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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..d7b82bc --- /dev/null +++ b/.gitattributes @@ -0,0 +1,4 @@ +*.txt text eol=lf +*.htm text eol=lf +*.html text eol=lf +*.md text eol=lf diff --git a/LICENSE.txt b/LICENSE.txt new file mode 100644 index 0000000..6312041 --- /dev/null +++ b/LICENSE.txt @@ -0,0 +1,11 @@ +This eBook, including all associated images, markup, improvements, +metadata, and any other content or labor, has been confirmed to be +in the PUBLIC DOMAIN IN THE UNITED STATES. + +Procedures for determining public domain status are described in +the "Copyright How-To" at https://www.gutenberg.org. + +No investigation has been made concerning possible copyrights in +jurisdictions other than the United States. Anyone seeking to utilize +this eBook outside of the United States should confirm copyright +status under the laws that apply to them. diff --git a/README.md b/README.md new file mode 100644 index 0000000..26561c2 --- /dev/null +++ b/README.md @@ -0,0 +1,2 @@ +Project Gutenberg (https://www.gutenberg.org) public repository for +eBook #60493 (https://www.gutenberg.org/ebooks/60493) diff --git a/old/60493-0.txt b/old/60493-0.txt deleted file mode 100644 index d7d3e67..0000000 --- a/old/60493-0.txt +++ /dev/null @@ -1,4422 +0,0 @@ -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) - - - - - - - - - - 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. 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} - .c019 { vertical-align: bottom; text-align: right; } - .c020 { vertical-align: top; text-align: left; text-indent: -1em; - padding-left: 1em; } - .c021 { vertical-align: top; text-align: right; padding-right: 1em; } - div.tnotes { padding-left:1em;padding-right:1em;background-color:#E3E4FA; - border:1px solid silver; margin:2em 10% 0 10%; font-family: Georgia, serif; - } - .covernote { visibility: hidden; display: none; } - div.tnotes p { text-align:left; } - @media handheld { .covernote { visibility: visible; display: block;} } - .section { clear: both; page-break-before: always; } - .ol_1 li {font-size: .9em; } - @media handheld {.ol_1 li {padding-left: 1em; text-indent: 0em; } } - body {font-family: Georgia, serif; text-align: justify; } - table {font-size: .9em; } - div.titlepage {text-align: center; page-break-before: always; - page-break-after: always; } - div.titlepage p {text-align: center; text-indent: 0em; font-weight: bold; - line-height: 1.5; margin-top: 3em; } - .ph1 { text-indent: 0em; font-weight: bold; font-size: xx-large; - margin: .67em auto; page-break-before: always; } - .vincula{ text-decoration: overline; } - .fraction {display: inline-block; vertical-align: middle; text-align: center; - font-size: 75%;text-indent: 0; } - </style> - </head> - <body> - - -<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> </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> </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. per cent.</td> - </tr> - <tr> - <td class='c004'>Cæsarean section</td> - <td class='c015'>13. 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 & 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> </td></tr> - <tr> - <td class='c020' colspan='2'>Average birth-rate per 1,000 for ten years (returns incomplete).</td> - </tr> - <tr><td> </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> </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'> </td> - <td class='c004'> </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 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> - - - - - -End of the Project Gutenberg EBook of The Brooklyn Medical Journal. Vol. II. -No. 2. 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