that in phonation the vocal bands become approximated naturally, but, if the phonatory effect be continued, the two ventricular bands are forced together in close apposition, and in further continuance of the phonatory effect, Hilton's sac on the left side suddenly bulges forward with an audible jerk into the interior of the larynx as if shot out from an air gun, presenting much such a picture as though the horn of the hyoid bone had just undergone dislocation; and in another second the right sac is thrust forward in a similar manner, but to a less extent. The sac in the left side looks like a small globular tumor the size of a small cherry, of much paler aspect than the remainder of the larynx by reason of distension of the mucous membrane.

TRACHOMA IN THE NEGRO.-Dr. Swan M. Burnett, in a report of the Washington Central Dispensary covering four years, cites forty cases of trachoma. One case only was found in a negro (a very light mulatto).

SKIN AND VENEREAL. LICHEN.-Vidal (“Gaz. Med. de Nantes") advises alterative purgatives in the treatment of this affection. In chronic types he advises sodium arseniate. Coffee, tea, strongly alcoholic beverages, salty meats, pork, game, cheese, shellfish, salt fish, late hours, violent emotions and fatigue must be avoided.

ERYTHEMA PAPULATUM OF THE BUTTOCKS IN INFANTS.-Dr. Sevestre ("Concours. Med.") is of opinion that it is at times difficult to distinguish between buttock papule erythema in infants and papulo-erosive syphilides unless the case be observed from its inception. The eruptions are dark red in color, sometimes shade off into brown or violet, flat, firm with shining epidermic center. Beside the papules are erosions of the same form. The eruption occupies the prominent part of the buttocks, and does not involve the natural folds of the skin. The disease begins as a vesicle, followed by an erosion and the papule after a few days fades into a brownish macule. The contact of urine and fæces is the exciting cause. The appearance of the fully developed papule resembles the syphilide. The diagnosis depends on the absence of other luetic symptoms and the history of the case.

ARSENIC CANCER AND DERMATOSES.-Dr. W. B. Hadden has seen several cases of erythematous eruptions in children, with chorea, taking arsenic. Mr. Harrison Cripps thought Mr. Hutchinson ought to bring forward further evidence. In the first case there was, so far as could be gathered, no evidence, clinical or microscopical, that

cancer.

the disease was epithelial cancer. In other cases the chronic psoriasis might have acted as a chronic irritation, and have thus produced the cancer. Mr. Makins suggested that inquiry ought to be directed to ascertain whether the arsenic eaters of Styria developed this form of Mr. Eve believed that epithelial palmar cancer always presented peculiar appearances which agreed with those described by Mr. Hutchinson, and added that lympho-sarcoma of the lungs occurred with considerable frequency in workers in cobalt mines, a fact which he thought lent support to Mr. Hutchinson's theory. Sir Jos. Paget had seldom heard an argument founded on clinical and pathological evidence more definitely suggesting the conclusion advanced. It must be remembered that chronic psoriasis was sometimes followed by cancer. In face of the facts advanced by Mr. Hutchinson it could not be doubted that arsenic had a power in predisposed persons to determine the development of cancer. The first two cases he had seen himself, and had been clearly of the opinion that the disease was cancerous. Mr. Hutchinson said that Dr. White, professor of dermatology in Harvard University, had already published the second case, and had advanced the opinion that the psoriasis produced warts, and the warts the cancer. But there were no warts, and the cancer developed not on the sites occupied by the psoriasis, but in the palms of the hand, which were quite free from disease. Microscopical evidence in the early stages of cancer was often misleading. In this American case many most competent pathologists, both in England and on the Continent, had, after examining the microscopical specimens, formed the opinion that the growths were not cancerous, yet the patient undoubtedly had cancer, and died of it. He believed that herpes zoster was certainly produced by arsenic; arsenic eczema had already been described. A remarkable fact about arsenic eruptions was that they were never symmetrical.

GENERAL MEDICINE,

MENTAL PHENOMENA FROM MALARIA.— Dr. J. P. Francez ("New Orleans Med. Jour.") reports the case of a 35-year-old V-para who had been subject to malaria from infancy, had been dyspeptic for years and had had two attacks of insanity prior to marriage. An aunt died insane. Last March she began to show dullness of spirits, fits of great abstraction, and indifference toward her husband, children and relatives. One day, while sitting upright in a chair, she fell prostrate to the floor, unconscious. After a few hours she became quite agitated, talkative and

emotionally excited. She was then subject to hallunciations, saw devils, battalions of soldiers and disguised men surrounding her and attempting to force her domicile for the purpose of raping her. She fought those around her bed; called her husband to stand by her, seized her new-born babe and almost choked it before it could be taken away from her. This condition continued twelve days; every second day more pronounced agitation was noted, and late in the evening fever occurred. During the fever and agitation she kept her hands between her thighs, violently shaking; groans, murmurs and uninteligible language accompanied these acts. On the thirteenth day the patient was lucid, the child was taken to the breast and her family affection seemed to revive. Next night some agitation occurred with the same acts with the hands. When the intelligence became brighter, during the acts, agitation and fever, she became violently nymphomaniacal. On the nights and days free of fever no sexual disturbance was manifested. Treatment consisted of potassium bromide and chloral hydrate, quinine sulphate, infusion of gentian root, muriatic acid diluted, pepsin, external application of iodine to the spleen, and Fowler's solution of arsenic. The patient recovered after four months' treatment. The phenomena descibed belong to the hysterical insanity of Spitzka and Kraft-Ebing, and it seems probable that the hysterical neurosis was present giving rise to mental disturbances which were evoked by the exciting influence of malaria. There is possibly a puerperal element in the case also.

PNEUMONIA WITH TYPHOID SYMPTOMS.— Dr. Jas. C. Thomas, Baltimore ("Med. and Surg. Rep."), reports the case of a 47 year old man who had been suffering from business worry and had been complaining for some time. He fainted once in a Russian bath and struck his shoulder, bruising it. He went on ailing and feeling badly. His wife noticed that he had fever; the week following he had symptoms of typhoid fever. He had no diarrhoea, no pain, no expectoration and little or no cough. All his uneasiness was situated at the pit of the stomach. He had had typhoid fever ten years before and this attack had commenced in the same way. On the second or third day some crepitation was discovered in the right lung and the whole lung became solid. Eight days after there was defervescence and the patient was very faint The temperature was normal. Three days later a pneumonic trouble was found in the left lung. Latter he did well, had no fever, pulse was normal and respiration 20, and he had a good appetite. On Sunday he took a cold bath, which brought on a pleurisy. The interest

ing points about the case were consolidation with crepitation and absence of pain, cough and expectoration.

ALBUMINURIA WITHOUT RENAL LESION.— Dr. Pavesi ("Gazz. degli. Ospit.") divides this condition into the following types: 1. Acute or accidental and transitory forms; albumen may sometimes be found in the urine of perfectly healthy individuals, after unusual mental or physical exertion, during digestion, or after cold baths. 2. Intermittent albuminuria; in this form the urine excreted during the night contains no albumen, that formed in the morning contains a small quantity, and the proportion goes on increasing up to noon, when it begins to fall off again and disappears completely in the evening. This is met with most frequently in youths, and has been called albuminuria of adolescence. The patients, usually not robust, may be weak and anæmic, but neither cardiac nor renal lesion is detectable. The prognosis is good. The remedies most useful in this albuminuria are iron, arsenic, quinine, milk diet and rest. 3. There is a form in which albumen is permanently present.

ELECTRIC LIGHT AND HEALTH.-Dr. Renk, Munich, has been experimenting on the utility of the electric light, from a sanitary standpoint, in the Munich National Theater. He found that the electric light had hardly any influence on the deterioration of the air, whereas the gaslight raised the temperature of the air, deprived the air of its oxygen and rendered it injurious by increasing the carbonic acid, especially in the lower regions of the theatre. Dr. Renk does not discuss the light in its eye relations.

CHINESE MEDICINE.-A Chinese physician ("Western Druggist") considers the following drugs of chief value in practice :

PUERPERAL ECLAMPSIA.

[To the Editor:] The accoucheur who is brought face to face with puerperal eclampsia for the first time is not likely to forget it during the rest of his professional career. In obstetric practice convulsions, according to statistics now at hand, occur about once in a thousand cases. These include all varieties; hysterical, epileptiform and toxic or uræmic. The differential diagnosis of these conditions is better understood than formerly, but whether there has been a corresponding advance in therapeusis is an open question. The fact that the majority of these cases is due to uræmic poisoning is pretty generally admitted, and this is doubtless the cause of death in most fatal cases. The proportion of fatal cases, under all methods of treatment, is, so far as can be determined, about 25 per cent. Under the old methods, venesection, calomel and antimony, some were doubtless saved who would have died under the modern anæsthetic and narcotic method. On the other hand there is reason to believe that patients recover under the judicious use of chloroform, morphine, veratrum viride, etc., who would have been sacrificed under the old method.

My present purpose is to provoke discussion by those of less limited experience in this interesting affection by outlining some cases which have come under my observation.

Thirty years ago while in Taunton, Mass., I was called to a 20-year old healthy-looking primipara at sunset. She was well advanced in the first stage of labor, with the os dilated to about the size of a silver dollar but rather markedly rigid. The pains were strong at five to ten minutes' intervals. She was a stout, phlegmatic woman who made little or no complaint during the pains. After a couple of hours I found scarcely any appreciable increase in os dilatation, but still considerable rigidity, whereupon I proposed ether. This was strenuously objected to by her mother and nurse, so I compromised on a 4 grain pellet of morphine, and went home, telling them to call me when the waters broke, since I lived but a few yards away, and the presentation was natural. At early dawn I was called and found the head pressing on the perineum, and everything progressing favorably. Labor had been active all night but the patient did not seem to suffer much and at 7 A. M. was naturally delivered of a lively, good sized boy. The placenta followed immediately. It was a remarkably clean labor. There was no perineal laceration and very little discharge of blood

The uterus contracted well, and the patient seemed to be in good condition, but rather drowsy, which I attributed to her rather protracted labor and the morphine given her the previous evening. I had hardly reached home when I was summoned in haste, as my patient had gone into a fit. I found her in a terrific clonic convulsion. She was given ether at once very freely, and a large hop poultice applied over the abdomen. She soon rallied from the convulsion which did not return. Her restoration to perfect health was rapid, and without other untoward symptoms. Her mother stated that she had never before had any kind of fit, and that her family was free from epilepsy, or hysterical attacks.

Just after the close of the war, while located in Kansas, I was called by a brother practitioner to see a multipara delivered the day before, who had several post-partum convulsions. She was rather a full-blooded woman and we agreed to bleed her, which was done freely. After the bleeding the fits recurred just about as often. She died in one of them some twelve hours from the time I first saw her.

During the past fifteen years of practice in Rhode Island, I have seen but two cases of puerperal convulsions, one in Warwick, and one in Cranston. The one in Warwick was an 18-yearold, well developed, apparently healthy primipara. Labor progressed naturally until the head pressed on the perineum. Suddenly she was seized with an awful convulsion. I gave ether at once, applied the forceps, and delivered her with very slight laceration. The fits continued at longer or shorter intervals for twenty-four hours, after which she rallied, and made a good recovery. The administration of ether was kept up whenever she had a spasmodic seizure. In this case recollection of all events three months previous to confinement was completely obliterated.

A 38-year-old, previously active and apparently healthy, VII-para, during the latter part of this gestation had been troubled with œdema of the lower extremities. Two days before I was called she had been about her family duties. While sitting at her bedside in the early stage of labor, before the presentation could be definitely made out, having a pleasant chat, I noticed every now and then a slight convulsive movement of the eyelids, and an occasional peculiar stare at the ceiling. On examination the urine was found loaded with albumen. Taking her husband aside, I told him I felt anxious about his wife and thought her liable at any moment to convulsions, and if he wanted consultation, it would be well

to call some other physician at once. He seemed much surprised, said she had been pretty well of late, had always got along nicely, and perhaps we had better wait. In less than ten minutes after we had returned to the room the patient was attacked by one of the most awful fits I ever saw. Many physicians were called in consultation, but the fits continued. Twenty-four hours after the first one she was delivered of a stillborn infant. Despite all treatment she had repeated convusions after delivery, and, several days after, died from effusion within the pericardium.

The present article has been intended rather to provoke discussion than to settle any of the mooted points in the management of this affection. W. J. BURGE, M. D.

PAWTUXET, R. I.

[To the Editor :] I am very thankful that my experience in puerperal eclampsia is limited to one case, which illustrates very decidedly the helplessness of the physician, be he ever so well prepared in mind and medicine chest. An 18year-old primipara near full term had complained for several months of oedema of the lower extremities and finally of the abdomen, but had declined to consult a physician. The evening before I was summoned she had partaken heartily of ice-cream. About midnight she was attacked by a violent headache and awakened those around her by moans. She suffered from extreme dyspnoea and soon became unconscious; the voluntary muscles exhibiting tonic and clonic spasms. A local midwife was summoned and endeavored to deliver her as labor was imminent. When I arrived, at 10 A. M., the patient was comatose; her body oedematous; face and neck dark from retarded circulation; pulse quick and wiry; respirations shallow and long drawn, soon degenerating into the Cheyne-Stokes type. The child was unborn. The case was of course hopeless, and the first indication was to empty the uterus which I proceeded to do by aid of the forceps. A great amount of blood had been lost, and just as I completed the delivery of the child a large pool in the bed began to run through on the floor. Thinking an extensive hæmorrhage had started, I thrust one hand into the vagina and with the other made pressure over the abdomen only to find the uterus well contracted and the secundines ready for delivery. From such prompt action of the uterus I hoped to restore some measure of vitality to the patient, but the rapid filling of the lungs by serous exudation soon dashed my hopes. The child was not viable as I ascertained before delivery. The above

[To the Editor :] I deem myself fortunate in not being able, from personal observation, to contribute much of value to the subject of puerperal eclampsia. Knowledge of such a subject, gained through personal experience, is dearly purchased. Although a general practitioner for many years my, experience in this disease has not been large. I shall make no attempt at systematizing, but such items as may appear to be of relative importance will be briefly given. There has always been a large foreign (mostly German) element in my clientele, in which the ordinary obstetric practice has been controlled by midwives; cases of dystocia only, coming into my hands, and these, especially mal-presentations, are not infrequent. Yet I have never seen a case of convulsions in this class of patients. A similar condition (as to the class of labors going to the physician), only in a far lesser degree, obtains in native obstetric practice; but here its influence is seen in the ratio of the cases of eclampsia, which, excluding cases seen in consultation, is 1 in 138 in the entire number of labors, a very large percentage. The fatality is 25 per cent. They were all, but one, primipara. All had albuminuria, at least at the access of the convulsions. As bearing on the nervous element in the etiology, it may be stated that in two or three cases the attack was apparently precipitated by preparations for the application of the forceps. Soon after the introduction of chloral hydrate as an analgesic in labor, I, for the first time, gave a patient a dose, and within a short time had a bad case of eclampsia to treat. Deeming this a mere coincidence, within a short time I again gave a parturient a dose, with a similar result. I now believe both cases were coincidences, and that the chloral had no causative relation to the convulsions, but this experience had the effect of banishing chloral from my obstetric practice. My treatment has conformed usually to the treatment most in vogue at the particular period of time in which my cases happened to occur. As that covers a period of nearly forty years, it is

evident to one familiar with the literature of the subject, that my patients have had the advantage of a variety of treatment and that cases must needs occur pretty nearly together, in order that any two should be treated alike. As full doses of morphine are just now fashionable, I may say that I consider this a dangerous practice, where there is a large amount of albumen in a scanty secretion of urine. The convulsions can be controlled, but only that the patient may die of uræmia and opium coma. Incidental to my last eclampsic case, I may be permitted to cite a valuable addition to the terminology of the lying-in-chamber. I have, like many others, recognized the paucity of our language in certain directions. We say our cow calved last night, our mare will foal soon, etc., but we have no similar verb to express the like physiological act in the genus homo. The patient was a primiparous schoolma'am who was attacked with convulsions before her child was born, became at once unconscious, remaining in that condition for some time thereafter. She awoke to perfect consciousness quite suddenly; and the first sound she noticed was the cry of her infant; she looked up with a startled air and asked: "What is that?" On being told, in an indescribably naive manner, she replied: “I didn't know I had babied."

ARTHUR YOUNG, M. D.

PRESCOTT, Wis., March 22, 1888.

[To the Editor:] That the use of venesection in puerperal eclampsia advocated by Dr. Hiram Corson of Coonshocken, Pa. (MEDICAL STANDARD, April), is fully justified, is in my opinion, demonstrated by my own experience. During thirty-four years of practice I have invariably resorted to blood-letting and always with satisfactory results. I regard it as the most reliable means of combating or preventing puerperal eclampsia. C. H. WETMORE, M. D.

EMPORIA, KAN.

DIPHTHERIA.

[To the Editor:] The MEDICAL STANDARD (February and March) contained several terse and forcible communications on diphtheria. I have been exceedingly interested in the question and confess a natural desire to express my own views on the subject, although I may shed no new light on an obscure subject, yet without any desire to play the critic. The search of genius into the hidden mysteries of disease is always inspiring, but too often the practical result is nil.

It seems to be characteristic of some to be positive as to the unknown yet skeptical, or at least

uncertain as to what is well established. One may say, "I consider diphtheria a zymotic disease affecting the entire system, through the presence of a foreign living organism in the blood, manifesting itself locally in the form of a plastic exudation on the mucous membrane of the throat, mouth, etc." Another believes that "diphtheria is an asthenic filth disease, which from the very outset attacks the very foundations of the system, and there is a time when it is strictly local, but unfortunately that time is hard to determine." Another claims that "true diphtheria is a specific germ disease requiring certain conditions for its development, upon which the type in a given case depends. Under conditions most favorable for such evolution, .. the results of any known treatment of the disease are slightly if any more favorable than the same would be if applied to the occupants of our dissecting tables in October. . . Fortunately, but few physicians ever meet with this type of the disease." The views of another, expressed in brief, are that "the disease is highly infectious, that it results from specific contagion, and that filthy surroundings favor its production and extension." These are well enough as opinions, but lack demonstration, and hence solve no enigma. I may say, also, that I regard diphtheria as a specific disease (perhaps a "germ" disease, although I am by no means certain of this), both infectious and contagious, though much less so than scarlet fever, variola, or measles, that it is a constitutional disease, with local manifestations allied to tuberculosis and cancer, which, perhaps, is not far from the truth. Hence, the assertion that it is a filth disease, or that it necessarily has its origin in filth, should be received with some degree of allowance. No doubt filth favors its development and extension, as cleanliness favors health; but that it produces it per se, or is capable of producing it, I don't believe, since I have known it to occur in the most cleanly of families, amid the most healthful surroundings, while, on the other hand, the most filthy may escape "scot-free," unless brought into contact with the infected. True croup and true diphtheria, though both constitutional, so far from being identical, are essentially different and distinct diseases, not simply in location, but in the non-contagiousnes of the former, and extreme prostration and tendency to epistaxis of the latter. Neither insures immunity against a second attack, and doubtless both rarely coexist in the same individual.

A short time ago, a newly-fledged M. D. read an essay before a county medical society in which the identity of membranous croup and