(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

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

This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project 
to make the world's books discoverable online. 

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject 
to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books 
are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover. 

Marks, notations and other marginalia present in the original volume will appear in this file - a reminder of this book's long journey from the 
publisher to a library and finally to you. 

Usage guidelines 

Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the 
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing this resource, we have taken steps to 
prevent abuse by commercial parties, including placing technical restrictions on automated querying. 

We also ask that you: 

+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for 
personal, non-commercial purposes. 

+ Refrain from automated querying Do not send automated queries of any sort to Google's system: If you are conducting research on machine 
translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the 
use of public domain materials for these purposes and may be able to help. 

+ Maintain attribution The Google "watermark" you see on each file is essential for informing people about this project and helping them find 
additional materials through Google Book Search. Please do not remove it. 

+ Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just 
because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other 
countries. Whether a book is still in copyright varies from country to country, and we can't offer guidance on whether any specific use of 
any specific book is allowed. Please do not assume that a book's appearance in Google Book Search means it can be used in any manner 
anywhere in the world. Copyright infringement liability can be quite severe. 

About Google Book Search 

Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers 
discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web 



at |http : //books . google . com/ 



B 3 9015 00208 407 




Digitized by VjOOQ IC 





by Google 



&/0 .S' 
CCf 



Digitized by VjOOQIC 



Digitized by VjOOQIC 



Digitized by VjOOQIC 



Digitized by VjOOQIC 



Digitized by VjOOQIC 



• 



» • • 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 ■ 

ii 

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 



n 



i]ii 



* • ■_ •. 




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



Digitized by VjOOQIC 



International Clinics 

A QUARTERLY 

OP 

ILLUSTRATED CLINICAL LECTURES AND 
ESPECIALLY PREPARED ORIGINAL ARTICLES 

ON 

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 



Digitized by VjOOQIC 



GOFTKIOHT, 1916 
BY 

J. B. LiPPiNOOTT Company 



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



Digitized by VjOOQIC 



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. 

m 



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. 



Digitized by VjOOQIC 



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 

T 



Digitized by VjOOQ IC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQ IC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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, 

Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



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- 



Digitized by VjOOQIC 



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. 



Digitized by.VjOOQlC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 

Digitized by VjOOQ IC 



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 

Digitized by VjOOQIC 



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). 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQ IC 



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- 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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- 

Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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- 
Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



Fia. 1. 




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



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 







Digitized by VjOOQIC 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



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, 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 
Digitized by VjrOO^ IC 



CHBONIO HABITUAL CONSTIPATION 



77 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



Fia. 10. 




Method of exercise suggested. 



Digitized by VjOOQIC 



FlQ. 11. 




Method of exercise suggested. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



82 



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 



Digitized by VjOOQIC 



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 



Digitized by 



Gofijgle 



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. 

• Digitized by Google 



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- 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 

87 

Digitized by VjOOQ IC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



z? 






2.5- 

o •» 

S-S: 



3 

o 



IT 



;?»• 



as 




Digitized by VjOOQIC 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQ IC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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& 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 

Digitized by Google 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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- 
Digitized by VjOOQIC 





Digitized by VjOOQIC 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



CANOEE OF THE FAKCBEAS IN NINE-TEAB-OLD BOT 



123 



1^ tf^if^eo ooooeooeoeoeoooooololo^^^^lOlOloto^^|o»-«»-• 



'^ oa Oi it^ CO 10 H* O « 00 *4 Ob Oi ll^ 00 10 »-• 



s 2^ 3c 



^525^?5'^255255255S53^^^2^?"2SS32gs^ 



f 












I n> hd^ ^T H3 nd "s hd ^ ^ ^ ^^ ^r;] > > on 
g 5^x:3.a.a3.3.3.2.a.3.3.3.:3,;i.g.:r£'S^ 






£3 C D-C 




s 

E 
E 






H 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 

Digitized by VjOOQ IC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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- 

Digitized by VjOOQIC 



Fia. 1. 



Fia. 2. 




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



Digitized by VjOOQIC 



Flo. 3. 



Fig. 4. 





Extreme limit of possible abduction. 



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



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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: 



Digitized by VjOOQIC 



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: 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. ' 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQ IC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQ IC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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, 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 




Digitized by VjOOQIC 



Digitized by VjOOQIC 



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 



Digitized by VjOOQ IC 



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 



Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



Fia. 




Osteoplasty of spine. Ossoo-aponeurotic gutter ready for insertion of tibial transplant. 



Digitized by VjOOQIC 




Digitized by VjOOQIC 



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- 

Digitized byCjOOQlC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



Fio. 7. 





Osteoplaaty of spino. Sarnc a» prcrodinR fifture. Anteroposterior view. 



Digitized by VjOOQIC 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by V^OOQ IC 



Fig. 8. 




Disjunction of upper epiphysis of humerus with characteristic displacement, .\nteropostprior view. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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). 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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, 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQ IC 



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. 



Digitized by VjOOQIC 



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.] 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



Fu;. 26. 




Twin-saw ready for use. Shows proper method of holdinK the motor. Spray attachment and 

fciiard connected. 



Digitized by VjOOQIC 



Fig. 27. 



i^ 




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. 



Digitized by VjOOQIC 



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 

BY 

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 

Digitized by VjOOQ IC 



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 



Digitized by VjOOQIC 



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.) 



Digitized by VjOOQIC 



Fia. 2. 




A, transverse meso; B, dilated duodenum. 



Digitized by VjOOQIC 



FfG. 3. 




' •an' 



A, fistula from duodcnuxn into large intestine; B, gastro-ontorostomy opening. 



Digitized by VjOOQIC 



Fia. 4. 



Fistula ^ 



Fistula 



Gastro- 
enterostomy 



m 




i / 



Jiuodcnom 



Gigantic duodenum due to kinking at duodenal-jejunal Junction. 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



o 

•a 



•o 
3 






•o 




Digitized by VjOOQIC 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



246 INTEBNATIONAL CLINICS 

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 



Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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- 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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. 



Digitized by V^OOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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." 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 




3 « 








Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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). . 

Digitized by VjOOQIC 



Fia. 9. 



r 



L 




CoheD's instruments for plastic work. 



Digitized by VjOOQIC 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 



Digitized by VjOOQ IC 



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. 

Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



OPERATIONS ON THE NOSE AND THEOAT 



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 



. Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



OPEBATIONS ON THE NOSB AND THBOAT 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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- 



i 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



294 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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- 



Digitized by VjOOQIC 



OPEBATIONS ON THB ITOSB AND THBOAT 



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. 



a 






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, 



Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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. 

Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 



Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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 

Digitized by VjOOQIC 



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. 



Digitized by VjOOQIC 



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 

B 

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 



Digitized by V^OOQ IC 



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 

B 

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 



Digitized by VjOOQIC 



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 

H 

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 



Digitized by 



Google 



INDEX TO VOLUME n 



311 



S 

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 



Digitized by VjOOQ IC 



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 

W 

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 



Digitized by VjOOQIC 



Digitized by VjOOQIC 



Digitized by VjOOQIC 



UNI^ 



o^fifM^Ttminrnr 



3 Soi6 07037 1808 





Digitized by VjOOQIC 




1