Property of the

Lancaster City and County Medical Society

No

I

THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

EDITED BY

I. MINIS HAYS, A.M., M.D.

IEf SERIES. VOL. LXXXII.

PHILADELPHIA:

HENRY C. LEA'S SON k CO. 1881.

69508

Entered according to the Act of Congress, in the year 1881, by

HENRY C LEA'S SON & CO., in the Office of the Librarian of Congress. All rights reserved.

PHILADELPHIA : COLLINS, PRINTER,

7o5 Jayup Street.

INDEX.

Abadie, Ophthalmology, review of, 521 Abdominal surgery, recent advances in,

564

Agnew's Surgery, review of, 511 Albuminuria of pregnancy and scarlatina,

benzoic acid in, 169 American Ophthalmological Society's

Transactions, review of, 204 Anaesthetics containing chlorine, bromine,

or iodine, dangers of, 50 Anchylosis, review of Brodhurst on, 211 Aneurism, inguinal, distal compression

in, 140

, treatment of, by Esmarch's

bandage, 568, 569 Antagonisms between medicines, 195 Antipyretics, action and uses of, 552 Antiseptic treatment in abdominal sur- gery, 560

midwifery, 575

Aphonia following division of right recur- rent laryngeal nerve by stab, 155 Apomorphia as an expectorant, 245 Atkinson, iodide of potassium as a cause

of Bright's disease, 17 Atlee, retention of menses from imperfo- rate hymen, 136 Atthill, inversion of uterus, 275

B.

Barker, nephrectomy, 265

Barlow, subcutaneous nodules in choreic or rheumatic children, 556

Bartholow, Antagonisms between Medi- cines, review of, 195

Bar well, nephrectomy for nephrolithiasis, 565

Battey, oophorectomy, 578 Beck, apomorphia as an expectorant, 245 Bellamy, treatment of aneurism by Es- march's bandage, 568 Bemiss, diagnosis of yellow fever, 246 Benzoic acid in albuminuria of pregnancy

and scarlatina, 169 Berininghain, Disposal of the Dead, 541 Billings, cholera and yellow fever, 581 Billroth, resection of stomach, 260 Binz, antipyretics, 552 Bladder, partial excision of, 566 Blepharoplasty, new method of, 269 Bloodvessels, treatment of injuries of, 569 Bone, transplantation of, 268 Bouchard, infective nephritis, 559 Brailey, sympathetic ophthalmia, 572 Brain, severe injury of, with recovery, 168 Bright's disease, iodide of potassium as a cause of, 17

, review of Tyson on, 171

Brodhurst, Anchylosis, review of, 211

I Broom-corn seed in cystitis, 164

! Browne, local treatment of diphtheria, 556

[ Bryant, Surgery, review of, 213

| Bull, colour perception, 574

I , treatment of scars of face involving

eyelids, 431 Burow, treatment of laryngeal growths,

563

Buzzard, certain little recognized phases of locomotor ataxy, 558

C.

Carbolic acid, poisoning by, 425 Cartilage, transplantation of, 360 Cavities in lungs, opening and drainage of, 370

Cerebro-spinal meningitis, epidemic, 251 Charcot, Diseases of Old Age, review of. 519

, hypnotic contractures, 252

Cheadle, two distinct fevers included

under measles, 555 Chloroform, poisoning by, 277 Cholera, experience of United States with

regard to, 581 Chorea, subcutaneous nodules in children

with, 556

Colorado Health Report, review of, 241

Colour-blindness, 270

Colour perception, new mode of examin- ing and numerically expressing, 574

Connecticut Medical Society's Proceed- ings, review of, 527

Connor, hot water in treatment of diseases of the eye, 466

Contractures, hypnotic, 252

Copeland, operation for removal of bursal swelling of wrist, 143

Cornea, anaesthesia of, 131

Creighton, Bovine Tuberculosis in Man, review of, 183

Cystitis, broom-corn seed in, 164

Czerny, nephrectomy. 565

-, resection of intestine, 263

D.

Dabney, peritonitis as a sequel to diph- theria, 486

Da Costa, nervous symptoms of lithoemia. 313

Darling and "Ranney, Anatomical Plates.

review of, 233 Day, Diseases of Children, review of, 200 Depressants, cardiac toxicology of, 411 De Weeker, treatment of glaucoma, 571 Diabetes, salts of ammonia in treatment

of, 258

Diphtheria, peritonitis as a sequel to, 486

, treatment of, 253, 556

Duhring, Diseases of Skin, review of, 236

II

Index

Duhring, instrument for removal of super- fluous hairs, 142

, painful neuroma of skin, 435

Duodenostomy, 261

E.

Ear disease in locomotive engineers, 271 Elsberg, hypassthesia of throat, 330 Empyema and its treatment, 77 Epilepsy, bromide of ethyl in, 248

, importance of early recognition

of, 527

Erb, syphilis and locomotor ataxy, 247

Esmarch, bandage of, in treatment of aneurism, 568, 569

, treatment of injuries of blood- vessels in the field, 569

Eye diseases, hot water in treatment of, 466

Eyeball, foreign bodies in, 574

F.

Fenger, opening and drainage of lung

cavities, 370 Fischer, partial excision of bladder, 566 Fistula in ano, ecraseur in deep-seated, 31 Fontenay, colour-blindness, 270 Foot, fiat, in young infants, 243 Fothergill, strychnia an expectorant, 553 * Fournier, Syphilis and Marriage, review

of, 242

Fox, Photographic Illustration of Cutane- ous Syphilis, review of, 212 Freund, extirpation of uterus, 577

G.

Ganglion of wrist, operation for removal of, 143

Garfield, report of case of President, 583 Garnett, broom-cord seed in cystitis, 164 Gaston, ecraseur in fistula in ano, 31 Gastrostomy, 261

Gastrotomy in extra-uterine pregnancy, 278

Gibert, transfusion in typhoid fever com- plicated with intestinal hemorrhage, 246 Glaucoma, operative treatment of, 571 Glazier, Trichinosis, review of, 521 Gould, Esmarch's bandage in treatment

of aneurism, 569 Gout, 557

Guerin, typhoid fever considered as fecal

intoxication, 554 Guttmann, salts of ammonia in treatment

of diabetes, 258

H.

Hairs, superfluous, instrument for removal of, 142

Hare-lip, Langenbeck's operation for, 258

Head, temperature of, 221

Heart disease, local sensibility of precor- dial region in, 256

, Structural Anatomy of Female Pel- vic Floor, review of, 225

Hearts, lymphatic, 70

Hemorrhage into ventricles of brain, 85, 337

, post-partum, prevention and

treatment of, 576 Hewitt, exciting cause of hysteria and

hystero-epiiepsy, 558

Hill, benzoic acid in albuminuria of preg- nancy and scarlatina, 169

Hip-joint, excision of, in children, 267

Hollister, opening and drainage of lung cavities, 370

Homatropine and atropia, comparative action of, 150

House, operative treatment of prolapse of uterus and vagina, 39

Hueter, treatment of scrofulous inflamma- tion of joints, 567

Humphry, cause of failure of primary union, 561

Hutchinson, rheumatism and gout, 557

Hysteria, exciting cause of, 558

Hystero-epiiepsy, 392

, exciting cause of, 558

I.

Illinois State Medical Society's Transac- tions, review of, 529 Intestine, resection of, 263

J.

Joints, treatment of scrofulous inflamma- tion of, 567 Jones, lymphatic hearts, 70

K.

KaczOrowski, intra-peritoneal transfusion,

245

Kassowitz, rbtheln, 555

Keith, antiseptic treatment in abdominal

surgery, 560 Kidney, extirpation of, 265, 565 Knee-joint, results of treatment in chronic

diseases of, 568 Kocher, results of treatment in chronic

diseases of knee-joint, 568 Koeberle, resection of intestine, 263 Krishaber, removal of foreign bodies from

larynx, 259 Kussmaul, treatment of splenic tumours,

257

L.

Labbe, salicylate of soda in neuralgia, 248 Landis, How to Use the Forceps, review of, 235

Landolt, blepharoplasty, 269 Lane, Lectures on Syphilis, review of, 541 Langenbuch, gastrostomy and duodenos- tomy, 261 Laryngeal growths, treatment of, 563 nerve, recurrent, aphonia fol- lowing division of, 155 Larynx, local anaesthesia of, 259

, removal of foreign bodies from,

259

Leber, foreign bodies in eyeball, 574

, relation between optic neuritis and

intracranial disease, 573 Lefferts, division of right recurrent laryn- geal nerve followed by aphonia, 155 Lichtheim, antipyretic action of the

phenols, 245 Limbs, osseous deformity of lower, 177 Lister, antiseptic treatment in abdominal

surgery, 560 Lithaemia, nervous symptoms of, 313 Litzmann, gastrotomy in extra-uterine pregnancy, 273

Index,

III

Liver, acute abscess of, 65

Diseases, review of, 489

Locomotor ataxy, certain little recognized phases of, 558

and syphilis, 247

Lombard, Temperature of the Head, re- view of, 221

Longmore, bullet-wounds of the Martini- Henry rifle, 562

Louisiana Health Report, review of, 240

Lung cavities, drainage of, 370

M.

Macewen, Osteotomy, review of, 177

, transplantation of bone, 268

Mackenzie, treatment of diphtheria, 556 Macnamara, Bones and Joints, review, 230 Madden, post-partum hemorrhage, 576 Marsh, excision of hip-joint in children, 267

, surgical fever, 560

Martin, extirpation of uterus though va- gina, 276

Martindale, empyema and its treatment, 77

Masse, Pocket Atlas of Descriptive Anat- omy of Human Body, review of, 233

Measles, two distinct forms of eruptive fevers included under, 555

Medin, epidemic cerebro-spinal meningitis, 251

Mendelson, acute abscess of liver, 65 Menses, retention of, from imperforate

hymen, 136 Mercury, action of small doses of, 244 Midwifery, antiseptic treatment in, 575 Mills, hystero-epilepsy, 392 Minor, anaesthesia of cornea, 131 Mitchell, Diseases of the Nervous System,

review of, 209 Mittendorf, Diseases of Eye and Ear, re- view of, 232 Moos, ear affections in locomotive engi- neers, 271 Murmurs, cephalic, adult, 255 Muscular contraction, paradoxical, 250 Mygge, chloroform poisoning, 277

N. •

Nephrectomy, 265, 565

Nephritis, infective, 559

Neuralgia, salicylate of soda in, 248

Neuroma of skin, painful, 435

Neurotic atrophy, 249

Nieden, nystagmus of miners, 573

Nodules, subcutaneous, connected with fibrous structures occurring in children having chorea or rheumatism, 556

North Carolina Board of Health Report, review of, 241

Nystagmus of miners, 573

O.

Obituary notice of Dr. G. A. Otis, 278

Isaac Ray , 284

Obstetrical Society of London, Transac- tions of, review of, 215 Oertel, treatment of diphtheria, 253 Ogneff, development of the retina, 551 Oliver, comparative action of homatropine

and atropia, 150 Onimus, atrophic infantile paralysis, 249

Oophorectomy, 578

Ophthalmia, sympathetic-, 572

Optic neuritis and intracranial disease,

relation of, 573 Osteotomy, review of Macewen on, 177 Otis, obituary notice of Dr., 278 , Syphilis, review of, 533

P.

Pagenstecher, operative cure of ptosis, 573 Paralysis, atrophic infantile, 249 Pericarditis treated by incision, 254 Peritonitis following diphtheria, 486 Peter, local sensibility of precordial region

in heart disease, 256 Phenols, antipyretic action of the, 245 Phthisis, pulmonary, conditions affecting

the origin and course of, 156 Piffard, Materia Medica and Therapeutics

of the Skin, review of, 231 Potassium iodide as a cause of Bright's

disease, 17

Pregnancy, extra-uterine, gastrotomy in, 273

President Garfield, report of case of, 583 Prudden, transplantation of cartilage, 360 Ptosis, operation tor cure of, 573

R.

Ranke, Physiology, review of, 229 Ranney, Surgical Diagnosis y review of, 549 Ray, obituary notice of Dr. Isaac, 284 Reichert, dangers of anaesthetics contain- ing chlorine, bromine, or iodine, 50

, toxicology of carbolic acid, 441

cardiac depres- sants, 441 Retiua, development of, 551 Reviews —

Abadie, Ophthalmology, 521

Agnew's Surgery, 511

American Ophthalmological Society's

Transactions, 204 Bartholow, Antagonisms between

Medicines, 195 Bermingham, Disposal of Dead, 541 Brodhurst, Anchylosis, 211 Bryant, Surgery, 213 Carpenter, The Microscope, 550 Charcot, Diseases of Old Age, 519 Creighton, Bovine Tuberculosis in Man, 183

Darling and Ranney, Anatomical Plates, 233

Day, Diseases of Children, 200

Diseases of the Liver, 489

Duhring, Diseases of the Skin, 236

Ewald, Lectures on Digestion, 546

Flint, Physiology, 549

Fournier, Syphilis and Marriage, 242

Fox, Photographic Illustrations of Cutaneous Syphilis, 212

Glazier, Report on Trichinosis, 521

Harris and Power, Manual for Physio- logical Laboratory, 539

Hart, Structural Anatomy of Female Pelvic Floor, 225

Health Reports, 240

Index-Catalogue of Library of Sur- geon-General's Office, 538

Landis, How to Use the Forceps, 255

IV

Index,

Reviews —

Lane, Lectures on Syphilis, 541 Legg, Bile, Jaundice, and Bilious Dis- eases, 489 Lombard, Temperature of Head, 221 Macewen, Osteotomy, 177 Macnamara, Bones and Joints, 230 Masse, Atlas of Anatomy, 233 Mitchell, Diseases of Nervous System, 209

Mitterdorf, Diseases of Eye and Ear,

232

Obstetrical Society of London, Trans- actions of, 215 Otis, Syphilis, 533

Piffard, Materia Medica and Thera- peutics of the Skin, 231

Public Health Reports, 539

Ranke, Physiology, 229

Ranney, Surgical Diagnosis, 549

Saint Bartholomew's Hospital Re- ports, 187

Simpson and Hart, Relations of the Abdominal and Pelvic Organs in the Female, 224

State Medical Societies Transactions, 525

Sturgis, Veneral Diseases, 220 Surgeon-General of the Navy, Report

of, 547 Tartenson, Syphilis, 226 Teale, Dangers to Health, 544 Turner, Hygiene of Emigrant Ships,

531

Tyson, Bright's Disease, 171

Van Buren, Diseases of Rectum, 198

Warren, Hernia, 239

Wilson, Continued Fevers, 534

Rheumatic gout, 557

Rheumatism, 557

— , subcutaneous nodules in

children with, 556

Rhode Island Medical Society's Transac- tions, review of, 525

Robinson, some of the conditions affecting the origin and course of phthisis, 156

Rosenstein, pericarditis treated by inci- sion, 254

Rotheln, real position of, 555

S.

Saint Bartholomew's Hospital Reports, re- view of, 187

Sanders, hemorrhage into ventricles of brain, 85, 337

Scars of face involving ej^elids, treatment of, 431

Schlesinger, action of small doses of

mercury, 244 Schroetter, local anaesthesia of larynx, 259 Seguin, importance of early recognition of

epilepsy, 527 Septicaemia, influence of antipyretics on,

552

Shoulder-joint, amputation at, 145 Simpson and Hart, Relations of Abdo- minal and Pelvic Organs in the Female, review of, 224 Snellen, sympathetic ophthalmia, 572 Spiegelbercf, antiseptic treatment in mid- wifery, 575 Splenic tumours, treatment of, 257

Squire, rotheln, 558

Stomach, resection of, 260

Strychnia as an expectorant, 553

Sturgis, Venereal Diseases, review of, 220

Suicide, medico-legal relations of, 472

Surgical fever, 560

Syphilis and locomotor ataxy, 247

T.

Tait, recent advances in abdominal sur- gery, 564 Tartenson, Syphilis, review of, 226 Teale, Dangers to Health, review of, 544 Throat, hypsesthesia of, 330 Tiffany, amputation at shoulder-joint, 145 Tongue, removal of, through mouth, 563 Transfusion in typhoid fever complicated with intestinal hemorrhage, 246

intra-peritoneal, 245

Tripier, adult cephalic murmurs, 255 Tuberculosis, Bovine, in Man, review of, 183

Turner, Hygiene of Emigrant Ships, re- view of, 531

Typhoid fever considered as fecal intoxica- tion, 554

Tyson, Bright's Disease, review of, 171 U.

Union, primary, cause of failure of, 561 Urea, quantitative determination, of, by

alkaline hypochlorites and hypobro-

mites, 128 Uterus, extirpation of, 577

, through vagina, 276

, inversion of, 275

, prolapse of, 39

V.

Vagina, prolapse of, 39 Van Buren, Diseases of Rectum, review of, 198

Varick, distal compression in inguinal

aneurism, 140 Ventricles of brain, hemorrhage into, 85,

337

Virchow, neurotic atrophy, 249 Volkmann, flat-foot, 243

W.

Warren, Hernia, review of, 239 Weise, treatment of diphtheria, 253 Westphal, paradoxical muscular contrac- tion, 250

Whitehead, removal of tongue through mouth, 563

Whitman, medico legal relations of sui- cide, 472

Wilson, Continued Fevers, review of, 534 Wolff, Langen beck's operation for hare- lip, 258

Wood, severe injury of brain, 168 Wormley, quantitative determination of

urea by alkaline hypochlorites and hy-

pobromites, 128 Wounds, bullet-, of Martini-Henry rifle, 562 Wrist, bursal swelling of, operation for

removal of, 143

Y.

Yellow fever, diagnosis of, 246

, experience of United States

with regard to, 581

TO READERS AND CORRESPONDENTS.

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Contributors who wish their articles to appear in the next number are requested to forward them before the 1st of August.

Liberal compensation is made for all articles used. Extra copies, in pamphlet form with cover, will be furnished to authors in lieu of compensation, provided the request for them be made at the time the communication is sent to the Editor.

The following works have been received : —

Grundzii^e der Physiolog;ie des Menschen mib Riicksicht auf die Gesundheitspflege. Von Johannes Raxke, Dr. Med. und Prof, an der Univ. zu Miinchen. Vierte urn- gearbeitete Auflage. Leipzig : Wilhelm Engelmann, 1881.

Die Temperatur des gereizten Saugethiermuskels. Von Dr. Meade Smith.

Ueber Nasenblutung, Nasentamponade und deren beziehungen zu erkrankungen des Hororganes. Von Dr. Arthur Hartmann, in Berlin.

Ueber der so«;enannten Schnellenden Finger. Sturz aus einem Fenster des dritten Stockwerkes ohne gefahrliche Verletzungen. Ein Fall von Lipoma multiplex sym- metricum. Von Dr. Carl Fieber.

De la Phthisie Pulmonaire et de sa Curabilite. Par Jean Louis Simon Jolt, Doc- teur en Medecine. Paris : J. B. Bailliere et Fils, 1881.

Impressions et Aventures d'un Diabetique a travers la Medecine et les Melecins. Par le Docteur Jules Ctr. 2me ed. Paris : Ad. Delahayes et E. Lecrosiner, 1881.

Transactions of the Obstetrical Society of London. Vol. xxii. for the year 1880. London : Longmans, Green & Co., 1881.

On Anchylosis, and the Treatment for the Removal of Deformity and the Restora- tion of Mobility in various Joints. By Berxard E. Brodhurst, F.R.C.S. -ith ed. London : J. & A. Churchill, 1881.

Dysmenorrhea : its Pathology and Treatment. By Hetwood Smith, M. A., M.D., Oxon. London : J. & A. Churchill, 1881.

Lectures on Diseases of Bones and Joints. By C. Macxamara, F.R.C.S. Eng., Sur- geon and Lect. on Surgery at the Westminster Hospital, etc. Second ed. London : J. & A. Churchill, 1881.

Mr. Spencer Wells's Note Book for Cases of Ovarian Tumours. 6th ed. London : J. & A. Churchill, 1881.

Observations on Fatty Heart. By Hexrt Kexxedy, A.B., M.D., Univ. Dubl. Dublin : Fannin & Co., 1881.

Report on " Surra" Disease. Military Dept., Dec. 1880.

Experimental Researches on some Points relating to the Normal Temperature of the Head. By J. S. Lombard, M.D., formerly Assist. Prof, of Physiology in Harvard University. Loudon : H. K. Lewis, 1880.

Nocturnal Incontinence of Urine. By Tom Robixsox, M.D. London : Henry Kimpton, 1881.

The Structural Anatomy of the Female Pelvic Floor. By David Berry Hart, M.D., F.R.C.S.P.E. Edinburgh : Maclachlan & Stewart, 1880.

The Relations of the Abdominal and Pelvic Organs in the Female, illustrated by a full-sized chromo-lithograph of the Section of a Cadaver frozen in the Genu-pectoral I position, and by a series of Wood-cuts. By Prof. Alexander Russell Simpson and Dr. David Berry Hart. Edinburgh : W. & A. K. Johnston, 1881.

On Axis Traction Forceps. By Alex. R. Simpson, M.D. Edinburgh, 1880.

On Lethargy in Trance. By Thomas Moke Madden, M.D.

Lectures on Diseases of the Nervous System, especially in Women. By S. Weir Mitchell, M.D. Philadelphia : Henry C. Lea's Son & Co., 1881.

An Introduction to Pathology and Morbid Anatomy. By T. Henry Green, M.D. Loud. Fourth Am. from the fifth revised and enlarged English edition. Phila- delphia : Henry C. Lea's Son & Co., 1881.

8

TO READERS AND CORRESPONDENTS.

Medical Electricity : A Practical Treatise on Applications of Electricity to Medicine and Surgery. Bv Roberts Bartholow, A.M., M.D., LL.D., Prof, of Mat. Med. and Gen. Therapeutics in Jefferson Med. Coll. of Phila. Philadelphia : Henry C. Lea's Son & Co., 1881.

A Treatise on Bright's Disease and Diabetes, with especial reference to Pathology and Therapeutics. By James Tyscn, A.M., M.D., Prof, of Gen. Patholoay and Mor- bid Anat. in Univ. of Penna. Including- a Section on Retinitis in Bri°;ht's Disease. By William F. Norris, M.D.. Clin. Prof, of Ophthalmology in LTniv. of Penna. Philadelphia : Lindsay & Blakiston, 1881.

What everv Mother' should know. By Edward Ellts, M.D. Philadelphia : Pres- ley Blakiston, 1SS1.

The Metric System. By Oscar Oldberg, Phar. D. Philadelphia : Presley Blakis- ton, 1881.

The Diseases of Children ; A Practical Systematic Work for Practitioners and Students. By William Henry Day, M.D. Second ed. Philadelphia : Presley Blak- iston, 1881.

Dyspepsia. How to avoid it. By Joseph F. Edwards, M.D. Philadelphia : Pres- ley Blakiston, 1881.

A System of Oral Sursrerv. By James E. Garretson, M.D., D.D.S., Dean of the Phila.' Dental Coll. Third ed. Philadelphia : J. B. Lippincott & Co., 1881.

A Treatise on Diseases of the Joints. By Richard Barwell, F.R.C.S. Second ed. revised. New York : William Wood & Co., 1881.

A Treatise on the Continued Fevers. By James C. Wilson, M.D., Phys. to the Philadelphia Hospital, etc. With an Introduction by J. M. Da Costa. M.D., Prof, of Practice of Med. in Jefferson Med. Coil. New York': William Wood & Co., 1881.

On the Antagonism between Medicines and between Remedies and Diseases. By Roberts Bartholow, M.A., M.D., LL.D. New York : D. Appleton & Co., 1881.

A Text-book of Practical Medicine. By Dr. Felix von Niemeyer. Translated by George H. Humphreys, M.D., and Charles E. Hackley, M.D. Revised ed., 2 vols. New York : D. Appleton & Co., 1881.

A Treatise on the Diseases of the Nervous System. By William A. Hammond, M.D. Seventh ed. New York : D. Appleton & Co., 1881.

Anatomical Plates arranged as a Companion Volume for " The Essentials of Ana- tomy," and for all Works upon Descriptive Anatomy. Edited by Ambrose L, Rax key, A.M., M.D. New York : G. P. Putnam's Sons, 1881.

The Student's Manual of Venereal Diseases. By F. R. Sturgis, M.D., Lect. on Venereal Dis. in Univ. of City of New York, etc. New York : G. P. Putnam's Sons, 1881.

Clinical Lectures on the Physiological Pathology and Treatment of Syphilis, together with a Fasciculus of Class-room Lessons covering the Initiatory Period. By Fessen- den N. Otis, M.D., Clin. Prof, of Genito-Urinary Dis. in Coll. of Phys. and Surgeons, N. Y. New York : G. P. Putnam's Sons, 1881.

Photographic Illustrations of Cutaneous Syphilis. By George Henry Fox, A.M., M.D.. Clin. Lect. on Dis. of Skin, Coll. Phys. and Surg., New York, Nos. 1, 2, 3, 4, 5, 6. New York : E. B. Treat.

How to use the Forceps. With an Introductory Account of the Female Pelvis and of the Mechanism of Delivery. By Henry G. Landis, A.M., M.D., Prof, of Phthisis in Starling Medical Coll. New York : 1881.

A Manual of the Practice of Medicine. By Henry C. Moir, M.D. New York, 1881.

United States Marine-Hospital Service. Report on Trichinae and Trichinosis. Pre- pared under the direction of the Supervising Surgeon-General. By W. C. W. Glazier, M D., Assist. Surgeon, M. H. S. Washington, 1881.

Anomalies of Perspiration. By J. H. Pooley, M.D. Columbus, 1881.

Strangulated Veins of the Uterus, and other Papers, Gynecological and Surgical. By Thomas II . Buckler, M.D., of Baltimore. Cambridge, 18S1.

Tiie Management of the Perineum during Labour, and immediate Treatment of Lacerations, and The Obstetrics and Gynecology of William Harvey. By Francis H. Stuart, M.D. New York, 1881.

Twenty-five Consecutive Cases of Ovariotomy. By John Homans, M.D. , Boston, Mass. Cambridge, 1881.

On unnecessary Surgical Operations in the Treatment of the Diseases of Women. By Clifton E Wing, M.D. Boston.

A Case of Primary Tuberculosis of the Larynx. By J. Solis Cohen, M.D. Phila- delphia.

Spasm of the Intra-Ocular Eye Muscles. By J. J. Chisolm, M.D. Baltimore, 1881 . A Statistical Report of 250 Cases of Inebriety. By Lewis D. Mason, M.D. An Improved Self-retaining Rectal and Vaginal Speculum. By A. F. Erich, M.D. Cincinnati, 1881.

Contributions to Ophthalmology. By Dr. C. R. Agnew.

TO READERS AND CORRESPONDENTS.

9

Sympathetic Inflammation following Operations for Cataract. By David "Webster, M.D. New York.

Intra-ocular Lipgemia. The New Constants of the Helmholtz Diagrammatic Eye. By Albert G. Heyl, M.D. Philadelphia, 1881.

On the Ventilation of Halls of Audience. By Robt. Briggs, C.E. New York, 1881.

Excision of the Rectum for Malignant Disease. By N. Senn, M.D., of Milwaukee.

The Cultivation of Specialties in Medicine. On the Localization of Diseases in the Spinal Cord. On the Early Diagnosis of some Organic Diseases of the Nervous Sys- tem. By E. C. Segtin, M'.D. New York. 1881.

Hysteria in Boys. Observations on Pertussis. By J. Henry Dessau, M.D. New York, 1880.

Hip-joint Disease : Death in Early Stage from Tubercular Meningitis. By De Forest Willard, M.D. Cambridge, 1880.

Clinical Illustrations of Favus and its Treatment by anew method of Depilation. By L. Duncan Bulkley, M.D. New York, 1881.

'Ventnor and its peculiar Advantages for the Invalid. By W. Thornton Parker, M.D. New York, 1881.

The Foundation of American Dermatology. Supplement to a Case of Inflamma- tory Fungoid Neoplasm. By Louis A. Duhring, M.D.

Sub-byoidean Pharyngotomy for the Removal of the Epiglottis for Epithelioma. By Clinton Wagner, M.D. 'New York, 1881.

The Hygiene of Emigrant Ships. By Thomas J. Turner, M.D. Boston, 1881.

Connection of Cardiac and Renal Diseases. By Robert T.Edes, M.D. Cambridge, 1881.

Simple Methods to Staunch Accidental Hemorrhage. By Edward Borck, M.D. Evausville, Ind., 1881.

Chest Drainage in Empyema. By George M. Staples, M.D. Dubuque, 1881.

Biennial Report of the North Carolina Board of Health, 1879-1880. Raleigh, 1881.

Report of the Board of Health of Louisiana, 1880. New Orleans, 1881.

Report of the Board of Health of the City of Dayton. Dayton, 1881.

Report of the Massachusetts General Hospital, 1880. Boston, 1881.

Report of the Pennsylvania Hospital for the Insane, 1880. Philadelphia, 1881.

Report of the Retreat for the Insane at Hartford, Conn. Hartford, 1881.

Report of the State Lunatic Asylum, Utica, N. Y., 1880. Albany, 1881.

Report of the Asylum lor the Relief of Persons deprived of the Use of their Reason. Philadelphia, 1881.

Transactions of the Rhode Island Medical Society, 1880.

Transactions of the Illinois State Medical Society, 1880. Chicago.

Transactions of Medical Society of State of New York, 1880. Syracuse, 1880.

Proceedings of the Medical Society of the County of Kings, April, May. June, 1881.

Proceedings of Academy of Natural Sciences of Philadelphia, Oct. to Dec, 1880.

Proceedings of American Pharmaceutical Association, 1880. Philadelphia, 1881.

The following Journals have been received in exchange : —

Canada Medical and Surgical Journal. Sept. 1880, to May, 1881.

Canada Medical Record. Sept. 1880, to May, 1881.

Canadian Journal of Medical Science. Oct. 1880, to June, 1881.

Canada Lancet. Oct. 1880, to May, 1881.

L'Union Medicale du Canada. Oct. 1880, to Mai, 1881.

Boston Medical and Surgical Journal. Oct. 1880, to June, 1881.

New York Medical Journal. Oct. 1880, to June, 1881.

Medical Record. Oct. 1880, to June, 1881.

American Journal of Insanity. Oct. 1880, Jan., April, 1881.

American Journal of Obstetrics. Oct. 1880, Jan., April, 1881.

Archives of Medicine. Oct. 1880, to June, 1881.

American Journal of Otology. Oct. 1880, Jan., April, 1881.

Archives of Ophthalmology. Sept., Dec. 1880, March, 1881.

Archives of Otology. Sept., Dec. 1880, March, 1881.

Archives of Laryngology. June, Sept. 18S0, Jan., April, 1881.

Buffalo Medical and Surgical Journal. Oct 1880, to June, 1881.

Annals of Anatomy and Surgery. Sept. 1880, to May, 1881.

Gaillard's Medical Journal. Oct. 1880, to May, 1881.

Medical Annals. Oct. 1880, to May, 1881.

Medical News and Abstract. Oct. 1880, to June, 188 1.

Philadelphia Medical Times. Oct. 1880, to June, 1881.

Medical and Surgical Reporter. Oct. 1880, to June, 1881.

Archives of Dermatology. Oct. 1880, Jan., April, 18S1.

Half-yearly Compendium of Medical Science. Jan. 1881.

College and Clinical Record. Oct. 1880, to June, 1881.

10

TO READERS AND CORRESPONDENTS.

Cincinnati Lancet and Clinic. Oct. 1880, to June, 1881. Cincinnati Medical News. Sept. 1880, to May, 1881. Ohio Medical Recorder. Sept. 1880, to April, 1881. Obstetric Gazette. Sept. 1880, to May. 1881. Indiana Medical Reporter. Aug. 1880, to April, 1831. American Practitioner. Nov. 1880. to June, 1831. Chicago Medical Journal. Oct. 1380, to June, 1881. Journal of Nervous and Mental Diseases. Oct. 1880, Jan., April, 1831. Chicago Medical Review. Oct. 1880, to June, 1881. Detroit Lancet. Oct. 1880, to June, 1881. Michigan Medical News. Sept. 1830, to May, 1881. Physician and Surgeon. Oct. 1880, to June, 1831. St. Louis Medical and Surgical Journal. Sept. 18S0, to May, 1831. St. Louis Clinical Record. Oct. 1880, to April. 1881. St. Louis Courier of Medicine. Sept. 1830,*to May, 1881. Alienist and Neurologist. Oct. 1880, Jan., April, 1881. Kansas Medical Index. Sept. 1880, to May, 1881.' Therapeutic Gazette. Sept. 1880, to May, 1881. Rocky Mountain Review. Sept. 1880, to March, 1881. Pacific Medical and Surgical Journal. Sept. 18S0, to May, 1381. . San Francisco Western Lancet. Sept. 1880. to May, 1831. Maryland Medical Journal. Oct. 1880, to June, 1881. Virginia Medical Monthly. Oct. 1880, to May, 1881. North Carolina Medical Journal. Sept. 1880, to May, 1881. Southern Medical Record. Sept. 1830, to May, 1881. Atlanta Medical and Surgical Journal. Sept. 1830, to June, 1831. New Orleans Medical and Surgical Journal. Oct. 1880, to June, 1831. Louisville Medical News. Oct. 1880, to June, 1881. Medical Herald. Oct. 1880, to June, 1881.

Nashville Journal of Medicine and Surgery. Oct. 1330, to Jaas, 1331.

Southern Practitioner. Oct. 1880, to June, 1881.

Mississippi Valley Medical Monthly. Feb_. to May, 18S1.

Sanitarian. Oct. 1880, to May, 1881.

The Quarterly Journal of Inebriety. April, 1881.

American Journal of Pharmacy. Oct. 1880, to June, 18S1.

Druggist's Circular. Oct. 1880, to June, 1881.

New" Remedies. Oct. 1880, to May, 1881.

Dental Cosmos. Oct. 1880, to June, 1881.

American Journal of Dental Science. Sept. 1830, to May, 1331. American Journal of Science and Arts. Oct. 1880, to June, 1881. Popular Science Monthly. Nov. 1880, to June. 1881. Journal of the Franklin Institute. Oct. 1880, to June, 1881. Boston Journal of Chemistry, Nov. 1880, to June, 1881.

The usual foreign exchanges have been received ; their separate acknowledg- ment is omitted for want of space.

Communications intended for publication, and books for review, should be sent free of expense, directed to I. Minis Hats, M.D., Editor of the American Journal of the Medical Sciences, care of Henry C. Lea's Son & Co., Philadelphia. Parcels directed as above, and (carriage paid) under cover, to Messrs. Nimmo & Bain, Booksellers, No. 14 King William Street, Charing Cross, London, will reach us safely and without delay.

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The advertisement sheet belongs to the business department of the Journal, and all communications for it must be made to the publishers.

CONTENTS

OF

THE AMERICAN JOURNAL

OF

THE MEDICAL SCIENCES.

NO. CLXIII. NEW SERIES. JULY, 1881.

ORIGINAL COMMUNICATIONS. MEMOIRS AND CASES.

ART. PAGE

I. Mar Iodide of Potassium Excite Bright' s Disease ? By I. Edmondson Atkinson, M.D., Professor of Pathology and Clinical Professor of Der- matology in the University of Maryland School of Medicine, Baltimore. . 17

II. Use of the Ecraseur for Curing Deep-seated Fistula in Ano. By J. M.

F. Gaston, M.D., of Campinas, Brazil 31

III. The Operative Treatment of Prolapse of the Vagina and Uterus. By

A. F. House, M.D., of Cleveland, Ohio. . ; . . . 39

IY. Are all Anaesthetics Dangerous which contain Chlorine, Bromine, or Iodine? By Edward T. Reiehert, M.D.. of Newark, X. J., formerly Demonstrator of Experimental Therapeutics and Instructor in Experi- mental Physiology in the Post-Graduate Course of Medicine in the Uni- versity of Pennsylvania. . . . . . . . . .50

V. A Case of Abscess of the Liver, complicated with Empyema ; Opera- tion ; Cure. By "Walter Mendelson, M.D., House Physician to the New York Hospital 65

VI. On Lymphatic Hearts and the Phenomena attending the Propulsion of Lymph from them into the Veins into which they open. By Thomas "Wharton Jones, F.R.C.S., F.R.S., Professor in University College, London. 70

VII. Empyema and its Treatment. By F. E. Martindale, A.M., M.D.. of Port Richmond, N. Y., Consulting Surgeon to the Child's Nursery and Hospital, Port Richmond. . . 7 7

VIII. A Study of Primary, Immediate, or Direct Hemorrhage into the Ventricles of the Brain. By Edward Sanders, M.D., late House Physician. Bellevue Hospital, New York ; Attending Physician to Mi. Sinai Hospi- tal Dispensary, Department of Internal Diseases. . . . . .85

IX. Quantitative Determination of Urea by Alkaline Hypochlorites and Hypobromites. By Theo. G. Wormley, M.D., Professor of Chemistry

in the University of Pennsylvania. 128

12

CONTENTS.

ART.

PAGE

X. Anesthesia of the Cornea and its Significance in certain forms of Eye Disease. By Jas. L. Minor, M.D., Assistant Surgeon to the New York

XT. Retention of the Menses, caused by Imperforate Hymen. Report of two cases, with some remarks. By Louis W. Atlee, of Philadelphia. . 136

XII. Distal Compression applied in Case of Inguinal Aneurism, with a suc- cessful Result. By Theodore R. Varick, M.D., Medical Director of, and Surgeon to, St. Francis Hospital, and Surgeon to Jersey City Charity Hospital, Jersey City, New Jersey. ....... 140

XIII. An Instrument for the Removal of Superfluous Hairs. By Louis A. Duhring, M.D., Professor of Skin Diseases in the Hospital of the Univer- sity of Pennsylvania, Philadelphia. . . . . . . .142

XIV. Operation for the Relief of Bursal Swelling of the Wrist. By J. E. Copeland, M.D., of Rectortown, Fauquier Co., Virginia. . . . 143

XV. Amputation at the Shoulder-joint. By L. McLane Tiffany, M.D., of Baltimore, Professor of Surgery in the University of Maryland. . . 145

XVI. The Comparative Action of Hydrobromate of Homatropine and of Sulphate of Atropia upon the Iris and Ciliary Muscle. By Chas. A. Oli- ver, M.D., of Philadelphia. . 150

XVII. Stab Wound of the Neck and Division of the Right Recurrent La- ryngeal Nerve, followed immediately by Absolute Aphonia. By George M. Lefferts, M.D., Clinical Professor of Laryngoscopy and Diseases of the Throat, College of Physicians and Surgeons, New York, etc. . .155

XVIII. On Some of the Conditions Affecting the Origin and Course of Pul- monary Phthisis. By Beverley Robinson, M.D., Lecturer upon Clinical Medicine at the Bellevue Hospital Medical College, New York. . . 156

XIX. The Sorghum Vulgare, or Broom-corn Seed, in Cystitis. By Alex. Y. P. Garnett, M.D., Emeritus Professor of Clinical Medicine in the National Medical College, Washington, D. C. 164

XX. Case of Severe Injury of the Brain, with Recovery. By William Wood, M D., of East Windsor Hill, Connecticut 168

XXI. Benzoic Acid in the Albuminuria of Pregnancy and Scarlatina. By

W. Scott Hill, M.D., of Augusta, Maine 169

XXII. A Treatise on Bright's Disease and Diabetes, with especial reference to Pathology and Therapeutics. By James Tyson, A.M., M.D., Profes- sor of General Pathology and Morbid Anatomy in the University of Penn- sylvania, etc. Including a Section on Retinitis in Bright's Disease. By William F. Norris, A.M., M.D., Clinical Professor of Ophthalmology in the University of Pennsylvania. 8vo. pp. 312. Philadelphia: Lindsay & Blakiston, 1881 .171

Eye and Ear Infirmary

131

REVIEWS.

CONTENTS.

13

ART.

PAGE

XXIII. Osteotomy, with an Inquiry into the vEtiology and Pathology of Knock-knee, Bow-leg, and other Osseous Deformities of the Lower Limbs. By William Macewen, M.D., Surgeon and Lecturer on Clinical Surgery, Glasgow Royal Infirmary. 8vo. pp. xvi., 181. London : J. & A. Churchill,

XXIV. Bovine Tuberculosis in Man ; an Account of the Pathology of Sus- pected Cases. By Charles Creighton, M.D., M. A. Cantab., Demonstrator of Anatomy in the University of Cambridge. 8vo. pp. xi., 119. London: Maemillan & Co., 1881 183

XXV. St. Bartholomew's Hospital Reports. Edited by W. S. Church, M.D., and Alfred Willett, F.R.C.S. Vol. XVI. 8vo. pp. xxvii., 363, 123. London: Smith, Elder & Co., . 1880 .187

XXVI. On the Antagonism between Medicines, and between Remedies and Diseases. Being the Cartwright Lectures for the year 1880. By Roberts Bartholow, M.A., M.D., LL.D., Professor of Materia Medica and General Therapeutics in Jefferson Medical College, Philadelphia, etc. etc. pp. 122. New York : D. Appleton & Co., 1881 195

XXVII. Lectures upon Diseases of the Rectum and the Surgery of the Lower Bowel. Delivered at the Bellevue Hospital Medical College. By H. W. Van Buren, M.D., LL.D. (Yalen), Professor of the Principles and Practice of Surgery in the Bellevue Hospital Medical College, etc. 8vo. pp.412. New York: D. Appleton & Co., 1881. . . . • .198

XXVIII. The Diseases of Children ; a Practical and Systematic Work for Practitioners and Students. By William Henry Day, M.D., M.R.C.P. Lond., Physician to Samaritan Hospital for Women and Children. Second edition. Rewritten and much enlarged. 8vo. pp. 728. Philadelphia : Presley Blakiston, 1881 200

XXIX. Transactions of the American Ophthalmological Society. Sixteenth Annual Meeting. 8vo. pp. 173. New York, 1880. .... 204

XXX. Lectures on Diseases of the Nervous System, especially in Women. By S. Weir Mitchell, M.D., Member of the National Academy of Science,

etc. etc. 12mo. pp. 233. Philadelphia: Henry C. Lea's Son & Co., 1881. 209

XXXI. On Anchylosis, and the Treatment for the Removal of Deformity and the Restoration of Mobility in Various Joints. By Bernard E. Brod- hurst, F.R.C.S., Surgeon to the Royal Orthopaedic Hospital, etc. Fourth edition. 8vo. pp. 100. London: J. & A. Churchill, 1881. . . .211

XXXII. Photographic Illustrations of Cutaneous Syphilis. By George Henry Fox, A.M., M.D., Clinical Lecturer on Diseases of the Skin, Col- lege of Physicians and Surgeons, New York, etc. Numbers 1 to 6. New York: E. B. Treat 212

XXXIII. A Manual for the Practice of Surgery. By Thomas Bryant, F.R.C.S., Surgeon to, and Lecturer on Surgery at, Guy's Hospital, etc. Third American from the Third Revised and Enlarged English Edition. Edited and Enlarged for the Use of the American Student and Practitioner. By John B. Roberts, A.M., M.D. pp. 1005. Philadelphia: Henry C. Lea's Son & Co., 1881 213

XXXIV. Transactions of the Obstetrical Society of London. Vol. XXII., for the year 1880. 8vo. pp. 314. London: Longmans, Green & Co.,

1880

177

1881

215

14 CONTENTS.

ART. PAGE

XXXY. The Student's Manual of Venereal Disease, being the University- Lectures delivered at Charity Hospital, B. I., during the Winter Session of 1879-80. By F. R. Sturgis, M.D., Clinical Lecturer on Venereal Dis- eases in the Medical Department of the University of the City of Xew York, etc. 12nio. pp. 196. New York: G. P. Putnam's Sons, 1880. . 220

XXXVI. Experimental Researches on the Temperature of the Head. By J. S. Lombard, M.D., formerly Assistant Professor of Physiology in Har- vard University. 8vo. pp. 100. London : H. K. Lewis, 1881. . . 221

XXXVII. The Relations of the Abdominal and Pelvic Organs in the Female, illustrated by full-sized chromolithograph of the Section of a Cadaver frozen in the Genu-pectoral position, and by a series of wood- cuts. By Professor Alexander Russell Simpson and Dr. David Berry Hart. Folio, pp. 11. Edinburgh; W. and A. K. Johnston, 1881. . 224

XXXVIII. The Structural Anatomy of the Female Pelvic Floor. By David Berry Hart, M.D., F.R.C.P.E., Assistant to the Professor of Midwifery in the University of Edinburgh, etc. 4to. pp. 42, with 26 figures and 2 plates. Edinburgh : Maclachlan & Stewart, 1880. .... 225

XXXIX. La Syphilis : son Histoire et son Traitement. Par le Dr. James Tartenson.

Syphilis : its History and Treatment. By Dr. James Tartenson. Second 'edition. 8vo. pp. 238. Paris : J. B. Bailli&re et Fils, 1880. . . 226

XL. Grundziige der Physiologic des Menschen mit Riicksicht auf die Ge- sundheitsptiege. Von Johannes Ranke, Dr. Med. und Professor an der Universitatzu Mlinchen. Vierte umgearbeitete Auflage. 8vo. ss. xxv. 1065. Leipzig: Wilhelm Engelmann, 1881 229

XLI. Lectures on Diseases of Bones and Joints. By C. Macnamara, F.R.C.S. Eng., Surgeon and Lecturer on Surgery at the Westminster Hospital, etc. Second edition. 12mo. pp. 551. London: J. & A. Churchill, 1881 230

XLII. A Treatise on the Materia Medica and Therapeutics of the Skin. By Henry G. Piffard, A.M., M.D., Professor of Dermatology, Medical De- partment of the University of the City of Xew York, etc. 8vo. pp. 351. Xew York: Wm. Wood & Co 231

XLIII. A Manual of Diseases of the Eye and Ear for the Use of Students and Practitioners. By W. F. Mittendorf, M.D., Surgeon to the Xew York Eye and Ear Infirmary ; Ophthalmic Surgeon to Bellevue Hospital, Out-patients' Department. 8vo. pp. 445. Xew York: G. P. Putnam's Sons, 1881. . . . . . . ... . . . 232

XLIV. 1. A Pocket Atlas of the Descriptive Anatomy of the Human Body. By J. N. Masse, M.D., Professor of Anatomy, Paris. Translated from the last Paris edition, and edited by Granville Sharp Pattison, M.D., Professor • of Anatomy in the University of Xew York, etc. 8vo. pp. xxii. and pi. 112, with Explanatory Text. Xew York: Harper & Bros., 1845.

2. Anatomical Plates arranged as a Companion Volume for " The Essentials of Anatomy" (by William Darling and A. L. Ranney), and for all works upon Descriptive Anatomy, comprising four hundred and thirty-nine de- signs on steel by Prof. J. X. Masse, of Paris, and numerous diagrammatic cuts selected or designed by the Editor, together with Explanatory letter- press, edited by Ambrose L. Ranney, A.M., M.D., Adjunct Professor of Anatomy in the Med. Dept. of the University of the City of Xew York, etc. 4to. pp. xvi. and pi. 124. Xew York: G. P. Putnam's Sons, 1881. 233

CONTENTS.

15

ART. PAGE

XLY. How to Use the Forceps, with an Introductory Account of the Fe- male Pelvis and the Mechanism of Delivery. By Henry G. Landis, A.M., M.D., Professor of Obstetrics and Diseases of Women and Children in Starling Medical College. 12mo. pp. 168. New York: E. B. Treat, 1880. 235

XLYI. A Practical Treatise on Diseases of the Skin. By Louis A. Duhring, M.D., Professor of Diseases of the Skin in the Hospital of the University of Pennsylvania, etc. Second edition, revised and enlarged. 8vo. pp. 644. Philadelphia: J. B. Lippincott & Co., 1881. . " . . .236

XLYII. Hernia, Strangulated and Reducible, with Cure by Subcutaneous Injections. Together with Suggested and Improved Methods for Kelo- tomy. Also an Appendix, giving a short Account of various New Surgi- cal Instruments. By Joseph H. "Warren, M.D., Member of American Med. Assoc. 8vo. pp. xii., 280. Boston: Charles N. Thomas, 1881. . 239

XL VIII. Health Reports.

1. Annual Report of the Board of Health of the State of Louisiana for

the year 1880. New Orleans, 1881. pp. 354.

2. Annual Reports of the State Board of Health of Colorado for the years

1879 and 1880. Denver, 1881. pp. 134.

3. First Biennial Report of the North Carolina Board of Health, 1879—

1880. Raleigh, 1881. pp.201. . 240

XLIX. Syphilis and Marriage. Lectures delivered at the St. Louis Hospi- tal, Paris. By Alfred Fournier, Professeur a la Faculte de Medecine de Paris, etc. Translated by P. Albert Morrow, M.D., Physician to Skin and Venereal Department, New York Dispensary. 8vo. pp. 251. New York: D. Appleton & Co., 1880 242

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES.

Anatomy and Physiology. Flat-foot in Young- Infants. Bv Prof. Volkmann.

PAGE

. 243

Materia Medica and Therapeutics.

page

Action of Small Doses of Mercury upon the Lower Animals. By Sehlesinger. .... 244

Antipvretic Action of the Phenols.

By Prof. Lichtheim. . .245 Apomorphia as an Expectorant. By

Beck 245

Intra-Peritoneal Transfusion. By

Kaczorowski. .... 245

16

CONTENTS.

Medicine.

PAGE

Transfusion of Blood in a Case of Acute Typhoid Fever complica- ted with Intestinal Hemorrhage. By Gibert. . . 246

Diagnosis of Yellow Fever for Sani- tary Purposes. By Dr. S. M. Be'miss. . . " . . . 246

Syphilis and Locomotor Ataxy. By "Prof. Erb 247

Bromide of Ethyl in Epilepsy. By Drs. Bourn ev'ille and Olier. 248

Treatment of Neuralgia by Salicy- late of Soda. By M. Labbe. " . 248

Neurotic Atrophy. By Prof. Vir- chow. . . . . .249

Atrophic Infantile Paralysis. By M. Onimus. . . * . '.249

Paradoxical Muscular Contraction. By Prof. Westphal. . . . 250

Epidemic Cerebro-spinal Meningi- tis of Children. By Dr. O.Medin. 251

PAGE

On Hypnotic Contractures. By M. Charcot. . . . . .252

Treatment of Diphtheria. By Weise 253

Treatment of Pharvngeal Diph- theria. By Dr. Oertel. . . 253

Pericarditis Treated by Incision into Pericardium. By Dr. Rosen- stein. ..... 254

Adult Cephalic Murmurs. By M. Tripier. . . . . .255

Examination of the Local Sensibili- ty of the Precordial and Pre- aortic Regions in Diseases of the Heart. By Dr. Peter. . . 256

The Treatment of Splenic Tumours. By Kussmaul. . . . .257

Treatment of Diabetes Mellitus by Salts of Ammonia. By Guttinan. 258

Surgery.

Langenbeck's Operation for Hare- lip. By Woltf. . . .258

Removal of Foreign Bodies from the Larynx. By Dr. Krishaber 259

Local Anaesthesia of the Larynx. By Prof. Schroetter. . " .259

A Second Case of Resection of the Stomach. By Dr. Billroth. .260

Gastrostomy and Duodenostomy. By Dr. Carl Langenbuch. . . 261

Intestinal Resection. By Prof. Czerny .263

Resection of about six and a half feet of the Small Intestine, with Recovery. By Dr. Koeberle . 263

Nephrectomy by Lumbar Section. By Mr. Arthur E. Barker. . 265

Excision of the Hip-Joint in Chil- dren. By Mr. Howard Marsh. . 267

Transplantation of Bone. By Dr. Mac E wen 268

Ophthalmology and Otology.

New Method of Blepharoplasty. On the Diseases of the Ear in Loco- By Dr. Landolt. . . . 269 motive Engineers and Firemen

Colour-Blindness. By Dr. De Fon- which may endanger the Travel-

tenay. ..... 270 ling Public. By Dr. Moos. . 271

Midwifery and Gynecology.

Gastrotomy in Extra-Uterine Preg- I Extirpation of the Uterus through nancy. By Prof. Litzmann. . 273 the Vagina. By Dr. Martin. . 276

Inversion of the Uterus. Bv Dr.

Atthill. . . . . . 275 I

Medical Jurisprudence and Toxicology. Poisoning by Chloroform. By Dr. Johannes Mygge. . . . .27 7

Obituary Notices. George Alexander Otis, M.I). .... Isaac Ray, M.D., LL.D. . .

278 284

THE

AMERICAN JOURNAL OF THE MEDICAL SCIENCES

FOR JULY 1881.

Article I.

May Iodide of Potassium Excite Bright's Disease ? By I. Edmoxd- sox Atkixsox, M.D., Professor of Pathology and Clinical Professor of Der- matology in the University of Maryland School of Medicine, Baltimore.1

vVhere there is afforded opportunity of examining after death, the bodies of persons who have suffered from late syphilis, an astonishingly large number of them will be found to present evidences of disease of the kidneys. In 24 autopsies of syphilitic subjects, Lancereaux observed renal degenerative changes 8 times (Gaz. Hebd. 1, 1864, p. 502). Moxon detected alterations in these organs in 14 out of 25 post-mortem examinations of syphilitics at Guy's Hospital {Guy's Hosp. Reports, 1868, p. 329). It must be acknowledged, however, that if we consider the whole number of persons who have had syphilis, the proportion who develop kidney disease is exceedingly small. Indeed, with very few ex- ceptions, syphilis and kidney disease would seem to exist in the relations of cause and effect only among those unfortunates who experience the late or tertiary manifestations of the affection.

Pathologists have long been aware that the diseased kidneys of syphili- tic persons present differences as great in microscopic as in gross appear- ances, changes that may be encountered with equal, even with greater frequency, as results of other affections, as well as changes that are essen- tially syphilitic. Of the forms of disease to which I now refer, the most fre- .quent by far is one that is not in itself syphilitic. This is lardaceous or albuminoid degeneration, and was first described as of syphilitic origin, by Rayer, in 1840 (Maladies des Reins, t. ii. p. 489). All subsequent

1 Read at the meeting of the American Medical Association, at Richmond, May 1, 1881.

No. CLXIII July 1881. 2

18 Atkinson, Iodide of Potassium and Brigbt's Disease.

writers have remarked its frequency. Moxon, in the article already quoted, observed, in his 27 autopsies, lardaceous degeneration of the kid- neys 11 times. But the frequency of lardaceous disease as the result of syphilis, may be more readily appreciated by studying the etiology of this form of degeneration. Thus Fehr (quoted by Roberts) reported syphilis as present in 34 out of 145 cases of lardaceous kidney. Dickinson (Dis. of Kidneys, part ii. 1877, p. 473), compiled 83 cases of lardaceous disease from the dead-house reports of St. George's Hospital, the presence of syphilis being noted 18 times This form, when of syphilitic origin, is identical with the same degeneration in persons free from the disease. It is true that some writers, Beer more especially (Die Eingeweide Syphilis, 1867), describe peculiar conditions and distributions of the process, to be met with only in syphilitics ; but these lack confirmation. On the other hand, there is a form of renal disease quite characteristic of syphilis, the circumscribed, new formation known as gummy tumour. This is of exceedingly rare occurrence. Moxon found it but once in his 27 autopsies, where there were 16 cases of renal disease. In Lancereaux's 24 autopsies, where kidney disease was detected 8 times, gummy tumours were met but once. Numerous cases of gumma of the kidney have been recorded, but the lesion is undoubtedly a rare one. From 1 to 20 may be encountered, and their size may vary from a mere point to the dimensions of " a small potato." It is stated, upon the authority of Beer, Moxon, and others, that purely parenchymatous nephritis may be dependent upon syphilis. It must be very infrequent. But there is still another form of renal alteration of syphilitic origin.

Generally diffused, interstitial hyperplasia and subsequent fibrosis of the kidneys, not associated with lardaceous disease, is rare in syphilitics ; and yet it is not uncommon to find these organs with circumscribed areas of interstitial hyperplasia, or of its cicatricial remains, distinct from ordi- nary gummy tumor. Just as one finds in other organs, notably, the liver, lungs, and testicle, syphilitic inflammation, not at all differing in their appreciable morbid appearances from simple inflammations, so, in the kidneys, we encounter diffused interstitial nephritis, that except for a dis- position to more circumscribed distribution is like interstitial nephritis from other causes.

Where the process involves the entire organ, there is no way of decid- ing upon its specific origin. Most frequently, however, only a portion of the kidney is affected, and when considerable contraction has resulted from this form of interstitial disorder, it is often seamed with scars, which from their circumscribed arrangement, are very characteristic. It is not unlikely that localized cicatrices may sometimes result from the absorp- tion of gummy tumours. A considerable degree of fatty degeneration of the epithelia of the tubules often accompanies these processes.

From the foregoing remarks, it will be seen that of the different altera-

1881.] Atkinson, Iodide of Potassium and Bright's Disease. 19

tions to which the kidneys of syphilitics are liable, but one can be re- garded as certainly syphilitic, the gummy tumour, the most rare of all. Diffused nephritis can only be recognized as probably syphilitic, when of limited and circumscribed extent. On the other hand, lardaceous degene- ration, most often observed, is only a result of syphilis as it is a result of tubercle, of scrofula, of prolonged suppuration. Now, while it is certain that we may have these forms of disease due to syphilis, it by no means fellows that disease of the kidneys in syphilitics is always of syphilitic origin. May it not arise from adventitious causes more often than is generally supposed?

It is evident, that apart from any influence that syphilis may exert in renal pathology, the kidneys of syphilitics are just as subject to morbific influences as those of healthy people, and that one should not necessarily attribute to this disease lesions that are not characteristically specific.

One occasionally finds in medical literature, statements that albuminu- ria and nephritic inflammation have been known to arise in consequence of the ingestion of the iodide of potassium. These reports, it is true, are few in number and quite vague in character, and yet they come from sources that entitle them to respectful consideration. Thus Van Buren and Keyes (Genito- Urinary Diseases with Syphilis, p. 380), state that it will some- times happen —

" that patients with visceral syphilis, under protracted treatment, by large doses of iodide of potassium, will gradually show morning nausea, and upon examina- tion their urine will be found light, slightly albuminous, and containing pale casts. In such cases the kidney-trouble is probably due to the irritation pro- duced by the large amount of iodide of potassium passing through them, and the albumen and casts may be made to disappear, together with the morning nausea, by reducing the activity of the treatment. Several such cases have fallen under the author's observation."

In another place Keyes again writes (Venereal Diseases, 1880, p. 220) : " I am certain that in some cases, slight, transient, albuminuria is produced by the prolonged use of the iodide of potassium in large doses." Mr. Jonathan Hutchinson in his famous address on syphilis before the Patho- logical Society of London (Lancet, 1, 1876, p. 204), thought that iodide of potassium, long-continued, might have had something to do with pro- ducing the long-continued albuminuria that preceded death in two cases of inherited syphilis in adults under his care. H. C. Wood ( Therapeu- tics, etc., p. 379), says : " During its passage through the kidneys, iodine undoubtedly exerts an influence upon these organs, as is shown by its producing albuminuria at times. It is indeed asserted, that it occasion- ally causes a true tubular nephritis." Statements such as these may be found in medical literature, but they lack deflniteness, and can hardly be accepted as decisive. They must be received with a great deal of reserve, especially when we consider that the very extensive literature that has been devoted to the pathological effects of iodine and the iodides upon the

20 Atkinson, Iodide of Potassium and Bright's Disease. [July

system, is singularly meagre in references to these actions upon the kid- neys, while the diuretic action of these drugs is universally recognized, and abundant proof of the morbific action often exerted by them upon different organs and tissues is everywhere available.

It is remarkable that alterations of the kidneys have been but rarely observed as resulting from their ingestion. Rodet, writing in 1847, states that the ingestion of the iodide of potassium may induce nephritis, and records a case where the patient, 56 years old, took, for non-syphilitic disease, one gramme of the iodide daily for fifteen days, abundant hematuria resulting. This subsided after the medicine was discontinued, but recurred when it was again administered (Gaz. Med. de Parts, 1847, p. 904). A very remarkable statement of Simon and Regnard may be found in V Union Medicate (vol. 22, 1876, p. 26). It was noticed that two chil- dren (girls), to whose integument tincture of iodine had been applied over a limited surface, for different affections, betrayed some symptoms of iodism, along with a notable quantity of iodine in the urine, and albumi- nuria. Attention having been drawn to this fact, eleven children were submitted to the same treatment. Of these, four developed albuminuria. In three other cases, where the urine previous to the experiment contained neither iodine nor albumen, both became very evident after three days, soon ceasing to appear, but both reappearing upon the renewal of the ap- plication. Badin (^These de Paris, 1876), contributes in support of these observations two cases. The first patient, a phthisical girl nine years old, had tincture of iodine applied in front of and behind the chest. Albumen was detected in the urine after the third application, and disappeared after the iodine was abandoned. The second observation concerned a scrofu- lous girl, to whose skin tincture of iodine was applied. After the fourth application, the urine, which had been daily tested, became albuminous, regaining a healthy condition shortly after the conclusion of the experi- ment. Badin holds that this action is confined to children, the immunity of adults being complete ; and that it results from the passage of metallic iodine through the kidneys. These very interesting observations have never been confirmed, and, indeed, do not seem to have met with the attention they deserve. Should their correctness be established, it would still remain undecided how the albuminuria is produced ; whether, as claimed, by the action of free iodine upon the kidneys, or, as is not impos- sible, as the result of the simple covering of a considerable surface with an impermeable coating, such as has been known to produce similar effects under the use of a variety of substances.

A diligent search through a very extensive literature has afforded me only these scanty proofs of the irritating influence of iodine and the iodide upon the kidneys. On the other hand, while the almost entire absence of references to this subject in the very extensive discussions of the phenomena of iodism, during the last forty years, is, to say the least,

1881.] Atkinson, Iodide of Potassium and Bright's Disease. 21

very suggestive, we have the distinct statements of several writers, that renal affections are not induced by the iodides. This was the experience of Ricord (Bulletin de llterapeutique, 1842, p. 164), and other writers. Arneth, Pelikan, and Zdekauer never found in the bodies of animals treated with iodine the smallest trace of renal disease (Med. Zeitschr. Busslands, 1856).

It is certainly important that we should have definite knowledge con- cerning the extent to which the presence of these agents in the system is capable of exciting structural alterations in, the organs and tissues, and that in our treatment we should not expose our patients to unjustifiable risks. If, however, it be necessary to expose them to these dangers, we should do so with a full consciousness of the same, and be prepared to obviate them as far as possible.

With a view to ascertain to some extent the general condition of the kidneys of persons who suffer from late syphilis, as well as to note the effects of anti-syphilitic treatment upon these organs, I have made a series of observations of cases that have come under treatment, for the most part, in my out-patient service, but also to some extent in the wards of the University Hospital and Bayview Asylum (the city almshouse). They do not represent selected cases, but comprise all that were available dur- ing the period of my investigations, suffering from late syphilis, and who, with very few exceptions, had b£en more than three years syphilitic. My notes embrace memoranda of seventy patients, of whom, those whose condensed histories are subjoined, presented evidence of renal alterations.

Case 1 Maria H., 32 years old, syphilitic for eight or nine years.

Prostitute. Symptoms severe from the first. Much scarring. Present lesions ulcerative and extensive. General health much reduced. No dropsy. Dec. 29. Urine acid, sp. gr. 1022. Albuminous. Iodine re- action. Microscope reveals pus cells in abundance, but no tube casts. Jan. 24. Urine acid, sp. gr. 1017. Iodide reaction. Albuminuria. Microscope reveals a few hyaline and pale granular casts of the renal tubules. Pus cells and vaginal epithelium abundant. Has taken much iodide of potassium within the past year.

Case 2 John P., 30 years old. Peddler. Syphilitic for thirteen

years. Paraplegia five years ago. Epilepsy for two years. Great mental hebetude. Cranial nodes. Excruciating headache. Jan. 24, 1878. Has been taking iodide of potassium for some time. Has had no ulcerative lesion. Never had dropsy, but six years ago had some swelling of the feet. Heart healthy. Urine pale and with iodine reaction. Small amount of albumen. Some hyaline tube casts, here and there studded with a cell of renal epithelium.- April 8. Urine neutral; pale ; sp. gr. 1016. A slight cloudiness to nitric acid and heat. No tube casts. May 17. Urine acid and high coloured; sp.gr. 1030. Iodine reaction. Albumen copiously present. Jan. 14, 1879; Urine alkaline, pale, without iodine reaction. Very slight amount of albumen. No tube casts. April 11. Has taken no iodide since last entry. Urine acid, and freely albuminous. Uric acid crystals. Hyaline tube casts, some of them studded with renal epithe- lium.

22 Atkinson, Iodide of Potassium and Bright's Disease. [July

Case 3 Francis B., negro, 54 years old. Syphilitic more than

twenty years. Has never had dropsy. Has led a hard life as a sailor on bay craft. Has now a gummatous ulcer of the penis. General health excellent. Heart normal. Jan. 15, 1878. Has had no treatment recently. Urine acid, and of sp. gr. 1026. Very slight precipitate to heat and nitric acid. Hyaline, pale, and coarsely-granular tube casts with renal epithelium. Feb. 23. Urine pale, acid, and of sp. gr. 1009. No albumen. No iodine reaction. No tube casts. March 22. Has taken iodide of potassium for several weeks until the past few days. To-day the urine contains no iodine, but has a small amount of albumen, also a few pale granular tube casts. April 27. Has not been taking iodide. Urine dark, sp. gr. 1020. No iodine reaction. No albumen, a few very pale hyaline tube casts. April 17, 1879. No treatment since last entry. Urine free from albumen and tube casts.

Case 4 Kate G., mulatto, 36 years old. Married. Syphilitic eight

years. Very severe symptoms. Tubercular eruptions, ulcers, and gummy tumours of integument. Tibial and frontal nodes. Has taken much mercury and iodide of potassium. Feb. 4, 1878. Urine straw-coloured and acid ; sp. gr. 1032. Iodine reaction. (Has been taking iodide since yesterday morning.) Slight albuminuria. Oxalate of lime crystals abun- dantly present. A few large and small hyaline tube-casts. March 6. Has taken no iodide for two weeks, until yesterday morning. Urine pale, acid; sp.gr. 1027. Iodine reaction. No albumen. Plenty of oxalate of lime, but no tube-casts. \Mh. Has taken iodide regularly. Urine, acid; sp. gr. 1030. Iodine reaction. No albumen. No tube-casts. Oxalate of lime in abundance. April 8. Urine pale, alkaline ; sp. gr. 1020. Small amount of albumen. June 3. Has taken no iodide for a month. Urine, acid and without iodine reaction. Small amount of albu- men. Hyaline and granular casts. Oxalate of lime crystals. Oct. 24. Has been taking no iodide for some time. Urine faintly acid. No iodide reaction. No albumen. No tube-casts. Octohedra of oxalate of lime. Nov. 26. Gums slightly affected from biniodide of mercury, of which she has been taking T\ gr. thrice daily, with her iodide. Urine gives iodine reaction; acid; no albumen. No tube-casts. Dec. 10. Has taken no iodide for four days. Urine free from iodine; acid; sp. gr. 1030. March 16, 1879. Has now been taking for several weeks 10 grains of iodide of potassium thrice daily. Urine shows no albumen to tests, but upon careful microscopic examination a few hyaline casts are detected. April 7. Has been taking iodine steadily. Urine, pale, acid ; sp. gr. 1027. Iodine reaction. No albumen. Oxalate of lime and a few mucous tube-casts are discovered. May Ah. Continues to take iodide as before. No albumen. No tube-casts; Oxalate of lime plentiful. Feb. 23, 1880. Has taken no iodide for some time. Urine normal. This patient has had upon one or two occasions slight swelling of the feet, but never decided dropsy.

Case 5 — Mrs. O., coloured, widow, 59 years old. Has had syphilis for 1 4 years. Faucial ulcers. Destruction of bony and soft parts of nose (partial). Feb. 17. Has been taking iodide of potassium for several weeks. Urine acid; sp. gr. 1017. Iodine reaction. Small amount of albumen. Hyaline and pale granular tube casts, the former numerous. March 1. Urine normal. 10th. Has taken no iodide since last entry. Urine pale and acid ; sp. gr. 1013. No iodine reaction. Minute amount of albumen. Microscopically, uric acid crystals, many mucous tube-casts

1881.] Atkinson, Iodide of Potassium and Bright's Disease.

and a few hyaline casts. April 6. Urine faintly acid; sp. gr. 1013. (Has taken no iodide since last date.) No albumen. A few hyaline casts. July 1. Has taken no iodide since last date. Urine pale and acid; sp.gr. 1012. No iodine reaction. No albumen. No tube-casts. Oct. 22. Has not been taking iodide. Urine healthy. Dec. 12. Has taken no iodide since last date. Urine normal. July 9, 1879. Began to take iodide three days ago. Urine pale and faintly acid. Iodine reaction. No albumen. A few mucous tube-casts. 25th. Urine pale. Iodine reaction exceedingly feeble. No albumen. Triple phosphates in abundance. Swarms of vibrios. After diligent search, a single hyaline cast is dis- covered. Oct. 1. Has taken no physic for some time. Urine normal. March 1, 1880. No physic. Urine healthy.

Case 6 Sarah W., coloured ; syphilitic for five years. Has had vari- ous systemic manifestations. Much " rheumatism." Has now. phthisis pulmoxialis. Has been taking mercury, iodide of potassium, and cod-liver oil. March 6, 1878. Urine shows presence of iodine; sp. gr. 1013. Albuminuria. Hyaline and granular tube-casts. April 17. Urine pale and acid; sp.gr. 1010. No iodine reaction. Albumen present in large quantity. Pale and coarsely granular tube casts. This woman had a large cavity in the apex of her right lung, and had been anasarcous.

Case 7. — M. G., white, about 50 years old. Twenty years syphilitic. During this period has suffered from many forms of constitutional mani- festations. Has been hemiplegic for several years. Last summer she took thirty-grain doses of iodide of potassium thrice daily. Is not at pre- sent, under treatment. March 6, 1878. Urine very pale, alkaline ; sp. gr. 1010. No iodine reaction. Albuminuria. April 17. Urine pale, faintly acid ; sp. gr. 1006. No iodine reaction. Small amount of albumen. Hyaline and pale granular casts present.

Case 8 — Kate M., negress, aged 46 years. Syphilitic nearly twenty- four years. Has had various eruptions and very much " rheumatism." Much headache, nausea, and vomiting. Has had dropsy. Heart normal. She is very obese. Has been taking iodide of potassium for twenty-five months. Now takes ten grains thrice daily. April 2, 1878. Urine pale ; sp. gr. 1023. No iodine reaction (!). No albumen. Lozenge crystals of uric acid, and mucous tube casts. Likewise a number of hyaline and pale granular tube casts. 17^. Urine, acid ; sp. gr. 1022. Iodine reac- tion. A barely perceptible amount of albumen is present. Uric acid crystals and hyaline and pale granular casts.

Case 9 — Lottie L., coloured, 29 years old. Syphilitic for several years. Cachectic. Broad condylomata of perineum. Also of vulval and anal regions. Enormous hypertrophy of left labium majus and clitoris, equalling a cocoanut in size. Has been taking iodide of potassium for some time. At present has twenty grains thrice daily. March 31. Urine acid; sp. gr. 1011. Considerable pus present. Albumen in limited amount. Iodine reaction. Hyaline tube casts. Nausea and dyspepsia trouble her greatly. Has never had dropsy. Heart healthy.

Case 10 — Annie B., 25 years old. Syphilitic ten years. Various constitutional manifestations, and extensive ulcerations. Several years since, her left leg was amputated, in consequence of intractable ulceration and necrosis. Has had much iodide of potassium, and is now taking 20 grains thrice daily. April 2. Urine straw-coloured, acid ; sp.gr. 1016. Iodine reaction. Copious amount of albumen. Multitudes of hyaline, pale, and coarsely granular tube-casts, some studded with renal epithelium and

24 Atkinson, Iodide of Potassium and Briglit's Disease. [July

blood disks, some fatty. 11th. Urine acid; sp. gr. 1012. No iodine re- action. Highly albuminous. She has at several times been anasarcous, not so at present. Heart hypertrophied ; valves normal. Casts not coloured by solution of iodine.

Case 11 — John P., 21 years old, sailor. Syphilitic since 1872. Sore throat ; iritis ; " rheumatism ;" periostitis. Has had various skin manifes- tations. Has taken iodide of potassium for seven weeks, never before. May 1, 1878. Urine high-coloured, acid ; sp. gr. 1023. Iodine reaction. No precipitate to heat and nitric acid. No tube-casts present, but large numbers of oxalate of lime octohedra. 28th. Urine acid ; sp. gr. 1030. Iodine reaction. Oxalate of lime octohedra of very minute size. A goodly number of mucous casts, and a few well-defined hyaline tube-casts. June 10. Urine acid ; sp. gr. 1027. Iodine reaction. No albumen. Careful search through several slides reveals, in addition to oxalate of lime, octohedra and mucous casts, a single hyaline tube-cast. lQth. Urine acid. Iodine reaction. No albumen. Mucous tube-casts. No crystalline deposit. No hyaline casts. This patient had no history of dropsy. His heart was healthy.

Case 12 — B. F. T., coloured, sailor, 25 years old. Syphilitic for four years. Frequent and various cutaneous eruptions. Iritis. Has had sup- purative adenitis. Has been taking iodide of potassium for one year ; now takes 10 grains thrice daily. May 18. Urine acid; sp.gr. 1020. Iodine reaction. No albumen. Microscopically, a few pus-cells and hyaline tube-casts, also a few pale granular casts. 2Qth. Urine acid ; sp. gr. 1023. Iodine reaction. No albumen. Hyaline and pale granular tube-casts. June 1. Urine acid ; sp.gr. 1030. Iodine reaction. No al- bumen. The microscope reveals only a few oxalate of lime octohedra. IQth. Has taken no iodide for several days. No iodine reaction. No al- bumen. No tube casts. Octohedra of oxalate of lime. 25th. Urine acid. No iodine reaction. No tube-casts. Oxalate of lime crystals. July 2. Has been taking iodide of potassium for one week. Acid urine ; sp. gr. 1028. No albumen. Microscopically, a few oxalate of lime octo- hedra and many hyaline and granular tube-casts. (No history of dropsy.)

Case 13. — J. M., white, sailor, 30 years old. Initial lesion twelve years ago. Various cutaneous affections. " Rheumatism." Iritis. Has been taking 10 grains of iodide of potassium thrice daily for five months. May 18, 1878. Pale and acid urine ; sp. gr. 1017. Iodine reaction. No albu- men. Some hyaline tube-casts are visible. 28th. Urine acid ; sp. gr. 1022. No abnormal deposit. June 1. Urine acid ; sp. gr. 1022. No albumen. No iodine reaction. No abnormal microscopic condition. June 16. Urine acid. Iodine reaction. No albumen. A number of sharply defined hyaline tube-casts. (He had not been taking iodide for nearly a month, but upon a recurrence of iritis, its use was resumed several days ago.) 25th. Urine acid. No albumen. Iodine reaction. Well defined and perfectly hyaline tube-casts.

Case 14 S. J., negro, 23 years old. Initial lesion in March, 1873.

Copious general eruptions, alopecia, ulcerative lesions, pulmonary hemor- rhages, dulness over right apex in front and behind. (Oct. 1877.) June 13,1878. Pulmonary softening and cavities. Very pronounced general adenopathy. Urine pale, alkaline ; sp. gr. 1020. No iodine reaction. Large amount of albumen. Microscopically, triple phosphates, but no tube-casts, loth. Urine pale, alkaline. Albumen present in smaller amount. Many pus-corpuscles. No tube-casts.

1881.] Atkinson, Iodide of Potassium and Briglit's Disease. 25

Case 15. — J. B., sailor, 32 years old. Initial lesion during the spring of 1872. Has now (July 14, 1879), ulcers upon legs, and many scars upon back, breast, and legs. The entire back is covered with scar-tissue forming an immense surface of cicatricial bands and depressions, the colour of which still shows the dusky red of recent repair. He took some iodide of potassium in 1874. Takes at present 4 grains, with gr. of bin-iodide of mercury thrice daily. Urine acid ; sp. gr. 1020. Iodine reac- tion. No albumen. Associated with minute oxalate of lime octohedra and pus-cells, there are quite a number of casts of the tubules, some mu- cous, others ordinary pale granular casts, which are very numerous. July 29. Has taken no iodide for two weeks. Urine acid ; sp. gr. 1022. No albumen. No iodine reaction. No tube-casts. Some oxalate of lime octohedra. Aug. 6. Urine acid; sp.gr. 1008. No iodine reaction. No abnormal deposit. No albumen.

Ca^e 16 F. J. K., 45 years old, paperhanger. Initial lesion twenty- five years ago. Symptoms of varied character since that time. Has now deep ulceration on breast and abdomen. Some oedema of lower extremi- ties. Line of hepatic duiness reaches below the level of the umbilicus, but recedes rapidly towards the left. Patient very thin and sallow, but not distinctly jaundiced. Some ascites. Girth at umbilical level 84 cm. General health much reduced. Has had paralysis of eye muscles. Can give no account of treatment, except of a profuse salivation. Takes now 8 grains of iodide of potassium thrice daily. July 21, 1879. Urine acid ; sp. gr. 1006. Iodine reaction. Small quantity of albumen. No tube- casts. 23flf. Urine pale and acid; sp. gr. 1010. Copious precipitate of albumen, and, microscopically, abundant tube-casts, granular and epithe- lial. Iodine reaction. Aug. 5. Urine acid; sp. gr. 1008. Iodine present. Much albumen. Hyaline tube-casts in small numbers. Sept. 9. General condition much improved. Ulcers healed. Urine albuminous and with hyaline and granular tube-casts. Heart enlarged, but valves healthy.

Case 17. — H., sailor, 30 years old. Chancre five years ago. Various constitutional symptoms, but no ulceration. Right hemiplegia and apha- sia for two months. Improvement under the iodide of potassium. Aug. 6. Urine not albuminous ; acid ; sp. gr. 1022. Copious deposit of oxalate of lime octohedra, and many hyaline tube-casts. 9th. Urine pale. Not albuminous. Iodine reaction. No tube-casts. Has not been taking iodide for several days. Sept. 5. Iodide resumed. Urine shows iodine reaction ; acid. Mucous and hyaline tube-casts and oxalate of lime octohedra in small numbers. 23c?. Urine acid ; sp. gr. 1010. Iodine re- action. No albumen. No tube-casts. Oct. 22. Urine free from albu- men and tube-casts, but with oxalate of lime in small quantity. Heart normal. No dropsy.

Case 18. — An elderly sailor, wretchedly emaciated and with pronounced cachexia, just from shipboard. Unable to stand. Can give no history. Body is seamed with white flat scars. Breath disgustingly fetid from deep faucial and pharyngeal ulceration. Large nodes upon right radius and ulna. No dropsy. Vomiting incessantly for several days. Death in three days apparently of exhaustion, without paralysis and with intellect clear to the last. Urine, examined day of admission (Aug. 13), was acid, of sp. gr. 1014. Small amount of albumen. Plenty of tube-casts, mu- cous, hyaline, and granular. Post-mortem examination : Kidneys dark brown. Capsules moderately adherent. Left kidney much smaller than right. Both hard and contracted, but without circumscribed alterations.

26 Atkinson, Iodide of Potassium and Bright's Disease. [July-

No signs of gummy infiltration in any part of abdominal cavity. Upon the spleen, which was slightly enlarged, there was a flattened, whitish mass of cartilaginous hardness, lozenge-shaped and measuring 3 x2cm.

Case 19 — B. R. Ostler; Irish; married. Chancre in Jan. 1876, followed by severe constitutional symptoms. Oct. 15,1 879. Deep ulcer- ation of right leg. Left testicle as large as a hen's egg, smooth, evenly enlarged, and painless. Patient is a large, burly man of dissipated habits. Urine acid ; sp. gr. 1020. No albumen, but numerous hyaline and gran- ular casts of the tubules. Begins to take iodide of potassium in 5 gr. doses thrice daily. Dec. 13. Urine free from albumen and tube-casts. Abun- dant uric acid crystals and oxalate of lime. 2'2d. Still takes iodide. Urine not albuminous. Copious deposit of amorphous urates and a few hyaline and granular casts.

Thus, it will be observed that of 70 cases investigated by me, 19 be- trayed evidences of renal disturbance ; 13 being characterized by the presence of albumen in the urine, constantly or at irregular intervals, while in 18 the microscope revealed, in the urine, casts of the renal tubules. In 12 cases albumen and tube-casts were simultaneously present. It is at once manifest that the kidneys were affected in very different degrees in the different cases. In few instances were the evidences of kidney disease pronounced and constant. For the most part, they were slight and tran- sitory, and my observations are remarkable rather for the large proportion where renal disturbances were detected, than for their gravity. For the present, I propose to turn aside from many of the interesting features of these cases, and to ask attention to the influence that may possibly have been exerted by the iodide of potassium in the production of abnormal conditions. For the purposes of such an investigation, a certain number of my cases may be excluded, as offering examples of pronounced renal degeneration, the exciting cause of which was buried in obscurity, and others, where the changes, though slight, existed already when first com- ing under notice, and before the iodide of potassium was administered. Similarly, must be excluded those cases where the albumen or tube-casts, or both, though irregularly and transitorily present in the urine and per- haps in some instances dependent upon the iodide of potassium, could not with any show of probability be traced to the ingestion of this drug.

Before proceeding to consider the cases where iodide of potassium did seem to exert an influence in exciting the morbid symptoms, let me briefly call attention to the very large proportion of cases where oxalate of lime crystals will be found in the urine of persons taking the iodide. Thus, of a series of observations of 81 cases, oxalate of lime crystals (usually in abundance, sometimes scantily) were detected in 21 cases. The urine of these 21 patients contained lime oxalate octohedra 39 times; and in 29 of these observations the simultaneous presence of iodine was ascertained. Although we may no longer accept the views of Golding-Bird and Prout concerning an oxalic acid diathesis or oxaluria, but must consider the con- dition simply as a manifestation of lithiasis, a result of imperfect oxidation,

1881.] Atkinson, Iodide of Potassium and Bright's Disease. 27

we may still in the present instance fairly assume that this incomplete oxidation is in some manner the result of the influence of the iodide of potassium in disturbing the digestive processes, or otherwise interfering with normal nutrition and metamorphosis.

The cases coming under my observation, where inconsiderable disturb- ance of the renal organs was associated with the administration of the iodide of potassium, have been, as I have shown, proportionally numerous. In only a few was it possible to attribute to the drug, with any degree of confidence, a causative influence in exciting the derangement. Simply asking attention, therefore, to the frequent association of evidences of renal irritation with the presence of the iodide of potassium in the circulation, I pass to the consideration of those cases where the iodide of potassium seemed to determine the abnormal condition of the kidneys. Case 5, for example, had been taking the drug for some weeks previous to my first observation, when albumen in small amount and hyaline and granular tube-casts were discovered. Shortly after the medicine was discontinued, the albumen disappeared from the urine, but it was not until the expi- ration of four months that the urine became perfectly normal, so far as concerns the presence of tube-casts, as shown by several examinations extending over a period of six months. My patient was not again seen for an additional six months, when the urine, examined three days after resum- ing the use of the iodide, revealed only mucous casts. Three weeks sub- sequently, diligent search revealed a single hyaline cast. Treatment was again suspended, and at the expiration of two months the urine was nor- mal, as far as concerns albumen and tube-casts ; and so it remained at the end of another six months. Case 12 likewise justifies to a great extent the suspicion that renal irritation, resulting in the formation of tube-casts, followed the ingestion of the iodide. This patient had been taking the remedy nearly one year. Albumen was not detected in the urine, but a number of hyaline and pale granular casts were discovered. A week later a similar condition was ascertained. Four days later the urine appeared normal, the ingestion of the iodide having been discontinued. The med- icine was not renewed for a month, during which time the urine was twice examined and found healthy. A week after the treatment was recom- menced, many hyaline and pale granular casts of the renal tubules were detected, but no albumen. Case 13 presents features showing the same tendency. The patient, a sailor 30 years old, had been twelve years syph- ilitic. He had been taking iodide of potassium in ten-grain doses, thrice daily, for five months. His urine, examined May 18, was acid, of sp. gr. 1017, and contained iodine. There was no albumen, but hyaline casts were present. May 2S. Urine healthy. June 1. Urine without iodine, albumen, or tube-casts. Jane 16. (He had not been taking iodide since the middle of May, but upon the supervention of a new attack of iritis it was resumed several days previous to this date.) The urine was without

28 Atkinson, Iodide of Potassium and Bright's Disease. [July

albumen, but contained iodine and a goodly number of well-defined hyaline tube-casts. June 25. Urine acid. No albumen. Iodine reaction. Well defined hyaline tube-casts. Case 15 also seemed to exhibit renal irritation from the ingestion of iodide of potassium. He had late syphilis and was taking four grains of iodide of potassium thrice daily. His urine con- tained hyaline and granular tube-casts, but no albumen. His iodide was stopped for three weeks. His urine, examined at the end of this period, showed no iodine reaction, no albumen, and, microscopically, no tube- casts. Examined again after a week, it remained free from abnormal appearances.

The following cases, abstracted from my note-book, though not included in the regular series of observations, on account of the recent date of the acquirement of syphilis, and not occurring in order, are of especial inte- rest, as bearing upon the point under discussion : —

Case 20 — S. F. B., a young negro, hostler, had a chancre of the penis about Christmas, 1877. April 6, 1878, he had a copious pustular syphilo- derm, and complained of very extensive " rheumatism." For this he had been taking, for a few days, the iodide of potassium. His urine, examined on the above date, was acid, of sp. gr. 1022, and showed the presence of iodine to the test. There was no deposit to heat and nitric acid ; no tube- casts. The treatment was continued more or less regularly until June 6, when the urine was straw-coloured and acid. The presence of iodine was ascertained ; there was no albumen ; crystals of uric acid and oxalate of lime were detected, and with them well-marked hyaline tube-casts. He now ceased to take the iodide, and his urine, at the end of two weeks, con- tained neither albumen nor tube-casts. The iodide was not resumed, and the urine examined July 9, 1878, Jan. 7 and 15, 1879, remained perfectly healthy.

Case 21 James W., Irish, 32 years old. Had a chancre during the

latter part of Sept. 1877, followed by extensive papular syphiloderm. His urine, examined Jan. 15, 1878, was pale, of acid reaction, and of sp. gr. 1022. Albumen was not present, and the microscope revealed no signs of renal disease. Nodes beginning to appear on the tibia, accompa- nied by excruciating nocturnal pains in the knees, the iodide of potassium was now ordered, and was continued irregularly until March 28, with, for short intervals, a small amount of mercury. At the latter date his urine was pale, faintly acid, of sp. gr. 1028, and was free from albumen. There was a slight sediment of oxalate of lime octohedra, and'some mucous tube- casts. The iodide was continued until early in May. The urine exam- ined May 20 was without iodine reaction, but contained a small amount of albumen and numerous hyaline and pale granular tube-casts. The patient remained irregularly under treatment for some months longer, and then was not again seen until Sept. 4, 1879, when he had taken no medicine for a considerable time. His urine was free from albumen and tube-casts

Although, in the greater number of my cases, no definite connection between the iodide ingested and the albumen or tube-casts found in the urine could be established, the occurrence of the latter was unexpectedly frequent, and out of all proportion to what is usually supposed to prevail. It is true that the number where pronounced renal disease was present was

1881.] Atkinson, Iodide of Potassium and Bright's Disease. 29

probably not much larger than will often be found in the wards and out- patient departments of large city hospitals. The point to which I especially desire to call attention is, that in so many of my patients albumen or tube- casts, or both, were detected, chiefly, however, as transitory phenomena, the former in minute quantity, the latter in the forms indicative of the smallest amount of renal alteration.

The question arises here, very naturally, of the significance of the pres- ence of albumen in small quantity and of hyaline casts of the renal tubules in the urine. So far as concerns the albumen there seems to be no reason to believe that it is present in healthy urine, or to doubt that the presence in the urine of even a small amount indicates a departure from health. " We must admit, however, that it may make its appearance under such conditions as to show only a very slight deviation from the natural state." (Ellis, Boston Med. and Surg. Journ., vol. cii., 1880, p. 361.) So far, then, as albumen was present in the urine of these patients, we may con- clude that it was as a result of pathological processes. In quite a number of the cases, however, hyaline and pale granular tube-casts were the sole evidences of a morbid condition of the kidneys. I have already referred to the unusual frequency of oxalate of lime-crystals, and their probable dependence upon the ingestion of the iodide of potassium. Should the same influence determine the appearance of the tube-casts, to what extent may these be considered to be the results of tissue change ? In other words, may hyaline casts of the renal tubules be found in the urine of persons whose kidneys are healthy ?

It has not unfrequently been asserted that l^aline tube-casts may appear in urine from healthy kidneys. Iienle, for example, claimed to have fre- quently discovered them in healthy Sidneys. (Handbuch der Systemat. Anat. der Mench.) Charcot also states that they may appear in the urine when the kidneys are not diseased, and says that the same assertion has been made by Robin, Axel Key, and others (Tyson, Phila. Med. Times, vol. x. p. 293). Nearly all authorities, however, consider the presence of tube-casts, of any variety (except, possibly, the mucous), as indicative of morbid change in the kidneys. Bartels declares (Ziemsseri 's Cyclo- pedia, vol. xv.) that true casts are never found under normal conditions, and that as a general rule they are attended with the excretion of albu- men (p. 87). It seems to be pretty certain that hyaline casts of the renal tubules are the results of irritation of the epithelia of these tubules, in consequence of which a coagulable material is secreted by these cells, which coalesces into cylinders, corresponding to the shapes of the tubules. (Aufrecht. Oentrabl. f. d. Med. Wissensch., 19, 1878; Langhaus, Vir- chow's Archiv, lxxvi. 85, Oedmanson, Rovida, and others.)

To what extent these casts may be evidences of tissue alterations it is impossible to say. It is certainly reasonable to suppose that at least they may be results of transient irritation that may subside without leaving

30 Atkinson, Iodide of Potassium and Bright's Disease. [July

its vestiges behind in the tissues of the organs. There can be no doubt that patients suffering from acute febrile disease may, during life, pass urine containing both albumen and tube-casts, and yet the kidneys of these persons may reveal nothing abnormal after death. This would simply indicate that the irritation that was sufficient to stimulate the glandular epithelium to the formation of casts, was not violent enough or sufficiently long continued to produce recognizable structural alterations. It must, therefore, be understood, that the influences producing these casts may vary from a slight stimulation of the epithelia of the tubules to extensive and irreparable destruction of renal substance ; but it must not be forgotten that while an insignificant and transient irritation may subside without leaving its traces behind it, it is most probable that if it be con- tinued for an indefinite time it may finally produce permanent effects. In the cases I have recorded, the results from the irritation of the iodide were, as observed, at most slight albuminuria and pale granular tube-cast-. jSIor was there noticed, in any of them, systemic evidences of renal dis- turbance. Certainly in no case was there the slightest reason to suspect, as produced by the iodide, an extensive parenchymatous inflammation, such as it has been claimed the iodide is capable of exciting. The effects were such as iodine and the iodides may occasion in mucous membranes generally, a catarrh, in fact. Beyond this it did not proceed, but, on the other hand, there seemed rather to be a tendency towards a subsidence of the irritation and a toleration of the drug. At least, there seemed to be no increase in the symptoms under its use, and in one case espe- cially, that of K. G. (Case 4), the renal affection that had been quite pronounced, gradually and completely disappeared under the full and sys- tematic use of the iodide, it is not 'impossible, however, that in this in- stance the results were due to the specific action of the drug upon a purely syphilitic renal disorder.

At the same time, I cannot avoid the conclusion that while the evil effects of the iodide of potassium upon the kidneys are small and for the most part transitory, the occurrence of more severe alterations is not im- possible, nay, is probable. But upon this point my investigations have been too few and imperfect to enable me to speak with confidence. It is perfectly well established that there is no constant tendency on the part of the kidneys to resent the presence of the iodide. My own observations are confirmatory of this, for they include a number of old s}rphilitics, to whom the drug had been administered for protracted periods, and in ex- cessive doses, without the smallest sign of urinary disorder. As in other parts of the body, the undesirable effects of the ingestion of iodine and the iodides have been attributed to idiosnycrasy, so must idiosnycrasy be in- voked to explain any undesirable results of the action of these prepara- tions upon the kidneys.

223 Madison Avenue, Baltimore.

1881.]

Gaston, Use of Ecraseur in Fistula in Ano.

31

Article II.

Use of the Ecraseur for Curing Deep-seated Fistula in Ano. By J. M. F. Gaston, M.D., of Campinas, Brazil.

The frequency of fistula in ano has its origin in some ill-defined pro- clivity on the part of the tissues about the rectum to a subacute form of inflammation. A proneness to the development of abscesses in this region may be explained by the turgescence of the abundant supply of blood- vessels connected with a want of proper evacuation.

The rectum being the receptacle of the excrementitious mass resulting from the materials that constitute our food, may be irritated by the long continuance of the indurated feces in the canal. It is also liable to injury by the passage of foreign bodies that have been swallowed, and that have rough or very irregular surfaces which offend the mucous membranes.

A purulent discharge from an inflammation exterior to the walls of the rectum, that finds its way outside of the sphincter ani, is not often attended with serious consequences. The source of trouble that terminates in fis- tula is generally an abrasion or pustular inflammation involving the lining membrane and the adjacent areolar tissue of the canal, by which the vitiated fluids penetrate the cellular tissue, and permeate the surrounding muscular substance. A tract or channel is thus formed which is destined sooner or later to reach the surface externally at varying distances from the anus. If the origin is near the outlet of the rectum, the point of discharge externally will usually be found immediately outside of the sphincter ani. But if the source of the fistula is high up in the canal, the route of the discharge may be in the direction of the sacrum or through the muscular fibres of the gluteus, and there may be several lines of communication with the surface. A single opening by the ulceration of the mucous mem- brane of the rectum may cause a fistula that diverges in different channels, and thus permeating all the tissues, finds several outlets at various points over the sacrum or on the buttocks. As a rule, when fistulous tracts are formed superficially over the sacral or gluteal regions, there will exist an ulcerated opening in the lining membrane of the upper part of the rectal canal. But it happens occasionally that we are unable to trace this con- nection, and perhaps in some cases the internal lesion has cicatrized while the outer fistulous tract continues. In a case that was under my care some time since for fistulous discharges over the sacrum, in a vigorous young Brazilian, I laid open the superficial communicating channels with the knife, and found in one of them a pledget of short hairs of an oblong shape, which had an unmistakable fecal odour. I expected from this to be able to trace a communication with the rectum, but no connection could be discovered, and the crucial fistula that was laid open closed by granulation, and gave no further trouble.

32

Gaston, Use of Ecraseur in Fistula in Ano.

[J%

Another serious case of extensive superficial fistula is under my obser- vation at present, and has prompted me to prepare this paper.

Case I There were four extensive tracts over the posterior gluteal

region, being two on either side of the sacrum, communicating each with its fellow, but not apparently connected with those of the opposite side. The two on the right side, being on the posterior aspect of the hip, were laid open with the bistoury and grooved director ten days since, while the two on the left hip have remained for another operation when the former shall have made some progress in granulating. In them it has been requisite to draw the gaping skin together by adhesive plaster for the advancement of the healing process, which has been proceeding regularly thus far with dress- ings of lint and carbolized oil.

In the tracts already laid open no communication was detected with parts more deeply seated, yet it may be that upon making the incision of the fistula over the left buttock the line of communication with the rectum may be found. Upon exploring the rectum indications of former ulcera- tion were discovered high up in the canal, and the posterior wall gives evidence of a cicatrization, with adherence to the promontory of the sa- crum. It is hence clear that this was the focus from which the fistulous tracts were extended to the superficial parts of each hip, and it is not im- probable that there may still exist a small orifice by which the secretions escape from the rectum, and keep up the irritation along the lines of com- munication with the external outlet. Although the cicatrization in the upper posterior part of the canal indicates that an orifice existed previously, and has been obliterated, the examination within does not reveal a lesion of the mucous membrane at present, and the final result will enable us to determine the mooted question as to the spontaneous closure of the inter- nal opening of a rectal fistula while the external outlet keeps up a dis- charge of pus.

This patient is a young negro man, who has done the ordinary service of a slave upon a coffee farm, and has doubtless received nourishing food, but has not had that variety in those plain articles which his condition demanded for alimentation. There exist over the region of the clavicle several patches of ulceration which indicate a scrofulous diathesis, yet they are improving under the influence of cod-liver oil and generous fare so that the restorative process in the incision is going on very favourably, yet the general condition of the subject is not altogether satisfactory for the good result of an operation on a large scale.

The other superficial tracts will be laid open with the knife as those have been ; yet should it turn out that some of them have a connection with the canal of the rectum, it may be requisite to separate the deep-seated tissues with the chain of the ecraseur, and hence I have introduced a notice of this case as a preliminary to the description of those which have been operated upon by this instrument.

It is not necessary that the ecraseur shall be used to perform simple operations that may be suited to the employment of a bistoury and grooved director, or to the use of gradual constriction by the loop of a cord or wire. The fistulse, which originate immediately within the anus and terminate at a short distance outside of it, may be divided so safely and expeditiously with the knife as not to require the use of an anaesthetic, and should the

1881.]

Gaston, Use of Ecraseur in Fistula in Ano.

S3

patient insist upon lessening the pain of cutting, local anaesthesia will serve the purpose without the risk or delay of inhalation.

The whole subject of fistula in ano affords an interesting field of inves- tigation, and there is much for study in the improvements which have been effected in the mode of treating the various forms of this troublesome affection. But, as I am limited to a notice of one important branch of the subject, this paper does not include those phases of the disorder that are most frequently encountered by the practitioner.

It has happened that a large variety of these fistulous affections about the rectum have come under my observation here within the past ten years, and it has been noted that the cases of gravity are far more frequent in this place than in the Southern United States, where an extensive field of ob- servation afforded few cases in comparison with those I have encountered in Brazil. Some of the cases that form the basis of this paper have occurred in the practice of other physicians with whom I have co-operated in their management, or in the necessary operations, while a considerable number have been under my own care. It is not my purpose to present any statistical record of the different kinds of fistula in ano that have been treated ; but, putting aside the more familiar examples of simple cases, such details will be presented as may give a proper conception of the graver varieties that have come under treatment. Not treating of cases in which palliatives are to be used, nor of the more simple operative pro- cedures for the cure of ordinary fistuke, no reference need be made to those examples, and hence attention is directed only to the class of deep- seated fistulas which are appropriate for the application of the ecraseur.

The principle upon which this instrument acts allows the use of a cord, wire, or chain to constrict and in the end divide the tissues, which are inclosed within the loop. Having employed the jointed chain formerly with satisfactory results in the excision of hemorrhoidal tumours, prefer- ence was given to it for dividing the parts that intervened in fistula. When the tract or channel penetrates to such a depth as to cause appre- hension of hemorrhage by cutting with the knife, the tissues may be divided without any risk by the chain of the ecraseur of Chassaignac. The instrument should be tightened up to the point of dividing the cellular tissue and muscular fibres, and, even when an extensive mass is divided, no bleeding occurs. The chain may pass high up into the canal of the rectum, where there are vessels which would bleed profusely from an incision with the bistoury, and yet no hemorrhage ensues upon their division by the chain of this instrument.

The essential conditions which indicated very clearly this operation have been presented in three cases of extensive fistula in ano, in which there was such correspondence in the history of the individuals as to be types of the uncomplicated rectal disease. No. CLXIII July 1881. 3

34

Gaston, Use of Ecraseur in Fistula in Ano.

[July

The patients were active, robust, and otherwise healthy persons, so that the affection could not be attributed to any constitutional disease, but was most probably the result of some local injury or ulceration of the mucous membrane of the canal immediately below the contraction of the circular fibres which serves as a division between the sigmoid flexure of the colon and the rectum ; or, in other words, near the internal sphincter which ordinarily retains the excrementitious matter within the lower part of the intestine. The internal opening in each case was high up in the rectum, and the fistula extended from this aperture deeply into the surrounding tissues, so that the tracts or channels lead out in one case over the sacrum, and in the other two reached the lateral aspect of the buttocks. The line of com- munication between the internal orifice and the external outlet of the fis- tulas, in each of the three cases, exceeded six inches in length.

Case II. wTas an athletic, middle-aged man of German descent, but a native of Brazil, who led an active life as manager and part owner of an extensive machinery establishment. Case III. was an able-bodied negro man, about twenty-five years old, who laboured upon a coffee fayenda. Case IV. was a robust black woman, of perhaps thirty years of age, whose service had also been in the coffee-field.

With all the antecedents of nourishing food and exercise in the open air, each of these cases developed extensive fistulas without any material impairment of their general health, and afforded most favourable conditions for an operation involving the deep-seated tissues.

It may be stated in advance that-in all these extensive divisions of the muscular fibres the subcutaneous injection of morphia, with the inhala- tion of chloroform, has been resorted to previous to operating, and a full dose of sulphate of quinia has been given subsequently, thus preventing the suffering and consequent shock to the general system of the patient.

In Case II. the fistulous openings were connected by channels that crossed immediately over the upper middle part of the sacrum, and when these were laid open the incisions presented two lines of 4x6 inches at right angles in their middle point so as to form a cross. This division was effected with the bistoury and grooved director, extending to every de- pression that could be reached, and yet Avithout discovering any aperture by which to trace a communication with the lesion that had been found in the rectum. This difficulty caused a postponement of the final operation until the close observation daily of the fistulous surface now exposed to view revealed the exact site of the orifice.

It may not appear impertinent to remark that all fistulous channels over the region of the sacrum and ischia, even when they appear to be super- ficial, should be suspected to have their origin in the rectum, and are to be explored with great care to locate the point of entrance. The opening may exist in any part of the superficial tract, and after the fistulous chan- nel is opened it may prove impracticable to pass a probe into the orifice, though there may exist a lesion high up in the rectum, which indicates that a communication should be found. A little patient watching, as in this case, will generally be rewarded with success.

Having determined with accuracy the orifice of the fistula and the line of its communication with the upper part of the rectum, the chain of the ecraseur was secured to an elastic bougie and thus drawn into the tract of the fistula, passing out of the rectum through the anus. This extremity

1881.1

Gaston, Use of Ecraseur in Fistula in Ano.

30

of the chain being joined with the other, which remained outside of the orifice on the right side of the sacrum, they were both attached to the in- strument. Thus it will be seen that all the tissues contained in the great sacro-ischiatic notch were included in the loop of the chain attached to the ecraseur. It was cautiously and gradually tightened until every portion of the substance, in which the sphincter ani entered, was entirely divided, and without any hemorrhage. Such a chasm has not perhaps been made previously into the canal of the rectum as was caused by the passage of the chain of the instrument through the large mass of the cellular and muscu- lar tissues adjacent to the sacrum and the coccyx on the posterior aspect of the right buttock. This immense wound was filled up with fine strips of old linen (which I prefer to lint in these cases), previously saturated with carbolic oil, and the dressings were daily renewed to the great dis- comfort of the patient, as there was such an extensive raw surface exposed. At the end of one month very considerable progress had been made toward the restoration of the divided parts, and within three months all was com- pletely healed. The only trouble that remained was some lack of reten- tive power on the part of the sphincter ani, which was so far relieved at the end of twelve months that only when there were fluid evacuations was any difficulty experienced. Five years have elapsed since this ope- ration, and the gentleman has been actively employed since the close of the first year without further inconvenience locally or generally.

Case III. presented quite a number of fistulous openings over the poste- rior aspect of the buttocks, and it was at first suspected by another physi- cian who examined the case that they resulted from brutal chastisement of the slave, though there was no allegation to this effect. But upon ex- amining the rectum the origin of the trouble was detected in the upper part of this canal, and the tracts extended from this in different directions to the surfaces over the sacrum and the ischia, involving the right and left buttocks. It was ascertained that the smaller superficial channel of some three inches in length could be divided safely with the bistoury and the grooved director that was passed on the posterior part of the left buttock. The other two extensive tracts involved tissues that would have caused bleeding if the division had been with a knife, and hence it was most ex- pedient to use the ecraseur. The chains of two instruments were passed through the respective channels and out at the rectum, in the manner de- scribed for the previous operation, and the division of both was effected at the same time without any loss of blood.

In Case II. the large gaping wound, resulting from such an extensive solution of continuity, presented something considerable for the healing process. But in this second operation there were two incisions quite as deep, and one of them of greater length ; while the third made with the knife, though less, would have been important but for the immensity of the others. There were two superficial fistulous tracts, communicating laterally with the main channels, which were left for treatment by the use of injections, and they were cured while the dressings were applied to the grand chasms with strips of linen and the carbolic oil.

In this operation the rectum, including the sphincter ani, was laid open to within a half inch of the ring of circular fibre that divides this canal from the colon and implicated all the sacro-ischiatic spaces, which corre- sponded very much to the second case. But independently of this there was a far more extensive division of the soft parts, making with the former something less than a right angle outwardly in the huge mass of the right

30

Gaston, Use of Ecraseur in Fistula in Ano.

[July

buttock. This last was divided much after the manner that a butcher would proceed in getting out a rump steak.

Even to the professional eye it was a hideous sight, and there seemed scarcely a hope for the restoration of this vast destruction of substance ; yet the curative powers of Nature asserted themselves in a most satisfactory manner, and in less than twelve months this negro returned to his ordinary work on the plantation entirely well, having complete control over the sphincter ani. He was operated upon three years ago, and for the past two years has not required any professional attention.

Case IV. had two deep fistulse, who.se external outlets were nearly equidistant from the junction of the sacrum and coccyx on either side, having each a communication with an opening about midway up the rec- tum. The channels being tortuous could not be traversed by a metallic probe or director, yet they were explored by a flexible bougie, to which the chain of the ecraseur was attached, and thus loops were thrown round the intervening parts. Two instruments were used so as to encircle the tis- sues on either side and divide them at the same time. As the chains in- cluded a portion of the buttock that contained no vessels that could yield any considerable amount of blood, the tightening of the screw in the one and the working of the handle in the other instrument were done ratl^er too fast, and, as a consequence, there was some sanguineous oozing from the divided surfaces of the muscles. This, however, ceased upon the applica- tion of a strong aqueous solution of phenic acid, which has proved in my hands an effective hemostatic, even when small arterial twigs are divided by the knife.

The usual dressing of fine strips of old linen saturated with carbolized oil was kept up for some weeks, and the cure was completed within two months, so that the negress went about her duties on the farm.

The most remarkable feature in connection with these extensive divi- sions of the deep-seated fistulas, involving the cellular tissue and the mus- cular fibre surrounding the rectum, is the comparatively slight effect produced upon the general system. There has been very little febrile ex- citement after any of these heroic operations, and the restorative process has also progressed very satisfactorily in all three cases.

Trusting that my record of these operations may induce others to pre- sent their experience in the management of deep-seated rectal fistulse, I have great confidence in recommending the ecraseur to the favourable con- sideration of my colleagues when they have to deal with these grave cases. The advantages of this simple instrument are so evident as only to re- quire a knowledge of the immediate and final good results of its applica- tion in such operations, that it may be appreciated by surgeons generally.

I make no reference to the hopeless cases that have come under my observation for which no remedial step was undertaken because of the general prostration, and not from any apprehension of the consequences of arresting the fistulous discharge. I will be excused by those who are most experienced in the treatment of these disorders of the rectum for not adopting the idea of former times, that the drain thus induced upon the adjacent parts has a salutary influence upon tubercular disease of the

1881.]

Gaston, Use of Ecraseur in Fistula in Ano.

37

lungs or upon chronic affections of the liver. The evidence is conclusive to my mind that the general debility and constitutional irritability result- ing from the constant wear and tear of fistulas involving the tissues sur- rounding the anus, are in most cases aggravating circumstances in the progress of other diseases, and the sooner and the more effectually they can be cured the better for all the disorders of the animal organization. Being advised of the position taken by Brodie, Astley Cooper, Theophi- lus Thompson, Druitt, Chelius, and others, in opposition to the radical cure of fistula in ano which occurs in the course of organic disease of the lungs or liver, I cannot acquiesce in the view of these high authorities and set aside the experience of other observers equally entitled to consid- eration. It may be held that distinguished names of our day are mar- shalled against operating under such conditions, and amongst them stands out bold and prominent that of the sagacious Dr. Gross.

"All attempts," he says, "at a radical cure are, of coarse, inadmissible when there is serious organic lesion in other parts of the body, especially the lungs. To avert the local irritation would, in such an event, prove highly detri- mental by expediting the fatal crisis. Palliation alone, not cure, is sought ; or cure, slow and chronic, occupying months instead of weeks, in its accomplish- ment."

This ipse dixit, coming as it does ex cathedra, must be weighed with facts. However great may be our respect for the professional opinion of such an erudite author, it is evident that holding this view in regard to therapeutic indications in this pathological state of the system, he could not, from the nature of the case, be supposed to have put the matter to a practical test. It must be inferred that he has based his statement upon a preconceived impression derived from those who have heretofore given judgment in a case of fistula in ano that is connected with some other organic disease unfavourable to any operative procedure that looks to a rad- ical cure. It is thus at best but negative testimony, which may be set aside by positive results.

The " chronic cure," which is recommended in the event of using any remedial measure, so as to spare the physical strength of the patient, re- minds one of lessening the shock to the dog by taking off his tail by piece- meal, an inch at a time, instead of removing it all at one stroke of the knife.

Thus the slow treatment suggested for the fistula in ano of the subject of hepatic or pulmonary disease must operate upon the delicate organi- zation of the tissues about the rectum, making the oft-repeated impres- sions of these temporizing applications, instead of the speedy and efficacious effect of a single and well-directed operation in cutting short the entire train of disorders.

No one would expect any advantage from resorting to a surgical opera- tion for fistula in ano when it occurs under circumstances that indicate a speedy fatal termination of some other disease, because the utter hopeless-

58

Gaston, Use of Ecraseur in Fistula in Ano.

[July

ness of the cure of the grave affection with which it is associated leaves no chance of benefiting the patient. But this consideration differs widely from the indisposition to cure the fistula from the impression of its proving hurtful to the subject of a disease less serious in its character.

It is not by any means satisfactorily shown that any pulmonary or other organic disease becomes aggravated by the cure of fistula in ano, and inde- pendent of my own results indicating the relief afforded by a timely resort to an operation under such circumstances, I am endorsed by the authority of Erichsen, who, thirty years since, wrote as follows : " I have, how- ever, in several cases found considerable advantage result by operating for fistula in the early stages of phthisis, or in suspected cases of that disease, the patient'*s health having considerably improved after the healing of the fistula."

The continuance of such a drain is not proven to be any advantage or its discontinuation shown to be productive of evil, and moreover the change is never brought about suddenly, as the suppuration from the in- cised surfaces diminishes gradually until the granulation completes the cure. Hence we should not be deterred by this supposed metastasis from the suppression of a customary discharge.

Addendum. April 22, 1881. — The incisions made in Case I. for fis- tulas on the right of the sacrum having made favourable progress, the fistulous canals on the left hip were laid open to-day by Dr. Melchert with the co-operation of Dr. Lima, in whose infirmary the negro is under treatment.

One of the canals, being eight inches in length and extending from the lower part of the sacro-iliac junction directly across the external iliac muscle, was laid open with a free incision of the knife passed on the di- rector. Two short tracts were opened likewise immediately over the sacrum. Upon exploring downwards from the principal incision, a fistula was discovered in the direction of the sacro-coccygeal articulation, and was laid open with the director and bistoury down to the outer boundary of the upper part of the rectum. As we could not trace the opening into the canal, and the extensive incisions already made must tax the recupe- rative powers, it was determined as best to await further observation as to the connection of the fistula with the rectum. When the incisions made formerly and these shall have healed, it will most likely appear that the tract communicating with the canal of the rectum still remains open, and the line of connection can be traced with more certainty. Should this orifice exist, as I am convinced it does, in the mucous membrane, the operation with the ecraseur will yet be in demand, as the tissues to be divided will not admit the application of the knife. With a view to pro- mote the granulation, lint well soaked in carbolized oil is placed in the channels of the fistulae that were laid open, and this dressing will be con- tinued from day to day until the approaching cicatrization admits adhesive plaster.

1881.]

House, Prolapse of the Vagina and Uterus.

39

Article HI.

The Operative Treatment of Prolapse of the Vagina and Uterus. By A. F. House, M.D., of Cleveland, Ohio.

The object of this paper is to present in a concise form the operative treatment of prolapse of the vagina and uterus with special reference to three different methods which have in late years come before and have been indorsed by the profession, namely, Simon's,1 Hegar and Kalten- bach's,2 and Bischoff's.3

The great majority of physicians still cling to the old method of treating these conditions with pessaries.

Among the prominent symptoms associated with prolapse of the vagina and uterus, pain in the back and loins, a constant feeling of impending loss of something from the external genital organs, paini'ul and disturbed micturition, a disordered condition of the bowels, and nervousness vary- ing from slight irritation to well-defined hysteria, may be mentioned. In view of the great number of women so afflicted, and the attention these conditions must necessarily have received from observing physicians in all ages of the world, is it not almost astounding to think that the first attempt at operative treatment of which we have record was made in the 19th-- century? Surgical treatment having been suggested, a brisk contest ensued between different operators as to the relative merits of the treatment they respectively advocated, until finally at this date operative procedure has been brought to such a state of perfection that Hegar and Kaltenbach can with justice say that kolpo-perineorraphy, in the surety and completeness of its results, stands equal in importance to any gynaecological operation, with perhaps the single exception of vesico-vaginal fistula.

In none of the systematic works on gynaecology accessible, has an at- tempt been made to present the various operations devised with an analy- sis of the results attending them, while in the majority of cases each author mentions only the single method he may have originated or adopted. As an established usage is not always applicable to an individual case, it happens that the profession often attempts what has been already tried and discarded, for want of that information our leading lights should have placed within its reach. A brief resume of some of the efforts and the progress made in this direction is therefore profitable.

The site of every operation for prolapse of the vagina and uterus has been respectively — 1. The vulva. 2. The introitus, or entrance to vagina proper. 3. The vulva and perineum. 4. The vagina. 5. The perineum, vulva, introitus, and vagina proper, strengthening the whole septum-recto- vagi nalis (Kolpo-perineorraphy).

1 Prager Vierteljalirschrift, 1867. 2 Die Operativ Gynsecologie, Erlangen, 1871.

3 Die Kolpopernioplastik nach Bischoffvon Dr. Banja. Basel, 1875.

40 House, Prolapse of the Vagina and Uterus. [July

The operation proposed and executed by P. C. Huguier,1 of which men- tion will be hereafter more particularly made, rests upon an entirely dif- ferent principle from the foregoing operations.

Gerardin in 1823 was the first who attempted to cure prolapse by operative means. His method comprised simply cauterization of the vaginal walls. During the year 1830, Mende proposed the operation of hymenorraphy, consisting, as its name implies, of an artificial hymen, but did not carry it out. Not much later Fricke attempted episiorraphy, by freshening the lower third of both labia? majorat and the posterior com- missure and uniting them with the quilled suture. The result was some- what unsatisfactory. Malgaigne freshened deep into the introitus, as did also in about the same way Baker Brown, Crede, Dieffenbach, Kiwisch, Kiichler,2 Linhardt, and Scanzoni. Heyfelder, Dammes, and Schiffer followed with a poor modification of episiorraphy, by drawing one or more rings through both labia?. We have next a series of operations, the so- called kolpodesmorraphy, performed w7ith a view of narrowing the vagina, and thus retaining the prolapsed parts in situ. These operations con- sisted in excising a number of folds of vaginal mucous membrane and at the same time inducing adhesions to neighbouring parts. Gerardin, afore- mentioned, was the first to propose this principle.

Benj. Philips cauterized the vaginal walls with fuming nitric acid, and thereby obtained favourable cicatricial contractions ; while Dieffenbach, Henning, Kennedy, and Velpeau drew the actual cautery over the vagi- nal mucous membrane in lines lying in the direction of its long axis, and Colles and Simon caused a ring-formed eschar at or near the cervical insertion. The " pincement du vagin" of Desgranges, although soon abandoned and forgotten, consisted in applying strong serre-fines to longi- tudinal folds of vaginal mucous membrane, then reapplying them to fresh folds, for months afterwards. He used chloride of zinc in his later opera- tions. What would the modern physician say to Chipendale's proposition to inoculate the vaginal mucous membrane with gonorrhoeal virus in the hope of obtaining cicatricial contraction similar to that of stricture of the male urethra? Bellini and Blosius performed kolpodesmorraphy by apply- ing ligatures to portions of the vaginal mucous membrane until they sloughed off. More recently the elastic ligature has been frequently em- ployed for the same purpose. Folds of mucous membrane of various lengths are raised with two pairs of toothed forceps, and a number of Karlsbader needles or hare-lip pins are passed through the base of these folds, and beneath the needles or pins a piece of rubber tubing is tightly applied and allowed to remain until the fold sloughs off, which usually occurs between the 8th and 11th days. As other than mucous membrane is often included in these folds, as the parts are slow to heal, as the disagreeable

' M^moire sur les Allongements hypertrophique du col de l'Uterus, etc. Paris, 1860. 2 Die Doppelnath zur Damm-schamscheidennath, u. s. w. Erlaugen, 1863.

1881.] House, Prolapse of the Vagina and Uterus.

41

fetid discharge is decidedly unpleasant to the patient, and as the operation does not secure a firm and durable cicatrix, its results have been unsatis- factory. This operation can be performed perhaps with favourable results where the prolapse of the anterior vaginal wall is but slight? or where there are folds of hypertrophied mucous membrane.

To Marshall Hall the credit is due of having first performed elytrorrhaphy. He excised an elliptical piece of mucous membrane from the anterior vaginal wall and united the edges of the wound with the quilled suture. A number of other operators removed elliptical or oval pieces from the lateral vaginal walls. More recently Simon connected this method with epesio-elytrorrhaphy. Marion Sims revived and revised this operation with a modification of his own in 1858. Through him we were made acquainted with a good vaginal suture. Where the prolapse is slight, and the patient can shun herself, a favourable result may be obtained. The so-called " median" operation of Spiegelberg1 is a very peculiar one. By it the middle of the lower portion of the anterior vaginal wall is suspended to the middle of the upper portion of the posterior one. But the operation of kolporraphy anterior of Hegar and Kaltenbach answers all expectations, and consists in removing an elliptical portion from the anterior vaginal wall (Fig. 1). The upper angle is made as blunt as possible for the purpose of increasing the breadth of the wound lying nearest the portio vaginalis to the fullest extent consistent with the parts. The simple lithotomy position is the best for the patient. As the operation is scarcely ever accompanied with severe pain, it is quite un- necessary to use anaesthetics. In 33 cases Rokitansky has had no occasion to use chloroform.

In operating, Hegar and Kal- tenbach direct that the vaginal membrane be seized with a double tenaculum about one- third to one-half inch from the anterior lip of the cervix, as near the median line as possible : another tenaculum attacks the membrane from one-third to three-quarters of an inch from the orificia urethras externa with- in the vagina, and two more tena- cula are applied opposite each other at the lateral margin of the vaginal surface about to be

Fig. 1. A

O

D

A. Os uteri. b. Flap on anterior vaginal wall excised, c. Sutures, d. Os urethrae externa.

1 Zur Entstehung und Beharidlring des Vorf'alls der Scheide und Gebarmutter. Berliner Klinische Wochenschrift, 1872.

42

House, Prolapse of the Vagina and Uterus.

[July

freshened. Slight traction being now made upon each tenaculum in opposite directions, a smooth field for operation is exposed correspond- ing to the size of the mucous membrane it is desired to excise. Its amount depends entirely upon the extent of the prolapse and the excess of tissue in the vaginal wall. In order to determine this amount, a fold of membrane may be picked up by tenaculae on each side of the me- dian line and approximated, thus making apparent the condition of the vagina after the operation. It is sometimes taught that the prolapsed parts should be placed in situ before freshening, but as this merely com- plicates and renders the operation tedious without corresponding benefit, it is entirely unnecessary. The boundary of the part to be freshened should be marked out with a sharp scalpel, whereupon the mucous mem- brane, at its lowest angle, should be seized with a pair of toothed forceps, and dissection commenced with a sharp scalpel, applied first to one, then to the other side. To be ambidextrous is of great advantage. The re- moval of the mucous membrane is generally accomplished with but little trouble, care being taken that all ragged and uneven edges be smoothly trimmed with forceps and scissors. Severe hemorrhage, and a soft friable and relaxed condition of the vaginal membrane with cicatricial eschars may complicate the operation. Hemorrhage is, however, usually easily controlled by the application of an ice-cold sponge, torsion of the bleeding vessels, and finally closure of the wound. Hegar and Kaltenbach unite by insertions deep into the tissues and use silk sutures. These are re- moved in from ten to fifteen days, and it is well not to be in too great haste. Before operating, the bladder should be entirely emptied by the catheter, the vagina and the whole external genital organs should be tho- roughly drenched with a three per cent, solution of carbolic acid, as well as occasionally during the operation, and again when the sutures have been fully adjusted and the parts placed in situ. The preliminary and subsequent treatment is similar to that of kolpoperineorraphy, of which mention will hereafter be made, with the exception of tying the knees together. The patient should not leave her bed before the fourteenth day, and should abstain from household duties for a still longer time.

Kolporraphy anterior is not a serious operation. It requires but a mode- rate amount of operative skill, is not followed by evil results, but can be most favourably commended for its effects upon cystocele ; it aids very materially in reducing prolapse of the uterus with complete prolapse of the vagina; it sometimes insures the good results of kolpoperineorraphy, and therefore should, in my opinion, precede all operations whose help- mate it is.

Elytrorrhaphy posterior, per se, excludes freshening of the introitus and vulva, is applicable to those cases where there are great relaxation and folding of the posterior vaginal wall, and can properly only be regarded as an adjunct of kolpoperineorraphy. Whether the mucous membrane to

1381.]

House, Prolapse of the Vagina and Uterus.

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be excised lies in the upper or lower part of the posterior vaginal wall, it has still mostly an elliptical form, and is united by suture. The field and method of operation are so similar and so closely allied to operations to be discussed hereafter that it is unnecessary to give details now.

Before considering the respective operations of Simon, Hegar and Kal- tenbach, and Bischoff, for the cure of prolapse of the vagina and uterus, attention is drawn to Huguier's treatment of these conditions. This French gynaecologist says in his work, page 49, that the disease described by authors under the name of Prolapsus is, in the large majority of cases, nothing more nor less than an elongated hypertrophy of the supra-vaginal portion of the cervix uteri, and he considers this elongation not as a conse- quence, but as an actual cause of the prolapse. Consequently, he proposes to cure prolapse by the amputation of the supra-vaginal portion of the cer- vix. Spiegelberg, in objecting to this idea of causation, maintains that the elongation is secondary in a majority of cases, being induced by the dragging of the vagina and bladder upon the uterus whose tissues, as well as those of its immediate appendages, are in a relaxed, ductile, and weak- ened condition. Position and constant downward traction he assumes to be causes, not effects. According to personal observations, I must believe this hypertrophied elongation of the supra- vaginal cervix to be secondary. Several times cases have come under my care exhibiting but slight pro- lapse of the vaginal walls and the normal position of the uterus, yet whose cavities at first measurement indicated a length of from two and one-half to three inches. In the course of time the prolapse of the vaginal walls progressed more and more until it became complete, while simultaneously the os uteri externum continued to descend lower and lower until finally it protruded far beyond the external genitals, while the fundus of the uterus retained its normal height, thus increasing the measurement of its cavity variously from five to seven inches.

Nevertheless, there may be cases of prolapse wherein an hypertrophied elongation of the portio supra-vaginalis is primary, but they cannot be distinguished from those in which the hypertrophy is secondary. Where hypertrophy is the primary cause, a cure may under favourable circum- stances be reached by Huguier's method; but, in the majority of cases of prolapse of vagina and uterus with hypertrophied elongation of the supra- vaginal cervix, a cure can never be induced by Huguier's operation.

In a large number of cases of prolapse we find an hypertrophied state of the infra-vaginal portion of the cervix, named by Spiegelberg, circu- lar hypertrophy. Observation has taught me that in prolapse of the uterus and vagina with hypertrophy of the supra-vaginal portion of the cervix, either with or without conjoined hypertrophy of the infra-vaginal portion, amputation after Huguier's method, or simply amputation of the infra-vaginal portion as practised by many of his followers, is entirely useless and without favourable result. Ample opportunity was afforded

44

House, Prolapse of the Vagina and Uterus.

[July

me by Rokitansky at the Maria Theresa Woman's Hospital at Vienna of watching the course and results of a simple replacement of the prolapsed parts without amputation, care being taken to retain the same in situ, and to enjoin absolute rest on the patient. By this means uterine cavities measuring five and seven inches were reduced to two and three-fourths, and three and one-half inches respectively, thus clearly proving the rapid diminution of the hypertrophied parts by mere replacement and rest. Rokitansky possesses a very instructive preparation by way of demonstration of this fact. Upon receiving a patient into the hospital on the 13th July, it was found that her uterine cavity measured seven inches. On the next day he performed kolporraphy anterior; on the 27th July, the patient died of cerebral apoplexy. At the post-mortem the uterine cavity measured but four inches, thus showing a reduction of three inches in thirteen days.

In my practice I pay no attention to simple hypertrophy of the cervix uteri, but perform the operation of kolporraphy anterior. The time the patient is obliged to remain abed is usually sufficient to reduce the elongated and hypertrophied uterus to quite its normal size. From its rapid decline in size under such circumstances it is fair to assume that its enlarged condition is partially due to oedema. It should be understood, however, that amputation of the prolapsed cervix is the only cure in cases of hypertrophied elongation of the infra-vaginal portion of the cervix with- out vaginal prolapse.

The operations to which special attention is hereby drawn, those of kolporraphy posterior of Simon, kolpoperineorrapby or perineauxesis of Hegar and Kaltenbach, and perineoplasty of Bischoff, seek to permanently narrow the vagina, change its axis forward and upward, and strengthen the recto-vaginal septum. Some description of the details of these ope- rations is necessary in order to clearly apprehend their differences and relative merits.

In Simon's operation of kolporraphy posterior, the patient is placed upon her back with her thighs flexed upon her abdomen. Simon's speculum, a modification of Sims', is then introduced for the purpose of raising the anterior wall of the vagina; two of Simon's flat specula are applied to the labia and the lateral walls of the vagina. Thus the field of operation is fairly presented to view. Along the boundary of the true skin and the mucous membrane of the vulva an incision is made varying from two to two and one-half inches in length (Fig. 2). Upon the line of this incision as a base, a pentagonal figure is constructed, whose sides vary from two to two and one-half inches, and whose apex lies in the medium line of the posterior wall of the vagina. This can be more perfectly represented by a diagram.

The mucous membrane covered by this figure is then excised, and the wounded surface coaptated by using alternately the deep and superficial silk sutures. In order to properly conduct this operation the operator should

1881.] House, Prolapse of the Vagina and Uterus. 45

have five assistants, three of whom should be acquainted with the operation. The armamentarium consists of, 1, Sims' or Simon's specula of different sizes; 2, two of Simon's lateral specula; 3, a number of scalpels ; 4, a curved scissors ; 5, two pairs of toothed forceps; 6, Jo- bert's or Bozeman's needle-holder and catcher; 7, a number of single and double-hooked tenacula; 8, Chinese raw silk for sutures; 9, an Esmarch's irri- gator; 10, sponges; and 11, a number of long and short needles. Under favourable circumstances the duration of the operation varies from one to three hours. In the after-treatment a soluble condition of the bowels should be maintained, and the catheter be resorted to when the patient fails to pass water spontaneously. The perineal sutures should be removed on the fourth, and the vaginal sutures about the ninth to the eleventh day.

When performing kolpoperineorraphy or perineauxesis, Hegar and Kal- tenbach place their patient in a lithotomy position. They excise a triangular piece of membrane from the posterior vaginal wall (Fig. 3). Its apex forms

Fig. 3. A A

A A. Vaginal sutures, b b. Perineal sutures.

an acute angle at a point from one-half to one inch from the portio vaginalis. The portion excised extends to and runs in a curve along the posterior

/

46 House, Prolapse of the Vagina and Uterus. [July

commissure. The instruments required are practically the same as those used by Simon, and the time of operation about the same. The wound is united by the silver wire suture, and the vagina is thoroughly douched through the irrigator with a solution of chlorine water. The patient is permitted to assume any recumbent position. Fetid discharges are com- bated with vaginal injections, and the smarting or burning of the wound is allayed wTith liq. plumbi subacet. in solution or cold compresses. The bowels should be kept open and the perineal sutures should be removed in three to five days. After that time a generous, nourishing diet should be allowed if there be no fever. The vaginal sutures are not removed until the fourteenth to the twenty-first day, and not even then if tension and swelling exist.

Preparatory treatment of the patient is necessary before attempting the operation of kolpoperineoplasty of Bischoff. The uterus should be replaced ; leucorrhoea, erosions of the cervix, and all inflammatory symp- toms should receive careful attention. The bowels should be properly evacuated by enemata, and the operation performed a few days after the cessation of the menses. The patient likewise, in this operation, takes position as in ordinary lithotomy. Four assistants are sufficient. A pair of scissors curved on the flat, a vulsella, several flat specula, with the instruments, etc., mentioned in connection w ith Simon's operation, com- plete the outfit. The anterior vaginal wall is elevated by a flat speculum, while two assistants separate the labia on each side respectively by pres- sure with three fingers, thus fully exposing the posterior wall of the vagina. A tongue-shaped flap is then marked out with a scalpel (Fig. 4). Its apex lies at the margin of the posterior commissure, and its base is from one and one-half to two and one-half inches above on the posterior vaginal wall ; it lies over the median line, and has a width of from three-fourths to one and one-half inches. This tongue-shaped piece of mucous membrane is dissected from the vaginal walls, but remains attached at its base. On

each side of the tongue-shaped flap a triangular piece of mucous mem- brane is excised. The apex of each of these triangles is at the side of the base of the tongue-shaped piece. From this point a line is drawn to the middle of the labia majora on each side, and the mucous membrane between this line and the tongue- shaped piece is completely excised The mucous membrane lying exter- nal to the introitus between the perineum and the points on the

Fig-

A tongue-shaped flap, a a. Base of same. v, B. Triangular pieces, c c c. U-formed perineal pieces, d d. Vaginal sutures, e f. Perineal sutures.

1881.]

House, Prolapse of the Vagina and Uterus.

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labia majora to which the mucous membrane of the vagina has been denuded is U-shaped, though with horns widely diverging, and this also is denuded to the edge of the true skin. Hemorrhage is usually easily controlled by torsion and ice. Care should be taken to remove all islets of mucous membrane and to leave a smooth denuded surface. The success of union by first intention depends largely upon this. The flap is secured to its new attachment by interrupted sutures, beginning at the base of the flap and so applied as to bring the apex of the flap in contact with the lateral margin of the denuded part bordering the flap. Slight traction with forceps or vulsella upon the edges of the wound will facilitate its coaptation. After the flap has been adjusted the perineal wound is closed. It is apparent that as the flap is made larger or smaller, and the denudation of the vaginal outlet is increased or decreased, we can break the axis of the vagina at a point more or less distant from the introitus, and simul- taneously reconstruct the vagina and perineum. The operator should recollect that the erficiency of the operation depends not merely upon narrowing the vagina, but upon changing the direction of its axis. Hence the necessity of a long and thick perineum.

The after-treatment is simple. A tampon dipped in carbolized oil or wTater is inserted into the vagina, and the perineal wound covered with a cloth saturated with the same solution. A cotton tampon is laid over this and fastened with a T bandage, for the purpose of exerting slight pressure and preventing the filling of the wound with blood. After twenty-four hours this bandage as well as the tampon should be removed, and the patient kept in the dorsal decubitus with knees slightly bent. It matters little if the. bowels are moved daily, although perhaps it is better that they should be constipated for the first four or five days. Subsequently mild salines, to induce daily stools, are useful. The diet should be mild and unstimulating. Due attention should be given to this, as to all fresh wounds, and proper rest be given to the wounded parts. If the operator carefully observes antiseptic treatment, union by first intention will be the rule. The perineal sutures are removed after about fourteen days, and the vaginal sutures some days after this. The patient should keep her bed for at least fourteen days alter the operation.

In applying in a general way the principles laid down by these authors to cases falling under my direction, my armamentarium consists of: 1, a double tenaculum ; 2, a number of scalpels ; 3, a pair of scissors curved on the flat; 4, one or two pairs of toothed forceps; 5. a pair of forceps smooth at the point, used in holding knots while tying sutures ; 6, a num- ber of artery forceps; 7, Langenbeck's needle-holder; 8, Bozeman's nee- dle-holder and catcher; 9, Sims', Emmet's, and surgeons' needles; 10, surgeons' silk, ZSo. 2 for vaginal, and Xo. 3 for perineal sutures; 11, car- bolized catgut for ligating bleeding vessels; 12, sponges ; 13, a G oz. hard- rubber syringe; 14, a flat speculum for elevating the anterior wall of the

48 House, Prolapse of the Vagina and Uterus.. [July

vagina; 15, two wooden specula for the labia and lateral walls of the vagina; and 16, one or two tenacula, and ice-water for sponges. Two good assistants, or at least two intelligent women, are indispensable as aids, while three or four add very materially to the ease of the operator. The instruments are arranged in order upon a stand, within easy reach while operating.

When time and convenience permit, my patient is directed to use warm sitz-baths for some days previous to the operation, to keep her bed, and to live upon light, easily digestible food. If the vaginal walls are firm, a 2 per cent, solution of carbolic acid in glycerine, soaked into a cot- ton tampon and changed every twelve hours for a few days, is inserted into the vagina. The day before operating, a mild saline laxative is given, and a few hours before an enema, in order to clear the rectum of any re- maining fecal matter. The patient is placed in the lithotomy position, with the nates well over the edge of the operating table, so that the vulva is easily accessible. As denudation of the introitus and perineum is pain- ful, full anaesthesia is necessary by any method. Before operating, the perineum and vulva should be shaved at least to the height of the middle of the labia majora, the bladder catheterized and emptied completely of its urine, and the external genitals should be well cleansed with a 3 per cent, solution of carbolized water. The patient should lie upon her back, care being taken that the pelvis inclines neither to the one nor the other side, lest an asymmetrical wound result. To secure perfect coaptation the labia majora should be brought together, and at the point where denudation shall commence a slight incision be made. This will mark clearly the prolongation of the vaginal freshening, and will insure a perfect perineum. The vaginal wall is better presented by having an assistant pass one or even two fingers into the rectum, and, by pressure on the anterior rectal, causing the posterior vaginal wall to bulge forward. Placing it thus gently upon the stretch, the field becomes smooth, and excision of the mucous membrane much less tedious. In one of my cases it became necessary to remove a flap measuring four and a half inches in length, with a base of three and one-half inches. To change sufficiently the axis of the vagina, and to render the necessary support to insure against subsequent malposi- tion of the uterus, a broad and thick perineum became essential, so that the labia majora was denuded and united by suture to one-half its height. The restored perineum measured two and a quarter inches.

Of the three operations herein specially discussed, that of Hegar and Kaltenbach is probably easiest; then follows Simon's; while BischofPs is the most difficult, and requires the most patience, skill, and attention to details, indeed some ingenuity in dissecting off the tongue-shaped flap, which should not only consist of mucous membrane, but also of submucous tissue. While dissecting, it is well to douche the parts frequently with a 3 per cent, solution of carbolized water, as again before introducing this

1881.] House, Prolapse of the Vagina and Uterus.

49

suture, when the whole wound should be thoroughly cleansed. I have always used silk for the vaginal sutures. After closing the wound, super- ficial sutures are introduced when the margins of the wound do not meet perfectly, and the parts are again douched with carbolized water. Both silk and silver wire have been used for the perineum with equally good results in my experience. After the kolpoperineoplasty of Bischoff, a tampon, saturated with a 2 per cent, solution of carbolized water is intro- duced into the vagina. As I have tied the knees together for five or six days, and the patient has been required to keep the dorsal decubitus as well, it has seemed unnecessary to apply the T bandage to hold the tampon to the perineal wound. The catheter is rarely necessary, and should only be used when the patient cannot micturate spontaneously. If there has been no stool for the first four clays, it is induced by enema. Vaginal in- jections of a 2 per cent, solution of carbolized water are daily used. The diet for the first five or six days consists of light soups, gradually yielding to the usual nourishment of a healthy subject. The perineal sutures are removed on the fourth or fifth day, but the vaginal not before the four- teenth to the twenty-first day. The patient should not leave her bed for at least twenty-one days, and should abstain from hard labour for several weeks more. There is usually little or no febrile reaction, and the smarting and burning of the wound can be allayed by cold applications. The ope- ration should be performed after menstruation, and not sooner than eight or ten weeks after confinement.

Which of these methods, it maybe asked, causes the greatest lesion? Which the least? Which affords the best chance of union by first inten- tion? Which from every point of view is attended with the most favour- able results ? It may be briefly answered that the guarantee of a good result is determined by a strong recto-vaginal septum, based upon a perineum which has been lengthened and thickened, and thus changes the

axis of the vagina in its lower half for- c ° Fig. 5.

ward. Narrowing the vagina, per se, has no lasting result, though it diminishes its calibre to the smallest size consistent with the parts operated upon. In Bischoff's operation the greatest change is effected in the vaginal axis, and the vagina is de- cidedly narrowed, as shown in the accom- panying diagram (Fig. 5) ; therefore we may reasonably expect from it the most happy results. It is, however, a somewhat complicated operation, and should only be attempted by one who is specially skilled in plastic operations, and particularly those of the female genital organs.

Hegar and Kaltenback.

No. CLXIII July 1881. 4

50

Reichert, Dangerous Anaesthetics.

[July

Where large cicatricial contractions of the perineum and vagina exist, it may be impossible to form a tongue-shaped flap, while in extreme relaxa- tion of the posterior wall it becomes necessary to substitute this operation by one of the two others. Simon, whose operation is much simpler, has cured the majority of his cases. Hegar and Kaltenbach have met with excellent results; and this operation narrows the vagina, changes its axis, and creates a strong and thick recto- vaginal septum.

Article IV.

Are all Ax/esthetics Dangerous which contain Chlorine, Bromine, or Iodine ?] By Edward T. Reichert, H.D., of Newark, N. J., formerly Demonstrator of Experimental Therapeutics and Instructor in Experimental Physiology in the Post-Graduate Course of Medicine in the University of Penn- sylvania.

As early as 1849, Nunnelly (Trans. Prov. Med. and Surg. Association, xvi. 1849) stated that the effects produced by chloroform by a like quan- tity and in parallel circumstances, as far as could be ascertained, were similar but not identical, and that they were far more considerable in some cases than in others, and even upon the same animal the effects of the same dose were greater at one time than at another. Proof of this truth is not wanting, but is unfortunately only too plentiful, as is instanced in the frequent deaths which have been reported as occurring from the use of this agent, and by doses wholly out of proportion to the effects produced. To the experimental physiologist and therapeutist, similar cases occurring in animals during anesthetization with chloroform must be numerous, if this agent has to any extent been employed ; and, in speaking from per- sonal experience in the chloroformization of some hundreds of animals, many such instances are recalled to mind, — some indeed, which are even the more striking because of sudden death occurring after the re- moval of the inhaler, and before complete anaesthesia was induced (see also Report Brit. Med. Assoc. Committee, Brit. Med. Journ., 1879) ; and even deaths taking place in patients under similar circumstances are not want-

1 It was the author's intention to give, in connection "with the folio-wing notes, the results of a physiological research which has been commenced in this connection, hut upon a second consideration it appeared doubtful as to how soon this investigation would be completed. As anything of practical value relating to aniesthetics must al- ways be of momentary importance to the profession, and as there is much to be learned from the literature of the subject alone, and as there are many facts herein contained which are of considerable interest and not generally known, and may prove of imme- diate value to both the therapeutist and experimenter, it was deemed best not to with- hold this portion of the paper, but rather to let the record of the experiments follow as a separate article.

1881.]

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ing, as is attested by Kappeler (Part XX., German Surgery, by Billroth and Luecke, quoted by Reeve), and by records of chloroform deaths already reported. In Kappeler's case death occurred in two minutes after the administration of chloroform had been stopped. In the report of the British Association's Committee on their experiments on animals it is stated that in two instances sudden and unlooked-for effects on the heart occurred after more than a minute had elapsed since the administration of any chloroform. My own experiments on animals with the ethyl bromide have yielded similar results, and so strikingly analogous that I can safely assert, that, were the results of my experience with the deaths following the use of chloroform and the ethyl bromide in anesthetization tabulated in parallel columns, not even the keenest observer would be able to tell which was which. In the laboratory the bottles containing these compounds were on the table together, and were employed without any special choice, the nearest or handiest being used ; and I must acknowledge that, where death ensued, as it did in quite a number of instances, the only way I knew which one of the two was the cause of it was by resorting to the odours of the two, and thus distinguishing them — their toxicological effects being so similar as to be beyond the power of discrimination. The same remarks apply equally well and with equal positiveness to several other chlorinated and brominated anaesthetics, and the list could be consider- ably amplified were it necessary, or did space permit.

That the halogens are decided and general depressants of the animal or- ganism is a fact undisputed by the therapeutist ; that they exert a special depressant influence on the heart is universally conceded ; and that most of the compounds in which either of these elements enters, especially in an elementary form and in any well-marked or appreciable proportions, par- take to a greater or less extent of this depressant quality, and more espe- cially so, if the elements are in a loosely molecular condition, such as is probably the condition in all ethers, is also acknowledged. Consequently, in looking over the list of compounds used as anaesthetics (some thirty or forty in number), it was a noticeable fact that the compounds contain- ing either of these elements were, as a rule, unmistakably more dangerous than others ; and the obvious reason of this was the presence of one or the other of these principles, which, being in a probably loosely molecu- lar combination, acted either in combination as such, or were readily dis- sociated under favourable conditions, and at such times made their de- cidedly paretic action on the heart manifest. The writer would not here be understood as inferring that either in these toxic elements, or in their probable liberation in the system alone, resides the power of causing sud- den, abnormal, and overwhelming effects, or of being invariably the cause of sudden death ; for it must be apparent that peculiar idiosyncrasies, gene- ral asthenic conditions and especially so of the heart, the greater impres- sionability of the heart or of its nervous mechanism at times than at others

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(even in apparently normal states of the economy), variations in the tem- perature of the surrounding media causing a greater volatility of the com- pound used, and the necessarily greater concentration of the vapour inhaled, etc. etc., must play at times a very important part in such cases. How- ever, that all chlorinated, brominated, and iodated anaesthetics may act at times altogether out of proportion to the dose and under similar circum- stances, and that those which have already been used to any extent have done so, is well attested in the papers already written, or by experiments recently made by myself on animals, as well as by the numerous deaths wThich have been reported from the needless use of this group of substances.

To look over the death-list from ancesthetization by this particular class of compounds, and in cases in which they were not especially indicated, and where some of the safer anaesthetics, such as ether, would have answered the purposes required, and where they have been unjustifiably used before their physiological actions were previously determined by experimentation on animals, and their safety assured or their dangers indicated, is posi- tively appalling ; while the number of cases, almost innumerable, where life's fragile thread was almost broken, the trusting patient but snatched from the chasm of death by the timely administration of physiological antidotes or the almost superhuman efforts of the physician and attend- ants, is alike shocking. Let us but glance, at the chloroform death-list, and, as horrible and incredible as it may seem, there have been reported an average of about a death for every month since the time of its introduc- tion. With this array of fully authenticated cases before us, what, indeed, must be the actual number ? — for it must be conceded that probably double, triple, or quadruple as many more were not reported, and will never come to light. Even Kappeler alone says that he knows of four cases never reported, and personalty I know of two. However, it needs no words of mine to remind the profession of the dangers of chloroform ; so let us but briefly notice several others of this class of anaesthetics.

Methylene Bichloride, which was introduced by Richardson {Med. Times and Gaz., 1867, p. 478) as a pleasant anaesthetic, but in connec- tion with which he expressed no definite opinion as to its safety, has now been entirely cast aside by the profession as being entirely too unsafe. Kappeler says that experience shows it to be as dangerous, if not more so, as chloroform, and furnishes a list of nine cases of death from its use. Unfortunately, I have not had a copy of Kappeler's work at my disposal ; but in looking over the details of cases published in the journals to which I have had access (Med. Times and Gaz., 1869, ii. p. 524; Lancet, 1869, p. 582 ; British Medical Journal, Sept. 1871 ; Pharmaceutical Journal, 1871, p. 875, two cases ; British Medical Journal, August, 1872 ; Lancet, 1873, i. p. 23 ; Ibid., 1877, ii. p. 26), I have found that in several of them doses of a drachm and a half caused death, and, judging from the symptoms, it must be undoubted that death ensued in some of them at least

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from cardiac paralysis. The experiments made by the British Committee on frogs show that the heart becomes slowed and is soon stopped, and that the heart ivas affected the same as by chloroform, the first sign of paralysis being the distension of the right ventricle. Even were it not certified by the above Committee that it affects the heart like chloroform, the fact of death occurring after doses but ordinarily sufficient to produce anaesthesia is suf- ficient to impress everyone with the truth that it acts, like chloroform and ethyl bromide, wholly out of proportion to the dose.

Let me revert to ethyl bromide or hydrobromic ether, which has but recently come into vogue through the recommendation of Turnbull and of Levis, and which has, during the few months of its usage, and indeed very limited usage, added proof to the above-asserted toxic properties of all the brominated anaesthetics. In referring to the articles published by these gentlemen, one is at once impressed with the strong recommendations given the ether, and the enthusiasm experienced in the discovery of so valuable a compound ; and Levis (reprint from Medical Record) stated, that practically it was the best anaesthetic now in use. But, if what he previously asserted, that " the physiological action of the bromide of ethyl did not incline to the dangers of cerebral anaemia and cardiac syncope, which sometimes occur in chloroform, and that no tendencies in such a direction seemed to threaten," were proven true by subsequent investiga- tion, the ether would not so early have fallen into disuse. And had ex- perimental investigations been pursued in the lower animals previous to those on man, like those by Wood (Phila. Med. Times, 1880, p. 370), such unfortunate results would probably not have followed in Levis's, as well as in the hands of others who have followed in his footsteps. While advising his practitioners to be cautious in its use, Levis describes the method of administration preferred by himself, which, in our opinion, is of itself dangerous. His method is this, that " in commencing the inhalation of bromide of ethyl to make a rapid and decided impression, with the lint and napkin held closely over the nose and mouth of the patient." If we have here an agent proven to be dangerous, if not quite as dangerous as chloroform, it needs no further argument to show that the same pre- cautions must necessarily be observed in its administration as with its more popular predecessor.

Squibb (Medical Record, 1880, p. 379) warns those who use bromide of ethyl to be cautious, because he deems it of the nature of a loosely molecu- lar compound, and hence he argues its liability to become broken up in the system and bromine liberated. Although the experiments of Wolff (Ameri- can Journal of Pharmacy, 1880) would seem to show that this change does not occur out of the body, yet as we do not know in what form the ether is eliminated, and that fatal effects have followed its use, which resem- bled those in bromine-poisoning, we are bound to accept Squibb's assertion with deference, at least until it is proven to be otherwise than correct.

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But whether bromine is liberated or not does not affect the argument, for we do know that Wolff (loc. cit.) found that death occurred in one of his experi- ments on rabbits, and that it typically resembled that caused by chloro- form by sudden cardiac failure ; and Wood {loc. cit.) has proved that it is a direct cardiac depressant, which I have fully corroborated by my own experiments, and have further indisputably proven that it at times acts altogether out of proportion to the dose used, as already stated; and that at least two deaths have followed its use (Sims, Medical Record, 1880, p. 361 ; Levis, Medical Neivs and Abstract, June, 1880), More- over, several cases have occurred in Philadelphia hospitals in which such alarming symptoms occurred that only by the most strenuous efforts could the patients be rescued from impending death ; and a case of this nature is reported by Little {Medical Record, April 3, 1880); and other instances, where the administration was stopped, or the ether was refused to be given by resident physicians through absolute fear of disaster, could also be given.

It will, however, undoubtedly be said, and indeed has been said, that neither of the cases reported by Sims or Levis was due to the use of anaesthetics per se: in the former instance because of the very depressed condition of the patient; and in the latter because death did not occur until many hours following the administration of the anaesthetic. But in connection with these cases we know, first, that Emmet {Gynaecology, 2d edition, p. 746) called the attention of the profession to the danger of admin- istering anaesthetics where any disease of the kidneys exists because of the active part taken by these organs in the elimination of them ; second, that Squibb asserts that bromide of ethyl is a loosely molecular article, prone to undergo decomposition in the system and to liberate free bro- mine ; 3d, that ethyl bromide is a marked cardiac depressant, as proven by both Wood and myself, by actual examination. Sims's case certainly did have symptoms in harmony with those caused by some toxic agent such as bromine. The woman also had a marked scantiness in the secre- tion of the urine, and on post-mortem examination it was found that she had acute catarrhal nephritis, indicating that the kidneys were disabled from performing their function in eliminating the ether, hence its retention and its probable decomposition in the economy, with the subsequent toxic symptoms. In Levis's case it seems plain that a simple expla- nation of the death of the patient lies in the fact that the heart, which had become so enfeebled from exhausting chronic disease, was unable to bear the strain of the powerful depression of its already diminished powers that ensued upon the administration of the anaesthetic, and as a consequence broke down under the excessive load.1 And lastly, as evidence going

1 An analogous instance of a medicine apparently acting- out of proportion to the dose is illustrated in the incipient stage of typhoid fever, where, on account of an irritative condition of the bowels, an ordinary cathartic dose will produce hyperca- tharsis.

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towards proving that Sims's case was due to bromine-poisoning, and in cor- roboration of Squibb's assertion, I quote from experiments made by Nunnelly (loc. cit., 327) with a similar compound, the Ethylene Bibromide, as well as with the Ethyl Iodide (loc. cit., p. 324), in which similar results fol- lowed, in so far that the animals appeared perfectly well after the experi- ments, but all of them, after some hours, perished from blood-poisoning (see, also, Ethyl Iodide, Methyl Iodide, Iodoform).

Methyl Iodide, which was introduced some years ago, has never come into general use because of its being considered unsafe by both Richardson and Simpson. The former observer (Med. Times and Gazette, ii. 1870, p. 470) found it to cause great excitement of the heart and circulation, which was evidently a sign of cardiac depression, if what he thought was true, that the iodine was the efficient cause of the phenomena which lie outside of the narcotism. He further certifies that the Amyl Iodide and Chloride act similarly to the Methyl compound.

Chloral Hydrate, although not an anaesthetic in a therapeutic sense, has, like chloroform and ethyl bromide, given us painful instances of its acting at times altogether out of proportion to the dose. Fuller (Lan- cet, March, 1871) quotes a case where thirty grains caused death in a young lady. Schwaighofer (Irish Hospital Gaz., 1873) reports another of a drunkard, in which a drachm produced death ; and three other cases (Reynolds, Practitioner, March, 1870; Watam, Med. and Surgical Re- porter, Jan. 1871 ; Fuller, loc. cit.), in which forty-five, eighty, and thirty grains respectively caused alarming symptoms, and from the large dose death nearly ensued. Death has resulted from a dose of ten grains (Amer- ican Dispensatory, 1880, p. 396). Other deaths have been reported (Med- ical Times and Gaz., 1871, pp. 131, 672 ; Norris, Lancet, 1871, i. p. 226, and Browne, ibid. p. 574), and in some of these cases indisputable evidences of its power of weakening the heart were present. Did chloral hydrate become decomposed in the system into formic acid and chloroform (Per- sonne, Journ. de Pharm. et Chimie, 1870; and Pellogio, Schmidt's Jahr- biicher, bd. cli. p. 89 ; Liebreich Wiener Med. Wochensch., Aug. 1860), we could readily account for its acting at times in a manner wholly dispro- portionate to the dose, and for its being a cardiac depressant ; but as recent investigations disprove this theory (Hammertin, Schmidt's Jahrbiicher, bd. cli.; Rajursky, Ibid., bd. cli.; Amory, N. Y. Med. Journ., 1870; Djurburg, Schmidt's Jahr., bd. cli. ; Leurison, Archiv Anat. u. Phys., 1870), we must look elsewhere for this toxic principle.

Hydriodic Ether or Ethyl Iodide, also used by Nunnelly (loc. cit., p. 324), was found to be so dangerous as to entirely preclude its use in medi- cine for anaesthetic purposes ; and he states that whatever anaesthetic prop- erty it might possess (and this is not insignificant) it never could be employed in practice, as its, action is so very deleterious ; for out of the four animals experimented upon, three of which were rendered insensible,

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all died, and the fourth had not sufficient of the vapour to render it in the least insensible, and yet for two or three days it was doubtful whether it would recover. Like the bromide of olefiant gas (ethylene bromide), its immediate effects were not so dangerous as the consequences of inhalation wrere in a few hours ; even when not enough to produce insensibility had been used, and when the animal to all appearances had been perfectly well, death would supervene. In one case the odour of the ether was dis- tinctly perceptible in the brain twelve hours after death, and Nunnelly thinks that death was caused by blood-poisoning. Therapeutically it has been used in recent years " by inhalation to bring the system speedily under the influence of iodine." (JSFational Dispensatory, 1880, p. 114.)

Bromide of Olefiant Gas or Ethylene Bromide was also condemned by Nunnelly (loc. cit., p. 327), who stated that, although it produced insen- sibility, it caused the respiration to become laborious, and although the appearances of distress speedily disappeared when the animals were re- leased, yet in a few hours they all, without exception, died. He further remarks that in this respect it differs from other (?) anaesthetics, because of the animals appearing well immediately following the experiments, but soon dying. He attributes this effect to blood-poisoning.

Iodoform was not sufficiently volatile to cause anaesthesia (Nunnelly), but, from what we know of its use, when given per stomach or used locally, it possesses powerful anaesthetic (analgesic) properties. Unfortunately it has not been used sufficiently internally, nor have physiological experi- ments been pursued to such an extent as to give us an accurate knowledge of its action on the economy ; yet we do know that it diminishes the pulse- rate, produces muscular and nervous debility, and is decomposed in the body, and that, when applied to mucous, serous, or abraded surfaces, it becomes decomposed by the fat, and the iodine is eliminated from the body in the form of soluble iodides. If iodine is liberated in the system, no further comment is needed.

Carbon Bichloride or Chloric Ether has been used to a sufficient extent to indicate that it produces distinct cardiac depression.

Bromoform, which possesses undoubted anaesthetic properties, was found in experiments of my own to powerfully depress the heart, and in one ex- periment on a small dog the intravenous injection of thirty minims of the preparation caused immediate cardiac arrest. Consequently, it was con- sidered useless to pursue any further investigation in this line.

Tetrachloride of Carbon (CC14) was used by Laffont (American Dis- pensatory, 1880, p. 354), who found that it caused great debility of the heart, and lowering of the vascular tension. Simpson (Medical Gazette, 1865, ii. p. 651) previously used it under the name of Bichloride of Car- bon, or Chlorocarbon, and more recently the same compound has been used by Smith (Lancet, 1867, i. pp. 575, 660). The latter observer found, in the post-mortem examinations of the animals experimented on, that

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the auricles were much distended with blood, and especially on the right side. He noticed that the heart did not beat after the cessation of respi- ration, and that the pulse was decidedly lowered. In conclusion, it is stated that " when pushed to extremes it seems to destroy life by causing an arrest of the circulation of the blood through the lungs, a distended condition of the right side of the heart, an insufficient supply of blood to the left side of the heart, and consequently diminished systemic circu- lation."

Chloride of Ethydene, or Ethylidene or Etliidene, was first used by Snow (Ancesthetics), and more recently by Liebreich (Med. Times and Gazette, 1870, i. p. 642) ; the British Medical Association Committee (Action of Anaesthetics, British Medical Journal, 1879) ; Bird (Medical Times and Gazette, 1879, i. pp. 62); and Reeve (New Remedies, Nov. 1880, p. 331 — quoted from Chicago Med. and Surg. Examiner, June, 1880). Liebreich considers it somewhat safer than chloroform ; the British Com- mittee found an enormous diminution in the arterial pressure, and that the heart-beats became so infrequent as to be virtually ineffectual in sup- plying the respiratory centres with blood. Bird esteems it a powerful cardiac stimulant, and states that all the patients under its influence pre- sented the appearance of a strong cardiac stimulant, but that he would not like to keep a patient long under its influence for fear of a reaction in the opposite direction. His investigations were not carried far enough to justify this conclusion of its cardiac action, and, as his conjecture is con- trary to the results of all other investigators, it must be rejected as unten- able. Reeve found a diminution of blood pressure, which differed from that caused by chloroform, because it did not advance to complete extinc- tion, nor exhibit such wide variations in its effects at different times in the same animal. A death from its use in Berlin has been reported by Kappeler (loc. cit.). Steffer (Binz's Evidences of Therapeutics, p. 69) says that it resembles chloroform in ultimate action, yet is not so dan- gerous.

Ethylene or Ethene Bichloride, or Butch Liquid, was used by Nun- nelly (loc. cit.), who speaks of it in a decidedly laudable way, stating that just as small a quantity will produce anaesthesia as chloroform, but that a much larger quantity is required to destroy life. Simpson (Edinburgh Medical Journal, 1848, vol. viii. p. 740) also made some investigations with it, and found that when its vapour was inhaled, it caused so much irritation in the throat that but few persons could endure inhaling it until anaesthesia was produced, and that the condition of anaesthesia was not attended with any excitement of the pulse. On himself it produced such a degree of irritation in the throat that it did not disappear for many hours. Recently, the British Committee (loc. cit.) used it, and report that no anaesthesia was produced up to the commencement of convulsions. The results of a series of experiments (Phila. Med. limes, May 7, 1881)

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made by the writer with this compound indicate that it is a powerful anesthetic, and that it fulfils considerable that Nunnelly claimed for it. It is undoubtedly a direct cardiac depressant. Why the British Com- mittee got such anomalous results is rather curious.

Butyl Chloride (British Committee) caused the cardiac pulsation to become weaker, and finally extinguished ; while Methyl Chloride only effected drowsiness. Isobutyl Chloride was not noticed as regarding any cardiac action.

Notwithstanding the fact that the above array affords indubitable proof to warrant the assertion that probably all chlorinated, brominated, or iodated anaesthetics do act as cardiac depressants, and goes to sustain Squibb's belief of their molecular condition, and as it likewise shows that unexceptionally, where used to any extent whatever, they have pro- duced death by doses wholly disproportionate to ordinarily cause such a result, yet it is but a little venture to further assert that were any of these compounds, of which either of the above facts has not been proven to be true, to be investigated thoroughly by experimentation in the lower animals, doubt would no longer exist of the correctness of this belief.

A most interesting, question here arises as to the modus operandi by which anaesthetics produce death, and one, indeed, which has constantly been in the minds of those particularly interested in these compounds, and consequently, as Reeve writes regarding chloroform, " we have had expla- nations without number, hypotheses the most untenable, and theories the most fantastical ; ingenuity has been taxed to the utmost in the formation of some of them, and logic torn to tatters." Thus we have had theories depending upon mechanical, chemical, and physiological effects ; stoppages of the air-passages with mucus, or by the falling back of the tongue ; im- purity of the compound used; idiosyncrasies of the patient; abnormal con- dition of the system; degree of concentration of the vapour; emotion or peculiar mental condition of the patient, such as fear of the possible con- sequences of the inhalation ; improper methods of administration ; the greater impressionability of the heart at times than at others, etc. And, as to the cause of death, about as many theories and as diverse have been advanced. But, without entering into all this distressing detail, it is only necessary to state that it is conceded that whatever may be the conditions favouring death, it does occur practically from either asphyxia or syncope, and that the latter condition may be the result of either a direct action on the heart, or by the inhibition of the heart through a stimulation of the inhibitory apparatus. But doubt can no longer exist that death in man in a vast majority of cases is the result of a paralysis of the heart itself by a direct local action, and not of a reflex nature by acting on the inhi- bitory nerves. The former has been proven ; the latter not. It is also equally certain, except in cases where the vapour has been administered for a prolonged period in very dilute form, that death very seldom is the

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result of asphyxia, so that, practically, sudden deaths are due to cardiac paralysis.

Just why it is that the heart appears to be more impressionable at some times than at others, and why a person may be safely anaesthetized several times with chloroform, and on a subsequent occasion and under similar cir- cumstances perish during its administration, is a question which has called forth many answers, some of which are as fanciful as the processes advanced to account for the deaths themselves. The whole answer practically can be simply and satisfactorily contained in the single word — dosage. It is one thing, as we all know, to give a man a grain of morphia in divided doses and spread out over several hours, and another to give him the whole at a single dose ; and just as true is it, that it is one thing to give a drachm or two of chloroform in a few inhalations, or to give it slowly during a period of some minutes. And while it is one thing to give a medicine hypodermi- cally or by the stomach, it is yet another (in effect) if given intravenously ; and especially so, in regard to medicines affecting the heart or nervous centres; and any one who has watched the blood-pressure of animals under the influence of chloroform must have been struck with the remarkable variations and the diminution of heart-beats which occur after each fresh administration, and of the sudden deaths often occurring immediately after, while, if the drug has been given by the stomach or hypodermically, these remarkable phenomena are comparatively absent. The drug when given by inhalation is absorbed so rapidly that practically it acts as an intrave- nous injection, and reaches the heart in a state of concentration almost as great ; where, on the other hand, it must be slowly absorbed from the stomach or subcutaneous tissue, the drug reaches the heart in such a dilute condition as to be unable to make such a decided impression, and as a consequence when death ensues it is from asphyxia, the same as when the vapour of chloroform is given very dilute and for a prolonged period. Reeve {Am. Jour, of Med. Sci., p. 199, July, 1880) says, that " we find no such idiosyncrasies in regard to other medicines," and that . " opium, strychnia, and arsenic never cause death when administered in ordinary doses." Although this is not by any means a parallel case, because neither of these medicines is ever administered either by inhalation or by intra- venous injection, nor are they decided cardiac depressants, yet deaths have occurred from the use of morphia in ordinary doses, when given hypoder- mically; for a death ensued in one case from an injection of one-sixth of a grain. Just now I recall a better instance, and in connection with apomor- phia ; a drug which promised to be the most valuable emetic of the Pharma- copoeia, but which has been almost entirely abandoned for therapeutic purposes. This drug was asserted by some of the early investigators not to affect the heart or arterial pressure, but more recently the reverse has been found true (and conclusively proven by my own experimentation). In clinical medicine such alarming symptoms of a syncopal condition

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and threatening collapse were induced by " very small doses'" (ordinary doses), that it is never used in this country as an emetic except in cases of ex- treme emergency.

Doubtless, if time permitted such a laborious research in the lite- rature before me, similar instances could be found where other cardiac depressants acted in this way,1 and scarcely anything could be more safely predicted than that, if it were the custom and practicable to give this class of remedies by inhalation or by intravenous injection, deaths from them would be proportionately as great as from the popular anaesthetics under consideration ; and there likewise can be no doubt that the reason they are looked upon as being safe is simply because they are never given by the above method, or in such doses as to produce such a profound impression on the system as is necessary to produce in anesthetization ; and hence they are absorbed relatively so slowly as to reach the heart in an exceedingly dilute condition, as already stated. An example illustrating the difference in the effects of intravenous and subcutaneous administra- tion of the same amounts, I quote from my experiments with apomorphia {Phil. Med. Times, Dec, 1879) on animals in which the heart was sepa-

1 Since the above was pat in type, the writer is enabled to cite several instances in corroboration of this belief, and which are only the more valuable because of their illus- trating the truth of it in three of our principal cardiac depressants. The first is a death which occurred in an adult in three hours from five grains of the fresh extract of aconite (Pareyra and Perrin, in Buchner's Report fur die Pharm., No. 68, p. 199, and Med. Chir. Rev., Oct. 1839, p. 544; quoted by Tucker, N. Y. Joicm. of Med., 1854, i. p. 230). Two others took the same amount and received the same antidotal treatment and recovered. Tucker does not state what extract it was, whether of the root or leaves, but as it was probably the latter, and as the usual therapeutic dose is one or two grains, and twenty grains or more have been used during the day, it appears to be an interesting case for us. It will also be remembered that three drops of the saturated tincture of the root caused alarming symptoms (National Dispensatory, 1880, p. 97). This tincture (Flemings's) being two-thirds the strength of a fluid ex- tract gives the amount of the drug in the dose taken as equivalent to one grain of the pure drug, or equal in a physiological point of view to from four to six grains of the leaves, or from a half to three-fourths of a grain of the extract of the leaves of the British Pharmacopoeia. If the first case is not altogether a fair one as an illustration, because of the uncertainty of the preparation used, yet it will be admitted that the last one is. Headland (Lancet, July, 1856) gives an instance where fifteen drops of the tincture nearly proved fatal. A case is reported of a medical student (AndraPs Clinique Midicale, Spillan, 1836, p. 698 ; quoted by Taylor, Guy's Hospital Reports, 1857, p. 415) who died in four hours from the effects of two grains of tartar emetic. Another is given by Riehelot (Ibid.) of death in a child of four years from one-third of a grain. Moreover, Noble states (Gtiy's IIosp. Rep., 1857, p. 415) that prostration and collapse followed in four cases of infants from ordinary doses. I have not yet seen his original paper. Stille quotes a case of a woman in whom alarming symptoms were caused by half a grain. Nunnelly, from the results of a series of experiments on animals with hydrocyanic acid (Med. Gaz.,x\. 1837, p. 508), apprehends that the same creature is u liable to be seriously affected by a dose which at another time would produce but little effect." I will take occasion to resume a discussion of this subject at an early day.

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rated from any central nervous influence, and so practically isolated, where after a subcutaneous injection no effect on the arterial tension was apparent, yet after an intravenous injection of the same amount, the arte- rial pressure was decidedly reduced, showing that although in both cases the dose was the same apparently, yet practically it was vastly different, and while it was evident that repeated subcutaneous injections could be borne with relative freedom from danger, on the other hand, regarding in- travenous injections, it must be obvious that the reverse is true. That this argument is equally applicable to anaesthetics needs no further com- ment.

Moreover, there can be no doubt that the heart and other parts of the system, but especially the former, are more readily influenced at times by impressions, both intrinsic and extrinsic, than at others, and particularly so in those persons possessing a nervous temperament; and it is not an uncommon thing for such individuals to experience, on some occasions, a palpitation, or some vague or indefinable sensation about the heart, while at others, under similar circumstances, they would appreciate nothing of the sort. If, therefore, the heart and other vital parts are at times more suscep- tible, and more readily influenced by mental or other intrinsic impressions at certain but indefinite periods, why is it not probable that they are more sus- ceptible at these periods to extrinsic influences, such as medicines ? If this is so, and we probably have good illustrations of the truth of it in the in- stances already given, it is not difficult to conceive how the same dose, under apparently similar circumstances, may have double the effect it would have had on other occasions. As, for instance, let us illustrate the resistance of the heart to a given drug as being 10: if, now, the resistance is reduced to 5 by causes which we do not as yet understand, it is readily understood how the same dose will produce a given effect in the first in- stance, and double the effect in the second. If Ave now superadd to this changeableness of the impressionability of the heart a second factor, as shown in the very excessive variability of the degree of concentration of the vapour inhaled, the subject is made still more comprehensible, and it certainly requires no stretcli of the imagination, when the many surround- ing and modifying conditions are considered, to understand how it is that some inhalations may contain a very large percentage of the ancesthetic, and others relatively less, and, as a consequence, how a comparatively larger quantity may thus reach the heart at one time than at others. For it must be obvious, when we consider these conditions attending the administration of an anaesthetic, that the drug does not reach the heart in a steady supply, but gaining entrance into the pulmonary acini in an ever-varying degree of concentration, sometimes in large, and at others in small quantities, it must be certain that it reaches the blood in similarly varying proportions, because it finds its way into the circulation immediately, and, as a conse- quence, its action on the organism must then be analogous to repeated

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intravenous injections of similarly varying amounts. For the sake of illustration, let us assume that when a given anaesthetic is administered the depressant effect on the heart is 10, and that now, as a result of the modifying conditions, the average degree of concentration of the vapour is doubled, is it not evident that the depressant action on the heart will be doubly felt? And now let us suppose we have a condition of the system when the heart's resistance is only half the normal, and we have the aver- age degree of the concentration of the vapour considerably increased, it is readily conceivable as to how death may supervene.

To reiterate : it therefore must be apparent that we have here two im- portant and self-evident factors, representing, respectively, two modes by which dosage is materially affected, and in accounting, in part at least, for the capriciousness in the action of chloroform and other cardiac de- pressants at different times under apparently similar circumstances, and a satisfactory explanation of the reason of their acting on such occasions altogether out of proportion to the dose used, and of the occurrence of death from ordinary anaesthetic doses.

Further, when we have a compound acting on the heart as a depressant, of a probable loosely molecular combination, which is liable to under- go under favourable conditions a decomposition in the blood, and of a composition which contains an element which, in a free state, is even more deleterious to the heart than the preparation itself, we certainly have added still another dangerous property.

It seems opportune in this connection to say a word in reference to the action on the nervous system, for we also have instances of the capricious- ness of the action of anaesthetics, and of deaths as a result of shock, which are attributed to a sudden overwhelming of the nervous centres, and are, therefore, but other instances illustrating what was stated with particular reference to the heart in a previous paragraph. But the nervous system appears ■ to be more strongly fortified against these sudden paretic im- pressions than the heart, and, as a consequence, death so seldom results from this cause, and as without exception probably every anaesthetic is capable of causing such an effect, it is obviously one of the dangers we must anticipate in the use of these compounds, but which we cannot guard against or expunge in our choice of preparations.

Therefore, the dangerous properties of anaesthetics, i. e., those proper- ties which we can avoid in our selection of a compound, resolve themselves, practically into decided depressant effects on the heart and on their con- taining toxic elements in their composition which may further, and possi- bly more powerfully, deleteriously affect the system by becoming liberated; and just such properties we find possessed by the group of preparations under consideration. It is taken for granted, of course, that compounds having such dangerous properties as some possess by causing an intense degree of irritation in the lungs and air-passages, etc., would undoubtedly

1881.]

Reichert, Dangerous Anaesthetics.

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be avoided if for no other reason than the impracticability of administering them.

It may be said, however, that beneath the truth the writer is burying the truth, in so far that many other anaesthetics have been used not be- longing to the above group, of which nothing has been said, and which also act as cardiac depressants, hence, that it must follow that this prop- erty of depressing the heart is not one peculiar to any class of anaesthetics, but a very general one. Admitting that other anaesthetics may induce cardiac paralysis before asphyxia is produced, — and it must be acknowl- edged that certain of them have a special tendency in this direction, such as hydrocyanic acid and creasote, the same as certain of the chlorinated compounds, such as the ethylidene and ethylene chlorides show a more decided tendency to the respiratory centres, but which is readily explained when we consider that the heart is so depressed as to be ineffectual in sup- plying the respiratory centres with blood, — yet the rule appears to hold good, and, to facilitate a comparison of these two classes of compounds, they are here placed in parallel columns : —

Chlorinated, Brominated, and Iodated

Anaesthetics. Chloroform, CHC13. Chloral hydrate, C2HCl3OH20. Carbon dichloride, C2H4. Carbon tetrachloride (chlorocarbon)

CC14. Bromoform, CHBr. Ethyl chloride (chloric ether), C2H5C1. Ethyl iodide, C2H5I. Ethyl bromide, C2H5Br. Ethylene bichloride (Dutch liquid),

CaH4Cl2.

Ethylidene bichloride (ethydene chlo- ride), C2H4C12. Iodoform, CHI3. Ethylene bromide, C2H4Br2. Methylene bichloride, CH2C12. Butyl chloride, C4H9C1. Methyl chloride, CH3C1. Isobutyl chloride, C5H9C1. Methyl iodide, CH31. Amyl iodide, C10H10I. Amyl chloride, C10H]0C1.

Miscellaneous Anaesthetics.

Aldehyde, C2H40. Benzole, C6H6. Coal gas. Creasote, C6HeO. Carbonous oxide, CO. Carbon bisulphide, CS2. Ethyl oxide (ether), C4H10O,

C2H302C2H;

(C2H5)20. Ethyl, acetate,

Ethyl, methylate, C2H60 (CH3)20. Ethyl, nitrate, C2H5ONO. Ethyl, formate, CH02C2H5. Acid, hydrocyanic, C2N2H. Hydrogen sulphide, SH2. Naphtha. Nitrous oxide gas, Olefiant gas, C2H4. Essential oils, C10H Pyrrol, C4H5N. Acetone, C3H60. Amylene, C3H10.

N202.

While these two classes represent the halogen and miscellaneous com- pounds respectively, yet were two other classes formed from them as representing syncopal and asphyxiating anaesthetics, or those having a de- cided tendency to depress the heart and those whose tendencies are to compromise the respiratory function, scarcely much change would be made, and with but few exceptions the above division would stand as it is. And while it is to be seriously regretted that our knowledge of the physio- logical actions of these compounds is so grievously inadequate, and that of

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such a small percentage of the whole number we have scarcely sufficient information to be able to assert positively what their action is, yet we do know that every one of the halogen anaesthetics which have been in- vestigated in reference to their action on the arterial pressure and as to their mode of producing death, have been found to both diminish the blood-pressure and paralyze the heart ; and that probably at least sixty per cent, of the deaths from chloroform have been due to arrest of the heart; while in regard to the miscellaneous anaesthetics, it is undoubted that some of them do diminish the arterial tension and depress the heart, and will cause death by cardiac paralysis ; yet, there seems to exist that unmistakable predominant tendency to produce death by asphyxia and not by sudden cardiac arrest, although with those which possess to any marked degree a cardiac depressant action, a sudden failure of the heart is likely to occur, as with the halogenated compounds. Every anaesthetic has a decided tendency to cause death by asphyxia, and the reason of this is very apparent when we consider how greatly all the functions of animal life are diminished, but particularly those of the nervous system, whose excito-motor functions especially must always be very decidedly lessened in anaesthesia ; and when we have such a serious interference with the trans- mission, reception, and origination of impulses, as is invariably present in complete narcosis, it is not difficult to understand how it is that any anaes- thetic possessing this powerful depressant power may, if given in exces- sive doses (a too concentrated condition of the vapour inhaled), or in states of the system when these centres are in an abnormally impressionable condition, cause a sudden paralysis, such as has followed the use of ether, which, as is generally admitted, is beyond doubt, with but one exception, the safest of all anaesthetics in general use, and the least liable to cause death without a warning such as the merest novice must appreciate. Yet because it must follow that every anaesthetic may and wrill cause death by asphyxia, the same universal rule does not apply to them in regard to their effects on the circulatory system, and instead of its being the rule to decidedly depress the heart and blood-pressure, excluding the chlorinated, brominated, and iodated compounds, it is probably the exception ; there- fore, it must be evident that while in the anaesthetic compounds such as creasote and hydrocyanic acid, their decided depressant action on the heart is an accidental concomitant associated with their other physiological properties, on the other hand, in the halogen preparations the action ap- pears to be so universally existent as to suggest that there must be some inherent toxic principle or principles which enter into the composition of each, and is. common to all of them, and which endows them with this one dangererous property.

That this toxic principle is not to be found in the radicles forming the bases of these compounds, but in the negative elements, is Obvious for several reasons, and some years ago Richardson reached a similar con-

1881.] Mendelson, Case of Abscess of the Liver.

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elusion regarding one of these particular divisions, and stated that he deemed all chlorinated compounds dangerous. More recently, Squibb has warned us to be careful in the use of ethyl bromide, for fear of inducing brominism ; and we know that by giving the ethyl iodide by inhalation, the system is rapidly brought under the influence of iodine. Now, for instance, let us take ether, an oxide of ethyl, and substitute for the oxygen bromine, and what is the result? The ether, which was before a cardiac stimulant, and would almost without exception cause death by asphyxia, has now become excessively increased in power, and the half drachm of the com- pound will produce an effect more intense than ten or twenty or more times the original amount, and, instead of a cardiac stimulant, we have a decided depressant, and instead of having deaths following from slowly induced asphyxia, we have deaths occurring from cardiac arrest, and sud- den, overwhelming, and unanticipated results following its use. Further, take olefiant gas, and we find that when inhaled it possesses but feeble anaesthetic powers and causes death by asphyxia ; but add bromine or chlorine to it, and we have powerful anaesthetics and undoubted cardiac depressants.

Considering all these things, there can be but little doubt that the dan- gerous properties, if not the degrees of potency, of anaesthetics, are de- cidedly enhanced by the addition of either of the halogens, and it is not at all improbable that these ethers are mostly loosely molecular compounds, some of which are more readily decomposed in the system than others, and that their degree of dangerousness, cceteris paribus, depends upon the rela- tive amount and relative physiological power of either of these halogen principles which enter into the composition of any one of them, and upon the degree of fixity of the molecules.

Article V.

A Case of Abscess op the Liver, complicated with Empyema ; Ope- ration ; Cure. By Walter Mendelson, M.D., House Physician to the Xew York Hospital.

Mart G., aged 32, a native of England, married, a labouring woman, was brought to the hospital on October 9th, 1880, and gave the following history : —

Two weeks previous to admission, she began to suffer from a sudden sharp pain in the right side of the chest, the pain being made worse by motion or cough, or by lying on the right side. Patient also had a hack- ing cough, with slight mucous expectoration, and suffered a good deal from shortness of breath. This condition persisted for one week, when she was seized with a chill followed by profuse sweating. Chills and sweats con- tinued to recur with tolerable frequency, and the patient lost her strength No. CLXIII July 1881. 5

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and flesh with great rapidity. The cough also increased in severity, and the expectoration became muco-purulent in character.

On admission the pulse was 116, the respirations 36, and the tempera- ture 102.8°. The patient was extremely exhausted, being almost too weak to speak. She lay on her back, propped up in bed, breathing very cautiously, as if in great pain, and wearing an expression of keen anxiety. Emaciation was very marked, and the patient presented all the appear- ances of having been used to much hard work and poor food.

Physical examination of the thorax showed the respiration on the left side, both in front and behind, to be vesicular, but exaggerated in degree. On the right side behind, from about two inches below the inferior angle of the scapula to the base of the chest, there was loss of tactile fremitus and flatness on percussion. Auscultation of the same region revealed gegophony and bronchophony. Above the inferior angle of the scapula the percussion note was dull-tympanitic, and on auscultation a rude res- piratory murmur was heard.

The upper border of the liver was at the sixth intercostal space ; the lower on a level with the umbilicus.

A hypodermic needle was inserted into the pleural cavity in the eighth right intercostal space, and some very thick bloody pus withdrawn.

The woman was ordered brandy ^ss, every three hours, and quinia sul- phate gr. v, three times a day. The pulse continuing ^ery feeble, she was ordered tinct. digitalis n^xx. every three hours during the night, and was also sponged "with a weak solution of tinct. belladonnas to allay sweating, which was very profuse.

Oct. 10. The patient's dyspnoea was still very severe. At 9.15 A.M. resp. 48; temp. 104.4°. At 12 M. it was decided to aspirate the chest, although the patient's condition was such as hardly to allow of hope for a favourable issue. The largest needle, No. 4, of Dieulafoy's aspirator was inserted twice ; first in the eighth, and then in the ninth intercostal space, about in a line with the angle of the scapula, the woman being propped up in bed with pillows. Each time only a drachm or t wo of very thick pus was drawn, owing to the needle becoming clogged, and as the patient became quite faint, and the pulse very feeble, further attempts were abandoned. At 2 P. M. the needle was again inserted in three dif- ferent places, but not more than two ounces altogether were withdrawn from the pleural cavity. The pus was of a thick, viscid nature, and con- tained more or less brownish blood.

12^. Temp. 100.2°. Patient slept very little at night, being troubled by a persistent cough, which opium only in part relieved. Vomited con- siderably, and sweated profusely. Complained of but little pain. Urine was normal.

16th. Very little change occurred in patient since the last date: the temperature averaging about 102°, the respirations about 50, and the pulse about 115. On the morning of this day there was noticed, for the first time, in the right hypochondrium, just above and to the right of the um- bilicus, a slight swelling. This was rather firm to the touch, and the seat of some tenderness.

19th. The tumour had become more distinct, being now as large as a goose's egg. The base was indurated and sloping, merging into the liver, whose lower border could be distinctly felt below it. The summit was crater-like, tbe basin of the crater being soft and fluctuating. There was no redness of the skin over the swelling ; its contents could not be evacu-

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ated by firm and persistent pressure, nor was there any impulse communi- cated to it by coughing. Examination of the chest showed the breathing and voice to be more resonant and amphoric in character, and the percus- sion note tympanitic, where it had formerly been dull. (Pneumo-thorax.)

21st. The tumour was slightly larger, though no signs of pointing were seen. Temp. 99° at 9 A. M. Patient still sweated profusely, which was in part checked by atropia gr. t-J-q, by the mouth, at frequent intervals.

23d. The tumour was less prominent and the edges more firm. The expectoration was rather scanty and whitish, and fibrinous in character. The sweating continued in spite of atropia. The range of temperature was lower, being from 99° to 101°.

28th. Patient sat up for a short time, her general condition being greatly improved, the. sweating having become much less.

Nov. 2d. On this morning about one o'clock, patient suddenly awoke with great dyspnoea and coughing. She expectorated large quantities of puru- lent material, having a very fetid odour. The expectoration continued more or less profuse all day, the dyspnoea gradually subsiding.

oth. Expectoration still continued, and was unchanged in character. The tumour in the epigastrium was nearly imperceptible and quite soft to the touch. Patient was ordered cerium oxalate to control cough.

12tk. The temperature had not been above 100.6° for the past four days. General condition was much improved.

18th. This morning the tumour was noticed to have reappeared, and was larger in size than before. It occupied the same position, was some- what rectangular in shape and not so conical as at first. It extended one and a half inches to the left and one inch below the umbilicus. Its right border was one and a half inches beyond the mammary line. Its upper limit was at the costal edge. It measured about five and a quarter inches transversely, by four and a quarter longitudinally. As in the beginning, no impulse was communicated to it when the patient coughed, nor could its contents be evacuated by firm and continuous pressure. The tumour was somewhat tender to the touch, and the skin over it had a boggy feel. Fluctuation was very evident. Poultices were ordered, and calcium sul- phide gr. \ three times a day administered internally.

20th. The tumour was aspirated with a hypodermic syringe, and a few drops of very thick odourless pus obtained. Temperature varied from 100° to 102°; pulse about 105 ; respirations 36. The expectoration on this day was noticed to have an orange-yellow colour, as if tinged with bile. (Unfortunately no chemical examination for bile was made.)

22d. By this time the tumour had increased considerably in size, its growth having taken place mainly to the left of the umbilicus. The skin over it had a brawny, hard feel, and was quite red and ecchymotic look- ing. The patient's breath was horribly offensive, having the same odour as her expectoration.

As the abscess showed such decided signs of pointing, it was determined to operate, which I did at 11 A. M., the patient being etherized. At 9 A. M. pulse had been 112, respirations 36, and temperature 101.8°.

An incision one and a quarter inches in length was made just above and one inch to the right of the umbilicus in the softest part of the tu- mour. After a rather superficial cut the pus was reached, and poured out in great quantities, about a pint or more discharging in a few minutes. The pus was thick, viscid, sanious, and clotted. It was mixed with portions of bright yellow pus and shreds of broken-down tissue. It was entirely

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Mendelson, Case of Abscess of the Liver.

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free from odour. The cavity was washed out with a solution of carbolic acid (1 to 40 of water), and on introducing a finger through the wound, the abscess was found to consist of two portions : one, the main cavity, lying to the right of the median line, and having the size of a very large orange ; the other, a smaller one, about the size of a pigeon's egg, just to the left of the median line, the two being freely connected by a canal run- ning transversely under the linea alba. The liver tissue could be felt pro- jecting into the cavity, in hard, nodulated masses, covered with a pulpy material, which was easily scraped away with the finger. It was impossi- ble to touch the bottom of the abscess with the finger, but a probe could be introduced for about four inches in a direction backwards, upwards and outwards.

A large drainage-tube was inserted and the wound covered with a com- press wet in a 1-40 solution of carbolic acid, over which a piece of mack- intosh was laid and the whole secured by a carbolized gauze body-bandage. A drachm of brandy and Magendie's sol. n^vwere given hypodermically.

At 1.30 P. M. the pulse was 118, the respirations 32, and the tempera- ture 98.6°. At 10.30 P. M. pulse 120, respirations 34, temperature 96.6°. An ounce of brandy was administered and hot bottles were applied to the body.

23c?. At 8.30 A. M., pulse 104, respirations 34, temperature 98.4°. Patient suffered little or no pain and slept well during the night. The abscess was dressed to-day by washing it out by means of an irrigator, with a weak solution of carbolic acid in warm water. A considerable amount of shreddy material and some pus came away. The discharge was per- fectly odourless. The pus which came from the abscess on first opening it was examined by Dr. George L. Peabody, pathologist to the Hospital, who made the following report: "Pus in bad condition, with many broken-down cells and a great deal of detritus. Also many large, round cells, three to four times as large as pus cells, containing considerable pig- ment and some fat globules." Nothing that could be distinctly identified as liver cells was found.

27th. The first rise of temperature occured on this day at 4 P. M., the thermometer registering 100.2°. The cavity had been washed out every day, and had very rapidly decreased in size, not being more than half its original dimensions at this date. The patient, with the exception of some cough and occasional vomiting, did very well.

Dec. 21th. The patient by this time had been up and about the ward for a month, had gained in weight and strength, and was in excellent physical condition. On two occasions only was there a rise of temperature ; once to 100.2°, and again to 102°. The abscess healed entirely, with the ex- ception of a small sinus about an inch and a half long, which discharged a few drops of serum a day, and for the care of which the patient did not want to stay any longer in the hospital. Her cough and expectoration had ceased entirely. Physical examination of the chest revealed good vesicular murmur all over, except on the right side toward the base in the axillary line, where it was feeble and the voice-sounds distant. The lower border of the liver was still at the umbilicus, being bound down by adhesions. Being anxious to go, she was discharged as cured on this date. At no time during her illness had she been jaundiced.

Remarks. — The woman had in all probability an abscess of the liver before entering the Hospital (Oct. 9th), as the enlargement of her liver,

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as measured on admission, showed. This abscess set up, by contiguity, a simple pleurisy, which lasted a week. At the end of that time the pleu- risy became an empyema, as it would be quite likely to do in one having a considerable deposit of pus anywhere in the body, and run down by an exhausting disease.

Physical examination of the chest ten days after admission (Oct. 19th) showed that the empyema had become a pyo-pneumo-thorax. As there had not been anything to call especial attention to the chest, no sudden attack of great dyspnoea, it is more than probable that the air entered the pleural cavity gradually through a small and valvular opening, for although the chest contained pus, as was shown by aspiration on the day of admis- sion, the woman did not expectorate any more than usual until two weeks after the discovery of the pyo-pneumo-thorax (Nov. 2d), when she was suddenly awakened in the night with great dyspnoea, and expectorated large quantities of very fetid pus, the expectoration continuing during the next day.

The bad odour of the material expectorated would go to confirm the previous presence of air in the pleural cavity, and the suddenness of its appearance would indicate that the opening through which air could enter into the pleural cavity was of such a nature (at least for a time) as to prevent the pus from escaping from the latter into the lungs. At this time the expectoration was simply purulent, and had not the appearance of being stained with bile. It is worthy of note that in the interval the epigastric tumour, which was observed (Oct. 16th) three days before the pyo-pneumo-thorax was discovered, had been diminishing in size, and a few days after the pus burst into the lung was almost gone. It would be hard to explain this subsidence of the tumour, except by supposing that it had discharged into the pleural cavity. Two weeks later, however, (Nov. 18th) the tumour was noted as having reappeared and to be larger than ever, and also that the sputum contained what appeared to be bile.

A few words in regard to the tumour. On its first appearance various theories relating to its nature were advanced. It seemed in the beginning as though it might be the gall-bladder, for it was in the place where this organ appears when distended, and was soft and globular. Careful ex- ploration, however, revealed the sharp edge of the liver below the tumour, a condition which of course could not exist had it been the gall-bladder. As the edges became more indurated it was supposed to be an abscess in the abdominal walls, the result of the pus from the empyema making its way downward, for, be it observed here, there was no suspicion of hepatic abscess when the woman was admitted, and all her trouble was referred to her empyema. Against this latter view was the fact that the abscess could not be emptied by pressure and received no impulse on coughing.

From the first the hepatic origin of the abscess had been strongly advo- cated, in view of the enlargement of the liver and the mound-like edge of

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the tumour, caused probably by the adhesions formed between the liver and the abdominal walls.

When the tumour was incised (Not. 22d), and after evacuating its con- tents, the finger was introduced into the cavity; of course no more doubt regarding its nature remained. The pus from the abscess did not resemble that spit up by the patient, for it was mixed with blood, and not fetid ; nor did it at any time subsequently become so.

Shortly after the abscess was opened the cough became less frequent and the expectoration less copious, and finally ceased altogether. This might have been due to the general and very marked improvement which occurred in the health of the patient immediately following the operation, and to the withdrawal of the irritation from the right side of the chest, which the proximity of the tumour to the diaphragm must have caused, even though no direct communication between the former and the chest necessarily existed.

It would seem to me, therefore, that most of the evidence would lie in favour of the empyema and hepatic abscess being distinct, though corre- lated ; the only marked evidence against this being the almost complete disappearance of the tumour for a while, and the presence for a short time of what appeared to be bile in the expectoration.

My chief grounds for supposing the abscess to be distinct from the empyema is the fact that the expectorated products of the latter were ex- tremely fetid, while the pus from the former was perfectly odourless. It seems to me that had an opening, no matter how small or valvular in character, existed in the diaphragm, the putrid pus in the pleural cavity must have infected that in the liver.

Thierfelder, in vol. ix. of Ziemssen's " Cyclopaedia," says that cases such as this one seemed to be are of rare occurrence, and quotes one (con- firmed by autopsy) reported by Loewer in the Berliner Klinische Wochen- schriftfoT 1864 (p. 461).

Article YL

On Lymphatic Hearts and the Phenomena attending the Propul- sion of Lymph from them into the Veins into which they open. By Thomas Wharton Jones, F.R.C.S., F.R.S., Professor in University College, London.

The object of this paper is: to describe the phenomena attending the propulsion of lymph from a lymphatic heart into the vein into which it opens ; and to point out the difference in these phenomena from those which attend the propulsion of blood from the left ventricle of the heart into the aorta and large arteries.

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Jones, On Lymphatic Hearts.

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Our minds being familiar with the pulsation of the arteries attending the propulsion of the blood into them, we are very prone to conclude that pulsation of the vein must, in like manner, be produced by the propulsion of the lymph into it from a lymphatic heart. It is a fact, however, that no pulsation of a vein is produced by the propulsion of lymph into it from a lymphatic heart. In the two cases, in which we can directly observe the propulsion of lymph into veins taking place, we see no dis- tension of the vessels such as that exhibited by arteries when the blood is propelled into them by the stroke of the heart, and on which the arterial pulse depends. The reason of this is plain : for the conditions under which the lymph is propelled from lymphatic hearts into veins are quite different, as we shall see, from those under which the propulsion of blood from the heart into the arteries causing their pulsation, takes place.

It is to be understood that I am not referring to the phenomena attending the systole and diastole of the hearts themselves, for, of course, the pulsa- tions of a lymph-heart are similar to those of the blood-heart. What I wish to maintain is this : that whilst the propulsion of the blood into the aorta by the contraction of the left ventricle distends the aorta and large arteries, so that a pulsation is felt by the finger applied over the vessel — the propulsion of lymph, on the contrary, into a vein, as observed under the microscope, does not cause distension of that vessel such as would indi- cate to the eye that anything of the character of a pulsation capable of being felt with the finger, supposing the vein large enough to be touched, was a result of the propulsion of the lymph into the vein.

Preparatory to entering on the proper subject of this paper, I beg to call attention: 1st. To the conditions under which the propulsion of blood into arteries causing them to pulsate takes place. 2dly. To the conditions under which regurgitation of blood into veins causing the venous pulse takes place. 3dly. To an inquiry as to whether pulsation attends the rhythmical contractions of the veins of the bat's wing, and the acceleration of the flow of blood in those vessels thereby occasioned.

First, then, as to the conditions on which the arterial pulse depends : By the contraction of the left ventricle of the heart, the blood is propelled into the aorta and its larger ramifications. These vessels thereby become suddenly distended, and it is this sudden distension which is felt as the pulse by the finger on being applied with a little pressure over an artery.

The walls of arteries, having elastic and muscular tissues entering into their structure, are endowed with both the physical property of elasticity and the vital property of contractility — contractility of the kind which is tonic or continuous in its action, not rhythmical. By the combined ope- ration of these two forces — elasticity and contractility — inherent in their walls, the arteries during the diastole of the ventricles, react and close in on the blood with which they had become distended at the time of the systole of the ventricles. The effect of the pressure thereby exerted on

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the blood is to force it onwards in its course through the smaller arteries and capillaries into the veins ; regurgitation into the ventricle being pre- vented by the semilunar valves of the aorta.

In consequence of the onward flow of the blood in the smaller arteries being in a great measure dependent on the pressure exerted by the reac- tion of the elastic and tonically contractile walls of the aorta and larger arteries on the blood distending them, during the diastole of the ventricles, the pulse of those smaller arteries is subsequent, by an appreciable interval of time, to that of the larger arteries.

In the web of the frog under the microscope, the conditions for pulsa- tion are observed to be manifested in a small artery by its dilatation from distension with blood, and if the vessel be tortuous, by its becoming, at the same time, more bent at the bendings.

The constrictions and dilatations which the artery in the rabbit's ear is seen to undergo, have been erroneously described as rhythmical, and the artery itself viewed as performing the function of an auxiliary arterial heart ; it being alleged that the artery by its dilatation receives and partly