of honest merit, and sometimes also in startling contrast with the utterances of men of brilliant gifts."

Book Notices.

TRANSACTIONS OF THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA.

This is a volume of over 500 pages, the first 276 of which are devoted to the proceedings of the society, and the papers read at the 1878 meeting. The remainder of the book is made up of reports from the county medical societies throughout the State. The plan of having local societies in affiliation with a central State society is a good one, and one which we should like to see adopted in this State. The volume before us reflects great credit not only on the profession of Pennsylvania, but also on the Secretary of the State Society, Dr. W. B. Atkinson.

THE DUTIES OF THE MEDICAL PROFESSION CONCERNING PROSTITUTION AND ITS ALLIED VICES.

This is the title of a pamphlet by Dr. Frederick H. Gerrish, of Portland, Maine. It is a very readable effort, and will well repay a perusal, notwithstanding a few impracticable suggestions which it contains. It takes

strong grounds against the legalizing of prostitution, and advances cogent arguments in support of this position. The summing up of the essay is as follows:

"Prostitution is alarmingly common. The methods of dealing with it which have been most extensively tried have failed to control it or to limit the diseases which arise from it. It is to be regarded as a disease of the body social, which we can not hope to cure unless we remove the causes on which it depends. The chief of these causes is ignorance, which creates a demand for illicit intercourse. While a lack of ordinary information and learning is conducive to depravity, it is ignorance of the laws of our being which is chiefly responsible for the mischief. The proper and competent teaching of physiology and hygiene to the young would result in such an improvement of morals that, in time, prostitution would largely disappear, for want of support and patronage. While education is the great means for removing the chief cause

of the social evil, it is necessary to employ other measures of a curative character, such as the punishment of sexual crimes, severe restrictions on the permanently diseased, and reformatory efforts; and the medical profession, being in the best possible position to appreciate the evil and to apply the remedy, owe it to the community to undertake the educational work, and to establish the other measures suggested."

OPTIC NEURITIS, WITH NOTES OF THREE CASES. By C. J. Lundy, M. D., Detroit. A fre-print from the Detroit Lancet.

This pamphlet opens with a concise, yet comprehensive, resumé of the views held by various authorities on the subject of optic neuritis, and closes with a very carefully written and clearly descriptive account of three cases which occurred in the writer's own practice. Dr. Lundy is a careful observer, and evinces that attention to minutiæ which is the secret of the successful specialist's success. There is one point, however, in the paper which is not clear to our mind, and which we should like the doctor to explain. In one of the cases he details, "the pupils were dilated, readily movable, not influenced by light, etc." How was this?

Paragraphs.

If we are obliged to earn our living why may we not urn our dead? is the latest conundrum.

Prof. Tyler, of Amherst College, says: "Half educated fledglings are fluttering and tumbling into the practice of law and medicine more frequently now than at any former period of our history."

Stilbeine is a preparation compounded of emery and rubber which is said to be an excellent article for cleansing instruments. All other agents while removing rust, blood spots, etc., also destroy the polish. Stilbeine is not open to the latter objection.

A doctor must be a mechanic, a nurse, a cook, a

chemist, a pharmacist, an anatomist, a physiologist; he must have the wisdom of Solomon, the patience of Job, the independence of Diogenes, the philanthropy of Howard.-Dr. Gibbons, in Pacific Med. and Surg. Journal.

The Boston Journal of Chemistry tells of a lady who suffered with sciatica for which she had sought physicians in vain. Hearing of man who was similarly afflicted, she called on him in hope of learning of him something that might mitigate her suffering.

"Do you" she asked "find any thing that affords any relief." "Yes marm" he replied "two things," "pray, what are they?" "Cursin' and_sw'arin' ?" said the pious invalid.

A child in Paris, one year old, without any ap. preciable cause, was attacked by tonic spasms for several weeks. One day its mother discovered a hair between the two front incisor teeth, and extending backward into the throat. The removal of the hair was followed by complete cessation of the

spasms.

It has been discovered that glycerine is largely employed as an adulterant in beer, and the German Society for the encouragement of industry has offered a prize of 3000 marks for the easiest method of determining, within twenty-five one-hundredths, the quantity of the article in the beverage. The method of Pasteur is effective but is tedious and troublesome. The cheating began in 1856, previous to which date 100 pounds or upwards of malt was used in a barrel of beer, and as much was consumed by ten brewers in New York City as is consumed by the whole number now engaged in the manufacture in that city.

As bearing somewhat, although, perhaps, a little remotely on this same subject, the following from a correspondent who was present at the recent meetmeeting of the Health Association at Richmond, is of interest: "The lager beer is excellent, but there is the American vice of no chairs and standing drinks. Moffat's bell punch, whereby the State revenue is enriched by one half cent for every glass of malt liquor consumed, and by two and a half for every glass of spirit, was a revelation to the majority of the visitors, and it was quite remarkable to see how many were curious to see how the thing worked."

The Medical Advance, after a suspension of several years, has been revived as a quarterly, and is now a candidate for professional favor under the editorial management of the versatile Dr. C. Henri Leonard, of this city. The first number of the new series is abundantly illustrated with well-executed cuts. These illustrations are to constitute a feature of the publication. We welcome the new comer, and wish it no less success than the admirable appearance of the first number of the new series gives promise that it will achieve. Fifty cents a year— very cheap and very good.

The Chicago Medical Journal says that one of its religious contemporaries of that city urges its readers to promote the social element in the church by following the example of a family where there was an informal social gathering: "No refreshments were served, but at one corner was a table with cold water, popped corn, raisins, walnuts and doughnuts."

There is a demand for ostrich pepsin in the retail Irug trade; and it is understood that the homeopahists are preparing a tenth decimal trituration of

"cold water, popped corn, raisins, walnuts and doughnuts."

The managing editor of the MICHIGAN MEDICAL NEWS names his dog Peru, just on account of his bark, it being the most valuable thing about him. Chinconing dogs never bite.-Medical Advance.

Although the Advance has scarcely yet cut its canine teeth, it is evidently capable of saying some cur-ious things-quite waggish in fact.

Original Articles.

An Unusually Large Carneous Mole: Error in Diagnosis.

REPORTED BY E. S. DUNSTER, M. D., Professor of Obstetrics and Diseases of Women, in the University of Michigan.

One frequently learns more from a mistake than when he is right, for having once made a decided mistake he is very apt to recollect it, and not again commit a similar error. Others, too, may learn the same lesson from one who acknowledges his own blunder and makes it public. If the error be one that it is difficult to avoid, great good may come from the publication of it, as it may prevent some one from falling into the same trap, no one being infallible. I accordingly put on record the following case, in which, happily, the mistake did not bring any detriment or injury to the patient, but unwittingly accomplished the very object which would have been attempted had a correct diagnosis been made.

A.

On the 11th of June last I was consulted by Mrs. resident of an adjoining town, in regard to herself. She gave the following history: Age, 32; had borne three children, the youngest nearly three years old. Her confinements had been comparatively easy, and she had gotten up from them well and early. Accustomed to hard work, such as usually falls to the lot of a farmer's wife, she had stood this work easily up to within a few months past. A year after the birth of the last child, who was nursed for some fifteen months, the catamenia returned with their accustomed regularity, and continued in their usual amount and manifestations until some six or eight months ago, when they became more profuse than usual. The January period began on the 14th, and from that time to the present she had been continuously "unwell,”—not a single twenty-four hours having passed without some hemorrhage. (On this point the patient was very positive.) At times the hemorrhage had been very profuse and exhausting, so that she would be compelled to take to her bed, and for some weeks past she had been unable to attend to her household duties. The appetite had remained good, yet there had been some loss of flesh. The bowels were daily

and spontaneously moved, and there was no derangement whatever of the stomach and digestive organs. There had been no fever and no pain beyond an uneasy sensation in the region of the womb. This did not amount to an ache or pain, but was rather a feeling of heaviness or weight. Micturition was more frequent than natural, the desire to pass water being present in a somewhat increased degree.

Objectively, her condition was as follows: Countenance pale; lips blanched; apparently some emaciation, and this, with a slightly pinched expression about the nostrils, indicated a marked degree of anæmia, which well accorded with the history of her case. The abdomen was enlarged, and a hard, painless tumor, symmetrically ovoid and centrally located, reaching nearly as high as the umbilicus, was easily detected. Per vaginam the cervix was tense, not softened to any appreciable degree, and bi-manual examination showed that the tumor moved with the uterus. As the history of five months (lacking three days) of profuse hemorrhage, and the absence of the rational signs of pregnancy, seemed to negative all idea of that condition, I ventured to explore the cavity of the uterus, and readily passed a flexible probe to the depth of six and one-quarter inches. Then bending a stout sound to the curve thus ascertained, it was passed in a right lateral and somewhat downward direction (the patient being in the dorsal decubitus) to the same depth. It was now easy to feel that the tumor was between the sound and the hand on the abdomen, and that it was very firm and resisting in its structure, and was about six inches long by four in its transverse diameter. These manipulations produced quite a brisk hemorrhage, which, however, ceased in half an hour, so that the patient was able to return to her home-fourteen miles distant-the same afternoon.

My diagnosis was fibroid tumor, probably of the sub-mucus variety, and the patient was put upon the use of ergot, in full doses. Two days subsequently the husband of the patient called upon me, his face beaming with satisfaction, and said that the tumor had already been expelled. On my expressing surprise and doubt, he replied, "Oh, yes, it is so, for I've got it here;" and he produced from a basket, which he carried on his arm, a package nearly the size of a two-quart pail, and on opening it, sure enough, there was an ovoid mass, about six inches by four in size, that looked at the first glance like a recently enucleated fibroid. A second glance, however, discovered, much to my chagrin, that there was placental tissue over a considerable portion of the surface of the tumor, and I thought to myself that I had made a most absurd and unjustifiable blunder in diagnosis, and had unwittingly produced an abortion, and that the ovum had been expelled en bloc. I then took the mass into my hands, and again I was, for an instant, puzzled, for it was throughout uniformly hard and resisting to

the touch-almost as hard, indeed, as a fibroid tumor. There was nowhere any fluctuation, and the surface otherwheres than upon the placental portion presented none of the appearance of the membranes of an ovum. With a scalpel I then laid it open from one end to the other, and thus disclosed its true character. It was a carneous mole of unusual size, with a central cavity less than three inches deep, into which jutted the bulbous, fleshy masses characteristic of these formations, and nowhere, on the most searching examination, was any trace of an embryo found. There was no fluid in the cavity, and the fleshy growths were so closely packed into it that I doubt if more than a teaspoonful of fluid could have been forced therein by strong pressure. I should have stated that the mass was expelled on the day following the exploration of the uterus, after nine hours of pains, the last three of which were as severe as any that the patient had experienced in her confinements at full term.

I make no excuse for this decided error in diagnosis, but frankly confess that although I excluded normal pregnancy, the idea of molar pregnancy did not once cross my mind during the examination. I cannot, however, reproach myself very seriously, for everyone of experience knows how difficult, and at times almost impossible, a correct diagnosis is in such cases. Indeed, had the idea of a carneous mole occurred to me, I do not know how I could have corrected my diagnosis, except by dilating the cervix and removing a bit of the growth for microscopic examination; for the history of the case, as well as the physical signs, accorded more closely with the supposition of a fibroid than anything else. If this procedure be resorted to no harm can come in either event after the diagnosis of normal pregnancy is excluded, for if it be a mole it will hasten its expulsion, which, is the only rational treatment, and if it be a fibroid it will help us determine the propriety of an operative interference.

The patient made a good but somewhat slower recovery than after her normal pregnancies. Menstruation returned in the fifth week, and recurred naturally up to the time of the last period, some three weeks since, when there was no show. She consulted me a few days ago regarding her condition, but the last mentioned fact, to say nothing of my former experience with her, put me upon my guard, so that it is needless to say I did not attempt an exploration of the uterus.

The case is certainly instructive, and may serve as a warning to others beside myself who are engaged in gynecological practice, where fibroid tumors are so frequently and carneous moles are so rarely met with that similar errors of diagnosis may readily happen, unless in every case one takes into consideration even the rarest of all possibilities and is governed accordingly.

ANN ARBOR, Dec. 30, 1878,

A Case of Extirpation of the Rectum for
Epithelial Carcinoma.

Reported to the Wayne County Medical Society, Dec. 12, 1878, by HENRY F. LYSTER, M. D., Detroit.

A professional gentleman, married, thirty-two years of age, five feet eleven inches in height, and weighing ordinarily one hundred and sixty-five pounds, and whose family I attend, consulted me about the middle of July, 1878, on account of general debility with constipation, together with bleeding at stool, and uneasy sensations in the pelvis, which he attributed to hæmorrhoids. I had made a rectal exploration three years previously on account of a similar train of symptoms, and having found nothing of any moment, I had advised a vacation of two or three weeks with change of air, which resulted at that time in complete restoration to health, with an increase in weight of twenty pounds. I repeated this advice at this time, but the patient returned unimproved in a few weeks, and after continuing without effect the usual remedial measures, tonics, exercise, etc., I made a digital examination of the rectum, and at once discovered a cancer of the rectum, of an annular shape, the lower border situated about an inch and one-quarter above the internal sphincter and extending upward to the extent of two and one-half inches, encircling seven-eighths of the rectum.

A longitudinal strip of intestine, apparently free from cancerous disease, about half an inch wide, was found toward the left sacro-iliac synchondrosis. The tumor presented itself as a shelf, extending toward the axis of the rectum. There was a passage way about an inch and one-half in diameter through the axis of the bowel, through which fæces were passed. The whole face of the tumor was ulcerated and was exceedingly painful to the touch. By introducing two fingers and drawing down the tumor with one and pressing up the perineum while the patient was in the lithotomy position and under an anesthetic, a tumor on the posterior wall of the rectum could be reached by the fully-extended middle finger. It felt like an enlarged gland in the mucous membrane, and was quite movable. A few disseminated seed-like particles of cancerous material extended up the posterior rectal wall toward the enlarged gland. No other signs of cancer could be made out by physical explorations in the different regions of the body.

The cancerous matter appeared to be thicker and firmer near the bladder, and it evidently had its origin upon the anterior wall of the bowel.

I removed a small portion for the microscope and found it to be a cylindrical epithelioma. He was ordered twenty drops of muriated tinct. of iron three times a day. Extract of hyoscyamus six grains in two teaspoonsful of sweet oil, to be used as an injection at bedtime, was recommended for rest and sleep. The diet was changed to a stimulating and nourishing one, consisting of milk and meat, broths and soup,

with a little bread, and no vegetables. These changes were followed by marked amelioration of the painful symptoms.

Drs. Book, Walker, Brodie and Maclean examined the patient with me upon different occasions, confirming in all particulars the diagnosis.

In referring to the standard writers with reference to an operation, I found that, with the exception of Lisfranc, nearly all the writers of surgical works were opposed to the operation for extirpation of the rectum. Where exceptions do occur they confine the operation to cases where there is a minimum of disease. Sir Benj. Brodie, Bell, Copland, Cooper, Curling, Wilson, Parker, Post, Vidal, Pinault, Druitt, Velpeau, Miller, Gross, H. H. Smith, H. Smith (Holmes) hold these views. Brodie, Pinault and' Vidal allow it if very low down. franc, of France; Schuh, Voss, Volkman, Bilroth and Koberlé, of Germany; Van Buren, Keyes and Stimson, of New York; and Fenwick, of Montreal, have all written in favor of the operation-Lisfranc in 1826, Schuh in 1868, and Volkmann and the others quite recently.

Lis

All of those writing in favor of the removal of the disease have reported cases in their own practice, a large proportion of which were successful, both as regards recovery from the operation and immunity from the disease while under observation until the present time. In some cases immunity from the disease has been observed for periods ranging from three to eleven years. In the more recent cases, sufficient time has not elapsed to determine the length of time during which the system will remain free from a recurrence of the disease. The history of this form of cancer would lead us to infer that, in a certain per centum of cases, upon its complete local removal from the rectum, as from the lip, it will not recur. Dr. Walker, of this city, made the operation last summer in a case in which the sphincters were involved, with a successful result, and it is to be hoped that he will place it on record. It is important that the clinical history of these cases be known in order that professional opinion may be modified, in case lengthened immunity is found to be the result of the operation.

The patient having been made aware of the nature of his case, and of the medical opinion, determined to accept the very slight chance afforded by undertaking so extensive an operation.

The preparatory dose of an ounce of castor oil was given twenty-four hours previous to the operation. This was assisted by enemata of warm water the next morning. Twenty drops of laudanum were given at 11:45 A. M., a glass of brandy and water at 12:30 P. M., and the anesthetic mixture (alcohol, chloroform and sulphuric ether, in the proportions of one, two and three) was administered at 12:55 P. M., in the presence of Drs. Brodie, Maclean, Walker, Farrand, Gustin, Book and Leonard, to whom I feel greatly indebted for the successful completion of the opera

tion, on account of their very valuable and necessary assistance, which could only have been rendered by persons fully alive to the exigencies of the case.

The patient having been tied in the lithotomy position, an incision was made directly through the sphincter and lower posterior wall of the rectum to the coccyx.

The index and middle fingers of the left hand were pushed through the wound, and found their way, externally to the rectum, around to the front of the bowel, and separated it from the urethra and pros. tate gland. Dr. Brodie held a steel sound in the bladder, which served as a guide, and enabled the operator to judge of the thickness of the intervening tissues. The sound was of great value, and gave much aid and confidence to the operator during this very important part of the operation. The wound was large enough to permit of very free manipulation, and the rectum was pulled down with one finger hooked about it, while two fingers of the other hand were introduced to assist and to continue the work of detaching the rectum from the surrounding tissues.

At the base of the bladder we found it most closely adherent, and it was at this point we feared lest the cancerous growth might 'have extended outside the rectum, and involved the walls of the bladder, in which case I would have been obliged to desist. Up to this point the operation in this case was exploratory. By slow and careful detachment of the cellu lar tissue with the fingers, I gradually completed the separation, and extended this separation so far up that we feared opening the fold of peritoneum, which drops down between the bladder and rectum, and forms the exterior coating of the bowel. With the exception of a couple of strong bands of cellular tissue in the upper sacral region, the posterior and lateral separation was easily performed. The bowel was cut across, just above the internal sphincter, and the rectum, with enclosed cancerous tumor, was withdrawn, and the intestine severed above it, and detained by means of a claw-toothed forceps.

By careful detachment with the fingers, the peritoneum at the meso-colon was also uninjured. Prof. Maclean cut a strong band of cellular tissue with the scissors, while the rectum was strongly pulled, and the bowel came down without further resistance, and with such redundancy that we were enabled to cut it off about an inch and a half above the upper border of the tumor, and just above the location of the enlarged gland previously mentioned. Half a dozen silver wire sutures, easily inserted, fastened the healthy tissue to the internal sphincter.

The weight of the tumor and tissues removed, after macerating in a disinfectant solution, was eight ounces, avoirdupois.

The rectum removed extended from the sphincter to an inch and a quarter above the tumor. The tumor measured two and a half inches in width, and

its lower border was one and a quarter inches above the internal sphincter. These measurements would show that five inches of the bowel were removed.

There was no hæmorrhage during any of the steps of the operation. A couple of little hæmorrhoidal branches severed in the first incision were all that it was found necessary to stop. Probably not more than eight ounces of blood were lost, and this was mostly venous. A horse-hair fascine, or tent, the size of a crow quill, was pushed up back of the rectum, to act as a drain, and the patient was placed in bed at 3:45 P. M., two hours and three-quarters after the commencement of the operation. During the last half hour stimulants were freely used, and the anæsthetic was discontinued.

The prostration was very great, and continued for three days. The temperature did not rise above 98° F., nor the pulse over 100, until the 25th of Nov. The catheter was used the morning after the operation, and was not again required. The rectum and pelvic cavity external to it were syringed with disinfectant solutions every four hours, thymol, quinine and carbolic acid each taking their turn. The horsehair fascines were used with excellent effect until the 17th.

Symptoms of peritonitis supervening on the second day, leeches were followed by a blister and hot poultices, covered by impermeable baudruche. Quinine was given, in doses of three grains, every three hours, for its tonic and antiseptic qualities. A pill of camphor and opium was also used for several days. A large fæcal evacuation took place on the evening of the 16th; and continued to appear from that date with the syringing. The patient suffered from an abscess on the sacrum, which was opened, and discharged laudable pus. He also suffered from sleeplessness, which was alleviated by a pill of four grains of extract of conium once or twice during the night.

The patient, at has discharged drive out, and He has an ex

A good deal of pain, of a neuralgic character, was felt upon the outer surface of the thighs and hips, which originated within the plevis. the present writing, January 6, his nurse, and is able to walk and has gained quite rapidly in weight. cellent appetite, and is free from the epigastric pain and indigestion which formerly disturbed him. Upon examination, the index finger was grasped so tightly by the internal sphincter that it felt as if com pressed by a tight ring. This tissue is so elastic, however, that fæces of full size, and quite firm, pass through it as in a normal sphincter. The external wound has not entirely healed, but is unimportant. Within the sphincter, the rectum conveyed a normal impression to the finger and was of full size and shape, and evidently retains its true anatomical relations. No one could tell from an examination that any important operation had ever been made.