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B 3 9015 00208 407

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by Google

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•

» • • 1* -' • • -sl C^' 4" Ji^'

I 2 3 4 5 6 7 8 9 10 11 12

13 14 15 16 17 18 19

PLATE I.
Cells observed in cerebrospinal fluid stained with Unna's polychrome methylene blue

n ■

i ,

^ 1
|:'i

A B

PLATE III.

A. Tubercle Bacilli

B. Diplococcus intracellularis meningitidis

12 3 4

PLATE II.

1. Nonne 3. Noguchi (butyric)

2. Ross- J ones 4. Fehlings

5432 2000 Control

i]ii

* • ■_ •.

PLATE IV.
A typical Paresis curve. Colloidal gold chlorid reaction

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International Clinics

A QUARTERLY

ILLUSTRATED CLINICAL LECTURES AND
ESPECIALLY PREPARED ORIGINAL ARTICLES

TREATMENT, MEDICINE, SURGERY, NEUROLOGY, PAEDIAT-
RICS, OBSTETRICS, GYNiECOLOGY, ORTHOPiEDlCS,
PATHOLOGY, DERMATOLOGY, OPHTHALMOLOGY,
OTOLOGY, RHINOLOGY, LARYNGOLOGY,
HYGIENE, AND OTHER TOPICS OF INTEREST
TO STUDENTS AND PRACTITIONERS

BY LEADING MEMBERS OF THE MEDICAL PROFESSION
THROUGHOUT THE WORLD

EDITED BY

HENRY W. CATTELL, A.M., M.D., PHILADELPHIA, U.S.A.

WITH THI COLLABORATIOII OP

CHAS.H.MAYO,M.D.

tOCHISTIS

SIR WM. OSLER, BART., M.D., F.R.S. A. MCPHEDRAN. M.D.

OBPORD TORONTO

PRANK BILLINGS. M.D. JOHN A. WITHERSPOON. M.D.

CHICAGO HASHVILLI

JOHN G. CLARK, M.D. JAMES J. WALSH, M.D.

PHILADILPHIA RIW YORK

J. W. BALLANTYNE, M.D. JOHN HAROLD, M.D.

RNRRUROH LONDOR

RICHARD KRETZ, M.D.

VIRRRA

WITH CORRBSPONDBNTS IN MONTRBAL. LONDON, PARIS, BERLIN.
VIENNA. LBIPSIC, BRUSSELS, AND GENEVA

Volume II. Twenty-fifth Series, 1915

PHILADELPHIA AND LONDON

J. B. LIPPINCOTT COMPANY

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GOFTKIOHT, 1916
BY

J. B. LiPPiNOOTT Company

miNTEO IV J. B. LIPPIMOOTT OOMPANY, PHIlAOtLPHIA U3.A.

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CONTRIBUTORS TO YOLUME II

(TWENTY-FIFTH SERIES)

Ballbncdeb, WnxiAK JjDxoofLR, MJ>., Chicago^ Illinois.

BiscH, Louis E., AJB., M.D., Ph.D., Associate in Educational Psychology, Columbia
Uniyersity; Formerly Visiting Neurologist^ New York. City Children's Hos-
pitals and Schools; Alienist^ Clearing House for Mental Defectives; Clinical
Assistant, New York Neurological Institute.

Bbill, a. a., Fh.B., MJ>., Lecturer in Psychoanalysis and Abnormal Pfifyehology,
New York Uniyersify.

BXTBDIOK, AUTBBD 8., M.D., Editor^ The Amerioan Jowmal of OUnical Mediome,
Chicago, Illinois.

Bush, Arehub Debmont, B.S., MJ)., Boston, Massachusetts.

Chahbebs, Gbahaic, B«A.., MB., Associate Professor of Clinical Medicine, Uni-
yersify of Toronto.

Chxnbt, HsiVBT W., MJ)., Associate Professor in Pediatrics, Northwestern Uni-
yerdty Medical School; Attending Pediatrician, St Luke's HospitaL

CuicsTOH, Chablbs Gbebnb, M.D., Priyat-docent at the Faculty of Medicine of
the Uniyersify of Geneya; Honorary Member of the Surgical Society of
Belgium; Fellow of the Boyal Society of Medicine (Ixmd.), etc; Qeneya,
Switserland.

I>BA.yEB, John B., MJ>., Philadelphia.

DoBBANGE, Gbobcdb M., MJ>., Philadelphia.

EcKSiJBSiON, Cabt, MJ>., Instructor in Pharmacology, Cornell Uniyersity Medical
School; Assistant Attending Physician, City Hospital, New York.

Gbulbb, C. G., M.D., Assistant Professor of Pediatrics, Rush Medical College,
etc, Chicago.

HATBy Habou), am., MJ)., F^CJB., Assistant Surgeon in Otology, New York
l^e and Ear Infirmary; Assistant Laiyngologist and Otologist, City Hospital;
Chief of Clinic (Nose and Throat), New York Polyclinic Hospital, etc

Hess, Julius H., M.D., Associate Professor and Head of Department of Pediatrics,
Uniyersity of Illinois; Attending PsBdiatrician to Cook County, Michael
Heese, and Englewood Hospitals, Chicago.

MiLLEB, UoaaiB Booth, MJ)., Professor of Surgery, Philadelphia Polyclinic;
Suxgeon to Douglas Hospital, Philadelphia.

280605 Digitized by GoOgk

iv OONTEEBUTOBS TO VOLUME U

MusFHT, John P. H., M.D., Assifltant PhyBidan at the Goyemment Hoepital for
the Insane, Washington, D. 0.

PuoE, Btbon SIfbaoub, M.D., New York City.

Rtebson, E. W., MJ>., Professor of OrthopcBdie Surgery, Chicago Policlinic;
Assistant Professor of Sargery, Rnsh Medical CoU^^; Orthopedic Surgeon
to Children's Memorial Hospital, etc, Chicago.

Skilexbn, p. G., Jb., MJ)., Philadelphia.

Smukleb, M. E., M.D., Philadelphia.

SiKWABT, Saicubl C, M.D., and Leveb F., M.D. (Formerly Resident Pathologist^
Pennsylvania Hospital), Surgeons to the Clearfield Hospital, Clearfield, Penn-
sylvania.

SuTTEB, Chabubb Cltdk, MJ)., from the Pathological Laboratory of the Rochester
Greneral Hospital, Rochester, New York.

Tatlob, J. Madison, A3., MJ)., Associate Professor of Non-pharmaceutic Thera-
peotios in the Medical Department of Temple University, Philadelphia, Pa^

Walsh, Jamxs J., MJ)., Ph J)., 6c.D., Sometime Dean and Professor of the History
of Medioine and of Nervous Diseases at Fordham University School of
Medicine; Professor Physiological Pqrohology at Cathedral College, New York.

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CONTENTS OF YOLUME II

(TWENTY-FIFTH SERIES)

DIAGNOSIS AND TREATMENT

PAGE

THE GEEEBROSPINAL FLUID IN DIAGNOSIS. Bj Chabixs Gltdb

Sdttkb, M,D, 1

THE DIAGNOSIS AND TREATMENT OF ARTERIOSCLEROSIS. By Btboit

SPKikGUS Pbiob, M.D ,17

SOME NEW PHASES OF EMETINE THERAPY. By Alfbed 8. Bub-

DICK, MJ) 39

ANIMAL EXTRACTS IN THE TREATMENT OF MEDICAL DISEASES.

By Gbaham Chambebs, B«A., M.B .• 60

CHRONIC HABITUAL CONSTIPATION: A PRACTICAL CONSIDERATION

OF ITS CAUSES, RESULTS, AND ITS RATIONAL TREATMENT BY

MECHANICAL MEASURES. By M. E. Smxtkleb, MJ> 64

THE PRESENT STATUS OF DIGITALIS THERAPY. By Cabt EoaissTOir,

MJ). 87

PiEDIATRICS

MILIARY TUBERCULOSIS IN NEW-BORN; CONGENITAL DIAPHRAG-
MATIC HERNIA; DEMONSTRATION OF X-RAYS AND PHOTO-
GRAPHS; HIRSCHSPRUNG'S DISEASE. By C. G. Gbulds, MJ) 98

DIAGNOSIS OF TUBERCULOUS JOINT DISEASE IN CHILDREN:
BRAIN INJURIES AT BIRTH. By E. W. Rtebson, M J). 103

ENLARGED SPLEEN; SPLENIC ENLARGEMENT; ANTERIOR POLIO-
MYELITIS. By Hezott W. Chenet, MJ) i 108

GYROSPASM (SPASMUS NUTANS) ; TUBERCULAR MENINGITIS VERr
SUS TRAUMATIC CEREBRAL INJURY; PROBABLE SARCOMA OF
THE RIGHT LUNG. By Juuns H. Hess, MJ) 114

A CASE OF CANCER OF THE PANCREAS IN A NINE-YEAR-OLD BOY,
WITH NOTES ON OTHER REPORTED CASES OF CANCER IN CHIL-
DREN. By Samuel C. Stewabt, MJ)., and Leveb F. Stewabt, M J) 118

A CASE OF EPIPHYSITIS. By Abthub Debmont Bxtsh, B.S., M.D 127

MEDICINE
PSYCHOANALYSIS: IT9 SCOPE AND LIMITATION. By A. A. Bbhx^

Ph.B., MJ) 132

EFFORTS AT ADJUSTMENT. By Louis E. Bisoh, A.B., MJ)., Ph.D 146

DISUSE CRIPPLINGS. By Jakes J. Waish, MJ)., Ph.D., ScD 156

TYPHOID AND THE PSYCHOSES. By John P. H. Mubpht, M.D 172

HUMAN CONSERVATION, A NEGLECTED FIELD FOR MEDICAL

SPECIALIZATION. By J. Madison Tatlob, A3., MJ) 181

A CONSIDERATION OF SOME PAINFUL CONDITIONS OF THE FOOT.

By MoBBis Booth MiLuai, MJ) 187

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VI CONTENTS OF VOLUME 11

SURGERY

PAGE

THE 0RTH0PJ3DIC CLINIC OF FRED H. ALBEE AT THE NEW YORK
POST-GRADUATE MEDICAL SCHOOL. By P. G. Skillebn, Jb., M.D.. 200

GIGANTIC DUODENUM DUE TO KINKING AT DUODENAL JEJUNAL
JUNCTION, ASSOCIATED WITH DILATATION OF THE FIRST
PORTION OF THE JEJUNUM, GASTROENTEROSTOMY, AND
FISTULA FROM THE JEJUNUM INTO THE TRANSVERSE COLON.
By Gbobgb M. Dobranoe, M.D., and John B. Deaveb, M.D 235

SOME REMARKS ON GASTROINTESTINAL SURGERY AND PATHOL-
OGY. By Chablbs Gbexne Cuicston, MJ> 238

INTRANASAL FRONTAL SINUS OPERATIONS: CONSERVATIVE SUR-
GERY. By WnxiAic Linooln Baixengeb, M.D 260

THE APPLICATION OF SURGICAL PRINCIPLES TO OPERATIONS ON
THE NOSE AND THROAT. By Habold Hatb, A.M., M.D., F.A.C.S 268

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LIST OF ILLUSTRATIONS TO YOLUME II

(TWENTY-FIFTH SERIES)

COLORED PLATES

PA0B

Plate 1. Cells observed in cerebrospinal fluid stained with Unna's polychrome

methylene blue.
Plate 2. 1. N<mne. 2. Ross- Jones. 3. Noguchi (butyric). 4. Fehling's.
Plate 3. A. Tubercle bacilli, B. Diploooccus intracellularis meningitidis.
Plate 4. A typical paresis curve. Colloidal gold chloride reaction.

Fr<mti9pieo6

PLATES, FIGURES, DIAGRAMS, AND CHARTS

Reactions with pathologic fluids. Typical paresis curve. Lues reaction.

Tabc^aresis. Non-syphilitic meningitis (Diagram) 13

R5ntgenogram showing a greatly dilated rectum as a result of chronic habitual .

constipation (Pig. 1) 66

R5ntgenogram showing the entire colon greatly dilated with prolapse of the
transverse colon in a case of chronic habitual constipation of long stand-
ing (Pig. 2) 67

Phot<^aphs (A) showing f&nlty position of stenographer due to habit; (B)

proper position with individual sitting upright (Fig. 3) 68

Hirschman's pneumatic rubber dilating rectal massage bag, partly inflated,

equipped with a hand bulb (Fig. 4) 76

Modiflcation of the Hirschman apparatus by the author (Fig. 6) 76

Position of patient and operator for giving a treatment with the pneumatic

rubber dilating rectal massage bag (Fig. 6) 77

Schematic drawing of author's tube for giving pneumatic massage and dilata-
tion with an electric tankless air-pump (Fig. 7 ) 77

niotograph of author's apparatus for giving pneumatic massage and dilata-
tion, attached to an electric tankless air-pump (Fig. 7 B) 77

Author's hydrostatic sphincter dilating bag (partly inflated) (Fig. 8 A) 78

Schematic drawing of the bag (Fig. 8 B) 79

Position of patient and operator for the author's method of dilating the

external sphincter (Fig. 9) 78

Method of exercise suggested (Fig. 10) 80

Method of exercise suggested (Fig. 11) 81

Illustration showing proper course of abdominal massage (Fig. 12) 82

Showing body with anterior wall of thorax before removaL Note position of

stomach, spleen, and liver (Fig. 1 ) 100

Showing tube passed through diaphragmatic defect. Note small intestines in

left side of thorax (Fig. 2) 100

Cancer of the pancreas. (Microscopic slide, low power.) (Fig. 1 ) 120

Cancer of the pancreas. (Microscopic slide, high power.) (Fig. 2) 120

Present physical condition of patient treated for epiphysitis. (Front and
posterior views.) (Figs. 1 and 2) 130

vii

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Viii LIST OF nXUBTRATIONS TO VOLUME U

Extreme limit of possible abductioii; (Fig. 3) 131

Extreme limits of possible flexion, and 0car of original operation (Fig. 4) . . . . 131

Fred H. Albee 200

Osteoplasty of spine. Curved incision through skin and subcutaneous tissue

(Fig. 1) 202

Osteoplasty of spine. Flap reflected, exposing tips of spines and supraspinous
ligaments. With the special, broad chisel, greenstick fractures of the

spinous processes are produced on one and the same side (Fig. 2) 203

Osteoplasty of spine. Osseo-ai>oneurotic gutter ready for insertion of tibial

transplant (Fig. 3) 204

Osteoplasty of spine. Removal of angular tibial graft with single motor-saw.

The calipers and the bent probe are shown (Fig. 4) 206

Osteoplasty of spine. The graft in its bed. The vertebral aponeurosis is being
sutured over it. Lateral cuts to relieve tension are shown just below the
retractors. B shows bone-chips placed about end of graft (Fig. 5) ..... . 206

Osteoplasty of spine. Skiagram of vertebral column involved in Pott's disease

at flrst lumbar vertebra. Tibial graft in position. Lateral view (Fig. 6) 207
Osteoplasty of spine. Same as preceding figure. Anteroposterior view (Fig. 7) 208
Tibia showing inlay bone-graft operation as performed for old, imunited

fracture, according to description in text (Fig. 7 A) 212

Tibia showing inlay bone-graft operation as performed for comminuted frac-
tures (Fig. 7 B) 212

l^hese spedmens were prepared by the writer from anatomic material

(Fig. 7 0) 212

Disjunction of upper epiphysis of humerus with characteristic displacement.

Anteroposterior view (Fig. 8) 213

Deformity in fracture of shaft of ulna with anterior luxation of head of radius

(Fig. 9) 216

Incision exposing head of radius, showing resection of latter (Fig. 10) 216

Incision exposing site of fracture, showing separation of fragments (Fig. 11) . 216

Forearm dressed in gypsum sling in Albee's position (Fig. 12) 217

Arthroplasty of hip- joint. Separation of upper rim of acetabulum with chiseL

B shows insertion of wedge-graft (Fig. 13) 222

Congenital luxation of both hips. Before reduction (Fig. 14) 223

Knock-knees. External osteotomy of two-thirds thickness of femur l^

McGuire's method (Fig. 15) 226

Knock-knees. Postoperative plaster dressing to maintain limbs in overcor-
rected position. Note incorporation of splint-board to prevent their

rotation (Fig. 16) 227

Congenital dub-foot. Wedge removed from cuboid (Fig. 17 ) 231

Ccmgenital dub-foot. Wedge removed from cuboid inserted into split scaphoid

(Fig. 18) 231

Congenital dub-foot. Scaphoid split into anterior and posterior halves with

an osteotome (Fig. 19) 232

Congenital dub-foot. Graft-wedge, obtained from cuboid or tibia, inserted
between halves of split scaphoid. Correction of deformity shown in out-
line (Fig. 20) 233

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UBT OF ILLU8TBATIONB TO VOLUME H IX

Valgus from infantile palsy of eztensors of foot. Tendon of peroneus tertius
retracted externally, and that of tibialis antigens internally, exposing
anterior snrfaoe of lower end of tibia. Note cavity left after arthrodesis
of astragaloecaphoid joint (Fig. 21 ) 234

Valgus from infantile pal^ of extensors of foot. Rectangular door lifted from
tibia and rotated inward on internal hinge. The external tibial edge and
the adjacent edge of the door had been previously drilled for the retaining
kangaroo-tendon suture (Fig. 22) 234

Valgus from infantile palsy of extensors of foot. Catgut sutures, inserted into
the tendons opposite the upper and lower tibial edges, serve, when tied, to
take in reefs (Fig. 23) 234

Valgus from infantile palsy of extensors of foot. Reefed tendons buried in
medullary cavity; door dosed and held shut by a strand of kangaroo-
tendon passed through drill-holes; cut edges of anterior annular ligament
stitched together. Note approximation of astragalus and scaphoid at the
site of arthrodesis (Fig. 24) 234

Dr. Albee's electric operating bone set (Fig. 26) 234

Twin-saw ready for use. Shows proper method of holding the motor. Spray
attachment and guard connected (Fig. 26) 234

Fracture of tibia and fibula. A Lane plate had been inserted into the tibia
elsewhere (Fig. 27) 236

External fistula in transverse colon (Fig. 1 ) 236

A, transverse meso; B, dilated duodenum (Fig. 2) 236

A, fistula from duodenum into large intestine; B, gastro-enterostomy opening

(Fig. 3) 236

Oigantio duodenum due to kinking at duodenal- jejunal jimction (Fig. 4) . . . 237

Operation for rectal prolapse (Fig. 1) 240

I>iagrammatic A, A, right and left antri; O, inferior turbinate; 7, 7,
infnndibuli; B, h, left and right bulla ethmoidales; E, ethmoid plate;
0, 0, exenterated ethmoid cells; e, e, e, ethmoid cells; P, cribriform
pUte (Jig. 1) 262

Diagrammatic O, total exenteration of ethmoid cells and ethmoid plate,
leaving large drainage space; E, swollen ethmoid plate left in situ after
exenterating the ethmoid cells; 7, small drainage area due to swollen
ethmoid plate; P, olfactory perforations in the cribriform plate (Fig. 2) . 262

Diagrammatio. P, P, cribriform plate; F, frontal plate partially covering the
ethmoid cells. Upper arrow shows drainage route from the posterior
ethmoid cells into the superior meatus. Lower three-tailed arrow shows
drainage routes from the antrum and anterior ethmoid cells (Fig. 3) . . . . 263

Showing cutting bone forceps removing the crista nasaUs in front of the
osteum frontalis, the anterior cells having been removed by curettage
according to Moiher's technic (Fig. 4) 263

Diagrammatic. 1, first or uncinate plate; 2, second or bulla ethmoidalis plate;
3, middle turbinate plate; 4, superior turbinate plate; 6, supreme tur-
binate plate (rare) ; F, processus frontalis; 0, X, line of catheterization
of frontal sinus before intranasal operation; Z, X, line of catheterizationa
of frontal sinus after intranasal operation (Fig. 6) 264

Rhinophyma (Fig. 1) 272

Carter's operation — ^transplanting rib for saddle-back deformity (Fig. 2) 272

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X LIST OF ILLUSTEATIONB TO VOLTJMB U

Saddle-back nose (author's case) (Fig. 3) 272'

Same case ten days after operation. Result excellent (Fig. 4) 272

Saddle-back nose, extreme type, due to syphilis. In this case the transplant

was a failure (Fig. 6) 273

The nose was misplaced to the left, due to old fracture. Ck)rrected by opera-
tion. (Author's case) (Fig. 6) 273

Cohen's case before correction (Fig. 7 ) 273

Cohen's case after correction (Fig. 8) 273

Cohen's instruments for plastic work (Fig. 0) 276

Diagram showing part to be removed in hump-nose (Fig. 10) 277

The Asch operation, no longer used for correcting septal deformities (Fig. 11) 278

Yankauer lacrimal duct operation (First step) (Fig. 12) 280

Yankauer lacrimal duct operation (Second step) (Fig. 13) 283

Yankauer lacrimal duct operation (Third step) (Fig. 14) 284

Submucous resection (Fig. 15) 285

Hazeltine's flap operation for perforation of the septum (Fig. 16) 286

Hazeltine's operation (Fig. 17) 287

Method of removing polypi from the nose at the time of Hippocrates (Fig. 18) . 288

The modem method of removing nasal polypi (Fig. 10) 289

Ballenger ethmoidal instruments (Fig. 20) 289

Beck operation on frontal sinuses (Fig. 21 ) 292

Removal of tonsil. Separator severing the tonsil from the anterior pillar

(Fig. 22) 294

Removal of tonsil. Snare placed around tonsil (Fig. 23) 294

Beck operation for removing adenoids by direct inspection (Fig. 24) 295

Ancient instrument for amputating uvula (Fig. 25) 296

Author's circumcision of the uvula (Fig. 26) 297

Author's uvulatome (Fig. 27) 298

Elillian suspension laryngoscope (Fig. 28) 299

KilHan suspension laryngoscope (Fig. 29) 300

Killian suspension laryngoscope (Fig. 30) 300

Spatula for Eillian apparatus (Fig. 31 ) 301

Lynch's instrument for operations upon the larynx under suspension. The

instruments are made of gun-metal to eliminate reflection (Fig. 32) ... . 302

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Bladttosts anb XTreatment

THE CEREBROSPINAL FLUID IN DIAGNOSIS

BY CHARLES CLYDE SUTTER, M.D.

From the Pathological Laboratoxy of the Rochester General Hospital,
Bochester, New York

The trend of modem medicine is to utilize every available means
for clearing up the obscure conditions which baffle the diagnostic
skill of the physician. Our attention is now being directed to the
examination of the cerebrospinal fluid. The value of this examina-
tion as a differential diagnostic agent in many obscure neurologic
and psychologic disturbances is steadily growing in importance.

No direct analysis can be made in nervous and mental diseases,
so our efforts must be expended in searching the secretions of the
body for evidences of the products which attend pathologic alterations
of the nervous tissue, particularly the brain. Our first efforts re-
sulted in failure, because the search was made of the blood, urine,
and fsBces, which represent the sum total of all of the metabolic
products of the body. Nervous tissue comprises only about two per
cent of the total body, hence one can readily understand why such
a small amount of products escapes detection. Examination of the
cerebrospinal fluid has been more promising, and at the present time
this examination is considered necessary as an aid in diagnosis in all
obscure nervous conditions. The cerebrospinal fluid comes into more
intimate relation with nervous tissue than the other secretions, so
should contain the products of metabolism of nervous tissue in more
concentrated and in least altered form.

The presence of the cerebrospinal fluid was first discovered in
1764 by Coligno, who thought it present only after death. Later it
was found by Haller in the spinal cord, but he failed to note the
relation between the fluid in the cord and the fluid in the ventricles.
This relation was described in 1840 by Majendie in his description
of the foramen which bears his name. It is now recognized that the
Vol. n. Ser. 26—1 1

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2 INTBBNATIONAI* OMiaOS

cerebrospinal fluid fills all the space of the cranial cavity not occupied
by the vessels and nervous tissue. Many authors now agree that the
principal source of the cerebrospinal fluid ic( to be found in the
choroid plexus of the lateral ventricles^ and that it is a true secretion.
By equalizing pressure it is supposed to adjust the mechanism of
the circulation of the nerve-cells. Its pressure is thought to equal
or exceed intravenous pressure. Increase in pressure is frequently
found in meningitis in all its forms, hydrocephalus, cerebrospinal
syphilis, organic nerve conditions, brain tumor, and in traumatism
of the brain. It may also be increased, at times, in tabes dorsalis,
paresis, cerebral arteriosclerosis, chlorosis, and during epileptic
attacks. Some knowledge, in a relative way, may be had of the
pressure of the cerebrospinal fluid from the rapidity of the flow
through the puncture needle, forty to fifty drops per minute being
considered the average. A partially-blocked needle will give an erro-
neous estimate of the pressure, so where it is of much importance to
know the pressure the needle should be connected to a vertical glass
tube graduated in millimetres. The pressure of the cerebrospinal
fluid in normal adults is quite variable, but should be about 120
mm. In the case of disease the fluid may give a pressure of from
200 to 800 mm. The knowledge of the pressure of the fluid is of
value in determining the danger mark in its withdrawal. The
minimal amount of fluid necessary for the examination should be taken
— 5 to 10 Cc. are usually sufficient for all the reactions if small tubes
are used in making the tests. When large amoimts are withdrawn
rapidly unpleasant after-effects may follow, such as headache, nausea,
vomiting, and pains in the back and neck.

Normally the color of the cerebrospinal fluid is that of clear
.water. In pathologic conditions it may become turbid or cloudy,
due to cellular admixtura Turbidity of the fluid, when not due to
the presence of blood, means an acute purulent meningitis. In
tubercular meningitis the fluid is usually clear, rarely slightly opales-
cent. After standing a short time a delicate, fibrinous clot separates,
in which the tubercle bacilli are especially abundant. In acute
meningitis, due to the meningococcus, the fluid is not infrequently
clear in the early stages. It is more often somewhat opalescent or
blood-tinged, rarely thick and purulent. This last condition is more
common in streptococcic or pneumococcic meningitis. In brain

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THE OBEBBEOSPINAI. FLUID IN DIAGNOSIS 3

tnmory hydrocephalus, cerebrospinal syphilis, tabes and paresis, and
organic nerve lesions the fluid is clear. Becent hemorrhage or that
caused by the puncture-needle may be recognized by the presence
of red blood-corpuscles and a clear fluid after filtering the cerebro-
spinal fluid. The yellow-amber tint (Bard-Sicard) in the filtrate
gives almost a certainty to the diagnosis of meningeal hemorrhage.
It occurs in other conditions also where haemoglobin or red corpuscles
cannot be demonstrated (Elieneberger, !N'onne). It has been
observed in compression of the cord, intramedullary tumors, and
intramedullary syphilis. An increase of globulin without lympho-
cytosis, and the yellow-amber tint, are of value in the differential
diagnosis between compressing spinal tumor and primary disease of
the spinal cord.

The reaction of the cerebrospinal fluid is decidedly alkaline.

Knowledge of the specific gravity of the cerebrospinal fluid
seems to me to be without value as an aid in diagnosis. Increase
in specific gravity in pathologic conditions, if present, is due to
the increase of protein and the number of cells. In a doubtful
nervous or mental disturbance the increase in specific gravity is so
small that one cannot be absolutely certain that an increase actually
exists.

CYTOLOGIO EXAMINATION

The cytology is probably the most important element in the study
of the cerebrospinal fluid. When studied differentially it gives some
insight into the severity of the meningeal reaction. The Wassermann
and other reactions are of value in determining the etiology of the
affection, but the intensity of the meningeal affection is more clearly
shown by the cytology. There are three methods of examining the
cerebrospinal fluid for its cellular elements : the French method, the
Fuchs-Bosenthal method, and the Alzheimer method.

1. The French method was introduced by Widal and Bivaut in
France and by Nissl in Germany. It consists in centrifuging 6 Cc.
of the fluid for twenty or thirty minutes, and then removing one drop
of the sediment, by means of a capillary tube, to a sUde. The slide
is then prepared and stained as any ordinary blood-smear. A negative
sUde will contain no cells or only an occasional cell, whereas the
positive slide will show large numbers of cells. This method gives

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4 INTBENATIONAI, CLINICS

only a rough estimate of the cellular elements and is by no means
accurate.

2. The Fuchs-Bosenthal method^ or counting-chamber method, is
much superior to the centrifuge method of the French. The chamber
of the Fuchs-Bosenthal instrument is 8 Gmm. in size instead of
1 Cmm., the size of the ordinary blood-counting instrument. The
method of counting is similar to the method used in counting the
leucocytes of the blood. The cells may be stained in the pipettes and a
differential count made in the counting chamber by using a stain
in the diluting fluid. Unna^s polychrome methylene blue or the
following may be used: 0.05 methyl-violet, 0.5 glacial acetic acid,
25 Cm. distilled water.

3. The Alzheimer method is a purely qualitative one, and when
used for this purpose alone gives very satisfactory results. By this
method the morphology can be' studied with more precision and with
greater accuracy. The following is Alzheimer's^ technic: "In a
centrifuge tube are put 10 or 15 Cc. of 96 per cent, alcohol, and then

5 Cc. of cerebrospinal fluid are added. The tube is closed with a
rubber stopper, and is centrifuged for from one-half to three-quarters
of an hour. Then there will be noticed at the bottom of the tube a dis-
tinct coagulum, which is marked in general paralysis, cerebrospinal
syphilis, and meningitis, but which in normal subjects has the thick-
ness of ordinary paper. The alcohol is poured off and the coagulum
is fixed with alcohol, ether and alcohol, and ether. The coagulum
becomes thick; it is taken out with a fine needle and embedded in
celloidin, and sections are made." Sections may be stained with
Unna's polychrome methylene blue, Unna's modification of Pappen-
heimer's st^in, or methyl alcohol.

From to 8 per Cmm. may be regarded ad normal, 8 to 15 as
borderland, while more than 15 cells per Cmm. constitute a patho-
logic increase. In acute meningitis the count may be from 200 to
2000 per Cmm. The cell count is useful for the establishment of
the diagnosis of pathologic conditions of the meninges. Probably
of as great importance is their aid in gauging the process of a given
remedial agent The borderland count is, with the questionable
globulin or weakly positive Wassermann test, of no particular signifi-
cance. Borderland counts should always be repeated within ten days.

The cells which one commonly finds in the cerebrospinal fluid

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THB OEBEBBOSPINAL FLUID IN DIAGNOSIS 5

are the lymphocyte and the neutrophilic leucocyte. The eosinophilic
leucocyte and the basophilic leucocyte are almost never found in the
cerebrospinal fluid, except when included in blood contamination.
Plate I shows the cells which one finds rather frequently in the cere-
brospinal fluid. They are stained with Unna^s polychrome methylene
blue. Each of these cells will be discussed separately and their char-
acteristics noted. The majority of cells found are the small lympho-
cytes. The cytoplasm of these is unstained and is visible as a small,
clear ring about the nucleus, which is usually a fairly dark violet
or blue. Occasionally the cytoplasm seems absent, and at times
shows a slight accumulation at one pole. The nucleus is usually
round, but may at times be slightly oval (Plate I, Nos. 1, 2, and 3).
These small lymphocytes are smaller, as a rule, than the ordinary
red corpuscles viewed with the same power lens. In pathologic
fluids one frequently finds small lymphocytes that stain rather poorly
(Plate I, No. 4). There is a very close resemblance between the
poorly stainable small lymphocyte and the red cell which is old; the
only point of difference is often that the entire body of the poorly
stainable lymphocytes is covered with fine, small dots, which are
not granules, but protoplasmic corrugations, whereas the old red
cells (Plate I, No. 5) have a slight pii^sh hue and no protoplasmic
corrugations. The large lymphocytes are larger and show more
cytoplasm than the small lymphocytes. The nucleus stains darker
and the cytoplasm stains a pale blue (Plate I, No. 6). The differ-
entiation between small and large lymphocytes has no special signifi-
cance. A meningitis may show small lymphocytes at first and later
small, large and the poorly stainable small cells. Increase in the
cellular elements in the cerebrospinal fluid has a particular signifi-
cance in diagnosis. Increase of lymphocytes may be observed when-
ever an irritation of the meninges is present, the amount depending
upon the d^ree of insult It is commonly observed in all cases of
meningitis and in luetic processes, such as cerebrospinal syphilis,
tabes dorsalis, and paresis. The more active the process the greater
the variety of cells and the greater the number present Lympho-
cytes may be found even in recent cases of syphilis which show no
involvement of the nervous system.

The polymorphonuclear leucocytes are rather commonly found
in the cerebrospinal fluid (Plate I, Nos. 7, 8, 9, and 10). They

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6 IKTBBNATIONAL CLINICS

are larger than the lymphocytes and are about twice the size of the
ordinary red cells encountered in the cerebrospinal fluid. The
cytoplasm stains a violet and contains granulations rather poorly
made out. The nucleus stains much darker than the cytoplasm.
These cells may be seen in all acute forms of meningitis, such as
tuberculous, purulent, epidemic cerebrospinal, and in abscesses that
invade the subarachnoid space. In acute forms of cerebrospinal
meningitis luetica the presence of these elements is an expression
of the acuity of the inflammatory process; they gradually diminish
in number as the process tends to become chronic, and in many
instances disappear entirely.

Epithelioid cells (Plate I, No. 11) are of infrequent occurrence
and are apparently an accidental occurrence in the cerebrospinal
fluid. They are somewhat larger than the polymorphonuclears,
irregularly shaped, but may appear round. The cytoplasm stains
evenly, the nucleus is small in relation to the cell and is clearly
defined.

Plasma cells of Alzheimer (Plate I, No. 12) are quite fre-
quently found in paresis, and are believed by Alzheimer to be
suggestive of paresis, although many cases do not have them. It is
not rare to find them in cerebrospinal lues. They are obtained by
the Alzheimer method. The cells are large, usually elliptical, but
may be round. The nucleus occupies an eccentric position and stains
rather intensely with clearly-defined edges and showing marked
chromatin staining. The cytoplasm is prominently and often
irregularly stained, and contains frequently fine granules or in-
clusions staining darkly. They often show a tendency to lighter
staining in the neighborhood of the nucleus. The cell is easily
recognized by the eccentric nucleus and the prominent cytoplasm,
which often appears to have a definite envelope. In some fluids it is
the most striking element present. Many other morphologic forms
of cells are to be found in the cerebrospinal fluid, large cells with
eccentrically placed nuclei, large cells with tails, cells with over-
lapping nuclei, etc. (Plate I, Nos. 14, 15, 16, 17, and 18).

Degenerated cells or " clear elements ^' are of frequent occurrence.
They stain with difficulty or not at all, except for small beads or
wreaths of chromatin material variously placed. Their appearance
often suggests that they are degenerated p6lymorphonuclear leu-

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THE OBRBBEOSPINAI. FLUID IN DIAGNOSIS 7

oocytes (Plate I, No. 19). There is no special benefit to be derived
from the elaborate classification of Alzheimer^ and Szesci.^

CHEMICAL EXAMINATIONS

In normal cerebrospinal fluid a small amount of a protein-com-
plex group (0.03 to 0.6 per cent.) is present. This protein-complex
group is usually spoken of as globulin. Increase in globulin is the
most constant of the present known chemical changes to appear in the
cerebrospinal fluid in pathologic alteration of the nervous tissue.
The commonest finding indicative of meningeal reaction is the
globulin, the positive Wassermann ranking next and the lymphocyto-
sis last A number of methods have been devised for determining an
increase of globulin in the cerebrospinal fluid. Most of these are
qualitative tests, but from them one can usually determine whether
there is increase in the globulin content.

1. Nonne Phase I Reaction.^ — This reaction consists of the addi-
tion of hot saturated solution of ammonium sulphate, which has been
permitted to cool, to an equal quantity of cerebrospinal fluid; 0.5
Cc. to 1 Cc. of each is sufficient for the reaction. If the globulins are
increased, there occurs a cloudiness or opalescence in the tube within
three minutes. Normal fluids may give a faint opalescence or none.
The amount of globulin is estimated from the rapidity of appearance
of the opalescence and from its intensity. Comparison should be
made with the reagent and with the cerebrospinal fluid alone in
weakly positive or doubtful reactions (Plate II, Tube 1).

2. Ross-Jones Reaction.* — ^This test is a mddification of the
Nonne-Aspelt test The same reagent is used, but, instead of mixing
the reagent and cerebrospinal fluid, the cerebrospinal fluid is per-
mitted to float on top. Within three minutes a white ring or zone
appears at the line of contact. The presence of this ring or zone is
considered to signify a globulin excess. Boss and Jones consider
the importance of estimating the thidniess of the ring, the time of
its appearance, and the performance of the test with diluted fluids.
The Boss-Jones test seems more satisfactory than the Nonne-Aspelt
test ; the end reaction is more constant, is less influenced by individual
interpretation, and is sharper (Plate II, Tube 2).

8. Butyric Acid Reaction {Noguchi).^ — The performance of the
Noguchi reaction is as follows: To 0.1 Cc. of cerebrospinal fluid

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8 INTEBNATIONAIi CLINICS

add 0.5 Cc. 10 per cent, butyric acid in physiologic salt solution.
This is boiled for a short time, and a quantity of a normal solution
of sodium hydroxide, equivalent to the amount of cerebrospinal fluid
used, is added. This mixture is again boiled for a few seconds. An
increase of protein matter is characterized by the appearance of a
granular or flocculent precipitate, which gradually settles to the
bottom of the tube. The greater the excess of globulin the more
pronounced is the precipitate. If the amount of protein is very
small, the precipitate does not appear until after standing two hours.
Such results are not considered as an excess. Although very well
adapted to qualitative work, this method does not give a sufficiently
accurate gauge regarding the quantitative relations of the excess
(Plate n, Tube 8).

4. Eaplin^s Qtumtitative Estimation of the Protein. — ^Kaplin has
given us a method by which we can estimate the amount of protein
in the cerebrospinal fluid and thus determine whether it is present
in a normal or excess amount The following is Kaplin's^ description
of the test: " Into a test-tube 1 Cm. wide and 8 Cm. long is placed
0.5 Co. of the spinal fluid to be examined. It is heated until it boils
up twice; then three drops of a five per cent, solution of butyric acid
in physiologic salt solution are added, followed immediately by 0.5
Cc. of a supersaturated ammonium sulphate solution, and the fluid
set aside for twenty minutes. In adding the ammonium sulphate
solution care must be taken to allow it to flow under the solution and
not to mix the test-tube contents. After about twenty minutes an
excess manifests itself in the form of a thick, granular, potrcheese-
like ring. When no granular, thick ring forms the fluid may be
regarded as normal. Every fluid that shows the ring just described
is further tested as to the intensity of the excess. For this purpose
four other tubes receive each 0.1, 0.2, 0.3, and 0.4 Cc. of spinal
fluid respectively, and each in turn is brought up to the 0.5 Cc. mark
with distilled water. The same procedure is followed as for the first
tube. The tubes are set aside for twenty minutes and readings taken
then. The quantity of protein matter permitting a ring to appear
in the tube containing only 0.1 Cc. of spinal fluid is designated as
0.1 excess, and marks the greatest degree of excess."

Tests for increased globulin in the cerebrospinal fluid are easier
to perform than the cell count, and have practically the same diagnos-

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THE CEBBBROSPINAL FLUID IN DIAGNOSIS 9

tic importance. The tests which the writer most frequently makes
use of are the Boss- Jones and the Nc^chi hutyric acid modifications
of Nonne's Phase I reaction. After the performance of these two
reactions for some time one can readily form a fairly accurate opinion
as to whether the protein content is increased or not Both tests are
used in doubtful cases, so that one may serve as a check for the
other. Both are increased under the same conditions; they are
positive in all cases of acute meningitis and absent in meningeal
irritation without actual inflammation; they are always present in
tubercular meningitis, and their presence is an aid in the diagnosis.
The absence of the globulin reactions in cases of suspected tubercular
meningitis is of great value in excluding meningitis. The reactions
are positive in general paralysis and in cerebrospinal syphilis (general
paresis and tabes dorsalis in from 90 to 95 per cent, of cases) ;
negative in brain tumor, cerebral arteriosclerosis, and psychoses. A
positive reaction in a doubtful nervous case is presumptive evidence in
favor of the diagnosis being a syphilitic or parasyphilitic disease of
the nervous system. These tests give us a means, in doubtful cases, in
differentiating between functional and organic affections of the
central nervous system, but not between luetic and non-luetic condi-
tions. The presence of globulin always; means organic disease,
while its absence, like most negative findings, is not of equal value in
absolutely excluding organic conditions. It is almost always found
in syphilitic nervous affections. In cerebrospinal syphilis, according
to Sonne's statistics, it is present in about 100 per cent, of the cases,
in tabes in from 90 to 96 per cent., and in paresis in from 96 to 100
per cent, of cases. It occurs with the greatest intensity in paresis.

The Capacity for Reducing Fehling's Solution. — In normal
cerebrospinal fluid there is present a chemical substance which re-
duces Fehling's solution, and this is absent in some cases of menin- .
gitis and present in others. There appears in the literature on the
subject considerable confusion as to the cases in which it is present
or absent, and considerable uncertainty as to its value. According
to Mott,^ the reaction is due to the presence of glucose. In pyogenic
meningitis, pneumococcus, streptococcus, and mixed infection sugar
is invariably absent. In cerebrospinal meningitis (meningococcic)
sugar is absent in the acute stage, but may return in some degree as
the infection recedes. In tubercular meningitis sugar is present,

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10 INTBBNATIONAL CLINICS

except in very rare cases shortly before death, in which stage diffi-
culty of diagnosis rarely exists. In poliomyelitis sugar is present.
The method used is to boil together equal portions of cerebrospinal
fluid and Fehling's solution in a narrow test-tube and allow it to
rest in a sloping position. In the course of an hour there will be
a marked yellow or red deposit forming a band on the lower side of the
tube, and with a little practice one can readily form a fairly accurate
opinion as to whether such a band is normal in amount or diminished.
Where sugar is absent no deposit will occur (Plate II, Tube 4).

BACTEBIOLOGIC EXAMINATION

The bacterial findings give us the only absolutely conclusive evi-
dence from the examination of the cerebrospinal fluid. The most
difficult of all the microbic invaders of liie spinal canal to detect is the
tubercle bacillus; the most commonly found microorganism is the
tubercle bacillus and the Diplococcus intracellularis meningitidis of
Weichselbaum ; the pneumococcus is occasionally found, while the in-
fluenza bacillus, the ordinary pus-forming coccus, and the Klebs-
Loffler bacillus are rarely seen. Other microorganisms have been
reported as found in the cerebrospinal fluid, but are extremely rare.
These are the gonococcus, ihe Bacillus coli communis, the Bacillus
pyocyaneus, the Bacillus mallei, the Bacillus anthracis, the Saccha-
romyces, and the Actinomyces.

A pure lymphocytosis in a child should always surest a tubercu-
lar meningitis, and a diligent search for the tubercle bacillus should
be undertaken. If one is careful of his technic and is persistent he
will be rewarded by finding the tubercle bacillus. Many methods
have been suggested for finding the tubercle bacillus, but the easiest
to perform and the most practical in the writer's hands is to place
a small, round cover-slip in the bottom of a flat-bottomed vessel con-
taining the cerebrospinal fluid. The sediment which will in this
way be deposited upon the cover-slip will contain cells and tubercle
bacilli. The cover-slip should then be removed, dried in the air,
fixed by passing through a flame, and stained in the usual way for
tubercle bacilli. Tubercle bacilli will in this way be present in large
numbers. In non-tubercular cerebrospinal meningitis a smear made
in this manner will show numerous polynuclear leucocytes and the
meningococcus. Some of the meningococci are intracellular and un-

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THB CEBEBBOSPINAI« FLUID IN DIAGNOSIS 11

stained by Gram, a fact which will eliminate any question of the
pneumococcns. (Plate III shows smears made by this method. They
show the large number of bacteria which may be obtained by this
method^ whereas by other methods but few are found.)

SEBOLOGY

The Wassermann reaction in the cerebrospinal fluid is highly
characteristic of the syphilitic process, and, generally speaking, is of
greater significance than the blood Wassermann when it is desired to
establish the nature of a given nervous disorder. There is little or
no relation between the blood Wassermann and the reactions of the
cerebrospinal fluid. Owing to the independence between the blood
and cerebrospinal fluid substances which produce the Wassermann
reaction may be present in the cerebrospinal fluid and not present in
the blood, or vice versa. In cerebrospinal syphilis the reaction occurs
more often in the blood than in the fluid, while in tabes most observers
agree that the Wassermann reaction is more frequently positive in
the fluid than in the blood. !N'oime, from his original experiences,
sou^t to establish a differential point between the true syphilitic
and the parasyphilitic affections. This opinion he has later modified
because of a change in his experiences in regard to tabes. No hard
or fast deductions can be made in regard to the presence or absence
of the Wassermann reaction in the blood or cerebrospinal fluid, but,
nevertheless, their value in differential diagnosis is of the greatest
importance. A thorough knowledge of this reaction is absolutely
essential to every neurologist who desires to be modem.

LAKGE COLLOIDAL GOLD CHLOEIDE EEACTION

One of the most recent of our laboratory tests applied to the
cerebrospinal fluid is the colloidal gold chloride reaction. This test
is based upon some of the observations made by Zsigmondy,^ in 1901,
in his exhaustive work with solutions of colloidal gold. These
observations are:

1. Colloidal solutions of gold or other metals are precipitated by
proteins or electrolytes when present separately. The amount of
reaction depends upon the degree of concentration and valency of
the electrolyte.

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12 INTBENATIONAIi CLINICS

2. Colloids are electrically charged and two oppositely charged
colloids mutually precipitate one another^ though only in definite
quantitative amounts^ If these amounts are exceeded in one way or
the other^ no precipitation occurs. The point at which protection
ceases and precipitation begins is different for each proteid.

3. Proteins in the presence of an electrolyte inhibit precipitation
in colloidal gold chloride solutions — ^the so-called " gold-Schutz.''

4. The relation existing between this opposed reaction of electro-
lyte and protein is definite for the same protein, but differed when a
different protein was used, and is, therefore, a specific property of
the individual protein.

Lange,® in 1912, attempted to apply this gold protection method
to the study of the proteins of the cerebrospinal fluid. Instead of
securing protection, as he had hoped, the reverse occurred when a
large amount of protein was present. He also observed that precipita-
tion or color changes occurred at definite dilutions. This point seemed
specific for definite conditions. In this way a method of differentia-
tion between syphilitic and non-syphilitic conditions was foimd.
Moreover, when cerebrospinal fluid, in the presence of a 0.4 per
cent, sodium chloride solution, was added to a definite amount of a
colloidal gold solution color changes occurred. Cerebrospinal fluid
from cases of tabes reacted almost as characteristically, but fluids
from cases other than syphilis gave no color changes at all, or less
reactions and at lower dilutions.

The technic of setting up the tubes as is used by Lange^ and
others ®' ^^' ^^ is as follows: Into each of ten sterile, chemically
clean test-tubes 1 Cc. of a 0.4 per cent, solution of sodium chloride
is added to hold the globulins and nucleoproteins in solution. Into
the first tube are then added 0.2 Cc. of the cerebrospinal fluid to
be examined and 0.8 Cc. of the sodium chloride solution. This makes
2 Cc of solution in the first tube and 1 Cc. in each of the other
tubes. After thoroughly mixing, 1 Cc. of the contents of the first
tube is removed and is added to the second tube, which now contains
2 Cc. From the second tube 1 Cc. is now taken and is added to the
third tube. This method is repeated until the tenth tube, when the
1 Cc. is removed and thrown away. In each tube there is now 1 Cc.
of cerebrospinal fluid in 0.4 per cent, sodium chloride solution in the
dilutions of 1 to 10, 1 to 20, 1 to 40 up to 1 to 5120. Into each tube

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THE CEBEBBOSPINAL FLUID IN DIAGNOSIS 13

are now added 5 Cc. of the colloidal gold chloride solution and the
tubes immediately shaken. A control tube may be used containing
no cerebrospinal fluid. In pathologic fluids definite color changes
will be observed in a few minutes, but a final reading should not be
made until after twelve or more hours have elapsed. Normal fluids
show no color changes. The color changes which occur in pathol(^c
fluids are: 6, colorless; 4, pale or gray-blue; 3, blue; 2, purple or
lilac ; 1, red-blue or a color slightly different from the original color;
0, red or no change from the control. Reactions with pathologic
fluids may be expressed diagrammatically thus :

1— "--

C—, L.C C«»«, X 8.

i I

3 ^^ Lues reaction. 3 Non-Syphllltfc

Z I \ ? Meningitis.

A/ V__ i

The following should be adhered to strictly in the performance of
this test:

1. Only high grades of chemicals should be used.

2. Fresh doubly-distilled water must be used everywhere, and
must be used within a few hours after the final distillation.

3. All solutions must be made with the above^lescribed water.
The sodium chloride solution must be made within two weeks of the
time it is to be used.

4. No rubber attachments should be used in the distilling
apparatus.

6. Pipettes should be cleansed with water, alcohol, ether, and dry
sterilized.

6. There must be accuracy in all measurements.

7. Needles used for the lumbar puncture should be cleansed with
alcohol and ether and dry sterilized.

8. Bacterial or blood contamination must be avoided.

9. The colloidal gold chloride solution must be brilliant red, trans-

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14 rNTBEWATIONAI- CLINICS

parent^ and free from any traces of blue, and no coagulum or deposit
must occur.

10. Beadings must be made in the proper light and with a suit-
able background. Artificial light may give misleading readings.

11. The technic of preparing the colloidal gold chloride solution
may be had by referring to any of the recent articles upon the gold
chloride reaction.** ®' ^' ^®» ^^

The colloidal gold reaction is one of our most valuable tests in
the examination of the cerebrospinal fluid. The reaction is particu-
larly useful in differentiating incipient general paresis and neuras-
thenic disturbances in a syphilitic. In general paresis there is a dis-
tinct curve, which is known as the paresis curve. A typical example
of this curve is seen in Plate IV, In tabes the reaction is not quite
so characteristic and is present less frequently. The reaction is more
delicate than the blood or fluid Wassermann, the cell count, or the
globulin content. It is nearly constant in syphilis of the central
nervous system ; it is extremely sensitive and is reliable when positive ;
the amount of fluid used is quite small (0.2 Cc.) ; definite conclusions
are reached with ease and rapidity ; the margin of error is exceedingly
small; it runs parallel with the Nonne and Noguchi and bears re-
lationship to the Wassermann reaction, which is constant The
chief advantages in this reaction are the small amount of fluid used,
its technical simplicity, the sharpness of the reaction, and its delicacy.
It differentiates spinal fluids due to other causes than syphilis. ^^ The
reaction peculiar to paresis is sufficiently constant to warrant its use as
an aid in the differentiation of this condition from others with which
it might be confused. The statement that they indicate the earliest
stages of the central nervous system involvement lacks proof ."^^ Nor-
mal fluids give normal reactions. An error in technic usually gives
negative reactions. This fact makes the positive reaction much more
conclusive.

GENERAL SUMMARY AND CONCLUSIONS

The conclusions which follow are based upon a study of the
cerebrospinal fluid examinations made at the Pathological Labora-
tory of the Eochester Gteneral Hospital and from the apparent con-
sensus of opinion as expressed by the recent writers on spinal fluid
examinations.

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THS OEBEBBOSPINAL FLUID IN DIAGNOSIS 15

In the oerebrospinal fluid not too much should be expected. In
only a few instances can absolute determinations be reached. The
finding of the tubercle bacillus or the pneumococcus is the occasional
hi^ light in routine study of the cerebrospinal fluid. A positive
globulin reaction does not mean any specific nervous disease any
more than does a leucocytosis mean pneumonia or the finding of a
small amount of albumin in the urine make a diagnosis of interstitial
nephritis. Beal significaQce of these findings in differential diagnosis
becomes apparent only when the absence or presence of these tests
is carefully construed with a full knowledge of all the clinical facts
in the case.

Properly to appreciate the diagnostic value of the study of spinal
fluids it is necessary to remember that the spinal fluid is, in a diagnos-
tic sense, aQalogous to the blood, and, as in the blood, only a few
tests of absolute value are known, so in the interpretation of the
examination of the cerebrospinal fluid most of the knowledge obtained
is relative. The globulin reaction and cell coimt tell us that we are
dealing with a pathologic fluid, but it remains for the bacterial find-
ings^ the Wassermann aad gold chloride reactions, and the clinical
evidence to classify the pathologic disturbances. Absence of findings
indicative of meningeal reaction in a single examination cannot be
taken as conclusive evidence of freedom from central nervous in-
volvement Positive findings always mean organic disease, while
negative findings, like most negative findings, are not of equal value
in absolutely excluding organic disease.

A complete examination of the cerebrospinal fiuid should be made
in every case of nervous or mental disturbance where there is some
doubt with regard to the diagnosis. If the Wassermann reaction is
negative and all other findings are positive and the clinical history
suggests syphilis, antisyphilitic treatment should be instigated.

' The greatest value in an examination of the cerebrospinal fiuid
in doubtful cases is its use as a means of differentiating between
functional and organic affections of the central nervous cfystem, as
a guide to therapy, and in deciding when to terminate treatment after
the complete disappearance of all clinical manifestations.

In borderland cases a number of tests should be used on the fiuid,
and if still in doubt the examination should be repeated at a later
date on fresh fluid. A borderland result, in the hands of a physician

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16 INTEENATIONAIi CLINICS

who does not know how to weigh laboratory reports^ will sometimes
be provocative of error if too much credence is given such report.
If careful technic is used and the proper interpretation is given to
the findings^ the value of the examination of the cerebrospinal fluid,
although not always absolutely conclusive, in diagnosis in doubtful
nervous cases can scarcely be overestimated.

BEFBSENCES

^Alzheimer: "A New Method for Fixing the Cell Element of the Cerebro-
spinal Fluid," Centr. f. Nervoenh, u. Pay., 1907, No. 239, p. 449.

■SzKSOi: Ztachr, f, d. gea. Neurol, u, Payohiatrie, 1914, xxii, 346.

*NoNNB: " Syphilis and the Nervous System" (English translation), 1913,
Lippincott.

«Ross and Joites: Brit. M. J., 1909, i, 1111.

*NoanoHi: ''Serum Diagnosis of Syphilis," 3d edition, 1912.

*KAPLm: "Serology of Nervous and Mental Diseases," 1913 edition.

» ZsiGMONDT: Ziaohr. f. anal. Chem., 1901, xl, p. 697.

*Lanqe: Berl. kUn. Wchnschr., 1912, xlix. No. 19, p. 897; Zeitach. f. Ohemo-
therapie, 1912, vol. i. No. 1, p. 44.

•Gbuleb and Moodt: "Lange's Colloidal Gold Chloride Test of the Cerebro-
spinal Fluid in Congenital Syphilis," A. M. A., Ixi, No. 1, p. 13.

^Lee and HmiON: "A Critical Study of Lange's Colloidal Gold Reaction in
Cerebrospinal Fluid," Am. Jour. Med. 8ci., July, 1914, No. 1, vol. cxlviii, p. 33.

'^MnxEB and Levy: ''The Colloidal Gold Reaction in the Cerebrospinal Fluid,
Bull. Johna Hopkina Hoap,, May, vol. xxv. No. 279.

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THE DIAGNOSIS AND TREATMENT OF ARTERIO-
SCLEROSIS

BY BYRON SPRAGUE PRICE, M.D.

New York City

Abteeioscleeosis represents but one link in a chain of fibroid
changes, resulting usually from some form of toxic irritation. The
allied organs principally involved in these sclerotic changes are the
kidneys, lungs, stomach, and prostate. Secondary structural results
may arise, as shown in atheroma with calcareous deposition, gangrene
of extremities, cerebral, retinal, or other hemorrhage, thrombosis,
cerebral atrophy, and myocarditis.

Increasing blood-pressure and arteriosclerosis are abnormal
(although frequently present) at any period in life, however late,
and quite as abnormal as is interstitial nephritis. In healthy people
a slight decrease in blood-pressure occurs after the period of greatest
vitality and activity has passed. The preorganic stage or that of
hypertension only, frequently covering a considerable period of years,
is the stage of greatest importance, for during it not merely arrest but
complete recovery may readily be obtained.

ETIOLOGY

Death claims its majority, either directly or indirectly, by the
way of arteriosclerosis. Its causes are both through hereditary
tendencies and acquired conditions. Families who in one generation
after another violate to excess the normal functional latitude of one
or more of their organs, whether it be through accumulation of
poisons, excessive nervous expenditure, or otherwise, must necessarily
transmit a defective inertia relative to the loss of such force in their
own possession. Much more important, however, in this condition,
is the use made of what one has, rather than the quality of what he
inherits, for, generally speaking, acquired causes are conspicuously
responsible. '

Lead and specific disease (acting directly on the arterial walls),
ursemic and diabetic products are capable of developing rapidly ex-
VOL. II. Ser. 26—2 27

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18 rWTBBNATIONAI* CLINICS

tensive atheroma. The less active: pjsemia, influenza, typhoid and
other bacterial poisons, various altered internal secretions (of the
adrenals, pituitary body, etc.), acid intoxication of muscular fatigue,
and certain drugs later referred to, are capable of producing and
maintaining hypertension. Under favorable conditions, also, various
reflex sources of local irritation, especially if acc(Hnpanied by much
pain: pelvic disturbances, joint affections, falling and painful foot
arches, intracranial irritation, increased cardiac action due to local
abnormalities {e.g., early valvular aneurism) and those more of the
obstructive nature (acting in part through suppressed metabolism) :
hepatic cirrhosis, nephritis, existing sclerosis of splanchnic vessels or
of the aorta, either by direct vasomotor contraction or indirectly
through digestive disturbances, are capable of aiding in the produc-
tion of hypertension.

Predominating, clinically at all events, and largely dependent
upon the nervous status influenced by excessive or unnatural mental
fatigue long continued, as shown in those subjected to worry, severe
suspense and anxiety, the most important immediate cause of hyper-
tension is directly due to bacterial activity in the gastro-intestinal
tract with the excessive development and absorption of organic acids
produced from carbohydrate disint^ration (which have been shown
.also to lead to other fibroid or cirrhotic changes), bodies of the
neurine and muscarine type, but principally of the aromatic nitrog-
enous derivatives, indol, skatol, etc., after the liver-cells have be-
come overloaded. This latter condition leads to inefficient oxidation
into the normal end-product, urea.

Last of all, the age factor (involution) cannot be ignored, because
of its inevitable effect upon normal tissue elasticity. However, in
health the lack of elasticity is more than compensated for by the
decreased energy and heart action of advancing age, so that normally
a decrease and not an increase in blood-pressure occurs..

In summing up as important among the daily causes of arterio-
sclerosis should be remembered the greatest underlying and under-
^mining influence, that of the unstableness of overfatigued nervous
centres, as a result of which imperfect digestion occurs and the re-
sisting powers, not of the intestinal mucosa alone, but of the hepatic
and other glandular functions as well, become relatively incapable of
withstanding usual or added exciting causes. These exciting causes

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T£LB DIAQNOSIS AND TREATMENT OF ABTBBIOSCLEBOSIS 19

are principally relative excess of food habitually taken, especially
of proteids, animal fats and sweets, of tobacco, the steady use of
stimulants in excessive or in more than minimum quantities, shallow
breathing which permits of insufficient surface for complete oxygena-
tion, habitually insufficient sleep, not drinking enough water to assist
digestion by exciting gastric juices or to aid in elimination, insuffi-
cent daily exercise leading to an excess of unused albumin because of
muscular inactivity, and to suboxidation, resulting in a surplus of
intake as well as a surplus of retention.

These conditions, like the gouty and rheumatic, keep up one of
altered chemical irritation and more or less storing up within the
various glands, in abnormal quantity and quality, of substances which
may only periodicaUy be liberated into the circulation in quantities
sufficiently large to produce other marked symptoms, but constantly
sufficient to produce arterial contraction. Further, the existent
systemic absorption in intestinal toxaemia is relative, dependent not
alone upon the quantity or quality of decomposition product within
the intestine, but very largely upon the tissue vitality or lines of
resistance which influence both the absorption and the neutralization
of the absorbed substances.

From some combination of these common causes the foundation
is established from which gastro-intestinal toxaemia, rheumatism,
gout or other suppressed metabolic state, or several in conjunction,
may arise (though years may pass before the trouble becomes evident
to the individual), leading to hypertension.

Whatever may be the cause for establishing hypertension, the
latter is to some extent automatically maintained through the counter-
recoil of the musculo^lastic arterial walls against the unnatural force
exerted within them, leading to arteriosclerosis aud even atheroma
with calcification.

The action of certain drugs and toxins is of special interest in
this connection, and, indeed, of practical etiologic significance. Some
of these act principally and directly upon the unstriated muscle of
the arterioles, others chiefly or wholly upon the heart muscle, while
still others exert their influence through the nerve-centres.

Of those acting mainly and directly on the arteriole, adrenalin,
nicotine, barium chloride, and ergot are the most decided (affecting
the heart muscle less).

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20 INTERNATIONAL CLINICS

Digitalis and its congeners (especially within the kidneys),
phrynin, caffeine, with other purin bodies, and apparently the colon
bacillus, while directly stimulating the arterioles, exercise their
grefiter influence upon the heart muscle, the latter in addition being
stimulated by the glucosides, strophanthus, etc.

Through the nerve-centres cardiovascular stimulation is also
induced by strychnine, purin bodies, digitalis, and nicotine. Nicotine
and alcohol, if taken in large doses, lead to paralysis and dilatation.
This is also true of muscarine and tuberculin, while adrenalin causes
pancreatic vasodilatation.

From tobacco smoke a relatively small amount of nicotine in
combination with a large proportion of pyridine and picoline bases is
absorbed.

PATHOLOGIC

The pathologic changes which take place in the structure of the
arteries and kidneys in this connection develop only after the func-
tional disturbances therein have existed for a considerable length of
time. Eventually the arterial walls, either locally or generally,
undergo fibrosis, in part as a result of the lowered nutrition to their
walls and inaction of the muscular coat because of its continuous
state of spasm. Arteriosclerosis in certain cases may thus develop
from hypertension without any primary injury or inflammation —
no endarteritis — ^while in others there appears to be an initial in-
flammatory thickening of the intima due to infective or toxic agents.
The former changes result from physiologic stimulation and strain,
with the laying down of fibrous tissue in place of the gradually-
decreasing muscle and elastic tissue. Such is the case in the usual
patchy fibrosis type of the aortic intima, as pointed out by Adami.

The localized bulging outward of the media, especially at the
points weakened by branch arteries (e.g., intercostal), may be fol-
lowed by a form of fatty d^eneration. Because of the better nourish-
ment of the intima it endeavors to compensate for this loss of support
by an overgrowth of fibrous tissue. Normally and during the early
stages of fibrosis the intima and inner layer of the media contain
no nutrient vessels, being nourished directly by the main blood cur-
rent As the condition progresses increase of the fibrous tissue layers
takes place in the intima between its inner and outer zones, filling the

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THE DIAGNOSIS AND TEEATMENT OF ABTEEIOSCLEEOSIS 21

area of distention^ until within the central portion of this fibrous
growth begins a process of degeneration, owing to its failing nourish-
ment Such, though usually banning at points of greatest strain,
extends to the smaller arteries as the rigidity in the larger develops.
Should the above process continue, calcareous deposits may later take
place in the necrosed areas of the media and intima. Such changes
are particularly liable to occur in the coronary arteries to the heart
muscle, the first portion of the aorta, the splanchnic vessels, and, to a
lesser extent, in the terminal arteries of the brain, especially around
the fissure of Bolando. Feri-arterial fibrosis, in senile cases, whether
primary or secondary, is a prominent pathologic condition. These
weak links in the circulatory chain may be able, imder favorable
conditions, to withstand the strain for a considerable period, but, as
a rule (especially if there is much atheroma), hemorrhage sooner or
later occurs, unless the pressure be relieved. In the absence of treat-
ment the pressure may become lowered as a result of fatty degenera-
tion and stretching of the heart muscle, because of the poor nutrition
to its substance, succeeding the stage of hypertrophy. Instead of
hemorrhage, thrombosis, with or without embolism, may occur.

Following closely upon, or often preceding or accompanying, the
arterial changes, the renal fibrosis resulting in chronic interstitial
nephritis usually develops.

The pathologic findings in cases of angina pectoris have not been
in accord with the clinical theory that the pain is necessarily de-
pendent upon atheroma of the coronary arteries. Persons suffering
from typical angina attacks frequently fail to show on post-mortem
any lesion in these vessels, while those never having suffered from
angina pectoris frequently show extensive coronary lesions and even
obliteration of an artery.

Manoelian has called attention to the existence of numerous
nervous centres in the posterior cardiac plexus. It is composed of a
rich anastomosis of nerve filaments and of ganglia made up of
sympathetic cells. In addition, he found solitary nerve-cells of the
sympathetic type in the connective tissue of the middle coat of the
aorta. From the connective tissue nerve-fibres ran towards the elastic
fibres and the smooth muscle cells, where they terminated either in
a rounded, knob-like swelling or in a finely-drawn-out end. What
simulated the motor plates of striated muscle were close to the smooth

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22 INTEENATIONAL CLIlflCS

muscle cells. The connective tissue of the middle coat was found
richly innervated, and a large number of nerve-fibres ended here.
Manoelian believed these nerve-fibres to be sensory in function, mak-
ing it possible and probable that a reflex vasomotor arc exists.

These findings strongly support those of Vaquez, by which the
latter concluded that any accidental increase of pressure distending
an already diseased aorta would bring about anginal attacks. Further
aortitis and peri-aortitis are almost always present in cases of angina
pectoris.

SYMPTOMS

Symptoms (of which there may be none or many), when one
or more of importance be present, suggesting the need for a thorough
examination of the circulation and for the condition so frequently
associated with it, intestinal toxsemia, are: hypersensitive nervous
system with neuralgic points and various nerve and tissue pains,
throbbing headaches, especially at the temples or baae, with grating
sensation, cranial pressure, photophobia, mental depression, or general
feeling of stiffness or aching with lassitude, these occurring espe-
cially when toxaemia also exists. Later, transient aphasia, hemi-
plegia or monoplegia, and, of great importance, mental enfeeblement
— as shown by incapability to concentrate, poor memory for recent
events, loss of words, uncertainty of thought and speech, pain or dis-
tress through upper part of chest upon sudden exertion or excitement
or after a hearty meal, vertigo, auditory pulsation, dyspnoea, and
fainting spells. Lameness increasing with fatigue — even to loss of
power with numbness in the legs, with or without pain — ^is a very
important symptom, as are also pyorrhoea, emphysema, and persistent
bronchial disturbances.

DIAGNOSIS

The diagnosis of arteriosclerosis requires much detailed care.
Hypertension does not mean arteriosclerosis any more than a low
blood-pressure means the absence of arteriosclerosis. Arteriosclerosis,
while usually capable of direct recognition, may in other cases be so
obscure that a diagnosis made by deduction will be all that can be
obtained. Even when the radial, temporal, and other superficial
arteries do not show the physical signs of sclerotic changes, nor the
skiagraphic appearance of the leg arteries, but when in middle-aged

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THE DIAGNOSIS AUTD TEEATMBNT OF ABTBEIOSOLBEOSIS 23

and older persons the renal secretion shows such changes in these
organs (increased quantity voided, hyaline casts, occasional traces of
albumin or granular casts), along with either a general lowering in
vitality as shown by skin, nails, peripheral arteriole inaction, pre-
cordial pains, or claudication with or without cramps and pain, espe-
cially if accompanied by evidences of myocarditis or gastric sclerosis,
sclerotic changes in the arteries should be strongly suspected.

In the majority of cases, however, there will also be one or more
of the following signs: hypertension or physical evidence in the
arteries, as beading, tortuosity, twitching, whipcord condition, or
palpation of radial artery below a point of firm pressure. In typical
'conditions skiagraphic evidences, changes in the superficial arteries,
cardiac hypertrophy or dilatation (frequently showing myocarditis),
arteriole fixation, and the relative difference between systolic and
diastolic sphygmomanometer readings will be present.

Symptoms and physical signs must be carefully analyzed: mere
sphygmomanometer reading is not sufficient in determining arterial
condition. A low reading may be present in advanced arterio-
sclerosis as a result of failing compensation. A relatively high read-
ing, usually without evidence of cardiac enlargement, may exist in
association with fatty right ventricle or myocardial degeneration and
small blood volume with atheromatous arteries, because of the latter
requiring slightly greater force to compress their walls (if athero-
matous at point of compression) without proportionate intra-arterial
pressure.

Slight variations in blood-pressure occur in health accompanying
brief physical exertion, active digestion, and following stimulants
and tobacco. Marked increase also results from certain acute sthenic

Systolic pressure estimation is of value for recording TnftYinmTn
strain upon heart or atheromatous arteries, but diastolic pressure
representing the constant element in blood-pressure is of greater
importance, recording the constant arterial load, and, because of its
influence upon the blood supply to the vessel walls, especially in the
lower limbs. With a low diastolic pressure there is less danger of
arterial rupture, even though the systolic pressure be high.

The aortic diastolic pressure representing the strain which the
aortic valves are objected to is of much importance, as se^i in aortic

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24 INTERNATIONAL CLINICS

incompetence or in " athlete's heart." It also represents the resist-
ance to be overcome by the left ventricle during the beginning of
systole. It gauges largely, too, the peripheral resistance, but with
increasing inelasticity of arteries there necessarily must be a rela-
tively higher systolic pressure and lower diastolic pressure (because
of less dilatation and less recoil to maintain the diastolic), thus dis-
guising the otherwise high diastolic pressure reading of increased
peripheral resistance. Great importance, therefore, is to be attached
to a high diastolic reading when accompanied by a fairly slow heart-
beat and inelastic arteries, as indicating a greatly-increased periph-
eral. The diastolic pressure is also increased by rapid heart action,
not giving time for pressure to fall during diastole, — ^in other
words, time for capillary circulation. A diminished pulse-pressure,
— Le,, a high diastolic with a relatively low systolic pressure, with
moderate heart-rate and aortic competency, — ^indicates a slow or poor
capillary circulation.

The extensive range between systolic and diastolic pressure in
such conditions as aortic regurgitation, shock, etc., cannot be regarded
as true pulse-pressure readings, as it does not represent the extent
of capillary circulation. As a rule, the amount of urine, urea, and
chlorides is directly in proportion with the extent of pulse-pressure,
while in nephritis the albumin varies inversely with it.

The auditory method of estimating blood-pressure is becoming
more generally accepted as the more reliable. By using a tambour
attached to a separate band on the distal side of the armlet, avoiding
undue pressure upon the artery, and raising the armlet pressure
above the systolic pressure, then releasing the armlet pressure until
the pulse again passes beneath the armlet, the systolic pressure sound
is heard (i.e., the first of the thud), and if the technic is accurate
this sound \^11 invariably be heard as early as, and usually before,
the pulse may be felt by the finger. Now if the armlet pressure be
further lessened the sound becomes louder with some murmur. Still
lower the sound becomes suddenly weak and dull in quality, indicating
at this point the diastolic pressure as worked out by MacWilliam
and Melvin. This may shortly be followed by disappearance of the
sound (especially in inelastic arteries), or the sound may persist to
a much lower reading, as in young adults.

In some cases the armlet pressure made upon the artery tem-

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THE DIAGNOSIS AND TREATMENT OF ARTERIOSOLEBOSIS 25

porarily lowers its diastolic reading, and for this reason a comparison
of a diastolic reading as taken above with a reading taken on the armlet
pressure rise may show much difference, and here the latter is more
accurate. The difference corresponds to the degree of arterial
inelasticity.

Normal systolic pressure by the auditory method in the adult
averages 116 mm. mercury. Normal diastolic pressure averages 75
mm. Normal pulse-pressure averages 40 mm.

TREATMENT

The treatment of arteriosclerosis in the past has been palliative
and expectant, treating symptoms as they might arise, but without
hope of eradicating or materially lessening the abnormal processes.
During recent years, as a result of the rapid development in a better
understanding of the modv^ operandi of various physical measures
(especially electrotherapeutic, the rapidity of which has not been
excelled, either in character or importance, by any other use of
electricity), the treatment of arteriosclerosis has been raised from
one of hopelessness to one of scientific usefulness in the saving of
life and the eradication or arrest, not alone of cause but of result, in
the majority of cases and with marked relief to those far advanced.

Treatment of arteriosclerosis must necessarily be considered
under different headings: preventative and remedial, as influenced
by the cause if still existent, the extent of the disease, and its associa-
tion with other conditions. In most cases the managanent of causes is
separate and different from that of the arterial condition itself, yet
the influence of the treatment directed especially at the arterial state
acts so profoundly upon the general metabolism that certain of the
causes are, in part at least, influenced by some modification of it,
as will be seen later. Therefore the general treatment may first
be taken up and followed by special attention to special conditions.

In addition to the hygienic regulation of living, so small a per-
centage of total benefit is obtained from the use of medicinal
remedies, with temporary and irregular lowering of blood-pressure,
and only at the expense of cardiac depression and disturbed com-
pensatory circulation, that the use of such agents is rapidly becoming
extremely limited.

These drugs, veratrum viride, aconite, chloral hydrate, and the

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26 INTBENATIONAI- OUNIOS

iodides^ weaken the heart muscle and produce ansemia and digestive
disturbances. In order to repair such damage done they are fol-
lowed by strychnine^ digitalis and its group, strophanthus, caffeine^
etc. These in turn rapidly raise the blood-pressure again, in part
through arteriole contraction, so increasing the heart's work often
out of proportion to its muscular ability and thus giving rise to a
fluctuating blood-pressure with failing compensation which serves
to keep the fatal pendulimi swinging from one direction to the other.
Out of these consequences has grown the impression that hyper-
tension should not be lowered or disturbed, and this is probably as
safe a general rule to follow, so far as drugs are concerned.

While nitrites are, per se, of great value in emergency conditions,
their effect is so temporary and varying that they compare most
unfavorably with physical measures. In contrast to drug therapy,
it has become a recognized certainty that such treatment as will
directly be outlined is incapable of depressing or injuring the heart
muscle upon which it has no direct action (in such doses), reducing
the blood-pressure only by its action on the arterial portion of the
vascular system with a minimum of fluctuation. Hence, too low a
blood-pressure, heart depression, and hemorrhage (the conspicuous
dangers and results in drug therapy) may be entirely obviated by
rational physical treatment

The use of rapidly-varying temperatures and overstimulating or
depressing baths, upright high-temperature light-cabinets, in treat-
ments which often demand much circulatory reaction during forced
relaxation, either by their nature or the conditions under which they
are administered (such as activity or upright position before circu-
latory readjustment becomes established), exact too large a percentage
of serious result (especially where atheroma exists) without com-
pensatory reward.

Certain physical measures, including the high-frequency currents,
produce what may be termed active tissue gymnastics without direct
chemical or electrolytic change. Such tissue activity, however, in-
volves proportionate oxidation and consequently produces relatively
normal metabolism and improved tone. Other physical modalities,
by their electrolytic or other physiochemical action, aid in promoting
absorptive changes with increased elimination of local products, while

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THB DIAGNOSIS AND TREATMENT OF ABTEBIOSOLEBOSIS 27

still other means are available for glandular activity and extensive
elimination.

It should and must be clearly recognized that in order to obtain
good results through the application of physical measures a careful
diagnosis of conditions, selection of properly-constructed apparatus,
proper modality, and correctly-applied technic be followed. There
can be nothing more certain than the failure resulting from partial
treatment because of inaccurate or incomplete details in diagnosis.
With drug treatment in sclerosis the details of diagnosis are not so
essential, because it will not so materially alter the treatment or its
results, but to undertake this line of physical treatment with a defec-
tive knowledge of the case in detail can only be rewarded by failure.

ITothing is more disappointing than the attempt to obtain good
results from an imperfectly constructed or adjusted apparatus. By
no means are all of the instruments on the market and in use for this
purpose of equal value. Even one of good make will not give good
results unless the accessories are properly adjusted. This requires
personal attention, with modifications for each patient, in order to
obtain the best results.

Many patients with hypertension receive only the most temporary
benefit, and frequently no benefit, but instead depression, because of
an imperfect machine or technic, and when the same patients are
given the benefit of proper technic they immediately and continuously
improve. There is nothing surer than the failure resulting from
treatment which will follow the use of indiscriminate physical
modalities. With all the above requirements perfected, there is still
nothing more essential than a knowledge based upon intelligent under-
standing and experience, giving the operator reasonable accuracy in
the application of technic.

PREVENTATIVE OB EABLY TREATMENT.

Prev^itative treatment, or that of hypertension and associated
causes before structural changes have occurred, consists essentially
in removing the causes and restoring normal metabolism. In very
early and slight cases attention to the mental source and hygienic
conditions, with prolonged rest or variety, may suffice where the over-
taxed nervous system is principally at fault, but such cases form so
small a percentage of those applying for treatment as to make their

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28 INTERNATIONAL CLINICS

number almost negligible. In more advanced conditions, in addition
to removal of cause, the treatment of the arteries resolves itself into a
means whereby the tissue spasm may be permanently relaxed to a
point of restoring a physiologic balance and bringing about normal
circulation, including that of the vasa vasorum.

There are several ways by which this may be accomplished. Auto-
condensation is recognized as the most desirable. The dosage, which
varies with conditions, gives most satisfactory results when used as
described by Dr. de Kraft, as follows : With the patient upon either
de Kraft's fibre chair (which closely follows the contour of the back
and legs) or a metal-covered chair with two or two and a half inches
of felt over it, or other heavy dielectric, such as a thick-glass-top table,
connected to the outer coating of the Leyden jar on one side of the
transformer, his hands in contact with metal hand-pieces attached to
the outer coating of the opposite Leyden jar through the meter, and
the soles of the feet resting upon a metal plate connected to the
rheophore from the hands, or with other suitable contact modified
for special indications, approximately 1500 milliamperes of current
are usually given when a Wappler transformer is used. In some
cases much less may be sufficient

The strength and duration of treatment are governed by the time
required to produce a physiologic reaction : softening of pulse with a
sensation of general warmth, flushing, relaxation, and rest; actual
flushing of face and dilatation of blood-vessels of hands. There may
or may not be free perspiration* The time required varies. It
may be ten minutes in one case and forty or fifty minutes in another.

Instead of using the usual connection to Leyden jars only, in
this method, the meter may be connected to the Oudin and the
patient's metallic connection made with the opposite side of meter,
the other jar being connected to a metal plate under a thick dielectric.
This treatment should be repeated daily, or less frequently, according
to severity, for days or weeks, until the peripheral dilatation which
is accompanied by increasing elasticity becomes established. In this
way will be brought about a gradual diminution of the excessive
tension and at the same time a lessening of the heart's work^ accom-
panied by increased tone in the latter organ until compensation is
restored with improved renal function, metabolism, etc. Treatment

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THE DIAGNOSIS AND TBEATMBNT OF ABTEBIOSCLEBOSIS 29

as above described will not reduce the blood-pressure below the point
of compensation.

Autocondensation given in this way does not depress the cardiac
muscle. On the contrary, the peripheral relaxation and improved
pulse-pressure, being the only means through which the relief from
hypertension is brought about, make it possible for complete cardiac
systole and more normal diastole and insure rapid recovery of
partially-lost cardiac tone.

When desirable to obtain a greater amount of increased tempera-
ture in a patient, it can best be accomplished by connecting the fibre
foot-piece to the back of the chair, while the patient's bared feet
rest upon the foot-piece, his hands in contact with the hand-pieces.

After the use of autocondensation, when much heat is produced
within the body, the patient, while insulated, may be connected to
the negative side of a static machine, moving the brush discharge
electrode at a considerable distance from the patient all over the
body, thus producing a cooling effect and just short of a true brush
discharge. In this way the oxidation processes are much increased.

Much care and close observation of patient must be given in
applying an electrode over the hypogastrium when administering auto-
condensation or thermopenetration, as sudden splanchnic dilatation
may occur with alarming symptoms, especially in advanced atheroma
with intestinal toxsemia. To avoid this, use metal plates of not less
than two hundred square inches each and a very high frequency.

Important results of such treatment, amply demonstrated both
experimentally and clinically, are: arteriole dilatation, improved
pulse-pressure, relief from venous stasis, and better oxidation, — in
brief, diminished peripheral resistance with improved nutrition.
As a consequence, the high blood-pressure, otherwise necessary for
compensatory purposes, is no longer required, a more normal com-
pensation having become established. In this way the harmful re-
sults upon nutrition of the blood-vessels because of intravascular
pressure lessen or cease.

USUAL OB ADVANCED CONDITIONS AND CAUSES.

In stubborn conditions or those accompanied by extreme lower-
ing of vitality, suppressed metabolism, and elimination, the additional
use of the ovenrbath is of the utmost value. It can in no sense sup-

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30 INTEENATIONAL CLINICS

plant the action of the currents, but as an adjunct it makes it possible
to use much larger doses of them without the unpleasant and even
serious development of increased toxsemic symptoms which arise from
the large quantities of oxidized waste matter thrown into the circu-
latory channels by the d'Arsonval and resonator effleuve treatment,
which in this class of cases may far exceed the accompanying elimina-
tion. As a result of this, much more progress can be made and valu-
able time saved, especially in urgent conditions wUh complications.
The importance of this can scarcely be overestimated.

The oven-bath accomplishes all that is useful in a febrile tempera-
ture elevation, and, in addition to such oxidation, establishes means
for the escape of the oxidized product by stimulation of glandular
tissue, as pathologic febrile elevations cannot do. Such treatment,
properly given, has a profound reflex effect upon glandular metab-
olism, enormously increasing the possibilities for elimination.

Special equipment is necessary in order to make the oven-bath
safe and efficient in this class of cases. A description of such technic
as elsewhere described is too extensive for this paper. Temperature
exceding 400° F. and absolute inaction on the part of the patient,
who must r^nain in the horizontal position for upwards of five
hours, are vitally essential factors.

Other benefits resulting from the oven-bath, as from d'Arson-
valization, are: arteriole dilatation, increased pulse-pressure, diuresis,
improved digestion and assimilation, chiefly through replacing the
venous stasis and detritus by arterial blood, and by reflex stimulation
through the nervous system. It is also highly important to maintain
a state of thorough portal and intestinal cleanliness throu^out

Venesection is a useful means of reducing blood-pressure in suit-
able cases (plethoric, sthenic, and urgent), and may prevent hemor-
rhage or save life. Occasionally a period of lowered tension follows
thorough venesection for weeks or months, during which time, if the
cause be removed, a more or less normal result may be established.
Physical treatment as outlined here, however, accomplishes all the
benefit derived from venesection in these cases, does it more rationally
and completely, and is under perfect control. It also succeeds where
venesection fails.

Clinically it would seem that gastric disturlxmees, as such, have
relatively little direct causative influence upon arteriosclerosis. Never-

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THB DIAGITOSIS AITD TBBATMENT OF ABTEBIOSOLEBOSIS 31

thelesS; cases present themselves in whom no other cause is detected^
which recover from the arterial conditions upon treatment for such
gastric disturbances, particularly catarrhal gastritis, atrophic gastri-
tis, and gastric stasis with pyloric constriction or muscular weakness.

For the removal of retained toxic debris and the mucus collecting
over night in these cases, morning lavage of the stomach with normal
saline solution is clearly indicated and invaluable, leaving the stomach
in its healthiest possible state to proceed for the day. In this con-
nection it is obviously but a poor substitute to drink salt water in
the morning, which quietly lies in the stomach until in part absorbed,
in part gradually expelled into the intestine, and especially because
of allowing the toxic matter to precipitate in the saline, only to be
mixed with food taken later and hence not lessening the amount of
harmful matter carried into the intestine to become a cause in the
production of hypertension. Hydrochloric acid given in these cases,
in the absence of normal gastrin production, will frequently hasten
the restoration of normal production and at the same time lessen the
degree of intestinal decomposition.

A large metal abdominal electrode covering the pylorus, connected
to one end of the d'Arsonval spiral while the patient is in contact
with a large dielectric or, better, with a large metal electrode over
the dorsal spine, connected to the other end of the spiral, excited by
a current of high heating value from a transformer up to 2000 milli-
amperee or higher, will quickly relieve the venous copgestion and
spasmodic state of the pylorus (when non-organic), frequently caus-
ing hitherto alarming symptoms to entirely disappear. The static
wave current over the stomach from a Holtz machine is very valuable
for its tonic effect in the above-described conditions.

Intestinal disturbances are of infinitely more direct importance
than gastric in the causation of arteriosclerosis. It is of the utmost
importance, when possible, that of these irregularities any and all
which make for the production of intestinal toxsBmia be eradicated.
Intestinal antiseptics are here comparatively useless, except for the
most temporary relief.

Once the condition has become developed, in which not only
bacterial decomposition is excessive, but also portal engorgement,
when the overworked liver-cells can no longer continue to return
through the biliary channels their repeatedly-absorbed portal vein

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32 INTEBNATIONAL CLINICS .

poisons, the immediate treatment indicated is removal by thoroughly
clearing out the intestinal tract either with castor oil or calomel
followed by saline. This temporary relief and useful beginning
should be immediately followed by irrigation of the colon as de-
scribed later.

The production of an active hyperaemia with the consequent
lessening of venous stasis and improved arterial flow as brought about
by d'Arsonvalization (described under gastric treatment, but with
the abdominal plate including the lower part of the liver) promptly
relieves hepatic congestion and enables the liver-cells to increase
the oxidation and transformation of nitrogenous bodies into urea,
thus restoring the normal renal stimulus and preventing the escape
into the general circulation and accumulation within the tissues of
suboxidized and deleterious material The static wave current applied
directly over the liver and abdomen through a large electrode and
with a very long spark-gap here renders excellent assistance.

When constipation exists it must be corrected by some selected
means until general treatment may reestablish normal tone. Some
cases of atonic constipation respond readily to careful massage, others
to vibration, but for permanency the improvement of the general
tone is vitally important. The latter is also essential for the eradica-
tion of abnormal absorption.

The sinusoidal current is one of the most effective means for
reestablishing intestinal tone. It is applied by means of a suitable
electrode, about eight by ten inches, over the abdomen, connected
to one pole, and an electrode four by seven inches placed either trans-
versely across the liimbar region or vertically extending from the first
dorsal vertebra downward. The treatment should be at least of half
an hour's duration and as strong as can well be borne.

Another current having similar effect and which may be classed
with the sinusoidal is the static resonator effleuve. This must be
obtained from a Tesla coil with specially heavy insulation and
gallon condensation jars of heavy coating. A large Holtz machine,
preferably one of sixteen plates, should be used as a source. A large
metal plate electrode connected to one terminal of the Tesla is
applied to the abdomen of the patient, who is insulated. A brush
or ring electrode connected to the opposite end of the Tesla, with
large solenoid interposed, approaches the patient to within eight to

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THB DIAGNOSIS AND TBEATMENT OF ABTEBIOSOLEBOSI8 OQ

twelve inches. This effleuve should be thoroughly applied from the
cervical spine downwards, but especially at the lower angles of the
8capul» and over the cutaneous liimbar branches until hypersemia
occurs.

In this way the abdominal muscles may be caused to contract
and relax as completely and rhythmically as desired. By repeating
this treatment daily, and later less frequently, striking evidence of
improved tone rapidly appears. By the use of one of these currents
or a judicious combination with the other factors (selected according
to indication) the production of complete contraction and relaxation
in the muscle, especially with the sinusoidal, results in thorough
emptying of the veins and lymphatics of their exudate and detritus,
which, alternating with the fullest possible inflow of fresh arterial
blood, rapidly leads to a marked increase in muscular and glandular
tona The intestinal decomposition decreases with improved state of
the mucosa and cessation of abnormal absorption or toxaemia.

The colon should be thorou^ly irrigated, at first daily, later
less frequently, with at least three quarts of normal salt solution,
by means of a long colon tube of soft rubber sufficiently flexible to
avoid injury to the mucosa, but firm enough to keep it from bending
readily upon itself. In this connection it is necessary to keep the
tube free from the slightest curve, which can be done by suspending
it from one end when not in use. Except in cases where unusual
obstruction exists, the tube can be carried up in the colon by any
carefuUy-trained and sensitive hand guiding it, but in troublesome
cases it is only possible to reach the colon by one with much experi-
ence, and in marked malposition or obstruction this all-important
procedure must, of course, be abandoned. Introduction of three or
four ounces of a saturated sugar solution in water, with a quarter
of a yeast cake added, allowing it to remain in the upper colon for
several hours, has proved itself to be of value in changing the culture
medium. Diuretic waters and alkaline laxatives must be used only
occasionally, because of the irritation produced by them and their
inhibiting effect under certain conditions on normal intestinal bacteria.

Skiagraphy indicates that many cases of severe intestinal toxse-

mia associated with extreme splanchnoptosis where the transverse

colon may be down in the pelvis recover, so far as clinical evidence

goes, without any marked change in the visceral location, implying

Vol. n. Ser. 25—3

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84 INTERNATIONAL OLINIOS

that the functional activity depends less upon displacement than upon
other factors.

Chronic interstitial nephritis, when moderate^ will yield to the
treatment outlined below. Clinical evidence indicates that in the
majority of these cases arrest of the disease and restoration of func-
tion as a whole take place. In the very far advanced cases decided
improvement results.

After paying full attention to all dietetic^ hygienic and other
therapeutic indications, the particular treatment for the kidneys con-
sists in applying four metal electrodes, each measuring about four
by six inches, for persons of average anteroposterior diameter, two
at the front and two at the back in such relation to each other that
each pair will lie directly in line with a kidney, the object being to
focalize the heat within each kidney. In thick abdomens a relatively
larger electrode should be used in front without increasing the size
of the posterior one. It will be found more practical to give this
treatment with the patient lying on his bacL

The anterior electrodes are now attached by suitable rheophore
connection to the outer coating of the Leyden jar on one side of an
efficient transformer, and the posterior electrodes similarly attached
to the opposite Leyden jar. These electrodes, as well as the skin in
contact with them, must be kept perfectly clean, and undue pressure
(as from electrode irregularity, folds, pimples, etc., on the skin)
must be avoided in order to prevent annoying bums.

By beginning the treatment with a small amount of current until
slight local perspiration occurs, forming good conduction, a general
and even contact will soon be established, making it possible to then
carry the current up to approximately 2000 to 2400 milliamperes.
This should be continued for half an hour daily until all granular
and epithelial casts, at least most of the hyaline and the most minute
traces of albumin have disappeared from consecutive twenty-four-
hour samples of urine for at least a week.

The number of weeks required by such treatment varies greatly.
Average cases do not require more than three or four weeks. Severe
cases may require proportionately longer, but all will eventually
yield in the most gratifying way, providing there remains a sufficient
amount of glandular continuity. The current effect no doubt acts

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THE DIAGNOSIS AND TBEATMENT OF ABTEBIOSOLEBOSIS 35

here as elsewhere, both directly and indirectly, upon the fibrous
exudate and tissue, as an absorbent.

The amount of current taken is limited by the sensation of heat
to the patient's skin. With proper connections and quality of cur-
rent 2400 milliampSres can usually be borne with comfort, giving a
sensation of penetration.

In severe cases the renal hypersemia so induced should be supple-
mented by general vascular and glandular flushing as brought about
by an oven-bath given either daily or less frequently, according to the
degree of suppressed metabolism and eliminatioiL The oven-baths
should be continued until the general elimination as shown clinically
becomes fully and permanently established. The twenty-four-hour
sample variations in urea and increase in total solid output in the
urine are very decided, as influenced by the oven-baths, in comparison
to the days on which no oven-baths are given. So long as any sub-
normal elimination exists the output of the twenty-four hours follow-
ing an oven-bath shows a marked increase over the twenty-four hours
preceding it, when the latter does not shortly follow an oven-bath.

It is quite evident that hypertension may originate from sup-
pressed metaholism; for instance, where the purin bodies are not
completely converted into urea, as in gout, but where, instead, the
suboxidation and faulty fermentation result in the formation of
undefined toxic bodies associated with phosphati6 production and,
later, uric acid and the urates. This condition, however, may not
be entirely independent of the digestive derangements.

The general treatment of such conditions is in the main covered
by that outlined above for digestive disturbances, the indication
being improved metabolism and elimination, which can best be ful-
filled through some of the following means as indicated: static
resonator effleuve, autocondensation, thermopenetration, static wave
current, oven-bath, and occasionally Ae brush discharge. Non-toxic
causes — ^local, obstructive, and reflex conditions which are of com-
paratively infrequent occurrence — are quite as important with regard
to their removal

The results obtained by the described means in the treatment
of arteriosclerosis are of a distinctly and highly permanent character,
depending upon how thoroughly it may be possible to alleviate causes,
and upon the extent of atheroma.

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36 INTEBNATIONAI. CMNIOS

Localized areas of arterial spasm are best treated bj statio
resonator effleuve (as described elsewhere) applied to the spine until
the skin becomes thoroughly reddened. As a result reflex stimulation
of hepatic and intestinal secretions occurs. This should be followed
by the oven-bath or by the static wave current with a large plate
applied to the abdomen, using a very long and slow spark.

Occasionally, for one reason or another, a case fails to respond
satisfactorily to the usual treatment, but in these cases one will
usually be rewarded by selecting some other modality acting along
similar physical lines.

FOE ADVANCED AND TERMINAL CONDITIONS.

In the far-advanced cases with marked atheroma, where mental
tardiness is so frequently a pronounced symptom, and less often
angina pectoris, removal of cause, when present and possible, is
important if anything is to be obtained beyond mere alleviation of
symptoms and prolongation of a comparatively safe and comfortable
existence.

Particularly in cases with mental symptoms, galvanism is often
beneficial, applied as follows : Across the forehead place the negative
metal electrode, about two inches by six inches, separated from the
skin by twelve to sixteen layers of surgical lint wrung out of a
three per cent, sodium chloride solution. With the positive electrode
similarly applied to the nape of the neck, from five to ten milliamperes
and, in exceptional cases, up to twenty miUiamperes may be given for
from ten to thirty minutes. Especial care must be taken that no
sudden change in contact or quantity of current be made, else ex-
tremely unpleasant sensations may result to the patient.

In angina pectoris, with a negative electrode over the sternum,
separated from the skin by the lint previously soaked in a solution
of sodium chloride or sodium salicylate, with the positive electrode
similarly prepared and applied from the first to the fifth dorsal spine,
using five to ten milliamperes as above, much relief is often obtained.
In advanced conditions of general sclerosis, where only comfort
and prolongation of life can be hoped for, much benefit may be de-
rived from moderate (about half) doses of autocondensation, fol-
lowed by the application to the skin of the abdomen of a large spiral
glass electrode excited from the Oudin to 200 or 300 milliamperes

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THE DIAGNOSIS AND TREATMENT OF ARTEBIOSCLEBOSIS 37

until a decided sensation of warmth is felt, accompanied by
hypersemia.

The technic for the relief of arterial contraction as previously
described must be methodically carried out for a longer period, and
when a marked suppression of elimination exists the ovetirbath, with
or without the catabolic influence of the static resonator effleuve,
has proved itself of inestimable value. It not only prolongs life,
but makes it comfortable by its general tissue-relaxing effect, and
aiding as no other agent does in promoting rapid elimination, in
maintaining peripheral dilatation without producing increase of local
blood-pressure at any point or endangering arterial rupture. Instead
of the rapid development of a very high temperature for this purpose,
a more gradual elevation to about 375° F. is desirable.

The oven-bath produces diuresis, relieves dyspnoea and lividity,
and reduces anasarca and oedema. When the oven-bath is not obtain-
able, a high candle-power incandescent light, including a large pro-
portion of heat rays applied over the body, and, in the case of angina
pectoris, applied locally, is of value.

The indications for immediate treatment in cerebral hemorrhage
are to lower hypertension and maintain the blood-pressure at a point
only sufficiently high to keep up an efficient compensatory circulation
without undue pressure being brought to bear upon the damaged
area. In this way less continued hemorrhage takes place and there
is greater possibility for more complete absorption and restoration
of function.

As has been demonstrated in a number of cases of apoplexy
where it was possible to promptly use autocondensation for lowering
the blood-pressure, the maintenance of a practically uniform, con-
stant, and moderate pressure as may be obtained by d'Arsonvalization
gives decidedly better results than the fluctuating pressure brought
about by nitrites or circulatory depressants. This prominent fact
may be due in part also to the more normal capillary circulation
resulting from the d'Arsonvalization as compared with the defective
capillary circulation resulting from the heart depressants. The treat-
ment of long-standing cases of cerebral hemorrhage is at the best
unsatisfactory.

In case of recent retinal hemorrhage d'Arsonvalization, when im-
mediately used, is promptly followed by absorption with either com-

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88 INTBRNATIONAI. 0LINI08

plete or almost complete clearing of the vision. When a residue is left,
the Bontgen ray is fairly efficient in promoting its absorption.

Without treating the subject of dietary, it may be said that, in
general, restriction of the total amount of food taken, especially of
the proteid element, meat fats, and sweets, to the least amount com-
patible with health and energy, substituting a fair proportion of
farinaceous lactose-bearing food, makes an appreciable difference
in the ease with which a hypertension may be controlled. Of itself
it occasionally, though seld(»n, reduces blood-pressure materially.

To sum up the treatment of arteriosclerosis: First, a correct
diagnosis is essential. In the second place, one should utilize every
available form of accessory treatment of distinct benefit, including
dietetic, hygienic, medicinal, etc In fact, nothing may be omitted
that is of definite value in desperate conditions.

Finally, in order to obtain desired results, physical treatment
on the principles outlined above is absolutely essential, and its proper
application insures in large percentages comfort, prolongation and
saving of life.

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SOME NEW PHASES OF EMETINE THERAPY

BY ALFRED S. BURDICK, M.D.

Editor, The American Journal of OUtUoal Medicine, Chicago, Illinois

When Leonard Bogers, of Calcutta, in 1912, took up the sug-
gestion made by Captain Edward B. Vedder, of the United States
Army, the preceding year, and demonstrated clinically that emetine
hydrochloride has a specific amojbicidal action, he made a discovery
of more far-reaching significance than most people seem to imagine.
Only one other therapeutic discovery of recent years can rival it in
importance — ^that of salvarsan. Not only has Eogers's experience
(a£( supplemented by that of many other physicians in all parts of
the world) demonstrated beyond doubt the specific curative action
of emetine in amoebic dysentery and amoebic hepatitis; it has had
another effect: it has led to a restudy of this important alkaloid and
to its application in a variety of other diseases, with results which
have been gratifying and, in some conditions, actually astonishing.
It is to some of the later uses that I wish to refer particularly in this
short paper.

The Use of Emetine in Hemorrhage. — Nearly a century ago
Trousseau recommended the use of ipecac in the treatment of
haemoptysis. For many years this method of treatment has been
employed by physicians — in France more than in America. Recall-
ing this fact, Flandin, of Paris, clinical assistant of Professor Chauf-
fard (the first French physician to apply the emetine treatment in
dysentery), conceived the idea of trying emetine in hsemopl^sis
occurring during the course of tuberculosis. It had been observed
that blood very rapidly disappeared from the stools of dysenteric
patients under emetine treatment, and this also suggested the possible
value of this substance in hemorrhagic cases. Flandin's report of
experience with emetine in hsemoptysis was published in Presse
Medicate, September 24, 1918.

The first case treated was that of a man suffering from very pro-
fuse tuberculous hemorrhage which had refused to yield to the usual

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40 INTEBNATIONAIi CLINICS

methods of treatment, such as ice, calciiim chloride, serum, etc. A
single injection of 0.04 gramme (% grain) of emetine hydrochloride
caused an abrupt cessation of the hsBmoptysis, while there was an
accompanying fall of temperature. Other cases were subsequently
treated in the same manner by Flandin, in association with Joltrain,
and with equally brilliant results. Since then the method has been
adopted by a large number of French physicians, including Lesng,
Eenon, Leon Bernard and Paraf, and Josue and Belloir. At a meet-
ing of the Societe Medicale des Hopitaux, July 18, 1913, Flandin
declared that up to that time he had personally seen twenty cases of
haemoptysis, all of which were successfully controlled with emetine.

This method of treatment wad soon adopted by English and
American physicians. For instance, Raebum, writing in the British
Medical Journal of March 28, 1914, is enthusiastic in praise of
emetine, agreeing with Flandin that the results obtained with the
drug in hemorrhage from the lungs have been far more satisfactory
than those secured by any other remedy or method. " At first," he
says, " I strictly confined myself to cases of hemorrhage on the
lines that Dr. Flandin had indicated, and with r^ard to its use in
such cases I can endorse all that he claims for it."

Eaebum also declared that not only does it check hemorrhage,
but it also serves to arrest the copious expectoration so often observed
in tuberculous cases.

While the number of published American reports of the use of
emetine in the treatment of hemorrhage from the lungs is relatively
small, there have come to the writer through personal sources of in-
formation a considerable number of such reports, and thus far these
have invariably been favorable. The following communication from
Dr. R. S. Irwin, of Denver, Colo., is a fair sample :

" My use of emetine hydrochloride has not been extensive enough
to give much data as to the value of this remedy in pulmonary hemor-
rhage. However, I have used it in eleven cases of hemorrhage with
good results; it gradually reduced the amount of blood, while
diminishing the cough and lessening the amount of sputum."

It will be noted that Doctor Irwin's observation with regard to
the effect of the emetine upon the amount of sputum verifies that
of Doctor Eaebum, already cited.

Emetine is also being used successfully in the treatment of other

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SOME NEW PHASES OF EMETINE THEBAPT 41

f omiB of hemorrhage. One of the first to recommend it was Eamond,
who used it successfully in the treatment of hemorrhage occurring
during typhoid fever. His comment is that under its use ^' intestinal
hemorrhage ceases as by enchantment'' It is proper to add, however,
that not all French clinicians have obtained equally favorable results
with emetine in the treatment of hemorrhage from this site, although
the consenetus of opinion is decidedly favorable.

Emetine has also proved very efficacious in the treatment of
hemorrhage from other sites. For instance, Dr. James T. Prestley,
in the New York Medical Journal, reports a case of nose-bleed occur-
ring in a woman of seventy-three, coming on regularly every night
for about ten days. One-half grain of emetine hydrochloride, given
hypodermically, checked the hemorrhage within twenty minutes, and
the result was maintained by one-half grain daily injections for five
succeeding days.

There have also been published favorable reports of the use of
emetine in the treatment of hemorrhage occurring in hsematemesis,
in the course of Barlow's disease (infantile scurvy), hemorrhagic
disease of the new-bom, uterine hemorrhage, rectal hemorrhage,
hemorrhage from the gums, and from other sites. Dr. Joseph Wein-
stein, of New York, is using emetine hydrochloride injections to
prevent and control the hemorrhage so often found associated with
tonsillar operations, and is enthusiastic in its praise. (See Medical
Record, January 16, 1915.) Dentists are using emetine to arrest
hemorrhage following tooth-extraction, and with alleged good results.

The writer is free to confess that, while he may be over-
enthusiastic, he has not thus far seen or heard of a single case of
hemorrhage in which this drug, promptly used, was a complete
failure. The evidence available indicates that emetine is, perhaps,
the most generally effective remedy thus far introduced for this pur-
pose, although the test of time is still lacking.

The usual dose of emetine hydrochloride as an antihemorrhagic
is from one-half to two-third grain, given hypodermically. According
to Flandin — and his observations are verified by other physicians —
such a dose of the drug causes almost instantaneous arrest of hemor-
rhage, and this result is obtained without producing any of the dis-
tress, nausea, and vertigo so frequent when the parent drug, ipecac,
is administered in large doses. French writers give the warning that

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42 INTEBNATIONAL CLimCS

the arrest of hemorrhage is not necessarily permanent, and, to insure
the patient against a recurrence, it is advisable to continue treatment
with one or more daily injections until the hemorrhagio habit is
under control

Emetine in Respiratory Diseases. — ^For generations ipecac has
been much employed as a nauseant expectorant in the treatment of
respiratory diseases. There is now accumulating considerable evi-
dence that the remedy had some beneficent action in this class of
diseases aside from that due to its expectorant properties. Just what
this action is has not been clearly determined, but Baebum, Flandin,
and others who have studied it believe the remedy has a marked
decongeettant action.

E6non, in a paper read before the Soci6t6 MSdicale des Hopitaux
{Gazette des Hopitaux, March 12, 1914), declares that the drug is
of great value in the treatment of pneimionia and bronchopneumonia.
Under its influence, he declares that, while the disease (lobar pneu-
monia) is not cut short, the temperature falls, the dyspnoea is reduced,
and the whistling rales are rapidly replaced by large subcrepitant
rales. The disease usually disappears by lysis. In bronchopneu-
monia, and especially in old patients, even when the disease is of a
severe type, this effect is even more clearly evident than in the lobar
type of pneumonia. Again, there ief a reduction of dyspnoea, fall of
temperature, and greater facility of expectoration. The experience
of this writer is in accord with that of Eamond, who has used it with
good results in acute and chronic bronchitis.

James A. Eaebum (see British Medical Journal, March 28, 1914,
p. 703) has particularly studied the action of emetine in pulmonary
tuberculosis. He has used the drug in more than forty cases, and
has come to some very interesting conclusions. He declarefl( that it
usually produces marked reduction of the expectoration, especially
in cases in which this is copious, and its influence upon congested and
inflammatory conditions of the lungs seems to be a very favorable
one. Doctor Baebum divides his cases into three groups:

First, those of the pretubercular stage, — ^that is, in which there
is bronchitis with no demonstrable tuberculosis. Provided the heart's
action is not impaired, the cases of this group nearly always improve
rapidly under emetine treatment The expectoration disappears,
and on auscultation the moist sounds cease to be heard. This im-

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BOMB NBW PHASES OF EMSTINB THBBAPY 43

provement is not transitory, but remains after the injections of
emetine are discontinued*

The second 'class of cases comprised those which are tuberculous
but in which the tubercle bacilli are not found in the sputum. All
of his patients of this class have improved under emetine treatment.
Doctor Baebum agreed with Doctor Flandin, that in this type the
action of the drug is essentially that of a decongestant; in other
words, it acts upon the attendant bronchitis rather than upon the
tuberculosis per se.

The third group includes the cases of a frankly tuberculous type,
in which the specific bacilli are found in the sputum. In this class
improvement was less uniformly marked than in the preceding two.
On the whole, however, the emetine was apparently of value in a
considerable percentage of eruch cases.

One contra-indication to the use of emetine hydrochloride in
pulmonary disease, according to Doctor Kaebum, is weakness of
the heart's action. In these cases the congestion iM secondary to the
weakened circulation — of the passive type. Doctor Baebum con-
cludes that the emetine hydrochloride has no specific action upon
the tubercle bacillus. It does, however, decidedly reduce congestive
conditions in the lungs, and is therefore both a preventive and cura-
tive agent in tuberculosis. In these pulmonary cases Doctor Kaebum
uses smaller doses than are generally employed for the treatment of
hemorrhage.

Pharmacologic Action of Emetine. — There has been much specu-
lation as to the manner in which emetine controls hemorrhage.
Flandin and other French physicians who have written much upon
the subject assure us that it deed not lower blood-pressure nor increase
the coagulability of the blood. That it does check hemorrhage, how-
ever, is undoubted; but, so far as we have been able to ascertain,
Maurel is the first to offer a definite explanation of its mode of
action. In a paper read before the French Academy of Medicine,
published in the March, 1914, number of the BuUetin of the Acad-
emy, he advanced the theory that its therapeutic action depends mainly
upon the power of the drug to influence the smooth, or unstriped,
muscle-fibres. It acts by contraction of these fibres in the blood-
vessels, thus causing vasoconstriction.

This theory is based upon a restudy of Claude Bernard's laws

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44 INTBRNATIONAL CLINICS

as to the selective action of drags upon specific tissue elements, and
it was worked out after an elaborate series of experiments made upon
eels, crawfish, frogs, and rabbits. All the pharmacodynamic proper-
ties of emetine, he believeef, can be explained through its influence
upon unstriped muscle.

In discussing Maurel's paper. Professor Chauffard stated it as his
opinion that the action of emetine as a vasoconstrictor must be limited
to the capillary system. An objection to Maurel's theory, at least
in its application to hemorrhage, is the apparent failure of the drug
to influence blood-pressure.

At my suggestion, Mr. Carl Neilsen, pharmacologist to The
Abbott Laboratories, has undertaken an elaborate series of experi-
ments relative to the haemostatic property of emetine. His report ap-
pears in the March, 1916, number of the American Journal of Clinical
Medicine. Mr. Neilsen was able to verify the observations of Flandin
and others, that in therapeutic doses emetine does not markedly in-
fluence the blood-pressure. Experiments upon dogs show that, as a
rule, there is at first a slight reduction of blood-pressure, then an in-
crease to a considerable d^ree above normal, then in a few minutes a
return to normal. There is usually a slight reduction in the rapidity
of th6 heart's action, this becoming more marked with increase of
dosage. A very careful series of experiments made by Mr. iNeilsen also
showed that in therapeutic doses emetine hydrochloride does not in-
fluence the physical composition of the blood nor increase its co-
agulability.

In toxic doses emetine produces increased salivation, nausea,
vomiting, slowing of the pulse, and muscular weakness; and in
lethal doses, centric paralysis with arrest of the heart in diastole.
Vomiting is apparently produced by local gastric irritation.

Apparently Professor Chauffard is at least partially right in his
assumption that hemorrhage is controlled through the action of the
drug upon capillary circulation. I quote the following interesting
report from Mr. Neilsen's record :

" A series of six frogs were ancesthetized with ether and the
intradigital membrane of the left hind leg stretched out and observed
imder a microscope. During the entire experiment the membrane
was kept moist vnth Singer's solution. Five to ten minutes were

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SOME NEW PHASES OF EMETINE THERAPY 45

allowed to elapse in order to permit the circulation of the blood to
become normal and regular.

" The rapidity of the circulation in a series of vessels in a chosen
field, as well as the size of the latter, was now closely and carefully
observed. Then % Cc. of a 1 to 1000 solution of emetine hydro-
chloride, in physiologic salt solution, was injected into the abdominal
lymph sac

^^ In all the experiments the same results were obtained: Five
minutes after the injection the circulation in the smaller capillaries
became slower ; in another ten minutes the decrease in the rapidity
of the circulation in the smaller capillaries was considerable and that
in the larger capillaries noticeable ; and during the next thirty minutes
the rapidity decrease gradually until it stopped completely in most
of the smaller capillaries, and became so slow in the larger capillaries
that eadi blood-corpuscle could be distinctly followed on its course
through the vessels. It was also noticeable, without the use of a
micromillimetre scale, that the capillary vessels had been contracted.
In a few cases the dose was repeated, and this, of course, produced a
more rapid effect The effect lasted a considerable time (more than
one hour) ; thereafter the rapidity of the circulation again increased
gradually to normal and all the frogs recovered.

" This experiment is so beautiful that it cannot be too strongly
recommended as a demonstration of the effect of emetine. '^

Emetine in Pyorrhcea. — At the meeting of the Pennsylvania
State Dental Society, held in June, 1914, M. T. Barrett and Allen
J. Smith (see Denial Cosmos, August, 1914) reported the results of
some careful investigation into the etiology of pyorrhoea alveolaris
(Kiggs's disease) . These investigations eventuated in their announce-
ment of the discovery of the uniform presence of an amoebic organism
in the gums and pericemental tissue obtained from persons suffering
from pyorrhoea. In all, forty-six cases were examined, and the organ-
ism was found in every one. These amoebse were subsequently
identified as the Entamceba buccdlis.

These results were subsequently verified by Bass and Johns, of
Tulane College of Medicine, New Orleans. The first announcement
of their work was published in the October, 1914, number of the
New Orlea/ns Medical and Surgical Journal, the details being sub-
sequently published in the November number of the same joumaL

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46 IKTTBBNATIONAL 0LIKI08

Several later papers by these gentlemen^ and others^ have appeared in
the Journal of the American Association^ and elsewhere. Base and
Johns examined 130 cases of pyorrhoea and found the anuBba con-
stantly present in nearly all cases of the disease^ varying from the
earliest to the latest. In only three cases did they fail to find
any organisms; in at least one of these there was some doubt as to
the identity of the disease. Bearding this organism, Doctor Bass
says:

^^ The amoebse are easily demonstrated in either fresh or stained
specimens. The pus or scrapings from the depth of the lesion should
be diluted with a little water or salt solution on a slide, covered with
a cover-glass, and examined. Motile amoebse from about eight to
about thirty microns in diameter are usually readily found. An
excellent stain is carbol fuchsin, ^ minim, followed by Loffler's
methylene blue, ^ minim. In stained specimens, dark-stained objects,
apparently the nuclei of pus-cells, can be seen inside the parasites."

In view of the brilliant results obtained by Bogers in the treat-
ment of another amoebic disease, tropical dysentery, through the use
of emetine hydrochloride, Barrett began the administration of this
remedy in a series of cases, using it at first locally only. Working
quite indep^idently, Bass and Johns took up the use of the same
drug, but employed it in the main subcutaneously. The results
obtained by both investigators were brilliant from the very start
Barrett, for instance, first injected a 1 per cent solution of emetine
hydrochloride in the pockets around the affected teeth, but, as the
drug in this strength seemed to produce irritation, he subsequently
reduced the solution to one-half per cent strength. This solution
was used to fill the gingival sacs of the affected teeth.

Thirteen individuals were treated with emetine in thitf manner.
In several the pus disappeared completely to gross inspection within
twenly-four hours. In every one of the thirteen cases this result was
obtained after three daily applications. There was an associated
improvement in the local conditions; the tissues took on a more
healthy appearance, the teeth became firmer, and the gums settled
down more tightly about the roots of the teeth. In none of the cases
treated by Doctor Barrett were the amoebae found after the second or
third treatment. Usually apparent cure was obtained after five or
six such treatments, although at the time this report was made the

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BOMB NEW PHASES OF BMBTINE THEBAPY 47

rneihod had not been tried long enough to establish the permanency
of cure.

Equally brilliant results were obtained by Bass and Johns, who
say : ^^ In more than one hundred cases treated we have found
amoebee constantly absent from the lesions in all except two cases
after the patient had been given one-haK grain emetine hydrochloride
hypodermically daily for three successive days. The tendency to
bleed stops in twenty-four to forty-eight hours, and, where only the
soft tissue is involved, the red, inflamed gums often appear practi-
cally normal in from three to ten days — apparently as quickly as
nature can heal them. Where the bony structure is involved and the
teeth are loose there are also rapid improvement and relief from
soreness and pain. The pus decreases and loose teeth often get
firmer in a few days, but it must be remembered that in most cases
where the disease has extended thus far the peridental membrane is
destroyed to a great extent, often almost to the end of the root.
Nature cannot grow new peridental membrane, and retraction must
therefore take place to the level of the living membrane. The heal-
ing process can be very much hastened by dental treatment, such as
scaling, scraping, cleaning, and removing overhanging tissue. It
must not be expected that removal of the specific cause and the best
dental treatment can save teeth denuded of peridental membrane
to the very end of the root and hanging in a suppurating cavity or
tooth socket"

It suffices to say that the results obtained by these pioneer in-
vestigators have already received what appears to be ample verification
in the experience of many physicians and dentists. Beports thus
far received from many sources are uniformly good. Such failures
as have come to the writer's attention have been mainly due to errors
*in technic, one of the most common being the use of too strong
solutions in the mouth, or the attempt to inject the emetine solution
directly into the patient's gums. When this is attempted the re-
action often proves very severe. A few failures have been reported,
and it is as yet too early to assume that the remedy is specific in all
instances.

The method of treatment now usually advised and apparently
giving the best results is a combination of that advocated by Barrett
and Bass ; in other words, the local application of a weak solution of

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48 INTEBNATIONAL CLINICS

emetine hydrochloride (one-half per cent, or even lees in some cases),
together with subcutaneous injections of the emetine. Usually one-
half grain of this drug is injected into the arms once daily for three
or more successive days, and a similar dose administered every three
to ten days, according to the severity of the case and the degree of im-
provement. It is advised to make the injections first into one arm,
then into the other, since there is likely to be some tenderness and
occasionally very troublesome itching.

Inasmuch as pyorrhoBa is one of the most common diseases known
to man, and since it is now known to be an important etiologic factor
in the production of a number of serious systemic diseases, includ-
ing rheumatism, acute and chronic, arthritis deformans, neuritis,
pernicious ansemia, and various visceral degenerations, the importance
of Barrett's and Smith's discovery cannot be overestimated. If, as
now seems to be the case, pyorrhoea is caused by an amoebic organism,
and this organism can be definitely destroyed by emetine, then another
real specific of extreme value to the race has been added to our too
scanty number of really dependable therapeutic weapons.

Emetine in Systemic Diseases. — The importance of the amoebic
factor in the etiology of a number of diseases has recently been
accentuated by the announcement made by Smith, Middleton, and
Barrett in The Journal of the American Medical Association (No-
vember 14, 1914), that at least some cases of chronic tonsillitis
apparently are due to this organism. Pyorrhoea and tonsillitis have
both been connected with the etiology of rheumatism. There is a
tendency to consider them foci of entrance for an increasing number
of infectious organisms. Since emetine will cure or relieve some
of the oral conditions which are responsible for systemic ailments,
it is reasonable to believe that the same drug may prevent and
possibly cure such diseases as acute and subacute rheumatism,
arthritis deformans, neuritis, and probably other diseases of amoebic
origin. Experience in this field is as yet too small to draw sweeping
conclusions, but it is large enough to encourage every physician
who is called upon to treat a recurrent arthritic affection, for instance,
to make a careful examination of the tonsils and gums, and if these
structures are found diseased, and particularly if the Entamoeba
biu^calis is found in the mouth, to make faithful therapeutic trial
of emetine hydrochloride.

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SOME NSW PHASES OF EMETINE THERAPY 49

I have not tried to cover the whole subject of emetine therapy.
The most brilliant evidence of its specific action^ its use in amoebic
dysentery and amcebic hepatitis, sprue, and lamblia dysentery, I
have not touched upon at all; neither have I referred to its alleged
cholagogue action, its possible cathartic action, its questionable value
as an emetic, nor to its use in cholera and in typhoid fever. It is
enough to emphasize in this paper the value of this promising remedy
in hemorrhage, as decongestant in bronchitis, pneumonia, and pul-
monary tuberculosis, and as a specific in pyorrhoea alveolaris, and
to express the hope that American physicians will give it the careful
study which it deserves.

Vol.. n. S«r. 26—4

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ANIMAL EXTRACTS IN THE TREATMENT OF MEDICAL

DISEASES

BY GRAHAM CHAMBERS, BJi., M3.
ABSocUte Professor of Clinical Medicine, University of Toronto

Thsbe is no field of therapeutics in which the results may be
more valuable than in the medicinal use of the animal extracts.

Let us take, for instance, the use of thyroid. If in a case of
myxoedema, of not too long standing, one administers from ten to
fifteen grains of thyroid daily, the health of the patient is, as a rule,
in a few weeks apparently restored and remains so as long as the
drug is administered. The change for the better is so rapid that
one is apt to marvel at the mode of action of the drug. Why does
the exhibition of thyroid relieve the symptoms of myxoedema ? The
answer to this question has been solved by our knowledge of the
pathology of the disease; for we know that the manifestations of the
affection are caused by hyposecretion of the thyroid gland. In the
administration of thyroid extract we simply make up the deficiency,
and, so far as we are able to determine, the administration of the
drug is just as valuable in the human economy of the patient as
receiving it from his own thyroid. This is the best-known use of an
animal extract. It is mentioned here merely to illustrate how effec-
tive thyroid extract is in the treatment of hypof unction of the thyroid
gland.

Let us now inquire as to the therapeutic value of other animal
extracts in the treatment of hypofunction of the glands of internal
secretion.

There are a number of glands upon which observation has be^i
made. The results have been most unfavorable. But, in order that
a more definite statement of the value of the method of treatment
may be placed before you, I shall give, in this connection, a brief
summary of the subject, including a statement concerning the thyroid.
60

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ANIICAL XZTRAOTS IN TBBATMBNT OF DISSASSS 61

BI8EASSS OF THE GLANDS OF INTEBNAL SEOBETION OHABAOTSfilZBD
BY HYPOFTTNOTION, WITH TEEATMBNT BY ANIMAL BXTBACTS

SuKMABY. — Thyroid Oland (Cretmism and myxoedema). — Thy-
roid extract improves the first and relieves the second so long as the
remedy is administered.

Parathyroid Glands. — ^Removal causes tetany. Tetany in preg-
nancy is believed to be due to hypofunction. Some observers have
reported that parathyroid eztrfu^ partially relieves the cfymptoms of
tetany.

Hypophysis, or Pituitary Olands. — This is made up of three
divisions, viz., anterior, middle, and posterior lobes. Hypofunction
of the anterior lobe produces obesity, hyperplasia of the genital
organs, headache, and other manifestations of the £fymptom-complez
known as dystrophia adiposa genitalia (Frohlich's syndrome) ; in
young children hypofunction produces dwarfisms. Eixtracts of the
anterior lobe are ineffective. Pituitrin extracted from the posterior
lobe is also ineffectual, but has many pharmacological characters of
value.

Suprarenal Olands. — ^Hypofunction is a marked feature of Addi-
son's disease. Extracts of the gland ar^ ineffective.

Epiphysis Cerebri, or Pineal Oland. — In children hypofunction
probably causes overgrowth, obesity, and general precocity. The
gland extracts are ineffectual.

Thymus. — This gland normally undergoes involution between
the ages of ten and fifteen years. Hypofunction is probably present
in marasmus and wasting diseases in young children. Thymus ex-
tract is without effect.

Pancreas. — ^Hypofunction of the islands of Langerhans is present
in diabetes. Extracts of the pancreas have practically no effect

Ovaries. — In children hypofunction produces infantilism; in
adults, amenorrhoea and obesity. Oophorectomy in adults causes
symptoms similar to those of the climacteric. Ovarian extracts are
probably ineffective, although some physicians report favorable
results.

Testicles. — ^Bemoval before puberty causes obesity, overgrowth
of bone, definite growth of hair on face, etc. Testicular extracts are
ineffective.

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62 INTEBNATIONAI* CLIiaOS

These observations go to show that, with the exception of thyroid,
animal extracts are of little value in correcting hypofunction of the
glands of internal secretion. The reason for this is probably that
the thyroid is the only gland of internal secretion in which the active
principle is stored in any quantity. In all the others the active
principles are stored not at all, or only to a slight extent, but pass
directly into the blood, in which they are quickly decomposed. Again,
thyroid extract is a stable substance, and two or three doses a day
are sufficient to supply the human economy of a myxoedematous patient
with sufficient active principle for the maintenance of metabolism.
It is quite different in the case of adrenalin or pituitrin. The period
of activity of adrenalin, given intravenously, is only a few minutes,
and that of pituitrin is probably not much longer. It is obvious,
therefore, that it is futile to attempt to relieve the symptoms of
hypofunction of the pituitary and suprarenal glands by the exhibition
of pituitrin and adrenalin, respectively. This is a very important
consideration in forming an opinion as to the value of animal ex-
tracts in the treatment of disease in general If a disease is chronic
and of such a nature that a more or less continual action of a remedial
agent seems necessary to cure it, it is not likely that most of the
animal extracts would prove effective.

THE INTEBBELATION OF GLANDS OF INTEBNAL SEOBETION COMBINED

THEBAPY WITH ANIMAL EXTBACTS

The data which have been collected from the study of hypofunc-
tion and hyperfunction of the glands of internal secretion indicate
that the active principles do not act independently, but are inter-
related in their functions and modify more or less the physiologic
actions of one another.

Thus in hyperthyroidism there is, as a rule, diminished tolerance
for sugar, while in hypothyroidism the tolerance is increased. This
suggests that the functions of the thyroid and pancreas are, as regards
part of their activities at least, antagonistic. Hyperthyroidism is
always characterized by irritability of the sympathetic nervous sys-
tem, which is itself closely related in function to the suprarenals.
Again, functional activity of the pancreas is dependent, to a certain
extent, upon the activity of the suprarenals. If a large dose of
adrenalin is administered to a healthy individual, glycosuria gener-

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AJSmiAL XZTBA0T8 IN TBBATMBNT OF DISXASBS 53

ally ensues. This indicates a close relationship between the adrenals
and pancreas. One might give many other illustrations of the
interrelations of glands. All this goes to show the close relationship
of the glands of internal secretion. It would appear that in a normal
individual the glands form a chain of functional activities. If the
function of any link of the chain is materially altered^ then the health
of the person suffers, not only from the altered function of the
individual gland, but also by changes engendered in others.

The interrelation of the glands of internal secretion makes the
study of the use of animal extracts in the treatment of disease diffi-
cult. It is one of the principal reasons, I think, why so little progress
is being made at the present in this field of therapy. Compared to
what appears to most of us to be unknown, we know very little about
the medicinal use of the animal extracts. We recognize the remark-
able action of thyroid extract in cretinism and myxcedema. We have
a valuable fund of knowledge concerning thyroid extract, pituitrin,
and adrenalin, based on the pharmacologic action of these drugs.
But it is probably only a little of what investigators in the future
will bring to our aid. The question is : Should we use in an almost
empirical manner extracts of the ovaries, testicles, lymphatic glands,
liver, and of other glands of the body ? Many physicians think we
should employ these agents. Some prescribe them individually, while
others combine several animal extracts, believing, by so doing, there
is greater chance of ^' striking the mark." The French clinicians are
prone to adopt the latter plan.

ANIMAL EXTBACTS IN THE TREATMENT OF FUNCTIONAL NEBVOUS

DISEASES

During recent years there has been considerable' change in our
views concerning the pathogenesis of functional diseases. We now
recognize that many of the so-called functional nervous disorders are
really due to toxic substances. Chorea, for instance, until recently
looked upon as a functional disease, is now believed to be caused by
the toxins of acute rheumatism. In acute infectious diseases, such
as pneumonia and typhoid fever, we may see a great variety of
nervous symptoms, such as hallucinations, delusions, tremors, and
spasms, which are no doubt of toxic origin. If these manifestations
did not occur in the course of a known infectious toxaemia, they would

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54r INTSBNATIONAL CLINICS

no doubt be looked upon as functional in origin. Is it, therefore^
not probable that many mental states, both in health and disease,
have a material origin ? If we accept this hypothesis, which appears
to me to be rational, then from our knowledge of physiology we look
to the glands of internal secretion as one source of the chemical
substances (hormones) which effect these changes. We may also
blame these structures for inefficiency in protecting the economy from
toxins generated in various parts of the body, for we believe that this
is one of the functions of glandular secretion, at least of some of the
glands. We know that the state of some of the glands has an intimate
relationship with the condition of the nervous system and, in particu-
lar, of the sympathetic. In Graves's disease the cfympathetic nervous
system is always in an irritable state, and in the fulminating type of
the disease there are marked delirium and other signs of mental dis-
ease. On the other hand, in myxoedema there are signs of want of
excitability in the sympathetic. Parathyroidectomy frequently re-
sults in tetany. Removal of the ovaries or testicles invariably pro-
duces mental changes. Among the patients in hospitals for the insane,
signs suggesting disturbances of the function of the glands of internal
secretion are common. All these facts seem to indicate that animal
extracts should be useful in the treatment of functional diseases of
the nervous system. At the present, however, our knowledge of
glandular secretions is so meagre that we have very little to guide
us in their administration in this field of therapy.^ The most memo-
rable statement which has been made on the subject was that of
Brown-Sequard, who, experimenting on himself, found that testicular
extract had a most beneficial effect. Brown-Sequard was seveDty-
two years of age at the time, and, according to his statement, the drug
produced a state of mental vigor which he had not experienced for
some years. At the time considerable credence was given to the
statement. Later it was thought the effect was due to suggestion,
which opinion is the one generally accepted at the present time.

The question naturally arises in connection with this statement:
What is the nature of the suggestion ? Is it possible that the extract
did produce transient improvement, and this, by suggestion, led the
way to a continuous betterment? I am firmly convinced that this
course frequently happens in the cure of disease. Anything which
we can do by the exhibition of drugs, by the use of baths, or other

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ANIMAL EXTRACTS IN TBSATMENT OF DISEASES 55

remedial agent which tends to make the patient feel better, even for
a few minutes, is frequently helpful. The patients who are con-
tinuously feeling miserable are very difficult to cure. Is it possible,
therefore, that the exhibition of an animal extract, such as that of
the testes or ovaries, may be the means of starting the curative process
in action t I may say that I have never used testicular extract, but
I have exhibited ovarian extracts in the treatment of the vasomotor
disturbances of the climacteric with, I think, some success.

THE MEDIOINAL USE OF ANIMAL EXTBAOTS BASED UPON THEIB
PHABMAOOLOOIO ACTION

Reference has already been made concerning the use of animal
extracts in relieving hypofunction of glands of internal secretion.
In this connection the use of the drugs will be considered in a wider
sense, — i.e., based upon their pharmacologic action. Unfortunately,
there are only three drugs, namely, adrenalin, pituitrin, and thyroid
extract, the physiologic actions of which have been studied. My
remarks in this connection will therefore be limited to these three
remedies.

Adrenalin. — This is the active principle of the medullary portion
of the suprarenal gland. A common drug in use is a solution of
active principle (1 to 1000). Other names of the active principle
are epinephrin, suprarenin, and paranephrin. Epinin is an artificial
product very similar to adrenalin. Adrenalin is a stimulant of the
ends of the sympathetic (not the autonomic). Therefore its exhibi-
tion will increase the normal action of that division of the nervous
system, acting on all parts of its distribution, including the thoracic
and abdominal viscera and the blood-vessels. If the sympathetic
is a motor nerve, the administration of adrenalin will increase the
action. On the other hand, if the sympathetic is inhibitory, the ex-
hibition of the drug will increase the inhibition. These are the
principles which guide us in the use of adrenalin in the treatment of
disease.

The principal diseases and morbid conditions in which the internal
administration of adrenalin has been found useful in treatment are
asthma, gastric hemorrhage, pain of gastric and intestinal diseases,
and circulatory failure. I shall discuss briefly the use of the drug
in the treatment of these affections.

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56 INTSBNATIONAIi CLIKIOS

Asthma, — This is characterized by spasm of the bronchi and
bronchioles. In the treatment of the spasm it is important to keep in
mind the nervous supply of the bronchi, as well as the different ways
in which the spasm may be produced. The vagus supplies both
motor and afferent filaments. The sympathetic is inhibitory. The
spasm is generally believed to be the result of reflex action through
irritation of the bronchi, mucous membrane of the nose, stomach,
and other parts of the body, the motor nerve in the reflexes being the
vagus. The function of the sympathetic is to check undue spasm
produced by these reflexes. If the action of the sympathetic is in-
effective, then asthma results. The use of adrenalin in asthma is for
the purpose of increasing the inhibitory action of the sympathetic
The dose is ten to fifteen minima of adrenalin solution (1 to 1000)
administered hypodermically. Some clinicians extol the use of ad-
r^ialin in the treatment of this disease. My experience is limited to
about fifteen cases. In most of these the exhibition of the drug gave
a great deal of relief from the dyspnoea ; in one there was no apparent
improvement. In one case a paroxysm was checked by fifteen minims
of adrenalin, combined with one seventy-fifth grain of atropin sul-
phate. In the exhibition of these two drugs an attempt was made to
diminish spasm in two ways, namely, (1) by stimulating the sym-
pathetic, which is an inhibitory nerve, and (2) by depressing the
motor filaments of the vagus by means of atropin.

The use of adrenalin in the treatment of asthma may be criticised
from the fact that the period of its activity is short It is well to
remember, however, that there is frequently a good deal of psychic
disturbance in asthma, and relief for a short time may, in itself, be
helpful.

Oaslric Hemorrhage. — The exhibition of adrenalin solution per
OS, twenty to thirty minims, in half an ounce of water, every half
hour for five or six doses, is, I think, a rational measure in the treat-
ment of this affection, for a hsemostatic action may be obtained with-
out any perceptible rise of blood-pressure. It is obvious that the best
time to begin the exhibition of the drug is immediately after the
patient has vomited blood, for then there may be a little dilution of
the adrenalin solution, and obviously more effective action. The
reason why adrenalin, exhibited per os, does not produce a rise in
blood-pressure is no doubt due to most of it passing into the intestine

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ANIMAL EXTRACTS IN TREATMENT OF DISEASES 57

and being decomposed in the alkaline juices of the intestinal canal.

PoMi of OastrtHntestindl Disease. — From an etiologic standpoint,
two kinds of pain, in diseases of the stomach and intestine, are recog-
nized. One kind is caused by spasm of the musculature; the other
by traction on adhesions between the viscera and parietal peritoneum.
It is in the treatment of the first kind of pain that adrenalin is use-
ful As in the bronchi, the sympathetic is the inhibitory nerve, except
possibly in the sphincters, and therefore the stimulation by adrenalin
should tend to reduce the spasm. As in the treatment of asthma,
the addition of one one-hundredth grain of atropin sulphate would
probably augment the antispasmodic action of the drug, for in this
viscus the vagus is the motor nerve, and the exhibition of atropin
tends to paralyze the ends of its filaments. In a number of cases in
my service in the Toronto Greneral Hospital, by means of the fiuoro-
scope or, where possible, by ordinary observation, the action and the
effect of the administration of adrenalin hypodermically upon the
peristalsis of the stomach have been watched. The results were very
variable. In one case of pyloric obstruction with active peristalsis
the administration of adrenalin abolished every sign of movement
in the viscus. In another case of the same disease it produced no
apparent effect. In cases of gastric ulcer with patent pylorus the
action was variable. The drug was administered hypodermically in
ten- to fifteen-minim doses. We have also given adrenalin for the
relief of the pain of gastric ulcer with results which have been, as a
rule, only partially successful.

CtrcuUUory Failure. — ^In the treatment of circulatory failure one
would think, from the study of the physiology of the circulatory
system, that adrenalin would prove an ideal drug. We know that
the medulla of the suprarenal gland is part of the sympathetic which
supplies the motor nerves of the blood-vessels. We also believe that
the suprarenals, by means of their hormone — adrenalin — ^take an
important part in the maintenance of the normal blood-pressure. If
the blood-pressure falls, it is possible for the suprarenals, by increas-
ing the outflow of adrenalin, to raise it again, for the greater the
quantity of adrenalin in the blood the higher the blood-pressure.
From the consideration of these data it would seem that the ad-
ministration of adrenalin would be an effective method of treatment
of circulatory failure with low blood-pressure. In practice, however.

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68 INTBBNATIONAIi CLINICS

its use for this purpose has been disappointing to a great extent
The principal reasons for this are briefly as follows :

1. Adrenalin exhibited per as has practically no eflFect on blood-
pressure^ owing^ no doubt, to the decomposition of most of the drug
by the alkaline juices of the intestines.

2. Adrenalin administered intravenously produces a sudden rise
of blood-pressure, which, however, lasts only for two or three minutes.
The rise is so abrupt and the increase so great that the exhibition in
this way is, I think, not free from danger. Some time ago, in a case
in which I administered three minims of adrenalin solution (1 to
1000), diluted with 10 Cc. of normal saline solution, intravenously,
the blood-pressure rose from 150 mm. to 195 mm. mercury in a few
seconds. The patient complained of severe pain, first in the head
and then in the back. All the symptoms disappeared and the blood-
pressure dropped to 125 mm. in three or four minutes. It is obvious
that the patient was not free from danger in this experiment, and
one can readily understand how the exhibition of adrenalin intrave-
nously may cause trouble, especially in elderly patients or in persons
with arterial degeneration. In emergency cases, such as the treat-
ment of shock, and poisoning by chloral hydrate or chloroform, the
administration of a minute quantity, say one drop, diluted with
normal saline, every fifteen minutes, might prove helpfuL

3. The administration of adrenalin hypodermically frequently
produces pain at the seat of injection, and with a moderate dose
there is very little rise of blood-pressure, which does not last more
than one or two hours. In this connection I should like to append a
report of a long series of careful observations on the action of adrena-
lin on the blood-pressure and pulse made by Dr. H. M. East, Toronto.

BFFBCT OF EPINEPHBIN AND EPININ ON THE BLOOD-PBESSUBB AND

PUXSB

The following are the results of the administration of epinephrin
and epinin. They were given hypodermically, preceded always by
a hypodermic of sterile water, and any physical eflFect, if present,
noted. The patients on whom the observations were made had some
normal and abnormal conditions of the circulation. They were
selected at random from public ward patients. The epinephrin used
was the preparation known as adrenalin, which is a solution of one

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ANIMAL EXTBAOTS TJX TBEATMBNT OF DISBASBS 69

part of active principle in 1000 of water. It was given in doses
of ten minims and fifteen minims (0.6 mgm. to 1.00 mgm. of
epinephrin). Such doses are said by Halsey to have a distinct effect
upon the pulse and blood-pressure. Each of eighteen cases received
ten minims in a half drachm of sterile water. In these eighteen
cases there was an average rise in the blood-pressure of 4 mm. Hg,
with an average lowering of the diastolic pulse of 8 mm. Hg^ and an
average increase of seven beats in the pulse-rata In four of these
eighteen cases there was no rise in the systolic pressure ; in four there
was no lowering; in one-half the number there was no increase in
the pulse-rate. The maximal rise in the systolic and the maximal
decrease in the diastolic occurred at about the same time, and about
fifteen to twenty minutes after the dose was given. The normal
was attained from one to two hours after. The effect of the ten
minimfl of adrenalin (1 to 1000) could not be said to be well marked
on either the pulse-rate or the blood-pressure. In eight of these same
cases a dose of fifteen minims of adrenalin solution, or 1.00 mgm.
of active principle, was given. These eight cases gave an average rise
in the systolic pressure of 16 mm. Hg. There was an increase in
the pulse-rate of an average of ten beats. The maximal increase and
decrease in the pressure came quicker with the increased dose, viz.,
from three to fifteen minutes after the dose was given, and was
normal in as short a time as with the smaller dose. The maximal
rise in the systolic pressure remained at its height only for a minute
or so, then fell at once to nearly normal. The decrease in the diastolic
was generally more pronounced than the increase in the systolic, with
less changes in its rise and fall. One case gave a rise in the systolic
pressure from 120 mm. Hg to 200 mm. Hg fifteen minutes after the
dose was given. During this increase in the systolic pressure the
pulse fell from seventy to fifty beats to the minute, showing that the
effect of central vagus stimulation, in that it slowed the heart, was
greater than the direct action of epinephrin on the heart in accelerat-
ing it. Directly after the pressure fell from 200 mm. Hg the pulse
rose from fifty to eighty beats to the minute. In this case the patient
noticed distress for a short time.

Thirteen cases received epinin in doses of 1 Cc, injected sub-
cutaneously by hypodermic. In these there was an average rise
in the systolic pressure of 30 mm. Hg, with an average rise in the

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60 INTEBNATIONAI. CLINICS

diastolic of 12 mm. Hg. The increase in the pnlse-rate was very
uncertain^ seven of the thirteen cases showing no increase at all.
The length of the time for the pressure to reach its maximum was
from five to twenty minutes after the dose was given. The marked
difference between this drug and epinephrin is the fact of the raising
of the diastolic blood-pressure in the former and the almost constant
lowering of it in the latter.

PUuUrin. — This extract is made from the infundibular portion
of the pituitary gland. We have already briefly referred to pituitary
extracts in the treatment of diseases of the hypophysis^ and called
attention to their ineffectiveness in the treatment of those conditions.
But there are many other affections in which pituitrin is of value
in treatment

In making use of pituitrin in the treatment of disease the pharma-
cologic action of the drug should be our guide. Pituitrin stimulates
smooth muscle in all parts of the body, which action is quite inde-
pendent of the innervation of the part. This is in marked contrast
to the action of adrenalin, which causes contraction of smooth muscle
through stimulation of the ends of the sympathetic. The results of
the action of adrenalin vary with the function of the sympathetic
If the nerve is motor, the exhibition of the drug will cause contrac-
tion of smooth muscle. On the other hand, if the sympathetic is
inhibitory, as it is in the body of the stomach and intestine, then
the exhibition of adrenalin will reduce the tonus. If pituitrin is
administered, however, smooth muscles of all organs contract

The action on the heart has not been definitely determined.
According to Dale, the action is slight, but similar in kind to that
of digitalis.

The usual dose of pituitrin is 1 Cc. (fifteen minims). The drug
is generally exhibited hypodermically or intramuscularly. The
period of its activity varies, as a rule, from one to three hours. The
hypodermic administration does not, as a rule, cause but little dis-
comfort

The medical diseases and morbid conditions in which pituitrin
is specially useful in treatment are acute dilatation of the stomach,
meteorism with constipation, and circulatory failure.

Acute Dilatation of the Stomach. — This may be due to a variety
of causes, including shock following traumatism, errors in diet, in-

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ANIMAL SXTRACTS IN TBEATMENT OF DISEASES 61

fectious diseases, and laparotomies. The genesis of the affection is
not definitely known. Spasm of the pylorus has been named as a
causative factor, as has also obstruction at the duodenojejunal
juncture.

The commonest variety is probably that form seen after surgical
operations, and especially after laparotomies. In this type there are
probably two varieties, one dynamic, the other destructive.

In the treatment of acute gastric dilatation, and especially in the
dynamic type of the disease, it is well, after thorough lavage, to ad-
minister a drug such as pituitrin or eserine to increase the gastric
tonus. The dose should be repeated every two or three hours for
three or four doses. As the object of this statctoient is merely to
call attention to indications for the use of pituitrin, I shall not dis-
cuss further the treatment of acute dilatation of the stomach.

Constipation with Meteorism. — ^In acute diseases, and especially
in pneumonia, the physician is frequently called upon to give quick
relief from meteorism. As an adjuvant to a cathartic or purgative
enema there is nothing equal to a dose of pituitrin. In our service we
have frequently made use of pituitrin for this purpose during the
last few months with, as a rule, great advantage. For obvious rea-
sons I should not advise the use of pituitrin in the trieatment of
meteorism occurring in the course of typhoid fever.

Circulatory Failure. — ^In the treatment of circulatory failure
with low blood-pressure, such as one has frequently to contend with
in pneumonia, shock, and other affections, pituitrin is a very valu-
able drug. It has the advantage over adrenalin given hypodermically
in that, first, it invariably raises the blood-pressure, and, secondly,
it keeps the blood-pressure raised for a considerable time; whereas
the effect of adrenalin is not constant, and, when it is present, is
more transient. If the statement of Dale should be confirmed con-
cerning the action of pituitrin on the heart, the drug should have
a very wide application in the treatment of acute disease. I think,
however, until there is further evidence, one should be content with
the exhibition of two or three doses a day.

Thyroid Extract. — ^Reference has already been made to the use
of thyroid in the treatment of myxoedema and cretinism, conditions
which are characterized by hypofunction of the thyroid gland. But
these are not the only affections in which this is of value in treat-
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62 INTBBNATIONAL CLINICS

ment. In simple goitre, especially in the form which occurs in
girls at puberty or early adolescence, it is very valuable. In ex-
plaining the action of the drug in simple goitre one must take for
granted — ^which I think is generally accepted — ^that the percentage
of iodine in iodothyrin — ^the active principle of the thyroid — ^is
variable, and that the more iodine present the greater the physiologic
activity of the gland. If the thyroid is poor in iodine, then hyper-
trophy of the glandular tissues ensues, in order to render the secretion
functionally eflScient. A patient, therefore, with simple goitre has
an excessive quantity of low-grade active principle. If one ad-
ministers an extract of the thyroid of the sheep to such a patient,
then the grade of the active principle is raised, and the hyperplasia
of the glandular tissues undergoes atrophy, and the goitre diminishes
in size. Preparations of iodine other than thyroid are probably
equally effective.

In studying hyperthyroidism, hypothyroidism, and simple goi-
trous conditions, in which the active principle of the thyroid has an
etiologic relationship, one gains some insight into some of the physio-
logic actions of thyroid extract which gives us some idea of how to
make use of the drug in the treatment of disease. A full discussion
of this subject would lead beyond the limits of this paper. I shall
therefore be content to mention a few of the more important physio-
logic activities and give a brief summary of the medicinal applica-
tions induced from them.

1. Hyperthyroidism of Graves's disease, as well as that pro-
duced by the exhibition of thyroid extract, is generally characterized
by emaciation. This emaciation is probably due to a variety of
causes, of which increased metabolism is the most important. The
increased chemical activity chiefly affects the metabolism of fats.
The inference to be drawn from this is that thyroid extract is useful
in the treatment of obesity. Clinical experience, I think, supports
this view. According to my experience, the loss of weight is most
marked in fat patients suffering from simple goitre. Care should be
exercised in the administration, as it is possible that Graves's disease
and diabetes may be precipitated. The maximum daily dose of
thyroid extract should not, I think, exceed twenty grains.

2. Patients suffering from myxoedema are very susceptible to in-
fection, and it is stated that the exhibition of thyroid extract raises

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ANIICAL BXTRAOTS TJX TBEATIMICNT OF DISEASES 63

the opsonic index and the phagocytic properties of the leucocytes.
These observations suggest the use of thyroid extract in chronic
infectious diseases* This has led some clinicians to make use of the
drug in the treatment of rheumatoid arthritis. From the literature
one is unable to draw any definite conclusions as to the value in this
affection. I have frequently exhibited thyroid extract in the treat-
ment of acne vulgaris. It will be remembered that acne and simple
goitre are prone to occur at puberty. Is it possible, therefore, that
there is a relationship between them as r^ards etiology? This sug-
gested to me that such is possible and led me to make use of it in
the treatment of acne. In some cases it has, I think, undoubted
favorable influence.

3. Other medical diseases in which thyroid extract has been
used are infantilism and tetany. It is possible to present a certain
amount of evidence in favor of these treatments. Its use in infanti-
lism was probably suggested from the fact that the cretinism might
very well be looked upon as a type of infantilism, and thyroid ex-
tract is an effective remedy in its treatment. Clinical evidence gives
support to a certain extent to this view. A form of tetany is, we
know, caused by excision of the parathyroids. Now it is held by
some that the thyroid and parathyroid are closely related in function,
and it is thought that possibly the exhibition of thyroid would for
this reason tend to correct the disturbance of tetany. Clinical experi-
ence gives very little support to this view.

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CHRONIC HABITUAL CONSTIPATION: A PRACTICAL
CONSIDERATION OF ITS CAUSES, RESULTS, AND
ITS RATipNAL TREiATMENT BY MECHANICAL
MEASURES '

BY M. B. SMUKLBR, M.D.
Philadelphia

Thsbb can be no question that the simple neglect of the " coils
of Nature " to observe the regularity in the hour of defecation or
to devote sufficient time to the act are the most important factors in
numbing the impulses essential to bowel regularity. Habitually to
disregard or defer the normal impulse of defecation eventually dis-
organizes the mechanism of defecation, v^hich sooner or later inter-
feres with the normal sequence of processes in the gastro-intestinal
tract The important influence of this function can only be appre-
ciated when the equilibrium is disturbed, which ultimately spells
disaster, though years may elapse before that occurs, because the
body is unable to wrestle physiologically with the toxins elaborated
when the human sewerage system is clogged up. This indirectly
brings in its train one of the ills that may be traced to the absorption
of the products of intestinal decomposition. The nature of the
disease brought on depends on the particular path of least resistance
that is offered to the malefic force expressed by the invader.

Daily evacuations, under normal conditions, result from the con-
tents of the alimentary canal being propelled by colonic peristaltic
contractions, which collect in the pelvic colon, at an acute angle formed
by the pelvirectal flexure, where they rest until ready to pass out
through the rectum and anal canal as a fecal movement. The gradual
accumulation of the fseces in the pelvic colon during the previous
twenty-four hours causes the distended pelvic colon to rise and
obliterate the acute angle it forms with the rectum so as to facilitate
the passage of the fseces into the rectum, resulting from the active
peristaltic contractions of the colon,^ generally brought about reflexly

^Bead before the Philadelphia Clinical Socieiy.

'The normal peristaltic contractions of the colon do not reach the rectum
except during defecation, otherwise the rectum is at rest and empty.
64

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OHBONIO HABITUAL CONSTIPATION 65

by such stiinuli as the entrance of food into an empty stomach at
breakfast^ drinking a glass of cold water on arising, a cold bath, or
the muscular activity involved every morning in getting up and
dressing, these being powerful stimuli to intestinal activity. When
the natural stimuli fail to force the fseces into the rectum, the desired
result may be produced by voluntary contractions of the abdominal
muscles and diaphragm, thereby increasing the intra-abdominal
pressure.

The actual desire to defecate is produced when the rectum be-
comes distended as a result of the pressure exerted by the entrance
of fsBces, which causes peristaltic contractions by stimulating the
nerve-ends in the mucous membrane, giving rise to the peculiar
sensation ' of the desire to defecate, together with an imcomf ortable
sensation of weight in the perineum and at the same time reflexly
stimulating the external sphincter ^ to contract, so as to close the anal
canal, which temporarily delays the act of defecation till the rectum
is full. Then the act of defecation is set in motion and completed
reflexly by the peristaltic contractions initiated by the rectal stimuli,
which send afferent nerve impulses to a centre in the lumbar spinal
cord,^ where they set in action efferent nerve impulses, producing
contractions of the muscular wall of the rectum, which is facilitated
in its action by simultaneous voluntary contraction of the abdominal
muscles, diaphragm, and voluntary relaxation of the external sphinc-
ter, resulting in the expulsion of the contents of the rectum. Usually
reflex peristaltic contractions of the colon cause it to empty itself
at the same time.

If after the fseces have entered the rectum ^ the desire to defecate

'The sensation of the desire to defecate may be artificially produced by
inflating the rectum. The desire is never present when the entire rectum has
been removed by surgical procedure.

*The external sphincter, being a volimtary muscle, is under the control
of the will, and may have its action augmented or inhibited by impulses arising
in the brain and acting through a centre situated in the gray matter of the
conus terminalis, which is therefore the centre for the reflex action of the
sphincter when the anus is irritated.

*The exact nature of the nervous mechanism of defecation is not yet fully
understood.

*The fieces remain in the rectum and do not go back into the colon by
antiperistalsis, as was once thought. This can be demonstrated by the X-ray
and digital examination.
Vol. II. Ser. 25—5

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66 INTBBNATIONAI. CLINICS

be unheeded, it will pass away after a period of rest This disap-
pearance of the desire is due to the relaxation of the contracted rectal
muscular wall, which naturally becomes fatigued after a period of
distention, as the strong expulsive efforts, when retarded by a volun-
tary contracted sphincter, soon weaken in a majority of people. The
desire is again experienced once or twice during the day on account
of the entrance of more f eoces into the rectum, accompanied usually
with a little colicky pain. Should the desire be continually neglected,
the nerve-ends become blunted by prolonged contact with the fseces.
Every time the desire is not satisfied the mucous membrane becomes
less sensitive, until finally the rectum is trained to disr^ard the
irritation produced by the presence of the faeces. Ultimately a full
rectum will not create the slightest desire to defecate; the centres in
the cord gradually lose their sensitiveness to normal response. If
the condition is fairly well advanced there will be necessary a greater
voluntary effort to initiate the defecation reflex, which may result
only in a partial evacuation when the rectum is overdistended with

Eventually the persistent failure to defecate leads to the gradual
accumulation of the fseces in the rectum and pelvic colon, which
gradually become more and more distended, frequently to an un-
believable extent. The persistent failure to defecate or an incomplete
evacuation after a great voluntary effort impairs their secretory
activity and muscular tone and finally produces in them atony and
dilatation (Fig. 1) ; they become incompetent to do their work. In
extreme cases, if the habit is persisted in, the rectum and pelvic colon
may become paretic. As a result of the abnormal delay of the passage
of the f ffices through the intestines, atony and dilatation may extend
throughout the entire length of the colon (Fig. 2), though it may
take years to accomplish it. In extreme cases the abnormal delay
causes the weighted transverse colon to loop down in the lower part
of the abdomen, frequently causing the bowel to angulate or kink
at its point of support and increasing the disorganization of defeca-
tion. Owing to the close physiological connection between the differ-
ent parts of the alimentary canal a vicious circle is inaugurated by
the disturbance, causing a depression all along the line.

The same form of constipation may be produced in a slightly
different manner, but the effect is virtually the same, because the

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Fia. 1.

Rdntgenogram showing a greatly dilated rectum as a result of chronic habitual constipation.

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FiQ. 2.

Rdntgenogram showing the entire colon greatly dilated with prolapse of the transverse colon in a
case of chronic habitual constipation of long standing.

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OHBONIO HABITUAL CONSTIPATION 67

secretory activity and muscular tone of the rectum and pelvic colon
are impaired by interfering with their normal nerve and blood sup-
plyj The impairment of the nerve and blood supply arises from
continuous pressure upon the buttocks produced by assuming a
cramped or faulty position at a desk or bench (Fig. 3) for a number
of hours. Such position, by hindering the full expansion of the chest,
prevents the upward and downward excursions of the diaphragm and
causes the abdominal muscles to relax and become weak. A more
or less fecal stasis results from the sluggish peristaltic movement in
the boweL The fecal masses gradually becbme harder, drier, and
more difficult to move, so that ultimately these dry, hard masses give
rise to considerable trouble by accumulating in the rectum and pelvic
colon; it therefore is impossible to produce the requisite rise in
intra-abdominal pressure so as to empty properly the atonic and
dilated rectum and pelvic colon, thus producing inefficient defecation.
This condition is most frequently observed in teachers, bookkeepers,
school children, stenographers, watchmakers, and shoemakers, whose
vocations compel them to lead a sedentary life and to assume for a
number of hours daily a faulty or cramped position.

Habitual constipation is prone to develop in women, especially
in those of the upper walks of life, as they will defer going to the
toilet on the slightest pretext. They prefer to delay the desire
if the toilet is somewhat inaccessible. Women in easy circumstances,
inclined to obesity, having a distaste for outdoor exercises, who
shop by phone and go automobiling for recreation, aggravate the
condition because the beneficial effects derived from walking are
lost Ko doubt many of the younger women in these classes take
active exercises, but as they grow older they fall into sedentary habits.
Young girls entertaining friends or on a social call are often prompted
by false modesty to delay the desire rather than suffer the embarrass-
ment of being seen going in the direction of the toilet They fear
it may give rise to the unsavory idea of defecation, particularly if
the toilet is somewhat publicly located. In factory and shop girls
many cases develop from the suppression of the alimentary toilet.
They prefer the discomfort and danger of postponing the act till

*It has been demonstrated hy a series of experiments that the circulation
throughout the intestines greatly influences the peristalsis, and that any dis-
order in the blood supply readily brings about an intestinal disorder.

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68 UmXKATlOTXAl. OlXIflCS

ihey arrive home rather liian use a cloeet that is offamye, oold, un-
comfortable, or inacoessible.

Constipationy as a role, affects men less freqoently than women.
It occurs mostly in the busy merchant or professional man, especially
in those living in the suburbs. The necessity of catching the train
often compels them to hurry their breakfast and defer defecation.
During business hours they are so occupied that the alimentfu^
hygiene id continually neglected, thereby inducing a chronic form of
^^ habit constipation." The same condition is frequently met with
in modest and timid school children, because they dislike to ask to
go out during school hours, for fear of annoying liie teacher. Often
the closets are so offensive as to increase the natural objection which
children, especially the girls, feel to the act

Many develop the habit by unduly delaying the normal impulse
of evacuation when the act is painful, as is frequently observed in
liiose suffering from local diseases of the rectum, anus, or adjacent
organs. This occurs in hemorrhoids, fissure in ano, excoriations of
anus, benign tumors and polyps of the rectum, abscess or inflamma-
tion of the prostate, prolapsed ovary and retroverted uterus, etc
Often in these patients the pressure of hard faeces makes the act
more painful or frequently causes a reflex spasm of the external
sphincter, rendering the act of defecation impossible for the time
being. Often in these cases the constant irritation of the external
sphincter causes it to undergo hypertrophy and become tetanically
contracted,* so that a great voluntary effort is required to force the
faeces through it This often results in the culminative form of
chronic habitual constipation, in which insufficient amounts of f seoes
are excreted, although the bowels may be opened every day.

The modem tendency of using highly-prepared food in order to
get the miiriTnnni amount of nourishment with the miTiiTn^im amount
of cooking or mastication constitutes a national danger. Such diet
may cause or aggravate any iorm of constipation, since the bulky
residue originating from a proper proportion of innutritions food
will be lacking. Other dietetic errors, such as irr^ularity or undue
haste in meals, eating excessive quantities or unwholesome foods,
and the insufficient ingestion of water, aggravate this form of
constipation.

'Herts, A. J.: "Constipation and AUied Intestinal Disorders," Oxford
Medical Publications, London, 1909, p. 147.

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OHBONIO HABITUAL OONSTIPATION 69

SYMPTOMS

The symptoms of chronic habitual constipation are chiefly pro-
duced either by intestinal auto-intoxication or mechanical pressure
on the surrounding structures^ while others are purely reflex in origin.
After the condition has existed for some time^ and increasing purga-
tive doses fail to produce a satisfactory result^ the majority of
patients seek medical advice. Frequently they complain of one of
its associated symptoms^ often attributing the phenomena to derange-
ments of the stomach and liver. These phenomena are characterized
by a furred tongue^ disagreeable taste in the mouthy and loss of
appetite^ with consequent loss of weight. Not infrequently they
complain of sensations of pressure and distention in the abdomen^
especially discomfort along the course of the transverse colon, often
in the form of heart-bum, with regurgitation of bitter fluids, nausea,
occasional vomiting, and flatulence. In well-advanced cases symp-
toms referable to the gastro-intestinal tract and liver predominate,
especially if thiis condition is complicated by visceroptosis or intestinal
stasis, or if the muscular tone and secretory activity have been de-
pressed or altered for a long time. Eventually there appear fer-
mentative and putrefactive changes, which give rise to the well-
known symptoms of auto-intoxication, such as headache, vertigo,
depression in spirits, disinclination to work, and at times a form of
neurasthenia, with very depressing symptoms. Occasionally these
patients seek relief from the paroxysmal neuralgic pains caused by
mechanical pressure; these pains may be referred to the coccyx or
suprapubic region, and frequently disappear after the bowel is
emptied.

When consulted for the relief of chronic habitual constipation
or one of its associated symptoms, or one of the more obscure diseases
originating from it, such as acne vulgaris, anaemia, or asthma, the
importance of eliciting a careful history in reference to the patient's
diet and alimentary habits will be seen when the question of treat-
ment presents itself. It may be possible to deduce that the condition
the patient complains of, though very remote at times, originates
from the impeded fecal movements. Then we can intelligently treat
the condition by removing the xmderlying cau&es. The patient is
carefully examined and the abdomen palpated for evidence of any
condition that may cause or aggravate the constipation. A bimanual

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70 INTEBNATIONAIi OLINIOS

examination Bhould be made in every female^ and a careful examina-
tion of the genito-urinary organs in every male^ because reflex irrita-
tions from these organs may cause or aggravate the condition* The
rectum and pelvic colon must be examined in every case by carefully
exploring them with a proctoscope, the patient being in the knee-
chest position.

It is important to bear in mind that constipation is only a relative
condition. It is best defined as a condition in which none of the
residue of a meal taken eight hours after defecation is excreted within
forty hours.^ In doubtful cases, where constipation is thou^t to
exist or be the underlying cause of some remote condition, it may be
ascertained by giving the patient two teaspoonfuls of charcoal with
a meal eight hours after defecation,^^ and if no black stools are
observed witliin forty hours constipation is present This consti-
pation may be due to faulty mechanical action of the rectum or to
intestinal stasis. These conditions can only be separated with absolute
certainty by the X-rays. After the large intestineif on the previous
day and on the morning of the first examination are completely
emptied by an enema the patient is given for breakfast two drachms
of bismuth oxychloride suspended in milk. A series of rontgenograms
or rontgenoscopic examinations are made at frequent intervals during
the next two or three days. During the period of observation the
patient is directed to continue the usual mixed diet, and, if possible,
to carry on the ordinary occupation. Whether the constipation is due
to intestinal stasis or faulty mechanical action of the rectum is
determined by the presence of kinks, angulations, or any other condi-
tion that may cause it, or by shadows of a dilated rectum, or perhaps
by both conditions.

TREATMENT

In treating chronic habitual constipation, not as a mere symptom
but as a distinct affection by itself, it at once becomes evident that
it may be the logical result of a wide variety of causes, some being
initial active causes, while others — ^without rising to the dignity of
active causes — ^may still be contributory factors, which by Aeir

* Hertz, A. J.: '' CoiiBtipation and Allied Intestinal Disorders," Oxford
Medical Publications, London, 1009, p. 46.

^ The charcoal may be given immediately after the bowels have been onptied
by a high compound enema.

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OHBONIO HABITUAL CONSTIPATION 71

presence increase its severity and thereby the difficulty of its correc-
tioiL Therefore in laying out a comprehensive scheme of treating
this form of constipation, in the light of our latest discoveries and
researches, a clear conception of the pathologic conditions present in
ev^7 individual case is imperative, especially when trying to imitate
successfully the normal physiologic methods, which are so efficient
in health, till the normal equilibrium can be maintained. Frequently
it taxes our utmost skill and patience to select properly and combine
those methods that will successfully increase the efficiency of the
natural forces of elimination in a dilated and atonic rectum and
pelvic colon where the physiologic secretions and functions were ex-
hausted by overwork or perhaps a^ravated by some other condition.
It is absolutely essential, therefore, to correct, first, any previously-
mentioned local condition that may cause or aggravate the constipa-
tion, by its presence preventing natural movements. These conditions
are generally amenable to proper treatment, which rarely fails to
overcome them. Abdominal conditions, such as congenital weak
abdominal muscles, weakness of the intestinal musculature, intestinal
stasis, and visceroptosis, can be corrected, at least to a satisfactory
degree, by applying the proper mechanical or supportive measures,
which will greatly aid us in gaining our desired results.

It has been conclusively demonstrated that the continual neglect
of the alimentary hygiene is the most important factor in causing
chronic habitual constipation; it is the most frequent cause of con-
stipation in a majority of every variety of cases. It is obviously
imperative that, before any results can be obtained, the faulty habits
must be immediately corrected, not only by instructing the patients
to correct their alimentary hygiene, but also by impressing them
with its importance to attain the desired result ; this is an indispen-
sable part of our method of treating this condition and every other
form of constipation. The patients should be instructed to select
a definite time each day to go to the toilet (preferably in the morning,
right after breakfast). The toilet selected should be one that is
comfortable and easily accessible, so they can devote to the act with
comfort at least fifteen minutes. The patients must be instructed
to wait a few minutes after the last stool has passed so as to be sure
there is no more fecal material left in the rectum, thereby preventing
any further decrease in the sensibility of the rectal mucous membrane.

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Y2 INTERNATIONAL CLINICS

The act is facilitated by having the toilet seat at the proper height,
so the patient can assume a squatting posture, thereby increasing
the mechanical aid to defecation, produced by flexing the thighs on
the abdomeiL It is of the utmost importance to impress upon them
the necessity of going to the toilet at a definite time each day,
whether the desire is present or not, so as to gradually retrain the
reflex centres in the cord to respond to the normal stimuli of defeca-
tion. Often the faulty habit exists so long that some people un-
consciously get a fixed idea that their bowels cannot move unless
some artificial measure is taken daily to secure a regular action of
the bowel. They fear that a dangerous condition will result if the
customary pill or enema is omitted. In such cases an attempt should
be made to persuade the patient to believe that the constipation is
merely the result of a faulty habit, which can readily be completely
overcome without recourse to artificial means if the simple measures
of alimentary hygiene are observed, together with some slight changes
in the diet

The fact that dietary errors are the commonest of all the numer-
ous causes that aggravate habit constipation makes it imperative that
this should be corrected at once, since frequently complete relief
can be obtained by merely correcting the diet and alimentary hygiene.
In considering the relation of dietary errors to constipation unlimited
space could be utilized, as the subject is practically inexhaustible ; but
the general conclusion has crystallized itself from the observations of
those who studied the problem in its manifold aspects that the per-
sonal equation of the individual is, after all, the fact that determines
in every instance the particular way in which the diet causes con-
stipation. Frequently the best diet for each individual case can be
determined only by oft-repeated trials and observations. The idea
is to put the patient on a natural laxative diet, consisting not only of
foods having all the elements necessary to nourish amply the body,
but also of a large proportion of indigestible material in the form
of cellulose, that will result in the formation of a soft, bulky mass of
fsBces, so that the residue is sufficient to be acted upon by the in-
testines, to promote its own peristalsis, in order that its passage
through the intestines should not be delayed and reach the rectum
in a comparatively soft condition, so that little force is required to
expel it. Care must be taken, in the early stage of the treatment,

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CHEONIO HABITUAL CONSTIPATION Y3

not to get a too bulky or coarse indigestible residue, that will ex-
cessively irritate the overdistended and atonic rectum and pelvic
colon, because the hard particles of undigested vegetable matter
present in the fseces remain in contact with the mucous membrane
for a considerable time and may give rise to a catarrh.

It is evident that intelligent cooperation of the patients is essential,
because they must carefully follow the instructions given them, espe-
cially in reference to the time and quantity of the food. Special
emphasis must be laid on the value of eating slowly and properly
masticating the food.

The subject is so vast that in summarizing the various dietetic
measures only the broadest generalizations can here be given. These
dietetic measures, so often neglected, have a definite place in the
management of constipation. Their importance warrants their
enumeration:

1. It is probable that many constipated persons drink too little
water ; it may be necessary to encourage them to drink at least eight
glasses a day, the first glass on arising and the last on retiring. They
should drink little at meals and plenty between meals.

2. They should be encouraged to drink freely the beverages of
fruit juices, buttermilk, and sour milk; these are intestinal correc-
tives and laxatives. There should be included in their diet plenty of
plain soups and broths.

3. They should be instructed to eat sufficient amounts of raw or
stewed fruits, which produce beneficial laxative effects by increasing
the peristalsis. It is best to have the patient eat at each meal one
fruit, preferably with skin and seeds, and, if possible, a large apple
or orange before retiring.

4. The special diet to be used by persons with a tendency to con-
stipation should include coarse bread, porridge, and sufficient vege-
tables. Such a diet, and especially green garden truck (chiefly cellu-
lose) with each meal, would assure a large, bulky residue. When
these articles of food cause indigestion their use must not be persisted
in. We must substitute well-cooked green vegetables or stewed fruits,
which can be obtained at all times of the year.

5. The moderate use of fats and oils, such as butter and olive
oil, is to be recommended, because they are highly nutritious and help
to lubricate the intestinal tract.

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74 INTERNATIONAL OLINIOS

GonBtipated persons should be instructed to avoid the food which
has a constipating effect. The following, in most cases, are to be
avoided: Bichly-made dishes, such as creamed soups and most
chafing-dish products ; also salted, potted, preserved, or smoked meats
and fishes, fresh pork, duck, dark meat of fowls, liver, brains, sweet-
breads, gravies, spices, baked beans, rice, tapioca, macaroni, spa-
ghetti, rich stews, blackberries, and excess of sugar, candy, pastry,
nuts, cheese, crackers, white bread, biscuits, griddle cakes, soda
water fountain drinks, malted milk, ginger ale, spirits, especially
brandy and red wines, heavy beers, ales, and cordials. The patients
should also be instructed not to drink milk or tea with their meals.
China tea may with advantage replace the more astringent varieties
from India and Ceylon.

That the correction of any or all these conditions will procure
permanent relief in every case can hardly be expected. The con-
stipation may have existed so long that the entrance of fseces into
the dilated and atonic rectum may not give rise to any desire to
defecate; it may give rise to such weak peristaltic contractions
which only partly empty the rectum, even though a great voluntary
effort is made. This occurs particularly when the weak peristaltic
contractions cannot wholly overcome the resistance offered by a
normal or tetanically contracted and hypertrophied sphincter. The
result is a culminative form of chronic habitual constipation, because
part of the fsBces remains in the rectum, although the bowels move
every day.

Heretofore the treatment of chronic habitual constipation was
limited and unsatisfactory, but recent investigation points to the
desirability of treating this form of constip|ition by aiding and sup-
planting the natural processed by some mechanical form of treatment^
rather than superseding them by artificial measures, in order to
restore the secretory activity and muscular tone of the rectum and
pelvic colon. To treat this condition the medical profession was
offered many drugless methods of treatment, such as various kinds
of hand, cannon-ball, electric, and vibratory forms of external mas-
sage and numerous forms of gymnastic exercises. All were given
a thorough trial by the profession. While satisfactory results were
obtained in certain cases, there still seems something to be desired
as a successful routine method of treatment. More recently a series

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CHEOiaO HABITUAL CONSTIPATION Y5

of extensive clinical investigations demonstrated that mechanical
stimnlation of the mucous membrane by direct massage of the rectum
and colon, with dilatation of the external sphincter by using such
cumbersome methods as tamponing the rectum and colon with cotton
or wool, inflating rubber bags in the rectum and colon, or by simply
inflating the rectum and pelvic colon with air through a proctoscope
while the patient is in the knee-chest position, all produced satisfactory
evacuations. These investigations further demonstrated that any
foreign body which stimulates the normal contents of the bowel will
produce satisfactory peristaltic contractions, thus conclusively prov-
ing the purely mechanical part the fsBces play in producing the
stimuli to defecatioiL Eventually it was observed that this mode of
treatment gradually restored the normal tone and secretory activity
of the rectum and pelvic colon by producing a gentle stimulus to the
muscular wall and by gradually dilating the external sphincter. This
method gave results in chronic habitual constipation of a character
and permanence possible from no other method of treatment, since
it eventually results in a permanent cure by restoring the normal
condition of the bowel

Eecently many authorities have reported permanent cures in
individuals suffering from chronic habitual constipation. Their
treatment consisted of pneumatic massage of the rectum and pelvic
colon and systematic dilatation of the external sphincter, best accom-
plished by using the simple apparatus (Fig. 4) suggested by Hirsch-
man,^^ consisting of a specially shaped rubber bag about five inches
long, with a stem, which is slipped over the distal end of a canalled
W^es bougie, having an air-vent in the handle, which is covered by
the finger while the bag is inflated with air to conform with the size
and shape of the rectum and sigmoid colon. My experience in a large
number of these cases has convinced me that better results may be
obtained in a shorter period of time by having the bag studded
throughout with small pointed rubber elevations, so that the mucous
membrane may be more efficiently stimulated. This is accomplished
by simply tying on the end of the Wales bougie, under the rubber
bag, a condom, having a number of granules (size and shape of
buckshot) fastened on it, so that when the bag is inflated an irregular

" Hirschman, L. J. : " Hand-book on Diseases of the Rectum/' 0. V. Mosbj
Medical Book Publishing Company, St. Louis, 1909, p. 86.

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76 INTBBNATIONAI- CLINICS

surface (Fig. 5) will present itself to the mucous membrane of the
boweL

Hirschman's apparatus^ or my modification of it, can be operated
with a hand bulb or an electric tankless pump in giving the pneumatic
massage to the rectum and pelvic colon and systematic dilatation of
the external sphincter. If the hand bulb is employed the method of
treatment is as follows: The patient is placed in the Sims position
(Fig. 6) and the deflated bag is lubricated and twisted' upon itself,
then with a spiral manoeuvre passed slowly into the rectum, following
the curve of the sacrum, imtil it reaches the desired height in the
pelvic colon. When the bag is in position it is inflated to conform to
the size and shape of the rectum and pelvic colon by using an ordinary
atomizer bulb until the patient complains of feeling a sense of fulness,
crampy pain, or desire to move the bowels. Then the air is allowed
to escape by removing the finger from the air-vent. The bag is
alternately inflated and deflated at intervals of flve to ten seconds.
While inflated the bag is gently moved to and fro so as to stimulate
the mucous membrane and massage the muscular coat, causing the
mucous membrane to r^ain its secretory activity and the muscular
fibres to contract and gradually regain their tone. In this way the
natural forces of elimination are finally restored. Care should be
taken not to infiate the bag too much, as it will overdistend the rectum
and pelvic colon, aggravating the condition we are trying to remove.
The method of withdrawing the apparatus is very important, since
by this manoeuvre the external sphincter is dilated. This dilatation
is produced by slowly withdrawing the aparatus with a to-and-fro
motion, having both holes in the handle covered by the thumb and
finger-tip to keep the bag inflated.

When giving the pneumatic massage and dilatation with a tank-
less air-pump I use a specially-constructed rubber tube with an air-
vent and two stems at one end (Figs. 7 and 7 B) ; to one is attached
a hand bulb, and the other is connected with the electric air-pump.
The treatment is given as follows: With the patient in the Sims
position the bag is inserted to the desired height as already de-
scribed, then the bag inflated with the hand bulb till the patient
complains of a sense of fulness, crampy pain, or desire to defecate;
the tankless pump is then started to give pneumatic massage (having
previously regulated it to give the slowest and weakest alternating

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Fia. 4.-

Hirscbman's pneumatic rubber dilating rectal massage bag, partly inflated, equipped with a hand bulb.

Fio. 5.

Modification of the Hirschman apparatus by the author.

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Fio. 6.

Potltiun of prititfal ;itni opv-rnior for Kiving a treaUnitil with I he pneuinaiic' rubber ftilRtmB rertal

nt«i!U)««K4? has.

Fiq rH

Photograph of author's apparatus for giving pneumatic massage and

electric tankless air-pump.

ind dilation. atl^checL to^ai
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CHBONIO HABITUAL CONSTIPATION

inflation and compression stroke). While the massage is being given
the bag should be inflated and deflated alternately with the hand
bulb, the air-vent being covered by the finger during inflation and
open during deflation. The method of withdrawing the apparatus
so as to dilate the sphincter is the same as previously mentioned, only
here the dilatation of the external sphincter is more efficiently accom-
plished, because the machine is kept ih motion when the inflated
bag is slowly removed. This method has given splendid results in a
large number of cases. The procedure appeals to me because of
its simplicity and the ability of the operator to have absolute control
over the amount of force exerted when giving the massage.

Fio. 7.

Sohematio drawing of author's tube for fiTing pneumatic massage and dilatation with an elee-
trie tankless air-pump: a. rubber tube; b. air- vent; c, rubber bag; d, air- vent in handle; e» stem
conneeted with hand oulb; /, stem connected with electric air-pump.

My experience in treating a large number of these cases by this
method has convinced me that especially in cases of long standing
the best results are obtained when the first three or four treatments
are performed on an empty rectum,^* so that the rectum will have
the benefit of a whole night's rest and be in better condition to mas-
sage the following morning. The treatments last from five to fifteen
minutes and should be given at a definite time each day, preferably
in the morning after breakfast. Daily treatments are given for the
first seven days, with instructions to the patient to try and defecate
after each treatment. After the third or fourth treatment he will

''Have the patient to empty the rectum with a low soap or oil enema on
the evening preceding the treatment.

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Y8 INTEBlf ATIONAIi CLINICS

have a small^ unaided movement. After the first week treatments
are given on alternate days, with instructions to go to the toilet at
the stated time on the interval days; the patients will report a
slightly larger stool and more satisfactory defecation. As the defeca-
tion approaches normal the intervals are gradually lengthened to two
days, then to three days, and so on, until one treatment is given
weekly, if the defecation continues satisfactorily. When the patient
reports satisfactory daily evacuations for two or three weeks the
patient is discharged as cured and asked to return for another treat-
ment on the first day that a normal stool is absent.

As a routine treatment this method has given splendid results
in the most obstinate cases of chronic habitual constipation of years'
standing. These cases have been successfully treated and cured in
one to three months' time, provided the case has been properly diag-
nosed and the patient faithfully cooperates by correcting the diet and
alimentary habits when massaging the rectum and systematically
dilating the external sphincter.

There is no doubt in my mind that the good results obtained by
this method of treatment are in a large measure due to the systematic
dilatation of the external sphincter, as we know that many cases of
chronic habitual constipation have been cured merely by systematic
dilatation of the external sphincter with graduated rubber bougies.
In long-standing cases of chronic habitual constipation the external
sphincter may become tetanically contracted and hypertrophied *• as
a result of chronic spasm, especially when produced by continuous
irritation of some local condition. It is obvious that in these pro-
tracted cases dilatation of the external sphincter with Hirschman's
apparatus will not relieve the condition, as the resistance offered by
the tetanically contracted and hypertrophied sphincter is too great
to be overcome by the pressure produced with the pneumatic dilating
bag; consequently the constipation will persist, in spite of the fact
that the muscular tone of the rectum and pelvic colon has been re-
stored by systematic massage. These cases are so rebellious to the
ordinary methods of treatment that manual dilatation of the sphincter,
under a general ansesthetic, is necessary before the condition is suc-
cessfully relieved. Far beyond my expectations, I have found that

^ Hertz, A. J.: "Constipation and AUied Intestinal Disorders/' Oxford
Medical Publications, London, 1900, p. 147.

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FxG. 8 A.

Author's h>drostatic sphincter dilating bag (partly inflated).

FiQ. 9.

Position of patient and operator for the author's method of dilating the external sphincter.

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OHBONIO HABITUAL CONSTIPATION Y9

relief from this annoying condition^ which requires dilatation under
*a general anesthetic, may be obtained by systematically overstretch-
ing the external sphincter to reduce its tonicity by means of a rubber
hydrostatic dilating bag (Fig. 8 A), an inexpensive apparatus^*
which I have devised, consisting of two pieces of Penrose drain about
six inches long, with a silk bag ^^ inserted between them, which is tied
to the closed end of a specially-constructed rubber tube having air-
vents near the closed end.

The treatments with this apparatus are given in the following
manner: After determining the full capacity of the bag, it is
lubricated and introduced to its proper position in the anal canal,
with the patient in the Sims position (Fig. 9), so that one-half of
the bag is exposed, and hydrostatic pressure gradually made by
means of a steel syringe (holding about 200 Cc, such as is commonly
used in removing wax from the ear) until pain is produced by the

Soliematio drawing of the bag: a, rubber tube; h, thread; e, hole in tube; d, Penrose drain;
e, silk bag; /, Penroae drain (actual aise).

hydrostatic pressure. It has been my experience that patients can
stand the pain of a fully dilated bag for ten to fifteen minutes with
very little discomfort, after a few short preliminary treatments, which
are necessary to accustom them to retain a fully dilated bag.

Treatments are given daily, or twice daily (morning and even-
ing), if the severity of the condition demands it, for the first three or
four days. The treatments are gradually reduced in duration and
frequency as defecation approaches the normal, and stopped when the
patients report satisfactory daily evacuations for one week. Then
they are allowed to go for one week without any treatment, and if
they still report satisfactory daily evacuations the ^treatments are

"For want of a better name I have suggested calling this apparatus a
'' Hydrostatic sphincter dilating bag."

"Silk bags made of three sizes (same diameter as Nos. 8, 10, and 12 Wales
bougie) mostly used, depending upon the size of the patient and the severity
of the condition.

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80 INTEENATIONAL CLINICS

disoontinued permanently, but given again on the first day they do
not have a normal stooL Usually only ten to twenty treatments are
neoessary to secure permanent relief. The number of treatments
depends upon the severity. The normal tone returns to the over-
stretched sphincter by the time the muscular tone of the rectum is
restored if the rectum is massaged with Hirschman's apparatus.
The rectal massage treatments are given immediately after the dilat-
ing treatments, discontinuing them so soon as the condition permits,
but continuing the treatments with Hirschman's apparatus until the
patient is cured.

This method of treatment for protracted cases of tetanically con-
tracted and hypertrophied external sphincters associated with chronic
habitual constipation has given results of a character and perma-
nence that were far beyond my fondest expectations. This method
has, moreover, the advantage of being simple and harmless and far
more practical and effective than manual dilatation under a general
anesthetic, which is always attended with great danger.

ACCBSSOBT TBEATMBNT

In addition to the routine method of treatment outlined for
chronic habitual constipation, there are certain forms of mechanical
muscular exertions that are not sufficient, as a rule, to constitute a
" cure,** which should be recommended to those patients having cer-
tain conditions that by their presence aggravate the constipation.
These accessory measures will play a bit of a part in alleviating the
constipation by removing the condition, thus increasing the efficiency
of our routine method of treatment and thereby making the cure
permanent

Persons of sedentary habits who suffer from chronic habitual
constipation cannot produce the requisite rise in intra-abdominal
pressure when their abdominal muscles are weak and their respiratory
excursions deficient This condition is commonly present in the aged
and obese, because they do not take any natural exercise, e.g., walking
and riding. Such patients should be instructed to take regular, sys-
tematic exercise, which is an essential accessory form of treatment in
these cases. Exercise hastens the successful result and prevents the re-
currence of the constipation by strengthening the voluntary muscles
of defecation and producing rapid changes in the intra-abdominal

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Fia. 10.

Method of exercise suggested.

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FlQ. 11.

Method of exercise suggested.

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OHBONIO HABITUAL CONSTIPATION 81

pressure^ thereby stimulating the intestinal movements. It also
increases the appetite and has an important mental effect^ taking
the thoughts away from business cares and household worries, because
any depression in the nervous system is an important factor in aggra-
vating many of these cases of constipation.

Natural exercise in the open air is most desirable. Walking,
rowing, swimming, golf and tennis playing, and horseback riding are
effective forms of exercise. In a majority of patients these forms of
exercise are impossible, because many of them are either seasonable
or unavailable for pecuniary reasons. They cannot be suggested in
the average case, for it is regularity that makes them helpf uL Conse-
quently^ as a rule, some simple, efficient, available routine plan must
be devised that every patient can take advantage of. The following
method (Fig. 10) gives excellent results in these cases: On a
secluded veranda, preferably outdoors, the weather permitting^ let
the patient lie flat on a couch, then rise slowly to a sitting posture,
with the arms folded, then slowly return to the prone position. This
plan for strengthening the abdominal muscles may be varied. The
patient is instructed to stand erect and bend forward, striving to
touch the floor with the finger-tips without bending the knees (Fig.
11). These exercises should be repeated twenty-five times, morning
and evening. The effect of either method on the abdominal muscles is
prompt. It is gratifying to know how hard and strong the muscles
become. In those individuals not accustomed to exercise it is wise
to begin a mild form for short periods, and gradually to increase its
severity as the patient becomes accustomed to the exercise; it is very
important to avoid taking too much or too violent exercise, as the
harm produced by the great fatigue more than outweighs the good
done by the exercise.

In this connection reference may be properly made to the value
of an abdominal binder in these cases of chronic habitual constipation
where visceroptosis or obesity is present; a well-fitting abdominal
binder is very helpful, because it acts as a support to the organs that
have prolapsed, and at the same time it braces the wall of the abdomen,
which hastens the beneficial effects of systematic exercise by prevent-
ing extreme relaxation of the abdominal muscles.

When chronic habitual constipation is caused or aggravated by
the want of activity or congenital weakness of the intestinal muscu-
VoL. n. Ser. 26—6

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INTSBNATIOITAL CLINICS

lature great satisfaction will be found by giving abdominal massage.
Still better results can be obtained from vibratory abdominal massage
when given in connection with the routine treatment. A few treat-
ments properly given (Fig. 12) will generally cause immediate
evacuation of the bowel, because the muscular tone and secretory
activity of the intestines are improved by exerting a direct stimu-
lating action upon the bowel and other underlying organs. Abdominal
massage is also valuable in those cases aggravated by weak abdominal
muscles, by imparting strength and tone to them. Massage, however,
in these cases is not so effective as the exercises.

Fig. 12.

niuitration showing proper ooune of abdominal massage. Operator stands at right of patient
and carries the manipulation along the course of the large intestines, — i.e., beginning at lower right
side, passes up, across, and down.

Massage is given with the patient in a recumbent posture and
the knees raised by a pillow in order to relax the abdominal muscles
as much as possible, the bladder being previously emptied. It should
be given daily, preferably in the morning before breakfast, when
the stomach is empty. The massage is thereby added to one of the
natural morning stimuli of defecation, which soon cause an evacua-
tion immediately after breakfast. If it is impossible to give the
massage in the morning, it should be given on retiring for the night

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OHBONIO HABITUAL CONSTIPATION 83

Its duration at first should not exceed five minutes, but it can
gradually be increased to thirty minutes, always stopping when the
patient cconplains of fatigue. As the condition improves the duration
and frequency of the massage should be gradually reduced. It is
also of value to give, at the same time, vibratory massage along the
lumbar sacral region, over the centres in the cord that control the
nerve impulses of defecation. Massage should never be given if it
causes pain, or when there is any evidence of an underlying in-
flammatory complication, or just after eating a full meaL

Abdominal massage requires some degree of special technical
knowledge of the abdominal anatomy. Unlesfi^ it is given by a physi-
cian or cconpetent masseur, it is useless and positively harmful at
times. To attain the desired results vibratory massage, when skilfully
given, is more efficient than hand massage. Vibratory massage is far
less laborious to the physician and less fatiguing to the patient.

Hydrotherapy also has its place in the treatment of chronic
habitual constipation, especially in those cases where the circulation
is a little below par. The morning bath or shower, acting as a tonic
to the whole system, has a valuable influence on peristalsis, which
results from the stimulating effect on the circulation. In some
patients cold compresses applied to the abdomen appear to stimulate
reflexly the muscular coat of the entire alimentary canal. The best
results are obtained when the compress is put on the abdomen the
last thing at night and removed on arising. This is exceedingly
beneficial in some cases. The spinal spray is an excellent tonic
procedure ; it increases the functional activity of the spinal cord, and
makes the centre of defecation more responsive to the normal stimuli.
Best results from hydrotherapy are obtained when used in conjunc-
tion with the morning exercises.

My experience has also convinced me that the efficiency of the
routine treatment may be increased in certain cases by the use of
paraffin oil and agar-agar, if judiciously used, when the proper in-
dications are present The normal function of defecation is aided by
producing a stool of normal size and consistency. Paraffin oil and
agar-agar are unirritating and act in the nature of an undigestible
ballast, passing through the gastro-intestinal tract practically un-
altered, each having its own special indication.

. In cases of chronic habitual constipation, complicated by intestinal

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84 INTBBNATIONAIi OLIIHCS

stasis or visceroptosis, which from age or obesity becomes difficult
to correct, because of the persistent lack of exercise, the internal
administration of paraffin oil, in my experience, adds to the efficiency
of the routine treatment by lubricating the bowel, softening the fecal
mass and rendering it slippery to facilitate its onward passage to the
rectum and ultimate expulsion. While paraffin oil, by its mechanical
action, may accomplish good results in selected cases, it should not
be forgotten that it is, after all, a foreign substance and was never
intended for the human economy. Its continued use will sooner or
later nauseate and produce a revolting aversion in most people. In
those inclined to obesity, who are heavy eaters and suffer from chronic
habitual constipation, the administration of paraffin oil usually re-
tards nutrition by covering the alimentary tract with a thin film,
so that it not only retards gastro-intestinal digestion but also prevents
the proper absorption of the products of digestion, and so prevents
further increase in obesity. Its dose and frequency are determined
by individual equation. The average dose is between one drachm
and two ounces three times a day. As the condition improves, the
dose and frequency should gradually be reduced.

Sedentary life, lack of exercise, and the use of concentrated food
may cause chronic habitual constipation by producing atony of the
bowel, which is also frequently observed in young ansemic individuals
suffering from constipation. When atony of the bowel produces con-
stipation it is often aggravated by the formation of hard fecal material
in small amounts. According to the investigations of Schmidt,^^ the
small quantity of fecal material produced when atony of the bowel
is present results from the food being overdigested, and, to quote him
exactly, ^' In cases of chronic habitual constipation the food is over-
digested, as compared with normal conditions, and that, as a result,
the faeces are insufficient in quantity and of too hard a consistency."

Agar-agar, administered when the above condition is present,
greatly increases the efficiency of our routine treatment, adding bulk
to the fsDces and softening them at the same time by its inherent
property to absorb many times its own weight of water. The faeces
are kept uniformly moist and bulky, thus aiding the intestinal contents
to develop their own activity necessary to produce a healthy evacua-
tion. Agar-agar does its work without molesting any organ or func-

'* Schmidt^ A., MUnohener fMdiefiniaohe Wochenaokrift, Nr. 41, 1005.

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CHBONIO HABITUAL CONSTIPATION 85

tion^ and may be given over a long period of time. The dose of agar-
agar is one to two heaping tablespoonf uls^ to suit the individual case,
to be taken morning and evening. It may be eaten with milk or cream
or mixed with any of the ordinary cereal breakfast foods or desserts,
with the addition of salt or sugar to make it palatable, as it is taste-
less; gradually reducing the dose and frequency as the condition
improves.

During the routine treatment the use of cathartics and enemata
(except the ones that initiate the treatment) is strictly enjoined.
It is a well-known fact that the routine treatment with drugs, no
matter in what form administered, has really never cured a case of
chronic habitual constipation. The indiscriminate use of cathartics
and enemata frequaitly does harm because of the unfavorable effects
on the tissue itself. These drugs irritate the intestinal mucosa,
causing the exhausted cells to produce increased secretions and ex-
cessive peristalsis, which results in increased tissue relaxation. The
relief is only transient. An increased d^ree of constipation results
from their use. Usually larger doses of the same drug are required
to get a result, until repetition causes it to lose its effect, so that a
more drastic purge is needed for another evacuation, till finally, in
some cases, the purgatives cease to act at alL

It should be borne in mind that long-standing cases of chronic
habitual constipation sooner or later interfere with the normal se-
quence of processes in the gastro-intestinal tract ; the different parts
of the alimentary system have such close physiological connection
that the disturbance of one function usually causes a depression all
along the line. Under such circumstances it is often found necessary,
in those patients who complain of symptoms referable to intestinal
indigestion, to administer those remedies that will help to restore the
normal physiological equilibrium of the alimentary tract. My experi-
ence has been that this is best accomplished by the hormone or
organotherapy, because their products are native to the tissues where
they are used and vastly superior to medicaments that naturally have
no place in the normal physiology of the alimentary system.

In those patients who suffer from intestinal indigestion resulting
from chronic habitual constipation the Administration of secretin
in five- to ten-grain doses after meals has, in my experience, been of
great value in relieving these symptoms. .Probably the splendid re-

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86 INTERNATIONAL CLINICS

suits obtained can be best explained by the results of Starling's
observations. ^"^ He has conclusively demonstrated that intestinal
indigestion in these cases is due to the interference with the normal
production of secretin, which normally stimulates the muscular tone
and secretory activity of the intestines, liver, and pancreas, and at
the same time stimulates its own production in the duodenum.

In patients who have a torpid liver and marked symptoms of
auto-intoxication due to intestinal putrefaction the administration of
bile is the remedy par excellence as a rational restorative measure,
since it is actually the missing element and the best cholagogue we
have. I have found that beneficial results are obtained by the ad-
ministration of three to five grains of the repurified and vacuum-
dried extract of bile three times a day, given until the foBtid odor of
the stools is controlled and their consistency and regularity brought
to normal. With these changes there is naturally a regulation of the
toxic manifestations, color of the skin, and health in general

In cases of chronic habitual constipation aggravated chiefly by
dietetic errors, where intestinal putrefaction is due to the ingestion
of excessive amounts of proteids, the administration of Bacillus bul-
garicus tablets or the culture which comes in vials, or encouraging
the free use of buttermilk or the artificially-soured milk, will restore
the bowel to its normal condition. This is brought about by the pro-
duction of lactic acid, which produces a change in the bacterial flora
of the intestinal tract.

CONCLUSIONS

Theories and opinions may aid and guide us in finding a remedy,
but our final judgment as to the value of any remedy in a disease
must be based on the results alone, obtained by practical experience
in using the remedy in a number of cases over a long period of time.
If cases of chronic habitual constipation are properly diagnosed and
the diets, alimentary habits, and local conditions corrected, the results
from the routine method of treatment will be very satisfactory, even
in the most obstinate cases of years' standing, as is attested by the
experience of many physicians who use this method in many cases.
Its usefulness lies in the fact that it relieves the constipation by
correcting the underlying cause.

"Further interesting references to this whole subject will be found in
Starling's " Principles of Human Physiology," 1912, p. 797.

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THE PRESENT STATUS OF DIGITALIS THERAPY *
BY GARY EGGLESTON, M.D.

Instructor in Pharmacology, Cornell University Medical l^diool; Assistant
• Attending Physician, City Hospital, New York

One hundred and thirty years have elapsed since digitalis was in-
troduced into medical practice, and, while it might seem as though so
long a period of use should have afforded abundant opportunity for
us to have become fully familiar with all of the problems of the actions
and uses of this drug, such is not the case — a fact too patently ob-
vious to need di&icussion. The reasons for our present only frag-
mentary knowledge regarding this drug and its allies fall into several
classes. We first have the fact that with the introduction of any new
remedy many fallacies promptly spring up from its employment in a
great variety of conditions in which its actions are not of therapeutic
valua Such fallacies arose in considerable number in connection
with digitalis, and we are only now beginning to come to their appre-
ciation. The second reason for our defective knowledge lies in the
fact that we had not until recent times any adequate conception of
either cardiac physiology or pathology. The third reason is that in
spite of the vast amount of clinical and pharmacologic work which
has been done with digitalis and its allies there has been too little
attention paid to the correlation of the pharmacologic observations
with those of the physiologist, the pathologist, and the scientific clin-
ical observer. A fourth source of considerable misunderstanding has
been the perpetuation by manufacturers of digitalis specialties of
incorrect statements concerning one or more of the actions of the
drug for reasons of financial gain.

The task which lies before ui^ then, is to discuss certain of the
advances in our knowledge of the actions and uses of this class of
drugs which have been made in more recent years. No effort will be
made to enter into an exhaustive consideration of any single problem,
but we must be content with a presentation of prevailing idea£{ on
both sides of any of the questions and with here and there a sug-

* From the Department of Pharmacology, Cornell University Medical School,
New York City.

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88 INTBBNATIONAIi CLINICS

gestion as to how opposite views may be reconciled, or with a remark
on the more obvious fallacies of one or another argument Only the
more important original articles will be referred to, but a more
extensive bibliography may be found by those interested in any of
the subjects treated in one or more of the papers here cited.

ACTIONS OF DIGITALIS

If therapeutics is to be rational it should be based upon a knowl-
edge of the action or actions of the therapeutic agent and the physiol-
ogy and pathology of the condition which is to be treated. The actions
of digitalis, in so far as it affects the circulation, may be briefly stated
as follows :

1. It increases the force of cardiac systole.

2. It increases the volume of blood expelled by each systole.

3. It slows the heart, mainly by lengthening the diastolic interval

4. It altersf the distribution of the blood and its rate of flow in
the several portions of the body, probably solely as the direct result
of its three main actions first stated.

5. It is reputed to have actions, both direct and indirect, upon
the blood-vessels whereby constriction and dilatation are believed to
occur simultaneously in different portions of the body.

6. It is reputed also to have some stimulant action upon the renal
functions.

In addition to these actions which are of tiierapeutic value in the
treatment of cardiac disease, its use is associated with certain side
actions of considerable importance, viz., the production of nausea or
vomiting; the appearance of diarrhoea in some cases and the develop-
ment of troublesome headache in otiiers.

The increase in the force of cardiac systole and in the volume of
blood thrown out at each contraction is probably due mainly to a
direct action on the heart, as was well shown by the experiments of
B. Oottlieb and E. Magnus^ upon the isolated heart of the cat
These obel^rvations have been so abundantly confirmed as to warrant
their acceptation. To this direct cardiac action there should also be
added the slowing produced by vagal stimulation which contributes
to the increase in the volume of blood expelled with each systole by
prolonging the diastolic phase and increasing diastolic dilatation of
the ventricles.

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THE PBESENT STATUS OF DIGITALIS THERAPY 89

The slowing of the heart which i^ produced by all digitalis bodies
under suitable conditions has been attributed entirely to an action of
the drug upon the vagus mechanism, probably mainly centrally.
Becently, however, evidence has been brought forth suggesting that
there may be some direct cardiac action of the drug by which a certain
degree of slowing is produced. Cushny, Marris and Silberberg^
have shown that in patients, both with normal rhythm and with
auricular fibrillation, in whom the heart had been slowed by digitalis
the subsequait administration of a dose of atropin sufficient to
paralyze the cardiac vagal endings did not restore the heart-rate to
the point to which an initial dose of atropin, before digitalis, had
raised it Just how important a role is played by this mechanism of
digitalis slowing has not yet been determined, but it seems probable,
from the study just cited, that it is relatively far less important than
is that produced by stimulation of the vagus.

The slowing brought about by digitalis is of two distinct types as
revealed by cardiographic studies. The one involves the whole heart,
leaving the ventricular contraction to follow in its normal sequence
upon that of the auricles. In this form of slowing the pulse may be
regular, or it may show some degree of more or less rhythmic increase
and decrease in rate — sinus arrhythmia. This type of irregularity is
commonest in youthful individuals, and is evident only in hearts
which were previously regular or which already showed some degree
of this form of arrhythmia before treatment.

The second type of slowing produced by digitalis is due to some
degree of interference with the conductivity of impulses through the
auriculoventricular bundle — ^heartrblock. It is not improbable that
two mechanisms are concerned in the production of this phenomenon.
It has been shown that any effective stimulation of the vagus is
capable of producing heart-block, and it is probable that the action
of digitalis upon the vagus is largely responsible for its production
in the course of the administration of this drug. Again, however,
the observations of Cushny and hist associates already cited suggest
that there may also be some local direct action of the drug by which
conductivity is depressed. In the present state of our knowledge it is
impossible to make a definite statement in r^ard to this action.

The alteration in the rate of blood flow and in the distribution of
the blood in the various organs and tissues of the body has been a

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90 INTBENATIONAIi CLINICS

field in which speciilatdon has been rife, and a.t times even fancifuL
Aooepting for the moment that therapeutic quantities of digitalis do
not raise the systolic blood-pressure to any constant or appreciable
degree, we are almost forced to believe that there must be some
alteration in the distribution and rate of flow of the blood to account
for the diuresis and disappearance of fluid from the tissues in
cedematous patients, and for other phenomena frequently observed.
The increase in the force of the heart-beat and in the volume output
per beat would seem to be quite sufficient to account for such changes
in the blood flow as would be required to produce any of these
beneficial effects, and the need for invoking any elaborate hypothesis
for their explanation is not apparent

The reputed actions of the drug upon the vacknilar system merit
some discussion. Two camps have arisen on this mooted subject
The larger one holds that the vascular actions of the drug are marked
and of great importanca The other, and much smaller one, holds a
diametrically opposed view. It has been shown by the first school,
of whom Gottlieb is one of tiie strongest supporters, that the several
digitalis bodies are capable of causing marked vasoconstriction in ani-
mals with an attendant great rise in blood-pressure. This has been
proved to be due to a direct action of these substances on the vessels
themselves, both in the intact animal and in isolated perfused vessels.
Gottlieb and Magnus^ have also shown that in dogs there was a
reflex vasodilatation in the peripheral vessels simultaneously with the
splanchnic constriction, though this was seldom observed with digi-
toxin. Oswald Loeb* has shown that the vasoconstriction extends
even to the coronary arteries in animals. Others, including Jonescu
and Loewi,^ have attempted to show that there is a local renal vaso-
dilatation produced in rabbits by digitalis and its congeners. The
one great fallacy which runs through practically all of these experi-
menter on animals and excised vessels is the fact that the doses of the
drugs used were always far above those possible in the therapeutic
use of the drug, in many instances even being far over the fatal dose
for the animal employed. In the course of a large number of ex-
periments performed in our laboratory on cats and dog8> in which
the fatal dose of one or other of the digitalis bodies wa£f slowly in-
jected into the vein, we have never seen more than a slight transitory
and hence unimportant rise in the blood-pressure during the injection.

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THE PRESENT STATUS OF DIGITALIS THERAPY 91

Just before death there is often a marked rise in the blood-pressure,
but it is asphyxial and in no way due to any direct effect of the drug.

Mackenzie,® Price,^ and othenf have shown by observations on
man that the administration of the digitalis bodies to the point of
maximum tolerance is not associated with any constant rise in the
blood-pressure. On the contrary, a slight fall was rather more fre-
quent than any rise. In my own experience, even when using pure
digitoxin to the point of tolerance, I have failed to see any constant
effect on the blood-pressure, the alterations observed falling well
within the normal limits of diurnal variation.

We may conclude our brief discussion of this question by saying
that it seems probable that very large doses of the digitalis bodies
given by vein to animals, or relatively very concentrated solutions of
them perfused directly through isolated vessels, are capable of causing
more or less marked vascular constriction by direct action. Such
quantities and concentrations, however, can never be concerned in the
tiierapeutic use of the drug, and careful clinical observation shows
that its therapeutic use is, in fact, not associated with evidence of
vasoconstrictor action.

So far as the sixth point is concerned at the present time, it can
only be stated that there is not sufficient evidence for the belief that
digitalis has any direct action on either the renal epithelium or the
vessels of this organ. The diuretic action is seldom seen in normal
animals or men, and in the cases of cardiac dropsy, in which the
greatest diuresis from the drug is encountered, the known beneficial
cardiac actions seem quite sufficient to account for the increased
urinary output

The therapeutic use of digitalis, in the present state of our
knowledge, rests, therefore, upon its three proved actions: (1) To
increase the force of cardiac systole; (2) to increase the output of
blood per systole; (3) to slow the heart, either directly or through
the vagus, or by both actions simultaneously.

So much able work has been done in the last few years, dating
from the publication of Mackenzie's epoch-making work,^ on the
various cardiac conditions in which the use of digitalis might be
expected to give favorable results, that I shall pass over thisf phase of
our subject with very brief remarks.

It may be stated in a few words that digitalis is indicated only in

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92 INTBRNATIONAI. OLINIOS

cases in which there is evidence of failure of cardiac compensation.
This includes cases with auricular fibrillation, particularly of rheu-
matic origin, and cases with regular rhythm, or at least having the
heart under the control of the normal pacemaker, in which there is
some d^ree of dilatation or other evidence of a failure of the mus-
cular power of the heart to carry on its function normally. The less
common condition of auricular flutter also seems to respond particu-
larly favorably to the intensive administration of digitalis. It is to be
borne in mind that not all cases coming within either of the first two
classes will respond favorably to treatment. Those which are least
likely to do so are the cases of auricular fibrillation which have had
many breaks in their compensation and such an have developed late in
life in conjunction with general degenerative changes in the circu-
latory system. In the second class more failures will be encountered
than in either of the others^ and, in fact, it has been held by some that
digitalis is of relatively little use in this class of cases. To this latter
idea I cannot subscribe, for personal experience leads me to believe
that a very considerable proportion of these cases respond quite satis-
factorily to intensive digitalis treatment^ and a further number show
sufficient improvement to make the treatment more than warranted.
Inasmuch as there seems to be no way of foretelling whether a patient
in this class will respond or not, it would seem wisest to give each the
benefit of the doubt and submit him to a thorough course of the drug.

There is one class of patients in which digitalis would seem to
be indicated but in which its use, unfortunately, is of little or no
value. This includes those whose hearts are showing signs of failure
in response to the effects of an acute intoxication, as in tuberculosii^^
pneumonia, and other acute infections, and in cases of exophthalmic
goitre. The evidence on this point seems so conclusive as not to admit
of discussion as to its validity.

Statements to the contrary notwithstanding, there seem to be no
definite contra-indications to the use of digitalis in a case of cardiac
failure. Certainly the existence of a valvular lesion, irrespective of
its nature, except an acute infective endocarditis, is per se neither an
indication nor a contra-indication for the use of the drug. It having
been shown that the therapeutic administration of digitalis does not
cause any appreciable increase in the blood-pressure, the old idea that
arteriosclerosis or hypertension was a contra-indication does not seem

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THE FBESENT STATUS OF DIGITALIS THERAPY 98

well founded. Digitalis is frequently given in such cases, and ill-
effects from its use have not been reported.

Since digitalis is capable of producing heart-block or of increasing
a preexisting tendency to this condition, the statement has been made
that it should not be given to persons already showing a lengthened
conduction time or a partial heart-block. Experience has taught us(,
however, that it may be given to such cases without harm if they show
signs of failure of the heart which demand its usa The danger asso-
ciated with some degree of increase in the block is more than out-
weighed by the beneficial effects produced by the drug where the
heart is incapable of meeting the demands thrown upon it

In the absence of evidence that digitalis exerts any stimulant
action on the kidneys^ and in view of the fact that it does not cause
diuresis in normal animals, or in man in the absence of cardiac in-
competency, its use in cases of nephritis is unwarranted unless there
is some measure of cardiac insufficiency.

Evidence of some d^ree of failure of the heart to carry on its
work efficiently, in brief, constitutes the one indication for the ex-
hibition of digitalis, and in the absence of sudi evidence we have no
rational basis for its administration.

SIDE ACTIONS

The most troublesome of the side actions of thict drug is probably
that by which nausea or vomiting is produced. It has long been held
that these effects are due to an irritant action of the digitalis bodies
upon the gastro-intestinal. tract This idea rested largely upon the
fact that all of the members of this group were known to be irritant
when injected subcutaneously. Clinical observation should have
shown the fallacy of this argument, for neither nausea nor vomiting
appears before a considerable quantity of the drug has been given, and
simultaneously with their onset there is practically always definite
evidence that enough of the drug has been absorbed to exert some
action on the heart Dr. Hatcher and I®'^^ have recently shown
that in dogs both nausea and vomiting are solely of central origin,
resulting from a direct stimulation of the vomiting centre. I ^^ have
also been able to show that such is almost certainly the case in man,
for it can be proved that these phenomena appear in the great ma-
jority of cases only after considerable of the drug has been absorbed.

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94 INTBBNATIONAIi CLINICS

Since the publication of this paper I have repeatedly given single
oral doses of from 8 to 15 Cc. (2 to 4 drachms) of the tincture of
digitalis without ever having seen either nausea or vomiting ensue.'"'
The same explanation, viz., central action, ahnost certainly accounts
for the diarrhoea which is sometimes produced by digitalis and its
allies. No one has doubted that the headache occasionally encountered
is also of central origin.

On the belief in the local irritant action of the drug as the causa-
tion of the gastro-intestinal symptoms it has been commonly advised
that these actions might be avoided by adopting some other mode of
administration. Since it has been shown that the action ii one result-
ing only after the absorption of the drug, such a practice becomes
obviously irrational. Equally irrational is the resort to some other
member of the group when nausea or vomiting has resulted from
the use of any given preparation, for all digitalis bodies share thid
central action to a greater or less extent

The nausea or vomiting can, however, be avoided in a large pro-
portion of cases while the full therapeutic action of the drug is yet
secured. This is possible only by the careful and frequent observa-
tion of the development of the action of the drug so that one can stop
its administration so soon as the therapeutic effects have been secured.
Even with such careful observation of the patient one will meet with
failure in some cases.

DOSAGE, ADMINISTBATION, AND FBEFABATION8

Dosage. — This question is in a state of considerable confusion,
and a perusal of the literature shows the widest divergence of opinion
as to the proper amounts of digitalis for administration to man. Few
seem to have approached the solution of this problem, and most have
been content to say that enough should be given to secure the desired
effects or to produce some of the symptoms calling for its withdrawal.
I have recently attempted to throw some light on this subject and
have found, from a study of forty-seven patients receiving digitalis
or digitoxin, that there is a fairly constant dose of the drug based

*Such large doses as this must not be used unless one is certain of the
activity of the preparation and unless one is prepared to make frequent graphic and
clinical observations to prevent the administration of an overdose, lliey are
certainly not suitable for use outside of a hospital where the patient can be under
the constant care of a trained observer.

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THE PRESENT STATUS OF DIGITALIS THERAPY 95

upon the weight of the patient and the activity of the preparation.
Briefly, it was found that about 15 mgm. (14 grain) of a first-dass
digitalis leaf or 0.15 Cc, (2^^ minims) of tincture was required for
each pound of body weight to produce full therapeutic eflFeets. Ap-
proximately half of all of the patients studied responded to a dose
within fifteen per cent either above or below this average. It is to
be borne in mind that specimens of digitalis vary considerably in
their activity, and that this dose applies only to an average high-
grade specimen. The actual study was made upon the basis of
activity of the specimen used as determined by the cat method of
standardizing devised by Hatcher. ^^ Inasmuch as this method is
not in common use among manufacturers and purveyors, it has been
deemed best to state the dose here in terms of an average leaf of high
grade. We have found in our laboratory, by tests of many such
samples, that they do not vary very widely from an average activity,
it being only the exceptionally active leaf or the poorer specimens
which fall wide of comparatively narrow limits.

Administration. — ^Except in the most urgent cases tbere is no
apparent reason for giving digitalis in any other way than by mouth,
for by this method, and with a suitable adjustment of the dose, the
full therapeutic action can be secured in from twenty-four to forty-
eight hours. To bring the patient xmder the full effects of digitalis
in so short a time, however, one must give large initial doses — ^up to
4 to 8 Cc (1 to 2 drachms) of the tincture — ^rapidly reducing the
subsequent doses so that the last few are only small fractions of the
total amount required.* Where even more rapid action is desired,
as in very urgent cases, resort should be had to the intravenous or
intramuscular administration of one or two doses of ouabain (crystal-
line strophanthin) or strophanthin (amorphous). The former may
be given in an initial dose of 0.5 mg. ( rh grain), and half this amount
may be repeated, if necessary, in from six to twelve houra The dose
of strophanthin is from 0.75 to 1.0 mg. (^ to ^^r grain), half to be
repeated as above if required.

The administration of digitalis to any patient should be pushed
to the appearance of the symptoms of the minor toxic actions of the
drug, or until the full therapeutic effects have been secured. In any
case, but especially where it is desired to bring the patient rapidly

* See footnote on p. 94.

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96 INTEENATIONAL CLINICS

under the influence of the drug, the patient must be watched carefully
and frequently during the course of the administration to discover
the signs of the toxic actions of the drug at their earliest appearance.
Clinical observation must always be supplemented by polygraphic or
electrocardiographic records taken at frequent intervals in such cases.
The later toxic manifestations, as diown by Bailey, ^^ resemble so
closely those often seen in failing hearts in cases in which no drug
has been given that they are likely to be confused with them and the
patient may be thought in need of more digitalis. Further adminis-
tration in such a case might well result fatally from the effects of
the drug itself. Such has doubtless occurred more than once without
the true cause of death having been suspected. The criteria of the
toxic actions of digitalis have been abxmdantly discussed elsewhere
and can only be enumerated here.

1. Nausea, vomiting, diarrhoea, headacha

2. Irregularity in a previously regular heart due to (a) sinus
arrhythmia, (6) partial heart-block, (c) extrasystoles, (d) combined
effects.

3. Heart-block of marked degree, extrasystoles, or coupled rhythm
in auricular fibrillation.

4. Auricular fibrillation in regular hearts, and excessive rate in
hearts with either normal rhythm or with auricular fibrillation.

Preparations. — Since the capacity of stimulating the central
vomiting mechanism is inherent in all members of the digitalis group
we cannot look for a preparation devoid of this action yet possei^ing
the desired action on the heart. Inasmuch as the therapeutic adminis-
tration of digitalis is apparently not associated with a rise of blood-
pressure or vasoconstrictor effects, no choice of preparation can be
made in this respect. BeaUy high-grade digitalis leaves are but little
more costly than the inferior varieties and are of reasonably uniform
activity, so that good galenical preparations should be readily obtain-
able. Several practical methods of standardization have been devised,
and many standardized tinctures, the activity of which is assured, are
now on tibe market As both dilute alcohol and water are capable of
completely exhausting the leaf of its active principlesf, both the tinc-
ture and the infusion have precisely the same ac&on as the leaf itself.
The tincture seems to have two advantages over the infusion : First,
that it is easier to approximately exhaust the leaf in its preparation

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THE PBSSENT STATUS OF DIGITAU8 THEBAPY 97

than is the case with the infusion if this is made according to the
I^armaoopceial directions; and^ second, that the infusion has some
tenden<^ to deteriorate if kept long, though this is not so great as
usuaUy supposed. The galenical preparations of digitalis then fulfil
all of the requirements of any preparation for oral administration,
and tliere is no obvious advantage in the several specialties and
proprietary preparations, so far as this mode of administration is
concerned.

For intravenous or intramuscular administration we have two
substances of constant composition and activity in ouabain and
strophanthin, both of which are cheap and easily prepared for hypo-
dermic use (intravenous or intramuscular only). Here, too, there
seems to be no advantage in resorting to the use of any of the more
expensive proprietaries, some of which are by no means constant in
activity, although such claims are made for them. There does not
seem, therefore, to be any adequate reason for employing any digitalis
preparations other than those which are offijcial in the pharmacop<Bia,
and ouabain and strophanthin which are not proprietary.

BXraiUUfGES

» Arch. ewp. Path. i». Pharm., 1903-04, li, 30.

•JJcori, 1912-13, iv, 33.

*Aroh. eofp. Path. u. Pharm,, 1902, xlvii, 135.

*lbid., 1904, li, 64.

•IWd., 1908, lix, 71.

•Heart, 1910-11, ii, 273.

' Brit. Med. Jour., 1912, ii, 689.

* " Diseases of the Heart," Oxford Medical Publications, London.

•Jowr. Pharm. and Ewp. Therapy, 1912, iv, 113.

>»fWd., 1913, Ixi, 767.

^Am. Jour. Pharm., 1910, Izxzii, 360.

^Am. Jour. Med. 80., August, 1911

Vol. II. Ser. 25

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Ipa^btattics

MILIARY TUBERCULOSIS IN NEW-BORN; CONGENITAL
DIAPHRAGMATIC HERNIA; DEMONSTRATION OF
X-RAYS AND PHOTOGRAPHS; HIRSCHSPRUNG'S
DISEASE

BY C. G. GRULEE, M.D.
Assistaiit Professor Pediatrics, Rush Medical College, etc., Chicago.

MITJAHY TUBERCULOSIS IN THE NEW-BOEN

I WILL diow you a specimen of miliary tuberculosis in the new-
bom. The mother of this baby entered the Cook County Hospital in
August, 1912, and was transferred to the woman's venereal ward
because of a vaginal discharge which on microscopic examination did
not prove to be gonorrhoea. The history was negative, with the notable
exception that die had tuberculosis of the hip, but die had no active
tuberculosis so far as we knew. She gave birth to a baby on the 6th
of September which weighed six pounds and eight ounces. The child
had a fair degree of nutrition. The temperature curve of that child
is interesting, although I do not know that it means very much, but
I will pass it around for what it is worth. It will be noted frcan
the second day the child ran an irr^ular temperature of from 96® F.
to 105° F. During the first night the baby was very cross. On the
sixth day I saw the child, at which time it was having twitchings and
convulsions. On examination there was very little to be seen except
that we had a sick baby with an enlarged liver and spleen. There was
no evidence of any infection about the umbilicus. I hesitated in my
diagnosis between septic infection and a combination of syphilis and
intracranial hemorrhage. The convulsions did not start until the fifth
or sixth day, which was rather late to expect the beginning of intra-
cranial hemorrhage. On the eleventh day the child died, and fortu-
nately we were able to get an autopsy. I show you the lungs, the kid-
ney, and spleen. You will notice around the portal vein just below the
d8

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MUilABY TUBEBCITLOSIS IN NBW-BOBN 99

liver some large nodules which were distinctly caseous, some of them
as large as the end of my pencil The spleen is thoroughly studded
throughout with white nodules. On the surface of the lungs there
are nodules. On one side you will see an occasional nodule in the
kidney. The liver shows quite a few. The heart shows none. There
was no involvement of the bronchial lymph-elands. Here, then, we
have a caseous miliary tuberculosis in a child that died on the eleventh
day after birth.

There have been reported some eleven cases in children who soon
after birth showed signs of tuberculosis. Of these eleven cases, only
seven will bear the limelight, because three or four of them were
cases where there had been found only tubercle bacilli, and nothing
further. Of the eleven cases, there is only one that presumes to have
any clinical history. Practically all the rest are cases of which post-
mortem findings alone are given. Lobenstine, of the Lying-in Hospi-
tal of the City of New York, reports one case in which there was
absolutely no rise of temperature whatever. On the other hand, in
his case the baby was premature, and it is not surprising that the
child showed no rise of temperature, since you all know premature
babies and babies congenitally debilitated may show marked infection
without any rise in temperature.

There is this one small point about the history of my case : It is
the only case on record where a child has died and the mother re-
mained apparently in good health. We know that for several months
after the child died and the mother left the hospital she was alive
and apparently well. It is very likely, although we did not have the
discharge examined, that she had tuberculosis of the uterus, and
this discharge or leucorrhoea was due to that. But she had nothing
but an old healed tuberculosis of the hip apparent clinically. In
every other case the child died two days before the mother, or two
or three days afterward.

I cannot tell you anything about the placenta in this case. The
placentas are not examined here as regularly as we would like to
have them, and we do not know what tiie placenta showed. There
are several cases on record where children have lived up to six or
twelve months without showing any signs of tuberculosis, in spite
of the fact that the placenta was tubercular. I think it is fair to
assume that this is unquestionably a case of congenital tuberculosis.

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100 INTEBNATIONAL CLINICS

The chief points are that the condition is primarily an abdominal
one, and the first glands affected are those about the liver, and that
the abdominal organs are most affected. We have here marked
caseous tuberculosis, and the child dying on the eleventh day. I
think you will agree with me that even though we consider the sli^t
resistance the infant has to tuberculosis, it would hardly reach this
stage in less than eleven days.

CONOENITAIi DIAPHBAOMATIC HEBNIAJ DEMONSTBATION OF X-|LAT8

AND PHOTOGBAPHS

The next case is that of another new-bom baby, the history of
which does not concern us very much, except that I received the
information that we had a case of dextrocardia in the obstetrical ward
and I wanted to examine it, as I had never seen one. I remained
rather sceptical as to the diagnosis, in spite of the fact that the apex
was apparently on the right side and there was heart dulness. Over
the lungs there was a resonant note which I could not distinguish from
the normal lung resonance in a child of that age. We had an X-ray
taken, with the result diown. Over at this point (indicating) is the
heart. About here is an area of clearness evidently different from the
corresponding area on the opposite side. The heart is apparently,
as you will observe, on the right side, but it is pushed over with the
base of the heart to the right and the apex near the median line.
There is a mass filling up the left side of the chest which is penetrable
to the ray and which contained a certain amount of air. With this
evidence I suggested the possibility of the case being one of diaphrag-
matic hernia, and this it proved to be.

The abdominal findings in this case were confusing. You could
palpate both the kidneys. The liver was away down and the spleen
was down. That will be explained by the picture. The first picture
was taken with the anterior thoracic wall present You will see the
liver coming away down in this region, and the spleen is away down
here (indicating). The stomach is away off in this region. You
can see a considerable part of the large intestine.

The second picture shows you the result of removing the anterior
wall of the thorax. You see the liver still down ; the spleen is over
here, the stomach is at this point, and the small intestine is pulled up
in this region and filling the whole left side of the thoracic cavity.

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2.5-

o •»

S-S:

;?»•

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MTLIABY TUBEBGTJLOSIS IN NBW-BOBN 101

The next picture shows a tube passed through the opening in the
thorax^ passing up in the posterior part of the left side of the dia-
phragm, and that will give you a fair idea of the size of the opening.

I find that these diaphragmatic hernias are not so uncommon.
One writer has recently collected 450 or 500 cases, and of this number
this type is the most common. The cases are divided into two main
types, the true and the false. The true type is covered with a mucous
membrane with peritoneum, and this is more uncommon than this
type which is not covered with peritoneum. Of the two types this
condition occurs far less frequently on the right than on the left
side. The left-sided false hernias are the most common, constituting
some 400 out of the 475 cases collected.

It seems to me there are two or three things by which we can
improve our diagnosis in cases of this sort One is by giving bismuth.
If this child had been given bismuth we would have found the
intestine was up in the thoracic cavity. The next time I see a case
of so-called dextrocardia I shall think of diaphragmatic hernia more
than I did at the time when I saw this case.

hibschspbung's disease

The boy whose case I am going to report died last Sunday in an
attack of convulsions, and I have nothing more than the X-ray of
the condition to show you. This child came in with about the follow-
ing history: He was fifteen months of age, and gave a history of
constipation. Since May the bowels have not moved even with
catharsis, except when soap suppository was used. The stools were
yellow, and there were bowel movements after the use of soap
suppositories every third day. There was no blood in the stool.

On examination of the child we found an enormously large abdo-
men, as this picture will show. This you will see very clearly, in
spite of the fact that we did not get the bismuth well up into the
colon. The colon is markedly enlarged and seemingly takes up the
whole of it, and is most marked in the region of the sigmoid. There
was a very distinct peristalsis along the line of the colon.

Here is a specimen which Dr. Helmholz was kind enough to let me
take which diows an enormously enlarged colon. The specimen is
rather interesting to me from two or three standpoints. One is, the
condition is double. In the first place, the ascending and transverse

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102 INTEBNATIONAL CLINICS

colon are markedly dilated; then at about the splenic angle there is
retention, evidently a sort of kink, and this going into the sigmoid,
which is markedly dilated. The sigmoid, on the other hand, does
not show any abrupt change except at the point which you see. It
seems as if tiiere is a sort of valvular formation here. To my mind
this double condition is a very interesting one. The diagnosis of
Hirschsprung's disease is made chiefly on three points ; namely, the
enormous enlargement of the abdomen, the presence of constipation
of very marked degree, and the active peristalsis as shown on the
abdominal wall Other things are confirmatory, such as the X-ray.

The question is not so much as to the diagnosis, because that must
of necessity be comparatively easy, but what the nature of the condi-
tion is. We have no examples, so far as I know, in pathology of
equal enlargement, with both a thickening of the wall and dilatation
of the organ, except those due to some obstruction. This obstruction,
according to some of the opinions I have read, is not necessarily an
obstruction as the result of mechanical means. It can be due to a
flap formation or a kink, and one of the suggestive things about it is
that it occurs more often in the sigmoid, the large intestine — and espe-
cially the sigmoid — ^being more mobile in a child of this age. But
it may result in some cases f rcmi some deficiency of the bowel wall, as,
for instance, defective musculature, insufficient elastic connective
tissue, or even faulty innervation.

There is on record one case which does not fit in with any of
these. It is where the ascending and transverse colon were enlarged,
but the enlargement, instead of being confined to the descending colon,
gradually went down into a funnel shape and terminated about the
sigmoid. This condition is hard to explain on any of the theories
just mentioned, but I think the consensus of opinion in the matter
of these cases is that the condition is the result of some obstruction
or some deficiency of the bowel wall, which renders it necessary that
the bowel shall either dilate or increase in muscular action.

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DIAGNOSIS OP TUBERCULOUS JOINT DISEASE IN
CHILDREN: BRAIN INJURIES AT BIRTH *

BY E. W. RYERSON, M J).

Professor of Orthopedic Surgery, Chicago Policlinic; Assistant Professor of Sur-
gery, Rush Medical College; Orthopeedic Surgeon to Children's
Memorial Hospital, etc
Chicago

We see here(Home for Destitute Crippled Children)80 many cases
every year of early joint tuberculosis which have not been correctly
diagnosticated, but have been treated as riieuniatism, or treated as
growing pains, or treated as anything but tuberculosis, that I feel
the profession in general needs to be more on the watch for joint
tuberculosis than it in fact is.

The very first objective sign of tuberculosis that one can demon-
strate is usually a limitation of motion in the joint, due to a spasm
of the muscles around the joint, and we cannot say enough and cannot
hear enough about this sign. It is, of course, a reflex spasm of the
muscles which nature produces in order to immobilize the diseased
and painful joint It is the most misused and misunderstood of signs.
It has nothing to do with ankylosis. Motion may be free and painless
through nearly all of its range, except perhaps at the extreme limit
of flexion or abduction or extension or rotation. Here is a patient
with hip-disease. I have not looked at this little girl for some time.
This leg is perfectly normal ; she has the full range of motion. Now
let us look at the other leg, the left one. You- can see the instinctive
effort at protection which this little girl shows. This is very exag-
gerated, of course, and it is not as typical as some of the cases I would
like to show you where the leg will go through a large range of motion,
but it will not come down perfectly into the extended position. It
will not hyperflex into the belly, nor rotate. The limb is painful and
sensitive, so much so that we cannot approach the normal range of
motion with it The hip is carefully guarded.

* Clinic given under the auspices of the Chicago Pediatric Society, October,
1914.

103

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104 INTERNATIONAL CLINICS

When a child has beginning tuberculosis of the spine, the first
symptom the parents usually notice is that the child holds the back
quite stiffly, and so the mother says it cannot possibly have anything
the matter with its back because it holds it so strai^t She thinks the
child must be all right, and cannot have anything the matter because
he walks in like a little major. When you drop something on the floor,
instead of stooping over like this (indicating), he will, if it be in the
lower dorsal and upper lumbar r^on, pick it up without bending
the back. This instinctive protection of the joint is the most valuable
sign we can have in the diagnosis of tuberculosis of the joint, and it is
one almost invariably neglected. Ask the average practitioner what
the signs of tuberculosis of the spine are, and he will say kyphos, the
hump, and cold abscess. We have many cases every year which never
have a cold abscess. We have a good many that never develop a
hump, and yet they are just as typical cases of tuberculosis of the
spine as anything can be when the child is laid face down on the table.
Most of the spine cases on my service have had the Albee operation
done, so that I cannot show you the stiffness in the back that a child
has with early Pott's disease, where there is no destruction perceptible
by the X-ray. If the child is laid upon the table with face down, and
the two feet are picked up with one hand and the patient is arched up
in this way to hyperextend the spine, instead of a perf ectiy regular
smooth curve, as the normal spine makes when it is hyperextended in
this way, perhaps three or four vertebr© will be fixed so that there will
be a flat spot in the spine. The rest of the spine, above and below, will
curve normally, but at the site of disease there will be a stiff area.

While the child is being held in this way, the fingers of the other
hand, pressing up and down the spine along the erector spinse muscle,
will detect a certain feeling of tension of the muscles due to spasm.
They are protecting the painful spine. These two signs in the pres-
ence of a positive von Pirquet reaction, to which I attach a great deal
of importance, will make it necessary to consider the average case of
this sort, with a chronic history, with a usually painless development
of stiffness of the back, ahnost certainly a case of Potf s disease. We
do not need to wait for a cold abscess or a hump in the back in Pott's
disease, or for flexion and deformity of the hip to make a diagnosis
of hip-joint disease, and it is enormously to the advantage of the
patient if we can make a diagnosis and institute treatment before

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TUBBECULOUS JOINT DISEASE IN GHILDBEN 105

there is fixation or marked deformity or destruction. This is pre-
eminently so in Potf s disease, because, with our present method of
treatment by artificial ankylosis of the spine by means of a bone
splint or by means of cutting throu^ the spinous processes and the
laminse and making an ankylosis after the method of Hibbs, it is
possible to cure a diild of tuberculosis of the spine with no deformity
whatever; and not only have they no deformity, but they will not get
any deformity, so far as our experience of three years is concerned.
It is now three years since the first three Albee operations were done
in this city by myself, and we have done a great many since, and
we have learned that the deformity of Potf s disease can in most
cases be corrected if we make the diagnosis early. If we wait for a
hump, we cannot correct the hump in some cases, although in others
we can.

Are there any other aids in the diagnosis of tuberculosis of joints ?
I have attached great importance to the von Pirquet test; I have seen
no case of joint tuberculosis up to this time that did not give a positive
von Pirquet reaction, although I have heard of such. I have seen some
syphilitic joints that had been diagnosticated as tuberculous which
did not give a positive von Pirquet reaction. I think the von Pirquet
test is extremely reliable and valuable, and our experience shows it is
almost infallible, so that I hesitate to make a diagnosis of joint tu-
berculosis in the absence of a von Pirquet reaction. I do not myself
think it is wise or safe or advisable to give the massive doses of tuber-
culin for diagnostic purposes which many other men consider safe and
proper. I would be unwilling to have them give such large doses to
me. I think there is no possible danger in the use of the von Pirquet
test, and it, of course, is of value only if it be n^ativa A positive
von Pirquet test means nothing. The child may have a positive
von Pirquet test and have no tuberculosis whatever in a suspicious
joint It may come from other foci or may exist only in small nodes.
The localization of tuberculosis in joints by the injection of massive
doses of tuberculin is very reliable. Undoubtedly, if we inject in the
average case one and a half or two milligrammes of tuberculin we
will get a positive and marked reaction in the affected joint However,
I believe that I have seen so much damage caused by such doses that
I am unwilling to use it We can make the diagnosis without it

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106 INTERNATIONAI. CUlflCS

What help does the X-ray give ns in the early diagnosis of tuber-
culosis ? In small diildren it can give us absolutely no help, because
we must remember that in small children the epiphysis, the head of
the femur, for instance, is not shown at all in a child at an early age.
The head of the femur is cartilaginous and soft, and the X-rays pass
readily through it The only thing we can see is a little centre of
ossification, and it is useless to try and size up a hip-joint tuberculosis
in a small child by the X-ray appearance. The entire head of the
femur may be destroyed except a little osseous centre or centre of
ossification that may happen to be the only part of the head of the
femur that is not destroyed, and yet the X-ray will not show it It is
only in the older cases or in those cases with wide destruction that
we can depend upon the X-ray picture.

Our time is rather short this morning, and I do not know that it
would interest you to see X-ray pictures of tuberculous lesions. We
have large numbers of them in the hospital, and I have a few here
which show the typical Pott's disease and hip disease and tuberculosis
of the knee, but they all are cases which are old enough to have prac-
tically complete ossified bone in the region where the lesion exists in
the spine. For instance, we can readily see in many of these pictures
the area of destruction. In the hip we can see in sudi pictures areas
of destruction, but I wish to impress upon you that in a small diild,
in a child under four or five years of age, it may be possible to have a
tuberculosis of wide extent, involving almost the entire head of the
femur, without any X-ray appearance that you or I or the most skilful
of X-ray interpreters can diagnosticate as tuberculosis. We read in
some of our books, and in some articles that are written, of the value
of the X-ray in the diagnosis of tuberculosis, and the X-ray is of great
value in the diagnosis of tuberculosis, and the X-ray is of great value
in the older cases, but it is of very little value in the young cases.

BBAIN INJURIES AT BIBTH

I am going to say a few words about a subject that has been in-
teresting us enormously in our various cUnics, and that is, birth in-
juries to the brain which apparently are very common, and which
are almost never diagnosticated at an age sufficiently early for proper
operative treatment to be instituted. Such cases fill our hospital
clinics, and at my clinic here and at the Children's Memorial we have

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TUBBBOUIX)US JOINT DISEASE IN OHTLDBEN 107

sometimes six or eight spastic imbeciles or idiots a week for whom
very little can be done.

Green, of Boston, has written what I consider a very important
paper on this line, emphasizing the fact that nearly all of these epi-
leptic and imbecile spastic cases are blue babies ; that most of them
had convulsions at the time of birth. He believes that most blue
babies have an intracranial injury. It is possible in some cases to
diagnosticate the location of the injury. If a child at birth be healthy
and well, and nurses well, and seems like a normal child, and then
fades off into a stuporous or semi-stuporous condition and refuses the
breast, and gradually becomes comatose, we know that in such a case
the lesion is usually a rupture of the longitudinal sinus, with a slow
venous hemorrhage, which produces the symptoms. If the child is
blue at birth and stays blue, and has a number of convulsions, and
there are no localizing symptoms — sometimes there are and sometimes
there are not — ^it is probably a meningeal hemorrhage.

The only early case I have operated on was through the kindness
of Dr. Churchill This child had a quadruplegia. There was com-
plete spasticity ; there was bulging on the left side. I turned down a
skull flap, and there came out from between the dura and skull a
mass or clot of blood half as large as a hen's e^. After the removal
of this the spasticity within twenty-four hours b^an to improve. A
little later it all disappeared, the child went on improving and made
a perfect and uninterrupted recovery, and returned to its home in
Virginia in a few weeks. If these cases are seen early enough the
clot can be taken out

Following the work of Farrell and Sharpe, of New York, we have
done wide decompressions on five or six of the older cases, with, in a
few instances, apparent benefit It is too early to draw conclusions
from our own material, but Farrell and Sharpe are convinced that'
much benefit may follow decompression in cases where the eyes show
any signs of increase in intracerebral pressure.

The subject is one of great interest, and needs full investigation,
but these cases should be diagnosticated and operated within a few
weeks after birth for ideal result&

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ENLARGED SPLEEN; SPLENIC ENLARGEMENT;
ANTERIOR POLIOlfYELITIS

BY HENRY W. CHENEY, M.D.

Associate Professor in Piediatrics, Northwestern University Medical School;
Attending Pflediatrician, St. Luke's Hospital

OASB OF BNLABOBD SPLEEN

This little girl is nine years old. Last spring it was noticed that
the abdomen was becoming larger. She was under observation in die
hospital during the summer. Since June it was found diat she had
more or less fever every day, her temperature rising in the afternoon
to 100^ and 101^. She had a distinct and uniform ailargement of
the abdomen — quite general, and much more marked than at the
present time. During July and August the abdomen was quite en-
larged, which enlargement consisted not only of the enlarged spleen,
but also an accumulation of fluid, which could be easily demonstrated
by die ordinary methods. Aspiration of this fluid and an examina-
tion of it showed it to be the result of a tuberculous peritonitis. The
cellular content of the fluid indicated that An injection was done
into a guinea-pig, and the animal died with the lesions of tuberculosis
of the glands and bowel, so that it proved that the little girl did have
a tuberculous peritonitis, causing the accumulation of fluid.

Under treatment that fluid disappeared, so that now there is prac-
tically none at all in die abdomen. All of this time, in addition to
the fluid, there was the enlarged spleen, which you see outlined. She
is not in the hospital now, but at home and attending school. In the
spring, when we first saw her, die spleen was larger than at die present
time, being on a level widi die umbilicus, or even below. During the
past two or diree months it has lessened in size, imtil it is as you
see it outiined. The spleen is not tender, and presents simply the
usual feeling of an enlarged spleen. The liver is not enlarged. Dur-
ing this time the blood examination has not shown any of the changes
which would be typical of a leukaemia. It has shown a simple ansemia,
the hsemoglobin ranging from 40 to 60 per cent during the hei^t
of the summer's illness> and a decrease in the red cells. I have not
108

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ANTERIOB POLIOMYELITIS 109

her history here, but the decrease in the red cells was marked. There
was no change in the white corpuscles.

Preceding her appearance in the hospital she also gave a history
of passing a tapeworm. There has been no return of that condition.
I think that was simply coincident with the other illness, and probably
had no relation to it

The treatment given her consisted of small doses of arsenic each
day, and then, after the tuberculous peritonitis was definitely estab-
lished, we b^an giving her small doses of tuberculin at regular in-
tervals. While in the hospital she also had daily exposures of the
abdomai to the direct rays of the sun, beginning with short intervals,
and lengthening those each day, to prevent severe burning of the skin,
and under that treatment the tuberculous peritonitis seemed to rapidly
improve and the fluid disappeared from the abdomen.

In my own mind, the diagnosis then was a combination of a
simple splenic ansemia, or von Jaksch's ansemia, and a tuberculous
peritonitis. The latter was definitely diagnosed because of the result
of our experimental injections. Evidently we have here a little girl
who has had tuberculous peritonitis which has been cured, or at least
so far cured that it will no doubt go on to a cura

In this little girl, also, I conducted an experiment, which may
be interesting to you, in the administration of urotropine, to see what
effect it would have upon the urine and, perhaps, upon the tuberculous
effusion. It promptly appeared in the urine, and continued there
all the time of administration, and we gave her ten grains, three
times a day, for a continued period of time. The second aspiration
of fluid from the abdomen was examined for any trace of formalde-
hyde, but none was found. That, perhaps, is a point to r^nember in
the excretion of urotropine or formalin from the body. There was
no trace of formalin from the urotropine in the tuberculous effusion.

The little girl is very much better now, but still has the enlarged
spleen, as before stated and as you can see. However, she is able to
attend school, and I tiiink will get quite well.

SPLENIC ENLABGEMENT

Here are two more cases of splenic enlargement occurring in the
same family, in a brother and a sister. The little girl is three and
a half years old, and the baby boy one and a half years of age. There

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110 INTBBNATIONAL OLINIOS

is a syphilitic history in the family. The mother has had several
miscarriages. There is no doubt about the syphilitic infection of
these two children. They came to the dispensary within the last
month, and have been under observation only for that period of
time. They were brought into the dispensary because of the enlarged
abdomens and apparently sick condition generally. We have not had
a chance to make as complete blood examinations or as extended his-
tories as we would like, because of the ignorance of the mother, an
Italian, who objects to almost any blood examination.

I will first show you the boy. The spleen is enlarged, as the out-
line shows, practically down to the crest of the ilium, and running
across below the level of the umbilicus. The liver also is enlarged,
one to two fingers' breadth below the border of the ribs. This
youngster has some enlargement of the glands. The epitrochlear on
one side is enlarged, and the cervicals slightly; the inguinals quite
markedly so. This condition is probably due to the syphilitic in-
fection. The blood picture in this case gives a very marked increase
in the leucocytes. There have been three counts of the white cells.
The first one, a month ago, gave 101,000 ; a few days later, 76,000 ;
and a count made a week ago, 140,000. No count has been made of
the red cells in this case. A differential count showed that of the
white cells, 50 per cent were lymphocytes; large mononuclears,
15 per cent. ; polymorphonuclears, 15 per cent., and the others scat-
tered among the other cells, eosinophiles, basophiles, and neutrophiles.

The sister is three and one-half years old, and the spleen in her
case is equally large, perhaps extending farther down into the iliac
fossa here (indicating) and farther over toward the umbilicus. The
liver also is rather more enlarged, as outlined here. With the sister
there are also the lesions of a hydrocephalus, as you will see. The
flat nose observed is due to the syphilis. Only one blood count has
been made in this case, which showed red cells, 3,000,000; leuco-
cytes, 32,800. The lymphocytes showed 41 per cent ; large mono-
nuclears, 10 per cent ; polymorphonuclears, 35 per cent The sug-
gestion from the laboratory man relative to the blood is that the blood
picture probably shows a splenomyelogenous leukfiemia* In my own
mind it is a little doubtful as to just the classification of these two
conditions. They are younger than any reported cases of leukaemia
that I can find, though it is quite possible that tiiey are leuksemic

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SITLABGED SPLBBN; ANTEBIOB POLIOMYELITIS 111

cases. It is quite possible, also, that the syphilitic infection may
acoonnt for the whole picture. Cases have been reported of this kind
which showed the blood changes resembling leuksemia* In die little
girl with the large head the syphilitic infection is probably respon-
sible for the hydrocephalus. The glands are also enlarged in the girl.
These children have not been with us long enough or regularly
enough to institute any definite treatment I simply present them
as probable leuksemic cases. The laboratory man who made the
blood count thinks it is a typical picture, but still there is a pos-
sibility that the hereditary syphilis may cause all of these changes
which diey show.

ANTEBIOB POLIOMYELITIS

During the summer there has seemed to be, from various reports
we get, somewhat of an increase in the number of cases of acute
poliomyelitis in the city, and we find that fact reflected in the clinic
here because we have had a larger number than usual coming to see
us. During the three months just passed we have had six cases or
more of this disease. That number is much larger than the average.
We do not average more than ten cases a year. This morning I have
two cases to show yoiL

This youngster is one and a half years old. He was taken sick
suddaily two months ago — about the middle of August The mother
said he suddenly developed fever and constipation, and slept a little
more than usual. This lasted a few days. Two days after onset of
the fever the mother noticed that the right arm could not be used,
which condition has persisted ever since. As you will notice, tbe
right arm hangs at the side, without any motion at all, whereas motion
in the other one is free. Paralysis of the right arm was not complete,
inasmuch as there was some motion in the fingers at all times, and
that has been improving somewhat He can use the fingers and the
hand muscles, but none of tbe shoulder group, the arm or forearm.
He can grasp objects fairly welL

Just about tbe same time, or within a wedc, this other child came
to the clinic, presenting almost the same history, only not sick quite
so long. He came to tbe clinic a few days after the onset witii the
history of acute fever, lasting two or three days, and then paralysis
of the left arm. It is rather unusual to get two cases so close together

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112 INTEBNATIONAIi CLINICS

and so much alike. In this case there is not qnite so much motion as
in the first one^ but still a few of the muscles of the hand and fingers
will work.

In some of the other cases we have had there has been a more ex-
tensive paralysis, monoplegia, or diplegia, both l^s being involved in
some cases> and the arm and 1^ in others.

Begarding treatment, we have prescribed urotropine, more because
we wanted to prescribe something than from any real belief in the
drug. Urotropine had considerable vogue some time ago, but more
recent experiments have questioned its value — ^whether it has any in-
fiuence on the organism in this condition or not We advised the care-
takers or parents of the children to do nothing at all in the way of
massage or passive motion in the very beginning. We suggested wait-
ing a month or perhaps six weeks before beginning the active treat-
mait in the way of massage and passive motion* We have not used
electricity at all. Refraining from active treatment at first is wise,
I think, particularly in those where the lower extremities are involved.
The use of these paralyzed muscles too early is, I think, inclined to
increase the later deformity. The muscles are liable to be stretched
if used too soon. So we advised both of these cases that after a month
they can begin encouraging the little ones to use the arm ; massage the
muscles thoroughly, and try in every way to get motion back. The
first case shows some slight improvement We can usually promise
the mothers that considerable improvement will take place. It is
remarkable, as most of you know, how much good will result in some
of these cases that seem to be hopelessly paralyzed in the b^inning.
I had a little girl who was paralyzed in both legs two years ago, and
under this line of treatment and steady, faithful care by the mother,
and massaging of the muscles, with encouragement to walk and, later,
consultation with an orthopeedic surgeon, who advised the wearing of
braces for the last year, this little girl is now able to walk around
quite well, and goes without any brace. There is a little extraluxation
of the knee and a little backward bending of the knee, but she gets
around without any help at all, and plays with some of the otiier
children. In the majority of these cases we can promise the parents
that improvement to a marked degree will take place, so that I think
with these patients the outlook is very encouraging. Good motion in
the arm will come in time, and surely in the hands — ^perhaps enough

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ANTEBIOB POLIOMYELITIS 113

to make the hands very useful members. Improvement often takes
place after the lapse of a year or even two years. We need not be
discouraged, and can keep on encouraging the patients even so long
as a year or a year and a half.

In this third case die paralysis occurred five years ago, and was
complete in both legs. Since then he has received all kinds of treat-
mait, and has improved somewhat Dr. Porter has operated on die
legs once or twice, and he can walk around now all ri^t without
any trouble. He still has a brace on one leg.

This shows the encouraging results of good treatment However,
the hope of the future will lie in preventive vaccination or inocula-
tion for diese cases, because when the diagnosis is made and we are
ready for treatment the damage is all done. I hope, as you do, that
before many years we will have some sort of preventive treatment
that we can give to all children, thus making them immune to the
infection.

Vol. II. Ser. 25—8

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GYROSPASM (SPASMUS NUTANS); TUBERCULAR MEN-
INGITIS VERSUS TRAUMATIC CEREBRAL INJURY;
PROBABLE SARCOMA OF THE RIGHT LUNG

BY JULIUS H. HESS, M.D.

Associate Professor and Head of Department of PsBdiatrics, University of Illinois;

Attending Pediatrician to Cook County, Michael Reese, and

Englewood Hospitals, Chicago

OYBOSPASM (spasmus NUTANS ) '

I FiBST saw this ansemie baby about two weeks ago, at which time
it presented considerable evidence of advanced rhachitis. The history
given by the mother was that it was breast-fed for the first four months.
About the fourth month it was able to sit up, when the lateral turning
of the head was first noticed, which has increased steadily since that
time. Also, when the child focused its attention on objects, there was
nystagmus. When asleep this lateral rotation of the head disappears.
The condition here is one of rotary spasm in contradistinction to the
nodding spasm, a similar but less frequent condition. As is usual,
rhachitis is an associated condition. The combination of head move-
ments and nystagmus suggests that the nuclei of the spinal accessory
and upper spinal nerves are in close relation to the oculomotor nerves.
The head, trunk, and extremities are not involved.

We placed the baby upon a mixed diet of vegetable soup, orange-
juice, and a little v^etable, and also gave cod-liver oil and phosphorus.
The mother believes the child's condition has already, in the course of
two weeks, shown some signs of improvement. The gyrospasm usually
disappears by the end of the second year, even if untreated, possibly
at the same time that the rickets disappears. At the time of cor-
rection of proof, four months later, the gyrospasm had entirely
ceased, while the nystagmus, though still present, is greatly decreased.

TUBEBCULAB MENINGITIS VEBSUS TBAUMATIO CEBEBBAL INJUBY

This second case is open for diagnosis. This infant entered the

hospital on October 13, 1914. Two and a half weeks before admission

the child fell from its baby cart, landing on its head. Two days later

ehe started to vomit, and was very listless and drowsy. She continued

114

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GYBOSPASM (spasmus NUTANS) 115

in stuporous condition for a week, had several convulsions, and
developed an internal strabismus. There were no chills, fever, or
headache. The stuporous condition continued, however. The child
has lost four pounds in weight Stools normal in number, consistency,
and color, but contain some mucus, but no blood. The child is the
youngest of four. Its birth was normal. Its first teeth erupted at
fourteen months. It does not walk or talk, and is seventeen months
old, and shows profound evidence of rhachitis. The child has been
bottle-fed, but has had no food disturbance to date. The child was
never put to the breast, because the mother had an active tuberculosis,
which has been aggravated by this pregnancy. At present she is in
an advanced stage of tuberculosis. This infant had pneumonia at the
age of one month. Other than for the mother's pulmonary history
the family history is negative.

Physical findings at the time of entrance were as follows: The
appearance of the child was that of an apathetic, drowsy infant
The eyes were sunken, and there was an internal strabismus present
The skin was dry and inelastic. The cervical glands were palpable.
The large fontanelle was nearly closed. The strabismus was more
marked in the right eye. The child could see objects before the eyes,
but did not follow them. Ear examination was negative; no mastoid
tenderness. There was no rigidity or tenderness of the necL The
thorax was negative. The abdomen was negative except for a slightly
enlarged spleen. Babinski's sign was present and quite marked on
both sides. Tache cerebrale was very markedly positive.

On entrance to the hospital, October 14, 1914, a spinal puncture
was made, after which the child seemed more listiess, but remained
about the same for three days, when another puncture was made, with
no untoward effect On the fourth day after the entrance the child
seemed better. The rigidity had almost gone. There was only very
slight internal strabismus of the right eye. This condition lasted for
two or three days. The child gained in weight and seemed to be im-
proving generally, when he started to vomit again and the general
condition became worse. The eye symptoms were somewhat more
marked, and the whole condition seemed to be one of retrogression.
Since October 26, four days following the second setback, he has not
vomited. Temperature normal, reflexes normal, and the strabismus
has disappeared and he seems quite welL

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116 INTEBITATIONAIi CLINICS

Laboratory Findings. — ^Urine n^ative on several occasicms. Tu-
berculin reactions, both cutaneous and intradermal, n^ative. Hsemo-
globin, 85 per cent; red cells, 4,000,000 plus; white cells, 12,600.
This blood count is quite normal for a child of seventeen months.

Spinal Fluid Examination. — First count, October 14 : 35 cells to
the cubic millimetre; 100 per cent lymphocytes. Pressure was not
markedly increased. !N^o organisms. IN'oguchi n^ativa Boss- Jones
n^ativa Two days following, the cells were 28 to the cubic milli-
metre; 90 per cent lymphoc^rtes. Globulin tests still n^ativa On
the 264 (yesterday) the lymphocytes were again 100 per cent ; 37
cells to the cubic millimetre ; globulin tests both positive ; no organisms
were found. Lange negative; Wassermann negative.

Conclusions. — ^With a history of active maternal tuberculosis, in
the presence of the other positive findings, even in die absence of
positive taberculin tests, naturally these findings led to a diagnosis of
tubercular meningitis. The spinal fluid findings were at the time
considered as early positive findings. We have rather reluctantly
changed our opinion from one of beginning meningeal tuberculosis to
possibly some cerebral injury due to the falL In the presence of the
history of the mother, one must still be suspicious of diese spinal fluid
findings, as indicating a latent or at least a subacute meningeal affair.

At the time of correction of this proof, four months later, the
infant is, to all appearances, in perfect health, while his mother is
still in the municipal tuberculosis sanatorium.

PBOBABLE SABCOMA OF THE BIGHT LUNG

This little girl of thirteen years gives a personal history of a
full-term, normal child. Breast-fed for six months. Past history also
n^ative, except for the fact that she was always a weak child, and
quite frequently suffered from headaches. Entered the hospital
April 8, 1914. The trouble was first noted two weeks before this
time, starting with a mild cough and general malaise. This cough
gradually became worse — ^it was not productive ; most marked at night
and in the early morning. ISo chills, no night-sweats. She lost about
two pounds in weight the week preceding coming to hospital No
urinary symptoms; no fever. Blood examination at the time of en-
trance to hospital (the first of four) showed 10,000 white cells ; lowest,
9400. Average of 56 to 74 neutrophiles, ranging within the normal.

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GYBOSPASM (spasmus NUTANS) 117

Ko abnormal cells. It can be readily seen that the child is somewhat
anBemic, notwithstanding the fact that she has red lips, which, on
further examination, you will find to be cyanotic.

Now when the chest is exposed you will notice a relative fulness
on the right side of her nedc, which extends down to the clavicle, so
that the supraclavicular space on the right side is obliterated, and the
same can be said of the infraclavicular space on the right side. You
will also notice that the anterior axillary border on the right side is
lower than on the left The veins are also somewhat larger and more
prominent tiian on the left sida In other words, the entire right
chest bulges. The right shoulder is also very much higher than the
left There is a very marked scoliosis, with the curve to the left side.
On percussion the upper part of the right chest is absolutely flat
Vocal fremitus is entirely absent over the upper part of the ri^t lung
posteriorly. The same is true anteriorly. On auscultation you hear
nothing but marked bronchial breathing — ^no rales.

Paracentesis was done on this girl repeatedly, both before and
behind, with the idea that possibly she had some form of aicysted
pus or other fluid in her right chest. However, nothing was obtained
except blood, which was also negative upon every examination made.
Two skiagrams were made, die first of which showed a very marked
scoliosis, the heart being pushed quite a distance to the left, so that
diere was about one^uarter of an inch of lung tissue between the left
border of die sternum and the heart The nipple is pushed about
two centimetres to the left of the mid-sternum line on the left side.
You see a very small area of lung tissue pushed up here (indicating),
just below and at the outer edge of the clavicle, and a small area of
lung tissue below at the lower outer border (indicating). The mass
assumes almost a perfect contour, and this is what led us to believe
that possibly we had to do with a cyst, possibly an echinocoocus cyst,
or, on the other hand, an aicapsulated new-growtL This second
picture, taken somewhat later, shows die entire process on the increase.
The heart is pushed somewhat farther over ; there is a more marked
scoliosis and less lung tissue, on die whole. The child's general ap-
pearance is not quite so good. To our minds, the diagnosis rests be-
tween a sarcoma of the lung, as the most possible new-growth, and
an echinocoocus cyst We have no reason to believe the latter present,
because the punctures were all negative. Our conclusions, therefore,
lead us to assume that this is a new-growth.

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A CASE OF CANCER OF THE PANCREAS IN A NINE-
YEAR-OLD BOY, WITH NOTES ON OTHER RE-
PORTED CASES OF CANCER IN CHILDREN

BY SAMUEL C. STEWART, M.D^ AND LEVER F. STEWART M.D.

(Formerly Resident Pathologist, Pennsylvaiiia Hospital)
Surgeons to the Clearfield Hospital, Clearfield, Pennsylvania

On March 10, 1913, a white male child, H. M., nine years of age,
was admitted to the Clearfield Hospital, complaining of dull pain
referred from the iliac crests to the pubic region. His family and
social histories were negative. He had always been unusually healthy
and robust, having escaped the usual diseases of childhood, and his
life had been spent largely in the country. Four months previously
a playmate had kicked him in the upper left abdomen; the pain
resulting was transitory and mild. One month later the lower
abdominal pain began and a mass was noticed in the upper left ab-
domen. This mass was never very prominent^ but was noticed to
fluctuate in size. Marked constipation appeared with the other
symptoms. Aside from constipation, there were no other intestinal
symptoms excepting an absolute loss of appetite during the two weeks
previous to his admission to the hospital. There were no symptoms
referable to the genito-urinary system; no nausea, vomiting, fever,
chills, sweat, jaundice, " heart-bum," " water-brash," nor pain in the
upper abdomen following the injury. 'No pain was referred to the back
or Moulders. The stools were always normal in appearance. The
patient thought he had lost some weight and he felt weak. There
were no chest symptoms.

Physical examination showed a well-nouridied, muscular boy,
with good color and eyes reacting normally. His tongue had a white
coating. The heart and lungs were negative; the abdominal muscles
well developed. The lower pole of the spleen during deep inspira-
tion was palpable below the left costal margin. Internal to the spleen
an irregular mass, feeling to be the size of the child's fist, descended
118

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CANCER OF THE PANCBEAS IN NINE-YEAB-OLD BOY 119

to the level of the umbilicus on deep inspiration ; on expiration its
lower border was two and one-half centimetres above the umbilicus.
Its upper border seemed to approadi die posterior abdomen and was
not sharply defined. The right border of the msBS was not well de-
fined, but did not seem to ext^id farther to the right than the midline.
The left border was well defined, reaching to a horizontal line dropped
from die tip of the left ninth costal cartilage. Deep palpation elicited
tenderness of the mass. There was no tenderness in die back. Press-
ure in the left loin threw the mass forward, but pressure over the
mass anteriorly made no impression on the hand in die loin. The
extremities and the glandular system, also die urine examination,
werenegativa

On March 11, 1913, an upper left rectus incision was made.
The left kidney was found to be normal in size and position. A
tumor was f oimd to be of the tail of the pancreas, and the aitire pan-
creas was slightly enlarged, hard, and irregular. The tumor-like tail
was nodular in addition (some of the nodules being the size of an
ordinary marble). Along the upper and lower borders of this por-
tion of the pancreas a few reddish lymph-nodes were noticed. The
pancreas was freely movable. The appendix was removed and found
to be normal. The liver, gall-bladder, common and hepatic .ducts,
stomach, colon, and intestines appeared normal. The spleen was
sli^dy enlarged, but otherwise of normal appearance. The trans-
verse colon was pulled upward and the peritoneum overlying the tail
region of the pancreas was incised. Next a knife was inserted on the
greatly enlarged portion pf the pancreas for a distance of 1.5 Cm.
This was withdrawn and a closed hsemostat was inserted at this Dlace
and vdthdrawn open. A small amount of serous fluid and a bit of
white, cheesy material exuded. To this there was no odor. The
opening in the pancreas was packed with selvedge gauze, and a cigar-
ette drain placed in diis region. This procedure was followed with
the feeling that, though the pancreas was of a malignant appearance,
the child was entitied to the chance it would afford for recovery if
the condition was inflammatory. The wound was closed to the
drainage. The operation did not consume much time, and the patient
was returned to bed in good condition.

Following operation the patient continued to refuse nourishment
by moudi. On the fifth day the drainage was removed. This was

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120 INTBBNATIONAIi CLINICS

followed by a free discharge of irritating fluid (producing the ex-
coriation characteristic in pancreatic fistulas). The patient gathered
no strength ; on the twelfth day after operation his abdomen became
distended ; two days later he died.

An incisional autopsy was the only available procedure, and this
showed the pancreas to be about twice as large as at the time of opera-
tion and of the same appearance. Portions of it were removed for
examination. Qeneral purulent peritonitis was present

The tissue removed was pale and surroimded by a thick, fibrous-
like capsule, varying from 0.05 to 0.3 Cm. in thidmess. This sur-
rounded cheesy, yellow and white, gelatinous-appearing areas which
went to make up lobules, in turn enveloped by whorls of fibrous-like
tissua There were several cysts about 0.5 Cm. in diameter present
which were found to contain serous fluid.

Microscopic examination of this tissue stained with hsematoxylin
and eosin showed a fibrous-tissue network that was quite thick in areas
(Figs. 1 and 2) . This was occupied by islands of endothelial-like cells,
closely packed ; some of these cells diowed mitotic figures, and some of
the islands of cells were entirely necrotic; others showed central
necrosis with signs of phagocytic action. Some were isolated, others
clumped and separated by thin, fibrous-tissue projections. After care-
ful study the condition was named medullary cancer of the pancreas.
(See photomicrographs of Section S 3298, Josephine M. Ayer, Clin-
ical Laboratory, Pennsylvania Hospital.)

Kiihn,^ in 1887, reported a case of primary cancer of the pancreas
in a two-year-old girL On physical examination the child showed
oedema of the legs and an enlarged liver. Pneumonia intervened and
terminated in death. At autopsy the pancreas was found to be
changed into a reddish tumor hardly die size of die normal gland.
It had hard, white nodules, and similar nodules were present in the
lungs in the form of metastases.

Microscopic examination showed connective-tissue prolongations,
lined by cylindric and other formed cells. A diagnosis of cylindric-
cell adenocarcinoma of the pancreas was made.

Simon* reports a case of cancer in a thirteen-yearK)ld boy who
came to him April 16th with a history of being ill all winter with
severe diarrhoea and loss of appetite, weight, and strength. Eight
we^ before admission jaundice appeared, followed by obstinate con-
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CANCEB OF THE FANGBEAS IN NINB-YBAB-OLD BOY 121

stipation. Eight days before admission he began to be bothered with
vomiting after meals, heaviness in the stomach, and extreme weak-
ness.

On physical examination the boy was found to be of medium size,
jaundiced and cachectic, with oedema of the extremities. The veins
of the abdomen were dilated, and liver enlarged, extending in the
axillary line 4 Cm. below the costal arch, l^odules were palpable
beneath the belly-wall, apparently attached to the liver. There was no
sign of lymphatic involvement. The urine showed the presence of
bile. On May 2nd of the same year the child died. Autopsy showed
a prominent, smooth, shiny, olive-green liver, dotted with many
whitish nodules the size of a lentil or cherry. The gall-bladder was
distended with bile. The abdomen contained 400 Cc. of slightly
cloudy fluid mixed with flakes of fibrin. The spleen was hard, its
capsule tense. There were adhesions between the colon and liver,
while the root of the mesentery showed a tumor the size of two fists.
On loosening the stomach at its lesser curvature the mass was en-
countered, and on opening the duodenum at the level of the head of the
pancreas its wall was found to be included in the tumor tissue. Five
centimetres beyond the pylorus its mucosa stopped, and the carcinom-
atous wall was found to extend to the beginning of the jejunum.
The common duct opening was in the midst of the mass and patulous,
though it had a stricture caused by the tumor. All of the pancreas was
occupied by the mass excepting a small portion of the taiL

A diagnosis of cancer of the duodenal portion of the pancreas, with
metastasis to the liver and kidneys, dilatation of the biliary ducts,
inflammatory hyperplasia of the spleen, chronic follicular enteritis,
hydrops, icterus, and ascites, was made. The question arose as to
whether the tumor was primary in the duodenum or pancreas. Simon
concluded that the growth probably originated in the pancreas, as
the microscopic sections showed no cylindrical cells such as he con-
sidered one should see in duodenal cancer.

The three cases permit of limited comparison and no valuable
conclusions.

Kiihn and Simon put different constructions on the presence of
the cylindric cells. Simon was not sure that the carcinoma was primary
in the pancreas. Kiihn was positive in his claims. In the case re-
ported a complete autopsy was impossible; however, there was no

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122 INTERNATIONAL CLINICS

evidence suggeBting that the cancer was not primary in the pancreas^
nor was there evid^ice of cancer elsewhera Loss of appetite, wei^t,
and strength, and obstinate constipation were symptoms common to
this and to Simon's case. (Edema of the legs and enlarged liver were
common to the cases of Kiihn and Simon, but in these metastasis had
taken plaoa

DaCosta,' in 1858, quoted Bokitansky as having mentioned an
instance of the pancreas being found scirrhous at birth. Todd * re-
ported the case of a female, fourteen years old, who was ill scnne
months with a tense swelling in the epigastric region, extending to
the right hypochondrium ; it was tapped, and greenish fluid escaped.
There was a pain in the epigastrium, at times very acute, that was in-
creased on pressure. The skin was deep orange colored. Great de-
bility and emaciation accompanied. Ascites and anasarca were
present, and there were dyspeptic symptoms. For some time ab-
dominal pain and convulsions were prominent symptoms. The de-
velopment of the disease followed a fever with relapses. The post-
mortem appearance of the pancreas showed the head and glands around
it converted into a hard, solid mass; its duct was obliterated. The
liver appeared healthy ; the cystic duct was dilated, but at its juncture
with the hepatic duct it was impervious ; the remaining portion was
natural.

These two cases are not supported by microscopic findings. So
far as we find, the cases of Kiihn and Simon and the one we have
recorded are the only cases of pancreatic cancer reported in children
that have seemed beyond a reasonable doubt to have been primary in
this organ.

Castle ^ reports 42 cases of carcinoma of the liver in childhood,
including his own.

Peiper * reports what he terms a malignant embryonal adenoma in
a seven-month-old infant who died three days after exploratory opera-
tion. Autop^ showed a tumor of the left lobe of the liver. Micro-
scopic examination showed carcinoma of the left lobe of the liver.
There was no evidence of cirrhosis. In places the tumor cells were in
nests, surrounded by connective tissue. The cells were of three kinds :
still undifferentiated embryonal structures; liver-cells; ducMining
cells. The latter he considered proof of embryonal origin.

According to Peiper, liver cancer in infants and children seems to

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CANOEE OF THE FAKCBEAS IN NINE-TEAB-OLD BOT

123

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124r INTEBNATIONAIi CLINICS

be more common, possibly for the reason that cancer of this lype is
of embryonal character.

Dibbelt, on " Hyperplasia, Adenoma and Primary Cancer of the
Liver/' described a primary liver cancer in a ten-year-old girl, similar
to Peiper's case.

Wagner, in eight-day and two-month-old infants, found in the
roimd ligaments nodules that were liver tissue.

In four hundred autopsies Birch-Hirschf eld '' twice found single
or multiple round knots, no bigger than peas, separated from the liver
substance by capsules. On microscopic examination these were found
to be liver-cells. " A tumor-like new formation was in the liver.'*

Weber reported a case of primary cancer of the liver in an
eleven-month-old child. It came from the right lobe and also filled
the portal vein. The microscopic diagnosis was adenocarcinoma
arising from the liver-cells. The case was similar to Peiper's.

Bennett,^ in 1849, mentioned a thirteen-year-old boy and a fouJ^
teen-year-old girl in whom he suspected cancer, but his evidence was
insufficient

Billroth,^ in 1887, showed that out of 3385 cases of cancer of the
uterus collected by Lever, Kuvisch, Chiari, Scanzoni, and others there
was one aged seventeen (Glatter) and one aged nineteen (Beigel).

Birkett mentioned a case of cancer in the mammary region in an
eight-year-old girl. This is looked upon as a sarcoma by Billroth and
others.

The cases of Carmichael and Everard Home, who are said to have
observed bilateral cancer of the breast in the twelfth and fifteenth
' years, were cited by Gross without reference.

Battle and Mayburjr ^^ recently reported an epithelioma of the
nipple in an eleven-year-old girl

Butzengeiger ^^ and Miiller** respectively reported primary
cancer of the appendix in girls seventeen and thirteen years of age.

MacCarthy and McGrath ^^ reported from the Mayo Clinic four
cases of carcinoma of the appendix in children.

Von Franque ^* reported a case of ovarian cancer in a sixtewi-
year-old patient His description, however, does not satisfy one as to
whether the growth was carcinoma or sarcoma.

Sakaguchi,^*^ among twenty-three specimens of cancer of the

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CANCEA OF THE FAKOBEAS IN NINB-YEAE-OLD BOY 125

teBticles, found two in children two and one-half and five years of age.
The disease ran a rapid course in both cases.

Gleason ^^ is responsible for the statement that malignancy of the
prostate is observed from earliest childhood until old age.

Quite recently Dr. Harry Deaver told one of the writers of a
childy fifteen years of age, on whom he had operated for cancer of the
transverse colon at the Mary J. Drexel Home, Philadelphia.

Bryan ^"^ reported a breast cancer in a boy fifteen years of aga
This would seem to have been a malignant degeneration of an adeno-
fibroma. Bryan also mentions the case of Blodgett^*^ who removed a
cancer from the breast of a twelve-year-old boy.

OONOLUSIONS

In going over these cases we find 63 that seem to be authentic
beyond a reasonable doubt. These were divided as follows :

rk«.».» n.»... Number Under 16 yeMi PeroenUge

Organ Cancer ofoneee ofage oftotal

liyer Tea 45 Tes 71.4

Appendix Yes 6 Tea 09.5

Breait Tes 5 Yes 07.9

PAnereM Yes 3 Yes 04.7

Testis Yes 2 Yes 03.1

Bowel Yes 2» Yes 03.1

*One of theee two ie Simon'i oaae, in whioh he concluded (he cancer had extended from the
pancreaa to the duodenum.

Of the total number of cancer cases^ 45, or 71.4 per cent, were of
the liver and 19 were of children under two years of age. Further-
more, some of the infants had cancer at birtL These facts incline
us to agree with Peiper's view that liver cancer in children is of
embryonal character. He based his opinion on the finding of duct-
lining cells in cancer of a seven-month-old infant.

Symptoms probably common to cancer of the pancreas in children
would seem to be loss of appetite, weight, and strength, and obstinate
constipation.

l^one of the cases reported above have been accompanied by
laboratory findings (sections excepted). In such cases as are reported
above, a virgin field is offered to those studying the etiology of cancer
and to those who would find an accurate test for it

In some of these cases we find exploratory operation has shortened
life. This, we believe, is due to a quick and decided lowering of

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126 INTERNATIONAL CLINICS

resistance occasioned by the rapid progress of the disease. There-
fore in exploring children abdominally on account of tumors a grave
prognosis should be given*

We can no longer adhere to the dogmatic statements of many that
cancer does not occur in the young. In considering tumors, espe-
cially abdominal ones, in children, consideration must be giv^i to
cancer as a possibility. However, after an extensive search of
literature on cancer the cases cited are the only ones we find recorded.

In this paper the words " carcinoma " and " cancer '' are used to
denote the condition, carcinoma.

BIBUOQBAPHT

^KdHN: Virohow'9 JahrBherichie, 1887.

'Simon: "Ueber ein PancreaBcarc. 13 Jahrigen Kind," 1880. Inaugural Dis-
sertation zur Erlangung der Doctorwdrde, etc.
'DaCobta: "Morbid Anatomy and Symptoms of Pancreatic Cancer/' 1858.
«Todd: Dublin Hospital Reports, voL i, 1818.
*Castlb: " Primary Carcinoma of the Liver in Childhood," Surgery, Gynecology

and Oh9tetrio9, xviii, 4, April, 1914.
•Pkipeb: "Cancer of Liver in Infants," Jahrbuch fUr Kinderheilkunde, Berlin,

Ixxv, 6, June, 1912.
*BiBOH-HutsoHmD.: Gerhardt's Handbuch, iv, 2nd part, 341-664, 1880.
•Bewnbtt: "On Cancerous and Cancroid Growths," 1849.
'BnxBOTH: Encyclopedia of Obstetrics and Gynecology, vol. iz, 1887.
>• Battle and Matbubt: " Primary Epithelioma of Nipple in a Girl Aged Eleven,"

Lancet, London, vol. i. No. 4683, May, 1913.
^^Butzbnoeioeb: "Zur Kasuistik des Primarem Krebees des Wurmfortsatzes,"

Deutsche Zeitsohrift fur Chirurgie, Leipsic, August, 1912.
^MuUAi: "Carcinoide des Wurmfortsatzes," Arohiv. fur klinische Chirurgie,

Berlin, ci, 1, 1913.
"HacCabtht Ain> McGbath: "The Frequency of Carcinoma of the Appendix,"

Armala of Surgery, Ux, 5, May, 1914.
'*VoN Franque: " Heilungeines OvarisB carcinoms mit Metastasendildung durch

Operation," etc., Deutsche Qesellsdh. f. Qynah., Halle, May, 1913.
"Sakaguohi: Deutsche Zeitschrift filr Chirurgie, Leipsic, cxxv, October, 1913.
" GuBASOif : Hew York Medical Journal, xcvii, 1913.
^BTAN : " Cancer of the Breast in Boy Fifteen Years Old," Surgery, Gynecology

and Obstetrics, xviii, 5 May, 1914.
''Bix>doett: Boston Medical and Surgical Journal, cxxxvi^ 611, 1897.

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A CASE OF EPIPHYSITIS

BY ARTHUR DBRMONT BUSH, B.S., M.D.
Boston, MasBachusetta

The patient, Richard B , was a fair-skinned, blue-eyed boy of

twenty-two months of age, being the first-bom in the family. Both
parents were free of any adverse history. The child was fairly
robust, though subject to rather sharp attacks of acute bronchitis,
a recent attack having been complicated with tonsillitis and otitis
media, the ear discharge continuing.

The first symptom noticed was an unusual thirst coming on soon
after midnight, the child calling frequently for milk and not being
satisfied with water. In the morning the child was found restless
and irritable, lying on his back with his left thigh completely flexed
and slightly rotated laterally; moderate elevation of pulse and
temperature. Attempts to extend thigh were resisted with cries
of evident distress. Palpation revealed nothing. A tentative diag-
nosis of acute tubercular coxitis was hazarded.

In the next few days the little patient developed a temperature
characteristic of acute purulent infections, the mercury rising to
104° to 105° in the evening and falling to 99° to 100° in the
morning. Local consultants, acquainted with the family, were called
in; they suggested the possibility of acute infective rheumatoid
arthritis, there being a strong maternal predisposition to rheumatoid
manifestations. All were now agreed on the desirability of expert
opinion, and a podiatrist from Boston was called. He made an
extensive examination, even to exclusion of meningitis by drawing
fluid from the spinal canal, and decided the case was either tubercu-
lar coxitis or infective epiphysitis. The symptoms at this time con-
sisted of the oscillating temperature previously mentioned; a rapid,
thin pulse, showing less decided remissions than the temperature;
complete flexion of the thigh, with slight abduction and slight lateral
rotation ; a scarcely discernible increase of tension along the antero-
inferior portion of the ileof emoral ligament ; a voluntary fixation of

127

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128 INTEBNATIONAL CLINICS

the hip-joint, apparently for the relative comfort afforded ; a tendency
to maintain a moderate lumbar scoliosis with the convexity toward
the affected side ; no definite swelling or localized area of tenderness.

The specialist advised the immediate application of the Bradford
frame, continued careful observation, and expectant treatment; from
which it will be seen that in his diagnosis he leaned in favor of acute
tuberculosis, though he did not find that temperature curve reassuring.

The continued pyrexia of infection for the next few days made
operative interference seem indicated ; but admittance to any hospital
was barred, owing to the adjoining tenement having been placarded
for scarlatina. The use of an operating room in the local hospital
was finally secured. Incision was made at the '^ point of election,''
posterolateral and inferior to the great trochanter. No pus was found,
and, as there appeared no swelling of the capsule, the joint was not
opened (this conservatism proved later to have been a discretionary
error, presumably). The incision was closed, and the patient was
removed to a tent and later taken home. A rapid and inexplicable
amelioration of symptoms ensued, and for forty-eight hours the little
fellow seemed to be on the mend. Then the pyrexia of infection re-
turned and the illness became worse than before. Finally, after
several days, the urgency of the case plus personal appeals overcame
red tape, and the child was admitted to a hospital in Boston and
came under the care of a leading city surgeon.

On the morning of the second operation the child was carried on
his frame ten miles by train and two miles by cab. He was bri^t
and cheerful and made several remarks, objecting particularly to
any cessation of the train's motion. His temperature that morning
was 104° F. ; pulse, 150. The left hip and upper thigh had become
somewhat swollen anteriorly and mesially. The condition of the
joint at that time is poorly shown in X-ray picture No. 1, taken just
previous to the operation. A vertical incision was made on the
anterolateral aspect of the thigh, extending downward 2^ inches
from the junction of the inferolateral border of the sartorius with the
line of the groin. About 50 Cc. of purulent material escaped. Ex-
amination disclosed destruction of the capsule on its antero-inferior
aspect, with erosion of the head of the femur and some involvement
of the ischiopubic portion of the acetabulum. The joint cavity was
repeatedly flushed with warm saline, then drained with fenestrated

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A CASE OF EPIPHYSITIS 129

rubber tubing passing through the first and second incisions. Patient
replaced on Bradford frame. Ether recovery prompt. Temperature
fell to 101° that evening, and to normal on the fourth day. Removed
from hospital to home on the eighth day. Use of wicks discontinued
on the tenth day. Wounds entirely healed on the eighteenth day,
after daily dressings with saline flushings and sterile cheesecloth
applications.

For the next ten weeks the child was kept out of doors, on a swing
cot by day and in a tent at night. All this time he was strapped to
a Bradford frame, with pulley and weight extension, interrupted
solely by the regular periods of massage and passive exercise. In
August he was fitted with a Thomas extension splint, and was soon
hobbling around. As his strength returned he was daily permitted
to attempt walking a few minutes without the splint, and in about
three months discarded its use altogether. A year later, as the
shortening of the leg became more evident, use was made of a shoe
with built-up sole, the outer half being thicker than the inner in order
to offset the partial genu valgum of that extremity.

Bacteriologic examination of the pus obtained at the time of the
second operation showed a practically unmixed growth of the Strepto-
coccus pyogenes. The bacterium most commonly productive of
epiphysitis is the Staphylococcus pyogenes aureus, though its type
is usually not so virulent as that of the Streptococcus. Since the
boy had been suffering previously from tonsillitis, complicated with
otitis media, it is assumed that the germ gained access to the blood
stream through the tonsils. The lodgement of the germs in the
epiphysis is due in part to the arteries being terminal in that region,
and in part to the low resbtance of those structures, which at that
period are semi-embryonic The primary focus was probably the
epiphyseal line; and, as this line is intra-articular at the hip, progress
of the infection inevitably produced a septic arthritis. The carti-
laginous condition of the head of the femur at this age resulted in
detritus erosion rather than in sequestration.

X-ray plate No. 1 was taken immediately before the operation.
This plate shows fairly well the extent of erosion of the head, and
less clearly the erosion of the acetabular cavity. X-ray plate No.
2 was taken about three months after the operation. Although a
poor plate, it shows to some extent the dense fibroplastic organization
Vol. II. Ser. 26—9

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130 INTEBNATIONAL CLINICS

about the femoral head. X-ray plate No. 3 was taken two years after
the operation. It shows very clearly the havoc the infection had
wrought^ three-fourths of the head of the femur and part of the neck
having been destroyed^ and about one-third of the acetabulum having
been eroded. Of particular interest is the involvement of the inferior
ramus of the pubis. The upward displacement of the involved joint
is well seen when comparing the planes of the lesser trochanters.
Note also the fibro-osseous union between the remaining fragment of
the liead and the ilium. Shortening at this date amounted to about
1.7 Cm.

X-ray plate No. 4 was taken four years after the operation^ the
boy being then six years old. It shows that there has been partial
bone regeneration of the ilium and of the pubic ramus^ growth of
the neck and head, and an extension of the synovial surface between
head and acetabulum. There remains a dense fibro-osseous union
which both limits action and gives strength to an otherwise weak
joint As it is, this joint is apparently as strong as the other, re-
ceives its full share of work in running, jumping, and climbing, and
shows its deficiencies chiefly in limitation of extensive movement
and in the limp caused by the shortening.

The accompanying cuts (Figs. 1, 2, 3, and 4) show his pres^it
physical condition. In the normal front view will be seen the shorten-
ing of the limb, the eversion of the foot, the genu valgvm of that side,
and the slight muscle underdevelopment. The other front view shows
the extreme limit of possible abduction. The rear view shows the
tilted pelvis resulting from the shortened limb, and the consequent,
though slight, lumbar scoliosis. The side view shows the extreme
limit of possible flexion, also the scar of the first incision. The child
is relatively thinner than before his illness^ but has had no further
sickness other than measles and ^^ colds.'' Chronic coryza gives an
adenoidal appearance.

The left leg is now 2 Cm. shorter than the right, the shortening
being in great part due to upward displacement at the hip-joint.
The comparative measurements are as follows : Anterosuperior spine
to internal malleolus — Left, 62.2 Cm.; right 64.7 Cm. Circum-
ference of thigh, middle third — ^Left, 33.3 Cm.; right, 35.9 Cm.
Circumference of knee — ^Left, 26 Cm. ; right, 28.5 Cm. Circum-
ference of calf — ^Left, 23.5 Cm. ; Right, 23.5 Cm. Heogluteal cir-

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Fia. 1.

Fia. 2.

Present physical condition of patient treated for epiphysitis. (Front and posterior views.)

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Flo. 3.

Fig. 4.

Extreme limit of possible abduction.

Extreme limits of possible flexion, and scar of
orifcinal operation.

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A OASE OF EPIPHYSITIS 131

cumference — ^Left, 52 Cm.; rights 53.3 Cm. E!zteiit of possible
flexion, 85 degrees; extent of possible abduction, 50 degrees; hyper-
eversion of foot in most comfortable posture, 35 degrees.

The latitude and relative freedom of movement have been called
unusual in view of the severity of the illliess and the extent of the
erosion.

In reviewing this case emphasis is laid especially on the delay
in reaching a positive diagnosis. There were a number of evidences
strongly suggestive of acute tuberculosis of the hip-joint, but it
would seem as if this possibility might have been eliminated by the
character of the temperature curve; and, though acute rheumatoid
arthritis and scurvy were suggested early in the case as possibilities,
they were not to be seriously considered after the full development
of the pyrexia. To be sure, two of the " classical symptoms '^ of
epiphysitis, swelling and tenderness, were absent at first, but the
balance of the symptoms when associated with the oscillating tempera-
ture would seem to have justified an earlier positive conclusion.

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flQebtctne

PSYCHOANALYSIS: ITS SCOPE AND LIMITATION i

BY A. A. BRILL, Ph3^ M.D.

Lecturer in Psychoanalyais and Abnormal Psydhology, New York University

Ths average physician who does not give much time to the
functional nervous and mental disturbances can hardly realize the
great progress that has been made within the last ten to fifteen years
in the study and treatment of these diseases. To state that this part
of medicine has been altogether rewritten and is still in its formative
period is hardly any exaggeration. In mental diseases the vague
terms of mania and melancholia have been replaced by definite
entities, such as manicdepressive insanity and dementia prsscox,
diseases which rest on a psychological foundation and which are
known to follow a definite course. In the realm of the functional
neuroses the term neurasthenia is becoming more and more limited,
and it is no longer used in the vague and careless manner of the old
school. It is generally recognized that most of the cases that were
wont to be diagnosed as neurasthenia really belong to hysteria,
anxiety, and compulsion neuroses, as well as to the mild psychoses.
The names of Charcot, Kraepelin, Wernicke, Freud, Bleuler, and
Janet, as well as those of Morton Prince, Adolph Meyer, J. J. Putnam,
August Hoch, and others in this country, will always be remembered
as pioneers in these fields. All these investigators have contributed
much valuable knowledge, but, as a detailed discussion of their re-
spective endeavors is not the purpose of this paper, we shall content
ourselves with saying that through their efforts many of the hitherto
perplexing problems have been solved and much good has already
been accomplished.

^ Read at Pittsburgh, Pa., before the Montefiore Clinical Society, on January
25, 1915.
132

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psychoanalysis: its soope and limitation 133

Perhaps the most surprising changes in both theory and treat-
ment have made themselves manifest in the psychoneuroses, and here
the name of Freud stands out most prominently. Nothing in science
since the advent of Darwin's theory of evolution has stirred up so
much discussion and so much opposition. Without resorting to long
analogies^ it may be said that just as the theories of evolution could
not be stemmed despite all bitter and bigoted criticisms, so psycho-
analysis has come to stay. Freud's theories are progressively ac-
cepted; his works are being rapidly translated into English, French,
Italian, Dutch, Norwegian, Hungarian, Polish, and Russian; even
our most unreasonable opponents now claim to use analysis and
dream interpretation, and speak of shocks and early impressions as
causative factors in the neuroses.

Psychoanalysis is Professor Freud's creation. It does not
signify mental analysis in the etymological sense; all that can be
said is that psychoanalysis is a special form of mental analysis,
though not every method of mental analysis is psychoanalysis.
Briefly defined, psychoanalysis is a method of mental investigation
formulated by Professor Freud for the purpose of exploring the un-
conscious mental forces of both normal and abnormal persons. It
seeks to discover the unconscious motives which are at the bases of
the psychoneuroses, psychoses, as well as so-called normal actions, by
utilizing certain technical means, such as interpretation of dreams
and psychopathological actions. The psychoanalyst assumes that
there is a definite reason or reasons for all normal and abnormal
manifestations. No symptom is accidental or meaningless ; there are
always unconscious underlying causes which, if found and brought to
the surface, become dissipated and cause the symptom to disappear.
In this respect the psychoanalyst acts precisely as his colleague who
resorts to physiotherapy in the examination and treatment of physical
diseases. Practising psychoanalysis one finds many wonderful
things; the patient is no longer the uninteresting and unwelcome
neurasthenic who is best liked by the doctor when he is not in his
presence, but the deeper one enters into his mind the more interesting
he becomes and the more problems he presents. Finally, in the
case of the psychoneuroses, when everything is brought to con-
sciousness and the problems intellectually explained, the patient re-
covers. It is, however, the real unconscious motives that one must

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184 INTEEITATIONAI- OUNIOS

find to bring about a cure; for the cauBes one usually holds re-
sponsible for the psjchoneurosea are only apparent In this respect
the neuroses show striking analogies to the present world-war.

Although six months have elapsed since the beginning of this
greatest war in history, no satisfactory decision as to its causes has
been reached. Unprejudiced observers realize that the stock reasons
advanced by either side cannot stand the test of examination, and that
the assassination of the Austrian heir to the throne, the Russian
iQobilization, and the violation of Belgian neutrality can only be
designated as agents provocateurs or exciting factors. The war was
expected for many years. When we take the anamneses of nervous
and mental cases we are usually told that the disease followed a
physical or mental shock, such as a fall or fright, but experience
shows that the patients were not quite normal long before the particu-
lar cause made its appearance. Moreover, many close observers main-
tain that for some time — ^many years — ^Europe underwent many
changes in population and other civic and economic factors, and that
the present struggle is an effort to establish a new balance of power.
In other words, the nations who have grown weaker and smaller dis-
trust and fear the nations who have grown bigger and stronger, and
by foraning new alliances they hope to reestablish the proper equilib-
rium. When we examine the individual psychotic we find similar
disturbances in his mental and emotional life, and the symptoms
are only a manifestation of the mental conflict and the attempt at
readjustment. They also make their appearance at some critical
period, say the age of puberty or menopause. Every individual is a
microcosm and continually adjusts himself to his macrocosm. As a
rule he succeeds, now and then a crisis ensues, and, depending on his
constitution, the form and amount of disturbance, we have either
a neurosis or psychosis.

Last May I saw a woman of sixty-five years who showed many
paranoid ideas. Her daughter told me that for years before she was
very depressed and delusional, she was afraid of death, was very
religious, and expressed many irrational ideas concerning dead people
of whom she was afraid. When I saw her she was happy and con-
tented and was not afraid of anybody or anything. She told me that
she saw spirits, with whom she could talk whenever she desired.
When I asked her who those spirits were, she said that they were her

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PSTOHOANAIiTSIS: ITS 800PS AND LIMITATION 185

dead husband and a Mr. X., with whom she was in love in her girl-
hood. The latter told her not to worry at all, that everything would
be well and nice when she passed out of this world, and that both he
and her husband were waiting to receive her.

Here one can see how nicely this woman adjusted herself to her
new world. Her mental disturbance followed an attack of nephritis
during which she was quite sick. As a reaction to her fears of death
and dead persons she now holds communion with the two dead men
whom she loved and trusted most in life, and they tell her not to fear
or worry. She has been in this condition for over ten years, and
adjusts herself very well to her strange world.

The adjustmeut of psychoneurotics and of normals follows a
different order, but here, too, changes occur. A woman who has
been through a disturbing love affair, with or without an hysterical
outburst^ is quite different in her reactions after the attack from what
she was bef ora

To continue with our analogy to the war, I will say that I do
not think that any one will disagree when it is maintained that this
war is not a manifestation of brotherly love, but that it is dominated
by greed, envy, hatred, and fear. When we enter into the deeper
mechanisms of the neuroses and psychoses we find that they, too, are
the expression of a conflict between the. individual's primitive im-
pulses and society. Thomas Hobbes's Bellum omnia contra omnea
is as true of the individual as of nations.

Just about two years ago I was consulted about a young lady
who was suffering from nervousness. Her mother, who came to see
me before she brought the patient, told me that her dau^ter had
been very nervous for about nine months; that she was obsessed by
the idea that she was going insane, that she was subject to crying and
trembling spells, that she slept poorly and had no appetite. She
could give no reason for her daughter's nervousness, which she claimed
came rather suddenly after the following shock : An insane boy from
the neighborhood jumped at her and frightened her with his wild
eyes. The young woman was twenty-nine years old, slightly burdened
by heredity, of average intelligence, and showed nothing wrong in her
physical condition. Mentally she appeared very depressed and
emotional She cried when I began to examine her, but answered
questions promptly. She was nervous because she was afraid of

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136 INTERNATIONAL CLINICS

insanity; she was treated by a number of doctors, who gave her
hydrotherapy rest cures and medications, and, as she was not im-
proving, she considered herself hopeless. To my question she
answered that she was tired of living, that she had no right to live
and make others suffer, and that she was not worthy of sympathy.
She did not, however, seriously think of suicide.

This case was looked upon as a traumatic hysteria as well as a
depression of the manicdepressive Ir^pe.

The psychoanalytic theories have been so often discussed that I
shall mention here only a few of their essential points. Originally
Breuer and Freud used what they called the cathartic method of
treatment^ It is based on the theory that hysterical symptoms de-
pended on past emotional experiences which were repressed and for-
gotten. The therapy consisted in hypnotizing the patient and causing
him to recall and reproduce these experiences, thus giving expression
to emotions which for some reasons could not be given vent to before.
With this abreaction the symptoms disappeared. It was a sort of
mental catharsis ; the patient's attention was directed to the traumatic
scene which gave rise to the symptoms, the psychic conflict was f oxmd,
and by giving him the opportunity to discharge the repressed emotions
he became freed from the symptoms. During these proceedings it
was r^ularly found that the patient's associations did not stop at the
scenes to be explained, but went back to much earlier experiences,
usually to childhood; hence, in order to correct the psychic en-
tanglements, it was necessary to occupy oneself not only with the
present but also with the patient's past. It was also found that not
every person could be hypnotized, a fact known to every worker in
this field, so that gradually Freud developed what he called the
psychoanalytic method. Here no hypnosis is necessary; by a process
of psychologic work the patient can be made to reproduce everything
without hypnotism. The procedure is as follows. Freud makes
use of what he calls the "continuous association" method. The
patient is told to concentrate his attention on a certain point and tell
everything that comes to his mind, r^ardless of whether it has any
visible relation to the point in question. This always brings up
associations which were repressed because they were of a painful

'For detailed discussion Of. BriU: " Psychanalysis: its Theories and Applica-
tion/' Chapter 1, 2d edition, Saunders, Philadelphia.

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psychoanalysis: its scope and limitation 137

and disagreeable nature, and the psychic efforts which inhibit these
associations from coining to the surface are designated as resistances.
It was while examining patients in this manner that Freud developed
his theories on sex and the interpretation of dreams. It is the theories
on sex that cause so much resistance to Freud^s work. Were it not
for the bold statement, '^ In a normal sexual life no neurosis is
possible," there would be little if any opposition to Preud. It is
hardly possible for me to enter here into a deep discussion of this
question. I shall merely repeat what I said so often, viz., that the
term sex is used by Freud in the broad sense of love,' and will add
that after eight years of continuous study I can corroborate Freud's
dictum, viz., that in a normal sexual life no neurosis is possible.

Now let us return to our case. What I pointed out in my prefa-
tory remarks concerning the causes of the war I can apply to the
causes of the emotional disturbances in this patient. All the relatives
were convinced that the cause of this young woman's trouble was the
fright she sustained through the insane boy, but a little questioning
soon showed that months before this occurrence the patient was not
quite well. The patient was very uncommunicative or rather barren
of ideas ; she assured me that she was quite willing to tell me every-
thing, but that she did not know what to tell me. Her life was
uneventful ; she had no love affairs to speak of. A young man did
pay attention to her some time before, but, as she did not care for
him, nothing came of it. When I pressed for details she insisted
that there was nothing to telL On one occasion she was very emo-
tional and cried much, and when I urged her to give me her reasons
for it she said that she was thinking how cruel and wretched a crea-
ture she was, and finally she told me that she was crying so much
because she drowned some kittens about twenty years ago. She was
then living in the country and there was a litter of undesirable
kittens and she drowned them. To my question she said that this
scene was rarely recalled before she became ill, but since then it had
often returned to her mind, and caused her much depression. She
herself could not explain why she thought of this particular scene
after so many years, and what was still more strange was the fact
that her mother positively denied that she ever did this. I spoke

•Cf. Freud: "Three Contributiona to the Sexual Theory," translated by
A. A. Brill.

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138 INTEBNATIONAL OLINIOS

to her mother about it, and she assured me that her daughter never
drowned the kittens, but that she probably witnessed it when a
farm hand did it.

Now in psychoanalytic work such trivial episodes cannot escape
us; we always ask, What does it mean? I naturally endeavored to
get the patient to explain it, but she could not give me any informa-
tion. She belonged to those who claim that they do not dream, so
that dream analysis could not help me. In my discouragement I
asked her to make up a dream,^ and after much instruction she made
up the following dream : '^ I see a horrible, ghastly object; U is some
animal; it breathes under the water. I wish to pvll it out, but I
cannot. Now it is coming up.*'

This, as you see, is an artificial dream made up, as it were, of
whole cloth. In a paper recently published,' where I quoted this
very dream, I have shown that artificial dreams have the same value
and evince the same mechanisms as actual dreams. For years I have
resorted to artificial dreams whenever real dreams were not forth-
coming. It will also be noted that this dream shows a decided re-
semblance to the* reminiscence of having drowned the kittens. "Now
as to the analysis of the dream. The dream as recalled by the dreamer
is called the mmiifest dream, and in order to analyze it we must find
the latent thoughts of the dream.^ Here I would have been again
confronted with the same difficulty, viz., the patient's inability to
give continuous associations, but I had enough material to get along
without her help. We have now reached a stage in our psycho-
analytic work where we can sometimes judge concerning dreams and
symptoms without the fuU cooperation of the patient, although to
produce good results the patient's cooperation is absolutely essentiaL
There were a number of factors that struck one as peculiar. I asked
myself. Why should she have recalled this kitten drowning episode t
Why cry over it twenty years later? Clearly there was a marked
disproportion between the affect and the idea, and experience teaches
that in such cases the emotions are only displaced; they belong else-

*Cf. Brill,l.o., p. 77.

*" Artificial Dreams and Lying," Journal Abnormal Paychology, January,
1915.

* Freud: "The Interpretation of Dreams," translated by A. A. BriU, the
Macmillan Ckmipany, New York.

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psychoanalysis: its scope autd limitation 139

where. Moreover, whenever I spoke to her mother she never failed
to volunteer the information that her daughter was a very good girl,
that she never cared for the men, and, as I never gave her any cause
for telling me this, I became convinced that the mother suspected
something of just the opposite nature, and for that reason she felt
the need of protecting her daughter's innocence. I had no doubt that
it was entirely unconscious on her part !N'ow what are the main
elements in the kitten drowning reminiscence ? The destruction of
life by means of or in connection with water. What are the main
elements of the dream? Something horrible and ghastly breathing
under the water, and a wish to pull it out I decided that this young
woman had something to do with an abortion, and after overcoming
very strong resistances she reproduced the whole episode. Over a
year before she came to me for treatment an abortion was performed
by a physician after she herself tried very hard to bring it about
through medications and douches. The fear of insanity was due
to a masturbation conflict, and also to the fact that the insane boy,
who turned out to be an idiot, was supposed to have become so
through masturbation. This also explains the fact that she was
frightened by the boy's wild eyes. As you know, masturbators have
the idea that they can be recognized by their eyes. This young
woman lost her symptoms a few weeks after the analysis of the
dream.''

This case, which I diagnosed as an anxiety hysteria, teaches that
the so-called traumatic hysterias are really not due to the traumata :
these are only exciting causes which help to determine the symptoms.
Analysis always shows that there was a ready soil for the attack.
Care must also be taken to differentiate such cases from the de-
pressions of manicdepressive insanity,^ and one should always ex-
amine the sexual factors. They are always to be found, although
it may not seem so to the inexperienced.

*l regret that I cannot here complete this case by showing the subsoil of
this psychoneurosis from early life. It is to be noted that the cat played a
prominent part in the patient's life. From early childhood she entertained an
ambivalent feeling (love and hatred) for this animal, and repeatedly identified
her mother and herself with it. (Of. Freud: ''Totem and Tabu/' an English
translation of which is in preparation.)

'Brill, I.O., p. 01. An important diagnostic point is retardation, which
is almost always absent in psychoneurotic depressions.

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140 IWTBBNATIONAL CLIBnOS

Eecently a young man who is under my care told me that his
memory went back to the time of his baptism^ when he was about a
week old. He said that he remembered distinctly the house^ the
stairway leading up to the first floor where he was supposed to have
been baptized He particularly remembered a lamp standing at the
foot of the stairs, a tall man in a black frock coat who was the minister
who held him. He also recalled vividly how his head was totally
submerged in a basin of water. I was naturally sceptical and ex-
plained to him that I would call this a concealing memory which
probably hides something else of a much later date. He then in-
formed me that he had entertained this memory for many years,
but that wheti he told it to his mother a few years ago she laughed
and said that there was no truth in it ; that he was not bom in this
particular house, but that he lived there from the age of four to
six; that she could not recall this peculiar lamp, and that the
minister who really baptized him was not tall, and, what was more,
that babies' heads are not submerged in a basin of water during
baptisuL Yet, notwithstanding his mother's denial, he continued to
entertain this memory, and told me that he felt that it was true in
spite of all facts to the contrary. I called his attention to the fact
that his mother had no motive for denying it, and that so far as I
know it would be impossible to retain anything from so early an
age. We then proceeded to analyze it. He stated that the most vivid
element in that memory was the lamp, so that I asked him to con-
centrate his attention on it and tell me what came to his mind. He
could see the lamp at the foot of the stairs, the stairway, and the
room on the first floor. He then recalled that at the age of about
five years he was standing one afternoon in that room watching a
Swedish servant who was either on a high chair or step-ladder clean-
ing the chandelier. He became very inquisitive sexually, and made
a great effort to look under her clothes. She noticed it and gave him
a strong rebuke. He then recalled that a few years later he watched
through a keyhole to see his mother dress, and somehow she caught
him in the act and punished him very severely for it. He was very
much humiliated because she took him downstairs to the dining-room
and told his father and brother, who were then at breakfast About
the same age, probably before this episode with his mother, he was
on the roof one evening and saw a woman undressing in a house

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psychoanalysis: its scope and limitation 141

acroBS the street He became very excited, and ran down to call
his brother, but when he returned the woman had a nightgown on
and soon pulled down the shades. He told me that for years he re-
gretted that he did not wait to see her undress. He reproduced more
scenes, all of which dealt with frustrated sexual looking. The lamp
therefore represented a contrast association of darkness which stood in
the way of his sexual inquisitiveness, and that is why the lamp
element was so accentuated in his memory. ITow, why did he
remember the fact of his baptism ? This young man is a good
Christian, his parents are Christians, but his paternal grandfather was
a Jew. He himself shows no trace of the Semite, but the only thing
he retains from his grandfather is the name. It is a (German name
which is often mistaken for a Jewish one, and for this reason it has
given him much trouble. He thinks that he was refused admission
to college fraternities because he was suspected of being a Jew, and
only a few years before he was again refused admission to a society
on accoxmt of his name. The concealing memory of his baptism is
thus a compensation for his suspected Judaism, and that is why it
retained its vividness, his mother's denial to the contrary. He had to
be assured that he was baptized and therefore was a Christian.
Altogether the memory represents a religious scene in order to hide
an immoral scene which took place in this room.^ I will add that at
the age of puberty there was a complete repression of all sexual ele-
ments, and he became a model boy in every way. He is now over
thirty-six years old and never had any kind of relations with the
opposite sex. He is a shy, seclusive, reserved personality, and is
remarkably ignorant of everything sexual. This is only a reaction to
his early immorality, and was brought about by the various shocks
or set-backs he sustained in his effort to adjust himself to his adult
sexuality.

Now these things may seem very commonplace and unscientific,
but let me remind you that just such episodes play a part in the
life of every individual, and that the average nervous patient does not
think in philosophical and abstract terms any more than he thinks in
terms of histology and pathology. The human mind resorts to every-
day language and feelings, and in the neuroses and psychoses we

•Freud: " The Peychopathology of Everyday Life," p. 67, translated by Brill,
the Biacmillan Company, New York.

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142 INTJ^UN ATION Al. OLINIOS

invariably find just such mechanisms. One of my patients who was
about to graduate from a university invited his best girl, with her
mother, to the commencement exercises. He had known this young
lady since his early boyhood, and had often invited her to college
functions before he entered this university. He was a member of a
fraternity, and whenever she and her mother came to one of these
college affairs they stopped in his fraternity home. It happened that
his fraternity had no home in this imiversity, so that in his invitation
he apprised the young lady of this fact, and informed her that he
had engaged rooms for her and her mother in a nearby hoteL He
added, " I am very sorry that I cannot offer you the luxurious sur-
roundings of a fraternity home,'^ but instead of writing " fraternity
home^^ he wrote "maternity home." You see, it was just an
innocent lapsus calami which should have offended no ona But
imagine his surprise when, instead of getting the usual nice letter
of acceptance, he received his letter back .with a chilly note asking
for an explanation of a remark in the letter. He read his letter
over and over again and could see nothing wrong in it, and to solve
the puzzle he asked his roommate to read it and to tell him what
was wrong in it. His roommate^ read it only once and discovered
the mistake and laughingly pointed it out to him. He then realized
that he made a mistake in writing, but he was still more puzzled why
the young lady and her mother should have been offended by an
innocent mistake. He at once wrote a letter assuring them that he
had just made a mistake, and the young lady, chaperoned by her
mother, attended the commencement exercises. Here the mistake
was determined by the fact that while writing the invitation he also
bemoaned the fact that he was not yet ready to think seriously of
marrying the young lady, hence the mistake, " I regret that I cannot
offer you the luxurious surroundings of a maternity home." The
strange action of the young lady and her mother may be explained
by the fact that they could see through the mistake and were probably
pleased, but in their effort to remove any suspicion from themselves
they had to sham resentment, which only betrayed them. They
showed what Bleuler calls a "complex readiness" {Complex^
bereitschaft). I will add that some time later this young man
developed a compulsion neurosis, and one of his symptoms was his
inability to write and send away letters. He would unseal his letters

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PSTCHOAKALTSIS: ITS SCOPE AND LIMITATION 148

and read them again and again in order to discover whether some-
thing improper did not slip in. Here^ too, the neurosis was attributed
to this insignificant episode, which was not at all the case.

I have purposely selected short examples to illustrate in as simple
a way as possible our mode of working. It would have been quite
impossible to bring before you one fully analyzed case, because it
represents the work of many months and usually fills a good-sized
pamphlet. As I said above, the conflicts at the bottom of the neuroses
are of a primitive nature; they represent infantile or archaic forms
of thinking, and as such are not only incomprehensible to the in-
dividual concerned but also to the average physician. It is the object
of psychoanalysis to bring all these tendencies to consciousness and
help the individual to solve his difficulties, and in doing this one has
to consider not only general tendencies but individual differences.
Every person has his own mode of reaction to this world, and the
only way to discover the truth is by studying his unconscious produc-
tions in the form of dreams and psychopathological actions. I find,
for instance, that not only does every individual have dreams which
show definite characteristics, but one can often tell by the dreams the
individual's environments. In this connection I wish to report a
rather curious phenomenon. I find that Southern gentlemen often
have erotic dreams in which colored women play parts. I never
found this among white cultured men who were brought up in any
other section of the country. This is explained by the fact that
Southern white children, and particularly of the better classes, are
invariably brought up by negro mammies, who in almost every re-
spect take the place of their own mothers during the most impression-
able period of their existenca Psychoanalysis has shown the enor-
mous part played by parents in their offspring's future existence.
Selection mainly depends on early parental influences. ^^ The man
is always guided in his selection by the image of the woman impressed
upon him during infantile life. The average man brought up by a
white woman finds no charms in colored women, and even among the
lower class it is rare to find that they show any tolerance, not to say
preference, for a negress. On the other hand, I was told by many
cultured Southerners that many white Southern men often consort
with colored women. That accounts for the hundreds of mulatto

» Brill, I.O., p. 288.

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144 INTERNATIONAL CLINICS

children that are annually bom in the South. In New York, for
example, such births are comparatively rare.

Psychoanalysis not only helps and cures, but, for the first time
in the history of medicine, we are now getting some insight into the
psychoses and neuroses which is of utmost importance in prophylaxis.
Thus a patient told me that he suffered from peculiar feelings of
fright which came on suddenly. The last attack appeared while he
took a walk in the slum district of New York, when the idea sud-
denly flashed through his mind : '^ Suppose one of those rough char-
acters should assault me or kill me ! " He became very much
frightened, his whole body shook, and this fear continued for over
three hours until he came home. When I asked him why he did not
leave that neighborhood, why he remained there so many hours, he
could not answer. He thought it strange that he had not left this
neighborhood sooner. I suggested that he must have liked to be
frightened; he smilingly admitted that I was right, and then con-
firmed my assumption by reciting many occurrences of a similar
nature. He told me that while travelling abroad he often engaged a
guide to take him out, and so soon as he began his tour he would
get frightened and keep it up for hours.

This man was a masochist who was made so by a brutal father
and a cruel tutor. He was brought up more like a trained dog than a
human being. He was not allowed to play with other boys, and the
slightest boyish transgression brought swift and severe corporal
punishment. If he misbehaved, the servants threatened with the
bugaboo man and with the deviL In his loneliness he became a
prolific reader of fairy-tales and similar literature, and so far as
he could recall he lived through in his fancies those characters who
were despised, punished, and assaulted. Later in life he found the
need for such reaction; in other words, he found pleasure in pain,
and unconsciously and sometimes consciously brought about such
situations.

Since Jean Jacques Eousseau we know the dangers of corporal
punishment of children, but little attention has been given to the
psychic influences in the early period of development. Most of the
reading material in the form of fairy-tales offered to children does
much harm.^^

"* Brill, I.e., p. 293.

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psychoanalysis: its scope and limitation 146

Perhaps the strangest part of this case is the fact that all his
life he consulted physicians — ^he is forty-five years old — and none
discovered the true nature of the case. He was told that he was a
neurasthenic^ was given sedatives and tonics and ordered to take
trips to different parts of the world. It is a sad commentary of our
medical education. Every physician, whether he is a Freudian or
not, should have a good knowledge of psychosexuality, and should
examine the psychic and sexual life of all his patients. That does
not mean that every physician should treat his patients psycho-
analytically. Psychoanalysis is a branch of psychiatry and neu-
rology, and to practise it one should have a previous training in
these specialties or should work together with one who possesses
these qualifications. For not every case can be benefited by psycho-
analysis or should be subjected to that treatment Only psycho-
neurotics of a certain mentality, age, education, and character can
be cured. ^^ Since 1908 I have also analyzed mild mental cases of
the prsBcox and depressive types with varied success, but nothing
definite can be said at present about the results.

^ For detailed diBCUssion Of. Brill, I. o^ pp. y. and vi.

Vol. it. Ser. 25—10

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EFFORTS AT ADJUSTMENT

BY LOUIS E. BISCH, A.B., M.D^ PH.D.

ABsociate in Educational Psychology, Ck>lmnbia Univeraity; Formerly Visiting
Neurologist, New York City Children's Hospitals and Schoola; Alienists
Clearing House for Mental Defectives; Clinical Assistant, New York
Neurological Institute

When thought processes become a source of disturbance to an
individual, or when they lead him into untoward acts, he seeks the
advice of the clinical psychologist. What he wants is peace of mind,
and unfortunately he usually waits until that peace has been very
definitely upset. A broken bone will knit tc^ther again, whether
controlled to grow anatomically correct by means of the surgeon's
art or not; the liver or any other organ will attempt to heal itself
even without the physician's aid; in like wise will the various mental
faculties adjust themselves when anything goes wrong with their
mechanisms. Ordinarily we think of the term adjustment as imply-
ing a successful issue; in point of fact, there is always an arrange-
ment of some sort effected, the important thing from the standpoint
of the individual being whether the new relationship spells happiness
— in other words, whether there has been successful adjustment.

The two cases which I will briefly outline here are examples of
unsuccessful adjustment. They have been chosen because they
present imusual features in so far as the form which the adjustment
took is concerned. The first case, one of somnambulism, was treated
intermittently for over a year, but a thorough analysis of the mental
processes was never accomplished. The second case, a sort of human
hibernation, was examined but once by the writer and could not be
studied further, because he lives about two hundred miles away.

Cass I. — ^Miss X, who first wrote stating that she wished to consult me
about giving her an hypnotic treatment. A subsequent visit revealed a neat,
precise little woman of forty-one, very intelligent, demure, quiet, and un-
assertive. She is a teacher by profession, and her work is very tedious and
exacting. Her trouble had b^^un four years previously, just after returning
from a visit to her parents in the country. At that time she was living with
four other teachers, who first made fun of her, later became afraid, and the
146

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EFFOBTS AT ADJUSTMENT 147

patient finally had to move. The patient had suffered a number of similar
experiences in other rooming houses after that, and this was the reason she
gave for wishing to be cured. Her sleep-walks gave her no personal annoyance
otherwise.

She had been worrying considerably for some days past about the winter's
work before her, and, aside from the details of arranging courses, etc., she
felt rather discouraged at the prospect of merely being able to accumulate
enough money to again support her parents the ensuing year. This latter, how-
ever, she hardly dared admit to herself, and she took what pleasure she could
in realizing that she was again in New York, among energetic people, with an
opportunity to visit the theatre now and again, to perfect herself in her chosen
work, and so on.

The patient was bom and brought up in the country, accustomed to getting
up early and working hard all day, with very little amusement except what
she could obtain from roaming the fields and hills, ccMnmuning with nature.
She always felt that she was different from other girls, and her own mother,
an attractive woman, did not hesitate to tell her so. She liked her father better
because he seemed able to understand her, and the two would often roam about
the country together. The father was also of a romantic and philosophic turn,
•but he possessed rather set and puritanical ideas as to how children should be
brought up. On one occasion, because he knew that the patient was afraid of
lightning, he got his little daughter out of bed at night and took her for a walk
in a heavy thunder shower, as a result of which both were thoroughly drenched.
The child was made to appreciate the beauty and comparative harmlessness of
lightning, however, and she ceased to be fearful after that. On another occasion
he persuaded her to walk alone on a narrow plank of some high scaffolding because
she had expressed a fear of high places.

When about twenty years of age the family took in boarders— teachers
who were attending a school nearby. These teachers frequently teased the
patient about her countrified ways, which hurt her feelings a great deal, but
which she kept to herself. The stories which they told of dty life fascinated
her, and so the seed was sown which later developed into an irresistible desire
to go to the dtj. She finally determined to leave home at all hazards, borrowed
money from neighbors, and subsequently entered a school in Boston. Here
she made rapid progress and was graduated with credit. It had been her
original intention to return home to live after completing her courses, but the
work in a large dty attracted her so that she later came to New York to live.
She was in residence and much confined within doors in her first position, which
she left to assume a similar one in another institution. It was in the latter
place that the close application of her work " got on tier nerves,*' and she began
to study another subject which would bring her into more immediate contact
with human beings. In addition, she developed the habit of wandering along
a fairly crowded thoroughfare, sometimes at night, with no very definite purpose
in mind, yet conscious of the fact that she was seeking adventure of some sort —
possibly with a member of the opposite sex. She always returned disappointed,
but would always start out again with renewed hope. Her work became more
and more boresome, so she gave it up and went in for private teaching, at which
she has been very successful ever since.

The patient's father was injured several years ago and has been incapacitated

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148 INTBBNATIONAL CLINICS

for rastained work. The mother had been an invalid even before that, and soon
after leaving Boston, at the age of twenty-seven, the patient assomed praotieally
the entire responsibility of caring for her parents financially. For this reason
she was never able to accumulate any money which she might call her own.
She has an older brother who is married and lives away {mm home. He suffers
from asthma, is sickly, and cannot contribute to the support of his parents.
In disposition he is much like his father, and the patient has always taken a
great interest in hiuL She has also an adopted sister a few years younger than
herself. This girl has always been rather erratic and, the patient says, of a
quite opposite disposition from herself. She was separated from the patient
when a baby and brought up by an uncle. Family history otherwise is negative.
The patient had asthma in childhood — otherwise no serious illnesses.

The patient's romanticism has been a dominant feature throughout her life.
She claims never to have fallen in love, but is attracted to and admires intelligent
men who are older than herself. She has never had any intimate friends. The
persons she likes do not care for her, and vice versa. She often finds herself eager
to adapt herself to s<»ne one with a disagreeable disposition. She thinks her
father is of this type. The patient has always been considered very reserved and
peculiar by her friends. She is a very efficient teacher, takes an interest in
the work for its own sake, but often becomes disconsolate and annoyed at her
pupils and sees no future ahead for herself. During her spare time she pre-
pares her lectures, reads romantic or philosophical novels, attends the theatre
or opera, or takes long walks in the city. On several occasions she has gotten
up early in the morning and gone down to the lower East Side to contemplate
the people hurrying to work. She still delights in the sky, the fields, and the
woods. She likes to let her thoughts drift in a purposeless fashion. "Tristan
and Isolde'' stands forth as being the most beautiful of operas. If a play
appeals to her she will go to see it several times. Fairy-tales and plays like
"Peter Pan," with "beautiful pictures" and "beautiful words," fascinate her.
She rarely recalls dreams, and they are usually of disagreeable happenings at
home. About a year before her chief complaint occurred she began to interest
herself in mysterious things. She has no use for women. She thinks she de-
veloped late, so far as worldly maturity is concerned. She never heard of sex
matters as a child— cannot recall a single, definite sexual emotion. She has
always been self-reliant, and has been considered the " man of the family " ever
since she assumed that responsibility. She lives in the constant dread of hear-
ing of her mother's death, which would mean her being compelled to leave the
city, give up her work, and care for her father. She enjoys her visits home,
when she works hard and "straightens things up," but she soon yearns to
be back in the city again. She considers herself very practical.

The patient's beginning attacks of somnambulism seemed to occur more
especially after a hard day and from one-half to one and a half hours after
retiring. They happened at irregular intervals, sometimes every night and
at times but once or twice. She would suddenly throw off the bed covers,
step out of bed, walk into another room— occasionally opening a door to do so—
and, as a rule, was rather voluble, coherent but rambling; would say, " How
stupid the women are! Won't somebody help meT " etc. When urged to return
to bed she often became resistive and would cry, " I won't do it," repeating this
over and over with determination. As a rule, so far as can be determined, she

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BFFOBTS AT ADJUSTMENT 149

clenched her fists, but nerer had either a tonic or clonic convuldon. After a
half hour or less she would again fall asleep and remain quiet the rest of
the night. She rarely recalled anything having, occurred to her ihe following
morning, but believes that sometimes, during the attack, she was conscious
in a cloudy and confused manner and realized when some one was standing near.
Other features of grand mal, petit mal, or Jacksonian epilepsy were absent. She
never displayed any homicidal or suicidal tendencies during the attacks.

Upon examination she presented no physical or neurological signs or symp-
toms; enjoyed good health; menstruation was still present and history unevent-
ful; no mental reduction apparent.

After six wedcs of these attacks she consulted a man who practises hypnosis
and who is said to have placed her in an hypnotic state by having her lie
down, giving her something to drink, placing his hand upon her forehead, and
bidding her sleep. The patient was in this state from 2 p.m. until 7 P.M., walked
about the office, talked in a rambling fashion— <»ntent not ascertained — ^heard
what was being said about her, but was herself unable to reply, was finally
taken home by her companion in a cab without having regained complete con-
sciousness, was put to bed, and did not come to again until 7 o'clock the next
morning.

Despite this experience the patient felt as though she had been helped,
and, in fact, she did not walk in her sleep again for about two and a half
years. However, instead of somnambulism, for some three months after the
treatment noted above, the patient had a sensation as though she herself — her
double — ^was always standing by her side. She never could see the figure, but
she felt its presence, which was definitely localized to the right and slightly
back of her. This "other self" would repeat everything she said, and when
lecturing it would '* shriek " so loudly that the patient would often look at the
class to see whether they had also heard.

One day, during this period, she rode in the cars about the city for many
hours in a dazed, confused, and semiconscious manner, not knowing where she
wanted to go or was going, but finally arriving safely at home, fully conscious.
Aside trcm this she felt well and happy, and, after the sensation of her double
being near gradually disappeared, the patient enjoyed good health and went
to the theatres, etc., as of old.

The sleep-walking began again one fall, after returning to New York from a
visit home, and in character was about the same as in the beginning. After six
months she consulted me and asked to be hypnotized, because she thought it
had helped her so much the first time.

This was done, and the patient proved to be a very good subject. At the
same time, however, psycho-analytic procedures were instituted, although it
took a number of treatments before she had any faith in the latter. Hypnosis
was what she wanted above all else.

Within two months it was learned in sufficient detail what her main mental
confiicts were, and, furthermore, the assumption was made that the somnambulism
was nothing more than auto-suggestion. By this time the attacks had greatly
diminished in frequency, due to the suggestion under hypnosis that she would
not walk in her sleep any more, but the patient would not believe that she was
merely hypnotizing herself when she did these things. Therefore the following
experiment was made:

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150 IWTBBNATIONAL GUNIOS

The patient was aaked to lie upon a oouch, close her eyes and imagine
herself in her own room, in bed. In aboat thirty seconds, without a word being
said to her, she arose from the couch and walked about the room, eyes open,
and in a manner identical with the somnambulistic attacks described previously.
The patient was returned to full consciousness by shaking her and clapping the
hands loudly.

She did not walk in her sleep again for several months and considered
herself cured.

However, since that time the patient has had periods in which she is free
of attacks of whatever kind, others again in which there is sonmambulism every
night or less frequently, and then times of longer or shorter duration when
apparently there are equivalents and she suffers depression, exaltation, etc.
Usually another hypnotic treatment will bring about a free interval — also
medication or a psycho-analytic talk has accomplished this — but unfortunately
the patient then always ceases treatment and later on something again happens.

On several occasions, always after a hard day, she has lost control of
herself on the street or in the cars and has wandered to my office in a state
of confusion not unlike the automatic state of grand mal. If left alone she
will come to herself again without any treatment, and is always most surprised to
discover where she is. From what she says these states come on suddenly,
without any warning. She is always more or less resistive at these times and
will carry on a conversation, but not if asked questions which are irrelevant to
her general stream of talk.

On one such occasion she talked as follows in the office, no conversation being
directed to her on the part of the examiner:

** So many doors shut — so many doors shut — doors of opportunity — it's a
great pity, isn't itT — a great pity — smother says it's a great pity — mother says
it's a great pity I was bom — ^the doors are not only shut, but locked — ^The
world is very hard — ^I don't want to make it harder for people, but easier — I
wouldn't hurt anybody — ^Perhaps you'd tell Dr. Bisch I'd like to see him^ — you
know. Dr. Bisch is my doctor and my friend — ^Won't you please tell him I'd
like to see himT — ^I can't remember where he lives — It's the far-away things I
want — I will have to go now" — (here patient goes to the door and tries the
lock) — ^''The doors are all shut — ^There isn't a bit <^ air in this room and I've
got to get out of doors" — (here patient tries another door)— ''I think I shall
have to go out now — ^Don't you hear that? — ^that ringing, singing, Canterbury
bells T — I can hear them so plainly — ^it doesn't do a bit of good to scold me —
I wouldn't do this if I could help it" — (here patient becomes tearful) — ^"it
doesn't do a bit of good to scold — I shall have to go now " — (here patient again
tries the first door, which is locked) — ^** Won't somebody open this door? — ^It's
ages since I started — I doubt if I'll ever get there — ^Mother says it's such a pity
you were bom — I haven't the courage to kill myself — I absolutely haven't the
courage" — (Here patient raises her arms, then holds her head and reels aa
if about to fall, but she does not, although unsupported. At this juncture the
examiner shakes the patient and says, ''Pull yourself together." She does so
at once and is very embarrassed.)

Whenever the patient gives up treatment she is accustomed to write the
examiner and to talk about her condition and attempt to put her feelings into
words. Excerpts from these letters, received at various times, are as follows:

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EFFOBTS AT ADJUSTMBNT 161

'' Alternately I am on the heights and in the depths. The heights I sup-
pose you would call ecstasy, and the depths depression. It began at

church last Sunday, while looking at the Christ picture and listening to the
beautiful music. I think peace descended on my soul (or whatever part of my
anatomy peace is supposed to reside) about the time this hymn was sung,
'Tarry with me, O my Saviour,' etc. It's not all religious exaltation, for
Hauptmann's 'Sunken Bell' sends me off at a tangent — I can — as you well
understand — endure these conditions with more fortitude than I could the
others.

" I wonder if you would have been interested if I had made away with my-
self — ^and a few others — as I seemed determined to do." (When the patient was
later asked whom she meant by "a few others" she reluctantly admitted her
parents, and said she had been very much ashamed of it since.) — " Now I am all
right. It seems to me like a disease— it runs its course to the bitter end.

"As to my 'walks' — ^I am perfectly all right now. I presume that you
will want to know if I am still seeing visions and dreaming dreams. Here is
my answer: 'Where there is no vision the people perish.' — ^Why can't life be
a sun-path and not a dull morass beneath the moont

"My happy longings have vanished. I can't work my pretty fancies —
they are all gone. I am ready and very anxious for my next reincarnation.
Surely there must be something beyond this well worth having — and it seems
as though I couldn't wait much longer. My love for my fatiier and mother
is almost overpowering."

At the time of writing the patient is with her parents in the country — ^the
father being in a critical condition — and the patient has been enjoying absolute
freedom from attacks of whatever sort for the past three weeks.

Whether one calls this case one of hysteria, psychic epilepsy,
somnambulism, or auto-suggestion — even a suggesteld dual personality
— seems of little moment To the examiner the important thing —
from the standpoint of improvement or cure — ^lies in the really un-
successful adjustment of the patient's mental conflicts, the two salient
ones being her sense of duty to her parents on the one hand, which
was opposed to her desire for freedom on the other. To tear herself
away from this strong parent attachment, to romance and marry,
would have been a normal development in her, as in every other
case. This, however, she was unable to accomplish. The basic,
subconscious, causative factor for these overpowering motive forces
in which she identified herself as being head of the household seemed
to lie primarily in an unusually strong father complex, but, as stated
in the beginning, a complete analysis could not be done. The patient
herself was neither able to give up her romancing nor the care of
her parents, and one way of removing herself completely from this

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162 INTERN ATIONAI* CLINICS

conflict was to die. In fact^ during the automatic-like state noted
previously she said she lacked the courage to do so, and, furthermore,
she once said during an hypnosis that she did not wish to live. Then,
in order to harmonize more completely with conscious activity — ^to
substitute death — ^the adjustment went even further, and in con
sequence her own mental mechanisms brought about periods of self-
hypnosis, during which times she removed herself temporarily from
her conflicts, could give expression to her fundamental wishes, and
yet consciously be held irresponsible.

The patient has not been cured, but apparently she has been
improved. Only time was allowed to bring out the main trends.
That suggestion played an important part in the treatm^it cannot
be doubted, but it would seem that suggestion accomplished on a
logical, analytical basis has more therapeutic value than suggestion
without it.

[Note of April 4, 1915. — ^While Miss X r^nained with her parents she was most
solicitous for her father's welfare, and she returned to New York only when his
illness took a decided turn for the better and the necessity to earn more money
in the city became most urgent. She has been here for four weeks and at irregular
intervals has had attacks of somnambulism, alternated by three visits to my office
in a state of trance. While with her parents she was free from these manifesta-
tions, but complained of a general feeling of confusion at times, with one very
decided period of depression.]

Case II. — Mr. Y, who was reported to me as follows:

'' The patient is now fifty-five years old and has been sleeping winters and
staying awake summers for the past ten years. His sleeping spells are evidently
lasting longer each year, his last one continuing for eight months. While in
these semicataleptic states he is thoroughly conscious of what is going on;
eats fairly well, but not as much as during the summer; gets up to attend
to his bodily functions; is apathetic all of the time; will talk when sufficiently
aroused, but prefers to keep quiet; loses about thirty pounds in weight (last
winter he lost thirty-five). Two years ago he weighed 206 — ^now only 165.
During the summer he eats ravenously, and up to the present summer has
gained what he has lost during the winter.

" During his wakeful period — from about April 1 to October — ^he is restless
and keeps going night and day, excepting for about two hours at night, when
he lies down, but seldom sleeps. He hitches up his team and drives out around
the neighborhood, paying no attention to time and often arriving home at one
o'clock or even later in the morning. He usuaUy starts out with some objective
point in view, but doesn't always get there. He stops and visits with everybody,
and apparently loses all sense of time or responsibility at home. He secretes

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EFFORTS AT ADJUSTMENT 163

from his wife what money he can procure by working around the neighborhood.
This he spends in a shy manner on peanuts — sometimes for drink — ^and he will
not let his wife know how much he has earned, where he got it from, or how he
spends it. ?is wife owns the farm and does not allow him much latitude in the
handling of money.

" On one occasion he accused his wife of feeding him something which has
caused his condition, and his wife has had him examined by local physicians,
who recommended a hospital for the insane. He is generally considered " crazy "
in the country thereabout, and probably has heard it said that he would be
better off dead.

"The patient is rational in his speech, relevant, reads a fair amount, and
is fairly well posted on affairs in general. He is rather an expert farmer
and talks very intelligently about crops, weather, and farming methods. He
always scans to live in the present moment, with no thought of the future.

" He occasionally has a slight shaking of his hands and arms, during which
times he raises both forearms slightly for a short time. This is not accompanied
by unconsciousness. He says that during his sleepy spells he occadonally has
flashes of light before his eyes, and that if he gets up for a few minutes the
flashes disappear. He also occasionally complains of indigestion.

" His first sleepy spell came on ten years ago, while he was driving his team
on the mowing machine one very hot day. He said his head dropped forward and
he felt dizzy and weak. He thought he had had a sunstroke and went to bed.
He slept for a day or two, and then returned to his work. That autumn he
hibernated for the first time.

*' There is nothing exceptional in his family history. He came from reliable
and well-to-do rural people. He has a brother, a photographer, who, according
to the patient, is ' very restless ' during the summer. The patient has married
twice. His first wife was quite a 'sport,' and he obtained a divorce from her.
She is reported to have said at the time of separation that she had lived with that

d fool long enough, from which it might be concluded that the patient was

peculiar even when young."

My own examination elicited the following:

The patient has three brothers, fifty-eight, forty-five, and foriy, and all
living and welL There are no brothers dead, and he never had any sisters.
His fathw died at sixty-eight from "inflammation of the bowels," and his
mother died at fifty-two with the menopause assigned as the causative factor.

Y married his first wife at the age of twenty-two, and there were only two
children — boys — both of whom are married. One has no children, while the
other has two that are said to be bright and normal.

He divorced his first wife at thirfy-five, having been much worried about
her. He married the second time at forty-five. His second wife bore him no
chUdren and she lias never been pregnant.

The patient left school at the age of twelve, and has worked at farming
ever since. He dainis never to have had any serious illnesses, although up to
the age of thirteen he suffered from stomach trouble. He denies venereal
diseases. He was an abstainer until two years ago, and has not partaken of
alcohol to excess since. Drug addictions were not elicited.

In contradiction to the first informant's history given above, the patient
stated that his first attack occurred five, and not ten, years ago, but the rest

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154r INTEBNATIONAL CLINICS

of the data remain the same, although he thinks he remained well for over a
year. The patient seemed somewhat hazy about these facts, bat his wife stated
positively, and he himself later corroborated it, that he has had a sleepy spell
every fall, as a rule, and that the longest one lasted from September 20 to May
16, 1914. He did no work during this period, and lay in bed most of the time.
He would know what was going on, would reply to questions, but would quickly
drop off to sleep again. The other attacks were similar to this last one, only
they did not last so many months. Daring his waking periods he works about
twenty-two hours a day, only lying on the bed with his clothes on for an hour
or two. He feels refreshed on awakening, and never feels sleepy during the day.

The patient said he could not recall ever having dreamed, and that he
had no complaints of a somatic nature, except occasional "indigestion." He
said his appetite is always good. He thought his memory was not quite so good
as it used to be. He said he was fifty-six, but could not figure out what year
he was bom in. He was very willing to discuss his own condition, and hoped
he might be cured, because people were saying that he was "crazy" and he
feared being put away in an institution. He told the examiner privately that
about the time his trouble began he had seen a neighbor — a woman — in a very
excited state (possibly mania), and that this woman was always complaining
of pains in the small of the back. He said he also had pains in his back about
that time, and that he thought it might be sexual weakness. Of late years his
wife has been sexually frigid towards him, which worried him considerably.
He is not himself impotent. He also confided to the examiner that the farm is
in his wife's name, and that her brothers want him to do all the work. He
admitted worrying a great deal about the time his first spell came on about
working for nothing, although he insisted that he is not lazy, but feels he ought
to be compensated somehow for what he does. About a year ago a physician
told him that the weakness in his back was due to overwork, and this explanation
appealed to the patient very much. He added that he thought that must be
why he needs so much sleep.

The patient presented no manifest psychotic symptoms, no delusions,
hallucinations, or obsessions. He was correctly oriented for place and person,
but was somewhat hazy for time, which, however, he was able to correct without
aid. He showed no emotional inadequacy, no mannerisms, stereotyped attitudes,
etc. He was slightly suggestible. He talked willingly and volubly about himself.
His wife stated that he was stubborn at times and that one could not " fool "
him. She admitted that he was trusted and well liked in the neighborhood.
There was no marked sclerosis of the radial vessels; the patient seemed in sound
physique; heart and lungs negative. He presented no neurologic signs, except
that the left pupil was slightly irregular, but both reacted promptly to light
and accopnmodation; a very slight and doubtful slurring on test words could be
detected, and there was fairly definite, but not total, anesthesia of thb comesB
and pharynx. The Wassermann test proved negative.

ITatorally^ a patient presenting such unusual symptoms ought to
be kept under observation to determine^ among other things, whether
the symptoms actually exist. However, the informant in the case is

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BFFOBTS AT ADJUSTMEI7T 155

a very reliable and accurate observer, and I personally had corrobora-
tion from five others who know Y welL

Dementia prsecoz was first thought of, but that does not seem
quite tenable; nor does a simple deterioration or even a cerebral
arteriosclerosis explain the case. It is even doubtful if the patient
is constitutionally inferior. I venture to suggest that the case is
one of hysteria.

One can only guess at the mental mechanisms involved, but
possibly because of his first marital disappointment, the fact that he
lives unhappily with his second wife, who owns the farm on which
he must work — as he thinks, for nothing — ^his long sleep states in-
dicate a submerged wish to get away from it all, not unlike the case
of hysterical blindness reported and analyzed by Ames.^ The slight
anfieethesia, his suggesitibility, the appeal which the physician's ex-
planation of overwork made upon him, may all be mentioned in
support of such a view.

[Note of April 4, 1915, — ^Friends of Mr. T write me that dnce my visit to him
he has been a changed man. He has not " hibernated/' works regular hours dur-
ing the day, and sleeps normally at night. He also now gets on well with his
wife, attends social functions with her, etc. His wife and neighbors are most
astonished at the patient's sudden turn for the better. He is said to have been
much impressed l^ my visits and believes that the taking of the blood for a
Wassermann had much to do with his " cure." Of course, I employed '' waking
suggestion" with as much force as I could when I saw him. These facts would
tend to corroborate the diagnosis of hysteria.]

^T. H. Ames, ''Blindness as a Wish," The Ptycho-andlytio Review, vol. i,
No. 1.

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DISUSE CRIPPLINGS

BY JAMES J. WALSH, M.D., PH.D^ SC.D.

Sometime Dean and Professor of the History of Medicine and of Nervous Diseases
at Fordham University School of Medicine; Professor Physiological Psydiol-
ogy at Cathedral College, New York

Pbobably one of the most interesting medical conditions in
modem life that many physicians have to see — and the sufferers
from which usually have to see many physicians and surgeons — is
what may be called, for lack of a better term, by the generic, quite
non-theorizing name of disuse cripplings. It is an affection par-
ticularly of those past middle life, though not infrequently seen in
those of younger years, and has usually developed, according to the
history, as a consequence of some accident causing a limb or a joint
or a set of muscles to be put out of commission for some time or to be
used much less than usual for some considerable period. As a con-
sequence, the muscles of the part atrophy, though often not to a
marked degree, from disuse, and then somehow prove incapable of
being brought back to their ordinary employment again. The simple,
familiar example of the affection may be seen whenever a patient
suffers from a fracture of a bone or a bad sprain or an injury of almost
any kind requiring rest as a part of the treatment The inaction
necessary, or supposed to be necessary, for proper repair brings on
a passing atrophic condition of the muscles. In the great majority
of people, and especially in those of younger years, this is perfectly
capable of being overcome by appropriate exercises during the period
of convalescence subsequent to actual repair. In a certain number
of cases, however, the failure to regain control of the muscles and
bring them back to normal nutrition and function leaves what is
practically a deformity, so far as function is concerned, or what I
prefer, for various reasons, to call a disuse crippling.

These cripplings first came into particularly prominent attention
not long after plaster-of-Paris bandages for sprains and breaks began
to be rather generally used. The utter disuse of muscles which so
often occurs in connection with the application and wearing for a
prolonged period of a snugly-fitting plaster-of-Paris bandage, and
156

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DISUSE CEIPPMNGS 167

especially if it be a rather heavy one, very soon brings about marked
atrophy of the muscles of the neighborhood of the joint of fracture
or sprain. It was noted that in a certain number of these cases the
rehabilitation of the muscles either did not take place properly or
was incomplete, or, at least, some subsequent muscular incapacity
remained and, as a consequence, there was a halt in the gait if a lower
limb was involved, or an awkwardness of movement in the upper
limb.

At first this was thought in most cases to be due to some definite
associated injury, perhaps undetected, owing to particular circum-
stances in the special case. It was concluded that a nerve must have
been injured or an artery pressed upon, or a vein compressed, or
that the circulation must have been interfered with by some vascular
disturbance either at the time of the accident or during the subsequ^it
process of repair. In some other cases it was thought that the
plaster-of-Paris dressing itself must have by pressure, particularly
at the ends of the wrappings, led to some injury of nerves or some
enduring disturbance of the circulation. While in a certain number
of the cases some such necessary accident or incident was responsible
for the subsequent crippling, in a large number of the cases it was
found to be impossible to demonstrate any definite organic patho-
logical condition. There was no existent nerve lesion and no demon-
strable morbid change of any kind in the circulation. There was
apparently nothing the matter, except that the muscles of the part
having atrophied to some degree, it seemed to be impossible, or
practically so, to bring them back to their original condition.

One of the most notable features of a number of these cases, and
the one which brought them particularly to my attention, was the
fact that after having gone the rounds from one physician to another,
and not inf requ^itly, be it said, from one skilled surgeon and expert
orthopeedist to another, practically always deriving some benefit for a
time from any mode of treatment that was applied to them, yet sub-
sequently very often lapsing back into their previous condition, not a
few of them — indeed, a disturbingly large number of them — ^were
cured by some form of irregular therapeutics, osteopathy, cheiroprac-
tics, or, perhaps, by a ^^ bonesetter " or some outlandish practitioner
of some special remedial cult, or even by Christian Science, or naturo-
therapy, or something or other of the kind that works no physical

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158 INTBBNATIONAL CLINICS

effect yet produces a cure in very obstmate cases. I have known two
clergymen, thorou^ly sensible men, one of them extremely intelli-
gent, cured by a well-known " bonesetter '^ who just made one simple
manipulation, ^^ set their bone right," though there had never been
any break or dislocation.

As a consequence of a single application of this simple manipu-
lation cases that had been so obstinate to treatment as to be considered
quite hopelessly intractable proceeded to get better, though a wealth
of the highest professional skill and expert scientific treatm^it of all
kindS) medical and surgical, had been applied to them in vain. I
have known a rather distinguished professor of a more than con-
ventional small collie receive the greatest possible benefit in a case
of distinct crippling after a muscular wrench from a series of treat-
ments by an osteopath, mainly directed to the correction of a sup-
posed subluxation of his vertebrse. My professional friend was quite
enthusiastic about the wonderful new discovery that explains all the
ills of men, and a few more besides, which Dr. Still, the inventor of
osteopathy, calmly asserted, in a little controversy that I once had
with him in a popular magazine, was responsible for ninety-five
per cent of all the ailments of mankind ; that is> not only the muscular
and nervous but also the organic ailments, the affections of the heart,
liver, kidneys, bowels, stomach, and even the lungs and blood-making
organs, as well as all the infectious diseases. The much-explaining
lesion is quite impossible of discovery on the cadaver, but I need
scarcely say that it is a mental lesion of the greatest possible signifi-
cance to osteopaths.

Besides these surprising cures of obstinate cases in our own time,
I have been very much interested in the historical accounts of cripples
of various kinds and their cures. For a number of recently past
centuries in every generation of which we have sufficient medical
records there has been some prominent new method of treating pa-
tients by which cripples or those who used certain members and groups
of muscles with a great deal of difficulty and marked discomfort were
cured after having tried in vain all the resources of the regular
medical profession. Men threw away their crutches and their canes
or left them with their benefactors as memorials of the cures that they
had worked. Wh^i Charles I, in England, was put to death and
there was no one to touch for the various ills that used to be cured

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DISUSE OBIPPUKOS 159

by the king's touchy an Irish adventurer^ Greatrakes, a soldier out of
a job for the moment, announced that he had been divinely inspired
by identical dreams on three successive nights to touch and cure the
people. He i(mched them very effectively, so far as getting money
out of them was concerned, and, in a modem phrase, his generation
was certainly done good by him. The cures of his that attracted
attention were particularly those of chronic pains and aches of all
kinds, though not a few people were able to throw away crutches
and canes that they had used sometimes for years, though their affec-
tions had been under the treatment of some of the most distinguished
physicians of the time. As this was just before Sydenham's day, and,
as I have shown in some articles on the physicians of the time^ their
knowledge of medicine was by no means to be despised, these cures are
just as surprising and need an explanation just as much as those of
the irregulars in our time.

In the next century a series of similar cures was worked by Father
Maximilian Hell, who used magnets in order to produce them, or
rather to bring them about The magnets, of course, had no in-
fluence of any physical kind^ and yet they were the instrument of
the cure. The magnets were made in different shapes, according
to the portion of the body that was to be acted upon, and sometimes
even in the shape of internal organs, when these were to be treated or
the affection was attributed to them. Pains in the back, for instance,
were treated by the application of a double magnet, made in the shape
of two kidneys^ with a cross-piece connecting them. It is easy to
understand how much of influence on the minds of patients shaped
magnets in all these peculiar forms would have, especially when it
was a great scientist who was applying them, well known as a teacher
of physics and astronomy, and when it was perfectly clear that his
only idea was the benefit of the ailing. Many of the patients had
been bent over and were so crippled as to be quite unable to work
before the " cure " b^an.

Mesmer saw these cures of Father Hell while he was at Vienna,
and he proceeded to treat patients in similar fashion. Besides the
magnets, however, he used also what he called a bacquet or battery,
a series of bottles filled with metallic particles and connected to-
gether by means of wires, in circuit with which patients were placed.
The apparatus was somewhat like a battery of Leyden jars^ and the

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160 INTERNATIONAL CUNICS

translation of his word would undoubtedly be battery, but a com-
mittee of a French Academy of Sciences appointed for that purpose,
one of whom, by the way, was our own Franklin, who was just then
in Paris as Ambassador from this country, declared that there was
not the slightest trace of electricity or magnetism or any other physical
force that they could detect in " Mesmer's battery.^'

In spite of the fact that Mesmer's name has become attached to
what used to be known as animal magnetism and, we now think, of
hypnotism, Mesmer never produced the hypnotic sleep, which was
not used until his disciple, or, at least, follower, De Puysegur, em-
ployed it Mesmer's effects were supposed to be electromagnetic,
just as Father Hell's had been, but there was no doubt at all about
the number of cases of persistent acquired deformity that he cured,
nor the apparent miracles of healing of cripples that he worked. Many
hundreds of people who had been treated in vain by prominent French
physicians of his time went to Mesmer and were improved and some
of them cured. Not a few of them were able to abandon the use of
crutches and canes and various appliances that they had been com-
pelled to use for a considerable period. He was looked upon literally
as almost a miracle worker in his power to cure chronic crippling
affections, the sufferers from which had practically given up hope of
ever being cured, and many of whom had tried almost every known
form of treatment in their time.

Another man who saw Father Hell's wonderful cures at Vienna
also followed him in his therapeutic experiences and successes, though
changing his methods ; for, while Mesmer wandered off into supposed
electrical applications. Pastor Gassner (or Pfa/rrer Ghtssner), of
Elwangen, gradually abandoned the use of the magnets and came to
depend entirely on mental influence or, as he was inclined to think
it, spiritual influence. He saw that, while under Father Hell's care,
the application of magnetized metals shaped like organs brought cures,
but then he demonstrated that the same metals, even if they were not
magnetized, produced similar startling cures. Further experiences
showed very clearly that the ^^ cures" would come without these
metallic applications when pati^its were deeply imder the influ-
ence of the healer. Pf arrer Gassner declared, after trying to solve
the mystery of these observations, that the ills of mankind came
from the devil, and God was responsible only for good. Any one

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DISUSE CMPPLINGS 161

who abandoned the service of the devil and turned with confidence
to Grod then would surely be cured. It was an anticipated para-
phrase of the Christian Science declaration that there is no evil
in the world, because Gtod creates only good, but, unfortunately,
mortal mind creates the idea of evil and then suffers from it The
number of people, many of them cripples of long standing, who
flocked to Elwangen and were cured was very large. Many left their
crutches behind them. After a time Father Gassner's teachings
and practices were condemned by the Church, and his therapeutic
efforts were at an end. To many people at that time this seemed an
arbitrary exercise of authority quite unjustified, for the number of
people who had been cured was literally legion. Always the curea
were particularly of chronic cases, sufferers from pains and aches and
disabilities, most of whom had been treated in vain by regular
physicians.

It was this same class of cases that was cured by Perkins with
his tractors, and a similar group by St John Long and his famous
liniment The liniment worked so many wonders of healing in
chronic hopeless cases, and apparently so many miracles of recovery
occurred among those who had been crippled, that the English
Parliament was practically forced by public opinion to pay a large
sum for the mysterious secret of this charlatan St John Long, who
was found afterwards to have been a convicted felon and who was,
with some justification at least, suspected of several murders. His
remedy had been discovered, so he claimed, after long years of the
study of various means of healing, and the invention of his liniment
was the result of practically exhausting all the known sources of
therapeutics. It proved, when the secret was bought by the govern-
ment, that it was with a turpentine liniment made up with egg in-
stead of oil that all these marvellous cures had been worked. It
ceased to cure after this ; it had lost its most powerful ingredient —
the influence upon the mind exerted by its secrecy. So striking was
this immediate falling off in efficacy that it was even suggested
for a time that St John Long had really deceived the government and
had not really betrayed his secret, in spite of the large sum of money
paid him. The liniment before and after, however, was made up in
just the same way and was in the British Pharmacopoeia for many
years.

Vol. II. Ser. 26—11

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162 IWTBBNATIONAL OLHaOS

The various improvements in electrical machines, from ike Leyden
jar down through the Wimshurst and the high-frequency current and
all the rest, have each in their turn worked wonders with regard to a
large number of these chronic cases. It is amusing to read the account
of the wonders, worked by the Leyden jar when that electrical in-
vention was novel and was scarcely more than a toy in size^ yet cured
and produced symptoms of all kinds. Priestley, the discoverer of
oxygen, has told the story of it in his history of electricity, published
about 1770. An electrotherapeutic journal published about 1800
gives a list of cures quite as numerous as any that have been obtained
by subsequent developments of electrical madiines. Indeed, that
electrotherapeutic journal ought to be reprinted in order to show how
much promise and potency there was in electricity in those days when
they knew so little about it Galvani and Yolta's discoveries had led
very generally to the thought that electrical energy represented one
phase of vital force, and it is easy to understand how much patients
were influenced by this thought and by this new method of treatment,
which actually gave them back some of the vital energy that they
had lost Atrophic muscles particularly were renewed in this way
better than any other.

To come down to our own time, it inust not be forgotten that a
modem phase of interest in hypnotism and its influence on disease
was precipitated by the observed cure, by means of hypnotism, of a
case of sciatica with cripplings which was brought to Bemheim's
attention at Nancy. He had tried by every means in his power to
cure this case of sciatica, involving considerable disability, but with-
out success. He knew that the case had been under the treatment of
others with similar failure, though all sorts of methods of treatment
had been employed. When, then, the patient was treated witii
hypnotism by Liebault for some time and was not only greatly im-
proved, but actually cured of his discomfort and disability, Bem-
heim's attention was attracted to this method, and as a consequence
the clinic at Nancy took up the study and the practice of hypnotism.
Bemheim himself became the protagonist of the movement which
proclaimed hypnotism as a new therapeutic agent capable of develop-
ing a wonderful force for good. The Nancy experiences led for some
ten years to the devotion of more attention to hypnotism by serious
medical teachers than had ever before been given.

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DISUSE 0SIPPLING8 163

Almost needless to say, hypnotism has now been relegated to de-
served n^lect 'No serious physician attempts to use it for anything,
tmless occasionally and for a very few seances in the treatment of
psychasthenic disturbances or for the lessening of dreads and ihe
like. It must not be f orgotteoEi, however, that when it achieved its
modem popularity it was apparently curing all sorts of physical ills.
It is interesting, for instance, to realize that in England, when the
first news of the use of ether in America to produce ansestiiesia
reached Britain for publication in the English medical journals,
those medical journals were engaged in an absorbing discussion of
the employment of hypnotism as an ansesthetic in surgical opera-
tions. It had been so employed successfully in India by Esdaile in a
large number of cases. It was because of its physical effeds that it
seemed valuable. In the relaxation of cramped muscles and of such
tension in atrophic or disused muscles as made it apparently im-
possible for patients to employ them properly it was particularly
valuable. This is what gave it its vogue. The cure of more purely
psychic symptoms would not have attracted nearly so much attention,
but the relief of physical pain and physical disturbance made it seem
certain that there was some marvellous new agent at work in the use
of hypnotic influence.

In our own time there are many other manifestations of this same
tendency for these crippled cases to be cured by means that have no
physical effect, yet succeed in producing cures where many physicians
have failed. A large number of those who were cured by Alexander
Dowie, the prophet of the new religion, who proclaimed himself
Elijah returned to earth, were of this class. Many of them gave up
the use of crutches and canes after having carried them for years.
These people were so firmly convinced of Dowie's power to heal that
these nuracles of healing became for them absolutely incontestable
evidence of the divine mission of the new prophet They were per-
fectly willing not only to follow him but to give that highest tribute
to their belief in his nuraculous power, the surrender to him of tiie
control of their money. He claimed to have cured 100,000 people.
Many hundreds at least, probably many thousands, of these were
cripples of various kinds who, as the result of Bowie's ^^ healing
touch," were able to walk straight again and regain former strength.
Nor were these cures merely imaginary or fictitious. They were quite

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164 INTERNATIONAL CLINICS

reaL There had been disuse of muscles and there was pain on using
them, and physicians had been unable to help the patients, and now
they were able to walk once more.

At all times, from Egypt and Babylon down the ages, there have
been crutches to hang in shrines or waxen images of cured limbs that
were left as exhibits beside the altars or in the rooms of healers of all
kinds or that were shown as demonstrations of their curative power by
prophets and seers and remedy venders of every description. Very
often the people who had used the crutches had previously consulted
many physicians and not been cured and then were completely healed
and were able to give up their crutches or orthopaedic apparatus of
one kind or another at the behest of these healers. The explanation
of these " cures " that are common in the history of the race for four
thousand years represents also the explanation of the success of the
quacks and charlatans and healing methods of a number of kinds,
Eddyistic, manipulative, naturopathic, psychopathic, psychologic, by
seer power or seventh son force or bonesetting heredity so common in
our time. What is necessary is to eliminate the cases in which there
is Bome real physical deformity from those in which a mental inhi-
bition is the cause of the lack of power in the crippled limbs.

There can be but one conclusion from all these observations of
cures, historical and actual, by remedial measures supposed to be
physical, yet proving eventually to have no physical efficiency: that
is, that the change in the mental state of the patients was the eminently
curative factor. Other indirect elements in it were the encourage-
ment to get out into the air more, with the consequent improvement
of appetite and sleep, and, in connection with them, of every other
physical function of the body. From the consideration of these cures
it is quite possible to argue back and trace what were the real causes of
the conditions that were cured and just why it was that remedies
of all kinds employed for them failed to produce the desired effect
until some mode of treatment came that brought with it a distinct
change in the attitude of mind toward themselves and their ailments,
a belief in the possibility of cure and a determination to use the
affected muscles as if they were cured, with consequent relief of
symptoms and gradual restoration of the nutrition and function of
the part

What happens with a great many people because of an injury or

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DISUSE CBIPPLINOS 165

interference with the use of muscles by a firm bandage or plaster
cast for any considerable time is that they first get out of the habit of
using muscles and then becom^ afraid to use them. There is only
one way to strengthen muscles, especially when they are weak, and
that is by exercise. Children have the task imposed on them of ex-
ercising their muscles so as to aid in their growth. Fortunately they
have no consciousness, in any morbid sense, of the significance of
muscle pains and aches, and, as a consequence, they go right on exer-
cising them in spite of the discomfort occasioned by the exercise or
the sensations of stiffness that occur when rest is taken after severe
exercise.

It is quite impossible to develop muscles by exercise without
making them sore and achy and painful. If a person who is unused
to walking walks three or four miles, muscles become quite stiff and
sore, both to the touch and to movement Whenever muscles infre-
quently used are employed to any extent there is distinct localized
soreness in them next day. When a man imused to horseback riding
rides even a few miles his adductor muscles are so sore that he walks
rather awkwardly next day, and it is difficult for him to assume a
number of positions. I once went through the Mammoth Cave in
Kentucky with a group of people, and, as the time of the party was
limited, we were taken through a much longer route than is usually
assigned to the first day's exploration. A good deal of the travel
through Mammoth Cave is up and down. All of it is extremely in-
teresting, and, as a consequence, people walk much farther and make
much more exertion than they have any idea of. Some of the walking
is through rather tortuous passages, up and down, requiring the use
of muscles that, especially, the city dweller, who uses elevators and
doesn't go up and down stairs much, brings very little into play, some
of the muscles, indeed, not being used in ordinary life at all. As a
physician I was given the confidences of the party with regard to
their feelings next day. I could sympathize thoroughly with them,
because I had most of them myself. The muscles of the anterior
portions of the thigh, particularly, and of its inner aspect, were dis-
tinctly sore to the touch, were very stiff and tender when used, and
most of us were exhibiting a marked tendency to go around on our
toes rather than the heel and toe of the ordinary walk.

Some of these people were quite sure that they had caught cold

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166 IKTEBNATIONAL CLINICS

in the draughty cave and were now sufiering from rheumatism or
some such serious constitutional condition. I am quite sure^ from
that experience^ that a good many people, especially those of very
sedentary, inactive lives, who are tempted to go Hirough the Manmioth
Cave are subsequently treated for rheumatism, when absolutely the
only condition present is the sore and achy tiredness of muscles that
had not been used before to the same extent The soreness lasted for
the better part of a week, and, indeed, was still felt distinctly even a
full week later on coming downstairs in the early morning, though
later in the day there was no manifestation of this.

I once had to care for a patient who had been struck by an express
train and not killed, though pretty badly injured. He was taken
aboard the baggage car and was to be carried to a railroad hospital
which was distant about an hour's journey. A little artery was
spurting, and, as I had no instrument case with me, I was compelled
to prevent bleeding by pressure. This required me to stay close beside
tiie patient, and, without quite realizing it, in my interest in the case I
assumed a squatting position, sitting on my ^^ hunkers^'' as it is some-
times familiarly called, for more than half an hour, when, finally, a
box was provided for me on which to sit In the meantime the train
was making even better headway than usual over a roadbed not too
good at the best, and at this point rather noted for its curves and
grades. The door of the baggage car was open, and, though it was
the summer time, a rather brisk breeze was blowing through the car
that was cold enou^ to make one shiver at times. I was quite sure,
when I woke the next morning, that I had the beginning of a serious
attack of rheumatism. Every muscle in my body ached, particu-
larly all those in my legs and back. It was fully a week before this
soreness and tenderness disappeared. For three nights I woke up
every night with muscle pain due to the painful effort required to
turn over in bed. There was never any temperature, however, and
during the course of the first day I realized that it was the unusual
use of muscles; above all, the rather strenuous exertion and exercise
of supporting a body that weighs 250 pounds, which a number of
muscles unaccustomed to such usage had to imdergo in order to main-
tain equilibrium, in what was, after all, a rather unstable position,
under pretty difficult circumstances, in the rapidly-going, jolting
train. '

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DISUSE GBIFPUNGS 167

Those who want to learn to ride horseback^ however, or to play
games hard, know that, in spite of muscle soreness, they simply must
go on and use their muscles. They must push through. A man who
is sore after three miles of walking soon learns, by exercising his
muscles, to walk four or five or six miles without noticing it very
much. The first day of the oarsman at the oars, if he rows for any
distance, makes every muscle in arms and shoulder and back and
many of those in the legs sore and tender. If he were to complain
and ask to be treated for this soreness and were to rest these muscles
until the soreness left, he would have to repeat his exercise ad ivr
finitum. He would never succeed in hardening his muscles to their
work. The next day the oarsman gets over his stiffness by exercising
all his muscles a little more, and repeating on the third day, taking
an occasional rest, but never resting until all the soreness is out In
this way, after a time, he can accomplish what made him so sore
the first day without noticing it at alL The walker, the football
player, all of them can and must do the same thing.

The first day's skating every winter brings to the i^ter vivid
reminiscences of the very first morning after his very first day's
skate, when, as a rule, almost without exception, he was quite sure
that skating wbb an exercise in which he could never have any pleasr
ure, since it made him so sore in unaccustomed places as to make
walking, particularly walking up and down stairs, quite uncomfort-
able, and made such things as sitting with the legs crossed or sitting
on a rocking-chair almost impossible because of the discomfort oc-
casioned. When he was learning to skate, however, he kept right
on trying day after day, taking the soreness and stiffness out by exer-
cise until he has gradually strengthened muscles. It is not long
before a couple of hours' fast skating becomes a pleasure and a satis-
faction and brings no achy tiredness. The memory of the original
tired incidents is forgotten. Sometimes people have never gone
throu^ them. It is well to recall them whenever people complain of
achy tiredness in their muscles and are prone to think of it as a con-
stitutional condition, rheumatic or the like, when it is only muscular,
quite natural^ and a sign of nature's power to react so as to strengthen
muscles and make them available for such movements without any
discomfort being attached to them.

When people are asked to restore muscles to activity which have

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168 INTERN ATIONAI. CLINICS

been lying idle for some time and which have become more or less
atrophied from disuse, feelings of discomfort occur in them similar
to those noted when indulging in unusual muscle exercise. There is
only one thing to do for this, and that is to pu^ through, to go on
using the muscles in spite of the discomfort, with a certain amount
of prudence, of course, and yet with constant, frequently-repeated
daily efforts. There is no other way to build up the function of the
disused muscles thsln this, just as there was no other way for the child
originally to learn to use its muscles and increase their size and
nutrition than by producing this achy tiredness in them, and no way
to learn to use the muscles required in various sports and exercises
other than by pushing through the discomfort and achy tiredness of
each day until the muscles are hardened and developed so that there
is no difficulty about using them. There is no royal road to the
development of muscle except through exercise of it, and that always
involves pain, stiffness, discomfort, soreness, and tenderness. It is
these feelings that the older people refuse to push through or that
are misunderstood by their physicians and treated by them as symp-
toms of disease and perhaps relieved by that falsest of remedies, rest

Unfortunately, older people, particularly, find it very hard to
redevelop their muscles in this way. The soreness and tenderness
seem to them to be so great that they cannot think that they are
natural, but that they must be abnormal and then they stop using
the muscles. !N'ot only that, but they put a strong brake of inhibition
on the use of them, and, as a consequence, gradually get accustomed
to using neighboring groups of muscles in an awkward, inefficient,
and crippled sort of way, but so that they enable them to accomplish
their purposes, though ineptly. The disused group of atrophic
muscles then is likely to be left almost unused, or at most is very little
exercised. As a consequence, they remain in their atrophic condition.
As time goes on the individuals become more and more unaccustomed
to using these muscles, and there is a strong inhibition to the sending
down of impulses to them. This further disturbs their trophic con-
dition and leaves them with a lack of full vital connection with the
central nervous system. Some of this is, perhaps, theoretical, but
over and over again I have seen it exemplified so clearly that it seems
to me a very concrete observation and not merely a theory.

Sometimes, unfortunately, these patients, when their first efforts

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DISUSE OSIPPLINOS 169

to use their muscles bring on the achy soreness and tiredness and
tenderness, are told that this represents a rheumatic or that other
precious word of marvellously wide significance, a netfritic condition.
They are told that rheumatism has developed, and perhaps their own
personal experience as to rheumatism is carefully revived by the
physician and, above all, any question of family inheritance in the
matter insisted on. There are very few people whose fathers and
mothers, if they lived to a good age, did not suffer from something
that was at least called rheumatism, and so a rheumatic family history
is obtained. Their tired soreness is then treated by coal-tar drugs,
especially by some of the salicylates or, in our time, by the newest-
fangled of all the coal-tars, aspirin, but tiie idea of keeping their
muscles at rest is dwelt upon for them. The barrier of inhibition is
strongly raised, and after this the habit of not using the muscles be-
comes more marked and it will be very difficult at any time to get
these patients to push through and exercise their muscles, in spite of
pain and discomfort, until they are back to normal conditions.

I have seen cases where a comparatively slight injury to the
knee led to considerable disuse and limping and an atrophic condition
of muscles, with the difference of over an inch in the diameter of
the thigh, in which the only reason that apparently would account for
it was that the patients had acquired the habit of sparing certain
muscles during the time that the soreness continued. It is a familiar
experience to find that patients who have suffered from the nipping
of a cartilage in the knee-joint get to walk with a halt in that limb
and spare the muscles of it until their wear on the shoe of that foot
is much less than in that of the other. In the old days when dentists
ran tiieir dental engines by foot-power many of them acquired a halt
in their gait, a distinct difference in the way that they used their legs,
which was well recognized by the profession and came to be known as
" dentists' halt" This did not develop in every one, but usually only
in those of not very strong muscle build, and especially those who,
with rather weak muscular systems, were above the average in weight
The halt occurred not in the 1^ which was used for power purposes,
as might naturally be expected, but in the one on which they stood,
usually, therefore, the left Some dentists escaped the derangement
by using the legs alternately. It was actually in the 1^ whose muscles

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170 INTERNATIONAL CLINICS

were not used that weakness and even^ aftelr a time, some pain and
discomfort developed.

An interesting feature of these cases where muscles are undevel-
oped is that in such atrophic muscles tendencies to muscle soreness
of various kinds in the muscles that are thus left unexercised are very
outspoken^ and any use of them in rainy weather is likely to be fol-
lowed by considerable discomfort Apparently their state of under-
nutrition makes them more subject to nervous sensitiveness. Besides,
there is usually a lack of circulation in these unused muscles or not
fully used muscles, and this adds to the sensitiveness of nerves. A
very common complaint is that they suffer more from cold than other
parts of the body, especially than the other limb, if the condition is in
a limb, or that the affected member perspires more easily and is often
said to be subject to ^^ cold sweats/' which is only another phase of
the supersensitiveness that has developed in them.

In a word, this whole question of disuse crippling becomes very
interesting from tiie standpoint of the influence of the mind on tiie
conditions. There is no doubt that many of tiiese cases occur for
which apparently no ordinary medical or surgical treatment proves
efficient On the other hand, there are a great many of them for
which, after all sorts of internal and external treatment have been
devised without success, some r^nedial mode that has no physical
influence of any kind at all proves successful in giving them back
power over the muscles which have been a long time lamed. These
are the cases that make the reputations of all sorts of new-fangled
methods of treatment which come and go. They are of tenest seen in
the old. It is the successful treatment of tiiese, especially when they
happen to be members of legislatures or men of political influence,
that brings up the question of legislative endorsement of the new-
fangled method of treatment, with full permission for its disciples
and advocates to treat all classes of disease, because they have suc-
ceeded in curing some chronic ailment of more or less crippling char-
acter either in a l^slator or a judge or a politician or some of the
friends and relatives of such men.

Such cases make the reputations of the hereditary bonesetters
and the various forms of manipulative therapy. The patients must
be told, above all, that they have had something quite serious the
matter with them, and something must be done to them to make them

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DI8TTSE CBIPPUNOS 171

feel that now this pathological condition has passed for good and alL
So soon as that persuasion comes they take down the bars of inhibition
which have prevented them from using these muscles properly, and,
in spite of certain pains and aches which occur, they push on to exer-
cise and develop these muscles. When similar pains and aches
occurred before they were quite sure that they represented serious
pathologic conditions which would surely increase unless cared for,
and which it might be serious to provoke by any further muscular
exercise. Kow they know that the tingling, achy, tired feeling which
they have is only a ^miptom of the new life which is stealing into
their muscles under the new mode of treatment This persuasion is
literally true, only they could have had it at any time if they had
only had the courage to exercise the muscles in spite of their pidns
and aches. They go on then to be cured and announce themselves as
interesting examples of the wonder-working effect of the new mode
of treatment It has treated their minds, not their bodies, though it
would be very hard to persuade them of this. Only when the whole
series of these cases as cured in the history of medicine is viewed to-
geliier does the real secret of what cures them become manifest At
the same time, the mystery of these disuse cripplings is solved. When-
ever a definitely localized physical pathologic condition cannot be
discovered — and this is rather often the case — ^then the mental pathol-
ogy of these cases should be considered, and it will often furnish a
clue not only to their etiology but to their successful therapeutics after
many forms of treatment and many hands have failed.

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TYPHOID AND THE PSYCHOSES*

BY JOHN P. H. MURPHY, M.D.

Assistant Physician

It is not the purpose of the writer to dwell at length upon a sub-
ject ably discussed elsewhere, but rather to briefly set forth the
salient points of a condition, the malign influence of which has un-
doubtedly been felt throughout the ages.

The pages of history portray that, while fevers with delirium
have been observed from the days of antiquity, the writings of
Hippocrates and Galen do not seem to indicate that any particular
form was recognized as a distinct identity, but as merely a different
expression of the same disease.

The decrease in the plagues which visited Rome after the intro-
duction of a water supply and drainage system suggests that some of
the epidemics might have been typhoid, as the disease termed
'^ hemitritseus '' embraced many of the phenomena characteristic of
this state. From a modem viewpoint, however, there seems to be
little doubt as to the identity of the malady described by Willis in
the early part of the seventeenth century, while it remained for
Huxham of Plymouth, in the next decade, to draw the line of dis-
tinction between the so-called " slow nervous " or typhoid and the
^^ malignant petechial" fever, typhus. Early in the nineteenth
century Murchism first suggested the possibility of contagion by
fseces, but, as much stress was laid on impure air and sewer gas as
sources of infection, it fell on Budd of Bristol, in 1866, to establish
the first tangible view on the matter, viz., that the disease always
sprang from some specific source. In 1880 Eberth discovered the
germ, while in 1895 the agglutination reaction was first brought into
practical application by Widal.

In reference to typhoid Osier writes : ^^ Of no other disease can
we read so full a history from American sources alona" But by this
statement we must not infer that the ravages of this malady are

* Written for the Clinical Society at the Goveniment Hospital for the Insane,
Washington, D. C.
172

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TYPHOID AND THE PSTOHOSES 173

mainly exerted within our own confines; for statistics prove that it
is most widespread in its scope. No country or race is immune.
We read of its occurrence in the far north and south latitudes, in
the mountains and at the sea level, in the cities and in the country,
and, in fact, any place existing under improper sanitary conditions.
Insidious in its mode of travel, it does not extend over an entire
continent or strike the majority of those exposed, but manifests
itself by epidemics scattered throughout the various portions of the
land ; an infected city may spread the disease throughout the country,
while from the country comes a stream of infected people to the city.

For some reason, not entirely clear, the disease is more prevalent
during the autumn months, but in this country no season is without
a few cases. It may be, as quoted from one writer, that during the
hot and dry season, when the ground water is low, the sources of
supply are likely to drain a wider area, while again in the sunmier
months, when flies and other insects are prevalent, there is not only
an increased liability to infection from this source, but from the
particles of dust which are blown about in the air, and which may
contain the germ.

Treating further on the subject, Flexner says : " Typhoid is
a protean disease when considered from its chemical, its pathologic,
and its bacteriologic aspects." Although most frequently observed
during young adult life, it has been noted during early childhood,
and is not uncommon in old age. Run-down conditions play little
part in the etiology, for it is observed in those who prior to the onset
enjoyed robust health ; while some maintain that a deficiency of the
gastric juice may cause the stomach to act as a suitable culture media,
there is no direct evidence to prove that the bacilli are actually killed
by the fluid, yet it is quite evident that the life cycle is vitally affected
by the varying chemical constituents of the body, as observed by the
growth of the germ on faeces of different chemical components, sub-
ject, of course, to atmospheric variations. This may also account
for the difference in severity of the individual attack.

If one would attempt a classical outline of the course and duration
of typhoid, he might quote Dieulafoy and say that normally the
disease is characterized by three stages — ascending, stationary, and
descending — these being preceded by a period lasting from a few
days to two weeks, which by some authors is termed the prodrome.

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I74r IWTBBNATIONAL CLIiaCS

Jaccotind, however, includes this under the period of ascent, which
he calls the stage of invasion, while the period of decline is con-
sidered as the stage of repair. These divisions, while convenient for
description, are not in all cases clearly marked clinically, for in
some the prodome may be entirely absent, and the disease be ushered
in by a chill, the typical symptoms and localized signs of lobar
pneumonia for a time completely disguising the true underlying
condition. Again, dyspeptic or intestinal trouble may open the
scene and the case be nustaken for one of appendicitis, while a
sudden shock from perforation of the bowel, with the manifestations
of hemorrhage or peritonitis, may be the first intimation of the
existence of the trouble. Again, in children it often lies hidden
beneath the illuding cloak of diphtheria or whooping-cough. Flexner
truly summed up the situation when he termed enteric fever a
protean disease.

Discussing the subject of temperature. Wood, in a recent article,
reminds us that, while lysis has for many years been considered as
the characteristic termination, a fall by crisis would suggest error
in diagnosis. Nevertheless, Jaccound, Curschmann, and others have
observed this phenomenon at the f astigium, which the latter called
the pseudocollapse, and which was unattended by any alteration in
the pulse. Wood cites siz cases of this nature, one of which showed
a drop from 103 to 97.6 in nine hours, with a favorable effect on the
pulse and no effect on the respiration. Another point which may be
of interest is that while in typical cases acceleration of temperature
occurs in the evening, followed by the characteristic morning re-
mission, the reverse may be noted in those who prior to the onset
had been accustomed to work at night, while a patient who comes to
the hospital with scarcely any temperature at all may, on being
placed in bed, show, after a few hours, a rise of three or four degrees.
Although the pulse may give no characteristic findings, it is, in the
early stages of the disease, much slower than would be expected in
comparison with the height of the fever. There is, according to
McCrea, no disease in which the dicrotic, or apparently double pulse,
is so prominent as in typhoid. This, he claims, is undoubtedly due
to alterations in the thermic centres of the brain, reduction in arterial
tension from vasomotor paralysis, together with degenerative changes
in the heart ganglion. It may be well to remember, therefore, that

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TYPHOID AND THE PSYOHOSBS 176

an increase in the pulse, together with a steadily falling blood-
pressure, is of grave omen, while sudden death has occurred from
acute dilatation due to myocardial degeneration.

A mere mention of the less common forms will suffice here, as
this portion of the subject has been ably discussed elsewhere. How-
ever, aside from the mild and ambulatory types which are not exempt
from perforation or hemorrhage, we have llie ahortvoe type, a term
applied to the short duration rather than the benign nature of the
trouble; the sudoral, characterized by paroxysms of temperature,
followed by drenching sweats, which phenomena may occur several
times within twenty-four hours; next the hemorriiagic, with bleeding
from the nose, lungs, gums, etc. ; the adynamic form, with lasting
stupor, foetor of the breath and sweat, with a tendency to gangrene;
and, last, the ataxic form, showing violent delirium, cramps, lumbar
pains, subsultus tendinus, and convulsions, the most fatal form of
typhoid.

Various authors claim that the Gruber-Widal test is best done
with high dilutions, a reaction being demanded within a certain time.
This feature is much more pronounced during the early stages of
the disease, while later in the course the reverse is the rule. In
explanation of this, Sahli claims that, in addition to the agglutinating
property of the serum, there is, early in the course, a counteracting
agent which may be overcome by more marked dilutions. He main-
tains, therefore, that a negative Widal should never be assimied
merely because the reaction is not given by a concentrated serum.
It must also be remembered that, although the Widal is usually
obtained during the early stages of the attack, it may not appear
until convalescence is well advanced, or even at the date of discharge,
and, while it may disappear within a few weeks after the recession
of the fever, it usually persists for about four or five months, and
cases are recorded wherein the reaction was obtained two years
after all signs of the disease had vanished. It would appear, therefore,
that in order to make a definite diagnosis of typhoid a blood culture
should be done in connection with the agglutination test Again,
Sahli reminds us that considerable confusion has arisen through
the creation of the pathologic conception of paratyphoid, a term
applied to a condition which, though not differing clinically from
the true form, is uniformly less severe, and in which the Widal

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176 INTEBNATIONAL CLINICS

reaction with typhoid bacilli is negative. He believes that both,
however, are merely different varieties of the same species, the result
of natural selection, because the typhoid bacilli can assume different
characteristics, depending upon the varying chemical susceptibility of
the living body, for within certain limits of dilution the typhoid germ
is agglutinated by the paratyphoid serum, and vice versa.

The works of various authors seem to indicate that, although the
immediate effect of vaccination is to diminish the resistance to in-
fection, it at the same time produces a marked increase in the
bactericidal and agglutinating properties of the blood ; and, although
the protection conferred by it persists for about two years, in view
of the temporary lowering of resistance it is not well to vaccinate
during an epidemic

Having reviewed the subject from the clinical side, the opportune
moment has arrived for a consideration of the disease in its relation
to abnormal mental states. Although the psychoses associated with
typhoid are, as a rule, distinct among other forms of mental aberra-
tion, being classed usually under the infection-exhaustion group, there
are, nevertheless, many features observed in connection witii these
delirioid states which may be of vital importance not only as regards
prognosis but from the fact that in some cases the true underlying
condition has been successfully, though temporarily, concealed.

Esquirol, towards the end of the eighteenth century, called atten-
tion to the relationship of the febrile processes to abnormalities in the
psychic sphere, and, although opposing views have arisen since his
time, the recognition of this fact is becoming more widespread with
the advancement of science.

Freidlander, in reference to the subject, writes, " There is a
unanimity of opinion that, of all acute diseases, typhoid is the one
most accompanied by mental symptoms.'' I think, however, that in
order to verify this conclusion it may be well to briefly review the
classification of psychic phenomena observed in connection with
typhoid as set forth by Kraepelin. It is interesting, however, to
remember that individual and racial characteristics are very in-
fluential factors from not only an etiologic but a prognostic point of
view ; this is clearly portrayed in the remarkable susceptibility of the
negro, as in other forms of psychoses, to acute delirioid states.

As mentioned in a previous paragraph, while enteric fever has

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TYPHOID AND THE PSYCHOSES 177

been known to lurk beneath the cover of some other physical malady,
an example of which may be cited in the so-called meningotyphoid,
so the initial or pref ebrile delirium may for a period so successfully
veil the true underlying condition as to cause serious error in
diagnosis. Cases have been admitted to institutions for the insane
which were thought to be suffering from delirium tremens, manic-
depressive or undifferentiated psychosis, while, on the other hand,
the typhoid state, the sequel of profound intoxication, may simulate
a case of catatonic dementia prsecox. This is not surprising, however,
when we consider that in many of these cases there is no temperature
rise, and that often the first intimation of the existence of the disease
is a sudden shock from intestinal hemorrhage or perforation of the
boweL

The occurrence of delirium, therefore, in a patient, no matter
under what circumstances it may be found, is always a grave prognos-
tic omen, as it is in almost every case a positive sign of diminished
cerebral resistance.

Case A. — ^The patient, a man of thirty-two, had been in excellent physical
and mental health. He always earned a good living, was of a jovial disposition,
and fond of outdoor sports. He was temperate in his habits, but owing to busi-
ness affairs he had been very irregular in his diet. He was admitted to this
hospital on a medical certificate which stated that the patient was markedly
retarded, but that he at times became excited and destructive. On admission he
was talkative, showed flight of ideas, with a tendency to rhyme. There were
distracUbility, hypermotor activity, and visual hallucinations; he was disoriented
in all spheres, and in a very emaciated physical condition. His temperature
was subnormal. After about two weeks in the hospital his hallucinations became
very pronounced in the visual, auditory, and tactile flelds; he became more
confused, and his physical condition grew worse. About the beginning of the
third week he suffered a slight hemorrhage from the bowels, followed shortly by
another, which was more severe, losing almost a pint of blood. The Widal re-
action taken at that time proved positive. Although he had several slight hemor-
rhages after that, he eventually made a good recovery. However, for several
months he was quite retarded, and had an amnesia for certain events which had
transpired during his illness. He also experienced considerable difficulty in
remembering dates, " a feature which," according to McOrea, " is quite noticeable
in typhoid." The case was diagnosed as " exhaustion psychosis," and in view
of the reduction noted in the psychic sphere at the time he left the hospital it
was thought that the mental disturbance might mark the beginning of a
prflsoox process.

Case B. — ^Parents were formerly inmates of this hospital. Patient had
been a healthy and intelligent girl until shortly after the birth of her first child.
The medical certificate stated that she imagined she was being poisoned. On
Vol. n. Ser. 25—12

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178 INTERNATIONAL CLINICS

admission she was in a delirioid state, talked constantly about her family.
Physical examination showed she was poorly nourished, the reflexes were ex-
aggerated. On the seventh day after admission the signs and symptoms of
typhoid became manifest: the Widal was positive and blood culture showed the
genu. There was marked subsultus tendinus and retraction of the head; she
developed a severe furunculoeis, grew gradually weaker, and died after a three
weeks' sojourn in the institution.

Some writers have claimed that if a patient suffering from mental
trouble goes through an attack of typhoid a beneficial effect upon the
psychosis may be noted^ one English author reporting twenty-one
cases of complete recovery. It would appear, however, that an in-
fecting agent powerful enough to produce such morbid psychic
phenomena as observed in typhoid conditions, viz., initial delirium,
febrile and asthenic psychoses, is in all probability able to go a step
farther, and in some cases leave in its wake the stigmata of per-
manent organic change — dementia.

Case G. — ^A synopsis of the record shows that one paternal uncle had always
been considered peculiar. One sister committed suicide owing to worry over
heart trouble. The patient was a healthy, normal boy tmtil he reached the
second year in high school, at which time he sufifered a fall from a horizontal
bar, and was tmconscious for some minutes. He recovered, however, and no
injurious effects were noted. About fifteen days later he fainted and was put
to bed. The physician being summoned diagnosed the case as typhoid fever.
The patient was in bed for six months, and during the height of the attack was
in a delirious condition. He apparently recovered and returned to school. He
was obliged to desist, however, as he would have a sick spell about once a week.
He tried work, but could not get along. He grew careless and would not change
his clothes. Finally he attempted violence on a member of the family and was
sent here, after having been in several sanitariums. At the present time his
mentality is markedly reduced, and he sits all day in a chair, staring vacantly^ at
the floor. He never speaks, but at times nods a reply to questions.

Case D. — Patient was a healthy boy until twenty years of age, when he
had lyphoid fever, foUowing which he was sent to this institution. The con-
flicting statements which he made in the history show evidence of memory
defect, especially for dates. He could not tell why he was sent here, except
that he was picked up on the street, because, for some reason which he could not
explain, he began to run around in an aimless manner. This was shortly after the
attack of typhoid. At present he is irritable, occasionally shows mannerisms,
and is inclined to be moody. There is a lack of moral tone. He is well oriented
at present, but still has some difficulty in remembering dates.

The last case which 1 shall report is of interest not only from
the possibility of error in diagnosis, but it may serve to bear out the

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TTPHOID AND THB PSYCHOSES 179

theories in regard to the persistence of the agglutinating properties
in the serum for long periods after an attack of typhoid or the
administration of prophylactic vaccine.

Case E. — ^The patient, a young soldier, gave a very unreliable history. It
was ascertained, however, that he had typhoid fever in 1902. He enlisted in the
army in 1908, and served in the Philippines. At the expiration of his term he
again enlisted and was sent to China. Although there is no record of his
having been vaccinated while in the Orient, he told the army surgeon and his
attending physician that on one occasion while in the East his arm was punctured.
On admission here he showed considerable dilapidation of thought, was dis-
oriented, suffered from auditory hallucinations, and gave voice to many absurd
and fantastic delusions. He has shown little improvement since he came, and
spends most of the day sitting on a bench, staring vacantly at the floor. In
the early part of October it was noticed that the patient was not eating well.
He appeared to be in a stupor, and was placed in bed in one of the hospital
wards. Within a few days the temperature showed a gradual step-like rise,
reaching a maximum of 103.3 ** on the thirteenth day. The Widal reaction was
strongly positive. The pulse ran about 80 per minute, the swiftest record being
114. It was dicrotic in character. The spleen was slightly enlarged, there was
slight tenderness over the gall-bladder, the bowels were constipated, so much
so as to require an enema of a cathartic almost every day throughout the illness.
The tongue was dry and brown, and the abdomen was tender and tympanitic.
The patient suffered from occipital and frontal headache, presenting a typical
picture of the typhoid state. The white coimt was 6000, and no malarial para-
sites were found. There were no chills, but sweating was noted at times. A
peculiar odor was emitted from the patient during his sickness. He had been
taking I. Q. S. prior to the onset. On several occasions he suffered from
diarrhoea with yellow, semifluid stools. A second Widal was positive in high
dilution, yet the serum failed to agglutinate the paratyphoid germ. Repeated
examination of the blood, faeces, and urine, however, failed to reveal the typhoid
bacilli, and the patient made a fair recovery. There seems to be no improvement
in the mental condition, as the retardation is even more marked than heretofore.
Whether this condition was in reality a case of typhoid fever or merely a typhoid
state due to the absorption of the toxic products from intestinal putrefactive
bodies I am not prepared to say; at all events, it plainly suggests how a disease
of this kind can for a time conceal itself beneath the shadow of dementia prsecox.

In conclusion I might say that in any condition giving rise to
excitement, delirium, or stupor, even though the temperature remain
normal for a time, we should be very careful in our examination so as
to avoid if possible a serious error in diagnosis, and at the same time
keep in mind that, while a delirioid state may subside with the
remission of symptoms, it may, if engrafted upon a constitutional
foundation already weakened by psychopathic heredity, lead to per-
manent mental impairment.

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180 INTBBNATIONAI. CLINICS

BIBUOGBAPHY

Ed. J. Wood: "Critical Defervescence in Typhoid Fever," Boston Med. Journal,

December, 1914.
S. S. Adams: Tr, American Pediatric Society, New York, 1896, "Four Cases

of Temporary Insanity Following Typhoid," vol. xiii, pp. 837-845.
C. M. Caicfbell: "Effects of Enteric Fever in the Insane," ** Jour, Med,

Science, London, 1882.
Thomas McGbea: "Typhoid Fever," Osier's "Modem Medidne," vol. ii, pp. 70-

230.
G. DiEULAiroY: "Typhoid Fever," vol. ii, pp. 1619-1693.
Hermann Sahu: "Course of Typhoid," pp. 77, 78; "Widal Reaction and

Paratyphoid," pp. 857-861, 2d Revised Ed., 1911.
Clabenge B. Fabbab: "On Typhoid Psychoses," Am. Jour, of Insanity, vol.

lix, pp. 17-61.
Nothnaoel: "Typhoid and Typhus Fevers," 1905.

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HUMAN CONSERVATION, A NEGLECTED FIELD FOR
MEDICAL SPECIALIZATION

BY J. MADISON TAYLOR, AB., M.D.

Associate Professor of Non-Phannaceutic Therapeutics in the Medical Department
of Temple University, Philaddphia, Pa.

The human unit has not yet been placed on a par (economically)
with other natural resources. It has become a world-impulse to
save and utilize all crude products and domestic animals; but for
the citizen (the elemental factor in the commonwealth) municipali-
ties, up to the present, are content to exercise protection and preven-
tion of disease, yet they disr^ard the large possibilities of individual
conservation.

Constructive and reconstructive measures in the domain of medi-
cal practice and correlated activities are subordinated to repair
work, to meeting emergencies^ to focusing research on definite clinical
problems.

Research is equally remunerative in formulating efficient ways
and means of raising the index of vitality and sustained capacity
in those whose condition leaves something important to be desired,
whether due to inherent defects or acquired disabilities.

By means of expert regulation of conduct, systematic conser-
vation or reconstruction, established upon a basis of scientific findings,
enriched by the already important, though scattered and partial, con-
tributions to medical, hygienic, or secular literature, it is entirely
possible to perform new wonders of betterment Evidence is forth-
coming from highest sources pointing out that skilfully directed adap-
tation of the individual to his environment is a significant and
available factor for human welfare. Here we have a clinical appli-
cation of the broadening science of euthenics, powers of betterment
through improving environment.

Expert r^ulation of conduct should be adjusted to particular
requirements, from the standpoint of (a) the status of individual
development and specialization, (&) sociologic or industrial limi-

181

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182 INTEBNATIONAL CLINICS

tationsj and (c) the existing states of health, vigor or relative disa-
bility. It is, moreover, reducible to percentages or other mathematical
formulations. Indeed, systematic rehabilitation measures are much
more businesslike procedures than emergency or repair measures
which the physician is ordinarily expected to supply. These latter
merely aim to stop the worst leaks in energy reserves, to patch up
the organism, or to place it imder the most favorable conditions for
self -restoration ; whereas the former takes full " account of stock '' ;
revises and supervises till the best obtainable bases for procedure are
determined.

Oftentimes the emergency work has been already well done^
whereas economic, reconstructive measures are omitted, or only
half-heartedly suggested, and it frequently happens that an individ-
ual urgently needs reconstructive supervision lest a worse state
follow.

Unless some' compelling circumstance arises to direct attention
to significant facts, then to the choice of a qualified adviser, these
very real but non-insistent leaks in force escape notica Or a person
may be conscious of vague losses of vigor or undefined disorders of
function, and seeks counsel of a physician who is unfamiliar with,
or uninterested in, suitable measures and misses the point There-
upon, dissatisfied, unrelieved, the temptation is to seek aid of some
of the muJtif arous well-meaning but uneducated " practical trainers,*'
physical culturists, or venal commercialists, advertisers of cure-all
" systems," so the underlying defect or damagement is still imrecog-
nized.

In the event of pronounced but obscure departures from health,
there is also involved the economic problem of raising the status,
or index, of vigor and profici«icy from a plane of relatively lowered
competence to that of which the inherent forces of the individual are
capabla

Convalescence from acute disease, injury, or operation is an-
other allied field. Here rescue measures are indicated and should
be applied with full recognition of their significance. Plainly,
constructive, or reconstructive, personal hygiene comes well within
the domain of vital economics.

My personal attention has been directed to the capabilitieB of

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HUMAN CONSEBVATION 183

intensive personal hygiene for thirty years. Collected data bearing
directly and indirectly on the subject have grown to a respectable
grouping of illuminating and effective suggestions. Hints well sus-
tained; working principles^ scientific explanations, and wise practical
recommendations are to be found, richly scattered under widely diver-
gent headings. The aggregate findings compare favorably in value
with those along most advanced clinical and laboratory lines.

Let me repeat a few points mentioned in a former paper.^

Every person, young or old, is capable of an appreciable increase
in vital dynamics by revising modes of lif a This is particularly
demonstrable as middle age approaches and elasticity subsides.
From earliest years the child begins to retrogress, to lose pliability,
adaptability ; to fall into one or another form or kind of disability.
Some of these deviations from int^rity merge into serious retro-
grade changes, often shown by local rigidities, densities, caused partly
by faulty habits or vitiated automatisms, due to omissions of suitable
variety in both impulses and energizing whereby alone symmetrical
action and reaction are assured. The factors involved are both
psychical and physical. The deadening effects of routine, of monot-
ony, are well known. Stimuli should be varied ; suggestion or auto-
suggestion alone is rarely adequate to preserve vital rhythm.

The ultimate destiny of our civilization will depend upon the
degree of efficiency of thought-power. Greater mental efficiency is
demanded not only in all modem industrial pursuits but also in
defensive and aggressive activities. Steps in advancing civilization
are marked by increasing strains, burdens, and insults thrown upon
the structures of the body, especially the most delicate of all, the
brain and nerves. Each new crisis in civilization calls for the
exercise of higher intelligence, increased cerebral capacity, and
better judgment in ^^ the man behind the gun."

The tendency is for each good citizen to make the best of his
condition, to treat lightly unobtrusive ailments, to forge energetically
ahead, ignoring slight symptoms, especially psychic phenomena; so
that, too often, serious states are revealed only when far advanced or
too late. This disregard of ailments is commendable; it makes

» " Reconstructive Personal Hygiene," Manihly Cyclopedia and Medical BtdUHn,
May and June, 1013.

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184 INTBBNATIONAI. CLINICS

for courage^ endurance, and renown ; for character-building and sue-
cefls. Through such pertinacity only are the highest ends achieved.
Carried to its logical limit, however, it lures the ignorant optimist
into a state of perilous monisnL Conversely, overmuch self -searching
leads to hypochondriasis, timidity, and inefficiency.

Unwarned, confident, one often assumes increasing burdens and
presses on to or beyond the limit of working powers. Then there
ensues some minor or major accident or disease, and mind and body
are distorted; all of which could have been avoided by adopting
one of two courses: (1) Had the family physician been observant,
wise, and, above all, dominant, corrective measures could have been
instituted sufficiently early. (2) Had the individual himself been
duly alive to his economic needs, capable advice would have been
sought and the full working efficiency reestablished.

It is true also of the specialists in almost any line that few are
skilled in directing after-cures; fewer are persistent or industrious
in that long supervision so necessary to reach the plane of restoration
of which each patient is capable. My revered master. Weir Mitchell^
was peculiarly accomplished in reconstructive measures. He in-
sisted on maintaining supervision for months, often years. Hence
his final results were, oftentimes, little short of marvellous in reju-
venation and regulation of both mind and body.

The human organism is admittedly a marvel of interacting, vital-
ized parts, mechanisms, and forces, a well-balanced organism, and,
to quote a former paper of mine, the body is a concrete, living
entity, not a mere aggregation of separate parts, like an insentient
machine, any one of which is capable of acting and reacting inde-
pendently of the rest In the human machine, wherever there is
local damage or derangement this can be removed only by eliciting
the full cooperation of all the component mechanisms, and being
aware of the interdependence of every part Nowhere is the signifi-
cance of this cooperation more direct and important than in the
treatment of protracted disabilities, and for many reasons. Take
traumata — ^fractures, wounds, and other strictly localized damage-
ments — ^the remainder of the organism is presumably at the time
in a state of full integrity (hence with full capacity for prompt and
complete repair), whereas conditions are otherwise in protracted,

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HUMAN OONSBBVATION 185

long-prevailing disorders; the results being manifest in slow but
steady disintegration of tissues — ^in the retroaction caused by de-
pression in both the psychical and physical spheres of activity.

In acute disease, notably the inf ections, there is fever, a defensive
process whereby the autoprotective forces are aroused to the per-
formance of their most perfect work. The problem is then relatively
simple, the organism being presumably normal when infected. But
in chronic disease the defensive powers are gradually overwhelmed,
and cannot be relied on to promptly meet and overcome morbific
agencies. Xot only this, the causal factors become increasingly complex
— a blend of psychic confusion and loss of physiologic conservation.
Therapeutic agencies must, then, include systematic encouragement
of all functions, rehabilitation of the whole system.

Chronic morbid processes, while of wide diversity and due often
to special diseased entities, none the less are at bottom mere out-
growths of vitiated physiologic processes. Physiologic processes are
uniform in their manifestations, not only when normal but also
when deranged. The human organism is disturbed by disease, of
whatever nature, along strictly analogous lines. The special features
may and do vary, but chiefly in accordance with the structures
altered, rather than by reason of the nature or character of the disease
itself, and the organism, as a whole, is usually capable of recovering
a fair measure of efficiency.

CONCLUSIONS

1. In chronic disease the organism, as a whole, becomes exhausted
through protracted, complex derangement; hence, reparative agencies
are at a disadvantage as compared with the normal poise and efficiency
of the organism when acute disease or injury arises.

2. Therefore, the pathology of chronic disease is something much
more than that of acute states, involving many problems of morbid
physiology and psychic disorder yet unsolved.

3. Eemedial measures must be directed to the restitution of func-
tional poise and include rational measures capable of conserving the
autoprotective and autoregulative forces.

4. The basis of relief and cure is to be found along the line of
palingenesis (development according to the primitive or original

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186 INTBBNATIONAI. CLINICS

method) ; the overcoming of agencies which retard physiologic proc-
esses; rehabilitation of all functional derangements, regulation of
all contributory factors in vital action, so that full compensation
shall be achieved of existing deteriorations.

6. The utmost drugs and medicines can do is to contribute to
these desirable effects, however nearly they may approach to the role
of " specifics,^' for overcoming disease ^itities, unlocking the doors
for toxic wastes, and freeing the organism, as a whole, from disabili-
ties present

6. The measures on which, in the final count, we must chiefly
depend are included under the term personal hygiene: (a) Conser-
vative personal hygiene; (b) constructive personal hygiene, and
especially (c) reconstructive personal hygiene.

7. The possibilities of reconstructive personal hygiene lie in the
direction of making available latent, undeveloped energies in any
adult below the norm, from whatsoever cause; in systematically
utilizing the inherent dynamics, and in raising the coefficient of

The practical purpose of this paper is to call attention to the fact
that much can be achieved by bringing into line the functional power
of the organs and tissues so as to secure the completest transfor-
mation of dynamic into kinetic energy, no matter what be the morbid
agency.

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A CONSIDERATION OF SOME PAINFUL CONDITIONS

OF THE FOOT

BY MORRIS BOOTH MILLER, M.D.

Professor of Surgery, Philadelphia Polyclinic; Surgeon to Douglas Hospital,

Philadelphia

As has been said, the foot is a lowly member. Apparently there
is no part of the human body about which so much is taken for granted,
and which is so routinely and persistently n^lected when in trouble,
as this humble but indispensable member. I do not hesitate to state
to you that twenty-five years of active hospital practice have served
to fix in my mind the impression that nearly ninety per cent of the
patients applying for relief from painful feet bring mute or spoken
evidence of careless, inade<]^uate, or unintelligent examination. Far
too often it happens that a patient seeking advice for pain in this area
is asked a few questions, is told that he ha£( rheumatism, is given an
antirheumatic prescription and a few general directions about his
diet, and is blandly dismissed without the foot ever having been in-
spected. It is obvious that such a state of affairg is inexcusably bad
and leads the patient to go elsewhere; perhaps to another physician,
who is no better; perhaps to a chiropodist, which is worse; imtil
finally, after needless suffering and expense, he falls into the hands
of the man who takes the time and trouble to discover what is the
matter, and who then knows what to do for it.

It is not my intention to discuss seriatim the rather large number
of pedal afflictions. I merely want to run over with you some of the
more common painful conditions, especially those which seem some-
what obscure, or, at least, are inferentially obscure, because their
recognition and significance are seldom grasped by the general prac-
titioner.

In the first place, that we may start without prejudice or handicap,
let us dismiss, once and for all, the too prevalent and erroneous idea
that an afebrile rheumatism can attack the foot Naturally this
r^on may be involved, and usually is, in a general attack of articular

187

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188 INTBBNATIONAIi OUNIOS

rheumatism; or, again, Neisserian infection may rarely visit its try-
ing afflictions upon some portion of the foot; or, yet again, gout may
follow its classic form and attack the joints of the great or other toes ;
but the broad fact remains that each of these conditions is accom-
panied by fever and other clear-cut clinical symptoms, and in no way
negatives the axiom that the so-called rheumatism of the foot is not
rheumatism at all but something else. Let us see what that something
else may be.

Flat-foot — ^By far the most important source of foot pain is due
to fiat-foot, especially that form which is known as static fiat-foot,
or the tarsalgia of adolescence (J^ static '' because it is primarily due
to improper balancing of the foot, and ^' adolescence '' because it gen-
erally develops during or soon after puberty). Allied conditions, sudi
as congenital, rhachitic, paralytic, or traumatic flat-foot, may be
passed over in this connection with the simple statement that they
involve problems of varying difficulty which properly belong well
within the domain of the expert orthopedist Static flat-foot, on the
contrary, especially in its early and curable stages^ is common enough
to merit the liveliest interest of every well-trained physician*

Let us glance for a moment at the mechanism involved before
taking up the clinical phases. Functionally the foot consists of a
supporting arch with the body weight resting upon its apex or key-
stone, the astragalus. Inasmuch as the osseous elements making up
this arch are not solid but are movable on each other, and serve to
form an arch only in certain definite positions, another factor must
be considered: that of the ligaments binding the variouja( bones to-
gether. These latter structures, as a matter of fact, form the main
resistance in preventing the arch from sinking. It is therefore clear
that the int^rity of an arch so constituted depends upon two factors,
— the absolute strength of the ligaments, and the incompressibility of
the bones. As a subsidiary factor, the calf muscles acting indirectiy
may be mentioned as contributing to a certain extent to the tensile
strength of the arch, but not so much as was formerly supposed.

When the weight of the body comes upon the foot the mid-line of
the arch neither corresponds to the inner nor to the outer border of
the foot, but quite closely follows its longitudinal axis. In front it
is supported by the head of the third metatarsal and bdiind by the
OS caJcis, while curving between are the third metatarsal, the external

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SOME PAINFUL CONDITIONS OF THE FOOT 189

cuneiform, the cuboid, and the astragalus. The weakest point along
this line is the joint between the cuneiform and the cuboid, for the
reason that it deviates about forty-five d^rees from the curved plane
of the arch instead of being perpendicular to it. The side strain
which results thereby does not fall on this joint alone, but is trans-
mitted and resisted by the astragalus, the scaphoid, and the calcaneus,
and through them by the other tarsal elements. The anterior trans-
verse arch, formed by the heads and foreparts of the metatarsals
bound together by the strong transverse ligaments, is another impor-
tant element of weight support, but the part it plaiys in flat-foot is
greatly overshadowed by that of the longitudinal arch.

Now, in a normal foot of solid bonefif, unyielding ligaments^ and
muscles of good tone there is no tendency whatsoever toward valgus
deformity, but just as soon as it becomes tired to the point of exhaus-
tion there will invariably be seen some d^ree of the eversion which
always suggests flat-foot The thoroughly foot-tired man stands with
knees slightly flexed, feet separated, and toes turned out With such
a posture the weight invariably comes upon the inner side of the
foot, and the foot in time becomes more and more everted and ab-
ducted. The effect of this, if long continued, is to stretch more and
more the supporting ligaments and finally to cause material altera-
tions, even to the extent of changing the shape of the bones.

The anatomical explanation of this phenomenon is very simple
and points directly to the well-known fact that flat-foot in its be-
ginning is merely an exaggeration of a perfectly normal motion of
the bones of the foot The weight of the body aS it comes upon the
astragalus presses it downward and forward upon the calcaneum and
at the same time rotates it inward about the oblique axis of the joint
between thede two bones. Excessive rotation of the astragalus at the
calcaneo-astragaJoid juncture invariably characterizes temporary, in-
cipient, or permanent flat-foot Inasmuch as the astragalus is quite
firmly fixed at the ankle, the effects of excessive rotation are mani-
fested in deviation and eversion of the more mobile foot As the
condition advances all the bones of the tarsus become altered in
position and frequently in shape through the transmission of stress
along abnormal lines, the ligaments are stretched, thickened, and
twisted from the same cause, until finally there develops a distinct
pathology with demonstrable changes in the hard and soft parts.

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190 INTEENATIONAI. OLIKICB

Certain fundamentals may be pointed out with reference to the
caiisation. As has been just stated, flat-foot in its earlier stages
merely represents over-emphasized fatigue, without any pathology
at first, and is entirely remediable. It occurs, as a rule, between the
fifteenth and twentieth years, although it may develop in later life in
soft-muscled individuals, especially women, who have suddenly grown
obese. It is commonly seen in those persons who are obliged to walk
or stand for long periods, such as shop-girls, textile workers, porters,
barbers, errand boys, servants, etc Often I have observed it in
trained nurses during, or shortly after, their probationary period,
with the attendant misfortune that their further training had to be
foregone. Hard work involving continued standing in any young in-
dividual who has grown rapidly and whose muscles are weak pr^
disposes toward flat-foot But over and above these factors in im-
portance, at least in my estimation, is the prime factor of faulty
habitual posture in walking and standing. There is but little doubt
that the improper weighting of the foot is more important than tlie
overweighting in the etiology. To " toe out " involves an abnormal
rotation of the astragalus inward in order to extend the foot, and it is
well within the experience of every pedestrian that walking with the
feet in this position quickly causes exhaustion; exhaustion in turn
tends toward inward sinking of the arch ; and the signs of long-con-
tinued or frequently recurring exhaustion and of banning flat-foot
are precisely identical. In a way the whole situation may be con-
sidered as a vicious circle; ue., a bad postural habit leads to exhaus-
tion, exhaustion leads to flat-foot, flat-foot fixes and renders perma-
nent the bad posture. In light of this fact, could anything be shorter
sighted than the common parental insistence that growing children
should learn to stand and walk with the feet in what is popularly
known as graceful attitudes ?

The symptomatology of flat-foot in its earlier stages may be
summed up in two words : f (digue, pain. Both of these are generally
seen before any distinct deformity can be made out, and, as a matter
of fact, the pain is less pronounced, as a rule, when the altered shape
of the foot has become clearly demonstrable. Both are increased by
long standing or walking. Sometimes the pain may occur acutely
after a particularly excessive use of the foot, and in these days of
almost universal dancing the significance of sudden foot pain must

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SOME PAINFUL CONDITIONS OF THE FOOT 191

not be overlooked in this relation. With the pain are seen definite
areas of tendemeser^ and here it is that a careful examination of the
foot becomes so essential. These point of tenderness are elicited by
pressure over the tuberosity of the scaphoid, the head of the
astragalus, and the juncture of the latter bone with the calcaneum.
Frequently the entire under surface of the heel is painfuL Much
lesis often tenderness may be found about the metatarsophalangeal
joints, on the dorsum of the foot, or about the external malleolus.
With all of this pain and tenderness the plantar arch may yet appear
normal, but there is always present that excessive eversion of the foot
which has already been emphasized. In manipulating the foot the
passive forced movements of inversion or eversion always augment
the pain, but the movements are otherwise normal in range.

In addition, patients often complain of cramps in the calf muscles
or those of the foot, sometimes occurring at night while at rest^ or
sometimes while walking, but in either instance followed by some
increased stiffness and lameness. When standing they will shift the
weight frequently from one foot to the other. In some extreme cases
where the foot is very painful the muscles are almost spasmodically
tense, the foot is held firmly in abduction and eversion, and voluntary
flexion and extension are decidedly limited. Xow and then there
will be found some swelling of the ankle, and it is probable that on
this slender peg the erroneous diagnosis of rheumatism hangs.

With your permission I shall omit all reference to flat-foot in its
later or final stages, the true talipes valgus, a subject of absorbing
interest but hardly germane to this paper. I would merely remind
you in passing, however, that n^lect of flat-foot in its early curable
phases may, and generally does, lead to the more serious, ineradicable,
pathologic state with its attendant disfigurement, mental and physical
distress, and lowered economic eflBciency.

In considering the treatment of flat-foot too much emphasis can-
not be placed on prophylaxis. We have seen how fatigue plays its
part, how faulty posture is an element of great importance, how
individuals of a certain type and at a certain particular age are
affected, and how those who are engaged in certain occupations are
subject to it In a social organization as complex as ours it is never
possible to order things quite to our liking, but it is still practicable,
and our sacred duty demands it, that we should advise our patients

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192 INTERNATIONAL CLINICS

in definite terms how to avoid the accident of flat-foot so far as
possible. Occupation i% of course, the most difficult problem to settla
Public opinion has already effected some reforms in forcing employers
to provide means by which their employees may adequately rest the
feet by sitting down from time to time, notably the conditions under
which shop-girls work have been improved, but much is yet to be done
in other. lines. Change of occupation is sometimes required in the
individual case. It is most unfortunate that the matter of faulty
posture is one to which little attention is given, and yet during the
formative period of life, when flat-foot is so apt to appear, the lesson
of correct standing and walking is not likely to be thrown away. To
teach growing boys or girls to stand with their feet side by side well
under them and to walk with the foot in the axis of the limb, strai^t
heel and toe, as it were^ may establish a sound postural habit which
will confer iimntmity from at least this type of foot trouble through-
out life. The parents of rapidly-growing children should be in-
structed in the significance of foot pain and the importance of avoid-
ing foot fatigue, and not lulled into a sense of false security by any
old woman's tale of "growing pains." There is no question that
defective local circulation also plays an important part in the pro-
duction of flat-foot, as well as nearly all the other painful foot con-
ditions, and, therefore, the practice of wearing circular garters is
strongly to be deprecated.

When it happens, however, that the first opportunity to advise
comes in the presence of a definite static flat-foot in its early stages
your efforts should be direct, vigorous, and comprehensive. Under no
circumstances resort to a fallen arch plate until you are quite sure
that all other measures have failed. Treatment should contemplate
rest, exercise, massage, hydrotherapy, and proper footwear. The pa-
tient should be taught to stand or walk with the toes turned in, to
often rise on his toes in this position, to assume a squatting position
and to rise from it while resting on the heels with the feet strongly
inverted — all in order to strengthen the muscles and improve the
circulation. Daily massage, even if self-administered, is of the
greatest possible benefit, especially if it is combined with the frequent
circulatory stimulus of hot- followed by cold-water douches. The
patient should be instructed to seize with avidity and premeditation
every opportunity to rest the exhausted structures by sitting or lying

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SOME PAINFUL CONDITIONS OF THE FOOT 193

down, and to persist in these and other measures long after all symp-
toms have disappeared. If the occupational factor seems the dominant
one, and the circumstances cannot be modified, then a change may be
necessary to less arduous and exacting working conditions. Above
all, do not forget that the complete rest afforded by a few days in bed
may prove the decisive measure in the cure of a doubtful case.

The problem of proper footwear is one which permits of divergent
views. My own preference is for a shoe which can readily be obtained
in the larger shops, or can be easily made to direction by any good
shoemaker. It has a broad, firm sole, soft upper, and two or more
modifications of the heel. The first modification is a projection for-
ward for about an inch of the inner third, the purpose of which is to
supply a support to the weakened arch. The second change that I
advocate is an approximate alteration of the height of the heel to allow
for the contraction of the tendo achillis, which is so common in these
cases. It is well to guard the heel against wearing down on the inner
edge by having inlaid in the leather one or two metal Vs. Finally, it
is sometimes advisable to have the inner edge of the heel a trifle higher
than the outer. This should not be over a quarter of an inch, and
usually an eighth will do.

In my opinion, the use of metal supports is always a mistake in
the earlier stages, and should not be considered until you are willing
to confess defeat If, and when, a plate becomes necessary, bear in
mind that most of those which are sold are worse than useless. The
Whitman plate, however, is not in this category and is theoretically
and practically sound. It is made of sheet steel or aluminum-bronze,
extends from the heel to the base of the great toe and from one side to
the other, has a curve corresponding to the normal arch, and not only
has a full inner curved portion but also a flange upturned on the outer
side to prevent the foot from slipping outward. In the individual
who cannot be cured such a plate may be worn permanently with
much relief of the accompanying dis^mfort and disability.

In the foregoing I have purposely not sp(^en of the extremely
acute type of flat-foot, nor of the severe chronic type, nor of the
various operative procedures which may be considered in connection
with either, but have confined my remarks to the average case which
is so apt to come under your notice and which will expect from you
relief and cure.

Vol. II. Ser. 26—13

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194r INTERNATIONAL CLINICS

Metatarsalgicu — In 1876 an eminent Philadelphia surgeon of a
former generation, the late Dr. Thomas George Morton, first de-
scribed a painful condition of the foot which has since been known
as Morton's toe or metatarsalgia. An early association with him, and
later with his gifted son, Dr. Thomas S. K. Morton, enabled me to
become thoroughly conversant with the clinical phenomena of this m-
teresting disease, and since then I have had the opportunity of study-
ing and operating upon it in a considerable number of my own
patients.

It may be described as a painful neuralgic condition affecting
usually the neighborhood of the fourth metatarsophalangeal joint,
though rarely it may involve the third or second. Gtenerally slight
trauma, such as stepping on a sharp stone or a misstep of some sort,
seems to play a part in its incidence. In sharp contrast to flat-foot, it
is practically never seen before the twenty-fifth year. It is much
more common in women than in men, doubtless due to the feminine
habit of wearing tighter shoes with higher heels, which not only
confines the forefoot, but pitches it forward. In severity it varies
from a transitory sharp twinge to an affliction so marked as to cause
continuous suffering, with an entire inability to wear a shoe. A
typical history details that the patient, usually a woman, while walk-
ing feels a sensation as though something had slipped or moved in
the anterior foot, and at once is seized with a paroxysm of duch
agonizing pain that she is obliged to stop where she is, or, if in the
street, to seek refuge in the nearest shop, in order to obtain relief by
removing the ^oe, extending the toes, and rubbing the foot Presently
the pain disappears and she is able to go on, either with or without
some slight resulting lameness.

Morton ascribed metatarsalgia to a pinching of the digital branches
of the external plantar nerve between the somewhat recessed head
of the fourth metatarsal and the neck of the adjacent third metatarsal
He further held that tight and short shoes were directly responsible
for its occurrence. Since the appearance of his papers, however, much
attention has been given by Whitman, Goldthwait, and others to the
whole subject of the anterior metatarsal arch in relation to various
other painful conditions, and it is now an open question if Morton's
neuralgia should be considered apart from these. A brief reference
to this arch may be illuminating in connection with the relation of

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SOME PAINFUL CONDITIONS OF THE FOOT 195

weakness of it to painful symptoms. In the normal foot the second
and third metatarsal heads are on a higher plane than the first, fourth,
or fifth, but when supporting the body weight they become level
with the others. In other words, there alternates normally a state of
arch and no arch, depending on the absence or presence of weight.
The highest point when at rest, the head of the third metatarsal, be-
comes the lowest when standing or walking and is the main anterior
support of the foot, as I have already pointed out. This point of
support is balanced laterally by the muscles about the first and fifth
metatarsals and by the toes in generaL There is also a high d^ree
of natural resiliency given by the transverse ligaments to the whole
arch.

Now when the normal elasticity of the arch is lost for any reason
and the bones become persistently depressed, or indeed permanently
fixed in this abnormal position, there ensued an active predisposition
to pain. This arises from two sources, — pressure from below, and
pressure from the sides. As to the former, I shall have a few remarks
to make when I discuss painful callus, but just now let us note the
effect of undue lateral pressure. It is probable that if the factor of
shoes did not enter into the question there would be slight, if any, dis-
comfort from such pressure on a depressed anterior arch, but the
wearing of shoes supplies the extraneous feature which is necessary.
When the heads of the metatarsals are permanently depressed they
present to their fellows a surface totally unused to pressure, and
hence are apt to become painful through slight changes in bone or
periosteum incidental to chronic irritation. Only recently, in exam-
ining a radiograph taken of a patient suffering from metatarsalgia, I
saw evidences of slight ostitis on the inner side of the fourth meta-
tarsal head. Undoubtedly such changes may occur elsewhere at any
point on the arch. It must be remembered that the brunt of tight
shoes falls directly on the outer supports of the foot, the first and
fifth metatarsals^ and particularly on the latter, because the shape
of the shoe raises it and consequently jams the head of the fourth
downward into such a position as to pinch the nerve. An explanation
such as this may readily account for some of the cased of metatar-
salgia. It is perplexing, however, to find in other cases no evidence
at all of a depressed anterior arch. In these it must happen that the
arch depression occurs only when the shoe is on and disappears

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196 IKTEENATIONAL CLINICS

when the shoe is removed. This theory iu borne out by the well-
known desire of the patient to remove the shoe when the attack is on,
and also by the complaint that the attack started with a sensation
as though something slipped. Instinctively the patient sieems to act
as though the reduction of a misplaced bone was the object of her
efforts.

The actual diagnosis of metatarsalgia, aside from the history, is
easily made by squeezing the foot with the hand while the toes are
pressed down. The characteristic pain is produced either by this
manoeuvre alone or by pressing on the fourth metatarsal joint

Treatment. — In the mild case attention to footwear seems suffi-
cient to obtain relief. The use of a broad-soled, rigid eihoe with a
low heel is quite enough to accomplish a cure in many cases. In Ihe
more severe form, additional efforts must be made to give support to
the depressed anterior arch, and I know of nothing quite so satis-
factory as a carefully moulded leather insole. Personally I have
never seen any benefit arise from the use of a band of adhesive plaster
about the forefoot, as recommended by some i^rgeons. For very
severe metatarsalgia, in my experience, nothing will do but a formal
excision of the offending metatarsal head. Formerly I did a simple
excision and left the toe alone, but now I remove both the joint and
the corresponding toe, because if the latter is retained it becomes in
time only a hammer-toe and causes further annoyance.

Painful Callus. — Callus or corns represent a large portion of tiie
net income from too tight or otherwise ill-fitting shoes. Most people
seem to prefer the occasional discomfort and annoyance of tiiem to
changing settled habits in footwear. Such benign aberrants prac-
tically never seek advice from us. There is, however, one form of
painful callus which merits some attention in passing. I refer to the
callus whidi is seen on the sole of the fore part of the foot It is
callus which does not lend itself in the slightest to the corn-paring,
corn-plaster methods of treatment of the amateur, and for that reason
is apt to come to our notice. Examination of a foot so affected will
show that it is always beneath the head of the third metatarsal, and
further investigation will develop the fact that there is always present
a depressed anterior arch. Here we have the painful phenomena
arising from a structural defect within the foot, and all measures to
obtain relief are futile which ignore thid fact The proper treatm^it

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SOME PAINFUL CONDITIONS OF THE FOOT 197

is obyious, — Hie support of the anterior arch by some means such as
a properly-fitting and padded insole. Pain disappears almost at once
and the callus soon goes.

Tarsalgia. — ^Dr. William J. Merrill has described recently a form
of static painful foot, which is apparently quite common, under the
name of tarsalgia, and in conjunction with Dr. P. G. Skillem, Jr.,
has carefully studied the pathologic anatomy. Clinically it is char-
acterized by lancinating pain in the neighborhood of the mediotarsal
joint and pain in the posterior tibial muscle. Frequently pain and
tenderness occur in the long flexor muscles of the toes, and occasionally
slight pain is noted in the anterior tibial. Fatigue and spasm are also
dominant features. In some respects the symptoms accompanying
flat-foot are similar, but with real tarsalgia there are such radical
differences that a differential diagnosis is easily mada The main
points are that the arch instead of being depressed is increased, and
instead of a valgus deformity there is a tendency to varus.

Merrill's explanation of this condition is direct and logical. He
holds that as the result of disturbed muscle balance, due to many
causes, the anterior tibial muscle loses power and tone, and hence the
posterior tibial and toe flexors are stimulated to greater action to
compensate for this deficiency. Under continued stimulation there
must result either muscle relaxation or spasm. If spasm occurs the
posterior tibial tends to uptilt the os calcis and to create in varying
d^rees an upward subluxation of the astragaloscaf^oid and the
calcaneocuboid joints. Hence we see the reason for the higher arch
and for the varus deformity.

For treatment he advises rest, massage, and exercises. If severe,
he uses a plaster-of-Paris case to secure the prolonged and complete
rest which is needed; in mild cases massage of the leg muscles and
the foot, adapted exercises, and proper footwear are usually adequate
to accomplish a cure.

Painful Heel. — ^For many years I have been accustomed to seeing
in my clinic now and then a patient suffering from an extremely
painful, acute condition of the heel, which, for want of a better name,
I have called '^ motorman's heel." Since it has been so well described
by Shaffer, I have called it Shaffer's heel, but it still needs a good
descriptive title and further elucidation of its pathology.

Clinically it is characterized by severe pain accompanied by

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198 INTEBNATIONAL CLINICS

tendernees at and about the posterior insertion of the plantar fascia
into the os calcis. In my own experience it is always due to oft-
repeated trauma, and I have seen it mostly in motormen, caused by
stamping on the bell plunger. Occasionally policemen and workers
who use a treadle have come under my notice. However, I am told
that it affects acrobats, supposedly as the result of sudden violent
effort and not of direct injury. Aside from the pain and tenderness,
with the attendant lameness, there are no physical signs. It is easily
differentiated from the plantar pain so often seen in flat-foot by the
greater d^ree of intensity of pain and tenderness, by the very definite
localization of this pain, by the absence of flat-foot, and by the occupa-
tional history. The lesion in the great majority of cases is probably
an inflammation of the bursa beneath the calcaneum, but there are
others in which the subsequent appearance of exostoses would suggest
local periostitis, or even perdiance near^fracture, as an adequate
explanation for the symptoms.

The treatment is very simple and generally is entirely satis-
factory, — abatement of the vulnerating cause, the wearing of a hair
or wool insole, and the use of rubber heels.

Before I bring this paper to a close I want to call your attention
to two interesting, though rather rare, painful conditions which affect
the back of the heel : achillodynia and retrocalcaneal bursitis.

The former was first described some years ago by Albert, the
Viennese surgeon, as a painful bilateral affection occurring in the
tendo achillis. The pain appears after walking and is relieved by
resting, but the symmetrical swelling permanently remains. The
important symptoms are given by Eshner as follows : " The circum-
scribed character and symmetry of involvement, the thickening above
the heels, the absence of inflammatory symptoms, the presence of
pain only after walking, and the rapid subsidence of the first attack.''
Constitutional causes and trauma are absent^ and, aa^a matter of
f act> the etiology is entirely unknown.

In sharp contrast to this affection is retrocalcaneal bursitis, which
consists of a unilateral inflammation of the bursa between the tendo
achillis and the tubercle of the os calcis. It usually results inxa
direct injury or severe muscular action, but not infrequently it may
be due to hsematogenous infections, such as sepsis, syphilis, gonor-
rhoea, tuberculosis or rheumatism. Here, as elsewhere, ill-fitting

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SOME PAINFUL CONDITIONS OF THE FOOT 199

shoes may plaj their part in the causation. Local tenderness over
the insertion of the tendo achillis^ swelling and later broadening of
the heel from calcaneal exostoses, together with lameness and tender-
ness of the calf muscles, are the cardinal symptoms. The treatment
consists of rest, with massage and counterirritation in the later stages.
If the bursa is infected it should be opened and drained, and if
exostoses remain permanently they should be removed. In the pres-
ence of tuberculosis the whole bursa must be carefully excised.

There are many other topics pertaining to the foot which are
deserving of careful consideration, but I realize that I must not let
my pedal enthusiasm, as I may call it, try your patience too far, or
the intended effect is lost If I have succeeded at all in arousing in
you an interest in this direction, and especially in some of those
affections which are so often overlooked, the full and only purpose
of this paper has been accomplished.

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Surgery

THE ORTHOPiEDIC CLINIC OF FRED H. ALBEE AT THE
NEW YORK POST-GRADUATE MEDICAL SCHOOL

BY P. G. SKILLERN, JR^ M.D.

Philadelphia

Whbn one turns his attention toward the epodb-making bone-
work of Dr. Fred H. Albee it seems but natural to learn that it is the
result of the knowledge of tree-grafting obtained in boyhood days,
combined with a mechanical bent of mind. Added to this are the
years of anatomical and surgical training as assistant of that master
surgeon, the late Dr. Maurice H, Richardson, and the later oppor-
tunities afforded by serving for a long time as rontgenologist.

The Orthopeedic Clinic is held four days a week, at two o'clocA.
On Monday there is a lantern-slide demonstration, in which Dr. Albee
diekmsses the mechanics, the pathology, and the treatment The
slides, made from skiagrams, photo- and microphotographs, diagrams,
and drawings, include two hundred and fifty on bone-graft work
alone. On Tuesday and Thursday there is an operative clinic, in
which operative technic is demonstrated. Later on Tuesday after^
noon there is a ward-visit for study of postoperative conditioner re-
cently operated upon: this is preceded by a half -hour in the dis-
pensary amphitheatre for cases operated upon months or years back.
On Saturday there is a diagnostic clinic for dispensary cases.

In addition to the Post-Graduate, Dr. Albee also operates at the
Roosevelt Hospital, the Blythedale Home for Crippled Children at
Hawthorne, the Plainfield Hospital, and the University of Vermont

The following account of his work has been culled from witnessing
operations at the first four institutions, and from protracted inteiv
views, in which the ground was thoroughly " hashed " over during
many pleasant hours. There will first be discussed the subjects in
which Dr. Albee is most interested; namely, osteoplasty of the spine
for Pott's disease, and the inlay bone-graft in the treatment of f rao-
200

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THE OBTHOP.EDIC CLINIC OF FBED H. ALBEE 201

tures; next^ the description of a few operations; and, finally, a
systematic discussion of the entire field of his work from the head
to the foot

OSTEOPLASTY OF THE SPINE FOE POTt's DISEASE (aLBEE^S OPEBATION)

If one turned back over the files of the Journal of the American
Medical Associalion to September 9, 1911, vol. Ivii, pp. 885 and 886,
he will see the first report of this operation, which is now known and
performed throughout the world. It is entitled: " Transplantation
of a Portion of the Tibia into the Spine for Pott's Disease: A Pre-
liminary Report" In the opening sentence he writes: " I was in-
duced to undertake this work on the spine on account of the excellent
operative results obtained in tuberculosis of joints elsewhere in the
body, where bony union with its perfect support and immobilization
has caused the tuberculous process to disappear so rapidly, although
only a fractional part of the tuberculous tissues was removed." In
principle the operation is based not only upon this splint, but also
leverage, action. In the latter the fulcra are the lateral processes;
the long arms, the spinous processes ; and the short arms, the vertebral
bodies. In this way fixation of the spinous processes prevents tele-
scoping of the bodies, and the nearer the graft is placed to the tips of
the spinous processes the greater the leverage. This is most impor-
tant, as teleeicoping of the vertebral bodies, due to superincumbent
weight, muscular spasm, and respiratory action, is a gross factor in
prolonging the convalescence of Pott's disease. Furthermore, because
of the dorsal projection of the spinous processes, the focus of disease
(in the bodies) is not entered, so that immediate bony union with
primary union of soft tissues can be expected. Therefore the bone-
graft is the simplest and most trustworthy method of actually im-
mobilizing the diseased vertebrae, which is impossible by external
means. The latter prevent expansion of the lungs — a serious handi-
cap in the cure of tuberculosis.

Technic of Osteoplasty of Spine. — With the patient in the ventral
position, a curved incision is made through the skin and subcutaneous
tissue only (Fig. 1). The advantage of the curve is that the scar
does not rest directly over the spines, as occurred in the early cases,
when the straight incision was used. The flap is dissected from the
deep fascia and retracted to the opposite side, exposing the tips of

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202

INTBBNATIONAL CLINICS

the spinous processes and the supraspinous ligaments (Fig. 2). With
a stout scalpel the periosteum on the tips and the supraspinous liga-
ments are split in the median line. Continuing, the interspinous
ligaments are split into approximately equal parts to a depth of
about one-half inch, without disturbing their attachments to the
spinous processes. Hemorrhage is slight, and contrasts with that
encountered in laminectomy, where the muscles are separated from

Fxa. 1.

Osteoplasty of spiBo. Curved incision through skin and subcutaneous tissue.

the spines. Next, with Dr. Albee's special broad chisel, which spans
more than one spine at a time and thus prevents inadvertent slipping
into the vertebral canal, the spinous processes are split longitudinally
into equal parts for the same depth as the ligaments, the aim being
to produce greenstick fractures on one and the same side (Fig. 2).
This completed, there results an osseo-aponeurotic gutter ready for
the reception of the tibial transplant (Fig. 3). The characteristics

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THE OETHOPiEDIO CLINIC OF FEED H. ALBEE

203

of this gutter are these : it is V-shaped, with the apex of the angle
anteriorly at the bases of the spinous processes. The sides of the
angle are formed by the halves of the rough, split spinous processes,
which are bound together by the interspinous and the supraspinous
ligaments. Externally the attachments of the vertebral aponeurosis
and spinal muscles to these structures remain undisturbed, preserving
the natural supports of the spine. The gutter is measured by a

FiQ. 2.

Osteoplasty of spine. Flap reflected, exposing tips of spines and supraspinous ligaments. With
tlie apeeial, broad ohisel, greenstiok fractures of the spinous processes are produced on one and the
same side.

flexible probe for contour and length : calipers may be used for the
latter. A hot saline pack is now placed in the wound, pending the
removal of the transplant from the tibia.

Removal of Transplant from Tibia. — With the patient still in the
ventral position, the leg is flexed on the thigh and a long incision is
made to the inner side of the crest of the tibia, preventing the scar
forming over the crest. The skin and subcutaneous tissues are dis-

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204r INTBBNATIONAL CLINICS

sected back so as to expose the antero-intemal surface of the tibia.
If the transplant is to be straight, as in the absence of marked kypho-
sis^ its length is measured on this surface of the tibia by the calipers^
and with the motor-saw that portion adjacent to and including the
crest is removed. In length the transplant must span, in addition to
the diseased vertebrae, two healthy ones above and two below if in the
thoracic region, and one each if in the lumbar region. In breadth it
varies from one-fourth to five-eighths inch. Its thickness is that of
the tibia between periosteum and medullary cavity, which varies,
according to the size of the bone, from three-sixteenths to three-
eighths inch. When the kyphosis is so marked that it will not take a-
straight splint, its shape is outlined on the periosteum with a scalpel,
according to the pattern obtained from the spinal gutter by the bent
probe, and the single saw follows the cuts in the periosteum (Fig. 4).
This splint is angulated rather than curved, for if curved the saw will
bind. In cases with extreme kyphosis the transplant is cut straight,
and then bent by the following method, after which it is inserted into
the spine with its breadth in a frontal rather than sagittal plana
After removal it is held with forceps by an assistant, with the mar-
row side up. With the single saw, the depth of the blade of which
has been graduated by a metal guard, cross cuts are made whose
depth corresponds to from one-half to two-thirds of the thickness from
the marrow side to the periosteum, and from one-half to three-eighths
inch apart, along the entire length of the splint, which varies from
four to seven and one-half inches. The periosteum is then incised in
many places. A hot saline pack is now placed in the wound on the leg.
Insertion of Transplant into the Spine. — ^Upon removing the pack
from the spinal wound it will be found that active bleeding has
ceased. The residual blood, serum, and plasma furnish a good
culture medium for the bone-graft The straight graft is inserted
into the gutter in such a manner that the marrow surface contacts
with the unbroken halves of the spinous processes and their connecting
interspinous ligaments. One narrow edge is anterior and one pos-
terior, and the periosteum rests against the broken halves of the
spinous processes, with their connecting interspinous ligaments. It
will now be found that by pressing the halved spinous processes upon
the graft with the fingers a very secure grip is obtained by the mere
approximation of the rough bone-surfaces. Beginning at the centre

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Fia.

Osteoplasty of spine. Ossoo-aponeurotic gutter ready for insertion of tibial transplant.

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THE OBTHOPJEDIC CLINIC OF FBBD H. ALBEE 205

of the graft, interrupted sutures of heavy kangaroo-tendon are passed
throu^ the supraspinous and the posterior edges of the halved inter-
spinous ligaments, near the tips of the spinous processes. When a
graft bent by notching is used, since its breadth id placed in the
frontal plane, it can be secured better by stitching the vertebral
aponeurosis over it, and where there is much tension this aponeurosis
may be cut laterally, relieving the tension (Fig. 5). A dozen sutures
may be necessary. Before tying the last ones, the posterior comers
of the graft-ends are nibbled down with the rongeurs, to prevent pres-
sure-necrosis of the overlying skin. The bone^ships thereby obtained
are placed about each end of the graft, to act as multiple osteogenetic
foci (Fig. 6, B). The ends of the graft are then drawn down by tying
the sutures over them. The skin edges are approximated without
drainage. The dressing consists of a large, gauze pad, retained by
adhesive plaster. The wound in the leg is closed by apposing the skin-
margins. The gutter in the tibia heals within three months, accord-
ing to Wolffs law.

Postoperative Treatment. — The patient is placed upon a fracture-
bed in the recumbent position. A child may be prevented from toss-
ing about by pinning a towel placed around it to the bed. Best in
bed id maintained for from six to eight weeks, althou^ there is bony
union of the graft within four weeks. At the end of the above period
the patient is allowed to walk about gradually. Plaster jackets and
braces are unnecessary, as they interfere with respiration as well as
with the function of the graft, and exert undue pressure upon the
latter. All patients receive from the b^inning the treatment for
tuberculosis in general

After operation the pain disappears immediately, due to the ex-
cellent fixation of the spine. A little girl seen at the Blythedale
Home, upon whom this operation had been performed twenty months
previously, did a ballet in a Christmas celebration. A patient with
upper thoracic Pott's came into the home with a plaster jacket and
jury-mast which another surgeon had applied after Dr. Albee's opera-
tion because he did not trust the graft. Dr. Albee removed these
apparatuses, and the child has done well since. This has occurred in
three cases.

Indications for the Operation. — ^In any case where pain or
muscle-spasm exists, and for the prevention and correction of increas-

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206 INTBENATIONAI. OLINICS

ing deformity. Here Dr. Albee made a special plea to operate upon
cases early, before deformity has occurred: then there will not be a
hunchback anywhere in the world. It is also urgent in late cases,
however, that are complicated by psoas spasm, cold abscess, or
paraplegia.

A little patient was seen at the Blythedale Home who had paraplegia from
Pott's disease in the upper thoracic r^ion, and who had been operated up<Mi
March 1, 1913. Six months later the paraplegia had disappeared, and the child
now walks without difficulty.

Cold abscesses about diseased vertebrse are revealed in the skia-
grams. A pool of tuberculous pus, however, does not interfere with
the vitality of the bone-graft. Dr. Albee never opens and drains a
cold abscess, because of the dangers of secondary infection, septic
absorption, and amyloid viscera. He stated that it does the pati^it
harm the surgeon can never retrieve. Some severe double psoas
abscesses have healed spontaneously in from six to sixteen we^
after the spinal operation. Once opened, a sinus may result, and be
kept open by a sequestrum, or persistent infection of soft tissues.

At the Roosevelt Hospital the following case, which had been referred to
Dr. Albee by Dr. Peck, was seen: Male, Italian, aged twenty-six years, was ad-
mitted for a large abscess in right iliac fossa and another in left iliac fossa. There
was a small kyphosis at the first lumbar vertebra. Skiagram showed destruction of
two vertebral bodies in this locality. At the operation, in February, 1913, a bone-
graft was inserted over four vertebrae. The patient left the hospital at the end of
five weeks. Two wedcs later, or seven weeks after operation, he went to work in a
brickyard. After working for six months he took another job aa night fireman,
shovelling coal into a stationary boiler. The abscesses were never touched.
After eight months a slight thickening was palpable in the right iliac fossa, but
nothing was to be felt in the left iliac fossa. He gained from fifteen to twenty
pounds and considered himself well.

Surely the following case ought to convince sceptics, especially
those who have wilfully remained such, of the efficiency of the
operation :

Another surgeon had inserted a bone-graft into a child's spine, and had even
applied a plaster jacket, but still the patient showed lack of spinal support by
resting the chin on the table and the hands on the knees ; by night cries, and by re-
fusing to play with other children. Skiagram showed that graft was entirely above
the site of kyphosis, wnd that it was half the length it should he. At the second
operation Dr. Albee found the graft to be of excellent shape, and that it had pro-
liferated. He took off one side of the graft and turned it down into the spinous
processes below. Since the graft was lengthened the control of the symptoms hat
been perfect.

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Fig. 5.

Osteoplasty of spine. The praft in its bed. The vertebral aponeurosis is being sutured over it.
Lateral cuts to relieve tension are shown just below the retractors. B shows bone-chipe placed about
end of graft. 4._

Digitized by OOOQ IC

Fia, 6.

Osteoplasty of spine. Skiagram of vertebral column involved in Pott'p disease at first lumbar
vertebra. Tibial graft in position. Lateral view.

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THB OBTHOPiEDIO OLINIC OF FBED H. ALBBB 207

Mechanical treatment means many years before bony union
oocurs, while with operation this union takes place within four weeks,
if well contacted.

In the visits to the various institutions mentioned above there
were seen under Dr. Albee's care twenty-three cases of Pott's disease.
Of these, eighteen involved the thoracic, one the oervicothoracic,
three the lumbar, and one the thoracicolumbar r^on. The mode of
onset in several cases was interesting.

One patient, a Russian, machinist, aged thirty-five years, had complained for
four years of sharp and dull pains in the middle of the back, radiating to left side
of abdomm. He had heen treated elsewhere for pleurisy and muMcular rheumatism.
Lateral bending was limited. The upper thoracic region was involved. The sensi-
tiveness left at the operating table, and there has been complete reUef of pain.

Another patient, aged seventeen years, noticed six months previously that he
could not use his back so freely as formerly, and that a dull pain had arisen. The
kyphosis in the back was constantly increasing. The thoracic region was involved.

A male, aged sixteen years, experienced seventeen months previously the slow
onset of gradually-increasing kyphosis and constant pain, night and day. Any
jar, riding in a carriage, etc., caused pain.

A man, aged twenty-four years, worked hard for eight and one-half years in
the lumber business at chopping. Six months later pain began in the back, and
eighteen months after this kyphosis developed. Any jar aggravated pain in back.
After {^ration the pain disappeared.

A brakeman, aged thirty-five years, nine months previously was thrown across
the vestibule of a car, so landing that the back struck against a sharp metal
corner. After this, pain began along the course of the left twelfth rib, for which
latter was resected elsewhere six months ago, but pain continued. Four weeks ago
began to complain of pains in back and a sensation of weakness. A skiagram taken
in the anteroposterior position was negative. Another, taken from an oblique
view, showed a tuberculous focus in the anterior portion of the lower half of the
tenUi thoracic vertebra, left side. A graft was inserted into the spine so as to span,
five vertebrse. The ** rib " pain disappeared after the operation.

This last case emphasizes the importance of taking skiagrams
from several aspects, not only the anteroposterior, but also the
oblique and the lateral. The necessity for this is apparent when one
considers the body of a vertebra, in which tubercle lodges, as a
rounded block of bone.

The cuts (Figs. 6 and 7), obtained from skiagrams taken in the X-ray Depart-
ment of the Post-Graduate Medical School, serve to orientate the graft in situ. The
patient, £, G., female, was operated upon by Dr. Albee on December 16, 1914, for
Pott's disease that involved chiefly the first lumbar vertebra. In the antero-
posterior view (Fig. 7) the graft is seen resting in the split spinous processes of
the eleventh and twelfth thoracic and the first, second, and Uiird lumbar vertebrae.

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208 INTEENATIONAL CLINICS

thus including two healthy ones above and two below the diseased first lumbar.
In the lateral view (Fig. 6) the function of the splint in relation to the sli^t
kyphosis is well shown.

A discussion of the symptoms, diagnosis, pathology, and treat-
ment of Pott's disease by the reporter is to be found in Inter-
NATIONAL Clinics, vol. i, series 24, 1914.

FUBTHEB indications FOB THE SPINAL GRAFT

Fractures. — In certain fresh fractures, and in cases of persistent
nonunion that present pain, disability, and increasing deformity.

Spondylitis Traumatica {KuemmeU's Disease). — This produces
crushing of the vertebral bodies with progressive kyphosis and ulti-
mate cord-compression.

Vertebral Osteo-urthropathy {Charcot's Disease of Spine). —
Syphilitic in origin, the vertebrae are compressed and reduced in
height and enlarged laterally, and the intervertebral disks are thick-
ened and ossified. In this malady pressure symptoms are liable to
arise from the hypertrophic osteitis. If the diagnosis be made early,
immobilize and support, and administer antiluetic remedies.

Paralytic Scoliosis. — In very flexible cases, uncontrollable when
the trunk is in the vertical position, where there are sharp angular
curves, the graft supports the weakened spine and prevents lateral
deviation, due to superincumbent weight and unbalanced muscle pulL
The graft is inserted into the split tips of the transverse processes
on the convex side, including six to eight vertebrae at the greatest
point of curvature. In most cases it is supplemented by a supporting
spinal brace.

Spina Bifida, — ^When the meningocele has been controlled and
there is a large defect in the spine, together with extreme weakness,
as evidenced by lordosis, etc. Here two grafts are inserted, one on
each side of the hiatus, and are fixed in by splitting the stumps of
the neural arches, while the lower ends are received into the split
first segment of the sacrum. The two grafts form an acute angle,
like an inverted V.

Tuberculosis of the Sacro-Uiac Joint. — ^When treated by con-
servative methods the prognosis is most unfavorable, but is better in
children than in adults. The graft is the most reliable, as well as
the easiest way of giving support The uppermost spinous process

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Fio. 7.

Osteoplaaty of spino. Sarnc a» prcrodinR fifture. Anteroposterior view.

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THE OBTHOPiEDIC CLINIO OF FBED H. ALBBB 209

of the sacmm is split horizontally and the posterior surface of the
sacrum denuded of periosteum, scarified, and freshened. The mass
of the ilium is split and the graft driven in. The other end is fixed
by fastening the soft parts over it

Luxation of the Sacro^iac Joint. — ^In severe cases the graft may
be used according to the technic just outlined.

THS INLAT BONB-OBAFT IN THE TBEATMENT OF FBAOTUBBS

Fresh Fractures. — Since here the osteogenetic function of the
fragments is active and only awaits accurate apposition for union
to take place rapidly, the temporary fixation required may, in suit-
able cases, be obtained by the proper application of the Lane plate,
provided that reduction and external fixation could not be attained.

In compound fractures metal, as is broadly recognized, is contra-
indicated, since it favors and maintains infection. Since the graft,
on the other hand, has shown germ-resisting properties in the pres-
ence of tubercle and of attenuated pyogenic infections, then its
reliability and trustworthiness are obvious in compound fractures,
which are either not infected or will become infected. The graft
stays in in toto, or, at the most, a small shell of it comes out

In gunshot and comminuted fractures of long hones the inlay
maintains the length of the limb and prevents amputation.

In a case of gunshot fracture of the humerus seen elsewhere, union by the
metal-plate method resulted in six inches of shortening.

In compound, comminuted fractures the graft is to be put in
inmiediately.

In 230 compound fractures Pringle operated right away. He foimd that (a)
cleaning operation without internal fixation gave ten per cent, of secondary ampu-
tations; and (5) cleaning <^>eration with internal fixation gave two per cent, of
secondary amputations. Pringle therefore recommended internal fixation, but by
metaL He took out fragments of bone^ cleaned them, and put them back, and got
union.

This work confirms the stand taken by Dr. Albee, who accom-
plishes the same thing with the dovetailed inlay.

Ununited Fractures. — In old, imunited fractures a different

problem must be faced. In the ends of the fragments, for as far as

one and one-half inches in some cases, osteogenetic activity is either

markedly diminished or entirely absent As a consequence, there is
Vol. n. Ser. 26—14

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210 INTEBNATIONAL CLINICS

always found marked sclerosis or ebumation. The therapeatic re-
quirements of these pseudo-arthroses are fixation, stimulation of
osteogenesis on the part of the fragments, and an osteoconductive
scaffold that connects the active bone in each fragment back of the
ebumated areas. While the inlay fulfils the whole of these require-
ments, even growing bone on its own part^ yet the Lane plate
furnishes but one, and that is temporary fixation, which is the sole
requirement in fresh fractures. On the other hand, the Lane plate
inhibits callus, favors infection, causes absorption and disintegra-
tion of bone, and gives too perfect fixation^

Bone Versus Metal Appliances. — Last December Dr. Albee stated
that since one year he has not used one grain of metal for internal
fixation purposes.

Instead of the plate, he uses the inlay bone-graft. For metal wire he sub-
Btitutes heavy kangaroo-tendon, which is just as efficient. If pressure be placed upon
metal wire in bone, it very rapidly cuts through. Kangaroo-tendon, being an ani-
mal membrane, does not cut through, and is not absorbed before forty days. Even
later than this, cutting down upon the tendon in a certain case, it was found to be
fully embedded, and pulled out with difficulty. Instead of screws, nails, or spikes,
he fashions pegs f r<mi a piece of bone with the surgical lathe.

Technic of the Inlay Method. — The reporter had the good fortune
of seeing Dr. Albee " inlay " a fractured tibia at the Plainfield Hos-
pital, and of assisting him in a similar case at the Polyclinic Hos-
pital, Philadelphia, on the first of March. The following is a de-
scription of his procedure at that time in these cases (Fig. 7 A) :

After painting the skin with iodine and applying a tourniquet
above the knee, the fracture was exposed by a generous skin incision,
made lateral to the intended site of the inlay. The skin and sub-
cutaneous tissues were retracted. The ends of the fragments were
released, developed, and freshened with chisel and mallet. In the
one case the slight overlapping was reduced without difBculty, while
in the other the sharp and pointed ends were found to be necrotic,
and upon their removal good apposition was obtained. The bone-
graft was outlined on the antero-intemal surface of the tibia by in-
cising the periosteum. It measured four inches in length by one-half
inch in breadth, and was marked out on the proximal fragment, be-
cause of the smaller amount of osteoporosis on that side of the fracture.
Upon the distal fragment an area of the same width, but one-half the
length, was outlined^ With the motor twin circular saw adjusted to

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THS OBTHOP^IO OLINIO OF FBED H. ALBEB 211

the same width, the periosteal incisions were continued through the
bone cortex to the medullary cavity, saline solution being sprayed
upon the revolving saws to prevent the development of excessive heat
from friction, witii its devitalizing effect upon the peripheral bone-
cells. Each segment of bone was released by cutting through its end
with the small single saw. Upon removing these pieces of bone the
medullary cavity was found filled with newly-formed bone. The
fibrous tissue was removed from half the surface of the bone-ends
preparatory to inserting bone-chips. With the motor^drill, holes were
bored in the cortex on either side of the gutter, slanting inward to the
medullary cavity. Two were made through each fragment near its
end, one on each side of the gutter; two others were made through
each fragment one and one-half inches from its end in a similar
manner. Through each pair of holes a heavy strand of kangaroo-
tendon was passed. The four-inch bone-graft, which had been placed
in normal saline solution, was reversed, so that its fractured end
pointed proximally, and was introduced into the gutter in such a
manner that two inches were received into the proximal portion of
the gutter and two inches into the distal portion, the middle of the
bone-graft coinciding with the line of fracture. As it was introduced
each strand of kangaroo-tendon was lifted over it, and upon tying
these the graft was drawn down firmly into its gutter. The smaller,
two-inch piece from the distal fragment was discarded.

In exceptional caaes, where much strain faUs upon the inlay, this piece is split
into convenient sizes for passage through the small end of the motor lathe, which
turns out bone-pegs. A drill of corresponding size bores holes l^rough the tibia
at the margins of the inlay, and into these the pegs are inserted. When, as in this
case, the twin-saw is used, the saw-cuts themselves remove enough bone to permit
the inlay to sink into the gutter slightly below the surface of the tibia, thus afford-
ing room on the margins of the tibial cut for the boring of the hiAes and the inser-
tion of the pegs. For ordinary purposes, however, it will be found that the
kangaroo-tendon suffices for retention. The inlay does not fall wholly within the
medullary cavity, because the latter is fiUed in with newly-formed bone in these old
cases. Enough room is allowed by the saw-cuts to permit the strands of tendon to
emerge on each side between the inlay and l^e gutter-wall.

The skin and subcutaneous tissues were apposed with a continuous
interlocking suture of catgut Dry gauze was placed over the wound,
the leg wrapped in compressed cotton sheeting, and a gypsum case
applied from the roots of the toes to above the knee. The tourniquet
was now removed.

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212 INTERNATIONAL CLINICS

Dr. Albee thus prefers a bloodless field for his work. He never ligates a
blood-vessel in these cases, but depends upon the obliteration of dead spaces by
suture and the compression of the gypsum case for controlling hemorrhage. The
tourniquet is never removed imtil after the case has been applied.

The technic illustrated by the above cases is that used for ununited
fractures where there has been minor loss of substance.

In frcBh fractures, in which the medullary cavity has not become filled with
newly-formed bone and there is nothing to prevent the inlay from slipping into it,
as would be the case if the twin-saw were used throughout, a slight variation in
the cutting of the graft must be made. The removal of both pieces is begun aa
above, by making parallel saw-cuts with the twin-saw, the difference being ihat this
time the blades cut to a depth only of V^ to ^/u inch, the purpose being to outline a
graft of uniform width throughout its whole extent. Iliese parallel saw-cuts are
then continued through the cortex to the medullary cavity with the single motor-
saw, held at such an angle as to eause the cuts to converge in approaching the
medullary cavity, in order to prevent the graft, when pressed tightly into posi-
tion, from slipping into the latter.

In oofnmiimt€d fractures, where there is a space to be spanned and the length
of the limb is to be maintained by the inlay, it is best to tongue-and-groove the ends
of the graft and the tibia at the ends of the gutter (Fig. 7 B) . The groove should
be in each end of the graft, and the tongue in each end of the gutter. Any tendoicy
to shortening of the limb by muscular pull causes the tongue-and-groove joints to
become so much the more firmly locked. However small, the graft in time hyper-
trophies, under the action of Wolff's law, so that eventually it becomes the sixe
and strength of the bone whose substance it is supplying. In these caaes^ iA
course, the graft cannot be obtained from the fractured bone itself, but must
be taken from the tibia. The bone that has been removed in shaping the tongue
and groove, as well as other bone-fragments, is finely chipped with a rongeur, and
pushed between and placed about the ends of the fragments at the line c^ fracture,
and in other crevices that may exist. In this type of fracture the comminuted
fragments themselves should be saved and used for this purpose. 8uoh bits act
most effectively aa supplementary foci of osteogenesis.

In the case of small bones, such as the radius or ulna, the encircling
of the fragments with the kangaroo-tendon, instead of boring holes
for the latter, inserting pegs, etc, suffices to hold the inlay firmly in
place. In the case of the large bones, such as the femur, the graft
must be at least five or six inches long, and as broad as the diameter
of the bone will permit Again, the more desperate the case and the
more frequently it has been unsuccessfully operated upon, the longer
must be the inlay. Proximity to a joint interferes in no way with the
success of the inlay. For example, in fracture of the tibia just above
the ankle the malleolus may be grooved even to its tip. The limb
should in every case be firmly immobilized in as near a neutral

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Fia. 7 B.

Fig. 7 a.

Fia.7C.

Fig. 7 A. — Tibia showing inlay bone-graft operation as performed for old, ununited fracture,
according to description in text. The small graft is placed on the left. Just above is a gutter left
after removing an angular bone-graft, which has been inserted into the split cervico-thoracic spines
on the right of Fig. 7C. On the popliteal aspect of the tibia there is shown a bone-peg made by
the lathe.

Fio. 7 B. — Tibia showing inlay bone-graft operation as performed for comminuted fractures.
The bone-^raft was taken from the opposite tibia. Tongue-and-groove joints were made, and
bone-chips inserted in the plane of fracture, which here is oblique.

Fig. 7C. — The««e specimens were prepared by the writer from anatomic material.

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Fig. 8.

Disjunction of upper epiphysis of humerus with characteristic displacement, .\nteropostprior view.

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THE OBTHOP.£DIO OLINIO OF FBED H. ALBSB 218

position as possible; that is, a posture of the limb which causes the
relaxation of those muscles which tend to displace the f ractura

In addition to the mechanical and biological advantagecf of the
bone-graft, each structural layer of the latter is brought into close
apposition with its corresponding layer in the recipient fragment;
namely, periosteum to periosteum, cortex to cortex, endosteum to
endosteum, and medullary substance to medullary substance.

Of the cases of ununited fracture Dr. Albee has operated upon by
the inlay-graft method, nearly fifty per cent had been plated previ-
ously. In citing statistics of 450 fractures gathered at the Cook
County Hospital, Thomas found that it had been necessary to remove
the Lane plates on account of suppuration or other causes in forty-
ei^t per cent, of the cases that had been plated. With the inlay-graft
method, on the other hand, 100 per cent of successes have been
secured.

There was Been in a ward walk at the Post-Graduate a patient with a frac-
tare of the tibia, which had been Lane-plated previously. Skiagram showed the
fragments to be in good position, but without any union. A six-inch inlay had
been uaed, without p^gs. Half of the fibrous tissue was removed from between
the bones, and bone-chips were put into this space.

SYSTEMATIC DISCUSSION OF THE SKELETON BY DB. ALBEE

In order to gain dome idea of the extent to which the use of the
bone-graft is applicable, as well as of his general orthopaedic work.
Dr. Albee was requested by the reporter to discuss the skeleton in
systematic manner from head to foot.

Head. — ^After nerve-resection for neuralgia, bone-p^ may be
used to effect a permanent closure of the foramina (Kanavel). Bone-
grafts are employed to correct congenital or acquired deformities of
the face, and to replace or repair defects of the mandible. For de-
formities of the nose, a graft may be contacted with the nasal bones.
If the skin incision is made in the tip of the nose, the scar is not notice-
able (Carter). After the mastoid operation, a button of bone may be
removed from the tibial malleolus to restore the prominence of the
mastoid process.

Upper Extremity: Clavicle. — ^In fractures, in order to prevent
deformity from fragments that cannot be controlled by mechanical
means, an inlay-graft may be placed in the superior surface.

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214 INTERNATIONAL CLINICS

ShouMer- joint: Disjunction of Upper Epiphysis of Humerus. —
Due to falls on the shoulder^ this injury is most frequently met with
between the ages of ten and eighteen* The symptoms are swellings
localized pain, wincing tenderness, limitation of abduction, muscular
spasm, muffled crepitus, and displacement of the shaft forward and
inward, with a characteristic wrinkling where its upper end projects
into the skin. The external rotators abduct and, acting together, pull
the epiphysis into the horizontal plane and forward (Fig. 8). Main-
tenance of reduction by conventional methods is most difficult, because
the upper end of the lower fragment is in contact with the slippery
head and slippery upper metaphysis, and traction is fruitless because
there are no connections between the upper and the lower fragment
For these reasonai, Dr. Albee proposed bringing the lower into align-
ment with the upper fragment, which is analogous to the treatm^it of
subtrochanteric fracture of the femur. The arm is elevated anteriorly
to the horizontal plane, and the humerus rotated inward, a position
similar to that one takes when defending himself from blows. Thus
the powerful prehensile muscles attached to the shaft are relaxed —
the pectoralis major, the biceps, the coracobrachialis, the strongest
part of the deltoid, as well as the supraspinatus and the subscapularis.
The position is maintained by a plaster-of -Paris spica. The method is
also applicable for fractures in the r^on of the anatomical neck, and
high or low in the surgical neck. Differentiation from luxation is
established by determining the presence of the head of the humerus in
the glenoid cavity.

Recurrent Luxation of Shoulder, — ^Because of the disproportion
in size between the large humeral head and the small glenoid cavity,
as well as the thin, flexible capsule and the frequent exposure of this
joint to trauma, luxation is frequent^ with a ratio to all luxations of
about 43.5 per cent The same factors, together with weakening of
the joint by laceration of its supports at the time of the first luxation,
predispose to recurrent luxations. Kon-operative treatment has been
very unsatisfactory. Operations, such as arthrodesis and resection, are
not to be considered. Dr. Albee employs his modification of Burrell
and Lovett's capsule-reefing operation with success.

An incision is made from the coracoid process along the delto-
pectoral groove to the insertion of the deltoid muscle, exposing the

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THE OBTHOP.£DIO CLINIC OF FRED H. ALBEE

215

capsule at its antero-intemal portion. With a curved needle, sutures
of No. 1 catgut are inserted through the base of this fold of capsule,
and between them an elliptical piece one inch long and one-half inch
wide is excised. Upon tying these sutures it is found that the cap-
sule is distinctly shortened. The muscles fall into place on bringing
the arm to the side, and it is only necessary to suture the subcutaneous
tissues and the skin. ' The arm is held to the side with a plaster
shoulder-cap. The weight of the arm is taken up by a tight sling
applied to the elbow and forearm. It is thus retained for two weeks,
when the shoulder-cap is removed. The sling is allowed to remain a
week longer, with passive exercises twice a day. At the end of three
weeks all apparatus is removed, and the patient encouraged to
perform both active and passive exercises.

Fia 9.

Deformity in fracture of shaft of ulna with anterior luxation of head of radius.

Humerus. — In intra-articular fracture-luxation the head of the
humerus should be replaced, at an open operation, as a graft

Dr. Albee considers the intramedullary splint as mechanically
and biologically imperfect, and cited the following case :

A patient received a fracture of the humerus at the junction of the upper
with the middle third, and went five and one-half years without union. One year
ago an intrameduUary bone-splint was inserted without success. The patient
has now a pseudarthrosis.

Forearm: Fracture of Ulna with Luxation of Head of Radius. —
According to Ashhurst, this combined injury is more frequent than
fracture at the junction of the upper with the middle third of the ulna
alone. This wafl( an old case, and the deformity is shown in Fig. 9.
Through a small, vertical incision beginning above at the external
epicondyle of the humerus the head of the radius was resected
(Fig. 10). Through a slightly longer incision at the site of fracture

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216

INTEBNATIONAI. CLINICS

the fragments of the ubia were separated with the osteotome and
mallet and straightened (Fig. 11). The skin-edges were apposed by
a dove-hitch continuous suture. A gypsum case was applied with the

Fio. 10.

Incision exposing head of radius, showing resection of latter.

forearm in the Albee position, that of acute flexion and semi-
pronation (Fig. 12). Thus the stump of the radius is retained in
place by impinging against the anterior surface of the humerus. It

Fio. 11.

Incision exposing site of fracture, showing separation of fragments.

thus produces strong traction and straightens the ulna, while the acute
flexion tends to separate the fragments of the ulna, especially the
upper, from the radius. The dressing was left on for four wedos.

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THE OBTHOP-fflDIC CLINIC OF FBED H. ALBEE

217

Congemtal Absence of Radi/us. — The valgus was so marked that
whenever the flexors or the extensors of the wrist contracted the hand
was abducted until it contacted with the upper arm. At operation a
radial incision was made between the flexors and the extensors. A
complete radius, even to the head and broad, lower end, was patterned
from the tibia, part of whose upper epiphyseal cartilage was included
to insure further growth. This graft was inserted into the bed that
had been prepared for it, and the wound closed.

Fio. 12.

Forearm dressed in gypsum sling in Albee's position.

Paralytic Wrist-drop. — In these cases the object is to maintain
the hand in the neutral position, to counteract the unopposed pull of
the flexor muscles. A bone-graft from the tibia is inserted into the
dorsum of the lower end of the radius and of the os magnum, thereby
immobilizing the wrist-joint.

Tvberculosis of the Wrist-joint. — The same technic may be em-
ployed in suitable cases of this affection.

Hand: Dactylitis. — ^When luetic, the skiagram shows the picture

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218 INTBRNATIONAIi CLINICS

of proliferative osteoperiostitis, and there is a gnawed appearance at
the sides. When tvbercvlous, the skiagram shows intense rarefaction,
and a cystic appearance. For the latter variety, in adults and in
severe cases in older children, after the diseased bone has been
removed, replace with bone-graft.

Lower Extremity: Hip: Osteo-arthritis, Hypertrophic {Morbus
Coxca Senilis). — This obstinate affection has its incipiency at an
earlier age than is usually conceded, the cases in this series having
varied from fifteen up to sixty-seven. In most cases there is the
history of an antecedent fall upon the hip affected. The patients have
difficulty walking just after rising from a sitting position ; it is hard
to cross the diseased limb over the sound one; difficulty is experienced
leaning over to fasten the shoes, and there is a varying degree of
" sciatica.'^ In advanced cases there is deformity in flexion and in
adduction, and moderate wasting of the thigh muelcles from limitation
of motion. Skiagram reveals wearing away of the femoral head and
acetabulum, ebumation, and osteophytes. Hygiene, rest> and brace
treatment fail to relieve a large number of advanced, progressive
cases. Eesection of the upper extremity of the femur, as practised
by Hoffa and others, gave very unsatisfactory results. In view of the
pathology, the operative indications seem to be to secure an imme-
diate firm ankylosis, and in order to compensate for the existing
practical shortening, to place the limb in a position of slight over-
correction of the deformity.

The hip-joint is exposed through an anterior incision. Osteo-
phytes are pushed aside, not being removed because of their bone-
producing possibilities. The portion of the acetabulum that over-
hangs the femoral head is thoroughly removed : this exposes the head
and facilitates the removal of its upper part. With the head of the
femur in situ, approximately one-half of its upper hemisi^ere is
removed with a large chisel, through a plane nearly parallel with
the long axis of the neck of the femur. This fragment is then split
at right angles to its cut surface with an osteotome into segments,
two-thirds of an inch in thickness. After the removal of the upper
part of the head the femur is strongly rotated outward, and all the
cartilage that can be reached on the anterior aspect of the remaining
portion of the head is removed with a chiseL Then the same instru-
ment is inserted between the head and the acetabulum, and the

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THE OBTHOP.EDIO CLINIC OP FBED H, ALBEE 219

cartilage on the contigaous surface of the latter is destroyed as
much as possible. The limb is immobilized in the sli^tly over-
corrected position by a long spica gypsum bandage. At the end of
four weeks the patient may walk with crutches. At the end of five
weekfi( the long spica is changed to a short one* At the end of eleven
weeks the latter is removed. The pain disappears immediately after
operation.

This operation has the following advantages :

1. It assures bony union by bringing two large bony surfaces into
close apposition^ and holds them there firmly by the mere correction
of the deformity^ if one exists thus eliminating the possibility of a
painful joint or a recurrence of the deformity, both of which are
probabilities in the event of an operation for mobility. Furthermore,
the stiff hip, in the position of fifteen d^rees of flexion, with the
compensatory movement of the lumbar spine, has proved of very
slight annoyance in every case.

2. It produces a minimum amount of bony shortening, which, as
well as that already existing, is compensated for by the fixed abduc-
tion of the limb.r

8. It involves very little cutting of soft tissues, and does not
require the luxation of the head from its socket, and thus produces
very little postoperative shock, even in the aged.

4. A luxation or displac^nent of the femur, even from weight-
bearing, is extremely unlikely immediately after the operation.
Therefore, aged patients can be gotten out of bed very early.

The operation is also of use in the following conditions :

1. Extreme paralysis of both hips and the lumbar spine {dangle
hips)y associated with marked lordosis, where contractures of the
fascia lata occur and recur. Here the ankylosing of one hip holds
the pelvis upright, corrects the lordosis, and makes bracing much
easier.

2. Dislocations following suppurative arthritis of infancy, where
the head of the femur has become disorganized and has disappeared.
In this event, the great trochanter should be mortised into the
acetabulum.

3. Fibrous ankylosis, where mobilization is not feasible, as a sub-
stitute for Gant's subtrochanteric osteotomy. This precludes two
disagreeable sequences of Gant's osteotomy ; namely, joint strain and

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220 INTERNATIONAL CLINICS

relapse of the old deformity, by a slow yielding or stretching of the
fibrous ankylosis. In other words, it is treating the hip under similar
conditions as the knee-joint has been treated for years.

4. Tvberculaus osteo-arthriiis in adidts, in selected cases. As a
guide in the selection of these cases, the accepted views concerning
the eligibility of excision in tubercle of the knee-joint must again be
referred to. It should be noted, however, that this procedure is some-
what more permissible in older children than an excision of the knee,

(a) because very little of the epiphyseal cartilage is removed, and

(b) normally much less growth occurs here than at the lower end of
the femur.

Tuberculosis involying the joints in adults must be considered separately from
that in children. In the latter, better repair may be had by conservative fixation,
and by prevention of weight-bearing when symptoms are acute. And children
can afford to spead a longer time in convalescence. Lorenz claims that bony
ankylosis is preferable for tuberculosis of the hip- joint in childhood: he applies
a short spica and allows the children to get around. This crushes the joint, and
ankylosis results. Dr. Albee puts the child in bed with traction vakUl the symp-
toms are alleviated. He then appUes Phelps's traction-brace, which gives good
extension and fixation, until rarefaction about the hip has disappeared to such
extent that no severe crushing can occur. After this he puts on a short spica
and allows function of the limb in order to avoid atrophy from disuse.

The key-note in tuberculosis in childhood is conservatism; in
adults, operation.

Dr. Albee referred to a' case of fracture of the cervix femoris dose to the
caput, with overgrowth of bone around the head and neck. Three times the
adhesions were broken up under ether elsewhere. Skiagram showed an old union.
He performed the immobilizing operation with a good result.

At the Post-Graduate he showed a case of tubercle of the hip-joint with
luxation and with disintegration. He immobilized it by the mortising operation,
and applied a gypsum case. Three months after the operation there is stiU no
pain on motion.

At the Blythedale Home he demonstrated a child with tubercle of the hip
and sinuses. There was no pain, for the joint had been ankylosed by nature.
The sinuses are healing under fresh air and forced feeding.

In non-tuberculous osteo-arthritis the head of the femur is ebumated and
sclerosed. In tuberculous osteo-arthritis it is softened and rarefied. In the
latter one sees the same crushing as in the vertebrie in Pott's disease.

Excision of the hip has no field of usefulness except as a life-saving measure
in certain cases of osteomyelitis that impinge upon it. In case the head and neck
of the femur have been destroyed, they may be replaced by using the head and
neck of the astragalus as the graft (Roberts).

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THE ORTHOPiEDIO CLINIC OF FBED H. ALBEE 221

LibxaHon of Hip, Paralytic and Congenital: Dr. Alhee's Arthro-
plasty. — In the one case the rim of the acetabulum is much worn, and
in the other it is shallow by nature. In the former the capsule is
much relaxed and the muscles about the hip lengthened. The blood-
less method is the preferable treatment At first Lorenz ruptured the
adductors, but he does not do so now, since they help retain the hip
after reduction. Dr. Albee applies traction of from ten to twelve
pounds for two weeks to stretch the periarticular structures. He
then endeavors to reduce with as little trauma as possibla If he
does not succeed in reducing the first time, he puts on more traction
and tries again. If an old case, he stretches to get full motion, or
even does a tenotomy. After reduction the limb is put up in plaster
in the frog position of Lorenz, which is maintained for four months.
If the acetabular rim is too meagre for retention of the head, operation
is indicated.

The disadvantages of Hoffa's operation, or deepening the acetabulum by the
removal of cartilage and bone, are great, in that it might result in an immediate
marked limitation of motion and pain.

The principle of Dr. Albee's arthroplasty is to separate the upper
half of the meagre rim of the acetabulum with a chisel (Fig. 13),
and to force it downward and outward, thus forming a pronounced
rim. The resulting cuneiform cavity is filled with wedge-grafts
(Fig. 13, B). The grafts may be taken from the tibia. He has also
obtained the grafts from negroes, cadavers, etc., and has even used
phalanges from a case of polydactylitis cut up into wedges by the
motor-saw. The technic for recurrent luxation is as follows :

Through a lateral incision the upper part of the great trochanter, together
with the attached muscles, is separated and reflected upward. The capsule of the
superior part of the joint is developed without incising it. With a wide, thin
osteotome a broad bone incision, about one-half to two-thirds of an inch above
and parallel with the superior edge of the acetabulimi, is made obliquely down
to the joint-cartilage at a point about the same distance internal to the edge of
the acetabulum. With silk sutures a sufficient reef is then made in the postero-
Buperior, or overstretched, part of the capsule, in order to tip down the loosened
edge of the acetabulum, and thus hold it in that position so as to form an
exaggerated acetabular rim. This opens up a wedge-shaped cavity above the
latter by the displacement outward of the bone-fragment. Measures of this
cavity are taken with calipers, and wedge bone-grafts are procured either from
the tibial crest or from the remaining portion of the great trochanter. If it is
necessary to shorten the trochanteric muscles, the grafts are always removed from

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222

INTKENATIONAI. CLINICS

the base of the trochanter. When the refleoted portion of the trochanter, together
with its attached muscles, is replaced, its position is lower by the thidmess of the
wedge-grafts removed, thus tightening the muscles to that extent. The grafts are
drilled and fixed in place by two sutures of medium kangaroo-tendon. Thus the
transplant fills the wedge-shaped cavity above the acetabulum while at the
same time assisting the shortened capsule in holding the fragment in its new
positioDi

Fig. 13.

Arthroplasty of hip-joint. Separation of upper rim of acetabulum with chisel. B shows insertion

Of wedge-graft.

This procedure preserves the whole of the joint-cartilage, is not
dLfficult of execution, and fulfils every anatomic requirement.

Dr. Albee showed, at the Post-Graduate, a baby girl, aged four years, who
had congenital luxation of both hips (Fig. 14). He reduced the left hip by the
bloodless method. A gypsum spica was applied and a skiagram taken. He did not
succeed in reducing the right hip at the same sitting, so no gypsum case was
put on, in order that the traction could be reapplied.

Osteitis Fibrosa. — This involved the upper end of the femur,
and there was marked angulation. The whole area was removed with

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THB OBTHOP^fiDIC GLIinO OF FRED H. ALBEE

the curette, and a strong graft from the tibia was inlaid into the
femur above and below the site of removal of the tumor.

Bane Cysts. — Theete occur more frequently near the slow-growing
ends of long bones, as the lower end of the humerus, the upper end of
the femur, and the lower end of the tibia. Dr. Albee makes an
osteoplastic door with the motor, turns it back on its hinge, carefully
avoiding trauma; curettes out the cavity and its lining membrane;

Congenital luxation of both hips. Before reduction.

dries it with alcohol, ether, and hot air ; fills it with Mosetig-Moorhof 's
wax, and replaces the door. He also uses bone^hips.

Dr. Albee emphasized the nndesirability of traumatizing tissue in bone-
work. As regards the skin and the subcutaneous tissue, this occurs unnecessarily
by too short an incision and too much retraction, and, in the case of the bone, by
the use of the ordinary, too blunt, dull chisel.

Fractures of Femur: Neck. — In children Dr. Albee uses Whit-
man's method of gypsum case and abduction. In adults, owing to

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224 INTERNATIONAL CLINICS

the mechanical disadvantage of the stress being directly crosswise to
the point of fracture, the poor blood-supply, and the sluggish osteo-
genesis in the joint, union is rendered notoriously difficulty if not
impossible. Metal spikes are liable to cause much bone-absorption,
with resulting non-union. Therefore, bone-graft pegging should be
resorted to in fresh asi well as ununited cases, and Dr. Charles
Scudder, of Boston, endorses this view, stating that he believes it
advisable to do it in all non-impacted cases. The technic of this opera-
tion is as follows :

The fracture is exposed by an anterior incision, and if necessary the ends
of the fragments are freshened by chisel and sharp curette. A pomt just below
the great trochanter is reached l^ a short, lateral incision. The proper location
through the centre of the neck, and the direction of the drill-hole for the peg,
are determined by thrusting a small hand-drill through the great trochanter,
.obliquely upward through the centre of the neck, and into the centre of the
fractured end of the proximal (head) fragment, as felt or seen throu^ the
anterior incision. This may necessitate the withdrawal and reinsertion of the
drill. Upon determining the proper location and direction for the driU-hole, the
large motor-driven drill is pushed inward in that direction through the centre
of the neck and well into the head. This drill produces a hole six-sixtemths of
an inch in diameter. The drill is then disengaged from the motor and left im iiiu
to hold the fragments in apposition while the bone-graft is being removed from
the tibial crest of the opposite limb. As removed by the motor-saw, the latter
measures four inches in length and six-sixteenths to seven-sixteenths in cross-
section. The lathe, which titms out a dowel of proper size to fit the drill-hole,
is then adjusted into the motor. While the lathe is securely held by an assistant,
the bone-graft is slowly fed into it. This is done with comparative speed, and
assures a perfect fit. This strong p^ is driven home by a metal mallet. The
skin is closed without drainage. The limb is secured in the neutral position by
a plaster spica.

The peg stimulates callus-formation, and conducts a blood-supply
from the spongy great trochanter. Firm union is usually present at
the end of six weeks. The causes of bending of Lane's plates and
strong spikes in these fractures are, first, that both of these appliances
contribute to non-union, so that the patient is liable to bear weight
before union has taken place; and, secondly, because the limb was
probably not dressed in the neutral position. If the latter condition
be fulfilled, neither the bone nor the metal peg can bend or break.

Svhtrochanteric, — Because of contraction of the iliopsoas muscle
with resulting flexion of the upper fragment, fracture at this site is
hard to control without operation. Here, again, the importance of
the neutral position is forcefully emphasized. The limb should be

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THE OBTHOP.SDIC CLINIC OF FBED H. ALBEB 225

dressed and secured in flexion and abduction, whether operated upon
or not

Middle of Shaft. — Treatment should be conservative at first In
long, oblique fractures of the shaft the mechanical principle of the
inlay has its best application if put on the side of the obliquity.

Supracondylar. — If above the gastrocnemius, the upper end of
the lower fragment is tilted backward into the popliteal space. If
below, the muscle exercises the same action upon the lower end of the
upper fragment Therefore, by flexing the 1^ upon the thigh,
thereby relaxing the calf and the hamstring muscles, a natural splint
is formed for the fracture.

Dr. Albee referred to a case of supracondylar fracture €ibove the gastroc-
nemius, with the characteristic deformity. The insertion of metal plates else-
where had failed twice. He found the lower end of the upper fragment in a
lake of serosanguineous fluid. After sliding an inlay from the upper fragment
down, perfect union was obtained.

Disjunction of Inferior Epiphysis. — ^Here, also, flex the leg upon
the thi^

Patella: Fracture, — If the middle portion is involved transversely,
as is usually the case, prepare a bed for an hour-glass dovetail inlay.
Outline the graft on the tibia according to the measurement of the
calipers, and cut it off with a small saw. Because of the thickness of
the patella, the full thickness of the tibial cortex may be included.
The sides of the patellar cut are bevelled in, just enough to place the
inlay in its bed. This insures bony union, instead of fibrous, which
is usually attained by the older methods.

Slipping Patella. — Cartilage is a greater preventative against
adhesions Uian the fascia-fat flap method of Murphy. In this con-
dition the external condyle is too low, and the patella slips over it
The principle of the operation is to split the external condyle and
insert bone-wedges behind it, as in arthroplasty of the hip-joint In
certain cases, where the condyle is especially low, it may be necessary
to plicate the capsule.

Injury to Semilunar Cartilage. — The meniscus may be luxated,

fractured, or teased out from injury. The crucial ligaments may be

torn and the tibial spine fractured. In cases in which the diagnosis

of injury to the semilunar is questionable, and thus for exploration

of the knee-joint. Dr. Albee favors Robert Jones's method of longi-
VOL. II. Ser. 25—16

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226

INTBENATIONAL CLINICS

tudinal splitting of the patella, and states that this method will
revolutionize the surgery of the knee-joint

A female, aged thirty years, was injured in a bicycle accident, her left leg
slipping from under her. The knee was swollen. With the diagnosis of damaged
internal semilunar cartilage, the joint was explored through an internal and
an external incision by another surgeon, who told her nothing could be found.
Other men had put on a brace. When Dr. Albee saw her, ten years after the
operation, she had become a nervous wreck. He found the symptom-complex of
an injured semilunar, which he picked out from her neurasthenic syndrome.
Upon splitting the patella vertically by Robert Jones's method he found the

Fia. 15.

Knock-knees. External oateotomy of two-thircU thickness of femur by McGuire*s method.

internal semilunar split from end to end, and the inner portion split longi-
tudinally, and, like a jumping-rope, playing back and forth. Removal of the
damaged disk cured the neurasthenia.

Dr. Albee also referred to a patient in whom, after making the above-
mentioned approach to the knee-joint, he discovered a fracture of the spine of the
tibia. He stitched the spine back into place with kangaroo-tendon.

Knock'hnees. — The three most frequent sequels of rickets are coxa
vara, knock-knees, and bow-legs. For the second Macewen recom-
mended osteotomy of the lower end of the femur on the inner side;
McGuire, on the outer.

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THE OBTHOP.£DIO CLINIO OF FBED H. ALBEE

227

Dr. Albee's patient was two years and eight months of age. He entered the
osteotome one finger-breadth above the external condyle, vertically through the
skin. Upon reaching the bone he revolved the instrument so as to spread the
periosteum, and then cut transversely through two-thirds of the thickness of the
femur (Fig. 15), fracturing the remaining third. Since no steps had been taken
to control hemorrhage, no stitch was placed in the skin, for if a hematoma form,
he would prefer to have it discharge into the dressing than retained in the wound.
The limbs were maintained in an overcorrected position by a double plaster
spica of the groin, and turns from the roots of the toes up to the groin, and a
splint-board, crossing transversely beneath the calves, was incorporated into
the dressing (Fig. 16). This splint strengthens the limbs, prevents their
rotating, and thus lessens the amount of plaster that needs be placed around the
waist. The dressing is retained for eight weeks.

Fia. 16.

Knook-kHeefl. Postoperative plaster dressing to maintain lirobe in overcorrected position. Note
incorporation of splint-board to prevent their rotation.

Non-union never results, since this is in reality a subperiosteal
fracture. After fracture of the upper end of the tibia in knock-knees,
he inserts a bone-graft wedge into the external surface.

BoW'legs. — For general bow-legs throughout the' length of the
tibia Dr. Albee uses the osteoclast; and for exaggerated anterior curve
of the tibia, the osteotome. Operations for bow-legs are not per-
formed until after from one and one-half to two years of age.

Knee-joint: Ankylosis. — If the knee is fixed in a bent position,
Dr. Albee excises a transverse, oval wedge of bone anteriorly from

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228 INTEBWATIONAL CLINICS

the femur or from the femorotibial synostosis, turns it a quarter of a
revolution, and inlays it vertically, after strai^tening the limb.

Tuberculosis of the Knee-joint: Erosion with Bone-transplantor
tion. — That poor results follow excision is shown by the f requOTicy of
non-union in a series of cases reported from the orthopeedic service of
the Massachusetts General Hospital That it is illogical to insert
Lane plates into a tubercular process is shown by the fact that two
out of eight cases in this series which had been fixed by plates and
clamps came to re-excisions, because of insufficiency of the callus
that formed. Dr. Albee's method is to perform erasion with removal
of the least possible amount of bone, and to immobilize by inlays
obtained from the edges of the patella. Firm union usually follows
in five weeks. The technic, which is also applicable for the correction
of complicating deformities, as fibrous or incomplete bony imion, is as
follows :

The first step, before entering the tuberculous joint, is to supply the bone-
graft. If the patella be not too much involved in the disease, it may be sawed
into inlay grafts, which answer the purpose. Otherwise, an eight-inch graft is
removed from the antero-intemal surface of the tibia by the twin-saw, with the
blades adjusted seven-sixteenths of an inch apart. It is then placed in warm
saline solution until needed.

An Esmarch constrictor encircles .the upper portion of the thigh. A large
U-shaped incision is made so that its lowest point is over the tubercle of the
tibia. The ligamentum patellse is divided at its insertion, and the patella is
turned upward and removed. The lateral ligaments are cut, and the leg is fully
flexed on the thigh. The tuberculous granulations are trimmed away with
scissors. With a narrow bow-saw, a thin section (6.35 to 8.46 Mm. in thldmess),
consisting of the cartilage with the underlying bone, is removed by following
a plane that is approximately parallel with the convexity of the femoral con-
dyles. With the same instrument a section is similarly removed from the superior
extremity of the tibia, but by a concave cut, so as to produce a surface which
will receive the convexity of the lower end of the femur: the bone should be so
removed that, when the cut surfaces are approximated, the leg is straight. The
anterolateral surfaces of the upper end of the tibia and the lower end of the
femur are each exposed for about three inches. On each side of the patellar site
the periosseous structures are incised down to the bone, both tibia and femur,
parallel with their long axes, and are turned sideways with the periosteal elevator.
With the femur and tibia held in good apposition, and with the blades of the
twin-saw adjusted to the same distance as before, two parallel cuts are made on
each side of the patellar site, each bone being traversed for a length of two
inches. The strips of bone are removed with the small, single saw and a narrow
chisel. The eight-inch bone-graft is now taken up and divided transversely into
equal parts. Each of the four-inch inlays will fit snugly into each gutter on each
side of the patellar site. They are retained in place by strands of kangaroo-
tendon, according to the technic described for the inlay treatment of fractures.

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THB OBTHOPiEDIO CLINIC OF FBBD H. ALBEE

The following illustrative case was seen during a ward walk at
the Poet-Graduate Hospital :

A woman, aged twenty-one years, began, in November, 1013, to have sharp
pain in the right hip, marked on exertion. This was cured by the application of a
plaster gpica with rest in bed for nine weeks. Then there b^gan a severe pain
in the left knee, which interfered with sleep from the beginning. She has not
been able to walk since. At operation, the posterior surface of the patella was
removed, and grafts fashioned from the healthy part of the patella were used
as inlays. Since the operation there has been no pain.

In tuberculosis of the knee-joint one does not see the same amount
of crushing as in the hip-joint and bodies of the vertebrsB, because it
is too strong.

Deficiencies in Bones of Leg. — The bone-graft method is appli-
cable for cases of congenital absence or acquired deficiency of the tibia,
and also for the fibula if the external malleolus does not functionate.
When the bone-ends are conical, as after osteomyelitis, split them and
insert bone-graft In favorable cases the long tongue-and-groove inlay
method may be used, just as in comminuted fractures.

The following very interesting case, operated upon in November,
1914, was described by Dr. Albee. It has not been published before.

The patient was a child. The right leg showed complete congenital absence
of the fibula. Hie tibia had a marked anterior curve. The foot was displaced
upon the outer side of the lower end of the tibia, the weight being borne upon
the internal malleolus. The left leg showed a mere conical stump, in which a
rudiment of the tibia and two small tarsal bones could be distinguished 2 it was
surmounted by a toe-nail. The stump was trimmed up, and the rudimentary tibia,
which was strong and large, was transplanted to the right leg and secured to the
lower end of the tibia in such a manner as to form an external malleolus.

Cases of congenital absence of the fibula were reported in the
British Journal of Surgery. Comer, of London, and Hay Groves, of
Bristol, discussed their rarity, but did not suggest treatment.

Tuberculosis of Tarsus. — ^Rogers, of Boston, collected the sta-
tistics in adults, and recommended early amputation on account of
poor results. Dr. Albee's experience confirms that of Rogers. A
severe case in a man, aged twenty-four years, was operated upon by
him as follows :

An incision was made over the internal cuneiform; another, over the tibial
malleolus; and the third, over the internal surface of the posterior part of the
OS calcis. With a broad ligament clamp he tunnelled through subcutaneously

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230 INTERNATIONAL CLINICS

and, puBhing grafts previously obtained from the tibia through the tunnda,
turned periosteal flaps over their ends. Through short incisions over the fibular
malleolus and the cuboid he inserted a graft by the same procedure, thus obtaining
immobilization of the tarsus. A gypsum case was then applied.

This patient had been in bed in another hospital for weeks with
a closely applied gypsum case on the tarsus, yet he had pain from
muscular spasm. After the grafts were applied this pain disap-
peared, because the tarsus was fixed. Despite their contamination
through opening into tuberculous pockets, these bone-grafts grew in.
The tarsal tuberculosis was cured, but a bad surgical kidney developed.
The resistance was not great enough to protect him from infection,
yet the tarsus healed.

Malleolar Fractures. — ^In these, as well as in fractures of the
lower third of the tibia, when ununited or united in bad position,
insert bone-graft-p% instead of metal nail. In the case of a bad
malleolar fracture, run the inlay to the tip of the malleolus, in the
shell of the latter, thus forming a new malleolus, as mentioned above
when dealing with the inlay treatment of fractures.

Fracture of Os Calcis. — ^In falls from a height this bone breaks
sooner than the astragalus, a battering-ram mechanism being oper-
ative. The line of fracture may be through the body of the os calcis
with obliteration of its arch, or from its posterior portion a blodc of
bone may be impacted into its body, thus diminishing the arch. In
the latter case the treatment is conservativa In the previous case
perform tenotomy of tendo achillis, with foot in equinus position.
Control the fragment by strapping, or by a Codivilla nail driven
through the os calcis to hold the posterior fragment down, and thus
restore the arch.

The astragalus may be driven down into a comminuted os calcis. The dis-
placement separates a fragment posteriorly, like a sudden impact into a semi-
solid mass. The posterior part of the os calcis is driven down and the anterior
part elevated, and dorsiflexion of the foot is obliterated.

Clvb-foot: Congenital. — If in an infant and mild, stretch forcibly,
strap with adhesive plaster, and five weeks later apply a gypsum
case with foot in overcorrection, thus correcting the varus. Leave
the equinus to be corrected by tenotomy of the tendo achillis later.
Operation should not be performed until after from two to three
years of age, when ossification has occurred. The soft-tissue opera-
tions of Phelps are followed by many recurrences. In severer, old,

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THE OBTHOP-EDIC CLINIC OF FRED H. ALBEE

231

and relapsing cases^ when the tarsus resists correction by tenotomies
and wrenchings, it is remodelled by removing a wedge from the outer,
longer, convex border of the tarsus, usually from the cuboid (Fig. 17),
and inserting it into the inner, shorter, concave border at the point
of its greatest concavity, the scaphoid bone, which is split to receive it
(Fig. 18). Where the foot is longer, the varus less marked, and the
cuboid lees hypertrophied, the bone-graft is taken from the crest of
the tibia of the opposite leg. The technic in the latter instance
suffices to illustrate both methods.

Fig. 17.

Fio. 18.

Congenital olub-foot. Wedge removed from cuboid.

Congenital club-foot Wedge removed from
cuboid inserted into split scaphoid.

In addition to preparing the deformed fdot for operation, both legs are also
prepared at the same time. A subcutaneous tenotomy of the tendo achiUis is
done, and the equinus deformity corrected. It is important that the heel be
thoroughly brought down, using the foot as a lerer over the lower end of the
tibia. With the foot on a sand-bag, a U-shaped incision, sufficient to expose the
inner aspect of the scaphoid, is made, and a flap of skin and subcutaneous tissue
turned back. The scaphoid is split into anterior and posterior halves with a
sharp osteotome (Fig. 10). The correction of the adduction and varus de-
formities is accomplished by the forced separation and readjustment of the
planes of the scaphoidal halves. While an assistant holds the foot in strong
overcorrection, the distance between the scaphoidal halves is determined by
calipers. The wound in the foot is then packed with saline compresses. The
crest of the tibia of the other leg is now exposed below the tubercle, and with
a scalpel a wedge-graft is outlined on the periosteum one-eighth to one-fourth
of an inch thicker than the caliper measurement of the scaphoidal cavity. With
the small motor-saw, cuts are made along the periosteal incision through the

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232 INTERNATIONAL CLINICS

bone cortex. Before disengaging the graft from its bed, drill-holes are made in
its centre with the motor-drill. The graft is then removed by wedging a thin,
narrow osteotome into the saw-cuts, and is threaded on a strand of medium
kangaroo-tendon, each end of whidi is threaded into a strong cerriz-needle.
One needle is forced through the anterior half of the scaphoid from the side of the
cut surface, and the other through the posterior half in simi^iBir manner. In
older cases, on account of the density of the bone, a drill may have to be sub-
stituted for the needle. The graft-wedge, slightly larger than the cavity in the
.scaphoid, is forced home between its halves (Fig. 20), thus closing up the tarsal
joints which have been forcibly separated anteriorly and posteriorly. The
kangaroo-tendon suture is then drawn taut over the graft and tied. The peri-
osseous structures are drawn over the inlay and sutured with chromic catgut,
and the skin-wound is closed with plain catgut. With the foot overcorrected and
the knee flexed to a right angle, a gypsum case is applied from the toes to the
groin. At the end of four weeks this is removed, and a second case, applied from
the toes to the knee, is left on for the same period.

Fio. 19.

Conseniial club-foot. Scaphoid split into anterior and posterior halves with an osteotome.

The advantages of the graft-wedge are, first, that by permanently
lengthening the short side of the skeleton of the foot it insures in a
most trustworthy way against a relapse of the deformity; secondly,
no interference with joint function or mobility is caused, since no
joint is involved by the operation.

Acquired (Paralytic Varus). — ^Here there is hypermobility in-
stead of the stiffness of the congenital variety. The indication is to
make the foot more stable, since the muscles are paralyzed and the
ligaments overstretched, permitting an abnormal amount of motion
in the most mobile joint of the foot, the astragaloscaphoid, and re-
sulting in a flail joint. This type of acquired club-foot is almost
always due to unbalancing of the musculature of the foot by paralysis
of the peronei, which are abductors of the foot and elevators of its
outer border. If these muscles are paralyzed, the foot falls into

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THE OSTHOP.SDIO CLINIC OF FBED H. ALBEE

233

adduction and varus, and the child walks on the outer edge of the
foot; thus causing exaggeration of adduction and overstretching of
the capsule of the astragaloscaphoid joint, so that weight-bearing in-
creases the deformity. In the treatment of this variety there are
three conditions to meet: (a) by correcting the deformity; (6) by
removing the flail condition and making the foot more stable ; and (c)
by elevating and holding up the outer border of the foot

The deformity is corrected by performing an arthrodeeis at the astragalo-
scaphoid joint. After abducting the forefoot, a large, cuneiform cavity is thereby
opened up in this joint This cavity is filled In by a graft-wedge from the tibia,
which is prepared and inserted as in the congenital variety described above. Thus
the foot is made more stable.

Fio. 20.

^^ .^'

Congenital olub-foot. Graft-wedge, obtained from cuboid or tibia, inierted between halves of split
ocaphoid. Correction of deformity shown in outline.

The third indication is met by stretching heavy braided silk Ugaments
between the fibular malleolus and the posterior part of the cuboid, or better,
since silk ligaments might pull out, by making use of the tendons of the paralysed
peroneal muscles as ligaments. In the latter case a door is turned up from
the fibular malleolus, hinging upon the periosteum. The synovial sheaths behind
the malleolus are incised, and the tendons are. slipped forward under the door,
which is fastened down and held by sutures. The tendon of the peroneus longus
is planted into the outer borders of the foot. The dense tendinous tissue holds
better than silk ligaments hold. This use of the peroneal tendons was suggested
by Codivilla, and later by Gallic.

Valgus from Infantile Palsy of Extensors of Foot — This opera-
tion was witnessed at the Post-Graduate Hospital the day before New
Year's.

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234 INTERNATIONAL, CLINICS

Tourniquet applied above left knee. Tendo achillis tenotomized because too
ebort. Arthrodesis of astragaloscaphoid joint performed, correcting valgus.
The remainder of the operation aimed at preventing toe-drop hy utilizing the
tendons of the peroneus tertius and tibialis anticus as ligaments. A four-inch
vertical incision with its centre over the front of the ankle-joint was made. The
anterior annular ligament was cut, and the two tendons drawn one to each side,
exposing the anterior surface of the lower end of the tibia (Fig. 21). On the
periosteum a rectangular door was marked out with the hinge internally, and the
small motor-saw bevelled the door free from the bone. Hie external tibial edge
and the adjacent edge of the door had been previously drilled. The door was now
turned inward upon its hinge (Fig. 22). With rongeur forceps bites were taken
from the upper and lower edges to accommodate the entering and leaving
tendons. The bone-chips thus obtained were inserted later as multiple foci of
osteogenesis. Catgut sutures inserted into the tendons opposite the upper and
lower tibial edges served, when tied, to take in reefs (Fig. 23). The tendons were
buried in the medullary cavity; the door was closed and held shut by a strand
of kangaroo-tendon passed through the drill-holes; the cut edges of the anterior
annular ligament were stitched together, and the de^ fascia and skin edges
apposed (Fig. 24). A gypsum case was applied from the roots of the toes to
above the knee-joint.

The gypsum case is maintained for a year: it overcorrects the
foot in both positions ; namely, in extension, and in elevation of the
inner border. The tendency to flat-foot is obviated by arthrodesis of
the astragaloscaphoid joint The tendons are fortified by burial in
the bone. In the latter so much disturbance wa£( made that a great
proliferation of bone will be stirred into activity, and the tendons and
bone will amalgamate into one large, bony mass. No brace is needed :
in fact, the object is ti) get rid of braces. A brace is a stigma to the
surgeon, because the patient must always wear it These tendons
cannot be transplanted so as to correct the deformity and functionate
at the same time. If the peronei be not involved, Dr. Albee performs
arthrodesis at the astragaloscaphoid joint, and then transplants the
tendons of the peronei, longus and brevis, to the scaphoid, suturing
them firmly to the tendon of the tibialis anticus: they are thus
transformed from a deforming to a functionating forea Thecie
operations are followed by muscle-training.

[The motor used by Dr. Albee, which is a modification of the
Hartley-Kenyon model, together with most of the instruments that he
devised for it, is shown in Fig. 25, while the apparatus connected and
ready for use is seen in Fig. 26. Fig. 27 shows a suitable case for an
inlay operation.]

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Fio. 21.

Fio. 22.

Valgus from infantile palsy of extensors of
foot. Tendon of peroneus tertius retracted ex-
ternally, and that of tibialis antious internally,
exposing anterior surface of lower end of tibia.
Note cavity left after arthrodesis of astragalo-
acaphoid joint.

Valgus from infantile pal.«iy of extensors of
foot. Rectangular door lifted from tibia and
rotated inward on internal hinge. The external
tibial edge and the adjacent edge of the door
had been previously drilled for the retaining
kangaroo-tendon suture.

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Fig. 23.

Valgus from infantile palsy of extensors of foot. Catgut sutures, inserted into the tendons opposite
the upper and lower tibial edges, serve, when tied, to take in reefs.

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Fio. 24.

Valgus from iDfantllo palay of extensors of foot. Reefed tendoDs buried in medullary cavity:
door closed and held shut by a strand of kangaroo-tendon passed throuRh drill-holes: cut edjrcs of
anterior annular ligament stitched together. Note approximation of astragalus and scaphoid at
the site of arthrodesis.

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Fio. 25.

Dr. Albee's electric operating bone set. 1, modification of the Hartley-Kenyon motor, with
guide handle attached; 2, Lambotte clamp; 3, Lowman clamp; 4, a carver's gouge, one of
several varieties for mortising work on foot ; 5, compasses; 6. Berg clamp; 7, Albee osteotome
for splitting spines; 8. angular saw; 9, lathe or dowelling mill; 10, male portion of the twin-saw;
11, twin-saw; 12, adjustable guard and spray attachment; 13, small, single saw for releasing
inlay at ends; 14, graduated burr for drilling neck of femur; 15, chuck and drill (former permits use
of ordinary hardware drill) ; 16, drill with a guard; 17, combination wrench or twin-saw; 18, wrench
for flat end of twin-saw; 19, calipers; 20, guards for graduating depth of saw.

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Fu;. 26.

Twin-saw ready for use. Shows proper method of holdinK the motor. Spray attachment and

fciiard connected.

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Fig. 27.

Fracture of tibia and fibula. A Lane plate had been inserted into the tibia elsewhere. This
skiagram shows non-union despite perfect apposition secured by the plate. After removal of the
latter, and owing to the good apposition, Dr. Albee performed an inlay operation within seventeen
minutes.

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GIGANTIC DUODENUM DUE TO KINKING AT DUODENAL
JEJUNAL JUNCTION, ASSOCIATED WITH DILATA-
TION OF THE FIRST PORTION OF THE JEJUNUM,
GASTRO-ENTEROSTOMY, AND FISTULA FROM THE
JEJUNUM INTO THE TRANSVERSE COLON

GEORGE M. DORRANCE, M.D.

AND

JOHN B. DEAVER, M.D.
Philadelphia, Pa.

The history of the patient is as follows: Age, forty-eight.
Family history negative. Previous personal history negative until
May, 1909, when the clinical symptoms of acute perforation of the
duodenum occurred. He was operated upon by Dr. Deaver, who
found the usual thin, discolored fluid and a perforation upon the
posterior wall of the first portion of the duodenum. The perforation
was closed by a purse-string suture and a no-loop gastrojejunostomy
performed. Following this there was an uneventful recovery and
subsequent perfect health for one year. He then developed another
attack, resembling a ruptured duodenal ulcer. He was operated upon
by Dr. H. Wharton, who found a ruptured duodenal ulcer and dense
masses of adhesions. The opening in the duodenum was closed and the
wound drained. He again recovered and was able to do his work and
remained in moderate health until the latter part of 1910. At that
time digestive disturbances appeared, consisting of nausea, vomiting,
and distress after eating. These symptoms gradually increased until
in March, 1911, when he had a third acute attack similar to the
former two. Dr. Deaver again operated upon him and found a thin,
grayish fluid, a granular layer covering the peritoneum, very much
enlarged mesenteric glands, a small pin-point perforation on the
posterior wall of the stomach. The perforation was closed by a purse-
string suture, and the wound drained both at the operative wound
and by a stab-wound above the pubes. At the operating table a diag-

235

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236 INTEBNATIONAL CLINICS

nosis of tuberculous peritonitiB was made. The tests for tuberculosis
subsequent to the operation, however, were all negative. He never
fully recovered his health. A fecal fistula developed immediately,
and several months later a large mass was noted in the centre of his
abdomen. Associated with this mass there were frequent attacks of
vomiting; sometimes several hours after eating and frequently imme-
diately after eating. There was a gradual loss of weight and strength.
In the later months of 1913 he developed a diarrhoea consisting of
ten to twenty stools a day of undigested or partially-digested food.
On admission the physical signs of value consisted in a tense mass
in the upper abdomen which varied in size. Associated with this
mass there was a condition of starvation due to the food either being
vomited or passed in an undigested condition. He died in August,
1914. 4 -'

Autopsy. — Only abdominal incision permitted. There were
numerous scars on the abdomen, with a small fistulous opening to
the ri^t of the umbilicus. On opening the abdomen the peritcmeum
was clear. There were a few adhesions in the lower abdomen, marked
adhesions along the ascending and hepatic colon. There was a large
retroperitoneal distention of the second and third portions of the
duodenum. It was five or six times the size of a normal stomach.
The st(»nach was sli^tly enlarged and thickened; the pylorus nor-
mal It easily admitted the middle finger, as seen in Fig. 1. The
first four inches of the duodenum were distended to three or four
times its normal size, the constriction at the end of the dilatation
being caused by the transverse mesocolon and adhesions, as seen in
Fig. 2. The second and third portions of the duodenum were dilated
into the huge loop, as seen in Figs. 3 and 4. At the junction of the
duodenum with the jejunum a marked kinking and sli^t twist
occurred (Fig. 4), the twist being caused by the jejunum being held
in place by the gastrojejunostomy. The kinking was caused by
adhesions. The more the distention of the duodenum, the more the
kinking and subsequent obstruction. The first three incheef of the
jejunum were dilated, the dilatation being caused by constriction
produced by an adhesion, otherwise the small intestines were normal
On opening the anterior wall of the jejunum (Figs. 3 and 4) the
gastrojejunostomy opening was seen, and it freely admitted three
fingers. Above this opening there was another fistula, leading from

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Fro. K

Fistula

External fistula in transverse colon. The upper and lower portion of the constricted duodenum.
(Dotted lines show complete area of duodenum obscured by the transverse colon and mesentery.)

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Fia. 2.

A, transverse meso; B, dilated duodenum.

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FfG. 3.

' •an'

A, fistula from duodcnuxn into large intestine; B, gastro-ontorostomy opening.

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Fia. 4.

Fistula ^

Fistula

Gastro-
enterostomy

i /

Jiuodcnom

Gigantic duodenum due to kinking at duodenal-jejunal Junction.

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GIGANTIO DUODENUM 237

the jejunum into the trauBverse colon, which freely admitted the tip
of the index-finger. There was a fecal fistula leading from the
ascending colon to the abd<»ninal wall The appendix was normal.
The mesenteric glands were sli^tly enlarged, but there was no evi-
dence of tuberculosis*

We then have a dilated first portion of the duodenum, a gigantic
dilatation of the second and third portions, twisting and kinking of
duodeno-jejunal junction, dilatation of the first three inches of the
jejunum, a wide-open gastrojejunostomy, and a fistula between the
jejunum and the transverse colon. The findings in this case were
especially interesting, as we had two perforations of the duodenum
and one subsequent gastric perforation, the latter two following the
gastrojejunostomy.

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SOME REMARKS ON GASTRO-INTESTINAL SURGERY
AND PATHOLOGY

BY CHARLES GREENE CUMSTON, M.D.

Privai-docent at the Faculty of Medicine of the University of Geneva; Honorary

Member of the Surgical Society of Belgium; Fellow of the Royal

Society of Medicine (Lond.), etc.; Geneva, Switzerland

I. Treatment of Rectal Prolapse. — First of all, before under-
taking any operative interference for prolapsus recti or ani, treat
the acute or chronic pitoctitis present, because in the majority of cases
this is the principal causal factor of the prolapse. Quite often,
particularly in infants and young children, the cure of the proctitis
is enough to ensure a cure, but in adults the sphincteric insufficiency
or the laxity of the pelvic structures composing the means of fixity
of the rectum may have become permanent, and then surgical treatr
ment is required.

In some cases it is indicated to repair the pelvic floor ; others —
and these the most frequent — ^will require repair of, or complete
change in, the means of the pelvic apparatus of fixity of the rectum:
so the problem to bo solved is, What portions of the structures of the
rectal fixity are insufficient and need repair ?

In prolapsus of the first degree there is a laxity of the mesorectom
which gives a mobility and the d^ree of prolapse which can be
estimated by the reduction of its pelvic curves, and in these cases
rectopexy is proper and colopexy would be without effect

A prolapsus of the second or third d^ree, depending upon a
relaxation of the mesocolon and the unrolling of the pelvic loop, is
the triumph of colopexy with or without colostomy, according to
whether or not the proctitis has been rebellious to previous medical
treatment But if the perineal int^rity is gone the above treatment
will not be enough ; the patient must be given a solid pelvic floor and
a well-closed anus in order to prevent the proctitis from recurring.
Colopexy or rectopexy, combined with perineorrhaphy, should be
done in one seance, and out of the large number of procedures devised
for the latter I shall briefly mention only a few that have some merit
238

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GASTBO-INTESTHS^AL SITBGEBY AND PATHOLOGY 239

One of the most original is that described by Schwartz. After
reducing the prolapsus, a deep dissection in front of the anus is
carried on to the sphincter to the extent of four centimetres in length
and two in height Then the raw surfaces are approximated by four
deep silver sutures and four superficial ones of silkworm gut He
insisted on the necessity of bringing the anus far back so that its
opening would bo in the axis of the rectal ampulla. His technic
may be combined with posterior perineorrhaphy, and can be done to
complete colopexy or rectopexy.

Another interesting procedure is that devised by Delorme, which
consists of a complete perianal incision made at the junction of the
mucosa with the skin, and the dissecting out of a cuff of mucous
membrane about four or five centimetres in height. This is next
divided into two valves and fixed to the anal margin by four U-
shaped sutures of heavy silk. Then the valves are resected, and, in the
interval of the U-shaped sutures, the mucosa is puckered up and
stitched to the skin with fine catgut. A large tube is then placed in
the rectum.

A word now as to myrorrhaphy of the levatores ani. A trans-
versal pre-anal incision is made and in the intervagino-rectal line of
cleavage the internal borders of the levatores are exposed and approxi-
mated by three catgut sutures. The skin incision is closed by silk-
worm gut without drainaga

I now come to a technic devised by Thiersch, which I think has
been neglected by American surgeons, yet deserves to be frequently
employed on account of its simplicity in execution and the excellence
of the results obtained. The operation acts in two different ways:
First, mechanically, by replacing the atomic or destroyed sphincter
by a metallic thread, thus exercising a constrictive action on the anus,
preventing the exit of the prolapse. At the same time the metallic
thread draws upon the iijsertion of the levatores ani and thus con-
tributes to the consolidation of the perineum. Second, it tends to
produce a proliferation of sclerous tissue, resulting in a solid adhesion
between the rectum and neighboring structures.

The night before operation the bowels are emptied and a careful
toilet of the rectal cavity made with repeated hot irrigations. The
entire perineal r^on should bo carefully soaped, shaved, and steril-
ized, otherwise the success of the operation might be compromised

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240 INTEBNATIONAI. OLIinCS

or even lead to development of very aeriouB complications. The
prolapse itself must be carefully cleaned and sterilized.

In children general narcosis is essential, while in adults local
ansesthesia is quite enough. This comprises several steps: (1) Anses-
thesia by imbibition of the anorectal mucosa with tampons soaked in
an anesthetic solution inserted in the anal canal; (2) injections
around the anal circimif erence and in the sphincter.

The solution for the injections is as follows:

3* — Physiological serum 100 grammes

NoYocaine 50 centigrammes

Solution adrenalin, ^^ . xr to zx gtta.

The patient should be placed in an ^utggerated lithotomy posi-
tion, with the pelvis raised high, so that the perineum is freely ex-
posed.

The steps of the operation are carried out as follows: (1) A
vertical incision, one centimetre long, in the posterior median line,
just back of the mucocutaneous border of the anus. (2) A Doy^s
needle inserted in the incision is pushed under the skin and the point
made to come out at A (see Fig. 1). The wire ligature is inserted
in the eye of the needle, which is then withdrawn, bringing out the
end of the wire at 0. (3) The needle is passed through the perianal
structures from B to A, the wire being inserted in its eye and drawn
out at B. (4) The needle is passed from C toB and the end of the wire
brought out at 0. A few drops of tincture of iodine are then put on
points A, B, and 0. (5) An assistant introduces the index-finger,
encased in a rubber cot, into the rectum and the wire is tied around it,
leaving just enough room to withdraw the finger. The ends of the knot
are next cut short and pushed into the incision, the latter being closed
by a metallic suture.

The postoperative case is simple. The patient should be consti-
pated with opium and diet for five or six days. Then castor oil is
given, and when a desire to go to stool is felt he is given a rectal
irrigation of warm sterile water. After this first movement the stools
should be procured daily.

The wire should be left in situ so long as possible, preferably about
a month, but if for any reason it must be withdrawn it can be done
in a fortnight Under local anesthesia the small incision is reopened.

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•a

•o
3

•o

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OASTBO-INTE8TINAL SUBOBBY AND PATHOLOGY 241

the ends sou^t for and cut^ and the wire pulled out Heavy silver
wire can be used, but I prefer the bronze-aluminum, as I do not
think it cuts the tissues as much.

II. The Choice of Operation and the After-treatment of Oastric
Ulcer. — ^In a recent paper published in the New York Medical
Journal, c, 515-617, 1914, on " The Surgical Treatment of (lastric
Ulcer,'' I pointed out what I considered the best methods to follow
in the management of this lesion, and what will now be said pertains
entirely to the choice of operation and after-care necessary.

The many methods which have been recommended during the past
twenty years are of unequal merit, and I shall refer only to jejunos-
tomy in gastric ulcer (this operation is not indicated in ulcer of or
near the pylorus). Its merits well apply to this lesion, but it is
essential that the technic employed be simple, easy, and rapidly
executed ; the new mouth must be continent

Simplicity i|i operation is the basis of good surgery, but jejunos-
tomy, particularly, should be rapidly done, for frequently one operates
on a weak subject who cannot withstand a long or complicated inter-
ference. The new opening made must be continent, — ^that is, it
must not let the bile and pancreatic juices escape from it, as they are
required for proper intestinal digestion; also a reflux of the food
introduced should be prevented. Its closure must be perfect, not
only at the commencement but during the entire time necessary for
a cure of the lesion, and this is a most important quality, because
the future of the patient depends on the proper functioning of the
jejunal fistula — a condition most difficult to realize.

In jejunostomy for gastric ulcer note that the fistula is only
temporary, and after having been used as long as necessary it should
close with ease spontaneously, or at least require only an unimpor-
tant surgical operation to attain this. When feeding by mouth has
at last been taken up, the circulation of the intestinal contents must
be perfectly free, without any hindrance at the point where the
fistula has closed, so that the latter must not be the occasion of a
stricture or a bend in the gut, which would result in serious accidents.
The best fistula will clearly be that which is easily made, gives the
most satisfaction during the time of its utilization, and will dis-
appear without creating trouble when its services are no longer re-
quired.

Vol. II. Ser. 2&— 16

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242 INTERNATIONAL CLINICS

Simple lateral jejunoBtomy requires little consideration^ as it
is probably never done at the present time. Its technic is assuredly
the simplest of any, and its performance very rapid. But its serious
defect is that the opening is incontinent, and the variations proposed
to remedy this defect have been universally unsuocessfuL Some, it
is true, have given a fistula which was continent at the b^inning, but
dilatation and secondary incontinence rapidly supervened. Thus the
insufficiency of the fistula destroys the great advantage offered by the
great operative simplicity of this operation and the absence of gravity.

Simplicity and gravity are certainly wanting in terminal Y-
shaped jejunostomy, and, although this procedure is about as perfect
as possible from the junctional viewpoint, it is hardly now ever
resorted to. The continence of the fistula is durable if the anastomosis
is situated sufficiently low down, and, with Souligouix's or Kelling's
modifications, one does away with the oozing of the borders of the
opening, thus making it a perfectly ^^ comfortable '' fistula for the
patient But these advantages are overshadowed by the fact that
the operation is long and complicated, necessitating great surgical
trauma, and, even when skilfully done, may be detrimental to the
patient's recuperative powers. Then when the time comes to close
the fistula another rather severe operation is required. It is, how-
ever, an excellent procedure when the jejunostomy is to be permanent,
as in gastric carcinoma, but it has no place in the operative treatment
of ulcer of the stomach, for the reasons already stated. Consequently,
one can eliminate lateral jejunostomy because it is too simple and
insufficient, and terminal jejimostomy because it is too complicated
and severa

Lateral jejunostomy with anastomosis, which is easier to do than
the procedure mentioned, is, however, subject to the same criticism
and should not be employed. Lateral jejunostomy with funnel-
shaped invagination, as obtained by Fontan's technic, gives an in-
continent fistula, and the various modifications which have been
suggested to overcome this defect are so complicated and long in
execution that in gastric ulcer, at least, they deprive the operation of
any value.

There now remain the procedures with canalization. Heiden-
hain's technic can at once be put aside on account of the dangers it
offers. Drucbert's offers more inducements, but is not generally

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OASTBO-INTKSTINAL SUBOEBY AND PATHOLOGY 243

known to surgeons, although undoubtedly excellent. It takes longer
than the Eiselberg-Witzel, of which I am about to speak, and is
somewhat more complicated, but it is still sufficiently simple to be
.used in cases of gastric ulcer. It is simply the application of
Mardwedel's procedure of gastrostomy applied to jejunostomy. It
cannot, however, satisfy the conditions required as well as the Eisel-
berg-Witzel to which I now refer.

This operation does not necessitate general narcosis; a simple
local anaesthesia amply suffices. It can be done in ten or twelve
minutes, and the operative manipulations are reduced to a minimum.
In the majority of cases it has given an absolutely continent fistula,
provided the technic is closely followed. The fistula has the great
advantage of usually closing spontaneously, or at least requiring only
a slight operation to attain this end. It has been said that this opera-
tion causes intestinal stricture or bends in the gut, and a few cases,
it is true, have been recorded, but the stricture was slight and the
bend so easily avoided, if vertical suspension of the loop is properly
executed, that it is hardly necessary to consider these possible com-
plications. There is no danger from the continued presence of the
catheter in the fistula, and the fistula does not close down when the
catheter is removed, which can bo safely done a few days after the
operation and only introduced at each feeding. The simplicity of
this operation, the facility of feeding, and the absence of any leakage
of bile and reflex of food render it far superior to any other yet
devised.

When the operation is completed an ordinary abdominal dress-
ing is applied through which the catheter is brought This should
have been sutured to the abdominal incision to prevent it from
slipping out, and is closed by a glass stopper. Jejunal feeding can
be commenced at once if conditions require, and the food is better
introduced through the catheter by means of a glass syringe. The
food should always be maintained at the body temperature, because
otherwise it would cause colic, distention, or even diarrhoea. The in-
jection should always be given slowly in order to avoid a sudden pain-
ful tension of the portion of the intestine which received the food,
likewise to prevent reflux. The first feedings must be given prudently,
and one should endeavor to ascertain the susceptibility of the in-
testine and gradually accustom it to its new function. Thus, in the

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244 INTEBNATIONAL CLIITIOS

b^inning^ only liquid food, such as milk, beef-tea, bouillon, etc,
should be given, as they are easily introduced, rapidly digested, and
easily absorbed.

Too much liquid must not be injected at once, because the intestine
functionates by successive segments, and one does not open to receive
the intestinal contents until the following one is empty. The amount
at the beginning should not exceed 150 or 200 Cc for one meal, but
this may be repeated as often as required to obtain sufficient nourish-
ment By d^rees the intestine becomes accustomed to its new func-
tions and will take care of a larger amount of food at each feeding,
so that gradually one can give more substantial food and in greater
quantity. Usually I have found four feedings a day, of about 250 to
300 Cc each, will carry the patient along in good condition.

After a time one can add thin vegetable pur6es, strained soups,
meat pulp, and fruit jelly. The food requires no particular prepara-
tion ; the only important point is to have the solids finely chopped or
powdered, so that they can be easily attacked by the digestive juices
and rapidly digested. Digestion and absorption are as readily
accomplished without the addition of hydrochloric acid or the use of
predigested food. As the gastric juice no longer can offer its anti-
septic power of defence, the cooking of the food should be careful in
order to sterilize it, and it should be of excellent quality. Likewise,
a rigorous asepsis of the glass syringe used is of the utmost impor-
tance.

The catheter must be left in situ for the first ten or twelve days,
after which time it can be removed and only introduced at each
feeding. If it should be seen that the canal is closing down, the sound
may be left in for a day or two.

Nothing should be given by mouth, not even water, during the
entire treatment, and the severe thirst at first complained of by the
patient will soon subside. The care of the mouth is of great impor-
tance, particularly so because the salivary secretion is greatly
diminished, and thus buccal infection with extension to the parotid
glands by the duct of Stenson is to be feared, but proper attention to
details of disinfection of the mouth and teeth will avoid any trouble
of this sort

III. The Classification of Icteric Syndromes. — The syndrome
of icterus is a most important one in abdominal surgery, so I feel a

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GASTEO-INTBSTINAL SUBGBBY AND PATHOJLOGY 246

olaasificatioii will be of much use to those working in this field. My
conception of the pathogenesis of the icteric syndromes leads me to
define icterus in its most general s^ose as: a syndrome characterized
by changes of the normal urinary pigmentation, the blood-serum,
stools, and humors in general, accompanied by a more or less yellow
color of the skin and mucosa and, according to the case, changes in
the blood and various functional disturbances. The essential facts,
such as the presence or absence of Gmelin's test applied to the urine
and blood-serum; coloration or decoloration of the fseces, logically
allow us to classify icterus in three groups: (1) choluric, (2)
acholuric, and (3) mixed.

Cholubio Ictbbus OB Eetbntion Iotbbus. — ^These correspond
to what was formerly called bilipheic icterus, and distinction should
be made between an icterus due to eztrahepatic retention and one
due to intrahepatic retention.

1. Icterus Due to Extrahepatic Betention. — (a) Acute: The
icterus of hepatic colic; emotive icterus, (b) Chronic: Cancer of the
head of the pancreas ; cancer of the choledochus, hepatic duct, Vater's
ampulla, and gall-bladder; chronic pancreatitis; congenital or ac-
quired strictures of the choledochus; cancerous lymph-nodes of the
hilum; compression from the neoplasms in the neighborhood (peri-
toneal, gastric, or omental malignant disease) ; chronic lithiasis of the
choledochus.

2. Icterus Due to Intrahepatic Betention. — (a) By compression
of the large intrahepatic biliary ducts : Secondary cancer of the liver ;
hydatid cyst of the liver; abscess of the liver, (b) By disordination
of the hepatic structures: During the toxi-infectious states (catarrhal
or mild infectious icterus, icterus gravior). (c) By solution of
continuity between the hepatic cells and the excretory biliary canalic-
ulus: During the cirrhoses. {d) By biliary blockage (biliary mud-
pleiochromic icterus).

In all these cases of icterus Gmelin's reaction is positive in the
urine, there is a varying amount of bilirubin in the blood-serum,
total or partial decoloration of the fseces, distinct signs of biliary
impregnation, on increase of the globular resistance and of the
diameter of the red blood-corpuscles. The recent studies on choles-
terinsemia have shown that this group of icterus the quantity of the
latter is increased.

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AcHOLUBic OB Hjemolytic Ictebus. — These correspond to what
was called hsemapheic icterus, and may be logically divided into three
groups: (1) Icterus due to blood changes; (2) to splenic syndromes,
and (3) to infectious and parasitic causes and the intoxications.

1. Icterus Due to Blood Changes. — (a) Acute congenital type:
Icterus of the newly bom, or icterogenous erythrodermy (from
globular fragility). (6) Chronic congenital type: Congenital
hffimolytic icterus (from globular fragility), (c) Acquired type:
During the various anemias.

This group also includes the simple chronic icterus, an exa^erated
type of Gilbert's physiologic acholuric icterus, described under the
name of familial chotemia, in its purely hsemolytic form.

2. Icterus Resulting from Splenic Syndromes. — The icteric
form of myeloid leuksemia ; the icterus arising during Banti's disease ;
hfiemolyzing and icterigenous splenomegalies (from haemolysins of
splenic origin).

3. Icterus Arising in Infectious or Parasitic Diseases and the
Intoxications. — (a) In infectious diseases: Syphilis, pneumonia,
typhoid, scarlet fever, streptococcic infection, colon bacillus infec-
tion, gastro-iritestinal infection, and tuberculosis, (b) In parasitic
diseases: Malaria, ankylostomiasis, anemia from tape-worm, (c)
In the intoxications: Postnarcosis icterus (chloroformic) ; lead poi-
soning.

All these are heemolysinic icterus. In these Gmelin's test is
negative in the urine, but GUbler's test is positive. Urobilinuria is
common. The blood-serum contains other pigments besides bilirubin.
The faeces remain colored. There is no evidence of biliary impregna-
tion. The icteric hue is very variable in intensity.. The hsema-
tologic characters vary greatly: diminution of the globulary resis-
tance in some (icterus from globulary fragility) ; the presence of
haemolysins in other cases (hsemolysinic icterus). A decrease in the
diameter of the red blood-cells is also found, along with the presence of
granular blood-cells (myeloid reaction) in the majority of cases, and
hypocholesterinaemia. With the exception of the icterogenous
erythrodermy of the newly-born, Mongour has applied the name of
pseudo-icteric xanthodermies.

Mixed Ictebus. — (a) From haemolysis due to biliary salts at the

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GASTBO-INTESTINAL SUBGEBY AND PATHOLOGY 247

end of choluric icterus. (6) Choluria and acholuria during the evolu-
tion of certain cirrhoses.

Leaving aside the last class of mixed icterus, the icteric syndromes
are divided into two large groups: choluric icterus and acholuric
icterus, each having its own distinct characters.

IV. Acute Colo-colic Invagination in Children. — Intestinal in-
vagination is, above all, met with in children. It may be either acute
or chronic, but in the child it is acute in 98 per cent of cases. Usually
the commencement is sudden, and generally the invagination gives
rise to symptoms of acute intestinal occlusion. Sometimes the pain is
localized, but more frequently extends over the abdomen and is ex-
tremely sharp. At the same time, the belly becomes distended and
abundant vomiting occurs, provoked upon the slightest movement, or it
may be spontaneous, occurring without the slightest effort. In color
the vomitus is greenish. The fseces are soon completely suppressed,
and even gas is not passed. In the second stage of the process abso-
lutely typical symptoms appear which are necessary to know in order
to formulate a correct diagnosis. There are : ( 1 ) The passage of bloody
mucus, which is rarely, if ever, absent, and sometimes has a fishy
odor ; (2) the presence of an abdominal tumor felt by palpation.

I have already referred to abdominal distention, but I would here
remark that this may be very slight, or the abdominal parietes are
even flat and soft to the exploring hand. In many cases it is possible,
by palpation, to find a tumor in the large intestine formed by the in-
vaginated portion. By rectal examination, which should never be
neglected, one may, in some cases, perceive the tumor.

Serious general i^mptoms accompany these various signs. The
child's skin, which is at first pale, takes on an earthy tint, he cries
plaintively and becomes restless. The pulse becomes very rapid,
while the temperature goes below normal and the skin is covered by
a clammy sweat

The clinical evolution occupies two stages : one corresponding to
the anatomical stage, in which the invaginated segment, as yet free
from ai^y lesion, produces an incomplete obstruction. The second
corresponds to the strangulation and gangrene of the invaginated
segment and complete intestinal obstruction. It is at this time that
the symptomatology is typical, because there are those of intestinal
occlusion with melsena, and an abdominal tumor to be felt by palpa-

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248 INTBBNATIONAL CLINICS

tion. When left to itself the process goes on to gangrene of the in-
volved segment, followed by a fatal peritonitis. The eUmination of
the invaginated segment is one maimer of spontaneous recovery very
infrequently met with, and which does not protect the patient foom
complications, as I shall presently show. £arly diagnosis should be
made, for upon this depends the prognosis. One must establish the
presence of an occlusion. To do this the positive signs of intestinal
occlusion must be used. These we have already considered. An im-
portant fact is to be mentioned and that is, when in presence of the
clinical signs of the process one must not neglect to examine the
hernial openings in order to eliminate a possible strangulated hernia.

When the diagnosis of occlusion has been made, the next thing to
do is to discover its nature. In the case of invagination in infants
a differential diagnosis must be made of all the various intestinal
hemorrhages, because in invagination the essential symptom is
melsena. But, should there be coexistence of bloody stools and
symptoms of occlusion, the diagnosis is certain if one finds an
abdominal tumor by palpation.

In children the diagnosis is an easier matter, because the majority
of cases of occlusion during the first few years of life are due to in-
vagination. There is a pathognomonic sign which imposes the
diagnosis, namely, the exit from the anus of the invaginated segment,
because in this case the invagination cannot possibly be mistaken for
rectal prolapse or polypus, which do not give rise to symptoms of
occlusion nor to the general physical condition arising in obstruc-
tion.

When the invagination takes place in the ascending colon the
differential diagnosis with appendicitis may really be most difficult,
but in invagination the tumor can be moved in the vertical direction,
while in appendicitis the tumor is fixed.

At the present time medical treatment is no longer considered in
acute intestinal invagination. Purgatives are to be absolutely dis-
carded, for their use leads only to disaster. Intestinal irrigation
is quite plausible theoretically, but in practice is to be rejected.
Half a litre of liquid is quite enough to rupture the bowel in a three-
month-old infant Insufflation of gas, air, or carbonic acid is not
to be considered, because it is, perhaps, only applicable in some few

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GASTBO-INTSSTINAI. SUBOBBY Ain> PATHOLOGY 249

well-determined cases, but, even then, one is never sore of having
obtained a complete reduction of the invagination.

Surgical treatment consists in opening the abdomen, preferably
at a point over the tumor, if this can be distinctly felt When the case
is dealt with early in the process one may try to reduce the invagina-
tion. This should be proceeded vnth with very great prudence —
not by traction on the gut, but by expression. To accomplish this,
circular pressure is made over the invagination, but with very great
gentleness and not persisted in if the desired result is not quickly
obtained.

The mortality considerably increases with the lapse of time be-
tween the first symptoms and the operation, but when it can be
accomplished reduction of the invagination is the method of choice,
for it is rapidly done and relatively easy. Some instances of re-
currence have been recorded.

When reduction does not succeed^ resection of the invagination
with enterorrhaphy is imperative Colostomy is out of the question,
for the good reason that the invagination is not cured, and gangrene
of the gut being, for this reason, inevitable, a fatal outcome shortly
occurs.

It is hardly necessary for me to describe the technic, which is
well known and can be found in all text-books on surgery, but it is
necessary to note a few points relative to the results. According to
Dewal, 30 per cent, of the cases are successful, but, no matter what
method is employed, the prognosis depends directly upon the age of
the invagination. I find the following table gives a fairly good idea
of the operative results, although I esteem the mortalily, when
operation is done within twelve hours, is much too high :

Operation done before 12 hours have elapsed, mortality 14 per cent
Operation done before 24 hours have elapsed, mortality 34 per cent
Operation done before 36 hours have elapsed, mortality 36 per cent.
Operation done before the second day, 37 per cent.
Operation done before the third day, 54 per cent
Operation done before the fourth day, 78 per cent.

My own experience teaches me that if the medical man will only
turn the case over to the surgeon within the first ten or twelve hours
from the time the symptoms first appear, and the surgeon, in turn,
operates without waiting to see what may turn up, the mortality may

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260 INTERNATIONAL CLINICS

readily be reduced to 2 per cent or even 1 per cent In 1911,
Binghton reported a series of fourteen cases with fourteen successful
operative results. These speak for themselves and fully bear out
my statement

V. The Pathogenesis of Pulmonary Embolus Following the
Radical Cure of Inguinal Hernia. — This complication necessarily
follows upon a thrombosis of the pelvic veins or those of the lower
limb. For an embolus to form, a thrombosis is necessary ; therefore,
the study of the causes of thrombosis results in the demonstration of
the mechanism of embolus, and of these infection unquestionably
plays the most important part The Staphylococcus albus is the cause
of mild infective processes, and, even after careful sterilization, an
infective focus may form around a suture or a ligature far more
frequently than is generally admitted. The peritoneum, being in
good condition and in possession of all its means of defence, easily
rids itself of bacteria introduced in small numbers, but if any of the
necessary conditions are lacking, a small local focus is the result,
from which arises the possibility of a thrombosis. There is no
operation whatever that can be ideally aseptic and give the operator
complete security.

The hernia sac formed by the vaginoperitoneal canal is situated
in the midst of the component parts of the cord, which adhere to it
more or less, and an ulceration of the spermatic veins, followed by a
thrombophlebitis, resulting from the dissection of the sac, is one
cause to be seriously taken into consideration. The numerous large
and frequently varicose spermatic veins are predisposed to infection
and phlebitis. How many times does every surgeon encounter a
tumefaction of the cord, lasting for some time, even when the opera-
tion of hernia has been conducted with the greatest aseptic care!
This tumefaction is inherent to the consequences of manipulation of
the cord, to traumatic lesions of the veins during the interference
while breaking up the adhesions, etc.

Sex and age appear to have no part of any import in the matter
under consideration, and if this postoperative complication is more
common in the male, it is simply due to the fact that inguinal hernia
is more common in man than in woman. Then, too, the radical cure
of inguinal hernia in the female is much simpler, and, being more
easy, there is less chance of wounding the vessels. In some cases I

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GASTBO-INTESTINAL SUEGBBY AND PATHOLOGY 261

am inclined to suspect that the omentum, particularly when very
vascular and inflamed, may be the starting-point of the venous in-
fection, especially when a portion of it has been resected.

In reality a lesion of a venule of the endothelium is all that is.
necessary, the endothelium playing a foremost part of defence in
respect to the infective toxins, so that the resulting lesion, either at
the point of ligature of the vessel or the tear of venules seated in
the operative field, may very well result in a change in the leucocytes
and a coagulation. It may be, too, that a change in the omental
vessels can give rise to pulmonary emboli by the anastomoses existing
between the portal system and the inferior vena cava. In a case of
my own there is no doubt that the pulmonary embolus came from a
phlebitis following ligature of a venous plexus.

In order to explain a femoral thrombus, a traumatic lesion of the
epigastric vein on the corresponding side has been evoked. During
their course both epigastric veins are United to each other by trans-
versal or oblique anastomoses in sufficient number to form a plexus,
and, in cases of inguinal hernia, these are in relation to the neck of
the sac. This accounts for epigastric phlebitis with involvement of
the femoral vein on the opposite side.

Why the left side is more frequently the seat of the process may,
perhaps, be explained from the fact that the venous circulation is
slower than on the right. On the left there are several reasons for
this slowness, one being the sigmoid flexure filled with fseces, which
compresses the left-iliac vein; then the arteries cross the veins and
press on them, while the greater length of the route followed on the
left side by the blood is also a reason.

Trauma during operation to a vein may be quite sufficient in it-
self to cause thrombosis without there being infection. Traumatism
changes the endothelium of the veins, and this simple change, by
liberating a few cells, causes them to become foreign bodies around
which clots may form in the way that any form of foreign body is
introduced into a blood-vessel. And all this occurs without the in-
tervention of bacteria, which, of course, is the ordinary factor, and
quite independent of a slowing down of the blood current or of blood
changes, both of which causes I shall now dwell on; for, although
unquestionably infection plays the principal part in the production
of a thrombosis, in most cases there are certainly other factors which

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252 INTBBNATIONAL CLINICS

favor it^ such as blood changes producing coagulation and also a
decrease in the intensity of the venous blood current At the present
time the tendency is to see only infection in all these cases and to
deny all other causative factors. The thrombus arises only in a
vein following upon a change in the endothelium of the vesseL In
several cases I have found it a difficult matter to admit the occurrence
of a primary infectious origin^ as the wound in each case was micro-
scopically and bacteriologically negative, repair having taken place
without the slightest untoward symptom. I cannot understand why,
theoretically at least, it is not perfectly possible in a vein suddenly
occluded by compression, either temporarily with a hsemostat or
permanently with a ligature, for the stagnant blood current to be-
come less susceptible to rapid coagulation, and from the fact of the
intravenous arrest of the circulation the immobility may facilitate the
solidification of the fibrin. I see no reason whatever why this reason-
ing is not perfectly logical, although I am perfectly aware that it is
fearfully old-fashioned, but, nevertheless, although I am not old, I
have seen in my day many an antique theory revived and accepted,
though disdained by many of my generation.

Betuming now to modem work, it has been shown that coagula-
tion is due to a ferment developed by the destruction of the elements
of the blood ; but the chemical change alone is not generally sufficient
to produce coagulation. The wall of the vessel is supposed by some
to prevent coagulation in the living on account of a catalytic action
which destroys the ferment, so that it is the integrity of the vessel
walls that prevents coagulation. Nutritive or traumatic changes favor
coagulation, but an aseptic ligature without trauma leaves the blood
perfectly liquid.

Vaquez has shown that a slowing down of the blood current
favors thrombosis, but is in itself insufficient to produce it, and he
explains thromboses in arteriosclerotic subjects and in old cardiacs
by the weak cardiac impulse which results in a slow circulation.
Any hindrance to the free circulation of the blood is a predisposing
cause. Thrombosis, as demonstrated long since by Lancereaux, always
forms in these portions of the vascular system where the blood has
the greatest tendency to stasis, — that is to say, at the limit of action of
the cardiac impulse.

Blood changes also enter into play, and among the patients re-

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GASTBO-INTB8TII7AL SUBGEBY AND PATHOLOGY 268

quiring operation many are ansemio, either on account of insufficient
nourishment or overwork, others from some diathesis, such as cancer
or some cachexia producing a dyscrasic state of the blood favorable
to the formation of a thrombua

The ansesthetic used has sometimes been incriminated. Chloro-
form produces changes in the hepatic cell which may even go as far as
degeneration. Urobilin appears in the bloody and the hepatic cell,
having become insufficient, no longer fulfils its antitoxic part, aUow-
ing the passage of toxic substances which accumulate in the blood.

The blood-cells themselves become altered. Studying the capil-
laries of the frog poisoned by chloroform, Witte saw the globules be-
come spherical^ present club-shaped prolongations, and become arrested
at certain points, forming pulmonary emboli. However, the part
played by chloroform is, I believe, of only relative importance in
practica

As causes favoring thrombosis some writers, particularly the
Teutons, have supposed that a too long rest in bed was a factor. Others
have mentioned abdominal distention following laparotomy and chill-
ing of the peritoneal cavity during operation. Hochenegg accuses
a latent infection from the intestine,— a plausible hypothesis after
the radical operation for hernia. From personal experience I am in-
clined to believe that obesity may have a predisposing influence on
the formation of embolus.

When the patient has no hereditary antecedent, no intercurrent
affection, nor the slightest trace of infection, can we assume that he
has an aseptic traumatic phlebitis ? I think in answer we can say
that when the trauma involves a varicose vein coagulation is more
considerable and persistent and may end in obliteration, just as
occurs in an infectious phlebitis. This asepsis of postoperative
phlebitis includes only those cases where the venous trunk has been
directly traumatized, and no phlebitis of the spermatic veins follow-
ing a radical operation for hernia, whose sac is peeled off with diffi-
culty, resulting in confusion of the veins of the cord, occasionally
presents such satisfactory conditions of clinical asepsis that, in spite
of the absence of a convincing direct bacteriologic examination, the
hypothesis of an infectious phlebitis seems imlikely.

Of course, in most cases the thrombosis is a manifestation of a
general organic infection or an infection starting from the area of

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264 INTBBNATIONAL CLINICS

the hernia. Infection also must be incriminated to explain those
thromboses arising some distance from the seat of operation ten to
twenty days later. The apparition of the thrombus is favored by
lesions of the vessels, a slowing down of the venous circulation,
changes in the blood causing more rapid coagulation, and the presence
of varicose veins in the lower limbs.

Now, the small intestine, the usual contents of a hernia, is a very
vascular structure; its veins, by their anastomoses, form the great
mesenteric vein, which is one of the branches of the portal vein. By
the intermediary of the peritoneum the small intestine is in contact
with numerous parietal and visceral veins of the pelvis.

The primal elements of the coagulum are composed by altered
leucocytes, whose action is completed by that of the haematoblasts,
which become the centre of fibrinous reticuli. The clot thus formed
at the level of a vascular spur or a venous valvule is propagated in the
direction of the blood current. The blood stagnating in front of this
obstacle coagulates in its turn, giving rise to a secondary clot, which
extends to the point where the vein opens into a main branch. It
extends even beyond this opening and penetrates into the lumen of the
vessel, into which it projects like the head of a nail. This head,
incessantly struck by the blood current, becomes fragmented, then
detached, and is thrown into the circulation, soon to give rise to an
embolus. In other instances the adhesion of a primary or secondary
clot is not sufficiently strong, and often it is at the time the pati^it is
to leave his bed that the clot becomes detached. It is carried by the
blood current, passes into the vena cava, where it freely circulates,
reaches the right auricle, whence it is thrown into the pulmonary
artery. The obstructing clot is all the more likely to break its ad-
hesions if the patient be debilitated or if he presents some organic
taint

When once a pulmonary embolus has taken place, three cases can
present themselves, according to the calibre of the artery occluded.
If the artery is small, we have a capillary embolus; if of medium
calibre, a lobular embolus; and, lastly, if a large embolus becomes
arrested in the main trunk or in one of its principal branches, a
lobar embolus results.

In capillary embolism, on account of the arrangement of the
pulmonary circulation in which the arteries are terminal, an anaemia

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GASTBO-INTESTINAIi SUBQBBY AND PATHOLOGY 266

of the area irrigated by the occluded vessel first takes place, after which
an infarction forms. If the vessel primarily involved recovers its
permeability, the area of the infarct will be restituted ad integrum;
otherwise fibrous or calcareous transformation arises. If, on the
other hand, the embolus was septic, a focus of gangrenous or suppurat-
ing pneumonia results.

When the embolus is of medium size, a lobular or lobar embolism
occurs, according to circumstances. If death does not take place,
pulmonary congestion and oedema ensue, sometimes even an infarct
of the entire lobe when progressive asphyxia with repeated haemopty-
sis is observed. When the embolus is large enough to occlude the
main trunk of the pulmonary artery sudden death takes place or,
at least, is not long delayed.

VI. Ounshot and Bayonet Wounds of the Stomach. — The tm-
fortunate war in Europe suggests the following brief remarks,
which are compiled from my lecture notes on the " Surgery of War.''

A bayonet wound is practically similar in all respects to any type
of stab wound, but the lesions produced by the Lebel bayonet present
some special aspects which should be examined. The Lebel bayonet
has four sharp, longitudinal projections, separated by four correspond-
ing grooves, and its effects have been studied by Sieur. He found the
wounds resulting in the stomach and intestine were rounded, with
irregular and slightly contused borders. In the experiments which
Sieur undertook on dogs he found that after the bayonet had been
withdrawn the borders of the wound came bad: in contact with each
other, resulting in a complete occlusion of the perforation, from
which it was difficult to force out the gastric contents. On the other
hand, when the arm remained in place, the grooves formed true
gutters along which the gastric contents escaped and accumulated in
the peritoneal cavity. Sieur is of the opinion that this bayonet acts
by retracting the tissues, rather than by their section or laceration,
and this applies to the muscular fibres in particular. A soldier who
was wounded in the epigastrium and who died from a wound of the
aorta showed at autopsy that, although the stomach was full of food
and completely transpierced, no gastric contents were found in the
abdominal cavity. A young girl who was wounded in the epi-
gastric r^on by a Lebel bayonet presented distinct symptoms of
gastric perforation, but recovered without operation.

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256 INTERNATIONAL CLINICS

Beferring now to the most important part of the subject, that of
gunshot wounds, it may be said that to-day the armies of all civilized
nations employ a pointed projectile of small calibre, animated by a
very great penetrating force, but^ as might be expected, judging from
recent events, we already have reports from the Belgian surgeons of
the removal of the dum-dum bullets in use by the Germans. The
modem projectile is elongated in shape and of an average calibre of
seven millimetres; its length is equivalent to about four times that
of its calibre, and it weighs about fifteen grammes. The nucleus is
composed of an amalgam of lead and antimony, which forms a very
hard mass, and is, at all events^ covered at the apex and usually also
in its entire surface, the base excepted, with an envelope of hard
metal. Of the new German S bullet, the new Fraich D bullet, and
other types now being studied in Switzerland and elsewhere, we
have, unfortunately, had an overabundant demonstration of their
respective valua

The lesions differ according to the distance at which the arm is
fired. Beyond 300 metres, these projectiles produce simple perfora-
tions which are small and circular, the bullet entering the tissues
like a gimlet^ spreading them apart, with the result that the borders of
the wound may close together, producing an almost complete occlusion.
The opening of the exit of the projectile is generally somewhat
larger than that of entrance. When the firing distance is less than
300 metres the lesions vary according to the state of plenitude of
the stomach. When the organ is empty the wounds present the same
characters as those just enumerated, and the resulting disturbances
will be slight, but the same cannot be said when the stomach is
distended with food, and the result is a genuine bursting of the
viscus. Such lesions have been made experimentally by Delorme
and reported in his work on the " Surgery of War." He states that
under these circumstances, besides the entrance perforation, which
has the diameter of the projectile, with the exit perforation con-
siderably larger, the viscus presents large lacerations and extensive
rents.

Gunshot wounds of the stomach are very frequently accompanied
by wounds of the neighboring viscera. When the shot is fired at a
moderate distance the projectile generally transpierces the subject,
passing through the pleura, lung, liver, spleen, pancreas, kidney, or

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GABTBO-INTSBTINAL SUBGEBY AND PATHOLOaY 257

even the pericardium and heart. The TninimnTn of damage is met
with when the projectile enters the area of Labb^'s triangle, an area
in which the stomach is in direct relation with the anterior abdominal
parietes, but even here the organs situated behind the stomach
(kidney, pancreas) will probably be involved. In other instances the
track of the projectile in the tissues is much longer when the bullet
follows the exit of the body. This is met with frequently in soldiers
who were in the recumbent position at the time they were shot, and
under the circumstances the lesions are multiple and varied. In one
case the point of entrance was in the anal region, while the point of
exit was found in the left sixth intercostal space in the mammillary
line. The bullet lacerated the hypogastric vein, perforated the small
intestine several times, likewise the colon and mesentery, and also
went through the stomach.

Such cases are of no clinical interest, however, because death takes
place before any aid can be offered, and, although such lesions are
frequent on the battle-field, there are, fortunately, instances in which
the stomach alone is involved, or at least represents the principal
lesion. It is just these cases that we may possibly consider as being
justifiable to operate on.

Let me now revert for a moment to what I may term the area of
gastric vuhterahiUty and which corresponds to the projection of the
stomach on the abdominal walL Over the anterior abdominal wall
this area has an oval shape, with its axis slightly inclined from left
to right and from above downwards, whose greater extremity occupies
the left hypochondrium, while the lesser is situated to the right of the
middle line corresponding to the pylorus. Its upper limit is repre-
sented by a curved line, with its concavity parallel to that of the
diaphragm, whose uppermost point is at the level of the left fifth
rib in the mammary line. This point undergoes slight oscillations
with the respiratory movement

The lower limits vary. When the gastric cavity is emply they
correspond to a transversed line passing at the point of union of the
ninth and tenth rib on each side. When the stomach is distended,
it becomes displaced downwards, and, since opinions differ as to this
point, I merely say that the most declivous point of the full stomach
will be found in the neighborhood of the umbilicus.

The left lateral limit in the state of complete distention becomes
Vol. n. Ser. 25—17

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258 INTBBNATIONAL OLINIGS

confounded with the limits of the hypochondrimn. Usually it
attains a vertical line passing slightly to the outer aspect of the
nippla The right extremity corresponds to the pylorus^ which is
also subject to variations^ but which, in its mean situation, is found
behind die eighth rib, this point corresponding to the external border
of the rectus.

Over the posterior abdominal wall the projection of the stomach
effects a shape similar to the preceding. The culminating point of
its upper curved limit is at the middle of the eighth rib in the left
scapulary line. In the middle line its upper limit, corresponding to
the lesser curvature, obliquely crosses the spine from left to right and
from above downwards, extending from the left side of the tenth
dorsal to the right side of the first lumbar vertebra. When the
stomach is distended the lower limit reaches about to the spinous
apophysis of the second lumbar vertebra.

Let it not be understood that a wound whose orifice of penetration
is located outside the limits of the area here given may not involve the
stomach. With firearms this can very well happen, but in this case
involvement of the stomach is rather the exception.

Gunshot wounds are the most frequent of any in battle, lesions
from the bayonet the exception. Usually the damage done by the
projectile within the abdomen is so extensive that death results at
once. Logically, it may well be argued that a laparotomy is indicated
to control the dangers of intra-abdominal hemorrhage, and, above
all, the effusion of the gastric and intestinal contents. This is what
the majority of surgeons thought who were called into action in the^
South African war, and everything had been prepared for the treat-
ment of abdominal wounds by immediate laparotomy. But the
results of this practice quickly showed that the mortality of the
operated cases was greater than that of those patients treated by tem-
porization, and the conclusion in all the amount of matter written on
the subject is that a great number of those thus wounded die before
they are removed from the field ; that among those removed a number
die from peritonitis, but quite a large proportion recover without
oper9,tion, and that almost all who submitted to laparotomy died. Con-
sequentiy, at the present time opinion is unanimous that abstention
is proper, and this is undoubtedly the correct view in the vast majority
of cases, since the time required in carrying out. these operations is

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GASTEO-HTTBSTINAI. SUBGBBT Ain> PATHOLOGY 269

simply lofls of time, which could be far more fruitfully employed in
the treatment of other injuries.

The results were quite the same in the Busso- Japanese war, and
it is sufficient to read the article by the Bussian military surgeon
Wreden, published in The Military Surgeon, Mardi, 1907, in order to
become convinced. In his paper on abdominal wounds in the same war,
published in the 84th volume of Langenbeck^s Archvv., Bomhaupt
gives statistics of 182 cases treated. All the cases were brought in late
to this surgeon, and he obtained a cure in 78 per cent of those treated
by conservative surgery, while 50 per cent of the operated cases died,
but it must be said that the majority of these presented peritonitis at
the time of operation.

Peritonitis is the only late indication for operating, and in these
cases the operative act should be reduced to the minimum: simple
incision, to let out the pus and drain the peritoneal cavity, without
searching for the gastric lesion, which, unlike wounds of the intestine,
have a much more favorable evolution. However, the existence of
lesions of the neighboring viscera may create special indications^
such as hernia of the intestine or omentum, and, above all, intra-ab-
dominal hemorrhaga What has been said of gunshot injuries to the
stomach applies quite as well to lesions from the bayonet, whose
resulting wounds generally have a favorable evolution.

The conservative treatment consists in absolute rest, and, if
possible, the subject should not be mobilized. This latter is the first
condition of conservative treatment Morphine and opium are to be
administered and an absolute diet maintained for the first few days,
which should be continued just so long as there is any doubt about
cicatrization of the gastric perforation. Usually, feeding by mouth
can be prudentiy commenced by the fourth day, but it may have to be
postponed for a week or so. During this time rectal feeding is ex-
clusively employed, along with the subcutaneous administration of
physiologic salt solution.

As I have already said, there are cases which will die from in-
ternal hemorrhage if not immediately operated on, and this is the
only indication for surgical interference in abdominal wounds when
the patient reaches the field-hospitaL

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INTRANASAL FRONTAL SINUS OPERATIONS:
CONSERVATIVE SURGERY

BY WILLIAM LINCOLN BALLENGER, M.D.

Chicago, niinoU

DuBiNG the past fifteen years there has been a growing tradency
to abandon external operations upon the frontal sinus, and to sub-
stitute therefor various methods of intranasal operating. Doubtless
many cases previously operated by the external route could now be
successfully operated by the intranasal route. Notwithstanding this
there is stiU a field for the external operation. Not all cases of
frontal sinus suppuration can be cured by the intranasal route, espe-
cially those cases in which there are partial, though almost complete,
septa, and those in which there are bone necrosis and extensive
granulation tissue. In one such case the author failed to get results
after an intranasal operation, and upon doing the Killian operation
found the left sinus entirely denuded of mucous membrane and
periosteum, the bone being quite porous and chalky in texture. After
draining the sinus by the Killian operation the suppuration entirely
ceased and the accompanying asthma was cured. The asthma was so
severe that for weeks at a time the patient was compelled to sleep
sitting with the head resting upon a table.

While there will be cases requiring the external operation, we
must admit that most of them may be successfully handled by the
intranasal route. This is of great importance to the patient, as it
avoids the possibility of disfigurement which sometimes attends the
external operation, especially in those cases in which the sinus is
deep and broad. The intranasal operations are also less severe and
are not attended by as great shock, though, unless performed with
great skill and the proper technic, they may be more dangerous than
the external operation.

We shall not attempt to discuss the comparative merits of the

various intranasal operations, but will confine our remarks to a few

of the procedures, and will not even then enter into a discussion of

the technic except in so far as may be necessary to make the point

260

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INTRANASAL FEONTAL SINUS OPBBATIONS 261

under discussion clear. It is assumed that nonsurgical measures
have been tried and found ineffectual before surgical procedure is
determined upon.

The various operations may be classed as (a) burr or drill opera-
tions, (b) rasp or file operations, and (c) curette operations.

Of the burr and drill operations mention may be made of the
Ingalls, Halle, and Watson Williams operations, though some of these
are modified by other technical procedures, as the use of biting forceps
and the curette.

Of the raspitory operations mention may be made of the Good,
Sullivan, Vacher, and S^ura operations.

Of the curette operations my remarks will be confined to Mosher's
operation, which I have performed about fifty times.

Instead of discussing the desirability of these various operations,
I shall confine my remarks to some general principles, which, being
based upon a ratter large experience in intranasal surgery, I hope
will help to clear the atmosphere in reference to the intranasal drain-
age of the frontal and anterior ethmoidal sinuses.

ANATOMICAIi CONSIDBRATIONS

To understand the drainage of the frontal and anterior ethmoidal
sinuses, the anatomical topography of these regions should be borne
in mind.

(a) Some of the anterior ethmoidal cells drain directly into the
frontonasal duct, which drains the frontal sinus. As a result of
this relationship to the frontonasal duct or canal the involvement of
the frontal sinus is nearly always accompanied by an involvement
of some of the anterior ethmoidal cells. Hence, in considering the
drainage of the frontal sinus, consideration must also be given to
the drainage of the anterior ethmoidal cells. The one cannot be
accomplished without the other. The frontonasal canal opens into
the floor of the frontal sinus near its median wall, and extends down-
ward and backward to a point below the attachment of the middle
turbinal body, and ends in a semilunar groove or open gutter, known
as the infundibulum (Fig. 1, /). The frontonasal canal and the
infundibulum may be considered as one continuous canal, the upper
portion of which is a closed, irr^ular, tubular canal, while the lower
or infundibular portion is an open or groove-like gutter. Some of the

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262 DTTEBNATIONAIi CLIKICS

more important anterior ethmoidal cells open into the upper or dosed
canal, especially on its orbital aspect, though some open into its
antmor and its posterior aspects (Fig. 5). Some ethmoidal cells
also open into the infuitdibulum or open portion of the canal, while
the bulla ethmoidalis and the concha ethmoidalis open directly into
the middle meatus above the infundibulum (Fig. 3). In empyema
of the frontal sinus, the ethmoidal cells, draining directly into the
closed upper portion of the canal, are most often affected, because of
their intimate connection with the portion of the canal concerned
with the drainage of the frontal sinus. The bulla ethmoidalis and
concha ethmoidalis are not so often involved because of their direct
drainage into the middle meatus. In some cases the crista nasalis
projects backward and interferes with the opening of the floor of the
frontal sinus, unless it is also removed. As this bone is dense it can
only be removed with a burr or a strong sliding bone-forceps (Figs.
4 and 6, F).

It is obvious, from the foregoing data, that in order effectually to
drain the diseased frontal sinus it is necessary to do it i;ta the
frontonasal canal (closed portion of the drainage conduit), which
necessitates converting the canal and the anterior ethmoidal cells
draining into it into one enlarged space or canal; that is, it necessi-
tates the destruction or exenteration of the anterior cells surrounding
the closed canal, and the reduction of the dense, bony crista nasalis.
Through this enlarged outlet the frontal sinus may usually be ade-
quately drained and the empyema cured.

(b) The second anatomical feature to be considered is the middle
turbinate body, the anterior end of which covers the lower portion of
the closed canal and entirely overhangs the infundibulum (open por-
tion of the canal), and may become an obstruction to the free flow
of secretion from the frontal and anterior ethmoidal cells. This is
especially true when the anterior end of the middle turbinate is en-
larged either from hyperplasia or bullous enlargement, the so-called
concha turbinalis (Fig. 3, ch). It may also become an obstructive
factor where a high deviation of the septum crowds it toward the
orbit Hence the middle turbinal must be considered in the treat-
ment of f ronto-ethmoidal disease.

(c) The bulla ethmoidalis is the third anatomical factor to be
considered in the drainage of the frontal sinus. The bulla is located

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Fio. 1.

P /

Diagrammatic. A, A, right and left antri; O, inferior turbinate; /, /, infundibuli; B, b. left
and right bulla ethmoidales; E, ethmoid plate: C. C, exenterated ethmoid cells; e, e, ', ethmoid
cells; P, cribriform plate.

Fio. 2.

Diagrammatic. C, total exenteration of ethmoid cells and ethmoid plate, leaving large drainage
space; E, swollen ethmoid plate left in aitu after exenteratin^ the ethmoid cells; /, small drainage
area due to swollen ethmoid plate; P, olfactory perforations m the cribriform plate.

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Fig. a

Diagrammatic. P, P, cribriform plate; F, frontal plate partially covering the ethmoid cell&
Upper arrow shows drainage route from the posterior ethmoid cells into the superior meatus. I-.ower
three-tailed arrow shows drainage routes from the antrum and anterior ethmoid cells. cA, bulla
conchalis, or anterior ethmoid cell in the middle turbinate.

Fio. 4.

Showing cutting bone forceps removing the crista nasalis in front of the osteum frontalis, the
anterior cells having been removed by curettage according to Mosher's technic.

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IKTRAJXABAJj FBONTAL SINUS OPBSATIONS 268

under the attachment of the anterior half of the middle turbinal,
above the hiatus semilunaris, and may impinge upon the hiatus and
obstruct the flow of secretion from it into the free space of the middle
meatus of the nose (Fig. 1, 6). In such a case it may cmly be neces-
sary to curette and thus destroy the bulla ethmoidalis to establish
free drainage of the frontal and the remaining anterior ethmoidal
cells (Fig. 1, -B).

(d) The fourth anatomical feature to be borne in mind is the
extreme anterior attachment of the middle turbinated body, as it is the
landmark by which the closed frontonasal canal and the anterior
ethmoidal cells draining into it are orientated; that is, they are
located above this point, and are covered by an extremely thin wall
of bone, which may be easily broken into with a suitable curette, as
has been shown by Mosher. Occasionally the more anterior cells
are covered by dense bone from the agger nasi anteriorly (Fig. 6, A),
in which event the curettage must be made a little posteriorly.
Mosher's operation is based chiefly upon the knowledge of these
simple anatomical facts.

(e) The fifth anatomical factor to be held in mind is the width
of the space between the septum and the orbital or outer plate of the
ethmoid cells. First study the free air-spaces from the septum to
the orbital plate with the middle turbinate in position (Fig. 1) ; and,
second, study it with the middle turbinate land cells removed (Fig.
2, C). Note the greatly-increased space with the turbinate removed.
Then study it with the cells removed and the middle turbinate (Fig.
1, E) in position, and note the relatively narrow spaces for drainage.
From this study it becomes obvious that in some cases it will be
necessary to remove the anterior half or third of the middle turbinated
body to establish free flow of secretion from the frontal and anterior
ethmoidal cells, whereas in others it may not be necessary to do so.
The aim should always be to remove as little tissue as will establish
adequate drainage of the involved sinuses.

(/) The sixth anatomical factor to be borne in mind is the cribri-
form plate of the ethmoid, as injury to it might result in meningitis
and death. The anterior end of the cribriform plate is directly above
the anterior attachment of the middle turbinate body, sometimes a
little more anteriorly. It is also medianward toward the septum.
If these facts are borne in mind during the curettage of the anterior

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264 INTBBNATIONAL CLINICS

ethmoid cells and the removal of the ethmoid plate it need not be
injured.

(g) The seventh anatomical factor bearing upon intranasal opera-
tions upon the fronto-ethmoid sinuses is the relation of the bony
plates from which the turbinated bodies and the cells develop. By
reference to Fig. 6 it will be shown that there are four and sometimes
five plates^ the first being the uncinate plate from which the uncinate
process (median waU of the infundibulum) is formed. Sometimes
cells, known as infundibular cells, also spring iiora this plate. The
second plate is the one from which the bulla ethmoidalis springs.
The third is the middle turbinal plate, and the resorption of the
bony tissue between it and the bullous plate gives rise to most of
the anterior ethmoidal cells. The fourth is the superior plate from
which the superior or fourth turbinate springs. The posterior ethmoid
cells arise from the resorption of the bony tissue between this and
the middle turbinate plate and drain into the superior meatus of the
nose. The fifth plate (rare) forms the foundation of the supreme
turbinate.

PRACTICAL DEDUCTIONS

Having given due consideration to some of the more important
anatomical data bearing upon the intranasal surgery of the frontal
sinus, we are prepared to discuss their bearing upon the operative
technic. Two factors are constantly striven for; namely, (1) the
safety of the patient, and (2) adequate drainage. The safety of the
patient should always take precedence when the two factors conflict.
To this end the operative technic should be such that it has the least
possible chance of injuring the cribriform plate, and at the same time
establishes adequate drainage of the frontal and ethmoidal sinuses.
To aid in getting a proper perspective on these cases we will make
the foUowing practical deductions, which, reviewed in the reverse,
orientate the various indications for treatment :

As shown in paragraph (a) under " Anatomical Considerations,*'
the most natural and accessible route for the artificial drainage of the
frontal sinus is via the anterior ethmoidal cells, which open into the
closed portion of the frontonasal canaL The canal lies at a point
almost directly above the anterior attachment of the middle turbinate
body on the outer wall of the nasal cavity, and the ethmoidal cells in

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Fia. 5.

Oiasrammatic. 1, first or uncinate plate; 2, second or bulla ethraoidalis plate; 3, middle turbi-
nate plate; 4, superior turbinate plate; 5, supreme turbinate plate (rare); r, processus frontalis;
O, X, line of catheterixation of frontal sinus before intranasal operation; Z, X, line of ratheteriiations
of frontal sinus after intranasal operation.

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INTRANASAL FBONTAIi 8INUS OPERATIONS 265

qnestioii lie eztemal, anterior and posterior, to it (Fig. 5). There
are no cells medianward to the canal ; that is, the curette when applied
to this region with slight force penetrates directly into the fronto-
nasal canal, or into a cell either directly anterior or posterior to it
Having entered into these air-spaces, their limitations may be readily
outlined with a curved silver probe, and curettage carried out without
undue trauma to the surrounding tissues. Having removed the
median waU of this area (see circle. Fig. 5, and black area. Fig. 4),
and the septa dividing the cells, the curettement may be carried for-
ward, where the enveloping bone and septa are more dense, without
danger of injuring the cribriform plate. The bone enveloping the
cells anterior to the canal, being of greater density (agger nasi),
requires vigorous instrumentation to break it down (Fig. 5, il).
Good's rasp-files (or Sullivan's) are sometimes employed for this
purpose. I have had some experience with Good's rasps and have
found them to be efficient for this purpose. My objection to the rasp
is that it must be used with a to-and-fro or sawing motion, the up-
ward stroke of which is liable to injure the cranial plate lateral to
the cribriform plate and posterior wall of the frontal sinus. Fortu-
nately I have had no untoward results following its use. However,
as the safety of the patient is the first consideration, I have ceased
using the rasp and have substituted therefor the curette, which
has proved most satisfactory.

I do not employ either the Ingalls pilot trephine or Halle's burrs.
Of the two, however, I regard Ingalls's as much safer, though per-
haps not as efficient as Halle's.

The paramount object of these or other procedures is to establish
good drainage of the frontal sinus with the least possible danger to the
patient, either as to nasal function or life. It has been a matter of
surprise to me to learn how simple and gentle Mosher's procedure is,
and how easily one may introduce a large cotton wound probe into
the frontal sinus at its close, even while the middle turbinate is still
in position. And, what is of still greater importance, the results
have been uniformly good.

Is it necessary to remove a portion of the middle turbinate to
establish adequate drainage of the frontal sinus ? This question has
given rise to considerable difference of opinion. Some authorities
have questioned it upon the ground that its removal exposes the

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266 INTBBNATIONAIi 0LIWI08

meninges to danger of infection via the cribrif onn pkte. They base
the opinion upon post-mortem findings in which meningitis f oUowed
the removal of the ethmoid plate. The infection was shown to have
traversed the openings in the cribriform plate. They reason that if
the middle and superior turbinals, the so-called ethmoid plate^ have
been left in situ, they would have formed a barrier to the invasion
of the pathogenic bacteria to the cranial cavity. Let us study the
factors in the case and see how they bear upon the question.

Beferring to Fig. 1, e, e, e, we see the ethmoid cells in place,
also the bulla ethmoidalis (&). On the opposite half of the drawing
the ethmoid cells and buUa are shown exenterated (B, 0), with the
middle and superior turbinals (ethmoid plate, E) unmolested. It has
been left in position, according to this theory, to protect the cribriform
plate from injury during the operation, and from subsequent infection.
The idea is that in order for infective microorganisms from the
wound to reach the cribriform plate they must traverse the distance
around the ethmoid plate, which undoubtedly forms a physical
barrier to infection, and if that were the only factor to take into
consideration it would be a good idea to leave it in each case operated.
Unfortunately there is another factor, often of the greatest im-
portance, to be considered ; namely, the establishment of good drain-
age of the operated area immediately following the operation. If
this should not occur, the mucosa of the area may become enormously
swollen and completely block the drainage, as shown in Fig. 2, E, I.
Not only may the mucosa of the operated area become swollen, but
that of the upper portion of the septum and of the median wall of
the ethmoidal plate may also become swollen, thus blocking the area
we are trying to protect. In such an event, the danger of meningitis
becomes imminent On the other hand, however, the removal of
the ethmoidal plate may result in direct injury to the cribriform
plate and cause meningitis. In any event we are between Scylla
and Charybdis. If we steer the surgical bark in one direction, we
may be wrecked upon the rocks of Scylla, and if we steer it in the
other, we may be wrecked upon the bleak shores of Charybdis.
The truth of the matter is that meningitis rarely occurs after either
method of procedure. When it does occur, however, it is a sad
eventuality. The thing to do is to study each case as it presents
itself, and determine, as nearly as can be done by ocular inspection

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INTBANA8AL FBONTAL SINUS OPERATIONS 267

and probing, the amount of space available for drainage with the
ethmoidal plate in situ, and, if it seems ample, do not remove it.
If it is found that the drainage space is small the anterior half of
the ethmoidal plate may be removed to provide greater space. After
its removal extreme care should be exercised to confine the use of the
curette or other instrument to the orbital aspect of the cranial plate ;
that is, the instrument should not be used alongside the septum, the
location of the openings in the cribriform plate.

The argument to be put forward for the removal of the ethmoid
plate is ihat ample drainage is always provided for, as is shown in
Fig. 2, C. Instead of two narrow spaces with four mucous membralie
surfaces to become swoUen, there is a space treble in diameter and
with only two mucous membranes to become swollen. As a conse-
quence the combined exenteration of the anterior ethmoidal cells
and the removal of the ethmoidal plate are rarely foUowed by ex-
cessive swelling and blocking of the drainage. This opinion is not
based upon theoretical grounds alone, but is based upon twenty years'
experience. Both methods have been used by the author and much
less trouble has attended those cases in which the ethmoidal plate
was removed.

After trying various methods of draining the frontal sinus through
the nose, I am convinced that Dr. Mosher's procedure is, on the
whole, the simplest, most direct, and by far the safest and, at the
same time, most effective yet devised.

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THE APPLICATION OF SURGICAL PRINCIPLES TO
. OPERATIONS ON THE NOSE AND THROAT

BY HAROLD HAYS, AM., MJ>., F.AC.S.

Assistant Surgeon in Otology, New York Eye and Ear Infirmary; Assistant
Laryngologist and Otologist, City Hospital; Chief of Clinic (Nose and
Throat), New York Polyclinic Hospital, etc. *

It is only within the past quarter of a century that the scientific
side of rhinology and laryngology has advanced to the stage where it
can be considered one of the more important specialties. This has
been made possible by the numerous inventions which have given the
workers in this field the opportunity to see into almost every nook
and cranny of the cranial cavity.

OriginaUy examinations of the nose and throat were made by
direct sunlight. ITasal specula of wood were used until the nine-
teenth century. Examination of the throat required no special instru-
ment. Then came the epoch-making discovery of Garcia — ^that the
vocal cords could readily be seen through a mirror held up against
the soft palate.^ Later ^ with the advent of gas and electricity, it
was found that indirect examinations from light reflected from a
head-mirror were more reliable. With the invention of the metal
speculum, the tongue depressor, the laryngoscope, rhinoscope, and
head-mirror, it was a comparatively simple matter for one to train
himself to a superior knowledge of the anatomy and pathology of these
regions. Since then, especially within the past decade, diagnostic
instruments of precision have become very numerous. The trans-
illuminator and the X-ray have brought the sinuses into view; the
nasopharyngoscope directly inspects the nasopharynx; the author's
pharyngoscope makes the examination of the nasopharynx and larynx
a very simple procedure; the laryngoscope and bronchoscope have
revolutionized the work upon the larynx and bronchi.

^ Czermak, in 1858, made use of lamplight and advised the employment of a
" large, perforated concave mirror for reflecting either the sun or artificial light."
Suhsequently he very correctly asserted that but for this invention of the re-
flecting mirror laryngoscopy would have been " a dead-bom child."

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OPEBATIONS ON THE KOSE AND THBOAT 269

In the early years of this specialty very few of the men who were
interested in it thought very seriously of it from the surgical point
of view. Surgery itself was in its infancy. It was therefore but
natural that laryngology should be looked upon as a medical, not a
surgical, specialty. However, these men soon found that certain
diseased conditions could be cured only by surgical intervention.
Where could the surgeon be found who was sufficiently trained in the
use of the reflecting mirror, the nasal speculum, and the laryngoscope ?
He couldn't be found, the result being that these early pioneers had
to do the surgical work themselves. In the beginning this work was
very crude, and the instruments used twenty years ago are now only
useful in a medical museum. The writer has in his possession an ear
speculum five inches long — suitable for examining an elephant's ear.
He has also various designs of nasal specula and eustachian catheters
that couldn't possibly be used on the delicate nose which comes to his
office to-day. One must remember that these instruments were used
before such anaesthetics and shrinking agents as cocaine and adrenalin
were known.

The self-trained laryngological surgeon of thirty and forty years
ago paved the way for the establishment of this specialty on a surgical
basis. At first he worked crudely, as stated before, with poorly-devised
and poorly-made instruments. But he worked out certain special
surgical principles, many of which are still in use. Some of these
men are still living; many of them have advanced with the times and
are doing excellent work — discarding old favorite methods and follow-
ing in the footsteps of their younger brethren.

It was but natural, as young, ambitious men came into this field,
that they should recognize that laryngology to-day meant surgical, not
medical, laryngology. Many men who have been thoroughly trained
in surgery began to specialize in this new field. Frequently they
worked with the older specialist, learning everything possible from
him about the diagnosis of nose and throat conditions and then
attempting to eradicate these diseased processes by methods more
suited to the times. He often wished to bring his general surgical
technic into play; he frequently desired to broaden the field of his
work

As a result of attracting these surgically trained men, laryngology
has reached the dignity of a well-defined surgical specially which

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270 UTTEBNATIONAL OLIinOS

includes in its domain not only intranasal and intra-oral operations
with "^hich the older specialist was content, but the major surgical
operations on the nasal sinuses, die delicate operations in the triangles
of the neck, operations on the thyroid gland, intracranial operations,
operations on the hypophysis cerebri, and, last but not least, operations
for pathologic conditions of the larynx and bronchi.

In view of the fact that laryngology has advanced to this stage
of perfection, the writer takes upon himself the task of setting before
you the newer operations on the nose and throat which evidence in
themselves that true surgical principles are being applied and that
very few of the older, antiquated methods are still in vogue.

PI*A.STIO SUBGEBY

The reconstruction of f eatural deformities is attracting a great
deal of attention. Formerly a great deal of this work was performed
by " beauty specialists,'^ many of whom knew little about surgery.
Just so long as the competent, ethical surgeon kept out of this field,
just for that length of time would the " faker '^ continue to ply a
lucrative trade. So many people suffered from the bad practices
of these vultures that it was necessary for the nasal surgeon to step
into the field.

In doing plastic surgery of die face the surgeon must employ his
creative genius, as no set rules can be laid down for this work Here
true surgical principles must be applied, or else the operator is sure
to meet with disaster. One must consider every minute detail — from
the maintenance of an aseptic field to the remodelling of foreign
tissue to fit a new part. Dr. John 0. Roe, of Rochester, N. Y., was
one of the pioneers in this field, but within recent years many of the
younger operators have done excellent work, among them Dr. W. W.
Carter, of New York, and Dr. Lee Cohen, of Baltimore.

The surgical treatment of rhinophyma or "bulbous nose" has
been exceedingly difficult. But this condition can be much improved
and sometimes cured by proper surgery. One must realize diat in
true rhinophyma the pathologic process reaches into the deeper
layers of the skin and that every particle of diseased tissue must be
eradicated if one desires to get a successful result Fig. 1 iUustrates
a patient with true rhinophyma who was operated upon at the Oity
Hospital within the past year.

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OPEBATIONS ON THB NOSB AND THBOAT 271

The operation was as follows : After the patient was placed under
general anaesthesia, the nose was thoroughly cleaned with tincture
of green soap and iodine. The surrounding parts were covered with
sterile towels. The growth was removed, well beyond the diseased
parts, with scalpel and scissors, down to the cartilaginous framework
of the nose. Considerable bleeding was encountered, which had to be
stopped before proper skin-grafts were applied. This was best
accomplished by applying compresses of very hot saline solution.
The arm was prepared beforehand for skin-grafting. After the dis-
section, small grafts, including all the layers of the skin, were removed
and applied carefully to the denuded part These were covered with
sterile rubber tisaue, over which was placed a piece of plain gauze
held down by adhesive plaster.

A few days after the operation the gauze and rubber tissue were
removed. The operated area was covered with dried-up particles
of ^^ graft " which were in a state of decomposition. A little boric
acid dusting powder was applied and the part again covered with
gauze. In the course of a week the grafts healed in place and the
patient went about without any protective covering to his wound.
In this instance the open treatment was very successful. Without
a knowledge of general surgical technic an operation of this kind
would have met with failure. Here the rhinologist had to " skin-
graft," excise an external tumor, and understand thoroughly those
surgical principles which would be of most importance.

The nasal surgeon who indulges in plastic work must be able to
operate upon other parts of the body, particularly if he wishes to use
bone transplants. The most successful work along this line has been
performed by Carter, who has transplanted a piece of the ninth rib
into the nose for saddle-back deformity. Formerly the only remedy
for this condition (usually caused by a destruction of the nasal
septum from syphilis) was the injection of paraffin, which, on account
of the lax condition of the tissues, often spread out into the face,
creating ^' paraffin nodules." The operator who wishes to construct
a nose from a rib must understand thoroughly the principles of
general sui^ery.

Carter describes his operation as follows: ^^ First, it should be
remembered, in transplanting bone, that strict asepsis is absolutely
essential; the slightest transient infection means death of the bone-

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272 INTBBNATIONAI. OUNIOS

graft and its subsequent absorption ; therefore the greatest care should
be exercised in every detail of the operation.

'^ "No syphilitic patient should be operated upon unless he is in a
good physical condition and we are satisfied that his disease is in a
quiescent state, the Wassermann test being negative.

" Preparation of the Patient. — Several hours before the operation
the skin over the nose, face, and the right side of the chest is scrubbed
with green soap, followed by alcohoL A wet dressing of bichloride,'
1 to 5000, is then applied. Just before the operation both operative
fields are painted with tincture of iodine and the eyebrows are
covered with collodion. After the operation b^ns no solution is
used except sterilized physiological saline solution (salt, 9 Gms.;
sterile water, 1000 Cc).

Fig. 2.

Carter't operation — transplanting rib for faddle-baok deformity.

" Technic of Operation. — ^A curvilinear incision (Fig. 2), con-
vexity downward, is made between the eyebrows ; this incision extends
down to the periosteum over the frontal bone. Lifting the flap up,
a transverse incision is made through the periosteum and into the
bone in order to favor osteogenesis at this point. This incision corre-
sponds to a line connecting the two comua of the semilunar incision,
and is at a point just below "the glabella. Above this incision the peri-
osteum is elevated for about three-eighths of an inch. With the sharp
elevator devised especially for this purpose, the skin and subcutaneous
tissue is then elevated over the dorsum of the nose, and to an extent
corresponding to the degree of deformity, over the sides of the nose
and in some instances over the cheeks. If any of the nasal bone is

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3 «

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Fig. 5.

Fio. G.

Saddle-back nose, extreme type, due to The nose was misplaced to the left, due to old

syphilis. In this case the transplant was a fracture. Corrected by operation. (Author's
failure. caae)

Fro. 7.

Fio. 8.

Cohen's case before correction.

Cohen's case after correction-

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OPEBATIONS ON THE NOSS AITD THBOAT 278

left^ its periosteum should be elevated so that the bone-graft, when it is
introduced, will lie in close contact with the bone and its torn
periosteum.

" The nose having been prepared for the reception of the graft,
we proceed to remove about two inches of the ninth rib, preserving
the periosteum on the outer surface. This piece of rib is then split
in its transverse diameter, the outer half is shaped to suit the de-
formity, and the cancellous tissue is scraped away, leaving only a thin
layer of compact bone.

" Without removing the blood, which by this time has accumulated
in the wound in the nose, the bone-graft is inserted nearly to the tip
of the nose, and the upper end is carefully placed beneath the peri-
osteum over the frontal bone. The semilunar flap is then brought
down into its place and the wound closed with horse-hair sutures.
A collodion and gauze dressing is applied. The sutures may be
removed on the flfth day, but great care must be exercised not to dis-
turb in any way by manipulation the blood-clot which has formed
about the graft The blood-clot seems to favor osteogenesis.

^^ When we get primary union there is no reaction of the tissues
due to the presence of the bone-graft; healing is usually complete in
ten days.

^^ If there are any signs of inflammation, even if the skin wound
has healed promptly, the wound should be opened up. Unless the
infection is quickly controlled the graft should be removed at once,
for infection means death of the bone."

The writer has operated upon four cases of saddle-back deformity
by the above method. The first case (see Figs. 3 and 4), operated
upon three years ago, was seen a short time ago. Her nose is in ex-
cellent condition. Fig. 5 represents a saddle-back nose in which
infection took place after operation.

The rhinologist is frequently consulted by patients whose noses
have been fractured some time before, resulting in a deflection of the
entire nose to one side of the face. It is important to know how to
correct such a deformity. Here again general surgical principles
must be applied, the variations in technic depending on the individual
casa

In most fracture deformities the f eatural deviation is due to a
Vol. II. Ser. 25—18

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274 INTBBNATIONAX CLINICS

deflection of the septum ; but in a few instances the nasal bones have
been fractured or the " nasal bone arch " has been misplaced. In
correcting such a deformity the surgeon must of t^i work intranasaUy
and extranasally. In one instance in which there was a set depressed
fracture of the nasal bone on one side the periosteum was separated
from this bone intranasallj, the bone severed with a chisel from its
attachment and replaced. The result was excellent. But not all cases
are so easily dona In the case illustrated (Fig. 6) the entire nasal
bridge due to injury had been swung to one side. The following
operation was performed:

A half -inch incision was made with a fine knife down the centre
of the nose from just above the V of the nasal bones. This was
deepened down to the periosteum, which was separated over both
nasal bones. A small chisel was inserted to the outer attachment of
these nasal bones (where it had originally been attached to the lachry-
mal bones) and the bones were freed at this place. As the ^^ nasal
bone arch '' was still held by the deflected septum, a small incision
was made into the nose just below the junction of the two nasal bones,
and into this was inserted a V-pointed chisel, which severed the upper
from the lower portion of the septum. We now had a loose fragment
composed of the two nasal bones and the upper part of the septum
which could be placed in proper position. The wound was closed
with fine silk and the parts were held in place with adhesive plaster.
At the end of a few days the parts had set in proper position.

In many of these cases intranasal deformities are present which
need correction at the same time, and very often excellent results
can be obtained by intranasal operations upon the septum and also
by intranasal manipulation of the nasal bones. Cohen, of Baltimore,
in his paper on " Corrective Khinoplasty," says : " Lateral deformity
is characterized by a displacement of the nose to one side of the middle
line of the face, thus producing a most unsightly appearance. The
entire nose is at times bent toward one side. In other instances the
bony portion is bent toward one side, while the tip curves in the
opposite direction, thus causing the nose to appear twisted. Such a
nose presents a very curved dorsal outline, and is usually associated
with a marked septal deflection which obstructs nasal breathing.
Again, a hump or prominence is not uncommon on one side of the

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OPEBATION8 ON THE N08B AND THBOAT 275

nose at the lower end of the nasal bone, making the nose appear very
large and broad at this point. In all cases where the entire nose
is deflected there is considerable difference in the breadth of the two
sides^ the side to which the nose is bent being much narrower than the
other.

''While overdevelopment of the framework on one side of the
nose may account for some of these deformities, the vast majority are
the result of old, unreduced fractures and dislocations.

" A satisfactory cosmetic effect in these operations depends upon
the free mobilization of the entire bony and cartilaginous framework,
the proper placing of the nose in the middle line of the face, and its
retention there with some suitable apparatus.

'' It is generally conceded that nasal breathing should be restored
by correcting any existing septal deviation before attempting to
operate for the external deformity. Berens corrects both with one
operation. Boe and Joseph reconmiend a preliminary submucous
resection in many cases. The writer has not been able to obtain
satisfactory results, so far as the septum is concerned, with the Berens
method, and is also convinced that a classical submucous resection
is not advisable where there is a very marked deflection of the tri-
angular cartilage, for the reason that the removal of a necessary
amount of this cartilage often too greatly weakens the support of the
nasal tip. Therefore, after undermining the mucous membrane of
the septum on both sides, as is done for the r^ular window resection,
I remove only sufficient cartilage from the extreme smnmit of the
deflection to permit an approximation of the edges of the gap so
made after the septum is straightened. The resiliency of the bent
cartilage is further overcome by incisions through it, so placed that
when the cartilage is straightened there is«no tendency to resume
its old curved position.

" Any curved condition in the perpendicular plate of the ethmoid
may be overcome by cutting partly through it with the Struychen
scissors and forcing it toward the middle line with the periosteal
elevator. Should the vomer below then be out of alignment, by
severing its attachment to the floor of the nose with hammer and chisel
it also can be forced into the middle line. The mucous membrane
is now replaced over both sides of the septum, the incision sutured,
and both nasal f ossse packed in the r^ular way for f orty-ei^t hours.

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276 INTBBNATIONAX OUNIOS

By this procedure we have been able to obtain a perfectly straight
septum^ and have found, moreover, that the support of the tip was
firmer afterward than before operating.

" After allowing three or four weeks for healing of the septum
we have proceeded in most cases very much after the method of
Berens : Under ether anaesthesia a posterior nasal tampon is intro-
duced, and with the Adams forceps, one blade of which is covered
with rubber to protect the skin on the outside of the nose and the
other blade introduced within the vestibule of the nose, the nasal
bones are grasped, first ojie and then the other, and fractured at their
articulation with each other and with the frontal bone. With these
same forceps, minus the rubber covering on the blade, one blade in
each nostril, the nasal spine of the frontal is mobilized and the
perpendicular plate of the ethmoid fractured freely just back of the
nasal spine. The nasal processes are then separated at their attach-
ment from the body of the superior maxillary bones with hammer
and an ordinary Hajek chisel. Should there still exist any projection
or hump on the side of the nose, by placing a chisel handle covered
with rubber tubing against it and giving it a smart tap with the
hammer mobilization may be completed (Figs. 7 and 8).

" So much force is at times required in fracturing these bones
that, observing the operation, one might suppose the nose was being
torn from the face, yet it is indeed surprising to note how trifling is
the reaction following. Once sufficiently mobilized, the nose may
readily be placed in the middle line and moulded into proper shape,
using for the purpose a small, dull elevator on the inside and the
thumb and index-finger on the outside. The vestibule is then lightly
packed with iodoform tape and the copper saddle placed over the
nose. By making tension of the adhesive strip holding the saddle
a bit greater on one side than on the other it is easy to overoorrect
the displacement somewhat, and this is always advisable.''

The operation for "hump-nose" is very simple. Intranasally
the periosteum is separated from the " hump " after the skin is
separated as far as necessary. When the hump is free it is sawed off
and removed. The surface is rounded and smoothed with a suitable
file. The operation can be done externally through a small external
incision. In cases where the nose is too long the external operation is
preferable (Figs. 9 and 10). .

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Fia. 9.

CoheD's instruments for plastic work.

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OPBBATION8 ON THE NOSE AND THBOAT 277

INTBANASAL 8UBOEBT

The technic of intranasal surgery has changed markedly during
the past decade. Formerly work was performed in a haphazard
manner with the idea in mind to give better breathing space, no
matter how much traumatism or destruction of tissue was caused by
doing so. The results were often appalling. But we must remember
that such work was performed by men who were self-made surgeons,
many of whom were forced into this surgical work against their will.

Fia. 10.

Diacnm ■howlnc part to be removed in hump-noee. CAfter Cohen.)

We have but to point to the surgical work on the nasal septum
to illustrate the point Until within recent years the Asch operation
(Fig. 11) was the operation par excellence. This consisted in grasp-
ing the deflected septum on either side, fracturing it, resetting it in
position, and holding it in place for weeks with suitable splints. Per-
forations were common, failures were usuaL To-day the rhinologist
employs the submucous resection or one of its modifications almost
entirely. The trend in the beginning was towards radicalism — ^re-
pioving as much of the septum as possible; to-day the trend is toward

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278

INTERNATIONAL CLINICS

conservatism — removing only so much of the septum as is necessary
to obtain the desired result The rhinological surgeon nowadays looks
at even a slight perforation as a gross error in technic, though this
perforation causes no symptoms. The change has been brought about
by those men who have been surgically trained to look upon their
work from the viewpoint of perfection.

One of the most important surgical procedures^ from the stand-
point of the rhinologist, is that devised by Yankauer for the relief

Fig. lU

fc\yt^

The Aflch operation* no longer used for correotinc septal deformitiee. (After BaUencer.)

of lachrymal sac disease by intranasal surgery. The cooperation
of the ophthalmologist and rhinologist in the relief of obscure eye
conditions is being appreciated more and more. The opening of the
sphenoid sinus has cured many cases of optic neuritis and Ix^inning
atrophy of the optic nerve. Stubborn cases of conjimctivitis have been
relieved by the removal of obstructions in the nose and throat

The majority of cases of stenosis of the lachrymal duct are due
to intranasal conditions. ^^ The fact that the lachrymal canal duct
is separated from the nose and its accessory cavities by a bony parti-

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OPBBATIONS ON THE NCN3E AND THBOAT 279

tion which is often quite thin and compressible, and sometimes
dehiscent, is the basis of this relationship/'

Yankaner's technic is as follows: "Previous to the operation
the patient receives an injection of morphine or morphine-scopolamine.
The patient is placed in the semi-recumbent position on an operating
table, the operator landing by his side. This position is desirable
because the field of operation is located so far anteriorly in the upper
part of the nose that the operator's eye must at times be on a level
with the patient's chin.

" The interior of the nose is ansesthetized with a solution of 10
per cent cocaine and 1 to 2000 adrenalin, by spray or application
in the usual manner, special attention being given to the under-surf ace
of the lower turbinaL If the lachrymal canal is pervious, a weak
solution of cocaine-adrenalin may be injected into the canal through
the lower punctum. If it is not pervious, an attempt may be made
to inject the canal from below, after locating its nasal orifice with
the Holmes nasopharyngosoope. These measures usually render the
field of operation insensitive and ischeemic, but if necessary they may
be supplanted by subperiosteal injections of weaker solutions along
the line of incision in the nose, and upon the outside of the nose below
the inner canthus.

" A self-retaining speculum adds to the convenience of the opera-
tor. As the outer nasal'wall is directed obliquely backward and out-
ward from the nostril, a better exposure is obtained if the septum is
retracted toward the opposite side. For this reason a speculum which
opens the nostril from side to side, like Myles's speculum, is prefer-
able, even though it must be held in place by an assistant. Freer's
retractors can also be used.

" The incision is begun at the anterior end of the attachment of
the middle turbinate bone with an angular knife. It extends hori-
zontally forward for a distance of 0.5 Cm. From this point it is
continued downward with an ordinary scalpel to the anterior end
of the attachment of the lower turbinal, and then backward along the
extreme edge of the lower turbinal for a distance of about 2 Cm.
(Fig. 12, A, B, C, D). The incision is made down to the bone, and
the irregular mucoperiosteal flap thus outlined is elevated. The lower
half of the lower turbinate bone is very rough, and the separation of
the mucoperiosteum requires a sharp elevator. Occasionally it is

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280

INTEBITATIONAL OLIinOS

necessary to facilitate matters by cutting with the scissors the pro-
longations of periosteum which extend into the deep pits on the
surface of the bone. The flap is turned backward, its upper part being
tucked under the middle turbinate, where it is held out of the way
during the entire operation.

^^ The mucoperiosteum is then separated from the outer surface
of the turbinal in order to remove the anterior third of the bone. As
the outer surface of the bone is just as rough as the inner surface,
the mucoperiosteum is elevated for a short distance at a time and the
bone punched away in small pieces (Fig. 12). The preservation of
the mucous membrane of the outer surface of the lower turbinal is
necessary to prevent contraction of the nasal orifice of the canal after

Fig. 12.

Yankauer Uoiinud duot operation. (First itop.)

the operation. When the anterior end of the turbinal is much hyper-
trophied, its lower edge may be removed in toto with the punch-
forceps.

" The line of attachment of the turbinate bone to the outer nasal
wall curves upward from its anterior end, and the bone must be
removed close up to its attachment and as far back as the posterior
margin of the nasal orifice of the duct

^^ When the lachrymal canal has not been cocainized and adrenalin-
ized, owing to the obstruction at the neck of the sac, there are apt
to be some pain and considerable bleeding from the veins surroimd-
ing the membranous canal at this stage of the operation. In order
to inject the lower part of the canal from below, it is necessary to
locate its nasal orifice. This is done by raising up the outer turbinal

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OFSBATION8 ON THE NOSE AND THBOAT 281

mucous membrane with an elevator and inserting a probe, the end of
which is bent upward for about 4 Mm. If the probe is inserted
anteriorly and moved backward, it will glide over the valve or fold
of Hasner and will not enter the canaL It is preferable to insert
the probe some distance back and to move it forward, so that its end
will pass under the fold of Hasner and enter the canal. When the
nasal orifice of the membranous canal cannot be found, the canal
may be injected by plunging a hypodermic needle, bent at right
angles, through its wall at the nasal orifice of the bony duct

" The precise localization of the nasal orifice of the bony duct is
an important step in the operation, as the removal of the inner wall
of the duct is begun at this point When the orifice is normal in size
its localization is not difficult ; but when it has become stenosed as a
result of the disease it is not always easy to locate it with certainty.
After the removal of the anterior third of the lower turbinate bone
a stump is left which forms an elevation on the outer nasal wall.
Below this line of attachment the mucous membrane of the outer tur-
binal surface is reflected upon the outer nasal walL The nasolachry-
mal duct, as above described, is continued below the lower turbinal
in the form of a groove, whose anterior edge forms a distinct ridge
on the outer nasal wall in front of the orifice of the duct If, now,
the right-angled probe is placed on the outer nasal wall just below
the stump of the turbinate, above the reflection of the mucous mem-
brane, in front of the orifice of the duct, with its point directed
outward, and then moved backward, the point will glide over the ridge
and will suddenly disappear in a lateral direction in the hollow of the
nasal duct The point of the probe can be turned upward, and by
moving it back and forth and from side to side definite information
as to the size^ shape, and location of the orifice is obtained.

^^ The next step is the removal of the inner edge of the nasal
orifice of the duct This is a thick, hard piece of bone. The use of a
chisel for this purpose would endanger the antrum. A suitable
forceps could not be found, so that it was necessary to design a special
forceps for the purpose. This forceps has a small but stout jaw,
turned upward nearly at right angles to the shank. After separating
the membranous canal from the duct by means of the right-angled
probe or the hook-shaped elevator, the male blade of the forceps is
introduced into the duct and the bone cut through.

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282 INTEBNATIONAL OLimCS

^^ The anterior edge of the nasal orifice is now removed. Tins
must be done with the chisel^ the most suitable being a gouge, bevelled
from the inside. As the chisel-cut ends in the incision previously
made by the forceps, the antrum behind the orifice cannot be injured.
To avoid injury to the antrum in front of the duct, which may occur
when a deep infra-orbital recess lies close to the surface of the nasal
wall, the bone is removed gradually, in thin shavings, the probe being
used after each cut. The cut in the bone is deepened imtil the entire
width of the membranous canal is clearly visible. Injury to the mem-
branous canal can and should be carefully avoided.

'^ The management of the nasal orifice, especially when it is smaU,
is one of the chief difficulties that is met, but when once the mem-
branous canal has been brought clearly into view the operation pro-
ceeds with greater celerity.

'^ Above the nasal orifice the inner wall of the duct is thin, the
anterior wall thick and dense. The inner wall is removed with the
forceps, and, to avoid injury to the ethmoid cells which lie behind the
duct in the middle part of its course, this is done first, before the
corresponding part of the anterior wall is attacked with the chisel.
As the upper parts are reached an ordinary straight nasal punch is
more easily adapted to the parts than the special forceps.

"When the neighborhood of the orbital orifice is reached the
gouge cannot be applied to advantage. For the enlargement of this
orifice the guarded chisel which the writer devised some years ago
for the enlargement of the frontonasal duct is the most efficient.
When the foot of this instrument is passed through the orbital orifice
it can be seen and felt through the skin below the inner canthus of
the eye. The upper limit of the cut in the bone is reached at the
level of the attachment of the middle turbinate bone. When sufficient
bone has been removed the entire lachrymal passage is clearly visible,
from the middle of the lachrymal sac down to the nasal orifice
(Fig. 13).

" The next step in the operation is to slit open the entire mem-
branous passage. As the inner wall of the canal is continuous with
the mucoperiosteum of the outer turbinal surface, the incision is
begun at the lower edge of this mucoperiosteum with a curved nasal
scissors. The nasal orifice of the canal is sometimes obscured by the
presence of a well-marked fold of Hasner. This is cut through with

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288

the scissors. When there is no stenosis at the neck of the sac the
incision is extended up to the middle of the sac with scissors. When
the sac is filled with pus or mucus its lumen is separated from the
lumen of the canal by a complete stenosis near the neck of the sac,
caused by inflammatory adhesions of its walls. So long as the fluid
remains in the sac these adhesions cannot be separated. The sac is
therefore opened by inserting a hook-shaped knife into it as high up
as possible, and cutting downward to the neck. After the contents
have been removed (by irrigation if they are purulent) the right-
angled probe is inserted into the sac with its point downward, and as
the adhesions are separated the neck of the sac is opened with the

Fia. 13.

Yankaner Uerimal duot opention. (Seoond step.)

scissors, or by cutting down on the probe with a small knife (Fig.
14). The incision in the membranous canal is made as far back on
its inner wall as possible. The part of the canal waU in front of the
incision is brought forward and laid against the bone.

^^ The mucous membrane of the outer nasal wall, which during
the entire operation has been tucked away under the middle turbinal,
is now brought forward and returned to its original position. It may
be held in place by a single suture at its anterior inferior border.

'^ When there is pus in the lachrymal sac, a piece of the flap,
about 4 Mm. in diameter, is removed from its upper comer in a
position corresponding to the incision in the sac, to provide direct
drainage into the middle meatus of the nose.

'^ After the operation the nostril is packed with gauze to prevent

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284 INTBBNATIONAL. OLIiaOS

hemorrhage and to insure perfect coaptation of the entire flap. The
packing is removed after twenty-four hours and the lachrymal passage
irrigated with normal saline solution. When there is pus in the sac,
the opening in the middle meatus remains patent In such cases the
sac is irrigated daily with the salt solution.

** During this time there is some epiphora, and when the patient
blows his nose air is driven through the fistula into the eye. When
the suppurative inflammation has subsided and drainage has become
reestablished through the natural passages, the opening in the middle
meatus closes. To determine when this opening has completely dosed
I have employed the following test: A pledget of dry absorbent
cotton is inserted into the middle meatus, and a second one in the

Fza. 14.

Yankauer Uorimal duot op«ntioii. (Third step.)

lower meatus^ below the lower turbinal and at about its middle. A
thin, watery solution of starch is then injected into the sac through
the lower pimctum. After a few minutes the cotton pledgets are
removed and tested for starch by means of a solution of iodine. When
the pledget from the middle meatus remains unaltered by the iodine,
while that from the lower meatus turns blue, we know that none of
the starch solution escaped into the middle meatus, and that the
lachrymal passage has resumed its normal fimction."

The submucous resection of the nasal septum is universally
recognized to-day as the most conservative operation upon the nose.
But, even with our advanced knowledge of this work, new points are
brought out yearly which make the work easier and flner. The

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285

essential point of the operation is to remove the deflected piece of
bone, separated from its periosteum, through a ^^ window '' or incision
(Fig. 15) made through the mucous membrane and perichondrium
over the fore part of the cartilage. The perfection of the operation
depends on the skill of the operator.

Local anaesthesia varies with different operators. But the most
satisfactory anesthesia is by the infiltration method suggested by
King, which the author has used for some time. The patient should
be given an opiate a half hour before the nose is sprayed with a
dilute cocaine solution, and then the entire septum should be infiltrated

Fia. 16.

Submucous resection. (After Ballenger.)

submucously with a one-quarter of one per cent, cocaine solution to
which are added a few drops of adrenalin. This not only produces
anaesthesia and ischsemia, but raises the perichondrium and peri-
osteum from the cartilage and bone, so that the separation is done
much more readily. Many operators do this work in the recumbent
position instead of having the patient sitting up in a chair — a much
easier position for the patient. The time will come when all nasal
operations will be performed with the patient flat on the operating
table. Some operators, after resecting the cartilaginous portion of
the septum, mould the part resected until it is straight and reinsert it.

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INTEBNATTONAIi OLINIGS

Many deflections occur on the floor of the noee. These do not require,
as a rule, extensive operations, and more of these '^ spurs" are
operated upon submucously now instead of being merely sawed off.

Perforations of the septum from submucous operations still do
occur. Aside from being an error in techniCy they mean very little,
but once in a while it is necessary to correct the trouble on account
of the accumulation of crusts or because of a whistling noise when the
patient breathes. Hazeltine has devised the operation (Figs. 16 and
17) of bringing down a mucous membrane flap from another portion
of the septum and suturing it in place. Suturing in the nose is not a
simple procedure, but well-devised instruments make it possible in
many cases.

Fia. 16.

Haieltine'B flap operation for perforation of the septum. (After operation.)

The inferior turbinate bone, with its covering mucous membrane,
is recognized as an important part of the nose, on accoimt of the
" filter action " of the mucosa. However, in well-defined cases of
hypertrophy of this membrane a portion of it must be removed. A
submucous operation here again is permissible. The bone and the
mucosa on its free side and below it are removed, the flap remaining
(the upper surface) being folded to form a new and smaller surface.
The posterior tip gives the most trouble, often enlarging and lying
free and (edematous in the posterior nares and nasopharynx. When
once the mucosa is shrunken with cocaine and adrenalin it is difficult
to remove the posterior tip. Here, again, infiltration anesthesia
helps; for by filling this tissue with a watery solution it becomes

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OPEBATIOKS OIT THX KOSB AND THBOAT

287

large enough to be seen and readily grasped. A cut is made into the
turbinate at its posterior third with angular scissors down to the bone.
The wire loop of a nasal snare is passed round the membrane to be
removed, the shank of the snare engaged in the incision made and the
part thus snared ofiF. When loose pieces of tissue remain it may be
necessary to " bite " them off with a suitable biting forceps.

Removal of a portion or the whole of the middle turbinate is now
done in a most precise manner. This bone, with its mucous covering,
is often the obstructing agent in various afiFections of the sinuses. By
removing it access is in many cases readily gained to the frontal

Fia. 17.

Haieltioe*8 operation. (After Ballenger.)

duct, and only by this operative interference can one gain a proper
view of the ethmoid cells and the sphenoid cavities (Figs. 18 and 19).

A great advance has been made in the surgery of the nasal
sinuses. To-day diagnostication of diseased conditions of these parts
can be obtained from carefully-taken X-ray plates. The technic of
operations on the frontal sinuses and maxillary antra has not changed
much within recent years except in minor details. However, the
surgical treatment of the ethmoid cells and sphenoid sinuses deserves
special mention.

Formerly suppurative conditions of the ethmoid cells was treated

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288

UmSRTXATlOlKAL CLINICS

by removal of the middle turbinate and curettage of the celk, thus
breaking down the frail septa between. To-day we have recourse to
the procedures of Ballenger and Mosher, whereby the ethmoid cells
are removed en masse.

Ballenger describes his operation as follows: '^The general
method of procedure is based upon the anatomical observation that the
ethmoidal cells have but three planes of attachment, namely: (a)
To the anterior wall of the sphenoid bone, (6) to the cranial plate,
and (c) to the outer or orbital wall of the nose. If, therefore, these
three planes of attachment are incised, a large portion of the lateral
half of the ethmoid body (including the posterior ethmoidal and one

Fig. 18.

Method of removing polyiri from the nose at the time of ESppoontee. (After Wright)

or more of the anterior ethmoidal cells, and the middle turbinated
body) is detached within the nasal chambers, from which it may be
readily removed.

" The instrumentarium required for this operation consists of
one instrument, supplemented by two others, which are only occa-
sionally required. The important one consists of a short blade set
at a right angle to a longer blade which is parallel with the shank of
the instrument. The short blade makes the incision along the anterior
wall of the sphenoid, and is then drawn forward and makes the
incision along the cranial plate ; when the instrument is drawn for-
ward the long blade makes the incision along the orbital wall and

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OPEBATIONS ON THE NOSE AND THBOAT

289

thus completes the excision of the ethmoid cells and middle turbinated
body.

'* Technic, — (1) Ansesthesia is induced by massage of the mucous
membrane of the middle and superior meatuses and the corresponding
portion of the septum with a small, cotton-wound applicator^ the cotton

Fia. 19.

The modern method of removing nasal poljrpi. (After Ballenger.)

being slightly moistened and dipped in powdered cocaine. The
application should be made at intervals of from five to ten minutes
to the areas previously named imtil complete anesthesia is induced.
If preferred, the operation may be done under general ansesthesia.
" (2) The exenteration is accomplished by the following pro-

Fxa. 20.

Ballenser ethmoidal instmments.

cedures: (a) Introduce the author's ethmoid knife (Fig. 20) into
the middle meatus, with the short blade turned upward until it
impinges against the lower portion of the anterior wall of the sphenoid
bone or until it engages the posterior end of the middle turbinated
body. During this procedure the handle of the instrument is turned
Vol. n. Ser. 25—19

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290 IITTEBNATIONAL CLINICS

horizontally acroBS the opposite side of the face. The short blade
is then forced outward into the tissues in front of the sphenoid.

^^ This procedure is facilitated by moving the instrument badk-
ward and forward over a distance of about one-fourth of an inchy
as these movements cause the short blade to penetrate the tissues to the
depth of the orbital wall and thus cut the ethmoid cells from their
attachment to the sphenoid body. These movements also engage the
short blade behind the posterior end of the middle turbinated body.

'' (&) The handle of the instrument is then rotated 45 degrees.
The short blade is then forced upward to the junction of the anterior
wall of the sphenoid with the cranial plate^ care being taken to have
the long blade pass between the middle turbinated body and the
outer wall of the nose. When the operator is assured that the blades
of the knife are in their respective positions he should work them
upward parallel with the anterior wall of the sphenoid until the
cranial plate is reached. The shorty right-angle blade should be
forced upward in front of the anterior wall of the sphenoid until it
strikes against the cranial plate^ the long^ perpendicular blade resting
against the orbital wall of the nose. The blades are not drawn for-
ward as in making a dean cut^ but are wiggled or rotated slightly
in their respective aizes. This is done in order to fracture the cell
walls in front of the blades^ which then readily cut the mucous mem-
brane. The instrument is thus brought forward to the anterior
attachment of the middle turbinated body.

'' (c) As the nasal chamber is quite narrow in its anterior portion,
the handle of the instrument should be rotated another 45 degrees.
This turns the shorty right-angle blade downward into the nasal
chamber and away from the septum. The knife should then be drawn
forward and downward to complete the severance of the tissues. This
being accomplished, the instrument is withdrawn throu^ the vestibule
of the nose. This movement of the instrument usually delivers the
severed ethmoid mass from the nose; otherwise it should be gently
seized with forceps and withdrawn.

^^ If it is found that the specimen is still attached to the nasal
walls by some fibres, the blunt hook knife should be introduced
between the specimen and the outer wall of the nose and the attach-
ments severed with it.

^' ((2) The blood should be mopped from the nasal chambers, and

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OPERATIONS ON THB NOSB AUTO THBOAT 291

the remaining fragments of cells should be broken down with the
curette. This completes the operation.

** The Dressing. — ^If there is serious hemorrhage, the upper or
ethmoidal region of the nasal chamber should be packed with a 1^-
inch strip of gauze impr^nated with the subnitrate of bismuth
powder. The bismuth prevents decomposition and infection, and thus
wards off the dangers of septic absorption. The gauze should be
introduced against the anterior wall of the sphenoid, and folded and
packed imtil the upper half of the nasal cavity is completely filled
with it. Stout dressing forceps should then be introduced beneath
the dressing, and the whole lifted in order to compress it into the
area which has been operated on. The dressing should be removed
in from one to twenty-four hours. The subsequent treatments consist
in lightly packing the nose with cotton tampons saturated with a
10 per cent, aqueous solution of ichthyol or of argyroL The applica-
tions should be repeated daily and left in place twenty minutes. This
mode of treatment is more effective in removing the secretions and
sterilizing the woimded surface than irrigations."

The Mosher operation may be described as follows :

'^ Technic. — ^Pirst. Cocainize the interior of the nose or ad-
minister a general ansesthetic.

^^Second. Introduce a curette into the nasal chamber until the cut-
ting edge of the instrument facing the orbit is above the anterior
attachment of the middle turbinate. This area covers the frontonasal
canal and the anterior ethmoidal cells draining into it The bone at
this point is usually very thin and easily broken down. In some cases
the bone at this point is very dense, thus making it necessary to break
through it more posteriorly. Having located the instrument, make
gentle but firm pressure toward the orbit, and at the same time with-
draw it downward and forward one-fourth to one-half inch. The
anterior ethmoidal cells are thereby completely opened. By con-
tinuing the curettage in a forward and upward direction the fronto-
nasal opening in the floor of the frontal sinus is enlarged and free
drainage of this sinus established. The frontal sinus may now be
entered with a blimt-pointed frontal sinus probe. Indeed, in most
instances a suitably bent, cotton-wound applicator may be easily
introduced.

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292 IBTTBENATIOlS'AIi OLIISTICS

" Third. The next step of the operation is the removal of the
posterior ethmoidal cells. This is done with the same curette intro-
duced through the opening already made. The curette is introduced
beneath the cranial plate and then brought downward between the
orbital and turbinal plates. This procedure is repeated several times
until the anterior wall of the sphenoid is reached.

"Fourth. The turbinal plate, consisting of the superior and
middle turbinate bodies, is then seized with suitable grasping forceps,
and by gentle traction combined with twisting motions is detached
from the cranial plate and removed from the nose.

rxo. 21.

(*Ue)

Beck operation on frontal linuses. (After Wright and Smith.)

" Fifth. The entire posterior and anterior ethmoidal regions are
again examined by ocular and probe inspection, and all portions of
cells remaining are removed."

In both these operations, particularly the former, the operator
must have a perfect knowledge of his anatomy and must realize the
dangers of operating on parts so intimately connected with the cranial
cavity. One is liable to fracture into the orbit — ^which does no harm,
provided the mucous membrane and periosteum remain intact.

External operations for sinus disease are frequently performed,
but the writer is glad to say that, now a better knowledge of the
pathology of these parts is known and now that patients realize the

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OPERATIONS ON THE NOSE AND THBOAT 293

importance of early treatment of sinus disease^ many of the cases do
not go on to the stage where an external operation is necessary.
Astringents^ suction massage, and the employment of autogenous
vaccines in these infections have tended to diminish their chronioityy
and many times a small intranasal operation^ such as the removal
of the anterior half of the middle turbinate^ will clear up the trouble.
The external operation of choice in frontal sinus disease (or in
pansinusitis) is what is called the Xillian operation. This consists
in making an incision along the eyebrow, which is continued down-
ward to the lachrymal sac. The incision is deepened through the
periosteum of the frontal bone, which is scraped bacL The bone is
chiselled through and the diseased parts eradicated. Through this
opening the other sinuses may also be cleaned out and a large enough
drainage opening into the nose established. Where there is disease
on both sides the Killian operation has been modified by Beck (Fig.
21), who makes an osteoplastic flap which uncovers both sinuses.

INTEA-OEAL STJBGBBY

The surgery of the throat is mainly confined to the region of the
soft palate and nasopharynx. Except for the major operations for
malignant disease, the attention of the rhinologist is confined mainly to
operations on tonsils and adenoids.

It is the almost universal opinion to-day that tonsillectomy is
preferable to tonsillotomy, — i.e., that the tonsil should be removed
with its capsule m toto. The means for doing this vary greatly. One
class of operators prefers various modifications of the tonsillotome and
uses the technic suggested by Sluder, of pressing the tonsil forward
against the ramus of the jaw and there engaging it in the instrument.
Another class thinks it is better to dissect the tonsil free until it is
hanging by a pedicle, which may be cut off in various ways, preferably
by a suitable snare. The writer is of the opinion that no set rules
should govern the removal of the tonsils. Each case should be judged
individually. The best results in the majority of cases are obtained
by freeing the anterior pillar and then dissecting the tonsil from its
other loose attachments either with the finger, a dissector, or, at times,
with a curved scissors. A simple snare can then be slipped over the
pedicle. One marked advance may be seen in the treatment of ton-
sillar hemorrhage which is frequently caused by an abnormal blood-

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IITTBBITATIONAL CTLIiaCS

veesel. Inspection may show the bleeding artery, which is caught
with an artery forceps and ligated. If there is general oozing f rcmi
the tonsillar surface, the pillars may be brought together (possibly
a gauze pad being held between them) and sutured with silk.

A novel change in the procedure for removing adenoids has been
practised by Beck. The technic of the operation is as follows : " Pass
the free ends of a rubber urethral catheter (the smaller sizes) ^ one
through either nostril^ and withdraw them from the mouth, thus cross-
ing the columella of the septum. Put a gauze sponge at this point to
prevent too much pressure on the columella. Allow them to remain

Fig. 22.

Fig. 23.

Removal of tonsO. Separator sevexing the
toniil from the anterior pillar. (After Wright
and Smith.)

Removal of tonaU. Snare placed around toneiL
(After Wright and Smith.)

in this position while the tonsils are being removed, usually placing
them to one side or the other out of the field of the tonsillectomy. As
soon as one tonsil is out the end of the catheter corresponding to the
side from which the tonsil was removed is drawn taut out of the
mouth and over the cheek, while tiie other end is held. This will
bring the pressure from bdiind forward against the hard palate, and
thus stop the greater portion of the bleeding and enable one to do the
opposite tonsillectomy with very little interference from bleeding of
the tonsil removed.. It will also bring the anterior and posterior
pillars in opposition, thus closing in the large cavity created by the

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OPERATIONS ON THB NOSB Aim THBOAT

295

tonsillectomy. If the bleeding is profase^ place a small gauze sponge
between the two pillars and then by a fine rat-tooth forceps (Tuffier)
hold them together, also taking in a small bit of the gauze so that it
cannot faU out at the bottom (Fig. 24).

" When both tonsils are excised and the bleeding perfectly con-
trolled the sbft palate is allowed to recede, the two pillars liberated
by the removal of the Tuffier forceps, and the gauze sponge removed.
The assistant then puUs both free ends of the catheter out over the
cheeks, causing large exposure. The head is now extended, and the

Fio. 24.

Beok operation for removing adenoidi by direot inspection.

r^on of the ostia, as well as the highest point of the vault of the
j^arynx, is seen. One must not look from the side to get the best
view of the tubal ends, but straight towards the vault With a large
laryngeal mirror inspection is made of the posterior nares with the
entire nasal contents, and the overriding of the adenoid mass into the
posterior choanse is noted.

'' The mass is now palpated so as to determine the consistency and
the amount of overriding. If the patient is not completely anaes-
thetized, or his pharyngeal reflex not yet completely abolished, the
exaTnining finger gains the same impression as when exaTnining the

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296 nrrEBiTATiONAL oliitios

postnasal space of a conscious patient, namely : the constrictor mnsde
Wulst folds many times in the form of an incomplete ring. So long
as that fold forms, the removal of the adenoids should be deferred
and the patient completely ansesthetized, because this muscle fold may
be cut and produce symptoms of stiffness of the neck, to which Fein
recently called attention but did not explain on this basis.

^' The removal of the adenoid mass itself may be done by any
method preferred by the operator; but the removal of the remaining
portions, especially in RosenmiiUer's fossa, should be performed with
a straight ring curette, such as it is customary to employ in the
curettage of the endometrium. It may be bent to suit any particular
shape desired. The pronoimced oozing that results from the removal
of the central mass is controlled by a gauze sponge moimted on a six-
inch artery forceps, by exerting firm pressure for a few minutes, or
until the time the patient awakes from the ansesthesia.

Fia. 25.

Andant iastmmeni for amptiUting UTula. (After Wright.)

" The instrument that I employ now for the removal of the main
mass is an adenoid curette of the St Clair-Thompson pattern, without
a guard, and with the cutting edge formed into a wave blade. The
motion of the instrument in the removal of the mass is not in the
usual rapid, sweeping movement of the elbow-wrist turn, but is from
side to side and dow elbow-wrist turn. The mass is cut off and re-
mains lying practically in situ; however, the last cut at the lower
margin of the mass may require the use of a forceps to hold it
Shredding of the mucous membrane is not possible imder these cir-
cumstances, nor is it possible to cut off any of the muscle fibres of
the constrictor fold, as I have seen in the operation when done by
feeling alone."

The amputation of the elongated uvula (Fig. 25) is usually done
with a pair of curved scissors which is supposed to out off the re-

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297

dundant mucous membrane in a satisfactory manner. The operator
attempts to excise more of the mucosa and muscular tissue on the
posterior surface of the uvula than the anterior surface. A raw area
is left which under the best of circumstances must heal by secondary
intention. Oftentimes there is a severe reaction with swelling and
oedema of the soft palate.

Bealizing the obvious objection to this method (and to other

Fio. 20.

musde

tz^'-^iz r..^ suture

Author'a oiroamoiflion of the nyula.

similar procedures in which a curved scissors is used on a very
movable part), the writer devised the following operation, which has
proved very satisfactory : (1) The region of the soft palate is sprayed
with a ten per cent, cocaine solution and the base of the uvula painted
with pure cocaine crystals. The entire uvula is then ansesthetized
by an infiltration ansesdiesia of a one-tenth of one per cent solution of
cocaine (Fig. 26, a) . The injection may be made with a tonsil-needle,

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298 INTBBNATIOlSrAL OLIISICS

the injection being started at the base of the uvula and progressing
downward toward the tip. About 30 minims of solution are used.
After the infiltration the uvula wiU have increased to two or three
times its size (&).

(2) As much uvula as one wishes to amputate is then ascertained.
One wishes to have a uvula remaining as near the normal size as
possible. The tip is grasped between the blades of a long artery-
forceps after passing it through the oval opening in the uvulatome,
which I shall now describe:

The author's uvulatome (Fig. 27) works on the same principle as
a Mackenzie tonsillotome, in that the blade works by pushing it to.
The blade of the instrument is angular in shape, so that it cuts a
V the same as a cigar-cutter cuts a V out of a cigar. The instrument
can be readily taken apart for cleaning.

(3) When the uvulatome is once in place the blade is strongly
pushed to, thus excising the portion within the blade (c). But the

Fia. 27.

'iri-i'TTfc

Author's uvulatome.

peculiarity of the instrument is soon apparent to one using it, for
more of the mucosa is removed than muscular tissue — ^precisely what
one wishes, as the redundancy and laxity of the mucosa are what
usually cause most of the trouble. If the cut has not been made all
the way through, it is a simple matter to finish it up with a sharp
scissors.

(4) When the portion desired is excised, one finds that the re-
maining mucous membrane covers the stump of muscular tissua
This mucosa is gathered together and united with 00 catgut, tying
one knot only, so that the suture will surely come away by itself.
This suture may be placed with any finoKnirved needle (preferably
an enterostomy needle) used on any needle holder (d). By the
method of ansBsthesia just described there is absolutely no pain, and,
for the purpose of suturing, the uvula can almost be brought out of
the mouth.

(5) No after-treatment of any kind is necessary except a gargle
of peroxide of hydrogen for the following twenty-four hours.

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OFBBATIONS ON THB NOSB AND THBOAT 299

INTBALABYNGSAL AND INTBATBAOHEAIi SXTBaSBY

Within the past decade surgery of the larynx has undergone
a marked change. Until the invention of the direct laryngoscope
any pathologic condition within the larynx which necessitated opera-
tion had to be removed by the so-called indirect method; i.e., the

Fia. 28.

ffllliaa suspension Uryngosoope.

operator viewed the larynx through a mirror held against the palate,
and therefore had to manipulate his instruments at right angles to
his plane of vision. Operations of any sort were difficult, and very
often destruction of normal tissue occurred. The first direct laryngo-
scopes of EiUian and Jackson paved the way toward a more exact
surgery of these parts. Through these instruments, illuminated

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300

INTBBNATIONAX CLINICS

electrically, one was able to carefully inspect the larynx and, after
a certain amount of practice, to remove abnormal growths. Through
the lumen of such instruments electrically-lighted tubes could be
passed through the glottis down into the trachea and bronchi. Thus
a new field was opened up to the laryngologist, who now could locate
and remove a foreign body, such as a saiety-pin, tack, false tooth, etc
However, the use of these laryngoscopes could only be made per-

Fia. 29.

Fici. 80.

KiUian euspeiuiion Uryngoeoope.

Killian suspeziBion UryngoBcope.

feet by long practice, and a number of assistants were necessary to
hold the patient's head, to keep up traction on the handle of the
instrument, etc. The procedure was always extremely tiring. But>
fortunately, Killian again came to the front with his suspension
laryngoscope, by means of which the patient " suspends ^' himself,
easily and comfortably and in such a way as not to aggravate the
tension on the muscles of the neck.

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OFBBATIONS ON THE NOSE AlH) THBOAT 301

The suspension laryngoscope (Figs. 28, 29, and 30) consists of
an especially-revised tongue spatula and mouth-gag (Fig. 31), which
hang, by means of a pivot, at right angles to a long, swinging bar
which fits into a permanent standard attached to the operating table.
The patient lies on his back on the table with the head hanging over
the edge. The tongue spatula is inserted into the mouth to the base
of the tongue and the mouth-gag adjusted. The head hangs from
the swinging bar attached to the standard. If the epiglottis is in
the way, an epiglottis retractor may be used. The position is not
particularly uncomfortable for the patient, and the operator thus has
both hands free for operative work. Illumination is supplied from
an electric head-lamp on the operator's head.

It remained for Dr. Lynch, of New Orleans, to develop a proper

FiCL 31.

Spatula for QlHan i4>paratiia.

operative technic for operations on these parts. Formerly the work
was done with specially-devised instruments which had for their
object the biting or tearing away of the pathologic tissue. Lynch felt
that it was now possible vnth " suspension '* to do the work in a more
precise manner, and therefore he devised an excellent set of instru-
ments which allow one to work vnth the nicety of the intra-abdominal
surgeon. I shall quote from Lynch's recent paper :

" The type of instrument that has served us up to this time is
some one of the hundred varieties of forceps, be they pinching, biting,
punching, or the double curette — dull or sharp, etc. Briefly, the
technic is to grab more or less accurately, and pull, or twist, or both,
let come what will — and therein lies the most unsurgical part of this
type of surgery. We should criticise our colleague, the laparotomist

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802

INTEBNATIONAX OLIiaCS

or gynsBOologist, for such a method in dealing with cdmilar lesions
in his domain. I hope to convinoe you that the way is now clear
to deal with the larynx in exactly the same manner as our brothers
do in other parts of the body; and with these instruments I c^
dissect accurately, ligate bleeding points^ cover raw surfaces by suture,
and do plastic work with almost as much ease and quite as much
accuracy as my brother surgeon who works in the vagina, rectum, or
abdominal cavity. The suspension laryngoscope is necessary to all

Fig. 32.

Lynoh's instrument for operationa upon the larynx under suspension. The instruments are
of gun metal to eliminate reflection.

this work, and I use it in its siniplest form, with an improvement that
to me is essential (Fig. 32).

" The primary requisite is perfect quiet of the part, so that the
selection of an ansesthetic and, above all, its administration are most
important. Eor all procedures that are to be somewhat prolonged
and in all children I much prefer a general ansesthetic, though I have
kept one patient on the suspension apparatus for one hour and ten

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OPBBATIONS ON THB NOSB AND THBOAT 303

minutes under local ansesthesia with perfect comfort during the
whole tima

^^ In local anaesthesia, with the patient in sitting posture, administer
a morphine-scopolamine tablet of appropriate dose one hour before the
operation. Then apply to the uvula and postpharyngeal wall a ten
per cent cocaine solution with such care as to avoid gagging or
coughing; to avoid these reflexes at the start is to have comfort and
quiet throughout the performance. Follow this with three drops of the
same solution from a laryngeal syringe upon the epiglottis, and wait
three minutes, requesting the patient to avoid swallowing and to spit
out the excess. Kext application, five drops into the larynx over the
cords and down the trachea, requesting the patient to cough out the
excess. From the sitting posture the patient is then put upon the
table, the speculum introduced carefully and quietly, adjusted per-
fectly and slowly, and the larynx tested with a cotton mop. If not
perfectly quiet, more cocaine of the same strength is applied until
ansesthesia is perfect and we can then proceed to work.

"I have removed a single, pedunculated fibroma, multiple
papillomatous vocal nodules, and specimens for microscope in adults
with complete satisfaction to myself and comfort to my patients with
this method of ansesthesia.

^^ General ansesthesia is more satisfactory for malignant tumors,
papilloma in children, for plastic work, and is essential in all cases
where perfect relaxation of the parts concerned cannot be secured by
local means. I select ether in every instance, administered with the
Cain-McDermott warm ether-vapor apparatus, under the supervision
of a trained ansesthetist

" As perfect quiet is of greatest necessity, I insist on my patient
being kept continuously in the surgical stage of ansesthesia, securing
perfect relaxaticm of the parts, conducing to the most accurate work,
and surrounding the patient with that type of anaesthesia which we
recognize as the safest

" Crowding the patient under to the limit and working during the
period of recovery — and, if that period is too short, crowding under
again — ^is, to my mind, neither wise nor safe. This type of anaes-
thesia will develop for the operator many disturbances just at the
wrong time, and is surely most dangerous for the welfare of the case.

" As our experience increases with the use of the warm ether

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304r HfTEBNATIONAL OLINIOS

vapor we are realizing that the tracheobronchial irritation following
the use of this drag is decidedly overrated — ^none having occurred in
nearly sixty anesthesias of this type. In order to eliminate the reflex
element in the larynx even under general anaesthesia, I paint the parts
carefully with a ten per cent solution of cocaine, using only one
application, taking particular care that none reaches the trachea,
heeding Jackson's advice regarding the cough-reflex in larynx opera-
tions. I then prepare the field by painting these surfaces again with
a twenty per cent solution of argyrol freshly prepared. Whether
this limits or prevents infection I cannot say ; so far I have had none,
and I am inclined to think I get less inflammatory reaction.

^^ I find some form of suction apparatus necessary to take away
the secretions that come from the salivary glands and oesophageal
mucosa, also to care for what bleeding occurs, and one can, with
ease, pick up small fragments of tissue that may drop and remove
those blood-clots that form and lie on the posterior wall of the
trachea. The careful use of the suction tube for cleansing purposes,
as against sponges, eliminates one of the factors of traumatism, to
which so little attention has been paid in laryngeal work, besides
giving the operator the cleanest field possible for his manipulations.

" Having obtained a perfect view of the larynx with that organ
and its owner remaining quiet, I proceed as follows : In vocal nodules
I pick up the affected cord gently, turn it nearly to an angle of 45
degrees, that I may see its under-surf ace, using for this purpose the
baby forceps of Killian. If the nodule is of pin-head type, I pick
it off with the Eillian baby double cup-forceps. These are so small
that they can be applied as accurately as one would pull a single
hair from a follicle.

"If the growth occupies the superior surface and is seen to
involve mainly the subepithelial structures, I split the surface layer
with the knife and pick out the small tumor with appropriate forceps,
reapplying the surface membrane and dressing the wound with tinc-
ture of benzoin compound, which will cover the area as collodion
would on the skin surface. Absolute rest to the voice for f orty-ei^t
hours will show the wound healed and practically free from inflamma-
tory reaction. Two cases operated on in this way have had clear tones
restored and no recurrence thus far — ^five months.

" In single pedunculated tumors I proceed by picking up the

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OFBBATIOKS ON THE NOSB AND THBOAT 306

tumor with the forceps, encircling its base with a wedge-shaped in-
cision, and remove it by clear dissection with a knife. In one case
operated on in this way quite a raw surface was left, which I closed
by stitching, using the finest plain catgut I believe this to be the
first instance on record of stitching in the larynx through the mouth,
and the results were a perfect healing, with as little reaction as one
sees in a skin wound healing by primary union*

" This to me is far more surgical than the older method of re-
moving by tearing, pulling, or twisting forces which must obviously
carry with it adjacent normal mucous membrane, leaving a surface
to heal by granulation and producing a scar of more or less size, the
contraction, perhaps, interfering with the normal function of the part

^^ Single papilloma are grasped with the forceps and shaved ofi
below the level from which they^spring. One case of this type left
but little raw surface, healed kindly,, and has not recurred. I have
often wondered why multiple papilloma recur with such tenacily.
The same tumors appearing on the skin and having the same histo-
logic characteristics are removed by the dermatologist without re-
currence unless the procedure is not complete, when they will recur
with the same frequency as occurs in the larynx."

The sui^ry of the trachea and bronchi is confined mainly to the
removal of foreign bodies and to the diagnosis of certain obscure
conditions causing stenosis of these tubes. The technic consists in
the use of suitable instruments through bronchoscopic tubes which are
passed through the direct laryngoscope. A description of general
methods would mean little, for the operator must individualize in
each case. Certain men like Chevalier Jackson, of Pittsburgh;
Bichard Johnston, of Baltimore, and Sidney Yankauer, of New
York, have become most expert in this work, and, as success depends
greatly on the experience of the operators, it seems to the writer that,
in all fairness to the patient, cases needing bronchoscopic examina-
tions should be put in the hands of those men who have become most
adept in the use of such instruments.

The surgery of the nose and throat to-day covers an enormous
field in which special acuity is often necessary. The surgical ad-
vance has been so rapid that it is difficult even for those who are
specializing in it to keep up with the very latest procedures. The
laryngologist, as he perfects the technic of his intranasal and intra-
VOL. n. 6er. 25—20

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306 IlfTBBirATIOKAI. OUNIOS

oral work, Ib constantly breaking down the limitations that were
previously forced upon him. External surgery of a specialized sort,
such as plastic surgery of the face^ has found its proper place; so
also the external operations for diseased conditions of the sinuses.
It will be recognized, as time goes on, that the laryngoldgist is the head
and neck surgeon par excellence, and that he is the man to do intra-
cranial operations, operations on the thyroid gland, and the surgery
of the triangles of the neck. Just as the gynecologist is seeking
recognition as an abdominal surgeon because he knows that he knows
the anatomy of the abdomen better than any one else^ so the laryngdo-
gist will seek recognition in broader fields of head and neck surgery.

BIBLIOQRAFHT

1. "OperationB for the Correction of Deformitiea of the Nose," Wm. Wedej

Carter, Medical Bedord, February 7, 1914.

2. " Correciiye Bhlnoplasty/' Lee Cohen, The Lwryngoeoope, June^ 1914.

3. " Tranaplantation of Rib for Depressed Deformity of the Nose," Harold Hays,

Mediotd Record, June 22, 1912.

4. Loeb's " Operative Surgery of the Nose, Throat and Ear," toL i, 1914.
6. '' Diseases of the Nose and Throat/' Wright and Smith, 1914 Ed.

6. " Local Amesthesia for Submucous Resection," James J. King, /our. of the

A. M. A., May 30, 1914.

7. " Diseases of the Nose, Throat and Ear," Wm. lincoln BaUenger, 4th Ed.,

1914.

8. "The Teehnie of Intranasal Operations upon the Laehrymal Apparatus,"

Sidney Yankauer, The Laryngoeoope, December, 1912.

9. " Circumcision of the Urula," Harold Hay3, The Laryngoeoope, July, 1912.

10. "Removal of Adenoids by Direct Inspection," Joseph C. Beck, AfmaU of

Otology, Rhinology amd Laryngology, June, 1913.

11. " New Teohnic for the Removal of Intrinsic Growths of the Larynx," Robert

Clyde Lynch, The Laryngoeoope, July, 1914.

12. " TracheobrondioBcopy, CEsophagosoopy and Gastrosoopy," Chevalier Jackson^

The Laryngoeoope Company.

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INDEX TO YOLUHE II

(TWENTY-FIFTH SERIES)

Acholuric icterus, 246

Adenoids, operation for the remoTal of, 295

Adenoma, embryonal, 122

Adjustment efforts at, 146

Adrenalin, administration of, 66

in the treatment of asthma, 66

in the treatment of gastric hemor^
rhage, 66
Albee, Fred H., orthofMBdlc clinic of, 200
Anesthesia, local, 285
Angina pectoris, 86

pathologic findings in cases of. 21
Animal extracts in the treatment of medi-
cal diseases, 50
medicinal use of, 56
Ankylosis, fibrous, 219

of knee-joint, 227
Anterior poliomyelitis. 111
Arteriosclerosis diagnosis of, 22

etiology of, 17

pathology of, 20

symptoms of, 22

treatment of, 26
Arthritis, suppurative, 219
Arthroplasty of hip-jotnt, 221
Asthma, use of adrenalin in the treatment

ot 56
Autocondensation treatment, 28

Bacteriologic examination of cerebrospinal

fiuid, 10
Ballenger, William Lincoln, M.D., Intra-
nasal frontal sinus operations: con-
seryatlve surgery, 260
Bisch, Louis B., A.B., M.D^ Ph.D^ Efforts

at adjustment, 146
Blood-pressure, diastolic, 28
eifect of epinephrin on, 68
systolic, 28
Bone cysts, 228

graft, inlay, in the treatment of frac-
tures, 209
transplants, 271
vertus metal appliances, 210
Bones of leg, deflciendea In, 229
Bow-legs, 227

Brain injuries at birth, 106
Brill, A. A^ Ph.B., M.D., Psychoanalysis:
its scope and limitation, 182

Bronchi, surgery of the, 806

Bulbous nose, 270

Bulla ethmoidalis, in the drainage of tha

frontal sinus, 262
Burdlck, Alfred 8., M.D., some new phases

of emetine therapy, 89
Bush, Arthur Dermont, B.8., M.D., A cast

of epiphysitis, 127
Butyric acid reaction, 7

CaUus, 196

Cancer of the pancreas^ 118

Carcinoma of the lirer, 122

in childhood, Uble ot 128
Cardiovascular stimulation induced by

strychnine, 20
Cartilage, Injury to, 226
Cerebral hemorrhage, 87

injury, traumatic, 114
Cerebrospinal fiuid, bacteriologic examina-
tion ot 10
in diagnosis, 1
pressure ot 2
specific gravity of, 8
Wassermann reaction in, 11
Chambers, Graham, B.A^ M.n., Animal
extracts in the treatment of medical
diseases, 60
Charcot's disease of spine, 208
Cheney, Henry W., M.D., Enlarged spleen ;
splenic enlargement; anterior poliomye*
litis, 108
Choluric icterus, 246
Chorea, believed to be caused by the toxins

of acute rheumatism, 58
Chronic habitual constipation, 64
Circulatory failure, 67
Club-foot acquired, 282

congenital, 280
Collodlal gold chloride reaction, 11
Colo-colic Invagination In children, 247
Conservation, human, 181
Constipation, chronic habitual, 4
mechanical treatment for, 74
symptoms of, 69
treatment for, 70
Corns, 196
Cretinism, thyroid extract in the treat

ment ot 51
Cribriform plate of the ethmoid, 263
Cripplings, cures for, 100
disuse, 156

307

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308

INDEX TO VOLUME H

Cumston, Charles Greene, M.D., Borne re-
marks on gastro-lntestinal sargcry and
pathology, 238
Cures for cripplings, 160
Cysts, bone, 228
Cytologic examination, 8

Alzheimer method, 4
French method, 8
Fuchs-Bosenthal method, 4

Dactylitis, 217
d'Arsonyalization, 82

Denver, John B., M.D., Qlgantic duodenum
due to kinking at duodenal jejunal junc-
tion, associated with dilatation of the
first portion of the jejunum, gastro-
enterostomy, and fistula from the je-
junum into the transverse colon, 285
Defecation, Importance of regularity of, 64
Dentist's halt, 169

Diagnosis and Treatment, Department of:
Arteriosclerosis, diagnosis and

treatment of, 17
Cerebrospinal fluid in diagnosis, 1
Constipation, chronic habitual :
a practical consideration of its
causes, results, and its rational
treatment by mechanical meas-
ures, 64
Digitalis therapy, the present

status of, 87
Emetine therapy, some new

phases of, 39
Medical diseases, animal extract!
in the treatment of, 50
Diagnosis, cerebrospinal fluid in, 1

and treatment of arteriosclerosis, 17
Diaphragmatic hernia, congenital, 100
Dietary errors, as a common cause of

constipation, 78
Digitalis, actions of, 88
administration of, 95
dosage of, 94

heart-block produced by, 93
preparations, 96

therapy, the present status of, 87
Dilatation of the Jejunum, 285
Disease, chronic, 185

medical, animal extracts In treatment

of, 60
mental, 182

nervous, animal extracts In the treat-
ment of, 58
Dislocations following suppurative arthri-
tis of infancy, 219
Disuse cripplings, 156
Dorrance, George M., M.D., Gigantic
duodenum due to kinking at duodenal
jejunal junction, associated with dilata-
tion of the first portion of the jejunum.

gastro-enterostomy, and flstnla from the

jejunum into the transverse colon, 235
Drainage, artificial, of the frontal sinus,

264
Dreams, artificial, 188
Duodenum, gigantic, due to kinking at

duodenal jejunal junction, 235

Efllciency, mental, 183

Biforts at adjustment, 146

Eggleston, Cary, M.D., The present status

of digitalis therapy, 87
Electrical machines. 162
Embolus, pulmonary, 254
Embryonal adenoma, case of, 122
Emetine hydrochloride as an antlhem«r-
rhagic, 41

in amoebic dysentery, 89

in cases of pneumonia, 42

in hemorrhage, 89

in pyorrhoea, 45

in respiratory diseases, 42

in systemic diseases, 48

pharmacologic action of, 43

therapy, some new phases of, 89
Epigastrium, swelling ot 122
Epinephrin, elfect of, on the blood-pres-
sure, 58
Epiphysis, disjunction ot 225

of humerus, disjunction of, 214
Epiphysitis, case of, 127
Epithelioid cells in cerebrospinal fluid, 6
Ethmoid, cribriform plate of, 263
Ethmoidal instruments, 289
Examinations of the nose and throat, 268
Exercise, desirable in the treatment fer

constipation, 81
Extracts, animal, 50

Faces, accumulation of, in the rectum and

pelvic colon, 66
Fehllng's solution, 9
Femur, fractures of, 228
Fibrosa, osteitis, 222
Fibrous ankylosis, 219
Flat-foot, 188

symptomatology of, 190

treatment for, 192
Foot, painful conditions of, ^187
Fractures, inlay bone-graft' in treatment
of, 209

malleolar, 230

of femur, 228

of nose, 273

of OS calcis, 280
Fronto-ethmoid sinuses, intranasal opera-
tions upon, 264
Fruits, the laxative effects of, 73

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INDEX TO VOLUME H

309

Omstrlc olcer, after-treatment of, 241

Gaatro-intestlnal diaeaae, treated with
adrenallD, 57
anrgerj, 288

Glands of Internal aecretlon, dlieaaea of.
51

Globulin In the cerebrospinal fluid, 7

GraTes*8 disease, hyperthyroidism ot 62

Gmber-Wldal test, 175

Grulee, C. G., M.D., Miliary tuberculosis
In new-bom; congenital diaphragmatic
hernia: demonstration of X-rays and
photographs ; Hirschsprung's disease, 98

Gyrospasm, 114

Hemolytic Icterus, 246

Hays, Harold, A.M., MD., FJLC.S^ The
application of surgical principles to op-
erations on the nose and throat, 208

Hazeltlne's operation, 287

Heart, slowing of. produced by digitalis, 89

Heart-block produced by digitalis, 98

Heel, pain In. 197

Hemorrhage, cerebral, 87
retinal, 87
gastric, treated with adrenalin, 56

Hernia, congenlui diaphragmatic, 100

Hess. Julius H., M.D., Gyrospasm (spas-
mus nutans) ; tubercular meningitis ver-
9US traumatic cerebral injury; probable
sarcoma of the right lung, 114

Hibernation, human, 152

Hip. luxation of, 221
paralysis of, 219

Hip-joint, arthroplasty of. 221

Hirschsprung's disease, 101

Human conservation, a neglected field for
medical specialisation, 181

Hump-nose, operation for, 276

Hygiene, neglect ot as an important fac-
tor in causing constipation, 71

Hypnotism as a therapeutic agent, 162

Hypofunction of glands, animal extract In
the treatment of, 50

Hysteria, case of, 146
traumatic, 186

Icteric syndromes, classification of, 244
Icterus, acholuric 246

cholurlc, 245

due to extrahepatic retention, 245
Injuries at birth, 107
Inlay bone-graft In the treatment of frac-
tures, 209
Interstitial nephritis. 84
intralaryngeal surgery, 299
Intranasal frontal sinus operations, 260
Invagination in children, 247

Jejunostomy, lateral, with anastomosis,

242
Jejunum, dilatation of, 285
Joint disease in children, 108

Kaplin*s quantitative estimation of the

protein, 8
Knee-joint, ankylosis ot 227

tuberculosis ot 228
Knock-knees. 226

Lacrimal duct, stenosis of, 278

operation, 280
Laryngological surgeon, 269
Laryngoscope, suspension, 299
Larynx, operations on the. 299
Lateral Jejunostomy with anastomosis, 242
Laxatives, used in the treatment for con-
stipation. 78
Leg, deficiencies in bones of, 229
Leucocyte, neutrophilic, 6
polymorphonuclear, 5
Liver, carcinoma of, 122
Local anssthesia, 285
Lung, sarcoma of, 116
Luxation of hip, 221
Lymphocytes, 6

Malleolar fractures, 280
M assage, pneumatic, used In curing chronic
habitual constipation, 75
vibratory abdominal, 82
Medical disc^Mes, animal extracts in the

treatment ot 50
Medicine, Department of:

Disuse cripplings, 156
Efforts at adjustment, 146
Foot, a consideration of some

painful conditions ot 187
Human conservation, a neglected
field for medical specialisation.
181
Psychoanalysis: its scope and

llmlUtion, 182
Typhoid and the psychoses, 172
Memory, concealing. 140
Meningitis, cerebrospinal fluid in cases
ot 2
tubercular, 114
Mental diseases. 182
eflldency, 188

symptoms in arteriosclerosis, 36
Metal versus bone appliances, 210
MeUUrsalgla, 194

treatment for, 196
Miliary tuberculosUi in new-bom, 98

Digitized by V^OOQ IC

310

INDEX TO VOLUME H

Miller, Morris Booth. M.D., A considera-
tion of some painful conditions of the
foot, 187
Mosber operation, 291
Murphy, John P. H., M.D., Typhoid and

the psychoses, 172
Muscles, deyelopment of, 165

rehabiUtation of, 157
Myxoedema, thyroid extract in the treat-
ment ot 51

N
Nausea produced by the use of digitalis, 98
NerYOus diseases, animal extracts in the
treatment of, 58
tissue, metabolism of, 1
Neurosis, 142
Nitrites, their yalue in emergency con-

diUons, 26
Nonne Phase I reaction, 7
Nose-bleeding cured by emetine, 41
Nose fractures, 278
operations on, 268

Operation for removal of adenoids, 295
for saddle-back deformity, 272
intranasal frontal sinus, 260
on frontal sinuses, 292

Orthopedic clinic of Fred H. Albee, 200

Os calds, fracture of, 280

Osteitis fibrosa, 222

Osteo-arthritis, 218

in adults, tuberculous, 220

Osteo-arthropathy, yertebral, 208

Osteopathy, cures in cases ot 158

Osteoplasty of the spine, 201

Ovarian extracts, 51

Oren-bath treatment, 80

Pttdiatrics, Department of:

Cancer of the pancreas in a nine-
year-old boy, with notes on
other reported cases of cancer
in children, 118

Enlarged spleen: splenic enlarge-
ment ; anterior poliomyelitis,
108

Epiphysitis, a case of, 127

Gyrospasm (spasmus nutans) ;
tubercular meningitis versuM
traumatic cerebral injury ;
probable sarcoma of the right
lung, 114

Miliary tuberculosis in new-bom ;
congenital diaphragmatic her-
nia; demonstration of X-rays
and photographs ; Hirsch-
sprung's disease, 98

Tuberculous joint disease in
children, diagnosis of: brain
injuries at birth, 108

Pancreas, cancer of, 118

extracts of, 51
Paralysis, case of, 112

of hips, 219
Paralytic scoliosis, 208
yams, 282
wrist-drop, 217
Parathyroid extract, 51
Patella, fracture of, 226
Pectoris, angina, 21, 86
Perforation of the septum, operation for,

286
Peri-arterial fibrosis, 21
Peritonitis, tuberculous, 109
Phlebitis, aseptic traumatic, 258
Pineal gland, disease of the, 51
Pituitary glands, disease of the, 51
Pituitrin extract in the treatment of
acute dilatatlcm of the
stomach, 60
circulatory failure, 61
constipation with meteorism.
61
Plasma cells frequently found in paresis, 6
Plastic surgery, 270
Pneumonia, treated with emetine, 42
Poliomyelitis, anterior. 111
Polypi, removal of, from nose, 288
Postoperative treatment, 205
Pott's disease, osteoplasty of the spine for,

201
Price, Byron Sprague, M.D., The diagnosis

and treatment of arteriosclerosis, 17
Prolapse, rectal, treatment ot 238
Prophylaxis in the treatment for flat-foot,

191
Protein in the cerebrospinal fluid, 8
Psychic epilepsy, 146
Psychoanalysis: its scope and limitation,

132
Psychoneurotics, adjustment of, 135
Psychosis, exhaustion, case of, 177
Pulmonary embolus, 254

following the radical cure of in-
guinal hernia, 250
Pulse, effect of epinephrln on the, 59
Puncture, spinal, 115
Pyorrhoea as treated with emetine, 45

Radius, congenital absence of, 217
luxation of head of, 215

Rectal prolapse, treatment of, 238

Respiratory diseases, emetine in, 42

Retinal hemorrhage, 87

Rheumatism of the foot, 188

Rhinophyma, surgical treatment of, 270

Rib transplantation for saddle-back de-
formity of nose, 272

Ross-Jones reaction, 7

Ryerson, E. W., MD^ Diagnosis of tu-
berculous Joint disease in children:
brain injuries at birth, 108

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INDEX TO VOLUME n

311

Sacio-Ulac Joint, tnbercnloaii of, 208
Inxation of, 209

Saddle-back deformity, 272

Sarcoma of the lang, 116

Sciatica, case of, 162

ScleroBls, advanced condttions ot 36

Scoliosis, paralytic, 208

Secretin, administration of, 85

Semilunar cartilage^ injury to, 225

Septum, perforation of, 286

Serology, 11

Sexual InquisltiTenefls, 141

Shoulder-joint, disjunction of upper epiph-
ysis of humerus, 214
luxation of, 214

Sinus, frontal, drainage of, 262

Sinuses, frontal, operation on, 292

Sinusoidal current as an effective means
for reestablishing intestinal tone» 82

Skeleton, systematic discussion of, by
Dr. Albee, 218

Skiagrams, taking of, from several aspects,
207

Skillem, P. Q., Jr., M.D., The orthopndic
clinic of Fred H. Albee at the New York
Post-Graduate Medical School, 200

Smnkler, M. B., MJ>., Chronic habitual
oonstipatl(m : a practical consideration
of its causes, results, and Its rational
treatment by mechanical measures, 64

Somnambulism, case of, 146

Spasmus nutans^ 114

Specialisation, medical, 181

Spinal graft, 208
puncture, 115

Spine, Charco^rs disease of, 208

insertion of transplant Into the, 204
osteoplasty of, 201
tuberculosis of, 104

Spleen, enlarged, case of, 108

Spondylitis traumatica, 208

Static resonator effleuve, 82

Stenosis of the lachrymal duct, 278

Stewart, Samuel C^ M.D., and Lever F.,
ILD., A case of cancer of the pancreas
in a nine-year^M boy, with notes on
other reported cases of cancer in chil-
dren, 118

Stomach, gunshot and bayonet wounds of
the, 256

Streptococcus pyogenes, growth of, 129

Submucous resection, 285

Suppurative arthritis, 219

Suprarenal glands, disease of, 61

Surgery, conservative, 260

Surgery, Department of :

Application of surgical principles
to operations on the nose and
throat, 268

Qastro-intestinal surgery and

pathology, 288
Gigantic duodenum due to kink-
ing at duodenal jejunal junc-
tion, 285
Intranasal frontal sinus opera-
tions : conservative surgery,
260
Orthopedic clinic of Fred H.
Albee at the New York Post-
Graduate Medical School, 200
intralaryngeal, 299
intranasal, 277
plastic, 270
Surgical principles, application of, to op-
erations on the nose and throat, 268
Sutter, Charles Clyde, M.D., The cerebro-
spinal fluid in diagnosis, 1 '
Syndrome of Icterus, 244
Systemic diseases, emetine in, 48

Tarsalgia, 197

Tarsus, tuberculosis of, 229
Taylor, J. Madison, A. B., M.D., Human
conservation, a neglected field for medi-
cal spedaUsatlon, 181
Testicular extracts, 51
Therapy, digitalis, 87
Throat, operations on the, 268

surgery of the, 298
Thrombus, femoral, 251
Thymus gland, disease of the, 51
Thyroid extract in the treatment of
cretinism, 51
myxoddema, 51
Tibia, removal of transplant from, 203
Tonsil, removal of, 294
Trachea, surgery of the, 805
Transplant from tibia, removal of, 203
Transplants, bone, 271
Trauma during operation, 251
Traumatica, spondylitis, 208
Treatment, postoperative, 205
Tubercular meningitis^ 114
Tuberculosis as treated by emetine, 48

miliary, in new-bom, 98

of the sacro-iliac joint, 208

of tarsus, 229

of wrist-joint, 217
Tuberculous joint disease in children, diag-
nosis of, 108

peritonitis, 109
Typhoid and the psychoses, 172

temperature in cases of, 174

Ulna, fracture of, 216
Urotropine, administration of, 109
Uvula, amputation of, 296
Uvulatome, 298

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312

INDEX TO VOLUME U

Valgus from infantile palsy of extensors
of foot, 288

Varus, paralytic!, 282

Vascular system, actions of digitalis on,
90

Venesection as a means of reducing blood-
pressure, 80

Vertebral osteo-artfaropathy, 208

Ton Pirqnet test, 105

Walsh, James J., ILD., Ph.D., BcD., Dis-
use cripplings, 156

Wassermann reaction in cerebrospinal
fluid, 11

Water as an aid In curing constipation, 78

sufficient ingestion of, 68
Wounds of the stomach, gunshot and

bayonet, 255
Wrist-drop, paralytic, 217
Wrist-Joint, tuberculosis of, 217

X-ray in the early diagnosis of tuberen-

losls, 106
X-rays, demonstration of, 100

Tankauer lacrimal duct operation, 280

»^UN 1 9 WIS

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3 Soi6 07037 1808

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