method is not so innocuous as the present usage would lead one to suppose. Sepsis and the drug itself are pointed out as the two great dangers, the first of which can be avoided, but should it once make its appearance the outlook is hopeless; the second has led Bier to predict a rather less brilliant future for the method unless a non-toxic drug which effects the same purpose can be discovered. possibility of this method superseding the anesthetic methods now in use is rather remote. Those that have used it most are loth to recommend it as a routine procedure. It will doubtless always retain a place where general anesthetics are barred on account of physical conditions and where local methods are not applicable. The How the anesthetic effect is obtained is still undetermined. The most generally expressed view is that the drug reaches the posterior horn centers by means of the perivascular lymph channels, while others believe that the ganglia of the posterior nerve roots are the points anesthetized. This latter view seems to be the most satisfactory explanation of the phenomenon. Since the preparation of the foregoing notes, Tuffier has given a general summary of his cases up to December 13, 1900. In none of his cases has he noted any subsequent troubles, nervous or otherwise, due to the use of the subarachnoid way, and he believes that the normal physiologic state is reached sooner than with general anesthesia. He claims that many of the untoward symptoms now observed may be obliterated if the patient receives the same preliminary bowel cleansing that are now customary previous to general anesthesia, and he gives hope that a new method of his, as yet unpublished, may suppress vomiting. He contends that only those thoroughly familiar with operating, par. ticularly about the abdomen, should practice this method, but that "whatever field any surgeon might reserve for this method, I firmly consider that it has come into the practice of medicine to stay, side by side with local and general anesthesia." He has tried the narcotics-trinitrin, morphin, atropin, eucain A and B, only to discard them as unsatisfactory and inefficacious. Eucain gave more vomiting than cocain, and he finds that caffien and ether are useless in combating the ill-effects of the injections. The results in his later cases have had fewer objectionable attendants than in the cases first recorded. In all he has operated 252 times, 142 intra-peritoneal and 110 outside the cavity. Before the Societé de Biologie in Paris on December 8, 1900, Tuffier and Hallion reported a number of experiments on dogs, demonstrating that the anesthesia by the subarachnoid way is due to a transitory physiologic section of the posterior nerve roots by the cocain. Fowler again draws attention to the large proportion of ineffectual anesthesias (5 out of 26) in operations on the peritoneum, and in half of his hernia operations pain sense remained in the ilioinguinal and ilio-hypogastric nerves when otherwise the field was painless. Inflamed peritoneum seems excessively sensitive. He has been as unsuccessful as Tuffier in finding a substitute for cocain, antipyrin and chloretone proving failures, although a mixture of antipyrin and cocain seemed more He efficacious for the amount of cocain used. feels that with consciousness, involuntary stools and emesis, headache and subsequent rise of temperature, this method should only be used in a certain undoubted field, and that we must look to the future for a general anesthetic as the ideal. Richardson has thrown his potent influence against the Bier method in citing the untoward features he observed in Tuffier's clinic, laying particular stress on the condition he describes as shock attending an operation he witnessed, while Tuffier emphatically states in his last article that shock is never encountered, and that the physiologic state is most speedily regained. Hawley and Taussig after using this method in 14 obstetric cases, state that in 5 the cocain seemed to have a toxic affect on the child in utero, affecting the pulse, and three times the child was somewhat asphyxiated when born. In multiparæ they conclude that the method is less called for than chloroform, but in instrumental cases it seems to meet every indication. Thus we find in general that as a routine approach the subarachnoid space for anesthetic applications is not advisable. In certain conditions, hard to formulate into short definite statements, this method is applicable, as in short operations, but only when a general anesthetic or a local or regional anesthetic is counterindicated or inapplicable and when the temperament of the patient is such that a wakeful and alert knowledge of the surroundings will not militate against the skillful performance of the operation. LITERATURE. Bier, Deutsche Zeitschrift f. Chirurgie, Bd. 51, p. 361. Goldan, Phila. Med. Journal, Nov. 3, 1900. A CENTURY OF MEDICAL PROGRESS. A recent number of the British Medical Journal contains a timely review of the progress of the medical sciences during the century which has just come to an end. Such a retrospect is at once an incentive to congratulation and to prudence. When we see the great advancement we have made, measured by milestones of discarded theories rather than years, by slow and painful steps of evolution rather than by leaps and strides, we have reason to pride ourselves on the achievements accomplished in the past and in fact still being wrought out. Should we not also examine our present point of vantage to see if it, too, is not built on unstable sands instead of founded on a rock? That we have progressed in many respects is shown by G. A. BLANDFORD in a paper on "City Life in 1800." War and bad harvests brought in their train exorbitant prices for even the common necessities of life. London had only 922,000 inhabitants, scattered over large area with intervening sections scantily settled. Tight clothing was the fashion; wigs were still used; the men wore knee breeches, etc.; the women were clad in thin material, wore their dresses low, with bare arms, and knew nothing of petticoats or drawers. Streets were poorly paved; transportation was by private conveyances or hackney coaches. Public amusements were confined chiefly to tea gardens; private, to excessive eating and drinking, hosts vying with each other in quan tity and variety of food and drink served and in splendor of appointment. Baths were practically unknown and water was obtained by means of cisterns, wells or from water carriers. Rivulets were converted into sewers, with which cesspools communicated or into which the latter were emptied by men at night. The city was poorly guarded by private watchmen and was lighted by candles. If these conditions are to our minds crude and antiquated, what is to be said of the picture drawn by A. MCCALISTER of the status of anatomy in 1800. This was confined to the limits of gross anatomy and what could be seen by the simple lens. What it lacked here it made up by spreading out over territory now confined to the special studies of physiology, surgery, etc. Dissection was limited by the difficulties of obtaining and preserving bodies, and the knowledge of the softer structures consequently lagged far behind that of the bones. The anatomy of the organs of special sense was scarcely considered and in the text book more space is devoted to theorizing about functions than to description of parts. But bad as was the state of anatomy, its scientific value was far in excess of physiology. H. POWERS has described the condition of the knowledge of that subject at the beginning of the last century. The fundamental facts of the circulation had been established, as was the mechanism of respiration, but the intimate relationship between these two was only beginning to be dimly understood towards the very end of the eighteenth century, and the chemical factor entering therein was undreamed of, except perhaps by the great chemist Lavoisier. In the domain of glandular activities are found the crudest of theories, e. g., "there are many arguments to persuade us that the liver is a mere vascular fabric whence the bile distils immediately from the extremities of the porta into the pons biliarii or roots of the biliary duct without passing any cells or follicles by the way." Animal heat was considered due to fermentation in the blood or else to friction of the blood cells in the capillaries. Digestion was regarded as a process of putrefaction or due to the muscular force of the stomach. Nervous activity was ascribed to a liquor distilled by the vessels of the cortex and carried thence by the small tubes of the nerves to the various parts of the body. Embryology was unknown; hygiene might as well have been. D. POWERS has given an able exposition of the relative condition of pathology in the eighteenth and the nineteenth centuries. The non-existence of the microscope made the field of cellular pathology a terra incognita to the scientist of the former. The half mythical, wholly mystical pathology of former years was swept away by the investigation of gross pathologic anatomy, to be supplemented and succeeded in part by results obtained from microscopic findings. The thermometer came into use in the latter part of the eighteenth century. Pathologic chemistry was unknown; alteration of generation in parasites was believed to be a spontaneous generation of each form. Much was known which more recent investigations have served to establish, but there remained great gaps to be filled by the labor of present pathologists. With this branch of medical sciences only an infant Hercules, it is not to be expected that T. C. ALLBUT could draw a very flattering picture of the state of medicine at the dawn of the nineteenth century. Theorizing obtained over wellordered experimentation. One author regards the body as a hydraulic machine and hence subject to the laws of hydrostatics. Diseases were either pyrexias or neuroses. Pyrexias were subdivided into fevers, inflammation, exanthemata, hemorrhages and profluvia; the neuroses into comata (apoplexy and palsy), adynamiæ (syncope, dyspepsia, hypochondriasis), and spasmodic affections without fevers (tetanus, epilepsy, chorea, etc.). Perhaps in no department of medicine is the contrast so great as in the treatment of lunacy in 1800 and in 1900. C. MERCIER, in terse and vigorous language, presents a spectacle which can but horrify the latter day physician. Compare our treatment by means of sedatives, judicious isolation, employment and the other numerous modern methods of ministering to the mind diseased" with the manacling, chaining and whipping, with the idea of appealing to a maniac fears," as the first essential step in this treatment. Venesection, purging and vomiting were the favorite remedies employed. Commitment to a madhouse was made after two signatures, one as a friend and the other as a practitioner, had been appended to the request. The same man might sign as both, and the signer might be the keeper of the madhouse, thus opening up vast possibilities of fraud. 66 G. E. HARMAN has presented the facts in regard to gynecology and midwifery. Of the former science there was practically none. Pelvic deformities, uterine growths and ovarian dropsy were known, but could not be treated. The forceps and the vectis were employed in difficult cases of labor. Puerperal septicemia and eclampsia were dreaded, and in each the mortality was very great. Cesarian section was known, but little employed, owing to an ignorance of asepsis. The retrospect of surgery presented by Mr. S. PAGET shows a wonderful advancement in the last century. Many operations now performed every day were at the beginning of the century the dread of the surgeon, and performed by only the boldest among them. Examples of such are intra-abdominal and intracranial interference. Others, such as amputation of the head of bones, were just becoming known; while others, such as tenotomy, ovariotomy, etc., lay still in the domain of the future. Of anesthetics and antisepsis they were, of course, ignorant; and thus they were confined to limits beyond which modern surgery has spread and is still speading. On the subject of fractures and dislocations, the older writers are at their best; was known macroscopically and treated cancer radically. If medicine desires to congratulate itself in regard to its advance in any one department especially, the contrast which W. H. CORFIELD shows between sanitary knowledge in 1800 and 1900 would afford the greatest grounds. The advances in the former were truly great. They include vaccination, antiscorbutic treatment, sanitary treatment of jail fever, establishment of military hospitals, and introduction of ventilation and sewerage. While most of these were to be found in the closing years of the eighteenth century, and their widespread application belongs rather to the nineteenth; without the microbic theory of disease, their exertions could be only tentative efforts and blind groping, which became steady advancement as soon as a point of departure was established. The poor laws, as dealt with by J. M. RHODES, shows their medical aspects to have been vastly improved in the last century. The crowding of the poor in tenements as well as public institutions, their insufficient nourishment and clothing, brought about an unsanitary condition of things with which the medical authorities were quite unable to cope. Later, owing to increased appropriation and systematic and intelligent expenditure thereof, the condition of the poor became much ameliorated, and, pari passu, their health better and their diseases more amenable to treatment. Naval and military medicine have likewise made great strides since 1800. The practical abolition of scurvy and ship fever belong to the century before, but the hospital in the field and the scientific and aseptic treatment on board ship and in the camp are features of the present century's work. In technique, owing to their opportunities during the several wars which marked the eighteen centuries, the naval and military surgeons were very good, but they lacked the scientific advantages enjoyed by their brethren of to-day. Society Proceedings. NEW YORK ACADEMY OF MEDICINE. MEETING OF DECEMBER 21, 1900. Reposition of the Congenitally Dislocated Hip. Dr. ELY, in a recent visit to Vienna, had spent some time in observing the practice of Lorenz, who was receiving cases of congenital dislocation of the hip from all parts of Europe. The cutting of tendons and instrumental traction were rarely seen. When the head of the bone had been replaced with suitable force and manipulation, the reduction was maintained by a most elaborately applied plasterof-paris spica, which did not include the trunk and extended below only to the knee. The patient was then sent home to stay several months. The results were good, and sometimes so brilliant as to justify the enthusiasm of the operator, who believed that when a knowledge of the operation was widely spread reduction would be made at such an early age as to almost preclude the possibility of a failure. The remarkable statistics of successes which had been published had their origin partly in enthusiasm and partly in the undoubted excellence of a method applied with requisite technique. Dr. H. L. TAYLOR reported that the experience of Calot, in his hospitals at Berck, on the channel coast of France, had shown that the bloodless reduction of congenital dislocation of the hip was applicable to children up to 8 years of age, or later in exceptional cases. Active treatment covered from six to twenty-two weeks, and included two or three weeks' traction with a weight of from 10 to 20 pounds, and at the operation the application of a force of 300 pounds for ten minutes to bring the head or the bone down to or below the acetabulum. When the retaining apparatus was removed massage and training in walking completed the treatment. Patients had recovered without the trace of a limp. He had practically given up the open method. The correct attitude obtained by cutting would be at the expense of limitation of motion or anchylosis, which might be properly sought by this method in certain cases in which replacement was impossible. Dr. R. H. SAYRE had seen Lorenz operate last year in Paris at the Redard clinic. The patient, a child of about 8 years of age, was moderately disabled by a single dislocation of the hip. The thigh was made to form an angle of perhaps 20 degrees posterior to the plane of the body. A great deal of force was employed for this and in turning the limb in various directions. The head of the femur could be heard as it popped around on the ilium in what must have been a mass of lacerated tissues. The spica, which was nearly two inches thick where the strain came, included two loose strings for subsequent use in scratching the skin and keeping it clean. The head did not assume a permanent residence in the acetabulum. It was said that it would do so after the child had walked about for a year or two in the spica-a question which would have to be answered in due time. Dr. C. H. JAEGER had recently spent six weeks at Vienna and reported that the treatment of congenital dislocation at the Lorenz clinic was exclusively by the bloodless method. Double cases were treated singly. The results were very favorable. The spica was applied with great care. Only a thin layer of cotton padding was used. The plaster bandage was applied very snugly, the thigh only being enclosed and a narrow strip going about the pelvis. This left the knee and ankle free and also the whole spinal column. The limb being thus fixed in extension and abduction, the patient soon learned to walk without crutches and with (in single cases) a high sole on the sick foot. It was most interesting to see a child with double dislocation, with both legs strongly abducted, spread eagle fashion, walking beautifully, hopping with one leg, then the other without a stick or help of any kind. Lorenz was accustomed to lay great weight on having the parents of the patient extend the knee many times daily, to prevent contracture. In opposition to these views Hoffa strongly advocated the open method. Dr. W. R. TOWNSEND said that Hoffa had stated in very positive terms that none other than the bloody operation could be of any use. An American authority also had reported that in a large number of open operations only two or three had exposed an acetabulum in which it was possible to place the head. The views and practice of Lorenz, however, were those of one whose experience with the open operation had been greater than that of all other operators combined. In one of the dissections reported by Dr. E. H. Bradford, the capsule had been found pushed in front of the head of the bone in such a manner that a perfect reduction could not be made. This had led to the suggestion that in some cases the open operation might be modified by slitting the capsule instead of gouging or boring the bone, which might lead to anchylosis or limited motion. Dr. JAEGER thought that Hoffa was dissatisfied with the bloodless procedure partly because of the position in which he fixed the limb after reduction of the deformity. He applied the spica with the limb in extension and strong inward rotation, which could not afford a very firm hold for the femoral head in the acetabulum. In this position it was probable that reluxation would occur during the application of the bandage or on the first attempt at walking. Dr. T. H. MYERS said that those American surgeons who, after trying both methods, favored the opening of the joint in every case, were at variance with Lorenz. In his own experience, which had been considerable, he had not yet opened a joint, believing that the bloodless method should be tried first. It secured some perfect results, and in the results which were not perfect the head was placed anterior to or above the acetabulum, which was better than to leave it on the dorsum. He Dr. G. R. ELLIOTT had passed several weeks with Lorenz in 1896, and had seen him operate many times by the non-cutting method, having already begun to discredit the cutting operation, which he had done so much to perfect. There could be no possible doubt of the good results obtained. had seen many instances and had repeated them in his own practice. Success lay in the thoroughness of the procedure and in the perfection of the technique: (1) The head of the bone should be brought down to the level of the acetabulum. (2) It should be lifted over the posterior edge of the acetabulum. (3) Abduction should be extreme, even posterior to the mid plane of the body. (4) The plaster bandage should be pressed posteriorly against the joint to keep the reduced head from slipping backward. Great force was often required, but neglect of any point would leave the head of the femur resting on the posterior acetabular to be dislocated as soon as the bandage was removed. Lack of success would be due to want of technique leading to imperfect reduction. Thorough padding was necessary beneath the bandage. Blood had appeared in the urine of a patient operated on by him last week. The child had been laid face downward to facilitate fortifying the splint posteriorly, and the soft plaster bandage had pressed against the abdomen and hardened. Cutting the bandage relieved pressure and the blood disappeared. Sea-Air for Tubercular and Rickety Patients. Dr. TAYLOR, in his review of the treatment at Berck, said that Calot was an enthusiastic advocate of sea-air for patients affected with external or peripheral tubercular lesions, those of the skin, glands, bones and joints. He rejected phosphorus in the treatment of rickets, prescribing intestinal antiseptics and a diet mainly of milk and eggs. Many of his patients were kept recumbent. He affirmed that rickety deformities would disappear during a sojourn at the sea-side. Dr. SAYER had listened to Calot as he described the advantages of sea-side treatment. His interest in the subject was shared by others of his countrymen, whose native enthusiasm perhaps lent a too rose colored light to their views. Dr. TAYLOR had been impressed with the pic. turesque quality of Calot's writings. His zeal often broke through the conventional boundaries of scientific composition. The reader was entertained and delighted, but not necessarily convinced. Treatment of Pott's Disease. Dr. ELY said that Lorenz used a corset composed of perforated strips of celluloid, metal bands and It laced in front and was probably sufficiently comfortable, but could not be said to splint the spine." canvas. Dr. TAYLOR said that although Calot declared that neither braces, plaster jackets nor corsets could prevent or arrest the deformity, all of his patients. wore the plaster jacket after subjection to manual pressure directed against the kyphos. In certain cases ablation of spinous processes without invasion of the tubercular territory was recommended in order to facilitate correction and avoid sores from pressure of the jacket. The use of suspension, the amount of manual pressure and the degree of lordosis to be enforced were points to be settled for each case. Severe pressure and all traumatism were to be carefully avoided, in marked contrast with the violent proceedings which called attention to the name of Calot in 1896, when he was claiming uniformly brilliant results from the outlay of all his strength on the kyphos supple. mented with cuneiform resections in obstinate cases. Dr. SAYRE said that Calot's recent methods, as he had heard him describe them, varied but little from those of Dr. L. A. Sayre when he introduced suspension and plaster of paris jackets. Calot had, however, secured a distinct advantage in extending the jacket up to the chin instead of stopping at the top of the sternum, thus promoting lordosis even of the lumbar spine and gaining a leverage over the entire spine, which was impossible when the upper part of the vertebral column was free. Treatment of Joint Diseases. Dr. ELY said that at the Lorenz clinic joint diseases generally were treated by retention in plaster of paris. The spica for hip disease usually had an |