Since then there had been complete incontinentia urinæ. Further information in regard to the case was not obtainable. When first seen, in the July following, it was found that the posterior wall was divided in the median line-the edges of the tear being smooth and approximate-there being no loss of tissue. The bladder was contracted, and there were trabeculæ, but no diverticula. The edges of the laceration were united and healed completely.

Worth concludes that there must be a certain vulnerability in these rare cases, the reason for which lies in a very slight degree of hypospadia.

Krukenberg is of the opinion that the position of his patient at the time of delivery of the head was also the cause of the lesion.

CONCEPTION

M.

AFTER DOUBLE OVARIOTOMY.Schatz, operating according to the method lately suggested by Schrieder-that is leaving the healthy portion of the ovary, the cystic part only being removed-reports the success of the method.

The operation was done in 1880. About six months later menstruation returned. In April, 1884, the patient married, and the following May (1885) gave birth to a well-developed girl after being 36 hours in labor. The forceps were used.-Centralblatt f. Gynakologie, 1885, No. 23.

PRACTICE of medICINE.

M.

THE MITRAL CARDIAC MURMURS.-The study of the mitral cardiac murmurs at the present time is of importance to every medical practitioner, as well as of interest to those whose attention is especially directed to the diseases of the heart. In an able article in the January number of The American Journal of the Medical Sciences Dr. Austin Flint reviews our existing knowledge of these murmurs. He holds that there are four mitral murmurs, namely, (1) the systolic regurgitant, (2) the systolic non-regurgitant or intraventricular, (3) the presystolic, and (4) the diastolic. Each of these four murmurs has distinctive characters which individualize it. Two, three, and even all four may be combined in the same case. This statement, as will be seen, applies to the systolic regurgitant and to non-regurgitant murmurs. The names post-diastolic and post-systolic, produced by Hayden, seem to the author unnecessary refinements, and, therefore, objectionable. If the reader would stop to reflect upon the inquiry whether the mitral murmurs offer topics for consideration and discussion of sufficient interest and importance to occupy the thirteen and onehalf pages which Dr. Flint devotes to them, let him refer to that portion of the elaborate and able work on diseases of the heart, by Hayden, which treats of the cardiac murmurs. He will there find a statement of the defects in our existing knowledge, together with differences of

opinion in regard to the number of the mitral murmurs, their characters, their significance, and the modes of their production, which must convince him that they afford scope for an article extended much beyond the limits to which the author restricts himself. In fact, the object of the article is to present certain conclusions and suggestions without attempting to consider the subject comprehensively and fully.

THE PRODUCTION OF THE SO-CALLED "ROSE COLD" BY MEANS OF AN ARTIFICIAL ROSE.-Dr. John N. Mackenzie, of Baltimore, relates, in the January number of The American Journal of the Medical Sciences, a unique case, which, among its many other interesting features, forcibly illustrates the rôle of purely psychical impressions in awakening the paroxysms of the disease familiarly known as "rose cold."

While we cannot fail to recognize, as Dr. Mackenzie points out, the important relation of olfaction to the imaginative faculty, and the frequency with which it serves as the connecting link between associated ideas, and while the above case illustrates the psychical element in the excitation of the paroxysm, it must not be considered that the affection itself is a disease of the imagination, a purely psychological phenomenon dependent solely upon a deranged mental impressibility. For both our present knowledge of the affection and the history of the case itself, militate against and destroy such a supposition. Indeed, we should distinguish carefully between a disease having a definite clinical history and subject to recognized pathological law, and a mere perversion of the perceptive faculty, although the latter may occasionally act as an exciting influence in the production of the paroxysms of the former. The chief lesson to be derived from the study of this particular case (i. e., so far as the psychical element is concerned) is that it opens our eyes to the fact that the association of ideas sometimes plays a more important rôle in awakening the paroxysms of vasomotor coryza than the alleged vital property of the pollen granule.

MITRAL STENOSIS.-Constriction of the mitral orifice is, on many grounds, the most interesting of the valvular affections of the heart. It is common and at the same time dangerous, standing, in point of danger, next to aortic incompetence; being, indeed, the more serious of the two in early life, so that it has a very practical interest. Its clinical history, again, presents peculiarities, some of which have long been recognized, while others have not yet received adequate notice. The special claim of this condition, however, upon our attention, arises, as Dr. W. H. Broadbent, of London, points out in an able article in the January number of The American Journal of the Medical Sciences, from the fact that it presents greater difficulties in diagnosis than any other diseases of the valves. It was the last of the

valvular lesions to be associated with distinctive physical signs, and it is still not unfrequently entirely overlooked by physicians, while more commonly it is diagnosed as mitral incompetence, which is a far less serious affection. The physical signs are, in fact, extremely varied, and the attempt to elucidate their significance, and especially to attach diagnostic and prognostic meaning to some of the combinations of modified sounds and murmurs, is the chief object of his paper.

PATHOLOGY.

NOTES TOWARD THE FORMATION OF CLINICAL GROUPS OF TUMORS.-Mr. Jonathan Hutchinson, of London, says, in the January number of The American Journal of the Medical Sciences, that, in his opinion, the time has arrived when it is both possible and desirable to make, for practical purposes, a much more detailed classification of tumors than has yet been attempted. Some grouping of the kind is needed, both for purposes of prognosis, and in order that we may lay down good rules for treatment. Such grouping must be accomplished chiefly by observation of external features of similarity, and of resemblance in general tendency. It is these conditions, rather than histological differences, which will be of chief assistance to the surgeon; or, perhaps, it may be convenient to have two classifications side by side, the one clinical, the other histological, and let the two help each other at all points where mutual help is possible.

Mr. Hutchinson does not attempt the ambitious task of presenting an arrangement of new growths based upon their clinical features and like histories. He is, however, so convinced both of its desirability and of its practicability in the future, that he ventures to offer a few hints and detached memoranda, which may possibly prove helpful toward its attainment at some future time.

MICROBES

THE TRANSITION OF PATHOLOGICAL FROM THE MOTHER TO THE FETUS.-Kubassow, experimenting upon swine in the laboratory of M. Pasteur (Wratsch., 1885), finds that such diseases as œdema malignum, rouget, and tuberculosis are transmitted to the foetus by means of the placenta. In the so-called Siberian pest, rouget and tuberculosis, the bacilli are transmitted to the milk, in which they may be found as long as this is secreted, or until the death of the animal. The offspring are not infected by this milk, although the parent may die of the disease. Swine affected with tuberculosis or rouget do not become pregnant. The protection against infection lies in an unbroken skin, and particularly in an intact digestive tract.-Centralbl. f. Gynakologie, No. 49, 1885.

M.

SURGERY.

ANEURISM OF THE ASCENDING AORTA, PERFORATING THE CHEST-WALL. TREATMENT BY ELECTROLYSIS, FOLLOWED BY ARREST OF GROWTH; DEATH; NECROPSY. -Dr. J. C.Wilson reports in the January number of The American Journal of the Medical Sciences, a case of aneurism of the ascending aorta, presenting unusual and striking clinical features, and illustrating a method of treatment which was followed by useful results, but of which the number of recorded cases is limited. The case was a peculiarly favorable one for the use of galvanism. The tumor was external, of very rapid growth under observation, and there was such straining of the walls as to make the danger of rupture imminent. The needles were connected with the positive pole on account of the firmer clot which it caused. The first séance was only a partial success, for the reason that the foci of coagulation were probably too small and the time not sufficiently long. The second séance may be regarded as, under the circumstances, altogether successful. During the application pulsation almost ceased, and although it returned, it was not so violent or so extensive, or did it possess to the same extent its former expansible character. The mass, it is true, increased afterward somewhat in size, especially in thickness, but this increase was very slow, and the measurements after death were little different from those at the date of the second operation. From that date, also, the disposition to dangerous local bulging was arrested, and the consistence of the tumor was at all points notably firmer. Notwithstanding the theoretical objections urged against the introduction of needles connected with the negative pole, the results in this case indicate its superiority when it is sought to promote the rapid coagulation of a large mass of blood in an external false sac.

A CASE OF DISSECTING ANEURISM OF THE THORACIC AND ABDOMINAL AORTA.—In the January number of The American Journal of the Medical Sciences, Dr. James E. Graham, of Toronto, describes a case of dissecting aneurism of the aorta which presents many points of very great interest. The patient lived after the first formation of the aneurism, a period of more than thirty years. The strain was taken off by an opening low down between the artery and the aneurism, which rendered it possible for the blood to flow readily back into its own channel. The aneurism extended throughout the whole length of the abdominal and thoracic aorta, and more than half the circumference of the vessel. The closing of openings in the inner coat, at the exit of arteries from the aorta, and the corrugated appearance of the inner surface of the aneurism, are also points worthy of notice in this remarkable case, which is an excellent example of the restorative power of nature, and demonstrates the possibility of the enjoyment of years of fairly good health in one suffering from an extensive dissecting aneurism.

by profession

and laity in both Europe and America, caused by the published discoveries of Pasteur and his claim to have a vaccine that would prevent the occurrence of the disease in persons after they had been bitten by rabid animals, provided the treatment by systematic inoculations could be given before the appearance of the first symptoms of hydrophobia. This interest was much increased in the United States a few months ago, by the sending of four children who had been bitten by a dog supposed to be rabid, to Pasteur for treatment. Since that time discussion of the subject has been kept alive by frequent allusions and comments on hydrophobia and Pasteur's investigations, by medical and secular journals.

The term hydrophobia is of ancient origin, and still retained to designate a disease supposed to depend on the introduction of a specific poison into the system through the saliva of animals suffering from rabies, and rabies seems to be confined to animals of the canine and feline species, all families of which are subject to it. There can be no question as to the existence of such a disease among these animals as rabies, or that it is capable of being propagated from one to another by inoculation, or by the same means communicated to other animals, wild and domestic.

There is positive evidence that dogs, wolves, jackals, cats and skunks are subject to rabies, and can communicate it to other animals. It is also certain that a number of the human race die from the effects of their bites.

Just what proportion of persons die from the bites of animals supposed to be rabid cannot be determined, but the number is certainly very small as compared to the number bitten; so small, indeed, that a majority of physicians go through life without seeing a case of hydrophobia, or numbering among their medical acquaintances

* Paper read before the Detroit Academy of Medicine.

propagated in the human family by inoculation, or whether it may be produced by other causes.

There is a great diversity of opinion among writers on this question, the weight of evidence going to show that among lower animals subject to it, rabies is propagated by inoculation from one to another by the medium of bites, though a few claim that it may occur spontaneously in dogs, and if in dogs, there is no reason why the rule would not apply to other animals. It is probable that many dogs thought to be rabid, without having come in contact with another rabid animal, were not suffering from that disease. I have seen a dog goaded to madness and a high state of cerebral excitement by being pelted with stones by a number of boys, after having been chased under a barn floor. After a time, in a state of frenzy, the dog ran out and through the streets of the town, snapping and biting at everything that was in his way. The cry of mad dog was raised, and

a crowd of men and boys armed with guns and clubs followed him several miles through the country before he was overtaken and killed. All dogs known to have come in contact with the supposed rabid dog were killed and other domestic animals bitten were kept in confinement. No person was bitten, and no case of rabies occurred among the animals confined. If this dog had rabies it was induced without inoculation, and if not, which was probable, the difficulty of distinguishing between true rabies and a state of intense cerebral excitement will be appreciated.

The question of hydrophobia occurring in man by other means than the bite of a rabid animal is important in its bearings on the specific character of the disease. and the preventive or curative inoculations of Pasteur. Here again the weight of evidence seems to be in favor of the specific theory, but there is sufficient on the other side to raise a grave doubt to say the least.

Hartshorne says "there is good evidence to believe

the disease may be communicated to man by the bite of animals not affected with rabies." Hammond reports two cases of hydrophobia caused by the bites of bitches in heat that were not affected by rabies and continued well afterwards.

They were never supposed to be rabid.

The bite of the small skunk, found so numerous on the western plains, seems peculiarly apt to be followed by hydrophobia.

The Rev. R. C. Honey, in the Amer. Jour. Med. Sciences for May, 1884, reports cases of the disease caused by the bite of skunks, and Assistant Surgeon John G. Janeway, U. S. A., in the Med. Record, of March 13th, 1885, reports a large number of such cases, Dr. W. Thornton Parker, in the same Journal of March 13th, 1886, makes a similar report, and says the bite of the skunk is more to be feared than that of the rattlesnake. It is not claimed that these animals are rabid. They prowl around and through the tents at night in search of food, and finding a toe, foot or hand uncovered, proceed to utilize it for that purpose. Dr. Parker says that so great was his fear of skunks that he always sodded around the bottom of his tent, and in addition to securely fastening the entrance at night, tied his dog to it, which was effectual in keeping the pests out. If the skunks had been affected with rabies they would probably have attacked the dog, which did not occur.

This view of the subject opens a field for investigation, for if it can be shown, as appears to be the case, that hydrophobia can be produced in man by the bite of animals not rabid, the theory heretofore accepted regarding its specific nature and method of propagation must be abandoned, and the conclusion forced upon us that there is a poison inherent in the saliva or secretions of the mouth of certain animals capable of producing the disease, or that it is developed in the same by conditions or circumstances not understood.

If not this, then it is a manifestation of tetanus, differing from the disease of that name only in the site of the lesion and its severity.

There have ever been men, some of them of eminence, who have denied the existence of such a disease as hydrophobia, declaring the one so-called to be a species of tetanus, and in support of that opinion point to the similarity of symptoms, and the fact that hydrophobia does not occur in persons bitten by dogs known to be rabid oftener than tetanus follows punctured or lacerated wounds of the extremities, the usual location of the bites of rabid animals.

It may be argued, also, that hydrophobia is either a specific disease or it is not; if it can be produced by the bite of animals not rabid, it is not; if not a specific disease, it is allied to tetanus, if not the same thing differing in degree. The weight of authority is largely preponderant in favor of its specific nature, but a comparison of

symptoms will show that those who claim the identity of the two diseases have at least some reason for their opinion.

In both diseases the symptoms point to the nerve centres as the seat of the lesion; in both we have early a sense of difficulty in deglutition which increases with the disease, terminating in laryngeal spasm. In both we have spasm of the voluntary muscles, which is increased or brought on by any cause that will excite reflex action, such as a touch of the body, sudden noises, a current of air coming in contact with the body, etc., and the fits may occur in either disease without these; in both we have a secretion of thick, tenacious mucus and saliva that adds much to the distress of the patient; in both the skin becomes hot and sensitive, and shows a decided rise in temperature. In tetanus the average duration is from three to five days; in hydrophobia from two to three days, though a fatal termination may occur in either in a shorter time, but is oftener prolonged in tetanus. In both the muscles of respiration are involved, especially during the paroxysm-to a greater extent in hydrophobia. In both the temperature of the body rises after death and remains above normal for a considerable period of time.

The principal points of dissimilarity are that in tetanus the disease follows the injury in a few days, sometimes in a few hours, while in hydrophobia the average period is from 30 to 40 days. Niemeyer gives from eight to ten days as the shortest period, and months, even years may elapse before the occurrence of the disease. Cases of hydrophobia have been reported as occurring three, five, and ten years after the reception of the bite. Law reports one case of ten years, but believes in these delayed cases the disease is not true hydrophobia, but the hydrophobié non-rabique, of the French writers. He terms it "Lyssaphobia," literally a fear of being mad, but equally fatal with the true disease. In tetanus the symptoms point to the spinal cord as the seat of the lesion, the brain being secondarily and but slightly affected; in hydrophobia the brain is primarily affected, the seat of the lesion seeming to be at its base and in the medulla oblongata, the cord being secondarily affected.

There is frequent laryngeal spasm in hydrophobia accompanying the pharyngeal, which is rare in tetanus. The general convulsions that take place in tetanus are attended with exacerbations and remissions, while they are chronic with intermissions in hydrophobia, though Flint says they are sometimes tonic in the latter disease.

The main points relied upon to make a diagnosis are the occurrence of trismus in tetanus, which is absent in hydrophobia, and the mental excitement with hallucinations and occasional violent delirium that sometimes occurs in the latter disease, while in tetanus the mental faculties are clear. Cases of hydrophobia have been noted in which there was no mental aberration. Some writers also call attention to the fact that tetanus follows

a wound or injury, and hydrophobia the bite of some animal, evidently forgetting that the bite is a wound.

The pathological changes as far as known are "general congestion of the brain and cord, more intense in the tissues of the cord and membranes, with structureless exudations, especially in the grey matter in tetanus" (Dr. Albert). In hydrophobia we have congestion of the brain and cord with an accumulation of leucocytes around the blood-vessels and their infiltration into adjacent tissues, most intense in that portion of the medulla contiguous to the lower part of the fourth ventricle, and in the hypo-glossal, glosso-pharyngeal and vaga nuclei" (W. R. Gowers).

In very few cases of either disease, as far as has been discovered, have the pathological changes been sufficient to account for the phenomena presented, and from a review of symptoms and general feature of both diseases, it does not seem difficult to believe that they differ only in degree and part of the nervous system affected, which would account for all differences in symptoms.

Neither disease has ever been communicated from one human being to another, though wounds and bites have been often given by patients laboring under each, and it is extremely doubtful if rabies can be communicated to dogs by inoculation from human saliva. The correctness of the few cases reported is denied by most authors, though it is not impossible that the power of reproduction of any virus may be lost by its transmission through man from lower animals. Pasteur found that the introduction of his most rabid virus caused no serious disturbance in monkeys, and after inoculation through a short series of monkeys, the virus was powerless on dogs. He had been experimenting for a long time with the virus of rabid dogs, and its effect on monkeys suggested the possibility of a sufficiently attenuated virus that would be harmless to man, and, at the same time, protect him from the bites of rabid animals. He worked faithfully for months to that end, and finally announced that he had succeeded.

In the course of his experiments he found that the brain and spinal cord of rabid animals would reproduce the disease when injected into or on the surface of the brain of other animals, and the medulla oblongata was used because it was as virulent as any other portion, more convenient to handle, and uniform in size. By using the medulla of a rabid dog and injecting the brain of a rabbit, and then from rabbit to rabbit through quite a number, given by Billings at from 10 to 25, Pasteur found that he had a virus which was uniform in its results, and caused death in rabbits in seven days by producing a progressive paralysis without symptoms of rabies, and that the medulla from a rabbit so treated produced the same effect when injected into the brain of a dog. These experiments have been continued for a long time with the same results, and there can be no

question but that Pasteur has succeeded in modifying the effects of rabific poison in animals, if not the result, or that he has produced a new disease from it. It was still necessary, however, to further change the character of, or attenuate the virus before venturing to use it on man. He found that the medullas from rabid rabbits, when exposed to a dry atmosphere at a temperature of 20° centigrade, lost in virulence with each day of the exposure, until the fourteenth day, when it became inert and produced no effect when injected into the brain of dogs or rabbits. Pasteur now had a virus of any strength from a super-virulent or fresh medulla, to the inert or that desiccated for fourteen days, and he believed in these he had a vaccine that could be used with safety upon the human race, and afford protection from the bites of rabid animals. The first inoculation was made on the 7th of July, 1885, less than one year ago, on a boy who had been bitten by a rabid dog.

His method of treatment is to take a portion of the driest and weakest virus mixed with bouillon and inject under the skin, and each successive inoculation to be made with virus stronger than the preceding. To make sure the virus used is all right a rabbit's brain is injected with the same virus at the same time and its effects noted,

The injections are made at first twice a day, then daily, and finally every other day until the strongest virus is used, when the patient is declared cured or protected. No constitutional effect is stated, and the only local effect is a "distinct hyperemia at the point of inoculation, not usually noticed until the last or most active virus is used." (Frank S. Billings, D. V. M.)

The absence of noticeable results is claimed to be due to the fact that the systematic inoculation "so prepares the elements of the body that they are enabled to resist the action of the more virulent rabid rabbit virus. The boy Meiser was discharged after twelve inoculations and Pasteur declared that "he has escaped a future outbreak of canine rabies." Of the four children sent from New Jersey to Pasteur for treatment, it will be noticed that Dr. Billings says they were bitten by a dog supposed to be rabid, and that two other children bitten by the same dog remained at home and have developed no symptoms of hydrophobia up to the present time.

If Pasteur's theory of hydrophobia and its prevention is correct, which is far from proven, it upsets all received theories and doctrines regarding preventive vaccination. All ideas relating to protective vaccination have grown out of the immunity against variola offered by the substitution of the modified form or vaccina in its stead, and the theory has almost come to be an axiom that vaccination for protection against a disease must produce a modified form of the disease under such conditions that its effects are visible, and that only diseases in which one attack secures immunity from future attacks