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Full text of "International clinics: a quarterly of clinical lectures .."

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INTERNATIONAL CLINICS: 



A QUARTERLY OF CLINICAL LECTURES 



ON 



MEDICINE, NEUROLOGY, PEDIATRICS, SURGERY, 

GENITOURINARY SURGERY, GYNAECOLOGY, 

OBSTETRICS, OPHTHALMOLOGY, LARYNGOLOGY, 

OTOLOGY, AND DERMATOLOGY, 



PROFESSORS AND LECTURERS IN THE LEADING MEDICAL 

COLLEGES OF THE UNITED STATES, FRANCE, 

GREAT BRITAIN, AND CANADA. 



EDITED BY 

JUDSON DALAND, M.D., Philadelphia, 

loitniotor In Cllnloal Medicine and Lecturer on Phjiical Dlagnoeis In the Unlverrity of PennqrlruiU; 

Aniatant Pbydclan to the Hoepital of the UnlTerslty of Pennfylrnnia ; PhyslcUn to the 

Philadelphia Hoepital and to the Bosh Hoepltal for ContumptiTee. 

J. MITCHELL BRUCE, M.D., F.R.C.P., London, England, 

Phyiiclan and Lecturer on Therapeutics at the Charing Croes Hoepital. 

DAVID W. FINLAY, M.D., F.RC.P., Aberdeen, Scotland, 

Profewor of Practice of Medicine In the Unlrerrity of Aberdeen ; Physician to, and Lecturer on Clinical 

Medicine In, the Aberdeen Boyal Infirmary ; Consulting Physician to the Boyal 

Hoepital for Diseaees of the Cheat, London. 



VOLUMB I. KOURXH SSRIBS. 1894. 



PHILADELPHIA: 

J. B. LIPPINCOTT COMPANY. 

1894. 



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Copyright, 1894, by J. B. Lippincott GoMPAmr. 



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Pmntcd by J. B. LiPPiNCOTT Company, Phiuoeiphia, U.S.A. 



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CONTRIBUTORS TO VOLUME I. 

(FOURTH SERIES.) 



Anders, J. M., M.D., Ph.D., Professor of Practice in the Medico-Chirurgical 
College ; Visiting Physician to the Philadelphia Hospital, etc. 

Ashton, William Easterly, M.D., Professor of Gynecology in the Medico- 
Chirorgical College of Philadelphia ; GynsBcologist to the Medico-Chirurgical and 
Philadelphia Hospitals. 

Baker, Albert Rufus, M.D., Professor of Diseases of the Eye, Bar, and Throat 
in the Medical Department of the University of Wooster, Cleveland, Ohio. 

Barling, Gilbert, P.R.C.S., Professor of Surgery in Mason College, England. 

Booth, J. Mackenzie, M.A., M.D., CM. (Aberdeen), Surgeon and Lecturer on 
Clinical Surgery at the Aberdeen Royal Infirmary ; Lecturer on Diseases of the Ear 
and Larynx in the University of Aberdeen. 

Brower, Daniel R., M.D., Professor of Mental Diseases, Materia Medica, and 
Therapeutics, Rush Medical College ; Professor of Diseases of the Nervous System, 
Woman's Medical College; Professor of Diseases of the Nervous System, Post- 
Graduate School, etc., Chicago. 

Bryant, Joseph D., M.D., Professor of Anatomy and Clinical Surgery and As- 
sociate Professor of Orthopsedic Surgery in the Bellevue Hospital Medical College, 
New York City, New York. 

Byfbrd, Henry T., M.D., Professor of Gyn»cology, College of Physicians and 
Surgeons, Chicago ; Professor of Gynaecology, Chicago Post-Graduate Medical School ; 
Professor of Clinical Gynaecology, Northwestern University Woman's Medical 
School ; Gynscologist to St Luke's Hospital ; Surgeon at the Woman's Hospital at 
Chicago. 

Chapin, Henry D wight, M.D., Professor of the Diseases of Children at the New 
York Post-Graduate Medical School and Hospital ; Attending Physician to Demilt 
Dispensary, New York City, New York. 

Cohen, Solomon Soils, M.D.. Physician to the Philadelphia Hospital ; Professor 
of Clinical Medicine and Therapeutics in the Philadelphia Polyclinic, etc. 

Dej^rine, Professor, Physician to the Hospice de Bicdtre ; Professor (Agr6g6) 
in the Paris Medical School. 

Dunn, James H., M.D., Professor of Gtonito-Urinary Surgery in the Medical 
Department of the University of Minnesota; Surgeon to St. Mary's and Asbury 
Hospitals. Minneapolis, Minnesota. 

Gaston, J. McPadden, M.D., Professor of the Principles and Practice of Sur- 
gery, Southern Medical College, Atlanta. 

ili 

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IV 00NTBIBUT0R8 TO VOLUME I. 

Hare, Holmn A., M.D., Professor of Therapeutics and Materia Medica in the 
Jefferson Medical College of Philadelphia. 

Haward, Warrington, P.R.C.S. Eng., Surgeon to and Lecturer on Clinical Sur- 
gery at St George's Hospital, etc 

Meckel, Edward B., A.M., M.D., Lecturer on Ophthalmology and Otology at 
the Western Pennyslvania Medical College ; Oculist and Aurist to the J. M. Gusky 
Orphanage and Home for the Aged of Western Pennsylvania, and the Home of the 
Friendless, Pittahurg. 

Horwit2, Orville, B.S., M.D., Clinical Professor of Genito-Urinary Diseases in 
Jefferson Medical College ; Surgeon to the Philadelphia Hospital, etc. 

Humphrya, Sir George Murray, F.R.S., M.D., LL.D., Sc.D., F.R.C.S.E., 
Professor of Surgery in the University of Cambridge, and Surgeon to Addenbrookes 
Hospital. 

Jackaon, George Thomas, M.D., Professor of Dermatology at the Woman's 
Medical College of the New York Infirmary. 

Jones, S. J., M.D., LL.D., Professor of Ophthalmology and Otology in North- 
western University Medical School (Chicago Medical College), Chicago. 

Lydston, G. Prank, M.D., Professor of the Surgical Diseases of the Genito- 
Urinary Organs and Syphilology in the Chicago College of Physicians and Surgeons ; 
Fellow of the Chicago Academy of Medicine, etc. 

Mann, Matthew D., A.M., M.D., Professor of Obstetrics and Gynaecology, Uni- 
versity of Buffalo ; Attending Gynaecologist to the Buffalo General Hospital. 

McOuire, Hunter, M.D., LL.D., Professor of Clinical Surgery in the Univer- 
sity Collie of Medicine, Richmond, Virginia. 

Mills, Charles K., M.D., Professor of Mental Diseases and of Medical Juris- 
prudence in the University of Pennsylvania ; Neurologist to the Philadelphia Hospital. 

Mund6, Paul F., M.D., Professor of Gynaecology in the New York Polyclinic. 

Park, Roswell, A.M., M.D., Professor of Surgery in the University of Buffalo. 

Patton, Joseph M., M.D., Professor of Clinical Medicine in the Chicago Poly- 
clinic, etc. 

Pershing, Howell T., M.Sc, M.D., Professor of Nervous and Mental Diseases 
in the University of Denver ; Neurologist to St. Luke's Hospital and St. Joseph's 
Hospital ; Alienist to the Arapahoe County Hospital. 

Pooley, Thomas R., M.D., Professor of Ophthalmology in the New York Poly- 
clinic ; Surgeon-in-Chief to the New Amsterdam Eye and Ear Hospital. 

Roberts, A. M., M.D., Professor of Surgery in the Woman's Medical College 
of Pennsylvania. 

Rockwell, A. D., A.M., M.D., formerly Professor of Electro-Therapeutics in the 
New York Post-Graduate Medical School, and Electro-Therapeutist to the New York 
State Woman's Hospital. 

Sansom, A. Ernest, M.D., P.R C.P., Physician to the London Hospital ; Con- 
sulting Physician and Vice-President of the Northeastern Hospital for Children. 

8a3rre, Lewis A., M.D., Professor of Orthopaedic Surgery in the Bellevue Hos- 
pital Medical College, New York. 

Schweinitz, G. E. de, M.D., Clinical Professor of Ophthalmology in the Jeffer- 
son Medical College ; Professor of Ophthalmology in the Philadelphia Polyclinic ; 
Ophthalmic Surgeon to the Philadelphia Hospital. 



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CONTRIBUTORS TO VOLUME I. V 

Skene, Alezmnder J. C, M.D., Professor of Gyn»cology, Long Island College 
Hospital, and Dean of the Faculty. 

Snell, Simeon, F.R.C.S. Ed., Ophthalmic Surgeon to the Sheffield General 
Inflrmaiy ; Lecturer on Diseases of the Eye at the Sheffield School of Medicine ; 
Consulting Ophthalmic Surgeon to the Botherham Hospital. 

Starr, M. Allen, M.D,, Professor of Diseases of the Mind and Nervous System, 
College of Physicians and Surgeons, New York. 

Stockton, Charles G., M.D., Professor of Medicine at the University of Buffalo ; 
Attending Physician, Buffalo General Hospital. 

Sutton, J. Bland, M.D., Assistant Surgeon, Middlesex Hospital, London. 

Von Noorden, Professor Carl, M.D., Berlin, Germany. 

White, W. Hale, M.D., F.R.C.P., Physician to Guy's Hospital, London. 

Wilson, H. Augustus, M.D., Clinical Professor of Orthopssdic Surgery in the 
Jefferson Medical College and in the Woman's Medical College ; Professor of (General 
and Orthopsedic Surgery in the Philadelphia Polyclinic and College for Graduates in 
Medicine, etc. 



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CONTENTS OF VOLUME I. 

(FOURTH SERIES.) 



PAOB 

MEMORIAL OP PROFESSOR JEAN-MARtE CHARCOT. By M. 

Allxn Starr, M.D., Ph.D xv 

THE TREATMENT OP RHEUMATISM. By A. Ernxst Sansom, 

M.D., P.R.C.P 1 

THE HAND AND TONGUE IN THE DIAGNOSIS OP DISEASE. 

By HoBART A. Hare, M.D 16 

THE CONDITION OP THE HEART IN MITRAL INSUPPI- 

CIENCY AND IN CHLOROSIS. By Professor Carl yon Noor- 

DEN, M.D f 25 

ACUTE PLEURISY WITH EPPUSION ; INTERSTITIAL PNEU- 
MONIA (CHALICOSIS), WITH ENCYSTED AND PROBA- 
ELY INTERLOBAR LOCULATED PLEURISY. By J. M. 
Anders, M.D., Ph.D 89 

PERNICIOUS AN/BMIA. By W. Hale White, M.D., F.R.C.P. . . 48 

MEDICAMENTS USEFUL IN PULMONARY TUBERCULOSIS. 

By Solomon Solis-Cohbn, M.D 60 

AMCEBIC DYSENTERY. By Charles G. Stockton, M.D 69 

ENDOCARDITIS AND PERICARDITIS ; EXOPHTHALMIC 
GOITRE; EMPYEMA; NERVOUS JAUNDICE. By Joseph M. 
Patton, M.D 74 

ELECTRO-DIAGNOSIS, WITH ILLUSTRATIVE CASES. By A. 

D. EocKWELL, A.M., M.D 84 

SOME FORMS OF MYELITIS AND OF SERIOUS SPINAL 
TRAUMATISMS. By Charles K. Mills, M.D 92 

HEMIDROSIS; APHASIA DUE TO SUBCORTICAL HEMOR- 
RHAGE; VERTIGO OF CENTRAL ORIGIN; PARETIC DE- 
MENTIA. By M. Allen Starr, M.D 102 

LESIONS OF THE POSTERIOR COLUMNS IN THE MEDUL- 
LARY SCLEROSIS OF ATAXIA. By Professor Dej^rine ... 110 

SIMPLE NEUROMATA. By J. Bland Sutton, M.D 116 

TUMOR OF THE CEREBELLUM, PROBABLY TUBERCULAR. 

By Howell T. PERSHUfo, M.Sc, M.D 122 

CEREBRAL MENINGITIS; LEAD-POISONING; ALCOHOLISM. 

By Daniel R. Brower, M.D 129 

vii 



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Vm CONTENTS OP VOLUME I. 

PAGE 

TETANUS NEONATORUM; BASILAR MENINGITIS, ETIOL- 

OQY AND TREATMENT. By Henbt Dwight Ghafin, M.D. . . 189 

POTT'S. DISEASE. By Lewis A. Sayeb, M.D 146 

CHRONIC ULCERS OF THE LEO. By Sib Gbobgb Muebat 

HuMPHBTS, P.R.8., M.D., LL.D., ScD., P.R.C.S.E 162 

SUPRAPUBIC CYSTOTOMY FOR THE FORMATION OF AN 

ARTIFICIAL URETHRA. By Huktbe McOuibe; M.D., LL.D. . 164 

TENO-SUTURE AND TENDON ELONGATION AND SHORT- 
ENING BY OPEN INCISION ; ADVANTAGES AND DISAD- 
VANTAGES OF THE VARIOUS METHODS. By H. Augustus 
Wilson, M.D 174 

ACUTE PERIOSTITIS. By Wabbinqtoit Hawabd, F.R.O.S. (Eng.) . 186 

ENTERECTOMY AND THE FORMATION OF AN ARTIFICIAL 
ANUS IN A PATIENT UPON WHOM CGELIOTOMY WAS 
PERFORMED FOUR TIMES ; REST IN THE TREATMENT 
OF RECTAL PROLAPSE, AFTER THE FORMATION OF 
AN ARTIFICIAL ANUS. By Josbfh D. Bbyant, M.D 196 

FORCIBLE REDUCTION OF UNREDUCED FRACTURE AT 
THE LOWER END OF THE RADIUS, FOUR MONTHS 
AFTER THE ORIGINAL INJURY, IN TWO PATIENTS, 
ONE OF THEM AGED SEVENTY-FIVE YEARS ; CURE IN 
BOTH CASES. By John B. Robebts, A.M., M.D 201 

MACEWEN'S OPERATION FOR RACHITIC DEFORMITY OF 
THE FEMUR; INFLAMED HEMORRHOIDS. By Roswell 
Pabk, A.M., M.D 208 

OPERATION FOR OCCLUSION OF THE CYSTIC DUCT, WITH 
CALCULI IN THE GALL-BLADDER. By J. McPaddek Gas- 
tow, M.D. . ' 212 

CHOLECYSTENTEROSTOMY WITH MURPHY'S BUTTON ; 
REMOVAL OF A FOREIGN BODY FROM THE LEFT BRON- 
CHUS; THE EXAMINATION AND REVIEW OF A « SUC- 
CESSFUL" CCBLIOTOMY. By James H. Dvmsr, M.D 219 

TUMORS OF THE BLADDER. By Gilbebt Babling, P.R.C.S. . . 281 

THE RESULT OF A PRETENDED OPERATION UPON A PA- 
TIENT SUFFERING FROM A DELUSION OF A SEXUAL 
CHARACTER; OPERATION FOR THE CURE OF EPIS- 
PADIAS : CASE OF PERINEAL SECTION FOR TRAUMATIC 
STRICTURE, WITH A DESCRIPTION OF A NEW FORM OF 
PERINEAL STAFF; NEW METHOD OF TREATING A RE- 
SILIENT AND NODULAR STRICTURE OF THE PENILE 
PORTION OF THE URETHRA. By Obyills Hobwitz, B.S., 
M.D 248 

PROSTATECTOMY; IMPERMEABLE STRICTURE OF THE 
URETHRA; PROLONGED RETENTION OF URINE; PERI- 

NEAL SECTION. By G. Pbakk Ltdston, M.D 261 

' TRACHELORRHAPHY AND ADHESIONS OF THE RETRO- 
VERTED UTERUS. By Henbt T. Btfobd, M.D. 269 



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CONTENTS OP VOLUME I. IX 

PAGE 

THE EXPLORATORY ABDOMINAL INCISION. By William 
Eastxblt Ashtok, M.D 265 

OVARIAN NEOPLASMS. By Alxxandxb J. 0. Skxkb, M.D 272 

RUPTURED TUBAL PREGNANCY. By Matthxw D. Mank, A.M., 

M.D 277 

UMBILICAL HERNIA, EARLY MENOPAUSE; LACERATED 
CERVIX AND VAGINAL ENTEROCELE; RECTOCBLE, 
LACERATED CERVIX, AND RETROVERSION. By Paul F. 
MuHDi, M.D 280 

AFFECTIONS OF THE LACHRYMAL GLAND. By Simxoh Snbll, 

P.R.C.S. Ed 286 

SCLERAL PUNCTURE IN DETACHMENT OF THE RETINA, 
WITH ILLUSTRATIVE CASES. By G. E. Dx Schwxikitz, 
M.D 296 

CONGENITAL PTOSIS; EPITHELIOMA OF THE EYELID; 
OPERATION FOR THE RELIEF OF TRAUMATIC ECTRO- 
PION. By Edward B. Hxckxl, A.M., M.D 807 

TREATMENT OF TRACHOMA BY EXPRESSION AND BY 

OTHER METHODS. By Thomas R. Poolxt, M.D 814 

BLBNNORRHGBAL CONJUNCTIVITIS ; ITS ETIOLOGY, DIAG- 
NOSIS, AND TREATMENT. By Albxbt Rufus Bakxb, M.D. . Q20 

CHRONIC NON-SUPPURATIVE INFLAMMATION OP THE 

MIDDLE EAR. By S. J. JoNxs, M.D., LL.D 826 

FIBROUS TUMOR OF THE NASO-PHARYNX. By J. Mackbmzix 

Booth, M.A., M.D., CM. (Aberdeen) 889 

RINGWORM; PEDICULOSIS AND SCABIES ; ECZEMA ; PSORI- 
ASIS ; EPITHELIOMA. By Gxobqx Thomas Jackson, M.D. ... 845 



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LIST OF ILLUSTRATIONS TO VOLUME I. 

(FOURTH SERIES.) 



PLATES. 

PAOB 

Professor Jean-Marie Charcot (portrait), opposite xv 

The application of the wire-cuirass (Fig. 2) and the deformities resulting from 

Pott's disease (Pigs. 4, 5, 6, and 7) 149 

Topographical relations of the cystic and common bile-ducts (Fig. 1) 213 

Boy of twelve from whose bronchus a cartridge-shell one and a quarter inches 

long by three-eighths of an inch in diameter was removed after tracheotomy 

(Pig. 4) 226 

Fibro-papilloma of the bladder (Fig. 8) and a flbro-myxoma (Fig. 4) .... 288 
A case of epispadias before operation (Fig. 1) and the result nine days after the 

operation (Fig. 2) 246 

Abscess of the lachrymal gland in a baby five months old (Fig. 1) ; enlarged 

lachrymal gland of the right eyelid in a man aged flfty-flve years (Fig. 2) ; 

adenoma of the lachrymal gland in a woman of twenty-flve years (Fig. 8) 289 
A case of congenital ptosis before (Fig. 1) and after the operation for its relief 

(Pig. 2) 807 

Epithelioma of the lower eyelid before (Fig. 8) and after operation (Fig. 4) . . 809 
Traumatic ectropion in a child relieved by operation (Fig. 6) 811 



PIGURES. 



Diagrams showing the recession of precordial dulness, in a case of rheumatic 

inflammation of the heart, in the space of twenty-four hours 12 

Diagrams showing the recession of dulness in a case of pericarditis with efilision 

in the space of nine days 18 

Areas of cardiac and hepatic dulness in a case of mitral insufficiency 28 

Sphygmogram of the radial pulse in a case of mitral insufficiency (Fig. 2) . . 29 

Areas of cardiac and hepatic dulness in a case of chlorosis (Fig. 8) 81 

Sphygmogram of the radial pulse in a case of chlorosis (Fig. 4) 82 

Chart of the percentage of red blood-corpuscles and of haemoglobin in a case of 

pernicious anemia 60 

Temperature chart of the same case (Case I.) 51 

Chart of the percentage of red blood-corpuscles and of hemoglobin in a case of 

pernicious anemia 62 

Temperature chart of (Case II.) pernicious anemia 68 

xi 



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Xll LIST OP ILLUSTRATIONS TO VOLUME I. 

PAGE 

Dr. Burney Yeo's perforated zinc respirator . 67 

A convenient electrode for the application of the galvanic current 90 

Microscopic section of the spinal cord showing acute hemorrhagic myelitis 

(Fig. 1) 94 

Acute hemorrhagic myelitis (Figs. 2 and 8) 94 

Diagrammatic sections of the spinal cord, showing the areas of sclerosis in com- 
mon tabes (Figs. 1 and 2) and in cervical tabes (Figs. 8, 4, and 5) . . . . Ill 
Sections of the spinal cord, showing the sclerosed area in a case of paralysis of 

the brachial plexus (Figs. 6 and 7) 114 

A neuroma from Scarpa's space undeigoing myxomatous change 117 

Padded cuirass with jury-mast attached for cervical Pott's disease 147 

Baby-carriage for child in cuirass made extra long and with rubber-tired wheels 

(Fig. 8) 149 

Jury-mast complete, with a firm basis of support to be incorporated in a plaster- 

of-Paris jacket (Fig. 8) 150 

Jury-mast and plaster-of- Paris jacket applied (Fig. 9) 160 

Topographical relations of the artificial urethra formed in advanced cases of 

prostatic enlargement (Fig. 1) . . . . ; 169 

Silver plug for keeping an artificial suprapubic urethra patulous (Fig. 2) . . . 172 
Apparatus for retaining the silver stopper securely in the suprapubic urethra 

(Fig. 8) 172 

Allis' knife for Rhoads' operation of tendon elongation (Fig. 1) 175 

Anderson's method of tendon elongation, illustrated (Fig. 2) 176 

Diagrams illustrating Dr. Keen's method by which tendons may be lengthened 

to a definite extent (Figs. 8, 4, and 5) 176 

Wilson's adapjtation of Anderson's method to tendon shortening (Figs. 6, 7, 

and 8) 177 

Willetts' method of tendon shortening (Fig 9) 177 

Esmarch's method (after Roberts) (Fig. 10) 177 

Le Fort's method (after Lejars) (Fig. 11) 178 

Wolfler's method (after Lejars) (Fig. 12) 179 

Le Dentu's method (after Lejars) (Fig. 18) 179 

Dr. Tmka's method of tendon suturing and the application of the catgut 

sutures (Figs. 14, 16, 16, 17, 18, and 19) 180 

Wilson's improvement over Trnka's method (Fig. 20) 181 

Ozemy's method (after Lejars) (Fig. 21) 181 

Schwartz's method of tendon anastomosis (after Lejars) (Fig. 22) 182 

Tillaux and Duplay's method (after Lejars) 182 

Two methods for lengthening tendons somewhat more complicated than the 

preceding (Fig. 24 A, Fig. 24 B, Fig. 26 A, Fig. 26 B) 188 

Deformity resulting from an unreduced fVacture of the lower end of the radius 

(Fig. 1) 202 

Restoration of the normal contour of the same case after refracture (Fig. 2) . . 202 
Line of incision to expose the gall-bladder, with the retractors and calculus- 
scoop in position (Fig. 2) 216 

The Murphy button in position in cholecystenterostomy (Fig. 1) 221 

Application of sutures to retain the Murphy button in position (Fig. 2) . . . 222 

Calculi fW)m the gall-bladder (Fig. 8) 228 

Polypoid tumors of the bladder (Figs. 1 and 2) 288 

Epithelioma of the bladder (Fig. 6) 286 

A newly devised perineal staff (Orville Horwitz) 248 



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LIST OF ILLUSTRATIONS TO VOLUME I. Xlll 

PAOl 

Diagram Doatic repreBentation of the method of applying a ligature to anovariau 

pedicle (Figs. 1, 2, 8, and 4) 262 

Adenoma of the lachrymal gland after removal (Fig. 4) 298 

Microscopic appearance of a section of adenoma of the lachrymal gland (Fig. 6) 298 

Diagram of the field of vision in a case of scleral puncture (Fig. 1) 297 

Field of vision of the same case two weeks after a second scleral puncture (Fig. 

2), and again two months later (Fig. 8) 298 

Diagrams of the field of vision of Case II. before the scleral puncture (Fig. 4) 

and one week after the operation (Fig. 5) 800 

Diagram illustrating the partial detachment of the retina in Case II. (Fig. 6), 

and the final result of treatment on the field of vision (Fig. 7) 801 

Field of vision of Case III., illustrating extensive detachment of the retina 

(Fig. 8) 802 

Diagram of the visual field of Case III. after operation practically without 

fevorable result (Fig. 9) 802 

Field of vision of Case lY., showing extensive detachment of the retina (Fig. 

10) and some slight improvement after the operation (Fig. 11] 808 

Diagrams illustrating the changes produced by the instillation of a solution of 

eserine in a case of detachment of the retina (Figs. 12, 18, and 14) ... 806 

Diagram of the visual field of a patient treated with eserine (Fig. 15) ... . 806 
Vertical section of a temporal bone, showing the external, middle, and internal 

ear and Eustachian tube 826 

Jones' compound otoscope and Troltsch's mirror with head-band attached . . 827 

Troltsch's mirror, with handle, ready for use 828 

Turck's tongue-depressor 829 

Tuning-fork for testing the hearing 829 

Nest of ear-specula 829 

Gross' ear-scoop and hook 882 

Conversation tube and long rubber tube adapted for aiding in the determi- 
nation of a diagnosis by exclusion 884 

Hard rubber nebulizer and bottle 885 

Complete steam -atomizer 885 

Silver Eustachian catheter (natural size) 886 

Vertical section of the naso-pharynx, showing the Eustachian catheter in posi- 
tion 887 

Buttles' inhaler and valve-bulb 837 

Galvanic battery ready for use 888 

Naio-pharyngeal growth after removal 842 



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JEAN-MARIE CHARCOT. 



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MtmoxidH of 

PROFESSOR JEAN-MARIE CHARCOT/ 

BY M. ALLEN STARR, M.D., Ph.D. 



By the death of Professor Charcot, which occurred on the 16th of 
August, 1893, the science of medicine has suffered the loss of its most 
accomplished and foremost clinical teacher, one whose wonderful powei 
of instruction was recognized over the entire world ; one who will be 
personally regretted by devoted pupils in every land. 

It is fitting, therefore, that in this volume of the Intebnational 
Clinics the place of honor should be given to some account of his life 
and of his work. Such a memorial will be welcome to his numerous 
admirers, and of interest to those who had no personal knowledge of 
him. It may also be a source of inspiration to those who, like him, are 
laboring in the field of clinical medicine. 

Charcot was born in Paris on the 29th of November, 1825. He 
was the son of a wagon-maker, a man of such limited means that 
he was not able to give all his children an education. Jean-Marie, 
however, showed so much ability in school that he was selected from 
among his brothers as the most promising member of the family, and, 
while one brother was enlisted as a soldier and another put to work in 
the father's shop, he was allowed to enter the Lycte St.-Louis, at that 
time the best academy in Paris. After his preliminary education was 
completed there, the choice of the medical profession was made with 
some hesitation, for the inclination of the young man was for the life 
of an artist, and his ambition in this direction had been increased by 
a journey to Italy and a residence there of several months. This 
love of art persisted in after-life, as was well known to those who 
visited his home of late years, where he had gathered many treasures 
of art, among which were a variety of paintings in oil and on porce- 
lain from his own hand. It was probably the lack of means that 

> Bead in part before the New York Neurological Society, October 8, 1898, and 
publiahed in the Medical News, October 14, 1898. 

XV 



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XVI MEMOBIAL OF 

finally determined him to take up medicine. After passing through 
the medical school and serving as an interne in La Salp^tri^re, — ^an 
almshouse for old women^ then almost unknown, but later to become 
famous as the theatre of his wonderful activity, — he took his doctorate 
degree in 1853. 

For the next three years he served as chief of the medical clinic 
in the medical school^ supporting himself meantime by giving private 
tuition. He was then appointed physician to the Central Bureau of 
Paris, with a moderate salary, his duties being to examine applicants 
for the hospitals and assign them to the proper services. While fill- 
ing these positions and slowly making his way, he was not idle, but 
was preparing for that competitive examination to which ambition for 
success leads every young physician in Paris. 

It is to be remembered that hospital apj>ointments in France are 
under governmental control, and that as fast as vacancies upon the 
attending staff of hospitals occur, they are filled by the appointment 
of men who have qualified themselves for these positions by passing a 
very rigid examination, by presenting theses, and on occasion defend- 
ing in public debate the positions taken in the theses. Charcot suc- 
ceeded in passing this examination in 1860, at his second trial, and it 
is said that he always supposed that he owed his success to his ability 
in defending the points made in his thesis upon chronic ulcerative 
pneumonia, which were ruthlessly questioned and criticised by his ex- 
aminers. One of his biographers states that it was the wonderful 
familiarity with the literature of his subject which really impressed 
the examiners, who were amazed at the long bibliography attached to 
his thesis. In this respect it may be noticed that his articles always 
excelled those of other French writers, Charcot never ignoring, as they 
do, the work done by other men in other lands. 

Having qualified for a position as attending physician to a hospital, 
Charcot was able to select in 1862 the service at his old hospital, La 
Salp^tri^re. He found a large number of old people collected together 
in this poor-house, and among them many with chronic incurable dis- 
eases. He had opportunities to watch the progress of disease, both 
acute and chronic, in old age, and, most important of all, he had un- 
limited pathological material to supplement his clinical observations. 
It is to this latter fact that he owed the b^inning of his reputation. 

In 1872, Charcot was made Professor of Pathological Anatomy in 
the Faculty of Medicine in Paris, the highest prize in the French 
medical world. He succeeded Vulpian in this professorship. For 
the ten following years he held this position, contributing during that 



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PBOFESSOB JEAN-MABIE CHARCOT. XVU 

time many important observations upon diseases of the longs, liver, 
kidneys, and other organs, meanwhile, however, not neglecting his 
lectures at the Salp^tridre upon diseases of the nervous system. It 
was these latter that were his favorite studies, and it was in this de- 
partment that his work brought renown to himself and to France. 

In 1882 this fact was officially recognized by the French govern- 
ment, under the leadership of Grambetta, — a personal friend of Charcot, 
— by the foundation in the Medical School of a Professorship of 
Nervous Diseases, and Charcot's appointment tp it, with the establish- 
ment of a public clinique at La Salp^tri^re. From that time until his 
death bis annual courses of lectures were attended by students of 
medicine from every land, and it may truly be said that there are few 
teachers of eminence at present living who have not drawn inspiration 
from his model clinics. 

It was in the spring of 1883 that I had the good, fortune to be 
numbered among his students, and it may be of interest if I relate 
some details of his work. On three mornings of the week, at half- 
past nine o'clock promptly, he would come to the dispensary of the 
hospital and seat> himself behind a little railing, which separated him 
on one side from the patients, and on the other from the crowd of 
students, many of them foreigners, and all graduates in medicine. His 
assistants would then bring the patients, one by one, from the adjoin- 
ing waiting-room. A concise history would be given of the case. 
Then Charcot would ask some searching questions, would elicit some 
unexpected symptom, would discover some physical appearance that 
others had not noticed, would examine the patient himself if there 
was any special point of interest, and then would quickly state his 
diagnosis, supporting the position taken, or discuss the probabilities 
or difficulties of diagnosis, often with interesting comments or some 
reference to the literature, and finishing occasionally with some thera- 
peutic suggestion. 

On Tuesdays the public clinic of the week was held in a large build- 
ing just within the hospital gate. The room was arranged with a 
stage and footlights, and tiers of seats arose from the front level to 
quite a height at the rear of the room. As many as six hundred 
students could be seated, and the place was always full. Afler the 
audience had gathered, dark shutters were closed at the windows, the 
footlights were turned up, and the clinic began. Charcot, attended by 
a number*of his assistants, entered and seated himself on one side of 
the stage, at a little table, looking not at his audience, but across the 
stage. Then the patient or patients, for he usually showed a number 



f 



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XVIU MEMORIAL OF 

at once, either to display variations of one disease or to draw contrasts 
with other diseases, were placed before the footlights, and sometimes, 
when a particular feature had to be demonstrated, a calcium light was 
turned on the patient, whose figure, the chief point of light in the 
darkness, could always be perfectly seen by all. In a distinct but not 
loud voice, with a slowness of speech that led to a clear understanding, 
— especially by the foreign element in his audience, — Charcot would 
describe the case, call attention to special symptoms, show the pecu- 
liarities of spasm or deformity or tremor or gait, compare them with 
other similar forms for the purpose of differentiation, and sum up the 
diagnosis. Then, dismissing the patient, he would b^in to describe 
the lesion, and at once on the screen at the opposite side of the stage 
the magic lantern would flash out the picture he wished to show, either 
in the form of a sketch made from nature, or an actual slide of a sec- 
tion of the spinal cord, or a part of the brain magnified by the micro- 
scope, or a photograph of some unusual clinical type of the disease in 
question. Thus, symptomatology, diagnosis, and pathology were pre- 
sented in orderly succession in a manner most clear and forcible, and 
with an effect that was most instructive and impressive. It has been 
said that the whole clinic was arranged for theatrical effect I believe 
that it was the only manner in which it was possible to demonstrate in 
a clear light to the large audience all the features, clinical and patho- 
logical, of the subject. But grant that it was theatrical : it left on 'the 
mind of the student a series of mental pictures of patients and of lesions 
which no amount of private study could possibly produce. It taught 
men so that they could not fail to remember ; and what higher result 
can a teacher wish ? And the students appreciated it. They gathered 
enthusiasm from Charcot's evident earnestness. No teacher has ever 
had such a constant company of devoted young men about him, eager 
to share in his studies, to be directed in their investigations, to be con- 
sidered a part of his working force. He had the faculty of engaging 
their interest, of stimulating their investigations, of directing their 
work. He supplied them with material and showed them how to use 
it. As a result, there have appeared in France during the past fifteen 
years an enormous number of clinical and pathological researches in 
the department of neurology, all of them inspired by Charcot, though 
carried out by some one of his pupils. He built up the school of the 
Salp^tri^re. One can hardly name a young man of eminence in medi- 
cine in France to-day who has not at some time been glad to' call him- 
self a pupil of Charcot. And when, in addition to the long list of his 
own articles, — his collected works will fill fifteen large volumes, — the 



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PROFESSOR JEAN-MARIE CHARCOT. XIX 

articles are collected on which his name appears as collaborator, there 
is presented a mass of medical literature far surpassing that of any 
other medical school in the world. 

Boumeville has said that Charcot was not fond of writing or of pub- 
lication, that it required two years of constant urging to induce him to 
publish the first two volumes of his lectures, and that he never would 
have given to the world many of his articles had not some one of 
his assistants attended to the details of publication. Oilles de la 
Tourette says that of late years all of Charcot's clinical lectures were 
carefully prepared in writing, so that at the close of the lecture he 
merely handed his notes to one of the assistants, who was then able to 
arrange them with the histories of the cases for publication. Those 
who have followed these clinical lectures in the Progrls MHioal during 
the past ten years know what a wealth of information they contain. 

It would take too much time to specify his various books, lec- 
tures, and articles published between 1865 and 1892. I cannot, how- 
ever, omit to mention his ^'Localisations des Maladies C6r6brales" 
and his '^ Localisations des Maladies de la Moelle 6pinidre,'' which 
did much to establish on a firm basis the doctrine of the localization 
of cerebral and spinal functions, and which appeared in the Betme de 
Midedne in 1879, and his numerous valuable papers on the pathology 
of spinal lesions. To him we owe the discovery of amyotrophic lateral 
sclerosis, which has been called Charcot's disease. It should also be 
known that^ with Vulpian and Brown-S6quard, he founded the Ar- 
chives de Physhloffie in 1869, the Progrls Midical in 1873, the Betme 
mensudle de MSdedne et de dwrurgie in 1877, now known as the 
Revue de Midedne, the Archives de Nearologie in 1880, and the NouveUe 
Iconographie de la ScUpitri^e in 1888. To all these he continued to 
contribute from time to time until his death. It is said that the sale 
of his three volumes of lectures published from 1872 to 1880 surpassed 
that of any other medical work ever published. These lectures have 
been translated into German, English, Spanish, Italian, Hungarian, 
and Russian, and new editions are demanded every year. 

Public recognition of his abilities and eminence was not wanting. 
He had been president of all the chief medical societies in Paris, and 
was a corresponding member of numerous societies in every city on 
the continent of Europe, of the New York Academy of Medicine, of 
the New York Neurological Society, and of the College of Physicians 
of Philadelphia. He was made a member of the Institute of France 
in 1883, and Commander of the Legion of Honor in 1892. It may be 
justly said that France honored herself by conferring honors upon him, 



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XX MEMORIAL OF 

for there are few Frenchmen who, during the past quarter-century, 
have done as much as he to support the waning French authority in 
matters of science or to preserve the &ding reputation of the French 
school of medicine. Not medicine alone, but French prestige as well, 
has reason to regret his untimely demise. 

It remains to allude to his personal characteristics. Charcot was a 
man of great dignity, of calm repose, of even temper, of slow thought 
apd utterance, but of much reserve power. In appeamnce like Napo- 
leon, and in manner reserved and observant, he was not the type of 
man to be popular. Yet his dignity was one that was felt to be appro- 
priate to a man of great power, and was never assumed. With patients 
suffering from trifling affections he showed no sympathy, possibly little 
interest. With patients whose diseases were grave, or obscure, or of 
rare type, he was kind, attentive, interested, and was ready to spend 
valuable time in most careful investigation. Of this I am assured by 
patients who had been under his care, and who would never have come 
away with such kindly feeling had they not experienced thoughtful 
attention at his hands. His relation to his pupils was also one of 
mutual interest and affection. He was never familiar with them, yet 
he always respected and sought their opinions, was never autocratic 
in the direction of their work, and was always the subject of their 
devoted admiration and respect. 

Without characteristics of many kinds of the noblest type, no man 
could have kept about him such a number of able medical workers, 
all loyal to him in the midst of their labors. 

His domestic life was a delightful one. He was married early in 
life to a lady of considerable wealth, who was enthusiastic in his work, 
and by whose aid many scientific undertakings, otherwise impossible, 
were carried out. He had two children, one a boy, whom it was his 
fond desire to see succeeding as a physician, and who gives promise 
of being worthy of the name. Their homes — he had a large country 
place at Neuilly, as well as a fine mansion on the Boulevard 8t.-Ger- 
main — ^were superb in every appointment, and contained many treas- 
ures of art ; for the artistic sense was one which he delighted to indulge. 
He was a designer, a painter on porcelain and in oils. The tiles in his 
study mantel and the ceiling of one of his salons were painted by his 
own hand. Many of the drawings displayed at his lectures and pub- 
lished in his books were made by himself. He delighted in gathering 
about him curios of every kind. He cared less for music than for 
painting, and always preferred the classic and Italian schools to Wag- 
ner, showing himself thoroughly French in this respect. His house 



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PROFESSOR JEAN-MARIE CHARCOT. XXI 

was open every Monday evening to his friends and pupils, and a con- 
siderable company was always glad to gather about him to enjoy his 
hospitality and to profit by the interesting discussions which went on. 
Like every man of eminence, Charcot had his enemies, critics in 
science, rivals in medicine. Yet, after all their criticism is exhausted, 
we must admit that Charcot remains the greatest French physician 
since Trousseau, the greatest ornament of the medical profession of the 
present age. We admire his genius ; we esteem his scientific work ; 
we respect him as the greatest of medical teachers ; we honor him as a 
noble, unselfish, and truly great man. 



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THE TREATMENT OP RHEUMATISM. 



CLINICAL LICTURS DELIYSRED AT THE LOKDOK HOSPITAL. 

BY A. ERNEST SANSOM, M.D., P.R C.P., 

Physician to the London Hospital ; Consulting Physician and Vice-President of the 
Northeastern Hospital for Children. 



Gentlemen, — We come to the practical question, How shall we 
treat our patient who is suffering from rheumatism in its various 
phases as you have observed them in these wards? We have en- 
deavored from our experiences to draw a clear picture of rheumatism 
in its clinical aspects, and I think we shall have little difficulty in 
differentiating our patients, — ^the rheumatic from the non-rheumatic. 
We have considered the outlines of the disease (see The Clinical Jour- 
fudy December 7, 1892, p. 81, and Allgemdne Wiener Medvdnisohe 
Zeitungy 7 Februar, 1893, p. 57). We have also discussed some pain- 
ful affections of the joints which are not rheumatic (see International 
dinicSy vol. i., third series, 1893, p. 58). We may thus summarize 
our views. Rheumatism is a morbid process, whose manifestations 
are chiefly in the serous membranes of the joints (attended with pain), 
in the pericardium (usually attended with symptoms of distress and 
pain), in the endocardium (not attended with pain), in the pleura, and 
sometimes in the fibrous tissues in various situations (rheumatic 
nodules). The disease is usually accompanied at some periods of its 
course by a moderate fever ; exceptionally it has such an effect upon the 
cerebro-spinal nervous system as to cause excessive fever (hyper- 
pyrexia) ; in the majority of cases there is sweating, and in some there 
are eruptions upon the skin. It is especially a disease of the early periods 
of life ; it may occur in the form of endocarditis, in the foetus even 
when the mother shows no rheumatic manifestations, and many of the 
congenital affections of the heart may be ascribed to the morbid 
changes which it has produced. It is very rarely manifested for 
the Jird time after the age of thirty-five. The course of the morbid 
processes is very protracted, and there are ofi;en explosive outbreaks 

1 



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2 INTERNATIONAL CLINICS. 

which may be determined by very slight or undiscoverable causes : 
these outbreaks are often miscalled " relapses." Dr. Cheadle has well 
said that ^^ the history of a rheumatism may be the history of a whole 
childhood" (see Keating's " Cyclopaedia of the Diseases of Children," 
vol. i. p. 786), but I would go further and say, not of a childhood 
only, but also of an early adult life. It is by no means limited to or 
traceable by its obvious signs and symptoms, objective and subjective, 
as it is liable, especially in the later years of adult life, to be modified 
by the disturbing influences of independent morbid complications. 

The painful manifestations of rheumatism are those which chiefly 
fix themselves upon the mind, especially those of the joints. We 
must, however, in discussing treatment, disabuse oureelves of the 
wide-spread fallacy that all painful aflections of the joints are 
rheumatic. I have shown you that there are many causes of non- 
rheumatic arthritis. Inflammations of the joints may be observed in 
cases of blood-deterioration and blood-extravasation (in scurvy, pur- 
pura, and haemophilia), in certain infective diseases (syphilis, septi- 
caemia, dysentery, enteric fever, mumps, gonorrhoea, influenza, and 
scarlatina), in a disease of perverted metamorphosis (gout), and lastly 
in the affection known as osteo-arthritis. It is this last-named dis- 
order which I believe to influence in the highest degree our success in 
the treatment of articular rheumatism, for it is one of the most fre- 
quent of complications. At any rate, I feel convinced that we often 
meet with "mixed" cases, — that a non-rheumatic may reinforce a 
rheumatic arthritis. 

Intelligent treatment must be dominated by theory. The principles 
which seem to be justified by our experience are these: that the 
pathogeny of rheumatism is chiefly and essentially humoral ; that the 
disease is due to a disturbance of metabolism, whereby certain unde- 
termined poisons or toxines are elaborated, which continue for long 
periods to induce morbid changes chiefly in the serous membrane and 
fibrous tissues, causing the phenomena which we have considered ; 
that the pathogeny of osteo-arthritis, which not infrequently com- 
plicates rheumatism, is essentially nervous ; that the central cerebro- 
spinal affection causes a disturbance of nutrition and a severe inflam- 
mation in a joint in a manner analogous to though different from that 
which occurs in tabes dorsalis, and that the associations of this disease 
are with other disorders of the central nervous system. 

I would not contend that the influence of the nervous system is 
to be Ignored in the pathogenesis of either form, but in the former 
such an influence is primarily manifested in disturbing the processes 



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THE TREATMEJ^T OF RHEUMATISM. 3 

of metabolism, whilst in the latter metabolism is not necessarily dis- 
turbed at all, but the direct effect of the central nervous disorder is 
upon the trophic nerve-mechanism of the joint or joints. 

With rc^rd to the treatment of rheumatism, I think that the 
plan best adapted for practical usefulness will be for me to place 
before you some supposititious cases which may be taken as types of 
certain groups. 

Case A. — We will assume that a child nine or ten years of age 
is brought in with a report from those in chai^ of him that he is in 
pain when he moves ; that he has cried because of j)ain in his knee- 
joints, which are found to be slightly swollen and tender on manipu- 
lation. His temperature is 102^ F. His throat shows no signs of 
recent inflammation. Our physical examination reveals nothing wrong 
with the heart or with other internal organs. 

Change the surroundings for a moment. Imagine that you are 
called to a case like this in one of the homes of the poor, where none 
of the appliances of the hospital are at hand, and where the direction 
of all the stages of treatment and nursing devolves upon yourself. 
You order that the child shall have his clothing removed by gentle 
hands (so that the joints be not pained) and be put to bed. The sheet 
should be taken away, so that the blankets be next the skin. The child 
being now without clothing, you are enabled to make, with all gentle- 
ness, a better examination of the joints. You will direct the mother 
or nurse to place another folded blanket under the child and sponge 
and cleanse the whole surface of the body with soap and warm water. 
After the sponging and cleansing and gentle drying with a well-warmed 
towel, the folded blanket will be removed, a warm night-dress put on, 
and the child left comfortable between the blankets of the bed. If 
any of the joints remain so painful as to cause restlessness, wrap these 
round with hot cotton-wool, and modify the position by interposing 
a few down or cotton-wool cushions. Very probably, and we will 
assume it so in the present case, the child will now be disposed to 
sleep, and the necessity for medicinal treatment will be little or none. 
You may be asked whether, the child being constipated, you should 
order an aperient. No, for its action means movement of the body 
and necessarily of the joints, and you want rest. If there be hard 
faeces in the rectum, a small glycerin enema, or equal parts of olive 
oil and warm* water, to the extent of half a pint, should be adminis- 
tered, but let the evacuation be received with the least disturbance 
possible of the position of the patient. You give orders that the 
diild shall have no solid food, but pure milk diluted with an equal 



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4 INTERNATIONAL CLINICS. 

quantity of water which has been previously boiled and allowed to 
cool. He may have, besides, some mutton, chicken, or I)eef broth. 
You may be asked whether very strong beef-tea or the artificial beef 
extract may be given, and the answer I am inclined to give is. No. 
I think these often do more harm than good in the febrile slage. A 
meat soup made in the following way answers very well. Let three 
ounces each of finely minced beef, mutton, and veal, with half a tea- 
spoonful of common salt, be put in a jar with a pint of cold water. 
After standing for two hours in the cold, add three ounces of pearl 
barley, and let the whole be stewed gently for four hours. Then strain 
off the liquid and add thereto, if the child likes the flavor, a pinch of 
celery salt. If thirst is not sufficiently quenched by the diluted milk, 
you may allow a small quantity of barley-water flavored with lemon ; 
it is better to sweeten this with a little pure glycerin than with sugar. 
Or a little weak tea may be allowed occasionally. When the milk 
and water are taken warm, it is well to add to each cupful a teaspoou- 
ful of isinglass jelly, made by dissolving a quarter of an ounce of dry 
isinglass in a Jarge break&st-cupful of boiling water. When cold, this 
becomes a jelly. 

Aft«r four or five days, if fever has subsided, toasted bread, rusk, 
or sponge-cake may be given with the milk, and a light milk pudding 
added to the dietary. Then there may be a gradual approach by fish 
and light meat to the ordinary diet. 

During the convalescence, your chief indication for medicinal treat- 
ment is the anasmia. For this you must rely on iron and arsenic. 
Small (twenty or thirty minim) doses, thrice daily, of vinum ferri or 
syrupus ferri phosphatis, with two- to five-minim doses of liquor 
arsenicalis, diluted with half-ounces of water, and administered after 
food, answer very well. You may consider whether a long-continued 
course of alkalies does anything to ward off rheumatic manifestations. 
I think not. 

You must give some directions as to the hygiene of convalescence, 
and you should steer in the middle course between "coddling" and 
rash exposure. Woollen or flannel clothing (light in summer) should 
be worn next the skin. You must settle the question of cold lathing. 
I advise that you insist that on rising in the morning the first opera- 
tion shall be a dry rub with a towel over all the surface, beginning 
with the soles of the feet, then a warm water or sdap-and-water 
sponge, then a sponge with cool or cold water, and a good towel 
drying. Do not permit a mere hot-water ablution, in which case the 
heart is weakened, because the arterioles are relaxed and the individual 



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THE TREATMENT OP RHEUMATISM. 5 

bleeds into his own skin. The final cold sponging contracts the arte- 
rioles^ stimulates the left ventricle to a good systole^ and tends to slow 
the heart-rate. 

It is right to urge upon the parents of a child who has once suffered 
from rheumatism that he should be brought for medical examination 
at intervals of a few months, for valvular disease of the heart may 
arise and progress without any manifested symptoms. Even slight 
pains in the joints — ^parents and nurses often call these " growing- 
pains'^ — are to be interpreted as rheumatic phenomena oft;en of serious 
import Many a child, in all probability, has been punished for 
inertness or shamming, many a rheumatism has been neglected, and 
many a case of valvular disease of the heart in a child has arisen and 
progressed unnoticed, because the subtlety and symptomlessness of the 
disease we are considering have not been appreciated. Impress also 
upon those who care for the young rheumatic subject that any sign of 
sore throat must be interpreted as the very probable b^inning of an out- 
break of the disease. Even a slight tonsillitis has a severe significance. 

I have^ in the case before us, taken an example of the treatment 
of rheumatism by the " little cares,'* — one managed without special 
treatment by drugs, but by attention to the laws of health, by the 
detection and avoidance of the beginnings of evil, in the hope that 
the years may pass away in which the proclivity to the disease is 
manifested. 

We now turn to a case in which our reliance upon medicinal means 
of treatment is much more decided. 

Case B. — A young adult, say aged twenty-one, is admitted with 
pain and swelling of several joints, and with other well-marked signs 
of acute rheumatism that I need not here recapitulate. There is no 
evidence of cardiac, pleural, or pulmonary involvement. The pain in 
the joints is severe. The sponging and cleansing, as in the case just 
mentioned, have been resorted to, but the suffering is still very great, 
and we do not hesitate to administer drugs. Our routine plan in such 
a case as this is to prescribe as follows : 

B Sodii salicylatis, gr. zx ; 
Sodii bicarbonatis, gr. xx ; 
Aqnm chloroformi, fji, 

in a mixture every two hours, until six doses have been taken ; after- 
wards every six hours. 

I will not stay to discuss the steps by which we have come to 
regard the treatment by salicin or its compounds as the best we can 



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6 INTERNATIONAL CLINICS. 

adopt in cases of rheumatism in which the painful affections of the joints 
constitute the chief feature, nor to debate concerning the best agent 
among the salicin preparations that we can prescribe. I have come to 
r^ard sodium salicylate as the most practically useful drug, and I 
think it is well to combine it with an alkaline bicarbonate. I usually 
order fifteen or twenty grains of each to an adult every two hours 
when the case in its painful stage first comes under our notice, and I 
reduce the frequency of administration to every six hours, or to 
three times daily, after the sixth dose has been administered ; in some 
cases at an earlier period, if the pains have almost disappeared and 
the temperature has approached the normal. We continue, however, 
to administer the drug three times daily for a considerable time, — 
usually until the patient is well enough to be discharged from the 
hospital. In the course of from two to six days, in the majority of 
cases, the temperature becomes reduced to the normal and the pains 
disappear. In a few cases the drug does not agree. The toxic symp- 
toms it can induce are delirium, vomiting, deafness, noises in the 
ears, headache, bleeding at the nose, irregularity or slowing of the 
action of the heart, and symptoms of heart-failure. In any case 
wherein such signs are manifested, the administration of the drug 
should be suspended. There may be, however, a fallacy in the inter- 
pretation of these signs, for many of them can be independent of the 
action of the remedy, and due to the influence of the disease itself 
upon the central nervous system. We may have recrudescences of 
pains in the joints under the treatment, but I cannot doubt that in 
the aggregate there has been greatly increased comfort to the patient 
since we adopted the plan I have indicated. If the {>ain returns, we 
administer the dose every two hours, as at first. The diet during the 
stage of pain and fever is what we term admission diet, consisting of 
twelve ounces of bread, two pints of milk, and one pint of beef-tea 
daily. After the subsidence of the stage of pain and lever there is a 
gradual approach, through fish and light minced-meat diet, to the 
normal. In convalescence, at or shortly before the discharge from 
the hospital, we order a mixture of iron or arsenic, or of both, — e»g. : 

B Solution of arsenic, n\,v ; 

Citrate of iron and cinchonine, n\,v; 

Distilled water to one fluidounce. 
Three times a day after food. 

The general rules of hygiene should be laid down as in Case A. 
A renewed outbreak in an adult is generally attended with more 



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THE TREATMENT OP RHEUMATISM. 7 

marked symptoms than in a child, but endocarditis often arises and 
progresses to deterioration of the valves of the heart without signs of 
distress or discomfort to mark its course. 

We come now to the treatment of a case in which the affection of 
the joints is of subsidiary importance. 

Case C. — ^An adult, male or female, is admitted with the ordinary 
signs of acute rheumatism, and, whilst these are still painfully mani- 
fested, it is observed that the heart and pericardium are acutely 
affected. It is surprising how great a variation in the intensity of the 
subjective symptoms occurs in patients whose heart-structures are 
attacked by rheumatic inflammation. In the majority the signs of 
suffering and danger are obvious enough : a sense of distressing 
oppression is referred to the praecordium ; there is pain on pressure, 
and the patient cannot bear any incumbent weight ; the countenance 
wears a look of intense anxiety ; there is hurried, shallow breathing ; 
the patient, unable to lie down, must be supported by pillows ; there 
may be extreme restlessness; the nervous system is profoundly 
affected. In a minority the signs of suffering are very slight indeed : 
there may be no complaint of pain except that referred to the joints, 
and, especially in children, the course of events can be followed only 
by the physician who diligently, from day to day, explores the heart 
by the various methods of physical diagnosis. In some cases your 
first sign will be a to-and-fro rubbing sound ; in others, percussion 
will demonstrate an enlargement of the outline of the space occupied 
by the heart, and such enlargements may occur rapidly. If your 
percussion-note at the upper limit, the third or second left costal inter- 
space, is very dull, abruptly differentiated from the clearer percussion- 
sound above it, you have good evidence of pericardial effusion. 
Such effusion may compress the lower lobe of the left lung, so that 'at 
the back you may find, over a limited area, about the angle of the left 
scapula, dulness, bronchophony, and bronchial breathing, indications 
of a consolidation of a portion of the lung : this is a valuable con- 
firmatory sign of effusion into the pericardium. I am convinced, how- 
ever, that the rapid increases of dulness over the heart in rheumatism 
are not all due to pericardial inflammation and the effusion of fluid; 
the whole heart may become swollen and dilated, — swollen with the 
products of inflammatory exudation, dilated because of the enfeeble- 
ment of the muscle of its right and left chambers. In some cases 
this condition of swollen heart disappears without any of the friction- 
signs of pericarditis being manifested ; in fact, the heart and its serous 
membranes may pass through changes like those occurring in a joint 



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8 INTERNATIONAL CLINICS. 

inflamed thix)ugb rheumatism. These variations in the bulk of the 
heart may be observed in some cases to be considerable from day to 
day, and there may be repeated enlargement at intervals of a few days, 
just as there may be repeated swellings in the joints. (See Fig. 1.) 

When signs of pericarditis or general carditis are observed in the 
course of rheumatic fever, I advise that an ice-bag be applied over the 
prsBcordium. I have adopted this plan in such cases for more than two 
years, and I feel sure that I have had better results than under former 
measures of treatment. In practice you will find that there are many 
prejudices to be overcome, but with judicious argument you will probably 
be able to get your own way. The hatred of cold applications is 
diminishing. I advise that you apply the ice-bag directly you have 
evidence of rheumatic pericarditis or of inflammatory enlargement of 
the heart. If a properly made india-rubber ice-bag is not readily to 
be procured, use an ordinary sponge-bag three-fourths filled with 
broken ice, the upper part being folded and clamped by two strips of 
thin wood placed on each side, and tied together at each end ; the 
leakage will be very slight. Apply this over the region of the heart, 
and envelop with a soft towel, or with lint or absorbent cotton-wool. 
Probably there will be a relief of the local suffering, and the applica- 
tion will be tolerated well. In some cases the weight upon the prse- 
cordium causes discomfort ; then suspend the bag from a cradle, and 
arrange it so that it covers the surface without exerting much pressure. 
At first the application may be continuous day and night, the bag being 
emptied when the ice becomes melted, and refilled. Usually, however, 
we apply the bag for two or four hours, and remove it for like periods. 
I believe with my friend Dr. D. B. Lees, who has done valuable ser- 
vice by his paper on the treatment of pericarditis by the ice-bag (see 
BritUh Medical Journaly February 18, 1893, p. 344, and The Clinical 
Joumaly November 2, 1892, p. 4), that the introduction of this method 
of treatment will be found " a great advance in therapeutics.'' 

You observed the boy, aged ten, in Currie ward, who suffered from 
intense pericarditis with pleuritis and pneumonia, and whose heart was, 
as I showed you, greatly enlarged and swollen. For several weeks he 
was in the greatest peril, but the ice-bag treatment was kept up, and he 
has gone out practically well and strong, though there is the systolic 
murmur of mitral incompetence at the apex. We traced in this case 
not only the disappearance of the pericardial effusion, but also the 
diminution of the bulk of the heart as a whole. I cannot think, from 
my experience of such cases before the employment of the ice-bag, that 
under other treatment we should have had so good a result. 



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THE TBEATMENT OP RHEUMATISM. 9 

The question will now arise, Shall we, in cases in which the heart 
is thus inflamed^ continue our treatment by the salicylates? This is 
answered by our experience that in some cases such treatment continues 
to act beneficially, and seems in no way to interrupt the favorable 
progress to\^'ards recovery, whilst in others it tends to weaken the 
heart and to produce symptoms of cardiac failure. It is a general 
opinion among tliose who have investigated the subject, and one that 
has the support of statistics, that the treatment by the salicyl prepara- 
tions exerts no direct influence in reducing the prevalency or in miti- 
gating the intensity of the ^rheumatic inflammations of the serous 
membranes of the heart. It is by no means proved, however, that it 
has no indirect beneficial action. If it tends to reduce the pain, and 
therefore increase the comfort of the patient, it is in the highest degree 
probable that it has some favorable influence during the stage of acute 
inflammation and suffering. I have already said that there may be a 
fidlacy, and that some of the adverse symptoms ascribed to it may be 
really due to the process of disease itself. Let us take two cases in 
illustration. 

Mary Ann W. was recently admitted with well-marked signs of 
rheumatic fever, of which she had sdffered three previous attacks. She 
was prescribed the usual twenty grains of sodium salicylate every two 
hours for six doses, afterwards every four hours. After the tenth dose 
she became very delirious and extremely noisy; then followed an 
epileptiform seizure. At this time the area of prsecordial dulness was not 
notably increased, but there was evidence of old mitral incompetence, 
and some dilatation of the left ventricle. The salicylates were omitted 
directly the signs of nervous disturbance were manifested. The tem- 
perature fell to nearly the normal, and the pains in the joints all ceased 
at the end of three days ; the patient was emotional, but all delirium 
bad passed away. Now we found that the heart became acutely and 
gravely inflamed, and the area of prsecordial dulness greatly enlarged, 
80 that the maximum breadth of the dull area was six inches, and at 
the upper limit in the second left interspace the dulness was absolute : 
there was undoubtedly pericardial effusion. Whilst these signs were 
occurring, four days after the previous total cessation of pain, the 
articular symptoms returned with all their suffering. Again we 
administered the salic}'lates in the full doses, but this time none of the 
toxic symptoms were manifested, and the relief was entirely satisfac- 
tory. Again there was a return of the pains and swellings of the 
joints, and again the salicylates were administered with success. The 
signs in regard to the heart and pericardium receded most satisfao- 



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10 INTERN ATIONAX CLINICS. 

torily^ so that fourteen days after their commenoement the area of 
dulness became reduced to a maximum breadth of three and three- 
quarters inches, and there was no abrupt line of demarcation at its 
upi)er limit ; the fluid had become absorbed, and the enlargement of 
the heart — evidenced not only by a reduction of the outline as deter- 
mined by percussion, but also by recession of the right ventricle as 
shown by palpation — had become greatly reduced. We noticed, how- 
ever, a change in the endocardial murmur, which altered its area of 
audibility and became shrill and musical. It is evident that in this 
case the rheumatism, which we commenced to treat with the salicylates, 
was of extreme intensity, recurring, as it were, in successive waves, 
and involving not only the joints, but also the pericardium, the endo- 
cardium, and the heart itself. We ask ourselves how much of the 
early signs of cerebral disturbance — the delirium and convulsion — was 
due to the drug, and how much to the intensity of the disease of which 
it might have been an initial manifestation ? You will bear in mind 
that on the second and third occasions, in the course of the same 
malady, the administration of the salicylates was attended by no toxic 
symptoms, but by the usual beneficial signs. 

Take the evidence of another case, which at the commencement of 
the attack was not treated by any preparation of salicin. 

Case D. — Margaret W., aged seventeen, was admitted with signs 
which closely simulated those of typhoid fever. The patient was in a 
state of profound prostration ; sordes existed about the lips and teeth. 
There was diarrhoea, and one stool showed the presence of blood. On 
auscultating the prsecordium, I heard a distinct to-and-fro friction- 
sound. We hesitated long in determining the question whether we 
had before us the rare conjunction of enteric fever and rheumatic 
pericarditis, or whether the simulated typhoid was the expression of 
the asthenia due to the rheumatism which declared itself, contrary to* 
its usual course, first by physical signs in the pericardium and the 
heart. In this case there was subsequently evidence of great disten- 
tion of the pericardium with fluid, together with pneumonia and 
pleuritis. Ice-bags were applied over the heart-r^ion, and, though 
the symptoms were very severe,— delirium, great dyspnoea, with irreg- 
ular rhythm of respiration, much pulsation of the arteries of the neck, 
compression of the lower lobe of the left lung by the distended peri- 
cardium, and increasing pneumonia, — ^yet aftier sixteen days of treat- 
ment the physical signs showed a subsidence of the pericarditis, and 
in two days more the rub had disappeared. 

During this period our chief reliance had been upon the ice-bags, 



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THE TREATMENT OF RHEUMATISM. 11 

judiciously supporting the patient with fluid diet^ and administering 
ammonia and ether as stimulants^ and brandy in small doses. Here 
let me say that I never in cases of pericarditis in the acute stage 
administer digitalis or other analogous heart-tonics. I believe that 
more harm than good comes from such administration. Failing cardiac 
fever is best treated by diffusible stimulants, — in critical cases by musk 
in three- to five-grain doses, or by hypodermic injections of one-sixtieth 
to one-thirtieth of a grain of strychnia. 

To return to our case. Just seven days after the disappearance of 
the physical signs of pericarditis, twenty-five days after admission, the 
large joints became swollen and painftil, and a typical attack of acute 
rheumatism ensued. The usual treatment by sodium salicylate was 
now put in force, and was followed by rapid recovery. The patient 
went out practically well, but manifesting the systolic apical murmur 
of mitral insufficiency, which imperfection was nevertheless well com- 
pensated. 

Now, supposing that we had treated this patient at the first, when 
the early signs of pericarditis were manifested, by the salicylates, we 
should have been inclined to ascribe the condition of extreme prostra- 
tion — the typhoidal state — to their toxic action. None of these drugs 
were given until the phase of her rheumatism associated with the 
articular inflammation : then they were of signal service. 

To sum up concerning the treatment of acute rheumatism mani- 
fested in the joints and in the heart : I advise you to treat any case of 
acute rheumatic arthritis with the salicylates, even though there be 
concurrent signs of pericarditis, but omit the drugs and trust to the 
ice-bag with judicious support and stimulants (and when necessary 
calmatives), if there be any toxic signs or evidences of inordinate car- 
diac enfeeblement. 

I wish you now to picture to your minds another case which may 
cause you, the patient in your care^ and those who are anxious for his 
recovery, worries and perplexities akin to despair. 

Case E. — A patient, the subject of acute rheumatism with disease 
of the heart (pericarditis, endocarditis, and the associated enfeeblement 
of the myocardium), does not recover under treatment, or, if there be 
periods of temporary amendment, the morbid process is repeated again 
and again. The course is so protracted, or the disease assumes a type 
of such malignancy, that therapeutic means all seem powerless. In 
such a case you may entertain two hypotheses,— either the rheumatic 
inflammation, though of the ordinary form, is of exceptional severity, 
or else there is a superadded infection. In the latter case there is in- 



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12 



INTERNATIONAL CLINICS. 



fective, maligDant, or ulcerative endocarditis. You will suspect the 
latter if there be very high risings and low fallings of the temperature, 
with rigors, perhaps, and sweatings, and if there be repeated signs of 
embolism ; or if, even in the absence of these signs, the patient sinks 
into a low and listless state, with very feeble heart and dicrotic pulse, 
and you hear murmurs changing their site and varying in their in- 
tensity. Examples of infective endocarditis in the course of acute 
rheumatism are rare, and your first hypothesis in the event of an un- 
usually severe and protracted course of heart-symptoms is the more 
probable one. 

In such cases I have adopted a plan of treatment to which I now 
call your attention, and I shall do this by giving you two illustrative 
examples. 

A lad, aged fifteen, suffered from a severe attack of rheumatic fever 
in March, 1889. He recovered sufficiently to take a tour in Norway. 
There, at the end of August, he had a second severe attack. The 

Fig. 1. 




Diagrams showlDg the leoesBion of precordial Tlulnew, In a case of rheumatic Inflammation of 
the heart, In the space of twenty-four hours. Endocarditis mitral and aortic. 

treatment by the salicylates was followed by improvement, but a fort- 
night afterwards all the signs returned ; the heart became greatly 
enlarged, the systoles irregular and ineffectual, and murmurs, first of 
mitral regurgitation and afterwards of aortic regui^tation, became 
audible. The patient was brought to London in charge of his phy- 
sician from Norway, and for many weeks his condition was one of 
extreme gravity. There were successive enlargements of the heart, 
successive storms of inflammation. The rapidity of enlargement and 



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THE TREATMENT OP RHEUMATISM. 



13 



subsidence was on some occasions extraordinary ; the variation in a 
period of twenty-four hours was most marked on one occasion. (See 
Fig. 1.) In September there was a period of comparative calm, but in. 
October the grave signs returned, and on one occasion I was sent for 
when the patient seemed to be in extremis. The pulse-rate was 100 
per minute, the temperature at night 103^ F. We again administered 
the salicylates, but, acting upon a plan which I have adopted for many 
years in the treatment of the rapid, the irregular, or the irritable heart 
(especially in Graves's disease), I caused the constant galvanic current 
from eight cells to be administered for six minutes three times daily. 
The modes of administration of the current in cases of Graves's dis- 



Fio. 2. 




Showing Uie reeeasion ofdnlnesB in a case of pericarditis with effteslou in the space of nine days. 

ease are carefully given by Dr. H. W. D. Cardew in his communica- 
tion to the Lancet of July 4, p. 6, and July 11, 1891, p. 64, to which 
I refer you. Suffice it now to say that one electrode (the anode) — a 
flat metallic plate, covered with soft tissue, moistened with hot water — 
is applied over the nape of the neck, and the other (the cathode) — a 
metallic tissue-covered button, similarly moistened — is pressed over the 
skin of the neck outside the larynx (t.e., near the situation of the 
great nerves in the neck), or moved slowly up and down from mastoid 
process to clavicle for three minutes on each side. 

Under this treatment the patient greatly improved ; the pulse-rate 
came down to 88, 84, and 76, with little variations. He soon gained 
strength, and was able to undertake a voyage to America. He has 
since returned, and I have seen him a hearty, strong, young man with 



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14 INTERNATIONAL CLINICS. 

no adverse symptoms but the warning note of a murmur of aortic re- 
gurgitation^ this condition being at present well compensated. 

Another case has been more recently under my care in consultation 
with Dr. Douglas Lithgow. A boy, aged fourteen, suffered in April, 
1893, a severe attack of rheumatic fever, when the systolic murmur of 
mitral r^urgitation became manifested at the apex. There were re- 
peated rheumatic storms, but in September the patient had sufiBciently 
recovered to be taken to the sea-side for convalescence. There (at 
Eastbourne) he was seized with most severe symptoms of pericarditis, 
pleuritis, and pneumonia. He was brought back to London, and I 
saw him again in November. There were then great dyspnoea and 
anxiety, the heart was greatly enlarged, especially the right chambers, 
pericardial friction was very marked, and there were abundant evi- 
dences of pneumonia and pleuritis. Systolic murmurs were heard at 
the apex of the heart and at the base of the ensiform cartilage. I 
considered that both the mitral and tricuspid valves were affected by 
rheumatic endocarditis. Subcutaneous rheumatic nodules were abun- 
dant and extremely large : four were over the right elbow, three over 
the left knee, others were over the right patella and the extensor 
tendons of the right middle finger and of the left middle finger. You 
will remember that such nodules have a dangerous significance : when 
they are present there is almost always a very severe heart-rheumatism. 
Salicylates had been judiciously administered, but all drug-treatment 
seemed to be ineffectual. At the end of December we commenced 
treatment by the continuous current from four dry chloride of silver 
cells (current, two to three milliamp^res) from the nape of the neck to 
the course of the great nerves in front of the neck for six minutes, 
three times a day. At the end of a week there was very great improve- 
ment, and in a fortnight the pulse-rate had fallen from 100-120 to 
84-80, all signs of heart-distress and of dyspnoea had gone (the respi- 
ration rate being reduced from 44-40 to 20 per minute), the area of 
pericardial dulness had so greatly diminished that the left border was 
well within the nipple-line, but the right border still projected beyond 
the right edge of the sternum. The case progressed favorably from 
day to day, and good nutrition rapidly returned. 

I will theorize no more than to say that it seems to me that the 
good results which I have observed to follow the use of the continuous 
galvanic current, employed in the way I have indicated, cannot be 
fortuitous, that it is unlikely that they are due alone to an awakening 
of the vagus to a more healthy control of the heart-rhythm, and that 
it is probable that an influence for good is exerted upon the trophic 



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THE TREATMENT OF RHEUMATISM. 15 

mechanisiD of the heart I recommend you to adopt this plan of 
treatment when jou meet with similar cases of protracted rheumatic 
inflammation of the heart and its membranes. 

If from the evidence presented to you you are of opinion that 
septic endocarditis is in progress, you may conclude that the case is 
almost hopeless, — ^but not quite. In The Practitioner of August, 1886, 
I described a case of grave or septic endocarditis in which the internal 
administration of thirty-grain doses of sulphocarbolate of sodium and 
the inunction of carbolized oil was followed, after some weeks, by such 
decided improvement that the patient was eventually dischai^ed from 
the hospital practically in good health. Ten months afterwards the 
patient was readmitted with a new outbreak, which soon proved fatal, 
and in a second communication to The PrddiUoner I detailed the sub- 
sequent history of the case, and the appearances manifested post 
mortem. There was clear evidence that the former inflammation and 
ulceration of the aortic valves had been arrested, one of the sites being 
marked by a depression and loss of tissue in one of the cusps, which 
appeared as if a portion of its border had been punched out. Ex- 
uberant v^etations, crowded with micrococci, attested the new out- 
break of the disease, which was &tal before therapeutic means could 
have any power to check it. I have since had under my care cases in 
both the male and female wards in which there seemed to me good evi- 
dence that septic endocarditis was in progress, but under the protracted 
administration of half-drachm doses of sodium sulphocarbolate every 
four hours there has been improvement and even recovery. 

I have now sketched the treatment, which I consider to be sanc- 
tioned by experience, of cases of various phases of rheumatism. Before 
concluding this lecture, I will ask you to bear in mind that in some 
cases we have found that an aflTection of the joints which we have 
considered to be rheumatic has been rebellious to the salicylates. The 
suffering has continued unabated, and then there has been a concen- 
tration of the morbid signs in one or two joints, where the swelling 
and the bony enlargements have been excessive. You may suspect 
these occurrences (1) in subjects previously rheumatic, over the age of 
thirtyifive ; (2) in young subjects when the pain and swelling are mani- 
fested not only in the larger but also in the small joints, especially the 
knuckles. Then it is my opinion that you have to deal with two 
processes, — first, true rheumatism ; secondly, a non-rheumatic arthri- 
tis. The treatment of these complicated cases will claim our attention 
on a future occasion. 



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THE HAND AND TONGUE IN THE DIAGNOSIS OF 

DISEASE. 

CLINICAL LECTURB DELIYERED 1.T TBE JEFFERSON MEDICAL COLLEGE HOSPITAL. 

BY H. A. HARE, M.D., 

Profeisor of Therapeutics and Materia Medica in the Jefferson Medical College of 

Philadelphia. 



GENTLEMEN; — I propose in the hour which has been set aside for 
this lecture to discuss^ the value of the hand and tongue in the diagnosis 
of disease. Every practitioner of experience gains a large amount of 
information concerning his patient from the appearance of the various 
parts of the body which are exposed to view under ordinarj' circum- 
stancesy and is thus enabled to form some idea of the character of the 
malady before a question is asked the patient. The advantage of ob- 
taining a clue which shall put the physician on the proper track to 
discover the minute details of a man's condition is great, and often 
will impress both the patient and his friends with the belief that the 
medical man is possessed of an extraordinary amount of penetration 
and acumen. Some of my hearers may have heard several lectures 
given by the late Dr. D. Hayes Agnew upon diagnosis at sight as-the 
patient appeared in bed or walked into the office, and every one who 
has put those lessons into his practice must have been impressed with 
the force of the observations made by that great surgeon. His lectures 
were, however, directed solely to sui^ical diagnosis, and so far as I 
know there is little in literature as regards the diagnosis of general 
medical ailments by means of superficial symptoms, unless it be in that 
clever little manual of Fothei^ill upon " Aids to Diagnosis." I shall, 
therefore, attempt to bring together a number of facts in such a way 
that they shall be grouped about the parts of the body named. 

Taking into consideration the hand and the diagnostic points to 
be obtained from it, we naturally first note such common signs of dis- 
ease as oedema, or the chalky pallor indicative of sabacnte or chronic 
nephritis. If the oedema is unilateral, it may be due to lymphatic or 
other injury in the axillary r^ion, or to aneurism of the aorta. In 
16 



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THE HAND AND TONGUE IN THE DIAGN06IS OF DISEASE. 17 

such a case the entire arm will share the swellings whereas a puflSness 
of part or all of the hand may be due to angioneurotic oedema. The 
development of thickening about the joints of the fingers tells the 
story of rheumatism^ rheumatoid arthritis^ or gout, and these can often 
be separated one from the other with readiness. In the first place, the 
joint-swelling of rheumatism is more apt to involve the wrist than the 
fingers ; whereas in rheumatoid arthritis and gout the phalanges are 
the parts most affected. In the second place, the joint-changes in acute 
rheumatism are attended with swelling and heat, the swdiing being 
soft or pufiy, while that of gout is hard and resistant. During the 
acute attack the tenderness of gout is greater than that of rheuma- 
tism, and in both of these affections the tenderness is in excess of 
that manifested by the fingers of rheumatoid arthritis. Again, rheu- 
matism is characterized by accessions of pain in the part aflected, 
whereas the pain of rheumatoid arthritis is practically constant, and 
because of this characteristic is more to be dreaded, on account of the 
greater suffering it entails. It is true that this question as to the 
relative amount of pain is more subjective than objective, and may not 
be of diagnostic importance ; but pressure with the fingers on the joint 
of rheumatoid arthritis, while it develops tenderness, never causes the 
agony produced when the same pressure is exercised upon the swelling 
of acute gout or acute rheumatism. Then, too, gout affects the toes 
far more frequently than the fingers. But what are the actual differ- 
ences to be noted in the joints of the hand in rheumatism, rheumatoid 
arthritis, and gout? As already said, the truly rheumatic finger is 
inflamed, puffy, angry, and hot, while the other diseases show none of 
these changes, unless it be during an exacerbation of gout. The joint 
of rheumatoid disease is deformed by the absorption of articulating sur- 
faces with consequent dislocation partial or complete, and the abnormal 
formation is produced by this and exostoses, while that of gout is 
characterized by the deposit of large amounts of sodium urate in 
the sheaths of the joints in such profusion that immobility and de- 
formity occur from fixation as with a splint, any actual alterations in 
the articulating surfaces themselves being secondary rather than pri- 
mary. Again, rheumatoid arthritis nearly always spares the thumbs, 
while gout oft;en affects them. 

An important &et to be remembered, however, is that the deflec- 
tion of the fingers of rheumatoid arthritis and gout may be equally 
great, but that in the one case the enlargement of the articulation is 
not excessive, whereas in the other the excessive deposits produce 
still greater deformity. 
Vol. I. Ser. 4—2 



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18 INTERNATIONAL CLINICS. 

In rheumatism there never occurs a deposit of chalk-stones in the 
joints. In gout the backs of the hands may be scratched^ from the 
itching of the skin produced by that diathesis. 

Leaving these points, we find the characteristic clubbed fingers of 
the victim of pulmonary disease (phthisis or emphysema) or cardiac 
lesion in early life, while the blue finger-nails, more constant in chil- 
dren than in adults, direct the ear of the physician to the prsecordium 
to discover cardiac diflSculty. Closely associated with this clubbing 
of the finger-tips are the enlarged joints with the thin bone shafts 
between the joints, indicating a tendency to struma. In rickety chil- 
dren near puberty this is particularly well marked. Again, in pul- 
monary tuberculosis the wasting or hollow interosseous spaces on the 
back of the hand may prove of value in discovering the cause of the 
illness, while the claw-like fingers, with dried and shrivelled nails, may 
indicate diabetes, particularly if the skin is dry and hai^sh. 

The nails not only appear lustreless, dry, and ridged perpendicu- 
larly in diabetes, but are often the best evidence of gouty taint in 
their striation, or in the white spots which dot them ; but, as Hutchin- 
son has shown, these spots also occur in children who injure the base 
of the nail by picking at it. 

Again, Fotheigill states that in some cases of jaundice stretching 
the skin on the back of the hand will show the characteristic yellowing 
which may not show elsewhere. The cold, clammy hand is thought by 
some to be a pathognomonic sign of masturbation, particularly in 
girls, and the clumsy, loosely-jointed, puffy or woolly hand is generally 
found in persons of feeble mental power. In some cases of phthisis 
the nails are arched from side to side till they seem like claws, and in 
nervous disease due to injury and resulting in trophic disturbance the 
nails may become incur vated or may fall. 

Other signs attached to the hand are tremor and contraction. 
Tremor of the hand may indicate paralysis agitans, general paresis, 
mercurial, plumbic, or alcoholic poisoning, hysteria, senility, Graves's 
disease, chorea, both ordinary and post-apoplectic, athetosis, and dis- 
seminated sclerosis. How shall we separate these states of tremor in 
the hand in order to reach any point of diagnostic value ? 

In paralysis agitans the whole hand is involved, and generally both 
hands are equally affected. The tremor is rhythmical and fine or 
minute in character. The tremor is a slow one, say five vibrations 
per second. It is more or less constant, and worse when attention is 
called to it, but it is not greatly increased, and perhaps is even de- 
creased, by a voluntary act, such as an attempt to raise a glass of 



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THE HAND AND TONGUE IN THE DIAGNOSIS OP DISEASE. 19 

water. The fingers are generally semi-extended, and the thumb is 
adductedy so that it constantly rubs the index finger with its pulp as 
if it were attempting to rub off the skin of that member. Frequently 
there is pain and aching of the extensor muscles of the forearm and 
wrist from the constant exertion* The tremors of disseminated 
sclerosis are also slow, but coarse in character. They are not constant, 
but are developed upon intentional movement, and have a greater 
amplitude than those of Parkinson's disease. Often threading a needle 
will be possible in such persons, because it is a short act, while lifting 
a glass of water will be impossible. The tremor of mercurial, plumbic, 
and alcoholic poisoning resembles that of paralysis agitans, save that 
it is more rapid, reaching nine or ten vibrations per second, and in the 
case of alcoholic tremor is decreased by a large drink of liquor, while 
those due to lead and mercury are rapidly relieved by potassium 
iodide. Further than this, the tremor of alcoholism is generally 
worse in the morning. The tremor of general paresis is also rapid, 
eight to nine per second, and is a very fine tremor, which may be felt 
only when the arm is extended and the fingers rested on the hand of 
the physician. The tremor of the hand of general paresis is generally 
not a predominant symptom, but is elicited when the muscles are put 
upon a strain. In regard to the fineness of the tremor of general 
paresis, it should be remembered that it closely resembles that of Base- 
dow's or Graves's disease, since the tremor of this condition is not only 
equally fine, but generally unseen except when the arm is extended and 
the tips of the fingers rested upon the fingers of the doctor. This tre- 
mor has been called the ^^ railroad bridge tremor,'' because of its fine- 
ness and vibratory character. The individual fingers do not separately 
tremble in Graves's disease. 

Beyond the state of tremor should be recalled the movements of 
chorea, which may be limited to one arm or hand, and which in their 
milder forms may be confused with the pronounced movements pro- 
duced by effort in disseminated sclerosis. The latter are often very 
arhythmical, and so the choreic movement the more closely resembles 
them ; but those of sclerosis are purposive, while those of chorea are 
not, since the movement contemplated in chorea is opposed by a con- 
tradictory contraction. Athetosis consists of movements in which there 
16 no rest, and the movements are incoordinated, as in chorea. On the 
other hand, athetosis is separable from chorea in that the movements 
are slower and limited to the fingers and wrists, the arm escaping. 

There remain three other important diagnostic possibilities in the 
band. The first of these is manifested in dactylitis due to syphilis, 



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20 INTERNATIONAL CLINICS. 

or some eruption characteristic of this disease ; the second in the 
ulcerated bases of the finger-nails with ecchymotic spots on the skin 
produced by the chloral habit ; and the third is the sign which tells us 
of the occupation of the patient^ — ^the smooth^ soft hand of the pro- 
fessional man or clerk, the homy hand of the laborer, or the blackened 
nails and skin of the machinist, or the blue-black dottings of the hand 
of the miner. 

Passing from the hand to the tongue, what are the diagnostic facts 
to be obtained from an examination of this organ ? They group them- 
selves, such as they are, about the character of the coating of the tongue, 
the general appearance, and the movements of the muscles governing 
it Let us see whether the coating is really of much diagnostic value 
beyond telling us that digestion is deranged. 

Before doing this, however, let us endeavor to have a clear idea 
of the condition of the mucous membrane of the tongue which un- 
derlies such changes. Probably the best study of this question, both 
clinically aud microscopically, is that of Dickinson, of London, with 
whose paper many of you are familiar. Very briefly stated, he 
finds that there may be a coated tongue in health as well as in disease, 
but that this tongue when it is coated is covered by a growth of the 
papillse which may be slightly excessive, and each papilla is capped 
with a minute white patch which consists chiefly of horny epithelium. 
Several of these white-capped papillae now coalesce and form what 
Dickinson calls a stippled or dotted tongue. When the coalescence 
of many takes place, an even coating is developed, which consists not 
only of the white-capped papillae, but also of free epithelium and other 
detritus which fills in the interspaces between the papillse. When this 
coating becomes so heavy that the papillsB or other objects are flush 
with the adventitious matter, or, in other words, when the cast-ofl* 
epithelial cells cover all objects, as snow levels the landscape, we have 
developed what Dickinson has called the plastered tongue. Again, we 
have what may be called the furred tongue, in which, as shown by the 
author just quoted, the papillse are elongated, and yet remain to some 
extent separated from one another so as to give a shaggy appearance. 
Last of all, these various degrees of coating may, as a result of mouth- 
breathing, fever, or lack of salivary secretion, become incrusted or dried, 
and in drying become brown or blackish. B^inning at this, the worst 
stage of coating, and going towards the conditions of denudation or 
nakedness of the tongue, which in many cases is more indicative of 
disease than the coating itself, we find that the process consists of a 
drying and therefore brittle state of the coat, which breaks or wears off. 



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THE HAND AND TONGUE IN THE DIAGNOSIS OP DISEASE. 21 

leaving a dry, translucent membrane vhich may look raw. If this 
surfiioe is moist, this change is favorable ; if dry, it may be quite the 
contrary. The membrane which is now present rapidly develops an 
epithelial covering, or, if the case is desperate, becomes dried, cracked, 
fissured, and bleeding. In other words, the process is one characterized 
by the infiltration of leucocytes, just as would occur in the true skin when 
denuded of its epidermis and exposed so as to become dry and harsh. 
Such a tongue is &r more indicative of grave disease than that coated 
with the heaviest coating, and is generally associated with some great 
drain upon vitality, as dysentery, particularly with hepatic abscess, or 
sloughing wounds. For this reason, therefore, we find this tongue is a 
symptom of prolonged disease, such as advanced tuberculosis (parrot 
tongue). The development of this state of the tongue is dependent 
upon deficient moisture associated with fiiilure of the growth of new 
epithelium and papillse, which is partly due to the deficient salivary 
secretion, and partly to great systemic depression, so that the r^ner- 
ation of all cells is almost impossible. The general indications of 
coating of the tongue,^ when sufficiently marked to be indicative of 
anything, are that through mouth-breathing micrococci and dust add 
to the dead epithelium already rapidly being cast ofi^, and the failure 
of the patient to move his tongue as actively as in health, either in 
speaking or in eating, results in an overgrowth of the papillse which are 
not worn down. The greater the depression of the geneitd system, 
the more wide-spread the death of the epithelial cells and the less the 
efibrt to dislodge them from the mouth either by swallowing saliva or 
by expectoration. So also the advance of an exhausting disease results 
in month-breathing, which dries the already coated tongue. 

Having considered the general indications of the coated and bared 
tongue, does this organ offer us any more definite information in rela- 
tion to individual disease? Every one with experience will say that 
it does. 

There is no doubt that the tongue of enteric fever is most charac- 
teristic in the adult, though of little value comparatively in the child. 
In the earlier stages, the glazed sui*face and bright red edges give at 
least a hint as to the malady, and in the second the heavy coating is 
almost rugose in appearance, brown or black, but leaving the centre 
comparatively bare, while the edges remain red and beefy-looking. In 
catarrh of the stomach or bowels in children two appearances of 
the tongue are characteristic, the one of acute disorder, the other of 
the more chronic form represented by general catarrh and called by 
Eustace Smith " mucous disease.'* In the first variety the tongue is 



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22 INTERNATIONAL CLINICS. 

generally a little dry and faintly coated over ; on its anterior surfiu"^ 
are distributed minute red points (enlarged papillse). In the second 
class the tongue^ still lightly coated^ has over its surface patches denuded 
of epithelium^ red and shining, or, as some one has expressed it, looks 
as if it had been worm-eaten. This is a process of denudation in 
localized areas due to some change in the nutrition of the mucous 
membrane characteristic of the disease. The tongue of scarlatina is 
often called the " strawberry tongue," because the enlarged and red 
papillse show over the generally red surface of mucous membrane even 
more markedly than the red of that membrane itself. 

What is the relation of the tongue to disorders of the digestive 
apparatus? There is no doubt whatever that Dickinson is in error 
when he is inclined to refer to imagination or erroneous belief in the 
relationship of cause and effect the differences in the tongue ascribed by 
physicians to digestive disorder. The heavily coated yellow tongue 
of the bilious is too well known to be disregarded, and, while we may 
not be able to define the causes which produce it, it still remains an 
undeniable indication for a cholagogue. Fothergill asserts that this 
color and taste are due to taurix^holic acid eliminated by the saliva, 
and, as the salivary glands act as such powerful eliminators, it is probable 
that other substances are at times set free in the mouth which directly 
or indirectly produce coating. Often in unilateral coating the trouble 
lies with a decayed tooth, the secretions from which cause a change in 
the epithelial cells near by. Similarly the color of the coating of the 
tongue may tell us what medicine, food, or drink the patient has been 
taking, as, for example, the black tongue of iron or bismuth, or the 
brown tongue of liquorice. 

So far as coating is concerned, the error of obsei^vation generally 
lies in examining the tip of the tongue, when in reality the back portion 
is heavily coated. 

We have still to consider the diagnostic value of the general ap- 
pearance of the tongue, and the way in which the organ is extended or 
retracted. Among the imj>ortant signs to be noted are scars of old or 
recent bites due to epileptic attacks, and these scars in those who are 
subject to fits are of importance diagnostically, since they serve to sepa- 
rate the attacks from those of hystero-epilepsy, in which the tongue is 
never bitten. The presence of a small ulcer may indicate a chancre of 
the tongue or a b^inning epithelioma. A somewhat smooth tongue, 
superficially fissured, is believed by Fothergill to indicate a person ad- 
dicted to the use of very hot tea, and the broad, flabby tongue marked 
all along the edges by the impression of the teeth is about as clear an 



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THE HAND AND TONGUE IN THE DIAGNOSIS OP DISEASE. 23 

evidence of general debility and atony of the digestive apparatus as it 
is possible to find. The color of the tongue often gives us a fair idea 
of the degree of ansemia from which a patient may be suffering. 

The movements of the tongue have as great significance as the coat- 
ing, if not even greater. Aside from the slow protrusion of the de- 
bilitated and the sudden extrusion of the nervous and excitable^ its 
movement tells us of conditions of the nervous system. Every one is 
familiar with the slowly protruded^ trembling tongue of advanced ty- 
phoid, which, when once out of the mouth, is apt to remain there till the 
physician repeatedly orders its return to the mouth. If the nervous 
symptoms of enteric fever are marked, the characteristic fine tremor of 
the tongue is notable, particularly when the effort is made to move the 
organ. While the order for showing the tongue needs to be repeated 
frequently in diseases associated with hebetude, it is a curious fisu^ 
that patients will often obey this command when so deeply comatose as 
to be incapable of any other form of obedience. In apoplexy the 
tongue is of course protruded towards the paralyzed side, and in glosso- 
labio-pharyngeal paralysis the tongue affords one of the earliest of the 
symptoms, in that its clumsy movements call the patient's attention to 
his condition chiefly through failure of the lingual sounds in speech. 
Later in this affection the tongue shows marked atrophy, which may 
be manifested by a fissured shrivelled appearance, or by local areas of 
marked atrophy along its edges, giving it a crenated appearance. The 
size of the tongue is also notably decreased to the eye and touch, and 
on the mouth being well opened the organ is seen to be affected by 
fibrillary tremors. If the patient be asked to remove a piece of food 
from between the cheek and the gum by means of the tongue, he will 
do it clumsily or not at all. Frequently severe bites of the tongue 
occur, showing the lack of power in the patient to keep it out of the 
way of the teeth. This loss of power of the tongue is also seen in 
rare cases of tabes and progressive muscular atrophy. 

While the tongue in true paralysis is always protruded towards the 
paralyzed side, in hysteria it is always protruded towards the well side. 

It is of interest to remember that, in multiple foci of cerebral soft- 
ening, where the lesion occurs in the cortico-muscular tract containing 
the fibres supplying the tongue, while the tongue may be paralyzed, it 
does not atrophy, as it does in glosso-labio-laryngeal paralysis. 

Sudden loss of power of the tongue indicates acute paralysis due 
to hemorrhage or embolism or thrombosis of the basilar artery. 
Again, there may be rapid loss of power in the tongue from acute 
bulbar inflammation, in which case the loss of power is not so rapid as 



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24 INTERNATIONAL CLINICS. 

in hemorrhage or embolism, but is more rapid than in glosso-labio- 
laryngeal paralysis. Compression of the medulla from tumors, aneu- 
rism, or bone disease may also produce paralysis of the, tongue. 

I shall not speak of the eruptions of the tongue closely allied to 
those of the skin, as, for example, herpes, though they have great 
diagnostic value in r^ard to other diseases, but shall finally call your 
attention to the small, wizened, contittcted, red, and irritable tongue of 
acute peritonitis, and to the ulcer of the frsenum in children which 
occurs in some cases of whooping-cough. 

In lesions of the nucleus of the hypoglossus the tongue is found to 
be affected with hemiatrophy, and to be subject to fibrillary tremblings. 
The appearance of the affected side of the tongue is like that of tiie 
entire organ in glosso-labio-laryngeal paralysis. Protrusion of the 
tongue is fairly well performed through the vicarious action of the 
normal half. 

Sometimes post-apoplectic diorea manifests itself in the tongue, and 
a tremor of this organ is also seen in general paresis when the patient 
attempts to speak. 



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THE CONDITION OF THE HEART IN MITRAL 
INSUFFICIENCY AND IN CHLOROSIS. 

CLINICAL LECTURK DKLIYXBED IIT THE CHABITi H08PITAT. 

BY PROFESSOR CARL VON NOORDEN, M.D., 
Berlin, Qennany. 



Gentlemen, — I bring before you to-day two cases which we will 
study with the purpose of ascertaining an exact knowledge of the con- 
dition of their hearts. You will then be convinced that the symptoms 
of disease which we find in the hearts and in many other parts of the 
circulatory systems of both patients bear an extraordinary resemblance 
to ^ach other, so that a careless examination and a superficial recog- 
nition of the accompanying circumstances would lead one to diagnose 
both cases as the same disease. A closer study of the two cases will 
show you that they are quite different. 

Allow me in the first place to consider a little the previous history 
of these patients. 

Case I. — Let us first take the case of Fraulein D. The girl is 
seventeen years old. Her parents are living and healthy, as are, also, 
her two brothers ; one sister suffers from chlorosis. She herself in 
childhood had measles and whooping-cough, and was then perfectly 
healthy until her fourteenth year, when menstruation began, which 
was generally accompanied by pain, so that the patient was confined to 
her bed during the first two days of her sickness. At fifteen she had 
articular rheumatism, which was, however, slight, and in three weeks 
her health was fully r^ained. Last year, while the patient was a 
salesw(nnan, she had influenza ; the attack, however, was slight, and 
was over in ^hree days. It was at that time that I first saw the patient 
and examined her. Because of her history of former articular rheu- 
matism, I examined her heart with particular attention, and I can affirm 
that at that time the size of this viscus and the heart-sounds were per- 
fectly normal. A few weeks later, when she had occasion to consult 
me r^arding an acne of the face and neck, I found the condition the 

25 



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26 INTERNATIONAL CLINICS. 

same. I am thus Id a position to state that there was not, as a sequela 
of the articular rheumatism or influenza, a lesion of the heart About 
ten weeks ago the usual symptoms of chlorosis began to show themselves 
in this hitherto apparently healthy girl, — ^paleness of the hands and of 
the mucous membranes, weakness, sleepiness, giddiness, twitching of the 
eyelids, palpitation of the heart, shortness of breath on going up-stairs, 
and paucity of menstniation. In the first weeks of the trouble she took 
Bland's pills ; later there was no treatment. At present her condition 
is ansemic. You see before you a very pale girl, whose external ap- 
pearance gives you the impression of a chlorotic patient. Her blood 
is thin. The number of the red corpuscles in a cubic millimetre is three 
million eight hundred thousand ; the amount of haemoglobin is about 
7.70 grammes, or a little more than one-half of the normal amount. 
The urine is plentiful (eighteen hundred to twenty-two hundred 
cubic centimetres per diem), fi*ee from albumin and sugar, and very 
pale, as is generally the case in chlorosis. The condition of the circu- 
lation will be spoken of later. In general the most careful examina- 
tion has been unable to detect any disease of the viscera. 

Case II. — Fraulein G. The girl is nineteen years of age. Her 
&ther is alive, and is healthy. Her mother died in childbirth. 
She has no sisters or brothers. As a child, she had measles, scarlet 
fever, and diphtheria. She has since been well. She was brought up 
in straitened circumstances. Her menstruation began in her thir- 
teenth year, and was r^ular. Later, she had articular rheumatism, 
and was five weeks in the hospital of her native town. At that time 
she was told that she had a heart-lesion as a result of the articular 
rheumatism ; nevertheless, she has never had subjective symptoms 
which could in the least be referred to such a condition of the heart. 
Soon after her recovery from the rheumatism her surroundings became 
improved, inasmuch as she obtained a situation in a family where her 
work made few demands upon her bodily strength. She tells us that 
here she became much stronger, and in fact you see before you a 
person of healthy appearance of whom you would not suspect that she 
had had to struggle with hunger and misery. She affirms, further, that 
she has at present no trouble with palpitation or breathlessness, and 
that it is only when she climbs a high stair that she feels any difficulty. 
I emphasize this the more, as the existence of a heart-lesion is well 
known. I shall speak later of the circulatory system. The other 
viscera are healthy. The patient was sent to us on account of a slight 
angina follicularis, which a two-days' treatment entirely relieved. 

It will be our purpose to apply ourselves to the study of the circu- 



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THE HEABT IN MITRAL INSUFFICIENCY AND IN CHLOROSIS. 27 

latory system of these two girls, and especially the condition of the 
heart. You will see that the differential diagnosis presupposes a very 
exact examination and careiiil consideration. We have now before us 
a question that is of practical value and often arises. How shall we 
determine whether the chlorotic girl (Case I.) is an example of hesy^t- 
lesion or not? The second case serves as a comparison. 

The Condition of the Circulatory Apparatus in Case IL (Mitral 
Inrnffideney) ; Condition of the Thorax. — I will next speak to you con- 
cerning the symptoms which are found by the objective examination. 
The thorax is normally formed, of average depth and width. It is 
necessary to recognize this, as a too wide or a too narrow thorax gives 
rise to a deviation of the apex-beat and heart^lulness, which must be 
considered. The apex-beat of the heart is perceptible over the sixth 
rib, in an area greater than normal ; it reaches to the left one and a half 
centimetres beyond the nipple-line. At the point of the apex-beat a 
forcible systolic upheaval of the intercostal space is felt. There is, 
however, no murmur to be detected, even when the patient sits up or 
lies upon the left side. 

The CUmire of the Valves of the Pulmonary Arteries. — In other parts 
of the thorax is discovered a heart's action that does not contradict this 
opinion. The examination of the second left intercostal space gives a 
positive murmur. Then there is felt, one centimetre from the left 
sternal border, a short, sharp, deep-seated and well-defined impulse, 
which recurs rhythmically and is most clearly heard on ftill expira- 
tion. 

The comparison of the time of the impulse with that of the carotid 
artery shows that the two alternate, and that the impulse is diastolic, 
and there can be no doubt that it is produced by the recoil of the blood 
against the pulmonary valves. 

Diagnostic Conclusions. — From these inspections and palpations it 
IS possible to draw very correct conclusions. At the same time it is 
necessary to be certain that the lungs are sound, as they are in this 
case. The outline of the lungs is normal ; they extend in front on 
the right side to the sixth rib, on the left from over the sternum to 
the fourth rib. Over all respiration and vesicular murmur are normal. 
There is nothing abnormal in their position over the heart. 

We learn from these conditions, and from the position and condi- 
tion of the apex-beat, that there is a dilatation of the left ventricle ; 
perhaps, also, an unimportant hypertrophy of the muscular wall. 
Further, we learn from palpation over the pulmonary orifices that an 
increased rebound of the blood-current occurs over these valves. We 



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28 INTERNATIONAL CLINICS. 

conclude from this with certainty that there is an increased i^esistance 
in the palmonary circulatory system, together with increased functional 
power and hypertrophy of the right ventricle. 



Pio. 1. 




1^ 

Areas of cardiac and hepatic dulnees in a case of mitral insufficiency (Case II.). 

The Cardiac Dvlness. — Percussion confirms our assertion that the 
cardiac dulness extends faither than usual to the left (Fig. 1) ; it reaches 
to the nipple-line ; but not so the apex of the heart. The apex is nor- 
mally covered by the lungs. Concerning the heart-dulness, we find that 
it extends nearly to the middle of the sternum, a little to the left of the 
middle line. Of course we do not expect to determine definitely from 
the percussion a diagnosis of the hypertrophy of the right heart. Unless 
the muscular structure of the heart wall is thicker by one and a half to 
two millimetres, that hypertrophy, as shown by the portion pressing 
against the thorax wall, will not be discernible. It is a different ques- 
tion when we consider if we can diagnose a ventricular dilatation that 
overlaps the left sternal border. I must here warn you that in many 
women you cannot draw this conclusion, as very oft:en the heart-dulness 
is not exactly in the left sternal border, but reaches a little farther to 
the right. We cannot carry our diagnosis by percussion further than 
that by inspection and palpation. 

AuacuUaiion of the Heart. — Auscultation of the apex gives a loud 
systolic smooth murmur. The second sound is clear. In the second 
intercostal space to the left of the sternum we find a loud smooth sys- 
tolic murmur, combined with a loud rattling second sound. In the 
right second intercostal space, pure sounds are heard ; the second sound 



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THE HEART IN MITRAL INSUFFICIENCY AND IN CHLOROSIS. 29 

is softer than at the pulmonary artery. Over the orifice of the tri- 
cuspid valves we hear two pure sounds. The second tone is more 
accentuated than the first. When we tabulate these phenomena in 
our usual method we get the following chart : 



A. 



P. 



T. 



mil 



Diagnoms, — ^The localization of the murmur over the apex and 
over the left auricle of the heart proves an insufficiency of the mitral 
valves. The intensification of the pulmonary sounds at the place of 
their origin and over the right ventricle confirms the diagnosis (tri- 
cuspid orifice). So, without researdi, except by the ordinary methods, 
we have established the diagnosis of mitral insufficiency. 

Condition of the Puke. — Let us now look at the general condition 
of the circulatory system. We find a medium full pulse, with eighty- 
two beats to the minute and r^ular. By compression of the artery 



Fio. 2. 




one feels a second impulse, for the detection of which practice is re- 
quired. The accompanying sphygmogram makes clearer this conclu- 
sion that we have to deal with a dicrotic pulse. 

AusculUiiion of the Arteries. — Over the carotid artery we hear two 
clear tones; on the crural artery a soft diastolic sound. Over the 
jugular and cniral veins there is nothing perceptibly abnormal. 

Case I. — Tfie EeaminatUm of the Circulation in the PoMerU D. 
{(yUorosia). — ^We will now compare with this case of mitral insuffi- 
ciency another case of chlorosis. We perceive at once that we have 
to do with a chlorotic girl. We will now study her case. You will 



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30 INTERNATIONAL CLINICS. 

see that the examination will bring us to oonclusions similar to those 
arrived at in the other patient. A few slight differences, however, are 
perceptible, which are generally overlooked, but which are very essen- 
tial to the diagnosis. Proceeding in a method similar to that adopted 
in studying the last patient, I shall examine with you each separate 
symptom; later we will study simultaneously the symptoms of the 
two patients and compare them. 

Condition of the Thorax; Frequency of the Breathing, — The thorax 
is normal in form, as strongly made as in the other case, and as wide. 
The breathing is increased in frequency, twenty-eight to thirty per 
minute. This high rate is due, in part, to the physiological excite- 
ment which the examination causes. Besides, we find, on the chait 
where we record the pulse, temperature, and respiration, a frequency of 
respiration of twenty-two to twenty-four per minute. As the normal 
respiration in healthy women is from seventeen to twenty per minute, 
we must conclude that this rate is above normal. 

The Pvlmonary Area is larger than normal : its boundaries are, on 
the right, the parasternal line, on the upper border of the fifth rib ; on 
the left side, the sternum, at the level of the third costal cartilage. 
There is full resonance, with vesicular breathing over the entire lung. 

The Apex-Beat — The heart's action shows its presence in the 
fourth intercostal space, immediately over the fifth rib. There we see 
a rhythmical impulse which is one and one-half centimetres outside of 
the nipple-line. On palpation one feels a strong action of the apex, 
as if directly under the finger, moving backward and forward. 

PuUaiwn of the Pulmonary Artery. — Besides this one sees a rhyth- 
mical motion in the second left intercostal space, just outside the ster- 
num, and towards the left, two to two and one-half centimetres wide. 
The intercostal space is upheaved during systole, and depressed during 
diastole. These movements are plainer during expiration than in in- 
spiration, though then they are not entirely lost ; when, however, the 
patient takes a deep inspiration and holds it for a short time, they are 
imperceptible. If the finger is laid upon the point an impulse like a 
shallow wave is felt during the systole of the heart, and if the finger 
remains there during diastole this is felt to disappear. A perfect, well- 
marked systolic impulse which is synchronous with the apex-beat or 
the peripheral arterial pulse is not felt. So, during diastole, an im- 
pulse with as sudden a banning and as sudden an ending is per- 
ceptible, which shows, when present, a return impulse against the 
pulmonary valves. Finally, there is in the thorax no perceptible 
movement that can be connected with the heart's action. 



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THE HEART IN MITRAL INSUFFICIENCY AND IN CHLOROSIS. 31 

The Hearfs Dulneaa. — Percussion gives absolute dulness, extend- 
ing from the level of the third costal cartilage towards the lefl in a 
shallow curve and thence downward to the apex. Over the apex we 
find, likewise, a dull sound. Outside of the apex-impulse there is, 



Fio. 8. 




Areai of cardiac and hepatic dolnew in a case of chlorosis (Case I.). 

about half a centimetre away, a clear percussion-sound. On the right 
side the percussion dulness extends diagonally across the sternum, in 
order to reach the junction of the fifth rib with the right sternal border. 
It is possible to establish by percussion that the heart extends well to 
the left, and particularly that it reaches farther than the left lobe of 
the liver (Fig. 3) ; the lower heart border is also easily mapped out. 
We find that at the junction of the upper border of the fifth rib with 
Uie nipple-line on the left the dull percussion-note is changed into a 
loud, deep tympanitic sound. 

AvscuUation of the Heart. — Auscultation gives the following. Over 



A. P. 

nil I I 

- " mill- 

T. M. 

Ill' 



the apex-beat is heard a loud systolic murmur which conceals com- 
pletely the first sound ; the second sound is clear. In the second left 



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32 INTERNATIONAL OLINIOS. 

intercostal space is a loud systolic soand ; the second soand is pure. 
Id the second right intercostal space is a loud systolic sound ; the first 
sound is scarcely to be heard^ the second one is clear. It is note- 
worthy that the systolic and diastolic sound phenomena are distinctly 
lower than in the pulmonary area. Over the tricuspid orifices is a soft 
systolic murmur, almost as strong as over the aorta. The first sound 
can be heard with it ; the second one is clear^ but is markedly softer 
than over the apex. 

AiLSCuUaUon of the Blood- Vessels gives over the right and left, caro- 
tids two clear tones. Over the bulbus wensd jugularis is heard a strong 
venous souffle, stronger on the right than on the left. The souffle is 
also to be heard when the patient stretches her head forward. Over 
both arteriffi crurales, by a lightly-applied stethoscope, an uncommonly 
perceptible double tone can be heard. The radial pulse is r^ular, 
eighty to the minute^ of medium fulness, though perhaps a little ftiUer 

Fio. 4. 




than normal ; the artery is soft. The artery swells out and contracts 
quickly ; there follows a second small wave, and one can thus with t|ie 
finger make the diagnosis of the dicrotic condition of the pulse. The 
sphygmogram shows the dicrotic condition of the pulse even better. 

Diagnosis. — We have now collected the material upon which we 
can establish a diagnosis of the condition of the heart. I will give 
you my diagnosis immediately, and then endeavor to confirm it. 

Diagnosis, chlorosis : retraction of the lung, with elevation of the 
diaphragm ; anaemic heart and heemic or functional murmur. 

Analysis .of the Symptoms and Confirmation of the Diagnosis. — Is 
the heart enlarged ? By the examination of the heart we recognize the 
fact that the heart presents a larger area of dulness on the thoracic wall 
than normal. Tlie very important question then arises. Is the' cause 
of this the enlargement of the heart or the contraction of the lung? 
If the first were the case, a serious condition of the heart would have 
to be admitted. 



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THE HEART IN MITRAL INSUFFICIENCY AND IN CHLOROSIS. 33 

The Elevation of the Diaphragm. — But we find here a condition 
which makes it plain that in our patient the heart-dulness is increased 
without any hypertrophy of the heart itself. We find, namely, an 
elevation of the diaphragm. We find in both sides of the thorax 
the explanation of this symptom. We have shown that the lung is 
one intercostal space and one rib too high, the liver-dulness on the 
right side being in the parasternal and nipple lines, at the upper bor- 
der of the fifth rib. On the left side, instead of mriting with the 
tympanitic sound of the stomach at the seventh rib, the clear lung 
tympanitic note is found in the fifth intercostal space, except in the 
r^on of the heart. Besides, we find the apex-beat one intercostal 
space too high. There can be no doubt, therefore, that the diaphragm 
is elevated. 

Cause of the Elevation of the Diaphroffm. — To account for this ele- 
vation, our attention is first directed to the condition of the abdomen. 
There is no particular distention : its conformation is normal. The ten- 
sion of the abdomen is not increased, as is readily seen by laying on 
the hand. The cause of the elevation of the diaphragm must be sought 
for in another source. There is no reason to believe that there is an 
enlargement of the upper part of the liver, as is seen in certain diseases 
of that organ, as abscess or echinococcus. Contraction of the lung re- 
sulting from fibroid thickening aftier old inflammatory processes is not 
present, nor is adhesive pleuritis. The existence of a loud percussion- 
note and vesicular breathing over both lungs testifies to their condition. 
In the deep inspiration which we now ask the patient to take, the lung 
and the border of the liver on the right recede to the upper border of 
th^ seventh rib, — ^that is, two ribs lower, — and on the left the heart- 
dulnesQ becomes as small as in the healthy person under the same cir- 
cumstances. The lungs have, therefore, thoroughly proved their power 
of expansion. When the lungs are apparently abnormally contracted 
and the diaphragm is drawn correspondingly fitrther upward, and yet 
both are normal, we can explain the condition only as the result of an 
abnormal type of respiration. In fact, this type of respiration has 
been observed in many cases of chlorosis, — a somewhat quickened but 
superficial breathing, — and it is reasonable to expect that the lung, by 
a long continuation of this form of breathing, will become retracted, 
which condition, naturally, can be detected only by an examination of 
the border of the lung. You will find this superficial breathing in all 
cases of severe chlorosis, especially where the patient has lain in bed 
for a long time. When the patient, on the other hand, has not been 
confined to bed, this condition will be less frequently found. You 
Vol. I. Ser. 4.-8 



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34 INTERNATIONAL CLINICS, 

will find, if you give your attention to this detail, that the elevation 
of the diaphragm disappears as the patient grows better. 

The Influence of an Elevated Diaphragm upon the Position of the 
Heart. — As soon as we discover the high position of the diaphragm 
we can explain the increased heart-dulness and the outward displacement 
of the apex-beat. You find in all books on physical diagnosis that 
the heart is more closely pressed to the anterior thoracic wall. In most 
cases where an elevation of the diaphragm exists it is caused by a 
pressing up of the contents of the abdomen, as in pregnancy, tym- 
panites, or ascites. The same anatomical condition must be produced 
by insufficiently deep inspiration in the thorax, with shrinking of the 
lung, as is seen in our patient. Retraction of the borders of the lung 
and the high position of the diaphragm explain the form and extent 
of the heart-dulness. These conditions are here, widening out to 
right and left, and an elevation of the upper border (third rib instead 
of fourth). 

Further, the position of the apex-beat to the left is explained by 
the fiict that the base of the pericardium, which is found by the aver- 
age from the examination of many cases to rest upon the diaphragm, 
would be carried upward only a little, since the middle portion of the 
diaphragm, held down as it is by its close connection with the vascular 
trunks, would be less movable than the lateral portions. The move- 
ment of the heart by the raising of the diaphragm must, therefore, be 
greatest at the point farthest removed from the middle ; that is, at 
the apex. The heart would be rotated on an axis which is antero- 
posterior, the apex describing an arc which is not only from below up- 
ward, but also from within outward. We find, when we have diagnosed 
the condition produced by an elevation of the diaphragm and the 
displacement of tlie apex towards the left, even as little change from 
the dilatation and hypertrophy of the left ventricle as is found in 
pregnancy. 

Evidently the rotation of the heart upon an antero-posterior axis, 
through the elevation of the diaphragm, is not the only alteration in 
position which the heart makes. It has already been shown that the 
heart leans strongly forward. The cause of this forward movement is 
explained by the greater bending of the left portion of the diaphragm 
during its change of form than of the right portion, and its consequent 
action upon the lieart. The greater pressure is from behind and to the 
left, so that the heart is also rotated a little upon its long axis. The 
portion that extends outward towards the left would be pressed forward ; 
that is, the apex, the anterior border of the left ventricle, a portion of 



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THE HEART IN MITRAL INSUFFICIENCY AND IN CHLOROSIS. 35 

the left auricle^ the orifice of the arteria pulmonalis, and the arteria 
pulmonalis itself. Because of this we find an exceedingly strong apex- 
beat. The apex is here entirely free from lung ; and^ besides^ we find 
a full and easily-felt pulsation of the pulmonary artery. The portion 
of lung that lies between the pulmonary artery and the thoracic wall 
is thinner than normal. A careful examination of this spot shows a 
distinct upheaval and sinking of the intercostal space. On the other 
band, every short diastolic action which the movement of the pulmo- 
nary valves makes cannot be perceived. This is a noteworthy fact, 
since it shows that the impulse in the r^ion of the pulmonary artery 
is not perceptibly heightened ; otherwise, with the superficial position 
of tiie artery, the recoil of the blood must be clearly felt. 

The Influence of the Elevation of the Diaphragm upon the RemltB 
of Aiiacultation of the Heart. — For the same reason, the deductions 
from auscultation are to be modified. The second pulmonary sound is 
louder than the second aortic ; this difference is very marked, as great as 
we find it in the failure of the mitral valve. Yet I must warn you 
as to the increase of the second pulmonary sound in these cases : do 
not mistake it for increased pressure in the region of the pulmonary 
artery in your diagnosis, and thereby contradict the result of palpation. 
Then it is dear that an increase of the second pulmonary tone can come 
about in two different ways : (1) when it is really louder than the aortic 
sound ; (2) when the attendant condition is more favorable for the 
arteria pulmonalis than for the aorta. The latter is true in those cases 
in which the orifice of the pulmonary artery approaches the thoracic 
wall, while the overlying aorta, over which we hear the aorta sounds, 
through the rotation of the heart upon its long axis, is somewhat far- 
ther removed from the thoracic wall. On that account we hear over 
the aorta both tones softly, while over the pulmonary artery both 
the systolic and the diastolic sounds appear very loud. The under- 
standing of these conditions — namely, the simultaneous systoHo and 
diastolic strengthening of the pulmonary tones — is important, and 
would in other cases besides chlorosis help to a better understanding 
of the differences in sounds. 

In order to confirm the above, we should not forget the other points 
over which the second tone of the heart can be heard, — that is, over 
the apex and the fifth costal cartilage. It is already known that the 
diastolic soond which can be heard at this point of the thorax is 
the result of the valvular closure. You must in all cases of mitral 
stenosis, mitral insufficiency, and other diseases in which there are 
pressure-symptoms in the pulmonary circulation and increase of the 



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36 INTERNATIONAL CLINICS. 

second pulmonary sound, remember that the second sound over the 
tricuspid valves is louder than at the apex; and, further, that in 
most cases the second sound over the tricuspids is louder than the first 
at the same place. The second sound here at the apex laps over the 
second tone on the tricuspid, and this is less than the first sound in 
intensity. 

Condufsuyns. — We come to the conclusions that the changed position 
of the apex-beat, the strong heart-impulse, the perceptible pulsation of 
the pulmonary artery, the loud pulmonary sounds, and the increased 
heart-dulness, are explained by the retraction of the lung margins from 
the heart, and by the elevation of the diaphragm ; and that we are 
not justified in allowing ourselves, because of these symptoms in 
connection with the systolic murmur, to make a diagnosis of mitral 
insufficiency. 

As you see, we base our diagnosis entirely upon objective examina- 
tion. We do not need to infer from past experience with chlorotic 
patients that there is never any physical change in the heart. This is 
always important, as it confirms our diagnosis and excludes the suppo- 
sition that perhaps she had a definite lesion of the heart-valves as a 
result of the articular rheumatism. Before we make our comparative 
conclusions between the two cases, I should like to call your attention 
to two symptoms which we observed in the arterial system of our 
chlorotic patient. 

I. The Quality of the Pulse in the Radial Artery, — ^The pulse is 
full, soft, and dicrotic. You will not find such a pulse in every case 
of chlorosis. You will not observe it if you make the mistake of 
confusing it with chronic cases of anaemia and oligsemia which have 
originated in childhood in a hyperplasia of the arterial system (Vir- 
chow) ; also in true chlorosis the dicrotic pulse is not always found ; 
but when you have a case before you where the finger is on the pulse 
of a strong and well-nourished girl suffering from an acute and severe 
chlorosis, then you will always have the chance to observe a full dicrotic 
pulse. We will not fail to recognize both these appearances as signs 
of a marked dilatability of the vessels, or, in other words, of utonicity 
of the arteries. 

II. The Quality of the Sound-Symptoms in the AHeria Cruralis. — 
It is well known that normally, by carefully applying the stethoscope, 
one hears either nothing at all or an arterio-diastolic tone ; on applying 
the stethoscope with more force, one hears an arterio-diastolic stenosis 
murmur; and by still further pressing the stethoscope, one hears the 
so-called pressure-sound. Here, in this chlorotic girl, we can perceive. 



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THE HEART IN MITRAL INSUFFICIENCY AND IN CHLOROSIS. 37 

as any begiDner can diBtinjguish, two distinct sounds during one pulsa- 
tion. With this, however, we ought not to be satisfied, as in the crural 
artery there are several kinds of double sounds. 

The phenomenon of double sounds is not infrequent. It was first 
observed in cases of aortic insufficiency ; later, in mitral stenosis, in 
anaemia, in pregnancy, in fevers, in contracted kidney, in arterio-sderosis, 
and in chlorosis. 

I have for a long time observed the symptoms, and find that there 
are three kinds of double tones in the arteria cruralis : 

(a) A double arterio-diastolic sound. The sounds generally follow 
quickly one upon the other ; the first is not finished when the second 
begins ; there is a separation as well as a doubling. This form is found 
in mitral stenosis, in saturnism, in chronic contracted kidney, in arterio- 
sclerosis, and often in pr^nancy. 

(5) A simple arterio-diastolic followed quickly by an arterio-systolic 
sound. The second sound b^ns immediately, or after a trifling pause, 
after the first sound. Oftien one can notice only that be has to do 
with two sounds, and cannot determine the quality of them. This 
form is found in aortic insufficiency, and in some cases of very high 
fevers. 

(e) Simple arterio-diastolic and delayed arterio-systolic sounds. In 
these cases the pause is longer, even longer than that between the first 
and second heart-sounds. This condition is, therefore, very easy to 
diagnose. This form is found in severe anaemia, in chlorosis, in per- 
nicious anaemia, in high fevers, seldom in pregnancy. 

With this last-named form we have to do here. You can see by 
the collected evidence that we have here such a condition as is shown 
by the tension of the vessels. 

In the following table I have summarized the symptoms which 
we have found in the circulatory system. A further explanation of 
this table is not necessary. The similarities, as well as the dissimi- 
larities, in the symptoms m mitral stenosis and in chlorosis with ele- 
vation of the diaphragm are both shown. The comparative value of 
the several symptoms in diagnosis can be seen by reference to the 
text 



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38 



INTEBNATIONAL CLINICS. 



A Schematic Illustration of the Diagnostic Symptoms in Mitral 
Insufficiency and in Chlorosis. 



Mitral Iniufflciency. 



Chlorosis with Elevation of the 
Diaphragm. 



Position of the dia- 
phragm. 

Apex-beat. 



Orifice of the pul- 
monary artery. 



Limits of heart-dul- 
ness. 



Auscultation of the 
heart: 

a. Apex. 

b. Pulmonaris. 
e. Aorta. 

d. Tricuspid. 

Radial pulse. 

Crural artery. 
Jugular vein. 
Crural -vein. 



On both sides at the sixth rib. 



Fifth intercostal space, one 
and one-half centimetres left 
of the nipple-line. Covered 
by lung. 

Closure of the valves can be 
felt. Pulsation of the pul- 
monary artery cannot be 
seen. 

Above : fourth rib. Left : nip- 
ple-line. Right: middle 
line. Below : sixth rib. 



Systolic murmur, second 

* sound. 
Systolic murmur increased ; 

second sound. 
Clear sound. 



Clear sound ; the second is 
louder than the first sound. 



Moderately accelerated. Indi- 
cation of dicrotism. 

One sound. 



On both sides at the fifth rib. 



Fourth intercostal space, one 
and one-half centimetres left 
of the nipple-line. For the 
most part uncovered by lung. 

Closure of the valves cannot 
be felt. Pulsation of the pul- 
monary artery can be seen. 



Above: third rib. Left: one 
centimetre left of nipple. 
Right : middle line. Below : 
fifth rib. 



Systolic murmur, second sound. 
Systolic murmur, second sound. 

Systolic murmur ; second sound 
is softer than at the pul- 
monary artery. 

Systolic murmur with first 
sound ; second sound, but 
softer than the first 

Moderately accelerated. Di- 
crotic. 

Two sounds. 

Venous soufile. 

• (Often venous souffle.) 



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ACUTE PLEURISY WITH EFFUSION; INTERSTI- 
TIAL PNEUMONIA (CHALICOSIS), WITH EN- 
CYSTED AND PROBABLY INTERLOBAR LOCU- 
LATED PLEURISY. 

CLINICAL LKCTT7BB DELIYICBED AT TBB PHILADELPHIA HOSPITAL. 

BY J. M. ANDERS, M.D., Ph.D., 

Professor of Practice in the Medioo-Chiruigical College ; Visiting Physician to the 
Philadelphia Hospital, etc. 



Gentlemen, — ^Those of you who were here at my last clinic will 
recall the case I then showed you, one of acute pleurisy with e£Fusion. 
We will call attention once more to the chief points in the clinical 
history of the case. Man, aged thirty-seven years ; laborer by occu- 
pation ; nativity, Italian. He had some of the diseases of childhood, 
followed by an attack of malaria, but since then has been in good 
health until the present attack, which b^an December 23, 1893. The 
onset was marked by a severe chill, followed by high fever, intense 
headache, and general muscular and bone pains. A few days before 
admission he was seized with a stitch-like pain in the region of the 
right nipple, extending to the back, and accompanied by dyspnoea and 
cough, with the expectoration of a scanty amount of mucus. On 
being admitted to the institution (January 4, 1894) the countenance 
was flushed, respirations were shallow and rapid, showing marked 
dyspnoea, and a Jiacking cough with little expectoration was present. 
Further examination at the time of admission revealed a right-sided 
pleural eflxision, the liquid rising to a level anteriorly with the nipple 
and posteriorly with the inferior angle of the scapula. Last week, on 
making an examination, Uie fluid still arose to the nipple-line with the 
patient in a sitting posture, and changed on changing his position. 
At that time the differential diagnosis, prognosis, and treatment were 
spoken of. I wish to-day, however, to add a few words as to Uie treat- 
ment in cases of sero-fibrinous pleurisy. As the efliision is due to an 
inflammation and not to a simple transudation, reduce the inflammation 

89 



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40 INTERNATIONAL CLINICS. 

of the pleura by means of mild diaphoretics and diuretics, together 
with repeated small doses of salines, sufficient to cause moderate purga- 
tion. Opium and quinine are two remedies which control inflamma- 
tions of serous membranes, the former being given in the form of 
suppositories or hypodermically, and the latter in divided doses, six- 
teen to twenty grains in twenty-four hours* In this patient, the 
temperature dropped to normal last week for the first time. In many 
cases, after the fever has entirely disappeared, the amount of fluid in 
the chest remains the same, and then the indications for paracentesis 
are to be considered. These may be properly subdivided into two 
classes or considerations. 

First, during the acute stage : (a) To save life, and not to get rid 
of the fluid. (5) When one pleural sac is completely filled, as shown 
by dulness on percussion reaching upward to the clavicle, or when 
Skoda's resonance extends downward only as far as the second rib or 
interspace, in which case there is considerable intra-thoracic pressure, 
this being always an indication for aspirating. If hyper-resonance 
extends lower, reaching the third rib or interspace, it is well to hesitate, 
as the danger from intra-thoracic pressure is not so great, and the fluid 
may be finally absorbed, (c) Marked displacement of the heart, with 
the development of one or more murmurs, may occur, and denotes the 
indication for immediate aspiration. Distortion and compression of the 
great vessels from pressure of the fluid take place, which disappear as 
the pressure is removed by withdrawal <rf the fluid, (d) In double 
pleurisies, if both sides are filled one-half with liquid, aspirate, as 
sudden death may occur from the rapid filling of one side, (e) Always 
watch the unaffJected side, and detect the first signs of involvement. 
If moist rftles, ogophony, broncho- vesicular breathing, and impaired 
resonance appear, aspirate immediately, stimulate the heart, and apply 
dry cups over the affected area. The risk in allowing the fluid to 
remain is too great Should serious symptoms arise during the acute 
stage, such as orthopnoea or a tendency to syncope, aspirate and with- 
draw a portion of the fluid. 

Second, in afebrile or subacute cases, when should aspiration be per- 
formed? When nature makes no attempt at absorption. At the time 
the temperature becomes normal a thorough examination should be 
made, and the exact amount of fluid in the chest ascertained. If the 
quantity be not diminished in one week afber the drop to normal, as- 
pirate, withdrawing a limited amount In cases where there is absence 
of temperature from the beginning, withhold operating for about three 
weeks, but do not wait longer ; the elasticity of the lung, if compressed 



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IKTEB8TITIAL PNEUMONIA WITH PLEURISY. 41 

too loDg^ will be destroyed ; the latter will not r^ain its function^ and 
dangerous sequel® may result The medical treatment in this case 
consisted of five grains of potassium iodide^ with ten minims of the 
syrup of ferrous iodide, given four times daily, to promote absorption. 
This combination has been much used, and rarely fails to produce some 
effect in lessening the amount of fluid. On making an examination at 
this time, I find the patient's general condition comfortable, the dyspnoea 
much less marked, and the cough much improved. The flatness does 
not extend as fisur upward as the nipple, both anteriorly and laterally, 
showing beginning absorption. The indications for aspiration are, 
therefore, not present, and we will continue the internal treatment, and 
notice Uie patient's condition one week hence. 

. The next case I have to show you is most interesting : it is similar 
in some respects to the one you have just seen, although not nearly so 
typical in character. Male, aged fifty ; occupation, brickmaker since 
eleven years of age. One parent and one sister are dead ; causes of death 
not known. His remaining parent and another sister are living and 
well. When a child he had measles and whooping-cough, and in 1876 
a severe attack of small-pox, from which, however, he fully recovered. 
Two years ago he noticed for the first time slight dyspnoea on exertion, 
accompanied by some cough with little expectoration. His general 
health, he states, was good at this time, and he did not lose flesh. The 
cough, however, continued, and one year ago last December he had a 
severe attack of influenza, followed by right-sided pleurisy with effu- 
sion, and was quite ill for some time, but finally recovered, and remained 
in good health until September, 1893, when he caught cold and the 
dyspnoea returned, accompanied by persistent cough with muco-puru- 
lent expectoration. He continued to work, and one month ago the 
symptoms became much intensified. Despite this he would not give up 
work until two days before admission. When I first saw him his face 
was flushed, dyspnoea was marked, and persistent cough was preseut, 
with scanty expectoration. The temj^rature was irregular and sub- 
remittent in character, reaching 101° in the morning and rising to 102° 
or higher in the evening. Physical examination of the chest in front 
showed diminished expansion on the right side, the supra- and infra- 
clavicular fossse being well marked, and the respiratory movement on 
that side in an upward and downward direction. Anteriorly on the 
left side expansion was good, the movement being upward and outward. 
The apex-beat could be seen in the fifth interspace, but was displaced 
nearly one inch to the right. The impulse was feeble. Posteriorly 
on the right side there was retraction, beginning at the angle of the 



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42 INTERNATIONAL CLINICS. 

scapula and extending laterally, together with diminished expansion 
on that side, some movement being noticed over the base. 

Palpation. — On the left side, anteriorly and posteriorly, tactile 
fremitus was good throughout. Over the upper half of the right lung 
anteriorly fremitus was much diminished or entirely absent, being rela- 
tively more marked over the right base. Percussion over the upper 
third of the right side anteriorly showed flatness with impaired reso- 
nance over the lower two-thirds. Posteriorly flatness extended down 
to the spine of the scapula, and from that point to the base of the right 
lung there was dulness; over the extreme base, impaired resonance. 
Percussion over the left side anteriorly and posteriorly showed extra 
resonance throughout. On auscultating over the right lung anteriorly, 
the breath-sounds were impaired down to the nipple ; below that friction 
rftles could be plainly heard, accompanied by a feeble respiratory mur- 
mur. On the same side posteriorly, above the angle of the scapula, 
breath-sounds were entirely absent ; below that the sounds were heard 
feebly, together with a few friction rftles. Four days later the physical 
signs were recorded as follows. Posteriorly over the lower half of the 
right lung increased tactile fremitus, with impaired percussion reso- 
nance, extending to the middle third. Above the angle of the scap- 
ula, where the breath-sounds were formerly absent, broncho-vesicular 
breathing could be heard. The diagnosis of plastic pleurisy with effu- 
sion, which had largely disappear^, was then made. One week later, 
practically the same signs were discovered posteriorly. Anteriorly on 
the right side percussion showed flatness extending to the base of the 
lung in front ; over the upper third of the lung vocal fremitus was 
entirely absent. The breath-sounds about the region of the nipple 
were also absent, no friction r&les being heard. From the limited area 
of dulness not changing with the position of the patient, in conjunction 
with the other physical signs, the effusion was thought to be an en- 
cysted or sacculated one ; hence the exploring needle was used, which 
confirmed the diagnosis. In cases of this character, where some doubt 
exists as to the condition present, the exploring needle affords the only 
sure means of establishing a positive diagnosis. In this case the 
needle was passed between the third and fourth ribs, in a line drawn 
obliquely outward and upward from the nipple to the apex of the 
axilla. When first examined, if you will remember, the area of flat- 
ness was circumscribed to the right apex, but to-day, on percussing, we 
have flatness extending to the base of the lung. The question now 
arises, Is this a monolocular or a multilocular cyst? which can be 
decided only by aspirating. In order to find whether the cysts, when 



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INTEKSTmAL PNEUMONIA WITH PLEURISY. 43 

multiple^ oommuDicate with one another^ we should aspirate first low 
down in the sac, and notice whether the liquid disappears from above. 
In multilocular pleurisy the cysts often communicate^ although separate 
cysts may occur having no connection with one another. The flatness 
obtained anteriorly high up on percussion it was thought might be due 
to a thickened pleura^ as the presence of a loculated effusion in that 
situation is rare. The marked retraction extending downward to the 
third rib would also denote chronic pleurisy with numerous fibroid ad- 
hesions. The patient has evidently had an acute attack in which the 
fluid has been confined within these fibrous bands^ forming cysts which 
probably do not communicate^ since they developed at two different 
periods. In cases of recent pleurisy with effusion, adhesion may de- 
velop, but this occurrence is rare. If we trace the direction of the 
eflusion, beginning in front, we have dulness over the mid-sternum, 
extending to the right and ending at the anterior axillary line, per- 
cussion resonance being good in the mid-axillary r^ion. Posteriorly 
on the right side there are increased tactile fremitus, good percussion 
resonance, and distinct vesicular murmur, all of which exclude the 
presence of an effusion. Compression of the lung from liquid may also 
give rise to symptoms, impaired percussion resonance and feeble or 
absent vesicular murmur, which, however, tend to disappear when the 
pressure is removed. Unless the sac be two-thirds full, no positive 
pressure is exerted upon the lung, although in cases of encysted pleurisy 
actual positive pressure exists earlier than otherwise. In this patient 
the amount of intra-thoracic pressure is not great, the fluid being con- 
fined within the fibrous adhesions, though the pressure may be con- 
siderable in the cyst itself. If the lung substance were compressed, we 
should have diminished breath-sounds, but no bronchial breathing with 
retraction of the chest walls, and no displacement of the apex-beat to 
the right, as exists in this case. Reviewing the clinical history and 
physical signs, I think we can safely say the condition posteriorly is 
one of cirrhosis of the lung, associated with chalicosis, of which I have 
lately seen one other case. The patient has been a brickmaker for 
thirty-nine years, inhaling particles of dust, and right here the question 
presents itself, Why did not infection take place before this time? 
Simply because the natural scavengers of the air-passages removed the 
dust The mucous cells and phagocytes take up the particles, while 
the ciliated epithelium sweeps them in a position to be expectorated. 
If the dust be too thick and insoluble matter be present, it enters Uie 
submucosa, is taken up by the bronchial glands and lymphatics, and 
the fibrous or connective tissues are infiltrated. Mechanical induration 



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44 INTERNATIONAL CLINICS. 

ensues, and a fibrous overgrowth is the result. In this case there is a 
history of chronic bronchitis, together with dyspnoea, the latter being 
an invariable symptom of cirrhosis. We also have here fever resem- 
bling in variation that of fibroid induration, being 100° to 101° in the 
morning, and rising to 102° or higher in the evening. The physical 
signs in this case also show posteriorly retraction from the spine of the 
scapula downward, and laterally on the right side, together with limited 
expansion. The diagnosis of cirrhosis should not be made without the 
presence of retraction, although this may occur in one other condition, 
— that of adhesive pleurisy. In this case also there is increased tactile 
fremitus over the lower two-thirds of the right lung, tc^ther with 
broncho-vesicular breathing, whereas in plastic pleurisy we have dimin- 
ished fremitus with impairment or entire absence of breath-sounds 
and frequent presence of harsh friction-sounds. On percussion in this 
case there is flatness above down to the spine of the scapula, and from 
that point to the lower lobe of the right lung, dulness, the sound 
being of a peculiar wooden quality, and accompanied by a sense of 
resistance imparted to the fingers, which is peculiar to this condition. 

In reviewing the signs, we have retraction of the chest walls, 
displacement of the apex-beat towards the side affected, increased 
tactile fremitus, showing some degree of consolidation of the lower and 
a portion of the middle lobe i>osteriorly, together with wooden dulness 
and exaggerated vocal resonance, almost amounting to bronchophony, 
all indicating consolidation of the lung. Mucous rkles and friction 
crackling at the end of inspiration are also heard in this case, showing 
the existence of dry pleurisy secondary to a chronic bronchitis. The 
latter often leads to pleurisy. In diagnosing eases of this kind we 
have to think of and exclude other conditions which may give rise 
to some of the symptoms and physical signs present. Cancer of the 
posterior portion of the lung may be confounded with fibroid indura- 
tion, but in this the clinical history is different, and, if the disease be 
far advanced, cancerous cachexia will be present. Physical examination • 
shows very slight retraction of the chest walls, or perhaps some 
bulging of the intercostal spaces, increasing with the size of the 
tumor. The bronchial glands and lymphatics also become enlarged 
and undergo cancerous change. Moreover, carcinoma of the lung is 
usually secondary ; among the primary seats being the mammary gland, 
the liver, the oesophagus, and the stomach. As the disease progresses, 
cachexia develops, with all its attending phenomena. In the patient 
before us the diagnosis of cancer can be positively eliminated. 

Fibroid Phthisis. — In this the physical signs may exactly resemble 



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THORACOCENTESIS. 45 

those of cirrhosis of the lung, and the therapeutic test — that of giving 
small and repeated doses of tuberculin — has to be relied upon. The 
sputa in such cases should be examined repeatedly for the presence or 
absence of tubercle-bacilli. Until late in the disease the differential 
diagnosis by means of physical examination cannot be estabh'shed. 
Such cases as this, in my opinion, almost invariably terminate in 
phthisis, although many authorities differ with me on this point. In- 
tercurrent acute pleurisies take place, and these favor the development 
of pulmonary tuberculosis. 

The prognosis in this case is good as to life. The patient may live 
many years, but will l)e prone to attacks of pleurisy, broncho-pneumonia, 
gangrene, and other dangerous conditions of the lung. The treatment 
is merely symptomatic and hygienic, so far as the element of fibroid 
induration is concerned, consisting in a carefully regulated diet, sufficient 
sleep, abundance of fresh air, friction to the skin with a limited amount 
of exercise, and other hygienic measures to improve the general health 
and to arrest or limit the process of connective-tissue formation. 

In a multilocular pleurisy the indications for aspiration are different 
from those of a general pleurisy with efiiision. Always operate early, 
as there is some danger of the sac rupturing, or of great cardiac dis- 
placement where the fluid is confined to the anterior part of the chest. 
Intra-thoracic pressure in this instance is slight, as shown by the decree 
of elasticity of the lung remaining. Always determine the extent of 
the effusion. Now as r^ards the modus operandi in thoracocentesis. 
The needle should be limited in size, being from one-half millimetre 
to two millimetres in diameter. See that the valves of the syringe and 
the stopcocks are in working order and adjuBted properly before using, 
as tedious and sometimes serious delay has been o<x}asioned by neglecting 
this minor detail. The patient should be in a semi-recumbent position, 
with the head and shoulders elevated, so that he can lie down easily 
and with little movement. The operation is not a serious one, nor, if 
performed properly, painful, and the patient may partake of a meal 
preceding it without harm following. After the needle is withdrawn, 
he should lie perfectly quiet for two hours, and should not be allowed 
out of bed for the following twenty-four hours. The next question 
that arises is, where to puncture. If the effusion is large, almost filling 
the chest, aspirate high up, the object being to draw off some but not 
all of the fluid : on the right side, in the fifth interspace, mid-axillary 
line, if full, and on the left side in the sixth interspace. If the effusion 
fill only two-thirds of the pleural sac, aspirate in the sixth interspace 
on the right side, and in the seventh interspace on the left;. By as- 



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46 INTERNATIONAL CLINICS. 

pirating in the seventh interspace the liver and diaphragm have been 
touched, with bad consequences. In a localized pleurisy, operate over 
the lower third of the sac. A vacuum having been produced in the 
bottle, the stopcock admitting air from the bottle to the syringe is 
turned off, and after the introduction of the needle another stopcock, 
connecting the tube with the bottle, is opened, and the vacuum present 
exerts a suction action on the fluid in which the needle dips, drawing 
it into the bottle. All aspirators work on this principle. The assist- 
ant having drawn the skin tense by placing his finger over the rib 
above the interspace to be tapped, the operator grasps the needle with 
his index finger placed one inch from the point, in order to guard 
against its going in too far, and with a quick push (not a boring mo- 
tion) he directs the point slightly inward and downward, allowing the 
liquid to drain into the bottle. Great caution should be observed to 
have the needle and index finger of the operator, as well as the skin 
over the seat of operation, antiseptically clean, in order to avoid con- 
verting a serous into a purulent effusion. In pleurisy with effusion 
the best situation for making puncture ordinarily is a little posterior to 
the mid-axillary line, although if the sac be full the latter may be 
chosen. Always remember in aspirating to hug the upper border of 
the rib bdow the interspace to be punctured. In this case fluid is 
present, showing the existence of an encysted pleurisy. As these cases 
are apt to be multilocular, aspiration at several points may become 
necessary. The fluid should be allowed to flow off slowly, and after 
four or five ounces have been withdrawn, the flow may be checked for 
a few minutes and then allowed to continue, thus inviting the lung 
to expand, though slowly. In aspirating a pleural cavity filled with 
liquid, two pints may be withdrawn, but not more. After withdrawal 
of the needle, the skin, which has been held tense by an assistant, is 
dropped, completely covering the opening. In the case of a recent 
cyst, if the fluid contained does not exceed ten or twelve ounces, it may 
all be removed. In this case we now remove nine ounces, and you will 
observe the flow has stopped. If, during the process of aspirating, 
cough, dyspnoea, or a tendency to syncope should develop, withdraw 
the needle immediately. In the case before us it is diflBeult to say how 
much of the consolidation was due to compression from the effusion 
and how much to fibroid induration. After the withdrawal of the 
fluid the lung expands slowly. On percussing, I find that the flatness 
from above down to the third rib, which was present on admission, 
still exists, which flatness makes us suspect the presence of another 
monolocular cyst, and on aspirating fluid is present. This probably is 



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OONTRA-INDICATIONS TO ASPIRATION. 47 

an interlobular cyst^ produced by the inflamed pleura dipping between 
the lobes ; these cysts contain usually but a small amount of fluid, and 
do not cause much bulging of the intercostal spaces ; in this case there 
is actual retraction. It is impossible by physical examination to dis- 
tinguish definitely between an interlobar and an encysted pleurisy. 

Finally, there are certain contra-indications for aspiration which 
must be borne in mind. The presence of shock or collapse is always 
a contra-indication, as is also an excessively feeble condition of the 
system, in which case the shock of the operation cannot be well borne. 
Croupous pneumonia, if ascertained, should always contra-indieate 
aspiration, as cases of this kind may prove rapidly fatal. Among other 
sequelse, albuminoid expectoration may occur. The respirations be- 
come rapid and jerky, and there is a sense of oppression in the chest, 
with excessive cough and rapid serous expectoration, reaching one or 
two pints in as many hours. The patient sometimes recovers rapidly, 
but the condition is quite as apt to terminate fatally. The symptoms 
are due to congestion of the lung followed by temporary oedema. 
Death from syncope may occur after the withdrawal of a large pleural 
effusion. The heart, being much displaced by the effusion, cannot 
accommodate itself to the sudden change of position, and death from 
pulmonary embolism is not uncommon. During its displacement the 
circulation is depressed, but as the fluid is removed the organ returns 
to its normal position, and the increased strength of the current washes 
an embolus into the circulation, which lodges in the pulmonary artery, 
producing instant death. Those cases invariably do best in which but 
twelve or fourteen ounces of fluid are removed at the first aspiration, 
which may be repeated, if necessary, in two or three days. 



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PERNICIOUS ANEMIA. 

CLINICAL LECTURE DELIYERBD AT QUT'S HOSPITAL, LONDON. 

BY W. HALE WHITE. M.D.. F.R.C.P., 

Physician to Guy's Hospital. 



Gentlemen,-— We have recently had in the hospital a man who 
died from pernicious anssmia, and I am able to show you his viscera. 
I shall also in a few minutes bring into the clinic a woman who is a 
well-marked example of the disease, and in Stephen ward you can see 
a man who exhibits the characteristic symptoms. We ought, there- 
fore, this afternoon to be able to learn a good deal aliout this rare 
malady. 

The clinical history of the fatal case is as follows : On admission, 
March 8, he was fifty-five years of age. He contracted gonorrhoea 
and syphilis when young ; otherwise he had had no illness. He had 
not suffered from diarrhoea or sickness. 

PresefU Illness. — Eight weeks ago he b^an to feel weak and lose 
color. Five weeks ago the dyspnoea and weakness became so marked 
that he had to take to his bed. At this time the ankles swelled, his 
pallor increased, and he became so weak that he was unable to stand. 

On Admission. — ^The whole of the body is of a well-marked lemon 
tint, but there is no jaundice. There is a flush over each malar bone, 
All the visible mucous membranes are very pale. 

Circvlatory System, — There is no evidence of cardiac dilatation. 
There is a loud blowing systolic murmur, best heard at the apex, and 
traceable from there in all directions. Pulse 80, r^ular, feeble, 
small, compressible. Red corpuscles, twenty-four per cent.; haemo- 
globin, eighteen per cent. ; no leucocytosis. 

Respiratory System. — This appears normal. 

Alimentary System. — Tongue and mouth very pale ; appetite bad ; 
stomach a little distended ; no vomiting ; motions normal. The edge 
of the liver can be felt three-quarters of an inch below the ribs. The 
spleen cannot be felt. 
48 



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PERNICIOUS ANiBMIA. 49 

N&'vom System. — Normal. He is sometimes giddy. 

Eyes. — In both eyes there are several well-marked hemorrhages 
which follow more or less the course of the vessels; the inner side of 
the right disk is a little blurred. 

Urine. — ^Distinctly dark, acid, no deposit ; specific gravity 1012 ; 
free from blood, albumen, sugar, or bile. 

He was treated with full diet and five minims of liquor arsenicalis 
three times a day. 

May 27. — Patient weaker and somewhat drowsy. He has been 
kept on arsenic, except when the increase to seven minims seemed to 
cause diarrhoea. The liver is now three inches below the ribs. 

June 15. — ^The dyspnoea is very marked. There is Cheyne-Stokes 
breathing. The liver is within an inch of the umbilicus. There is a 
pericardial rub. 

June 17. — He died comatose. 

Axdopsy. — Heart. — Recent pericarditis. Well-marked tabby stria- 
tion. 

Lungs. — Fifteen ounces of clear fluid in each chest. Lungs 
ansemic. 

Spleen. — Soft ; appeared normal. 

Lwer. — Sixty-six ounces ; appeared normal. 

Kidneys. — (Edematous and tough. 

Bones. — Normal. 

All the other parts of the body had nothing visibly amiss with 
them except ansemia. The liver and kidneys, as you can see by the 
pieces of the organs I show, stained blue with ferrocyanide of potas- 
sium and hydrochloric acid, and the liver gave a black color with 
ammonium sulphide. The spleen also gave the Prussian blue re- 
action. 

Subsequent analysis showed that the liver contained when dried, 
freed from blood, and analyzed with the greatest care, 1.038 per cent, 
of iron. 

(The normal percentage of iron in the liver is 0.083.) 

The spleen, dried and freed from blood, contained 0.301 per cent, 
of iron. 

(The normal percentage of iron in the spleen is 0.171 per cent.) 

Stale of the Blood during the patient's stay in the hospital : 

ReacOofn. — ^The alkalinity of the blood was tested on March 14 
with graduated litmus papers of different d^rees of acidity. It could 
not be made out that the patient's blood differed from that of a healthy 
individual, but the test appeared far from delicate. 
Vol. I. Ser. 4.-4 



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60 



INTERNATIONAL CLINICS. 



Specific Gravity. — On June 10 this was taken in a mixture of 
chloroform and xylol^ and was found to be 1042. 

The following chart shows the proportion of hsemc^lobin and red 
blood-corpuscles. 

Chabt 1. 







» 


Mt 


U 


IT m 


*K 


m 


f II I* 


IV 


w 


1 1 . 1 - 


11 n 


«? » *i 4 


! 

1 


Ml 

m 






SKI 

, ; 


^--' 




-— 






- — 1 


1 : 




p;^ 


w 



Chart of the blood of Richard Forge (Case I.). Black line ihows the percentage of red blood- 
corpusclee; broken line, percentage of hemoglobin. 

The Urine. — This was carefully examined every day, and the 
following is a summary of the results. 

Quantity. — ^This varied, but not more than in health, and was 
usually about two pints. 

Specific Oravity. — This was nearly always between 1010 and 1012. 

Albumen. — ^None, except a trace the day before death. 

Bile. — None. 

Indican. — This gradually appeared as the urine got darker from 
April 14, and increased until at the end of the case there was a con- 
siderable amount. 

Color. — ^The color, from admission up to April 1, was decidedly 
dark, and the urine was clear. From April 1 to April 14, color 
normal ; urine not clear. From April 14 it gradually passed through 
the stage of high color to darkness, so that by April 25 it was moder- 
ately dark and clear. On May 1 it was dark and clear. On May 18 
it was very dark and clear, and it remained in this condition till the 
death of the patient. The specimen before you shows very well the 
dark color. Whenever the urine was dark or very dark, the urobilin 
band was broad ; in fact, the width of the band increased proportion- 
ally to the darkness; on no occasion, although repeated examinations 
were made, could any accessory spectral bands be detected, the only 
one visible being the broad urobilin band, which yon can see in the 
present specimen. On several occasions the color was observed in 
each specimen, passed at different times of the day, and it could not 



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PERNICIOUS ANiEMIA. 



51 



be made out that the time at which the urine was passed made any 
differenee in the color. 

TempercUure. — This was raised during the whole of the patient's 
stay in the hospital : usually it was a d^ree or two above normal, 
higher in the evening than in the morning. The following chart shows 
the temperature during the first three weeks. 

Chart 2. 




Temperatare chart of Case I. 



Microscopical Examination of the Viscera. — Pieces of the organs 
whidi had been stained with ferrocyanide of potassium and hydro- 
chloric acid were cut in sections, and you can examine some kindly 
exhibited by Mr. Steward under the microscopes on the table. You 
will observe that in the liver the deposit of Prussian blue is in the 
outer two-thirds of the hepatic lobule, and is most abundant in the 
hepatic cells. In the kidney it is in the cells of the convoluted tubes, 
with a little lying free in the lumen of the tubes. 

Case II. — ^Annie G., aged about forty-eight, admitted March 18, 
1893. In 1866, when at Constantinople, she had a slight attack of 
cholera, and has been liable to summer diarrhoea ever since. She has 
also suffered from constipation. 

Present IRness, — Four and a half years ago the menopause com- 
menced. Since then she has suffered from shortness of breath and 
palpitation. She has had vomiting and diarrhoea, bearing no relation 
to food. She was in the hospital under Dr. Taylor for four weeks, at 
the end of 1892. Then she was of a lemon color, was slightly deaf, 
had a hsemic murmur and a venous hum. Red corpuscles, twenty-two 
per cent. ; hemoglobin, fifteen per cent. Urine, light brown, with a 
trace of albumen and a broad urobilin band ; eyes normal. Tempera- 
ture every evening over 100°. She improved somewhat on arsenic. 

On Admission. — She says that since she has l)een out she has been 
very weak and her feet have swelled. For the last fortnight she has 
had vomiting and diarrhoea, ringing in the ears, giddiness, headache, 
and severe palpitation. Now she is, as you can see, of a lemon tint, 
and extremely emaciated. There are a few subcutaneous hemorrhages. 



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62 



INTERNATIONAL CLINICS. 



There is a loud hsemic murmur and venous hum, and the pulse is feeble. 
Respiratory system normal. Both optic disks blurred. 

The case may be summed up as follows. The optic neuritis became 
more marked. There was diarrhoea on March 24, April 6, and May 

2, and on these occasions the urine was particularly dark : one of these 
dark specimens I show you here. Otherwise she improved consider- 
ably. She took arsenic during the whole of her stay, and for some 
time large doses of /9-naphthol, but this was left off, as no improvement 
could be attributed to it, and it made her feel sick. Oxygen inhala- 
tions were tried, without any good result. She left the hospital on May 

3, but has come in again within the last few days. 

State of the Blood. — The following chart shows the quantity of 
hsemoglobin and red corpuscles. There is no excess of leucocytes. 

Chart 8. 







u 


II 


» 


7 




19 


91 


tft 


St 


1 


111 


17 


IT 


1 






1 

■4 
a. 


iO 



































































ll — "^"^ 




i'.^ — '■ 


s:^ 




V--- 


Z^^I^ 




^ 


M 


^^^ 


:=S 


P^ 


mX 
























h — — 


































- 






























































' — 




L- 


:z_J 


J 


— -- 





Chart of the blood of Annie Goodhart (Case II.). Black line, percentage of red corpusdeB; 
broken line, percentage of hsemoglobin. 

The Urine. — This was carefully examined every day. 

Quantity. — Normal. 

Specific Gravity. — Almost always between 1010 and 1012. 

Albumen. — On four occasions a faint trace was detected. 

Bile. — ^None. 

Indican. — None. 

Color. — March 18-21, high-colored; March 22, more highly col- 
ored ; March 23-30, high-colored ; April 1-5, light-colored ; April 6- 
8, dark; April 9-11, light; April 12, rather dark; April 14-22, 
light ; April 23-24, rather dark ; April 25-29, light ; May 2, dark. 
When the urine was dark the urobilin band was particularly broad, 
but there was never more than one band. This can be seen by looking 
at the specimen I show you. 



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PERNICIOUS ANJEMIA. 



53 



The Temperature. — This was, as the aoDexed chart shows, raised 
during the whole of the patient's stay in the hospital, and was on the 
whole a trifle higher than in the first case. It was usually higher in 
the evening than in the morning. 



Chart 4. 





nh 


Vi. 


^ 


Jat^ 


i*L_ 


mL_ 


^ 


r^ 




HJL Mi. 


«U. 


»fe- 


r^ 


r^ 


-fit 


r^ 


*^ 


MC 


r**n 


«^ 


Hit 






?^=i3 




^ 


m 


m 


1 


nn 






^;— 








— 


— 


J 


^ 


^^^iiE 


















i 








-^ 










ip^ 


-=^ 


.^ 



Temperature of Cajie II. 

Case III. — Samuel Davis, aged forty-five, admitted December 23, 
1893. 

Family HUiory. — Unimportant. 

Personal History. — Is said to have had rheumatic fever twice, and 
dysentery at the age of thirty. Six years ago he had some severe 
illness, which the doctor said was cholera. 

Present Illness. — In January, 1893, he had influenza, since which 
he has suffered from loss of appetite, with occasional days of constipa- 
tion and vomiting. Early in August, the symptoms being especially 
bad, he was treated by a doctor, and he improved, but latterly he has 
been worse again. He has suffered much from weakness, palpitation, and 
breathlessness. Appetite poor. Occasionally his ankles have swelled. 

Condition on Admission, — He is, as you can see, very pale, with 
perhaps a slightly yellow tint. 

Circulaiory System. — He suffers from palpitation. The apex is 
very slightly outside the normal position. There is a soft systolic 
murmur at the apex, and a humming murmur in the neck. The lungs 
appear normal. The liver, spleen, and optic disks are normal. There 
is some headache, giddiness, and buzzing in the ear. There are no 
enlarged glands. The rectum is normal. The bowels are open about 
twice a day. 

The Urine, which I show you, is rather dark, and a band of urobilin 
can be seen in the same position as in the other cases ; acid ; specific 
gravity 1012. No sugar, blood, or albumen. Urea, one per cent. 

Blood. — Red corpuscles, twenty per cent. ; haemoglobin, seventeen 
per cent. No excess of leucocytes. 

Temperature. — This varies a fraction of a d^ree either side of 100®. 



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64 INTERNATIONAL CLINICS. 

An examination of the motions did not show them to be suggestive 
of ulcerative colitis. 

Now, the chief feature that all these cases have in common is that 
the ausemia is profound, and therefore it behooves us to consider what 
are the varieties of anaemia. They are, — 

1. Anaemia secondary to some well-defined disease or condition, 
such as severe hemorrhage, severe long-standing diarrhoea, as in ulcer- 
ative colitis, phthisis, syphilis, malignant disease, malignant endo- 
caixlitis, exophthalmic goitre, malaria, etc. 

2. Anaemia due to poisons, as lead and arsenic. 

3. Anaemia due to parasites which suck blood, as Ankylostoma 
duodenale and Bilharzia haematobia. 

4. Primary anaemias, — so called because we do not know the cause, 
but what evidence we have shows that they are due to some primary 
disorder of blood formation or destruction. These are (a) leucocythae- 
mia, (6) Hodgkin's disease, (c) chlorosis, (d) pernicious anaemia, and 
(e) splenic anaemia. Now, with regard to the diagnosis : in the first 
two cases we have had many opportunities of carefully examining the 
patients, and we could never find the slightest evidence that the anaemia 
was due to any of the first three groups, and therefore we were narrowed 
down to that of primary anaemia. Neither of the patients had any 
leucocytosis or any enlargement of the spleen, and consequently they 
were not suffering from leucocythaemia ; the absence of enlargement of 
the lymphatic glands rendered Hodgkin^s disease out of the question ; 
the age of all three and the sex of two negatived chlorosis ; the fact 
that the spleen was not enlarged put splenic anaemia out of court : so 
that we were left with the diagnosis of pernicious anaemia. 

With r^ard to the third case, this line of reasoning renders it very 
probable that he has pernicious anaemia ; but we must remember that 
the history of diarrhoea renders it just possible that he may have ulcer- 
ative colitis, though I think this unlikely, for tlie diarrhoea has been 
too slight to account for the profundity of the anaemia, and the motions 
are unlike those of ulcerative colitis. Also, as the patient has been so 
short a time under observation, it is possible that we may have failed 
to discover some obscure form of malignant disease or phthisis. It is 
very important to bear these two conditions in mind when thinking of 
pernicious anaemia, for they have often been mistaken for it. Lastly, 
when a patient who has had rheumatic fever and who has a cardiac 
murmur is anaemic and seriously ill, we should always think of 
malignant endocarditis; but in this case the duration of the illness is 
very much against such a diagnosis. 



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PERNICIOUS AN.£MIA. 55 

Now that we have arrived at a diagnosis^ the next thing is to point 
out to you that you have in every case of anaemia two sets of symptoms 
to consider. First^ there are those which are simply due to the fact 
that the patient is anaemic ; and, secondly, there are those which are 
peculiar to the particular anaemic disease from which he is suffering, 
because they are caused by the same factors which produce the anaemia. 

I have fastened up on the wall a list of the first group of symp- 
toms, and you will see in the annexed table which of them are present 
in each of our three cases. 

fivmnftnm Present in Pretentln Present In 

symptom. ^3,^^ Case II. CMelU. 

1. PaUor Yes. Yes. Yes. 

2. Blood-changes ". ** »« 

8. Dyspnoea « »« " 

4. Hffimic munnur " " " 

6. Bruitdediable " " 

6. Feeble pulse Yes. " . . 

7. Palpitation of heart " Yes. 

5. Dilatation of heart «« " 

9. (Edema of ankles Yes. " « 

10. Hemonhages " " 

11. Optic neuritis <* << 

12. Headache «« Yes. 

18. Giddiness Yes. " " 

14. Buzzing in the ears " *' 

16. Coma Yes. . . " 

16. Delirium 

17. Dyspepsia Yes. Yes. 

18. Constipation . . '< 

19. Amenorrhoea 

20. Rise of temperature Yes. Yes. Yes. 

21. Wasting " " 

22. Weakness Yes. " " 

28. Patty degeneration of heart (P.M.) . " 

You see, therefore, that these tiiree cases present most of the 
sjrmptoms which are pathognomonic of ansemia quite independently of 
the cause. Of those that are absent, some, as those connected with thci 
circulation, would certainly have been present had the patients not 
been kept quietly in bed ; and the coma and delirium are especially 
characteristic of anaemia rapidly produced by sudden losses of blood. 

Next we have to inquire what are the symptoms peculiar to perni- 
cious ansemia. They are, — 

Fird. The cbaracteristi<f pallor. This is usually of a light lemon 
tint. The man who died showed it admirably. The woman you have 
seen shows it very well, and the man considerably less. Careless ob- 



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56 INTERNATIONAL CLINICS. 

servers mistake it for jauDdice, a mistake that can be avoided by i*emem- 
bering that bile stains the conjunctivae uniformly yellow. Associated 
with this lemon or primrose tint is a soil, delicate-looking condition 
of the skin. 

Secondly. The blood-changes. Earlier observers described many 
variations in the shape of the red blood-corpuscles as peculiar to per- 
nicious anaemia^ but we now know that there are no such alterations 
specially characteristic of this disease. The diminution of red blood- 
corpuscles and of haemoglobin is often very profound^ as in all these 
three cases. It is stated that the diminution of the haemoglobin is 
often not so great as the diminution of the number of red corpuscles^ 
each of which, therefore, contains more haemoglobin than in health ; but 
this, as our cases show, is by no means constant. There is no increase 
of leucocytes. 

Thirdly. Hemorrhages. These are very often well marked in 
pernicious anaemia. They are especially met with in the retina, as in 
our first case. 

Fourthly. Optic neuritis. This is more common 'in pernicious 
anaemia than in most other forms of anaemia. Our second case shows it. 

Fifthly. Rise of temperature. It is very characteristic of pernicious 
anaemia that the temperature should be slightly raised ; usually it is 
about 100^. All our cases illustrate this point. 

Sixthly. Weakness. This is generally very great. 

Seventhly. The urine. Mudi interest attaches to this, for it has 
been shown that in the greater number of cases of pernicious anaemia 
the urine is at some time or other in the course of the illness of a 
very dark color, as you see in the specimens before you. This darkness 
is all the more remarkable since in patients suffering from any other 
form of anaemia the urine is — unless there is some special reason to 
the contrary — pale, the d^ree of paleness corresponding roughly to 
the degree of anaemia. It is rare for the dark urine to be constantly 
present. Usually, as in our cases, it is present for a time, and then 
the urine is pale for some days, and then it becomes dark again, and so 
these irregular alternations go on. This dark color is due to a great 
excess of urobilin in the urine, and consequently there is a broad 
spectroscopic band between the blue and green parts of the spectrum, 
whidi can be seen in the specimens before you. For some time this 
color was stated to be due to pathological urobilin, and a three-banded 
spectrum was described, but this Mr. F. G. Hopkins has shown to be 
an error, the two extra bands being due to the presence of haematopor- 
phyrin in the urine. 



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PERNICIOUS AN.£lfIA. 57 

Pathology. — Pernicious anaemia is a disease in which all of us who 
are at Guy's Hospital feel an especial interest^ for it was Addison who 
first described it^ and his recognition of it as a distinct clinical entity 
is one of the masterpieces of the art of clinical observation. Also the 
publication in Guy's Hospital ReportSj by various members of the 
staff, of an account of the cases that have occurred in the hospital 
since Addison's time has continued the work he b^an, and proved the 
accuracy of his original description. 

Many physicians, and particularly some in Grermany, have not fully 
grasped what is meant by pernicious ansemia. Addison, for clinical 
reasons, said that it was '^ a remarkable form of ansemia occurring 
without any discoverable cause." But it is quite clear that many 
writers who have described cases fail to understand this, and they 
detail cases of severe chlorosis, hemorrhage, etc., as ultimately becoming 
examples of pernicious anaemia. This is manifestly wrong. It is essen- 
tial that for the case to be one of pernicious ansemia none of the usual 
causes of anaemia which we have put in our list should be present. 
No doubt pernicious anaemia has a cause, but we have not as yet been 
able to discover it 

Now, the first step, and a very difficult one, in the case of a rare 
disease, is the recognition of it as a clinical entity. Addison did this 
for pernicious anaemia. Hodgkin did it for Hodgkin's disease. Gull 
did it for myxoedema. The next step is so to advance our knowledge 
that we can prophesy that, if the patient has during life this or that 
ass^nblage of symptoms, a constant characteristic condition will be 
found at the post-mortem. 

During the last few years this advance has been made in the case 
of pernicious anaemia, and now if you diagnose this disease during life 
yon imply that at death it will be found that the quantity of iron in 
the liver is greatly increaseil ; if at the post-mortem this is not so, your 
diagnosis will have been wrong, just as you would be wrong if, having 
diagnosed cirrhosis of the liver during life, when the patient died you 
should find that the liver was healthy. 

The figures I have read to you show that in our fatal case there 
was about twelve times as much iron in the liver as normal. The 
excess of iron is easily demonstrated at the post-mortem, either by 
treating the organ with sulphide of ammonium, when it turns black, or 
by dipping it in a mixture of ferrocyanide of potassium and very weak 
hydrochloric add, when it turns a fine blue color, owing to the forma- 
tion of Prussian blue. This is beautifully shown in the sections under 
the microecope and in the piece of liver you see before you. Some- 



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68 INTERNATIONAL CLINICS. 

times^ if the iDcrease of iron in the liver is not great, the Prussian blue 
does not show well till sections are cut and examined microscopically, 
when it is found most abundantly in the hepatic cells of the outer two- 
thirds of each lobule. ^ 

If, as in this case, the increase of iron in the liver is very great, 
some increase may be found in the spleen and kidneys, but it is never 
anything like as great as in the liver. 

The next question is, how does this iron get to the liver? As it is 
so abundant in this organ, and yet is probably not formed there, for it 
is found only at the periphery of the lobule, it is fair to assume that it 
arrives by the portal vein, which supposition would explain why the 
iron is in the periphery of the lobule ; consequently the following very 
plausible hypothesis has been put forward. There is somewhere in the 
wall of the gastro>intestinal tract a great destruction of red blood-cor* 
puscles : this explains the ansemia. The iron resulting from the destruc- 
tion is stored up in the liver, and occasionally if the amount is very 
great some gets carried into the general circulation, and is met with in 
the spleen and kidney. 

Other results of the breaking up of the red blood-corpuscles are the 
pigment which stains the skin the peculiar lemon tint, and the urobilin 
which darkens the urine. It is not thought probable that the destruc- 
tion of the red corpuscles takes place in the cavity of the gastro- 
intestinal tract, for free iron would not be absorbed, nor are the faeces 
black ; nor that it takes place in the spleen, for the quantity of iron in 
that organ is not much, if at all, increased in this disease ; and there is 
no evidence that it takes place in the pancreas. To see if any sup- 
port can be lent to this view from the presence of gastro-intestinal 
symptoms during life, I have carefully collected the reports of all the 
cases of pernicious ansemia we have had in Guy's since the time of 
Addison. The result * is that forty-one per cent, gave a history of 
vomiting before admission, and thirty-four and a half per cent, gave a 
history of diarrhoea. After admission fifty-five per cent, suffered from 
vomiting, and forty-one per cent, from diarrhoea. Cases in which the 
vomiting and diarrhoea might be due to arsenic are not included in 
these figures. Therefore an analysis of our cases, showing that vomit- 
ing and diarrhoea are very common in pernicious ansemia, to a certain 
extent supports the view that the seat of the blood-destruction is in the 
wall of the gastro-intestinal tract. 

Prognosis. — In order to gain information on this point I followed 

^ Guy's Hospital Reports, vol. zlvii. p. 149. 

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PERNICIOUS AN.£MIA. 59 

up cases that had been in Guy's and had been discharged as improved, 
and an analysis of the results shows that sometimes the patients die in 
a few months from the onset of the disease, as in our fatal case. 

Five cases which were discharged as improved returned later to 
our hospital. The first left in April, but he returned in August and 
died. The second left in February, returned in October, and died in 
December. The third left in July, came back in five months, and died 
four months after his second admission. The fourth left the hospital 
on January 27, having improved; was readmitted June 12 because she 
had relapsed ; again she improved, and left on August 7, but was re- 
admitted October 29, and died November 20. The fifth case was in 
the hospital in 1887 for pernicious anaemia : he improved very much 
and went out. On Mai'ch 5, 1889, he was readmitted for pernicious 
anaemia ; again he improved, and went out on March 13, but on June 
5 he was readmitted for pernicious anaemia, from which he died June 
30, 1889. Thus we see that a very common thing is for the patients 
to get very much better under treatment, then to relapse aft^r a few 
months of fistir health, but perhaps again to get better under treatment. 

This alternation is very well seen in the woman I have shown you. 
The usual course is for the second or third relapse to be exceptionally 
severe, and for the patient to die in it. Recovery is very rare ; still, it 
does occur, and I have recorded two instances of it. One patient, 
though feeble, was well eleven years after the disease first came tinder 
observation. The other patient, four years aft^r he was first seen, was 
in robust health. 

To sum up, we may say that the prognosis is very grave, and you 
must be especially careful not to take too hopeful a view of the case 
because the patient improves under treatment, for in all probability he 
will soon relapse. 

Treatment. — Every observer is agreed that the only known treat- 
ment which will do any good and help to stave ofi^ the end is arsenic 
in full doses, taken immediately after food, together with complete rest 
in bed for a time. Iron has ofien been tried, and it does more harm 
than good, for it upsets the digestion while it does not ap{)ear to im- 
prove the anaemia. I had an opportunity of demonstrating this in the 
wards some six years ago. On the supposition that possibly ihe cause 
of the breaking up of the blood in the portal area is some mi(3x>- 
organism, intestinal antiseptics have been tried, without, however, any 
good result. You will remember we could not make out that the 
woman you saw was any better for taking /9-naphthol, one of the 
most powerfiil intestinal antiseptics. 



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MEDICAMENTS USEFUL IN PULMONARY TUBER- 

CULOSIS. 

CLINICAL LECTURE DELIVERED AT THE PHILADELPHIA HOSPITAL. 

BY SOLOMON SOLIS-COHBN, M.D., 

Physician to the Philadelphia Hospital ; Professor of Clinical Medicine and Thera- 
peutics in the Philadelphia Polyclinic, etc. 



Gentlemen, — I have spoken to you on a previous occasion con- 
cerning the hygienic measures to be employed in the prevention and 
treatment of pulmonary tuberculosis. I shall now say a few words 
concerning the drug treatment of that disease, merely premising that 
in this, as in the hygienic management of the case, each patient must 
be an individual and special study. 

In our application of drugs we have to consider a number of points. 
First and most important is the nutrition of the patient. Drugs that 
will improve nutrition are not many, and they are familiar to you from 
their uses in other conditions. They are those which we call robo- 
rants, hsematinics, tonics, nervines, and cardiants. Among them I 
place arsenic foremost ; the second is strychnine, — not, however, in large 
doses. While both these drugs are given for constitutional effect, acting 
as they do to improve the blood and to stimulate the respiration, circu- 
lation, and organic functions generally, in the details of their use we 
must be guided largely by the effect upon digestion ; for, after all, it is 
to alimentation that we have chiefly to look to preserve the strength of 
the patient, and to bring up his vital forces to that point at which they 
will resist the development of the tubercle-bacillus, the toxsemia and 
the lesions which it causes, and the secondary infections for which it 
prepares the way. Now, alimentation depends largely and in the first 
instance upon digestion. Arsenic and strychnine, therefore, are to be 
used to improve digestion, — locally by their effect upon the digestive 
tract, and constitutionally by their effect upon the blood and the ner- 
vous system. The best form of strychnine is strychnine arsenate, in 
which we combine small doses of arsenic acid with small doses of 
60 



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MEDICAMENTS USEFUL IN PULMONARY TUBERCULOSIS. 61 

strychnine. Strychnine arsenate may be given in doses of one-half 
milligramme (gr. yfy ), or of one milligramme (gr. ^). 

If you give it in the smaller doses, give it frequently ; that is to 
say, in the average case of chronic pulmonary tuberculosis give about 
six doses in the course of the day. If you give the larger doses, give 
about three doses in the course of the day. If it is possible and con- 
venient, and does not concentrate the attention of the patient upon 
drug taking, I prefer the frequent administration of the smaller doses. 
Arsenic may also be given in the form of Donovan's solution or of 
Fowler's solution, in doses of one-half minim before meals, for local 
eflect, or in doses of from two to five minims after meals, for constitu- 
tional effect. When given in solution it is more likely to cause arsenical 
poisoning, if long continued, and one must be on his guard against 
that. The drug may also be given in the form of sodium arsenate or 
as arsenic iodide, concerning which latter salt I shall have something to 
say in another connection. 

In addition to the use of strychnine and arsenic, I usually advise 
the patient to drink one-half pint to one pint of hot water about half 
an hour before each meal or the principal meal. The purpose of this 
is to cleanse the digestive tract, which is usually in a state of catarrh 
from impaired nutrition, and gently to stimulate the mucous membrane. 
Whenever a decided gastro-intestinal disorder exists, it must be treated 
aax)rding to the special indications in each individual case. Lavage 
with alkaline solutions is highly useful in many cases. Turpentine is 
an important remedy, particularly in cases presenting decided intestinal 
catarrh. It may be given in the form of oil of turpentine, terebene, 
or terpin hydrate ; from five to fift^een minims of one of the liquids 
in emulsion with acacia, or from three to five grains of the powder, 
being given, preferably before meals, for local effect, as well at the time 
of absorption as at the time of excretion. 

Ammonium chloride is another remedy which can be used to alle- 
viate gastro-intestinal symptoms. It is more useful than turpentine 
when gastric symptoms predominate. About fift^n grains before 
meals is the average dose. It can be given at the same time as the 
hot water. 

Sodium phosphate is useful under similar conditions, especialFy if 
there is a tendency to duodenal or hepatic catarrh. It may be given 
in half-drachm to drachm doses, in hot water, half an hour before 
meals. It frequently has a laxative and sometimes a purgative effect. 
The dose must be r^ulated accordingly. 

To prevent or check fermentation processes in the alimentary canal. 



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62 INTERNATIONAL CLINICS. 

creosote in doses of one-half minim before meals, hydrogen dioxide 
water (three per cent.) in doses of two fluidrachms, well diluted, before 
meals; salol, beta-naphtol, benzouaphtol, and similar agents, may be 
used. When indigestion or other disorder is manifestly dependent on 
impairment of circulation, digitalis, sparteine sulphate, and remedies 
of that group are indicated. Strychnine may, however, so improve 
the circulation as to render any other drug unnecessary. In a few 
cases nitrites may be usefully given coincidently with cardiac tonics. 

Among roborants, the hypophosphites occupy a prominent place. 
They may be given in capsule, compressed tablets, or syrup. Of the 
commercial preparations of syrup of hypophosphites, I prefer that made 
according to Churchill's formula by a well-known pharmacist of Paris. 
Unlike most of the widely-advertised preparations, it contains not 
seventy, but only two, ingredients ; it is a syrup of hypophosphites 
of calcium and sodium, or, as commercially termed, lime and soda. 
Churchill adopted this combination empirically ; but certain recent in- 
vestigations into the chemistry of the blood in tuberculosis, and into 
the chemistry of food and nutrition in animals insusceptible to tuber- 
culosis, point towards a. physiological explanation for Churchill's ex- 
perience. Syrup of hypophosphites may sometimes be combined with 
iron in cases in which there is diminution of red blood-cells or of 
haemoglobin. While marked diminution of the proportion of red 
cells is not comnion in tuberculosis, there is often considerable reduc- 
tion of the haemoglobin percentage, and probably of the total volume 
of blood. In such cases the combination of iron with arsenic or with 
the hypophosphites is extremely useful. 

A good formula for this iron combination, originally suggested by 
J. Solis-Cohen, is the following : 

Tincture of chloride of iron, 2 fluidrachms ; 

Diluted phosphoric acid, 3 fluidrachms ; 

Churchill's syrup of hypophosphites, enough to make 8 fluidounces ; 

the dose being a dessertspoonful in water after meals. 

And then comes cod-liver oil. You note that I place it last 
Cod-liver oil is of much utility as a food and as a menstruum for the 
administration of certain remedies. I do not think that it has any 
other therapeutic value. It is a useful food; and when you can- 
not get patients to take enough food without it, and especially enough 
fatty food, it should always be prescribed. But when the patient is able 
and willing to take butter, meat-fat, salad oil, and cream in sufficient 
quantity, the necessity for ood-liver oil as a food usually disappears. 



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MEDICAMENTS USEFUL IN PULMONARY TUBERCULOSIS. 63 

Sometimes^ when a patient seems unable to take or digest fatty food, 
the administration of compound spirit of ether, one or two flui- 
drachms before or just after meals, or of some preparation of the pan- 
creas or of bile, will answer a useful purpose. Cod-liver oil may be 
employed as a menstruum, especially for creosote ; and that brings me 
to the other class of remedies, those which correct morbid cell-action 
and combat toxaemia. While I am not convinced that the bacillus 
tuberculosis, per se, does much harm to a patient, I do believe that the 
toxaemia resulting from the presence of tubercle-bacilli in the lungs, 
through the chemical processes set up by their activity and the activity 
of various other microbes for which they prepare the soil, causes very 
many distressing symptoms, and may finally kill the patient. The 
fever, the night-sweats, the loss of appetite, the emaciation, the rest- 
lessness, are probably directly and indirectly due to the absorption of 
various toxins. To combat that toxaemia we have two remedies of 
prime importance : creosote and iodine. Iodine may be given in various 
forms : of these I place first iodoform, and second ethyl iodide. Iodo- 
form is not a germicide of high rank, but it has, when applied locally, 
a corrective influence over the histologic processes of tubercle forma- 
tion, and probably acts in somewhat the same manner when taken 
internally. When a patient can take iodoform, — when his stomach is 
not against it, and when it does not cause distressing symptoms, — it is 
extremely useful, and should be pushed to the point of tolerance. It 
may be given in capsules, with correctives for stomach-trouble, if you 
like, or may be given in pill-form, with glucose. Sugar-coated and 
gelatin-coated pills are in the market, but, as a rule, are not to be de- 
pended on. Certain changes take place after a while that render them 
insoluble and irritating. Extemporaneous manufacture is best. With 
antitubercnlous and antitoxsemic medication, roborant medication may 
be combined. A combination that I have prescribed for some years 
consists of: 

Reduced iron, ] grain ; 

lodofonn, 1 to 6 grains (increased accordinjf to tolerance of patient) ; 

Arsenic iodide, ^ grain to -^ grain ; 

And enough (say 2} grains) balsam of Peru to make up the maes, which is 

given in capsule. 
Dose, one capsule after food, thrice daily. 

Most patients can take this without trouble ; in other cases we have 
to give with it small doses of opium or of extract of hyoscyamus for the 
sake of the stomach. Some patients cannot take it even then. A 
patient taking iodoform, pushed to the point of tolerance, and observing 



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64 INTERNATIONAL CLINICS. 

the hygienic measures of which I have spoken, will often surprisingly 
recover strength and weight. I have at present under my care a man 
some forty-five years of age, whom I first saw about four years ago 
with pulmonary hemorrhage. He has not fully recovered, some laryn- 
geal lesions persisting, but he has remained for two years in fairly good 
• condition, the lungs presenting to percussion and auscultation no evi- 
dence of active morbid process. He has been taking iodoform at 
intervals and for months at a time, and now weighs about one hundred 
and ninety pounds. This is about what he weighed when first taken 
sick, perhaps a few pounds heavier. In a patient seen at the Jefferson 
Hospital some seven or eight years ago there was a gain of eleven 
pounds in two or three weeks under the combined administration of 
iodoform and large quantities of milk. Iodine may likewise be given 
as arsenic iodide, as calcium iodide or strontium iodide, as compound 
tincture or compound solution of iodine, as syrup of hydriodic acid, 
and by inhalation as ethyl iodide. The latter has sj^ecial indications. 
Drs. Shurly and Gibbes advocate hypodermatic injections of iodine 
dissolved in glycerin with the aid of potassium iodide, as part of a 
special routine which includes injections of gold-and-sodium chloride 
and inhalations of diluted chlorine gas. In general, iodine is to be 
employed in the early stages of chronic forms of pulmonary tubercu- 
losis, especially in scrofulous subjects, and even in advanced cases when 
there is but slight tendency to softening or cavity formation ; in other 
words, when proliferation exceeds necrosis. Some patients, however, 
are unable to take iodine in any form, and then we have to fall back 
upon creosote. This also has a special indication when there is much 
catarrhal inflammation of bronchi or alveoli, when there is rapid 
softening or decided cavity formation, and when there is a tendency to 
high or prolonged fever ; in other words, when desquamation or necrosis 
is active, or sepsis is marked. Jaccoud believes that creosote favors 
fibrosis, on which, as we have previously seen, local healing depends. 
In my own view this action is indirect, being due rather to removal of 
hindrances to healing than to direct stimulation of reparative processes. 
Whatever the method, the result is good. The drug should be pushed 
nearly but not quite to the point of tolerance. I have already said 
that creosote may be usefully given in small doses, such as one-half 
minim three times a day, before meals, as a corrective to stomach- 
disorders ; but when employed against the toxaemia of tuberculosis it 
should be given in comparatively large doses. The best way of giving 
it, on the whole, is in milk, if the patient can take it, running up to 
about five minims of creosote in a tumblerful of warm milk, four times 



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MEDICAMENTS USEFUL IN PULMONAHY TUBERCULOSIS. 65 

a day^ taken between meals^ so as to supply the patient with that much 
extra nutriment. 

Success with the prescription of creosote will depend largely upon 
whether the patient really uses creosote or something else. Most of the 
stuff that is sold for creosote is principally something else. There are 
two brands of creosote in the market upon which one can depend. 
That which I have used for the longest time, and with which I am 
perfectly satisfied, is '^ Morson's Beecbwood Creosote/' which is made 
in England. More recently there has been brought into this market a 
beech wood creosote, made in Grermany and highly recommended by 
Grerman authorities in whom I place confidence ; but my own recom- 
mendation, from my own experience, is Morson's, and that is what I 
usually prescribe. If you simply write *^ creosote,^' and let the druggist 
give what he pleases, which will often be the cheapest article he can 
buy, you may get no result, or may irritate the patient's stomach to suoh 
a degree that he will refuse to take the drug ever afterward. When 
creosote cannot be given in milk it may be given in capsule. Capsules 
of creosote and cod-liver oil are made. A useftil preparation is the 
combination with morrhuol put up in capsules by Chapoteaut, of Paris. 
Creosote may be given in cod-liver oil without capsules. Put half an 
ounce of cod-liver oil in an ounce phial, add the dose of creosote, and 
then let the patient shake it well and swallow the mixture. Some like 
it ; they say it tastes like fat mackerel. Creosote may be given with 
alcohol and glycerin. I ofi;en add tincture of cardamom to suoh a 
mixture. 

Dr. W. H. Flint, of New York, claims excellent results from the 
administration of creosote by the rectum. I think he suspends it in 
oil or milk. I have not tried the method, but I do not doubt its 
usefulness in any case in which the patient's stomach would not tolerate 
the creosote. I have given eucalyptol in that way, — useftdly, I think, 
— suspending it in mucilage of acacia or dissolving it in olive oil. 
When I cannot get patients to take creosote, however, I resort, if the 
expense is not a hindrance, to a salt of guaiacol. The salicylate, the 
carbonate, and the benzoate are now in the market They are almost 
tasteless, and any one of them may be administered in powder, pill, 
cachet, or capsule, in doses of three to five grains, three to five times a 
day. I prefer the salicylate, as the salicylic acid is useful. When the 
giuuacol salts are too expensive, I use phenyl salicylate in correspond- 
ing doses. There is now in the market a so-called carbonate of creo- 
sote which is highly recommended. Carbonic acid is a gastric sedative, 
and hence this combination may be useful. 
Vol. I. Ser. 4.-5 



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66 INTERNATIONAL CLINICS. 

When we wish to administer creosote or iodine so as to affect the 
respiratory tract especially, we resort to inhalation. First as to iodine. 
The most convenient form is ethyl iodide, or hydriodic ether, as it used 
to be called. Although it belongs to the ethers, it is twice as heavy as 
water, in which it will, therefore, sink. And this is one means of ad- 
ministering the drug : take a wide-mouthed four-ounce phial, put in a 
tablespoonful of water, and drop into that five drops of ethyl iodide, 
which will sink to the bottom. Then, as the drug is volatile, the 
warmth of the patient's hand as he grasps the phial will cause the 
vapor of the ether to rise through the water, diffusing through the air 
above it, and the patient can place the bottle to his mouth and inhale. 
This method may be used when you wish the patient to have a measured 
dose of the iodide. I rarely, however, give a measured dose ; I let the 
patient take in his hand an ounce phial containing originally one-half 
ounce of ethyl iodide, and inhale by simply holding the unstoppered 
bottle to his mouth or nostril. It should be an amber-colored bottle, 
and, when not in use, kept cool and away from the light, to prevent 
decomposition of the contained drug. Let the patient inhale the medi- 
cament through the nose and mouth from one minute to five minutes, 
gauging the time by his susceptibility. Some persons become vertigi- 
nous in a short time, some in two or three minutes, and others not 
until after quite a long time. By this method there is systemic absorp- 
tion of iodine, and the drug likewise exercises a useful influence upon 
local inflammations and ulcerations in the respiratory tract, especially 
in the larynx, both when inhaled and, later, when eliminated. Part of 
the usefulness of the terebinthinates, of creosote, and of iodine prepa- 
rations, when given by the mouth, skin, or rectum, is likewise due to 
local effect during elimination by the respiratory mucous membrane. 
Some physicians oppose inhalations in pulmonary tuberculosis because 
the method does not bring the drugs in contact with the bacilli in the 
lungs ; but these drugs are not employed with any such purpose. They 
certainly do not act by killing tubercle-bacilli, either in elimination or 
in absorption, but they nevertheless do good. Don't get the idea that 
the purpose of inhalations or of antitoxaemic medication is bactericide, 
for it is not. Action upon the cells and fluids of the body is what is 
aimed at ; and while we cannot at present explain that action, its effects 
can be clinically recognized. A convenient method of inhalation is by 
means of the little perforated zinc respirator devised by Dr. Bumey 
Yeo, of London (Fig. 1), or a similar appliance made of perforated 
celluloid. 

In addition to ethyl iodide, I have found creosote, terebene, eu- 



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MEDICAMENTS USEFUL. IN PULMONARY TUBERCULOSIS. 67 

calyptol, thymol, menthol, and chloroform useful, by inhalation, in 
relieving cough, promoting the healing of laryngeal and bronchial 
catarrh, and disinfecting the contents of 
bronchiectases and accessible vomicae. For _ 

use on the sponge of the Yeo respirator, 
a mixture of equal parts of creosote, tere- 
bene, ethyl iodide, and spirit of chloro- 
form is a favorite prescription. Twenty 
drops is about the quantity used at one 
time, and it is renewed about twice daily. 
In cases of laryngeal ulceration, menthol 
(twenty per cent.) in olive oil has been 
useful topically, though there are other and sometimes better applica- 
tions. These drugs in oily solution may likewise be injected into the 
trachea and allowed to run into the bronchi and lungs, for local effect. 
I show you here a curved hard-rubber syringe, the nozzle being per- 
forated so as to send the finely-divided stream in several directions. 
Inserting this by a rapid motion between the vocal bands, a drachm of 
sterilized olive oil, containing five minims of creosote or three minims 
of guaiacol, is gently injected into the trachea. In some cases the 
solution may be made stronger. You see how little distress it causes, 
and especially in bronchiectatic cases it seems to he extremely useful. 

Such is a general otftline of the medication useful in chronic pul- 
monary tuberculosis. I have said nothing of intrapulmonary injec- 
tions, as that subject is deserving of a special lecture. 

In acute cases, and in the more acute stages of chronic cases, rest in 
bed, the application of an ice-b^ over the prsecordium to reduce tem- 
perature and quiet the heart, the inhalation of nitrous oxide, — say two 
gallons at a time (eight gallons in all), before twelve o'clock noon, daily, 
to check cough, reduce febrile and nervous excitement, and promote 
sleep at night, — and the administration of opium, of codeine, of mor- 
phine, of digitalis, of phenyl salicylate, of quinine hydrobromate, are 
among the measures most useful in varying conditions. To check 
hemorrhage, rest, ice over the heart, ice in the mouth, turpentine, and 
calcium chloride internally ; to check night-sweats, atropine, picrotoxin, 
camphoric acid internally, sponging with alcohol and quinine; to 
check cough and vomiting, codeine, hyoscine hydrobromate, strontium 
bromide, and dilute hydrocyanic acid ; to relieve dyspnoea, quebracho 
and strychnine, — are among the most approved remedies. Do not give 
several drugs at once, but try to select one, such as codeine or turpen- 
tine, for example, which meets several indications. Do not n^lect a 



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68 INTERNATIONAL CLINICS. 

patient because he cannot recover. Even when all hope of promoting 
recovery or prolonging life is gone^ palliation^ the promotion of com- 
fort, the lessening of pain and distress, are objects well worthy of your 
highest skill. All thb, however, is but the extended application of 
principles familiar to you. 

As to treatment that aims at the promotion of recovery, I beg that 
you will remember, as the sum and substance of my teaching, that 
there is no ^^ specific'' in the treatment of tuberculosis; that each case 
must be an individual study ; that, above all, drug giving is second- 
ary to food, water, light, and air, oiu* aim being not microbicide, but 
nutrition. 



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AMCBBIC DYSENTERY. 

CLnriCAL LBCTUBX DBLIYEBBD AT THE BUFFALO GEKBRAL HOSPITAL. 

BY CHARLES O. STOCKTON, M.D., 

Professor of Medicine at the UDivenity of Buffalo ; Attending Phyiician, Buffalo 

Qeneral Hospital. 



Gentlemen, — ^This patient is a German teamster, forty-eight 
years old, whose fiunily and personal history are without interest in 
relation to his present illness. About six weeks ago he b^an to fail 
in health, but his symptoms were vague. Three weeks thereafter he 
was seized with acute abdominal pain and diarrhoea. There is some 
doubt as to whether or not he vomited, as his statements are conflicting. 

He entered the hospital ten days since, very weak and emaciated, 
having a brown, dry tongue, loss of appetite, and from ten to twenty- 
five evacniations daily. There was slight abdominal tenderness, but no 
distention. His temperature was 99^ F., and his pulse 80, weak and 
small. He was given calomel on entrance, and thereafter received 
large hot lavements and laudanum and starch-water injections without 
benefit From the defecation-book I learn that his evacuations have 
occurred as follows : 



First night 8 

Second night 7 

Third night 6 

Fourth night 6 

Fifth night 6 

Sixth night 4 



First day 10 

Second day 

Third day 20 

Fourth day 17 

Fifth day 8 

Sixth day 16 



For sixteen hours he has had no passage. As now seen, the patient 
is emaciated and extremely debilitated, requiring constant and full 
stimulation. There is but slight elevation of temperature. The pulse 
is weak, and at times almost imperceptible. It has risen in frequency 
from sixty to one hundred and ten beats per minute. His weakness is 
also shown by the shrunken appearance of his face, and by the relaxa- 
tion of the body. His decubitus is that of prostration ; he lies low 
in bed, with little power to move, so that he remains about as we put 
him. His tongue is protruded slowly. It is rather narrow, dry, and 

69 



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70 INTERNATIONAL CLINICS. 

heavily coated. Grenerally it is drier and browner than at present, its 
improved appearance being due to local applications. You will notice, 
also, that the patient is hiccoughing, and this is simply an expression 
of his enfeeblement. This hiccough has been present at intervals for 
thirty-six hours, and is, as you are aware, a most unfavorable prog- 
nostic symptom. The abdomen is natural in appearance ; it is neither 
tympanitic nor flat. He complains of quite general tenderness on 
pressure over the abdomen. Careful examination, however, reveals the 
fiict that there is greater tenderness over the region of the colon 
throughout its entire length than elsewhere. 

So much for the general description of the case. The evacuations 
from the bowels contained at first mucus and blood. They have 
always keen very fluid, very offensive in odor, and at times have 
contained a yellowish sediment. In this bottle you will see an evac- 
uation of this morning, and, except that medication has rendered 
it darker than usual, it exemplifies the character of the diarrhoea. 
Above the sediment you will notice a comparatively clear serous dis- 
charge without mucus or blood. There is no evidence in it of a hurry- 
ing down of food, undigested, and therefore we cannot consider the 
case one of serous diarrhoea due to trouble with the small intestine. 
If the character of the discharge was similar to this except for the 
presence of mucus and blood, and with the symptoms of pain, fever, 
and tenesmus, then we should pronounce the disease an acute colitis or 
dysentery. The local tenderness over the colon in this case su^ests a 
colitis, but not of the ordinary kind, both because the character of the 
discharge does not correspond, and because of the low temperature ; the 
absence of excessive tenderness and of tenesmus is inconsistent with 
the idea of an acute colitis. The facts that this case did not seem 
like one of ordinary colitis or diarrhoea, tjiat the man was gravely ill, 
and that the trouble began later in the season than do most diar- 
rhoeas, led me to have his stools examined, with the idea that we might 
find in them the cause of tropical dysentery. This disease, which is 
not common in this section of the country, depends upon a micro- 
organism, a representative of a low form of animal life, — ^an amoeba. 
The disease has, therefore, been termed " amoebic dysentery," and the 
micro-organism the " amoeba coli," or, by Councilman, the " amoeba 
dysenteriee." These amoebae, as I expected, were found in great numbers 
in the stools of this patient by Dr. Bergtold, and, later, by several of us. 

This amoeba has a diameter two or three times that of a white 
blood-corpuscle, — that is, twenty or thirty micro-millimetres. It has a 
nucleus, and around the nucleus a granular mass, and two or three or 



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AMCEBIC DYSENTERY, 71 

more vacuoles which are characteristic of amoebae. Around this is a 
perfectly clear zone with a very distinct^ dark boundary. Like all 
amoebee, it has the power of making the so-called amoebic movements 
by putting out projections of its mass called '^ pseudopods'' and then 
drawing itself forward by means of them. The pseudopods of this 
amoeba are large masses^ not slender filaments^ as in the case of other 
amoebse. It assumes, therefore, not always a circular outline, but some- 
times one suggestive of a human foot, sometimes one almost rectangular, 
and again, various insularities. According to my observations, the 
amoeboid movements are made«quite quickly, aud then there is a pause. 
These movements are only to be noticed when the fresh discharge is 
examined. After a short time the amoebse die, and it is difficult to 
determine their nature. These bodies are very easily discovered by a 
microscope of faur power, and are easily recognized after having once 
been seen. I had the privil^e of seeing these organisms with Council- 
man, in a case that he subsequently reported, two or three years ago. 
The post-mortem appearances in such a case are striking. The changes 
in the tissues brought about by the amoebse are quite unlike those of 
ordinary dysenteric inflammations. The ordinary dysenteric stool con- 
tains pus, mucus, and broken-down tissue; but especially pus. On 
the contrary, pus-corpuscles are rarely found in the discharges of amoebic 
dysentery, although you will find broken-down tissue and fatty de- 
generation showing itself in the epithelium. On examining the l)owel, 
you will find ulceration occurring in any part of the colon, and some- 
times in the ileum, but especially in the transverse colon. The ulcers 
are in the b^'nning round or ovoid, but later they become insular, 
from a softening and liquefaction of the intercellular substance which 
holds together the connective tissue. The parenchymatous cells, also, 
are dissolved, but later than the connective tissue, so that there is left 
an overhanging wall, a bank-like projection, on the margins of an ex- 
cavated ulcer. Sometimes the ulcers meet beneath the submucosa, or 
beneath the transverse layer of the muscular coat. Occasionally the 
ulceration goes even deeper, and passes entirely through the longitudinal 
muscular coat. It rarely causes a complete perforation of the bowel, 
when, of course, peritonitis is set up, and, unless altered in its character 
by the presence of other micro-organisms of the pus-forming kind, it 
will be as distinct and peculiar as the disturbance in the bowel itself. 

It has been noted that certain epidemics of dysentery have been 
followed by many instances of abscess of the liver. Careful study of 
amoebic dysentery shows that hepatic abscess takes place in a far larger 
proportion of cases of amoebic dysentery than in other kinds. In some 



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72 INTERNATIONAL CLINIG8. 

groups of cases the proportion complicated with hepatic abscess has 
been fifty per cent., in other groups forty per cent, thirty per cent., or 
twenty-five per cent. When you examine the hepatic abscess as I have 
had the opportunity of doing, you will find that that also has the same 
peculiar character as the ulcerative process in the bowel. It is not an 
ordinary d^eneration of suppuration, but there is a mass of broken- 
down liver-tissue apparently liquefied and containing changed hepatic 
cells. The abscess has irregular walls, and upon them new cells have 
apparently rushed in to protect against the advance of the degenerative 
process. In abscesses which have healed, a hard, dense, limiting struc^ 
ture lines the cavity. In these respects the pathological changes of 
amoebic dysentery are peculiar to it alone. 

The amoeba coli was discovered in 1859, by Lambl, a Grerman ob- 
server. Later, it was studied by Losch, who correctly attributed the 
peculiar dysentery which he found, clinically, to this organism. Later 
still, Cartulis, of Egypt, found that this amoeba was a very common 
accompaniment of dysentery in that country, and particularly in the 
dysentery of European residents. The native Egyptians are nearly 
exempt The disease is more common in Algiers than in I^ypt ; but, 
on the whole, it is mudi more common in warm climates than in cold 
ones. In this country it was studied first by Osier, who discovered it 
in a sailor who came from (Jalveston or Panama. Since then it has 
been observed in several cities of this country, and I believe also in 
Montreal. The amoeba coli was first found in this city by Dr. Herbert 
Upham Williams, in a case which I had last summer. This is the 
second case in which the amoeba has been demonstrated in Buffalo. 

You will find a good description of the disease in the Transactions 
of the Association of American Physicians for 1892. 

You may ask me why I was led to consider this case as other than 
a common dysentery. In ordinary dysentery the symptoms are quite 
different The patient is suddenly seized, vomiting is more frequent 
and persistent, the temperature is higher, the inflammation is more 
nearly like ordinary inflammation due to pyogenic bacteria, and, conse- 
quently, the dejecta contain not so much serum as muco-pus and blood. 
The disease, too, runs a shorter course, usually not more than a week 
or ten days. Amoebic dysentery does not resemble closely the severe 
form of epidemic dysentery with the formation of a croupous exudate, 
for, while both are accompanied by severe depression, the former has 
not the immense amount of shreddy croupous exudate coming away 
in the fecal discharges, and the microscopic examination for the amoeba 
coli makes a definite diagnosis possible. 



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AMOSBIC DYSENTERY. 73 

Amoebic dysentery is a somewhat prolonged disease, lasting from six 
to twelve weeks, and it is a dangerous affection. While some reports 
show that about twenty-five per cent, of the cases are fatal, the cases 
studied in this country, particularly in Baltimore, have resulted in a 
mortality of nearly ninety-five per cent. 

The treatment is, of course, directed towards supporting the patient, 
for, whether the amoeba is alive in the intestines or not, the poisons 
produced by this organism cause marked depression, calling for stim- 
ulation and careful diet. Local measures are undertaken with the hope 
of destro}ring the parasite, and quinine in solution has been found of 
apparent benefit. Even a 1 to 6000 solution has proved sufficiently 
strong, and Osier has used enemata varying from this strength to 1 to 
1000. Although these enemata destroy the organisms wherever they 
can be reached, it is manifest that they cannot reach the amoebse lying 
in the overhanging wall of the ulcer, or in the Ijrmphatics, or in the 
hepatic abscesses. As these abscesses are most frequently in the right 
lobe of the liver, it is not unusual for the inflammation to extend 
through the diaphragm to the right pleura, and thence to the lung, 
wh&re abscesses may be formed. The expectoration in these cases has 
been found to contain living amoebee, and the immediate cause of death 
in this form of dysentery has sotnetimes been the pulmonary abscesses. 
Besides washing out the bowel for the sake of cleanliness, injections of 
starch-water and laudanum have been beneficial in lessening the number 
of evacuations. 

In the present case the outlook is a very serious one. With hic- 
cough and great prostration in spite of the fact that everything has 
been done to support his vitality, with the poisoning going on continu- 
ally, and with the probability that abscesses have formed in other parts 
of the body, the lethal result is daily expected. 

I am very glad to show you this case, for the disease, though more 
wide-spread than was believed a few years ago, is, in this section, still 
rare. But it is necessary for you to be able to recognize even the in- 
frequent diseases, for your practice will not be limited to common affec- 
tions. I am certain that I have seen a number of cases of amoebic 
dysentery, especially when physician to the penitentiary, where there 
were many prisoners from the South, and these cases passed unrecog- 
nized simply because I was unacquainted with the disease. 

[Note. — This patient died three days after the delivery of the 
lecture. The changes in the colon and liver, as revealed by the autopsy, 
corresponded with the description above given.] 



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ENDOCARDITIS AND PERICARDITIS; EXOPHTHAL- 
MIC GOITRE; EMPYEMA; NERVOUS JAUNDICE. 

CLINICAL LSCTUBB DBLIYEBED AT THE CHICAGO POLICLINIC. 

BY JOSEPH M. PATTON, M.D., 

Professor of Clinical Medicine in the Chicago Policlinic, etc. 



ENDOCAKDITIS AND PERICARDITIS. 

Gentlemen, — This young lady is seventeen years of age. She 
had always been healthy, until about six weeks ago, when she was 
taken with manifestations of acute rheumatism, located in the joints, 
which, her physician tells me, pursued no unusual course. About a 
week after the commencement of the rheumatic attack I was called to 
see her in consultation because of the symptoms, which were attributed 
to her heart. Three or four days before I was called to see her she 
had developed a systolic murmur in the region of the aortic valve. 
The murmur had the usual cliaracteristics of aortic stenosis. The 
heart was rapid and excitable, but there were no unusual manifesta- 
tions imtil the time I saw her, a few days later. At that time, the 
physician in charge noticed that the previously strong, energetic beat 
of the heart had become less perceptible, and the motion more heaving 
and undulating in character. The heart seemed to work harder, and 
there was more dyspnoea. At the time that I saw her, the tempera- 
ture was about 100.5°, the pulse was rapid and irregular, and there 
was considerable dyspnoea, but no cough. 

Examination of the heart showed that the area of motion was in- 
creased, the apex-beat could not be distinctly located, the motion was 
rather heaving and undulating in character, and extended all over the 
cardiac area. The heart was evidently working hard and energetically, 
and yet the previous well-defined apex-beat was lacking. Percussion 
showed that the dulness extended from the second intercostal space to 
the sixth, and from one-quarter of an inch to the right of the sternum 
along the right parasternal line to about the left nipple-line. The dul- 
ness was wider below than above. Auscultation showed a blowing, 
74 



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ENDOCARDITIS AND PERICARDITIS. 75 

systolic marmar in the aortic area, which was transmitted into the ves- 
sels of the neck, and which was evidently an aortic stenosis caused by 
rheumatic inflammation about the aortic valve. The murmur was not 
nearly so distinct as it had been a few days previous. The first sound 
of the heart was mufi9ed and indistinct, although the heart was labor- 
ing with considerable force. At the base of the heart there could be 
heard at times a harsh, rubbing double sound, which was evidently a 
pericardial friction-sound. A diagnosis was made of endo- and peri- 
carditis, of a rheumatic nature. She was kept on anti-rheumatic 
treatment ; a blister had been applied to the pericardial r^on, and it 
was allowed to remain until it had acted sufficiently. In the course 
of a week the area of dulness had decreased markedly. The heart 
was not laboring so strenuously, the friction-sound at the base was 
more apparent, and she was improving in every respect, and went on 
to recovery. I show her to you to-day because you may still hear the 
dry, rubbing friction-sound at the base of the heart, but not so clearly 
as it could be heard a week ago. 

These cases of combined inflammation of the endocardium and 
pericardium in the same subject are somewhat rare. They are usually 
associated with rheumatism. 

The diagnosis is usually not very difficult, especially when you get 
the signs of efiiision as clearly as they were obtained in this case ; but 
where the two conditions are associated, it may be difficult to distin- 
guish between an endocardial and a pericardial murmur. Endocardial 
murmurs are sofler, and are either systolic or diastolic. Pericardial 
murmurs are harsher, more apt to be rubbing, and are usually double. 
They are not transmitted, and they are apt to disappear sooner than 
endocardial murmurs. Small amounts of fluid in the pericardial sac 
may be difficult to recognize ; large amounts, sufficient to distend the 
sac, will increase the area of dulness in a direction unlike that given 
by enlargement of the heart itself. The dulness may extend as high 
as the first rib and as low as the sixth, and from an inch to the right 
of the sternum to the left of the nipple, but usually the limits are 
much more circumscribed than this. The dulness is more or less 
pyramidal in shape, being wider at the bottom. There may be some 
change in the lines of dulness when the patient changes position. 
Dulness in the fifth intercostal space to the right of the sternum is 
stated by Rotch to be diagnostic of even very small effusions, and to 
be a valuable diagnostic sign. Roberts also states that this sign is of 
value where aspiration of the pericardium may be demanded. 

Effusion into the pericardial sac may be confounded with pleural 



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76 INTERNATIONAL CLINICS. 

effaeioii^ but the dulness of pleural effusiou will extend lower, and 
farther around to the side and back. The respiratory sounds in the 
infra-scapular r^ion in the back are very seldom interfered with, ex- 
cept in very large pericardial effusion ; whereas in pleurisy they will 
be modified by small efiiision. The valuable point in diagnosing be- 
tween these two conditions would be the displacement of the apex- 
beat, which nearly always occurs with pleural effusions, even if they 
be small in quantity and circumscribed. 

The diagnosis between these two conditions, of course, would be 
between efiusion in the left pleura and effusion in the pericardium ; 
and therefore this displacement of the apex-beat in pleural effusions is 
a decidedly valuable sign. 

The question of aspiration of the pericardium will occasionally 
present itself in these cases, and in deciding the necessity of such a 
procedure you must bear in mind that rheumatic effusions into the 
pericardial sac tend to get well of themselves, and usually the fluid 
disappears about as rapidly as it came ; therefore they are to be treated 
conservatively, and not interfered with unless the danger to the heart 
is imminent. If the pressure of the fluid on the heart so interferes 
with the action of that organ as to produce great dyspnoea and failing 
circulation, the sac should be aspirated. This is best done by an ordi- 
nary aspirator, or by a small one, where the current can be reversed. 
The needle should be entered from half an inch to an inch to the 
left of the sternum, in the fifth intercostal space, in a direction back- 
ward and upward. As soon as the needle enters the tissues, the vacuum 
should be turned on, and the needle then advanced in search of the 
efiusion. Sometimes the fluid can be reached by inserting a needle at 
the apex of the notch between the xiphoid appendix and the cartilages 
on the left side. It is possible that some cases may be aspirated imme- 
diately to the right of the sternum, but this must be the exception. 

An interesting prognostic question in regard to these cases is the 
liability to permanent adhesion between the two surfaces of the peri- 
cardium. This is a condition which we are practically unable to diag- 
nose. There are no positive signs of its occurrence. Some writers 
have designated signs for the recognition of its occurrence, but they 
are more or less unreliable. Hope has stated that an irr^ular, jog- 
ging, trembling motion, very abrupt in its character, is distinctive of 
adhesions between the two surfaces of the pericardium. Aran has 
claimed that in this condition there is a loss of the second sound. 
We oftien see cases where both of these conditions are present and yet 
adhesion has not taken place. Perhaps the most reliable sign is that 



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EXOPHTHALMIC GOITRE. 77 

given by Skoda^ where there is systolic retraction of the intercostal 
spaces, and perhaps, also, some depression of the lower end of the 
stemam. There is apt to be arhythmia associated with adhesion of 
the pericardial surfaces, but it is not in any way distinctive, and I 
have seen cases where this condition has obtained, yet in which none 
of these signs were present daring the life of the patient. Where the 
pericardium has become adherent to the sternum this adherent condition 
has been termed indurated mediastinal pericarditis. Bands from these 
lesions may compress the aorta, and resulting from these conditions 
Kussmaid has described the pulsus paradoocuSj — a pulse which dis- 
appears with full inspiration. Traube has noticed this sign in cases 
where the mediastinum was not involved. 

This young lady, while the pericardial friction-sound can yet be 
heard, is rapidly improving: the sound is growing weaker. The 
endocardial murmur still remains, and in all probability the aortic 
valve has been permanently affected. How much the blister had to 
do with the improvement in her case it is difficult to say. Blisters 
are objected to by some writers for this disease, and very often we 
see them entirely fail. We will continue her for some time on anti- 
rheumatic remedies, such as sodium salicylate and potassium iodide, 
with iron, arsenic, and stiychnine as general tonics. 

EXOPHTHALMIC GOITRE. 

This young lady is twenty-one years of age. She has never suf- 
fered from any special illness previous to the present one, although her 
menstruation developed early and was never very r^ular. She has 
been suffering from some dysmenorrhoea, with, at times, a little menor- 
rhagia, but not enough to demand any treatment for either of these 
conditions. She says that about four months ago she begain to notice 
some palpitation of the heart. This troubled her at intervals, — more 
when under excitement or mental strain than on exertion. About a 
month afler this she b^an to notice some prominence of the eyes, and 
about the same time her attention was called to some enlargement of 
her throat While these two symptoms developed about the same 
time, she thinks that the prominence of the eyes was present before the 
enlargement of the throat. The latter symptom, she tells us, was first 
noticed after some unusual mental excitement, and developed within 
the space of two or three days to the size which we see presented now. 
The thyroid, you notice, is quite large, — somewhat larger on the left 
than on the right side. It is not very firm. There is no murmur 
present in the gland. Examination of her heart shows it to be 



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78 INTERNATIONAL CLINICS. 

slightly dilated. There ai'e no murmurs present in the heart The 
action is rapid, the pulse being now 130. There is at times consider- 
able arhythmia, which varies greatly under different mental conditions. 
Her eyes, you see, are quite prominent, the right being a little more so 
than the left. She thinks that they are more prominent about the 
time of her menstruation, and both the eyes and the neck sometimes 
are apparently worse after mental excitement Stellwag^s sign, of 
widely-open lids, showing more of the sclerotic than usual, is slightly 
shoVn in the right eye. Von Graefe's sign, the incoordination of the 
after-following lid when the patient looks down, does not show in this 
case. Examination of her eyes in the ophthalmological department 
shows that Becker's sign, pulsation of the retinal vessels, is present to 
a slight d^ree. Moebius's sign — that is, insufficiency of convergence 
— is present in this case. Spasm of the elevator of the upper eyelid 
is said to be pathognomonic ; it is not marked here. This is a typi- 
cal case of exophthalmic goitre, in which the three cardinal symp- 
toms are all present and have developed in a comparatively regular 
manner. As a rule, the cai'diac symptoms — that is, the rapid and 
arhytlimic action of the heart — develop early in these cases. They 
may, however, succeed the enlargement of the thyroid and the exoph- 
thalmos. There may be only one of these classical symptoms pres- 
ent, or they may all three be present. The value of the various signs 
mentioned as diagnostic aids is somewhat difficult to estimate. In the 
eases that I have seen, Moebius's, Becker's, and Stellwag's signs have 
l)een present in the order mentioned. Von Graefe's sign has seemed 
to be the least reliable of any of them. Of the cases that I have 
noted in which Von Graefe's sign was present, a large proportion were 
males. My experience with this disease has practically been limited 
to females, and whether Von Graefe's sign is most often present in 
males I do not know. 

The various manifestations of the disease which may present them- 
selves will occur alike on both sides, which will aid in distinguishing 
the. symptoms of this disease from like symptoms produced by press- 
ure on one sympathetic by thyroid tumors. In the latter event the 
pupils must be irregular. In my experience I have not found a 
glandular murmur with sufficient regularity to give it the diagnostic 
importance ascribed to it by Guttman, Da Costa, and others. 

This condition is associated with all kinds of manifestations re- 
garding the general and nervous systems. Tremors of the extremities 
ai'e often present ; the so-called Charcot's knee-symptom may at times 
be found where there is giving way of the knees ; but these symptoms 



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EXOPHTHALMIC GOITRE. 79 

vary so widely in their characteristics that they are not of much ac- 
count The heart is usually quite rapid, with a pulse-rate of from 
100 to 200. It is. usually more or less irregular, and the arhythmia 
does not seem to depend much on the lesions of the heart itself. Those 
cases which show the least change in the condition of the heart muscle 
or cavities are likely to show as much arhythmia as those where there 
is considerable change in the heart itself, if not indeed more. The 
continued rapidity of the heart's action does not seem to affect the 
int^rity of the heart as much as one would expect. 

The etiology of the condition is largely undetermined. Lesions 
of the central nervous system have been found in some oases and have 
been absent in others, so that there is no definite pathology of the 
disease known. Enlargement of the thymus gland has been found 
present in some instances, but just what relation this may have to the 
disease has not been ascertained. 

The treatment of this condition is somewhat unsettled, but the 
general indications are to increase the tone and strength of the nervous 
system, to increase the control of the vaso-motor system over the ves- 
sels, and to tone up the heart and stimulate it, if necessary. The 
necessity of having all three of the classical symptoms of the disease 
present in order to recognize it is not acknowledged now. It is be- 
lieved by many that there are very many modified cases of this disease 
in which the manifestations may belong largely to the nervous system, 
or perhaps to the heart, or to both, and in which there may not be 
enlargement of the thyroid or exophthalmos, and yet in which the 
diagnosis would be the same as in this case. In the incipient stage of 
the trouble, especially where it b^ns with rapid and irregular heart, 
the indication is to relieve the tachycardia as much as possible. This 
can largely be accomplished by rest, instead of by depressing remedies. 
These cases should be put to bed, in order that their circulation may 
be as qniet as possible. Exercise should be given them by massage, 
and this can be done without exciting the heart in the least ; in fact, 
the heart may become from ten to fifteen beats slower during a care- 
fully-performed massage treatment, and the bodily strength and health 
are thus kept up without taxing the circulation. Medicinally, they 
should get general tonics, — quinine^ strychnine, iodides, perhaps, in 
some cases, and belladonna. Belladonna has been recommended and 
is largely used in these cases, and seems to benefit them. A favorite 
combination of mine for these cases is a pill containing a grain or two 
of iron, one-half grain of quinine, one-sixth of a grain of extract of 
nux vomica, and one-quarter of a grain of extract of belladonna, three 



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80 INTEBNATIONAL CLINICS. 

times a day. This girl has improved under this form of medication. 
The exophthalmos is not so marked, the enlargement of the thyroid 
is not so great, and the arhythmic condition of the heart has much 
improved. We will continue her on this same line of treatment 

In r^rd to the administration of heart stimulants in these oases, 
I believe that we should be guided by the condition of the heart 
muscle and cavities, and should not give this class of remedies indis- 
criminately in cases of exophthalmic goitre, simply because the heart 
is rapid or arhythmic. The arhythmia, in many instances, is purely 
from nervous influences, and cardiac stimulants will do more harm 
than good when such is the case. 

EMPYEMA. 

This boy is fourteen years of age. Some two months ago he had a 
severe attack of what his physician said was la grippe, with bronchial 
manifestations. These went through a moderately severe course, and 
be was apparently convalescent, when he became worse, the tempera- 
ture went up, and he suffered from dyspnoea. I was called to see him 
at this time, and discovered signs of effusion in the right pleural cavity. 
The temperature at that time varied from 100.5° to 102.5° in the even- 
ing. There were no sweats. Aspiration was resorted to for the relief 
of the effusion, and about two quarts of pus were withdrawn through 
an ordinary aspirator. Following this, for two or three days the ti?m- 
perature was lower, when it again got back to the old figure, and the 
pleura was again filled. It was evident that this was a secondary 
invasion of the pleura, and that little could be done with simple aspi- 
ration : an operation was therefore advised. In view of the recent 
onset of the affection, the character of the pus, which was not very 
thick, and the rapidity with which the cavity refilled, it was deemed 
possible to drain this cavity without resorting to resection of the ribs. 
While in many instances the latter operation is probably the best, it is 
an open question if it is not done in many cases where it is not abso- 
lutely necessary. Therefore, with a view of saving the lung expansion 
as much as possible, and to avoid compromising the action of the lung 
by retraction of the chest wall, we inserted a tube into the pleura, after 
the method recommended by Bulau, of Hamburg. This was done in 
the following manner. A wide, flat trocar, of sufficient size to admit 
of the passage of some three-sixteenths-inch tubing, was introduced in 
the anterior axillary line, in the seventh intercostal space, first incising 
the skin and pushing the trocar and canula in with a rapid motion, in 
order to prevent any plastic deposit from pushing in front of the trocar 



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EMPYEMA. 81 

and blocking up the passage of the flaid. The trocar was then with- 
drawn^ leaving the canula in place, and through this was introduced 
some three-sixteenths-inch syringe tubing, which had previously been 
sterilized. About six or eight inches of this was introduced into the 
pleural cavity. It was connected by a glass coupling, about four inches 
from the chest wall, with a coil of tubing some two or three yards 
long, which emptied into a vessel of water by the side of the bed. In 
this way continuous siphonage was obtained, and the pus was drawn 
off as fast as formed. An ordinary cleat was put on the tubing, about 
three feet from the chest wall, and as fast as the tube filled up it was 
stripped out and the cleat replaced. The temperature ranged from 
99® in the morning to 100.5° in the evening, and continued at about 
that figure. The tube was gradually withdrawn an inch or two at a 
time at intervals until but an inch or two remained inside of the 
pleural cavity. The lung had meantime expanded well, and about 
three weeks after the operation the tube was withdrawn and replaced 
by a soft, pure-rubber tube, about four or five inches long, which was 
left open and drained into some dressings at the side. The discharge 
had diminished to about one-half teaspoonful in twenty-four hours, 
and when this amount was reached the tube was \vithdrawn and the 
opening allowed to close up. Recovery went on in an uninterrupted 
manner, and I show him to you to-day that you may see the condition 
of the lung. You notice there is a slight difference of expansion be- 
tween the two sides. At the level of the eighth rib the expansion is 
one-half inch less on the right side than on the left;. At the level of 
the middle of the scapula there is no difference. The boy feels per- 
fectly well, has a good appetite, and is strong. He has no cough, is 
not short of breath, and is daily using a breathing-tube in order to 
increase the action of his lung, and probably will soon diminish the 
difference in expansion to less than it is now. 

This operation, I think, is advisable for a certain class of cases, of 
which this is a type. It has given good results, although it is objected 
to by some because of the difilculty of keeping up the drainage. In 
cases where much plastic material had been deposited, or where the 
flui4 was flaky, the tube might easily become blocked. By using 
ordinary syringe tubing, which is stiffer than pure rubber, and does not 
bend as easily, and therefore is not so likely to become blocked, this 
difficulty is partly avoided. One objection to the syringe tubing is 
that it becomes very hard ; but with a tractable patient this will not 
cause much difficulty. 
Vol. I. Ser. 4.-^ 



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82 INTERNATIONAL CLINICS. 

NERVOUS JAUNDICE. 

The next patient I show you is a young woman^ twenty-two years 
of age. She has not been in very good health for the past six or eight 
months, although she has not been under the care of a physician. The 
only trouble she complains of is a poor appetite, a tendency to consti- 
pation, and loss of strength. She says the day before yesterday she 
experienced great and unusual mental excitement. Following this she 
was nervous, restless, slept badly all night, and upon getting up in the 
morning noticed that her eyes and skin were decidedly yellow. This 
condition increased somewhat during the day, and by evening the skin 
was as yellow as you see it now. As you see, the skin is quite yellow, 
and the conjunctiva is decidedly so ; otherwise she has no complaint 
to make. 

This is one of the unusual cases of jaundice arising rapidly from 
nervous influences. These cases are not very common, but occasionally 
we see one. Just how or in what way they occur we do not know. 
We do not understand the nervous conditions which produce jaundice 
in this way. Jaundice is merely a symptom of some other condition, 
and yet it is so prominent a symptom that we discuss it largely in 
the light of a disease. Jaundice may result from anything which 
affects the liver-tissue itself, — from anything which affects the pervious- 
ness of the bile-ducts,- either within the ducts, such as calculi, inspis- 
sated bile, or mucus, or an inflammation of the lining membrane of 
the duct, or from anything outside of the duct which will exert press- 
ure, such as tumors, morbid growths, etc. Changes may result in 
connection with systemic conditions in general diseases, such as some 
of the fevers, pysemia, etc., giving rise to jaundice, or it may result 
from poisons introduced into the system, which affect the blood. This 
particular form of jaundice does not come under any of these heads. 
There is no way that we can distinguish the nature of jaundice except 
by considering it in its relation to the other symptoms involved. We 
can by examination of the urine, perhaps, get some idea as to its 
nature. For instance, if the urine be dried on a slide, with a little 
salt, and a little glacial acetic acid run under the cover-glass, and 
heated to boih'ng, we may obtain the so-called Teichmann's hsemin 
crystals, which would indicate hsematogenous jaundice; but this is not 
an absolutely reliable test. We have to consider the condition in rela- 
tion to the other sj^mptoms present, as, for instance, those symptoms 
which point to the various diseases of the liver, or those which point 
to obstruction of the gall-ducts, or its relation to fevers or other 



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NERVOUS JAUNDICE. 83 

general conditions, or to poisonous substances. The particular form 
of jaundice which we have in this case usually disappears of itself in 
a few days. The only treatment necessary is to keep the bowels open, 
attend to the diet, allowing only those things which are easily /iigested, 
and quiet the nervous system. The jaundice will disappear in a few 
days, and the young lady will be as well as ever. 



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ELECTRO-DIAGNOSIS: WITH ILLUSTRATIVE 

CASES. 

OLIKICAL LBCTUBB DELIYERED TO A PRIYATE CLASS OF STUDENTS. 

BY A. D. ROCKWELL, A.M., M.D., 

Formerly Professor of Electro-Therapeutics in the New York Post-Graduate Medical 
School, and Electro-Therapeutist to the New York State Woman's Hospital. 



The value of electricity as a means of diagnosis can hardly be 
overestimated. Neither acoustics nor optics, mechanics nor chemistry, 
can throw more light upon obscure pathological changes. In many 
cases it points unerringly to certain histological states as well as to 
the exact location of lesions, and through it we obtain information 
which it would be quite impossible to elicit by any form of analysis, 
or examination, or instrument of precision. The methods of electro- 
diagnosis have, therefore, by no means been utilized to the extent that 
their great importance demands. This is due, without doubt, to the 
difficulties in the way of eliciting the desired information and in apply- 
ing the knowledge thus obtained. 

It is a very easy matter to get a theoretical knowledge of electrical 
reactions and their relation to health and disease, but it is not so easy 
to determine the exact relationship that exists between the normal 
anatomical condition of nerve and muscle, and deviations from the 
normal state. These difficulties are, however, by no means insur- 
mountable, and by the exercise of knowledge, care, and patience one 
may become perfectly familiar with the delicate manipulations neces- 
sary for the expert in the art of electro-diagnosis. The ophthalmoscope, 
the stethoscope, and the apph'ances for urinary analysis are quite use- 
less in the hands of the inexperienced. This is so well understood that 
few possess these instruments without having in greater or less measure 
acquired a capacity for using them. With electricity it is quite different. 
It is the exception to find one in the possession of electrical apparatus 
who is able to utilize it efficiently for diagnostic purposes. This was 
well illustrated in a recent case that I was called upon to see with a 
84 



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ELECTRO-DIAGNOSIS. 85 

very eminent practitioner of medicine in his special line of work. He 
wished me to see with him a patient whose condition he had diagnosti- 
cated as locomotor ataxia, and whom he had been treating for some 
time. He had used electricity, or rather had the nurse use it for the 
most part, but, as the patient was gradually getting worse, he desired 
counsel. It was not very diflBcult to see by the most cursory exami- 
nation that the patient was not suffering from locomotor ataxia, and an 
electrical interrogation of the muscles at once revealed the true character 
of the complaint. There was no reaction to the faradic current, and 
there was greatly decreased reaction to the galvanic, associated with the 
reactions of d^neration. The case was one of poliomyelitis anterior, 
and the attending physician had the mortifying reflection that he had 
not only mistaken one disease for another with which it ought not to 
be confounded^ but had persistently pursued methods of treatment for 
which there were no indications. 

Thus is closed to those who possess no knowledge of the principles 
of electro-diagnosis a wide field of investigation and the attainment 
of accurate knowledge relating to the diagnosis and prognosis of dis- 
eases of the brain and spinal cord, injuries and diseases throughout the 
peripheral nervous system, and injuries to the muscular tissue itself. 
Before offering a few illustrative cases, allow me to suggest the follow- 
ing general principles, which must be thoroughly understood before one 
can intelligently avail himself of the aid of electricity in the diagnosis 
of the various forms of paralysis. 

When the paralysis is due to a lesion either of the brain or of the 
white columns of the spinal cord, the electrical reactions are, as a rule, 
normal. It is, therefore, no difficult matter to distinguish between 
paralysis due to brain lesions and disease of the white columns of the 
cord and paralysis of a purely peripheral origin, where the reactions 
are invariably abnormal. In paralysis of a single limb, when the re- 
actions are normal, electricity will fail to indicate the seat of the lesion, 
but fortunately this question of differential diagnosis does not oflen 
arise, as loss of power of a single limb from columnar disease of the 
cord is exceedingly rare. Unlike the brain and white columns of the 
cord, any injury to the gray matter of the cord or pressure along the 
course of a peripheral nei've, sufficient to cause loss of voluntary 
movement) is associated with abnormal electrical reactions. 

It is not difficult, as a rule, to distinguish between disease of the 
peripheral nerves and disease of the central gray matter of the cord, but 
when only a single limb is affected it is not always so easy to decide be- 
tween the two, and therefore it is very important to take note of the dis- 



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86 INTERNATIONAL CLINICS. 

tribudon of the paralysis. It will be found that when the lesion is in 
the gray matter of the cord, either the limb is affected equally through- 
out, or the muscles are paralyzed in physiological or irr^ular groups. 
In peripheral paralysis, on the contrary, the loss of power taices place 
mainly, if not altogether, in anatomical groups. The value of elec- 
tricity, again, as a diagnostic agent is seen in enabling us to discrimi- 
nate readily between three very important diseases of the gray matter 
of the cord, — namely, myelitis, progressive muscular atrophy, and 
poliomyelitis anterior. In myelitis, when the entire length and thick- 
ness of the cord are involved, the abnormal electrical reactions are 
uniformly elicited in every muscle paralyzed, or there may be complete 
loss of electro-muscular contiuctility,— certain evidence of a gross lesion 
of the cord. 

If only a limited section of the whole transverse area is d^n- 
erated, the reactions of degeneration are elicited only in the parts to 
which are distributed the nerves derived from the diseased s^ment, 
while above and below the reactions remain normal. 

In progressive muscular atrophy the abnormal reactions are ob- 
served only in certain physiological groups, and indicate disease of the 
multipolar cells of the anterior comua. 

• In poliomyelitis, individual muscles and groups of muscles are 
attacked here and there in a random manner, without regard to dis- 
tribution or function. Every muscle thus suffering from structural 
degeneration reacts abnormally to the current and points unmistakably 
to an irregular destruction of the nutritive centres. 

In all these three forms of paralysis, and especially in myelitis, 
many modifications will be met with, and various complications, in- 
creasing the difficulty in the way of a definitely correct diagnosis, but 
a good anatomical knowledge and a familiarity with electrical methods 
will seldom fail to solve problems as to diagnosis that would otherwise 
remain unsolved. Peripheral paralysis, it may be remarked, is not 
always attended with abnormal reactions. In such cases we assume 
that whatever changes have occurred, while sufficient to modify the 
transmission of voluntary impulses, ai'e insufficient to influence nerve- 
or muscle-nutrition. 

Before presenting a few cases illustrative of the diagnostic value 
of electricity, I desire to remark that much experience convinces me 
that the two most important points relative to the subject are the 
presence or absence of farado-muscular irritability, and the presence 
or absence of galvano-muscular irritability. In the latter case the 
d^ree of the increase or diminution of muscular irritability is also 



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ELECTBO-DIAGN06I8. 87 

of importance as bearing upon the question of diagnosis. I do not 
by this mean to have it understood that the so-called reactions of 
d^eneration are of no import. They represent exceedingly interest- 
ing and not unimportant phenomena^ but they are by no means 
elicited with such precision and certainty as has been generally taught, 
and changes in the order of the normal polar opening and closing 
contractions are in general of no greater significance than the simple 
presence or absence of, or diminution in the readiness of, response to 
the two forms of current. The case here . presented of double facial 
paralysis is an excellent illustration of the value of electricity in diag- 
nosis, and is of especial interest because of its unusual character. The 
attack upon the right side of the &ce came on suddenly, and when 
the patient came under my observation he presented the characteristic 
symptoms of a lesion somewhere along the course of the nerve itself, 
with paralysis of the orbicularis palpebrarum muscle, thus preventing 
complete closure of the eye. There is no response to the faradic cur- 
rent, and this is an unmistakable indication that the nerve is affected 
somewhere along its course, and probably before it leaves the petrous 
portion of the temporal bone. To the galvanic current, on the con- 
trary, the muscles respond with undue readiness, a strength of two 
milliamp^res — quite insufficient in a condition of health — causing very 
appreciable contractions in the paralyzed muscles. To what may this 
phenomenon be attributed ? may be asked. This gives me an oppor- 
tunity to explain a very interesting condition of things. Either 
current when applied directly to a healthy muscle causes contrac- 
tions in about the same degree as when it is applied directly to the 
nerve that supplies the muscle. If, however, through the action of 
poison, or disease, or injury, the intra-muscular nerve-filaments become 
affected, leaving the muscular fibres untouched, the currents act* very 
differently. 

The faradic current produces no contractions whatever, for the 
reason that it acts only through the nerves themselves, while on 
muscular fibre deprived of its nerve influence it exerts no effect. 

The galvanic current, on the contrary, calls forth contractions 
through its action both on nerve and muscle. In the case before us 
the facial muscles have been entirely deprived of their nerve influence, 
and therefore fail to react to faradic stimulation. The muscular fibres 
are, however, as yet healthy, and respond to galvanic stiq;iulation, and, 
as is seen, fer more readily than in health. Why this is so is conjec- 
tural, but the most rational explanation seems to be that this increased 
galvano-muscular excitability is due to some nutritional change in the 



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88 INTERNATIONAL CLINICS. 

muscle itself^ and perhaps to the absenoe of a certain inhibitory influ- 
ence exerted by the healthy nerve supply. The diflferential action of 
the two currents on nerve and muscle may be thus stated. The faradic 
current more powerfully stimulates healthy nerve, and the vigor of the 
reactions is according to the strength of the current and the rapidity 
of the interruptions. 

The reactions following the application of the galvanic current are 
very much the same, only less vigorous. When the muscle is deprived 
of its nerve influence the faradic current causes no contractions, what- 
ever be the strength or rapidity of its interruptions, while the galvanic 
current not only causes contractions that are vigorous according to its 
strength and the rapidity of its interruptions, but excites them more 
readily than in health. The left side of the face of this patient is also 
paralyzed, and at first glance one would take it to be a case of peripheral 
paralysis also, from the fact that the patient finds it difficult to close 
the left eye completely. The diagnosis is, however, made perfectly 
clear the moment I subject the patient to the electrical test. To both 
currents the reactions are perfectly normal, thus indicating that the nerve 
itself is healthy, and that the lesion, whatever it is, is cerebral, — i.e., 
in or beyond the supra-nuclear space. 

Any loss of function of the orbicularis palpebrarum muscle is very 
rarely associated with facial paralysis of cerebral origin : so rare, indeed, 
is the occurrence, that inability to close the eye is regarded as almost 
pathognomonic of a peripheral lesion. Nevertheless, this is not the 
only case of central paralysis associated with more or less inability to 
close the eye that has fallen under my observation, and serves to em- 
phasize the utility of electricity in diagnosis. While the electrical 
reactions, or want of reaction, on the right side of the face of this 
patient indicate degeneration of the nerve structure, they just as plainly 
indicate no d^eneration of the muscular structure itself. 

Should this patient improve, as is most probable, the muscular irri- 
tability to the galvanic current will gradually diminish until it reaches 
its normal condition, and farado-muscular contractility will again be- 
come manifest. Should the galvano-muscular contractility become less 
than normal, it would indicate atrophy of the muscular fibres ; and its 
total loss would show complete muscular degeneration. 

The second case that I have to present has long been under my 
observation, and illustrates the condition of things to which I have 
just alluded. 

The paralysis of the right side of the face came on rather gradually 
some four years ago, and has progressed to complete nerve- and almost 



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ELBCTRO-DIAGNOeiS. 89 

to complete muscle-degeneration. The faradic current is powerless to 
induce the slightest reaction. 

A mild galvanic current of four or five milliamp^res elicits no 
response^ and it is only when the strength of the current is increased to 
twelve milliampdres that contractions are produced, and these are so 
feeble as to be hardly perceptible. The histological state of both 
nerve and muscle is thus quite clearly made out, and demonstrates the 
probable inutility of any further effort in the case. 

Another case of which I will speak not only illustrates points of 
diagnostic value, but is an example as well of what can sometimes, be 
accomplished by judicious and persistent treatment in certain unprom- 
ising cases. This girl, aged eighteen, was quite well in every respect 
previous to the attack which paralyzed her. She had been in constant 
attendance, night and day, at the bedside of her mother ; and in getting 
out of her own bed at all times of the night, and often when in a pro- 
fuse perspiration, she caught a severe cold. Her limbs gradually 
became heavy and unmanageable, and finally she lost the power of 
locomotion altogether. 

When I saw her^ some time after, at the solicitation of her phy- 
sician, Dr. J. O. Farrington, the paralysis of the lower limbs was 
absolute and complete. Atrophy had taken place to a marked extent, 
and the patient was unable to move the limbs below the knees, or to 
flex or extend the toes. No respon^ in any of the muscles of the 
lower limbs could be obtained by the use of the fitradic current, nor 
to the galvanic current when it was applied to the nerve-tninks. A 
powerful current, however, when applied to the muscles, elicited fiiint 
contractions ; but they were the reactions of degeneration, and indi- 
cated advanced d^nerative changes in the muscular as well as the 
nerve fibre. 

The symmetrical and profound character of the muscular degen- 
erati(M), as indicated by the complete loss of farado-muscular contrac- 
tility in every muscular group, and the almost complete loss of gal- 
vano-muscular contractility, quite surely indicated a gross lesion of 
the cord, and not poliomyelitis, as had been previously suggested ; for 
in this last-named disease the muscles are attacked in an irregular 
manner, corresponding to the irr^ular distribution of the pathological 
changes in the gray matter of the cord. There can be little question but 
that the disease was a myelitis, involving the lumbar gray matter. 
While the disease evidently occupied a considerable vertical extent of 
the cord, the presence of sensation in the extremities indicated that it 
did not involve the whole transverse area. 



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90 



INTERNATIONAL CLINICS. 



The prognosis in this case was certainly very unpromising, and 
but little hope was given of ultimate recovery ; and yet recovery has 
taken place and is almost complete. The toes still fall a little in walk- 
ing, but the weakness is so slight as not to interfere materially with 
locomotion. Nature has undoubtedly accomplished much in this case, 
but there can be no question that the persistent and judicious use of 
the constant current has greatly aided in the recovery. 

A word in regard to the method to be employed in the prolonged 
treatment of cases of this kind. It is a great mistake to use strong 
and frequently interrupted galvanic currents. Our object is to aid 
nutrition, not to overstimulate. 

I have known cases where the muscular irritability has become en- 
tirely extinguished, and limbs that might have regained more or less 
power of locomotion under judicious methods have become hopelessly 
paralyzed, through too violent attempts at muscular contraction. 

The effects obtained by such methods are most undesirable, and, in 
their relation to nutrition, destructive rather than reconstructive. The 
continuous passage of the galvanic current is in a certain sense stimu- 
lating in its effects, but combines influences that are sedative and tonic 
and pre-eminently reconstructive, and is alone equal to the task of resist- 
ing progressive d^enerative changes in nerve and muscle. 

The electrode here presented (in two parts) is one that I have used 
with much satisfaction in eliciting the various abnormal reactions that 
are associated with the many forms of paralysis. 




It will be observed that there are three binding posts to the right 
of the handle. The one marked P is to be connected with the posi- 
tive pole of the apparatus ; the other, marked iV, with the negative. 

The third post is to be connected with an electrode applied to some 
indifferent part of the patient's body. The small knob marked j4, 
when moved towards P, renders the electrode O positive ; when moved 



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ELECTRO-DIAGNOSIS. 91 

towards iVj the tip becomes negative. B is an interrupting button^ 
which when pressed closes the circuity and by sliding it slightly for- 
ward the circuit can be kept closed^ when so desired^ without effort 
of the operator. This form of electrode is exceedingly convenient in 
electro-diagnosis from the fact that by a single movement of the finger 
of the hand that holds the electrode the knob A is moved, the direction 
of the current instantly changed, and anodal and cathodal contraction 
elicited in quick succession. 

There is one other point relating to electricity as a diagnostic agent 
which does not include the phenomenon of electrical reactions, but refers 
only to the question of the presence or absence of pain. It is not, per- 
haps, generally understood that there is a wide difference in the physio- 
logical as well as therapeutic effects of induced currents of quantity 
and tension. The induced current of quantity, — i.e., the current from 
a short, thick coil of wire, — ^when applied to mucous surfiswes which offer 
but slight resistance to the passage of the current, and especially if the 
bi-polar method of application is used, is powerful to cause muscular 
contractions, but has no power to relieve pain. The induced current 
of tension, on the contrary, — i.e., the current from a long, thin coil of 
wire, — when applied internally, induces only feeble muscular contrac- 
tions, but has a remarkably sedative effect in neurotic troubles. If 
there exists, however, a d^ree of inflammation or acute congestion, this 
so-called sedative current has little power to relieve, and if applied with 
much strength will aggravate the pain. If, therefore, in a given case 
of uterine or ovarian pain, or in a more generally diffused abdominal 
pain, the induced current of tension by the bi-polar method of appli- 
cation causes relief, we are justified in believing that the pain is of 
nervous origin, and a continuation of electrical treatment is indicated. 
If, however, the application increases pain rather than relieves it, it is 
quite certain that we are dealing with something more than a mere 
neuralgic condition, — that acute congestion or active inflammation is 
present, imperatively contra-indicating the use of electricity. 



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SOME FORMS OF MYELITIS AND OF SERIOUS 
SPINAL TRAUMATISMS. 

CLINICAL LECTURES DELIVERED AT THE PHILADELPHIA HOSPITAL. 

BY CHARLES K. MILLS, M.D., 

Professor of Mental Diseases and of Medical Jurisprudence in the University of 
Pennsylvania ; Neurologist to the Philadelphia Hospital. 



LECTURE I. 

Gentlemen, — For years the subject of myelitis claimed much at- 
tention from teachers and text-books, — ^although, unfortunately, its 
consideration was largely theoretical, — ^and neural inflammations were 
scarcely thought of or discussed ; but during the last ten years neuritis, 
and particularly multiple or diffused neuritis, has filled a large space in 
medical literature. Myelitis has been overshadowed ; but it is a sub- 
ject which should not be neglected even by the general practitioner of 
medicine. Pure non-traumatic myelitis, while not of frequent occur- 
rence, is not rare. 

I have here a specimen of the vertebral column with the spinal 
cord in position. The cord, you will observe, occupies only about 
two-thirds of the length of the spinal cavity, the several inches below 
containing the cauda equina, or leash of spinal nerves, which proceed to 
their various areas of distribution by way of foramina placed far below 
their points of origin. Roughly speaking, the spinal cord itself can be 
subdivided into at least four general regions, — a cervical, including 
the cervical enlargement, which extends from the oblongata to about 
the second dorsal vertebra ; a dorsal or thoracic, from the second to 
about the tenth or eleventh thoracic vertebra ; the lumbar enlargement, 
chiefly opposite the last two thoracic vertebrre, and the conus, which is 
the tapering of this enlargement. The regions of the cervical enlarge- 
ment, and of the lumbar enlargement and conus, are, in some respects, 
of the greatest importance, as from them arise the nerves wliich supply 
the limbs, and, in the case of the conus, important pelvic organs. The 
lumbar-conus portion of the cord is crowded into narrow vertical 
limits, as the columns of the cord become less and less in bulk as we 
get lower, allowing important gray masses to be thus condensed. 
92 



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TRANSVERSE MYELITIS. 93 

The portion of the cord most liable to be attacked by acute non- 
traumatic myelitis is the mid-thoracic region. If the syphilitic or 
tuberculous infection, or the poison of any infectious disease^ or any 
toxic agent, attacks the spinal cord acutely, it often shows the most 
virulence here. This may be due to some peculiarity of the blood- 
supply or to the lack of resisting power in this least organized r^ion.. 
It is rare in this hospital to see acute transverse myelitis confined to 
the lumbar or cervical enlargements, although localized poliomyelitis 
most frequently assaults one of these regions. When the enlargements 
are involved in a primary inflammation, it is usually by extension, the 
inflammation banning in the dorsal cord. 

I shall first direct your attention briefly to acute transverse myelitis 
of this region. Transverse myelitis may be variously subdivided, 
according to the method of consideration of the subject ; but a prac- 
tically good plan is according to the apparent innate curability or 
Vitality of the disease. I have had considerable personal experience 
with at least three varieties, — one rapidly fatal ; a second destructive, 
from which the patient partially recovers but is left paralyzed perma- 
nently for years ; and a third in which recovery takes place rapidly 
or at least in a comparatively short period. 

RAPIDLY FATAL TRANSVERSE MYELITIS. 

At the meeting of the American Neurological Association in 1892 
I reported a case of fatal acute myelitis, mainly of the dorsal cord.^ 
This patient, with an uncertain specific history, six months before 
coming under observation had had a large carbuncle between the 
shoulders, and for months had shown some tendency to drag his 
feet. Four days before he was first seen he was taken with severe 
pains across the loins ; in thirty-six hours he could not stand, and 
twenty-four hours later he was completely paralyzed in both lower ex- 
tremities and totally anaesthetic as high as the nipples, with inconti- 
nence of urine and faeces and abolition of knee jerks, muscle jerks, and 
skin reflexes; temperature rose rapidly to 104° and 105®, with corre- 
sponding increase of pulse and respiration. For a few days his serious 
condition did not change much, then rapid increase of symptoms took 
place, and he died evidently from cardiac and respiratory paralysis. 
The entire course of the acute attack was about ten days, and included 
a first period of rapid development lasting about four days, a second 
period of little change or advance lasting four days, and a final rapidly 

^ Journal of Nervous and Mental Disease, August, 1S92, vol. xvii., N. S., p. 667. 

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94 



INTERNATIONAL CLINICS. 
Fig. 1. 




Section of spinal cord showing acute hemorrhagic myelitis ; the vessels throughout the sec- 
tion are engorged with blood, but the hemorrhages are confined to the central portion. At some 
points, as at a, are considerable hemorrhages, while in and around the central canal the blood 
is extravasated throughout the tissues, the central canal itself being stuffed with red blood-cor- 
puscles. 



Fig. 2. 



Fig. 3. 




'■"-Km ■ JLiftii*"- . **-.flL' - jMi'L*! 



1^. 








Acute hemorrhagic myelitis, showing hemorrhage 
into left of centre of gray matter, marked a in 
Fig. 1; small artery and its accompanying vein, 
which have been the origin of hemorrhage- 




"M 









Acute hemorrhagic myelitis; portion of section of spinal 
cord showing hemorrhage into central canaL 



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TBANSVEBSE MYELITIS. 95 

fatal period of about two days. Autopsy showed acute transverse 
myelitis in the mid-thoracic r^ion, where a shell of solid cord ticsue 
surrounded a creamy mass. Towards both the cervical and the 
lumbar r^ion the evidences of myelitis were less and less marked. 
Microscopical investigation showed the nervous tissue almost entirely 
destroyed, with distended blood-vessels, and many scattered hemor- 
rhages. Figures 1, 2, and 3 are drawings by Dr. J. C. McConnell of 
microscopical sections prepared by Dr. C. W. Burr from the cord of 
this patient. 

This case affords a good illustration of a rapidly fatal type of 
dorsal transverse myelitis, which was probably dependent upon pysemio 
infection. Some cases run their course even more rapidly than this, 
lasting only three or four days. Active specific and supporting 
measures and counter-irritants were used, but without avail. 

OLD CASE OP TRANSVERSE MYELITIS WITH SECONDARY 
DEGENERATIONS. 

The second patient has been in the wards since 1878, and has been 
under my observation more or less during the whole of this time. I 
studied him first ten years ago. In 1878 he was in a theatre and 
fell, landing on the back of a chair, and a day or so afterwards felt 
sore in his legs. He attempted to keep on his feet, but three days 
afterwards fell, and found himself unable to walk, and he has not 
walked since. While on his feet he had no pain, but a sense of con- 
striction. The records tell that in 1878 he had total loss of sensation 
and of motion in the lower limbs, with exaggerated reflexes. For 
months his legs were in a peculiar spastic state, so that he could not 
rest on his back, and his bed was arranged so that he could lie on his 
chest and side, with a contrivance to support his limbs, his feet point- 
ing upward in the air. 

This man has improved considerably after many years, and if he 
had been put to bed at once instead of going round for the first few 
days he might now have been on his feet. Gradually sensation came 
back, and little by little some motion, and even after fourteen years he is 
improving a little, and now can barely stand with some support. He 
has now perfect sensation. He has still some inability to control his 
bladder. • His limbs are not much wasted, probably not more than can 
be accounted for by not being used. His muscles all respond to the 
electric currents. He has pronounced contractions, chiefly flexures at 
the knees and ankles. Ankle clonus, exalted knee jerk, and front tap 
are present, but the toe jerk is absent. 



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96 INTERNATIONAL CLINICS. 

It should not be forgotten that in a long-standing case like this 
some of the most striking conditions present are due, not to the origi- 
nal acute disease or its direct consequences^ but to secondary d^nera- 
tion of the tracts of the cord below the r^ion acutely affected. The 
crossed pyramidal tracts, particularly in a case of this kind, are d^n- 
erated ; the phenomena present are indeed similar to those of primary 
lateral sclerosis, where the parts originally attacked by the subacute 
or chronic d^nerative disease are the lateral tracts. 

MILD TYPE OP TRANSVERSE MYELITIS. 

The next case is a fair illustration of a mild and, under favorable 
circumstances, curable type of transverse myelitis. H. S., twenty- 
eight years old, a seamstress, has had six children, only two of whom 
are living, and it is suggestive that her health was good until the 
birth of her first child, but since has been bad, and that with each child 
she has lost her hair. Seven months ago she b^an to have trouble with 
her feet and legs, principally the left leg ; first a feeling of heaviness, 
which became quickly worse, until both her feet and 1^ were numb 
and as though asleep. For two days she had complete loss of motion in 
both lower extremities ; in her own woixls, she could not even move a 
toe. She had also for a brief time complete loss of sensation in the 
1^, and trouble in passing her water, requiring to strain very much, 
although it did not become necessary to use the catheter. This, so far 
as I can obtain it, is the history of the acute onset : as I have no record 
of examination made at the time, I must depend upon her own state- 
ments. After a few days she b^an to improve, and soon was able to 
walk, but she has never been quite strong in her legs since. Exami- 
nation now shows no pain or tenderness and impairment of sensation. 
She sways on standing, and more on attempting to walk with her eyes 
closed. All movements are preserved in both lower extremities, but 
she shows some general weakness, and especially some loss of power on 
the left, most marked for dorsal flexion and abduction of the foot. 
Knee jerk and muscle jerk are very pronounced, but more marked on 
the left ; front tap is present on the left, but not on the right ; ankle 
clonus is decided on both sides ; toe jerk is absent ; electrical responses 
are normal. 

COMPRESSION-MYELITIS PROBABLY DUE TO CARIES. 

I have had considerable difficulty in getting any history from the 
next patient, both because of his ignorance of English and because 
of his probable mental deficiency. I have, however, obtained the fol- 



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OOMPRESSION-MYELITIS. 97 

lowing points before bringing him into the arena. He is a German, 
aged thirty-one, and has been in this country but a few years. He 
probably had some convulsive attacks, 6^m what we have been able 
to learn, before the onset of the peculiar train of symptoms and condi- 
tions which we are now to consider. About three or four months 
ago he was working on a farm, and was probably much exposed and 
did not take good care of himself; he had a convulsion of some 
description. Since he has been in the hospital he has had one general 
convulsion, which was witnessed by one of the nurses in the ward, and 
he tells us that his previous attack was like this. He had pain a short 
time, especially in the abdominal r^ion reaching to the back and below 
the umbilicus; he also had a sense of constriction. He began to be 
affected in a peculiar way in his limbs. This came on not abruptly 
but rapidly, — for you must make a distinction between abruptness and 
rapidity of onset, — and in a short time he lost power in both legs, and 
at the same time, to some extent, sensation. He next developed a 
peculiarly excitable condition of his reflexes. 

He has now been in the wards some weeks, and is practically neither 
better nor worse than when he entered. When I ask liim to draw up 
his 1^, he is unable to do so ; at least he does not do it, and he is ap- 
parently unable. His legs are as rigid as bars of iron, and when he 
makes an effort to draw them up they become locked at the knees and at 
the hip-joints. When I ask him to sit up, he meets with still greater 
difficulty. With these spastic patients we have to be very careful. 
Some time since we had a patient in the ward with a somewhat similar 
spastic condition, but who could stand ; his limbs would suddenly lock 
and he would fall, and he cut his head badly several times in this way. 
This man's legs lock instantly in extension when he moves them, and 
they are also thrown into vibration ; but with manipulation they can 
be again flexed. His limbs are almost constantly in a state of tremulous 
oscillation or vibration. 

Beginning at his feet, we will test his so-called mus(*le and tendon 
phenomena, which are not purely reflex in every instance. Even the 
so-called toe jerk, which is rare, is marked here ; we have also ankle 
clonus, front tap clonus, knee jerk (which is greatly exaggerated), 
and muscle clonus, from the quadriceps. Passing to the other reflexes, 
it is doubtful whether this man felt the point of the compass or not, 
and you must not be thrown off your guard by this. The cutaneous 
reflex from the bottom of the foot is marked ; there is no particular 
response elsewhere. He has some sensory change, probably loss of 
tactile sensibility up to a certain height above the hips. I examined 
Vol. I. Ser. 4.-7 



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98 INTERNATIONAL CLINIGB. 

him in the wards, but this was difficult to make out clearly. He feels 
painful sensations, and can tell the difference between heat and cold. 
His limbs are not wasted. 

He has some incontinence of urine, and has some trouble with his 
bowels, thinking they are never moved, which may be a delusion, or 
may be due to ansesthesia of the rectum, which may not respond to 
sensory stimulL He has no optic neuritis. 

Summarizing, the chief symptoms referable to a spinal cause are 
abdominal pain and constriction, rapid loss of power in the limbs, with 
accompanying partial loss of sensation, excitable reflexes, a tendency to 
coastant spasticity, with attacks of extreme spasm in the legs on every 
attempt at movement, and incontinence of urine. His 1^ are not 
wasted, and electrical changes have not occurred. 

Everything in this case points, as in the other cases, to a lesion of 
the thoracic cord, but one differing in character from those we have 
considered. The dominating symptoms are those of compression and 
irritation. It might be a case of compression-myelitis from a rapidly 
developing extra-medullary tumor or an inflammation of the cord sub- 
stance. It is most probably a case of compression-myelitis associated 
with rapidly developing caries of one or more of the thoracic vertebrae. 
The lesions causing compression of the spinal cord are usually fractures, 
growths, aneurisms, pachymeningitis, and caries ; the last probably oc- 
curring oftener than any of the others. In caries, inflammation of the 
bone and its surroundings is present, and pachymeningitis often de- 
velops, and sooner or later mechanical compression from giving way 
of the bones. The attack of explosive spasticity in this man's case is 
to be explained by the irritation of the nerve-roots by an inflammatory 
process ; most of the other symptoms by compression, although some 
may be due to limited destruction.^ 

Independently of his history, his symptoms will scarcely bear any 
other translation. This man, without atrophic disorder of the muscles 
which are supplied by the nerves of the lumbar enlargement, has lost 
cerebral control over his limbs, — a loss which is due to the breaking of 
connection between his brain and the parts of the spinal cord which 
supply the lower limbs. 

' It is now several months since the delivery of this lecture. This man soon be- 
came entirely bedridden, and recently died in the wards of my colleague Dr. J. H. 
Lloyd, having developed shortly before his death cauda-equinal symptoms in addition 
to those just related. Autopsy revealed dorsal caries and its usual accompaniments, 
much as anticipated in the lecture, and also invasion from a trophic eschar of the 
equinal region. 



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C50MPRES8ION-MYELITIS. 99 

What else ootild this be except transverse myelitis^ from compression 
or other cause? He may have a brain lesion, as he had convulsions, 
which are probably cerebral in origin ; but no single cerebral or intra- 
cranial lesion could produce symptoms such as we have observed here. 
A small growth in a very unusual position in the pons might give 
many of the phenomena present ; but it is inconceivable that you would 
then have uniform paralysis of the two extremities and uniform spastic 
phenomena, and that his arms and the upper part of his body should 
also be involved. He might have a double lesion of the cerebral 
hemispheres, involving only the cortical centres for the 1^, but it is 
not probable ; or a tumor in the longitudinal fissure pressing in both 
directions on the 1^ centres of both hemispheres, but that also is 
improbable. We have no evidence of caries of the vertebrae, and as a 
result localized pachymeningitis and compression-myelitis. 

The convulsions and his mental state may be accidental concom- 
itants, or a spinal affection may be superimposed upon a past cerebral 
state. It is true that in certain acute diseases of the spinal cord we 
occasionally have convulsions at the onset of the disorder. In one case 
reported three general convulsions, with unconsciousness, accompanied 
the onset of an acute myelitis. I have had one or two similar cases. 
I have in mind a patient who was attacked with myelitis and neuritis, 
and had almost universal convulsions in the very early stages of the 
disease, before it had rendered her incapable of using the limbs. So 
you see that we may have occasionally a history of convulsions with 
acute spinal disease. It is more probable in this case, however, that 
the patient had convulsions which had no connection with the disease 
we are particularly studying. 

For the acute stages of any form of myelitis the treatment would 
be practically the same. First, let me again emphasize the fact that it 
is most important to recognize that the case is one of transverse myelitis. 
Nine out of ten cases probably are not recognized at first. They may 
be supposed to be simply cases of weakness, or of rheumatism, or of 
hysteria ; or— which is most likely — they may not be diagnosticated 
until the patients are off their legs and much central mischief has 
been done. Later, the mistake is made too often of supposing the case 
to be necessarily hopeless. As soon as you suspect that a patient has 
banning inflammadiHi of the spinal cord, put him to bed, and keep 
him Aere. Even the position in bed is important. Put him on or 
towards his &ce, or on his side, arranging this, if possible, so that he 
will not be on a strain. The 1^ may be made dependent below the 
level of the bed. If you simply place the patient on his side he will 



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100 INTERNATIONAL CLINICS. 

not Stay there ; he needs more support, which can be had with a board, 
which should be padded. Keep him absolutely still. Use counter- 
irritation to his back ; and probably the best way to do this is by the 
alternate application of water at the temperature of 116^ F. and ice- 
cold water, ten or fifteen minutes at a time, two or three times daily. 
Use either dry or wet cups, and have the bowels opened in such a way 
that it will not be necessary to move the patient much. 

Internally, many remedies of questionable value have been used. 
Ergot is one of these, and reports differ as to the results obtained, al- 
though theoretically it should be of value. One of the best combina- 
tions of drugs in the early stages is probably that of the iodides, 
bromides, and ergot. Mercury is usually recommended, and seems to 
do good at times. If mercury is used, it should be in the form of 
inunction, or of calomel, kept up for some time. 

Remedies such as salicylic acid, the salicylates, phenacetin, antipyrin, 
etc., which have been found so useful in neuritis, should also be tried in 
myelitis, — at least in its early stages, — ^although but little use has been 
made of them for this affection. 

In transverse dorsal or lumbar myelitis serious accidents may arise. 
The tendency in myelitis of a certain type and of certain severity will 
be paralysis or paresis of the bladder walls, and perhaps of the sphincter. 
If of the bladder walls, there will be more or less retention of urine, 
and these patients also dribble sometimes ; the bladder gets nearly full 
and dribbles over, but a certain amount is left, which decomposes and 
sets up cystitis. The necessity of making careful examinations and 
catheterizing is apparent, or in a week or two you may have secondary 
myelitis or other constitutional conditions from infection. In catheter- 
izing, of course, you should be careful to see that the instrument is 
perfectly clean. It may be necessary in certain instances to keep the 
bladder washed out with antiseptic solutions or benzoic acid, and to 
give morphine, with camphor water and belladonna, internally. Be 
on the watch for bed-sores, which may be of two kinds, — that is, from 
pressure, or trophic due to the cord disease. If the patient suffers much 
fix)m the first variety of these, it will be your fault; but, in spite of all 
you can do, trophic sores may appear. Everything should be done to 
prevent this, as by the use of air-cushions and water-beds, and of per- 
oxide of hydrogen in washing out the sores, and of iodoform or a mild 
galvanic current to stimulate. 

If, in spite of this treatment, the case goes on to a paralytic 
condition, the treatment will be different. The patient should not, 
boveever, be put on his feet too soon, and you should not give up all 



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OOMPBESSION-M YBLITIS. 101 

hope of improvement even if he shows no signs of it for weeks or 
months. Keep him in bed from five to ten weeks, until you are sure 
no further improvement from enforcing quiet will take place. Now use 
tonics, as strychnine, and everything to improve the nutrition of the 
patient ; and alteratives, such as hydriodic acid, may prove useful. He 
should be treated at intervals with the galvanic current, but too strong 
currents should not be used. Massage is useful, and should be applied 
skilfully and at first gently. Strychnine may be used hypodermically. 
In compression-myelitis attention should, of course, at first be given 
to the source of the compression. If spinal caries is suspected, it is of 
great importance, and may save the patient, to put him in bed at the 
right time and treat him carefully by extension and other measures 
called for in this affection. In fractures and fracture-dislocations, 
extension and o})eration must be always carefully considered. 



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HEMIDROSIS; APHASIA DUE TO SUBCORTICAL 
HEMORRHAGE; VERTIGO OF CENTRAL ORIGIN; 
PARETIC DEMENTIA. 

CLINICAL LKCTUBE DBLIYBBED AT THE YAKDEBBILT CLINIC. 

BY M. ALLEN STARR, M.D., 

Professor of Diseases of the Mind and Nervous System, College of Physicians and 

Surgeons, New York. 



Gentlemen, — Here is a man who shows the peculiar condition of 
sweating of the whole of one side of the head. As I touch him I can 
feel a very perceptible difference between the two sides, one side being 
moist, whereas the other is dry. Unilateral sweating is a rather un- 
common affection. The sweating here cannot be ascribed to a paralysis 
of the vaso-motor nerves, as it can be in many cases. You can very well 
see that the man might have dilatation of the vessels and increased 
secretion as a result of that. You know that increased secretion of 
saliva is accompanied by great functional hyperaemia of the vessels in 
the glands. A paralysis of the vaso-constrictors will lead to dilatation 
of the arteries, and consequently to increased circulation in the skin at 
large, and, of course, in the sweat glands pertaining to the skin. We 
find such cases, but this does not belong to that cat^ory, because there 
is no apparent difference in the color of the two sides of the face. The 
ears are of exactly the same color that they have always been«. Here 
then is a unilateral sweating of one side of the head, which cannot be 
attributed to paralysis of the vaso-motor nerves. We have to think, 
therefore, of those nerves that govern the secretion of sweat "There 
are such nerves ; their existence has never been doubted, although they 
cannot be distinguished from other nerves under the microscope. You 
know very well that sudden fright will throw one into a tremendous 
perspiration, and you know very well that anxiety or grief is capable 
of drying up the sweat entirely. Abnormalities in the secretion of 
perspiration occur frequently in neurasthenia. So there must be some 
mechanism governing this secretion that is capable of being affected 
102 



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HEMIDR08IS. 103 

by mental causes, and by causes that change the nutrition in the ner- 
vous system. Hence, when you find the condition of general sweating 
you usually look for a central cause affecting the mechanism which 
may be set into play by fright or anxiety. This case cannot be put in 
that cat^ory, because it is not general. Instead of affecting the whole 
body it is limited to a particular part. So there must be some irrita- 
tion in the part that governs the secretion of sweat. Where that is we 
cannot say. It is possible that it may be in the medulla, because some 
cases with a lesion of the medulla were followed by great sweating, 
the lesion being in the floor of the fourth ventricle, near the tenth 
nerve nucleus. You may recall a case of Basedow's disease with 
marked flushing. In that case there was an increased secretion of sweat 
which made the body so moist that when we applied a current of elec- 
tricity to the body of the patient the skin was so wet with perspiration 
that the resistance to the current was decreased, and she could bear 
only a weak current. Basedow's disease is probably due in some cases 
to a lesion in the floor of the fourth ventricle. In this man we have 
a history of trauma followed by sweating in a small part of the body. 
You will notice that the part affected is not the part governed by any 
one particular nerve. The nerve which supplies the &ce is affected, 
but so also are the occipital nerves. His sweating involves the entire 
right half of the head in fi-ont and behind. It is not limited to the 
&oe alone ; it does not cease at the back of the head, and therefore it 
is not limited in its distribution to the parts supplied by the fifth 
nerve; it involves the area supplied by the occipital nerves as well. 
We cannot locate the cause in any one nerve in this case, because the 
entire head islnvolved. We do have changes in the secretion of per- 
spiration due to nerve lesions. Thus, in multiple neuritis, especially 
the alcoholic form, I have often seen a great increase of sweat in the 
extremities. In this man we are thrown back upon a central lesion as 
the probable reason for the condition from which he is suffering. Now, 
such a condition might be due to a lesion, or it might be of reflex 
origin. We know that peripheral irritation constantly sent to a cen- 
tral organ results in great variations in that organ's action. This is 
manifested by irritation of some kind. We know that long-continued 
eye-strain may give rise to twitching of the eyelids and neck and to 
choreic movements of the extremities. We know that a hard secre- 
tion beneath the prepuce will oft^n lead to fits or general convulsions, 
which are explained by an accumulation of irritation in the nervous 
system, the irritation being slight at first, but kept up a long time. It 
is not improbable, inasmuch as this man has had an injury of the 



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104 liJTERNATIONAL CLINICS. 

nose resulting in a deformity which has persisted ever since the blow, 
and inasmuch as this sweating has come on since that blow, that there 
is some irritation of the fibres of the fifth nerve in the nose. Some 
irritation of this side is being transmitted to the pons Varolii and 
medulla, especially the upper part of the medulla, where the terminal 
branches of this nerve end. You know that the fifth nerve is a 
very long nerve in the medulla, and has a very long nucleus, which 
extends through the entire pons and medulla some distance beneath 
the floor of the fourth ventricle. The different branches of the 
fifth nerve are connected with different parts of this nucleus. The 
branch of the fifth which supplies the forehead comes to a point about 
half-way down the pons. The second branch, the infra-orbital, comes 
to a portion of the fifth nerve nucleus lower down, and the lowest 
branch, the infra-maxillary, goes to the lowest point. The lowest 
part of the nucleus is continuous with the posterior gray horn of the 
upper cervical s^ment ; hence irritation in it can spread downward 
to the cervical r^ion. Now, the nose fibres of the fifth lie to the 
middle part of the nucleus of the fifth, and an irritation from them 
would come in at the point near where the tenth nerve nucleus lies, in 
which are located the vaso-motor and sweat centres of the entire body. 
My diagnosis then is a reflex irritation in a part of this nucleus due to 
the disease in the nose. This is hypothetical, but it is the only ex- 
planation I can offer. He is being treated for this condition now, and 
is going to Dr. Lefferts to have the septum sawed out [The relief of 
the nasal irritation caused the sweating to cease.] 

APHASIA DUE TO SUBCORTICAL HEMORRHAGE. 

Case II. — This man has been sick for two months ; before that 
time he was quite well. His attack began suddenly about one o'clock 
in the morning. He could not speak. He remained absolutely speech- 
less for a week, then speech liegan to return, and he could say " yes'* 
and " no." He seemed from the very first to understand what was said. 
He is able to read, and reads the papers every day, that being his only 
employment at present. At first he had headaches, but he does not have 
them much now. He has dizziness at times, and you see the difficulty 
the man has in articulating what he wants to say. He appeals to his 
wife to speak for him. He sj^eaks with difficulty, but you can under- 
stand what he says, although it will be only one or two words at a 
time. He cannot frame long sentences. At first he was unable to 
write, but now he can write well. Agraphia usUally accompanies 
motor aphasia, but if that is of slight d^ree the agraphia is apt to 



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APHASIA DUE TO 8UBCOBTICAL HEMORRHAGE. 105 

wear off. This man was unable to talk or write for two weeks. You 
notice also the ()eculiar emotional state in which he is. He has shown 
something of a lack of control at home, and even here his eyes fill 
with tears. He laughs easily^ and he cries like a baby. I have seen 
patients yield to that inclination to cry under similar circumstances to 
an extreme degree, — to such a d^ee that they could not say the most 
commonplace thing, even " yes'' or " no," without crying. Lesions in 
the frontal lobes are commonly accompanied by lack of power of self- 
control. This is particularly so in the left hemisphere when speech is 
involved. As he laughs, the right side of his face shows a little fall- 
ing; there is but slight, if any, affection of the tongue, therefore little 
paresis ; there is no paralysis in any part of the body, so that the only 
thing you have to deal with is pure motor aphasia, partial in character 
and with lack of self-control. We can. rule out a tumor, because of the 
sudden onset. As he is fifty-five years of age, we might suspect end- 
arteritis. He has a rather high-tension pulse, with atheroma of the 
arteries, and this would lead us to examine the urine. If there were 
a low specific gravity and albumin, the condition would, in all proba- 
bility, be cerebral hemorrhage due to chronic endarteritis, and the only 
question would be whether that endarteritis is one affecting the entire 
system including the kidneys, or whether it is an endarteritis with 
miliary aneurisms in the brain which have ruptured. The examination 
shows the urine to be normal : hence we can rule out chronic Bright's 
disease. The lesion can be located in the third frontal convolution or 
near it. The question is, is it cortical or subcortical? I should say 
subcortical, because if it were cortical the aphasia would be permanent. 
Here recovery has taken place, and recovery from aphasia takes place 
only when the lesion is in the track between the third frontal centres 
and the pons. The third frontal convolution of one hemisphere is 
connected with the third frontal convolution of the other hemisphere 
by fibres that pass over through the corpus callosum ; we know also 
that the tract from the third frontal convolution enters the inter- 
nal capsule and passes down to the pons and medulla ; the impulses 
of speech in passing down go through this tract to set in motion the 
various muscles controlled by the nuclei in the floor of the fourth 
ventricle in the pons and medulla. Suppose you have a lesion in- 
volving the entire third frontal convolution and the motor-aphasic 
area, or that you have a subcortical lesion cutting off the commis- 
sural fibres, and also the fibres going to the pons, then you have total 
motor aphasia. If the lesion, however, is in the internal capsule, 
we find, as a matter of fact, that these patients recover their speech 



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106 INTERNATIONAIi CLINICS. 

in part. There is no entirely satisfactory explanation of this fact. 
It is a curious thing that when the tract is all right on one side, speech 
is recovered. This is said to be because the impulses are switched over 
through the commissural fibres to the other side, where they are i^in 
switched off on to the descending tract and pass down : so that in that 
way the impulses get around the clot. If this explanation were cor- 
rect, we ought to see an analogous condition from hemiplegia; we 
ought to see a partial recovery. But we do not. My theory is that 
there are cases in which the lesion is so small that some fibres have 
escaped : so I suppose some of the direct fibres have escaped in the 
case of this patient I think that is a more natural explanation. It 
is well known that in lesions affecting the anterior portion of the in- 
ternal capsule aphasia occurs. You know that a number of these fibres 
pass down through the internal capsule, and it is a matter of fact 
that if your lesion is in the anterior part of the capsule in the fibres 
passing from the frontal region down into the pons Varolii, that is, in 
the frontal cerebral tract, you will have the same manifestation as in 
the frontal lobe lesion, — namely, a disturbance in speech and in mental 
powers. So a lesion in the anterior limb of the internal capsule, 
affecting some of the fibres that come from the frontal lobe, may be 
present in this case. I suppose this aphasia is due to a subcortical 
lesion that is small, so that the man has a good chance of recovery. 
These are the easiest cases for diagnosis, and are very interesting. 

VERTIGO OP CENTRAL ORIGIN. 

Case III. — ^This man has been complaining for three months. He 
cannot hear on the lefl side, and has vertigo and some trouble in the 
back of the head, which is worse on the lefl side. There is also some 
pain in front. The condition, then, is one of pain in the head, deaf- 
ness in the left ear, and a sensation of vertigo, referred chiefly to the 
lefb side. The man on examination has a good drum-head and a 
normal ear. Bone conduction to the acoustic nerve is, however, very 
imperfect, tested by a tuning-fork. His deafness is therefore central. 
This trouble coming on very suddenly has to be referred, not to the 
external or middle ear, but to the internal ear, or to the nerve from it 
to the brain. We have to deal here with a case such as is not very 
frequently seen. The condition has been called M6ni6re's disease, 
which is of sudden onset, a sudden deafness followed by pain in the 
head and a marked d^ree of vertigo. The question arises, to what is 
it due? M^ni^re described the condition many years ago, but we have 
to distinguish at present many conditions associated together under 



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VERTIGO OF CENTRAL ORIGIN. 107 

that name, and whether this man has it is a question. Vertigo, we 
know, is a symptom that may be due to many different conditions 
within the head. The last patient had motor aphasia, and had severe 
attacks of vertigo occasionally. This man has vertigo with deafness and 
headache. Whether that vertigo is from the ear or from the brain, we 
have to determine. We have a mechanism for determining our situa- 
tion in space. This mechanism involves a number of different organs, 
chief among which are the semicircular canals in the middle ear. The 
nerves from these pen in the acoustic nerve, which goes inward to 
the medulla, ends in the pons, and from there impulses pass up into 
the cerebellum. There is a nucleus on the floor of the fourth ventricle 
that receives impulses from this part of the acoustic. Lesions of the 
semicircular canals will lead to vertigo. Experiments on rabbits and 
dogs show that. You get different effects by dividing different canals. 
No interference with the function of hearing is associated with this 
vertigo ; but if you have nerves for the canals running into the brain 
and transmitting impulses from them, it is evident that you can get 
vertigo from pressure upon these nerves which will be similar to ver- 
tigo arising when the canals themselves are affected. Such vertigo, 
however, will be associated with deafness. Thus, in tumors of the 
pons, and where the pons is pushed to either side, the nerve being 
pressed upon, you have vertigo and deafness. In basilar meningitis 
the nerve is pressed upon by the thickening about it, and then symp- 
toms appear. Furthermore, we find that lesions in the medulla, small 
tumors, or hemorrhages, anything affecting the medulla at the point 
of termination of the nerve, will produce vertigo. When the irrita- 
tion is in the pons or the termination of the nerve, the tendency of the 
patient is to feel as if he were falling to the opposite side, and cona^- 
quently he turns himself towards the side of the lesion. If I have a 
tendency to fall to the left side, I will go to the other to correct that 
tendency. The result is that every lesion in the right half of the pons 
would lead me to fall to the lefl, and as I was fidling to the lefl I 
would throw myself to the right to correct it, and therefore I would 
go to the right. So every patient turns towards the side of the lesion 
when the pons is irritated. It is a voluntary movement to correct the 
tendency to fall. On the other hand, when the pons is destroyed by 
disease, the patient staggers away from the side of the lesion. We 
find the nucleus in the pons is connected with the cerebellum. Lesions 
in the cerebellum have for a symptom vertigo, which leads us to 
stagger to one side. I have shown you cases of tumors of the brain 
in which vertigo was a symptom. In one of these, a man, there was 



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108 INTERNATIONAL CLINICS. 

also vomiting and staggering to the left side. He had pain in the 
occipital region, and pain and tenderness of the right occipital bone. 
There we made a diagnosis of tumor in the cerebellum on the right 
side, with destruction of pons fibres and staggering to the side opposite 
to the tumor, and we found the tumor after death. So conditions of 
the cerebellum, affecting the terminations of this nerve from the semi- 
lunar canal, will cause vertigo. There may be an affection of the 
nerve going up through the middle peduncle of the pons from Deiters's 
nucleus to the termination of the tract in the vermiform lobe in tlie 
cerebellum, but if that is involved there will not be deafness with 
the vertigo. Now, M^i^re was not familiar with all these details of 
nervous anatomy, and, while he presented as much as was known in 
his day, he did not know these facts. Hence in all cases a sudden 
onset of vertigo, associated with pain and disturbance of hearing, was 
referred by him to the ear ; but it is really, in many cases, due not 
to hemorrhage into the semilunar canals, as he supposed, but to 
lesions in the pons or cerebellum. There is nothing more difficult to 
determine than the location of the lesion in these cases. I am not 
sure that this man has trouble in the cerebellum, or that he has any 
organic disease, but the sudden onset suggests it. Cases of marked 
disturbance of equilibrium may be caused by functional disorders; 
hence we see cases of neurasthenia and ansemia with these symptoms 
markedly developed. So, too, we have vertigo of gastric origin from 
irritation of these same nerve-centres in the pons reaching them by 
way of the vagus nerve. In such cases there is rarely any deafness. 
I have seen a number of cases where the patient has been deaf several 
years or months before the onset of the other symptoms: so you 
cannot always bring deafness into connection with the vertigo and 
headache. In this man the conduction bf sounds, as tested by the 
tuning-fork, shows that the acoustic nerve is diseased. When we 
send a galvanic current through his acoustic nerve, his hearing-power 
is increased, but the current increases the vertigo. These facts lead me 
to think that in his case we have to deal with a central affection, not 
merely with a hemorrhage into the semilunar canals. It is a very 
difficult thing to determine whether the trouble is in the ear, or in the 
acoustic nerve, or in the cerebellum, or whether it is functional or 
organic : so the physiology is interesting, but the diagnosis is a very 
difficult one to make. As to treatment, almost any form of vertijro 
can be relieved by giving the jiatient potassium bromide in ten-grain 
doses three times a day. 



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PARETIC DEMENTIA. 199 

PARETIC DEMENTIA. 

Case IV. — ^This man copies complaining of his head. His wife 
tells us that he cannot talk as well as he used; he thinks he was 
well until four months ago. The trouble in speech came on suddenly. 
He can repeat the letters of the alphabet. I ask him to repeat the 
words "Third Artillery Brigade/' and, you see, he does so quite 
awkwardly. As his tongue is projected, you notice a very marked 
tremor in it, and not only that, but also a more or less marked 
trembling about the lips and face. There is tremor on intention ; the 
movement increases and spreads up to the sides of the face, becoming 
very much more marked ; his hands tremble, the knee-jerks are in- 
creased ; he walks as well as ever ; his memory is not so good as it 
was. In making the diagnosis of brain-disease, you have to get at the 
symptoms in an indirect manner. When a man who is questioned as to 
the duration of his illness, which dates hack but four months, asks his 
wife for the information, you can rely upon it that in that particular 
patient there is some defect of memory. When you ask a patient if 
his memory is good or not, he may not be conscious of defects. Many 
will deny the imputation of loss of memory, and say they recollect 
things, but if they appeal to others, as this man asks his wife, you 
may be certain there is some defect. This maq becomes excited easily, 
his face flushes, and he loses patience at the least provocation. He 
laughs at the silliest things. He never cries ; though he feels depressed 
a good deal, and his despondency increases as he sits brooding at 
home. A lack of mental control is quite evident. There is only one 
other thing to notice, and that is the anxious expression about his eyes. 
His wife has noticed this. You have also noticed the flatness about 
the face, and the lack of expression, unless he is excited, when there 
is an over-action. These symptoms, taken in connection with the 
tremor of the tongue, the peculiar tremor of the hands, and the lack 
of memory and self-control, constitute basis enough for the diagnosis 
of chronic encephalitis or inflammation of the cortex of the brain, 
the ordinary name for which is paretic dementia, or general paresis, 
or, commonly, softening of the brain. Do not forget that in such 
oases you must find both physical and mental symptoms before your 
diagnosis is sure. 



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LESIONS OF THE POSTERIOR COLUMNS IN THE 
MEDULLARY SCLEROSIS OF ATAXIA. 

CLINICAL LSCTURE DELIYEBSD AT THE PARIS MEDICAL SCHOOL. 

BY PROFESSOR DEJERINB, 

Physician to the Hospice de Bicdtre ; Professor (agr^6) in the Paris Medical School. 



Gentlemen, — ^You know what lesions are found in the spinal 
cord in subjects who have presented more or less of Duchenne's malady 
during life. The sclei*osis of the posterior columns and the atrophy 
of the corresponding roots always exist, but, while the characteristic 
features of these lesions have been known for a long time, their exact 
pathology is still under discussion. There are two things to consider 
in the medullary lesions of tabes, — their nature and their topography. 
It is this last that it is especially important to study. It is just here, 
as in all cases of sclerosis of the spinal cord, that we should devote 
our attention. Friedreich's malady is an exception : we proved with Dr. 
LetuUe, in 1890, that in that disease the nature of the lesion does not 
present anything special. 

In tabes, the lesions are found in the neuroglia, the vessels, and 
the connective tissue. 

In order to interpret in a satisfactor}' manner the topography of 
tabetic sclerosis, we must not only examine the different regions of the 
cord in the same case, but also compare preparations coming from other 
eases, which may be different in their evolution or symptomatology. 
This done, we can then compare the lesions we find with those that 
are observed in the spinal cord after alteration of the posterior roots, 
whether these be experimental or pathological in nature. 

Here are preparations from three cases of tabes (locomotor ataxia) 
who died in our service. In the first case there was a tabes which 
commenced in the dorso-lumbar region and later reached the cervical 
r^ion. That is the usual form. The second case was a cervical one, 
in which the symptoms — pain, incoordination, and troubles of senn- 
bility — affected the superior members mostly. The inferior members 
no 



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LESIONS OF THE POSTERIOR COLUMNS IN ATAXIA. Ill 

were normal. The preparations of the third case come from a patient 
whO; following a papillary atrophy at the onset, never had any further 
evolution of the disease. After fourteen years of fulgurating pains in 
his 1^, he had no trace of incoordination. 

These are the three usual types of tabes : the first, or ordinary 
type; the second, or cervical ; and the third, that remains in the pre- 
ataxic stage, the spinal lesion not advancing. 

What is the state of the spinal cord in these cases? 

In the first, or ordinary case, you will find, about the level of the 
Inmbar r^on, that Burdach's and Gk>irs columns are entirely sclerosed. 
About the level of the dorsal r^on the lesions remain nearly the 
same, but at the inferior portion of the cervical region you will find 

Fig. 1. Fio. 2. Fig. 8. 






Oommon tabei, Inmbar Common tabes, cervical Cervical tabes, cervical 

region. region. region. 



Fig. 4. Fig. 6. 





Otrrlcal tabes, dorsal region. Cervical tabes, lumbar region. 

that the aspect is changing, and this continues as you go higher. 
Though the columns of Goll are invaded completely here, Burdach's 
columns are not, for in them the lesion diminishes as we ascend the 
cord. 

The atrophy of the posterior roots follows the same course, and 
they show less change as we ascend the cord. Here are preparations 
of the cord in cervical ataxia (or tabes). Throughout the cervical r^ion 
and the superior dorsal r^on the nervous fibres have completely dis- 
appeared in Burdach's columns, but they begin again about the level 
of the sixth dorsal pair. From here the lesion diminishes from above 
downward, so that at the lumbar swelling the lesion is hardly seen. 
As to the columns of Goll, in the cervical region they are altered only 
in the anterior two-thirds, while the posterior third is normal. These 



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112 INTERNATIONAL CLINI03. 

alterations diminish so that at the lower lumbar r^on they can be 
considered normal. The posterior roots undergo the same change as 
Burdach's columns; that is, they diminish progressively from above 
downward, as to the alteration, and become almost, if not quite, 
normal in the lumbar r^ion. It is only after staining the sections 
with osmic acid that we can find a very few fibres atrophied. 

Let us now examine the third case, in which the tabes had remained 
for fourteen years in a preataxic state with blindness. In the lumbar 
region the sclerosis occupies Burdach's columns, Lissauer's zone, and 
the radicular zone, while Goll's columns are attached in their ante- 
rior two-thirds only. On the contrary, in the cervical region, GrolPs 
columns are attacked with sclerosis in their posterior two-thirds only, 
while Burdach's fibres are normal. 

Here, again, the alterations of the posterior roots are proportional 
to those of the rest of the cord. They are well seen in the dorsal 
and lumbar regions and absent in the cervical region. 

We have, then, three cases of tabes in which the lesion presents 
itself with a topography somewhat different in each case. In the first, 
or ordinary tabes, the columns of Goll are as much sclerosed in the 
cervical r^ion as in the dorsal and lumbar r^ons, while the 
sclerosis of Burdach's fibres diminishes from below upward in the 
cer\dcal region. In the second case, cervical tabes, the lesion 
diminishes from above downward. In the third case, tabes arrested 
by blindness, Burdacb's 9olumns are altered only in the dorso-lumbar 
region, while the columns of GroU are less affected, and yet they are 
completely sclerosed in the two-thirds of the posterior cervical region. 
One single feature they have in common : that is, the alterations of the 
posterior roots follow the other alterations. 

How shall we interpret this different topography? Is ataxia a 
systemic and primitive sclerosis of the posterior cord, as Charcot and 
Strumpell admitted, and as FQchsig and Raymond held ? 

To answer this question we must go into the history of the posterior 
comu or horn in the sclerosis of tabes. Bourdon and Luys (1861) first 
described the pathological anatomy of Duehenne's malady, and for a 
long time we had no better description. In 1872 appeared Pier- 
ret's work, based on a study of the spinal cord in tabes. He showed 
that ordinary ataxia commences in the external bands of the posterior 
comu. These have since been called Burdach's columns. The isolated 
sclerosis of the columns of Goll in the cervical region, observed in these 
cases, was seen only when the sclerosis of the lumbar r^ion was very 
pronounced in character. This sclerosis of the columns of Groll, says 



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LEBIONS OP THE P08TERI0R COLUMNS IN ATAXIA. 113 

Pierret^ is produced by a process of secondary ascending degeneration. 
While the theory of the secondary degeneration of Groll's columns was 
tacitly accepted, at this time, by a large number of neurologists, these 
lesions have been carefully studied of late years, and the accuracy of 
the original investigations clearly demonstrated. 

The idea of a primitive sclerosia of the posterior columm, which 
made its evolution in situ and of its own will, did not, however, seem 
doubtful to clinical observers who followed exp^imental physiology. 
Waller's experiments were, in fact, a contradiction to the generally 
accepted idea. Vulpian, in 1879, expressed himself as follows : " We 
must admit that the alterations of the posterior roots are primitive. 
It may be that they are so only in a certain measure.^' 

According to this, Vulpian was not far from admitting that in 
tabes the lesion of the posterior comu is the consequence of the 
alteration of the roots. At this time embryology had not shown that 
the fibres of the posterior comu are developed at the expense of the 
spinal ganglia, and the study of the posterior fibres had not yet been 
begun by section of the roots. Only one thing prevented Vulpian 
from admitting that the lesion of the cord in tabes was consecutive to 
that of the roots ; that is, that there existed lesions of the cord without 
alteration of the roots. This question of the r6le played by the 
posterior roots was left undisturbed for sopie years, until Leyden, in 
1889, took up his former conception, to the effect that this disease is an 
affection of the sensitive fibres of the cord. . 

We first promulgated our theory in 1889, in a series of lectures 
before the Faculty of Medicine. We held thai tabetic (atoartc) lesions 
were only the prolongation of the process into the posterior comu of the 
corresponding roots. We announced this theory after a study of the 
topography of the lesion, and of the proportion, which is constant, in 
the cases of tabes examined especially in relation to possible alterations 
of the roots and the posterior cord. We also compared the work of 
Tooth, who showed by experimental physiology that the lesionfe of the 
cord were as we have stated. His, by embryonic studies, has proved 
that the posterior columns are developed at the expense of the spinal 
ganglia. So we concluded that the lesions of tabes were the conse- 
quence of the lesions of the posterior roots. In 1890 we had occasion 
to say, in a work on paralysis during ataxia, " To-day tabes appears 
to be less and less a malady that is localized in the spinal cord. The 
peripheral nerves, both sensory and motor, are constantly found 
altered in character ; besides, the lesions of the posterior columns are 
always proportionate to the lesions of the corresiwnding roots. In 
Vol. I. Ser. 4.-8 



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114 INTEBNATIONAL CLINICS. 

other wordSy there is nothing to prove that the spinal lesion is primiHve, 
It ia mod likely secondary, being a conseqtience of a neuritis of the 
posterior rootsJ^ 

This new conception of the malady has met with some opposition. 
Dr. Babinski, in his lessons, in Professor Charcot's wards, on peripheral 
neuritis, said that ^' sclerosis of the posterior columns in certain cases 
is preceded by the lesions in the posterior roots.'' Blocq gave the 
same reason for opposing our ideas. But Marie and Bedlich, after 
twenty post-mortems, found that we were correct Neither of these 
authors had heard of the theory which we had already advanced, but 
they came to the same conclusions. 

In order to show that the lesions of the cord in ataxia are simply 
those of the posterior roots, we will compare them with those produced 
by experimental physiology. Taking first the case of compression of 
the terminal nerves of the cord in men, following a tumor or even 
a traumatism of the end of the vertebral column, we find that the 
lesions occupy the posterior columi^s only, and constantly present the 
same topography. 

Here you notice that Goll's and Burdach's columns are totally 
sclerosed in the lumbar r^ion, just as in tabes. In the dorsal region 
the columns of GoU are still in the same state, but those of Burdach 
are so only in their internal half. In the cervical region Burdach's 
columns are normal, and GolFs are attached only in their posterior 
portion. So that in compression of the cauda equina the posterior 
roots are altered in character, and the sclerosis which occupied the 
whole of the posterior column in the lumbar region is limited more 
and more to the posterior half of the columns, until, in the cervical 

Fio. 6. FiQ. 7. 





Root paralysis of brachial plexus : compression Root paralysis of brachial plexus, cervical 
of first and second pairs, left side (Pfeiffer). region (Pfeiffer). 

region, it no longer occupies any part but GoWs columns, and here 
only the posterior half. Compare this with Figs. 4 and 6, in tabes, 
and you will see that there is no real difference between them. 

If you compare the accompanying drawings (Figs. 6 and 7), taken 
from Pfeiffer (1891) with the preparations of cervical tabes, you will 



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LESIONS OF THE POSTERIOR COLUMNS IN ATAXIA. 115 

see the relation of these cases. Pfeiffer describes a case of radicular 
paralysis of the brachial plexus, called in German 'Hhe Klumpke 

type/' 

You will notice (Fig. 6) that the zone of d^eneration occupies the 
external portion of Burdach's columns, just at the level of the poste- 
rior roots, and as the preparation is taken from higher up (Fig. 7) in 
the cervical r^on, the columns of Burdach are intact in the outer 
three-quarters, and altered only in the inner quarter, which is close to 
Goll's columns. 

In one word, the topography of this lesion is the same as that of 
cervical tabes, and experimental physiology shows us that in old cases 
of this kind where the columns of Gt)ll take part in the lesion the 
posterior parts of these columns remain clear of trouble. 

We know from the experiments of Wagner, Tooth, Singer, Munzer, 
Barbacci, Oddi, Rossi, and Berdes that the posterior columns of the 
oord are affected. 

Why does this alteration occur in the roots? It must be admitted 
that we do not know much about it. From this comparative study 
but one definite conclusion can be drawn, — namely, that in ataxia the 
spinal lesions are not primitive, but are a systematized sclerosis of the 
posterior roots, following the intra-meduUary tract, which we believe 
to be primitive in character. 



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SIMPLE NEUROMATA. 

CLINICAL LBCTUBB DBLIYXRED AT THB MIDDLISEX HOSPITAL, LONDON. 

BY J. BLAND SUTTON, M.D., 

Assistant Sui^eon. 



Gentlemen, — It is important to remember that the term neuroma 
is often employed clinically in the same sense in which it was used by 
Odier in the begianing of this century, to indicate a tumor proceeding 
from a nerve. More accurate knowledge of the minute structure of 
tumors connected with nerves has taught us that they may be sarco- 
mata, or fatty tumors, or be composed of tissue identical in structure 
with the endoneurium and perineurium, or consist largely of myxoma- 
tous tissue. 

Up to the present time, aided by all the best methods of histologi- 
cal research, no one has detected a tumor (apart from amputation 
bulbs) connected with a nerve composed of new-formed nerve-fibrils. 
Taking these facts into careful consideration, a neuroma should be 
defined as a tumor ffrowing from and in structure resembling the sheath 
of a nerve. 

A neuroma may grow from the sheath of any cranial or spinal 
nerve ; usually the nerve is spread over the tumor like a strap ; the 
nerve may traverse the neuroma, — this is rare, — or it may grow within 
the nerve and spread out its fasciculi like the ribs of an umbrella or a 
fan. In shape they may be rounded, obovate, or like spindles. The 
roots of the spinal nerves are sometimes beset with neuromata which 
take the form of ring-like segments imperfectly demarcated, so that 
they resemble the annulated rootlets of ipecacuanha. 

In the early stages the tissue of a neuroma is dense and resembles 
the tough tissues of neurilemma: all neuromata are furnished with 
capsules continuous with and derived from the sheath of the nerve 
from which they arise. Later, parts of these tumors undergo de- 
generation, and in large tumors the central parts liquefy. Thus the 
terms fibromata, myxomata, and cystic fibromata often applied to these 
116 



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SIMPLE NEUBOMATA. 



117 



PlO. 1. 



Nerve. 



tumors are of no taxonomic value. They may all be classed as simple 
neuromata or neuro-fibromata. There is a very extraordinary species 
which is known as plexiform neuromata ; but with these we have no 
concern at present, nor with those rare cases in which neuromata occur 
in scores on the nerves of the same patient ; but to-day I must limit 
my remarks to the simple species of neuroma of which several examples 
have presented themselves in my practice, and some which you have 
had opportunities of examining. Bear in mind, neuromata are not 
common tumors : if you take our hos- 
pital reports you will find that in this 
institution, where we deal with large 
numbers of tumors, the average number 
of nerve-tumors is not more than two 
annually. Consequently, it is not un- 
usual when a neuroma comes to hand for 
mistakes to be made in diagnosis : hence 
I propose to show you how errors arise, 
and how important it is to be vigilant 
when removing apparently simple tu- 
mors lying in the track of large nerve- 
trunks. The first neuroma I ever re- 
moved was of interest from this point of 
view. A young woman came to the out- 
patient room for advice concerning a 
small swelling on the back of her right 
wrist, situated near the styloid process 
of the radius ; this swelling was smooth, 
rounded, non-adherent to the skin, pain- 
ful when pressed, and exhibited all the 
clinical characters of a synovial cyst 
(ganglion), except that it did not disap- 
pear when the wrist was extended. From 

a superficial examination I concluded that it was a cyst arising as a 
diverticulum from the synovial membrane between the radius and the 
first row of carpal bones, and, as it had existed two years, I thought 
this would explain the thickness of its walls and its non-disappearance 
when the wrist was extended. I punctured it with a slender knife, but 
this had no effect on the swelling, and did not give the patient much 
pain : it was clearly a solid tumor. Cocaine was injected into the skin 
covering the tumor, which was then exposed by a free incision. It 
was discovered to be a neuroma connected with the radial nerve as it 




A neuroma firom Scarpa's space 
connected with the trunk of the an- 
terior cmral nerve. The tumor has a 
distinct capsule; the cavities are due 
to degenerative (myxomatous) change. 



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118 INTERNATIONAL CLINICS. 

lies ID the triangular space bounded by the tendons of the extensor 
primi and extensor secuudi intemodii poUicis. The neuroma^ as large 
as a ripe cherry, was then dissected from the nerve without any diffi- 
culty, the wound rapidly healed, and there was no impairment of the 
sensation of the hand. Judging from a study of the literature relating 
to the subject, it would appear that the wrist is a very unusual situation 
for neuromata. 

They are by no means uncommon on the intercostal nerves. In 
one of my cases, a woman thirty years of age complained of a lobu* 
lated tumor occupying the eighth intercostal space on the right side in 
the axillary line, which was a source of trouble and pain to her be- 
cause preventing her from tightening her stays. The tumor was shaped 
like a dumb-bell ; the extremities were as large as the top of the middle 
finger, freely movable, and non-adherent to the skin. Several who 
examined the patient regarded it as a fatty tumor, but its mobility, its 
situation (deeply in the intercostal space), and its painfulness induced 
me to regard it as a neuroma. On incising the skin, the tumor was 
found lying between the external and internal intercostal muscles, con- 
nected with the nerve by a stalk : it was easily removed. 

Some of you will doubtless remember a woman of twenty-eight 
years, recently under my care, who complained of a painful swelling 
in the bend of the elbow, which on account of its situation, lateral 
mobility, the depth at which it was situated, and the pain it caused in 
the fingers when pressed or even lightly manipulated, led several of us 
to think the tumor was a neuroma of the median nerve. Under this 
supposition I cut down upon it, and found a tumor in the substance of 
the supinator brevis muscle the size of a marble ; it was slightly ad- 
herent to the sheath of the brachial artery just at its bifurcation. On 
microscopical examination it turned out to be a gumma. After a most 
careful interrogation we failed to get a history of syphilis, but a year 
later the woman again came under observation with a similar tumor 
higher in the arm, which quickly yielded to iodide of potassium in- 
ternally, and thus confirmed the opinion as to the syphilitic nature of 
the swelling in the supinator brevis muscle. 

It is somewhat curious that neuromata rarely produce pain unless 
touched ; then the sensations are usually very acute. Probably of all 
nerves the trigeminal is the one most liable to be the seat of neuro- 
mata, and even on such a sensitive nerve as this they rarely produce 
much suffering ; but there are conditions under which they render life 
unendurable. Smith in his admirable monograph on *' Neuroma" 
describes the case of a woman who complained of severe pain in the 



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SIMPLE NEUBOMATA. 119 

course of the right trigeminal nerve, which was so increased by masti- 
cation that she ate but little ; speaking aggravated the pain to such a 
degree that she always remained silent unless interrogated, and fre- 
quently on these occasions she replied by signs. The patient died after 
enduring severe and uninterrupted pain during four and a half months. 
At the post-mortem examination a neuroma as large as a walnut occu- 
pied the situation of the right Gasseriau ganglion. It is probable that 
the intense pain experienced by this unfortunate woman was due to the 
fact that the tumor grew in a confined situation. This view was im- 
pressed upon me by the following case : 

A woman twenty-two years of age complained of very severe pain 
confined to the region of the right upper jaw. Notwithstanding the 
intense pain (which at night amounted to agony) this patient complained 
ofy the region of the face supplied by the palpebral, nasal, and labial 
branches of the right infraorbital nerve was anaesthetic; a slight 
thickening could be made out by the finger along the lower margin of 
the orbit, and there was a slight upward displacement of the eyeball. 
On examination, the skin supplied by the temporal twig of the orbital 
branch of the second division of the fifth nerve was found to be 
normally sensitive ; this was also true of the mucous membrane sup- 
plied by the posterior dental branch of the same nerve. The symptoms 
were best explained by supposing the right infraorbital nerve to be 
entangled in a tumor connected with the roof of the antrum or floor 
of the orbit. Acting on this hypothesis, I reflected the skin of the 
cheek, and on cracking away the anterior wall of the antrum I found 
the cavity occupied by a geliftinous sarcomatous-looking tumor. The 
parts were freely removed, including the Gasserian ganglion. The pain 
was immediately and permanently relieved. On investigating the 
tumor it turned out to be a neuroma growing from the infraorbital 
nerve and invading the antrum ; in the main it consisted of myx- 
omatous tissue. A neuroma of this character on a limb-nerve would 
have been painless save when submitted to pressure, but imprisoned 
within the unyielding walls of the maxilla it was subjected to un- 
remitting pressure, and was in contequence the source of continual 
pain. 

It by no means follows because a neuroma is seated upon a sensory 
or a mixed nerve that it will be productive of pain. I have seen these 
tumors on the supraorbital and lingual nerves, but they gave rise to no 
painful sensations, and cases have been described in which neuromata 
grew on the cords of the brachial plexus, the median nerve, and the 
greater sciatic nerve unaccompanied by pain. When springing from the 



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120 INTERNATIONAL CLINICS. 

trunk of a motor nerve they are painless ; it is important to bear this in 
mind^ as a neuroma has been observed on the trunk of the facial nerve 
in the parotid gland ; the tumor was removed under the impression that 
it was an ordinary parotid adenoma^ and permanent &eial palsy was the 
unfortunate consequence. Cases have been reported in which surgeons 
have removed tumors from the forearm which had been absolutely 
painless^ and subsequent examination showed that in the course of the 
operation a large and important nerve, such as the median, had been 
completely severed. This is very unsatisfactory, and could be avoided 
if surgeons realized that neuromata are encapsuled tumors, and when 
situated in the immediate neighborhood of large vessels, and upon 
important nerves, admit of easy enucleation, as the following case will 
show. 

A single woman, thirty-five years of age, was placed under my 
care for a tumor of the mamma. On examining it there was little 
doubt that it was a carcinoma, and whilst examining the axilla for 
enlarged lymph-glands I perceived a tumor in the supra-clavicular 
region. Manipulation of this tumor provoked pain, not in the neck, 
but in the ball of the thumb and in the tips of the thumb and fore- 
finger of the same side. The patient was an intelligent woman, and 
stated that the tumor in the breast had attracted her attention only a 
few months, whereas the cervical tumor had been present fourteen 
years. This definite statement was, of course, important, for nothing 
would have been easier than to regard the neck tumor as a collection 
of supra-clavicular lymph-glands infected by the mammary cancer. 
The long duration of the tumor, the pain referred to the digits when it 
was pressed, and its mobility and uniformity, induced me to regard it 
as a neuroma connectM with the fifth and sixth cervical nerves, impli- 
cating more particularly those strands which help to form the median 
nerve. This diagnosis was verified at the operation, for after ampu- 
tating the mamma I exposed the tumor in the posterior triangle by a 
vertical incision, and saw a large nerve-trunk embedded in it : the cap- 
sule of the neuroma was then opened with a knife, and a tumor the 
size of a bantam's egg was readily enucleated by means of a raspatory. 
There was no bleeding from the capsule. After the removal of the 
tumor the conjoined trunks of the fifth and sixth cervical nerves were 
made out. As soon as the patient recovered consciousness I tested the 
movements of the thumb and fingers, and had the satis&ction of 
assuring myself that there was no [xaralysis nor evidence of anaesthesia 
in any part of the limb. In this instance, had I attempted to remove 
the tumor with its capsule I should have been obliged to perform a 



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SDIPLE NEUROMATA. 121 

very difficult dissection in an extremely dangerous region, and run the 
risk of irretrievably paralyzing important muscles of the forearm, of 
wounding some large venous or arterial trunks, or of opening the 
pleural cavity. By simply enucleating the tumor from its capsule, a 
proceeding which consumed only a very few minutes, I avoided all 
these risks, and the patient was convalescent in a few days. 

A very important case was published in the Medioo-Chirwrgical 
7Varwac^io7i9, vol. Ixix., in which Chavasse removed a neuroma as 
large as a duck's ^g from the right posterior triangle of the neck. 
The dissection was difficult and deep. The patient, a woman thirty 
years of age, died six days after the operation, from spinal meningitis. 
At the post-mortem examination it was found that in removing the 
tumor the sixth cervical nerve had been torn off, the root giving way 
inside the dura mater. Pus from the wound had leaked into the canal, 
producing fatal meningitis. 

My chief object in this lecture is to impress upon you the impor- 
tance of remembering that all simple neuromata are eucapsuled tumors, 
and that when the capsule is split they can be shelled out with the 
greatest ease and safety. When growing from the side of a nerve they 
may be removed with their capsules. 

It is true that in some instances where surgeons have unconsciously 
divided large nerve-trunks they have sometimes been able to repair the 
breach in their continuity by nerve-suture or nerve-grafting. It is, 
however, always better to avoid the accident by careful surgery than 
to remedy it by secondary measures, however brilliant. 



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TUMOR OF THE CEREBELLUM, PROBABLY TU- 
BERCULAR. 

CLINICAL LECTUBX DELIVERED AT ST. ANTHOKT'S HOSPITAL. 

BY HOWELL T. PERSHING, M.Sc, M.D., 

Professor of Nervous and Mental Diseases in the University of Denver ; Neurolo^t 

to St. Luke's Hospital and St. Joseph's Hospital ; Alienist to the 

Arapahoe County Hospital. 



Gentlemen^ — The patient is a well-built though somewhat 
emaciated man^ aged twenty-eight, with no apparent hereditary taint 
Twelve years ago a chronic cough set in, and for about a year he occa- 
sionally spat blood, but these symptoms gradually disappeared. Six 
years ago he worked for a short time with lead ores, without any ap- 
parent bad effects. Although he confesses to frequent attacks of gonor- 
rhoea, there is no history of syphilis. He says that for three years, 
ending in March, 1893, he was drunk half the time ; since then he has 
had no alcohol. 

A year ago he began to have severe headaches, and at the same time 
noticed that he sometimes staggered in walking. For six months past, 
the headaches growing more intense, there have been attacks of giddi- 
ness, dimness of vision, and vomiting. Once, during July, he fell 
and was unconscious for some minutes. 

For a short time this summer he was in the County Hospital, 
where, on account of some mental symptoms, he was transferred from 
the general ward to the care of Dr. Eskridge, who found, among 
other symptoms, optic neuritis and exaggerated knee-jerks. A few 
days ago, while I was examining his ears, he suddenly fell back with 
all his muscles rigid. His head was drawn back, the eyes opened 
widely and the pupils dilated, while respiration was somewhat quick- 
ened. In three or four minutes the tonic spasm had {Assed off and con- 
sciousness gradually returned. 

He now complains of intolerable headaches, pains over the body 
generally (more especially in the left thigh), giddiness, frequent vomit- 
ing, failing sight, and occasional visions, which he recognizes as hallu- 
122 



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4 
TUMOB OF THE CEBEBELLUM. 123 

cioations. The pulse is regular, and ranges from eighty to one hun- 
dred and twenty beats a minute. During his stay in this hospital his 
temperature, with one trifling exception, has been perfectly normal. 
There is no heart-disease. The urine is normal, although there is 
sometimes a little difficulty in passing it. At the apex of the right 
lung expiration is prolonged, harsh, and blowing, almost bronchial. 
Although his general strength is much depressed, there is no paralysis 
of the limbs, face, tongue, or ocular muscles. A slight paresis of the 
left arm with distinctly exaggerated tendon reflexes, which I detected a 
few weeks ago, is no longer apparent 

His gait is unsteady, often so much so that he seems about io fall. 
It is not the high-stepping, stamping gait, with double footfall, charac- 
teristic of advanced tabes, but rather the reeling walk of a drunken 
man. Neither walking nor standing is decidedly aflbcted by closing 
the eyes. The patient feels as though he were going to fall to the lefl. 
Sometimes, when lying still, he is so giddy that he is afraid to stand 
or even sit up, for fear of falling. In these giddy spells his bed may 
seem to move with him, or the next bed may appear to be moving 
towards him. There is some incoordination of the movements of the 
arms ; with eyes closed he cannot readily touch the tip of his nose 
with either hand, nor can he bring the tips of his index fingers together 
above his head. 

Sensibility to pain, touch, and posture are perfect, or nearly so, 
throughout the body. Smell and taste are normal. Hearing is greatly 
impaired on both sides, so that it is necessary to speak to him in a 
very loud tone. He attributes his deafness to catarrh, but the tuning- 
fork shows that the defect is in the nerves or brain, a strongly vi- 
brating tuning-fork held against the skull being scarcely heard in 
either ear. The deafness has rapidly increased during the past few 
months. The tympanic membranes show no sign of present or past 
suppuration. The right eye is blind from an injury received in child- 
hood. Vision in the left eye is for a part of the time quite good, but 
objects are oflen obscured by an apparent cloud, which after a few mo- 
ments clears away. These intervak of cloudiness are growing more 
frequent and last longer. There is no considerable limitation of the 
visual field in apy direction. The ophthalmoscope shows intense optic 
neuritis on the left side. The right fundus cannot be seen. 

The knee-jerks are entirely absent. They have been repeatedly 
tested, making sure that the flexor muscles are not contracted, and 
having the patient pull on his hands to re-enforce the jerk, but without 
eliciting any distinct response. 



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124 INTERNATIONAL CLINICS. 

Mental symptoms are not conspicuous, although his deafness makes 
him appear dull when he really is not so. He answers intelligently, 
and his attention can be held during the examination. Nevertheless, 
his memory is slightly impaired for recent events. There is no trace 
of aphasia ; he understands, speaks, reads, and writes apparently as 
well as ever. 

Now, what disease do these symptoms suggest to you ? One answers, 
locomotor ataxia ; another, alcoholic neuritis ; a third, tumor of the 
brain. 

The loss of knee-jerk, and the unsteady gait, with the slight diffi- 
culty in micturition, certainly suggest tabes dorsalis ; but we may dis- 
miss the idea. There is no history of lancinating pains ; the pupils are 
normal ; the optic nerve is inflamed, not simply atrophied as in tabes ; 
and, what is quite decisive, the knee-jerks were present and even ex- 
aggerated after the main features of the disease had fully developed. 

Alcoholic multiple neuritis may in rare cases be accompanied by 
optic neuritis, but multiple neuritis reveals itself by both motor and 
sensory loss in the extremities, symptoms absent in this case. There 
is a rare form of inflammation of the brain, caused by alcohol, in 
which optic neuritis may occur ; but, in the absence of palsy of any 
of the motor cranial nerves, with the mental condition fairly good, 
this form of alcoholism is excluded. 

Now, as to the third suggestion. Intense headache, giddiness, 
vomiting, and mental aberration, however slight, must always cause a 
grave apprehension of intra-cranial tumor, and if to these symptoms 
optic neuritis be added, the diagnosis of tumor is well-nigh certain. 

Optic neuritis and optic nerve atrophy are of such great significance 
that every physician ought to be able to use the ophthalmoscope. We 
cannot hope to equal the oculists in the niceties of ophthalmoscopic 
diagnosis, but we can all, without a great deal of trouble, learn to dis- 
tinguish a normal nerve from one that is distinctly inflamed or atro- 
phied. Learn to examine by the direct method, and if the pupil is 
small, use cocaine to dilate it. Do not use atropine : it usually paralyzes 
accommodation for a week or ten days, and in that time the neuritis or 
atrophy may advance so that good vision can never be restored ; in such 
a case the patient ever afterwards blames tlie physician for destroy- 
ing his sight. Cocaine has but little effect on vision, and that quickly 
passes off. 

Optic neuritis is fiur more frequently caused by brain-tumor than 
by any other disease, hence it is the most decisive symptom of tumor. 
Still, it is not absolutely decisive, even in connection with the other 



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TUMOB OF THE CEREBELLUM. 125 

symptoms, until some other diseases besides the forms of alcoholism 
already discussed have been excluded. 

Unemia may, in rare cases, cause an optic neuritis just such as oc- 
curs in tumor, instead of the neuro-retinitis so characteristic of chronic 
nephritis. Now, as ursemia may also cause headache, vomiting, dul- 
ness, and perhaps convulsions, it is readily seen how easily disease of 
the kidneys might be mistaken for tumor of the brain. Such a possi- 
bility- is not excluded by a failure to find albumin in the urine, for in 
interstitial nephritis albumin as well as casts may at times be absent 
When, however, as is the case with this patient, there is no albumin, 
the quantity and specific gravity of the urine are not below the aver- 
age, and there is an absence of the arterial and cardiac changes com- 
monly associated with interstitial nephritis, then we may safely dismiss 
the idea of uraemia. 

Lead-poisoning in its severest forms may involve the brain and 
cause optic neuritis, so as to be mistaken for tumor ; but this cannot 
be the case with our patient, for he has not had even the milder symp- 
toms of plumbism, such as dry colic or wrist-drop, and there is no lead- 
line on the gums. 

Profound ansemia may also simulate tumor, but a glance at the 
patient shows that he is not profoundly anaemic. 

Still, we are not able to rest securely in the diagnosis of tumor. 
Meningitis and intra-cranial abscess must yet be considered. Acute 
meningitis is excluded in this case by the slow development of the 
symptoms. Chronic meningitis is practically either alcoholic or syphi- 
litic. Our patient does not have the tremor or delirium that is asso- 
ciated with alcoholic meningitis. Syphilitic meningitis alone could 
hardly cause the intense optic neuritis seen in this case, and, besides, 
the fiiilure of large doses of mercury and iodide of potassium fitvorably 
to influence the disease is strongly against any idea that it may be 
syphilitic. 

Abscess of the brain has many symptoms in common with tumor. 
But in abscess there is usually an ascertainable cause, such as suppura- 
tion in the ear or elsewhere ; the pus is apt, though not at all certain, 
to betray itself in slight rigors and evening rise of temperature ; the 
optic neuritis, if present at all, is rarely intense ; the course of the 
disease, if chronic, is not steadily progressive, but a period of rapid 
development exceeds one of comparative latency. In the light of each 
of these distinctions our patient's symptoms indicate tumor rather than 
abscess. 

After this rather tedious, but absolutely necessary, consideration 



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126 INTBRNATIONAL CLINIC8. 

of other diseases^ we may take it as only too well established that the 
patient suffers from a morbid growth within the skull, and it becomes 
of the utmost importance to know where it is and whether it can be 
successfully removed. 

There is a striking absence of the more easily interpreted localizing 
symptoms. There is no tenderness of the skull on percussion, no 
localized spasm or paralysis, no hemianopsia, no aphasia. This makes 
it highly probable that the motor areas and occipital lobes on- both 
sides, and the parietal lobe, first temporal convolution, and Broca's con- 
volution on the left side, are not involved. The central ganglia, crura, 
pons, and medulla are also fairly excluded by the absence of paralysis, 
ansesthesia, and hemianppsia. 

As between the latent r^ons of the cerebnim and the cerebellum, 
certain symptoms point positively to the cerebellum. A reeling gait is 
so associated with cerebellar disease that it has been called ^* cerebellar 
titubation." Moreover, the absence of knee-jerk, the prominence of 
giddiness and vomiting, the intensity of the optic neuritis, the rapidly- 
approaching blindness and deafiiess, — all are most readily accounted 
for b^ assuming a tumor of the cerebellum. 

Absence of the knee-jerk in a case of brain-tumor is an important 
localizing symptom. In the great majority of cases of tumor of the 
cerebrum the knee-jerk is either exaggerated or it is unaffected ; in a 
small proportion of cases it is diminished ; very rarely indeed is it 
abolished. 

In tumor of the cerebellum, on the other hand, while the knee-jerk 
is often increased, its total abolition is quite common. It follows, then, 
that from absence of the knee-jerk we may infer that the tumor is in 
the cerebellum or presses upon it. 

The deafness of this patient, which we have seen to be nervous, not 
catarrhal, also points towards the cerebellum. It cannot be accounted 
for by pressure on the auditory nerves, because a growth could not select 
both of these nerves for destruction and leave the facial nerves and 
other important stnictures unaffected. Now, while the course of each 
auditory tract from the auditory nuclei at the junction of the medulla and 
pons is not definitely known, it is very probable that Growers is right 
in supposing it to pass nearly directly upward in the most superficial 
layer of the t^mentnm, — ^that is, just beneath the aqueduct of Sylvius. 
If this be so, or if, as the researches of Monakow and of Spitzka tend 
to prove, the posterior tubercles of the corpora quadrigemina have the 
same relation to hearing that the anterior ones have to sights it is easy 
to see how a growth of the middle cerebellar lob^ pressing forward, 



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TUMOR OF TH£ CEREBELLUM. 127 

could cause bilateral deafheBS. The blindness is in all probability 
due, in part at least^ to such pressure on the r^on of the anterior 
tubercles.^ 

This explanation implies that the growth is in the middle cerebellar 
lobe, which is in harmony with other localizing symptoms. Cerebellar 
titubation does not occur unless the middle lobe is affected ; if it does 
not appear until late in the course of the disease, the tumor has prob- 
ably begun in one of the hemispheres and afterwards encroached upon 
the middle lobe ; but if, as in this case, staggering is one of the earliest 
symptoms, the tumor was probably in or near the middle lobe from the 
start' The tendency to fall to the left is an indication that the lesion 
is to the right rather than to the left of the median line ; but this is 
not conclusive. Starr found that in twenty cases of cerebellar disease 
the patient staggered away from the side of the lesion in sixteen and 
towards it in four. The weakness and exaggerated tendon reflexes of 
the left arm, though transient, are also indications that the lesion is on 
the right side. 

Now, what can be said as to the nature of the tumor? Syphilis 
must first be considered, for gumma probably occurs more frequently 
than any other form of intra-cranial growth. Here we not only have 
no history of syphilis, which counts for little, but both mercury and 
potassium iodide have been thoroughly tried, the dose of the latter 
reaching two hundred and seventy grains daily, without the slightest 
apparent benefit. The local diagnosis is strongly against syphilis, for, 
while gumma in the cerebrum is common, in the cerebellum it is very 
rare ; of twenty-two fatal cases of intra-cranial gumma, recorded by 
Sterr, in not one was the growth found in the cerebellum. 

The history of cough with hemoptysis, confirmed by physical signs 
still present, naturally suggests that the tumor is tubercular ; and the 
local diagnoeis fiivors this view, for the cerebellum is a favorite seat of 
tabercular growths. Carcinoma at this man's age, in the absence of a 
known aoorce of seoondaiy infection, is practically out of the question. 
While there is nothing to exclude glioma or sarcoma, there is nothing 
indicatii^ the presence of either, so it is fair to presume that we have 
to deal with a tubercular growth. 

We are now ready to consider what can be done for the patient. A 
tabereular tumor can never be removed by medicines, and only in the 
rarest of rare cases can tonics and full feeding even arrest its growth. 

^ Dereum, Journal of Mental and Nervous Diseaset, October, 1898. 
> Starr, Brain Sui^ry, 1898, p. 289. 



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128 INTERNATIONAL CLINI08. 

Still, with this slender hope, the antisyphilitic treatment has been dis- 
placed by tonic and supporting measures, apparently with some advan- 
tage. Occasional free watery purgation relieves the headache somewhat, 
and by the use of antineuralgics and morphine much of the otherwise 
inevitable suffering is avoided. In such a case it would be cruel to 
withhold morphine on account of the danger of the morphine habit 
or on account of the slightly increased danger of a rapidly fatal ter- 
mination. 

But before we resign ourselves to a merely palliative treatment we 
must earnestly consider whether it is possible to cure by surgical means. 
Of all intra-cranial tumors, about one in twenty is so situated and of 
such a nature that its complete removal and the subsequent restoration 
of the patient to health are possible. The cerebellum is a very un- 
favorable region for operation. A growth in it can be reached only 
through the inferior surface, and it is not known how much damage 
the organ can sustain and the patient live. All manipulations in this 
region are exceedingly dangerous, on account of the close proximity of 
the pneumogastric nerves and of the vital centres in the pons and 
medulla. Starr tabulates sixteen cases of operation for cerebellar tu- 
mor : in nine the tumor was not found ; in two it was found, but could 
not be removed ; in three it was removed, but the patient died ; in two 
cases the tumor was removed and the patient recovered, at least for a 
time. Now, if our patient had one chance in eight of a successful 
removal of the tumor, there could be no question of the propriety of 
operation ; but he has no such chance. The staggering and deafness 
indicate that the middle lobe is involved, probably in its anterior part : 
so we have the most unfavorable situation for an operation. Moreover, 
a tubercular tumor is a very unfavorable kind for removal, on account 
of the danger of there being more than one growth, and of the diffi- 
culty of removing completely even a single one. Von Bergmann rather 
advises against attempting to remove tubercular tumors of the brain in 
any situation ; and, while in this he is probably over-cautious, there 
can be no doubt that the successful removal of a tubercular tumor from 
the middle and anterior part of the cerebellum is entirely beyond any 
reasonable hope. 

We must be content, then, merely to palliate this patient's suffering, 
while waiting for death to end it. Nevertheless, this minute study 
of his case has not been useless, for the application of the same prin- 
ciples to the next case of intra-cranial tumor may lead to a cure by 
means of mercury and potassium iodide, or perhaps to a successful 
operation. 



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CEREBRAL MENINGITIS; LEAD-POISONING; 
ALCOHOLISM. 

CLINICAL LECTURE DELIVERED AT THE COOK COUNTT HOSPITAL, CHICAGO. 

BY DANIEL R. BROWBR, M.D., 

Professor of Mental Diseaaes, Materia Medica, and Therapeutics, Rush Medical Col- 
lege ; Professor of Diseases of the Nervous System, Woman's Medical College ; 
Professor of Diseases of the Nervous System, Poet-Graduate School ; eta 



Ladies and Gentlemen, — ^Those of the class who saw the infant 
with tubercular meuingitis will recognize the decubitus of this patient 
as the same. You notice the head is thrown backward. This has been 
the position of the patient ever since he came into the hospital. We 
can always get a great deal of information by simple observation. I 
am inclined to think the older practitioners in medicine, in having to 
rely more upon it, were better observers than we of to-day, with our 
many instrumental aids to rapid and accurate diagnosis. While these 
aids are very valuable, we are apt to place too much dependence upon 
them. Learn to study that which may be seen without the use of 
any but the ordinary means of observation you all possess. The 
physiognomy of the patient, the position in bed, the number and 
rhythm of the respirations, and the many other important points ac- 
cessible to the eye should not be ignored for the more accurate and 
invaluable evidence furnished by the thermometer, the stethoscope, the 
aspirator, and the instruments of percussion. 

Hidory. — Patient admitted to hospital, February 23 ; no previous 
history, except that he had been sick for a week before admission ; was 
delirious ; complained of intense pain in the head and along the spine 
in the cervical region. Examination of the heart, abdomen, and lungs 
negative ; pupils dilated ; bowels constipated. 

Mark the three symptoms which in this case are especially worthy 

of your attention, — ^headache, vomiting, and constipation. These are 

the three leading symptoms of meningitis. The pain in the head was 

excruciating. When I saw this man last Monday, the 22d, he had 

Vol. I. Ser. 4.-9 129 



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130 INTERNATIONAL CLINICS. 

his hands to his head and was tossing back and forth in bed inces- 
santly. This IS the pain of meningitis ; and with it he had vomiting, 
constipation, and delirium. To-day, the 26th, he is very quiet, and just 
what this quietude means is not so certain. These cases of meningitis 
may very often deceive us. We shall find our patient delirious, rest- 
less, full of pains, hyperaesthetic, as this man was the other day ; when 
touched almost anywhere, he showed evidence of pain. To-day he is 
sleeping and seemingly quiet. The only thing peculiar about the sleep 
is that his eyes are not closed. When we raise the lid, we find*the 
pupil not fiir from the normal condition, neither especially contracted 
nor dilated. This quietude may be the result of his treatment. He 
has been taking potassium bromide and deodorized tincture of opium, 
supplemented by hypodermic injections of morphine. The indications 
for treatment during the first stage of meningitis are to quiet the pa- 
tient, — ^to calm the nervous system ; for this purpose we give the bro- 
mides and opium in some form. The movements and feelings of the 
patient should guide their use. I think these remedies should be given 
in sufficient doses to produce quietude. This condition which we find 
to-day may be the result of the treatment, and I ho{)e it is, but we are 
often deceived in such a case. At one visit the patient may be fouud 
in a state of delirium ; at the next he may be perfectly quiet, as this 
man is. Such quietude often means the passage from irritation to a 
state of pressure, when congestion gives place to exudation. Is this the 
coming on of the second stage of meningitis, or not? Has the intense 
congestion that has been prevailing in this patient^s brain for so many 
days at length resulted in exudation ? I am free to confess I do not 
at present know ; to-morrow, probably, I shall be able to tell. The 
other day the pulse was strong and bounding, now it is soft and easily 
compressible. Then it required considerable pressure to obliterate it, 
now it takes but little. This may mean improvement of the patient, 
or it may indicate a more serious condition in the increase of pressure. 
The patient having reached this quiet stage, hypnotics and analgesics, 
no longer indicated, should give place to those remedies adapted to 
promote absorption. The patient has had an ice-cap on his head from 
the time of entrance, and counter-irritation along the spine. The 
former, having fulfilled its purpose, should be removed, and the seda- 
tive remedies should he gradually withdrawn, to be replaced by the 
iodides, preferably potassium iodide, in alterative doses. ^ 

These cases of meningitis are always very serious, and the promise 
of recovery is doubtful ; many of them get up from their beds and go 
about their business, but retain as a legacy some intracranial disturb- 



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CEREBRAL MENINGITIS; LEAD-POISONING; ALCX)H0LI8M. 131 

anoe in the way of headaches, or in the shape of paresis. It is a most 
remarkable thing for one of these patients to make a full and com- 
plete recovery, and the prognosis as to recovery of any sort in menin- 
gitis is bad. It would be interesting to find out what is the cause of 
this disease. In the case of the little child you saw the other day, I 
expressed the opinion, which the post-mortem verified, that it was 
tubercular meningitis. Is this case one of tubercular meningitis? I 
think not, because of the suddenness of its onset and the violence 
of its symptoms. Furthermore, tubercular meningitis is not likely to 
occur at this time of life, this man being thirty yeai's of age. What, 
then, is the cause? The man comes into the hospital without any his- 
tory at all. We do not know whether or not he received an injury to 
the head, giving rise to an inflammation bf the dura mater, making it 
in that case a pachymeningitis. There is no evidence of suppuration 
of the ear, nor is there any suppurative inflammation about the nose or 
eyes, which might lead one to suppose that it came from these not un- 
common sources of meningitis. The afiection comes on very often 
simply from exposure to cold ; it is sometimes the result of an exces- 
sive use of alcohol, and sometimes the result of overwork ; too much 
brain-work produces congestion of the organ, and meningitis is but a 
step farther in the same pathological direction. Syphilis is another 
cause. But what produced this man's disease we do not know ; it is a 
case of simple non-tubercular meningitis. It looks like an example 
of the ordinary type, where the inflammation usually b^ins in the pia 
mater, but soon extends to the arachnoid, to the dura mater, and to the 
brain itself. When a case has progressed as &r as this one has, you 
may reasonably suppose that the three membranes enveloping the brain 
participate in the inflammatory process, as does the brain itself, and at 
this stage you can safely call it meningo-encephalitis, — inflammation of 
both meninges and brain. 

Case II. — We have here another interesting but not an un- 
common case of nervous trouble. This is one of the great class of 
neuroses. 

History. — Family history, none. Patient, a man forty years old ; 
drinks, and uses tobacco ; was admitted to the hospital seven or eight 
months ago for the same trouble. Present afiection began three weeks 
ago. Patient is well nourished, has a bluish line along the margin 6{ 
the gums, and sordes in the mouth, has pain and slight tenderness over 
the abdomen, complains of weakness in the lower limbs, and is unable 
to extend the hands. 

This man has been a painter for twenty years, and for nineteen years 



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132 INTERNATIONAL CLINICS. 

he had do disturbance of the nervous system ; then he was seized with 
this oolic, and shortly afterwards there came on the wrist-drop, from 
paralysis of the extensor muscles of the wrist You see he has not 
yet recovered the use of these muscles. 

Lead gets into the system by several methods : I think its entrance 
is accounted for in the case of painters by their own carelessness. 
They get their hands all smeared over with the lead, and then are not 
careful enough in cleansing them before they eat ; consequently, a good 
bit of the metal, doubtless, gets into the system by the stomach. Of 
course these men are continually exposed to minute particles of lead 
floating about in the atmosphere of the paint-shops and rooms where 
they are at work. Slight wounds, as bruises or cuts upon the hands, also 
afford entrance i;o the subcutaneous tissues, and, finally, to the general 
circulation. But I think the great majority of painters get lead into 
their system with their food. Some of these cases of lead-poisoning 
will be very perplexing to you, I remember being sent for, a few years 
ago, to see a gentleman of this city, a gentleman of leisure, with noth- 
ing to bring him in contact, in any ordinary way, with lead. He had 
painter's colic and wrist-drop, and for some time that case was a riddle 
to me. Finally, upon one occasion I got a good look at his hair, which 
gave me a clue to the mystery. He dyed his hair with a preparation 
of lead, and in that way had become poisoned. I have seen several 
ladies who were thus affected from the use of cosmetics. Some of the 
cosmetics that are most enduring, and do not come off with ordinary 
perspiration, consist largely of lead, arid now and then you will find, 
among your fashionable female patients, cases of lead colic and wrist- 
drop which owe their origin to these preparations. 

The chief indication in the treatment of lead-poisoning is to pro- 
mote elimination. The lead is very largely excreted by the kidneys 
and bowels, and by the skin to a slight extent. Elimination is pro- 
moted in these cases by the administration of Epsom salt, or some 
equally efficient saline laxative; magnesium bisulphate is esteemed 
one of the best of this class. In addition, potassium iodide is the one 
remedy indicated par excellence. The metal is taken up and carried 
out of the system by the influence of the iodide upon the absorbents. 
You can often verify your diagnosis by examining the urine. TTiere 
is only one precaution to use in these cases of chronic lead-poisoning. 
Do not attempt too rapid elimination. I have once or twice seen bad 
results follow in the way of cerebral disturbance, intense pain in the 
head, and some delirium, from a too rapid letting loose of the lead in 
the system. If you give potassium iodide too freely, and endeavor too 



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CEREBRAL. MENINOITIS ; LEAD-POISONINQ ; ALCOHOLISM. 133 

quickly to dispose of it, the lead is set free from its lodgement, wher- 
ever that may be, more rapidly than it can be excreted, and so, accumu- 
lating in the circulation, it may become a source of irritation to the 
brain or spinal cord. If it is deposited in the peripheral nerves, of 
course it does harm ; if it is taken up by the liver, it does harm, but 
the injury is not so serious as that by its lodgement in the brain or 
spinal cord. You must be cautious, therefore, in these cases, not to 
give potassium iodide too rapidly. It should be administered in four- 
or five-grain doses, three times a day, accompanied by sufficient saline 
laxative to keep the bowels open. The next indication is to relieve the 
intense pains that the patient suffers, and, of course, the only reliable 
pain-relieving remedy is morphine. The great objection to morphine is 
that it interferes with elimination : it must be used, therefore, in the 
smallest possible amount. Some of the new remedies — for instance, 
antipyrine — are well worth your consideration in relieving the pain of 
painter's colic. In addition to the work of elimination, this man needs 
something to improve the tone of these extensor muscles, and the best 
agent for this purpose is the galvanic current. I doubt if you would 
get any response from faradism. The doctor who has attended him 
says he has given him hypodermic injections of strychnine. That is 
capital treatment for this paralysis. Faradism was used when he was 
in the hospital before, and if that will make the muscles respond, it is 
the most convenient method. If not, then the galvanic current should 
be applied in strength sufficient to produce extension. There should be 
daily use of that form of electricity which will produce muscular con- 
traction, and the daily administration of strychnine, hypodermically or 
by the mouth. There is loss of power in the extensors and in the 
hand : his grasp is feeble, not more than half what such a man ought 
to have who has been a laboring man all his life. 

Case III. — Our third patient belongs to the same great class of 
neuroses, and yet at first sight would seem to have nothing whatever 
in common with this other patient. You see in this case there is a 
disturbance of the cerebrum. You notice the way in which she stares 
around the room ; that of itself shows some disturbance of the brain. 
Yon notice also the tremor in her hands. 

ERdory, — Patient, aged forty-two, admitted to the hospital Febru- 
ary 26. Had been indulging in alcoholic stimulants freely of late ; was 
wildly delirious ; saw animals ; had to be restrained. She was given 
bromides. The doctor says she had delirium and visual hallucina- 
tions ; that she saw objects. And so they do : they see snakes and 
other things on the wall, moving about in every conceivable way. 



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134 INTBKNATIONAL CLINICS. 

The visual kallucinatious and the tremor are the typical symptoms of 
this form of deh'rium, the alcoholic delirium, or delirium tremens. 
This condition is probably brought about by a combination of cir- 
cumstances. These patients drink until the brain becomes saturated 
with alcohol, and that is one way in which its functions are disturbed, 
by the circulation of the alcohol itself in the brain ; then again alcohol 
produces vaso-motor paresis, which brings about congestion of the 
brain. We consequently have two causes operating to produce this 
delirium, — the presence of alcohol in the brain, and the congestion of 
the brain. These patients always have, as this one has, very great 
flushing of the face, and usually their eyes are very much injected : I 
think there is probably a similar condition of the brain, but even 
more intense than that shown in the face. This patient has a very 
dry tongue, and is suffering from profound prostration ; she is very ill, 
and we will let them take her back to the ward, and continue the sub- 
ject with another case. 

Case IV. — Here is a young man who has just recovered from 
this same condition. There is some slight tremor here, although not 
so much as there was a few days ago ; there is also some paralysis. 

Hiatory. — Patient had been drinking hard for some time previous 
to his admission to the hospital ; was delirious when admitted. Phys- 
ical examination negative. Soon after admission he became wildly 
delirious ; had hallucinations and had to be restrained ; was very sick 
for five or six days. 

The hallucinations peculiar to alcohol are visual ; they are not 
auditory nor of any special sense except the sense of sight. This 
young man has recovered from that delirious condition, but is still 
feeble, and has some tremor remaining, together with some paralysis 
of the extensor muscles. His tongue looks pretty well, and his general 
condition is improving. He says he did not have this drop of the 
hand before the last attack of delirium tremens, and it may be that 
as his brain entirely recovers from the storm through which it has 
passed, this will disappear. Alcohol plays havoc not only with the 
brain, but with the nutrition of the spinal cord and with the peripheral 
nervous system. Whether or not this paresis is due to degeneration of 
the spinal coi*d remains to be seen : it does not seem to be due to any 
peripheral disturbance, and it may be that it is due simply to want of 
restoration of the functions of the spinal cord. It may not be due to 
any degeneration ; but alcoholism produces all forms of inflammation 
of the spinal cord, and sets up inflammation of the brain itself and of 
the membranes that surround the brain ; it also produces inflammation 



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CEREBRAL MENINGITIS; LEAD-POISONING; ALCOHOLISM. 136 

of the nerves. In some of these cases of alcoholism, where the man 
has been drinking for a number of years, the attack is brought about 
by the sudden withdrawal of alcohol ; in other cases drinking is con- 
tinued until the stomach refuses the alcohol and everything else, and 
the result is exhaustion from lack of food and much vomiting, naturally 
culminating in delirium. 

The first indication in treatment is to aflford proper restraint. The 
subjects of acute alcoholism are as violent as can be : seeing all sorts of 
horrible things, they very naturally seek to escape from them, and in 
that way spend their energy very unnecessarily. Such cases should 
be put into a strait-jacket, and tied to the bed if necessary. They 
should be kept as still as possible, this being, I believe, the most suc- 
cessful part of the treatment. They must be fed : the stomach will 
reject all ordinary kinds of food, but beef-tea, with a pretty strong 
allowance of capsicum, makes a good mixture ; these people like fiery 
things, and red pepper and beef-tea make a very good combination. 
Give them small quantities of food at regular intervals : they need an 
abyndance of nourishment, and as the stomach gradually improves it 
must be increased in quantity. To reduce the delirium they must have 
some sort of sedative. I believe a mistake is often made in giving 
sedatives to these patients. Some people think that they must be forced 
to sleep ; that is a mistake ; I think the amount of narcotic that would 
be necessary to put a patient with delirium tremens to sleep is a dan- 
gerous dose, and I have no doubt some of the sudden deaths from 
delirium tremens are due to the efforts of the attendants to produce sleep. 
I don't think it is a very serious matter if they do not sleep for the first 
twenty-four hours. They should have moderate doses of potassium 
bromide and chloral hydrate, but in all cases you should guard against 
heart-failure, which is liable to occur : use a tonic, such as strychnine 
or digitalis, or tincture of hyoscyamus. My favorite drug is strych- 
nine along with moderate doses of potassium bromide and chloral hy- 
drate. Watch carefully the circulation, and see to it that you do not 
too much depress the heart's action by the use of such drugs as chloral 
and potassium bromide. I think in all these cases of delirium tremens 
where the condition is one of great prostration, where the patient has 
been drinking for a long time, it is not wise to attempt their treatment 
without small doses of alcohol. One cause of death in these cases is 
the stopping abruptly the use of alcoholic stimulants, and it has always 
been my practice, if there is much prostration, to give small doses of 
alcohol. I think that strychnine, the bromides, chloral, and alcohol 
are the remedies to use, with the precautions I have given. And then 



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136 INTERNATIONAL CLINICS. 

when the acute delirium passes and they get into the condition this 
patient is in^ they no longer need the bromides and chloral, but must 
have tonics. At St Joseph's Hospital, in this city, where we treat a 
great many of these cases, we use a combination of tincture of cap- 
sicum, nux vomica, and compound tincture of cinchona ; it contains 
one to two minims of the tincture of nux vomica, four to five minims 
of capsicum, and enough tincture of cinchona to make a drachm, and 
the patient is given a dose every three to four hours, according to the 
amount of prostration shown. And with that we increase the food : 
instead of giving them beef-tea and capsicum, we give them milk and, 
after a little while, the ordinary diet that such people are accustomed 
to have. 

Case V. — ^You notice in this case great wasting of the muscles, 
marked atrophy of the hands, some atrophy of the forearm, and some 
atrophy of the arm. This patient is a laboring man ; he had about a 
year ago a swelling of the arm, followed by loss of power. There is, in 
addition to this wasting of the muscles, tenderness over the nerve- 
trunks, especially in the arm, and over the ulnar and radial nerves. 
You observe the atrophy, the muscular tenderness, and the history of 
pain and swelling. This patient tells me he has been in the habit of 
drinking a great deal for about eight years. The condition of the 
hands is due either to a peripheral disease or to a disease of the spinal 
cord ; it is one of the forms of inflammation of the anterior horns, 
or it is due to peripheral disease. It does not look unlike a case of 
progressive muscular atrophy; the wasting of the muscles and the 
paretic condition of the hands are very suggestive of chronic anterior 
poliomyelitis ; but the amount of pain he claims to have had, the dis- 
turbance of nutrition in the way of swelling in the arm, and the tender- 
ness over the nerve-trunks point to some other cause for this wasting 
of the limb and its want of power. I therefore r^ard this as a case 
of neuritis, or inflammation of the nerve-trunks. He has this atrophy 
in both arms, so it is a case of multiple neuritis ; and as almost all cases 
of multiple neuritis are of alcoholic origin, this one is probably no ex- 
ception to the rule. Multiple neuritis does not usually confine itself to 
the upper extremities, but tends to progress along the important nerve- 
trunks of the body, sooner or later involving both the extremities. 
From the patient's stand-point, the chief difference between this condi- 
tion and inflammation of the anterior horns is as regards prognosis ; 
the victim of progressive muscular atrophy has an outlook that is 
positively bad, while the subject of multiple neuritis has a more favor- 
able prospect 



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CEREBRAL MENINGITIS; LEAD-POISONING; ALCOHOLISM. 137 

The internal treatment should consist in the employment of mild 
alteratives and tonics : small doses of potassium iodide and mercury ^ 
together with strychnine and some preparation of phosphorus^ are 
therefore indicated. Of prime importance, however, is the application 
of ooonter-irritation over the aflTected nerve-trunks. I think it advisa- 
ble to paint the part with the tincture of iodine, and would get up as 
much irritation, superficially, as can be conveniently borne by the 
patient. After the more acute symptoms subside, electricity should be 
applied to the muscles, to prevent their becoming atrophied, and to help 
the injured nerves r^ain their suspended function. I do not suppose 
there would be any response to the faradic current ; but if the inter- 
mpted galvanic current will produce a response, it will be of benefit to 
the patient when used in strength just sufficient to produce contraction 
of the muscles. 

Case VI. — ^The case I now bring before* you is one of left-sided 
hemiplegia. There has not been at any time disturbance of this pa- 
tient's speech. You remember the cases of right-sided hemiplegia ex- 
hibited last week were all more or less aphasic, some of them completely 
so : in some the function of the speec*ii centre had been somewhat re- 
stored. This centre, it may be remembered, is located on the left side 
of the brain, together with the other centres governing the right side 
of the boHy; hence, in right-sided paralysis, where communication 
between the left side of the brain and the right side of the body is 
more or less completely cut off, some impairment of speech usually 
accompanies the other impaired functions of the right side. In these 
cases the lesion is upon the right side of the brain, consequently there 
is no interference with speech. 

Hidory, — This patient was admitted to the hospital on February 22. 
He has been a hard drinker for many years ; had syphilis two years ago. 
Recently he had been sick about a week ; was delirious, and had been 
treated for typhoid fever, no paralysis having been noticed. On his 
admission to the hospital, physical examination revealed partial anaes- 
thesia of the left side, paresis of the left side of the face, almost com- 
plete motor paralysis of the left arm, and not quite as complete paralysis 
of the lower extremities. Two days aft:er his entrance he had a con- 
vulsion lasting several minutes ; next day, the 25th, he had a second, 
with the right arm and both 1^ in a state of chronic contraction ; this 
lasted several minutes. Since then he has had two similar attacks. 

When I first saw this patient in the ward he had that very interest- 
ing and important accompaniment of hemipl^ia, conjunctional deviation 
of the head and eyes. This is not a common symptom of the disease. 



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138 INTERNATIONAL CLINICS. 

but when present it is a valuable aid to diagnosis. This man's eyes 
were turned to the extreme right, away from the paralyzed side, his 
head being rotated in the same direction ; and any effort to move his 
head seemed to be painful to him even in his semi-comatose condition. 
The right side was in constant motion, a feature which made it less 
difficult to locate the paralysis. From the history we conclude that 
this, in all probability, is a case dependent upon cerebral hemorrhage 
secondary to syphilitic d^eneration of the blood-vessels. I say ^^ prob- 
ably," because I do not think we should make a very positive diagnosis. 



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TETANUS NEONATORUM; BASILAR MENINGITIS, 
ETIOLOGY AND TREATMENT. 

CLINICAL LICTURI DILITKRKD AT THE KKW YORK POST-ORADUATK MIDICAL 

SCHOOL. 

BY HENRY DWIQHT CHAPIN, M.D., 

Profetsor of the Diseasee of Childnoi at the New York Post-Oraduate Medical 

School and Hospital ; Attending Physician to Demilt Dispensary, 

New York City, New York. 



Gentlemen, — On January 1 there was admitted to the babies' 
wards of the hospital an infant suffering from tetanus neonatorum, 
who died about four hours after admission. I was enabled to exhibit 
the child to a few before its death, and I will now give a more detailed 
history of this instructive case. 

Simon F , ten days old, was bom healthy, weighing nine 

pounds. The mother had been deserted by her husband, and was in 
poor circumstances. She seems to have been fiiirly healthy, and has 
never had any miscarriages, this being the first and only child. The 
condition at birth was normal. The first disturbance that was noted 
was on the sixth day, when the infant turned its head to one side 
as if in a slight spasm. This grew somewhat worse, and on the eighth 
day the child had clonic convulsions, which passed off in a few hours. 
There has been no history of vomiting. On the ninth day the infant 
refused the breast, and, as the mother was in a bad condition, it was 
brought to the hospital. 

An examination showed the infant to be in a condition of poor 
nutrition ; it seemed to be suffering from a general tonic spasm, the 
arms and legs were flexed and rigid, the fingers tightly clinched, the 
head thrown back, and the jaws somewhat rigid. Opisthotonos was 
fairly well marked ; the infant could be raised with one hand under 
the head and the other under the 1^, while it remained as stiff as 
a poker. During the few hours of life it had exacerbations of this 
condition; at times, however, there was considerable relaxation; the 

139 



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140 INTERNATIONAL CLINICS. 

pupils were contracted and reacted to light. An examination of the 
lungs gave a n^ative result. The child swallowed with mucn diffi- 
culty, although it managed to take part of a bottle of sterilized milk 
and lime-water. There was frothing at the mouth when the spasms 
increased in severity. An examination of the head showed that the 
occipital bone was much depressed, the parietal bones overriding upon 
both sides. This was rieduced without any difficulty, but the reduction 
made no difference in the condition of the spasm. A rather untidy 
dressing was removed from the umbilicus, and the stump was seen to 
be suppurating and in an unhealthy condition. Swallowing grew 
more and more difficult, and the infant soon died of exhaustion. 

Much trouble was encountered in procuring an autopsy. How- 
ever, I refused. a certificate, and finally, after a week's delay, secured 
the privilege of examining the body. During this interval it was 
packed in ice and frozen stiff. An examination showed no disease or 
lesion of the central nervous system, the brain and cord both being 
studied. The inflammation in the umbilicus could be recognized, and 
a phlebitis extended about half an inch back of the stump. There 
was no evidence, however, of peritonitis or pleurisy. The intestines 
were decomposed, and presented nothing worthy of note. It was evi- 
dent that the cause of the tetanus was infection derived from the 
umbilicus. 

It has long been recognized as a fact that although this disease is 
distributed through a very wide geographical area it is nearly always 
found in filthy surroundings. Among the negroes in the South it is 
exceedingly common, also in India and the West Indies, and in parte 
of Iceland. One of the physicians in the class, who has been prac- 
tising in China, tells me it is exceedingly common among the poorest 
classes there. He mentioned one family in which four infants died of 
this fearful malady. The beginning of the affection is seen in most 
cases after the navel-string has separated. We are indebted for a 
better understanding of this disease to bacteriology. Something be- 
sides filth is necessary ; there must be a specific cause. As early as 
1884, Nicolaier observed that tetanus could be produced in guinea-pigs 
and rabbite by injecting various particles of earth. This earth con- 
tained a bacillus which, although not then separated, produced by ite 
cultures the same disease. This bacillus was afterwards described as 
being of the pin-head and bristle-shaped form. It may exist in straw 
or dust from hay, which explains the fact that horses are subject to this 
disease, and that traumatic tetanus is often seen among laborers who 
'are employed about farms and stables. Guelpe, in 1889, published a 



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TETANUS NEONATORUM. 141 

most opmplete monograph upon this disease. He arrived at the fol- 
lowing conclusions : " (1) Tetanus is an infectious disease ; traumatic 
tetanus in the true sense of the word does not exist. (2) Although 
the horse is one of the animals most apt to contract this disease^ tetanus 
is not of equine origin. It would be more correct to attribute it to a 
telluric origin, but this would be too restricted. We believe it pref- 
erable to affirm simply that it is of microbic origin. (3) The symp- 
toms of tetanu9 are not the direct effects of the microbes, but occur in 
consequence of the toxic substances generated by them. (4) During 
the first manifestations of tetanus, at least, the multiph'cation or the 
microbe is limited to the seat of infection ; it is only later, and quite 
rarely, that the bacillus becomes generally diffused through the organ- 
ism. (5) Although opposing the nervous theory of tetanus, we must 
admit that the nervous system possesses an excessive susceptibility 
altogether peculiar to the action of the micro-organisms or products 
generated by them.'' 

While the bacillus of tetanus does not necessarily exist in any one 
place, the umbilical sore is undoubtedly the source of its entrance in 
the vast majority of cases of tetanus neonatorum : hence the utmost 
cleanliness must be observed in cutting the cord and in dressing it. 
Dirty scissors are often employed, or string that has not been in a 
clean place. Scissors can be rendered antiseptic by drawing them 
through the flame of a spirit-lamp. The excess of the gelatinous 
matter may be stripped off the cord, and a dry antiseptic dressing ap- 
plied. Speedy mummification of the stump will be the best safeguard 
against the entrance of microbes. There may be no evidences, how- 
ever, of marked inflammation at the umbilicus. 

Special care must be exercised in the umbilical dressings when the 
infimt's parents work in stables, or where the dwelling is easy of access 
to stable-yards containing horse-manure or loose earth. 

It is interesting, in connecjtion with the case here cited, to observe 
the condition of the occipital bone. The late Dr. J. Marion Sims con- 
sidered depression of the occipital bone to be the most common cause 
of tetanus neonatorum, and thought that relief could be frequently 
procured by putting the infant upon the face, and thus removing 
pressure from the back of the head. In this case the occipital bone 
was markedly depressed, but it was immediately reduced, and the re- 
duction resulted in no change in the symptoms. 

Prophylactic treatment is the most satisfactory. When the disease 
has become thoroughly established it is almost invariably fisttal ; how- 
ever, means should be taken to discover, if possible, the seat of infection. 



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142 INTERNATIONAL CLINICS. 

In cases of suppuration about the umbilicus^ frequent washings with 
a solution of mercuric bichloride of suitable strength should be em- 
ployed. Guelpe states that the bacillus exists to a great extent in the 
deeper portions of the wound, and hence curetting or free incision may 
be employed. This could hardly be done in the case of the umbilicus. 
Free antiseptic washing, however, is certainly indicated. With refer- 
ence to drugs, the two most valuable are potassium bromide, in large 
doses, and chloral hydrate. At the same time these are administered, 
the infant must be given nourishment frequently, and stimulants freely 
employed. The difficulty of swallowing, however, handicaps us in 
satisfactorily carrying out these measures. 

The next case I shall present to you is an infant, thirteen months 
old, who was admitted to the babies' wards December 29, 1890. His 
mother has always been healthy, has had no miscarriages, and has two 
other children, aged three and seven years respectively, and both are 
healthy. This infant was on the breast for a year. Dentition began 
two months ago, when the two lower incisors were cut. The infant 
seems to have been perfectly healthy until six weeks ago, when the 
present trouble began. The child then fell from a sofii, striking the 
back of the head. The parents are Polish Jews and very stupid, and 
it is difficult to obtain an accurate history from this time, but one 
week afterwards the infant was seized with convulsions, each lasting 
several hours. It had two attacks of these convulsions daily for 
about two weeks. A few days ago he apparently lost his sight, and 
the bowels were costive, acting only by injections. The infant is very 
dull and stupid, sleeps most of the time, vomits, and has some cough ; 
the pupils are dilated and do not react to light, and there is internal 
strabismus in both eyes. An ophthalmoscopic examination has shown 
the fundus of the eye to be healthy. The reflexes are somewhat ex- 
aggerated. The child's weight on admission was nineteen pounds two 
ounces; temperature, 99°; respiration, 24; pulse, 118. 

Since admission it has been unconscious all the time, lying with 
the head thrown back in the position in which you see it. It seldom 
cries except when disturbed ; the limbs are held in the flexed position, 
but are not stifi; Examination of the lungs is negative. The pulse 
is irr^ilar at times. On the second day of its stay in the hospital its 
temj>erature went up to 100°, but since then it has remained between 
98° and 99°. The pulse has varied from 110 to 130, and is becoming 
more rapid and irr^ular. The respirations have ranged from 22 to 36. 
The skin is somewhat hypersemic and apparently hypersesthetic, as the 
infant will cry if handled much. Both sight and hearing are largely 



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BASILAR MENINGITIS. 143 

in abeyance, although the peroeptioD of light is not entirely lost The 
bowels were at first quite costive, and an enema was given soon after 
the in&nt entered the hospital. In a day or so they began to act more 
freely, and finally a condition of diarrhoea ensued, which has proved 
difficult to check. For two days the infant had six stools in the 
twenty-four hours, and yesterday eight stools, and to-day blood has 
been noticed in the discharges. This diarrhoea has come on in spite 
of careful feeding, the infant being given nothing but sterilized milk, 
and in the last few days large doses of bismuth subnitrate have been 
administered. To-day I have tried to control these discharges by injec- 
tions of bismuth and starch-water. I r^ard this sanguineous diarrhoea 
which does not yield readily to treatment as a grave symptom in the case. 

We evidently have here a case of basilar meningitis in which the 
prognosis is bad. The unfavorable prognosis may be based upon the 
&ct that the pulse is becoming more irr^ular, and it is a clinical fi^^t 
that few cases of meningitis of any kind go on to recovery when the 
functions of the brain are seriously impaired and the cranial nerves 
and special senses severely crippled. 

The question naturally arises as to the cause of the meningitis in 
this case, and the relation of the fall to the symptoms. Marked cere- 
bral symptoms do not seem to have come on until a week afler the 
accident, but it is well known that maiingitis is very insidious in its 
early manifestations. The active cerebral symptoms are nearly always 
preceded by very great fretfulness and restlessness, with intolerance of 
light and more or less headache. Doubtless a careful observation 
would have established these symptoms in the week that elapsed before 
the occurrence of the convulsions. 

I believe we can broadly distinguish two leading varieties of menin- 
gitis, septic and tubercular. The constitutional disease, cerebro-spinal 
meningitis, is not here considered. Septic meningitis is produced by 
pyogenic microbes. These microbes commonly gain entrance through 
the nose or ears. There may be otitis media, with or without caries of 
the petrous portion of the temporal bone ; or there may be suppurating 
foci in the nose which communicate with the brain through the cribri- 
form plate of the ethmoid. We may likewise have abscesses or tumors 
in the brain, and occasionally extension of inflammation from some of 
the structures in the orbit Doubtless in not a few cases injury acts 
by producing a fracture somewhere at the base, and thereby affords 
entrance for the germs. But septic processes in distant parts of the 
system may occasionally be responsible for meningitis, as the microbes 
enter the circulation and are thus carried to the meninges. 



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]44 INTERNATIONAL CUNICS. 

In this case there does not appear to have been any discharge from 
the nose or ears, but stilly in some way unknown at present, septic 
germs have gained entrance to the meningeal surfaces, with the produc- 
tion of inflammation. 

In addition to sepsis, the second cause is found in the tubercle- 
bacilli. Tubercular meningitis, however, runs a more subacute course : 
while the septic meningitis terminates usually before the twentieth day, 
tubercular inflammation may run for several weeks, or ev^ much 
longer, presenting exacerbations and remissions. There is often in 
these cases a history of phthisis in the family ; heredity is therefore 
an important aid to the diagnosis. There is also a history of previous 
ill health in the child, as well as lymphatic enlargements and other 
evidences of struma. In fact, the distinction between septic and tu- 
bercular meningitis must rest principally upon a careful study of the 
previous history of the cases and the mode of onset, this being much 
more gradual and insidious in the latter variety. In well-developed 
meningitis, where, as already noted, the functions of the brain and 
special nerves are seriously crippled, the prognosis is about equally bad 
in both varieties. 

The hopeftil time for the treatment of meningitis is the prodromal 
period. By giving a mild mercurial laxative, applying cold cloths to 
the head, and administering large doses of potassium bromide, you 
may succeed in some cases in controllmg the b^inning of the inflam- 
mation. At the same time a very careful search must be made for 
the source of entrance of any septic germs, and to this end the nose 
and ears must be subjected to careful scrutiny and, if possible, a 
thorough antiseptic cleansing. The distant organs of the body must 
also be examined to find a possible source for the microbes that are 
b^inning to affect the meningeal surfaces. 



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POTTS DISEASE. 

CLINICAL LVCTURI DILIYSRSD AT THE BKLLBYUB HOSPITAL. 

BY LEWIS A. SAYRB, M.D., 

Professor of Orthopsedic Surgery in the Bellevue Hospital Medical College, New 

York. 



Gentlemen, — ^Two days ago this little child was brought to me 
from one of the extreme Southern States for the purpose of having a 
diagnosis made. She had been seen by a number of eminent physi- 
cians in the South, and for some months there had been much difficulty 
experienced in making the diagnosis. The parents have very kindly 
consented to bring the child here before you to-day in order that you 
may pix)fit by seeing the case. Whether the long journey from the 
South has developed the disease still more, or not, I cannot say, but 
when I first saw the child the diseased condition was quite evident. 
The child is twenty-one months old, and was perfectly healthy and 
active up to last May, when she first complained of stomach-ache. 
Please bear this symptom in mind. She was eating insularly at the 
time, and the physician who saw her then thought her trouble was 
entirely due to indigestion. But attention to the diet did not relieve 
the stomach-ache. In July another physician saw her, and an exam- 
ination of the child's body at that time showed a '^ knuckle'^ on the 
back, and consequently a diagnosis was made of spinal disease. At 
that time she could pick up objects from the floor very naturally, and 
could move around very actively without complaining of pain in the 
back. She has never complained of pain in the back, but only of pain 
in the stomach. This is the rule : stomach-ache, not back-ache. An- 
other physician was called in after the diagnosis of spinal disease was 
made, but the physicians, I am told, were not positive of their diag- 
nosis, on account of the negative character of some of the tests em- 
ployed, and because there was no pain in the back. Aflier a while she 
began to lie around on the floor and to move less actively, and she 
then complained of feeling "tired." While the fiimily physician 
Vol. I. Ser. 4— 10 146 



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146 INTERNATIONAL CLINICS. 

believed there was spinal disease, he was not sufficiently sure of it to 
feel justified in putting on a plaster jacket. It is amusing to note 
that the parents observed that the child walked peculiarly, but they 
thought she was imitating the peculiar gait of their old fat cook. 

Now, watch the way in which this child stoops to pick up an object 
from the floor ; see how she sbrugs her shoulders and throws her head 
back and her chin forward. This stiffness of attitude, this muscular 
splinting, is in itself a sufficient indication not only of disease of the 
spinal column, but of the plan of treatment which should be instituted. 
The child also has a peculiar grunting respiration which is characteristic 
of spondylitis. As I lay her across my lap, with the arms hanging 
over one thigh and the legs over my other thigh, and stretch ^my 
thighs apart a little, so as to make slight traction on her spine, you see 
she becomes perfectly comfortable and the grunting respiration ceases. 

The physicians who sent this child here thought that there was no 
disease of the spine, bedause pressure over the spinous processes pro- 
duced no pain. You should not expect to elicit pain by such pressure ; 
very often, instead, the pain is diminished by laying the child upon its 
face and pressing on the knuckle in its back, as this pressure tends to 
separate the anterior parts of the bodies of the vertebrce where the in- 
flammation exists, and so relieves pain, while by crowding the head 
and buttocks together these same inflamed vertebrae are pressed more 
closely together and pain is elicited. Please bear this fact in mind : 
it is pressure in the long axis of the body that causes pain, and not 
direct pressure on the knuckle itself, except in unusual instances, where 
the spinous process itself is inflamed. 

Many people think the deformity is the disease ; but it is not so, for 
the disease has been there long before the projection was visible ; there 
has been an inflammatory process which has caused a crumbling away 
of the anterior portion of the bodies of the vertebra, and it is this 
which causes the projection of the spine. 

If the disease is detected in its early stages, before the deformity 
occurs, and proper treatment is then instituted, in many cases recovery 
will take place without deformity. 

This instrument which I hold in my hand is called Seguin's sur- 
face thermometer ; it is a very delicate test for different^s in surface 
temperature. As I approach the instrument to the diseased area, you 
can all see that the index rises, showing that there is an increase of 
surface temperature at this point. It is an exceedingly useful instru- 
ment for determining obscure inflammatory action going on in the 
body. 



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POTTOS DISEASE. 



147 



Pio. 1. 



We shall now apply to this child the only treatment which is 
proper at present, — namely, rest and extension in the cuirass. 

I have frequently had little children brought to me wearing plaster 
jackets which slipped up and down on their bodies and were simply 
an additional weight for their already enfeebled spines to carry about. 
It is almost impossible to apply a plaster jacket to any child under the 
age of three years and have it of use. Exceptional children may be 
so large for their age that it is ]K)ssible to get a sufficient grasp on the 
ilium, but such cases are very rare, and in the pi'esent instance the child 
is altogether too small to allow the application of any apparatus which 
will permit it to walk, and the very fact that it is horizontal in its 
cuirass will greatly improve its chances of recovery, while its small 
size makes it very easy to care for it in the cuirass, which would not 
be the case if it were ten or twelve years old. 

Here is a cuirass, — ^a wire framework roughly approximating the 
shape of the body, and padded on the inside like a 
mattress. The part where the buttocks rest is pro- 
tected by rubber sheeting. A jury-mast is also 
applied to the cuirass. The child is bound fiist to 
the apparatus by roller bandages, and the feet secured 
to the adjustable foot-pieces. If the parents cannot 
affonl to purchase a cuirass, you can make a substi- 
tute by placing the child on a piece of paper and 
making an outline of the body, and from this pattern 
cutting out a similar apparatus from a piece of board 
and padding it. It is important that the child 
should be carefully adjusted so that the anus shall 
come opposite the opening. (Fig. 1.) 

We now fasten the leather head-piece under the 
chin and occiput, and fasten the upper ends of the 
strap to the cross-bar, which is attached to the jury- 
mast by means of an elastic strap, and make just 
sufficient traction on the child's head to overcome 
the muscular spasm which is always present in dis- 
ease of any joint. In this child the disease is so 
high up that it is necessary, in addition to keeping 
it horizontal and making traction by its head and 
heels, to hold the shoulders securely back against the cuirass, which I 
do by means of a little steel rod which passes from the tip of one 
shoulder across the chest to the other shoulder, the ends terminating in 
hollow hard-rubber cups, which fit the tips of the shoulders oomfort- 




Padded culnuu with 
Jury-mast attached. 



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148 INTERNATIONAL CUNIOS. 

ably. These cups are held firmly against the shoulders, holding the 
latter back against the cuirass, by means of straps which pass above 
and below the shoulder to the back of the cuirass, where they are 
secured by buckles. The bar which passes across the chest is made 
of two pieces, which slide past each other and are retained in position 
by two set-screws, wliich enable the bar to be elongated as the child 
grows larger. This apparatus is an adaptation of Dr. Whitman's 
support in eases of high dorsal disease, which he uses in children that 
are walking about, and which I have applied with very good result in 
a number of cases treated in the cuirass. (Fig. 2.) 

Case II. — You recollect the child from Philadelphia who was here 
last Wednesday : I saw that child only once before, and that^was last 
February. When only nine months old it fell and injured its spine in 
the mid-dorsal region. Some physician in Philadelphia who thought 
the jacket and jury-mast were the only means of curing disease of the 
spine applied a plaster jacket and jury-mast to this little one, with the 
result that the lower extremities became paralyzed and the child was left 
in a terrible condition. She was only three years old when I saw her, 
and only one when the jacket was applied. The trouble in this case 
was that there was no pelvis to support the jacket. It is utterly im- 
possible to put a jacket or jury-mast on a child who has no pelvis to 
put it on, and this is the case with all children not more than a year 
old. Do not attempt, therefore, to do the impo&sible, and at the same 
time bring into discredit a treatment which, when rightly used, is a 
great blessing to humanity. 

I placed this child in a cuirass and taught the mother how to 
attend to it. With the exception of seeing it the next day, it was not 
under my supervision from that time until it was shown to the class 
the other day. At this time the projection was very much less than 
before, and the child was in every way improved. I brought it before 
you to show you that the mother or any one else who puts her heart 
and soul in the thing can attend the child properly. The great ma- 
jority of physicians have too much else to attend to or take too little 
interest in the case to give it the proper attention : hence the nurse or 
mother must be taught the details of treatment, if you would succeed. 

I have found that the simpler your apparatus, and the more per- 
fectly the nurse, mother, or other attendant understands the practical 
application of it, the better will be the result. It is impossible for me 
to see all my patients daily, and if proper instructions are given there 
will be no trouble in securing effective co-operation on the part of the 
parents or relatives. 



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6 





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pott's disease. 



149 



I should advise the father of this child to procure an easy, springy, 
rattan baby-carriage, fitted with cushion-tired bicycle wheels, so that 
the child can be readily carried around out-doors, in this easy-riding 
carriage, without any jarring. (Fig. 3.) 




Baby-cuTiage Urt child in cainn. Made extra long and with rabber^lred wheels. 

Case III. — Here is a little girl, ten years of age, who had nothing 
done to her for six or seven years. She first came under our obser- 
vation six months ago, and at that time was very tender and much 
emaciated. She was put up in this jacket and jury-mast, and has 
been more comfortable ; but, as you see, the deformity is very great. 
(Fig. 4.) Although the case presents unusual difficulties as regards the 
proper application of apparatus, you see it has been done very thor- 
oughly, and the relief of pain and tenderness is complete. Of course 
we cannot expect to cure the deformity in the case of this little girl, 
the great secret of success being to diagnosticate the disease in the early 
stages and begin treatment then, before deformity has taken place, 
when it is often possible to cure these cases without deformity, as in 
these patients, who have worn jackets for periods of from two and a 
half to three years, and who now, as you see, have practically normal 
spines. (Figs. 6, 6, 7.) 

Case IV. — Here is another girl who was brought to me two years 
ago with disease of the right hip. She was put to bed with a weight 



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160 



INTERNATIONAL CLINICS. 



and pulley, and with a blister over the trochanter. Afterwards she was 
put on a long hip splint, which she wore until entirely well. A few 
weeks ago she returned, having developed disease in the dorsal verte- 
brae. Owing to sickness in the family, she did not return again until 
a few days ago, when a jacket was applied. We shall now add to this 
jacket a jury-mast, which will enable us to make traction on the head. 
There is quite a prominent knuckle in the upper dorsal r^ion. She 
gives no history of having fallen while going about on her crutches, 
and we cannot say what is the cause of this present trouble. Her 
father is a healthy-looking man, and the child herself has rosy cheeks 
and appears to be well nourished and healthy ; yet the history would 



FiQ. 9. 



Fig. 8. 





Jury-mast complete, with a firm basis of support to 
be incorporated in a plaster-of-Paris Jacket. 



Jury-mast and plaster-of-Parls Jacket 
applied. 



seem to indicate a possible constitutional defect. This girl should be 
contrasted with the cases which you have just seen. The other one 
before you is in the early stage of the disease, and consequently we can 
promise, if the treatment is properly persisted in, to effect a cure. The 
jacket has added very much to her comfort, but there is still some pain 



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pott's disease. 151 

present, which is relieved by traction, so we shall now add the jury- 
mast. (Fig. 8.) The plaster jacket is first wet, and a few turns of 
fresh plaster-of-Paris bandage are applied. The jury-mast is placed 
in the exact median line of the body, and in such a position that the 
cross- bar is directly over the middle of the head. (Fig. 9.) Sometimes 
the jury-mast comes from the instrument-maker's with the transverse 
strips of tin passing entirely across the upright pieces. The portions 
of tin embraced between these two uprights at the bottom of the jury- 
mast should be clipped out, otherwise, if there is a very prominent 
knuckle on the spine, the tin strip is likely to exert injurious pressure 
on it 

Some orthopsedic surgeons prefer a rigid chin-piece to the head-sling 
of the jury-mast ; but the patients, after trying both, always prefer the 
jury-mast, notwithstanding its less el^ut appearance, because of the 
greater elasticity and comfort. 

Case V. — Here is a boy who has had disease in the lower lumbar 
r^on for a long time, and who had practically no treatment until I 
saw him about eight months ago. He is now wearing a plaster-of-Paris 
jacket ; the deformity is not marked, and the boy will in time recover 
completely. You notice that his jacket is pressed in close to the crests 
of the ilium. This " waisting-in" of the jacket is very carefully done 
while the jacket is still moist. This is a detail of treatment which is 
especiaUy important when applying plaster jackets to young children. 



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CHRONIC ULCERS OP THE LEG. 

CLIKIOAL LSCTUBE DELIYSBKD AT ADDENBROOKS'S HOSPITAL, CAMBBIDQE. 

BY SIR QBORQB MURRAY HUMPHRYS, F.R.S., M.D., LL.D.» Sc.D.» 

F.R.C.S.B., 

Professor of Surgery in the University of Cambridge, and Surgeon to Addenbrooke's 

Hospital. 



Gentlemen, — Chronic ulcere, that is to say, simple chronic ulcere, 
are peculiar, or nearly so, to the lower half of the 1^, more particu- 
larly the inner and fore part of the leg, and the adjacent region of, or 
behind, the malleoli. In other words, a simple ulcer rarely holds its 
ground in any other part of the body. If, therefore, you see an ulcer 
of such standing and of such charactere as to be rightly called simple 
chronic ulcer in any other part of the body, except, of course, a bed- 
sore, you may infer, indeed may be almost sure, that there is some- 
thing special in its nature, that it is syphilitic, cancerous, or tubercular, 
or is maintained by some peculiar pereistent local source of irritation. 
We often find an ulcer at the side of the great toe nail, but it is main- 
tained by pressure and chafing upon the bare jagged edge of the nail, 
and is quickly cured by removal of the nail. Ulcere, or fissures as 
they^re called, within the margin of the anus pereist because they 
are, time after time, torn open by the passage of faeces through the 
sphinctered part ; and they heal when the sphincter is divided, stretched, 
or otherwise impaired. From a nearly similar cause a crack or ulcer 
at the edge of the middle of the lower lip is often a source of con- 
tinued annoyance ; but it is cured by collodion, or some application 
which prevents the tearing apart of its edges by the action of the 
orbicularis muscle. An ulcer in the damaged skin under the thick, 
hard cuticle of a corn will remain for a long time, and may perforate 
the tissues down to the bone or joint, especially if there be any atro- 
phic, neural, or senile condition of the part If, however, irrespective 
of these causes, we find an ulcer or ulcere upon the toes or in the clefts, 
behind them, about the anus or the lip, we suspect syphilis, unless the 
base and edge be hard from cancerous infiltration or the surround- 
162 



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CHBONIG ULCEBS OF THE LEG. 153 

ings dotted with tuberculous points. The ordinary simple ulcer rarely 
is met with in these parts. Let us then consider how it comes about 
that ulcers so often affix themselves and hold their ground on the lower 
part of the 1^ while other regions of the body are so free irom them. 

VARIX CONSIDERED AS A CAUSE. 

Varix is one of the causes^ perhaps the most frequent one, though 
I think its influence in this respect is somewhat overestimated. The 
internal saphenous vein has a longer subcutaneous, that is, compara- 
tively unsupported, course than any other vein in the body, and it bears 
the weight of a long column of blood ; and the frequency with which 
its coats yield under the pressure exerted shows that it is scarcely equal 
to its requirements. A varicose state of the vein does not interfere 
directly with the circulation in the skin, or with the nutrition of the 
skin, for the blood-current through the small vessels of a part is but 
little, commonly not at all, affected by the increased calibre or varicose 
condition of the vein leading from it. The blood-stream in the dilated 
vein itself is slowed, but not so th^t in the tributary vessels, any more 
than the stream through a pipe or system of pipes is affected by the 
bulging of the tubes at one or more parts. An illustration in point is 
furnished by the testicle, which does not seem to suffer in size or struc- 
ture or activity in consequence of varicocele, even though the dilatation 
of the spermatic veins be very considerable. The way in which a 
varicose vein acts injuriously upon the skin is, jird^ by throwing the 
covering skin into prominence, and so subjecting it to friction, which 
may induce irritation or inflammation, and often leads to pigmentation, 
or other degenerative changes, and perhaps may induce ulceration of the 
skin. SeconcUy, these changes are further promoted by the pressure of 
the dilated vein causing atrophy and absorption of the subcutaneous 
tissue, including the blood-vessels, and so interference with the blood- 
supply to the skin. Thirdly, the stretched vein-walls and the immedi- 
ately investing tissue are liable to inflame ; and the inflammation with 
extravasation or proliferation, or both, of cells spreads around, causing 
oedema and induration of the subcutaneous tissue, and probably in- 
flammation. Not infrequently has the dilated soft fluctuating vein, 
thus circumstanced with its tender surroundings and red covering of 
skin, been mistaken for an abscess and opened, much to the discom- 
fiture of operator and patient, when blood only was seen to issue instead 
of pus. Fourthly, the slowed blood-stream in the stretched, and more or 
less altered, epithelial lining of the dilated vein oft:en leads to the for- 
mation of blood-clots, which are commonly attended with inflammation 



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154 DTTERNATIONAL CLINICS. 

of the vein and its surroundings, extending to and involving the skin. 
The blood-clots may, and usually do, become removed, and the channel 
in the vein may become restored, but the effects on the skin may never- 
theless remain. By one or more of these various causes, rather than 
by any immediate effect on the circulation, inflammation of the skin, 
with its consequences, more particularly eczema and ulceration, may 
be, and often is, induced and maintained by a varicose condition of 
the subcutaneous veins.* 

It is worthy of notice, however, that these ill effects, beyond some 
pigmentation of the skin, rarely take place at or above the knee, even 
although the vein in the thigh may be considerably more dilated and 
tortuous than in the leg ; nor do they attend upon varix in other parts 
of the body, except about the anus, where the conditions are peculiar. 
We must, therefore, search for some other conditions which render the 
skin and subcutaneous connective tissue of the lower part of the 1% 
so liable to derangement. 

OTHER CAUSES. 

One of these conditions is, I think, to be traced to the fact that for 
the purpose (much nullified by the unphysiological construction of our 
supra-pedal garments) of facilitating progress, especially in running, 
and to permit the other foot to sweep by without contact, the human 
leg at, and more especially just above, the ankle is reduced to the 
smallest possible dimensions, the result of which is that a greater 
weight is borne upon a given transverse sectional area than in any other 
r^ion of the body ; and this renders the part, as we know, very liable 
to fractures and to rickety flexures, as well as to affections of the peri- 
osteum and other soft pai*ts. In short, all the tissues are placed at a con- 
siderable disadvantage by this reduction in size. The muscles are heaped 
up behind into the calf, and in front into the bulging tibialis anticus 
and extensors of the toes, whereas below they, as well as the peronei, 
are reduced to tendons ensheathed in dense fascise. This arrangement, 
while it gives comeliness to the leg and ankle and contributes to the 
freedom of the step, has, like many other peculiarities of the human 

1 1 must, however, not leave the valves out of account. In the natural condi- 
tion the valves prevent a return current, and facilitate the onward flow by causing 
external pressure to operate in the right direction, and by counteracting the impulses 
of the blood-pressure from above during abdominal straining and various movements 
of the limbs. When in varix, owing to the dilatation of the vein-walls, the valves 
are rendered inefficient, there is nothing to resist the reflux of blood, which may 
act prejudicially upon the tributary veins and cause dilatation of them. Even theD, 
however, it does not seem very detrimental to the capillary circulation. 



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CHRONIC ULCERS OF THE LEG. 155 

form, its pathological disadvantages. The tissues, compressed within 
narrow limits, and somewhat tight or stretched, suffer in vascularity. 
In by-gone years, when it fell to me to inject bodies for dissection, I 
was struck by the tardiness with which the colored fluid thrown into 
the aorta permeated this r^ion. Moreover, the skin lying upon the 
surface of the bone and the fiiscise, and separated from them only by 
a comparatively thin layer of connective tissue, is very liable to suffer 
severely from slight injuries. We all know how easily a broken shin 
is caused, and how much trouble it often gives. These features, then, 
in the anatomy of the part — ^the sraallness of the circumference or 
weight-bearing area, and the consequent compactness and relatively 
low vascularity of the several tissues, bone, tendons, fascise, connective 
tissue, and skin, with their well-known liability to injury — are, I be- 
lieve, the causes which, in addition to the disturbances attendant upon 
varix, lead to the formation of ulcers of the leg, and to their continu- 
ance when formed. 

CAUSES WHICH RETARD HEALING. 

The shape of an ulcer which is least favorable to healing is the 
circular, because in it the skin-forming margin bears the least proportion 
to the surface to be healed ; and, cwteiis pafnbvs, the more the ulcer 
deviates from the circular shape, and the more irr^ular is its margin, 
the quicker will the healing be. Again, the more adherent and the 
more compact are the surroundings, the slower and more difficult will 
the healing of an ulcer prove. An ulcer with soft swollen circumfer- 
ence, and with perhaps a thick, white, overhanging edge of cuticle, will 
commonly, under moderate carefully-applied pressure by adhesive 
plaster or other means, soon acquire a level edge, and a delicate red 
film of cuticle will be seen shooting from the edge over the granula- 
tions. This proceeds more slowly as it approaches the centre of the 
ulcer, where the greatest difficulty in healing is encountered, owing to 
this part being farthest from the growing or healing base. When, 
however, the surrounding infiltrating media have hardened, rendering 
the skin thin, smooth, shiny, and tightly bound to the subjacent bone 
or &scia, the reparative work is, under the best of circumstances, very 
slow and, for the most part, inefficient. Even if such an ulcer can be 
induced to heal, it commonly soon breaks out again, and is as bad as 
ever, or worse. 

CUTICLE-GRAFTING. 

I believe good results in such cases as those last named can be 
obtained in one way only, — ^namely, by the Thiersch method of grafting, 



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166 INTERNATIONAL CLINICS. 

as you have in several instaDces seen it done in the hospitaL After a 
few days' rest in bed, sufficient to bring the tissues into a fairly healthy 
state, the part and the skin for some distance round being rendered as 
aseptic as possible, the granulations are scrubbed off, so as to get rid 
of all suppurative germs, and the fresh surface thus exposed, as soon 
as the bleeding has subsided, is covered over in its whole extent 
smoothly and carefully with thin layers of cuticle razored off, with the 
thinnest possible stratum of subjacent cutis, from some healthy r^ion 
which has also been rendered aseptic. A piece of thin, soft oil-silk 
no larger than the ulcer is applied, and the limb is covered, from the 
ankle to the knee, with aseptic cotton-wool and a light soft bandage. 
Aft«r a few days, when the dressings are removed, the cuticular cover- 
ing will probably be found adherent, and it will usually go on to the 
formation of good skin much sounder, softer, and more enduring than 
that which would have resulted after months of the old plans of treat- 
ment. This method, which ranks high among the many great im- 
provements in modem surgery, answers so well that we often adopt it 
in earlier stages before the ulcers are so chronic, and before their sur- 
roundings have acquired the firm adherent glossy characters I have 
mentioned, thus saving time and getting sounder and more supple 
cicatrices, with less danger of the recurrence of ulceration. 

SKIN-GRAFTING. 

Before the time at which cu^tcfc-grafting came into vogue we used 
to practise «Ainrgrafting, — cutting out, that is, and applying upon 
the granulating surface of the ulcer small pieces of the whole, or 
nearly the whole, thickness of the skin. This answered to a certain 
extent, but not so well as the cuticular grafting. The ulcer was not 
so well covered, and the skin-pieces did not so firmly cohere and form 
cicatrizing centres. The part was kept covered up for a week or so 
after the operation. It was then often noticed that the cicatrization 
was proceeding briskly from the circumferential skin ; and this was 
by some persons attributed to the influence exerted by the grafts in 
stimulating the process of cicatrization around. I observed, however, 
that it occurred whether the grafts had taken or not ; and it was, I 
believe, due in great measure, if not entirely, to non-interference with 
the ulcer, the cell-growth at the margin being allowed quietly to un- 
dergo epitheh'al transformation instead of being hurried off by removal 
of the dressing and by the customary ablutions, — ^a hint which I have 
often turned to valuable account in the treatment of ulcers even with- 
out grafting. Cover up an ulcer which is in a condition suitable for 



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CHRONIC UXiCEBS OF THE LEG. 157 

healing, and do not touch it or look at it for several days, unless 
copiousness of discharge or other cause requires it to be exposed, and 
you will probably be surprised at the progress which the unmolested 
efforts at cicatrization have made. 

INFLAMMATORY AND ATONIC ULCERS. 

If the ulcer be in the opposite condition, — namely, spreading, — an 
opposite treatment must be pursued, and the foul discharge and ragged 
decomposing and detached fragments be washed away by dripping of 
water, or keeping the limb in a warm-water bath, or by frequent 
changes of wet antiseptic di^essings. Spreading of an ulcer of the 
1^, when not due to syphilis, is commonly dependent either upon 
acute inflammation or upon an atonic condition of the patient In 
the former case elevation of the limb, with some soothing application 
and the administration of aperients, will usually check the progress of 
destruction ; and the healing of such ulcers, more particularly if slough- 
ing has occurred, commonly goes on quickly at the circumference, 
because the surrounding tissues have not had time to become infiltrated 
and indurated by a persistence of the inflammatory condition in them. 
Towards the centre, however, the process goes on more slowly, and the 
thicker, coarser, middle part of the cicatrix may often, for a long time, 
be distinguished from the finer, more supple, and more quickly formed 
border. In atonic vicers, the feature of which is that tissue-destruction 
is out of all due proportion to, or outruns, as it were, the inflammatory 
cause, the prognosis is bad. They occur, so far as I have seen, most 
frequently in women, and are dependent upon failing health, combined 
perhaps with diabetes. The efforts to restore tone to the system are 
often ineffectual ; and the removal of the limb by amputation is too 
often followed by bad results. 

BONES AND FASCIiE INVOLVED. 

In course of time the slow thickening process attendant upon the 
chronic ulcer reaches the periosteum, causing thickening of it and of 
the subjacent bone. These specimens ft*om the museum, in each of 
which yon see on the inner side of the tibia a broad, tolerably defined, 
raised ^' table-land"-! ike eminence, are examples of the effects of chronic 
ulcers beginning in the skin. The process may diffuse itself around 
the bone, and even extend, as it has done in this instance, to the fibula, 
which bone is rather liable to periosteal thickening and nodular osteo- 
phytes. In one case, in my recollection, of this kind, the ulceration 
extended into the posterior tibial artery and caused fatal hemorrhage. 



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158 INTERNATIONAL CLINICS. 

I do Dot remember an instanoe of the cure of such long-etandiDg, bone- 
involviug ulcers, and should think that cuticle-grafliDg would offer the 
only prospect^ and that not a very good one, of such a result. In a case 
where the ulcer was over the fibula, I contemplated cutting away a 
piece of the thickened bone in its whole thickness, which would prob- 
ably have enabled the ulcer to heal ; but I lost sight of the patient. 
When an ulcer has perforated the deep fascia and involved the subja- 
cent muscles or tendons, the muscular movements and twitchings consti- 
tute a serious hinderance to the formation and maintenance of a cicatrix. 
Improvement may be effected by the application of splints or plaster 
of Paris to the foot and leg, or by division of the implicated muscles 
or tendons, but a permanent good result is rarely attained. Even if 
the ulcer heals, the tendons or muscular fibres remain involved in the 
cicatrix, and soon cause it to give way. 

ULCERS AT THE INNER ANKLE. 

Ulcers beneath and behind the inner malleolus, where there is often 
a plexus of small dilated veins, though not large or deep, are frequently 
very irritable and painful, which results apparently from the repeated 
movements of the part and the stretching of the skin, which is here 
attendant upon the movement. The requisite quiet is best afforded 
and healing promoted by the application of a splint along the back of 
the leg with a foot-piece ; or, if the repose in bed requisite for this 
cannot be maintained, the foot and leg may l)e covered with plaster of 
Paris, leaving the ulcer free, and the patient can go about with a knee- 
rest. In these, and in other cases to which the term irritable is especi- 
ally applicable, that is to say, where the pain and possibly the spreading 
are out of proportion to the inflammatory or other obvious cause and 
may be referred to some nerve-condition of the patient or part, opium 
is especially beneficial, one, two, or more grains being administered in 
the twenty-four hours. 

OTHER MODES OP TREATMENT. 

The effect of a passing inflammatory condition of the skin, such as 
erysipelas, in promoting healing of a chronic ulcer suggested the ap- 
plication of a blister or acetum cantharidis to the skin around obstinate 
ulcers, and it has been found in some cases to be productive of good. 
I suppose it acts by causing the effusion of fresh leucocytes, which more 
or less clear away the products of past inflammation and leave the 
tissues more free for reproductive efforts. The plan never had much 



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CHRONIC ULCERS OP THE LEG. 159 

aooeptance^ and, like most other irritating and painful appliances, has 
fallen pretty much into disuse. 

Of all the various modes of treating chronic ulcers, none has held 
its ground so long and so well as pressure, which seems to act, to some 
extent, like a blister, by promoting the absorption of inflammatory prod- 
ucts and, in addition, by supporting the blood-vessels. Accordingly, 
itd good effects are best seen when the tissues about the ulcer are most 
thickened by the presence of more or less solid effusion and are in a 
comparatively quiet or indolent condition. A surgeon who for many 
years enjoyed a great reputation in this neighborhood for the treatment 
of sore legs told me that his sheet-anchor was a flannel bandage care- 
fully applied, which regulated the circulation not only by exercising 
pressure, but also by keeping the limb warm. He showed good 
judgment in the selection of his material ; and the stiff linen or calico 
bandages of former days have now pretty much given place to those of 
sofler texture. When adhesive plaster is used, in broad strips, over the 
ulcer and partially or wholly encircling the limb, which acts like a 
charm in the case of some old sores with thickened surroundings, it 
should be first soaked in warm water, whereby it is softened and can 
be more evenly and accurately applied, and is therefore much less 
irritating. It should be covered by a soft; bandage over the foot and 
1^, and may oft^n, as I have before said, be allowed to remain undis- 
turbed for several days ; and in some cases the healing processes will 
be set lip and continued while the patient goes about. I find this, on 
the whole, to answer better than the Martin's india-rubber bandage, 
which is liable to cause irritation and an eczematous condition of the 
skin. 

Another very favorite application with us, particularly among the 
out-patients, is the " gelatin paste,'' composed of gelatin, glycerin, zinc 
oxide, and water. This, when softiened or rendered fluid by heat, 
is painted on the limb and covered by a bandage. It forms an un- 
irritating, close-fitting protection, and exercises some pressure. It may 
remain undisturbed for several days, and is especially suitable when 
there is an eczematous condition of the skin around the ulcer. Indeed, 
in that troublesome affection, chronic eczema of the leg, of which we 
see so many cases in the out-patient room, I know of no application so 
serviceable as the gelatin paste. In another form also, that of zinc 
ointment, the zinc oxide is very serviceable. It is unirritating and 
forms a cake about the ulcer which should only be occasionally re- 
moved ; and it suits, I think, in a greater number of out-patient cases 
with ulcers of the legs than any other ointment There is, however, a 



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160 INTERNATIONAL CLINICS. 

great variety of other oiutments^ as well as of lotions, some stimulating, 
some sedative, some neutral, in the selection of which observation and 
experience will aid you. I will make one remark applicable to them 
all, — viz., that the skin is very sensitive to annoyance from them, in- 
deed from anything to which it is not accustomed. Many a trouble- 
some bad leg, ulcerated or eczematous, has owed its origin to the 
ointments or lotions under oil-silk, or to poultices applied on and 
around a simple skin lesion, which might have been avoided by merely 
protecting the injured part in the first instance with a little collodion, 
or with a small piece of plaster soaked in hot water and changed as 
occasion required. It is no uncommon thing to find that, though the 
original wound has healed, eruptions and ulcers have broken out around 
which are traceable entirely to the applications that have been made. 
Where, therefore, such applications (ointments, lotions, etc.) are judged 
to be necessary, they should be reduced to the minimum in extent 
and in time that may be requisite for the end to be obtained. 

IN THE AGED. 

Chronic ulcers of the leg are most common in middle life, and are 
very common in married women, in whom child-bearing gives rise to 
varix and swelling of the legs, and whose domestic duties pi*event the 
rest requisite for repair. I have on several occasions called attention 
to the facility with which the healing of wounds and sores takes place 
in the aged, which may be one reason for our not more often seeing 
chronic ulcers in elderly persons, and when they do occur they more 
readily yield to appropriate treatment than at earlier periods of life. 
In the out-patient department these ulcers of the 1^ seem to me to do 
best when the patients have well passed the middle term of life. I 
suppose the tissues, being drier and with lower nerve-sensitiveness, are 
less liable to suffer from the various disturbing causes which lead to 
ulceration and prevent healing; just as, and probably for the like 
reason, the old frame is less amenable than the young to the evil action 
of contagious influences. It furnishes, that is to say, a less succulent 
and fertile soil for bacterial germination ; and this has a local as well 
as a general preservative purpose. I have sometimes thought also, how- 
ever improbable it may seem, that, irrespective of a less liability to 
disturbance, the work of repair goes on as quickly as in the young, if 
not even more quickly. 

EPITHELIOMA. 

In common with other surface-parts which have long been subject 
to some irritation and have in consequence suffered a lowering of 



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CHRONIC ULCERS OP THE LEG. 161 

Dutritive force and of resistance to disease^ chronic ulcers are liable to 
be the seat of epithelioma^ which, infiltrating the skin and giving it a 
raised, hard, knotty edge, spreads over the ulcer, giving it an uneven, 
coarsely granular surface, with thin, perhaps bloody, discharge. It 
eats into and destroys the subjacent tissues, causing ragged holes in the 
bones like those which you see in these specimens from the museum, 
some of which look as if they had been gnawed by an animal. The 
absorbent glands in the thigh do not early become involved, not nearly 
so early as they do in the case of the more numerous and active lymph- 
plexuses and glands about the mandible and neck when the lip or the 
tongue is the seat of this disease. It is not a very painful affection, 
and is usually allowed to go on till amputation of the limb is the 
only recourse. 

EFFECT ON THE GENERAL HEALTH. ^ 

There is one further point to which I would direct your attention, 
that, namely, of the relation of chronic ulcers to the general health, or 
rather the influence which they exert upon the body, and the effects 
which are liable to ensue upon their closure. Such is the mutual inter- 
dependence of the several parts of the body that a wrong-going in any 
one must be felt in the others ; and though an ulcer in the skin of the 
1^ may be a comparatively little matter, still the abnormal process 
concerned and the discharges, together with the attendant nerve-irrita- 
tion, must have some influence, and that, under ordinary circumstances, 
can scarcely be a beneficial one. It may be evinced in a slight general 
depression of which some persons are conscious; they do not feel 
quite so well during the time of the existence of a sore 1^, and feel 
better when it is healed ; and on this, as well as other accounts, the 
period of its existence should be curtailed. But the further question 
arises whether in certain slightly deranged conditions of the system 
the influence of the ulcer may he beneficial and the effect of its closure 
be prejudicial. It may be that its appearance in some way meets a 
rising want, as occasionally does a purge or a sweat, or as the outbreak 
of the eruption of measles relieves the preceding symptoms, or as an 
attack of gout often clears the constitutional atmosphere. A friend, 
whose authority no one would doubt, has told me that when a small patch 
of psoriasis, which he has long had on one log, is in abeyance, he is 
subject to slight though distinct evidences of disordered health, which 
disappear as soon as the irritation from the greater activity of the 
psoriasis returns. Such a "derivative'^ idea was the basis of the 
theory upon which issues and setons were employed formerly as a 
Vol. I. 8er. 4—11 



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162 INTERNATIONAL CLINICS. 

meanB of preventing and suppressing disease ; and we cannot say there 
is nothing in it. It may be that there is a great deal in it which we 
should recognize if we knew better how to observe and interpret 
phenomena. There is^ however^ still another point, which more con- 
cerns us in relation to chronic ulcers and their treatment, which is 
this. The ulcer may have, and commonly has, originated from an 
accident or some local cause, and had therefore, at first, no connection 
with any particular condition of the system ; but by long continuance 
it may have acquired an influence, and have become more or less ad- 
vantageous or necessary to the system which has in time been habit- 
uated to it and accustomed to rely, as it were, upon it The difficulty 
in determining this arises in no slight degree from the fact that suf- 
ferers from chronic ulcers commonly belong to the class of persons 
whose struggle for existence prevents much heeding of slight health- 
derangepients, and who are, therefore, not likely to observe, still less to 
remember, any variations that may be associated with the open or the 
healed state of an ulcer. Still, we do find patients who have had long 
personal experience of the kind remarking that they feel best when 
the ulcer is open, and that when it is closed they suffer from heaviness, 
loss of appetite, and, not unfrequently, a sense of sinking at the pit 
of the stomach ; and we now and then meet with cases in which more 
serious symptoms, such as those of apoplexy or heart-failure, follow 
upon the closing of a long-standing ulcer. Without attaching too 
much importance to these exceptional cases, we ought not altogether to 
ignore them or to turn a deaf ear to the statements respecting them, 
on the ground that our pathological knowledge does not afford us a 
satisfactory explanation of them. They should leave some mark upon 
us causing us to inquire with care into the general condition of each 
patient with an old ulcer, and the history during the progress of the 
ulcer, more particularly whether the variations in it have been iasso- 
ciated with any variations in the health ; and we should act accord- 
ingly, suggesting perhaps some alteration in diet, or prescribing some 
mild aperient or so-called alterative to be continued during, and for 
some time after, the healing of the ulcer. The more rapid and decided 
method of cure which cuticle-grafting places in our hands renders some 
precautions of this sort still more desirable. We need not revert to 
the practices of the Abernethian era and treat sore legs with blue pill, 
— such excursions from the orbits of common-sense gravitation being 
usually followed by more or less production of corresponding move- 
ments in an opposite direction. We do well, however, to let the 
thoughts of past periods have their weight in determining the views 



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CHBONIC ULCEBS OP THE LEG, 163 

of the present, and not, in the pride and presumption of recent 
advance, to think that our fathers were all wrong. As I have already 
said, the relation of local disease to the constitution is a matter of 
peculiar difficulty, whi«h must await its solution in the pathological 
developments of the future, combined, as they should be, with accuracy 
of clinical observation. 



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SUPRAPUBIC CYSTOTOMY FOR THE FORMATION 
OF AN ARTIFICIAL URETHRA. 

CLINICAL LKCTURB DELIYKRAD AT THE UNIVERSITY COLLXOK OF HBDICINE. 

BY HUNTER McGUIRB, M.D., LL.D., 

Professor of Clinical Surgery in the University College of Medicine, Richmond, 

Virginia. 



Gentlemen, — ^The patient I present to you to-day is a man sixty- 
eight years of age, who has hypertrophy, or enlargement, of the pros- 
tate gland. As the trouble is one you will fi'equently meet with in 
practice, and as the logical treatment of the disease is based upon a 
correct appreciation of the anatomy of the parts, the etiology of the 
condition, and the pathological changes which occur, I shall, contrary 
to my usual custom, devote my entire time to-day to this one case. 

The prostate gland is situated at the neck of the bladder, which it 
aids in supporting, and surrounds the first inch of the urethra. It is 
in close relation to the pubis in front and the rectum behind, and is 
about the size and shape of a horse-chestnut. It is composed of 
fibrous, muscular, and glandular tissues, and might as appropriately 
be termed the prostatic muscle as the prostatic gland. 

The prostate is divided into two lateral lobes by a deep notch 
behind, and by a furrow on its upper and lower surfaces. The so- 
called third or middle lobe is that portion which is between the two 
lateral lobes* at the under and pf)sterior part of the gland, and lies 
just beneath the neck of the bladder. The function of the prostate 
gland is purely sexual. It contracts spasmodically at the b^inning 
of a sexual orgasm, and forces the semen from the prostatic sinus into 
the urethra in jets or spurts. In its normal condition it neither assists 
nor retards the flow of urine, but when the gland becomes hypertro- 
phied, as a result of clianges in its size and shape produced by dis- 
ease, it may act as a mechanical obstruction to the flow of urine, and 
produce great suffering, or seriously endanger life. 

The amount of obstruction and the symptoms produced by hyper- 
trophy of the prostate depend more upon the form and direction of 
the enlargement than upon its size. Thus, for instance, a growth 
164 



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FORMATION OP AN ARTIFICIAL URETHRA. 165 

which directly encroaches upon the lumen of the prostatic urethra or * 
the neck of the bladder would produce more trouble than a much larger 
growth which projects into the free cavity of the bladder or extends 
towards the rectum. Hypertrophy of the pcostate is a disease of ad- 
vanced life, and rarely occurs in men under fifty-five years of age. 
One-third of the men past this age suffer with bladder-trouble from 
enlargement of the prostate, and the trouble is so common that I 
wonder it was not included in that vivid description of old age found 
in the last chapter of Ecclesiastes. Hypertrophy of the prostate is 
due to an increase of the muscular and fibrous elements of the organ, 
the glandular constituent undergoing little or no change. It may be 
simply a symmetrical enlargement of the whole prostate, thus increasing 
the prostatic urethra three or four times its normal length ; or one of 
the lateral lobes may enlarge more than the other, thus compressing 
the urethra to a mere slit or chink; or the middle lobe may alone 
enlarge, and thus constitute a bar which obstructs the internal orifice 
of the urethra. 

Various theories have been advanced by different writers as to the 
etiology of the disease. Guyon believes that the hypertrophy of the 
prostate is due to general atheroma. Lydston thinks that as the 
prostate is a sexual and not a urinary organ, the explanation of its 
pathological changes must be in the direction of some perturbation of 
its physiological function, and attributes its hypertrophy to what he 
terms "prostatic overstrain,'^ due to excessive venery. Harrison 
takes the view, and my own clinical experience confirms his theory, 
tfiat prostatic hypertrophy is secondary to changes which occur in the 
bladder itself from senility. The bladder in early life is almost an 
abdominal organ, but as years go by it descends lower and lower into 
the pelvis, until in old age the posterior wall has sunk to a lower level 
than the outlet of the organ. As soon as this occurs, incomplete evacu- 
ation of the bladder can be prevented only by repeated and prolonged 
efforts of the muscular elements of the wall of the bladder and of 
adjacent muscles, and hypertrophy is the result. The prostate partici- 
pates in this compensatory hypertrophy, and its enlargement adds to 
the obstruction and increases the violence of muscular contraction. 
Changes occur also in the bladder itself, which according to the theory 
of Lydston are the result of the hypertrophy of the prostate, and 
according to Harrison occur before the enlargement of the prostate 
takes place, and bear a causative relation to its increased growth. Be 
this as it may, pouches form in the walls of the bladder, and urine col- 
lects in these depressions, which is called '^ residual" because it cannot 



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166 INTERNATIONAL CLINICS. 

be expelled. This residual urine decomposes, undergoes ammoniacal 
decomposition ; ptomaines are formed, which irritate the bladder and 
cause cystitis. The mucous membrane of the bladder becomes con- 
gested, thickened, and inflamed, and unless relief is afforded the process 
extends to the ureters and kidneys, causing ureteritis, pyelitis, pyelo- 
nephritis, and death. 

The first symptom of enlarged prostate is increased frequency of 
making water, especially at night. The patient complains that the 
flow is slow to start, that a longer time is necessary for the act, and 
that the stream is not projected far from the body, but drops perpen- 
dicularly to the ground. There may be a sense of weight, fulness, 
and discomfort in the bladder, due to the residual urine, which cannot 
escape on account of the prostatic dam. 

Sudden retention of urine may occur, or there may be incontinence, 
or dribbling, due to over-distention of the bladder. Soon there is 
cystitis, due to ammoniacal decomposition of the urine, and the water 
becomes alkaline, fetid, and loaded with mucus. Pain and vesical 
tenesmus are constant, sleep is disturbed, the general health feils, and 
the condition of the patient is pitiable. 

The diagnosis of prostatic hypertrophy is not difficult. If a patient 
past middle life comes to you and complains that he has to get up two 
or three times during the night to make water, that his stream is feeble, 
that even after prolonged efforts he fails to satisfactorily empty his 
bladder, that he " never feels as if he had done," that his urine has an 
ammoniacal smell, and that a sediment forms in the pot which looks 
like white of egg, you may suspect that his prostate is too large. If, 
after he has emptied his bladder as completely as he can, the introduc- 
tion of a catheter shows the presence of residual urine, and if a digital 
examination of the rectum shows that his prostate is larger than normal, 
your suspicions become certainty. 

The cystoscope, which you saw me use last week in making a diag- 
nosis of a case of tuberculosis of the bladder, unfortunately cannot be 
used in this trouble. The growi;h of the prostate and the alteration it 
has caused in the curve of the urethra prevent the introduction of so 
short beaked an instrument, and hence we are deprived of the positive 
and accurate information which a view of the interior of the bladder 
would give. 

Frequently hypertrophy of the prostate is accompanied by the 
presence of a stone in the bladder. This complication intensifies the 
symptoms and hastens the termination of the disease. The presence 
of a stone may be suspected if exercise, riding in a rough vehicle, or 



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FORMATION OP AN ARTIFICIAL URETHRA. 167 

sudden jars increase the pain and irritability of the bladder ; its exist- 
ence can be definitely proved only by the use of the sound. Some- 
times, when from the symptoms, and frx>m the character of the urine, 
you are certain that there is a stone in the bladder, you will be unable 
to touch it with the instrument, because it has lodged in a deep pouch 
behind the prostate gland. In these cases the patient should be placed 
in Trendelenburg's position, as the stone will then be displaced by 
gravity and come within easy reach of the point of the sound, unless, 
as is rarely the case, it has become encysted or adherent to the walls of 
the bladder. 

What should be the treatment of enlarged prostate ? If the growth 
does not seriously obstruct the flow of urine, if the patient does not 
have to get up more than once or twice during the night to empty his 
bladder, if he suffers little or no pain, and if the catheter shows that 
only one or two ounces of residual urine have been retained, and that it 
is clear, and there is no evidence of ammoniacal decomposition, then 
drugs or local treatment are contra-indicated. The patient should be 
directed to empty his bladder as regularly and completely as possible, 
to prevent becoming chilled, by dressing warmly, to avoid getting his 
feet wet or sitting on a cold stone or a damp saddle, to eat only easily- 
digested food and keep his bowels open, and to let whiskey and other 
alcoholic drinks alone. If the patient has to get up to empty his 
bladder so often during the night that sleep is seriously interfered with, 
if pain in the bladder and tenesmus are constant, and if the catheter 
shows that the residual urine exceeds two ounces, and is cloudy and 
alkaline, then, in addition to the observance of the general measures just 
mentioned, systematic use of the catheter should be commenced. The 
patient should be given a soft;-rubber instrument, and directed to intro- 
duce it into his bladder and draw off the residual urine once, twice, or 
three times a day, according to the indications of the case. Careful 
instructions should be given for keeping the catheter clean, and the 
patient should be cautioned to throw the instrument away and buy 
another as soon as it shows any evidence of wearing out. In some 
cases, where the urine is fetid and cystitis is pronounced, great benefit 
may be effected by irrigating the bladder once a day with some feeble 
antiseptic solution, such as a one-per-cent. solution of acetate of alumi- 
num, a two-per-cent. solution of carbolic acid, or Thiersch's solution 
of boric and salicylic acids. 

Fortunately, the majority of cases of hypertrophy of the prostate 
need only the treatmait just spoken of, but in a certain proportion of 
cases there comes a time when general measures and local use of the 



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168 INTERNATIONAL CLINICS. 

catheter fiul to give relief. The catheter becomes more and more diffi- 
cult to introduce, and when withdrawn is followed by straining and 
tenesmus and no relief to the sufferer. Sleep is broken and disturbed, 
the appetite fails, and breaking down of th^ general health soon follows. 
Interstitial injections of iodine, ergot, sclerotic acid, and other drugs 
into the prostate have been tried, without good results. Electricity 
has been employed in various ways, but without success or even tem- 
porary relief. It is by surgery, and by surgery alone, that you can 
hope to prolong life. 

There are two principles upon which operations for prostatic over- 
growth are based : one is to excise the portion of the prostate gland 
which interferes with the flow of urine, and thus relieve the obstruc- 
tion ; the other is to let the prostate alone and make a new channel by 
which the water can escape. On the first principle are baseAthe various 
operations of prostatectomies ; on the second is based an operation which 
I myself have devised, and which I wish to show you to-day. 

A prostatectomy consists in the enucleation or removal of the por- 
tion of the prostate gland which obstructs the passage of urine. The 
prostate gland is exposed by opening the bladder by either the perineal 
or the suprapubic route, the latter being the preferable, as it enables 
the surgeon to see what he is doing and gives more room in which to 
work. The mucous membrane covering the projecting or obstructing 
portion of the prostate is cut through, and the removal completed with 
the fingers, rongeur, forceps, or ^raseur. The operation is tedious and 
difficult, the hemorrhage is often alarming, and the mortality is from 
nine to twenty per cent, in the hands of the best surgeons. If the 
views of the etiology of the disease advanced by Harrison, Guyon, 
and Thompson are correct, if the enlargement of the prostate is not a 
local process, but is secondary to general and local changes which occur 
with advanced age, then the operation of prostatectomy is aimed at the 
result rather than at the cause of the trouble, and hence is illogical and 
valueless. When we consider the fearful risk of death from a pros- 
tatectomy, when we remember that it is not always possible to remove 
the obstructing growth in this way, and that even if removed it may 
recur, when we know that if atony of the bladder exists the organ 
will never regain its power or be able to expel its contents, and when 
we take into consideration the fact that the patient is usually old, 
broken down from long suffering, with nephritic disease impending 
or already in existence, we naturally look for some less hazardous and 
more certain means of relief. Such an operation is based upon the 
second of the two principles I have already mentioned, and was first 



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FORMATION OP AN ARTIFICIAL URETHRA. 



169 



published in the Tranmctions of the American Surgical Association in 
1888, and consists essentially in the formation of an artificial urethra^ 
through which the patient can expel his water. 

The prostate is left untouched^ and a new channel is made^ whose 
length is the thickness of the anterior abdominal wall, which commu- 
nicates internally with the bladder, and opens externally in the median 
line just above the symphysis pubis, as shown in the accompanying 
illustration (Fig. 1). 

Fig. 1. 







Topography of Uie artiflcial urethra fbrmed in adyanced caaes of prostatic enlaigement 

The operation is simple, the time consumed is inconsiderable, the 
relief afforded is instantaneous, and the mortality in my hands has not 
been more than three per cent. 

The patient on whom I am going to show you the operation for 
the formation of an artificial urethra has received careful preparatory 
treatment, and is in good condition to stand the operation and to 
make a speedy recovery. He has been under observation for several 
days; his bowels have been carefully regulated, the action of his 
skin stimulated by daily baths, and his heart examined to ascertain 
the safety of the anesthetic. His urine has been carefully tested, 
chemically and microscopically, by the pathologist of the hospital, and 
his report shows that it is alkaline and contains an excess of phos- 
phates, but there is no evidence of kidney-disease. The alkalinity 



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170 INTERNATIONAL CLINICS. 

has been corrected by large closes of citric acid administered in the 
form of lemonade. 

Wounds in the bladder heal kindly and readily when the urine is 
acid ; but if the urine becomes alkaline^ regenerative changes do not 
occur, and the sur&ce of the wound becomes dry, glazed, and covered 
with a slough. Bacteriological research has proved that germs cannot 
live in an acid medium, and clinical experience has led me to believe 
that feebly acid urine is aseptic, and that strongly acid urine is anti- 
septic. Hence the importance of correcting alkalinity of the urine be- 
fore doing any operation in which it will necessarily come in contact 
with the wound. Phosphoric acid, salol, and many other drugs may 
be employed to effect this purpose, but lemonade is my &vorite agent 
This morning the patient^s rectum has been emptied by a simple 
enema, and he has taken three doses of sulphate of quinine, of five 
grains each, to prevent shock and promote reaction. Since he has 
been chloroformed you have seen my assistant prepare the site for the 
operation. The skin above the pubes has been cleanly shaved and 
well scrubbed with potash soap and warm water. It has then been 
washed with alcohol and covered with a towel wrung out of a warm 
solution of bichloride of mercury, I shall now supervise the final 
preparations myself, as they are most important. A rubber catheter 
is inserted into the bladder and the organ thoroughly irrigated with a 
two-per-cent. solution of boric acid. The patient's limbs are next 
flexed on his abdomen, and a rubber bag inserted into his rectum above 
the internal sphincter. This rectal bag is filled with water by means 
of a syringe, and the patient's legs again extended. Great care should 
be taken not to fill the bag too full, as many cases are on record where 
the bowel has been ruptured or fatal hemorrhage produced by oVer- 
distention of the rectum. Usually from twelve to fourteen ounces of 
water will be sufficient. The object of the rectal bag is to lift the 
bladder out of the pelvis^ and thus bring its anterior wall, which is 
uncovered by peritoneum, opposite the point in the abdominal parietes 
through which your incision is to be made. If you are called upon 
suddenly to do the operation and cannot get a rectal bag such as I am 
using, you can fill the rectum with sponges or cotton and accomplish 
the same purpose. 

The rectum having been distended, I now pump four or five ounces 
of water into the bladder, to distend its walls. I remove the catheter 
apd tie it tightly around the penis, to prevent the escape of the fluid. 
The lower part of the abdomen is again flooded with an antiseptic 
solution, the penis closely wrapped in a piece of gauze, and the patient 



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FORMATION OP AN ARTIFICIAL URETHRA. 171 

is ready for the operation. With a small scalpel I make an incision 
through the skin and superficial fascia in the median line, commencing 
about two inches above the pubic bone and extending down to the 
level of its upper border. The recti muscles are now exposed, and I 
separate their fibres with the handle of my knife, and the wound is 
deepened to the transvei*salis fascia. This I incise, and you see the 
prevesical iat, which always lies just in front of the bladder. There 
are several large veins running through it, so I shove them aside with- 
out injuring them, and scratch through the friable tissue. My finger 
now rests upon the wall of the bladder, and I can plainly feel the fluc- 
tuation of the water it contains. Formerly I used to hook the bladder 
with a tenaculum before opening it, but this is unnecessary. I place 
the back of my knife closely against the upper border of the pubis, 
and boldly push its point through the wall of the bladder and cut 
upward about half an inch. You can see by the gush of water that 
its cavity has been entered. Before all the fluid can escape and the 
bladder contract, I introduce my finger through the opening I have 
made and examine the interior of the viscus. There is no stone. The 
prostate is greatly enlarged. The mucous membrane lining the bladder 
is thickenei and hypertrophied. My assistant lets the water escape 
from the rectal bag, and removes it from the rectum, and the bladder 
sinks down in the pelvis to its normal position. I follow the bladder 
as it descends into the pelvis with my finger. I introduce a rubber 
catheter along the finger into the bladder, and, to prevent its slipping 
out, I take a stitch through its walls and the skin at the margin of the 
wound, and the operation is completed. It has not taken me more 
than two minutes, and* I have used no instrument except this little 
knife. The loss of blood has not exceeded a teaspoonful, as the in- 
cision has been made through tissues which contain no vessel large 
enough to be dignified by a name. 

The wound is dressed simply by laying some gauze around the 
catheter, and the patient is put to bed, and the free end of the cath- 
eter inserted into the neck of a bottle to catch the urine, which it 
wiU siphon from the bladder as fast as the kidneys excrete it. No 
stitches are employed, nor any effort made to approximate the sur- 
feces of the cut. The wound will heal by granulation, and in two 
weeks only a fistulous tract will be left in the line now occupied by 
the catheter. You might naturally ask why the result which I ac- 
complish could not be secured by distending the rectum, filling the 
bladder with water, plunging a trocar into it, and inserting a drainage- 
tube through the canula. This has been tried, not by myself, but by 



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172 



INTERNATIONAL CLINICS. 



Fig. 2. 




Silver plug for vtificUa 
suprapubic urethra. 



men who possess greater confidenoe and boldness, with disastrous re- 
sults. Urinary infiltration occurred, and the lives of the patients were 

saved only by prompt and heroic measures. 

The after-treatment of the patient I have operated on is simple. 
He will be kept in bed for two or three weeks 
until the wound heals, his urine kept acid by 
the administration of lemonade or drugs, and his 
bowels kept open by the r^ulation of his diet or 
the use of simple laxatives. At the end of two or 
three weeks the wound will have become cica- 
trized, and the artificial urethra lined with a coat- 
ing closely resembling, if not identical with, true 
mucous membrane. The patient will then be al- 
lowed to get up, and a silver plug or stopper (Fig. 
2) will be placed in the opening. 

This plug should have a diameter of about a 
No. 12, American scale, bougie, and should be just 
long enough to enter the bladder. Its purpose is 

to keep the opening patent, and to act as a stopper and prevent 

dribbling of urine. It should be constantly worn, and never taken 

out except when the patient wants to 

make water. 

Some sort of belt has to be worn to 

prevent the plug from slipping out and 

being lost, and the contrivance shown in 

the accompanying cut (Fig. 3) has been 

devised by one of my patients. It con- 
sists essentially of a belt which goes 

around the hips and passes over the 

plate of the plug, thus retaining it in 

its position. This belt is prevented from 

slipping up or down by being attached to 

a second belt above, which is supported 

by the hips, and by perineal bands which 

encircle the thighs. 

The result of the operation for the 

formation of an artificial urethra has been 

very gratifying, both in my hands and in 

those of other surgeons. The patients 

can retain their water without discomfort from three to six hours in 

the day, and from six to eight hours at night, cystitis rapidly dis- 



FiG. 8. 




Apparatus for retaining eilver stopper 
in suprapubic urethra. 



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FORMATION OP AN ARTIFICIAL URETHRA. 173 

appears^ and often the prostate shrinks so that the patient can again 
pass his water by. the natural channel. In these cases the great anxiety 
of the patient to keep the artificial channel open, and the fear he shows 
of its closing, are strong attestations to its merits. 

Only yesterday a patient came into my office for whom I had 
made this artificial opening in his bladder eight years ago, to consult 
me for some other trouble. He still passes his water through the 
suprapubic opening, and, although his condition is not entirely free 
from annoyance, he has no pain or discomfort. 



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TENO-SUTURE AND TENDON ELONGATION AND 
SHORTENING BY OPEN INCISION; ADVAN- 
TAGES AND DISADVANTAGES OF THE VARIOUS 
METHODS, 

CLINICAL LSCTUBS DSLIYERKD AT THE JEFFERSON MEDICAL COLLEGE HOSPITAL. 

BY H. AUGUSTUS WILSON, M.D., 

Clinical Professor of Orthopaedic Surgery in the Jefferson Medical College and in the 

Woman's Medical College ; Professor of General and Orthopaedic Surgery in 

the Philadelphia Polyclinic and College for Graduates in Medicine, etc 



Gentlemen, — In a former clinic you saw the subcutaneous 
methods of dividing tendons demonstrated by suitable cases, and heard 
the merits of each one discussed and the disadvantages indicated. This 
morning I shall speak of the different open methods of splicing, short- 
ening, and elongating tendons, and shall endeavor to point out clearly 
the advantages and disadvantages of each one, and illustrate them. 

Subcutaneous tenotomy obviates, in a great measure, the risk of 
suppuration, but at times the disadvantage of failure of union obtains, 
whether from simple failure of the tendon ends to unite, or from nutri- 
tive or suppurative changes, or from muscular action disturbing the 
relation of the ends. Again, faulty union may occur from insufficient 
tendon surfaces being in contact, or from the united portions being 
too small and thin, thereby causing a weakness of the parts : so that 
in doing a tenotomy or a teno-suture many points must be carefully 
considered in order to insure safe and good results. In cases with 
inactive muscles the results are apt to be much less satisfactory than 
otherwise, as there is generally interference with nutrition. 

Cases which have previously had cellulitis or traumatism about 
the tendon frequently prove very unsatisfactory because of the cica- 
tricial tissue in the part and the danger of again exciting the inflam- 
matory processes. 

* Reported by J. Torrance Bugh, M.D., chief clinical assistant of the OrthopsBdio 
Department 
174 



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TEN0-8UTURE. 175 

Simple division of the tendon does not always allow suflScient 
correction of the deformity ; for example, after an abscess in the foot, 
contractures, due to the adhesions about the tendinous parts ana the 
extensive infiltration of the connective-tissue structures, prevent cor- 
rection^ even though tenotomy has been carefully and thoroughly 
done. In such cases the open method is much the safer and surer, as 
all other contracted tissues can thus be readily reached. 

One of the first methods of elongating other than by simple division 
was suggested about six years ago by Dr. J. Neely Rhoads, of Phila- 
delphia. It is done subcutaneously, and a knife (Fig. 1) for the pur- 

Fio. 1. 



AUis' knife for Rhoftds* operation. 



pose was devised by Dr. O. H. AUis, of Philadelphia. This knife has 
a long shank and a short blade with a curved cutting edge. The 
method of procedure is as follows. After puncturing the skin above 
the upper point of division, introduce the knife-blade flatly between the 
skin and the tendon, turn it, and cut through the middle of the tendon, 
longitudinally, for the required distance, then cut out at one side and 
withdraw the knife. Introduce it at the lower end of the longitudinal 
incision and cut off the opposite half of the tendon. Elongation can 
thus be accomplished and the ends be allowed to overlap for tendinous 
union. No sutures are employed, as the entire procedure is subcuta- 
neous. Dr. Rhoads also suggested the use of this method in lengthen- 
ing nerves and bones. Where but a small amount of lengthening is 
desired, he suggested {Medical News, November 28, 1891) cutting 
half through die tendon at different levels and from opposite sides, 
leaving some longitudinal fibres to slip on each other, thus gaining 
slight elongation. 

Where lengthening of the tendon is desired, and splicing and 
tenotomy are inadvisable. Dr. F. Lange, of New York, suggests 
(Medical News, January 9, 1892) cutting the tendinous portion in 
the fleshy part of the muscle. The muscular fibres are easily stretched 
the desired length, and there is no risk of non-union of the tendon. 

Mr. Anderson, of London, on October 18, 1889, devised and prac- 
tised a method {London Lancety July 2, 1891) of tendon elongation, 
which, though the tendon is incised similarly, differs from and excels 
Dr. Rhoads' method in being done openly and with sutures through 



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176 



INTERN A.TIONAL CLINICS. 



the severed ends. It also obtains a positive and definite increase in 
lengtli, and perfect apposition of the severed ends. (Fig. 2, A, B, C.) 



Fio. 2. 



A 

B 



■^ 



A, tendon split longitudinally: B^ section completed by incisions at extremities of the finore; 
Ct divided tendon elongated and sutored. (Anderson's method.) 

Dr. W. W. Keen, of Philadelphia, performed, independently, the 
same operation on November 29, 1890 (thirteen months after Mr. 
Anderson), and published it (four and a half months before Mr. An- 



Pia. 8. 



Fio. 4. 



Fig. 6. 



5SatMUTS 






Diagram illustrating a new method of tenotomy, by which the tendons are lengthened to a 
definite extent, instead of the present hap-hazard method. (W. W. Keen, " Transactions of the 
CoUege of Physicians," 1891, page 67.) 

Fig. 3 shows the first or longitudinal section. 

Fig. 4 shows the two transverse sections, each going through one-half of the tendon. 

Fig. 5 illustrates the position of the sutures and the definite amount of lengthening. 

derson's paper appeared) as an original method of obtaining positive 
and definite lengthening of a tendon ; but upon learning of Mr. An- 
derson's priority in performing it, he resigned all claims of originality 



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TENO-SUTUBE. 



177 



in favor of the former. (Figs. 3^ 4, and 5 are diagrams from Dr. Keen's 
article showing his results^ and are exactly like Fig. 2, A, B, C.) 

After the publication of this method of elongation, I suggested its 
use in shortening a tendon, and I have performed it with marked suo- 



FiG. 6. Fio. 7. 



Fio. 8. 









* 


a 




— 1 


" 


f 





OnArncy 



Wilson'i adaptatton of Andenon'i method to shortening. 

cess, the first occasion being on June 10, 1891. {International Medin 
cat Magazine^ August, 1893.) The incisions are made in the same 

Fio. 9. 




WiUetti' operation. 



manner, sufficient tendon is removed from a (Fig. 7) to obtain the 
desired shortening, then a corresponding amount is removed from 6 
(Fig. 7) for symmetry, and the ends are stitched, as shown in Fig. 8. 



Fio. 10. 




Bimarch'f method. (After Robert!.) 

Another method which has been adapted to lengthening or shorten- 
ing is that of Mr. Willetts, of London. (British Medical Journal, May 
Vol. I. Ser. 4.— 12 



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178 



INTERNATIONAL CLINICS. 




Le Forf 8 method. (After 
Lejan.) 



31 and June 14, 1884.) After the tendon has been exposed, it is cut 

diagonally from without inward and from below upward, the ends are 

allowed to slip past each other for the required 

Fig. 11. distance, and are there held by two sutures 

/^^'^^'^^ on each side ; if for shortening, the necessary 

I i '[ M amount is removed from one end and the ob- 

Jj I M lique surfaces are brought together, as shown 

f--|,^ fniii-— \ in Fig. 9. 

Of the methods of suturing divided tendons, 
that of Esmarch is the simplest. (Roberts* 
" Surgery," p. 140.) It consists in overlapping 
the ends and holding them by means of a 
suture passed through and through. (Fig. 10.) 
Another is end-to-end anastomosis, as done by 
Le Fort {JcnimaJ of the American Medkxd 
Aaaodation, October 14, 1893), in which a 
suture is passed into the side of one end, out 
in front, into the front again, and out at the 
other side; then each end of the suture is 
passed into the corresponding side of the op- 
posite end and out in front and there tied. 
(Fig. 11.) This secures the tendon ends in the desired position, and 
prevents separation by muscular contraction, which frequently follows 
tenotomy. 

Wolfler's method {Journal of the American Medical Aftsodationy 
October 14, 1893) differs from the above in the suture's being passed 
in and out several times, partially encircling each end of tlie tendon, 
and in its being tied at the side. (Fig. 12.) The same end is accom- 
plished as above, but the method illustrates, as do others I shall 
presently show you, the ingenuity of surgeons in attempting to obtain 
the same results. 

Another method is that of Le Dentu. (Journal of the American 
Medical Association^ October 14, 1893.) One suture, passed through 
each end, is tied at the side, and two supplementary sutures, one on 
each side of the tendon, are introduced nearer the ends, and at right 
angles to the first suture, as is shown in Fig. 13. These three methods, 
all very much alike, were originated about the same time by three 
different men, each ignorant of the other's plans. 

About a year and a half after these were published, Dr. Trnka 
published a method which had been devised by him in 1887. (O^- 
iralblatL far Chirurgie, No. 12, p. 258, March 25, 1893.) It differs 



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TENO-SUTURE. 



179 



from those mentioned in the manner of inserting the suture. It is 
passed transversely through the anterior half of one end of the tendon 
and back through the posterior half^ then in the same manner through 
the other end^ loops being left on that side on which the suture is 
passed directly back through the tendon. (Fig. 14 ; an end view is 
shown in Fig. 15.) The free ends of the suture are tied, and the loo})8 
are connected by a separate suture (Fig. 16), and when drawn taut 
equal tension is made on each side of the tendon. (Fig. 17.) A sim- 
pler method of joining the loops does away with the extra suture. 



Fio. 12. 





Wdlfler*! method. (After Lejan.) 



Le Denlu's method. (After Lejars.) 



After the suture is passed through the one end, a long loop being left, 
it is passed through one side of the other end^ through the first loop, 
and then back through the other side and tied. (Fig. 18.) This 
method secures firm apposition of the ends and aids very much in ob- 
taining strong union. A method of lengthening has also been devised 
by him in which the upper end of the tendon is split from within three- 
eighths of an inch of fhe end upward the required distance, then cut out 
to one side, and this half turned downward to be joined to the lower end. 
In the same manner as the suture was introduced in the other, a suture 
is passed through the end which was split, the half turned downward 



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180 



INTERNATIONAL CLINICS. 



being included in the loop, then through the other end, including the 
connecting half, and then tied. (Fig. 19.) The half which was 
8plit out and turned over acts as the extra suture used in Fig. 17 or 
the joined loops in Fig. 18. 



Fio. 14. 



Fia. 15. 




cr 




Fio. 16. 




FiQ. 17. 




Fio. 19. 



Fio. 18. 





Reproduced from the OentralblaU fUr CMrurgie, No. 12, page 268, March 25, 1808. 



Figt. 14 and 15 show the method of inserting the catgut suture so as to form the loop into 
which is to be engaged the connecting material. 

Dr. Tmka emphasises the importance of the loop e, as shown in Fig. 16. A simpliiication, for 
the sake of quick adjustment, is shown in Fig. 18. Instead of forming the loop c, in Fig. 16. any 
proper material may be inserted, such as catgut or a piece of the tendon itself, turned down as 
shown in Fig. 19. 

When the catgut used is thin, it can be tied as in Fig. 16; but when it is heavy, it should be 
sewed fast to both ends of the divided tendon, in the same manner as shown in Fig. 19. 

It is strongly urged that sutures through the tendon should not be drawn so tight as to cauae 
the nutrition of the tissues to suffer. 

Some time ago I devised (and performed for the first time in Sep- 
tember, 1893) a method which has the advantage over Tmka's of 
there being more tendinous tissue between the two severed ends and 



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TEN0-8XJTURE. 



181 



Pio. 20. 



consequently a stronger tendon after union. It is done by splitting 

both parts of the tendon equally for the required 

distance from within three-eighths of an inch of 

the end and cutting out to one side at the other 

end of the incision and at opposite sides of the 

tendon. Now turn over these cut halves and 

pass a suture through each one in the manner 

shown in Fig. 19, and tie each separately. The 

result is shown in Fig. 20. 

Czerny {Journal of the American Medical As- 
sociation, October 14, 1893) provided for strength 
by utilizing part of the tendon for the lengthen- 
ing process, transplanting the end of the part cut 
from the side of one tendon end into the other 
free end, so that tendinous structure is secured 
through the entire course. (Fig. 21.) This 
method can be illustrated by placing one finger 
of one hand between two fingers of the other, the 
exact relation of the two tendon ends. They are 
held in place by through-and-through suturing. 

Schwartz (Journal of the American Medical 
AModationy October 14, 1893) devised a method 
of anastomosis where junction of the two ends, 
for some reason, cannot be effected. He divides 
a neighboring tendon longitudinally, as in the ex- 
tensors of the fingers, and cuts off one-half at the 
distal end of the incision, then attaches the distal end of the severed 
tendon to this freed end of the half of the neighboring tendon (Fig. 




Wllsou'8 method. 



Fjq. 21. 




Cserny*8 method. (After Lejare.) 

22), thus securing the movement of the two parts or members by means 
of the one muscular action. 



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182 



INTERNATIONAL CLINICS. 



The Tillaux and Duplay method {Journal of the American Medical 
Association, October 14, 1893) is a very ingenious one, accomplishing 
the same purpose as that of Schwartz. A longitudinal incision is made 



Fio. 22. 




Schwartz's anastomoslB. (After Lcijars.) 

f 

through a contiguous tendon^ and the distal end of the severed tendon 
inserted in it and sutured in position. Two members may thus be 
operated by one muscle, or two muscles, if the proximal end be in- 
serted, may operate one member. (Fig. 23.) 

These operations represent the principal ones for tendon splicing, 
lengthening, or shortening by division of the tendon in its entirety. 
Several complicated methods have been devised for the purpose of 
utilizing tendinous tissue in lengthening and yet not entirely dividing 

^IG. 28. 




Tillaux and Duplay method. (After Lejars.) 

the tendon at any point. The originator of either plan is unknown to 
me. The first one is the more complicated of the two which I shall 
mention, and is done as follows. Divide the breadth of the tendon 
into fifths. From each side and at the same level cut transversely 
through two-fifths to the middle fifth, then longitudinally for the re- 
quired distance. Then enter the knife at a point one- half inch below 



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TENO-SUTUBE. 



183 



the transverse cut on one side, and in the line separating the first 
and second fifths cut longitudinally a distance equal to the first lon- 
gitudinal incisions, turn the knife and sever the middle three-fifths, 
turn it again and cut upward for the same distance as the parallel in- 
cisions. The last incision will embrace the first two between the longi- 
tudinal cuts, and the diagram of the incisions is seen in Fig. 24 A. 
When the tendon is drawn out to its limit of lengthening, it presents 
the appearance of Fig. 24 B. The amount of elongation is graduated 
by the length of the longitudinal incisions. The disadvantages of the 



Pig. 24 A, Fio. 24 B. 



Fig. 26 A, Fig. 25 B. 




^ 




X\^ 





method are that the tendon must be a very broad one, and that a great 
degree of skill on the part of the operator is required to perform it^ 
even in a large structure. 

The other method which I shall show you is adapted to the same 
purpose, but is less complicated than the one just explained. The 
breadth of the tendon is divided into thirds, and longitudinal incisions 
of equal lengths, but at different levels, the right being the higher, 
are made between them. Then cut transversely through the left two- 
thirds to the upper end of the right longitudinal incision, and through 
the right two-thirds to the lower end of the left longitudinal incision^ 



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184 INTERNATIONAL CLINICS. 

as shown in Fig. 25 A. Draw on the tendon ; it is elongated, is com- 
posed of tendinous structure through the entire length, and presents 
the shape seen in Fig. 25 B. In both these methods re-enforcement 
by sutures of that part of the tendon where the ends remain intact 
would be necessary. Both show considerable ingenuity on the part of 
the originator, yet lack that simplicity which is necessary for practical 
application. 

There is a case this morning for the operation of lengthening the 
tendo Achillis, and, if suitable for the operation, I shall do Rhoads' 
subcutaneous elongation without sutures. The last operation of length- 
ening done before you was by the Anderson method. It was the fifty- 
fourth operation done by me by the open incision and suturing, and is 
the first one in which I have had suppuration. The cause of the sup- 
puration I do not know. However, the wound is open and has been 
thoroughly cleansed of suppurative material, and is now doing very 
well. In this patient observe that about three-fourths of an inch of 
elongation must be obtained in order to secure correction of the existing 
equinus, yet there is sufficient length of tendon to allow of the opera- 
tion and still leave tendinous sur&ces in contact. 

The long knife is introduced under the skin about two and a half 
inches above the heel. The tissues are found very firmly bound to 
the tendon, and quite extensive adhesions are present, showing that a 
cellulitis had formerly existed in the part. A point of abrasion 
exists about one and a half inches above the os calcis, which looks as 
though it had been a point of suppuration, and, if so, might account 
for the present condition of the structures. These circumstances make 
the expediency of Rhoads' operation very doubtful, and if, upon another 
trial, the kmife cannot be easily introduced, I shall abandon it. The 
tissues are as firm in one part as in another, and the inflammatory 
action has been so wide-spread that I shall do simply a transverse 
tenotomy, largely because the imrts have not been prepared aseptically, 
as required for all open wounds. After cutting the tendon, there is 
but a slight gap between the ends upon extension, because of the ad- 
hesive bands about the sheath. Having divided them, I shall apply 
carefully controlled force to separate the adhesion and secure correc- 
tion. The amount of controlled force which can be applied to a part 
for correction depends upon the control. Considerable harm may be 
done by the application of unregulated power, but with judiciously em- 
ployed force very great good can be accomplished. I can feel the ad- 
hesive bands give way each time I apply force, and you can see the foot 
yielding. Notice how easily it is now straightened, and that not en- 



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TBNO-SUTURE. 185 

tirdy by dividing the tendo Acbillis, but partially by tearing loose the 
contracted peritendinous tissue. There is about three-fourths of an 
inch separation of the tendon ends now, the deformity is corrected, 
and the foot can be easily maintained in the corrected position. This 
case illustrates the fact that deformities do not always yield to simple 
tenotomy, but that other structures must sometimes be loosened. 

It is not at all probable that full restoration of the function of the 
1^ muscles in this boy can be accomplished, and therefore the aim will 
be to secure a good position, so that a suitable apparatus may be worn 
later. The foot will be placed at right angles to the leg, and plaster 
of Paris applied as a temporary retainer. 

[Note. — One month later the patient walked firmly upon the 
foot with the assistance of a steel supporting apparatus. There had 
been an uninterrupted recovery, with firm union of the divided tendon.] 



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ACUTE PERIOSTITIS. 

CLINICAL LECTURE DELIVERED AT ST. GEORGE'S HOSPITAL, LONDON. 

BY WARRINGTON HAWARD, P.R.C.S. Eng., 

Surgeon to and Lecturer on Clinical Surgery at St. George's Hospital, etc. 



Gentlemen^ — ^The subject of my lecture to-day will be acute peri- 
ostitiS| and I have chosen this important disease because there have 
been recently in the hospital several cases illustrating some of its chief 
varieties, and some of these patients are still under our observation. I 
call acute periostitis an important disease, first, because of its com- 
paratively frequent occurrence, and, secondly, because of its destructive- 
ness to both life and limb, if not speedily arrested. 

Of its frequency you have had many opportunities of judging, for 
scarcely a week passes without the admission of a case of this disease 
into our wards. And surely any disease which is of such frequent 
occurrence should have, therefore, for us the greatest interest, especially 
if it be, as in this instance, of serious gravity. 

My second reason for regarding acute periostitis as an important 
disease is that if not recognized and checked at its outset it speedily 
brings the patient into a condition of serious danger, and, if not fatal 
to life, may rapidly cripple or destroy one or more of his limbs. 

Let me first define for you what I mean by " acute periostitis.*' It 
is an inflammation of the fibrous covering of the bone, rapidly leading 
to a separation of the membrane from the surface of the bone, by the 
effusion of inflammatory products beneath it, and also to the obstruc- 
tion of the periosteal vessels on which the nutrition of the bone largely 
depends. 

It is usual to distinguish two kinds of acute periostitis, the simple 
and the diffuse, — a convenient division, though not always easily made 
at the outset of the disease. By simple acute petiostitia is meant an 
acute inflammation of the periosteum which, though rapidly leading to 
the formation of matter, is soon limited to a comparatively small area 
from its point of commencement. It may occur in apparently healthy 
1S6 



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ACUTE PERIOSTITIS. 187 

persons^ tboagb it is more often seen in those of depressed vitality or 
who have been debilitated by recent zymotic disease. The symptoms 
are these. The patient^ probably a young person somewhat out of 
health, receives a blow on one of the more prominent bones. Next 
day the bone aches severely, the pain being increased by the use of the 
limb or its dependent position, the temperature rises, and by the second 
or third night is probably 101° or 102°. The limb now feels hot, 
and there is acute tenderness over the seat of injury, with a limited 
elastic swelling upon the bone, and perhaps a blush of redness over 
the corresponding area of skin. Under appropriate treatment these 
symptoms may subside without suppuration ; otherwise the pain in- 
creases, matter forms beneath the periosteum and eventually makes its 
way to the surface, its escape being followed by a subsidence of the 
pain and fever, and subsequently probably by the separation of a thin 
fragment of the outer layer of the bone, the healing of the sinus, and 
the recovery of the patient. 

Such a case you have recently seen in M. J., aged nineteen, an 
overworked and underfed general servant, who was admitted into the 
hospital three days after a slight blow on the upper and inner part of 
the tibia. She complained of great pain and tenderness over this part 
of the bone, where there was an elastic swelling about three inches long, 
the skin over which was (edematous and red. Her temperature was 
102°, her pulse 120. The limb was placed on a splint, and an incision 
made without delay through the swelling down to the surface of the 
tibia, the periosteum being freely divided. An escape of blood-tinged 
senim occurred, but no pus had formed. Hot boracic dressings were 
applied, and quinine was given internally. Immediate relief of the 
symptoms followed, and the girl made a good recovery. In this case 
the proximity of the swelling to the knee-joint, and the decided evi- 
dence of fluid beneath the periosteum, made it desirable to cut down 
upon the bone without delay ; and as, happily, pus had not yet formed, 
the case came speedily to a good end without any necrosis. 

In the early stages of this disease the inflammation may often be 
cut short by the application of a few leeches, followed by some sooth- 
ing application, such as a lotion of lead and opium, applied hot and 
frequently renewed. The limb should of course be kept entirely at 
rest upon a splint or pillow, and be well raised. The pain in these 
cases varies greatly with the position of the limb, and is much relieved 
by keeping the affected part elevated and quiet. Do not, however, 
n^lect the general treatment : the patients are often out of health, and 
are usually constipated. An aperient therefore may be desirable, and 



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188 INTERNATIONAL CLINICS. 

this may be followed by cinchona and mineral acids^ or quinine. 
Stimulants are best avoided : they increase the pain. 

The patient to whom I have referred was notably benefited by the 
rest, good food, and tonics, as well as by the local treatment. 

If, however, in spite of such care, or through the lack of it, the in- 
flammation persists, and fluctuation can be felt in the swelling, an in- 
cision should be made without delay, and this incision should divide the 
periosteum freely. If the fluid has not yet become purulent, so much 
the better ; but in any case a drainage-tube should be inserted, so as to 
insure the escape of whatever exudation may occur. 

Sometimes such periostitis is a manifestation of a chronic form of 
pysemia. The pysemia is chronic, but the periostitis is acute. Many 
of you have seen a girl (L. K., now about fourteen years old) who has 
been frequently under my care during the last five years, in whom a 
great number of the bones have been affected with acute periostitis. 
In this form of pyaemia, as Sir James Paget has pointed out, the same 
tissue is apt to be selected by the inflammatory process through the 
whole course of the disease. This child has had both thigh-bones, 
both tibisB, the bones of the arms and forearms, and one wrist affected 
at different times. She becomes feverish, a bone is painful, and in a 
few hours a periosteal abscess forms, which may reach a considerable 
size. On one occasion, before the abscess could be opened, the pus made 
its way into the intermuscular cellular tissue of the thigh and there 
formed an immense collection. A most remarkable feature of this case 
is the ansemia which rapidly ensues on every periosteal attack : the child 
can be seen to become daily more pallid, and after the healing of the 
abscess gradually r^ains her color. I have frequently seen and called 
your attention to the occurrence of this ansemia in such cases, but in no 
instance has it been so marked as in this child. 

Other examples of pysemic periostitis are seen after fevers, especially 
typhoid fever, in which the ribs are peculiarly liable to be the seat 
of the disease. This form of periostitis in connection with fevers 
usually ends in recovery after the exfoliation of a thin layer of 
bone. I would remind you that a syphilitic node — i.e., a localized 
syphilitic periostitis — may sometimes be acute and very painful, and 
that acute periosteal swellings are occasionally seen in connection with 
rheumatism. 

You see, however, that the form of acute periostitis which I have 
hitherto spoken of, though locally damaging, painful, and disturbing, 
IS not a disease of any special gravity, and it presents a marked con- 
trast to the diffuse form, of which I shall next speak. This disease. 



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ACUTE PERIOSTITIS. 189 

known as " acuie diffuse pmoatife/* and sometimes, on account of its 
common termination, as ^^ a4i\Jiie necrosis," is a serious and dangerous 
affection, the issue of which will largely depend upon its early recog- 
nition and efficient treatment Every case of it which you have an 
opportunity of seeing is worthy of your careful examination and study. 

Now^ one important characteristic of this disease is that it attacks 
almost exclusively the young. It is most commonly met with between 
the ages of ten and fifteen, and more often in boys than in girls. In 
the majority of cases an injury, oft«n quite a trivial one, seems to have 
started the inflammatory process; and this may account for its more 
frequent occurrence in boys, who are more exposed to injury than 
girls. In some cases, however, no traumatic origin can be discovered. 
As in the less serious form of periostitis which I first spoke of, the 
disease selects usually those who are out of health or who are living 
under unfavorable conditions. 

Of those cases lately under our observation, No. 1 was a boy of 
fourteen years, who lived over a stable. He was in miserable condition, 
depressed, pale, and ill nourished, and a week before admission had 
received a blow on the affected bone (the femur) ; No. 2 was a boy 
of ten years, also very pale and thin, who lived in a very poor and 
crowded neighborhood, and who three days before had fallen and hurt 
the affected limb ; No. 3 was a girl nine years of age, who came from 
an industrial school, of the sanitary state of which we had no knowl- 
edge, but she was a delicate, pale, and thin child, and she also had a 
week previously received a slight injury to the affected tibia. 

The symptoms are at first those of fever, — rigors, vomiting, raised 
t^nperature; these are soon followed by local pain, generally over 
one of the long bones of the lower limb ; a few hours later there will 
be found great tenderness to pressure over the bone, and perhaps some 
deep swelling may be felt ; then effusion occurs in one or both of the 
joints belonging to the bone, the temperature continues to rise, reach- 
ing 103° or 104°, fresh rigors occur, and profuse sweating; a little 
later the whole limb becomes swollen and intensely painfol, the skin 
being more often pallid tlian red. If free incision upon the bone has 
not now been made, matter makes its way along the limb and towards 
the surface, as well as perhaps into one of the adjacent joints ; pysemic 
symptoms {e,g,, pleurisy, pericarditis, pneumonia) probably ensue, and 
tlie case in a few days is likely to come to a fatal end. 

In some instances pysemia occurs within a few hours of the com- 
mencement of the inflammatory process, and before there has been 
an opportunity for surgical interference ; in other and less severe cases. 



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190 INTERN ATIONAIi CXINICS. 

when the matter has been let out or has made its way to the surface^ 
the fever abates, and the symptoms are chiefly connected with the 
suppuration and consequent necrosis. The symptoms in Case No. 1 
were typical, and I will briefly relate them ; those of the other two 
cases so closely resembled them that I need not give them in detail. 

The boy, who was aged fourteen years, and was weak, pale, and 
thin, lived over a stable ; a week before admission he received a blow 
on the left thigh. The next day he was feverish and ill ; he shivered 
and vomited and took to his bed. On the third day he had great pain 
in the left thigh, and on the fourth day the left hip- and knee-joints 
became swollen and painful. When admitted he looked ver}' ill. 
Temperature, 103°. Pulse, 120. Tongue dry and brown. Urine 
1020, depositing lithates ; no albumin. Heart and lungs natural. 
There was great tenderness along the whole shaft of the left femur, 
eflbsion in the corresponding hip- and knee-joints, and intense pain in 
the whole thigh. There was no swelling of the thigh, except slight 
oedema near the knee, nor could any deep fluctuation be detected. An 
incision was made through the periosteum down to the bone on the 
outer side of the femur, and exit given to several ounces of sero- 
purulent fluid. The outer two-thirds of the femur were felt to be 
separated from the periosteum for several inches, both upward and 
downward from the incision. A drainage-tube was inserted and an 
antiseptic dressing applied. Quinine, port wine, and nourishing food 
were administered freely. Next day the temperature had come down 
to 101°, and the boy was much easier. On the fifth day after ad- 
mission the temperature was 100°, and from this time the symptoms 
subsided, the incision eventually healing without any separation of bone. 

Case No. 2 was an almost exact counterpart of No. 1, except that 
when the femur was cut down upon no pus was found, but the peri- 
osteum was extensively separated from the bone by inflammatory 
exudation. On the eighth day from admission a large abscess rapidly 
formed in the deep intermuscular cellular tissue over the inner side of 
the lower half of the thigh, whence a large quantity of septic pus 
was evacuated by incision. A counter-opening was made, and the 
abscess- cavity thoroughly drained and cleansed. From this tim^ 
the boy went on well, and at the end of three months the incision 
had, healed, and the boy, though still anaemic, was well enough to go 
to the convalescent hospital. No bone separated, but there remained 
great periosteal thickening over the lower third of the femur, and a 
little stiffness of the knee-joint. Almost the same description would 
apply to the case of the girl (No. 3), only that the bone affected in her 



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ACUTE PERIOSTITIS. 191 

case was the tibia. As was seen in these cases, the disease may be 
sometimes arrested by timely incision, and hence an early and correct 
diagnosis is of the greatest importance, though I shall relate presently 
a case which nevertheless came to a fatal end. Now, the diagnoisis at 
the outset is not always easy, and a great many of the cases are sent 
to the hospital as acute rheumatism. The reason of this mistake 
is that the patient has rigors, sweating, and high temperature, and 
perhaps one or more swollen joints ; he may have, besides, pericarditis : 
all of which looks rather like acute rheumatism. But note the points 
of difference. In the first place, acute rheumatism affects several 
joints, whereas, if there be effusion in more than one joint in acute 
periostitis, you will observe that only the joints at either end of the 
painful bone are affected. Then you will also note that the pain and 
tenderness are much more marked over the shaft of the bone than over 
the joints. Moreover, though the urine may be concentrated and con- 
tain abundant lithates, there is not the acid urine and sweat of rheu- 
matism. The tongue, which in rheumatism is coated with a thick 
white and moist fur, is in periostitis dry and brown. 

If, therefore, you see a boy or a girl about the age of puberty very 
ill with rigors, high temperature, and swelling of oTie joint, or of the 
two jovrUs only which are at dther end of a Umg bonCj examine most 
carefully the long bone to which that swollen joint belongs, for you 
may be nearly sure that it is not rheumatism you have to deal with, 
but most probably a case of acute periostitis. 

The only other disease for which the periostitis is likely to be 
mistaken is diffiise cellulitis. From subcutaneous cellulitis the diag- 
nosis will not be difficult, for in that condition there will probably be 
a wound as a starting-point ; the skin and lymphatics will usually be to 
some extent involved ; the area of inflammation will not correspond 
to the limits of one of the long bones, but will extend along the sub- 
cutaneous tissue without regard to the adjacent joints. Besides these 
distinctions, if the case has been observed from the commencement, it 
will be noticed that in periostitis pain and deep tenderness precede 
obvious swelling. From cellulitis affecting the deeply situated planes 
of intermuscular connective tissue the diagnosis may be at first more 
difficult; but here again the limitation of the area of the disease in 
periostitis will help us, and in deep cellulitis there will be in post 
cases the originating wound, and swelling of the limb will be more 
early apparent. Should, however, the decision between these two 
diseases be difficult, an exploratory incision will not only be justifiable 
for diagnosis, but will be in either condition beneficial as treatment. 



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192 INTERNATIONAL CLINICS. 

One serious danger of acute periostitis is that pyaemia may occur 
almost at the very commencement of the attack. It is this compli* 
cation which brings many of the fatal cases to a rapid end. The 
pyaemia is usually of a severe type, and there is a special liability of 
the heart and kidneys to secondary deposits. 

I will briefly relate a case illustrating this point. Elizabeth C, 
eight years of age, was admitted into the hospital with extreme pain 
in the right 1^, which was swollen from the knee to the ankle. There 
was no effusion in either of these joints, but careful examination 
revealed not only superficial oedema, but deep swelling over the shaft 
of the tibia. The child looked very ill : the temperature was 104*^, 
and the pulse and breathing very rapid. The history was that a week 
before admission she fell down-stairs and struck the right 1^, that the 
following day she was ill and had great pain in the leg, that swelling 
of the limb gradually ensued, and that the day before admission she 
had had some sort of convulsion. 

An incision was at once made over and down to the shaft of the 
tibia, a quantity of pus let out, and the shaft of the bone felt to be 
completely bare. Although the incision gave great relief to the pain, 
the general condition of the child did not materially improve. She 
had severe pain in the right humerus, and also in the back. Diarrhoea 
and hsematuria occurred at intervals, and she died on the tenth day 
from her admission. 

Post'Mortem. — The diaphysis of the tibia was found to be com- 
pletely necrosed, the periosteum was completely stripped by suppura- 
tion from the shaft of the bone, the lower epiphysis was separated 
from the diaphysis, and there was commencing myelitis at that end of 
the shaft ; the adjacent joints were natural. There were numerous 
small pysemic abscesses scattered throughout the substance and on the 
surface of both lungs. There was turbid fluid in the left pleura. The 
pericardium was natural ; but there were two abscesses in the tricuspid 
valve, one of which had ruptured and was surrounded by exuberant 
granulations. The left side of the heart was natural. The liver was 
natural. The spleen was soft and contained several embolic infarcts. 
The pancreas was natural. The suprarenal bodies both contained 
patches of embolic hemorrhage. There were numerous small hemor- 
rhagic infarcts in both kidneys. In this case the post-mortem exam- 
ination showed that the pyaemia must have begun quite early in the 
disease, and you see that both the heart and the kidneys were the seat 
of secondary deposits. 

In another example of pyaemia in connection with acute periostitis 



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ACUTE PERIOSTITIS. 193 

of the femur which I saw a short time since, there was suppuration of 
the stemo-clavicular joint, and of one of the interphalang^ joints of 
a finger on each hand. This patient, after passing through many 
dangers, eventually recovered. 

Concerning the causes of acute diffuse periostitis our knowledge is 
still incomplete. There certainly seems good reason to suspect the 
invasion of a specific bacillus. But this at least we know, that it is 
usually met with in persons living under unhealthy conditions: so 
that it is obviously our duty when called to a case of this disease to 
seek for any such conditions in the dwelling or surroundings of the 
patient The disease is not confined to the poor, and you may often 
discover serious unsanitary defects in the houses of the wealthy, where 
more attention has perhaps been given to the decorations than to the 
drains. 

When the inflammatory process is once started, exudation occurs 
with great rapidity between the periosteum and the bone : this exu- 
dation quickly becomes purulent, and, having no escape, spreads along 
the surface of the bone, stripping off the periosteum, closing the peri- 
osteal blood-vessels, and cutting off a great part of the blood-supply 
to the bone. The disease most commonly starts on the shaft of a long 
bone, and if unchecked rapidly spreads to the epiphyses, by which it 
is often limited. Suppuration may, however, pass the epiphyses and 
extend to the neighboring joints ; or it may b^in in the epiphyses 
and spread to the shaft or the joint In the more vy^Ient cases the 
inflammation extends from the periosteum to and along the marrow of 
the bone, and necrosis of the bone speedily ensues. Some pathologists, 
especially those of the French school, maintain that when acute necro- 
sis occurs there is always osteo-myelitis as well as periostitis; bat 
though this is oft^n it is not always the case. Necrosis of the entire 
diaphysis of a long bone may be seen a few days afl«r the commence- 
ment of an attack of acute diffiise periostitis in which there is no 
evidence whatever of any affection of the medulla. Sometimes, as 
after amputation, the medulla is the part chiefly affected, and the 
inflammation extends to a greater distance along the interior than along 
the exterior of the bone. If early incision be made through the peri- 
osteum, the attack may end with only a limited and superficial necrosis ; 
in other cases there is no necrosis, but the periosteum is left more or 
less thickened. 

The disease selects, as a rule, the long bones, especially these of the 
lower extremity. I have on various occasions removed for acute 
necrosis more or less of the shaft of most of the long bones of the 
Vol. I. Ser. 4— 18 



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194 INTERNATIONAL CLINICS. 

body, — viz., part of the shaft of the femur, part of the humerus 
(on a recent occasion the upper third of the shaft and the head of the 
bone), the entire diaphysis of the tibia, of the iBbula, of the radius, 
of the ulna, and of the clavicle. If the patient survive, and the 
necrosed bone be removed, excellent repair occurs, and the dead bone 
may be almost completely reproduced. 

We now come to the treatment of the affection ; and I know of no 
disease in which prompt and active surgery is more urgently called 
for. It is for this reason that I have said so much upon the diagnosis ; 
for as soon as you have satisfied yourself that you have to deal with a 
case of acute diffuse periostitis you should cut down upon the bone. A 
sufficiently free incision should be made through the soft parts over 
the most tender part of the bone to enable you to pass your finger an 
inch or more along the periosteum. Then you should cut firmly upon 
the bone, taking care to divide the periosteum thoroughly. Do not 
wait for evidence of suppuration : the best chance of arresting the 
disease is to incise the periosteum before the exudation between the 
periosteum and the bone has become purulent If, however, matter 
has formed, the incision may have to be more extensive, and if pus 
has made its way along the deep planes of connective tissue, counter- 
openings for drainage will probably be needful. When suppuration has 
occurred the pus mudt be thoroughly syringed out with an antiseptic 
solution, and the limb enveloped in antiseptic dressings. Daily careftil 
examination oi the limb must be made, to insure the free escape of 
inflammatory products. Lai^e collections of pus sometimes form with 
extraordinar}' rapidity in the deeper cellular planes, and must be treated 
by incision and drainage. Quinine and opium should be freely given, 
as well as a supporting diet, and whatever stimulant seems needful. 
If necrosis occurs of the entire diaphysis of a long bone, early removal 
of the dead bone is desirable, and should be practised as soon as it is 
easily separable from the epiphyses and as the condition of the patient 
permits. Care must then be taken to maintain the length of the limb, and 
to keep it at rest in such a position as may best allow of a satisfactory 
r^neration of the bone. In cases of acute necrosis wherein the sup- 
puration has spread to one of the large joints, and in which the con- 
dition of the patient is severely depressed, it may be necessary to 
amputate the limb, and thus at once rid the patient of a severe drain 
and a source of constitutional irritation or septic absorption. 

Young people suffering from this disease will be observed to 
become extremely anaemic and to lose flesh very rapidly ; it is neces- 
sary, therefore, during recovery to feed them carefully and well, in 



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ACUTE PERIOSTITIS. 195 

addition to which mild preparations of iron will generally be useful. 
But better than any medicine is the restorative effect of sunlight and 
fresh air. When, therefore, circumstances do not permit of the patient 
being sent into the country, great attention should be paid to the 
ventilation of his room ; and much good may be done by placing him 
in that part of the house into which the direct rays of the sun most 
freely enter. 



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ENTERECTOMY AND THE FORMATION OF AN 
ARTIFICIAL ANUS IN A PATIENT UPON WHOM 
CCELIOTOMY WAS PERFORMED FOUR TIMES; 
REST IN THE TREATMENT OF RECTAL PRO- 
LAPSE, AFTER THE FORMATION OF AN ARTI- 
FICIAL ANUS. 

CLINICAL LECTURE DELIVERED AT BELLEVUE HOSPITAL. 

BY JOSEPH D. BRYANT, M.D., 

Professor of Anatomy and Clinical Surgery, and Associate Professor of Orthopedic 
Surgery, in the Bellevue Hospital Medical College, New York City, New York. 



Gentlemen, — ^The first case which I shall show you to-day has 
been a puzzle to us at times, on account of the personal peculiarities 
the patient has frequently displayed. This patient is illustrative of 
four distinct, full-fledged cceliotomies, besides two other penetrating 
incisions which cannot be dignified by the use of this expression. 
The first coeliotomy was done several years ago, and by Kocher, ac- 
cording to the patient's statement. For what exact purpose it was then 
performed one can only conjecture, but presumably it was for the relief 
of suspected intestinal obstruction, since when she was seen first by me 
she had many of the symptoms of this condition. The second opera- 
tion was performed through the cicatrix of the first one by a sui^eon 
in Connecticut, whose name the patient does not recall. As the patient 
has never complained of other symptoms than those quite easily attrib- 
utable to intestinal obstruction, I believe that the reason for the second 
operation can also be based on this assumption. The third operation 
was done in the City (Charity) Hospital of New York by an able 
surgeon. Dr. Norris, only a few years ago, and the necessity for it was 
based on a similar belief. The fourth was performed by myself about 
two years ago in Bellevue Hospital, at the site of the preceding ones, 
for the cure of what was then supposed to be a fistulous communica- 
tion between the transverse colon and the stomach. The belief in this 
condition was founded on the fact that when coloring waters and fluid 
196 



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EXTERECTOMY. 197 

food were injected into the rectum they were soon discharged from the 
mouthy attended with vomiting. It should be said that the amount of 
time was not given to the personal consideration of this case that 
should have been, as she was committed to my care with the diagnosis 
already suggested. However, as was suspected, she did not have a fis- 
tulous conmiunication. The symptoms already stated were self-imposed 
by means of the concealment in her mouth, when unobserved, of the 
material which, when expectorated at the proper time for deception, 
easily accomplished the purpose. 

She possessed the ability of increasing the rectal temperature at 
will, but in what manner I could not ascertain. A rectal temperature 
of 110° was exhibited, although it was evident that elsewhere it was 
scarcely above the normal figure. She asserted that she could take 
no nourishment by the mouth, which appeared reasonable in the face 
of the fact of the occasional vomiting of fecal matter. However, in- 
asmuch as but little physical deterioration and general disturbance were 
noticeable, it was thought she was practising a subtle deception in some 
manner r^arding nourishment. Afler a little she was placed under 
strict surveillance and allowed no food whatever. The pangs of hun- 
ger soon forced a confession that she had been given food at night by the 
ward attendants, and had secured it herself, even, while others slum- 
bered. As a sequel of the fourth ooeliotomy a fecal fistula developed in 
the umbilical region, caused by a limited sloughing of the transverse 
colon at that point. A complete history of this most interesting case 
of hysteria is published in the Medical Record of October 7, 1892. 

While I am not certain of the cause of this sloughing, still, I re- 
gard it as dependent on undue exposure of the free surface of the gut, 
caused by the separation of the adhesions that existed intimately be- 
tween the transverse colon and the anterior surface of the stomach 
during the search there for the suspected fistula. Great care was exer- 
cised in this respect, and no evidence of denudation was observed at 
that time. About one year ago I dissected out the fistula, and closed 
the consequent opening into the colon in the usual manner, hoping to 
secure primary union. The attempt failed, dependent, as was supposed 
at the time, on the efforts of the patient to remove the dressings. At 
a later period I again exposed the opening, and, owing to the undue 
narrowing that would have resulted from another simple longitudinal 
enterorrhaphy, the opening in the bowel was extended on either side 
along the free surface for about two inches, and then closed entirely by 
the " elbowing'^ process. 

I will explain this method to you. Let us, for the purpose of the 



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198 INTERNATIONAL CLINI08. 

explanation, tie this string tightly around my extended arm, at the 
seat of the elbow. Of course it is apparent that it causes a oonstric- 
tion there, diminishing considembiy the transverse diameter at that 
point. If an incision be now made along the anterior surface of the 
arm four or five inches in length, its centre corresponding to the con- 
stricted point, through the textile fabrics down to the integument, it is 
plain that the string (stricture) will be divided. I will now flex the 
forearm sufficiently to permit the distal extremities of the incision in 
the fabrics to be properly united with each other, and while in this 
position will sew securely to each other the opposed divided borders at 
either side of the opening. If we now substitute the colon for the 
arm, divide it longitudinally in a manner similar to that in which the 
textile fabrics are divided, flex the colon on itself at the centre of the 
incision, and sew the borders to each other, the gut is then " elbowed." 

This attempt failed also, and, in my opinion, for two reasons: 
1. The occurrence of a severe diarrhcea, which was persistent, not- 
withstanding proper treatment. 2. The absence of suitable peritoneal 
surfaces at the sewed borders. You should l)e told now that the pre- 
vious peritonitis excited by the numerous operations had been followed 
by entire loss of the glistening surface of the peritoneum, not only of 
the transverse colon, but of all the small intestines under observa- 
tion. Adhesions everywhere between the intestines were substituted 
for normal tissue. This condition robbed the tissues of the intestine 
largely of the inherent tendency they possess to unite quickly, and 
likewise so lessened the activity of the nutritive processes of the wall 
of the bowel, through interference with the circulation, as to hinder 
union. 

The next eflbrt at cure was directed to turning aside the fecal cur- 
rent, in order that the colon might be at rest while undergoing repair. 
To meet this end an artificial anus was made on the right side, con- 
nected with the csecum. It was hoped that the discharge of the fecal 
matter through this opening would lead to spontaneous closure of the 
fistula, and that it would i*emain healed after closure of the artificial 
anus. At any rate, the presence of the artificial opening in the caecum 
was deemed necessary for the safety of the patient in the event of the 
performance of enterectomy, or even the use of the enterotome for the 
removal of the constricted portion of the colon. It was believed that 
prompt union of the divided tissues would be hindered by the changes 
in them induced by the inflammation that had followed previous oper- 
ations. Moreover, the passage of fecal matter through the united gut 
under these circumstances could not but be highly objectionable and 



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ENTEBECTOMY. 199 

even dangerous. At onoe^ after the establishment of the artificial anus, 
the old sinus communicating with the colon b^an to close, and soon 
healed entirely, notwithstanding only the lesser portion of the fecal 
matter escaped by the new opening. 

It is in this condition that the patient is now presented to your 
notice. What can be done to relieve her, and what are the prospects 
of success? The removal of the intestinal constriction is the urgent 
indication. If this be done, then the artificial opening will soon close 
of its own accord. It is estimated that a diminution of one-fourth the 
transverse diameter of an intestine is not inconsistent with the proper 
performance of its functions. In this instance a careful measurement 
of the gut at the time of the first operation established the fact that 
three-fourths of the normal diameter remained unaffected by the closure 
of the fistula. 

In view of these facts, I have determined to close the artificial 
opening and await developments. If this course be not adopted, en- 
terectomy with end-to-end-union, division of the intestine at the seat 
of the narrowing with lateral anastomosis, or the employment of the 
enterotome, offer the only practical measures of cure. The danger 
attending either of these acts is so much greater than the simple 
measure of closure as fully to justify this course, especially since, in 
case of failure, by reopening the old sinus one can b^in over again 
with but little danger to the life of the patient. 

[Note. — At the end of a week after the closure of the artificial 
anus the patient suffered from severe pain at the seat of the old fistula, 
attended with a small, painful, tender, deep-seated induration at the 
same site, which was not influenced by large high enemata. 

At the end of two weeks the old sinus opened, but of less diameter 
than formerly. During this entire time the patient's bowels moved 
fi-eely only with the aid of cathartics or enemata ; otherwise nothing 
unusual was observed. I now intend to re-establish the artificial anus 
and employ the enterotome for the purpose of cure, as this is believed 
to offer the safer plan of procedure. Enterectomy with end-to-end 
union is regarded as unsafe, owing to the loss of normal peritoneal 
surface and the presence of dense adhesions. Lateral anastomosis is 
thought to be impossible, on account of the firm adhesions that confine 
the transverse colon its entire length.] 

The second case is one exhibiting the influence of '' physiological 
rest'' on an obstinate prolapse of the rectum* which had been already 
subjected to many well-recognized methods of treatment of an opera^ 
tive nature without a resulting benefit of any kind, through the medium 



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200 INTERNATIONAL CLINICS. 

of an artificial anus. The artificial anus was established with the 
sigmoid flexure three months ago. At pi*esent the following improve- 
ments are distinctly appreciable. (1) Pain and tenesmus have nearly 
disappeared. (2) Mucous and bloody discbarges are arrested. (3) 
The prolapse is scarcely more than one-half its previous dimensions. 
(4) The sphincter ani is fast gaining tone ; before this it was entirely 
paralyzed. (5) The patient's physical condition is now all that could 
be wished, and he expresses himself as being comfortable in any pos- 
ture. About three-fourths only of the alvine matter escape through 
the artificial opening, the remainder passing by the rectum, aided by 
small enemata. 

I shall continue to observe this patient until the fullest benefits of 
the measure are thought to be experienced. Please remember that this 
measure is contemplated only for the worst forms of otherwise irre- 
mediable prolapse, the only other remedial measui^ being amputation 
of the protrusion. 



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FORCIBLE REDUCTION OP UNREDUCED PRAC- 
TURE AT THE LOWER END OP THE RADIUS, 
POUR MONTHS APTER THE ORIGINAL INJURY, 
IN TWO PATIENTS, QNE OP THEM AGED 
SEVENTY-PIVE YEARS ; CURE IN BOTH CASES. 

CLINICAL LECTURS DSLIYSRSD AT THS WOMAN'S HOSPITAL OF PniLADBLPHIA. 

BY JOHN B. ROBERTS, A.M., M.D., 

Professor of Surgery in the Woman's Medical College of Pennsylvania. 



I NOW show you what may be gained by aggressive surgery in 
maltreated fractures of the lower end of the radius. This woman^ 
aged seventy-five years, had a fall from some steps, over four months 
previously to coming to the clinic, which caused the ordinary fracture 
of the base of the right radius. She was treated by a physician, but 
since that time had sufi^ered much pain. The deformity of the wrist, 
when I first saw her, was considerable, and there was stiffness of the 
fingers. The finger-joints of both hands were somewhat enlarged 
with the deposit which occurs in rheumatoid arthritis. The patient's 
general condition was good, except that she had a chronic 1^-ulcer. 

Examination of the wrist showed marked backward displacement 
of the lower fragment, giving the characteristic deformity which is so 
often seen in such fractures immediately after injury. It was evident, 
therefore, that the fracture had not been reduced, but was treated as 
these fractures oft^n are, by a splint, without the fragments being put 
in apposition. 

A little over four months aft^r the date of the original injury, I 
refractured the maltreated bone and reduced the lower fragment with 
comparatively little difficulty. This operation was done under ether, 
before the class, and the bone fractured at the original seat of the in- 
jury by forcible hyperextension of the hand. A straight splint, made 
of a narrow piece of board, was then put upon the posterior aspect of 
the wrist and hand. This was worn for a few days, and subsequently 

201 



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202 



INTERNATIONAL CLINICS. 



replaced by a band of adhesive plaster placed about the wrist as a sort 
of wristlet. 

At the end of thirteen days all dressings were removed and the 
anatomical outline of the wrist was found to be restored. The patient 
stated that she had suffered less pain tlian before the operation of 
refracture. Massage and friction with oleaginous preparations were 
kept up for some time, after which treatment the patient rapidly re- 
gained the normal functions of the wrist and fingers. 

These photographs, taken before and some weeks subsequent to the 
operation, show the difference in 4;he limb made by the replacement of 
the lower fragment, which had been so long allowed to be unreduced. 

Fig. 1. 




Defonnity from unreduced fracture of the lower end of the radius. (The x shows the point 
where the unreduced lower fragment made an eaaily felt elevation or ridge on the dorsal surface 
of the radius.) 

If you will examine the wrist as she passes before you, you will find 
that the contour of the dorsal surface of the radius is almost identical 
with that of the uninjured arm. When she first came here there was 
a distinct shelf or ridge felt at the point where the fracture had oc- 
curred. 

This bone, as I have often told you, is usually broken about half 
an inch above the radio-carpal joint. The line of fracture is nearly 

Fig. 2. 




Restoration of contour after refracture. Observe that the dorsum of the radius shows no upward 

projection of bone. 

always transverse and the fragments impacted. The essential of treat- 
ment is the forcible reduction of the lower fttigment, which should 



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FORCIBLE REDUCTION OF UNREDUCED FRACTURE. 203 

be pressed into place by your thumb, while you make extension and 
counter-extension accompanied by sudden flexion of the wrist. This 
procedure is exceedingly painful to the patient, but is done in a moment 
I seldom give ether, since it is accomplished by a sudden movement of 
my hands, before the patient has time to think. By all means give an 
ansesthetic if you have not courage to reduce the fracture properly 
without such an adjunct. 

After reduction there is little tendency to displacement, and a 
narrow and short straight splint on the back of the wrist, or a simple 
wristlet of adhesive plaster applied around the wrist, is all that is re- 
quired in the way of fracture dressing. These fractures are often im- 
properly treated because the reduction is u^lected ; hence pain and 
rigidity of the fingers remain for many weeks or months. It is one 
of the easiest fractures to treat satisfactorily if it is managed with 
energy at the b^inning and with common sense aftierwards. 

It is unfortunate that the name of Colles is still associated with 
fractures of the base of the radius. Such personal nomenclature is 
always objectionable, and is especially so here, since Colles placed the 
seat of lesion at a higher point than that at which fractures of the base 
of the radius usually occur. 

Clinically, fractures of the lower end of the radius vary very little 
in essential details. The amount of displacement, comminution, and 
impaction is not always the same, but through all the variations due 
to the degree and continuance of the vulnerating force, the surgeon sees 
the same essential lesion, situated at nearly the same point of the bone. 
The treatment, too, needs little variation, and consists in immediate 
forcible reduction. 

The usual line of fracture is situated at from one-third to three- 
quarters of an inch above the articular surface of the bone, and is 
generally more or less transverse in direction, though some tendency to 
lateral or antero-posterior obliquity is not infrequent. Displacement 
of the lower ft*agment backward upon the lower end of the upper frag- 
ment is the ordinary deformity, and is due to the fracturing force, not 
to muscular contraction. Some impaction is not unusual from driving 
of the dorsal wall of the upper into the cancellated structure of the 
lower fragment, and actual loss of substance from crushing of the bone 
tissue is not infrequent. When true impaction does not exist, entangle- 
ment of the fragments by interlocking of the irregular surfaces is very 
common. Sometimes the]:e is no displacement, at other times it occurs 
at the radial but not at the ulnar side of the lower fragment, which is 
tilted obliquely backward. The styloid process of the radius is carried 



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204 INTERNATIONAL CLINICS. 

upward and backyard by this displacement, and therefore the radial 
styloid process is often as high as, or even higher (that is, farther from 
the hand) than, the ulnar styloid process. This angular displacement 
tends to throw the articular surface with the attached carpus upward, 
backward, and to the radial side, and produces the peculiar deformity 
so recognizable. Sometimes the integument over the ulnar head is torn 
asunder by this radial displacement of the hand, and the ulna may 
even protrude through the laceration. Such a wound by no means 
implies an open or compound fracture of the radius, for fre<iuently the 
wound has no communication with the fractured surfaces. I some 
months ago presented a case to the class where the skin over the ulna 
was thus torn. 

The fracture just described, with or without comminution of the 
inferior fragments, is the one usually seen. Associated fracture of the 
lower end of the ulna or of the ulnar styloid process, synchronous 
rupture of the radio-ulnar ligaments, or epiphyseal fracture, may, 
however, occur. 

Fracture of the lower end of the radius, with forward displacement, 
occurs, but is very rare. Dislocation of the carpus backward or for- 
ward is rare. Fracture such as this woman had is quite often sup- 
posed to be a dislocation. 

Fractures identical in pathology and deformity with those found 
clinically can readily be produced in the surgical laboratory by sudden 
hyperextension of the hand caused by heavy blows. As there is no 
opportunity for living muscles to assist in the production or main- 
tenance of deformity in such cases, it is reasonable to suppose that 
muscular action has little influence upon the similar fracture in living 
patients. The tonic contraction of the muscles of the forearm may be 
an agent in holding the fragments in their abnormal position when 
there is simple entanglement of the rough surfaces without true impac- 
tion, and the tendons may similarly cause the normal relations to be 
maintained after reduction by the surgeon. Further than this, muscular 
influences are unimportant, if my experience has taught me correctly. 
The conditions in a transverse fracture of the broad base of the radius 
are very diflerent from those in an oblique fracture of the shaft above, 
which is surrounded by muscular bellies. The statement that there is 
a great tendency to displacement from muscular action after reduction 
has been accomplished is unconfirmed by clinical observation. 

That reduction is at times impossible may be true, but I have never 
seen a recent fracture of the base of the radius which the power of my 
hands, aided by leverage across my knee, could not reduce under anses- 



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FORCIBLE REDUCTION OP UNREDUCED FRACTURE. 206 

tliesia. Rediustion is to be accomplished by forcCy not by genUe presmire 
and manipulation^ as some would have us believe. I usually accomplish 
it by extension and counter-extension applied to hand and forearm, 
aided by sudden flexion of the wrist with simultaneous pressure on the 
dorsum of the lower fragment. This manoeuvre is repeated, if neces- 
sary, until I feel no edge of bone at the seat of fracture, when I carry 
my forefinger or thumb along the dorsal surface of the lower third of 
the radius. The work is so quickly done that ansesthesia is generally 
omitted. In recent cases this is usually sufficient, but in unreduced 
cases of several weeks' duration, and sometimes in recent cases, I have 
been obliged to bend the limb over my knee so as to break up the con- 
nection between the misplaced fragments. It has been asserted that 
the long supinator or square pronator opposes reduction of the defor- 
mity. This is undoubtedly a fallacy in so far as any real obstacle is 
offered by these muscles. 

This other woman shows the exact deformity possessed by the old 
-woman before I reset her mal-united fracture. I will now exhibit to 
you the manner of correcting the deformity in unreduced fractures of 
the lower end of the radius. This patient was treated four or five 
months ago for fracture of the radius, and it was believed that the 
lower fragment was properly reduced. If it were properly reduced, a 
Bond's splint or some equally bad form of splint, which did not con- 
form to the curvature of the palmar surface of the bone, was probably 
used. As I have frequently told you in this clinic, a straight splint 
put on the palmar aspect of the forearm in the treatment of these frac- 
tures is very apt to push the lower fragment upward into the position 
of former displacement. It is quite probable that this is what occurred 
in the present case. 

At any rate, the woman has now an unreduced fracture with the 
fragments united in an improper position. Under ether I bend the 
hand strongly backward, taking care to bring the strain upon the seat 
of fracture and not upon the wrist-joint, which I protect by the man- 
ner of grasping the limb. Failing to break the union, I now bend the 
bone across my knee, using, as you see, great force. You can hear the 
tearing of the bone as the fracture gives way through the bond of 
callus. I can now push the lower fragment into position by making 
extension and counter-extension, and pressure with my thumb on the 
back of the lower fragment. You see the difference produced in the 
shape of the forearm. A straight splint will be applied to the dorsal 
surface of the wrist for a few days, and I shall then use a wristlet of 
adhesive plaster without other restraining apparatus. The pain in her 



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206 INTERNATIONAIi CLINICS. 

wrist and fingers, as well as the stiffness of the fingers, will probably 
be at once greatly relieved. 

It is curious that these two cases should come to the clinic for 
operation within a few months of each other. It shows how com- 
mon is improper treatment of these fractures. I frequently have to 
reset imperfectly set, or refracture improperly united, fractures in 
this locality. 

[Note. — ^The patient returned at subsequent clinics and recovered 
the good use of her fingers and wrist with but moderate deformity. 
She stated that the discomfort after refracture was much less than before 
the operation. The result naturally was not quite as satisfactory as it 
would have been if the fracture had been properly reduced in the early 
treatment of the case.] 

The ignorance of the true pathology of this fracture was formerly 
so great that many ridiculous splints were devised for its treatment. 
Many were constructed on the theory that the extensor muscles of the 
thumb were a cause of the deformity, and not a few were employed 
that failed to recognize the curvature of the palmar surface of the lower 
portion of the radius. 

Afi«r reduction, the ordinary fracture of the inferior extremity of 
the radius rarely requires such rigid support as a splint, because the 
transverse fracture gives a broad rough surface of contact, and the ex- 
tensor tendons running over the dorsal surface of the bone act as tense 
straps to hold down the lower fragment. 

If there is much comminution, or if the patient is a careless man 
or a romping boy, it is at times wise to use, as an extra precaution, a 
short and narrow dorsal splint upon the back of the wrist It may be 
made of a piece of cigar-box, a strip of metal, or two or three whale- 
bones such as are used in ladies' dress-waists. It should extend only 
from the middle of the metacarpal bones to the junction of the middle 
and lower thirds of the forearm, being therefore about six inches long. 
Its width need not be over one inch. It should be held in place by 
adhesive plaster or a bandage encircling the limb. 

This dressing should not be employed longer than ten days or two 
weeks at the outside, during all of which time the patient ought to be 
encouraged to use his fingers as freely as pain and swelling will permit 
In the great majority of cases this dressing is unnecessary, and a simple 
roller bandage or a wristlet made of two or three superimposed strips 
of rubber adhesive plaster is all that is needed. 

This simple method of treating the fracture gives the patient the 
necessary freedom in moving his fingers from the instant the fi'acture 



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FORCIBLE REDUCTION OP UNREDUCED FRACTURE. 207 

is set, does not prevent his wearing a sleeve^ allows inspection of the 
parts, is inconspicuous, light, clean, and efficient. 

The dressing employed may usually be discarded in t^n days or 
two weeks in ordinary cases, an<l in three or four weeks in comminuted 
fractures. Long retention of the appliances is unnecessary and even 
deleterious when splints are employed, because of the greater tendency 
to stiffness thereby induced. 

In properly-treated cases of ordinary severity, perfect use of wrist 
and fingers is obtained within a few weeks after tlie injury. Patients 
can often write a little, and use the hand for dressing themselves, within 
two weeks. This facility varies with the amount of comminution and 
inflammation. Persons of gouty and rheumatic tendencies are probably 
more liable to stiffness of fingers and wrist than others. Fractures in 
other regions present the same complication in such individuals. Much 
of the rigidity of vrrist and fingers attributed to rheumatic and gouty 
causes, or to the senility of the patient, I believe to be due to imperfect 
reduction of the fragments and to unscientific and unwise treatment 
I have not recognized the stifihess and rigidity aft^r this fracture in 
the aged which some authors mention with emphasis. I expect the 
same early and perfect freedom of motion in these as in the young, 
except in so far as the aged are more liable to rheumatism and gout 



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MACEWENS OPERATION FOR RACHITIC DEFORM- 
ITY OF THE FEMUR; INFLAMED HEM- 
ORRHOIDS. 

CLINICAL LKCTURK DBLIYKBED AT THE BUFFALO GENERAL HOSPITAL. 

BY ROSWBLL PARK, A.M., M.D., 

Professor of Surgery in the University of Buffalo. 



Gentlemen, — This case \p that of a young child with rachitic de- 
formity of the lower limbs. Ou inspection you will notice that there 
is very much more deviation of the axis of the leg from that of the 
femur than there should be. The tibia appears to be perfectly formed ; 
the trouble is that the inner condyle of the femur is ou a lower level 
than is natural. We cannot raise the condyle without splitting it off 
and performing an operation that is unwarranted on account of its se- 
verity, but we can bend the femur, or, at any rate, break it, and thus 
atone for the position of the condyle. An operation below the knee 
would be a mistake in such a case as this. When the knees are directed 
forward and brought together, we find that there is marked knock- 
knee and anterior curvature of the femur. 

If one had sufficient room to grasp it, the bone could hardly resist 
the force which I apply ; but, on account of the small size of the bones 
of the child, I will use the osteoclast. I now apply considerable force 
with the osteoclast. Afler the removal of the osteoclast, I find that 
nothing has been accomplished. I think, therefore, that I shall do 
less harm to break the bone by means of the chisel. There is a preva- 
lent opinion that a child's bones break very easily, but in more than 
one instance I have exerted all my strength on such a case and have 
felled to break the bone. 

The point for the insertion of the chisel in this operation is just 
above the tubercle of the adductor magnus, which is slightly above the 
internal condyle of the femur. After carefully washing and disinfect- 
ing the 1^, a small incision is made just above the tubercle for the 
insertion of the great adductor, high enough to avoid the femoral 
artery and its accompanying structures. The wound is relatively 
larger in a small child than in an adult. After introducing the chisel. 



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OPERATION FOR RACHITIC DEFORMITY OF THE FEMUR. 209 

the wound is closed temporarily with antiseptic gauze wound about the 
handle of the chisel, the bone is cut into sufficiently to allow it to be 
broken with the hand, and then a light gauze dressing is wrapped 
about the thigh. I will repeat the operation on the other leg. 

I now dress the wounds with iodoform gauze, and bichloride gauze 
over that, held on by a gauze roller bandage. A cotton-wadding roller 
is applied to the leg and thigh, beginning at the foot, and over this a 
starch bandage. 

Professor Macewen, of Aberdeen, Scotland, has done this operation 
nearly a thousand times without a death. Those figures will give you 
an idea of the amount of rachitic disease in Scotland. Do not imagine 
that the operation is finished with putting on this bandage, for a great 
deal remains in seeing that the position of the leg is correct while the 
plaster-of-Paris bandage, which we will now apply, hardens. If we do 
not correct the deformity now it will not be corrected at all. It is better 
to over-correct the deformity slightly than not to correct it sufficiently. 
In the left foot the child has a slight tendency to talipes equino-varus, 
and in applying the plaster-of-Paris bandage I will overcome that 
deformity also. 

You have seen that I have made two wounds here, and have sealed 
them hermetically without thought of drainage. You remember a 
little colored infant from whom I removed the astragalus for an 
aggravated case of club-foot. That was quite a severe operation of 
the removal of bone and opening into a joint-cavity, but we observed 
perfect asepsis throughout the operation, and the wound was closed 
without drainage, and it healed perfectly in two weeks. This present 
operation is certainly much less severe: nevertheless, if I had not 
absolute confidence in our aseptic precautions, I should not think 
of so closing any wound without drainage. 

My next case is one of considerable pathological importance, and 
one which would probably give you considerable trouble. I have not 
yet seen the case, but, taking the statement of others as to his condition, 
I am having him ansesthetized, and I shall present him to you in a 
few minutes. It is a case of inflamed piles. Let us consider the 
nature of acutely-inflamed hemorrhoids. A number of hemorrhoidal 
protuberances which comedown frequently, or which remain down, con- 
stitute a bad enough state of affieiirs, but when to this is added the ele- 
ment of acute inflammation there is positive danger. Our patient was 
sent here late in the afternoon yesterday, and the main thing then was to 
give him relief. He was given a quarter of a grain of morphine and 
a suppository of opium, belladonna, and ergot. 
Vol. I. Ser. 4.— 14 



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210 INTERNATIONAL CLINICS. 

Hemorrhoidal tumors^ composed as they are of a series of enlarged 
veins, being really nothing but originally varicose veins covered by 
mucous membrane, are just as liable to inflame as venous structures 
enlarged into varices anywhere else. I have told you that inflamma- 
tion of veins is always a very serious thing, though it is not necessarily 
fatal. The exposed veins and the hemorrhoidal tumors are covered 
ordinarily only by mucous membrane, which, however, by constant con- 
tact with the clothing and the air, if the piles are always exposed, be- 
comes thickened and tough, and sometimes loses its characteristic ap- 
pearance, while the exposed veins bleed frequently, as is well known to 
the laity. They are easily ruptured and are subject to inflammatory irri- 
tation. When once inflamed, the trouble may remain in the group of 
varicose veins, or it may spread to two or three veins with which they 
are connected. While the external hemorrhoidal veins are virtually 
subcutaneous veins, and connect with the veins of the skin, the middle 
and superior hemorrhoidal plexuses connect with the veins of the portal 
system. An inflamed pile may degenerate and suppurate, forming a 
septic focus; septic thrombi may then form in the veins, become dis- 
lodged by defecation or by some motion on the part of the patient, and 
may be carried, as thrombi always are, along the course of the venous 
circulation, and taken, not to the right side of the heart, but to the 
liver, where they will set up just the same trouble as thrombi from the 
systemic veins would set up in the lungs, — that is, a series of minute ab- 
scesses. Thus, not infrequently, men have died of abscess of the liver 
consequent upon trouble which began in hemorrhoidal tumors. That 
is one objection to the method of treating hemorrhoids by injection 
with carbolic acid, a procedure which is largely practised by a number 
of quacks who travel about the country, advertising to cure piles with- 
out pain. That is a euphemism, because they do inflict some pain, 
although it is a minimum. They usually keep their method secret; 
they get the patient to expose the part, and then they draw a hypo- 
dermic syringe and make an injection without letting the patient see 
what they are doing. Usually there is not a great deal of pain, and a 
cure is effected, though sometimes death follows from abscess of the 
liver and aepticsemia or pysemia resulting. 

An inflamed vein, under any circumstances, is to be dealt with with 
great caution. To treat an acutely-inflamed pile as one would treat an 
uninflamed pile would be the height of rashness. I do not mean to 
say that the result would be always fatal, but that there would always be 
danger of such a result. One must adopt the mildest form of treat- 
ment and subdue the inflammation unless there is some element of the 



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INFLAMED HEMORRHOIDS. 211 

case which calls for radical treatment at the b^inning. You may be 
sure of this, that inflamed plies will cause the same kind of spasm of 
the sphincter aui that an inflamed cornea causes about the eye. With 
a child who has inflammation of the cornea or any other part about 
the eye, there will be vigorous spasm, so that you cannot separate the 
eyelids unless you anaesthetize the child or use considerable force. The 
spasm of the sphincter ani is always painful, but in the case of inflamed 
piles there is another feature which is important. The hemorrhoidal 
veins pass not merely between the mucous membrane and skin of 
the anus and the muscular coat of the rectum, but also between the 
fibres of the sphincter muscle ; spasm of the sphincter, therefore, causes 
pressure on the veins and distention of the piles, and this again causes 
increased spasm of the sphincter, the two phenomena reacting on each 
other. In this engorged and inflamed condition, what is to be done? 
If the engorgement be apparently the most prominent feature, you can 
tap the hemorrhoidal tumors and let the blood escape. You must not 
do this too freely, or you will invite secondary hemorrhage. If, on 
the other hand, the spasm seems to be the prominent feature, the 
sphincter must be vigorously stretched, so as to paralyze it 

Here appears to be an inflamed and gangrenous condition of afiairs. 
This was represented to me as a case of acute inflammation, but I do 
not find the indications of very acute inflammation, and so I shall treat 
it in a different way from that which I have just been describing to 
you. On examining the rectum with a Sims speculum, I find a tumor 
which was evidently originally a hemorrhoid, but it feels hard, and on 
puncture the blood does not gush out, as it would from a distended 
vein : there has evidently been an organization of the hemorrhoid into 
connective tissue. 

I think we will be pursuing the wisest course by simply stretching 
the sphincter to-day, and then endeavoring to build up the patient's 
strength and watching him carefully, using fomentations to get a line 
of demarcation between the living tissue and the gangrenous portion 
of the pile, and then, in a week or so, we will perform the radical 
operation of removing the tumor. I should not be at all surprised if 
after four or five days very much of the present inflammation would 
have subsided, leaving simply the chronic condition. His sphincter 
will be paralyzed for two or three days, during which time he will get 
a large amount of relief from the necessary local rest We will use 
suppositories containing morphine enough to control pain, a litle ergot 
for its effect on the vessels, and some antiseptic in addition, such as 
iodoform or aristol. 



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OPERATION FOR OCCLUSION OF THE CYSTIC 
DUCT, WITH CALCULI IN THE GALL-BLADDER. 

OLIKIOAL LECTURB DBLIYEBBD AT THE SOUTHERN MEDICAL COLLEGE, ATLANTA, 

GEORGIA. 

BY J. McPADDBN QASTON, M.D., 

Professor of the Principles and Practice of Surgery, Southern Medical College, 

Atlanta. 



Gentlemen, — ^The patient who comes before you to-day is the 
widow of a physician. Mrs. K., as you will see, is a white woman, 
about fifty years old, but little emaciated, of whose previous sufferings 
the family attendant, Dr. Grarrett, furnishes a brief account. He has 
attended her at her home, near Austell, in this State, at various times 
within the past four years, for hepatic colic and jaundice. Event- 
ually there appeared an enlargement, with tenderness upon pressure, 
below the points of the ribs on the right side, and she complained of 
acute pains at times in this r^ion. 

Upon examination of her case yesterday, when she arrived in this 
city, I learned that the attacks from which she had suffered formerly 
had been less frequent of late, and not followed by any discoloration of 
the skin within the past twelve months. It was also learned that her 
fecal evacuations, which had for two years prior to the last year been 
clay-colored, had resumed their natural appearance. But there was per- 
sistent torpor of the bowels, requiring frequent resort to purgatives of 
an active nature. 

When my attention was directed to the right hypochondriac r^ion, 

I found a very perceptible enlargement of the liver, extending below 

the points of the false ribs, and by palpation I detected an indurated 

mass at the lower margin of the liver, which was quite movable. The 

outline was rather globular below, but extended upward beneath the 

liver, and inclined to the right when the patient turned ujwn her right 

side, and towards the median line when she turned upon her left side. 

When she lay upon her back the indurated mass corresponded to the 

usual site of the gall-bladder, and could be lift;ed upward and forward 
212 



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OPERATION FOR OOCOLUSION OP THE CYSTIC DUCT. 213 

by the fingers thrust under it. The eflTect of gravity in this position 
caused it to drop backward, and to the eye there was no promi- 
nence from it when the thighs were flexed upon the body in the dorsal 
decubitus. 

Considering the great mobih'ty of the mass, with the absence of 
jaundice recently, there were some grounds for suspecting that it might 
be a floating kidney, and a colleague who made a careful examination 
of the case spoke of this without any suggestion on my part. But 
after comparing the indications for a diagnosis of floating kidney with 
the points observed in this patient, we both concluded that the pre- 
ponderance of evidence was in favor of an obstructed gall-bladder with 
retained biliary calculi, and this is the diagnosis upon which I shall 
operate in this case. 

It may be stated in advance that I do not expect to find the com- 
mon bile-duct obstructed by gall-stones, as the bile is finding its way 
into the alimentary canal, as indicated by its presence in the evacuations. 
It is dear that an impediment of some kind exists in the cystic duct, as 
the contents of the gall-bladder are evidently confined in tliat viscus, 
and it is most likely that biliary calculi will l)e found in it You per- 
ceive from the drawing on the wall before you that, with the relations 
of the cystic and common bile-ducts, the duct connecting with the gall- 
bladder may be entirely occluded, while that leading directly from the 
liver to the duodenum may be free from obstruction. (See Fig. 1.) 

The procedure in this case is entirely different from that which 
would be requisite for the relief of occlusion of the common duct The 
latter being unable to convey the bile into the intestinal canal, while it 
flows freely into the gall-bladder from the hepatic ducts, calls for a 
communication to be effected by attaching the gall-bladder to the duo- 
denum or some portion of the small intestine. Various operations 
have been resorted to for this purpose, based upon a series of experi- 
ments made upon dogs, by me, nine years ago, with a view to demon- 
strate the feasibility of effecting an anastomosis of the gall-bladder 
with the duodenum or the upper portion of the small intestine. It 
matters not whether an opening is made by my process or by some 
other, 80 that the bile is given an outlet from the gall-bladder directly 
into the intestinal canal, and thus plays its r6le in intestinal digestion. 
Belief is thus afforded to the colaemia which is poisoning from the 
presence of bile throughout the system, and which is shown by jaundice 
in cases of biliary obstruction. 

Our patient will not require to have an operation of this nature, 
but simply to have the contents of the sac removed, and to have the 



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214 INTERNATIONAL CLINICS. 

gall-bladder secured by sutures to the parietal opening, so as to accom- 
plish thorough drainage from its cavity. 

The patient took an active purgative of Epsom salt with senna 
tea yesterday afternoon, and was instructed to take nothing but tea and 
toast this morning. Our clinical staff have been directed to cleanse 
effectually the surface of the hypochondriac r^ion, administer hypo- 
dermically morphine ^ gr., and atropine y^ gr., and give her an 
ounce of rye whiskey with a little sweetened water. This being done, 
she will be put under the influence of the A. C. E. mixture, which has 
proved most satisfactory as an anaesthetic, and which you have seen so 
often used in my clinics without untoward results of any kind. With 
the preliminary use of morphine and atropine, followed by whiskey 
toddy, I am convinced that there is less danger from shock in employ- 
ing this combination of one part alcohol, two parts chloroform, and 
three parts ether, than from any other mode of securing anaesthesia for 
protracted operative procedures. 

As the patient has already been submitted to the influence of this 
ansestheti« with the use of an ordinary cone formed with a towel, she 
may be brought in from the adjoining room for the operation. 

You perceive no marked prominence below the points of the ribs 
on the right side, but palpating over this region I distinctly feel the 
outline of what has been diagnosed as a distended gall-bladder, about 
the size of a turkey's egg. I proceed to make an incision, three inches 
long, diagonally across this mass, just below the margin of the liver, 
and about two inches below the costal cartilages, parallel with the lower 
border of the false ribs. (See Fig. 2.) Having sponged off the blood 
from this incision with hot water, and the oozing being arrested, the peri- 
toneum is opened, and now we have fully exposed the fundus of the 
gall-bladder. Finding it impracticable to bring the distended sac out of 
the parietal opening, either with ray finger or with a lever scoop passed 
beneath it, I proceed to secure the wall by a curved needle with a st^'ong 
silk ligature carried through the anterior portion of the fundus of the 
gall-bladder ; letting it remain double, the needle is cut loose and the 
ends knotted together, making a loop, including an inch of the tissue 
of the sac, which is delivered to an assistant to keep the fundus sup- 
ported, and projecting at the external incision. A trocar is now thrust 
into the fundus, and you see a mucoid fluid, without any appearance 
of bile, flows out. Introducing my finger outside of the sac, I feel 
a number of gall-stones within its cavity, and with a view to their 
removal an incision is made with a scalpel from the point where the 
canula enters, extending an inch across the fundus of the gall-bladder. 



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OPERATION FOR OCCLUSION OP THE CYSTIC DUCT. 



215 



With the calculus-scoop introduced at this opening, one calculus after 
another is removed, until we have six, and upon passing them around 
it will be seen that each has facets from contact with the others and 
friction in the gall-bladder. Upon introducing my index finger into 
the sac, no other loose calculi are found, but I can feel distinctly a gall- 
stone embedded in the mucous membrane, near the neck of the gall- 
bladder, and thus completely encysted. As there is no probability that 

Fio. 2. 




Line of incision to expose tiie gall-bladder, with the retractors and calcnlus-scoop in position. 

this can become a source of trouble if left alone, and as there might be 
hemorrhage from making an incision for its removal, I shall adopt the 
plan of masterly inactivity and not interfere with it. 

Upon passing the finger outside of the sac along the cystic duct, it 
is found like a hardened cord, with its walls completely agglutinated, 
and hence there is no prospect of its becoming pervious, so as to carry 
bile into the gall-bladder. There is no evidence of any obstruction in 
the common duct from palpation with the point of my finger along its 
tract, and therefore a free outlet of the bile from the hepatic ducts, 
through the common duct, into the duodenum, may be relied on for the 
future, as it has occurred during the past year. We shall expect atro- 
phy and obliteration of the gall-bladder under the further observation 
of this case, with the use of drainage. 



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216 INTERNATIONAL CLINICS. 

The gall-bladder will now be anchored to the abdominal wall, by 
threading needles with the ends of the ligatures passed through the 
wall of the sac and carrying them through the edges of the external 
incision. It is observed that when the ligatures are brought out and 
the ends are crossed, the external wound is closed up at that point com- 
pletely. But previous to knotting them I proceed to suture the parie- 
tal peritoneum to the cystic peritoneum, around the incision in the sac, 
and thus effectually obviate the escape of any of the mucoid contents 
of the gall-bladder into the peritoneal cavity of the abdomen, and af- 
ford it a free outlet, externally, through a large fenestrated drainage- 
tube, which is left in the opening from the gall-bladder. 

Being now prepared to close the upper and anterior portion of the 
parietal incision, three stitches of interrupted suture are inserted through 
all the structures of the abdominal wall, and, these with the anchoring 
suture being knotted, there is left only an opening at the lower and 
posterior end of the external incision, at which the edges of the cystic 
incision afibrd an outlet from the cavity of the gall-bladder. The 
drainage-tube which has been inserted will be attached by a safety-pin, 
for the present, to the margin of the skin, but subsequently this will 
be removed and secured to the dressing. 

The incision is dusted over with iodoform, and iodoform gauze, 
with a hole for the drainage-tube, is laid over this, while a thick com- 
press of absorbent cotton is held in position by a broad roller bandage 
carried several times around the body of the patient. 

You observe that the patient inhaled the A. C. E. mixture without 
any indication of disturbance during this somewhat tedious operation, 
and that she is now recovering from its influence without any signs of 
shock. 

The patient will be removed on the operating-table to the waiting- 
room, and after she is entirely restored to consciousness will be placed 
on a litter and carried to her quarters, with instructions for the nurse 
to withhold food and drink during the day. 

It will be profitable to draw your attention to some points which 
could not be well referred to in the course of the operation which has 
just been completed. I would note, first, the great tension of the wall 
of the gall-bladder from the accumulated mucus in the cavity, and the 
consequent firmness and resistance of the tumor when palpated through 
the abdominal parietes. Even after the sac was laid bare by the external 
incision, the sensation upon manipulating the ovoidal body was that 
of a solid mass rather than the elasticity of a sac containing fluid. 
The color of the sac was seen to be rosaceous with a pearly opaque hue, 



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OPERATION FOR OCX3LU8ION OF THE CYSTIC DUCT. 217 

differiBg very much from the greenish complexion of the sac when 
bile is contained in the cavity of the gall-bladder. As you perceived, 
the edges of the cut in the sac were much thicker than natural, and 
the tissue was considerably indurated, so that it might be inferred to 
be impaired in vitality and prone to ulceration or disint^ration, from 
contact with the gall-stones within. 

In these conditions we recognize the fact that an operation was requi- 
site to secure against serious results, such as those reported recently 
as verified by a post-mortem examination in a case under the care of 
Dr. J. H. Musser, of Philadelphia. The patient had suffered re- 
peatedly from the presence of gall-stones, but declined to have any 
operation, when ulceration of the sac allowed them to escape into the 
abdominal cavity, and peritonitis ensued, from which she died. A fatal 
result of perforation is reported by Dr. Anders also. 

The woman who has just been relieved of these biliary calculi by a 
procedur^nvolving but little risk to her life has assuredly been spared 
from a hazardous condition, threatening grave consequences. 

Th&re might have been some grounds for resorting to complete ex- 
tirpation of the gall-bladder in this case, as there is no prospect of the 
restoration of the functions of the organ. Had I concluded to do this, 
it would have been necessary to make a larger incision into the abdo- 
men, and the detachment of the gall-bladder, whether by dissection Srom 
the liver or by cutting off its walls from the adherent surface, would 
have been attended with hemorrhage, which might have jeopardized 
the life of the patient. There would pot have been any trouble in this 
case connected with the ligation of the cystic duct, as it was completely 
obliterated ; yet the great increase of traumatism from cholecystectomy, 
beyond what is requisite for cholecystotomy, induced me to give prefer- 
ence to the latter. Had the wall of the gall-bladder presented indica- 
tions of disint^ration, I should have removed the sac ; but, having the 
tissues in a favorable state for external drainage, it was best to retain 
the sac, and suture the incision in its wall to the incision in the abdomi- 
nal wall, as you have just witnessed in my operation. 

It is expected that atrophic d^neration of the gall-bladder will 
ensue, after a longer or shorter period of drainage, and that the mucous 
coats will disappear and the inner surfiu^es become agglutinated, form- 
ing simply a fibrous band from the solidified cystic duct to the point 
of attachment to the parietes of the abdomen. 

Yon observed that silk was employed in suturing the edges of the 
parietal peritoneum to the serous covering round the incision in the 
fundus of the gall-bladder : this will be allowed to remain, in the ex- 



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218 INTERNATIONAL CLINICS. 

pectation that it will be encysted and remain buried in the tissues after 
the healing process has been completed. 

In view of the fevorable results of similar cases, under various op- 
erators, in different parts of the world, I feel confident that our patient 
will be entirely relieved by this operation. 

[Note. — ^The temperature did not exceed 100® F. at any time after 
the operation. 

The anchoring suture was removed on the third day, and the inter- 
rupted suture in the parietal incision was left until the eighth day. 

The drainage-tube was cut off gradually, and was finally removed 
on the twelfth day. 

There was a considerable discharge of watery mucus during the 
first week, but this diminished from day to day, and on the thirteenth 
day there was no longer any discharge. The wound was all closed 
on the fifteenth day, except at the lower end, where a piece of gauze 
had been kept to prevent union of the skin. There has hetm no trace 
of bile in the discharge from the gall-bladder at any time. It is 
evident that the sac will undergo slow atrophy and be ultimately 
obliterated. The bile is passing through the common duct into the 
duodenum, and is fulfilling its ofiice as heretofore. 

The patient left for home on the twenty-third day, with the wound 
closed, and with a fitir prospect of complete restoration to health.] 



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CHOLECYSTENTEROSTOMY WITH MURPHY'S 
BUTTON ; REMOVAL OP A POREIGN BODY PROM 
THE LEPT BRONCHUS; THE EXAMINATION AND 
REVIEW OP A •* SUCCESSPUL" CCELIOTOMY. 

CLINICAL LECTUBB DELIYERED AT ASBURT METHODIST HOSPITAL. 

BY JAMES H. DUNN, M.D., 

Profenor of Genito-Urinary Surgery in the Medical Department of the Univenity 

of Minnesota ; Surgeon to St. Mary's and Asbury Hospitals, 

Minneapolis, Minnesota. 



Gentlemen, — ^This woman, thirty-seven years of age, and the 
mother of six children, presents nothing in her &mily or individual 
history previous to her present trouble which need detain us. It will 
be observed that she is poorly nourished, is so emaciated that she 
appears older than her years, and is slightly jaundiced. She has not 
been herself physically since the banning of her present disease, about 
four years ago. An acute seizure of severe pain in the right hypo- 
chondrium radiating into the shoulder and across the abdomen, vomit- 
ing, and intense headache, then ushered in her malady. Relieved by 
morphine, she gradually recuperated, and left her bed in a few weeks, 
but with impaired digestion, constipation, soreness in the right hypo- 
chondrium, and some jaundice. At intervals of three or four months 
ever since, similar attacks, more or less well marked, have occurred, 
relegating her to bfed for from three to eight weeks, and frequently re- 
quiring morphine for their final relief. Several times she has been 
markedly jaundiced, and she has eventually become practically invalided 
all the time. She has been in the hospital ten days, during which 
time she has had one acute attack requiring the hypodermic use of 
morphine. Her urine is highly colored with bile-pigment ; her bowels 
are torpid, and the movements clay-colored. 

On examining the abdomen, the whole right hypochondrium is 
found tender, but the most sensitive point is apparently just under the 
costal cartilages at a point about three inches from the mesial line. 

219 



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220 INTERNATIONAL CLINICS. 

Careful palpation reveals the presence of a slight enlargement in 
the anatomical location of the gall-bladder under the margin of the 
liver. The obscure tumor appears to slip away, and the patient 
has called my attention to having felt it herself, and describes it as 
slightly movable and specially sensitive when manipulated. Just 
exterior to this is a much more distinct, larger, and harder mass 
continuous with the liver, also sensitive to pressure and manipula- 
tion. It is either simply the edge of the liver projecting very low 
beneath the costal border, or, as I have suspected, the hepatic border 
plus inflammatory exudate and adhesions from repeated inflamma- 
tory reactions in this vicinity. In short, the patient presents a very 
fair history of cholelithiasis. What consecutive changes obstruction 
and irritation may have led to I cannot say. In fact, it might be 
more prudent not to be even thus explicit in diagnosis, and, going 
only as far as we know, say, as I have said, to the patient, that we 
evidently have obstruction in the gall-passages sufficiently serious to 
demand an exploratory incision, after which we will cope with the 
conditions found to the best of our ability. If so far mistaken that 
nothing can be done, we will close the wound after achieving only the 
small but not altogether unpractical comfort, of arriving at a positive, 
if disappointing, diagnosis. To be sure, there are advantages and 
comforts in knowing just what is going to be done before beginning an 
operation, but in abdominal surgery this is not always entirely possi- 
ble; hence it is well to consider carefully the different conditions 
which might be encountered, so that being forewarned we may be fore- 
armed. 

1. This obstruction could be due to a variety of conditions, — viz., 
(a) to cholelithiasis or gall-stones ; (6) to cancer or neoplasms involvng 
the gall-ducts ; (c) to cholecystitis. 

2. Assuming the cause to be gall-stones, these might be located, — 
(a) in the gall-bladder ; (6) in the cystic duct ; (c) in the hepatic duct ; 
(d) in the common duct, or in diverticula. 

3. The state of the gall-bladder and neighboring parts may present 
a variety of conditions. There may be adhesions and various sec- 
ondary changes. The bladder may be greatly distended, or, as in a 
case successfully operated upon in this hospital last year, it may be 
contracted to the size of a bean and occupied by a sandy debris. 

In dealing with these varying conditions incident to the same 
primary disease the procedure must obviously vary. In the case just 
mentioned the remnant of the organ was removed,^-cholecystectomy. 
Finding calculi in the gall-bladder, it might be incised and the stones 



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CHOLECY8TENTEROSTOMY WITH inJRPHY^S BUTTON. 221 

evacuated, — cholecyBtotomy, — after which the incision might be sutured 
and the abdomen closed, or the bladder could be stitched to the ab- 
dominal walls and the fistula established. The former treatment has 
been associated with too discouraging a mortality to allow of its meeting 
with general approval ; the latter leaves a fistula more or less trouble- 
some to close, while if all the gall be thus discharged by it the patient 
{)erishes of inanition, since the bile appears to be indispensable to di- 
gestion. Nature has sometimes by adhesions and ulceration into the 
duodenum indicated what appears to be the best treatment of the most 
common obstructions of the bile-passages, — viz., establishment of a 




The Murphy button in position in cholecystenteroetomy. 

fistula between the gall-bladder and the duodenum, — cholecystenter- 
ostomy. Until recently, however, this operation has been so difficult 
of successful performance as to be practically out of the question. 
Thanks to the genius of a brilliant American surgeon. Dr. J. B. 
Murphy, of Chicago, we are now in possession of a mechanism — the 
Murphy anastomosis button — which reduces cholecystenterostomy to 
one of the most simple, rapid, and precise of surgical procedures, and 
one apparently safer by far than any method heretofore devised. 

. We are indebted to Professor F. A. Dunsmoor for this case, but, 
owing to his own serious illness, he is unable to operate, after having 
made the diagnosis and set the day for the operation. I now make 



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222 



INTERNATIONAL CLINICS. 



Fia. 2. 





Application of Botares for the use of 
the Murphy button. 



an incision three inches long in the right linea semilunaris from the 
costal border downward, and dissect down to the peritoneum. Now, 
pausing a moment to stanch all hemorrhage as thoroughly as possible^ 
this membrane is opened, and the border of the liver, with its notch, 
from beneath which the gall-bladder slightly projects, comes to view. 
The bladder is not materially abnormal in size, but is felt to be nearly 
filled with concretions. A little search brings to view the adjacent part 

of the duodenum. Having no mesentery, 
it is not easily drawn up into the wound, 
but being the largest portion of the small 
intestine, and lying so close to the gall- 
bladder, there is no great difficulty in 
bringing it within easy reach. It is 
necessary to avoid mistaking the colon 
or other portions of the intestinal tract 
for the duodenum. I now relieve the 
tension of the gall-bladder by aspirating 
three drachms of abnormal bile. Now, 
with a straight needle armed with silk, 
two running stitches are taken in that 
viscus, then the needle is turned and two more stitches are placed 
parallel to and one-fourth inch distant from the first. This is exactly 
repeated on the duodenum. (Fig. 2.) 

A small incision in each organ admits the respective ends of the 
button, the loops of thread are drawn down and tied around their 
necks, the adjacent peritoneal surfaces slightly scratched, the halves of 
the button pressed together, and the wound is ready to be closed with 
carefully applied silkworm-gut sutures. These should be so placed 
as to secure the most exact apposition of the several parts, i^eritoneum 
to peritoneum, fascia to fascia, muscle to muscle, and skin-border to 
skin-border. To best accomplish this result the needle is entered near 
the border of the skin, so passed as to surround more and more of the 
wall until the centre of its depth is reached, then less and less until 
its exit just behind the peritoneal border ; then on the opposite sid^ 
exactly the same procedure in reverse. So placed, the stitch^ enclose 
a round mass of tissue so pressed together as to insure the most perfect 
apposition of tissue to tissue. 

I have taken out some twenty-five or thirty of these stones (Fig. 
3) to show you before putting in the button, but this is not only i\ot 
necessary, but not in accord with the theory of the operation, since 
they will readily pass into the intestine when the fistula is established 



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CHOLECY8TE>'TER06TOMT WITH MURPHY'S BUTTON. 223 

by surgical interference, and the time spent in removing them is 
simply so much time lost. There are still a number left in this case 
to be passed through the intestine. The great service of the button 
in such a case lies in the ease, rapidity, and safety with which a chole- 
cystenterostomy may be eflfected. The operation has been performed 
in ten or twelve minutes, while to make it by safe suturing would 
require an hour or more at the hands of a most expert operator, and 
sometimes might present almost insurmountable difficulties, to say 
nothing of the long handling, the possible soiling, and the uncertain- 
ties and dangers of many stitches, which must not leak, must not 
penetrate all the coats of the intestine, and the fate of which must be 

Pio. 3. 



-^ -•-•^-ri 




Oalculi from the gall-bladder. At the right end of the cut is shown the button m it appeared 
after paadng through the patient's intestinal tract. 

uncertain and fraught with more or less danger. The button is easily 
manipulated, has almost the precision of mathematics, and appears 
to be the n€ plus uUra of cholecystenterostomy. So far as I am in- 
formed, there have been about twenty successful operations reported 
since the introduction of this truly ingenious mechanism by Dr. J. B. 
Murphy in June, 1892. Thus far I know of no failures chargeable 
to this mode of operation. In some cases of biliary obstniction due to 
advanced malignant disease the patients have died of their incurable 
disease. It is not often that we can decide positively concerning the 
worth of a new surgical procedure in so short a time,^-only mature 
judgment after wide and large experience can ordinarily fix its status, 
— ^but in this instance the principle is admitted, and the means of its 
accomplishment has given such uniform experimental and clinical re- 
sults that it would appear established as the most perfect yet devised 
for the relief of a large part of the not infrequent and serious cases 
of biliary obstruction. 

[Note. — ^The patient made a good recovery, the highest temperature 
recorded after the operation being 100°. The jaundice rapidly cleared 
up, the appetite became keen, and the button (Fig. 3) was passed on 
the eighteenth day. It contained the two loops of thread and a small 
ring of necrotic tissue.] 



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224 INTERNATIONAL CLINICS. 

FOREIGN BODY IN THE LEFT BRONCHUS. 

This twelve-year-old lad has just been brought into the hospital 
from a country town with the report that he has a foreign body in his 
air-passages. It is reported that while playing with an empty car- 
tridge-shell some time yesterday it was drawn into and passed through 
the larynx. You observe there is marked dyspnoea, he complains of 
pain and oppression in the chest, while his face, neck, trunk, and arms 
are phenomenally distorted and tumid, the eyes being closed by dis- 
tention of the skin. On palpating any part of the upper half of the 
body, a fine crackling is felt, which readily explains the cause of the 
striking bloated appearance of the patient, — viz., the areolar connec- 
tive tissue is inflated by air which has escaped from the pulmonary 
air-cells. This is termed cellular emphysema, and this boy presents 
one of the most pronounced examples of the condition that I have 
ever seen. This condition of subcutaneous transfusion of air may 
arise under four circumstances : (a) penetration of the lung through 
the chest- wall, as by a fractured rib piercing the visceral pleura ; (6) 
rarely in certain wounds of the thorax opening the pleural cavity 
without injuring the lung, the external air being sucked into the 
pleural sac during inspiration, and, if the wound be valvular or 
tortuous, during expiration it is partially injected into the subdermal 
connective tissue ; (o) in like manner a wound or ulceration of the 
lung from the mucous side, through a bronchus, allows the air in the 
lungs to be forced, under the pressure of expiration, into the pulmonary 
connective tissue, from which it finds ready exit through the medias- 
tinal areolar tissue to the subcutaneous; {d) without any external 
injury to the skin or pleura, or any internal lesion of the bronchial 
mucosa, pulmonary air-cells are ruptured, eg. by severe coughing, es- 
pecially when a bronchial tract is tightly plugged, air escapes into the 
pulmonary areolar tissue, and ♦takes the same route as before. This 
last is evidently the explanation in this case. During the violent ex- 
pulsive efforts of coughing, the column of air having no outlet, air- 
cells have been ruptured like closed gas-bags subjected to pressure 
greater than their strength. 

Emphysema is said to occur in but a small percentage of cases 
of this character, and according to some, e.g. Poulet, "Treatise on 
Foreign Bodies in Surgical Practice," its appearance renders the prog- 
nosis very grave. This author says that death has occurred in all 
or almost all such cases. I see no reason why this complication 
should be so grave, unless it be that the distention of the pulmonary 



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Fig. 4.— Boy of twelve from whose bronchus a cartridge-shell one and a quarter 
Inches long by three-eighths of an inch in diameter was removed after tracheotomy. 



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FOREIGN BODY IN THE LEFT BRONCHUS. 225 

connective tissue reduces the distensibility of the lungs and leads 
to gradual asphyxia. In the considerable number of cases in which 
I have observed the condition, nothing has ever occurred to give 
the symptom much significance; but, never before having observed 
the symptom in connection with foreign bodies in the air-passages, I 
can express no opinion. On physical examination I find loss of fre- 
mitus, absence of vesicular murmur, and normal or increased resonance 
over the lower part of the left lung. The probable seat of the foreign 
body is the left bronchus or its lower secondary division. This is 
rather unusual, since, owing to the position of the bronchial spur, some- 
what to the left of the mesial line, the chances are about two to one 
that a foreign body will pass into the right bronchus. Our duty is 
plain : an attempt must be made to remove the shell. Not only is the 
lad suffering greatly, but secondary pulmonary destruction will surely 
follow sooner or later. Though foreign bodies have often been luckily 
expelled even aft^r long delay, and though instances of the establish- 
ment of a wonderful toleration of the passages are on record, such 
remote and uncertain results at the expense of great risks and pro- 
longed agony are not worthy of consideration. We shall open the 
trachea, search for the offending body, and, finding it, attempt to ex- 
tract it by the forceps. If we are unable to find it, the tracheotomy 
may not prove in vain, since if by coughing or by position it is pos- 
sible to move the foreign body, experience has shown that it is more 
readily expelled through the tracheal wound than through the rima 
glottidis. 

The patient is not an encouraging subject to operate upon. The 
extensive emphysema is apparent enough to you on the exterior, but 
the mediastinum and pulmonary areolar spaces are likewise injected. 
The dyspnoea is marked. Naturally short-necked, he now appears not 
to have neck enough for our short incision. He is now sufficiently 
ansBsthetized (by chloroform), and I make an incision from over the 
median notch of the thyroid down to just above the epistenud notch, a 
distance in this patient of only about an inch and a half. The soft parts 
are quickly separated in the median line, and the larynx and first ring 
of the trachea exposed. Copious air-bubbles appear as soon as the skin 
is incised. I now pass a thread through each side of the thyroid carti- 
lage, to serve as retractors, and incise the larynx in the mesial line. I 
have then made a laryngotomy instead of a tracheotomy. It is much 
easier and quicker, and will, I think, serve our purpose quite as well. 
There would be no great difficulty in going a little lower, incising the 
crico-thyroid cartilage and the first ring of the trachea (laryngo- 
VoL. I. Ser. 4.-15 



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226 INTERNATIONAL CLINICS. 

tracheotomy) ; but a true tracheotomy below the isthmus of the thyroid 
gland would be exceedingly difficulty if indeed possible, in this subject 
I now pass this bullet-probe down into the left bronchus. It passes a 
distance much greater than I would suppose, about six inches, and the 
body is felt. This long alligator urethral forceps is now substituted 
for the probe. It does not so readily find the body. I think I feel it, 
however, as the forceps are withdrawn. It is evidently lodged beyond 
the primary bronchus, and this straight and stiff instrument passes it 
and goes off more to the left. I shall try to keep more directly down- 
wskd to the median line. It strikes a haixl substance, and I have 
opened and grasped something, but it gives so little on traction that I am 
b^inning to fear something else is grasped : however, it yields finally, 
and here is the shell. I was prepared to see something small, supposing 
it to be a small pistol-cartridge cap, but we have here a rifle shell (one 
and a fourth inches long by three-eighths of an inch in diameter). The 
fact that the closed end was downward and wedged so tightly into a 
secondary bronchus that a very distinct pull was necessary to dislodge 
it accounts for the physical signs of a part of the left lung undergoing 
consolidation and the extensive emphysema. I tie the retracting threads 
across, pulling the laryngeal incision together, and pack a little gauze 
into the outer incision. It might do to close both wounds, but, as con- 
siderable dirty bronchial secretion is being raised, it is perhaps better 
to dress it once in this open manner, and after two or three days the 
external wound may be pulled together. 

[The boy rapidly recovered, leaving the hospital eight days later. 
Fig. 4 represents the boy at the first dressing, three days after, with the 
forceps and shell held in approximately the direction from which the 
latter was removed, but the shell is represented about one inch too 
high. The emphysema had all disappeared.] 

A *' SUCCESSFUL" CCELIOTOMY REVIEWED. 

Our next case, now being etherized in the anteroom, is in many 
ways an exceedingly instructive one. It ought to impress on your 
minds a fact too often forgotten, — ^that operating is not necessarily the 
summum bonum of surgery. To use the knife skilfully may be an 
important qualification of the surgeon, but on the whole it is only 
one of many necessary accomplishments, and, I dare almost say, far 
firom the highest. 

I will read you the patient's anamnesis, as recorded by the house 
physician-surgeon. Alice S., American, aged eighteen. Father living, 
but has " lung trouble ;" mother living, has " rheumatism anc^ heart 



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CCELIOTOMY REVIEWED. 227 

troable ;" four brothers, all living, three healthy, " one is sickly ;" two 
sisters, one " pretty healthy," but the other had " bad spells" and died at 
twenty-four ; does not know the cause. The patient when nine years 
old fell from a horse, soon after which there was a slight flow of blood 
from the vagina. At fourteen she had typhoid fever, followed by in- 
flammation of the stomach and bowels. She b^an to menstruate at 
fifteen, and during her sixteenth and seventeenth years she was irregidar. 
She subsequently had a tape- worm removed, and she thinks that the 
head still remains and is growing. She had severe pains in the ovaries, 
and "bad spells," and in November, 1892, she had both ovaries re- 
moved. She was then in Kansas City. After this she was very well 
until September, 1893. Since then she has had severe pain in the uterus 
and the ovarian r^ion, and, she says, severe irr^nlar flowing : she 
states that it continued once for ten weeks. She has come here to have 
the uterus removed. This is all very indefinite ; but let us study it in 
conjunction with her physical state and her condition while m the hos- 
pital, as observed by disinterested parties. She was present two weeks 
ago, anxious for immediate hysterectomy ; but I would not think of 
judging o^ her case on so short an acquaintance. As she comes before 
you it is at once evident that the patient appears in excellent physical 
condition, — well nourished, of ruddy complexion, muscles firm and 
strong. The expression of her mouth " is that of a stubborn and bad 
disposition." Her appearance certainly belies any genuine martyrdom 
to pain or exhausting hemorrhage. During her two weeks in the hos- 
pital her appetite has been very good ; bowels regular ; there has been no 
uterine flow, and her demeanor has been somewhat insular, at times 
crying from pain, at others, when interested in some novelty in sur- 
roundings, very jolly, but on interrogation always sufiering. On the 
third day of her stay with us she had one of her " bad spells," the 
first since her operation. She became unconscious, breathing almost 
stopped ; after a few minutes she came out of it, with no biting of the 
tongue or frothing at the mouth. 

An anaesthetic has been given in order to make a thorough pelvic 
examination. In obscure cases the relaxation of anaesthesia enables us 
to make a very accurate bimanual palpation of all the pelvic organs, 
and I would impress upon you the great advantage of resorting to it 
in most cases in which the ordinary examination leaves you in doubt. 
In virgins, too, a proper examination when necessary is made with 
less pain, more success, and less sliock to modesty, by giving an an- 
feethetic The cervix is found to be lacerated, presumably by some 
dilating operation. The uterus, normal in size, is normally located and 



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228 INTERNATIONAL CLINICS. 

movable, except that the fundus appears to be somewhat attached by 
adhesions behind the pubes, and I should judge that a hysteropexy 
had been performed when the ovaries were removed. There are no 
discoverable thickenings or exudations about the pelvis. A curette is 
carried into the uterine cavity, and the interior is, so far as I can dis- 
cover, healthy. That is all I wish to do with the patient. She may be 
removed while we consider her case. If her uterus is to be removal, I 
prefer that some one else shall do it. 

Now, I am very suspicious of patients presenting so much com- 
plaint and so little discoverable organic disease. Sometimes shiftless 
£imilies with insufficient healthy exercise of body and mind all 
"enjoy poor health." A young lady, very miserable in appearance 
and full of trouble, brought to me a long story of medical treatment 
After considerable observation tending to show a large neurotic ele- 
ment in her case, a sister, equally miserable, came with her. I then 
said to her, "Is it not a fact that your whole family habitually 
spend most 'of their energies in being sickly and in complaining?'' 
She confessed that it was a family trait, that the mother had always 
been ailing, and that the various ills to which women are heirs were 
the chief topics of consideration. The whole atmosphere in which 
she had lived had been one of dyspepsia, nervousness, and complaint. 
The advice to quit medicine and to go to live out of doors with some 
healthy and sensible persons for six weeks worked more benefit than 
she had before experienced. This was accomplished only by chance, as 
such sufferers are generally inseparable. They ordinarily believe that 
they cannot live apart, and advance a multitude of reasons for this 
belief. The one cannot get along without the other. Now, as to the 
girl who has just gone out, she may suffer with pain and excessive and 
disturbed menstruation from the fixation of her uterus. I take it that 
she was a neurotic girl of wild and untrained emotional and mental 
make-up, probably with uterine displacement. That she was well for 
a time after her ovaries were removed was probably due to a temporary 
change of her circumstances rather than to the operation. Then a 
change comes over her capricious dreams, and she again becomes an 
injteresting invalid. I would not say that the adhesions of her uterus 
may not cause pain, but it may be questioned whether releasing these 
for new ones to form will make matters better. All that I know is 
that one of the greatest abdominal surgeons in the world, after telling 
us that the uterus cannot be hitched up like a horse, very skilfully 
released the adhesions in a similar case, but the patient pursued the 
even tenor of her complaints just as before. After a very limited 



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229 

experience in fastening retrofleeted uteri to the anterior abdominal 
wall, I have decided to do so no more. I shall advise this girl to live 
properly and let medicine and surgery alone. 

Perhaps I ought not to say much of this case, as I have little to do 
with strict gynaecology. The abdominal work within my experience 
has been chiefly for everything else rather than for tubal and slight 
ovarian troubles; but the score or two of stray cases of this kind 
which I have operated upon, as well as those examined after operation 
by others, have taught me some unpleasant lessons, which I give for 
what they may be worth. One is, to have nothing to do with such 
operations for neuroses, or in persons not presenting very distinct and 
dangerous organic diseases, and to be especially shy of women with a 
maximum of complaint and a minimum of discoverable cause or ob- 
jective symptoms. Some seven years ago I saw a womao in consultation 
who had been long invalided. I could discover little wrong with her 
ovaries. (They were somewhat enlarged and full of small cysts.) With 
some hesitation I coi^/sented, on the advice of several consultants, to 
remove them. For a time she did well ; then came a &mily unpleasant- 
ness, and she stepped back into her bed. Then she wrote me, describing 
terrible pains and " bearing-down sensations,'* and wished me to remove 
her uterus. I wrote her frankly that I had become wiser, that her 
trouble was more in her head than in her uterus, and that the sooner 
she put her trust in philosophy and sense rather than in medicine and 
surgery, the better for her and for all concerned. Since then I have 
learned that she has been several times '^ cured*' by mind-cures and 
other humbugs less troublesome and quite as successful as coeliotomy 
in such cases. This class of cases no longer '^ fool" the initiate. A 
larger class are those with more or less organic tubal and pelvic dis- 
ease, but with complaints out of proportion to the organic trouble. 
Possibly operations are here justifiable, but the results are not very 
prompt, to say the least. It has been my observation that they oflen 
offer about as much (X)mplaint for a few months or years afler opera- 
tion as before. In other words, they nm about the ordinary course 
of the trouble with which they are affected, unless, forsooth, new ones 
are superadded by some accident of the operation. 

In a field in which I feel more competent to speak I meet with men 
cranked on the subject of their genitals. There I feel competent to say 
that the trouble is often chiefly or solely the result of self-introspection. 
In the majority of cases the trouble is much more largely mental, 
nervous, and dyspeptic than local ; and only rarely is the disease chiefly 
a local one. It is certainly not rare to meet with dyspeptic or neuras- 



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230 INTERNATIONAL CLINICS. _ ^ 

thenic women who, by suggestion, have come to look upon their wombs 
as the source of all their woes, even such as arise from such diverse 
sources as bad habits, jealousy, overwork, abuse, prostration from 
various acute and chronic disorders, or what not Occasionally we 
meet with morbid individuals wholly occupied with introspection, who 
are so intensely concentrated upon self that they make an industry, as 
it were, of being ill. Classify it as we may, or build what fine theories 
we will, the practical fact remains that the best cure is to have them 
early launched upon the bark of self-support, with no one to lie down on, 
equally unfed by misplaced sympathy and unirritated by unjust abuse, 
but stimulated by rational and just kindness, and surrounded by a sane 
physical, mental, and moral environment. A system of treatment is 
perhaps of more importance than the system. If good sense could be 
furnished on prescription to such sufferers and those around them, the 
management of such cases would be much easier and more effective 
than it is at present. 

[Note. — The girl was very buoyant in spirits, even happy, after 
her " operation," until her departure a week later. She inquired if she 
was in a condition to marry. She shortly turned up for treatment at 
the office of another physician whom she had met at the hospital. She 
reported her appetite poor, but her Jocks and a relative denied it. 
There was now a moderate bloody flow from the uterus, probably 
menstrual, as it is not very rare in my experience for menstruation 
to continue after complete removal of the tubes and ovaries. She 
declared that she was engaged to be married, but would not wed until 
she was properly cured and in good condition. During all her com- 
plaints diversion of her attention brought a momentary laugh, and 
the points of greatest tenderness, on examination, were very indefinite 
and changeable.] 



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QE^^nita-IKrinart) anh Venereal 

TUMORS OF THE BLADDER. 

CLINICAL LECTUBS DBLIYSBBD AT THS aSMBRAL HOSPITAL, BIBlflNaHAM. 

BY GILBERT BARLING, ti'.R.C.S., 

Professor of Surgery in Mason College, England. 



Gentlemen, — Cases of tumor of the bladder present themselves 
somewhat infreqaentlj, and, as we have at present a patient just re- 
covering from an operation for this condition, I take this opportunity 
to discuss the matter with you to-day. 

Let me first appeal to my note-books for reports of past cases. 
One of the most remarkable occurred some years ago, when I was 
resident surgical officer at the I^ospital. 

A young man, aged sixteen, first came under my notice in June, 

1881, when he gave a history of hsematuria, intermittent in character, 
extending over a period of ten years. During that time there had 
been intervals of months, weeks, or hours in which no bleeding occurred. 
The attacks arose without any definite cause, and they disappeared as 
suddenly. Clots had been seen in his urine, and when pressed the 
patient called to mind that he had passed ^' bits of gristle" with sharp 
pain. On admission he was sufiering from an attack of bleeding of 
great severity, the urine having been almost the color of porter for 
about a fortnight ; he was very exsanguine, sufiered from dyspnoea with 
the least exertion, and had &inted eight or nine times recently. On 
one occasion before admission he was unable to pass any water for nearly 
two days, and obtained relief by jumping into a very hot bath : this 
was the only occasion on which retention had occurred. Pain was not 
a marked feature in the case, but there was some felt during and after 
micturition, and it was situated in the hypogastrium and perineum. 
Sounding revealed nothing, and frequent examination of the urine 
showed blood only. No definite diagnosis was arrived at, but during 
the next year the patient was kept under observation, and on July 31, 

1882, he was readmitted for hsematuria. During this time every 

^ 2ni 



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232 INTERNATIONAL CLINICS. 

medicine which has any repute as a haemostatic was used, bat without 
any evident advantage. Constant search was made in the urine every 
day for fragments of a suspected neoplasm, and on August 7 a piece 
of tissue the size of a large hazel-nut was found, and this examined 
microscopically showed that it had been part of a fimbriated papilloma. 
The diagnosis now being cleared up, Mr. Jolly, the surgeon in whose 
care the patient was, performed a median perineal section, and removed 
with nasal polypus forceps, ring forceps, and scoop a number of poly- 
poid growths scattered widely over the bladder. The patient left the 
hospital well about six weeks after. Three years later he was read- 
mitted with hsematuria of slight severity, which had occurred several 
times during the previous three months. Perineal section was again 
performed, and a small quantity of simple papillomatous growth was 
removed, the patient again making a good recovery. I made inquiries 
about him again three years later, when he presented himself for 
examination in thoroughly robust health, free fi*om hsematuria, but 
with an occasional pain at the end of micturition. This patient was 
treated in this way during what might be called pre-cystoscopio 
days. 

The next case is one of a similar kind of growth, but, occurring 
much more recently, was much more easily and earlier diagnosed. A 
man, aged forty-five, was admitted to the hospital under my care on 
January 14, 1892, with a history of hsematuria for the first time nine 
months before. At that time he had noticed a quantity of blood in 
his urine for about forty-eight hours, and this was associated with a 
certain amount of pain ; six months later he had a similar attack. On 
admission there was a considerable quantity of blood in the urine, 
generally mixed equally with the urine, but on the last occasion of 
voiding the blood appeared only at the end of micturition, and pain 
of a smarting character was felt at the base of the penis ; there was 
slight increase in the fi^uency of micturition. On January 18, the 
urine being quite fi'ee fi-om blood, the patient was examined with the 
cystoscope, when a branching delicate papillomatous growth was seen 
on the floor of the bladder, just behind the trigone and close to the 
orifice of the right ureter. Its fimbrise were of a delicate pinkish color ; 
there was no solid formation, no ulceration or necrosis ; a pedicle was 
not seen. A week later, suprapubic section was performed and the 
tumor found to be attached by a single delicate pedicle close to the 
right ureteral orifice. The pedicle was divided with scissors, and there 
was hardly any bleeding : the wound was healed in three weeks. I 
learn that the patient remains quite well. I show you this patient's 



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V^T 



Pia. 3.<-FIbro-papllloma of the bladder removed by suprapubic sectloo, divided and held 

apart at a. 




Fig. 4.-Multiple tumor of the bladder-flbro-myxomata (ajP'^'^®^ ^^ VjOOg IC 



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TUMOBS OP THE BLADDER. 



233 



tumor (Fig. 1), and a specimen (Fig. 2) which illustrates a similar 
growth : this is multiple and could have easily been dealt with. 

The next case I wish to mention is a patient now in the hospital. 
She is a woman, aged thirty-two, married six years, but never preg- 
nant, and suffered a first attack of hsematuria a little more than three 
years ago ; this was followed speedily by frequent and painful micturi- 
tion. The bladder .was sounded at another institution, and, no stone 
being found, it was washed out several times, which gave relief. The 
patient renuuned fairly well until three months ago, when blood again 
appeared in the urine and severe pain after micturition also came on. 



Fig. 1. 



Fig, 2. 




Polypoid tamor of bladder ramoTed 
by Mr. Jolly. 



Polypoid tumors of bladder. 



On admission the patient was very ansemic, emaciated, and cachectic ; 
the urine contained a good deal of matter, but no appreciable quantity 
of blood, only occasionally a few drops of blood appeared aft^er mic- 
turition. She passed urine every hour, day and night, sometimes even 
oftener, and there was pain in the urethra before, during, and afi«r tlie 
act. On October 19, on examination with the cystosoope under an 
anaesthetic after gentle irrigation of the bladder, I found an almost 
complete collar of papillomatous growth surrounding the internal 
orifice of the urethra. The growth extended from this backward 
along the floor and up the left side of the bladder, wliere there was a 



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234 INTERNATIONAL CLINICS. 

raised patch of considerable size, in the centre of which was a dead 
yellowish- white patch looking like a piece of necrotic growth. Ex- 
amining bimanually, an elastic tumor of considerable size could be 
palpated between the two hands. It did not appear to infiltrate the 
walls of the bladder, nor was there any fixation of the pelvic tissues. 
October 30, suprapubic section was performed and a growth the size 
of a small orange, sessile on the bladder wall, buj; not indurated, was 
removed with various forms of forceps and scissors. A considerable 
amount of blood was lost, but there was no difficulty in controlling 
the hemorrhage by hot douching and sponge-pressure. The patient 
did fairly well till November 1, when she had pain in the lower part 
of the abdomen, which was tender, rigid, and distended; there was 
frequent vomiting, with quick pulse and anxious face. Peritonitis 
being diagnosed, purgatives and turpentine enemata were freely ad- 
ministered, and, though the bowels did not act, flatus was voided, and 
by November 5 all threatening symptoms had passed away. Con- 
valescence was interrupted, however, by two terrible attacks of pul- 
monary embolism on November 7 and 8. For three days the patient's 
life was in the greatest jeopardy ; but from that time till now she has 
made a steady recovery. Her wound is now healed, she holds her 
urine from three to four hours, she has hardly any discomfort, there is 
no blood in the urine, and she has gained flesh rapidly, so that you can 
have no conception of the wretched condition she was in before opera- 
tion. Examination of this growth shows it to be a fibro-papilloma, 
and I have here a specimen (Fig. 3) which illustrates this form of 
growth extremely well. It shows the base or pedicle of the tumor 
separated into two halves, which blend intimately with the coats of the 
bladder. 

These three cases, then, may be taken as typical of the tumors spoken 
of as papillomata, which afibrd us the most successful and satisfactory 
cases for operation. The great feature of these, dwelling on their 
symptoms, is hsematuria, though you will observe that in the more 
solid growth in the third case symptoms sometimes described as 
bladder irritation speedily followed. 

Let me now very briefly mention to you a case of another innocent 
form of tumor to contrast with these, in which the main symptom is 
irritation of the bladder, — that is, pain and frequent micturition. This 
is an example of fibro-myxoma, and I show you the specimen (Fig. 
4). A male, aged four, was admitted to the hospital with almost in- 
cessant micturition and great pain and in a very emaciated and cachectic 
cojidition. Blood had not at any time been seen in his urine, but on 



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TUMORS OF THE BLADDER. 235 

one occasion he passed by the urethra a small substance which looked 
like a black grape. Sounding detected no stone, and from the passing 
of some foreign body it was surmised that there might be a tumor in 
the bladder. The wretched condition of the child forbade any explo- 
ratory operation, and he died in a few days. The post-mortem exami- 
nation revealed a patch of polypoid growth attached over a surface two 
and a half inches square, spread over the posterior and inferior walls 
of the bladder. Some of the growths had narrow pedicles and were 
as large as the end of the finger, others were much smaller and sessile, 
the mucous membrane around being like thick wash-leather. To the 
naked eye the tumors looked when fresh like nasal polypi, and it 
could be seen that they were connected only with the mucous mem- 
brane, which could be stripped off, leaving the other coats healthy. 
The specimen shows the general appearance of the tumor. There are 
a few other tumors, fibromas, myomas^ and dermoids, which have a 
history similar to this. 

Let me now relate a case to illustrate another clinical variety of 
bladder tumor, a malignant form. 

A male, aged fifly-one, was admitted to the hospital on May 16, 1892, 
complaining of difficulty in passing water and of pain under his penis 
after he had passed it, and of clots of blood in his urine. His history 
showed that he had passed blood for the first time three years before, 
and at intervals of varying length ever since. Some time later he had 
pain and frequent micturition, but he was quite certain that the hsema- 
turia preceded the other symptoms. The pain now is at the end of 
the penis when he passes water ; he also has pain in the loins. The 
frequency of micturition is both by day and by night. Examination 
with the cystoscope showed a wide-based growth attached to the floor 
and posterior wall of the bladder ; this was ulcerated in the centre. 
The finger detected thickening and infiltration in the floor of the 
bladder. The growth being diagnosed as malignant, the patient was 
advised not to have an operation done unless his symptoms of pain 
and frequency of micturition became more severe. In about a month 
he returned b^ging for relief from his pain and frequency : so on July 
4 a suprapubic cystotomy was done, and the growth scraped away down 
to its base with a sharp spoon. In three weeks all the urine was pass- 
ing by the urethra, the patient was free from pain, and the frequency 
of micturition was much less marked than before the operation. On 
July 31 the wound, which had quite healed, broke open again, and 
from this time on there was a steady increase of pain, firequency, and 
loss of condition. The first week in September there were rigors and 



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236 



INTERNATIONAL CLINICS. 



FiQ. 6. 



vomiting, and masses of growth b^an to project through the suprapubic 
opening : the patient died at the end of September. The post-mortem 
showed that the whole cavity of the bladder was filled with a growth 
which had involved the tissues of the wound. Both ureters and kidney 
pelves were dilated, and both kidneys were in a state of pyelo-nephritis. 
Microscopically the growth was an alveolar carcinoma. The photo- 
graph (Fig. 5) of an epithelioma shows the flat, thick-edged, sessile 
tumor which is characteristic of malignancy. 

These cases illustrate, then, the three chief groups of bladder growths, 
— the innocent group, which chiefly gives rise to hemorrhage ; the second 

innocent group, in which hsema- 
turia is slight or passing, and 
pain and frequent micturition 
are the chief features; and the 
third group, the malignant, in 
which painless hemorrhage is 
nearly always the first symp- 
tom, though it is speedily fol- 
lowed by painful and frequent 
micturition. 

When a patient presents 
himself or herself with symi>- 
toms suggestive of bladder tu- 
mor, we have by careful in- 
vestigation to determine the 
presence of a growth, and, if 
possible (and it generally is 
possible), whether that growth is innocent or malignant, and how it is 
to be dealt with. In arriving at a diagnosis we weigh the signs and 
symptoms presented, and we resort to physical examination. I propose 
to consider the various points which present themselves for investiga- 
tion, and the first I shall deal with is haematuria. You will apprec*iate 
the importance of this symptom when I tell you that in seventy-five per 
cent, of all cases of tumors of the bladder hsematuria is the first symp- 
tom. Other symptoms may arise later on, but in many papillomata there 
is no other indication of the presence of a tumor. The hsematuria may 
be slight, or severe, so much so as to make the patient quite faint if he 
gets out of bed, as in the first case I related to you, but the amount of 
bleeding is no criterion as to the size of the tumor. In one patient, 
between sixty and seventy years of age, upon whom I operated, there 
was a severe attack of hsematuria lasting nearly eighteen days, and yet 




Epithelioma of the bladder. 



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TUMORS OP THE BLADDER. 237 

the papilloma which gave rise to it did not weigh altogether a drachm. 
One feature, which in a certain number of cases differentiates the 
haematuria of tumors of the bladder from that caused by other con- 
ditions, is that the bleeding may take place only towards the end of the 
act of micturition, or at all events the amount of bleeding is much 
increased then, owing to the obstructiou of the venous return from the 
growth, or else to the actual involvement of the growth in the urethral 
orifice. In a certain number of cases of papilloma the intermittent 
hemorrhage unaccompanied by other symptoms (unless there be slight 
increase in frequency and some pain due to the passage of clots) is 
most characteristic, and is paralleled only by the bleeding which occurs 
in some few cases of malignant growth of the kidneys. Besides being 
intermittent and symptomless, the hemorrhage in the cases I have just 
alluded to is capricious : it comes without apparent cause and disappears 
in the same way ; it is practically uninfluenced by drugs ; it may last 
an hour, a day, or a week, and the intervals between the various attacks 
are just as uncertain. Such hemorrhage as I have been speaking of 
may be present in any malignant groAvth of the bladder, but at the 
end of a few months pain and frequent micturition, often due to cystitis, 
arrive, and trouble the patient much more than the bleeding. This is 
not always so in malignant growths, and depends to some extent upon 
the nature and situation of such growths; for instance, I operated upon 
a patient in pre-cystoscopic days, in whom for two years intermittent 
symptomless hemorrhage had occurred suggesting {lapilloma, but on 
opening the bladder I found at its vertex an ulcerating growth of 
limited extent, which proved to be a typical scirrhous carcinoma, a 
growth very rarely seen in the bladder. The absence of pain and the 
frequency of the hemorrhage were doubtless due to the growth being 
situated in a locality distant from the usual one — the floor of the 
bladder. 

Pain and frequent micturition are often merely the indications of 
cystitis, which comes on early in malignant growths and in the firm 
innocent growths, such as the myxoma I mentioned to you. Cystitis is 
not common in connection with papilloma, though it may arise when 
the growth has existed for some time, perhaps not till the end of years. 
Patients with the more solid forms of papilloma, however, as, for ex- 
ample, the case of fibro-papilloma I related to you, may early suffer 
from cystitis and its results, pain and frequency. When pain is present 
it is most oft;eu associated with the act of micturition, and is especially 
felt towards the end of the penis. It may, however, trouble the 
patient at other times, and may be felt in the perineum, in the rectum, 



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238 INTERNATIONAL CLINICS. 

and down the thighs^ or it may be experienced as a dull ache above the 
pubes. It is always necessary to ascertain whether the pain is due 
simply to the passage of clots along the urethra ; otherwise a wrong 
conclusion may be drawn from it The frequency of micturition is 
very variable, sometimes only a moderate increase on the normal state, 
at others so frequent that the patient's rest is constantly broken by it, 
and at last life may become unbearable from the incessant demands to 
empty the bladder. With r^ard to frequency it must be borne in mind 
that the presence of blood from an innocent tumor may cause some 
increased frequency, which passes off as the hemorrhage subsides, and 
must not be misinterpreted as meaning that a more formidable growth 
exists. Pain and frequent micturition, usually secondary to hemor- 
rhage in their appearance, may be the earliest symptoms, and if so they 
suggest an innocent tumor of solid formation, or a malignant growth. 

Retention of urine, may occur from a portion of growth becoming 
impacted in the internal orifice of the urethra, as happened in the first 
case I related to you. In the same way the patient may suffer from a 
sudden interruption of the flow of urine when he is micturating, as 
does a patient with stone, owing to the foreign body corking the urethra 
and then being displaced, when the urine again flows. Sometimes 
dribbling of urine may occur, either an overflow or a true incon- 
tinence. The first is due to an over-distended bladder with growths 
in its orifice, by the side of which a little urine manages to escape ; the 
second may be due to absolute inexpansibility of the bladder from in- 
filtration of the growth in its walls, or in the female to a massive tumor, 
such as a fibroma, being gradually forced through the urethra, some- 
times until it appears externally. 

When a tumor is suspected, the urine should be constantly ex- 
amined for the presence of fragments which may be passed, as 
occurred in two of the cases I have mentioned to you : this accident is 
most likely to occur in papilloma, but it may occur in any kind of 
tumor. To detect fragments, all the urine the patient passes, especially 
when an attack of bleeding is on, should be carefully collected every 
day, and the surgeon himself should pour it from one vessel into 
another, looking carefully in any sediment which may remain, and, if 
necessary, breaking up any clots of blood which may hide what he is 
seeking for. It is, of course, impossible to overrate the value of the 
evidence which a fragment gives as to the presence of a growth, pro- 
vided it is examined by a person competent to give an opinion upon it 
under the microscope, — ^to show, in fact, that it is not an accidental 
foreign body. When it comes to the naiure of the growth, however, 



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TUMORS OF THE BLADDER. 239 

it mu8t not be concluded that the tumor in the bladder is of the same 
nature as the fragment which has been shed. The fragment is no 
doubt most commonly of the same nature as the bulk of the tumor, 
but to this there are many exceptions, and from the surface of malig- 
nant growths fragments may be separated which, examined microscopi- 
cally, are nothing more than simple papilloma. Again, do not commit 
yourselves to a diagnosis of malignant growth because of certain irreg- 
ular shaped and sized epithelial cells in the urine, which occasionally 
betray the inexperienced into speaking of them as "cancer-cells.'' 
From the urinary passages generally very various epithelia may be 
shed, and the knowledge of this should put us on our guard. 

Thus far I have been speaking of the information to be obtained 
by interrogating the patient and by examining the urine. I now come 
to what may be learned by physical examination. The first method 
resorted to generally is the use of the sound. The evidence obtained 
by this instrument is usually n^ative, — that is, we learn that there is no 
stone present to cause the symptoms, and we may learn nothing more 
than this ; on the contrary, though no stone may be found, irr^ular 
solid projections may be recognized, and subsequently sharp haematuria 
may follow, showing that some growth has been abraded by the 
sound. When the instrument is in the bladder, the finger introduced 
into the rectum may recognize thickening and infiltration about the 
base of the organ. Objection has been taken to the use of the sound 
in the diagnosis of tumor of the bladder. When the chief symptom 
is hemorrhage, such as suggests papilloma, I never trust to sounding 
to tell me anything, but resort to tiie use of the cystosoope forthwith. 
When the symptoms are mainly pain and frequent micturition, the 
exclusion of stone is the first business, and then the sound must be 
employed, and this, of course, is especially true where cystosoopic ex- 
amination cannot be provided. Bimanual examination should also be 
instituted, to tell the physical character of the growth if it may be 
learned in this way. With one hand above the pubes, and the fingers 
of the other in the rectum or the vagina, according to the sex of the 
patient, a tumor of any consistency and size may be recognized if the 
patient is under an ansesthetic. This method of examination will also 
tell whether a tumor infiltrates the floor of the bladder, giving a dense 
leathery nodulated feeling, and whether it fixes the lateral walls of the 
bladder to adjacent parts, either of these conditions, of course, indi- 
cating malignancy. 

And now I must point out the value of our modem instrument 
the electric cystoscope. This, like other instruments of precision, as 



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240 INTERNATIONAL CLINICS. 

the laryngoscope and the ophthalmoscope, is limited in its utility, (I) by 
the conditions present which facilitate or prevent thorough examina- 
tion ; (2) by the skill of the individual observer, who must be able to 
interpret correctly what he sees. In the adult with normal patency 
of the urethra, there is no difficulty in introducing the cystoscope into 
the bladder, even when there is considerable enlargement of the pros- 
tate. When an examination is attempted, the fluid in the bladder must 
be free from blood and pus, either of which even in small quantities 
obscures the field, and nothing is learned. It is hardly necessaiy to say 
that before the cystoscope is introduced care should be taken to see 
that the battery is working efficiently, that the lamp is secure, and that 
all the connections are perfect. All the above conditions being com- 
plied with, we may learn first of all that a tumor is present, perhaps 
how it is attached, whether by a pedicle or otherwise, the exact site of 
the attachment, whether the growth is ulcerated or not, and, with some 
degree of probability, whether it is innocent or malignant. The more 
distinctly pedunculated a tumor is, the more likely it is to be innocent ; 
the more delicate its papillae, and the more they ai^ localized to one 
part of the bladder, the greater is the presumption of innooency. When 
the tumor is sessile, when instead of delicate papillse we have raised 
bossy masses giving the appearance of a solid oedema, and especially 
if there is ulceration, the indications point to malignant growth. 
Summing up the value of the cystoscope, under suitable conditions it 
is impossible to overrate it. Its great virtue is that it tells almost 
with absolute certainty whether a tumor is or is not present. I said 
that the value of this instrument, when it is really available, cannot be 
overrated, and I emphasize this by pointing out to you five conditions 
which are most likely to be confounded with tumors of the bladder, 
and in which exclusion of tumor is of the utmost importance : these 
are sarcoma of the kidney, stone in the kidney, granular kidney with 
severe hemorrhage, tuberculosis of the kidneys commencing, as it occa- 
sionally does, with severe bleeding, and hsematuria in a hsemophilic 
subject 

TreatmerU. — ^Whether this is to be operative or not will depend 
upon the opinion formed as to the nature of the tumor. If it is believed 
to be innocent, it should be removed if the patient's general condition 
permits. If the characters are distinctly those of a malignant growth, 
as a rule operation is not called for; the exceptions to this rule will be 
dealt with later. 

As a very large proportion of tqmors of the bladder are located 
on the floor and parts adjacent, it seems at first sight reasonable to 



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TUMORS OF THE BLADDER. 241 

approach them by a perineal opening ; but this method is deservedly 
falling into disuse. In elderly men with deep perineums, the finger 
introduced by a median opening may fail to recognize the presence 
of a growth, because the tip of the finger only just reaches into 
the bladder. Even when the finger can fully explore the viscus, the 
repeated introduction of fingers and instruments through the peri- 
neal opening, with the unavoidable bruising and laceration of the parts, 
renders the operation, in my opinion, more serious than suprapubic 
section, which should be the routine method adopted. This, when the 
patient is in the Trendelenburg position, gives free access to the bladder- 
cavity for the manipulation of instruments, and especially so if the 
attachments of the recti are divided, and by the introduction of retrac- 
tors or of a large Fergusson's speculum, and the aid of electric light, 
the tumor may be exposed to direct observation. It is not necessary 
for me to dwell upon the details of the suprapubic section, with which 
you no doubt are all familiar from seeing it done so often here. 

The bladder being opened, various instruments may be used to 
remove the growth. If it has a slight pedicle, it may be snipped ofi* 
with scissors curved on the flat, or it may be evulsed with nasal polypus 
forceps. If its base be more solid, but still pedunculated, it may be 
snared with wire, and this may be more effectually done if a perineal 
opening be made through which the snare can be introduced, the fingers 
above the pubes manipulating it round the base of the growth. For 
tumors such as the fibro-papilloma of Case III., Thompson's forceps for 
evulsing the tumor in fragments are useful. 

If the tumor has been diagnosed as malignant, an operation is called 
for under two conditions : the first is when the growth is so limited in 
extent, and located in such a part of the bladder, as to justify the belief 
that it can be extirpated completely. The other condition is when a 
tumor too extensive to be completely removed is yet causing the 
patient so much distress, from pain, frequent micturition, and bleeding, 
that some relief has to be given to make life bearable. 

I have now only to say a few words as to the prognosis of bladder 
tumors. Complete and permanent cure by the excision of a malignant 
growth is 80 rare that it need scarcely enter into our calculations. At 
the same time it is necessary to remark that the progress of many 
malignant growths is slow, the mean duration being about three years, 
and the tendency to secondary infection of the viscera and glands is 
slight. The prognosis in papilloma is better than in any other form of 
tumor, but cases accurately recorded show that occasionally a papilloma 
becomes carcinomatous, as, for instance, one published by Mr. Alexan- 
Vol. I. Ser. 4.— 16 



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242 INTERNATIONAL CLINICS. 

der in the Ixmcety vol. xvii. p. 8, 1878. More important than this rare 
oocairenoe is the tendency of the firmer papillomas to recur. This 
will^ I expect^ be the case with the female patient whom I have shown 
you to-day, and in such it not infrequently happens that two or three 
recurrences take place which can be removed, and then at last a recur- 
rence so extensive is produced as to be beyond relief by operation. In 
a case such as the second I related to you the prognosis is extremely 
good. Cases are occasionally recorded of papilloma of the bladder 
and of some of the other innocent forms going on for many years ; for 
instance, in the first case I described to you, symptoms had existed for 
ten years. It may not unreasonably be asked, why interfere with 
tumors which seem to have the capacity of doing so little harm ? The 
answer is, that almost invariably secondary dilative and inflammatory 
changes are set up in the ureters and kidneys, producing hydronephro- 
sis and pyonephrosis, which will eventually kill the patient, or will 
militate against a successful operation if the growth be left until along 
time has elapsed. 



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THE RESULT OF A PRETENDED OPERATION UPON 
A PATIENT SUFFERING FROM A DELUSION OF 
A SEXUAL CHARACTER; OPERATION FOR THE 
CURE OF EPISPADIAS; CASE OF PERINEAL 
SECTION FOR TRAUMATIC STRICTURE, WITH 
A DESCRIPTION OF A NEW FORM OF PERINEAL 
STAFF; NEW METHOD OF TREATING A RE- 
SILIENT AND NODULAR STRICTURE OF THE 
PENILE PORTION OF THE URETHRA. 

CLIVICAL LBCTUBS DBLIYKKBI) AT THE JEFFXB0ON MEDICAL COLLEGE HOSPITAL. 

BY ORVILLB HORWITZ, B.8., M.D., 

Clinical Profesior of Genito-Urinary Diseases in Jeffenon Medical College ; Surgeon 
to the Philadelphia Hospital, etc 



Qentlemen, — ^The first case that I bring before the class to-daj 
is that of an individual who applied for relief at this institution five 
years ago. At that time he was suffering with spermatorrhoea dormi- 
allium^ or nocturnal pollution^ accompanied by well-marked neuras- 
thenia. I call your attention to the case not only because it is one of 
great interest from a psychological point of view^ but also because it 
illustrates what I have so frequently insisted upon when lecturing 
upon the treatment of individuals whose condition was similar to that 
of this person now before you ; that is^ that in order to benefit these 
cases every effort should be made to gain the confidence of the patient^ 
and all your tact must be employed to allay his fears until the dis- 
ordered nervous system r^ains its tone. You must ever be ready to 
meet all complications which from time to time will arise. 

This individual is twenty-eight years old. He is a carpenter. 
When he applied to the surgical department of this hospital he asked to 
have his testicles removed, believing that it was the only way whereby 
the seminal discharges might be stopped, and saying that their continual 
recurrence was undermining his health, and that his reason would be 

248 



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244 INTERNATIONAL CLINICS. 

destroyed unless he was relieved. He stated that the various methods 
of treatment resorted to by numerous practitioners had all &iled to 
benefit him. His condition bad preyed upon his mind to such an 
extent that he declared that unless he could find some one who would 
be willing to castrate him, he would himself perform the operation. 
Six months previously he had attempted excision of the scrotum, but 
after making an incision his courage failed him. You may readily ob- 
serve the scar resulting from this attempt at emasculation. The scars 
that you see on the body of the penis are the results of ulcerations 
produced by acids employed to render the organ sore, so as to make 
masturbation impossible. At the age of sixteen he had contracted the 
habit of self-pollution, which he had continued until the time of his 
application for treatment He attributed his condition to this unfortu- 
nate practice. 

His nocturnal emissions occurred as often as three times weekly ; he 
occasionally experienced pain along the course of the urethra, extend- 
ing into the spermatic cords and testicles. He urinated with abnormal 
frequency. 

He stated that his appetite was poor ; that he had a feeling of 
gastric depression ; that his sleep was neither sound nor refreshing. 
He was oppressed by heavy pains in the groin, lumbar r^ion, and 
back of the head ; there was great mental hebetude ; he was easily 
fatigued ; his hand was unsteady ; he had an anxious look ; was 
markedly anaemic. When a seminal discharge took place it was 
followed by unusual depression and lassitude, with increased pains. 

The urethra was intensely hyperaesthetic, especially the prostatic 
portion. The meatus was contracted; there was no stricture. The 
prepuce was elongated. 

The individual was placed upon full doses of bromide of potas- 
sium and fluid extract of ergot, atropine being given at bedtime ; hot 
douches were applied to the spine, and a bougie was passed every third 
day. 

Under this treatment the emissions lessened in frequency, and, in 
&ct, became normal ; that is, they occurred about once in two weeks. 

The patient's mental condition remained unimproved, and when- 
ever a seminal discharge took place he was plunged into the depths of 
despondency. 

Observing that he was not improving mentally, and fearing that, 
unless some means was resorted to that would make a strong impression 
upon him, he would either become insane or do himself bodily injury, I 
resolved to perform upon him a pretended or bogus operation. Both 



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Fio. 1.— Epispadias, before operation. 




Fio. 2.— Perfect union, nine days aAer operation, igi^ized by 



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A DELUSION OF A SEXUAL CHARACTER. 246 

the mother and the patient had frequently b^ged me to remove his 
testicles. 

By means of anatomical plates, he was made to understand that 
absolute removal of the testicles was not necessary, but that the object 
sought for would be accomplished if the vasa deferentia were divided. 
It was furthermore explained to him, so that the delusion might be 
carried out, that after the operation he must expect that emissions would, 
from time to time, take place, which, however, would be only mucoid 
in character, and that whilst this discharge would simulate a nocturnal 
emission, it could contain no semen. 

He was much pleased with the suggestion, and was glad to believe 
that the functions of the testicles could be destroyed without marked 
mutilation. 

The parts having been properly prepared, he was etherized, and an 
incision three and a half inches in length was made over each abdom- 
inal ring, care being taken npt to cut deeper than through the skin 
and superficial fascia. The wound was closed with sutures, and prop- 
erly dressed. To produce greater mental effect, he was circumcised, 
and to control nocturnal pollutions, if possible, an application of a few 
drops of a solution of twenty grains of nitrate of silver to an ounce 
of water was made to the prostatic urethra. 

He was kept in bed for the space of two weeks, that he might be 
fully impressed with the gravity of the operation. Doses of bromide 
of sodium and atropine were administered at bedtime. 

After leaving the hospital he remained under my care for the space 
of four months. A full-size bougie was passed twice a week. He 
was placed upon the use of strychnine and the chlorides of gold and 
sodium, and an ice-bag was applied over the lower portion of the 
spine for one hour every night before retiring. 

His neurasthenic condition rapidly improved. He gained in weight 
and in strength, and finally resumed his occupation, perfectly cured. 

A year after all treatment had been discontinued, he called at my 
office in apparently perfect health, but looking very sheepish. After 
talking around the subject for some time, he stated that he had &llen 
in love with a young woman and wished to marry her, provided I 
could put him in proper condition by cutting down and &stening 
together the severed ends of the vasa deferentia. The exhibition of 
his inordinate joy, together with his astonishment, was very amusing 
when he understood that the ducts had never been cut, and that he 
could become a married man whenever he saw fit. He is now the 
fietther of two children and enjoys perfect health. 



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246 INTERNATIONAL CLINICS. 

This patient suffered from intense hypersesthesia of the urethra, 
brought on by excessive masturbation ; the hypersesthetic condition of 
the canal in time caused an irritable condition of the ejaculatoiy 
centre and an anaemic state of the lumbar portion of the cord, known 
as neurasthenia. 

Now, as regards the treatment pursued. The first point was to 
remove the cause of trouble, by restoring the urethra to its normal 
condition. It will be observed that whilst the patient steadily im- 
proved physically, his mind remained in a morbid state : hence the 
necessity for producing a strong mental impression by the means 
already described. 

After the operation had been performed and the discharges had 
been reduced to normal frequency, the condition of the nervous system 
was improved by the use of strong tonics. Castration in this case 
would have been not only barbarous, but criminal ; the effect of the 
operation would not only have still further impaired his mental con- 
dition, but in all probability, from constant brooding over his mutila- 
tion, he would have either committed suicide or become insane. 

EPISPADIAS. 

The case that I next bring before you is of especial interest because 
of its great rarity. It is one of epispadias, the urethral opening being 
at the middle of the dorsum of the penis. 

This patient is about seventeen years old. The penis is well de- 
veloped, but the opening of the urethra is situated at the upper middle 
portion of the organ, instead of terminating at the end of the glans. 

When he first applied for relief the glans was well-nigh solid, with 
only a urethral trough, covered with mucous membrane, marking the 
natural site of the urethra, besides which there was a marked upward 
curve of the organ. There are many theories advanced by writers as 
to the cause of this abnormal condition. I shalF not take up your time 
by recounting them, but shall go immediately on with the case before us. 

This individual has already had two operations performed on him 
before the class ; the object of the first was to straighten the membrum 
virile ; the second was to endeavor to form a canal from the epispastic 
opening to the extremity of the glans. To-day I bring him befoi'e 
you to complete the cure by changing the urethral-furrow inta a tube. 
The parts have been made aseptic in the usual manner. The patient 
has been given ten grains of boric acid three times daily for the last 
three days, so that the urethra may be as nearly as possible in an 
aseptic condition. 



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TRAUMATIC STRICmJRE. 247 

For the purpose of denuding the skin and mucous membrane you 
will observe that I make use of an iris forceps and scissors. The 
forceps have the advantage of being light, and at the same time taking 
firm hold of the tissue which is about to be removed, without the pos- 
sibility of slipping. I now freely denude both sides of the canal, and 
I wash the wound with 1 to 20,000 corrosive sublimate solution. Wait- 
ing a few minutes, until all hemorrhage has ceased, the abraded sur- 
feces are brought together by means of a silkworm-gut suture, and 
the operation is completed by inserting a new thoroughly aseptic 
N^laton catheter, which will effectually prevent the urine fit>m gaining 
access to the wounded surface. The catheter and sutures will be re- 
moved on the eighth day. The wound will be dressed with sterilized 
iodoform and dry bichloride gauze. 

To prevent erections, as far as possible, which would naturally have 

a tendency to impede union, full doses of bromide of potassium will be 

administered. 

TRAUMATIC STRICTURE. 

You will recall the case which I next present as one which I 
brought before you at the last clinic. 

The individual is affected with a tight traumatic stricture of the 
membranous portion of the urethra. This condition was brought 
about, some seven years ago, by the patient falling from a height 
astride of a wood-horse and violently striking on the perineum. Yon 
will recollect that the calibre of the urethra was found to be very 
small, and that the stricture was tortuous : a filiform bougie could not 
be made to pass through. 

I propose this morning to perform a perineal section by the method 
known as the Wheelhouse operation, — ^modifying and, I hope, simpli- 
fying it by substituting a staff of my own device, to take the place of 
that recommended by Mr. Wheelhouse. 

You will observe that this instrument consists of two blades, in 
close apposition, which together form a smooth staff, with a thumb-screw 
at one end, by means of which the blades may be readily separated. 
The other end terminates in a hook, similar to that on the Wheelhouse 
staff. 

The advantages claimed for this instrument are, that when it is 
placed in position, and the blades separated, the urethra is firmly fixed, 
and that the operator, after having made an incision through the skin^ 
can open the. canal with as much ease as he would an ordinary abscess. 
The fixation of the urethra prevents it from sliding from one side of the 
staff to the other, which is the objection to the Wheelhouse instrument ; 



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248 



INTERNATIONAL CLINICS. 



especially is this slipping apt to take place when the tissues of the 
perineum are dense and fibrous. 

As soon as the canal is fairly opened, 
the blades must be brought into contact 
by turning the thumb-screw at the handle. 
The instrument is then adjusted, so that 
the hook presents in the perineal wound, 
and is to be clasped to the upper edge of 
the incision. The sides of the canal are 
now to be caught by means of a pair of 
haemostatic forceps, and given to an assist- 
ant to bold. Thus, by tension made above 
and at the two sides of the open urethra, 
the strictured portion is drawn forward, so 
that it presents directly towards the face of 
the operator, who now attempts to pass 
through it a probe-pointed director ; if he 
succeed, he incises the stricture on the floor 
of the urethra by means of a probe-pointed 
i i\ bistoury. The director having been re- 

moved, the instrument .which I here ex- 
hibit, known as a Teale gorget, is inserted 
through the wound into the bladder, and 
serves as a guide for the passage of the 
catheter. 

This patient having been etherized, he 
is placed in a lithotomy position ; the stafi*, 
with the hook turned away from the oper- 
ator, is passed gently down to the seat of 
the stricture, then withdrawn for the length 
of a quarter of an inch, so that I may open 
the urethra at a healthy point. My assist- 
ant now separates the blades, by means of 
the thumb-screw; this dilates, fixes the 
urethra, and at the same time makes it 
evident to the touch. 

You will observe that I have incised 
the skin, and without the slightest diffi- 
culty carry the knife directly onward through the centre line, being 
very careftd not to cut too far forward, lest I wound the artery of the 
bulb, nor too fiir backward, for fear of wounding the rectum. 




Clowd. Open. 

Newly deviled perineal staff. 



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BESILIENT AND NODULAB STRICTURE. 249 

The urethra has thus been opened between the separated blades, 
which are now closed and turned until the hook presents in the wound, 
and by elevating it in the manner here exhibited I catch the upper 
angle, and by means of two haemostatic forceps fix the sides of the 
urethra. You will observe that the grooved director has found the 
opening of the stricture and has passed through it. I now divide the 
seat of coarctation by means of this probe-pointed knife. 

The next step is to pass the gorget into the bladder; this being 
accomplished, a full-sized silver catheter is inserted and the gorget 
removed. The catheter will be left in sUu until the perineal wound 
is closed, which will take place in from three to four weeks. 

The incision will be irrigated with 1 to 20,000 bichloride of mercury 
solution, and the urethra will be washed out twice a day with warm 
water to which has been added boric acid. The catheter will be re- 
moved every third day, disinfected, and replaced. The incision will 
be dressed with iodoform and dry bichloride gauze. 

[This patient made an excellent recovery, leaving the hospital on 
the twenty-sixth day, the wound being entirely healed. He was en- 
abled to pass a 35 French bougie without difficulty.] 

RESILIENT AND NODULAR STRICTURE. 

The next case that I bring before you is an individual thirty-two 
years old, apparently in good health. He is suffering from a resilient 
and nodular stricture situated three and a half inches from the meatus. 
Dr. Fleming, to whom I am indebted for this patient-, tells me that he 
has repeatedly dilated the stricture so as to admit of the passage of a 
32 French bougie, but that within forty-eight hours contraction takes 
place to so marked a d^ree that it is with great difficulty that an 18 
Frendi can be passed. 

On examining the parts you will observe that a little in front of 
the peno-Bcrotal junction there is an indurated mass. This marks the 
site of the stricture. From what you have heretofore been told, when 
I have lectured on this subject, yon will readily understand that the 
case before you is one upon which to perform internal and external 
urethrotomy. 

With this operation you are already familiar. The indication for 
suigical interference in these cases of stricture is their irritable, re- 
silient, or nodular condition. 

Internal urethrotomy is primarily performed ; then a perineal punc- 
ture is made, so as to put the parts at perfect rest and thus allow the 
indurated tissue to undergo fatty degeneration and absorption. Some 



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260 INTERNATIONAL CLINICS. 

time sinoe it occurred to me that this result might be produced bj cut- 
ting the stricture on the roof and on the floor of the canal so as to 
produce a condition illustrated in these figures : 

I conceived that instead of performing 
\ Z the perineal section the same effect might be 

0^ produced by passing a full-size silver catheter 

y^ ^^ and allowing it to remain in position for the 
( J space of at least two weeks^ thus putting the 

^— 'y^T"^ parts at rest, and at the same time allowing 
them to receive the benefit of continual press- 
ure on the nodular mass surrounding the urethra. 

I have twice performed the operation in this manner with perfect 
success, and I propose to repeat it before you to-day. 

The urethra has been rendered as nearly aseptic as possible. 
As I can only pass a filiform through the constriction, I will first, 
by means of Maisonneuve's urethrotome, proceed to cut the coarctation 
on the roof of the urethra. Having done this, I readily pass an Otis's 
urethrotome, by which means the stricture is divided on its floor. The 
canal is now to be irrigated with 1 to 20,000 corrosive sublimate solution, 
and a full-size silver catheter, which has been rendered aseptic by heat, 
will be passed into the bladder, there to remain for two weeks, re- 
moving it for a few minutes every day, so that it may be cleansed. 

[At the end of two weeks the patient left the hospital, being able 
with ease to pass a 33 French bougie. The induration at the seat of 
stricture had almost completely disappeared.] 



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PROSTATECTOMY; IMPERMEABLE STRICTURE OP 
THE URETHRA; PROLONGED RETENTION OF 
URINE; PERINEAL SECTION. 

CLINICAL LECTITBS DXLIYEBED BEFORE A PBIYATE CLASS 07 STUDENTS 07 THE 
COLLEGE 07 PHYSICIANS. 

BY Q. PRANK LYD8TON, M.D., 

Professor of the Surgical Diseases of the Qenito-Urinaiy Organs and Syphilology 
in the Chicago College of Physicians and Surgeons ; Fellow of 
the Chicago Academy of Medicine^ etc. 



GENTLEMEKy — I will present for your consideration this morning 
several cases of more than usual interest The patient whom I first 
present to you is sixty-eight years of age, a tailor by occupation, and 
had always enjoyed excellent health up to four or five years ago. As 
you see, he is very young-looking for his age, and his nutrition is ap- 
parently perfect. Four or five years ago he began to be troubled with 
frequency of micturition, appearing in the manner characteristic of 
cases of this kind, — i.e.y being of normal frequency during the daytime, 
but compelling the patient to rise several times at night to micturate. 
These symptoms progressively increased until about a year ago, when 
an attack of complete retention came on. This retention lasted several 
days without relief, overflow finally occurring. It was followed by a 
marked d^ree of vesical atony, which has persisted up to the pres- 
ent time. He is in such a condition now that unless the bladder is 
frequently emptied, extreme distention, followed by incontinence and 
overflow, will result Infection has already occurred, and, as a conse- 
quence, the patient is sufiering from a moderately severe chronic cys- 
titis, the urine being somewhat ammoniacal. The bladder has been 
carefully explored for stone, but none has been found. Exploration 
of the urethra and bladder and the rectal touch disclose an immensely 
hypertrophied prostate, which is moderately painful on pressure. The 
enlargement is apparently difiused, and, although there are no definite 
symptoms of circumscribed obstruction at the neck of the bladder, I 

251 



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252 INTERNATIONAL CLINICS. 

should not be surprised if on opening that organ we found a posterior 
median hypertrophy. The extreme exaggeration and elongation of the 
urethral eurve are strongly suggestive of a median enlargement. 

The first duty of the surgeon in cases of this kind is to determine 
whether or not the kidneys are performing their function properly. 
It is necessary to determine whether albumin is present, and in what 
quantity. It is even more essential, if possible, to determine the amount 
of solid excrementitious matter thrown out by the kidneys during the 
twenty-four hours. For the estimation of this no complicated or minute 
analysis is necessary. Flinf s rule, although a simple one, is as good 
as any that could be devised for practical clinical work. This method 
consists in estimating the total number of ounces of urine passed in 
the twenty-four hours, and then determining the specific gravity of the 
mixed urine. The last two figures of the specific gravity represent 
approximately the number of grains of solid material per ounce of 
urine. Simple multiplication shows, with a sufficient degree of accu- 
racy for practical purposes, the number of grains of solid urine passed 
during the twenty-four hours. If the kidney is not performing its 
functions properly, there will be a relative decrease in the amount 
of urea. I find merely a trace of albumin, and no casts, in this old 
man's urine, and the amount of urea is approximately normal, yet I 
am still suspicious of renal disease. 

The patient is desirous of having some radical operation performed, 
and in my opinion the case is more favorable for operation than the 
average case of the kind. The point I would impress upon you at 
this juncture is that, no matter how healthy the urine may appear in 
long-standing cases of chronic genito-urinary disease, particularly in 
enlargement of the prostate, chronic disease of the kidney may be in- 
ferred. Chronic obstructive, irritative, and infective conditions of the 
lower portions of the genito-urinary tract cannot exist for a great length 
of time without reacting with a greater or less degree of severity upon 
the stnicture and functions of the kidney. A functional aberration at 
first, and finally structural changes in the renal secreting tissue itself, 
make up the usual history of all cases of long-standing prostatic en- 
largement. Unfortunately, we have no accurate means of estimating 
the precise condition of the kidneys in chronic cases, and we oftentimes 
deceive ourselves in regard to the d^ree of tolerance for operative 
procedures which the patient is likely to present. The amount of 
albumin and casts in the urine is a very poor criterion of the condition 
of the kidneys in surgical affections of the genito-urinary tract. The 
estimation of the amount of urea, already suggested, is by far the most 



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PROSTATECrOMY. 253 

accurate criterion for our guidance in determining the question of 
operative or non-operative treatment. I believe that in these cases a 
radical operation is warrantable. I have therefore suggested a com- 
bined suprapubic and perineal section. Precisely what will be done in 
this case will depend entirely upon what we find when the bladder is 
opened. The choice of routes by which we may enter the bladder in 
cases of this kind is much a matter of taste. For my own part, taking 
into consideration all the indications and contra-indications in these 
cases, — and these I shall not attempt to outline here, — I am inclined 
to prefer a combined suprapubic and perineal section. This operation, 
it appears to me, presents the following distinct advantages. 1. Easy 
access to and management of tumors, calculi, and enlarged prostatic 
lobes. 2. Drainage can be established for a few days through the 
perineal wound, thus giving the suprapubic opening an opportunity to 
become thoroughly glazed with plastic lymph, and thus protected from 
the infectious urine, which in these cases must always be regarded as 
toxic — sometimes intensely so. 3. Better control of hemorrhage. 4. 
More perfect drainage by two channels. Knowing, as we do, the great 
danger of infection by toxic urine, the feasibility of suprapubic section 
in two stages has suggested itself to numerous surgeons, primarily, I 
believe, to those of the French school. The operation of suprapubic 
section in two stages has erroneously been attributed in certain quarters 
to American surgeons, but it was in vogue in France, and, for aught I 
know, in other countries of Europe, long before it was performed in 
this country, or, at least, long before any report of such an operation 
was made. 

In the case before you, I performed, three days ago, the preliminary 
operation of exposing the bladder. As you see, the parts are protected 
by the usual antiseptic dressing of gauze and iodoform. I propose 
this morning to open the bladder by both the perineal and suprapubic 
routes ; and if I find conditions suitable for the operation I shall per- 
form a prostatectomy. In a general way, my advice to you is, where 
there are no distinct indications for operation upon the prostate itself 
it is best to content yourselves with suprapubic section and drainage, 
or, perhaps preferably, a combined suprapubic and perineal section 
with drainage, leaving the prostate to take care of itself, which it 
usually does very satisfactorily, inasmuch as we find that even in the 
case of enormous diffused enlargements decided shrinkage of the organ 
occurs in a few days, and within a few weeks it is so reduced in volume 
as to produce marked and permanent improvement in the condition 
of the patient. We will give this patient chloroform instead of ether, 



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254 INTERNATIONAL CLINICS. 

inasmuch as it is generally known that chloroform is the safer of the 
two in operations upon cases of this kind. It is perfectly practica- 
ble in these cases to open the bladder and even to perform a perineal 
section under the use of cocaine without resorting to general anaesthesia. 
I have done this in several instances, and with success. I will state 
that where the kidneys are known to be seriously impaired I do not 
think that an operation, if performed at all, should be done under 
general ansesthesia. The use of cocaine, I firmly believe, will reduce 
the mortality in certain cases to a very marked decree. Most surgeons 
use, in the performance of suprapubic section of the bladder, the Peter- 
son or other apparatus for distending the rectum and raising the pre- 
vesical fold of peritoneum, thus gaining a larger space for the perform- 
ance of section of the bladder. I find that rectal distention is rarely 
necessary. In cases of this kind in which the bladder is atonied and 
may be readily distended with a large quantity of fluid, and in cases 
in which retention is present and the bladder is raised to a considerable 
extent above the pubes, there is abundance of room for the opera- 
tion. In cases in which the bladder is contracted and cannot be dis- 
tended, the viscus may be readily exposed by the ordinary incision, and 
without danger to the peritoneum, if the posterior surface of the pubes 
be closely hugged by the finger in stripping up the prevesical fat 

The patient now being under the influence of the ansesthetic, we 
will proceed to open the bladder above the pubes. On removing the 
gauze with which the preliminary wound was packed, we find the 
wound in a perfectly aseptic condition. We will, however, irrigate 
it thoroughly with a 1 to 5000 bichloride solution and asepticize the 
surrounding area of skin by careful irrigation with the bichloride, fol- 
lowed by the application of absolute alcohol. I have had the bladder 
thoroughly irrigated before the patient came on the table. This was 
done with a warm boric-acid solution, and about sixteen ounces of 
the solution were allowed to remain in the bladder. To prevent the 
possible escape of the urine from the bladder through the urethra, the 
penis has been surrounded by a piece of roller bandage which com- 
presses the urethra tightly. You will understand, of course, that the 
patient's rectum was thoroughly emptied before he came into the oper- 
ating-room. The bladder being exposed, I make an incision into it 
with the bistoury, the back of the knife being turned towards the pre- 
vesical fold of peritoneum, care being taken not to cut or disturb the 
suspension sutures with which the bladder was fixed at the time of 
the primary operation. Withdrawal of the knife is followed by a 
gush of urine, which guides my finger into the interior of the bladder. 



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PROSTATECTOMY. 265 

I would suggest that the first incision into the bktdder be made very 
small, as the bladder walls, being elastic, will admit of the insei-tion of 
the finger through an opening much smaller than would appear suffi- 
cient to admit the finger. The precaution of a very small incision is 
particularly desirable where the incision into the bladder proves to 
be merely exploratory in character. On passing my finger into the 
patient's bladder, I find three distinct, circumscribed tumors at the pos- 
terior border of the prostate and jutting into the bladder. The lateral 
lobes of the prostate are immensely hypertrophied and constitute two 
of the three tumors which I mentioned. The third tumor is a dis- 
tinctly circumscribed and almost pedunculated growth in the posterior 
median portion of the prostate. This growth must, it appears to me, 
have acted very much like a ball- valve in producing obstniction to the 
outflow of urine from the bladder. To make these tumors more 
accessible, I shall now make a median puncture of the perineum ; this 
I do upon a central grooved staff. This perineal puncture does not 
complicate the operation particularly, and, as you see, is in uncompli- 
cated cases very speedily performed. On withdrawing the grooved 
staff from the urethra, I substitute for it my index finger, so that I 
have succeeded in accomplishing the bimanual manipulation of the 
prostatic overgrowths. At this point I will inform you that while I 
believe it desirable to remove the hypertrophies in this case, I shall do 
so with as little cutting as possible. I introduce a probe-pointed bis- 
toury, and, after incising the mucous membrane covering the median 
tumor, I succeed with the index finger and thumb in twisting the 
tumor entirely off. I now have it in my hand, and it presents de- 
cidedly the appearance of a myo-fibroma. An incision is now made 
in the mucous membrane covering each lateral lobe ; die finger is next 
introduced into the opening over the lobe and the mass of prostatic 
tissue which it contains shelled out, as near as may be without any 
cutting, if it is possible to avoid it. I find that the prostatic tissue is 
friable and breaks down readily under my fingers, it being consequently 
necessary to remove it piecemeal. You will please remember that it is 
by no means necessary to remove every particle of hypertrophied pros- 
tatic tissue, because after an operation of even moderate thoroughness a 
considerable portion of the hypertrophy will speedily shrink down and 
cease to give annoyance. Having removed the hypertrophied tissue 
as far as possible, the question of drainage comes up. I prefer in 
cases of this kind a straight fenestrated tube of the ordinary quality 
of drainage tubing, but of good size. This is passed through and 
through the bladder from the upper to the lower wound. For the 



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256 INTERNATIONAL CLINICS. 

first few days the urine may be compelled to run entirely through the 
perineal tube, thus protecting the suprapubic wound from infection. 
Flushing of the bladder is much more easily carried on by means of 
a through-and-through drainage-tube. You must remember, however, 
that it is necessary to have the upper tube tightly sealed, or else the 
urine will infect the suprapubic wound. In a few days it may be 
found advantageous to drain suprapubically. I shall order this patient 
put upon a generous and easily digestible diet, and in the way of 
medication I shall order ten minims of oil of eucalyptus four times 
daily. The oil of eucalyptus is in my experience the most reliable of 
all remedies for the prevention and treatment of so-called urinary fever. 

IMPERMEABLE STRICTURE OF THE URETHRA; PROLONGED RE- 
TENTION OF URINE; PERINEAL SECTION. 

The next case I present to you is. a most interesting one. The 
patient is thirty years of age, by occupation a railroad employee. 
According to his statement, he has suffered from a deep stricture of the 
urethra for fifteen years. This has been treated with varying degrees of 
success at intervals during that period. He has had several attacks of 
retention, which were relieved by the catheter and were followed by 
cystitis. The patient presented himself to me yesterday suffering fix)m 
retention of urine, with overflow. The bladder was distended to such 
a d^ree that it reached almost to the umbilicus. I found it impossible 
to enter the bladder by the natural route, and so was compelled to do 
a preliminary aspiration above the pubes. The urine which I with- 
drew was strongly ammoniacal, and contained a great deal of mucus. 
The patient, as you see, is in a bad condition generally, having but a 
few weeks since recovered from a severe attack of pneiunonia. He 
presents the general cachectic appearance characteristic of those patients 
whom Guyon has so euphoniously termed urinaires. The cachexia 
incidental to cases of this kind is due to three causes : (1) the pain 
and irritation incidental to the chronic condition of urinary obstruc- 
tion ; (2) a moderate d^ree of urinary toxsemia incidental to pertur- 
bation of the function of the kidneys ; (3) a certain degree of toxaemia 
produced by the absorption from the genito-urinary tract of the prod- 
ucts of decomposing urine and chronic inflammation of the mucous 
membrane. These elements in the production of cachexia in urinaires 
must be taken into consideration, as it is of the utmost importance in 
deciding the question of operation, especially with reference to prog- 
nosis. They are too frequently lost sight of by the operating surgeon. 

We are confronted, therefore, in this case with what may be truly 



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niPEBMEABLE 8TRICTUEE OF THE URETHRA. 257 

termed an emergency in genito-urinary surgery. This man's bladder 
must be relieved, and effectually so, else a fetal result will surely 
occur within a very short time. We are confronted with a strong 
probability of septic infection following the operation, on account of 
the highly toxic condition of the urine, which must certainly bathe the 
operative field the instant the bladder is reached by the knife. I will 
state that the patient has been prepared for the operation by the ad- 
ministration of oil of eucalyptus, as is my custom. The patient now 
being under the influence of the aneesthetic, — and by preference chlo- 
roform is administered, as I believe it to be safer in cases of this kind 
than ether, — I shall proceed to explore the urethra. It is very desira- 
ble to introduce a guide through the stricture if possible. This may 
often be done under the ansesthetic in cases in which prior to ansBS- 
thesia it was impossible to pass an instrument, however small. I find 
tliat even aft^er careful manipulation with filiforms and small flexible 
bougies it is impossible to pass one through the stricture. We are 
confronted, therefore, with what we shall term, for the sake of clinical 
accuracy, a surgically impermeable stricture. That the stricture is 
permeable in the ordinary sense of the term is shown by the feet that 
urine has been constantly trickling away. Strictures that are tnily 
impermeable are very rare ; those that are surgically impermeable are 
not so rare. 

We have the choice in this case of two procedures : (1) perineal 
section without a guide ; (2) suprapubic section and retrograde cathe- 
terization combined with perineal section. We shall be guided some- 
what by the conditions found during the operation. I shall attempt to 
perform the operation of perineal section without a guide, — the original 
operation as perfected by Syme and modified by Wheelhouse. The 
patient's perineum and pubes having already been shaved and made 
thoroughly aseptic prior to his being put under an ansesthetic, we 
are ready to b^n the operation. As we cannot introduce a filiform 
through the obstructed portion of the canal, we do the next best thing 
possible, and pass a medium-sized sound down to the point of obstruc- 
tion. I make an incision in the median line, following the raph6 
accurately until the point of the sound is exposed and the urethra 
freely opened just in front of the stricture, which is located at the 
bulbo-membranous junction. I find the urethra thickened, with con- 
siderable periurethral induration over the entire extent of the bulb. I 
now pass a couple of strong ligatures through the edges of the wound, 
including the skin, fescia, and edges of the urethra. These ligatures 
are looped and given to the assistant to hold. I now take the staff 
Vol. I. Ser. 4.— 17 



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268 INTERNATIONAL CLINICS. 

from the hand of my assistant and turn its point out of the wound in 
the perineum hook-wise, which enables me to keep the upper part of 
the wound held well up. The tension upon the ligatures, the sound 
being hooked up well in the upper angle of the wound, gives me a 
much more capacious opening into the urethra and enables me to search 
for the opening of the stricture. Having exposed the face of the 
stricture, I find that I cannot pass any instrument, however small, 
through its lumen ; in fact, I cannot even find the tortuous and ex- 
tremely narrow channel through the strictured tissue. Three courses 
are now open to me : (a) to perform Cock's operation of tapping the 
urethra at the apex of the prostate ; then, after entering the urethra, to 
dissect from behind forward ; (6) to dissect carefully, guided by the 
sense of touch and my knowledge of the anatomy of the parts, in the 
direction of the neck of the bladder, cutting the cicatricial tissue by 
slight strokes of the point of the knife ; (c) to open the bladder above 
the symphysis pubis and introduce a guide into the urethra from 
within outward. I confess I am somewhat partial to this last method 
of operating, and I think it will probably be the quickest solution of 
the difficulty in this case. You see, gentlemen, I have readily exposed 
the bladder above the pubes. I shall now incise it My finger soon 
enters the bladder, and, guided by the finger, I pass a good-sized bougie 
into the vesical orifice of the urethra down into the perineum, which I 
find I can readily feel with the finger. I now have a distinct and posi- 
tive guide to the urethra, and cutting upon the guide I find that I am 
enabled to pass ray finger through the perineum and prostatic portion 
of the urethra into the bladder. I shall drain in this case, as I did 
in the previous instance, by a through-and-through tube. 

The prognosis in this case is a little doubtful : still, it is surprising 
how some of these apparently desperate cases improve afl«r operation. 



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C£^t)nirc0l00t) anh (SDbotdrtco. 



TRACHELORRHAPHY AND ADHESIONS OF THE 
RETROVERTED UTERUS. 

CLINICAL LECTCRB DELIYBRBD AT 8T. LUKB'S HOSPITAL, CHICAGO. 

BY HENRY T. BYFORD, M.D., 

Professor of Gjnsecology, Collie of Physicians and Surgeons, Chicago ; Professor of 

GyniBcoIogy, Chicago Post-Graduate Medical School ; Professor of 

Clinical Gynecology, Northwestern UniTersity Woman's 

Medical School ; Gynsscologist to St Luke's 

Hospital ; Surgeon to the Woman's 

Hospital of Chicago. 



Gentlemen^ — While the patient is being anaeethetized we shall 
have time for a few remarks. She is a married woman, forty-two 
years of age, and has been suffering ever since the birth of her yoimg- 
est child, two years ago. She is a servant, but in her present condition 
is unable to do her work. An operation for laceration of the cervix 
was performed upon her a year ago, which resulted in making her feel 
worse. I cannot tell you how often patients have told me that they 
have felt worse after a trachelorrhaphy. Sometimes this is due to the 
&ct that the everted lips of a lacerated cervix were full of diseased 
follicles before being turned in by the operation. Pressure of the 
inflamed surfaces of the cervix against each other thus adds to the 
patient's pain, while the concealment of the diseased parts from view 
increases the difficulty of treatment In such cases it sometimes may 
become necessary to reopen the cervix and amputate after Schroeder's 
ingenious method. 

In this instance, however, the contra-indication lay in the fact that 
there was retroversion, with adhesions both of the fundus and of the 
diseased ovaries ; and let the sufferings of this poor woman be a warn- 
ing to you never to operate under such circumstances. 

Our object to-day is to separate these adhesions and replace the 
ntems. To do this the peritoneal cavity must, as a rule, be opened. 
B. 8. Schnlze has taught us how to do this through the rectum, but I 
would advise only those of you to attempt it who expect to become 

269 



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260 INTERNATIONAL CLINICS. 

gynsBcologists, or, better still (both for the patient and yourselves), not 
until after you have become gynaecologists. Separate a hundred ova- 
ries through the open abdomen before you attempt to separate one per 
rectum. I once made a vaginal opening into the bladder, and en- 
deavored to separate an ovary from adhesions to the posterior surface 
of the broad ligament with one finger in the bladder and another in 
the rectum. After trying for quite a while I gave it up, opened the 
posterior vaginal fornix, and then succeeded with the greatest difficulty 
in separating and removing the organ. If I had persisted without 
opening the peritoneal cavity I should have injured the bladder and 
rectum and lacerated the pelvic tissues before separating the ovary, and 
then should have only imperfectly succeeded and have made my patient 
very much worse. Only a small proportion of adhesions are sufficiently 
within reach of the finger in the rectum to be completely separated, 
and a still smaller proportion of these are frail enough to be broken 
through by the pressure which can be brought to bear in this way. 
Considerable experience is necessary to enable one to judge of the 
amount of force that may thus be safely employed. The method con- 
sists in passing two fingers into the rectum under the adherent ovaries, 
pressing the fingers of the other hand over the abdominal walls down 
upon the diseased appendages, and then forcing the tips of the rectal 
fingers up between the appendages and the parts to wliich they are 
adherent, — the abdominal fingers making counter-pressure. These 
tissues must not be pulled asunder, but must be pressed apart by the 
insinuating rectal fingers. I have a few times succeeded in separating 
adhesions in this way, but seldom with satisfactory results. In only 
one case have I separated them so completely that I felt justified in 
doing an Alexander's operation. There is nearly always sufficient 
adhesion or contraction in the tissues left either to keep the uterus in 
retroversion or to draw the replaced fundus backward again. In a few 
cases a pessary will keep up the uterus thus separated, but, as a rule, 
only as long as it remains in the vagina. Alexander's operation is also 
usually a failure, because either the ligaments will not run or the 
resistance of the diseased tissues will subsequently stretch the shortened 
ligaments. 

To-day we will open the peritoneal cavity, separate the adhesions, 
and stitch the uterus to the anterior abdominal wall over the bladder. 
As the patient is ready, I shall ask Dr. Gravin, the senior assistant, to 
commence the operation, while I take the part of first assistant, and 
thus have a better opportunity to talk to you. 

He stands on the right side of the patient, using his right hand for 



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TRACHELORRHAPHY. 261 

the knife, scissors, forceps, and needle, and his left for intra-abdominal 
exploration, separation of adhesions, lifting and holding of the organs, 
etc With one deliberate stroke of the knife he makes a cataneons 
incision in the median line from about half-way between the um- 
bilicus and pubes downward for about two inches. With another 
stroke he lays bare the superficial fascia. With sponges squeezed out 
of cold water I clean the wound and check the oozing. He is now 
nicking the fascia, and rapidly enlarges the incision upward and down- 
ward, keeping close to the median line, which is easily found by the 
probe or point of the fiiscia scissors. The edge of the rectus is sepa- 
rated from the median septum with the knife-handle, the posterior 
&scia' nicked and slit upward and downward, and the subperitoneal &t 
exposed. This is easily separated or pressed to one side by the finger. 
Now, as the careful operator grasps the peritoneal membrane on his 
side with a pair of forceps, I grasp it similarly on my side, and we 
hold it well up while he nicks it. As he does so his forceps recede, 
and he takes a new and deeper hold, and nicks again. This time a 
small black hole in the membrane appears and the peritoneum rises 
around one forceps. Air has passed underneath the membrane, and we 
know that the peritoneal cavity is opened, and the first stage of the 
operation is completed. Now I close tliis small opening by holding 
the forceps together, and press a cold sponge upon the oozing incised 
tissue while the operator is soaking and warming his hands in sterilized 
hot water and the nurses are putting hot water into the sponge basins. 

I now hold up the forceps, that the operator may enlarge the in- 
cision with scissors. This he does to a slight extent, puts in his 
finger, and incises the membrane thus elevated upon the protecting 
finger. As is usual in these low incisions, a lively little artery has 
been cat, which bled on both sides until I compressed it with artery 
forceps. It is well to look out for the bladder in making these low 
incisions, for it is sometimes elevated and in the way. By pressing 
the membrane up by the left index finger, as you have just seen 
done, the membranous character of the tissues is easily made apparent 
before cutting, and the absence of the dense and vascular vesicle well 
insured. Increasing thickness of the peritoneal tissues as we get 
near the pubes, and abundant hemorrhage, should cause one to stop 
and investigate. 

While we have been talking, our operator has thrust two fingers so 
fiur down behind the pubes as to touch the uterus in the middle line, 
and is feeling back towards the retroposed fundus, and from thence first 
to one of the ovaries and then to the other. His delay is caused by 



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262 



INTERNATIONAL CLINICS. 



the attempt to separate both ovaries before lifting them up. But by 
persevering he has at last succeeded in bringing to light the enlarged 
ovary, which was still larger before this cyst ruptured. You noticed 
that I placed a small round sponge in the peritoneal cavity just under 
the incision, to remain there while the pedicle is being transfixed, to 
prevent infection. Meanwhile the operator is putting a slip-noose 
around the pedicle with the doubled end of the silk thread passing 
through it, and the loop is brought over the ovary and tube, so as to 
surround the pedicle. (See illustrations.) Now he draws one of the 
free ends over the loop and one end under it, and 
tightens the slip-noose and holds it firmly between his 
left; thumb and finger while he ties a single knot. As 



Fio. 1. 




Fig. 2. 



Fig. 8. 



Fio. 4. 





Method of Applying Ligaturb to Ovarian Pedicle.— «. «, section of pedicle ; a, loop of silk 
passed through pedicle ; b and c, ends of silk ligatures to be tied. 

Fig. 1— First step,— ligature passed through the pedicle. 

Fig. 2.— Loop of ligature, a, thrown oyer the appendages so as to surround pedicle and lie 
upon the ends, b and c. 

Pig. 8.— The end c drawn through the loop so as to lie over it, b remaining under it 

Fig. 4.— Loop drawn tightly around pedicle and a single twist or knot taken with ends of 
ligature. 

his left hand holds the tied thread at the pedicle, I take hold of one 
of the threads, and pull against the one he has in his right hand. 
Having tightened it, he holds the knot with his left thumb and 
finger while we tie again, and the thing is done. Let me warn you 
never to take two turns of the thread (surgical knot) in tying the first 
knot, for you would be unable to draw it tight enough. The doctor 
has already cut off the ovary and tube about one-third of an inch 
from the constriction, and I will ask him while I hold up the stump 
with the forceps to take another turn around it with the ligature and 
tie it as tightly as possible with an ordinary knot. The young operator 
will learn the importance of this precaution after he has lost a case 
from hemorrhage. The ligature is cut off about one-tenth of an inch 
from the knot. 

While the second ovary is being removed I shall explain what is to 
come later. 



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TRACHELORRHAPHY. 263 

Dr. Qavin intends to anchor the uterus to the anterior abdominal 
walls over the pubes. This may be done in various ways. When the 
appendages are removed^ the stumps may be stitched on either side by 
some deltcate, unabsorbable material. When the appendages are not 
removed^ the round ligaments about an inch from their uterine origin 
may be thus sutured to the same places. Just now the most popular 
method is to stitch the upper portion of the anterior wall of the uterus 
in the abdominal incision, thus making a rigid fixation. The objec- 
tion to the first^mentioned methods is that the uterus is not fixed firmly 
enough ; the objection to the last is that the uterus is too firmly fixed, 
or immobilized. Some writers fear that intestines may become stran- 
gulated between the fundus of a loosely suspended uterus and the 
abdominal walls, but surgeons have not, so far as I know, met with 
any such accident. I have stitched the stumps to either side of the 
incision in many cases, and since I have used silk for the purpose 
have not noticed any failures. We will use silk to-day. 

Now that both ovaries are removed, I take hold of the peritoneum 
and fascia at the middle of the incision on the right side and left, and 
slightly evert the edges. Dr. Gravin, with a slender needle on a 
holder, passes a fine silk thread through a small section of the peri- 
toneum, about an inch to the right of its cut edge, taking care to 
include a bit of the contiguous &scia, then through the stump, which 
we hold up by forceps, and draws the stump firmly against the peri- 
toneum and ties it there. Another portion of peritoneum and stump is 
similarly included in the thread, and tied, and one stump is anchored. It 
takes but a moment to do the same thing on the other side, and the 
second part of the operation is completed. I now place a long, flat 
retractor down over the posterior wall of the uterus, while the oper- 
ator holds the intestines away with his fingers and passes a small 
sponge into the recto-uterine cul-de-sac, and, as you see, gets a trace of 
blood. In order to be sure that too much oozing is not going on from 
the raw tissues at the site of the former adhesions, I pass, for tempo- 
rary use, a glass drainage-tube down into the cul-de-sac. These sutures 
which are now being put through the entire thickness of the incised 
tissues are of silkworm-gut, which possesses nearly all the advantages 
of both silk and silver wire, and none of the disadvantages of either. 
Now that the sutures are in, we pass a small rubber tube down to the 
bottom of the drainage-tube, and draw out the fluid by means of a 
glass syringe already attached. Only a few drops of serum slightly 
tinged with blood appear, and we know that we can safely take out 
the tube and completely close the peritoneal cavity. Before tying the 



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264 INTERNATIONAL. CLINICS. 

last stitches^ the small sponge which was kept over the intestines is 
taken oat, and the omentum adjusted under the incision to prevent 
adhesions of the intestines to the line of incision. 

The only item of the after-treatment worth mentioning is the ad- 
ministration of a saline laxative in divided doses as soon as the ether 
nausea has subsided, for the purpose of securing a movement of the 
bowels or an abundant passage of flatus by the end of the first twenty- 
four hours. If the laxative does not act properly, an enema composed 
of an ounce each of glycerin, sulphate of magnesia, and water is given. 
This action of the bowels prevents either the adhesion of a kinked 
intestine to the stump or an adhesion between the fundus uteri and 
the abdominal wall. 



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THE EXPLORATORY ABDOMINAL INCISION. 

CLINICAL LKCTURX DXLIYXBXD AT THX MXDICO-CBIRURaiCAL HOSPITAL. 

BY WILLIAM BASTBRLY A8HTON, M.D., 

Profenor of Gynncolo^ in the Medico-Chinirgical College of Philadelphia ; Gjiub- 
oologist to the Medico-Chirurgical and Philadelphia Hospitals. 



Gentlemen, — The patient before us came from the interior of the 
State to the hospital on the 15th of last October. Her history was as 
follows. Mrs. Margaret B., forty-eight years of age. She vras married 
twenty-four years, but has been a widow since 1887. She has had ten 
children and four miscarriages. The menopause occurred in August, 
1892. 

Three years ago, while reaching for an object upon a high shelf, she 
felt something suddenly snap or give way within the abdomen. Since 
that time she has suffered from backadie, bearing-down sensations in 
the pelvis, and a feeling of soreness over the entire abdomen. About 
one year and a half ago she began to complain of more or less pain 
around the umbilicus. Urination was normal, and the bowels were 
constipated. For the past four or five years there has been a profuse 
yellowish leuoorrhoea. 

Upon examination, the uterus was found to be enlarged and retro- 
displaced, but not fixed. The cervix was hypertrophied and deeply 
torn. A careful examination of the abdomen revealed nothing ab- 
normal. As the subjective symptoms were evidently due to the dis- 
eased condition of the uterus, the patient was etherized on the 20th of 
October, when the cervix was amputated and the interior of the womb 
curetted. The patient made a rapid recovery from these operations, 
with the relief of all her former symptoms. On the 3d of Novem- 
ber, however, she b^an to complain of pain and slight soreness over 
the entire abdomen. The temperature and pulse were normal. The 
pain has increased in severity, but shows no tendency to become local- 
ized. A most careful examination of the pelvis and abdomen has 
revealed nothing except a slight soreness over the entire surface of the 

266 



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266 INTERNATIONAL. CLINICS. 

heUy, but not accentuated at any one point. A chemical and micro- 
scopical examination of the urine has excluded disease of the kidneys 
or bladder. At no time has the temperature or pulse been abnormal. 

This is the eleventh day since her symptoms b^an^ and I bring 
the case before you to make an exploratory incision to discover, if 
possible, the cause of the pain and remove it. 

While the patient is being etherized, let us discuss briefly the indi- 
cations for an exploratory abdominal incision. 

My rule in practice is to open the abdomen for purposes of diag- 
nosis in all obscure cases where the symptoms indicate immediate 
danger to life or where they point to pathological conditions that are 
likely in the future to cause death ; and, finally, in all obscure cases 
for the relief of pain or of symptoms producing chronic disability. 

To illustrate these points, permit me to refer briefly to a few cases 
coming under my personal observation. In the fall of 1891 I saw, in 
consultation with Dr. Thomas Curry, of this city, a patient who was 
dying gradually from chronic intestinal obstruction. Upon examina- 
tion, the abdomen was so tympanitic that no cause for the condition 
could be demonstrated. An exploratory incision revealed a tumor of 
the ileum which almost completely occluded the lumen of the gut. A 
lateral anastomosis was performed, and the patient is to-day in perfect 
health. Another case was that of a boy, eleven years of age, whom 
I saw in consultation with Dr. Fries, also of this city. The child 
had received an abdominal injury seven days before my visit. The 
day following the accident symptoms of peritonitis began to develop, 
and the attending physician urged a consultation with an abdominal 
surgeon. The family, however, refused to give their consent until 
a week later, when I was sent for. An exploratory incision revealed 
intussusception in the small bowel, extensive sloughing, and a general 
purulent peritonitis. Death occurred a few hours later. In neither 
of these cases was a diagnosis made prior to abdominal section. 
Both patients were operated upon solely on account of the symptoms 
which indicated danger to life. Had an exploratory incision been 
performed in the case of intussusception when the attending physician 
first urged it, the boy would in all probability have recovered. I 
wish to emphasize this fact, because it so often happens that the sur- 
geon is called in at a time when the patient is beyond the resources 
of surgery. This is especially true in cases of abdominal injury, 
acute intestinal obstruction, ectopic gestation, appendicitis, and other 
like conditions. 

Among those cases where the symptoms point to pathologic condi- 



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THE EXPLORATORY ABDOMINAL INCISION. 267 

tions that are likely in the future to cause death^ and consequently call 
for an exploratory incision, the most important is malignant disease 
of the stomach. Unfortunately, the surgeon is not consulted in the 
majority of instances until the patient is so exhausted by the disease 
that even the temporary relief afforded by a gastro-enterostomy is 
contra-indicated. If an early exploratory incision is made in these 
cases, even if a radical cure cannot be promised, we can at least prolong 
life and save the patient from the symptoms of pyloric obstruction. 
I would not have you infer that I advise opening the abdomen upon 
the slightest suspicron of malignant disease, or without a most careful 
consideration of the case, but I do most emphatically believe that we 
should not wait for the presence of a, tumor and other unmistakable 
signs before considering the question of an exploratory incision in 
certain chronic diseases of the stomach. 

I saw, in consultation with Dr. Strittmatter, of this city, a case 
which illustrates in a striking manner the intense suffering caused by 
delay in resorting to surgery. The patient was a man about fifty years 
of age. He had been bedridden for several months, and was ema- 
ciated to the last d^ree, and suffering intensely from all the symptoms 
dependent upon pyloric stenosis. The man's condition did not war- 
rant an operation, and he died a few days later. Had Dr. Strittmatter, 
however, seen this patient early in the course of the disease, an oper- 
ation would have saved months of needless suffering. 

Again, an early exploratory incision will enable the surgeon to 
make a positive diagnosis in the non-malignant varieties of pyloric 
stricture, and not only to cure the condition, but also to save the 
patient from painful and exhausting symptoms or even from death ; 
the same is also true in certain cases of gastric ulcer. 

Finally, the abdomen should be opened in all obscure surgical 
diseases involving its contents, to enable a positive diagnosis to be 
made, and to obtain, if possible, radical relief. To impress upon you 
the necessity for abdominal exploration under these circumstances, I 
shall refer to a case sent to me by Dr. D. H. Oliver, of Bridgeton, New 
Jersey. The patient was a man twenty-five years of age. He had 
during 1893 three attacks of appendicitis. At the time he consulted 
me he had entirely recovered from the last attack, and was attending 
to his duties as a railroad conductor. There was apparently nothing 
immediately dangerous in his condition, yet the history of three recent 
attacks of appendicitis settled in my mind the absolute necessity for 
an exploratory incision. To this the patient consented. Upon open- 
ing the abdomen the appendix was found behind the colon, buried 



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268 INTERNATIONAL CLINIGB. 

beneath firm and dense adhesions which required the free use of the 
knife to separate them. The base of the appendix had sloughed, and 
surrounding it was a small abeoess-cavity containing about fifteen drops 
of pus. The patient made an uninterrupted recovery. 

This case is most instructive, as it illustrates forcibly what I have 
been teaching for the past two years, — namely, that as it is impossible 
in cases of appendicitis to know the patliological conditions present 
at the seat of trouble, there is no treatment for the disease so reliable 
as the knife. 

In those cases where an exploratory incision is* indicated for pain 
or disability to carry on the duties of life, the symptoms have been 
present for a long period of time, without, however, there being any 
immediate or apparently remote danger to life. The diagnosis in 
these cases is not only obscure, but in many instances impossible. In 
this group of cases we include various chronic pelvic troubles, intes- 
tinal adhesions, non-mah'gnant abdominal growths, etc 

I could readily cite many instances that I have seen, not only in 
ray own practice, but also in the hands of other surgeons, in which no 
idea of the true condition could possibly be formed prior to an ex- 
ploratory incision, and yet in a number of these cases not only was a 
positive diagnosis made upon opening the abdomen, but, more im- 
portant still, radical relief was obtained. I shall not have time, how- 
ever, to enter more fully upon this subject, as the patient is now fully 
under the influence of the ansesthetic. 

You will notice that I have made the incision through the beUy 
wall in the median line. This should always be its situation, except 
when the symptoms are localized or refer to certain regions or organs 
within the abdomen. For example, if the symptoms indicate that 
the seat of trouble is in the stomach, the liver, the appendix, or one of 
the other organs, the incision must be made directly over its normal 
position within the peritoneal cavity. As the symptoms in the patient 
before us are not localized, the median incision is selected &s being the 
best from which to explore all of the alidominal contents. I have 
now examined the pelvis, but fail to find anything abnormal. En- 
larging the incision towanls the umbilicus, and introducing my entire 
hand within the abdomen, I examine the small intestines, the large 
abdominal blood-vessels, and the kidneys. Continuing the investi- 
gation higher, I have ascertained the condition of the viscera in the 
upper s^ment of the peritoneal cavity. Thus far nothing has been 
found a*bnormal ; the oi^ns are apparently healthy and free from ad- 
hesions or new growths. 



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THE EXPLORATORY ABDOMINAL INCISION. 269 

We shall now examine carefully the right iliac fossa. The csecum 
evidently in this case is entirely, covered by peritoneum^ the meso- 
colon^ as there is more latitude of movement than is generally present 
Making gentle traction and endeavoring to bring the colon into view, 
I find that after reaching a certain point it becomes fixed. This means 
either that its limit of movement has been reached or that an adhe- 
sion prevents the bowel from being brought nearer to the median line. 
Keeping up gentle traction upon the head of the colon, I pass my 
finger around the bowel and find that the appendix is taut and its tip 
adherent to the side of the pelvis. This condition at once explains not 
only the fixation of the bowel, but also, I take it, the cause of the 
symptoms from which this patient has sufiered, as these adhesions 
mean a pre-existing inflammation. The tip of the appendix has now 
been freed, and at once the csecum comes into view. The appendix 
is somewhat thicker than normal, but not markedly so, and at its tip 
you can see distinctly the little fringe-like projections which are the 
adhesions that have been separated. 

The slight thickening of the appendix, and especially the fact that 
it was adherent, settle in my mind the necessity for its removal. As 
the appendix is not attached by a fold of peritoneum, we at once place 
a silk ligature around the base and remove it. The mucous membrane 
is now (mretted away from the stump, which is invaginated into the 
colon and held in position with silk sutures. As irrigation is not in- 
dicated, nothing remains to be done but to close the abdomen and apply 
the usual dressings over the wound. 

I shall now make an incision into the appendix and expose its 
interior surfiu^e. Those of you who are near will notice the fin of a 
fish occupying the extremity of its canal. The mucous membrane is 
inflamed, and you will also observe the evidences of traumatism caused 
by the fin as it worked its way downward. 

We have, then, in this specimen a full explanation of the symptoms 
in this case. It is one of those rare instances of appendicitis in which 
the symptoms failed to indicate the grave pathologic conditions present 
or to show a tendency to become localized. This is the second case of 
its kind of which I have a personal knowledge. The first case occurred 
in the practice of Professor Keen, of this city. He performed an ex- 
ploratory operation upon a woman for severe abdominal pains which 
were not localized. The symptoms were so obscure that a diagnosis 
was impossible. Dr. Keen found upon section that the patient was 
sufiering with appendicitis, and he removed the appendix. The macro- 
scopic examination showed a catarrhal inflammation and a stricture in 



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270 INTERNATIONAL CLINICS. 

the middle of the appendix ; there was no foreign body. The patient 
made a good recovery, with entire relief from all her former symptoms. 

The happy result of the operation which has been performed 
before you this morning will impress upon your mind the urgent 
necessity for appreciating the position which the exploratoiy incision 
holds in surgical practice. We have in this method of diagnosis a 
means which is not only perfectly safe, but also accurate in many 
instances. Although I do not hesitate to say that an exploratory in- 
cision is without danger to life, yet you must thoroughly understand 
that it is frequently fatal unless performed by a surgeon whose aseptic 
technique is beyond criticism. Dirt introduced within the peritoneal 
cavity will be followed by a septic infection just as certainly as micro- 
organisms will develop in a culture medium in the laboratory. Again, 
the post-operative environment of a patient upon whom an exploratory 
incision has been performed can in no way cause the development of 
sepsis, and if this condition supervenes, the infection occurred at the 
time of operation. Sepsis cannot occur from external causes after the 
abdomen has been completely closed. Take, for example, if you please, 
the culture medium contained in a glass tube whose open end is closed 
tightly with a plug of cotton. After sterilization, it makes no differ- 
ence where the tube is placed, or where it is kept, or what may be its 
surroundings, the culture medium remains sterile so long as the cotton 
plug is not disturbed. This is precisely the condition aft>er an abdom- 
inal operation not septic at the time or followed by drainage. No 
germs from without can enter an abdomen tightly closed, any more 
than they can infect the culture medium protected by the cotton plug. 
Therefore the surgeon who has a septic infection following an abdom- 
inal operation under these circumstances must look to the operative 
technique, and not lay the blame for want of success upon the subse- 
quent environment of his patient. I have referred to this subject, as 
it is important for you to know and appreciate the causes of death 
following an exploratory abdominal incision. 

[The patient made a prompt recovery.] 

The following is a report from the Kyle-Da Costa laboratory of an 
examination made of the appendix. 

The Macroscopic Examination. — ^The appendix had been opened by 
a longitudinal incision which extended above and below the inflamed 
area and exposed the fin of a fish. The tissues surrounding the base 
of the fin are highly inflamed. The irritation caused by the foreign 
body in its passage down the appendix is marked by a well-defined line 
of inflammation. 



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THE EXPLORATORY ABDOMINAL INCISION. 271 

The JHcroscopio Examination. — The examination of sections made 
from the inflamed area shows that the pressure and irritation of the 
foreign body had caused capillary thrombosis or a blocking up of the 
circulation which was almost complete. The obstruction to the cir- 
culation is further increased by transudate, and possibly by a pro- 
liferation of exuded corpuscles. The hemorrhagic area showed disin* 
t^ration of the mucous epithelial cells, some having undergone fatty 
d^eneration. If this process had continued, an abscess would have 
resulted^ owing to the evident infection of the parts. 



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OVARIAN NEOPLASMS. 

CLINICAL LXCTURE DELIYEBBD AT THE LONG ISLAND COLLEGE HOSPITAL. 

BY ALEXANDER J. C. SKENE, M.D., 

Professor of Gynaecology, Long Island College Hospital, and Dean of the Faculty, 



Gentlemen, — Diseases of the ovary of the degenerative order 
will occupy our attention this morning. First of all, we shall con- 
sider ovarian tumors or ovarian neoplasms. There is a great variety 
of these neoplasms. I simplify the classification, so that you can easily 
remember it, as follows : tumors that can be controlled and the lives 
of the sufferers saved by surgical means, and those that are not so 
amenable to treatment and in which the tendency is towards the de- 
struction of the individual. You will see at a glance that the latter 
class includes all the malignant diseases of the ovaries, fortunately the 
most rare. The most common are the simple cysts or cystomata, neo- 
plasms made up of a single cyst or a number of cysts, usually the 
latter. First let us inquire as to where they take their origin in the 
ovary, because we shall find that according to their location in the 
ovary will be their character or anatomy to a certain extent. 

The ovary is divided into a mature glandular portion, where are 
found the matured Graafian follicles, and a deeper portion, where we 
find the immature or rudimentary ones. In the glandular structure the 
ordinary ovarian cysts are developed ; in the deeper structure we find 
another variety of cysts, differing somewhat from the ordinary cysts 
in their character. They are all cystic neoplasms, but they differ to 
some extent in their anatomical characteristics. 

Let me also call your attention to another variety of cysts ; they are 
formed in the neighborhood of the ovaries and are oflen confounded 
with them. They are the parovarian cysts, which originate in the paro- 
varium, — ^a number of convoluted tubules or dncts above the ovary, 
the remnant of a foetal organ ; they seem to serve no purpose, and we 
never hear of them except when occasionally a cyst is formed in one 
of the ducts. These cysts grow in the same way as ovarian cysts. In 
272 



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OVARIAN NEOPLASMS. 273 

the books they are sometimes called cysts of the broad ligament. Occa- 
sionally a cyst that is developed in the ovary becomes an intra-liga- 
mentous cyst, and so has been confounded with a parovarian cyst, and 
there is apt to be more or less coDfusion in the minds of students and 
even of physicians with r^ard to these cysts. There is no broad liga- 
ment cyst, properly speaking, and I should like to have that term 
blotted out of our books. It is either a parovarian cyst or an ovarian 
cyst that has found its way into the broad ligament There is no such 
thing as a cyst that takes its origin, in the broad ligament, as a rule at 
least. 

Ovarian cystomata are usually multiple, or multilocular, but they 
may be unilocular. When one cyst so fer outstrips the others that it 
monopolizes them, we call that, clinically speaking, a monocyst; 
whereas if a number of cysts make up the cystoma, we call that a mul- 
tilocular or multiple cyst They consist of a cyst wall and the cyst 
contents. When a cyst is developed in the deeper structures of the 
ovary, it is nearly always complicated by a growth from its inner wall, 
and this is known as a proliferous cyst. Ocoisionally we find developed 
in the deeper structures of the ovary another form of cyst, known as 
the dermoid cyst, the contents of which differ very materially from the 
contents of the other forms, as it contains hair, bone, teeth, and some- 
times fatty material ; in fiEu^, the fluid contained in a dermoid cyst is 
often composed of fat in a fluid state. The parovarian cyst is always 
single, with no other little cysts around it ; it always contains fluid, 
which is pure serum or water ; the inside and outside of it are per- 
fectly smooth. The simple cyst consists of a cyst wall and a pedicle 
which attaches it to its source or point of origin. A true ovarian cyst, 
as it grows, carries with it the peritoneum and the Fallopian tube ; the 
utero-ovarian ligament is included in the pedicle, also the vessels, both 
veins and arteries ; these often become v^y markedly enlarged. 

These tumors of the ovaries grow slowly and persistently, and we 
find three clinical stages of their growth : first, when they are yet 
small and occupy the pelvis ; second, when they become so large that 
the pelvis can no longer contain them, and Ihey rise up into the ab- 
dominal cavity ; third, when they become so enormously large as to 
interfere, by reason of pressure, with the functions of the abdominal 
and thoracic organs and the general nutrition. Between the second 
and the third stages it is a matter of d^ree ; between the first and the 
second it is a matter of location. At first such a tumor may give rise 
to no great inconvenience. As the growth increases it presses upon the 
abdominal oi^ns, interferes with the quantity of food taken, with di- 
VoL. I. Ser. 4.— 18 



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274 INTERNATIONAL CLINICS. 

gestioD^ and with respiration by crowding upon the diaphragm^ and 
thus the general nutrition begins to suffer. The tendency of these 
tumors is towards the destruction of the individual. They keep on 
growing until the individual is crowded out of existence. Besides this, 
there are often complications which are of vast importance to the sur- 
geon. The first and most important complication of all is circum- 
scribed peritonitis. The frequency with which this occurs and the 
extent of the inflammation depend considerably upon the nature of the 
tumor. A simple cyst, if no accident happens, rarely excites very much 
inflammation. The proliferous cyst seems more inclined to do that, 
probably because it is more vascular and can more easily set up an in- 
flammation. The dermoid cyst — fortunately a rare one — almost always 
sets up an inflammation. These inflammations lead to adhesions, and 
the extent of such adhesions depends upon where the peritonitis tskes 
place. If it take place in the first stage of the tumor, the cyst will 
become adherent to the pelvic organs, and will not be able to rise into 
the abdomen. If, however, no inflammation take place until the tumor 
rises into the abdomen, the adhesions to the abdominal walls, intestines, 
and omentum will occur. Sometimes the lower portion may adhere to 
the broad ligament 

If inflammation does not take place until the third stage, the adhe- 
sions may be to the diaphragm, the liver, or the upper part of the 
abdominal walls. The degree and extent of the adhesions will depend, 
naturally, upon the duration of the tumor. Nowadays we seldom see 
adhesions so high up. The laparotomists are so alert that they hardly 
ever allow a patient to go on to that stage. Now, why this inflamma- 
tion? The nature of the tumor itself favors adhesions. The more 
complicated the pathological anatomy of the tumor the more certain 
are you to have adhesions. We may also have a rupture of one of 
these cysts, and its contents, poured into the abdominal cavity, will set 
up a peritonitis. This may occur in any stage, but it is most likely to 
occur in the second or the third stage. Then the peritonitis is very 
likely to prove fittal unless the surgeon is quickly on hand. If the 
patient is in a state of c6llapse, the surgeon may not dare to operate. 
Sometimes the rupture, if a small one, will close and the tumor will 
grow again, and then if you endeavor to remove it you will find it 
much more difficult or even impossible to do so. I have seen it im- 
possible to remove such a tumor at a post-mortem. Then, again, the 
cyst may open, not by direct rupture, but by ulceration and perforation. 
A little d^eneration takes place at a given point; the contents seem 
to get ahead of the development of the sac, which is very tense, and 



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OVARIAN NEOPLASMS, 275 

perforation takes place ; then there is a discharge of the ovarian fluid, 
and that may set up a general peritonitis. Again, if the sac is not so 
tense, and the cyst wall is ample, and the leaking not so marked, but 
enough to set up a conservative peritonitis which closes the opening, 
all you will find there will be a rather firm adhesion. 

There is another curious complication which sometimes takes place, 
where the tumor rotates or revolves. Usually an oblong or irregularly- 
shaped tumor will turn around and twist the pedicle. If this is re- 
peated it cuts off the blood-supply, and then there is acute starvation 
of the cyst. The return of the blood from the cyst is also interrupted, 
and there will be an extraordinary engorgement of the sac, and in 
general more pressure and pain and constitutional symptoms. If there 
be starvation and death of the tumor, there will be present the general 
and local symptoms due to this mass suddenly dying. When the 
pedicle becomes twisted, it requires immediate interference, as it may 
prove fatal in a very short time. This dead mass will excite inflamma- 
tion, and if the patient is not relieved by the surgeon, septicaemia will 
result There is yet another complication, less severe and less alarm- 
ing, and that is partial necrosis of the sac,^-death of the cyst wall. 
That comes about where the cyst wall is tolerably thick and where the 
circulation is not well developed. It is likely to occur in patients who 
have a feeble constitution, — ^in stout old women. One-half or one-third 
of the cyst wall dies. It may be due to a degeneration of the blood- 
vessels which supply these parts. It shows itself by producing, a 
certain d^ree of malnutrition, as if this dead mass caused a slight 
septicsemia. It rarely excites acute inflammation. The constitutional 
symptoms are generally the first to be noticed : the patients lose flesh 
and have general malnutrition, and you can find no local pain nor 
inflammation to account for it. 

There is another condition which I wish to speak about, and that 
is utero-gestation. Pr^nancy occasionally occurs in the presence of an 
ovarian cyst, and it is a serious complication ; serious because if gesta- 
tion goes on the tumor will grow more rapidly. This will cause a 
distention of the abdomen from the gestation and from this tumor also, 
which will give rise to unusual pressure and inflammation. So when 
you find a case of gestation accompanying a tumor of the ovary, you 
may expect all complications to take place. We take a hint from this, 
and either remove the tumor before the period of gestation has advanced 
very far, so as to allow gestation to go on, or, as others recommend, 
interrupt gestation at an early stage. But here comes in a moral ques- 
tion which I have no right to settle for you : you must settle that for 



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276 INTERNATIONAL CLINIOS. 

yourselves and for your patients. I may say here, however, that the 
early removal of the ovarian cysts gives about as good results as 
emptying the uterus, and by that method we are free from all question 
of doing wrong. 

There are many other conditions complicating ovarian cysts, but I 
shall omit them, as they are less important. The causes of these ovarian 
cysts are very obscure. We know very little about them. We have 
speculated and investigated for a long time, and the conclusions we have 
come to are not very satisfactory. And yet it is a question that we are 
being asked all the time. To save my own time, I always say £ do not 
know. One holds the idea that it is simply a dropsical condition on 
account of disease of one or more of the Graafian follicles, — that the 
wall of the follicle goes on growing and cyst fluid forms. Another 
tells us that in the deeper structure of the ovary, where we meet Mrith 
the proliferous form of the cysts, there is a d^neration of the blood- 
vessels, which forms a cyst. 

Eespecting the cause of dermoid cysts, much speculation has been 
indulged in. We know to-day that they occur in the deeper portion 
of the ovary, and we believe that the germ of these cysts exists from 
the beginning, from the development of the ovary ; that they remain 
latent until adult life. Anotlier theory is that during the* development 
of a single embryo, there was material enough for two ; that the original 
design was to have twins, but by some means one got ah^, and the 
other one got caught in the ovary and remained quiescent until the 
adult age of the first, and then formed a dermoid cyst. 

Much time and study have been spent in trying to discover the 
causes which produce the several varieties of ovarian cysts, but there 
is very little definite knowledge on the subject ; if we knew their 
causation, we might, by some means or other, prevent their coming ; 
but until then we are unable to battle with them successfully. 



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RUPTURED TUBAL PREGNANCY. 

CLOriGAL LKCTUBI DKLIYERSD AT THB BUFFALO OSKSRAL HOSPITAL. 

BY MATTHEW D. MANN, A.M., M.D., 

ProfesBor of Obstetrics and Gynsecology, University of Buffalo ; Attending Gyna 
cologist to the Buffalo General Hospital. 



Gentlemen^ — ^This patient came to the collie dispensaiy^ whence 
she was referred to the hospital that I might see her and give an 
opinion r^arding her case, which is somewhat unusual and interesting. 
She is thirty-two years of age, and has been married fourteen years, 
having had three children; the last nine years ago. Her general 
health has been good, her menstruation r^ular and painless, and not 
too copious. A week ago last Friday, about the time when she ex- 
pected to be unwell, she had bearing-down pains in the back, and 
extreme pain in the bowels, which was relieved by the external appli- 
cation of heat and the internal use of some alcoholic stimulant. The 
pain lasted, however, a whole week, — not continuously, but intermit- 
tently, like labor pains. After two days the menstrual flow began, 
the pain remaining unchanged. She was not relieved till she went 
to the dispensary, where she was given phenacetin, and the flow did 
not cease till yesterday (Sunday), nine days from the b^inning of the 
trouble. 

Now, from the clinical history of the case we have not been able to 
make a diagnosis with any certainty, but fortunately my assistant was 
able to examine her when she came to the dispensary last Friday, a 
week after the beginning of the trouble, and at that time he found 
something more than can be found to-day. Behind the uterus, and es- 
pecially on the right side, there was more or less enlargement, — a mass 
of some kind, rather firm and exceedingly tender, so tender that it was 
difficult to make a careful palpation of it She was still suffering from 
the bearing-down pains. The doctor was in doubt as to the diagnosis, 
though he surmised what it might be, gave her appropriate medicinal 
treatment, and asked her to come here. She is now very much better, 
and the pelvic mass which the doctor felt the other day has very greatly 

277 



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278 INTERNATIONAL CLINICS. 

diminished^ so much so that if I had not had my attention called to it 
I should hardly have found it. There is still, however, a little thicken- 
ing behind and to the right of the uterus, and as I press directly back- 
ward there is some tenderness. At the time the patient was at the 
dispensary neither elevation of temperature nor acceleration of pulse 
were found. 

From the history, perhaps the first thing of which we should think 
would be extra-uterine pregnancy, with a ruptured tube. It might also 
be an inflammatory condition in the tul)es, with a certain amount of 
pelvic peritonitis, or some growth which had existed there ; for example, 
a small dermoid cyst of long duration, which had given no previous 
trouble and had suddenly become irritated and had caused this pain. 
Or the case might simply have been one of dysmenorrhoea, with the 
inflamed condition of an old dermoid cyst or some other tumor. Some 
of these diagnoses are thrown out at once by the examination to-day. 
If there had been a dermoid or ovarian cyst or other tumor, it would 
remain to-day, and we can safely exclude these suggestions. With 
r^ard to the diagnosis of inflammatory trouble, there was no rise of 
temperature, and the woman had been previously in good health, with 
no reason for inflammation in the pelvis. Although the result of the 
digital examination would correspond with inflammation and the for- 
mation of an exudate, the lack of febrile symptoms does not corre- 
spond, nor should we expect an inflammatory mass to have disappeared 
so rapidly. The case might also have been an abortion at one month, 
and the expulsive pains would lend credence to this view ; but there 
would not have been the mass behind the uterus unless there had been 
retained secundines and septicaemia with septic salpingitis and peri- 
tonitis, and these conditions would not have passed away in three days ; 
so I think we can throw out that idea also. There might have been 
an abortion and possibly a hsematooele, a certain, amount of blood 
escaping from the tube without any tubal pregnancy, but we have 
no proof that such a condition can exist, and tubal pregnancy is much 
more likely to be the true diagnosis than the r^urgitation of blood 
from the tube and a consequent hsematocele. I think, therefore, that 
we are brought down to the diagnosis of ruptured tubal pregnancy. 
As I have told you in the didactic lectures, I believe tubal preg- 
nancy is very much more common than has ordinarily been supposed. 
I have no doubt that there was blood in the peritoneal cavity, and 
that the extreme tenderness was due to irritation of the peritoneum 
and slight peritonitis, but not of a septic type. In the mean time 
almost all the blood has been absorbed and there is left only a little 



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RUPTURED TUBAL PREGNANCY. 279 

thickening, which can be explained as being a little remaining blood, 
and a certain amount of exudation into the peritoneum, which exuda- 
tion will be absorbed much more slowly than the blood itself. The 
amount of hemorrhage was very slight. 

These cases of ruptured tubal pr^nancy almost always have a 
bloody discharge from the vagina soon after rupture, — within a few 
hours or sometimes afl«r a day or two, — and they flow almost continu- 
ously. The books do not state this, but describe gushes of blood and 
stoppages, which I do not find to be the case in my experience. I 
have seen patients who have flowed six weeks, dating from the time of 
rupture. In such a case as this there is nothing to do ; nature has 
taken charge of the affair ; the hemorrhage has ceased and the blood 
has been almost entirely absorbed. The patient will doubtless entirely 
. recover, and the tube may even r^ain its normal condition, as the rup- 
ture at so early a time in pregnancy is slight, and perhaps in a year 
from this time, if we had an opportunity to examine the pelvic organs, 
we might find nothing more dian a little scar showing the place of 
rupture. 

Only the other day I saw an undoubted case of ruptured tubal 
pr^nancy. The patient was operated upon by another operator, and, 
unfortunately, died, but the diagnosis was confirmed. I have seen 
twenty cases of tubal pr^nancy in the last eighteen months. Half 
of these have been subjected to operation and the diagnosis confirmed ; 
the others were either treated by electricity and cured, or their condition 
was not such at the time that I saw them as to demand any treatment 
whatever. 



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UMBILICAL HERNIA, EARLY MENOPAUSE; LACER- 
ATED CERVIX AND VAGINAL ENTEROCELE; 
RECTOCELE, LACERATED CERVIX, AND RETRO- 
VERSION. 

CLINICAL LSCTURS DSLIVXRSD AT TBI NEW TOBK POLTCLIKIC. 

BY PAUL P. MUND£, M.D., 

Professor of Gyniecology in the New York Polyclinic. 



UMBILICAL HERNIA; EARLY MENOPAUSE. 

GENTLEMEN; — This patient is forty-one years old. She has been 
married about eight years^ and has had three miscarriages, the last at 
the third month, one year ago. She complains of pain in the lower 
part of the back and in the ovarian r^ons, and of hot flashes through 
different parts of the body, followed by profuse perspiration. You 
notice the woman has a large abdomen, which is very tense and which 
closely simulates an abdominal tumor. On percussion it is found to 
be resonant throughout, and on lifting up the abdominal wall with 
the hand we find she has a great deal of adipose tissue. Besides this, 
on allowing her to lie quietly for a moment with her mouth open, 
the parts are relaxed and the abdomen is gradually reduced in size, 
thus showing that there is no abdominal tumor, but that the disten- 
tion is due to &t, flatulence, and muscular resistance. This, then, is a 
&lse tumor. In addition to this you notice a protrusion at the um- 
bilicus, which is increased on coughing, and on gently inserting the 
finger into the centre of this protrusion we find it can be replaced, and 
that the finger encounters a sharp, tense ring about half an inch in 
diameter. This is the umbilical ring, and the protrusion is an umbili- 
cal hernia. As there is considerable discomfort and pain on pressure, 
we shall advise her to get an abdominal supporter with a hard rubber 
or wooden pad, which will gently press down the protruding intestine 
and dose the ring. Such bandages, however, are very apt to slip, and 
if the pressure be great the pain will be more severe than the condi- 
tion which they are expected to relieve. I have seen the intestines 
280 



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UMBILICAL HERNIA; EARLY MENOPAUSE* 281 

forced out through an opening even smaller than this until the protru- 
sion was as large as an ^g, and the i>art becoming incarcerated, it was 
necessary to give an ansesthetic and freeze the tissues before the pro- 
trusion could be returned. If this had not been successful, an incision 
would have had to be made down to the ring and the latter slit 
upward and downward, to allow of the reduction of the hernia. It 
would be desirable, then, to freshen the edges of the ring and unite 
th^n by deep sutures passed through the peritoneum and the whole of 
the abdominal wall. Sometimes these umbilical hernias are very large. 
The largest abdominal hernias we find are not umbilical hernias proper, 
but are really ventral hernias, from the separation of the recti muscles 
as a result of numerous confinements, or after a laparotomy. The scar 
from such a wound often weakens the abdominal wall, allowing the 
formation of such a hernia. In operating upon one such case I re- 
moved an intra-Iigamentous ovarian tumor. She had had two previous 
laparotomies done. I freshened the parts on either side and brought 
them together by deep sutures after removing the ligamentous cyst. 

This woman, who is forty-one years of age, has not menstruated for 
nine months, and complains of hot flashes or waves followed by profuse 
perspiration. This is one symptom of the condition which I presume is 
already here established, — viz., " the change of life." You might look 
for pregnancy at her age, but menstruation has already ceased for a time 
equal to the normal period of gestation, and an examination n^atives 
this theory. The uterus is, however, enlarged, hard, and slightly ante- 
flexed. The enlargement of the uterus is due in all probability to a 
fibroid in the anterior wall and towards the left side. One would ex- 
pect, under such circumstances, that the patient, instead of being amen- 
orrhoeic, would be menorrhagic ; but subperitoneal fibroids do not, as a 
rule, have any such efiect upon menstruation. Almost all women who 
are passing through the period known as ^^ the change of life" sufler 
more or less from hot flashes and perspiration, and also from a great 
variety of other neurotic symptoms, which disappear when the meno- 
pause is fully established. The cervix is so &r behind in this case, 
and the patient so nervous, that I shall make no further attempt to 
introduce the sound. Usually in cases of uterine fibroids the meno- 
pause is postponed, yet in this patient the menopause seems to be rather 
earlier than common. I am unable to explain her reaching the meno- 
pause so early. I have two patients (sisters), one about forty and the 
other forty-four years of age, who have told me that they have at times 
skipped long periods — at one time six years and at another nine years 
— without being unwell at all, and then menstruation has returned 



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282 INTERNATIONAL CLINIOS. 

naturally. The sister who is forty-four years of age conceived about 
one year ago^ and was four months pr^nant when she came under 
my care on account of diabetes. Some years before she had had a 
dead child, and had nearly lost her own life from the debility conse- 
quent upon the confinement complicated with the diabetes. She came 
to get my advice as to the advisability of allowing pr^nancy to go on 
to term. There is very little literature upon this subject, but I found 
in Lusk^s book a brief risvmi of the statistics of the subject, showing 
that about fifty per cent, of the diabetic women who went to term 
died. The family physician not agreeing with me about advising 
abortion, the case was referred to Dr. T. G. Thomas, who also advised 
abortion, and this I produced. She is now in good health. The 
case is interesting as showing that a person may, under certain circum- 
stances, go for nine years without menstruating and yet afterwards con- 
ceive. An early menopause is sometimes due to excessive involution of 
the uterus and ovaries following confinement. I have seen it occur as 
early as the twenty-sixth year. I have been told by one of my patients 
that she ceased menstruating at the age of twenty-five, after a difficult 
confinement. Both uterus and ovaries might atrophy as a result of pel- 
vic peritonitis and a consequent shrinking of the peritoneal adhesions, 
and of course such a condition is not amenable to treatment ; but so long 
as there is a menstrual molimen, even without any flow, the local use of 
electricity, intra-uterine applications of carbolic acid, hot douches, and 
measures directed towards building up the general health may prove 
successful. 

LACERATED CERVIX AND V^^GINAL ENTEROCELE. 

The next patient is twenty-six years of age. She has been mar- 
ried three years, and has had two children and one miscarriage. The 
last delivery was six months ago. She flows every four weeks for six 
days, the last time being two weeks ago. She complains of pain in 
her back and on the left side of the abdomen, and of proftise white 
vaginal discharge. After the birth of her first child she says she had 
" blood-poisoning," and was sick in bed for some time. 

This is a case in which the finger detects a rather peculiar condi- 
tion. The uterus is in the first degree of prolapsus, the cervix being 
two inches within the vulva, and, as is usual in such cases, it is also 
retroverted in the first d^ree, the axes of the uterus and the vagina 
being about in the same plane. The external os gapes so as to allow 
the passage of the finger one-half inch into the canal ; the cervix 
has evidently been torn, but this laceration has been intra-cervical, and 



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MENOPAUSE. 283 

the tear has not extended into the mucous membrane of the vagina. 
This laceration has been the cause of the subinvolution. The only 
cure for such a tear is to make it a complete laceration hy cutting 
the rent in the cervix down to the vaginal wall, paring the edges^ and 
sewing it up in the usual way. There is a coil in Douglas's cul- 
de-sac which feek like a loop of small intestine^ into which you can 
introduce your finger and push it from side to side. On the left side 
you can feel the ovary and tube. I think, therefore, this is an empty 
loop of small intestine which has dropped down into Douglas's pouch. 
This is mi unusual condition, for ordinarily this pouch is empty. In 
the normal position the uterus is slightly antecurved, the anterior 
wall of the rectum lying against the posterior wall of the uterus, and 
the superincumbent intestines keeping the uterus well anteverted, so 
that there is not room for a loop of the small intestine to slip down 
into Douglas's pouch. Formerly it was not known that anything 
ever occupied this pouch, but laparotomists have shown that it is not 
always empty. I am unable to explain the condition here, unless it be 
that the uterus lias changed its position and has sunk down into the 
pelvis so as to remove the fundus from the anterior surfisice of the 
rectum. This cord-like body might be a Fallopian tube, 'but it is not 
very tender, and if a tube had reached this size it would be decidedly 
tender. Ordinarily the contents of this pouch are not of much impor- 
tance ; but if it became necessary to operate, as, for instance, for supposed 
abscess in Douglas's cul-de-sac, the possibility of a coil of small intestine 
getting down into this pouch would be a matter of some importance. 
It also assists us in understanding how a vaginal hernia may take 
place, — the so-called enterocele. A number of cases are on record 
where, during confinement, an obstacle to delivery has been found in 
the shape of an elastic tumor at the vulva, which at first was naturally 
supposed to be an ovarian cyst. An examination, however, woqld 
show that it was resonant all over on percussion, and hence the proper 
treatment would not be tapping, but would consist in puMing the 
woman in the knee-chest position and trying to push up the presenting 
part and the prolapsed intestine. The obstacle might become so great 
as to necessitate the performance of craniotomy, in order to avoid 
dangerously long pressure upon the bowel. 

MENOPAUSE. 

Our next patient is forty-seven years old. She has been married 
thirty years, and has had four children and two miscarriages, the last 
twenty-two years ago. Her last menstruation was four months ago. 



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284 INTERNATIONAL CLINICS. 

This case is similar to the one first presented to you to-day. She 
comes to us complaining of headache^ hot flashes^ and sweatings. She 
is suffering from the symptoms of the climacteric^ and I mention the 
case only to associate it with the other one which has already been 
brought before you. The fact that this woman has pretty well passed 
the menopause is shown by the introduction of die sound, which 
indicates that the uterus, instead of being two and one-half inches long, 
is only two inches in depth. The shortness of the cervix at once 
indicated to me that the uterus was beginning to undergo the natural 
atrophy of the climacteric The treatment of such patients consists in 
the use of valerian, asafcetida, and similar drugs, in regulating the 
functions of the body, and in explaining away their fears as to the 
gravity of their symptoois. 

REOTOCELE, LACERATED CERVIX, AND RETROVERSION. 

I next present to you this woman, who is thirty-nine years old. 
She has been married seven years, and has had two children and two * 
miscarriages. The last was a miscarriage at the tenth week, and oc- 
curred eleven months ago, since which time she has complained of 
pain in the back and right side of the abdomen, and of headache. She 
menstruates every four weeks for two or three days, the last time being 
one week ago. There is a bloody vaginal dischai^. 

On separating the labia, you notice in this case a protrusion of the 
mucous membrane, which, on introducing the finger, is seen to be the 
posterior vaginal wall. This is a pretty well marked case of what is 
known as rectocele, a term which implies that the rectum comes down 
with the vagina. This is not always the case, hence a better name is 
colpocele, or posterior colpocele, just as a prolapse of the anterior 
vaginal wall is better termed an anterior colpocele ratlier than a cys- 
tocele. The protrusion is the result of the laceration of the perineum, 
which, as you see, has extended about half-way down to the sphinc- 
ter, and is also due to the redundancy of the posterior vaginal wall. 
When the posterior vaginal wall comes down to a greater d^ree, the 
part is exposed unnaturally, and under such circumstances it gives 
rise to considerable discomfort. In old and aggravated cases the only 
satisfactory method of treatment consists in a surgical operation, and 
this is best done by removing a triangular piece of mucous membrane 
from the posterior wall of the vagina, so as to include a larger portion 
of the rectocele, and then with a running catgut suture sew from the 
upper angle down to the perineum. This gradually narrows the 



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RBCrOCELE, LACERATED CERVIX, AND RETROVERSION. 286 

vagina, and it is still further narrowed by introducing several deep 
sutures through the perineum. 

In addition to the rectocele, we find three other conditions depend- 
ent upon much the same causes, — viz., a pretty deep laceration of the 
cervix on both sides, with the papillae and glands of the cervix con- 
siderably enlarged, a somewhat enlarged uterus, and a retroversion. 
The dragging down of the posterior vaginal wall has probably given 
rise to this retroversion. The lacerations of the cervix and of the 
perineum are the two primary factors in this case. The former has 
kept the uterus large and has led to the retroversion ; the latter has 
given rise to subinvolution of the posterior vaginal wall and to the 
formation of the rectocele, and the rectocele, in its turn, has helped to 
drag the uterus still farther down ; hence you see that these different 
lesions are more or less interdependent. To cure this case, the uterus 
must first be replaced manually and kept in position by a properly 
fitting Hodge pessary. After one or two menstrual periods have been 
passed with the uterus in its restored position, hot douches being 
constantly used during this interval, the lacerated cervix should be 
repaired and a pessary kept in place during convalescence from this 
operation. If, however, the cervix and perineum are operated upon at 
the same time, the pessary cannot be used until these wounds are 
entirely healed. The wire sutures are then removed from the cervix, 
and about one week later a pessary may be inserted, which it will 
probably be necessary to wear for a number of months. 



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AFFECTIONS OF THE LACHRYMAL GLAND. 

CLINICAL LECTURE DELIVERED AT THE SHEFFIELD GENERAL INFIRMARY. 

By SIMEON SNBLL, P.R.C.S. Ed., 

Ophthalmic Surgeon to the Sheffield (General Infirmary ; Lecturer on Diseases of the 

Eye at the Sheffield School of Medicine ; Consulting Ophthalmic 

Surgeon to the Rotherham Hospital. 



Gentlemen, — Some cases which have recently been here nnder 
treatment afford me an opportunity of bringing to your notice certain 
affections of the lachrymiJ gland. 

Diseases of the tear-passages are perhaps among the most common 
that you will see in this or any other eye clinic. Affections of the 
gland itself are, on the other hand, by no means frequent If you 
consult any text-book you will find that diseases of the gland are 
usually referred to as being extremely rare. Mr. Swanzy, in his excel- 
lent hand-book, afler mentioning that inflammation of the lachrymal 
gland may be either acute or chronic, and that it is extremely rare in 
either form, says, " I have seen one case of acute purulent dacryo- 
adenitis, but no instance of the chronic form." Mr. Henry Power, 
at a meeting a little time since of the Ophthalmological Society, re- 
marked that Sir William Lawrence had stated that in forty thousand 
cases of ophthalmic disease that had fallen under his observation at 
Moorfields he had not observed a single instance of disease of the 
lachrymal gland. 

My experience has been different from that of Lawrence, and, as 
will appear in the course of this lecture, a fairly lai^ number of in- 
stances in which the lachrymal gland was implicated have come under 
my notice. Affections of the gland may be justly placed among the 
rarer ophthalmic disorders that are met with, but the instances brought 
before the Ophthalmological Society during recent years testify to their 
not being so extremely infrequent as some would lead us to think. 

A girl (M. J.), aged twenty, has recently been under your notice. 
She does, in &ct, come to us occasionally even now. She has been the 
subject of acute inflammation of the lachrymal gland going on to 



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AFf'ECTIONS OF THE LACHRYMAL GLAND. 287 

suppuration. On September 24 last (1893) she b^n to have pain in 
the left eye. It commenced very suddenly, and between the evening 
of this day and the next morning the eye had become red and the 
eyelids swollen. She was seen shortly after this by Dr. T. H. Morton, 
who has kindly supplied me with his notes as to her condition at this 
time. On September 30, he tells me, there was a good deal of chemosis. 
On this day he took these two photographs of her, which give an ex- 
cellent idea of the state of things then present You will observe that 
there is a good deal of swelling of the conjunctiva round the cornea, 
but that this is particularly marked above, and with the eyelids sepa- 
rated, as they are in the print, the conjunctiva is seen to be pressed 
down and protruding rather under the upper eyelid at the outer canthus. 
The photographs afford evidence also that at this period there was 
marked swelling over the eyelid at its outer portion. Dr. Morton also 
tells me that an ulcer developed at the upper part of the cornea. She 
first came to us on October 16. At this time the ulcer on the cornea at 
the upper and outer part, as far as it could be seen, was showing some 
signs of healing, and the chemosis below was a good deal abated, but 
she was still suffering a considerable amount of pain. The upper eye- 
lid was immovable, greatly swollen, and with the sur&ce reddened. 
Fluctuation was at once detected. To those of you who were then 
present I pointed out my reasons for not thinking this an ordinary 
abscess of the lid. No very definite edge of gland could be made out, 
but it was clearly deeper than the palpebral tissues. There was no 
history of injury, and, on the other hand, the account which was ob- 
tained from the patient, and which will be presently given, strengthened 
the opinion expressed. She was admitted into the wards, and the next 
day an incision was made just below the orbital ridge at its outer part, 
and a considerable quantity of pus was evacuated. She quickly re- 
covered. You have seen her lately, and have noticed that tiie scar left 
by the incision is a very faint one, and is well hidden in the fold of 
the eyelid below the orbital ridge. The ulcer of the cornea has left 
that structure a little nebulous at its upper part, but in such a position 
as not materially to interfere with vision. 

As has been said, this girl had sustained no injury to the eyelid. 
In this respect her case contrasts with that of a young girl whom we 
saw yesterday, with an abscess involving the eyelid at just the same 
situation as the one under consideration. This girl had received an 
unintentional blow over the eyelid by the hand of her mother. Dis- 
coloration of the eyelid followed the injury, and subsequently the 
abscess formed for which she sought relief at our hands. 



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288 INTERNATIONAL CLINICS. 

There was in our patient M. J. no previous history of any eye- 
affection. She had suffered from influenza in 1892^ and again during 
Easter of 1893. Beyond this^ there is nothing in her general condi- 
tion that calk for comment She was weakly and ansBmic-looking. 
Inquiry elicited that at the time the left eye commenced to be affected 
in the manner already described the right also became affected in the 
same situation in the upper eyelid. It was never^ however, implicated 
in anything like a corresponding d^ree to the left, and the swelling 
subsided in the course of two or three days. 

Bearing on the cause of the affection of the gland in this case 
must be remembered the account ascertained from the girl, which has 
already been hinted at She had been passing through a great deal of 
trouble, she tells us, in consequence of the serious illness of her brother 
and the fear that the sickness would prove fatal. For a fortnight she 
cried for hours'together. This would seem to be unusual with her, and 
she does not bear a lachrymose appearance. When the inflammation 
had set in she tried to cry, but was unable to find any tears. Then 
she managed to cry with the right, and ultimately the fimction on both 
sides has been restored. 

In this connection I can tell you of an interesting case mentioned 
some years ago in the Transactions of the Ophthalmological Society 
by Mr. McHardy, in a discussion which took place on some lachrymal 
case. He referred to an old gentleman in whom both glands became 
suddenly and simultaneously enlarged, in consequence, as Mr. McHardy 
expressed it, " of a sudden and grievous bereavement which prompted 
him to weep, though, through fifty years* n^lect, the habit had fisdlen 
so much into disuse that no visible tears were shed. He suffered for 
some days great inconvenience from such distention.'* 

The interference with the secretion of tears in instances in which 
the lachrymal gland is involved has been pointed out, I believe, by 
other observers. It is, at all events, a matter to bear in mind, and is 
corroborative of your diagnosis. I am, however, disposed to think 
that in some instances of simple abscess of the outer part of the lid 
the flow of tears may be interfered with. A case at present under 
observation suggests this, and it appears possible that swelling con- 
tiguous to the gland ducts could by pressure limit the supply. I shall 
have occasion to refer to an instance of simultaneous enlargement of 
both lachrymal glands in a woman. The affection was subacute, but 
here there was a very marked interference with the secretory function 
of the glands. She said the change was considerable. She had tried 
to cry several times, but the tears would not come ; from the right 



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AFFECTIONS OF THE LACHRYMAL GLAND. 289 

there was hardly any moisture, and from the left the secretion was 
much less than usual. On the subsidence of the glands to a normal 
condition, the secretion was re-established. 

I have seen at least two cases similar to the one which I have just 
brought under your notice, and in which the gland suppurated. 

At the same time that this girl was under treatment there was a 
little baby also in my wards, whom you will i-emember to have seen, 
as your attention was directed to him in connection with the one just 
related. The baby was only five months old, and came on September 
29, in consequence of a swelling situated at the outer part of the orbit. 
The appeatance at this time is admirably shown in the photograph 
(Fig. 1) which Mr. Bellamy kindly took for me. You will see that the 
eyelid at the outer part is prominent just in the same situation as was 
the case in our former patient, M. J. It was somewhat tender to 
the touch when first seen, but this disappeared, and there was no red- 
ness of surfiice nor feeling of heat. The child did not now appear to 
sufier much pain, if any. The history of the onset of this condition is 
by no means clear. According to the mother, the side of the &ce and 
the ear were at one time also swollen, but it would seem as if the real 
seat of disease had always been the orbital region, because as subsi- 
dence took place elsewhere it remained evident at this place. It appears, 
further, to have commenced when the babe was only a few weeks old. 
Inquiry fails to obtain any history of injury either at the time of birth 
or subsequently. The birth was natural, and no instruments were 
used. There has been no ear-disease, nor indeed any other afiection. 

A hypodermic syringe was passed into the swelling, and revealed 
the presence of pus, which was then let out through an incision along 
the orbital margfh. We have seen the little patient quite recently, and 
noticed that all sign of the former distention has disappeared, both eyes 
looking alike. 

I do not present this case to you as one of lachrymal disease. It 
may have been so, but to my mind the reason for the occurrence of an 
abscess under the circumstances, and also at the situation named, is by 
no means clear. My chief object, however, in mentioning it in this 
connection is that it was a case under treatment at the same time as 
our first one, with suppuration going on at the same situation, and that, 
owing to the kindness of one of your number, we have been able to 
preserve an excellent representation of the conditions present. 

All cases in which the lachrymal gland is inflamed, it need hardly 
be said, do not go on to suppuration. Those that do so may ultimately, 
after a good deal of pain and swelling, point through the skin or 
Vol. I. Ser. 4.— 19 



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290 INTERNATIONAL CLINICS. 

through the conjunctiva, and in some cases a fistula may result. There 
are cases, however, in which the glands become enlarged and painful 
and subside without the formation of pus. This last year a lady 
patient suffered from some swelling of the lids, especially on the left 
side ; the enlarged lachrymal gland could be felt through the upper lid, 
and pressure gave some measure of discomfort; it was less easily 
detected on the right side, which was, during the few days that the 
condition lasted, but little affected. The patient was, I believe, gouty, 
but otherwise there was no cause discoverable. The oedema of the lids, 
which was the first symptom, as well as the enlargement of the gland, 
soon passed away. 

Further back than this, a woman rather over thirty was attending 
here, with simultaneous dacryo-adenitis. The enlarged glands were 
visible in the eyelids and were evident to the touch. There was some 
oedema of both eyelids. The right side was more affected than the 
left. In a few weeks' time both glands returned to a normal condition. 
The interference with the secretion of tears in this patient has already 
been alluded to. (Transactions of the Ophthalmological Society, 
1892.) 

Under treatment at the same time in our wards as the girl M. J., 
whose case has been related at length, was a man (B. W.), aged fifty- 
five. He came for the first time on September 4, 1893, in consequence 
of a swelling in the right orbit. It had been noticed by him for three 
weeks. It came on quickly. There was during this time a good deal 
of pain, but there was not so much when he came to us. The right 
upper eyelid was oedematous, dusky red, but with no abnormal heat 
of skin. It closed a good deal over the eyeball, and he could not 
raise it suflSciently to expose the globe. To examine the eye it was 
necessary to pull up the lid. Through the eyelid could be felt what was 
taken to be the lachrymal gland ; there was a well-marked edge, and 
it could be traced from the outer angle along the orbit almost to the 
inner ; it was especially marked at the outer side. The gland margin 
was rounded and felt somewhat lobulated. On raising the eyelid, the 
ocular surfece was seen to be reddened, and at the outer side, above, the 
conjunctiva was swollen. In addition, the globe was pressed down- 
ward and movement upward was interfered with. There was not at 
this time or subsequently any interference with vision. The accom- 
panying photograph (Fig. 2) was taken a few days after his admission 
to the infirmary. 

The diagnosis made was that the lachrymal gland was subacutely 
inflamed and attended with considerable enlargement. The cause was 



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AFFECTIONS OF THE LACHRYMAL GLAND. 291 

obscure. He was a very healthy countryman from Lincolnshire, and 
had had no trouble recently, and indeed appeared from his account to 
have led 9 life singularly free from anything likely to cause any grief 
or trouble. There was no history of syphilis. The only conjecture 
the patient formed nimself to account for the affection was that, as an 
agriculturist, he had before its onset been using "sheep dip.** This 
lotion, employed for the sheep, was just then made particularly strong 
with sublimate. He had had no wound of the fingers, and even if 
affected in the manner he suggested there was no confirmatory evi- 
dence in other parts of such poisoning having taken place. In every 
other r^on he was healthy. There were no enlarged glands in the 
neck and no implication of the salivary glands. 

He was treated at different times with iodide of potassium alone^ 
and later with the addition of perchloride of mercury. Some increase 
took place in the size of the tumor after his admission, and then for 
some weeks it remained stationary. At this time I obtained the opinion 
of my surgical colleagues, who suggested the possibility of the tumor 
being malignant, and at all events thought that an operation for its 
removal might become necessary. There was no reason to adopt any 
such procedure immediately, and therefore he was allowed to go home 
into the country. He was to return in three weeks — or before, if worse. 
The date was October 27. He returned on November 17, with the 
tumor greatly reduced in size. The edge of the gland could still be 
felt along the margin of the orbit, but it was thinner and receded a 
great deal. The appearance of the lid outside had also improved. The 
change for the better had commenced only a few days before his return. 
He had ceased to take any medicine soon after leaving the infirmary. 
He remained with us for some days, during which time it was evident 
that the enlargement of the gland was abating. The only treatment 
adopted was a soda and gentian mixture. He again returned home, 
and revisited us on January 5 (1894). Improvement was now very 
marked. The gland had subsided so much that it was with difficulty 
felt with the finger, and then only after pressing well under the orbital 
margin. The eyelid was resuming a healthy appearance ; ptosis was 
not, however, altogether absent ; the ocular conjunctiva was normal, 
but the movement of the globe upward was still a little interfered 
with. Altogether, the progress had been most satisfactory, and when 
he returns again in a few weeks the right eye should be as normal as 
the left. 

This man tells us that when he came here first the right eye was 
very dry, but that now, when in the cold, it becomes moist. Among 



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292 INTERNATIONAL CLINICS. 

the points of interest that this case possesses may be mentioned the 
size to which the gland became enlarged^ the displacement of the eye- 
ball which it caused^ and the resulting interference with the movements 
of the lid and globe. The reproduction of the adenoma (Fig. 4), to 
be referred to presently, also illustrates these points. 

These cases which have thus far been brought to your notice 
present the gland as affected with acute or chronic inflammation. It 
is liable, however, to other conditions. I have seen two instances at 
least in which the lachrymal gland has been perceptible in each eyelid 
to the touch, but less evident to the sight, and also movable. One of 
these was a young man under treatment for comeitis, and there was 
reason to believe the condition was congenital. In both the distinct- 
ness with which they could be made out was their only abnormality. 
I have recorded a case also in which the gland became dislocated. The 
situation, size, and feel of the " lump" at once suggested that it was 
the lachrymal gland. It could easily be reduced, but almost imme- 
diately returned. One day, after I had replaced it and kept it in 
position for some time, it did not again make its appearance. The 
reason for the presence of this gland in the eyelid was not clear. He 
had, however, a large naevus at the margin of the orbit, and after 
"drinking bouts" the patient suffered from epileptiform convulsions, 
and I was informed that the nsevus at the orbital rim became greatly 
distended during these, attacks, looking as if it would burst. This 
nsevus also passed into the orbit close to the upper and outer margin, 
and it appeared probable that the vascular engorgement might have 
had to do with separating the gland from or weakening its connective- 
tissue attachments. The distention of the same from the coughing with 
which he had been racked on the night previous to the " lump" being 
noticed should be reraembered. 

The lachrymal gland may also be the seat of simple or malignant 
growths. The only instance I have met with approaching the former 
condition is that of a woman who was in this infirmary several years 
ago with symmetrical tumors of the lachrymal glands, and with im- 
plication also on both sides of the parotid and other salivary glands. 
The disease was very slowly progressive, and she died five years after 
she had first come here, and long after she had passed from under 
observation. The tumors in all parts had greatly increased, and on the 
sides of the face had ulcerated, and her death was due apparently to 
exhaustion. The cases of this character on record are very few in 
number. When publishing this case last year (1893) in the Lancet^ 
those already on record were dealt with. 



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AFFECTIONS OF THE LACHRYMAL GLAND. 



293 



Fig. 4. 



Two cases of adenoma of the gland have been under my care. One 
instance occurred in a domestic servant, aged twenty-five, and she 
was seen many years ago. It had been of 
slow growth, bad been noticed at least from 
her sixteenth year, and had gradually become 
larger since then. It formed a hai*d tumor in 
the upper eyelid at the outer part, and it did 
not appear to be att€u;hed either to the lid itself 
or to the wall of the orbit, but rather to pass 
backward beneath the orbital margin. There 
was no tenderness, and no pain had been expe- 
rienced. It pressed the eyeball downward and 
outward. The tumor was removed by making 
an incision extending outward through the ex- 
ternal commissure. It easily turned out. It reached almost to the 
back of the orbit, being surrounded by cellular tissue, but not attached 
to bone. The tumor measured nearly one and a half inches by one 
and a quarter inches ; it appeared encapsuled ; immediately on its re- 

Fio. 6. 




Adenoma of lachrymal gland 
after removal. 




Microscopic appearance of a section of adenoma of the lachrymal gland. 



moval the eyeball returned to its normal position. The photograph 
represents the appearance of the patient (Fig. 3) before the removal of 
the tumor, and the drawing (Fig. 4) that of the tumor. A section of 
the growth under the microscope showed it to be distinctly adenomatous. 



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294 INTERNATIONAL CLINICS. 

Acini of various shapes and sizes are seen lined with cubical epithelium. 
In some parts the acini are expanded to form cysts {vide Fig. 5). The 
other case was that of a baby, aged eight months. The tumor, on re- 
moval, was found to be the size of a bean. Its microscopic structure 
was similar to that of the other one. 

These two cases have been recorded in the Transactions of the 
Ophthalmolc^ical Society, but the photographs of the first patient as 
she appeared before the removal of the tumor, and the drawing of the 
tumor and of its microscopic structure, have not yet been published. 

With the help of the two cases which formed our text, I have now 
been able to bring under your notice the various cases in which the 
lachrymal gland was implicated which have from time to time come 
under my observation and of which records have been kept They 
suffice to show that, though this gland may be but rarely affected, in 
process of time a single observer's experience may nevertheless be 
not inconsiderable. 



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SCLERAL PUNCTURE IN DETACHMENT OP THE 
RETINA, WITH ILLUSTRATIVE CASES. 

WARD LECTURE DELIVERED AT THE PHILADELPHIA HOSPITAL. 

BY Q. E. de SCHWEINITZ, M.D., 

Clinical Professor of Ophthalmology in the Jefferson Medical College ; Professor ot 

Ophthalmology in the Philadelphia Polyclinic ; Ophthalmic 

Surgeon to ^e Philadelphia Hospital. 



Gentlemek, — ^In discussing the treatment of detachment of the 
retina in a previous lecture/ I described five procedures which have 
been employed at various times and are still utilized in the treatpienl 
of this condition. These were classified as follows: (a) the anti- 
^ phlogistic regimen ; (6) the rest cure ; (c) the instillation of myotics, 
particularly eserine ; (<f) the diaphoretic method ; and, finally, (e) the 
various operative procedures. In order to place clearly before your 
minds the relative value of these different methods, the very interesting 
r68wn4 published by Emil Grosz ' was quoted. I will repeat the main 
points of this summary. Statistics gathered from various sources seem 
to show that in sixty-five per cent, of the cases puncture of the retina, 
in forty-four per cent puncture of the sclera, in sixty-six per cent 
iridectomy, and in fifty-nine per cent, pilocarpine injections, remained 
fruitless. Grosz doubts the trustworthiness of these results, because 
most of the authors were satisfied with an indefinite expression of im- 
provement, without careful investigation of the visual acuity and the 
duration of the improvement In contrast to these statistics, he records 
those from the ophthalmic clinic of Professor Schulek in Buda-Pesth. 
Sixty-seven cases of retinal detachment were treated by one or other 
of the following methods : puncture of the sclera, iridectomy, puncture 
of the retina, pilocarpine injections, combined puncture of the sclera 
and pilocarpine injections, and iodine injections after the method of 
Schoeler. Improvement was obtained in thirty-three per cent, with 

* Therapeutic Gazette, January, 1898. 

* Abstract in Nagel's Jahresbericht f. Ophth., vol. zzi. p. 95. 

295 



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296 INTERNATIONAL CLINICS. 

pilocai'pme injections, with iridectomy in thirty-three per cent., with 
pancture of the sclera in twenty per cent., and with combined pilocar- 
pine injections and puncture of the sclera in thirty-three per cent. 

To one of these procedures — namely, scleral puncture — I desire to 
direct your further attention, chiefly because it may be recommended 
as the surgical method least likely to do harm and most likely to do 
good, but which should be emplayed, as should all other surgical 
measures in connection with this disease, only after a thorough rational 
medicinal treatment has been tried. 

The curability of detachment of the retina by scleral puncture was 
first demonstrated by J. Sichel in 1859,^ and the following cases are 
examples of the application of this operation. Inasmuch as they have 
been watched in one or two instances for a long period of time, they 
present some interesting features. 

Case I.^ — Hugh M., a man aged fifty ; laborer. The right eye 
was injured by a blast twenty-four years ago, and was considered by 
the patient to be valueless until his left eye was afiected. 

There is an irr^ularly oval pupil, with adherence of the iris to a 
small scar in the cornea, and a separation of the iris at the outer ciliary 
margin. Over the cornea are scattered several cicatrices. The remains 
of the capsule of the lens are seen to border the pupillary margin. It 
is not possible to obtain a view of the fundus, but the field of vision 
indicates that there is detachment of the whole lower half of the retina, 
with concentric restriction of the field furnished by the unseparated area. 

' Hirschberg, in a paper entitled " Notes on the Operative Treatment of Detach- 
ment of the Ketina,'' Archives of Ophthalmology, vol. viii., 1879, p. 12, inserts the 
following foot-note in regard to the literature of scleral puncture in the treatment of 
retinal detachment: " J. Sichel, in 1859, performed the operation on a myopic man, 
aged forty, with a lance-shaped knife downward, and raised the sight, which was 
very weak, to -^j^. According to this, we have to correct the quotation of A. von 
Graefe (Arch. f. Ophth., Bd. ix. 2, p. 35), which has been reprinted by several au- 
thors. Kittel (Wiener allgem. med. Zeitschr., Nr. xxiii.) in 1860 operated on one 
case ; Von Arlt at the same time on several (Operationslehre, p. 871) ; Wecker, in 
1869 (Jaeger-Wecker, Trait^), likewise recommended the operation. 1 witnessed 
one operation performed by the lance-shaped knife by Coccius, who informed me 
that he had proceeded in this way for years. Kries (Arch, f Ophth., Bd. xxiii. 1, 
p. 239) reported, in 1877, A. von Graefe's cases and recommendations. Pufahl 
described two cases operated on by me (Centralbl. f. Augenheilk., December, 1877). 
Wolf (The Lancet, 1878, No. 15) describes scleral puncture as a new operation." 
Since 1879, the date of Hirschberg's writing, numerous operations for the cure of 
detachment of the retina by scleral puncture have been performed, and, as we have 
seen, in one series of cases at least, with twenty per cent, of improvement. 

* The earlier history of this case has been described in the previous lecture, Thera- 
peutic Gazette, January, 1898. 



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SCLERAL PUNCn;URB IN DETACHMENT OP THE RETINA. 297 

Fortunately, however, the macular region is not involved, and with a 
cataract-glass the patient's visual acuity is scant i^. 

The sight of the left eye was good until July, 1891, and then, 
while he was working, sudden blindness occurred. There has never 
been pain or inflammation. He consulted Dr. Sutphen, of Newark, 
New Jersey, who has very kindly furnished me with an account of 
what he did for the patient at this time. He was ordered to bed and 
treated by injections of pilocarpine, and later iodide of potassium was 
administered internally. There was a steady increase of the detach- 
ment until it became total, and scleral puncture was performed upon 
the left eye December 1, 1891. There was no reaction at all from the 
operation, except slight oedema of the conjunctiva, which lasted three 
days. Material improvement in the vision was noted from the second 
day folloMring the operation. The patient remained in bed three weeks, 
and left the hospital January 15, 1892, with the retina in its normal 
position and vision ^. The patient states that, contrary to Dr. Sut- 
phen's orders, he returned to hard work, and very speedily his sight 
became as bad as ever. He declares that he was ashamed to go back 
to consult Dr. Sutphen, and well he may have been, because, owing 
to his own foolishness and disobedience, the benefit of Dr. Sutphen's 
excellent treatment was lost, and there has been a return of the 
disease, so that there is now an 
extensive detachment of the retina, ^^<»- 1- 

which has involved the fixing point. 

The disk which is visible is 
oval, and contains a small central 
excavation with a dot of pigment 
upon its margin. The detached 
retina floats up as a gray veil in 
the vitreous, which in its turn is 
filled with opacities, the lens is 
hazy, and there are a number of 
cortical opacities downward and in- j,,^^^^ ^^ the'fleiTof vision of Case i. 

ward. The accompanying diagram nearly one year after scleral puncture had ef- 

•11 . . ., £ ij r • • J fected primary cure; relapse three weeks later. 

Illustrates the held Ot vision, and The outerllne bounding the shaded area m- 

was obtained by causing the patient dica^s the Umltof the normal form-field ; the 

. n 1 'ui shading, where Tision was lost All the other 

to nx as nearly as possible upon a diagrams are constructed on the same plan. 

candle placed at the centre of the 

perimeter, while a large white test-object was utilized to map the field. 

(Fig. 1.) 

For many reasons this was an unfavorable case from which to ex- 




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298 



INTERNATIONAL CLINICS. 



pect good results, but, as experience shows that harm does not follow 
the operation, and as the man was extremely anxious to have another 
trial, I performed at that time (December 2, 1892) the operation of 
scleral puncture, which is done as follows. 

The precise position of the retinal detachment being ascertained, the 
eyeball is rotated in a suitable direction, a narrow Graefe cataract-knife 
is thrust directly through the sclera and choroid and turned slightly 
upon its axis, and the subretinal fluid is allowed to drain away beneath 
the conjunctiva. Very little reaction follows. Great care should be 
taken to perform a perfectly antiseptic operation, and, as Dr. Sutphen 
has suggested, the rotation of the eyeball back to its normal position, 
when released by the fixation forceps, virtually converts the scleral 
wound into a subconjunctival one, and this appears to be advantageous 
in preventing infection. 

As the knife was turned upon its axis, the wound gaped, and there 
was an escape of serous fluid, forming a good-sized bleb beneath the 
conjunctiva. A double figure-of-eight bandage was applied, and the 
patient put to bed, and enjoined to keep upon his back as much of the 
time as possible. 

FiQ. 2. Fig. 8. 





Diagram of the field of vision of Case I. two 
weeks after a second scleral puncture. Com- 
pare with Fig. 1. 



Diagram of the field of vision of Case I. two 
months after a second scleral puncture. Com- 
pare with Figs. 1 and 2. 



Two weeks after the operation (December 16, 1892) a field of 
vision was obtained which is represented in the accompanying diagram 
(Fig. 2), somewhat resembling that obtained at the original examina- 
tion, being slightly larger on the upper vertical meridian. 

The rest treatment and bandage were continued, and on the 23d of 
January, 1893, or nearly two months after the operation, the field of 
vision as represented in Fig. 3 was obtained, and, moreover, in the 
ordinary way with the perimeter, the patient being able to fix fairly 
attentively a white spot in the centre of the perimeter semicircle. He 



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SCLERAL PUNCrUBE IN DETACHMENT OP THE RETINA. 299 

could count fingers readily in all directions, the previous vision having 
been light-perception only in the lower portion of the field. There 
was practically no change to ophthalmoscopic examination except that 
showing the partial reattachment of the retina. The patient was now 
allowed to be up, and there was no alteration in his vision, either for 
better or for worse, during the next few weeks. 

He then disappeared from view, part of the time being out of the 
hospital and part of the time in an almshouse, and did not present 
himself again until the 8th of December, 1893, or almost a year after . 
the operation. 

The pupil then reacted fidntly to the changes of light and shade 
when thrown obliquely into the eye, the lens was hazy, and there were 
numerous opacities in the vitreous, and apparently a complete detach- 
ment of the retina. Very faint light-perception was present in the 
lower portion of the field, but further than this a map at all accurate 
was unobtainable. He stated that the result of the operation had 
gradually disappeared, and he now depended for sight entirely upon 
his right eye, which amounted to counting fingers. 

Once more he b^ged for the operation, and, although told that it 
could be productive of no favorable result, he still insisted. 

Partly for diagnostic purposes, inasmuch as the tension of the eye 
seemed higher than ought to be present in one containing so large a 
detachment of the retina and so many vitreous opacities, a carefully 
performed scleral puncture with a very narrow Graefe knife was re- 
peated, resulting in the draining away of a moderate quantity of serum 
slightly blood-stained. Whether, however, the staining of the serum 
was due to contamination from the blood of a small conjunctival vein 
which was incised, or not, could not exactly be told. The usual afler- 
treatment of rest, bandage, etc., was tried until the 15th of January, 
and, in addition, iodide of potassium was administered. There was 
at no time reaction, nor was there the slightest effect upon vision, and 
there remains at the present time faint light-perception in the lower 
portion of the field, but the answers are so contradictory as to pre- 
clude the possibility of securing, an accurate map. 

The case may thus be summarized : primary scleral puncture by 
Dr. Sutphen resulted in a cure; relapse about eight weeks later. 
Second scleral puncture by myself resulted in a partial restoration of 
the visual field and moderate improvement in visual acuity, from 
light-perception to counting fingers; relapse after leaving hospital. 
Third scleral puncture, when detachment was total, wholly without 
result. 



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300 



INTERNATIONAL CLINICS. 



Case II. — Peter D., aged thirty-seven ; an iron-moulder ; bom in 
Ireland ; became blind in the right eye one and a half years ago, 
suddenly, while lifting a heavy weight. The left eye was similarly 
affected four years ago. There is no history of blindness in his family ; 
his general health, with the exception of malarial fever in 1873, has 
been good ; he denies venereal trouble. He was always long-sighted. 
In the left eye there is faint light-perception, and this rather uncertain. 
There is no view of the fundus, the lens being cataractous. 

In the right eye there is an extensive detachment of the retina, 
almost complete, the height of the detachment being + 7 D. The 
disk is faintly seen, oval in shape, in its maigins hazy. The vitreous 
contains opacities. Vision amounts to seeing the movements of the 
hand in the lower portion of the field. The field of vision is repre- 
sented in Fig. 4. 



Fig. 4. 



PiQ. 6. 





Diagram of field of vision of Case II., rig^t 
eye, before the scleral puncture. 



Diagram showing restoration of yisual field 
of Case II. one week after operation. 



November 10, 1893, scleral puncture was performed, the incision 
being placed between the inferior and the internal rectus, and there was 
a free escape of serum, at least half a drachm, forming a large bleb 
beneath the conjunctiva. The subsequent treatment was bandage, bed, 
and liquid diet. 

One week later the ophthalmoscope revealed the retina completely 
in place, and the field represented in Fig. 6 was obtained. The lens 
was slightly hazy, and patches of disseminated choroiditis were visi- 
ble. Vision equalled D = XXX at one metre (^). The patient was 
kept in bed until the 24th of November, and then was allowed to be 
up for one day, but not to leave the ward. 

On the 25th the fundus was slightly hazy, and directly below 
there was evident redetachment of the retina beginning, the apex of 
the elevation being + 3 D. Fig. 6 illustrates the field of vision. The 



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SCLERAL PUNCTURE IN DETACHMENT OP THE RETINA. 301 

patient was put to hed again, and kept there until the 7th of December, 
when he was allowed to get up, and the field was again mapped, 
giving practically the same result as Fig. 6, the area of retina in place 
being probably a little wider, and the vision amounting to ^^. The 
patient was now allowed to be out of bed and around the ward, and 
up to the final measurement of the visual field — namely, January 31, 
1894 (Fig. 7) — ^the vision remained as last recorded. A second scleral 
puncture was not performed, although there is reason to believe that it 
would have been followed by a good result. 

This case is very interesting, showing an almost complete success. 



Pig. 6. 



FiQ. 7. 





Diagnxn illustrating partial redetachment 
of the retina in Case II. 



Diagram illustrating the final result on the 
field of yision of Case IL 



SO far as restoration of the field was concerned, while the patient re- 
mained flat in bed, speedy redetachment when he arose, although 
performing no more exertion than that of sitting and walking in tlie 
ward, and a final return to the primary condition of affairs, if we may 
judge from the two fields (Fig. 4 and Fig. 7), with, however, the 
preservation of central acuity of vision (y^) far in excess of that 
which he had before the operation, — viz., movements of the hand in 
the lower part of the field. 

Case III. — Frederick D., aged fifty-six ; American-bom ; a tin- 
smith by trade ; gives the following history : the vision of the right 
eye failed two and a half years ago, that of the left eighteen months 
ago, neither of them suddenly, the dimness of the left eye starting as 
a cloud in the lower part of the field and lasting for one month before 
sight was practically obliterated. He was under treatment in the 
Wills Eye Hospital during April, 1893, with pilocarjiine injections. 
His general health is good, and there is no account of excesses in his 
life. He never used glasses for close work. 

The right eye sees vaguely the movements of the hand down and 



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302 



INTERNATIONAL CLINICS. 



out, but cannot count fingers. The disk is oval, gray-red in color, 
contains a small cup, and there is a huge detachment of the retina, 
almost complete, which floats upward into the vitreous. ( Vide Fig. 8.) 

On the 24th of November, 1893, two scleral punctures were per- 
formed, one between the inferior and the internal rectus and one be- 
tween the inferior and the external rectus, each being followed by the 
escape of a small quantity of clear serum beneath the conjunctiva. No 
immediate ophthalmoscopic change was visible. The usual treatment 
of rest in bed and bandage was kept up until the 7th of December, 
without, however, any practical change either in the field or in visual 
acuity. 

Although a distinctly unfigivorable case, at the man's earnest request, 



Fio. 8. 



Fig. 9. 





Diagram of the field of ylsion of Case III., 
right eye, illustratiug extenaiye detachment 
of the retina. 



Diagram of the visual field of Case III. after 
operation, practically without fiivorable re- 
sult. 



and as there had not been the slightest reaction, a third scleral puncture 
was performed. The incision, after consultation with my friend Dr. 
Charles Kollock, of Charleston, South Carolina, who was visiting the 
wards at the time, was made on the temporal side, just below the margin 
of the external rectus muscle. When the knife was turned and the 
wound made to gape, an unusually large quantity of clear, straw- 
colored fluid escaped, which formed a large bleb beneath the conjunc- 
tiva. The patient immediately stated that his vision was better. This, 
however, was probably an expression rather of his own anxiety that it 
should be improved than of what was actually the case. 

The bandage, rest in bed, and the internal administration of iodide 
of potassium were continued until the 4th of January, 1894, when prac- 
tically no change was visible with the ophthalmoscope, and the field of 
vision (Fig. 9) was obtained, which may be compared with the one 
originally found (Fig. 8), closely resembling it in all particulars. 



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SCLERAL PUNCTURE IN DETACHMENT OF THE RETINA. 303 

Down and out the patient could distinguish the movements of the hand, 
but could not certainly count fingers. When the eye was last studied 
(on the 31st of January, 1894), there was practically as complete a 
detachment of the retina as there had been originally. The pupil was 
slightly pear-shaped, and, unless the rays of light were skilfully directed 
upon the small patch of retina still functionally active, the iris was 
immobile to the changes of light and shade. 

Still hoping that his left eye might be benefited by a similar 
operation, and, curiously enough, insisting that his vision was better, 
although no improvement could be demonstrated, an operation was 
performed on this eye. 

Case IV. — Frederick D. Left eye. The pupil was round, reacted 
sluggishly to light-impulse, the lens was slightly hazy, the disk was 
dimly seen as a vertical oval of gray-red color, and containing a small, 
sharp central excavation. There was extensive detachment of the 
retina, as is evident from the field of vision. (Fig. 10.) 

Fio. 10. Fio. 11. 





Dia^rrun of the field of vision of Case IV., Diagram of the ylsnal field alter operation 
left eye, showing extensive detachment of the in Case IV. Slight improvement 

retina. 

Two scleral punctures, performed January 5, 1894, resulted in a 
moderate escape of straw-colored fluid, without, however, any imme- 
diate ophthalmoscopic change. One month later, after almost con- 
tinuous rest in bed^ during most of the time with eyes bandaged and 
continuously taking iodide of potassium, the patient was allowed to get 
up and the field of vision carefully mapped, resulting in the accom- 
panying diagram. (Fig. 11.) This, when compared with Fig. 10, will 
show a slight improvement ; so slight, however, that it is doubtftil 
whether the improvement was the result of the operation, or whether, 
in a case so difficult to determine accurately the limits of the still 
functionally active retina, there may not have been some error in 
making the measurements. 



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304 INTEBNATIONAL CLINICS. 

It will thus be seen that in the case of Frederick D. there was 
practically no improvement (and also no harm)^ although in one eye 
there were three scleral punctures and in the other two, each of which 
was followed by the escape of subretinal fluid, in one instance in large 
quantities. This case belongs to what Hirschberg would call the un- 
fortunate examples of total detachment of the retina which are not 
likely to be benefited by any operation or form of medication. 

These four cases, or, to speak more accurately, three patients and 
four eyes, have been sel^3ted from a number because they illustrate 
the various results which are likely to follow an operation of this 
character, namely : 

1. That primary relief or cure may be expected in idiopathic retinal 
detachment after scleral puncture, but that relapses are frequent, even 
while the patient is still in the hospital, and that they are almost sure 
to occur if, as in Case I., even some time after the operation, the subject 
of the disease performs work requiring special exertion. 

2. That although the operation seems justifiable while there still 
remains light-perception, chiefly because, under proper precautions, no 
harm can result, it is extremely unlikely, even when it is followed by 
the free escape of sei-ous fluid, that there will be any reattachment of 
the retina when the separation has been a practically total one, as, for 
example, in Case IV. 

3. That occasionally, even when there has been a primary cure, so 
far as the restoration of the field of vision is concerned, followed by 
a relapse, the gain in central visual acuity seems to remain, although 
the field indicates that the redetachment has equalled the original sepa- 
ration, as, for example, in Case II. 

Finally, I have brought these cases to your notice because all of 
them were exceedingly unfavorable, as all were detachments of long 
standing, and occurred in eyes which showed, in addition, other exten- 
sive degenerative changes. Therefore we may assume that in a similar 
series — which, however, should be very much more extensive if any 
safe conclusions are to be drawn — of favorable cases, fairly creditable 
results mi^t be obtained ; indeed, these, as you know from the statistics 
already quoted, have been secured. 

Of course a very important point is to determine the suitable time 
for operation, and in the earlier cases on which this operation was per- 
formed, many years ago, it was claimed that the most advantageous 
results were obtained in recent cases. Graefe, however, maintained 
that the process of spontaneous descent of the retinal fluid should first 
be awaited, or, in other words, that at least six weeks should elapse 



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8CLEBAL PUNCTURE IN DETACHMENT OP THE RETINA. 306 

before operative interference was undertaken. Hirschberg, in the 
paper already referred to, coincides with Graefe's opinion^ and believes 
that in an ordinary myopic retinal detachment at least eight or ten 
weeks should expire after the onset of the affection before scleral 
puncture should be performed. At the same time it does not do to 
wait too lon^^ lest the perceptive power of the retina depreciate. In 

Pio. 12. 




Pio. 18. 



Pio. 14. 





Illofltiating the changes prodaoed by the ioBtilUtlon of a solution of eierlne in a case of 
detachment of the retina. 

closing his paper^ Hirschberg states that an extended experience will 
have to decide these points and designate the best period for the 
repetition of the operation. This experience has come^ in large 
measure, during the last ten or fift;een years, without especially modi- 
fying the principles he then laid down. 

Were I to judge solely from my own experience, which is probably 
not different from that of many other operators, I should be inclined, 
after a thorough medicinal treatment, especially pilocarpine injections, 
iodide of potassium, and salicylic acid, to employ scleral puncture, with 
the understanding that after the operation the patient should remain 
in bed for at least six weeks with the eyes bandaged, and should then be 
Vol. I. Ser. 4.— 20 



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306 INTERNATIONAL CLINICS. 

permitted to rise only with the understaDding that no violent exertion 
was permissible. 

Although not strictly pertinent to the surgical treatment of this 
affection by scleral puncture^ I desire, in closing, to refer to a case 
quoted in the former lecture {he. cit.), which had been treated with 
instillations of eserine according to the recommendation of Guaita, who 
states that under these circumstances he has obtained amelioration of 
the symptoms and inci'ease of the visual field, although there was re- 
sumption of the symptoms on ceasing the use of the drug. In one 
of my cases thus managed, the accompanying diagrams (Figs. 12, 13, 
and 14) illustrate graphically the effect of the instillation of this myotic 
drug. Although there was slight increase in the size of the visual field. 

Fig. 16. 




Diagram of the Tisual field of the case treated with eserine. Result after three years' use of 

this myotic 

central vision did not improve. This patient has reappeared within 
the last few days, and I insert a diagram of the field of vision as it is 
at present (Fig. 15), obtained with the aid of a candle-flame, and ex- 
hibiting only a small patch down and out where there remains light- 
perception. Strange to say, this patient, a highly myopic woman of 
twenty-eight, has used the eserine solution (a twelfth of a grain to the 
ounce twice a day) almost continuously since the original fields were 
mapped out, now more than three years ago. Certainly no improve- 
ment could be ascribed to the effect of the drug. 



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CONGENITAL PTOSIS; EPITHELIOMA OP THE 
EYELID; OPERATION FOR THE RELIEF OF 
TRAUMATIC ECTROPION. 

CLINICAL LECTURS DELIVERED AT THE WESTERN PENNSYLVANIA MEDICAL 

COLLEGE. 

BY EDWARD B. HECKBL, A.M., M.D., 

Lectnrer on Ophthalmology and Otology at the Western Pennsylvania Medical 

College ; Oculist and Aurist to the J. M. Giuky Orphanage and Home 

for the Aged of Western Pennsylvania, and the Home of 

the Friendless, Pittsburg. 



Gentlemen, — The cases before you are not strange to most of 
yoUy as I have referi*ed to them on several occasions. My chief object 
in bringing them here again is to show you the results of a few plastic 
operations on the eyelids. In order to get the full benefit of a case, 
it is necessary not only to witness an operation, but to follow it in its 
subsequent course. 

The first patient whom I introduce to you is Anna L., aged four- 
teen years, who consulted me in March last. Her father gave the 
following history. The left eyelid has drooped ever since birth, com- 
pletely covering the eyeball and presenting a peculiar appearance, such 
as is photographed in the picture which I pass aroAnd (Fig. 1). 

Parents are always ready to assign some cause for any defect that 
may be present in a child. In this instance the father states that the 
patient was one of twins, and that her twin brother's foot had pressed 
against her eye during intra-uterine life, producing the condition pres- 
ent By a supreme effort the patient was able to elevate the lid by a 
contraction of the forehead, due mostly to the action of the occipito- 
frontalis muscle. Upon elevating the lid with my finger, the eyeball 
presented a perfectly normal appearance, and followed the other eye in 
all its excursions, except when the eye moved upward, showing that 
the superior rectus muscle of the eyeball was likewise involved in the 
paralysis. The pupillary reflex was normal. The vision of the left 
eye was -^y that of the right eye was J^. 

807 



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308 INTERNATIONAL CLINICS. 

The refraction, as shown by the ophthalmoscope, was found to be 
about normal in each eye ; in other words, the condition was that known 
as congenital ptosis. In many of these cases (which are rare, however) 
we find the patient able to elevate the lid by a supreme effort of open- 
ing the mouth, — that is, by depressing the lower jaw. In this patient 
such was not the case ; even whett the lower jaw was depressed, the 
upward movement of the lid was slight, scarcely more than when the 
jaw remained closed or fixed. Congenital ptosis, as stated by some 
authorities, is usually found to be bilateral ; but in this case it was 
monolateral, being confined to the left eyelid. The treatment in such 
a condition, of course, would be purely surgical, although it is never 
advisable to operate upon a congenital case of ptosis in early youth ; by 
that I mean at the age of three or four, for very frequently these cases 
improve as the child grows older, sometimes regaining almost their 
entire functional activity ; consequently an early operation might prove 
in later years an over-correction. 

The opemtions devised for the relief of this condition are numerous, 
and the mere fact that such is the case is indicative of one thing, — 
namely, that no single operation is suitable for all cases ; and it is an 
operation which should be coolly deliberated upon before undertaking 
it, for there are ceilain dangers connected with it : you may operate 
and under-correct, — that is, after the operation is completed, the eyelid 
may still droop some, enough perhaps to interfere with the pupillary 
space; and, on the other hand, you may over- correct, — that is, interfere 
with the patient's closing the eye, and hence expose the eyeball to all 
sorts of external influences, which may eventually lead to corneal ulcers 
and complete destruction of the eyeball. 

The chief object of an operation in this case was a cosmetic one, 
as the left eye is amblyopic, and will very likely remain so, though 
some improvement in vision is to be looked for. As it was, the young 
lady presented a rather peculiar appearance, the left eye remainfng 
closed at all times, and consequently detracting very much from her 
general appearance. 

The old method of operating upon such cases as this was that de- 
vised by Von Graefe, which consisted in the excision of some of the 
fibres of the orbicularis muscle. The object aimed at was dual : first, 
the weakening of the orbicularis, which is the antagonist of the leva- 
tor ; and, secondly, the subcutaneous shortening of the lid. The effect 
of this operation, in most cases, was but slight, and the result disap- 
pointing. Since then other operations have been devised, the principle 
of which depends upon the fact that the occipito-frontalis muscle can 



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CONGENITAL PTOSIS. 309 

be called in to perform the service of the disabled levator. The first 
operation involving this principle was devised by Pagenstecher, and 
consisted simply in the insertion of two subcutaneous sutures, which en- 
tered near the free border of the lid and emerged above the eyebrow. 
They were allowed to remain in Mu until some evidence of suppuration 
developed, when they were removed. The object of this procedure 
was to induce slight suppuration along the course of the sutures, which 
would result in a cicatricial band, thus uniting the lower portion of the 
lid with the occipito-frontalis muscle. This operation was later modi- 
fied by Wecker, who first excised a crescent-shaped piece of int^ument 
overlying the muscular fibres, and used sutures similar to those of 
Pagenstecher. This operation is one which at times^ and in the hands 
of some operators, has given very good results. 

There is still another operation, which is known as Panna's, the 
purpose of which is the direct union of a tongue-shaped flap of integu- 
ment from the lid to the occipito-fix)ntali8 muscle. This is accom- 
plished by making an incision along the upper border of the tarsal 
" cartilage," interrupted for a distance of about five millimetres at its 
middle portion. A second incision is then made, parallel to the first, 
just below the eyebrow. This one is carried down deep and is con- 
tinuous. A third incision is then made, parallel to the second and just 
above the eyebrow. Then the first and second incisions are united by 
two vertical ones, after which the tongue-shaped flap is carefully 
loosened from the lid down to the free border of the same. Then the 
tissue of the brow is so undermined as to unite the second and third 
incisions, forming a free bridge of integument, nn^er which the tongue- 
shaped flap is pushed, so as to unite it with the upper lip of the inci- 
sion above the eyebrow. This is accomplished by means of two looped 
sutures which enter the tongue-shaped flap and pass under the l)ridge of 
tissue and emerge at the upper lip of the topmost incision, after which 
they are drawn tight and tied, thus elevating the lid. This operation, 
as briefly described, is the one which was followed in the patient before 
you. The patient was anaesthetized and strict antiseptic precautions 
observed. The upper incision was united by three interrupted sutures, 
so as to insure union by primary intention. The wound was then 
dressed with powdered boric acid and bichloride gauze, one to five 
thousand, and overlaid with absorbent cotton and secured by a roller 
bandage. The following day the patient was resting easily, pulse and 
temperature normal ; hence the dressing was not removed, but the eye 
was redressed on the third and fifth days. On the seventh day the 
sutures were removed and the bandage left off. During this time there 



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310 INTERNATIONAL CLINICS. 

was not the slightest evidence of any pus. The lid, of course, was 
somewhat swollen, and the immediate effect of the operation was ob- 
scured. This swelling gradually disappeared, and with its disappear- 
ance an improved condition of the eyelid was noticed. So that to-day, 
after a period of about three months, the patient stands before you 
with both eyes open, and has her lids under perfect control (Fig. 2). 

The second patient is Mrs. S. M., aged forty-three years, who 
came to me at the banning of April last with the following history. 
About a year and a half ago the patient noticed on the left lower eye- 
lid, near the inner canthus, what she described as a pimple. She had 
never had it treated, save with home remedies. It gradually grew 
larger. At that time it presented an indurated, open sore about seven 
millimetres long and about four millimetres wide, near the inner can- 
thus, involving the free border of the lid, which was destroyed for an 
extent of four millimetres. The ocular conjunctiva was not involved. 
The sore was covered over with a thin crust, the removal of which 
caused it to bleed freely. Her family history, as near as could be 
elicited, proved negative. In cases of this kind it is a matter of some 
importance to arrive at a diagnosis, so as to be governed in the treat- 
ment. Considering the age of the patient and the course of this sore, 
we are immediately led to suspect some malignant growth, and the one 
which we should expect to find is epithelioma. The situation of the 
sore is almost typical of epithelioma of the eyelid (Fig. 3). It matters 
little in these cases whether we arrive at a positive diagnosis or not, 
— ^that is, within certain limits; always satisfy yourself whether it 
is specific or not, as our treatment should necessarily be of a surgical 
character in all, save when specific, when the usual remedies should be 
resorted to. The application of caustics in a location of this kind 
would result in the destruction of the tissue and the eyelid, and 
leave an unsightly cicatrix, as well as expose the eyeball. 

The patient was ausesthetized, and with the usual antiseptic precau- 
tions the operation was begun, the first step being the excision of 
the malignant growth, which was carefully dissected out and the re- 
maining wound curetted, so as to remove all possible fragments of 
diseased tissue. The bleeding was somewhat profuse, but was easily 
controlled by the application of a hot bichloride solution. The next 
step was the formation of a flap to fill in the gap left afl:er the excision 
of the growth. This was done by means of a sliding flap from the 
cheek. An incision was made parallel with the free border of the 
remaining portion of the lower lid ; there remained about one-third of 
it. This incision was carried horizontally across the cheek to the base 



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Fio. 5.— John L. after the operalion fur Ihe relief of traumatic ectropion. 



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OPEKATION FOR THE BELIEF OF TRAUMATIC ECTROPION. 311 

of the ear. Another incision was then made, b^inning at the lower 
border of the wound and carried down to the lobe of the ear, after 
which it was dissected up, care being taken to dissect onlj the int^u- 
ment with a small amount of the underlining tissue. Care was also 
taken to preserve the vitality of the flap by means of a towel wrung 
out of a hot bichloride solution. After it was thoroughly loosened it 
was slid over into place and trimmed so as accurately to fill up the 
gap left by the excision of the growth, and made fast by interrupted 
sutures. Silk was used in this case, and in all there were twenty-four 
sutures, which were dusted over with boric acid, then covered with 
wet bichloride gauze, over which some absorbent cotton was placed, and 
the whole secured by means of a roller bandage. On the following 
day the patient was resting easily, suffering no pain, with pulse and 
temperature perfectly normal, consequently the dressing was not re- 
moved. On the second day, however, the dressing was removed, and 
the line of sutures was found to be perfectly dry. It was then re- 
dressed and allowed to remain closed for two days longer, afl»r which 
the sutures were removed and the dressing left off. So that in tiiis 
case we had union by primary intention without the slightest trace of 
pus, and the patient, as you see her to-day, has this malignant growth 
removed and an eyelid which is quite serviceable, answering all neces- 
sary purposes, and presenting no special disfigurement, save two lines 
of cicatrices which will gradually grow less (Fig. 4). 

The third case to which I desire to call your attention is that of a 
diild, John L., aged one and one-half years, who met with an accident 
some months ago which produced a wound of the right upper eyelid, 
which became infected and suppurated, resulting in the complete 
destruction of the eyelid. The cicatricial band of tissue which had 

formed had contracted in such a manner as to leave a condition of ex- 

» 

treme ectropion. The palpebral conjunctiva was turned out, forming a 
bulbous mass completely covering the eyeball. The conjunctiva, of 
course, being very much irritated by its exposure to external influences, 
the only result in a case of this kind would be -a destruction of the 
exposed conjunctiva and an ultimate loss of the eyeball. The method 
of procedure first contemplated was the operation known as Wolfe^s, 
which consists in the transplantation of a flap without a pedicle ; but 
the results of this operation are so varied that it was decided best not 
to employ it in this case, but to use instead a sliding flap with a pedicle. 
The technique of the operation was as follows. The child was placed 
under a general anaesthetic, in this case chloroform being used. After 
cleaning the parts thoroughly with a solution of bichloride one to 



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312 INTEKNATIONAL CLINICS. 

five thousand, an incision was made about two millimetres from the 
edge of the lid and parallel with it, extending from the inner to 
the outer canthus, and a similar incision was made along the orbit, 
parallel with the orbit, the inner point uniting with the lower incision, 
the outer extremity being three millimetres above the lower incision, 
thus including the entire amount of cicatricial tissue, which was then 
excised, care being taken not to include the underlying muscular fibres. 
The bulbous mass of conjunctiva was then turned in and the lids placed 
in position. In this case I did not suture the lids together, as is recom- 
mended and as is very frequently done, but the lid was simply allowed 
to remain in place. The next step was the preparation of the flap to 
fill in this gap. The flap was taken from the temple by making a 
vertical incision at the extremity of these two parallel incisions, carry- 
ing it upward and slightly forward, but not allowing it to encroach on 
the tissue of the forehead. Another incision was made, b^inning at 
the upper extremity of this incision, carried downward and sh'ghtly 
backward, so as to leave a flap about six millimetres in width. This 
was then carefully dissected, with a small amount of underlying tissue, 
and was then slid into place, covering the defect of the lid, when it was 
found to be accurate without trimming. In this case, as in the other, 
care was taken to preserve the vitality of the flap. After all bleeding 
had ceased, the flap was secured by means of interrupted sutures. The 
gap left by the removal of this flap was then drawn together by several 
interrupted sutures, the edges of which approximated very nicely, 
after which a dressing similar to the one described in the foregoing case 
was applied. The wound was allowed to remain closed for forty-eight 
hours, aft^r which it was opened and all found to be doing nicely. It 
was redressed, and opened again two days aft^er, at which time the 
sutures were removed, and in this case, as in the former one, we got 
union by primary intention. So that at the present time, a few months 
aft;er the operation, we have the child with a useful eyelid, which can 
be opened and closed at will. The only deformity at present is a 
somewhat thickened eyelid and a vertical scar on the temple. This 
thickening of the eyelid has gradually become less, as no doubt some of 
you have noticed, since you have had the privily of seeing the patient 
several times during the healing process, and the eyelid will probably 
improve very much as the child grows older. At any rate, we have 
given the child a useful eyelid and preserved a perfect eyeball, which 
no doubt would have gradually been destroyed if the ectropion had 
persisted (Fig. 5). 

In performing plastic operations great care and deliberate judg- 



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OPERATION FOR THE RELIEF OF TRAUMATIC ECTROPION. 313 

ment are essential. Do not be in haste to operate^ but carefully con- 
sider what you intend to do and kow you are going to do it. When 
at all possible, use a flap with a pedicle, and always bear in mind that 
your flap will shrink, and that due allowance must be made for the 
shrinkage. The flap should be about one-third larger than the space 
to be filled ; then, with proper care and neatness, you are quite sure 
to achieve success. 



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treatment of trachoma by expression 
And by other methods. 

CLnriOAL LSOTUBX DKLIYEBKD AT THE KEW TOBK POLTCLIKIO. 

BY THOMAS R. POOLEY, M.D., 

Professor of Ophthalmology in the New York Polyclinic ; Surgeon-in-Chief to the 
New Amsterdam Eye and Ear Hospital. 



Gentlemen, — ^This boy, whom I have shown here before, has had 
both of his eyelids subjected to the operation of expression of the 
trachomatous follicles. The operation is quite painful, and cocaine 
anaesthesia does not seem to be sufficient to allay the pain ; hence the 
operation, under these circumstances, is not apt to be done so thoroughly. 
You notice that in the eye operated upon under general ansesthesia 
there are no trachomatous follicles to be seen, and the lid is almost 
well. The result is certainly far more satisfactory than that which 
would follow in the same time from the use of the sulphate of copper 
or other similar means. The expression of the follicles may be done 
with instruments, preferably with the forceps of Noyes or Gruening, 
or the roller-forceps devised by Knapp ; but most convenient of all 
is the use of the perfectly clean finger-nails.^ The operation is 
exceedingly tedious and uninteresting, and I think that any device 
which would control the hemorrhage would be a valuable help in 
the performance of the operation. The conjunctiva is naturally very 
vascular, and this condition is much increased when trachoma is 
present The hemorrhage which accompanies the operation of ex- 
pression prevents you from seeing distinctly how thoroughly you have 
removed the trachomatous follicles. I think in the future I shall not 
only employ ether, but shall also thoroughly cocainize the eye, for 
cocaine, if employed to a sufficient extent, is a good haemostatic. It is 
almost impossible to treat thoroughly all the follicles present, but do 

1 1 have given up the use of the finger-nails and now use Knapp's roller-forceps 
altogether. 
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TREATMENT OP TRACHOMA BY EXPRESSION. 315 

this as nearly as possible, and then rub the surface thoroughly with 
sulphate of copper, with the idea of exciting a very severe hypersemia 
which will absorb the remaining granulations.^ The reaction following 
this operation has never been sufficiently severe to alarm me, although 
the lids swell very much. Cold applications should be employed 
continuously during the height of the inflammation, and then, as it . 
subsides, they may be used at intervals of one or fwo hours. The 
conjunctiva rarely returns to anything like the normal condition until 
some time after the operation, and you might expect this because of 
the thickening of the conjunctiva which is the result both of the 
trachoma and of the traumatism of the operation. The operation has 
yielded much better results than the treatment by bluestone. I men- 
tion the bluestone treatment because I do not think there is any other 
treatment for granular lids, in the way of applications, to be com^iared 
with it. After the reaction which is directly due to the operation the 
conjunctiva remains thick, and if any trachomatous granulations are 
still present I employ the sulphate of copper, carefully, every day or 
two, just as I would in an ordinary c&se of trachoma. In cases of 
diffused or of long-standing trachoma which has already been sub- 
jected to operation, the follicles are not isolated, but are agglomerated 
by inflammatory action, and much of the exudation is subconjunctival, 
and therefore expression of the follicles under these circumstances does 
not promise a good result. This operation of expression is apparently 
a revival of an old method, and we must guard against the enthusiasm 
that so often leads astray those who attempt new methods of treatment. 
Examining the results with a critical spirit, but without prejudice, I 
think we may say that they are sufficiently good to encourage us to 
continue its use. 

A word or two might be said here about the inconsiderate way in 
which the diagnosis of trachoma has often been made. Nearly every 
case in my own hospital, for instance, in which there is a chronic swel- 
ling of the conjunctiva, with elevations, is dubbed "trachoma." Now, 
trachoma is comparatively rare, and the cases which are so misnamed 
are usually those of chronic follicular conjunctivitis, or more or less 
acute inflammation with enlargement of the papillae of the conjunctiva. 
Some of the treatises very confusedly call this papillary trachoma. 
Increase in size of pre-existing elements of the conjunctiva, such as the 
papillse, does not constitute a disease, but is simply an expression of an 

^ Further experience has taught me that this is not necessary, the thorough 
expression alone being sufficient. 



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316 INTERNATIONAL CLINICS. 

inflammatory conditioD^ and not an indication of an organic change in 
the conjunctiva. The truth is that trachoma, as found in this hayy is 
an essentially different disease ; it is one which is characterized by the 
formation of a pseudoplasm of a different kind of tissue from that whidi 
exists in the conjunctiva, and, so &r from yielding readily to treatment, 
as do these other conditions, it is in all instances essentially inveterate 
in its character, and it has the quality of destroying the tissue in which 
it has its birth. All recuperation from a true trachomatous process is 
at the expense of the int^rity of the conjunctiva, and in this respect 
trachoma is a good deal like tuberculosis. 

Without going too much into the details of the pathology of 
trachoma, I may say that these forms of true trachoma require to be 
treated in such a way as to bring about absorption of the trachomatous 
process with as little injury as possible to the conjunctiva. If you let 
granular lids alone, many of them make a fair recovery. I wish to 
remark just here that if, after the treatment has been carried to a cer- 
tain point and the patient appears to be comparatively comfortable, 
you relinquish treatment, the progress to recovery goes on as well as 
if you had continued the treatment, if not better. Your object should 
be to aid nature in the treatment of trachoma. Let me caution you 
especially against the use of powerful escharotics. The treatment of 
granular lids by the use of nitrate of silver in stick, whether, as was 
formerly done sometimes, by the pure stick, or, as in later years, by the 
mitigated stick, has been very largely discontinued. Some employ 
solutions of nitrate of silver, and these are not so harmful. I recently 
saw a gentleman from Idaho who had been very variously treated for 
a number of years for granular lids. So powerful had been the 
remedies employed that there were numerous symblepharon bands in 
the lower conjunctival cul-de-sac which very much restricted the move- 
ments of the eyes upward. The granular condition had nearly 
disappeared, but the results of the treatment were fully as bad as 
the original disease. This patient said that, except when there was 
unusual purulent secretion, vaseline or cold cream kept his eyes far 
more comfortable than any of the remedies which had been employed. 

The treatment of granular lids, excluding for the present the 
methods of expression and grattage, is reduced in tny practice to the 
employment of the sulphate of copper. You should be guided in 
your treatment by the chronicity of the condition. Acute trachoma is 
very rare, but should you meet with it where, in addition to the usual 
trachomatous process, there is excessive swelling, with much secretion 
and pain, which is very coilsiderably aggravated at some times of 



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TREATMENT OF TRACHOMA BY EXPRESSION. 317 

the day^ and where the whole ooudition Bimalates an acute catarrhal 
inflammation of the conjunctiva, remember that such a case should be 
left alone, so far as the use of astringents is concerned. Your only 
aim at such a time should be to prevent the inflammatory condition 
from reaching too great a height. If you find that there is danger of 
implication of the cornea, you should make use of cold applications. 
This will be very seldom necessary. On the contrary, sometimes, if 
there seems to be a subsidence of the acute symptoms, and the case tends 
to become one of chronic trachoma, you may increase the hypersemia 
by using hot applications and keeping the eyes thoroughly cleansed. 

In chronic trachoma, if the case come to you at such a period that 
the operation we have been considering is no longer indicated, the ap- 
plication of sulphate of copper should be made in such a way that the 
whole surface of the conjunctiva where the granulations are present is 
touched with the bluestone. The immediate comfort of the patient, 
the amount of suffering you inflict, and the final good results all de- 
pend very largely upon the manner in which you make this application. 
The lid being everted and the patient told to look down, so as to 
expose as far as possible the whole extent of the conjunctival cul-de-sac, 
you should make the application with a perfectly smooth crystal of the 
sulphate of copper, and this crj'stal should be flat, sufficiently long to 
reach the depth of the cul-de-sac, and sufficiently thin to admit of its 
being carried between the conjunctiva and the globe. It should be 
applied very lightly once or twice over the exposed part of the con- 
junctiva, and then carried between the upper lid and the globe, so as 
to touch the whole conjunctival surface in the reflection fold. Then 
immediately wash off the whole surface with a camel's-hair brush 
dipped in water. Your attention should be next directed to the lower 
culnde-sac, the patient looking upward, so as to expose this surface. 
This likewise is washed after the application. The next important 
step is to decide how often these applications should be repeated, and I 
think that in every case at the outset, and especially in private practice, 
where explicit directions are expected, you should require the patient 
to come to you daily for some time. The object of this is that you may 
see whether the applications should be made daily or at longer intervals. 
The amount of reaction caused by the application depends very largely 
upon the person who makes it, or rather upon the lightness of the 
touch employed. In many institutions no subsequent washing is em- 
ployed, and the patients, under such circumstances, must suffer half an 
hour or more of pain, and, in addition to this, I am not sure but that 
such treatment also does harm. The crystal of sulphate of copper 



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318 INTEKNATIONAL CLINICS. 

should not be left moist^ and, as this salt tends to absorb moisture 
from the atmosphere, it should be kept where this cannot occur, for 
the surface then becomes quite rough, and such a crystal is very apt 
to leave behind in the cul-de-sac a minute fragment of sulphate of 
copper, which will of course cause much suffering. 

If you find on the day following the application that the reaction 
has not yet subsided, then postpone the application until the next day. 
In an old case of trachoma a touching of this kind produces a &vor- 
able effect upon the patient's feelings within fifteen minutes, and in 
these cases you can very properly touch the eyes daily ; but if there 
have been much pain, inflammation, and secretion, it is better to defer 
the application for one or two days. Bear in mind, then, that your 
object is not to bum the granulations, for such treatment certainly 
causes scars and a worse condition than would result from not treating 
the granulations at all. The applications are to be made in such a 
way as to cause sufficient inflammation in the lids to bring about a6- 
8orption of the granulations. The one other essential feature of the 
treatment is to keep the conjunctiva clean, and this part of the treat- 
ment is to be done at home. The patient should be carefully instructed 
about washing out the cul-de-sac, and, since we know that all such 
directions are more carefully followed if we give a written prescrip- 
tion, we may prescribe a solution of bichloride of mercury or boracic 
acid, chlorate of potassium or common salt, all of which are excel- 
lent remedies. These all accomplish the cleansing I have insisted 
upon, and hence you should see that they are frequently repeated. 
Much aid is derived from the use of hot applications, which favor the 
action of the sulphate of copper by increasing the vascularity of the 
membrane, thus favoring the absorption of the granulations. They 
are grateful to the patient, and in chronic trachoma I almost invariably 
advise their use. 

So far I have been referring to the treatment of cases where there 
is no corneal complication. Trachoma, however, does not exist for a 
long time without implication of the cornea. The commonest way 
in which the cornea becomes affected is by the upper third of it be- 
coming vascular, — ^the condition we call pannus. Your treatment will 
depend upon whether you think the condition is produced entirely 
by the rubbing of the rough lids over the cornea, or hold to the 
view that the trachomatous extension to the corneal epithelium is 
responsible for it. Probably both conditions fiivor it, but careftil 
microscopical examination of the corneal tissue shows that there is 
an extension of the trachomatous process to the corneal epithelium^ 



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TREATMENT OP TRACHOMA BY EXPRESSION. 319 

and cases in which there was ulceration of the cornea have been seen 
by competent observers where the trachomatous process has even ex- 
tended into the interior of the eye. Some patients may come to you 
for the first time with this vascular condition^ and you are at once led 
to suspect the existence of granular lids. You should determine by 
careful inspection of the cornea whether or not there is an extension 
of the trachomatous process to the epithelium of the cornea^ and this 
will be usually shown by an examination with oblique light. If such 
be the case^ you will see minute yellowish millet-seed spots in the 
cornea in addition to the deep-seated vascularity or pannus. If this 
condition be present^ it is best to touch these spots gently with the 
sulphate of copper at the same time that you touch the lids. Dr. 
Gruening has recently practised scraping of the cornea in these vas- 
cular conditions, but his cases have not yet been published, and I am 
not well acquainted with this method, although I should consider it 
probable that such a procedure would be successful. I think this 
scraping should be done only when the lids are comparatively weU, 
for if the rftw surfiuse were exposed to the granulations they would 
almost certainly become infected. The use of atropine in trachomatous 
pannus is to be deprecated, and, as a rule, atropine is not to be resorted 
to in trachoma unless there be infiltrations and ulcerations, for in most 
cases it aggravates the trachomatous process. 



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BLENNORRttCEAL CONJUNCTIVITIS; ITS ETIOL- 
OGY, DIAGNOSIS, AND TREATMENT. 

CLINICAL LECTURE DELIVERED AT THE UNIVERSITY HOSPITAL. 

BY ALBERT RUPUS BAKER, M.D., 

Professor of Diseases of the Eye, Ear, and Throat in the Medical Department of the 
University of Wooster, Cleveland, Ohio. 



Case I. — ^This child; as you see^ is a typical case of old granulated 
lids. I do not present it because there is anything remarkable about 
the case, but on account of its history, which is an instructive one luid 
may help us to arrive at some knowledge of the etiology of the disease. 

The history of the case is as follows. About three years ago an 
in&nt sister of this little girl suffered from ophthalmia neonatorum. 
Within a few days another child of the family, about two years of age, 
was attacked with a severe purulent conjunctivitis. When the case 
came under my observation a few days later, the cornea of one eye 
was perforated, the eye being entirely destroyed, and there was a large 
central ulcer of the cornea of the other eye. The child was imme- 
diately put in the hospital, and with vigorous treatment and careful 
nursing fair vision was preserved in that eye. Some months later tUs 
still older child was brought to my office suffering from granulated lids. 
She has been under my observation almost continually since that time, 
and, as you see, has almost recovered. The case was first treated with 
nitrate of silver, and afterwards the granulations squeezed out with 
Knapp's roller forceps, which seemed to aggravate rather than benefit 
the disease, as I have found this treatment to do in other cases of true 
granulated lids, though it is of inestimable value in the treatment of 
follicular conjunctivitis. You will notice, instead of the normal ap- 
pearance of the conjunctiva, the peculiar cicatricial appearance which 
it presents ; also that the palpebral opening is somewhat narrow, the 
lid drooping, giving the peculiar sleepy expression to the eyes so char- 
acteristic of old cases of granulated lids. This peculiar appearance is 
of diagnostic importance. We can often say that a patient has suf- 
fered from a certain disease from the tracks it leaves (although the 
820 



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BLENNORRHCEAL CONJUNCnVITIS. 321 

disease itself may be entirely cured), the same as when a hunter in the 
woods finds chips he will be certain that an axe-man has been there. 

Case U. — ^We have here another interesting case bearing upon the 
same subject. This gentleman comes here from Michigan for treat* 
ment. He has been under the care of various physicians during the 
past three years. 

Upon examination we notice the peculiar drooping of the upper 
lid and the shortening of the palpebral opening, as in the other case, 
but affecting only one eye. Upon everting the upper lid we do not 
find the cicatricial appearance. The lid is rough and covered with 
the peculiar granulated bodies from which the disease derives its 
name. The upper half of the cornea also has a peculiar fleshy 
appearance, which we call pannus. 

This man is an Israelite, about forty years of age. His occupation 
is that of circumcising children according to the rites of his church : 
he has made between five and six hundred circumcisions. He has 
kindly consented to show us his instruments and the dressing which 
he uses, and will relate to you the method which is pursued by him. 
You will notice that he purposely permits his thumb-nails to grow 
very long for tearing the mucous membrane. But the particular thing 
to which I wish to call your attention is the entire absence of antiseptic 
precautions, and the ease with which the blennorrhoeal poison may have 
been carried to his eyes. I think it is altogether probable, in his case, 
that this was the origin of the eye-trouble, as well as in the case of the 
little girl who contracted a purulent ophthalmia from her baby sister 
three days old. The point I wish to emphasize is that gonorrhoea, 
purulent conjunctivitis, and granulated lids are due to the same cause. 
I am aware that this is not in accordance with the teachings of your 
text-books. But if I were going to write a text-book on the diseases 
of the conjunctiva, I should make a somewhat different classification 
from that usually given. I think I should make a classification as 
follows : 

Irritative Conjunctivitis. 

Catarrhal Conjunctivitis < ^^^ \ _ ... , ^ . ... 

I Chronic — Follicular Conjunctivitis. 

{A tp /Ophthalmia Neonatorum. 
\ Gronorrhoeal. 
Chronic — Granulated lids. 
Phlyctenular Conjunctivitis. 
Diphtheritic Conjunctivitis. 

Strictly speaking, the affection which I have called irritative con- 
VoL I. Ser. 4.— 21 



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322 INTERNATIONAL. CLINICS. 

junctivitis is not conjunctivitis at all, but a hyperemia of the conjunc- 
tiva due to eye-strain, generally the result of an error in refraction. 
I should not speak of it in this connection if it were not so frequently 
mistaken and treated for granulated lids by ignorant practitioners. 
The disease is characterized by a feeling of irritation in the eye, as 
though there were sand in it ; an excessive flow of tears ; considerable 
photophobia ; a frequent desire to rub the eyes ; often a blurring of 
sight, especially in the latter part of the day. It is often associated 
with blepharitis marginalis. The conjunctiva is slightly redder than 
normal, and there is a slight exaggeration in the normal velvety 
appearance of the conjunctiva, which is so frequently mistaken for 
granulations. There is little or no muco-purulent secretion ; no stick- 
ing of the lids together in the morning ; no thickening of the lids or 
narrowing of the palpebral opening, nor any of the serious symptoms 
characteristic of granulated lids. Irritative conjunctivitis occurs more 
frequently among the most intelligent people of a conmiunity, because 
they are most apt to abuse their eyes. 

Granulated lids is a rare disease and seldom met with among the 
better class of patients. In fact, we saw but a few cases in Cleveland 
until the recent influx of Kussian Jews. It would scarcely seem 
necessary to call the attention of a class so intelligent as this to the 
differential diagnosis between diseases which have so little in common. 
And I should not do so if it were not for the fact that I meet doctors 
all over the country who are subjecting patients who need nothing 
but a pair of spectacles to a long and severe course of treatment 
which does great harm. It is not uncommon to meet doctors in 
Cleveland in general practice who are treating scores of cases for 
granulated lids, while I doubt if any specialist in the city has seen 
that many cases in a year. 

Follicular conjunctivitis, which is a chronic form of catarrhal con- 
junctivitis, is frequently mistaken for granulated lids. It is to be 
regretted that our text-books are not more definite in their descrip- 
tion of this condition. I think it is now generally recognized by ocu- 
lists that there is an essential difference between follicular conjunctivitis 
and granulated lids. 

Case III. — ^This is a case I have had sent over from one of our 
Children's Homes. A few years ago I found twenty-five per cent, of 
the inmates of this institution suffering from follicular conjunctivitis. 
At my last visit this was the only case I found. The improvement of 
the condition of these children's eyes is undoubtedly due to the im- 
proved hygienic surroundings. Upon examining the palpebral con- 



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BL£NNORRH(£AL OONJUNCTrVTnS. 323 

junctiva you will see several small oval yellow-pinkish prominences 
about the size of a pin's head. These are tumefied lymph follicles ; 
they are not so high nor so prominent as the ordinary hypertrophied 
papillse present in all conjunctival inflammations. This child com- 
plains of the ordinary symptoms of chronic catarrhal conjunctivitis, — ^a 
slight sticking of the lids together in the morning, a feeling as of sand 
in the eyes, a frequent disposition to rub the eyes, a slight photophobia ; 
and all these symptoms increase when the eyes are used for reading 
or close work. 

These cases are common in residential schools, orphan asylums, 
prisons, and garrisons ; also in the lower walks of life and wherever 
lai^ numbers of people are crowded together, especially if occupying 
ill-ventilated rooms, where the atmosphere is vitiated, and there is ab-. 
sence of sunlight The management of these cases consists in improv- 
ing the hygienic surroundings. Remove all exciting causes, and they 
will usually recover without any treatment ; but as long as the patient 
remains surrounded by filth and dirt the disease will continue for 
months and years without improvement under the most vigorous treat- 
ment. In fact, the ordinary astringent and caustic treatment applied 
to granulated lids will in that case only aggravate the disease. 

One of the essential differences between this disease and granulated 
lids is its tenden6y to get well without leaving any deformity of the 
lid. Cases in which the follicles cause no unpleasant symptoms are 
best let alone without treatment. In other cases a solution of boracic 
acid instilled into the eye frequently, and a small amount of dilute 
citrine ointment placed between the lids before retiring, will give the 
best results. If more radical measures are deemed necessary, the use 
of Knapp's roller forceps will give most satisfactory results. 

There is much diversity of opinion as to the etiology. Many 
eminent pathologists believe it to be due to contagion ; others, that it 
is caused by dust, filth, bad air, bad food, and unhealthy surroundings. 
I am inclined to accept this latter theory. 

Case TV. — ^This old lady comes to us with the following history. 
She says she has suffered with inflamed eyes for one and a half years ; 
that first one eye was affected, and a few months later the other ; she 
was under the care of several practitioners, who repeatedly brushed 
her lids ; afterwards she went to one of the dispensaries, where she 
was treated twice a week for several months by an eminent oculist ; 
when she was faithful in her attendance and had the lids brushed 
regularly twice a week with nitrate of silver or rubbed with blue 
stone she was comparatively comfortable ; during the past two months 



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324 INTERNATIONAL CLINICS. 

her health has not been good^ the weather has been bad, and she has 
not been regular in her attendance^ and the eyes are now more painftil 
than at any previous time. 

She wishes to have some radical measures taken to relieve her of 
this painful affection. As you will see, the upper lid is thick and 
(edematous. She shuns the light, and it is impossible for her to open 
her eyes widely. The left eye is the more painful, but she can see 
better with it than with the right, which is almost blind. We find the 
right cornea almost entirely covered with pannus, and on the left there 
are several small ulcers along the sclero-comeal mai^in. These are 
what cause the intense pain and photophobia of which the patient 
complains. You will notice that there is considerable purulent secre- 
tion, and upon everting the lid it presents a red, thickened, and some- 
what uneven surface. These changes are due to hypertrophy of the 
mucous membrane, and constitute the characteristic feature of granu- 
lated lids. It does not seem possible that this great thickening of die 
entire lid, with effusion of fibro-plastic material into the subconjunctival 
tissue, should be mistaken for ordinary follicular conjunctivitis, such as 
that presented by Case III. ; or for the slightly hypertrophied papillae 
characteristic of irritative conjunctivitis. 

We shall now give this patient an anaesthetic, and take this com- 
mon tooth-brush and cut it down about two-thirds and thoroughly 
brush the lids with a 1 to 500 solution of mercuric bichloride. I 
have found this the most efficacious method of treating such cases. 
It sets up an intense inflammatory reaction, and as the inflammation 
recedes much of the effused fibro-plastic material will be carried away 
and the lids will be much thinner than before. The principle is some- 
what the same as that by which the surgeon will cure an efiiision into 
the knee-joint by the application of the actual cautery externally, and, 
indeed, I believe this is nature's method of curing the disease. The 
reason we do not have more cases of granulated lids following oph- 
thalmia neonatorum or gonorrhoeal ophthalmia is that, owing to the 
intensity of the inflammatory reaction, the disease cures itself, although 
it often destroys the eye in doing so. It has been the custom from 
time almost immemorial in extreme cases in which vision was almost 
entirely lost from granulated lids to resort to inoculation, usually with 
pus from a recent case of ophthalmia neonatorum. In more recent 
years we have resorted to the use of jequirity. An infusion is made 
from the jequirity bean and is brushed upon the lids, which causes an 
intense purulent ophthalmia nearly, if not quite, as violent as that due 
to inoculation. 



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BLENNORRHOEAL CONJUNCTIVITIS. 325 

I believe this method of brushing the lids with a strong solution 
of bichloride is destined to supersede most of the older procedures. 

Operation. — The patient is anaesthetized^ and the face and eyes 
thoroughly scrubbed with soap and water; the granulated lids are 
brushed vigorously with the tooth-brush, which is repeatedly dipped 
in the bichloride solution ; there is free bleeding, which is washed off 
with a bichloride douche by an attendant; the lids are dusted with 
acid and covered with gauze, cotton, and a roller-bandage. The 
patient was ordered to bed, and an ice-bag applied to control pain. 

From what I have said before you will readily conceive that I 
believe blennorrhoeal ophthalmia and granulated lids to be identical, — 
one an acute and the other a chronic form of the same disease. We 
might compare the acute blennorrhoeal disease to an acute gonorrhoea, 
and granulated lids to a gleet. Further, I believe that the primary 
origin of the disease is probably referable to the secretion of genitals 
affected with gonorrhoea, and that this secretion produces in the human 
conjunctiva acute blennorrhoea, which may become chronic, and then 
we call it granulated lids, or trachoma. The disease is most frequently 
communicated from one eye to another, probably by means of towels, 
handkerchiefs, fingers, etc., but it is not infrequently contracted more 
directly from its first source, as in. the case of the child whom I first 
presented to you to-day. 



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|itn)n0ala0t| an^ Kt)inala0t)^ 



CHRONIC NON-SUPPURATIVE INFLAMMATION OF 
THE MIDDLE EAR. 

CLINICAL LECTURE DELIVERED .AT ST. LUKE'S HOSPITAL, CHICAGO. 

BY S. J. JONES, M.D., LL.D., 

Profeesor of Ophthalmology and Otology in Northwestern University Medical 
School (Chicago Medical College), Chicago. 



Gentlemen, — I have arranged to present to you to-day a number 
of cases of chronic nou-suppurative inflammation of the middle ear, 
grouped together to illustrate an affection that has been r^arded as 
among the opprobria of otology, — that large class furnishing the most 
frequent cause of progressive impairment of hearing. In addition to 



f/?CSM<lS 






COGHUA 




Vertical section, showing external, middle, and internal ear and Eiistachian tube. 

the cases in the hospital I have requested some of my private patients 
to present themselves, that you may have an opportunity of witnessing 
the fact that no age and no climate seems to exempt people from this 
826 



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CHRONIC N0N-8UPPURATIVE OTITIS MEDIA. 327 

affection. The cases that will be presented to you manifest several 




Jones' compoond otoscope. 



allied conditions producing the same result, impairment of hearing, 
not total deafness. They vary from youth to old age. 




Trdltsch's mirror, with head-band. 

The first is A. B., sixteen years of age, who is, as you see, in appar- 



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328 



INTERNATIONAL CLINICS. 



ently vigorous health, of good constitution, and the son of healthy 
parents. Although a native of an Eastern State, most of his life has 
been spent at his present residence, San Jo86, California. His case is 
one of hypertrophy of the tissues of the middle ear. Inspection of 

the external meatus shows normal 
shape, but absence of the normal 
secretion of cerumen. The drum- 
heads are unnaturally concave ex- 
ternally. Instead of presenting the 
normal pearly-gray appearance, the 
membranes are less translucent than 
normal. They look more like 
parchment or ground glass. The 
change in the shape of the drum- 
head has diminished the size and 
modified the appearance of the re- 
flection of the light thrown upon it, 
wliicli si[Ould appear as a sharply-defined tri- 
angle, lilt; apex of the triangle being at the cen- 
tral part af the membrana tympaui, and its base 
in the anterior and inferior quadrant The nos- 
trils aru nearly normal in shape and condition. 
Inspeotion of the pharynx shows follicular en- 
largement and altered mucous secretion. In test- 
ing hearing with a watch as a convenient, though 
iuaceumte, test of the hearing-power, it will be 
peroeivod that he does not hear it tick when as 
i-emott' fVom his left ear as from his right, the 
hearfDg-<listance being five inches with the left 
ear and eight with the right. This corresponds 
with the usual result in examination of ears, in 
which it is generally found that the left ear is 
more frequently affected and more changed than 
the right one. On testing with a vibrating tuning-fork it will be 
noticed that he hears the fork more readily also with his right ear 
through the ordinary conducting apparatus, but when that vibrating 
fork is brought in contact with the teeth the sound, through bone-con- 
duction, is heard more loudly in the left ear than in the right, which 
is frequently a cause of great surprise to patients. Because they hear 
the ticking of a watch at a greater distance with the better ear, tliey 
are apt to answer, when asked with which ear they hear the vibrating 




Trdltsch'B mirror, with 
handle. 



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CHRONIC NON-SUPPURATIVE OTITIS MEDIA. 



329 



tuning-fork better when placed against the teeth, that they hear it 
louder in the ear with which thev have heard the tick of a watch 




Tilrck'8 tODgue-depressor. 



better ; but upon fixing their attention closely upon the matter when re- 
quested, to their astonishment they find that it is heard louder and quicker 




Tuning-fork. 



in the more affected ear. This patient is not an exception to that rule. 
He is more fortunate than many in not being troubled with tinnitus 
'aurium, which patients frequently say is much 
more annoying to them than their impairment of 
hearing. It is more apt to occur in patients more 
advanced in life, as is also aural vertigo. These 
patients manifest a susceptibility to atmospheric 
and telluric influences as marked as in rheumatic 
patients. This one is not an exception in that re- 
spect, either. Great and sudden changes of tem- 
perature quickly modify the hearing-power. Even 
though a change in the weather be from bad to more 
favorable states, if that change be great, hearing is 
apt to be worse for a few days, until the system shall have adapted 
itself to the altered atmospheric conditions. 

The next patient is a young man, C. D., twenty-three years of age, 
a resident of Walla Walla, Washington. His vocation is that of a 




Ne&t of ear-8pcculA. 



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330 INTERNATIONAL CLINICS. 

butcher. He has resided for a number of years in that climate, which 
is r^arded as one of the most fitvorable in our territoiy for affections 
such as that now under consideration. His business has not unduly 
exposed him to unfavorable weather, and the calling is not usually 
considered an unhealthy one. His general physical condition also in- 
dicates nearly perfect health. His case, however, differs from the pre- 
ceding one in the absence of hypertrophy of tissue, on the contrary 
showing atrophy of the conducting apparatus, notwithstanding his 
excellent health. On inspection the external meati and the drum- 
membranes present almost exactly the same appearance as in the pre- 
ceding case. In many of these cases the lining membrane of the 
Eustachian tube, instead of being hypertrophied, thus diminishing 
its calibre, is sufficiently atrophied to make the calibre abnormally 
large. Such patients frequently complain of a great sense of fittigue 
following a sustained effort to hear, saying that it is sometimes more 
exhausting to them than a moderate amount of manual labor. One 
of the early evidences of diminishing acuteness of hearing is less power 
of accommodation of the ear, dependent in part, probably, upon paresis 
or atrophy of the tensor tympani muscle. In case of atrophy, persistent 
and annoying tinnitus is more apt to occur than in hypertrophy of the 
tissues. This may be in part dependent upon contraction, especially 
of the fibrous layer of the drum-head, thus, by pressure through the 
ossicles, forcing the stapes too firmly into the foramen ovale, producing 
undue pressure in the labyrinth. In these cases fluctuations in the 
hearing- power are also less frequent, because the air in the middle ear 
is not apt to be rarefied, and, in consequence of that, inflation of the 
middle ear does not even temporarily improve hearing as much as it 
does in cases where hypertrophy of the mucous lining of the Eustachian 
tube exists. 

The third case, E. F., is a resident of this city, seventy years of 
age, not well nourished physically, but enjoying average good health. 
He has had impairment of hearing for over thirty years. The origin 
of the disease causing it is unknown. It is not bdieved to have had 
its start in any of the eruptive diseases, nor in any marked pharyngeal 
inflammation that he remembers. It is the same history so often given, 
that an accidental circumstance drew attention to the fact of slight 
impairment of hearing, which perhaps existed for a considerable length 
of time before being recognized, but had occurred so gradually that 
the patient had become accustomed to the changing condition and did 
not realize it. Moreover, frequently one ear — generally the left — is 
considerably affected, but, the other being in a better condition, the defect 



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CHRONIC NON-SUPPURATIVE OTITIS MEDIA. 331 

is not noticed in conversing with persons immediatelj in front of the 
patient or on the side of the better ear. In this way the existing con- 
dition of the diseased ear b overlooked until some special circumstance 
draws attention to it and the hearing-power of each ear is tested sepa- 
rately. In these cases usually there has never been pain enough in 
the ear to have attracted attention, a circumstance that is in one respect 
unfortunate for the patient, for, had the inflammation been of a higher 
grade so as to have been accompanied by swelling and pressure enough 
to produce pain, attention would have been drawn to it, and the most 
favorable time for treatment would probably not have passed before 
the patient realized the necessity for proper care of his ears. This &ct, 
and this condition, which is usually in an advanced stage when recog- 
nized, afford some explanation of the difficulty experienced in treating 
these defects successfully, which has led to their being r^arded as a 
reflection upon otologists. All three of these cases have shown an 
absence of the normal secretion of cerumen for the protection of the 
external meatus, due to its suppression, because primarily of the con- 
dition within the middle ear. In other cases ear-wax is secreted, but 
not in its normal condition, and therefore does not pass to the outer 
part of the external meatus under the influence of the movement in- 
volved in the act of mastication. Being secreted in a drier state than 
natural, it is retained, gradually becoming harder and darker than 
the normal rosin-colored appearance of the wax. Often it accumulates 
to such an extent as to fill the meatus. In some instances, when re- 
moved by the use of alkaline solutions, it is found that the dermoid 
layer of the external meatus and membrana tympani is thrown off, 
showing almost a ^rfect cast of the lining of the meatus and of the 
outer layer of the drum-head. This condition constitutes another factor 
in producing impairment of hearing by blocking up the external meatus, 
but it is a condition which never occurs in a healthy ear ; therefore the 
general impression which obtains, that if such an accumulation be 
removed, it is all that is necessary to be done. Such is not the fact. 
The case should subsequently be properly treated to remedy the con- 
dition which has produced this state as one of the consequences of the 
abnormal condition of the remainder of the conducting apparatus. 

Without such treatment the accumulation usually occurs with in- 
creasing frequency and with greater change in the conducting apparatus, 
further increasing the impairment of hearing. 

The fourth case, G. H., is a patient fifty years of age, also a resident 
of this city, of fair average health, and with similar impairment of 
hearing. There is no accumulation of ear-wax in the external meatus ; 



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332 INTERNATIONAL CLINICS. 

on the contrary, there is itching of the meatus, with a scalj condition of 
its walls resembling in appearance slightly moistened flour. Examina- 
tion has shown this to, be the parasite aspergillus, which is accompanied 
by persistent pruritus in the meatus, causing a desire, that is almost 
irresistible, to rub and scratch the affected part, which is frequently 
done until such chafing has been produced as results in circumscribed 
or diffuse inflammation of it This pruritus, though generally in a 
less marked d^ree, is a very general accompaniment of the absence 
of normal secretion of ear-wax, and has its origin usually in inflam- 
mation of the middle ear, with interruption of normal secretion in the 
conducting apparatus, which makes a state of the parts favorable for 
its occurrence. 

The hopeful feature of all these cases is that the lesion is confined 
almost entirely to the condxiding apparatus; the perceptive apparatus 
being but little, if at all, affected by the imperfect circulation and 
consequent malnutrition. 

The next case is I. J., a young man twenty-three years of age, of 
full average physical development, with good family history, a carpenter 
by trade. Inspection of his ears shows an accumulation of dark, hard 
ear-wax in each ear, not, however, filling the meatus. It is in such 
a condition that it can be removed by means of a small metallic ear- 
scoop. On removing it we find opaque drum-heads quite scarred. 



■^^■^^^gli! 



isHgffORO >cuw.cy 



Gross's ear-scoop and hook. 

showing the fact of perforation in the drum-head having occurred early 
in life, so early, in fact, that he has no remembrance of it. This shows 
another feature that is not generally understood by the public, — viz., 
that perforations in the drum-head are not fatal to hearing and are not 
always and necessarily permafnent ; but that, on the contrary, the drum- 
head being well-nourished tissue in the acute stage of a suppurative 
process, with good nutrition of the parts, closure of openings of mod- 
erate size made by discharge from the middle ear occurs readily when 
the inflammation has subsided and the consequent abnormal secretion 
has ceased. This case of non-suppurative inflammation at least had 
its origin in that condition. The inflammation subsided ; the exces- 
sive secretion ceased, and the perforations closed, leaving the cicatrices ; 
but such structural change had occurred in consequence of that in- 
flammatory process that there have always been since then rigidity 



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CHRONIC NON-SUPPURATIVE OTITIS MEDIA. 333 

of the tissues^ more or less contraction, and altered secretion of ear- 
wax combining to interfere with the transmission of sound to the 
perceptive apparatus. It is found also on inspection that there is 
considerable follicular pharyngitis, and that the same condition extends 
up through the posterior uares, diminishing the lumen of the nostrils 
and interfering with ready breathing through the nostrils, a condition 
which has led to the designation of such patients as ^^ mouth-breathers/' 
and the affection as aprosexia, a condition that is unfavorable because 
the air is not tempered by passing through the nostrils to the pharynx • 
but, on the contrary, breathing through the mouth causes evaporation 
from a larger surface of mucous membrane, producing a dry state that 
is undesirable, and there is not the sifting of the atmosphere by the 
short, stiff hairs of the nostrils to prevent the passage of irritating 
particles floating in the atmosphere into the pharynx. There is then 
a non-suppurative condition in this case as a consequence of a previous 
suppurative inflammation, differing in that respect from all the pre- 
ceding ones. 

These cases give some idea of the range of age and other attendant 
circumstances which produce these conditions. They are found as 
sequelse of eruptive diseases, sometimes of acute suppurative processes ; 
at other times it is difficult to trace the origin or the time at which the 
inflammation commenced. Too oft«n patients are seen only in an 
advanced stage of the trouble. You will have noticed in these patients 
a result similar in character from two opposite conditions, — namely, 
one of hypertrophy, the other of atrophy, each influencing un&vorably 
the conducting apparatus. 

An advance has been made in later years in recognizing the &ct 
that these conditions which produce gradual impairment of hearing 
are affections of the conducting apparatus, whereas not many years 
ago they were all considered as cases of progressive nervous deafness. 
This condition, although chronic in character, may from adverse in- 
fluences be lighted up into subacute or acute simple inflammation or 
even suppurative inflammation, thus adding another factor of danger. 
Such acute aggravations occur most frequently in this lake region in 
the latter part of winter and in early spring. Next to this time the 
most unfavorable period for them is during the hottest weather of 
midsummer. 

In their chronic stage they are usually dangerous, only as impairing 
the function of hearing ; but when lighted up, as they frequently are, 
by the great and frequent changes in the atmospheric conditions in 
the latter part of winter and spring, resulting in a higher grade of in- 



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334 INTERNATIONAL CLINICS. 

flammation, another factor of danger is added,^anger to the life of 
the patient, by extension of the inflammation from the middle ear to 
the meninges of the brain and the brain itself, often resulting in death. 
DiagTioais of these cases is not difficult. Inspection of the external 
ear to the drum-head enables one to determine the existing condition. 
The vibrating tuning-fork held near each external meatus and subse- 





Convenation tube. DiagnoAtic tube. 

quently placed, whilst vibrating, against the teeth demonstrates the 
fact that the lesion which produces impairment of hearing is not a 
defect in the perceptive power of the auditory nerve. Thus by exclu- 
sion the seat of the difficulty is narrowed down to the middle ear and 
the Eustachian tube. 

Treatment of these cases is a much more difficult matter, and it 
must vary with the two principal forms of hypertrophy or atrophy. 

Prognosis is more favorable in cases of hypertrophy than in cases 
of atrophy. Bearing in mind the changes which have taken place in 
each of these two forms, they will guide in the modification of the 
treatment adapted to each condition. In cases of hypertrophy, usually, 
the mucous membrane of the naso-pharynx has been so modified by 
inflammatory action that it is thickened and the secretions are altered 
in amount and character. That same condition usually extends through 
the Eustachian tube and involves more or less the middle ear. With 
that hypertrophy there is sluggish circulation, passive congestion. 
There is a debilitated state of the tissues, making them less able to resist 
adverse influences which periodically aggravate the existing condition. 

In treatment, cleansing of the mucous surface is important, in order 
to get rid of this altered secretion, which has practically become foreign 
material, and when retained adds to the irritation of the parts. Its 
removal also permits more thorough medication of the diseased mucous 
membrane, not only of the naso-pharynx, but also of the Eustachian 



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CHRONIC NON-8UPPURATIVE OTITIS MEDIA. 336 

tube and middle ear. For this purpose many devices have been re- 
sorted to at different times, the so-called nasal douche, the use of which 
is not free from danger, being one of the means of effecting its removal ; 
the use of a syringe for the posterior nares has been another method 





Hard-rubber nebulizer and bottle. Complete steam-atomizer. 

of cleansing. Perhaps the most agreeable as well as the most efficacious 
mode of effecting this removal is by inhalations of alkaline steam from 
an atomizer, breathing through the mouth — some of it escaping through 
the nostrils as well as through the mouth. It practically is an appli- 
cation of the principle of a poultice to soften the secretions, effect their 
removal, and soothe the inflamed membrane. Although the steam 
will not under these circumstances enter the Eustachian tube, the effect 
upon the naso-pharynx will also be produced, though in a less degree, 
on the lining of the Eustachian tube. Where no abnormal perforation 
of the drum-head exists, the only route to the Eustachian tube and 
middle ear is either through the nostril or through the mouth. Ad- 
vantage is usually taken of the nostril as the more direct route to these 
parts. 

For the purpose of inflating the middle ear three principal methods 
are resorted to. The jirsl of these, known as Valsalva's method, con- 
sists in closing the mouth and nostrils and expelling air from the lungs, 
which, because it cannot escape from the mouth or nostrils, is forced 
through the Eustachian tubes into the middle ear. The second^ known 
as Politzer's method, is the reverse of Valsalva's ; in it advantage is 
taken of the fact that the act of swallowing closes the soft palate 
against the posterior wall of the pharynx, thus bridging over the space, 
and while in that condition, if air be forced through one nostril, the 
other being closed by pressure to prevent its escape, the air is rendered 
more dense in the naso-pharynx, and in that way is forced through the 
Eustachian tube into the middle ear. 

In the third method the Eustachian catheter is introduced gener- 



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336 INTERNATIONAL CLINICS. 

ally through the nostril to the opening of the Eustachian tube and air 
is pumped through that into the middle ear. Inflation 
simply with air is most serviceable in cases of hyper- 
trophy with diminished calibre of the Eustachian tube 
frequently occurring in children. Where the air has 
become rarefied in the middle ear such inflation will 
usually temporarily increase more or less the hearing- 
distance of the ear inflated. Where such inflation does 
not increase the hearing-distance^ the structural change is 
usually chiefly within the cavity of the middle ear, and 
experience shows that the prognosis is less favorable. 

The defects in what is known as Politzer's method 
of inflation are that the bulb used for inflation is larger 
than is necessary, thus exerting more violence upon the 
parts than is justifiable, and that where the Eustachian 
tubes are unequally open most of the force fa exerted 
upon the more o{)en or* less aflected ear, and also that the 
air thus forced in has no therapeutic effect, the result 
being simply mechanical. Therefore a method of treat- 
ment which combines with mechanical inflation proper 
medication to remedy the existing condition is what the 
case demands. Here some latitude exists in the selection 
of remedies to be used. It should be borne in mind that 
there exists the third or chronic stage of inflammation 
of a mucous membrane with the usual structural changes 
of such chronic inflammation of that membrane. The 
necessity for decided stimulation of the parts in that stage 
is recognized the same as elsewhere. The ear should be 
^ no exception so far as the principle fa involved. The 

delicacy of the structure, as well as its importance, neces- 
sitates some modification in the method of applying the 
same principle. Of all remedial agents used, probably 
none on the whole has given such satfafactory results as 
iodine. 

Air is medicated with iodine and forced through the 
Eustachian tube into the middle ear, thus stimulating 
Pure silver Eu- sufficiently to produoc a hy i^raemic condition of the drum- 

atachian cathe- i j , . , . . , i i. . ^ . 

ter (natural die), head, showing the impression made upon the lining of the 

middle ear. The effect may be increased by first cleansing 

the Eustachian tube with warm alkaline solutions as supplemental to the 

use of the steam atomizer and preceding the use of the iodized air. Since 




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CHRONIC NON-8UPPURATIVE OTITIS MEDIA. 337 

there are imperfect circulation and imperfect nutrition^ even in the hjper- 





Vertical section of head, ahowiug Euttacliian catheter in position. 

trophied form, whatever will quicken the circulation and stimulate the 
parts will have a tendency to re- 
store normal circulation and normal 
nutrition. For that reason the 

galvanic current may often be ad- ButUeB" inhaler and yaive-buib. 

vantageously used, not for an im- 
pression upon this nerve of special sensation, but simply to improve 
the nutrition of the conducting apparatus. Mildly stimulating appli- 
cations may also be made to the external meatus and to the dermoid 
layer of the drum-head. Since the parts have been deprived of the 
protection of the cerumen spread over the surface of the meatus, a 
substitute for that should be applied, and for this purpose the petroleum 
Vol. I. Ser. 4.-22 



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338 INTERNATIONAL CLINICS. 

products are among the best. Should the disease of the middle ear 
have so influenced the dermoid lining of the external ear as to have 
produced a soil favorable for the growth of parasites, such as asper- 
gillus^ some parasiticide 'should be used. For this purpose solutions 




Galvanic battery. 

of carbolic acid, of peroxide of hydrogen, and of bichloride of mercury 
have been applied advantageously. In this state of imperfect circula- 
tion of the blood the normal temperature of the middle ear is not main- 
tained. As a consequence, exposure to high winds causes discomfort 
and greater impairment of hearing and temporarily aggravates the 
existing difficulty. Therefore some protection, as by wool or cotton, 
should be introduced into the external meatus, but not habitually used, 
or the auricle be lightly covei'ed, when exposed to low temperature and 
high winds. 



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FIBROUS TUMOR OF THE NASO-PHARYNX, 

CLINICAL LECTUBB DELIYERXD AT THX ABEBDBKN BOYAL INFIRMARY. 

BY J. MACKENZIE BOOTH, M.A., M.D., CM. (Aberdeen), 

Surgeon and Lecturer on Clinical Surgery at the Aberdeen Royal Infirmary ; Lecturer 
on Diseases of the Ear and Larynx in the Univenity of Aberdeen. 



Gentlemen, — I wish to direct your atteutioD to the case of a lad 
who has been in one of the wards under my care for the last few days. 

The case possesses more than ordinary interest as being that of a 
growth which, though benign in character, has always been justly 
dreaded from its inaccessibility and its tendency to recurrence; also 
from the fact that our modern increased &cilities of diagnosis have 
rendered its early recognition easier, while recent improvements in 
instruments have enabled us to cope with it with greater success than 
was possible heretofore. 

The subject of this affection is a tall, thin country lad, sixteen 
years of age, who has of late been growing very rapidly. About four 
years ago, aflei* being much frightened by the occurrence of a fire in the 
house where he resided, he was noticed to stammer ; and shortly after, 
on account of this affliction along with his rapid growth, his medical 
attendant recommended a reduction in his tale of school work, — afler 
which the stammering was lessened. Only for a time, however, did 
the improvement last, when the stammer recommenced, and then b^n 
the symptoms more distinctly referable to the present ailment. These 
were symptoms of nasal obstruction, interference with respiration 
through the nose, first in one and then in both nostrils, and a sensation 
of discomfort in the nasal cavity, — mouth-breathing, nasal voice, and 
snoring during sleep, — all of which symptoms gradually increased in 
severity and grew more constant as time passed. There was a muco- 
purulent secretion both from nose and mouth, necessitating ofl-repeatcd 
efforts at hawking and spitting ; and the breath acquired a somewhat 
disagreeable odor, though it could not be called fetid. His speech be- 
came so thick as at times to be almost unintelligible. Of late months 
another and very characteristic symptom has appeared, — viz., bleeding, 

839 



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340 INTERNATIONAL CLINIOS. 

generally as hsemoptysis, though occasionally epistaxis has been present 
This symptom has been very variable, occurring at irr^ular intervals 
and varying in the amount of blood lost, but coming on more especially 
after any violent exertion. Its profuse occurrence a few days since, 
while he was acting as a beater to a cover shooting-party at which his 
medical attendant was present, led to his being sent to the Infirmary 
for treatment. During the last few months deafness has become a 
prominent and distressing symptom, getting gradually more marked 
up to the present time. Latterly, also, his friends noticed some flatten- 
ing and broadening of the bridge of the nose, and the nasal obstruction 
became much more complete, so that no amount of blowing could clear 
it, and he had to keep his mouth open in order to breathe, and even 
then there was some dyspnoea. This was more noticeable during sleep, 
which had become more disturbed in consequence, — the breathing 
getting sometimes obstructed and the patient becoming blue in the face 
before he awoke and b^an to breathe again. The snoring had become 
louder than before, and the patient constantly groaned and tossed from 
side to side during his troubled sleep. For a short time back, too, his 
friends said, he had some difficulty in retaining his urine. So that 
altogether, as you can see, the patient arrived at the Infirmary in a 
pitiable plight.. So far as I have been able to ascertain, the only inter- 
esting points in the family history are the removal of a mammary 
tumor from his mother, and the death of his maternal grandmother 
from a cancerous growth. 

On his admission to the hospital the patient's appearance tallied 
exactly with the history we had received, and you could see at a glance 
the silly expression so characteristic of nasal obstruction and the conse- 
quent deafness. Otherwise the lad seemed intelligent enough. 

Physical examination elicited the following particulars. On inspec- 
tion of the mouth with the tongue depressed, the soft palate was seen 
to be pushed down into the mouth and somewhat stretched, convex 
instead of concave, with the convexity extending into and greatly 
diminishing the capacity of the mouth and pharj^nx. Just below the 
free margin of the velum could be made out a red swelling inter\^ening 
between the velum and the posterior pharyngeal wall. Digital exami- 
nation of the pharynx could hardly be borne even with the aid of co- 
caine, and revealed merely a hard, dense, globular swelling filling the 
vault of the pharynx and very slightly movable on pressure. Its 
relations with the surrounding parts it was impossible to discover, 
though it seemed to be inseparable from the soft ])a1ate. A palate-re- 
tractor could not be introduced, and only by pulling on the uvula with 



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FIBROUS TUMOR OP THE NASO-PHARYNX. 341 

a pair of dressing- forceps could a little more of the swelling be exposed 
to view. There was not room for the rhinoscopic mirror between the 
tongue and the swelling, and no further information could be obtained 
from the employment of anterior rhinoscopy. In order to examine the 
case more fully, and in view of a consultation with my colleagues, — for 
I thought it probable that a somewhat extensive preliminary operation 
would be necessary to get at the growth,— chloroform ansesthesia was 
determined on. This was no easy matter, on account of the impeded 
respiration ; but, in the absence of the regular anaesthetist, it was skil- 
fully managed by the house-surgeon. Dr. Mathieson, who at the same 
time kept the tongue out by means of a Listen's forceps applied to its tip. 
When ansesthesia was complete, the finger could be passed along be- 
tween the velum and the tumor, which seemed to be springing from 
the left side of the vault of the pharynx, to which it was attached by 
a strong tough stalk. Owing to the difficulty of ansesthesia and the 
urgency of the patient's condition, I resolved to attempt the immediate 
removal of the growth. Of the instruments available, the one I 
selected as most likely to suit my purpose was a Koeberle's serre-noeud 
armed with a strong steel wire. The loop of wire was with some dif- 
ficulty passed through the left nostril into the pharynx, where the left 
forefinger pushed it over the body of the tumor and as close as pos- 
sible to the point of attachment Then the loop was tightened and an 
attempt made to cut through the pedicle. This was not so easily done 
as I had anticipated, for, though the screw was very gradually tightened, 
so resistant was the tissue that the strong steel shaft of the instrument 
was bent like a bow, and I feared that the wire would give way. When 
it was nearly cut through, a volsella was introduced by the mouth, 
and the fundus of the tumor firmly grasped. As soon as the pedicle 
was fairly divided, traction was made on the volsella and the tumor 
removed through the mouth. Rather profuse bleeding ensued through 
the nostrils and mouth, so by means of a Bellocq's canula a plug of lint 
previously prepared was introduced into the posterior nares in the 
usual manner. The tumor was a very dense, ovoid, slightly flattened 
mass, weighing about one ounce after removal, and evidently composed 
of dense fibrous tissue, having a deep notch where it had been pressed 
on by the posterior edge of the septum, and being flattened where it 
had been in contact with the posterior pharyngeal wall and the upper 
surface of the palate. The accompanying illustration, made from a 
photograph, shows the exact size of the tumor in the position it occupied 
in the naso-pharynx, its attachment, and the details of conformation 
above mentioned. The plug was removed on the day following the 



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342 INTERNATIONAL CLINICS. 

operation, and the nares irrigated daily with a warm saturated solution 
of boracic acid. 

The result so far has been exceedingly satisfactory. The respiration 
was immediately I'elieved, and the first night, notwithstanding the pres- 
ence of the post-nasal plug, the breathing wa^ undisturbed and the 
snoring almost gone. I may here mention that the lad had to be put 
into a separate ward on account of the disturbance of the other patients 
by his extraordinary snoring. The voice lias lost its nasal character 
to a great extent, the deafness is already less marked, and the patient's 
general condition is vastly improved. There is, indeed, marked paresis 
of the soft palate, due to the long-continued pressure, more especially 
on the left side ; but daily improvement has been noted since the opera- 




z, X, X mark base of attachment ; p, projection into the right nasal passage ; t, mark of septum ; 
/«, flattened surface pressing on posterior pharyngeal wall ; U, lower surfeioe pressing on velum 
and causing bulging in roof of mouth. 

tion, and with its disappearance we may confidently hope for a corre- 
sponding improvement in the voice and, though perhaps to a lesser 
extent, in the hearing power. The power of swallowing has been 
almost entirely regained already, and this will be aided by the improve- 
ment in the muscular condition of the velum. The stammer to which 
the patient has been subject for several years seems to have been 
independent of the naso-pharyngeal growth, though the boy's relatives 
say it is not so pronounced as formerly. 

In the consideration of this case, the outlines of which I have given, 
there are several points of considerable interest apart altogether from 
its comparative rarity. This affection is admittedly rare, though it 
seems to be of more common occurrence in Continental clinics than in 
our own. With reference to the diagnosis, the presence of hemorrhj^ 
following prolonged nasal obstruction, with a hard, smooth, rounded 
mass in the pharyngeal vault, occurring in a young man, was strongly 
suggestive of fibrous tumor. These tumors always occur in males 
from twelve to twenty-five years of age, as lias been pointed out by 
various writers, at the time when many of the more important fibrous 



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PIBKOU8 TUMOR OF THE NASO-PHARYNX. 343 

structures undergo their principal development ; and N^laton has shown 
that in most instances they primarily spring from a limited area of the 
periosteum covering the basilar process of the occipital bone or the 
body of the sphenoid. It has been generally considered that heredity 
does not play any part in the production of these tumors ; but in the 
case before us there is a distinct history of a tendency to tumor-forma- 
tion. The attacks of hemorrhage and the hardness of the growth 
excluded the diagnosis of ordinary mucous polypi, and, coupled with the 
age and sex of the patient, pointed to the likelihood of a fibrous rather 
than a sarcomatous or other malignant growth. This proneness to 
hemorrhage is an almost invariable symptom, and the bleeding is some- 
times so profuse as to endanger the life of the patient The occurrence 
of deafness is usual in these cases, as in most nasal affections in the 
neighborhood of the Eustachian orifices, — at first the effect of simple 
blockage of the tubes, and afterwards of catarrhal inflammation of the 
tympanum resulting from this. 

As you will doubtless find in many of your cases in after-practice, 
the production of ansesthesia greatly facilitated the diagnosis, and en- 
abled us to devise and carry out a suitable method of treatment. 

In such cases as this it is necessary to give a very guarded prog- 
nosis. It has been shown that up to twenty-five years of age these 
growths are very liable to recur, and that the younger the age at which 
they appear the graver is the prospect, — statistics which are not very 
reassuring in a case like the one before us, where the patient is but 
sixteen years of age. Consequently, it behooves us to warn the lad's 
relatives of the danger attending this condition, and of the necessity 
of careful supervision for several years to come. 

The question of the treatment of the case was also interesting. 
From the symptoms, the duration, the hardness and the size of the 
growth, I thought that a rather formidable preliminary operation, 
such as a resection of the upper jaw, would be necessary to get at the 
tumor ; and had the case been somewhat more advanced, such an opera- 
tion would certainly have been required. The modem treatment which 
is most admirably adapted for these tumors when they are recognized 
sufficiently early, as they can often be with the rhinoseopic mirror, is 
unquestionably their removal by means of the galvano-caustic snare. 
But, though this was in readiness in the operating-theatre on the occa- 
sion referred to, the size, toughness, and resistance of the pedicle were 
such as to render its employment useless. Accordingly, I had recourse 
to a much stronger instrument, the serre-noeud, which is, as you know, 
generally used for a different purpose ; and even its strong steel wire 



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344 INTERNATIONAL CLINICS. 

was exposed to a coDsiderable straio before I managed to cut through 
the thick fibrous pedicle of the tumor. 

The after-treatment is also of importance. R^ular daily antiseptic 
irrigation of the nares till the 6craseur wound has healed^ which along 
with occasional inflation of the tympanum will also benefit the aural 
affection^ has been enjoined. Massage, and the application of the 
faradic or galvanic current to the muscles of the soft palate, will be 
desirable in order to improve the voice and swallowing power, together 
with such hygienic measures as will benefit the patient's general condi- 
tion. And lastly, and most important of all, a careful watch must be 
maintained for several years, so that, should there be any appearance 
of the neoplasm, early treatment may be undertaken with a good pros- 
pect of success. 



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P^tmatalagt). 



RINGWORM; PEDICULOSIS AND SCABIES; EC- 
ZEMA; PSORIASIS; EPITHELIOMA. 

CLINICAL LSCTURB DRLIYERED AT THK WOMAN'S MEDICAL COLLEGE OF THE NEW 

YORK INFIRMARY. 

BY GEORGE THOMAS JACKSON, M.D., 

Professor of Dermatology. 



RINGWORM. 

Here is a little girl who has two circular patches upon the left side 
of the neck. They are scaly, of a rather pale red, and have a well- 
marked elevated border. Their central portions are beginning to clear 
up, and look as if depressed. They are therefore ring-shaped patches. 
We also notice that the child has enlarged glands in the neck. 

What are the eruptions that occur as circles or rings ? It is well, 
for diagnostic purposes, to group in your minds the various dermatoses 
according to form, distribution, or some specially-pronounced symptom. 
Here the most striking element is the circular shape of the lesions, 
and we remember that erythema multiforme, psoriasis, pityriasis rosea, 
syphilis, and ringworm are all apt to occur as ringed eruptions. 

Is this a case of erythema multiforme? No: because we have 
not a simple redness that fades away under pressure, to return again 
when pressure is removed. In this case the border is not only raised, 
but also decidedly scaly, and if you press upon it you will leave a 
yellowish stain that soon assumes the red color again. Besides, the 
eruption occurs on the neck alone, and not on the forearms and backs 
of the wrists, where an erythema multiforme would be quite sure to 
appear. 

Is it psoriasis? Although the color is somewhat like that of psori- 
asis, and the patch is scaly, that is about as far as the resemblance goes. 
It is a localized and not a general eruption ; the elbows, knees, and 
scalp are all spared, locations where we should find lesions were the 
case one of psoriasis. 

845 



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346 INTERNATIONAL CLINICS. 

Is it pityriasis rosea? Here, again, the limitation of the disease to 
one locality throws out the diagnosis of pityriasis rosea. In that dis- 
ease we find, especially on the trunk, dozens, perhaps scores, of rings 
and oval lesions which are slightly scaly. These do not clear in the 
centre, but present a wrinkled condition of the epidermis, looking like 
old parchment, appearances tliat are wanting here. 

It is said that syphilis must be considered in every diagnosis, it is 
so protean a disease. There is a form of syphilis that looks some- 
what like the eruption under consideration. It is known as the cir- 
cinate syphilide. While it might occur in a child of this age, it prac- 
tically is so rare a lesion in children that it should not be given much 
prominence in the diagnosis. Moreover, the light color of these lesions, 
the evidence of scratching that we find, and the superficial character of 
the whole aiFair, are against syphilis. Syphilides have a dark-red color, 
are not itchy, and present an infiltrated edge. 

Having thrown out the other circinate eruptions, we have left the 
diagnosis of ringworm. This diagnosis we readily make directly and 
not by exclusion, because we know that ringworm of the body occurs 
in the form of superficial, scaly, light-red, round or ring-formed 
patches that itch slightly. So, then, we have established the diagnosis 
of the patches on the neck : they are ringworm. 

But why should there be these enlarged glands in the neck ? When- 
ever you find glands like these in this child's neck, you should first 
think of the possibility of there being some inflammatory disease of the 
scalp, as such diseases are always accompanied by enlarged lymphatic 
glands. If you should find an eczema capitis, look out for pediculi, 
as they very commonly are the cause of the eczema. Remember that 
pediculi are found most easily and abundantly on the occipital and 
temporal regions of the scalp. The most cursory examination of the 
scalp in this case shows abundant nits in the favorite r^ons, and 
more or less eczema. So the child has both trichophytosis corporis and 
pediculosis capitis. 

Up to this year, it was thought and taught that there was but one 
trichophyton fungus, and this gave rise to both ringworm of the scalp 
and ringworm of the body. Sabouraud, of Paris, has upset all this. 
He has made extensive studies of the disease, and you will find a series 
of papers by him, on the subject, in the Annates de DermaJtologie d 
de SyphUigraphte for 1893. It seems to me that his work is the 
most important of the year. He teaches us that we have no longer a 
single trichophyton fungus, but a number of them. He has found 
that the variety that causes ringworm of the scalp always breeds true, 



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PEDICULOSIS AND SCABIES. 347 

and has small spores. This he names the ^^ trichophyton microsporon.'' 
It is the one most constantly found in the ringworm of the scalp that 
proves so obstinate to treatment. He has also found another varieiy 
constant in ringworm of the body, and sometimes found on the scalp. 
If it occurs on the scalp, the ringworm caused by it is easily cured. 
Now, we knew, by clinical experience, that there were some cases of 
ringworm of the scalp which were easy of cure, and others that were 
very obstinate to treatment. Sabouraud's discovery throws new light 
upon the subject, and explains the reason why. This second form of 
fungus has large spores and is named by its discoverer the '^trichophy- 
ton megalosporon.'' This large-spored fungus is the one that occurs 
especially in animals, and has many varieties, one being apparently 
peculiar to horses, another to cats, another to fowls, and so on. 

The case now before us is due to the trichophyton megalosporon, 
and has probably been derived from some animal. Ringworm is very 
common in horses, dogs, cats, and other domestic animals. Whenever 
you find a ringworm in a child, always institute a search of the child's 
pets. You will frequently find a cat with the hair off its 1^, scaly 
skin, and a generally distressed look. 

It is usually as easy to cure ringworm of the body as it is to rec- 
ognize it. There are nearly as many ringworm cures as there are 
wart cures, and they are many. You can cure ringworm by almost 
any antiparasitic application, such as sulphur ointment, painting with 
tincture of iodine, chrysarobin, or bichloride-of-mercury solution, two 
grains to the ounce. The objection to the iodine and the chrysarobin 
is that they both stain the skin. The old women cure cases by the 
application of common ink, or of vin^ar in which an old-fashioned 
copper cent has been soaked. 

SCABIES; PEDICULOSIS CAPITIS. 

This little boy has a general eczema of the pustular variety, the 
pustules forming patches. We note that the crusts are rather green- 
ish. On the neck there are many pustules. We know the disease 
is itchy, because we see the scratch-marks. It is a pustular eczema, 
but we must find out if there is anything behind the eczema. We 
see the hair has been cut off, and that there are large crusts on the 
scalp. These crusts are always suggestive of pediculosis. We think 
also of scabies and of urticaria, because those are itchy eruptions, and 
when they occur over the body pretty generally are apt to cause an 
artificial eczema. In this case the hands are very much implicated, 
and we are sure there is something besides pediculosis, because that 



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348 INTERNATIONAL CLINICS. 

does not affect the hands. We also notice that the prepuce is swolloi 
and has upon it a number of scratched lesions. 

Whenever you find the penis so much affected as in this case, you 
may be quite sure that you have scabies to deal with. This is a very 
important point, because often you will examine a patient all over, 
and he will show scarcely any decided symptoms of scabies, but if you 
find the genitals are affected, as in this case, you may suspect scabies. 
That this child has pediculosis capitis we know from the location of 
his eczema on the occipital r^ion and by finding nits on the hair. 
That he has not pediculosis vestimentorum we know, because the erup- 
tion here does not occupy the typical location for that form of the 
disease, that is, over the shoulders and on the outer and inner aspects 
of the limbs where the seams of the clothing come, and over tlie but- 
tocks, which is very common, and around the waistband. 

On the other hand, scabies occurs on the anterior face of the wrist, 
between the webs of the fingers, around the umbilicus, and on the 
genitals of the male and the breast of the female. It is also apt to 
affect the axillae, and this child has it quite well marked in that loca- 
tion. Scabies never occurs upon the face, but you may have an eczema 
on the face with scabies, which is sympathetic. The eruption consists 
of excoriations, pustules, and eczematous patches. Another diagnostic 
sign of scabies is the furrow, which is often hard to find. Our patient 
has therefore two diseases, — pediculosis capitis and scabies. This is 
the second case to-day with more than one skin-disease. 

To cure scabies is easy if you recognize it. Never be content with 
the simple diagnosis of eczema until you are sure that you have ex- 
cluded scabies and pediculosis. Sometimes cases of scabies will be 
treated by the physician for months under the mistaken diagnosis of 
eczema. Oxide-of-zinc ointment won^t cure scabies. Perhaps as 
efficient a remedy for its cure as any is sulphur ointment The patient 
is directed to take a warm bath and scrub his skin thoroughly with 
soap. He is then to dry the skin with a coarse towel, and rub in 
sulphur ointment. He is to rub in the ointment each morning and 
evening for three days, and then take another bath and report to the 
doctor. Perhaps a second course of treatment may be necessary for a 
cure. Two courses are almost always enough. At the end of the 
second course it is always best to suspend treatment for a few days 
and use only vaseline and corn-starch to the skin, even though itching 
is still complained of, because sulphur will at times set up an eczema 
of its own that will be itchy. In small children balsam of Peru will 
be as efficient as sulphur, and is less objectionable to the attendants. 



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ECZOiA. 349 



ECZEMA. 



Eczema is the most important of all our skin-diseases. There are 
six cardinal signs of eczema, — namely, redness, itching, infiltration, 
moisture, crusting or scaling, and cracking. 

This boj has an eruption on the skin. You can see that it itches ; 
you will also notice that it forms patches, and that these patches are not 
definitely shaped, and have no particular outline. If you look at his 
right arm, for instance, it would be very hard for you to draw a 
picture of the outline of the patch on the blackboard and say where it 
b^an and where it ended. The skin feels harsh and dry, and also 
thickened. If you take up a fold of the diseased skin, and then one 
of the sound skin, you will appreciate that there is a difierence in the 
thickness of the skin. The patches are red. The disease seems to 
be quite a dry one, but you see a number of lately-tom-off little crusts 
with excoriated points, and, looking at it closely, you can see here 
and there the shining of a vesicle, showing that there is a tendency to 
moisture. So we have here redness, itching, infiltration, and a tendency 
to moisture. You can see also a certain amount of both scaling and 
crusting. There is no cracking, because the disease is not located where 
cracks occur, — that is, it is not over the joints. 

This is an excellent illustration of a case of eczema. . What sort 
of eczema shall we call it? There are a variety of eczemas put down 
in the text-books : which is this? It is sufficient for us to know in the 
first place that it is an eczema ; and after that to know whether it is 
acute, subacute, or chronic. These are the important points so far as 
the cure of the case is concerned. 

Behind the ears we find little scaly patches. Recollect that behind 
the ear is the place where eczema is very fond of retiring. A scaly 
patch behind the ear is indicative of eczema, while one in front of the 
ear suggests psoriasis. Now, as to treatment. The case is at least sub- 
acute, as we find no evidences of much activity. Choose your treatment 
from what you see, not from the length of time the disease has lasted. 
We may have an acute outbreak upon a chronic eczematous patch. 
Remember that in an acute eczema you should use the mildest possible 
remedies, such as lime-water, or vaseline and corn-starch ; in subacute 
cases astringents and protectives are in order, such as oxide-of-zinc 
ointment, Lassar^s paste, and diachylon ointment Still later, when the 
squamous stage is reached, and there is more or less thickening of the 
skin, we should use stimulating treatment, and our most usual stimu- 
lant is some form of tar, especially the oil of cade in the strength of 



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350 INTERNATIONAL CLINICS. 

from twenty drops to the ounce up to a drachm or more. In the 
present case we can use an ointment composed of a drachm of the oil 
of cade to an ounce of oxide-of-zinc ointment 

PSORIASIS. 

Here is a young girl with psoriasis. Whenever you find this erup- 
tion it is always the same. It always appears in the form of li^t-red, 
slightly elevated patches which are covered with scales, no matter what 
the size of the patches may be. When we scrape off the scales there 
is exposed a smooth shining surface which will soon have on it little 
red points, caused by oozing of blood from the ruptured capillary 
vessels escaping through the mucous layer of the epidermis. This is a 
sign of psoriasis that is regarded by some as pathognomonic. To pro- 
duce it you must take a spot that is a rather fresh ona This patient 
presents the papular, punctate, and nummular forms of the disease. 
She has no patch in front of the ear. Another common location for 
psoriasis is along the edge of the hair on the forehead ; and that is also 
absent in this patient. The extensor surfaces of her arms and elbows 
have patches on them ; there are also a few on the flexor surfaces of 
the arms, and some on the legs. 

Most cases of psoriasis occur early in life. It is rare for it to b^in 
in old age. . This patient is eighteen. You will notice that the patches 
are scaly and dry, and that the outlines are easily marked. This is one 
very striking difference between eczema and psoriasis. In eczema there 
is thickening of the skin ; here it is not so marked. Here there is never 
moisture nor a tendency to it ; in eczema there is always moisture or a 
tendency towards it. These lesions have been scratched somewhat, 
which shows that the disease is slightly itchy. 

The latest remedy in the treatment of psoriasis is thyroid feeding. 
The best method of using the thyroid is probably the glycerin extract. 
This has not yet been put on the market. There is a preparation of 
desiccated thyroids, made by Parke, Davis & Co., and this is the one 
we shall use here. The extract made from the thyroids of lambs is 
supposed to be more active than that made from sheep's thyroids, and 
to be less likely to cause rise of temperature and other untoward 
symptoms. 

EPITHELIOMA. 

Here we have a lesion on the nose of a woman who is past middle 
life. Whenever you find a lesion on the face, which is isolated, 
hard, and either crusted or ulcerated, in a person who is past middle life, 
and which has lasted some time, you can be sure that it is epithelioma. 



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EPITHELIOMA. 351 

This particular lesion, if left to itself, its crust not picked off, would 
probably go on to the formation of a cutaneous horn, which is often 
seated upon an epithelioma as a base. Sometimes these excrescences 
stand out several inches from the face, and look like the horns of 
cattle. This patient picks at the lesion all the time, removing the 
crust, and the growth grows deeper and deeper. It has not yet grown 
very deep. It bleeds very easily. You will note the cartilaginous- 
looking border and the dilated vessels running over it, — pathogno- 
monic symptoms of epithelioma. 

The way to treat it is to remove the crust and scrape away all the 
growth with a dermal curette. There is no danger of going too deep, 
as the curette will not attack sound tissues. The chances are that this 
scraping alone will not be enough to cure it, so we shall have her use a 
thirty-three-and-one-third-per-cent. ointment of pyrogallic acid for five 
or ten days, to encourage suppuration, and then wear a piece of mercu- 
rial plaster, under which it will heal. In most cases this will perma- 
nently destroy the growth. If a relapse takes place, — ^and epithelioma 
is prone to relapse, — as soon as the hard point appears it will be a simple 
matter to scrape it out and destroy it with pyrogallic acid. 



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INDEX TO VOLUME L 

(FOURTH SERIES.) 



A. 

Abdominal inoision, exploratory, 285. 
Abortion, a oaae of perminlble, 282. 
Aoote perioetitis, 186. 
definition, 188. 
kinds, 186. 

•imple, 186. 
diflfuse, 186, 188, 198. 
symptoms, 187, 189. 
history of oases, 189. 
differential diagnosis, 191. 
treatment, 194. 
operatire, 194. 
tonio, 194. 
Acute pleurisy, with effosion; interstitial 
pneumonia (chalicosis), with 
encysted and probably inter- 
lobar looulated plearisy, 39. 
history of cases, 39, 41. 
Affections of the lachrymal gland, 286. 
history of cases, 286, 294. 
Alcohol in treatment of delirinm tremens, 

135. 
Alcoholism, 129. 

history of cases, 133, 134, 136, 137. 
symptoms, 134. 
causation, 134. 
treatment 135. 
Ammonium chloride as larigant of alimentary 
tract in treatment of pulmonary tubercu- 
losis, 61. 
Amoeba coli as the cause of amoebic dysentery, 
70. 
discoverer, 72. 
Amoebic dysentery, 69. 

history of case, 69. 
cause, 70. 

differential diagnosis, 72. 
prognosis, 73. 
treatment, 73. 
Anssmia, pernicious, 48. 

Tarieties, 54. 
Anders, J. M., M.D., Ph.D., 39. 
Antipyrin in treatment of myelitis, 100. 

of painter's colic, 133. 
Aphasia due to subcortical hemorrhage, 102. 
history of case, 104. 
diagnosis, 105. 
Appendicitis, 269. 

history of case, 265. 
operatire treatment, 268. 
Vol. I. Ser. 4.-28 



Appendicitis, prognosis, 270. 

macroscopic examination, 270. 
Arsenic in treatment of pernicious anaemia, 59. 

of pulmonary tuberculosis, 60. 
Arthritis, acute rheumatic, with pericarditis, 

treatment of, by salicylates, 11. 
Ashton, William Easterly, M.D., 265. 
Aspiration, when indicated in pleuritic effu- 
sion, 40. 
in multilocular pleurisy, 45. 
method and precautions, 45. 
where to puncture, 45, 46. 
after-treatment, 45. 
Atropine, use of^ to check night-sweats of pul- 
monary tuberculosis, 67. 

B. 

Baker, Alfred Rufus, M.D., 320. 
Balsam of Peru in treatment of scabies, 348. 
Bariing, Gilbert, F.R.C.S., 231. 
Basilar meningitis, 139, 142. 
history of case, 142. 
diagnosis, 143. 
cause, 143. 
treatment, 144. 
Belladonna in treatment of exophthalmic 

goitre, 79. 
Beta-naphtol in treatment of pernicious 

anaemia, 59. 
Bichloride of merouiy solution in treatment of 

ringworm, 347. 
Bladder, tumors of the, 231. 
Blennorrhoeal coi^unctiritis, its etiology, di- 
agnosis, and treatment, 320. 
history of cases, 320, 321, 322, 
323. 
Booth, J. Mackeniie, M.A., M.D., CM. (Aber- 
deen), 339. 
Bronchus, foreign body in left, 224. 
Brower, Daniel R., M.D., 129. 
Bryant, Joseph D., M.D., 196. 
Byford, Henry T., M.D., 259. 



Calcium chloride, use of, in hemorrhage of pul- 
monary tuberculosis, 67. 

Camphoric acid, use of, to check night-sweats 
of pulmonary tuberculosis, 67. 

Carditis, rheumatic, treatment o^ by ice-bag, 
8, 10. 

858 



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354 



INDEX TO VOLUME I. 



Cerebral meningitis, 129. 

bistorj of case, 129. 
symptoms, 130. 
prognosis, 130, 131. 
treatment 13U. 
cause, 131. 
diagnosis, 131. 
Chapin, Henry Dwight, M.D., 139. 
Charcot, Professor Jean-Marie, memorial of, ix. 
Chloral hydrate in treatment of delirium tre- 
mens, 135. 
Chloroform as a medicament in pulmonary 

tuberculosis, 67. 
Chlorosis and mitral insufficiency, condition 
of the heart in, 25. 
history of cases, 25, 26. 
Choleeystenteroetomy with Murphy's button, 
219. 
history of case, 219. 
operation, 222. 
results, 223. 
Cholelithiasis, 219. 

history of case, 219. 
diagnosis, 220. 
etiology, 220. 
operative treatment, 222. 
Chronic non-suppuratire inflammation of the 

middle ear, 326. 
Chronic ulcers of the leg, 152. 
causation, 153. 
treatment, 155. 

effect of, on general health, 161. 
Chiysarobin in treatment of ringworm, 347. 
Codeine as a medicament in pulmonary tuber- 
culosis, 67. 
Cod-liver oil in treatment of pulmonary tuber- 
culosis, 62. 
CoBliotomy, a '' suceessftil," reviewed, 226. 

history of case, 226. 
Collee fracture, objections to personal nomen- 
clature, 203. 
Congenital ptosis, 307. 

history of case, 307. 
cause, 307. 
diagnosis, 308. 
treatment, 308. 
Conjunctivitis, blennorrhoeal, its etiology, di- 
agnosis, and treatment, 320. 
Com starch in treatment of scabies, 348. 
Cough of pulmonary tuberculosis, medica- 
ments for checking, 67. 
Creosote in treatment of toxssmia of pulmo- 
nary tuberculosis, 63. 
Cuirass for treatment of Pott's disease, 147. 
Cuticle grafting for chronic ulcers of the leg, 

155. 
Cystic duct, with calculi in the gall-bladder, 

operation for, 212. 
Cystoscope, electric, value of, 289. 

D. 

D^^rine, Professor, 110. 

Dermatology, 345. 

Diachylon ointment in treatment of eciema, 

349. 
Digitalis as a medicament in pulmonary tuber- 
culosis, 67. 
avoidance of, in pericarditis, 11. 
Donovan's solution in treatment of pulmo- 
nary tuberculosis, 61. 



Bctropion, traumatic, operation for the relief 
of, 307, 311. 
history of case, 311. 
Eotema, 349. 

history of case, 349. 
symptoms, 349. 
treatment, 349. 
Effusion in pleurisy, cause, 39. 
treatment, 39. 

operative, 39, 45. 
medical, 40. 
Bleetricity in treatment of neuritis, 137. 
Bleotro-diagnosis, with illustrative cases, 84. 
Empyema, 80. 

history of case, 80. 
operative treatment, 80. 
Endocarditis, septic, treatment, 15. 

prognosis, 15. 
Endocarditis and pericarditis, 74. 
history of case, 74. 
diagnosis, 75. 
differential diagnosis, 76. 
prognosis, 76. 
treatment, 75. 
Entereetomy and the formation of an artificial 
anus in a patient upon whom eoeliotomy 
was performed four times ; rest in the treat- 
ment of rectal prolapse after the formation 
of an artificial anus, 196. 
Epispadias, operative treatment, 246. 
Epithelioma, 160. 

of the eyeUd, 807, 310. 

history of case, SIO. 
operative treatment, 310. 
of the nose, 350. 

treatment, 851. 
Epsom salt in treatment of lead-poisoning, 

132. 
Ethyl iodide as a medicament in pulmonary 

tuberculosis, 66. 
Eucalyptol in treatment of pulmonary tuber- 
culosis, 65. 
Eucalyptus in preventive treatment of urinary 

fever, 256. 
Exophthalmic goitre, 77. 

history of case, 77. 
etiology, 79. 
treatment, 79. 
Exploratory abdominal incision, 265. 
history of case, 265. 
indications for, 266. 
prognosis, 270. 
Eyelid, epithelioma of the, 307. 
Eyelids, granular, sulphate of copper in treat- 
ment of, 316. 

F. 

Faradism in painter's colic, 138. 

Femur, Macewen's operation for rachitic de. 

formity of, 208. 
Fibrous tumor of the naso-pharynx, 339. 
history of case, 339. 
treatment, 340, 343. 
operative, 340. 
after, 344. 
diagnosis, 342. 
prognosis, 343. 
Forcible reduction of unreduced fracture of 
radius, 201. 



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n«DKX TO VOLUME I. 



366 



Foreign body in left broncbas, 224. 
history of oaae, 224. 
operative treatment, 225. 
Fowler's solution in irestment of pulmonary 

tnberouloeis, 61. 
Fraotnre of radius, forcible reduction of un- 
rednoed, 201. 
history of oases, 201, 205. 



Oall-bladder, extirpation of, when performed, 

217. 
GhJvanism in treatment of heart-rheumatism, 
13. 
method of mplication, 13. 
Gaston, J. MoFadden, M.D., 212. 
*' Gelatin paste" in treatment of chronic ulcers 

of the leg, 159. 
Genito-urinary and venereal diseases, 231. 
Goitre, exophthalmic, 77. 
GynsBoology and obstetrics, 259, 265, 272, 277, 
280. 

H. 
Hand and tongue in the diagnosis of disease, 

Har^ Hobart A., M.D., 16. 
Howard, Warrington, F.R.C.S. Bng., 186. 
Hearty condition of the, in mitral ii^ufficiency 
and in chlorosis, 25. 
history of oases, 25, 26, 29. 
diagnosis, 27, 29, 82, 36. 
symptoms, 37. 
He^el, Edward B., A.M., M.D., 307. 
Hemidrosis, 102. 

history of case, 102. 
cause, 104. 
treatment, 104. 
Hemipleffia, case of, 137. 
history, 137. 
diagnosis, 138. 
Hemorrhage of pnlmonaiy tuberculosis, med- 
icaments for controlling, 67. 
Hemorrhoids, inflamed, 209. 
history of case, 2. 
treatment, 209, 211. 
causation, 210. 
Horwits, OrviUe, B.S., M.D., 243. 
Hot water as lavigant of digestive tract, 61. 
Humphreys, Sir George Murray, F.R.S., M.D., 

LL.D., ScD., F.R.C.S.B., 152. 
Hydriodic acid in treatment of myelitis, 101. 
Hydrocyanic acid, use of, to check cough and 

vomiting of pulmonary tuberculosis, 67. 
Hyoscyamus, tincture of, in treatment of de- 
lirium tremens, 135. 
Hyoscine hydrobromate, use of, to check 
cough and vomiting of pulmonary tubercu- 
losis, 67. 

I. 

Ice-bag, use of, in rheumatic pericarditis, 8, 

10,11. 
Ice, use of, to check hemorrhage of pulmo- 
nary tuberculosis, 67. 
Impermeable stricture of the urethra; pro- 
longed retention of urine; 
perineal section, 256. 
choice of procedures, 267. 
operation, 257.. 
prognosis, 258. 



Inflamed hemorrhoids, 208. 
history of case, 208. 
treatment, 211. 
Interstitial pneumonia (chalicosis), with en- 
cysted and probably interlo- 
bar pleurisy, 39. 
clinical history, 41. 
causation, 43. 
diagn^pis, 43. 
symptoms, 41, 44. 
differential diagnosis, 44. 
prognosis, 45. 
treatment, 45. 
Iodide of potassium in treatment of pleuritic 

effusion, 41. 
Iodides in treatment of exophthalmic goitre, 

Iodine in treatment of toxssmia of pulmonary 
tuberculosis, 63. 
when indicated, 64. 
tincture in treatment of ringworm, 347. 
Iron, theory for excess of, in liver of per- 
nicious ansBmia, 58. 

J. 

Jones, 8. J., M.D., LL.D., 326. 



Lachrymal gland, affections o^ 286. 
Laoerated cervix and vaginal enteroeele, 282. 
Larynffology and rhinology, 326, 839. 
Lassars paste in treatment of ecsema, 349. 
Lavigants of digestive tract in treatment of 
pulmonary tuberculosis, 61. 
hot water, 61. 
alkaline solutions, 61. 
turpentine, 61. 
ammonium chloride, 61. 
sodium phosphate, 61. 
Lead-poisoning, 129, 131. 

history of case, 131. 
cause, 182. 
treatment, 132. 
Lesions of the posterior columns in the med- 

ullary sclerosis of ataxia, 110. 
Lime-water in treatment of ecsema, 849. 

M. 

Macewen's operation for rachitic deformity 
of the femur; inflamed hem- 
orrhoids, 208. 
after-treatment, 209. 
Magnesium bisulphate in treatment of lead- 
poisoning, 132. 
Mann, Matthew D., A.M.. M.D., 277. 
Massage in treatment of myelitifl, 101. 
McGuire, Hunter, M.D., LL.D., 164. 
Medicaments useful in pulmonary tuberculo- 
sis, 60. 
drugs improving nutrition : 
cardiants, 60. 
hsBDiatinice, 60. 
nervines, 60. 
roborants, 60, 62. 
tonics, 60. 
Medicin^ 1, 16, 25, 39, 48, 60, 69, 74, 84. 
Memorial of Professor Jean-Marie Charcot, Iz. 
M^nidre's disease, 106. 
causation, 106. 



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356 



INDEX TO VOLUME I. 



Menopause, 283. 
Bjmptoins, 284. 
treatment, 284. 
case of early, 281. 
Menthol as a medicament in pulmonary tuber- 
culosis, 67. 
Mercurial planter in treatment of epithelioma 

of the nose, 351. 
Middle ear, chronic non-suppuratire inflam- 
mation of the, 326. 
Mills, Charles K., M.D., 92. 
Mitral insufficiency and chlorosis, condition 
of the heart in, 25. 
history of cases, 25, 26, 29. 
Morphine as a medicament in pulmonary tu- 
berculosis, 67. 
in treatment of painter's colic, 133. 
Myelitis, some forms of, and of serious spinal 
traumatisms, 92. 
transverse, rapidly fatal, 93. 

old case, with secondary degenera- 
tions, 95. 
mild type, 96. 
compression, 96. 
treatment, 99. 

N. 

Necrosis, acute, 189. 
Nervous jaundice, 82. 

history of case, 82. 

causation, 82. 

treatment 83. 
Neuritis, a case of, 136. 

diagnosis, 136. 

prognosis, 136. 

treatment, 137. 
Neurology, 92, 102, 110, 116, 122, 129. 
Neuromata, simple, 116. 

definition, 116, 121. 

description, 116. 

history of cases, 117, 118, 120. 

treatment, 117, 119, 120. 
Night-sweats of pulmonary tuberculosis, med- 
icaments for controlling, 67. 
Nitrate of silver in treatment of granular 

Uds, 316. 
Nitrous oxide as a medicament in pulmonary 
tuberculosis, 67. 

O. 

Oil of cade in treatment of eczema, 349. 
Ointment of pyrogallic acid in treatment of 

epithelioma of the nose, 351. 
Operation for occlusion of the cystic duct, 
with calculi in the gall-blad- 
der, 212. 
history of case, 212. 
treatment preparatory to opera- 
tion, 214. 
operation, 214. 
results, 218. 
Ophthalmology, 286, 295, 307, 314, 320. 
Opium in treatment of sero-fibrinous pleurisy, 
40. 
use of, to control inflammation 
of serous membranes, 40. 
Otitis media, chronic non-suppurative, 326. 

history of cases, 327, 329, 330, 

331, 332. 
diagnosis, 334. 
treatment, 334-338. 



. Otitis media, prognosis, 334. 
Ovarian neoplasms, 272. 

classification, 272. 

description, 273. 

symptoms, 273. 

complications, 275. 

etiology, 276. 
Oxide-of-cinc ointment in treatment of eo- 
sema, 349. 
of scabies, 348. 

P. 

Paracentesis, when indicated in pleuritio 

effusion, 40. 
Paretic dementia, 102. 

history of case, 109. 
symptoms, 109. 
diagnosis, 109. 
Park, Roswell, A.M., M.D., 208. 
Patton, Joseph M., M.D., 74. 
Pediatrics, 139. 
Pediculosis capitis, 347. 
Pericarditis,, rneumatic, treatment of, by ice- 
bag, 8, 10. 
Periostitis, acute, 186. 
Pernicious anssmia, 48. 

history of cases, 48, 51, 53. 
classification, 54. 
diagnosis, 54. 
symptoms, 55. 
pathology, 54, 57. 
prognosis, 58. 
treatment, 59. 
Pershing, Howell T., M.Sc., M.D., 122. 
Phenacetin in treatment of myelitis, 100. 
Phenyl-salicylate as a medicament in pul- 
monary tuberculosis, 67. 
Picrotoxin, use of, to check night-sweats of 

pulmonary tuberculosis, 67. 
Pleurisy, acute, with effusion, 39. 
treatment, 39. 
history of cases, 39, 41. 
Pneumonia, interstitial (chalicosis), with en- 
cysted and probably inter- 
lobar pleurisy, 39. 
clinical nistory, 41. 
causation, 43. 
diagnosis, 43. 
differential diagnosis, 44. 
prognosis, 45. 
treatment, 45. 
Pooley, Thomas R., M.D., 314. 
Potaasium bromide in treatment of delirium 
tremens, 135. 
of vertigo, 108. 
iodide in treatment of pleuritic effusion, 
41. 
efficiency of, in treatment of lead- 
poisoning, 132. 
precautions, 132. 
Pott's disease, 145. 

history of cases, 145, 148, 149, 151. 
treatment, 147. 
Pregnancy, ruptured tubal, 277. 
Pn»tate gland, enlargement of, 164. 
etiology, 164. 

Sathology, 165. 
iagnosis, 166. 
treatment, 167. 
Prostatectomy, description of, 168. 



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INDEX TO VOLUME I. 



367 



ProfUtMtomj, 251. 

hiitory of esM, 251. 

ehoioe of methods, 253. 

ehlorofonn preferable to ether m aiuee- 
thetie, 253. 

cocaine fuiBcieiit in, 254. 

operation, 254. 
PBoriaeis, 350. 

history of case, 350. 

symptoms, 350. 

treatment, 350. 
Ptosis, congenital, 307. 
Pulmonary tubercnlosis, medicaments osefdl 

in, 00. 
Pyrogallic-aoid ointment in treatment of epi- 
thelioma of the nose, 351. 



Quebracho, ose of, to relicTe dyspncea of 

pulmonary tubercnlosis, 07. 
Quinine in treatment of exophthalmic goitre, 
79. 
of sero-fibrinons pleurisy, 40. 
Quinine hydrobromate as a medicament in 
pulmonary tuberculosis, 07. 



Badius, forcible reduction of unreduced frac- 
ture of, 201. 
Bectooel«!, lacerated cerriz, and retrorersion, 
284. 
history of case, 284. 
treatment, 284, 285. 
Resilient and nodular stricture, 249. 
Result of a pretended operation upon a 
patient suflTering from a delusion of a sexual 
character, 243. 
Retina, scleral puncture in detachment o^ 

with illustrative cases, 295. 
Rheumatism, the treatment of, 1. 
definition, 1. 
symptomatology, 1, 5, 7. 
history of cases, 8, 5, 7, 10, 11. 
treatment, 1. 
dietary, 3, 0. 
clothing, 4. 
bathing, 4. 

galvanism, 13. 
Ringworm, 345. 

history of case, 345. 

differential diagnosis, 345. 

cause, 340. 

treatment, 347. 
Roberts, John B., A.M., M.D., 201. 
Rockwell, A. D., A.M., M.D., 84. 
Ruptured tubal pregnancy, 277. 

history of case, 277. 

differential diagnosis, 278. 

S. 

Salicylate of sodium, efficiency of^ in treat- 
ment of rheumatism, 0. 
Salicylates in treatment of acute rheumatic 
arthritis with pericarditis, II. 
with cardiac enfeeblement, 11. 
Salicylic acid in treatment of myelitis, 100. 
Sansom, A. Ernest, M.D., F.R.C.P., 1. 
Sayre, Lewis A., M.D., 145. 



Scabies, pediculosis capitis, 347. 
history of case, 347. 
differential diagnosis, 347. 
de Schwelnits, O. £., M.D., 295. 
Scleral puncture in detachment of the retina, 

with illustrative oases, 295. 
Seguin's surface thermometer, delicacy of, in- 
aicating surface temperatures of the body, 
140. 
Septic endocarditis, treatment, 15. 

prognosis, 15. 
Sero-fibnnous pleurisy, treatment, 39. 
Simple neuromata, 110. 
Skene, Alexander J. C, M.D., 272. 
Skin-grafting for chronic uloers of the leg, 

150. 
Snell, Simeon, F.R.C.S., Edin., 280. 
Sodium phosphate as lavigant of digestive 
tract in treatment of pulmonary tuber- 
culosis, 01. 
salicylate, efficiency of^ in treatment of 
rheumatism, 0, 9, 11. 
Solis-Gohen, Solomon, M.D., 00. 
Starr, M. AUen, M.D., Ph.D., ix., 102. 
Stockton, Charles O., M.D., 09. 
Stricture, 247. 

traumatic, 247. 

history of case, 247. 
operative treatment, 248. 
resilient and nodular, 249. 
operative treatment, 250. 
Stricture of the urethra, impermeable, pro- 
longed retention of urine; perineal section, 
250. 
Strontium bromide, use of, to check cough and 

vomiting of pulmonary tuberculosis, 07. 
Strychnine in treatment of delirium tremens, 
135. 
of exophthalmic goitre, 79. 
of myelitis, 101. 
of pulmonary tuberculosis, 00. 
arsenate best form of, 00. 
rheumatic cardiac fever, 11. 
use of, to relieve dyspnoea of pulmonary 
tuberculosis, 07. 
Sulphate of copper in treatment of granular 

eyelids, 310. 
Snlpho-carbolate of sodium in treatment of 

septic endocarditis, 15. 
Sulphur ointment in treatment of ringworm, 
347. 
of scabies, 348. 
Suprapubic cystotomy for the formation of an 
artificial urethra, 104. 
preparatory treatment, 109. 
operation, 170. 
after-treatment, 172. 
results, 172. 
Suprapubic and perineal section, advantages 

of, in prostatectomy, 253. 
Surgery, 145, 152, 104, 174, 180, 190, 208, 212, 

219. 
Sutton, J. BUnd, M.D., 110. 



Teno-sutnre and tendon-elongation and short- 
ening by open incision ; advantages and dis- 
advantages of the various methmls, 174. 

Terebene as lavigant of alimentary tract in 
treatment of pulmonary tuberculosis, 01. 



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INDEX TO VOLUME !• 



TetaBos neonatomm; basilar meningitis, 
etiology and treatment, 139. 
history of cases, 130, 142. 
Thoracocentesis, method, 49. 
Thymol as a medicament in pulmonary taber- 

culosii, 67. 
Thyroid feeding in treatment of psoriasis, 350. 
Tincture of iodine in treatment of ringworm, 

347. 
Tongue and hand, diagnostic value of, 16. 
Trachelorrhaphy and adhesions of the retro- 
verted uterus, 259. 
operation, details of, 260. 
aher-treatment, 264. 
Trachoma^ treatment o^ by expression and 
other methods, 3 14. 
diagnosis, remarks on, 315. 
pathology, 316. 
Traumatic stricture, 247. 
Trychophyton fongus, varieties, 346. 

miorosporon as a cause of ringworm, 347. 
Tuberculosis, pulmonary, medicaments usefU 

in, 60. 
Tumor, fibrous, of the naso-pbarynx, 330. 
of the cerebellum, probably tubercular, 
122. 
history of case, 122. 
symptoms, 123. 
diagnosis, 124. 
differential diagnosis, 124. 
causation, 127. 
treatment, 127. 
Tnmon of the bladder, 231. 

history of cases, 231, 232, 233, 

236. 
symptoms, 234-238. 
treatment, 232, 240. 
operative, 232, 234. 



Tumors of the bladder, diagnosiB, 286. 
prognosis, 241. 

U. 

Ulcers of the leg, chronic, 152. 
Umbilical hernia, 280. 

history of case, 280. 

treatment, 281. 
Urinary fever, preventive treatment for, 254. 



Varix as a cause of chronic ulcers of the leg^ 

153. 
Vaseline in treatment of eoiema, 349. 

of scabies, 348. 
Vertigo of central origin, 102, 106. 

history of case, 106. 

causation, 106. 

diagnosis, 108. 

treatment, 108. 
Vomiting of pulmonary tuberoulosis, medica- 
ments for checking, 67. 
Von Koorden, Carl, M.D., 25. 

W. 

Whit^ W. Hale, M.D., F.R.C.P., 48. 
Wilson, H. Augustus, M.D., 174. 



Zinc ointment in treatment of ohronio nleen 
of the leg, 159. 



END OF VOLUME L 



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AN ELEMENTARY TREATISE ON HUMAN ANAT- 

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language." — CimcimnaH Medical News. 

'* Da Costa's work is well known and highly 
and justly esteemed in England as in America. 
It is too firmly established, and its value too 
thoroughly recognized, to 'need a word pro or 
eon** — London Medical Times and Gtuette. 



** It is a book which every practitioner needs 
as an assistant in the discrimination of diseases, 
and for a reference in such cases as are con- 
stantly arising, wherein there is doubt as to their 
positive diagnosis. To be a good diagnostician 
is more than half the battle in the treatment of 
disease ; and a thorough knowledge of the topics 
treated of in this work is certain to add to the 
success of him who gains it. It is a treatise as 
necessary to the physician as his anatomy or 
materia medica, and none should be without it." 
— A^no Orleans Medical and Surgical youmal, 

** The book before us is the work of the first 
diagnostician in America. It is the best book 
on diagnosis extant." — The American Practi- 
tioner, 



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J, B. Lippincott Company s Medical and Surgical Works, 



THERAPEUTICS: Its Principles and Practice. A work 
on Medical Agencies, Drugs, and Poisons, with Especial Reference 
to the Relations between Physiology and Clinical Medicine. By 
H. C. WOOD, M.D., LL.D., Professor of Materia Medica and 
Therapeutics, and Clinical Professor of Diseases of the Nervous 
System in the University of Pennsylvania. 

Latest revised edition, rewritten, and enlarged. 8vo. Cloth, |6.oo; sheep, I6.50. 



Scarcely three years have elapsed 
since the appearance of the seventh 
edition, yet the preparation of the 
present volume has necessitated a 
careful study by its author of more 
than seven hundred memoirs. In 
the present edition no revolutionary 
changes have been made comparable 
to those of the seventh revision, but 
great care has been exercised to see 
that every portion of the work has 
been thoroughly revised, and a number 
of the articles have been completely 
rewritten, while some new drugs have 
been noticed. Among those portions 
of the book which are practically new 
may be mentioned, as important, the 
whole subject of Anaesthetics, the 
articles upon Cocaine, Strophanthus, 
Caffeine, Antipyrin, Antifebrin, Phen- 
acetin, Hydrastine, Paraldehyd, Lead- 
Poisoning, etc. Among the absolutely 
new articles may be mentioned Sul- 
phonal, Chloralaroid, Aristol, and 
others. 



[SPBCXMBN IXXUSTRATION.] 




PRB88 COllliBNTS ON THB 8BVBNTH BDITION. 



" This book should be in the hands of all who 
wish a safe and reliable treatise on the subject of 
therapeutics." — Southtrm Clinic, Richmcndt Va, 

" Although always a fiivorite for the concise- 
ness of the text and the reliability of therai>eutic 
teaching, in its new dress it has excelled itself, 
and is likely to hold its own against all rivals." 
^WUmim^om {N.C) MidUal journal. 

**We doubt if any work published on the 
subject of Therapeutics has proved as popular 
on this continent as this. We have for years 
had a very high opinion of Wood's * Therapeu- 
tics/ and we are pleased to notice in the pres- 
ent volume that the distinguished author is 
keeping fully up to the times. We can recom- 
mend this book ¥rith great confidence, as being 
a safe and reliable guide to the senior medical 
student and the general practitioner." — PracH- 
Horner, Toronto, Canada, 



*' As a work of reference it will form a most 
valuable addition to the library of every mem- 
ber of the medical profession." — Bdinhurgh 
Mtdical journal. 

" Taken all in all, we have little hesitation 
in pronouncing this the most reliable work on 
therai>eutics in the English language." — Pkiia, 
Midical Times, 

" As a whole, for both practitioner and stu- 
dent, it is in our judgment the best work in the 
English language upon the subject of which it 
treats."— ZItf Sanitarian, 

*' It is a work of condensed matter and 
onerous labors, without a single line of useless 
verbiage or tautological sentence, bringing be- 
fore the examiner's mind the pith and fulness of 
the old professional acumen, and brought up t« 
the times by most modem additions." — Si, Lomit 
Medical Journal, 



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/. B. Lippincott Company s Medical and Surgical Works. 



DISEASES OF THE KIDNEYS AND BLADDER. A 

Text-Book for Students 
of Medicine. By W, 
F. McNUTT, M.D., 
M.R.C.S. Ed., L.R.C.P. 
Ed., Professor of the 
Principles and Practice 
of Medicine, University 
of California, etc. 

Crown 8vo. Cloth, I2.50. 

The medical student alone 
will value at its full worth this 
exhaustive text-book on a topic 
scarcely ever before treated 
with such thoroughness. 
There have been innumerable 
writers on special diseases of 
the kidneys, and the subject 
necessarily forms a part of all 
comprehensive works on pa- 
thology. But a single volume 
devoted to this theme in all 
its varying phases, and pre- 
pared by an eminent special- 
ist, is a convenience which every owner of a medical library will consider essential to his 
collection, no matter how full his shelves may be of the less complete material. 




DISEASES OF THE NERVOUS SYSTEM. By JEROME 
K. BAUDUY, M.D., LL.D., Professor of Diseases of the Mind 
and Nervous System and of Medical Jurisprudence in the Mis- 
souri Medical College at St. Louis. 

Second Edition. 8vo. Cloth, I3.00. 

<* In the present volume diseases of the brain and insanity are fully considered in a mas- 
terly manner, a result which was certainly to be expected when we consider that the author 
is not only well known as a recognized authority on his subject, but has been a brilliant 

teacher for quite a number of years '' — St. Louis Medical and Surgical Joumaf^ 

August, 1892. 

« .... It cannot be denied that the excellences of the work are many, and sufficient to 
render the volume a really valuable one in its field ; and it is quite probable that this second 
edition will find a vindication in a third before many years. A perusal of the volume in- 
dicates at once that the writer is a teacher, probably a teacher of the old, impressive school 
modernized and energized, and probably proud of his method of teaching." — University of 
Pennsylvania Medical Magazine^ September, 1892. 

<* It is an admirable critical analysis developed from the stand-point of a studious but 
practical and experienced physician." — Gaillard*s Medical Journal , New York, July, 1892. 

THE PRINCIPLES AND PRACTICE OF SURGERY. 
Being a Treatise on Surgical Diseases and Injuries. By D. 
HAYES AGNEW, M.D., LL.D., Professor of Surgery in the 
Medical Department of the University of Pennsylvania. 

Revised Edition of 1890. Three volumes. 870. Price per volume : Extra cloth, I7.50; 
sheep, ^.50 ; half Russia, ^9.00. 
8 



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/. B. Lippincott Company's Medical and Surgical Works. 

DISEASES OF THE SKIN. A Practical Treatise on 
Diseases of the Skin. By LOUIS A. DUHRING, M.D., Pro- 
fessor of Skin Diseases in the Hospital of the University of 
Pennsylvania, Dermatologist to the Philadelphia Hospital, Consult- 
ing Physician to the Dispensary for Skin Diseases, Philadelphia ; 



author of "Atlas of Skin Diseases." 

A new revised and improved edition in preparation, 
8vo. Illustrated. 
This work is essentially practical, being presented 
to the reader in a condensed, though thoroughly sim- 
ple and intclligeRt form. While the author has given 
due prominence to the methods most approved of by 
dermatologists at large, he has carefully avoided 
all questions of theory and points of discussion, 
and has brought forward more particularly the 
remedies and modes of treatment which have 
proved of the greatest benefit in his own p(jr- 
sonal experience. The new ediiion has 
undergone careful revision, and many new 
and important additions have been made. 

PRBSS COMMENTS. 

" We regard it as the most complete 
and satis&ctory work on dermatology in 
the English language, and most he,iiii1y 
commend it to the practitioner anti Uf 
student." — Boston Mtdical and 
Surgical JoumaL 

"It is seldom our good for- 
tune to meet with so satisfactory 
a book as the present one. In its 
clearness of description, its 
terseness and comprehensive- 
ness, it is certainly exceptional, 
and it will for years take high 
rank as a hand-book for dis- 
eases of the skin." — New York 
Medical Record. 

** Dr. Duhring gives the plain- 
est evidence that he is a large- 
minded, well-read, and accom- 
plished dermatologist. He may 
foirly be congratulated on having 
produced a most readable and 
trustworthy text - book." — Tke 
Lomdom Medical Record, 



[specimen illustration.] 




Fig. IV.— Thb Hair and the Hair-Foluclb. 



AN ATLAS OF SKIN DISEASES. By LOUIS A. 
DUHRING, M.D., autlibr of " Diseases of the Skin," etc. 

With Table of Contents, and Classification of Diseases Treated in the entire work. Royal 
Quarto. Contains thirty-six full-page plates, and explanatory text of the case repre- 
sented. In one volume. Large 4to. Half morocco, I25.00. 
The Atlas consists of a series of original, nearly life-size, chromo-lithographic illustra* 
tions, painted from life, representing Uie most important diseases met with in thx 



United States. 



PRESS COMIIBNTS. 



" The Atlas is a credit to the author as a der- 
matologist, to the artists who have worked so 
fidthfully upon it. and to the publishers for the ex- 
cellence of its general appearance, and deserves 
the most liberal support nrom the profession." — 
American yommal of tlU Medical Sciences. 



'*The Atlas, in its completed form, is the 
best and cheapest atlas of skin diseases with 
which we are acquainted, and reflects the 
utmost credit upon its author and its pub- 
lishers."— Z7ji^/fVt youmal of Medical Science* 



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J. B. LippincoU Company s Medical and Surgical Works. 

A DICTIONARY OF PRACTICAL SURGERY. By 

Various British Hospital Surgeons. Edited by CHRISTOPHER 
HEATH, F.R.C.S., Holme Profi^ssor of Clinical Surgery in Univer- 
sity College, London ; and Surgeon to University College Hospital. 

One volume. 8vo. Upward of two thousand pages. Cloth, I7.50; sheep, ^.50. 

This work will not only prove to be of great service to the student of surgery, but supply 
a want in the library of the busy practitioner, who necessarilv frequently meets with cases of 
surgical disease or injury on which he desires to have immediate mformation as to diagnosis 
and treatment. The Dictionary of Practical Surgery is printed from the original plates of 
the English edition. 

PRACTICAL PATHOLOGY. A Manual for Students and 
Practitioners. By G. SIMS WOODHEAD, M.D., F.R.C.P. Ed., 
etc. 

With 195 Colored Illustrations. Third Edition, Greatly Enlarged and Revised. 
8vo. Cloth, ^7.00 ; sheep, ^.00. 

During the last decade great advances have been made in the methods of studying pa- 
thology ; students are more thoroughly groimded and trained in practical work, and the gen- 
eral standard of pathological knowledge is now certainly much higher than it was even ten 
years ago. It is therefore the more necessary that any one essaying to offer instruction in 
practical patliology should take the greatest care to bring his descriptions into line with the 
results obtained by modem methods. A sense of this responsibility and further experience 
in teaching, and of the needs of both student and teacher, have impelled the author to en- 
large the scope of the work and to alter it very materially in several respects. The chapter 
on Methods has been brought well up to date ; a chapter on Inflammation and Healing of 
Wounds has been added, and other matter, especially as regards the naked eye appearances 
of diseased organs, has been introduced. Special attention has been ]>aid to arrangement, 
much repetition has been avoided, and the references to methods of Hardening, Preparing, 
and Staining have been so arranged as to interfere as little as possible with the continuity of 
the text. In short, the work has been almost entirely rewritten, and so recast as to make it 
available not only as a practical hand-book for the class-room and laboratory, but also as a 
book useful for home study in connection with practical work. The number of illustrations 
has been increased from 162 to 195, and many of the original figures have been redrawn or 
replaced by drawings of more typical specimens. 

FEMALE PELVIC ANATOMY. By J. CLARENCE 
WEBSTER, B.A., M.D., etc. 

4to. Cloth, 129 pages, ^.00. 
The author's chief aim in this yery elaborate work has been to observe accurately, and 
to describe With faithfulness, the great mass of facts which have come under his observation. 
He gives in detail the anatomical condition found in the pelves of women who died of dis- 
eases causing no alteration in pelvic relationships. The details were obtained both from 
sectional and dissectional study. The majority of the plates which illustrate the work were 
drawn from nature by the author. 

TUBO-PERITONEAL ECTOPIC GESTATION. By J. 
CLARENCE WEBSTER, B.A., M.D., etc 

4to. Cloth, 52 pages, |6.oo. 

This monograph gives a detailed account of an original research into the nature of a 
mixed variety of ectopic gestation, prairtly within the left Fallopian tube and partly within 
the peritoneal cavity. Such a variety has never yet been described. The work contains 
eleven colored plates. 

10 



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y. B. Lippincott Company s Medical and Surgical Works. 

SYSTEM OF ORAL SURGERY. Being a Treatise 
on the Diseases and Surgery of the Mouth, Jaws, Face, Teeth, 
and Associate Parts. By JAMES E. GARRETSON, AM., 
M.D., D.D.S, President of the Medico-Chirurgical Hospital, and 
Emeritus Professor of Oral and General Clinical Surgery in the 
Medico-Chirurgical College; Dean of the Philadelphia Dental 
College, etc. 

Illustrated with steel plates and numerous wood-cuts. Fifth Edition, thoroughly 
revised, with important additions. 8vo. Cloth, ^9.00; sheep, #10.00. ' 




manner replaces, in no sense, the old, for the writer 
any opinion or judgment that has been advanced, 
with the rapid growth and advance of the specialty, 
this is with view to a still further con- 
densation of the matter of the book 
and to such elaboration in way of 
presentation of the subjects treated 
in it as shall make them easier of 
comprehension by a student, and, if 
possible, more practical. 

PRB88 COlflfBNTS. 

■' So much of new matter has been 
introduced as to make it obligatory 
upon every dentist, who desires* to 
keep abreast of the advance of 
thought, to add the latest edition of 
the standard work to his library. 
Altogether, to say that the whole 
work is satisfactory is but feebly to 
express the sentiments with which 
every intelligent dental surgeon will 
receive it." — New York Independent 
PraeiiHoner, 

** The reader is not obliged to wade 
through pages of words to catch a few 
ideas, nearly every sentence convey- 
ing a thought clearly and tersely. So 
comprehensive are the subjects pre- 
sented, and so minutely and thor- 
ooghly considered, we have no hesita- 



The interim between the present 
and the immediately preceding edi- 
tion of this book has been a con- 
tinuation of work by its author with 
view to enlarging and elaborating 
experiences that might prove of 
benefit to his patients, his students, 
and himself. An observer, in look- 
ing over the volume in hand, and 
comparing it, even with the last of 
former issues, will find continued in- 
crease in the way of new chapters, 
together with many added illustra- 
tions, while alterations and interpo- 
lations will meet his eye on almost 
every page. This new matter and 
happily is without occasion to change 
The meaning of the additions lies 
As to change of manner to be seen. 




tion in saying that, could the dental profession have but one of the text-books now in existence, 
GarretKm'fl* System of Oral Surgery' would ht, par excellence J^ehooV.^' — Dental Practitioner. 



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J, B, Lippincott Company s Medical and Surgical Works. 



NEW ENCYCLOPAEDIA OF CHEMISTRY. Theoret- 
ical, Practical, and Analytical, as Applied to the Arts and 
Manufactures. By Writers of Eminence. 

Illustrated with ijumerous wood-cuts and steel-pUle tngravings. In two 

Lin penal octavo volumes. Price per set : Cloih, #15.00; Jjbraiy 

sheep, ^iS.oo; half Turkey, ^20,00. 

The plan of the New Encyclopcedia of 
Chemistry formed on the lines of its well- 
known predecessor (Dr* Muspratt's " Chem- 
istry as Applieil tu the Arts and Sciences/' 
published now up- 
ward of twenty yews 
ago) incl iides sti cfe , 
novel features as sue 
likely to make it even 
more convenient and 
valuable ihun wdstbat 
work in its day. 

It being manifest 
that the infinite va- 
riety of subjects now 
embraced m such a 
^vork could be ad- 
eqnately treated by 




no one writer, however learned or painstaking, the publishers in carrying forward their enter- 
prise have availed themselves of the assistance of the leading chemists of the present day, as 
well as of writers who are practically acquainted with all the details of our great manufac- 
tures; while no expense has been spared to add to the clearness and usefulness of the articles 
by means of copious illustrations. This department of the work will be found to comprise, 
besides very numerous wood-cuts in the text, a series of highly-finished plate engravings of 
the most important or elaborate manufacturing plant in use at the present time, — a feature, it 
is hoped, which will add greatly to its value and interest. 

INSANITY CONSIDERED IN ITS MEDICO-LEGAL 
RELATIONS. By J. R. BUCKHAM, A.M., M.D. 

Svo. Cloth, ^2.00 ; sheep, I2.50. 
A treatise on the subject of insanity as affected by legal decisions, especially in the crim- 
inal courts, exposing the errors and dangers of the system, and indicating the reforms that 
are necessary. 

ADVICE TO A WIFE, AND ADVICE AND COUNSEL 
TO A MOTHER. By PYE HENRY CHAVASSE. 

i2mo. Cloth, I2.00. 
Advice to a wife on the management of her own health and on the treatment of some 
of the complaints incident to Pregnancy, Labor, etc. Advice to a mother on the manage- 
ment of her children and on the treatment of some of their illnesses and accidents. 



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J. B. Lippincott Company's Medical and Surgical Works. 

A CLINICAL MANUAL OF THE DISEASES OF THE 
EAR. By LAURENCE TURNBULL, M.D., Ph.G., Aural Sur- 
geon to the Jefferson Medical College Hospital, Philadelphia; 
President of the Subsection of Otology of the British Medical 
Association at Cork ; author of a work on Hygiene of the Ear, 
etc , etc. 

With a colored lithographic plate, and numerous illustrations on wood. 
Revised edition. 8vo. Extra cloth, I4.00. 

PRESS COlflf BNT8. 

" The author has greatly improved his work to the author, and they have been extensively 

in this edition, and it will meet a greater demand quoted in otological literature. All persons that 

. than ever. It is well issued, and worthy a place pay more than a passing interest to aural sur- 

in the library of all practitioners." — Anurican gery will be amply rewjJded by reading Tum- 

LoMcet, Detroit. bull's book, which gives full information on 

" It is the most thorough treatise on diseases so™© important subjects that are scarcely mcn- 

of the ear that it has been our pleasure to read, tioncd in others."— A^. K Arckivts of Otology, 

Every physician is in need of such a work, ..^e cheerfully commend the work, not 

whether he has any other work on the subject only to the specialist, but to the general practi- 

or not — ^. Loms Mtdwal Bruf, tioner, as one of the best treatises yet issued 

" There are, in this book, a great many most upon diseases of the ear." — NaskvilU youmal 

valuable observations and suggestions personal 0/ Medicint and Surgery, 

HAND-BOOK OF NURSING. For Family and General 
Use. Published under the auspices of the Connecticut Training- 
School for Nurses, State Hospital, New Haven, Connecticut. 
i2mo. Extra cloth, I1.25. School Edition. Cloth, flexible, |i.oo. 

PRESS COIfMBNTS. 

" It is evidently prepared by some one who notes on baths, rubbing, disinfection, and the 

has had long experience, and who has a natural use of the medical thermometer ; the second is 

vocation for nursing. There is scarcely a ques- devoted to monthly nursing ; and the third to 

tion that a new and inexperienced nurse would the practical hygiene of house-keeping, cleaning, 

ask which is not here intelligibly answered, ventilation, care of the nursery, sleeping-rooms. 

It is especially a book for the fJEunily. giving kitchen, cellar, wash-tubs, and closets. It should 

valuable hints to every one who undertakes the be the commonplace-book of every household, 

care of the sick, even where nothing but care and the hand-book of every nurse.**— AVw York 

and proper attention is required." — Harm's Sanitarium. 
Weekly. ** This is probably the best work of the kind 

" A clear, practical, common-sense book on ever given to the world, and we thoroughly as- 
hygiene, no less serviceable to the mother and sent to the endorsement of President Porter, of 
bottse-keeper than to those who make a business Yale College, that, though brief in language 
of nursing, for whom it is more particularly in- and simple in its form, it is the fruit of the ex- 
tended. It consists of three parts. The first perience of years in the supervision of hospital 
describes medical and surgical nursing, with cases and duties." — Philadelpkia Press. 

DISEASES OF THE MOUTH, THROAT, AND NOSE. 

Including Rhinoscopy and the Methods of Local Treatment. For 
Practitioners and Students. By Dr. PHILIP SCHECH. Trans- 
lated by R. H. BLAIKIE, M.D., F.R.C.S.E. 

With illustrations. 8vo. Extra cloth, I3.00. 

This translation was undertaken with the idea of presenting to the profession a short and 
concise work on the subjects with which it deals. The very favorable criticisms of the book 
in the German medical journals show that it is one deserving the attention of all interested 
in this branch of medical science. The author in his preface says, "There are certainly 
many good works and writings on these subjects already, hut most of them seem to be either 
too voluminous or too short. I have therefore very gladly 'complied with the request of the 
publishers to write a short but exhaustive treatise on the subjects, all the more because, hav- 
ing worked for twelve years at the literature as well as the practice of these diseases. I have 

' come to know exactly what the practitioner requires." 

»3 



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J. B. Lippincott Company s Medical and Surgical Works. 
PRACTICAL LESSONS IN NURSING. 

1 2mo. Extra cloth, 1 1 .00 each. 
I.— THE NURSING AND CARE OF THE NERVOUS AND THE INSANE. 
By CHAS. K. MILLS, M.D.. Professor of Diseases of the Mind and Nervous 
System in the Philadelphia Polyclinic and College for Graduates in Medicine ; 
Neurologist to the Philadelphia Hospital, etc. 

PRESS COMMENTS. 

" The book is a valuable one, and should be too fiEuniliar with the proper management of 

read by every nurse as well as by physicians who many of the nervous diseases met with in general 

realize the importance of extra-medi<^ influences practice." — Canadi a n Practitioner, 
and agendes in the cure of disease."— A^. K .. i consider it a most valuable addition to a 

Medical Digest, nurse's library, and shall advise all nurses under 

" This work may be perused with advantage, my charge to obtain it." — yennie Dalnel, Head 

not only by professional nurses, but also by Nurse at Philadelphia Hospital, 
medical men, who, it must be admitted, are not 

II.— MATERNITY ; INFANCY ; CHILDHOOD. The Hygiene of Pregnancy ; the 
Nursing and Weaning of Infants ; the Care of Children in Health and Disease. 
Adapted Especially to the Use of Mothers or Those Intrusted with the Bringing 
up of Infants and Children, and Training Schools for Nurses, as an Aid to the 
Teaching of the Nursing of Women and Children. By JOHN M. KEATING, 

M-^- PRESS COMMENTS. 

" The first part of this book is intended for " It is probable that every physician has many 

mothers.— giving them just that sound, practical times realized th^ need of such a work as this, 

advice they so much need, the observance of which, while giving the necessary information to 

which must result in healthier women and off- those having the care of children or of the mother 

spring. For her own sake and for the sake of during maternity, does not trench upon the duties 

her child, we wish every mother had a copy of of the physician. It is manifestly impossible for 

this book." — Practice, Richmond, . the physician to be always at hand to direct the 

" Dr. Keating, in a simple, easy manner, tells n«»e. <>' *« provide for all possible emergencies 

the story of what to do. and how to do it ; so by any set of direcUons, short of systematic in- 

that any one can readUy catch the authors mean- struction ; but what he cannot do this little work 

ing. We know of no better book on the subject, does admirably, as a glance at the list of contents 

We commend it most zoidxsXlyr ^Philadelphia will show. ^Archives of Gynecology, N. Y, 
Medical Register, 

III.— OUTLINES FOR THE MANAGEMENT OF DIET; or, The Regulation of 

Food to the Requirements of Health and the Treatment of Disease. By E. T. 

BRUEN, M.D. PRESS comments. 

" It is an excellent book for its many hints "The work is well arranged, well written, 

regarding the action of foods, regulation of diet, and forms a small but excellent addition to the 

etc. It will be of great service to young nurses literature of dietetics." — Chicago Medical your* 

on account of its numerous suggestions concern- nal and Examiner. 

lag the preparation of various articles of food .. Physicians cannot be cooks, but have a 

for the sick-room. It is worthy also of a place rfght to expect nurses to know how to prepare 
•Q the physician s table, among those books the proper food as weU as druggists should know 
which are aptly called hMid-books, for it con- how to compound medicines. For this reason 
tains many important details, too easily forgotten the little book will serve a valuable purpose and 
amid the preMure of more scnous consideraUons, cannot be recommended too highly."— Cfi»«*»- 
which can thus be recalled and grasped at a f^^a Lancet' Clinic. 
moment's notice." — N. Y. Medical youmal, 

IV.— FEVER-NURSING. Designed for the Use of Professional and Other Nurses, 
and especially as a Text-Book for Nurses in Training. By J. C. WILSON, A.M., 
M.D., Visiting Physician to the Philadelphia Hospital and to the Hospital of the 
Jefferson College ; Fellow of the College of Physicians, Philadelphia ; Member 
of the American Association of Physicians, etc. 

PRESS COMMENTS. 

•• Dr. J. C. Wilson has the happy fiiculty of prehenslve, and while brief in his explanations, 
writing a book which his readers can comprehend he always covers the ground intended without 
without an effort. His style is clear and com- missing a point." — A^. Y, Health, 

14 



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y. B. iJppincott Company s Medical and Surgical Works. 



PRESS COMMENTS ON PEVER-NURSING.— Continued. 



" Such books as constitute this series are in- 
▼alutoble in the training of nurses, and should be 
added to the reading course for nurses in all our 
ho^itals. 

Dr. Wilson's treatise keeps the series up to 
the high standard of its predecessors." — Indian- 
apolit Medical yournaL 



"A cursory reading of the several chapters 
has convinced us that this hand-book contains 
much that will be of interest to the practising 
physician, and especially those of our school, 
many of whom, alas 1 are wofiilly deficient in 
aught save the application of remedial measures. 
We commend the work." — N, K HomaopatkisU 



v.— DISEASES AND INJURIES OF THE EAR : Their Prevention and Cure. 
By CHARLES H. BURNETT, A.M., M.D.. Aural Surgeon to the Presbyterian 
Hospital, and one of the Consulting Aurists to the Pennsylvania Institution for 
the Deaf and Dumb, Philadelphia; Lecturer on Otology, Women's Medical 
College of Pennsylvania, etc. 

PRESS COMMENTS. 



" The instructions contained in these books 
are applicable to almost any form of disease, ex- 
cepting surgical cases. They can be recom- 
mended in the strongest terms to nurses and to 
physicians, and are well written and very hand- 
sontely printed." — Philadtlphia Medical and 
Smrj^ical Reforter. 

*' This series of Practical Lessons in Nursing 



should be in the library of every physician, and 
could be given by him to the nurse as a means 
of carrying his patient through successfully, and 
save him many words and valuable time in ex- 
plaining to the person in charge just what to do 
and what to avoid. There are now five of these 
little works, and the price is within the reach of 
all."— 5f. Uuis Medical Brief. 




THE ROLLER BANDAGE. By 
WILLIAM BARTON HOPKINS, 
M.D., Senior Surgeon to the Episcopal 
Hospital; Surgeon to the Out-Depart- 
ment of the Pennsylvania Hospital, etc. 



[SPBCIMSN ILLUSTRATION.] 



With 73 designs fully illustrating the process of bandaging. 
i2mo. Cloth, flexible, I1.25. 



[SPBCIMBN ILLUSTKATION.] 



PRESS COMMENTS. 

" This is a very clear and satisfactory treatise on the stjbj«:t» 
The text is framed without waste of words, and the illustra lions 
are excellent. As a text-book for the student, and as a (jutde 
to the practitioner in a most important department of profc*- 
sional work, it is destined to do good service." — Li>uist*iik 
Medical News, 

*• The book is of value to the early beginner in surgical 
dressing, and may be read with advantage by older mcn^ for 
good bandaging is an exceedingly important adjunct of good 
Kiix^ry:* —Philadelphia Medical and Surgical Reporter, 

*' Books on bandaging are not numerous, and such as ivrc ^ 
extant are profusely adorned with fancy diagrammatic drillings. 
which, on attempted application, will be found impossiblF.' of 
accomplishment. The diagrams in this work are exitrsmeiy , 
realistic, and have the appearance of bandages as they mf seen 
in applicaiion. The author, in his preface, states that these dia- 
grams are intended to do the teaching, rather than by elaboraie 
descriptions, which are usually mystifying. He has sucteetled 
most admirably. We can commend this work to thoTn; wlnj 
feel the need of a compendium on roller dressings.'* — PAila^ 
delphia Polyclinic. 

" Every student and every physician not thoroughly conversant with the various methods of 
applying the roller bandage should not fail to buy a copy of the above work. It contains cuts 
upon almost every page, illustrating the various methods of applying the bandage, is printed on 
heavy paper, neatly bound, and in size is convenient to carry in the pocket."— /«</»a»a Medical 
journal. 




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y. B, Lippincott Company $ Medical and Surgical Works, 



THE PRACTICE OF PHARMACY. A Treatise on the 
Modes of Making and Dispensing Officinal, Unofficinal. and Ex- 
temporaneous Preparations, with Descriptions of their Properties, 
Uses, and Doses, Intended as a Hand-Book for Pharmacists and 
Physicians and a Text-Book for Students. Second Edition, En- 
larged and Thoroughly Revised, By JOSEPH P. REMINGTON, 
Ph.M., F.C.S., Professor of Theory and Practice of Pharmacy and 
Director of the Pharmaceutical Laboratory in the Philadelphia 
College of Pharmacy, etc. 

Containing over 1300 pages and 630 illustrations. 8vo. Cloth, extra, |6.oo; sheep, ^.50. 

The value of the 
method of proving 
progress in knowl- 
edge by answering 
questions has been 
recognized in this 
edition, and a series 
of questions on the 
subjects embraced 
has been appended 
to each chapter. 

After the chapter 
on Metrology, typi- 
cal pharmaceutical 
problems and exer- 
cises in alligation 
have been inserted. 
Part v., treating of 
Magistral P h a r - 
macy, and Part VI., 
containing the 
Formulary of Un- 
officinal Prepara- 
tions, have been 
revised and greatly 
extended. More 
than one hundred 
illustrations and fifty 
pages have been 

added to Part V. Fac-similes of one hundred autograph and questionable prescriptions, 
selected to demonstrate how various difficulties occurring in daily practice may be overcome, 
and accompanied by running comments, constitute the most important addition to this portion 
of the work. These have been printed upon enamelled paper with special care, in order 
that the originals may be faithfully reproduced. By the incorporation of the National For- 
mulary, the elision of those formulas which might conflict with this authority, and the addition 
of others, it is believed that greater usefulness in this Part will be secured. The additions 
represent a net increase of two hundred pages, the illustrations numbering six hundred and 
thirty-nine, or one hundred and forty more than were in the first edition. A very complete 
and useful index has been added. 

TESTIMONIALS. 




Remington's Percolating Stand. 



'*I do not hesitate to say it is the most 
complete book on Pharmacy that can be had. 
By the excellent arrangement the editor has 
adopted at the end of each chapter, students 
can avail themselves of a self-examination 
which can only result to their good, and give 
them a better understanding of Pharmacy in 
all its branches. I can conscientiously say 
that no druggist or druggist's clerk should be 



16 



without a copy." — Edward W. Runyon^ 
Dean of the Faculty^ College of Pharmacy, 
San Francisco, CaL 

** It is not too much to say that * Reming- 
ton's Practice' is the greatest and most com- 
prehensive exponent of the science and che 
art from the time of Paracelsus to the present 
dAy."—fVeslem Druggist, Chicago, IlL 



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J. B. Lippincott Company s Medical and Surgical Works. 



DOCTOR AND PATIENT. By S. WEIR MITCHELL, 
M.D., LLD., Harv., author of" Fat and Blood, and How to Make 
Them," " Wear and Tear ; or, Hints for the Overworked," etc. 

Extra cloth, I1.50. 



*'Dr. Mitchell's papers on 
Patient* seem to us admirable. They embody 
the teachings of a remarkably broad experience, 
and contain strongly-presented warnings against 
the modem tendency to seek protection against 
nervous complaints and pain in opiates. . . . 
fai all respects the little book is meritorious and 
one which may be most profitably studied by 
vSXr—New York Tribune, 

" While in sympathy with all sufferers, tmd 



i2mo. 

PRBS8 COMMBNTS. 

Doctor and especially those with nervous ills, he writes with 
a vigor and discernment that carry conviction 
to the invalid. We wish the chapters on Ner- 
vousness, Pftin and its Consequences, and The 
Moral Management of Invalid Children, could 
be read by every man and woman that has had 
experience in these directions. We commend 
the book as a valuable addition to the many 
excellent writings of the author.*'— A^. K Indt* 
pendtnt 



WEAR AND TEAR; OR, HINTS FOR THE OVER- 
WORKED. By S. WEIR MITCHELL, M.D., LLD., Harv., 
Member of the National Academy of Sciences, President of the 
College of Physicians of Philadelphia, etc. 

Fifth edition, thoroughly revised. i6mo. Cloth, |l.oo. 
PRESS COlfMBNTS. 

" It is a physician's duty and a layman's 
privilege to instruct himself from this little work, 
so wise in matter, so graceful in style, on a sub- 
ject vital to both profession and laity.'* — New 
England Medical Gcuette, 

"The author's position on the subject of 
overwork is moderate and reasonable, and the 
book contains many valuable hints worthy the 
attention of every one." — Poplar Science 
Nevu, 



" Dr. Mitchell's excellent litUe work is, in its 
new edition, a repetition and re-enforcement of 
the remonstrance made by the author in pro^ 
vious editions against the wear and tear of over- 
work, so characteristic of us as individuals and 
as a people. The advice and suggestions are 
alvrays timely, and commend themselves to 
physician and laity alike, for the spirit of unrest 
is not limited to class, sect, or sex/'-^Pkilada, 
College and Clinical Record, 

FAT AND BLOOD. An Essay on the Treatment of Cer- 
tain Forms of Neurasthenia and Hysteria. By S. WEIR 
MITCHELL, M.D., author of " Doctor and Patient," " Wear 
and Tear," etc. . 

Third edition, revised, with additions. i2mo. Extra cloth, I1.50. 
PRESS COlflfBNTS. 

"A most practicable, sensible, and well- 
written monograph on a very important sub- 
ject. Doctor Mitchell deserves the gratitude 
and thanks of every medical man for bis origi- 
nal and practical treatment upon neurasthenia 
and hysteria." — St. Louis Medical Brief. 

" If properly heeded it can do more good in 
proportion to iu pages than almost any volume 
which has recently come imder our notice." — 
Boston Post. 



**We cannot too highly recommend Dr. 
Mitchell's book to the attention of our readers. 
In order to understand the mode of carrying 
out the treatment, all its details must be studied 
carefully, and in the pleasantly and clearly 
written pages of the work under notice such a 
detailed account will be found as to enable 
any one to select his cases and direct their 
treatment with success." — Dublin JoumcU of 
Medical Science, 

INJURIES OF THE NERVES AND THEIR CONSE- 
QUENCES. By S. WEIR MITCHELL, M.D., author of 
" Fat and Blood," " Wear and Tear," etc. 

8vo. Cloth, I3.00. 
PRESS COlfMBNTS. 

" It is certainly one of the most valuable great value to the profession. We know of no 
contributions to modem medical science." — other in the English language at once so com- 
Pmci/tc Medical journal. picte, so original, and so readable." — Detroit 

••The work is evidently a contribution of Review of Medicine and Surgery. 



17 



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y. B. Lippincott Company s Medical and Surgical Works, 

NERVOUS DISEASES AND THEIR DIAGNOSIS. A 
Treatise upon the Phenomena Produced by Diseases of the Nervous 
System, with Especial Reference to the Recognition of their Causes. 
By H. C. WOOD, M.D., LL.D., author of "Thermic Fever," "On 

Fever," etc. 

8yo. Extra cloth, ^oo; sheep, ^50. 
PRESS COlflfENTS. 

"Dr. Wood has added a very important in this department of science, constitute the truly 

woric to American medical literature, a book great attractions of this book. The distinguished 

which shows progress in the most difficult branch author is widely recognized as one competent 

of the profession, and of which he may justly for his task."— /f/^oaiy Medical AhhoIs, 

feel a pride in being the author. "—/'Aiyaiif^^Afa *' It is at once a substantial contribution to 

Medical News. neurology, and a trustworthy gmd^^-^Londom 

** Dr. Wood is an able clinician, and this Practiiicntr, 

makes the book valuable. His observations are " The honest effort of one who never writes 

practical and to the point, and show careful study without teaching, and who always wntes and 

of the laige number of cases which have fallen teaches well."— A5w York younuU of Insanity. 

under his care." — New York Medical youmal, " As a text-book forstudents and piactitioners 

" Lucid language, clear type, a full index, we most cordially recommend W^^St, Louis 

imd, above all, the presentation of late advances Medical yourmal, 

A TEXT-BOOK OF CLINICAL DIAGNOSIS. The 

Chemical, Microscopical, and Bacteriological Evidence of Disease. 
By Dr. RUDOLPH VON JAKSCH, of the University of Prague. 
Translated from the Tkird Edition by JAMES CAGNEY, MA:, 
M.D. With Additions by WM. STIRLING, M.D., ScD., Pro- 
fessor of Physiology, Owens College, Manchester. With numerous 
Illustrations in color. Medium 8vo. Cloth, I6.50. 

" The American practitioner and student ** The book prepared by this intellectual 

has now the opportunity of adding a very trio of men, who possess a practical and a 

valuable work to his libraiy, and one that he world-wide reputation, will be of assistance 

will often consult with due advantage.'* — to the author, student, and practitioner.'* — 

Medical Brief, Si. Louis. Medical Bulletin, Philadelphia. 

ILLUSTRATIONS OF THE NERVE TRACTS IN THE 
MID AND HIND BRAIN, and the Cranial Nerves arising there- 
from. By ALEXANDER BRUCE, M.A., M.D. Containing a 
number of figures in the text and twenty-seven full-page colored 
plates. 

Oblong 4to. Cloth, f 12.50. 

i 
PRACTICAL HISTOLOGY. A TextiBook of Practical 
Histology, with Outline Plates. By WILLIAM STIRLING, 
M.D., ScD., F.R.S.E., Regius Professor of the Institutes of Medi- 
cine in the University of Aberdeen. 

With 30 outline plates, i colored plate, and 27 wood-engravings. 
Quarto. Extra cloth, I4.50. 

** The author has endeavored to give a faithful account of the methods which he has 
fotind to be the most useful for the preparation of each of the tissues and organs of the body 
for microscopic purposes. No method is introduced which he has not found (rom repeated 
trials to be successful. The methods described are those which, after nine years' experience 
in the teaching of practical histology, he has found to be really reliable." — Preface. 

18 



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J, B, Uppincott Company s Medical and Surgical Works. 

HYPODERMATIC MEDICATION. The Treatment of 
Diseases by the HypcMJermatic or Subcutaneous Method. By 
ROBERTS BARTHOLOW, M.A., M.D., LL.D., Professor of 
Materia Medica, General Therapeutics, and Hygiene in the Jeffer- 
son Medical College of Philadelphia ; Fellow of the College of 
Physicians of Philadelphia, etc. 

New Edition. Entirely revised and enlarged. With Illustratioiis. 
i2mo. 542 pages. Cloth, I3.00. 

PRESS COIflfBNTS. 

*' This is now the most complete work upon results of bacteriological research as far as this 
the subject of subcutaneous medication.'* — form of treatment is affected thereby, and in- 
GaiUards Medical youmal, M Y. eludes all of the later additions to the materia 

" The information it gives cannot elsewhere be medica which are capable of use in this manner, 
obtained. ... It is the authority upon the sub- Pyoktanin. cantharidin. creolin. etc., among the 
iect upon which it treats, a subject that is grow- late antiseptics are given careful review. There 
Ing in extent and importance every day, and it would seem to be nothing omitted which the 
is indispensable to every physician who would practitioner may desire to investigate, and we 
keep abreast with medical progress and dis- can commend the work to our readers as em- 
covery."* -Maryland Medical yintmal. bodying in complete form the very latest re- 

" A complete presentation of the subject of searches into this important field of medica- 
hypodermatic medication. It has been brought tion." — CimcitmaH Lancet'Clituc, 
well up to the present year, embodying the latest 

THE REFRACTION AND ACCOMMODATION OF 
THE EYE AND THEIR ANOMALIES. By E. LANDOLT, 
M.D., Paris. Translated under the author's supervision by C. M. 
CULVER, M.A., M.D., Albany, N. Y. 

With 147 illustrations. 8vo. Extra cloth, I7.50. 

This work was first published in the French language. The present English edition has, 
however, been considerably modiBed by the author's experience since its first publication. 

It is dirided into Three Portions, or Divisions, as follows : I. PHYSICAL PORTION. 
11. THEORETICAL PORTION. III. CLINICAL PORTION. And also contains a 
Complete Index. PRESS COlClfENTS. 

"There is no work which the beginner in the appearance of Donders's great work, no book 
the study of refraction can read to greater profit upon this important branch of ophthalmology has 
than this one of Dr. Landolt's. The author has been published which can at all compare with 
a happy faculty of simplifying things, and it finds the work before us. It contains less of mathe- 
nowhere a more appropriate field for its em- matical and more of the clinical element than 
ployment than in the dominion of refraction. Donders's book, and will, we believe, on that 
Dr. Culver has done his work as a translator account, to a great extent, replace in this country 
well." — Archives of OpkthalmoUgy, N. Y, the latter as a book of reference.*' — London 

*' We have no hesitation in saying that, since Medical Record. 

WILSON'S CLINICAL CHART, Designed for the Con- 
VENiENT, Accurate, and Permanent Daily Recording of Cases 
IN Hospital and Private Practice. By JAMES C. WILSON, 
M.D., Physician to the Philadelphia Hospital, and to the Hospital 
of the Jefferson College. 

50 Charts, in tablet form. Size, %% x 11 inches. Price, 50 cents per block of 50 CharU. 

PRB88 COIflfBNTS. 

"This Chart, designed for the convenient, ac- keep such a record of his cases as Mrill enable 

curate, and permanent daily recording of cases him to review them at any time ; in doing so 

fai hospital and private practice, is so arranged he always benefits himself. While this chart 

as to be an invaliiable aid to all practitioners would not answer the purposes of the specialist, 

who desire to avail themselves of every op- yet it is the best we have seen for the general 

portunitv to improve themselves and thereby practitioner." — Si, Louis Medical and ^rgicaX 

oenefit their patient. Every practitioner should yowmal, 

19 

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J. B, Lippincott Company s Medical and Surgical Works. 

FOODS FOR THE FAT. A Treatise on Corpulency, and 
a Dietary for its Cure. By NATHANIEL EDWARD 
DAVIES, Member of the Royal College of Surgeons, England, 
author, of "Aids to Long Life," "Medical Maxims," "Nursery 

Hints," etc. j^mo. Qoth, 75 cents. 

PRESS COMIfBNTS. 

" It will prove a valuable guide to those who ulants, etc., and gives a dietary to be followed 

wish tp reduce their surplus weight. The vol- for the reduction of flesh. The latter is espe- 

ume closes with a large number of recipes for cially generous, and will make it possible for 

tempting dishes that will assist far better than any ' fot man' to starve himself and yet live, 

medicine in bringing the body back to health- The author's thesis is that such a man ' can go 

ful slenderness." — Pittsburgh Bulletin, on eating very well indeed, and yet be cured 

"It treats suggestively of the uses and the of excessive stoutness.'" — Washington Public 

elimination of food, over-eating, exercise, stim- Opinion, 

INTRACRANIAL TUMOURS. By BYRON BRAM^ 
WELL, M.D., F.R.S.E., Lecturer on the Principles and Practice 
of Medicine in the Extra-Academical School of Medicine, Edin- 
burgh. 

116 illustrations. 270 pages. 8vo. Qoth, ^.50. 

PRBSS COlfMENTS. 

"The book is of great value from its wealth latter include such beautiful engravings and 
of personal observations, and is an excellent reproductions of photographs, showing the mac- 
manual upon a subject which has recently be- roscopic and microscopic appearances of a 
come so much more important than ever before, great variety of morbid conditions of the brain 
The arrangement is good, the style clear, and and its adulxa. that it is hard to find words to 
the illustrations, whidi are most profuse, are express the admiration they excite. And these 
most admirable. They alone are worth the attractions of the book are entirely in keeping 
price of the book, for almost every one of them with the scientific merits of its contents. Dr. 
is new. and they are drawn from specimens in Bramwell is well known as a careful observer 
the possession of the author or his friends." — and an able writer, and his reputation — already 
Boston Mtdical and Surgical Journal. sufficiently established — will only be enhanced 

" There have been few books issued from the by this work. No careful student of brain- 
medical press of this or any other country pathology can afford to be without it. and we 
which can compare with this magnificent vol- can recommend it in the most unqualified terms 
umc. It is printed in the most admirable way, to the attention of our readers." — Philadelphia 
and its illustrations are unusually fine. The Mtdical and Surgical Reporter, 

HYDROPHOBIA. An account of M. PASTEUR'S system. 
Containing a translation of all his communications on the subject, 
the technique of his method, and the latest statistical results. By 
RENAUD SUZOR, M.B., CM., Edinburgh, and M.D., Paris, 
commissioned by the Government of the Colony of Mauritius to 
study M. PASTEUR'S new treatment in Paris. 

With 7 illustrations. i2mo. Fine cloth, I1.50. 
PRESS COMMENTS. 

" For the better comprehension of what this no need to repeat this labor, so well done is it 

benefactor of mankind (M. Pasteur) aims at in the work before us. , 

doing, and how far he has advanced towards " Preliminary to the chief part of the work 

the attainment of his object, we cordially wel- is a short description of hydrophobia, so far as 

come this small work by Dr. Suzor, which es- known previous to the end of the year 1880, 

sentially consists of a translation of all M. when M. Pasteur turned his attention to the 

Pasteur's communications to the Academy of disease. The description is excellent, and well 

Sciences and elsewhere on the subject of hydro- worthy of perusal by those even who are not 

phobia, with a description of his technique, and above a free expression of opinion on this most 

the latest sutistical results. . . . There will be difficult subject." — London Saturday Revitw, 



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J. B. Lippincott Company s Medical and Surgical Works, 

ELEMENTS OF MODERN CHEMISTRY. By 

ADOLPHE WURTZ, Senator, Professor of Chemistry of the 
Faculty of Medicine of Paris, etc. Third American Edition. 
Translated and edited with the approbation of the author, from the 
Fifth French Edition, by DR. WM. H. GREENE, Professor of 
Chemistry in the Philadelphia Central High School, etc. 

New edition, revised and enlarged. 132 illustrations. 8yo. Cloth, I2.50; 

library sheep, I3.00. 







The progress of ihe science has mat^e necessary many changes in the 
fifth edition of this little book, which has «o far retained about ihe form 

and scope glveri to it son:te years ago. 
It h£is been deemed advisable to com. 
pleie the organic portion, and a large 
number of additions and corrections 
have been made. Whole chapters 



[««BCtl«lJi ILLUSmiATfOJf,] 




have been added to the history of the cyanogen compounds, the hydrocarbons, the acids, and 
the aromatic compounds. Among these will be particularly noticed the articles on isomerism, 
the azoic and diazoic compounds, and the pyrodic bases, subjects which have acquired great 
importance during the last few years. 



THE HUMAN VOICE. By JAMES RUSH, M.D. Em- 
bracing its Physiological History, together with a System of Prin- 
ciples which Criticism in the Art of Elocution may be rendered 
intelligible, and Instruction definite and comprehensive. To which 
is added a brief analysis of song and recitative. 

Seventh Edition, 8vo. Cloth, I3.00. 



INEBRIETY: Its Causes, Its Results, Its Remedy. By 
FRANKLIN D. CLUM, M.D., author of " Men and Women." 

Cloth. 1 1. 25. 

••This is an admirable treatise.** — Philadelphia Ledger. 

"The work of Dr. Clum is the best monograph upon the subject of inebriety with which 
we have ever met. It is worthy the attention of physicians, and we hope that all our readers 
will attentively read it. The author's observations have been very extended, and, besides, 
he has given the subject his profoundest reflections. It may be thought by many that they 
know all that is to be known in regard to intemperance, iu causes, effects, etc., but we feel 
sure that ther»are lew who will not be both interested and instructed by this volume."— 
Cincinnati Medical News. 



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J. B. Lippincott Company s Medical and Surgical Works. 

ATLAS OF VENEREAL DISEASES. By P. H. MAO 
LAREN, M.D., F.R.C.S.E. . 

Containing 30 colored plates and over 40 subjects. Complete in ten parts. Royal 4tou 
Paper, tijoo per part ; or one rolnme, folio, half morocco, $2^.00, 

This work consists of a series of life-size plates. The illustrations, without ezceptioi^ 
are original. They are copied from paintings of cases which have come under the author's 
oUervation during the past few years. The chief aim of this work is to offer to the medical 
profession a series of illustrations which may prove useful. To medical students who have 
not sufficient time nor opportunity afforded them in their curriculum for the systematic study 
of the multiform expressions of this class of diseases, it is hoped that this Atlas will be 
specially serviceable. In the pnroduction of the plates neither labor nor expense has been 
spared to reproduce the original paintings with accuracy and finish. Each will be accom* 
panied by a concise and clear description of the conditions portrayed. The Atlas is hand- 
somwly printed on a thick specially-prepared paper, folio size, 15x11. 



GYNiCCOLOGICAL ELECTRO-THERAPEUTICS. By 
Dr. HORATIO R. BIGELOW, Permanent Member of the 
American Medical Association, Fellow of the British Gynaeco- 
logical Society, etc., with an Introduction by Dr. GEORGES 
APOSTOLI. 

Illustrated. 8vo. Ooth. I3.00. 

** This comprises a recapitulation of the ment ... To those who are unable to read 

work and methods of Dr. Apostoli. The book his papers in the original, this book affords 

is opened by an introduction on the advan- an opportunity to acquaint themselves with 

tages of the use of electricity in the treatment the great success attained by this diligent 

of the diseases of women, and the class of student Those interested in the treatment 

cases which are most likely to derive benefit of pelvic disorders will find themselves well 

from its use. repaid for a perusal of this work. The re- 

** The first three chapters are devoted to suits given are so flattering that the operator 

the physics of electricity, — knowledge neces- who cures such diseases by mutilation should 

sary to a proper understanding of the thera- hesitate before sacrificing organs that may be 

peutic application of the agent. rendered productive and painless by other 

" The balance of the book is Uken up methods of treatment" — Philadelphia Medi- 

with a risumk of Apostoli's plans of treat- cal Bulletin, 



HYDATID DISEASE IN ITS CLINICAL ASPECTS. 
By JAMES GRAHAM, M.A., M.D., late Demonstrator of Anat- 
omy, Sydney University. 

204 pages. With 34 full-page colored plates from original drawings. 
8vo. Qoth, I4.50. 

NERVES OF THE HUMAN BODY. With Diagrams. 
By ALFRED R. HUGHES, Bachelor of Medicine and Master 
in Surgery of the University of Edinburgh, etc. 

4to. Cloth, 32 pages, ^3.00. 

While chiefly designed to lighten the task' of students of medicine in acquiring a 
knowledge of the nerves of the human body, this volume may also be used to advantage as 
an adjunct to the standard works on practical anatomy. The letter-press covers all that is 
required, and the diagrams are carefully executed. The book will be found a great help to 
students in their practical work. 



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J. B. Lippincott Company s Medical and Surgical Works, 

THE DISEASES OF THE MOUTH IN CHILDREN. 
(Non-Surgical.) By F. FOJICHHEIMER, M.D., Professor of 
Physiology and Clinical Diseases of Children, Medical College of 
Ohio, etc. 

I2mo. Cloth, I1.25. 

*< llus little book of two hundred pages is the most valuable contribution to the advance- 
ment of our knowledge of diseases of the mouth which has as yet appeared in the English 
language. The object of the book is' essentially that of establishing a proper nomenclature 
for the varied and absurd names which, for so many years, have been applied at hap-hazard 
to the local lesions of the mouth. The author has given much time and original investiga- 
tion to the subject, and has given to medical literature a book which should be on the shelves 
of every general practitioner who wishes to keep abreast of the times." — Medic<U and Sur- 
^al Journal, Boston. 

<* The non-surgical diseases of the mouth, which are more or less confined to children, 
are so many and so important that Dr. Forchheimer's excellent book seems to supply a want. 
It deals with a considerable number of subjects of interest to the medical practitioner, and 
does so in a clear and practical way. We have read the book with much interest and profit, 
and can recommend it as a useful contribution to practical medicine." — Medical Journal^ 
Edinburgh. 

" The consideration of diseases of the mouth in children is of great importance to every 
practitioner : first, as a means of diagnosis ; and, second, to relieve the little sufferers and 
keep up the nutrition of their bodies. The author, in this very able work, has placed before 
the profession, in a thorough manner, a full account of all the diseases of the buccal cavity. 
The volume includes almost two hundred pages — well written — and with most practical ad- 
vice from a good clinician. One of the very instructive chapters b No. 9. which refers to 
the tongue and mouth in disease of remote parts." — Philadilphia Medical Bulletin* 

THE COMPLETE MEDICAL POCKET-FORMULARY 
AND PHYSICIAN'S VADE-MECUM. CoUated for the Use 
of Practitioners. By J. C. WILSON, A.M., M.D., Physician to 
the German Hospital, Philadelphia, etc. 

262 pages. Bound in leather, pocket-book fonn (size, zH ^ ^ inches), |2.oo. 

** This is a compact and exhaustive compilation of the favorite prescriptions of physicians 
eminent in their profession, and must prove of inestimable value to practitioners who find 
little time for the thorough reading of large text-books. The author is clearly to be congrat- 
ulated on his presentation of the subject-matter and on his judicious selection of formulas. 
It contains a foirly full list of the solubilities and therapeutic applications of new drugs, be- 
sides a brief account of external anti-pyretics and urinary tests. The book is one which can 
be recommended with confidence to all desirous of rendering themselves familiar with the 
application and posology of special and general medicaments.'' — Pharmaceutical Record. 

HYSTERICAL OR FUNCTIONAL PARALYSIS. By H. 
CHARLTON BASTIAN, M.A., M.D., author of "On Paralysis 
from Brain Disease in its Common Forms/* etc. 

Crown 8vo. Ooth, I2.25. 

The nucleus of this little book was published last year in the London Lancet. The 
records of several new cases have now been incorporated, and the discussion of the subject 
has, in reference to some poinU, been still further developed. There has also been added 
three appendices dealing with the scientific foundations upon the basis of which, together 
with careful clinical observations, the views here expressed have been gradually built up. It 
is a book in which every progressive physician should be interested, and is of special value 
to neurologists and gynaecologists. 

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MOTHER AND CHILD. Mother, by 
EDWARD K DAVIS, AM., M.D. Child, 
by JOHN M. KEATING, M.D., LL.D. A 

compendium of modern scientific knowledge 
on the relationship between the mother and 
her Tamily. Everything that will add to the 
comfort and health of both mother and child 

in this excellent work. 

illustrated with numer- 

Crown Svo. Cloth, I2.50. 
•A thoroughly responsible 
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" An excellent manual^ 
both instructive and reada- 
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ical Brief , . 

*'A valuable 
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" The book is the most complete work of the kind that has ever come under our notice, 
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** It is a gem of the first water. As we go further into the volume, we find that it is 
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of every nurse." — New England Medical Monthly, 

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Pocket-book form. Thirty patients, 1 1. 25; sixty patients, ^1.50. 
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DIAGNOSIS AND TREATMENT OF 

Diseases of the Ear. Noseband Throat. 

BY EMINENT 

American, British, Canadian, and Spanish Authors. 



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CHARLES H. BURNETT, A.M., M.D. 

Complete in two imperial 8yo yolumes of about 800 pages each. Price per volume : GoUi« 
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The increased and 
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thorough, practical, and 
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between the ear and 
the nose and throat 

renders it highly advantageous, both to the specialist and the general practitioner, not only to 
have all that is settled as best in the learning on these kindred subjects, but also to have it 
contained within the limits of the same work, rather than scattered throughout single treatises 
devoted to the diseases of each organ separately. 

To fulBl these conditions, therefore, the editor has embodied, in one system, all the 
learning of the medical world in these special departments, — thus making it a complete, 
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The writers of the different chapters have been chosen, by the editor, from among 
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SYSTEM OF 

DISEASES OF THE EYE. 

By American, 
British, German, French, and Spanish Authors. 



EDITED BY 

WILLIAM F. HORRIS, i.M., M.D., and CHARLES A. OLIVER, A.M., M.D. 



A systematic treatise on Ophthalmology which embodies 
the most advanced theoretical and practical views. 



Complete in two handsome imperial octavo volumes of about 1200 pages each. 
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have all operated not only to place this department of 
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CYCLOPAEDIA OF THE 

DISEASES OF CHILDREN, 

MEDICAL AND SURGICAL. 
BY AMERICAN, BRITISH, AND CANADIAN AUTHORS. 



Edited by JOHN M. KEATING, M.D. 



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CX>NTENXS : 
VOL. I. — Part I. General Subjects. Part II. Fevers and Miasmatic Dbeases. 
VOL. II. — Part I. Diseases of the Skin. Part II. Constitutional Diseases and Diseases of 
Nutrition. Part III. Diseases of the Respiratory Tract. Part IV. Diseases 
of the Circulatory, Hsematopoietic, and Glandular Systems. Part V. Diseases 
of the Mouth, Tongue, and Jaws. 
VOL. III.— Part I. Diseases of the Digestive System. Part II. Diseases of the Genito- 
urinary Organs. Diseases of the Blood. Part III. Surgery. Part IV. Dis- 
eases of the Osseous System and of the Joints. 
VOL. IV.— Part I. The Ear. Part II. The Eye. Part III. Hygiene. Part IV. Diseases 
of the Nervous System. 



" The most perfect work yet published on the diseases of children." — The Medical Press ^ 
London. 

•• A work worthy of the distinguished authors who have prepared it, and of the thought- 
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International Clinics. 

A OyARTERLY COLLECTION OF CLINICAL 
LECTURES ON 

MEDICINE, NEUROLOGY, PEDIATRICS, SURGERY, GENITO- 
URINARY SURGERY AND VENEREAL DISEASES, GYNAE- 
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BY PROFESSORS AND LECTURERS IN THE LEADING MEDICAL COLLEGES OF 
THE UNITED STATES, GREAT BRITAIN, AND CANADA. 



EDITED BY 

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Colorado Springs, Colo., Philadelphia, Pa., 

AND 

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London, England. Aberdeen, Scotland. 



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which have been found to yield the best results in the treatment of a given disease. 

No expense or pains has been spared in the way of illustrations wherever they will add 
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EUich volume contains about 350 pages, octavo, is printed from large, clear type on good 
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Regional Anatomy 

IN ITS RELATION TO 

MEDICINE Zand: surgery. 

By GEORGE McCLELLAN, M.D., 

Lecttuer on Deierlptlve and Regional Anatomy at the Pennfylvania Sohool of Anatomy: 

Profevor of Anatomy at the PennsyWania Academy of the Fine Aria; Member of the 

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ILLUSTRATED. 

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From the British Medical Journal, February 6, 1892. 

** The illustrations are perfectly correct anatomical studies, and do 
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of the anatomy of the chest, are of great excellence. The book is 
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*'^^'*" J. B. UPPINCOTT COMPANY, Publishers, 

715 and 717 Market Street, Philadelphia. 



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IntematUmcU dinios.-^Announoements. 



Three New Medical Books. 

Is a hand-book for Medical and Dental Practi- 

Ana^thetlCS tioners and Students. The aim of Dr. Hewitt 

and Their AdminiS" has* been to present to the practitioner a clear 

t ration. ^°^ y^^ detailed description of the best meth- 

By Frederick Hewitt, M.A., ^^ of inducing and maintaining surgical an- 

M.D.» sesthesia in ordinary cases ; to indicate what 

modifications in procedure should be resorted 
to on exceptional occasions ; and to systematically consider the chief diffi- 
culties and dangers connected with general anaesthetics, and the proper 
manner in whic];L they should be met. He has endeavored, in fact, to make 
the book one to whidi reference may be made when any doubt exists as to 
the anaesthetic which should be given in any particular case. The volume 
contains numerous illustrations. Crown 8vo. Cloth, $3.35. 

Until quite recently but little attention has 

The Hygienic Pre- been given to the question of the prevention of 

vention of Con- consumption, and, with the hope of increasing 

sumption. ^^^ interest in this branch of sanitary science. 

By J. Edward Squire, M.D., ^^^ author offers this volume to the profession 

(Lond.). * and to all who are interested in preventive 

hygiene. ** That consumption depends largely 

upon conditions which are preventable is becoming recognized by the medical 

profession," says Dr. Squire ; ** and I believe that the bringing together of 

hygienic rules applicable to those with a tubercular tendency, or with early 

consumption, may be acceptable to my professional brethren, as well as to 

others." Crown Svo. Cloth, frontispiece illustration, $3.00. 

-^ J ^ - .- 1^ **The author of this valuable work is a 

Pain : in its INeurO- physician who has already commanded re- 

PatholoS^ical, DiaS^- spect and gained repute because of earlier 

nostic, Medico- LeS^al 9 publications which embody the results of his 

and Neuro-Thera- ^^^^ experiences and that of the ablest physi- 

flw^ifl^l/^ DAlfl^lnriA ^^^ ®f ^^ ^^y- ^^s \iO(S\L, therefore, is sure 

?^T .I^^S 7l!?i-f 'a m to be received with interest by medical men, 

gK X Leonard Coming, A.M., ^^ ^^^ ^^^ something of popular interests 

as well because some of the chapters contain 
suggestions which the author has received while conducting experiments 
in tiie use of compressed air as a remedial agent. A few years ago this 
physician published the results of certain experiments which he had made 
with compressed air, causing thereby very much discussion in medical circles, 
both in the United States and in Europe. The journals devoted to the inter- 
ests of the medical profession devoted much space to this matter, some of 
them speaking with much enthusiasm, regarding it as quite possible that 
a remedial agent of immense value had been cj^covered.*' — New York letter 
in Philadelphia Press, May ist Svo. Clotli, $1.75. 



J. B. LIPPINCOTT COMPANY, Publishers, 

715 and 717 Market Street, Philadelphia. 



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International Clinics. — Announcements. 



oto<tt m iio>iioo m oot m iooi n >>tioi>o n oo n o n t<oto»oooto M >>ooot n i » 



HYDROLEINE 

{HYDRATED OIL) 

Is m purely scientific preparation of Cod Liver Oil for the treatment of Incipient 
Consumption, Scrofula, Rickets, Bronchitis, Whooping>Couch, 
and all wasting diseases. 
Pormnia— Each Dose Contains: Pur t Norwegian. Cod Liner Oil, 80 m. {drops). Distilled 
Water, ss*^' {drops). Soluble Pancreatine^ grains. Soda, .}^ grain. Salicylic Acid, % grain. 
DOSE. — Two teaspoonfuls alone or aaixed with twice quantity of water, to be 
taken after each meal. 

HYDROLEINE ^^ ^ pancreatized Cod Liver Oil preparation of pure 
^^m^^^^^^^^mm^^ Norwegian Cod Liver Oil (from Lofoten), that is pre- 
pared as the direct result of a long series of physiological experimen(Sf conducted 
by H. C. Bartlett, Ph.D., F.C.S., and G. Overend Drewry, M.D., M.R.C.S., and 
encouraged with many practical suggestions by Bence Jones and Baron Liebig. 
HYDROLEINE ** ^^'^^ ^^ sound scientific principles; it is easily di- 
^MH^B^MMMHM^^^^HB gested and assimilated, without producing eructations. 
Appetite is increased, and that, so far from possessing the unpleasant taste of 
Cod Liver Oil and its emulsions, HYDROLEINE is palatable as milk, and 
pleasant. The formula is well known, and the preparation has received the en- 
dorsement of physicians throughout the United States. It is sought to introduce 
HYDROLEINE exclusively on its merits, and for that reason the profession is 
appealed to only through the columns of medical journals. 

50LD BY DRUaaiSTS QBNERALLY. 

: The Charles N. Crittenton Co., *^{?„tiS"ltiu5?* New York. ; 
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JOHN P. LOVELL ARMS CO., Afanufacturers, 

Send for Catalogue. Free to all. BOSTON, MASS. 



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NOV 29 1907 



UNIVERSITY OF MICHIQAN 

imiiipi 

3 0015070370048 





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