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urine lent no countenance to this view. It was tolic murmur is present. I find, as the result found to have a specific gravity of 1020, with of this exploration, that the endocardial muran acid reaction, free from albumen and free mur at the apex is a little more distinct than it from sugar. He was excessively pale, and was, and, on the other hand, that the pericardial although the muscular system was fairly well friction is not quite so marked, nor as harsh nourished, he presented an appearance of as when first noticed. great debility and anæmia; there was no The lungs are found to be clear on percusswelling of the feet.

sion. The vesicular murmur is distinct at the The physical conditions present on admis- lower part of both lungs. On the right side sion are practically those which exist to-day. there is a little impairment of resonance at There has, however, been a distinct improve the base, due to slight congestion. There is ment in the general appearance. The pulse no cough. The shortness of breath is not so also has improved, being of better volume, much complained of and the pain is not so and the dyspnæa has diminished. In order severe. For the last two nights he has reto bring the history up to the present time, it quired no opium, which, previously, had been is only necessary to state, that since admission absolutely necessary to relieve the pain. the temperature has not gone above 100°. What have we here? This is a case of The tongue is clean and of a good color. The pericarditis, but that does not cover all. It is lips are of good color, the ears slightly red- a case of pericarditis, with practically no liquid dish, as if from capillary congestion. The face effusion, but with exudation of lymph, most has lost a good deal of the pallor and swelling decided at the base. We know that there is which it at first presented. The pupils are no marked effusion, because the impulse is so somewhat dilated. The respirations are twen- distinctly felt. Granting that there is perity-four in the minute.

carditis, with plastic exudation, this will not When I come to examine the heart, I find account for the mitral systolic murmur, which a diffused impulse perceptible in the epigas- is different in character. There must be, in trium, extending to the upper border of the addition, mitral regurgitant disease. sixth rib and felt also slightly outward from Are these conditions acute or chronic? The the nipples. The area of cardiac dullness is pericarditis is acute and the valvular disease distinctly increased in the transverse direction, chronic. When the patient, in Italy, had some passing almost to the right edge of the ster- pain in the cardiac region, it is possible that num. On auscultation, I hear a systolic mur- he then had the beginning of this mitral dismur at the apex, rough in character, also per

We infer that the mitral affection is ceived in the left axilla and at the angle of the chronic, because there is an amount of cardiac left scapula. When I place the stethoscope enlargement quite out of proportion to the over the base of the heart, especially toward amount of pericardial effusion. The diffused the left, I hear a double sound, apparently a impulse and the increased percussion dullness murmur; but it is not. It is a friction sound. point to enlargement of the left ventricle. This The second part, that which follows the sys- is not compatible with the supposition that the tole, is much the more distinct, and is broken mitral affection is acute. up into several rather rough sounds. Pressure We know that the pericarditis is acute, from with the stethoscope increases the intensity the history that it began with a chill and pain, of these sounds. We have, then, a double followed by fever. The acute pain in the carpericardial friction sound, or to-and-fro mur- diac region persisted for some days after admur, as it is sometimes called. These sounds mission. We also know that the marked are also heard to the right of the sternum, but dyspnea and the signs of general distress as we go away from the cardiac region they came on suddenly. All these features characbecome very indistinct. In the carotids, that terize the pericarditis as an acute affection. of the left side especially, a rather faint sys- With reference to prognosis, I may say that

ease.

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the boy will recover, although, of course, the account of the anæmic condition. The time organic condition of the mitral valve will re- has now come when the use of small blisters main. The pericarditis will diminish and over the upper part of the heart, with the largely disappear, but whether entirely or application of poultices, will be of advantage. not,* I cannot say. When he recovers from He has not required stimulants, but if there this acute attack, he will probably be not had been flagging of the pulse they would much worse than before.

have been given. If the heart's action had What is to me the most interesting feature been irregular and disturbed, it would also of this case is that he should have pericarditis have been proper to give digitalis. We have at all. This appears to be one of those rare carefully watched the pulse, but have seen cases of idiopathic pericarditis, that is, where nothing to cause us to use digitalis, nor even, the disease occurs without apparent cause.

as yet, stimulants.
The majority of cases of pericarditis arise in
the course of acute rheumatism, but the pa-

Original Communications.
tient has not had the least sign of this disease.
Next in order of frequency as a cause of peri-

COCAINE TOXÆMIA.
carditis stands Bright's disease, but the exam-

BY J. B. MATTISON, M.D., ination of the urine, made more than once, sets

Of Brooklyn, N. Y. this aside. Then we must not overlook the Read before the American Association for the Cure of Inebriates,

November 8th, 1887. possibility of some pyæmic process as a cause of pericarditis. There is not a particle of At a meeting of the New York Neurologievidence of anything like pyæmia. Neither cal Society, November 5th, 1886, Dr. Wm. A. the spleen nor the liver presents anything ab- Hammond, in the course of some remarks normal, and the temperature is barely above on Cocaine, expressed his belief in the toxic the normal. Nor is there any evidence of blow power of that drug, declaring "he did not or injury sustained over the cardiac region. believe any dose that could be taken was We have here to deal with a case of idiopathic dangerous.” In a paper by the writer, on pericarditis, a disease so rare that its very ex- "Cocaine Dosage and Cocaine Addiction," istence has been denied by some. I know, read before the Kings Co. Medical Society, however, that it does occur. In the course of February 15th, 1887–reprint of which may be my life, I have seen four or five instances of had if desired-evidence was presented to this affection.

prove this opinion a mistaken one. This The next question that we have to consider proof, furnished by forty different authorities is the treatment. This has consisted of opium - English, French, German, Austrian, Rusat night, with Rochelle salts occasionally in the sian and American-cited more than fifty cases morning and half an ounce of acetate of potash to support the assertion that there is a danger, daily. To this was soon added the tincture near and remote, in the use of this drug on of the chloride of iron, of which he took some patients, that does not warrant such twenty drops three times daily. Turpentine reckless disregard of care as the opinion stupes were also employed for the relief of referred to implies. the pain. Under this treatment, he has stead- The cases noted more or less in detail showed ily improved. There seems to be no reason that cocaine caused toxic symptoms, so marked to change the treatment. The acetate of in four as to be fatal. The amount of the drug potassium was given as an alkali, to act as an used varied from a small fraction of a grain to alterative upon the exudation and also as a twenty-four grains, and was applied to the eye, diuretic. The iron was administered on ear, nose, throat, larynx, teeth, gums, stomach,

bowel, bladder, uterus, urethra, and under the * In a week from the time the case was shown, the pericardial

skin. The symptoms noted were nausea, friction had largely disappeared entirely from over the lower part of the left ventricle. The boy was able to sit up some hours daily. vomiting, headache, deafness, blindness, loss

of taste and smell, profuse sweats, cold per- maining so for about five minutes. As the spiration, lividity, gastric cramp; frequent, convulsive seizures gradually subsided, he feeble, irregular, intermittent, unaccountable regained his consciousness, but that, too, only pulse; shallow, gasping, irregular, difficult, gradually. For instance, would answer me, convulsive, suspended breathing-artificial res- look bright, and said he felt all right, but in a piration required in some cases; gait, speech few seconds more would complain of fullness and swallowing greatly impaired; rigid mus- in the head and become drowsy. This occles, palpitation, sense of suffocation and great curred several times before he recovered enconstriction about chest; loss of motion and tirely. Altogether the attack lasted about sensation in arms and legs; general numb- half an hour. His pulse was weak, although ness; intense restlessness, extreme prostra- could not be felt very well on account of the tion, giddiness, faintness, feeling of impend-convulsive movements. Pupils slightly dilated. ing death; unconsciousness, convulsions, pa- The following day found the patient doing ralysis, hallucinations, mania, delusions, de- very well, only complaining of some soreness lirium-death.

in his muscles." Summarizing, it was asserted : Cocaine CASE 11.-Female: operation for hæmormay be toxic-sometimes deadly-in large rhoids; cocaine to produce local anæsthesia. doses. It may give rise to dangerous, or even "I injected a solution of the drug containing fatal symptoms, in doses usually deemed safe. altogether about five grains of muriate of coThe danger, near and remote, is greatest when caine. In about fifteen minutes, without any given under the skin.

premonitory symptoms, except a little nausea In further proof of these conclusions, added and faintness, she was seized with violent genevidence of over forty cases is appended. eral convulsive movements, which were so

Two more cases of fatal effect from cocaine strong, and so much more pronounced on the have been reported-one, in dental practice, right side, on which she was lying, as to turn in Poland; the other in France-but the her over on her belly. She had opisthotonos, writer has not yet been able to secure the de- entire loss of consciousness for about five sired details.

minutes, after which it gradually returned, Dr. Samuel T. Earle, Maryland Medical and seemed entirely restored at the end of Journal, noted these cases: “Mr. Z. presented fifteen minutes. Asphyxia; muscles of the himself for the treatment of hæmorrhoids. lower jaw violently convulsed; pupils unevenly Found, on examination, one external and dilated after consciousness began to return; several small internal hæmorrhoids, which I mouth drawn to the right side; speech decidecided to remove by the clamp and cautery. dedly thickened for some minutes after her March 5th, I proceeded to do the operation. I return to consciousness; respiration very injected in the subcutaneous tissue around the labored, and at the height of the attack was anus about one drachm of a four per cent. arrested for some seconds; pulse very feeble ; solution of cocaine, which amounted to about cutaneous surface decidedly blanched where two grains of the drug. In about five minutes not purple, until after consciousness began to after the injection, and before I had taken any return, when it alternately became flushed and other step in the operation, he complained of pallid; she now broke out in a profuse sweat. strange feelings in his legs, accompanied by a There was great prostration following the twitching of the muscles. In a few minutes attack and a disposition to sleep. She recovmore these twitchings amounted to decided ered entirely after several hours, and only tetanic convulsive movements, which involved complained of feeling tired. This patient had all the muscles of the trunk and extremities. never had any nervous attack of any kind By the time these convulsive movements had previously, and both patients were remarkbecome general he complained of fullness in ably robust and healthy." the head and soon became unconscious, re- Dr. A. N. Blodgett, Boston Medical and Surgical Journal, cites case of Dr. R., aged 23, caution in young children under all circumwell and strong, to whom he gave

subcutane

stances.” ously, for local anæsthesia, three minims of a Dr. Heimann cited case of a melancholic twelve per cent solution. “Thirty seconds female to whom he gave 2-7 of a grain, subcuafter the injection was made the patient began taneously. In five minutes she became very to complain of a feeling of great depression, maniacal, continuing nearly an hour. a sensation of coldness, and of faintness. It Schnyder reported case of a druggist who was thought at first that these sensations were took two doses of 34 grain each, 45 minutes due to fright, or to an undue amount of ap- apart, for relief of headache, causing loss prehension as to the action of the drug ; but of sensation, trembling of hands and feet, this proved to be erroneous. The patient rap- spasms, cold extremities, thready pulse of 150, idly became cyanosed, the breathing changed labored breathing, intense headache, jactita-, to a sighing character, the pulse was 140 and tion, gesticulation and delirium. weak, the face was bathed in cold perspira- Dr. F. Tipton reported to me the case of a tion, there were short periods of profound | vigorously healthy female in whom he injected collapse with unconsciousness. The patient four minims of a four per cent solution for was assisted to a couch, where he soon be- local anæsthesia. In five minutes she was came quite helpless. Stimulants were ad- | “deathly pale, vomiting, feeble frequent pulse, ministered, the heat of the surface was main- sighing, hiccoughing, and complaining of tained, and the body warmly covered. At great numbness, with a sense of impending the expiration of a quarter of an hour the death.” Symptoms persisted three hours. finger on the pulse showed a commencing im- Dr. Howell Way gave me details of four provement in the patient's condition. With cases observed by him, in which 5 to 60 the restoration of the organic functions came minims of a four per cent. solution, instilled, a mild form of delirium, the patient talking in- or injected for local anæsthesia, caused toxic cessantly upon all possible subjects, and ap- symptoms-blanched face, blue lips, aphasia, parently not realizing that he had been in any dyspnea, hallucinations, delirium and unconabnormal condition. Soon the pulse was re

sciousness. duced to 80 per minute, and the skin became Dr. Geo. N. Monette, Journal American warm. The delirium gradually subsided, and Medical Association, noted three cases occurthe patient slowly returned to his natural ring in dental practice, in which two to four state.”

drops of a twenty per cent. solution injected in Dr. Emmet Holt, New York Medical Jour the gums caused vertigo, blindness, cold pernal, reported five cases of children, aged 3 to spiration and inability to walk—"completely 21 months, suffering from whooping cough, unnerved; acted as if deranged.” in which the use of a four per cent. solution by Dr. R. M. Griswold informed me of a lad, swabbing or spraying caused toxic symptoms. aged 15, in whom he injected fifteen drops of They were vomiting, great restlessness, rapid, a four per cent solution for local anæsthesia. shallow respirations, pulse too frequent to be In four minutes patient complained of faintcounted, pupils widely dilated, profuse perspi- ness, vertigo, had stertorous breathing, with ration, temperature rise to 102 degrees, con- thready pulse of 160, and became blind and stant and disconnected talking, marked de- unconscious. lirium and convulsions; “very critical condi- Manheim noted a woman in whom the tion.” In a child 4 months old, one swab- subcutaneous injection of two decigrammes bing with a four per cent. solution caused well- caused dyspnea, irregular and suspended marked toxic symptoms; and “alarming" breathing, dysphagia and agryphia, lasting effects followed two sprayings of the same so- thirty hours. lution in two infants, 3 and 6 months old. His Gougenheim has collected a number of opinion is "cocaine must be used with great cases in which cocaine solution, applied to the throat, was followed by urgent symp- the hand can be passed into the cavity to toms.

remove it. Conclusions.—There is a lethal dose of co

0. The duration of the first stage is a very incaine. This dose is uncertain. Toxic effects definite period, lasting from a few hours to are not rare. They may be sequence of doses several days or even weeks. The duration of large or small, in patients old or young, the the second stage is a more definite period, feeble or the strong. This risk should induce varying from a half-hour to four hours. The caution. Antidotes should be at command; only positive sign that the expulsion of the these are nitrite of amyl and hypodermic uterine contents is about to take place is the morphia.

dilatation of the distended cervix, accompanied

by regular contracting pains not relieved by THE NATURE OF LABOR. opium. Dilatation is not complete until the

cervix has expanded enough to allow the exit BY HENRY LEAMAN, M. D.,

of the presenting part. Then begins the secOf Philadelphia, Pa.

ond stage of labor, and the advancing mass Read before the Philadelphia County Medical Society, now comes in contact with the pelvic wall. November 23d, 1887.

The nature of labor consists particularly in This paper does not claim to offer all the the manner in which the uterus expels its contheories and problems of labor, but is simply tents, not in the mechanism of the pelvis. an attempt to throw some light on the phe- The fætal contents are passive in delivery. nomena of labor, with special reference to The life of the ovum in viviparous animals is everyday work. In speaking of labor, we part of the mother life, connected through understand physiological or natural, not path- the uterus and placenta, and identified by a ological labor. Harvey said that the kind of mutual growth and development. The uterus birth in which the fætus is born enveloped in is the outer contractile layer of the ovum. its coverings appeared to him by far the most When their cyclical development is complete, natural; it is like the ripe fruit which drops or has been terminated in any way, differenfrom the tree without scattering its seed, before tiation, or birth, takes place. This is accomthe appointed time. This statement is, doubt- plished through contractility of the uterus, less, physiologically correct.

But in my ex- which gives to the fætus a series of ameboid perience the separation of the elements of the movements that cause it to advance through ovum generally occurs, the waters preceding the pelvic opening. The fætal mass moves and placenta succeeding the fætus, the true under the persuasive action of flexion and rotaprocess of labor being in no manner altered tion produced by the uterus alone, and, in virtue or changed thereby. Any presentation or of its adaptation to its surroundings, overcomes position that can be terminated without assist- great obstacles. The overcoming of obstacles ance may be called natural.

is due not to the amount of force, but to the There are only two stages in labor. The adaptation of the faetus to the pelvis. first embraces all the phenomena that imme- Dr. D. B. Hart, in the Obstetrical Transacdiately precede or occur during the dilatation tions, Edinburgh, vol. v, in a paper on "The of the cervix. The second embraces all the Bearings of the Shape of the Foetal Head on phenomena occurring during the expulsion of the Mechanism of Labor," says: “It will be the contents of the uterus. This includes the seen that the shape of the fætal head, face and so-called third stage. If labor has pursued a breech is, to a certain extent, a preparation for natural course, and due time has been allowed, the emergencies of birth. In a normal head the placenta will be found loosened by the case in a normal pelvis, flexion and rotation pains and ready to be removed immediately are favored by it. Should the pelvis be rickafter the birth of the child. If the placenta ety, the head, either first or last, still has the is adherent or there is an irregular contraction, shape which favors its passage through the

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