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+Project Gutenberg (https://www.gutenberg.org) public repository for
+eBook #60493 (https://www.gutenberg.org/ebooks/60493)
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-The Project Gutenberg EBook of The Brooklyn Medical Journal. Vol. II. No.
-2. Aug., 1888, by Various
-
-This eBook is for the use of anyone anywhere at no cost and with
-almost no restrictions whatsoever.  You may copy it, give it away or
-re-use it under the terms of the Project Gutenberg License included
-with this eBook or online at www.gutenberg.org/license
-
-
-Title: The Brooklyn Medical Journal. Vol. II. No. 2. Aug., 1888
-
-Author: Various
-
-Editor: Joseph H. Raymond
-        Alex. Hutchins
-        Glentworth R. Butler
-        Joseph H. Hunt
-        Fred. D. Bailey
-
-Release Date: October 13, 2019 [EBook #60493]
-
-Language: English
-
-Character set encoding: UTF-8
-
-*** START OF THIS PROJECT GUTENBERG EBOOK THE BROOKLYN MEDICAL ***
-
-
-
-
-Produced by Richard Tonsing and the Online Distributed
-Proofreading Team at http://www.pgdp.net (This file was
-produced from images generously made available by The
-Internet Archive)
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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_.
-
-
-
-
-
-End of the Project Gutenberg EBook of The Brooklyn Medical Journal. Vol. II.
-No. 2. Aug., 1888, by Various
-
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-<pre>
-
-The Project Gutenberg EBook of The Brooklyn Medical Journal. Vol. II. No.
-2. Aug., 1888, by Various
-
-This eBook is for the use of anyone anywhere at no cost and with
-almost no restrictions whatsoever.  You may copy it, give it away or
-re-use it under the terms of the Project Gutenberg License included
-with this eBook or online at www.gutenberg.org/license
-
-
-Title: The Brooklyn Medical Journal. Vol. II. No. 2. Aug., 1888
-
-Author: Various
-
-Editor: Joseph H. Raymond
-        Alex. Hutchins
-        Glentworth R. Butler
-        Joseph H. Hunt
-        Fred. D. Bailey
-
-Release Date: October 13, 2019 [EBook #60493]
-
-Language: English
-
-Character set encoding: UTF-8
-
-*** START OF THIS PROJECT GUTENBERG EBOOK THE BROOKLYN MEDICAL ***
-
-
-
-
-Produced by Richard Tonsing and the Online Distributed
-Proofreading Team at http://www.pgdp.net (This file was
-produced from images generously made available by The
-Internet Archive)
-
-
-
-
-
-
-</pre>
-
-
-<div class='tnotes covernote'>
-
-<p class='c000'><b>Transcriber’s Note:</b></p>
-
-<p class='c000'>The cover image was created by the transcriber and is placed in the public domain.</p>
-
-</div>
-
-<div class='titlepage'>
-
-<div>
-  <span class='pageno' id='Page_97'>97</span>
-  <h1 class='c001'><span class='large'>THE</span><br /> BROOKLYN MEDICAL JOURNAL.</h1>
-</div>
-
-<div class='nf-center-c0'>
-<div class='nf-center c002'>
-    <div>PUBLISHED MONTHLY BY THE MEDICAL SOCIETY OF THE COUNTY OF KINGS.</div>
-    <div class='c003'><em>EDITORIAL COMMITTEE</em>:</div>
-    <div class='c003'>JOSEPH H. RAYMOND, M. D.,</div>
-    <div>ALEX. HUTCHINS, M. D.,</div>
-    <div>GLENTWORTH R. BUTLER, M. D.,</div>
-    <div>JOSEPH H. HUNT, M. D.,</div>
-    <div>FRED. D. BAILEY, M. D.</div>
-  </div>
-</div>
-
-<table class='table0' summary=''>
-  <tr>
-    <td class='c004'><span class='sc'>Vol. II.</span></td>
-    <td class='c005'><span class='sc'>Brooklyn, N. Y., August, 1888.</span></td>
-    <td class='c006'><span class='sc'>No. 2.</span></td>
-  </tr>
-</table>
-
-</div>
-<div class='chapter'>
-  <h2 class='c007'><em>ORIGINAL ARTICLES.</em></h2>
-</div>
-
-<h3 class='c008'>PAIN, WITH SPECIAL REFERENCE TO ITS DENTAL RELATIONS.</h3>
-
-<div class='nf-center-c0'>
-<div class='nf-center c003'>
-    <div>BY WM. M. THALLON, M.D.</div>
-    <div class='c003'>Read before the Brooklyn Dental Society, May 28, 1888.</div>
-  </div>
-</div>
-
-<p class='c009'><span class='sc'>Mr. President and Gentlemen</span>:—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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_98'>98</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_99'>99</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_100'>100</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>But, as we have already said, the lessened power of resistance may
-be acquired, it need not be inherited.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_101'>101</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'><span class='pageno' id='Page_102'>102</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>A course of mercury in small doses completed the cure. Two
-years have now elapsed, and the patient has had no recurrence of pain.</p>
-
-<p class='c009'>Gout and rheumatism were formerly ascribed a much more important
-role in the production of pain than they now occupy. Leaving
-<span class='pageno' id='Page_103'>103</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_104'>104</span>the preceding one, the first indication in treatment is the complete removal
-of the sufferer from their baneful influence.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>A very common example of the former is seen in the headaches
-<span class='pageno' id='Page_105'>105</span>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.</p>
-
-<p class='c009'>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:</p>
-
-<p class='c009'>“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
-<span class='pageno' id='Page_106'>106</span>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.</p>
-
-<p class='c009'>“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.”</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.”</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_107'>107</span>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:</p>
-
-<p class='c009'>1st. The presence of the micro-organism.</p>
-
-<p class='c009'>2d. The existence of a suitable pabulum.</p>
-
-<p class='c009'>3d. A certain degree of moisture.</p>
-
-<p class='c009'>4th. A certain degree of warmth.</p>
-
-<p class='c009'>5th. A certain amount of oxygen or air.</p>
-
-<p class='c009'>6th. A lessening of the resisting power of the tissues affected, as
-compared with health.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_108'>108</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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 <span class='fraction'>1<br /><span class='vincula'>200</span></span> 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.</p>
-
-<p class='c009'>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 <span class='fraction'>1<br /><span class='vincula'>200</span></span> of a
-grain.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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?</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_109'>109</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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?</p>
-
-<p class='c009'>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?</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_110'>110</span>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.</p>
-
-<p class='c009'>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?</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'><span class='pageno' id='Page_111'>111</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>I will more than have attained my object if I have pointed out,
-<span class='pageno' id='Page_112'>112</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<h3 class='c008'>BACTERIA, WITH A METHOD OF STAINING FOR DIAGNOSTIC PURPOSES.</h3>
-
-<div class='nf-center-c0'>
-<div class='nf-center c003'>
-    <div>BY JOSEPH KETCHUM, ESQ.</div>
-    <div class='c003'>Read and Demonstrated before the Section on Microscopy of the Brooklyn Institute.</div>
-  </div>
-</div>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_113'>113</span>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:</p>
-
-<p class='c009'>1. Bacterium, or rod-like—three species.</p>
-
-<p class='c009'>2. Vibrio, snake-like and flexible—nine species.</p>
-
-<p class='c009'>3. Spirillum, or spiral, but inflexible—three species.</p>
-
-<p class='c009'>4. Spirochœte, spiral, but flexible—one species.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'><span class='pageno' id='Page_114'>114</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_115'>115</span>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 <span class='fraction'>1<br /><span class='vincula'>1,000</span></span> 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.</p>
-
-<p class='c009'>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.”</p>
-
-<p class='c009'>Our breweries demonstrate the truth of this hypothesis; for, in
-twenty-four hours, a single yeast cell, which is <span class='fraction'>8<br /><span class='vincula'>1,000</span></span> mm. in diameter,
-will yield one hundred-weight of yeast.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_116'>116</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>The apparatus necessary is as follows:</p>
-
-<p class='c009'>One two-inch glass funnel.</p>
-
-<p class='c009'>One package filter papers to fit same.</p>
-
-<p class='c009'>Four medium size test tubes.</p>
-
-<p class='c009'>Two glass or porcelain staining glasses.</p>
-
-<p class='c009'>One glass or agate mortar and pestle.</p>
-
-<p class='c009'>One cover holder.</p>
-
-<p class='c009'>One pair pincetts.</p>
-
-<p class='c009'>One alcohol lamp.</p>
-
-<p class='c009'>Package of wooden toothpicks.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>The reagents necessary are as follows:</p>
-
-<p class='c009'>A five per cent. solution of nitric acid in alcohol (95 per cent.).</p>
-
-<p class='c009'>Saturated alcoholic solution of fuchsine.</p>
-
-<p class='c009'>Saturated alcoholic solution of methyl blue.</p>
-
-<p class='c009'>Small quantity of alcohol, 80 to 95 per cent.</p>
-
-<p class='c009'>Pure colorless aniline oil (anilin).</p>
-
-<p class='c009'>The method is as follows:</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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 <span class='fraction'>1<br /><span class='vincula'>100</span></span> 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
-<span class='pageno' id='Page_117'>117</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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 <em>dry</em> objective.</p>
-
-<p class='c009'>I have found it necessary to use an objective at least as high as one-fifth
-<span class='pageno' id='Page_118'>118</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<div class='lg-container-l'>
-  <div class='linegroup'>
-    <div class='group'>
-      <div class='line'><span class='sc'>171 Gates Ave., Brooklyn.</span></div>
-    </div>
-  </div>
-</div>
-
-<h3 class='c008'>ADDRESS TO THE GRADUATES OF THE LONG ISLAND COLLEGE HOSPITAL TRAINING SCHOOL FOR NURSES, DELIVERED JUNE 12, 1888.</h3>
-
-<div class='nf-center-c0'>
-<div class='nf-center c003'>
-    <div>BY GEORGE G. HOPKINS, A.M., M.D.</div>
-  </div>
-</div>
-
-<p class='c009'><em>Ladies and Gentlemen and Class of 1888</em>: 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
-<span class='pageno' id='Page_119'>119</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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,
-<span class='pageno' id='Page_120'>120</span>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.</p>
-
-<p class='c009'>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!</p>
-
-<p class='c009'>I have seen sick men, absent from home and friends, sigh for a
-mother, sister, or wife who is not at hand.</p>
-
-<p class='c009'>Thanks to this school, and others, everyone can now have skilled
-female care when sickness and disease are upon them.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'><span class='pageno' id='Page_121'>121</span>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 <em>skilled</em>
-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 <em>yourself</em>
-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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_122'>122</span>their next battle their courage and deeds of prowess again surprise
-every one. So be it with you.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_123'>123</span>you owe it to your patient to give the best possible service, and thus
-only can you do it.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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 <em>one</em> virtue is of
-more value in your arduous calling than this one of self-possession.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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 <em>tact</em>. 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
-<span class='pageno' id='Page_124'>124</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>“Like a star which maketh not haste and taketh not rest, let each
-be fulfilling his heaven born hest.”</p>
-
-<div>
-  <span class='pageno' id='Page_125'>125</span>
-  <h3 class='c008'>THE ETHICS OF OPIUM HABITUES.</h3>
-</div>
-
-<div class='nf-center-c0'>
-<div class='nf-center c003'>
-    <div>BY J. B. MATTISON, M. D.,</div>
-    <div class='c003'>Read before the Society of Medical Jurisprudence and State Medicine, June 14, 1888.</div>
-  </div>
-</div>
-
-<p class='c009'>“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.”</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'><span class='pageno' id='Page_126'>126</span>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,” <cite>Detroit Lancet, 1884</cite>, and “The Responsibility of
-the Profession in the Production of Opium Inebriety,” <cite>Med. and Surg.
-Reporter, 1878</cite>.</p>
-
-<p class='c009'>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?</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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:</p>
-
-<p class='c009'>“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.
-<span class='pageno' id='Page_127'>127</span>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.”</p>
-
-<p class='c009'>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?</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>But to this there are numerous exceptions, for many a captive to
-<span class='pageno' id='Page_128'>128</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_129'>129</span>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.</p>
-
-<p class='c009'>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 <em>all</em> as liars because <em>some</em> 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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>In a recent letter from a lady who honored the writer with her
-<span class='pageno' id='Page_130'>130</span>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
-<em>would</em> avail, and during <em>all</em> 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 <em>real</em> conflict
-begins.”</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>And now, gentlemen, what are the conclusions of this whole matter?
-These.</p>
-
-<p class='c009'>Reason and right alike demand a more rational and correct
-idea as to the origin of the toxic neurosis we have noted.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>The medico-legal status of such cases will then be more in keeping
-with advanced forensic medicine.</p>
-
-<p class='c009'>The medical care of these cases will tend to a more humane
-method, with a larger promise of good results, both near and remote.</p>
-
-<p class='c009'>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.</p>
-
-<div class='lg-container-l'>
-  <div class='linegroup'>
-    <div class='group'>
-      <div class='line'><span class='sc'>314 State Street.</span></div>
-    </div>
-  </div>
-</div>
-
-<div>
-  <span class='pageno' id='Page_131'>131</span>
-  <h3 class='c008'>A CASE OF SPINA BIFIDA.</h3>
-</div>
-
-<div class='nf-center-c0'>
-<div class='nf-center c003'>
-    <div>BY JAMES W. INGALLS, M.D.</div>
-    <div class='c003'>Presented to the Brooklyn Pathological Society, April 12, 1888.</div>
-  </div>
-</div>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<div><span class='pageno' id='Page_132'>132</span></div>
-<div class='section ph1'>
-
-<div class='nf-center-c0'>
-<div class='nf-center c010'>
-    <div>THE BROOKLYN MEDICAL JOURNAL.</div>
-  </div>
-</div>
-
-</div>
-<div class='chapter'>
-  <h2 class='c007'><em>EDITORIAL.</em></h2>
-</div>
-<h3 class='c008'>THE FINANCIAL RESULTS OF MEDICAL PRACTICE.</h3>
-
-<p class='c011'>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.”</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_133'>133</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_134'>134</span>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.”</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_135'>135</span>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.</p>
-
-<h4 class='c012'>THE OPEN STREET-CAR WHISTLE.</h4>
-
-<p class='c011'>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
-<span class='pageno' id='Page_136'>136</span>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 <span lang="fr" xml:lang="fr">corps d’esprit</span>
-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,
-<span class='pageno' id='Page_137'>137</span>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.”</p>
-
-<h4 class='c012'>PROMPT TELEPHONE SERVICE.</h4>
-
-<p class='c011'>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.</p>
-
-<div>
-  <span class='pageno' id='Page_138'>138</span>
-  <h4 class='c012'>OFFICIAL ORTHOEPY.</h4>
-</div>
-
-<p class='c011'>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.</p>
-
-<div class='chapter'>
-  <span class='pageno' id='Page_139'>139</span>
-  <h2 class='c007'><em>PROCEEDINGS OF SOCIETIES.</em></h2>
-</div>
-<h3 class='c008'>THE MEDICAL SOCIETY OF THE COUNTY OF KINGS.</h3>
-
-<p class='c011'>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.</p>
-
-<p class='c009'>The meeting was called to order at 8.30 P. M., with Dr. Wallace
-in the chair.  There were eighty members present.</p>
-
-<p class='c009'>The minutes of the previous meeting were read, and on motion
-adopted as read.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>The following gentlemen were proposed for membership:</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>No objection was offered.</p>
-
-<div>
-  <span class='pageno' id='Page_140'>140</span>
-  <h4 class='c012'>SCIENTIFIC BUSINESS.</h4>
-</div>
-
-<p class='c011'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>A paper, entitled “Note on the Disinfection of Physicians’ Clothing,”
-by Dr. R. L. Dickinson, was then read and discussed.</p>
-
-<h4 class='c012'>REPORTS OF COMMITTEES.</h4>
-
-<p class='c011'>The President called for the report of the Obituary Committees upon
-the late Drs. Chapman and Mitchell.</p>
-
-<p class='c009'>The obituary report of the late Dr. Chauncey L. Mitchell was then
-read by Dr. Burge, as follows:</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_141'>141</span>Ergot,” “Labor Complicated with Disease of the Heart,” and an occasional
-contribution to the journals, are all that we can find of his
-writings.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>In 1843, Dr. Mitchell married <em>Caroline</em>, daughter of Hon. B. F.
-Langdon; in 1857, <em>Frances</em>, daughter of Hon. Benjamin Wright; in
-1875, <em>Kate</em>, daughter of Hon. J. M. Van Cott, of this city.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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:</p>
-
-<p class='c009'><em>Whereas</em>, In obedience to the Divine Law the fully matured life of
-Chauncey L. Mitchell is ended on earth, and</p>
-
-<p class='c009'><em>Whereas</em>, He was destined to fill a high position in the profession
-of medicine and as a citizen of this country, and</p>
-
-<p class='c009'><em>Whereas</em>, 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</p>
-
-<p class='c009'><em>Whereas</em>, 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;</p>
-
-<p class='c009'><em>Therefore be it resolved</em>, 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.</p>
-
-<p class='c009'><em>Resolved</em>, That we offer our deepest sympathy to his bereaved
-<span class='pageno' id='Page_142'>142</span>family, and that a copy of these resolutions be conveyed to them as a
-humble tribute to his superior worth.</p>
-
-<p class='c009'>All of which is respectfully submitted by your committee.</p>
-
-<div class='lg-container-r'>
-  <div class='linegroup'>
-    <div class='group'>
-      <div class='line'><span class='sc'>J. H. Hobart Burge, M.D.</span>,</div>
-      <div class='line'><span class='sc'>Alex. J. C. Skene, M.D.</span></div>
-    </div>
-  </div>
-</div>
-
-<p class='c009'>The report of the Obituary Committee, as above, was accepted and
-committee discharged.</p>
-
-<p class='c009'>The Resolutions introduced by this committee were adopted as
-read.</p>
-
-<h4 class='c012'>NEW BUSINESS.</h4>
-
-<p class='c011'>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.</p>
-
-<p class='c009'><span class='sc'>The President.</span>—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.</p>
-
-<p class='c009'><span class='sc'>A Member.</span>—I move that the By-Laws be suspended so that the
-election may be had this evening. Carried.</p>
-
-<p class='c009'><span class='sc'>The President.</span>—Nominations are now in order. The present
-incumbents are Dr. J. H. Hunt and Dr. C. E. De La Vergne.</p>
-
-<p class='c009'><span class='sc'>A Member.</span>—I move that the two present incumbents be continued
-in office, if it be the voice of this Society, until the annual meeting.</p>
-
-<p class='c009'>Seconded and carried.</p>
-
-<p class='c009'>There being no further business, the Society adjourned.</p>
-
-<div class='lg-container-r'>
-  <div class='linegroup'>
-    <div class='group'>
-      <div class='line'><span class='sc'>W. M. Hutchinson, M.D.</span>, <em>Secretary</em>.</div>
-    </div>
-  </div>
-</div>
-
-<div class='chapter'>
-  <span class='pageno' id='Page_143'>143</span>
-  <h2 class='c007'><em>PROGRESS IN MEDICINE.</em></h2>
-</div>
-
-<h3 class='c008'>PREVENTIVE MEDICINE.</h3>
-
-<div class='nf-center-c0'>
-<div class='nf-center c003'>
-    <div>BY ELIAS H. BARTLEY, M.D.,</div>
-    <div class='c003'>Professor of Chemistry and Toxicology, and Lecturer on Diseases of Children, Long Island College Hospital, Brooklyn.</div>
-  </div>
-</div>
-
-<h4 class='c012'>THE GERM THEORY A CENTURY AGO.</h4>
-
-<p class='c011'>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: “<cite>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</cite>.”</p>
-
-<p class='c009'>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,
-<span class='pageno' id='Page_144'>144</span>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 <i><span lang="la" xml:lang="la">de novo</span></i>. 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.</p>
-
-<p class='c009'>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.”</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>ALBUMINURIA A FREQUENT RESULT OF SEWAGE POISONING.</h4>
-
-<p class='c011'>Dr. George Johnson, in <cite>Br. Med. Jour.</cite> 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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<div>
-  <span class='pageno' id='Page_145'>145</span>
-  <h4 class='c012'>SEWER-AIR POISONING.</h4>
-</div>
-
-<p class='c011'>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.</p>
-
-<p class='c009'>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 <cite>Science</cite>, 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.</p>
-
-<p class='c009'>According to the <cite>Sanitary News</cite>, 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.</p>
-
-<p class='c009'>The <cite>Sanitary Inspector</cite> for February and March, reproduces from
-the <cite>Medical News</cite> 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.</p>
-
-<p class='c009'>“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:</p>
-
-<p class='c009'>“1. Vomiting and purging, either separately or combined.</p>
-
-<p class='c009'>“2. A form of nephritis.</p>
-
-<p class='c009'>“3. General debility, in some cases of which the heart is especially
-involved.</p>
-
-<p class='c009'>“4. Fever, which is frequently accompanied by chills.</p>
-
-<p class='c009'>“5. Sore throat, which is frequently of a diphtheritic character.</p>
-
-<p class='c009'>“6. Neuralgia.</p>
-
-<p class='c009'>“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
-<span class='pageno' id='Page_146'>146</span>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.”</p>
-
-<h4 class='c012'>EFFECTS OF FOOD PRESERVATIVES ON THE ACTION OF DIASTASE, PANCREATIC EXTRACT AND PEPSINE.</h4>
-
-<p class='c011'>This subject has recently received experimental study at the hands
-of Dr. Henry Leffman and William Beam, the results being published
-in the <cite>Analyst</cite> for June, 1888.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>In the following experiments a solution of arrow root starch, 30
-grains to the litre, was used.</p>
-
-<p class='c009'>To 100 c.c. of this solution was added 0.5 c.c. of maltine diluted
-to 50 c.c. with water.</p>
-
-<p class='c009'>The figures give the proportion of antiseptic to the whole volume
-of liquid.</p>
-
-<h5 class='c012'><em>Experiments with Maltine.</em></h5>
-
-<table class='table1' summary=''>
-  <tr>
-    <th class='c005'><em>Antiseptic used.</em></th>
-    <th class='c005'><em>Amount.</em></th>
-    <th class='c013'><em>Fehling’s Solution reduced by the Maltose formed.</em></th>
-  </tr>
-  <tr><td>&nbsp;</td></tr>
-  <tr>
-    <td class='c004'>None.</td>
-    <td class='c004'>None.</td>
-    <td class='c013'>245 cc.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Salicylic acid.</td>
-    <td class='c004'>1 to 500.</td>
-    <td class='c013'>No sugar formed.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Salicylic acid.</td>
-    <td class='c004'>1 to 1,000.</td>
-    <td class='c013'>No sugar formed.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Salicylic acid.</td>
-    <td class='c004'>1 to 20,000.</td>
-    <td class='c013'>245   cc.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Boric acid.</td>
-    <td class='c004'>1 to 1,000.</td>
-    <td class='c013'>245   cc.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Sodium bisulphite.</td>
-    <td class='c004'>1 to 1,000.</td>
-    <td class='c013'>245   cc.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Saccharine.</td>
-    <td class='c004'>1 to 1,000.</td>
-    <td class='c013'>18.5 cc.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Saccharine.</td>
-    <td class='c004'>1 to 500.</td>
-    <td class='c013'>5.6 cc.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Beta-Naphthol.</td>
-    <td class='c004'>1 to 1,000.</td>
-    <td class='c013'>204   cc.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Beta-Naphthol.</td>
-    <td class='c004'>1 to 500.</td>
-    <td class='c013'>174   cc.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Alcohol.</td>
-    <td class='c004'>1 to 25.</td>
-    <td class='c013'>245   cc.</td>
-  </tr>
-</table>
-
-<p class='c009'>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.</p>
-
-<div>
-  <span class='pageno' id='Page_147'>147</span>
-  <h5 class='c012'><em>Experiments with Fairchild’s Pancreatic Extract.</em></h5>
-</div>
-
-<table class='table1' summary=''>
-  <tr>
-    <th class='c005'><em>Antiseptic.</em></th>
-    <th class='c005'><em>Amount.</em></th>
-    <th class='c013'><em>Fehling’s Solution required.</em></th>
-  </tr>
-  <tr><td>&nbsp;</td></tr>
-  <tr>
-    <td class='c004'>None.</td>
-    <td class='c005'>None.</td>
-    <td class='c013'>78 cc.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Salicylic acid.</td>
-    <td class='c005'>1 to 1,000.</td>
-    <td class='c013'>No sugar formed.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Saccharine.</td>
-    <td class='c005'>1 to 1,000.</td>
-    <td class='c013'>No sugar formed.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Beta-Naphthol.</td>
-    <td class='c005'>1 to 1,000.</td>
-    <td class='c013'>78 cc.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Boric acid.</td>
-    <td class='c005'>1 to 1,000.</td>
-    <td class='c013'>78 cc.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Sodium bisulphite.</td>
-    <td class='c005'>1 to 1,000.</td>
-    <td class='c013'>80 cc.</td>
-  </tr>
-</table>
-
-<p class='c009'>The tests were made with 0.2 grams of the extract.</p>
-
-<p class='c009'>It seems from these experiments that salicylic acid and saccharine,
-in the proportions used, entirely prevent the action of pancreatic ferment
-upon starch.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>Saccharine and salicylic acid had a slightly retarding action. Beta-naphthol
-almost entirely prevented the action.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>Sodium bisulphite and boric acid are practically without retarding
-effect.</p>
-
-<p class='c009'>Beta-naphthol decidedly interferes with the formation of sugar by
-diastase, but not with the action of pancreatic extract on starch.</p>
-
-<p class='c009'>It almost entirely prevents both peptic and pancreatic digestion of
-albumen.</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>MILK AND SCARLATINA.</h4>
-
-<p class='c011'>In a recent number of the <span class='sc'>Journal</span>, 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
-<span class='pageno' id='Page_148'>148</span>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 <cite>British Medical Journal</cite> of December 17, 1887, and January
-21, 1888.</p>
-
-<p class='c009'>We have only space here to reproduce the conclusions reached by
-Dr. Cruikshank, which are as follows:</p>
-
-<p class='c009'>1. The nature of the contagium of scarlet fever is unknown.</p>
-
-<p class='c009'>2. The micro-organism regarded by Dr. Klein as this contagium is
-the <em>streptococcus pyogenes</em>.</p>
-
-<p class='c009'>3. <em>Streptococcus pyogenes</em> is found sometimes in company with
-<em>staphylococcus pyogenes aureus</em>, as a secondary result in scarlet fever and
-many other diseases.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>5. Both the Wiltshire and Hendon cow diseases were called cow-pox
-by the people on the farms.</p>
-
-<p class='c009'>6. Both diseases correspond in their clinical history.</p>
-
-<p class='c009'>7. The ulcers on the teats correspond in naked eye and microscopical
-appearances, and the latter vividly recall the appearances of
-cow-pox.</p>
-
-<p class='c009'>8. Calves inoculated from the discharges of the ulcers are similarly
-affected.</p>
-
-<p class='c009'>9. <em>Post-mortem</em> examination of such calves, or of calves inoculated
-with streptococci isolated from scarlet fever cases, show similar appearances.</p>
-
-<p class='c009'>10. The <em>post-mortem</em> appearances in such inoculated calves are the
-result of septicæmia.</p>
-
-<p class='c009'>11. There are no specific visceral changes in cow-pox, apart from
-complications or coincident affections.</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>THE CAUSE OF DEATH IN PHTHISIS.</h4>
-
-<p class='c011'>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 <cite>Brit. Med. Jour.</cite> of Jan. 28th, 1888.</p>
-
-<p class='c009'><span class='pageno' id='Page_149'>149</span>His experiments were conducted with an extract prepared from
-fresh sputum from phthisical patients, as follows:</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<h3 class='c008'>SURGERY.</h3>
-
-<div class='nf-center-c0'>
-<div class='nf-center c003'>
-    <div>BY GEORGE R. FOWLER, M. D.,</div>
-    <div class='c003'>Surgeon to St. Mary’s Hospital and to the Methodist Episcopal Hospital, Brooklyn.</div>
-  </div>
-</div>
-
-<h4 class='c012'>CONTRIBUTIONS TO THE STUDY OF MYXŒDEMA FOLLOWING TOTAL OR PARTIAL EXTIRPATION OF THE THYROID BODY.</h4>
-
-<p class='c011'>J. L. Reverdin (<span lang="fr" xml:lang="fr">Congrès Francais de Chirurgie, 2 session, Paris,
-1886.</span>) 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
-<span class='pageno' id='Page_150'>150</span>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.</p>
-
-<h4 class='c012'>UPON LUXATION OF THE HEAD OF THE RADIUS FORWARD.</h4>
-
-<p class='c011'>Raestock (<span lang="de" xml:lang="de">Deutsche Militärärztl. Zeitschrift, 1887, p. 331</span>) 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.</p>
-
-<p class='c009'>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.</p>
-
-<div>
-  <span class='pageno' id='Page_151'>151</span>
-  <h4 class='c012'>CHOLECYSTOTOMY, WITH LIGATURE OF THE CYSTIC DUCT.</h4>
-</div>
-
-<p class='c011'>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.”</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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 (<span lang="fr" xml:lang="fr">“De l’intervention chirurgicale dans certains
-cas de lithiase biliaire,” <cite>Revue de chirurgie, 1886, No. 3</cite></span>), 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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_152'>152</span>the feasibility of the operation of cholecystectomy upon the
-lower animals, at least.</p>
-
-<p class='c009'>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 (<span lang="pl" xml:lang="pl">Przegl. lekarski, 1887, No. 48</span>). 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.</p>
-
-<h4 class='c012'>SUPRA-PUBIC PROSTATECTOMY.</h4>
-
-<p class='c011'>A. F. McGill, F.R.C.S.  (<cite>The Lancet</cite>, 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,
-<span class='pageno' id='Page_153'>153</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>RESEARCHES UPON THE VAGINAL PROCESS OF THE PERITONEUM AS A PREDISPOSING CAUSE OF TENDENCY TO EXTERNAL INGUINAL HERNIA.</h4>
-
-<p class='c011'>H. Sachs (<span lang="de" xml:lang="de">Archiv. f. Klinisch. Chirurgie, Band xxxv., p. 321–372</span>)
-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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_154'>154</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-(<span lang="de" xml:lang="de">Korrespondenzblatt f. Schweizer Aertze, 1887, No. 18</span>), but is really a
-slowly occurring disease, to which certain well-defined anatomical
-peculiarities act as predisposing causes.</p>
-
-<h4 class='c012'>ACID SUBLIMATE SOLUTION IN SURGERY.</h4>
-
-<p class='c011'>E. Laplace (<span lang="de" xml:lang="de">Deutsche Med. Wochenschrift, No. 40, 1887</span>), 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.</p>
-
-<div>
-  <span class='pageno' id='Page_155'>155</span>
-  <h4 class='c012'>OPERATIVE TREATMENT OF PYOTHORAX.</h4>
-</div>
-
-<p class='c011'>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.</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>WOUND-HEALING UNDER THE DRY ASEPTIC SCAB.</h4>
-
-<p class='c011'>Prof. Kuester (<span lang="de" xml:lang="de">Centralblatt f. Chirurgue</span>, 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
-<span class='pageno' id='Page_156'>156</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>THE TREATMENT OF CAROTID HÆMORRHAGE.</h4>
-
-<p class='c011'>Mr. Frederick Treves (<cite>The Lancet</cite>, 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 <i><span lang="la" xml:lang="la">in situ</span></i> for four days.
-<span class='pageno' id='Page_157'>157</span>The second case was the fatal one. In the third and fourth cases the
-loop was removed on the seventh day.</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>ARTIFICIAL AID IN THE FORMATION OF CALLUS.</h4>
-
-<p class='c011'>Prof. Helferich (<span lang="de" xml:lang="de">Archiv. f. Klinische Chirurgie, Band 36, 4. Heft,
-1888</span>). 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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>It is suggested that the formation of varicose veins may be an objection
-<span class='pageno' id='Page_158'>158</span>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.</p>
-
-<h4 class='c012'>COMMUNICATION OF TUBERCULOSIS BY RITUAL CIRCUMCISION.</h4>
-
-<p class='c011'>F. S. Eve (<cite>The Lancet</cite>, 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.</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>TRANSPLANTATION OF THE SKIN.</h4>
-
-<p class='c011'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_159'>159</span>solution of carbolic acid, and dried; the pieces of skin should also be
-washed in a weak solution of carbolic acid.</p>
-
-<p class='c009'>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.</p>
-
-<h3 class='c008'>OBSTETRICS.</h3>
-
-<div class='nf-center-c0'>
-<div class='nf-center c003'>
-    <div>BY CHARLES JEWETT, A.M., M.D.,</div>
-    <div class='c003'>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.</div>
-  </div>
-</div>
-
-<h4 class='c012'>THE IMPROVED CÆSAREAN SECTION.</h4>
-
-<p class='c011'>Garrigues (Am. J. M. S., May, 1888,) describes in detail a successful
-case of Cæsarean section with observations on the <em>technique</em> 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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>Dr. Garrigues believes Cæsarean section safer than <em>difficult</em> extraction
-through the natural passages.</p>
-
-<p class='c009'>Eleven Cæsarean sections were done in this country between December
-16, 1886, and February 24, 1888, (Dr. R. P. Harris) all by
-<span class='pageno' id='Page_160'>160</span>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.</p>
-
-<p class='c009'>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.—<span class='sc'>Ed.</span></p>
-
-<p class='c014'>The paper concludes with a detailed statement of the <i><span lang="la" xml:lang="la">modus operandi</span></i> 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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>The maternal mortality was as follows:</p>
-
-<table class='table0' summary=''>
-  <tr>
-    <td class='c004'>Induced premature labor</td>
-    <td class='c006'>2.2 per cent.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Version and extraction</td>
-    <td class='c006'>4–8 per cent.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Perforation</td>
-    <td class='c006'>2–8 per cent.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Cæsarean section</td>
-    <td class='c006'>8–6 per cent.</td>
-  </tr>
-</table>
-
-<p class='c009'>The fœtal mortality was in</p>
-
-<table class='table0' summary=''>
-  <tr>
-    <td class='c004'>Premature labor</td>
-    <td class='c015'>33.4 per cent.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Version and extraction</td>
-    <td class='c015'>41.&nbsp; per cent.</td>
-  </tr>
-  <tr>
-    <td class='c004'>Cæsarean section</td>
-    <td class='c015'>13.&nbsp; per cent.</td>
-  </tr>
-</table>
-
-<p class='c009'>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.:</p>
-
-<p class='c009'>Complete asepsis.</p>
-
-<p class='c009'><span class='pageno' id='Page_161'>161</span>The patient strong and not long in labor.</p>
-
-<p class='c009'>The fœtal heart-beats normal in rate and rhythm.</p>
-
-<p class='c009'>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 <i><span lang="la" xml:lang="la">nil</span></i>, 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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>Zweifel reports six additional cases of the Cæsarean operation after
-Saenger, saving five mothers and all the children.</p>
-
-<h4 class='c012'>THE MECHANISM OF LABOR IN HEAD PRESENTATION.</h4>
-
-<p class='c011'>Sutugin (<span lang="de" xml:lang="de">Sammlung Klin. Vorträge, No. 310</span>) 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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_162'>162</span>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.</p>
-
-<h4 class='c012'>MANAGEMENT OF THE PLACENTAL STAGE OF LABOR.</h4>
-
-<p class='c011'>Fehling (<span lang="de" xml:lang="de">Sammlung Klin. Vorträge, No. 308</span>) 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
-<span class='pageno' id='Page_163'>163</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>SCARLET FEVER: ITS RELATION TO PUERPERAL FEVER</h4>
-
-<p class='c011'>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
-<span class='pageno' id='Page_164'>164</span>no appreciable effect upon the course of the puerperium in patients
-who escaped scarlatina.</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>MITRAL STENOSIS AND THE THIRD STAGE OF LABOR.</h4>
-
-<p class='c011'>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.</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>TREATMENT OF ABORTION.</h4>
-
-<p class='c011'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_165'>165</span>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.]</p>
-
-<h4 class='c012'>PLACENTA PRÆVIA.</h4>
-
-<p class='c011'>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:</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>The results in the sixty-four cases were eighty-nine per cent. of the
-mothers and forty-seven per cent. of the children saved.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_166'>166</span>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.]</p>
-
-<h4 class='c012'>OBSTETRIC SEPSIS AND ANTISEPSIS.</h4>
-
-<p class='c011'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.]</p>
-
-<h4 class='c012'>AUTO-INFECTION IN CHILDBED.</h4>
-
-<p class='c011'>Ahlfeld (Cent. f. Gyn., No. 52,) shows that it is not always safe
-to presume upon the impossibility of self-infection, and reports two
-<span class='pageno' id='Page_167'>167</span>cases in point. In rare cases infection may arise from organisms primarily
-present in the genitalia. [This goes to fortify Auvard’s position.]</p>
-
-<h4 class='c012'>OCCURRENCE OF GERMS IN THE DISCHARGES FROM THE UTERUS AND VAGINA DURING THE PUERPERAL PERIOD.</h4>
-
-<p class='c011'>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.</p>
-
-<p class='c009'>The uterine lochia of women suffering from puerperal sepsis in any
-form invariably contain germs, the streptococcus pyogenes being constantly
-present.</p>
-
-<h4 class='c012'>SUBLIMATE SOLUTION.</h4>
-
-<p class='c011'>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.]</p>
-
-<h4 class='c012'>TRICHLORIDE OF IODINE.</h4>
-
-<p class='c011'>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
-<span class='pageno' id='Page_168'>168</span>solution. [One disadvantage of this antiseptic is the powerful
-corrosive action of nascent chlorine and iodine upon metal instruments.]</p>
-
-<h4 class='c012'>DANGERS OF ANTISEPTICS.</h4>
-
-<p class='c011'>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.</p>
-
-<h4 class='c012'>EFFECT OF ERGOT ON THE INVOLUTION OF THE UTERUS.</h4>
-
-<p class='c011'>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.</p>
-
-<p class='c009'>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.</p>
-
-<div>
-  <span class='pageno' id='Page_169'>169</span>
-  <h4 class='c012'>ANÆSTHESIA WITH CHLOROFORM AND OXYGEN.</h4>
-</div>
-
-<p class='c011'>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.</p>
-
-<hr class='c016' />
-
-<p class='c009'>Veit, of Berlin, has operated in seven cases of tubal pregnancy before
-rupture, in all successfully.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>Saenger says the process of uterine involution is not a fatty degeneration
-but normal metabolism.</p>
-
-<p class='c009'>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.</p>
-
-<h4 class='c012'>QUININE AS AN OXYTOCIC.</h4>
-
-<p class='c011'>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.</p>
-
-<div class='chapter'>
-  <span class='pageno' id='Page_170'>170</span>
-  <h2 class='c007'><em>REVIEWS.</em></h2>
-</div>
-
-<p class='c017'><span class='sc'>The Applied Anatomy of the Nervous System</span>—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.</p>
-
-<div class='lg-container-r'>
-  <div class='linegroup'>
-    <div class='group'>
-      <div class='line'>New York: D. Appleton &amp; Co., 1, 3, and 5 Bond Street.</div>
-    </div>
-  </div>
-</div>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_171'>171</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.”</p>
-
-<p class='c009'>Now this division is quite artificial, and is only for purposes of
-description, and these parts are not <em>perfectly independent of one another</em>.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.”</p>
-
-<p class='c009'>This sounds like a most formidable and delicate task in the <em>judicious
-employment</em> 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 <em>the judicious employment of gradually increasing powers in the microscope
-objectives</em>; if he use a No. 2 and a No. 7 of Verick, or some
-<span class='pageno' id='Page_172'>172</span>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.</p>
-
-<p class='c009'>I will refer to one other paragraph on page 56, where it is stated:</p>
-
-<p class='c009'>“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.”</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>The spinal cord cannot be taught to perform such complicated
-acts without the intervention and guidance of the higher centres to
-begin with.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<div class='lg-container-r'>
-  <div class='linegroup'>
-    <div class='group'>
-      <div class='line'>J. C. S.</div>
-    </div>
-  </div>
-</div>
-
-<div class='chapter'>
-  <span class='pageno' id='Page_173'>173</span>
-  <h2 class='c007'><em>MISCELLANEOUS.</em></h2>
-</div>
-
-<h3 class='c008'>DR. J. B. MATTISON.</h3>
-
-<p class='c011'>Dr. Mattison recently spent several weeks in Bermuda, and the
-<cite>British Med. Journal</cite> in reporting a meeting of the British Med. Association,
-held in the Town Hall at Hamilton, says:</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>Dr. Mattison is translating Erlenmeyer’s <span lang="de" xml:lang="de">Die Morphiumsucht und
-ihre Behandlung</span>—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.</p>
-
-<h3 class='c008'>LONG ISLAND COLLEGE HOSPITAL TRAINING SCHOOL FOR NURSES.</h3>
-
-<p class='c011'>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.</p>
-
-<div>
-  <span class='pageno' id='Page_174'>174</span>
-  <h3 class='c008'>“<span lang="la" xml:lang="la">POST TENEBRAS LUX.</span>”</h3>
-</div>
-
-<div class='nf-center-c0'>
-<div class='nf-center c003'>
-    <div>BY PROF. F. H. GERRISH, OF BOWDOIN COLLEGE.</div>
-    <div class='c003'>The Era Prize Essay.—Reprint from the Pharmaceutical Era.</div>
-  </div>
-</div>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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
-<span class='pageno' id='Page_175'>175</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'><span class='pageno' id='Page_176'>176</span>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?</p>
-
-<p class='c009'>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,
-<span class='pageno' id='Page_177'>177</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>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;
-<span class='pageno' id='Page_178'>178</span>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.</p>
-
-<p class='c009'>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.</p>
-
-<h3 class='c008'>BROOKLYN VITAL STATISTICS FOR JUNE, 1888.</h3>
-
-<div class='nf-center-c0'>
-<div class='nf-center c003'>
-    <div>By <span class='sc'>J. S. Young</span>, Dep. Commissioner of Health.</div>
-  </div>
-</div>
-
-<h4 class='c012'><em>Data of comparison</em>:</h4>
-
-<table class='table1' summary=''>
-  <tr>
-    <td class='c018'>Population, estimated on July 1st, 1888</td>
-    <td class='c019'>793,960</td>
-  </tr>
-  <tr>
-    <td class='c018'>Inhabited houses, about</td>
-    <td class='c019'>93,000</td>
-  </tr>
-  <tr><td>&nbsp;</td></tr>
-  <tr>
-    <td class='c020' colspan='2'>Average birth-rate per 1,000 for ten years (returns incomplete).</td>
-  </tr>
-  <tr><td>&nbsp;</td></tr>
-  <tr>
-    <td class='c020' colspan='2'>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.</td>
-  </tr>
-  <tr><td>&nbsp;</td></tr>
-  <tr>
-    <td class='c018'>The number of births reported was</td>
-    <td class='c019'>937</td>
-  </tr>
-  <tr>
-    <td class='c018'>The number of marriages reported was</td>
-    <td class='c019'>531</td>
-  </tr>
-  <tr>
-    <td class='c018'>The number of still-births reported was</td>
-    <td class='c019'>113</td>
-  </tr>
-</table>
-
-<p class='c009'>The mortality by classes and by certain of the more important diseases
-was as follows:</p>
-
-<h4 class='c012'><em>Causes</em>:</h4>
-
-<table class='table1' summary=''>
-  <tr>
-    <td class='c004'>1. Zymotic</td>
-    <td class='c006'>434</td>
-  </tr>
-  <tr>
-    <td class='c004'>2. Constitutional</td>
-    <td class='c006'>251</td>
-  </tr>
-  <tr>
-    <td class='c004'>3. Local</td>
-    <td class='c006'>644</td>
-  </tr>
-  <tr>
-    <td class='c004'>4. Developmental</td>
-    <td class='c006'>121</td>
-  </tr>
-  <tr>
-    <td class='c004'>5. Violence</td>
-    <td class='c006'>63</td>
-  </tr>
-  <tr>
-    <td class='c004'>Measles</td>
-    <td class='c006'>6</td>
-  </tr>
-  <tr>
-    <td class='c004'>Croup</td>
-    <td class='c006'>8</td>
-  </tr>
-  <tr>
-    <td class='c004'>Diphtheria</td>
-    <td class='c006'>82</td>
-  </tr>
-  <tr>
-    <td class='c004'>Scarlet Fever</td>
-    <td class='c006'>45</td>
-  </tr>
-  <tr>
-    <td class='c004'>Typhoid Fever</td>
-    <td class='c006'><hr /></td>
-  </tr>
-  <tr>
-    <td class='c004'><span class='pageno' id='Page_179'>179</span>Whooping Cough</td>
-    <td class='c006'>5</td>
-  </tr>
-  <tr>
-    <td class='c004'>Malarial Diseases</td>
-    <td class='c006'>4</td>
-  </tr>
-  <tr>
-    <td class='c004'>Diarrhœal Diseases (all ages)</td>
-    <td class='c006'>244</td>
-  </tr>
-  <tr>
-    <td class='c004'>Diarrhœal Diseases (under 5 years)</td>
-    <td class='c006'>233</td>
-  </tr>
-  <tr>
-    <td class='c004'>Phthisis</td>
-    <td class='c006'>137</td>
-  </tr>
-  <tr>
-    <td class='c004'>Bronchitis</td>
-    <td class='c006'>45</td>
-  </tr>
-  <tr>
-    <td class='c004'>Pneumonia</td>
-    <td class='c006'>80</td>
-  </tr>
-  <tr>
-    <td class='c004'>All Respiratory Diseases</td>
-    <td class='c006'>149</td>
-  </tr>
-  <tr>
-    <td class='c004'>Bright’s Diseases</td>
-    <td class='c006'>35</td>
-  </tr>
-  <tr>
-    <td class='c004'>Puerperal Diseases</td>
-    <td class='c006'>17</td>
-  </tr>
-  <tr>
-    <td class='c004'>Old Age</td>
-    <td class='c006'>17</td>
-  </tr>
-  <tr>
-    <td class='c004'>Suicide</td>
-    <td class='c006'>10</td>
-  </tr>
-</table>
-
-<p class='c009'>Reported cases:</p>
-
-<table class='table0' summary=''>
-  <tr>
-    <td class='c004'>Diphtheria</td>
-    <td class='c006'>214</td>
-  </tr>
-  <tr>
-    <td class='c004'>Scarlet Fever</td>
-    <td class='c006'>255</td>
-  </tr>
-  <tr>
-    <td class='c004'>Measles</td>
-    <td class='c006'>128</td>
-  </tr>
-  <tr>
-    <td class='c004'>Typhoid Fever</td>
-    <td class='c006'><hr /></td>
-  </tr>
-</table>
-
-<p class='c009'>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.</p>
-
-<p class='c009'>Deaths by sex, color, and social condition were as follows:</p>
-
-<table class='table0' summary=''>
-  <tr>
-    <td class='c004'>Male</td>
-    <td class='c021'>846</td>
-    <td class='c004'>Female</td>
-    <td class='c006'>667</td>
-  </tr>
-  <tr>
-    <td class='c004'>White</td>
-    <td class='c021'><hr /></td>
-    <td class='c004'>Colored</td>
-    <td class='c006'>21</td>
-  </tr>
-  <tr>
-    <td class='c004'>Native</td>
-    <td class='c021'>1102</td>
-    <td class='c004'>Foreign</td>
-    <td class='c006'>411</td>
-  </tr>
-  <tr>
-    <td class='c004'>Married</td>
-    <td class='c021'>328</td>
-    <td class='c004'>Single</td>
-    <td class='c006'>1006</td>
-  </tr>
-  <tr>
-    <td class='c004'>Widows, Widowers, and not stated</td>
-    <td class='c021'>&nbsp;</td>
-    <td class='c004'>&nbsp;</td>
-    <td class='c006'>179</td>
-  </tr>
-</table>
-
-<p class='c009'>Still-births (excluded from list of deaths) were as follows:</p>
-
-<table class='table0' summary=''>
-  <tr>
-    <td class='c004'>Males</td>
-    <td class='c006'>60</td>
-  </tr>
-  <tr>
-    <td class='c004'>Females</td>
-    <td class='c006'>53</td>
-  </tr>
-  <tr>
-    <td class='c004'>Total</td>
-    <td class='c006'>113</td>
-  </tr>
-  <tr>
-    <td class='c004'>Deaths in public institutions</td>
-    <td class='c006'>115</td>
-  </tr>
-  <tr>
-    <td class='c004'>Deaths in tenement houses</td>
-    <td class='c006'>745</td>
-  </tr>
-  <tr>
-    <td class='c004'>Inquest cases</td>
-    <td class='c006'>156</td>
-  </tr>
-  <tr>
-    <td class='c004'>Homicides</td>
-    <td class='c006'><hr /></td>
-  </tr>
-  <tr>
-    <td class='c004'>Suicides</td>
-    <td class='c006'>10</td>
-  </tr>
-</table>
-
-<h4 class='c012'><em>Age Periods</em>:</h4>
-
-<table class='table1' summary=''>
-  <tr>
-    <td class='c004'>Deaths under 1 year</td>
-    <td class='c006'>496</td>
-  </tr>
-  <tr>
-    <td class='c004'>Deaths under 5 years</td>
-    <td class='c006'>253</td>
-  </tr>
-  <tr>
-    <td class='c004'>Total deaths under 5 years</td>
-    <td class='c006'>749</td>
-  </tr>
-  <tr>
-    <td class='c004'>Total deaths&nbsp; 5 to 20</td>
-    <td class='c006'>126</td>
-  </tr>
-  <tr>
-    <td class='c004'>Total deaths 20 to 40</td>
-    <td class='c006'>223</td>
-  </tr>
-  <tr>
-    <td class='c004'>Total deaths 40 to 60</td>
-    <td class='c006'>233</td>
-  </tr>
-  <tr>
-    <td class='c004'>Total deaths 60 and upwards</td>
-    <td class='c006'>182</td>
-  </tr>
-</table>
-
-<p class='c009'><span class='pageno' id='Page_180'>180</span>Certain foreign and American cities show the following death-rate
-for the month of June:</p>
-
-<table class='table0' summary=''>
-  <tr>
-    <td class='c004'>Brooklyn</td>
-    <td class='c006'>23.78</td>
-  </tr>
-  <tr>
-    <td class='c004'>New York</td>
-    <td class='c006'>26.86</td>
-  </tr>
-  <tr>
-    <td class='c004'>Philadelphia</td>
-    <td class='c006'>18.98</td>
-  </tr>
-  <tr>
-    <td class='c004'>Berlin</td>
-    <td class='c006'>19.40</td>
-  </tr>
-  <tr>
-    <td class='c004'>Dublin</td>
-    <td class='c006'>23.58</td>
-  </tr>
-  <tr>
-    <td class='c004'>Vienna</td>
-    <td class='c006'>31.50</td>
-  </tr>
-  <tr>
-    <td class='c004'>Paris</td>
-    <td class='c006'>21.68</td>
-  </tr>
-  <tr>
-    <td class='c004'>London</td>
-    <td class='c006'>16.10</td>
-  </tr>
-  <tr>
-    <td class='c004'>Glasgow</td>
-    <td class='c006'>22.98</td>
-  </tr>
-</table>
-
-<h3 class='c008'>NEW INSTRUMENTS.</h3>
-
-<p class='c011'>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.</p>
-
-<h3 class='c008'>ANTIFEBRINE.</h3>
-
-<p class='c011'>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.—<cite>Pittsburgh Medical Review.</cite></p>
-
-<h3 class='c008'>ENEMA LESIONS.</h3>
-
-<p class='c011'>“Dr. Achilles Nordmann, of Basle,” says the <cite>Lancet</cite>, “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.”—<cite>N.
-Y. Medical Journal.</cite></p>
-
-<div class='pbb'>
- <hr class='pb c003' />
-</div>
-<div class='tnotes'>
-
-<div class='chapter'>
-  <h2 class='c007'>TRANSCRIBER’S NOTES</h2>
-</div>
- <ol class='ol_1 c002'>
-    <li>Silently corrected typographical errors and variations in spelling.
-
-    </li>
-    <li>Anachronistic, non-standard, and uncertain spellings retained as printed.
-    </li>
-  </ol>
-
-</div>
-
-
-
-
-
-
-
-
-<pre>
-
-
-
-
-
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