearly demonstrated. One point I think important, the small amount of stimulus I saw occasion to use,_only in two or three was this pushed,—and the kind most approved was that in the various forms of fluid beef. The bichlo- ride was used in all instances in pretty good-sized doses. Both my assistants and myself gave a great deal of attention to these people. The dispensary cases were reported to the Board of Health, but treated by us, except two, who were taken to the hospital, who also made a good recovery. j. MADISON TAYLOR, M.D., Professor of Diseases of Children, Philadelphia Polyclinic. A FATAL CASE OF DIPHTHERIA, TREATED WITH ANTITOXIN. THE following case is of interest in view of the attention now being given to the antitoxin treatment of diphtheria. The patient was a male infant, 9 months old. It was breast-fed, well-nourished, and vigorous, but somewhat anemic from lack of fresh air and sunshine. The parents are healthy. It was taken sick on March II, with an ordinary coryza and bron- chitis of very mild type. There was no suggestion of membrane about its pharynx. The following day, March 12, it was so much better that I did not call to see it on the 13th. On the 14th its bronchitis was Memoranda. 6OI practically well, and the child, in general, had improved. It exhibited, however, a few small blisters scattered about the face, right eyelid, and trunk, particularly in the flexures of the groin. The lesions were about the size of large pin-heads, were raised, rounded, and looked like unusually large varicella vesicles, except that they were not appar- ently developed at the apices of papules, and had no red base. Never- theless I was at this time rather inclined to think that the catarrhal symptoms and the eruption might all be due to varicella. The child seemed so well, however, that I did not think it necessary to see it on the following day, March 15. On the morning of the 16th, the vesicles were found to be large blebs, a few reaching the size of hickory-nuts, and those in the flexures of the groin the size of walnuts. There were from a dozen to twenty pemphigus lesions on the entire body, most of them being on the face, neck, and trunk, but a few were on the scalp and forearms. The child looked ill, being pale and depressed, with moderate fever and frequent pulse. It nursed without difficulty or apparent discomfort. The baby's throat was examined, not because there were any in- dications of throat-trouble, but because that has become a routine measure. I found a few blebs on the tongue and mucous membrane of the mouth ; and on each side of the posterior pharyngeal wall, extending from each posterior pillar of the tonsil nearly to the median line of the pharynx, there was an appearance as though some one had painted on the pharynx a thin coating of grayish-white paint. The tonsils were not involved. The membrane did not extend high up behind the soft palate, nor deep down into the pharynx. While regarding it as probably diphtheritic, the appearance was unusual, and final judgment was suspended. Meantime the patient was given every two hours a teaspoonful of a mixture containing two drachms of tinct- ure of chloride of iron, and simple syrup two fluid ounces. Dr. Carter made a culture from the throat for bacteriological examination. By the evening of the same day, however, and before the results of the bacteriological examination could be known, the appearance of the throat left no doubt that the disease was diphtheria. The membrane had become thicker and more yellow. The use of antitoxin was there- fore advised, and it was procured the same night. One-third of a bottle- full of No. 2 solution was injected into the buttock on the night of March 16, and the remaining two-thirds in two portions on the follow- ing day. There was no apparent effect from the injections, but the child seemed somewhat better. On the 18th, however, the child was worse. Dr. Carter reported that the colonies, in the culture made, consisted of Klebs-Löffler bacilli. The diagnosis of diphtheria was therefore established. The membrane had extended somewhat, and 6O2 Memoranda. there was cough with some hoarseness. The full-strength antitoxin solution was therefore employed, and given in two portions. Calomel was given to secure a good movement of the bowels, and the iron con- tinued. It is noteworthy that the infant continued to nurse and to swallow medicine and whiskey uninterruptedly, though it was evidently weak and much depressed. The laryngeal symptoms subsided, and there was no further extension of membrane following the last injections, which seemed to me to have been helpful. Nevertheless, the baby was very ill and looked worse than it was, owing to the horrible appearance caused by the black crusts on face and eyelid, left by the pemphigus blebs as they dried. The infant was removed to the Municipal Hospital on the night of March 19, and died the following afternoon. It continued to nurse, so the mother tells me, until the last. The diphtheria in this case probably developed on March 15. No suggestion of its presence existed before that date, and no membrane was seen until the 16th. But as no visit was paid on the 15th, it may have existed then. Injections were given on the 16th, 17th, and 18th, and the infant died on the 20th. Apart from the fact that the infant was anemic from too much housing, it should have been a good subject; for it was well-nourished and strong. It is true the surroundings were not favorable to careful treatment of the throat, which was not attempted; but, on the other hand, the infant took abundance of breast-milk and sufficient whiskey, did not vomit, and consequently did not suffer as much from lack of nourishment as do most children. Moreover, the injections were given sufficiently early. To sum up, the case seems to teach that while the antitoxin may be helpful, it certainly cannot be relied upon as an antidote. HERMAN B. ALLYN, Instructor in Physical Diagnosis. CONGENITAL, ABSENCE OF FRENUM LINGUAE AND VELUM PALATI (TONGUE SWALLOWING). By the courtesy of Dr. O. S. Brigham I saw an infant a few days 1 4- $ 1-3 + ſº © a tº ld that exhibited in an extreme degree the condition known as “tongue swallowing.” There was no frenum, and the pressure of the tongue against the palatal arch had evidently prevented the growth of the velum palati. There was not a vestige of the soft palate, the edge of the hard palate being sharply defined. The tongue lay most of the time with its tip pressing hard against the posterior naso-pharyngeal wall, and from its constant motion, as in the act of Alumni Notes. 603 sucking, it had excoriated the mucous membrane in this region. It was by considerable effort occasionally thrust into its natural position. While sleeping, the tongue was evidently swallowed so that it impeded respiration. There was much disturbance of the act of deglutition, and, judging from the coughing excited, some of the fluids entered the larynx. The tongue itself was well formed, except that it was slightly heart-shaped at the tip, indicating that the absence of the frenum was accounted for by delayed development and union at the tip. This infant died in about thirty-six hours from inanition. THOMAS HUBBARD, M.D. TOLEDO, OHIO. ALUMNI NOTES, APPOINTMENTS. At a recent meeting of the Board of Trustees of the University, Dr. A. Feree Witmer was appointed instructor in physiology, and Dr. Charles F. Nassau lecturer on bacteriology in the School of Biology. At a meeting of the City Board of Trusts held on April Io, Dr. S. Potts Eagleton, of the class of ’90, was elected assistant Surgeon to Wills Eye Hospital. A GIFT TO THE UNIVERSITY HOSPITAL. DURING the past month the University received gifts amounting to $59,979, including one of $5000 from Miss Helen Louisa Murphy for the endowment of a bed in the University Hospital in memory of her brother. A SUMMER SCHOOL IN CHEMISTRY TO BE INAUGURATED. ON July 6 of the present year, the University is to inaugurate a summer school in chemistry, which is to last through six succeeding weeks. It is announced that the course will include the study of four subjects, elementary inorganic chemistry, qualitative analysis, organic chemistry, and quantitative analysis. A fee of $25 will be charged for the course, which is open to every one desiring to study chemistry. The teachers who will have charge of the work are Dr. Edgar F. Smith, professor of chemistry; Dr. Hermann Fleck, Daniel L. Wallace, J. Bird Moyer, and Owen L. Shinn, instructors in chemistry. This is the first of summer schools established by the University, and will probably be followed by others in law and physics. 6O4 ** Alumni Notes. FOR THE DORMITORIES. THE Provost has announced a gift, by Mr. Robert H. Foerderer, of $10,000 for the erection of a house in the dormitory system. NECROLOGY. DR. JOHN ADAM RYDER, professor of Comparative Embryology in the University of Pennsylvania, died in Philadelphia on March 26, 1895, at the age of 43 years. Dr. Ryder was born near London, Franklin County, Pa., in 1852. He received a common school education and entered an academy, where his educational course was interrupted by financial reverses to his father. He then adopted his life work, teaching, and entered as a Jessup scholar, under an endowment held by the Academy of Natural Sciences of this city. He readily showed great interest in scientific study and pursuit, and immediately began original research which has made him prominent in scientific circles. Early in life he began the publication of those original investigations that soon stamped him as one of America’s foremost biologists. He was called by the late Pro- fessor Spencer F. Baird to the position of Embryologist to the United States Fish Commission. In 1886 he was invited to take the Professorship of Comparative Embryology at the University, and thereafter, although actively en- gaged in undergraduate and graduate teaching, he still was busy with his pen. The proceedings of the Academy of Natural Sciences, of the American Philosophical Society, the American Naturalist, as well as the most prominent of European journals, were enriched by his con- tributions. His chief writings and papers embrace “The Inheritance of Modifications Due to Disturbances of the Early Stages of Develop- ment, especially in the Japanese Domesticated Races of Gold Carp;’’ “Dynamics in Evolution ;” “The Mechanical Genesis of the Form of the Fowl's Egg;” “A Physiological Hypothesis of Heredity and Variation;” “The Origin of Sex through Cumulative Integration, and the Relation of Sexuality to the Genesis of Species;” “On the Mechan. ical Genesis of the Scales of Fishes;” “The Sturgeons and Sturgeon Industries of the Eastern Coast of the United States, etc. ;” “The Development of the Common Sturgeon ;” “Evolution of the Special- ized Vertebral Axes of the Higher Types;” “A Physiological Theory of the Calcification of the Skeleton ;” and “The Origin and Meaning of Sex.” At the last meeting of the Board of Trustees of the University, after Dr. S. Weir Mitchell had paid a warm tribute to the memory of Dr. Ryder, the following minute was adopted : Alumn? AVotes. 605 “The Trustees of the University of Pennsylvania deplore the loss sustained by it in the death of Dr. John A. Ryder, professor of Com- parative Embryology. Called to that chair in 1886, he quitted for it a congenial field of labor under the United States Fish Commission, in which he had rendered great service to the government, and acquired for himself a world-wide reputation. Thenceforth he devoted himself equally, and with a fidelity and effectiveness that ended only with his life, to the work of a teacher and that of an investigator. “His characteristic traits were modesty, unselfishness, and sincer- ity in the search for truth. To these were added a rare talent for inves- tigation, strong intellectual capacity, and unremitting industry, and these inured not only to the benefit of the school in which he taught, but to the distinct advancement, both in theory and in application, of the science of biology to which his life was consecrated.” DR. WILLIAM M. KINPORTs, class of '93, died at his home, Cherry Tree, Indiana County, Pa., on February 18, 1895. His death was caused by consumption. CONGENITAL SPOTS ON ANNAMITES A MEANS OF RACIAL IDENTIFICATION. AT a recent meeting of the American Academy of Arts and Sciences, Dr. Stephenson, United States Navy, read a paper entitled “Congenital Spots on Annamites a Means of Racial Identification, with Remarks on Linguistics in Connection with Migration of Peoples.” Reference was made also to the studies of the Annamese savant, Petrus Truong Urichky, of Cholon (near Saigon, Cochin China), and to his works on linguistics, comparative philology, etc. Such investigations, as well as examination of bodily peculiarities, enable us to trace the origins and history of various peoples in their world wanderings. The article is published in the AVew York Medical Journal of March 2, 1895. EDITORIAL. SALINES IN THE TREATMENT OF PUERPERAL ECLAMPSIA. IN spite of the fact that the exact etiology of puerperal eclampsia is not known, the value of purgation in the treatment of the disease has long been recognized. It is a widely-observed clinical fact that in those case of eclampsia associated with and apparently dependent upon renal inefficiency the patient’s improvement and recovery occur more frequently when, in addition to treatment directed to the circulatory and nervous systems, prompt, free, and almost continuous action of the bowels has been obtained. Croton oil and elaterium are the purgative drugs upon which most reliance is usually placed. While they sometimes succeed, it very often happens that they do not act, or when a movement is secured, that they cannot be persistently employed to obtain continuous pur- gation on account of the marked irritation and inflammation of the intestinal tract which attend their free use. As a means towards hastening the effect of these drugs it is worth remembering that an enema, administered when the purgative action of the drug used has been delayed, will often start peristalsis, when the desired effect of the drug given by the mouth is thereby secured. While a simple injection will often be sufficient for this purpose, the “saline enema” commonly employed to excite catharsis after celiotomy is always more efficient. It is, therefore, a useful rule to always add to the enema glycerin and Epsom salts, two to four ounces of the former and one ounce of the latter. To secure free and almost continuous catharsis, after the first few movements of the bowels there is abundant evidence that no drug answers so well, when the patient can be made to swallow, as a satu- rated solution of Epsoul Salis given in small doses, two to four drachms every fifteen to twenty minutes. By this means continuous watery evacuations may usually be secured, and these may be observed, in proportion to the frequency of the stools and the amount of fluid evacuated, cessation of convulsions, improvement in the mental con- dition, rapid disappearance of edema, not only of the extremities but also of the lungs; and it is, no doubt, true that patients whose lives 606 Aditorial. 607 were in immediate jeopardy from pulmonary edema, have been saved by the persistent use of the saline solution throughout a period of forty-eight hours. It should be remembered that the very free catharsis desired rapidly depletes the patient, who should always be given additional draughts of water, and, besides, the action of the heart should be observed, and when indicated cardiac stimulants must be employed. Whatever may be the etiology of puerperal eclampsia, the speedy elimination of stored up excrementitious products, be these waste matters from the body, or, as some would believe, toxines from micro-organisms, the clinical fact remains that up to the present time free catharsis by means of salines is one of the most valuable adjuncts to the treatment of the affection. UNTOWARD EFFECTS OF ANTITOXIN. WHEN the antitoxin treatment of diphtheria was first introduced, it was claimed that whatever the merits of the new remedy might be proven to be, it was certainly free from all harmful after-effects. The experience derived from a somewhat extensive use of the serum therapy indicates that the claim is scarcely a just one. Recently a number of careful observers have reported untoward effects, which seem to have been directly traceable to the use of the serum. Erythema and urti- caria have been frequently noted, but their appearance is of little con- sequence. The more serious disturbances which the serum is charged with inducing are: elevation of temperature, swelling of the glands, inflammation of the joints, a greater liability to paralysis, hematuria, and albuminuria. Dr. Lennox Brown reports that a further experi- ence in the use of antitoxin has resulted in six deaths out of a total of eight cases treated, all due to inflammation of the kidneys. Benda (Medical Press, No. 2905, 1895) reports that he found in thirty-nine subjects dying under the antitoxin treatment, nephritis in thirty-three, the inflammation being of a severe type in eight. From an analysis of Iooo consecutive cases of diphtheria he found that death under the usual treatment had resulted from uremia in only 21's per cent., the total mortality being at the rate of 27# per cent. Monti (Wiener medicinische Wochenschrift, No. 5, 1895) also states that the serum exerts an injuri- ous effect upon the system, and that it tends to produce the evil con- sequences which we have mentioned. Fischer (Medical Record, April 6, 1895) reports 225 cases of diphtheria treated with antitoxin, with an average mortality of 15% per cent. In sixty-eight of this number he observed distinct evidence of nephritis; in 141 others albumin in 608 Bditorial. the urine without tube-casts; and in sixty-four hematuria within from thirty-six to forty-eight hours after the injection. While these untoward effects seem to be directly attributable to the action of the antitoxin, yet it would be unwise to attach, at this time, too much importance to them. They are neither sufficiently grave nor nu- merous to excite a reaction against a most thorough and impartial inves- tigation of the merits of the new treatment. Moreover, many able authorities still deny that pure serum, from carefully-selected horses, when administered with due care, is capable of producing serious dis- turbances. Kolisko, of Vienna, after comparing the changes observed in the organs of seventy-five fatal cases of diphtheria treated with anti- toxin, with those observed in Iooo cases dying under the old plan of treatment, concludes that serum therapy exerts a distinctly favorable influence upon the infectious process. Von Kahlden (Centralblatt für Allgemeine Pathologie und filr pathologische Anatomie, Band VI, Nos. 3 and 4) found that the injection of antitoxin into healthy rabbits and guinea-pigs produced no pathological changes either in the heart-mus- cle or kidneys. Even Monti, who claims that the antitoxin produces unfavorable symptoms, admits that they are of short duration, and do not materially influence the progress of the disease. Virchow, who has been frequently quoted as being opposed to the serum treatment, warmly advocated it in a recent communication to the Berlin Medical Society, and concludes that the occasional ill effects are not sufficient to discourage the use of the remedy. Again, the great reduction in the death-rate of diphtheria, which has apparently resulted from the em- ployment of antitoxin, is a powerful plea for a complete study of its range of usefulness, its indications and contra-indications. In a series of 2740 cases of diphtheria treated with serum, collected by Foster, the average mortality was only 18.54 per cent., while the mortality in an equal number of cases treated by the older methods was 45.36 per cent. It is fair to presume that experience will tend to improve the tech- nique of production and administration of the serum, and so lessen the untoward effects resulting from its use. MEDICAL PROGRESS. - N/IE DIC INE. JN DER THE CHARGE OF WILLIAM PEPPER, M.D., LL.D., AND JAMES TYSON, M.D., ASSISTED BY M. HOWARD FUSSELL, M.D. CASES SIMULATING MENINGITIS witHOUT CORRESPONDING ANATOMICAL LESIONS (“PSEUDOMENINGITIS”). KRANNHALs (Deutsches Archiv für klinische Medicin, Vol. LIV, Part I) reports seven cases in which the symptoms were almost exclusively nervous, and in which the diagnosis of meningitis was made, although some of the more char- acteristic symptoms were wanting. One case ended in recovery; the termination of another could not be determined; five died. The findings at the post-mortem examination did not confirm the diagnoses, there being no exudate, no inflamma- tory turbidity, nothing but hyperemia and edema of the pia, and a varying number of hemorrhages in the same membrane. The microscopical examination of two cases confirmed the pre-eminent hemorrhagic character of the affection, and the absence of any real inflammatory changes, if one does not regard as such the edema of the pia, which in reality had the character of an edema due to congestion rather than inflammation. The brain itself showed no inflammatory changes; on the contrary, here and there, in the superficial layers of the cortex, there was a retrograde metamorphosis, a beginning necrosis due to a disturbance of the circulation brought about by the numerous hemorrhages in the pia. Bacteriological examination of the meningeal serum of three cases proved nega- tive. Krannhals seeks to explain an intimate relationship between influenza and these cases of “pseudomeningitis,” occurring as they did during the spring of 1890, following the influenza epidemic. He believes that the symptoms of the cases of “pseudomeningitis,” due to some infectious process, and of acute meningitis in general, depend especially upon the action upon the central nervous system of certain toxines, and secondarily upon the anatomical lesions present. ACUTE AND CHRONIC ANGIO-SPASTIC CARDIAC DILATATION. JACOB (Centralblatt fir Innere Medicin, No. 5, 1895) describes a class of cases, the symptoms of which consist essentially in a very acute, transitory dilatation of the heart, which from frequent repetition of the attacks becomes permanent. A person apparently well is suddenly attacked with a chill, and often with pain in the skin, or in one extremity, or in the abdomen. The skin is really cold, sensa- tion much diminished, face pale and often covered with sweat. Patient complains of paresthesias of the limbs. If vertigo and dimness of vision follow, the pupil is much dilated. Patient is anxious, has dyspnea, and pain in the region of the 609 6IO Medicine. heart; pulse is hard, artery small, but slightly compressible, a solid cord. The area of cardiac dulness increases; the apex-beat becomes stronger, and within an hour or two displaced downward and outward one or more centimetres; pulsa- tion at end of sternum and in four to six intercostal spaces. In severer cases pulmonary edema and albuminuria appear. This condition lasts for from a few hours to as many days, until suddenly warmth returns to the skin and the pares- thesias, vertigo, dilatation of pupil, etc., disappear; then the anxiety, dyspnea, and cardiac pain, pulmonary edema, albuminuria, and cardiac dilatation, the 1atter requiring a full week for its completion. Repeated attacks, although slight, cause permanent dilatation of the heart. The nature of the affection consists in a spasm of the general arterial system, producing such a resistance to the onward plan of the blood that the heart, being unable to overcome it, must, in conse- quence, dilate. The results of therapy tend to confirm this view. Heart-tonics are of no avail. In acute cases, injections of morphia are of greatest service. Chronic cases are much benefited by judicious use of carbonated baths. CARDIAC ARHYTHMIA IN CHILDREN. HEUBNER (Zeitschrift für klinische Medicin, Vol. xxvi, Parts 5 and 6, 1894), gives the following causes of cardiac arhythmia, excluding in this study tuber- culous meningitis and organic disease of the heart in which its occurrence is well Rnown. (1) Following poisonings, by digitalis or opium (?). (2) Accompanying digestive derangements, auto-intoxications. (3) In intra-abdominal affections, especially those accompanied by vomiting, and in which no other symptoms of poisoning exist. (4) During the course of infectious diseases. (a) During the development and at the height of the disease,_rather rare. (5) During convalescence from diphtheria, scarlet fever, measles, pneumonia, typhoid fever, etc.,-much more CO111111011. (5) In anemic and nervous children. (6) Intestinal parasites (no personal experience). (7) Physiological conditions to which children more than adults are suscep- 4:1-12 ~~~~ *** ~tº a 1 dict-tº-han rec rold hath c etrº * A A.M.A. &e ~~~~~ --~~~~~~ --~~~~~~ --- ~~~ y - ~ -- ~~~~– ~ y - - - - 2 (8) Idiopathic cardiac arhythmia (no personal observation). V-cloco univas a vica. Sevsº iv vs • O, V, “anvi / cºa º v^* those under Nos. I and 2 are possibly due to a direct action of the poison on the heart-muscle and upon the central regulating cardiac mechanism. Cases of class No. 4 are also in all probability due to a direct action of the toxine upon the heart- muscle. The cause of the arhythmia in the cases of class No. 5 is unknown. Various as are the causes of cardiac arhythmia in children, the cases are mostly of a transitory nature, and usually yield to a few general rules of treatment which are given. lºc, 1 r Al-AA * * * * * * * 1-2 : * ~ • a ſºl cº- g *** * * * *-* icº. *-*.*.*. **E**** £º *~~ * * *5 J. *, LA W. -Cº- 5 HEMORREIAGIC NEPHRITIS IN DIPHTHERIA. TREYMANN (Deutsche medicinische Wochenschrift, December 20, 1894) reports a case of diphtheria in which, because of the unſavorable progress of the case, repeated injections of Behring's antitoxin were used. The fourteenth day of the disease (the eleventh of treatment), the day following the fourth injection, the child developed a hemorrhagic nephritis, accompanied by high fever and an Medicine. 6 II eruption resembling measles, from which, however, it recovered, albumin disap- pearing from the urine at the end of five days. SCHwa I,BE (Ibid.) reports a case of diphtheria which, because of laryngeal stenosis, was tracheotomized as soon as admitted to the hospital. Excepting this there was no particular treatment, no antitoxin being used. On the twenty-fifth day of the disease (the twentieth of treatment) the patient complained of severe headache; some edema of the face developed. The following day a hemorrhagic nephritis was very evident. The patient, however, recovered, the urine being free from albumin at the end of twenty-eight days. Schwalbe draws attention to the similarity between the two cases, and cautions against the post hoc, propter hoc argument in our judgment of the symptoms following the injection of the antitoxin. PRESYSTOLIC APEX MURMIUR OF AORTIC REGURGITATION. FISHER (Lancet, March 9, 1895), cites a case and remarks that a low-pitched presystolic murmur may occasionally be heard at the apex in cases of aortic regurgi- tation. The high-pitched, blowing diastolic murmur may possibly be audible from base to apex, and even in the axilla, but just at the apex a rumbling sound takes its place. It may be made to disappear by pressure of the stethoscope, and thus be overlooked. “In this instance, the presystolic bruit was not low-pitched and rumbling, but of that loud, rolling character which reminds one of the sound pro- duced by a flapping sail as it is filled by a puff of wind. Well-marked though the murmur was, the mitral orifice proved to be of natural size.” There was also present a presystolic thrill at the apex. Fisher also mentions that presystolic apex murmurs may occur unassociated with either mitral stenosis or aortic insufficiency, being due simply to adherent pericardium, and suggests that in both of these conditions simulating mitral stenosis, the innervation of the heart may be, in some obscure way, affected, giving rise to the production of the 111111111 ll1. THE DIAGNOSIS AND THEORY OF MORBUS BASEDOwſ1 (GRAves's DISEASE). LEMKE (Deutsche medicinische Wochenschrift, December 20, 1894) comes to the following conclusions concerning Graves's disease : (1) A patient suffers with Graves's disease as soon as delirium cordis and tremor are present. All other symptoms are consecutive and of secondary nature; they simply confirm the diagnosis. (2) The cause of Graves's disease is in all probability to be sought in a faulty chemical influence exerted on the blood by the thyroid gland. (3) Graves's disease, therefore, is no disease of the nervous system ; one requires for its diag- nostication no special neurological knowledge. He believes the diseased product of the thyroid gland to be a special muscle-poison, the delirium cordis being the result of this poison exerted on the heart-muscle and the tremor, the result of the same poison on the skeletal muscles. MASKED DIPHTHERIA. HEUBNER (Deutsche medicinische Wochenschrift, December 13, 1894), calls at- tention to the occurrence of masked diphtheria, reporting three cases, two of which died. Masked diphtheria is spoken of as being secondary, affecting always sick or sickly children, beginning and progressing insidiously, suddenly manifesting itself by the production of marked laryngeal stenosis, or by the death of the child 44 6I 2 Surgery. in collapse. Respecting the remarkable deviation from the ordinary course of diphtheria, and the difficulty of diagnosis in such cases, two points are to be espe- cially considered. (I) The patients who—being constitutionally weak (scrofulous, rachitic)—respond but slightly to the infection. (2) The indistinct nature of the disease itself which never assumes any particularly positive character. Conclusion: Whenever, in a child constitutionally sick, there occurs any sudden change accom- panied by fever and catarrhal symptoms, always make a bacteriological examina- tion of the secretion. surg-ERY. UNIDER THE CHARGE OF J. WILLIAM WHITE, M.D., ASSISTED BY G. G. DAVIS, M.D., M.R.C.S., AND ELLWOOD R. KIRBY, M.D. FRACTURE OF HYOID BONE ; ACUTE BULBAR PARALYSIs ; RECOverY. RAMSDEN (Lancet, December 8, 1895) gives the case of a man, aged 50 years, who, while engaged in unloading a wagon, fell a distance of four yards on his head. He was feverish and delirious for the next fourteen days. Speech was unin- telligible, and he could swallow solids and liquids only with difficulty. Saliva dribbled constantly from his mouth. The hyoid bone was found broken in two places, at the junction of the body and greater cornua on each side. Later the right half of the tongue was found to be atrophied and was protruded towards the right. The lips were slightly wasted, and in swallowing the liquid regurgitated into the nose. The treatment adopted was wearing stiff collars and administration of tonics. Eight years later, though speech is impaired, it is intelligible, the drib- biing of Saiiva has ceased, and he can biow and whistie, and, with the exception of occasional pain, the neck is well. The fractures united by fibrous union. The question of diagnosis rested between (I) acute bulbar paralysis, (2) 1njury of hypoglossal nerve at the seat of fracture, (3) hemorrhage into the vagus centre, and (4) 1abio-glosso-laryngeal paralysis. This last is always progressive and fatal. Hemorrhage into the vagus would account for the difficulty of speech and swal- lowing, but would not account for the atrophy, besides, there was no vomiting or other symptoms pointing to the vagus. The difficulty of swallowing and altered speech would not have been so extreme in unilateral lesion of the hypoglossal nerve, though the fracture would complicate matters. The extreme symptoms are in favor of acute bulbar paralysis. There were no epileptiform convulsions, and the arms and legs were not affected, but these symptoms are by no means always present in acute bulbar paralysis. The actual lesion was an embolism or hemor- rhage in the medulla, most probably occurring at the time of the accident. OPERATION FOR CEREBELLAR ABSCESS. DEANESLY (Lancet, December 8, 1894) details a case of cerebellar abscess from middle-ear disease in a boy 16 years of age treated by operation. A semicircular Surgery. 6I 3 flap of ten inches radius was turned down behind the left ear. The pin of a one- inch trephine was placed one and a half inches behind and one-half inch above the centre of the external auditory meatus. The lateral sinus laid at its posterior and 10wer half. The opening was enlarged upward and brain explored with a fine hydrocele trocar in various directions. The bony opening was then enlarged downward and backward and the dura incised well below the lateral sinus. The same trocar was thrust inward and forward for an inch and a quarter but struck nothing; but one slightly larger allowed several drachms of thin, yellow, inodor- ous pus to escape. A drainage-tube was inserted and gauze plug put in. No part of the bone was replaced. The patient recovered. In cases not unduly compli- cated with suppuration of the middle ear the above operation is to be preferred to that of Macewen, who first opens the mastoid antrum and thence proceeds further as the case requires. LAPAROTOMY FOR PERFORATION IN TYPHOID FEVER. PARKIN (British Medical Journal, January 26, 1895) gives the history of a case in which the perforation was promptly diagnosed and operated on only two hours after it had occurred. The patient died three days after the operation. The author states that this added one more to the list of twenty such cases which had been so treated with only one recovery. There is no doubt that perforation in the course of enteric fever is almost invariably fatal, and any recovery from such a complication can only be regarded in the light of an accident unless surgical treatment be adopted. TREATMENT OF OBSTRUCTION OF THE BOWEI, BY ELECTRICITY. ALTHAUS (British Medical Journal, January 26, 1895) gives the details of two cases in which he was enabled to produce passages from obstructed bowels by means of electricity. An insulated sound with free metallic end was introduced into the rectum and a moistened conductor applied to the parietes chiefly in the region of the sigmoid flexure. The primary faradic current was sent through and its force gradually increased until the patient experienced a decided feeling of vibra- tion in the bowel. This was done in one patient at ten o’clock A.M. and the same evening he had a copious movement. In the second case the application was made at half-past five P.M., and a good motion followed at one o'clock A.M. The method employed by Boudet and Laral of injecting some salt-water in the rectum to act as an electrode is also mentioned. The author states that if electric injections were made soon after the appearance of bad symptoms, and laparotomy followed quickly after failure of electricity, the electrician, as well as the surgeon, would have a better chance of saving the patient’s life than now, when they are often called in too late. BILIARY CALCULI. THIRIAR (Gazette Hebdomadaire de Médecime et de Chirurgie, August 12, 1894) gives several cases illustrative of the surgery of the biliary tracts, and con- cludes as follows: Choledochotomy is clearly indicated in those cases of impac- tion of a calculus in the hepatic duct producing chronic icterus and symptoms of cholemia. When there exist, along with the calculous obstruction of the duct, calculi in 614 Surgery. the gall-bladder which necessitates the opening or removal of that organ, then crushing may be resorted to with subsequent catheterization of the bile-duct. Pregnancy is not a contra-indication in such cases of biliary obstruction demand- ing operation. VESIcAI, IMPLANTATION OF A DIVIDED URETER (URETERo-CYSTONEOSTOMY). BAZY (Annales des Maladies des Orgames Genito-Urinaires, July, 1894) gives the details of two cases in which the ureter had been divided in the removal of the uterus for fibroma. The divided ureter in each case discharged its urine into the vagina. The operation is performed as follows: Open the abdomen in the median line and search for the lower end of the upper portion of the divided ureter. This is apt to be distended with urine which should be removed by an aspirator. The bladder should then be incised at the point nearest to the end of the ureter. The ureter is placed in the bladder and fixed by sutures. In the first case it was found so difficult to isolate the end of the ureter, as it was embedded in a cicatricial mass, that further procedures were stopped and the abdomen closed. Two months later, when the patient was in a better condition, another attempt was made, this time successfully. By means of a blunt trocar, introduced through the urethra, the bladder was made to project at the point nearest to the ureter, and a small incision made, into which the end of the ureter was sutured with fine silk. The peritoneum was dissected up and sutured to the peritoneum of the ureter by catgut stitches. A No. 13 Nélaton catheter was con- ducted through the trocar and into the ureter, and another left in the bladder. The two tubes were sutured with silkworm gut to the labium minor. In the second case the author assisted Peyrol to operate, and what was supposed to be the ureter was sutured in the bladder, but it was unsuccessful as the urine continued to come from the vagina. A second operation was successfully performed by the author eight months later. At the first operation it was only a mass of fibrous tissue which, being mistaken for the ureter, had been sutured in the bladder. FERITYPHLITIC ABSCESS NOT DUE TO APPENDICITIS. HoMANs (Boston Medical and Surgical Journal, December 13, 1894) gives the details of a case of abscess in the right iliac region occurring in a child 4 years of age. There was pain to right of and around the umbilicus, also distention of abdomen and tenderness. The pulse was I2O, and temperature Io99 F. A dose of oil produced only a slight movement. On opening the abdomen the healthy bowels were seen, and to the right of the umbilical region was a level surface of grayish color. This was the roof of an abscess, and on it lay the healthy appendix. The abscess was evacuated and recovery ensued, the appendix not being disturbed. Except for the youth of the patient and the fact that the appendix was normal, the case did not differ from others that are called appendicitis when operated on, and in which the appendix does not happen to be seen. * AcTION OF CHLOROFORM ON THE HEART. GUERIN, in a paper read before the French Surgical Congress (Revue de Chirurgie, 1894, p. 915), claimed that death from arrest of the heart's action in chloroform anesthesia could be avoided by allowing the respiration of the vapor by the mouth only. He held that arrest of the heart was not due to the action Surgery. 615 of the drug on the cardiac muscle, but was caused by a reflex influence from the nasal nerves, which produced inhibition of the heart through the pneumogastric. Chloroform was administered to a rabbit through a tracheal tube; the heart was not influenced. The trachea then being cut, chloroform was applied to the nose, and immediately the heart was arrested; as the trachea had been divided no vapor reached the bronchi. He claimed that death from arrest of the heart's action was no longer to be feared, provided the nostrils of the patient were closed by the fingers until anesthesia was accomplished. TEARING OUT OF NERVES AS A CURE OF NEURALGIA. ADENOT, at the French Congress of Surgery (A’evue de Chirurgie, 1894, p. 919), advocated, in neuralgias, section of the nerve as high up as possible, then seizing the peripheral end with a pair of forceps it is to be wound around it until as much is removed as possible. Eight or ten centimetres can thus be taken away. Good results have been obtained by this method of treatment by Mollière, Tripier, and Gangolphe. Chipault also spoke favorably of the method, having had a complete success with it in a case of neuralgia of the forearm which had pre- viously resisted section of the ulnar nerve. RESTORING PERSONS APPARENTLY DEAD FROM CHLOROFORM. LEEDHAM-GREEN (Birmingham Medical Reviezºy, February, 1895) calls attention to the König-Maas system of rapid compression of the precordium as used in Göttingen. The case on which he tried it was a child four months old. The operation of circumcision had nearly been completed when the child became deadly pale, the pupils dilated, and the respiration and the heart’s action ceased. The child was apparently dead. The surface became pale and cold, the eyes shrunken, pupils widely dilated, and there was a collection of froth at the mouth. Rapid compression (about 120 per minute) of the precordium was followed by a faint gasp and ultimate recovery. Seven minutes had elapsed during which neither heart-beat nor respiratory effort could be detected. Sylvester's method which was first used, was totally inadequate. SARCOMA OF ABDOMINAL CAVITY CURED BY TOXINES OF ERYSIPELAS. MYNTER (Medical Record, February 9, 1895) relates the case of a girl, aged 12 years, well developed, extremely pale and short of breath, being unable to lie down, who had a swelling in the left inguinal region. The abdomen enlarged, the urine was passed involuntarily ; temperature IO2°F. ; pulse I3o, small and weak. Laparotomy being performed, revealed about two quarts of a thick, odorless, chocolate-colored fluid, and there was also an inoperable growth involving both the parietal peritoneum, the mesentery, pelvic organs, and cecum. A piece as large as a fist was removed. Gauze tamponning was employed. Then followed a profuse discharge of the same kind of fluid as already described. On the fourth day and each day thereafter there was injected in the upper end of the femur one grain of filtered toxines of erysipelas, obtained from Dr. Roswell Park. During the next week, while the discharge still kept up, masses of necrotic tissue of the size of large oysters were cast off. The discharge became gradually less and more purulent in character, and the tumor appeared to be receding and the abdomen getting smaller. The patient was discharged about two and a half 6 I 6 Surgery. months after the operation with a small sinus. Microscopic examination of some of the large pieces showed masses of round and elongated cells with some pig- ment. In portions of the growth no cellular elements were visible, the specimen having a coarse fibrous appearance. Blood-vessels through the tumor were quite numerous. Neurotic changes were observed in some parts, and Dr. Thornberry, who examined the growth, regarded it as sarcomatous. INJURIES OF THE SEMILUNAR CARTILAGES OF THE KNEE. PAUZAT (Revue de Chirurgie, February, 1895, p. 97) gives the results of his investigations on the anatomy, physiology, and pathology of the semilunar cartilages. Rupture of the cartilages is diagnosed by, - (I) The subcutaneous ecchymosis. (2) Pain elicited by pressure on the cartilage. (3) The appearance of an enlargement of the meniscal prominences appreci- able by touch and sometimes by sight. The treatment recommended is compression with cotton and immobilization. Luxation of the cartilages outward is the most frequent injury, and is usually the only one recognized clinically. A projection of the cartilage appreciable in certain positions of the leg is the most important and constant symptom. It is not allowable to diagnose a luxation in a case in which pain is felt on rising from a crouched position. This is due in most cases to partial tears of the cartilages or menisco-patellar folds. Luxations inward, behind, and in front are not known clinically. In them the prominences of the cartilage disappear. In treating these luxations, extensive movements of the limb, flexion, extension, and rotation tend to replace the cartilage. Subsequently rest is to be advised, the part is to be bandaged in cotton, and the joint immobilized in an extended position. This treatment should be pursued for several months. If this fails, it is perfectly proper to open the joint and suture the anterior part of the meniscus to the retracted menisco-patellar fold (operation of Annandale), or excise the displaced cartilage. - DISPERSIBLE TUMoRS OF THE BREAST. SNow (American Journal of the Medical Sciences, March, 1865) describes mammary tumors occurring in females between the ages of I4 and 25 years. He names them the ‘‘fibroma of adolescence,” and treats them as follows: Moderate the injunctions of fashion in the matter of stays; tranquillize the nervous system ; abolish tea; and order some absorbent ointment with frequent local friction. The lump will disappear in a few weeks, seldom more than six. He uses pulv. plumbi iodidi, 3 i ; lanoline, 3 vi; adipis ad, 3 i ; to be well rubbed in four times daily. Sometimes he uses green mercuric iodide, twenty grains to the ounce, employed night and morning; also two drachms of the British red iodide ointment in place of the same quantity of ung. plumbi iodidi. Fifteen grains of bromide are usually given at bedtime. Treating in this manner he has not found it necessary to subject any such case to operation since 1889. Therapeutics. 617 THE FA PELITICS. UN DER THE CHARGE OF HORATIO C. WOOD, M.D., LL.D., AND ARTHUR A. STEVENS, M.D. PRACTICAL POINTS IN THE TREATMENT OF DIPHTHERIA witH ANTITOXIN. INDICATIONS AND CONTRAINDICATIONS. FischER (Medical Adecord, April 6, 1895) states that of 225 cases of diphtheria, in which he has employed the antitoxin treatment, thirty-five have died. Twenty- two cases were under 5 years of age ; sixteen of the latter were under 3 years. His mortality has, therefore, been equivalent to 15% per cent., although his per- centage of cures in the first thirty-four cases was only 51% per cent. This high death-rate he attributes to the fact that the antitoxin was used in a great many cases which were regarded as hopeless. The contraindications for the usage of antitoxin, according to the author, are: (1) Cases of mixed infection ; cases of a scarlet fever complicating diphtheria; cases of measles complicating diphtheria; cases of chicken-pox complicating diphtheria, and so on. (2) Cases that are moribund. (3) Cases that appear to be true septicemia, where we have rather a result of the diphtheria than a real diph- theria to contend with. (4) Cases which show a distinct evidence of casts and large quantities of albumen should not be injected with antitoxin. In the application of the remedy the following suggestions are offered: (1) To apply the remedy as soon or as early in the disease as possible. (2) To inject a sufficient quantity. (3) To remember that the remedy is absolutely harmless. (4) That it can be used for prophylactic purposes by injecting the one-tenth part necessary for healing an acute case of diphtheria. (5) That the use of antitoxin does not render local antisepsis, the use of stimulants, and careful hygienic regu- lations unnecessary. The technique of the injection consists: (1) A careful sterilization of the skin at the seat of injection,-the interscapular space or the pectoralis region. Steriliza- tion consists in washing the skin with soap and warm water, then sponging with a IOOO to 2000 sublimate solution. (2) The hands of the physician must be care- fully cleaned and rendered aseptic. (3) The syringe should be completely steril- ized by boiling fifteen minutes in a soda solution. The needle should be dipped in alcohol, followed by a 2-per-cent. solution of carbolic acid. (4) It is necessary to inject slowly; at the same time to have the proper quantity of serum drawn into the barrel of the syringe, so that no time is lost. The needle should be pushed into the deep cellular tissue, at least two inches in a semi-horizontal position. (5) Massage of the fluid injected should not be practised. Finally, it is well to apply a very small pledget of absorbent cotton over the injected space. The injected spot can also be sealed by dropping collodion over it. The absorption of the antitoxin takes usually from one-half to one hour. If given with the above precautions, the writer believes it to be a safe remedy, capable of curing every case of diphtheria which is treated early. TREATMENT OF URIC AcID GRAVEL. VAUGHAN HARLEY (British Medical Journal, March 23, 1895) concludes an article on the pathology and treatment of uric acid gravel with the following directions as to treatment: 6I 8 Therapeutics. The treatment of uric acid gravel takes two directions, according as we desire to increase the solubility or decrease the amount of uric acid formed. It is well to remember that in the majority of cases uric acid deposits are due to an increased tendency to precipitation, and not to excessive formation of uric acid. In cases due to an increased tendency to precipitation, we have to give drugs which help to hold uric acid in solution. Piperazine is of great service, particularly in all cases in which gravel has been due to diminished Šolvents and not excessive formation of uric acid. It has no action on the quantity of uric acid formed, but merely on its solubility. On this account it is best given in combination with alkalies. The diet in these cases is not of so much importance except in favor of Salines and vegetables. In cases, again, when the uric acid deposit is due to excessive formation, a car- bohydrate diet is most useful. The old idea that sugar causes an increase of uric acid has no foundation. Alcohol, on the other hand, should be prohibited, as it causes an increase in the uric acid voided. Quinine and arsenic decrease the quantity of uric acid because they diminish the quantity of leucocytes, and there- fore, in cases where gravel is due to an excessive formation of uric acid, they are most valuable. While moderate muscular exercise is of service, excessive exercise is harmful. In cases of excessive formation, although alkalies are of some assist- ance, they, like piperazine, are only of secondary importance by increasing the solubility of uric acid formed. THE TREATMENT OF NERVOUS DISTURBANCES OF THE HEART RESULTING FROM INFLUENZA. SANSOM (Practitioner, April, 1895) furnishes a practical article on the above subject. He advises as a routine practice the use of sulphocarbolate of sodium in doses of twenty to thirty grains, every two, three, or four hours, according to the severity of the case. The diet should be almost entirely liquid. Alcoholic stimu- lants should be administered with caution. Champagne diluted with Apollinaris, or brandy in dessertspoonfuls every three or four hours with milk and soda-water. When the temperature rises above Iogº F., quinine is the best antipyretic. Phen- acetin or antipyrin gives comfort, but their action must be watched as they some- times increase the already profuse perspirations. Pains are best controlled by phenacetin or antipyrin, unless profuse perspiration or signs of nervous prostration are contraindications. In profound adynamia the writer knows of no more efficient remedy than musk in five-grain doses. The hypodermic injećtion of brandy, ether, or strychnine may be called for. During convalescence, for several weeks, the sulphocarbolate of sodium with Fowler's solution is to be given three times a day after meals, and the 11aso- pharynx repeatedly sprayed with an antiseptic solution like the following: Cam- phor and menthol, of each twenty grains; pure carbolic acid, one-half drachm; parolein, four ounces. The signs and symptoms referred to the heart resulting: from influenza in the author's cases were thus distributed : In IOO cases: pain referred to the heart, 23 cases; tachycardia, 37 cases; irregular heart, 25 cases; bradycardia, 5 cases; organic disease of the heart, Io cases. For heart-pain after influenza, complete rest, morphine hypodermically (one- fourth to one-third grain) with diffusible stimulants are the remedial measures recommended. Once the severity is mitigated, five grains of quinine dissolved in hydrobromic acid is preferable to morphia. Therapeutics. 6 I 9 For more continuous treatment of the early painful phase, sodium bromide (twenty grains) with Fowler's solution (three minims) three times a day after food is recommended. In some cases sodium iodide (five grains) is added with benefit. When pain is persistent, local treatment is useful. Mustard poultices sprinkled with tinctures of opium, belladonna, and aconite give relief in some cases. In others a fomentation of lint soaked in a hot solution of sodium salicylate is very efficacious; or an ointment, containing 20 per cent. of salicylic acid and Io per cent. of menthol in a fatty basis of lanolin and lard, may be rubbed in over the painful area. In more chronic cases small blisters prove efficient. In tachycardia, or palpitation following influenza, the writer considers digitalis and analogous cardiac tonics not only useless but dangerous. The mixture of sodium bromide with small doses of arsenic, as suggested for the treatment of the cardiac pain, is perhaps most generally useful. For the insomnia, chloralamide (twenty to twenty-five grains) at bedtime is regarded as the most useful and 1east harmful hypnotic. Opium, the author thinks, should be avoided or reserved for emergencies. For continuous tachycardia, a galvanic current from a Schall’s four- or six- celled battery is recommended, the anode held over the nape of the neck and the cathode gently pressed into the groove of the neck outside the larynx. Abnormal retardation of the pulse-rate may be relieved by phenacetin and camphor, with 1ocal warmth and counter-irritation of the epigastrium and abdomen. Permanent bradycardia is serious. Tincture of belladonna (ten minims thrice daily), massage, and graduated muscular exercise are useful ; but it must be realized that the condition of very slow heart is one of peril. SHEEP’S THY ROID IN GRAVES’S DISEASE. VOISIN (Semaine Médicale, October 24, 1894) reports the case of a woman, aged 32 years, afflicted with exophthalmic goitre, to whom was given six to eight grammes of sheep's thyroid daily before meals. Marked improvement followed the treatment. The patient continued to take small amounts of the gland daily, omitting its use, however, for ten days every three weeks. Finally all symptoms disappeared except a slight swelling of the neck and slight exophthalmos. Dreyfus, Brisac, and Beclerc declared that in their hands the remedy had aggravated the symptoms of the disease. HYPODERMIC USE OF ARSENIC IN LEUKEMIA. RUMMO (Riforma medica, No. 98, 1894) strongly recommends arsenic in leukemia and pseudo-leukemia. Fowler’s solution is painful. The author uses a solution of arsenite of soda (two grains to the ounce), and begins with a dose of one-twenty-seventh of a grain. The dose is gradually increased through fifty injections until nearly half a grain is reached. During the treatment great care is necessary to detect toxic manifestations. According to the writer, it is necessary to push the drug until signs of intolerance begin to appear. He thinks that, given in this way, it is by far the most satisfactory of all the remedies recommended for 1eukemia. CAFFEINE IN DISEASES OF THE RESPIRATORY ORGANS. SKERRITT (Practitioner, April, 1895) calls attention to the value of caffeine in bronchial asthma, and in bronchitis associated with spasm of the bronchial tubes. 62O Obstetrics. # When a paroxysm of asthma is present he prescribes five grains of the citrate of caffeine every four hours until relief follows. When the attacks come on regularly in the early morning, a dose of five or ten grains at bedtime often serves to avert them. No ill effects have followed the treatment, even when continued for years. The drug sometimes causes slight wakefulness, but, as a rule, patients go to sleep without difficulty after the nightly dose of five or ten grains. O ESTETRICS. LIN DER the CHARGE OF BARTON COOKE HIRST, M.D., ASSISTED BY RICHARD C. NORRIS, M.D., AND FRANK W. TALLEY, M.D. HEMATOMA OF THE VULVA. INCIDENT TO PARTURITION. GLASGow, of Lexington, Va. (Virginia Medical Monthly; February, 1895), reports the following case of pudendal hematocele: He was called, December I, I894, to attend a 32-year-old II-para in confinement. The labor progressed nor- mally, head presenting in 1. o. a., and when the os was fully dilated was terminated by four or five hard, expulsive pains. There was a slight laceration on the inner surface of the left labium majus, which did not require suture. Five hours after he was called to see the patient and found her with a weak and rapid pulse and suffering acute pain, similar in character to labor pains. There was considerable hemorrhage, and in the left and anterior vulvo-vaginal regions a large hematoma had formed, which extended well up into the submucous areolar tissue on the an- terior and left sides of the vagina and also the subcutaneous areolar tissue of the 1eft labium majus, forming a tumor as large as a cocoa-nut. The hemorrhage was controlled with cold compresses and morphia and stimulants administered. On the next day the clot had formed, and cloths wet with hot bichloride-of- mercury solution were kept constantly applied to the tumor to favor absorption. On the eighth day there were signs of the clot breaking down and the discharges began to have a foul odor. The patient had a chill followed by fever and sweating. Glasgow then opened the cavity, turned out the clot and packed the opening with iodoform gauze. The after-treatment consisted in supporting internal medication and daily irrigation. She made a good recovery. SPONTANEOUS REPOSITION OF THE UTERUS. Vogt (Norsk Magazin for Lågevidenskaben, p. 647, 1894) reported a case which he had observed of spontaneous involution of the uterus after acute inver- sion. It was that of a primipara, 42 years old, who had been delivered by the aid of forceps and the placenta had been expelled. Compression of the uterus and vaginal arch was performed to arrest hemorrhage, when the hand, introduced into the vagina, felt the uterus move and the fundus descend. The other hand applied to the abdomen could feel no trace of the uterus. Hot water was immediately injected, when the uterus ascended, resuming its normal position. Obstetrics. 62 I SEQUELAE OF SYMPHYSEoroMy. TIssrER (Archives de Tocologie et de Gymécologie, February, 1895) exhibited recently at a French society a woman upon whom he had performed symphyse- otomy six weeks previously. She was a multipara and rachitic. The conjugate was about three inches. Her previous labors had been severe. Labor was induced by Tarnier's bags and the forceps applied three times without result. Symphyse- otomy was then performed. The hemorrhage was free. When the pubic bones parted a prolapse of the pelvic organs was distinctly observed. Delivery was ac- complished with ease. There was troublesome tympanites about the third day. By the seventeenth day the symphysis was not consolidated and the pubic bones still slid on each other a little, consequently the patient could not walk long with- out feeling fatigued. A thrombus developed around the levator ani on each side during the puerperium, but both became absorbed. The child died when a few weeks old. The question as to the cause of the tympanites was raised at the society. Tissier believed it to be due to the prolapse of the uterus, which inter- cepted the free descent of the flatus. Fournel believed it to be due to temporary intestinal paralysis, as is frequent after abdominal section. PREMATURE BIRTHS. M. VILLEMIN (Universal Medical Journal, March, 1895) reported before the Société Obstetricale et Gynécologique the case of a 2-year-old child, born in the sixth month of pregnancy. That the child had not had six months of intra- uterine life he could vouch, the statement being borne out by the last menstrual period of the mother, the date of the first fetal movements, the child’s weight, which was thirty and a half ounces, and its appearance. BUDIN had had this infant under observation from the beginning and corrob- orated Villemin’s statements. He had examined infants of six or seven months that had cried and lived a few days and had found the alveolar cavities filled with epithelial cells, the lung sinking when placed in a vessel of water. CHARPENTIER reported a case of premature birth in his practice, the child being not more than 6% months and weighing thirty-three and one-third ounces. So sure was he that it would not live that he placed it in a basin while he was at- tending to the mother. After the mother was attended to, the child being still alive, he wrapped it in cotton, and was surprised next day to find it alive. It was then placed in a small well-heated room and fed with a spoon on human milk; on the twelfth day it could take the breast, and since it has thrived and grown. GONORREIEAL FEVER DURING THE PUERPERIUM IN A WOMAN WHO HAD NOT UNDERGONE VAGINAL, EXAMINATION. LEOPOLD (Centralblatt für Gynākologie, No. 29, 1893) reports the case of a woman aged 18 years, who gave birth to a child at term, after labor of seven hours and forty minutes. The perineum was not lacerated. No examination was made before labor. Two days after delivery the lochia became fetid. The vagina was irrigated with a I : 4ooo sublimate solution. The temperature rose to IOI.5° F. Three days later there was slight headache and the vagina was found to be covered with a greyish deposit. The cervix had been torn on the right side and showed a greenish-gray lining. The fever subsided after intra-uterine irrigation with I : 40 phenol solution. A bacteriological examination of the cervical deposit showed masses of diplococci and in several places typical gonococci. Leopold draws the following conclusions: 622. - Obstetrics. (I) A woman may have fever after labor, though no internal examination has been made. (2) The cause of such fever may be the presence of the gonococcus on and within the cervix. - (3) Simple vaginal irritation may not be sufficient in order to reach the infected locality. (4) A woman who had no suspicious vaginal dischage, either before or after labor, nevertheless showed undoubted signs on the fourth day of the puerperium of gonorrheal infection. (5) In such a case the fever cannot be legitimately regarded as due to auto- infection. (6) When a woman is normally delivered, without having undergone vaginal examination, and develops fever on the third day after, there is ground for sus- pecting gonorrheal endometritis, and no blame can attach in such a case to any of the attendants who assisted at the confinement. DIABETES IN LABOR AND PREGNANCY. LUDw1G (Centralblatt für Gymäkologie, No. 11, 1895) observed a severe case of diabetes in pregnancy. The patient was a 42-year-old IX-para. She was admitted to the hospital December 14, 1894, in an almost dying condition. She had suffered from marked diabetes for two and a half years. Her pregnancy began in April, 1894. She was troubled with pruritus vulvae, but this symptom grew better. A few days before her admission to the hospital the size of her abdomen suddenly increased and she became very ill. The urine contained 3.8 per cent. sugar. On admission the patient looked very ill and was hardly con- scious. The urine was of a specific gravity of IoI8, but the percentage of the sugar was 2.3, and acetone and aceto-acetic acid were present in considerable quantity. The membranes were ruptured and nearly nine pints of liquor amnii came away. Ten hours later a male fetus, in a high state of maceration, was delivered sponta- neously. For two days the patient was very ill, vomiting all food. Enemata of salt solution, with peptone and wine were given. On December 16 she had an appetite, and on the 24th she left in good condition. There was practically no milk, nor could any pure blood be obtained by any justifiable means. The per- centage of sugar in the patient’s urine rose on December 17 to 2.5 per cent., falling to o.8 per cent. in twenty-four hours. The day before discharge it was o. I per cent, and the specific gravity Ioog. No aceto-acetic acid, and but a trace of acetone remained. The liquor amnii contained o.3 per cent of sugar. It is not certain if the hydramnios was due to transfusion of the diabetic mother's blood or urine passed by a diabetic fetus. The latter seemed improbable, for the fetus must have been dead for some time and the hydramnios had appeared only a few days before labor. * A ContRIBUTION TO THE SUBJECT OF GONORRHEAL AFFECTIONS OF THE MOUTH IN INFANTS. DR. H. LEVIDEN, of Boston (Centralblatt für Gyndiéologie, February, 1894), reports the following case: An unmarried woman, aged 20 years, was confined January 17, 1894. She had profuse leucorrhea, which she said had appeared during the last months of her pregnancy. Immediately after the birth of the head the child's eyes were washed with 1:7000 corrosive sublimate solution. On the seventh day marked swelling of the right eye appeared with free, yellowish, clear Obstetrics. 623 discharge. The left eye was unaffected. On the following evening a small yellowish pustule about the size of a pea was found on the inner surface of the upper lip. There were numerous gonococci found in the discharge from the eye and the pus- tule in the mouth. The swollen upper lip prevented the infant from nursing freely. The mouth was treated by frequent moppings with corrosive sublimate solution I : 7000, and in nine days after its appearance all traces of the pustule had disappeared except a little grayish epithelial desquamation. The eye proved more obstinate. Leyden considers the inoculation during birth improbable. He advances the theory that the infective lochia were transferred on the mother's fingers to the infant’s hand, and points out how easy would become the inoculation by the actions of sucking the fingers and rubbing the eye, observed so frequently in new- born infants. TOXEMIA AND INFECTIONS IN PREGNANCY. DoRIA (Il Policlinico, March 1, 1895) holds that in the uterus of a gravid woman, between the walls of the uterus and the membrane of the ovum, a morbid process is set up with the productions of lesions upon or in which bacteria belong- ing to the saprophytic group may develop. These bacteria are usually considered non-pathogenic. Along with this local process a form of toxemia is slowly devel- oped, characterized by hemorrhages. Then follows localization of the bacteria in numerous hemorrhagic and necrotic foci within the spleen and liver. These micro-organisms are identical with those contained in the uterus, and may give rise during life to gas as readily in one part of the body as another. This gas may make its way into the circulation during life and so give rise to some of the symp- toms of eclampsia. One of the most constant lesions met with in eclampsia is the presence of small hemorrhagic foci in the liver and spleen. These hemorrhages may be due to the micro-organisms contained in them, or it may only be that the organisms have found a suitable nidus in the focus of dead tissue. The bacteria may produce hemorrhage through their toxines. SUGAR IN THE TREATMENT OF UTERINE INERTIA DURING LABOR. M. BossI, of Génes (Revue Illustrée de Polytechnique Médicale, May 30, 1894), practically applied the hypothesis of Drs. Paoletti and Mosso, two Italian physi- cians, that sugar, administered internally, might have stimulating action on uterine muscle as it has on voluntary muscles. Bossi tried it in eleven cases, administer- ing one ounce of sugar in about eight ounces of water. In ten cases the effect was excellent. The echolic action showed itself in from twenty-five to forty minutes, and in most cases lasted till the birth of the child. In other cases a second dose had to be given. The uterine contractions were always quiet, regular, and free from any tendency to tetanus. TypHOID FEVER COMMUNICATED TO THE FETUS. JANISEwsKI (Presse Médicale, March 24, 1894) records the case of a woman, eightmonths pregnant, who was admitted to the hospital with typhoid fever. The diagnosis was confirmed by a bacteriological examination of the stools. Twelve days after her admission she gave birth to a child which lived until it was five days old. At the autopsy no lesions were found except enlargement of the spleen. Cultures, however, from the spleen, intestine, mesenteric glands, kidneys, and lungs produced typical typhoid bacilli. § 624 Gynecology. ” • THE USE OF COCAINE FOR SUPPRESSION OF THE SECRETION OF MILK. DR. JoiSE, of Lille (British Gynecological Journal, November, 1894), has observed that cocaine, when applied to cracked nipples, has the power of diminish- ing the milk secretion. From this fact he was led to make use of this agent when he desired a complete suppression of milk. He uses a 5-per-cent. Solution as follows: - B. Cocain. hydrochlorat. . . . . . . . . . 5.O Aquae destillatae - Glycerini, aſſi . . . . . . . . . . . . 5O.O The solution is applied with a soft brush five or six times daily to the nipples. The suppression follows in two to six days. He has never experienced any incon- venience from the use of this drug on account of the small surface to which it is applied. Cocaine, by producing anesthesia of the nipple, prevents its erection, thus favoring, according to Joise, the decrease in the quantity of the milk. GYN ECOLOGY. UNDER THE CHARGE of CHARLES BINGHAM PENROSE, M.D., ASSISTED BY WILLIAM A. CAREY, M.D., AND H. D. BEYEA, M.D. A CASE OF OBLITERATION OF THE UTERINE CAVITY AFTER CURETTING. FRITsch (Centralblatt für Gynākologie, No. 52, 1894) reports the following case: Mrs. X., 25 years of age, after a perfectly normal labor on January 31, 1892, followed by a feverless puerperium, began to have continual hemorrhage, small in amount, from the uterus. A specialist was consulted and curettement advised. This operation was performed on February 24, 1892. The husband of the patient was present at the operation, and said that the curetting was long continued, severe, and that, finally, a portion of flesh, hard in consistency, which could not be crushed between the fingers, was removed. The uterus was tamponned, and after eight days the patient was discharged perfectly well. Since this operation she had not seen her menstrual flow. She consulted the writer because of sterility. She is a woman apparently in perfect health, without the least symptom of hyste- ria or nervousness, and simply complains of “flashes of heat,” symptoms of in- duced menopause. On examination the vagina was found normal, the cervix small and hard, and the os partially obliterated, only a small opening being found towards the left lateral fornix. The uterus was very small (infantile), and the ovaries and tubes normal. After incising the cervix, the cervical canal was found to be four-fifths of an inch in length, but the smallest instrument could not gain an entrance into the uterine cavity. With a knife and uterine dilators the uterine cavity was opened until a sound could be introduced one and two-fifths inches. This sound could easily be felt at the fundus through the abdominal wall. A lam- inaria tent was then introduced and allowed to remain twenty-four hours, when the cavity was packed with iodoform gauze. After fourteen days the cavity was Gynecology. 625 again obliterated. In October, 1894, the same original condition was found. The patient was still in perfect health. Fritsch remarks that severe curetting during the period of fatty degeneration of the uterus, removing all of the endometrium and tearing the muscle tissue, can easily result in complete obliteration of the uterine cavity, but that it is scarcely possible at any other time. THE IMPROVEMENT OF THE RESULTS IN COMPLETE HYSTERECTOMY FOR CARCINOMA OF THE UTERUS. MACKENRoDT (Zeitschrift für Geburtshilfe und Gymäkologie, Bd. xxix) be- lieves that the operation of complete hysterectomy for carcinoma of the uterus does by no means offer absolute results, that the disease returns in more than half of the cases operated upon. One cause of this unquestionably lies, as shown by the investigation of Winter, in the possibility of the inoculation of healthy tissue from the carcinomatous part ; also, and particularly, has the writer concluded from the same investigations that the operation is usually not radical enough. Carcinomatous nodules are very frequently allowed to remain in the broad liga- ments, and a necessary result is, that the disease sooner or later returns. Mack- enrodt has demonstrated this through the careful examination of a large number of extirpated uteri. The operator, he says, has believed that the incisions were made only in healthy tissue, but the microscopical examination of removed organs show the infiltration extending to the line of incision. Thus, in order to improve the results of complete removal of the uterus for carcinoma, he believes that more tissue should be removed from the broad ligaments than is the custom. In accom- plishing this the injury of the ureters must be carefully avoided. This last is attained by separating the bladder not only from the uterus, but also from the anterior surface of the broad ligaments. The bladder with its attached ureters are thus considerably separated from the uterus and the tissue for a distance of an inch on each side of the cervix can easily be excised. The injury of the ureters after this procedure is scarcely to be considered. The separation of the bladder and ureters from the anterior surface of the broad ligaments can be accomplished quite as well in vaginal as in abdominal hysterectomy. Where there is a rigid vagina, large uterus. and advanced carcinoma, Mackenrodt usually does abdominal hysterectomy. THE TREATMENT OF DYSMENORRHEA. SCHw ARZE (Therapeutische Monaţsheſte, May, 1894) writes upon treatment of the forms of dysmemorrhea which are unassociated with inflammatory disease of the uterus at its appendages, those due to anatomical changes and congenital malformation of the uterus. Therefore that associated with pathological ante- flexion, retroflexion in the virgin uterus and the different forms of congenital de- formity of the uterus. This class includes stenosis of the external and internal os and all forms of dysmenorrhea in which no anatomical changes can be demon- strated. He believes the following drugs are of use: the preparation of iron, antipyrin, phenacetin, antifebrin, exalgin, and sodium salicylate. In some cases it may be necessary to administer codeine and opium, the dose being small. In young girls and women of apparent good health the Thure-Brandt’s method of gymnastics of the entire body is frequently followed by marked benefit. It should particularly be applied for a week preceding each menstrual period. In well-devel- oped and apparently healthy virgins, with severe dysmemorrhea, the writer advises ext. viburnum prunifolium Fl., a teaspoonful three times daily, for five to seven 626 Gynecology. days before and during the menstrual period. Usually the Thure-Brandt gymnas- tics and the viburnum prunifolium treatment are combined. Massage of the uterus does good in those cases where there is an undeveloped or infantile uterus. It should not be employed in young girls. The introduction of a sound into the uterus just before the menstrual period, removing the pathological anteflexion and dilating the canal, is often followed by relief of symptoms. Rapid dilatation of the cervical canal a day before the period is the better method. Electricity applied to the uterus does good in many cases. The negative pole, an aluminium sound, is introduced into the uterine cavity, and the positive pole, a large, flat electrode, is placed upon the abdomen. A faradic current of from 50 to 150 milliampères is employed. Finally, should there be no anatomical lesion and the menstrual period so very painful that life is made unhappy, oëphorectomy should be per- formed. ELECTRICITY AS A MEANS OF DIAGNOSIS IN GYNECOLOGY. HoudARF (Centralblatt für Gynākologie, No. 45, 1894) believes that since elec- tricity has been employed to advantage as a method of diagnosis in nervous dis- eases, it can also be a distinct help in the differential diagnosis of the diseases of the female genital organs. The principle of its application is as follows: That in every instance where the uterus is surrounded by healthy adnexa a continuous current of IOO to 150 or 200 milliampères can be applied without symptoms; that in every instance where there is inflammatory disease there is intolerance to this current, and the application is always followed by pain or fever. The fever always indicates the presence of pus. Other conditions, as nausea, vomiting, headache, syncope, nervousness, and diarrhea have been noticed in a few cases, and are of secondary value in diagnosis. They indicate either adnexa disease or hysteria. In those cases where intolerance is dependent upon nervousness, positive results can be gained by using the faradic current. Houdarf, after reporting the results observed by himself and other investigators in thirty cases, concludes: first, that by the use of electricity, the continuous or faradic current, the diagnosis of pelvic inflammatory disease is made much easier; that, as in every other method of clinical examination, it is not infallible. Second, that by means of the faradic current it is not possible to discover inflammatory disease surrounding the uterus, but ovarian and uterine pain of nervous origin can be isolated. Thus it can be determined whether the pain is due to organic disease or nervousness. Third, that the application of the continuous current of medium intensity (fifty-six mil- 1iampères) is followed by no symptoms, or a reaction-pain, or fever. If no reac- tion follows, it is positive that no inflammatory disease of the uterine adnexa or neighboring organs exist. If pain or fever results, 90 times out of IOO, there is present inflammatory disease of the adnexa or in the pelvis. Therefore, where there is intolerance, it is a positive indication for operation ; on the other hand, where there is tolerance, operation is not indicated. Fourth, that with antiseptic precautions electrical examination is without danger. The contraindications for its employment are pregnancy and acute peritonitis. VAGINAL, HySTERECTOMY FOR PROLAPSE OF THE UTERUS. QU£NU (Gazette Médicale de Paris, No. 51, 1893), in reviewing the literature, finds that this operation was first performed for prolapse of the uterus only where sloughing and gangrene had taken place. Later, the indication was where the patient is beyond the menopause and the prolapse complete. Before the meno- Pathology. 627 pause ventro-fixation was advised. Quénu does this operation on women who are between 50 and 55 years of age, where the prolapse is associated with urinary symptoms, difficulty in locomotion, lumbar pain, and digestive symptoms. His results have been very satisfactory. In the operation the ligaments are sutured ...together and to the vagina, so that they act as ligaments to the vagina. In the discussion of the writer's paper (Gazette Médicale de Paris, No. 1, 1894) Ségond advises that hysterectomy should be performed only when the supporting apparatus or disease of the surrounding structures cause the prolapse, as follows: First, when disease of the uterus demands operation,-i.e., when it contains a fibroid tumor; second, where associated with adnexa disease; third, neo- plasms of the adnexa which are causing the prolapse; fourth, where replacement is impossible; fifth, where many operations would be necessary in women over 50 years of age. He employs the clamp method of operation. Richelot formu- lates his opinion as follows: First, that colporrhaphy is very advantageous; second, that vaginal fixation is illusionary; third, that hysterectomy should par- ticularly be performed in women who have passed the menopause. If the prolapse is associated with disease which demands operation, hysterectomy should be the one performed. When there is prolapse alone and the uterus small, colporrhaphy is the best operation, and this associated with amputation of the cervix when the uterus is large. Where prolapse has returned, he advises colporrhaphy and ventro- fixation. Where hysterectomy is done in this last instance, he believes it advisa- ble to do colporrhaphy. Lucas-Championnèire has performed hysterectomy in eight cases where the prolapse has returned after operation. He recommends as- sociating the hysterectomy with colporrhaphy, and that the operations should be performed in separate sittings. Schwartz and Reclus also advise the last. Routier has given up the operation. P A THOLOGY. UNDER THE CHARGE OF JOHN GUITÉRAS, M.D., ASSISTED BY JOSEPH McFARLAND, M.D. A DETAILED REPORT OF SOME EXPERIMENTS IN THE PRODUCTION OF THE DIPHTHERIA ANTITOXIN. A. P. OHLMACHER (Medical Vezws, March 16, 1895), in a rather voluminous report, gives the entire process by which he accomplished the manufacture of the “antitoxin.” The originality in Dr. Ohlmacher’s paper includes the rejection of the special flasks for growing the toxines; abolishing the current of air suggested by Fernbach ; and ceasing to attempt to increase the virulence of the bacillus by artificial culture means. In cultivating the bacillus the flasks are agitated once daily so as to distribute the bacilli which tend to settle at the bottom of the flask. The cultures grow for two to three weeks, are trikresolized, and then filtered. Light was not found to change the toxines. The one horse upon which the observations are based was im- 45 628 Pathology. munized in a very short time. The first injection of O.5 cubic centimetre was given December 20, 1894, the last dose of 250 cubic centimetres February 5, 1895, —forty-seven days in all. Eleven injections were given. The blood was not taken with a trocar, but a careful dissection was made, two inches of the jugular vein exposed, a snip made into it with scissors, and the blood caught as it flowed from the opening made to gape with a dull hook. One per cent. of sodium salicylate is most strongly recommended instead of camphor, phenol, or trikresol as a preservative for the serum. The points upon which emphasis is laid are as follows: (1) The necessity of obtaining a pure culture of a highly virulent diphtheria bacillus. º . (2) The fact that the toxines may be made by simply growing the bouillon cultures . . . in the incubator (in ordinary flasks) for two or three weeks, then adding 94 per cent. of trikresol and filtering. (3) The secret of a highly potent toxine lying in the virulent characters of the organism employed. (4) The fact that the immunizing injections in the horse can be pushed more rapidly than is usually done. (5) The fact that a number of small vesselfuls of blood will yield more serum than a single large vesselful. (6) The advantages of sodium salicylate as a preservative agent (I per cent. is added to the serum) for the diphtheria antitoxin. TETANUs ANTIToxin ; ITS PREPARATION AND PROPERTIES. HEwº, ETT (British Medical Journal, March 2, 1895, p. 464) gives the following method: The cultures are made in “yeast flasks” of about 120 cubic centimetres’ capacity, with a narrow glass tube attached to the neck, for the first inch or so passing horizontally outward, then bent downward at right angles. The neck of the flask is corked with a perforated rubber cork, through which a narrow glass tube passes to the bottom of the flask, projecting two inches above the cork. This projecting portion is loosely plugged with cotton. The flasks are filled with grape- sugar bouillon, sterilized, and inoculated after momentarily withdrawing the rubber cork and tube. The air is expelled from the flask and replaced by hydrogen by connecting the projecting glass tube with a Kipp apparatus. The gas bubbles through the bouillon and escapes from the side tube. After hydrogen has passed through for half an hour, a small capsule containing mercury is applied to the free end of the lateral tube so that its free end just dips beneath the surface of the mercury. The projecting end of the tube which passes through the rubber cork is then sealed off in the blow-pipe flame. The flask is thus filled with hydrogen which cannot escape, nor can air enter on account of the mercurial valve, though if any gas be formed during the growth of the organism it can escape, while the flask can be used again and again. The flask with the mercurial valve in situ is placed in an incubator at 37°C. After the lapse of two days the bouillon becomes turbid, and gradually a small precipitate, consisting chiefly of bacilli and spores, falls to the bottom. A surface film never forms. The culture can be used after it has been grown for three weeks, but preferably for a month. After five weeks' growth the virulence seems to diminish. Such a culture is so toxic that after filtration rāg cubic centimetre is sufficient to kill a guinea-pig weighing 300 to 400 grammes. The cultures are filtered and an antiseptic (o.5 per cent. carbolic acid) is added to prevent subsequent putrefactive changes. Pathology. 629 The filtered culture will keep indefinitely in a cool place. For the immunization of the horse, which is the animal preferred, the toxine is in the beginning mixed with an equal volume of Gram's solution, this being gradually decreased as the toxine is increased in amount. The beginning dose is O.5 cubic centimetre, and is gradually increased to 90 cubic centimetres. Such an increase took from May to December, three injections being given weekly to the horse the writer observed. When the blood was drawn it was found to have an antitoxic power of 1,000,000. The horse is bled from the jugular vein, the blood allowed to coagulate, then the clear serum pipetted off. As this serum may have to be kept indefinitely, it is preferred to dry it in vacuo over sulphuric acid. Heat cannot be employed as it changes the antitoxin. The serum yields 9 to II per cent. of dry antitoxin, which can be finely powdered, and when needed can be diluted with 5 to Io cubic centi- metres of distilled water. The dose is from one to four grammes of the dry substance. A PSAMMO-CARCINOMA OF THE FEMALE BREAST. NEUGEBAUER (Langenbeck’s Archiv, Band XLVIII, 1894) reports an adeno- carcinoma of the breast, in which the epithelium was of the columnar type, but in which and in the secondary axillary tumors derived from it the appearance of concentric masses of carbonate of lime occurred. These masses were without epithelial covering. The only other organ in which such a tumor has been reported is the ovary. THE COMMUNICABILITY OF CARCINOMA. GEISSLER (Langenbeck’s Archiv, Band XLVI, 1893), following the idea of Adamkiwicz that carcinoma was specific in its action upon the nervous system, inoculated twenty-five rabbits with fragments of perfectly fresh tissue. The frag- ments of tissue were introduced under the most thorough antiseptic precautions into the brains of the animals, but never produced any other change than mechan- ical irritation. They remained in situ longer than if introduced into the perito- neal cavity, but no development of the epithelial constituents was ever observed. THE RAPID DIAGNOSIS OF GLANDERS BY THE METHOD OF STRAUS. LEvy and STEINMETz (Berliner klin ische Wochenschriſt, 1895, No. 11) report an interesting case in which Straus's method for detecting glanders was in error. Thé patient suffered from typhoid, and had upon the hand an angry ulcer caused by the bite of a horse. It was thought to be due to glanders, and the Straus test was employed. Some of the pus was scraped off, diluted, and injected into the abdominal cavity of a male guinea-pig. In three days the orchitis began, was typical in its course, and was followed by the death of the animal with general symptoms in eight days. When the pus contained in the suppurative areas of the testicle was examined, not a trace of a glanders bacillus could be found, nothing being discovered, but the staphylococcus pyogenes aureus was present. The writers explain that the seminal vesicles in the animal were very long; that the injection into the abdominal cavity was made as low down as possible; and that the injection may have caused the orchitis by the injection of staphylo- cocci into the seminal vesicle. 63O Book AVožices. CORRESPONDENCE. VAN WERT, Ohio, March 11, 1895. DR. BARTON COOKE HIRST. Dear Sir : Having seen in the last UNIVERSITY MEDICAL MAGA- ZINE a few lines about the heavy weight of new-born children, I will report a case which may be of interest, owing to the large size of the child and the proportion of child's weight to its mother. While practising in Chicago, I was called on March 17, 1891, to assist a midwife in delivering a Swedish woman. She was a V-para, aged 37 years, and weighed usually about 11o pounds. I applied forceps and brought the head well down on the perineum and allowed nature to expel the child. A male child, weighing fourteen pounds (naked), was born without lacerating the perineum. The proportion of the child's weight to that of the mother was 1 to 8. The mother was up and around in the usual length of time. Yours very truly, DR. A. BERTRAM GILLILAND (U. of P. '90). BOOK NOTICES. ASEPTIC SURGICAL TECHNIQUE, witH ESPECIAL REFERENCE TO GYNECOLOGICAI, OPERATIONS. By HUNTER ROBB, M.D., Asso- ciate in Gynecology, Johns Hopkins Hospital, Professor of Gyne- cology, Western Reserve University, Cleveland, Ohio. Phila- delphia : J. B. Lippincott Co., 1894. This is one of the best books which we have recently read. The experience which Dr. Robb has had in the practical application of the subject of this book, the many contributions which he has made in surgical bacteriology and aseptic technique claim for him the attention of all physicians interested in modern surgery. The book is in no way disappointing; one feels after reading it that he has learned facts of practical value, or at least that his previous knowledge of aseptic sur- gical technique gathered from many scattered sources has been sys- tematized and defined, and is, therefore, more valuable for practical use. Enough facts in bacteriology are given to engage the interest and to enable the reader to understand the reasons for the details of the technique which are described. Book Motices. 631 He who is familiar with the contents of this book will be most thoroughly equipped in all the theoretical and practical details of mod- ern aseptic surgery. We consider it most valuable in the hands of the nurse, the student, and the practitioner. A SYNOPSIS OF THE PRACTICE OF MEDICINE. By WILLIAM BLAIR STEwART, A.M., M.D. New York: E. B. Treat, 1894. The extension of the course of study in most medical schools does not seem to have diminished the demand for compends and manuals. The average student makes a distinction between reading and study- ing ; he reads from text-books and studies from compends. He de- rives information from both sources, but from the latter he especially acquires the information that will carry him through the crisis of an examination, and probably as long as the present tests of attainment are in vogue, so long will there be a demand for manuals and compends. If such books are to form a part of the students' armamentarium, it is very important that they should be of high standard ; they must em- phasize principles, they must present the essential facts concisely, and in a logical sequence, and above all, they must be absolutely accurate. Dr. Stewart's compilation is fairly complete, it is very concise, but it is far from 1ogical in its arrangement, and it is scarcely accurate in all of its statements. Thus, we are told that succussion splash is heard in hydrothorax, that the bacillus malaria is the exciting cause of malaria, and that the dicrotic pulse has the same characteristics as the water-hammer pulse. The two statements under the treatment of atonic dyspepsia— “Forbid spices or condiments,” and “No remedy will settle nerves and restore the equilibrium better than capsicum,’’—are scarcely con- sistent. Typhlitis and perityphlitis are allotted two pages, while all that we learn of appendicitis is that the inflammation of the cecum may involve the appendix vermiformis. The prognosis in these cases— “Last one week or more, and usually recover’’—is difficult to recon- cile with our preconceived ideas of perforation and collapse to which the author refers. In the chapter on convulsions the relation between Jacksonian epilepsy and organic brain disease is not intimated, and the student is directed to treat minor and Jacksonian epilepsy on the same general plan as epilepsy major. Most examiners would be loath to accept the description of the Brand method of treating fevers given by the author on page 23. Faults of omission are also quite numerous; no reference is made to the ameba coli in dysentery, to venesection in thermic fever, and to enteroclysis in the summer diarrhea of childhood. Myxedema and lithemia are not even mentioned, and ulcerative endocarditis is dis- missed with a half a dozen lines, while more than a page is wasted on tuberculin. It must, unfortunately, be said of this manual that it presents the subject, in the hackneyed way common to many works of its class, that it contains many inaccuracies and omissions, and that it is difficult to find sufficient justification for its appearance. 632 Book Mofices. BLOOD-SERUM THERAPY AND ANTITOxINs. BY GEORGE E. KRIEGER, M.D., Surgeon to the Chicago Hospital, etc. Chicago : E. H. Colegrove & Co., 1895. # In this little volume the author gives an interesting and accurate idea of the theory and practice of serum therapy with special reference to diphtheria. There is no pretended originality, the style is German, there are occasional inaccuracies, but the little work is useful for the “busy doctor” who desires to obtain without extended research a defi- nite knowledge of the now important subjects comprehended in the title. º TRAVAUx D'ÉLECTROTHERAPIE GYNſ coloGIQUE. By DR. G. Apos- TOLI. Vol. I. Paris: 1894. The use of electricity in gynécologic conditions has been, and still is, subjected to adverse criticism by the gynecologic surgeon, and espe- cially is this so in its application to the removal of fibroid tumors of the uterus. Many regard the effect of electricity in these cases as of doubtful value, and by all surgeons the attempt at removal of uterine fibroids by electricpunctures is considered not only vain but highly- fraught with danger to life. In the minor gynecologic conditions the, use of electricity can at least do no harm, while in those scores of cases which consult the gynecologist for vague pelvic pain with no apprecia- ble lesion its use may do great good. This book is a collection of the more important papers dealing with electricity in its relation to gynecology, translated into the French language, with added foot-notes by Apostoli and his co-editors. Vol- ume I contains papers from the English, Belgian, Danish, Austrian, Polish, Hungarian, and Canadian literature. To those interested in electricity, the French translation of these papers will be of great value. The publication will appear half yearly. TO CONTRIBUTORS AND SUBSCRIBERS. All Communications to this Magazine must be contributed to it exclusively. Reprints will be furnished free to authors of articles published among the original commu- nications, provided the order is distinctly stated upon the manuscript when sent to the Editorial Committee. Type-written copy preferred Contributors desiring extra copies of their articles can obtain them, at reasonable rates, by gºing to the General Manager immediately after the acceptance of the article by the Editorial Staff. Contributions, Letters, Exchanges, Books for review, and all Communications relating to the editorial management, should be sent to the Editorial Committee, 214 South Fifteenth Street. Alterations in the proof will be charged to authors at the rate of sixty cents an hour, the amount expended by journal for such changes. Subscriptions and all business to UNIVERSITY OF PENNSYLVANIA PRESS, 716 Filbert Street, Philadelphia, Pa. UNIVERSITY MEDICAL MAGAZINE. JUNE, 1895. THE OPERATIVE TREATMENT OF FRACTURE OF THE PATELLA. By J. WILLIAM WHITE, M.D., Professor of Clinical Surgery, University of Pennsylvania ; Surgeon to the University and German Hospitals, Philadelphia. THE important questions to be considered in regard to the treat- ment of fracture of the patella are as follows: (1) Are the results obtained by the ordinary methods of treatment satisfactory P (2) If not, what are the causes of failure ? (3) Is there no method less radical than that of opening the joint and wiring the fragments which will be equally effective? As to the results obtained by the use of splints, plaster dressings, etc., every surgeon is familiar with the disability accompanying liga- mentous union in cases of transverse fracture of the patella, and it is safe to say that bony union is one of the rarest occurrences after such an injury. The patient, with a fibrous band of an inch or more in length interposed between the upper and lower segments of his patella, will have a gait which is peculiar and unmistakable. He cannot bring forward the foot without flexing the knee; he cannot go down-stairs without placing both feet on the same step at the same time, on account of his inability to maintain the leg of the injured side with any cer- tainty in the line of the thigh. If he is in the supine position he can- not lift the limb while holding the leg in full extension. . In addition, there is a feeling of uncertainty in standing and walking, frequent and recurrent hydrops articuli, atrophy of the quadriceps femoris, often more or less joint-pain, in many cases the necessity for a brace or knee- cap, and other minor inconveniences. Refracture is not uncommon, 46 633 634 J. William White. and in the very best cases convalescence is tedious and protracted. These conditions are not exaggerated. While Malgaigne states that he has never seen the function of the limb completely restored even when the separation was limited to one-third of an inch, Dennis asserts that, after a careful analysis of a large number of cases treated by the older methods, he has found that a separation of the fragments amount- ing to half an inch is considered a most favorable result. It is evident, without further argument, that, as compared with this condition, a close bony union of the fragments is greatly to be desired. Mr. Henry Morris has, to be sure, called attention to the fact that in cases where the fibrous band is very short and firm there is practically no weakening of the joint, and that in such cases, when refracture occurs, it is the bone and not the ligamentous band that breaks. Even admitting these statements as correct, I am convinced, after an independent investigation of the subject, that such results as Mr. Morris describes are extremely rare, and cannot be confidently expected in more than 5 per cent. of ordinary cases, The alleged causes of failure to procure better results by ordinary methods may be divided into three classes. (a) Lister believed that non-union was usually due to two factors: the separation of the fragments by the contraction of the quadriceps muscle, and the presence of accumulated fluid within the joint. (b) von Bergmann thinks that the atrophy of the quadriceps, due to the pressure of the dressings employed and to disuse, is progressive, and believes that this condition is responsible for a large proportion of the cases in which it is impossible to extend the limb. (c) Macewen believes that the chief cause of non-osseous union is the interposition of fibrous and aponeurotic structures between the fractured surfaces, and that, before such union can be obtained, it is requisite in the first instance to elevate all the tissues which lie over the fractured surfaces and which prevent them from coming into intimate contact. In explanation of this view he details cases in which he has found portions of the soft parts lying between the fragments, either forced there by the vulnerating body in cases of direct injury, or driven in by atmospheric pressure when the fracture is the result of muscular vio- lence. In such cases the fibrous and aponeurotic structures being more elastic than bone, the latter breaks first and then contracts, while the soft parts stretch, give way, and are then forced in between the frag- ments by the pressure of the outside air. Macewen's observations have been corroborated by Hardy, Laylard, and others. Fowler, of New York, reported a case in which he found irregular, shreddy fibres of the soft tissues at the upper edge of the rent intimately adherent to the projecting spiculae of the roughened fractured surface of the upper Operative Treatment of Fracture of the Patella. 635 fragment. Sir Joseph Lister has recently told me that, in his own cases of fractured patella, he had frequently found it necessary to ele- vate such portions of the soft tissues from between the fragments, and he expressed a general acquiescence in the view which attri- butes to them the chief importance in the production of ununited fracture. It is safe to say that the above-named causes include all the chief factors which tend to produce non-union ; but much depends upon the relative importance which is assigned to them. It is self-evident that continued separation of the fragments must prevent union by bone. It is almost equally probable that a large unabsorbed or organized effu- sion of bloody synovia will have the same effect. Atrophy of the quadriceps will, of course, and necessarily, interfere with the further use of the limb, and would serve to increase the disability apparently due to the want of bony union. As to the influence of fragments of soft parts interposed between the bones, while it might seem, on a priori grounds, to be the least potent factor of the three, as absorption and disappearance of soft and living tissues under such circumstances might reasonably be expected, the clinical facts appear to demonstrate that it is the real cause of non-union in most cases. I used to think that if Macewen's explanation were the correct one, and the interposition of the prepatellar fibrous structures were the chief causes of non-union, the only rational method of procuring bony union was by cutting down and elevating these fragments of the soft parts. The other indications could be met by much simpler and safer methods of treatment. The exudation in the joint can be removed by aspiration. The fragments can be brought together and held in posi- tion by bandages, or by Malgaigne's hooks, as in a case I operated on in 1888. Indeed, immediate aspiration of the joint and the aseptic application of Malgaigne's hooks covered by sterilized or aseptic dress- ings, together with the use of a posterior splint and a light, moderately firm bandage, would seem to meet every indication except the one which has been mentioned. The use of the hooks enables us to dis- pense with the excessive pressure by bandages or otherwise required to keep the fragments in apposition. It certainly approximates them more nearly and accurately than does any other method I have ever seen, with the exception of wiring or suturing. It combines all the advantages of the old methods by splints and plaster with a greater degree of accuracy in bringing and holding the fragments together. There should be scarcely more risk of septic infection than in an ordi- narily subcutaneous tenotomy, provided care as to aseptic precautions be taken at the time the hooks are introduced. If Macewen had been mistaken in assigning to the influence of the presence of the prepa- 636 J. William White. tellar structures the majority of cases of non-union, the aseptic use of Malgaigne's hooks would in my judgment be the most rational method of treating transverse fracture of the patella. But in 1891 Mr. Barker, of London, described an operation which I soon after adopted and have since employed in a considerable number of cases. I have not inva- riably succeeded in getting bony union, but have done so in the great majority of the cases, and have never had any extensive separation of the fragments. My average results as to shortening the time of treatment and as to the functional usefulness of the joint later have been far superior to any I had obtained before adopting this method. The patients have never had the least after-trouble, and in no case has there been suppuration, or fever, or even marked pain. It is only fair to say that I know of cases in other hands in which septic arthritis has followed the same operation, and the patients barely escaped with their lives. It must, of course, be admitted that this is among the possibilities, but it ought to be avoidable, and I have thus far found it so. The operation is easy and simple, and can be done in a very few minutes. The lower fragment of the patella is steadied by the finger and thumb, and a narrow-bladed knife thrust into the joint, edge upward, in the middle line of the ligamentum patellae at its attachment to the lower fragment. Through the wound thus made a stout-handled pedicle- needle is thrust into the joint behind the lower fragment, and pushed up behind the upper fragment and through the quadriceps tendon in the middle line as close to the border of the bone as possible, the upper fragment at this time being forced down and steadied. When the point of the needle becomes apparent beneath the skin the latter is drawn upward and an incision made upon the needle, the eye of which is then threaded with sterilized silk and the needle withdrawn, carrying the thread behind the fragments. The needle is next unthreaded and passed through the same skin wound below and out of the upper wound, but this time in front of and close to both fragments. Here it is threaded with the upper end of the suture and withdrawn. The two fragments are then brought together, friction is made to displace clots or other foreign material, and the ligature tied tightly over the lower border of the patella. The two ends of the ligature are cut short and the wound closed. A posterior splint and figure-of-eight bandage are applied. Passive motion may be begun on the tenth day. The patient may get out of bed wearing a light plaster bandage at the end of the third week. Good use of the joint may be expected in from eight to ten weeks or earlier. In estimating the comparative value of the different methods, it is needless to say that the danger to life should exert a predominant influ- Operative Treatment of Fracture of the Patella. 637 ence. This danger is undoubtedly greater by the method of wiring than by any other plan of treatment. And it is this fact which causes careful surgeons to hesitate to-day in recommending its employment. Of the 186 cases included in a table compiled by Dennis a few years ago there were 34 cases of suppuration, 4 amputations, 24 cases in which the result was said to be “poor” (14 of them were said to have resulted in complete anchylosis), and there were eleven cases which terminated fatally. Of the remainder, 35 were marked as ending with a “fair.’’ result, 17 of them having incomplete or partial anchylosis. Lister himself has told us that before he made the incision in the first case of wiring which he ever performed, he remarked to those sitting around him in the amphitheatre that he considered no man justified in performing such an operation unless he could say with a clear con- science that he considered himself morally certain of avoiding the entrance of any septic mischief into the wound. The opposition at this time (November, 1883) was very strong, and such surgeons as Mr. Bryant, Mr. Adams, Mr. Sydney Jones, Mr. Henry Morris, Mr. Edmund Owen, and Mr. Grant placed themselves on record as opposed to the operation, believing that the bulk of sim- ple fractures do well enough without it, Mr. Christopher Heath going so far as to remark that he thought Mr. Lister’s paper would cost many knees and many lives. As recently as August, 1887, we find that Messrs. Barker, Thompson, Stoker, and Robson were equally opposed to the indiscriminate performance of the operation. The strength of the feeling against the operation, only a few years ago, is well shown by the following conclusions reached editorially by the London Lancet, after a full consideration of the subject. They were : (1) That the operation is not suitable as a primary measure. (2) That in view of all its dangers and of the good results obtained by other and perfectly safe methods of treatment, it is not commendable for general employment. (3) It is not justifiable unless with most absolute asepsis. The French Academy of Surgery pronounced against it with almost equal force, and the most recent writers on fractures and dis- locations have freely agreed with Pick, who says that he would not permit the operation to be done upon himself, and therefore cannot recommend it to his patients. Mr. Howard Marsh says, that the prevailing opinion in regard to this operation is that in cases of recent fracture it is uncalled for, while in many cases of old fracture it is impossible to carry it out in a satis- factory manner. He adds that he cannot recommend Malgaigne's 1 “Fracture of the Patella,” Heath's Dictionary of Practical Surgery. 638 J. William White. Hooks, as their use has been followed by diffuse inflammation around the patella, and even by suppuration of the knee-joint, ending in some cases fatally, in others in anchylosis, and because, although they draw the fragments more closely together than any other method except wiring, they do not by any means insure bony union. It is obvious that a few years ago at least some other method than open incision and wiring was needed to satisfy the majority of the profession, who pre- ferred the imperfect results obtained by splints and bandages to the risks of operation. I believe that with proper care the procedure I have here described—Barker's operation—meets the indications, and with a reasonable degree of safety gives far better results. Other methods have been devised to reach the same end. Fowler' has recently reviewed this subject in a paper read before the New York Surgical Society, and proposed an operation which dif- fers in some of its details from the other procedures described. In his preliminary remarks he makes a distinction between the fractures oc- curring as a result of muscular action, in which the fibrous structures in front of the joint are driven by atmospheric pressure between the fragments (as Macewen long ago demonstrated), and fracture occur- ring as a result of direct violence, in which he apparently does not believe that this interposition of the aponeurotic tissues occurs. In the latter cases he does not advise operation, and seems to ex- pect bony union. I do not believe either that the difference between the two conditions is so frequent as to offer a reliable basis for different plans of treatment, or that bony union is likely to follow in the major- ity of such cases. In the former class—fracture from muscular action—he recom- mends a delay of two or three weeks to permit of the subsidence of the effects of the traumatism upon the surrounding structures, as well as the closure of a possible rupture of the upper recess of the capsule, which according to Riedel is frequently opened and permits of infection of the soft parts of the front of the thigh. He then by a U-shaped flap exposes the line of fracture, dissects out the intervening fibrous tissue, fastens the bone with fixation hooks and closes the wound. The hooks are allowed to remain about three weeks. He claims for this method the following advantages. (1) The parts to be operated upon are in better condition, both as regards vital resistance and asepsis than when the primary operation is done. (2) There is the minimal exposure of the joint surfaces and dis- turbance of the fragments. (3) The operation can be done in a remarkably short space of time, hence less risk is taken both as to sepsis and the anesthetic, * Annals of Surgery, June, 1895. Operative Treatment of Fracture of the Patella. 639 (4) No foreign suture material is left in the bone to produce caries, or to demand subsequent reopening of the wound and removal. (5) The hooks may be removed, and if the union is not found to be complete or firm, they may be reapplied. If my experience with Barker's method had been either less ex- tensive or less satisfactory I would be disposed to consider this, but I can see no present reason for doing so. In the discussion which followed the reading of Dr. Fowler's paper, Dr. Stimson, Dr. Bryant, Dr. Abbe, and Dr. Lilienthal expressed in a general way disapproval of operative treatment except in the hands of hospital surgeons of large experience, and the last three a preference for the non-operative methods in most cases. Ceci describes a method consisting of a subcutaneous buried suture which surrounds the patella, and passes through the tendons above and below it close to its margin. He believes that this plan of treatment has the following advantages: The general applicability of the suture, no matter how great the comminution of the patella ; the mechanical union of the fragments, independent of new bone-forma- tion, and affording sufficient and permanent resistance to the disjunc- tive forces; the subcutaneous character of the entire operation, per- mitting of rapid and thorough repair of the superficial and deep soft parts, completed in his cases in from four to eight days; the removal of the splints as early as the end of the first week, after which the joint requires neither immobilization nor compression. The practical advantages of the method he thinks may also be seen when it is studied in its relation to the causes of non-union. If, for example, union does not take place, on account of blood or synovial exudation, puncture of the joint or aspiration is not required, as the exudation will escape through the openings made to admit the suture, and this emptying the joint can be facilitated by the employment of gentle massage. Atrophy of the quadriceps is to a great extent avoided, by the very early period at which passive motion or even active movement can be per- mitted. If union is prevented by the interposition of fibrous bands, the subcutaneous wire suture is sufficiently strong to hold the frag- ments together. In several of his cases, months afterwards, the wires could be felt plainly through the skin and gave rise to no trouble or inconvenience of any sort. The operation appears to bear a close resemblance to that of Volkmann, who employed a silk suture passing out through the quadriceps tendon and through the tendo-patellae; and to that of Kocher, who passed a silk thread above and below the fragments by * Deutsche Zeitschrift für Chirurgie, February, 1888. 64O Charles B. Penrose. means of a transverse or longitudinal incision. König has done a similar operation, employing catgut. Stimson has also employed a particular suture after the manner of Ceci. But all of these methods are, in my opinion, theoretically inferior to that of Barker, which for ease and celerity of performance, and thoroughly satisfactory results, is, I believe, to-day the operation of choice. I present three patients this evening, one operated on eighteen months ago for Dr. Taylor, of Beverly, one eleven months ago for Dr. Gerhard, of Bryn Mawr, and one eleven weeks ago at the University Hospital in the presence of the class. They all have either absolute bony union or such close fibrous union that no motion between the fragments can be demonstrated. There is often much difference of opinion between surgeons as to the presence or absence of very slight degrees of mobility. But, although I think that in each of these cases firm bony union is demonstrable, it is after all a matter of secondary importance. They all have, as you see, the most complete use of the joint. The two oldest have tested it in their daily work in every imaginable way. If the union is fibrous, it has not lengthened the smallest fraction of an inch in all this time, and whether it is or not becomes a question of pathological interest, but scarcely important from the stand-point of practical surgery. LACERATION OF THE CERVIX UTERI." BY CHARLES B. PENROSE, M.D., PH.D., Professor of Gynecology in the University of Pennsylvania; Surgeon to the Gynécéan Hospital. GENTLEMEN: In presenting this paper on laceration of the cervix uteri to you, I do not wish to enter upon an exhaustive discussion of the whole subject of laceration of the cervix, but to consider only practical points, which, after a large experience with this disease, I have found are not generally recognized by the medical profession. Sufficient importance is not attached to laceration of the cervix uteri as a cause of suffering in women. A large number, I think, perhaps the majority, of the women upon whom I operate for laceration of the cervix tell me that they had been previously advised by one or more physicians that there was no uterine disease which required operative treatment. Or, they very frequently tell me that they have been told that there was an ulcer of the neck of the womb, which could be cured by local applications and vaginal douches. For these raw-looking surfaces are still generally called ulcers, notwithstanding the fact that 1 Read before the Clearfield County Medical Society, April 29, 1895. Zaceration of the Cervix Ute, i. 64I Emmet has been teaching the true cause of this so-called ulceration since 1869, and that Ruge and Veit and many others have shown their true pathology; that the apparently raw surface is covered with epithe- lium, and is in no sense an ulceration. Emmet tells us that at least one-half the ailments among those who have borne children are to be attributed to lacerations of the cervix uteri. What are the most important of these ailments 2 The usual form of laceration which we see is a bilateral tear which results in a separation or a rolling out or an eversion of the anterior and posterior lips of the cervix. The cervical mucous membrane is no longer contained within a closed canal where it is protected. It is exposed to friction and pressure against the posterior vaginal wall at all times, but most when the woman is on her feet and the heavy uterus sinks towards the floor of the pelvis. Being a true mucous membrane, the lining of the cervical canal does not become hardened or toughened by such exposure. After the lapse of years it may become converted into cicatricial tissue, but until that time it is a constantly irritated sur- face, just as a prolapsed mucous membrane of the rectum or an ectropion of the conjunctiva. The mucous membrane also proliferates, extending beyond its normal limit at what had been the external os until it may occupy an area one or two inches in diameter, presenting the appearance so erro- neously described as an ulceration. The rolling out of the lips of the cervix obstructs the circulation at the base of the lips in the neighborhood of the internal os; con- tinuous passive congestion results in hypertrophy of the cervical tissues, and the cystic changes we are all familiar with. The large number of racimose glands of the cervix become inflamed ; they pro- liferate, the orifices of the ducts become occluded, so that in extreme cases the whole hypertrophied cervix becomes a mass of cysts, varying in size from a mustard seed to a pea. . So much for the cervix, now for the uterus. Laceration of the cervix takes place in a uterus enlarged by pregnancy, and for this reason lesions occur which would not occur if a simple bilateral incision were made in the cervix of a non-pregnant woman. Subinvolution follows, and the lesions are those incident to subinvolution : endo- metritis, retrodisplacement, and general pelvic congestion. Finally, let me mention as not insignificant results of the con- tinuous irritation from the split in the cervix, from the erosion, and the fissure at the angle, involvement of the pelvic lymphatics, the pelvic lymphangitis and lymphadenitis. None of us will underrate the suffering, the disability accompanying this condition when we recall the lameness accompanying an inguinal lymphadenitis, due to 642 Charles B. Penrose. . such a small cause as a minute sore upon the penis or an irritated corn. Similar lameness is caused by the pelvic pain resulting from a lymph- adenitis excited by a fissure or an irritated surface upon the neck of the 11tert1S. Admitting all these lesions as results of the laceration, what symptoms would we expect to find produced by them P Backache, sideache, headache, leucorrhea, menorrhagia, neuralgia in any part of the body, and reflex nervous symptoms caused by the pelvic focus of irritation, constantly nagging and exhausting nervous energy. We recognize similar reflex disturbances and acknowledge the cause in the case of such an irritating lesion as a fissure of the anus, while some of us are slow to admit that such disturbances may be caused by an irritating lesion of greater physical dimensions in the neck of the uterus. All of the symptoms described, in various degrees and combinations, accompany laceration of the cervix uteri of even small magnitude, and these symptoms are due primarily to the lacera- tion. The proof of this is within the reach of all of us, for the proper repair of the injury in suitably selected cases will relieve the woman of all suffering. This brings me to the consideration of the cases suitable for operative treatment and the methods of operating. There are three kinds of laceration to which I shall call your attention. These are the bilateral, the incomplete, and the combined bilateral and incom- plete. A - - The bilateral laceration of the cervix uteri can only be properly recognized by the finger or by inspection after the vagina has been opened by the Sims speculum. The bivalve speculum masks the lesion. If the examiner keeps before his mind the conical or dome shape of the normal cervix, he will usually recognize a laceration by a digital examination. The vaginal finger comes in contact with the broad face of the cervix, the centre of which is occupied by what appears to be the external os, but what really is a part of the cervical canal some distance above the external os., The finger then glided posteriorly over the broad cervix passes around a corner, either rounded or sharp, and enters the posterior vaginal fornix. If passed anteriorly it enters similarly the anterior vaginal fornix. The presence of this corner or edge is indicative of a bilateral laceration. It is never felt as the finger is passed over the normal conical cervix. In some cases of bilateral laceration it exists in a very marked degree, and it can be rolled in by the finger introduced in the posterior vaginal fornix. In other cases it becomes rounded by swelling of the cervix, and the con- dition of two gaping and rolled out lips is not so strongly marked. In these cases, however, the cervix feels flat and broad, and is in no sense conical or dome-like, as in the normal condition. Maceration of the Cervix Uteri. 643 The condition is still more readily recognized if the woman is placed in the Sims position or the knee-chest position, and the cervix is exposed by retracting the perineum with the Sims speculum. If, then, the anterior and posterior lips are caught with tenacula and drawn towards each other, the apparent ulceration or erosion disappears and the normal shape of the cervix is produced. In any case of doubt this test will make plain the character of the lesion. You are all probably familiar with the nature of what has been called incomplete laceration of the cervix ; but I venture to direct your attention to it because its existence is so often overlooked. In incomplete laceration the structures of the cervix are split unilaterally, or bilaterally to, but not through, the mucous membrane of the vaginal aspect of the cervix. The two lips of the cervix are then held together, and gaping is prevented by this membrane alone. The split may extend from the internal to the external os, converting the cervical canal from a cylindrical or slightly spindle-shaped structure into a cavity as broad as the transverse diameter of the cervix. This condi- tion can readily be recognized by passing a sound into the cervix and directing the point towards either side of the cervical canal, when it will be found that it comes directly in contact with the mucous mem- brane of the vaginal aspect of the cervix. This condition of simple incomplete laceration is not very common. I mention it because it is so often overlooked. The combined condition, however, of a complete bilateral split of the lower part of the cervix with an incomplete laceration of the upper part is one which I have found not unusual, though I have never seen it described. In this condition the eversion or rolling out of the lips of the cervix is not very marked, because they are held together above by the intact mucous membrane of the vaginal aspect. There are present an erosion, a patulous os, a profuse leucorrhea, and other symptoms of laceration more marked than one would expect from the visible lesion. The detection of the incomplete part of the laceration is readily made with the sound. In operating for slight bilateral tears of the cervix one will often discover this con- dition of incomplete laceration in the upper portion of the canal if the excision of tissue is carried well up towards the internal os. It will then be found that almost as high as the internal os the anterior and posterior lips of the cervix are only held together by the mucous mem- brane of the vaginal aspect of the cervix. The recognition of this condition and its operative repair are essential to the success of any treatment. Success in treating laceration of the cervix uteri depends upon the following three factors: (1) Proper selection of cases. (2) Preparation for operation. (3) Attention to certain essential operative details. 644 - Charles B. Penrose. The selection of cases is most important. In many cases of lacera- tion of the cervix uteri the operation of trachelorrhaphy is contra- indicated. It not only will not cure the woman, but it may kill her. Failure to recognize the contra-indications has resulted in a great deal of harm, and has done much to bring discredit upon the operative treatment of laceration. The chief contra-indication to operation is the presence of pelvic inflammatory trouble outside of the uterus, the presence of disease of the tubes and ovaries. Emmet recognized this contra-indication before the days of our modern pathology of pelvie diseases, when he advised preparatory treatment with hot douches and vaginal applications until all symptoms of “pelvic cellulitis,” indicated by lateral tenderness and fulness, had disappeared. Marked disease of the Fallopian tubes may in general be considered a contra-indication to the operation of trachelorrhaphy; or at least a contra-indication to the operation of trachelorrhaphy alone, uncombined with salpingo- oöphorectomy. º The presence of a pyosalpinx exposes the woman to a very obvious danger, the danger of an acute attack of pelvic inflammation if the uterus is subjected to the traumatism and manipulation incident to trachelorrhaphy. Most of the deaths after the operation of trachelor- rhaphy are due to this cause, and we should not only never have a death after this operation, but the convalescence should be easy and painless. If a woman suffers with local or general peritonitis after trachelorrhaphy, the condition is due to one of two causes: failure to recognize pre-existing inflammatory disease of the Fallopian tubes, or septic infection introduced at the time of operation. The first, I think, is the usual cause. Very recently one of my medical friends lost a patient a few days after the operation of trachelorrhaphy from perito- nitis caused by rupture of a tubal abscess which he had not recognized. Tubal disease is too often overlooked in these cases. I have often operated for pyosalpinx upon women who had but a short time before been subjected to the operation of trachelorrhaphy. During the past month I have removed the Fallopian tubes for pyosalpinx and for hydrosalpinx in women who had had the cervix uteri repaired during the previous year. It is not sufficient warrant for the operation of trachelorrhaphy merely to introduce a finger in the vagina and to recognize a laceration of the cervix, or to introduce a speculum and to see the gaping os. Such superficial examination may cause fatal results. A most careful bimanual examination is necessary to deter- mine the condition of the tubes and ovaries, and this examination should always be made as a final precaution, when the woman is under ether, immediately before proceeding to the operation of trachelorrhaphy. Another important fact to remember is that when a woman has a Maceration of the Cervix Uteri. 645 lacerated cervix there usually co-exist other lesions, repair of which is also necessary before perfect health can be restored. Failure to recog- nize these other conditions results in disappointment to physician and patient. Trachelorrhaphy alone will not cure the woman if she suffer also with endometritis, retrodisplacement, and loss of muscular support to the pelvic floor. Curetting of the uterus is usually a valuable addi- tion to the operation of trachelorrhaphy, and perineorrhaphy is in most cases also necessary. - You are, of course, familiar with the operation of trachelorrhaphy, for repair of laceration of the cervix uteri, which was invented by Emmet. But there are several very important points essential to the success of this operation which are very often neglected. Chief of these is the previous preparation of the cervix. Women are often sent to the University Hospital suffering with old laceration of the cervix uteri, with the request from the physician that they be operated upon immediately. The cervix is hypertrophied and congested; often full of Nabothian cysts, hard, Sclerotic, presenting a catarrhal patch or erosion, perhaps the size of a silver dollar, surrounding the cervical canal. Such a cervix is in no condition for operation. Most women with old lacerations of the cervix uteri require a certain amount of local treatment before the operation can be successfully performed. Such treatment may require ten days or a month. It consists in the free puncture every five days of the whole cervix to evacuate the cysts and to relieve the congestion. The thorough application of Churchill's tincture of iodine to the whole vaginal vault and the cervix and exposed canal. The use of the glycerin tam- pon to relieve congestion and frequent hot-water douches. The change which takes place in the cervix uteri and in the feelings of the woman after from one to four weeks of this treatment is wonderful. The hy- pertrophied cervix diminishes in size. The cysts disappear, inflam- matory tissue is absorbed, the cervix is softened, and the area of erosion shrinks until it occupies only the true cervical canal. With the improvement in the local condition, the woman's suffering diminishes. The backache, sideache, and leucorrhea improve ; and I have some- times found that women, after such local treatment, refuse operation, because they feel perfectly well without it. Operation is, of course, nowever, necessary, for the old condition will return as soon as the local treatment is stopped. Such local treatment not only makes the operation more certain of curing the woman, but it renders the opera- tion very much easier of performance. There is less bleeding; the tissues are less friable; excision is easier, and the sutures can be passed more easily and with more precision. If, after a few weeks of rest and such local treatment, there is not 646 Charles B. Penrose. a decided improvement in the condition of the cervix, then I think it very doubtful whether the woman will be cured by the operation of trachelorrhaphy. In some cases of long standing the secondary changes in the cer- vix become permanent in character. The cystic degeneration becomes too widespread, the inflammatory induration too well established to yield to any treatment; and then amputation of the cervix becomes necessary. Therefore, in extreme cases, the preparatory treatment to which I have alluded is of advantage in enabling us to determine the best method of operation to pursue. If the condition of the cervix improves, the woman can be cured by trachelorrhaphy; if it does not improve, we shall be obliged to resort to amputation. It should not be forgotten that the mere closure of a tear of the cervix, even though union may be perfect, does not always cure the woman. It will not cure her if the cystic degeneration and the sclerotic condition persist. I have recently amputated the cervix for these conditions in three women in whom bilateral laceration had been closed, well and success- fully so far as the mere surgical result was concerned ; and yet the sclerotic and cystic condition persisted and the woman continued to suffer with all the symptoms presented before the trachelorrhaphy. In regard to the details of the operation of trachelorrhaphy I will allude only to one mistake which is very often made and the occurrence of which destroys any benefit that might be derived from the opera- tion. This concerns the method of introducing the sutures. In a case of bilateral laceration after the tissue upon each side of the lips of the cervix and in the angle of laceration has been excised, we have upon each lip two raw surfaces between which lies the strip of mucous mem- brane which is to line the new cervical canal. A mistake which is often made consists in introducing the needle so that it emerges upon the raw surface, and when this occurs the suture does not include in its embrace the whole of the denuded area, and after union has taken place we have produced the condition which has been described as incom- plete laceration of the cervix,−a cervix closed to all external appear- ances but having a canal, perhaps three or four times as broad as nor- mal, bounded on each side by but little more thickness of tissue than the mucous membrane of the vaginal aspect. The result is persistence of the subinvolution and a cervical catarrh which will yield to no treat- ment except another operation. I have several times this winter oper- ated upon the cervix which had been closed in this way. It has been necessary to treat it as a primary case of incomplete laceration, to split up the line of union, to excise the tissue again, and to introduce the sutures in the proper way, so that they enter upon the vaginal aspect of the cervix, pass around the whole of the denuded area, and emerge Laceration of the Cervix Uteri. 647 in the edge of the mucous membrane which has been left for the cervical canal. Before concluding this paper, I wish to speak of a condition which is of great interest from a pathological point of view and which might be of considerable medico-legal importance. This is a condition of congenital lateral split of the cervix uteri. The appearance was de- scribed by Fischel in 1880, and in his paper he gives a photographic illustration of the cervix of a new-born infant presenting this condi- tion. He says, “I am now able to show a photographic representation of the cervix of a new-born infant which presents an inferior degree of this condition. The separation of the lips does not extend all the way to the vaginal junction, but concerns only the lower two-fifths of the lateral corners, nevertheless, the two lips deprived of their com- missures gape open, the crest of one being nine millimetres from that of the other, exposing the cervical surface of both lips for a distance of five to six millimetres.” “This case shows that a peripheral notch- ing of the cervix is not always a sign of a previous labor, but may represent a condition of the cervix in pregnant women whom we were forced to consider primiparae not only through their own statements, but also from the condition of the external genitalia.” “This case is of great medico-legal importance, in that the proof of a former labor can no longer be claimed for such a condition of the cervix.” I have recently seen two women in whom I have found a condition which I think must be due to a congenital splitting of the cervix. One was a married woman, about 30 years of age, who had never con- ceived. In her there was a state of things resembling perfectly a bad bilateral tear of the cervix with marked eversion of the lips, and the two lips of the split cervix could be brought together so that the ap- pearance of a normal cervix was produced. The other was a respectable girl of 16 years. There was an un- usually perfect hymen, with an orifice barely large enough to admit the little finger. The hymen was so delicate that it was lacerated by the gentle traction of a very small Sims speculum. The cervix uteri was split on the left side, and, though there was no eversion, the os was surrounded by a catarrhal patch. The appearance was identical with that very often seen in women who have a slight cervical tear after a miscarriage or labor. The girl had never been treated for any uterine disease, and the condition was discovered accidentally during an endoscopic examination of the bladder. Finally, gentlemen, permit me to call your attention to the impor- tance of diagnosticating as early as possible between a bad laceration of the cervix uteri with erosion and beginning cancer of the cervix. Cancer of the cervix in practically all cases occurs in an old laceration. 648 Charles B. Penrose. All statistics show this. Cancer of the cervix is a disease of child- bearing women. One series of statistics shows that the average num- ber of children per woman with cancer of the cervix is five, -an unusu- ally large average productivity. For this reason I think that all, except the slightest lacerations of the cervix uteri, should be closed; so that when the woman reaches the menopause, the age of the greatest liability to cancer, the cervix uteri may not present a spot of least vital resistance favorable for the development of this disease. But this is prophylactic medicine. Contrasted with these cases are those in which cancer has already begun in an old laceration. The cases on the bor- der-line between chronic, deep-seated, non-malignant disease of the cervix the result of laceration, and the earliest stages of malignant disease. It is of the greatest importance that we recognize these cases early. I cannot over-rate the importance of this early diagnosis. Upon it depends the life of the woman. I think that it is no exagger- ation to say that if the disease is recognized early hysterectomy prom- ises cure in the majority of cases. While, if the diagnosis is delayed for a few months, the case becomes hopeless with our present surgical methods. - If the physician has even the slightest suspicion of malignant dis- ease in a case of laceration of the cervix uteri, he is criminal if he idly waits developments. There are two methods by which the early diag- nosis may be made. If with local treatment, as puncture, tincture of iodine, glycerin, and douches, the condition improves and the sus- picious appearance disappears, the disease is not beginning cancer. Or we have even a quicker test by microscopic examination of a portion of excised tissue. The suspected tissue should be hooked up with a tenaculum and a wedge-shaped piece cut out with curved scissors. This is practically painless and can be done without ether. - I have on several occasions during the past winter diagnosticated in this way cancer in the very earliest stages. In one case the attending physician told me that the condition of the cervix had not improved under preparatory local treatment conscientiously carried out for four weeks. To digital examination and unassisted visual examination there was no indication of malignant disease. It looked like an ordi- nary bilateral laceration with erosion. I excised a small portion and the microscope showed malignant disease. I have ventured to dwell upon this point in speaking of laceration of the cervix because most women with cancer of the cervix die of the disease, and their horrible deaths could be avoided by early diagnosis. CEPHALIc TETANUs. Cephalic Tetanus. 649 CEPHALIc TETANUS; GENERAL TETANUs AssociateD witH HEMIFACIAL PARALYSIs; RECOVERY." BY DE FOREST WILLARD, M.D., Surgeon to the Presbyterian Hospital. ASSISTED BY JAMES I. JOHNSTON, M.D., Resident Physician, Presbyterian Hospital. THE coexistence of unilateral facial paralysis with tetanus is a sufficiently peculiar combination to warrant the classification of the cases presenting these two prominent symptoms into a distinctive class, to which has been applied the title of cephalic tetanus, or head tetanus, Kopftetanus, tetanus hydrophobicus, etc. The latter term was employed by Rose from the fact that the spasm of the muscles of deglutition often occasioned such dysphagia as to resemble hydrophobia ; but its use is misleading. In the majority of the cases of recovery the spasm did not extend beyond the muscles of the jaw and pharynx ; but in the case about to be reported the disease became general, and all the muscles of the body were involved, thus making a case of general tetanus. The rarity of cephalic tetanus is illustrated by the fact that this patient is the only reported living case in America, while but two other American cases have been placed upon record, that of Phelps,” which died on the sixteenth day, and Hunt’s case,” which died on the sixth day. In the variety known as cephalic, the tetanus is produced by injury affecting one of the cranial nerves, and is accompanied by hemifacial paralysis. The history of the majority of cases of head tetanus is that of slow onset, and, as in ordinary tetanus, the severity of the disease is determined by the rapidity of onset and of development, the acute cases being speedily fatal, while the chronic ones frequently recover. A ſistory.—Joseph T., 12 years of age, was admitted to the hospital wards November 23, 1894, with the following history: Ten days before admission, while at play, he was struck by a small, dirty stick taken from the ground. A slight wound was inflicted near the inner canthus of the right eye, just breaking the skin. The wound was dressed in the receiving ward of the hospital, and the patient referred to the sur- gical dispensary, where two or three days later the wound was again 1 Read before the College of Physicians of Philadelphia, March 6, 1895. 2 Transactions New York Academy of Medicine, November 12, 1888. 8 Transactions College of Physicians, Philadelphia, 1862, 466. 47 65o De Forest Willard and James I. Johnston. dressed and found in good condition. The patient did not return again for about a week, when it was noticed that he had a peculiar spastic gait, and that he also had paralysis of the facial nerve on the right side, with trismus. While in the dispensary he had a slight attack of spasm of the muscles of the jaw and neck. He stated that he first began to walk unsteadily about three days before, and found he could not whistle nor open his jaw. The symptoms probably commenced about one week after the receipt of the injury. The child was taken into the hospital ward at once, on probably the fourth or fifth day of the disease. On admission, the patient was suffering from peripheral paralysis of the facial nerve on the right side, which was the seat of injury. He had a peculiar jerking gait, and suffered from stiffness of the muscles of the legs, abdomen, back, and neck, with marked trismus. The paralysis involved the fibres supplying the frontal and orbicular mus- cles, as well as those of the cheek. The risus sardonicus was naturally present only on the unaffected side. From the history the patient had had no spasm before that seen in the dispensary. Near the inner canthus of the right eye was a red, edematous area, the seat of the wound, now healed. There were no signs of suppuration of the wound, rendering it impossible to obtain material for making eultures. He complained of no pain in the wound or elsewhere. The pupils were normal and reacted readily both to light and distance, while the right eye could not be closed and was the seat of conjunctivitis. Trismus was by this time so marked that the patient could open his mouth only about one-fourth the normal amount, and with difficulty could protrude his tongue, which was coated and at the edges bore evidences of having been bitten. The muscles about the neck were prominent and rigid, especially the posterior group. The chest was well formed, and the head and lungs were normal. The abdominal muscles and those of the back were hard and prominent; otherwise the abdomen was negative on examination. The scrotum and testicles were normal, the prepuce was adherent, but was easily pushed back, and considerable smegma was removed. The temperature was normal and his general condition was good. The first night in the hospital the patient slept well, but the fol- lowing night he was quite restless and cried out several times in his sleep. Three days after admission, the eighth of the disease, the tris- mus was much more marked, the muscles of the neck and back were stiffer, and a tendency to opisthotonos was first noticed. He then for the first time complained of continuous pain in the back and legs, and he was quite rigid all over except his arms, which could be readily used, although his grip was weak and his thumbs presented a tendency Cephalic Tetanus. 651 to be drawn into the palms of the hands. He resisted the most vigorous efforts to flex the legs on the thighs, but could slowly flex them voluntarily when told to do so. The right leg was the more rigid. On searching for the cause of the facial paralysis, an indistinct history of a “running ear” on the right side was obtained, and a careful examination was made by Dr. C. A. Burnett, aurist. The tympanic membrane was found to be normal, as well as the meatus and the auditory canal, and there were no evidences of mastoid disease. On this date the patient bit his tongue twice, but was seen in no marked Spasm. - The day following the boy was etherized and the cicatrix loosened by a tenotome, as the scar could not be excised without causing subse- quent contraction of the lower lid and eversion. The opisthotonos and trismus increased, and only liquids through a tube could be taken. During deglutition slight spasms of the muscles of the pharynx occurred (hydrophobicus). Pain was complained of principally in the right heel and calf of leg. When the patient was turned on his side, the arching of the back and legs and the retraction of the head were greatly marked and accompanied with flushing of the face. On November 29, the twelfth day of the disease, the temperature was IoI.4° F., pulse 98, and respiration 20. This was the highest temperature during the course of the disease. By December 1 some improvement of the lad’s condition was noticed. He slept better, pulse and temperature were normal, he could swallow much better, and the trismus was not so great. At this time he could flex his leg on the thigh (the right one), but not the left. The right side was the side of the injury. The opisthotonos remained about the same, as far as the head, neck, and body were concerned, but he still complained of pain in the back and legs. There were still occasional spasms of pharyngeal muscles, accompanied by flushing of the face during deglutition, and the patient bit his tongue once or twice. - On December 5 (nineteenth day) the trismus and opisthotonos again increased, pains in the right leg and heel were more marked, and the temperature rose to 99.8° F., pulse IOO, but weaker, and respiration 24. The entire body was now so rigid that when rolled upon his side the position of the limbs presented precisely that of a frozen cadaver. The feet were extended in a straight line with the legs, and none of the joints of the lower extremities could be flexed except by full force of a man’s strength. The bowels were constipated, requiring enemata. On being visited on the morning of this date he was found by the resident uncovered and with the bedclothes in disorder and soiled by feces and urine, possibly the result of an opisthotonos spasm, although heretofore no general convulsion had been seen. The next day he 652 De Forest Willard and James I. Johnston. complained of pains in the head and back, was quite rigid, and had an involuntary discharge of urine. During the night previous he had bitten his tongue and cried out with pain in his right leg, which was relieved by rubbing. He then improved, and by December II his con- dition was the best since admission to the hospital. There was no change in the facial paralysis. At this time a careful examination of his eye-ground was made by Dr. George Strawbridge, and the following report made : “There is anemia of both optic nerves, especially the left. There is no choked disk and no signs of tortuosity of the veins. Both show physiological excavations.” Otherwise the eye-fields were normal, and there was no evidence of intracranial pressure. An examination of the ears was again made at this time, and the tympanic membrane was found to be normal on both sides, and no pus was found in the external auditory canal. The handles of the mallei were plainly seen. The patient now was on the highway to recovery. On December 14 (twenty-eighth day), while the paralysis of the face was still complete, reactions to the different electric currents were tested by Dr. James Hendrie Lloyd, as follows: “To faradism on the right side the response is free to a moderate current, perhaps slightly less than on the left. To galvanism the response is free to a medium current (eight cells). Because of the excitation of the patient reactions of the different poles were not taken.” Dr. Lloyd kindly saw the case daily, and made many helpful suggestions. On the following day the patient attempted to get out of bed in the absence of the nurse, and, falling to the floor, received a wound of considerable size on the scalp, which required suturing. For two nights before the accident he had been very noisy, rebellious, and evidently delirious. At one time he was so boisterous that morphia hypodermically was given, and for some time afterwards he was quite stupid, although only a small dose had been employed. For a short time after the accident the patient was much more rigid, but this soon passed away. On December 19, about one month after admission to the hospital, he was bright, quiet, and rational. There was but slight rigidity, while he could move all his limbs readily and open his mouth easily. He expressed himself as being very hungry, -for a month he could take nothing but fluid food, and would have nothing but milk. At this time he still occasionally voided urine involuntarily. For the next ten days he improved very slowly and was very irritable, seeming much better in the evening than in the morning hours. He was now moved back into the general ward from which he had been isolated. His facial paralysis, which had begun to improve a few days before, was now rapidly disappearing, and there were scarcely any signs of Cephalic Tetanus. 653 trismus, but there was still some hardness of the muscles of the back and abdomen. His pain had almost disappeared, and by January 7, 1895 (fifty-two days), the patient was up out of bed. On January 9 he was able to walk alone, but with a halting, spastic gait. The facial paralysis had now almost disappeared, and both eyes could be readily closed. His gait improved slowly, and at the present time the boy is perfectly well. A’emarks.—The features worthy of note in the above case seem to be, first, that the patient suffered evidently from general traumatic tetanus of a chronic nature, and recovered after an illness of about two months; secondly, there was associated with it a unilateral facial paralysis, which disappeared with recovery from the tetanus; third, the wound was an insignificant one, but involved the filaments of a cranial nerve ; fourth, throughout the course of the disease the patient was not at any time in a markedly asthenic condition nor threatened with asphyxia; fifth, there was a decided improvement of the symptoms for a week after the subcutaneous section of the nerves in the injured area; sixth, the infecting bacillus probably came from the earth and reached the system through the markedly susceptible infection-atrium of the eyelid. The stick may have been soiled by manure also, which is a favorite soil for the growth of the bacillus. - Hulke" reports a case of tetanus with facial paralysis occurring in a man, 27 years of age, in which there was both a wound of the finger and of the nose. He had a right-sided facial paralysis with initiative symptoms of trismus. The patient died about two weeks after the receipt of the wound, of asphyxia, due to spasm of the muscles of respiration. There was here complete absence of tetanic spasms of the trunk and limbs, they being of a clonic character. Nankivel1* also reports a case of acute traumatic tetanus compli- cated with facial paralysis, which proved fatal four days after trismus first appeared, and ten days after a slight attack of facial erysipelas from a wound on the bridge of the nose. In this case, also, the paral- ysis was on the side of the face. There was no opisthotonos, but the patient had several general spasms, and died of asphyxia caused by spasm of the muscles of respiration. The man had attended the out- patient department for his erysipelas, and the day he paid his last visit and was discharged cured being cold and wet, Nankivell offers for an explanation for the facial paralysis the probability of his catching cold and suffering from an inflammation in the aqueductus fallopii, and thus producing the palsy. * London Lancet, July 12, 1882. * London Lancet, July 14, 1883. 654 Pe Forest Willard and James I. Johnston. Huntingdon also reports a case of tetanus with double facial paralysis which recovered. In this case a lad of 14 years fell and re- ceived a small wound on the forehead. Trismus appeared in ten days, and six days later the jaws were firmly locked and there was complete paralysis of both sides of the face. This patient also suffered from fre- quent cramps in the legs and abdomen, while the arms were but slightly involved. One week after the paralysis became complete it began to subside on the left side, and in another week the right side began to improve. He was discharged in six weeks almost well, and when seen six months later was in perfect health. In this case dysphagia was the prominent symptom. As will be noted, in none of these cases was there marked opisthot- onos; they all suffered from dangerous symptoms of asphyxia, while the present case had very marked opisthotonos, but practically had no embarrassment of respiration, suffering only from pharyngeal spasm occasionally during deglutition. Gowers, writing of cephalic tetanus (Kopftetanus), called also hydrophobicus by Rose, says that it results from wounds of the head, chiefly of the fifth nerve. Its chief peculiarity is that the initial tris- mus is associated with paralysis of the face on the same side of the injury. He also states that all parts of the facial nerve are involved, but the cause is not known, as no degeneration of the nerve has been found; hence it has been supposed to be of a reflex character. Cultures were not made in the present case, as the wound was healed at the time of admission to the hospital. Later, and in the absence of pus, it was deemed unwise to open the wound or to attempt any inoculation experiments on the white mouse, as the bacilli are but infrequently found in the blood. Examination of the urine on two occasions gave negative results. The treatment pursued in the case was as follows: The patient was put to bed in a darkened and isolated room, which was kept at a temperature of about 72° F., and guarded from draughts of air, from noises, and from disturbance. The diet throughout con- sisted almost entirely of milk, the patient preferring this to other forms of liquid food, and never tiring of it. As there was a marked tendency to constipation, the bowels were kept open by calome1 with an occa- sional enema or brisk saline. The surgical treatment consisted of sub- cutaneous section of the nerve filaments leading to the cicatrix with a narrow tenotome, which procedure was followed for several days by a subsidence of the symptoms. The medical treatment consisted of the administration of bromides, chloral, and opium, increased from small doses (he was 12 years of age) until he took each twenty-four hours * London Lancet, September 17, 1892. Cephalic Tetanus. 655 seventy-five grains of bromide, thirty grains of chloral, and thirty-six drops of tincture opium deodorata. These doses were maintained steadily for four or five weeks. He was never narcotized, and during the day slept but little. On December 15, when he became so noisy and unmanageable, he was given one-eighth of a grain of morphia hypodermically, which was the only hypodermic given. At no time were we called upon to give an anesthetic for convulsions. When he began to convalesce and was on a fuller diet milk-punches containing two drachms of whiskey were given three times a day. On February 15 the patient was discharged from the wards cured. All signs of facial paralysis were absent and the boy was the picture of health. During the early part of attack an attempt to procure and use the antitoxin for tetanus, as recommended by Tizzoni and Cattani,' was made, which proved futile, as none could be obtained. This was unfortunate for the antitetanin, but possibly not for the boy, as he is now entirely recovered, and the plan of treatment by antitoxins is still in its experimental stage. When dealing with a poison of such intense virulence, however, as that of tetanus any and all means of cure should be employed. At the time I was deeply disappointed at the failure to secure the antitoxin, but the favorable result under the plan of treatment adopted is most satisfactory. Klemm,” as well as Brunner, believes that the injury need not be limited to the distribution of the facial nerves, but that the paralysis, which is toxic, may be due to injury of any of the cranial nerves. Klemm very properly draws a distinction between the cases where the spasm remains limited to the muscles affected by the initial symptoms, as in true cephalic tetanus and in those (as in the case under consider- ation) where the spasm becomes general and in whom the conditions practically become those of ordinary tetanus. It is advisable to dis- tinguish such cases from those not associated with paralysis. It is quite possible that all cases of tetanus commence with these local spasms in the region of the injury; but the local condition, being in the hand or foot, is unobserved, especially in acute cases where more prominent symptoms speedily develop. The facial region being so abundantly supplied with nerve filaments is probably more susceptible to irritation of the tetanus bacillus and is a most favorable infection- atrium. The facial muscle-mechanism is also exceedingly delicate. The presence of this bacillus in the earth must be limited, as a very large proportion of injuries become soiled with earth. The poison of tetanus has two modes of action; first, peripheral, * Medical Press and Circular, London, 1894, Lv1.11, 153; also Berliner klinische Wochenschriſt, 1893, Vol. XXX, pp. II85, 1215, 1245, 1265; 1894, Vol. xxx, pp. 64, 772. * Berliner klinische Wochenschrift, 1893, p. 63. 656 De Forest Willard and James I. Johnston. by direct alteration of the peripheral nerves; second, by reaching the central nervous system through the circulation. It is difficult to decide why the symptoms in grave cases remain distinctly local. But the slow onset would indicate that an inherent germicidal action was at work destroying the invading bacilli in some instances; while in other cases this phagocytosis is overpowered by the virulence of the poison, and the toxin is admitted to the general system. Billroth' states that the character of the symptoms points evidently to a local contagion. - Not every case of injury of the cranial nerves, even when followed by tetanus, is accompanied with facial paralysis. In a case seen some years ago in consultation with Dr. J. A. Ogden, the wound was in the forehead and had nearly healed when symptoms of tetanus developed, but there was no paralysis. I promptly excised the scar, but the patient died in two days. Dr. Ogden, in a recent letter to me, reports two cured cases of tetanus, but in neither case was there associated paralysis. Merlich’ gives a most valuable paper on this subject, and a large number of references to the literature. These, with the references found in the Index Catalogue and the Index Medicus, show that much valuable work has been done upon this subject. Merlich also gives several excellent microscopical drawings of the appearances found in the motor region of the trigeminus. Taf (XIII, I, 2, 3) demonstrates the degeneration and vacuolation incident to this condition. He also agrees that this variety of Hopftet- anus may follow an injury to any of the cranial nerves, but is more frequently found after injury to the orbicular and nasal regions. The influence of the tetanus bacillus in the production of this con- dition seems thoroughly demonstrated, thanks to the work of Nicolaier, in 1884, the first one to show the causative action of the soil in the production of this disease. His experiments, followed by those of Rosenbach, and especially those by Kitasato,” who isolated the pin- shaped bacillus and obtained pure cultures, are most valuable. Guinea- pigs and white mice are the animals especially susceptible to this poi- son. The pinhead and drumstick appearance of the short rod is evidently due to sporulation at the end or ends. The bacillus is markedly anaërobic. A number of alkaloids, tetanin, tetanotoxin, muriate of spasmo- 1 Lehrbuch der allgemeine Chirurgie, S. 507. 2 Archiv. Psychiat., 1892, xxi.II, p. 672. 8 Deutsche medicinische Wochenschrift, 1889, xv, No. 31, p. 635; also Zeitschrift für Hygiene, 1890, Bd. VII. Cephalic Zetanus. - 657 toxin have already been separated, and it is probable that in time the product of the bacillus will be employed for the cure of this disease, as is indicated in the present use of the various antitoxins. The use of tetanus antitoxin has been chiefly advanced by Tizzoni and Cattani." Brunner,” by a series of experiments, determined that injections of cultures of the tetanus bacillus into animals, or of the cultures free from the bacilli, will produce tetanus, the spasm starting after a few hours in the muscles in the region injected. If the injection is made in one side of the face,—e.g., the left, this is first involved, then the right side of the face, then the left forelimb, then the right, and then the rest of the body. Post-mortem examinations of the animals revealed no characteristic microscopic changes in the nervous system or any of the tissues. He gives a number of excellent illustrations of the effects on rabbits and guinea-pigs. Injections of a considerable amount of the poison in the face often determine a paralysis of the muscles in the immediate region ; injection into the blood-current or peritoneal cavity produces general tetanic manifestations, not preceded by local spasm. The bodily temperature of the injected animal sank steadily. Attempts to obtain from the tetanus poison separate alkaloids, as tetanin, tetanotoxin, spasmotoxin, as causes of the different manifestations, were not successful. The symptom-complex is produced by the undivided filtrate of cultures. The tetanus poison circulates in the blood of animals suffering with tetanus; it is also found in the urine and saliva. Injections of the poison into a motor sensory nerve—e.g., sciatic– produce the same effect as a subcutaneous injection, first local, then general spasm. Injection under the dura mater produces, first cephalic, later general tetanus. . The tetanus poison cannot cause muscular spasm by direct action, but must act through the nervous system ; and if a motor nerve to a region is cut, injections of the toxin in this region cannot produce spasm. The centres in the medulla, pons, or cord must also be intact for the production of spasm, but the higher centres are not essential. The poison does not act reflexly, but by a direct action on the central motor apparatus, probably reaching this along the nerve-trunks rather than by the blood or lymph-channels. It can ascend the motor as well as the sensory tract. The cause of facial paralysis has given rise to much discussion. 1 Medical Press and Circular, London, 1894, Vol. Lv1.II, p. 155. Berliner klinische Wochen- schrift, 1893, Vol. XXX, pp. 1185, 1215, 1245, 1265; 1894, Vol. XXX, pp. 64, 72. 2 Exper, u. klin. Studies ufer de Kopftet.; Beitrag für klinische Chirurgie, Bd. Lx, pp. 83 and 269; Berliner klinische Wochenschrift, 1891, vol. xxv.111, p. 881; Deutsche Zeitschrift für Chirurgie, Bd. XXX, S. 574. 658 De Forest Willard and James I. Johnston. In my own case a most careful investigation was made to exclude the possibility of its being merely a coincidence due to independent causes, and the absence of middle-ear disease, intracranial growths, brain abscess, etc., were thoroughly demonstrated. In the present stage of our bacterial knowledge it seems much more rational to refer it to a direct toxic effect of the poison acting upon the filaments of the seventh and fifth nerves rather than to a “cold, rheumatism, etc.” I have succeeded, with the kind assistance of Dr. Alfred Hand, Jr., in collecting 75 cases of cephalic tetanus; 57 males and 13 females are noted. In 45 acute cases (counting those acute ones in which the symptoms have developed within the first week), 39 died and only 4 recovered ; a mortality of 90 per cent. Of 32 chronic cases (where the symptoms arose after the first week), 8 died and 24 recovered ; a mor- tality of 25 per cent. Gowers states that all cases over 25 years of age died ; but my table shows that of acute cases (one week) there were 2 recoveries in 32 cases in persons over that age, and 13 recoveries in 15 persons who were classed as of the chronic variety. Under 25 years, in 12 acute cases there were 2 recoveries, and in 16 chronic cases, 13 recoveries. In the 75 collected cases when the spasm extended to the muscles of the jaw, throat, and neck they have been denominated “local ;” while if opisthotonos and spasm of limb muscles occurred they were denominated as “general.” There were 29 cases of the former condi- tion and 46 of the latter. Of the “local” cases, 14 recovered and 15 died; while of the “general,” 14 recovered and 32 died. In this form of tetanus, as well as in general tetanus, the actual mortality is far higher than statistics will indicate, as in my personal experience I have certainly seen twenty deaths from tetanus to one of recovery, and yet none of the twenty fatal cases are on record. Cephalic Tetanus. 659 Acute Local o Reporter. Reference. § Or Or Result. Z. ** % / % | //#/. | | º Huacos pottery, wine or water bottle, from pre- Columbian grave, Peru. edges after the operation. There is no evidence of fracture. The instrument (which must have been a stone one, as iron came only with the Spaniards) did not entirely pierce the internal table, for there are Some spicula of the internal table left around the lower circumference of the opening. This shows that these people understood the danger of injuring the dura mater, and that they knew that they must not go 688 Albert S. Ashmead. through the entire bone without precaution. The fact that the woman lived for some time after undergoing those woes proves that the sur- gery of the time was not bad. This is the only instance of trephining which has been discovered in the old land of Mexico. It offers to the surgeon a peculiar interest, because the cut is made circular, although not perfectly, as we make it now, and also not square, as it was mostly made in old Peru. (In Peru some are oval, some oblong.) There is another specimen of a cadaver whose foramen magnum shows in the circumference where the second cervical vertebra, the axis, has been at some time dislocated, and the odontoid process has afterwards carved for itself a new opening or gap ; a destruction of part of the bony structure, making a kind of gulf or bay or gap in the rim of the foramen magnum in one place. This gap is three-fourths of an inch in depth and a half inch in width, showing what one might call a false joint-opening for the odontoid. In this same cadaver, one femur represents fracture (diagonal) and repair, good repair, although the bone is about two inches shorter than its mate. Evidently the poor Indian (from synostosis, Professor Putnam thinks him to be 25 years of age) had fallen down a cliff, fractured his thigh, and dislocated his neck. What is most remarkable, he recovered from all these calami- ties, which proves again that, in those old times, they knew a great deal about surgery. II. SYPHILITIC LESION OBSERVED IN A PRE-COLUMBIAN SKULL. IN the Bandelier collection, American Museum of Natural His- tory, New York, there is a skull of a mummy just being classified, from Pachacama, on the Peruvian coast, near Lima. It was found twelve feet underground, and no other part of the skeleton was in a condition to be shipped. It is without doubt, according to Mr. Saville, the director, and Professor Putnam, who examined it with me, pre- Columbian. In this burial-place, nothing modern, nothing post-Colum- bian has ever been found. - In the right supratemporal region of the skull, on the fronto- parietal suture, implicating both bones, there is mark of disease, one and a half inches in diameter. The bone is cancellated, eburnated, with deep corrugations, as if eaten by disease ; the tissue is almost eaten through. But what is most peculiar is that a knife-mark, so fine that it can only be seen clearly with a glass, winds around the dis- eased spot. When held to the light and examined from the inside through the foramen magnum, this part of the skull appears extremely thin, the bone being almost entirely eaten through. No evidence of disease, except by this transmission of light, shows on the internal sur- Memorandum. 689 face of the skull. Evidently an operation had been made on an ulcer. or tumor of the scalp, a piece of scalp had been, perhaps, removed, and the instrument had left its mark on the bone beneath the periosteum ; what followed we may guess ; it was found that the skull itself was affected, and the case was left alone, and the man lived long enough to almost allow time to obliterate the mark of the surgeon’s instrument. To my mind, this is an instance of syphilis in a pre-Columbian skull. The location of this lesion, and the appearance of the diseased bone throughout, are peculiarly syphilitic.' I have seen instances many times in Japan on the living body, and once in a post-mortem examina- tion in a yosbiwara (licensed prostitute). MEMORANDUM. REPORT OF A CASE OF HEMIGLOSSITIS. A YOUNG 1ad of I2 years, of excellent health, and free from any constitutional disease, called to consult me on account of acute inflam- mation of the tongue. It was in June, and he had been in swimming quite often, but had no cold or evidences of pharyngitis. One-half of the tongue was much swollen and tender to touch and painful on move- ment. The other half was quite normal. During the two days fol- lowing the swelling increased until he could hardly swallow. There was no cellulitis of contiguous tissues and no glandular involvement. The pain was very great and the temperature above Io2° F. The constant use of ice during waking hours, and lead-water and laudanum compress during sleep, with laxatives, was the only treat- ment. In three days improvement began, and he rapidly progressed to recovery. Cases of hemiglossitis are very rare. It is a very strange patho- logical condition to see such violent cellulitis and swelling with abrupt line of demarcation following exactly the median line of the tongue. Whether the cause was actual trauma or infection it cannot be said, but there was no evidence of either. THOMAS HUBBARD, M.D. TOLEDO, OHIO. 1 See Exostosis and Caries of Os Frontalis ; Caries and Necrosis of Os Frontalis, and others. Devergie's plates: Clinique de la Maladie syphilitique. Par M. M. Devergie, Paris, 1826. 690 Alumni Notes. ALUMNI NOTES, THE RESIGNATION OF DR. HARRISON ALLEN. AT a meeting of the Trustees of the University, held on May 8, 1895, the resignation of Dr. Harrison Allen as professor of Compar- ative Anatomy and Zoology was accepted. Although the resignation was not altogether a surprise, the news was received with much regret. Dr. Allen was born in Philadelphia in 1841, and graduated from the Medical Department of the University in 1861. From 1862 to 1865 he was assistant surgeon in the army, and was stationed at Washington, ranking as brevet-major in 1865. In 1865 he accepted the chair of Comparative Anatomy and Zoology in the Auxiliary Department of Medicine in the University, which position he held until 1878. In that year he became professor of Physiology in the Medical Department, holding the chair until 1883, when he was compelled to resign on account of the pressure of private work. Upon the death of Dr. Joseph Leidy, in 1891, Dr. Allen voluntarily tendered his services, and offered to furnish original research in anatomy to graduate students. He felt that there was no opportunity for students to acquire a knowl- edge of anatomy, except in connection with medicine, and through his efforts graduate students were given opportunities for deeper research in what Dr. Allen believed to be a branch of science as pure as mathe- matics or astronomy. In 1893 Dr. Allen accepted the directorship of the Wistar Institute of Anatomy, which had just been completed. After holding the position for one year, he found that it was too great an undertaking for a busy physician, and resigned in June, 1894. Dr. Allen was also visiting surgeon to the Philadelphia Hospital from 1874 to 1878, and assistant surgeon to Wills Eye Hospital from 1868 to 1870. He was professor of Anatomy in the Philadelphia Dental Col- lege from 1866 to 1878. Dr. Allen's official connection with the University, lasting as it did thirty years, has been surpassed by but five professors: Alfred Stillé, M.D., LL.D. ; Francis A. Jackson, A.M.; ex-Vice-Provost E. Otis Kendall, LL.D. ; Peter Lesley, LL.D. ; and Richard A. F. Penrose, M.D., LL.D. GIFTS TO THE UNIVERSITY. DURING the month of April gifts aggregating $36,388.30 were received by the University. Alumni AVotes. 691 THE ANNUAL REUNION OF THE ALUMNI OF THE MEDICAL DEPART- MENT OF THE UNIVERSITY OF PENNSYLVANIA. THE Twenty-fifth Anniversary Reunion of the Society of the Alumni of the Medical Department of the University of Pennsylvania will be held on Wednesday, June 12. The annual dinner of the Alumni will take place at the Bullitt Building, Fourth below Walnut Streets, at 8.30 P.M. All alumni of the Medical Department are cor- dially invited to attend, as every effort will be made to make this re- union noteworthy in every way and in keeping with the progress of the University. Appropriate toasts will be responded to by representative alumni. The subscription price has been placed at $5, which should be sent to the Treasurer, Dr. Samuel D. Risley, 1722 Walnut Street, before June 5, in order to facilitate the work of preparation. Although a continual effort is being made to secure a complete list of the Alumni of the Medical Department, it has been found impossible to secure the correct address of many of the Alumni, a fact which accounts for the frequent failures to receive invitations in former years. A special invitation, therefore, is extended to every University alumnus, whether a member of the Alumni Society or not, to attend the annual reunion. The ballot for the election of officers and executive committee to serve for the ensuing year will be opened at Medical Hall, University of Pennsylvania, from Io A.M. until 12 o'clock noon, on Wednesday, June 12, and again at the meeting in the evening. The annual busi- ness meeting of the Society will be held in a room adjoining the banquet-hall at 8 o'clock. * Committee of Arrangements : Richard A. Cleemann, M.D., chair- man; Wm. Barton Hopkins, M.D.; H. R. Wharton, M.D.; Judson Daland, M.D.; Charles A. Oliver, M.D.; Joseph Leidy, M.D.; Elliston J. Morris, M.D.; Samuel D. Risley, M.D., treasurer; Joseph P. Tunis, M.D., secretary. IMPROVEMENTS. THE Howard Houston Hall is rapidly nearing completion, and the contractors state that it will be ready for occupancy the latter part of September. The hall will add greatly to the appearance of the college campus, and will be the first of a series of new University buildings to be erected at an early date, prominent among which will be the new dormitories, the astronomical observatory, and the new archeological museums. Work on the dormitories will be begun in June upon the old athletic grounds. The new museum will be started soon thereafter. The large ornamental and scientific botanical gardens, which will 692 Alumni Notes. rank next to the famous Kew Gardens of London in beauty and area, and which will surround the Biological Building, are progressing rapidly. - The high iron fence at present surrounding the College, Medical and Dental Halls, Library and Mechanical Engineering Building, will be removed during the summer, and will be replaced by a low stone coping. The pavements in front will be replaced by asphalt. A row of white elms will tend to beautify the appearance of the campus. PORTRAITS TO BE PRESENTED TO THE MEDICAL DEPARTMENT. A PORTRAIT of the late Dr. William Goode11, painted by Vonnoh in oil, will be presented to the Medical Department of the University at the commencement to be held on June 13. The presentation address in behalf of the donors, Dr. Goodell’s family, will be made by Dr. John Ashhurst, Jr. On the same occasion a portrait of Dr. Horatio C. Wood, painted in oil by his son, Dr. James Wood, will be presented to the Medical Department of the University by the H. C. Wood Medical Society of the University. APPOINTMENTS. At a recent meeting of the Board of Managers of the Methodist Episcopal Hospital Dr. Edmund W. Holmes was elected visiting sur- geon. Dr. Thomas F. Drown, of the Massachusetts Institute of Tech- nology, and a graduate of the Medical Department of the University of Pennsylvania, has been chosen president of Lehigh University. NECROLOGY. DR. A. ROSEWALD OPPENHEIMER, of the class of '93, late resi- dent physician at Johns Hopkins Hospital, died of typhoid fever a few weeks ago. - DR. Joseph RowlanD died in Media on April 29, 1895. He was in the eighty-first year of his age, and had been in active practice for fifty-five years. He was a graduate of the University of the class of 1840. He was widely known, and was held in high esteem both as a physician and as a citizen. - DR. Isa Ac WAYNE HUGHES died in Philadelphia on April 26, 1895. Dr. Hughes was born at Gulf Mills, Montgomery County, Pa., sixty-three years ago. He graduated from the Medical Department of the University in 1852. He established himself in West Philadelphia and built up a large practice. He held a prominent place in both medical and financial circles. A/um772 AVotes. 693 DR. W. MALLET-PREVOST died at Fresnillo, Mexico, on May 14, 1895. He was thirty years of age. He graduated from the Medical Department of the University in 1887, and after serving as resident physician to the University Hospital, he located in the City of Mexico, where in a short time he established a lucrative practice. He was also given charge of two hospitals, and was appointed surgeon-in-chief of the Mexican National Railway. On account of heart-disease he left the City of Mexico, the climate of which was unfavorable, and estab- lished himself in Fresnillo, which is in a lower altitude, and where he was joined by his father, Dr. Grayson Mallet-Prevost, who was with him at the time of his death. DR. WILLIAM S. W. RUSCHENBERGER, the eminent naval surgeon and scientist, died on March 24, 1895, in Philadelphia, in his 88th year. He was born in Cumberland County, N.J., September 4, 1807. After receiving an academic education in Philadelphia and New York schools, he entered the medical service of the United States navy as a surgeon's mate August IO, 1826. His medical tutors were Dr. J. P. Hopkinson and Dr. Nathaniel Chapman, of the Medical Department of the University of Pennsyl- vania, from which he received the degree of Doctor of Medicine in March, 1830. He was commissioned a surgeon in the navy April 4, 1831, and from 1835 to 1837 was fleet surgeon to the East India Squadron, with which he circumnavigated the globe. In 1840–1842 Dr. Ruschenberger was attached to the naval rendezvous in Philadel- phia. From 1843 he was superintendent of the United States Naval Hospital at Brooklyn, and during his term of service there organized the Naval Laboratory, for supplying the service with pure drugs. He was again fleet surgeon of the East India Squadron from 1847 to 1850, fleet surgeon of the Pacific Squadron from 1854 to 1857, and of the Mediterranean Squadron from August, 1860, to July, 1861, having served in the intervals between cruises at Philadelphia. During the Civil War Dr. Ruschenberger was surgeon of the Boston Navy-Yard. From 1865 to 1870 he was on duty in Philadelphia. From 1866 to the time of his retirement, September 4, 1869, he was the senior officer in the Medical Corps, and March 3, 1871, he was commissioned Medical Director on the retired list, with the relative rank of Commo- dore. - - Dr. Ruschenberger has been best known in Philadelphia, perhaps, for his scientific labors, and particularly for his efforts in behalf of the Academy of Natural Sciences, which bestowed on him the highest honors within its gift. He was elected vice-president of the Academy in January, 1869, 694 Alumni Notes. and president in December of the same year, serving in the latter office until 1881, when he was succeeded by Dr. Joseph Leidy. At the time of his death he was one of the curators. Dr. Ruschenberger won considerable reputation by the results of his scientific observations during his various cruises, which he pub- lished at different times. Some of his works were “Three Years in the Pacific,” “A Voyage Round the World,” “Elements of Natural History,” “Lexicon of Terms used in Natural History,” “Notes and Commentaries During a Voyage to Brazil and China.” Besides these, he wrote “A Notice of the Origin, Progress, and Present Condition (1852) of the Academy of Natural Sciences of Philadelphia,” and various pamphlets on the rank of medical officers in the navy. He was also a contributor to the leading medical, pharmaceutical, and scientific journals. * Dr. Ruschenberger was also a member of the American Medical Association, the College of Physicians of Philadelphia, of which he had been secretary and vice-president; also a member of the American Philosophical Society and the Historical Society of Pennsylvania. THE CHINESE PHARMAcoPEIA. MUCH has been written by travellers about Chinese medicines, usually in a spirit of ridicule, as if, though nothing else in their books should be provocative of mirth, this subject might confidently be relied on to raise a laugh. A common belief is that Chinese medicines consist almost entirely of mineral substances, the vegetable kingdom being little drawn upon. But the opposite is the case. In Mr. R. Braun's work, “A List of the Chinese Medicines Exported from Hankow and the other Yangtze Ports,” which contains the names of most of the medicines in use in the central parts of China, there are 412 medicines, classed as under: Insects, 9; roots, 113; barks and husks, 25; twigs and leaves, 16; flowers, 21 ; seeds and fruits, 93; grasses, 18; sundries, 117. ICHTHYOL IN THE TREATMENT OF ERYSIPELAs. ZELEWSKY has found ichthyol efficacious in every form of erysip- elas, and in his opinion it is superior to other remedies. In some cases of migratory erysipelas affecting both sides of the patient's body, he painted one side with Trousseau's solution (acidi tannici, camphorae, ââ 2.0 grammes, 31 grains; aether. Sulph., I5.0 grammes,<-334 fluid- drachms), and the other with ichthyol, the morbid process subsiding much more quickly under the latter treatment than under Trousseau's solution. He prescribed the drug as follows: Ammon. sulpho-ichthyol, spir. aether., aa I part; collodi. elastici, 2 parts.-Jugno-russkaya medic. gazetta. g EDITORIAL. CARBOHYDRATES IN DIABETES. THE injunction to eliminate from the dietary of diabetic patients all saccharine and amylaceous matters has been so thoroughly incul- cated that we fear a too strict adherence to the prescribed regimen has sometimes resulted in harm rather than good. The practice, not uncommon, of furnishing the patient with two printed diet lists, the one of admissible and the other of prohibited foods—simply directing him to use the former and to abstain from the latter, without reference to the quantity and digestibility of those foods which are admissible— is certainly injudicious. Sydenham's advice: “Let the patient eat food easy of digestion, abstaining from all sorts of fruits and garden stuff,” is not always followed in its entirety. In diabetes the appetite is often inordinate, while the digestion is weak, and under these circumstances the ingestion of large quantities of albuminous food may be fraught with danger to the patient. The value of a given dietary should always be determined not only by the quantitative estimation of the glycosuria, but also by the influence on the digestion, general health, and body-weight. Further, Ebstein (Medical Chronicle, Vol. xv.1, No. 6), in an article dealing with this subject, remarks that purely albuminous food cannot be tolerated for a long time by the diabetic patient, and that the more severe the disease the greater the dangers from such a diet. This danger is recognized by the appearance of diacetic acid in the urine. Ebstein never introduces the diabetic diet suddenly, but gradually, especially so when the disease is a serious one. Rolfe (Lancet, April 23, 1892) also believes that the advantages resulting from a strict adherence to an absolute diet of proteids may sometimes be gained at too great an expense to the patient's well-being, since the too long continuance of such food may prove dangerous by causing the forma- tion in excess of bodies such as the morbid products of proteid meta- bolism, and that some benefit may be derived in other directions by permitting a slight relaxation from too rigid a proteid dietary. In the early stage of the disease, when the health is still vigorous, the diges- tion good, and the excretory functions adequate, the danger is at a minimum ; but later, when the general health fails and the digestive 695 696 Baſitorial. powers become impaired, a toxemia may develop from the accumulation of the products of faulty metabolism. - Grube (Lancet, Vol. II, 1893) states that in his opinion it is a mis- take to treat patients too one-sidedly, and to think that the chief part of the treatment is to prohibit the ingestion of carbohydrates. The importance of this treatment, he continues, is not to exclude the carbo- hydrates entirely, but to induce the patient's system to utilize them again. He also points out that in advanced cases diabetic coma, when imminent, can be averted by giving carbohydrates. Pavy (“Croonian Lectures,’’ Lancet, Vol. II, 1894) says that in proportion as the power of properly disposing of carbohydrate matter becomes restored, a more liberal diet is found not only to be tolerated but to be required, and that when a recovery of assimilative power has taken place, a continuance of the restricted diet is attended with a fall of weight and a decline of strength. Saundley (Lancet, Vol. I, 1894), in an address before the Eleventh International Congress of Medicine at Rome, remarked that in the future we should reverse the funda- mental rule that diabetics should be allowed as little carbohydrates as possible, and declare that they should be permitted to eat as much carbohydrates as they can assimilate without increasing their sugar secretion. He has found from experience that the majority of patients can take a moderate amount of carbohydrates without injury, and he maintains that this method is very much better for the patient and affords a régime which it is possible for him to conform to. Schmitz (Centralbl. filr Nerv., Psych, u. gericht. Psycopath., No. 27, 1893) insists that large quantities of meat in grave types of diabetes decidedly aug- ment the amount of sugar in the urine, a fact confirmed by Nannyn and others. He therefore limits the amount of meat in grave cases, and allows a varied diet, and especially fat. It is well known that all carbohydrates do not act the same in diabetes ; indeed, some seem to be quite free from deleterious effects. The employment of an exclusive milk diet, suggested by Donkin and advocated by Tyson in certain cases, often acts most happily, although milk is rich in lactose. Minkowski (Archiv. für exp. Path. u. Pharm., Vol. xxx1, 1892) draws attention to the changes of various carbohydrates in diabetic animals. He shows that levulose in small doses is lost in the organism, and that only minute quantities appear in the urine. On the other hand, inulin causes a marked increase in the glucose elimination. When levulose is administered in large doses, a portion is excreted unchanged, while a part is converted into dextrose. Of late, considerable testimony has been advanced showing the value of levulose in diabetes, both as a food and as a sweetening agent. Aditorial. 697 Levulose or fruit-sugar is an uncrystallized sugar found in honey and the juices of fruits. The French speak of it as invert sugar, because it has a rotating power to the left instead of to the right like glucose and cane-sugar. Leyden (Deuts. med. Zeit., p. 498, 1893) found that the addition of six to seven drachms of levulose to the diet increased but slightly the amount of sugar in the urine, and infers that this sugar is better adapted than any other for use in diabetes. Haycraft (Medical Chronicle, September, 1894), from experiments and observations made on three patients with diabetes to whom levulose was administered, draws the following conclusions: (1) A patient suf- fering from chronic diabetes can utilize fifty grammes or more of levulose daily. (2) In some acute cases a part of the levulose taken with the food is excreted as such, a part is utilized in the body, and a part is transformed into glucose. (3) In rabbits glycogen is formed from the levulose taken, and is stored up in the liver. W. Hale White (Guy's Płospital Reports, Vol. I, 1893) reports the results of a number of careful experiments on eight diabetic patients with regard to the effect of giving levulose. He concludes that if large amounts are administered, some of it appears in the urine; that it does not exert the pernicious effect of some carbohydrates of increasing the output of sugar beyond the extra quantity given ; that some of the levulose was retained and used up in the body. None of the patients felt worse for taking the levulose; indeed, some felt better and gained in weight. Grube (Zeit. fºr innere Med., Bd, xxv.1, Hefte 3 u. 4), from experiments on seven cases, reaches similar conclusions to those of White. If further research should confirm the truth of these statements, levulose will fill a long-felt want in the treatment of diabetes, not only as an assimilable carbohydrate, but as substitute for glycerin and sugar, which as sweetening agents have been far from satisfactory. SERUM TREATMENT OF CHOLERA. FREYMUTH (Deutsche medicinische Wochenschrift, October 25, 1894) has treated three cases of undoubted cholera by the injection of serum obtained from patients who had recently passed through an attack of the disease. Of these three cases, two recovered. In the fatal case, death was due to a mixed infection, as the bacteriological examination showed. In one case particularly the patient rapidly improved after the injection. The serum was used in doses of ten, thirty, or even fifty cubic centimetres. It was shown to protect guinea-pigs against injec- tions of virulent cholera bouillon. The treatment is easily carried out, and is without danger. The serum should be taken from those who flave had a severe attack of cholera.—British Medical Journal. 5O MEDICAL PROGRESS. NMEDICINE. UNDER THE CHARGE OF - WILLIAM PEPPER, M.D., LL.D., AND JAMES TYSON, M.D., ASSISTED BY M. HOWARD FUSSELL, M.D. THE INFLUENCE OF THE LIVER IN THE PRODUCTION OF PANCREATIC DIABETES. MARCUSE (Zeitschrift für klinische Medicin, Vol. xxvi, Parts 3 and 4, 1894), endeavoring to demonstrate that following pancreas extirpation diabetes may also occur in cold-blooded animals, removed the pancreas from each of nineteen frogs. The animals lived from two to eighteen days, twelve became diabetic, the second day following the operation at the latest, the urine containing a few tenths per cent. of sugar. He then removed from twenty-one frogs both the liver and the pancreas, and although the majority of the animals lived some days, in none did sugar appear in the urine. The supposition is that by the extirpation of the liver, there is removed the source whence springs the sugar following pancreas extrac- tion. An absolutely satisfactory explanation of the phenomenon is, at present, not to be given. - . THE PREPARATION OF ‘‘FATTY MILK.” GAERTNER (Wiener medicinische Wochenschrift, No. 44, 1894) describes his method, whereby it is possible, from cow's milk, to prepare a milk, which, in its proportion of casein and fat, resembles human milk. It is also possible to prepare the milk so that it may contain any desired quantity of casein or fat. This is effected by means of a centrifuge (Pfannhauser's), the barrel of which is provided with two outlets, one on the side, the other, a tube, which may be introduced into the bar- rel to any desired extent. They are in this case so arranged that the outflows through each opening may be equal. The milk is diluted with an equal quantity of warm water and subject to centrifugation. The lighter fat drops tend towards the centre, the heavier constituents, including various foreign matters, dirt, etc., towards the periphery. The distribution of the casein, sugar, and salts is not in- fluenced. The milk—the “fatty milk”—which one obtains through the more centrally located opening contains therefore (1) all of the fat (a very small quantity only being lost in the “thin milk”); (2) half of the casein ; (3) half of the sugar, and half of the salts. Excepting the smaller amount of sugar, which can be corrected by the addition of a litle milk-sugar, this “fatty milk,” in all essential particulars, resembles human milk. One obtains after centrifugation ex- actly the same quantity of milk as originally used. There is, therefore, no waste. After centrifugation, the milk is allowed to cool or can be sterilized. 698 Medicine. 699 TREATMENT OF FURUNCULOSIS BY COLCHICUM. BRocQ (Journal de Médecine et Chirurgie pratique, February 10, 1895) remarks that gouty patients who have neither diabetes nor albuminuria are fre- quently troubled with furunculosis. This condition is best treated by the pro- 1onged use of the extract of colchicum of three to four centigrammes daily. He cites the following case: A man, aged 40 years, had suffered for several months from a furunculosis, which had resisted all treatment both internal and external. After five days’ treatment with colchicum the furuncles were arrested, and no new ones developed. Cessation of the treatment was followed by a fresh outbreak of the boils. They were again arrested by continuation of the treatment. It was found that if the treatment was continued for a long time and the dose gradually diminished that the boils did not reappear. At the same time the whole body was bathed daily in camphorated alcohol. - GAERTNER’s “FATTY MILK,” A NEw METHOD OF INFANT FEEDING. EscERICH (Wiener medicinische Wochenschrift, No. 44, 1894) makes mention of the fact that of all the methods tried to provide a substitute for mother's milk for infants, none have proven satisfactory. There is one exception—Gaertner's “fatty milk.” This was given to a number of children. It was always taken with relish. The stools were rather frequent than otherwise, of slightly acid reaction, soft, fatty, shining, and contained small flakes. Microscopically there were a number of bacilli, not decolorized by Gram’s method. There was never that ob- stinate constipation with hard feces which so often accompanies feeding with diluted cow's milk. The increase in weight of the children was progressive and exceeded that of other artificially fed children. In the treatment of disorders of digestion the “fatty milk” was not of such avail, the reason to be sought more in hygienic mismanagements than in the milk. The milk is warmly recommended. HEMATURIA OF GOUT. MABBoux (Lyon Médical, March 3, 1895). An attack of renal gout consists anatomically in hyperemia, but there is not of necessity hematuria. The appear- ance of albumen in the urine or its sudden increase, whether or not it is coincident with articular pain but accompanied with tenderness in the loins, is most fre- quently due to an attack of renal gout. These attacks are to be distinguished from renal colic due to calculi. Some attacks of hematuria occur without pain or pre- existing hematuria. Renal gout occurs in females quite as frequently as in males. Gouty hematuria is practically always renal in origin, as attacks of cystic gout resemble those of an ordinary cystitis, and a urethral gout possibly does not exist. In neither of the last instances are the blood and urine intimately mixed. Gouty renal colic may occur suddenly or after some days of lumbar pain. It often is the first expression of the diathesis in individuals of full habit without any genito-urinary disease; it is frequently accompanied by a chill; it is not influenced by walking or jolting; the pain is always bilateral, and the passage of the bloody urine is not painful. Its duration is variable; it may last from a few hours to several days. Sometimes there are a series of attacks lasting over several days. The urine frequently contains considerable renal epithelium in addition to the blood, and contains albumen in excess of the amount of blood, which continues after the blood has disappeared. The pain is not frequently acute nor sharp, as it is in stone. 7oo Medicine. SOME RESEARCHES INTO THE CHEMISTRY OF TYPHOID FEVER. FENwick and BOKENHAM (British Medical Journal, April 13, 1895), in their report to the scientific Grant's Committee of the British Medical Association respecting the pathologic effects of certain chemical substances extracted from the spleen of patients dying during the third week of typhoid fever, came to the following conclusions: (1) Three varieties of chemical substances can be extracted from the spleen after death from enteric fever during the third week of the disease, albumoses, alkaloids, and fatty bodies. (2) The injection of the albuminous extract into lower animals causes an elevation of the temperature of the body, which lasts for about thirty hours, and is associated with anorexia and emaciation. Under ordinary circumstances a fatal result is not observed, and no pathological changes of importance are to be detected in the tissues. (3) The administration of the alkaloidal and fatty extracts is unattended by any pathological results. OBSERVATIONS ON THE BLOOD IN DISEASE. ZAPPERT (Zeitschrift für klinische Medicin, xxIII, parts 3 and 4) has exam- ined blood with a I-per-cent. solution of osmic acid and a solution of eosin in water and glycerin with the following results: In healthy individuals, between 20 and 70 years of age, the eosinophile cells vary from 50 to 270 to the cubic milli- metre. In some entire normal individuals the number is as great as 700 to the cubic millimetre. In children’s blood the eosinophile cells are always numerous. Menstruations and pregnancy do not increase these cells. In leukemia the eosin- ophile cells are absolutely increased. In chlorosis and other anemias sometimes there was an increase, sometimes a diminution of these elements. Heart-failure did not alter the number. In diseases of the stomach and intestine the numbers varied. In diseases of the liver there was frequently an increase. In cases of tu- berculosis of the lungs with fever there was frequently a decrease, while bronchial asthma and emphysema were always accompanied by an increase. In nephritis the number is great, independent of uremia. In functional nervous diseases the number is increased, but not enough to make a differential diagnosis. In diseases of the skin and syphilis they are usually increased. In malignant tumors there is usually a decrease. In febrile diseases there is a decrease at the height of the fever ; in scarlet fever the cells are increased. BücKLERS (Minchener medicinische Wochenschrift, 1894, Nos. 2 and 3), on the increase of eosinophile cells with the presence of Charcot's crystals in feces of pa- tients with worms, found a very usual increase of the cells. This increase was coin- cident with the appearance of Charcot's crystals in the feces. KANTHACK (British Medical Journal, July, 1892) has found eosinophile cells in eczema, prurigo, and asthma, and believes they are not characteristic of leu- lcemia or pseudo-leukemia. - Ewing (New York Medical Journal, December 16, 1893). In most cases of 1obar pneumonia there is a decided leucocytosis, and the grade is proportionate to the extent of the pneumonia. In cases of acute tubercular pneumonia there is no leucocytosis nor is there in typhoid fever. In empyema and actinomycosis of the lung there is a leucocytosis. Marked leucocytosis is in favor of pneumonia where the question is between this disease and typhoid. A severe leucocytosis in pneu- monia is not always a favorable sign, while a small degree in a severe case of pneumonia is of bad prognostic import. Medicine. 701 A NEW METHOD OF GENERAL, NARCOSIS. RoseNBERG, in the Berlin Medical Society (Deutsche medicinische Wochen- schrift, No. 50, 1894), described a new method for inducing general narcosis. Before commencing the anesthetic, the patient’s nasal mucous membrane is to be sprayed with a ten-per-cent. Solution of cocaine. During prolonged anesthesia, the spraying is to be repeated every thirty minutes, and again at the end of the operation, no matter how short. His conclusions are: (1) excluding cases of negligence and of poisoning, cardiac syncope in chloroform narcosis is, in so far as it can be attributed to the chloroform, reflex. (2) The syncope and the accom- panying respiratory embarrassment are due to irritation of the peripheral trigem- inal filaments in the nasal mucous membrane. (3) Every anesthetic inhaled pro- duces the same reflex symptoms as chloroform. (4) By proper cocainization of the nasal mucous membrane, all such reflexes can be positively prevented. (5) Thus a greater part of the dangers of inhalation anesthesia, particularly of chloro- form, can be removed. (6) Cocaine possesses a certain action antidotal or antitoxic to chloroform, and thus further reduces the dangers of chloroform. (7) Chloroform in such cases is to be preferred to ether, as being less dangerous. The chloroform must always be administered drop by drop. RENAL COMPLICATIONS OF TYPHOID FEVER. Roth (Milmchener medicinische Wochenschrift, No. II, March 12, 1895) cites a number of statistics in relation to the frequency of nephritis as a complication of typhoid fever. He mentions the observations of Mygge, who, systematically examining the urine of seventy-two typhoid fever patients, found albumen present in fifty-two. In half of these cases it was due to nephritis, in the other half to pyelitis or to cystitis. He refers particularly to cases in which the renal symptoms may be much more marked than those referable to the gastro-intestinal tract, and cites a case of a boy taken suddenly ill with headache, thirst, fever, and pain in the right loin. On admission, fourth day of disease, the urine was scanty, dark- red, cloudy, contained considerable albumen, epithelial cells, numerous white blood-corpuscles; no casts. On the eighth day roseola were found; on the ninth day the spleen was palpable; the urine contained albumen and epithelial cells from the pelvis of the kidney; no casts. The disease thus began as a pyelitis; it being only on the eighth day that the diagnosis of typhoid fever could be made. The constant absence of casts argued against nephritis. The patient recovered. Care- ful examinations will prevent the overlooking of pyelitis occurring during the course of typhoid fever, but in cases beginning as pyelitis the diagnosis may be obscured. Unless absolutely necessary in such cases the cold bath should not be used. During convalescence, great care must be exercised regarding the diet, especially in the use of albuminous foods. THE RELATION OF THE PANCREAS TO DIABETES. HANSEMANN (Zeitschrift für klinische Medicin, Vol. xxvi, Parts 3 and 4) sees no reason why the results of experimentation on dogs whereby diabetes follows pancreas extirpation cannot be applied to man. On the one hand, none of the nineteen cases of disease of the pancreas without diabetes which he reports is free from objection ; and, on the other, there are numerous positively proven cases of disease of the pancreas with diabetes. Of these latter he reports forty cases from personal observation, and seventy-two from the literature of the subject. (1) Dia- 702 - Medicine. betes without disease of the pancreas; not discussed. (2) Disease of the pancreas without diabetes. With the formation of calculi in the pancreatic duct, lipomatosis, sclerosis, and cysts, there is always a portion of the glandular substance of the organ remaining; therefore no diabetes. It requires the most careful examination to reveal these small portions. Acute inflammation, suppuration, and necrosis of the entire organ do not lead to diabetes, probably because death occurs too soon. The diffuse carcinoma affects, indeed, the entire organ, but as the cancer cells originate in the pancreatic cells, it is possible that they can continue to exert their antidiabetic action, although they have lost all secretory function. (3) Disease of the pancreas with diabetes. Of the forty cases of personal observation, thirty-six were of simple atrophy, three of fibrous induration, one a complicated case. The disturbance in the pancreas corresponded to no particular form of diabetes; twenty-six patients were very much wasted, three moderately so, seven were well nourished, and of four the condition of nutrition was not known. Twenty-two died in coma; eighteen under other symptoms. It is not so much the nature of the disease of the pancreas, as it is the extent of the degeneration of the organ that determines the diabetes. To this there is one exception, the genuine granular atrophy of the pancreas which from the beginning produces a diminution of the antidiabetic action of the pancreatic cells, and of necessity leads to diabetes. NEPHRITIS WITHOUT SYMPTOMS. The urine of all patients applying at this department for treatment is exam- ined whatever the nature of the complaint from which they suffer. (From the University Medical Dispensary, service of M. HowARD FUSSELL.) While it is a well-known fact that serious kidney lesions can exist without giving rise to any symptoms whatever, these cases are published as showing the necessity of a routine urine examination if we would make ourselves certain in our diagnosis. And while it is not literally the fact that all the cases were without symptoms, they either did not complain of their serious condition, or the symptoms of which they complained would not have suggested a urine examination. CASE I-John —, aged 32 years, applied at the Medical Dispensary for relief from swollen cervical glands. He denied all symptoms except a slight pain in the inflamed gland. A physical examination was made (as is done in all cases however apparently trivial their complaint). The pulse was feeble, and there was a tendency to cyanosis. The cardiac dulness was greatly enlarged, with the heart apex in fourth interspace inside midclavicular line. There was an evident peri- cardial effusion. The urine was examined and found loaded with albumen and casts. The patient was warned of his condition, but never returned for treatment, CASE II.-Emma P., aged 9 years, a private patient, was seized with slight nephritis, low grade of fever, and swollen cervical glands. Just such a picture as is constantly seen in children with catarrhal affections. An examination of urine was made, and it was found to be diminished in quantity and to contain large quantities of blood, blood-casts, and granular casts. The patient was at once put on proper treatment and improved, but at this date, three years after the onset, casts and albumen may be found constantly in the urine. The patient grows, is florid, and the picture of perfect health. Never- theless, the serous renal complication still exists. CASE III.-John G., aged 61 years, came to the Medical Dispensary November 28, 1894, complaining of cramp-like pains in the calves of both legs, which pains had existed more or less constantly for a period of fifteen years. Physical exam- Medicine. 7O3 & ination revealed slight atheroma of the arteries. There was some slight increase in the area of heart dulness; and the lungs were normal. The examination of the urine on this date was negative. The urine was again examined on December 19, 1894, and the following note made : specific gravity IOo8, reaction acid, albumen a trace, and a few hyaline casts. The urine has been examined at intervals of a week or ten days up to the present time, and with two exceptions albumen and casts (granular and hyaline) have been found. Under appropriate treatment the cramps have disappeared and dyspnea, a symptom, developed, which also has disap- peared. The muscular cramps are looked upon in this case as a symptom which, in reality, were renal in origin and which have been relieved by treatment directed to the kidneys. CASE IV.-Fred. —, aged 32 years, presented himself suffering with an arthritis of wrist joint. No other complaint was made nor could any symptoms be developed upon careful questioning. Urine examination on two occasions showed considerable albumen with granular and hyaline casts. The arthritis was cured and the patient passed from observation, the last urine examination showing the same condition of kidneys. CASE V.—A. G., aged 36 years, presented himself suffering from hemoptysis, cough, and profuse expectoration with night-sweats. Physical examination re- vealed a marked consolidation at right apex. The heart-sounds were weak, no enlargement of organ, nor murmurs. Examination of urine showed it to contain one-half by bulk of albumen with dark granular casts. The casts and albumen presented up to the last examination on March 19, 1895. The condition of the kidneys necessarily must have an effect upon the prognosis and treatment of the case, and it would have been a grave error to have overlooked it. CASE VI.—Benj. G., aged 41 years, applied for treatment January 15, 1895, complaining of pain in hip-joints, in lumbar region, and in the testicles. Physical examination showed a slight accentuation of the second sound of heart. The lungs normal. Urine, specific gravity, IOI8, acid, a trace of albumen, with pale, granular casts. Several subsequent examinations showed the presence of albumen and casts, both of which have disappeared under treatment. Unquestionably, the symptoms here complained of were due to a slight renal lesion which has appar- ently recovered. CASE VII.-Howard S. presented himself for examination because, on the previous day, he had been rejected by a life insurance society. A physical exami- nation of heart and lungs showed them to be normal, but the urine contained one- fifth albumen and numerous casts. He came simply for an opinion and passed from under observation. CASE VIII.-Henry N., aged 23 years, came February 2, 1895, complaining of severe epigastric pain, and numerous nervous phenomena, none of which would have suggested a kidney lesion. The heart and lungs were normal, a slight epi- gastric tenderness existed. The man was and still remains the picture of health, but the urine contains a large number of granular and blood-casts with about one- fifth albumen. It is unnecessary to say that the treatment in this case is entirely changed by reason of knowing the urine conditions, and though the patient may, perhaps, not be cured, he certainly can be treated rationally. All the urine examined was treated by the centrifugal machine. This instru- ment gives results far more satisfactory than the usual method of allowing the urine to stand twelve to twenty-four hours. Not only can the urine be examined fresh, but the sediment is concentrated, and casts can frequently be found which would almost certainly be overlooked in the older method. 7O4 Surgery. SUFG ERY. UNIDER the cHARGE OF J. WILLIAM WHITE, M.D., ASSISTED BY G. G. DAVIS, M.D., M.R.C.S., AND ELLWOOD R. KIRBY, M.D. A CASE OF PANCREATIC CYST TREATED BY DRAINAGE: RECOVERY. RICHARDSON (Boston Medical and Surgical Journal, March 21, 1895) reports the case of a man, aged 26 years, who had always been well and strong up to his present illness. He first noticed a painless swelling in the pit of the stomach, about six weeks before the operation. This swelling gradually grew larger, and became so painful that he could not sleep at night. The pulse, temperature, and urine were normal. On examination the tumor was found large enough to interfere considerably with respiration, and distended tensely the upper half of the abdomen. A diagnosis of cyst of the pancreas was made from the position, and an inci- sion made from the ensiform to the umbilicus, the omentum being carefully sep- arated, the tumor was brought into view and the contents aspirated. The fluid was viscid and of a dirty-gray color. About two pints of fluid were withdrawn by the aspirator. The parts about the exposed portion of the tumor were then walled off with gauze, a free opening was made, and about two quarts of fluid escaped. - Exploration with the finger revealed a large cavity in the retroperitoneal space. º On account of the great number of adhesions, the sac could not be removed. The cyst-wall was then sutured to the abdominal wound and a 1 tube inserted. The author says in the surgical treatment of these conditions, the important question to decide is between drainage and radical removal of the sac. Numerous observations show that complete healing usually follows simple drainage of the sac. e a roſe drain a ore- -- c - --------o- AN OPERATION FOR THE RELIEF of IMPERMEABLE OccLUSION OF THE ESOPHAGUS. BERNAYS (AVezw York Medical Journal, March 23, 1895) reports the case of a child, aged 6 years, with the following history: When two years old she swallowed concentrated lye. The accident was discovered immediately after its occurrence, and prompt medical assistance given; great edema of the parts followed, and for a period of four days was unable to draw the tongue into the mouth. When the local swelling and edema had subsided, she was found to be unable to swallow. t No attempt was made to prevent the formation of a structure until four months afterwards. - Many attempts were made to pass bougies, but only a few of these trials were successful. - No further attempts were made to relieve the stricture until fourteen months afterwards. Surgery. 705 Gastrostomy was then performed and the patient nourished through the fistu- lous opening. At the time the patient was etherized the fistulous opening into the stomach was dilated and the cardiac end of the esophagus explored, but no structure could be found. A soft metallic sound was introduced through the stomach into esopha- gus so as to locate the lower margin of the structure. A bougie was introduced through the mouth and found to stop at eighteen centimetres from the teeth. At the first operation a metal male catheter was introduced into the esophagus and pushed forward and to the left of the trachea, until the point could be felt immediately beneath the skin. An incision was then made in the neck, the esophagus opened, and stitched to the skin wound. At the second operation, three weeks later, the finger was introduced into the esophagus through the opening in the neck. A bougie, with a point like a trocar, was introduced into the esophagus through the gastric fistula and pushed through the structure to the finger above. It was pushed up into the wound in the neck and a stoutsilk ligature attached and pulled out at the gastric fistula. A Nélaton rubber catheter was fastened to this ligature (external diameter one and a half centimetres). This was drawn through the esophagus until the upper end had entered the neck, and then pushed upward until the upper end could be seized in the pharynx and drawn forward out of the mouth ; both ends of the catheter were now outside of the body; they were sutured to the 1igature, the ends of which were tied together. On the seventh day a Renvers funnel was introduced over the catheter as a guide down through the stricture, and the catheter then removed through the gastric fistula. Fourteen days 1ater the funnel was removed and patient allowed to swallow naturally. te At this date patient has bougie regularly passed every second or third day. OBSERVATIONS ON A FURTHER SERIES OF RELAPSING TYPHLITIS TREATED BY OPERATION. TREVES (British Medical /ournal, March 9, 1895) reports a series of eighteen cases treated by operation. In all cases the appendix was removed only when all inflammatory symptoms had disappeared. All the cases but one recovered from the operation. - It has been now apparently demonstrated that the form of localized peritonitis, which is known by the names of typhlitis, perityphlitis, and appendicitis, is due in the great majority of instances to the bacterium coli commune. This organism exists normally in the human body, and is said to be the most abundant and the most constant of the bacteria found in the healthy individual. The organism varies greatly in its virulence; so far as experiments show upon animals it appears to be harmless when taken from the normal intestine. Viru- lence has been found to be developed in cases in which the bowel was obstructed, strangulated, congested, or inflamed, in diarrhea and in advanced constipation. Two elements, at least, would appear to be necessary to produce an attack of 1ocalized peritonitis through the medium of the appendix. The first is such a condition within the bowel as will render the colon bacillus virulent, and the second is such a lesion in the appendix as will permit that organism to reach the peritoneum. 706 +. - Therapeutics. The invasion of the peritoneum by organisms gives rise to sudden violent and acute symptoms, to an outbreak so abrupt and intense as to produce the impression that the appendix has become perforated. Perityphlitis, due primarily to a sud- den definite perforation of the appendix, is certainly uncommon. If a large series of cases of this affection be reviewed, it will be found that the number of instances in which there is only one attack is much greater than that in which there have been several attacks. - In a certain proportion of the examples of a single attack there has been an abscess, and the great majority of the subjects of typhlitis who have passed through the stage of suppuration are thereby rendered free from any further attacks. The cause of the trouble has been removed by the suppurative process. Among the marked conditions of the appendix necessary to cause relapse, the following are probably the most common. The lumen of the appendix is in some places narrowed or occluded. Such occlusions may result from a husky or an acute tending. e Occasionally the organ shows a condition well adapted for volvulus, or there is lodged with it fecal or calcareous concretions. As to the treatment of these conditions the author recommends the following, when the cases are very mild: (1) The digestion must be well attended to. (2) The bowels must be made to act daily, the aperient given should be fre- quently changed. (3) Massage of the abdomen appears in many cases to have a very desirable effect, partly by favoring the absorption of inflammatory exudate, and partly by encouraging a normal action of the bowel. (4) The use of some intestinal antiseptic, the most efficient of which appears to be salol. It should be given in a powder, ten grains night and morning. THE RAFEUTICS. UNDER THE CHARGE OF HORATIO C. WOOD, M.D., LL.D., AND ARTHUR A. STEVENS, M.D. THE INFLUENCE OF HIGH ALTITUDES ON THE BLOOD. THIS subject is reviewed at some length in the Archivio di Farmacolgio e Terapeutico, for January, 1895. Vrault found, during his travels in Bolivia and Peru, that the indigenous men and animals of those high altitudes had an abnormally large number of red cor- puscles to the cubic millimetre. He found that in himself and a companion the number of red corpuscles rose to 8,000,000 after a stay of three weeks at an alti- tude of 4392 metres. The llama, with its I6,OOO,OOO globules to the cubic milli- metre, is the animal par excellence for high altitudes. Koepe and Wolff counted the red blood-cells of people at Leipsic, and then each day of their stay at Reiboldsgrün, at an altitude of 7oo metres. In the city the average was 5,000,000 red corpuscles to the cubic millimetre. On the first day Therapeutics. 707 at Reiboldsgrün there was an increase to 5,970,000; on the second day a fall almost to normal; on the third day another increase, and this was permanent; on the fifth day 6,000,000 ; on the sixteenth day 6,200,000. Karcher observed in himself, at Champry, altitude IO52 metres, after twenty- one days, an increase of I5.7 per cent. of red cells, and in others an increase of 9.3 per cent. Suter, at 985 metres, and Veillon, at 700 metres, observed an increase of 19.5 per cent. and 7.7 per cent. respectively. Mercier, of Zurich, draws the following conclusions: (1) The greater the altitude at which man lives the greater the number of red cells in the unit of volume. (2) The number of red cells increases proportionately to the altitude. (3) The increase is characterized by the new formation of cellular elements of 1ess volume. (4) This ascensional polycythemia (Mercier) or hyperglobulia (Vrault) dimin- ishes as man lives in a region less elevated. (5) This increase has been noted in all, and is independent of individual pecu- liarities, age, sex, health, sickness, occupation, or social state. (6) This change in the blood constitutes a physiological phenomenon of man’s adaptability to a different environment (Translated by James J. Walsh.) THE BACTERICIDAI, ACTION OF FLUORIDE OF SILVER. LAZZARO (Archiv. di Farmacol. e Terapeut., January, 1805) says that the well- 1