anon, to call into requisition the inventions of modern science. The hard-working student passes out from his Alma Mater, brimful of science and without half enough of practical training. In the writer's opinion, more importance should be given to the education of the student's five senses. The superiority which one physician attains over another, in the successful treatment of disease, is not so much on account of his knowledge of the dead languages, or of the higher mathematics (although the acquisition of the same is not to be condemned) as to an educated touch, keen ocular observation, and a well-trained ear. A great clinician contributes largely from the storehouse of his experience, and observation, and if we ask him from whence he derived his knowledge of diseased conditions, he will point to the laboratory, the microscope, ophthalmoscope, analysis of blood, tissues, urine, etc.

One of the most useful instruments given to us, during the last half century, is the ophthalmoscope; although relegated largely into the hands of the specialist, its requisition and application by the general practitioner would aid him in arriving at a correct and precise diagnosis. HELMHOLTZ' attention was called to the color of the pupil, a question being raised why it was always black, (save under exceptional conditions). Upon this subject he concentrated his close observations and rare aptitude for physics. He not only revealed the true condition, but invented a mirror, which made it possible to see the fundus of the eye. Still further pursuing the subject of physiological optics, he finally gave us one of the most complete treatises in existence. PROF. VON GRAEFE with this instrument began his studies in clinical ophthalmology and achieved the most brilliant results. The correct and scientific employment of spectacles is due, almost entirely to the labors of DONDERS. About the same time and from the same stimulus he began the study of refraction and accomodation of the eye. To the above trio will remain the honor of first giving to the medical world, the fundamental principles of optics. The three chief methods of examining the fundus oculi, are: 1. The direct method; 2. The indirect method; 3. Retinoscopy, or the shadow test. For a minute information and proper directions, the student is referred to the textbooks on ophthalmoscopy.

To M. BOUCHUT is given the credit of first calling the attention of the profession in general to the use of the ophthalmoscope in brain diseases.

The eye is

so closely connected with the nervous system in general, and the brain in particular, both anatomically and physiologically, that very often in morbid conditions of the brain and meninges (with or without diseased conditions of the whole nervous system) an ophthalmo

scopic examination of the fundus oculi will add the missing link to what would otherwise be a doubtful diagnosis. In interstitial nephritis, one of the most prominent systems is sudden diminution of sight. The ophthalmoscopic appearances in albuminuric retinitis has often led to a correct diagnosis, when the patient had previously been treated for dyspepsia, colic, biliousness and headache. In this form of Bright's disease albuminous depositions are not constant, dropsical effusions are not always present; hence the diagnosis is rendered obscure. I have had under my care during the last four months, an old gentleman who had previously enjoyed good health. His appetite became capricious, memory treacherous; mental depression and dimness of vision followed. Frequent urination and increase in quantity; no oedema present. Diabetes was suspected, and appropriate urinary tests made with negative results. Two examinations for albumen were then made with the same result. The diagnosis still being very obscure, an ophthalmoscopic examination of the fundus oculi was made, which revealed the true condition. Subsequent urinary analysis and microscopic examination developed cortical degeneration. In this disease the following changes take place in the retina: 1st, a general haze of a dim grayish tint in the central part of the retina, and very frequently retinal hemorrhage: 2d, the second stage, the sight becomes impaired, and we find a number of white dots or patches in the hazy region; when these are few, they are generally found near the yellow spot, and are of a peculiar white, opaque color. Hemorrhages are generally present, and constitute the most marked feature of the case.

HENRY JULER, F.R.C.S., of London, in one of his admirable lectures on the ophthalmoscope as an aid to diagnosis, relates from his experience the case of a medical man of active habits and literary tastes, who consulted him upon a matter which had been to him a source of greatest anxiety. His left eye had become useless, and he had been told by competent authority that it would not improve. His right eye was also becoming so dim that he could not read by night and very little by day. He was given to understand that tobacco was the cause of the condition, and consequently relinquished its use; he also suffered from headaches. From the history as given by the pa tient, DR. JULER thought he had a serious case to deal with. The ophthalmoscopic condition of the left eye, the worst one, revealed hypermetropia of thin dioptrics, and the optic disk somewhat congested. The right eye was also hypermetropic, although of a less degree, and the disk also hyperæmic. Correcting glasses were adjusted and vision restored, and the man sent away happy with the assurance that he had no tobacco amaurosis.

This, says PROF. JULER, is another case shirked by the practitioner, or altogether misunderstood. He also states that he has known of ametropes who have been advised to desist from all study, change their vocation in life, and go abroad in search of recreation, when all that is required on the part of the practitioner is a glimpse with the ophthalmoscope.

DR. HUGHLINGS JACKSON, in a discussion before the Ophthalmological Society of London, in 1881, said in reference to optic neuritis: "Your health goes for nothing in our estimation of the gravity of the situation. We all have seen healthy-looking children and adults who have double optic neuritis with good sight, who are supposed by those who do not use the ophthalmoscope to have no intracranial disease at all."

MR. HUTCHINSON wrote: "The routine use of this instrument would save us from many errors. No one would make the diagnosis of hysteria or liver disease only, if he saw by looking at the disk optic neuritis."

The want of space and time prevents me from following the subject any farther at present.

A CASE OF DOUBLE HARE-LIP.

BY DANIEL LA FERTÉ, M. D., PROF.ORTHOPEDIC SURGERY AND CLINICAL SURGERY, DETROIT COLLEGE OF MEDICINE.

It falls to the lot of every medical man to meet with deformities of various kinds. When they involve some exposed portions of the human frame it is but natural that the surgeon summon all the ingenuity at his command for their removal. The resultant scar, if this is unavoidable, is to be borne in mind. He plans his incisions and he removes certain portions, and in such a manner that as little trace as possible of the original trouble may be left. In fact he endeavors to accomplish as nearly as practicable what nature would have done if the process had gone on uninterruptedly.

Within the range of malformations about the face, there are few which are more mortifying to the parents, few which give to the features a more hideous look, than a well developed case of hare-lip. If it is a case of the double variety, with a fissure through the alveolar border of the superior maxillary bone; poss ibly a fissure corresponding to each fissure in the soft structures and, consequently, not infrequently a well-marked protrusion of the intermaxillary bone, we have then before us truly an object of pity. In a case of this sort a wellplanned and well-executed operation, and one terminating favorably in its results, will be certain to win for the surgeon the everlasting gratitude of the parents.

Parents are not always easily persuaded to

allow their infant to be subjected to so severe an operation as one required when some of the complications mentioned above exist; within the range of their acquaintance they know of some case that was very little benefited by the operation. They have possibly heard of another case that was made worse, and possibly of another that resulted fatally. The latter mishap cannot always be avoided, for when the bone is fissured the operation is necessarily a severe one, entailing a great shock to the system.

There seems, however, to be very little excuse for not greatly improving or entirely curing a case of this kind. The operation is an easy one. but, nevertheless, it requires a certain amount of nicety of judgment for its proper execution and successful termination.

We have all been taught that a very frequent cause, if not the prime factor in an unsuccessful

case, is the want of a sufficiently extensive dissection of the soft parts from the superior maxillary bone. This part of the operation is, however, sometimes deceiving. We find this especially the case if we attempt to make an extensive dissection of the nose corresponding to the depressed side in a case of fissure of the alveolar border of the jaw when one part overrides the other. An extensive dissection here will certainly add to the deformity of the nose. This I have learned by actual experience in my anxiety to make certain that I made my dissection sufficiently extensive.

By the exercise of a little tact and judgment we obtain results in these cases as gratifying as any in plastic surgery.

Among others I select from my note-book the case of a little child, three months old, which was brought to me from Canada. It was a case of double hare-lip, with a fissure through the whole of the alveolar border of the jaw corresponding to the fissure on the left side. There was severe advance of the right side of the bony

A

cleft in front of that of the left side, and wellmarked depression of the left wing of the nose (Figure 1.) The parents readily consenting to an operation, the little one was placed under an anæsthetic. The little island under the nose was pared all around its circumference. piece of soft leather was then placed over the projecting alveolar process, to avoid bruising, and by means of firm pressure with the handle of an instrument, it was fractured and forced backwards into as perfect coaptation as practicable with the other side of the fissure. No sutures were used here as the fragment manifested no tendency to displacement. I felt safe then in trusting to the pressure which the sutured lip would exert upon it to have it retain its place. The next step of the operation was to split the soft parts corresponding to the left fissure, and make a flap along the margin of the right fissure, in other words following Colles' method, which is familiar to all surgeons.

FIG. 2.

The little flap on the right side was stitched partly to the lower part of the little island under the nose, and partly planted into the slit made on the left side. Finally the raw edges of the clefts were stitched to the sides of the little island above mentioned, which completed the operation. The parts were supported by means of adhesive plaster, which was removed every two or three days. At the end of the twelfth day all sutures were removed and complete healing had taken place.

At the end of the third week the mother being very anxious to return home, I had the little one photographed. His appearance at that time is shown in figure 2. It will be seen by that plate that the scars are yet quite visible. Three months after the operation the mother brought the little patient to my office and at that time scarcely any scar was to be seen, even the little dimple in the centre of the lower border of the upper lip having disappeared.

COCAINE DOSAGE AND COCAINE ADDICTION.*

BY J. B. MATTISON, M. D., BROOKLYN, N. Y.

The sad story, in a recent Record, of the Russian surgeon's suicide from sorrow or remorse due to his belief that a patient had died from an overdose of cocaine, points a moral, the import of which demands more than a passing notice.

No advent in the therapeutic arena during the last decade, has been attended with such varied and extensive claims for favor as cocaine. Its marvelous effect in ophthalmic surgery roused a spirit of experimental research in other directions which has added largely to its well-proven power for good; but, as has been well observed, a potency for good implies a potency for harm, and the risk impends of its ardent advocates being carried by over-enthusiasm, beyond the limit of a safe regard for the welfare of their patients or themselves, that may imperil an otherwise well-founded

success.

Surely it is, in the writer's opinion, full time to draw the line; to re-voice a warning as to the use and abuse of this valued, but, at times, toxic drug, lest the roll of alarming, dangerous and fatal effects from its ignorant or incautious using be sadly extended, and a reaction ensue that, by creating distrust within and without the profession, will damage its good repute, and hinder its use in cases where it would be almost certain of serving us well. And the need of this seems all the more called for in view of opinions expressed, the past year, in certain quarters, affirming the harmless character of cocaine-opinions which, I am convinced, are at variance with well-accredited facts, and should not be allowed to pass uncontradicted.

Cocaine seems to have secured for itself a more than usual share of attention aside from the professional press. One metropolitan daily, in particular, has, again and again, given its columns to a discussion of the topic, and in a somewhat lengthy article not long ago, an eminent but unnamed specialist "—DR. FRANCKE H. BOSWORTH-was reported as saying "there is not a well authenticated case on record, as yet, where cocaine has effected injury."

In view of cases cited in this paper, and others elsewhere recorded, such a statement is no longer tenable, and any conclusion based thereon as to the harmless nature of cocaine is misleading and incorrect.

And the evidence herewith presented weighs even more heavily against an assertion by DR. WM. A. HAMMOND, at a recent meeting of the New York Neurological Society, in the

* Read before the Kings County Med. Soc. Feb. 15, 1887.

course of his "Remarks on Cocaine and the socalled Cocaine Habit," when, after telling of his taking of eighteen grains at a subcutaneous dose, he asserted "he did not believe any dose that could be taken was dangerous!" What might be the outcome of such an opinion put in practice? The Russian surgeon's error of judgment, fatal to his patient and himself, was largely due to his reliance on the asserted use by other surgeons of large doses without illeffect. Might not a like result follow an incautious dependence on DR. HAMMOND'S disbelief in the toxic power of cocaine? The Record well said of PROF. KOLOMNIN'S case: "The experience, though so sad, may not be without its lesson," and put a very pertinent query as to whether there are not other surgeons who could report very serious, if not fatal, results from injudiciously or ignorantly using too large a dose of cocaine?

Fifty cases herewith noted, attest a power in this drug on some patients, that warrants caution with all.

"A young man, aged twenty-three, was sent to PROF. KOLOMNIN, and found to have a large ulcer of the rectum, which was diagnosticated to be of tuberculous nature. He decided to scrape and cauterize the lesion and to use co caine anæsthesia during the operation.

"In order to produce anæsthesia, he had fifty grammes of a five-per-cent. solution of hydrochlorate of cocaine prepared: of this, thirty grammes were brought into use, containing exactly twenty-four Russian grains of the salt, or twenty-three English grains-the Russian grain is exactly one-sixteenth of a gramme-six grains being injected at a time into the rectum. After the third of these injections, it was found on examination that the part was still sensitive A speculum was then introduced, the ulcer dabbed with a dry sponge, and then the fourth injection given, making twenty-four grains in all. After this the parts were tolerably anæs thetic. The ulcer was scraped, and a tampon saturated with oil inserted. The pulse was then accelerated. During the operation the patient groaned, so that even the twenty-four grains had not produced complete anæsthesia.

"After the operation, KOLOMNIN went round his ward, and in three quarters of an hour a message was sent to him that the patient was very low. He found the pulse very weak, the face and hands cyanotic, and the respiration labored. He considered that she was in a toxic state, and used every means to bring her round. PROF. SUSHCHINSKI being also invited to a consultation. Faradization, artifical respiration, hypodermatic injection of ether, adminis tration of ammonia, tracheotomy for the inhalation of oxygen, stimulating and nutrient enemata-all were tried, but without success. KOLOMNIN had no doubt that death was due to cocaine"

DR. W. H. LONG, U. S. Marine Hospital Service, reports in the American Lancet the case of a man aged thirty three, to whose larynx he applied, three times, a four-per-cent solution of cocaine. Prompt relief was given, but three and one-half hours later the patient was found unconscious; breathing, labored; respirations, twenty; pulse, ninety; general condition, one of profound anæsthesia. Diagnosis, cocaine poisoning. Several doses of whiskey were given subcutaneously. In half an hour, consciousness partially restored, then gradual and full improvement save a feeling of great exhaustion.

Four days later cocaine was again used. Thinking the former toxic effect due to swallowing some of the solution, and probable absorption by larynx, extra precaution was taken to have it expelled and the pharnyx well rinsed. Two applications of a two-per-cent. solution were made. Relief was again complete, but three and one-half hours after, patient was in same condition as before, except the anesthesia not so profound. Frequent injections of whiskey were again used with partial success-could swallow and answer questions-but, soon after, he suddenly ceased to breathe. The heart beat a short time longer. All efforts at resuscitation failed. The probable immediate cause of death was paralysis of the respiratory centre due to cocaine.

DR. F. M. THOMAS, Leonardsville, Kansas, reported to PROF. R. OGDEN DOREMUS, as follows:

"Friday morning, October 23d, 1885, I was called to see Mrs-,aged thirty-nine, whom the messenger reported as dying. I found her unconscious; breathing heavily and irregularly, pulse thirty-five, intermittent; temperature normal; left pupil largely dilated, right natural; right arm and lower limbs motionless; face spasmodically drawn upwards toward the dilated eye.

"Spasmodic action of the left arm and upper part of the body came on regularly at intervals of a few minutes, during which she clutched the bed-clothing, and seemed to be trying to vomit. Twice during my attendance she ejected small portions of the previous evening's meal. Salivation was excessive; retained a dorsal decubitus; would not lie on either side. Heart seemed almost exhausted.

"I saw her at 5 A. M, and was with her nearly all the time till she expired apparently completely exhausted, about 3.30 A. M.”

On inquiry, the doctor learned that Mrs. had been freely using a four per-cent. solution of cocaine, for toothache, due to several much decayed left upper molars. His diagnosis was cocaine poisoning.

DR. KNABE, of Berlin, records the case of a girl aged eleven, who was given four to twelve drops-the exact amount was not determined

In the Australasian Medical Gazette, August, 1886, DR. W. E. RAMSDEN WOOD reports this case. "A. B. suffered from neuralgia, due to a defective tooth. Extraction being impracticable, cocaine-amount not stated-of a tenper-cent. solution was injected, with prompt relief, lasting some hours. Next day, the pain, being very severe, patient sent to his chemist for a similar solution, and three minims were injected, but without the desired effect; he returned it to the chemist and asked him to make it stronger, which he did, making it twenty per cent. He brought this to me, but omitted to tell me that the solution was double the strength of that which I had used. He told me that three minims had not given, him the relief that he had experienced from mine; I therefore gave him four minims of what I believed to be a ten per cent. solution, and within five minutes he became restless and inclined to vomit; he then began to feel a sensation of pins and needles in the left hand and arm, which rapidly extended to the right side. This was speedily followed by contraction and rigidity of the fingers, arms and legs: there was also a tendency to opisthotonos. His pulse became extremely rapid and feeble, his face livid, and the muscles of his mouth and cheeks strongly contracted. His respirations were short and convulsive, his feet and hands very shortly became cold, and a profuse perspiration broke out on his head and face.

I first gave him half a tumbler of brandy, followed at short intervals by drachm doses of spiritus ammon. aromatica, and applied strong mustard over cardiac region, and used friction to the upper and lower extremities; at the same time I let him inhale a few drops of chloroform to try and check the spasmodic contractions. After continuing these remedies for nearly an hour the pulse began to improve, the color to return to the face, and the rigidi ty of the muscles lessened, but returned immediately I stopped the friction. At the end of two hours he improved more rapidly, but felt somewhat drowsy, and it was not until about four or five hours that all the symptoms had subsided.

On questioning him afterward regarding his sensations, he told me that although he was unable to speak coherently, he knew all that was passing, and it was not until he felt the abdominal muscles becoming rigid that he felt anxious, for then he thought he was dying. and a sensation of suffocation came over him.” DR. T. H. BURCHARD, in the Medical Record,

December 5th, 1885, reports a case in which he injected ten drops of a four-per-cent. solution to induce local anesthesia before removing a needle from the foot. "In about four minutes my patient suddenly clutched his throat, exclaiming 'I am dying!' and fell from his bed unconscious. Respiration ceased, his jaw dropped, his eyes rolled upward, and to all ap pearance he was dead. His heart was beating very faintly, although his radial pulse was imperceptible." Artificial respiration, hypodermics of ammonia and atropia, alcohol, sinapisim over heart and hot bottles were employed, and in "fifteen minutes after the catastrophe, his pulse was about forty-eight, very feeble, and respirations seven to eight. Unconsciousness continued twenty minutes." Patient recovered.

DR. SPEAR, U. S. N., in the Medical Record, reports the case of a man aged twenty-nine, who took, subcutaneously, within seventeen hours, to remove the effect of a rum debauch, nearly ten grains of cocaine, Squibb's make. He was found in a toxic state; unconscious, face congested, and whitish grey; hands and lips blue; pulse feeble, fluttering and uncountable; respirations slow and almost imperceptible: face and neck streaming with sweat and body bathed in cold perspiration. Under treatment, in about 90 minutes he began to be conscious, and gradually recovered.

S. C. KILHAN, L.R.C.P., Sheffield, England, read before the Sheffield Medico-Chirurg. Society, November 25th, 1886, this case: On Nov. 9th, 1886, at 12 noon, JOHN B. accidently took four and four fifth grains of cocaine hydrochlorate in the form of solution. At 12:30, he was seized with severe cramps in the stomach, nausea, throbbing and feeling of bursting in his head, failure of eyesight, loss of use of his legs, incoherence of speech and confusion of ideas, and drowsiness, but could always answer questions when aroused. No delirium; appeared as if drunk and got quite helpless. Brandy was given to him, and he vomited after it, but only the remains of food. About 12:50, he commenced sweating most profusely, shirt, etc.. being soaked through, perspiration streaming down his face and body, and his head steaming. Pupils were normal and equal. No loss of taste. The sweating lasted some time, and was succeeded by very severe prostration, shivering, and feeling of impending death. At intervals, the patient had severe cramps in the stomach with retching and vomiting of a quantity of clear mucus, which relieved the pain. About 1:15 P.M., the pulse became intermittent -missing every fifth beat. This was accompanied by cyanosis of the face, and intense feeling of suffocation over the cardiac region. Relief was afforded by sinapisms. The pulse varied from 80 to 86, never more, and became gradually regular. About 1:45, P.M., he began