Title: The Brooklyn Medical Journal. Vol. II. No. 2. Aug., 1888
Author: Various
Language: English
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                                  THE
                       BROOKLYN MEDICAL JOURNAL.


    PUBLISHED MONTHLY BY THE MEDICAL SOCIETY OF THE COUNTY OF KINGS.

                         _EDITORIAL COMMITTEE_:

                       JOSEPH H. RAYMOND, M. D.,
                         ALEX. HUTCHINS, M. D.,
                      GLENTWORTH R. BUTLER, M. D.,
                         JOSEPH H. HUNT, M. D.,
                         FRED. D. BAILEY, M. D.

             VOL. II. BROOKLYN, N. Y., AUGUST, 1888. NO. 2.



                          _ORIGINAL ARTICLES._


         PAIN, WITH SPECIAL REFERENCE TO ITS DENTAL RELATIONS.

                        BY WM. M. THALLON, M.D.

         Read before the Brooklyn Dental Society, May 28, 1888.

MR. PRESIDENT AND GENTLEMEN:—Some months ago, when sitting in the
operating-chair of your Chairman of the Committee on Subjects, he asked
me if I would not read a paper before the Brooklyn Dental Society. In
the helpless condition in which I then was, with literally a gag in my
mouth, robbing me of the prerogative of free speech, and under the
shadow of a formidable mallet, I somewhat timorously signified an
assent. Under those circumstances I know of few men who would have had
the moral and physical courage to have resisted such an appeal. When in
the course of his further practices, he asked me what my subject would
be, I promptly replied by mentioning the thing then most vivid in my
mind: Facial Neuralgia.

I hardly realized my rashness and what I had undertaken, until I
received your printed bulletin of subjects. But it has seemed to me on
further thought that we might perhaps spend an hour profitably together
in comparing notes about that borderland of facts and problems, which
you touch on the one side as dentists and I on the other as physician.
And I trust you will be lenient with me in your judgments if I go astray
in my talk, and I pray you to remember that we doctors labor under great
disadvantages compared with you dentists, contrasting the width and
vagueness of our territory of research with the precision and accuracy
of yours. I have again and again envied the exquisite dexterity and the
certainty of adapting means to ends which I have seen exhibited by
members of your profession, and vainly longed for the same in my own.
But on the other hand, I think it may justly be urged that the dentists
have not contributed as much to the general stock of knowledge,
especially to the solution of disputed questions of pathology, such as
the relation of micro-organisms to disease, as their unrivaled
opportunities for observation would allow.

I shall therefore not hesitate, Mr. President, to somewhat dogmatically
present my views on certain subjects, but I ask you to believe it is
mainly because I hope the gentlemen present will honor them by frank and
full discussion.

I shall also ask permission to change the subject of my remarks from the
announced title to one of a little wider scope, namely, Pain, with
special reference to its dental relations.

I presume the symptom of pain is the one for which the overwhelming
number of your patients, as the majority of ours, apply to us for
relief. And yet common as this sensation is both in ourselves and in
others, it is very remarkable how little settled opinion is, as to its
nature. If you have never had occasion to try and put into the form of a
definition the idea of pain, and proceed to consult the authorities, you
will be surprised that so many different views could be held of what at
first seems so common and obvious as to be beyond dispute. As you
proceed in your inquiries, the question instead of becoming simpler
apparently becomes more complex, for as you think of the different forms
of pain, and contrast, for instance, that of an inflamed rheumatic
joint, with its definite structural changes and well-marked
constitutional symptoms like fever, with an idiopathic neuralgia, pure
and simple, often lacking in any outward manifestation other than the
pain itself, you wonder if the pains resulting are not as different as
the diseases producing them. But the common consciousness of mankind
which has given the same name to the sensation produced, whether by an
inflamed bowel or a carious tooth, is sure to be right in believing that
there is essentially the same substratum in each. Now what is the nature
of that substratum? It is evident that whatever else it is, pain is a
disagreeable sensation, and the word sensation further obliges us to
remember that it involves a central nervous system (in its simplest type
a single cell), capable of feeling impulses, conveyed to it from
without, or else generated within itself. Now, it is very evident that
pain must consist either in some change in the nature of the impulses
sent to our central cell, or else in some change in the condition of the
receiving centre. So eminent an authority as Prof. Erb defines pain
simply as an increase in the ordinary sensory stimulus, a heightening
more or less intense of ordinary sensation. On the other hand, Anstie
defines pain as a perturbation in the nervous system, especially of the
central cells, involving a lowering of function, a diminution of
ordinary sensation. It is very evident that both of these great
authorities cannot be exclusively right, and I propose to see what light
we could get on this subject from the abundant clinical evidence you
have.

This question is no mere quibble about words or definitions, but it is
one of the utmost practical importance in its relation to treatment.
According as we settle in our minds whether a given case of pain is an
exaggeration or a lessening of the ordinary physiological condition, our
treatment will logically be either narcotic or stimulant.

Leaving for the present the question as to the nature of pain, let us
examine some of the modes in which it expresses itself; and as far as
practicable I will limit myself to the various pains about the head, for
all the varieties are there manifested.

The first point which strikes every observing man is the difference of
individuals in their susceptibility to pain. It is not merely or even
mainly a question of the amount of courage of the patient in bearing
pain, but it is far more a question of inherited or acquired
sensitiveness. The same amount of injury, as nearly as we can judge, in
two differently organized individuals will produce extremely differing
degrees of pain. In general it may be stated that the unduly susceptible
individual has either inherited a weak nervous constitution as regards
pain, or else that some depressing agency has lowered his power of
resistance. When I speak of a weak nervous constitution as regards pain,
I do not mean that it need be a generally weak physique. Perhaps a more
happy word would be unstable. You remember the physicists talk of bodies
being in stable equilibrium when after a disturbance they tend to return
to their bottom, or centre of gravity; while unstable equilibrium is
that state where a little shove off the centre, results in a big tumble.
Now, the people who are markedly susceptible to pain, who have
recurrences of it, may be said to have a nervous system in a state of
unstable equilibrium. In other respects these same individuals may be
splendid types of muscular or mental development.

The same condition holds good with pain’s first cousin, muscular spasm.
The analogue to the sensory crisis of attacks of neuralgia is seen in
the muscular convulsions of attacks of epilepsy. And yet some of the
greatest men of the world’s history in mental vigor have been
epileptics, notably Napoleon Buonaparte and Julius Cæsar. Although at
first we may not be able to see any outward manifestation of such
attacks of pain as I have spoken of, if they recur sufficiently often
they are sure to leave their traces behind.

If we prosecute our inquiries in the other direction, to find what has
predisposed our patient to recurrences of pain, we find in a large
number of cases that his immediate progenitors have suffered from
similar or allied manifestations. By allied manifestations I mean such
other nervous diseases as epilepsy or chorea (St. Vitus’ dance), or
insanity. Moreover, there is one predisposing cause that I believe to
have quite peculiar efficacy, and that is the tendency to phthisis.
Again and again I have verified the truth that where a member of a
tubercular family escapes consumption, he is extraordinarily liable to
develop one of the graver neuroses, preferably recurrent attacks of
pain.

Now, the first point we may consider settled, as to the mode in which
pain expresses itself is in an inherited susceptibility, a lessened
power of resistance, and this can only reside in the central nervous
system.

But, as we have already said, the lessened power of resistance may be
acquired, it need not be inherited.

Without stopping to dwell very long on this part of our subject, it will
suffice to enumerate one or two of the principal efficient agents. And
the first and far the most important of these is malnutrition of the
nerve tissues, whether accompanied by the signs of anæmia and general
constitutional malnutrition or not, the main cause being our
civilization, with its excessive nervous wear and tear, no less in the
educational period than in the intense competition of mature life. No
more striking verification of this fact is needed than the results
obtained in the relief of pain by physiological rest, by systematic
feeding, especially of certain kinds of food, particularly fatty food.
It is the general rule that in these cases there is either an
indisposition to take sufficient food, or else that certain necessary
ingredients are omitted owing to the patient’s repugnance.

In the familiar example of sick-headache, or migraine, the patient
invariably ascribes his condition to a disordered stomach, and
scrupulously avoids such foods as eggs and milk and fat, which he will
tell you always make him bilious. It is the hardest thing in the world
to convince him that he has put the cart before the horse, and that the
real fact is that the nervous trouble, the neurosis of the ophthalmic
division of the fifth, is the cause and not the effect of the gastric
disturbance. I am convinced that much of the suffering in the dental
branches of the fifth nerve can similarly be traced to the nervous
malnutrition of insufficient food, and, in addition, the local condition
of the teeth is pathologically influenced by their not getting their
proper physiological stimulus in the quantity or character of the food
to be chewed.

Of all the means at our command in combating the neuralgic condition,
the regulating and increase in the quantity of rest and of the food
supply should stand first. These facts have been known and recognized
for a long time; but it is due to an American, Dr. Weir Mitchell, of
Philadelphia, to have intelligently systematized their use. The
principles of his treatment of nervous prostration, spinal irritation,
and allied disorders, in which pain is often a prominent symptom,
consists in a system of rest and forced feeding by which a larger
quantity of nutriment is gotten into the system, and the waste
eliminated by means of artificial exercise, by massage. It is evident
that in this process the increased food absorbed into the blood goes
indifferently to nourish all the tissues; but inasmuch as the muscles
are not the seat of the trouble, if left alone unexercised, they would
become diseased under the very stuffing process. That is where the
kneading and shampooing, and movements supplied from without, are so
valuable; the muscles get their healthy action without drawing on the
forces of the enfeebled nervous system to set the process going. And so
the nervous system has a chance to lie idle and grow fat. Similar
remarkable results have been obtained in another disease whose
hereditary relations to pain I have spoken of, namely consumption, by a
process of forced feeding. The recent results obtained, more especially
in France, by stuffing phthisical subjects, have constituted by far the
greatest advance in the treatment of this disease in recent years. But
in these cases the massage is entirely inapplicable because the waste of
tissue is already too great. The lessons taught by the treatment of
these two classes of diseases are invaluable in combating the more
inveterate forms of pain.

The next acquired condition to which I would invite your attention,
which may act as a cause of pain, is the presence of certain poisonous
compounds in the blood or system. These are more especially the poisons
of malaria, of syphilis, of gout and rheumatism, of alcohol, of certain
drugs, and lastly of certain metallic poisons, as mercury, phosphorus,
lead and arsenic.

Although this group includes a tolerable number of members all together,
it is less important than either the preceding division of nontoxic
malnutrition of the nervous tissues, or of our first class, in which
heredity plays the main role.

Still the toxic cases are sufficiently common. What we have already said
as to treatment here holds good, but we must superadd the means of
combating the particular poison.

In the malarial cases the pain is often entirely relieved by quinine or
one of its substitutes; on this all are agreed, whether homeopaths or
allopaths, or outside of any regular path. It is quite curious how the
malarial neuralgias preferably locate in the first division of the
fifth. But one word of caution, the mere fact of recurrence or
periodicity, more or less regular, does not suffice to establish the
diagnosis of malaria, for all neuralgias are apt to be more or less
periodic. You must get definite symptoms of chill or fever before you
can be sure. Once sure, the treatment is plain: efficient doses of the
antiperiodic.

When we come to the syphilitic cases we enter more debateable territory.
The pains about the head, especially the teeth, are sometimes not due to
the disease, but to the means taken to combat it. I do not intend here
to take up the question of the treatment of the secondary stage, except
to enter my protest as to the harm done, especially to the teeth, by
routine overdosing with mercury. Fortunately this abuse of a most
valuable remedy is much lessening. In the third stage of syphilis you
sometimes get most remarkable pain manifestations, and I had one in my
practice that I cannot refrain from quoting.

A gentleman, aged between 40 and 45, had suffered for years from
recurrent attacks of pain of great severity. When I saw him the pain,
although more or less present constantly, had very marked exacerbations
every afternoon. It was located in the great occipital nerves,
especially on right side. Had formerly had considerable pain in
distribution of right inferior dental nerve. His occupation was
sedentary and involved considerable mental application. He stated on
questioning that some eighteen years before he contracted syphilis. From
this he believed himself cured. He had subsequently married, but had no
children. Having suffered for six or eight years from these attacks of
pain at varying intervals, he had consulted numerous physicians with
only temporary benefit. He was very despondent; his sufferings were very
intense, and only the most powerful anodynes gave relief. After some
investigation, I made up my mind that the syphilitic dyscrasia lay at
the bottom of his suffering. I therefore began specific treatment with
iodide of potash. Prof. Seguin, who saw him in consultation, concurred
in both diagnosis and the line of treatment. He suggested pushing the
iodide until its therapeutic limit was reached. This was done; but it
was not until the enormous dose of one-half ounce thrice daily was
reached that the pain yielded. During one week this patient took over
one pound of iodide of potash.

A course of mercury in small doses completed the cure. Two years have
now elapsed, and the patient has had no recurrence of pain.

Gout and rheumatism were formerly ascribed a much more important role in
the production of pain than they now occupy. Leaving out of account the
acute manifestations of these diseases, their influence is slight as
predisposing causes in the production at least of facial pain. There is
perhaps one disease of the dental apparatus to which I shall allude
later on, in which gout may act as an efficient cause.

On the other hand, the class of pains due to the action of the chronic
abuse of certain therapeutic agents is unhappily an increasing one; I
allude to alcohol, opium, cocaine, chloral and other drugs, originally
taken for the relief of pain, which induce a pernicious habit in their
unfortunate victims, of which pain is one of the main expressions. It is
an undoubted fact that this class of sufferers is on the increase. Much
of this tendency is due to the excessive wear and tear and the unhealthy
competition of our modern civilization. It has always been the refuge of
the weak, the attempt to escape from the moral evils of our lot by means
of something that will temporarily dull our consciousness of the trials
we have gone through and the apparently greater trials that lie ahead of
us. The moment the competition for existence and for wealth becomes
keener, the greater will be the temptation of the unsuccessful or
depraved to seek oblivion for their failure in some narcotic, which will
for the time being quiet their disappointed consciousness. When in
addition you have an inherited weakness on the part of your patient in
his susceptibility to pain, or in a condition of pain actually existing,
can you wonder that so many fall by the way? It seems to me that a
terrible responsibility lies upon us all, especially upon us physicians,
lest by our treatment we encourage this tendency. Nor do I think that as
a profession we can be altogether acquitted of carelessness, to put it
mildly, in this regard. It is so much easier to relieve the symptom
pain, when called to a sufferer, by a dose of morphine, and then when
the next attack comes on to repeat it, than to analyze the complex group
of phenomena on which that pain depends. You will perceive that the
question with which we started as to the nature of pain is of vital
importance in this regard.

The last group of constitutional agents which act as pain disposers is
one with which you are all familiar, namely, the action of certain
metallic poisons; of these the most important are mercury and
phosphorus. It is highly significant that they have their main action in
the structural changes they cause in the periosteum of bones, the
peridental membranes.

In the case of phosphorus, I think it is now pretty generally believed
that its poison has very little effect in the mouth unless there exist a
precedent caries of a tooth or its socket. These facts almost suffice to
take these agents out of the group of constitutionally acting into that
of peripherally irritant causes. In this class of agents, as in the
preceding one, the first indication in treatment is the complete removal
of the sufferer from their baneful influence.

We have now briefly reviewed the main agencies which act
constitutionally in the production of pain. It is apparent, to recur to
our simple illustration, that they must have their main efficiency in
the action they have on the central cell, and not on any modification of
the impulses sent to that cell. It cannot be denied that in rare
instances these various agents are productive of pain referred to a
particular nerve, when we cannot find anything in the nerve itself or in
the tissues supplied by it to account for the morbid manifestation. We
are, therefore, constrained to believe, at least for the present, that
morbid manifestations, sensations of pain, may originate in the cell
itself and thence be referred outward. But I would remind you that the
whole tendency of modern medical thought is to more accurately localize
the starting point of disease, and to circumscribe the area of cases in
which such outward cause of disease is unknown. So long as men were
satisfied to cover up their ignorance in such vague phrases as “humors
of the blood,” “rheumatic diathesis,” etc., etc., few were tempted to
carefully examine the local conditions for an explanation. But the last
fifty years have seen an enormous change in our attitude of mind to
these problems. It is a change which is one of the greatest in the
history of the human mind. And while I do not for a moment wish to
underrate the great importance of a due regard to the constitutional
causes of pain, especially of the malnutrition of the nerve cells, I
believe that in the main they must be classed as predisposing causes and
not as efficient ones. When we come to the question of why pain is
located or referred to a particular nerve, I believe the answer in the
overwhelming majority of cases will be because there is some peripheral
abnormality in that nerve or in some other nerve with which it is
intimately associated; for we have to recognize in the philosophy of
pain the same fact that we do in the philosophy of the human mind,
namely, that our ideas are so closely associated that one thought will
almost necessarily suggest another. Just as, if we have always been
accustomed to see Smith and Jones together, we can hardly think of Smith
without Jones also putting his nose in; so in feeling sensations,
certain ones get so closely intertwined that one will almost inevitably
causes the other. This, then, leads us naturally to the second great
division of our subject, and that is the influence of peripheral
irritation in causing pain.

From what I have just said, this may be of two kinds—a reflex or
associated pain expressed in some other nerve than the one affected, or
else it may be due to direct irritation in the nerve itself.

A very common example of the former is seen in the headaches from which
many women suffer, from the menstrual congestion (irritation of the
nerves) of the ovaries and uterus. It is, however, quite outside the
scope of this paper to enlarge on this curious and obscure part of our
subject. I prefer to take up the more understood and more common form of
direct peripheral irritation, and especially the irritation arising from
diseases of the teeth and jaws.

In that delightful book, “Rest and Pain,” by Mr. John Hilton, the
eminent London surgeon, he narrates a case, which is so instructive in
illustrating the mode in which peripheral irritation may cause not only
pain, but local disease, that I cannot forbear from quoting it:

“A gentleman, aged 63, came to consult me about an ulcer situated upon
the left side of his tongue. On examination, I found an elongated, very
ugly-looking ulcer, nearly as large as a bitter almond, and of much the
same shape. The surrounding parts were swollen, hard, red, and much
inflamed, and a lymphatic gland was enlarged below the horizontal ramus
of the lower jaw on the same side. I saw in the mouth a rugged tooth,
with several projecting points upon it, opposite the ulcer. This
gentleman observed to me: “Having suffered a good deal from earache on
the left side for a long time, without experiencing any relief from
medical treatment, it was thought that I must be gouty, and I went to a
surgeon who treats gouty affections of the ear. This surgeon paid great
attention to my ear, but certainly did not do it the slightest degree of
good. I accidentally mentioned to him that I had for some time past
something the matter with my tongue. On seeing it, he immediately began
to apply caustic vigorously; moreover, not satisfied with applying it
himself, he gave it to my wife that she might apply it at home. I have
gone on in this way from day to day, until the pain in my ear is very
considerably increased, and the ulcer on my tongue is enlarging; so I
have come to you for your opinion regarding my state; for, to tell you
the truth, I am afraid of a cancer in my tongue.” I thought I saw the
explanation of this patient’s symptoms. The pain in the ear was
expressed by the fifth nerve, and there was a rugged tooth with little
projections on it, some of which touched a small filament of the
lingual-gustatory branch of the fifth nerve in the surface of the ulcer.
I detected this little filament by placing upon it the end of a blunt
probe. It was situated near the centre of the ulcer, and was by far its
most exquisitely painful part. This exposed nerve caused the pain in the
auditory canal which led him to go to the aurist, and the aurist,
instead of confining himself to his own department, seized the tongue,
put nitrate of silver upon the whole of the ulcer, and increased the
mischief. I simply desired that the ulcer should be left at rest; that
the patient, to avoid touching the tooth, should neither talk nor move
his tongue more than necessary; that he should wash his mouth with some
poppy fermentation, and take a little soda and sarsaparilla twice a day.
In three days about one-third of the ulcer was healed up, actually
cicatrized, the enlarged gland nearly gone, and the earache much
diminished.

“This rapid improvement might appear something like exaggeration, but
all surgeons know that the tongue has those elements within it which
contribute to the most rapid repair of injury. I do not know any tissue
that repairs itself more rapidly. It is abundantly supplied with
capillaries filled with arterial blood, and has an enormous distribution
of nerves, and these are two elements that contribute to rapid
reparation. It was quite clear that the treatment was in the right
direction, viz., that of giving rest to the tongue and ulcer. After a
few more days I requested him to consult a dental surgeon with respect
to the propriety of taking off the points of the tooth. This was
afterwards done, and the patient soon lost his anxiety about cancer, his
earache, and all his other severe symptoms.”

I cannot doubt that the starting point of a large number of similar
painful ulcers and of true cancer of the mouth is to be looked for in
disease of the teeth.

When we come to the teeth themselves, the pain lies in the irritated
nerves of the pulp. Of course it cannot be denied that the pulp itself
may be the original seat of the pain, but, if so, the number of such
cases must be few. When we reflect on the mode of nutrition of the
tooth, it seems almost self-evident that any depressing agency which
could lead to disease of the pulp must, by an augmented action, cause
greater disease in the structures which depend on the pulp for their
nutrition to start with. At most, disease and pain in the pulp alone
must be nothing less than a pathological curiosity. Such, however, is
not the case in the vast multitude of cases dependent on caries, in
which the pulp has lost in part or in whole its protection from external
morbid influences. The origin of caries is one of the most interesting
subjects in the whole domain of surgery. I have been astonished to find
that among dentists it is not more definitely settled. So able a writer
as Wm. Henry Potter (of Harvard) says: “In the first place, it may be
said that caries of the teeth does not resemble caries of the bone. The
term caries, as applied to the teeth, is a misnomer, given at a time
when the true nature of the process was not understood.... The
pathological change which occurs in caries is a decalcification and
disintegration of the several tissues of the teeth.”

I confess that strikes me as a very excellent description of what
surgeons usually term caries, namely, a molecular death of bone tissue.
Nor can I see any difference in the essential nature of the two
processes, if you make due allowance for the morphological modifications
of tooth structure from bone structure, and the different environment
under which the process takes place. If I were asked to define dental
caries, I should say it was a molecular death of the tooth structures,
especially the dentine, due to the action of micro-organisms; that in
the course of the process lactic or other acid is developed, which
decalcifies the teeth, is doubtless true, but the very presence of acid
fermentation in a normally alkaline cavity necessitates the assumption
of the action of micro-organisms. I would remind you that the conditions
favorable to the activity of such organisms are all apt to be present.
They are:

1st. The presence of the micro-organism.

2d. The existence of a suitable pabulum.

3d. A certain degree of moisture.

4th. A certain degree of warmth.

5th. A certain amount of oxygen or air.

6th. A lessening of the resisting power of the tissues affected, as
compared with health.

All of these first five conditions are notoriously present in the mouth.
That we do not oftener suffer from their effects is due to the absence
of our sixth element, the lessening of the resistance of the tissues.
Thus, in health, those organisms which flourish best in an acid
secretion have their baneful activity held in check by the alkaline
saliva as well as the resisting power of the dense enamel. But once let
the alkalinity of the saliva be lessened, or changed to an acid
reaction, or let ever so small an abrasion occur in the enamel, and the
myriads of these agents find a foothold for starting the morbid train of
symptoms. Similarly, even in the tissues themselves, the enamel, no less
than the dentine, suffers from those predisposing causes of
constitutional malnutrition, which are so important in their effect on
the central cell, and which act in lessening the normal resistance of
the periphery.

It would be a work of supererogation to trace the progressive course of
caries and the mechanism of the production of pain through irritation of
the pulp. But when we come to the question of treatment, the two main
considerations to be accomplished are worth our study; these are: the
relief of the pain, and the arrest of the carious process. The arrest of
the pain is what the patient comes to you for, and prompt action is
eminently desirable. I was much impressed with this in a case I saw a
few weeks ago, in which an active business man, somewhat run down by
overworking, suffered from toothache (I think due to caries) for several
days before consulting his dentist, my friend Dr. Jarvie. The pain in
the third division of the fifth nerve gradually subsided after
treatment, but was followed by a well-marked neuralgia in the great
occipital nerve of the same side. He again allowed some days to elapse
before sending for me, and I found him suffering from a very intense
crisis when I called. It was promptly relieved by the use of a remedy to
which I invite your particular attention, namely, aconitia.

It has seemed to me for some time that this agent should form parts of
the armamentarium of every dentist. From the fact that I have found it
unused or unknown by some of your most progressive men, I shall not
hesitate to say a few words about it to bring it before you.

Aconitia, or aconitine, is the active principle of the familiar drug
aconite. Although discovered fifty years ago, it is only within the last
ten or twelve years that it has been intelligently used. It is an
extremely potent remedy, and must be used with great caution. In large
doses it acts as a dangerous heart depressor, and paralyzer of motion
and sensation. But in physiological doses it is without danger and is
pre-eminently useful, because of a special action it has in relieving
pain of the fifth nerve. In other neuralgias it is, for some unknown
reason, far less potent. Our excellent Brooklyn pharmacist, Dr. Squibb,
has put upon the market a most reliable preparation of this drug, an
oleate, containing two per cent. of the crystallized salt. This seems to
me a form which is peculiarly adapted to dental work. Ordinarily in
prescribing this remedy internally I begin with 1/200 of a grain and
repeat it every hour; often one or two doses will suffice to relieve the
pain, and it is seldom that more than four are required.

In using it locally if you wished to begin with the same doses, it would
be necessary to dilute one drop of Squibb’s oleate with three drops of
bland oil for each drop of the mixture to contain 1/200 of a grain.

An application of this medicament would be more effective, I believe, in
relieving the pain of an exposed or inflamed pulp than those remedies
now in use. I can testify from personal experience of the frequent
inefficacy of the local application of oil of cloves and chloroform,
while the use of the stronger remedies, as ninety-five per cent.
carbolic acid or pure creosote, can only be efficacious by more or less
coagulating and therefore in so far destroying the nerve tissue and the
pulp. And this I take it is always to be avoided when practicable. I
hope therefore, that some of you will give this remedy a trial, and
verify practically my suggestion.

Having relieved the pain by one way or another, what means do you adopt
to stop the progress of the caries and restore the tooth as a useful
member of the economy?

Now if our considerations as to the origin of caries were true, that it
is a disease due to the agency of septic micro-organisms, the logical
consequence is that successful treatment must be in the line of
antiseptic treatment. I presume this will cause a smile at the
presumption of an outsider venturing to enter on so practical a subject,
and perhaps some one will mentally quote the line about “fools” rushing
in where angels fear to tread. But it is possible that much of your
practice may have been truly antiseptic, just as the wise surgeon’s has
been, long before we knew the why and wherefore of what experience has
now taught us to be true. We are all more or less like the hero of
Moliére’s comedy, who was astonished to find when he arrived at middle
age that he had been talking prose all his life without knowing it.

Now if we analyze your proceedings in the treatment of caries, and thus
relieving the painful or inflamed pulp, let us see if they are not based
on antiseptic principles, even though unconsciously employed.

First of all I take it you aim to remove all the carious material by
means of your instruments, and the success of the operation is dependent
on the thoroughness with which that is done. Does not that seem as if
you were removing a true infective centre, and thus obviating the first
condition favorable to the development of caries—the presence of
micro-organisms.

Now let us see how you combat the second favoring condition, and that is
the presence of a suitable pabulum; is not that done by the simple
mechanical interposition of your filling between the diseased surface
and the fluids in the mouth?

Again we found a certain degree of moisture needed, do you not
scrupulously dry as well as clean out your cavity, and is not your
filler non-absorbent as far as possible?

Fourthly. We found a certain degree of warmth was favorable; that is, of
course, always present in the living body, and in choosing a good
non-conductor of heat as your plugging material, it is with reference to
the secondary effects of caries, the pain caused by thermal extremes,
and not with special reference to the disease itself. Indeed, could we
obtain a substance which would combine the resistance to organic and
chemical action that gold does with the poorness of conducting power of
gutta percha, it would be a great advance.

The presence of air in the decayed tooth is also prevented by the
mechanical means; while lastly you substitute an artificial tissue to
resist in place of the dentine and enamel that is gone.

Indeed it seems to be that the whole process of successfully filling a
decayed tooth is one of the most perfect examples of antiseptic
treatment I am acquainted with. I doubt not there will be further
advances made in your technique, but the principles will not change. I
believe it quite likely that it will prove desirable to more thoroughly
disinfect the carious cavity before filling than is always done now, and
it may prove possible to devise some material which, either by its
hardness or by its chemical constitution, or by some antiseptic
incorporated with it, will longer resist the destruction due to
attrition and to chemical and micro-organic action than the ones now in
use.

To recur to the main problem of our paper—the relief of pain—is it not
true in this class of cases that after the first effects are stilled,
its recurrence is prevented by affording artificially that immunity to
the pulp from peripheral irritation which it possesses in health?

Disease of the peridental membrane causes a characteristic pain, but one
which need not long detain us. From the fact that it is nearly always
secondary and not primary, its treatment should first of all necessitate
the removal of the originating cause. The spread of inflammation or
decomposition from the pulp to the periosteum which so often occurs can
be better accounted for by the hypothesis of the action of
micro-organisms than by any other supposition. Moreover, in the advanced
cases, where pus has formed, the same cardinal indication of treatment,
viz., proper drainage, obtains here as in other departments of bone
surgery.

We have already spoken of the constitutional poisons, syphilis and
mercury and phosphorus, which may be causes of this form of trouble, and
I would only like to say one more word, and that is in the way of
treatment.

Occasionally it has seemed to me that you can stop the further progress
of a periostitis, if you get it in an early stage, and prevent it from
going on to suppuration. I remember one case of a gentleman who applied
to me for a very painful gumboil in his lower jaw opposite the first
molar. The gum was swollen and reddened, and a well-marked phlegmon
could be felt. I gave him fairly large doses of mercury for a couple of
days, and it gradually melted away. There was no suspicion of syphilis
in this case.

Another remedy I believe to be of great value in treating neuralgia of
the face starting in periosteal irritation, is phosphorus. The best form
in which to administer this remedy is the preparation known as
Thompson’s solution. I can testify to this from personal experience.
Some twelve years ago I suffered from periostitis of the first bicuspid
of the upper jaw on the right side. A couple of years later, while
working hard, I had an attack of intense neuralgia of the entire second
division of the fifth. When it subsided, it left some periosteal
thickening at the exit of the nerve from the infra-orbital foramen; and
ever since then, whenever I get run down by overwork or worry, the same
pain crops out. But I have found that a few doses of phosphorus will
completely hold it in check; and in one or two patients, since then, I
have seen the same fact, that in the neuralgia due to periosteal
irritation this remedy holds a high place.

It has seemed to me highly significant that the two drugs, mercury and
phosphorous, which in continued toxic doses cause this very class of
diseases, should in physiological doses be curative. But this is in
entire consonance with the general laws of tissue irritation, and the
therapeutic fact that certain drugs acting through the nervous system
stimulate in small doses and narcotize in large ones.

The last type of dental pain I will speak of is that arising from
pressure due to hypertrophy of the cement. Where this is not due to the
peripheral irritation of a carious tooth, the causation is both
interesting and obscure. It has seemed to me that we must postulate the
agency of a constitutionally acting cause to account for certain of
these cases. I think it quite probable that in certain cases a
well-marked gouty diathesis will be found underlying this form of
disease; and a similar constitutional error must be invoked to explain
the allied cases of calcification of the pulp.

We have now briefly reviewed the main forms of peripheral irritation,
which act as the efficient causes of dental pain, just as we have
glanced over the main constitutional causes that predispose to it. I
think you will all agree with me that for the successful treatment of
these cases, especially in the chronic and inveterate type, local and
constitutional treatment have both to be employed. It seems to me there
is great need for the more intelligent co-operation of physicians and
dentists to attain the best results. Attention to one side of the
question is not sufficient. For the permanent cure of our patients, the
treatment of the local mischief has to be supplemented by attention
directed to the constitutional conditions that predispose to it. One of
the cases I quoted illustrated the important fact that a local
irritation may set up a condition of pain in other nerves which the cure
of the original lesion entirely failed to relieve. This fact is borne
out by many similar conditions which we meet with in other departments
of medicine. On the other hand, while a particular attack of pain may be
relieved by constitutional remedies, its recurrence can only be
prevented by curing the local condition, which acts as the exciting
cause. The enormous preponderance of cases of pain of the fifth nerve,
compared with other nerves, is to be accounted for by the liability of
the delicately adjusted mechanism of the organs supplied to get out of
order. This is especially the case with the eye and the teeth.

It is beyond the scope of my paper to take up the various constitutional
remedies of which we can avail ourselves, rest, the influence of food,
the use of the various drugs, the employment of counter-irritation, of
electricity, and, lastly, of those surgical procedures, exsection and
stretching of painful nerves, which are our last resort.

I will more than have attained my object if I have pointed out, however
imperfectly, some of the many interesting points at which our respective
fields of work touch. Those points where we need your help, and you
ours, to accomplish the best results.

And now, in conclusion, if we revert to our original question as to what
it is that constitutes pain, I think that we will find that both the
great authorities I quoted are wrong, and both are right; each has
stated half of the truth.

If your observation and reasoning agree with mine, we will be forced to
believe with Anstie that pain in its essential nature consists in a
diminution of the vitality of our central cell, but to further allow
with Erb that this is occasioned, or first brought to our notice in most
cases, by an increase in the impulses sent to that cell by means of
peripheral irritation.


      BACTERIA, WITH A METHOD OF STAINING FOR DIAGNOSTIC PURPOSES.

                        BY JOSEPH KETCHUM, ESQ.

 Read and Demonstrated before the Section on Microscopy of the Brooklyn
                               Institute.

In presenting the subject of Bacteria, I wish to disclaim any
originality for the matter offered. I have endeavored to collect from
such sources of information as I have access to the important dates,
names and facts which have marked the progress of bacteriology up to the
present time.

So far as we know, the first observer of bacteria and the so-called
infusoria was Leeuwenhoek, who, with a simple magnifying glass, noticed
in a drop of putrid water the multitude of little granules moving about
in it. This was in 1675, and his observations were communicated to the
Royal Society of Sciences in the same year. In the following year he
recognized bacteria in the tartar from the teeth, and though he did not
name them, his description of their forms and his drawings enable us to
identify them as vibrios. There appears to have been no important
investigations carried on until nearly one hundred years later, or in
1773, when Müller, a Dane, attempted to classify the organisms then
known. He called them all infusoria, from the fact that they were the
product of infusions, and divided them into two genera—the monas and
vibrio. The monas he subdivided into ten forms and the vibrio into
thirty-five; but his descriptions of them are so faulty that it is at
present impossible to identify them from his writings. During the
following century the study of bacteriology attracted more or less
attention, and in 1829 Eherenberg, who is the Humboldt of the science,
commenced his investigations, which for fifty years he pursued with an
ardor and enthusiasm second to not even Darwin himself. He, in 1838,
classified the family of vibrioniens, and with the additions made by
Dujardin in 1841, placed them in a scientific category. Of course during
this period many were the disputes and discussions as to specie, genera
or family, each newly discovered member belonged to. And we have to come
to the period of Hallier, Hoffmann and Cohn, and many others, before the
questions, which had up to that time been in dispute, were settled.
Ehrenberg’s original classification was into:

1. Bacterium, or rod-like—three species.

2. Vibrio, snake-like and flexible—nine species.

3. Spirillum, or spiral, but inflexible—three species.

4. Spirochœte, spiral, but flexible—one species.

Dujardin, in 1841, in his Natural History of the Zoophytes, accepted the
classification of Eherenberg, except that he unites the spirillum and
spirochœte, calling them all spirillum. Up to this time all bacteria had
been considered animals, but a close study of their life history and
habitat by those who followed declared them to belong to the vegetable
kingdom, and as such they are accepted to-day.

In 1853, M. Chas. Robin pointed out the relationship of bacteria to
Leptothrix, a form of fungi closely allied to that of mildew; and M.
Davaine, in 1868, clearly demonstrated their relationship to the
vegetable world. From this time the progress of bacteriological
investigation has made rapid strides. Prof. Pasteur in the organisms of
fermentation and the role they play therein; Davaine and Hallier in
demonstrating the specific relationship of bacteria with charbon or
anthrax; and the work of Koch, Nageli, Kohn, Bilroth, Miguel, Burdon,
Sanderson, Klein, Weigert, Klebs, Ehrlich, Sternberg, and many others,
are too recent to require special mention.

Few have more than the faintest conception of the minuteness of these
organisms. Prof. Cohn, justifying himself for the unscientific method of
comparison which he uses in class instruction by Prof. Tyndall’s
argument on the scientific use of the imagination, says he compares man
to the cheese mite, as the Strasburg cathedral to a sparrow. Of the
animalcules which Leeuwenhoek discovered, they are to man as the bee is
to the horse. As improvements have been made in microscopes, just so
fast have we penetrated into the world of micro-organisms, until now the
proportion between the smallest we can see and man, is as man is to Mont
Blanc.

Of course, with these exceedingly minute structures, nothing can be made
out except points. Among some of the larger forms, a few have been able
to see cellia, and in some cases the growth of the spores; but in the
present state of microscopical optics the work is slow, and progress in
this direction is waiting an advance in the science of optics.

Like all living organisms, bacteria propagate themselves. The most usual
method is by fission or by partition, though Magnin and Cohn have
recorded their observations on the formation of spores and sporangia,
and I have myself witnessed the last named method. It is of importance
to note that while the bacterium is killed by continued exposure to
temperatures of freezing or 176° F., the spores will germinate after
protracted exposure to temperature as high as 205° F. or as low as °123
F. These spores will also withstand complete desiccation, and it is in
this form, mixed with the air we breathe and move in, that present the
conditions from which all zymotic diseases originate. Miguel has shown
that, while the air contains very few adult bacteria, it contains
myriads of their spores. To the researches of Koch, Pasteur, and others,
we are indebted for the certain information that, while these
omnipresent germs withstand such vicissitudes of temperature, they
require certain food for their maintenance; and though we cannot as yet
tell what that food is, we know that when nutrient material is submitted
to their action they thrive for a time, and when the particular
principle which supports them is exhausted they die. This is
particularly true of pathogenic germs, and the accepted theory of the
bacillus tuberculosis, or the germ of consumption, is a good
illustration. It has been demonstrated by Koch, Klein, Pasteur,
Frankell, Sternberg, and others, that they require some product of
inflammatory action for their support within the body of their victim.
This is also true of cholera, at least so far as their dietary
requirements are concerned. The animal cannot be infected with
tuberculosis by merely introducing the germ-laden material into the
stomach or upon any of the mucous membranes; but if an inflammatory
condition be present, either due to the puncture of the introducing
needle or scalpel, or to extraneous causes, such as a catarrhal
condition of the lungs, tuberculosis is as sure to follow as the sun is
to rise again.

The human mind can scarcely comprehend the enormous numbers of these
omnipresent atoms without a resort again to the legitimate use of the
imagination. A computation of the increase from a parent germ shows as
follows: We know that the parent grows until it reaches double its
original size, when it constricts itself in the middle like a figure
eight and breaks into two individuals. Each of these divides again, and,
on account of the rapidity with which this is done, we find them usually
in chains or squares. The warmer the air, the faster this proceeds, and
at the temperature of the body the entire life history of a germ, from
the time of fission of the parent to the time of his own subdivision
into two new individuals occupies less than one hour. This gives us a
known quantity for our problem. Let us look at the result. From a single
germ increasing by the power of two each hour, we have at the end of
twenty-four hours 16,777,220; at the end of two days the number has
increased to 281 billions, and in three days to the enormous number of
48 trillions, and in one week the number can only be expressed by
figures of fifty-places. In order to make this number comprehensible,
let us figure the mass and weight of this, the result of a single
bacterium. A single Bacterium Termo has an average width of 1/1,000 mm.
A cubic mm. would therefore contain six hundred and thirty-three
millions, and in one day would be one-fortieth full. At the end of the
following day there would be required 444,570 such cubes to contain the
product of the parent, or say half a litre. Suppose the seas of the
earth cover two-thirds of its surface with a mean depth of one mile, the
aqueous product would be 929 million miles. Now, our parent germ and its
product would in five days completely fill this space. More wonderful
still is a gravimetric estimation. Suppose we call the specific weight
of the parent germ the same as water, which cannot be far from right, it
would appear that the parent weighs, or his equal bulk of water weighs,
136 millionths of a gramme; in forty-eight hours, 442 grammes; in three
days, nearly 7½ million kilograms; and, inside of thirty days, the
weight of the earth itself.

Prof. Cohn, in offering these figures, says: “I don’t consider this idle
play; without it we can form no conception of not only the enormous
increase, but the tremendous destruction of these germs which is going
on around us. Food is lacking to support more than a comparatively small
proportion of the product of the parent, and, as it is demonstrated that
they feed from their environment, one can readily understand that
without a constant supply a given infectious germ will with its
followers soon destroy its nidus or perish from starvation.”

Our breweries demonstrate the truth of this hypothesis; for, in
twenty-four hours, a single yeast cell, which is 8/1,000 mm. in
diameter, will yield one hundred-weight of yeast.

I have endeavored to present the subject in a condensed but general way
without burdening you with technical details of species, genera or life
history. The subject is a vast one and to which the best minds of the
scientific world are devoting themselves. To those who are or may become
interested in bacteriology and particularly to those who study the
relation of these germs to disease, is held forth the reward which is
sure to come to those who work persistently and intelligently.

The method which I shall employ to-night is eclectic. Doubtless each
investigator will find fault with some parts of the process and perhaps
suggest a better one. The following, however, has in my hands worked
well and given entire satisfaction, so far as I know, to those who were
and are most interested.

The apparatus necessary is as follows:

One two-inch glass funnel.

One package filter papers to fit same.

Four medium size test tubes.

Two glass or porcelain staining glasses.

One glass or agate mortar and pestle.

One cover holder.

One pair pincetts.

One alcohol lamp.

Package of wooden toothpicks.

The cover holder may be easily made by taking a piece of thin platinum,
two inches long and one-eighth wide, splitting one end for half an inch
up and bending into a Y shape, then lashing to a small handle (I use a
match). This little tool is most convenient for floating cover glasses
in staining fluids.

The reagents necessary are as follows:

A five per cent. solution of nitric acid in alcohol (95 per cent.).

Saturated alcoholic solution of fuchsine.

Saturated alcoholic solution of methyl blue.

Small quantity of alcohol, 80 to 95 per cent.

Pure colorless aniline oil (anilin).

The method is as follows:

First pour enough aniline into a test tube to cover the bottom and half
fill with water, shake violently for two minutes, and filter through
funnel, which has previously had wet filter paper fitted. It is
essential that the filter paper be saturated with water, else the
aniline oil will separate during filtration. Our next step is to deposit
specimen of sputum in mortar (if very viscid, add a few drops of water),
and triturate thoroughly in order to break up encapsulated colonies, and
distribute evenly through the specimen.

Now remove an amount which will just cover end of toothpick, and deposit
it on a previously cleaned cover glass, which should not be over 1/100
inch thick, and thinner if possible; immediately cover with another
cover glass, allowing sputum to spread by capillarity or slight
pressure, and separate by sliding apart, and put aside to dry without
heat. I have found that specimens dried without heat (and consequent
coagulation of albumen) will show a much larger number of bacilli than
when heat is used. I believe this is due to the fact that the fuchsine
penetrates more thoroughly through the albumen when not coagulated, or
that when it is coagulated by heat it to a greater or less extent it
protects them from the action of the stain. While the covers are drying
we will pour out a sufficient quantity of the aniline water, which by
this time has filtered into one of the staining glasses, and add one or
two drops (not more) fuchsine solution. Now, placing one of the cover
glasses on our cover holder, sputum side down, we lower it into the
staining fluid and withdraw holder from the side, and repeat the
operation for the other cover glass. It is my habit to allow the covers
to remain in this solution for at least eight hours or over night. The
time may be reduced to ten or fifteen minutes by heating the red stain
to about 140 or 150 F., but the result is not so brilliant, nor is it
sure, as I have frequently failed to find the bacilli by the short
method, but have been able to demonstrate their presence by the long
one.

At the end of either of the above periods of time, the cover glass is
lifted out of the staining solution and, without washing, immersed in
our five per cent. solution of nitric acid and alcohol. It is this part
of the process, if any, which will give trouble, as the time of
immersion is governed by the thickness and general character of the
sputum. My custom is to hold the first cover immersed until the color
has just disappeared, or say fifteen seconds, and the second five
seconds longer; but a very little experience will remove any difficulty
from over-decolorizing.

From the decolorizing solution they are immediately immersed in water
and thoroughly washed, when they may be again floated in the
contra-stain, which is prepared by filling the other staining glass with
water to which a few drops (three or four) of our methyl blue has been
added. They should remain here for from five to eight minutes, when they
are again removed with the pincetts, and a few drops of alcohol poured
over them to wash off the surplus stain. Again wash in clean water, and
dry by gentle heat (which will now do no harm) over the alcohol lamp,
and place sputum side up on table.

A very small drop of thin benzole balsam is now placed in the centre of
each cover, and a cleansed slide gently lowered over one in such a
position that both covers may be mounted on a single slide. As soon as
the slide has been sufficiently lowered to come in contact with the drop
of balsam, it spreads by capillarity, and draws the cover close to the
slide without the slightest danger from air bubbles being engaged, and
the slide may at once be inspected by a _dry_ objective.

I have found it necessary to use an objective at least as high as
one-fifth or one-sixth, with central illumination without diaphragm, as
cases will frequently occur where the staining is so faint, that with a
lower power they will escape observation, though a good, wide angle,
four-tenths inch, will show them well when strongly stained.

I have endeavored to explain the method with perhaps too strict a regard
to detail, but am sure that one who follows the various steps once or
twice cannot fail to acquire the necessary technique without occupying
more than fifteen minutes of working time; that is to say, five minutes
to the first staining, and then the following morning to prepare and
mount for observation.

 171 GATES AVE., BROOKLYN.


 ADDRESS TO THE GRADUATES OF THE LONG ISLAND COLLEGE HOSPITAL TRAINING
              SCHOOL FOR NURSES, DELIVERED JUNE 12, 1888.

                    BY GEORGE G. HOPKINS, A.M., M.D.

_Ladies and Gentlemen and Class of 1888_: We are apt to claim the
trained female nurse as the outcome of the more rational treatment of
disease, in modern times, but this is wide of the truth. So far as I can
ascertain, in my researches among the ancient Vidas of Hindostan, and
the literature of Egypt, Greece and Rome, I find no allusion to female
nurses as a class, until the third century of the Christian era. Surgery
and medicine had attained a high degree of perfection, many operations
which to-day we claim as new to the nineteenth century were successfully
performed 4,000 years ago; but the special nursing of them seems to have
been done by the medical student, or by the practitioner himself. The
earliest record I can find of women devoting themselves to the care of
the sick, and attending to all the duties of a trained nurse, is that of
Empress Helena, mother of Constantine the Great. This noble woman, who
lived nearly fifteen hundred years ago, not only founded a hospital and
endowed it, but herself, with the ladies of her court, there gave the
most devoted and tender care to the sick poor. The Emperor Valens
presented the most beautiful grounds and buildings in the neighborhood
of Cæsarea to Archbishop Basil, “for the benefit of the poor whose
bodies were afflicted with disease,” as being those who stood most in
need of assistance. And as early as A. D. 373, the Archbishop had
organized at Cæsarea an immense hospital, called the “Basilides,” which
Gregory Nazienza thought worthy to be recorded among the wonders of the
world; so numerous were the poor and sick who came thither, and so
admirable was the care and order in which they were served. The charge
of these sufferers was not at first assigned to humble hands; the most
illustrious ladies of the empire participating in the offices of mercy.

At Constantinople the Empress Flacilla, wife of the elder Theodosius, in
the year 380 was watching with solicitude over all those whose bodies
were mutilated, or who had lost limbs. She visited them in their own
dwellings, waited upon them herself, and supplied their wants. She
repaired with the same zeal to the public hospitals of the church, where
she attended the sick, made ready their culinary utensils, tasted their
broth, carried the dish to them, broke the bread, divided the meal,
washed the cups, and performed for them all the offices which usually
devolve upon servants. One might justly be proud to be in such royal
company, and regard, as she did, nothing degrading which is necessary to
be done for a sick patient.

In modern times, the revival of nursing by trained women is due in great
measure to that noble and accomplished woman, Florence Nightingale. As
early as 1844, at the age of twenty-one years, she began to exhibit her
interest in and the alleviation of suffering, and the improvement of the
care of the sick poor in the hospitals of Great Britain. She visited and
inspected the hospitals of Europe, and in 1851 entered into training as
a nurse, in the institution of Protestant Deaconesses, at Kaiserworth on
the Rhine. On her return to London she put into thorough order the
Sanitarium for Governesses, in connection with the London Institute. She
served ten years of apprenticeship before entering on her life work.

In the spring of 1854 war was declared with Russia, and an army of
25,000 men was despatched to the Crimea. The faulty arrangements of the
British government for the care of the sick and wounded furnished the
theatre in which Florence Nightingale was to win her first laurels. The
hospitals were soon crowded, and the mortality in the wards so great
that the casualties of the fiercest battles were as nothing in
comparison.

The war office recognizing the condition of affairs, gladly accepted the
offer of Miss Nightingale to go to the seat of war and organize a
nursing department.

Her devotion to the sufferers can never be forgotten, she has stood
twenty hours at a time, directing and assisting in the care of the sick
and wounded. Her unfaltering devotion and incessant work undermined her
health; but though sick and feeble, she never left the field of duty
until Turkey was evacuated by the English troops. Major Delafield (who
with Maj. Mordecai and Capt. Geo. B. McClellan, U. S. A., had been sent
to Europe by our government, to study the art of war in the Crimea), in
his report to the War Department, remarks, in speaking of the English
hospital at Scutari, “It was in this well-arranged hospital that that
most estimable lady, Miss Nightingale, exercised her powerful influence
in alleviating the condition of the sick and wounded from the
battle-field. Women as nurses were employed to attend upon the men in
the wards, under the kind and beneficent guardianship of this good lady,
with the many advantages that would naturally follow the most gentle,
painstaking, and cleanly attendance of women as nurses. Miss
Nightingale’s efforts have resulted in the establishing, in connection
with the English army, an office known as the ‘Superintendant General of
Army Nurses,’ the office to be always filled by a woman. She has under
her a corps of female nurses, who take care of the sick in the military
hospitals.” The Sanitary and Christian Commission of our late war was
the outcome of the volunteer nursing in the English war of the Crimea
and the fruit of these efforts in this country are the training schools
for nurses which have sprung up all over this land.

Next to our entrance into this world and our departure from it,
occasions such as the present, when we have completed our education and
are about to enter upon our chosen vocation, are the most important
events in our lives. The calling which you have chosen, while not a new
one, is comparatively new in having special schools, and courses of
study provided for it. Nursing has always been considered peculiarly
woman’s work—more or less adaptation to such work is inborn in woman.
What man can smoothe the pillow of the sick, or soothe an aching brow as
gently and acceptably as one of the gentler sex! Who can move as
quietly, and approach the bed of pain so gently as woman!

I have seen sick men, absent from home and friends, sigh for a mother,
sister, or wife who is not at hand.

Thanks to this school, and others, everyone can now have skilled female
care when sickness and disease are upon them.

You who are about to go out from us to-day, are entering upon a calling
which will require all the skill, faithfulness, courage, patience,
forbearance, endurance, watchfulness, self-possession, tenderness,
cheerfulness and tact, that a human being can possess, and above all, “a
conscience void of offence toward God and man.” “To thine own self be
true, and it doth follow as the night the day, thou canst not then be
false to any other.” You have each and all of you received, at the hands
of your admirable Superintendent, and the lecturers of the College, such
definite and varied information in all the departments in which you may
be called to act, that you ought to be prepared for most emergencies,
and have shown by your examinations that you have heard and understood
them.

The fault will be yours, and yours alone, if you do not treasure them in
your minds, so that you may be not only trained but _skilled_ nurses.
The responsibility for the proper management of a sick-room and the
patient in it is a very high and grave position, and requires the utmost
faithfulness on the part of the nurse. Unless you are willing to put
aside everything that may interfere with your giving _yourself_ entirely
and conscientiously to the care of your patient, do not assume the
charge. But when you once receive that charge remember that you are
dealing with that which disease can destroy by your negligence, and no
human power can restore—a precious human life. You therefore owe to each
case all that a faithful mind can suggest and the body endure; and such
faithfulness has not been wanting in the former graduates of this
school.

I can never forget the scene when one of our graduates, after having
charge of over thirty cases of typhoid fever among some orphan children,
and we had to lose one, whom she had nursed as faithfully and tenderly
as its own mother could have done, how, when she had done her all and
death claimed him, there were tears shed for one who had no mother to
shed them. And it was due largely to her unremitting faithfulness that
we were able to record but two deaths in thirty-three cases. That woman
has not had an idle day to my knowledge in several years.

When any unexpected emergency arises, which to your educated eye teaches
you that your patient is in extreme danger, do not alarm the friends
unnecessarily; try not to show in your voice or conduct that you are
demoralized and have lost courage. While doing the best you can (until
the arrival of the physician, whom it was your first duty to have
summoned), encourage those around you, and keep them busy if you can,
as, unless they are occupied, the coming of the physician will seem to
them unreasonably delayed, even though he be at hand when called. Above
all, do not let every physician within reach be sent for, unless the
situation is one of great urgency, as I believe many patients have been
frightened to death by the demoralization of solicitous friends.

If you can show yourself capable and maintain your own composure of
mind, you will be able in nearly every instance to avert a panic, and in
many cases prevent disastrous results to your patient. But if you fail
at times for want of proper courage, do not give up with a feeling that
you are unequal to emergencies, only be the more determined not to show
the white feather again.

It is a well known fact to military men, that veteran troops who have
stood the brunt of the fight in many a battle, become demoralized
unexpectedly and retreat, to the utter surprise of their officers. But
in their next battle their courage and deeds of prowess again surprise
every one. So be it with you.

In the sick-room nothing so distresses the helpless sufferer as a want
of frankness on the part of the attendant. You may refuse or neglect to
answer, or turn the subject if possible, but never tell what are called
“white lies.” One lie always requires another to cover it, and sooner or
later you will be caught. If it is not best to tell, say outright it is
better for me not to answer that question; or it may be the least of two
evils to answer it faithfully as patients often imagine that things are
far worse than they are. I believe that we of the medical profession
often err in withholding from patients that which it is best in the end
that they should know. This is one of our most difficult lines to draw.

If you have not learned or are not determined to learn to endure the
caprices and demands of unreasonable men and women in the most
unreasonable hour of their lives, you have mistaken your calling; as
without Christian patience, I do not believe it possible for a nurse to
succeed for any length of time. The trials and vexations of a nurse’s
life are so numerous and so constant, that it is a wonder to me that
there are so many who are ready to enter this calling in life. There is
no need since the revival of professional nursing for women to torture
themselves or do penance. Be as ready to minister to disagreeable people
as a person who two years ago wrote that she would take a fresh air
child, saying “send me one of the dirtiest, most unattractive and unruly
of the children, one whom nobody else wants.” An unreasonable, selfish
and wilful patient is a purgatorial discipline for both nurse and
doctor.

Remember that the most gentle and considerate of people will say and do
things when sick unwittingly, that in health they would sooner cut out
their tongues or destroy a limb than say or do. The mind is sick as well
as the body, and the patient not responsible. Cultivate forbearance and
endeavor to sear all your tender points. Be ever ready to excuse and
believe that no slight was intended, unless it is reiterated and you are
forced to believe it.

The physical and mental strain which you are at times called to bear
will be very great; that you may be able to endure it, you must give
special care to your health. You have been taught the laws of health,
and yours is so arduous a calling you must observe them strictly. Dame
Nature is a stern mistress, and if you disobey her you will surely
suffer for it. When you are out of employment you will need recreation
and diversion to keep both body and mind in the best condition. When you
are in charge of a patient, the time away from the bedside is not yours
to do with as you please, but for rest and fresh air; as you owe it to
your patient to give the best possible service, and thus only can you do
it.

You must cultivate the habit of observing the least change in your
patient’s condition, so as to be ready to meet any emergency; it will
not do to sit down and watch your patient as a cat would a mouse. Yet in
severe cases your eye should hardly ever be off your patient; this
should be accomplished and can be done in such a way as to be almost
imperceptible to the sufferer. Every little change should be noted, and
if any importance may attach to it, it should be written down as soon as
you can conveniently do so. You are the physician’s eyes, ears, and
hands while he is absent; you cannot therefore be too watchful.

Each one of us has certain vulnerable points of character, but it is not
always easy for us to see them. If we would be self-possessed we must
seek to discover these weak points in our armor by seeing ourselves as
others see us; then by learning how to cover them, and not be
disconcerted when our weak point is attacked. No _one_ virtue is of more
value in your arduous calling than this one of self-possession.

In this world of care and trouble much can be done to ameliorate
suffering and soften the sting of pain by tender, sympathetic care; your
patients will expect less of you if all you do is done with ease and
quietness and thoughtful tenderness. You will then be likely to gain a
friend in every patient; the patient will feel that a friend has gone
when you depart.

A cheerful character rides smoothly over many rough places in this world
that otherwise would jolt terribly. A bright, cheery nurse is better
than many a dose of medicine for the patient; therefore be always
cheerful. By cheerful I do not mean frivolous, as levity is the last
thing that should appear in a room where such mighty elements are at
work as in the sick-chamber. Therefore be cheery, but not mirthful or
giddy.

There are some words in the dead languages which it is almost impossible
to put into English without, in a great measure, losing their meaning
because they contain so much in themselves; they are so difficult to
define. So there is one little word in the English language that
contains so much in itself that it is impossible to define it in a few
words, and after using many you feel that you have only sailed around it
without getting at the central and most important part of it—that word
is _tact_. But it is the want of that which has consigned some of the
brightest and noblest minds that I have known to oblivion. I call to
mind just now one of the best read and most highly cultured and gifted
men that the medical profession of Brooklyn has ever known. He lived and
died among us, unappreciated except by the few who knew him best, little
sought after by those who needed balm for their diseases, which he was
better able to apply than most of his companions, and with scanty
maintenance, while medical sky-rockets about him were riding into
lucrative practices. The suffering continued to suffer, when, if they
had only known it, skilled and efficient help was at hand, in a man who
did not know how to so bear himself as to win the confidence of the
community. Had he possessed a little tact his name would have been known
to the world.

I want to say to each one of you, consider well if you propose to follow
this arduous calling, pause and consider whether you really feel that it
is your vocation, and feel equal to its physical and mental demands.

An ideal to strive after is good for us all. I will lay before you
to-night one that was realized in the history of a friend who is now in
a better and happier clime than this, and whom I would be glad to have
each one of you strive to emulate.

Some years ago, before, as far as I know, there were any trained nurses
in this city, I was asked to go to see a lady in a neighboring village,
who had been confined to her bed for more than a year, and was supposed
to be incurable. A year from that time she was able to be about, and six
months later she determined to devote her time to the care of the sick
poor. She did so, and I never had any one who would, or could, take
better care of every case that fell to her charge. I always felt that,
as far as human skill and strength could do it, my directions would be
carried out to the very letter. Her last case was that of a little girl
who had been burned over about three-quarters of her body, a degree of
burning usually considered fatal; but in this case it did not prove so;
and for months this noble woman dressed this suffering child, and would
let no one else do it. Little Tina dreaded to have any one else touch
her. The child was almost well, and this good woman was just finishing
her morning dressing of the burn, when she suddenly fell back and
expired. The soldier died at her post of duty.

“Like a star which maketh not haste and taketh not rest, let each be
fulfilling his heaven born hest.”


                     THE ETHICS OF OPIUM HABITUES.

                       BY J. B. MATTISON, M. D.,

  Read before the Society of Medical Jurisprudence and State Medicine,
                             June 14, 1888.

“All men are liars,” said the writer of ancient days, and the revised
version of modern times is, “All men—who take opium—are liars.”

The writer—whose initial acquaintance with this question dates back
nearly two decades, and whose professional experience for several years
has been exclusively devoted to a large and enlarging clientele of this
class—has long held this opinion to be a mistaken one. Years ago he
wrote—“Clinical Notes on Opium Addiction,” read before the Kings Co.
Med. Soc., 16th January, 1883—“Nor do we share in the opinion, largely
held, that no reliance is to be placed on the word of opium habitués.
That the habitual use of opium, in many cases, does exert a baneful
influence on the moral nature we are well aware, but we also know that
in the ranks of these unfortunates are those who would scorn to deceive,
and whose statements are as worthy of credence as those upon whom has
not fallen this blight.” Increasing attention to this topic has only
confirmed that belief, and the recent statement—unwarranted and
untrue—of a medical writer and teacher, that “no morphia habitué can be
depended on to tell the truth,” with the courteous invitation of your
honored President to present you a paper, has prompted me to offer some
thoughts on this subject—the result of observation, reflection and
applied common sense.

Putting the query—why do men take opium?—the answer to-day is that made
nearly twenty years ago by Dr. Joseph Parrish, Pres. Amer. Assoc. for
the cure of Inebriates—“men take it for a physical necessity.” In an
experience covering the history and treatment of hundreds of cases, I
have noted only two exceptions.

Let it be distinctly understood that my remarks apply only to the better
class of habitués, who have become such by force of conditions beyond
control. With those who, viciously indulgent and lacking alike in
principle and purpose, take opium from mere sensual desire, we have
nothing to do.

This physical necessity, the great genetic factor in an opiate using, it
need scarcely be said, has its rise in painful disorder of body or mind.
For this opium in some form is given, which, when the legitimate need
for its action is ended, entails a demand for continued taking that will
not be denied.

The larger share of responsibility then rests on the medical man who
prescribes—very properly it may be—this valued drug, though the main
measure of his responsibility depends not on the initial using, but upon
the case being dismissed without full thought as to the ultimate result
of the opiate taking, and with a neglect to warn the patient against the
danger of continued using, and insisting upon—giving to this his
personal attention—the entire narcotic disusing when the proper need for
its taking is ended. Vide “The Genesis of Opium Addiction,” _Detroit
Lancet, 1884_, and “The Responsibility of the Profession in the
Production of Opium Inebriety,” _Med. and Surg. Reporter, 1878_.

Granting this correct, on what principle of equity or right can one be
held accountable, and so culpable, for his use of the drug when, unaware
of its ensnaring power, and, confiding in the counsel of his medical
adviser he avails himself of the relief it affords?

Another and most important auxiliary factor obtains in these cases—one
of which the laity knows little or nothing, and the profession
appreciates less than it should—and that is the power opium possesses to
create a necessity of its own. Of this, I venture to assert that no one,
other than the subject of a painful personal experience, or of large
observation, can form a fully adequate idea. The writer has been
studying opium and opium habitués for more than sixteen years, with an
annual experience, of late, as regards number of cases, that is probably
unequalled in this country, and yet he stands more and more in awe of
this peculiar power with every case that comes under his care.

Granting a painful physical necessity, and the daily or semi-daily use
of opium—especially morphia, subcutaneously—for a few weeks or months,
and there are few, if any, who can withstand the ensnaring, enslaving
power of this drug. Men stronger of brain and brawn than we have gone
down before it. I have known a superbly athletic specimen of physical
manhood, able to resist the wintry rigor of a polar expedition, succumb
to the power of morphia in less than a month. I have seen a man so
generously endowed that he survived the horrors of Salisbury when the
death rate averaged eighty per cent., go down before the same resistless
power in four weeks. It was my pleasure to see this gentleman recover,
and take the lecture platform to tell of his bondage and escape, and
this is what he said:

“I proclaim it as my sincere belief that any one afflicted with neurotic
disease of marked severity, and who has in his possession a hypodermic
syringe and morphia solution, is bound to become, sooner or later, if he
tampers at all with the potent and fascinating alleviative, an opium
habitué. The first dose is taken, and mark the transformation. This
overmastering palliative creates such a confident, serene, and
devil-may-care assurance, that one does not for once think of the final
result. The sweetness of such harmony can never give way to monotony.
Volition is suspended. You may not think of it when the pain for which
it was taken subsides. But when distress supervenes you go at once for
the only balm that abounds in Gilead, and every additional dose is but
another thread, however invisible, of which the web is made that binds
us fast as fate.”

If this be true—and it is true—what justice is there in the charge that
these unfortunates continue the use of opium from an innate propensity
to evil, or a merely vicious desire? What right have we to set ourselves
up in judgment to note the beam in our brother’s eye, when the only
reason it is not in our own—when the only reason you and I are not opium
habitués—is because a kind Creator has so conditioned us that this
physical necessity, and consequent opiate need, does not, with us,
obtain?

Having thus touched upon the etiology of this disorder, let us reason
together regarding the special ethical point involved, and note the
reason—if reason there be—for the commonly accepted idea that all men
who use opium are liars. While admitting that the habitual need and use
of this drug does, in many cases, warrant such assertion, I hold that
the leading factor in this moral obliquity is the principle of self
protection—the habitué’s desire to shield himself from that censure
which the prevalent opinion—uncharitable and untrue—that he is simply
the victim of his own vicious indulgence, involves.

There are various proofs that this holding is correct, and, too, without
resorting to the opinion held by Lahr, Fiedler, and some others, that
opium habitués are the subjects of a mental alienation, both in the
creation and continuance of their addiction, and therefore absolved from
culpable wrong—an opinion in which I do not share. Nor do I believe, for
reasons given, with another German observer, that “the morbid craving
for morphia ranks among the category of other human passions, such as
smoking, gambling, greediness for profit, etc.,” for if this were true,
the impulse to protect one’s self would not so largely prevail.

The opium habitué realizing that he is looked upon as one who has given
himself up to a vicious habit, a habit in which he persists from mere
desire to enjoy the pleasures of opium—pleasures which, be it ever
remembered, soon give place to its pains—and so liable to the censure
which a vicious indulging involves, is impelled—by a feeling common to
us all of guarding our good repute—to yield to the protective temptation
to untruth.

But to this there are numerous exceptions, for many a captive to this
drug, though well nigh crushed by his captivity, and that “cruelty of
ignorance,” which the unjust reproaches of should-be friends entails,
still refuses to seek refuge behind such subterfuge, and scorns to tell
a lie.

And do we not note this same impulse to deceit in most non-habitués who,
lapsing from the right, make effort to avoid the sequence of their sin?
Does the swindler always confess his swindling? Do the thieves, the
forgers, the rascals of any degree, never deny their wrong doing? And
while, in these cases, such double wrong may be the outcome of a general
depravity, that, of itself, tends to prove that if the pernicious effect
of opium in this regard were due solely to its baneful effect upon the
morale in general, we should note the same tendency to lying along the
various lines of life, whereas, it is a fact that on any question other
than one involving his opiate taking, and consequent accountability, the
habitué may be, and often is, a very prototype of truth.

What is the bearing of this question on the medico-legal status of these
cases? If they be held culpable for the inception and furtherance of
their condition, whatever outcome there may be affecting the
jurisprudence of their action, must, from such erroneous view of the
situation, fail of that legal justice which a correct appreciation of
their case demands.

The writer was recently called upon to testify in the case of a
physician who had been under his care for treatment of narcotic
inebriety. This gentleman was the subject of delusions and
hallucinations, so marked, that, in my opinion, he was not accountable
for his conduct. Suit for separation was brought against him, and the
referee’s remarks during the trial, and his final decision, were in
keeping with the belief that the defendant was responsible for the
consequences of his alienation.

Again, a right appreciation of the status of such patients will lessen
the labors of the doctor and the lawyer in their legal aspect, and
remove the risk of failure to determine the true physical condition of
the habitué where the question of narcotic taking is the leading issue
in the case. To illustrate. Granting a general acceptance of my
assertion that the class to which this paper pertains are the subjects
of a disturbed organism, beyond their control, and for which they are
blameless; and granting an appreciation of this belief by the patients
themselves, then their main motive for concealment will be removed, and
no more reason for untruth exist than if they were the victims of any
other functional disease.

Again, the present general opinion of these patients is such that once a
case comes into court to settle the question of an opiate using, the
defendant, desirous of protecting himself, by denying his drug taking,
makes it essential that evidence be secured to disprove his statement,
and if certain signs be wanting, the habitué may quite outwit the
medical expert. The writer noted a case of this sort last summer. A
lady, cultured and refined, who had fallen a victim to morphia years
before, and who was party to a suit in court, was examined by two
well-known female physicians of this city, who, failing to apply the one
infallible test of an opiate using, testified that she was not an
habitué. They were mistaken—the lady was taking morphia, though she has
since recovered. The point involved, to spare the chagrin of such an
error, is obvious.

Lastly, what is the trend of a more rational view of this question as
regards the treatment of these cases? Reference has been made to the
statement that “no morphia habitué can be depended on to tell the
truth”—a statement so often at variance with the fact that it must be
the outcome of an experience with the baser class of cases—and I submit
the wrong of regarding _all_ as liars because _some_ fail to tell the
truth; or, added evidence of the “cruelty of ignorance;” or, an
unwarranted libel on a worthy class of unfortunates, who, Heaven knows,
have enough to bear without loading them with the reproach such an
injustice implies.

Nevertheless it is just such an opinion, and consequent lack of
confidence in the honor of these patients that influences their
management by some medical men. Looked upon as the victims of their own
wrong-doing, or as unworthy the sympathy that should ever exist between
physician and patient, or treated on the erroneous belief that such is
the only proper method, they are consigned to the brutal ordeal of
abrupt and entire opiate disusing, which, while it may end in the
desired result, entails such suffering of mind and body as to be utterly
inexcusable—because a more humane method will avail—except under
conditions peculiar and beyond control.

I am well aware that such coercive measures are the only hope of cure in
some cases, but I also know that such patients are not of the better
class, and that, once the drug abandoned, the prospect of continued
recovery is small, because they lack one of the essential requisites for
a permanently good result—that is an earnest desire to be cured.

And the promise of good results from this better way in regarding such
patients is more far reaching than on first thought might appear, for
the ex-opium habitué forced to stem a tide of distrust—special, as to
his cure, and general, as to the permanence of that cure—finds himself
hampered in continued well-doing by the lack of that hopeful trust that
would largely conduce to his good getting on.

In a recent letter from a lady who honored the writer with her care,
nearly three years ago, she referred to the permanence of her recovery,
and added—“but as I found it difficult to make every one believe this,
much less acknowledge it in my favor, I resorted to the best means I
could think of to establish corroborative testimony that _would_ avail,
and during _all_ the time I have been in or near—the past two years, I
have gone regularly every few days to a physician of prominence here, my
old friend and medical adviser of many years’ standing, and had him make
every test he desired, placing on record my exact condition, and showing
the real truth of the matter. I continue to do this, and intend to do
so, and have let people generally know that such a record is being made.
I need not tell you that I am proud of my victory. The struggle against
ungentle and unfair judgment of those around you make a combination of
overwhelming power against the reformed opium taker. It is there that
the _real_ conflict begins.”

The writer’s professional work among this class has long been along the
line here noted. He has extended confidence—very rarely has it been
broken; he has asked for confidence, and the general result can be truly
and tersely stated—increasing satisfaction and success.

And now, gentlemen, what are the conclusions of this whole matter?
These.

Reason and right alike demand a more rational and correct idea as to the
origin of the toxic neurosis we have noted.

This demand complied with—regarding such patients, with certain
exceptions, as creatures of conditions beyond control, and so no more
culpable than the subjects of other functional disorder—will be most
helpful against the protective temptation to untruth.

The medico-legal status of such cases will then be more in keeping with
advanced forensic medicine.

The medical care of these cases will tend to a more humane method, with
a larger promise of good results, both near and remote.

It will, too, be likely to lessen the increase of habitués, and the
number now existing, for a more correct idea as to the genesis of this
disorder will prompt medical men to greater care in avoiding the cause,
while many a patient—who now shrinks from disclosing his
misfortune—feeling he is not denied the charity his case deserves, and
that he can command resources both helpful and humane, will be impelled
to avail himself of the aid that scientific treatment can surely extend.

 314 STATE STREET.


                        A CASE OF SPINA BIFIDA.

                       BY JAMES W. INGALLS, M.D.

    Presented to the Brooklyn Pathological Society, April 12, 1888.

On September 25th, 1888, was called to attend Mrs. H. in confinement.
Patient was a primipara about twenty years of age, and a native of
Mexico. Both she and her husband were free from any deformity, and had
always enjoyed excellent health. Duration of pregnancy about nine
months. Upon examination, I found the breech presenting. Labor
progressed favorably, and nothing occurred worthy of special note,
except that about half an hour before delivery, while making a digital
examination, I discovered over the sacrum of the child a loose flap or
fold of tissue, the nature of which at that time I was unable to
satisfactorily determine.

After delivery I found the following condition: Over the lumbosacral
region were two flaps, each two inches and a half long and about an inch
wide; the outer borders were free, the middle portions of the inner
borders were attached over the spinal column, and at this point of
attachment there was an opening which communicated with the spinal
canal. This opening was about large enough to admit the tip of the
little finger. The anterior surface of the flaps was simply a
continuation of the integument, the posterior surface was a continuation
and expansion of the membranes of the spinal cord. The edges of these
folds were straight and showed no signs whatever of having been torn or
lacerated. There was atrophy and complete paralysis of both lower limbs.
No other deformities existed. Flaps were placed in close apposition over
the opening into the spinal canal, and upon them was put a thick
compress, held in place by a wide bandage. The child continued to do
well until the morning of the fourth day, when convulsions developed,
and death took place in a few hours.

Dissection showed that there was a fissure of the spinal canal extending
from the second lumbar vertebra down to the sacrum, the laminæ being
absent. Both sciatic nerves were given off in the usual manner.



                     THE BROOKLYN MEDICAL JOURNAL.



                              _EDITORIAL._


               THE FINANCIAL RESULTS OF MEDICAL PRACTICE.

The medical men of the Bay State have been treated several times during
the past decade to the mournful story of the meagre financial results
from a life-long practice of medicine in that commonwealth. The detailed
cases, narrated by Dr. Cotting, were pitiful enough, for they were proof
that a faithful, conscientious and skillful medical career could find
little laid aside for the “rainy day” of personal illness or the
vacation for the tired brain and body, or the reposeful life of a
physician’s family when death had closed in on his labors. In the same
strain Dr. Jeffries, in his late annual address before the Massachusetts
Medical Society, proclaims that “no man has made a fortune as a
physician, I mean no one ever paid his expenses and laid by at interest
enough to live on through the practice of medicine.”

This breathes in the atmosphere of complaint as if the profession of
medicine were exceptional in life’s vocations; as if it, alone of all
the lines of work, did not lead to financial results where “enough to
live on was laid by at interest.” It is very pertinent to ask, in what
pursuit in life inheres that tendency to make the laborers therein
independent of labor? It is equally pertinent to ask, where is there an
instance, in the history of labor, where a man, following the duty
common to his fellow workers and relying on his own unaided hands and
brain, ever acquired the competency to live, in his accustomed sphere,
independent of labor? Dr. Cotting’s instances of the poverty of medical
men are pitiful, but they are duplicated in the ranks of the promoters
of literature, art, science and philanthropic work through historic time
and will be multiplied to the end. Great wealth is the possession of but
very few and, on the lines of legitimate industry, is always the result
of combination and the use made of the labor of others. In the early
part of the century, Mr. Astor founded a fortune by buying up pelts from
the trappers of the Northwest. Had he depended on what his own hands
could have done, his old age would have found him drying his skins and
frying his bacon with his own hands in his forest cabin. Mr. Carnegie
to-day, utilizing the labor of miners in iron and coal and giving
direction to the skill and toil of a multitude of mechanics, is still
adding to his fifty millions. Had he depended on the limitations of his
own brawn, he might still each evening be washing the grime from his
horny hands under the faucet in the hallway of his tenement house
lodgings. These great possibilities of combination are in the genius of
commercial enterprise, though they are realized by few. They are foreign
to the genius of labor where combination is impossible, and where the
labor is of such a character that there is no monopoly of skill and many
can accomplish it equally well. A medical man’s labor is limited by what
he can himself do, personally and unaided. He can neither delegate nor
superintend. His income is limited by these personal conditions,
modified only by the possession of some exceptional skill and the
accidents of popularity or environment. The engrossing character of his
occupation hinders him from the experience that justifies outside
speculation with acquired capital and restrains him from participation
in outside ventures which require freedom both of time and thought. He
cannot well add another string to his bow.

The results of combination in trade and the income from professional
labor are issues from distinct and opposite sources and have no right to
be compared or made the subject of invidious reflection. A number of
lawyers, each an expert in a special department, may form a partnership,
occupy a common office, each helping the other, the emoluments going to
the common fund. This is a sort of combine. But the time is not yet
ripe, and probably will never come, for the incorporation of a great
Medical Trust, with the names of a specialist in eye, ear, throat, nose,
lungs, liver, sphincter ani, corns and fallopian tubes, and so on to the
minutest subdivision, with the addition of some general practitioners
and apothecaries, displayed around the casings of some common front
door, to scoop in the community and pool the receipts on a graded
tariff. Trade is essentially selfish and works for the individual. “If
you don’t work for number one, number two will be working for you.” The
accumulation of money is neither end nor contingent in professional
life. The pursuit and application of medical science are on the higher
level with the learning of jurists, scientists, educators and
literateurs, whose mission is the unselfish search for knowledge for the
immediate benefit of mankind and the advance of civilization.

While it is true that very few in any calling “lay by at interest enough
to live on,” a very small number of that few do actually retire from
active work and live on that interest, and this for two reasons: First,
a man in successful professional life is in receipt of an income which
enables him to live in luxurious surroundings, gratify tastes and enjoy
recreation, which income, considered as interest, would represent a
capital sum exceptional even among the results of successful trade,
stock gambling or railroad wrecking. Such a man, and he is one of many,
could live on what he “has laid by at interest,” if he saw fit to live
in less luxury and sacrifice the gratification of tastes which have been
cultivated and become necessary to his comfort. He could live on his
interest, but he does not care to live in idleness. On the other hand,
the conditions of a cultured life are of an ever widening horizon, and
it is characteristic of medical men that their intellectual sense is
inquisitive, keen, appreciative and alert in their own sphere of action,
less satisfied with what is and more anxious for better results, beyond
the genius of any other professional life, and this for the distinctive
reason that every new discovery in medical science promotes accuracy in
the application of medical art. Working becomes a passion with medical
men; the more they know the more eager they are to work. This passion is
not to “lay by at interest enough to live on.”

It is quite in the sentiment of medical addresses to bewail the
profession as ill-paid, and that, for a learned and self-sacrificing
body of men, its labor and accomplishments are very inadequately
rewarded. The exact contrary is, probably, very much nearer the truth.
There are many learned men in the profession and there is a wide range
of special learning which is the common property of the profession, and
all are more or less adept in the use of agencies of the art. There is,
likewise, a vast amount of patient and uncompensated care given in the
routine of practice, which is a natural outcome of the practice of the
medical art. It would be absurd to claim the diploma as representing a
liberal education or even high special attainments, as it would be
ridiculous to assert that a dispensary patient regularly received the
attention given to the German Kaiser or General Sheridan. There are
instances of failure and poverty among medical men, but when the doctors
in the country stand to the population in the proportion of 1 to 580,
the assumption is that they have become needful, each to his 580.
Doctors have many book charges that are not collected. Laborers are
swindled by their bosses, and every business man meets his unlucky
customers; the parish gets behind with its rector. The doctor is no
worse off than the rest, and besides he has no salary list, and no
accommodation at the bank to make good.

Most men are discontented, and the want of contentment is just as
querulous with the cosmopolitan reputation that unblushingly pockets a
double eagle for a few raps on the thorax as with its suburban and
obscure double that explores a whole chest half an hour for a dollar.
The latter pays a shilling to the village blacksmith to reset a shoe,
and the former hands over eight dollars every time the farrier looks at
his team. Discontent goes with a misfit, and Depew told the Syracuse
students that “misfits were everywhere and were always cheap.” It is
doubtful if, upon the whole, there are in any walk in life such an
unbroken line of splendid fits, the man to his duty and his clientage,
as in the medical profession. It is not to be doubted that medical men,
each to his location, his culture, his taste and his instincts, are
better housed and clothed, more liberally supplied with the machinery of
their technique, have greater demands on their purse in the interests of
charity and reform which are duly met, have better educated families,
have longer and more frequent opportunities for enjoyment which are not
wasted, than can be counted item for item on the balance sheet of the
average worker in any other profession or occupation. And these are the
proofs of financial success, and they put aside the plaint that because
the doctors do not “lay by at interest enough to live on” they are an
ill-used class of men. The community pays liberally for being taken care
of, and it ought to. The medical man’s entire time is taken up in
acquiring the experience to exercise prompt judgment in emergencies, and
this is precisely what the community pays for and is far from niggardly
in the payment. Experience, needful to prompt judgment, is worth more
than day’s wages or marginal profits, and this the community recognizes,
and its estimate on the value of this experience is generally just. It
may not be invariably accurate, but a doctor’s annual cash total is a
very liberal estimate of what his individual experience is worth to the
community. If the doctor does not “lay by at interest,” it is not
because he does not receive enough, but because his relations to life
make a free expenditure of money a necessity. He is at a certain
disadvantage with a fair share of the people in being compelled to pay
his debts. An excellent physician who is also a bohemian or with loose
ideas as to honorable obligation, would be a nondescript. He is a
fixture in the community with an open reputation, and it is proof of his
liberal income that he is able to make and sustain that reputation.


                      THE OPEN STREET-CAR WHISTLE.

The open street car is in its mid-career for 1888, and the fiend of the
whistler is on the vertex of successful practice. The stranglers of the
Orient were an occasional incident in that sunburnt civilization as
compared with the death-dealing, pestilential prevalence of the Brooklyn
open street-car conductor, literally “armed to the teeth” with his
offensive weapon, out of whose depths, impelled by æolic volumes from
jerky and gigantic costo-diaphragmatic spasms, issue the ear-splitting
and nerve-rending combination of fog-horn and prolonged rifle-crack.
From stable to terminus and back, circulating along the outer step,
holding on to the uprights with extended arms, facing forever the
five-cent and helpless “fares,” two to four inches of potential reed or
metal protruding from his embracing lips, like an ill-placed proboscis
on a witless pachyderm, he summons the driver to screw up his brake and
arrest his sportive team for a fare to unload, or to reverse the process
for the temporary torture of more victims in hoisting in of other
patrons of the line, and the shrill horror of his whistling signal,
right in the faces of the passengers, is made more agonizing by the
uncertainty of when and on whom it will discharge its blast, being
forever ready for action, like the lance in rest of the jousting knight.
It would be easy to aim this calliope at the curbstone or the empyrean,
but this regard for the passengers’ tympanum disturbeth not the peaceful
slumber of the tramway directory, whose shibboleth is the Vanderbilt
curse of “the public be ——.” But sadder than the disregard of
common-carriers for public comfort is the unearthed conspiracy of the
otologists with the ill-paid conductors on the horse-cars. For some
years this specialty throve on the otitis acquired at the bathing-houses
at Rockaway and Coney Island, but the public discovered that a little
cotton in the meatus was the needful prophylactic, and otitis, as a
source of revenue, dwindled to the starvation point. Again, and for a
time, the horn of plenty overflows in the otologist’s operating room,
and his commissions to the car conductors promise to put them soon on a
plane with the diamond-bedecked shirt-fronts of the average hotel clerk.
It was said that so possessed was a certain London specialist with the
operation of tonsillotomy that these amputated glands were each morning
shoveled out of his office by the basketful. There are compensations all
through life, and the hordes of cash boys, whose occupation vanished
with the introduction of mechanical carriers into the great dry good
bazaars, now find ample and continuous employment in sweeping out the
heaped up fragments of shattered ear drums from the infirmaries of
otological specialists. Verily, this deal among the ear men with the
whistling open car conductors for the embezzlement of the community
deserves the most summary and high-handed reprobation. There is but the
faintest justification for such combination in the new code, but even
that cannot fairly be pleaded when the integrity of the community’s ear
is imperilled. A proper corps d’esprit would impel to the conservation
of a professional brother’s prosperity, but even that laudable sentiment
must have subordinate place when the profession at large, who are the
conservators of society, see that society is likely to turn a deaf ear
to the varied forms of human plaint, and all owing to the men who can
neither stop or start an open car of a horse railroad without blowing
out the ear drums of the community. The public is in peril and who shall
be the Curtius to jump into the breach. The conductor cannot be appealed
to. He is insensitive, and, besides, he is in authority. One cannot
knock the beastly clarion from his lips’ embrace: there would be the
claim for assault and ejection for disorder. The directors are a weak
reed; they dread a strike. Municipal ordinance would be vainly sought:
workingmen have a union and votes. The police, even the finest, are not
open to bribery: they are at home in a brawl, and noise is their normal
condition of repose. The profession must interfere. Henceforth let the
cry be “boycott the whistle.” If it must exist, let the instruction be
boldly posted at the starter’s office: “Conductors must aim their
whistles at the curbstones and not in the ears of the passengers.”


                       PROMPT TELEPHONE SERVICE.

The telephone is too useful not to be treated properly. It is always an
affair of two parties and each is in duty bound to be considerate of the
other. The bell rings, it is answered promptly, and patience becomes
well nigh exhausted before “central” succeeds in establishing the
connection, and the time of the respondent is wasted. The reason for
this rests on the thoughtlessness or selfishness of the one who makes
the call. He rings and asks for a certain connection, and then hangs up
his instrument, goes away to wait for a summons. In the meantime the
respondent answers, stays by his instrument, “central” endeavors to call
up the caller, perhaps through another office, the connection is often
broken, and after much tribulation the connection is fully made. This is
of very frequent occurrence and could be avoided, for the most part, by
the caller staying by his instrument for the few seconds usually
required to make the connection. There are occasional instances of bad
management and some ugliness in the central office, but they are quite
rare, and the service is very prompt. More delay and annoyance are
caused by thoughtlessness of the users of the telephone than by any
neglect of duty on the part of the operators at the central offices. One
who is called up has a right to consider that he is wanted, and that
promptly. It is the duty of the caller to be careful not to annoy the
central office or waste the respondent’s time. Moral: When you call,
stay by your instrument till the reply comes.


                           OFFICIAL ORTHOEPY.

The Mayor has made his appointments to the vacancies in the Board of
Education. The proper assumption is that they are all good men and true,
able to read, write and cipher. It would be worse than libelous to give
houseroom to the rumor that any member of this responsible Board ever
“made his mark.” One would be properly horrified at the audacity of the
narrator of such a tale as the following: A member of a local committee
entered the class-room as the teacher was conducting the recitation in
spelling from the Reader. After listening for awhile, he intimated his
desire “to give out a few words,” which desire was politely acceded to,
and the book handed to him. A number of words were correctly and
promptly spelled, and he gave out the word “Egg-pit.” One child after
another was downed by the astute member until the teacher, in pity for
her flock, suggested that the word was not in the lesson. Smiling
disdainfully at her ignorance and presumption, he pointed his No. 11
forefinger to E-g-y-p-t. Tableau. The Directory for 1888 intimates that
we live in a city of nearly 800,000 inhabitants.



                      _PROCEEDINGS OF SOCIETIES._


              THE MEDICAL SOCIETY OF THE COUNTY OF KINGS.

A regular monthly meeting of the Medical Society of the County of Kings
was held at the rooms of the Society, No. 356 Bridge Street, Brooklyn,
on June 19, 1888.

The meeting was called to order at 8.30 P. M., with Dr. Wallace in the
chair. There were eighty members present.

The minutes of the previous meeting were read, and on motion adopted as
read.

The Council reported favorably on the names of the following gentlemen:
Drs. Sidney Allen Fox, George H. Treadwell, Fred. L. Goddard, Stanton
Allen, Horace B. Scott.

The following gentlemen were declared elected members of the Society:
Drs. Chas. S. Fischer, James L. Carney, Eliot Gorton, Heber N. Hooper,
Henry H. Morton, Geo. B. Rockwell, Lewis S. Meeker.

The following gentlemen were proposed for membership:

Dr. J. Le Roy Tettemore, 128 Rockaway Avenue; graduated at L. I. C. H.,
1881, proposed by Dr. J. H. Hunt and seconded by Dr. W. B. Chase.

Dr. Stanton Allen, 114 Montague Street, graduated at College of
Physicians and Surgeons, 1881, proposed by Dr. Richmond Lennox and
seconded by Dr. J. S. Prout.

Dr. James W. E. Roby, 115 Lee Avenue, graduated at Medical Department,
N. Y. University, 1887, proposed by Dr. D. Myerle, seconded by Dr. W. M.
Hutchinson.

Dr. Charles G. Purdy, 56 Pulaski Street, graduated at the University of
the City of New York, proposed by Dr. Chase and seconded by Dr. Little.

The Secretary stated that the name of Dr. Stanton Allen was among the
propositions for membership presented at this meeting, and also among
those reported favorably by the Council.

He said in explanation that Dr. Allen’s diploma had been sent to the
Board of Censors and passed upon before his name had been proposed, in
order that the diploma might not remain with the Censors till next
September.

This was an infringement of the By-Laws upon admission of members, but
if no objection was raised, the By-Laws would be waived in this case.

No objection was offered.


                          SCIENTIFIC BUSINESS.

The first paper of the evening, “On the Relation of the Bacillus
Tuberculosis in Pulmonary Phthisis,” was read by Dr. I. H. Platt, of
Lakewood, N. J., and discussed by Drs. G. R. Butler, J. M. Van Cott, J.
H. H. Burge, P. H. Kretzschmar and G. A. Evans.

The next paper was “A Case of Dystocia and Double Phlegmasia-dolens,” by
Dr. Lucy M. Hall. This was discussed by Drs. Dickinson, Thayer, Skene,
Chase, Schenck and Harrigan.

A paper, entitled “Note on the Disinfection of Physicians’ Clothing,” by
Dr. R. L. Dickinson, was then read and discussed.


                         REPORTS OF COMMITTEES.

The President called for the report of the Obituary Committees upon the
late Drs. Chapman and Mitchell.

The obituary report of the late Dr. Chauncey L. Mitchell was then read
by Dr. Burge, as follows:

Chauncey L. Mitchell, whose ancestors were of Puritan stock, coming to
this country from Halifax, England, as early as 1635, was born in New
Canaan, Connecticut, November 20, 1813. An excellent general education,
obtained here and at Union College, Schenectady, was supplemented by a
full course of study in the medical department of the University of the
State of New York, better known as the College of Physicians and
Surgeons, where he was graduated in 1836. The next twelve months were
spent in the New York Hospital, and the succeeding two years on the
continent of Europe. All who knew Dr. Mitchell intimately are so
familiar with his studious habits that they need not be told that he
never lost an opportunity for observation and improvement. This was true
of him, not only during the period of his pupilage, but in all the fifty
years of his active practice, five of which were in the City of New
York. He came to Brooklyn in 1844, was admitted to membership in the
Society of the County of Kings soon after, and was thrice honored by an
election to its highest office. All the duties of his active life he
performed with dignity and zeal. No one more than he enjoyed the
uninterrupted confidence and affection of this community. Among his
friends and patients were numbered the best of our citizens, and he is
now equally missed in the profession, in the church and in the
household. Dr. Mitchell was an earnest and devout believer in the
Christian religion. His connection with the Church of the Pilgrims
antedates the pastorate of the Rev. Dr. Storres, between whom and
himself there was an intimate, personal and professional relationship
for forty years.

Dr. Mitchell’s powers of observation and discrimination and his
exactness of verbal expression were so excellent, that we regret that he
did not give more time to authorship. An article on “The Effects of
Ergot,” “Labor Complicated with Disease of the Heart,” and an occasional
contribution to the journals, are all that we can find of his writings.

During the period of declining health, which occupied more than two
years, Dr. Mitchell resigned many positions of responsibility, yet, at
the time of his death, he was Sn. member of the Council of the Long
Island College Hospital, member of the Amer. Med. Asso., Consulting
Surgeon to St. John’s Hospital, to L. I. Coll. Hospital and to the Home
for Aged Men, a member of the New York Academy of Medicine, New York Co.
Med. Soc., and Kings Co. Med. Asso. He was also a life member and
Corres. Sec’t’y of the L. I. Historical Society. It is matter of record
that he was once a member of the Medical Staff of the Brooklyn City
Hospital, and that he also filled with honor the Professorship of
Obstetrics in the Castleton Medical College.

In 1843, Dr. Mitchell married _Caroline_, daughter of Hon. B. F.
Langdon; in 1857, _Frances_, daughter of Hon. Benjamin Wright; in 1875,
_Kate_, daughter of Hon. J. M. Van Cott, of this city.

Dr. Mitchell’s tastes were professional, literary, artistic and
religious, but the centre of all was his own home. In the house which he
had built more than forty years before, he died on the 8th of May, 1888,
terminating a long career of untiring usefulness.

Mr. Chairman: In the preparation of this minute for the records of the
Society, your committee have recognized the fact that they were
appointed for this simple duty only. The pronouncing of a suitable
eulogy belongs to other hands and to another occasion. We offer for your
consideration the following:

_Whereas_, In obedience to the Divine Law the fully matured life of
Chauncey L. Mitchell is ended on earth, and

_Whereas_, He was destined to fill a high position in the profession of
medicine and as a citizen of this country, and

_Whereas_, He met all these requirements, fulfilled every duty, and
discharged every obligation in such manner as only a highly cultivated,
educated and honest man could, and

_Whereas_, When the end came, those who knew him best could truly say
that he had left nothing undone to complete a noble, highly useful and
honorable life;

_Therefore be it resolved_, That while paying this tribute to his memory
we desire to express our high appreciation of his many virtues, and that
while we deeply feel our loss, we also cherish his memory, and are
grateful for the honor, dignity and advancement which his life’s work
gave to this Society.

_Resolved_, That we offer our deepest sympathy to his bereaved family,
and that a copy of these resolutions be conveyed to them as a humble
tribute to his superior worth.

All of which is respectfully submitted by your committee.

                                               J. H. HOBART BURGE, M.D.,
                                               ALEX. J. C. SKENE, M.D.

The report of the Obituary Committee, as above, was accepted and
committee discharged.

The Resolutions introduced by this committee were adopted as read.


                             NEW BUSINESS.

The Chairman read a communication from the Secretary of the Kings County
Pharmaceutical Society, stating that the term of office of the two
members of the Board of Pharmacy from this Society had expired, and
asking that their places be filled.

THE PRESIDENT.—As I understand it, our elections take place only at the
end of the year, and if this communication is to be acted upon, it will
be necessary for the Society to pass a special resolution authorizing
the election of these gentlemen. If it is the desire that the Society
pass such a resolution, a motion will be in order.

A MEMBER.—I move that the By-Laws be suspended so that the election may
be had this evening. Carried.

THE PRESIDENT.—Nominations are now in order. The present incumbents are
Dr. J. H. Hunt and Dr. C. E. De La Vergne.

A MEMBER.—I move that the two present incumbents be continued in office,
if it be the voice of this Society, until the annual meeting.

Seconded and carried.

There being no further business, the Society adjourned.

                                    W. M. HUTCHINSON, M.D., _Secretary_.



                        _PROGRESS IN MEDICINE._


                          PREVENTIVE MEDICINE.

                       BY ELIAS H. BARTLEY, M.D.,

   Professor of Chemistry and Toxicology, and Lecturer on Diseases of
           Children, Long Island College Hospital, Brooklyn.


                     THE GERM THEORY A CENTURY AGO.

Under this caption the British Med. Journal for February 11, 1888,
contains an editorial review of a pamphlet of 87 pages, published in
1788, and entitled: “_A Treatise on Fevers, wherein their Causes are
exhibited in a new point of view, to prevent Contagion; and Putrid Sore
Throat, Inflammatory Fluxes, Influenza, Consumptions, as well as the Low
Nervous Fevers that terribly affect the Spirits, may be cured with
ease_.”

The most remarkable part of the book is the speculative or explanatory
part, consisting of an exceedingly ingenious argument, based upon the
analogy of admitted facts, to prove that the cause of contagious fevers
is some invisible noxious matter in the air. Of the intimate nature of
this matter he says: Some consider it to be a sulphurous exhalation from
the earth; but this cannot be, for, if so, acrid and sulphurous fumes
would increase it, instead of checking or annihilating it. Another
theory is that it is due to the products of putrefaction; but how can
dead putrid matter ever get such activity as to work such astonishing
results? It must therefore be something endowed with a more powerful
activity than anything belonging to the mineral kingdom or simply
putrefying matter, and must, therefore, be something “actually living.”
He further concludes that these living organisms must have an existence
independent of the body in which they are found. For this view,
surprising and novel enough at first, loses some of its singularity, if
we search for resemblances elsewhere. Now, just as it was well known
that itch is due to the presence of acari, insects visible by the aid of
the microscope, so close attention to these matters in numberless cases
during many years, has proved beyond a doubt that the gaol distemper,
putrid fever, plague, and infectious epidemics generally, proceed not
from matter putrid in itself, but from invisible insects also, that,
floating in the air at times, are lodged in the skin in immense
quantities; feeding here in clusters, they produce pimples, pustules,
etc.; for instance, the eruption of small-pox. He overlooks, or fails to
mention, the possibility of their entering by the air passages or
digestive system. “Medicines,” he says, “which poison insects without
injuring the constitution have always proved specific.” These insects,
which constitute contagion, are communicated by air, the raiment, as by
contact. He admits that vegetables as well as animals suffer from the
ravages of these animalcules. He believed that they originated from eggs
and not _de novo_. He advises fumigations with sulphur and frankincense
to destroy contagion in rooms, and shows that many diseases in lower
animals are cured or prevented by the use of certain agents known to
kill insects.

In summing up his theory, he says that, generally speaking, there are
two sources of these animalcules. First, from subterranean sources,
which operate in all sorts of weather and are accompanied by electrical
phenomena. Second, from the surface of the earth, swamps, filthy lakes,
stagnant ponds, etc. The eggs left on the soil develop in summer, and
“the multitudes effluviate into air.”

The essay is interesting to us because of the very clear foreshowing of
a theory that we are apt to regard as the creation of recent years. It
is a good example of the power of attentive observation and inductive
reasoning, which is so seldom met with even in scientific medical men of
the present day.


           ALBUMINURIA A FREQUENT RESULT OF SEWAGE POISONING.

Dr. George Johnson, in _Br. Med. Jour._ for March 3d, gives the
histories of four cases of albuminuria which he believes were the result
of breathing sewer air. In addition to other diseases, the result of
drain poison, the author has met with several cases of albuminuria which
he believes can and does under continued exposure to the sewer poison,
result in incurable disorganization of the kidneys. He thinks that, in
the absence of other probable exciting causes of albuminuria, the
possibility of sewer poisoning should be constantly borne in mind. It is
needless to dilate upon the importance of discovering the exciting cause
of a disease so serious in its consequences as nephritis. In each of the
four cases cited, albuminuria and casts were found in the urine, and
blood in two of them. In each case defective drainage was proven, and in
two of the four an immediate improvement occurred on removing this
cause. One proved fatal from suppression of the urine.

The author suggests as an interesting point, that amongst the various
diseases resulting from drain poison, diphtheria is in a very large
proportion of cases associated with albuminuria.

It would be interesting to know whether a large proportion of cases of
diphtheria occurring in houses having defective plumbing suffer with
albuminuria, than in houses where no such defect exists. If these
observations are confirmed, we may learn from them something of the
cause of the great fatality of scarlet fever and diphtheria in houses
which contain defective drains.


                          SEWER-AIR POISONING.

The question of sewer-air poisoning has received no inconsiderable
attention at the hands of sanitarians within the past few years, some
claiming that it is a carrier of many of the contagious diseases,
including malarial affections, while others have denied its harmful
action in these respects.

The last class, in substantiation of their claim, point to the assumed
fact that plumbers and those who work in sewers are not, as a rule,
especially subject to the diseases generally attributed to sewer air.
That plumbers are not exempt from troubles of this kind is attested by
numerous examples. According to _Science_, an inquest was recently held
in Liverpool, Eng., on the body of a plumber’s apprentice who had been
engaged in repairing pipes which connected with the sewer. Quantities of
gas came through these pipes, and at the time the young man complained
of pain and sickness, and died forty hours afterward. The jury rendered
a verdict of poisoning by sewer air.

According to the _Sanitary News_, Dr. Vaughn, of the Michigan State
Laboratory of Hygiene, claims to have found the specific germ of typhoid
fever in the air of a soil pipe from the prison at Jackson, in that
State, during an outbreak of typhoid fever.

The _Sanitary Inspector_ for February and March, reproduces from the
_Medical News_ an article by Dr. Henry Hun upon this subject. Dr. Hun
cites twenty-nine cases in support of his statements. The histories are
those of non-contagious diseases, and therefore were probably cases of
illness produced by non-infected sewers. He says: “In all of these
twenty-nine cases there was an escape of a large amount of sewer gas
into the air which the patients breathed; and at the time that the case
was observed, it seemed extremely probable that the sewer gas was the
cause of the disease.

“From the consideration of these twenty-nine cases, we may conclude that
it is probable that the following conditions may result from sewer-air
poisoning:

“1. Vomiting and purging, either separately or combined.

“2. A form of nephritis.

“3. General debility, in some cases of which the heart is especially
involved.

“4. Fever, which is frequently accompanied by chills.

“5. Sore throat, which is frequently of a diphtheritic character.

“6. Neuralgia.

“These conditions may occur separately, but are frequently combined, and
it is especially common for the fever to be associated with other
symptoms of sewer-gas poisoning. Finally, in cases of sewer-gas
poisoning, there is one group of symptoms which is almost always
prominent, and these symptoms are: loss of appetite, drowsiness, extreme
prostration, and a dull, unpleasant feeling in the head; and whenever
this group of symptoms occurs, not as the result of an attack of acute
disease, but as a chronic condition, we are justified in suspecting that
the patient is exposed to sewer-gas infection.”


  EFFECTS OF FOOD PRESERVATIVES ON THE ACTION OF DIASTASE, PANCREATIC
                          EXTRACT AND PEPSINE.

This subject has recently received experimental study at the hands of
Dr. Henry Leffman and William Beam, the results being published in the
_Analyst_ for June, 1888.

The antiseptics selected were those which have been known to be used to
preserve articles of food and drink. They were salicylic acid, boric
acid, sodium acid sulphite (sodium bisulphite), saccharine,
beta-naphthol and alcohol.

In the following experiments a solution of arrow root starch, 30 grains
to the litre, was used.

To 100 c.c. of this solution was added 0.5 c.c. of maltine diluted to 50
c.c. with water.

The figures give the proportion of antiseptic to the whole volume of
liquid.


                      _Experiments with Maltine._

 _Antiseptic used._  _Amount._   _Fehling’s Solution reduced by the Maltose formed._

 None.              None.                              245 cc.
 Salicylic acid.    1 to 500.                     No sugar formed.
 Salicylic acid.    1 to 1,000.                   No sugar formed.
 Salicylic acid.    1 to 20,000.                      245   cc.
 Boric acid.        1 to 1,000.                       245   cc.
 Sodium bisulphite. 1 to 1,000.                       245   cc.
 Saccharine.        1 to 1,000.                       18.5 cc.
 Saccharine.        1 to 500.                          5.6 cc.
 Beta-Naphthol.     1 to 1,000.                       204   cc.
 Beta-Naphthol.     1 to 500.                         174   cc.
 Alcohol.           1 to 25.                          245   cc.

Experiments with varying amounts of diastase showed that one part of
salicylic acid to 1,000 of liquid prevented the diastasic action
completely. Saccharine in the proportion of 1 to 1,000 prevented the
formation of sugar when the proportion of diastase was 1 to 1,000 of
liquid. When the proportion of diastase was reduced to 1 in 2,000,
salicylic in the proportion of 1 to 3,000 prevented the formation of
sugar. It seems, then, that the weaker the diastasic solution, the more
is its action hindered by salicylic acid, saccharine, etc. Sodium
bisulphite has little if any power of hindering diastasic power.


           _Experiments with Fairchild’s Pancreatic Extract._

       _Antiseptic._     _Amount._  _Fehling’s Solution required._

     None.                 None.                78 cc.
     Salicylic acid.    1 to 1,000.        No sugar formed.
     Saccharine.        1 to 1,000.        No sugar formed.
     Beta-Naphthol.     1 to 1,000.             78 cc.
     Boric acid.        1 to 1,000.             78 cc.
     Sodium bisulphite. 1 to 1,000.             80 cc.

The tests were made with 0.2 grams of the extract.

It seems from these experiments that salicylic acid and saccharine, in
the proportions used, entirely prevent the action of pancreatic ferment
upon starch.

In similar experiments with saccharated pepsine with hydrochloric acid,
except that the temperature was kept at 105° F., sodium bisulphite and
boric acid were without effect.

Saccharine and salicylic acid had a slightly retarding action.
Beta-naphthol almost entirely prevented the action.

With pancreatic digestion of albumen the results were practically the
same, but the retarding action of the salicylic acid and saccharine was
not quite so well marked.

From these experiments it will be seen that salicylic acid prevents the
conversion of starch into sugar under the influence of either diastase
or pancreatic extract, but does not seriously interfere with peptic or
pancreatic digestion of albumen. Saccharine holds about the same
relation as salicylic acid.

Sodium bisulphite and boric acid are practically without retarding
effect.

Beta-naphthol decidedly interferes with the formation of sugar by
diastase, but not with the action of pancreatic extract on starch.

It almost entirely prevents both peptic and pancreatic digestion of
albumen.

The bearing of these experiments upon the sanitary question of
permitting the use of these preservatives in foods, is self-evident.
Prof. Leffman says: “Their use is scarcely allowable under any
circumstances, and certainly only when the nature of the preservative
and the amount is distinctly stated.” The use of saccharine as a
sweetening agent must be looked upon as deleterious to health, and ought
to be forbidden by sanitary authorities.


                          MILK AND SCARLATINA.

In a recent number of the JOURNAL, we published an abstract of the
reported investigations of Mr. Power, Dr. Cameron and Dr. Klein of a
disease among cows, which they believed had caused scarlatina among
persons using the milk. The conclusions reached by these gentlemen
seemed so startling that the Agricultural Department of the Privy
Council began an investigation of the disease. The investigation was
given into the hands of Dr. Cruikshank, whose reports are published in
the _British Medical Journal_ of December 17, 1887, and January 21,
1888.

We have only space here to reproduce the conclusions reached by Dr.
Cruikshank, which are as follows:

1. The nature of the contagium of scarlet fever is unknown.

2. The micro-organism regarded by Dr. Klein as this contagium is the
_streptococcus pyogenes_.

3. _Streptococcus pyogenes_ is found sometimes in company with
_staphylococcus pyogenes aureus_, as a secondary result in scarlet fever
and many other diseases.

4. A streptococcus was first observed in scarlet fever by Crooke, later
by Löffler, Huebner and Bahrdt; but its exact relation to scarlatina,
and its undoubted identity with the streptococcus from pus and puerperal
fever, was definitely established in 1885 by Frankel and Freudenberg.

5. Both the Wiltshire and Hendon cow diseases were called cow-pox by the
people on the farms.

6. Both diseases correspond in their clinical history.

7. The ulcers on the teats correspond in naked eye and microscopical
appearances, and the latter vividly recall the appearances of cow-pox.

8. Calves inoculated from the discharges of the ulcers are similarly
affected.

9. _Post-mortem_ examination of such calves, or of calves inoculated
with streptococci isolated from scarlet fever cases, show similar
appearances.

10. The _post-mortem_ appearances in such inoculated calves are the
result of septicæmia.

11. There are no specific visceral changes in cow-pox, apart from
complications or coincident affections.

To the above criticism of Dr. Klein’s investigation of the Hendon cow
disease, this gentleman claims that Dr. Cruikshank studied a different
affection, and that the organisms were not the same. It is insisted upon
by Dr. Klein, that Dr. Cruikshank’s conclusions were the result of
studying cow-pox and not the peculiar disease he described as the Hendon
cow disease.


                    THE CAUSE OF DEATH IN PHTHISIS.

Dr. R. W. Philip has made an experimental study to determine the cause
of death in phthisis. The results of his study are published in the
_Brit. Med. Jour._ of Jan. 28th, 1888.

His experiments were conducted with an extract prepared from fresh
sputum from phthisical patients, as follows:

The sputum was treated with alcohol, put in a sterilizer, and heated to
37 to 40° C. for some time, filtered clear, and evaporated at a low
temperature until the alcohol was expelled. This extract was used for
subcutaneous injections in frogs, mice, and rabbits.

This extract was found to possess very marked toxic properties upon
these animals, which manifested themselves by a depression of the higher
nerve centres and of the heart. The depressant action upon the heart
seemed to be exerted through the cardio-inhibitory mechanism, and is
more or less completely antagonized by atropine.

The toxic principle he believes to be the result of the growth of the
tubercular bacilli, and allied to the ptomaines. He found the quantity
of the substance to be extracted from the sputum to be proportional to
the abundance of the bacilli present in it. These observations are in
accordance with the observations of various experimenters with other
pathogenic organisms, and with the theory that seems to be gaining
ground that immunity is the result of such by-products of the growth of
these organisms.


                                SURGERY.

                       BY GEORGE R. FOWLER, M. D.,

 Surgeon to St. Mary’s Hospital and to the Methodist Episcopal Hospital,
                                Brooklyn.


   CONTRIBUTIONS TO THE STUDY OF MYXŒDEMA FOLLOWING TOTAL OR PARTIAL
                    EXTIRPATION OF THE THYROID BODY.

J. L. Reverdin (Congrès Francais de Chirurgie, 2 session, Paris, 1886.)
This disease, following frequently in the after-history of cases of
extirpation of the thyroid body, and called by Kocher, of Berne,
cachexia stumpriva, was first described by Reverdin, and by him called
“operative myxœdema.” His description of this disease coincides in
general with the views now generally held, although we find some not
unimportant deviations from Kocher’s conclusions; for instance, the
latter observed the disease twenty-four times following thirty-four
operations, it appearing to attack by preference those who had not
attained their full development. On the other hand, R., basing his
experience upon copious statistics, believes the disease is
comparatively rare, following upon operations of the thyroid in only
twenty-seven per cent. of cases. In his experience, it likewise
preferably attacks children and young persons, but that it occasionally
fails to occur after complete thyrotomy. Further, R. has observed a
milder form of the disease, differing essentially from the graver type
of the affection, which latter invariably tends progressively to a fatal
termination. In the milder form, the disease is described as oscillating
between relapses and improvement, lasting for years, cure sometimes
resulting. Several cases are detailed supporting these observations. In
two of these, it was supposed that the thyroid had been extirpated in
toto, but it was subsequently discovered that a small portion of the
gland had remained. Three cases are worthy of especial note. In these,
after partial extirpation, in one the right lobe, and in two the left
having been removed, an imperfect form of the disease made its
appearance after several months. The characteristic signs, such as
swelling of the face and limbs and hesitancy of speech and of muscular
movements were absent; while the other symptoms, such as general
weakness, pains in the limbs, chest, and head, greater or less loss of
memory, chilly sensations, reminded one distinctly of the more complete
form of the disease. In all these cases slow improvement followed.
Another case is worthy of notice from the fact that, two months after
the operation, the remaining lobe had so atrophied as to be scarcely
distinguishable. Cases of this atrophy following partial extirpation
have been observed both in Germany and in England.


            UPON LUXATION OF THE HEAD OF THE RADIUS FORWARD.

Raestock (Deutsche Militärärztl. Zeitschrift, 1887, p. 331) has, by
means of experiments upon the cadaver, shown that this accident occurs
in forced pronation while the radius is resting upon the ulna at the
point where the former crosses the latter, the ulna acting as a fulcrum.
The head of the radius is pressed against its capsule and tears the
latter. More rarely, the accident may occur in forced supination, by
pressing the bone against the posterior edge of the ulna, the head of
the radius being luxated through a rent made by a rupture of the
external lateral ligament between the outer and inner sides; upon
pronating the hand, this outward dislocation is converted into a forward
one. The annular ligament is either torn or else the coronoid process of
the ulna is broken. In either case the interposition of the annular
ligament in the fold of the joint becomes an obstacle to reduction. In
the experiments as detailed, great force was necessary in the production
of the luxation.

Should active and passive movements, manipulation, etc., fail to remove
the obstacles to reduction, the author advises a resort to secondary
resection of the displaced head of the radius; this, with proper
precautions, is certainly a most wise and rational procedure.


           CHOLECYSTOTOMY, WITH LIGATURE OF THE CYSTIC DUCT.

Zielewicz (Centralblatt f. Chirurgie, No. 13, 1888,) proposes in
addition to the so-called “ideal” method of Spencer Wells, that of
suturing the gall bladder to the abdominal wound, to ligate the cystic
duct, in order to insure the patient against the return of the biliary
lithiasis. The only case in which he has tried it was one in which an
attempt was being made to perform cholecystectomy, but the adhesions
between the gall bladder and liver were so dense and unyielding as to
render the removal impossible, on account of severe hæmorrhage. He
therefore passed two ligatures around the cystic duct and divided the
latter between them. The gall bladder was then fastened to the abdominal
wound, incised and emptied of its contained calculus and biliary
secretion. The patient made a good recovery, a fistula remaining, of
which the writer says, that “after a time it was almost closed.”

The author claims for this operation the following advantages: 1st.
Rapid healing without a resulting fistula. The gall bladder is
practically removed from the organism. With appropriate after treatment,
its secretion soon ceases, and it becomes obliterated. 2d. The operation
is simple and less dangerous than cholecystectomy, and gives the same
results.

In contrasting this operation with cholecystotomy, it may be said that
the latter simply aims at removing the existing calculi, and makes no
provision against the recurrence of the same. Where the “natural” method
of Bernay is adopted, and the gall bladder dropped back into the
abdominal cavity after suturing the incision made in its walls for the
removal of its contents, in case of a recurrence of the disease, the
entire operation must be repeated. In the “ideal” method of Spencer
Wells, only an incision need be made, in such an emergency, at the site
of the first operation. Troublesome fistulæ, however, are apt to remain.

In cholecystectomy, on the other hand, hæmorrhage from breaking down of
adhesions between the gall bladder and the surface of the liver, it is
claimed, is a frequent and troublesome complication. It is claimed by
Thiriar, however (“De l’intervention chirurgicale dans certains cas de
lithiase biliaire,” _Revue de chirurgie, 1886, No. 3_), that
cholecystectomy is a less dangerous operation than simple
cholecystotomy. Again, by Bardenheuer, that hæmorrhage from the liver
can be readily arrested. The abstractor witnessed an operation in which
the liver was accidentally wounded and the resulting hæmorrhage arrested
by the thermo-cautery.

Hertin, a French naval surgeon, in 1767, after experiments made upon
dogs, proposed, in wounds of the gall bladder, extirpation of the
latter, after ligature of the cystic duct. In these experiments he
demonstrated the feasibility of the operation of cholecystectomy upon
the lower animals, at least.

Campaignac, in 1826, proposed ligature of the cystic duct, with partial
resection of the gall bladder (Journ. hebdom. Bd. ii, 1829). K. Zagorski
has recently attempted this latter procedure on dogs, with fatal results
(Przegl. lekarski, 1887, No. 48). Nevertheless, to Zielewicz belongs the
credit of being the first to demonstrate, by its successful performance,
the feasibility of combining in man the two operations of ligature of
the cystic duct and cholecystotomy with suture of the gall bladder to
the abdominal wound. Upon further trial the operation may prove to be
not only feasible, but to follow out a rational indication with relative
safety.


                       SUPRA-PUBIC PROSTATECTOMY.

A. F. McGill, F.R.C.S. (_The Lancet_, February 4, 1888). The operation
consists of two parts: (1) The opening and drainage of the bladder; and
(2) The removal of the prostatic valve which prevents the egress of the
urine. A full sized silver catheter, curved according to the nature of
the case, is passed into the bladder, its contained urine withdrawn and
its cavity washed out with a warm saturated solution of boracic acid
till this is returned clean and unchanged. The usual rubber rectal bag
is now introduced and filled with fourteen ounces of water. The bladder
is now rendered prominent by injecting it with a sufficient amount of
warm boracic acid solution. The catheter is retained in the bladder, and
the fluid with which the latter has been distended, prevented from
escaping. The usual median supra-pubic incision is now made, the bladder
exposed and made to project into the abdominal wound by depressing the
catheter. A large curved tenaculum is now passed transversely into the
bladder, touching as it goes the point of the catheter. An incision is
now made longitudinally through the bladder wall, the fluid being
prevented from escaping by plugging the opening with the finger. The
bladder is now seized with nibbed forceps, and applied on each side of
the incision, the catheter is withdrawn from the urethra and the bag
from the rectum, and the first part of the operation is complete. The
interior of the bladder and its neck is now examined, in order to
ascertain the exact nature of the prostate enlargement. A pedunculated
middle lobe can be removed with the curved scissors, but in the case of
a sessile middle lobe, this must be assisted with the finger and
forceps. The “collar” enlargement is removed with greater difficulty. In
order to insure the patency of the urethra, it is advised to pass the
forefinger into the canal as far as the first joint. It is claimed that
the hæmorrhage is not excessive. The operation completed, drainage is
effected by passing a rubber tube out of the abdominal wound, the latter
being partially closed by a point or two of suture. The tube is removed
after forty-eight hours.

The author’s experience is limited to five cases, four of which have
proved successful, while the fifth case is still under treatment. He
claims that, in cases operated upon early, before diseased bladder or
surgical kidney have developed, a radical cure may confidently be
expected.

Two objections to this method occur to us: (1) Whoever has performed or
witnessed supra-pubic cystotomy, either for the purposes of removal of a
calculus or a neoplasm from the interior of the bladder, must have been
struck by the difficulties in the way of a thorough appreciation of the
condition of its posterior wall low down, or of the cystic neck. Unless
specially devised instruments are available for each particular form of
prostatic enlargement, it would seem to be a matter of great uncertainty
as to just how much of the growth is removed. (2) Until satisfactory
granulation of the wound surfaces has been accomplished, drainage, to be
efficient, must be facilitated by placing the patient upon one or the
other side, a position difficult to maintain, particularly in old
people.


RESEARCHES UPON THE VAGINAL PROCESS OF THE PERITONEUM AS A PREDISPOSING
             CAUSE OF TENDENCY TO EXTERNAL INGUINAL HERNIA.

H. Sachs (Archiv. f. Klinisch. Chirurgie, Band xxxv., p. 321–372)
advocates quite decidedly the view, basing his opinions upon
preparations of the spermatic cord examined and upon microscopic
examinations of cross sections of the latter, particularly as to the
relations of the vas deferens and the vessels to the vaginal process of
the peritoneum, that the latter is formed before the beginning of the
descent of the testicle rather than as a portion of the abdominal wall
formed or dragged into position by the testicle in its descent. In
proof, he alleges that he has always found, in cases of incomplete
descent of the testicle, that organ upon the posterior wall of the
vaginal process, and not on the floor of the same. In females, the
formation of the canal of Nuck cannot be said to be due to any dragging.

The entrance to the opening of the vaginal process is found covered by a
valve arrangement, and the same is particularly noticeable in the canal
of Nuck. The opening of the vaginal process can be caused to gape
through a spreading out of the mesentery attached to the ilium or that
of the sigmoid flexure. The diameter of the opening is, in general,
greater on the right side than on the left in boys, while in girls this
difference is not observed. Further, the different forms of the
incompletely obliterated opening of the vaginal process agrees with the
most frequently occurring forms of the hernial sac in inguinal hernia.
The relations of the vaginal process to the elementary parts of the
spermatic cord are not constant. On the contrary, the relations which
the smooth muscular structures of the cord bear to the vaginal process,
in so far as their arrangement into bundles, and their positive relation
to the posterior and lateral walls of the same are concerned, are quite
constant, and almost form an integral part of the same. The obliteration
of the vaginal process depends upon a granulating process, which begins
in the middle third of the funnicular portion, and from thence proceeds
more rapidly in a downward than in an upward direction. This granulation
formation takes place essentially during the first ten to twenty days
after birth; after this time it takes place more slowly. The canal of
Nuck, on the contrary, is found to have almost entirely disappeared at
the time of birth. They are both found to be more frequently open upon
the right side.

From these observations it would appear that it is not essential to the
production of inguinal hernia that a broad and short inguinal canal
should be present. The only essential predisposing cause, in children at
least, depends upon the condition of the vaginal process of the
peritoneum itself.

The question of the legal responsibility of employers is an interesting
one, in connection with this question. Hernia cannot be considered as an
accident, in the surgical sense, according to Socin (Korrespondenzblatt
f. Schweizer Aertze, 1887, No. 18), but is really a slowly occurring
disease, to which certain well-defined anatomical peculiarities act as
predisposing causes.


                  ACID SUBLIMATE SOLUTION IN SURGERY.

E. Laplace (Deutsche Med. Wochenschrift, No. 40, 1887), after repeated
and careful examinations and experiments, became convinced that dressing
materials consisting of wood-wool, made with sublimate in the usual
manner, were far from being germless themselves, much less efficient as
antiseptic applications. Gauze, however, showed much better results, but
were far from realizing an idealistic asepsis. He likewise found that
ordinary sublimate, in the presence of albuminous material, is quickly
precipitated and becomes at once ineffective. L. experimented at first
with hydrochloric acid as a means of preventing changes in the sublimate
from occurring in the presence of organic matter, and particularly
albuminous material. But, as hydrochloric acid itself was far from
possessing the stability needful for the purpose of preparing dressings,
he substituted for it, with the most gratifying results, tartaric acid.
The proportions are as follows: sublimate, 1 part; tartaric acid, 5
parts; distilled water, 1,000 parts.


                   OPERATIVE TREATMENT OF PYOTHORAX.

E. Rochelt (Wiener med. Presse, No. 32 and 38, 1887). The expansion of
the lung is greatly impeded after the usual operation for empyema by
incision, by the free entrance of air in the pleural cavity. Mader,
Subbolik and Immerman devised means for preventing this. R. operates by
first resecting a rib, leaving the periosteum intact, and subsequently
opening the pleural cavity by means of a trocar and canula. A drainage
tube accurately filling the latter is now introduced, through which a
disinfecting fluid is injected and its outer opening closed by means of
a spring clamp. The tube is connected to an aspirating bottle, into
which the pus is discharged. The tube is again clamped, and the bottle
into which the pus has been aspirated removed, being replaced by another
containing a sublimate solution, 1 to 500. Removal of the clamp and
raising and lowering the bottle thoroughly irrigates the pleural cavity.
This being accomplished, the patient holding his breath in expiration,
and the clamp again applied, the irrigating bottle is removed, and a
short hard rubber tube connected to the outer end of the drainage tube.
This hard rubber tube has a soft rubber diaphragm which acts as a check
valve, effectually preventing the ingress of air during inspiration, but
in no wise interfering with the egress of fluid from the pleural cavity
during expiration, fits of coughing, etc. For purposes of further
irrigation the short rubber tube containing the valve may be removed
after guarding against the entrance of air by clamping the drainage tube
beyond, and the washing bottle reapplied. During the intervals of
irrigation, absorbent antiseptic dressing are kept applied.

The abstractor would suggest the application of this method,
particularly in recent cases and in children, without the previous
resection of a rib. The increased support afforded the canula by the
greater thickness of the thoracic walls would be a still greater
safeguard against the entrance of air into the pleural cavity. A certain
proportion of acute cases will recover without resection of a rib.


               WOUND-HEALING UNDER THE DRY ASEPTIC SCAB.

Prof. Kuester (Centralblatt f. Chirurgue, March 17, 1888,) in reply to
remarks made by Dr. Sonnenberg before the Association of Berlin
Surgeons, January 9, who characterized K’s method of treating the wound
after the operation for the radical cure of hernia as an “open method,”
objects to this designation of his method, and takes occasion to more
fully describe his method as follows: After the reduction of the
contents of the sac, the latter is sutured and excised, and the ring is
also closed by suturing. The wound cavity itself is now closed by
several rows of buried sutures, so arranged as to bring together the
edges of the several layers, tissue to like tissue. In congenital cases
he does not loosen the sac, but sutures its opposing surfaces down to
the point where the testicle lies free. The wound of the skin is now
closed by a continuous silk suture, and an iodoform and collodion
mixture brushed over the line of suturing until it is perfectly covered
in and blood no longer oozes through. No drain is used, and no further
dressing is deemed necessary. If, after two or three days, a split
occurs in the scab or crust formed by the drying of the iodoform and
collodion, the gap is quickly filled by a slight oozing from the deeper
portions of the wound, which, upon drying, becomes a bar against
infection.

There can be no doubt, if thorough asepsis is observed and obtained
during the operation, the method of completely obliterating every space
in which blood clot or serum could accumulate would do away with the
necessity for drainage. This granted, it follows, as a natural sequence,
that absorbent dressings are superfluous, simple protection of the line
of suturing from atmospheric influences, infection, etc., being alone
indicated. The iodoform and collodion compound would seem to fulfil this
admirably. The method could scarcely find application in large or deep
wounds, particularly if the latter invaded planes of dense connective
tissue, fasciæ, etc. Here it would be manifestly best to provide
drainage, etc.

In marked contrast to K’s method is that of McBurney, who, providing
against infiltration by suturing the entire thickness of each edge of
the wound together in such a manner as to render it practically but one
layer, packs the wound cavity, and thus obliterates the inguinal canal,
the latter filling up by granulation, a firm cicatricial plug taking its
place.


                  THE TREATMENT OF CAROTID HÆMORRHAGE.

Mr. Frederick Treves (_The Lancet_, January 21, 1888). In the neck,
pressure upon the carotid artery, in hæmorrhages from the branches of
that vessel, cannot be applied in the ordinary way with success, nor
could it be maintained for a sufficient length of time, if the pressure
succeeded in arresting the hæmorrhage, to be of service. Treves
proposes, however, to occlude the vessel temporarily by throwing a broad
piece of catgut around it, tying it in a loose loop, and then making
traction upon the same. The circulation through the vessel is at once
arrested, but can be at once restored upon relaxing the tension upon the
loop. He relates four cases in which the method proved successful, so
far as the arrest of the bleeding was concerned. One of the patients
succumbed to the great loss of blood sustained prior to the application
of the ligature, although the other carotid had been previously tied. In
the first case the loop remained _in situ_ for four days. The second
case was the fatal one. In the third and fourth cases the loop was
removed on the seventh day.

The method is based upon the fact that temporary arrest of the
circulation in certain cases of hæmorrhage from the limbs, where
ordinary means may be employed to exercise pressure, are quite
sufficient, not only for the purposes of a temporary expedient, but also
seems as a curative measure. This temporary modification of the blood
current may be all that is required in many instances. Just how long the
blood current may need to be checked, must be carefully studied in each
individual case. The thought occurs to us, however, that some risk may
be run of setting up an ulcerative action in the vessel walls by the
prolonged application of a loose ligature, upon which must be exercised
an intermittent pressure, by the pulsation of the vessel itself.


               ARTIFICIAL AID IN THE FORMATION OF CALLUS.

Prof. Helferich (Archiv. f. Klinische Chirurgie, Band 36, 4. Heft,
1888). In cases of delayed union, and even in normal cases, to hasten
the natural process of repair, H. advises the application of an elastic
rubber bandage in such a manner as to retard the return flow of venous
blood, by this means favoring an increased amount of pabulum to the
field of repair, thus indirectly augmenting the formation of callus. The
patient must be taught to regulate the pressure, attention being
directed to the condition of the nails, in order that the bandage may be
adjusted to suit the varying condition of congestion present. Œdema may
be controlled by the application of a flannel bandage to that portion of
the limb below the site of fracture. It is claimed that by this method
the cure, in normal cases even, is considerably shortened. The process
of repair is hastened by keeping the limb in a dependent position. The
presence of small erosions at the site of fracture is not a
contra-indication to the use of the elastic band. The time of
application is of some importance, a too early application leading to
too active hyperæmia; while, on the other hand, if too long delayed, the
period of time in which the action will take place has passed. In wired
compound fractures and in resections, pressure may be applied in from
five to fourteen days after the operation, providing inflammatory
symptoms are absent.

Thomas, of Liverpool, has recommended a procedure, which is known as the
percussion method, to hasten the repair in delayed bony union, in cases
of imperfect union, and in ununited fractures. This consists of
percussing, once in a day or two, the site of the injury with a small
copper hammer for five minutes or more, and subsequently bandaging the
parts firmly.

It is suggested that the formation of varicose veins may be an objection
to the method of Helferich. Further, it is quite clear that the method
is not to be thought of in tuberculous subjects, as well as in cases of
large open wounds at the site of fracture, or where a gap is left by
resection of bone, removal of tumors, etc. The question of its
applicability to atrophic members is an open one.


         COMMUNICATION OF TUBERCULOSIS BY RITUAL CIRCUMCISION.

F. S. Eve (_The Lancet_, January 28th, 1888), relates the case of a
Jewish child, in whom, six weeks following the usual rite, a small
swelling appeared in each groin. They were found to be filled with
caseous material, which, upon being inoculated beneath the skin of
guinea pigs, gave rise to tuberculosis in the latter. The “Mohl,” or
person performing the rite, had ejected some wine from his mouth over
the cut surfaces of the prepuce. It was subsequently learned that this
person had died of pulmonary consumption shortly afterwards. Another
child in the same house, operated upon by the same person, suffered from
the same infection. Both children finally recovered.

Similar experiences have been recorded by Eisenberg (Berlin Med. Woch.,
No. 35, 1886), and Meyer (Centralblatt f. Chirurgie, No. 46, 1887). Of
greater importance, because of a probably greater frequency, is the
transmission of syphilis in this manner. A group of cases of this kind
were recently collected and made the subject of study at the London
Hospital.


                      TRANSPLANTATION OF THE SKIN.

Baratoux and Dubonsquet (Progres. Med., No. 15, 1887). D. treated two
extensive wounds caused by burning, in which no attempt at cicatrization
seems to have been made, although granulation was progressing well, by
transplantation. Simultaneous auto-transplantation, and pieces of skin
from a frog’s back the size of a thumb-nail, was practiced. Most of the
latter lost their pigmented aspect after ten days, and adhered well,
taking on the natural color of the human skin. The wound where the
frog’s-skin transplantation had been performed healed more rapidly than
the other where human skin was used, the cicatrix being softer as well.
B. treated cases of ulceration of the nose, and also perforations of the
membrana tympani, successfully by transplantation of frog’s skin,
healing taking place in from one to two weeks.

In three old cases of perforation of the drum membrane, the margins were
freshened by touching them with nitrate of silver, and a piece of frog’s
skin attached. In three days a cicatrix had formed, with considerable
improvement in the hearing. Transplantation must be practiced with a
healthy granulating wound, hæmorrhage being avoided. According to the
authors, the wound should be irrigated with a strong solution of
carbolic acid, and dried; the pieces of skin should also be washed in a
weak solution of carbolic acid.

It suggests itself to the abstractor that still better results would be
obtained by substituting a sterilized solution of chloride of sodium,
say of the strength of 6 to 1,000, for the strong carbolic solution
recommended, to be used just prior to the operation. The changes
produced in the vessels and their contained blood by the use of strong
disinfecting solutions are calculated to prevent early adhesion of the
new skin. At least such is the general experience of recent observers.
Reliable disinfection of the ulcerated surface may be obtained by
keeping the parts covered with gauze wrung out of a 1 to 12,000 solution
of potassio-mercuric iodide for a day or two previously.


                              OBSTETRICS.

                     BY CHARLES JEWETT, A.M., M.D.,

     Professor of Obstetrics and Diseases of Children, and Visiting
 Obstetrician, Long Island College Hospital; Physician-in-Chief to the
 Department of the Diseases of Children, St. Mary’s Hospital, Brooklyn.


                     THE IMPROVED CÆSAREAN SECTION.

Garrigues (Am. J. M. S., May, 1888,) describes in detail a successful
case of Cæsarean section with observations on the _technique_ of the
improved operation. He prefers a long abdominal incision, and
eventration of the uterus before opening it, the advantage claimed being
the easier application of the rubber constrictor. The constrictor is
more manageable if held in the hand of the assistant instead of the
clamp, since it can be loosened and tightened as required. To prevent
prolapse of intestines he sutures the upper end of the abdominal
incision before turning out the uterus, tying the sutures before that
organ is opened. Extraction of the fœtus by the head is much easier than
by the feet. When a long uterine incision is required, it is better to
go an inch into the fundus than to extend the wound into the lower
segment, which may cause troublesome hæmorrhage.

Removal of the ovaries for the prevention of subsequent pregnancies he
thinks not justified. The omentum he pushes up above the uterus to
prevent adhesions to the suture line and the consequent danger of
subsequent intestinal obstruction.

Dr. Garrigues believes Cæsarean section safer than _difficult_
extraction through the natural passages.

Eleven Cæsarean sections were done in this country between December 16,
1886, and February 24, 1888, (Dr. R. P. Harris) all by the improved
method but one. Six women and eight children were saved. Six of the
operations were performed in hospitals, saving five women; five in
private practice, saving only one. All the five hospital cases operated
by the improved technique were successful. The bad results in private
practice Dr. G. ascribes to imperfect antisepsis. He alludes to the
tardy adoption by our own countrymen of the antiseptic methods in
general obstetric practice which have met with almost universal
acceptance elsewhere—in Germany midwives being even compelled by law to
use antiseptic precautions in every case of confinement.

Including the above-mentioned case, one hundred and sixty-three Cæsarean
sections had thus far been done in the United States (Harris). One
hundred and seventy to date of this writing.—ED.

The paper concludes with a detailed statement of the _modus operandi_
and after-treatment in the modern Cæsarean operation. (A loop of the
constrictor can usually be readily passed over the fundus and slipped
down to the cervix while the uterus is still in the abdomen as we have
shown.) (A Case of Cæsarean Section, N. Y. M. J., August 29, 1885.)
Traction upon the constrictor perfectly occludes the short abdominal
wound during the incision of the uterus, eventration taking place as the
uterus collapses on removing the fœtus. The advantage, therefore, of
extending the abdominal incision some inches above the umbilicus in all
cases and turning out the uterus before opening it may be doubted. It is
sometimes, however, impossible or difficult to apply the constrictor to
the uterus in situ. Extraction of the fœtus by the head is certainly
easier than delivery by the feet as advised by most writers.

The comparative results of induced labor, version, perforation and
Cæsarean section in the Dresden Clinic have been recently considered in
a series of papers by Leopold and his assistants, Korn, Lohman and
Praeger.

The maternal mortality was as follows:

                 Induced premature labor 2.2 per cent.
                 Version and extraction  4–8 per cent.
                 Perforation             2–8 per cent.
                 Cæsarean section        8–6 per cent.

The fœtal mortality was in

                 Premature labor        33.4 per cent.
                 Version and extraction 41.  per cent.
                 Cæsarean section       13.  per cent.

Leopold concludes that while Cæsarean section cannot yet be substituted
in all cases for craniotomy, it is at least justifiable as an
alternative when the following conditions are present or possible, viz.:

Complete asepsis.

The patient strong and not long in labor.

The fœtal heart-beats normal in rate and rhythm.

Strauch (Arch. f. Gyn.), analyzing the results in twenty-eight cases of
induced premature labor arrives at like conclusions. While the mortality
in cases of the mothers was _nil_, the fœtal mortality was fifty-five
per cent. The rights of the fœtus demand a more frequent choice of
Cæsarean section, the mortality of which by the modern method is thus
far 11.8 per cent. for the mothers and 8 per cent. for the children.

Dr. Felice La Torre, of Paris, reaches the conclusion from extensive
clinical research that craniotomy or premature labor is better than
Cæsarean section, since the former saves all the mothers.

Krassowski (Arch. f. Gyn., B. 32 H. 2) reports five Porro and two
Saenger operations saving six mothers and five children. K. uses thymol
1:1,000 for instruments, and the biniodide of mercury 1:4,000 for the
hands, etc. He seals the abdominal wound with collodion to which
biniodide of mercury has been added.

Zweifel reports six additional cases of the Cæsarean operation after
Saenger, saving five mothers and all the children.


              THE MECHANISM OF LABOR IN HEAD PRESENTATION.

Sutugin (Sammlung Klin. Vorträge, No. 310) makes an important
contribution to the knowledge of this subject. The paper deals with an
“almost wholly neglected factor in the mechanism of labor,” namely, the
position of the fœtal trunk in utero, the mechanism of the trunk
movements and their effect upon the positions of the head during labor.
He first shows that the views commonly accepted with reference to the
position of the fœtal trunk during pregnancy are in part erroneous.
Observations by the author in six hundred and sixty cases, published in
1875, established the fact that before labor, in either right or left
positions, the dorsum of the child is almost invariably turned to the
mother’s back, the vertebral column of fœtus, as a rule, lying but
little to one side or the other of the spinal column of the mother; and,
furthermore, the changes of position during pregnancy, as from right to
left, probably take place by rotation along the posterior wall of the
uterus. On the occurrence of energetic uterine contractions, especially
at the beginning of labor, the back of the child is sometimes rotated to
the mother’s side. Kehrer has confirmed the conclusions of Sutugin in
observations upon certain of the lower animals. It may be noted in
passing that, according to Kehrer’s observations, gravity is a
subordinate factor in determining the attitude of the fœtus in utero.

The author of the paper declares that, in a large number of cases
examined during the last twelve years he has not in a single instance
found the back of the child turned wholly forward during pregnancy, not
even in first positions of the head. He has more recently made a study
of the varying positions of the trunk during labor. Early in the labor,
in first positions of the head, the trunk rotates so that the back of
the child looks sideways, the shoulders lying in a plane parallel with
the introitus. The breech rotates more slowly than the shoulders, the
spinal column of the child thus assuming the form of a spiral during
delivery. The fœtus, therefore, in its descent moves in a screw-like
direction around its own axis, but the back of the child is not turned
forward even during parturition, as authors generally have assumed.
These views are born out by the frozen sections of Chiara, Waldeyer, and
Shroeder. The rotation of the head is in part due to the rotation of the
trunk, “the torsion of the axis of the fœtus,” and is not to be referred
solely to the action of the pelvic planes. The author claims that a
torsion of the uterus upon its axis similar to that of the child also
occurs. With reference to the etiology of the torsion in case of uterus
or fœtus, he ventures no explanation.


              MANAGEMENT OF THE PLACENTAL STAGE OF LABOR.

Fehling (Sammlung Klin. Vorträge, No. 308) compares the views and
practice of authorities in the treatment of the third stage of labor.
The various methods of placental delivery that have been advocated by
different writers are recounted. The reaction against Credé in favor of
expectancy, first started by Dohrn and Ahlfeld, has resulted in proving
the inferiority of the latter plan, and in a return to more active
methods. In a large number of German clinics, the uterus is allowed to
rest immediately after the expulsion of the child, without friction.
When the placenta lies detached in the lower uterine segment, which is
generally the case after fifteen or twenty minutes, nothing is to be
gained by longer waiting. The author is favorably disposed toward the
practice of Credé, which as he says, has never been shown by its
adversaries to be capable of harm when properly conducted. With
reference to the mechanism of placental separation, both theoretical
considerations and clinical observations favor the views of Duncan, yet
the question is not settled. Retained membranes may be removed with the
aseptic hand. Yet Credé and Olshausen consider the retention of even the
whole chorion free from danger, and clinical experience has shown better
results by the expectant plan in case of retained membranes than by
interference. These results, the author thinks, in the light of
Döderlein’s researches, are explained by the fact that the hand may
transport the peccant germs from the vagina into the uterus. The active
plan, with a preliminary vaginal disinfection and a vigorous asepsis
throughout, should yield better results than expectation. Interference
with these precautions is, at least, justified in case of atony and
hæmorrhage or fever, including, if need be, the use of the curette and
subsequently ergot. Dührssen’s method of tamponing the uterus in
post-partum hæmorrhage with iodoform gauze is favorably mentioned.

In the event of cervical tears causing troublesome hæmorrhage,
Kaltenbach, Schroeder and Leopold practice immediate suture. The author
thinks the vaginal tamponade is generally to be preferred. Yet, in
certain cases the suture may also be required, or the application of the
perchloride of iron on cotton pledgets to the bleeding surfaces.

Credé (Arch. f. Gyn., B. 32, H. 1) again discusses and defends his
method of managing the placental delivery which he prefers to call the
external method.

The duration of the third stage need not in the majority of normal
labors exceed fifteen to thirty minutes. In many instances a more
expectant plan of treatment is better. In occasional cases more rapid
delivery is demanded in the interest of the mother. Since the method is
free from danger when properly conducted, the expulsion of the placenta
may be hastened within reasonable limits if for no other purpose than to
save the time of the attendants and to spare the sufferings of the
patient. He claims that the amount of blood-loss is diminished under his
treatment of the placental stage, and that the membranes are not more
frequently retained. Furthermore, he believes the retention of portions
of the membranes or placenta to be harmless in an aseptic condition of
the passages.

The method of Credé, briefly restated, is as follows: First apply
gentle, painless friction in a circular direction over the anterior wall
of the uterus, laying the hand flat upon the abdomen. Bring the axis of
the uterus in conformity with the axis of the pelvic inlet. If the
placenta is not expelled after three or four pains assist the next
contraction, at its acme only, by compressing the upper segment,
grasping the fundus with the thumb in front and the fingers behind, at
the same time using gentle downward pressure. Use slight friction only
but no compression during the intervals between the pains nor even
during the contraction except at its height. Success usually attends the
eighth or tenth pain.


             SCARLET FEVER: ITS RELATION TO PUERPERAL FEVER

Boxall (Br. Gyn. J.) in sixteen cases of scarlet fever in childbed found
septic manifestations in but one. In forty lying-in patients exposed to
the scarlatinal poison the puerperium was entirely normal. Three hundred
patients or more were admitted to the hospital during the epidemic of
scarlatina therein, yet a comparison of the morbidity during this time
with that which immediately preceded the outbreak showed that the
prevalence of scarlet fever in the hospital exerted no appreciable
effect upon the course of the puerperium in patients who escaped
scarlatina.

Galabin (Br. M. J.) thinks there is strong evidence of the bacterial
relation of puerperal sepsis to scarlet fever. Septicæmia does not
represent a distinct entity like scarlatina. Cheyne found the common
microbes of suppuration in the blood of scarlet fever patients not
infrequently.


             MITRAL STENOSIS AND THE THIRD STAGE OF LABOR.

Dr. D. B. Hart (E. M. J., Feb. 1888,) reports eight cases of this
complication with seven deaths. With reference to the etiology Dr. Hart
thinks the progress of the cardiac lesion is greatly accelerated by the
increased amount of work imposed upon the crippled heart during
pregnancy. At the beginning of labor, therefore, we may get failure of
compensation, dilated heart and engorgement of the lungs. At the close
of the labor, if free hæmorrhage does not occur, the extra blood before
accommodated in the utero-placental sinuses is returned to the right
heart. Death is therefore liable to occur in the third stage from over
distention of the right heart.

Dr. Ballantyne (E. M. J., March, 1888,) adds two more cases to the above
record, both terminating fatally. Sphygmograms obtained in these cases
show that the period immediately following the expulsion of the placenta
is the one of greatest danger, and they are entirely consistent with
Hart’s theory of the cause of death.


                         TREATMENT OF ABORTION.

Fry (Am. Obs. J., June, 1888,) advocates the use of the galvanic current
as a substitute for the curette for the removal of retained fragments of
the secundines. He uses a current of sixty to ninety milliamperes with
the anode in the uterus. The application is continued from six to ten
minutes and repeated on alternate days. The placental tissue, owing to
its relatively low vitality, is destroyed without injury to the uterus
itself. Separation and expulsion follow. Hæmorrhage is relieved by the
well known hæmostatic action of the positive electrode. Dr. Fry also
claims antiseptic properties for the positive pole since here are
liberated oxygen and chlorine in a nascent state and also acids.

Goodell thinks the curette an inefficient instrument for the evacuation
of the uterine cavity and liable to injure the uterus. He advocates
polypus forceps. Parrish finds the curette deceptive. He uses the
finger. Longaker prefers the finger. [A Sims’ speculum, a dull curette
and a strong, straight uterine dressing forceps, with its joint two and
a half inches from its distal end need never fail. The finger is
awkward, difficult, painful, and sometimes requires preliminary dilation
of the cervix. It cannot, moreover, be so easily sterilized, and even
though clean primarily is liable to carry septic organisms from the
vagina. Injuries to the uterus are for the most part the fault of
imperfect asepsis.]


                            PLACENTA PRÆVIA.

Obermann (Arch. f. Gyn., B. 32 H. 1.) discusses the treatment of
placenta prævia by version with the results obtained in sixty-four cases
at the Leipsic clinic. The method, which has become known as Hofmeier’s
method, he states as follows:

Perform bimanual version with deliberate extraction in case of much
hæmorrhage. The podalic extremity of the child makes an effectual
tampon. Massage of the uterus during extraction is advised to aid
expulsion. Iodoform gauze tampon may be used in case of hæmorrhage in
the early months. The colpeurynter is recommended in case of hæmorrhage
with a closed cervix. Alcoholic stimulants are given early and often.

The results in the sixty-four cases were eighty-nine per cent. of the
mothers and forty-seven per cent. of the children saved.

Nordmann, of Dresden, condemns early resort to operative procedures as a
routine measure, a more expectant plan of treatment being competent in a
certain proportion of cases.

Robt. Barnes (Br. Med. Jour., March 3d, 1887) sums up his views
substantially as follows: The hæmorrhage in placenta prævia proceeds
from so much of the lower zone of the uterus as is laid bare by
separation of the placenta during canalization. This comprises all that
portion of the uterus that lies below the equator of the fœtal head.
When canalization is complete the hæmorrhage is almost invariably
arrested spontaneously by retraction of the lower zone thus freed. Until
canalization is completed flooding is liable to persist, but after that
process is accomplished the case becomes practically a natural labor.
The too prevalent idea that the hæmorrhage is unavoidable and must go on
till delivery is erroneous and mischievous. Enough placental attachment
usually remains after complete dilatation to preserve the life of the
child. The fœtal life is not necessarily compromised except in certain
extreme cases of complete central placenta prævia. His views of
treatment follow as a corollary. Expedite the first stage, avoiding
violence or precipitation. His caoutchouc bags accomplish this
indication and control hæmorrhage. Detach the placenta with the finger
from the zone below the equator of the head, thus permitting retraction
and arrest of flooding. Rupture of the membranes and the use of the
binder meet the indications in certain cases. The vaginal plug may be
used in occasional instances if carefully watched. The os uteri
moderately expanded and the placenta separated from the lower zone,
hæmorrhage having ceased, wait. With sufficient dilatation, deliver, if
necessary, by forceps, version, or craniotomy. Dr. Murphy’s success by
this plan has been unexampled. [Dr. Barnes does injustice to version in
placenta prævia, since he appears to assume that immediate extraction
and violence to both mother and child are a necessary part of the
procedure. The success of that plan he attributes in great part to the
fact that, in carrying out the operation of turning, the placenta had
probably been detached from the lower zone. These criticisms certainly
cannot apply in case of external or bipolar version. With reference to
Barnes’ bags, it is safe to say, “the German teachers” are not the only
practitioners who have found them, in many cases, more or less
impracticable.]


                    OBSTETRIC SEPSIS AND ANTISEPSIS.

Auvard, writing to the Annals of Gynec., April, 1888, says, while before
the days of antiseptics it was better for a woman to be delivered in the
street than in a hospital, the hospital ward is now less dangerous than
the isolated lying-in chamber of the out-patient obstetric service. He
points out the importance of improving the resisting power by use of
tonics before the labor, in debilitated patients. In Auvard’s practice
every woman takes a thorough bath at the beginning of labor. The whole
vulvar and vaginal surfaces and cervical canal are sterilized before
expulsion begins, before obstetric wounds are developed. Asepsis before
and during the birth is more effectual than the use of antiseptics at
the close of labor and renders the latter unnecessary.

Sublimate soap and the sublimate solution, with which this soap makes a
lather, are well rubbed into the surfaces to be cleansed by aid of the
fingers. The dangers of sublimate poisoning do not obtain while the
surfaces are intact.

In the event of septic developments during the puerperal period he
thinks sublimate irrigation insufficient for genital antisepsis. The
vulva and vagina should be scrubbed by aid of the fingers with the
sublimate soap and solution. The uterus should be scraped with the
curette. Auvard has devised for this purpose a curette with a hollow
stem through which a stream of the antiseptic solution is kept flowing
during its use. [The mercurial salts may be replaced with a 1:1000
hydronaphthol solution for use within the passages after labor, though
the danger from the former antiseptic may be greatly diminished by
washing away the mercurial with a final injection of plain boiled
water.]


                      AUTO-INFECTION IN CHILDBED.

Ahlfeld (Cent. f. Gyn., No. 52,) shows that it is not always safe to
presume upon the impossibility of self-infection, and reports two cases
in point. In rare cases infection may arise from organisms primarily
present in the genitalia. [This goes to fortify Auvard’s position.]


OCCURRENCE OF GERMS IN THE DISCHARGES FROM THE UTERUS AND VAGINA DURING
                         THE PUERPERAL PERIOD.

Döderlein (Arch. f. Gyn., B. xxxi., H. 3,) finds in a series of
carefully conducted observations, that in normal cases the uterine
discharges contain no germs, while in the same patients numerous
varieties of germ life abound in the vagina. Pathogenic organisms may
occur in the vagina apart from any internal examination. These germs may
gain access to the uterus of themselves when not carried by
intra-uterine instrumentation or manipulation. These conclusions are
confirmed by Kaltenbach.

The uterine lochia of women suffering from puerperal sepsis in any form
invariably contain germs, the streptococcus pyogenes being constantly
present.


                          SUBLIMATE SOLUTION.

Laplace has shown the importance of acidulating sublimate solutions for
general antiseptic use. Neutral solutions on mingling with blood or
other albuminous fluids become more or less inert by the precipitation
of the albuminate of mercury. That precipitate is not formed in the
presence of hydrochloric or tartaric acids. The proportion for
sterilizing wounds should be five parts of the acid to one of the
sublimate in one thousand of water. [Biniodide solutions require no
acid. This is one of the many advantages of the mercuric iodide over the
bichloride for antiseptic use. In a series of experiments made for the
purpose of determining the reaction of biniodide solutions on albuminous
fluids we found that neutral solutions of the biniodide of mercury yield
no precipitate with albuminous fluids. No reaction was obtained with a
biniodide solution acidulated with hydrochloric acid in the proportion
of five parts to the thousand. The addition of organic acids, such as
acetic, citric or tartaric, as is well known, causes a precipitate of
albuminate of mercury. There is no chemical incompatibility between
sublimate soap and biniodide solutions.]


                         TRICHLORIDE OF IODINE.

One of the new antiseptic agents is iodine trichloride. In contact with
organic bodies it gives off iodine and chlorine in the nascent state.
The final products, moreover, hydrochloric and iodic acids, are well
known oxidizing agents. The strength of solution used is one part in
1,000 or one in 500 parts of water. Such a solution is equivalent in
sterilizing power to a 1:1,000 or 2,000 sublimate solution. [One
disadvantage of this antiseptic is the powerful corrosive action of
nascent chlorine and iodine upon metal instruments.]


                        DANGERS OF ANTISEPTICS.

Senger (Br. M. J., May 19, 1888,) has proved by experiments on dogs and
rabbits that the antiseptic agents commonly employed are liable to cause
degeneration of the kidneys. He injected into perfectly healthy animals
corrosive sublimate, carbolic acid, etc., in one-twelfth the quantity
necessary to kill them. Then on extirpation of one kidney he found in
all cases, on microscopical examination, glomerulo-nephritis. He also
found fatty degeneration of the liver, spleen, the heart-muscle, etc.
The various antiseptic agents were found to be injurious in different
degrees, corrosive sublimate being the most dangerous, then the others
in the following order: iodoform, carbolic acid, salicylic acid, boric
acid. These observations especially enforce the importance of avoiding
the use of antiseptics in the abdominal cavity, or in other large
cavities under conditions favorable to absorption. Sterilized water or a
five per cent. chloride of sodium solution should be substituted for use
in the peritoneum. Senger has shown that the salt solution in no way
injures the organs, and that it possesses moderate antiseptic power,
killing the streptococcus pyogenes aureus in twenty-eight minutes.


            EFFECT OF ERGOT ON THE INVOLUTION OF THE UTERUS.

Drs. G. G. Herman and C. O. Fowler (Br. M. J., Feb. 11, 1888,) discuss
this question, basing their conclusions on the results noted in
fifty-eight cases treated with ergot for a fortnight after delivery, and
sixty-eight in which a single dose only of ergot was given at the close
of labor. In the cases continuously ergotized the diminution of the
uterus in size was more rapid than in those who received but a single
dose. On the duration of the lochial discharge no appreciable effect was
observed from the use of ergot.

Dr. Boxall has made similar observations on two parallel series of cases
of one hundred each. Every alternate patient was given a mixture
containing ext. ergot. ammon., ♏︎ xv., t.i.d., during the first three
days after labor. Dr. B. concludes from the experience of these cases
that the practice of giving ergot as described tends to prevent the
formation of clots, to hasten their expulsion, and to diminish the
frequency, intensity and duration of after-pains. That if omitted at
first and given afterwards ergot tends to promote the expulsion of clots
and to relieve after-pains.


                 ANÆSTHESIA WITH CHLOROFORM AND OXYGEN.

Dr. Kreutzmann (Cent. f. Gyn.) recommends a mixture of oxygen and
chloroform vapors as an anæsthetic in obstetric and surgical practice.
The mixture may be made by passing freshly prepared and pure oxygen
through chloroform on its way to the inhaler. Neudörfer injects a small
quantity of chloroform into a balloon filled with oxygen, administering
through a face piece. It is claimed for this method, that anæsthesia is
at once established after a few deep inspirations without the least
excitement, and that there are no disagreeable after-effects, the
patient awaking promptly on ceasing the anæsthetic as from a refreshing
sleep.

                  *       *       *       *       *

Veit, of Berlin, has operated in seven cases of tubal pregnancy before
rupture, in all successfully.

Breisky, of Vienna, has recently performed the first successful
laparotomy for the removal of an ectopic viable fœtus in which all the
fœtal appendages were at the same time removed. The operation was done
at the end of the eighth month. Breisky advocates primary laparotomy
with extirpation of the entire sac in preference to the secondary
operation.

Brunniche (Cent. f. Gyn.) treated a case of vomiting of pregnancy
successfully by feeding the patient through a tube introduced into the
upper part of the œsophagus.

Duncan (London Lancet) reports three cases of hyperemesis in which
complete relief followed the application of cocaine in five per cent.
solution to the vaginal vault and cervix.

Saenger says the process of uterine involution is not a fatty
degeneration but normal metabolism.

Dr. Temple, of Toronto, Canada, in a case of post-partum hæmorrhage, hot
water and other measures having failed, injected the uterus with a
tumblerful of undiluted brandy. Prompt contractions and arrest of
hæmorrhage followed.


                        QUININE AS AN OXYTOCIC.

Dr. Cordes finds in quinine an efficient oxytocic in incomplete
abortion. He administers two and a half grains hourly till the desired
result is accomplished.



                               _REVIEWS._


  THE APPLIED ANATOMY OF THE NERVOUS SYSTEM—Being a study of this
    portion of the human body from a standpoint of its general interest
    and practical utility. Designed for use as a text-book and as a work
    of reference. By Ambrose L. Ranney, A.M., M.D. Second edition,
    revised and enlarged. 8vo. Profusely illustrated. Cloth, $5.00;
    sheep, $6.00.

                   New York: D. Appleton & Co., 1, 3, and 5 Bond Street.

A second edition of this work has just been issued and, as the author
says, has been enlarged. It contains 791 pages including the index; and
is divided into four main parts, the first part treating of the brain;
2d, the cranial nerves; 3d, the spinal cord; 4th, the spinal nerves.

It is very difficult to give a review of a work like this, which treats
so largely of the anatomy of the nervous system; and which is the most
difficult part of anatomy, and a great deal of which is not positively
settled, but is under sharp discussion by those who pay special
attention to the subject.

The work is a more or less successful compilation, which is prepared
with the idea of its being used as a text-book. Its size indicates that
it contains an enormous quantity of material on the gross and fine
anatomy, but excursions are also made into the domain of medicine to
illustrate the application of the anatomical knowledge to the
explanation of symptoms in disease; and quite frequently physiology and
pathology are dealt with.

As a text-book the work appears to me a great deal too large; and the
treatment of the subjects too diffuse; and often not clear; this is
especially so in the anatomical part. Cerebral anatomy is one of those
subjects of which it is very difficult to treat in a clear and
comprehensive manner so that others can understand it; and for this
reason a text-book should be small and contain only such anatomy as is
clearly made out and can be made practical use of as applied anatomy.
The finer anatomy and the study of the course of fibres, etc., should be
taken up as a special work, and studied with patience on specimens,
sections, etc.

A great many digressions into physiological questions might have been
left out, and some other subjects properly belonging to general
medicine, which the student could best study in some of the recent works
on diseases of the nervous system, or at the clinics. As an illustration
of what is meant, take, for instance, a consideration of the tendon
reflex on page 576, and the short imperfect sketch on page 621, on
progressive muscular atrophy, when on the next page is a figure of a
man, forty-five years old, with progressive muscular atrophy, from
Freidreich’s work; a case which, by the way, is probably not a case of
chronic myelitis of the anterior horns, but one of the cystrophies. The
subject of progressive muscular atrophies is now undergoing close study,
and a large number of cases are not dependent upon lesions of the
anterior horns, but are due to changes in the muscles themselves. The
work of Freidreich, Erb, Lichtheim, Ladaur, Charcot, Landonzy and
Dejeuni, and many others, have placed the subject in a different light
from that in which it was viewed some ten years ago.

Subjects like these can be found more satisfactorily treated in other
works, and are altogether out of place in a book like this and only adds
to its bulk.

The descriptions are often such as to confuse and mislead a student; for
instance, take the opening chapter on the brain, where the author says:
“In man and the vertebrates, the cerebro and spinal axis may be divided
into three separate portions, each perfectly independent of one another
and yet very intimately connected.”

Now this division is quite artificial, and is only for purposes of
description, and these parts are not _perfectly independent of one
another_.

Again, he says: “The nervous system of all animals may be subdivided
into two distinct histologic elements, nerve cells and nerve fibres.”
What has become of the neuroglia and neuroglia cells; are they not
important histologic elements in the nervous system of all animals?
Without this supporting framework what would become of the nerve tubes
and ganglion cells? And in many of the diseases of the central nervous
system this neuroglia takes on a very active condition, as is seen in
such a disease as disseminated cerebro and spinal sclerosis.

On page 45, in speaking of the study of sections of the cortex, the
author says: “By a judicious employment of gradually increasing powers
in the microscopic objectives used, the general arrangement of the
elements may be first mastered, and later on the minute details of each
of the component parts may be studied.”

This sounds like a most formidable and delicate task in the _judicious
employment_ of objectives in increasing powers in the study of these
sections. No one should attempt to study the histology of the nervous
system without previously knowing something about the use of the
microscope and having some practical knowledge of general histology and
pathology; to such a person the study of sections does not depend upon
_the judicious employment of gradually increasing powers in the
microscope objectives_; if he use a No. 2 and a No. 7 of Verick, or some
objective of about the same magnifying power, it is then simply a
question of studying the specimens with those powers and learning to see
and understand what he sees; there is no mystery about it.

I will refer to one other paragraph on page 56, where it is stated:

“The central gray matter of the spinal cord. This has no connection with
the higher senses. It is capable in itself of the simplest kind of
reflex acts by means of the spinal nerves. These can be produced at the
will of the experimenter, in the beheaded frog, when an irritation of
the skin by an acid, etc., is created; and Robin has satisfactorily
performed the same experiment upon a beheaded criminal. We have reason
to believe that the spinal cord can be slowly and in a purely automatic
way taught to perform certain series of muscular movements (as in
playing scales upon a musical instrument, for example,) without any
intervention of the higher ganglia.”

This is physiology. Is it true that the central gray matter of the
spinal cord has no connection with the higher senses? The complicated
movements which are performed by a person playing on a musical
instrument, like the piano, for instance, are more than a simple reflex
action of the spinal cord; and we do not believe that the spinal cord
can be taught to perform such movements without the intervention of the
higher ganglia. When one is learning to play the piano or other musical
instrument, the higher centres are constantly in action, guiding and
regulating the muscular contractions which go to make up the act of
playing; after constant repetition under the guidance of the higher
centres, the spinal cord and lower centres, as it were, learn and retain
the combinations necessary to the performance of the act, all that is
necessary is to start the particular combination, and the spinal cord
will carry it on automatically.

The spinal cord cannot be taught to perform such complicated acts
without the intervention and guidance of the higher centres to begin
with.

Dr. Ranney has done a great deal of work in the preparation of this
volume, and deserves much credit for his endeavors to collect this
somewhat scattered material.

The work has numerous illustrations and diagrams, most of them
exceedingly good, but we observe among them some of the worthless and
often fanciful illustrations from Luys’, which are reproduced here.

                                                                J. C. S.



                            _MISCELLANEOUS._


                          DR. J. B. MATTISON.

Dr. Mattison recently spent several weeks in Bermuda, and the _British
Med. Journal_ in reporting a meeting of the British Med. Association,
held in the Town Hall at Hamilton, says:

By request of the Society, Dr. J. B. Mattison, of Brooklyn, gave an
address on the subject of narcotic inebriety. Attention was called to
the extensive use of opium, chloral, and cocaine, notably in France,
Germany and America. The genesis of the disease was a physical necessity
in many cases. The speaker said in proper cases his plan—an original
one—was to secure an entire narcotic disuse by regular reduction, in ten
days, meantime bringing the nervous system under the sedative influence
of bromide of sodium, in initial doses of thirty grains, at twelve-hour
intervals, increasing the dose ten grains daily, and reaching, if
required, a maximum of one hundred and twenty grains at the end of the
withdrawal period. The resultant reflex irritation was treated by hot
baths, cannabis indica, hyoscyamus, coca, and electricity, with a
subsequent tonic regime. The prognosis was good as to recovery, but in
most cases, sooner or later, there was a return to the narcotic, due to
a renewal of the original cause, or to other conditions beyond control.
A vote of thanks to Dr. Mattison closed the meeting.

Dr. Mattison is translating Erlenmeyer’s Die Morphiumsucht und ihre
Behandlung—the Morphia Disease and its Treatment; third and last German
edition, the latest and largest work on the subject, which, with notes
and comments by the translator, will be brought out the coming autumn.


        LONG ISLAND COLLEGE HOSPITAL TRAINING SCHOOL FOR NURSES.

The graduating exercises of this training school took place on June
12th, at the hospital. Prof. Jarvis S. Wight presented the diplomas, and
Dr. George G. Hopkins delivered the address. The following are the
graduates of the class of 1888: Mrs. Elizabeth Raifstanger, Nellie E.
Russell, Elizabeth Munday, Abigail Collins, Lucy Wood, Elizabeth
Ritchie, Ellen Enright, Florence Jackson, Jennie E. Stuart, Minnie M.
Flower, Florence Crompton, Signa Johnson, Eleanor Mary Senkler.


                          “POST TENEBRAS LUX.”

              BY PROF. F. H. GERRISH, OF BOWDOIN COLLEGE.

       The Era Prize Essay.—Reprint from the Pharmaceutical Era.

Originally every physician was his own apothecary, and at the present
time probably a majority of medical practitioners dispense their own
medicines, very rarely writing a prescription. These will have but a
languid interest in the subject of this essay, which deeply concerns all
physicians who are not their own apothecaries, and all compounding
pharmacists.

In medical, as in every other science, the increase of knowledge so
widened the field that it became impossible for one mind to grasp all
the facts, and a division of labor took place, the part of the work
which related to the collection, preservation and dispensing of drugs
being assigned to a class of men who had displayed peculiar aptitude for
that branch. Thus was constituted as a distinct occupation, the
specialty of the apothecary, which, beginning as a department of medical
science, is inherently honorable, and has been so developed that it
gives scope for a lifetime of fascinating research, elevating study, and
profitable endeavor, independently of any proper work of the modern
physician. The two callings are, for the purposes of this discussion, as
in their best actual operation, practically distinct; and yet they are
not independent, but interdependent. The greater part of the physician’s
labor would be vainly spent, were it not supplemented by the service of
the pharmacist; the latter’s business would cease to have a reason for
existence but for the vocation of the former.

In this paper it will be taken for granted that the physician is well
educated and experienced in his profession, that the apothecary knows
his business thoroughly, and that both are actuated by high moral
purposes. The grievance of neither, therefore, will result from the
intentional wrong-doing of the other, but from his thoughtlessness or
conservative adherence to long-established custom. The honesty of each
being presupposed, such a charge as the substitution of an inferior
article for some ingredient in a prescription, or the false insinuation
that a mistake in the medicine is due to the compounder’s carelessness
need not be raised. Let us consider the grievances of each against the
other.

The physician complains that the apothecary exceeds his function by
prescribing for the sick. A person applies to the pharmacist for a
remedy for a specified disease. The latter consults the dispensatory,
finds a number of medicines mentioned in the therapeutical index under
the name of that malady, selects one, and sells the article to the
patient. He regards the protest of the doctor merely as the wail of one
who is disappointed at not getting a fee for prescribing. The physician
has a right to complain of those who prescribe for any but the indigent
without a professional fee, for this makes it vastly harder for him to
collect the charges to which he is entitled; but he has higher ground
than this. With him the first step in every case of disease is
diagnosis, without which prescribing is simply drawing a bow at a
venture, with small probability of penetrating a joint of the harness;
and he insists that neither the apothecary nor the patient is qualified
to make a diagnosis. The determination of the character of a disease is
not a simple matter, often baffling the profoundest learning and the
broadest experience, and, in most cases, requiring special knowledge and
discriminating judgment. The most obtrusive symptoms are by no means
necessarily the most characteristic; a given symptom may be the
accompaniment of different diseases, and sometimes attends pathological
changes of diametrically opposite nature. But one who is uninstructed in
this branch has nothing but symptoms to guide him, and therefore
frequently, if not commonly, is led into error, which may produce the
gravest results. The educated physician is the only person who is
equipped to solve the problems of disease; and it is, in the long run,
cheapest, even from the financial point of view, for one who is ill to
obtain competent medical advice. Therefore, considering merely the
welfare of the patient, the physician deplores the custom of
counter-prescribing.

The universal practice among apothecaries of refilling prescriptions
indefinitely, without the sanction of those who wrote them is frequently
the subject of adverse criticism by physicians. “But,” says the
pharmacist, “is not the prescription mine?” Probably the reply will be
affirmative, though this is a question not entirely settled in the minds
of those concerned. Granting, however, for the sake of the argument,
that the apothecary is the rightful owner of the prescription, he
triumphantly asks, “May not one do as he chooses with his own?” Not
always, by any means, unless he elects to use his property in a way
which will not imperil the welfare of others. The law puts many
restrictions on the natural rights of ownership, for the purpose of
shielding society from the ignorance, the malice, and the cupidity of
proprietors. In the matter of prescriptions there are no such
limitations; but in this, as in so many other affairs, we should be
controlled not merely by considerations concerning our legal rights. The
unwritten, but greater, law regards the question from a higher plane;
and from this point of view one sees that there are moral reasons which
should restrain the apothecary in these premises. Let us look at
prescription-refilling in its remote as well as its immediate bearings.

The physician writes his prescription for one occasion and for one only.
He designs it to fulfil the indications in a particular case at a given
visit. It is often in the highest degree improbable that the conditions
of the case will remain the same for a given length of time; and, when
they change materially, another prescription is needed to satisfy the
altered requirements. Of these things many patients and apparently, all
apothecaries are accustomed to take no note; and, therefore, the
prescription is refilled for the same person on many occasions, when
something very different ought to be furnished, the expected improvement
does not occur, and the physician is blamed for the failure. The
prescription, intended for the treatment of a certain condition afforded
relief and changed the state of affairs. Thereupon, further advice
should have been sought by the patient, his physical condition
investigated anew, and another recipe given by the physician, if he
deemed it desirable. To hold the doctor responsible for the ill effect
or lack of effect of his prescription in circumstances unlike those for
which it was designed is obviously unjust. Yet this is done habitually,
both in the case just supposed and in those other instances, quite as
common, in which the recipe is compounded, not for whom it was written,
but for some other person, who supposes (on what slender evidence it is
appalling to contemplate), that his ailment is identical with that of
the original patient. The refilling really amounts to the apothecary’s
abetting the patient in self-treatment. There is a trite remark to the
effect that he who undertakes to be his own lawyer is sure of a fool for
a client. In legal actions the matters at stake mostly relate to
property; in medical affairs, health and life are involved. Can anything
better be said of the wisdom of him who, without adequate training,
undertakes to settle questions in which his very existence is concerned,
than of the sagacity of the man who, with no competent knowledge of law
and the methods of the courts, presumes to manage a case in which merely
a sum of money may be lost?

But undesirable as is the custom of pharmacists in this respect, it is
unreasonable in physicians to grumble at it, until they reform a habit
of their own, which encourages the practice which they deprecate. When a
physician finds a sick man improving with a certain plan of treatment,
and wishes the same medication continued, usually he simply tells the
patient to have his bottle refilled at the apothecary’s. The latter,
knowing that this is the usage of the medical profession, is accustomed
to suppose—constructively, at least—that, when the bottle is returned to
be replenished, it is brought at the desire of the doctor; and he again
compounds the medicine, as he would not be justified in doing, if the
method of physicians was different. If the latter would habitually
rewrite their prescriptions, or indite orders for repetition, whenever
they wish a continuance of treatment, apothecaries would have the best
possible sanction for supplying medicines to patients a second or a
thousandth time, and would have no moral warrant for such action without
the written direction of the authors of the recipes. When the doctors
adopt the plan suggested, a violation of their request that their
prescriptions shall not be repeated without their written order will
furnish abundant ground for complaint; until such change of method is
established, the consistency of their protest does not conspicuously
appear. By the practice proposed, the apothecaries would lose some
business, indeed, but the community would experience an immeasurable
gain.

The sale of so-called patent medicines by pharmacists is a continual
irritant to doctors. Their objections have the same basis as in the
preceding case, namely, that apothecaries ought not to encourage the
people to prescribe for themselves. A distinguished physician once said
that drugs do more harm than good—a statement which will not be disputed
by those most conversant with the facts. But this is no argument against
the employment of medicinal remedies in any proper way. Drugs taken by
advice of educated, competent physicians do an immense amount of good;
the injury comes almost altogether from their administration
independently of the recommendation of qualified medical men. Concocted,
not to benefit humanity, but to enrich their manufacturers, advertised
as positive cures of diseases which the utmost skill of the medical
profession cannot control, sometimes inert, sometimes dangerous from the
poisons which they contain, pressed upon the attention of the people
with impudent persistence and colossal mendacity, the infamous
compounds, called patent medicines, are purchased by the credulous
public in almost incredible amounts. Nobody knows as well as the
pharmacist what quantities of drugs are sold in this form; nobody knows
as fully as the physician the enormously baneful effects which they
produce. If apothecaries would refuse to handle this class of goods,
they would confer a wonderful blessing on humanity, by demonstrating
their belief in the injuriousness of these articles, and thus bringing
them into disrepute; and they would vastly dignify their profession by
displaying its sense of moral obligation, even at the sacrifice of a
lucrative part of its business.

Apothecaries complain that, to meet the demands of prescriptions, they
are obliged, at great expense, to keep in stock a large number of
whimsical preparations, and also many brands of the same standard
medicines, when really one is practically as eligible as another. There
is force in this complaint. As a rule, the former class of preparations
has but an ephemeral popularity, and, as for the latter, there cannot
often be need of specifying the goods of a particular manufacturer; for
a worldly-wise, not to say honorable, pharmacist certainly may be
trusted to furnish only fine articles, that he may keep the favor of
those upon whose good-will his legitimate business depends. If a special
brand is deemed necessary by the doctor, he can request a convenient
apothecary to procure a quantity, and then can send to his shop the
patients who require this article. Thoughtful consideration of this
grievance will dictate some such course and effect its redress.

Occasionally, in places where apothecaries are accessible, physicians
furnish their patients with medicines. This the pharmacist rightly
regards with disfavor, as diminishing his legitimate business. The truly
wise physician shuns this practice, perceiving that he cannot be as
competent a pharmacist as is one who is nothing else, and furthermore,
preferring to avoid the suspicion of administering medicines
unnecessarily for the purpose of making a profit on them. Enlightened
selfishness prompts him to encourage scientific pharmacy as a specialty.


               BROOKLYN VITAL STATISTICS FOR JUNE, 1888.

              By J. S. YOUNG, Dep. Commissioner of Health.


                         _Data of comparison_:

 Population, estimated on July 1st, 1888                         793,960
 Inhabited houses, about                                          93,000

 Average birth-rate per 1,000 for ten years (returns incomplete).

 In the month of June, 1888, there were 1,513 deaths, the rate of
   mortality being 23.78 in every 1,000 of the population.

 The number of births reported was                                   937
 The number of marriages reported was                                531
 The number of still-births reported was                             113

The mortality by classes and by certain of the more important diseases
was as follows:


                               _Causes_:

                 1. Zymotic                         434
                 2. Constitutional                  251
                 3. Local                           644
                 4. Developmental                   121
                 5. Violence                         63
                 Measles                              6
                 Croup                                8
                 Diphtheria                          82
                 Scarlet Fever                       45
                 Typhoid Fever                      ———
                 Whooping Cough                       5
                 Malarial Diseases                    4
                 Diarrhœal Diseases (all ages)      244
                 Diarrhœal Diseases (under 5 years) 233
                 Phthisis                           137
                 Bronchitis                          45
                 Pneumonia                           80
                 All Respiratory Diseases           149
                 Bright’s Diseases                   35
                 Puerperal Diseases                  17
                 Old Age                             17
                 Suicide                             10

Reported cases:

                           Diphtheria    214
                           Scarlet Fever 255
                           Measles       128
                           Typhoid Fever ———

During the month 13 cases of small-pox were reported, of which number 13
were confirmed as small-pox. 13 cases of small-pox were sent to
hospital. No deaths from small-pox occurred in the city and 2 in the
hospital.

Deaths by sex, color, and social condition were as follows:

           Male                              846 Female   667
           White                              —— Colored   21
           Native                           1102 Foreign  411
           Married                           328 Single  1006
           Widows, Widowers, and not stated               179

Still-births (excluded from list of deaths) were as follows:

                   Males                          60
                   Females                        53
                   Total                         113
                   Deaths in public institutions 115
                   Deaths in tenement houses     745
                   Inquest cases                 156
                   Homicides                     ———
                   Suicides                       10


                             _Age Periods_:

                    Deaths under 1 year         496
                    Deaths under 5 years        253
                    Total deaths under 5 years  749
                    Total deaths  5 to 20       126
                    Total deaths 20 to 40       223
                    Total deaths 40 to 60       233
                    Total deaths 60 and upwards 182

Certain foreign and American cities show the following death-rate for
the month of June:

                           Brooklyn     23.78
                           New York     26.86
                           Philadelphia 18.98
                           Berlin       19.40
                           Dublin       23.58
                           Vienna       31.50
                           Paris        21.68
                           London       16.10
                           Glasgow      22.98


                            NEW INSTRUMENTS.

This is a bulletin of inventions and improvements of interest to the
physician and surgeon, and is published quarterly by Leach and Greene,
Boston, Mass. It is mailed free to any address.


                              ANTIFEBRINE.

Antifebrine as a proprietary name is controlled by patents, and when
bought under this name it costs about thirty cents per ounce. The name
acetanilide, for exactly the same substance, is not and cannot be
controlled in any way, and under this name it can be bought for about
fifteen cents per ounce. As acetanilide is about one-eighth the price of
antipyrine, and effective in half the dose, it is far more economical to
the patient.—_Pittsburgh Medical Review._


                             ENEMA LESIONS.

“Dr. Achilles Nordmann, of Basle,” says the _Lancet_, “has published a
description of twenty-five bowel lesions due to the operation of
administering enemata. They include three complete perforations and
ulcers, and wounds of various depths and sizes. The causes of these
lesions seem to have been the use of defective instruments, ignorance of
the direction of the rectum, catching of the transverse fold on the
tube, extreme irritation of the mucous membrane of the bowel, and
obstructions caused by certain conditions of the uterus, the fœtal head,
or an enlarged prostate. As a rule, these lesions are to be found on the
anterior wall of the rectum, from one to seven centimetres from the
anus. They are not always easy to diagnose, as other foreign bodies or
caustics may produce similar appearances. Tubercular and hæmorrhoidal
ulcers may be mistaken for them; these are, however, generally higher
up. A perforating wound gives rise to paraproctitis, but this is not
necessarily fatal, though a stricture generally results.”—_N. Y. Medical
Journal._

------------------------------------------------------------------------



                          TRANSCRIBER’S NOTES


 1. Silently corrected typographical errors and variations in spelling.
 2. Anachronistic, non-standard, and uncertain spellings retained as
      printed.
 3. Enclosed italics font in _underscores_.





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