Part 9

Veit, of Berlin, has operated in seven cases of tubal pregnancy before rupture, in all successfully.

Breisky, of Vienna, has recently performed the first successful laparotomy for the removal of an ectopic viable fœtus in which all the fœtal appendages were at the same time removed. The operation was done at the end of the eighth month. Breisky advocates primary laparotomy with extirpation of the entire sac in preference to the secondary operation.

Brunniche (Cent. f. Gyn.) treated a case of vomiting of pregnancy successfully by feeding the patient through a tube introduced into the upper part of the œsophagus.

Duncan (London Lancet) reports three cases of hyperemesis in which complete relief followed the application of cocaine in five per cent. solution to the vaginal vault and cervix.

Saenger says the process of uterine involution is not a fatty degeneration but normal metabolism.

Dr. Temple, of Toronto, Canada, in a case of post-partum hæmorrhage, hot water and other measures having failed, injected the uterus with a tumblerful of undiluted brandy. Prompt contractions and arrest of hæmorrhage followed.

QUININE AS AN OXYTOCIC.

Dr. Cordes finds in quinine an efficient oxytocic in incomplete abortion. He administers two and a half grains hourly till the desired result is accomplished.

_REVIEWS._

THE APPLIED ANATOMY OF THE NERVOUS SYSTEM—Being a study of this portion of the human body from a standpoint of its general interest and practical utility. Designed for use as a text-book and as a work of reference. By Ambrose L. Ranney, A.M., M.D. Second edition, revised and enlarged. 8vo. Profusely illustrated. Cloth, $5.00; sheep, $6.00.

New York: D. Appleton & Co., 1, 3, and 5 Bond Street.

A second edition of this work has just been issued and, as the author says, has been enlarged. It contains 791 pages including the index; and is divided into four main parts, the first part treating of the brain; 2d, the cranial nerves; 3d, the spinal cord; 4th, the spinal nerves.

It is very difficult to give a review of a work like this, which treats so largely of the anatomy of the nervous system; and which is the most difficult part of anatomy, and a great deal of which is not positively settled, but is under sharp discussion by those who pay special attention to the subject.

The work is a more or less successful compilation, which is prepared with the idea of its being used as a text-book. Its size indicates that it contains an enormous quantity of material on the gross and fine anatomy, but excursions are also made into the domain of medicine to illustrate the application of the anatomical knowledge to the explanation of symptoms in disease; and quite frequently physiology and pathology are dealt with.

As a text-book the work appears to me a great deal too large; and the treatment of the subjects too diffuse; and often not clear; this is especially so in the anatomical part. Cerebral anatomy is one of those subjects of which it is very difficult to treat in a clear and comprehensive manner so that others can understand it; and for this reason a text-book should be small and contain only such anatomy as is clearly made out and can be made practical use of as applied anatomy. The finer anatomy and the study of the course of fibres, etc., should be taken up as a special work, and studied with patience on specimens, sections, etc.

A great many digressions into physiological questions might have been left out, and some other subjects properly belonging to general medicine, which the student could best study in some of the recent works on diseases of the nervous system, or at the clinics. As an illustration of what is meant, take, for instance, a consideration of the tendon reflex on page 576, and the short imperfect sketch on page 621, on progressive muscular atrophy, when on the next page is a figure of a man, forty-five years old, with progressive muscular atrophy, from Freidreich’s work; a case which, by the way, is probably not a case of chronic myelitis of the anterior horns, but one of the cystrophies. The subject of progressive muscular atrophies is now undergoing close study, and a large number of cases are not dependent upon lesions of the anterior horns, but are due to changes in the muscles themselves. The work of Freidreich, Erb, Lichtheim, Ladaur, Charcot, Landonzy and Dejeuni, and many others, have placed the subject in a different light from that in which it was viewed some ten years ago.

Subjects like these can be found more satisfactorily treated in other works, and are altogether out of place in a book like this and only adds to its bulk.

The descriptions are often such as to confuse and mislead a student; for instance, take the opening chapter on the brain, where the author says: “In man and the vertebrates, the cerebro and spinal axis may be divided into three separate portions, each perfectly independent of one another and yet very intimately connected.”

Now this division is quite artificial, and is only for purposes of description, and these parts are not _perfectly independent of one another_.

Again, he says: “The nervous system of all animals may be subdivided into two distinct histologic elements, nerve cells and nerve fibres.” What has become of the neuroglia and neuroglia cells; are they not important histologic elements in the nervous system of all animals? Without this supporting framework what would become of the nerve tubes and ganglion cells? And in many of the diseases of the central nervous system this neuroglia takes on a very active condition, as is seen in such a disease as disseminated cerebro and spinal sclerosis.

On page 45, in speaking of the study of sections of the cortex, the author says: “By a judicious employment of gradually increasing powers in the microscopic objectives used, the general arrangement of the elements may be first mastered, and later on the minute details of each of the component parts may be studied.”

This sounds like a most formidable and delicate task in the _judicious employment_ of objectives in increasing powers in the study of these sections. No one should attempt to study the histology of the nervous system without previously knowing something about the use of the microscope and having some practical knowledge of general histology and pathology; to such a person the study of sections does not depend upon _the judicious employment of gradually increasing powers in the microscope objectives_; if he use a No. 2 and a No. 7 of Verick, or some objective of about the same magnifying power, it is then simply a question of studying the specimens with those powers and learning to see and understand what he sees; there is no mystery about it.

I will refer to one other paragraph on page 56, where it is stated:

“The central gray matter of the spinal cord. This has no connection with the higher senses. It is capable in itself of the simplest kind of reflex acts by means of the spinal nerves. These can be produced at the will of the experimenter, in the beheaded frog, when an irritation of the skin by an acid, etc., is created; and Robin has satisfactorily performed the same experiment upon a beheaded criminal. We have reason to believe that the spinal cord can be slowly and in a purely automatic way taught to perform certain series of muscular movements (as in playing scales upon a musical instrument, for example,) without any intervention of the higher ganglia.”

This is physiology. Is it true that the central gray matter of the spinal cord has no connection with the higher senses? The complicated movements which are performed by a person playing on a musical instrument, like the piano, for instance, are more than a simple reflex action of the spinal cord; and we do not believe that the spinal cord can be taught to perform such movements without the intervention of the higher ganglia. When one is learning to play the piano or other musical instrument, the higher centres are constantly in action, guiding and regulating the muscular contractions which go to make up the act of playing; after constant repetition under the guidance of the higher centres, the spinal cord and lower centres, as it were, learn and retain the combinations necessary to the performance of the act, all that is necessary is to start the particular combination, and the spinal cord will carry it on automatically.

The spinal cord cannot be taught to perform such complicated acts without the intervention and guidance of the higher centres to begin with.

Dr. Ranney has done a great deal of work in the preparation of this volume, and deserves much credit for his endeavors to collect this somewhat scattered material.

The work has numerous illustrations and diagrams, most of them exceedingly good, but we observe among them some of the worthless and often fanciful illustrations from Luys’, which are reproduced here.

J. C. S.

_MISCELLANEOUS._

DR. J. B. MATTISON.

Dr. Mattison recently spent several weeks in Bermuda, and the _British Med. Journal_ in reporting a meeting of the British Med. Association, held in the Town Hall at Hamilton, says:

By request of the Society, Dr. J. B. Mattison, of Brooklyn, gave an address on the subject of narcotic inebriety. Attention was called to the extensive use of opium, chloral, and cocaine, notably in France, Germany and America. The genesis of the disease was a physical necessity in many cases. The speaker said in proper cases his plan—an original one—was to secure an entire narcotic disuse by regular reduction, in ten days, meantime bringing the nervous system under the sedative influence of bromide of sodium, in initial doses of thirty grains, at twelve-hour intervals, increasing the dose ten grains daily, and reaching, if required, a maximum of one hundred and twenty grains at the end of the withdrawal period. The resultant reflex irritation was treated by hot baths, cannabis indica, hyoscyamus, coca, and electricity, with a subsequent tonic regime. The prognosis was good as to recovery, but in most cases, sooner or later, there was a return to the narcotic, due to a renewal of the original cause, or to other conditions beyond control. A vote of thanks to Dr. Mattison closed the meeting.

Dr. Mattison is translating Erlenmeyer’s Die Morphiumsucht und ihre Behandlung—the Morphia Disease and its Treatment; third and last German edition, the latest and largest work on the subject, which, with notes and comments by the translator, will be brought out the coming autumn.

LONG ISLAND COLLEGE HOSPITAL TRAINING SCHOOL FOR NURSES.

The graduating exercises of this training school took place on June 12th, at the hospital. Prof. Jarvis S. Wight presented the diplomas, and Dr. George G. Hopkins delivered the address. The following are the graduates of the class of 1888: Mrs. Elizabeth Raifstanger, Nellie E. Russell, Elizabeth Munday, Abigail Collins, Lucy Wood, Elizabeth Ritchie, Ellen Enright, Florence Jackson, Jennie E. Stuart, Minnie M. Flower, Florence Crompton, Signa Johnson, Eleanor Mary Senkler.

“POST TENEBRAS LUX.”

BY PROF. F. H. GERRISH, OF BOWDOIN COLLEGE.

The Era Prize Essay.—Reprint from the Pharmaceutical Era.

Originally every physician was his own apothecary, and at the present time probably a majority of medical practitioners dispense their own medicines, very rarely writing a prescription. These will have but a languid interest in the subject of this essay, which deeply concerns all physicians who are not their own apothecaries, and all compounding pharmacists.

In medical, as in every other science, the increase of knowledge so widened the field that it became impossible for one mind to grasp all the facts, and a division of labor took place, the part of the work which related to the collection, preservation and dispensing of drugs being assigned to a class of men who had displayed peculiar aptitude for that branch. Thus was constituted as a distinct occupation, the specialty of the apothecary, which, beginning as a department of medical science, is inherently honorable, and has been so developed that it gives scope for a lifetime of fascinating research, elevating study, and profitable endeavor, independently of any proper work of the modern physician. The two callings are, for the purposes of this discussion, as in their best actual operation, practically distinct; and yet they are not independent, but interdependent. The greater part of the physician’s labor would be vainly spent, were it not supplemented by the service of the pharmacist; the latter’s business would cease to have a reason for existence but for the vocation of the former.

In this paper it will be taken for granted that the physician is well educated and experienced in his profession, that the apothecary knows his business thoroughly, and that both are actuated by high moral purposes. The grievance of neither, therefore, will result from the intentional wrong-doing of the other, but from his thoughtlessness or conservative adherence to long-established custom. The honesty of each being presupposed, such a charge as the substitution of an inferior article for some ingredient in a prescription, or the false insinuation that a mistake in the medicine is due to the compounder’s carelessness need not be raised. Let us consider the grievances of each against the other.

The physician complains that the apothecary exceeds his function by prescribing for the sick. A person applies to the pharmacist for a remedy for a specified disease. The latter consults the dispensatory, finds a number of medicines mentioned in the therapeutical index under the name of that malady, selects one, and sells the article to the patient. He regards the protest of the doctor merely as the wail of one who is disappointed at not getting a fee for prescribing. The physician has a right to complain of those who prescribe for any but the indigent without a professional fee, for this makes it vastly harder for him to collect the charges to which he is entitled; but he has higher ground than this. With him the first step in every case of disease is diagnosis, without which prescribing is simply drawing a bow at a venture, with small probability of penetrating a joint of the harness; and he insists that neither the apothecary nor the patient is qualified to make a diagnosis. The determination of the character of a disease is not a simple matter, often baffling the profoundest learning and the broadest experience, and, in most cases, requiring special knowledge and discriminating judgment. The most obtrusive symptoms are by no means necessarily the most characteristic; a given symptom may be the accompaniment of different diseases, and sometimes attends pathological changes of diametrically opposite nature. But one who is uninstructed in this branch has nothing but symptoms to guide him, and therefore frequently, if not commonly, is led into error, which may produce the gravest results. The educated physician is the only person who is equipped to solve the problems of disease; and it is, in the long run, cheapest, even from the financial point of view, for one who is ill to obtain competent medical advice. Therefore, considering merely the welfare of the patient, the physician deplores the custom of counter-prescribing.

The universal practice among apothecaries of refilling prescriptions indefinitely, without the sanction of those who wrote them is frequently the subject of adverse criticism by physicians. “But,” says the pharmacist, “is not the prescription mine?” Probably the reply will be affirmative, though this is a question not entirely settled in the minds of those concerned. Granting, however, for the sake of the argument, that the apothecary is the rightful owner of the prescription, he triumphantly asks, “May not one do as he chooses with his own?” Not always, by any means, unless he elects to use his property in a way which will not imperil the welfare of others. The law puts many restrictions on the natural rights of ownership, for the purpose of shielding society from the ignorance, the malice, and the cupidity of proprietors. In the matter of prescriptions there are no such limitations; but in this, as in so many other affairs, we should be controlled not merely by considerations concerning our legal rights. The unwritten, but greater, law regards the question from a higher plane; and from this point of view one sees that there are moral reasons which should restrain the apothecary in these premises. Let us look at prescription-refilling in its remote as well as its immediate bearings.

The physician writes his prescription for one occasion and for one only. He designs it to fulfil the indications in a particular case at a given visit. It is often in the highest degree improbable that the conditions of the case will remain the same for a given length of time; and, when they change materially, another prescription is needed to satisfy the altered requirements. Of these things many patients and apparently, all apothecaries are accustomed to take no note; and, therefore, the prescription is refilled for the same person on many occasions, when something very different ought to be furnished, the expected improvement does not occur, and the physician is blamed for the failure. The prescription, intended for the treatment of a certain condition afforded relief and changed the state of affairs. Thereupon, further advice should have been sought by the patient, his physical condition investigated anew, and another recipe given by the physician, if he deemed it desirable. To hold the doctor responsible for the ill effect or lack of effect of his prescription in circumstances unlike those for which it was designed is obviously unjust. Yet this is done habitually, both in the case just supposed and in those other instances, quite as common, in which the recipe is compounded, not for whom it was written, but for some other person, who supposes (on what slender evidence it is appalling to contemplate), that his ailment is identical with that of the original patient. The refilling really amounts to the apothecary’s abetting the patient in self-treatment. There is a trite remark to the effect that he who undertakes to be his own lawyer is sure of a fool for a client. In legal actions the matters at stake mostly relate to property; in medical affairs, health and life are involved. Can anything better be said of the wisdom of him who, without adequate training, undertakes to settle questions in which his very existence is concerned, than of the sagacity of the man who, with no competent knowledge of law and the methods of the courts, presumes to manage a case in which merely a sum of money may be lost?

But undesirable as is the custom of pharmacists in this respect, it is unreasonable in physicians to grumble at it, until they reform a habit of their own, which encourages the practice which they deprecate. When a physician finds a sick man improving with a certain plan of treatment, and wishes the same medication continued, usually he simply tells the patient to have his bottle refilled at the apothecary’s. The latter, knowing that this is the usage of the medical profession, is accustomed to suppose—constructively, at least—that, when the bottle is returned to be replenished, it is brought at the desire of the doctor; and he again compounds the medicine, as he would not be justified in doing, if the method of physicians was different. If the latter would habitually rewrite their prescriptions, or indite orders for repetition, whenever they wish a continuance of treatment, apothecaries would have the best possible sanction for supplying medicines to patients a second or a thousandth time, and would have no moral warrant for such action without the written direction of the authors of the recipes. When the doctors adopt the plan suggested, a violation of their request that their prescriptions shall not be repeated without their written order will furnish abundant ground for complaint; until such change of method is established, the consistency of their protest does not conspicuously appear. By the practice proposed, the apothecaries would lose some business, indeed, but the community would experience an immeasurable gain.

The sale of so-called patent medicines by pharmacists is a continual irritant to doctors. Their objections have the same basis as in the preceding case, namely, that apothecaries ought not to encourage the people to prescribe for themselves. A distinguished physician once said that drugs do more harm than good—a statement which will not be disputed by those most conversant with the facts. But this is no argument against the employment of medicinal remedies in any proper way. Drugs taken by advice of educated, competent physicians do an immense amount of good; the injury comes almost altogether from their administration independently of the recommendation of qualified medical men. Concocted, not to benefit humanity, but to enrich their manufacturers, advertised as positive cures of diseases which the utmost skill of the medical profession cannot control, sometimes inert, sometimes dangerous from the poisons which they contain, pressed upon the attention of the people with impudent persistence and colossal mendacity, the infamous compounds, called patent medicines, are purchased by the credulous public in almost incredible amounts. Nobody knows as well as the pharmacist what quantities of drugs are sold in this form; nobody knows as fully as the physician the enormously baneful effects which they produce. If apothecaries would refuse to handle this class of goods, they would confer a wonderful blessing on humanity, by demonstrating their belief in the injuriousness of these articles, and thus bringing them into disrepute; and they would vastly dignify their profession by displaying its sense of moral obligation, even at the sacrifice of a lucrative part of its business.

Apothecaries complain that, to meet the demands of prescriptions, they are obliged, at great expense, to keep in stock a large number of whimsical preparations, and also many brands of the same standard medicines, when really one is practically as eligible as another. There is force in this complaint. As a rule, the former class of preparations has but an ephemeral popularity, and, as for the latter, there cannot often be need of specifying the goods of a particular manufacturer; for a worldly-wise, not to say honorable, pharmacist certainly may be trusted to furnish only fine articles, that he may keep the favor of those upon whose good-will his legitimate business depends. If a special brand is deemed necessary by the doctor, he can request a convenient apothecary to procure a quantity, and then can send to his shop the patients who require this article. Thoughtful consideration of this grievance will dictate some such course and effect its redress.

Occasionally, in places where apothecaries are accessible, physicians furnish their patients with medicines. This the pharmacist rightly regards with disfavor, as diminishing his legitimate business. The truly wise physician shuns this practice, perceiving that he cannot be as competent a pharmacist as is one who is nothing else, and furthermore, preferring to avoid the suspicion of administering medicines unnecessarily for the purpose of making a profit on them. Enlightened selfishness prompts him to encourage scientific pharmacy as a specialty.

BROOKLYN VITAL STATISTICS FOR JUNE, 1888.

By J. S. YOUNG, Dep. Commissioner of Health.

_Data of comparison_:

Population, estimated on July 1st, 1888 793,960 Inhabited houses, about 93,000

Average birth-rate per 1,000 for ten years (returns incomplete).