Vol. CXIL, No. 2.

AUGUST, 1896.

No. 292.

THE

AMERICAN JOURNAL

MEDICAL SCIENCES.

EDITED BY

EDWARD P. DAVIS, A.M., M.D.

WITH THE CO-OPERATION IN LONDON OF

HECTOR MACKENZIE, M.A., M.D., F R.C.P.

PHILADELPHIA AND NEW YORK:

LEA BROTHEES & CO.
1896.

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A TREATISE ON SURGERY

FOR STUDENTS AND PRACTITIONERS

BY AMERICAN AUTHORS.

Edited by ROSWELL PARK, M.D.,

Professor of the Principles and Practice of Surgery and of Clinical Surgery in the Medical Depart-
ment of the University of Buffalo, Buffalo, New York.

IN TWO LARGE AND VERY HANDSOME ROYAL OCTAVO VOLUMES COPIOUSLY ILLUSTRATED WITH ENGRAVINGS
AND FULL-PAGE PLATES IN COLORS. VOL. I. 794 PAGES, WITH 356 ENGRAVINGS AND 21 FULL-PAGE
PLATES IN COLORS AND MONOCHROME. PRICE, PER VOLUME, CLOTH, $4.50 ;
LEATHER, $5.50. NET. VOL. II. IN PRESS FOR EARLY ISSUE. *

THE early publication of Park's '^Surgery by American Authors'' will place in the
hands of students and practitioners a work thoroughly reflecting the science and
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the honorable position universally accorded to America in the surgical world. The
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Numbering in its list of authors the surgical teachers in many leading colleges,
Park's Surgery will exemplify the best methods of placing its topics clearly and com-
pactly before the mind. Space will thus be available for full practical details concerning
everything of importance. From these considerations it will be obvious that the work
will at once become a standard text-book for students and an indispensable guide for
the general practitioner as well as for the specialist in surgery.

In point of richness and beauty of illustration Park's Surgery will mark a departure
in surgical literature, the engravings and colored plates being largely original, and
introduced wherever clearness and fulness of information can be aided by pictorial eflect.

IN PRESS.

DAVIS' OBSTETRICS.

A TREATISE ON OBSTETRICS.
FOR STUDENTS AND PRACTITIONERS.
By EDWARD P. DAVIS, A.M., M.D.,

Professor of Obstetrics and Diseases of Infancy in the Philadelphia Polyclinic, Clinical Professor of
Obstetrics in the Jefferson Medical College of Philadelphia.

IN ONE VERY HANDSOME OCTAVO VOLUME OF 700 PAGES, WITH OVER 200 ENGRAVINGS IN THE TEXT AS
WELL AS 16 FULL.PAGE PLATES IN COLORS AND MONOCHROME.

IN this new work, shortly to appear, medical students and practitioners have assurance
of a treatise of the highest excellence. The author is eminently koown in con-
nection with the teaching and practice of this great and responsible department of
medicine. Clearness and practicality of instruction will be marked features of the text,
and equally noteworthy will be the series of illustrations, among them being a large
number of photographic reproductions of obstetrical scenes carefully selected in view
of the amount, vividness and permanence of the instruction which can be conveyed
thereby. Ample use will be made of colors.

LEA BROTHERS & CO., PUBLISHERS, {',j>f^/„f^^^^^^^^

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Dr. G. HalSTEAD BoYLAND, Late Professor of Surgery, Baltimore Medical College, Late Surgeon French
Army {Decorated), Member Baltimore Academy of Medicine, Member of American Medical Association.

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By ALEXANDER DUANE, M. D.,

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Second edition. In one large square octavo vol. of 690 double-columned pages. Cloth, |3.00 ;
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Dr. Alexander Duane, who is well-known as a
medical writer of wide experience, and who has
had special training as the Reviser of Medical
Terms for Webster's International Dictionary,
has issued a work which proves to be a model
of conciseness, convenience and thoroughness.
The book is brought accurately to date by
extended research. The definition of diseases
includes a brief synopsis of their etiology, symj)-
toms ajid treatment ; the anatomical and physi-
ological terms are accompanied by outlines of
the essential features of structure and function,
and each drug is described with its action, thera-
peutic uses and pharmacopoeial prei^arations.
Although contained within the limits of a handy
volume of 650 pages, many of the definitions
possess encyclopaedic value. Useful anatomical
tind other data are tabulated with originality and
precision. Under the word Artery, for example,
is found a table covering eight pages, presenting

the origin, lateral and terminal branches and
their distribution, of each vessel. Twenty tabu-
lar pages are allotted to the origin, direction and
insertion of the muscles, with their action and
nerve-supply ; wliile thirty-two more are given
to the " Table of Bacteria and Fungi," with
their origin, morphological characters, proper
temperature for culture, properties, etc., as well
as a complete list of all bacteriological diseases.
The latter is the most comprehensive and service-
able table of the kind yet issued. The system of
pronunciation is simple, and the spelling is in
accordance with the best usage. Derivations
from foreign tongues are given, those from the
Greek being in English text for the benefit of
readers unfamiliar with tlie original. The au-
thor is to be congratulated upon the production
of a work combining such practical utility with
a fund of most extensive research. — 3Iedical
Record.

New (2d) Edition,

Musser's Medical Diagnosis-SiT

A Practical Treatise on Medical Diagnosis. For the Use of Students and
Practitioners. By John H. Musser, M.D., Assistant Professor of Clinical Medicine. Univer-
sity of Pennsylvania, Philadelphia. In one octavo volume of about 950 pages, with about
200 engravings and 10 colored plates.

THE great value of Professor Musser's Practical Treatise on Medical Diagnosis has been recog-
nized in the early exhaustion of the first edition. This new issue has been thoroughly revised,
every page bearing evidence of the author's complete command of this important subject, in-
cluding its latest developments. The series of illustrations has been much enlarged, and the list of
colored plates has correspondingly increased and enriched with many instructive pictures. Eeaders
of this work, will find in it a complete working guide to an art underlying any rational and contin-
ued success in treatment.

VOLUME I. IN PRESS.

The American System of Medicine.

In Contributions by Eminent Specialists. Edited by Alfred L. Loomis,
M. D., late Professor of Pathology and Practical Medicine in the New York University, and
William Oilman Thompson, M. D , Professor of Materia Medica, Therapeutics and Clinical
Medicine in the New York University. To be completed in four large octavo volumes, con-
taining about 1000 pages each, with illustrations in colors and in black.

THE appropriate time is at hand f()r the presentation of an entirely new and encyclopaedic work
emanating from acknowledged leaders of the American medical profession and dealing witli
the vast subject of Practice in a manner re])resenting the world's latest knowledge and in the
full development of clinical application for which this country has so enviable a reputation This
service cannot be satisfactorily performed exce]>t by those who are in actual touch with our people
and practically acquainted with the special features of disease developed by the social and climatic
conditions of this continent. The eminent editors of the American System of Medicine have
secured the willing assistance of gentlemen of the highest ability and experience, and have
assigned the various subjects to those who are recognized as peculiarly qualified to speak with full
authority. The work will therefore be regarded as representative in the best sense and as occupy-
ing a i)lace which can be filled in no other manner. The first volume will shortly be ready fi)r
issue and the remaining volumes will promptly follow.

BROTHERS & CO., Publishers J?N7rZ!:X.'ISr-;'sM;'Nrvork.

READY IN A FEW DAYS.

HARE'S PRACTICAL DIAGNOSIS.

The Use of Symptoms in the Diagnosis of Disease. By Hobaet Amory
Hare, M. D., Professor of Therapeutics in the Jelferson Medical College of Philadelphia,
Laureate of the Medical Society of London, of the Koyal Academy in Belgium, etc. In one
handsome octavo vol. of 566 pages, with 191 engravings and 13 colored plates. Cloth, |4.75.

THE experience of the author in both didactic and clinical teaching has shown that the all-im-
portant subject of diagnosis can be relieved of much of its difficulty by treating it exclusively
from a clinical standpoint. The object of this volume is to place before the physician and
student a guide to this art as it is actually used in practice. To accomplish this the symp-
toms used in diagnosis are discussed first, and their application to determine the character of
the disease fallows. Thus, instead of describing locomotor ataxia or myelitis, there will be found in
the chapter on the Feet and Legs a discussion of the various forms of and causes of paraplegia,
so that a physician who is consulted by a paraplegic patient can in a few moments find the various
causes of this condition and the differential diagnosis between each. So, in the chapter on the
Tongue, its appeai'ance in disease, both local and remote, is discussed. In other words, this book is
written upon a plan quite the reverse of that commonly followed, for in the ordinary treatises on
diagnosis the physician is forced to make a supposititious diagnosis, and, having done this, turn
to his reference book and read the article dealing with the disease supposed to be present, when if
the description fails to coincide with the symptoms of his case he must make another guess and
read another article. In this book, however, the discovery of any marked symptom will lead
directly to the diagnosis. Thus, if the patient is vomiting, in the chapter on Vomiting will be
found its various causes and the diagnostic significance, and the differentiation of each form of this
affection from any other.

The two indexes form an especially valuable and practical portion of the work. In the Index
of Diseases under each heading will be found annotated references to the various symptoms which
constitute its clinical picture. Conversely, the Index of Symptoms, Organs, and Terms furnishes a
ready-reference list of the various diseases in which any given symptom may appear as a feature.
It would be difficult to conceive of a work of greater utility. In connection with it the same author's
Practical Thera2)eutics (see page 8), may be most advantageously consulted for the best treatment.

Simon's Clinical Diagnosis — Just Ready.

A Manual of Clinical Diagnosis by Microscopical and Chemical Methods.

For Students, Hospital Physicians and Practitioners. By Charles E. Simon, M. D., Late
Assistant Resident Physician, Johns Hopkins Hospital, Baltimore. In one very handsome
octavo volume of 504 pages, with 132 engravings and 10 colored plates. Cloth, $3.50.
rpiIIE art of determining a disease from the evidences it presents as to its character must logically
I underlie any merited and continued success in treatment. To this end it is incumbent upon
the physician to avail himself of all the methods and facilities for precision in diagnosis
which modern research has placed so readily at his command. Among them none are more impor-
tant than those afforded by microscopy and chemistry, and it is the purpose of this volume to
describe such methods in detail so that the student or practitioner who has not had special training
in such manipulations, may nevertheless be enabled to obtain satisfactory results. The volume will
be found to be richly illustrated in black and colors and replete with practical information repre-
senting the most advanced knowledge obtained in American and European laboratories, clinics and

The American Text= Books of Dentistry — In Press.

In Contributions by Various Authors. Opekative Dentistry, edited by
Edward C. Kirk, D.D.S., Professor of Clinical Dentistry in the Department of Dentistry,
University of Pennsylvania. Prosthetic Dentistry, edited by Charles J. Essig, M.D.,
D. D. S., Professor of Mechanical Dentistry and Metallurgy in the Department of Dentistry,
University of Pennsylvania, Philadelphia. In two very handsome octavo volumes of 700 to
800 pages, profusely illustrated.

FOE many years the dental profession and teachers in dental colleges have expressed a desire
for works which would clearly and thoroughly reflect the practice of dentistry as it is known
in America. Recognizing the justice of these expressed needs, the publishers have placed in
the hands of gentlemen of peculiar fitness the task of editing two volumes intended to furnish a
practical working knowledge of the two main departments of dental science and art. It will be
found that these two works combine the features of text-books with those of laboratory manuals.
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the multifarious procedures in operative and prosthetic dentistry. Combined with a wealth of
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dental practice, and the student is thereby guided not only to technical skill, but also to a broad
intelligence in the application of principles.

The several contributors to these volumes are teachers of distinctive a>^ility in their respective
fields. The chapters will, accordingly, be found replete with material which the advanced yet
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detail in the technique, and a clear exposition of foundation principles are so happily combined in
these new works that their recognition as the standard text-books on their subjects is already
assured. They will be equally favorite reference works for dental 2:)ractitioners.

LEA BROTHERS & CO., Publishers, ^?^p^rA«„"!8^ts™^^

2

New (8th) Edition. Thoroughly Revised. Just Ready.

SMITH ON CHILDREN,

A Treatise on the Diseases of Infancy and Childhood.
By J. LEWIS SMITH, M. D.,

Clinical Professor of Diseases of Children in the Bellevue Hospital lledical College, New York.

New (8th) edition, thoroughly revised and rewritten and much enlarged. Handsome
octavo of 983 pages, with illustrations and 4 colored plates.
Cloth, $4.50; leather, $5.50.

The advances in our knowledge of the etiology,
therapeutics and pathology of the diseases of
children have called for a thorough revision of
this classical work. The author, in order to
perfect the subject in every possible way, in-
trusted the surgical diseases of children to Dr.
Stephen Smith and assigned certain of the
topics to Dr. Frederick M, Warner. The chap-
ter dealing with intubation was specially pre-
pared by Dr. Joseph O'Dwyer, and Dr. A. R.
Robinson contributed to the text and the illus-
tration of the portion of the book dealing with
skin diseases of children. In other words, the
distinguished author with rare modesty deter-
mined to secure assistance in the elucidation of

those portions of the book wherein he felt others
were more competent to speak with the weight
of authority, giving us a treatise which in every
respect can more than hold its own against any
other work treating of the same subject, be it
elaborate composite system or more modest text-
book. The result is that the practitioner will
still, as he has for long in the past, look to
Smithes Diseases of Children for that accurate
portrayal of symptoms, that lucid exposition of
treatment which stand him in good stead at the
bedside of his little patients. For years the
work under review has been the favorite, and
under the present auspices we question not that
it will remain such. — Am.Medico-Surg. Bulletin.

Parvin's Science and Art of Obstetrics — New (3d) Ed.

The Science and Art of Obstetrics. By Theophilus Parvin, M. D., LL.D.,
Professor of Obstetrics and the Diseases of Women and Children in Jefferson Medical Col-
lege, Philadelphia. New (3d) edition. In one very handsome octavo volume of 677 pages,
with 267 engravings, and 2 colored plates. Cloth. $4.25 ; leather, |5.25.

The book is complete in every department,
and contains all the necessary detail required by
the modern practising obstetrician. Many prac-
tical suggestions are otfered for physicians, both
young and old. Great stress is laid on the im-
portance of strict asepsis in obstetrical work,
and considerable space is devoted to the various
complications following infection. When treat-
ment is indicated, Dr. Parvin is explicit in di-
rections, the remedies suggested being those
which have given the best results in his own
practice, and the experience of other obstetri-
cians is never disregarded. The book deserves
our highest praise ; we consider it one of the
most comprehensive of its class published, and

take pleasure in recommending the same to
students and to physicians. — International lled-
ical 3Iagazine.

This most excellent treatise on the art of ob-
stetrics has arrived at its third edition. In the
present issue about one-third has been re-written,
and every page bears evidence of revision in con-
formity with the latest scientitic advancement.
The distinguished author and teacher has given
to the American profession a work on which
they can rely, and it is safe to say that it ranks
second to none in the English language. The
series of illustrations has been increased, render-
ing the work still more complete. — Annals of
Gynecology and Pediatry.

Yeo on Food in Health and Disease. — New (2d) Ed. just Ready.

Food in Health and Disease. By I. Burney Yeo, M. D., F. R. C. P., Profes-
sor of Therapeutics in King's College, London. In one 12mo. volume of 592 pages, v^ith
4 engravings. Cloth, $2.50.

PROPER feeding has rightly come to be recognized as one of the natural methods of combat-
ting disease and on that account more important even than the use of drugs. Conversely,
errors in recommending diet may be quite as serious as errors in prescribing. Physicians will
therefore value this convenient and authoritative manual, which approaches its subject rationally,
showing the proper use of foods in health and giving full information for the judicious pre-
scription and preparation of foods best suited to the needs of the system in the various diseases.

Treves' System of Surgery— Complete Work. Just Ready.

A System of Surgery. In Contributions by tvrenty-five English Authors
Edited by Frederick Treves, F. R. C. S., Surgeon to and Lecturer on Surgery at the
London Hospital, Examiner in Surgery at the Univ. of Cambridge. In tvv^o large octavo vol-
umes, containing 2322 pages, with 950 engravings and 4 plates. Per volume, cloth, $8.00.

Careful and acciinitc wi-iiing, close attention to
practical usefulness, well-balanced distribution
of space and material, and tliorough editorial
supervision, characterize this volume from cover
to cover. An excelk'iit level is maintained
throughout, and practical information brought

up to the latest knowledge upon each subject
abounds on every page. The book will make
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suri^-eon and of the practitioner. '^Phe illustra-
tions are most creditable; the majority of them
are original. — Annals of Surgery.

LEA BROTHERS & CO., Publishers,

Taylor on Venereal Diseases —

The Pathology and Treatment of Venereal Diseases. By Robert W.
Tayloe, A.m., M.D., Clinical Professor of Venereal Diseases in the College of Physicians and
Surgeons, New York. In one very handsome octavo volume of 1002 pages, with 230 engrav-
ings and 7 colored plates. Cloth, |5.00; leather, $6.00. Net

The best work on venereal diseases in the En-
glish language. It is certainly above everything
of the kind. Nothing is omitted and every-
thing carefully noted. Illustrations are numer-
ous and well chosen. The colored plates are
superior in execution. Every physician who
desires a complete and reliable library on the
subject of venereal diseases should avail him-
self of the opportunity of obtaining Taylor's
work. — St. Louis Medical and Surgical Journal.

Dr. Taylor's personal reputation is so high,
his experience has been so wide and full that it
is but natural that one should have the highest
expectations of the work which must be regarded
as the mature result of his ex])erience. It meets
the highest expectations. Treatment is taken up
at length. All the various methods and sugges-
tions are fully described and given careful con-
sideration. The whole subject of gonorrhoea
is dealt with in the broadest light. The subject
of chancroid is completely considered. All the
varieties of syphilis are considered. The ex-

position of the subject is clear, distinct and
broad, and is marked by the same practicality
and rational conservatism that characterize the
rest of the work. In treatment nothing has been
neglected. In its completeness the book leaves
almost nothing to be desired. It is a veritable
storehouse of our knowledge of the venereal dis-
eases. It is commended as a conservative, prac-
tical, full exposition of venereal diseases of the
greatest value. — Chicago Clinical Review.

This is by long odds the best work on venereal
diseases it has ever been our fortune to read.
The subject is treated in an exhaustive and com-
prehensive way that leaves nothing wanting.
Every possible information that could be desired
in the treatment of these diseases will be found
in this most excellent work. In this new work
Taylor has done much to render the services of
the non-specialist successful. Much praise is
due the illustrations, the colored plates being
particularly fine. — Louisville 3Iedical Monthly.

VAUGHAN & NOVY ON

Ptomains and Leucomains, Toxins and Antitoxins.

New (3d) Edition. Just Ready.

Ptomains, Leucomains, Toxins and Antitoxins ; or the Chemical Factors
in the Causation of Disease. By Victor C. Vaughan, Ph.D., M. D., Professor of
Hygiene and Physiological Chemistry in the University of Michigan, and Frederick
Gr. NovY, M. D., Junior Professor of Hygiene and Physiological Chemistry in the University
of Michigan. New (third) edition. In one 12mo. volume of 603 pages. Cloth, $3.00.

IT is now generally recognized that those diseases which cause the greatest mortality and conse-
quently are of the greatest importance are in reality cases of poisoning; that pathogenic germs
are living poisons and that every infectious disease is actually an intoxication. Not only are
there chemical factors in the causation of disease, but furthermore, specific chemical agents are now
being employed in its prevention and cure. In the present volume will be found a systematic expo-
sition of etiological, preventive and curative chemistry. The widespread interest in its department,
and the acceptance of this volume as the standard authority has led to the demand for three editions.
These opj^ortunities have been utilized by the authors to keep it always abreast with the rapidly
advancing knowledge in its dejsartment. The j^resent edition has not only been thoroughly revised
throughout but also greatly enlarged, s]3ace being given to the new subjects of Toxins and Anti-
toxins, which have assumed great and merited j^ractical importance of recent years.

Abbott's Bacteriology— New (3d) Edition. Just Ready.

The Principles of Bacteriology : a Practical Manual for Students and Physicians.

By A. C. Abbott, M.D., First Assistant, Laboratory of Hygiene, University of Pennsylvania,

Philadelphia. New (third) edition, thoroughly revised and greatly enlarged. In one very

handsome 12mo. vol. of 492 pp., with 98 illustrations, of which 17 are colored. Cloth, $2.50.

As a practical compend on the principles of
bacteriology this treatise has no superior among
American works, and has accoi-dingly come into
very general use as a laboratory manual among
students. All that portion of the book that re-
lates to technical procedures is very satisfactory,
and directions are stated with sutficient minute-
ness to guide any ordinary beginner. Of special
value to the student of bacteriology are the out-
lines of experiments to be followed in the study
of the various species. The chaj^ters on animal
experimentation contain descriptions of all the
newer apparatus and procedures, and will be
found invaluable to anyone who is not perfectly

familiar with the ditficulties of this work. Not
only are the needs of the student considered, but
the advanced worker will find a very full choice
of all the newer staining methods, instruments,
and procedures for diagnosis. In the descrip-
tions of several important species many recent
additions to our knowledge have been properly
incorporated and these chapters may be consid-
ered as giving all that is certainly known on the
subjects. It only remains to rejDeat our unre-
served recommendation of the work for the use
of all laboratory workers in bacteriology. — New
York Medical Journal.

LEA BROTHERS & CO., Publishers, I^FTrA^^^oris^^^^^

4

Dercum on Nervous Diseases-Just Ready.

A Text-Book on Nervous Diseases. By Twenty-two American Authors.
Edited by F, X. Deecum, M.D., Clinical Professor of Diseases of the Nervous System in the
Jefferson Medical College, Philadelphia. In one handsome octavo volume of 1046 pages, with
341 engravings and 7 colored plates. Cloth, |6.00 ; leather, |7.00. [Net.)

The work is representative not only of Ameri-
can neurology, but likewise of the best methods
of teaching as developed in the leading medical
colleges ot this country. Actual experience
with our social and climatic conditions is essen-
tial as a qualification in those who would sjjeak
with authority upon this especial subject. —
Alienist & Neurologist.

Here is a volume which bespeaks present-day
neurology in no uncertain or unauthoritative
voice. There is here gathered the very cream of
our knowledge of to-day. Most of the writers are,
or have been, associated with various leading
schools, and consequently bring to their aid the
faculty of lucid statement, always forcible and
understandable. The book wiJl remain the stand-
ard one in its line. — Chicago Clinical Review.

The best text-book in any language, especially
adapted to the wants of the student and the gen-
eral practitioner. — Medical Fortnightly.

The whole book is the most thoroughly up-
to-date treatise that we have on its subject, and
should be in every hospital and asylum. —
American Journal of Insanity.

This volume is made up of the writings of
twenty-two authors including most of that band
of workers which has lifted neurology in this
country up to the high plane which has made it
command the respect and admiration of workers
in all departments of medicine. The book is
the most comprehensive of its kind yet pub-
lished in the United States, and will be found a
safe guide either as a text-book or work of
reference. — The Pittsburgh 3fedical Review.

Hayden on Venereal Diseases— Just Ready.

A Manual of Venereal Diseases. By James R. Hayden, M. D., Chief of
Venereal Clinic College of Physicians and Surgeons, New York; Professor of Genito-Urinary
and Venereal Diseases, University of Vermont, etc. In one 12mo. volume of 263 pages, with
47 engravings. Cloth, $1.50.

PRACTITIONERS as well as students will welcome this authoritative and compendious guide
to the diagnosis and treatment of the three venereal diseases : Gonorrhoea, Chancroid and
(Syphilis.

Foster's Physiology— sixth American Edition.

Text-Book of Physiology. By Michael Foster, M. D. , F. R. S , Prelector in
Physiology and Fellow of Trinity College, Cambridge, England. New (sixth) and enlarged
American edition, with notes and additions. In one handsome octavo volume of 922 pages,
with 257 illustrations. Cloth, |4.50 ; leather, |5.50.

Dr. Foster's text-book has long held its place
at the very forefront of physiological teaching.
We will admit that for the purpose of a text-
book for the medical undergraduate the sixth
American edition is superior to any of its prede-
cessors, and is unquestionably the best book
that can be placed in his hands, and as a work of
reference for the busy physician it can scarcely
be excelled. — The PhUadelphia Polyclinic.

The great popularity of the work is shown by
the fact that it is included as a text or reference
book in nearly every medical college annual
announcement. For physician, student or
teacher this is and long will remain the stand-
ard, up-to-date work on physiology. It needs

no recommendation beyond its own merits to
establish its claim as the physiological text-
book of the day. — Virginia Medical Monthly.

Every practitioner, whether general or vSpecial,
should have at hand a new up-to-date physi-
ology. There can be no mistake in selecting a
Foster, either on the part of the medical student
or practitioner. — Pacific Medical Journal.

In the new American edition just at hand
additions have been made to render the volume
suitable for junior as well as advanced students,
so that this single volume contains all that will
be necessary in a college course, and it may be
safely added all that the physician will need as
well. — Dominion Medical Monthly.

Mitchell on Nerve Injuries and Their Treatment— ^'^^^ady.

Remote Consequences of Injuries of Nerves and Their Treatment.

An examination of the present condition of wounds received in 1863-65, with additional
illustrative cases. By John K. Mitchell, M. D., Assistant Physician to the Orthopaedic
Hospital and Infirmary for Nervous Diseases, Philadelphia. In one handsome 12mo. vol
ume of 239 pages, with 12 illustrations Cloth, $1.75.

Cases of such long duration and of such severity
are so seldom reported that every case presents
individual symptoms of great interest, which
cannot, hovever, be enumerated in a brief re-
view. The work has been admirably done and
it will prove indispensable to every neurolo-
gist and surgeon. — Boston Medical and Surgi-
cal Journal.

The work before us is an unusual one, if not
absolutely uni<iue. It is a study, thirty years
after the war, of the cases of gunshot and other
injuries of nerves collected l)y the elder Mitchell
during the war. In spite of the enormous diffi-
culties in following up the cases after sucli a.
long period, the author has given us an elabor-
ate study of fifty-two cases of gi-eat interest.

LEA BROTHERS & CO., Publishersjrr7rAir:X.T87HSM:''^^^^^

York.

5

New Edition. With Appendix. Just Ready.

DUNQLISON'S

Dictionary of Medical 5cience.

A Dictionary of Medical Science. — Containing a Full Explanation of the
Various Subjects and Terms of Anatomy, Physiology, Medical Chemistry, Pharmacy, Phar-
macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Surgery, Ophthalmology,
Otology, Laryngology, Dermatology, Gynecology, Obstetrics, Pediatrics, Medical Jurisprudence
and Dentistry, etc., etc. By Eobley Dunglisox, M. D., LL.D., late Professor of Institutes ot
Medicine in the Jefferson Medical College of Philadelphia. Edited by Richaed J. Dungli-
SON, A. M., M. D. New edition, thoroughly revised, greatly enlarged and improved, with
the Pronunciation, Accentuation and Derivation of the Terms. With Appendix.
In one magnificent imperial octavo volume of 1225 pages. Cloth, |7.00 ; leather, |8.00.
Thumb-letter Index for quick use, 75 cents extra.

It is a fact recognized by all those interested
in the medical sciences tliat Dungiison's Medical
Dictionary is the most satisfactory and authori-
tative guide to the derivation, definition and
pronunciation of medical terms. Everybody is
familiar with this dictionary. It has i)assed
through twenty-one editions. — The Charlotte
Medical Journal.

Covering the entire field of medicine, surgery
and the collateral sciences, its range of useful-
ness, can scarcely l)e measured. Perhaps the
most valuable feature in the present work is the
addition of a vast amount of practical matter. —
Medical Record.

There has been a i>raiseworthy attemi>t to
render the work an epitome of the existing con-
dition of medical science. Tlius, under the
heading Hernia, besides tlie definition of the
condition, a condensed tal)le is given of the
various forms, and a l>rief resume is given of
the therapentie indications. Under the heading
Murmurs, l)esides a deseri]>tion of the various
forms, a table is given of the significance of
the murmurs of valvular origin. Under Bacteria

the leading classifications are recorded, and a
l)aragraph is devoted to the questions of the de-
termination of the pathogenic properties, and
anotlier to modes of culture of the bacteria. In
addition, the work is for the first time made a
l>ronouncing dictionary. — Montreal Medical
Journal,

The new "Dunglison" is new indeed. The vast
amoiuit of new matter and the thoroughness
with whieli the work has been brought down to
date cannot fail to strike even the least observant
reader. The immense advances made in all
branches of medical science here find representa-
tion. In respect to accuracy the book quite
equals and usually surpasses any of its contem-
poraries that we are acquainted with. — The
American Journal of the Medical Sciences.

So fully have derivations and definitions been
considered, and so great is the amount of practi-
cal matter, such as symptoms, treatment and
prognosis of many of the diseases described,
that the volume is entitled to be called an en-
cyclopsedia rather than a dictionary. — Brooklyn
\ Medical Journal.

Gray's Anatomy— 13th Ed. ''TrTnbuack

Anatomy, Descriptive and Surgical. By Henry Gray, F.R.S , Lecturer on
Anatomy at St. George's Hospital, London. Edited by T. Pickering Pick, F.R.C S., Surgeon
to and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Eoyal
College of Surgeons of England. A new American from the thirteenth enlarged and improved
London edition. In one imperial octavo volume of 1118 pages, with 636 large and elaborate
engravings on wood. Price of edition with illustrations in colors : Cloth, $7.00 ; leather,
$8.00. Price of edition with illustrations in black : Cloth, $6.00 ; leather, $7.00.

Teachers of anatomy are almost unanimous in
recommending " Gray " as the standard work
for the student. The illustrations are conceded
to be the best that have yet been given to the
profession. In short, Gray'' s Anatomy is the
ideal text-book on this subject, and it is sufficient
to say of the present edition that it is fully equal
to the previous ones, with many valuabie addi-
tions, and that it fully deserves the same un-
qualified commendation it has received in the
past. — Cleveland 3Iedical Gazette.

Gray has been the unvarying standard for
anatomical study by the vast majority of
English-speaking medical students. — Medical
Fortnightly.

It has thoroughly and completely established
itself as the anatomy ^jar excellence. — Brooklyn
Medical Journal.

In modern times no book on any medical sub-
ject has held the position of a standard so long

as Gray^s Anatomy. It is a complete atlas of
anatomy. The physician or student who requires
but one work on anatomy will not need to ask
which. The work is admitted to be easily first
on anatomy in any language — The American
Practitioner and News.

We always had a kindly regard for the illus-
trations in Gray, where each organ, tissue,
artery and nerve bear their respective names,
and in this edition, color has been worked to
advantage in bringing out the relationship of
vessel and nerve. — Buffalo Medical and Surgical
Journal.

The matchless book of the doctor's or surgeon's
library is and has been Gray^s Anatomy. It has
held the leading place in all colleges as a text-
book, and has been the one central figure in the
many text-books in anatomy that have claimed
attention. It is still the standard text-book. —
Kansas City Medical Index.

LEA BROTHERS & CO., Publishers,

CULBRETH'S
Materia Medica and Pharmacology — Just Ready.

A Manual of Materia Medica and Pharmacology. Comprising all Organic
and Inorganic Drugs, which are and have been official in the United States Pharmacoposia,
together with important Allied Species and Useful Synthetics. For Students of Medicine,
Druggists, Pharmacists and Physicians. By David M. R. Culbketh, M. D., Professor of
Botany, Materia Medica and Pharmacognosy in the Maryland College of Pharmacy. In
one handsome octavo volume of 812 pages, with 445 illustrations. Cloth, |4.75.

ALL the several classes of readers for whom this work is intended will find in it a thorough,
authoritative and systematic exposition of its most important domain. Etfective treatment
by means of drugs necessarily depends upon knowledge of the agents employed. To place
this most easily and rationally at command the author has grouped the various substances according
to their natural relations, giving the classification, name, source, constituents, adulterations,
preparations, manufacture, properties, medical uses, dosage and allied drugs. The materia medica
of the animal, vegetable and mineral kingdoms are thus exhaustively and practically described,
including the new and important additions with which organic and synthetic chemistry has
increased the powers of the physician. The volume closes with sections on use of the microscope,
poisons and antidotes, various useful tables, maximum doses, customary abbreviations and a very
full index. The series of illustrations is exceptional for the number and beauty of the engravings.

Caspari's Pharmacy — Just Ready.

A Text-Book on Pharmacy. For Students and Pharmacists. By Charles
Caspaei, Jr., Ph. G., Professor of the Theory and Practice of Pharmacy in the Maryland
College of Pharmacy. Baltimore. In one handsome octavo volume of 680 pages with 288
illastrations. Cloth, $4.50.

The author is widely and favorably known as
ioint-editor of The National Dispensatory, and
as Professor of Pharmacy in one of the foremost
pharmaceutical colleges of this country. His
exceptional opportunities for knowing the needs
of students and pharmacists and how to answer
them in the best manner are conspicuously em-
bodied in this work. It has been possible to
include in a convenient volume all the theoreti-

cal and practical information which the student
and pharmacist will need. The multifarious
details of every-day work are described and
illustrations have been liberally employed
wherever they could elucidate manipulations
and processes. It is the most practical book
possible. The working formulas are models of
their kind. — Pacific Record of Medicine and
Surgery.

JUST READY.

The National Dispensatory
^i^^airgSi^ror The National Formulary.

The National Dispensatory. Containing the Natural History, Chemistry, Phar-
macy, Actions and Uses of Medicines, including those recognized in the Pharmacopoeias of
the United States, Great Britain and Germany, with numerous references to the French
Codex. By Alfred Stille, M.D., LL.D., Professor Emeritus of the Theory and Practice of
Medicine and of Clinical Medicine in the University of Pennsylvania ; John M. Maisch,
Phar. D., late Professor of Materia Medica and Botany in Philadelphia College of Phar-
macy, Secretary to the American Pharmaceutical A^ssociation ; Charles Caspabi, Jr., Ph.G.,
Professor of Pharmacy in the Maryland College of Pharmacy, Baltimore; and Henry
C. C. Maisch, Ph. G., Ph. D. New (fifth) edition, thoroughly revised and incorporating
the new U. S. Pharmacopoeia (Seventh Decennial Revisioa) and likewise embracing the new
edition of The National Formulary. In one magnificent imperial octavo volume of 2025 pages,
with 320 engravings. Cloth, |7.25 ; leather, $8.00. With Ready Reference Thumb-letter
Index, cloth, $7.75 ; leather, $8.50.

The careful examination of this large volume
will strike the reader with surprise at the great
number of new articles added, and the amount
of useful and accurate information regarding
their properties, methods of preparation and
therapeutical effects. The large number of new
articles containing all the latest synthetic
remedies and unofficial remedies, compass the
entire range of available information in the line
of the work. A number of very complete tables
together with all the official re-agents and sohi-
tions for qualitative and quantitative tests,

appear in the appendix. Altogether this work
maintains its previous high reputation for
accuracy, practical usefulness and encyclopaedic
scope, and is indispensable alike to the phar-
macist and physician. Every druggist knows
of it and uses it, and almost every physician
properly consults it when desirous of settling-
all doubtful questions regarding the properties,
preparation and uses of drugs. — Medical Record.

It is the official guide for the medical and
pharmaceutical professions. — Buffalo Medical
and Surgical Journal.

LEA BROTHERS & CO., Publishers, jrrp7rAr„!:X^';":8u:'N'r^

York.

Hare's Text-Book of Practical Therapeutics -New (gth) Ed.

A Text-Book of Practical Therapeutics ; With Especial Reference to the
Application of Remedial Measures to Disease and their Employment upon a Rational Basis.
By HoBART Amory Haee, M. D., Professor of Therapeutics and Materia Medica in the
Jefferson Medical College of Philadelphia. With special chapters by Des. G. E. de
ScHWEiNiTZ, Edward Martjn and Barton C Hirst. New (fifth) edition. In one octavo
volume of 740 pages. Cloth, |3.75 ; leather, $4.75.

Five editions in as many years constitute a
remarkable record for any book, aud further-
more, an evidence that medical teachers and
practitioners appreciate a work closely adapted
to their requirements. Professor Hare is well
known as a progressive and able therapeutist
and teacher, and his ability in both directions
is attested in the highly original plan of this
work, as well as in its execution. His purjiose
has elearly ])een to bring a knowledge of the
remedial agents into close relation with a knowl-
edge of disease. The book consists essentially
of two x^arts, the first being a, treatise on thera-
peutics, both medicinal and non-medicinal ; the
second being a treatise on disease, its symptoms,
varieties, treatment, etc. The two parts are
brought into direct connection by means of refer-
ences so that a knowledge of any subject treated
is easily gained. Ease of reference is, moreover,
l^rovided for in the highest degree by the ali)ha-

betical arrangement of the book and by the two
full indexes. Practitioners will find the Thera-
peutical Index, in which all the remedial mea-
vsures are listed with brief annotations under the
headings of the several diseases, most suggestive
and serviceable. Like preceding issues, the
present edition has been revised to the latest
date. — Columbus Medical Journal.

We have stated in public through previous
reviews, and often remarked in private, that
Hare's Practical Therapeutics was one of the
most useful books which a physician could have
in his library. It is this combination of the
theoretical and the practical which makes the
book so valuable to the practitioner especially.
It is a book precisely adapted to the needs of
the busy jjractitioner, who can rely upon find-
ing exactly what he needs. — The National Med-
ical Review.

Simon's Chemistry— Fifth Edition.

Manual of Chemistry. A Guide to Lectures and Laboratory work for Begin-
ners in Chemistry. A Text-book specially adapted for Students of Pharmacy and Medicine.
By W. Simon, Ph. D., M. D., Professor of Chemistry and Toxicology, Coll. of Phys. and
Surg., Baltimore ; Professor of Chemistiy in the Maryland College of Pharmacy. Fifth
edition. Jn one 8vo. volume of 501 pages, with 44 engravings and 8 colored plates illus-
trating 64 of the most important chemical tests. Cloth, $3.25.

The exhaustion of tlie very large fourth edi-
tion in less than two years indicates the leading
position achieved by professor Simon's Chem-
istry as a text-book in medical and i)harma-
ceutical colleges. It furnishes an admirable
selection of material bearing upon the bnvs and
phenomena of chemistry. As an aid to labora-
tory work a number of exixriments have been
added. Physicians as well as students will
appreciate the value of the colored ] dates of
reactions, which give a permanent and accurate
series of standards for comi)arison of tests, a
matter not susceptible of satisfactory explana-
tion in words. In medical ])ractice important
pathological and toxicological questions depend-

ing on the test-tube may with certainty be
referred to this series of colors and color-changes.
The new edition has been most carefully re-
vised in accordance with the advance of science
and in order to bring it into complete harmony
with the new Pharmacopoeia. All chemicals
mentioned in the last issue of that work are
included. Special care has been taken to detail
the most modern methods for chemical examin-
ation in clinical diagnosis. The author's ex-
perience as a physician and as a teacher of medi-
cal and pharmaceutical students is reflected in
the special adaptation of his book to the needs of
all concerned with the applications of chemistry
to the art of healing. — Southern Practitioner.

Maisch's Materia Medica — Sixth Edition.

A Manual of Organic Materia Medica ; Being a Guide to Materia Medica of
the Vegetable and Animal Kingdoms. Eor the use of Students, Druggists, Pharmacists and
Physicians. By John M. Maisch, Phar. D., Professor of Materia Medica and Botany in the
Philadelphia College of Pharmacy. New (sixth) edition, thoroughly revised by H. C. C.
Maisch, Ph. G. In one very handsome 12mo. volume of 509 pages, with 285 engravings.
Cloth, $3.00.

Maiseh's Materia Medica is too well established
in the favor of pharmacists, druggists and botan-
ists to need introduction. New matter has been
added, and the whole work has received careful
revision, so as to conform to the new United
States Pharmacopceia. The great value of the
work is the simplicity of the style and the accu-
racy of each description. It considers each article
of the vegetable and animal pharmacopceia, and,
where important, sections on antidotes, etc.,
are added. Several useful tables are incorpor-
ated.— Virginia Medical Jfonfhly.

The best handbook upon pharmacognosy of
any published in this country. The revision

brings the work up to date, and is in accord
with its previous high standard. — The Boston
Medical and. Surgical Journal.

AVe can add nothing to our previous commen-
datory notices of this standard text-book of
materia medica. It is a work of such well-tried
merit that it stands in no danger of being
superseded, but will always remain a splendid
monument to the genius and untiring industry
of one to whom Americian pharmacy is under a
great debt for many notable contributions to the
sum of our knowledge of vegetable drugs. —
American Druggist and Pharmaceutical Record.

LEA BROTHERS & CO., Publishers, ZVZ.'^^lT^lZ.rsT^T^^^^^^^^^^

8

Complete Work Just Ready.

A SYSTEM OF SURGERY.

BY AMERICAN AUTHORS.

Edited by Frederic S. Dennis, M. D. , Professor of the Principles and Practice of
Surgery, Bellevue Hospital Medical College, New York ; President of the American Surgical
Association, etc. Assisted by John S. Billings, M. D., LL. D., D. C. L., Deputy Surgeon-
General, U. S. A. In four imperial octavo volumes, containing 3652 pages, 1685 engravings
and 45 full-page plates in colors and monochrome. Price per volume : Cloth, $6 ; leather, $7 ;
half morocco, $8.50, For sale by subscription only. For prospectus with order blank address
the Publishers.

We very much doubt whether any work has
ever appeared in the English language which
better represents the height to which American
surgery has attained. The authors are types of
American surgeons, and they deal with the sub-
jects allotted to them in a masterly manner. —
Brooklyn lledi'ccU Journal.

The authors are all men who, from their
positions as teachers of surgery, either clini-
cally or systematically, can claim to be ^ble to
speak with authority on the subjects which they
have undertaken, and the names of many of
them are well known in this country. It is not
possible to judge of the whole work from this
first volume ; but we may say of it that it gives
a careful and accurate account of that part of
surgery of which it treats, and that it is worthy

of the position to which surgery has attained
in the great republic whence it comes. — The
London Lancet.

The whole is the work of American surgeons,
and it may be fairly said to represent the most
advanced condition of American surgery. —
Annals of Surgery.

Its intrinsic worth is of such a character that
no progressive and intelligent operator could well
do without it. — St. Louis 3Ied. and Surg. Jour.

It is almost an act of supererogation to at-
tempt to criticise a work of this importance,
every chapter of which is written by an ac-
knowledged authority in his sphere. It is the
most valuable contribution that we have had of
late years to the subject of general surgery. —
American Medico-Surgical Bulletin.

Politzer on Diseases of the Ear — New Edition.

A Text-Book of Diseases of the Ear and Adjacent Organs. By Dr.

Adam Politzer, Imperial-Eoyal Professor of Aural Therapeutics in the University of
Vienna, Chief of the Imperial-Royal CJaiversity Clinic for Diseases of the Ear in the General
Hospital, Vienna. Translated into English from the third and revised German edition, by
Oscar Dodd, M. D.. Clinical Instructor in Diseases of the Eye and Ear, College of Physicians
and Surgeons, Chicago. Edited by Sir William Dalby, F.K.C.S., M.B., Consulting Aural
Surgeon to St. George's Hospital, London. In one large octavo volume of 748 pages, with
330 original illustrations. Cloth, |5.50.

This edition of the eminent Vienna professor's
well-known work will be welcomed by those
who wish to obtain a complet'* account of all
that is known in connection with aural diseases.
Whoever peruses it carefully cannot fail to be
struck with the details, the extensive references,
and especially the valuable pathological data,
which underlie the clinical remarks and details
of methods of treatment. The anatomy and
physiology of each part of the organ of hearing

are carefully considered, and then follows an
enumeration of the diseases to which that special
part of the auditory apparatus is especially
liable. The indications for treatment are clear
and reliable. We can confidently recommend
it, for it contains, as stated by the editor in his
preface, all that is known upon the subject. —
London Lancet.

A safe and elaborate guide into every part of
otology. — American Journal of the Med. Sciences.

Norris & Oliver's Text=Book of Ophthalmology.

A Text-Book of Ophthalmology. By William F. Norris, M.D., Pro-
fessor of Ophthalmology in the University of Pennsylvania, and Charles A. Oliver, M.D.,

Surgeon to Wills Eye Hospital, Philadelphia,
engravings and 5 colored plates Cloth, $5.00

We take pleasure in commending the " Text-
book " to students and practitioners as a safe
and admirable guide, well qualified to furnish
them, as the authors intended it should, with
" a working knowledge of ophthalmology." —
Johns Hopkins Hospital Bulletin.

The first text-book of diseases of the eye writ-
ten by American authors for American colleges
and students. Every method of ocular precision
that can be of any clinical advantage to the
e very-day student and the scientific observer is
offered to the reader. Ilules and procedures
are made so plain and so evident, that any
student can easily understand and employ
them. It is practical in its teachings. In treat-
ment it can be accepted as from the voice and
the pen of a respected and recognized authority.

Very handsome octavo, 641 pages, with 357
leather, $6 00.

The illustrations far outnumber those of its con-
temporaries, whilst the high grade and unbiased
opinions of the teachings serve to give it a rank
superior to any would-be competitor. Wonder-
fully cheap in price, beautifully printed and
exquisitely illustrated, the mechanical make-up
of the book is all that can be desired. After a
most conscientious and painstaking perusal of
the work, we unreservedly endorse it as the
best, the safest and the most comprehensive
volume upon the subject that has ever been
offered to the American medical public. We
sincerely hope that it may find its way into the
li&t of text-books of every English-speaking
college of medicine. — Annals of Ophthxdmology
and Otology.

LEA BROTHERS & CO., Publishers, ^?^p7^Arn!:X^*8rH^«:'Nr'v

York.

NEW (SECOND) EDITION.

Gray on Nervous and Mental Diseases.

A Practical Treatise on Nervous and Mental Diseases. By Landon
C!artee GrRAY, M. D., Professor of Diseases of the Mind and Nervous System in the New
York Polyclinic. New (2d) edition. In one very handsome octavo volume of 728 pages,
with 172 engravings and 3 colored plates. Cloth, |4.75 ; leather, $5.75.

We have here what has so often been desired
— an up-to-date text-book upon nervous and
mental diseases combined. Although, as re-
garded to-day, these branches constitute two
distinct specialties, yet they are intimately con-
nected. Therefore the presentation of a well-
written, ter^e, explicit and authoritative volume
treating of both subjects is a step in the direc-
tion of popular demand. The glossary of words
and terms is of much importance to the student,
readily enabling him to become familiar with
terms frequently encountered in neurological
study — The Chicago Clinical Revieiv.

It is a pleasure to write a notice of a book of
this character. The well-known literary attain-
ments of the author, the fine paper and beautiful
text, the elegant illustrations, many of which are
in colors, make it easy to understand why this
book has passed to a second edition. Five new
chajiters have been added in this edition. "The
word treatment," says the author, " has been con-
strued in the broadest sense to include not only
medicinal and non-medicinal agents, but also

those hygienic and dietetic measures which are
often the physician's best reliance." This edition
will be found carefully revised and brought up
to date. The book will be found as interesting as
its predecessors, and retaining all of the charac-
teristics which made the first edition popular. —
The Jour, of the American Medical Association.

This treatise has principally been written for
the benefit of the general practitioner. Mental
diseases have been considered from the stand-
point of the general physician. Therapeutic
suggestions in the book are detailed and precise,
and only such knowledge has been admitted to
the pages of the book as has stood the test of
exj)erience. Unlike many other text-books, due
attention has been paid to the medico-legal as-
pects of nervous and mental diseases. The term-
inology is rendered easy of acquisition by the
derivations and definitions given in an appended
glossary. The mimerous illustrations are very
good. The work will be found a most useful
and valuable addition to the library of every
practitioner and student. — Medical Revietv.

Stimson's Operative Surgery • — New (3d) Edition. Just Ready.

A Manual of Operative Surgery. By Lewis A. Sttmson, B.A., M.D., Pro-
fessor of Clinical Surgery in the New York University. New (3d) edition. In one royal
12mo. volume of 614 pages, with 306 illustrations. Cloth, $3.75.

The book contains clear and concise descrip-
tions of the most important oj^erations of mod-
ern surgery. It is well illustrated, and we take
pleasure in recommending it to the profession
as a handy descriptive manual of operative
surgery. — Annals of Surgery.

This compact, tersely written manual has been
almost rewritten in the laudable eftbrt to note
the imj^ortant changes in the science and prac-

tice of operative surgery. The illustrations are
plentiful, and the descriptions of technique are
admirable for their clearness. — Medical Record.

The thorough, concise and clear manner in
which it is written, with its accurate illustra-
tions, make this aji indispensable book for all
busy operators and students. — The Medical
Fortnightly.

Ashhurst's Surgery. — Sixth Edition.

The Principles and Practice of Surgery. By John Ashhurst, Jk., M. D.,
Barton Professor of Surgery and Clinical Surgery in the University of Pennsylvania, Surgeon
to the Pennsylvania Hospital, Philadelphia. Sixth edition, enlarged and thoroughly revised.
In one octavo volume of 1161 pages, with 656 illus. Cloth, $6.00 ; leather, $7.00,

We have yet to see the same amount of
scholarly and extensive inf(trmation on the sub-
ject of surgery in any other single volume — and
seldom in a number of volumes. As a masterly
epitome of what has been said and done in sur-
gery, as a succinct and logical statement of the
principles of the subject, as a model text-book,
we do not know its equal. It is the best single
text-book of surgery that we have yet seen in
this country. — New York Post- Graduate.

The fact that a book has reached its sixth edi-
tion should speak volumes in its favor, and an
examination of the work before us will soon
reveal the reasons of its popularity. It is sys-
tematic and takes up and treats subjects in
logical order, Avhich makes it esi^ecially valu-

able, because the subject thereby becomes more
clearly understood and easily remembered. The
author has not l^een content merely with giving
his own favorite notions, but has presented the
views of other surgeons as well, always, how-
ever, indicating his own judgment or prefer-
ence. This makes it valuable and suggestive as
a reference book for the jjractitioner. In fact,
it is surprising what an encyclopsedic amount of
information is condensed within its eleven hun-
dred and sixty-six pages. In the present edition
fifty pages of new matter have been added. In
short, it is about what one would expect in an
up-to-date edition of a standard American text-
book.— Cleveland 3Iedical Gazette.

lEA BROTHERS & CO., Publishers, ;?^p7^A":„!:"^7.^'8^\^?;rNrv.*.

10

SEVENTH EDITION.

Flint's Practice of Medicine.

A Treatise on the Principles and Practice of Medicine. Designed for the
use of Students and Practitioners of Medicine. By Austin Flint, M. D., LL. D., Professor
of the Principles and Practice of Medicine and of Clinical Medicine in Bellevue Hospital
Medical College, N. Y. Seventh edition, thoroughly revised by Frederick P. Henry,
M. D., Professor of the Principles and Practice of Medicine in the Woman's Medical College of
Pennsylvania, Philadelphia. In one very handsome octavo volume of 1143 pages, v^ith
illustrations. Cloth, $5.00 ; leather, $6.00.

Its peculiar excellences and its breadth of
conception have made it a recognized authority.
The author was a born teacher, an indefatigable
observer, a painstaking worker and a thorough
medical philosopher. His clinical pictures of
diseases are models of graphic description,
minuteness of detail and breadth of treatment.
This may appear to be high praise, but the
work has so well earned its leading place
in medical literature that but one view can be
expressed concerning its general character as a
text-book. The editor has done his part in bring-
ing it up to date, not only in reference to treat-
ment and the adaptation of the newer remedies,
but has made numerous additions in the shape
of the newly discovered forms of disease, and has
elaborated much in the commoner forms which
the recent advances have made necessary. The
element of treatment is by no means neglected ;

in fact, by the editor a fresh stimulus is given to
this necessary department by a comprehensive
study of all the new and leading therapeutic
agents. — Medical Record.

The leading text-book on general medicine in
the medical schools of the United States. It is
of all books the book of an American physi-
cian, looking at disease as it is seen in this
country. A great charm about Flint is the
clear and straightforward way in which he goes
at the work of describing disease from the clin-
ical standpoint, arranging it all as the ])racti-
tioner himself would handle a case, and follow-
ing out the train of thought that arrives most
quickly and surely at the important results of
diagnosis, prognosis and treatment. The revision
has been well done by Professor Henry, who
has added much that is new. — Northwestern
Lancet.

Thomas & Munde on Diseases of Women — Sixth Ed.

A Practical Treatise on the Diseases of Women. By T. Gaillaed Thomas,
M. D., LL.D., Emeritus Professor of Diseases of Women in the College of Physicians and
Surgeons, New York, and Paul F. Munde, M. D., Professor of Gynecology in the New
York Polyclinic. Sixth edition, thoroughly revised and rewritten by Dr. Munde. In one
large and handsome octavo volume of 824 pages, with 347 illustrations, of which 201 are new.
Cloth, $5.00 ; leather, $6.00.

The best practical treatise on the subject in
the English language. The original work is
preserved as a basis, but amplified and enriched
with the results of modern research. Much has
been interspersed with the old material and
several new chapters added. It is, as we have
said, the best text-book we know, and will be
of especial value to the general practitioner
as well as to the specialist. The illustrations
are very satisfactory. Many of them are new
and are particularly clear aiid attractive. The
book will undoubtedly meet with a favorable
reception from the profession. — Boston Medical
<ind Surgical Journal.

This work, which has already gone through
jfive large editions, and has been translated into

French, German, Spanish and Italian, is too
well known to require commendation now
upon the appearance of this, the sixth edition.
It has been thoroughly revised and brought up
to date by Dr. Munde, who is announced as joint
author. Many new illustrations have been
added, and the text has been increased by the
addition of new chapters. The distinctive fea-
tures of the work, which made it so attractive
when first issued, have in a measure been re-
tained, so that it continues to be the most prac-
tical and at the same time the most complete
treatise upon the subject in print, the changes
that have been made only increasing its value. —
The Archives of Gynecology, Obstetrics and
Pediatrics.

Merrick's Handbook of Diagnosis — Just Ready.

A Handbook of Diagnosis. By James B. Herrick, M.D., Adjunct Professor
of Medicine, Rush Medical College, Chicago. In one handsome 12mo. volume of 429 pages,
with 81 engravings and 2 colored plates. Cloth, $2.50.

It is an excellently arranged, practical, concise
and well-written treatise on the subject, brought
U]) to date, and eminently well fitted for the use
■of the practitioner as well as of the student. —
The Chicago Medical Recorder.

We commend the book not only to the under-
graduate, but also to the physician who desires
a ready means of refreshing his knowledge of
diagnosis in the exigencies of professional life.
A number of illustrations, comprising many
characteristic engravings in black and two plates
in colors, add much to the practical value of the
text. — Memphis Medical Monthly.

It is a pleasure to say, after a careful ex-
amination and comparison, that this volume

accomplishes its objects more thoroughly and
completely than any similar work yet pub-
lished. Good judgment is displayed in the
allotment of space, the commoner ailments
being treated of with sufficient fulness while
the rarer forms are by no means ignored. Each
section devoted to diseases of special systems
is preceded with an exposition of the methods
of physical, chemical and microscopical exam-
ination to be employed in each class. The tech-
nique of blood examination, including color
analysis is very clearly stated. Uranalysis re-
ceives adequate space and care. The volume is
deserving of high commendation. — Neic York
Medical Journal.

LEA BROTHERS & CO., Publishers,

706, 708 & 710 Sansom Street, Philadelphia.
Ill Fifth Avenue (Cor. 18th St.), New York.

11

NEW (Sd) EDITION-JUST READY.

Wharton's Minor Surg. & Bandaging.

Minor Surgery and Bandaging. By Henry E. Whaeton, M. D., Demon-
strator of Surgery in the University of Pennsylvania, New (third) edition. In one 12mo.
volume of 594 pages, with 475 engravings, many being photographic. Cloth, $3.00.

THIS work covers a considerably greater range of subjects than usually implied in the main
divisions noted on its title page. The reader will tind in it an exceptionally clear and com-
plete seetio]! on Bandaging with an excellent series of photographic engravings, showing in
the most instructive manner the application of all such dressings. The department of Minor
Surgery includes the preparation and use of materials employed in antiseptic aad aseptic surgery,
the procedures in minor surgery, ansesthetics, use of trusses, catheters and bougies, sutures ancl
ligatures, the treatment of hemorrhage, abscesses and the dressing of wounds, burns, bedsores,
sj^rains, etc. Subsequent jjarts deal with fractures, dislocations, ligations, amputations, excisions,,
resections and special operations, such as trephining, tracheotomy, intubation, operations on the
kidney and colon, lithotomy and osteotomy. The demand for three large editions shows the value
attached to this authoritative and convenient work by teachers, students and surgeons, and the au-
thor has thus been enabled to keep it continually abreast of the latest surgical progress. The series
of illustrations is exceedingly rich and instructive, the volume containing no less than four hun-
dred and seventy-five.

Young's Orthopedic Surgery.

A Manual of Orthopedic Surgery, for Students and Practitioners. By

Jajmes K, Young, M. D., Instructor in Orthopedic Surgery, University of Pennsylvania,
Philadelphia. In one octavo volume of 446 pages, with 285 illustrations. Cloth, $4.00
leather, $5.00.

The author of this work has styled it " A I oughly modern and the paragraphs on treatment
Practical Treatise on Orthopedic Surgery," with j are replete with judicious conservatism. The-
which title we fijid no fault. It is a thorough, i author having fully accomplished his objects as
a very eoni]»i'ehensive work upon this legitimate set forth in the Preface, and having also given

surgical specialty and every ]»age al)()unds with
evidences of practicality. We find an immense
amount of thoroughly u})-to-date information
upon more than the usually limited number of
common deformities. The pathology is thor-

ns the clearest and most modern work upon this
growing department of surgery with which we
are familiar, we can but add an unqualified
commendation for this manual. — The Chicago
Clinical Revieiv.

Seiler on the Throat and Nose — Fourth Edition.

A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose
and Naso-Pharynx. By Carl Seiler, M. D., Lecturer on Laryngoscopy in the University
of Pennsylvania. Fourth edition. In one handsome 12mo. volume of 414 pages, with 107
illustrations and 2 colored plates. Cloth, $2.25.

This little ]»(»(>k is eminently practical, and
will jtrove of interest not only to the specialist,
but to the general practitioner as well. It deals
with the subjects in a clear and distinct manner,
and the text is copiously illustrated with dia-
grams and colored i)lates. So little attention is
paid ordinarily to the examination of the larynx
that the heed of such a book has long been felt.
By consulting its pages anyone can learn the
necessary manii^ulations, and, by a little prac-

tice, soon become expert in the use of the laryn-
geal mirror, a method of examination too often
neglected. The anatomy of the larynx is ex-
plained with especial care, and the operative
procedures for various diseases of the throat,,
tonsils, etc., are carefully explained. Approved
methods of treatment are dealt with in a very
satisfactory way, and all the most useful reme-
dial agents are described. — International Medi-
cal Magazine.

Field's Manual of Diseases of the Ear— Fourth Edition.

A Manual of Diseases of the Ear. By George P. Field, M.E.C.S., Aural
Surgeon and Lecturer on Aural Surgery in St. Mary's Hospital Medical School, London.
Fourth edition. In one octavo volume of 391 pages, with 73 engravings and 21 colored
plates. Cloth, $3.75.

a work as is needed by every general practitioner
to enal)le him to treat intelligently the large class
of cases of ear disease that comes jjroperly within
his province. The illustrations are apt and well
executed while the make-up of the work is
beyond criticism. — The American Practitioner
and News.

To those who desire a concise work on diseases
of the ear, clear and practical, this manual com-
mends itself in the highest degree. It is as far
removed as well may be from the character of a
compilation, every page giving evidence that
the author writes from his own careful observa-
tion and thoughtful experience. It is just such

LEA BROTHERS & CO., Publishers, IJ^pI^h A.^ufZ^s^h'tu iit'^

12

NEW (2d) EDITION-JUST READY.

Jackson's Ready = Reference Handbook of Skin Diseases.

The Ready-Reference Handbook of Diseases of the Skin. By George
Thomas Jackson, M. D., Professor of Dermatology, Woman's Medical College of the New
York Infirmary. New (2d) edition In one 12mo. volume of 589 pages, with 69 illustrations
and a colored plate. Cloth, $2.75.

THIS volume fully deserves the title aptly chosen for it. The classification of skin diseases ac-
cording to their natural relationship is appropriately explained, but the body of the volume
is devoted to the various aftections under aa alphabetical arrangement. The practitioner and
specialist will thus find it a prompt and ready source of knowledge on all the points of terminology,
symptoms, varieties, etiology, pathology, diagnosis, treatment and ])roghosis of dermal affections.
Tables of differential diagnosis and standard prescriptions will be fouiKl scattered through the text
and the work ends with an appendix of well-tried formulse. Tlie series of illustrations is rich and
instructive.

Green's Pathology and Morbid Anatomy — Eighth Edition.

Pathology and Morbid Anatomy. By T. Heney Geeen, M. D., Lecturer on
Patholog7 and Morbid Anatomy at Charing-Cross Hospital Medical School, London Seventh
American from the eighth and revised English edition. In one handsome octavo volume ot
595 pages, with 224 engravings, and a colored plate. Cloth, $2.75.

A work that is the text-book of probably four-
fifths of all the students of pathology in the
United States and Great Britain stands in no
need of commendation. The work precisely
meets the needs and wishes of the general practi-
tioner.—2Vie American Practitioner and News.

Greenes Pathology is the text-book of the day
— as much so almost as Gray's Anatorny. New
illustrations and a colored frontispiece have been
added, so that altogether we have now a text-
book fully up to date in the record of fact, and
so profusely illustrated as to give to each detail
of text sufficient explanation to be easily under-
stood. The work is an essential to the j^racti-

tioner — whether as surgeon or physician. The
work is the best of up-to-date text-books. — Vir-
ginia 3Iedicnl Monthly.

If a total issue of fifteen editions of a Avork is
any criterion of its value the volume before us
must surely take a foremost place among its
kind. An inspection of the book reveals the
secret of its success, namely, real, practical
merit. Comj^lete without verbosity or rejieti-
tion ; comi^rehensive and everywhere lucid, it is
an excellent every-day manual for medical stu-
dents and practitioners — one which they will
find always interesting and profitable. — The
Den ver Medica I Times .

Fuller on Male Sexual Disorders— Just Ready.

Disorders of the Sexual Organs in the Male. By Eugene Fullee, M. D.,
Instructor in Venereal and Genito-Urinary Diseases, New York Post-Graduate Medical
School. In one very handsome octavo volume of 238 pages, with 25 engravings and 8 full-
page plate''. Cloth, $2.00.

From time immemorial this department of
human maladies has afforded charlatans their
most lucrative business, a fact which it may be
wholesome to consider as reflecting somewhat
upon the comparative success of the regular
practitioner. Against rational methods empiri-
cism should have no chance, and a work based
on sound knowledge performs a service of moral
and physical value to the patient, and of finan-
cial value to the profession. The author's wide
experience in this special line has convinced
him that male sexual disorders arise more fre-
quently from pathological states of the organs

concerned than from neurological or mental
causes. He has endeavored to place the litera-
ture of sexual pathology on a par with that of
sexual neurology, and to deal with etiological
factors in the order of their real importance.
His treatment, founded upon a grasp of the
whole subject, can be regarded with confidence
by those to whom this large class of cases apjily
for relief. The work is of value to the physician
in general practice, as it is he who first encoun-
ters the cases of this character. It treats as real
a class of cases too often ridiculed as imaginary
by regular physicians. — llie Ohio Med. Journal.

Morris on the Skin.

Diseases of the Skin. An Outline of the Principles and Practice of Derma-
tology. By Malcolm Moeeis, F.R.C.S., Surgeon to the Skin Department, St. Mary's Hos-
pital, London. In one ]2mo. volume of 572 pages, with 19 chromo-lithographic figures and
17 engravings. Cloth, $3.50.

Entirely new and thoroughly modern iu all its
teachings. It is compact, essentially clinical and
practical in its sco))e, and the reputation of the
author and his vast exi:)erience as a dermatolo-
gist are a sufficient guarantee of the soundness
of his views. There are nineteen chromo-litho-
graphic figures and seventeen engravings, all of
which are good, and there is no other branch of

medicine in which these can be used to better ad-
vantage. The book will l)e a valuable one to both
students and practitioners. — Med. FortnigJitly.

The details of diagnosis, special and general
symptoms, individual i)athology and, finally, spe-
cial treatment, are full in their discussion. The
well-selected ])lates add to the value of the book.
— Neiv Orleans Medical and Surgical Journal.

LEA BROTHERS & CO., Publishers., JJ^/i^rA^lMr. r^iu '^'^^^^^^

13

Hyde on the Skin — Third Edition.

A Practical Treatise on Diseases of the Skin. For the use of Students and
Practitioners. By J. Nevins Hyde, A.M., M.D., Professor of Dermatology and Venereal
Diseases in Rush Medical College, Chicago. Third edition. In one octavo volume of 802
pages, vs^ith 108 engravings and 9 full -page plates, 3 of which are colored. Cloth, |5.00 ;
leather, |6.00.

The third edition fulfills all the expectations
warranted hy the great accumulation of derma-
tological material since the earlier editions were
brought out, and puts his work at the head of the
modern American treatises on skin diseases.
The excellence of the chapters on treatment, to-
gether with the care that has been bestowed on
subjects that have acquired new interest, make
the book one to be warmly recommended. —
Boston Medical and Stirgical Journal.

Dr. Hyde's book may be heartily recom-
mended to the student and practitioner alike
as one of the liest exponents of the subject now
before the profession. — The American Journal
of the 3Iedical Sciences.

The qualities that have contributed so much
to its previous popularity still remain. The
chief of these unquestionably are the standpoint
of practical medicine from which it speaks and
its wealth of therapeutical information. The

writer knows no book in which one can seek
more satisfactorily for information as to how to
manage his patients with skin diseases. The
present edition may be commended as being an
exposition of the subject fully up to the present
state of our knowledge. — Chicago Clin. Review.

The volume in its new form commends itself
more than ever to those requiring a treatise on
the skin well up to the times. — Medical Record.

Dr. Hyde is an experienced scholar as well as
a competent author, and his former editions were
received with approval by dermatologists as well
as by those general practitioners who are inter-
ested in the study and treatment of diseases of
the skin. The treatise is one that affords much
satisfaction in that it is a safe guide for both
students and practitioners, either general or spe-
cial, and particularly does it adapt itself to the
use of dermatologists. — Buffalo 3Iedical and
Surgical Journal.

King's Manual of Obstetrics — Sixth Edition.

A Manual of Obstetrics. By A. F. A. King, M.D., Professor of Obstetrics
and Diseases of Women in the Medical Department of the Columbian University, Washing-
ton, D.C., and in the University of Vermont, etc. Sixth edition. In one 12mo. volume of
532 pages, with 221 illustrations. Cloth, |2.50.

This is und()u])tedly the Ijest manual of ol)stet-
rics. Six editions in thirteen years show not only
a demand for a book of this kind, but tliat this
partieuhir one meets the requirements for popu-
larity, Ix ing clear, concise and practical. The
l)resent edition has been carefully revised, and a
tuimber of additions and modifications have been
introduced to bring the book to date. It is Avell
illustrated, well arranged ; in short, a model
manual. — The Chicago Medical Recorder.

This valuable little work on Obstetrics has
now reached its sixth edition, and justly merits
the popularity whicli it enjoys. For clearness
of diction it is not excelled by any book of simi-
lar nature, and by its system of captions and
italics it is abundantly suited to the needs of
the medical student. The book, as a whole, is
undoubtedly the best manual of obstetrics extant
in English. — The Philadelphia Polyclinic.

Hayem & Hare's Physical and Natural Therapeutics.

Physical and Natural Therapeutics. The Remedial Use of Heat, Electricity*
Modifications of Atmospheric Pressure, Climates, and Mineral Waters, By Georges Hayem,
M. D., Professor of Clinical Medicine in the Faculty of Medicine of Paris. Edited, with
the assent of the author, by Hob art Amory Hare, M. D., Professor of Therapeutics in the
Jefferson Medical College of Philadelphia. In one handsome octavo volume of 414 pages
with 113 engravings. Cloth, $3.00.

This ver}^ excellent work by two such eminent
authorities should be upon the shelf of every
physician. It opens up a field which, while
much written upon, has never before been pre-
sented in the form of a standard book. Written
largely in this edition and entirely in the ori-
ginal "by one of the foremost therapeutists of
the day, not only are his views expressed, but
also those of standard writers on thermic agents,
climate, electricity, etc. An authoritative work
upon these great branches of therapeutics has
until now been a desideratum. The author and
editor of this work enjoy equal standing, and
the volume is certain to command attention and
to render widespread service. The section on
climate, rewritten by Professor Hare, will, for
the first time, place the abundant resources of
our own country at the intelligent command of
American practitioners. The extended section
on medical electricity, likewise rewritten, con-

forms to the American development of this sub*
ject, and explains the many excellent forms of
apparatus readily available in this country. —
The 3Iedical Progress.

In this compact and substantial volume we
find a satisfactory rendering of the work of its
distinguished author. The editor has supplied
the articles on American climate and mineral
springs, added much valuable matter upon the
subject of electricity, and supplemented the
work of the author at many places in the text
with judicious and instructive interpolations.
We note the Therapeutic Index, which is use-
ful quite as much for the determination of con-
traindications as for indications. We welcome
this book as a worthy supplement to the text-
book which treats of therapeutics in the
ordinary acceptation of the term, and we be-
speak for it a cordial reception. — TJie Post-
Graduate.

LEA BROTHERS & CO., Publishers, ;?^T^Ar„!:";^o".^*8^\^M:'Nrv,H<.

Playfair's Midwifery— New (8th) Ed.

A Treatise on the Science and Practice of Midwifery. By W. S. Play fair,
M. D., F R C P., Professor of Obstetric Medicine in King's College London. Sixth American
from the e ghth English edition. Edited, with additions by Robeet P. Harris, M. D. In
one very handsome octavo volume of 697 pages, with 217 engravings and 5 plates Cloth,
$4.00 ; leather, $5.00.

The author's object has been to place in the
hands of his readers an epitome of the science
and practice of midwifery, which embodies all
recent advances, and especially to dwell on tlie
practical part of the subject, so as to make his
book a reliable guide to the doctor in the
practice of this most imijortant and responsible
branch of medicine. The demand for this
eighth edition of the work testifies to the success
with which the author has executed his pur-
pose.— The Medical Fortmghtly.

Since 1877 Playfair has been accepted as au-
thority in the department of obstetrics. When

his first edition was issued it was found to be
such a clear exposition of the subject that
Playfair's treatise was readily adopted by our
colleges as a text-book. Students therefore be-
came familiar with it at once, and obstetricians
have followed it through its several editions with
interest and satisfaction. This work of Playfair
must occupy a foremost place in obstetric medi-
cine as a safe guide to both student and obstetri-
cian. It holds a ])lace among the ablest English-
speaking authorities on the obstetric art. — Buf-
falo Medical and Surgical Journal,

Hamilton on Fractures and Dislocations — Eighth Ed.

A Practical Treatise on Fractures and Dislocations. By Frank H. Ham-
ilton, M.B., LL.D., iSurgeon to Bellevue Hospital, New York. Eighth edition, revised and
edited by Stephen Smith, M.D , Professor of Clinical Snrgery in the University of the
City of New York. In one octavo volume of 832 pages, with 507 illustrations. Cloth, |5.50 ;
leather, $6.50.

Its numerous editions are convincing proof, if
any is needed, of its value and popularity. It
is preeminently the authority on fractures and
dislocations, and universally quoted as such.
In the new edition it has lost none of its former
worth. The additions it has received by its
recent revision make it a work thoroughly in
accordance with modern practice theoretically,
mechanically, aseptically. The task of writing

a complete treatise on a subject of such mag-
nitude is no easy one. Dr. Smith has aimed to
make the resent volume a correct exponent of
our knowledge of this department of surgery.
The more one reads the more one is impressed
with its completeness. The work has been
accomplished, and has been done clearly, con-
cisely and excellently well. — Boston Medical
and Surgical Journal.

Taylor's Medical Jurisprudence — Twelfth Edition.

A Manual of Medical Jurisprudence. By Alfred S. Taylor, M.D., Lec-
turer on Medical Jurisprudence and Chemistry in Guy's Hospital, London. New American
from the twelfth English edition. Thoroughly revised by Clark Bell, Esq., of the New York
Bar. In one octavo volume of 787 pages, with 56 illustrations. Cloth, $4.50 ; leather, |5.50.

This is a complete revision of all former
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book. This edition contains a large amount of
entirely new matter, many portions of the book
having been rewritten by the editor. Many
cases and authorities have been cited, and the
citations brought down to the latest date. The
book has long been a standard treatise on the
subject of medical jurisprudence, and has gone
through many editions — twelve Englisli and
eleven American. Mr. Clark Bell has en-
larged and improved what already seemed com-
plete, by bringing his many citations of cases
down to date to meet the present law ; and by
adding much new matter he has furnished the

medical profession and the bar with a valuable
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owing to its exhaustive character. It would
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the legal practitioner whose duties take him into
the criminal courts. The editor has given to
two professions a reference-book to be relied
upon. — The Amer. Journal of the Med. Sciences.

No library is complete without Taylor's Medi-
cal Jurisprudence, as its authority is accepted
and unquestioned by the courts. — Buffalo Medi-
cal and Surgical Journal.

Attfield's Chemistry— New (14th) Edition.

Chemistry, General, Medical and Pharmaceutical ; Including the Chemistry
of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their
Application to Medicine and Pharmacy. By John Attfield, M. A., Ph. D , F.I.C., F.C.S.,
F.K.S., etc., Professor of Practical Chemistry to the Phai maceutical Society of Great Britain,
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LEA BROTHERS & CO., Publishers,

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15

We should be glad to have
you write for a sample of

Taka=Diastase.

Acts more vigorously on starch than does
Pepsin on proteids.

RELIEVES

Starch Dyspepsia.

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starch, and can aid our patients, during con-
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nevertheless very necessary, starchy foods.
We trust that the readers of the Gazette will at
once give this interesting ferment a thorough
trial, administering it in the dose of from
I to 5 grains, wdiich is best given in powder,
or, if the patient objects to the powder, in
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Pepsin is of In ailments arising from Faulty Digestion

no Value of Starch.

PARKE, DAVIS & CO.,

BRANCHES:

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NEW ORLEANS: Tchoupitoulas and Gravier Sts. nCTDniT iMir'H

BRANCH laboratories: DETROIT, MICH.

LONDON, Eng., and WALKERVILLE, Ont.

16

CONTENTS.

ORIGINAL COMMUNICATIONS.

PAGE

Practical Application of the Rontgen Eays in Surgery. By J. William White,

M.D., Arthur W. Goodspeed, Ph.D., and Charles L. Lkonard, M D, . . 125
Painful Points in Gouty Compared with Rheumatic Arthritis. By W. 11. Thomson,

M.D,LL.D 148

On the Functions of the Neuron, with Especial Reference to the Phenomena Pre-
sented by Hysteria and Hypnotism. By F. X. Dkrcum, M.D. . . .151

Extrauterine Foetation. Report of Fifteen Cases Treated by Operation. By

Andrew J. McCosh, M.D 169

On the Treatment of Aneurism by Electrolysis Through Introduced Wire: Report

of a Successful Case. By D. D. Stewart, M.D., and J. L. Salingkh, M.D. . 170

Compound Depressed Fracture of the Skull. By Charles L. Scudder.M.D. . 177

Diagnosis of Chronic Abscess of the Brain. By J. T. Eskridge, M.D. . . . 179
The Differential Diagnosis of Ursemia and Meningitis, with Report of Obscure

Cases. By Arthur R. Edwards, A.M., M.D 191

REVIEWS.

An Introduction to Pathology and Morbid Anatomy. By T. Henry Green, M.D. 197

Histopathology of the Diseases of the Skin. By Dr. P. G. Unna 199

Epidemic Ophthalmia : Its Symptoms, Diagnosis, and Management. With Papers

upon Allied Subjects. By Sidney Stephenson, M.B., F.R.C.S. Ed. . . . 201
Geschichte der Volksseuchen wach und mit den Berichten der Zeitgenossen, mit

Beracksichtigung der Thierseuchen. Von Dr. B. M. Lersch .... 203
Deaf-mutism. A Clinical and Pathological Study. By James Kerr Love, M.D. . 203
Les Suppurations de I'Apophyse mastoide, et leur traitement. Par A. Broca and

F. Lubet-Barbon 204

Spectacles and Eyeglasses: Their Forms, Mounting, and Proper Adjustment. By

R. J. Phillips, M.D 204

A Pictorial Atlas of Skin Diseases and Syphilitic Affections . . . . . 205

The Functional Examination of the Eye. Ly John Herbert Claiborne, Jr., M.D. 205
A Manual of Operative Surgery. By Lewis A. Stimson, B.A., M.D , and John

Rogers, Jr., B.A., M.D 200

PROGRESS OF MEDICAL SCIENCE.

THERAPEUTICS.

PAGE

PAGE

Treatment of Pulmonary Tuberculosis

207

Treatment of the Dyspepsias

212

Action of Sodium Bicarbonate .

207

Immunity in Asiatic Cholera .

214

Action of Salicylic Acid and Salicylates 208

Use of Antitoxin in Private Practice

214

Effect of Diphtheritic Toxin

209

Death from Behring's Antitoxin

215

Action of Quinine in Paludism .

210

Treatment of Scarlet Fever

215

Gastric Crises of Tabes Dorsalis .

210

Death from Antidiphtheritic Serum

216

Guaiacol in Diphtheria

210

Death from Antitoxin Injections

216

Death from Diphtheria Antitoxin

211

Antivenene for Snake-bite .

216

Treatment of Cancer and Sarcoma .

211

A Smallpox Antitoxin

217

Treatment of Enteritis

211

The Use of Vaccine Virus .

217

Use of Glycerin for Hepatic Colic

212

Administration of Thyroid Gland

217

VOL. 112, NO. 2.— AUGUST, 1896.

9

11

CONTENTS.

MEDICINE.

PAGE

PAGE

Changes in Blood in Hsemoglobinuria

218

Gliosis in Epilepsy . . . .

224

Gaucher's Disease ....

219

Two Cases of Cerebral Spastic Diplegia

225

Tetragenus Septicsemia

219

Cerebral Hemorrhage in Whooping-

Hemorrhagic Myxoedema .

99fi

Fericarditic Pseudo-cirrhosis of Liver

221

Diphtheria and Antitoxin .

225

The Etiology of Serous Pleurisy

221

Urgemic Aphasia . . . .

226

Gastroscopy

222

The Mobility of Abdominal Tumors .

227

Diagnosis of Cysticercus in the Brain

222

Hepatic Neuralgia . . . .

227

Paroxysmal Hgemoglobinuria .

223

Fibrinous Bronchitis . . . .

228

223

Percussion of the Heart

228

Croupous Pneumonia in Diabetes

224

Eespiratory Neuroses . . . .

229

Symmetrical Gangrene

224

The Thoracic Organs in Chlorosis

229

OPHTHALMOLOQY.

Optic Nerve Atrophy in Three Brothers 230
Eecurrent Oculomotor Palsy . . 230
Supernumerary Caruncle . . .231
Eye-lesions in Myxoedema . .231

Detachment of the Eetina . . 231

Treatment of Ulcers of the Cornea . 231
Non-existence of a Separate Cortical

Color-centre 232

DISEASES OF THE LARYNX AND CONTIGUOUS
STRUCTURES.

Stricture of the Larynx . . . 233 j Nasal Tuberculoma .... 235
Multiple Papillomas of the Larynx . 234 | Suppuration of Maxillary Sinuses . 235

OBSTETRICS.

Removal of Old Ectopic Gestations . 236 Treatment of Face- presentation by

A Study of Fcetal Excretion . . 236 Manipulation 237

Pregnancy and Labor Complicated by Albuminuria and Eclampsia . . 237

Cancer of the Cervix . . . 236 Ten Operations for Ectopic Gestation 238

GYNECOLOGY.

Shortening of the Sacro-uterine Liga- [Vaginal Fixation .... 240

ments for Retroversion . . . 239 Diagnostic Curettage .... 240

Hysterectomy with the Cautery . 239 Treatment of Pruritus Vulvae . . 241

€olporrhaphy in Prolapsus Uteri . 240 ; Cancer and Tuberculosis of the Uterus 241

PAEDIATRICS.

Increase in Weight of Premature Infants 242 Bacteriology of the Anginas of Scarla-

Tuberculosis of Intestine by Ingestion 242 tina 244

Primary Sarcoma of Vagina in Children 243 A Variety of Streptococcus Refractory

Bacteriology of Vagina of Newborn Girls 244 to Marmorek's Serum . . . 244

PATHOLOGY AND BACTERIOLOGY.

Spirillum of Asiatic Cholera . . 245 Alimentary Tuberculosis . . . 247
Death in Acute Lobar Pneumonia . 246 j

HYGIENE AND PUBLIC HEALTH.

Toxicity of Alcoholic Beverages . 248 | Dust in Consumptive Communities . 249

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES.

AUGUST, 1 896.

CASES ILLUSTRATIVE OF THE PRACTICAL APPLICATION OF
THE RONTGEN RAYS IN SURGERY.

By J. William White, M.D.,

PROFESSOR OF CLIMICAL SURGERY, UNIVERSITY OF PENNSYLVANIA ;

Aethur W. Goodspeed, Ph.D.,

ASSISTANT PROFESSOR OF PHYSICS, UNIVERSITY OF PENNSYLVANIA ;
AND

Charles L. Leonard, M.D.,

ASSISTANT INSTRUCTOR IN CLINICAL SURGERY, UNIVERSITY OF PENNSYLVANIA.

The Rontgen method is, of course, in its infancy. It has, however,
already reached a degree of usefulness that makes it obvious that the
necessary apparatus will be an essential part of the surgical outfit of all
hospitals and will be employed constantly in a variety of cases. Those
to which the method can now be applied with advantage may be sum-
marized as follows, emphasis being placed on the fact that what is
written to-day may require revision or reversal to-morrow, so rapidly
are improvements and discoveries taking place :

1. Foreign bodies imbedded in any of the tissues of the body. This is
at once the most obvious and the simplest application of the skiagraph
to surgery. Hundreds of cases have already been reported. Bullets,
fragments of metal or of glass, needles, etc., are easily found, and, even
if they are lodged in bone, the varying density of the shadows cast by
substances of different permeability or of different chemical constitution
will serv^e to define and locate them. It is desirable, if the foreign
body be in a locality containing important surgical structures, that
skiagraphs be made from at least two points of view, so that the depth
from the surface and the exact relations of such body can be determined
by measurement. A single skiagraph of a piece of steel in the arm,
for example (Case X., Plate VIII.), taken from the front sliows merely

VOL. 112, NO. 2 —AUGUST, 189G.

12G WHITEj GOODSPEED, LEONARD: RONTGEN RAYS.

its relation to the inner or outer edge of the arm, not at all its depth.
A second view taken laterally would make the precise situation evident.

2. Foreign bodies in certain of the organs and viscera are likely to be
discovered and located with a degree of accuracy that will vary with the
region or structure involved and with the thickness of the enclosing tissue.
Waggett and Rowland have shown (^British 3IedicalJournal,M.a.YG]i 19,
1896) that a fish-bone and a small nail attached by plaster to the side of
the neck in the position of the ventricle can be skiagraphed with ease.
The larynx itself did not show at all, but by the aid of a chart of the
region the exact position of a foreign body in the larynx ought to be
easily determinable. It is obvious that extension of the method to the
location of such bodies in the trachea, bronchi, and other portions of the
air-passages is sure to come with further improvements in technique. In
the digestive tract, except, perhaps, the first third of the oesophagus, the
difficulties are greater ; but the presence or absence of foreign bodies can
doubtless be determined, although below the stomach it is questionable
whether any definite information as to the exact situation can be obtained.
In many cases, however, especially in children, it is a matter of grave
doubt as to whether or not some foreign body has been swallowed. As
the most uncertain cases occur in the youngest children, and as the ease
of skiagraphy of the whole body is in direct proportion to the thinness
and softness of the tissues, we may expect in just these cases to get the
exact information which is so often lacking in the history given by anxious
})arents or nurses. AVithin the cranium neither experimental tests nor
trials in actual cases have yet given any practical results in the discovery
or location of foreign bodies, but there is every reason to believe that
this Avill become possible in the near future.

3. Foreign bodies formed within the organism itself include chiefly gall-
stones and renal, vesical, and prostatic calculi.

Gallstones skiagraphed without the body cast very faint shadows ; cal-
culi of oxalate of lime, of phosphate of lime, and of triple phosphate
cast shadows as dense as those of bone or metal ; uric-acid calculi cast
easily recognizable but somewhat fainter shadows (British MedicalJour-
nal, London, April 4, 1896).

No practical results have yet been obtained in the discovery of these
forms of calculi, but it seems within bounds to expect that after we be-
come more familiar with the shadows cast by the normal viscera and the
normal skeleton, we may be able to distinguish gallstones from malignant
disease involving the ducts ; may locate or exclude renal calculi in doubt-
ful cases ; and may see encysted vesical or prostatic calculi even through
the shadows cast by the pelvic bones themselves. Many skiagraphs
show in outline the shadow of one bone through the shadow of another
(Case YI., Plate V.), and it is not improbable that after a time accurate
diagnoses can be made in this manner. At present it is not possible.

c>2

PLATE VII.

Case IX. The Results Obtained in Excision of the Knee.

Case X. Foreign Body in the Arm.

X

WHITE, GOODSPEED, LEONARD: RONTGEN RAYS. 139

4. Inflammaiory sivellings and neio growths (except when bony) have
not yet been shown to offer any special features diagnosticating them
from normal structures. Bony tumors can plainly be seen, and as the
method improves it is to be expected that intracranial and intraspinal
osteomata may be discovered and located and possibly even periosteal
thickenings due to tubercular, syphilitic, or pyogenic infection. Dead
bone cannot as yet be distinguished from living bone, but it is reasonably
certain that by greater perfection in detail we shall soon be able to out-
line the exact position and extent of a sequestrum, this again being made
possible by the transparency of the bone-shadow itself ; so that, for ex-
ample, in a case of necrosis of the femur the shadow of that bone and
the shadow of a sequestrum contained within it may be superimposed
and plainly separable on the skiagraph. Abscess in bone can be made
out perfectly.

Comparison of the normal limb with that which is the subject of tuber-
cular or other chronic bone-disease will often reveal the full extent of
the latter better than any method of exploration, and in a recent case
led me to perform amputation through the hip-joint instead of through
the upper third of the femur, the condition found abundantly justifying
the procedure.

5. Fractures and dislocations at present offer the greatest field for the
every-day use of the Rontgen method. It- is impossible at this time to
present exhaustively the conditions under which it should invariably be
used, or to separate them from those in which it is a matter of interest
rather than of necessity ; but it is safe to say that it will be wise to
employ it when possible.

a. In all fractures in or about joints either as a preliminary to the
reduction of the deformity, or as evidence that such reduction has been
accomplished. These fractures are, for unavoidable reasons, often fol-
lowed by some limitation of motion and a more or less imperfect func-
tional result. They have, therefore, on innumerable occasions been the
basis for suits for malpractice. It will be both a satisfaction and a safe-
guard for the surgeon if he can see that his work has been accomplished
properly and can retain definite evidence of that fact.

h. In doubtful cases or cases supposed to be of great rarity, it will be
of inestimable value (Case VII., Plate VI.), both as aiding diagnosis
and as demonstrating and recording the conditions present.

c. In cases of old injury in which, as so frequently happens, no reliable
clinical history is obtainable and no accurate diagnosis can possibly be
made by the ordinary methods. (Cases III., IV., and V., Plates II.,
III., and IV.)

d. In cases of ununited fracture, both to show the exact position and
relation of the fragments prior to operation, the presence or absence of
interposing structure, etc. (Case II., Plate L), and also to show after

VOL. 112, NO. 2.— AUGUST. 1896. 10

140 WHITE^ GOODSPEED, LEONARD: RONTGEN RAYS.

operation the degree of efficiency of the wire, or of the peg or screw,
or of the splint, or other retaining-apparatus. We may frequently
determine in such cases whether or not open operation is needed, union
often being obtainable, where the fragments can be brought into good
position and nothing is interposed, by mere friction and the reapplica-
tion of the splint or other dressing.

6. In cases of excision of joints at the time when, for example, in the
knee it is desirable to demonstrate that bony union has been obtained
and in the elbow that it has been avoided. (Case IX., Plate VIII.)
(Case V.)

7. In cases of deformity of all sorts affecting the bones, their epiphy-
ses, or diaphyses, and requiring careful investigation before surgical
interference is declined or advised. (Case VI., Plate V.)

8. In many obscure cases of the type of metatarsalgia, in which the
demonstration of the cause of the nerve-pain and the indication for sur-
gical treatment are equally clear and convincing. (Case XII.)

ILLUSTRATIVE CASES.

I. — The patient, W. S., Avas admitted to the wards on January 23,
1896. Seventeen weeks previous to his admission he sustained a com-
pound fracture of both bones of the right forearm. The flesh-wounds
healed rapidly, but the bones remained ununited and at an angle,
although they were treated by fixation in a plaster-dressing for some time.

The operation showed that the line of fracture was in the middle third
of each bone. The extensor carpi radialis was found interposed between
the fragments of the radius, where they overlapped one and one-half to
two inches, eflectually preventing any chance of union. The upper frag-
ment was in extreme supination, while the lower was in extreme prona-
tion.

The fragments of the ulna showed an attempt at the formation of a
false joint, the proximal end of the lower fragment containing a cavity
in which the distal end of the upper fragment was held. Great diffi-
culty was experienced in getting anything like a proper approximation
of the bones on account of the extreme rotation in opposite directions of
the two fragments of the radius and because the interosseous space was
more nearly obliterated between the lower fragments.

The resected ends of the bones were held in position by wire sutures
and the flesh-wounds closed by interrupted sutures. The flesh-wounds
healed rapidly, but bony union seems doubtful as yet. The skiagraph
shows the position of the bones and the silver sutures in position, and
illustrates the ability we now have, without disturbing the wound itself,
or the limb, or even the dressings, to obtain accurate knowledge of the
exact position of the bones after an operation of this character. Such
information might be of the very highest practical importance. It might
lead to a change of apparatus, to an alteration in the position of the
limb, to a second operative attempt, etc., and it would almost certainly
aid in giving definiteness to prognosis and in determining without undue
motion of the part the final result as to the presence or absence of bony
union.

WHITE^ GOODSPEED, LEONARD: RONTGEN RAYS. 141

II. — H. P., aged thirty-three years. On February 7, 1896, the patient
was caught in the belt of a pulley and thrown down about six feet. He
fell upon his left hand, bending it under him in extreme flexion. The
patient was taken to a hospital, which he left seven weeks afterward
without the consent of the attending surgeon. On admission to the
University Hospital an ununited fracture was diagnosed, with the for-
mation of callus and an attempt at union ; preternatural mobility was,
however, marked.

The operation showed the condition to be exactly that seen in the
skiagraph, the lines of fracture were as they are there shown ; a fibrous
union existed between the distal end of the upper fragment of the ulna
and the proximal end of the lower fragment of the radius. This attempt
at union was broken up, and the ends of the fragments were freshened
and united by drills, which were left in situ. The skiagraph was here
of distinct assistance during the operation, enabling me to cut down upon
and to remedy the deformity with the least possible disturbance of parts.

III. — C. R. L., aged thirty-six years, was admitted to the University
Hospital March 31, 1896, with an ankylosis of the elbow. He gave
the following history : In the latter part of January, 1895, he fell down
stairs, striking on his elbow. The arm was dressed on a splint in full
extension. This was continued for three weeks, when the arm. was
placed at an angle and dressed on a posterior moulded metal splint.
After about four weeks passive motion was commenced, and a little later
considerable force was used. The patient continued treatment for about
three months longer and then stopped all treatment until he came to the
hospital.

The diagnosis of dislocation of both bones of the elbow backward was
easily made.

The skiagraph gave an apparently blurred and indefinite outline of
the joint, which before operation seemed rather unsatisfactory. The
operation, however, showed it to be exactly correct, the joint was dislo-
cated, was ankylosed, and was surrounded by a large amount of dense
callus, making excision of the joint with the arm in extension and
fixed very difiicult. The callus was exceedingly hard and united the
olecranon process to the humerus. It was necessary to divide the ole-
cranon and cut it free from the humerus with a chisel. The joint was
cut part way through and then broken, thus permitting the completion
of the excision.

There can be no doubt that as we acquire greater familiarity with this
method we shall be able to recognize exact conditions as shown by differ-
ent depths of shadow, etc., with much more accuracy. In this instance,
for example, the facts were before me prior to the operation, but except
that I saw that my diagnosis of backward luxation was confirmed, I got
no help from the skiagraph. In future cases of the same sort I shall
profit far more by the picture — at least to the extent of anticipating —
and, when necessary, providing for the special difficulties of the case.
This patient has recovered with a most useful and satisfactory arm.

IV. — F. McD., a carpenter, aged twenty -four years, fell from the roof
of a house, a distance of forty-four feet, four years previous to his
admission to the University Hospital.

142 WHITE, GOODSPEED, LEONARD: RONTGEN RAYS.

There was a great amount of ecchymotic swelling ; a fracture was
diagnosed and the arm dressed in a posterior moulded felt splint. It
was kept in this position for ten weeks ; after this time the patient began
by himself the use of passive motion, and succeeded in getting sufficient
movement to enable him to pursue his occupation, although the arm was
always tender, and cannot be flexed sufficiently for him to reach his
mouth.

Two days before he presented himself at the hospital he heard, while
at work, a loud snap which was followed by pain and increased disability.
The skiagraph shows the normal outline of the bones, with in addition
an amount of callus on the coronoid process of the ulna (?) and a free
fragment of bone (?) above and external to the head of the radius. (See
figure.)

This case has not yet been operated upon. It illustrates better than
any I have ever seen the uncertainty which still exists as to the inter-
pretation of the skiagraphic picture, and it also shows the obscurity of
many of these combined bone- and joint-lesions. I exhibited this patient,
with the skiagraph, at a recent meeting of a surgical society. He was
examined by several skilful and able surgeons, each of whom reached a
different conclusion as to what he saw in the picture and felt in the arm.
They all differed from my own view. The case will be reported in full
after operation.

V. Excision of the head of the radius. — This case, of excision of the
head of the radius for forward luxation with limitation of the power of
flexion, was sent to the hospital by Dr. D. P. Miller, of Huntingdon ;
the history was obscure, as a previous injury had made a clear diagnosis
impossible.

Excision of the head of the radius was decided upon and the opera-
tion was performed ; the patient regained the power of flexion, with,
however, only a very slightly increased amount of pronation and supin-
ation.

The skiagraph, taken after the recovery of the patient, shows the
radius after the excision of the head and also an old fracture of the ulna
with adhesions to the radius, accounting for the limitation still remaining

Case IV.— External view, showing displaced fragment of bone.

WHITE^ GOODSPEED, LEONARD: RONTGEN RAYS. 143

in the power of pronation and supination. It also illustrates in a most
marked manner the great usefulness of the Rontgen photographs in cases
of old injury that are sent to hospitals for treatment, without a true his-
tory or diagnosis of the condition of the parts at the time of the former
accident. The failure to secure a greater amount of pronation and supi-
nation was a disappointment to me at the time, and seemed inexplicable.
The discovery of the old fracture and its adhesions completely cleared
up all doubt as to the cause of the continuing disability and at the same
time enabled me to decide that further operative interference was not
indicated.

VI. Curvature of the radius due to arrested developmeut of the ulna at
its distal epiphysis. — E. A., aged fifteen years, came to the hospital for
advice in January, 1896. The family history showed one case of tuber-
culosis, a paternal aunt, but there were no other cases in any other gen-
eration. The paternal grandfather had an epithelioma of the lip, which
was excised without recurrence.

The patient had had the diseases of childhood, but no severe or pro-
tracted illness. The present trouble began in the seventh or eighth year,
when a little lump was noticed on the arm and the patient complained
of pain located at that point. There was no sign of curvature at that
time, it has come on gradually since, while the pain has been inconstant
and rheumatic in character, seemingly following a slight cold at each
attack.

The patient has fair use of the hand and can write with it and do
almost everything needful, so no operation was advised.

The skiagraph and the photograph show very well the condition and
appearance of this forearm, and, if functional disability were greater,
would serve excellently in locating the proper seat for operation if, for
example, excision of a portion of the radius were decided upon.

VII. Diastasis of the distal epiphysis of the humerus, resulting from
a fall on the hand. — W. McL., aged eleven years, came to the hospital
on March 31, 1896, with fracture of the humerus.

The history was of a fall from a wall five feet high to the pavement,
striking on the left hand. The patient weighed about seventy-five
pounds ; he sustained no other iniury.

The case was diagnosticated and dressed before the skiagraph was
developed, the latter demonstrating the correctness of the diagnosis and
showing the position of the fragments resulting from this rare form of
epiphyseal separation.

The new record that will now be made and kept of such cases as this
will in time alter our statistics entirely as to the frequency of various
forms of fracture or of epiphyseal injury. It will no longer depend on
the skill and experience of the particular surgeon (though they will be
of no less value to the patient than before), but will doubtless soon be
made up of irrefutable testimony as to the exact conditions present.

VIII. Diastasis of the proximal epiphysis of the humerus, with over-
lapping of the fragments and union in a faulty position. — S. B., aged six-
teen years, fell heavily on the left shoulder, while playing football, in
December, 1895. He passed through the hands of two doctors ; the
condition was then recognized by Dr. E. M. Corson, of Norristowu,
who sent him to the hospital for operation.

144 WHITE^ GOODSPEED, LEONARD: RONTGEN RAYS.

At the operation a longitudinal incision through the deltoid toward the
anterior border showed the proximal end of the lower fragment overlap-
ping the upper fragment by about two inches, with firm bony union
between the two fragments. The upper end of the lower fragment lay
beneath the coracoid process and interfered materially with the function
of the joint. The upper portion of the lower fragment was resected,
giving the joint free motion. The patient made a good recovery. The
skiagraph showed the position of the fragments after the operation and
their lateral union in a faulty position.

IX. The results obtained in excision of the knee. — This skiagraph shows
the union between the femur and tibia resulting after an excision for
marked tubercular disease. As in the cases of ununited fracture, it
illustrates the advantage which may accrue from escaping the necessity
of determining by an attempt to elicit motion whether or not bony union
between apposed bones has been obtained. Very often while both patient
and surgeon are anxious as to the result of operation it can only be deter-
mined positively by the application of a degree of force which is in itself
harmful. The progress of the case can be watched if necessary by the
use of this method, any displacement of bones immediately remedied,
and the final outcome seen Avithout the very least disturbance of the
parts.

X. Foreign bodies in the arm,. — This skiagraph shows a piece of steel
in the lower portion of the upper arm, which was easily located by the
aid of the skiagraph. It shows, however, as has already been said,
merely the relation of the steel to the inner border of the arm, leaving
in doubt its relation to the anterior or posterior surface. The former
point was easily made out by exact measurement, and, of course, in this
case and in this locality, removal was easy. But it might be of vital
importance to know the depth of the layer of tissue occupied by such a
body. A second radiograph taken laterally would supply this informa-
tion.

XI. Bullet in. the forearm. — This was an interesting illustration of
the difierence in accuracy between the old methods and the present ones
in the search for foreign bodies. The bullet (32-calibre, rifle) had entered
the upper arm on the outer side, years before. An elaborate dissection
had been made some time afterward in the attempt to find it. The
patient was annoyed by the knowledge of its presence and complained
of more or less vague nerve-pain afiecting the whole extremity, no local-
izing symptoms being present. The arm was large and muscular. The
skiagraph happened to include the forearm and by accident the bullet
showed on the extreme edge of the plate. It lay on the inner edge of
the ulna, partly overlapping the interosseous membrane. While Von
Bergmann's warning against meddlesome surgery in these cases is timely
and Avell-founded, it is certain that in this situation there were possibili-
ties of later troubles if by a second traumatism the sharp edge of the
missile had been driven against either the nerves or vessels of the part.

XII. Metatarsalgia. — Mrs. , a patient of Dr. S. Weir Mitchell,

had suflfered for years from pain about the metatarso-phalangeal junc-
tion of the right foot.

The skiagraph shows that as a result of wearing pointed shoes there
is a deformity consisting in part of the obliteration of the normal meta-
tarsal spaces, with consequent pressure upon digital nerves and pain,
sometimes intolerable. Walking in the bare feet or in stocking-feet as

WHITE, GOODSPEED, LEONARD: RONTGEN RAYS. 145

a systematic exercise is, in mild cases, sometimes curative. Resection
of portions of the metatarsal bones is indicated in others. In either
case the skiagraph is of great advantage as a guide to the surgeon.

XIII. Condensing osteitis. — This skiagraph shows the femur of a
young adult, a patient of Dr. Pyle, of Wilmington, who has had a
tubercular osteitis of the lower end of the femur with necrosis. Fol-
lowing operation the wound healed entirely. The picture was taken
some months later. It appears to show distinctly the area of condensing
and formative osteitis which followed the operation, and also seems to
show that no cavity and no sequestrum remain. Such deductions will,
however, become more and more positive as we obtain larger numbers
of skiagraphs, both of diseased conditions and of normal ones with
which to compare them.

XIV. Subperiosteal abscess. — This skiagraph, taken from the diseased
right and normal left thighs of a child, shows indistinctly on the right
the outline of a very large swelling having every clinical characteristic
of sarcoma, occupying its upper two-thirds. Months previously I had
made a diagnosis of periostitis in this case. This fact led me to con-
sider the possibility of abscess, although the physical conditions of the
swelling seemed most unlike it. The skiagraph also seemed too indis-
tinct in outline to represent a true bony growth, though as yet all this
was problematical. At any rate the case proved to be an enormous
abscess, stripping the periosteum from the femur throughout its entire
length. At the time of operation the child had a temperature of 100°
to 101°. It is apparent that even such swellings, while far more
indistinct in the skiagraphs than normal bone, and probably not so
definite as growths originating in bone, may yet easily be differentiated
from the surrounding structures.

I confidently anticipate great improvement in this direction and the
extension of the method to the differential diagnosis between abscess and
new growths involving deeper portions of the body.

XV. Foreig7i body in the oesophagus. — This case was the first, so far
as I know, either in this country or abroad, in which the presence of a
foreign body in the oesophagus was revealed by the Rontgen rays. A
child, aged two years and five months, a patient of Dr. Taubel, of
Philadelphia, had been complaining for ten days of some difficulty in
swallowing and had begun to reject all solid food, although it would
still take small quantities of milk. Attempts at feeding it with even
semi-solids invariably resulted in vomiting. There was no clear history
of any foreign body having gained access to its digestive tract, but it
was known that a plaything known as a jack-stone was missing from
a set which the child had been using. When she was brought to me
I sent her at once to Professor Goodspeed to have a skiagraph made,
with the result of immediately obtaining the most accurate and definite
information. The plate obtained after a three minutes' exposure re-
vealed not only the presence, but the precise location of the body.
The following morning, after carefully weighing the chances of the case
after oesophagotomy or gastrotomy, I decided in favor of the latter, as
the length of time which had elapsed made it probable that the jack-
stone had become very firmly lodged and would be difficult to withdraw
by the forceps even through an oesophageal wound. The result showed

146 WHITE, GOODSPEED, LEONARD: RONTGEN RAYS.

the correctness of this belief. After the stomach was opened a fine rub-
ber explorer was passed through the pharynx and out of the stomach-
wound carrying a long piece of stout silk attached to it. The explorer
was withdrawn and wads of gauze of various size were tied to the silk ;
some of these could not be carried either way beyond the jack-stone, but,
whether pulled downward through the mouth and pharynx or upward
through the stomach, were arrested when they reached it, even although
very considerable force was used. Finally, however, the proper size was
found and the jack-stone was pulled dowuAvard into the stomach, from
which it was easily extracted. The mucous membrane was then at once
stitched together with a continuous catgut suture and the whole wound
was inverted by a continuous Lembert suture. The operation, including
preliminary attempts at removal by forceps, took something less than a
half hour. The child reacted well, and has entirely recovered.^

The propriety of attempting extraction by forceps, guided by direct
inspection at the time with the aid of the fluoroscope, was considered
by me ; but the attemj^t was not made on account of the presumably
ulcerated and inflamed condition of the oesophagus, contraindicating
instrumentation in that canal. The method will doubtless prove appli-
cable in the future to many cases seen earlier.

A large number of other cases have occurred in my service, but these
are sufficiently illustrative of the extent and variety of the application
of this method of surgery.

Professor Goodspeed has kindly prepared the following account of the
method by which he secured the excellent and helpful pictures of the
foregoing cases :

The apparatus which has been used in the work illustrating this article
consists essentially of four parts. The first is a storage-battery of twelve
cells, arranged six in series and two in multiple arc, giving an electromo-
tive force of about twelve volts. The second part of the apparatus is a
current-interrupter of special construction run by a motor and arranged
to give from one to three thousand breaks per second. The contact-
points of the interrupter are made of thick pieces of platinum, and on
either side are attached the terminals of a variable condenser in three
parts to take up the extra current due to self-induction in the coil and
thus to make the break more sudden. The third part consists of an
inductorium of the Ruhmkorff" type, the primary coil of which is
attached to the interrupted battery circuit. The secondary circuit is
attached to the terminals of the fourth element of our set of apparatus,
viz., the Crookes's tube. The tube which has been used in much of the
work and found very efficient was made by the Knott Company, of Boston,
from a plan made by the writer. It is a glass bulb about four inches in
diameter, exhausted to such an extent that under the electric discharge
no blue halo appears at either terminal. The glass fluoresces a brilliant
green. The cathode or the terminal attached to the negative pole of the

1 This case was published in full iu the University Medical Magazine for June.

WHITE, GOODSPEED, LEONARD: RONTGEN RAYS. 147

secondary coil is a concave aluminum disk about one and a quarter
inches in diameter. In the centre of the curvature of this, viz., about
three inches from it, is placed the anode, consisting of a flat platinum
disk. The wires to which these disks are fastened are sealed into the
glass by German enamel and covered nearly their whole length within
the tube by this material.

By this means internal sparking is almost entirely avoided. We have
several coils capable of giving different intensity-effects. The one which
seems best adapted to all grades of work gives a ten-inch spark in air.
The exposures required depend, of course, upon various conditions, and
were from a few seconds to three or four minutes. This leads us to an im-
portant detail in connection with this work, viz., the sensitive plate upon
which the negatives are made. We have made many experiments upon
various plates on the market and have been associated with Mr. John
Carbutt in the development of a plate especially adapted to this purpose.
Upon the efficiency of the plate that Mr. Carbutt now makes depends,
I feel sure, much of the excellence of the work that we have lately done.

For sharpness of detail it is necessary, of course, to have the part to
be skiagraphed as near the film as possible. It is found convenient,
therefore, to wrap the plate in two or three thicknesses of thin black
rubber-covered cloth, which is quite effectual in excluding all light dur-
ing the exposure. This plate is then bound tightly to the part with long
^auze bandages, film-side to the skin. The Crookes's tube is placed on
the other side of the part from one to two feet away, according to circum-
stances. It is probable that the resultant effect obeys the law of in-
verse squares ;" so that to produce the same density in the negative in
two experiments the times of exposure should be proportioned to the
square of the distance of tlie tube from the plate.

Many details in the manipulation of the various parts of the apparatus
have to be attended to continually, and the best results are obtained only
when all the various parts are carefully and properly balanced. When
the cathode is large the tube seems to be more powerful for the time, but
it wears out soon — i. e., its exhaustion gets so high that the largest coil
will produce no discharge through it. Under these circumstances it has
to be opened and re-exhausted to the proper degree. It is clear, then,
that the conditions necessary for the very best results cannot be realized
very long at a time.

The fluoroscope, consisting of a screen of cardboard covered with cal-
cium tungstate, is a very useful and almost necessary addition to the
equipment. If such a screen takes the place of the photographic plate,
and the eye, shielded from external light, be placed behind it, shadows
of the bones or foreign bodies can be plainly seen on the screen.

In many simple operations the use of the fluoroscope would be quite
sufficient to gain all needed information.

148 THOMSON: PAINFUL POINTS IN GOUTY ARTHRITIS.

PAINFUL POINTS IN GOUTY COMPARED WITH RHEUMATIC

ARTHRITIS.!

By W. H. Thomson, M.D., LL.D.,

PROFESSOR OP PRACTICE OF MEDICINE IN THE NEW YORK UNIVERSITY.

The differential diagnosis between acute gout and acute rheumatism
is usually simple enough in typical cases, especially when of recent origin.
In many chronic cases, however, particularly when gouty arthritis has
become general, the differentiation may not be so easy, and in practice
we frequently find gouty cases treated for rheumatism or rheumatic
patients dosed with colchicum.

For a number of years I have been accustomed to point out that
a careful manipulation, of the inflamed joints in these affections will
show specific contrasts between them in the localization of the greatest
tenderness on pressure. I supposed that this clinical fact had been noted
before, but, not finding any reference to it in the works which I have
been able to consult, I take this occasion to present the following obser-
vations on cases of gout and of rheumatism occurring in my service at
the Roosevelt and the Bellevue Hosj^itals, of New York, during the
past few months, with some cases of gout in private practice.

Gout. Whole number of cases of gout, 34 : males, 27 ; females, 7.
The first attack in the history of the patients began in the lower extremi-
ties in 31, or 98.9 per cent. In two chronic cases the patients were uncer-
tain where it first began. In one, a painter by trade, and affected with
chronic plumbism, the first attack involved the left shoulder as well as
his feet.

The first attack was monoarticular in 73 per cent., and polyarticular
in 27 per cent. I am inclined to think, however, that the percentage
of monoarticular first attacks was higher, particularly in the hospital
patients, for the memory of some of the more chronic cases on this point
was rather indefinite.

The pulse was noted as of high tension in 98 per cent., and not of
high tension in 2 per cent. The arteries were found thickened in 44
per cent., and not thickened in 56 per cent.

Tophi were present in the ears in 12 cases, or 35.1 per cent.

As to painful points : There were 38 instances of inflammation of the
knees. In every one of these cases, without exception, the points of
greatest tenderness on pressure were on the condyles. The more acute
the inflammation, the more distinctly is this tenderness pronounced.
In the decline of the inflammation tenderness will persist there when
it cannot be elicited elsewhere. This is in marked contrast with acute

1 Read before the American Association of Physicians, Washington, May 1, 1896.

THOMSON: PAINFUL POINTS IN GOUTY ARTHRITIS. 149

rheumatism, in which, as we shall see, increased tenderness on the con-
dyles, as compared with the other parts of the joint, was not once found.

Of 23 cases of inflammation of the ankles, the points of greatest
tenderness were found on the malleoli in 11, just below the malleoli in
10, and on the astragalus in 2. ;

On the great toe no uniformity in points of greatest tenderness was
made out.

The hip-joint was affected in two cases, but without any localized ten-
derness to pressure in either.

In the upper extremity, among the numerous phalangeal finger-joints
affected, and in many instances distorted with gouty deposits, those of
them which were painful enough to give indications showed, without
exception, the points of greatest tenderness on the condyles — that is, on
transverse pressure ; while pressure between the dorsal and palmar sur-
faces did not occasion pain, or very slight pain, compared with pressure
on the condyles. I have found this in private practice a valuable sign,
in women especially, as these joints are frequently in them the only ones
involved in gouty inflammation.

The elbows were affected in 12 cases. Of these the most tender points
were on the condyles in 6, on the olecranon in 4, and on both the condyles
and the olecranon in 2.

The shoulders were involved in 5 patients. In 2 of them both shoul-
ders were attacked. No particular point of tenderness was noted except
in 1, and that was on the acromion.

The cases of inflammation of the metacarpo-phalangeal joints were not
enumerated, because their lateral tender points cannot be isolated. The
same applies to the wrists, but in both cases of these joints there is more
tenderness to lateral pressure than in rheumatism.

Rheumatism. Number of cases of rheumatism observed, 49. All
of them hospital patients. Males, 32 ; females, 17.

Among these the heart was or had been affected in 18, or 36.7 per cent.
Tonsillitis occurred shortly before or during the attacks in 11, or 22.4
per cent. Pleurisy occurred in 3 cases, or 6 per cent.

The pulse is reported as of low tension, or compressible, in 42, or 85.7
per cent. ; of high tension in 5, or 1.02 per cent. ; and in 2 not stated.

The first attack was polyarticular in 46, or 94 per cent. ; monoartic-
ular in 3, or 6 per cent.

In rheumatism, particularly when a joint is acutely inflamed, there is
usually more superficial or cutaneous tenderness than in gout. This may
mislead as to the existence of special points of tenderness unless the exam-
ination be made with special reference to this subject, when in the great
majority of instances, notably in some joints, rheumatism will be found
to be scarcely less specific than gout in the localities of greatest pain on
pressure, and, what is e(|ually important, that these are in only^a few

150 THOMSON: PAINFUL POINTS IN GOUTY ARTHRITIS.

joints the same as in gout. Thus, in the knee, the typical points of ten-
derness are on the tendon of the quadriceps just above the patella, and
below it also at the tendon insertion. Posteriorly equally characteristic
points of tenderness are found along the tendons of the hamstring mus-
cles. Out of 58 cases of inflamed knees in my list, 53, or 91.4 per cent.,
were thus typical, and in 5, or 8.6 per cent., the pain was uniformly
diffused over the joint. In no case were the condyles the seat of most
tenderness.

Rheumatic inflammation of the ankles is not so distinctive in the loca-
tion of painful points as in the case of the knees. Of 32 cases my notes
are that the most pain was elicited by pressure on the tendons of the
dorsal aspect of the joint in 20, or 64.4 per cent. This pain, however,
is not so pronounced as in the tendons of the quadriceps and hamstring
muscles of the knees. In 3 cases, or 10.6 per cent., the most painful
points were under the malleoli ; and in 8, or 25 per cent., there was no
sjDecialized place.

The hips were affected four times, but no localized pain was noted in
either.

Of the joints of the upper extremity, the shoulders were affected in
20 cases. In only one of these was a special tender point found on the
coracoid process.

The elbow was affected in 13 cases. Of these in 9, or 70 per cent., the
most painful point was elicited by pressure on the triceps tendon. In
4, or 30 per cent., there were no special points.

The wrists were affected in 24 cases. Of these the most pain was
elicited by pressure on the tendons of the dorsal and palmar aspects in
20, or 83.3 per cent. It was uniformly diffused in 3, or 15 per cent. ;
and one case complained of most pain on transverse pressure, as in gout.

In every case noted of inflammation of the finger-joints in the rheu-
matic patients the pain was localized in the tendons and not on the con-
dyles.

Why the hips and shoulders do not commonly show specially painful
points may be due to these joints being so covered by large muscles.

It seems natural to infer that the difference between these two forms
of arthritis in the respects noted, of pain on pressure, is because gout
chiefly affects the periosteal, while rheumatism chiefly attacks the syno-
vial structures.

With the exception of the hips and shoulders, therefore, it would
seem that the distribution of pain on pressure may be often of use in the
discrimination of these two articular inflammations. The ankles and
wrists also do not present such marked contrasts as the more simple
joints, apparently from the greater number of bones entering into the
formation of these articulations.

dercum: the functions of the neuron. 151

ON THE FUNCTIONS OF THE NEURON,

WITH ESPECIAL REFERENCE TO THE PHENOMENA PRESENTED BY
HYSTERIA AND HYPNOTISM.

By F. X. Dercum, M.D.,

CLINICAL PROFESSOR OF NERVOUS DISEASES, JEFFERSON MEDICAL COLLEGE ; NEUROLOGIST TO
THE PHILADELPHIA HOSPITAL.

There has been noticeable of late years a tendency strangely to mis-
construe the structure of the nervous system and to misinterpret the
truths which that structure teaches. Curiously enough, this tendency has
appeared with our increasing knowledge of the details of the intimate
structure of the neurons and of the relations which they bear to each
other. It is known, for instance, that the afferent fibres, those which
convey impressions from without up to the cortex [themselves processes
(axons) of peripheral neurons], terminate not in nerve-cells, but in the
uppermost layer, the so-called molecular layer or molecular plexus of
the cortex. Here in some way the minute divisions of the afferent
fibres affect the fibres of this molecular plexus. The latter are in turn
in direct communication with the nerve-cells of the cortex, are, in fact,
themselves cell-processes. These facts suggested the idea that afferent
impulses are diffused through the molecular plexus without involving or
affecting the nerve-cells at all, and according to this interpretation the
nerve-cells are left out of consideration entirely in studying nervous
phenomena. This view has been especially advanced by Nansen, who
maintains that the old manner of view relative to the composition of the
reflex arc and the physiological importance of the nerve-cells can no
longer be sustained, inasmuch as the cells are not in direct communica-
tion with each other, and because direct communication between the
central nerve-cells and the sensory or centripetal nerve-fibres is equally
lacking. The reflex arc is constituted, according to Nansen,* first, by
the centripetal nerve and its flbrillary ramifications passing directly into
the nervous meshwork of the cortex — that is, into the molecular layer ;
secondly, by the propagation of the excitation through this molecular
plexus ; thirdly, by the transmission of stimuli to the minute lateral
branches of the centrifugal or motor nerve-fibres. It follows that im-
pulses are transmitted to the superior centres without passing directly
through the nerve-cells. " We can admit in the same manner," con-
tinues Nansen, " that the voluntary impulses emanating from the
nerve-fibres which emerge from the superior centres transmit themselves
directly to the centrifugal fibres of the inferior centres without passing
through the nerve-cells of these centres." He says, further, that it is

1 Soury, Les Fonctious du Cerveau, p. 316.

152 dercum: the functions op the neuron.

impossible to admit that the iierve-cells of the inferior centres possess a
direct importance either in relation to reflex movements or to the vol-
untary movements, and that this seems to apply equally well to the
nerve-cells of the suj^erior centres. This view forces us to the conclusion
that the activity of the nervous system, intelligence, consciousness, etc.,
is seated really in a fibrillary meshwork of the cortex, the molecular
layer, and has nothing to do with the nerve-cells of the cortex. The
latter, indeed, deprived of their psychic functions, become simply
" trophic " centres. They serve only for the maintaining of the nutri-
tion of the nerve-fibres and their innumerable arborescent ramifications.

This view of Nansen's has been adopted by my esteemed colleague. Dr.
Mills, who, in a discussion on cerebral localization at the last meeting of
the American Neurological Association, and also in the Text-hook on
Nervous Diseases by American Authors, has maintained this position ; he
holds that " impulses are conveyed from processes to processes through
the entire reflex arc, through the entire length of a cortico-efferent, or a
corti co-afferent, projection-system," without passing through nerve-cells,
and that " the function of the nerve-cell body is trophic;" that its
* ' nuclei and nucleoli preside over the nutrition of the long or short fibres
which 2)ass out of or grow into them ; " and, further, that cells are of enor-
mous bulk in order that they may be able to sustain these processes. In
his words, " the aggregations of gray matter at various levels of the
nervous system are watering- and feeding-places, not places for renewing
nerve-activity."

Certainly this view does violence to the fundamental principle that the
properties of a given tissue depend upon its cells, and that the cells are
the integral parts of the tissues. Nowhere in the whole range of biology
do we find a similar anomaly obtain as is implied by this view. It
asserts that merely incidental structural attributes are of greater value
than the individual cells, whose building up constitutes the tissue. Surely
there is here an intrinsic contradiction.

Not only upon general principles is this view untenable, subversive of
all that we have hitherto learned ; but, if carefully analyzed, it is found
to present insuperable difficulties. If it be true that a nerve-fibre diffuses
the energy which it conveys : in a general way, scatters it though all the
fibres or nerve-cell processes near which it happens to lie, it becomes im-
possible to explain the definite and precise actions of the nervous system,
properties which are so characteristic of it. Nothing but hopeless con-
fusion of function could result if such a thing were possible. It would
mean that nerve-currents course indiscriminately without relation to each
other through this network of fibres. It would mean that everything
that had been done by nature to conserve and isolate nervous impulses
by enclosing the nerve-fibres in special sheaths of insulating material
previous to their entrance into the cortex had, after all, no purpose,

DERCUM: THE FUNCTIONS OF THE NEURON. 153

because in the end the currents are turned wildly loose into a common
receptacle.

The conservation of nerve-currents along cell-processes, no matter how
long these may be, or whether they be in the cortex or below it, is an
absolute requisite. Were it not so, the various commissural and associa-
tion tracts, whose existence we know of upon anatomical as well as upon
physiological grounds, would assuredly be unnecessary, would have no
meaning if the loose and unrestrained diffusion of nervous energy in the
cortex, such as is implied by Nansen's view, were possible.

Further, such facts as we possess are directly opposed to a diffusion
of nervous energy. According to Berkley,^ by far the larger number of
the finer fibres of the cortex are meduUated almost to the extremities of
the end- terminations. It is highly probable that Berkley maintains
" that in no instance except at the free termination is there actually such
a thing as a naked axis-cylinder," and that " the conduction of the nerve-
force from cell to termination and from termination to cellular proto-
plasm again is only through the medium of the ending of the nerve-fibre,
and that there is no diffusion of the dynamic forces through the cortex,
but that the action is a direct one." In this connection he further says :

To suppose for an instant, that naked axis-cylinders are present in
considerable numbers in the cortex is to me an impossibility, for we
must necessarily suppose in such an event that in the closely packed
arrangement of axons and dendrons presented by the outer portion of
the pyramidal and in the molecular layer, where fibres and dendrites
touch each other in all directions, the stimuli would quite as often be
aberrant as direct, and as frequently reach the wrong as the right desti-
nation. Naked axis-cylinders are in all likelihood a physiological im-
possibility in the cerebrum, for were they numerous we can suppose
nothing but a constant overflow of stimuli from one cell to another, and
consequent in co-ordination, not only of thought, but also of action."

Far from lending support to the ^ iew of Nansen, that the cell is to be
left out of account in the consideration of nervous action, the discoveries
of Golgi, Ramon Cajal, Van Gehuchten, and others have shown exactly
the reverse. They have demonstrated beyond all question that, as in all
other tissues, the cell is the actual integral structure. And while it was
formerly held that the various cell-processes anastomosed freely with
each other, we now know as a matter of fact that such anastomoses do not
occur. The nerve-cell is a cell entirely by itself. It is a cell as distinct
and as self-limited as any cell of any tissue with which we are acquainted.

Far from being continuous through its processes with other cells, we
learn that its processes nowhere fuse with other structures. Its processes
are well limited, sharply defined, and bear no relation to those of other

1 Medical News, November 9, 1895, p. 50G.

154 dercum: the functions of the neuron.

cells save that of propinquity or perhaps contact. The individuality of
the nerve-cell as a morphological integer is wholly preserved.

If we grasp this idea in its full meaning, our conception of the nervous
system changes profoundly. It is no longer a stringing together of tele-
graph wires and way stations, but it consists of an aggregation of cell-
integers, each one of which does its share in the production and in the
transmission of nervous energy. For instance, the impulse proceeding
from a motor neuron in the cortex is transmitted by the neuron through
its own protoplasmic extension (the efferent nerve- fib re) to a definite
aggregation of cells in the spinal cord. It communicates its energy to
these cells in the spinal cord without in any way fusing with their pro-
toplasm or their processes. In the same way the impressions that come
by the various sensory paths come from peripheral neurons, those situated
in the skin, in the retina, in the ear, in the taste-buds, or in the Schnei-
derian membrane, and are conveyed by fibres which are merely proto-
plasmic extensions of these peripheral neurons up to the cortex. Here
in turn these fibres transmit the energy they convey to the cortical neu-
rons without fusing with the latter or with their processes. Everywhere,
and no matter in what light we view the nervous system, the signal im-
portance of the nerve-cell as an individual entity is strikingly apparent.

A consideration of the above facts has suggested to me the following
thought : Can it be that the neuron is not an absolutely fixed morpho-
logical element ? Can it be that it possesses a certain, though perhaps
limited, power of movement ? Realizing the practical value and the
wide application of this idea, I have examined the literature to see
whether a similar interpretation of nervous phenomena has occurred to
others, and to gather such facts, if any, as could be brought forward in
its support. I found that this thought had occurred independently to
three observers, one in Germany and two in France. I found that in
1890 Rabl-Ruckhard, in a short paper published in the Neurologische
Centralblatt, had suggested the view that nerve-cells have an amoeboid
movement, and he also hinted briefly at the possible significance of such
a fact, if true, upon our interpretation of the phenomena of hysteria.
Rabl-Riickhard's ideas attracted little or no attention, and in August,
1894, without any knowledge of Rabl-Riickhard's theory, in a paper on
" A Case of Hysteria of Peculiar Form," published in the Revue de
Medecine, Lepiue advanced the same view. In endeavoring to interpret
the various shifting phenomena observed in his patient he advanced the
idea that the neurons were capable of movement to such an extent as to
enable them to vary the degree of their relation to each other. About
half a year later Mathias Duval, without any knowledge of either the
views of Rabl-Riickhard or those of Lepine, in a communication made to
the Societe de Biologic, advanced the same theory. A week later Lepine,
before the same body, repeated his former arguments in its support.

DERCUM: THE FUNCTIONS OF THE NEURON. 155

Curiously enough, this view, so suggestive, so pregnant with possibilities,
did not meet with the indorsement either of that veteran histologist, Kol-
liker, or that other high authority, Ramon Cajal. In a paper entitled
" Some Conjectures on the Anatomical Mechanism of Ideation, Associa-
tion, and Attention," published in the Revista de Medicma y Cirurgia
Practicas, May 9, 1895, Ramon Cajal contended that the nerve-cells do
not move, because (1) the terminal branches of the nerve-cells of the
cerebellum, of the olfactory bulb, of the acoustic ganglia, optic lobes,
etc., always present the same shape and the same degree of approxima-
tion to the cell-bodies irrespective of the mode of death of the animal
(chloroform, hemorrhage, curare, strychnine, etc.) ; (2) because the ter-
minal nerve-branches of the retina and of the optic lobes in reptiles and
bactrachians presented always the same appearance, no matter whether
the organs mentioned had remained in a condition of rest (the animals
having been killed after remaining in darkness for a long time) or
whether they had been functionally active (the animals being killed
after prolonged exposure to sunlight).

While Ramon Cajal thus opposes the theory of mobility of the neuron,
he maintains, on the other hand, that the neuroglia-cells possess a great
degree of mobility. He points out, for instance, that the neuroglia-cells
of the cortex are at times stellate and at others much elongated. Their
processes have numerous short, arborescent, and plumed collaterals. Two
phases can be observed in them : first, a stage of contraction, in which
the cell-body becomes augmented while the processes become shortened
and the secondary branches disappear ; secondly, a stage of relaxation,
during which the processes of the neuroglia-cells are again elongated.
Ramon Cajal maintains that the processes of the neuroglia-cells in reality
represent an insulating or non-conducting material, and that during the
period of relaxation they penetrate between the arborizations of the
nerve-cells and their protoplasmic processes, and render difficult or im-
possible the passage of nerve-currents. On the other hand, when the
processes of the neuroglia-cells are retracted, the various nerve-cell pro-
cesses which they formerly separated from each other are now permitted
to come into contact. To me it seems as though Ramon Cajal admits
the very thing against which he contends. Evidently, if the nerve -cell
processes are not at one time in contact, and at another are in contact,
they must certainly move, and the question at issue is self -admitted It
certainly does not matter whether the nerve-cell processes move little or
move much, but that they move at all is the question at issue ; and this,
it seems to me, Ramon Cajal admits, although he makes that movement
a purely passive one and dependent upon the interposition of the pro-
cesses of the neuroglia-corpuscles. It is certainly a minor point whether
the movement of the nerve-cell processes is active or passive, though
it seems tliat it is far from evident, from the histological facts at our

VOL. 112, NO. 2. -AUGUST, 1896. 11

15G dercum: the functions of the neuron.

disposal, that the neuroglia-corpuscles play the role of an insulating mate-
rial. To me it further seems that a single positive observation outweighs
all other negative observations, no matter how great the authority behind
them, and this positive observation has actually been made. Wieder-
sheim' actually saw in the living animal, leptodora hyalina, an entomo-
stracan, the nerve-celle in the oesophageal ganglion move. The oesopha-
geal ganglion may in one sense be regarded as the brain of the animal,
inasmuch as it receives the fibres of the optic nerve and Wiedersheim
saw its cells move and change their shape. He describes their move-
ment as slow and flowing. Certainly this observation possesses a pro-
found significance. Even if the animal in which the phenomena were
observed is far removed from the vertebrates, it must be remembered that
it is just in the lower forms that general biological truths must be sought
for, and it is just in the lower forms that they have been found. I do
not for a moment contend that the nerve cells of vertebrates possess a
gross amoeboid movement as in the oesophageal ganglion of the entomo-
straca ; but I do contend that it is in the highest degree probable that
such facts as we have, scanty though they be, are in favor of the view-
that a certain amount of movement does take place in the terminal por-
tions of their processes, their dentrites and their neuraxons, although
this movement is probably small in extent.

Let us turn our attention for a moment to the subject of hysteria, and
let us see what a flood of light is cast upon this subject, heretofore so
obscure and mysterious. Let us take the simple example of a hyster-
ical paralysis, and see how easily it is explained, The neurons of a cer-
tain area of the cortex, for instance, retract the terminal branches of the
neuraxon to such an extent that the latter are no longer in contact, or
sufticiently near to the neurons of the spinal cord which supply the mus-
cles of the paralyzed part. It explains also the marvellous fact that a
hysterical paralysis may at one time be so real, so genuine, as to be
indistinguishable from a grossly organic paralysis, and yet the next
moment upon a suggestion may absolutely disappear. The shifting of
symptoms in hysteria, this sudden disappearance of paralysis or anaes-
thesia, can be explained by the view here advanced as it can be by no
other. When power is suddenly re-established in a hysterically palsied
limb it simply means that the terminal branches of the cortical neur-
axon, previously retracted, are again extended so as to re-establish the
proper relations with the spinal neurons. Take again the example of
a hysterical anjesthesia. How often do we see a segmented anaesthesia
or a hemi-an?esthesia coming and going under the influence of no other
stimulus than that which applies to the psychic make-up of the indi-
vidual, namely, a treatment which we call mental or moral treatment, or

1 Anatomischer Anzeiger, 1890, p. 673.

dercum: the functions of the neuron. 157

that more powerful treatment, suggestion under hypnotism. It would
be interesting, indeed, to follow out the ideas here brought forward in
their application to the various phenomena presented by hysteria, its
sensory, motor, and visceral stigmata. Even the hysterical convulsion,
I contend, can be explained by the view here advanced. Time will not,
however, permit more than to indicate the line of thought.

When we turn to hypnotism we can see what a ready explanation it
affords for the phenomena presented. Under the fixed stare necessi-
tated by the ordinary method of bringing about hypnosis, and under the
suggestion of sleep, the neurons are thrown into certain fixed relations
with each other, corresponding solely to the ocular strain and singleness
of thought induced. At the same time such relations of the neurons as
ordinarily bring them into true contact with the outer world are sus-
pended, probably by retraction of cell-processes. We can easily under-
stand, in the light of the theory here advanced, how under hypnotic
suggestion a hysterical paralysis disappears, or how, under hypnotic
suggestion, anaesthesia is produced in this or that part of the body. Fur-
ther, the various stages of hypnotism itself — lethargy, catalepsy, som-
nambulism— are all of them capable of a scientitic explanation upon this
theory. Hypnotic lethargy, for instance, a stage so easily produced in
the majority of patients, merely signifies that so general has been the
retraction of the cortical neurons from each other that not only is sleep
produced, but also a stage of general motor relaxation, due to the re-
traction of the terminal branches of the neuraxons in the spinal cord.
In hypnotic catalepsy, on the other hand, the reverse obtains. Here the
relations of the cortical neurons to the spinal neurons (contact or in-
creased proximity, whatever it may be) are established to a degree be-
yond that which is normal, and the consequence is an enormous general
increase of muscle-tonus. In somnambulism, again, certain of the neurons,
especially those which stand in direct relation with the various sensory
organs, form partial combinations with a limited number of other corti-
cal neurons, so as to produce the various limited psychic phenomena
characteristic of somnambulism, whilst the great bulk of the neurons of
the cortex, the summation of whose action constitutes the ego and brings
it into close relation with the outer world, have their processes retracted
in sleep.

Leaving this interesting field, let us see for a moment of what enor-
mous value this interpretation of cortical action is for normal mental
phenomena. Sleep, instead of resulting from brain anaemia, or some
other apocryphal condition of the circulation, merely means that when
the substance of the cortical cells has been diminished by functional
activity, which diminution we have reason to infer, from the researches
of Hodge,^ (on the changes in nerve-cells in fatigue), there comes a time

1 Journal of Morphology, 1892, vol. vii p. 95,

158 DERCUM: THE FUNCTIONS OF THE NEURON.

when the cell-processes are retracted, so that the neurons no longer stand
in active relation to each other. Interchange of action cannot then take
place ; unconsciousness follows ; sleep is established. Spontaneous waken-
ing merely means that after nutrition has reached a certain point, a point
where the wasted cell has been replenished, extension of the cell-processes
again takes place, and interchange of active functional relations is re-
established.

Numerous other ideas also suggest themselves in relation with the view
here advanced. Take, for instance, a train of thought. This appears to
follow purely mechanical lines. Thus a sequence of sound-vibrations im-
pinging upon the peripheral auditory neurons, the auditory cells, produces
in them a change, which in turn affects the relations which their neur-
axons bear to the auditory nuclei, and secondarily to the auditory cor-
tical neurons. Not only are the latter affected by the impressions re-
ceived from the afferent neuraxons, but they in turn react in such a way
as to change their relations to each other, and the new positions assumed
by them will depend largely upon the fact as to whether a similar se-
quence of impressions has passed through them before. If so, the old
combinations will be reformed, and as a corollary the recognition by the
ego of the sounds as something heard before. From the cortical audi-
tory centre there now passes through the general cortex a series of com-
binations among the neurons, also along the oldest and best-travelled
lines, so that a given sequence of musical sounds may suggest at first a
familiar air, and a moment later a vivid recollection of an opera once
heard and seen. Here is the physiology of memory.

A startling thought which also suggests itself in connection with the
theory of cortical action advocated in this paper is that not all of the
neurons are functionally active at the same time. It is exceedingly prob-
able that the number varies greatly. For instance, in fatigued states
fewer combinations are made — fewer are possible — because of the ex-
hausted condition, the diminished volume of the cell-protoplasm. After
rest, on the other hand, not only are combinations more readily made,
but a larger number of neurons are active. It is further probable that
in states of mental or emotional excitement the number of neurons that
are active and the number of combinations accordingly formed enor-
mously exceed those occurring during ordinary mental states.

Many other thoughts also suggest themselves, and some are extremely
interesting. For instance, the receptivity and marvellous adaptability
of youth and early manhood appear to depend upon the relatively great
mobility of the cell-processes, while the retarded and restricted mental
action so often seen in old age appears to be related to a much diminished
mobility of these processes. Certain it is that the theory that the neuron
is not an absolutely fixed morphological element renders clear and com-
prehensive many of the Avell-known facts of mental physiology. The

mccosh: extrauterine fcetation.

159

application of this theory, for instance, to memory, sequence of thought,
association of ideas, and even more complex mental processes, is evident,
but the limits of this paper have forbidden any but a mere mention of
them.

EXTRAUTERINE FCETATION.

REPORT OF FIFTEEN CASES TREATED BY OPERATION.

By Andrew J. McCosh, M.D.,

OF NEW YORK.

Within the past four years the following fifteen cases of extrauterine
foetation have been operated on by me at the Presbyterian Hospital.
The admission of so many cases to the service of one surgeon in a
general hospital must indicate that an ectopic pregnancy is a compara-
tively common occurrence. From the histories which follow certain
facts have been derived. The youngest patient was twenty-three years
of age, the oldest thirty-nine. Three were nulliparae. Twelve had
previously been normally pregnant, nine having borne one or more
children, three having had miscarriages only. Five had complained of
more or less pelvic pain prior to the ectopic gestation ; ten gave no
history of special distress in their pelvic organs.

Symptoms during the ectopic pregnancy. All had suffered from pain.
In three the pain had been slight, in twelve severe. All had skipped
one or more menstrual periods. In fourteen there had been irregular
uterine bleeding ; in one there was no history of bloody vaginal discharge.
In eight there had been signs of shock on one or more occasions indicating
rupture, in two of these amounting to severe collapse. In seven there
had been apparently no sign of shock. Seven had considered themselves
pregnant ; eight had not suspected the existence of pregnancy.

Conditions found at operation. In two cases the foetus was in the tube,
which was unruptured (eight weeks and ten weeks). In five rupture into
the broad ligament had occurred (less than three months). In eight the
foetus or its remains was found in the peritoneal cavity. • The duration
of the pregnancy was under fourteen weeks in thirteen cases, over four
months in two cases (four and a half and six and a half months).

It may be well to note that most of these patients were from the lower
grades of life and would not be apt to pay special attention to either
their menstrual dates or their signs of pregnancy, and perhaps not to
pain unless it was severe in character.

It will be noticed from a review of the above symptoms that these
cases emphasize the fact that the main points in the diagnosis of extra-
uterine pregnancy are, first, delay of the menstrual period, with or

160 mccosh: extrauterine fcetation

without signs of pregnancy ; second, pain generally severe in character
and sudden in its onset, sometimes agonizing, with signs of shock ; third,
irregular uterine hemorrhage very commonly accompanying the first
attack of pain.

Case X. is of special interest on account of the viability of the child,
which was fairly robust for a six and one-half months' foetus. As both
the head and extremities were deformed, an incubator was not employed.
The history of this case is also of interest because of the frequent and
severe attacks of hemorrhage in the cavity of the peritoneum. The
placenta was removed at the operation instead of being left in situ, as is
the usual custom.

Case XII. is of interest on account of the time selected for operation
and the large amount of blood found in the abdomen. Laparotomy
was done thirty-six hours after the gravest of three hemorrhages. Had
the abdomen been opened on her admission to the hospital she would
certainly have died on the operating-table. A delay of twenty-four
hours enabled the patient to recover sufficiently to withstand the imme-
diate shock of operation. Her depleted state was, however, unable to
withstand the poison absorbed from the blood which was necessarily left
in the abdominal cavity, and she succumbed on the fifth day. This was
the only fatal case.

Case XIV. is of interest on account of three successive ruptures of
the foetal sac, as is shown by the history of the case and by the condi-
tions found at operation. The first rupture, that of the Fallopian tube,
occurred presumably between the fifth and sixth weeks. Its contents
apparently escaped into the broad ligament and a large blood-clot was
left in the tube. The second rupture occurred about two weeks later.
It was of the broad ligament, and resulted in a large hsematocele in the
floor of the pelvis, which evidently became sacculated. This was also
accompanied by severe pain and by a uterine hemorrhage. The third
rupture occurred about the tenth or eleventh week and evidently was
of the sac of the h[«matocele, and resulted in either a fresh hemorrhage
or an escape of the already clotted blood into the free peritoneal cavity.
The conditions found at the operation, consisting of an enlarged Fallopian
tube, in the end of which was a cavity in which the foetus had formed, the
distended broad ligament showing a tear in its superior layer, the hsema-
tocele in Douglas's pouch with a rent in its fragile sac, and the free blood
in the peritoneal cavity, form a chain which beautifully illustrates the
history of the three ruputres, each one of which was accompanied by
pain and " flow."

Case I. — Mrs. D., aged thirty-seven years ; married ; one miscarriage,
six years ago ; no children. Menstruation regular and painless. Last
normal menstruation November 1, 1891. Considered herself pregnant
until January 27, 1892, when she thought she had a miscarriage, as

MCCOSH: EXTRAUTERINE FCETATION.

161

there was sudden uterine hemorrhage lasting some days, accompanied
by pain, and followed by severe " colic " which continued two or three
days. From February 5th until February 20th felt well, but was then
attacked with another " colic " and with vomiting. In a few days these
symptoms disappeared, but there remained a continuous pelvic pain. A
week later another colic," and again in another week. Admitted to
the hospital on March 14th : Temperature 100° ; pulse 92. There had
been no vaginal discharge since February 1st. Complained of general
abdominal discomfort and enlargement. On examination, to the right
of the uterus was a mass the size of a foetal head. Diagnosis — probable
extrauterine pregnancy, which had ruptured.

Operation, March lijth. Ether. Median laparotomy. Omentum
found tightly adherent to superior surface of tumor and to intestines ;
ligated in three portions and cut away. Tumor then seen to occupy right
iliac fossa and to be adherent to uterus, intestines, and floor of pelvis.
It consisted of a thin sac, which was situated in the general cavity of the
peritoneum. It was filled with blood-serum, and in it was a four and a
half months' foetus, cord, and placenta. Sac was ruptured ; contents
removed with moderate loss of blood. Sac peeled from its attachments
with ease. The distended and thickened Fallopian tube ligated and
removed. The abdomen closed by suture. The patient made a good
recovery, was out of bed April 12th, and discharged cured April 20th.

Case II. — M. H., aged twenty-seven years ; married five years ; no
children ; one miscarriage (second month) four years ago. With the
exception of the abortion, never suffered from pelvic pain until present
illness. Menstruation always regular and painless. Last normal men-
struation March 11, 1892. April 10th, menstrual molimina for two days,
but no flow ; noticed fulness of breasts and occasional nausea. May
7th, colicky pain in abdomen, which became localized into a constant
pain, or rather a sense of discomfort, in the left iliac fossa. May 10th,
when an examination was made a mass the size of a large orange, some-
what soft to the touch and slightly sensitive to pressure, was felt in the
left of the uterus ; uterus seemed enlarged and soft. Diagnosis of
probable extrauterine foetation.

Operation, May 12th. Chloroform. Median laparotomy. To the left
of the uterus and adherent to it was found a mass the size of an orange,
which evidently contained fluid and blood-clots. On separating it from
the adhesions it was seen to be a distended Fallopian tube. Partial
rupture with the escape of some bloody serum occurred in extirpating
the tube, which was clamped close to the uterus. Clamp was replaced
by a ligature, and after cleansing of the pelvis the abdominal wound was
closed. In the sac was found a shrunken foetus seven to eight weeks old.
The temperature of the patient did not rise above 99.5°, and she was
out of bed on the nineteenth day, and was discharged cured on June 7th.

Case III. — C. P., aged thirty years ; married ten years ; four children,
last four years ago. Menstruation had been regular. For the past four
years had suffered from dysmenorrhoea and pain in the right side. Last
normal menstruation in the middle of August, 1892. At the next men-
strual period, September 15th, the flow was profuse and continued more
or less until her admission to the hospital on November 1st. During
these six weeks she suffered from abdominal pain, frequently severe in
character, and from fever every afternoon and evening. No suspicion of
pregnancy. On admission morning temperature averaged 99° ; evening

162

MC COSH :

EXTRAUTERINE

FCETATION.

temperature 101°. Uterus was enlarged and attached to its right side,
and posterior to it Avas a tumor the size of a cocoanut. Diagnosis of
probable extrauterine pregnancy.

Operation, November Mh. Ether. In a preliminary examination of
the patient by bimanual palpation for diagnostic purposes the tumor was
felt to rupture and disappear. This rupture confirmed the diagnosis, as
but slight force had been employed. Patient placed in Trendelenburg
position and the abdomen opened by a median incision. In the right
broad ligament and escaping from it through a tear in its posterior wall
were found fluid and clotted blood sufficient to fill a ten-ounce measure,
and there were also shreds of tissue which afterward on microscopical
examination Avere found to contain chorionic villi. The right Fallopian
tube Avas enlarged and thickened, and Avith the ovary was removed.
After careful sponging of the cavity the peritoneal caA^ty was irrigated
with salt-solution, a strip of iodoform-gauze inserted for drainage, and
the abdomen closed. Recovery Avas uncomplicated. The gauze was
removed on the fifth day. The patient Avas out of bed on the twenty-
fifth day and was discharged cured December 8th.

Case IV. — O. G., aged thirty years ; married ten years ; three chil-
dren, last fifteen months ago. Menstruation had been regular and free
from pain. Last normal menstruation in beginning of September, 1892.
After skipping period about October 1st, she considered herself pregnant
and Avas " treated " by a midwife, the result after the second local treat-
ment being severe pelvic pain and a slight bloody vaginal discharge.
This continued, together with a feeling of discomfort referred to the
rectum, from October 15th until November 14, 1892, when she was ad-
mitted to the hosj^ital. On examination a mass the size of an orange
was found behind and to the left of the uterus. No tenderness on pal-
pation. Diagnosis -pyosalpinx or extrauterine pregnancy.

Operation., November 15th. Ether. Median laparotomy. Mass was
situated in left broad ligament, and was found to consist of a blood-clot
and shreds of organized tissue. Left tube much enlarged and adherent
to the sac, which, with the left tube and ovary, Avas removed. Abdomen
irrigated and closed by suture, a strip of gauze being inserted for drain-
age. The patient Avas out of bed at the middle of the fourth week and
was discharged cured December 25th. Foetal villi found on microscop-
ical examination.

Case V. — R. L, aged thirty-three years ; married ; five children ; three
miscarriages. Menstruation regular and no complaint of pain until pres-
ent illness. Last normal menstruation October 11, 1892. Skipped
period in November ; breasts swollen ; suspected pregnancy. December
13th, severe cramp-like pains in right side, followed by expulsion of large
clots from vagina. Patient remained in bed ; had fever, and floAV con-
tinued. Admitted to the hospital December 19th, complaining of severe
pain in right side; temperature 101.5° ; pulse 100. On examination a
doughy, tender mass the size of a fist felt to the right of the uterus, which
was immovable. Diagnosis — pyosalpinx or extrauterine pregnancy.

Operation, December 12th. Chloroform. Median laparotomy. Mass
to right of uterus proved to be a distended Fallopian tube adherent to
intestines and uterus. In separating it from the adhesions the tube rup-
tured and gave exit to an ounce or two of dark grumous blood and
some organized tissue, Avhich on microscopical examination was found to
contain chorionic villi. Tube extirpated with ovary. Left tube found

mccosh: extkauterine fcetation.

163

to contain a few drops of pus, also removed. A strip of iodoform-gauze
inserted behind right broad ligament and brought out through abdom-
inal wound, the remainder of which was closed. December 27th, gauze
removed, rather foul. January 20th, patient out of bed. Sinus healed
slowly and did not close until April 1st, but patient was discharged from
hospital on February 10th.

Case VI. — R. Z., aged thirty years ; married six years ; one child ;
seven miscarriages. Had been curetted several times. Four years
before suffered from an attack of pelvic peritonitis, which followed a
severe uterine hemorrhage. Since that time menstruation regular and
no complaint of pain until present illness. August 15, 1893, another
severe hemorrhage, and again followed by the use of the curette ; in bed
for a few days, but back at work in a week. Felt comparatively well
until September 12th, when she was seized with severe pain in right iliac
region, followed by a chill, fever, and sweating. These symptoms con-
tinued until September 80th, when she was admitted to the hospital ;
temperature 101.5° ; pulse 114. Complained of pain and tenderness
in right iliac region. Uterus retroverted and immovable. In right broad
ligament a fluctuating tumor the size of a large orange ; a smallar oae on
the left. Diagnosis — extrauterine pregnancy. October 1st to 10th,
temperature ranged between 100° and 102°. From the 10th to the 17th
it remained normal. From the 18th to the 26th it ranged between 99.5°
and 100.5°. Constant pain in right side.

Operation, October 26th. Chloroform. Trendelenburg position. Me-
dian laparotomy. To left of uterus a mass the size of a cocoanut found
firmly adherent to uterus, to walls of pelvis, and to intestines, and Avhich
apparently consisted of a distended broad ligament. Rupture occurred in
separating the adhesions and eight ounces of offensive bloody fluid escaped.
Left Fallopian tube enlarged, and, with the ovary, removed, two clamps
being left on the pedicles. Cavity cleansed, packed with gauze, and
abdominal wound partly closed. Considerable shock followed, but patient
rapidly rallied. November 2d, packing removed ; convalescence unin-
terrupted. November 20th, out of bed. December 2d, discharged
cured.

Case VII. — E. B., aged twenty-three years ; married two years ; never
pregnant. Menstruation always painful and rather irregular. Since
marriage more or leps sense of discomfort in right inguinal region.
During the spring and summer of 1893 continuous pain in this region.
August, 1893, on examination I found a mass to right of uterus and
adherent to it the size of a billiard-ball and very sensitive. Last regu-
lar menstruation in end of July. September 15th, slight bloody vaginal
discharge ; mass increasing in size. November 1st, pain more severe ;
mass larger, very tender; occasional "flow;" breasts tender; some
vomiting. Diagnosis of intra-ligamentous cyst, and operation advised.
Patient losing flesh and strength rapidly ; no fever. For the next two
weeks pain and tenderness increased and general condition worse. No
further flow. Possibility of extrauterine pregnancy considered, but
diagnosis inclined to tubercular salpingitis.

Operation, November 14, 1893. Chloroform. Trendelenburg pos-
ture. Median laparotomy. To the right of uterus spongy mass the size
of a goose-egg, consisting of Fallopian tube, ovary, and broad ligament,
surrounded by firmly adherent intestines. With considerable difficulty
and much hemorrhage entire mass extirpated piecemeal, as it was so

164

mccosh: extrauterine fcetation.

brittle and so adherent. Many ligatures employed. Tampon of gauze
placed in the cavity from which the tumor had been removed. Abdo-
men partly closed. On examination mass consisted of enlarged and
much-thickened tube, of part of broad ligament, and remains of foetal
tissue. Considerable shock. Slow convalescence. Discharged December
17th, with deep, narrow sinus, which persisted for months.

Case VIII. — J. M., aged thirty-one years ; married ; three children ;
one miscarriage ; last child three years ago ; miscarriage eleven months
ago, followed by a curetting of uterus. With these exceptions no com-
plaint of pelvic pain or history of disease in pelvic organs. Last regular
menstruation January 10, 1894. Skipped period due on February 8th.
Morning nausea and fulness of breasts. Considered herself pregnant. No
pain and no flow until March 10th, when after a hard day's work felt
severe colicky pain in right iliac region and noticed a slight show.
Remained in bed twenty-four hours, when pain ceased, and again moved
about the house, but complained of a sense of discomfort in the right
side of pelvis. March 18th, another attack of pain, not very severe,
and described as " tearing " in character; a slight bloody vaginal dis-
charge accompanied the pain, and as these continued she consulted Dr.
S. Graber, who made the diagnosis of extrauterine pregnancy and sent
her into the hospital for operation. Admitted March 23d, tempera-
ture 99.5° ; pulse 90 ; abdomen not distended and not tender except
on deep pressure in right iliac region, where, on vaginal examination, was
felt a boggy mass to the right of the uterus the size of an orange, and
it seemed adherent.

Operation, March 2Mh. Chloroform. Trendelenburg position. Omen-
tum adherent to fundus of uterus and to top of right broad ligament.
Uterus enlarged, position good. In right broad ligament a semi-fluctu-
ating mass the size of an orange, somewhat adherent to floor of pelvis
and to small intestine. In endeavoring to enucleate this tumor it rup-
tured and gave exit to an ounce or two of semi-solid blood and a small
oblong solid mass of organized tissue, which was afterward found by the
microscope to contain chorionic villi and remnants of a foetus. The sac
consisted of the layers of the broad ligament, with an enlarged and rup-
tured Fallopian tube forming the roof. The latter, with the ovary, was
removed, the cavity carefully cleansed, the layers of the broad ligament
sutured, and the abdomen closed. Convalescence uneventful. Out of
bed on the twentieth day, and discharged cured on April 20th.

Case IX. — A. S., aged twenty-eight years ; married ten years ; never
pregnant. Menstruation normal, slight pain. Eight years before, mild
attack of pelvic peritonitis. Since then six or eight similar attacks, the
last one a year ago. Last normal menstruation February 15, 1894.
Skipped period in March and considered herself pregnant. April 10th,
severe cramp-like abdominal pain, especially in left inguinal region, fol-
lowed by slight " flow." The pain increased in severity, the abdomen
became very sensitive, and the flow continued. On April 18th she was
admitted to the hospital. Temperature 99 5° ; pulse 100. On exam-
ination a doughy mass, sensitive to pressure, was felt behind the uterus,
which was crowded forward and to the right. Abdomen slightly tym-
panitic and tender. Diagnosis — probable extrauterine pregnancy.

Operation, April 20th. Choroform. Trendelenburg position. Median
laparotomy. To the left of uterus and behind it a mass the size of a
duck's egg, adherent to floor of pelvis and to intestines. In separating

MC COSH:

EXTRAUTERINE FCETATION.

165

this a rupture took place and a blood-clot with some shreds of tissue
escaped. The Fallopian tube was enlarged and adherent to the right
wall and roof of the sac, which, with the tube and ovary, was removed.
Several silk ligatures used. Cavity cleansed. Abdomen closed without
drainage. Convalescence rapid. Out of bed on the twenty-first day,
and discharged cured May 19th.

Case X. — M. B., aged thirty-five years ; married seven years ; one
child five years ago. No miscarriages. Menstruation has always been
regular. Has complained of no pain in pelvic organs until present
illness. Last normal menstruation in the middle of February, 1894.
At next menstrual period, March 15th, the flow was very profuse and
continued for twenty-five days and was accompanied by dull pain. This
was followed by a foul vaginal discharge which continued until May 1st,
when she was seized with a uterine hemorrhage and was taken to a hospital,
where for ten days she suffered from frequent vomiting, severe abdominal
pain, and tympanites. On May 12tli there was sudden attack of severe
pain in the right inguinal region, followed by vomiting and collapse.
A foul vaginal discharge persisted, until June 1st, when, being somewhat
improved, she was removed to her home. On July 9th she was admitted
to the medical side of this hospital. Abdomen was swollen ; she vom-
ited frequently and suffered from more or less constant abdominal pain.
On July 17th she was transferred to the surgical division for operation.
Abdomen much distended, giving on palpation a feeling of irregular
bogginess, especially to the right of the median line, where in the lumbar
region could be felt a hard mass which proved to be a foetus. Tempera-
ture 100.5° ; pulse 100.

Operation. Chloroform. Abdomen opened by median incision. Omen-
tum adhered to abdominal wall and to the agglutinated intestine beneath.
On separating adhesion a large quantity of dark blood poured out, and
the peritoneal cavity was found to contain an enormous quantity of blood,
both in clots and fluid, certainly as much as could be contained in a two-
quart measure. Clots were adherent to the intestines, and as they w^ere
removed considerable bleeding followed. The mass which occupied the
right half of the abdomen was a foetus, with its placenta apparently
encysted among adherent intestines. The placenta was implanted partly
on intestines and partly on the lower border of the liver. The head of
the foetus was pressed against the under surface of the liver. The hem-
orrhage following the separation of the agglutinated intestines was severe.
The live foetus was rapidly removed and the cord clamped. As there
was no sign of cessation of the hemorrhage, which was venous and seemed
to issue from all parts of the sac, the placenta was rapidly separated from
its attachments and removed. This was accompanied by a tremendous
hemorrhage, which was controlled by strong compression with gauze-pads,
and by a few clamps which grasped the large veins. The right tube,
enlarged and thickened, was removed. The abdomen w^as irrigated with
hot water. Numerous gauze-strips were used as packing to control the
bleeding, with the ends projecting through the abdominal wound, which
was then partly closed. The loss of blood had been excessive and the
shock was profound, but the patient rallied well, and at the end of forty-
eight hours was in fairly good condition. The gauze was removed on the
fifth day and the patient was out of bed at the end of the fourth week,
and was discharged cured September 9th. The foetus moved and breathed
vigorously ; it was apparently about six and one-half months old. The

166

MCCOSH: EXTRAUTERINE FCETATION.

head was deformed and both legs were crooked. It was not placed in
an incubator, and died at the end of a few hours.

Case XI. — K. K., aged thirty-two years ; married eleven years.
Never pregnant. With exception of an attack of pelvic pain five years
before, no complaint of uterine or ovarian trouble until present illness.
Last normal menstruation July 8, 1895. July 15th, seized with severe
pain in pelvis which continued for two days. August 6th, bloody vaginal
discharge for six days, accompanied by slight pain. August 20th, attack
of severe pain and return of " flow." Pain and flow continued more
or less constantly until her admission to hospital on September 12th.
Pain described as cramp-like, mainly on right side. Temperature 100°
to 100.5° ; pulse 80 to 100. On examination moderate abdominal dis-
tention and a boggy, ill-defined mass was felt extending out of pelvis
well above its brim and as high as the right anterior superior spine of
ilium. Diagnosis — probable extrauterine pregnancy. Immediate oper-
ation advised, but refused. During following five days evening temper-
ature ranged between 100° and 101° ; pulse 100 to 120.

Operation, September 17th. Ether. Trendelenburg position. Median
laparotomy. Intestines agglutinated to each other and to the mass,
which, the size of an orange, occupied the right iliac fossa, and was
attached to uterus and floor of pelvis, and apparently consisted of a dis-
tended broad ligament to which were adherent an enlarged tube and right
ovary. Sac ruptured ; an ounce or two of bloody fluid escaped. Tube
and ovary removed. Cavity cleansed and in it was placed a gauze-strip,
the other end projecting through abdominal wound, the remainder of
which was closed by suture. Convalescence uneventful. Gauze removed
September 21st. Patient out of bed October 16th. Discharged cured
October 26th.

Report of Dr. Thacher, pathologist, states : ' ' The Fallopian tube
presents a dilatation one inch in diameter near its centre. This sac has
ruptured and is filled with a solid blood-clot. Microscopical examina-
tion : Villi of the chorion."

Case XII. — D. S., aged thirty-seven years ; married ; three children.
Last normal menstruation September 6, 1895, after which no sign of
bloody vaginal discharge until the day of her admission to hospital, No-
vember 6, 1895. On October 25th she was seized with a severe attack of
abdominal pain, chiefly located in the left iliac fossa, which was followed
by leucorrhoea. On October 30th another sudden attack of pain, fol-
lowed by syncope and vomiting. Great prostration and some abdominal
pain and distention foUow^ed and continued until the morning of Novem-
ber 6th, when she was seized with a third attack, in which the pain was
agonizing, the patient losing consciousness and continuing in a condition
of collapse until her admission to the hospital in the evening of that day.
In the ambulance during transfer to hospital she had several attacks of
syncope in spite of active stimulation. On admission her radial pulse
was almost imperceptible. Abdomen considerably distended and tender.
By vagina the pelvis was found filled with a boggy mass. Diagnosis —
ruptured ectopic gestation. Collapse, however, was so great that opera-
tion was for the present out of the question, as she would surely have
died on the operating-table. During the night she rallied somewhat and
on the next afternoon her condition was such that a laparotomy was
deemed justifiable, as further delay probably meant a fresh hemorrhage.
Under ether-ansesthesia in Trendelenburg position, the abdomen was

mccosh: extrauterine fo^tation.

167

rapidly opened. As soon as the peritoneum was nicked a spout of dark
fluid blood spurted out, and on enlarging the opening it was found that
the abdominal cavity was full of blood, both fluid and in clots. Two
quarts at least of fluid blood were washed out and clots were removed in
handfuls, certainly enough to fill another quart measure. After the
greater bulk of blood had been removed patient was placed in Trende-
lenburg position, and to the left of the uterus was seen a mass as large
as a small orange, consisting of an enlarged Fallopian tube, with a rup-
ture in its wall, and a thin, semi-transparent empty sac, also ruptured.
These were removed and clamps left on the pedicles. Peritoneal cavity
washed out with gallons of hot salt-solution. Irrigation could, however,
not be continued until the fluid ran out clear on account of the patient's
condition. Gauze was packed into the left iliac fossa and a large glass
drainage-tube placed in the pelvis, and the wound partially closed. The
shock of the operation was great, but the patient rallied and on the fol-
lowing day was in fair condition, with a pulse of 140. There was a pro-
fuse discharge of bloody fluid through the tube. Temperature 99° to
101°.

JSfover)iber Sth. Temperature 100^ to 101° ; pulse 135 to 140. Free
discharge of bloody serum Patient looks septic.

9th. Temperature 100° to 101.5^; pulse 130. Gauze-packing removed.
Some vomiting.

10th. Temperature 100.5° to 102° ; pulse 140. Several movements
of bowels. Abdomen less distended.

nth. Temperature 100° to 102° ; pulse 140. Patient weaker. No
vomiting. Bowels moved.

12th. Died. Cause, exhaustion and saprsemia.

The pathologist reported foetal villi in the specimens removed.

Case XIII. — M. C., aged twenty-six years , married seven years ; no
children. One miscarriage at second month, three years ago, after which
uterus was curetted. Since then regular menstruation and 'freedom from
pain until present illness. Last normal menstruation August 15, 1895.
At the time of next period, September 13th, sudden profuse hemorrhage
lasting a day or two, and since then more or less constant bloody vaginal
discharge. Cramp-like pains in the pelvis and occasional vomiting,
which continued until her admission to the hospital on October 21st,
when the temperature was 99.5° and pulse 120. Abdomen distended
and very tender. Mass felt most prominent on the right side, extending
out of the pelvis nearly as high as the umbilicus. Diagnosis — either
extrauterine pregnancy or an abscess.

Operation,, October 22d. Chloroform. Median laparotomy. Tren-
delenburg position. Bladder found adherent to the anterior surface of
the tumor and to the agglutinated intestines as high up as the umbilicus.
A catheter had been passed previously to the operation, but there remained
more than a pint of urine in the bladder, which was opened before it
could be separated from the nuiss, which separation was accomplished
with considerable difficulty. Tumor as large as a cocoanut found to
right of uterus, firmly adherent to broad ligament and to neighboring
intestines. In separating this the sac ruptured and about eight ounces
of bloody purulent-looking fluid escaped. Right Fallopian tube ad-
herent to the sac and nnich enhirge(l,au(l near its centre was an old tear.
It, with the ovary, was removed. On a loop of small intestine which
had foriued part of the sac-wall was a crater-like spot as large as a

168

mccosh: extrauterine fcetation.

silver dollar, evidently the site of the placenta. Cavity sponged out,
a strip of gauze packed into it and the end brought out through abdom-
inal wound, which with this exception was closed. Patient suffered from
considerable shock, but rallied well. Gauze removed on fifth day, and
a fecal discharge indicated the existence of a fistula, most probably
from a slough at the site of the placenta. With this exception recovery
was uninterrupted. Fistula rapidly contracted. Fecal material ceased
to pass on November 25th. Patient out of bed December 2d. Dis-
charged cured December 14th.

Case XIV. — L. M., aged thirty-seven years ; married ; four children ;
one miscarriage. Last child two years ago. Menstruation had been
regular and painless. No special complaint of pelvic pain until present
illness. Last normal menstruation September 16, 1895. October 1st,
complained for a few days of pain in left iliac fossa, not severe. Skipped
menstruation which was due on October 14th. November 12th, after a
slight fall felt severe cramp-like pains in left iliac region, and twenty-
four hours later there was a sudden gush of blood from vagina. The
pain continued for several days, and there was occasional vomiting.
She suspected that she might be pregnant. November 13th, another
attack of severe pain accompanied by a " fiow," which latter continued
more or less constantly until her admission to the hospital ( n December
13th. The pain continued for a few days, and afterward she was com-
paratively comfortable until December 7th, when she was again seized
with severe pain and pregnant- vomiting. This continued until Decem-
ber 12th, when she was seen by Dr. Forbes Hawkes, who made the diag-
nosis of probable extrauterine foetation which had ruptured, and he
advised immediate operation. Temperature 101.5° ; pulse 110. Ou
admission, December 13th, temperature 100° ; pulse 98. On examina-
tion a boggy mass was felt in Douglas's pouch about the size of a foetal
head. Just above and under the symphysis a solid mass the size of a
hen's egg. Diagnosis — extrauterine fetation which had ruptured into
abdominal cavity.

Operation, December VMh. Ether. Trendelenburg position. Median
laparotomy. On opening peritoneum considerable blood, both fluid and
clots, found in its cavity. Omentum adherent to pelvic mass, easily
separated. In median line under symphysis pubis and projecting toward
the left side, a firm tumor the size and shape of a short, thick sausage.
To its left, apparently on top of broad ligament, a thin sac the size of a
hen's egg Uterus pushed over to right side of pelvis. In Douglas's
pouch, surrounded by adherent intestines, a soft mass the size of two fists.
The sausage-shaped tumor above the symphysis found to be a distended
Fallopian tube (left). It was removed, two clamps being placed on ped-
icle. During this extirpation the sac to the left ruptured and an ounce
or more of bloody fluid escaped. This sac apparently consisted of a
distended portion of the left broad ligament and was afterward removed.
The mass in Douglas's pouch consisted of black blood-clots enclosed in
a fragile sac, through the wall of which some leakage had apparently
occurred. The clots were scooped out by the hands. The table was
then lowered and the abdominal cavity irrigated with gallons of hot salt-
solution until it ran out comparatively clear. A large amount of blood
was thus washed out. The pelvis was again elevated, the pedicle and
a few bleeding points in broad ligament and omentum ligatured with
catgut, one clamp remaining. A strip of gauze was packed^into Douglas's

MCCOSH: EXTRAUTERINE FCETATION.

169

pouch and brought out through the abdominal wound, the upper half of
which was closed by suture. On opening the tube it was found to be
distended with a firm mass of clotted blood. The distal end was open
and led into a cavity about the size and shape of the last two joints of
one's index-finger, the walls of which were composed of solid blood-clots.
Considerable shock followed, and on the following day condition of
patient was serious. Temperature 103° ; pulse 130. Frequent vomiting.

December 15th. Temperature 102 ^° ; pulse 120.

December IQth. Temperature 10H° ; pulse 110. Gauze removed.

Convalescence uneventful. Out of bed January 12th. Discharged
cured January 27th.

Case XV. — A. B., aged thirty-nine years ; married ; two children ; no
miscarriages. Menstruation had been regular and painless, and no com-
plaint of pelvic pain until present illness. Last regular menstruation
December 20, 1895. Menstruation in January probably skipped. Feb-
ruary 21st, menstrual flow appeared. February 22d, while sitting on a
privy-seat was suddenly seized with severe abdominal cramps and vomit-
ing, accompanied by profuse vaginal hemorrhage. Abdomen became swol-
len and tender, and cramps continued. There was some evening tempera-
ture, and vomiting was frequent. The vomiting, pain, and distention
increased until March 26th, when she was seen by Dr. J. C. Jay, who
made a diagnosis of peritonitis. I saw her on the same day, and we de-
cided that her condition would not justify an operation. Vomiting was
constant ; pulse 130 ; temperature 103° ; no movement of bowels for five
days. Probable diagnosis — ruptured extrauterine foetation. Abdomen
very sensitive, but by vaginal examination could be felt a boggy mass
filling the pelvis and extending upward to near the umbilicus. Under
Dr. Jay's care gradual improvement until April 25th, when he deemed
a laparatomy justifiable. The mass extended well out of the pelvis and
on the right side above the anterior superior spine of ilium. Pulse 110 ;
temperature 100° to 100^°; stomach very irritable.

Operation. Chloroform. Median incision below umbilicus. Peri-
toneum incised superior to mass, which was shut off" from general peri-
toneal cavity by adherent intestines, and was adherent to anterior
abdominal wall. Perixoneum closed by suture, and incision extended
downward. Bladder adherent to anterior surface of tumor, pushed
downward. Under peritoneum blackish-green mass. Peritoneum opened
and large quantity of dark blood, fluid and in clots, poured out. Hand
scooped out clots and a three months' foetus, with cord and placenta,
which was easily separated. Total amount more than two quarts. The
cavity, the roof of which was formed of agglutinated intestines, was
irrigated and drained with tube and gauze. During the first week there
was much vomiting and development of urinary suprapubic fistula.
Otherwise convalescence was uneventful. Discharged cured June 16th.

170 STEWART, SALINGER: TREATMENT OF ANEURISM.

ON THE TREATMENT OF ANEURISM BY ELECTROLYSIS
THROUGH INTRODUCED WIRE: REPORT OF A
SUCCESSFUL CASE.

By D. D. Stewart, M.D.,

OF PHILADELPHIA,

PROFESSOR OF DISEASES OF THE STOMACH AND INTESTINE IN THE PHILADELPHIA POLYCLINIC ;
PHYSICIAN TO THE EPISCOPAL HOSPITAL ;

AND

J. L. Salinger, M.D.,

OF PHILADELPHIA,

CHIEF OF THE MEDICAL CLINIC AT THE JEFFERSON MEDICAL COLLEGE HOSPITAL ;
PHYSICIAN TO THE PHILADELPHIA HOSPITAL.

In a paper by one of us (Stewart) recently^ the unquestionable advan-
tage of combining electrolysis with the introduction of wire, in the
treatment of sacculated aneurism not susceptible of cure by medical
treatment or by time-honored surgical means, was fully set forth. It
was remarked as evident that the employment of galvano-puncture
alone, however perfect the technique, had beyond doubt proved a failure
in the therapy of aneurism. The introduction into the sac of filiform
material, but especially of wire (Moore's operation), was shown to offer
much to recommend it. The literature of the subject was then carefully
surveyed in the paper, and individual cases in which wire had been used
were analyzed. The conclusion seemed apparent that, given a proper
subject, Avith proper technique, little risk attended the method and much
promise of benefit. It was pointed out that failure in several of the
cases reported lay in the direction of improper technique, such as the
use of too great a quantity of wire,^ and to the occurrence of septic
complications, as in Moore's case.^ These, present knowledge would lead
us to avoid. The fact that in most of the cases the operation was un-
dertaken as a forlorn hope, with the aneurism on the point of rupture,
had also to be borne in mind, for it was apparent in nearly all of the
fatal cases that any other issue was scarcely to be expected. As con-
cerns result, Loreta's case and Morse's* plainly showed the great prom-
ise of the method when other conditions were also propitious for cure.

1 The Treatment of Sacculated Aortic Aneurism by Electrolysis through Introduced Wire.
American Journal of the Medical Sciences, October, 1892.
- In Moore's case 108 feet of wire were introduced, and in Cayley's, 75 feet.

3 Death here occurred from pyaemia.

4 lu Loreta's case an abdominal aneurism, the size of a foetal head at term, contracted to the
dimensions of a walnut, with obliteration of the sac-cavity, by the seventieth day after the
introduction of two yards of silvered copper wire. Death resulted subsequently from rupture
of the aorta below the sac. In Morse's case it is stated that eight weeks after the insertion of
one and a half yards of one-half millimetre silver-plated copper wire into the sac of an abdom-
inal aneurism the size of two fists, all indications of aneurism had disappeared, a hard nodule
replacing the pulsating tumors. The patient remained well.

STEWART, SALINGER: TREATMENT OF ANEURISM. 171

Electrolysis combined with the introduction of wire, by which a strong
galvanic current is conducted through coils of the same filling the
sac, was shown to be an incomparably superior method of promoting
prompt coagulation to the use of wire alone. Apart from the harmless-
ness of the procedure, its advantages over the use of wire without elec-
trolysis consisted in that " instead of a soft, unstable coagulum about
the wire, tardy in appearing, there may be produced almost immediately
a tough clot, which, in favorable cases, should tend by accretion to pro-
duce prompt obliteration of the sac-cavity." Over mere galvano-punc-
ture the superiority lay, as w^as remarked, in that in the former, if the
wire were properly disposed, a firm coagulum, perhaps completely filling
the sac, might be expected to occur promptly, instead of a few small
nodules at the periphery which would have little effect upon a large
mass of circulating blood.

The seven cases then on record were analyzed and a new one reported.
It was shown that these scarcely bore collective review. Burresi-Corradi's
case — a thin-walled, rapidly growing aneurism — had been regarded as
utterly hopeless for any treatment prior to operation, as were those of
Barwell, Roosevelt, Abbe, and my own. In another of the seven the
sac was fusiform in character, and not, as remarked, suitable for the
application of the method. In several the technique employed was
most faulty. Far too much wire was used in two than could have been
productive of ultimate good.^ The current-strength and the polarity
employed in several were not mentioned. In these it seemed likely that
the former was insufficient and the second scarcely the best. In Abbe's
case, which had been regarded as utterly hopeless prior to operation, it
was still unfortunate that a beneficial current of 50 milliamperes anode
for a half hour should have been succeeded by one calculated to soften
rapidly and 'separate the clot so induced — 100 milliamperes cathode
the second half hour. On individual study of these cases it appeared
obviously unfair to hold that the operation was of slight promise be-
cause of the seven cases but two were cured. From the evidence these
two were the only ones susceptible of cure.

In the senior writer's case the aneurism was of enormous size, showing
advanced pressure-symptoms. A large part of the sac-boundary con-
sisted no longer of arterial tunics, but of eroded ribs and vertebrse, and
in the situation of the bodies of several of the last which had been
largely absorbed lay spinal cord protected only by its membranes and
by clot. In this case the operation had been attempted rather as a
means of euthanasia than with idea of cure. Intense suffering from
nerve- and bone-pressure rendering constant use of anodynes necessary

1 In Roosevelt's, 225 feet of wire were introduced ; in Abbe's, 150 feet, nine days after the
insertion of 100 feet of catgut.

VOL. 112, NO. 2.— AUGUST, 1896. 12

172 STEWART, SALINGER: TREATMENT OF ANEURISM.

was hoped to be obviated for a time through the formation of support-
ing coagula. This case proved fatal on the ninth day succeeding opera-
tion, an indiscretion on the part of the patient causing rupture of the
sac in a section of the aneurism some distance from the wire or the clots
that engaged it. The enormous size of the sac had precluded the possi-
bility of complete solidification by clot. In this case, as with all of the
others in which the conditions were at least moderately favorable for
clot-formation, decided evidences of this were evident soon after opera-
tion. A necropsy, when obtained, strikingly demonstrated the value of
the method.

It has since been Dr. Stewart's good fortune, through the kindness of
his collaborator, to repeat this procedure. In the present case, here re-
ported, there was a large and rapidly increasing innominate aneurism.
Its anterior surface was unprotected by clot, and indications of early rup-
ture were very evident. The patient's condition was most unfavorable
otherwise. He was an inmate of Blockley ; had been for years of dissi-
pated habits and had had syphilis. There were evidences of advanced
nephritis, of greatly enlarged heart and of badly damaged aortic leaflets.
Blood-pressure was persistently high and utterly uninfluenced by large
doses of potassium iodide.

Although an absolute cure^ was here scarcely to be expected for these
reasons, the result obtained well illustrates the usefulness of the method
in promoting clot-formation, its innocuousness, and the benefit which
may accrue in a case the duration of the life of which was then regarded
as ephemeral. The patient after a few weeks in bed has since steadily
been about. The aneurism, although still somewhat prominent and
pulsating, can be handled with impunity. It causes no obvious pressure-
symptoms.

History of the Case, by Dr. Salinger.

G. D., aged forty years ; white male. Syphilis in 1881. Very severe
attack of acute articular rheumatism in 1887. A heavy drinker since
early manhood. For a number of years worked in lead, but no history
is obtainable of plumbic poisoning. Has been a stonemason lately.
This occupation necessitates great physical strain. Had a bad fall (from
the second story of a house) in December, 1891. Was injured about
the body and extremities. States that he also bruised the right side of
the chest in the situation at which the aneurism developed a year later.
In December, 1892, severe pain was first felt in the neck on both sides,
but especially on the right. Paroxysmal cough, and slight, although
continuous dyspnoea, also appeared. In April, 1893, he first noticed a
swelling below and to the right of the right sterno-clavicular junction.
This steadily increased in size. Admitted to the writer's wards, Phila-
delphia Hospital, June 23, 1893. The following was then also noted :
Patient had dissipated appearance, suggesting a heavy drinker. Face

1 A cure as concerns complete obliteration of sac.

STEWART, SALINGER: TREATMENT OF ANEURISM. 173

swollen, cheeks flushed, conjunctivae injected. Dilated venules on face
and upper extremities. Right pupil smaller than the left. Chest fairly
well developed, Aneurismal swelling extends from the middle of right
clavicle to left sterno-clavicular junction and from upper border of the
second rib to two inches above clavicle. The prominence is four inches
in vertical direction, four inches in transverse, and three-quarters of an
inch above the level of the sternum. Dulness appears at the centre of
the right clavicle. Transverse measurement of dulness seven and three-
quarters inches. Tumor in shape that of segment of circle, curve down-
ward, with radius three and a half inches. Expansile pulsation over all
parts of tumor. Thrill and bruit present and transmitted into carotids.

Heart : Apex-beat diffused ; pulsation visible over large area ; to pal-
pation most apparent in sixth interspace, a half inch outside mamillary
line. Marked double aortic murmur, the diastolic part of which is
transmitted to apex. Typical water-hammer pulse absent. Little differ-
ence noted in the two pulses by finger or sphygmograph. Aneurismal
character absent. Both pulses at times anacrotic, the left rather than
the right shows tendency to complete obliteration of dicrotic wave, so
common in aortic regurgitation. Both have usually great altitude of
percussion-wave. Laryngeal examination negative. Patient has con-
siderable cough, both dry and attended with expectoration. Sputum
examination for tubercle bacilli and elastic tissue negative. Upper
part light chest shows poor expansion, vesiculo-bronchial breathing,
slightly impaired resonance. Blood-spitting occurs. Urine contains
much albumin.

Patient placed on potassium iodide in ascending doses. Tuffnell's
treatment was also adopted. Despite this aneurism rapidly increased in
size. Rupture externally seemed imminent. Outlook apparently hope-
less. Interference by deligation on the part of the surgeon on duty
refused. Dr. Stewart invited to see the case with a view to treatment
by his method of electrolysis through introduced wire.

History of the Operative Procedure, by Dr. Stewart.

I concluded in this case to adopt practically the same technique as in
the other case detailed in my first paper. In this instance, however, in
which apparently better ultimate results might be expected, I choose for in-
sertion, by preference, a finer wire. In my first case, as I have elsewhere
remarked, ' ' I concluded a better chance of immediate success lay in the
introduction of wire of sufficient calibre to form large, supporting spirals in
the sac, thus occupying considerable of its cavity, and affording a frame-
work for clot, than in the use of a thinner, more pliant wire, which,
though better calculated to permit of ultimate contraction of organized
fibrin and sac-walls — apparently not to be hoped for here — might
undergo deflection from its course in introduction through impingement
on loose coagula already in the sac, thus perhaps rendering it necessary
to repeat the process, which from the patient's enfeebled condition would
have been impracticable." In the present case, with a much smaller
sac, and one less likely to contain interfering clot, the interior of which,
on all sides, could be reached by a few feet of properly drawn spirals,
the ideal wire was one of as small a calibre as would, while maintaining
its spiral shape, subsequently admit of coincident contraction with the
large enveloping coagulum to be formed under the current's influence.

174 STEWART, SALINGER: TREATMENT OF ANEURISM.

I had at first intended employing silver wire ; but as difficulty then
existed in obtaining it sufficiently firm of a suitable fineness, after con-
sulting with Mr. Otto Flemming, I concluded to resort to gold wire,
which latter seemed to meet better the indications. The chief objection
to the use of gold wire, we agreed, lay in the fact that a greater strength
of current was necessary to promote roughening of its surface, to induce
the prompt coagulation about it desired. Iron wire was impracticable
and even dangerous for use for the reasons fully cited in my paper, based
on very convincing experiment. The wire w^as drawn hard to No. 30
gauge and so wound that when finally passed through the needle it
formed separate spirals of moderate dimensions.

The procedure was carried out on July 27, 1893. Strict antisepsis was,
of course, adopted. As in the other case, I determined upon the con-
joint use of galvano-puncture, by means of several needles connected
with the same rheophore as the wire, hoping thus better to secure an
extensive coagulum from wire to needles and to sac-wall.^ Two plati-
num needles of good calibre were first introduced toward the periphery
of the sac. These were well insulated at their base to protect the skin.
More than an inch penetrating into the aneurism was left uninsulated.
About this from the wire to the sac-wall it was desired to promote clot-
ting under the current's influence. One of the two needles after intro-
duction could be freely moved about in the sac. Upheld after insertion
it fell from the perpendicular to a horizontal position, showing how thin
was the sac-wall in this position and that no supporting clot lay beneath
it. The other, introduced at another point at the periphery several
inches from the first, seemed less free, so that after a time it was with-
drawn, blood flowing freely from the site of puncture. The receiving
canulated needle was of as small a calibre as would admit the passage
of the wire, and was insulated to its tip. This I introduced into the
most prominent and central portion of the sac, at a point so thin-walled
that blood spurted through the needle when penetrated to a depth of but
a fifth of an inch. Blood continued to flow between canula and wire
until the current was closed. Ten feet of wire were now sloivly passed
into the sac and the points of contact connected by the anode. A large
clay plate forming the indifferent electrode, was placed upon the abdo-
men. Its position was changed from time to time without breaking the
circuit. The current was, of course, controlled by a rheostat. The elec-
trical outfit contributed by Mr. Flemming was in his care. The cuirent
was passed without interruption for seventy-five minutes. It was grad-
ually increased to 30 milliamperes in one minute to 65 milliamperes in
five minutes ; to 75 milliamperes in ten minutes and 80 milliamperes in
fifteen minutes, and maintained steadily at the latter point for one and
a quarter hours. Both of the needles, which from their weight (the
weight of the wire in the canulated one) tended to lay horizontal to the
sac-wall unless upheld as they w^ere, at the expiration of half an hour
remained perpendicular without assistance, showing well the wonderful
clot-forming power of this strength of current through the anode. To-
ward the end of the procedure it was generally remarked by all present
that pulsation had quite markedly lessened over a large part of the sac.
The patient was carefully watched by Dr. Salinger and myself during

1 See my paper in The American Journal of the Medical Sciences, October, 1892, p. 432,

STEWART, SALINGER: TREATMENT OF ANEURISM. 175

the operation. The procedure was well borne. No pain was felt at
any time during it or subsequently, and there was no evidence of
shock.

Subsequent History and Remarks. An Account of a Second
Attempt at Introduction of Wire which Demonstrated
Clot-formation.

Slight oozing recurred from the site of one of the punctures for a few
days subsequent to operation. It was controlled by iodoform collodion
and the application of ice. Pulsation in the sac steadily diminished, and
showed little of an expansive character by the end of the second day.
Thrill, too, was then noted to have largely disappeared. The patient
complained only of stilfness in the neck, caused by lying so long- in one
position. He swallowed fairly well. Respirations at first were stridu-
lous, but later became normal. No elevation of temperature occurred.
All who had followed the case noticed the decided lessening in pulsation
in the sac, especially its lower half, through which the wire had been
passed, and which previously had shown the most expansile movement.
Potassium iodide was repeated after a time. It was thus hoped to assist
in clot-formation through influence on blood-pressure. Later, for short
periods, we also used calcium chloride in small doses, after Wright's
method, measuring its effects upon blood-coagulability by the latter's
apparatus. Little benefit was obtained from it ; we found that even in
small doses its effect early was to delay the onset of coagulation after
ephemerally having had the opposite effect.

At the expiration of three weeks, although we agreed that the lower
half of the aneurism had unquestionably diminished in size, become
firm and no longer showed expansile pulsation, so marked a change in
the upper portion was not apparent. It was evident that clot-formation
had been induced, although its extent seemed limited. The patient's
bad physical condition, from the arterial wall-changes evident, the dam-
aged heart, and very incompetent kidneys, did not render the outlook
promising. Blood-pressure was constantly abnormally high, and rupture
in the upper segment of the sac seemed still to be feared for a reason men-
tioned by Dr. Stewart in his first paper' as the probable immediate cause
of death in a certain number of cases in which filiform material was
introduced, irrespective of any direct danger from injury by the ma^terial
itself. The risk seemed to be " in consequence of the partial oblitera-
tion of the sac-cavity by former coagula resulting in rapidly raised pres-
sure in an unprotected and weakened portion of the sac now exposed to
a greater pressure than formerly." We regarded it as likely that the
wire had only filled the lower segment, which was probably larger than
we had supposed. Dr. Stewart thought it well to attempt to repeat the
operation, if possible introducing more wire into the upper segment of
the sac. This was the portion in which the platinum needle had been

1 Page 436.

176 STEWART, SALINGER: TREATMENT OF ANEURISM.

placed, which at first was totally unprotected, but which at the end of the
electrical session showed decided evidences of coagulation.

Accordingly, four weeks after the first operation he inserted perpen-
dicularly a canulated needle, an inch and a quarter in length, to its full
extent, into this part of the sac, which now seemed the weakest and
thinnest portion. No blood flowed at any depth, although the needle
was inserted slowly. But one to two inches of wire could be forced into
it, with most patient effort. The wire and finally the needle were with-
drawn. Not the slightest oozing followed, nor was either needle or wire
blood-tinged. An attempt was now made to pass the needle at another
point which seemed from external evidences less protected. The result
was similarly negative. No blood flowed, no wire could be passed, and
the needle could be moved about only with difficulty in the previously
fancied cavity. On the following day a needle of larger calibre, two
inches in length, was tried by Dr. Stewart with similar result. This he
thrust into the sac in two situations in a direction perpendicular to the
surface as before. The new sites of puncture chosen were those in which
the sac also seemed weak. Another attempt was also made by entering
the needle near the upper base in a direction obliquely downward. In
each instance the result was similar. No blood flowed at any depth
penetrated (upward of tAvo inches), and at no depth could more than two
inches of wire be with difficulty thrust through the needle. This was
a beautiful demonstration that consolidation had been effected in all
parts of the sac, which other evidence had previously rendered doubtful.
No oozing occurred after these multiple and deep punctures, and no ill
result. The patient was soon after discharged from the hospital. He
has been under observation to the present. Indications of chronic
nephritis continue as before. The urine is constantly diminished in
amount (averaging, in recent estimations, 800 c.c. in twenty-four hours) ;
albumin is steadily present (2 J grammes to the liter) ; there is low urea
(12| grammes in twenty-four hours), and an abundance of granular,
epithelial, and hyaline casts. Symptoms of renal inadequacy are common,
although not decided. His habits are, as before, irregular He is about
the streets, and still drinks freely of spirits when opportunity offers.

Despite these most unfavorable conditions the aneurismal tumor,
although still prominent, has caused him no inconvenience for a long
time. Pulsation is still evident, but is apparently a communicated one.
No thrill is present in the aneurism, although one still persists in the
carotids. Although clot-formation has unquestionably occurred, such
complete subsequent organization of the mass necessary for final obliter-
ation of the sac-cavity has probably been impossible because of the
very bad physical condition and habits of the patient. The sac is, how-
ever, so well protected by clot that no direct or remote symptoms occur
from the aneurism itself.

^^^^^^^

G. D., April 25, 1894 ; right radial, pr. 3 oz. ; left radial, pr. 3 oz. ; sitting.

scudder: fracture of the skull.

177

Decided improvement has also occurred in the cardiac condition since
the operation, presumably scarcely to be accounted for as a direct result
of the change in the aneurism. The area of cardiac dulness is consid-
erably less ; the double aortic murmur is much diminished in intensity
— the systolic bruit is now scarcely appreciable, and the diastolic not
marked. The radial pulses are equal. The sphygmograms exhibit
markedly the evidences of sustained high blood-pressure constantly
present, the result of inadequate kidneys. The accompanying tracings
well illustrate this.

Aneurismal character and evidences of the aortic valve lesion are now
absent from the pulse.

June 23, 1896. Almost three years have now elapsed since the date of
the operation (July 27, 1893). The patient, followed to the j^resent, is
in his usual health. Two quite small, soft areas are now apparent in
the otherwise firm aneurismal sac, not present a few months previously.
That he has lived so long, despite the ill-result of the extensive cardiac
and renal disease, and his vagrant habits, on his general condition, with
an aneurism of such dimensions is surprising. Such a result in what
was so hopeless a case is most gratifying and suggestive.

COMPOUND DEPRESSED FRACTURE OF THE SKULL; ABSENCE
OF UNCONSCIOUSNESS ; PARALYSIS OF ONE-HALF
THE BODY; OPERATION; RECOVERY.

By Charles L. Scudder, M.D.,

ASSISTANT IN CLINICAL AND OPERATIVE SURGERY, HARVARD UNIVERSITY ; SURGEON TO OUT-
PATIENTS AT THE MASSACHUSETTS GENERAL HOSPITAL BOSTON, MASSACHUSETTS.

This case illustrates that consciousness may be unimpaired following
an injury to the head severe enough to cause paralysis.

A boy, nine years old, was struck in the head by a brick falling from
a height. He was seen immediately after the injury at the hospital and
found to be conscious. He answered questions naturally. There was
a large scalp-wound over the parietal bone and a little anterior to the
parietal eminence to the right of the median line. The bone beneath
the scalp-wound was fractured and depressed into the brain-substance.
The left arm and the left leg were completely paralyzed to motion.
The right pupil was dilated; sensation was present. The right upper
eyelid drooped. There was a scar in the right cornea. Immediately
after the injury the temperature was 96° F., the pulse was 74, the res-
piration was 26. When examined one hour after the accident the pulse
had fallen to 68, he had vomited once, and had been somewhat nause-
ated.

The operation of elevation of the depressed fragments of bone was
done under ether. The fragments of bone removed were about the size
of a silver half-dollar. There was no fissure in the skull. The dura

178

SCUDDER: FRACTURE OF THE SKULL.

mater was torn and the brain slightly lacerated. Upon elevating and
removing the depressed bone hemorrhage occurred from the vessels of the
dura mater. The depressed bone was not replaced. The dura was left
open and the cavity was drained by a wick of gauze, which was removed
upon the third day.

A few hours after the operation the boy was perfectly conscious as
before the etherization, the pupils were normal, and motion had returned
in the paralyzed limbs.

Three weeks after the operation a small, granuating wound remained
and there was a slight tendency to hernia cerebri.

Four months following the accident the boy's condition is as follows :
The wound is nearly healed and continues to discharge at times. He
walks naturally. There is no paralysis of arm or of leg. No mental
symptom is present.

The interesting and unusual fact in this case is that after a blow suffi-
ciently severe to cause a depressed fracture of the skull and paralysis
of one-half of the body the patient remained conscious.

Compound depressed fracture of the skull.
X. The mid-point between glabella and inion. A. Middle of depressed bone.

The exact location of the iujury to the head and brain is shown in
the accompanying photograph.

Note. — For a study of the interval of consciousness after head-injuries,
see The American Journal of the Medical Sciences, April, 1895.

eskridge: chronic abscess of the brain. 179

DIAGNOSIS OF CHRONIC ABSCESS OF THE BRAIN.
By J. T EsKRiDGE, M D..

OF DENVER, COL.,

PROFESSOR OF NERVOUS AND BIENTAL DISEASES IN THE MEDICAL DEPARTMENT OF THE
UNIVERSITY OF COLORADO ; NEUROLOGIST TO THE ARAPAHOE COUNTY
AND ST. LUKE'S HOSPITALS.

Chronic abscess of the brain may, for the sake of convenience of de-
scription, be divided into two varieties. The one is the result of acute
or subacute focal intracranial suppuration in which the symptoms have
become more or less latent ; while the other begins with symptoms so ill-
defined and unobtrusive as scarcely to attract attention, if, indeed, they
do not escape observation entirely during the early stage of the morbid
process. It would aid in preventing confusion in the study of abscess of
the brain if all those cases that begin wdth more or less pronounced cere-
bral symptoms, and continue with unmistakable and progressive signs of
brain-disorder, were regarded as acute or subacute, no matter what may
be the duration of their course. It may be argued that it would be
more definite to call those abscesses of the brain that begin with acute
or subacute symptoms, and are followed by a latent period, as latent,
leaving the term chronic to apply only to those whose early period is
insidious. It does not matter much which course is followed so that it
is distinctly understood what is meant to be conveyed by the word
chronic as employed to designate certain varieties of abscess of the
brain. A chronic abscess is essentially latent from its commencement
to the beginning of its terminal period, and the so-called latent abscess
is usually one whose duration is more or less prolonged. An abscess of
the brain whose early symptoms have been so unobtrusive as to place it
in the category of the chronic variety may run a much shorter course
than the one ushered in by pronounced symptoms and followed by a
latent period.

Wide differences of opinion are held to-day by physicians and sur-
geons of recognized ability regarding the difficulties encountered in the
diagnosis of chronic abscess of the brain. Much of this discrepancy is
due, it seems to me, to many accepting all intracranial suppuration as
the result of an acute process. At the Surgical Congress held in Berlin
April 17, 1895, the distinguished surgeon. Professor von Bergmann, in a
paper entitled " Progressive Cerebral Surgery," stated : " Cerebral ab-
scess must always be operated on. Its diagnosis is easy if the etiology
is considered. The principal cause of cerebral abscess is inflammation
of the middle ear ; it is usually situated in the temporal lobe." Leube,
than whom few have attained to greater distinction as careful and pains-
taking diagnosticians, says: "The diagnosis of subacute and chronic

180 ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN.

abscess of the brain is, on the whole, easy." According to Professor
Murri : " He (Leube) gives the most important indications of cerebral
abscess, intermittent fever associated with rigors, and attributes great
value to the absence of optic neuritis and etiological considerations."
{Lancet, January 12, 1895).

Gowers, in his work on Diseases of the Nervous System, begins the para-
graph on diagnosis of cerebral abscess with " The extreme variability
and frequent latency of the course of cerebral abscess often render its
diagnosis difficult and even impossible,"

Spitzka, in Pepper's System of Medicine, after making the statement
that " there is little difficulty in recognizing the existence of cerebral
abscess in which well-marked focal and constitutional symptoms coin-
cide, or where a distinct abscess-producing cause, such as an ear-trouble,
a head-injury, or a putrid bronchiectasis, coexists, adds, " but there are
a number of cases, varying from the latent form to forms with obscure
general symptoms, whose recognition is impossible or at best a matter
of conjecture." (Vol. v. p. 799.)

Professor Murri states that Martins has made a study of seventeen
cases of cerebral abscess occurring in the German hospitals during the
past few years, and not one of them Avas recognized during life (Lancet,
January 5, 1895, p. 12). I might continue at great length to quote
from various writers concerning the difficulties of recognizing, during
life, chronic cerebral abscess, and I might add mistake after mistake in
diagnosis, not a few of which would be my own, but I have no need to
extend my remarks in this direction, as you are aware, I have no doubt,
from personal experience, of the uncertainties attendant upon the diag-
nosis of intracranial suppuration, especially of the chronic variety. I
do not wish to underestimate the difficulties that are sometimes encoun-
tered in diagnosticating acute cerebral suppuration. These not infre-
quently prove insurmountable, but they are, on the whole, less than are
met with in diagnosis of chronic abscess. Many of our text-books are
content with a description of abscess of the brain, as though it always
originated in acute cerebral suppuration.

The importance of recognizing the essential difference between acute
abscess and chronic abscess of the brain will justify a rather lengthy
quotation from Professor Murri's admirable " Address on Experimental
Craniotomy and Diagnosis of Cerebral Abscess" (Lancet, January 12,
1895, p. 79) :

" Abscess of the brain, which, when clinically considered, seems to be an
essentially miique morbid process, resolves itself into two varieties which
differ utterly in diagnosis, viz.: acute abscess and chronic abscess. Writers
aiming at the unity of the process lose sight of the clinical side, and do not
bring into sufficient relief the practical differences which exist between the
two varieties. What they say of abscess applies chiefly to the acute form.
Bacterial analysis might throw more light on the causes of the differences

eskridge: chronic abscess of the brain. 181

which are developed in the process of suppurative inflammation of the brain.
At present what we chiefly know is the intensity of the exciting causes ; the
duration of the process depends much on these. If a considerable cerebral
artery is closed by an embolus ; if a wound on the head causes disturbance,
contusion, or hemorrhage in a zone of the brain ; if a suppurative otitis
media violently aflects the bony substance and gives rise to a thrombus in
the cranial sinuses, or. excites inflammation in the adjacent meninges, the
nutritive process of the cerebral tissues near cannot avoid deterioration, the
pyogenic agents find a field well prepared, and their devastations are in con-
sequence very rapid. But here, besides the rapidity of the disease, there
arises another clinical distinction. These occurrences, being more intense,
cannot easily happen without being perceived by both the patient and his
medical attendant. Moreover, the succession of phenomena aroused by
them is not so disconnected as to lose the evidence of their reciprocal rela-
tion and the unity of the process they reveal. Finally, even the reaction of
the brain provoked by rapid and great intracranial changes is more evident
and appreciable to the practitioner. If to all this we add that the rapid
diffusion of suppuration causes fever, and even a special fever, as a phe-
nomenon revealing the nature of the morbid process, then it is easy to com-
prehend how the clinical idea assumes a form so distinct that the diagnosis
of acute abscess naturally follows.

" When we come to the chronic forms of cerebral abscess, the description
and opinions of pathologists inspired by the observation of such facts no
longer correspond to the facts themselves. In these the exciting causes are
less intense or less apparent. It is one thing, for example, if an embolus
from a pulmonary vein closes the artery of Sylvius, and another if pus pen-
etrate unperceived into the brain by one of those narrow ways which lead
there from without. The slightness of the latter is not only marked by the
absence of disorders perceptible to the patient, but it also causes a slower
succession of changes around itself ; the surrounding tissues, not previously
aflected and violently attacked, have time to organize themselves for the
defence, and in time circumscribe with a solid barrier (pseudo-membrane) the
hostile element (pus) which tends to destroy it. This mysterious faculty
which the brain possesses of adapting itself to the most serious lesions as
long as they are gradual has full opportunity to act completely. Thus it
follows that, from ignoring or forgetting the primary cause, it seems as
though no external cause exists ; and here we have the idiopathic abscess,
which is almost always chronic. Even where the primary cause is known,
if it be not violent, the process which succeeds follows with less rapidity,
and hence the slight changes of the brain may not arouse perceptible func-
tional disorders. Here we have the latent abscess or the latent period of the
chronic abscess. The slowness with which brain-alterations proceed proves
that a length of time is required for their development, and here we see the
abscess become chronic. The perception of these internal processes is often
defective, as is frequently seen in the doctrinal works of the pathologists and
in the reasoning of clinical physicians who write and think of cerebral
abscess as though it existed only in the acute form. But the abscess exists
also in the chronic, idiopathic, latent, or semi-latent form, and this, though
less frequent than the acute, is by no means as rare as statistics would make
us believe."

A small number of cases of chronic cerebral abscess, from their incep-
tion to the beginning of the terminal period, and a few others in their
most latent stage, may not present pronounced symptoms of organic
brain disease until there are manifestations of the terminal period, but
a careful study of cases of obscure brain diseases will reduce this num-
ber to a minimum. The symptoms of abscess of the brain are common
to several forms of organic brain disease, and a correct interpretation of

182 eskeidge: chronic abscess of the brain.

them will depend upon the experience, diagnostic skill, and thorough-
ness of the medical attendant. Professor Murri's precaution to bear in
mind the possibility of the presence of chronic cerebral abscess in in-
vestigating cases of obscure brain disease might be advantageously ob-
served by all. The frequency of this form of cerebral abscess is not
great, but the presence of chronic cerebral suppuration is too often over-
looked for the credit of medical science or the welfare of the unfortunate
sufferer.

Conclusions reached by an analysis of the most accurate history may,
in some cases, lead from the truth ; but in the vast majority of in-
stances information thus obtained, together with a thorough examina-
tion of the mental and physical condition of the patient, when all the
modifying circumstances of the case are carefully considered, will greatly
aid in arriving at an accurate diagnosis. Not infrequently the history
of some condition that is known to be favorable to abscess-formation in
the brain will be obtained from the patient. Months, and in rare cases
years, may have elapsed since the cause was apparently active, and at
the time of the examination it may have been forgotten both by the
patient and his friends, and memory of it is only revived by a careful
and intelligent line of questioning. It may have been a blow on the
head ; a fall from a height and lighting on the feet or buttocks without
striking the head ; a painful condition of one or both ears, either with
or without otorrhoea ; suppuration in some portion of the body ; or some
exhausting disease, possibly influenza, diphtheria, rheumatism, or tyjohoid
fever, from which recovery has never seemed complete. In typical cases
the history will develop the fact that headache, intermittent or constant,
has been a prominent feature for a greater or less part of the time that
has occurred since the time of the illness that left the patient's health
impaired. In some cases irregular febrile phenomena, dimness of vision,
vertigo, failing nutrition and strength, and sometimes mono-spasm,
mono-paresis, hemiplegia, or general convulsions have been experienced.
In the majority of instances, on examination of persons suffering from
chronic cerebral abscess, we shall find evidence of organic brain disease ;
but occasionally the patient may present a vigorous appearance, and
death may occur without warning, as was the case in Professor Murri's
experience {Lancet, January 12, 1895, p. 80). The most careful and
exhaustive examination of the motor apparatus and of the general sen-
sory phenomena ma}^ yield negative results. The reflexes may be nor-
mal or slightly exaggerated. If the motor cortical areas or the moto^
tracts of the brain are affected, either directly or indirectly by the ab-
scess, symptoms of paresis, ^^aralysis, or muscular rigidity will be pres-
ent, corresponding to the extent and situation of the abscess and the
softening resulting from its presence. Nutrition and muscular strength
usually fail in the course of the disease, but in some cases these are

ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN. 183

iminipaired. Mental failure, especially slow action of the mental faculties,
and difficulty in maintaining mental concentration for a length of time,
and lessened power of memory, together with irritability of temper, are
not infrequent results of chronic cerebral abscess. Recurring convul-
sions, sometimes mistaken for those of idiopathic epilepsy, are occasion-
ally found in cases whose other symptoms of cerebral disease are most
obscure.

Individual Symptoms. Among the special symptoms of chronic
abscess of the brain headache is the most important. Its significance is
that its beginning dates from exposure to certain conditions that are
known to be capable of giving rise to abscess of the brain. It is rarely
constant, but there are very few cases of this disease in which headache
has not been more or less pronounced during some portion of their course.
At times the headache is severe, and at others it amounts simply to a
dull or uncomfortable cephalic sensation. In some instances the head-
ache, if present at all, has been so slight as to escape attention entirely.
When the terminal period, caused by softening, oedema, or extension of
the abscess, is reached, headache, even if absent before, often becomes a
very prominent symptom, and its severity marks the beginning of the
end. The seat of the pain does not always correspond to that of the ab-
scess. If the terminal period is short and the symptoms tumultuous, the
obscured consciousness often prevents any voluntary complaint of head-
pain being made, although, even in such rapid cases, if the patient can
be aroused and his attention engaged for a few moments, the fact that
headache exists can, not infrequently, be obtained from the patient in
answer to a direct question. The typical temperature of chronic ab-
scess of the brain, if the morbid process is sufficiently large to exert
much depression, is normal or slightly subnormal. At times there may
be slight intermittent febrile processes which are frequently attended by
cool and clammy perspiration. Optic neuritis, when present, is a symp-
tom of great importance. Some observers seem inclined to think that
it is of infrequent occurrence, while others have observed it in a suffi-
ciently large proportion of cases to regard it as a valuable aid in the
diagnosis. In the cases that I have observed it has been present more
frequently than absent, but the extreme degree of swelling so commonly
seen in association with tumor of the brain I have not observed as a
symptom of abscess.

Terminal period. This period may extend over several weeks or a
few days, and, possibly in some cases, may last only a few hours. Its
duration depends upon the manner in which the abscess causes death.
The latent period may end suddenly by the abscess bursting into the
lateral ventricles and giving rise to all the symptoms of intra-ventricu-
lar hemorrhage. The rupture may occur on the surfiice of the brain
and .cause local, or, more commonly, general lepto-meningitis, which

184 ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN.

proves rapidly fatal. When the pus finds its way to the surface of the
brain in the posterior fossa, both by the meningitis and the direct irrita-
tion of the pons and medulla, the cardiac and respiratory centres are
interfered with. In the latter case, if the patient survives the shock,
the symptoms wall be those of cerebro-spinal meningitis, prominent
among which will be retraction of the head, rigidity of the muscles of
the back of the neck, and sometimes of the spine, wdth manifest opisthot-
onus and shock-like convulsive rigidity of the muscles of the limbs, es-
pecially of the arms. Oedema and softening of the brain-substance are
the causes of death in about one-half the cases of abscess of the brain.
In many of these in which the motor and sensory areas of the brain are
not especially affected, either directly or indirectly, by the abscess, the
softening may take place so gradually that no symptoms of it may be
detected until sudden collapse or death results from the apparent arrest
of cerebral function. It is probable, however, that if these cases that
end suddenly from softening and oedema were carefully watched, symp-
toms of failing brain-power and general vigor, together with increased
headache, irritability of temper, and a tendency to depression, might be
detected weeks before the fatal end. In all the cases of chronic abscess
of the brain except one which have come under my observation during
the terminal period the symptoms of this stage have developed in a
subacute manner. The prominent symptoms have been headache, usu-
ally dull and heavy in character, but at times attended with severe par-
oxysms of pain, failure of nutrition, energy, and strength ; mental dul-
ness and slowness, and irritability of temper ; vomiting only when
associated with severe paroxysms of pain in the head ; optic neuritis in
a number of instances ; slow or normal pulse w^hen the patient is quiet,
but sometimes easily accelerated by exercise ; subnormal temperature in
nearly every case ; convulsions occasionally at the beginning or ending of
the terminal period ; paralysis, usually hemiplegic in character, or pare-
sis, with rigidity of the affected muscles from pressure on the motor
fibres of the brain, in more than one-half the cases, and in a number
hemianjesthesia with hemianopsia. As the terminal period progresses
the symptoms increase in gravtiy ; the sensory functions become more
and more blunted, the patient's apathetic condition increases, and finally
stupor, followed by coma, sets in, and the patient dies after remaining
unconscious several hours to several days. It is rare after symjjtoms
of the terminal stage become prominent for the patient to show more
than temporary improvement.

Localizing Symptoms. Percussion has afforded me little or no aid
in diagnosticating a chronic abscess. The localizing symptoms of ab-
scess of the brain may vary from those of tumor because pressure-symj)-
toms are sometimes less marked in the former than in the latter, and on
account of the more complete destruction of tissue and greater oedema

eskridge: chronic abscess of the brain. 185

and softening found associated with abscess. We must remember, how-
ever, that a tumor may exert no more pressure than abscess, and that
it may as effectively destroy brain-substance as the latter. Definite
focal symptoms are less frequent from abscess than from a morbid
growth, because the most common seats of the former are in those por-
tions of the brain, the cerebellum, frontal and temporo-sphenoidal lobes,
whose functions are not definitely known. It is probable that distinct
localizing symptoms are as frequently absent as present from abscess of
the brain.

Frontal lohe. A large abscess may exist unsuspected in the anterior
portion of the frontal lobe, and a small one may be situated just anterior
to the motor region without giving rise to symptoms indicative of its
location. It is only when softening or oedema extends backward to the
motor area of the cortex or the white substance beneath it, or pressure
is exerted on this portion of the brain, that localizing symptoms develop,
except in a few cases in which pupillary symptoms are found when
the abscess is in the posterior and lower portion of the frontal lobe. If,
with general symptoms of abscess of the brain following a blow on the
front of the head, a septic embolus from the lungs or associated with an
infective process in the frontal sinus, a gradual increasing paresis or
paralysis of the face or arm on one side should occur, preceded, or
not, by convulsive movements of the affected muscles, pupillary symp-
toms would indicate one frontal lobe as the seat of the abscess. If the
pupil on the side opposite to the one on which the muscles are involved
should become sluggish or inactive, while its fellow responded normally
to light and accommodation, it would aid in locating the abscess in the
posterior portion of the frontal lobe. It must be borne in mind, how-
ever, that the same pupillary phenomena may be present when the an-
terior portion of the temporo-sphenoidal lobe is the seat of the abscess,
as occurs from a similar lesion in the posterior portion of the frontal,
but suppuration in the former situation usually results from middle-ear
disease. Macewen's observations in relation to the pupillary phenom-
ena may be quoted in full : " When the abscess is situated in the tem-
poro-sphenoidal lobe or the frontal lobe, the pupil on the same side as
the abscess may either become myotic or mydriatic, accompanied by a
degree of stability. When the abscess is small and produces cerebral
irritation the pupil on the affected side may be more or less contracted
and sluggish. When the abscess is large and exercises considerable
pressure the pupil on the affected side is prone to stabile mydriasis.
An abscess which is small and produces a stabile myosis to begin with,
may, as it augments in bulk, produce a stabile mydriasis in the same
eye. Occasionally, the only difference detectable is sluggishness of one
pupil to both light and accommodation, while its neighbor acts freely.
In a case of cerebral abscess a sluggish pupil with either mydriasis or

186 ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN.

myosis on the same side as an infective injnry to the skull, or a uni-
lateral otitis media, affords further evidence of the abscess being on the
corresponding side of the brain." {Pyoge)iie Infective Diseases of the
Brain and- Spinal Cord, p. 145.) In five cases of abscess of the frontal
lobe observed by me the pupillary phenomena described by Macewen
were present in only one, but this was the only one of the five in which
the abscess was located in the posterior portion of this lobe.

Temporo-sphenoidal lobe. A small abscess, and even one of consider-
able size, may be situated in the temporo-sphenoidal lobe without giving
rise to any distinct localizing symptoms. In the case of chronic ab-
scess of this lobe the history, most likely otitis media on the same side
as the abscess, might afford the only clue to localization. A large ab-
scess, on the other hand, would probably develop localizing symptoms
from the effects of pressure on the surrounding structures, and if exten-
sive softening and oedema should occur, regions of the brain whose func-
tions are fairly well knoAvn would become involved. If the abscess were
on the left side in the posterior portion of the temporal region, so as to
affect the first and second temporo-sphenoidal convolutions, sensory
aphasia would be present. On either side of the brain a large ab-
scess in the anterior portion of this lobe might cause paresis or paraly-
sis, first in the face, and secondly in the arm of the opposite side, with
pupillary symptoms, such as sometimes occur in abscess situated in the
l)Osterior portion of the frontal lobe. Macewen has observed in cases
of abscess in the anterior portion of the temporo-sphenoidal lobe paraly-
sis of the third cranial nerve of the same side, thus producing crossed
paralysis, the third cranial nerve on the same side as the abscess being
affected and paralysis of the face and arm of the oj^posite side result-
ing. A careful study of the direction in wdiich the paralysis extends
after the first group of muscles is involved will often afford valuable
information upon which to base a localizing diagnosis. Not infre-
quently the middle-ear disease which leads to acute abscess of the brain
paralyzes the facial nerve as it passes through the Fallopian canal, but
this rarely occurs in chronic abscess.

Occipital lobe. In three cases' of chronic abscess of the occipital lobe
observed by me paresis and muscular rigidity, nearly complete hemi-
ansesthesia, and hemianopsia of the opposite side existed. In each case
the abscess was large and situated in the white substance, so as to exert
pressure on the fibres of the posterior half of the internal capsule. It is
probable that the fibres coming from the cortical centre of sight in the
cuneus were rendered functionless, either by pressure or softening, as
the cortical substance of this region did not seem to be directly involved.
A small encapsulated abscess, in all probability, might remain in the

1 The Medical News. July 27, 1895.

eskridgp:: chronic abscess of the brain, 187

white substance of the occipital lobe for a long time without giving rise to
any localizing symptoms. It should be borne in mind that chronic absce? s
of the so called idiopathic variety (probably due to suppuration in distant
portions of the body) is most commonly situated in the occipital lobe.

Cerebellum. An encapsulated abscess of considerable size situated in
the posterior portion of one lateral lobe of the cerebellum might cause
no definite symptoms so long as it remained more or less latent. An
abscess in the anterior portion of either lateral lobe or one in the middle
lobe would likely give rise to pressure-symptoms on the pons and me-
dulla, in which case cerebellar ataxia would be manifest. The cardiac
and respiratory phenomena, together with yawning, observed in acute
abscess of the cerebellum, would probably not occur in the chronic
abscess until the terminal stage develops.

Differential Diagnosis. Other organic lesions than abscess of
the brain are attended by symptoms common to intracranial suppura-
tion, so that one of the most difficult problems encountered by the clini-
cal physician in the diagnosis of chronic cerebral abscess is differentiating
it from other diseases that so nearly resemble it, both in their clinical
history and apparent etiology.

The following case illustrates the similarity of the symptoms of cere-
bral softening following thrombotic occlusion of an artery to those of
cerebral abscess :

A man, aged twenty-two years, an Austrian by birth, a miner by occu-
pation, living in Colorado four years, was admitted into the Arapahoe
County Hospital, March 25, 1895, completely paralyzed in the left leg
and arm and lower side of the face of the same side, the upper portion
of the latter being paretic. His family history was negative, and he
had always enjoyed good health up to the beginning of his present
illness. He denied indulgence in alcohol further than an occasional
glass of beer, and said that he had never exposed himself to venereal
poison. About two months before coming under my care he suffered
for two or three weeks from pain in the left side of the head and the
left ear. Bleeding by the application of leeches over the left mastoid
process seemed to relieve the pain, both in the head and ear. About
four weeks ago he felt weak in the left arm for a day or two. The
arm seemed all right on the third day, but on the fourth it became
quite weak, and he began to suffer from pain in the left side of the head
in the parietal region, and occasionally in the anterior temporal. Two
days later the left leg was weak and awkward, and the day following
the left side of the face was observed to be smooth and the mouth drawn
to the right. Seventeen days ago, when he first came to Denver, from
Idaho Springs, he could ascend and descend stairs, but the whole of the
left side was weak, yet he could still use the left arm some, although not
so well as the left leg. Two days later, or on the 10th of March, the
left arm and leg and the lower portion of the left side of the face be-
came completely paralyzed, and remained in this condition until he en-
tered the hospital on the 25th day of March. Consciousness had never
been affected.

VOL. 112, NO. 2.— AUGUST, 1896. 13

188 eskridce: chronic abscess of the brain.

Exammation on admission. There was complete flaccid paralysis of
the left arm, left leg at ankle and knee, and lower half of the left side of
the face. The upper portion of the face and the hip were paretic. He
could not close the left eye as tightly as he could the right. The tongue
was protruded slightly to the left, and when the face was at rest the
mouth was drawn a little to the right. The left side of the face seemed
equally weak both for voluntary and emotional movements of the af-
fected muscles. The deep reflexes were slightly increased on the left
side, but the superficial were absent. It was impossible to make a satis-
factory examination of the sensory phenomena in the absence of an in-
terpreter. The fundi and disks of the eyes were normal. Both pupils
were dilated, the left being larger than the right, and both acted feebly
to light and accommodation. The axillary temperature was 98.6° F. ;
pulse 72 ; respiration 20. His mind seemed clear, and he appeared to
appreciate what occurred around him. Three days later, or on the 28th,
I began having the temperature registered in each axilla thrice daily,
at 6 A.M., 12 M., and at 6 p.m. ; and this was continued until April
12th, the time of the operation. At noon of the 28th the temperature
was R. 99.8° F., L. 99.6°. It remained about the same until the next
day at noon, when it was found one degree below normal, and the
same in each axilla. On the 30th the temperature was found to be
100° F. in each axilla and the next two days it was normal. The
pulse varied from 70 to 72, and respiration from 18 to 24.

On April 1, 1895, assisted by an interpreter, I made a more careful
examination. At that time he could raise his left leg from the bed and
hold it straight at the knee, but there was absolute paralysis of the mus-
cles below the knee. The arm and face remained about the same as on
the former examination. The left trunk-muscles were weaker than the
right, but still retained considerable power. Dyn. : R., 120 ; L., 0.
Knee jerks : R., absent ; L., increased. Ankle-clonus: R., absent ; L.,
present and continuous. Tendo Achillis : R., absent ; L., increased
and attended by clonus. Plantar reflexes : R., present ; L., absent.
Cremaster and abdominal reflexes : R., present ; L., absent. The deep
reflexes of the right forearm were slightly increased ; the left were
exaggerated. All the sensory phenomena were lessened on the left
side, the temperature-sense being the most impaired ; on the right,, sen-
sation normal. Taste and smell present on each side and about equal.
Hearing with watch: R., 10/12; L., 8/12; with tuning fork hearing
better in left ear. Eyes : R., V. = 20/30(?) ; fields — temporal normal,
nasal absent up to median line ; and fundus and disk presented nothing
abnormal. L., V. = 20/30(?) ; fields — nasal preserved, temporal ab-
sent up to median line. Some obscuring of the nasal side of the disk
by congestion and recent exudate. Beginning neuro-retinitis was ap-
parent. The next three or four days the axillary temperature was about
normal or slightly subnormal. On one occasion it was nearly two de-
grees below normal. On April 4th the left fundus and disk remained
about the same as on the 1st, and the right were still normal. Power
seemed to be returning in the left leg, but no change could be detected
in the arm and face. Bilateral left homonymous hemianopsia was still
absolute. Sensory function was greatly lessened throughout the left
side, but it was most impaired in the arm. During the entire time he
had been in the hospital he had comj^lained of considerable pain in the
right side of the head, extending from the anterior temporal region back
to the posterior parietal. Just how long he had had pain in the right

eskridge: chronic abscess of the brain. J89

side of the head I could not ascertain. It will be remembered that at
the beginning of his illness the pain was in the left side of the head.
The head-temperature had been persistently slightly elevated, and the
rise was sufficient to lead me to diagnosticate an irritative lesion in the
brain. From the 4th to the 12th of April the patient remained in nearly
the same condition that he had been in from March 25th to April 4th,
except that headache became more troublesome, and was limited to the
right parietal region. The axillary temperature remained practically
normal, was about equal in each axilla, but occasionally it was 0.1° to 0.2°
higher in the left than in the right. As time wore on the tendency was
for the temperature to be slightly continuously higher on the paralyzed
side, but the difference was never more than a few tenths of a degree.

On April 10th he made a slight correction in the history of his illness.
In the original history he had stated, or the interpreter had made him
state, that he had pain in the left ear, and this, together with the head-
pain, had been relieved by leeches applied over the mastoid region ; but
in his revision he said it was four months ago when he had pain in the
left parietal and frontal regions of the head, and there was no pain in
the ear. He reaffirmed the former statement that the pain in the left
side of the head ceased on the aj^plication of leeches to the left mastoid
region. About this time (or April 3d) it was observed that anaes-
thesia of the left side, including the face and scalp, was becoming more
pronounced, and the special senses, taste and smell, were less acute than
on the right side. Repeated registration of the surface-temperature of
the head showed the head-temperature to be about two degrees above
normal. This indicated an irritative lesion of the brain. The urine
had been examined a number of times and found free from albumin and
sugar, and no cardiac murmur had been detected. The young man's
age was against the idea of hemorrhage ; there was no cause, so far as
I could detect, for embolism, and his repeated and positive assertion
that he had never exposed himself so as to contract syphilis made me
inclined to disregard the vascular lesions, although, in a clinical lecture
on this case delivered the day before the patient was subjected to an
operation, I stated that thrombotic occlusion of arteries of syphilitic
origin would best explain the symptom-group. The localizing symp-
toms indicated two separate and distinct lesions, one in the Rolandic
region on the right side, involving primarily the arm-centre, and the
other in the centrum ovale of the temporo-occipital region of the same
side. I argued that a single lesion in the centrum ovale so situated as
to cause anaesthesia of the opposite side would affect the leg as much
or more than the arm, and the face would be involved to a less extent
than the leg or arm ; but in this case, the face and arm being more
affected than the leg, indicated that we should find two lesions. Ex-
cluding a vascular lesion, the probabilities were in favor of a tumor or
an abscess. Multiple tumors in the centrum ovale are uncommon, and
the absence of choked disks was decidedly against the diagnosis of
tumor. In favor of abscess we had the gradual onset of the 2)aralysis
involving one group of muscles after another, and the seat of one of the
lesions in the centrum ovale of the occipital lobe was the common loca-
tion of abscess of pysemic origin. No distinct cause could be found for
abscess, but I consented to recommend an operation for the relief of the
patient in hopes that we should be fortunate enough to find and evac-
uate one or more abscesses.

On the 12th of April Dr. Edmund J. A. Rogers removed a button of

190 ESKRIDGE: CHRONIC ABSCESS OF THE BRAIN.

bone from the skull over the arm-centre on the right side and found the
brain-substance, including the cortex immediately beneath the trephine-
opening, soft and diffluent, looking very much like pus. On exploring
the centrum ovale in the occipital region another area of softening was
found. Dr. Leonard Freeman, pathologist to the hospital, examined the
material as it was taken from the brain, and his report is as follows :

" The soft, white material removed from the brain by Dr. Rogers
closely resembled pus to the naked eye, but under the microscope no pus-
corpuscles could be seen. A few red corpuscles were detected, but they
probably came from the blood that mixed with the material during the
operatioD. The corpuscles of Gluge were quite numerous, and some small
fat-globules were observed here and there. The mass of the substance
was composed of disintegrated nerve-fibres, which were rather short, and
could be distinctly seen and accurately studied as they floated in the cur-
rent of the fluid across the field. There were no gliomatous or other tumor-
cells, and no crystals of any kind. There was no reticulated structure."

The operation was carried no further than to remove the most diffluent
of the broken-down brain-substance. The wound was carefully dressed
and the patient regained consciousness, and said his head felt better.
About twelve hours after the operation he began to exhibit evidences of
failing, and the temperature rose to 100° F. After this he lost rapidly,
and died fifty hours after the operation, the temperature reaching 106° F.
just before death.

Autopsy, six hours after death, j^erformed by Dr. Leonard Freeman :
On removing the iodoform gauze from the wound softened brain-substance
and yellowish-whitish particles resembling disintegrated brain-substance
ran out. The middle meningeal vessels on either side arose from the oph-
thalmic vessels. Great oedema existed at the base of the brain, espe-
cially around the cerebellum, pons, and medulla. The arteries at the
base of the brain presented no evidence of disease, except on the right
side, where the middle cerebral Avas thickened and its calibre was occluded
by a thrombus at the point Avhere the nutrient vessels to the basal gan-
glia are given off. The cortex of the middle and lower Rolandic region
and temporo-sphenoidal lobe was softened. The cortex of the left hemi-
sphere was negative. On cutting into the right cerebral hemisj^here a large
area of softening, about three inches by two in size, occupied the cortex
of the middle and lower Rolandic region and the white substance beneath.
The occipital lobe was the seat of a large area of softening which occu-
pied nearly the entire white substance of this lobe. The softening in the
occipital lobe reached the cortex postero-laterally. The entire corpus
striatum and thalamus were softened but not diffluent. The interior of
the left hemisphere presented no pathological appearances. Cerebellum
and ventricles negative. The microscope showed the change in the arte-
rial walls to be syphilitic.

In the light of the autopsy the clinical history is clear, and had not
syphilis been so strenuously denied, no other diagnosis than that of arte-
rial occlusion would have been seriously considered. It is useless to
speculate whether the man knew he had syphilis ; whether he had con-
tracted it withovit sexual intercourse and did not know it ; or whether
the condition of his cerebral bloodvessels was due to hereditary syphilis.
The latter is very improbable.

(To be concluded.)

EDWARDS: UREMIA AND MENINGITIS.

191

THE DIFFERENTIAL DIAGNOSIS OF URAEMIA AND MENIN-
GITIS, WITH REPORT OF OBSCURE CASES.

By Arthur R. Edwards, A.M., M.D.,

PROFESSOR OP THERAPEUTICS IN THE NORTHWESTERN UNIVERSITY MEDICAL SCHOOL, CHICAGO ;
ATTENDING PHYSICIAN TO COOK COUNTY HOSPITAL; PATHOLOGIST TO
COOK COUNTY, ST. LUKE'S, AND WESLEY HOSPITALS,

Uremia is usually readily differentiated from organic cerebral disease,
yet confusion may occur in atypical cases. Leube's^ chief rule in the
diagnosis of uraemia is formulated as follows : In patients with nephritis
ursemic intoxication is to be assumed as the cause for nervous symptoms
only when other causes can be excluded This method of diagnosis by
exclusion has served Leube well, and he considers the method important,
since in the course of renal disease occasional organic nervous lesions,
such as hemorrhage and meningitis, may simulate ursemia. The clinical
diagnosis in such cases is often made only with a certain degree of
probability.

Pre-eminent importance attaches to the presence of albumin and casts,
and to the amount of urine. With typical nephritic findings in the
urine the diagnosis of uraemia is usually easy. Exceptions exist in that
nephritis may be unattended by albuminuria,^ casts may be permanently
absent (Ackermann), and uraemia may intervene when the amount of
urine and urea is normal (Christison). I have had under observation
for over a year a case of chronic parenchymatous nephritis in which
every variety of cast — epithelial, granular, and hyaline— is constantly
present, while albumin is absent for months consecutively. Liebermeis-
ter^^ instances a case in which immediately before a ursemic seizure
both urine and urea were increased twofold. To offset this case, Biermer^^
reports an instance of anuria for 222 hours before uraemia appeared.
Albumin alone is no proof of uraemia, as it may occur in nervous lesions ;
e. g., meningitis, hemorrhage, epilepsy, tetanus, etc. According to
Fleischer,^ uraemia being due to cerebral anaemia, we must guard against
confusion with cerebral aniemia of other origin, since lowered arterial
pressure may induce both cerebral anaemia and albuminous urine. Such
albuminuria is transitory and unaccompanied by casts.

When conspicuous cardio-vascular symptoms attend nephritis, they
become valuable diagnostic adjuvants, worthy of considerable, but not
implicit, confidence. Case III. exemplifies this point (latent meningitis
with albuminous urine and cardio-vascular alteration, v. i.). Cardiac
hypertrophy predisposes to apoplexy, hemorrhages, and inflammations
in various viscera, especially in the retina. Cortical irritation increases
arterial tension.^ Moderate arterial tension increases the cardiac force,
while excessive tension decreases it. Redundant toxins paralyze the

192

EDWAEDS; URJEMIA AND MENINGITIS.

vasomotor system and the heart's strength flags by the absence of that
difference in arterial tension imperative for the maintenance of the
circulation, hence the multiplicity of cardiac conditions conceivable in
ursemia.^ The pulse is slow, 40 to 60, before a ursemic attack (Thomas,
Rosenstein, and Wagner), and later, after a convulsion, it is usually
rapid. Early in meningitis the pulse is slow ; later it is frequent.

Most important are the ophthalmoscopic findings, for retinitis albu-
minurica is rarely absent in chronic nephritis, leading to uraemia (Leube),
and in acute urseraia the abundant albumin, casts, and oedema are suffi-
ciently suggestive. In meningitis the pupils are mostly narrow and in
ursemia dilated, yet ursemic myosis is observed.

Leube does not hesitate to admit that in certain cases the diagnosis of
meningitis is for him more difficult than of any other cerebral lesion,
because the complexus of symptoms varies and certain signs of menin-
gitis occur in other intracranial diseases. Uraemia and meningitis have
many symptoms in common — delirium, headache, vertigo, coma, convul-
sions, irregular breathing, and vomiting. Confusion is especially prob-
able when the convulsions are localized in a few muscles, in which partial
contractures, focal paralyses, and temperature appear. In such combina-
tions the most experienced diagnostician may err. Meningitis and
uraemia may coexist, yet meningitis is the least frequent of all the forms
of serositis to which the uraemic patient is exposed. Broadly speak-
ing, circumscript convulsions and paralyses speak strongly for ana-
tomical changes in the central nervous system, especially when constant,
although such alterations occur rarely in uraemia. In uraemia they are
chiefly fugitive. Literally I know of no focal nor general symptom or
sign observed in meningitis which has not been recorded, singly or
combined, in uraemia.

A synopsis of anomalous cases observed by others, with several of my
own, seems in place because of meagre mention of the subject in litera-
ture. Jolly and Guinon^^ admit possible errors between uraemia and
meningitis. Desnos^*^ reports a case in which the patient during sound
sleep was suddenly seized with dyspnoea, coma, and vomiting, and the urine
showed much albumin. On autopsy the kidneys were normal, but there
was a hemorrhage the size of a nut in the pons Varolii, breaking into
the fourth ventricle. Rosenstein remarks that diagnosis is nearly impos-
sible wdien motor and sensory symptoms occur synchronously with
nephritis, which are due, however, not to urinary retention, but to a
palpable disease — e. g., meningitis. He cites a case : Urine 1009, much
albumin, red and white blood-cells, casts, fat-granules ; headache ; dilated
heart ; coma ; temperature 39.4° C; wide pupils ; no paralysis ; slight
twitchings of arms ; autopsy disclosed nephritis plus suppurative basal
meningitis. Murchison has described cases of uraemia closely resembling
meningitis, presenting rigid neck, convulsions, and coma ; but Gowers

EDWARDS:

UREMIA AND MENINGITIS.

193

remarks that the temperature is normal in ursemia, v. i. Rosenstein's
experience includes a case of ursemia with oedema, but without urinary
findings, presenting a typhoid appearance ; the post-mortem disclosed
nephritis

Stenhouse Kirkes^^ drew attention to the fact that not all cerebral
symptoms in nephritis are functional, but that some are of organic origin
— e. g., apoplexy. Thus uncomplicated aphasia was found due to hemor-
rhage in Broca's convolution.^

In meningitis the breathing is frequently sighing, irregular, and of
the Cheyne-Stokes type. In uraemia, asthmatic attacks, angina pectoris
vasomotoria,^ a laryngeal croup type, Cheyne-Stokes breathing, and
cyanosis are recorded.

The subject of temperature in ursemia is a mooted point. Many main-
tain it is reduced (Kien, Roberts, Hirtz, Billroth, Thaon, Hutchinson,
Bourneville, Budin, Hanot, Lecombe, Behier, Lionville). Netter ob-
served the temperature fall as low as 30° C. Others note a rise (Tarnier,
Torday, Hippolite, Chauffard, Tenneson, Chantemesse). Lepine^ found
that the temperature may rise without convulsions or inflammation,
explicable by vasomotor irritation and decreased heat-elimination.
Landois produced a rise of temperature by irritation of the cerebral
cortex, caused by vaso-constriction. Unusually low temperature is
found where vasomotor paralysis exists and effete products accumulate
in the system. StriimpelF observed not uncommonly a temperature
rising to 39° C, irregular in type, rarely reaching 41.5°, and often asso-
ciated with chills, vertigo, sweating, headache, and tinnitus aurium.
Rosenstein^ expects low temperature only in subjects depleted by diar-
rhoea and vomiting. Bartels, Guyot, d'A. Robert, Dumont, and others
confirm Rosenstein's position, although most authorities oppose his views.

The most concise general statement^ regarding ursemic nervous phe-
nomena asserts: 1. That paralysis affects especially the sensorium, to a
less degree the special senses, and rarely motility ; 2. That irritation
seldom selects the sensorium (e. g., delirium) ; it mostly engages the motor
paths (convulsions), and never implicates the special senses.

Ursemic convulsions are tonic or clonic. Described usually as general,
they may by unusual localization resemble focal symptoms. Thus Rosen-
stein,^ Strumpell,"" and Bartels" have found convulsions on half the
body, one-half the tongue, and in the left arm and leg, with deviation
of the head to the left. They have occurred with convergent strabis-
mus, facial spasm like tic convulsive (Lasegue and G. See), delirium,
etc. Convulsions have simulated epilepsy and Jacksonian epilepsy.
Nystagmus,** localized tremblings, and twitchings are recorded." " "
Twitchings are easily overlooked before and after coma (Traube*^).
Grinding of the teeth, frequently observed in meningitis, also occurs in
uraemia (Striimpell and Bourdillat*^). Although tonic convulsions rarely

194

EDWARDS: URAEMIA AND MENINGITIS.

complicate iirsemia, yet a tetanic type is recognized. The cases of
ursemia of Thomas, Weiss, d'Aran, de Hausser, Rauth, and Jaccoud
exhibited trismus. Avrard relates a case in which convulsions on one
side and contractures on the other were combined. Jaccoud" places on
record three cases of spasmodic contractures of the forearm and cervico-
dorsal flexors, producing opisthotonos. Convulsions and contractures
have coincided upon one side of the body, and a case of flaccid hemi-
plegia was transformed by uraemia into hemiplegia with convulsions and
contractures (Raymond).

Rigidity of the neck, rarely absent in meningitis, cannot be excluded
from the symptomatology of ura3mia (cases of Jaccoud," Kussmaul,^^
Rose,'^ Weiss," Coheu,^^ and Thomas). The hands, usually free in teta-
nus, are involved in uraemia. Retraction of the head is also caused by
rheumatism,'*^ diseases in the medulla, aneurism of basilar artery, brain-
tumors in the posterior fossa, peripheral irritation, tender cervical glands,
and abdominal disturbances.*

Paralyses in uraemia are infrequent, so that Lesegue, Lecorche, and
Talamon deny their existence. They are chiefly transitory hemiple-
gias. The cases assigned are cerebral oedema, capillary hemorrhage,
softening, apoplexy, inflammatory foci, or cortical overstimulation by
toxins. Some instances of hemiplegia are the following : Cases of
Fuchs,^^ Baginsky,^° Addy (with aphasia, amnesia, and deafness''),
Paetsch,^^ Churchille,'^ Imbert-Gourbeyre,^* Rego (aphasia''^), Lequiraa,^^,
Raymond,"^^ Charpentier,^" Thomas,^ Blackball, Leichtenstern, Simpson,
Townsend, Rosenstein, Chauifard, and Mutenesse. Paraplegia seems to
have occurred but twice.^^ " Jaeckel in four hemiplegias found facial
paralysis twice and one crossed oculomotor paralysis, with no post-mor-
tem lesion except oedema cerebri. Other combinations are : aphasia
with facial paralysis (Dieulafoy'''^) , glossoplegia,^^ neuralgia, myosis,
spasticity of arm, right facial paralysis and right hemiplegia.^' Dunin's^
cases exhibited the following focal symptoms : Case 1, unilateral spasms ;
2, unilateral spasm with aphasia ; 3, aphasia, both internal recti par-
alyzed, diplopia, nystagmus.

The following histories illustrate the difficiilties met in equivocal
cases :

Case I. — Woman, aged forty years ; delirious ; pulse 90 to 120 ;
fairly continuous temperature, ranging between 101.9° and 102.6°;
tongue dry and coated brown ; glazed pharynx ; respirations 30 ; diffuse
bilateral moist mucous rales, with signs of hypostasis over the lower lobes
behind and at base ; pulse not tense ; second aortic tone slightly accentu-
ated ; arteries somewhat tortuous and rigid. The urine is ammoniacal,
1015, albuminous, but contains considerable pus and micrococci, yet no
casts warranting a diagnosis of cystitis ; the amount cannot be obtained
on account of involuntary evacuations. There is divergent strabismus
due to paralysis of the left internal rectus ; there is ptosis on the left

EDWARDS; UREMIA AND MENINGITIS.

195

side and right hemiplegia, complete save for the upper facial twig. The
paralyses were present five days ante mortem. Clinical diagnosis —
meningitis and cystitis. Autopsy — oedema of the brain ; no meningitis ;
no cerebral lesion ; arterio-sclerosis ; diffuse bronchitis with hypostasis ;
diffuse pyelonephritis secondary to cystitis ; hence uraemia.

Case II. — Married woman, thirty-three years old ; denies syphilis and
abortions ; mind wanders, and her accounts of the previous history and
present illness are unreliable. No oedema ; no leucoderma ; no erup-
tion ; slight alopecia ; pharynx and mouth negative ; pulse, tempera-
ture, and respiration normal ; reflexes somewhat exaggerated ; sensation
normal except some slight general hyper&esthesia, especially over tibise.
The left abducens and left oculomotor nerves and the lower half of
the right facial nerve are paralyzed ; power in the extremities is appar-
ently normal, but the mental condition makes voluntary muscular tests
difficult. The urine shows hyaline and granular casts and abundant
albumin, still an additional lesion in the cranium is suspected from the
multiple nerve-affections, and a process at basem cranii, probably syph-
ilis, is diagnosticated. Antisyphilitic treatment futile ; sudden death.
Autopsy — chronic parenchymatous nephritis, with the usual macroscopic
and microscopic findings ; left heart dilated, but not hypertrophied ;
hrain absolutely negative; hence no cerebral lesion, but ursemia.

Case III. — Man, aged forty years ; admitted to Cook County Hospital
in delirium, without any history ; marked arterio-sclerosis ; tortuous
brachials ; atheromatous plaques on radials ; pulse 90, tense, regular,
quick ; no temperature ; left heart distinctly dilated ; apex in left ver-
tical nipple-line strong and heaving ; the second aortic tone loud and
metallic ; urine heavily loaded with albumin, but no casts nor formed
elements found. The diagnosis lies between uraemia and meningitis.
No rigidity of neck, no ear disease, no temperature, no focal symptoms ;
retina negative. Because of the cardio-vascular changes and albuminuria
I diagnosticated uraemia. Autopsy — marked universal arterio sclerosis ;
atheroma aortse ; hypertrophy and dilatation of the left ventricle and
to a less degree of the right ; kidneys and other viscera wholly negative ;
a diffuse purulent meningitis over base and convexity originating from
an empyema of the sphenoid sinuses. (V. s., regarding value of cardio-
vascular signs in the diagnosis of uraemia.)

Case IV. — A case closely resembling delirium tremens, with history
of recent and ancient alcoholic excesses. Urine 1018, acid, much albu-
min, 1500 to 1800 cm. per diem ; moderate number of hyaline, granular,
and epithelial casts ; history of previous anasarca and ascites ; left ven-
tricle hypertrophied and dilated ; pulse very tense with appropriate
sphygmographic tracings ; headache, delirium, sopor, and vomiting ; no
convulsions, but two sudden lapses into coma, with temporary recovery ;
neuro retinitis hemorrhagica; suddenly a paralysis of the right and a
paresis of the left rectus internus, lasting four days, causing diplopia,
disappearing for three days, recurring with right ptosis. Death. Clin-
ical diagnosis — secondary contracted kidney, cardiac hypertrophy, and
dilatation ; oedema of brain. Autopsy confirmed clinical diagnosis ; the
cerebral oedema being very pronounced. There were no gross brain-
lesions.
103 State St., Chicago.

196

EDWARDS:

UREMIA AND

MENINGITIS.

Bibliography.

1. Leube: Specielle Diagnose Innerer Krankheiten.

2. Marion: Arch. gen. deMed., March, 1895

3. Leube : Der Symptoms complex Angina pectoris physiologische analyzat. Correspondenz
Bl. f. Psychiatrie von Erlenmeyer, 1866.

4. Money : Treatment of Diseases of Children, 1887, p. 457.

5. Landois : Die Urasmie.

6. Bochefontaine et Lepine: Compt. rend., t. Ixxxiii. : Arch, de Phys. norm, et Path., 1876.
Citation 5, S. 120.

7. Lepine: Revue de Med., 1889.

8. StrilmpeU: Arch, der Heilkunde, 17 Jahrgang, 1876, S. 40.

9. Bosenstein: Nierenkrankheiten.

10. Haguenin : Ziem?,sen Handb. Spec. Path. u. Therapie, xi., Bd. i. S. 518.

11. Jaccoud : Lec. de Clin. Med., Paris, 1887 ; Nouv. diction, de Med., Paris, 1833.

12. Kussmaul: Berl. klin. Woch., 1871.

13. Rose: Pitha-Billroth Handbuch, Bd. i., Abth. 2.

14. Weiss: Wiener med. Woch., 1881, No. 4.

15. Coheu : Gaz. de Hop., 1853.

16. StrilmpeU; Arch. f. Heilkunde, 1876.

17. Bartels: Virch. Arch., Bd. Ivi.

18. Weiss: Wiener med. Wochsch., 1881, No. 90.

19. Fiichs: Gynak. Centralbl., 1882.

20. Baginsky : Schmidt's Jahrbuch, 1887.

21. Addy: Lancet, 1875.

22. Paetsch: Zeitsch. f khn. Med., 1881, Bd. iii.

23. Churchille: Arch. gen. deMed., 1855.

24. Imbert-Gourbeyre : Des Paralys. Puerper., Pans. 1861.

25. Rego: Canst. Jahresb.. 1842.

26. Dembinth: Canst. Jahresb., 1842.

27. Bourdillat: Gaz. de Hop., 1866, 38.

28. Leqidma: Bull, de I'Acad. de Med. des Beige, 1856.

29. Raymond : Revue de Med., Sept. 1885.

30. CMrpe/z^iey .• Presse med. Beige, 1880.

31. Chaniemesse et Tenneson : Revue de Med., Nov. 1885,

32. Dieulafoy: Gaz. de Hop., 1867.

33. Sell: Hosp. Tid., R. 2, 1884.

34. Rosensteiii: Med. Centralbtg., 1858.

35. Traite de Med. (Charcot-Bouchard), Guinon, t. vi. p. 574.

36. Desnos: Union Med., 1869, No. 20.

37. Stenhoiise Kirkes : Med. Times and Gazette, 1855.

38. Liebermeister : Prager Vierteljahrschr., xviii. Jahrg., Bi. iv. S. 17.

39. Biermer : Virch. Arch. f. path. Anat., Bd. xix.

40. Dubois: Ann. d'Obstet., 1843.

41. Lauer: Canst. Jahresb., 1842.

42. Chauffard: Arch. gen. de Med., 1887.

43. Burkmann : Deut. med. Woch., 1880.

44. Van Vyre: Arch. med. Beiges, 1876.

45. Traube: Berl. klin. Woch., 1867, Nos. 47 and 48.

46. Bourdillat: Gaz. de Hop., 1866.

47. Legroux : L'Encephale, 1885, No. 1.

REVIEWS.

An Introduction to Pathology and Morbid Anatomy. By T. Henry
Green, M.D., F.E.C.P., Physician and Special Lecturer on Clinical Medi-
cine at Charing Cross Hospital, and Physician to the Hospital for Con-
sumption and Diseases of the Chest, Brompton. Seventh American, from
the eighth English edition. Revised and enlarged by H, Montague
Murray, MD, FR.CP., Physician to Out-patients and Lecturer on
Pathology and Morbid Anatomy at Charing Cross Hospital. Illustrated
by two hundred and twenty-four engravings. 8vo., pp. 598. Philadelphia
and New York : Lea Brothers & Co., 1895.

Theee is little to be said by the reviewer on the occasion of the re-
issue of a book so widely known and of such tried excellence as the one
before us. His function is for the most part to bring the fact of its re-
appearance to the notice of those who may be interested and to pass upon
the quality of its editing.

In the present, the seventh American from the eighth English edition,
we see the same familiar dress as heretofore, the same excellent typog-
raphy, and on every page there is evidence of the thorough and pains-
taking revision which the text has undergone at the hands of Dr. Murray
in the effort to bring it in line with the most recent advances in our
knowledge. As the result, the book, though in some particulars retain-
ing a somewhat disjointed presentation of the subject, may be fairly said
to contain one of the clearest and best statements in the English lan-
guage of our present knowledge of pathology.

The presentation of the subject is spoken of as in a measure disjointed
because there is noticeable throughout the book what we believe to be an
unfortunate lack of generalization. The relations of various processes
closely allied to one another are not brought out as we would wish and
as the present status of our knowledge of disease in its various phases
would warrant.

We conceive that at the present day a work upon pathology to be
thoroughly scientific should seek to present the subject in such a light
that the sequence of cause and effect should be most clear. It is apt to
be forgotten that the changes incident to disease are natural phenomena,
and that a mechanical, or, perhaps better, a physical, basis underlies them
all just as it does all other natural phenomena. While it would be
absurd to hold that we are in possession of all the influences conducing
to every process of disease, we are, nevertheless, able to comprehend a
number in each case, and their careful study in relation to the condition
which they induce throws much light on the nature of the process in
question and serves to bring it in touch with the other natural plienomena
of disease.

An illustration may serve to make our meaning more clear. In tlie

198

REVIEWS.

book before us the chapter on Inflammation contains a most excellent
and straightforward statement of the various changes incident to that
process in general and to the different so-called varieties of inflammation.
In all the structural peculiarities are well stated, but we search in vain
for any explanation of them. A¥e are left unaided in our efforts to
understand why in suppurative inflammation, for instance, emigration
should have such an important part, and why in tubercular inflamma-
tion we should have so considerable a develoj)ment of connective tissue,
cheesy degeneration, etc.

Now, we hold, and have already suggested in this Journal in con-
nection with another matter, that the recent advance in our knowledge
of the exciting cause of these and the other specific varieties of inflam-
mation in which the etiological factor is known, enables us to formulate
a most satisfactory correlation of cause and effect between the qualities
of the specific bacteria in each case and the peculiarities of the lesion
which they excite. Thus, in the case of suppurative inflammation study
of the cause has shown it to include several distinct species of bacteria,
often very diflerent in many of tlieir characteristics, but all invariably
possessed of one character in common, the production in their growth of
a substance possessed of marked positive chemotactic quality. Here we
have at once a physical reason for the preponderant feature of suppura-
tive inflammation. It may be that in the case of some of the germs
producing suppuration the precise manner in wdiich this positive chemo-
tactic influence is exercised is as yet unknown, but in the most important
of these germs such action has been clearly demonstrated and affords the
ground for our present understanding of the suppurative process.

In the case of tuberculosis the evidence is, if possible, even more defi-
nite. The dead bodies of the tubercle bacilli have been shown to possess
the jDOwer of stimulating connective-tissue growth, while the broth in
which the bacilli have grown and from which they have been removed
by filtration (tuberculin^ has been demonstrated to possess the power of
inducing exudation and cheesy degeneration. Connective-tissue growth,
exudation, and cheesy degeneration, all the elements of the tubercular
process, are thus found to have their raison d'etre in qualities inherent in
the germ which causes the disease, and we may further submit in expla-
nation of the chronicity of the process the sluggish growth which char-
acterizes the tubercle bacillus.

As before remarked, to contend that we are in possession of all the
factors conducing to the production of all pathological processes, or,
indeed, of any one of them, Avould be manifestly absurd ; but we have
definite knowledge of a number of such factors which has stood the most
critical tests and which may safely be made use of in the elucidation of
tlie processes with which they are associated, and we maintain that they
slioukl be so made use of to the utmost.

It is in just this working out of the relation of cause and effect that
our text-books of pathology are lacking to-day, and without the indica-
tion of such relationship pathology consists of little more than a con-
fused jumble of abstract facts, difficult to remember, and devoid of any
scientific or rational inter-relationship.

Another point in which the present volume is disappointing is in its
illustration. Though the illustrations are reasonably numerous, they
are for the most part of very poor quality and poorly reproduce the con-
ditions they are intended to depict. This appears to be in the main the

unna: diseases of the skin.

199

result of two shortcomings : They are too small to exhibit clearly the
topographical relations of the lesions, and many of them are lacking in
detail in cases where the intimate relation of cells and stroma should be
clearly demonstrated. As instances of the former of these faults, we
may cite the majority of the illustrations of lesions of the lung, kidney,
liver, and lymph-nodes. Figure 75 is a striking example of both. It
is supposed to represent in two cuts the structure of a scirrhus of the
mamma. The cut marked a has about the area of a 25-cent piece, the
other, marked b, is easily covered by a 5-cent piece ; both are nearly as
nondescript as far as showing any structural relations as could well be
conceived. Such illustrations are worse than useless, as they occupy val-
uable space. We note with regret that a number of the worst of them
have come down through editions as far back as 1884, and are probably
of even greater antiquity. Is it possible that the editors of the various
editions have been oblivious of the utter worthlessness of these plates ?

A few typographical errors in a book of this size are, of course una-
voidable. We call attention to two as they render the meaning obscure
and are liable to lead to misconception. These are " now " for not on
page 38, bottom line; and " oxidation for exudation on page 291,
line 16. J. S. E.

HlSTOPATHOLOGY OF THE DISEASES OF THE SkIN. By Dr. P. G. UnNA.

Translated from the German, with the assistance of the author, by Norman
Walker, M.D., F.R.C.P. Ed., with double colored plate containing nine-
teen illustrations and forty-two additional illustrations in the text. 8vo.,
pp. 1205. Edinburgh and New York, 1896.

This work in German was recently reviewed in this Journal (Feb-
ruary, 1895). Its appearance now in English must be gratifying to all
readers of the English language. On the former occasion we expressed
high appreciation of the value of the book, and perusal again in a more
familiar language fully corroborates that opinion. The author has long
been favorably known throughout the civilized world in connection with
diseases of the skin, and especially as an earnest, indefatigable worker
in pathology and pathological anatomy. As he states in the preface to
the book before us, the study of pathology in connection with the skin
has two very great advantages. First, we can always get fresh, living
material for investigation ; and, secondly, it is possible to observe the
part, and to note its relation to the disease as a whole, before excision.
By comparing clinical symptoms with the histological details, the macro-
and microscopic appearances may be brought into harmony with each
other. Under these circumstances it is easy to see that a thorough study
of cutaneous pathology must have an important bearing upon general
pathology. As Unna states, the aim of all of our pathology should be
enlightenment of clinical study, and this observation forms the basis of
the work under review. The older methods of examination of tissue
are nearly all nuclear stains, many of which, especially the mitotic stains
of Flemming, have been of great value in many pathological processes ;
but the most important changes occur in the protoplasm of the cells,
where alone, in the author's opinion, can the history of many diseases be

200

REVIEWS.

studied. The nuclei are the reproductive organs of the tissues, and they
are to be studied through speeific staining-methods for the protoplasm.

The subject-matter of the book is considered under (1) Anomalies
of Circulation ; (2) Inflammations ; (3) Progressive Disturbances of Nu-
trition ; (4) Regressive Disturbances of Nutrition ; (5) Malformations ;
(6) Saprophytes and Foreign Bodies.

The section on Inflammations comprises a vast array of diseases
grouped into it : a. Traumatic ; h. Neurotic ; and c. Infectious ; the latter
including eczema, psoriasis, lichen, ichthyosis, acne, and other diseases
of the sebaceous and sweat glands, and many other diseases too numer-
ous to mention. In fact, by far the majority of all the diseases of the
skin are to be found in this group.

To analyze the contents of a work so great, exhaustive, and volumi-
nous as this is, of course, not to be attempted, but we may direct atten-
tion to one or two points in connection with the commonest disease of
the skin, namely, eczema. This is considered under two distinct head-
ings : (I.) Acute Vesicular, and (II.) Chronic. The former the author
defines as the " j)rimitive acute outbreak of eczema in the form of vesi-
cles, which, as such, rapidly heals or passes into the ordinary common
eczema — that is, a chronic skin disease." This is a very diflferent concep-
tion from Hebra's acute eczema, accompanied by erysipelatous swelling
and oedema. Chronic eczema proper is regarded as a moist catarrh of
the skin, which is a uniform histological process ; but the unity does not
consist in a constant series of stages (papular, vesicular, rub rum, etc.).
A uniform complex of three histological symptoms is really the basis of
every eczema ; these are : (I.) the scale-formation (parakeratosis) ; (II.)
the papule-formation, or the epithelial growth (acanthosis) ; and (III.)
the vesicle-formation, or the spongy transformation of the epithelium.

It is notable with eczema as with other diseases that the histo-pathol-
ogy is approached from a novel standpoint, familiar, however, to those
readers who have followed the distinguished and brilliant author through-
out the dermatological literature of the past fifteen or twenty years.
Upon every page we note evidences of minute and careful study with
the modern methods of research, with the result that with each disease a
new page of information is unfolded. There exists an extensive chapter
devoted to the histo-pathology of the syphilitic cutaneous manifestations,
which is much the best work that has ever been published on the subject.
Preceding almost all the diseases considered there is a short statement of
the clinical features, which serves as a guide to the main work, so that
one is never left in doubt as to the precise clinical picture which is being
discussed from the histo-pathological standpoint.

We earnestly commend the book to all interested in general pathology
as well as to dermatologists, and while we cannot agree with some of
the ultra views put forth by the distinguished author, we have no hesi-
tation in stating that a great wealth of valuable information is contained
in the volume. It is the most remarkable and valuable work that has
ever been written on the subject, and contains an almost inexhaustive
fund of knowledge upon which pathologists will draw for many years
to come.

The translation, in itself a great undertaking, has been done by the
skilful hand of Dr. Norman Walker, of Edinburgh, formerly a favored
pupil of Dr. Unna in Hamburg, and leaves absolutely nothing to be
desired. The reading is intelligible, plain, and free from German idioms.

STEPHENSON: EPIDEMIC OPHTHALMIA.

201

We questiou whether another translator so particularly well trained and
equipped for this task could have been found.

The illustrations are new and are chosen to represent some of the many
novel features discussed, but the reader must not exj^ect to find an atlas.
The text is infinitely more important than the drawings, which, we may
observe, are not numerous, considering the magnitude of the book.

The publisher (Mr. William F. Clay, of Edinburgh) has given a very
elegant volume from the standpoint of paper and type. An index of
diseases with many references completes the book. We again cordially
commend the book to all who are interested in scientific medicine.

L. A. .D.

Epidemic Ophthalmia : Its Symptoms, Diagnosis, and Management.
With Papers upon Allied Subjects. By Sidney Stephenson, M.B.,
F.E O S. Ed. Edinburgh and London : Young J. Pentland. New York :
McMillan & Co., 1896.

Dr. Stephenson is a recognized authority on all subjects pertaining
to contagious inflammatory affections of the conjunctiva, and he is much
to be congratulated upon having gathered together the literature of this
subject, which is carefully analyzed and sifted, and still more to be con-
gratulated upon having added to it the results of his own ripe experi-
ence.

Under the title "Epidemic Ophthalmia," which might be more suitably
replaced with the words " epidemic conjunctivitis," the following diseases
are included : Muco-purulent or catarrhal ophthalmia, purulent ophthal-
mia, diphtheritic ophthalmia, and acute trachoma. Of muco-purulent
conjunctivitis two varieties are described, the ordinary infectious con-
junctivitis which is common in the spring and autumn, and that conjunc-
tival inflammation which the older writers were accustomed to call
" pustular," or aphthous ophthalmia." Dr. Stej^henson regards the
latter as an affection distinct from a true phlyctenular conjunctivitis.

Purulent ophthalmia, which includes ophthalmia neonatorum and
gonorrlioeal ophthalmia, is considered always to be due to a contagion,
and true diphtheritic ophthalmia to the presence of the Klebs-Loefiler
bacillus. While acute trachoma is believed to arise through the agency
of a specific contagion, the exact nature of the micro-organism, or pos-
sibly the parasitic protozoa, has not been determined. In this connec-
tion the following significant sentence occurs : " However trachoma
begins, it is, in my judgment, a malady that originates in contagion and
in that alone. I no more believe in its spontaneous evolution than
I do in the de novo origin of measles or of ringworm."

A brief summary of this author's views of the origin of these conjunc-
tival inflammations is contained in the following quotation : "Of the
four acute affections, then, grouped together under the common name
epidemic ophthalmia, three arise from contagion, viz., purulent and
diphtheritic conjunctivitis and acute trachoma. With regard to the
fourth, catarrhal ophthalmia, whatever be its origin, it spreads, at any
rate, by transfer of discharge. A proper knowledge of these facts under-
lies all successful preventive treatment and furnishes us with a clue to
many precautions that might otherwise seem unnecessarily tedious and

202

REVIEWS

minute." The bacillus of Weeks is described, and its presence considered
to indicate that the case is one of catarrhal ophthalmia. We are of the
opinion that the author might have gone further and declared this micro-
organism to be the specific cause of epidemic conjunctivitis.

Stephenson agrees with Raehlmann that these contagious types of con-
junctivitis are incapable of atmospheric dissemination, and therefore all
preventive measures should be based on a theory that contagious eye
maladies are spread by the direct or indirect conveyance of specific dis-
charges from eye to eye. The most likely agents in passing on infectious
particles are washing utensils, hands and fingers, handkerchiefs, bed-
linen, body-apparel, animals, and miscellaneous agents.

This portion of the book concludes with a full consideration of the
management of outbreaks of epidemic conjunctivitis in schools, asylums,
and similar institutions, the education of those suffering with ophthalmia,
and contains full directions for securing proper medical inspection and
hygienic arrangements.

The next chapter comprises, according to its title, a clinical inquiry
into the prevalence and significance of the follicular granulation of the
conjunctiva, and discusses fully the vexed question of the relation of
follicular conjunctivitis and folliculosis to trachoma. Dr. Stephenson
concludes that the follicular granulation does not constitute the initial
stage of the specific disease trachoma ; that it is not necessarily an imme-
diate and direct outcome of an unhealthy environment ; that there is no
decisive evidence that it predisposes to trachoma ; that in all likelihood
it is an expression of what he terms the " adenoid activity " of young
subjects, being comparable to the follicular projection of the pharynx.

The chapter on the Treatment of Trachoma and its Complications
opens with a very interesting introductory sketch of the history of this
disease and the methods which have been practised for its cure. This is
followed by the various plans of treatment which have been of particular
service to Dr. Stephenson. His most important conclusions are as fol-
lows : Bluestone and lunar caustic are the most trustworthy escharotics ;
expression is an operation of great value and deserves a permanent place
in the treatment of trachoma ; excision of the upper cul-de-sac is worthy
of trial in cases of trachoma that resist ordinary methods of treatment ;
a combination of surgical and escharotic methods not infrequently forms
the speediest, safest, and the most rational means of attacking the disease.
The last quotation deserves emphasis, because one reason of the lack of
success in many operations for trachoma consists in the failure to carry
on the medicinal treatment of the case after the completion of the oper-
ation.

The complications of trachoma receive full consideration, both in de-
scription and treatment, and a special chapter is devoted to the treatment
of follicular conjunctivitis. Dr. Stephenson prefers ointments contain-
ing lead, and his usual plan is to commence the treatment with a 1 per
cent, ointment of the subacetate, which is gradually increased in strength
to 5 per cent. Expression is also employed, but only when the growths
are of comparatively large size. If much discharge is present, he uses
a tepid solution of corrosive sublimate, 1 to 5000.

The book concludes with an Appendix, well illustrated, describing the
proper lavatory arrangements in schools, barracks, and asylums, and also
the proper management of the accessories — towels, sponges, and the like.

We commend this excellent book not only to every physician whose

LOVE: DEAF-MUTISM. 203

practice is likely to bring him in contact with the diseases which are
described, but also to superintendents, officers, and managers of alms-
houses, asylums, children's homes, and similar institutions, in which it
is essential to endeavor to prevent the entrance of epidemic conjunctivitis,
and in which, if the disease has already found a footing, all measures to
stamp it out of existence should be employed. G. E. de S.

Geschichte der Volksseuchen wach und MIT DEN Berichten der
Zeitgenossen, MIT Beracksichtigung der Thierseuchen. Von Dr.
B. M. Lersch. Pp. 445. Berlin : S. Karger, 1896.

This is an extremely valuable reference-book, the preparation of which
must have involved an enormous amount of reading and research. It
presents a history of epidemic diseases from the earliest to the present
time, giving the dates and main facts of outbreaks of these diseases
wherever occurring. Many of the most important and widespread epi-
demics are described in great detail, with full accounts of symptoms,
treatment, meteorological conditions, and other matters of interest. The
insertion of full references to authorities would have added greatly to
the v-alue of the book for other workers in the field of epidemiology.
In a very great number of instances, for example, no authority what-
ever is given and this omission is inexcusable. C. H.

Deaf-mutism. A Clinical and Pathological Study. By James
Kerr Love, M.D , Aural Surgeon to the Glasgow Royal Infirmary;
Honorary Aurist to the Glasgow Deaf and Dumb Institution. With Chap-
ters on the Education and Training of Deaf Mutes, by W. H.
Addison, A.C P., Principal of the Glasgow Deaf and Dumb Institution.
Pp. 369. Glasgow: James MacLehose & Sons, Publishers to the Univer-
sity, 1896. New York : Macmillan & Co.

Chapters I. to VIII. are the work of Dr. Love, and are the only
ones that appeal to the medical man. The work as a whole is emphat-
ically one to be studied by teachers of the deaf and dumb. The name
of the book should be Deaf-dumbness, and not Deaf-mutism." The
latter is a translation of the French " Surdimutite," and we could never
understand why English writers preferred it to honest English " deaf-
dumbness." The Germans command our respect with their word
" Taubstummheit." Why do not our English writers show similar regard
for their own language and use pure English when they can ?

The chapter on Diagnosis, Prognosis, and Treatment of Deaf-mut-
ism," or the " surdism" — i. e., the deafness of the mute — is very inferior
to what it might have been had the author shown any knowledge of
what might be done to relieve the deafness of the mute. The latter can
certainly be done in the acquired cases, especially in many instances of
purulency. Not one suggestion is made that such aid may be given to a
mute, just as it is in many cases of deafness in those not mutes, by intra-
tympanic operations. And it must be remembered that any improve-
ment in hearing enables the deaf-mute to accpiire more easily li})-reading
and articulation. The author of this chapter either knows nothing about

VOL. 112, NO. 2.— AUGUST, 1896. 14

204

REVIEWS.

such operations or suppresses what he knows. He contents himself with
treatment of the nasopharynx. His indifference to any rational treat-
ment of the ear in the deaf-mute may be due to his view (p. 181) that
the deafness in the mute is generally due to damage to the internal
ear, the auditory nerve, or its connections in the brain " — a state-
ment, however, which cannot be substantiated, at least in the acquired
cases with purulency.

The book is well written and handsomely printed and bound.

C. H. B.

Les Suppurations de l'Apophyse mastoide, et leur traitement. Par
A. Broca and F. Lubet-Barbon. Pp. 259. Paris : G. Steinheil, 1895.

This work, which shows care and industry in observation and record-
ing cases of mastoid disease, is divided into an introduction and four
chapters. The latter are denominated Mastoid Abscesses, Mastoid
Fistulse, Chronic Suppurative Otitides, with Latent Mastoiditis, and a
chapter on Results.

The first chapter is subdivided into (1) Sketch of the Pathological
Anatomy and Physiology, (2) Symptoms, (3) Diagnosis, (4) Thera-
peutic Indications, and (5) Treatment of Acute Mastoiditis.

The second chapter is subdivided into (1) Physical Signs and Osseous
Lesions, (2 ) Therapeutic Indications and Surgical Operations, and (3)
Intracranial Complications.

The third chapter is not subdivided, but the fourth chapter is divided
into (1) Cases, (2) General Statistics, and (3) Results According to the
Nature of the Lesion.

The authors make the term mastoiditis, or mastoid abscess, very com-
prehensive, placing under it many comparatively trifling affections of
the soft parts of the mastoid and intramastoid processes which have ter-
minated safely and spontaneously beneath the soft tissues of the mastoid
cortex. It also seems from a scrutiny of the notes of cases that in many
instances the so-called mastoid abscess or fistula was the result of an
irritant and secondarily infectious treatment of the inflamed ear. Viewed
in the light of the recent papers upon antiseptic treatment of ear disease
by Gradenigo and Pes, in Italy, and Lermoyez and Helme,' in France,
this work under review belongs to the period of what may be termed
" septic aural surgery." C. H. B.

Spectacles a^^d Eyeglasses: Their Forms, Mounting, and Proper
Adjustment. By R. J. Phillips, M.D., Ophthalmic Surgeon to the Pres-
byterian Hospital in Philadelphia, etc. Second edition, revised, with
forty-nine illustrations. Philadelphia: P. Blakiston, Son & Co., 1895.

This excellent manual, which has reached its second edition, continues
to be the best book on the subject of which it treats. It should be read
by everyone who is interested in that most important portion of the
ophthalmic surgeon's work — the supervision of the proper adjustment of
spectacles. It is doubly useful for those practitioners of ophthalmology
who are unable to command the services of a skilled optician.

G. DE S.

' See this Journal, July, 1895, pp. 101, 105.

CLAIBORNE: EXAMINATION OF THE EYE.

205

A riCTORiAL Atlas of Skin Diseases and Syphilitic Affections. In
Photo-lithochromes from Models in the Museum of the Saint Louis Hospi-
tal, Paris. With explanatory woodcuts and text. By Ernest Besnier,
A. FouRNiER, Tenneson, Hallopeau, du Castel, Henri Feulard,
and Leon Jacquet. English edition, edited and annotated by J. J.
Pringle, M.B., F.R.C.P. Part II. London : The Rebman Publishing
Co. Philadelphia: W. B. Saunders, 1896.

The first plate in Part 11. of this most promising Atlas is one of lupus
erythematosus, portraying the disease on the nose, cheeks, and ear.
This case and accompanying notes are presented by Hallopeau. The
representation of this disease is most life-like. A woodcut of the same
is also given with explanatory references to the parts, showing the dif-
ferent stages of the process. As supporting its asserted tuberculous
nature, it is stated that the patient had lost one brother and one sister
from tuberculous disease, and that the patient himself had in childhood
suppuration of a cervical gland. The next plate shows hypertrophic
rosacea of the nose and lower and middle forehead, in which regions the
skin forms veritable convoluted masses, resembling the frontal leontiasis
of leprosy. The case and notes are presented by Besnier. This illus-
tration is presented as that of a rare case, and will be of much interest
to dermatologists. The third plate exhibits a circinate papulo-squamous
syphiloderm, the eruption being in great profusion. The plate shows the
face. Woodcuts of two other cases are also given — one showing papulo-
•squamous patches on the back of the hand and wrist, and the other
exhibiting enormous syphilitic patches of a papulo-crusty form on the
anterior trunk. The fourth, and last, plate of this part is one showing
xanthoma planum et tuberosum. The plate presents one-half of the
apper face and forehead and the palm of the hand of the same patient.
In the former xanthoma of the eyelid and adjacent region is most satis-
factorily depicted. That on the palm is also well shown, but this is a
rare site for the disease and is not so valuable, therefore, from the every-
day physician's standpoint. The case and notes are given by M. Darier.
The patient was " glycosuric, icteric, and obese." This completes Part
II. It further emphasizes the fact that this publication is a most admir-
able and artistic one ; the coloring is true to nature, and the histories
given and the clear explanatory text add materially to its value.

H. W. 8.

The Functional Examination of the Eye. By John Herbert Clai-
borne, Jr., M.D., Adjunct Professor of Ophthalmology in the New York
Polyclinic. With twenty-one illustrations. Philadelphia : The Edwards
& Docker Co., 1895.

Dr. Claiborne's little book, according to a statement in the intro-
duction, is the result of a course of lectures delivered to the students of
the New York Polyclinic. It is elementary, and written in an easy, col-
loquial style, which the author informs us he has adopted because he
believes he can by it make his meaning more clear. The book describes
the faculty of vision, the method of conducting an examination, a few
of the properties of lenses and prisms,^ and then devotes itself to the

206

REVIEWS

correction of astigmatism and presbyopia. The chapter on Presbyopia
is the best one in the book. If the correction of errors of refraction,
particularly of astigmatism, was really as non-laborious an occupation
as Dr. Claiborne's sentences make it appear, what a saving of time
there would be in the practical ophthalmic surgeon's office !

A good many surgeons will not agree with Dr. Claiborne's view of the
mydriatics. Personally we are inclined to believe with him that homa-
tropine and atropine sulphate are sufficient for all practical purposes. We
do not believe, however, that it is an advantage to add cocaine to the
homatropine solution. Neither do we believe that there is any difficulty
in prescribing a glass during the effect of a mydriatic, provided a proper
examination of the functions of the eye and the balance of the external
ocular muscles has been made before the mydriatic was instilled. These
examinations are omitted in Dr. Claiborne's book. We regret that the
author should not have made his manual somewhat larger, and included
it the examinations of muscles, the field of vision, the field of fixation,
and the estimation of the color-sense and the light-sense. The title of
the book entitles the reader to expect a description of these topics.

G. DE S.

A Manual of Operative Surgery. By Lewis A. Stimson, B A., M.D.,
Surgeon to the New York, Bellevue, and Hudson Street Hospitals ; Pro-
fessor of Surgery in the University of the City of New York, etc., and
John Rogers, Jr., B.A., M.D., Assistant Demonstrator of Anatomy in the
College of Physicians and Surgeons, New York ; Surgeon of the Out-patient
Staff, Hudson Street Hospital. Third edition. New York and Philadel-
phia: Lea Brothers & Co., 1895.

The whole of this work has been thoroughly revised by the junior
author. A large number of well-executed cuts and about one hundred
pages of text have been added. The descriptions of many operations
formerly in vogue have been omitted, and a more lengthy and detailed
description given to the ones substituted. The author has confined him-
self to the practical aspect of treatment by operation. The indications
are not dealt with, neither is included the preparation of the patient
or the after treatment of the case.

The section devoted to the cranium and abdomen has been entirely
rewritten and brought up to the requirements due to the advances in
this important branch of work. The chapter dealing with plastic oper
ations is well illustrated, clear, concise, and thoroughly practical, dealing
with all that is really essential and important.

On the whole, we can commend the book as a useful and practical
guide to the most important surgical operations. It is by no means an
exhaustive treatise, yet it is eminently readable, and should be appreci-
ated by all students and practitioners who wish to obtain a clear and
comprehensive insight into any operative procedure. The publishers'
share in the production of the volume is deserving of all praise. The
paper is good and the printing neat and more than ordinarilv accurate.

R. H. H.

PROGRESS

OP

MEDICAL SCIENCE.

THERAPEUTICS.

UNDER THE CHARGE OF

REYNOLD W. WILCOX, M.D., LL.D.,

PROFESSOR OF MEDICINE AND THERAPEUTICS AT THE NEW YORK POST-GRADUATE MEDICAL
SCHOOL AND HOSPITAL ; VISITING PHYSICIAN TO ST. MARK'S HOSPITAL.

The Treatment of Pulmonary Tuberculosis by Injections of

GUAIACOL AND IODOFORM IN STERILIZED OlIVE OiL.

Dr. Breton has made use of this method for fourteen months, observing
thirteen patients who received in all one hundred and fifty injections. Of
these patients five, in the last stages of the disease, have died. The formula
is : Guaiacol, 5 ; iodoform, 1 ; sterilized olive oil, 100. The injections are
made into the abdomen or flank, with all antiseptic precautions. The amount
is gradually increased from fifteen drops to three or four times that amount,
and repeated every eight to ten days. The inconvenience is a persistent, burn-
ing pain. It is contraindicated during congestive attacks, when there is fever
or haemoptysis, or even small masses of blood in the expectoration ; when
there is intolerance or momentary saturation, or when albuminuria super-
venes. The results obtained are a diminution and later disappearance of the
thoracic pain ; the dyspnoea is relieved ; the cough, especially the nocturnal,
becomes less frequent and less painful ; the expectoration is less abundant,
less discolored, although the bacilli are not diminished in number ; the appe-
tite is re-awakened, and at the same time the general condition improves ; the
sweats are less abundant, and, finally, auscultation shows that real progress is
being made. — Journal des Praticiem, 1896, No. 9, p. 134.

The Action of Sodium Bicarbonate.

M. G. LiNOSSiER considers the action of this substance upon the gastric
secretion, particularly in relation to the memoir of Reichmann. The imme-
diate action is the total or partial alkalization of the stomach-contents ; this
is produced without any participation of the gastric mucous membrane. Its
physiological action consists in an excitation of the glandular cells of the
stomach, which has for its result an exaggerated secretion of hydrochloric
acid. The reasons for the errors which have been made in regard to this late

208

PROGRESS OF MEDICAL SCIENCE.

action are to be found in the fact that only a single examination has been
made. If this has been done prematurely, before the alkalinized gastric
fluid has reacquired its alkalinity, then the conclusion has been reached that
its action is depressive ; or if the examination is made at the moment when
the normal acidity has been neutralized, the conclusion is that it has no
action ; or, further, if the examination has been made late, and only if the
dose is suitable, it may be said to have an excitant action. Eeichmann
made only a single examination, and in general an early one, sometimes about
ten minutes after ingestion, more often after thirty minutes, and exception-
ally after one and a half to two hours. Further, he made the error of not
experimenting upon the same patient with variable doses, and of generally
employing insufficient doses to provoke a notable excitation of the secretion.
For these reasons, and the additional one that the duration of his experiments
was too short, the result was that he reached the opinion that its action was
either depressive or at least nil. The remote action of the drug can be
summed up as follows : The sensibility of its action is in inverse ratio to
the richness of the hydrochloric acid in the gastric secretion. — Bulletin Gene-
ral de Titer ajjeutique, 1896, 4e liv., p. 155.

The Therapeutic Action of Salicylic Acid and the Salicylates.

M. G. Ponchet states that salicylic acid diminishes the activity of proto-
plasm, slows the organic processes of formation or retrogression, acts upon
formed and soluble ferments, arrests the amoeboid movements of leucocytes,
and suspends diapedesis. On the other hand, thirty to forty-five grains pro-
duce cerebral congestion, accompanied by symptoms analogous to those
observed from quinine-intoxication, notably tinnitus, disturbances of vision,
and headache. Occasionally these attain to deafness and vertigo due to
congestion of the middle and internal ear, which rarely may go on to true
inflammation. Large doses produce hallucinations, delirium, profuse sweat-
ing, vomiting, and collapse. The kidneys may be the seat of haematuria, of
hemorrhage, and albuminuria. In a healthy man neither pulse nor tem-
perature is changed. But in animals, after poisonous doses, there is a
marked depression of the vascular tension, paralysis immobilizes the organs of
respiration, and death follows convulsions, caused by carbon-dioxide poison-
ing. In man, if ingested by the stomach, the sharp taste and vigorous irrita-
tion of mucous membrane, which may go on to nausea and vomiting and give
place to burning sensations, are noted. Sometimes colicky pains, accompanied
by diarrhoea, follow its administration to dogs. These symptoms should not
be produced in man if the injunction, never to prescribe the sodium salicylate
in powder or in concentrated solution, is followed. The only inconvenience,
if the drug is properly administered, lies in a temporary intolerance, after
prolonged administration, showing itself as a disgust for food as complete as
after the use of an alkaline water or after alcoholic drinks. Salicylic acid is
diff'used through the organism with great rapidity ; in healthy individuals it
stimulates the urinary flow by irritating the renal epithelium, as does potas-
sium nitrate, but this effect is diminished as inflammation develops. In
inflammatory conditions of the kidneys and in severe general aff'ections this
secretion may be retarded or diminished ; for instance, in typhoid patients

THERAPEUTICS

209

it may produce a true urinary break-down. We find the urinary solids in-
creased, phosphoric acid, the sulphates, carbonates, and preformed sulphates,
the latter and, as a consequence, the phenol show that some of the acid
has undergone decomposition. There is also a remarkable elimination of
uric acid, even more notable than that produced by lithium ; in fact, lithium
salicylate is an excellent evacuant of the urates. The saliva is sometimes,
the perspiration and bile always, increased. Sodium salicylate is an energetic
cholagogue in small doses, fifteen to thirty grains ; it increases and liquefies
the bile, attaining its maximum action in two to three hours after its admin-
istration ; but gentle purgatives should be associated with it to stimulate in-
testinal peristalsis. However, it may give rise to hepatic congestion more
or less intense, sometimes obliging the discontinuance of the drug.

The physiological action of salicylic acid can be summed up in the state-
ment that it diminishes the vital activity of protoplasm. It is a specific
in acute articular rheumatism and in gout, showing itself by a special
action exercised not upon a cause still unknown in its real essence, but on
account of the power of the anatomical element to sustain this cause and
react under its influence. This, however, does not exclude a true specific
action upon a cause still unknown, analogous to that exercised by quinine
upon the blood-parasites of paludism or mercury upon syphilis. Besides this
specific action, which may be called a special antiseptic, there is a general
antiseptic one, which may be useful in variola, diarrhoea, diphtheria, and
orchitis after blennorrhagia. It is antithermic, but this is not a therapeutic
property, for it is the first symptom of the toxic action. To characterize in
few words the remarkable specific action of this drug : It is a remedy of a
symptom, and not of a diathesis ; its use relieves only temporary accidents,
preventing neither their production nor return, nor indeed their complica-
tions, as does quinine the accidents of paludism, or mercury those of syphilis.
— Les Nouveaux Rlmedes, 1896, No. 3, p. 57, and No. 4, p. 89.

The Effect of Diphtheritic Toxin upon the Histological
Elements of the Nervous System.

DoTT. Carlo Ceni, from his studies, concludes that in patients dying of
diphtheria we cannot always recognize appreciable morphological changes
in the nervous elements, especially if death has taken place early. Experi-
mentally in rabbits subjected to inoculations with diphtheritic bacilli or to
injection with diphtheria toxin, death is constantly accompanied by marked
morphological alteration in the nervous elements. The intensity of the
alteration depends not so much upon the amount as the duration of the toxic
action. In patients the general rule is that these changes are limited to the
protoplasmic prolongations, leaving unaltered the cell-body and the nervous
prolongations. Only in rare, special cases, through prolonged action of the
diphtheritic toxin, the atrophic process of the nervous elements presents itself
in a more advanced state, indicating alterations in form, both of the cell-body
and nervous prolongations. In patients dying of diphtheria the incipient
atrophic process of the nervous elements is limited to a few isolated cells
disseminated through the encephalic mass ; in animals, on the other hand,
it extends to diffuse groups of cells, acquiring the character of a diffiised

210

PEOGRESS OF MEDICAL SCIENCE.

alteration, more marked especially if death has taken place by slow poisoning.
Individual conditions of acquired immunity show remarkably that these
elements require an enormous resistance against the deleterious action of the
diphtheritic toxin. Animals refractory to diphtheria can tolerate in their
circulation even five hundred times the fatal dose of toxin without producing
any change in the nerve-centres or elements. — La Rifonna Medica, 1896, Nos.
29, p. 338 ; 30, p. 351 ; 31, p. 363.

The Preventive Action of Quinine in Paludism.

M. Laborde believes that this is no longer in doubt. If this is not every-
where admitted at present, it is because the rational indications have not
been studied and the choice of preparation, its form, and appropriate dose
made out. In general, too small doses and too long intervals have been the
sources of failures. In general, one and one-half to three grains every day,
according to the severity of the service, seem to be sufficient. The objection
to the continued use of the drug that it presents, among other inconveniences,
that of habituation, so that its specific activity may be lessened or abolished
at the time when its intervention is absolutely necessary, is not of sufficient
weight to induce complete reliance to be placed, as do Kelsch and Kiener,
upon the habit of not exposing one's self, when fasting, to fever-producing
emanations, and the use of tonic drinks, coffee, tea, and alcohol in small
doses. — Journal des Fraficlens, 1896, No. 10, p. 155.

The Gastric Crises of Tabes Dorsalis-

M. H. HucHARD calls attention to the fact that in 1885 Sahli noted that
these crises depended upon an attack of deficient hydrochloric acid, and
should be treated by sodium bicarbonate, two and one-half to three and one-
half drachms per diem. More recent work tends to point out that the proper
treatment during the crises and hypopepsia is absolute rest, and, for food,
undercooked eggs, some vegetable purees, crust of bread, and, for drinks,
water, but no milk. During the period of quiescence or hypopepsia (hydro-
chloric acid equalling zero), sodium bicarbonate in from fifteen to thirty
grains, an hour before meals ; a solution of hydrochloric and lactic acids
(hydrochloric acid, 1 ; lactic acid, 5 ; water, 500) ; a Madeira glass, after
meals. For food, purees of feculent vegetables, some meats well cooked,
boiled and chopped eggs, and water to which is added a little wine. — Jour-
nal des Praficlens, 1896, No. 8, p. 114.

GUAIACOL AS A TOPICAL APPLICATION IN DIPHTHERIA.

Dr S. Solis-Cohen states that this drug early used seems to destroy the
bacilli and prevent the spread of the pseudo-membrane. Bacteriological
examination of cultures taken from the same throat before and after its
application has shown in the first instance the bacilli, and in the second
none have been found. The formula is guaiacol, 10 ; menthol, 1 ; sterilized
olive oil, 10. The same application is of service as a prophylactic against
diphtheria by application to the throat of the healthy inmates of the house

THERAPEUTICS.

211

in which the disease has appeared. This has been proved by Elwyn in two
epidemics. In folliculous tonsillitis it is capable of cutting short the disease
if early and thoroughly applied, and even in parenchymatous tonsillitis miti-
gates considerably the severity of the affection. — Philadelphia Polyclinic, 1896,
No. 16, p. 157.

A Possible Explanation of Sudden Death after the Adminis-
tration OF Diphtheria Antitoxin.

Dr. C. B. Fitzpatrick suggests that the cause of death of a male infant,
aged twenty-one months, who died suddenly while in perfect health, in con-
sequence of an injection of this substance, may have been due to the carbolic
acid which is known to have been present. This is present to the amount
of 5 per cent., and the dose administered contained between three-fourths
and four-fifths of a grain. The patient in question received about five times
the safe dose, and, inasm.uch as the minimal fatal dose is unknown, perha23s
a fatal dose.— ^Ae Medical Record, 1896, No= 1328, p. 571.

The Treatment of Cancer and Sarcoma by Forced Alimentation
AND THE Use of the Toxin of Erysipelas.

Dr. B. H. Detwiler reports five instances. Hypernutrition was insti-
tuted in the form of large quantities of concentrated peptonized liquid food,
with from one to two pints daily of a very superior old port wine, indepen-
dent of the usual food. The cases were : 1. Cancer of the spine by metas-
tasis from the breast, with a renewal of the disease in the cicatrix of the
breast. 2. Cancer of the uterus. 3. Ulcerating surface after removal of one
breast, with involvement of the other. 4. Immense sarcoma of liver. 5. Rap-
idly growing sarcoma of the neck. So far as the toxin injections were con-
cerned, they were barren of results, although there were temporary good
effects from the hypernutrition. — Therapeutic Gazette, 1896, No. 3, p. 149.

The Treatment of Enteritis.

Dr. Edward P. Davis states that in the artificial feeding of infants clean-
liness, the scalding (not boiling) of milk, and its administration at regular
intervals are essential. In weakly, marasmatic babies the milk should be
partially digested ; this is readily done with the peptogenic milk- powder.
Barley-water, 1 to 32, is a valuable addition to the diet, exerting an astrin-
gent action in case of diarrhoea. Oatmeal-water of the same strength exerts
a laxative action. If the child vomits, is feverish, and has frequent stools;
the milk should be stopped altogether for twenty-four to thirty-six hours
and albumin-water substituted. The latter is prepared by adding the white
of one raw egg to eight ounces of water ; in addition, the child should get
light chicken- or mutton-broth or freshly extracted beef-juice. Brandy and
water form a good stimulant, and may be administered in ten-drop doses
six or eight times daily. The administration of a dose of castor-oil, guarded
by some brandy to prevent griping, is of exceeding value to clean out the
irritating material from the intestines. Lavage of the intestines is of first
importance in intestinal infantile disorders. It is accomplished by the use

212

PROGRESS OF MEDICAL SCIENCE.

of a No. 11 or 12 soft-rubber catheter and a fountain-syringe, with one or
two quarts of warm water. The best result is obtained if the infant is
placed on its abdomen across the nurse's knees, the water being at a tem-
perature of 100° F., and a little soda or salt added to it. Great relief is
obtained from the evacuation of the flatus and feces. In chronic cases some
antiseptic must be added to the water. For each quart of water the follow-
ing may be added : Boric acid, four drachms ; creolin, thirty drops ; sodium
salicylate, ten grains ; thymol, seven and one-half grains ; or mercuric chlo-
ride, one and one-half grains. The last should be followed by irrigation with
warm water. The irrigation of the intestines not only cleanses them, but
exerts a stimulant action upon the bowel. — The Philadelphia Polyclinic, 1896,
^^0. 3, p. 221.

The Use of Glycerin for Hepatic Colic.

De. Clemente Ferreira presents a strong plea for the use of one-half
to one ounce of this substance, diluted with water, as an excellent resource
against the painful attacks. If administered at the outset, it may abort
them and even bring about a respite of long duration from the attacks. —
Bulletin General de Therapeiitique, 1896, 8 liv., p. 251.

The Treatment of the Dyspepsias.

Dr. Albert Robin divides the premonitory dyspepsias into (1) those
caused by excess of fluids and (2) excess of peptones. The latter can be
readily relieved by a diminution of the quantity of food eaten. With the
former there is a difficulty, because a sudden suppression of the abundant
drink frequently gives rise to a very disturbing vertigo. The better plan is
to allow the patient to drink according to his desire only, one or two hours
after the meal. The true dyspepsias may be divided into (1) gastric hyper-
sthenia ; (2) hyposthenia or weakness ; aud (3) vicious fermentations. The
first class is divided into those of (1) neurotic origin (without lesion) ; (2) cen-
tral nervous origin ; and (3) gastric or reflex. The first of these has been
named gastroxynsis by Eossbach, and should be treated expectantly and par-
ticularly by hygienic methods ; absolute intellectual repose, open-air exer-
cise in the country, in the mountains for excitable patients, but for those in
need of stimulation at the seashore. For the second, in connection with
hysteria, tabes dorsalis, or general paralysis, great difficulties are encoun-
tered. The pain should be allayed by the usual means, and milk given in
small quantities is well borne in the interval, but not during the crises. In
the third there is greater opportunity for success. The antiseptics should be
discarded, because they interfere with the action of the soluble ferments. The
usual remedy is sodium bicarbonate, in order to saturate the free acids of the
gastric fluid, but rather in small dose, in order to avoid the production of a
large amount of sodium chloride, from which hydrochloric acid can be elab-
orated. To suppress the condition of the crisis, that is to say, to neutralize
the excess of acidity, chalk, or, better, magnesia is used, and with the addi-
tional advantage that it is of itself an excellent laxative. The formula em-
ployed is : Calcined magnesia, 22 ; bismuth subnitrate, 3 to 10 ; morphine
hydrochl orate, to 3V ; sodium bicarbonate, 15 ; lactose, 7 grains. This is

THERAPEUTICS.

213

to be taken in one dose, in water, at the moment of the attack. In addition,
hydrotherapy renders good service. In the treatment of permanent gastric
hypersthenia, of which the most striking symptom is hyperehlorhydrie, it is
not necessary to saturate the excess of acid by large doses of alkaline bicar-
bonate ; but rather we should use calcined or hydrated magnesia, given in
small doses and three or four hours after the meal, at the time that the albu-
minoids are digested and the syntonins are being formed. Further than
this, the excess of hydrochloric acid can be saturated by taking before each
meal one or tvv^o cachets containing washed sulphur, 2 ; potassium bitartrate,
15 ; and magnesia, 3 grains. In other cases the same result may be obtained
by the use of salts of the organic acids or cream of tartar, potassium bitar-
trate, selde Selgnette [potassium and sodium tartrate], in thirty to forty-grain
doses, thrice daily, which are eliminated as alkaline carbonates. Rarely, in
acute attacks, it may be necessary to administer milk or raw eggs, three or
four hours after the meal, to fix, with the contained albumin, the hydro-
chloric acid and prevent its action upon the mucous membrane. Gastric
excitability may be relieved by a milk diet for about a week. Later, two
to six eggs underdone, finally reaching ordinary diet in about a fortnight.
Fish, especially the lean, with lemon only as condiment, are preliminary to
a full diet. Various indigestible substances, acids (exception noted above),
raw vegetables and fruits, all of the cabbage family, butter, cheese, smoked
meats, long-kept game, truffles, wines, and alcohol are prohibited. Pure
water is best for drinking ; next comes those feebly mineralized, and skimmed
milk. Light beers are good, provided they are well fermented and are not
acid. Coffee and tea are allowed if their use is not followed by nervous
excitement. The pathological phenomena which we must combat are
(1) hypersecretion of the mucous membrane, which exceeds the physio-
logical necessities, and an exaggerated afflux of blood ; and (2) rarely a
diminished amount of pepsin. For the first indication, to diminish the
reflexes may be given veratrum viride, cocculus indicus, cannabis indica,
opium, belladonna, or cocaine — the last with great care and in small dose.
For the hypersemia, ergotin, 3, in distilled water, 4 ; dissolved, filtered, and
mixed drop by drop with tincture of cocculus indicus, veratrum viride, bella-
donna, and anise, of each, 5 ; and of this six to ten drops before the two
principal meals. For the second condition, pepsin, capable of digesting fifty
times its weight of fibrin, 5 ; with diastase, 2 grains ; and in addition pan-
creatin, in two to four-grain keratin-coated pills, may be given. Various
springs also are apparently of benefit in these conditions. The treatment
of gastric hyposthenia or functional insufficiency, showing itself in a dimi-
nution of the hydrochloric acid, does not call for the administration of this
acid unless the gastric glands are certainly destroyed. Milk is prohibited ;
meat must be used with great care, and only when finely divided. The
starchy vegetables should constitute the bulk of the food, but always finely
divided. All condiments are useful, and for fluids light white wines mixed
with stimulating mineral waters, as Condillac, Pougues, or Soultzmatt. Good
red wines, particularly old Bourgogne, are well borne when they produce a
favorable stimulation. Of the drugs, bitter tonics, potassium salts, sodium
bicarbonate, which stimulate the stomach functions, and small doses of
ipecacuanha, which excites the muscular apparatus, are indicated. Various

214

PROGRESS OF MEDICAL SCIENCE.

bitters of complex formulas may be recommended. Patients suffering from
this condition are markedly benefited by a sojourn at Vichy, Pougues, Saint-
Nectaire, Carlsbad, and Homburg. At one's home the waters of Sautenay
and Maizieres, which bear transportation, may be used. If intestinal phe-
nomena complicate the gastric, the waters of Chatel-Guyon, Royat, or
Kissingen are indicated. — Bulletin General de Therapeutique, 1896, 4e liv., p.
145 ; 5e liv., p. 193 ; 7e liv., p. 289 ; 8e liv., p. 337 ; 9e liv., p. 391.

Immunity in Asiatic Cholera.

DoTT. G. Galeotti has made a study of immunization of guinea-pigs
against experimental choleraic peritonitis in order to discover the substance
either in a culture of the bacilli or in the blood-serum of an animal strongly
vaccinated against this micro-organism. From the culture were extracted
(1) divers albumins ; (2) a peptone ; (3) a nucleo-proteid, which is probably
a constituent of the bacterial cell. No substance extracted from the culture
by alcohol, ether, or chloroform showed any value for vaccination. From the
serum of vaccinated animals were separately isolated globulin, resins, fibrin,
and a proteid substance of undetermined origin capable of dialysis. All
these substances showed strong vaccinal properties. As to how these sub-
stances act this much can be said : They do not possess either a bacteri-
cidal or antitoxic power, but are capable of stimulating in a living guinea-
pig a bactericidal powder of an unknown nature, which the animal normally
does not possess. — La Settimana Medica, 1896, No. 19, p. 239.

The Use of Antitoxin in the Treatment of Diphtheria in Private

Practice.

The report of the American Psediatric Society based upon its collective
investigation presents for analysis the results in 3384 cases which occurred
in the practice of 613 physicians. In addition two series of cases, one treated
in the tenements of New York and the other a partial report from the inspec-
tors of the Health Department of Chicago, are included. The report may be
summarized as follows : More than six hundred of these physicians have
pronounced themselves as strongly in favor of the serum-treatment. The
localities from which reports have been received are so widely separated that
no peculiarity of local conditions can account for the favorable record.
Doubtful cases which have recovered have been excluded, while doubtful
cases which were fatal have been included. No new cases of sudden death
immediately after injection have been returned. The number of cases in-
jected reasonably early, in which the serum did not appear to influence
favorably the progress of the disease, was but nineteen ; nine of these were
of doubtful diagnosis, four cases complicated measles, three were malignant,
and in two the serum was of uncertain strength and of doubtful value. In
three cases the patients appeared to have been made worse ; of these, in but
one may the result be fairly attributed to the injection. The general mor-
tality was 12.3 per cent.; excluding the cases moribund at the time of the
injection or dying within twenty-four hours, it was 8.8 per cent. The most
striking improvement was seen in the cases injected during the first three

THERAPEUTICS.

215

days ; here the mortality was 7.3 per cent. — excluding cases as above, 4,8
per cent. The mortality of cases injected on or after the fourth day was 27
per cent. Of the laryngeal cases (membranous croup) one-half recovered
without operation ; in a large proportion of cases the symptoms of stenosis
were severe. Of the cases upon which intubation was performed the mor-
tality was 25.9 per cent., or less than one-half as great as has ever been
reported under any other method of treatment. Broncho-pneumonia occurred
in 5.9 per cent. In contrast to the two or three instances in which the serum
is believed to have acted unfavorably upon the heart may be cited a large
number in which there was distinct improvement in its action after the serum
was injected. There is little if any evidence to show that nephritis was caused
in any case by the injection of serum. The effect upon the nervous system
is less marked than upon any other part of the body, paralytic sequeloe, being
recorded in 9.7 per cent, of the cases. The most concentrated strength of an
absolutely reliable preparation should be administered as early as possible on
a clinical diagnosis, not waiting for a bacteriological culture. However late
the first observation is made, an injection should be given unless the progress
of the case is favorable and satisfactory. The dosage for a child over two
years old should be, in all laryngeal cases with stenosis and in all other severe
cases, 1500 to 2000 units for the first injection, to be repeated in from eighteen
to twenty-four hours if there is no improvement. A third dose after a similar
interval may be necessary. For severe cases in children under two years,
and for mild cases over that age, the initial dose should be 1000 units, to be
repeated as above if necessary ; a second dose is not usually required. The
dosage should be always estimated in antitoxin units and not in the amount
of serum. — Pcediafrlcs, 1896, No. 1, Supplement.

Sudden Death after a Peeventive Injection of Behring's

Antitoxin.

Dr. R. Paltauf, noting the previously reported cases of Maizard, Qui-
non, and Alfoldi, claims that these were not definite in that thorough exami-
nations were not made. It is admitted that local and general erythemata,
exanthemata, even marked fever, may arise, and occasionally joint-symp-
toms, but denies that a fatal case has resulted or that permanent injury has
been done. The beneficial influence of the serum upon diphtheria is incon-
testable, and the assumption that death is due to its action only prevents its
use through the anxiety, of the laity, to which these reports give rise. In-
stances of sudden death in children are not uncommon, and may be attributed
to causes not found save after especial examination. Among these may be
cited acute interstitial myocarditis, the lymphatic-chlorotic constitution of
rhachitis. — Wiener Uinische Wochenschri/t, 1896, No. 16, S. 297.

The Treatment of Scarlet Fever.

M. E. Apert reports that two attempts in severe cases with the serum of
Marmorek (c/. The American Journal of the Medical Sciences, 1896,
No. 290, p. 745) were not encouraging. The ordinary treatment is a milk-
diet, fifteen to thirty grains of ammonium acetate daily during the period of

216

PBOGRESS OF MEDICAL SCIENCE.

eruption, buccal irrigations of aromatic boiled water, and an injection into
the nasal cavities of 2 per cent, of menthol in oil.

M. CoMBY states that the mortality of this disease treated by injections of
Marmorek's serum was 8 per cent., while in the same pavilion the previous
mortality was 5 per cent. Not only did the antistreptococcic serum fail to
lower the mortality, but it did not prevent the complications due to the
streptococcus. One can say that its value is nil in the treatment of this
disease. — Journal des Praticens, 1896, No. 20, p. 317.

Death following Antidiphtheritic Serum.

M. Variat reports a single observation. A child of eighteen months suf-
fered from a slight pharyngeal diphtheria, followed by croup. After intuba-
tion five drachms of serum were administered. Death resulted in forty-eight
hours ; the temperature was lOS'^ F. On necropsy nothing was found to indi-
cate the cause of death. The pharnyx and larynx were entirely free from
membrane and appeared healthy. — La Semiine Medlcale, 1896, No. 22, p. 173.

The Cause of Sudden Death from Antitoxin Injections.

Drs. a. Seibert and F. Schwyzer, from laboratory-experiments, conclude
that : (1) Antitoxic serum does not seem to be capable of causing threatening
symptoms and speedy death even when brought quickly into the blood-
current in very large doses. 2. The carbolic acid used as preservative must
be in such a weak solution as to be unable to cause the characteristic carbolic
convulsions. 3. Even very small quantities of air will cause severe disturb-
ances and ultimate cessation of breathing, and to this cause the authors
attribute the sudden deaths reported. — New York Medical Record, 1896, No.
913, p. 708.

Treatment of Snake-bite with Antivenene.

Dr. Fraser cannot as yet adduce any actual experience of its use in human
beings, although a considerable quantity in both the liquid and dry state has
been sent to India and Africa. Other remedies, however, should be used
which may assist the action of this antidote in preventing death and also
by prolonging life increase the opportunity for a more thorough use of it ;
such would be medicines which increase secretion — diaphoretics and diur-
etics— rapidly acting stimulants of the circulation, alcohol and the old snake-
remedy, ammonia ; stimulants of the respiration, atropine and strychnine ;
the latter of which has received attention. Certain auxiliary measures, as the
application of a ligature, removal of the venom by opening up wounds, and
suction, are useful. The dose varies with the amount of venom, conditions
of administration of the remedy, and time which has elapsed since the bite.
The symptoms do not give information as to the quantity of venom received.
Probably eleven and one-half ounces would be required surely to antidote
the poison if injected not much longer than thirty minutes after the bite had
been inflicted ; possibly four ounces may be sufficient. The bulk, however,
may be reduced one-half by dissolving the dried antivenene. Even with

THERAPEUTICS.

217

this substance in its present condition human life may be saved in a consid-
erable, if not in large, proportion of cases of snake-bite which would other-
wise terminate in death. — British Medical Journal, 1896, No. 1842, p. 957.

A Smallpox Antitoxin.

Dr. S. MoncktoN Copeman records the well-known fact that vaccination
is practically of no avail when once smallpox has become developed. The
recent contributions of Beclere, Chambon, and Menard tend to show that the
serum of a vaccinated heifer, gathered after the drying of the pustules, im-
munized to a certain extent against the effects of subsequent vaccination?
but the antagonism is by no means complete. Better results might probably
be obtained by employing colts instead of calves for production of the serum,
since, as Chauveau has shown, an inoculation of colts not infrequently gives
rise to a generalized eruption, the effect of which on the system is likely to
be more potent than when the reaction, as is the case with calves, is limited
to the area of inoculation. If further investigation should be attended with
a greater measure of success than has at present been attained, we may hope
before long to be in possession of an effectual method for the treatment of
those cases in which the system has already became invaded by smallpoxj
which would form a fitting complement to the Jennerian process of preventive
vaccination.— ^riVisA Medical Journal, 1896, No. 1847, p. 1277.

The Use of Vaccine Virus.

Dr. Francis Martin uses ivory points, making two sets of scarifications
— a half-dozen short lines close together — about two inches apart with a dull
bleeding-lancet, cutting just deeply enough through the skin to draw a tinge
of serum and blood. These lines are crossed with a similar set of cuts at
right-angles. The virus is thoroughly dissolved on the point with a little
water, the cuts wiped thoroughly, and it is immediately rubbed into the cuts
for ten seconds with the flat side of the point. The arm is exposed to the
air for one minute. No plaster or subsequent dressing is necessary. The
arm should be washed at bedtime. In three or four days the vesicle will
begin to appear, and will be at its height in about eight to nine days, after
which it will decline. Unless the crust is broken, there will be no severe
symptoms with good virus, and, indeed, there should never be bad and
sloughing arms if the patient is in any reasonably healthy condition at
the Medical Record, 1896, No. 1334, p. 757.

The Administration of Thyroid Gland.

Dr. H. Huchard prefers the administration of the gland in its natural
condition to subcutaneous injections of the juice or its extract, because there
is no risk of introducing into the syringe septic material, and there is always
the assurance that the gland is in a fresh condition. The gland from the
sheep should always be used on account of the absence of tuberculosis in this
animal. The dose is one lobe, fifteen to twenty grains, in bouillon, slightly
fried or raw when cut in small morsels. — Journal des Praticiens, 1896, No. 16,
p. 242.

218

PROGEESS

OF MEDICAL

SCIENCE.

MEDICINE.

UNDER THE CHARGE OF

WILLIAM OSLER, M.D.,

PROFESSOR OF MEDICINE IN THE JOHNS HOPKINS UNIVERSITY, BALTIMORE, MARYLAND ;

AND

GEORGE DOCK, M.D.,

PROFESSOR OF MEDICINE IN THE UNIVERSITY OF MICHIGAN.

The Changes in the Blood in Hemoglobinuria.

Vacquez and Marcano report the result of their examination of the
blood in a case of the so-called idiopathic haemoglobinuria. The disease was
of the paroxysmal form, and occurred in a young man in whom the only
possible assignable cause was malaria, which he had suffered from some
years previously. At the time he was under observation he was perfectly
free from malaria, and no other organic disease could be made out; the
urine, however, contained a small amount of serum-albumin.

The examination of the blood was made before, during, and after a
paroxysm.

It was found that six hours after the attack the red corpuscles had dimin-
ished 400,000 in number, and twenty-four hours later the count showed a
diminution of 1,000,000. The diminution in haemoglobin was not propor-
tionate with the diminution in red corpuscles, but was considerably greater
than would have been expected, and the regeneration of the haemoglobin
was not so rapid as that of the red corpuscles.

The alteration in the appearance of the red corpuscles, already described
by Hayem, was observed, viz. : That certain corpuscles had the appearance
of losing their color gradually. The white corpuscles showed no special
change. The authors state, in conclusion :

1. That haemoglobinuria is rarely pure; it is generally accompanied by a
real destruction of red blood-corpuscles at the moment of the attack.

2. The loss of haemoglobin greatly surpasses the loss of red corpuscles, as
in one case the loss of haemoglobin equalled one-third of the normal, while
the loss of red corpuscles only equalled one-ninth of the normal.

3. The resistance of the blood is much diminished at the time of the
attack. On testing by Melassez's method it is found that the red corpuscles
destroyed at the end of twenty-four hours during the attack are equivalent
to one-third of the total count, while during the normal state not one-quarter
of the normal count are destroyed.

4. The so-called paroxysmal haemoglobinuria being only a symptom, and not
a morbid entity, it is important to examine in every case the modifications in
the blood in order to find out if different varieties of haemoglobinuria are
associated with different changes in the blood. If this proves to be the case
the blood-examination will be of great help in establishing a rational classi-
fication of these cases. — Archives de Medecine Experimentale, January, 1896.

MEDICINE.

219

Gaucher's Disease.

Under the heading of primary epithelioma of the spleen Picou and
Ramond describe a case, of which only one other example is reported,
that of Gaucher, whose name has been given to the disease.

The patient was a young woman, aged thirty-two years, and presented the
same clinical picture as Gaucher's original case, the main points of which
are as follows :

The disease comes on in an insidious manner, with enlargement of the
spleen, accompanied by dull pain in the left hypochondriac region. The
hypertrophy of the spleen is accompanied by an increase in the size of the
liver, and almost the entire abdomen may be filled by these viscera at an
early date. There is no ascites. The hypertrophy of the organs is smooth
and regular.

The functional symptoms are the pain above mentioned and also symptoms
due to compression, dyspepsia, constipation, dyspnoea, frequent urination,
oedema, and at times cramps of the lower limbs.

Hemorrhages are one of the most marked features of the disease ; they take
the form of epistaxis, subcutaneous hemorrhages, etc. The gums become
soft and spongy, like those of scorbutus. Slight icterus may occur. Two
symptoms upon which Gaucher lays particular stress are the complete
absence of glandular enlargement and anaemia without leukaemia. The
duration of the disease is protracted.

The main anatomical lesions consist in the hypertrophy of the spleen and
liver. Both organs retain their original shape, and their surfaces remain
smooth.

The color of the spleen is described as violet, paler than normal. The
splenic parenchyma is sclerosed, and the trabeculse of the organ are much
thickened.

Microscopic sections of the spleen show that its proper substance is de-
stroyed, and its place taken by alveoli, formed of the thickened trabeculse,
filled with large cells with sharply defined nuclei. The liver presents the
macroscopical lesions of cirrhosis, the increase in connective-tissue being
both peri- and intra-lobular.

According to Picou and Eamond, the tumor of the spleen resembles some-
what endothelioma, but they were unable to trace an endothelial origin in
their case, and so are inclined to regard it as a carcinoma. — Archives de
Medecine Experimentale, March, 1896.

Tetragenus Septicemia.

In a recent article Chauffard and Ramond report two interesting cases
of septicaemia occurring in human beings due to the micrococcus tetragenus
of Gaffky.

The organism has been described before as a cause of local infection and
as a frequent inhabitant of phthisical cavities, but these are the first reported
cases, the authors think, of general infection due to it.

The first case was that of a girl, aged fifteen years, in whom, following
la grippe, a polyarthritis appeared, attacking the hips, knee, thumb, shoulder,

VOL. 112, NO. 2.— AUGUST, 1896. 15

220

PROGEESS OF MEDICAL SCIENCE.

and elbow-joints, and accompanied by chills, an erythematous skin eruption,
and great dyspnoea. The patient died on the eleventh day from the onset of
the disease. The second case was that of a young man who was taken with
chills, nausea, and headache, followed by great swelling of the right knee-
joint. This was followed later by extensive infiltration of the right hip and
leg, and enlargement of the inguinal glands. On the tongue was an ulcera-
tion, opposite to a carious tooth containing a cavity. The patient died in
spite of operative interference ten days from the onset of the disease. In the
first case the right knee was aspirated during life and eight centimetres of a
chocolate-colored pus, containing numerous oil-drops, were evacuated.

At the autopsy the lesions of a general infection were present. There were
pericarditis and pleuritis, the pericardium and pleura containing fluid, on
the surface of which floated many oil-drops. In the wall of the left ventricle
were foci of purulent myocarditis with abscess-formation, and in one segment
of the tricuspid valve was a small, round ulcer of one centimetre in diameter
and unaccompanied by any vegetative process. The lungs showed one or
two infarcts. All of the organs contained abscesses whose contents had
a caseo-fatty appearance.

In the second case no autopsy was obtained, but cultures were made during
life from the ulcer of the tongue, the cavity in the tooth, and from the
infected knee.

In the first case cultures from all the organs with the exception of those
from the lung gave a pure growth of an organism which corresponded in
every way to the micrococcus tetragenus of GafFky. In the lung infarct the
colon-bacillus was also present.

In the second case the tetragenus was present in large numbers in the
cultures from the carious tooth and the tongue ulcer, and in pure culture
from the knee-joint.

The organism from each case was pathogenic for animals, and the oily
appearance of the pus was noted in them as in the original cases.

The authors conclude that the tetragenus is capable of causing general
infections in man, as had been previously suspected from its pathogenicity
in animals. — Archives de Medecine Experimentale, May, 1896.

Hemorehagic Myxcedema with Contractures.

Under the title oi" Myxodermie Contracturante Hemorrhagique," de Brun
has recently described what he considers to be a new disease, which is charac-
terized by the following phenomena :

The onset is sudden, with high fever, malaise, vomiting, headache, and the
rapid appearance of typhoid phenomena, with great agitation at night. The
delirium is often violent. The temperature-curve divides itself into three
periods :

1. Rapid rise of the temperature to 39° C, the temperature remaining
between 39° C. and 40° C. for from eight to ten days.

2. Apyrexia or even hypothermy for eight days.

3. The temperature again rises to 39° C.

During the disease there is a general contracture of the muscles, especially
those of the face and neck and the muscles of mastication. The skin becomes

MEDICINE.

221

malleable" like soft wax, and subcutaneous hemorrhages in the form of
ecchymoses, surrounded by a white, painful zone, appear in the third period
of the disease.

There is absence of meteorism and rose spots.

The disease lasts from three to four months. The prognosis is grave. The
cause has not yet been discovered. — La Presse Medicale, May 13, 1896.

Pericarditic Pseudo-cirrhosis of the Liver.

F. Pick {Zeitschrift fur klin. med., Bd. xxix. p. 385) publishes an interest-
ing article, the substance of which he gives in the following conclusions :

1. There are cases resembling precisely the mixed form of cirrhosis of the
liver, with enlargement of the liver and marked ascites, but without jaundice,
which are due to a latent pericarditis. This causes disturbances in the cir-
culation of the liver which lead to connective-tissue overgrowth and to most
intense ascites through congestion of the portal circulation.

2. This occurs especially in early life, but may also be observed in old age.

3. In the differential diagnosis the following points are important : The
absence of an etiological factor for cirrhosis, a history of pericarditis, and a
previous oedema of the legs. An accurate result can only be obtained through
a complete examination of the heart.

The Etiology of Serous Pleurisy.

AscHOFF has analyzed the cases of pleurisy in Albert Fraenkel's wards,
and has made a useful contribution to our knowledge of that subject.

Two hundred cases were examined with reference to the questions : Is
there an idiopathic," non-tuberculous, serous pleurisy? Is there an acute
rheumatic pleurisy, equivalent to a previous acute arthritis? Are there
serous exudates, with pyogenic organisms, which do not become purulent?

The exudates were examined by inoculating three agar-tubes each with
three large drops and keeping the tubes at 37° C. Fresh and stained prepa-
rations of the fluid were also examined. In twenty cases intraperitoneal
inoculations were made in white mice. Forty-three of the 200 cases were
demonstrated to be tuberculous by finding bacilli in the sputum or other pro-
ducts. Nineteen more had the suspicion of tuberculosis in the history.
Of the 200 cases only seven gave a positive result when examined for bac-
teria. Out of seventeen inoculations only two, belonging to the seven just
mentioned, gave positive results. These were a case of sepsis and one of
tuberculosis. The others were : metapneumonic, 2 ; so-called idiopathic, 2 ;
one of each showing streptococci and one pneumococci ; one following gan-
grene of the lung with streptococci. The first two patients died. In the
other five the exudates became purulent ultimately. Operation is not always
necessary in such cases. Some recover spontaneously, so that recovery in
case of pleurisy does not prove a non-purulent exudate. In all the rest of
the 193 cases bacteriological examination was negative. The author answers
the possible criticism that his negative results were due to the small amount
of exudate used. Perhaps a more pertinent objection, not mentioned, is that
anaerobic cultures should have been made. The most interesting cases were

222 PROGRESS OF MEDICAL SCIENCE.

those in which there was demonstrable or suspected tuberculosis, and the
so-called idiopathic cases. Of thirteen belonging to the first class, inocula-
tions in guinea-pigs gave positive results in seven. Of inoculations in twelve
suspected cases, three were negative. A similar proportion was observed in
the so-called idiopathic cases, nine out of twelve causing tuberculosis in
guinea-pigs. This confirms the view that most cases of idiopathic pleurisy-
are tuberculous. That such cases may recover completely is emphasized by
the author. Aschoff thinks it very doubtful whether rheumatic pleurisy ever
occurs without the joints or the heart being also affected. In the sixteen
cases observed by him a complication on the part of the heart was not missed
once. As regards the question of serous exudate and pyogenic bacteria, the
author draws the conclusion that such exudates are almost always free from
bacteria. If pyogenic organisms are present, suppuration is likely to occur
sooner or later. This is not so often the case when pneumococci are present,
probably by reason of the early death of those organisms. The author holds
that the spontaneous recovery of serous pleurisy is not uncommon, and that
salicylic acid has no advantage in its treatment. — Zeitschrijt fur klin. Med.,
Bd. xxix. p. 440.

Gastroscopy,

Peel {Zeitschrift fur klin. Med., Bd. xxix. p. 494) has made some observa-
tions which throw much light on the difficult subject of gastroscopy. The
position and shape of the cardia were learned by making plaster-of-Paris
casts. These show that the subphrenic part of the oesophagus is more fixed
than the thoracic part, and that its direction is usually toward the left. The
cardia was usually found at the level of the twelfth dorsal vertebra. The
average length from the incisors to the cardia was found to be 60 cm. In
passing metallic sounds of 12. mm. diameter the instrument is introduced at
the right angle of the mouth, by which the difficulty presented by the turn
to the left in the lower part is overcome. Out of twenty-three men only
three failures were met with ; out of ten women only one — a much more
favorable showing than most investigators have been able to make. In some
cases the passage of the instrument is hindered by a spasm of the oesophagus,
usually of neurasthenic origin. A natural difficulty is presented by short
and thickset persons, in whom the j^assage of an oesophageal sound may be
impossible. Other obstacles are exudates, tumors of the liver or stomach,
and curvature of the spine.

The Diagnosis of Cysticercus m the Bkain.

MORITZ {St. Petersburger med. Wochenschrift, 1896, No. 10) had a. case in
which the diagnosis of benign tumor in the posterior fossa was made during
life. Autopsy showed a cysticercus cyst as large as a hen's-egg. From a
study of other reported cases, some of them closely resembling his own^
Moritz draws the following conclusions as to the diagnosis of cysticercus in
the brain when there are no external cysts :

1. There are signs of a severe afebrile, non-inflammatory disease of the
brain, the chief symptoms being irritative.

2. Paretic symptoms speak against cysticercus, except in the last stage.

MEDICINE,

223

3. Choked disk is always present.

4. The exclusion of other brain-tumors is only possible by continued obser-
vation. Malignant new growths have a more uniform course. Gliomata
sometimes show periods of improvement, but usually have more severe
symptoms than has cysticercus. Isolated tubercles, which occur especially
in the cerebellum, also have a protracted course, but with them pain, head-
ache, and dizziness are more constant. Slowly growing cysticerci cause
irregular exacerbations of convulsions, headache, and dizziness, alternating
with periods of comparative comfort, the latter sometimes lasting weeks or
months.

5. Death usually occurs in convulsion.

Abstracts of all the available cases are appended to this paper.

Simulated Paroxysmal H^emoglobinuria.

EiCHTER reports the case of a man, who, having had an extensive experi-
ence in hospitals, endeavored to simulate paroxysmal hsemoglobinuria. His
urine contained blood, leucocytes, and detritus. The temperature rose to
42.2° C. As the patient had previously simulated haemoptysis, and as he did
not feel hot to the touch, notwithstanding the high temperature, and as his
intellect was clear, the urine-glass was carefully watched and the tempera-
ture taken in the rectum. From that time the man remained free from
symptoms. — Prager med. Wochenschrift, 1895, No. 35.

Thyroiodin.

Baumann furnishes some interesting additions to our knowledge of this
substance (Munchener rned. Wochenschrift, 1896, No. 14 ; see The American
Journal of the Medical Sciences, May, 1896, p. 597).

The greater part of thyroiodin occurs in the gland in combination with
two albuminous bodies, an albumin and a globulin, especially the former.
The effect of thyroiodin on parenchymatous goitres, myxosdema, and obesity
was found to be precisely like that of the gland itself. Observations on
metabolism in men and animals gave the same results, and finally accidental
intoxication from overdoses also showed the new substance to represent the
characteristic constituents of thyroid gland. Experiments show that the
action of thyroiodin is more prompt than that of the gland, which may be
explained by the fact that it must be liberated from the gland by digestion.

A very interesting fact brought out by Baumann is that the amount of
iodin in the thyroid is much greater in normal than in goitrous glands, and
greater in non-goitrous than in goitrous localities. So in Freiburg, where
goitre is common, the average amount of iodin in the thyroids of adults was
found to be 2 mg., whereas in glands from Hamburg, though only half as
large as the former, the average was 3} mg. In children the difference was
still greater. Disease other than goitre did not seem to affect the amount of
iodin, which was not greater in the thyroid of suicides than in persons dying
of various diseases. In early life and old age the amount is relatively small ;
greatest between twenty-five and fifty-five years. The kind of food, esi)ecially
the use of sea-fish, has a marked effect on the amount of iodin in the gland.

224

PROGRESS OF MEDICAL SCIENCE.

Whether there is less iodin in the soil and water in goitre-districts is not
known.

Later experiments have shown Baumann that the thymus (of calves) con-
tains a small amount of iodin, an important fact in connection with the
other, that the use of thymus in some cases of goitre has been followed by a
diminution in the size of the gland. The use of iodin or iodoform causes
an increase in the amount of iodin in the thyroid, sometimes as much as 20
to 30 mg. In the thyroid of a large dog, whose abdomen was repeatedly
rubbed with iodoform, 48 mg. were found.

Croupous Pneumonia as a Fatal Complication of Diabetes. Sugar

IN THE Sputum.

Bussenius reports from Senator's clinic {Berliner Min. Wochenschrift, 1896,
No. 14) the case of a woman, aged fifty years, who was found to be diabetic
in February, 1895, was taken with pneumonia in November, and died on the
eleventh day. On admission to the hospital the urine was found to contain
glucose to the amount of 4.2 per cent. Sugar was present to the end, varying
in relative and total amount, but increasing with the final crisis and falling
just before death. The sputum contained one-fourth of 1 per cent, of sugar.
This was said by Biermer to be a normal constituent of sputum, a statement
afterward abandoned. From observations made by Bussenius, the latter
thinks the small quantities of sugar occasionally found in the sputum of
non-diabetics may be due to accidental contamination from food. The com-
parative rarity of pneumonia in diabetes appears from the experience of
Senator, who, out of nearly 700 cases of diabetes, saw only seven cases of
pneumonia, not counting one case of broncho-pneumonia and five of influ-
enza-pneumonia. In none of these cases did the sugar disappear during the
febrile period, though in one case it fell from 3.55 to 1.78 per cent. The
prognosis is always unfavorable. It is impossible to say whether death is
due to the pneumonia or to coma.

Symmetrical Gangrene — Death from Apoplexy— Arteriosclerosis.

Thiersch {Miinchener rned. Wochenschrift, 1895, No. 48) reports the case of
a man, aged thirty-five years, who for ten years had symmetrical gangrene,
beginning in the toes. Later, the skin over the feet became livid and discol-
ored. Death took place with symptoms of apoplexy. Autopsy showed hem-
orrhage in the left lateral ventricle and extensive and severe arteriosclerosis.
The arteries of the legs were especially afiected.

Gliosis in Epilepsy.

Bleuler {Miinchener med. Wochenschrift, 1895, No. 33) has found an in-
crease of the neuroglia-tibres in all of twenty-six cases of epilepsy. The
hypertrophy occupies a position between the pia and the external tangential
nerve-fibres. All the patients had had severe epileptic imbecility. Control-
examinations of fifty-four brains, fifty-one from cases of insanity, three from
persons free from mental symptoms, did not disclose a similar condition.

MEDICINE.

225

The histological picture was so striking that the sections from epileptic cases
could easily be recognized. The author does not attempt to prove that the
gliosis is the cause of the epilepsy, but believes it probable that the change
is at least simultaneous, as it is not more marked in cases of long duration
than in recent ones.

Two Cases of Cerebral Spastic Diplegia.

Oppenheim observed this in a mother, aged thirty-one years, and her
daughter, ten years. Ever since her childhood, perhaps from birth, the
mother had motor disturbances in the muscles of the body, extremities, face,
tongue, palate, pharynx, and larynx. The condition was one of paresis or
paralysis, with spasms and athetosis. The intellect was well preserved, but
the patient was perfectly dumb. The motions of crying and laughing were
preserved. The expression was somewhat drawn ; trismus was permanent ;
the muscles of the face moved with difficulty or sometimes involuntarily ;
motion of the tongue was difficult. There were distinct athetosis of the hands
and spastic paralysis of the feet.

The daughter was able to speak only for the last year, and then with diffi-
culty, but otherwise was in much the same condition as the mother. The
spastic condition of the legs was not so marked, but there were the same facial
expression, trismus, and difficulty of swallowing and chewing. — Berliner klin.
Wochenschri/t, 1895, No. 34.

Cerebral Hemorrhage in Whooping-cough.

Oppenheim reports the following rare case : A lad of eight years sud-
denly became unconscious while sick with whooping-cough. At first there
were no local symptoms. Later, the previous agitation subsided, complete
somnolence followed. Gradually spasms began in the right side of the face,
and extended over the whole right side. The convulsions came on in par-
oxysms, following closely after attacks of coughing. After three days the
attacks became less frequent and severe. Paralysis of the right arm and leg,
with absent reflexes on that side, then developed. On the sixth day the in-
tellect began to clear up, though aphasia persisted until the tenth day. By
the end of three weeks recovery was complete.

It appeared that the boy was in the habit of closing the mouth and nose
at the beginning of a coughing-paroxysm, and to make strong expiratory
efforts, in order to check the cough. It can hardly be doubted that this
assisted in the production of a hemorrhage in the left hemisphere, as Oppen-
heim supposed. — Deutsche med. Wochenschri/t, 1896, No. 17.

Diphtheria and Antitoxin.

The Metropolitan Asylums Board of London has recently issued a statis-
tical report on the use of antitoxin in diphtheria, as observed in six fever
hospitals during 1895.

The statistics are based on a comparison with cases treated during 1894,
when no antitoxin was used, this year being chosen on account of the fact
that the mortality was exceptionally low at that time.

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PROGRESS OF MEDICAL SCIENCE

The tables show a general decrease in mortality of 7.1 per cent, in favor ot
1895. The reduction is more striking if age and the day of the disease on
which the antitoxin was administered are taken into account.

In the first quinquennium of life the results are most striking, and here the
mortality is reduced 13.2 per cent, in 1895, lower than it was in 1894.

The necessity of administering the antitoxin early is forcibly shown by the
statistics bearing on the relation between date of administration and mortal-
ity, as it is shown that those cases in which the antitoxin Avas administered
on the first and second days show a mortality of 4.6 per cent, and 14.8 per
cent., respectively, in 1895, as against 22.5 per cent, and 14.8 per cent, in 1894.

The mortality in laryngeal cases is also shown to be greatly reducer! , the
percentage in 1895 being 49.3 as compared to 70.4 in 1894.

The complications of the disease were apparently not influenced by the
antitoxin, as cases showing complications were rather more numerous in 1895
than in 1894. That this was not due to the antitoxin is shown by comparing
an equal number of cases in 1894 and 1895 not treated by antitoxin, when it
is seen that the 1895 cases show a higher percentage of complications.

The authors summarize the results of their inquiry in the following conclu-
sions :

1. There is a great reduction in the mortality of cases brought under the
antitoxin treatment on the first and second days of the disease.

2. That in this series of hospitals the combined general mortality is below
that of any other year.

3. That there is a particularly remarkable lowering of mortality in the
laryngeal cases.

4. That there is a uniform improvement in tracheotomy results.

5. That there is a beneficial effect produced upon the clinical course of
the disease.

They consider the value of the antitoxin to be demonstrated from the study
of this large number (2182) of cases ; and lay particular stress upon begin-
ning the treatment as early as possible. — Metropolitan Asylums Board. Report
of the Medical Saperintendents upon the Use of Antitoxic Serum in Diphtheria.
London, 1896.

UrvEmic Aphasia.

At a recent meeting of the Hospital Medical Society of Paris Rendu gave
the history of a patient presenting this interesting condition.

The patient was a man of fifty-six years, and was admitted to the hospital
with the history of having suddenly been seized with an apoplectic attack.
The morning following admission he had regained consciousness, and his
three main symptoms were aphasia, monoplegia of the right arm, and a sys-
tolic murmur at the base of the heart.

" From these signs a diagnosis of cerebral embolism was made. Some days
later the patient was seized with a sudden attack of intense dyspnoea, with
Cheyne-Stokes breathing ; the urine was scant and very albuminous, and the
blood contained seventy-five centigrammes of urea to the litre. The diag-
nosis was then made of ursemic i)oisoning.

The patient was bled immediately, and recovered in a day or two, both the
monoplegia and the aphasia entirely disappearing.

MEDICINE.

227

Eendu regarded the aphasia and partial paralysis as both being due to
ursemic intoxication, and in the discussion Hanot expressed the opinion that
the similar lesions which may take place in pneumonia and other infectious
diseases were also toxic. Duflocq mentioned a case of aphasia occurring in
the course of cholera, in which the autopsy showed no lesion whatever. —
Gazette Medicale de Paris, April 4, 1896.

The Mobility of Abdominal Tumors.
NOTHNAGEL {Festscfirift zur 100 J ahr. Stiftiingsfeier des Med.-Chir. Friedrich
Wilhelms- Institutes) in this article considers the mobility of abdominal tumors
under four principal causes: Respiratory, or the motion of the diaphragm;
the peristaltic motion of the stomach and intestines ; external pressure '■>
gravity.

1. All organs immediately beneath the diaphragm descend in inspiration
and ascend in expiration. Diagnostic errors due to the inspiratory disten-
tion of the abdominal wall can only be avoided by experience. In the differ-
ential diagnosis of tumors of the liver and stomach the possibility of retaining
the tumors in expiration is in favor of the stomach. Respiratory motions
may be absent on account of pleurisy, emphysema, or adhesions, or in enor-
mous enlargement of the liver or spleen, by which the contraction of the
diaphragm is limited. The mobility of renal tumors, though slight, is
important as contrasted with that of retroperitoneal neoplasms.

2. Tumors of the stomach and intestine may be moved by the peristaltic
action of those organs, but the temporary disappearance of a tumor does not
permit the conclusion that the growth is in the stomach or intestine. Peri-
staltic motion is usually limited, although sometimes it causes a considerable
excursion.

3. Dislocated organs, such as the liver, spleen, and kidney, are easily moved
by palpation unless adhesions have formed. Intestinal tumors are usually
very movable, a fact of great importance in distinguishing between these and
paratyphlitic exudates. Tumors of the stomach, especially the pylorus, have
great passive mobility, but are not much influenced by respiration. Tumors
of the gall-bladder, omentum, ovaries, and uterus are slightly movable, but
abscess, circumscribed exudates, aneurisms, pancreatic tumors, tumors of the
retroperitoneal glands, bones, and undescended testes are immovable.

4. Gravity influences especially tumors of the stomach and intestine.

Hepatic Neitralgta.
Pariser, in the Congress for Internal Medicine {Centmlblattfilr inncre Med.,
1896, No. 17, p. 467), reported seven cases of nervous hepatic colic. This is
usually mistaken for gallstone colic, and in one case of the author's an opera-
tion was performed under the erroneous idea. The clinical picture is usually
precisely like that of colic from calculus. Fiirbringer thinks that in hepatic
neuralgia the most intense pain is localized in the liver, and is not radiating,
and although this is true in many cases, exceptions occur. The attacks Inst
from a few minutes to four or more hours. As in biliary colic, the attack
may end in vomiting. The disease is a visceral neurosis, with a neurasthenic
or hysterical basis. The most successful treatment consisted in the use of
tonics, the exclusion of exciting causes, and cannabis indica.

228

PROGRESS OF MEDICAL SCIENCE.

Fibrinous Bronchitis.

SoKOLOWSKi (Deutsches Archiv fur Min. Med., Bd. Ivi. p. 476) reports four
cases of this uncommon disease, on which he was able to make some inter-
esting observations. One case was remarkable for its long and steady course,
without fever, with daily expectoration of bronchial casts and blood. The
patient died of exhaustion, after four years. Physical examination, as well
as repeated examinations of the sputum, gave no evidence of tuberculosis.
There was never elastic tissue in the sputum. The author believes that the
cases of so-called primary fibrinous bronchitis, in which tuberculosis was
found post mortem, have really been cases of tuberculosis with the peculiar
form of bronchitis as a complication. In another case the patient had all
the symptoms of a severe septic infection, with chills, fever, and sweats, for
more than three weeks. These symptoms led to a careful examination of
the sputum, which contained staphylococcus albus and aureus. There
seemed to be ground for believing the patient, a physician, was infected in
the pathological laboratory. Staphylococci were also found in the sputum
of a third case, in which the course was acute, began with chills and fever,
and resembled influenza. In the sputum large numbers of Charcot's crystals
and Curschmann's spirals were found. A similar case was reported by Zenker
in 1876, and some after that by others, and from these the author draws the
conclusion that fibrinous bronchitis and bronchial asthma have a close rela-
tionship.

The casts expectorated were found to be made up of leucocytes, mucus,
and epithelial cells, with a small amount of fibrin. Many of the cells were
in a condition of coagulation-necrosis.

Sokolowski formulates his views on the disease as follows :

1. Acute fibrinous bronchitis has the type of a pure infection, and is pos-
sibly due essentially to staphylococci (albus and aureus). Typical acute cases
are rare, the milder forms being more frequent, and the latter are probably
often overlooked or mistaken for asthma.

2. Chronic fibrinous bronchitis is an obscure process, with a different eti-
ology, but included with the acute disease on account of the occurrence of
the casts. The latter, however, may occur in other chronic diseases (tuber-
culosis, heart-disease).

3. Pulmonary tuberculosis appears to play only a subordinate role in the
etiology of chronic fibrinous bronchitis.

The Percussion of the Heart with the Body Inclined Forward.

GuMPRECHT {Deutsches Archiv fiir Min. Med., Bd. Ivii. p. 490), who has
made an extensive series of observations, gives this subject a more important
place in diagnosis than it has had hitherto. The most convenient position
is to have the patient on the hands and knees, though the examination can
be made with the patient standing, leaning forward, or sitting in a chair
placed on a table. In this position the boundaries of the normal heart-
dulness are the left edge of the sternum, the fourth rib, the left nipple-line,
or as much as one and one-half cm. beyond it. The width of the heart-
dulness as compared with the circumference of the thorax is as one to eight.

MEDICINE.

229

The greater the fraction the greater is the probability that the heart is
enlarged. Of the advantages of the method the chief one is that the result
is more easily obtained than by other methods. This depends partly on the
fact that the heart-dulness is larger than when percussed in the ordinary
position ; partly on the fact that the layer of lung over the heart is thinner,
so that the difference in sound is more intense. The sense of resistance is
also increased. In fact, in many cases the cardiac dulness is first discovered
when this method is used, especially in cases with great tympanites. Unfor-
tunately, the condition of the right heart is not much more easily demon-
strated by this method than by others. Absolute dulness to the right of the
sternum is not very frequently found, so that for the demonstration of hyper-
trophy of the right ventricle the accentuation of the pulmonary second sound
must still be used. In cases with hypertrophy of the left ventricle, such as
that in arteriosclerosis, nephritis, etc., the new method gives brilliant results,
an increase of four to six cm. in width being not uncommon, and even greater
widths being found. Gumprecht has not yet encountered a case in which
emphysema prevented the detection of enlargement, both dulness and resist-
ance being very marked and easily recognized. Effusions in the pleura,
especially the right, render the method difficult and uncertain.

Eespiratory Neuroses ; Spanopncea and Tachypncea.

Strubing {Zeitschrift fur Min. Med., Bd. xxx. H. 1 and 2) describes some
rare respiratory neuroses. In two cases there were attacks of slow and deep
breathing. In one case this amounted to orthopnoea, with subjective dysp-
noea and feeling of anxiety. Strubing gives this condition the name of span-
opnoea. He looks on it as an inhibitory neurosis. In one case the attacks
seemed to be due to irritation of the respiratory inhibitory fibres of the
superior laryngeal nerve in swallowing. In another it appeared as an
asthma from irritation of the trigeminal fibres in chronic rhinitis and hyper-
trophy of the turbinated.

Tachypnoea also comes on in paroxysms, with increase of the frequency
and diminished depth of the respirations. Two cases were seen. In one the
attacks ceased after the restoration of a retroflexed uterus. In the other
case there were nervousness and mental deficiency.

The Thoracic Organs in Chlorosis.

F. Muller {Berliner Min. Wochenschrift, 1895, No. 38) calls attention to the
fact that in chlorosis the diaphragm is abnormally high, so that the percus-
sion is much like that in children. The fact that in chlorosis the cardiac
dulness is enlarged has been variously explained. Muller has noticed that
in recovery from chlorosis the diaphragm and the heart-dulness return to
the normal, the cardiac dulness to the right of the sternum being the first
abnormality to disappear. As a hypertrophy of the heart can hardly be
supposed to exist in these cases, and as the shape of the heart opposes the
idea of dilatation, Muller assumes that the enlarged heart-dulness is due to
incomplete expansion of the lungs. This would also explain the high posi-
tion of the diaphragm.

230

PROGRESS OF MEDICAL SCIENCE.

OPHTHALMOLOGY.

UNDER THE CHARGE OF

GEORGE A. BERRY, M.B., F.R.C.S. Edin.,

OPHTHALMIC SURGEON, EDINBURGH ROYAL INFIRMARY ;
AND

EDWARD JACKSON, A.M., M.D.,

PROFESSOR OF DISEASES OF THE EYE IN THE PHILADELPHIA POLYCLINIC ; SURGEON TO
WILLS EYE HOSPITAL, ETC.

Optic Nerve Atrophy in Three Brothers.

F. N. Ogilvie reported at the January meeting of tlie Ophthalmological
Society of the United Kingdom the cases of three brothers, aged twenty-four,
twenty-two, and twenty-seven years. In the first the sight was said to have
failed in one night, in the second in three months, and in the third in six
months. They had all been smokers, but one had given it up more than
seven years before. In all of them there was a central scotoma, in two
defective color-vision, and in only one were the fields for white contracted.
The ophthalmoscopic changes were not well marked. In two of the brothers
there was pallor of the disk, but the atrophy was not of very high degree in
any of them. Vision was much reduced. One had improved somewhat
under strychnine and galvanism. A jiteculiarity which they shared with
other members of their family was tortuosity of the retinal vessels. So far
as the family history could be traced there were no other cases of optic
atrophy.

Recurrent Oculomotor Palsy.

G. E. DE Schweinitz (Philadelphia) reports {Trans, of the Amer. Ophthal.
Soc, vol. vii. page 309) the case of a woman, aged thirty years, who, when
one and one-half years old, was violently ill with vomiting, convulsions,
right divergent strabismus, and ptosis. At the end of six weeks ptosis and
divergence disappeared. From that time she had frequent attacks of neural-
gia, mostly associated Avith divergence of the right eye and closure of the
lids ; occasionally the ocular symptoms were absent. During childhood
these attacks occurred as often as three times a week ; later there had not
been over five or six in a year. When four years old the divergence became
more or less permanent. Two years ago, after an unusually severe attack,
ptosis also became permanent. The attacks were preceded by dizziness and
full feeling of the head, swelling of the periorbital tissues, and distention of
the cutaneous veins. Pain began in the right eye and extended to the occi-
put, where it settled. Following the onset of pain there was vomiting, last-
ing from twelve to twenty-four hours. The pupil was oval and absolutely
fixed ; vision 6/60 ; the left eye was normal. Treatment by mercury, iodides,
and strychnine produced no result.

In a case exhibited by Dr. Ormerod and Mr. Holmes Spicer at the Decem-
ber meeting of the Ophthalmological Society of the United Kingdom, the

OPHTHALMOLOGY.

231

boy, then aged fifteen years, was first attacked when one year old, but the
second attack did not occur until the age of seven, since which time an
attack came every nine or ten months. The left eye was affected, and an
intense headache occurred on that side. There were slight ptosis, dilated
pupil, and complete paralysis of the external muscles supplied by the third
nerve.

Supernumerary Caruncle.

Sidney Stephenson (London) reports {Ophthal. Review, No. 171) this
condition occurring in a girl, aged eleven years. It presented on the right
lower lid as a small reddish growth, oval, about as large as a hemp-seed, with
a granular surface, lying behind the inferior canaliculus ; but was not con-
nected with the caruncle. No change was observed in it during six months
she was under observation. It was then snipped away ; and, examined micro-
scopically, was found to consist of epidermic and dermic tissue, the latter
containing hair follicles, sebaceous glands, and muscular fibres. He had
been unable to find any case previously reported.

Eye-lesions in Myxcedema.

P. A. Callan (New York), discussing the ocular conditions presented by
patients with this disease, states {Trans, of the Amer. Ophthal. Soc, vol. vii.
page 391) that the prominent symptoms are lacrymation, due to the swelling
of the lids, and an appreciable amount of corneal anaesthesia.

Eeferring to the statement of Hamilton, ' ' that the fundus oculi presents a
peculiar tumefied appearance and choked disk is occasionally found," he
says that in four cases repeatedly observed there were no such lesions. One
of his patients, after treatment for two years with thyroid extract, had de-
veloped a typical albuminuric retinitis.

Detachment of the Retina.

R. B. Duncan (Melbourne) concludes, with reference to retinal detach-
ment {Australian Medical Journal, vol. xvii. No. 12), that it is impossible for
it to occur in a perfectly healthy eye. Disease of the retina itself, as a rule,
precedes any detachment. Vitreous changes in the form of fibrillary altera-
tions, with or without retraction, are invariably present, and are generally
antecedent to the retinal changes and detachment. In idioj^athic cases the
retraction of the vitreous is the primary cause of the retinal detachment. In
traumatic cases, while the retinal detachment may suddenly occur, it is only
possible when some anterior changes have occurred in the vitreous. Retinal
ruptures are common to the great majority of retinal detachments.

Treatment of Ulcers of the Cornea.

E. W. Wood White, in the Middlemore lecture {Birmingham Medical
Review, vol. xxix. No. 1), deals chiefly with the treatment of ulcers of the
cornea. He thinks the protective bandage should generally be adopted to
prevent irritation of the surface ; but that it is contraindicated where there

232

PROGRESS OF MEDICAL SCIENCE.

is considerable conjunctival discharge and irritation, in sloughing ulcers
secondary to lacrymal disease, and in young children. After corneal perfor-
ation he would use the pressure-bandage. Mydriatics are of great assistance
in a large proportion of cases. For painful superficial ulcers he prefers the
mydriatic dissolved in vaseline or castor oil, rather than water. Of drugs of
this class he has found the hydrochlorate of scopolamin most satisfactory.

If the ulcer is extending, more active treatment is necessary. For this,
he says, " the galvano-cautery has been universally used with splendid
results." It is not necessary to cauterize the whole ulcer, but the advancing
margin must be thoroughly destroyed. After cauterization he fills the ulcer
with finely powdered iodoform or iodol. Scraping the ulcer, the dropping
upon it of water heated to 150° and daily applications of carbolic acid, form-
alin, or a saturated solution of mercuric chloride, are mentioned. He be-
lieves that only in rare instances is eserine the best drug to use, and that it
had better be avoided by those whose experience is not large. For rapidly
spreading ulcers with hypopyon, paracentesis of the cornea, with or without
the entire removal of pus from the anterior chamber, or the Saemisch inci-
sion, may be resorted to.

. Regarding subconjunctival injections, he finds weak solutions of mercuric
chloride, 1 to 4000, less painful than strong solutions and equally efiective,
but that probably the best agent for this use is a 4 per cent, solution of com-
mon salt.

The branching ulcer of so-called dendriform keratitis generally requires
touching with the cautery or scraping. The absorption or faceted ulcer
demands tonics and nourishing food ; so does keratomalacia.

Non-existence of a Separate Cortical Color-centre.

Ward A. Holden (New York) {Archives of Ophthalmology, vol. xxiv. No.
4) opposes the view that color-perception is connected with a cortical centre
distinct from that for the perception of form, by a series of observations made
on cases of hemichromatopsia. He had one-centimetre squares of pale green,
saturated red, and saturated blue placed on gray,cards having the same light-
intensity as the colors. Three gray patches were then prepared on a white
ground having such intensity that each gray patch was seen throughout as
large a field as one of the color-squares. He also had three black dots of
different sizes on a white ground, each of which had a normal field also cor-
responding to one of the color-squares. In the normal eye the black dot,
gray patch, and corresjDonding color were seen over equal fields ; and the same
relation was found to hold good in most cases of amblyopia.

In three cases of hemianopsia for colors it was found that where the colors
were not seen, neither the corresponding dots nor the gray patches could be
recognized. He therefore concludes that the slight interference with con-
duction of any of the fibres of the visual tract leads to inability to recognize
green, or even red, or to distinguish slight differences in luminous intensity ;
that a greater interference with conduction prevents the distinguishing of
white from black ; that the recognition of color varies with the light-sense ;
and, therefore, the assumption of the involvement of a particular cortical
centre in cases of hemichromatopsia is unnecessary and erroneous.

LARYNGOLOGY.

233

DISEASES OF THE LARYNX AND CONTIGUOUS
STRUCTURES.

UNDER THE CHARGE OF

J. SOLIS- COHEN, M.D.,

OF PHILADELPHIA.

Stricture of the Larynx.

At a recent meeting of the Hungarian Society of Otologists and Laryngolo-
gists {Revue Hebd. de Laryngologie, d'Otologie et de lihinologie, 1896, No. 4) Dr.
V. Navratil described three cases of stenosis of the larynx. The first case
had followed tracheotomy for dyspnoea attending acute laryngitis. The sec-
ond had followed an attempt at suicide, and was due to bilateral cicatricial
anchylosis of the cricoid arytenoid joints. The third case is the interesting
onc'of the series, and seems to have been an instance of scleroma. A jour-
nalist, forty-eight years of age, had for a long time suffered with dryness of
the throat, and continual cough with inability to expectorate. Serious dys-
poena had rendered tracheotomy necessary. As the respiration by the mouth
could not be re-established, the case was referred to Navratil, who detected
a subglottic bilateral hypertrophy of the vocal bands. All other treatments
having failed, laryngotomy was performed for the purpose of excising the
tumor, but the growth resisted both the knife and the scissors ; hence it had
to be burned away with electric cautery, and in consequence it had been im-
possible to preserve any portion for microscopic examination. The hyper-
trophic neoplasm was so incorporated with the vocal band on the right side
that it was necessary to destroy in part that structure also. Consequently
a portion of the right vocal band penetrated into the glottis in the form of a
flap. The glottis regained its normal proportions and the patient respires
comfortably on closing the orifice of the canula. The canula will be removed
after the ablation of the flap, when the patient will leave the hospital com-
pletely cured.

This case gave rise to considerable discussion, in the course of which Dr.
Morelli stated that he had observed analogous cases in which the secretions
produced by chronic catarrh had become accumulated and fixed into the
trachea. In one case, indeed, it had been necessary to practise tracheotomy^
and after the removal of the canula a second tracheotomy had become neces-
sary. This patient had a stenosis of the nose so great that a No. 3 bougie
could hardly pass ; the vocal bands were thick, and a great quantity of thick
mucus accumulated in the trachea. Despite successful dilatation the exu-
dation accumulated to such an extent that the removal of the canula was
impossible. The patient finally became tuberculous and died.

The same gentleman had as a patient a young woman, whose nose, pharynx,
and larynx, as far as the trachea, had become covered with a thick colloid
mucus as hard as a stone. The patient being almost near her end, trache-
otomy could not be performed in consequence of the local conditions. These

234

PROGRESS OF MEDICAL SCIENCE.

cases, he contends, demonstrate that dry rhinitis and pharyngitis are not so
infrequent maladies as is often believed.

Dr. Newmann cited two cases of subglottic hypertrophy in which there
were thick folds beneath the vocal bands, the pathological nature of which
could not be determined, as the patients had quit the hospital after being re-
lieved by tracheotomy.

He had also observed in a child of twelve years a subglottic stenosis, conical
in form, and produced in sequence to conjunctive hyperplasia of such a char-
acter that tracheotomy had to be performed. He had also observed, five
years ago, a case similar to that of Navratil's, in which the stenosis extended
as far as the bifurcation — this in sequence to primary scleroma of the nose
and larynx.

Operative Treatment of Multiple Papillomas of the Larynx.

Papers on this subject were read by Dr. Navratil and Dr. Neumann
at the late meeting of the Hungarian Society of Otologists and Laryngolo-
gists {Eevue Hebd. de LarynKjologie, d^ Otologie et de Rhinologie, 1896, No. 4).

Navratil contends that while endolaryngeal extirpation usually succeeds
in simple papilloma, whether in the adult or in the infant, the result is dif-
ferent in multiple papillomas when they obstruct the calibre of the larynx
and give rise to dyspncea. Here it is necessary to practise proi^hylactic tra-
cheotomy first, and then to undertake the extiri)ation of the papilloma ; in
which he proceeds differently in the infant from what he does in the adult.
In the infant he used to perform laryngotomy and endeavor to remove the
papillomas along with the subjacent mucous membrane. Many cases had
been operated upon in this way, but recurrences had taken i>lace, though less
rapidly than after the endolaryngeal method. He attributes these recurrences
to the limited field, which does not permit precision in operation. Of late
he has jjerformed his tracheotomy and then extirjiated the pai:)illomas in
several sittings, partly through the mouth and partly through the wound ;
and for two or three years he has had no recurrences in these cases.

In the adult, where the conditions and space are more favorable, he per-
forms laryngotomy immediately after tracheotomy, and extirpates the papil-
lomas with their base. In this way he has avoided recurrences. He con-
cludes by stating that while he has observed no untoward results after repeated
endolaryngeal operations in infants, he has three or four times seen the con-
secutive formation of epithelioma in adults.

Dr. Neumann, after calling attention to the great tendency to recurrence
of papilloma in infants (so great that a half-pint bottle might have been filled
with the growths removed from one infant in four years), states that cure
seems to depend less upon radical operation than upon extinguishment of
the power of reproduction, which, unfortunately, does not cease for years.
He mentions an interesting case in which the papillomas disappeared of
themselves, probably by spontaneous absorption, and he believes this obser-
vation to be a unique one. But, although the occurrence is rare, it has been
reported before. An infant, six years of age, about whom he was consulted
in the winter of 1892, had been hoarse for two years and completely aphonic
for several months. Both vocal bands were covered with papillomas. These

LARYNGOLOGY.

235

were removed in the course of three weeks at different sittings ; but although
the larynx was cleared out, the irritated borders of the vocal bands would not
permit loud phonation. Two or three weeks afterward the patient recom-
menced to respire with difficulty, the separation of the vocal bands having
become insufficient. The vocal bands became inflamed, and there were two
or three recurrences of these conditions. The stenosis augmenting, the
patient was sent to the hospital for purposes of intubation. Intubation sup-
pressed the dyspnoea, and the respiration remained free for a couple of hours
after the removal of the tube. The recurrences increased, and it was feared
that portions had been forced by intubation into the trachea, as the papil-
lomas covered not only the vocal bands, but the free border of the epiglottis
also. Toward the end of February, 1893, Dr. Kovacs performed trache-
otomy, which relieved the dyspnoea. The papillomas now appeared to
diminish in volume. When Dr. Neumann examined the patient in the
autumn he was astounded that the vegetations on the epiglottis had become
completely reabsorbed, while only one papilloma was to be seen in the ante-
rior wall of the larynx. This also gradually disappeared of itself, and cer-
tainly was not expelled by cough.

Nasal Tuberculoma.

Dr. Polyak reports {Revue Hebd. de Laryngologie, d' Otologie et de Rhinolo-
gie, 1896, No. 4) a ease in a man, forty -nine years of age, who had complained
of hemorrhage and obstruction in the right nostril of six months' duration,
and subsequent hemorrhage and formation in the left nostril. The right
nostril was completely filled by an irregular tumor resembling granulations,
which bled easily. On the left side of the anterior portion of the septum
was a tissue partly covered with dried crusts of a dull white, of the dimen-
sions of a thaler-piece, flattened, granulous here and there, but not promi-
nent, and bleeding easily. The tumor on the right side was at once removed
with the incandescent snare, when it was found that the base of the neoplasm
had occupied the right side of the septum at a point corresponding with the
lesions described upon the left side. Slight hemorrhage, consecutive to the
operation, was arrested immediately by an insuffiation of dermatol. The
tumor removed was thirty millimetres in length and forty millimetres in
breadth, and had erosions upon the external surface where it was covered with
granulations. It contained many tubercles and very few bacilli. There
was no tuberculosis of the lungs or other portion of the body.

Subsequent history of the case is unknown.

Suppuration of the Maxillary Sinuses Consecutive to Deflection
OF THE Nasal Septum.

In the Revue Internationale de RJwiologie, Otologie, et Laryngologie, 1896,
No. 3, Dr. Augieras, of Laval, details a case of suppuration of the right
antrum of Highmore in a man forty years of age, the septum of the nose
being strongly deflected to the left side. This inflammation of the maxillary
sinus, after existing for many years, had given rise to alveolo-dental perios-
titis.

VOL. 112, NO. 2.— AUGUST, 1896. 16

236

PROGRESS OF MEDICAL SCIENCE.

OBSTETRICS.

UNDER THE CHARGE OF

EDWARD P. DAVIS, A.M., M.D.,

PROFESSOR OF OBSTETRICS AND DISEASES OF INFANCY IN THE PHILADELPHIA POLYCLINIC
CLINICAL PROFESSOR OF OBSTETRICS IN THE JEFFERSON MEDICAL COLLEGE ; CLINICAL
PROFESSOR OP DISEASES OF CHILDREN IN THE WOMAN'S MEDICAL COLLEGE ;
VISITING OBSTETRICIAN TO THE PHILADELPHIA HOSPITAL, ETC.

The Removal of Old Ectopic Gestations.

Von Herff {Zeitschrift far Gehurtshulfe, Band xxxiv. Heft 1) concludes
from his study of these cases that in removing ectopic gestation-sacs which
are complicated by adhesions it is important whenever possible to ligate the
uterine and spermatic arteries. An attempt should then be made to shell
out the sac, beginning at the periphery of the placenta, using clamps and
ligatures to control bleeding. The aperture left should be tamponed with
gauze. In rare cases the site of placental attachment must be compressed by
a running stitch ; compression of the aorta must be employed or removal of
the uterus, with application of clamps to the bleeding vessels. Gauze pack-
ing is especially valuable where oozing exists or secondary bleeding is found.

A Study of Fcetal Excretion.

In the Zeifschrift far GeburUhhlfe, Band xxxiv. Heft 1, Rensing reports
experiments on forty-two pregnant and parturient patients to determine the
excretion by the foetus of material introduced into the mother's body. He
gave methyl-blue in capsules to the mothers, in amounts of fifteen grains
daily. The drug was given until two months before labor. From half to
one hour after giving this to the mother traces could be detected in the urine.
When a mother was given methyl-blue half an hour before labor the urine
of the foetus showed its presence. This substance does not enter the mother's
milk, as do potassium iodide and salicylates. About eight days seemed to be
required to remove the methyl-blue wholly from the foetal body, although it
disappeared much more rapidly from the mother. It was found that the
excretion of methyl-blue increased steadily for the first three days after birth.
This corresponds with what has been observed regarding the discharge of
uric acid in the newborn.

Pregnancy and Labor Complicated by Cancer of the Cervix.

In the Zeifschrift fiir Gebartshiilfe, Band xxxiv. Heft 1, Beckmann reports
two cases of pregnancy and labor complicated by cancer of the cervix.

The first was a multipara, aged forty-seven years, v/ho was seen in the first
months of her seventh pregnancy. A sero-sanguinolent discharge was pres-
ent. Malignant disease had destroyed the posterior lip of the cervix and
invaded the vagina on the right. The uterus was removed by the vagina, the
patient making a good recovery. Six weeks after the operation she was in a
good condition.

OBSTETRICS

237

In connection with this case Beckmann calls attention to the fact that
cancer does not predispose to sterility nor does it tend to interrupt preg-
nancy ; on the contrary, gestation is often prolonged. Abundant evidence
shows the utter worthlessness of delay and palliative treatment; vaginal
extirpation of the affected uterus is the treatment indicated.

His second case was admitted to the hospital in the ninth month of her
sixth pregnancy ; the cervix was infiltrated with carcinoma on the left side.
Spontaneous labor occurred, with a living child. The puerperal period was
normal. Fifteen days after labor the uterus was removed through the vagina,
the carcinomatous tissue having been first thoroughly seared. The patient
made a good recovery.

In studying the literature of the subject Beckmann concludes that in cases
in which the entire uterus cannot be safely removed that delivery by abdom-
inal section offers a far better chance for the mother and child than does
spontaneous birth.

Treatment of Face-presentation by Manipulation.

In the Archiv far Gynakologie, Band li. Heft 2, Jungmann reports three
cases of face-presentation in which he succeeded in changing the presenta-
tion to an occipital one by a combined manipulation ascribed in various
portions to Baudelocque, Schatz, and Thorn.

The patient is anaesthetized by chloroform and the shoulder of the child
raised and its back moved obliquely in the direction best fitted to promote
descent of the occiput by the external hand. The internal hand meanwhile
raises the chin and brings down the occiput, maintaining it in the desired
position until the patient wakes from the anaesthetic and pains begin. When
the occiput has engaged and flexion is secured the case is allowed to proceed
spontaneously.

Jungmann concludes that in cases seen before active labor has begun that
Schatz's manipulation of raising the foetal body by external manipulation
and procuring flexion instead of extension should be employed. When dila-
tation has begun and the chin is posterior, combined manipulation should be
employed when two or three fingers can be inserted through the os and
cervix ; when the pelvis is normal or very little contracted ; and when the
foetus is movable. Anaesthesia is usually required for this manipulation. Any
condition of danger demanding prompt and rapid delivery is a contraindica-
tion for the use of this method.

Albuminuria and Eclampsia.

Saft {Archiv fur Gyndkologie, Band li. Heft 2) reviews current knowledge
on this subject and adds his own studies. He declares, with those who have
most thoroughly studied the subject, that while the relation between albu-
minuria and eclampsia is intimate, that it is not invariably causal ; the direc-
tion of our study should lie in searching to identify the causal agent present.

Saft found albuminuria in 54.1 per cent, of pregnant women, usually in the
second half of pregnancy, most often near the close. The greatest amount
of albumin is often found several weeks before the end of pregnancy, occur-
ring more often in primigravidse than in multigravidae, and so continuing

238

PROGRESS OF MEDICAL SCIENCE.

during labor, when the quantity of albumin is much greater. While albumin
usually disappears from the urine during the first few days aftei labor, it
persists longer in primigravidae than in multigravidse ; kidney-lesions are
more serious and persistent in primigravidse than multigravidae.

Blood-corpuscles without albumin in the urine of pregnant women come
from the bladder, casts accompanying albumin. Casts and albumin do not
stand in close relation to each other, nor do the amounts of albumin and casts
maintain a corresponding ratio. Twin pregnancy, hydramnios, and con-
tracted pelvis favor albuminuria in pregnancy, especially in primigravidse.
In multigravidse these complications cause albuminuria during labor. Abor-
tion often occurs in albuminuric patients.

Saft believes the pathology of eclampsia to be as follows : The organism
becomes partially intoxicated by products of metabolism. During labor
great muscular activity increases this condition. The elimination of these
toxins produces a partial degeneration of the kidneys, from which healthy
women speedily recover. Corresponding changes occur in other organs of
elimination. When heart-lesions are present or acute nephritis occurs the
prognosis is most grave. Patients in good condition previous to pregnancy
usually recover completely.

Ten Operations for Ectopic Gestation.

Harrison Cripps {British Medical Journal, 1896, No. 1839) reports ten
cases of ectopic gestation, in all but one of which a successful result followed
operation. In one case, upon opening the abdomen and removing a large
quantity of blood, it was found that the Fallopian tube had ruptured, and that
a blood-clot was protruding through an aperture of considerable size. The
ovary and tube were removed, the abdominal cavity flushed, but not drained.

The second case was that of a woman who had borne two children, and
who had almost constant pain, with vaginal hemorrhage, for some time. The
contents of the abdomen and pelvis were found matted together. A cavity was
found containing a blood-clot as large as the foetal head, while a second cavity
contained a smaller quantity of blood. The ovaries and tubes were removed,
and the abdomen flushed and drained for a few days with a successful result.

In another case, in which pain and hemorrhage had gone on for some time
with previous sterility, a cyst was found upon the opening of the abdomen.
The cyst was removed, and the cavity flushed and drained.

In another interesting case a ruptured cyst was discovered in Douglas's
cul-de-sac, and the effort was made to separate it and draw it up ; this caused
hemorrhage, however, so severe that the sac was ligated and removed. Sev-
eral other cases of the series presented very similar conditions.

His tenth case was in a multigravida, in whom a tumor was found behind
the uterus, apparently between the folds of the broad ligament ; this pre-
sented the appearance of the gravid uterus, and was found to contain a living
foetus. The placenta was firmly adherent to the wall of the sac. An effort
was made to stitch the sac to the abdominal incision, but it was situated so
deeply that the result was not satisfactory. The abdomen was closed without
drainage. Death ensued three days later. On post-mortem examination it
was found that the placenta, which had been left, was soft and friable, and
beginning to decompose.

GYNECOLOGY.

239

GYNBOOLOGY.

UNDER THE CHARGE OF

HENRY C. COE, M.D., M.R.C.S.,

OP NEW YORK.

Shortening of the Sacro-uterine Ligaments for Retroversion.

GoTTSCHALK {Ceniralhlatt f'tir Gyndkologie, 1896, No. 16) believes that since
relaxation of the sacro-uterine ligaments and loss of normal fixation of the
cervix are the principal causes of movable retroflexion (as pointed out by
Schultz), especially after labor, shortening of the ligaments is the most
rational way of effecting a cure. His technique is as follows : The uterus
is first replaced, if movable. A median vertical section is then made
through the posterior vaginal fornix, which begins half an inch behind the
portio and extends downward to the extent of two inches. Douglas's pouch
is opened ; the edges of the vaginal and peritoneal incisions are united with
temporary sutures, which always serve to keep the wound open. If the
uterus is fixed, the adhesions are separated and the uterus is replaced. The
operator then fixes the left sacro-uterine ligament with the tip of the left
forefinger at a point as far as possible from its cervical insertion (one to two
inches), while an assistant strongly everts the edges of the wound by making
traction outward on the temporary ligatures. Guarded by the finger, and
under direct control of the eye, an aneurism -needle carrying a stout silk
suture is passed from above downward through the middle of the ligament,
and the suture is tied. The other end of the suture is threaded on a sharp
needle, which is entered in the posterior wall of the cervix just below the
level of the os internum, and being carried deeply emerges in the portio at
a point near the edge of the vaginal wound. Both ends are tied so that the
knot lies in the vaginal fornix. The same procedure is adopted on the
opposite side, a small strip of gauze is introduced into Douglas's pouch, and
the wound is allowed to close by granulation. If the uterus has in the mean-
time fallen backward, it is again replaced, and is kept in position by a firm
vaginal tampon. The patient is kept on the side or stomach, but is allowed
to leave her bed on the seventh day, when the tampons are removed and
replaced by another in the anterior fornix, which is left in situ for three
days. The sutures are not removed. The writer has performed two opera-
tions by this method, with perfect results, the uterus remaining in a normal
position, but with free mobility. There were no unpleasant symptoms.
Both patients had been treated with pessaries for several years.

Hysterectomy with the Cautery.

Klmmell {Centralhlatt fiir Gyndkologie, 1896, No. 16) refers to the fact
that the statistics of total extirpation for cancer during the last sixteen year
show that only 7 per cent, of the patients operated upon are radically cured.
He believes that if the glands are already involved the radical operation is

240

PROGRESS OF MEDICAL SCIENCE.

useless, and that it is impossible to avoid metastases. Eecurrences are due
to the fact that either all the diseased tissue has not been removed, or the
surrounded surface was infected during the operation.

That such infection does occur has been amply proved in numerous re-
ported cases as well as by experiments. Different plans have been suggested
for avoiding this. Winter advises against preliminary curettage of the can-
cerous tissue, and sutures the cervix in cases of carcinoma of the corporeal
endometrium. Hahn suggests constant irrigation with sublimate solutions
throughout the operation. The writer believes that infection can be pre-
vented by the use of the galvano-caustic knife, which he uses to separate the
broad ligaments and open the anterior and posterior culs-de-sac. He also
uses clamps.

Anterior Colporrhaphy in Prolapsus Uteri.

NiEBERGALL {Inaugural Dissertation, abstract in Centralblatt fur Gyndkolo-
gie, 1896, No. 16) reports the results of operations for prolapsus at the Basle
clinic during seven years. Fifty cases were treated by simple anterior col-
porrhaphy and sixty by double anterior colporrhaphy, the cervix being pre-
viously amputated in nearly every instance. Seventy patients were kept
under subsequent observation. Twenty-nine out of thirty-four in the latter
class were cured ; in the former twenty-eight out of thirty-six were cured,
the total percentage of cures being 81.5 per cent. Posterior colporrhaphy
was always performed two weeks after the first operation, silver-wire sutures
being used. Considerable stress is laid upon the importance of allowing an
interval of time to elapse between the two operations.

Vaginal Fixation.

JOHANNOVSKY ( Wiener klin. Wochenschrift, 1896, Nos. 6-10) has performed
thirty operations, no patient having become pregnant. One case resulted
fatally from sepsis, but in all the others the uterus was subsequently found
to be in normal position, though the symptoms were not always relieved.
The operation is not applicable to cases in which the retroflexed uterus is
firmly fixed by adhesions to the posterior and lateral walls of the pelvis. In
operations on the adnexa he recommends dividing perimetric adhesions with
the Paquelin cautery, as suggested by Diihrssen and Kiistner. Omental and
intestinal adhesions do not constitute a contraindication.

The disadvantages of the vaginal operation are the frequent technical
difficulty and the great care necessary to secure absolute asepsis ; so that it
cannot be regarded as a substitute for abdominal section.

On account of the serious results which have followed pregnancy and labor
after vagino-fixation of the uterus, the writer advises against its performance
in the case of young women.

Diagnostic Curettage.

Gessner (Ibid.) believes that the value of curettage for diagnostic pur-
poses is not yet sufiiciently appreciated in spite of thie advance in micro-
scopical technique. Even in Germany palpation of the uterine cavity is

GYNECOLOGY.

241

still regarded as the best method of examining the uterine cavity in cases of
suspected malignant disease. Preliminary dilatation of the cervix sufficient
to admit the examining finger, whether rapid or gradual, is not free from
danger ; in fact, fatal cases have been reported. On the other hand, curet-
tage is safer, even with the possible attendant risks of perforation and infec-
tion. Narcosis is unnecessary, and the diagnosis is made at a single sitting.

Under some circumstances (in the case of a narrow, senile vagina, a long,
rigid cervix, or a uterus enlarged by fibroid) intrauterine palpation may be
impossible. The finger cannot always distinguish malignant from non-
malignant growths. Here the removal of fragments with the curette fur-
nishes positive information.

During the past five years the diagnosis of malignant disease of the cor-
poreal endometrium has been made at the Berlin clinic in forty-one cases,
and the uterus extirpated, direct palpation having been entirely discarded.

Diagnostic curettage is best performed under ether, the cervix being pre-
viously dilated. The entire surface of the uterine cavity should be scraped,
the fragments removed being hardened in alcohol and examined micro-
scopically.

Treatment of Pruritus Vulv^.

In a recent discussion on this subject before the Berlin Obstetrical Society
{Centralblatt fur Gynakologie, 1896, No. 18) Ruge stated that pruritus was
nearly always due to some local cause, and that he seldom failed to cure it
by thorough cleaning of the external and internal genitals.

Martin agreed with this statement, but also recommended shaving the
external genitals and applying flower of sulphur. Flaischler uses solutions
of sulphur varying in strength from 20 to 50 per cent. Glockner employs
1 per cent, solution of sulphate of zinc and 10 per cent, aristol ointment.
Gottschalk recommends 10 per cent, thymol ointment, with or without
cocaine. Olshausen thought that diabetes was the cause of obstinate pru-
ritus in the majority of the cases, though in some it was a neurosis which
resisted all treatment. Bodenstein uses a strong solution of nitrate of silver
(40 per cent.), though he had cured the affection with a 1 per cent, solution.

Cancer and Tuberculosis of the Uterus.

Nassaner {Centralblatt fur Gynakologie, 1896, No. 18) reports a rare case
of epithelioma of the cervix uteri, in which an examination of the extirpated
organ showed several tuberculous nodules, the size of cherries, situated in
the corporeal endometrium, the lowest being an inch above the upper limit
of the malignant disease. These nodules were supposed to be cancerous
until they were examined microscopically, when they were found to contain
numerous giant cells and tubercle bacilli. The apparently healthy endome-
trium was also the seat of beginning tuberculous disease.

Since the cancerous affection was upward of four months' standing and the
tubercles were evidently of recent origin, the writer inferred that the latter
developed subsequently and were the primary seat of infection. There was
no evidence of tuberculosis elsewhere in the body.

242

PROaRESS OF MEDICAL SCIENCE.

Pu^DIATRIOS.

UNDER THE CHARGE OF

LOUIS STAER, M.D.,

of philadelphia ;

Assisted by
Thompson S. Westcott, M.D.,

OF PHILADELPHIA.

The Increase in Weight of Premature Infants.

PoTEL devotes his thesis (Paris, 1895) to this interesting snbject, found-
ing it upon a study of 173 infants born at periods from six and one-half to
eight months of intrauterine life, who survived the dangerous period and
were discharged from the maternity after a sojourn of an average of eighty-
two days for the six and one-half months children and of twenty-eight days
for those of eight months. Of 56 infants born at six and one-half months,
11 survived— a survival of 19,6 per cent., or a mortality of 80.4 per cent.
The average increase in weight per day for one of these children was 9.4 gm.
Of 131 infants born at seven months the survival was 41.9 per cent.; the
mean daily increase of weight was 11.5 gm. Of 53 infants born at seven and
one-half months the survival was 69 per cent, and the increase of weight 13.8
gm. Of 110 infants born at eight months 64.5 per cent, survived and the
daily increase averaged 22.8 gm. The average weights at birth were as fol-
lows : At six and one-half months, 1408 gm. ; at seven months, 1700 gm. ; at
seven and one-half months, 1900 gm. ; and at eight months, 2150 gm. The
loss of weight of the first three days in the premature is not more marked
than in infants at term, but its consequences are more grave, since the re-
covery of the initial weight takes longer ; it is also during this period of loss
or stationary weight that the mortality is highest, those infants exempt
from hereditary taint being the most resistant.

The increase in weight, as shown by the figures quoted, is longer deferred
and slower as the infant is more premature. Thus, with an infant of six
and one-half months the increase often does not commence till after the
second week.

The proportion of infants saved is a tribute to the modern methods of
dealing with these unfortunate cases.

A Case of Tuberculosis of the Intestine by Ingestion.

Marfan and Apert {Revue Mensuelle des Alaladies de VEafance, June, 1896,
p. 273) record an interesting example of a form of tuberculous disease which
is rare under the age of two years. The child, aged sixteen months, had
been nourished only at the breast, with the exception of certain days, when
the mother being at work, cow's milk had been given. The family history
showed healed tuberculous cervical adenitis in the mother ; one of her nine
other children had died of tuberculous peritonitis and another had coxalgia.

PEDIATRICS.

243

At the age of nine months the patient had come under treatment for a sup-
purative adenitis of the neck, and at this time it was noticed that there were
ulcerations upon the gums, covered by pultaceous and fetid exudate, which
persisted despite treatment instituted at the time. At the age of thirteen
months a diarrhoea began and persisted without amelioration till death, a few
days after admission to the hospital. The autopsy revealed an enormous
mass of tuberculous mesenteric glands, with tuberculous ulcerations of the
colon, ileum, jejunum, and duodenum ; liver, spleen, heart, and kidneys
normal ; a few small, recent grayish granulations in the lungs, with two
small foci of broncho-pneumonia in the right base.

According to the authors, the first focus of disease was the mouth and the
ganglia of the neck ; next the intestine. The slight pulmonary lesions were
of recent origin. The source of the infection may have beeu the milk of the
mother or of the cow, or through the medium of soiled objects put in the
mouth. Inoculation-experiments to clear up this point were not possible at
the time.

Tuberculosis of the intestine is exceptional in the first two years of life, as
shown by the statistics of Wiederhofer, who, in 101 cases of intestinal tuber-
culosis in childhood, found only six under two years of age and a percentage
of eight for all cases of tuberculosis under two years, as opposed to 28 per
cent, for cases in children from two to fifteen years of age. Three sources of
origin for intestinal tuberculosis are possible : 1. In acute miliary tubercu-
losis small, gray, semi-transpai ent granulations may be found upon the intes-
tinal mucous membrane. These are haematogenous in origin. 2. In young
children with chronic pulmonary tuberculosis with cavities the intestine may
be infected from the swallowed expectoration ; the lesion then assumes the
common ulcerous form seen in adult consumptives ; it is extremely rare
under two yeais. 3. After the ingestion of tuberculous food, especially the
milk of a tuberculous cow. In these cases there may be no lesion of the
intestinal mucous membrane, the bacillus having travel sed it to find a suit-
able soil for growth in the mesenteric glands. When lesion of the mucous
membrane occurs it ordinarily assumes a special form — discrete without
ulceration. This is characterized by scattered submucous nodules, the size
of a pea, filled with gray or cheesy, more or less softened material, and lim-
ited by a delicate fibrous covering, these nodules corresponding in position
with the affected mesenteric gland.

Primary Sarcoma of the Vagin^a in Children.

D'Arcy Power (St. Bartholomew's Hospital Eepoi^ts, 1896, vol. xxxi.) records
a case under this title occurring in a girl of two years and four months, and
quotes abstracts of twenty-four other cases collected in a rather hasty exam-
ination of the literature. From a consideration of these cases he concludes
that primary sarcoma of the vagina is only a specialized form of malignant
disease which may affect any or all of those connective tissues which are
involved in the complicated developmental processes associated with the
formation of the cloaca. The sarcoma grows in the connective tissue of the
pelvic organs, and extends into the bladder, the urethra, the uterus, or the
vagina. It is either well circumscribed, as in the case described^ or is diffuse,

244

PROGRESS OF MEDICAL SCIENCE.

as in a case reported by Ahlfeld {Archiv f. GynakoL, Bd. xvi. p. 135), but
whether circumscribed or diffuse, whether affecting the vagina alone or in-
filtrating all the neighboring organs, this form of sarcoma shows an almost
constant tendency to become polypoid and multiple.

As it occurs in children, primary sarcoma does not, in the majority of cases,
run a very rapid course. It does not ulcerate very readily. It does not usu-
ally affect the lymphatic glands. It does not disseminate, but its prognosis
is very grave. It recurs quickly after removal, and it kills by interfering
with the action of the pelvic organs, by retention of urine more often than
by obstruction of the bowels. The diagnosis is easy, but the polypi are often
looked upon as innocent growths, and their true nature remains unrecognized
until the presence of a tumor in the pelvis shows that it is too late for sur-
gical interference. Multiple polypi of the rectum and of the genito-urinary
tract in young people, however, are so rare, and, when they do occur, are so
often associated with malignant disease, that their presence should always
lead to a suspicion of such a condition. The complete cure which has been
effected in one or two cases of primary sarcoma of the vagina in children
shows that the early and complete removal of the growth may be effectual
in this as in other forms of malignant disease.

Bacteriology of the Vagina of the Newborn.

Vahle {Zeitschrift f.Geburtsh.u. Gyndkol., vol. xxxii. No. 3) has examined
cultures from the vaginas of 75 newborn girl-babies shortly after birth. In
the first twelve hours the vaginal secretions were always sterile. From this
time to the third day the results showed a decreasing number in which sterile
secretions could be found, until finally at the end of three days micro-organ-
isms were found in all cases. Pathogenic bacteria were quite often encoun-
tered, the streptococcus being found in 14.6 per cent, of the cases.

Bacteriology of the Anginas of Scarlatina.

Lemoine {Societh 3Iedicale des Hopitaux, December 20, 1895) has analyzed
100 cases of scarlatinal angina observed at the beginning of the infection.
Cultures were made from the deep tissue of the tonsils after searing the
surface by the actual cautery. In all the cases he found the streptococcus,
ninety-three times in pure culture, seven times associated, fifteen times with
the bacillus of Loeffler, twice with the colon-bacillus. Clinically it is inter-
esting to note that these two associations i^roduce the same symptomatology.
The author thinks that there is here only one variety of streptococcus, but
that the virulence of this microbe varies with its soil, whether found in the
mucus, false membrane, or tissue of the tonsil.

A Variety of Streptococcus Refractory to Marmorek's Serum.

Mery {Soc. de Biologie, April 18, 1896) states that he has isolated from a
case of scarlatina a streptococcus without any morphological or cultural
peculiarity to distinguish it from other streptococci, but showing the remark-
able property of causing purulent arthritis and death in injected rabbits
despite the previous or contemporaneous inoculation with Marmorek's serum.

PATHOLOGY AND BACTERIOLOGY.

245

PATHOLOGY AND BACTERIOLOGY.

UNDER THE CHAEGE OF

JOHN SLADE ELY, M.D.,

PROFESSOR OP PATHOLOGY IN THE WOMAN'S MEDICAL COLLEGE OP THE NEW YORK
INFIRMARY ; ASSISTANT IN PATHOLOGY IN THE COLLEGE OP PHYSICIANS
AND SURGEONS; PATHOLOGIST TO BELLEVUE HOSPITAL.

Identification of the Spirillum of Asiatic Cholera.

In the course of an exhaustive study of the cholera vibrio, more particu-
larly as regards the artificial induction of immunity to its inoculation in
animals, E. PfeifFer discovered the interesting fact that when mixed with the
serum of immunized guinea-pigs, and inoculated into the peritoneal cavity
of susceptible animals, virulent cultures of the spirilla in large dose remained
innocuous, and that on subsequent examination of the peritoneal contents
the bacteria could be seen to have undergone disintegration to a greater or
less extent, dependent upon the relative immunizing strength of the serum
of the immunized animal. This power of destroying the cholera spirilla
is believed by PfeifFer to depend upon the presence in the serum of certain
antagonistic substances {" Antikorper ") which have a distinct inhibiting in-
fluence upon the vital processes of the bacteria. As a result of this discovery
Pfefffer {Zeitschrift f. Hygiene und Infectionskrankheiten, 1895, xix. p. 75)
has suggested a test of the identity of the cholera spirillum, for his investi-
gations show that no other species of bacteria is affected in the same way
by mixing with the serum. It will be remembered that a similar test was
alluded to in connection with the identification of the typhoid bacillus {Cf.
American Journal of the Medical Sciences, May, 1896, p. 624).

The method suggested by PfeifFer is as follows : A loopful of the culture
to be tested is mixed with a cubic centimetre of bouillon, to which ten times
the amount of serum necessary to protect a guinea-pig of 200 grammes weight
from a similar dose of virulent cholera spirilla has been added, and the
whole is at once inoculated into the peritoneal cavity of a young guinea-pig
of from 200 to 300 grammes weight. In the inoculation care should be taken
to avoid injury of the intestines, and the cultures employed should be recent
and should have been shown to consist of well-formed and actively moving
germs.

As control, a similar quantity of the same culture is mixed with a cubic
centimetre of bouillon as before, an amount of ordinary guinea-pig serum
equal to the amount of immunizing serum made use of in the original test is
added, and the whole is inoculated into another guinea-pig.

In twenty minutes some of the peritoneal contents in each case is with-
drawn by means of glass pipettes, and is examined. If the bacteria are the
specific germs of cholera they present a very different appearance in the
two cases. Those obtained from the control-animal are well formed, active,
and seem to have multiplied. Those which were exposed to the action of
the immunizing serum are small, misshapen, immobile for the most part,
apparently dead. PfeifFer maintains that unless a distinct difference is

246

PROGRESS OF MEDICAL SCIENCE.

observable between the bacteria in the two experiments the micro-organism
under examination must be regarded as probably not the cholera vibrio, since
the change described is very constant in the case of the cholera germ, and
has not been observed to occur with any other under similar conditions.
PfeilFer accordingly presents this as a specific differential test for the cholera
bacillus.

Since the imblication of the above test a simpler modification of it, not
requiring the inoculation of animals, has been suggested by Pfeiffee, and
Vagedes {Centralhlatt /. Bakteriologie, etc., 1896, xix. No. 11, 385), and has
been found to be of great use in distinguishing the pathogenic species from
other closely allied forms.

In the course of experiments directed to the explanation of the disintegra-
tion of the bacteria which occurs when they are mixed with immunizing
serum and inoculated, it was discovered by Pfeiffer that the bacilli did not
undergo disintegration when they were exposed to the action of the serum
in a test-tube only. In this case the activity of the germs was inhibited,
and they collected at the bottom of the test-tube in flocculi, but their shape
remained unaltered. It was further noted that after a variable time in the
incubator the flocculi began to break up, microscopic examination showing
that the germs were recovering their mobility and were gradually returning
to their normal condition. From this Pfeiffer inferred that the effect of the
immunizing serum is to inhibit temporarily the activity of the germs, but
that without the body-juices it is incapable of destroying them.

The test evolved from these observations depends upon the fact that no
other germ than the cholera-bacillus is similarly inhibited in its activity by
the specific immunizing serum. As suggested by Pfeiffer and Vagedes, it is
carried out in the " hanging drop." The serum employed by them had an
immunizing power such that one-fifteenth milligramme was capable of pro-
tecting a 200-gramme guinea-pig against a dose of 2 milligrammes of viru-
lent cholera-culture. This serum was diluted with fifty times its quantity
of bouillon, and hanging drops of it were inoculated with the culture to be
tested. The microscope showed the gradual inhibition of the activity of
the cholera-bacilli, resulting in the complete inactivity of all present after
twenty minutes. The cultures were then placed in the incubator and ex-
amined from time to time. In the course of twenty-four hours the activity
had returned, and the germs had undergone considerable multiplication.

The constancy of this test may be inferred from the fact that Pfeiffer and
Vagedes tested seventy different cultures of the cholera-bacillus and twenty
of various other closely allied species, and found it reliable in all. The
cholera-germs were always inhibited in their activity ; the other species,
never.

Pfeiffer announces that he is prepared to furnish serum of a sufficient im-
munizing strength for this test to any who desire to confirm the reliability
of the test or to determine the nature of any suspected cultures.

The Cause of Death in Acute Lobar Pneumonia.

Some recent observations of Bollinger {Miinchener med. Wbchenschrift,
1895, No. 32) made at autopsies in cases of pneumonia are of interest as

PATHOLOGY AND BACTERIOLOGY.

247

suggesting a new factor in bringing about a lethal outcome of the disease. In
addition to the causes of death usually recognized as operative in lobar pneu-
monia— intensity of infection, insufficiency of the lungs, complications, such
as meningitis, etc., and heart-failure — Bollinger draws attention to oligaemia
as a common and often very pronounced feature of the disease, and argues
that the collapse often observed in it is due, in great part at least, to the
diminished quantity of blood and consequent poor nutrition of the vital
organs.

This belief is based upon the anaemic condition of all the organs, as ob-
served at autopsy, more particularly of the skin, brain, liver, kidneys, and
spleen, and the paucity of blood is attributed to the great drain upon it in-
cident to the accumulation of the pulmonary exudate. This Bollinger finds
to be often enormous. The weight of 100 pneumonic lungs showed that in
fifty the exudate had accumulated in an amount greater than two pounds in
weight ; in forty there was between one and two pounds of exudate, and in
only ten was there less than a pound. The diminution in the quantity of
blood in the body seemed to bear a direct relation to the quantity of exudate.

Of course, without a defective generation of blood, the withdrawal of it in
the exudate would quickly be compensated by the formation of a new supply
by the blood-forming organs, and Bollinger is accordingly forced to suppose
a diminished vitality of these organs in the cases in which oligaemia is marked.
In this connection attention is drawn to the fact that leucocytosis in pneu-
monia has been shown to be a distinctly favorable prognostic indication, and
Bollinger would interpret this leucocytosis as an evidence of blood-formation.

The critical collapse and heart failure so often met with in pneumonia are
explained as the direct results of the oligaemia, in consequence of which the
already greatly weakened heart-muscle gives out because of an insufficient
blood- and oxygen-supply.

Alimentary Tuberculosis.

ZiNN {Miinchener medicimsche Wochemchrift, 1895, No. 37, 856) gives a de-
tailed account of an interesting case of acute general miliary tuberculosis in
a man thirty-eight years of age, in which the evidence points very strongly to
an alimentary source of infection.

The lungs showed no old lesions of the disease in any part. At the ileo-
coelic junction there was a large cluster of cheesy mesenteric glands containing
myriads of tubercle-bacilli, while in the intestine near the ileo-csecal valve an
old healed scar was believed to mark the site of the original ulcer through
which the entrance of the infectious material had occurred. Above and
below this point, in the small and large intestine, there were recent tuber-
culous ulcerations. Tubercles were also distributed along the course of the
thoracic duct, whose lumen was in places completely filled by cheesy masses.

Zinn believes that the bacilli were conveyed in the lymph from the original
intestinal ulcer to the neighboring mesenteric lymph-glands, the disintegra-
tion of which led to their further transport to the thoracic duct, through
which they found entrance to the general circulation and gave rise to the
general infection which caused the patient's death.

The exact source of the original infection was uncertain, but milk is men-
tioned as a possible carrier of the bacilli.

248

PROGRESS OF MEDICAL SCIENCE.

HYGIENE AND PUBLIC HEALTH.

UNDER THE CHARGE OF

EDWARD F. WILLOUGHBY, M.D.,

OF LONDON ;
AND

CHARLES HARRINGTON, M.D.,

INSTRUCTOR IN MATERIA MEDICA AND HYGIENE, HARVARD MEDICAL SCHOOL.

Toxicity of Alcoholic Beverages.

Dr. a. Jeffroy and Dr. R. Serveaux {Archives de Medecine Experimen-
tale et d'Anatomie Pathologlque, 1895, p. 569) have devised a new method for
determining the toxic equivalents of the various alcohols and other mat-
ters in alcoholic drinks. The liquids were injected into the circulation
through the vein of the ear of rabbits, and in order to prevent clotting of
the blood, which with other experimenters has always been a drawback,
a watery extract of leeches was injected at the same time. This was ob-
tained by macerating for four to six hours in dilute salt solution the anterior
ends of leeches cut up into small bits. As a result of their experiments we
have a table of equivalents which in some respects agrees with and in
others disagrees with those of Dujardin-Beaumetz and Audige. The toxic
equivalents — i. e., the amount in grammes necessary per kilogram to kill a
rabbit — determined by their process were as follows :

Dujardin-Beaumetz. Jeffroy-Serveaux.
Methyl alcohol 7.00 25.25

Ethyl " 7.75 11.70

Propyl " 3.75 3.40

Butyl " 1.85 1.45

Amyl " 1.50 0.63

Aldehyd ........ 1.00 1.14

Furfurol 0.24

Acetone 5.00 5.27

In other words, the poisonous properties increase with the boiling-point and
molecular weight. The toxic equivalent of new (genuine) cognac was found
to be 11.41 ; that of apple brandy 10.57. Absinthe appeared to be extremely
toxic, about like furfurol and amyl alcohol.

Dr. G. Daremberg, experimenting in the same line [Archives de Medecine
Experimentale, etc., 1895, p. 719), found that, in general, reckoning from equal
alcoholic content, the alcoholics are injurious in direct proportion as they are
natural and least adulterated. If rectified spirits have been added, they
become relatively less poisonous, since the particularly injurious matters, the
higher alcohols, furfurol, aldehyd, etc., are especially present in natural
wines and in spirits obtained by distillation of such wines. Thus cognac, the
pure article, is more toxic than the artificial substitute made with pure alco-
hol. For instance, an old genuine cognac contains about 2 per cent, of
impurities, chiefly fatty acids, as acetic, higher alcohols, as amyl alcohol,

HYGIENE AND PUBLIC HEALTH.

249

aldehyds as furfurol or pyromucic aldehyd ; and all of these are much more
poisonous than the ordinary ethyl alcohol. Apple brandy is more toxic than
cognac, anisette and angostura bitters very toxic, and absinthe the " plus
terrible des aperitifs." His conclusions are that of all alcoholic drinks the
most dangerous are the liqueurs such as absinthe and anisette, the least harm-
ful those made with pure alcohol and non-toxic flavors and without essential
oils ; that wines are proportionately more toxic than brandy, and white wines
less than red.

Dr. J. KouBiNOWiTCH {Gazette des Hopitaux, 1895, p. 237), speaking of
the greater toxicity of alcohols with increase in the molecular weight, calls
attention to the fact that the beverages distilled from cider, perry, grains,
potatoes, and molasses are much more injurious than those derived from wine.
In dealing with the question of restricting the use of alcohol by legislation,
Dr. Eoubinowitch, after considering the various methods, such as increasing
the tax on alcohol, restricting the number of licenses, the Norwegian system,
etc., concludes that the system of total prohibition is the best, and falls into
the curious error of citing the results of the prohibitory laws of Maine as a
most convincing argument, when, as is well known, Maine is practically a
" free-rum " State. Ce fut pour I'etat du Maine une revolution des plus
heureuses, puisque en pen d'annees cet etat, le plus pauvre de TUnion Ameri-
cainedevint I'un des plus prosperes."

INFECTIOUSNESS OF DuST IN CONSUMPTIVE COMMUNITIES.

Dr Irvin H. Hance {Diebetic and Hygienic Gazette, February, 1896, quot-
ing from Medical Record) has conducted some instructive experiments to de-
termine the danger of infection in a large community of consumptives, where
all sanitary measures for the care and disinfection of sputa are enforced.
These experiments were performed at the Adirondack Cottage Sanitarium,
and a complete examination was made of the group of buildings, some of
which had been occupied by consumptives for eleven years. Dust was taken
from the places most likely to be infected. One square yard of dust from
each of four buildings (the main building containing parlor, sitting-room,
and library, the infirmary where all the acutely sick are sent, the oldest cot-
tage and the newest) was collected and inoculated into ten guinea-pigs,
and half a square yard from each of thirteen other cottages was collected and
inoculated into others. The animals were kept from one to three months and
then killed. In all, eighty-one were inoculated with from two to three cubic
centimetres of sterilized water with the dust in suspension. Four inoculated
with dust from the infirmary and main building died of other infectious dis-
eases on the third to sixth day. Five of the ten inoculated with dust from
the oldest cottage, which was always occupied by the sickest men, one of
whom had been complained of by his room-mate for spitting about the cot-
tage, were tuberculous. The dust from the other sixteen buildings occupied
by consumptives was found to be absolutely free from infectious material.
At this Sanitarium the methods taken to guard against infecting the cottages
and public rooms are to burn all cuspidors daily and the Japanese napkins
as soon after using as possible ; never to expectorate except into the large
sanitary cuspidors or into the small individual hand- cuspidors. Paper

250

PROGRESS OF MEDICAL SCIENCE.

napkins are used in hemorrhage cases and where patients are too feeble to get
up on their elbows to spit into the cuspidors, and these are burned after being
once used. The cottages are buiJt to insure thorough ventilation, the rooms
wainscoted and painted rather than papered, thus permitting thorough cleans-
ing, and they are furnished simply and with a minimum of tapestry. Not
one of the twenty to twenty-five attendants has ever developed tubercu-
losis.

In this connection, the following from Food and Sanitation, January 18,
1896, is pertinent : Forty years ago Mentone was a healthy village in France,
where lived peasantry happy on their farms, and their superb physical state
conditioned by the climate. It was discovered that the region was a most
healing climate for consumptives, and it became the Mecca for the unfortu-
nates of Europe so stricken. The inhabitants abandoned their farms to wait
upon the strangers. The strong, healthy women forsook their dairies and
became the washerwomen of the consumptives' clothes. No precautions were
taken ; the disease was not then understood as now, the theory of the tubercle-
bacillus not having been discovered. The place to-day is bacillus-ridden, a
pest-hole, death itself. The hitherto strong inhabitants are emaciated, a
coughing, bleeding people, filled with the germs of consumption. The soil
and the air are both contaminated with them. It is no longer a resort. The
same fate, it is believed, awaits many other similar health-resorts unless active
measures are taken to destroy all germs. This will be a most difficult task,
because consumptives themselves, as a rule, are not thoughtful of the danger
they spread or of the rights of others. They should bear in mind that if all
others had been careful they, too, might have escaped.

Notice to Contributors. — All communications intended for insertion in the Original
Department of this Journal are only received with the distinct understanding that they
are contributed exclusively to this Journal.

Contributions from abroad written in a foreign language, if on examination they
are found desirable for this Journal, will be translated at its expense.

Liberal compensation is made for articles used. A limited number of reprints in
pamphlet form, if desired, will be furnished to authors in lieu of compensation, provided
the request for them he written on the manuscript.

All communications should be addressed to

Dr. Edward P. Davis, 250 South 2 1st Street, Philadelphia, U. S. A.

Or

Dr. Hector Mackenzie, 59 Welbeck St., Cavendish Sq., London, W., Eng.

AWAYS Tim SAMB.
A STANDARD OF ANTISEPTIC WORTH.

LI5TERINL ^

LISTERINE is to make and maintain surgical cleanliness
in the antiseptic and prophylactic treatment and care of
all parts of the human body.

LISTERINE is of accurately determined and ukJorm anti-
septic power, and of positive originality.

LISTERINE is kept in stock by all worthy pharmacists
everywhere.

LISTERINE is taken as the standard of antiseptic pre^-
parations : The imitators all say, "It is something
like Listerine."

LAMBERT'S

Lithiated Hydrangea.

A valuable Renal Alterative and Anti-Lithic agent
of marked service in the treatment of Cystitis, Gout^
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generally.

DESCRIPTIVE LITERATURE

UPON APPLICATION.

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TONGALINE

ANTI-RHEUMATIC ANTI-NEURALGIG

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Tongaliae, 5 grs. Litbiam Salicylate^ 1 gr.

TONGALINE AND QUININE.

Tongaliae, 3V2 st%, Quinine Salpli, 2V2 grs.

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PONCA COMP.

UTERINE ALTERATIVE.

Formula.— Each Tablet Contains Ext. Ponca, 3 grs. ; Ext. Mitchella Repens, Igr. ; Caulophyllin, M gr. ; Helonin, >^ gr. ; Viburnin, H gr.

For the treatment of all functional, uterine and ovarian disorders.
Samples and Literatnre on Application. MELLIER DRUG COMPANY, ST. LOUIS.

Lyman's Practice of Medicine.

The Principles and Practice of Medicine. For the Use of Medical
Students and Practitioners. By Heney M. Lyman, M. D., Professor of the Principles
and Practice of Medicine, Push Medical College, Chicago. In one octavo volume of 925
pages, with 170 illustrations. Cloth, $4.75; leather, $5.75.

discussion. The reader is not confused by having pre

Professor Lyman's valued and extensive experience
here reduced in text-book form, is indeed very valu-
able both to college students and physicians. In this
work we have an excellent treatise on the practice of
medicine, written by one who is not only familiar with
his subject, but who has also learned through practical
experience in teaching what are the needs of the stu-
dent and how to present the facts to his mind in the
most readily assimilable form. Each subject is taken
up in order, treated clearly but briefly, and dismissed
when all has been said that need be said in order to
give the reader a clear-cut picture of the disease under

sented to him a variety of diflPerent methodi of treat-
ment, among which he is left to choose the one most
easy of execution, but the author describes the one
which Is, in his j udgment, the best. This is as it should
be. The student and even the practitioner should be
taught the most approved method of treatment. The
practical and busy physician, who wants to ascertain
in a short time all the necessary facts concerning the
pathology or treatment of any disease will find here a
safe and convenient guide.— JAe Charlotte Medical Jour'
nal.

Klein's Histology— Fourth Edition.

Elements of Histology. By E. Klein, M.D., F, R.S., Joint Lecturer on
General Anatomy and Physiology in the Medical School of St. Bartholomew's Hospital,
London. Fourth edition. In one 12mo. volume of 376 pages, with 194 illustrations. Limp
cloth, $1.75. Students^ Series of Manuals.

The large number of editions through which t>T.
Klein's little handbook of histology has run since its
first appearance in 1883 is ample evidence that it is
appreciated by the medical student and that it supplies
a definite want. The clear and concise manner in

which it is written, the absence of debatable matter,
of conflicting views, and the convenient size of the
book and its moderate price, will account for its un-
doubted success. — Medical Chronicle.

Schafer's Histology— New (4tli) Edition.

The Essentials of Histology. By Edwaed A. Schafee, M. D., F. R. S.,
Jodrell Pt"<fessor of Physiology in University College, London. New (4th) edition. In on©
octavo volume of 311 pages, with 288 illustrations. Cloth, $3.00.

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Spurious Aseptolin on the Market.

When Dr. Edson invented his
Aseptolin he gave the formula
to the public, as he had no ob-
jection to any one making it if
they would use pure materials
and follow his directions closely,
so as to present a preparation
that would be fully up to the
standard and give satisfaction,
but his Trade Mark must not be
used. He even went into the
details of the process very min-
utely to assist manufacturers in
manipulating such an important
and delicately adjusted com-
pound.

The large demand, however,
for this preparation, which has
been supplied by the Whitehall
Chemical Co.'s Laboratory (and
sold by them through the Equit-
able Chemical Company, 30
Reade St., New York City),
working under the Doctor's
supervision and which fur-
nished the samples for all the
preliminary tests, has induced
a number of parties to place im-
itations upon the market, many
of which produce very unsatis-
factory and dangerous results,
much to the injury of Dr. Ed-
reputation, which he can

son s

not permit to suffer from such a
cause — particularly as it is also
a great injury to the public.
Professors Berry, Endemann and
Mott, of this city, have analyzed
several of the spurious and im-
itation preparations, represented
to be the same as Dr. Cyrus
Edson 's and they all declare
them to be quite different in
composition. Recent experi-
ments have been made with sev-
eral counterfeits of Aseptolin-
Edson in which injections
proved fatal to guinea pigs, al-
though the same quantity of the
genuine produced no ill effects.

In consequence of the numer-
ous complaints that have been
made in regard to the bad ef-
fects from these dangerous im-
itations bearing his name, Dr.
Edson has decided to bring smt
at once against all retail drug-
gists and others who knowingly
sell the spurious article, so as to
protect the public'and his repu-
tation in the matter — as this
has been recently assailed by
parties who try to ,hold him
responsible for the bad effects
produced by the dangerous im-
itations of his Aseptolin.

Dr. Ransom, Physiciaa to the Clinton Prison, Dannemora, N. Y., has
written a paper giving his experience in treating 57 cases of Tubercu-
losis with Aseptolin, which will be sent on application to .... ^

THE EQUITABLE CHEMICAL CO., 30 Reade Street, New York.

Protonuclein

Is now recognized by those who have carefully studied its effects as the most important thera-
peutic agent known to the profession.

METCHNIKOFF, who discovered ** The secret of health will have been
the nature and function of the leu- discovered when science learns
cocyte, stated that in his opinion, how to increase the number of

white blood=corpuscIes at will."

Protonuclein produces leucocytosis as soon as taken into the organism, and in this way
becomes nature's tissue-builder and antitoxic principle. It is within the leucocyte that all proteid
matter is converted into living substance, there that it receives the impress of life, is changed
into a cellulized, vitaHzed pabulum ready for appropriation by the tissue-cells. Protonuclein
is obtained from the lymphoid structures of healthy animals by a mechanical process which
does not destroy its integrity.

Protonuclein is indicated in all forms of wasting diseases and asthenic conditions. It
rapidly restores the vitality of all the tissues by stimulating and supporting assimilative nu-
trition. It is also indicated in all diseases due to toxic germs and in the treatment of
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a prophylactic in exposure to contagion or infection.

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5

The Jefferson
Medical College

OF PHILADELPHIA.

PROFESSORS.

J. M. DA COSTA, M. D., LL. D.,

EGBERTS BARTHOLOW, M. D., LL. D.,
HENRY C. CHAPMAN, M. D.,
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THEOPHILUS PARVIN, M.D.,LL. D.,
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Four years of graded instruction required. The annual announcement will be sent on

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Dean.

Bellevue Hospital Medical College,

CITY OF NEW YORK

The Regular Session begins on Monday, September 21, 1896, and continues for twenty-six weeks. During
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^ Session 1896-97 oi>ena October 1, 1896. Four years' graded course. Lectures, Clinics, Re-
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6

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Smith's Operative Surgery— Revised Edition.

The Principles and Practice of Operative Surgery. By Stephen
Smith, M. D., Professor of Clinical Surgery in the University of the City of New York,
Second and thoroughly revised edition. In one very handsome octavo volume of 892 pages,
with 1005 illusti ations. Cloth, $4.00 ; leather, $5.00.

This excellent and very valuable book is one of the
most satisfactory works on modern operative surgery
yet published. The book is a compendium for the
modern surgeon. The present edition is much en-
larged, and the text has been thoroughly revised, so
as to give the most improved methods in aseptic sur-
gerv and the latest instruments known for operative
work. It can be truly said that, as a handbook for
the student, a companion for the surgeon, and even as

a book of reference for the physician not especially
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long hold a most conspicuous place, and seldom will
its readers, no matter how unusual the subject con-
sult its pages in vain. Its compact form, excellent print,
numerous illustrations, and especially its decidedly
practical character, all combine to commend it.— if<w-
ton Medical and Surgical Journal,

Berry on the Eye— Second Edition.

Diseases of the Eye. A Practical Treatise for Students of Ophthalmology.
By George A. Berry, M.B., F.R.C.S., Ed., Ophthalmic Surgeon, Edinburgh Royal Infirm-
ary. Second edition. In one octavo volume of 750 pages, and 197 illustrations, mostly
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The most notable feature of Berry's book is its
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of these that are entirely new, making in all eighty-
seven, the finest collection of such illustrations of

the normal and pathological appearances of the eye
to be found in any work published in the English
language. To the practitioner who has not the advan-
tage of a large special clinic in which to become
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illustrations are invaluable.— PAiiadei!pAia Polyclinic.

Field's Manual of Diseases of the Ear.

A Manual of Diseases of the Ear. By George P. Field, M.R.C.S.,
Aural Surgeon and Lecturer on Aural Surgery in St. Mary's Hospital School, London.
Fourth edition. In one octavo volume of 391 pages, with 73 engravings and 21 colored plates.
Cloth, 13.75.

There can be no question of the need of more per-
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of general practitioners of medicine. Professor Field
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of aural anatomy and pathology by the exactness and
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the fact that three editions have already been disposed

of, the last numbering 3000 copies. The work has, of
course, been revised to keep pace with the times. — The
Medical Age.

This book is written by an authority on this subject,
and may be recommended as a good text-book fo^ the
student and a safe and reliable guide for the practi-
tioner.—jE'drnftw^'A Medical Journal,

Morris on the Skin.

Diseases of the Skin. An Outline of the Principles and Practice of
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As a work presenting modern dermatology in a form
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Medical Magazine^

Seller on the Throat and Nose— Fourth Edition.

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LEA BROTHERS & CO., Publishers. [?fv7rArr(^^"SrH'^^,"'Nrv

York.

Complete Work — Just Ready,

A SYSTEM OF SURGERY.

By American Authors. Edited by Feedeeic S. Dennis, M. D., Professor of
the Principles and Practice of Surgery, Bellevue Hospital Medical College, New York ;
President of the American Surgical Association, etc. Assisted by John S. Billings, M. D.,
LL. D., D. C. L., Deputy Surgeon-General, U.S. A. In four imperial octavo volumes con-
taining 3652 pages, with 1585 illustrations and 45 full-page plates in colors and monochrome.
Price, per volume : Cloth, $6 ; Leather, $7 ; Half Morocco, $8.50. For sale by subscription
only. For prospectus with order blank address the publishers.

ROBERT ABBE, M. D.,
Post-Grad. Medical School, New York.
GORHAM BACON, M.D.,
Pres't American Otological Society.

HERMANN M. BIGGS, M.D.,
Bellevue Medical College, New York.

JOHN S. BILLINGS, M.D,,
Deputy Surgeon-General, U. S. A.
WILLIAM T. BULL, M. D.,
Col. physicians & Surgeons, New York.

WILLIAM H. CARMALT, M.D.,
Yale University, New Haven.
HENRY C. COE, M.D.,
New York Folyclinic.
PHINEAS S. CONNER, M. D.,
Medical College Ohio, Cincinnati.
WM, T. COUNCILMAN, M.D.,
Harvard Medical School, Boston.
D. BRYSON DELAVAN, M.D.,

New York Polyclinic.
FREDERIC S. DENNIS, M.D.,
Bellevue Medical College, New York.
EDWARD K. DUNHAM, M.D.,
Bellevue Medical College, New York.
WILLIAM H. FOR WOOD, M.D,,
Deputy Surgeon-General, U.S.A.
GEORGE R. FOWLER, M. D ,
Surg, to St. Mary's Hospital, Brooklyn.
FREDERIC H. GERRISH, M.D,
Bowdoin College, Portland, Me.
ARPAD G. GERSTER, M.D,,
New York*Polyclinic.

From

LIST OF CONTRIBUTORS.

VIRGIL P. GIBNEY, M.D,

Surgeon, Hospital Ruptured and Crip-
pled, New York.
WM. A. HARD AWAY, M.D.,
Missouri Medical College, St. Louis.

FRANK T. HARTLEY, M. D.,

Roosevelt Hospital, New York.

JOSEPH T. JOHNSON, M.D.,
University of Georgetown, D. C.

WILLIAM W. KEEN, M. D.,
Jefferson Med. College, Philadelphia.

WILLIAM T. LUSK, M. D.,

Bellevue Medical College, New York.

CHARLES McBURNEY, M.D.,
Col. Physicians de Surgeons, New York.

RUDOLPH MATAS, M.D.,
Tulane University, New Orleans.

HENRY H. MUDD, M.D.,

St. Louis Medical College.

CHAS. B. NANCREDE, M. D.,
University Michigan, Ann Arbor.

HENRY D. NOYES, M.D.,

Bellevue Medical College, New York.
ROSWELL PARK, M. D ,
University of Buffalo.
WILLARD PARKER, M.D,
Academy of Medicine, New York.

LEWIS S. PILCHER, M.D ,
Post-Grad. Medical School, New York.

WILLIAM M. POLK.M.D.,

University of New York.

CHARLES B. PORTER, M.D.,
Harvard Med. School, Boston.

MAURICE H. RICHARDSON, M.D.,
Harvard Med. School, Boston.

JOHN B. ROBERTS, M.D.,
Woman's Med. College, Philadelphia.

GEO. E. deSCHWEINITZ, M.D.,
Jefferson Med. College, Philadelphia.

NICHOLAS SENN, M.D.,
Rush Medical College, Chicago.

STEPHEN SMITH, M.D.,

University of New York.

LEWIS A. STIMSON, M.D.,
University of New York.

ROBERT W. TAYLOR, M. D.,
Col. Physicians & Surgeons, New York.

LOUIS McL. TIFFANY, M.D.,

University of Maryland, Baltimore.
J. COLLINS WARREN, M. D.,
Harvard Medical School, Boston.

HENRY R. WHARTON, M. D.,
University of Pennsylvania, Philada.

ROBERT F. WEIR, M.D.,

Col. Physicians & Surgeons, New York

WILLIAM H. WELCH, M.D.,
Johns Hopkins University, Baltimore.

J. WILLIAM WHITE, M. D.,

University of Pennsylvania, Philada

HORATIO C. WOOD, M.D.,

University of Pennsylvania, Philada.

The American Journal of the
Medical Sciences.

There really is now no complete work in Eng-
lish which can be considered as the rival of this.
That the editor has selected his collaborators judi-
ciously will be conceded when the names are read
over. Each one of them is a teacher of surgery
or a director of some large clinic, and each is,
therefore, prepared to speak from an extended
experience as well as from extensive study.

From the London Lancet.

The authors are all men who, from their posi-
tions as teachers of surgery, either clinically or
systematically, can claim to be able to speak
with authority on the subjects which they have
undertaken, and the names of many of them are
well known in this country. It is not possible to
judge of the whole work from this first volume;
but we may say of it that it gives a careful and
accurate account of that part of surgery of which
it treats, and that it is worthy of the position to
which surgery has attained in the great republic
whence it comes.

From the Annals of Surgery.

Such a work carries with it an encyclopaedic
importance. Its circulation is larger because
the professional interest in its authorship is
more widely distributed. The System of Sur-
gery which now lies before us is a beautiful
example of these principles.

From the American Medico-Surgical Bulletin.

It is almost an act of supererogation to attempt
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but it has more than realized our expectations,
and is to our mind the most valuable contribu-
tion that we have had of late years to the subject
of general surgery. It has been taken for granted
that this work "is to occupy the encyclopedic
position.

LEA BROTHERS & CO., Publishers, ^r^7^AZ!:X.T8^;^"rv

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n

"Marvelous Discovery."

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236 Clarendon Street, Boston, Mass.

12

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(Powder Form).
C Phenacetine-Bayer - - 5 parts ^
< Caffeine . . _ _ l part >
( Citric Acid - - _ _ l part )
Put up in ounce tins.

For neuralgias, hemicrania or migraine, and headaches of all kinds, especially
cephalalgias of nervous origin, the combination of Phenacetine, Caffeine and
Citric Acid has frequently been suggested, and as there seems to be a growing
tendency to prescribe this combination, we offer it in the form of Powder,
*TO/5 and Tablets.

^U. yfemieranine, 5 ^r4.

Phenacetine-Bayer - - 5 parts ~)
Caft'eiiie - - - - 1 part >
Citric Acid - - - _ l part )

Compressed Tablets of Hemicranine, the same strength as the Soluble Trills. ^

Schieffelin & Co New Yorl<:

13

n^g^ The only prominent Emulsion of Cod'Liver Oil introduced directly to the medical profeeeiom

*» advertised exclusively in medical Journals.

Produces rapid increase in Flesh and Strength.

IFORMUI^.— Eaeh Dose contains :
Pbm Cod Liver Oil 80 nn (drop*) | Sod*. 1^3
DUtillsd WBter „3S " SaHcyllc A<ld..„ M
Solubl* Pxncreatin S Qr»ln«. | :

Becommended and Prescribed by
EMINENT PHYSICIANS Everywhere.
It Is pleasant to the Taste and
acseeptable to the most delicate Stomach.

IT IS ECONOMICAL IN USE AND CERTAIN IN RESULTS.

■■-1 YDROLEiWE (Hydrated OH) is not a simple alkaline ermilsion of oleum morrhua^ but a hydro-

pancreated preparation, containing acids and a small percentage of
soda.. Pancreatin is the digestive principle of fe^ty foods, and in the soUible form here used, readily converts
the oleaginous material into assimilable matter, a change so necessary to the reparative process in all wasting:

The following are some of the diseases in which 3E3EI V-lL3I^OXj?E3C3Xr3E8 is indicated :

Phthisis^ Tubercuiosigf Catarrh, Cough, Scrofula, Chlorosis,
Ceneral Debility, etc.

TO BRAIN WORKERS of all classes, HITDROLEINE is invaluable, supplying as it does, th»
true brain-food, and being more easily assinulated by the digestive organs than any other emulsion.

The principle upon which this discovery is based have pe«n described in a treatise on " The Ingestion and
Assimilation of Fats in the Human Body,** aad "Consumption and Wasting Diseases," by two distinguished
(London physicians, which will be sent free on application.

soj,j> BY jaitvoQiaxa ajEjrjBMALX,T.

SOLE ACUEIIT FOR THE UWiTEJP. STATES. 116 FULTOli STREET, N. Y.

A Baaph of Hydrolaine irill ba seat fkws npoa appUoation. to aay physieian (aaoloaiQS baaiaeas oanD In the U. S.

SUN.

MON.

TUE5.

^Phases of theJ^ooi^ for Augu

30

Send your Professional Card
tor Brochure a&d ~

WED.

THUR5.

THE ANTIKAMNIA CHEMICAl CO.. St. Louis. Mo.. U. S. A.

14

Has stood the test of Twenty-eight years in
the hands ef the Medical Profession, and has

given more universal satisfaction than any
other medicine in the world, as a safe and
rpliable

ANTISPASMODIC, NERVINE AND TONIC

IN THE AILMENTS OF WOMEN, and in all
Spasmodic Affections of both sexes, particularly
in Obstetric Practice, in which it stands alone.
Reference — Any leading physician in the U. S.

ToTH^sia^ "'^ MEW YORK PHARMACEUTICAL CO.,

BEDFORD SPRINGS, MASS.

A Vitalizing Tonic to the Reproductive System.

SANMETTO

FOR

GENITO-IJRINARY DISEASES.

Scientific Blending of True Santal and Saw Palmetto in a
Pleasant Aromatic Vehicle.

SPECIALLY VALUABLE IN

Prostatic Troubles of Old Men— Pre-Senllity,

Difficult Micturition— Urethral Inflammation,
Ovarian Pains— Irritable Bladder.

POSITIVE MERit AS A REBUILDER

DOSB:--One teaspoonful four times a day.

Od Chem. Co., new york.

15

A REFRESHING TONIC AND RECONSTRUC-
TIVE.

While the most prominent use for
the Hypophosphites of Lime and Soda
is in the treatment of Consumption
and Scrofula, in which its tonic and
tissue-building properties render it
particularly efficacious, yet it has other
and quite varied uses based upon these
same properties. One of the most
marked of these is its use as a tonic
reconslructive in hot weather.

Many persons have fair health dur-
ing the cooler months of the year, yet
suffer greatly from debility during the
long, hot summer. The relaxing ef-
fects of the heat itself, besides the loss
of the salts of the tissues, through the
excessive colliquative perspiration,
prove exceedingly depressing to the
vital powers. Not only is this condi-
of extreme debility very depressing in
itself, but it also predisposes the victims
to attacks of disease which they would
otherwise be able to resist. Thus, to-
wards the latter part of the heated
term, we have a long list of protracted,
exhaustive fevers, for the fatal issue of
which the extreme debility of the
patients is largely responsible.

In all this we may see another
demonstration of the value of the
phosphorous salts of lime and soda as
tonic and vitalizing agents in the
animal economy, and also a definite
clue to the proper remedy for the
condition described, as these tissue-
salts are largely wasted in excessive
perspiration. This remedy is the pure
Hypophosphites oi Lime and Soda.

By its tonic properties, refreshing,
revitalizing and invigorating the entire
system, it restrains the excessive per-
spiration and the consequent waste is
checked. But it also furnishes the
system with healthy tissue-food to
replace with new and vigorous cells
the necessary waste incident to the
ordinary physiological processes. Thus
the system is kept all the time up to a
prime condition of physical strength
and mental exhilaration, and germs of
disease find little encouragement for
invasion.

It would be advisable that those
who do not bear hot weather well "
should resort each year to a course of
the Hypophosphites of Lime and
Soda, and thus fortify the system
against certain exhaustion amd possible
malignant disease. Direct them to
put a teaspoonful of Mc Arthur's
Syrup occasionally in a glass of cold
water, as a drink, and the " insatiable
thirst" will be more easily relieved.
Recommend this, also, to your con-
sumptive and scrofulous patients, and
those afflicted with diseases character-
ized by exhausting discharges and
great debility, and they will report the
summer as the most refreshing season
they have ever passed. The McArthur
Hypophosphite Co., Boston, Mass.,
will send upon request to any physi-
cian not familiar with McArthur's
Syrup, a sample bottle, without ex-
pense; also, interesting matter about
the value and uses of the Hypophos-
phites.

6 ■

Observations

on Infant Feeding

Sir William 0. Priestley, M. D., contributes to the British
Medical Journal for December 7tli an article on tins subject,
in which he remarks that the well-being of infants is so im-
portant, noc only in a domestic sense, but in relation to the
State, that it may well engage the best faculties of medical
men, and not be left to the bungling mismanagement of ignor-
ant nurses. The prevailing fallacy among these women, he
says, is that an infant's food cannot be nutritious unless it is
thick, and they feed infants soon after birth with various
mixtures of farinaceous stuffs which the young stomach cannot
assimilate. — New York Medical Journal.

Mothers' milk is the standard which we take, and it is thin
and " watery" apparently. It is a popular fallacy that a thick food
is a rich food ; this is, no doubt, due to the long use of farinaceous
foods. Milk thickened with " farinaceous food," etc., is in reality,
not "richer" but is diluted, and diluted with substances indigestible
for a nursing infant. — Fairchilds Peptogenic Pamphlet,

Fairchild's Peptogenic Milk Powder is the only means of
modifying cows' milk to a correspondence with normal
mothers' milk on the basis of comparative analyses.

SMITHSONIAN INSTITUTION LIBRARIES

QLYCOZONE

Both Medal and Diploma

Awarded to Gliarles Marchand'g Glycozone by World's Fair of Chicago, 1893, for Itf

Powerful Healing Properties.

This harmless remedy prevents fermentation of food in the stomach and it cures :
DYSPEPSIA, GASTRITIS, ULCER OF THE STOMACH, HEART-BURN, AND ALL INFECTIOUS DISEASES

OF THE ALIMENTARY TRACT.

HYDROZONE

IS THE STRONGEST ANTISEPTIC KNOWN.

One ounce of this new Kemedy is, for its Bactericide Power, eqmralent
to two ounces of Charles Marchand's Peroxide of Hydrogen (medicinal), which
obtained the Highest Award at the World's Fair of Chicago, 1893, tor
Stability, Strenfrth, Purity and Excellency.
CURES ALL DISEASES CAUSED BY GERMS.
Send for free 152-page book giving full information with endorsements of leading physidana^
Physicians remitting express charges wiU receive free samples.
GliYCOZOrVE is put up only in 4-oz., S -oz.
and 16-oz. bottles bearing a. yellow label,
whiite and black letters, red and blue border,
vrith 8is;nature.

IIV1>ROZOIVE is pat np ^nly in small,
nedium and large size bottles, bearing a red
label, white letters, gold and blue border.
ISp'Mention this publication. Chemist and Graduate of the "Ecole Cenirale des Arts et Manufactures dt Paris" (Francey

«ad.nS o'bugc.sts. Charles Marchand 28 Prince St., New York.

Prepared

ONLY BY

For the

Modification of
Fresh Cow's Milk

''Malt Extract. This

pfeparation, of which tjie best and the best
known is Mellin^s Food remains to be de-
scribed and is of real value when used in
combination with milk. It is essentially the
same as Liebig^s Soup, but so prepared as to
be marketable.''

Domestic Hygiene of the Child.

Julius Uffelmann, M. D.

USE Mellins
Food ^

"MELLIN'S FOOD is not

only readily digestible itself, but it actually
assists to digest milk or other foods with
which it is mixed.''

G. W. Wigner, FJ.C,

Pres. Society Public Analysts,

London, Eng,

FRESH COWS^ MILK prepared

with MELLIN'S FOOD accord-
ing: to the directions, forms a true
LIEBIG'S FOOD and is the ^
BEST SUBSTITUTE for J'
Mother's Milk yet produced*^ ^

THE DOLIBER-GOODALE COMPANY, BOSTON, MASS.