in the successful treatment and amelioration of the con- tion in the State, nor did the medical colleges show any dition of those bereft of reason. interest in the matter. Their indifference would seem We have learned with profound regret that the Chief to indicate that they are rather pleased than grieved. Executive of the State of Missouri has taken it upon It is all gammon to talk of the dereliction of the Legishimself to displace the medical profession without just lature and the criminal folly of recognizing osteopathy cause or provocation from the management of the oldest and largest asylum in this State, and to place it in the hands of persons who neither by experience nor scientific training have fitted themselves to assume the responsible duties which their positions entail. We protest in the name of humanity and of scientific medicine against the unwarranted action of the Board Managers. It is a stain upon the fair escutcheon of our State, a detriment to the best interests of society, and a crime against the unfortunate inmates of the Institution. A. B. Miller, 1st Congressional District. Does the Missouri State Legislature and the assignment of Fulton to the homeopaths, when the weightier matters of the law "are ignored or thrown to the moles or bats." Now let the frogs and lice and vermin of every kind come in and do their work, that we may still have something to howl about, and thereby put forth claims to a virtue we do not possess. H. CHRISTOPHER, M.D. The signer of the letter is Dr. Hiram Christopher, A.M., M.D, Professor of Chemistry and Medical Jurisprudence and Dean of the Faculty of the Ensworth Medical College and Hospital of St. Joseph, Mo. CORRESPONDENCE Spurious Imitations. Editor MEDICAL REVIEW:-The attention of the medical profession is earnestly directed to the various dangerous decoctions masquerading as Coca wine. These decoctions are intended as meretricious imitations of the standard French preparation, "Vin Mariani," which has been so widely endorsed by and whose merits are so well known to the medical fraternity, that it would be superfluous to enter into any lengthy enumeration here of its virtues. Investigation discloses that these so called coca wines are generally variable solutions of the alkaloid cocaine, in sweetened wine of a low grade (artificial wines). Quantities of such so called coca-wine have been seized upon by various health authorities and destroyed. Any physician will realize the danger ensuing from the use of decoctions of such a character. pared and properly administered, have long since been recognized by the medical fraternity. From the proceedings of the Missouri State Medical Association it would appear that the reason why no action was taken by the Association for the purpose of creating a higher standard of medical education was These spurious and dangerous preparations are hav. due to the fact, which was distinctly mentioned at the ing the effect of causing misapprehension and working meeting, that the present Legislature does not favor a an indirect injury to a really valuable drug, for the real higher medical education and that it would be useless, usefulness and value of Coca, when conscientiously pretherefore, to make efforts in that direction at present. There were some speakers at the meeting, however, who expressed the view that any failure of securing proper legislation was due to dissenting opinions among the members of the medical profession itself. That the profession could have any laws enacted which it desired, provided that an effort was made by the entire profes sion. In the following letter which Dr. F. J. Lutz had the courtesy to send us a similar opinion is expressed in a rather plain and unembellished manner, here it is: ST. JOSEPH, Mo., May 21, 1897. F. J. Lutz, M.D., ST. LOUIS: [There have been placed on file by Mariani & Co. more than 8,000 endorsements from leading practioners, all coinciding as to the merits of "Vin Mariani." can thus be claimed, "Never has anything been so highly and justly praised."] Physicians will not encounter disappointment when. ever using "Vin Mariani" the standard French Coca wine, as an adjuvant in treatment, as a tonic-stimulant, and as a restorative in cases of profound depression, anemia and exhaustion. It has stood the test in practice during nearly thirty five years, and during that period has been strongly endorsed as a reliable and standard Stated Meeting, Saturday Evening, May 1, 1897; To Dr. Paul GibiER, Director of the Pasteur Institute, the President, W. J. LANGAN, in the chair. New York. DEAR DOCTOR:-In answer to your wish I will give you a short account of my experience with the Diphtheria Antitoxin of the New York Pasteur Institute, and to that account it will be needless for me to add any high sounding recommendation. Appendix or Dermoid Cyst? DR. MAYFIELD presented a specimen, and said: I have here a specimen for which I have been battling for the last day and a half, to save for this meeting; it is an appendix which we removed, and which has not yet been opened-it is intact. I began the use of Serum in the early months of 1895, following the lead of my most esteemed confrere, Dr. E. W. Saunders, of this city. The very first case on The patient from whom this came was brought here which I used it did not recover, as the parents had only by ber family physician from Central Missouri day bewhich I used it did not recover, as the parents had only given their consent to its exhibition "in extremis;" still, fore yesterday morning. She is 42 years old, the moth the patient survived long enough (about 24 hours) to er of six children. The patient had been suffering for show plainly the wonderful effects of the serum on the diphtheritic membranes. a week or more with general malaise, the cause was not definitely settled by her physician and he did not prescribe for her until four days prior to her starting for Since that time I have used it in 37 cases of my St. Louis, when the family physician diagnosed appenown practice and in 6 consultation cases, and lost 4: one dicitis. He found great tenderness over the region of from croup, two from mixed infection, and one from McBurney's point, and there was a continuous temperascarlatinal diphtheria. The detail of the cases would be tedious and profitless; still, as they should have led ture of 102° from that on, not going beyond 102° and a fraction, with a pulse of 110, and the swelling being me to some useful remarks and deductions, and as a con well-defined in the region, enabling him to make a di sequence have brought me to a set determination from agnosis of appendicitis, and as the swelling was becom which I never swerve any more, I will state that no ing so painful they decided to bring her to the city, matter how light the case may appear at first, both which they did on a stretcher, with considerable diffi. symptomatically and upon inspection, I now invaria-culty. The inflammation was not extensive, it was bly open the treatment with a full dose of your serum: confined about the cecum, however, it extended almost 25 cc. d'emblee, and only in a very few of my cases through the abdominal wall to the skin, the wall being have I had to repeat the injection; it seemed to arrest almost gangrenous, and the peritoneum in contact with the disease in the following 20 hours, so that a very it. The tumor pointed toward Poupart's ligament, and simple antiseptic was sufficient to dispel all remnants of the local lesion. I must also, in justice to your serum, add that in two cases in which I had used the Behring product first, owing to the distance of the source of supply, I had, the next day, to repeat the injection with the New York Pasteur Institute serum and I ascribe the former's inertness to its age; it was 10 months old. Now with the great improvement which your letter has just imparted to me, the immunization of most of your serum horses against both the diphtheritic and the streptococcic infections, I feel confident that the New York Pasteur Institute serum will more than hold its own in the good opinion of the physicians and that the parts round about the cecum were gangrenous. The patient had had much pain during the past four days; the pain around McBurney's point became so very intense that the doctor in charge had to give morphine freely, hypodermically, to control it. The tumor showed in the iliac region prior to the operation, there was not the usual rigidity about the abdominal wall, but the blood vessels were greatly congested. The tympanites was a little misleading at the site of the tumor. In percussing the tumor, it seemed as if you were percussing an inflated gut. It rested tightly against the distended bowel, owing to the fact that the bowel was distended. The absence of swelling in the immediate vicinity was also misleading. The patient vomited considerably, DR. LUTZ-I would like to ask Dr. Prewitt if I understood him to say because it was a dermoid cyst it must have had its origin in the ovary? DR. PREWITT.—I think we may say with absolute certainty that, admitting it to be a dermoid cyst, it had its origin in the ovary; I think there is no question about that. DR. LUTZ.-How do you explain those cases of der. moids which are found in other portions of the bodyabout the eye or in the neck? DR. PREWITT.-They are all fonnd in those positions where there has been an involution of the integumentary layer, the layers that go to make up the structures connected with these things and the ovary; that is where they are found. And in this particular instance, I think, there is no question but that it came from the ovary. was constipated and a strong fecal like odor was emit that it is a dermoid cyst which had been detached from ted from her skin, with the perspiration, soon after she its pedicle which connected it with the ovary and had was admitted. There had been no antecedent attack of lodged at this point and contracted some adhesions. I appendicitis, so far as could be learned. The patient think the Doctor said it was adherent and, consequently was in much pain, and the tumor was so well defined it was misleading by its position. The contents demthat we feared its rupture, so that we did not spend the onstrate that it is a dermoid cyst, and, of course it had usual 24 or 48 hours in preparing the patient, moving its origin in the ovary; it could not have been anything the bowels, etc., but simply went to work and operated else. There are many cases on record in which these at noon. I made an incision about half way between cysts have been twisted off and have been found lying the umbilicus and the anterior superior spine of the loose in the peritoneal cavity. This is not an unique ilium, about 44 or 5 inches long, longitudinally, cutting condition. down upon the tumor cautiously and entering the peritoneal cavity, and there was no trouble to outline the goose egg-shaped tumor which was adherent to everything which it touched. Realizing the danger which would attend a rupture of the tumor, I proceeded very cautiously. I moved my fingers around it until I had detached it from the gut and from the viscera, it was adherent down to the cecum, and when I had it ready to cut, I called for the threads to ligate the diverticulum, meanwhile supporting the tumor with the right hand and also guarding the bowel back, for it was resting in among the bowels; guarding the tumor so that if it did burst, I could, possibly, with sponges around my hand, keep the pus from touching the bowels as much as pos sible, and as the thread came to make the ligation, the tumor rolled off into my hand and I lifted it out, the tumor leaving a smooth looking stump, there was no bleeding; it looked as if Nature had rejected the tumor, and after throwing it off, was making repair. I rapidly packed the cavity with iodoform gauze, turning the margins of the gangrenous looking peritoneum out as much as possible, and using no irrigation whatever. It looked as if there had been considerable exuded mate rial, and that it had been absorbed. The patient was put on hot sterilized milk and hot water, morphine was given hypodermatically, and perfect quiet was enjoined; the patient seemed to gain strength from the start. I operated on Friday at noon; the patient vomited a considerable quantity of bile, but has since been doing perfectly well; the temperature having dropped to 99.4° and has remained at that up to short time ago. Visions of cherry seed and grape seed, and the various things which usually cause these troubles came to our minds, but we have not opened the sac and are curious to know what it contains, and we propose to open it here before the Society. The specimen has shrunken and softened somewhat since we removed it; it is in a solution of eu calyptol. [The specimen was then opened and examined.] DR. PREWITT.—This is certainly a very interesting specimen and, probably, before it was opened it would have been impossible to say just what it contained. Finding it in the region of the appendix and attached there, one would naturally conclude that it was the ap. pendix dilated and filled with something; this is a very natural conclusion. But on opening it we find it filled with sebacious material and hair, which is so characteristic of dermoid cysts, I think there is no question but DR FUNKHOUSER.-I would like to ask the Doctor if he put a ligature around the pedicle? DR. MAYFIELD.-I was preparing to put a ligature around it, and called for it, and either Dr. Finley or brother was about to hand me the ligature when the tumor came off in my hand, and I lifted it out. Dr. Finley was present at the operation and assisted in it. DR. FINLEY.-I may add a few words here, I suppose, by way of explanation. There was a remnant of a ped. icle on the cecum, which was not entirely healed, and is not yet, it did not exceed one half inch in length, and there was no reason why it should be ligated; there was no discharge from it, in fact, it was hardly long enough to ligate, and there was an indication on the tumor that it was a remnant of a pedicle, and when the tumor was removed that part of the tumor containing this pedicle came right up from over the remains of the pedicle on the intestine. I do not know whether this tumor was attached to the gut or not, but I think it was. DR. MEISENBACH.-I would like to have Dr. Finley describe the anatomical relations of the tumor to the cecum and the wall of the ilium. DR. FINLEY.-There would be no reason for that, because the position of the appendix is not constant; what good would it do to describe it? DR. MEISENBACH.-It makes a great deal of difference from a surgical standpoint to explain the anatomical relationship of tissues in order to clear up the pathological conditions? That is a very plain proposition. I should like to have Dr. Mayfield describe it. DR. MAYFIELD.-I am, of course, not an authority, but I have certainly done enough laparotomies to know where the ovaries are and where the appendix is, and so we performed the other operations before we got to this was in the region of the appendix, without any this, and those operations required nearly an hour. We question. After the tumor came away I manipulated then examined this patient a second time and found this the bowel, lifted it up and examined it, and the projec- tumor; the patient was in such a condition as to warrant tion there was about like a rubber nipple which is furn- an operation-the tumor seemed to be as large as a ished children when the natural nipple is not sufficiently goose egg; she was vomiting and had been constipated. long, except that it was red-almost exudating blood; I am satisfied this tumor was attached to the appendix I examined it cautiously, and we discussed the propriety if she had one. of ligating it, but thought we would cut it off if we attempted it, and leave a hole, so we did not ligate it. I had made a large incision, because I was not afraid of such a one, and we had the thing just as clearly before us as it is now, and I am satisfied it was the appendix. When we got down through the skin the first thing we encountered was a dense black mass of connective tis sue; then we went on a little further and the blood ves-lieve that Dr. Prewitt is right in his idea, that it was sels were as black as tar. DR. KIEFFER.-I think Dr. Mayfield was perfectly justified in operating in this case, and that he was also warranted in making the diagnosis of appendicitis under the circumstances, because everything in that region is considered an appendicitis. This is evident for two reasons: First, there was no fecal matter in the tumor, and, secondly, there is no opening in the tumor. I be originally a cyst of the ovary and had been dislodged. DR. MEISENBACH.-The blood vessels in what, the If the tumor was attached to the appendix it was simp tumor or the abdominal wall? Dr. Mayfield.-In the abdominal wall. When I got down to the peritoneal cavity I found it adherent to the abdominal wall, then we cautiously felt our way and lifted up the peritoneum carefully and it was so rotten that it tore out every time we would catch it with the sharp forceps, so we proceeded carefully until I got my fingers down around under it. DR. MEISENBACH.-Did you find any pus? DR. MAYFIELD.-We did not find any pus except a sort of exudate around the tumor and in the region of the cecum; it looked as if there had been pus and it had dried up. ly by adhesions caused by its resting against the appendix. DR. MEISENBACH.-The reasons I asked the questions I did was because it is a very important matter, from a pathological standpoint, to know what are the relations of the surrounding parts to each other, otherwise it is at times often difficult or even impossible to arrive at a positive conclusion. It is well known that the right side of the female may give rise to conditions that look like appendicitis which are in fact caused by other pathological conditions. The picture which Dr. Mayfield has given in his first and also in his second statement, and corroborated by Dr. Finley, is not a pic DR. JOHNSTON.-What was this tumor attached to, ture of appendicitis. The tumor which Dr. Mayfield has the bowel? presented is a fully organized cyst-it has a fully or DR. MAYFIELD.-Certainly, I am absolutely sure of it. ganized cyst wall and contains detritus in its interior. DR. JOHNSTON.-Did you pull it loose? This would be a pathological anomaly as far as appen DR. MAYFIELD.-It broke loose; it came loose before dicitis is concerned. The pathological picture of appen. I could tie it. DR. F. J. LUTZ-I would like to have Dr. Mayfield give the indications for the operation. I was not present when he stated them. dicitis is one which once seen can not be easily mis. taken. In the first place, when the appendicitis is cir. cumscribed, when it is still in the appendix alone we have the form of the appendix still retained, but if it DR. MAYFIELD.-The indications were there. Dr. has gone on to perforation and suppuration, the tissues Fiest, of Windsor, Mo., brought the case here. He had around become involved, it is probable that we will been called a few days before to see the patient, and have only the stump of the appendix. But then we will when he examined her he found nothing wrong; that find pus present. But then we either have one of two was one thing that puzzled me. It may be that he did conditions: a sac containing the pus, which is clearly not make a very extensive examination, but at any rate, outlined, or the remains of inflammation at the site he did not find this tumor until four days before he where the appendix was. In the normal picture as we brought her here to me. It was then well circumscribed; find it in a case of diffuse appendicitis, when you get the abdominal walls, save in the region of the tumor, through the abdominal wall you meet with turg. were not at all enlarged, and there was no such rigidity escense of the peritoneum; the peritoneum may be as we may expect to find. Finding the tumor there, the edematous, and when you enter the cavity beneath you patient becoming prostrated and suffering intense pain, may come directly upon the pus sac. So it becomes of he at once decided to come to the city. He used at one importance to determine the relationship of these parts. time as much as half a grain of morphine, I think, to I think every practical surgeon will bear me out in control the pain. When he got her here she was very that. Mistakes are very apt to be made in the female much depressed and fatigued. We had two laparotomies to do just then, and did not have much time to in cases of inflammation about the pus tubes, the kidgive her a thorough examination, as the hour for the ney or gall bladder; they may be taken for appendicitis. other operations were set, and the doctors were all ready; | We would never expect to find such a picture as Dr. Mayfield has described. pendicitis at all, but a cyst. Dr. Mayfield.-I will call attention to one thing: that when the tumor was removed it was as soft as a raw egg without a shell and after putting it in the listerine I noticed that it has become hard and its contents may have been materially changed by the chemical action of the fluid. DR. JOHNSTON.-Did you ever see a tumor like that originating from the bowels? DR. LUTZ.-No, sir. I do not think this is an ap- But I repeat that I can not understand how this completely formed tumor is an appendix. I do not wish to be understood as saying that the appendix did not slough off. I do not know about that, but from the description given I should doubt that somewhat. At any rate, so far as the operation is concerned, from the description of it, I am satisfied that it was perfectly justi fiable. And I will say that as the chewing of the string DR. LUTZ.-I do not think there is any question proves the quality of the pudding, the fact that the pa. about the propriety of surgical interference in a case of tient is getting well proves the propriety of the operathis character. Dr. Mayfield tells us that when he ex- tion-that is the practical point in the case, and if she amined the patient he found a distinct tumor in the gets well the scientific point will probably remain in abdominal wall-although he did not tell us whether it obscurity, at least partly so, unless a microscopical exwas movable or not, but I assume from the fact that amination of the contents of the cyst, as well as the cyst the abdominal wall was infiltrated that the tumor was wall, will illustrate the dark points in the pathology of adherent to the parietal peritoneum. I think a tumor this tumor. I do not think it was an appendicitis—or at with a distinctly formed sac precludes, according to my least I do not think this is an appendix; I am rather conception, that it is an appendix-the fact that you inclined to think from the superficial view which I got have a well formed cyst wall contravenes the thought of the tumor and its contents, that it is a dermoid and that you are dealing with an appendix for the reason it is a little unfortunate that the condition of the right that in appendicular inflammation the appendix is or ovary was not examined. dinarily destroyed. I can understand how you might have a distension of the appendix itself, but to have a tumor separate and distinct from the appendix with no evidence that the stump of the appendix had a perfora. DR. KIEFFER.-I wish to remark that a short stumpy tion of any kind, merely presenting, according to the condition of the appendix is not so very infrequent. description given, the appearance of inflammation which To operators who do not see the appendix unless it is can be ascribed to contiguity, just like we find in the inflamed and sloughed off it may seem that the appencase of inflammation and infiltration of the abdominal dix is usually long, but in the dissecting room I fre wall, does not suggest to my mind an appendicitis. quently find one out of every dozen less than half an The diffculy in making this post-operative diagnosis inch in length, and of course such an appendix, for comes more particularly from the fact that the rela- good reasons, will not take on inflammation-will not tionship of this tumor is not clearly presented to us. be the seat of appendicitis, and so operators will not be I understand how we often come across cases where it apt to find these appendices-these little short, stumpy is difficult to make out the exact anatomical relation appendices. We know that the vitality of the appendix ship of the part. Then it is difficult in the ileo-cecal is lower than that of the tissues surrounding it, and if region to make out exactly the starting point of the this inflammation was sufficient to set up gangrene in difficulty. In point I might mention a case, which I the peritoneum it would be apt to do so in a greater presented about two meetings ago to the Obstetrical degree there than in the short, stumpy appendix, beSociety, of a case in which a clearly marked double cause of the vitality of the parts being low. So I do not pyosalpinx existed and for the removal of which a think the fact that there was a short stump at the central incision was made. I found outside of the dis- usual site of the appendix is any argument that the tended tube on the right side a pus cavity formed on tumor was attached to it. I do not see for my part how the one side by the wall of the tube; on the other side the appendix could have sloughed off and leave such a in the immediate vicinity of the cecum and surrounded, cyst wall in such close proximity to it. But the point I as these cases ordinarily are, by the omentum, and wanted to make was that a short, stumpy appendix is when I had cleaned out this cavity and had removed not very uncommon, although it is the kind that the opthe pus tube, an area of the size of a silver dime was erators are not likely to meet with. found on the appendix and I suggested that the question was whether the pus tube had not infected the appendix and we had an appendix from it, associated with DR. KIEFFER.—I saw an aypendix 8 inches long the pyosalpinx, and I uselessly, as the specimen showed, after it was dried in the subject. The subject was being amputated the appendix. It was clearly a case in which dissected and the appendix had not been discovered, the peritoneal covering of the appendix had become and one of the students looked for it and followed down infected as a result of the pyosalpinx, yet when I cut the attatchment of the appendix and it turned underopen the appendix the mucous membrane was found to neath the cecum and passed up under the ascending be as intact as is usually found or would be supposed colon and the top was near the liver. It was very to exist in such a case as I describe. So the difficulty in long. I am satisfied it must have been fully nine inches making a diagnosis presents itself at once to the mind. [long before it dried. DR. JOHNSTON.-What is the longest appendix you ever saw? |