lodged between the drum membrane and the anterior wall of the meatus. It was dislodged with some little difficulty, and upon examination was found to contain a small, white, irregular pebble, about the size of a hypodermic tablet. Mr. L. was very much surprised to find that he had a pebble in his ear, and for some time was unable to account for its presence. He could not remember ever having got anything in his ear or ever having suffered the slightest discomfort. He said that in summer, while bathing, he would frequently lie on the sand and let the surf break over him. We therefore came to the conclusion that the pebble must have been driven into his ear by the force of the water. If such is the case—and it undoubtedly isMr. L. carried that foreign body in his ear for over two and one-half months, as he had not been to the seashore since the latter part of July.-Medical Record. Nerve Grafting. Dr. Robson reports (British Medical Journal, October 31, 1896) a case admitted under him seven months after a wound of the right arm above the elbow. Dissection showed the ulnar nerve connected by a fibrous band about three-fourths of an inch in length, and the divided ends of the median nerve could not be approximated nearer than two and one-half inches. There was complete loss of power in the hand, and only very limited power of flex'ion and extension of the hand at the wrist. Measurement showed the forearm to be twothirds of an inch smaller than its mate. The sciatic nerves of a freshly killed rabbit were grafted between the separated ends of the ulnar nerve, and the spinal cord was used to connect the median. Healing occurred by first intention, and there was absence of fever or pain. Sensation returned in ten days to the thumb and forefinger, and from this time sensation and muscular development gradually improved. In four and one-half months patient could pick up small objects. Six years after the forearm was only one-eight of an inch smaller than its mate, and in the hand all the muscles were as well developed as in the other, except the abductor of the thumb, which was still weak. Dr. Robson concludes his reports by the following remarks: "It is thus seen that though the recovery has been tardy, it was complete in almost every respect, the only exception being that of the abductor pollicis, which for some unexplained reason did not recover its function. The case is very encouraging, since it clearly demonstrates the possibility of restoring continuity of nerves by grafting. Whether the spinal cord in this case took up the functions of a nerve, or whether it simply served as a basis on which the nerve tissue was built up, I am quite unable to say. But that it did answer its purpose is clearly shown in the case. Why restoration of function in the ulnar nerve should have been longer than in the median, I am unable to say, as the ends of the nerve were not separated more than three-fourths of an inch, whereas the ends of the median nerve were between two and three inches apart. Could it be that the spinal cord offered a better medium for establishing continuity? "I feel sure that we have still much to learn concerning the repair of nerve lesions, and I am not at all certain that the conclusion of physiologists is correct when they affirm that the peripheral portion of a divided nerve always undergoes atrophy." Rupture of the Quadriceps Extensor Muscle and Its Tendon Above and Below the Patella. Dr. Walker, in an analysis of two hundred and fifty-five cases of rupture of the quadriceps extensor, muscle, notes the following conclusions: I. In recent cases, in which there is not much effusion and the joint is apparently not closed, in which the separated ends can be approximated and retained by suitably adjusted pads, the mechanical treatment may be carefully considered. In the hands of the intelligent general practitioner, this method may be expected to bring about a complete. recovery in the larger number of cases. From nine to twelve months will be required to reestablish fully the normal functions. 2. A too prolonged fixation in bed is unfavorable to an early recovery; therefore early massage and passive motion are strongly advised. 3. The skilled aseptic surgeon who primarily resorts to the operative method in suitable cases (but the age and vitality of each patient must be most carefully considered) may quite reasonably hope to obtain a better result in a larger number of cases and save his patient three to six months' time. 4. Catgut, 4. Catgut, kangaroo tendon, or silkworm gut should be used, and when there is much effusion drainage should also be employed. 5. When the separation is greater than one and one-half inches, or when the case has not recovered under the mechanical treatment, the operative is indicated. 6. As the length of time required for treatment is a very important consideration, so the operative method, which has diminished this period and also succeeded in a larger number of cases without increasing the danger, will be more often indicated and more frequently applied in the hands of the skilled surgeon.-Medical Record. Miscellany. Large Fees. Patients and their friends so often complain and find fault with the fees of their physician, usually when convalescence is complete, that it is a great relief to see the value for medical services named by the would-be patient. An eccentric millionaire has offered a fee of one million dollars to the person who will restore his lost sight. He has atrophy of the optic nerve and it is likely that this fee will never be earned, but it only shows what value a man with the necessary money puts on his sight. The question will doubtless be raised whether this fee would be paid should sight be restored. Such fees should be collected while gratitude is fresh and the memory is green. A man will grudge a paltry five hundred dollars to the surgeon who by skill and care saves his limb, but let this man lose that same limb later in a railroad accident and notice if he sues the company for only five hundred dollars. He sues the company for what his lost member is actually worth to him and he has forgotten what his faithful attendant did for him. Medical service for the deserving poor cannot be too small and for the deserving rich cannot be too large. No medical man should spring a large price on a wealthy man just because he is wealthy, when he has charged one less well off a smaller fee for the same work, but in operative work the sum to be charged should be named and then if objections are offered the patient able to pay large sums should be given a chance to seek out one who will work for less money. If a surgeon is known to make high charges and the patients visit him and demand service without asking what the cost will be, no complaint should be made if it is high. No physician is obliged by law to render service if he does not choose to do so and where there is other medical talent at hand there is no cruelty or neglect. The question of charging clergymen comes up again and again. Many of them pay nothing for medical services and seem to take it for granted that no fee will be asked. Because a man is a clergyman receiving a large salary and with small expenses, is there any reason why he should get free services from a young physician who is struggling to succeed? There is only one answer to this question. The clergyman should at least offer to pay and if the medical man prefers to make no charge or thinks it is policiy to put the clergyman under obligations to him, then the clergyman cannot be blamed, On top of all this false sentiment about physicians doing so much good and giving free services to clergymen, comes the statement that Louisville has imposed an income tax on physicians ranging from ten to one hundred dollars, according to the income received. This, of course, will be fought, for class legislation should never be allowed. The laborer is worthy of his hire and the sooner that such false ideas of giving something for nothing are brushed away, the sooner will the public begin to understand that because a class of men and women, too, follow a profession because they love it, there is no reason why their services should be given free or at a greatly reduced price when the ability to pay a full price is evident.-Maryland Medical Journal. Some Interesting Variations in the Flexor and Extensor Muscles of the Forearm. Edward Judson Wynkoop, M. D., Demonstrator of Anatomy, College of Medicine, Syracuse University, writing to the New York Medical Record, says: The following condition was noted in the flexor and extensor tendons and muscles in a male subject: The most interesting variation was the peculiar division of the flexor sublimis digitorum. The flexor sublimis digitorum arises as practically four distinct muscles or heads. The outer head or muscle arises by two heads, one from the oblique line of the radius above the insertion of the pronator radii teres, the other from the common tendon from the inner condyle of the humerus. These heads unite and become tendinous, and the tendon passes to its insertion in the second phalanx, dividing before its insertion to allow the tendon of the flexor profundus to pass through it on its way to the last phalanx. Just where these two muscular heads unite, a strong tendon is given off and passes to and blends with the flexor longus pollicis. The next muscle or second head, from without inward, at its origin resembles more in its common characteristics the flexor sublimis digitorum. It arises from the common tendon and the internal lateral ligament of the elbow joint, soon becomes tendinous, and when about half way down the forearm widens out into a muscular belly, which is about two inches in length. The muscle becomes tendinous again and passes to its insertion in the index finger. From the small muscular belly above referred to, a tendon arises which passes to its insertion in the little finger. The third or most internal head or muscle arises from the common tendon and passes down the forearm to its insertion as an entirely separate muscle. The insertion of this muscle is in the ring finger. The relation of the tendons passing under the annular ligament of the wrist joint is as follows: The tendons passing to the index and middle fingers are anterior; those passing to the ring and little finger are posterior. The flexor profundus digitorum is normal except that it becomes tendinous very high up in the forearm. The extensor minimi digiti is wanting. The extensor ossis metacarpi pollicis has an additional tendon which arises from the anterior and outer border of the radius. In the foot an extra tendon was given off from the extensor proprius pollicis and was inserted into the first phalanx of the great toe. In looking over the records I can find no account of a similar condition. To Mr. Gere, a student, I am indebted for the excellent dissection. In Memoriam. DR. J. B. MURDOCK. They've shrouded him! They've buried him! They've buried him, the soldier's friend, They've buried him, whose radiant face, When peace had spread her wings, Was messenger to gladden homes; So hope his presence brings. They've buried him, a noble son Of Scotia's famed soil, Physician born of kingly mien, High bred, in humble toil. They've buried him, who bore the yoke If like him they would earn the crown Richmond, Va., Nov. 5, 1896. Fortunes of British Physicians. The Practitioner records the following amounts devised by doctors in England who have died during the year 1896: Dr. Patrick Fraser, $2,100,000; Sir John Erichsen, $450,000; Sir George Humphry, $400,000; Dr. Samuel Holdsworth, $265,000; Dr. William Statten, $200,000; Dr. George Harley and Sir William Moore each $125,000; Sir George John son and Sir Russell Reynolds each about $60,000. The comment is made by the same authority that these fortunes were not made so much by the accumulation of fees as by judicious investments. The Physician as Citizen. That an unreasoning prejudice and all prejudices are unreasoning-exists against the participation by physicians in political and sociologic agitations is an undeniable fact. We do not now refer to the scheming and officeseeking of place-hunters with medical degrees, but to that legitimate coöperation with one's fellow-citizens in behalf of social or economic measures believed to be of benefit to the community, which, according to the prejudice spoken of, is to be forbidden to physicians only, of all classes of the community. Of course there have been notable exceptions. Doctor Joseph Warren, who fell at Bunker Hill while in command as General of the Massachusetts troops, and Doctor Benjamin Rush, no less eminent in the Continental Congress than in his lecture room at the University of Pennsylvania, occur to everyone. But what may be forgiven to the dead, or to men of genius, is denied to the living, or to those whose less commanding position and abilities render them more amenable to discipline by popular censure. Nor is the laity alone responsible for this feeling; many physicians share it, and look askance upon any colleague whose public spirit leads him into opposition to the powers and wrongs that be. In this state of public and professional opinion, what is the duty of the individual physician? Shall he yield to public sentiment, which punishes its violation by curtailment of practice and income, or shall he pursue the even tenor of his way, fulfilling his duties as man and as physician to the best of his ability? It is a difficult question to decide. There is no doubt that medicine requires not only close and constant devotion to study, but that the physician shall be within ready call of those to whom he has undertaken to minister. It is quite evident, therefore, that close and continuous devotion and engrossment in public matters, and the undertaking of a large share of the direction of political movements is incompatible with the active practice of the profession. So much being granted, however, it is also quite evident that a physician may, without detriment to his professional studies, and without neglect of his patients, give a portion of his time and thought and action to the public welfare; how much and how applied, circumstances and individual discretion must determine. As the physician's habits of research, his en deavors to trace the causes and study the mechanisms of the disorders of the human frame, peculiarly fit him to trace the causes and study the mechanisms of the disorders of the social organism; and as his experience in combating disease of the human body fits him to pass upon the wisdom of measures proposed to prevent or relieve social distress, his active and interested participation in public affairs should be welcomed by all classes. We firmly believe that if the measures from time to time proposed in the various legislative bodies could be referred to committees of physicians, to investigate in a scientific manner, without partisan prejudice or self-seeking ambition to influence their decision, the volume of legislation would be diminished nine-tenths, to the great relief of the suffering body politic. But to return to the question of how that physician should act whose interest in the welfare of his fellow men leads him to desire to do his share toward bettering the social environment, yet who knows that the penalty of running counter to the prejudice of the community is loss of a part of his income; it will depend upon which consideration is, or must be, the weightiest. If he need not depend on professional earnings there is no obstacle to his doing as he prefers. In the other case, his first duty is to earn a livelihood for himself and his family; this being provided, his own character will decide how far he is willing to forego ease and comfort and position, for the sake of doing what he considers it his duty to do for his compatriots or for mankind at large. What should be the attitude of the profession toward physicians who strive to perform their civic duties is easier determined; it ought to be one of encouragement, sympathy and active support, professionally and personally. That it is not such is a matter of everyday observation-and of reproach.-Philadelphia Polyclinic. An Unusual Case of Lockjaw. Sachse reported in the Centralbl. f. Chir., No. 40, 1896, an unusual case of lockjaw, occurring without known cause in a male, aged 24 years. On waking one morning he found he could not open his mouth as far as usual. The disability increased daily, until he was unable to separate his teeth. For four years he was treated without benefit, until it was discovered that the right upper wisdom tooth pointed directly outward, and so pressed against the internal pterygoid muscle as to prevent the jaw from opening. It was removed with difficulty. Immediately after its extraction the jaw could be partially opened, and in eight weeks function was fully restored. BOOKS AND PAMPHLETS RECEIVED. "Surgical Clinic at St. Mary's Hospital, September 23, 1896," by H. O. Walker, M. D. Reprinted from The Leucocyte, December, 1896. "Anterior Soft Hypertrophies of the Nasal Septum," by Edwin Pynchon, M. D. Reprinted from The Larynoscope, November, 1896. "Reviews of Some Points of Surgical Interest in Abdominal Cases," by Edmund J. A. Rogers, M. D. Reprinted from the Colorado State Medical Society, June, 1896. "A Review of Some Interseting Points in Surgery Observed During the Six Months Ending June 1, 1895," by Edmund J. A. Rogers, M. D. Reprinted from the Colorado State Medical Society, June, 1895. "Iniencephalus," by Henry F. Lewis, M. D. Reprinted from the American Journal of Obstetrics, Vol. xxxv, No. 1, 1897. "Sprays and Inhalents," by Seth Scott Bishop, M. D., LL. D. Reprinted from the Medical Standard, February, 1897. "The Mineral Waters of Mt. Clemens, Mich.," by Richard Leuschner, M. D. "Treatment of Stricture, Granulated Urethritis and Prostatitis by Electricity and Allied Remedies," by G. W. Overall, M. D. Reprinted from the Medical Mirror, St. Louis, Mo., 1896. "Anæsthesia of the Trunk in Locomotor Ataxia," by Hugh T. Patrick, M. D. Reprinted from the New York Medical Journal for February 6, 1897. "Improved Hypodermic Svringe and Remedy Case," by Elmer Lee, M. D. Reprinted from the Journal of the American Medical Association, March 28, 1896. "Two Years' Clinical Experience with the Gold Solutions," by Eustathus Chancellor, M. D. "The Treatment of Carcinoma Mammæ,” by Carl Beck, M. D. Reprinted from the Clinical Record, October, 1896. "Pyothorax," by Carl Beck, M. D. Reprinted from the International Medical Magazine, January, 1897. "Sonderabdruck aus dem Archiv fur klinische Chirurgie," by Carl Beck, M. D. "A New Contrivance for Intestinal End-toEnd Anastomosis," by J. Frank, M. D. Reprinted from the Medical Record, October 3, 1896. "Genito-Urinary Surgery and Venereal Diseases," by J. William White, M. D., and Edward Martin, M. D. Philadelphia: J. B. Lippincott Company, 1897. THE STUDY OF SYNTHETIC METABOLISM IN THE HEALING OF GRANULATING WOUNDS. BY WARREN B. OUTTEN, ST. LOUIS, MO. Chief Surgeon Missouri Pacific Railway Company. It is an accepted belief that immediate union of wound surfaces never occurs at any part of any tissue of the body; that all wounds heal by the interposition between the severed parts of granulation tissue. If the wounded surfaces are kept in apposition and remain in an aseptic condition, healing by first intention occurs in a very short time, and with the production of the least quantity of embryonic tissue. It can be stated as a general truth that in wounds where we have varying large loss of tissue and the attendant inability to place them in favorable apposition, such wounded surfaces must heal by the production of large quantities of granulation tissue. Hence healing by both first intention and by granulation is essentially by the same process, with only this difference, that in healing by first intention, favorable conditions accomplish the result by the formation of a small quantity of the reparative material, and the non-interference of adverse elements and conditions, while in healing by granulation unfavorable conditions debar the economical use of healing elements; hence greater length of time is required and furnishes greater elements of infection, and healing of wounds by granulation is the repeated history of wound. infection and of varying degrees depending likewise upon varying adverse conditions, such as extent of injury, loss of tissue, the lowering of the normal standard of cell resistance, along with repeated opportunities of septic contamination. Granulation tissue cells are formed by both direct and indirect cell division; this, of course, only in their embryonic No. 22. state. Senn says, "The bulk of all granulation tissue is derived from the connective tissue, as this mesoblastic structure is diffused throughout the entire body, and with the exception of the nervous system is found in almost every organ." Ziegler, Thiersch and Recklinghausen have shown that formative granulation cells are not direct descendants from emigrated leucocytes, but that the original fixed connective tissue cells are among the essential factors in wound healing. Connective tissue cells always give birth to new connective tissue cells, epithelial cells give rise to new epithelial cells. A connective tissue cell is never formed from an epithelial cell. In other words, fixed tissue cells always come from fixed tissues and have no tendency toward reversal or other forms of cells. These fixed tissue cells, both connective and the endothelial of the vessels, are the real factors in the formation of the cicatrix. Tillman claims that the leucocytes which are present are either absorbed or perish, or they wander back into the circulation as in inflammation. He says, "On the other hand, I believe that some of the protoplasm of the wandering cells is employed as cell material in both the scar formation and the regenerated processes carried on in the original fixed tissue cells in the neighborhood. I am unable to say whether the white blood corpuscles can themselves form fibrillar connective tissue when the circulation is sufficiently active, for example, in a granulating wound of granulations, but their importance in this respect is much less than that of the fixed tissue cells, i. e., the cells of the connective tissue and the endothelium of the vessels, which have been demonstrated to be the real producers of the scar and are called fibroblasts. Reinke and others believe that further development is possible in those wandering cells, which make their appearance after the proliferation of the fixed cells has begun, |