The recumbent posture was painful, and, even when prolonged twenty-four hours, caused but slight diminution in the size of the tumor. After seventy-two hours' recumbence, they were found considerably diminished; pains in the right hypochondrial region, vomiting, etc., were, however, so constantly complained of, that all efforts to prolong this posture were necessarily abandoned.

She had borne three living children (and here is an important point); but although now five months advanced in pregnancy, she pronounced herself, and was pronounced by those who had seen her, to have been worse at two months than ever before at full term-the diseased condition, commencing with the first pregnancy, having grown gradually worse from that time. At the birth of the last child a long and hazardous delay of the head on the perineum had been allowed by the attendant (Homoeopath), under the belief and assurance that any interference was too hazardous to be thought of. After a tedious recovery this same physician, who afterward saw fit to make a directly contrary statement, assured her that she could never live to bear another child.

The danger of chance rupture of the veins was immediately recognized, and the imminent peril also, should the patient chance to survive till full term. A meeting of the Essex Medical Union being at hand, the case was laid before that body for expression of opinion and advice. A consultation was also called at the house of the patient, with Dr. John F. and Dr. Arthur Ward, of Newark. It was decided that, while the chances of recovery were against her, yet forced abortion offered the only rational ground of hope, and the patient and relatives were so informed. Here occurred a division. Her mother and sisters in the city opposed it as outrageous and unnecessary (they not having seen the condition of the diseased veins for some weeks, and most of them not at all)—the husband and patient, together with all who were cognizant of the facts in the case, uniting in urging that relief, if any could be afforded, should be granted.

Accordingly, March 22, the first attempt to bring on labor was made with a Simpson's sound, introduced through a glass speculum of small size, the great protrusion of veins into the vagina rendering a Sims speculum useless. For one month various efforts were made without success, the delays being occasioned by a desire to appease the strong opposition of the mother, who could only see in the very word abortion a terrible crime, but more especially, perhaps, by the presentation and non protrusion of membranes, and a peculiar want of sensitiveness on the part of the uterus itself, which failed to respond to any of the ordinary means usually resorted to in cases of such emergency, cold douche, extreme dilatation of os, etc., etc.

During this period the condition of the patient became more and more critical; the size of the veins increased, and the thinness of integumentary covering grew each day more alarming. The pain and distress also increasing, added a strong though silent appeal to the urgent entreaty of the suffering patient for relief. The membranes were at length with difficulty ruptured, and delivery occurred, April 23, 1868. Although a breech presentation, careful pressure over the distended veins, aided by continuous expulsive pains and the ordinary manipulation, was successful in preventing rupture.

Phlebitis followed on the second day, commencing in the vulva, and almost occluding the vagina with the now sodden and inelastic masses, gradually extended towards the uterus; severe pains occurred under the pubes, with sensations as of scalding water poured over the

vulva and groins, and swelling of extremities. By the 1st of May the symptoms were those of ordinary puerperal fever, the tympanitis, however, very slight, and condition of the patient on the whole not unfavorable. A consultation, however, was held by request of the relatives, with Dr. Tichenor, of Newark.

It is here necessary to refer again to the opposition of certain of the relatives, and it is with reluctance that I place on record proceedings so abhorrent to every sensitive mind. They had been forbidden the house by the incensed husband, but called again by the wife, who, fearing lest she might not recover, wished to leave no unkind feelings behind. They filled and took possession of the house, and, as if anxious to verify their previous forebodings, persisted in not only telling the patient she would die, but, filling the room to suffocation, stood fourteen hours about the bed, and in spite of all indignant protest prayed with her, bidding farewell, neglecting proper stimulants, etc. Having left the house in disgust, I was recalled in a few hours with the assurance that, as I had predicted, she was not dying, and was better. The lochia had returned, pain was no longer intense, the pulse reduced to ninety and of reasonably good condition-in fact, really improved. The improvement being found to be permanent and real, the time appeared to have come for a plain opinion to the relatives mentioned, in regard to their most reprehensible conduct, which resulted in a transfer of the case at this interesting juncture into the hands of their own and the patient's former physician (Homoeopath), who suddenly discovered that she could have had another child safely "under Homœopathic treatment" at full term, his former opinion to the contrary having been conveniently overlooked.

Thus were days and weeks of anxiety and unremitting attendance suffered to lose their fruits.

The subsequent history, however, furnishes a fitting sequel. Improvement continued until nature, unsupported and unstimulated by sugar of milk and infinitesimals, began to yield. The patient died of exhaustion on the 23d of May, one month after the delivery of the foetus. 105 Orange street, Newark, N. J., June, 1868.

ON THE USE OF

DISINFECTANTS IN SCARLET FEVER EPIDEMICS.

BY NELSON L. NORTH, M.D.,

OF BROOKLYN, N.Y.

BEING A PAPER READ BEFORE THE AMERICAN MEDICAL ASSOCIATION, IN MAY, 1868, AND RECOMMENDED TO BE PUBLISHED IN SOME WIDELYCIRCULATED MEDICAL PERIODICAL.

Ir is certainly not greatly creditable to the medical profession of the present day, that while such rapid advances are being made in the general theory and practice of physic, still one of the most malignant and destructive diseases is rapidly increasing in prevalence.

Scarlatina, at once a contagious and infectious malady, often so malignant as to be terribly destructive to life, in its acute stage, and in its sequele so sadly effective in destroying the constitutional vigor, as well as bodily symmetry of such a considerable number of children in every community, is so constantly prevalent in most of our large cities and villages, at least, as to make it almost appropriate to speak of it as a continuous epidemic.

An epidemic of small-pox in a neighborhood is justly deemed a misfortune, and city authorities, healthofficers, and Boards of Health, bestir themselves to have every known means employed to arrest the spread of the malady. An epidemic of cholera arouses to activity all classes of the community-preventives and disinfec

tants are resorted to almost without limit-medical officers are very properly appointed by the authorities to watch over and care for the poor, and every effort is carefully and systematically made to quell the epidemic; so with yellow fever, and partly-but not enough-so with typhus and typhoid fevers.

In the Transactions of the American Medical Association, for the year 1864, Dr. Charles W. Parsons, of Providence, R.I., in his report on the medical topography and epidemic diseases of the State of Rhode Island, gives a statistical table, in which he shows that the deaths from scarlatina were many more than by any of the other zymotic diseases, and he found by statistics that a little more than one-twentieth of the deaths from all causes in the State of Rhode Island for ten years were from scarlatina.

In the same number of the Transactions, Dr. Cyrus Ramsay, of New York, gives a very full table of the deaths in New York city for thirteen years previous to 1864, from which I discover that the aggregate of deaths from scarlatina in New York for that time was far greater than that from any of the other zymotic diseases, except cholera infantum, and this notwithstanding the fact that during the time the city had been visited by an epidemic of Cholera Asiatica.

In the report of Dr. R. C. Hamil, of Chicago, to this Association, in 1867, upon the epidemic diseases of Illinois, we find that the deaths from scarlatina in that State for eleven consecutive years averaged nearly four per cent.

In the report of the New York Metropolitan Board of Health for 1866, I find it stated that there were five hundred and sixty-four deaths in New York, during the first nine months of the year, from scarlatina.

In the report of the same body for 1867, Dr. Elisha Harris, Registrar of Vital Statistics, etc., says, "As a persistent and obstinate foe, scarlatina is more to be dreaded than Asiatic cholera." And Dr. R. C. Stiles, Registrar of Vital Statistics for Brooklyn, says, "There has been no intermission in the prevalence of scarlatina during the past year, every week having furnished its quota of deaths from this cause." And thus might be continued quotations and statistics almost indefinitely, and all would be found to show that scarlet fever in the aggregate has been for years, and is to-day, causing more deaths than any other zymotic disease.

Dr. Shrady, editor of the New York MEDICAL RECORD, in the number for April 1st, states that he has the promise from the Sanitary Superintendent of the New York Metropolitan Health Board, of semi-monthly reports of the contagious diseases of the district. The first report states that during the two weeks ending March 15th, 1868, there were one hundred and fifty-nine cases of scarlatina, fifteen cases of typhus fever, seven cases of typhoid fever, fourteen cases of diphtheria, and two cases of small-pox; nothing is said of the great number of cases of scarlet fever, as it is so common a thing that nothing is thought of it.

In the next report in the RECORD, dated April 15, 1868, we are told that from March 16 to March 31, inclusive, there were two hundred and sixty-eight cases of scarlatina, six of typhus fever, seven of typhoid fever, forty-five of diphtheria, and six of small-pox.

And now, gentlemen, as it is not my purpose at this time to go further into detail to prove what is so evident as not to require demonstration, viz., that scarlet fever is a very prevalent disease, and a very fruitful cause of death, I come at once to the suggestion, whether something more than is being done, might not be done to prevent the spread and mitigate the malignancy of this malady.

Could Boards of Health be induced to adopt plans for

systematic and thorough cleansing of the apartments and houses containing the sick of scarlet fever, as well as carefully to disinfect the clothing and persons of the sick, I cannot doubt but great good would result. At present it is not too much to say, that nothing effective is being done in this direction.

Physicians note the frequent and still more frequent epidemics of scarlatina, observe its spread from house to house, and from street to street, evidencing its contagious and infectious character in all its course, and yet they do nothing but follow on in old routines. Nothing authoritative, nothing systematic, is being done to prevent the onward progress of the malady. It certainly is not upon merely theoretical grounds that a systematic use of disinfectants is urged in zymotic epidemics-facts demonstrate the beneficial results from such a course; and did time permit, a very considerable amount of individual experience might be brought to bear upon this point, but I forbear.

Dr. Elisha Harris, of the New York Board of Health, from whom I have before quoted, says (Report for 1866): "But while it holds true that this malady is most prevalent, as it is also most infectious, among the tenant-house and cellar population, it is also painfully true that both its communicability and malignancy is increased by the foul local atmosphere of such domiciles;" and says the doctor, "from the first organization of the Board of Health, this bureau has made it a duty to forward to the family where scarlatina is reported fatal, plain advice to gather up and boil for an hour all infected clothing of the patients, or to immerse the things in dilute chlorinated soda, or in a well-colored solution of permanganate of potassa; and to ventilate the sick-room, etc., for days, very thoroughly; "prompt action recently taken by the Sanitary Superintendent in regard to scarlatina will save many lives."

The Registrar-General of England says, "It should not be overlooked that prophylactic measures are available against scarlatina as well as small-pox."

The Metropolitan Board of Health of the State of New York, which includes within the limits of its district the cities of New York and Brooklyn and suburbs, demonstrated during the last cholera epidemic, how much could be and how much was done by that body to prevent the ravages of that dreaded pestilence, simply through the use of disinfectants, in connection with a careful plan of quarantining, and separating the well from near contact with the sick. I am glad to say they have recently taken another step in the right direction, and require the physicians of the district to report to them all contagious diseases, and advise the use of disinfectants, particularly in scarlet fever; and it is to be hoped that at no distant day they may see the necessity of adopting some yet more decided measures, looking to the prevention of the disease in question. If they would but enforce during epidemics of scarlet fever, the very excellent and complete set of rules which they now simply recommend, I feel certain that such good would result therefrom, as would be eminently satisfactory both to the profession at large, and to the general public.

And let us continue to hope and urge that not only the New York Board of Health, but that other governmental bodies and health authorities will follow in the course, until it shall be demonstrated beyond a cavil that zymotic diseases may to a very great extent be prevented, if not wholly exterminated, by destroying with disinfectants the subtle poisons which are the communicable causes of such diseases.

HEAVY BRAIN.-The brain of the late Hon. D'Arcy McGee weighed fifty-nine ounces.

viii

IN August, 1867, I was called to see a little Swede boy æt. 11 years, said to have typhoid fever. I found that he had been sick three weeks; that now, with but little diarrhoea, his body was covered with dark colored petechiæ, some of them quite large. Pulse rapid and weak; tongue red and dry. By the use of quinine and acid. sulph. aromatic., with wine and proper food, hydr. c. creta and anodynes internally, and salt spongebath externally, he convalesced in four weeks. Giving his parents warning of the danger of exposure to damp and cold, I discharged him. In October I was again called, and found that a week before his face on the right side had begun to swell and pain him. When I saw him the swelling was so great as to obliterate almost entirely the features of that side. It extended over the temporal region and below the inferior maxilla. The skin was hot, red, and shining. Making a free incision just in front of the masseter muscle, about of pus were discharged, much of it coming from the temporal region under the zygoma. The poor little fellow was almost exhausted by the suffering which he had undergone; the jaws were closed, and swallowing, even of fluids, was very difficult. Hot fomentations were applied, and tonics and anodynes resumed. Pus discharged freely from the wound, and from sloughs in the mouth, and externally under the eye. In ten days I was enabled to get a view of the cavity of the mouth. The posterior portion of the alveolar process of both superior maxillæ and of the inferior maxillæ, right side, with a portion of its body and ramus, was necrosed, as was also the orbital plate of the superior maxilla of same side. After a severe struggle with exhausting purulent discharge and consequent hectic, he began to mend rapidly in December, and exfoliation as rapidly advanced. I removed, before he was well, most of the alveolar process of the molar and bicuspid teeth, with the teeth themselves; a good share of the orbital plate of superior maxillary bone, several pieces of bone, which I cannot exactly locate; and on January 28th, the patient being under chloroform, I removed the right angle, ramus, and articulating head of the lower jaw entire, with nearly the whole of its coronoid process. When he had recovered consciousness, I gave the boy a piece of spruce gum to chew. He masticated it easily on the right side, and I found he had every natural motion of the jaw, except that he could not open the mouth to the normal extent, because of the thickening and induration under the jaw, caused by the exfoliation of the adjacent surface and alveolar border, which was not yet complete. On the first of March he reported perfectly well, every motion of the jaw perfectly performed. Careful examination proves the existence of new bone so perfect as to differ in no respect, except in a little increase of size, from that which it replaces. New teeth have succeeded the ones lost, and their mucous alveolar border is as perfect as in the healthiest mouth, the lost bone seeming to have been replaced in every instance. The deformity remaining consists of a slight retraction of the lower eyelid by the contraction of the infra-orbital cicatrix and the attached cicatrices about the right angle of the lower jaw. In my library I do not find a case of more complete restoration of bone on record. Hav

ing watched this case from the beginning, and having the specimens and their history, I venture to offer it for publication. As to the cause of so extensive necrosis, I am ignorant. I at first thought of mercurial salivation, ing his sickness did he take mercury, except in the form but that was negatived by the fact that at no time dur of hydr. c. creta, and of that but little. Nor at any time did he manifest any symptoms of such effect. When I saw him in October I found the gums, except where necrosis was in progress, perfectly healthy, the teeth white and clean, and there was no unusual secretion of saliva, or mercurial foetor of the breath, nor, as far as I could learn, had there been any.

I attribute the restoration of the bones and of motion to the jaw, and the regular eruption of the teeth, to the care taken not to interfere with the natural process of repair till it was evident that the separation of the dead bone was complete and its substitute nearly complete also. Except in the case of the angle and ramus of the jaw, this process was evident in the elevation and extrusion of the necrosed bone. As to the angle and ramus, when satisfied that the separation of living and dead was complete, and that the new bone was strong enough to permit the extraction of the old, I removed it by the exertion of considerable force.

Original Lectures.

LECTURES ON TUMORS:

BEING A PORTION OF THE COURSE OF SURGERY AT THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA,

SESSION 1867-8.

BY S. D. GROSS, M.D., LL.D.,

PROFESSOR OF SURGERY. (Reported expressly for THE MEDICAL RECORD.) VII.

(Concluded from page 174.)

THE TREATMENT OF MALIGNANT TUMORS.

IN regard to extirpation, or ablation, or excision, the profession is not agreed as to the propriety of the measure. Some surgeons advocate the removal of all tumors that are accessible to the knife, especially in the earlier stages of the affection; others, on the contrary, are opposed to this kind of interference even in the earlier stages of the disease. I suppose we shall find that a proper medium is at least the safest guide for the surgeon. There are cases, according to my observation, in which the knife should undoubtedly be employed; the only question that arises is as to the time for the operation, and the circumstances under which it should be performed; this is the great point for our consideration. Now there are certain contra-indications in regard to the performance of these operations. In the first place, when the disease is congenital or when it exists as an intra-uterine affection, or comes on within a short period after the birth of the child, such cases ought not to be interfered with by the knife, for experience has shown that these are not suitable cases for surgery; no matter how carefully the operation may be performed, how accurately the parts may be excised, there will be a return of the affection within a compar atively short period after the operation has been performed, either at the cicatrix, supposing the wound to heal, which is not always the case under such circumstances, or in some other part of the body more or less remote. The same is true when these diseases coexist

When the patient is laboring under what is called the cancerous cachexia, when the disease has made an impression of a peculiar character on the system at large, as evinced by the peculiar appearance of the countenance, rapid waste of muscle, disorder of the digestive apparatus; in other words, when there is serious constitutional involvement; under such circumstances we abstain from the use of the knife. We abstain from the use of the knife when there is serious lymphatic involvement; for example, in a case of scirrhus of the mammary gland with serious involvement of the axillary ganglions. We abstain from incision when there is ulceration to any extent; if we operate under such circumstances, it is simply to get rid of the offensive odor, which, in itself, is frequently enough to poison the system. Such a case was before you recently, in which I removed the mammary gland after ulceration had occurred, because the discharge was offensive to the patient herself, as well as to those around her, for there was a copious flow from the ulcer, establishing a serious drainage on the system, and for these reasons I was induced to perform the operation.

We operate then, generally, when the case is of a favorable character; that is to say, when there is no serious constitutional involvement; when the tumor has been growing slowly, when it has not acquired any very large size, or when it is comparatively small; when it has not contracted any extensive adhesions to the surrounding structures; when there is no tendency to ulceration; when there is no lymphatic involvement, when the constitution at large is perfectly sound, as not unfrequently happens in cases of this kind; under such circumstances we do not hesitate to operate, or excise the affected structures.

Cases sometimes occur in which the disease, especially when of the scirrhous variety, is of long standing. I have myself seen a number of instances of this kind. When this is the case, when the disease is, as it were, latent, manifesting no disposition to progress, or to involve the surrounding structures, or the constitution, the best plan, according to my judgment, is to allow the tumor to remain; not meddling with it in the slightest degree. It has been shown, under such circumstances, that the patient may live in comparative comfort for many years, fifteen, twenty, or even twenty-five years. I had such a case eight or nine years ago, in a lady over seventy years of age, formerly a patient of Sir Astley Cooper, in whom such a tumor remained for twenty years in the mammary gland, in a state of latency. At the time she presented herself to me, it was progressing, and I removed the gland. She subsequently died, in North Carolina, from some other intercurrent disease.

All these cancerous products have, usually speaking, a short life, in consequence of the peculiarity of their organization; and when we perform an operation, the tendency is to return, either at the cicatrix, in the neighboring lymphatic ganglions, or in some other part

These affections are not inoculable. Experiments have been performed in many instances, especially with the matter of melanosis and epithelioma, without any results to prove the fact that the disease can be propagated in this way. There would seem to be, therefore, no specific poison, such as that which characterizes chancre, gonorrhoea, small-pox, and other affections, where the poison is of that peculiar zymotic character; no poison, but a peculiar cell development; but whether the cells of these formations are peculiar, or whether they are superadded to the structure in which the morbid affection appears, or whether they are simply modifications of the original or preexisting natural cellsfor the whole body is nothing but a series of congeries of cells-is a point not yet determined. This much is perfectly certain, that when a disease of this kind is once called into activity, there is rapid proliferation, formation and multiplication of cells; and these cells, as has been shown by Schroeder Van der Kolk, are not always limited to the morbid mass itself, but are scattered through the surrounding tissues, forming thus new foci of further development, so that, no matter how thoroughly extirpation may be effected, these cells, existing in the neighborhood of the mass that has been excised, will form the basis of new growths, or of secondary formations, as they are called.

You will find, gentlemen, that the experience of surgeons, in regard to the operations performed for the relief of these growths, varies very much in different countries, and in different communities. Some surgeons, well-informed, intelligent, and apparently honest, will tell you that nearly every operation of this kind is a success. I beg you always to receive such declarations with a grain of allowance, and a very big grain at that. It is the result of my observation, now extending through a period of active professional engagements of upwards of thirty-five years, that comparatively few of these operations are ever successful. I can point to only a few instances where my efforts have been crowned even with temporary success, much less anything like permanent triumph. I recollect a lady who used to live in Thirteenth street, in this city, from whom, after the age of sixty-five years, I removed, five years ago, the mammary gland of the left side on account of a scirrhus of that organ. She had previously been subjected to an operation involving only a portion of the gland. When I saw her, some six months afterward, I found that all the symptoms were well marked; there was every characteristic feature of scirrhus. I removed the whole mammary gland, and to this day she has remained entirely well, enjoying excellent health.