urine lent no countenance to this view. It was found to have a specific gravity of 1020, with an acid reaction, free from albumen and free from sugar. He was excessively pale, and although the muscular system was fairly well. nourished, he presented an appearance of great debility and anæmia; there was no swelling of the feet.

The physical conditions present on admission are practically those which exist to-day. There has, however, been a distinct improvement in the general appearance. The pulse also has improved, being of better volume, and the dyspnoea has diminished. In order to bring the history up to the present time, it is only necessary to state, that since admission the temperature has not gone above 100°. The tongue is clean and of a good color. The lips are of good color, the ears slightly reddish, as if from capillary congestion. The face has lost a good deal of the pallor and swelling which it at first presented. The pupils are somewhat dilated. The respirations are twenty-four in the minute.

When I come to examine the heart, I find a diffused impulse perceptible in the epigastrium, extending to the upper border of the sixth rib and felt also slightly outward from the nipples. The area of cardiac dullness is distinctly increased in the transverse direction, passing almost to the right edge of the sternum. On auscultation, I hear a systolic murmur at the apex, rough in character, also perceived in the left axilla and at the angle of the left scapula. When I place the stethoscope over the base of the heart, especially toward the left, I hear a double sound, apparently a murmur; but it is not. It is a friction sound. The second part, that which follows the systole, is much the more distinct, and is broken up into several rather rough sounds. Pressure with the stethoscope increases the intensity of these sounds. We have, then, a double pericardial friction sound, or to-and-fro murmur, as it is sometimes called. These sounds are also heard to the right of the sternum, but as we go away from the cardiac region they become very indistinct. In the carotids, that of the left side especially, a rather faint sys

tolic murmur is present. I find, as the result of this exploration, that the endocardial murmur at the apex is a little more distinct than it was, and, on the other hand, that the pericardial friction is not quite so marked, nor as harsh as when first noticed.

The lungs are found to be clear on percussion. The vesicular murmur is distinct at the lower part of both lungs. On the right side there is a little impairment of resonance at the base, due to slight congestion. There is no cough. The shortness of breath is not so much complained of and the pain is not so severe. For the last two nights he has required no opium, which, previously, had been absolutely necessary to relieve the pain.

What have we here? This is a case of pericarditis, but that does not cover all. It is a case of pericarditis, with practically no liquid effusion, but with exudation of lymph, most decided at the base. We know that there is no marked effusion, because the impulse is so distinctly felt. Granting that there is pericarditis, with plastic exudation, this will not account for the mitral systolic murmur, which is different in character. There must be, in addition, mitral regurgitant disease.

ease.

Are these conditions acute or chronic? The pericarditis is acute and the valvular disease chronic. When the patient, in Italy, had some pain in the cardiac region, it is possible that he then had the beginning of this mitral disWe infer that the mitral affection is chronic, because there is an amount of cardiac enlargement quite out of proportion to the amount of pericardial effusion. The diffused impulse and the increased percussion dullness point to enlargement of the left ventricle. This is not compatible with the supposition that the mitral affection is acute.

We know that the pericarditis is acute, from the history that it began with a chill and pain, followed by fever. The acute pain in the cardiac region persisted for some days after admission. We also know that the marked dyspnoea and the signs of general distress came on suddenly. All these features characterize the pericarditis as an acute affection.

With reference to prognosis, I may say that

the boy will recover, although, of course, the organic condition of the mitral valve will remain. The pericarditis will diminish and. largely disappear, but whether entirely or not,* I cannot say. When he recovers from this acute attack, he will probably be not much worse than before.

What is to me the most interesting feature of this case is that he should have pericarditis at all. This appears to be one of those rare cases of idiopathic pericarditis, that is, where the disease occurs without apparent cause. The majority of cases of pericarditis arise in the course of acute rheumatism, but the patient has not had the least sign of this disease. Next in order of frequency as a cause of pericarditis stands Bright's disease, but the examination of the urine, made more than once, sets this aside. Then we must not overlook the possibility of some pyæmic process as a cause of pericarditis. There is not a particle of evidence of anything like pyæmia. Neither the spleen nor the liver presents anything abnormal, and the temperature is barely above. the normal. Nor is there any evidence of blow or injury sustained over the cardiac region. We have here to deal with a case of idiopathic pericarditis, a disease so rare that its very existence has been denied by some. I know, however, that it does occur. In the course of my life, I have seen four or five instances of this affection.

The next question that we have to consider is the treatment. This has consisted of opium at night, with Rochelle salts occasionally in the morning and half an ounce of acetate of potash daily. To this was soon added the tincture of the chloride of iron, of which he took twenty drops three times daily. Turpentine stupes were also employed for the relief of the pain.

Under this treatment, he has steadily improved. There seems to be no reason to change the treatment. The acetate of potassium was given as an alkali, to act as an alterative upon the exudation and also as a diuretic. The iron was administered on

* In a week from the time the case was shown, the pericardial friction had largely disappeared-entirely from over the lower part of the left ventricle. The boy was able to sit up some hours daily.

account of the anæmic condition. The time has now come when the use of small blisters over the upper part of the heart, with the application of poultices, will be of advantage. He has not required stimulants, but if there had been flagging of the pulse they would have been given. If the heart's action had been irregular and disturbed, it would also have been proper to give digitalis. We have carefully watched the pulse, but have seen nothing to cause us to use digitalis, nor even, as yet, stimulants.

Original Communications.

COCAINE TOXÆMIA.

BY J. B. MATTISON, M.D.,
Of Brooklyn, N. Y.

Read before the American Association for the Cure of Inebriates,
November 8th, 1887.

At a meeting of the New York Neurological Society, November 5th, 1886, Dr. Wm. A. Hammond, in the course of some remarks on Cocaine, expressed his belief in the toxic power of that drug, declaring "he did not. believe any dose that could be taken was dangerous." In a paper by the writer, on "Cocaine Dosage and Cocaine Addiction," read before the Kings Co. Medical Society, February 15th, 1887-reprint of which may be had if desired-evidence was presented to prove this opinion a mistaken one. This proof, furnished by forty different authorities

English, French, German, Austrian, Russian and American-cited more than fifty cases to support the assertion that there is a danger, near and remote, in the use of this drug on some patients, that does not warrant such reckless disregard of care as the opinion. referred to implies.

The cases noted more or less in detail showed that cocaine caused toxic symptoms, so marked in four as to be fatal. The amount of the drug used varied from a small fraction of a grain to twenty-four grains, and was applied to the eye, ear, nose, throat, larynx, teeth, gums, stomach, bowel, bladder, uterus, urethra, and under the skin. The symptoms noted were nausea, vomiting, headache, deafness, blindness, loss

of taste and smell, profuse sweats, cold perspiration, lividity, gastric cramp; frequent, feeble, irregular, intermittent, unaccountable pulse; shallow, gasping, irregular, difficult, convulsive, suspended breathing—artificial respiration required in some cases; gait, speech and swallowing greatly impaired; rigid muscles, palpitation, sense of suffocation and great constriction about chest; loss of motion and sensation in arms and legs; general numbness; intense restlessness, extreme prostration, giddiness, faintness, feeling of impending death; unconsciousness, convulsions, paralysis, hallucinations, mania, delusions, delirium-death.

Summarizing, it was asserted: Cocaine may be toxic-sometimes deadly-in large doses. It may give rise to dangerous, or even fatal symptoms, in doses usually deemed safe. The danger, near and remote, is greatest when given under the skin.

In further proof of these conclusions, added evidence of over forty cases is appended.

Two more cases of fatal effect from cocaine have been reported-one, in dental practice, in Poland; the other in France-but the writer has not yet been able to secure the desired details.

Dr. Samuel T. Earle, Maryland Medical Journal, noted these cases: "Mr. Z. presented himself for the treatment of hæmorrhoids. Found, on examination, one external and several small internal hæmorrhoids, which I decided to remove by the clamp and cautery. March 5th, I proceeded to do the operation. I injected in the subcutaneous tissue around the anus about one drachm of a four per cent. solution of cocaine, which amounted to about two grains of the drug. In about five minutes after the injection, and before I had taken any other step in the operation, he complained of strange feelings in his legs, accompanied by a twitching of the muscles. In a few minutes more these twitchings amounted to decided tetanic convulsive movements, which involved all the muscles of the trunk and extremities. By the time these convulsive movements had become general he complained of fullness in the head and soon became unconscious, re

maining so for about five minutes. As the convulsive seizures gradually subsided, he regained his consciousness, but that, too, only gradually. For instance, would answer me, look bright, and said he felt all right, but in a few seconds more would complain of fullness in the head and become drowsy. This occurred several times before he recovered entirely. Altogether the attack lasted about half an hour. His pulse was weak, although could not be felt very well on account of the convulsive movements. Pupils slightly dilated. The following day found the patient doing very well, only complaining of some soreness in his muscles."

CASE II.-Female: operation for hæmorrhoids; cocaine to produce local anesthesia. "I injected a solution of the drug containing altogether about five grains of muriate of cocaine. In about fifteen minutes, without any premonitory symptoms, except a little nausea and faintness, she was seized with violent general convulsive movements, which were so strong, and so much more pronounced on the right side, on which she was lying, as to turn her over on her belly. She had opisthotonos, entire loss of consciousness for about five minutes, after which it gradually returned, and seemed entirely restored at the end of fifteen minutes. Asphyxia; muscles of the lower jaw violently convulsed; pupils unevenly dilated after consciousness began to return; mouth drawn to the right side; speech decidedly thickened for some minutes after her return to consciousness; respiration very labored, and at the height of the attack was arrested for some seconds; pulse very feeble; cutaneous surface decidedly blanched where not purple, until after consciousness began to return, when it alternately became flushed and pallid; she now broke out in a profuse sweat. There was great prostration following the attack and a disposition to sleep. She recovered entirely after several hours, and only complained of feeling tired. This patient had never had any nervous attack of any kind previously, and both patients were remarkably robust and healthy."

Dr. A. N. Blodgett, Boston Medical and

It

Surgical Journal, cites case of Dr. R., aged 23, well and strong, to whom he gave subcutaneously, for local anesthesia, three minims of a twelve per cent. solution. "Thirty seconds after the injection was made the patient began to complain of a feeling of great depression, a sensation of coldness, and of faintness. was thought at first that these sensations were due to fright, or to an undue amount of apprehension as to the action of the drug; but this proved to be erroneous. The patient rapidly became cyanosed, the breathing changed to a sighing character, the pulse was 140 and weak, the face was bathed in cold perspiration, there were short periods of profound collapse with unconsciousness. The patient was assisted to a couch, where he soon became quite helpless. Stimulants were administered, the heat of the surface was maintained, and the body warmly covered. At the expiration of a quarter of an hour the finger on the pulse showed a commencing improvement in the patient's condition. With the restoration of the organic functions came a mild form of delirium, the patient talking incessantly upon all possible subjects, and apparently not realizing that he had been in any abnormal condition. Soon the pulse was reduced to 80 per minute, and the skin became warm. The delirium gradually subsided, and the patient slowly returned to his natural state."

Dr. Emmet Holt, New York Medical Journal, reported five cases of children, aged 3 to 21 months, suffering from whooping cough, in which the use of a four per cent. solution by swabbing or spraying caused toxic symptoms. They were vomiting, great restlessness, rapid, shallow respirations, pulse too frequent to be counted, pupils widely dilated, profuse perspiration, temperature rise to 102 degrees, constant and disconnected talking, marked delirium and convulsions; "very critical condition." In a child 4 months old, one swabbing with a four per cent. solution caused wellmarked toxic symptoms; and "alarming" effects followed two sprayings of the same solution in two infants, 3 and 6 months old. His opinion is "cocaine must be used with great

Dr. Howell Way gave me details of four cases observed by him, in which 5 to 60 minims of a four per cent. solution, instilled, or injected for local anesthesia, caused toxic symptoms-blanched face, blue lips, aphasia, dyspnoea, hallucinations, delirium and unconsciousness.

Dr. Geo. N. Monette, Journal American Medical Association, noted three cases occurring in dental practice, in which two to four drops of a twenty per cent. solution injected in the gums caused vertigo, blindness, cold perspiration and inability to walk-" completely unnerved; acted as if deranged."

Dr. R. M. Griswold informed me of a lad, aged 15, in whom he injected fifteen drops of a four per cent. solution for local anesthesia. In four minutes patient complained of faintness, vertigo, had stertorous breathing, with thready pulse of 160, and became blind and unconscious.

Manheim noted a woman in whom the subcutaneous injection of two decigrammes caused dyspnoea, irregular and suspended breathing, dysphagia and agryphia, lasting thirty hours.

Gougenheim has collected a number of cases in which cocaine solution, applied to

the throat, was followed by urgent symp

toms.

Conclusions.-There is a lethal dose of cocaine. This dose is uncertain. Toxic effects are not rare. They may be sequence of doses large or small, in patients old or young, the feeble or the strong. This risk should induce caution. Antidotes should be at command; these are nitrite of amyl and hypodermic morphia.

THE NATURE OF LABOR. BY HENRY LEAMAN, M. D.,

Of Philadelphia, Pa.

Read before the Philadelphia County Medical Society,
November 23d, 1887.

This paper does not claim to offer all the theories and problems of labor, but is simply an attempt to throw some light on the phenomena of labor, with special reference to everyday work. In speaking of labor, we understand physiological or natural, not pathological labor. Harvey said that the kind of birth in which the fœtus is born enveloped in its coverings appeared to him by far the most natural; it is like the ripe fruit which drops from the tree without scattering its seed, before the appointed time. This statement is, doubtless, physiologically correct. But in my experience the separation of the elements of the ovum generally occurs, the waters preceding and placenta succeeding the foetus, the true process of labor being in no manner altered or changed thereby. Any presentation or position that can be terminated without assistance may be called natural.

There are only two stages in labor. The first embraces all the phenomena that immediately precede or occur during the dilatation of the cervix. The second embraces all the phenomena occurring during the expulsion of the contents of the uterus. This includes the so-called third stage. If labor has pursued a natural course, and due time has been allowed, the placenta will be found loosened by the pains and ready to be removed immediately after the birth of the child. If the placenta is adherent or there is an irregular contraction,

the hand can be passed into the cavity to remove it.

in

The duration of the first stage is a very definite period, lasting from a few hours to several days or even weeks. The duration of

the second stage is a more definite period, varying from a half-hour to four hours. The only positive sign that the expulsion of the uterine contents is about to take place is the dilatation of the distended cervix, accompanied by regular contracting pains not relieved by opium. Dilatation is not complete until the cervix has expanded enough to allow the exit of the presenting part. Then begins the second stage of labor, and the advancing mass now comes in contact with the pelvic wall.

The nature of labor consists particularly in the manner in which the uterus expels its con. tents, not in the mechanism of the pelvis. The foetal contents are passive in delivery. The life of the ovum in viviparous animals is part of the mother life, connected through the uterus and placenta, and identified by a mutual growth and development. The uterus is the outer contractile layer of the ovum. When their cyclical development is complete, or has been terminated in any way, differentiation, or birth, takes place. This is accomplished through contractility of the uterus, which gives to the fœtus a series of amoeboid movements that cause it to advance through the pelvic opening. The foetal mass moves under the persuasive action of flexion and rotation produced by the uterus alone, and, in virtue of its adaptation to its surroundings, overcomes great obstacles. The overcoming of obstacles is due not to the amount of force, but to the adaptation of the foetus to the pelvis.

Dr. D. B. Hart, in the Obstetrical Transactions, Edinburgh, vol. v, in a paper on "The Bearings of the Shape of the Foetal Head on the Mechanism of Labor," says: "It will be seen that the shape of the fœtal head, face and breech is, to a certain extent, a preparation for the emergencies of birth. In a normal head case in a normal pelvis, flexion and rotation are favored by it. are favored by it. Should the pelvis be rickety, the head, either first or last, still has the shape which favors its passage through the