ture of iodine being his usual application. In speaking of some of the other men in his department of work, he freely criticized some of the more prominent authors and teacher, but in a pleasant and inoffensive manner. Hypnotism has been tried as a relief of pain during labor. A very nervous woman was placed under this influence and carried through her parturition with apparently no pain. She was aroused, however, from her unconscious condition with much difficulty, and the practice was not gaining many adheIn this connection I may remark that Dr. Wagner, a graduate of the College of Physicians and Surgeons of this city, while in London, commenced some experiments in this direction. He has already reported to me two cases, and he is quite an enthusiastic believer that there is much for us to learn in this procedure, by which the pangs of parturition may be lessened.

rents.

with the laryngoscope of every patient who came to me with this symptom. The result was communicated in a paper to the Congress of Laryngologists held at Milan in 1880. I found that but very few cases indeed are of a hysterical character-that is, of the nature of a phantom sensation-though uterine or ovarian disorder is a not infrequent predisponent, or, at least, concomitant of the throat condition in the female sex.

Extending the term globus hystericus, I find that, with hardly an exception, all and every other subjective sensation in the throat is symptomatic of an objective cause. The chief of such feeling are those of a heat, a prickling, a swelling, a weight, a straw, a hair, or other foreign body. A few patients-one especially, a hale farmer-have complained of a feeling of intense cold, which is sometimes relieved, sometimes aggravated, after foodtaking. In some instances there is actual pain with spasm, cramp, and a sensation of

THROAT AILMENTS.

BY MR. LENNOX BROWNE, F. R. C. S., OF LONDON.

this symptom varies in degree from a slight hacking, to the loud hyena-like bark known as nervous laryngeal cough. Many of the cases of so-called laryngeal vertigo, or, as I

tember 19, 1887.

In accepting the very flattering invitation of your President to speak a few words to the members of the Philadelphia County Medical Society, it appeared to me both more becoming and more profitable to offer you some practical remarks explaining the rationale of some of the commoner of throat ailments, than to attempt to magnify the office of the laryngoscope by the relation of rare and wonderful cases. I was the more inclined to this view because I was well aware that, through the assiduous industry and wellknown skill of your President and other members of your Society, you have for some years been kept thoroughly posted in all that is new in laryngology.

It is now some ten years since first I sought an objective explanation of the condition known as globus hystericus, and since I commenced to make a systematic examination

seizures, are capable of explanation and cure, on the lines I am at present taking.

On examination of the throat of a patient with symptoms such as I have described, one may or may not see chronic congestion and relaxation of the fauces and uvula, enlargement of the tonsils or obstruction by caseated material of the orifices of the crypts, granular pharyngitis, or even laryngeal hyperemia. Where any one of these conditions is present, treatment thereof may or may not give relief; but none of them represents the class to which I would draw your attention, namely, that in which there is no generally recognized morbid state of local significance.

The results of laryngoscopic investigations. in my hands have shown that there is:

1. A varicose, and even truly hemorrhoidal condition of the veins at the base of the dor. sum of the tongue, sometimes at the under surface and sides, in which last case it may

severe hepatic derangement, or even of cerebral lesion. There is often a similar varicose state of the vessels in the superior surface of the epiglottis.

2. An enlargement of circumvallate papillæ at the back of the tongue, causing the epiglottis to be hindered in its movements--imprisoned, as your President first called it.

Just drawing attention to the fact that the structure of these glands is very similar to that of the tonsils, I may mention that in a few instances I have seen actual blocking of the orifices, similar to the condition known generally as chronic follicular tonsillitis.

I may also note that it is not possible to see these things either with a tongue depressor or in the laryngeal mirror as ordinarily employed. Many observers, especially beginners, seem to consider that their sole aim is to see the vocal cords, and if these are sound, they write down, "larynx normal"; but they omit to look well to the frame-work. To see this condi tion of lingual varix and glaudular hypertrophy, the mirror must be placed quite high up in the throat.

Where, as is often the case, there is no actual or noticeable enlargement of the thyroid gland, it will be observed, on passing the hand gently over the front of the throat, that there is a distinct fulness of the thyroid isthmus. If the least pressure be made at this situation, the patient--not necessariya female--will complain that the abnormal sensation is at once excited, and, on being questioned, will admit that when it occurs the collar is felt to be too tight for the neck. Inquiring into the general health, and happily failing to find any of the more serious lesions to which I have alluded, it will be noted that habitual constipation and a generally defective circulation are both frequent symptoms; while in others there will be concomitant evidences of a varicose diathesis, as rectal hemorrhoids, varicocele, or varicose veins of the extremities.

In females the menstrual flow is often morbidly frequent or excessive, and there are other evidences of an enfeebled vasomotor

excitants of the condition; and in the cases of singers or public speakers, defective methods of filling the lungs-forcing the lower registers upward, or other functional fault which may lead to undue strain on the palato-pharyngeal muscles and engorgement of the vessels in this region are fruitful predisponents.

In this connection, I may refer to the accurate explanation offered by your fellowcitizen, Dr. Carl Seiler, of the etiology and pathology of chronic pharyngitis when occur ring to voice users.

Some of those obscure cases which come under our occasional notice, of the presence of small quantities of blood in the mouth, or of the taste thereof on rising from sleep, will be explained by the leakage of one or other of these enlarged and hemorrhoidal venous capillaries in the region now under consideration.

A few words as to treatment. If the case is not of long standing or of aggravated character,correction of the main constitutional cause-cessation of the faulty method of voice production, or prohibition of a vicious habit or indulgence-may be sufficient to effect a cure, but this is rarely the case. Of remedies, I give chalybeates and aperients with digitalis or ergot, as may be indicated. Locally, astringent applications, especially of chloride of zinc or perchloride of iron, are by no means without avail; they can be applied by the patient himself. Gargles as ordinarily employed are useless, and occasionally are productive of exacerbation of the symptoms. Not so if employed by the method known as that of Von Troeltsch. Of lozenges, I find those of muriate of ammonia much more active in leading to resolution of the venous congestion, than those of red gum, rhatany, etc.

Recent investigations show that the astringent properties of tannin have been exaggerated. Where the uvula is relaxed, the snipping of an elongated portion, especially if other functional or constitutional faults are corrected, may lead to a cure; but in a certain proportion of patients in which the promises

of the specialist as to the good effects to be gained by the procedure are not realized; the cause of failure will be found in non-recog nition of the various vessels. Treatment of these is best effected by the galvanocautery point, and it is necessary to seal each individual enlarged vessel. For this purpose it may be necessary to make more than one application. Lastly, there is often a hyperemic tumefaction of the vessels, glandules, and submucous tissues of the pharynx, nasopharynx, and turbinated bodies; these will also be best treated by galvanocautery.

In conclusion, I would say that in case it may be objected that the conditions I have described are but representative of an advanced chronic congestion, I do not deny that such occasionally may be the case. In the majority, however, there are no such antecedents; and where the two exist, the practitioner will fail to cure his pharyngitis, or what not, until he has recognized and treated the varix.

And it is in this light that I have ventured to call attention to the subject as one that is not generally recognized, for beyond a short communication at Milan by my deceased colleague, Llewelyn Thomas, I have seen no allusion to it in any books or archives, and no notice is taken of it by the great teachers of Vienna. I therefore make no apology for having occupied your time with considerations that may at first appear trivial, or of exaggerated importance.

REPORT OF A CASE.-LAPAROTOMY.

DR. R. L. JOHNSON, ROLLA, MO.

The patient was a woman aged 58 years; had not menstruated for many years, youngest child being 26 years of age. For last twenty years has suffered from time to time with pain in right inguinal region. For the last eight years has known that she had a tumor in her abdomen. When first noticed, the tumor was movable and situated in the median line. Vaginal examination revealed nothing markedly diagnostic; no vaginal discharge.

When the finger was held against the neck of the uterus, and the tumor freely moved about, no motion from it was communicated to the cervix. Has suffered from dysuria and ascitic distention of abdomen. Tumor now occupies umbilical region, is movable, apparently firm in texture, and from the extent and direction of its mobility, we judged its attachment to be in the left iliac region. Dr. T. J. Jones, the case being under his care, diag nosed ovarian cyst, and proposed an operation. In this I concurred, and being asked by Dr. Jones to use the knife, I made the incision from the umbilicus to the pubes.

Chloroform had been administered, and through the relaxed abdominal wall it was evident that a portion of the tumor at least was solid. As soon as the abdominal cavity was opened, the contained fluid began to pour forth, and the cavity was emptied by means of a siphon tube. Examination of the tumor then showed it to be a large solid mass, rough from ulceration, and apparently immovable. Remembering however how freely movable it had been in the fluid, I concluded that it must be pedunculated, and pushing my hand down to the left portion of the pelvic cavity, found a pedicle the size of my two thumbs. Although only weighing five pounds, the tumor was solid and unyielding, and the incision had to be extended upward a short distance. The mass was lifted up, and pedicle tied. The extremity of the Fallopian tube was found firmly attached to the pedicle, and to avoid delay was removed with it. Pedicle was lig ated, and cut with a hatchet-shaped cauteryiron, which had just turned to a black heat. The action of the cautery was extremely satisfactory. The only adhesion which the tumor had formed was to the small intestine, and was not extensive nor firm. The incision was then closed, silver wire sutures at intervals of three-quarters of an inch being inserted, including half inch of peritoneum and edge of tendon. These were clamped by perforated shot; silk sutures were placed between them through the skin. No sponging or irrigation of the cavity had been resorted to, the fluid being simply pressed out carefully.

Iodoform was the antiseptic used in dressing, and the wound was almost hermetically sealed up by adhesive strips and bandages. There was decided shock, but reaction was established in a few hours. Suffered considerable pain and discomfort for some hours, which were relieved after drawing off the urine. The following day was greatly annoyed by retching and vomiting, which ceased at the end of twenty-four hours. Pulse on the third day after operation was 130, but was not much increased in rapidity the remainder of

the time.

Temperature only once reached 101°, and was generally but little above normal. In tellectual disturbances, such as incoherency and lapses of memory troubled her for a number of days, but gradually disappeared.

The deep wire sutures were removed on the 10th day, and wound found completely closed and union of its edges firm. From this time on patient progressed favorably and rapidly.

The tumor consisted of two masses, each being nearly cylindrical, the smaller about the size of an orange, the larger about five times this size. The free end of large lobe was ulcerated, exposing a very hard calcareous mass. At present, nearly three years after the operation, the patient has a ventral hernia, which she herself attributes to heavy

work done soon after recovery. The tumor was referred to Dr. Robt. Luedeking, Prof of Pathological Anatomy in the St. Louis. Medical College, and was pronounced by him to be a fibro-myoma.

NYSTAGMUS AMONG EPILEPTICS.

Dr. Ch. Fere found 24 cases of nystagmus among 170 epileptics. In the case of hemiplegic epileptics he found the oscillations moving in the direction of the healthy side. Fere believes that the nystagmus in these cases is owing to a paresis of a certain mus cle that cannot fully antagonize its counteracting muscle, and that the direction of the oscillations is always toward the diseased hemisphere, and points to the anatomical seat of the lesion. Nystagmus occurring in epileptics is, moreover, frequently accompanied by strabismus, differences in the size of the pupils, etc.

COCAINE IN CHOLERA INFANTUM.

Paris Medical says that wonderful results have been obtained from the administration of cocaine, in even far advanced cases of cholera infantum. One centigramme of chlorohydrate of cocaine was given every two hours, or even every hour, according to the severity of the case.

WEEKLY MEDICAL REVIEW,

EDITED BY

THE MEDICAL PRESS AND LIBRARY ASSOCIATION.

Contributions for publication should be sent to Dr. B. J. Primm, 3136 Olive Street.

ments or Subscriptions should be addressed to

J. H. CHAMBERS,

914 LOCUST STREET, ST. LOUIS, MO.

SATURDAY, OCTOBER 8, 1887.

PATHOLOGY IN MEDICAL SCHOOLS.

An article by Frank S. Billings on this subject, which has but recently appeared, although strongly worded in its denunciation of the present method of teaching pathology, is yet probably called for by the imperfect state of affairs in medicine, and, as he clearly shows, more particularly in regard to the teaching of those subjects which are generally looked upon by American practitioners as theoretical, and poorly adapted to the pecuniarily successful practice of medicine.

That most of our schools are but poorly equipped for the pursuit of the study of pathology, and that but little interest is shown by its teachers in awaking that enthusiasm among its students which is necessary for its earnest pursuit, is plainly evident to anyone who, like Billings, will send for the catalogues of our best medical colleges, and glance over the curriculum of studies. And yet we can not but feel that in his article he is influenced by the feeling that every student of any special branch has-that feeling which attributes to his own branch the highest importance, and which leads him to think that it is the study of that particular branch which will best enable a student to arrive at success. The teacher of general medicine thinks that his lectures are the all important ones; the teacher of surgery is of the opinion that the surgical lectures are the ones most necessary to the student; and so on, throughout an entire faculty, each member feeling the importance of his own branch to himself, and unable to bring himself to the belief that they

would be but poorly supplied, and pathologists, for instance, would find their value far below par. Pathology is not confined to Germany, nor inventive genius to America, yet in their respective countries each far surpasses the other in thoroughness; still, that does not call for an equal distribution of labor at these two pursuits, for different kinds of mental conditions and the most widely varying circumstances,adapt one people to one kind of work, and another to a different kind. No two persons can reach the same point in all branches, and it is far better that each should follow the study for which he is best fitted, and by mutual intercourse aid one another, than for both to be mediocre in both branches. It is the same principle which has established our system of civilization of to day

that of "division of labor." If Germany is doing better work in pathology than other countries, America is reaping benefits from it; while, at the same time America is doing. better work in some line than Germany, and the latter is benefited thereby to an equal extent to our gain from her. Too much, however, cannot be said in favor of pathological work in this country, for, as Billings says, it is the "reason why" of all disease— the beginning point from which we start on our way to successfully meet it and treat it; only, in striving to put the matter before the profession, he has viewed it from his own standpoint as a patho-biological director, and not as an individual part of a great whole, each member of which has his own particular work to do, benefiting others, and being benefited by their work.

ONE MAN'S FEES.

Dr. J. Marion Sims, in a letter to the late Professor Samuel D. Gross, published in the